'•:%:f1' ■*■—. ■ v •is '#*. >£' "^ ■re *: Ss -^<.' ■-.. "N. ^ v' €^^^^«^<-^^^^# PROPERTY OF JAMES B. ELMENDORF. 1 NATIONAL LIBRARY OF MEDICINE Washington OBSERVATIONS ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES IN SEVERAL DISEASES. BY JAMES HAMILTON, M. D. FELLO'VT OF THE ROYAL COLLEGE OF PHYSICIANS, AND OF THE ROYAL SOCIETY OF EDINBURGH ; AND SENIOR PHYSICIAN TO THE ROYAL INFIRMARY OF THAT CITY. Firtt American, from the second Edinburgh Edition, ---—M»Q»«m.--- PHILADELPHIA: MINTED FOR BENJAMIN JOHNSON, NO. 249, MARKET STREET, AND COLLINS AND PERKINS, NO. 189, PEARL STREET, NE W YORK. 1809, TO JAMES RUSSELL, ESQ. professor 01 clinical surgery ix the uvivehsi'i \ of edinburgh. My Dear Sir, IF the following Observations had been of that im- portance in respect of science, as to have made a particu- lar Dedication of them necessary, or proper ; and if I had been to select a Patron of distinguished literary endow- ments, and of extensive and correct professional acquire- ments, there is no one who would have sooner occurred to me than yourself. Sentiments, however, prompting an address less for- mal, and therefore, I trust, to you not less agreeabii. induce me, in a manner more familiar and more since:\ . to acknowledge my obligations to you for many instances of your private friendship ; and to thank you for the en- couragement you gave me on the present occasion, without which, I probably neither would have undertake';, nor have accomplished this Utile work. I am, Dear Sir, With much regard, Your faithful and obedient Servant, James Hamilton. edinburgh, ~) \st"Nov. 1805. S CONTENTS. Chlorosis, on Purgative Medicines in ■------, cases of Chorea, on Purgative Medicines in ------, cases of ..... Chronic Diseases, on Purgative Medicines in ----------------, cases of HjEmatemesis, on Purgative Medicines in ------------} cases of Hysteria, on Purgative Medicines in ■----, cases of .... Marasmus, on Purgative Medicines in ---------, cases of Observations General, on Purgative Medicines Scarlatina, on Purgative Medicines in -----------, cases of .... Tabulae, quae designant nomenclaturam novam Medi- caminum, quae reperiuntur in hocce libello 11 7 Tabula, qua innotescunt formulae Medicaminum, quo- rum mentio fit in hisce paginis, etquae Phar- macopoeia Nosocomii Regii Edinensis, pro- pria sunt . . . • . 121 Tetanus on Purgative Medicines in . ----«----, cases of ... . Typhus, on Purgative Medicines in . -------, cases of . • • ■ ■ Page 58 182 75 198 109 265 69 185 88 242 48 165 17 33 149 93 251 26 125 PREFACE. AS the doctrine which I maintain, with respect to the exhibition of purgative medicines, may have the appear- ance of novelty ; in order to obviate any prejudice, it is therefore incumbent on me to state the rise and progress of the opinions which I entertain upon this subject, and to produce the facts on which the practice which I recom- mend is founded. With this view, I hope it will not be thought presump- tuous, to give some account of the opportunities which I have enjoyed, for collecting accurate and extensive in- formation, in the different diseases of which I treat in the following Observations. I have occupied places of professional trust and respon- sibility in Edinburgh for upwards of thirty years. During the whole of this period, I have discharged the duties of Physician to the Royal Infirmary, to George Heriot's Hos- pital, and to the Merchants and Trades Hospital of this city. In the midst of the constant, and sometimes laborious occupation, in which, in consequence of being placed in these situations, I have been engaged, my attention was, 8 PREFACF. many years ago, attracted to the purgative effect of medi- cines given in Typhus fever. The facts which then pre- sented themselves to my notice, induced me to repeat these medicines again and again ; till, by s;ow advances, T at last acquired confidence in the practice. Many op- portunities have since occurred to me of confirming these observations, which, in my apprehension, clearly establish the safety and utility of givinr purgative medicines in the course of Typhus fever, under the limitations which I point ovit. I was afterwards disposed to juckre favourably of the same practice in Scarlatina ; and the utiity of it in this disease has been confirmed by much experience. Thus my views respecting the use of purgative medi- cines became more and more extended ; and, in process of time, I employed these, with a freedom not usual, but with manifest advantage, in several other diseases. My own experience of the utility of this practice, is the circumstance which encourages me to pursue it with steadiness. Rut to inspire others with the same degree of confidence, it wbi be requisite to adduce the proofs which have satisfied me of its supeiiority to that in com- mon use. The number, the authenticity, and the apposite appli- cation of the cases inserted in the Appendix, will, I trust, prove sufficient to establish the soundness of the princi- ples upon /which I proceed, and to satisfy the most scep- tical. Many of these cases are those of patients, who have been under my own care in the Infirmary ; and they are transcribed from the records of that institution, by the permission of the managers. To shew the conse- quence and authenticity of these cases, I shall mention some particulars relative to tbdLjftuain em. i.t of medical practice in the Hospital. ^^T PREFACE. 9 The University of Edinburgh had already attained a high and deserved reputation as a school of medicine, when the Royal Infirmary was opened in the year 1741. It was soon perceived, that the University and the Infir- mary might be made to afford mutual and valuable aid to one another. The medical education, it was evident) would be rendered more complete, by giving the students of the University access to the Infirmary, where they might learn the practical part of their profession ; while the funds of the hospital wovildbe augmented by the fees which the students would pay lor the liberty thus granted to them to visit the patients, and observe the practice as conducted in it. Accordingly, arrangements respecting the detail of prac- tice in the Hospital, suiteo to these views, were made ; which, while they secured to the patients benefits supe- rior, 1 believe, to what are experienced in most similar institutions, at the same time afforded to the medical student opportunities of acquiring the practical know- ledge of his profession, seldom to be found in other Hos- pitals. By the regulations of the Managers, the Physicians of the Royal Infirmary give regular daily attendance, at a certain hour; take the full charge of their respective pa- tients, and interpose directiy in every circumstance rela- tive to the conduct of their cure. The two physicians named by the managers, have an equal share of duty, and divide the patients equally be- tween them. A clerk is attached to each physician. He is common- ly a young gentleman, who is advanced in bis studies. He resides in the Hospital, and has a general superintend- JO PREFACE. enceof the patients, who are under the charge of the physician, with whom he is connected. Besides other du- ties, it is his business to prepare a written account of the symptoms of those patients, who fall under the care of the physician, whose clerk he is. He inserts this account in the journal book, and reads it to the physician at the bedside of the patient, on the following daily visit. The physician either admits this account simply, or makes additions and alterations, as lie may think proper. Regular reports of the subsequent state of the symp- toms; of the remedies prescribed, and of the effects of theser are given.daily, or as often as the chronic nature of thec^se, may make them necessary. These repo.tsare the result of the accounts, which the patients give of themselves, or of the accounts which are received from the nurses, or of both together ; they are dictated by the physician to his clerk,.who at the time, enters them into sAhe ournal book. -*t -7^kll these proceedings take p'ace in public, in the pre- sence, and in the hearing, of a number of young gentle- men, who attend t< e Hospital, many of whom are com- petent judges of what is going forward. Thus, the physician must include, in his reports, all the circumstances, as they arise in particular cases ; cir- cumstances over which he has no controul, and which must inevital ly direct his practice. Further, the^pfaysi- v -T; cian of the Royal Infirmary, in consequence of his atf^n- *7 ? dance every day, is enabled to follow out his practice,, with peculiar precision and accuracy ; ,to do wBfchrdke is also stimulated by.the interest which h- cannot but take in his patients, frequently friendless strangers-, and, by the un- avoidable publicity of his whole procedure respecting them, which places him often in delicate and trying situa- tions. PREFACE. 11 Cases then of this description, which, in their progress, cannot be perverted to particular purposes, and which cannot afterwards be altered, by any retrospective emen- dation of the practitioner, possess an authenticity peculiar to themselves ; and in the establishing of medical facts, may be produced as an authority, that cannot be contro- verted. Indeed, I esteem myself fortunate in having documents of this kind to adduce, in support of a practice, which may be thought to require all the confirmation which the most incontrovertible evidence can afford. * These cases inserted in the different numbers of the Ap- pendix, are dated from the Royal Infirmary. Again, in further support of the exhibition of purga- tives, in the diseases of which I treat, I insert in the proper numbers of the Appendix, histories of cases from my private practice ;—and although these are not sup- ported by the same public testimony, as those which are extracted from the records of the Hospital, yet I trust they will be received with all the credit due to cases, which rest upon the authority of any individual practitioner, The favour of my friends, who have had the gootlnefs to oblige me with communications from their private practice, likewise enables me to give farther evidence pf the utility of the plan which I recommend. This is the more gratifying to me, as it thus appears, that gentlemen of high professional respectability, approve andfidoptyrtn the instances to which their communications refer, the practice which I have endeavoured to introduce. Before I conclude these preliminary ret^ks, I beg leave to obdfcve, that I do not willingly obtrude myself* on the pubS/in the character of an author ; but different reasons concur to overcome my backwardness to do so, and even to render a full exposition of my practice, a measure of prudence and of self-defence. A number of 12 PREFACE. intelligent, well-informed young gentlemen, who attend the Hospital, have become converts to the free exhibition of purgative medicines, which they have seen me employ with so much advantage. By this means, the peculiari- ties of my practice here, have passed silently into the ■world, unexplained and unsupported by the proofs and il- lustrations which it was in my power to produce; they have been partially noticed in one . periodical publication; and made the subject of hasty and mistaken criticism in another. Dreading, therefore, that under these disad- vantageous circumstances, the practice might be prejudg- ed, and of course, neglected, I have endeavoured to pro- cure for it a fair and unprejudiced hearing, by placing it before the public, in my own words. To the public decision I will submit, with deference and respect; at the same time, I rely with confidence on its impartiality; and trust, that no person of character will condemn the practice, which I now recommend, till after repeated trials, agreeably to the plan, which I have myself ob- served. % ADVERTISEMENT TO the SECOND EDITION. THE rapid and extensive sale of the First Edition of these observations, is, I trust, an indication of the favoura- ble opinion which the public in general entertain of the work. I have also the satisfaction to be honoured with letters from gentlemen of the first professional eminence ; in the capital and in other parts of the kingdom, expressing ' the most unqualified approbation of the doctrines and practice which I have endeavoured to establish respecting the use and administration of Purgative Medicines. This reception, which so far exceeds what my most san- guine expectations would have allowed me to hope for, may, perhaps, be ascribed in a great measure to the in- dulgence which is due to every publication which professes merely to communicate the result of long and patient ex- perience. At the same time, I must consider the res- pectable nature of the testimonials, and the great number of them, as affording a strong presumption in favour of the justness of the opinions which I have advanced. To my. self, at least, they present a most powerful confirmation 13 14 ADVERTISEMENT of what experience had suggested; and have encouraged me to proceed with confidence and alacrity to prepare a Second Edition, which the Booksellers informed me some time ago, was required. I have exerted all the diligence and attention which the shortness of the time admitted of, to correct and enlarge this Edition ; as I am sensible that it is in this way only. that I can acquit myself of my obligations to the public, and testify my gratitude for their candour towards me. I have made some alterations and additions, which I will briefly notice. I have suppressed a few observations, which, while they were of little importance, have excited a diversity of opin- ion, which might require some discussion to support. This discussion, on subjects not necessary to my argu- ment, must have appeared frivolous to some, and have proved tedious to all. J have"changed the arrangement of my subject; and although the different chapters may be considered as so many distinct essays, yet they are now placed in a some- what systematic form. In making this change, however, I have been guilty of one improper anticipation, which I did not discover in time to remedy completely. The chapter on chlorosis now precedes that on chorea, while in explaining the practice in the former, I make I refer- ence to that in the latter. To obviate any difficulty that may arise from this transposition; the observations on chorea may be perused previous to those on chlorosis. / TO THE SECOND EDITION. 15 The form of the typography in the appendix, will, I hope, be found to be improved. This improvement would not indeed deserve to have been noticed, were it not that the proofs of the utility of purgative medicines are chiefly deduced from the history of the cases contained in the appendix. The same cases also afford means of acquiring a perfect knowledge of the administration of purgatives. It is therefore of importance to Facilitate the perusal of narratives confessedly dry and unentertaining, and to ren- der them more ftleaaant and accessible. I have withdrawn some cases from the appendix to the former edition, and have added others; and I have occa- sionally inserted remarks and observations which are not to be found in the former edition ; though these are not of sufficient importance to merit particular notice here. • The material additions which I have made, consist of a chapter on hysteria, and of one on tetanus, with an ap- pendix to each, containing cases of both diseases. But as these are now before the public for the first time, it be- hoves me to observe a respectful silence with regard to them. EDINBURGH, } MAY 1st. 1806. J OBSERVATIONS ON PURGATIVE MEDICINES, &c. i-l.NERAL OBSERVATIONS ON PURGATIVE MEDICINES. JQjVERY Physician, in the commencement of his pro- fessional pursuits, is necessarily guided by the opinions which he has formed in the schools ; by the sentiments of the authors whom he has chiefly consulted, and by the example of those whose practice he has proposed to him- self to follow. Subsequent information, however, and new discoveries, and the experience which he gains by personal intercourse with the sick ; may dispose him, sooner or latter, to make some change in his more early opinions and practice. Hence the science of medicine has been reproached with being fluctuating and uncertain ; but in my apprehension with no good reason. It would be more candid to consider it as in a state of improvement, in which it has advanced in proportion .to the genius and learning which its cultivators have possessed ; or according as the B 2 18 GENERAL OBSERVATIONS ON spirit of prevailing philosophies, always interwoven with reasoning in medicine, has been favourable to its progress or otherwise. The change in opinion andfpractice, to which I allude, is always for the better, provided the practitioner possesses good sense, industry and talents for observation. It is the natural consequence of the situation in which he is placed, and neither indicates the want of steadiness on his part, nor of certainty in his profession. So that to represent the practice of medicine as variable from the change of opinion, inseparable from the progress of medical im- provement, is to take an unfair and a partial view of the case. All the principal employments of life are liable to a similar objection, on the same grounds, and w ith equal justice. Several circumstances indeed connected with the science of medicine, have retarded its improvement, and given a plausibility to this charge of uncertainty ; and none more than the different theories which have been advanced in explanation of the phenomena of the animal system in health and in disease. As the frame and bent of the human mind render theo- ry unavoidable ; and as theory in medicine will be safe and useful in proportion as it is free from error; it is of consequence to ascertain the causes of those errors to which it is exposed. Errors in theoretical medicine may be referred, in the first place, to the hasty conclusions which the earlier Phy- sicians drew ii-cm the few facts which were known to them ; and to the fascinating propensity to form systems, upon data too limited in number, and often contradic- tory PURGATIVE MEDICINES. 19 In the second place, physicians have been unsuccessful in the establishment of true theory, from not having had sufficiently comprehensive views of the different organs and functions of the animal body. To this circumstance is owing the rise of the humoral, the chemical, the me- chanical, and of the nervous pathologies, as distinct sys- tems. Had th^ dogmatists cautiously embraced the views, which each of these systems presents, and combined them, we might have enjoyed a more perfect, because a more comprehensive system of medicine. In the third place, a strong passion for distinction and fame in the professors of medicine themselves, has coun- teracted the utility which might have been derived from the fortunate combination of these systems. The glory of forming a new theory, and of constituting a new sera in medicine, has seduced the leaders of each succeeding sect to an attempt of setting aside the doctrines of their pre- decessors, in order that their own particular system might be more firmly established, and might shine with unrivalled lustre. In the fourth place, the dogmatists in forming their systems, have often adopted certain data, which rest only on specious reasoning, a firiori, -and are supported neither by facts nor observation. This circumstance, has as much as any other, greatly retarded the improvement of medi- cal knowledge. It has introduced much false reasoning and obscure language into medicine ; whence, it is to be feared, and to be regretted, that erroneous, and therefore not harmless practical conclusions have been drawn, I do not officiously or willingly point out what I conceive to have been the grounds of mistake in medicine. I ven- erate the learning and ingenuity of our predecessors, which contributed to procure for the medical art, a name 20 GENERAL OBSERVATIONS ON and a consequence in the estimation of mankind. If, however, they have failed in some things, we ought to take a lesson from this failure, and by shunning the specious fallacy of hasty generalization, and by having recourse to a diligent, accurate, and minute enouiry after facts, which enquiry, the state of medicine demands of us, endeavour to promote its best and truest interests. I make these' observations as an apology, if one be ne- ' cessary, for my having occasionally, in the following ob- servations, disregarded prevalent and fashionable doc- trines of the schools ; and for my having departed from the usual routine of practice in respect of the administra- tion of purgative medicines. A habit which I early ac- quired of attending to the means of supporting, and of re- storing the healthy action of the stomach and intestinal canal, has led me to consider this subject with minute at- tention. The importance of the functions of the stomach and in.cstines is commonly known and admitted. By means of these functions our food is received, digested, assimi- lated, and carried under the form of a nutritious fluid into the system. Besides, sympathy as it is called, connects the stomach and bowels with other parts of the complicated animal structure, and strengthens the influence which these or- gans maintain over the comfort, the health., and the life of every individual. Hence it is obvious, that disorders of the stomach and bowels must greatly affect the system at large ; and that in proportion to the duration and se- verity of these disorders, the auction of the general ha- bit will be more or less serious and afflicting. PURGATIVE MEDICINES. 21 There is certainly nothing new in the observation, that the constipated and loaded state of the intestinal canal, is a common cause of general bad health. But when I go the length of saying, that this state generally accompanies, and aggravates the other symptonsofa fever; that it is also the immediate cause of certain disorders peculiar to children and young people, I am conscious that I advance opinions in which there is considerable novelty ; but in which I trust the following sheets will satisfy the medical reader, that there is also, at least an equal degree of sound- ness. I have also observed, that in mature age, and in the de- cline of life, symptoms, which are attributed to previous irregularities, to ideosyncracy, to hereditary disposition, to disease, and to approaching old age, frequently arise from constipation of the bowels, or are intimately connec- ted with it. The consideration however of these is but partly comprehended in my present undertaking. Thus I have learned, that a knowledge how to regu- late the alvine evacuation, constitutes much of the pro- phylatic part of medicine ; and hence how necessary it is . to advise those, who either wish to preserve good health, or who are in quest of the lost treasure, to attend to this circumstance. It may be proper, on some occasion's, to propose to them to forsake the haunts and habits of fashionable life, to leave the crowded city, alluring amusements, or seri- ous occupations, conducted in airless or even in tainted rooms, to shun luxurious tables, indolence and late hours ; to retrace the footsteps by which they have deviated from simple nature ; and to court the country, pure air, mode- rate exercise and simple diet. 22 GENERAL OBSERVATIONS ON This advice, however, cannot be always followed, and it may not always remove costiveness and the ills which proceed from it. In this case, as well as in the costiveness which accompanies disease, the interposition of purgative medicines will be necessary. In infancy the alvine evacuation is more abundant, more frequent, and more fluid than in after periods of life. In mature years, the belly is generally moved once in twenty- four hours. In the healthy state the feces, although soft, preserve a form too well known to require description ; they are of a yellow colour, and they give out a certain odour. But when the feces are evacuated less frequently than the age of a person requires ; when they are indu- rated ; when their natural colour is changed, and when they acquire peculiar fetor, they indecate derangement of the stomach and bowels, whence the approach of disease, if disease be not already formed, may be apprehended. I am not ignorant that costiveness, even to a considera- ble extent, will prevail in robust and otherwise healthy people, without immediate injury. In such instances, the circulating and absorbent systems are active and power- ful ; in consequence of which the fluid contents of the intestines, may be so quickly and so completely absorbed, as to leave a comparatively small mass, incapable from its bulk, of giving a stimulus sufficient to excite the propensi- ty to evacuate the bowels ; but which, by gradual and slow accumulation, acquires this bulk, and is at last voided un- der the appearance of an indurated stool. This constitutional costiveness is of dangerous tenden- cy, and however desirable it may be to rectify it, the con- sideration of it is not comprehended in my present plan, which embraces only a few diseases, of which, I consider costiveness to be the cause, or in which I apprehend it to be a leading or permanent symptom. PURGAT1YE MEDICINES. 23 In prosecuting my subject, when I oppose the opinions of respectable authors, I trust I shall speak with the def- erence and respect which I feel to be due to them. And when I propose changes in practice which experience has taught me to be useful ; I will do so with a confidence proportionate to that experience which has been my guide. In the dawn of physic, purgative medicines were em- ployed ; but, although they have been recommended by the earliest, as well as by latter writers; and although the indications they are meant to fulfil, have been an ob- ject of attention to practitioners in all ages ; yet it does not appear to me, that the extent of their utility has been always clearly perceived, or that the administration of them has been always properly directed. Physicians, tinctured with the tenets of judicial astrolo- gy, prescribed purgatives at certain times and seasons; conceiving that they would prove more beneficial or hurt- ful, according to the junction or opposition of the planets, or the age of the moon. But these reveries, which im- peded rational practice, havelong since vanished. Those who were partial to the doctrines of humoral pathology, employed purgative medicines, with the in- tention of expelling peccant matter, but not before it had been separated from the mass of fluids, by an appropriate fermentation. The same pathologists taught, that differ- ent purgatives possessed distinct powers, and moved dif- ferent fluids by a specific action. Hence they have talked of cholagogues, phlemagogues, hydragogues, and of me. lanagogues ; and have displayed much apparent sagacity, in selecting the purgative adapted to the expulsion of the fluid prevalent at the time. 24 GENERAL OBSERVATIONS ON This fermentation, however, and what was supposed its natural consequence, the deposition of peccant hu- mours, have ceased to hold a place in the doctrines of physic. While the specific operation of purgatives in expelling particular fluids, is neither confirmed by sub- sequent experience, nor allowed to nave any influence in practice. Modern physicians have two objects in view, in the ad- ministration of purgative medicines ;—the one is to empty the bowels simply ; the other, to promote an increased secretion of fluids into the cavity of the intestines, or in other words, to induce purging. They have accordingly considered medicines thus employed, to be of two kinds, laxative and purgative ; and they prescribe the one or the other of these, as the circumstances of the case may seem to require them. This distinction is neither, perhaps, so correct nor philosophical as it might be. Purgative medicines act by their stimulating power, which will be in proportion to the quantity of the medicine that is given. Four grains of calomel, three or four of aloes, and ten or twelve drachms of rochelle salt, will generally prove purgative ;— and any of these in reduced doses, will have a laxative ef- fect only. But as this distinct.- n has acquired the sanc- tion of ages, I mig ht have passed it in silence, had it not been necessary for me to notice it; as, from experience of their superior usefulness, I employ almost solely what are understood to be purgative medicines, in the diseases of which I am to treat, while at the same time I avoid their full effect of purging. This consideration obviates an objection, not unfrequent- ly made, to the employment of purgative medicines; namely, that they reduce the strength of a patient, al- ready too much weakened. Purging will undoubtedly PURGATIVE MEDICINES. 0;3 debilitate the body, by causing a sudden, and a greater than usual flow of fluids, that are in general secreted slowly ; and by hurrying off the chyle, and preventing it from passing into the circulation. Purgative medicines, thus acting, are useful on some occasions; and are ad- vantageously employed in some diseases. But purging is not desirable in the diseases, which are the subjects of the following observations. Here, the sole intention, is to bring off the contents of the bowels, which are out of the course of the circulation; and, in so far, are already, in a manner, extraneous to the body ; and I can hardly sup- pose, that debility will ensue from purgative medicines, given under this limitation. Besides unloading the bowels, purgative medicines are said to act by emulging the excretory ducts of different secreting organs and glands, connected with the stomach and intestines.—I do not think it necessary to consider this question minutely. Without derogating from the > good effects of purgatives acting in this manner, I will only observe, that for the sake of perspicuity, I refer the benefits which result from the use of purgatives to their sensible effect, rather than to one which is less obvious ; and that for the sake of precision, I speak of this effect, as removing a cause of irritation, without, however, mean- ing to advance or support any theory on the subject, C 26 CHAP. I. OBSERVATIONS ON THE UTILITY AND ADMINISTRA- TION OF PURGATIVE MEDICINES, IN TYPHUS FEVER. A considerable diversity of opinion has prevailed, respecting the cause of fever. Fhysicians seem now to be agreed; in referring it to a general or specific conta- gion ; the former giving rise to typhus, ia the various forms under which it appears ; while the exanthemata, or eruptive fevers, proceed from the latter. The manner in which contagion acts on the living body has been the subject of much discussion. But the con- sideration of this question is altogether foreign to my purpose. It will be sufficient for me, to note the usual symptoms of typhus. The presence of typhus is first known, by derangement of the stomach, which is marked by sickness, loss of ap- petite, thirst, headach, white, or loaded tongue, and gxn- ci'uliy by costiveness. These symptoms are soon follow- ed by affection of the surface, of the sanguiferous system, and of different secretions. 1 o which, in the more ad- vanced state,of the fever, are super-added delirium, tie- m crs, subtultus tendinum, floccitatio, singultus; these are supposed to denote considerable affection of the ner- vous svstem. ON PURCATIVE MEDICINES, &C. 27 The symptoms above enumerated appear in succession, and generally in the order in.which I have enumerated them; those which affect the stomach, as they are th^ first, so they are the most permanent throughout the fe- ver. They accompany the others as they arise, and very possibly influence them, in respect of their mildness or severity. They are, therefore, of great import, in the treatment of fever, and demand particular attention. At the time when I was appointed physician _to the Royal Infirmary, the cure of typhus fever was thought to consist chiefly, in the removal of atony, and spasm of the vessels of the surface of the body. For this purpose, among other remedies, weak antimonial, and nauseating medicines, were given freely. The state of the stomach and bowels, after the exhibition of an emetic and purga- tive, on the first approach of the attack, was little regard- ed in the after periods of the fever. An occasional stool was procured by a mild glyster ; while a purgative medi- cine was given with extreme caution. Apprehensions were entertained, that the operation of a purgative would rivet the spasm of the extreme vessels, and increase de- bility, one of the supposed direct causes of death, in fever. These apprehensions may stiil bias the practice of manv, as they certainly did bias .nine, for a long time. A typhus fever with symptoms more than usually ma- lignant, appeared in Edinburgh, in summer 1779. 11 originated in the hospital of the prisoners of war, who were confined in the Castle. Notwithstanding the em- ployment of every precaution which prudence could sug- gest, the spreading of the disease was not altogether prevented. Several of the troops, then in the garrison, and some of the inhabitants of the city, were seized with the fever. -8 ON PURGxVTIVE MEDICINES In summer 1781, a fleet of merchantmen from Jamaica, with their convoy, consisting of several ships of war, came to anchor in Leith roads. -The passage had been tedious, the crews were sickly, and they had been for some time, on short allowance of provisions. Nevertheless, they were obliged, from the circumstances of the war, to avoid the channel, and come round by the north of Scot- land. From the beginning of July, to the ninth day of Au- gust, no less than one hundred and twenty-six men in fe- ver, were sent ashore, from his Maiesty's ship Suffolk, one of the convoy, of whom twenty-three died. And of forty men in fever, who were landed from his Majesty's ship Egmont, another of the convoy, on the tenth, ele- venth, and thirteenth of July, eight died. Such of these men, as could not be accommodated in a temporary hospital, were quartered in Leith, two, three, or four being billeted in one house ; and many of the in- habitants were seized with a fever, of the same kind with that under which the sailors laboured, and it continued to prevail for many years in the town. These circumstances, the proximity of Leith to Edin- burgh, and the great and daily reciprocal intercourse which subsists between the inhabitants, will account for a typhus fever of greater than usual malignity, which ap- peared in Edinburgh about this time, and which continued to prevail for some years afterwards. Being frequently disappointed in curing this fever by the mild antimonials which were then employed, I was induced by similar views to use the calx antimonii nitrala ; Pharmacofi. Edinburgen. editae anno 1774, of Avhich I gave four or six grains for a dose, which was repeated three or four times, at an interval of two hours between IN TYPHUS FEVERr 29 each dose, unless sweating, vomiting, or purging, Avere previously excited. I resorted to this practice, towards the end of the fever, and in the treatment of those patients only, of whose re- covery I was exceedingly doubtful. I entertained hopes, that a favourable crisis might be procured, by the efficacy of the antimonial; and, in the mean time, I supported the strength of the patient, by the moderate vise of wine. This antimonial remedy was not ineffectual; but I re- marked that it was beneficial only, when it moved the bel- ly. The stools were black and fetid, and in general co- pious. On the discharge o7 these, the low delirium, tremors, floccitatio, and subsultus tendinum, which had prevailed, abated in some cases ; the tongue, which had been dry and furred, became moister and cleaner, and a feeble creeping pulse acquired a firmer beat. Reflecting afterwards on these circumstances, it oc- curred to me, as the purgative effect appeared to have been the useful one, that any purgative medicine might be substituted, for the calx antimonii nitrata; and that by this substitution, the unnecessary debilitation of an ex- hausted patient, by vomiting and sweating might be avoided. More extended experience confirmed these conjec- tures ; and I was gradually encouraged to employ purga- tive medicines early, in typhus, ana to repeat them in the course of the disease. And after having long a^d strictly directed my attention to this point of practice, I am now thoroughly persuaded, that the fu'.l and regular evacua- tion of the bowels, relieves the oppression of the stomach, and mitigates the other symptoms of fever. Farther, I am disposed to refer the usefulness of pur- C 2 • 30 ON PURGATIVE MEDICINES gative medicines, to their acting through the whole ex- tent of the intestines, and to their consequent moving and conveying off feculent matter rendered offensive and ir- ritating, by constipation, and by the changed nature of the fluids secreted into the intestinal canal; a change which appears to take place in the febrile state. If these things be so, how inefficacious must be the operation of a glyster, the stimulus of which, nearly limited to the rectum, cannot be adequate, to procure the full evacua- tion in question! Accordingly, it is now some years since I have left off dmost entirely, the praitice of ordering emetics and glysters in fever. I trust to a purgative, to ensure a regu- lar alvine evacuation. For this purpose, however, a daily purgative is not always required. Thus, avoiding the harassing distress, which generally accompanies the ope- ration of an emetic given to patients in a state of fever ; as well as the trouble and fatigue, which the exhibition of glysters occasions; I think I conduct the treatment of ty- phus fever, to a favourable issue, with greater certainty, and with more ease and comfort to the patient. This practice, which I have found useful, and which respects only the state of the intestinal canal, supersedes by no means, usual attention to thi various other means of cure, employed in fever. I am even ready to allow, nlthough I exclude emetics and glysters from my general practice in typhus, that peculiar circumstances may, oc- casionally, make both the one and the other necessary. I cannot, however, omit remarking, that for some years past, I find wine less necessary in fever, than I formerly thought it was. This maybe owing to the fever which has prevailed of late, being less malignant than it was :;ome years ago ; or to the effect of the purgative medi- IN TYPHUS FEVER. 31 cines which I have employed, and which may obviate symptoms of debility, as well as remove them. If this be a just view of the case, the plain inference is, that the employment of purgative medicines, to pre- serve a regular state of the belly, does not increase the debilitating effects of fever. This doctrine, I know, is contrary to the opinion generally received; but I am con- fident, that it is consonant to the fact. The object to be attained, is the complete and regular evacuation of the offensive feculent matter collected in the bowels, in the course of fever. Within this limit, the practice is safe and salutary. Of this 1 am assured, that I have had much satisfaction in the prosecution of it; and have not in a single instance, had occasion to regret anv injury or bad consequence proceeding from it. For I am not an advocate for its being carried to the length of exci- ting unusual secretion into the cavity of the intestines, and of procuring copious watery stools. Such indeed, while they are not requisite, might increase the debility so much and so justly dreaded. In further recommendation of the practice, I observe that it is conducted with ease, and a tolerable degree of certainty, The precise effect of purgative medicines, may not, in every instance, be altogether under command ; but in general it is so, if, to a little experience, we join a previous knowledge of peculiarities in particular con- stitutions. At any rate, the subsequent doses of purgative medicines, and the repetition of them, will be regulated by the effect of preceding ones. It is of importance, to consult in all respects the quiet and comfort of patients, in fever. On this account, the exhibition of purgative medicines should be so timed, that their effects may be expected during the day, when proper assistance can be best procured to the patient. 32 ON PURGATIVE MEDICINES, &C. The purgative medicines which I have chiefly employ. ed in fever, are calomel, calomel and jalap, compound powder of jalap, aloes, solutions of any mild neutral salt, infusion of senna, and sometimes the two last mentioned medicines conjoined. In the Appendix, No. II. I have inserted several de- tailed cases, in illustration of the utility of purgative medi- cines in fever, and of the manner in which I have used them. 33 CHAP. II. OBSERVATIONS ON THE UTILITY AND ADMINISTRA- TION OF PURGATIVE MEDICINES, IN SCARLATI- NA. No disease has attracted greater attention, 4han scarla- tina. Its frequent appearance, and its fatal tendency, have claimed the exertion of practitioners, and have stim- ulated them to enquire into the nature of the disease, and the most successful mode of treating it. The ancients do not seem to have had any very accurate views, with regard to scarlatina. Various authors, from an early period of the sixteenth century downwards, mention an ulcerated sore throat, accompanied with a scarlet efflorescence on the surface of the body, as frequently desolating different parts of the continent of Europe. Sydenham describes scarlatina, as we often see it, to be a mild disease, requiring only common attentions, quiet, and simple diet; and more likely to be aggravated than relieved, by the •' nirma medici diligentia." Iluxham and Fothergill afterwards wrote on scarlatina, and the ulcerated sore throat; and since their time, many British and foreign physicians have published their senti- ments, with regard to this disease ; and have spoken of it under the title of scarlat.na anginosa. 34 ON PURGATIVE MEDICINES These different accounts of scarlatina, have given rise to much nosological discussion, respecting the identity of the disease, as described under different names. Little doubt is now entertained on the subject, so far as scarlati- na, and scarlatina anginosa are concerned It appears to be admitted, that the affection of the throat in the lat- ter may give a variety, while the diseases are the same in their origin, course, and termination. Greater uncertainty prevails in regard to this question, respecting the ulcerated sore throat, or cynanche malig- na, the name by which it is now generally known. This very namj may have contributed to confirm the opinion, that it is a distinct disease from scarlatina ; an opinion, which, sanctioned by authors of respectability, and by our intelligent and latest nosologist, has been, and is still prevalent. It is altogether foreign to my purpose, to engage in this controversy ; and the more so, as I apprehend that the distinction, the subject of it, begins to lose ground, as our knowledge of the disease becomes more compre- hensive and accurate. The time may not be far distant, when scarlatina will be received as the generic disease, the full history of which, will include the adventitious smptoms as they appear in scarlatina anginosa, and in cynanche maligna; in the same manner as the history of variola comprehends the varieties of the distinct, and of the confluent small pox. . Scarlatina, as an epidemic, does not always assume precisely the same appearance. This diversity depends in part, upon the varying nature and constitution of scar- latina itself, independently of all extrinsic circumstances ; in part, upon certain contingencies, which are common to all the inhabitants of a whole district of country, such as the season of the year, the temperature of the air, the IN SCARLATINA. 35 kindliness or inclemency of the weather, together with other unknown puauties of the atmostphere ; and in part, upon circumstances which apply to individuals, subjected to the disease ; their general habit of body and constitu- tion, their particular state of health, at the time of attack, and their situation, with respect to lodging, ventilation, and cleanliness. These circumstances concur in modifying the character of the epidemic ; and while they introduce a varietv in the symptoms of scarlatina, they likewise point out the necessity of making a corresponding change in the me- thod of cure, and of accommodating our practice to the particular nature of the case. Hence various opinions have been entertained, of the nature of scarlatina ; and, apparently, discordant methods of cure have been proposed. Undoubtedly, varying epidemics of scarlatina have led to the practice of blood-letting, in some Instances, and to the rejection of it, in others ; to the adoption of emetics and of blisters, by some practitioners, while others neg- lect and positi eiy forbid them. It is owing to the same cause, that cinchona is warmly recommended and almost exclusively trusted, for the cure of scar atina; while on the other hand, it is reprobated, as tending to induce sloughs, and putrid ulcers in the throat, which it was ex- pected to have obviated and removed. In like manner, purgatives have been condemned as useless, if not dan- gerous, in scarlatina; and lately, the affusion of cold wa- ter over the surface, or the ablution of .the skin, by means of tepid water, have been recomn.ended and practised in scarlatina, according to circumstances, by men, whose opinions have great weight and authority. Thus the young and timid practitioner is distracted, 36 ON PURGATIVE MEDICINES and at a loss what course to pursue, that he may embrace a safe and decided line of conduct. It will be a difficult task, to dispel the clouds that overshadow medical prac- tice in scarlatina. The only way of accomplishing it will be, to give a full statement of the leading symptoms of the different epidemics of scarlatina noticed by authors; and to appropriate to each, the general and topical reme- dies which they require. Whoever embarks in this un- dertaking, and executes it with success, will render an useful service to the public. These reflexions occurred totne, upon turning my thoughts towards the subject of scarlatina ; and I con- ceive them of sufficient importance, to merit the atten- tion which I have bestowed upon them. I proceed now, to the proper object of this paper: in prosecuting which, I beg to be understood, as considering scarlatina, and scarlatina anginosa, to be the same disease, using always the term scarlatina, as including both. And thus, in compliance with common custom, and for a rea- son which will afterwards appear, I shall treat of this mo- dification of the disease, separately from cynanche ma- ligna, of which I shall take distinct notice, in the sequel. An inflammatory diathesis frequently prevails on the first attack, and during the early period of scarlatina For this reason, venesection has been ranked, by some practitioners, among the remedies which ought to be em- ployed, in scarlatina; and it has even been practised with advantage. Possibly too, the existence of the inflamma- tory diathesis, may have disposed other practitioners to give purgative medicines, more freely in scarlatina, than in typhus. But this practice has not been universal; for IN SCARLATINA, 37 many physicians do not admit the good effect of purga- tives, while others deny it altogether, and consider it to be highly prejudicial, by inducing a dangerous and fatal tendency in the disease. This question, one of great importance in practice, is not as yet, satisfactorily decided; although I think the opinion gains ground, that purgatives are useful in scar- latina, either during the whole course, or towards the close of the disease; in which last case they are given, to obviate, or to remove dropsical swelling, a common, and sometimes, a fatal consequence, of scarlatina. Many years ago, when the prejudices against the use of purgatives in scarlatina, were more decided, and more prevalent, than they are at this time, I ventured to employ them. My doing so, was indeed a necessary consequence of the benefit I had experienced from purgative medfcines in typhus. I had learnt that the symptoms of debility which take place in typhus fever, so far from being en- creased, were obviousiy relieved, by the evacuation of the bowels. I was, therefore, under httle apprehension from them, in seanatina. I have never witnessed sinking and fainting, as mentioned by some authors, and so much dreaded by them ; neither have I observed revulsion from the surface of the body, and consequent premature fading, or in common language, striking in of the efflorescence, from the exhibition of purgatives. Accordingly, in treat- ing scarlatina, I have confided much, in the use of pur- gative medicines ; and no variety of the disease, as ap- pearing in dirferent ep'demics, or in the course of the same epidemic, has hitherto prevented me from following out this practice, to the extent which I have found neces- sary. Here, I beg again to caution the reader against the common association of purging, with the use of purgative O 38 ON PURGATIVE MEDICINES medicines ; these are given only in the present case, to remedy the impaired action of the intestines, and secure the complete expulsion of their contents, and thus to pre- vent any accumulation from remaining to aggravate the severity of the symptoms, and produce further source of suffering to the patient. Besides these motives for the exhibition of purgatives I have observed, that the febrile state in scarlatina is more apt to induce costiveness, and to change the nature of the contents of the bowe.s, than it is in typhus. 1 or in most cases of scarlatina, the alvine evacuation has an unna- tural appearance, and. in general, a peculiarly fetid smell. While I have thus found, that purgative medicines mitigate the symptoms of scarlatina, I have also in gene- ral, experienced them to afford the most certain means either of preventing dropsical swellings, and other subse- quent derangements of health, or of removing them, when formed. For this reason I give purgatives, not only during the fever, but ior some time after convalescence. On this subject, it is proper to remark, that the ter- mination of scarlatina cannot be ascertained, from its previous state ; we can form no general conclusion as to the dropsical tendency, from the violence or mildness of the preceding symptoms. 1 have been involved in the greatest perplexity by the appearance of dropsical affec- tion, after the termination of a mild scarlatina. During the progress of scarlatina, practitioners cannot be too much on the watch against unexpected changes, and unfa- vourable appearances. They must never, in the slightest case, lose sight of the ' dil'gentiamedici,'although Syden- ham seems to ridicule this attention, by applying to it the epithet nimia.' IN SCARLATINA. 39 The same activity, however, in the exhibition of pur- gative medicines, is not required in every epidemic, and in every case of scarlatina. In some instances, the belly is moved v/ith ease, and in others, not without difficulty. Scarlatina was frequent in Edinburgh, in autumn 1804-5 In this epidemic, the bowels were peculiarly constipated, the termination in dropsy was frequent, and the mortali- ty great. I have not ascertained the circumstances to which this different state of the boweis in scarlatina, is to be ascribed. But on whatever cause the difference de- pends, it will be necessary for us to adapt our practice in the use of purgatives, to the nature of the prevailing epidemic. It is not perhaps, of great moment, to be solicitous about the selection of purgative medicines in scarlatina. In general, I have chiefly employed those, which I have mentioned in my observations on typhus. Children can- not be always easily induced to take medicines of any- kind. Submuriate of mercury, may. on this account, be proper for them. But we ought to be on our guard against too great an affection of the mouth, from the fre- quent necessary repetition of the mercury. In scarlatina, as in typhus, we should keep in view the procuring the effect of purgatives, during the day, and the avoiding, in this manner, the disturbance of the sick, in the night time. The use of purgative medicines in scarlatina, does not supercede the other sources of relief and comfort, which have been found proper in the treatment of the disease. On the contrary, the good effects of these, and their co- operation with purgatives, will contribute to abate suffer- ing, and avert the danger which follows scarlatina. +0 ON PURGATIVE MEDICINES I have purposely declined entering into any argument respecting the identity of scarlatina, and cynanche malig- na, that I might be at liberty to notice them separately. I am, however, disposed to consider them, as constituting one disease : yet, so long as this is not the general opin- ion, I was unwilling that doubt should arise from this quarter, respecting the use of purgative medicines in scarlatina. For while in this, the more simple form of the disease, purgatives are considered by almost every one as dangerous, they are universally, and altogether condemn- ed in cynanche maligna. Had I therefore spoken in a general way, and seemed to have recommended purgative medicines in all the varieties of scarlatina, my proposal would have been received with such distrust, that the practice which, from a conviction of its utility, I was anx- ious to promote, might have been neglected, and passed from, without a trial of its expediency. But the line which I have taken, will avert this danger. I have stated my practice, of exhibiting purgatives in scarlatina ; I proceed now to consider it in relation to cy- nanche maligna. The extreme debility which is manifest in the malig- nant sore throat, has given rise to a strong objection to evacuations of any k'nd, and particularly to that by purging, in the treatment of it. It wouid indeed appear, that this objection has been urged with ellect, against the use of purgatives even in scarlatina, in consequence of the con- nexion which had been observed to subsist between it and cynanche maligna. For it was imagined, that the danger from cynanche maligna winch supervenes upon scarlatina, a supervention not unfrequent, wou'd be increased, in pro- portion to the debility previously induced by the purga- tives used in scarlatina. But the restricted use of purgative medicines, to the IN SCARLATINA. 41 extent of unloading the bowels only, does not increase this debility, while it relieves the symptoms of the gene- ral fever, and either may thus prevent its termination in cynanche maligna, or alleviate the attack. Writers also condemn purgatives in cynanche maligna, from an apprehension, that they serve to diffuse the acid matter, descending from the throat into the stomach, over the whole surface of the intestines, and thus to increase the source of contagion, and to aggravate the irritation which arises from the presence of this acrid matter. But in stating this objection, they do not consider, that this matter accumulating, and becoming more offensive, in consequence of retention in the stomach and bowels, will produce greater mischief and greater irritation, than can possibly proceed from the gentle operation of a purgative medicine ; while they lose the benefit ensuing from the movement and expulsion of an acrimonious feculent mass. An exhausting diarrhoea, or even adysentry, it is said, are troublesome and common consequences of cynanche maligna; on which account, purgative's are conceived to be injurious. But I cannot see the force of this objection. For were I to devise a means of preventing these conse- quences, or of removing them when they had taken place ; none more likely would occur to me, than the use of those very purgatives, which are thus so dogmati- cally proscribed. While I employed them, however, I would carefully limit their effect to the express purpose of unloading the bowels, and shun tht inconvenience of inducing weakness, by full purging. Under these impressions, I have formed a favourable opinion of the utility of purgative medicines in cynancae maligna. But let me here caution the reader, that in D 2 \2 ON PURGATIVE MEDICINES giving this opinion, I have departed from the rule which I had formed to myself. It is a theoretical opinion, and not so fully supported by experience, as to enable me to deliver it with confidence. The peculiarly healthy, airy, and dry site of Edinburgh ; the general cleanliness andcomfoit which the inhabitants enioy, since the extension of the royalty, and the erection of the houses in the New Town, will account for the rare appearance of cynanche maligna among us, and for my good fortune, in having witnessed few instances of it. I have said, that the opinion of purgative medicines be- ing useful in scarlatina, gains ground. Accordingly, others, besides myself, have employed them with con- siderable freedom. But these practitioners do not seem to have set a proper value upon this mode of treatment; and have been inclined to impute benefits, evidently re- sulting from purgatives, to other medicines which they may have used at the same time. Mr. Oaxly of Pontefract, and Dr. Binns, in conducting the cure of scarlatina, which appeared among the children in the school at Ackworth, gave calomel in repeated doses, to an extent beyond former example. And the utility of the practice was self evident, and acknowledged. Yet Dr. Binns, in the subsecment part of his account of this epi. dernic, derogates from the efficacy of purgatives, and at- tributes much of his success, and his success was great, to other remedies, particularly to gargles. In the Gentleman's Magazine for June 1772, an anony- mous correspondent mentions an epidemic scarlatina which prevailed at Ipswich. His letter is a medical curi- IN SCARLATINA. 43 osity. It is little known, and is not now readily accessible, as the depository of it has become scarce, and is generally to be found only in public libraries. I insert it therefore at length, for the gratification, I may hope, for the instruc- tion of my readers It runs thus ; " Mr. Urban, " If the following comports with the design of your use- ful collection, please to give it a place the first opportunity, and you will obiige a constant reader." To Dr.------, London. « Sir, " Notwithstanding you are an absolute stranger to me, your character as a physician, and as a candid, humane, and benevolent gentleman, has emboldened me to trouble you with the contents of this, without any further apology, than the goodness of the intention. " The ulcerated sore throat, and scarlet fever, has been very rife in this place and the neighbourhood, for some months past, and has been, in a considerable number of instances, fatal. It has in every respect, answered the de- scription given of it by Dr. Fothergili; and therefore a repetition of the symptoms and appearances would be needless I shall only i elate what appears to me to be the predisposing cause, the proximate cause, the pabulum morbi, the treatment I have given it, and the success. " The predisposing cause is, whatever generates a quan- tity of ac id bile in the primse vise. " The proximate cause, is the sudden transition from heat to cold, and the contrary. This had been so very evident, that whenever the wind has changed from the south or west to the north or east, a considerable number 44 ON PURGATIVE MEDICINES. of people have been almost instantly seized with the dis- ease. « The pabulum morbi is, acrid bile. This is certainly known by the immediate cure cf the sick, who apply very soon after the seizure, and take such medicines as act smartly on the stomach and bowels ; by the great relief all others find by vomiting and purging ; and is confirmed by the contents of the evacuations, which are little else but acrid or putrid bile. " The treatment I have given the sick is, immediately to evaluate them, in proportion to the strength of the pa- tient, the violence of the symptoms, the time of the disease, and the particular state of the constitution. " The evacuating medicines I have given, are the fol- lowing : " Pecipe—Ras. c. c. antimon. crud. pulv. an ; p. ae. calcinentur simul in crucicuo donee fumi suhphuris eva- nescant, et regulus antimonii manifestus sit; deinde ab igne remove, etin pulverem subtilissimnm redige. " Pecipe—Pulv. supradict. partes tres.—Mercurii dul- cis sexies sublimati, et subtilissime triturati, partem unan.misce. " Of this I have given from half a scruple to half a drachm, to adults, and have found it constantly to answer the intention. But to chiidien, I have given the mercu- rius dulcis only, from five grains to a scruple ; and if the symptoms are very violent, and the child very robust; I have given even a half a drachm with the greatest sac- icss. After the sick has had severa. stools, I give him the fohowing julep: IN SCARLATINA. 45 « Recipe—Mann, aq. pur. unciis septem ; solut. unci- am, crem. tartar, drachmam, a p nucis moschat. unciam dimidiam. Mr. Capiat cociilearia tria, quartis horis, if he is an adult; if a child, according to his age and strength. It is an agreeable medicine., and answers the intentions of keeping the bowels lax, the bile insipid, and the mouth and fauces quite clean. " If the patient is in the first stage of the disease, I di- rect him to gargle fre ;uently ,with Spiritus Mindereri in cold water, which prevents an ulceration : if in the second stage, with Spiritus Mindereri, tincturae myrrhas uncia dimidia, decocti hordeati, unciis septem. M. If in the third, and the sloughs be :in to separate, with mel rosar. tincturae myrrhae.—corticis Peruv'an. a. uncia dimidia, decoct, hordeati unciis septem, M. and made just tepid. " If the ears are affected. I have used the last mention* ed mixture, as soon as they discharge, just tepid, as an in- jection, several times a clay. " After the sloughs are all off, and the fever gone, I have found it necessary, in some few cases, to give of the following tincture; Kecipe—Infus. corticis Peruviani Huxhami, uncian unara et dimidiam, —Rhabarbari spirit. unciam dimidiam ; drachmam unam vel drachmas duas, bis in dies, horis medicinae in aqua pura. " The liguors I have used, have been water-gruel, bar- ley-water, chicken water, sage tea, rosemary tea, or baum tea, occasionally Of these I have recommended the sick to drink freely, cold or just tepid ; keeping them at the same time cool, and admitting fresh air freely into the room, remembering always Piso's maxim, " putredo fit a calore alieno et interno." " The success has been beyond my most sanguine ex- 46 ON PURGATIVE MEDICINES pectations; I have had considerably more than one hun- dred patients, and have not buried one." " Ipswich, June 3." " This letter was written some months ago, since which time the number of patients have increased to near three hundred, with the same success." The facts here set forth, afford an uncontrovertible evi- dence of the safety and efficacy of the practice of exhibit- ing purgative medicines, not only in scarlatina, but even in cynanche maligna; for the epidemic described in the above letter, appears to have been of this nature. Dr. Ford, physician in Chester, has informed me, that Mr. Rodbard, of Ipswich, an ingenious practitioner and respectable man, is the writer of this letter. In a late letter to Dr. lord, Mr. Rodbard inter alia thus expresses himself, " I have not seen Dr. Hamilton's treatise, but I have seen no reason to deviate from my plan of treating scarlatina anginosa; and my success, since I adopted it, has been constant and uniform." Mr. Rodbard verifies my observation, that different epidemics of scarlatina, require a variety of the same practice. In the scarlatina of 1772, at Ipswich, the bow- els appear to have been easily moved. But I believe the gentle purgative employed in the course of that epidemic, for I do not take into account the highly active one given in the first instance, would have been of no avail in the scarlatina which prevailed in Edinburgh, in 1804. I give a narrative of this epidemic, as it appeared in George Herriot's hospital, as well as the cases of a few of the patients who laboured under it, in the Royal Infirmary. These will be found in the third number of the subjoined Appendix.—They illustrate my mode of practice, both in scarlatina, and in its consequences ; for I apprehend other derangements of health, besides dropsy, arise from IN SCARLATINA. 17 it. Several years ago, I witnessed a case of scarlatina, in which violent epileptic paroxysms accompanied drop- sy, the consequence of the disease. The dropsy was quickly removed by brisk purgatives, and the epileptic fits immediately ceased. 48 CHAP. III. OBSERVATIONS ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES IN THE MARASMUS WHICH APPEARS IN CHILDHOOD AND EARLY YOUTH. I comprehend under the general title, marasmus, a variety of symptoms which affect the young of both sex- es. A sluggishness, lassitude on slight exertion, depravity and loss of appetite, wasting of the musciEai flesh, full- ness of the features and paleness of the countenance, swelling of the abdomen, an irregular and generally a costive state of the bowels, a change in the colour and odour of the feces, fetid breath, swelling of the upper lip, and itching of the nose, mark the beginning of the disease. When these symptoms have continued for some time, they are followed by alternate paleness and flushing of the countenance, heat and dryness of the skin, feeble and quick pulse, thirst, fretfulness, increasing debility and disturbed sleep, during which the patients grind or gnash their teeth, and are subject to involuntary starting, and twitching of different muscles. Every case of marasmus does not necessarily include all the symptoms which I have enumerated. Different ON PURGATIVE MEDICINES, &C 49 combinations of them give a variety of the disease, which is, however, in general, readiiy known and distinguished. Marasmus appears most commonly among weak and infirm children, whether they are so from delicacy of con- stitution, or from incidental causes. It is particularly pre- valent in large and populous cities, where children are de prived of ready access to exercise in pure air, and sicken and pine in the nursery ; or when they are confined in crowded and airless school-rooms, whither they are sent, partly for the purposes of education, and partly, to use a common phrase, with the view of being kept out of harm's way. Children also, who are employed in manufactories, where their occupation and confinement are such as to weaken and enervate them, are liable to be attacked with this disease. Irregularity in diet and improper food, also give rise to marasmus. We accordingly observe it to prevail most commonly in autumn, the season which af- fords opportunity for eating unripe fruit and vegetable articles from the garden. In proof of the operation of these causes, I remark, that I have held the office of Physician to George Herriot's Hospital for two and thirty years. During this long peri ■ od, I scarcely recollect an instance of this marasmus among the children entertained in that institution. This may be attributed to the healthy site of the building ; to the cleanliness and free ventilation of every part of it; to the wholesome nourishing food of the children, and to their exposure to pure air while enjoying their infant sports. Marasmus has been generally attributed to the presence of worms in the alimentary canal. This supposition, however, is questionable. Ascarides, Teniae, and Lum- brici, are the worms most commonly found in the hu- man intestines. E 50 ON PURGATIVE MEDICINES Ascarides, which are often passed in great numbers by children when at stool, are not accompanied by the symp- toms of marasmus. Except an itching about the anus, they give little other uneasiness. The tenia or tape worm, the presence of which is known by peculiar symptoms, which are the source of much suf- fering in after periods of life, is altogether unknown in in- fancy and childhood. The lumbricus, or round worm, therefore, must be the generally supposed cause of the symptoms of marasmus. Medical gentlemen, who have practised in tropical cli- mates, speak much of the lumbricus, and mention the number of them that is occasionally passed to be very great. There may be something in the climate, soil, or state of the air of these regions ; in the mode of life or constitution of the inhabitants, with which we are unac- quainted, which may account for thistircumstance. But in our cooler latitudes, no such instances of numerous lumbrici have been noticed. On the contrary, after the best directed course of anthelmintic medicines, when the symptoms of the disease are going off", no lumbrici have been seen, unless we admit, that the worms, destroyed by the efficacy of the medicines, constitute the unnatural and fetid feces which, in such instances, are voided in great abundance. This admission, however, is not to be readily granted; for similar feces are passed upon the exhibition of an early purgative, and before any specific vermifuge is em- ployed. Farther, the presence of lumbrici in the bowels is by no means an unilorm cause of bad health. They have been known to exist in the mtestinai canal without any disease ensuing. These instances are not rare, and are not con- IN MARASMUS. 51 fined to childhood. They militate against the received opinion, that lumbrici, withinlhe intestines, are the cause of marasmus ; for if they are so in a single case, they should be so in every one. This opinion, however, that worms exist, and exert a baneful influence in the intestines, has been so prevalent for ages, that a great many anthelmintic medicines, some peculiar to the nursery, others to the regular practitioner have been mentioned and extolled. Of these, some have been considered as specific poison to the insect, and others are conceived to destroy it by mechanical friture. Most of them have had their partisans for the day, and have passed in succession through the ordeal of experience, into oblivion. The utility of such anthelmintics as have been found to be most beneficial, has, in my opinion, been in proportion to the purgative powers which they possessed. When I consider the langour and la&eitude vhich pre- cede this marasmus ; when I recollect the constitutional or acquired debility of those who are more particularly exposed to be affected by it, instead of adopting the com- mon opinion, of its being occasioned by worms, I am more disposed to think, that a torp;d state, or weakened action of the alimentary canal, is the immediate cause of the disease; whence proceed costiveness, distension of the bowels, and a peculiar irritation, the consequence of re- mora of the feces. I have accordingly been long in the habit of employing purgative medicines for the cure of this marasmus ; the object is, to remove indurated and fetid feces, the accumulation perhaps of months ; and as this object is accomplishing, the gradual return of appe- tite and vigour mark the progress of recovery. The history of the disease, from the first indisposition to the appearance of more urgent symptoms, disposes me 2 ON PURGATIVE MEDICINES to consider it as consisting of two stages or periods ; the incipient, and the confirmed. The first period commen- ces with the disease, and continues to the accession of the febrile symptoms. These usher in the confirmed stage, which continues to the end. This is not a frivolous re- mark ; it is of use in practice. In the incipient stage, the bowels are not altogether torpid and inactive, neither are they overloaded with accu- mulated feces Mild purgatives, therefore, repeated at proper intervals, effect a cure. They preserve the bow- els in proper action, carry off feces which had begun to be offensive and hurtful, and prevent farther accumula- tion. In selecting purgative medicines, we must flatter the taste of our young patients. Powder of jalap is not alto- gether unpleasant. The mild neutral salts, dissolved in a suitable quantity of beaf tea, are also convenient purga- tives ; but calomel will prove, on several accounts, the most certain and useful remedy of this kind. Neglect, on some occasions, and too great confidence in inert medicines on others, allow the confirmed stage of marasmus to steal on imperceptibly. Manifest danger now threatensjhe young sufferer, whose remaining flesh, and strength are rapidly wasted by the supervening fever; while prostration and depravity of appetite withhold ne- cessary nourishment. And at the same time, the more inactive bowel, and greater bulk of feculent matter, throw additional difficulties in the way of a cure. Under these circumstances, I adopt active practice, in the view of stimulating the intestines, and of putting the collected mass in motion without delay. I find these ends are best obtained by giving small doses of the purgative IN MARASMUS. 5o medicine which I employ, and by repeating these fre- quently ; so that the latter doses may support the effects of preceding ones,—When the bowels are once opened, stronger purgatives, given at longer intervals, will ac- complish the cure. I observe calomel to be equally useful in this, as in the inciph-iu state of the disease ; but great attention must be given during the exhibition of it. Without this, as the fetor of the breath prevents us from recognizing the mer- curial fetor accurately, the mouth may be affected unne- cessarily and unexpectedly. While I thus give appropriate purgative medicines, I find it necessary in order to have full information of their effects, to inspect aaily what is passed at stool. The smell and appearance of the feces are a criterion of the progress we make in the cure, and direct the farther administration of the purgatives. This inspection is the more necessary, as Ave cannot expect the information we want from our little patients ; and we will often look for it in vain from the attendants, whose prejudices, and whose ignorance of our views, prevent their seeing the propriety of the en- quiry. During the prevalence of the disease, the feces are dark, fetid, and varying from a costive consistence, to that of clay, and are often fluid ; and such they appear upon the first exhibition of the purgative medicines. I observe that the recovery of the sick keeps pace with the return of feces of natural colour, form, and smell; a change which the repetition of purgatives does not fail to pro- duce. While I give purgative medicines after this manner, in this stage of marasmus, in which the obstinacy of the dis- ease is sometimes great, and the danger attending it im- E 2 54 OX PURGATIVE MEDICINES minent, nourishing food, of light and digestible quality , and suited to the taste of the patient, and the moderate use of wine, are much wanted. For some time after the symptoms have disappeared, it is expedient to continue a mild stimulus to the bowels. As they have recently suffered, and have been weakened by over distension, they are apt to favour subsequent accu- mulation of feces, the forerunner of a relapse, which is to be dreaded the more, as the patients have been weakened by the previous disease. This gentle solicitation of the alvine evacuation, for it ought to be gentle, is not attended with danger; on the contrary, it is the greatest promoter of recovery in this case, with which I am acquainted. It relieves the stom- ach, and improves the appetite and digestion. Besides, nothing more is intended by this practice, than to establish a regular action of the bowels, after long constipation, by procuring dally one or two easy motions, which are indeed at all times necessary to the healthy condition of child- hood. With this precaution, I do not feel the necessity of em- ploying tonic and bracing medicines to complete the cure; this object is readily obtained, in general, by the use of light nourishing food, and by the patient being much in the open air. I do not, however, say that strengthening medicines may not be useful towards the close of the disease, and many practitioners set a value upon them. Lime-water, infusions of vegetable bitters, and chalybeates, are of this description ; and, provided they do not, by any peculiar effect on the stomach, prevent nourishment being taken, will advance the return of the tone and vigorous action of the stomach and alimentary canal. IN MARASMUS. 55 I have thus endeavoured to unfold the opinion I enter- tain of this marasmus, and of the causes which induce it; and to explain the method of cure which I have employ- ed for a great length of time, with success, in my private practice. As marasmus proceeds from symptoms of slight indis- position, through a series of others which become daily more and more obstinate and dangerous ; as the first de- viation from health is easily obviated by the stimulus of purgative medicines, which brings the sluggish bowels into regular action, and evacuates their contents ; and as the disease attacks the young and thoughtless, who can hardly explain their feelings, it behoves mothers, and nurses, and superintendants of nurseries and of manufac- tories, to whom the care of the young is committed, to watch over their charge with assiduity. Prostration and depravity of appetite, a changing complexion, tumefaction of the abdomen, scanty and unnatural stools, and fetid breath, indicate approaching danger. When these there- fore, are observed, assistance should be asked; by the prompt interposition of which much eventual distress, and even death itself may be prevented. But other considerations weigh with me also, when 1 call for this assiduity. Marasmus has a close connexion with other formidable diseases, and either precedes or seems to accompany them ; of these, I shall at present notice two, hydrocephalus and epilepsy. Hydrocephalus internus, the bane of infancy and of childhood, a disease big with much suffering, and of a fa- tal tendency, has at all times occupied the attention of physicians. They have endeavoured to investigate its 56 ON PURGATIVE MEDICINES nature, to assign the causes which induce it, and to pro- pose curative indications. Different sentiments on these subjects have led them to employ numerous and discor- dant remedies. Nevertheless, even now they are not at one as to the causes of hydrocepha'us, so involved are these in obscurity. Neither have they made the most distant approaches towards the discovery of a certain reme- dy for it. This much is known, that hydrocephalus often steals slowly on, with symptoms resembling those of incipient marasmus. Till some better theory, therefore, is estab- lished, it is not unreasonable to suppose, that the maras- mus, of which I have treated, may on some occasions give rise to hydrocephalus, by impairing the vigour of the constitution, and by favouring serous effusion into the ventricles of the brain. This conjecture merits the greater attention on this account, that while the symptoms of hydrocephalus re- semble those of incipient and even of confirmed maias- mus, they have been removed by the diligent exhibition of purgative medicines. The truth of this observation has been repeatedly confirmed in my pi irate practice, and it affords an additional reason for the exercise of watchful attention, to prevent the confirmed state of marasmus which may, in more instances than we are aware of, have, been the forerunner if not the cause of hydrocephalus. Epilepsy, than which no disease is so distressing to the patient, and perplexing to the physician, often appears hi childhood. It acquires a hold, and is confirmed by the repetition of the fits, till their frequency, and the force of habit fix it, and make it a constitutional disease for life. It is not my present purpose to enquire in what manner IN MARASMUS. 57 the functions of the organs more immediately affected by epileptic paroxysm are influenced, so as to give perma- nency to the disease. The uncertainty of the theories proposed on this subject, and the little benefit that arises from them in practice, hold out little inducement to en- ter on the discussion. It is however, I believe, generally understood, that the first attacks of epilepsy are not always idiopathic, but are frequently the effect of particular irritation of the mind or body. There are many instances of irritation of the body inducing epilepsy. When no other is evident, the loaded intestine and the change induced on its contents in the course of the marasmus, of which I have spoken, may be suspected of giving the irritation in question. In fact, practitioners have had this circumstance in view ; for they enumerate worms in the intestines, or marasmus, as 1 understand their language, among the causes of epilepsy. Surely, therefore, this consideration suggests another cogent reason for watching the rise and progress of marasmus. And it will induce us on the first attack of epilepsy in children, arising from an uncertain cause, to set on foot the most decided and active course of purgative medicines; and not peradventure to allow the disease to strike root, while we are idly employed in the exhibition of inert and useless vermifuge medicines ; or are groping in the dark in quest of other causes of the disease, or of uncertain remedies for their removal. In the fourth number of the appendix, I give the his- tory of two cases of marasmus from the records of the Royal Infirmary. And in the same number, I insert also communications from Mr. James Russell and from Mr. Benjamin Bell, in confirmation of the connexion that sub- sists between the marasmus of infancy, and hydrocephalus, These communications will be read with interest. 58 CHAP. IV. ON THE UTILITY AND ADMINISTRATION OF PURGATIVL MEDICINES, IN CHLOROSIS. The young of either, but particularly of the female sex, are exposed, about the age of puberty, to a series of symptoms!, which, although slight in the beginning, become by slow degrees, abundantly distressing and se- vere. They are ushered in by a disagreeable breath, or exhalation from the mouth, not unfrequently of a feculent odour'; by acid and fetid eructations, by prostration, and depravity of appetite, marked by an aversion to usual food, and a desire for substances, which are not digestible, such as chalk, cinders, sand. These symptoms are generally preceded by costiveness, which prevails throughout the disease. A rosy complexion now gives place to a pale, and some- times to a greenish, and at other times to a yellowish colour of skin. The lips and gums exchange their ver- milion tint for a death-like paleness; the eyes are dull, and the inferior part of their orbits is puffy, and of a dark hue ; the motions beeome languid and feeble ; the pulse, which is generally small and slow, is readily excited to a quick and irregular beat; palpitation of the heart, and hurried and labouring respiration are brought on by slight exertion ; syncope often occurs ; head-ach, vertigo, dul- ness, and impaired memory aad judgment afterwards su- ON PURGATIVE MEDICINES, &C. 59 pervene. To these succeeds a peevish and recluse turn of mind, which makes the unhappy sufferer shun society, and court darkness and solitude. In the progress of the disease, the flesh becomes loose and flaccid, the urine is diminished, and the perspiration seems to be checked. Seiious effusions into the cellular membrane, produce at first oedema of the lower extremi- ties, and afterwards anasarca. Languor and debility con- tinuing, death, in some instances, closes the scene. In the female, these symptoms are commonly accompanied with irregular or suspended menstruation. Different authors arrange these symptoms indiscrimi- nately, under different names, Chlorosis, Leucophlcg- matia, and Cachexia ; whicn are, in medicine, therefore, nearly synonymous. Chlorosis has attracted the notice of the earliest medi- cal writers, and various opinions respecting its nature and causes have been entertained. It is not perhaps necessary at this era, to consider at length, the doctrines ot the humoral pathjlogy, which prevailed in physic, from a remote period and about which the Boerhavian school was so much occupied. The dog- mata respecting spontaneous gluten, the lentor and fluidity of the blood, and the alkaline and acid acrimonies of the fluids do not now arrest much attention. Even in the pre- sent improved state of chemistry, we are little able to ascertain the nature jfthe animal fluids, either in a state of health or of disease ; so as to say, in what the former consists ; or by what deviations the latter is introduced. Nevertheless, to this suppos d cachectis state of the juices, the above mention d symptoms of chlorosis have been r^ Erred > and, to promote a cure, recourse has been 60 ON PURGATIVE MEDICINES had to diluting, incrassating, and strengthening medicines, and rectifiers of peculiar acrimonies, Accordingly, a crude, multifarious, and often inert practice has been adopted ; little calculated for the spee- dy removal of a disease, which gains strength by delay, and which, in some instances, becomes quickly too formi- dable to be cured by any means that can be devised. When the humoral pathology sunk in estimation, other opinions arose, on which the explanation of the symptoms of chlorosis, and the indications for its cure were founded. As chlorosis generally appears about the age of puberty, and in the female, either before, or soon after the first flow of the menstrual flux, many have supposed the re- tention or suppression of the menses to be the immediate cause of the disease. This supposition, however, is liable to objections. We cannot ascertain the precise time, at which the retention of the menses maybe considered as a circumstance con- nected with disease. The age of puberty is not the same in every female: chlorosis may therefore exist, long be- fore the agency of the menstrual flux is felt in the con- stitution. But, opposed to this theory, a still more conclusive argument is drawn, from the circumstance of chlorosis appearing occasionly among the more feeble, and delicate of the male sex ; for although females are attacked more frequently and more severely with chlorosis, yet it is not peculiar to them. For these reasons, this doctrine is now generally re- jected. Another, founded on the state of the genital or- gans, occupies its place ; it comes from most respectable authority, and it has obtained many proselytes. IN CHLOROSIS. 61 Dr. Cullen thus expresses himself in paragraphs M, MI, Mil, Mill, of his First Lines of the Practice of Phy- sic ; " These symptoms," namely, some of those which I have enumerated above, (and which the Dr. details,) " when occurring in a high degree, constitute the chloro- sis of authors; hardly ever appearing separate from the retention of the menses ; and attending to these symptoms, the cause of this retention, may, I think, be perceived. " These symptoms, manifestly shew a considerable laxity and flaccidity of the whole system, and therefore give reason to conclude, that the retention of the menses accompanying them, is owing to a weaker action of the vessels of the uterus, which therefore do not impel the blood into their extremities, with a force sufficient to open these, and pour out blood by them. " How it happens, that at a certain period of life, a flac- cidity of the system arises in young women, not generally affected with such weakness or laxity, and of which, but a little before, they had given no indication, may be diffi- cult to explain ; but I would attempt it in this way. " As a certain state of the ovaria in females prepares and disposes them to the exercise of venery, about the very period at which the menses first appear, it is to be presumed, that the state of the ovaria, and that of the ute- rine vessels, are, in some measure, connected together ; and as, generally, symptoms of a change in the state of the former appear before those of the latter, it may be inferred, that the state of the ovaria has a great share in exciting the action of the uterine vessels, and in producing the menstrual flux. But analogous to what happens in the male sex, it may be presumed, that, in females, a cer- tain state of the genitals is necessary to give tone, and F '2 ON PURGATIVE MEDICINES tension to the whole system ; and therefore, if the stimu- lus arising from the genitals be wanting, the whole sys- tem may fall into a torpid or flaccid state, and thence the chlorosis and retention of the menses may arise." " It appears to me, therefore, that the retention of the menses is to be referred to a certain state or affection of the ovaria ; but what is precisely the nature of this affec" tion, or what are the causes of it, 1 will not pretend to explain ; nor can I explain in what manner that primary cause of retention is to be removed. Dr. Cullin afterwards entertained and promulgated the opinion, that the retention of the menses always accom- panied the symptoms of chlorosis. In the uncertainty in which Dr. Cullin admits the af- fection of the ovaria, to which he refers suspended men- struation, as well as the causes of this affection, to be in- volved, he recommends, in conducting the cure of reten- tion of the menses, to obviate particular symptoms, by restoring the tone of the system in general, and by exci- ting the action of the uterine vessels in particular: the same means being subservient to the cure of chlorosis. By this theory, Dr. Cullen attempts to establish, that the retention of the menses, and chlorosis, a. e co-existent diseases, appearing about the age of puberty, and origi- nating in a defective communication of a due stimulus from the genital organs, on which the tone and tension of the whole system depend. Whilst I acknowledge the great importance of the sex- ual organs ; while I perceive that they influence the char- acter and disposition of the acu It of every species of ani- mals; yet I cannot help thinking, that these organs, and IN CHLOROSIS. 63 the doctrines of their functions, have had too great a share in our pathological reasonings, and too great weight, in directing our conduct in the cure of diseases. And having experienced the uncertainty of the usual means which are recommended for the cure of chlorosis, and the utility of another mode of treating the disease, I was led, great- ly hesitating, to question the theory of the Cullenian school on this subject. The assumption, that the state of the ovaria, and that of the uterine vessels have a connexion ; and that the for- mer has a great share in exciting the action of the latter, and in producing the menstrual flux; the presumption, that a certain state of the genitals is necessary to give tone and tension to the whole system, and. that, if the stimulus arising from this state be wanting, the whole system may fall into a torpid, or flaccid state, whence chlorosis may arise ; appear to be merely a begging of the question, and lead to no certain conclusion, as to the nature, or cause of this state of the genitals, the supposed prime mover in the retention of the menses, and in the introduction of chlo- rosis; or to a knowledge of the means of curing either. The partial and temporary suspension of the influence of the genitals, is supposed, according to this theory* greatly to affect the general system. But there are in- stances, where this influence is altogether, and irretrieva- bly lost ; and where no disease ensues. Castrated and spayed animals suffer certain changes of constitution, but they retain the enjoyment of perfect health. And, in our own species, eunuchs, however much degraded in the estimation of society, in consequence of their emascula- tion, are neither a short lived, nor an unhealthy set of men. Reasoning from this analogy, I do not understand how the influence of the female genitals can be so great, as that its partial suspension should occasion retention of the menses, or should induce chlorosis. 64 ON PURGATIVE MEDICINES Another theory has been broached on this subject, which it elucidates by a reference to sexual desire. Insinua- tions, injurious to the purity of mind, and offensive to the modesty of the fair sufferers, have been thrown out. The medical moralist talks of the chlorosis amatoria, and fol- lows up his notion, with apposite counsel. Into what con- tradictions do the refinements of dogmatism lead us! Can passion exist, when the organs which rouse it have not as yet been evolved into action ; or, if evolved, have been afterwards rendered effete by disease ? I could not avoid entering upon these discussions, which I have conducted with all brevity ; I thought it was necessary to show, that the doctrines on the subject of chlorosis, are neither so clear nor so well founded, as to warrant the conclusions, which follow necessarily from them. In this manner, I prepare the reader for the can- did consideration of what I have to propose; a candour perhaps not the less wanted on this account, that my opin- ion of the disease may appear at first sight too simple ; and my practice too little adorned with the show of varied prescription. It would have been fortunate, if medical enquirers bad always followed the progress of diseases, step by step, and viewed them as a whole, from the first deviation from health, to their termination. A contrary procedure has often betrayed them into confusion and error. Thus in chlorosis, the doctrine of the cacochymia of the juices, and that of the peculiar state of the genitals af- fecting the whole system with flaccidity and laxity, are evidently founded on the appearances, which the disease exhibits, when it is fully formed ; and from which appear- ances also, it has its name ; when, at the same time, the history of its incipient state ha* been little regarded. IN CHLOROSIS. 65 The slightest attention to the general history of the dis- ease evinces, that costiveness precedes, and accompanies the other symptoms. Costiveness induces the feculent odour of the breath, disordered stomach, depraved appe- tite, and impaired digestion. These pr elude a sufficient supply of nourishment, at a period of growth, when it is most wanted: hence paleness, laxity, flaccidity, the ner- vous symptoms, wasting of the muscular flesh, langour, debility, the retention of the menses, and suspension of other excretions, serous effusions, dropsy, and death. This view of chlorosis explains some circumstances connected with it. The feeble and delicate of either sex, in whom the languid action of the bowels readily gives place to costiveness, are more exposed to chlorosis, than the robust. Females are, in general, more delicate, and, in certain ranks of life, are more sedentary, than males ; hence costiveness, and chlorosis are more" common with the former, than with the latter. It is well known, that the alvine evacuation is periodical, and subjected to the power of habit; if the regular call is not obeyed, the ne- cessity for the evacuation passes away ; and the call being again and again neglected, habitual costiveness is the con- sequence. Hence, from the feelings of the sex, and fre- quently from the want of proper opportunities, costive- ness, and its attendant chlorosis, are more prevalent among girls, than among boys. Again, the greater ca- pacity of the female pelvis gives more room, for that part of the intestinal canal which is contained within it, to di- late, and, of course, to admit of greater accumulation of feculent matter, which, in proportion to its remora, be- comes more and more abundant, and moie impacted. Hence costiveness is more obstinate, and chlorosis, and other diseases originating in costiveness, are more severe, and are of more difficult cure, in the female, than in the male. F 2 66 ON PURGATIVE MEDICINES Impressed with these considerations, and with a pre- vious favourable opinion of the utility of purgative medi- cines, in other complaints, I, many years ago, adopted the use of them in chlorosis. I expected, by obviating costiveness, to remove the stomachic symptoms, and of course, others that depended upon them. I pursued this practice with the greater readiness, because I had expe- rienced, on many occasions, the uncertain, and protracted cure of chlorosis, by the remedies in common use. Scarcely had I begun the exhibition of purgative medi- cines in chlorosis, when I had the satisfaction to find that the opinion, which I had formed of them, was well founded, and that they proved at once safe, and quickly salutary. As chlorosis proceeds by slow degrees, from its com- mencement, to its confirmed state ; so I found, according to the progress which it had made, that the bowels were more or less easily moved. I therefore varied the strength of the purgative medicines, which I employed, as well as the frequency of their repetition, as this circumstance seemed to require. The unloading the constipated bow- els is the object to be obtained here, as it will be found to be in chorea Sancti Viti; and the means, by which it is obtained, are the same in both diseases. As it will be seen in chorea, so in chlorosis, the quanti- ty of feculent matter accumulated is often very great; and the movement of it, a task of no small difficulty. Of course, the same attention, and assiduity in the ex- hibition of purgative medicines, which I shall point out to be so necessary in chorea, are equally demanded in chlo- rosis, The practitioner, who is not aware of this, and who, yielding to the importunity of his patients, or to the IN CHLOROSIS. 67 caprice of their relations, does not steadily pursue this plan of cure, will be disappointed, his abilities will be called in question, and his practice vilified and neglected. After the due evacuation of the intestinal canal, recove- ry may be promoted by the interposition of tonic medi- cines. If such, however, abate appetite, and induce sick- ness, they will be of doubtful efficacy. In this case, the patient may be directed to trust to the use of nourishing food of easy digestion, and to frequent exposure to the open air, when the weather is good. After all, I am not singular in this practice. The fa- vourers of the humoral pathology have recommended a gentle purge, at intervals, to carry off whatever loads the intestines. Others advise the same practice, that the stimulus excited by the purgative may be communicated to the vessels of the uterus, which have connexion with those of the rectum. But as the objects, in these instan- ces, were only secondary, the direct good effects of pur- gative medicines seem not to have been understood, or to have been lost in other views, directing other treatment. In concluding this subject, I must observe, how much it behoves those, who have the charge of young people, particularly of the female sex, to impress them with the propriety, nay, with the absolute necessity of attention to the regular state of the bowels; and to put it in their power, by the use of proper means, to guard against con- stipation ; and, at the same time, to watch over them, lest, through indolence, they neglect a circumstance, which promoting, in the gay season of youth, the enjoy- ment of health and happiness, opposes a sure barrier against the inroads of chlorosis, always a distressing, and sometimes a fatal complaint. 68 ON PURGATIVE MEDICINES, &C I cannot adduce instances of chlorosis treated by the use of purgative medicines. This disease is not frequent among that class of society, who seek a refuge in a public hospital; while my notes of private cases, although suffi- cient for my own purpose, are too imperfect to afford ma- terials for authentic histories fitted for public inspection. I am however enabled to supply my own deficiency in this particular, by inserting in the fifth number of the ap- pendix, a case of chlorosis communicated to me by my friend Mr. Russell, which he had treated by purgative medicines. This case merits the attention of the reader. 69 CHAP. V. ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES, IN VOMITING OF BLOOD. Vomiting of blood is an alarming and often a distress- ful disease ; but having been generally considered to be symptomatic of other affections, it has not found a place in any regular system of physic. I do not propose to attempt a general history of vomi- ting of blood. But there is one variety of it, which at- tacks females, who are from eighteen to thirty years of age, and it rarely appears sooner or later than these peri- ods, which I shall endeavour to illustrate. As I confine my attention to this variety, the observa- tions which I am about to make, will not apply to hxmat- emesis, which originates in organic affection of the stom- ach, and viscera connected with it, either a constitutional disease, or the consequence of previous irregularities, and intemperance. I have seen several instances of this vom- iting of bio 3d, the cure of which is doubtful in the extreme, and difficult. The attack of the haemorrhagy, of which I am to speak, 70 ON PURGATIVE MEDICINES is preceded by langour, and oppression, both about the chest, and the praecordia; and by a sense of fullness of the praecordia ; by cough, dyspnoea, and sometimes by pain of the breast; by loss of appetite, headach, vertigo, and dis- turbed sleep; the eye is dull, the countenance is ex- pressive of much distress, the pulse is feeble and the bowels are constipated. In this state of impaired health, a particular fit of sick- ness and nausea is the immediate fore-runner of the at- tack of the vomiting of blood. The blood vomited is sometimes florid, and, at other times, black, and grumous. The quantity of blood brought up at one time, varies from a few ounces, to the quantity of a pound or more. The distressing symptoms are relieved by this discharge of blood; but are again aggravated, previously to the return of a similar attack. This disease, under the usual management, is of uncer- tain duration, and of unequal severity. The time of life, at which this haematemesis takes place, and the circumstance of being peculiar to the fe- male sex, have induced practitioners to imagine, that it is intimately connected with the menstrual flux ; the sup- pression of which has been generally considered as the sole cause of the disease. It has been said to be a ha> morrhagy, vicarious of the mensis. The high importance of the uterine system in the ani- mal oeconomy cannot be doubted; but the functions of ' this system are veiled in deep obscurity, and will not', per- haps, be at any time clearly understood. They have occu- pied much of the attention oi the speculative enquirer; and ingenuity has been taxed, to invent theories in expla- nation of them, and of their influence, in health, and in disease. IN VOMITING OF BLooD. 7\ The menstrual flux, the most obvious of the uterine phenomena, has afforded a wide fieid for discussion. It is interwoven with the opinions we entertain of almost every disease, to which the female sex is exposed. Its overflow, or its suppression, are the ready expounders of many symptoms ; the fruitful, though perhaps imaginary source of many diseases. This flux is a constant object of attention to females, who are in general well schooled, as to the importance, and necessity of it. These theories of the schools, and these early impress- ions on the female mind, give a consequence to this sub- ject, and force it upon the notice oi the medical practition- er, who must subscribe to the general opinions respect- ing the menses, and seem to adopt them, although he may question, in some respects, the foundation on which they rest, and the conclusions to which they lead. Too curious a research into the arcana of nature is nu- gatory. These, doubtless lor wise reasons, seem to be placed beyond the ken of mankind. When, therefore, we adopt the views and language of the schools, on points merely theoretical, and deduce practical conclusions from them, it is probable we may err. 1 lor one, am inclined to think, that too much has been imputed to the influence of the menses, in circumstances of disease. In explaining these circumstances, we seem to have reasoned too much on a subject, that is but too little understood. The interruption of the evacuation of the menses fre- quently takes place for a length of time, without prejudice to the health. May not this interruption, therefore, be of- tener the symptom, or consequence, than the cause of dis- ease ? It is not uncommon for females to complain, about the usual period of menstruation ; and if the menses do not appear, the previous disease is hastily attributed to this 72 ON PURGATIVE MEDICINES circumstance. But it may, with equal reason, and with equal probability, be said to have been the cause of the suppression. If these things be so, we cannot but regret theoretical disquisitions, which have, in other instances, as well as in the present one, led us to an attempt of difficult accom- plishment, and of uncertain issue,—the restoration of sup- pressed menstruation; while a different practice, more certain, and more useful, and founded on different views of the case, has been either never devised, or has been en- tirely neglected. I feel myself at perfect liberty to make these reflections; because, in the case now before us, the cause assumed, to account for vomiting of blood, proceeds upon limited, or mistaken information. Suspended menstruation is not a necessary concomitant of haematemesis, which appears when the menses are regular. 1 do not know in what proportion of instances this is the case ; but if it be so in one instance, this one instance overturns the theory, does away the vicarious of haematemesis, and gives it a place, where I conceive it ought to have one, among idiopathic diseases. About ten years ago, Dr. Casking, of Plymouth, passed a season in Edinburgh. I had the pleasure to be acquaint- ed with him, and I cultivated his friendship. At this time I had ascertained the efficacy of purgative medicines in several diseases: I conversed with Dr. Gasking free - ly on these subjects, communicating the observations I had made. Dr. Gasking frequently walked the hospital with me, He observed a patient labouring under vomiting of blood, whom I had been treating in the usual routine, with cool- IN VOMITING OF BLOOD. 73 ing acidulous medicines, and with different emenagogues., to no good purpose. He requested me to open her bow- els with calomel; he spoke with the decision which ex- perience gives, and I followed his advice. This patient was from the country ; of a robust make, and hale constitution. She was about twenty years of age. The alvine evacuation, procured on the exhibition of the purgative, was copious, and of unnatural appearance. She obtained immediate relief ; vomiting of biood did not return; and a few more purgatives established*her recovery. She left the hospital, strongly enjoined to preserve a regular state of her belly,—means for this pur- pose being furnished to her. In three or four months, this patient returned, labouring Under contispation, and vomiting of biood. Tne con- stipation, was again removed, by means of calomel, and a great load of indurated, and fetid feces was brought off. In a short time she leit the hospital, again cured, and again admonished to be more attentive to the state of her bow- els. This instructive lesson was not lost upon me ; it taught me, that the vomiting of biood of which i speak, depends upon constipation of tne belly, a circumstance which I had not before suspected. I have followed the practice which this case suggested, in the instances of the disease which I have since met with ; and my success has been so uniform, that I now lay it down as a certain position, that the proper exhibition of purgative medicines affords sure, and effectual means of removing haematemesis, the subject of this chapter. The purgatives, which I have used in these cases, have never excited vomiting ; and, what may be thought sin- 74 ON PURGATIVE MEDICINES, &C gular, I have never been able to ascertain the presence of blood in the feces. As the strength of patients labouring under this vom- iting of blood is generally pretty entire, we need not dread full purging; but this effect is not wanted; it we unload the bowels, we accomplish the cure. The feces which are brought off are copious, unnatural in colour, consistence, and smell, as they generally are after long remora, the consequence of obstinate, and pro- tracted costiveness. The different circumstances, which not only expose women to costiveness more readily than men, but, when it does occur, to a more obstinate kind of it, as mentioned in the chapter on chlorosis, may explain, why they are exclusively the subjects of this disease :—A consideration, which affords me a strong additional argument, for incul- cating the most sedulous attention to the careful support of a regularly acting state of the bowels ; the only secur- ity against costiveness, that bane of health, and source of manifold distress. In conducting the cure of vomiting of blood, I have not confined myself to the use of calomel alone ; I have oc- casionally substituted other purgative medicines, as will be instructed by the cases inserted in the Appendix, No. VI. In which Number, I insert also a letter addressed to me, from Mr. James Law, one of the surgeons of the Infirmary, and surgeon to the Bridewell of Edinburgh. This communication from so respectable a quarter, will, in the general opinion, corroborate my practice in haemat- emesis. 75 CHAP. VI. OBSERVATIONS ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEOICINES IN CHOREA SANCTI VITI, OR ST. VITUS'S DANCE. Systematic writers have paid little attention to chorea Sancti Viti ; and practitioners have regarded it with indif- ference. These circumstances will surprise us the more, when we consider the formidable appearance of the dis- ease, the obstinacy with which it holds its course, and the distressful state to which it always reduces, and the danger in which it sometimes involves, those whom it attacks. Dr. Sydenham described chorea Sancti Viti, a hundred and twenty years ago, and his description, with little va- riation or addition, has been copied by the few succeeding authors who have written on the subject. Sydenham, in his " Schedula Monitoria de novas febris ingressu," gives the history of chorea Sancti Viti, in the following words : " Chorea Sancti Viti convulsionis est species, "u* ut plurimum pueros puellasve a" decimo aetatis anno, ad pu- bertatem usque invadit; primo se prodit claudicatione quadam vel potius instabilitate alterutrius cruris, quod aeger post se trahit fatuoruin more ; postea in manu ejus- dem lateris cernitur, quam, hoc morbo affectus, vel pecto- ri, vel alii alicui parti adplicitam, nullo pacto potest con- tinere in eodem situ vel horse momento, sed in alium 7fc ON PURGATIVE MEDICINES situm, aliumque locum convulsione quadam distorquebitur, quicquid xger contrlt nitatur. Si vas aliquod potu re- pletum in manus porrigatur, antequam illud ad os possit adducere, mille gesticulationes, circulatorum instar, exhi- bebit; cum enim poculum recta linea ori admovere ne- queat, deducta a spasmo manu, hue illuc aliquamdiu ver- sat, donee tandem forte fortuna illud labris propius appo- nens, liquorem derepente in os in licit, atque avide haurit, tanquam misellus id tantum ageret, ut dedita opera, spec- tan tibus risum moveret." This history, so far as it goes, is correct. It exhibits a faithful picture of the disease, of the various contortions and gesticulations of the patient. Put it is silent on other circumstances, the affections of the natural and animal functions, which are essential to the disease, and which ought not to have been omitted. Besides, Sydenham de- tails the symptoms of the advanced and confirmed state only, while he either has not perceived, or has altogether overlooked, the rise and progress of chorea. For these reasons, I give the following more extended narrative of the symptoms of chorea. Chorea Sancti Viti attacks boys and girls indiscriminate- ly ; and those chiefly, who are of a weak constitution, or whose natural good health and vigour have been impaired by confinement, or by the use of scanty or improper nour- ishment. It appears most commonly, from the eighth to the fourteenth year. I saw it in two young women, who were from sixteen to eighteen years of age. The approaches of chorea are slow. A variable, and often a ravenous appetite, loss of usual vivacity and play- fulness, a swelling and hardness of the lower belly inmost cases, in some a lank and soft beiiy, and, in general, a constipated state of the bowels, aggravated as the disease IN CHOREA SANCTI VITI. 77 advances, and slight irregular involuntary motions of dif- ferent muscles, particularly of those of the face, which are th-night to be the effect of irritation, precede the more violent convulsive motions, which now attract the atten- tion, of the friends of the patient. These convulsive motions vary. The muscles of the extremities, and of the face, those moving the lower jaw, the head, and the trunk of the body, are at different times- and in different instances affected by it. In this state, the patient does not walk stead ly ; his gait resembles a jump- ing or starting; he sometimes cannot walk, and seems palsied; he cannot perform the common and accessary motions, with the affected arms. This convulsive motion is more or less violent, and is constant, except during sleep, when, in most instances, it ceases altogether. Although different muscles are sometimes successively convulsed, yet, in general, the musc;es, affected in the early part of the disease, remain so during the course of it. Articulation is now ^impeded, and is frequently com- pletely suspended. Deglutition is also occasionly per- formed with difficulty. The eye ioses its lustre and in- telligence ; the countenance is pale and expressive of va- cancy and languor. These circumstances give the patient a fatuous appearance. Indeed there is every reason to believe, that, when the disease has subsisted for some time, fatuity, to a certain extent, interrupts the exercise of the mental faculties. Fever, such as arises in marasmus, is not a necessary attendant on chorea, nevertheless, in the advanced periods of the disease, flaccidity and wasting of the muscular flesh take place, the consequence of constant irritation, of abating appetite, and impaired digestion, the common G % 78 ON PURGATIVE MEDICINES attendants of protracted chorea ; and which, I doubt not, may, in some instances, although contrary to the opinion that chorea is not fatal, have been the forerunners of death. From this history, chorea may be considered as con- sisting of two states or stages ; the incipient, and the confirmed. The incipient state takes place from the first derangement of health, till the full formation of the involuntary motions ; with these the confirmed state com- mences, and continues to the end of the disease. After detailing the history, Sydenham proceeds in the Schedula Monitoria, to deliver his theory and his conduct of the cure of chorea. " Cum affectus iste," (chorea scilicet,) " ab humore aliquo in nervos irruente, quorum irritatione istiusmodi motus praeternaturales producuntur, pendere mihi vide- retur ; indicationes curativas primum ad humores illos tam venae sectione, quam purgatione minuendos, dein ad corroborandum genus nervosum omnino dirigendas cen- sebam. Quern in finem hac utor methodo. Sanguinem ex aegri brachio ad uncias septem, plus vel minus, pro ratione aetatis, educijubeo. Die sequente vel dimidiam partem, vel quiddam amplius, (pro ratione vel aetatis, vel etiam majoris minorisve corporis, ad subeundam ca- tharsin, aptitudine) potionis purgantis communis exhibeo. " Recipe— Tamarind, unciam dimidiam; fol. senn. drachmas duas ; rhabarb. drachmam unam et dimidiam ; coq. sufi quant, aq. ad uncias tres, in colat. dissolv. mann. et syr. rosar. solutiv. utriusque unciam. ' Et vespere haustulum paregoricum propino. u Potionem istam catharticam ad tres vices alternis IN CHOREA SANCTI VITI. 79 diebus repetendam prescribo, et haustum paregoricum iisdem noctibus. Postea sanguinem rursus extrahi euro, dein ut ad catharsin, uti prius, aeger revertatur. Atque ita, alternatim sanguinem mitto, et subduco alvum, donee aegro vena ter quaterve fuerit incisa, et post singulus ve- naesectiones toties fuerit purgatus, quoties viros ferre posse viderentur ; eo tamen temporis spatio inter alternas evacuationes diligenter observato, ut nihil ir.de periculi aegro immineat. Diebus a purgatione vacuis, sequentia prescribo." Haec sunt medicamenta stimulantia, uti di- cuntur, corroborantia, et alterantia quae hie recensere inulile est. " Quanto magis convalescit aeger, tanto minus pedem ducit, tanto pariter et diutius, et constantiiis manum in eodem situ continet, et scyphum ori magis directa. via. admovet: quae certissima sunt indicia quantum profecerit in sanitate redintegranda. Ad quam quidem consumma- tius perficiendam, licet author non sim ut plus ter qua- terve ut plurimum sanguinem emittat aeger, attamen aeger, attamen remedia cathartica et alternantia eousque in usum sunt revocanda donee rectissime tandem valeat." Sydenham mentions his success under this manage- ment: "Quo morbo," chorea scilicit, " haud pauciores quinque laborantes et vidi, et sanavi ipsemet." Sydenham passes over in silence the time requisite for the cure of chorea. The intervals, however, between the three or four bleedings, during which purgative and paregoric medicines were given, and the injunction to continue the use of cathartics and alteratives, after the last blood-letting, till the patient is at length completely recovered, make it probable, that many weeks, if not months, must have elapsed before the cure was affected. The theory of the present day differs from that of Sy- 80 ON PURGATIVE MEDICINES denham, which, although not very intelligible, may be as good as its substitute ; and the only useful part of his practice, has fallen into disuse. Latter physicians, there- fore, instead of elucidating the theory, and of improving the method of Guring chorea, have been retrograde in both respects. It is now sufficient to say, for what length of time the authority of Sydenham, and the credit which his opinions obtained, encouraged and protected the practice, which he recommtnded. It is certain, however, that a doctrine and practice discordant w th his have long prevailed. And it is probable, that the anxiety expressed by Syden- ham, that, in the administration of blood-letting and purg- ing, his patients should catch no harm ; together with the weakness both of body and v ind- characteristic of the disease, may have introduced this change. Be this as it may, physicians are now inclined to refer chorea to a certain debility, or loss of tone, in which the convulsive involuntary motions originate. They of course neglect the " humor alicuis in nervos irruens ;" they convert the caution of Sydenham mto a total prohibition of blood- letting and purging ; and in the cure of chorea they adopt the exclusive employment of stimulant and tonic medicines. Under this practice, opium, camphor, sulphuric aether, valerian, cinchona, and different vepetab.e bitters, zinc, steel, ammoniaretum cupri, cold bathing, and electric'ty, are the medicines which have, been chiefly used. Most of these are casually mentioned in periodical publications, and are supported by that authority only which attaches to solitary facts. De Haen is an advocate for electricity. In his Ratio Medendi he gives several cases, in which it appears to have been exhibited with success. Medical electricity has, however, lost much of its early cele- brity. IN CHOREA SANCTI VITI. 81 Notwithstanding the employment of these remedies, chorea has been found a tedious disease ; experienced practitioners having admitted that it has continued for many months, nay, for years; terminating only, on some occasions, about the age of puberty. This confession is not much in favour of the modern practice, or of the doctrine on which it rests. It is me- lancholy to reflect, that months, and years, the most valu- able in respect of after life, should glide on, while an ef- fectual check is given to the improvement of the mind, the cultivation of useful learning, or the acquisition of the necessary arts; with the hazard of permanent fatui v, to a certain extent, or of a grotesque appearance, from the unconquerable remains of irregular motions being im- posed on the young sufferers for life. To these certain consequences of protracted chorea, I will add, the danger which attends it; I have no doubt, but that *. must have, on some occasions, proved fatal. In the course of my practice, I have seen above twenty- cases of chorea : a greater number than it may have fallen to the lot of many to observe. I cannot say, with Syden- ham, that I have succeeded in curing all of these. For several of my patients presented themselves while I yet employed tonic and stimulating medicines; when my practice shared the common fate, and met with disap- pointment. I am afraid I may even sometimes have done harm, by the indiscriminate use of the cold-bath, a remedy not always suited to the exhausted and irritable state of the subjects of chorea. I now began to desert a practice in which I had lost confidence, and to consider chorea in a different light, from that in which it had been commonly viewed. I con- ceived that the debility and spasmodic motions, hitherto so much considered, might not be the leading symptoms 82 ON PURGATIVE MEDICINES of the disease, but might depend upon previous and en- creasing derangement of health, as indicated by irregular appetite, and constipation of the bowels. Under this impression with regard to the erroneous opinions, which I had heretofore entertained concerning the nature of the disease, and the consequent improper practice, which I had employed for the cure of it, I re- solved to alter my mode of treatment, in order that I might fulfill those indications which the new, and, as I flattered myself, the more correct view of the disease had suggested. If my conjectures were well founded, the first and principal object of practice wou d be to remove the con- stipated state of the bowes. In pursuance of this object, I began to try the effects of purgative medicines, given regularly in moderate doses. At first, I confess, I acted with all that caution and dif- fidence, which the adopticn of a line of practice, at variance with that which had been long approved and established, naturally inspires. But experience had convinced me of the safety of exhibiting purgative medicines in typhus fever; I therefore did not think any great risk would ensue from a cautious use of them in the most debilitated state, which chorea might induce. The conjecture proved to be well founded ; the success of the practice confirmed the justness of the opinion on which it was formed, and encouraged me to persevere with steadiness, and activity. The purgatives which I employed m the first instance, were of the weaker kind, and inadequate to the object to be obtained. Stronger ones were found to be necessary to move, and discharge the indurated and fetid feces. I observed the quantity of feculent matter collected, to IN 6H0REA SANCTI VITI. 83 vary in different subjects, and at different periods of the complaint. I could not ascertain this oy any previous circumstance. One would ti.ink, that, in proportion to the fulness and prominence ot the abdomen, and in pro- portion to the age and vigour of the patient, the accumu- lation, ceteris paribus, would be ; but 1 do not find that this is so. Perhaps the lengthened duration of the com- plaint, and the reduced state of the patient, the conse- quence 01 this, are attended with the greatest feculent accumulation. 1 think my observation bears me out in this conjecture, as in the instance of David Anderson, the history of whose case will be found in the Appendix, No. VTI. This boy was emaciated ^nd exceedingly puny, and his abdomen was lank ; yet from the fifteenth day of De- cember, when the commencement of his recovery was observable, to the twenty-fifth day of the same month, the quantity of feces disci*arged was most wonderful, such as I had never seen before, it appeared to me, du- ring the above period, to have nearly equalled in weight, that of the whole body of the extenuated patient. I have already noticed, that chorea consists of two stages. In the first, while the intestines yet retain their sensibility, and before the accumulation of fecis is great, gentle purgatives, repeated as occasion may require, will readily effect a cure, or rather prevent the full formation 01 the disease. In the confirmed stage, more sedulous attention is ne- cessary. Powerful purgatives must be given in successive doses, in suo: manner that the latter doses may support the effect of the former, till the movement and expulsion •f the accumulated matter are effected, when symptoms of returning health appear. Whoever undertakes the cure of chorea oy purgative medicines, must be decided, and hrm to ni:> purpose. The confidence which he as- 34 ON PURGATIVE MEDICINES sumes is necessary to carry home, to the friends of the patient, conviction of ultimate success. Their prejudi- ces will otherwise throw insurmountable obstacles in the way. Half measures, in instances of this kind, will prove unsuccessful; and were it not for perseverance in un- loading the alimentary canal, the disease would be pro- longed, and, recurring, would place the patient in dan- ger, and thus bring into discredit a practice which pro- mises certain safety. Here, as in all other cases of extreme debility induced bydisease, the recovery is at first slow and gradual. A regular appetite for food, a more intelligent eye, and lightened countenance, cheerfulness, and playfulness of temper, increasing aptitude for firmer motions, the res- toration of articulation, and of the power of deglutition, a renovation of flesh and strength succeed each other, and being more and more confirmed, are, ere long, followed up by complete recovery. For some time after these salutary changes take place* the state of the bowels must continue an object of at- tention. An occasional stimulus from purgatives will be requisite to support their regular action, and to restore their healthy tone, the only security against the recurring accumulation of feces, and of a consequent relapse. About this time also, remedies possessed of tonic and stimulant powers, may be used with propriety and effect; they restore energy to the torpid bowels, aid the purgative medicines in obviating costiveness, and thus confirm a recovery already advanced. Vegetable bitters, or the preparations of steel, may perhaps be the most useful for accomplishing these ends, I have not felt the necessity of having recourse to medicines of this kind: under a proper regimen of light and nourishing food, and of exer rise in the open air, my .patients, in general, quickly re- IN CHOREA. , 83 cover their strength. But many practitioners set a value upon tonic medicines; and the usual routine of practice demands them. This exhibition of purgative medicines in chorea, is, I apprehend, countenanced by the practice of Sydenham and De Haen. It is probable,that the purgative medicine was the only useful one which Sydenham employed; and that his protracted cures may be attributed to the interruption of the use of it, during the interposition of blood-letting, and of alterant and paregoric medicines. De Haen, in the eighth chapter of his first volume of the Ratio Medendi, narrates a case, in the following words : —" Novcm annorum pueliam, cui post variolas morbil- losque, primo tussis frequens, deinde sputum purulentum aderat, sputum demum plane cessabat, chorea Sancti Viti prehendit, sinistra potissimum brachio pedeque, ac diversimoda faciei convulsio. Biinestri spatio, adhibita vi electrica, pustulae copiosae, eaeque turpiter crustosa, brachiuin et cms cingunt, inter/wlatis fmrgavtibus, per- fecta salus redivit." By this treatment, which I have endeavoured to recom- mend, chorea is speedily cured, generally in ten days or a fortnight, from the commencement of the course of pur- gative medicines. I had lately two patients, Ann Ross, and Elizabeth Webster, under my care, whose cases proved most obstinate ; four or five weeks elapsed, before I could pronounce them in the way of recovery. The history of these cases is given in the Appendix, No, VII. In the structure of the female pelvis, and in the pre- vious duration of chorea, Ave may find the reason why it admits of a more or less difficult cure. When the disease is protracted, or when it occurs in giris, greater opportu- H 36 ON PURGATIVE MEDICINES nity for the accumulation of feculent matter is afforded, than in more recent cases, or than where it attacks boys, Of course, a longer time, and brisker purgatives will be required to move, and expel the offending mass, in the former, than in the latter instances. This observation is aptly illustrated by the case of Elizabeth Webster, in- serted in the Appendix, No. VII. This girl, after a pro- tracted chorea was dismissed cured from the Infirmary, on the eleventh of June 1805, but through neglect, the disease returned, ana she again became a patient on the third of February 1806 ; but the relapse having recently occurred, the cure at this time was completed in ten days. Since I have employed purgatives in chorea, I have been disappointed in effecting a cure, in one case only. About three years ago I visited a young girl, who had been the victim of chorea for many weeks. The purga- tive medicines, which I administered, gave full eA-idence of a disordered, and loaded state of the intestines. My patient Avas not under proper management; my advice was followed in an irregular, and desultory manner, and the disease was protracted. After some time she was carried home to a considerable distance, and I understood a quack medicine was given to her Avith the best effects. To my regret, however, I saAv her about a year ago in the same situation in Avhich she had left me, and I then learned, that she had continued in this situation, during the whole of this interval. During the exhibition of purgative medicines in chorea, practitioners will learn the propriety and necessity of in- specting the alvine evacuations. They are, in this im- portant point, generally careless ; the attendants, in sick rooms, are of course, ignorant on the subject, and cannot IN CHOREA. 87 give the information necessary for their ascertaining the effect of purgative medicines, or for directing them re- specting their dose, and frequency of repetition. I have said that chorea consists of two stages, a cir- cumstance which should induce those Avho have the su- perintendance of children to attend most carefully, at all times, to the state of their bowels. For the timely inter- position of purgative medicines will be the best means of averting the accession of chorea, which is so formidable. and which, on some occasions, has been found so obstinate a complaint. The caprice of children will often tlvwart us, and oblige us to employ purgatives, not because they are such as we would prefer, but because they are such as will be taken. I have in general used the purgative medicines in chorea, which I had found useful in marasmus. I have inserted in the Appendix No. VII, the histories of some cases of chorea, which, while they illustrate the practice I have endeavoured to recommend, will, at the same time, shew the manner in which I have conducted it. 88 CHAP. VII. OBSERVATIONS ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES, IN HYSTERIA. The symptoms of hysteria are numerous, and being differently modified in different instances, they give a va- riety to the disease Avhich is embarrassing to young prac- titioners. The most common symptoms of hysteria, and those which are esteemed to be pathognomonic, are acute pain in the forehead, or over either orbit, which is confined to a small spot; shifting pains of the abdomen, flatulence' constipation of the body; sometimes, though rarely, vomiting and purging; acrid and fetid eructations; an irritable and occasionally a despondent state of mind; unquiet sleep, which is frequently disturbed by incubus and frightful dreams. Those symptoms produce the chronic state of hysteria. and predispose to the excitement of the more violent hys- teric affections, of fits or convulsions. These fits some- times attack suddenly, but are more frequently preceded by other symptoms Avhich give warning of their approach ; such as a sense of oppression over the chest, palpitation of the heart, a dry cough, a copious flow of pale coloured ON PURGATIVE MEDICINE,S &C. 89 urine; and above all, by the sensation, as if a ball formed, on the lower part of the belly, traversed the abdomen, ascended by the left side, and reached the stomach, and from it the oesophagus and larynx, producing difficult deglutition and sense of suffocation. After this the patient falls doAvn, and is violently agi- tated with convulsions of different muscles, particularly those of the abdomen, which is thereby greatly contracted and drawn inwards. This convulsive motion continues for some time, when sleep supervenes. From this sleep, the patient awakes sobbing and sighing, and with a mur- muring noise through the abdomen, but most commonly without any recollection of what has passed during the fit. This fit is frequently renewed for a length of time, in the same person, who enjoys tolerable health during the intervals. Hysteria is more frequent and more severe in women than in men. Hence it has been thought, although erro- neously, to be peculiar to females. The period Avhen it prevails most, is from puberty to the age of thirty-five. Women of a plethoric habit, or of what is called the sanguine temperament, are most com- monly exposed to it; and in them it often accompanies me regular flow of the catamenia. Slight causes readily induce hysteric paroxysms, in persons predisposed to them, such as fatigue, great and sudden evacuations, peculiar odours, and certain objects, which, either from a constitutional or acquired aversion, •ccasion unpleasant or uneasy sensations. Mental agi- tations also, from surprize, grief, joy, and other passions, are common exciting causes of hysteria. Here too the medical moralist again appears; but I believe that his 3 H >J ON PURGATIVE MEDICINES insinuations, equally groundless and indelicate, exist only in his own prurient imagination. I have felt the necessity of premising this short history of a disease, which is indeed difficult to describe, because I shall refer to it in the subsequent part of this chapter. Frequent disappointments in curing hysteria have led me to take a full, and I hope an impartial revieAV of the subject. This review has inclined me to doubt the solidi- ty of the opinions which have been entertained respecting hysteria, and the soundness of that uniform practice, which have been so long followed in the treatment of it. .Hysteria, as this name implies, has been conceived to proceed from affections of the uterus. Accord ngly suffocation of the womb, and effluvia from corrupted se- men and depraved menstrual blood, are, by the suffrage of the ancient, and eren of some of the more modern physicians, accounted to be its immediate cause. Our countryman, Sydenham, Avho reasoned more than he seems to have been aware of, and often in a manner not very intelligible, in dis&ertatione eftistolari ad Gulicl- mum Cole, speaks thus of hysteria. " Pendent ergo, af- fectiones istae, quas in feminis hystericas, in maribus hypochondriacas insignire libet, quantum ego judico, a spirituum animalium «Ta|T>,^,XyA/,J-./ Tartarus emeticus Tartarum vitriolatum Tinctura jalapae « Tinctura thebaica Aqua potassae. Carbonas magnesiae. Magnesia. Sulphas magnesiae. Oxydum hydrargyri cinere- um Submurias hydrargyri. Pillulae rheicompositae. Myrtus pimenta. Potio carbonatis calcis. Sulphas magnesiae. Sulphas sodae. Tartris sodae et potassae. Cassia senna. Phosphas sodae. Tartris sodae et potassae. Sulphas sodae. Aqua acetitis ammoniae. Oxidum ferri nigrum purifi- catum. Sulphas potassae. Tinctura convolvuli jalapae. Tinctura opii. NOMENCLATURA. 119 TABULA SECUNDA, EXPONIT MEDICAMINUM TITULOS POSTERIORES, El PRIORES. TITULI POSTERIORES. Aqua acetitis ammoniae Aqua potassae Bolus jalapae compositus Carbonas ammoniae Carbonas magnesiae Carbonas potassae Cassia senna Citrus medica Convolvulus jalapa Glycirrhiza glabra Gummi resina ferulae as- saefaetidae Laudanum Linum usitatissimum Magnesia Myrtus pimenta Oxydum ferri nigrum pu rificatum Oxydum hydrargyri cine- rerum. - Phosphas sodae Pilulae aloes cum colocyn- thide - Pilulae rhei compositae Potio carbonatis calcis Submurias hydrargyri TITULI PRIORES. Spiritus Mindereri. Litivium causticum. Bolus ^iapae, cum mercuric Ammonia preparata. Magnesia alba. {Lixiva purificata. Alkali fixum vegetabile pu- rificatum. Senna. Limon. Jalapa. Glycirrhiza. > Assafaetida. Tinctura opii Linum. Magnesia usta. Pimenta. " i Squamae ferri purificatae. f Mercurius cinereus. -< Hydrargyrus praecipitatusci- (^ nereus. Soda phosphorata. {Extractum catharticum. Extractum colocynthidis compositum. Pilulae stomachicae. Potio cretacea. Caiomelas, mercurius dulcis, 120 APPENDIX NO. I. Sulphas magnesiae Sulphas potassae Sulphas sodae Supertartris potassae Tartris antimonii Tartris sodae et potassae Tinctura convolvuli jalap Tinctura opii Sal catharticus amarus. Tartarum vitriolatum. Sai Glauberi. Soda vitriolata. Crystalli tartari. Cremor tartari. Antimonium tartarisatum. Tartarus emeticus. Sal rupellensis. Soda tartarisata. Tinctura jalapae. Laudanum. in ctura thebaica. FORMULA OF MEDICINES. TABLE EXPLAINING THE FORMULAE OF THE COMPOUND MEDI- CINES IN THIS WORK AND WHICH ARE PECULIAR TO THE PHARMACOPEIA OF THE ROYAL INFIRMARY OF EDINBURGH. Bolus Jalapae Compositus. Compound Bolus of Jalap. Take of Jalap in powder fifteen grains, Calomel five grains, Conserve of Roses q. s. Decoctum Furfuris. Decoction of Bran. Take of Bran two ounces. Spring or River Water twelve pounds, Boil to nine pounds. Enema Domesticum. Common Enema. Take of common salt Mkriat Soda, half an ounce, Rape seed oil an ounce, Warm water a pound. Mix. Enema Fcetidum. Foetid Enema. Take of assa faetida two drachms. warm water, ten ounces, dissolve, L 122 APPENDIX, NO. I. Enema Purgans. Purging Enema. Take of the leaves of Senna, three drachms, Sulphate of soda, an ounce, Boiling water, a pound, Infuse and strain. Haustus Anodynus. Anodyne Draught. Take of Opium tAventy five drops, Spring water an ounce, Simple syrup two drachms. Mix. Haustus ex oleo Ricini. Draught of Castor Oil. Take of Castor Oil half an ounce, Distilled water an ounce, Spirit of pimento a drachm, Water of pot ash twenty drops. Mix. Haustus salinus effervescens. Saline effervescing draught. Take of purified carbonate of potash four scruples, Spring water four ounces. Dissolve, and when the feces shall have subsided, strain. Take of lemon juice two ounces, Simple syrup, Spring water of each an ounce. Mix. An ounce of each of the mixtures to be given for a dose ; the solution of the carbonate of patass being first taken, the mixture of Lemon juice is tu be immediately given. FORMULAE OF MEDICINES. 12o Infusum cassia senna;. Infusion of Senna. fake of the leaves of senna an ounce an half, Coriander seeds bruised, an ounce and half. Supertartrite of potass two drachms, Spring water a pound. Dissolved the supertartrite of potass in boiling Avater ; then pour the boiling liquors on the senna and the seeds ; macerate for an hour in an open vessel, and when cool strain. Infusum lini usitatissimi. Infusion of Flaxseed. Take of flaxseed two ounces, Liquorice root iiaif an ounce, Boiling Avater four pounds. Infuse by the fire for some hours, and strain. Mistura corticis Peruvianae aromatica. Aromatic mixture of Peruvian bark. Take of peruvian bark in powder half an ounce, Mucilage of gum araoic, two ounces, rub to- gether and add gradually spring water five ounces, Tincture of cassia lignea, an ounce and half, Mix. Mistura diaphoretica antimonialis. Diaphoretic antimonial mixture. Take of spring Avater five ounces and half. Reiined sugar a drachm and half. Wine of tartrite of antimony two drachms. Tincture of opium thirty drops. Mix. 124 APPENDIX, NO. I. Mistura diaphoretica salina. Diaphoretic Saline Mixture. lake of spring Avaterfour ounces, Refined sugar three drachms, Prepared carbonate of ammonia ten grains, Dissolve and add Water of acetite of ammonia three ounces. Spirit of pimento two drachms. Mix. Mistura mucilaginosa. Mucilaginous Mixture. Take of decoction of marsh mallows four ounces. Simple syrup half an ounce. Mix. Mistura salina ammoniata. Sali?ie ammoniated mixture. Take of prepared carbonat of ammonia half a drachm. Juice of limes or lemons two scruples. Cinnamon Avater three ounces. Refined loaf sugar half an ounce. Mix. Potus acidus vegetabilis. Vegetable acid drink. * ake of decoction of bran two pounds. Supertartrite of potash four scruplesj Simple syrup one ounce. Mix. Solutio gummi resinae ferulae assae foetidae. Solution of assa foetida. Take of assa foetida four drachms, Boiling Avater twenty four ounces, dissohre 125 APPENDIX, * No. II. CASES OF FEVER. Royal Infirmary, Aug. 2lst 1796* JOHN DENHAM, Mtatis 11. Complains much of headach—.virtigo—general uneasi- ness and sickness. Pulse 120—skin very hot—tongue loaded—much thirst -—belly rather slow—no appetite—-indifferent nights. Complaints began on the l"8th current. He had an emetic on the 19th, with some temporary relief. Let the common Enema be injected. Aug. lid. One stool—restless during night—skin dry, and of a pungent heat—tongue loaded—pulse about 120, and full—abdomen feels tense, and is painful. Take of Calomel, PoAvdered Jalap, Loaf Sugar, of each three grains. Mix Avell in a powder, to be taken immediately. Toast and Avater for drink. L 2 126 APPENDIX, NO. II. August 23d. A bad night, Avith delirium—skin con- tinues hot—tongue more loaded—pulse towards 120, less full—much thirst—tAvo scanty stools. Let ten ounces of the common Enema, be injected as soon as possible, Take of the leaves ofsenna, one drachm, Extract of liquorice, half a drachm, Boiling Avater, eight ounces, Make an infusion to be taken at two doses. 24th. A better night, with less delirium— skin less pungent! y hot—pulse about 120, and soft—tongue less loaded, and moist—-complains of headach—considera- ble thirst—a copious stool from the injection—another since taking the physic—belly seems someAvhat distend- ed ; he complains on its being pressed. Let the common enema be repeated in the evening, and let him have a draught with fifteen drops of the thebaic tincture. 25th. Easy during the first part of the night— restless with delirium since morning—belly more distend- ed, and pained on pressure—tongue more loaded and parched—a loose feculent stool after the injection—a similar one s!nce morning, which, as well as the urine, has been voided without notice—pulse about 120, of mid- dling strength—skin moderately cool. Take of Avater, four ounces, Calcined magnesia, one drachm, Sugar, half a drachm, Form a mixture, of Avhich half an ounce is to be taken every hour. Let the anodyne draught be repeated in the evening. 26th. Three stools since yesterday—the first of a natural appearance, the two last watery and greenish TYPHUS. 127 —a lumbricus has been voided—fulness and pain of ab- domen much abated—skin cool—-tongue clean—pulse about 90, feeble—mixture used—a good night. Let the mixture Avith magnesia be repeated, as also the draught in the evening. August 27th. Two loose and green coloured stools voided in bed since yesterday—-fulness of abdomen gone- no complaint on pressure—tongue clean—pulse about 80, tolerably firm—skin cool—sensible to the stimulus of urine—a good night—appetite returning. Let the draught, and the mixture with magnesia be continued. 28th. Is at present asleep—he has had a good night. Two stools not passed in bed—some food taken this morning. Let the draught and mixture be continued, 29th. No stool—a good night—noAV asleep—■ appetite improving. Let the mixture of magnesia be continued. Let the anodyne draught be omitted. Let him have a pound of beef broth every day. 31 st. Another iumbricus, of a large size, voided since yesterday—belly regular—pulse about 80 and soft . tongue clean—appetite good—an easy night. Let the magnesia alba be continued. Sept. 10th. Gradual convalescence. Dismissed cured. 128 APPENDIX, NO. II. Royal Infirmary, Aug. 31sf, 1796. JAMES JWKECHNT, JEtatis 20, Complains of headach, pain in his back, general uneasi- ness and sickness. Has at times a slight cough, but no particular uneasi- ness about his breast. Belly regular—considerable thirst—tongue white- pulse 110, pretty full—skin hot—tolerable nights. Complaints began nine or ten days ago, and have been frequently attended with shivering. Has used no medicines. Sept. 1st. Let him take of the compound powder of Jalap half a drachm. Let him have the bran decoction for drink. .------2d. Headach abated—cough and thirst con- tinue—pulse about '100—an indifferent night—as yet no stool. Let the compound powder of Jalap be repeated immediately, Let him have the common enema, in the evening if necessary, and The anodyne draught at bed time. Sept. 5th. Free passage of belly previous to the in- jection—headach and cough gone—pulse calm—appetite returning. ------6th. Convalescent. Full diet. —. ■ — joth. Dismissed cured- i TYPHUS. 129 Royal Infirmary, Sept. 29tb. 1796. ROBERT GRANT, Mtatis 21. Complains of headacli—virtigo—nausea—chilly fits, succeeded by heat and sweating, great uneasiness and oppiession, much thirst, and loss of appetite. Pulse 96—tongue very foul—c-kin at present moist— belly regular—seeps indifferently—on the 19th after ex- posure to cold, while on guard in the night time, was seized Avith headach, coldness, shiArering, and prostration of strength ; he has continued daily Avorse since that time, although he took an emetic on the 20th. Sept. 30th. Febrile symptoms continue—pulse about 90, someAvhat full—tongue pretty clean and moist—a stool in the course of yesterday. Take of Jalap, in powder ten grains Calomel three grains. Mix into a powder to be taken immediately. The vegetable acid drink to be taken ad libitum. October 1st. Two copious stools, after an injection in the evening—febrile symptoms much abated—skin moist —pulse calm. October 2d. Convalescent. 12th. Dismissed cured. 130 APPENDIX, NO. II. Royal Infirmary, Sept. Stb. 1796. JONATHAN GREEN, AEtatis 22. Complains of headach, pain of back, general uneasiness, and sickness. Pulse 96—skin cool—tongue Avhite—thirst natural- belly rather loose'—appetite bad—urine high coloured- sleeps ill. Complaints began yesterday, Avith shivering, follower! by increased heat and SAveating-—attributes them to cold and wet, being exposed to the rain, for a considei able time on Saturday last 3d current. Has used no medicines. Sept. 6th. Let him have immediately Of ipecacuanha wine one ounce for an emetic. And to morrow morning Compound powder of Jalap half a drachm. ------7th. Full voming—febrile symptoms abated —pulse calm—three stools. Full diet. ------10th. Aggravation of headach, with feebleness and langour—pulse about 120—belly slow. Let him have immediately, of the compound powder of jalap, two scruples. ------11th. As yet no stool—headach continues— pulse about IOC, rather feeble. Let him have in the evening, The common enema, and should it not operate fully, of the compound powder of jalap one drachm tomorroAV morning. TYPHUS. 131 Sept. 12th. One stool by the injection—four by the physic this morning—headach relieved, and countenance lightened. ------13th. Frequent scanty stools, since yesterday, with gripes and tenesmus—much thirst-p-tongue white— pulse about 100. Take of tartrite of soda six drachms, Water twelve ounces. Make a solution, to be taken as soon as possible at two doses. Let him have the anodyne draught in the evening. Toast and Avater for drink. .------14th. Gripes and purging gone—-tongue whitej rather loaded—pulse about 90. Let the solution of tartrite of soda be repeated to- morrow morning. ------16th. Convalescent. Fuli diet. ------19th. Slight headach at times—belly open— pulse about 90. Let him have of the cretaceous mixture one ounce thrice a day. ■------21st. Belly regular—slight headach continues, Let him take of the poAvder of the peruvian bark half a drachm four times a day. Omit the cretaceous mixture. ------26th. Headach gone—belly regular. Dismissed cured. 132 APPENDIX NO. II. Royal Infirmary, April 19tb. 1798. DONALD WATSON, Mtatis 23. Complains of severe pain in his head, with general sore- ness—puise about 90—tongue white—thirst considerable appetite impaired—no stool since the 16th instant, on Avhich day his complaints began with shivering. Take of Calomel five grains, Jalap in powder twelve grains, Mix into a powder to be taken immediately. Afiril 20th. Tavo stools—tongue loaded—pulse to- wards 108, and full—thirst moderate—a tolerable night, and still disposed to sleep. Let the powder of Calomel and Jalap be repeated to- morrow morning. ------21st. Another stool in the evening—none since the exhibition of the powder—headach continues—pulse about 90, and soft—tongue still loaded. Let him have the common Enema in the evening, if ne- cessary. ------22d. Three scanty stools in the course of yester- day—headach relieved—tongue less loaded—skin cool and moist—pulse calm—a good night. Let him have tomorrow morning of the Compound Powder of Jalap one drachm. April 23d. A good night—several stools—tongue clean —pulse calm. ------27 Convalescent. Full diet. Dismissed cured. TYPHUS. 133 Royal Infirmary, April 20tb. 1798. JAMES DENNET, JKtatis 12. Complains of pain in his head, and in his belly—of vertigo—great sickness, and occasional vomiting—pulse about 100—tongue white—considerable thirst—appetite impaired—belly bound. These symptoms commenced with shivering on the 16th, and he had been exposed to the contagion of fever. April 21st. A natural stool—no recurrence of vomiting —headach and sicknes contiriue—pulse about 120—skin hot. Let him have, of the compound poAvder of Jalap, a scruple. and, A draught Avith fifteen drops of the thebaic tinc- ture at bed time. ------22nd. Headach and sickness relieved—tongue clean and moist—pulse quick and feeble—two stools pre- vious to giving the powder, and two since—a good night. Let him have of the diaphoretic saline mixture one ounce every three hours. let the draught at bed-time be repeated. ------. 23d. A good night—stilj dipsosed to sleep— free of complaint. Let the draught be omitted. April 24th Gripes in the course of yesterday—tAvo stools since morning, fifteen grains of compound poAvder of jalap being given—pulse quick—skin Avarm—tongue Avhite— still droAVsy—gripes continue. 134 APPENDIX NO II. Let him have of ipecacuanha wine six drachms for an emetic. ------25th. Two dark coloured stools—no vomiting— gripes gone—a quiet night. ■------ 30th. Convalescent. Full diet. May 11th. Dismissed cured. TYPHUS. 135 Royal Infirmary, May 17tb. 1798. JAMES GRANT, Mtatis 18. Complains of great pain in the umbilical and epigastric regions ; of severe headach and much sickness, with gen- eral uneasiness and lassitude. His internal fauces are painful, and there is an eruption of reddish spots over his face and most of his body. Pulse about 90—belly sIoav—ap- petite impaired —tongue rather Avhite—has great thirst. On the 12th current he Avas affected with shivering ; the spots appeared about the 15th, and hac'i been increasing since that time ; the affection of his throat has likeAvise been increasing. He had been recovered eight days from a febrile attack, which had continued for a fortnight with- out any eruption. He took an emetic on the 13th, which relieved in some degree the pain of his head. He took also some pills on the 15th, Avhich acted as a laxative. Let him have the purging Enema. May 18th. P? in ofabdomen, affection of internal fauces, and eruption continue—skin moderately warm—pulse about 80, and soft—a costive stool. Let him have immediately of jalap in poAvder calomel of each six grains. With the vegetable acid drink ad libitum. May 19th. A costive stool in the evening, after an injec- tion—pain of abdomen, affection of throat, and eruption, stationary__tongue loaded—much thirst—pungent heat of skin—pulse about 80. 136 APPENDIX NO. II. Take of sulphate of soda six drachms Sugar, two drachms Chrystals of tartar Leaves of senna of each a drachm Boiling water sixteen ounces. Let an infusion be made to be taken immediately, the throat to be wrapped in flannel. -20th. Complaints stationary—a bad night—tongue still loaded—Avith thirst—skin cooler—pulse about 80— four dark coloured stools. Let him have the anodyne draught in the evening, and An ounce and half of the infusion of senna to-mor- roAV morning Two pounds of wine whey taken at different times every day. ------21st. Pain of abdomen is abated—that of inter- nal fauces, which appear considerably inflamed, continues —eruption, copious on the face, is less frequent on the rest of the body—heat of skin again more pungent—pulse about 100—thirst urgent—no stool—indifferent night. Let him have the common Enema if necessary. May 22d. A copious dark coloured stool after the injec- tion—affect on of throat and eruption continue—pulse about 90, of moderate strength—skin of a less pungent heat- thirst not abated. Let ten drops of the thebaic tincture be added to the draught. ------23d. Pain of epigastrium has recurred—pain of fauces continues.—skin less hot—pulse about 80, soft and firm—no stool—an indifferent night. Let him have of the infusion of Senna, two ounces immediately. TYPHUS. 137 Repeat the draught. Discontinue the wine whey. —24th. Two dark coloured stools—pain of epigas- trium and fauces relieved—eruption fading—tongue clean- er__pulse about 80, and soft—skin moist—thirst abated— a good night. ______26th. Convalescent—belly rather sIoav. Let him have of poAvdered rhubarb ten grains every morning. Discontinue the draught. Full diet. ------30th. Belly has been regular. Dismissed cured, M 2 138 APPENDIX NO. II. Royal Infirmary, Aug. 7tb 1801. JOHN BAIRD, Matis 11. On the 2d instant, by account, was suddenly attacked with rigours, increased heat, and general sweat. Since ad- mission, he has been very indistinct, and frequently, Avhile awake, is observed to mutter and speak to himself: while asleep, he often starts, and awakes in a fright. Pulse 130, and weak—skin very warm—tongue clean—some thirst ■—the day before his illness was exposed to febrile conta- gion—a scanty stool since admission—no remedies em- ployed. Let him have the common Enema immediately. August 8th. A scanty stool—pulse about 120, and ra- ther feeble—tongue white—more distinct—injection not triA'en. The bolus of jalap, with three grains of calomel to be given immediately. The bran decoction to be taken ad libitum. -------9th. Two or three stools—skin cool—pulse about 90—a good night, and disposed to sleep—making no com- plaint. Continue the bran decoction, August 10th. Has had delirium and irregular convul- sive motions—belly slow—pulse feeble. The boltfs o'f ialap and calomel to be repeated. His head to be shaved. Let him have 8 ounces of port Avine, of which he may take an ounce frequently. TYPHUS. 139 ------11 th. Delirium and involuntary motions still continue—a better night—two loose stools—pulse towards 120, and feeble—wine not much relished. ------Let a blister be applied to the whole head. Let him have a draught with 15 drops of Lauda- num. The port wine to be discontinued. .-----12th. Delirium much aggraA'ated towards even- ing—quietness succeeded the exhibition of the draught, which still continues—irregular convulsive motions aba- ted, pulse about 120, and firmer. Let him have of the diaphoretic, saline mixture, an ounce every three hours. The draught to be repeated in the evening. .-----13th. A tolerable night—disposed to be drowsy __on awaking, he appears agitated, screaming occasion- ally, but makes no complaint—appetite indifferent—pulse quick and feeble—belly slow—involuntary motions not per- ceived face more or less flushed—copious discharge by the blister. Let him have immediately of the infusion of senna, tAvo ounces and also of the same infusion an ounce once every day. To take a pill of the ash coloured oxyd of mercury, morning and evening. The anodyne draught to be discontinued. August 14th. An indifferent night—although less drow- sy, has on the whole slept much—tongue clean and moist __skin cool and soft—pulse about 100, and feeble—expres- sion of countenance more natural—one stool—but little food taken. The mercurial pills and the mixture to be continued. 140 APPENDIX NO. II. ------17th. Appetite mending—looks improving— sleep natural—pulse calm—skin cool—belly open. The mercurial pill to be discontinued. An egg to dinner. _-----27th. Dismissed cured TYPHUS. 141 Royal Infirmary, Marcb 27tb. 1804. DONALD STEWART, JEtatis 19. Complains of violent headach, virtigo, nausea, and oc- casional vomiting, pain under the sternum, with frequent short cough, and slight dyspnoea—debility—general unea- siness—pulse 90—skin hot—-tongue loaded—-belly, by account, regular. Was attacked tAvo days ago, with ri- gors—has used no remedies. March 28th.—Let a blister be applied immediately to the sternum, and let him take the compound bo- lus of Jalap. And of the saline ammoniated mixture an ounce occasionally. ------29th. Headach and sickness—cough, and pain of breast relieved—frequent stools—pulse calm—skin cool and moist—tongue white—thirst inconsiderable—an indifferent night—blister has answered well. To take the anodyne draught in the evening. The saline ammoniated mixture to be continued. ------31st. Purging gone—cough returns at times, with uneasy breathing—pulse 90, and feeble. Take of the mucilaginous mixture four ounces, Wine of tartrite of antimony two drachms, Thebaic tincture thirty drops. The mixture being shaken, let him take every noAV and then half an ounce of it. Discontinue the saline ammoniated mixture. April 3d. Belly having been slow, a laxative was given last evening, as yet without effect. Face at times is flushed, and he is somewhat delirious—cough is however abated—breathing easy—pulse calm. 142 APPENDIX NO. II. Let him take immediately of the infusion of senna three ounces. Let the mixture with the tartrite of antimony be continued. .------4th. No stool till he got an injection—two since—pulse 80—tongue foul, but moist—eyes suflused. Let the mixture with the tartrite of antimony be continued. ------5th. Headach and delirium gone—a good night—complains of pain of throat, with difficult deglu- tition—pulse 80—skin hot—belly slow. Let the ammoniated oil be applied with a piece of flannel to the external fauces—let him have tAvo scruples of the compound powder of Jalap. ------7th. Pain of throat gone—a good night—pas- sage of belly—pulse 80—skin cool. April 13th. Convalescent. Discontinue the medicines. Full diet. ------ 17th. Four loose stools. To take of the cretaceous mixture, one ounce every two hours and the thebaic pill tAvice a day. ------ 18th. Four stools. Let him have of the tartrite of soda 6 drachms. The cretaceous mixture and thebaic pills to be continued. ------20th. Purging gone—tongue appears loaded— headach—pulse calm. Let him have of the bitter infusion half an ounce four times a day. The cretaceous mixture and thebaic pills to be discontinued. TYPHUS. 143 ——■ 21 st. Stools have become frequent, and of a natural appearance, Avith gripes, and occasionally sickness, and spontaneous vomiting—tongue white—thirsty. Let him have of ipecacuanha, a scruple for an emetic. The bitter infusion to be con- tinued. ------22d. Stomach appears to have been loaded— gripes relieved. ------23d. General uneasiness and pain— tendency to delirium—eyes are suffused—pulse feeble—indifferent nights. Take of port wine four ounces, Water four ounces. Mix. Let him take half an ounce every now and then; The anodyne draught in the evening. i-----24th. Restless, and more delirious, without particular complaint. Eyes less suffused, but heavy— tongue somewhat loaded—pulse at the Avrist hardly felt— a natural stool in the evening—wine relished, and some food taken. Let him have of port wine twelve ounces, Water eight ounces—to be taken mixed, as yesterday. ______25th. Has had a quieter night, but continues indistinct, with feeble pulse—parched tongue, and invo- luntary twitching—no stool. Let him have immediately the bolus of jalap and cal- omel ; and in the evening if necessary, the common enema to move his bowels. The wine to be continued. ______26th. A quiet night—disposed to sleep since morning—countenance more florid, and of a more natural appearance—a copious, dark-coloured, and fetid stool, after the injection. 144 APPENDIX, NO. II. Repeat the bolus of Jalap and calomel, and the com- mon enema if necessary. The wine also to be repeated. >------27th. One stool by the injection, and another an hour after—continues to sleep much—pulse 120 still feeble. The enema to be repeated in the evening. The wine to be continued. -------28th. Continues drowsy and indistinct, with tremor of hand, and slight subsultus tendinum—.tongue loaded—pulse feeble—wine relished. A blister to be applied to the head after it is shaved. The bolus of Jalap and calomel to be repeated as above , also the common enema in the evening if necessary—the winejto be continued. -----.— 29th. A fetid and rather scanty stool after the injection. A good discharge by the blister—appears less drowsy—has been more distinct-—tremor and subsultus at present gone'—tongue dry and less loaded—pulse feeble -—wine still relished, and little food taken. The bolus of Jalap and calomel to be repeated, as also the enema—the wine to be continued. ■------30th. A copious, but still fetid and dark-colour- ed stool, from the injection. Has passed an easy night- wine still relished, and a little more food taken—slight subsultus Avith appearance of floccitatio. In other respects as yesterday—pulse feeble. The bolus of Jalap and calomel to be repeated, as also the enema if necessary—and the wine to be continued. May 1st. Two stools after the injection, the last co- TYPHUS. j. 4,:, pious, dark and fetid—a quiet night—tremors and flocci- tatio abated—pulse 80, and good strength. Repeat the Avine. ------2d. A good night, Avith less delirium—tremor and floccitatio gone—pulse 80. Repeat the Avine. ------3d. Febrile symptoms continue to abate—free of complaint—puise calm—belly rather sIoav. Let him take of the compound poAvder of jalap, two scruples. In the evening the common enema unless the boAvels should be previously moved—the Avine to be con- tinued. ------6th. Tavo stools in the course of yesterday— continues apparently convalescent, but is greatly emaciated —tongue clean—pulse calm—improving appetite. Let him have of port Avine eight ounces. Water four ounces. ------30th. Discontinue the Avine—full diet. June 15th. Dismissed cured. N 146 APPENDIX NO. II. Royal Infirmary, Itb Oct. 1805. MARGARET MAN SON, JEtatis 20. Complains of headach, Arertigo, nausea, and occasional vomiting—pain of back, and general pains—pulse 108 and Aveak—skin hot—tongue very foul—belly costive—. complaints of tAvo days duration, for which she knows of no cause. Let her have the compound bolus of jalap tomorroAV. October 8th. Tavo full stools of natural appearance— headach continues—two or three attacks of vomiting uring the night, none since morning—sickness relieved -—tongue still much loaded. Repeat the compound bolus of Jalap in the evening. ------9th. Headach is relieved—no return of vo- miting—sickness abated—tongue less loaded—surface of natural heat—pulse 100 and soft—three copious stools. The bran decoction to be taken ad libitum. ------ 10th. Pulse calm—skin cool—tongue clean— m kes no complaint—good night, Avith returning appetite ------ 15th. Convalescent. Full Diet. ------ 18th. Dismissed cured TYPHUS. 147 Royal Infirmary, 6tb Nov. 1805. MARGARET KENNEDT, AEtatis 17. Complains of severe headach, vertigo, and nausea, Avith pain in the small of her back and general uneasiness— pulse 100, and feeble—skin cool—tongue furred—belly slow—says she has been subject to flying pains for some weeks, but they have been aggravated for tAvo days with headach and other symptoms of general fever. Let her have the compound bolus of jalap tomorroAV morning. Nov. 7th. Pain of loins and other symptoms of gene- ral fever as described—alternate attacks of chilly and warm fits followed by sweating—by her account headach has morning remissions—pulse about 100 and feeble—as yet no stool. Let her have immediately, Of the infusion of senna, Of the infusion of flaxseed each three ounces. ----- 8th. Pain of loins and headach continue, Avith nausea, and one attack of spontaneous vomiting—com- plains still of alternate rigors and hot fits—pulse about 100 and feeble—skin cool—tongue moist—little thirst—full alvine evacuation of a dark colour and fetid smell—a quiet night. 148 APPENDIX, NO. II. The bran decoction to be taken ad libitum. Early to morrow morning of the compound powder of Jalap a drachm. -------9th. Copious and natural stool in the course of yesterday—appetite good—easy night. 11th. Dismissed cured. 149 APPENDIX, No. III. CASES OF SCARLATINA. NARRATIVE OF SCARLATINA, AS IT AFFECTED THE CHILD- REN IN GEORGE HERIOT'S HOSPITAL, IN AUTUMN. 1804. George Heriot's hospital is a large building of noble architecture, forming a quadrangular court. By this construction, and by means of cross windows in the dif- ferent apartments, complete ventilation is procured. The house occupies a dry situation, on the highest part of a ridge immediately to the south of the city, and is placed in the middle of an inclosure, consisting of several acres. On the south and west, it commands extensive vieAvs of the country ; these are more confined on the north and east, by the castle, and by the buildings in the old town, from both of which, hoAvever, it is at a considerable dis- tance. Great attention to the cleanliness and airyuess of every part of the hospital, is added to these advantages of situa- tion. The diet of the children is well regulated; and there 150 APPENDIX, NO. III. is an abundant supply of spring-Avell water, from the city's reservoir, which adjoins the house ; and the medical gen- tlemen attached to the hospital, and acting under the reg- ulations of the governors, put a negative on the admission of any child, Avho appears to them to labour under scro- fula. These circumstances are so favourable to the health of the inmates of this foundation, that I have the satisfaction to say, that during two and thirty years, that I have had the medical superintendance of it, I have seldom knoAvn any serious illness prevailing among them. The sons of burgesses, freemen of Edinburgh, are re- ceived into this hospital. They are admitted when be- tween the seventh and eleventh year of their age ; and are maintained and educated till they reach their four- teenth year. Their present number is one hundred and twenty, and they, together with the matron, masters, and domestics, form a family, of about one hundred and forty persons. ToAvards the end of September, 1804,1 visited one of the youngest of the children, in fever. I found him la- bouring under symptoms of scarlatina, which had been epidemic in the town, for some months. He was moved immediately to the sick room, and thus secluded from his companions; and I directed every precaution to be em- ployed, in washing and ventilating the apartment or ward which he had left. The whole of the children were con- fined within the precincts of the hospital, lest, through communication with their relations in town, they might be affected with the fever, and thus add to the accumula- tion of contagion. I was not, hoAvever, fortunate enough, indeed I did not expect to be so, to make this the solitary instance of the SCARLATINA. 151 disease, in the midst of so numerous a family. Day after day, my sick list increased; and during three months that the fever prevailed in the hospital, upwards of fifty of the children passed through it. And I remarked, that by far the greatest number of the sick came from the ward in which my first patient had lain. About the end of the year, the last of my little patients left the sick room, Avhich Avas then shut, and it has fortu- nately continued so, to this date, 15th of March 1805; and some weeks have now elapsed, since communication with the toAvn has been opened. In all the children, particularly in those who were first affected, the symptoms were so mild, that but for my knowledge of the prevalence of the epidemic in town, I might have mistaken the disease on its first appearance, and been lulled into a blameable security. The throat was not much affected. The uvala and amygdalae Avere slightly swelled and inflamed in every instance ; in a few cases, superficial suppuration and sloughing appeared. The efflorescence on the surface was partial, and in gen- eral transitory, leaving a peculiar paleness of countenance. The eye was dull and heavy. Sickness and prostration of appetite, continued throughout the disease. The thirst was moderate ; great debility prevailed in every case; and in some, a peculiar dejection and despondency, hardly to be looked for in subjects so young. The pulse was variable ; always quick, till towards the end of the disease, when it sometimes sunk beloAv the natural standard; it was never full. The surface of the body was occasionally of a pungent heat. Obstinate constipation prevailed in general. My patients were objects of serious attention for twelve or fourteen days ; the convalescent state of almost all of them, Avas protracted for nearly the same length of time ; 152 APPENDIX, NO. III. and x weeks elapsed before some Avho entered the sick room, left it. Such was the appearance, and such is the history of this epidemic in Heriot's Hospital; in conducting the cure of which, I employed purgative medicines fully; Avhile food suited to the weak appetite and feeble powers of di- gestion, was directed. The effect of the purgatives was favourable. The feces were hard, generally of a black, or greenish colour, and fetid; and sometimes of the colour and consistence of clay, and less fetid. In proportion to the evacuation of these feces, relief Avas perceptible. Returning appetite and vivacity accompanied the decline and cessation of the various symptoms. As the weather had become cold, and otherwise incle- ment, the children were detained in the sick room, for many days after they were perfectly well; purgatives Avere administered, as the state of the bowels demanded ; and the general Avarm bath was repeatedly used, on the supposition, that, by its restoring a perspirable state of the skin, it would, in concert with the purgative medicines, tend to prevent dropsical swelling, Avhich, from the symp- toms, I greatly dreaded. At last, healthy and robust, and impatient of farther restraint, the convalescents were permitted to return to their particular Avards, and in no long time, to mix with their companions in school, and at play. Happy I am, that I had been thus careful and provident in using these precautions ; for I haAre to relate the fate of three boys, Avho in two or three weeks from their passing from under my care, Avere again reported as unAvell, and again appeared in the sick room. Their symptoms, and their fate were the same. They had a leucophlegmatic SCARLATINA. 153 look, incipient anasarca, total prostration of appetite, scan- ty, if not suspended secretion of urine, swelling of abdo- men, obstinate constipation, nausea, extreme debility, and feeble pulse. Alarmed by these symptoms, I requested Messrs. Alex- ander and George Wood, surgeons to the hospital, to join me in consultation. Suitable cordials were ordered, and purgative medicines, of appropriate quality, and in repeated doses, Avere directed. The disease in all the three, proceeded with a rapidity, which afforded little farther opportunity, for deliberation or action. The stomach gave way; all food, cordials, and medicines, were rejected, by vomiting. The watery effusion rapidly filled the cellular membrane, and every cavity. Within less than thirty-six hours, from the recurrence of com- plaint, the boys died, labouring under symptoms, denoting ascites, hydrothorax, and hydrocephalus. This termination was altogether new ; I had never seen dropsy from scarlatina fatal. In consequence of this event, I approached the Hos- pital for many days, under deep anxiety, because I was conscious, that other children were, at the time, in a situa- tion which might lead to the same unfortunate issue. I continued to pay unceasing attention to the alimentary canal, which every day's experience proved to be much disordered. Strong purgatives Avere given, in large and repeated doses, sometimes twice and thrice in the same day, before the necessary evacuation was procured. In some instances, the colon, hard, and distended, could be traced by the finger, in those places where it approaches the parietes of the abdomen. In two cases, general fulness of the belly, oedema of the 154 APPENDIX, NO. III. lover extremities, nausea, retching, and scanty secretion of bloody coloured urine, shewed themselves. In these, stimulating glysters supported and promoted the efficacy of the purgatives, and ensured a determination doAvn- wards; without which, I am satisfied, I should have had to regret the loss of two other boys ; one of Avhom had taken, Avithin the space of twenty-four hours, a drachm of the mass of the aloetic pill, and thirty grains of the sub- muriate of mercury. The other, Avhen danger was over, was much distressed, by affection of the mouth, and bloody ptyalism, the consequence of the quantity of calomel preATiously given. For greater security, an additional apartment was open- ed for convalescents. Here, they were sedulously watch- ed ; purgative medicines Avere occasionally employed, to secure and establish a regular state of the belly ; and returning appetite was satisfied with light and nourishing food. I always inspected the alvine discharge of the sick' the quantity of which, varying in consistence, colour, and fetor, daily evacuated during the fever by each boy, was astonishing to me. An emetic was given occasionally, but not generally, on the approach of the fever; and toAvards its decline, a moderate quantity of wine Avas allowed This seemed to be necessary, in a few instances ; but to avoid the appear- ance of partiality, the practice of giving it was general. Gargles, composed of port wine, diluted with water, or of vinegar and water, sweetened with honey or sugar, Avere also employed in a few cases ; as were s. line and diapho- retic mixtures. At length, under this management, care and anxiety on the present occasion came to a period. SCARLATINA. 155, Royal Infirmary, Nov. 17tb, 1804. JAMES RITCHIE, Soldier, jEtatis 19. Feels great pain and difficulty of deglutition, the inter- nal fauces being of a deep red colour, and the tonsils considerably sw^ led, Avith a large greyish coloured slough occupying the left one : complains of headach, general oppression and debility. Appetite is bad—puise 1U0— skin very hot—tongue very dry—thirsty—beiiy slow.— He was attacked with these symptoms four days ago, and can assign no cause for his complaints. Has used no remedies. Let him have the bolus of Ja'ap and calomel. Take of the oxygenated muriatic acid two drachms. Spring Avater sixteen ounces. Make a mixture to to be kept in a dark place, of Avhich he is to take an ounce out of a glass tumbler every two hours. Aov. 18th. Headach, sickness, and oppression are re- lieved—tongue less parched—surface less pungently hot —pulse about 100, rather feeble—state of internal fauces as described, with difficult deglutition—countenance pale —no stool. Take of the tincture of jalap six drachms, Water of eanella alba two drachms, Sugar one drachm. Make a draught to be taken immediately. The ammoniated oil to be applied to the external fau- ces by means of a piece of flannel. Let the oxygenated muriatic acid be continued. 156 APPENDIX, NO. III. Nov 20th. One easy stool—skin cool—pulse calm- countenance less pale—deglutition more free. The draught of the tincture of Jalap to be repeated. The oxygenated muriatic acid to be continued, —-----24th. Affection of internal fauces, and febrile symptoms gone—appetite improves. ------25th. Tongue clean—belly regular. Discontinue the oxygenated muriatic acid. ------29th. Continues feeble—countenance pale, and expressive of langour. Let him have of the aromatic mixture of peruvian bark, one ounce, every three hours. Full diet. Dec. 3d. Since yesterday, considerable oedema has occurred. By account, urine has been in natural quantity, and boAvels regular—puise about 70. Let him have immediately the bolus of Jalap and calo- mel, to be repeated in the evening; also early tomorrow morning unless the bowels should be sooner moved. Discontinue the bark mixture. ------4th. Three stools ; the last of natural appear- ance—oedema abated. Tavo bolusses taken. Let the bolus of jalap and calomel be repeated to- morroAv morning. No stool. —----- 5th. Take of tartrite of soda one ounce, Infusion of senna two ounces, Bran decoction one pound. A solution to be made and taken in divided doses. SCARLATINA. 157 Dec. 6th. Five Avatery stools—oedema continues, ra- ther aggravated, Avith considerable dyspnoea, particularly during last night—pulse 60, and soft. Take of the submuriate of mercury twelve grains, Powdered Jalap half a drachm, Let them be rubbed together and divided into four equal parts—one to be taken every three hours. ■------7th. Has had plentiful alvine discharge, of natural appearance—urine is also natural and abundant— oedema seems abated, and dyspnoea relieved—the powders taken—mouth not affected. Let the poAvders as prescribed yesterday, be repeated tomorroAV morning. ------8th. Has had two stools, rather scanty—dysp- noea still rather relieved—one powder only taken. Let the poAvders be continued—one to be taken every three hours. Take of tartrite of soda six drachms, Infusion of senna two ounces, Spring Avater one pound. A mixture to be made and taken in three doses tomor- row morning. ■------9th. Three poAvders taken—four stools—-but the alvine discharge on the Avhole scanty, of a green co- lour, and fetid—urine scanty, of a dark and almost bloody colour—oedema continues—breathing easy—mouth is affected. Let the solution of tartrite of soda as yesterday pre- scribed be repeated immediately ; to be again re- peated tomorrow morning.| ______10th. Sickness and vomiting after the last dose O 158 APPENDIX, NO. Hi. of solution this morning—alvine discharge more abun- dant and natural—urine also in greater quantity and more natural—oedema abated. Beef broth one pound daily. Bason of tea to breakfast. Dec. 11th. OEdema still more abated—feculent dis- charge, of natural quantity and appearance. Let him have two aloetic pills, every morning and evening. Port wine eight ounces daily. ---■---13th. Belly regular—cedema gone, and coun- tenance more lively than hitherto. Let the Avine and the aloetic pills be continued. ------ 16th. Has had two stools daily, in abundant quantity, and of natural appearance. Let him take two aloetic pills only, every day. -. ■. 24th. Dismissed cured. SCARLATINA. 159 Royal It fir mary, Feb. lltb. 1805. WILLIAM GORDON, Mutatis 22. Complains of pain of throat, Avith some difficulty of deglutition—the internal fauces are of a deep red colour— general redness of surface—frequent scanty stools, with tenesmus—loss of appetite—pulse 98—tongue loaded— thirsty—skin Avarm. Was attacked three days ago Avith general pains. The efflorescence appeared yesterday. Has used no remedies. Let him have of the tartrite of soda and potash six drachms, Infusion of senna two ounces, To be taken at two doses out of six ounces of the infusion of flaxseed. ,______12th. Has had several stools—efflorescence faded—internal fauces relieved—pulse calm—tongue load- ed—much thirst and languor. Let him have the anodyne draught in the evening TomorroAv morning the cathartic solution as pre- scribed yesterday. The tepid decoction of bran ad libitum. ------ 13th Tongue cleaner—febrile symptoms and eruption gone—-a good night—is less languid—pulse calm four stools. The anodyne draught to be repeated in the evening, ______ 14th. A quiet night—two stools of natural ap- pearance—free of complaint. 16o APPENDIX, NO. III. Repeat the anodyne draught. Let him have ten grains of powdered rhubarb every morning. Feb. 15th. One stool. Convalescent. The anodyne draught to be repeated. ------ 17th. Belly regular—stools natural. Full diet. ------23d. Belly open—tongue loaded. Let him have of ipecacuanha, one scruple in the eve- ning. The anodyne draught at bed time. .—---24th. No vomiting—tongue clean—purging gone. "——28th, Dismissed cured. SCARLATINA. 161 Royal Infirmary, Jan. 6tb. 1805. ALEXANDER CORNER, JEtatis 7. Complains of almost constant headach, and occasional vertigo—pain of abcomen, Avith some tension and swelling —the pupils appear dilated—disturbed sleep, from which he sometimes awakes with a loud scream—loss of appe- tite—feebleness—pulse 90—skin rather hot—tongue moist —thirsty—belly costive—he has a slight excoriation on each haunch, from lying on them iong. The above symptoms have been present three weeks, and succeeded a fever which was accompanied with gene- ral efflorescence of surface and sore throat, followed by desquamation of the cuticle: during the fever he took an emetic. Two days ago he took a dose of senna and manna, but with little effect. Let him have of powdered jalap six grains. Of the submuriate of mercury three grains. Of Avhich a bolus is to be formed to be taken imnic mediately. ------7th. As yet no stool. Let eight ounces of the common enema be injected immediately. Let him have four bolusses, as prescribed yesterday ; of which he is to take one every three hours. ------8th. Three stools, dark and fetid—an incon- siderable quantity ; the first, after the injection ; the se- cond, after the third bolus ; the third, this morning, the fourth bolus being previously given—has passed a bad i62 APPENDIX, NO. III. night, awaking suddenly, screaming, from short sleeps, but complains less of headach, and more of pain of abdo- men—pupils seem to possess more contractility—appetite indifferent—pulse 80, and s»ft. Jan. 9th. An easier night, sleep being of longer con- tinuance, he aAvakes less suddenly, and without screaming —by his account, is free of headach, but complains of pain of abdomen—countenance at present pale—pulse towards 100, and feeble—a fetid, fluid, and dark coloured stool—urine in small quantity, and high coloured—little food taken. Let him have of the compound powder of Jalap one scruple immediately ; to be repeated tomorrow morn- ing. A small bason of tea, morning and evening. ------ 10. Countenance more florid, and expression more lively—pain of abdomen gone—tongue clean— pulse calm—surface cool—tAvo stools, both abundant, and of more natural appearance and odour—some food taken, and seemingly relished—both powders given—a good night. Let the poAvderbe repeated as prescribed yesterday. ------11th. Free and full feculent discharge, and he continues free of complaint. Let him have with him tAvelve of the compound powders of Jalap as prescribed above. Signa, one to be taken daily. Dismissed cured. SCARLATINA. 163 Royal Infirmary, Jan. 145 Let him take of this mixture, after agitating it, half an ounce every two hours Let the abdomen be bathed with a little of the anodyne liniment three or four times a day and wrapped in flannel. Jan. 14th. Has had a pretty copious fluid and feculent alvine discharge, accompanied with much flatus—passed a bad night, but pain of aodomen, and accompanying ten- sion, for the present, are subsided—has nearly declined all nourishment—tie Avine has been ta^en with reluc- tance—mixture sparingly given, on account of its exciting retching. Pulse quick, but firmer. Take of the solution of assa faetida one ounce, Water five ounces. Make a mixture to be injected as an enema. Let the other prescriptions be continued as yesterday. ------ 15th. Injection, after being retained for some time, was returned, accompanied with much flatus and feculent evacuation. This last, since yesterday, has been copious, nearly of natural appearance, but containing somewhat, resembling scybala; food has been taken ; wine relished, and mixture used ; complains less of pain of abdomen, swelling and tension of which are abated. Repeat the enema of the solution of assa faetida. Continue the prescriptions. ------16th. Injection retained till the morning; dis- charge of flatus and feculent evacuation has been less abundant, but tension and pain of abdomen, continue re- lieved ; food, wine, and mixture, taken. The wine and the mixture of magnesia to be continued. A little beef stake to dinner. ______17th. Three stools, copious, and of clay-co- P 170 APPENDIX NO. IV. lour; belly rather tense; a good night; appetite continues to improve. TheAvine and the mixture of magnesia to be continued. ■----- 18th. Copious feculent discharge, resembling that which has been voided for some days past; belly less tense, and less pained ; much flatus has been voided; appetite and strength are improved, and looks are more lively ; injection has not been given. Omitting the enema continued the other medicines. —----20th. Daily and copious alvine discharge, partly fluid, and partly costive as formerly, somewhat re- sembling scybala, but now of more natural appeal ance and odour; pain and tension of abdomen continue to abate ; and strength to improve. Let the medicines be continued. ------21 st. Let the wine and the mixture of magne. sia be continued, of which he is to take but half the quantity every day. .------24th. Belly continues regular; stools, except being somewhat of a whitish colour, natural; some fulness of abdomen remains, but pain is gone; quiet nights; appetite good ; is become more active, and more lively. Discontinue the wine. ------28th. Has continued convalescent. Let him have of the compound powder of jalap one ounce, to be diA'ided into sixteen doses. Signa, one to be taken once or twice a day, so as to preserve a regular state of the boAvels ; Avarmth of surface and nourishing food, recommended. Dismissed cured. MARASMUS. 171 Royal Infirmary, Jan. IStb. 1806. ALICIA CASSIDT, JEtatis 7. *• Complains of a constant and frequently severe pain about the umbilicus, and of occasionally severe headach ; she is observed to pick her nose much, and to start in her sleep, screaming violently; her abdomen is full and prominent; pulse quick and small; tongue loaded ; belly very irregular ; appetite voracious ; her countenance is pale and languid, and she is said to have been falling off in respect of flesh and strength for the last eighteen months. January 19th. Take of the submuriate of quicksilver twelve grains, Powdered jalap, Sugar of each half a drachm. Mix and divide into eight doses of Avhich she may take one morning and evening. ______20th. Plentiful alvine evacuation, partly fluid, partly consistent, and of a.whitish ciay colour. The powders prescribed yesterday to be continued. ------21st. Has had a copious, partly fluid, and partly consistent, dark coloured alvine evacuation. Let her take the powders as above prescribed thrice a day. ______22d. Alvine evacuation is scanty, consisting chiefly of dark coloured scybala. Let the submuriate of quicksilver be continued, and early tomorroAv morning let her take at two doses Four ounces of the infusion of senna, 172 APPENDIX NO. IV. ------24th. Alvine evacuation of yesterday copious, partly of a clayish consistence, and partly fluid with scy- bala ; the feces are fetid. Let her have late at bight the compound bolus of jalap with submuriate of nuicksilver six grains, and Early tomorroAv morning of the infusion of senna three ounces at tAvo doses. Discontinue the powder of the submuriate of quick- silver. ------25th. Spontaneous vomiting some hours after taking the bolus ; several stools since morning, consistent, of more natural appearance and smell; starting, screaming under night, picking of the nose, with py*e look and Avasted appeal ance continue, complains less of gripes, and of headach ; and appetite is less voracious ; abdomen less full and tense ; pulse firm ; tongue clean. Let her have of po't Avine three ounces, and Beef broth a pound daily. Every morning o7 the compound poAvder of jalap tAvo scruples. ------26th. Alvine evacuation pretty copious, some- what scybalous, but of more natural appearance and less fetid. Continue the compound poAvder of jalap, Wine and the beef broth. .------■ 27th. Alvine evacuation sufficiently abundant; fluid, without scybala, or unusual fetor. ------28th. Has easy nights without screaming or starting ; fulness of abdomen gone ; is less disposed to pick the nose ; countenance clear ; eyes lively ; appetite natural; belly regular ; she is become playful and active. Discontinue the compound poAvder of jalap and the wine. MARASMUS. 173 -------30th. Free of complaint, but belly is rather slow, and feces consistent and of a white colour. Take of the submuriate of-quicksilver, Sugar, of each three grains, Mix into a poAvder to be taken every night. Take of the infusion of senna, Infusion of flaxseed of each an ounce, The inspipated juice of liquorice half a drachm, Make a mixture to be taken every morning. ------ 31st. Alvine evacuation has been more than usually copious ; it is lumpy and of a whitish colour without fetor ; her looks continue to improve in respect of colour and liveliness of countenance ; easy nights. Continue the/infusion of senna and the poAvder, Feb. 1st. Alvine evacuation less abundant than that of yesterday ; it is still lumpy, but of a natural colour. Repeat the submuriate of quicksilver and the infusion of senna. ------2d. Feces in respect of quantity and appearance correspond with the description of yesterday. Repeat the medicines. ______3d. Full alvine evacuation of the consistence and appearance last described ; she continues free of com- plaint. Let her have powdered jalap an ounce divided into tAventy four doses. Signa, laxative poAvders ; one occasionally, so as a regu- lar alvine evacuation is procured, Dismissed cured. P 2 174 APPENDIX, NO. IV. TRADES MAIDEN HOSPITAL, September 25th, 1805. About the middle of August last, Euphemia Winter, one of the children entertained in this Hospital, twelve years of age, complained of severe headach, sickness, and constant vomiting of the contents of the stomach. Mr. Wood, surgeon of the Hospital, asked me to visit her, which I did a few days after the appearance of the above symptoms. She was confined to bed. She appeared to be languid ; her eyes were heavy, but she was strongly susceptible of the impression of light, Avhich gave her much uneasiness ; her pulse was feeble. With these she laboured under prostration of appetite, want of sleep, and obstinate costiveness. She had been taking pills of calomel and rhubarb, with little effect on her bowels ; but her mouth became sore, and her breath acquired the mercurial fetor. We were not without apprehensions for the event of these symptoms, which seemed to us to indicate approach- ing hydrocephalus. We put our patient on a course of aloetic pills, of which ten grains Avere frequently given for several days together, and the calomel was omitted. The alvine discharge became more copious ; it was pe- culiarly fetid, and of a dark green colour. The propen- sity to vomit having subsided ; powder of jalap in doses of fifteen grains, repeated at short intervals, was substituted for the aloetic pills. Under this course, the belly became more and more regular ; till at last natural motions Avere procured ; and the different complaints gradually abated. In four weeks from the first attack, this girl, furnished with proper pur- gative medicines, went to the country, for the complete re-establishment of her health. MARASMUS. 175 st. Andrew's square, September 18th, 1805. MY DEAR SIR, I shall be happy to give you an account of the case of my daughter, whom you, and Mr. Benjamin Bell did me the favour to attend, in summer 1803. The child was then about three years old. and had been falling off in her health, some time before you saw her. She was then pale and languid, with a quick pulse, loaded tongue, and impaired appetite. But as she was reported to have had regular and daily evacuation of her bowels, none of these symptoms were ascribed to, costiveness. Soon after you began to visit, however, you suspected an accumulation of feces, to be the chief of her complaint, and wished to treat the case, accordng to this view. But, notwithstand- ing every proper remedy was employed without loss of time, she got gradually Avorse for some days ; till at last she shoAved some tendency to stupor, accompanied with pain in her head, and throbbing of her temples. The presence of these symptoms suggested a suspicion of an incipient attack of hydrocephalus, which made so strong an impression upon the attendants, that leeches Avere applied to the head, end the blood discharged, produced some temporary relief. Notwithstanding all these varia- tions in the symptoms, however, you still continued steady to your original opinion, and persevered in the practice of giving laxative medicines. Perseverance in this plan, gradually unloaded the boAV^ Is, from a quantity of feculent matter, Avhich appeared to have been lodged for a conside- rable time, and procured very manifest relief. From the time of this salutary discharge, the spmptoms became dai- ly more moderate, till at last the recovery was complete. 176 APPENDIX, NO. IV. Upon revieAving all the circumstances of this case, which naturally attracted much of my attention, I regard it as a satisfactory illustration of your opinion, respecting the effect of costiveness, in exciting much distress, and in producing symptoms which counterfeit diseases, that are generally supposed to have a very different origin. I am With much respect, My dear Sir, Ever, most sincerely, Yours, Sec. James Russel, Dr. James Hamilton. *:&*?. MARASMUS. 177 NEWINGTON-HOUSEj September 20th, 1805. Dear Sir, As you favoured me with the perusal of the manuscript, which you are about to publish, on the utility of purga- tive medicines in certain diseases ; and as the practice, which you inculcate meets with my approbation ; I think it right to communicate to you a remarkable instance of the good effects of this practice, Avhich has recently oc- curred to me, in one of the most fatal diseases with which we are acquainted. On Wednesday, the 4th instant, I received an anxious call from a lamily newly arrived at one of our hotels, from the distance of forty miles, with their eldest daughter, a girl of about eight years of age ; who had become unwell on Saturday the 24th of August last. Her symptoms, when I visited her, were, severe head- ach, greatly aggravated by motion. Pulse 96, and irreg- ular ; the pupil of each eye, was more dilated than in health, scarcity of urine, an uncommon dryness of the skin ; and no discharge from the nose. All the remedies that are commonly used in ordinary cases of headach had been prescribed, without any ad- vantage ; such as the locai discharge of blood by leeches j the discharge produced by a blister, and gentle doses of calomel and jalap. 178 APPENDIX, NO. IV. The symptoms being aggravated by the journey ; I again advised leeches to be applied, and a laxative of calo- mel and jalap to be given ; which operated properly, and afforded relief. The head was likewise shaved ; but the case being highly important, I advised an early consulta- tion, which being agreed to by the family, Dr. Monro, senior, and Mr. James Russel, surgeon, one of my part- ners, met with me, accordingly, next morning. The opinion adopted at this consultation, was, that the symp- toms were those of hydrocephalus internus. We direct- ed a grain of calomel, and the same quantity of the pow- der of foxglove, to be giAren three times a day ; a drachm of the stronger mercurial ointment to be rubbed on her limbs, evening and morning ; a blister to be applied to the crown of the head ; and the poAvder of betony to be used as snuff, in order to excite a discharge from the nose. " This plan was continued, and in the course of the third day, the gums were red and swelled, but still no benefit was derived from the mercury. The pain of the head had been relieved by the leeches, but it soon became as violent as before ; the iris Avas, in a considerable degree, insensible to the stimulus of light, and the pulse was quick and irregular. With these symptoms, she now complained of severe pain in her bowels, which led to the suspicion, of their being oppressed Avith an accumulation of feces, notwith- standing the laxatives which had already been given. A full dose, therefore, of an infusion of senna was exhibit- ed, on the morning of the 9th instant. Next day, we found that the senna had purged briskly, not less than nine times ; and at every motion, that a large quantity of black coloured feces, fully formed, and uncommonly fetid, had been discharged. MARASMUS. 179 Perceiving that she was relieved, her head being less pained, and the pulse more regular, another dose of senna was given, early in the forenoon of the 11th; and the mercurial med.cines were omitted. This dose also, ope- rated briskly, and brought off, notwithstanding the large evacuations of the preceding day six or seven copious stools, all of them uncommonly letid, and of a dark co- lour. She suffered much from sickness, oppression, and gripes, during the operation ot both doses of senna; but immediately after tne last dose, every symptom of dis- ease vanished. The headach was felt oniy on quick mo- tion ; her eyes recovered their natural appearance ; heri pulse was regular; and she became equally alert, as in her best health. On the 12th, she had a third dose of senna, not how- ever, so strong as the preceding ones ; but nevertheless it procured three or four stools, less fetid than the for- mer, and of more natural appearance. On the morning of the 13th, our patient informed us, that she was cured of all her complaints. And her mo- ther, who watched her carefully in every state of her illness, said, that ever since the violent purging, produc- ed by the senna, on the first exhibition of it, she, as well as the servants, had remarked, that a disagreeable noise which took place, during the sleep of our patient for several years, and which was occasioned by the grinding of the teeth, had ceased. As our patient continued perfectly well; she Avas per- mitted to return to the country, on the 17th instant. Her mother was directed to give her repeated laxatives for some time, to prevent immediate accumulation of the feces; and to interpose them on any occasion in future, 180 APPENDIX NO. IV. when the stools appeared to be unnatural, or not sufficient- ly copious. I remain, dear Sir, Your's, faithfully, Benj. Bell. Dr. Hamilton, 4, Nicholson's Street, Edinburgh. The mother of this girl, wrote to Mr. Bell on the 29th Oc- tober 1805, to the following effect: « Dear Sir, " As you were so good as to request me to let you hear again of my little girl, I trouble you with a few lines, to say, she is now almost quite well; indeed Avhen she does not take too much liberty with herself, she is entirely well. I Avas impatient Avhen I last wrote you ; but your ansAver was very satisfactory, and bus turned out exactly true. It must be admitted that purgative medicines have been her cure, which I find necessary to continue once a week, but hope as she gets stronger, these may be got rid of. I remain, Dear Sir, Your humble Servant, These cases, from Mr. Russel and from Mr. Bell, gen- tlemen in full practice, and of high professional resptca- MARASMUS. 181 bility, are singularly important. The practice therein set forth, coincides with, and corroborates the sentiments which I entertain respecting marasmus, as inducing, or as connected Avith hydrocephalus in tenuis. Stronger and more decided proofs of the utility of purgatives, given in these instances, which had so much of the character and appearance of hydrocephalus, cannot be desired. They give a confidence in the prosecution of a simple practice, which, when fully established, as I doubt not it Avill be, will rob this scourge of infancy, of childhood, and early youth, of much of the terror which its dreaded approach has hitherto been Avont to inspire, by remoAdng in main instances a tendency to a disease, for which, Avhen once fully formed, we are Avithout a remedy. Q 182 APPENDIX, No. V. CASE OF CHLOROSIS. Edinburgh, 30th October, 1805. A young lady, about 14 years of age, of a very deli- cate constitution, and small growth, never menstruated, had for many months been pair and emaciated, and affec- ted with a preternatural quickness of pulse ; she had been subjected to the ordinary treatment t mpioyedin chlorosis; about the middle of October her pulse was so high as 140 in the minute ; her stomach soon became very irritdblef and for some Aveeks she retained nothing ; whatever she took was rejected in the course of a few hours in a very undigested state ; she was reported to have been rather costive ; was ordered effervescing draughts, with aglyster at bed-time. October 31st. Much the same. Take of the mass of stomachic pills 12 grains, Calomel tAvo grains. To be taken about mid-day. Had one scanty bound stool in the evening, of a very dark colour and almost in the state of scybala. November 1st. Not much relieved—pills were repeated —had four or five dark coloured stools—belly tense to- Avards evening. An injection in the evening. CHLOROSIS. 183 Nov. 2d. Flad some passage early in the morning— the last not so dark coloured. Continue the saline draught. Let the pills be repeated tomorrow morning. ------3d. No vomiting for 24 hours ; three evacua- tions of a dark colour, not very copious. ------4th. No A'omiting ; pain and tension of lower belly. Repeat the pills immediately -----. 5th. No return of vomiting ; had a darkish passage late in the evening. ------6th. No return of vomiting. Let her have of the mass of stomachic pills fifteen grains. Calomel three grains. ------7th. Appetite improved; in the evening a copious stool, more natural than any of the former; pulse about 96. ------8th. Much the same ; took six drachms of rochelle salts in the morning, Avhich did not operate ; had an injection in the evening which brought off but little ; this however was more natural in colour and smell. ------9th. Continues better. Let the stomachic pills be repeated in the dose of fifteen grains. Calomel three grains. To be taken immediately. ------10th. Had a copious stool, figured and dark coloured. Let her take tomorroAv morning, in a glass of water, four ounces of the following solution. 184 APPENDIX, NO. V. Take of soluble tartar three ounces. Sulphate of potass Avith sulphur half an ounce Water one pound. Nov. 11th. Vomited the solution. Omit the solution. Take of magnesia, Peruvian bark in poAvder of each two drachms. Water four ouuces. Mix. To take an ounce at noon. —:---- 12th. No vomiting; gums still slightly af- fected. The patient continued easy and rather improving in health; but stools never quite natural, and even at the last occasionally passing some indurated feces and scybala till she Avent to the country on the 2d of December. She was advised to continue the use of purgative medicines. Mr. Russell has lately informed me, that this patient quick- iv recovered pei Ect health, under the use of the purgatives ■Inch had been recommended. 185 APPENDIX. No. VI. CASES OF HAEMATEMESIS. Royal Infirmary, Feb. I8tb 1805. MARTMUNRO, JEtatis 28. Has pain and sense of Aveight at the scrobiculus cordis,' increased on pressure. Headach and virtigo, vomiting of ingesta, and sometimes, by account, grumous blood, to a considerable extent, is brought up by coughing—much debifity, and lowness of spirits—appetite impaired—pulse 80—skin cool—belly habitually costive—catamenia regu- lar, and rather profuse—says she has had stomachic complaints, more than a year and a half—the discharge of biood occurred first about the beginning of this winter, preceded by occasional ep'.staxis for a month before—has used no remedies before admission, but has taken a con- since, which procured a darx. greenish stool. To take three of the aloetic pills every three hours. U. 2 18G APPENDIX, NO. VI. ----- 19th. By account, two dark greenish coloured stools have been passed this morning. Let the aloetic pills be continued as prescribed yes- terday. ------20th. Twelve pills taken—five copious dark greenish coloured stools—stomachic symptoms, headach, and virtigo are relieved—pulse calm—no vomiting. ■------21st. No stool—no vomiting—weight at epi- gastrium—pulse calm. Let the aloetic pills, as prescribed above, be repeated. ------22d. Several stools of more natural appear- ance—no return of vomiting—stomachic symptoms still more relieved, and expression of countenance more lively. -------23d. No stool—apparently convalescent—ap- petite good. Take of the sulphate of magnesia three drachms, Supertartrite of potass one dracnm. Mix. To be taken every morning in six or eight ounces of water. ______26th. Belly has been regular—appetite has continued good, and to all appearance she has been free of complaints. Let her have of the compound powder of Jalap tAvo ounces, divided into thirty doses. Direct one each morning. dismissed cured- HiEMATEMESIS. 187 Royal Infirmary, April 28tb 1805. JEAN CLARKINSON, Mtatis 29. Complains of general soreness in her breast, with great oppression about the praecordia, headach, and some degree of langour. Says she has been affected for three weeks, with frequent vomiting of fluid and dark coloured blood, sometimes to the amount of a pound or more— that she lias always vomited trore or less, every day du- ring that time. At present she has little or no cough; but Avhen she first became affected, she had a severe cough, with great hoarseness. Pulse at present 66, and very weak—tongue white— belly habitually costive—appetite impaired—catamenlu natural. Attributes her complaints, to carrying heavy loads of coals—has been using the pulvis cinchonae, with porter, without relief. ------29th. A small discharge of blood, brought up apparently Avithout retching—no stool since admission. Let her have immediately the compound bolus with eight grains of calomel—and late at night, unless the bowels should have been previously moved, the common enema. A pound or two of beef broth every day. April 30th. General soreness of breast—oppression about praecordia—headach and faintness are relieved— pulse firmer, and expression of countenance more lively —a copious, fetid, dark and greenish coloured alvine evacuation—no vomiting. 188 APPENDIX, NO. VI. Let her have tAvelve of the aloetic pills ; to take three every tAvo hours ; and after taking the pills, let the enema be repeated as yesterday. May 1st, Injection not given—has had two pretty co- pious stools—feces formed, but still of a dark and green- ish colour—uneasiness of praecordia—oppression of the breast, and headach are still more relieved—no vomiting, The compound bolus of Jalap as above prescribed to be repeated in the evening, and tomorrow morning early, let her take of the tartrite of soda and potass an ounce in water. -------2d. No vomiting—in other respects, free of complaint—a very copious alvine evacuation since morn- ing, and of more natural appearance than hitherto. The cathartic medicines to be repeated as prescrib- ed yesterday. -------3d. Has had pretty full alvine evacuation ; someAvhat costive, but in colour, more approaching the natural. Is free of complaint. Let her have of Jalap in powder four drachms, divi- vided into eighteen doses. Direct one occasionally. Dismissed cured. H^MATEMESIS, 189 Royal Infirmary, April Wtb 1805. MARTHA IRVINE, JEtatis 23. Says, that on Sunday, the 27th ultimo, she became affected Avith great difficulty of breathing, severe pains through her chest, and a sense of great Aveight about the region of the stomach ; Avhich complaints were im- mediately succeeded by violent retching, when she dis- charged a quantity of clotted blood, and immediately felt herself relieved. On the ninth, the above symptoms re- curred, and she vomited about a pound of liquid, which, in every respect, resembled pure blood; and yesterday she discharged nearly the same quantity; since which time, she has been pretty easy—Complains at present, of a general soreness in her breast—of a sense of, great weight in her stomach—frequent rough, and occasional headach—pulse 72, and Aveak—tongue Avhite—belly, by account, has been regular, and catamenia natural—at- tributes her complaints to fatigue, and carrying heavy loads—has used no medicines. -----■ 12th. Cough, by account, is of a fortnight's duration, and has been accompanied Avith pain about the middle of the sternum—no stool since admission—tongue clean—pulse calm and feeble Let her have of the common emulsion one pound daily. -----13th. No stool—no vomiting—cough has be- come less frequent, and by subsequent account, the pain mentioned yesterday, seems to be seated about the scro- biculus cordis. Headach is increased, and she complains of oppressive sickness—pulse toAvards90, and firmer. Continue the emulsion. 190 APPENDIX, NO. VI. April 14th. Has had neither vomiting, nor evacuation by stool—cough nearly gone—headach, and much sick- ness continue. Continue the common emulsion. ------- 15th. Ffas had neither passage of belly, nor vomiting—complains of severe headach and sickness— oppression and pain of epigastrium—cou0h gone—pulse calm. Let her have the purging enema. Omit the emulsion. ------16th. Headach and oppression of praecordia continue—sickness relieved—no A-omiting—copious alvine discharge after the injection. Let her have immediately the compound boius of jalap with ten grains of calomel, and late at night the common enema unless her bowels should have been freely moved. ------ 17th. Headach and oppression about praecordia are much relieved—expression of countenance lightened —very copious, consistent, dark coloured alvine evacua- tion. Let the bolus and also the enema be repeated imme- diately, as yesterday ------ 18th. Alvine evacuation similar to that of yes- terday—injection not given—vomiting of blood has not recurred, and she is free of complaint. Repeat the bolus as above prescribed. ------ 19th. Alvine evacuation resembling the last but in smaller quantity-—no recurrence of complaint. Let her have twelve of the pills of aloes andcolocynth Direct two every night. Dismissed cured. H-EMATEMESIS. 191 I did not doubt the veracity of this patient, Martha [rvine.----Her symptoms and her appearance convinced me that she laboured under haematemesis; but I was willing that the existence of the disease, should be placed beyond a doubt, by the actual discharge of blood, in order, that my practice, which was to todow, might be more decidedly conclusive in favour of purgative medicines, in this disease. I therefore temporised for the first four days. But her sufferings increasing, commiseration for my patient made me desert my scheme. I could not longer with-hold the certain means of relief which I had at command. In five days from my first employing these, she left the Hospital, in perfect health. 192 APPENDIX NO. VI. Royal Infirmary, Nov, 6tb. 1805. BETTY ROBERTSON, JEtatis 20. Complains of a sense of weight, and great uneasiness about the chest and praecordia, headach, and great lan- guor. Her eyes are dull—her countenance pale, and expressive of much distress—has some difiiculty in breath- ing, but little or no cough—says that in the course of last night and this morning, she has discha >-ed. by vomiting, a considerable quantity of pure liquid but dark coloured blood—pulse quick and soft—tongue Avhite—belly habitu- ally slow, and for the iast four days she has had no stool— catamenia natural—knows of no cause for her complaints. Let her have immediately twelve of the aloetic pills To take three every three hours. ------7th. Uneasiness about the praecordia, and sense of weight somewhat relieved—headach gone—pills taken —one costive dark coloured and fetid stooi—no recur- rence of bloody discharge. Take of the sulphate of magnesia five drachms, Infusion of senna two ounces, Infusion of flaxseed four ounces. Mix. To take two ounces every hour. -------8th. By mistake the mixture Avas omitted— no stool since yesterday—slight return of haematememe- sis—complains more of uneasiness and tightness across the chest. Let her have immediately the cat hartic solution as prescribed yesterday. II/EMATEMESIS. 193 Nov. 9th. Solution taken—as yet no stool—severe attack of haematemesis last night, folloAved by relief of previous uneasiness and stiffness in the chest: but she complains of a general soreness about the inferior part of the sternum. Let her have eighteen of the aloetic pills, To take three every tAvo hours. ------10th. One costive stool this morning—no re- turn of haematemesis—nine pills taken. The aloetic pills to be continued. ------ 11th. The eighteen pills taken Avith the effect of only one costive stool—but complains less of uneasiness- no haematemesis. ------ 12th. Complains of seA-ere pain about the scrobiculus cordis, of slight cough, and general uneasi- ness—pulse quick and sharp—tongue Avhite—mo stool—■ no vomiting. Let her have four of the laxative pills every tAvo hours to the fifth time. ------13th. Twenty pills taken—one scanty stool has been voided—and at three different attacks, about ten ounces of pure blood have been discharged. The purging enema in the evening. Take of the sulphate of magnesia an ounce, Supertartrite of potass two drachms, To be dissolved in a pound of water, of which four ounces are to be taken every half hour after the enema has operated. ------- 14th. A fluid and rather scanty stool after the injection—another since morning also fluid and dark coloured, Avith numerous small scybala floating in it. R 194 APPENDIX, NO. VI. Take of the tartrite of soda and potass tAvo ounces. Infusion of senna four ounces, Infusion of flaxseed one pound and half. Make a solution, of which she is to take four ounces every hour. Nov. 15th. The' Avhole of the solution being taken, pretty copious alvine evacuation has ensued—the first part of which is fluid, dark coloured, and fetid, contain- ing several scybala. The latter part is also fluid and fetid with similar scybala, but it has a more natural appearance —■expression of countenance lightenec—no haematemesis. Repeat the cathartic solution as yesterday. ■------ 16th. Alvine evacuation since yesterday ra- ther scanty, fluid, Avithout scybala, and more natural in respect of colour and odour—no haematemesis—solution taken. ------- 17th. Has had pretty copious alvine discharge since yesterday—natural in respect of colour and smell— no haematemesis—free of complaint. Take of rhubarb in poAvder tAvelve grains, Ipecacuanha tAvo grains. To be taken every morning. -------19th. Free passage of belly—appears lively and cheerful—no haematemesis. 20th. Dismissed cured. HAEMATEMESIS. 195 Mr. James LaAV, one of the surgeons of the Royal In- firmary, and surgeon to Edinburgh Bridewell, has oblig- ingly favoured me Avith the following observations, in a letter addressed to me. They are as follow: Edinburgh, Aug. 1st, 1805. My dear Sir, I have accidentally found some slight notices of cases of haematemesis, in looking over rny Bridewell records. As I had formerly been A-ery unsuccessful in removing this complaint by sulphuric acid, and other astringents; and as I received the first hint of the practice I now fol- low, from you, I think it a duty I owe to you and the profession, to lay before you all the information I can, on the subject, that you may make such use of it as you think proper, in your intended publication. I am, { My dear Sir, Your's ever, James Laav. 196 APPENDIX, NO. VI. JEAN HAT. A patient admitted the 21st March, 1804, for rheu- matic, and other complaints, Avas on the 10th of April, seized with vomiting of blood. fc Let her take three of the aloetic pills. March 16th. Vomiting of blood has ceased. It appears by the records, that this woman, being af- flicted Avith amenorrhoea, and its concomitant dyspeptic symptoms, Avas put under a course of steel, with occa- sional laxatives. April 29th, and frequently after this had epileptic fits, Avhich ceased about the 12th of May. Sept. 23d. A return of haematemesis, Avith costivre belly. f • Let her take of the compound powder of Jalap one drachm. After this, had several returns, treated Avith laxatives, and on October 25 th, was dismissed from the house, cured. HAEMATEMESIS. 197 MARGARET PEAT, Feb. I2tb 1805. Has been in the house, since November the 20th> 1804, with venereal and other complaints. Attack of haematemesis. Let her take of the sulphate of soda one ounce. ------ 13th. Salts operated gently, and the vomiting of blood almost gone. ______ 15th. Haematemesis more severe. Let her take two of the aloetic pills night and morning . ______ 17th. Continued the pills, till they operated fully, and produced eight stools—haematemesis gone, ------21 st. No return of haematemesis. N. B. In this case also, there was amenorrhoea. R 2 198 APPENDIX. No. VIE CASES OF CHOREA. Royal Infirmary, Aug. 2d. 1802. WILLIAM SINCLAIR, JEtatis 10. Affected with irregular involuntary motions of the superior extremities, and occasionally with a diseased ac- tion of the muscles of the face, producing great distor- tion in the expression of the features, attended Avith flushing in the face, pain in the occiput, and difficult ar- ticulation. Although he cannot stand erect without be- ing supported, yet he possesses in some degree t!.e com- mand over the inferior extremities, and was observed, before this took place, to drag one leg after the other. He seems much debilitated—belly is someAvhat tense and tumid—pulse acout 90, rather feeble—appetite impaired —belly regular, but the stools in small quantity. He Avas taken ill a fortnight before admission, and within these feAV days the'symptoms have become Avorse. Has used no remedies. CHOREA. 199 lug. 3d. Take of calomel three grains, Jalap powdered ten grains, Make a powder to be taken early tomorroAV morning. Jug. 5th. The stools of yesterday and this morning are copious, and of natural appearance—belly is less tense—pulse calm-—irregular motions and pain of occiput continue, but he Avalks with more steadiness. Let the powder of jalap and calomel be repeated to- morrow . .-----6th. One feculent stool since morning—head- ach and irregular motions nearly the same—his step is still more steady and firm. ------8th. Has continued convalescent. Let him have of calomel ten grains, Sugar two scruples, To be intimately mixed and divided into eight doses. Signa, one every night. Dismissed cured. -00 APPENDIX NO. VII. Royal Infirmary, Sept. \2tb. 1803. ELIZABETH LAURIE, Mtatis 14. Is affected with almost constant involuntary motions of the left arm. The muscles of the face are also involuntari- ly contracted, and in walking she is observed to drag the % left leg after her—articulation is at times impeded—skin of natural heat—pulse 75—belly, by account, regular- has laboured under this complaint two Aveeks; it Avas preceded by headach and spontaneous vomiting. She has used some medicines, with the nature of Avhich she is unacquainted. Sept. 13th. Let her haA-e immediately the bolus of jalap and calomel—and late in the evening, unless the bowels should be moved, the common enema. ~------14th. Several copious feculent but fetid stools. Let her have three aloetic pills every evening. ------15th. One stool in the course of the evening. Involuntary motions abated. The aloetic pills to be repeated in the evening, and let her take three ounces of the infusion of senna tomorrow morning. ------- 16th. Has had free passage of belly—stools more frequent, but still fetid—motions more staid. The aloetic pills and the infusion of senna to be repeated. ,------17th. Walks with increasing firmness and vi- gour-—irregular motions of left arm continue—no stoel CHOREA. 201 Let her have immediately the draught of castor oil. The aloetic pills and the infusion of senna to be re- peated. Sept. 18th. Let the pills and the infusion, as pre- scribed yesterday be continued. —----19th. No stool—involuntary motion of left arm aggravated. Let her have immediately the bolus of jalap and calomel. Discontinue the aloetic pills and the infusion of senna. ------20th. Consistent fetid bilious stool—rejected the bolus by vomiting. To have twelve aloetic pills; of which she is to take tAvo every four hours. ------21 st. No stool. The pills to be continued as yesterday. ------22d. Passage of belly in the course of yester- day—motions of the arm more steady. Continue the pills as yesterday. ------24th. Belly open—stools of firm consistence, dark colour, and still fetid—irregular motions still more relieved. The aloetic pills to be continued. ______ 26th. No stool since the 24th. Pills have been regularly taken. Let her have the purging enema in the evening; and to morrow morning four ounces of the infusion of senna, at two doses. Discontinue the aloetic pills. 27th. Three natural stools. 202 APPENDIX, NO. VII. Let her have of the compound powder of Jalap two ounces; to be divided into sixteen doses. Signa, one every morning. Dismissed cured. CHOREA. 203 Royal Infirmary, Dec. 28tb. 1803. THOMAS WILIE, Mtatis 9. Has constant irregular and involuntary motions of both superior and inferior extremities ; the right side seems to be more affected than the left; these motions continue during sleep ; Avhen he wa.ks, he has the appearance of dragging the one leg after the other ; his head is also occasionally moved involuntarily, with twitchings in the muscles of his face, and some difficulty of articulation. Pulse natural—belly open. These symptoms have been present eight days ; the right side was first affected. He has used some calomel powders. Dec. 29th. Several small dark coloured stools since admission. Let him have the bolus of jalap and calomel. ------30th. But a scanty feculent discharge, pre- ceded by vomiting—much thirst—tongue Avhite—invol- untary motions continue ; not interrupted during sleep- appetite indifferent—pulse feeble. Repeat the bolus of jalap and calomel. To have one pound of beef broth, daily. ------31st. Tavo stools, both scanty, of a pale yel- low colour and somewhat tough consistence ; involuntary motions are less violent and disappear during sleep. He Walks more steadily The bolus of jalap and calomel to be repeated. Jan. 1st, 1804. Tavo stools, the first pretty copious, and much resembling those of yesterday—involuntary motions more abated—appetite continues indiderent. Repeat the bolus of jalap and calomel. 204 APPENDIX, NO. VII. Dec. 2d. Involuntary motions more abated, and movements more steady and firm—two or three small stools, of a pale colour. To take two aloetic pills, every three hours. —----- 3d. Copious feculent discharge, of natural appearance—eyes more lively, and countenance of more healthy appearance—involuntary motions nearly gone- appetite improves—ten pills taken. The aloetic pills to be still continued untill theboAvels shall be again thoroughly moved. -------4th. Has had farther copious, and, to appear- ance, natural alvine discharge—appetite still mending, and involuntary motions subsiding. The aloetic pills to be discontinued. A littie beef-steak to dinner. ------7th. Has continued conA'alescent. To take twenty four aloetic pills. Signa, one or two every night. Dismissed cured. CHOREA. CiO.'i Royal Infirmary, Dec. Stb. 1804. DAVID ANDERSON, JEtatis 8. Is subject to violent irregular and involuntary motions of the muscles of the head, eyes, lower jaw, abdomen, both superior and inferior extremities, which attack hirn by fits, at intervals of tAvo or three hours, and are from ten minutes to an hour in duration ; these motions some- times appear to oe general, at other times they are con- fined to the head and loAver jaAV, producing gnashing of the teeth ; at other times, to one or both of the superior and inferior extremities ; and sometimes only to the mus- cles of the abdomen. By account, they occasionally ter- minate in sopor. During sleep, the motions cease, and he commonly awakes with a scream. He is much debili- tated and emaciated—complains of pain of abdomen__ appetite not impaired—skin cool—pulse 120—belly bv account regular. About a month ago, he began to complain of general pains and uneasiness, with slight pain of throat and of the lower jaw ; and about eight days ago was suddenly seized with a fit similar to those described above, beginning with a loud scream, and lasting about four hours—such have continued to prevail since that time. His head has been shaved, and vinegar applied to it. Took a dose of physic, which produced several stools of a greenish appearance and fetid smell. Let him have the bolus of jalap and calomel. ------6th. Refused the bolus—jaw is at present \-.> ed, and general spasm affects the bodv. S 206 APPENDIX NO. VII. Take of the submuriate of quicksilver a scruple, Loaf sugar a drachm. Rub them thoroughly together, and divide into twelve doses of Avhich he is to take one every two hours. Dec. 7th. Trismus and spasm Avere of short duration —involuntary motion of the n.uscles of the abdomen and of the lower jaw continue—one rather costive, but pretty copious fetid and green stool—uses little food—eight poAvders taken. Repeat the poAvders of the submuriate of quicksilver, to be taken as yesterday, untill the bowels are again moved. Let him have a pound of beef broth, A pound and half of Avine whey daily. ----- 8th. Irregular motions as yesterday, but tris- mus and spasm have not recurred—two scanty stools re- sembling those of yesterday—pulse 90, of moderate strength—fourteen powders taken. Take of tincture of Jalap an ounce and half, Syrup six drachms, Water tAvo ounces. Make a mixture of Avhich half an ounce is to be given every hour. Let him have a pound of porter, in place of the Avine whey. ------9th. Alvine discharge has been scanty, and of a dark broAvn colour—complains still of occasional pain of abdomen—irregular n otions in appearance nearly the same, but by account less frequent, less violent, and of shorter duration—has taken only about half of the mix- ture, and nourishment is almost entirely declined—mouth does not appear affected. Let him use the tepid bath twice or thrice a day, and repeat the submuriate of quicksilver as above pre- scribed. CHOREA. 207 —----- 10th. Has had the bath tAvice, Avhich he bore well—one pretty copious consistent green coloured and fetid stool—seven poAvders taken—mouth sore with mer- curial fetor—has taken more nourishment—irregular con- vulsive motions as described yesterday. The tepid bath to be continued, morning and evening. Repeat the mixture Avith the tincture of jalap, as above prescribed. ------ 11th. One dark coloured consistent fetid and rather scanty stool since yesterday—irregular motions disappeared during the Avhole of yesterday, and at present affect only the muscles moving the head—pulse good- more nourishment taken, but he has refused altogether the laxative mixture. Continue the bath. Discontinue the tincture of jalap. ------12th. Has had two stools of more natural ap- pearance, and less fetii tiian hitherto—irregular motions continue, but are still less fre ment and less severe—spasm resembling tetanus, by account, occurred Avhile in the bath—continues to take food, but declines the beef-te;i and porter. Take of calcined magnesia, Sugar, of each two drachms, Water six ounces. Make a mixture to be given daily in divided doses. Discontinue the beef broth, the porter and the tepid bath. A little beef-steak to dinner. ------13th. Has taken the mixture sparingly, and has had no stool—irregular motions confined to the mus- cles moving the head and loAver jaw, and appear to be somewhat under command. Repeat the mixture of magnesia as prescribed yesterday. 208 APPENDIX, NO. VII. Dec. 14th. Mixture, as prescribed, has been near- ly taken—no stool—irregular motions as last described- mouth continues affected. In the evening ten ounces of the common enema are to be injected. Apply a blister to the neck. Take of the tincture of jalap, Water, of each an ounce, Syrup half an ounce, To take half an ounce of this mixture noAV and then. Discontinue the magnesia. —.-----15th. A copious feculent alvine discharge, of more natural appearance and smell than hitherto-—mo- tions continue more moderate, and less frequent in their attack—appetite is improving—blister not yet moved. Repeat the tincture of jalap as yesterday. ------ 16th. A pretty copious, costive, and light co- loured stool—blister answered well—mouth still affected, and irregular motions as last described. Repeat the mixture with the tincture of jalap as above prescribed. ------17th. A copious stool, similar to that of yes- terday—irregular involuntary motions by account much declined, with improving appetite—mouth mends. Repeat the mixture with the tincture of jalap. ------- 18th. Mixture taken—a more copious and clay coloured stool than the two former. Repeat the tincture of jalap. _.,____19th. Alvine discharge copious, consistent, and clay coloured—motions ..continue to abate, and appetite still to improve. Continue the mixture of the tincture of jalap, daily. CHOREA. 209 Dec. 21st. A stool yesterday, similar to the preceding- one—none since. Add two drachms of the tincture of jalap to the mix- ture. Let him have four ounces of port wine. ------22d. A stool similar to those lately described —irregular motions are still less frequent and violent, not without suspicion of their being occasionally induced at will—wine is relished. Continue the wine and also the mixture Avith the tincture of jalap. -------24th. Alvine discharge in abundant quantity, and now of natural appearance—irregular motions have nearly, if not altogether ceased—appetite continues good, and general health is improved. Continue the Avine, also the mixture Avith only six drachms of the tincture of jalap. .------25th. Continues convalescent—alvine discharge is abundant and natural. ----:— 27th. Let him have two ounces of the tincture of jalap. Signa, laxative tincture, from two to three spoonfuls daily. Dismissed cured. This case, obstinate and protracted, yielded at length to the efficacy of the purgatives; although, f.cm Ji, P 2 210 APPENDIX NO. VII. extreme puny and debile state of the child, they might have been supposed to have been improper. The dan- ger was great, from the weakness of my patient, as well as from the violence of the symptoms; but I was not de- terred from employing the only remedies that I kneAv could save him. CHOREA. 211 Edinburgh, March 2d, 1805. ANNE ROSS, AZtatis 10. On the above date I visited this girl. She had a pale complexion, a dull eye, a vacant expres- sion of countenance. After previous bad health, she had laboured, for six weeks, under involuntary motions oi the muscles moving the trunk of the body, and the supe- rior and inferior extremities, Avhich, although slight in the beginning, had now become violent and irregular, and did not cease altogether, during sleep. She could not articulate—muscular flesh was loose, but not wasted- abdomen was hard and prominent—appetite was keener than when in health ; and her belly was said to be reg- ular. Let her take fifteen grains of the mass of aloetic pills, every three hours. March 3d. Forty five grains of the above mass taken. One copious, consistent, dark coloured stool. Continue the aloetic pills. Light nourishing diet to be used. ______4th. Fifty grains of the aloetic mass have been taken. One stool, consisting of many scybala floating in a dark coloured fetid fluid, has been passed. Continue the aloetic pills. _______5th. I found the involuntary motions as des- cribed, but Avas informed that they had been less violent in the course of the preceding afternoon. Swelling and hardness of abdomen someAvhat subsided— 212 APPENDIX, NO. VII. a scanty alvine discharge has taken place. The stool Avas fluid, and approaching the natural appearance—forty-five grains of the aloetic mass have been taken. Continue the aloetic pills. ------6th. Forty grains of the aloetic mass have been taken—one stool rather fluid, but, in respect of ap- pearance, more natural than hitherto—appetite still keen —involuntary motions ceased last night, during sleep. Take of gum aloes one drachm, Calomel, Soap of each one scruple, Mucilage of gum arabic, sufficient to form a mass, to be divided into tAventy pills of equal size, of which she is to take two every tAvo hours to the fifth time. -------7th. Fourteen pills taken—one copious, con- sistent, dark, and fetid stool—an easy night—motions suspended during sleep are Aveaker and more regular this morning. Let her take what remains of the pills prescribed yes- terday. caik ■------8th. The six pills taken—tAvo stools of colour, and in part of a clayey consistence, adhering to the sides of the containing vessel—,' is more languid, and cheeks paler than usual. She cannot as yet articulate - —an easy night Avithout motion—mouth somewhat pained Avith mercurial fetor of the breath. Take of the leaves of senna three drachms, Cream of tartar, Extract of liquorice of each one drachm. Infuse for an hour in twelve ounces of boiling water. To take a fourth part of the strained infusion every two hours. Let her have a glass or two of port Avine every day. CHOREA. 21:i ------. 9th. Alvine discharge similar to the last, bdt more copious—a quiet night. Take of calomel six grains, Powdered jalap, Soap, ot each ten grains, ^ Mucilage of gum arabic sufficient to make six pills to be taken in the evening. Take of tartrite of soda four drachms, Leaves of senna two drachms, Extract of liquorice one drachm, Boiling water twelve ounces. Make an infusion to be ta^en tomorrow morning at four doses—Continue the wine. 10th. Pills taken—vomiting succeeded the third dose of the infusion, on account of which it was intermitted. One fluid fetid dark green coloured stool, accompanied with much flatus—fulness of abdomen more subsided— eyes more lively, and some colour in the cheek—a good night—mouth easier, Continue the Avine ; and in the evening let her take the remainder of the infusion. ------ 11th. Infusion not taken—no stool.—an indif- ferent night. She seems, by description, to have labour- ed for a short time, under general rigidity—and has been given to involuntary laughter—involuntary motions more violent at times—food taken. Take of gamboge one scruple, Soap ten grains, Mucilage of gum arabic sufficient to make eight pills. Let her take two every two hours, and in the evening Avhat remains of the infusion of senna, 214 APPENDIX, NO. VII. ------12th. Continue the wine. Being sickened by the pills, four of them only Avere given, and the infusion was not given—she is much as yesterday ; but the rigidity and involuntary laughter have noLrecurred—no stool. Take of the tincture of jalap twro ounces , of which she is to take a small spoonful, in water every hour. Continue the wine. :——- . 13th. Tavo thirds of the tincture taken—a fluid stool more natural than hitherto—no sickness—a quiet night—motions less frequent and less violent. Take of calomel six grains, Powdered jalap tAvelve grains. Make a powder to be taken in the evening. Take of the leavres oi senna three drachms, Extract of liquorice a drachm, Infuse in tAvelve ounces oi boiling water, of which she is to take a fourth part every hour tomorrow morning. Continue the Avine. -------14th. A quiet night; under greater involunta- ry agitation than yesterday—gripes and vomiting succeed- ed the third dose of the infusion—a copious stool of a light green colour, fluid and fetid. Repeat the powder as yesterday; and tomorrow morn- ing let her take what may remain of the infusion. Continue the wine. ------ 15th. A copious, partly fluid, green coloured and highly fetid stool—slight nausea after the infusion— an indifferent night—motions continue violent—food taken. Take of soap, Aloes, of each a drachm, to be made into thirty pilis of which sue is to take tAvo every hour, CHOREA. 21a Let her have the common enema in the evening. Continue the wine. March 16th. A better night—scanty evacuation after the injection—a copious feculent one this morning—mo- tions less violent. Continue the pills as yesterday, and the wine. Repeat the enema, and let her take of the phosphate of soda two drachms in beef broth, every three hours. ------- 17th. The remaining ten pills, and an ounce and a half of the phosphate of soda have been taken—■ injection not Avell received—one scanty, feculent stool— an easy night—fulness of abdomen continues, and motions are less violent. Let her take of the mass of pills of aloes and colocynth tAvelve grains every three hours. Repeat the enema. Continue the phosphate of soda and the Avine. ------ 18th. Haifa drachm of the above mass, and half an ounce of phosphas sodae taken—injection better received—a large feculent stool, in consistence approach- ing to costive, has been passed—a restless night—motions less violent, and articulation at times distinct—abdomen still foil. Continue the pills, the phosphate of soda, the enema, and the Avine as yesterday. To take tAvelve drops of the tincture of opium, in the evening. ------- 19th. One scruple of the mass of pills, and an ounc- and a half of phosphas sodae have been taken—in- jection retained for some time—a stool, copious as that of yesterday—slept during the first part of the night—rest- less Avith much agitation, in the morning, but at eleven A. M. more calm, and motions less violent. 216 APPENDIX NO. VII. Continue the pills, the phosphate of soda, the enema, and the wine. Omit the tincture of opium. ------20th. A restless night—involuntary motions more violent; but countenance clear, and eyes lively__ fulness of abdomen continues—feculent discharge of more natural appearance, but more scanty. To take of the tartrite of potass and soda one ounce in beef broth in divided doses. Omit the enema, the pills of aloes and colocynth, and the phosphate of soda. -------21st. A better night—motions more staid—a copious alvine evacuation, somewhat costive—fulness of abdomen not diminished—food and wine taken. Let her take three pills of aloes and calomel as pre- scribed on the sixth day of the month. Continue the wine. Repeat the tartrite of potass and soda as yesterday. -------22d. Nearly in the same state as yesterday. Continue the pills, the tartrite of potass and soda, and the wine as yesterday. ------23d. A restless night—motions more irregular and violent—a scanty and unnatural stool—fulness of ab- domen continues—looks improve—but she appears to be thinner, and muscular flesh to be more flaccid. Let her take tAvo of the pills of aloes and calomel eA'ery two hours—also an ounce of the tartrite of potass and soda, in beef broth in divided doses. -------24th. An indifferent night, but motions more staid. Fulness of abdomen continues—a copious alvine discharge, partly of a natural, and partly of a clayey tough consistence—six pills and the Rochelle salts taken. CHOREA. 217 To take of the pills "of aloes and calomel, three every tAvo hours to the third time—also an ounce of the tartrite of potass and soda in beef broth in divided doses. Continue the wine. March 25th. A better night—motions more staid, cease noAV altogether during sleep—articulation improves, and looks continue lively—fulness of loAver abdomen un- changed—a copious alvine discharge, feces are more natu- ral, hard, and in detached pieces, something resembling scybala. Let her take eight grains of the mass of pills of aloes and colocynth every two hours. Repeat one ounce of the tartrite of potass and soda. Continue the Avine—omit the pills of aloes and calomel. ------26th. A good night—involuntary motions and fulness of abdomen, as last described—seventy grains of the pills, and the Rochelle salts taken. Copious fluid alvine discharge. Let her take of the compound poAvder of jalap, one scruple every three hours. Repeat the tartrite-of potass and soda and also the Avine. Omit the pills of aloes and colocynth. -------27th. Three doses of the powder, and the ounce of Rochelle salts taken—copious evacuation of feces, of natural appearance, and for the first time, of natural form—a good night, with much refreshing sleep— involuntary motions less violent than hitherto. Repeat the compound poAvder of jalap, as also the tartrite of potass and soda as yesterday—continue the Avine, -------28th. A good night—motions still less violent, looks are cheerful—a copious, natural} and well-formed alvine discharge. T 218 APPENDIX, NO. VII. Let her take of the compound powder of jalap two scruples thrice a day—also of the tartrite of potass and soda an ounce and a half, in beef broth, in divided doses. Continue the wine. March 29th. Jalap and Rochelle salts taken—a quiet night—motions as yesterday—a natural, but a less formed, and less copious alvine discharge. Take of the compound powder of jalap two drachms, to be divided into three doses, Let her take one immediately, and another in the eve- ning ; also six drachms of the tartrite of potass and soda in beef broth in the interval. Continue the wine. ------■ 30th. In respect of sleep, motions, and alvine evacuations, as yesterday—appears to lose flesh, and looks are more Avan—articulation does not improve. Take of the powder of jalap one drachm, Divide into six doses of which she is to take one every two hours. Let her also take of the tartrite of potass and soda six drachms in beef broth. Continue the Avine. Omit the compound powder of jalap. ------31st. Medicines, Avine, and full nourishment taken—wan looks and enfeebled state, continue—a good night, much quiet sleep.—motions weaker, and more un- der command, than hitherto—a very copious ah ine evac- uation, in part costive, and not so natural in appearance as late ones. Take of the jalap in poAvder one drachm and half, di- vided into six doses, to take one every two hours. Repeat the tartrite of potass and soda as above, and continue the wine. CHOREA 219 April 1st. The salts, and five doses of the powder taken—alvine discharge and symptoms, as yesterday. Repeat the powder of jalap, also the tartrite of potass and soda. Continue the wine. ------2d. Salts and five poAvders taken—countenance fresh—looks lively—motions still more under command. Take of jalap in powder tAvo drachms ; Divide into six doses, to take one four times a day Repeat the tartrite of potass and soda. Continue the wine. ______3d. The salts and five poAvders taken—copious, feculent, consistent, and natural aivine discharge. Continue the wine and the poAvder of jalap as yesterday. Omit the tartrite of potass and soda. ______4th. Five powders taken—alvine evacuation as yesterday—a quiet night, refreshing sleep—she Avalks with a steady, but rather feeble gait—involuntary motions, but to no extent, of the superior extremities continue, those of the trunk of the body are gone—fulness of ab- domen almost subsided. To take of the powder of jalap one scruple thrice a day. Discontinue the Avine. Let her be much in the open air, as the weather is fine- ______5th. Four scruples of the poAvder of jalap ta- ken ; sickness and slight vomiting—natural alvine evacu- ation—fulness of abdomen gone—motions regular and vo- luntary—poAver of articulation much recovered—looks lively ; she enjoyed the open air much, and she walked a little. .Let her take a scruple of jalap in powder every morning. _____ 9th. Eyes clear—countenance expressive of vivacity__poAver of articulation recovered—motions regu- 220 APPENDIX, NO. VII. lar and voluntary—daily alvine evacuation in full quantity— stools are formed, consistent, and in all respects natural. Let her take ten grains of powdered jalap every morning. April 17th. Finding my patient fully convalesced, the belly regular, the feces formed, and of natural ap- pearance, I recommended exercise in the open air, and fresh vegetables in diet; and I intimated, that 1 ceased to take farther charge. On the eighth day of the folloAving month, (May) I passed near to the house Avhere my late patient, Ann Ross lived. Curiosity led me to enquire for her. hhe Avas employed in Avork; she was abundantly muscular and active, and she approached me in a cheerlul, playful manner. This has proved the most protracted case of chorea, under the treatment by purgatives, that has occurred to me ; which may be OAving, in part, to the duration of the complaint, before I saAV the patient, and in part, to her sex. The strong and repeated purgatives that were given, are a proof that the constipation Avas great; and the almost daily alvine evacuation, and the nature of the stools, shew the accumulation of feculent matter, to have been abundant and offensive. My directions in the con- duct of this case, Avere faithfully complied Avith, by an anxious and sensible mother, Avhom I encouraged to per- severe in the exhibition of purgatives, by positive assur- ances, that a perfect recovery was to be obtained ; Avhile my little patient was enticed to compliance, by occasional presents, suited to her time of life. CHOREA. 221 Royal Infirmary, April 2Stb 1805, ELIZABETH WEBSTER, JEtatis 9. Is subject to constant irregular and involuntary motions of both the superior and inferior extremities ; but the left arm and leg appear less affected than the right. The trunk of the body is also frequently affected by these ir- regular motions, and there is constant grinding of the teeth during sleep, Avhen these motions are suspended, and she appears calm and easy. This complaint has existed for about five weeks, and since the 2d of April she has been under a regular course of purgative medicines, Avhich have had various effects but have given no relief of symptoms ; had two spoiled teeth extracted, and on the 22d instant she passed a worm of the lumbricus kind, about ten inches in length ; her appetite is good, and food is relished ; her abdomen is soft, without fulness; poAver of articulation nearly sus- pended. Take of submuriate of quicksilver half a drachm, Loaf sugar one drachm. Let them be thoroughly rubbed together and divided into ten equal powders. To take one every tAvo hours to the fifth time. Take of the tartrite of soda and potass six drachms, Beef broth one pound. Make a solution to be taken in divided doses. ______, 27tb. A rather scanty alvine evacuation, fluid, partly of natural appearance, and partly of a greenish co- lour, not fetid—has passed a bad night, with but little T 2 22'J APPENDIX NO. VII. sleep—five of the powders, and about half of the beef-tea taken. Continue the submuriate of quicksilver as yesterday. Take of the tincture of jalap, Syrup, of each three drachms, Water one ounce. A draught to be made and taken tomorrow morning. Discontinue the tartrite of soda and potass. April 28th. Has had three stools, of a deep green colour and fetid—the discharge upon the whole is scanty— has passed a better night, and this morning the involun- tary motions are less general and less violent'—vomiting succeeded the first dose of the mixture—five powders taken. Take of poAvdered jalap, Brown sugar of each a drachm, Rub intimately together and divide into twelve doses. To take one every tAvo or three hours; the medicines above prescribed being omitted. ------29th. Has passed a quiet night,, enjoying soft sleep—has had ten stools—the feces upon the whole are abundant, of a light greenish colour, partly fluid, and partly someAvhat in separate knots, approaching in ap- pearance to scybala; these evacuations are highly fetid— the convulsiAe motions are still more stayed and less vio- lent—nine powders, taken without reluctance, have been given. Continue thepoAvder of jalap as prescribed yesterday. -------30th. Alvine discharge, in respect of quantity, cannot be ascertained, feces having been voided Avithout notice in bed ; but on the whole they have not been so abundant as yesteroay; they are of a lighter colour and fetid—involuntary motions still less violent—appetite for food abates—thirsty—articulation still suspended, and deglutition is diificult. CHOREA. 223 Let her have of port wine, Water each six ounces. To take an ounce noAV and then. May 1st. Four fetid stools, but rather of more natural appearance, since yesterday; evacuation on the whole copious, has been \oided without notice—abdomen seems more distended—involuntary motions still abate—pulse is feeble, and looks are rather languid, and muscular flesh apparently Avasted—appetite still indifferent—eight pow- ders taken, and Avine relished. Let her have a pound and half of beef broth, daily. Take of the submuriate of quicksilver, Sugar, of each three grains. Form into a powder to be taken in the eA-ening. Continue the powder of jalap, of Avhich a dose is to be taken every three hours. Repeat the Avine. ------2d. The poAvder of the evening, andtAvelvcof jalap taken—she appears more languid, and excoriations of different parts of the surface, and some of considerable extent, have appeared in succession for tAvo days past- pulse at the Avrist is feeble, and surface is disposed to be cold—no stool—urine passed insensibly—wine has been relished, and little food taken—has had an indifferent night—involuntary motions as last described. Take of port wine eight ounces. Water six ounces. Make a mixture to be taken every day in divided doses. Let ten ounces of the common enema be injected ; and afterwards four ounces of beef broth be throAvn up per anum every three hours; for this purpose let her have three pounds of beef broth. Let the excoriated parts be dressed in the usual manner. Discontinue the powder of jalap. 221 APPENDIX, NO. VII. May 3d. A stool previous to the injection, pretty co- pious, of a dark green colour, and fetid; a smaller one after the house injection ; those of beef-tea have been re- tained—has had a I etter night, and appears somewhat revived—motions as described—wine relished, and a little beef-tea has been SAvallowed. Take of calcined magnesia tAvo drachms, PoAvdered jalap one drachm, Mucilage of gum arabic, Syrup, Cinnamon Avater, of each half an ounce. After they are well mixed, add Water four ounces and half. To give an ounce of the mixture well shaken thrice a day. Continue the wine and the beef broth as yesterday. ■------4th. Three doses of the mixture taken—in- jections of beef-tea have "been continued and retained— some beef-tea and a little food have also been taken—wine is relished—one pretty copious green coloured and fetid stool passed in bed—excoriations mend. Continue the mixture of magnesia, the Avine, and the enema of beef broth. ------5th. Four stools, of a dark green colour and fetid smell; the evacuation upon the whole has been co- pious, and passed in bed—spasmodic motions cease alto- gether at times, and again return Avith some violence'— has passed an indifferent night—appetite mends. Continue the wine, the beef broth and the mixture of magnesia. A night nurse. ------6th. Has passed a good night—involuntary- motions as last described, with longer intervals betAveen different attacks—appetite more improved, and excoria- tions more disposed to heal—four alvine evacuations con- sistent, dark, and fetid; on the whole in small quantity. CHOREA. 225 Take of the submuriate of quicksilver, Sugar each six grains. Make a poAvder to be taken in the evening. Continue the mixture of magnesia as above prescribed, adding a drachm of poAvdered jalap. Continue the wine and tne beef broth. ' May 7th. Has passed an easy night—irregular spas- modic motions are now but little perceived—appetite con- tinues to improve—expression of countenance is more lively—pulse calm, and firmer than hitherto—excoria- tions healing—alvine evacuation of a lighter colour, less fetid, and also iess copious than for some days past—• calomel given, and mixture as prescribed taken. Take of the phosphate of soda four drachms to be taken in six ounces of beef.broth. Continue the mixture of magnesia and jalap. Let her have the Avine and the beef broth as aboA'e pre- scribed. ------8th. Involuntary motions nearly* gone—appe- tite good—a quiet nii^ht—sens'bleto the stimulus of urine and of feces ; the latter has been passed in abundance, is partly fluid and feculent, partly scybalous and of a green- ish colour, and stiil fetid—Avine is relished—salts and mixture taken, as prescribed. Repeat the phosphate of soda. Continue the mixture of magnesia and jalap, and also the wine. Discontinue the enema of beef broth. -------9th. Alvine eA^acuation more in quantity, fecu- lent, of natural colour, with less fetor—irregular motions nearly, if not altogether gone—good night—mixture, and salts, and full alloAvance of nourishment taken. Let her have but four ounces of the port wine, with which four ounces of water are to be mixed. The cathartics to be stiil continued. 226 APPENDIX, NO. VII. May 10th. Involuntary motions have not recurred— deglutition is free, and she begins to articulate—stools feculent, and natural in appearance and smell. Continue the wine as also the mixture of magnesia, omitting the powdered jalap. Omit the phosphate of soda. ------11th. The alvine discharge since yesterday is abundant, fluid, of a greenish colour, and more fetid than the last—excoriations are healed—pulse firm and regular —disposition to coldness of the suiface has gradually yielded—skin now of natural heat. Take- of the submuriate of quicksilver, Sugar of each five grains. Make a powder to be taken early tomorroAV morning. Continue the mixture of magnesia. -------12th. A more copious and more natural stool —continues convalescent. Let her have every morning fifteen grains of powdered jalap Avith as much broAvn sugar. Discontinue the mixture of magnesia and the wine. ------- 14th. The alvine evacuation of yesterday and of this day abundant, fluid, and without peculiar fetor— pulse regular and firm—articulation not farther recovered. To take six grains only of the powdered jalap daily. ------- 17th. For tAvo mornings laxative powder not given—alvine evacuation continues sufficiently copious, of natural appearance, and fluid—appetite good, but flesh and strength are siowly recovered—articulation still sus- pended—pulse calm—good nights. Discontinue the powder of jalap. ------ 18th. Pretty copious alvine discharge from six motions, more fetid than for two days past—consider- able fulness of abdomen is still perceived. CHOREA. 227 Take of the submuriate of quicksilver, PoAvdered jalap, Sugar of each eight grains. Make a powder to be taken early tomorroAV morning. Let her have four ounces of port wine. May 19th. A more copious alvine evacuation, still fetid, with slight fulness of abdomen—spontaneous vomit- ing of contents of stomach this morning, preceded by sickness—Avine relished. Let the powder prescribed yesterday be repeated to- morrow morning. The Avine to be repeated. ------20th. Since taking the powder, a rather scanty alvine evacuation has taken place : it is feculent, fluid, and fetid—fulness of abdomen continues—wine relished. Take of the infusion of senna two ounces, Extract of liquorice a drachm. Dissolve, to be taken immediately as a cathartic. In the evening give twelve ounces of the common ene- ma. ■------ 21 st. The infusion Avas taken, and the injection was soon returned without feces—the alvine evacuation on the Avhole since yesterday has been copious, and fetid, and of a dark colour, Avith scybala intermixed ; for some days she has appeared more wan, and seems to have lost in respect of flesh—the Avine is relished, and food taken— no return of involuntary motions. Take of the infusion of senna tAvo ounces and half. Tincture of jalap three drachms, Extract of liquorice a drachm. Make a mixture of which she is to take an ounce every hour. In the evening throAvup six ounces of the faetid enema. ---=.—• 22d. The alvine evacuation, in respect of quan- 228 APPENDIX, NO. VII. tity and appearance, as yesterdays unless perhaps it is more of the natural colour; it contains a feAv scybala, and is still fetid—the injection was retained nearly five hours, Avhen it was voided, accompanied with much flatus- pulse towards 90, and firmer—abdomen seems less dis- tended—food and Avine relished. Repeat the infusion of senna with the tincture of jalap ; also the foetid enema in the evening. Continue the wine. Omit the other medicines. May 23d. The alvine evacuation is more copious, of a darker colour, and fetid—the injection, retained four hours, was voided along with feculent matter and much flatus—fulness and tension of belly continue to abate— appetite for food flags, but wine is relished—pulse about 90, and feeble—she seems to lose in respect of flesh and strength Let her have immediately tAvo pounds of beef broth; of Avhich six ounces are to be injected as an enema every two hours. Let her take the compound bolus of jalap late at night; and tomorrow morning let the infusion of senna Avith the tincture of jalap be repeated. Continue the wine. ■------24th. Ah-ine evacuation, since yesterday, is less copious, fluid and fetid—injections of beef-tea re- tained—pulse firmer, and more food taken. Repeat the foetid enema as above prescribed in the eve- ning ; let her have the draught of castor oil tomor- row morning. Continue the Avine and the enemata of beef broth. ------25th. A feculent stool, with much flatus, in about half an hour from receiving the injection ; another since morning; on the whole, the alvine discharge is CHOREA. 229 more copious, fluid, and of nearly natural colour, but fetid—-appetite continues good—pulse regular and firm__ fulness of abdomen more subsided—had a visit from a brother and sister, both children, in whose company she appeared delighted, and, by account, conversed Avith them freely and easily ; in their absence, she resumes her usual dulness and taciturnity. Take of the purified black oxide of iron six grains. Powdered jalap, Brown sugar of each four grains. Make a powder to be taken thrice a day in any vehicle. Repeat the Avine. Discontinue the enemata of beef broth. May 28th. The alvine discharge, from the 25th till yesterday, has been nearly as described, but rather scantv —no stool these last 24 hours—abdomen seems fuller__ feebleness continues—food and wine relished. Let her have eight of the aloetic pills ; to take tAvo even two hours. Take of the tincture of assa foetida tAvo drachms, Warm water eight ounces, for an enema to be injected to morrow morning, unless the boAvels should be previously moved. Discontinue in the mean time the poAvder of the black oxide of iron. Continue the wine. -------29th. Pills being taken in the course of the night, a copious, and, for the first time, formed stool Avas voided—the injection given, and as yet without farther effect—fulness of abdomen, and particularly of the epi- gastrium, continues—pulse quick, soft and tolerably firm Repeat the aloetic pills ; and after they are taken re. peat also the foetid enema. u 230 APPENDIX, NO. VII. May 30th. A scanty stool in the afternoon of yester- day ; six have since occurred, giving on the whole a copi- ous feculent, fluid, and fetid discharge—the injection Avas returned accompanied with much flatus—fulness of abdo- men continues—appetite good. Let her have four of the aloetic pills in the evening; the foetid enema to be repeated tomorrow morning. - -----31st. Ffas had several stools—the evacuation on the whole copious, fluid and feculent, and Avithout pe- culiar fetor—befly is less full—articulations distinct, and she has become cheerful and playful. Let her have only three aloetic pills in the evening. June 1st. Several natural stools—fulness of abdomen continues—in other respects apparently Avell. Two of the aloetic piils only to be given. Continue the wine. -------2d. Repeat the aloetic pills and the Avine. — 3d. To have only one aloetic pill in the evening. ------4th. Repeat the aloetic pill. -----5th. fulness of abdomen much subsided—■ stools natural—in all respects convalescent. Let her have an aloetic pill every second night. Discontinue the wine. ------8th. Regular and natural stools—flesh and strength regained in some degree. -------11th. Has continued well. Let her have twenty four of the aloetic pills. Signa, one to be taken occasionally, so as a regular state of the bowels may be insured. Dismissed cured. CHOREA. 231 This case has proved equally obstinate with that of Ann Ross; at the same time, it is one in which I had the greatest reason to despair of success. I lost all hope more than once; and I expressed myself to this purpose to several gentlemen Avho were witnesses of my conduct, in order to prepare them for my failure. But the steady perseverance in the only means of safety, snatched my patient from danger, and must convince every unpreju- diced person of the utility of purgative medicines in chorea. 232 APPENDIX, NO. VII. Royal Infirmary, Feb. 3d, 1806. ELIZABETH WEBSTER, JEtatis 10. For some days past she has complained of general un- easiness, and some degree of lassitude, and yesterday the muscles of her arms were observed to be agitated with irregular and involuntary motions—her looks are rather Avan—her lower abdomen feels hard and prominent, and, by account, her belly has been irregular for some time past, OAving to the. indisposition of her grandfather, Avith whom she has lived since her dismission in June last— her appetite is somewhat voracious. Let her have tAvelve of the pills of aloes and colocynth. To take two every two hours and tomorroAV morning, after haAdng taken the pills, Infusion of senna tAvo ounces. Feb. 4th. Pills and infusion have been taken and as yet without effect. Take of the tartrite of soda and potass four drachms, Compound tincture of senna half an ounce, Infusion of flaxseed three ounces. Make a solution to be taken immediately. ------5th. The solution taken, Avas followed by a pretty copious costive lumpy stool, but of natural colour and not fetid—fulness of abdomen perceptibly less. Let her take late at night six grains of the submuriate of quicksilver, PoAvdered jalap fifteen grains. Tomorrow morning early three ounces of the infusion of senna, in six ounces of the infusion of flaxseed CHOREA. 233 Feb. 6th. Only one stool, rather scanty, soft and of natural appearance. ------7th. Has had a more copious stool, consisting partly of fluid feces, and partly detached, consistent and rather to appearance hard lumps—in other respects feces are natural. Take of powdered jalap a drachm Brown sugar half a drachm. Rub thoroughly together and divide into six doses, of which she is to take one every three hours. ■------8th. Sickness and lassitude are abated—coun- tenance florid and ot healthy appearance—by account is more active, with less tendency to irregular motions of the right arm and leg—appetite is more natural—alvine evacuation since yesterday resembles that last described—■ all the powders have been taken—temporary sickness followed the exhibition of the last. Take of Avater five ounces, Loaf sugar two drachms, Tincture of jalap an ounce. Make a mixture of Avhich she is to take one ounce every two hours. Discontinue the powders of jalap. Animal food to dinner. ------9th. Sickness and spontaneous A-omiting, at- tributed to the mixture—alvine evacuation has been less abundant, and is fluid. Discontinue the mixture with the tincture of jalap. ------ 10th. No stool—involuntary motions apparent- ly gone. Let her have three of the aloetic pills in the evening ; Tavo ounces of the infusion of senna early tomorrow morning. U 2 234- APPENDIX, NO. VII. Feb., 11th. A scanty, but in other respects natural stool. Let her haA'e four ounces of port Avine daily. Repeat the cathartic medicines as yesterday. -------12th. Continue the cathartic medicines. ------13th. Alvine eAracuation has been fluid, other- wise natural, and she has continued free of complaint. Take of poAvdered jalap four drachms, to be divided into eighteen equal doses. Laxative powders ; one to be given at any time, Avhen appearance of costiveness takes place. Dismissed cured. In this case we have an example of the facility with which chorea is cured, when it is of short duration. Con- trasted with the former, and immediately preceding case of the same patient, it clearlv pt'oves the truth of this observation. CHOREA. 235 Dr. James Home, Professor of Materia Medica and of Pharmacy, in the University of Edinburgh, has favoured me with the following valuable and interesting communi- cation. His candid and polite manner of making it, adds to my obligations to him on this occasion. Edinburgh, Oct. Wth, 1805. Dear Sir, I have heard with great pleasure, that you are noAV publishing an account of the good effects of purgatives, in the cure of some diseases. I take the liberty of sending you thereiore, an abstract of two cases of chorea, which occurred in the clinical ward, and which shew in a very striking manner, the good effects of purgatives in the cure of this disease. To these cases you are certainly Avell entitled, because, as this mode of curing chorea was entirely new to me, and contrary to my opinion of the nature of the disease, the treatment of these cases, was, if you recollect, entirely conducted upon your suggestion. I intended also to have sent you a very remarkable history of the good effects of purgatives, in a very bad case of ty- 236 APPENDIX NO. VII. phus, in Avhich they were employed at your suggestion. but unluckily I cannot at present find it. I am, Dear Sir, Your most obedient Servant, James Home To Dr. James Hamilton, ) Physician, Edinburgh, £ CHOREA. 237 MARGARET JAMESON, Was admitted into the clinical Avard, upon the 10th of May, 1804. She was sixteen years of age, and of a san- guine temperament. About three months ago, previous to which she had been in good health, some involuntary motions were first observed, in her left arm and leg. These, about a fortnight ago, changed to the right side. At present, these involuntary motions are so considerable, that she can hardly walk, and cannot feer1 herself. They cease during sleep, Avhich however, is much disturbed. Pulse 84—tongue clean—appetite impaired—thirst con- siderable—belly costive. The menses have appeared once only, and in small quantity, about a month ago. She had used a great variety of remedies, of the nature of Avhich she Avas ignorant, without receiving any benefit. A compound, consisting of the submuriate of mercury and of jalap, at first in the proportion of three grains of the former, and ten grains of the latter, was given. This, however, producing no effects, the quantity of the submuriate of mercury was increased to five grains, and that of the jalap, to fifteen irrains. It was repeated four times in eight days. It never operated above four times, The feces were at first natural: they afterwards became black and fetid ; and then again assumed a natural ap- pearance. The involuntary motions gradually became better: they ceased altogether, in eight days ; and on the tenth day, she was dismissed, cmed. As the cure, however, might have been temporary only, she was de- 2^8 APPENDIX NO. VII. sired to return frequently to the Infirmary. But, al- though she presented herself often, she remained en- tirely free of the disease ; and her countenance exhibited the appearance of health and vigour. GH0REA. 239 MART MURRAY. Aged 15, and of a delicate, irritable habit, was ad- mitted on the 8th of June, 1804. In her, the disease had commenced about three months before, with pains in her legs and arms. These pains she ascribed to cold, and they Avere removed by laxatives, and external applications. After this, involuntary motions gradually came on, at first in the right ieg, and then in other parts. At the time she was admitted, the muscles of the head, of the lower jaw, of both superior extremities, and of the right leg, were affected, so that she could hardly walk, she could not feed herself; and could not speak intelligibly. She was affected also with frequent headachs; with great imbe- cillity of the mental faculties ; with frequent fits of crying, without any evident cause ; and Avith SAvelling of the ab- domen, towards evening. Pulse about 80—tongue clean —appetite good—belly very bound. The menses had never appeared. To this patient, five grains of the submuriate of mercu- ry, and fifteen grains of jalap, Avere given in the form of bolus, every day, for fourteen days. After this, they were given everv second day only, for six days. During these three weeks, this medicine had the effect of pro- ducing three or four stools every day. At first, the stools were of a natural appearance ; aftenvards they became black, and very fetid ; gradually, however, they assumed a natural appearance. During this time, she became stronger. Her countenance assumed a healthy appear- ance, and the involuntary motions gradually diminished, so that she was able to walk more steadily, to carry li- quids to her mouth, and to speak more distinctly. 240 APPENDIX, NO. VII. As the progress of the cure appeared to be slow, a com- pound, consisting of equal parts of the cinchona officinalis, and of the Valeriana silvestris, Avas given in the quantity of half a drachm twice a day. At the same time, the above purgative was occasionally prescribed, Avhenever there Avas any tendency to costiveness, or when the stools were not of a natural appearance. Under this plan, which continu- ed three Aveeks, this patient gradually got better, so that Avhen she was dismissed, after having continued in the Infirmary about six weeks, the involuntary motions had entirely ceased, and she Avas in perfect health. •CHOREA, 241 I have had favourable accounts of the efficacy of purga- tives in chorea from Dr. Freer, Professor of the Practice of Physic in the University of Glasgow, from Dr. Rhind, Physician in Stirling, and from Dr. Wightman, Physician in Dunbar : This last gentleman, in a letter of date 9th of January, 1806, addressed to me, inter alia thus expresses himself: " I have derived considerable instruction from your late valuable treatise on the use of purgative medi- cines in different diseases; I have been successful in curing a very obstinate case of chorea by this mode : it required a prosecution of the course for about six weeks, and had it not been for the encouragement, Avhich you held out in the cases you detail, I frankly acknowledge I should have abandoned it, before the cure Avas com- pleated. X 242 - APPENDIX. No. VIII. CASES OF HYSTERIA. Royal Infirmary, Sept \2tb. 1803. JEAN DOUGALD, JEtatis 45. Seven days ago, was attacked with pain of abdomen, borborygmi, and the sense of a ball moving up toAvards her throat, occasioning the feeling of suffocation, after Avhich she became insensible, and continued in that state for some time ; on recovering she had frequent eructations of flatus. Since that time, she has had several fits of the same kind. Pulse about 70—belly costive—catamenia have ceased. Let her have the bolus of jalap and calomel. ------12th. One costive stool. Repeat the bolus of jalap and calomel. ------13th. One stool more fluid and natural—pain HYSTERIA. 243 of abdomen, eructations, and hysteric symptoms have not returned. Repeat the bolus of jalap and calomel. Sept. 14th. Let: her take half an ounce of the solu tion of assa fsetida thrice every day. ------23d. Belly has been regular, stomachic symp toms have not returned. Tincture of assa faetida tAvo ounces. Signa, fillecn drops twice a duy in a glass of water. Dismissed cured. ■-■44 APPENDIX, NO. VIII. Royal Infirmary, March, 16tb 1805. JEAN LAWRIE, JEtatis 17. Is subject to violent involuntary and irregular motions of the trunk and extremities, Avhich generally last from five to ten minutes, and sometimes return several times successively, without any apparent cause. Complains of severe headach during the intervals, and flying pains in her loins, breast, and extremities. Pulse at present 104 and weak—face flushed—skin hot, alternating Avith a sense of cold—belly rather bound—catamenia, which Avere sup- pressed for upAvards of four months, returned about eight days ago. Was seized yesterday, Avhile Avalking, Avith pains in the breast and back, faintness and difficulty of respiration. These continued for about half an hour, and Ave re suc- ceeded by a fit, as above described. Has been subject to headach, vertigo, and stomach complaints, for about three years. Let her have immediately the compound bolus of jalap, and in four hours aitenvards, the common enema, unless the bowels should be previously moved. ------- 17th. One costive, but in other respects natural stool—tongue clean—pulse calm—headach continues, Avith Bushings of face—three attacks of spasmodic affection, as described, but in a slight degree, since admission—has passed an easy night. Let her take tAvo of the pills of aloes and colocynth every four hours untill the bowels are moved. HYSTERIA. 245 March 18 th. Twelve pills taken—no stools procured— headach is relieved—one fit of short duration, resembling hysteria. Let her have the purging enema immediately; and early tomorrow morning the compound bolus of jalap , with eight grains of calomel. ------19th. Several copious dark and fetid stools af- ter the injection—none since the bolus of this morning— headach is relieved—no return of paroxysm. Repeat the purging enema immediately. ______20th. Tavo slight fits—several stools. Let the compound bolus of jalap be repeated tomorrow morning. ______21st. No recurrence of fits—pain under the sternum, increased by the recumbent posture, continues __headach gone—free passage of belly—pulse calm. Apply a blister to the painful part of the sternum. ______23d. Blister has risen Avell, and pain is relieved —no stool—no recurrence of fit. Let the compound bolus of jalap be repeated tomorrow morning. ______25th. Has had full passage of belly—free of complaint. Let her have eighteen pills of aloes and gamboge, Signa. One or two occasionally at bed-time. Dismissed cured. X i A.PPENDIX, NO. VIII. Royal Infirmary, January 2d. 180C. ISABELLA BLACK, JLtatis 18. Complains of severe pain at the scrobiculus cordis, slight headach and nausea, Avith passing sickness—she describes the pain as if the sides of the chest Avere drawn together, Avhich continuing for some time relaxes, and she has considerable ease for a feAV minutes, when the pain returns with the same uneasy feeling—pulse about 80 and full—tongue white—belly slow. This affection came on suddenly about five hours ago Avhen carrying water up a stair, but says she has been subject to similar attacks for some time, To take the compound bolus of jalap. Jan. 3d. As yet no stool. Let her have immediately a draught of one ounce of castor oil. And in the evening the common enema, if necessary, ------4th, Headache and sickness—gastrodynia, with sense of draAving or tightness, are abated—one return only of spontaneous vomiting—pulse calm—tongue clean—. three copious stools of natural appearance, but fetid smell —an easy night. Let her have eighteen of the aloetic pills, to take three every three hours untill the bowels are again unloaded ------6th. During the night betAvixt the 4th and 5th she complained more of gastrcdyn'a, and she had seA-eral attacks of syncope Avith feeling of occasional globus. All these symptoms continued to distress her in the course of yesterday. The pins 1; st vrescrihsd having been taken without effect, tne following solution was given. HYSTERIA. 247 Take of the infusion of senna four ounces, Tartrite of potass and soda an ounce and half, Infusion of flaxseed eight ounces. Mix. She passed an uneasy night, but has been free of com- plaint since morning. Copious dark coloured, and fetid alvine discharge has been procured. Let her take six aloetic pills. Tomorrow morning early three ounces of the infusion of senna in six ounces of infusion of flaxseed. Jan. 7th. No stool. Infusion not given—no complaint. Let her take immediately the infusion of senna as pre- scribed yesterday. ______8th. Has had free passage of belly. Let her have tAvelve of the pills of aloes and colocynth. Signa, purgative pills—one or two at bed time. Dismissed cured. -J4X APPENDIX NO. VIII.' Royal Infirmary, January 2Stb, 1806. SARAH MAC MILL AN, Mtatis 14. On the afternoon of the 23d instant, she Avas suddenly seized with sickness and fainting, and remained for some time in a state of insensibility—when she began to laugh, cry, and scream alternately, and the whole body became agitated with violent convulsive motions—in the course of three hours she became calm, and seemed to fall into a sleep, but was observed to sob and sigh much—Avhen she awoke, she complained of headach, and an uneasy feeling about the praecordia. Yesterday she was again attacked in a similar manner, but the paroxysm was preceded by borborygmi and globus, and during the whole of last night the fits Avere almost constant—pulse at present 66—tongue white—belly said to be rather slow, she complains of se- vere headach and pain of loins'—catamenia appeared for the first time about ten months ago, and have been regular and are noAV present. During the first paroxysm she took a draught containing camphor, but Avithout relief. Let her have immediately the compound bolus of jalap. TomorroAV morningthree ounces of the infusion of senna. ------26th. PreA-ious to the exhibition of the infusion of senna, a large, costive, dark coloured stool took place— passed an easy night without farther attack of hysteric paroxysm—the last occurred yesterday about one o'clock afternoon. Let the compound bolus of jalap with ten grains of calo- mel be repeated late at night. The infusion of senna to be repeated tomorroAV morning. HYSTERIA. 24-y Jan. 27th. Repeated and severe hysteric paroxysms in the course of last evening—complains of headach— eyes appear dull—pulse about 80 and soft—no alvine evacuation since the exhibition of the bolus and infusion of senna—after the cessation of the paroxysms she passed an easy night—fluunt catamenia. Let her have the purging enema immediately. Let her have eighteen of the aloetic pids—to take three every three hours. And four hours after having taken the pills, the purging enema to be repeated, unless the boAvels should be previously fully evacuated. Four leeches to be applied to each temple. ■------28th. Complains still of headach—but eyes are less heavy—pulse calm—no return of Insteric paroxysm —she has passed an easy night—some food taken—injec- tion of last evening Avas followed by copious alvine eAracua- tion at different motions—at first the feces appeared cos- tive, the latter ones were less so, but formed—the Avholc of a dark colour and fetid—the pills have been taken with- out farther effect—leeches did not succeed well. All the prescriptions to be repeated as yesterday, ------■ 29th. Alvine evacuation since yesterday suffi- ciently abundant—of a whitish colour, and seemingly of a clayish consistence—headach gone—eyes are lively—tAvo slight hysteric paroxysms last evening. Let her have the compound bolus of jalap Avith eight grains of calomel late at night The draught Avith twelve drachms of castor oil tomor- roAV morning. -------30th. No return of hysteric paroxysm—alvine evacuation plentiful, someAvhat scybalous, otherwise natu- ral. Let her have a drachm of the compound poAvder of jalap every morning. 250 APPENDIX NO. VIII. Feb. 1st. As yet no stool—catamenia pridie defluxe- runt. Let her have immediately four'ounces of the infusion of senna; In the evening four of the aloetic pills. Let the compound poAvder of jalap be repeated tomor- row morning. ■------2d. Pretty full alvine evacuation—feces con- sistent, formed, and nearly of natural appearance—free of complaint. Let her have half an ounce of jalap in poAvder divided into eight doses. Signa, laxative powders—one every morning. ------3d. Dismissed cured. 251 APPENDIX. No. IX. CASES OF TETANUS. Royal Infirmary, Aug. 27tb 1805. DAVID M-KENZIE, JEtatis 66. Complains of most excruciating pains in his legs, thighs, and arms, and about the scrobiculus cordis; the muscles of his legs and thighs feel hard and contracted, and are frequently agitated by violent, irregular, and in- voluntary motions. The muscles of the thorax and ab- domen are occasionally affected Avith the same involuntary motions, giving a sense of suffocation, and severe pain. Has sometimes a difficulty in swallowing—pulse 90, weak and hard—features much shrunk—tongue foul—complains of constant purging, with gripes—is unable to articulate, but in a Ioav Avhisper. Says, that last night, about tAvelve o'clock, when asleep, he was roused with severe pain in his legs; they Avere contracted, and he Avas unable to stretch them out. In about an hour, the pain became easier, and he could move 252 APPENDIX, NO. IX. them a little, but the pains and spasm have continued to recur every half hour since. Let the anodyne enema Avith the addition of eighty- drops of the tincture of opium be injected immedi- ately. Aug. 28th. Last night, about the time he Avas first seized, the spasmodic action became very violent. The muscles of his legs were much agitated, and contracted, and the knees draAvn up towards the abdomen; he was unable to speak or move ; the injection, which was given about two hours before, was retained only a few minutes Take of camphor ten grains, Sugar two drachms, Rub intimately together, then add Mucilage of gum arabic one drachm and a half. Water an ounce. Make a draught to be taken immediately. .------28th, Noon. Since the exhibition of the draught, he has been quiet, and slept some ; the spasmodic action of the muscles of the lower extremities has recurred, but not so severely—complains still of pain about the scrobi- culus cordis—thirst urgent—diarrhoea continues—has passed only about four ounces of urine, since admission. Continue the draught Avitfi camphor. Take of tartrite of soda and potass six drachms, Infusion of senna two ounces, Water six ounces; Make a solution to be taken immediately. . Let him have eight ounces of port wine. •------29th. Paucity of urine, and prevalence of di- arrhoea continued ; the stools were scanty, Avhite coloured, and fetid—since the exhibition of the cathartic, a very copious alvine evacuation has taken place ; it is fluid, of TETANUS. 253 a mixed greenish and clayish colour, of a someAvhat acid smell, and otherwise of a peculiar fetor. Tavo camphor draughts have been given, and Avine has been used—pulse is less hard—cramps of the loAver ex- tremities occasionally recur since morning, but the .invo- luntary action of other muscles has ceased—countenance lightened—he has enjoyed some sleep. Let the cathartic solution be immediately repeated, four hours after having taken the above, let him have the purging enema ; after the operation of Avhich let him have a draught with forty drops of the tincture of opium. Let him have two pounds of beef broth. Repeat the wine. Discontinue the draught Avith camphor. Aug. 30th. Injection given—was soon returned—he has had very copious alvine evacuation—fluid, of a dark- green colour, and of a high, and peculiar fetor—pain of epigastrium gone—two slight attacks of spasm of the lower extremities, last night—no other irregular muscu- lar action has occurred—tongue clean and moist—pulse' feeble—a peculiar fulness, and general tension of abdomen is perceived—Avine has been relished, and he has passed a good night. Let him have tAvelve aloetic pills ; to take three every two hours; after these have been taken, let him have the common enema, unless the boAvels should be pre- viously evacuated. Repeat the Avine and the anodyne draught. ______31st. Pills and injection given—feculent dis- charge less copious than yesterday, and less fetid; is of a clay-colour, partly fluid, and partly scybalous. Fulness and tension of abdomen gone—a slight return of spasm . of the lower extremities was of short duration—surface Y ^54 APPENDIX, NO. IX. inclines to be cold—pulse feeble—droAVsy, Avithpain across the forehead—pills taken. Let the legs be fomented, every three hours, for the space of half an hoUr. Continue the beef broth and the wine. Omit the anodyne draught. Sept. 1st. Has had farther alvine evacuation—fluid, of a more natural appearance, Avithout fetor or scybala—. spasmodic affection has once appeared, and has been slight .—surface Avarm—pulse firmer—painful affection of both eyes—headach and droAvsiness gone. The eyes to be Avashed noAv and then Avith a solution of the sulphate of zinc. Let him have two scruples of the compound powder of jalap tomorrow morning. Continue the Avine. ------2d. Pain and inflammation of eyes are relieved —one short and slight return of cramp of the lower ex- tremities—countenance has a more natural, and more lively appearance—appetite improving—no stool. Repeat the compound powder of jalap immediately, and in the evening if necessary, let him have the common enema. Repeat the wine. ------3d. Has passed an indifferent night—has had longer and more severe attack of cramp in the lower ex- tremities—a costive, green, and fetid stool followed the njection, when previous uneasiness subsided. He ap- pears more languid, but pulse continues firmer, and sur- face Avarm—tongue clean—appetite declines. Let him have six ounces of the infusion of senna. One ounce to be taken immediately and repeated every hour. After the infusion has been taken let him again have the common enema, Repeat the Avine. TETANUS. 255 Sept. 4th. No return of spasmodic affection—has used more food—affection of eyes gone, and looks are improv- ed—has had copious, and more natural than hitherto, al- vine evacuation, upon the injection being given, the in- fusion having been previously taken—complains of gripes. Take of the mucilage of gum arabic half an ounce, Magnesia two drachms, PoAvdered jalap a drachm, After they are Aveil mixed pour on six ounces of Avater. Let him take an ounce of the mixture Avell shaken every tAvo or three hours. Let him have a pound of port Avine daily. ------5th. Fluid and natural alvine evacuation in full quantity—gripes continue. Let him take a dose of the mixture of magnesia every four hours—the thebaic pill in the evening. Repeat the wine. ______7th. Gripes are gone—spasms have not re- curred—alvine evacuation, natural and plentiful—appetite good. Discontinue the medirines and the wine. ______9th. Belly rather open. Let him have three ounces of lime Avater four times a day. ______ 13th. Belly has been regular. Dismissed cured. In this case the early exhibition of camphor Avas acci- dental ; and the use of it was speedily relinquished. I ordered laudanum in compliance with common custom ; 256 APPENDIX, NO. IX. but Ave may gather from the report of the 1st September, that it Avas given with no good effect. The small quantity of wine Avhich I prescribed, respected the general debility and exhausted state of the poor patient, suffering under a painful disease ; I did not view it in the light of a medicine operating toAvards a cure, which I conceive to have been effected in this case, by the purgative medicines alone. TETANUS. 257 Royal Infirmary, 2d Nov. 1805. ALEXANDER DULLER Mtatis 35. Twice in the course of last night, and once since morn- ing he has been affected with a violent spasmodic action of the muscles of the thorax and lower extremities, du- ring the continuance of Avhich he was unable to speak or move, and breathed with much difficulty. The mus- cles of the extremities felt like stretched cords with several small knots' in different parts There Avere also two lumps near the scrobiculus cordis evidently formed by the contraction of the muscles—these lumps on the chest were only of momentary duration, but returned frequently for the space of five or six minutes. The affection of the extremities was stationary for that period—he complains of constant pain in his arms and shoulders impeding the free motion of the joints, and after each attack of the cramp he had frequent flatulent eructations—pulse quick and sharp—tongue foul—belly very costive. Has been in the house for about a month for a slight venereal affection, for which he used mercury in the form of ointment—the chancres have healed, and his mouth which Avas affected is noAV quite well—as he compoiried of costiveness, he^was ordered yesterday, previous to the present complaints, A drachm of the compound poAvder of jalap, and in the course of the night he had three fetid, dark coloured and costive stools. Take of the infusion of senna five ounces, Compound tincture of senna one ounce, Infusion of flaxseed six ounces. Y 2 ' 258 APPENDIX, NO. IX. Make a mixture of which he is to take three ounces every hour untill the bowels are moved, and in the evening, unless the intestines should be completely evacuated let him have the purging enema. Nov. 3d. One slight attack of pain of breast, Avith affected respiration as described, and also of the left loAver extremity—no farther recurrence of spasmodic affection —pain of superior extremity continues, with SAvelling of left wrist since yesterday—pulse quick and full—infusion being given, a copious costive light coloured stool ensued —injection being also given, was followed by a fluid dark coloured alvine evacuation. Take of the draught of castor oil, (containing one ounce of the castor oil,) Compound tincture of senna an ounce. Make a mixture to be given immediately, and in the evening, if necessary, let the purging enema be re- peated Let four leeches be applied to the painful Avrist. -------4th. No return of spasm—Avrist less pained— tongue clean—pulse calm—has had full alvine evacuation —little or no food taken. Let him have a pound of beef broth, Tavo or three pounds of pale ale daily. -------5th. Spasmodic affection Avith oppressed breath- ing and general uneasiness of the muscles of the abdomen yesterday evening. This attack continued only for a feAV minutes, but left him for a considerable time sick and faint—pain of left Avrist is gone—pain of right arm and of right Avrist has supervened—pulse calm—a dark coloured stool in the course of the evening. Let him have immediately twelve pills of aloes and colo- cynth—to take three every tAvo hours. Take of the infusion of senna four ounces, Infusion of flaxseed six ounces, HYSTERIA. 259 Make a mixture which after the pills have been taken, is to be given in tAvo doses. Nov. 6th. Pain and sAvelling of right wrist continue —spasmodic affection has not recurred—pulse about 70 and soft—copious fluid and fetid alvine discharge—a bad night. Let four leeches be applied to the painful wrist. To take the anodyne draught in the evening. TomorroAV morning the draught of castor oil, with an ounce of the oil and four drachms of the compound tincture of senna. ------7th. Pain of Avrist relieved—no return of cramp —an easier night—thirst, of Avhich he had complained, is abated—pulse soft—alvine evacuation scanty, of a clay- colour and fetid. Let him have tA\-elve aloetic pills, to take three every three hours. ______8th. Thirst more abated Avith improving appe- tite__an easy night—no return of cramp—alvine discharge more copious than hitherto, partly fluid, and partly of unusual consistence, fetid, and of a clay colour—twelve pills taken. Let him have two scruples of the compound powder of jalap every morning. Continue the draught. _______9th. He continues convalescent—pretty copi- ous alvine discharge, discoloured and fetid. Repeat the compound poAvder of jalap. _______10th. Three copious alvine evacuations of more natural appearance and consistence, and less fetid than hitherto—free of complaint—appetite good. Let him have half a drachm of the compound powder of jalap every morning. Full diet. 260 APPENDIX, NO. IX. Nov. 13th. Belly open—feces natural. A bit of beef steak dai ------ 14th. Belly rather open—stools natural—free of complaint—strength and appetite much recovered. Let him have twelve ounces of lime Avater, in divided doses daily. ------ 17th. Belly regular. Omit the lime Avater. ------19th. Dismissed cured. If the symptoms, in this case, are not precisely those of tetanus; they certainly denote a disease greatly re- sembling it. And if mercury, as some maintain, removes the severest tetanic spasm, it may appear singular that it had no effect in averting that, Avhich, in the preseni instance, supervened so immediately upon a full mercurial course. TETANUS. Royal Infirmary, Dec. 29tb 1805. BETTY NESBIT, JEtatis 24. Complains of severe pain at the scrobiculus cordis, and along the margin of the false ribs of the left side—also of shooting pains in the back of the neck descending along the spine—occasional severe headach accompanied Avith pain in the orbits and much dimness, of sight—general debility and loss of appetite—pulse 96 and soft—tongue clean—belly slow—catamenia have been suppressed for three months, during which time she has had these com- plaints ; which, hoAvever, have been much aggravated for the last fortnight, and attended with obstinate costiveness __was blooded and got some medicines, of which she can give no account. Let her have the compound bolus of jalap tomorroAV morning. • Dec. 30th. One scanty fluid green coloured stool. Let her have tAvelve of the aloetic pills to take two every tAvo hours. After the pills have been taken let a purging enema be given if necessary. 31st. Headach and pain of the orbit of both eyes are relieved—pain of scrobiculus cordis and along the margin of the false ribs, stiffness and pain of hind neck, shooting doAvn the spine, continue. This last seems to excite or is accompanied with occasional spas- modic affections of both arms—has had copious and dark 262 APPENDIX, NO. IX. coloured alvine evacuation—pills have been taken and in- jection given. Repeat the aloetic pills as yesterday. Let her have early tomorroAV morning four ounces of the infusion of senna and six ounces of the infusion of flaxseed, at tAvo doses. Jan. 1st, 1806. Sickness farther relieved, and headach and pain of the orbits less uneasy than yesterday—affec- tion of hind neck, of spine, and the spasms continue— has had plentiful alvine evacuation—the first motion was costive—latter ones less so, but consistent; the whole of natural appearance. Repeat the aloetic pills and the infusion of senna as yesterday. -------2d. The affections of hind neck, of spine, and of both arms have been more severe during last night and this morning ; all of these, but particularly the latter, she now admits have been present tAvelve months, and came on after much mental agitation. Has had spontaneous vomiting—alvine discharge has been copious, and consists, chiefly of large scybala floating in a dark green fetid fluid, Continue the aloetic pills, and the infusion of senna, ------ 3d. Pretty copious alvine discharge, containing scybala, but in other respects more natural than yester- day—retching has occurred. Take of the carbonate of magnesia, Powdered rhubarb of each fifteen grains, Mix Prepare twelve such powders. To take one every tAA-o hours in an ounce and a half of mint water, untill the bowels are again Avell moved. -------4th. TAvelve powders taken—alvine evacuation scanty, more natural and less scybalous—pain of the TETANUS. 263 orbits still more relieved—that of hind-neck and spas- modic affection considerably abated—no return of vomit- ing—headach continues—gastrodynia aggravated. Let her have three thebaic pills immediately. The purging enema in the evening. Discontinue the powder of rhubarb. ------5th. Gastrodynia continued severe during the first part of the night—it remitted towards morning, and is noAV nearly gone—headach is abated—pain of hind neck, of orbits, and spasm have disappeared—has had scanty alvine evacuation. ~-----6th Take of sulphate of magnesia five drachms, Supertartrite of potass a drachm, Infusion of senna three ounces, Infusion of flaxseed six ounces. Prepare a solution immediately, to be taken at tAvo doses. ------8th. Alvine evacuation upon the exhibition of the last physic rather scanty—headach and pain of orbits are returned. Repeat the solution of the sulphate of magnesia as above. ------9th. Has had full alvine evacuation—headach is gone—pain of orbit continues. Let three or four ounces of blood be taken from each temple by cupping. ------10th. Pain of orbits gone, and otherwise free of complaint—full quantity of blood taken. Let her have three aloetic pills every night. Sulphate of magnesia four drachms every morning. Full diet. 264 APPENDIX NO. IX. Jan. 13th. Belly has been fully regular. Let her have thirty six aloetic pills. Laxative pills—two, three, or four for a dose, when nc cessary. Dismissed cured. 265 APPENDIX. No. X. CASES OF CHRONIC DISEASES. Royal Infirmary, March I9tb. 1804. MARGARET CLAPPERTON, AEtatis 20. *- Complains of fixed pain situated in the left side, Avith occasional difficulty of respiration, pain at stomach, with flatulence, and loss of appetite—pain of loins—catamenia have been irregular—pulse auout 90, and full. These complaints began about twelve months ago, with pain of stomach, and have gradually increased since. March 20th. To take the compound bolus of jalap in the evening. Infusion of senna tAvo ounces tomorrow morning. 21st. Copious alvine evacuation—pain of side, of loins, and flatulence still continue—pulse 80—stomach is relieved. Let the compound bolus of jalap be repeated tomorrow morning. Half an ounce of the bitter infusion to be taken four times a day. 266 APPENDIX NO. X. March 22d. Pain of stomach still farther abated, and flatulence relieved—pain of side and loins continue—co- pious alvine dark coloured discharge. Take of carbonate of magnesia a scruple, PoAvdered jalap ten grains; prepare a powder to be taken every morning. Continue the bitter infusion. ------26th. Belly has been regular—stools of a natu- ral appearance—pain of side gone—-that of loins continues —pulse calm. Continue the powder of the carbonate of magnesia, 8cc. ------27th. Pain of loins gone. Let her have twenty of the powders of jalap and mag- nesia as above prescribed. Dismissed cured. CHRONIC DISEASES. 267 Royal Infirmary, Jan. I3tb 1803. EUPHAN MAYGLES, ALtatis 29. Complains of pain and sense of Aveight at the scrobicu- lus cordis increased on pressure, with occasional sick- ness, and vomiting of ingesta—loss of appetite—is much emaciated—pulse 72—tongue clean—catamenia regular —no passage of belly for eight days, during which the above symptoms have been much aggravated, though by account, she has been more or Ess subject to them for about two months, during which she has been habitually costive. The common enema to be given immediately. TomorroAV morning early an ounce of the tartrite of soda and potass, in Avater, at two doses. Jan. 14th. Three stools—the first by the injection was costive, the tAvo latter, since the exhibition of the laxa- tive, scanty. Pain of epigastrium, and sickness continue. Let her have twelve of the aloetic pills, of which she is to take two every three hours. -----15th. Stomachic symptoms and uneasiness of abdomen continue—one very scanty and costive stool— the twelve pills taken. The purging enema to be given immediately. Repeat the aloetic pills, to be taken as yesterday. ------16th. A scanty stool after the injection , ano- ther more abundant, and of more natural appearance, since morning—pain of epigastrium and sickness are re- lieved—vomiting has not recurred—tongue clean—pulse calm—an indifferent night. 268 APPENDIX, NO. X. Take of the compound tincture of senna seven drachms. Ammoniated tincture of opium a drachm. Make a draught to be taken in the evening. Jan. 17th. Two stools, both scanty, by account, of natural appearance—pain of epigastrium and sickness continue easier—no vomiting—a good night. Repeat the draught as yesterday. ------18th. Tavo stools, copious, and of natural ap- pearance—continues convalescent—an easy night. Continue the draught of the tincture of senna, ------19th. One scanty stool—a good night. To take four of the aloetic pills in the evening. Three ounces of the infusion of senna, in six ounces of the infusion of flaxseed, tomorrow morning early. Discontinue the compound tincture of senna. ------ 2oth. Two scanty stools since morning—pain of epigastrium continues easy—a good night. To have twelve aloetic pills, of which she is to take two every three hours, untiii the boAvels are effectu- ally moved. ——---.21st. By account, has had tAvo copious natural stools. Free of complaint. Let her have every morning tAvelve grains of poAvdered rhubarb. ------22d. Appetite improves—belly regular. Continue the powder of rhubarb. ------25th. Belly has become slow—complains of headach, and spontaneous vomiting occurred in the course of yesterday—tongue clean—pulse calm. CHRONIC DISEASES. 269 Sulphate of magnesia four drachms, Supertartrite of potass a drachm. To be taken immediately in water. Let her have half a drachm of the compound powder of jalap every morning. Disccntinue the rhubarb. Jan. 26th. No return of vomiting—headach abated, Pretty copious dark coloured alvine discharge. ------27th. Belly is regular ; in other respects con- valescent. Continue the compound powder of jalap. Full diet. ------30th. No stool for two days. Take of the sulphate of magnesia four drachms, Supertartrite of potass, Leaves of senna, of each a drachm. To be infused half an hour in eight ounces of boiling water, to be taken as soon as possible. Feb. 4th. Take of the cathartic extract tAvo drachms, to be divided into thirty equal pills. Signentur, laxative pills, one or two when necessary Dismissed cured- Z 2 ;70 APPENDIX, NO. X. Edinburgh, October 1805, A young Avoman of a delicate constitution, but not liable to general bad health, was seized with frequent violent and bound cough, unattended with pain of breast, dysp- noea, quickness of pulse, or heat of surface. In order to mitigate the cough, the seveiity of which excited much alarm, lest rupture of vessels, and haemoptysis should ensue ; bloodletting was practised once and again, and a Mister was applied to the breast; while a Ioav regimen was enjoined, and laudanum was given to procure sleep, which the cough had altogether banished. These means ^o likely to have piocured relief, were of no avail. The experience of the effect of some purgative medi- cines, which had been given in the course of the disease, proved that the patient Avas either of a peculiarly consti- pated habit of body, or laboured under temporary consti- pation. It seemed, therefore, reasonable to me, as Avell as to another medical gentleman in attendance, to force the alvine evacuation by more powerful medicines, than Ave had as yet employed. We succeeded, but not without difficulty, in attaining the object in view. The appearance and odour of the feces evinced their mor- bid state ; while the quantity that was dislodged proved that the feculent accumulation had been great. And there was no doubt of these circumstances having been the cause of the ailment, for the cessation of the cough, and the progress of convalescence kept pace with the gradual unloading of the boAvels. Our patient was so satisfied of this, that she readily agreed to folloAv out a regular course of purgative medicines, in order to pre- serve her boAvels in a regular state of daily and full evacu- ation. This patient four months afterwards, had another attack CHRONIC DISEASES. 271 of pectoral symptoms, different however from the former one. She now complained of acute fixed pain across the lower part of the sternum, aggravated by the gentlest bodily exertion, and attended with great languor and fee- bleness. Her appetite was altogether gone—she passed sleepless nights—her countenance betokened much dis- tress—her cheeks were alternately flushed and pale. With these symptoms she had no cough, and Avhen completely at rest, even in the recumbent posture, no dyspnoea. On the first attack, the pain Avas so violent, as to threat- en instant suffocation, which appeared to have been avert- ed only by a prompt and copious blooding. Bloodletting was afterwards repeated, Avhich, as well as blistering, Avas of no use ; the application of leeches seemed to mitigate the pain ; and on account of it, low diet Avas. enjoined. The other medical gentleman in attendance, and I, trusting to the account of our patient, and to the appear- ance of one alvine evacuation- were satisfied that the belly was regular ; and we were the more readily so, as our pat'ent, ever since her former indisposition, had been ac- customed to attend to this circumstance. Disappointed in our expectations of relief, we now be- came seriously alarmed, dreading the existence of vomi- ca, Avit!i whicu Ave connected apprehensions of impending phthisis. These fears avcre not altogether concealed from the friends of oiu patient, who immediately asked the assistance of another medical gentleman. Our joint opinion iioav turned upon the probability, chat the disease mir lit depend upon nervous irritation. Exercise in the open air, a fuller diet, and a tonic powder and mixture, were proposed. The patient's inability to bear the slightest motion, and her total want of appetite, precluded compliance Avith the tAvo first proposals,; and 272 APPENDIX, NO. X. the tonic medicines, taken Avith great reluctance, were scarcely in use, Avhen a copious, fluid, dark coloured, and peculiarly fetid stool arrested our attention. The pre- vious history of this patient's health, and the present occurrence, indicated clearly our line of practice. Much fetid feculent matter was brought off by appropriate pur- gative medicines; immediate abatement of the pain took place, and complete relief in all respects soon ensued. In eight or ten days no vestige of complaint remained. The patient is now perfectly well. CHRONIC DISEASES. Royal Infirmary, Feb. 7tb 1805. JEAN MDONALD, JEtatis 28. Complains of pain, and sense of weight at the epigas- tric region, increased on pressure, vpmiting of ingestaj in an acid state, with frequent eructations, headach, and virtigo, vague pains in her limbs—strength is impaired— loss ol flesh—appetite bad—pulse 80—skin cool—tongue white and moist—thirsty—belly is habitually costive— catamenia have been suppressed a twelvemonth, during which period she has been more or less distressed with the above symptoms—has used no remedies. Feb. 8th. No stool since admission. Take of the compound extract of colocynth a drachm and half, Form into twenty four pills. To take two every tAvo hours untill the boAvels are moved. ------9th. Three copious stools, of a dark greenish colour, and fetid—sense of Aveight at scrobiculus cordis— headach and vertigo are considerably relieved. Sixteen pills taken. ------10th. Three copious, and in appearance, more natural stools, since yesterday. Spontaneous vomiting, and acid eructations do not recur—indifferent appetite. -----*-llth. Vomiting occurred in the evening—> gastrodynia since morning. Take of the carbonate of magnesia two scruples, PoAvdered rhubarb a scruple, To be taken intAvo ounces of peppermint water, 274 APPENDIX, NO. X. Feb. 12th. Gastrodynia gone—vomiting has not re- curred, and in other respects is free of complaint—tongue clean—pulse calm—no stool. To take immediately three ounces of the infusion ol senna in six ounces of the infusion of flaxseed. ------ 13th. A copious, consistent, blackish, and fe- tid stool, upon the exhibition of the injection—general pain of abdomen—pulse calm. Let her have sixteen aloetic pills. To take three every three hours. ------14th. Has had several stools, of dark, or green- ish appearance—the alvine discharge on the whole, copi- ous—pain of abdomen gone—nine pills t..ken. Take of the sulphate of potass with sulphur half a drachm, PoAvdered rhubarb fifteen grains. Make a powder to be taken every morning. Full diet. ------ 18th. Has had regular stools, and continues con Arale scent. Take of the sulphate of magnesia an ounce, Supertartrite of potass, Sulphate of potass Avith sulphur of each tAvo drachms. Signentur, to be dissolved in a pint and a half of water and a tea-cuplul taken each morning. Dismissed cured. FINIS- ^ \0mm^^ \-.:vi**v V-';. 7 '&§$*■; iff -r-M* ■' ■%,.■' ■^•^•- ■■■■■■ >;• • VV' .... --.-'■■-■ .Lm. -- • .. l-ll'A' .«■; *-. r, *« '■^ pw7 ■ *• • rafc-•'/;■• ^* ""luf rf--». • J'- • ' ■• ilW^- W- .rv ■. •,*a|»B,vt ■/XLSfc: • -.' >.j . »-• -W^iNk^** ¥& >"' ■ Hfr<''&■*.*■ - • =* -. - - ->f;3 ■ 'V^^v- tog**, ' ■?•■'- .*■ '■ .•■3'] fc^-7" -%^' *" n-^Ut