f Vft_l S.\ i V MEDICAL HISTORIES AND REFLECTIONS. <£>>v LWfflgj, h W. ^ ^ *e~-S .«' THE MODERN EXHIBITING THE CHARACTERS, CAUSES, SYMPTOMS, PROGNOSTICS, MORBID APPEARANCES, AND IMPROVED METHOD OF TREATING THE DISEASES 0¥ Alili CliIMATES. * v ^ -ANNEX BY ROBERT THOM^ M. D. THE FIFTH AMERICAN, FROM THE SIXTH LONDON EDITION, REVISED, AND CON- SIDERABLY ENLARGED BY AN ADDITION OF MUCH IMPORTANT MATTER. AS WELL AS BY AN ENGLISH TRANSLATION OF THE FORMULAE OR PRESCRIPTIONS, RENDERING THE WORK THEREBY OF GENERAL UTILITY. WITH AN APPENDIX, BY DAVID HOSACK, M. D. Professor of the Theory and Practice of Physic, and of Obstetrics, and the Diseases tf' Women and Children, in the University of the State of New-York. —-•©©©*— NEW-YORK : PUBLISHED BY COLLINS AMD CO* NO. 189 PEARL-STREET. J.4 J. Harper, Printers* DISTRICT OF NEW-YORK, ss. BE IT REMEMBERKD, That on the twenty eighth day of February, in the forty-fourth year of the independence of the United States of Amer- ica, Colins & Co. of the said district, have deposited in this office the title of a book, the right whereof they claim as proprietors, in the word following, to wit : " The Modern Practice of Physic, exhibiting the Characters, Causes, Symptoms, Prognostics, Morbid Appearances, and Improved Method of Treating the Diseases of all Climates By Robert Thomas, M. D. The fifth American, from the sixth London edition, revised and consid- erably enlarged by an addition of much important matter, as well as by an English translation of the Formulae or Prescriptions, rendering the work thereby of general utility. With an Appendix by David Hosack, M. D. Professor of the Theory and Practice of Physic, and of Obstetrics, and the Diseases of Women and Children, in the University of the State of New York." In conformity to the act of the Congress of the United States, entitled " An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the time therein mentioned," and also to an act, entitled " An act, supplementary to an act, entitled an act for th encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned, and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." GILBERT L. THOMPSON, Clerk of the Southern District of New-York. TO DAVID HOSACK, M. D. F. R. S. PROFESSOR OF THE THEORY AND PRACTICE OF PHYSIC, OF OBSTETRICS, AND THE DISEASES OF WOMEN AND CHILDREN, IS THE UNIVERSITY OF THE STATE OF NEW-YORK, vims w©ibs IS MOST RESPECTFULLY DEDICATED THE AUTHOR PREFACE. The observations which are contained in the succeeding pages on the nature and treatment of the various diseases to which the human frame is liable, from the period of birth to a very advanced age, are grounded on a practice and expe- rience of forty-five years in different climates, after a regu- lar classical education under a dignitary of the established Church in Ireland; succeeded by a long pupillage under the late Dr. George Fordyce, then physician to St. Thom- as's Hospital; and a study of several years at the Edinburgh University, at the time it was at the zenith of its reputation, and justly boasted of its able professors, among whom were the elder Munro, Dr. Cullen, Dr. Black, and Dr. Gregory, senior. Having had such opportunities of acquiring medical knowledge, assisted by daily observations at the bedsides of the sick, an attentive perusal of the works of the best mod- ern writers of every nation, and an insight obtained into the practice of the physicians of both Russia and Sweden, du- ring a residence of some months in the capitals of those em- pires, the Author trusts he will not be deemed presumptu- ous in having undertaken this very important task; nor be thought defective in judgment by not having properly dis- criminated between matters of fact and those grounded on vague Hypothesis. The five former editions of this work having met with a very favourable reception from the different branches of the profession throughout the British dominions, both at home and abroad, as also in North America, where several editions of the work have also been printed, the Author is induced to hope that the present one will prove equally ac- ceptable, particularly as it has been carefully revised, and much new and important matter added under the heads of several diseases. The great variety of the subjects which pass under discussion throughout the work, and the obliga- tion he was under of limiting it to a single volume, are pleaded in apology for what to some may appear concise- ness on a few topics. VI PREFACE. As in the former editions the diseases arc divided into the following classes, viz. Pyrexiae, or Febrile Diseases ; Neu- roses, or Nervous Diseases; Cachexia?, or Diseases con- nected with a general bad Habit of Body; Locales, or Dis- eases only affecting Parts; those not rcferrible to any par- ticular class: the Diseases of the Pregnant and Parturient States, and those of Infancy; and although this arrange- ment is by no means perfect or unobjectionable, (indeed all the systems of nosology yet published are imperfect and have important defects,) still it may be sufficient to an- swer all useful purposes. The necessity of studying nosology and teaching medi- cine upon a nosological pian, has indeed been denied by some professional men; but this can only have arisen from an imperfect acquaintance with its nature and tendency, and a consequent inadequate estimate of its utility. It is necessary, in the opinion of the Author, that every practi- tioner should be enabled to distinguish diseases by their symptoms or si^us, if he would hope to cure them by ap- propriate remedies. He must therefore possess in his own mind an arrangement of the characteristic symptoms of every disease, and especially of those by which one disease may be distinguished from other diseases which resemble it, or with which it has several symptoms in common. The different prescriptions are conformable to the new nomenclature, and a table of the synonyms of the colleges of London, Edinburgh, and Dublin, has been annexed to the work. It must ever be a desirable object to be able to arrest the progress of contagious diseases, and therefore the most ef- fectual means for doing this, and for totally annihilating contagion of every kind, have been pointed out under the several beads of Typhus, Scarlatina, Cynanche Maligna, Variola, Pestis, and Dysenteria. The best means for pre- serving the health of Europeans in warm climates, and of sailors on shipboard, have also been noticed ; and as both cold and warm bathing, as well as many mineral waters, may be regarded as useful auxiliaries in the cure of some diseases, their different qualities and virtues have been specified. Such is the nature of this work, and the Author trusts it will be deemed a concise but accurate compendium of the present state of medical practice, from which the in- PREFACE. vii experienced may derive much information and instruction, while it may also prove a serviceable reference occasionally to those of longer standing in the profession. In cases of emergency it may likewise serve as a safe guide to the clergy and other country gentlemen, who on any sudden and violent attack of illness, either in their own families or those of the neighbouring poor, might find it necessary to administer some appropriate remedy in the interval of their being able to obtain professional assistance, and for more effectually answering this purpose, a table of the weights and measures used in the compounding of medicines is laced at the commencement; and the different formulae ave been translated into English, so as to render the work generally useful. The Author begs leave to observe, that the doses advised in the various prescriptions are intended for adults, except where particularly specified for infants or children; and that in general women require a smaller quantity of me- dicine to produce a desired effect than men; and those of a sanguine temperament less than those of the melan- cholic. In regulating the doses due consideration ought therefore to be paid to the sex, temperament, habit, idio- syncracy, and disease of the patient, as no correct general rule can be laid down. Salisbury, February, 1810. J ADVERTISEMENT. The very extensive circulation which the work of Dr. Thomas has met with, and the high estimation in which it is held by the profession as a compendium of the present state of medical practice, render any commendation, on the part of the American editor, altogether superfluous. While the Preface by the Author announces the nume- rous and important additions which have been made to the present edition, it is due to the American reader to observe that the Appendix has been revised with great care, and such additions have been made to it as the Editor believed would be best calculated to enhance the value of the work to which it is annexed. New-York, February, 1820. A SYSTEMATIC ARRANGEMENT OF THE DISEASES INTO CLASSES JLND ORDERS ; TOGETHER WITH AN EXPLANATION AND DERIVATION OF THEIR NAMES CLASS I. x YREX1./E (Febrile Diseases) from srvp, fire, and t%is, habit. ORDER I. Febres or Fevers, from ferbeo, to be hot. Febris Intermittens (Intermittent Fever). Febris Remittens [Remittent Fever). Synochus (Simple Continued Fever), from , to continue. Synocha (Inflammatory Fever), from ditto. Typhus Mitior (Low or Nervous Fever), from rvipa, stupor. By some it is supposed to be derived from rvQa, to inflame. ------Gravior (Malignant or Putrid Fever), from ditto. ------Icterodes (Yellow Fever), from tv$o$, and /*T*fes, icterus. ORDER II. PrfLEGMAsi^ (Inflammations), from $Xtya>, to burn. Phlegmon (Phlegmonous Inflammation). Erysipelas (Erysipelatousditto), from e%va, to draw, and sr*A««, adjoining; named from the neighbouring parts being affected by the eruption. Phrenitis (Inflammation of the Brain and its Membranes), from ppmrif, a frenzy or distraction. Ophthalmia (Ditto of the Eye), from ofydctxpus, the eye. Otitis (-----------Ear), from »«-, the ear. Cynanche Tonsillaris (Inflammatory Sore Throat), from kvuv, a dog, ar^d tt*x,u, to suffocate. ---------Parotidaea (Mumps). --------Maligna (Putrid or Ulcerated Throat). ---------Trachealis (Croup). ---------Pharyngaea (Inflammation of the Pharynx). --------Laryngsea (.--------■-----------Larynx). Pleuritis (Pleurisy), from ntevpot,, the membrane which lines the lungs. Pneumonia (Peripneumony), from 7rnv(M>v, the lungs. --------. Notha (Spurious Peripneumony). Gastritis (Inflammation of the Stomach), from yct&ih the stomach. Enteritis (-----------------Intestines), from w*fov, an intestine. Hepatitis (-----------------Liver), from t-xu.%, the Jiver. Splenitis (--------■ Spleen), from e-xAijv, the spleen. Nephritis (■------------Kidney), from vetyor, the kidney. Cystitis (-----------------Bladder), from x.v$rts; a bag or bladder. Podagra (Gout), from zrw, the foot, and ax^et, a seizure. Rheumatismus (Rheumatism), from pivfjutn^a, to be afflicted with defluxions. X SYSTEMATIC ARRANGEMENT OF DISEASES* ORDER III. Exanthemata (Eruptive Fevers), from t%cu6tv, to effloresce. Variola (the Smallpox), from varius, changing colour, and the skin beinpf disfigured. Variolar Vaccinae (Cow-pox). Varicella (• Ihiv.ken-pox), the word being a diminutive of varia, Rubeola (the Measles), from rubeo, to become red. Scarlatina (Scarlet Fever), from scarlato (Ital.), a lively red. Pestis (Plague). Miliaris (Miliary Fever), from milium, the millet. Pemphigus (Vesicular Eruption), from 5T£f*p/£, a pustule. Urticaria (Nettle Rash), from urtica, a nettle. ORDER IV. Hemorrhagic (Involuntary Discharges of Blood), from <», to flow. Epistaxis (Hemorrhagefrom the Nose), from eiriraga, to distil. Haemoptysis (Spitting »f Blood), from ec^u,, blood, and 9r7tw, to spit. Heematemesis (Vomiting of Blood), from aiput, blood, and t^ua, to vomit. Hematuria (Bloody Urine), from cct^ut, blood, and «f*», urine. Menorrhagia (Immoderate Flow of the Menses), from nujw*, the menses, and ptryv/u, to break out. Haemorrhois (Piles), from cuyM, blood, and pw, to flow. ORDER V. Profluvia [Fluxes with Pyrexia), from prtrfluo, to run down. Catarrhus (Catarrh), from x.ccrxppia,to flow down. Dysenleria (Dysentery), from hr, bad, «»*■*£«», the intestine, and pta, to flow CLASS II. NEUROSES (Nervous Diseases), from ytv%w, a nerve. ORDER I. Comata (Soporose Diseases), from ku^uc, a propensity to sleep. Apopiexia (Apoplexy), from «*-« and iry*){, water, and filthy. Sibh^ns, or Sivvens. Frambcesia (Yaws), from framboise, the French for a raspberry. Elephantiasis (Leg swelled like an Elephant's), from extras, an elephant. Lepra ,' Lepiosy), from terns, a scale. Plica Polonica (Plaited flair), from plico, to entangle. Scorbutus (Scurvy), from shorbact (Germ.), scurvy. Icterus (Jaundice), from jjcti£««, the jaundice. CLASS IV. LOCALES (Local Diseases), from locus, a place. ORDER I. Dysesthesia (Diseases of the Senses), from ovs, bad, and ouo-Sve-it, feeling. Nyctalopia [ Night Blindness), from vug, the night, and a^, an eye. Amaurosis, or Gutta Serena, from xt^cv^uTt^, obscurity. Paracusis (Deafness), from irxgx, wrong, and xkuu, to hear. ORDER II. Increased Appetite. Dysorexie (Depraved Appetites), from frvs, bad, and «f*gj, semen, and pea, to flow. Leucorrhoea (Whites), from Xtvitm, white, and pea, to flow. ORDER V. Epischeses (Obstructions), from t7ris-, difficulty, and v%ai, the urine. Auienorrhcea { Partial or total Obstruction of the Me -i»esfrom other Causes than Pregnancy), from », priv. jtwj», month, and pea, to flow. Chlorosis (Retention of the Menses, or Green Sickness), from -^hu^oa, to look green. SYSTEMATIC ARRANGEMENT OF DISEASES. XlH Mensium Suppressio (Suppressed Menses). Menorrhagia Difficilis (Difficult and painful Menstruation), from /m>», a month, and Pvytpju, to break out. ORDER VI. Tumores (Tumors), from tumeo, to swell. Carcinoma (Cancer), so named from the tumors exhibiting blue veins like crabs claws. Fungus Haematodes (Medullary Sarcoma), from r, the head, and «Ay«{, pain. Odontalgia (Toothach),from o$w, a tooth, and xXycs, pain. Faciei Morbus Nervorum Crucians (Tic Douloureux, or painful Affection of the Nerves of the Face). Gastrodynia (Pain in the Stomach), from yarw, the stomach, and *&>»?, pain. Luxatio (Sprain), from luxo, to loosen or displace. Calculus (Stone in tfie Bladder and Gravel). ORDER VIII. Dialyses (Solutions, or Discontinuity of Parts), from hxXvu, to dissolve. Ulcus (Ulcer), from «A^««, a sore. Vulnus ex Ustione factum (Scalds and Burns), fromvidnus, a wound. Herpes (Tetters), from ip™, to creep. Tinea Capitis (Scald Head), from teneo, to hold. Psora (Itch), from ipa^x, the itch. Impetigo (Ring-worm), from impeto, to infest. Acne .' Blotched and pimpled Face), from x%v>i, chaff. Chigre (an Insect resembling a Flea). Pernio (Chilblain). diseases not referrible to any particular class. Vermes (Worms). Venena (Poisons). Animatio Suspensa (Suspended Animation). Gelatus (Frost-bitten). DISEASES OF THE PREGNANT STATE. Convulsiones (Convulsions), from convello, to rend. Abortio (Abortions and Floodings), from aboriur, to be steril. DISEASES OF THE PUERPERAL STATE. Lochia (Discharge after Labour), from *o%eva, to bring forth. Febris Lactea (Milk Fever). Inflammatio Mammae (Tumor and Inflammation of the Breast). Papillae Excoriatae (Excoriated Nipples). Eruptiones Miliaria (Miliary Eruptions). "XIV SYSTEMATIC ARRANGEMENT OF DISEASES. Phlegmatia Dolens (Painful Intumescence of the lower Extremity), from QXeyu, to burn. Hysteritis (Inflammation of the Womb), from ire^x, the womb. Peritonitis (Inflammation of the Peritonaeum), from vepirma, to stretch round. Febris Puerperam (Puerperal or Child-bed Fever). Inversio Uteri, p. 779. Prolapsus Uteri. DISEASES OF INFANTS. Asphyxia (Apparent Cessation of Life), from «, priv. and e-p»f/r, the pulse. Infantum Color Lividus (Blackand livid Colour of new-born Children). Meconii Retentio (Retention of the Meconium). Icterus Infantum (Yellow Gum). Excoriationes et Ulcerationes (Excoriations and Ulcerations). Singultus (Hiccups). Erysipelas Infantile (Infantile Erysipelas). Eruptienes (Eruptions). Tormina ( Gripes from Acidities and Flatulency). Vomitus ( Vomiting). Diarrhoea (Purging). Trismus (Locked Jaw). Febris Remittens (Remittent Fever). Aphthae (Thrush). Prolapsus Ani t Falling of the Fundament). Atrophia Ablactatorum ( Weaning Brash). Ophthalmia Purulenta (Purulent inflammation of the Eyes). Dentitio ( Teething). Coovulsiones. Syphilis. A TABLE OF THE WEIGHTS &XD MEASURES USED BY APOTHECARU2S, -willr#llli»»- Weights. The Found..........ft } „ ( Twelve Ounces! — Ounce........... | f .5 \ Eight Drachms. — Drachm..........3/a \ Tnree Scruples. — Scruple..........3 \ ° / Twenty Grains. — Grain...........gr. / u V. These, and the Signs by which they are denoted, are the same in *H the British Pharmacopoeias. Measure of Fluids. The Gallon, Cong. } » f Ei&ht Pints. — Pint (Octarius)......O. / a \ Sixteen fluid Ounces.. — Fluid Ounce ......f ^ \ £ / Eight fluid Drachms. — Fluid Drachm......f3 £ § 2 Sixty Minims. — Minim............rtl J U v. The value of these Measures is the same in all the Pharmacopoeia?; but the signs by which they are denoted are peculiar to the London. The Edinburgh and Dublin retain the old signs, which are, for the gallon, cong. the pint, lb. the ounce, f, the drachm, 3, and the drop, gt. The London College of Physicians, when they directed the drop- ping of fluids from bottles to be discontinued on account of the un- certainty of the dose (much depending on the size of the phial and the quantity of the fluid contained in it), and the minim to be substi- tuted for the drop, oughtto have cautioned practitioners against consid- ering these terms as synonimous ; for there is a considerable difference between them, the former exceeding the latter by at least half as much again : thus ten minims of any fluid, if measured by the gradu- ated minim measure, will amount to about fifteen drops. In the administration of very active medicines, such for instance as the liquor arsenicalis and tinctura opii, this may be of great importance. The signs of the London Pharmacopoeia have been adopted in the different Latin formulae throughout this work ; but in the translated copies, for the convenience of those who are not of the profession, and who may not possess the graduated measure, the drop has been sub- stituted for the minim, attention having been paid at the same time to their relative proportions. PRACTICE OF PHYSIC. CLASS I. PYREXLE, or FEBRILE DISEASES. The character assigned to this class of diseases is, increased heat and frequency of the pulse, after a shivering, accompanied with a disturbance in many of the functions, and diminution of strength, especially in the limbs. ORDER I. FEBRES, or FEVERS. It is impossible to give a concise and proper definition of the disease known by the name of fever, as it has no symptom invaria- bly attendant on it, which can point out its real nature or essence. The pulse is exceedingly various in such cases : it may be small, weak, slow, contracted, and unequal; or it may be strong, quick, full, and regular; hard or soft, according as the fever is at the com- mencement, increase, height, or in the remission and termination ; or as the genus and nature of the fever may chance to differ. So, also, the heat may be equally diffused, or confined to particular parts : sometimes the external parts are cold, with a sense of inter- nal heat; at others, there is general heat or cold over the body; and sometimes the heat is not greater than what is natural. Some- times the face is pale, and at others it is red or swelled ; now it has the natural look, and now the reverse of this. The eyes are heavy, languid, and sad ; or red, and impatient of light; they are promi- nent, distorted, or wild; shining, dull, or ghastly; sometimes be- dewed with tears, and deprived of their usual lustre. The tongue is generally dry, chapped, scabrous, red, white, or variegated; often covered with mucus ; but not unfrequently moist and natural, without any thirst. The breathing is frequent, hot, unequal, or impeded; the breath is often offensive. The appetite is usually extinct; but, in a few instances, some desire for food remains. Some- times the urine is crude and watery ; at others, red and thin ; or often thick, soon becoming turbid, and depositing a sediment: sometimes it is of a natural appearance. To these symptoms are added, pains in different parts of the body ; depression of strength, and watchfulness; or, on the other hand, heaviness, stupor, or 1 '2 PYREXIA, OR FEBRILE DISEASES- Class I. imbecility of mind, delirium, diarrhoea, or constipation, vomiting, tension of the hypochondria, subsultus tendinum, emaciation, and other affections arising with the fever itself, or gradually super- vening to it. Besides the ordinary febrile symptoms of hot skin, irritated cir- culation, foulness of the tongue, thirst, and deficient or irregular secretions, preceded by lassitude, heaviness, listlessne^s, and rigours, there are pains in the head, generally of the throbbing kind, and ex- tending along the continuation of that portion of the brain which is lodged in the channel of the spine; increased heat of the head (easily perceived on compressing it with the hands), even though the body and extremities be cold ; unusual throbbing of the arteries in the temples and neck; suffusion of the eyes, and an altered expression of features, easily observed, but difficult to be described, together with disturbance of all the functions immediately belonging to the brain. If to these be added irregularity in regard to sleep, and watching, which, though common to many diseases, belongs, in a peculiar manner, to the one under our investigation, we shall have characters always sufficient to enable us to detect the presence of fever in the system, and affording at the same time the clearest indications of its nature. It is only from a diligent examination of these appearances con- joined together, that we are enabled to judge of the presence or absence of fever; not from any of them taken singly. By making a general assemblage of the symptoms, we may venture to call it a disease which affects the whole system, the head, trunk of the body, and extremities ; the skin, muscular fibres, and membranes, the circulation, absorption, and nervous system, the body, and likewise the mind. It does not, however, affect the various parts of the sys- tem uniformly and equally; but, on the contrary, one part is much more affected than another *. Fevers are usually divided into intermittents, remittents, and con- tinued, on account of their taking up different times in their natural duration; some being compounded of a number of paroxysms, fol- lowing each other in a regular succession, at some distance of time, as happens in intermittents : in others, a fresh paroxysm comes on, immediately on the crisis of the former, so as hardly to leave the patient entirely free of fever, as happens in remittents ; and in others, there is such a quick succession of paroxysms, that the one comes on before there is any visible abatement of the febrile symp- toms, as in continued fevers. In some instances of the last-mentioned fever, the remissions and exacerbations are so inconsiderable, as not easily to be perceived, which has induced a few practitioners to conclude, that there is a species of fever which subsists for several days together, and which is composed only of a single paroxysm ; but we may safely presume, that no such fever ever existed ; on the contrary, we may be well * See Dissertation on Fever, by Dr. George Fordyce. Order I. INTERMITTENT FEVERS. 3 assured, that every continued fever consists of a repetition of paroxysms, in the manner just mentioned. Now and then we meet with a fever consisting of only a single paroxysm, and which goes through its course in a few hours, as in the ephemera simplex; but this does not very frequently occur. Continued fevers usually last nearly of the same violence for several days, there being commonly an exacerbation in the evening, and a remission towards morning. The fevers of this species have been noticed to be of great diversity, by ancient nosologists ; but modern ones have limited them, very properly, either as they show an inflammatory irritation, or as they point out an affection of the nervous system, and in which the powers of sense and motion are particularly impaired. The distinctions of inflammatory and nervous fevers are, therefore, those now generally made use of; the former being known by the title of synocha, and the latter by that of typhus. A combination of these two genera seems, however, to be that form of continued fever which is most prevalent in this climate, and this I shall treat of under the appellation of simple continued fever, or synochus. A variety of continued fever has been noticed by some physicians under the title of synochus biliosa, where, in addition to the other febrile symptoms, we meet with a redundant secretion and vitiated state of the bile, giving rise to a vomiting of dark green matter, or diarrhoea, and excited by an exposure to extreme heat of weather. In some cases, however, the bowels are very torpid, and the motions procured even by purgatives, are of a hard consistence, and dark as pitch; but as this variety of fever seldom appears under a continued type, and rather assumes a remittent form, it ought, undoubtedly, to be considered as a remittent. Several species are comprehended under the head of typhus: they do not, however, imply any specific difference, but seem to arise either from a different degree of power in the cause; from different circumstances of the climate or season in which they happen; from some peculiarity in the constitution of the person affected; or from the peculiar state of the fluids predisposing to putrescency. As hectic fever cannot be considered as an idiopathic disease, but merely as a symptom of some other, and of phthisis in particular, it is not noticed under a distinct head, but under that of pulmonary consumption. FEBRES INTERMITTENTES, or INTERMITTENT FEVERS. The title of intermittent is applied to that kind of fever which consists of a succession of paroxysms, between each of which there is a distinct and perfect intermission from febrile symptoms, or an apyrexial period. Different names have been applied to this fever, according to the distance of time observed between the periods of its return. When 4 PYREXIAE, OR FEBRILE DISEASES. ClaSS L it comes on within the space of every twenty-four hours, it is called a quotidian; when it returns every other day, or there is a space of forty-eight hours between its attacks, it is called a tertian; and when it attends on the first and fourth day, with an interval of seventy-two hours, it is named a quartan. That under the tertian type is most apt to prevail in the spring, and is, indeed, the most frequent form of the disease. The quartan is the most obstinate and dangerous, being chiefly prevalent in autumn. The quotidian is more likely than the others to assume the continued type. Of the quotidian, tertian, and quartan intermittents, there are several varieties and forms ; as the double tertian, having a paroxysm every day with the alternate paroxysms similar to one another. The double tertian, with two paroxysms on one day, and another on the next. The double quartan, with two paroxysms on the first day, none on the second and third, and two again on the fourth day. The double quartan, with a paroxysm on the first day, another on the second, but none on the third. The triple quartan, with three paroxysms every fourth day. The triple quartan, with a paroxysm every day, every fourth paroxysm being similar. When these fevers arise in the spring of the year, they are called vernal; and when in autumn, they are known by the name of au- tumnal. Intermittents often prove obstinate, and are of long dura- tion, in warm climates; and they not unfrequently resist every mode of cure, so as to become very distressing to the patient, and often give rise to other chronic complaints, but more particularly anasar- cous swellings, and an enlargement of the liver, or spleen. It seems to be pretty generally acknowledged, that marsh mias- mata, or the effluvia arising from stagnant water, or marshy ground, when acted upon by heat, are the most frequent exciting cause of this fever. In marshes the putrefaction of both vegetable and animal matter is always going forward, it is to be presumed ; and hence it has been generally conjectured, that vegetable or animal putrefaction imparted a peculiar quality to the watery particles of the effluvia arising from thence. We are not yet acquainted with all the circumstances which are requisite to render marsh miasmata productive of intermittents. According to the observations made in the fenny districts of this kingdom, it has been ascertained, that marsh miasma, when much diluted with aqueous exhalation, as in summers where an unusual quantity of rain has fallen, are nearly inert; but when arising from stagnant waters of a concentrated foulness, in consequence of great drought and heat in the latter end of summer and the early part of autumn, they act with great violence and malignancy. In admitting the powers of marsh effluvia to produce intermit- tents, we ought not, at the same time, to look on them as their universal cause, since it is found that persons residing constantly in the most healthy part of cities, and far remote from marshes, are sometimes attacked by them. The testimony of unquestionable writers, proves that febrific Order I. intermittent fevers. £ miasmata may arise, under certain conditions, from almost any soil; and what is still more extraordinary, that these febrific miasmata may be wafted by currents of air* to a distance far exceeding what has been supposed or admitted upon this subject. By some physicians, the heavenly hodies have been supposed to have a considerable influence on intermittent fevers, particularly in warm climates. Dr. Lind mentions, that eight seamen were seized with a return of their fevers exactly at the moment of the beginning of an eclipse ; and others have cited cases where people have been seized with intermittents at the full and change of the moon. Many of these observations have, however, on a more par- ticular scrutiny, been referred to the tides, which, in warm climates, sometimes rise to a prodigious height, at the new and full moon, and leave a great extent of marshy ground, the exhalations from which produce the disease ; and it has been found, that by removing to a proper distance from these, the disorder was prevented, although the influence of the moon remained the same. People in warm climates usually take their exercise very early in the morning, but frequently in the evening, being prevented in the day by the excessive heat: the cool and damp air, to which they are thereby exposed, often produces fevers, which have absurdly been attributed to the influence of the moon. A similar explana- tion may be given of the influence which the winds are said to have on fevers. In some marshy countries they produce intermittents, when they blow over the marshes, and cease to spread when the wiiad changes its direction* A watery, poor diet, great fatigue, long watching, intemperance, grief, much anxiety, debility, exposure to cold, lying in damp rooms, or beds, wearing damp linen, a warm, moist, or cold damp atmosphere, the suppression of some long accustomed evacuation, the recession of eruptions and preceding disease, have been ranked among the exciting causes of intermittents; but it is more reason- able to suppose that these circumstances act only by inducing that state of the body which predisposes to these complaints. By some it has been imagined, that an intermittent fever may be communi- cated by contagion; but this supposition is by no means consistent with general observation. One peculiarity in this fever is, its great susceptibility of a renewal from very slight causes, as from the prevalence of an easterly wind, or from the repetition of the original exciting cause. It would appear likewise, that a predisposition is left in the habit, which favours the recurrence of the complaint. In this circum- stance, intermittents differ from most other fevers, as it is well known, that after a continued fever has once occurred, and been completely removed, the person so affected is by no means so liable to a fresh attack of the disorder, as one in whom it had never taken place. * See Report of the Epidemic Fever, in the years 1S09—10—11, by the Ccwniittte of Physicians appointed by the Madras Government. 6 PYREXIA, OR FEBRILE DISEASES. CUtSS L We have not yet attained a certain knowledge of the proximate cause of an intermittent fever; but a deranged state of the stomach and primae viae is that which is most generally ascribed. Each paroxysm of an intermittent fever is divided into three different stages, which are called the cold, the hot, and the sweating stages, or fits. The cold stage commences with languor, a sense of debility, and sluggishness in motion, frequent yawning, and stretching, and an aversion to food. The face and extremities become pale, the features shrink, the bulk of every external part is diminished, and the skin over the whole body appears constricted, as if cold had been applied to it. At length the patient feels very cold, and uni- versal rigors come on; the respiration is small, frequent, and anxious; the urine is almost colourless; sensibility is greatly im- paired ; and the pulse is small, frequent, and often irregular. In a few instances, drowsiness and stupor have prevailed in so high a degree, as to resemble coma, or apoplexy; but this is by no means usual. These symptoms abating after a short time, the second stage commences with an increase of heat over the whole body, redness of the face, dryness of the skin, thirst, pain in the head, throbbing in the temples, anxiety, and restlessness; the respiration is fuller and more free, but still frequent; the tongue is furred, and the pulse has become regular, hard, and full. If the attack has been very severe, then, perhaps, delirium will arise. When these symptoms have continued for some time, a moisture breaks out on the forehead, and by degrees becomes a sweat, and this at length extends over the whole body. As this sweat con- tinues to flow, the heat of the body abates, the thirst ceases, the urine deposits a sediment, respiration is free and full, and most of the functions are restored to their ordinary state : the patient is, however, left in a weak and wearied condition. This constitutes the third stage. Having pointed out the phenomena usually attendant on a paroxysm of intermittent fever, and likewise their mode of succes- sion, it may not be unworthy of observation to notice, that in dif- ferent cases they may prevail in different degrees; that the series of them may be more or less complete; and that the several stages, in the time they occupy, may be in different proportions to one another. After a specific interval, according to the species of ague, a fresh paroxysm commences in the manner above described. Such a depression of strength has been known to take place on the attack of an intermittent fever, as to cut off the patient at once; but an occurrence of this kind is very uncommon. Patients are seldom destroyed in intermittents, from general inflammation, or from a fulness of the vessels, either of the brain, or of the thoracic viscera, as happens sometimes in a continued fever; but when their duration is of any length, they are apt to induce other complaints. Order I. intermittent fevers. 7 such as loss of appetite, flatulency, scirrhus of the liver and spleen, dropsical swellings, and general debility, which, in the end, now and then prove fatal. In warm climates particularly, intermittents are very apt to terminate in this manner, if not speedily removed ; and in some cases they degenerate into continued fevers. When the paroxysms are of short duration, regular in their recurrence, and leave the intervals quite free, we may expect a speedy recovery; but when they are long, violent, and attended with much anxiety and delirium, the event may be doubtful. Other unfavourable symptoms are, great prostration of strength, vertigo, foetid excretions, the presence of dysentery, cholera morbus, en- largements of the liver and spleen, inducing dropsy or jaundice, and convulsions occurring during the paroxysm preceded by coma. Relapses are very common to this fever, at the distance even of five or six months, or even a year; and autumnal intermittents are more difficult to remove than vernal ones. Dissections of those who have died of an intermittent, show a morbid state of many of the viscera of the thorax and abdomen; but the liver, and organs concerned in the formation of hiile, as likewise the spleen and mesentery, are those which are. usually most affected. The indications of cure in the treatment of intermitteiits, are, first, to put as speedy a stop as possible to the fit, when it has taken place, and, secondly, during the intermission to prevent its return, at the usual, or any after period, both by exciting a new action in the system, by administering certain remedies at the commencement or immediately before the accession of the cold fit, thereby destroy- ing the morbid concatenation induced by the cause of the disease, and by invigorating the body. To effect the first of these intentions, it is proper to have recourse to warm diluent liquids, artificial warmth, th Haustus tertiis horis repetendus. Vel, 4. R- Liquor. Amnion. Acetat. f. 3"j- Aq. Cinnam. f. 3ij. — Purae f. 3 v. Vin. Antimon. Ill x. Syrup. Cort. Aurant. f. 3j- M. ft. Haustus. Vet, 5. RPulv. Antimonial. gr. ij. ----Contrajerv. gr. x. M. ft. Pulv. 4tis horis sumendus. Vel, 6. & Pulv. Ipecac. C. gr. x. Capiat tertia quaque hora. Tartarized Antimony, the sixth of a grain. Common Syrup, two drachms. Mix them for a draught, which is to be re- peated every three hours. Or, 4. Take Solution of Acetate of Ammonia, three drachms. Cinnamon Water, two drachms. Pure Water, five drachms. Antimonial Wine, sixteen drops. ... , s7ruP of Orange Peel, one drachm. Mix them for a draught. Or, 6. Take Antimonial Powder, two grains. Powdered Contrajerva Root, ten grains. Mix them, and let this powder be takea every four hours. Or, 6. Take Compound Powder of Ipecacu- anha, ten grains, repeating the- dose every three hours. Order /. intermittent fevers. 11 The Doctor has always observed, that the effects of opium are more uniform and constant in intermitting fevers, than in any other disease, and are there more quick and sensible than those of any other medicine. An opiate thus given soon after the commence- ment of the hot fit, by abating the violence, and lessening the duration of the fever, preserves the constitution so entirely un- injured, that, since he used opium in agues, a dropsy or jaundice has seldom attacked any of his patients in those diseases. When opium did not immediately abate the symptoms of the fever, it never increased their violence; on the contrary, most patients reaped some benefit from an opiate given in the hot fit, and many of them bore a larger dose at the time than they could at any other. Dr. Lind offers it as his opinion, that opium in this disease is the best preparative for the bark, as it not only produces a complete intermission, in which case alone that remedy can be safely admin- istered, but occasions such a salutary and copious evacuation by sweat, as generally to render a much less quantity of bark requisite. When we obtain an intermission, the cinchona bark is to be given, during the intervals, in large doses. One or two drachms of the powder may be taken every hour, if the stomach will bear so much, as the benefits to be expected from this medicine greatly depend on a large quantity being administered in a short space of time; for five or six ounces of bark taken in a few days, will be attended with a much better effect than perhaps as many pounds taken in the course of some weeks. If it will not sit easy on the stomach in substance, we must be content to substitute a decoction or infusion of it, or we may give the extract*, joining a few drops of sulphuric acid. Where the intermissions between the paroxysms are long, as in the tertian and quartan types, we should delay giving the bark until within eight hours or so of the accession of the cold fit. If all the forms which have been mentioned are nauseated and rv iected by the stomach, we may advise the bark to be given in cl} sters, in which form it likewise proves very efficacious. For this pi. pose, about a drachm of its extract, dissolved in a sufficient quantity of water, with the addition of a few drops of tinctura opii, in order to its being longer retained, will be most proper. With children who cannot be prevailed on to take the bark, we may administer it with much efficacy in this way, repeating the clyster every four hours. For the cure of intermittents in children, the bark has sometimes proved effectual when applied externally, by putting the powder of it into a quilted waistcoat. * 7. R Extract. Cinchon. gr. xv. Decoct, ejusdem f. ^jss. Tinct. Cort. Aurant. f. 3j. M. ft. Haustus alternis horis sumendus. * 7. Take Extract of Peruvian Bark, fifteen grains. Decoction of the same, one ounce and a half. Tincture of Orange Peel, one drachm. Mix them, and let this draught be taken every other hour. 18 PYREXI/E, OR FEBRILE DISEASES. Class I. In most intermittents it would perhaps be the best practice to unite opium with the cinchona bark, as it would enable the stomach to bear much larger doses of the latter, and likewise add very con- siderably to its good effects. Various substances of either an astringent, stimulant, or aromatic nature, such as alum, the various preparations of iron, &c. nutmeg, and snake-root, have been joined to the cinchona bark, with a view of increasing its powers ; but as these lessen its dose by their bulk, it will be best to give it by itself, unless it occasions a purging, and then about eight or ten drops of tinct. opii, or about a drachm of the tinct. kino, may be added to each dose. On the contrary, should it produce costiveness, some gentle laxative may be taken occasion- ally, such as a few grains of rhubarb. In intermittents of long continuance, where the person is advanced in years, and weak, the habit phlegmatic, the season rainy, and the situation damp, it will be proper to make an addition of snake-root and some warm aromatic* to the cinchona bark, and when the symptoms have more of an inflammatory tendency, it may be given with a small portion of the potassae subcarbonasf. In cold climates, it will in general be advisable to wait for a perfect and regular intermission before we give the bark : but in warm ones, where intermittents are apt to degenerate into continued fevers or remittents, and in which the habit is more irritable and weak, it will be right to administer it, even on the most imperfect intermission, or slightest remission. In all cases of intermittents, it will not be sufficient that the recurrence of paroxysms be stopped for once or twice by a use of the bark; a relapse is commonly to be expected, and it should there- fore be prevented by a continued exhibition of the medicine at proper intervals; even for some weeks after the disease appears to be re- moved, it may be advisable to take a little of it occasionally, particu- larly in damp weather, or during the prevalence of an easterly wind. Various species of the bark are now to be met with among the venders of this medicine, and we have been favoured with the report * 8. 3- Pulv. Cort. Cinchon. ^j. Coq. in Aq. Font. Oj. ad Oss. Colat. adde Tinct. Serpent. Rad. ----Card. C. aa f. 3vj. M. Capiat Cochl. ij. magna pro dos. saepe per diem. f 9. {J; Decoct. Cort. Cinchonas f. |jss. Potassae Subcarbon. gr. x. ad xv. Syrup. Althaea? f. 3ij- M. ft. Haustus quartis horis adhibendus, * S. Take Powdered Peruvian Bark, one ounce. Pure Water, one pint, boil it over a slow fire until redu- ced to half a pint, strain it, and when cool, add Tincture of Snake-root. Compound tincture of Carda- moms, six drachms of each. Mix them, and take two large spoonsful for a dose, several times a day. t 9. Take Decoction of Peruvian Bark, aa ounce and a half. Subcarbonate of Potass, from ten to fifteen grains. Syrup of Marshmallows, two drachms. Mix them. This draught may be takea every four hours. Order L intermittent peyers. 13 of several gentlemen* of eminence in their profession, giving a decided preference to the yellow (cinchonae cordifoliae cortex), as possessing virtues far superior to the red, or any other species yet introduced into use. From various trials made with it, these physicians report, that it is bitterer to the taste, and more astringent, than the other sorts ; that a decoction and infusion of it are less liable to undergo fer- mentation ; and that in every instance in which it was used by them, it invariably proved successful. Half a drachm of the yellow bark in powder, given every two hours, has in general been found sufficient for the cure of an intermittent; hence they have presumed that it possesses nearly a double febrifuge power to that of common bark. Of its good effects I can myself bear testimony, having used it with the most decisive success. During my residence in the West Indies I met with many cases that resisted the powers of cinchona, and that gave way to a use of quassia. Indeed, so sovereign a remedy was this found in inter- mittents, and so easy was it to be obtained, that it was pretty gene- rally substituted by all practitioners for the cinchona, in common cases, on the plantations. The best way of administering it is in the form of infusion, as belowf. The angustura bark (cortex cuspariae) is another remedy which I have often used with success. Other substitutes for cinchona have been mentioned and advised. In the sixth volume of Medical Facts and Observations, published in the year 1795, we are favoured by Dr. Roxburgh with an account of a new species of the swietenia (mahogany), which from repeated trials, and experience of its effects, he proposes as a substitute for the cinchona. He calls it the swietenia febrifuga, and says, its astringent and bitter qualities are more intense than those of the Peruvian bark, and that its active parts are much more soluble than those of the other, particularly in watery menstruums. He adds, that it contains a much larger share of active (bitter and astringent) powers than cinchona oblongi folia or red bark; that watery pre- parations of it remain good much longer than similar ones of the latter; that spirituous and watery preparations of it bear being mixed in any proportion without decomposition; and that its antiseptic powers are stronger. A great variety of other barks, such as the cinchona Jamaicensis discovered by Dr. Wright; the cinchona Charibbaea, or St. Lucia bark, the Tellicheri bark, &c. have been substituted for the Peruvian * Dr. Relph, Dr. Saunders, and Dr. Babington, physicians to Guy's Hospital; Dr. Lind, of Haslar Hospital; and the late Dr. Woodville. t 10. B Quassia? 3ij. Aq. Bullient. f. |viij. Post heram unam Col.et adde Tinct Cascaril. ----Cardam. C. a af. |ss. M. Cbcblearia itj. magna tertiis horis sumenda. t 10. Take Quassia Bark bruised, tw» drachms. Boiling Water, eight ounces ; in- fuse for an hour, then strain off the liquor, and add Tincture of Cascarilla. Compound Tincture of Carda- moms, each half an ounce. Mix them. Three large spoonsful are fo be taken every three hours. 14 PYREXIA, OR FEBRILE DISEASES. ClaSS 1. with a very good effect when this could not be obtained. As a tonic and febrifuge, the willow bark has of late years been much employed with considerable success both in England and on the Continent. The varieties of the willow which have been noticed by botanical writers, are very numerous; but the salix latifolia or caprea (broad-leafed willow bark) seems to possess virtues greatly superior to the others. A late writer* has endeavoured indeed to convince us, that it has a superior efficacy above the cinchona in various diseases, more particularly that branch of the healing art termed medical surgery. The decoction is the form to which this practitioner gives the preference : one ounce and a half of the dried and pounded bark boiled for a quarter of an hour in two pints of soft water. Of this, the ordinary dose is two , or three spoonsful, given three or four times a day. A cheap substitute for the bark of cinchona, and which has proved very successful, consists of equal parts of bistort and calamus aromaticus, with the addition of a little ginger. This remedy may be given in the same doses as the former. The radix rhataniae is another substitute, which has lately been proposed for the cinchona; but from a few trials I have made of it in intermittents, I am convinced that it is by no means deserving of the encomiums which have been lavished on it by Dr. Rees. Twenty grains of the powder may be considered as a moderate dose; and it may also be employed either in the form of extract, decoction, or tincture. All these barks, probably, owe their efficacy to one common principle ; but what this is, it may be difficult to ascertain. Their febrifuge power has been attributed by some principally to the tannin, which they all contain in a greater or less quantity; but this opinion must be erroneous, as it appears, from Mr. Davy's ex- periments, that very little tannin is contained in the cinchona, or in the other barks supposed to be possessed of febrifuge properties. Charcoal is a remedy much employed by physicians in Sicily in the cure of intermittent fevers, and apparently with much successf. It is administered in doses of one scruple, or half a drachm, three or four times a day. In intermittents, where from flatulency, distention of the abdomen, or a retention of faeces, it becomes necessary to have recourse to laxatives, we may employ something of a warm aromatic naturej * See Wilkinson's Experiments on the Broad-leafed Willow Bark. f Edinburgh Medical Journal for October 1814. $1L R Pulv. Rhei g. xv. } 11. Take Powdered Rhubarb, fifteen grains. ----Cinnam. Compos, gr. v. Compound Powder of Cinnamon, five grains. ft. Pulvis. Mix them. Vel, Or, 12. R Infus. Sennas f. |jss. 12. Take Infusion of Senna, one ounc« and a half. Tinct. Rhei f. 3ji. Tincture of Rhubarb, two drachms. ----Lav. C. f. 3j- M. Compound Tincture of Lavender, ft. Haustus. one drachm. Make them into a draught. Order I. INTERMITTENT FEVERS. 15 which should be taken during the intermissions, so that its operation shall have ceased before the accession of the next paroxysm. It often happens, when intermittents have continued a long time, that scirrhosities of the liver or spleen take place, which are vulgarly denominated ague-cakes. These complaints have been attributed to an improper use of the cinchona bark; but they evidently arise from the great quantity of blood which is thrown on these parts during the cold fit, which distends them, and so produces a scir- rhosity in them, and which we often find it difficult to remove, although a stop is put to the fever. In such cases it may be proper to join deobstruents with cinchona, as below*. If these do not answer, we must have recourse to mercuryf. A small dose should be given every night, so as just to affect the mouth, but the tonic medicines are to be continued. If the patient cannot take this remedy internally, he must substitute its external use in the form of unction, rubbing into the groins about a scruple, if an adult, of the unguentum hydrargyri fortius every night at bed-time. Mercury is, however, employed unsuccessfully in many instances of these enlargements, and which have afterwards given way to other remedies. Two cases of enlarged spleen, which resisted the effects of mercury, although the salivary glands had been suffi- ciently excited, and were afterwards removed by the succus in- spissatus conii, are recorded in the work of a late writerj. In warm climates particularly, these swellings are often to be met with as the consequence of long continued intermittents; but of these, more particular mention is made under the head of Chronic Inflammation of the Liver, as also of the Spleen. These tumors, by pressing on the ramifications of the vena portarum, which passes into the liver, and branches in the manner of an artery, prevent the blood from returning from the abdominal viscera with the same facility that it commonly does. The passage X See Essay on Hepatitis tmd other Bilious Complaints in India, as well as Europe, by Charles Griffith, M. D. * 13. RPulv. Cinchon. |j. ----Rhei 3jss. Sodae Subcarbon. 3»j- Syrup. Zingib. q. s. M. ft. Elect. Gujus sumat Cochl. min. ter quaterve in die 114. Ek Hydrargyr. Submuriat. gr. j. Confect. Opii gr. iij M. Fiat pilula omni nocte sumenda. Vel, 15. g: Pilul. Hydrargyri gr. iij. ----Opiat.gr. jj. M. ft. pilula. 13. Take Peruvian Bark in powder, on« ounce. Powdered Rhubarb, one drachm and a half. Subcarbonate of Soda, two drachms. Syrup of Ginger, as much as may be sufficient to form the whole into an elec- tuary ; of which, take about a teaipoonfuS three or four times a day. t 14. Take Submuriate of Mercury (Calo- mel), one grain. Opium Confection, three grains. Form them into a pill, to be taken every night. Or, 15. Take Mercurial Pill, three grains. Opiate Pill, two grains. ForHiJjiem into a pill, to be taken as (*i« former 16 PYREXIA, OR FEBRILE DISEASES. Class I. of the blood being thus retarded, occasions a greater extravasation of lymph in the cavity of the abdomen, so that the ordinary exertion of the absorbents is not sufficient to take up the whole lymph. Thus an ascites takes place, and in this case we must have recourse to the means advised under that head. Dropsy likewise arises sometimes from mere weakness, without any tumor of the abdominal viscera, and occasioned by the long continuance of the disease. In these instances it may be removed by exhibiting the bark of the cinchona together with stomachic bitters, diuretics, and chalybeates. As the strength returns, and the patient recovers his health, the dropsical appearances will diminish by degrees. When tumors are formed in any of the abdominal viscera, it not uncommonly happens that they press on the ductus communis choledochus, the duct of the gall-bladder, the hepatic duct, or the pori biliarii; by which means the bile is prevented in part, or wholly, from getting into the duodenum; it is therefore absorbed, and produces jaundice of itself, without any concomitant dropsical symptom, or along with it, ascites. When this happens, the disease is generally fatal. The blood, by being determined from the blood vessels upon the abdominal viscera, when the patient becomes weak after an inter- mittent has continued for some months, sometimes occasions an increased secretion from the glands of the intestines, and thus gives rise to a diarrhoea. This affection usually proves more severe during the remissions and intermissions; and Jess severe, or ceases altogether, at the time of the accession and during the time of the paroxysm. Such diarrhoea tends to increase the weakness consi- derably, and not unfrequently occasions dropsical appearances. At first, oedematous swellings appear in the lower extremities; these increase, rising up to the thighs, and then to the integuments of the abdomen. Ascites also takes place. If astringent remedies be em- ployed, so as to put a stop to the diarrhoea, the dropsical appear- ances usually increase, and the intermittent continues to recur, although often very obscurely and very irregularly. If the diarrhoea be permitted to go on, or if it has been stopped, and is allowed to return by leaving off the astringents, the weakness increases in such a degree as to destroy the patient. If the bark of cinchona be exhibited, it often increases the diarrhoea without having the effect of preventing irregular returns of the attacks or exacerbations. In this case, Dr. Fordyce* says it will be best to clear the primae viae, by employing about twenty-five grains of rhubarb ; after its opera- tion is over, to exhibit cinchona in pretty considerable quantity, such as a drachm every three hours, and to give at the same time a grain of ipecacuanha with fifteen drops of tinctura opii, together with a moderate quantity of any warm spice, every four hours. In some cases of intermittents, which have continued a great * See his Fourth Dissertation on Fever. Order I. intermittent fevers. 17 length of time, owing to their having been entirely neglected in their beginning, or where the cinchona has failed to procure the desired effect, preparations of iron and copper have been adminis- tered with success. The oxydum zinci, given in the dose of two grains thrice a day, has removed obstinate intermittents when the usual remedies have failed. The sulphas zinci has likewise been administered with much success. The sulphate of copper, given in doses of a quarter or half a grain every four or six hours, is also said to have proved very efficacious in some cases of obstinate intermittents. As a tonic, the cuprum ammoniatum* has been given with advantage. AH these may be employed along with a decoction of the cinchona, or any of the other tonic bitters which have been mentioned. Arsenic has been strongly recommended as a remedy in intermit- tents, and it is undoubtedly a very powerful medicine, for I have found it to remove obstinate intermittents which had long resisted all other means. The inhabitants of a considerable portion of the country which surrounds Salisbury (the place of my residence), are very subject to these fevers, but I have never yet been disappointed in removing even those of an obstinate nature, by a proper use of the arsenical solution ; it is, however, my constant practice to con- join four or five drops of tinctura opii with each dose of it. The late Dr. Fowler seems to have been the first physician to advise this medicine in agues, and on his recommendation many practitioners have used it, agreeably to his directions, with the most pointed success. The preparation he advised is now introduced into the London Pharmacopoeia, under the name of liquor arsenicalis. The dose is from two to twelve drops, once, twice, or oftener in the day, according to the age, strength, he. of the patient. Eight days' administration of the medicine, in the manner just mentioned, will generally be found sufficient for the radical cure of an intermittent. 'Vomitings, gripings, swellings, and the loathing of food, are the troublesome symptoms now and then produced by an improper use of the arsenical solution. They however disappear generally on a discontinuation of the drops, or only require the exhibition of gentle opiates, or some warm cathartic, such as the tincture of rhubarb. From the observations which have been made on the use of arsenic in agues, there seem just grounds for believing it to be the most powerful of all the medicines which have been recommended in these complaints. In Lincolnshire, which is a fenny country, where agues are very prevalent, it is universally used, and with the * 16. $ Cupr. Ammoniat. 3j. Mic. Panis 3>j- Syrup. Cort. Aurant. q. s. M. fiant pilul. xxiv. capiat j. ret ij—iij. (sensim augendo dnsem) Iiora decubitus quotidie. •16. Take Ammoniated Copper, onescruple. Crumb of Bread, two drachms. Syrup of Orange Peel, as much as will be sufficient to form the mass, which divide into twenty-four pills, 'lake one, two, or three, every night at bed-time, gra- Juallv inert;umg the dose. 18 PVKEXIA:, OR FEBRILE DISLAr-ES. ClaSS I. most uniform success. Military and naval surgeons will find the arsenical solution a valuable substitute for the bark of cinchona, when their store of this is small or exhausted. Arsenic has long been administered by empirics with the greatest success in inter- mittents, under the appellation of the ague-drop. The manner in which arsenic acts in curing intermittent fevers, Dr. Darwin thinks, cannot be by its general stimulus, because no- intoxication or heat follows the use of it; nor by its peculiar stimulus on any part of the secreting system, since it is not in small doses succeeded by any increased evacuation or heat, and must therefore exert its power on the absorbent system. He sus- pects its success in the cure of intermittents to depend on its stimu- lating the stomach into stronger action, and thus by the association of this viscus with the heart and arteries, prevents the torpor of any part of the sanguiferous system. A combination of the arsenical solution with cinchona* in sub- stance, decoction, or infusion, is likely, I think, to prove a valuable remedy in cases of obstinate intermittents, and where either of these medicines administered singly might fail. During the fits of an intermittent, the patient's strength is to be supported by food of a light nutritive nature, such as preparations of barley, sago, panado, and the like; but when the fit is off, he may be allowed animal food, and a moderate use of wine. A change of air and situation has sometimes a happy effect in removing an intermittent, particularly if from a low marshy country to an ele- vated one. In autumnal intermittents it has been found, that the air of a city oi* large town is more favourable than that of the country, owing most likely to the great number of fires that are p.lways burning. When none of the viscera are affected, cold bathing may be used with advantage. As intermittents are very apt to return, the patient should care- fully avoid all such causes as might produce a fresh attack. Should he be incommoded by a giddiness of the head, which is not un- * 17. R Liquoris Arsenical, fit. iij.—viij. Decoct Cinchon. f. 3*- Tinct. Cort. Aurant. f. 3U* ----Opii, fit. v. M. ft. Haustus ter in die sumendus. Vel, 18. & Infus. Rad. Calumb. f. 3xj. Liquor. Arsenical, fTL v. Tinct. Opii, TTV iv. ----Cinchonae C. f. 3j. M. ft. Haustus 4ta vel 6ta quaque hora capi endus. * 17. Take Arsenical Solution, from five to twelve drops. Decoction of Peruvian Bark, ten drachms. Tincture of Orange Peel, two drachms. ------of Opium, eight drops. Mix these, and let the draught be taken thrice daily. Or, 18. Take Infusion of Calumbo Root, eleven drachms. Arsenical Solution, eight drops. Tincture of Opium, six drops. Compound Tincture of Peruvian Bark, one drachm. Mix them, and let the draught be taken every fourth or sixth hour. Order I. INTERMITTENT FEVERS. 19 commonly the case even after a slight attack of this fever, it may generally be relieved by volatiles* and the bark in wine. The chief malady which prevailed among the British troops on the island of Walcheren, and which swept off so many of them in a short space of time, was evidently the endemic fever of marshy countries. It made its appearance towards the close of summer, and became very prevalent during autumn, particularly in the months of August and September, showing itself at first under the quotidian, tertian, double tertian, quartan, and even remitting type, (but of all these the double tertian was the most common,) after- wards degenerating, in many instances, into a continued fever of the typhoid nature, accompanied with considerable malignancy. The disease apparently was not contagious in itself, but assumed this new form and character of fever wherever ventilation was defective, the patients much crowded together, or where other local causes of impurity prevailed. This was particularly noticed at Flushing, where the accommodations for the sick were very con- fined and crowded, and where the ditches were foul and obstructed, from the consequences of the siege, and the streets filthy from an imperfect police. Among those whose constitutions had not been habituated to the climate, who had been much exposed to wet and damp, who had undergone great military fatigues, and who were accommodated in close confined quarters, the disease assumed a character of much malignity, corresponding with the degrees of combinations of all the predisposing causes. On the approach of winter the disease subsided, but was only put a stop to by removing the convalescents as speedily as possible to England, previous to the entire evacuation of Walcheren. The treatment was varied as the fever assumed an intermittent, remittent, or continued type, and the appropriate remedies noticed under each of these heads, were resorted to accordingly. Most of the cases which did not terminate fatally, were tedious, and subdued with difficulty, and when overcome, left behind them great debility, as well as a strong disposition to relapse : perfect recoveries were rare, convalescence never secure, and where the recurrences of fever did not destroy life, they laid quickly the foundations for visceral obstructions, thereby rendering a large portion of the sufferers unfit for after military purposes. Chronic diarrhoea, dy- sentery, and dropsy, were frequent consequences. The deaths were numerous, and often sudden. Had several large hospital ships been moored in convenient situ- ations at a little distance from the land, and the convalescents been "* 19. ft Aq. Menth. f. ^iijss. * 19 Take Mint Water, three ounces and a half. Spirit. Ammon. Aromat. 1t[, xxx. Aromatic Ammoniated Alcohol, forty-five drops. Syrup. Cort. Aurant. f. Zss. M. Syrup of Orange Peel, half an ounce. Capiat Cochl.larg.j.terquarterve in die. Mix them. The dose may be one large spoonful three or four times a day. 20 PYBEXIiE, OR FEBRILE DISEASES. ClaSS J. quickly removed to them on their recovering from the first attack of the fever, several of the fatal relapses which took place among these who continued to be exposed to the local exhalations, might have been prevented, and many valuable lives have been saved. REMITTENT FEVER. By a remittent is to be understood where the fever abates, but does not go off entirely before a fresh attack ensues; or, in other words, where one paroxysm succeeds the other so quickly, that the patient is never without some degree of fever. It is to be observed, moreover, that the remissions happen at very irregular periods, and are of uncertain duration, being sometimes longer and some- times shorter. This fever is principally induced, as well as the intermittent, by marsh miasma, or the exhalations arising from stagnant water im- pregnated with the decaying remains of animal and vegetable sub- stances, and is most apt to arise when calm, close, and sultry weather quickly succeeds heavy rains or great inundations. In warm climates, particularly as we approach the tropics, where great heat and moisture rapidly succeed each other, the remittent is a very prevalent type of fever, and often appears under a highly aggravated and violent form, prevailing epidemically. It is like- wise often met with in low marshy situations abounding with wood. and water, from which miasma are consequently evolved, and is most apt to attack those of a relaxed habit, those who undergo great fatigue, and those who breathe an impure air, and make use of a poor and unwholesome diet. Although this fever is produced originally by marsh miasma, and in its simple state is consequently not of an infectious nature, still, under bad management, such as crowding too many sick together, and neglecting proper cleanliness and a free ventilation, there cannot be a doubt that it may, in its course, engender a matter capable of occasioning a highly contagious fever. Remittent fever cannot be communicated at any great distance from the source of its exciting cause, however severely and epide- mically it may prevail in certain situations and districts; and although the matter producing it be essentially the same, still we may conclude, I think, that a more aggravated form of disease is occasioned by a more concentrated state of the poison : hence the different degrees of severity of remittent fever at different periods of the year, and in different climates. It has long been observed, that the natives of any place are much less liable to be affected with the diseases peculiar to the situation than strangers, or those newly arrived; and it may like- wise be added, that when they are attacked with any endemic affection, it is rarely so severe as it is found to prevail among strangers, and those not accustomed to the climate. This I had great opportunities of seeing confirmed in the West Indies, in the Order I. remittent fever. 21 case of remittent fever, which seldom affects the natives so severely as it does Europeans not sufficiently naturalized, although in every respect using the same diet, and adopting the same mode of life. Preceding an attack of a remittent fever, the patient is usually heavy and languid, arid is troubled with anxiety, listlessness, sighing, yawning, and alternate fits of heat and cold. On its accession, he experiences severe pains in the head and back, in- tense heat over the whole body, with thirst, difficulty of breathing, and great dejection of spirits; the tongue is white; the eyes and skin appear yellow ; there is a pain and sense of swelling about the region of the stomach; nausea, and a vomiting of bilious matter, ensue ; and the pulse is frequent and small. After a continuance of these symptoms for a time, the fever abates considerably, or goes off imperfectly by a gentle moisture diffused partially over the body; but, in a few hours, it returns with the same appearances as before. In this manner, with ex- acerbations and remissions, it proceeds at last to a crisis, or is changed into a fever of a different type. In warm climates, the remission often occurs so early as the second day; but in cold ones, it frequently does not take place until from the fourth to the sixth or eighth day. The accession of fever, which has just been described, is how- ever the mildest form under which it ever makes its appearance ; for sometimes a severe delirium arises, and carries off the patient during the first paroxysm; or the remission, perhaps, is scarcely perceptible, and is immediately followed by another paroxysm, wherein there is a considerable aggravation of all the symptoms. The heat of the body is greatly increased, the face is highly flushed, the thirst is excessive, the tongue is covered with a dark brown fur, respiration is laborious, the pulse is quick, throbbing, and tremulous, and a delirium arises. At the distance of some time, perhaps another short or imperfect remission again takes place ; but the symptoms return once more with redoubled violence, and at length destroy the patient. The symptoms which attend a remittent fever are apt to vary according to the situation and constitution of the patient, and like- wise the season of the year, and therefore it is impossible to give a certain detail of them ; for sometimes those pointing out a re- dundancy of the bile predominate, sometimes the nervous are most prevalent, and at other times the putrid. A remittent fever is always attended with some hazard, particu- larly in warm climates, in which it usually goes through its course in the space of five or six days; but in cold ones, its crisis is not usually effected until the twelfth or fourteenth. The shorter and more obscure the remissions are, the greater will be the danger, and each succeeding paroxysm is attended with more risk than the former. On the contrary, the milder the attack, and the nearer the fever approaches to an intermittent, the fairer will be the prospect for a recovery. 22 PYREXIA, OR FEBRILE DISEASES. (JlttSS L The usual appearances on dissection are, congestions of blood in the liver and spleen, inflammations in the alimentary tube, a dis- tended state of the venous vessels of the brain, and serous effusion into the cavities of that organ. From the determinations to particular organs which take place in a remittent fever, and the marks of inflammation which are occa- sionally observed on dissection in the brain, stomach, and biliary organs, it would seem that bleeding is a necessary operation. In both cold and warm climates, and at an early stage of the disease, it will be proper to have recourse to it, where the patient is young and of a full plethoric habit, the pulse full and hard, the heat in- tense, the breathing difficult, or the head much affected with stupor or delirium ; and in some cases it may be necessary to repeat the operation in a few hours, if the force of the circulating fluids is not sufficiently diminished thereby : but in warm climates, when none of these symptoms are present, it will be better to omit it, especially if the person has been an inhabitant therein for any length of time, and not lately arrived from Europe. In all protracted cases of this fever, under every climate, where the pulse is weak but still the head much affected, the application { of cupping glasses to the occiput, or of leeches to the temples, and blisters, will be more advisable than venesection. To assist in allaying the violence of the fever, it will be prudent carefully to remove and avoid every thing that might in the least contribute to increase it, such as too strong a light falling on the eyes, all noise and motion, and likewise any excess of heat. The patient is therefore to be kept perfectly quiet; the covering of his bed is to be light, and his chamber of a moderate temperature, by allowing a free admission of cool air into it. To assist these means, he should be presented from time to time with some cooling acidu- lated liquor, such as lemonade, tamarind beverage, or a solution of the crystals of tartar, or even cold water. Throughout the whole course of the disease, it will be advisable to change his body-linen, as well as that of the bed, frequently; to sprinkle his chamber often with vinegar, and to remove immediately whatever he voids by stool. As in most cases there is a determination to the brain, the patient's head should be kept rather elevated, and being shaved, numerous folds of linen, moistened with vinegar and water (artificially cooled), may be kept constantly applied to it: his feet may be immersed 1 occasionally in warm water. i As nausea usually prevails at the commencement of the disease, it will, in all cases, be right to cleanse the stomach by giving a gentle emetic of ipecacuanha, or a solution oftartarized antimony, which perhaps may be preferable : the operation of this being over, the bowels may then be emptied by some gentle laxative, which will seldom fail in bringing off a considerable quantity of dark bilious matter. Drastic purges, by determining inwardly and increasing the irritability of the stomach, would be prejudicial; and therefore, ' if it is necessary to obviate costiveness in the course of the disease, Order f. REMITTENT FEVER. 23 it will be most advisable to do it by the laxative medicines here prescribed*, assisted now and then with aperient clysters. The necessity of carefully inspecting the alvine discharges in remittent fever, cannot be too strongly inculcated, as it affords the best or principal index as to the regulation of our employing pur- gative medicines. In this fever, as well as typhus icterodes, the submuriate of mer- cury, combined with rhubarb or jalap, may be regarded as a valuable remedy, where we wish to carry off putrid feculent matter from the bowels, and there is at the same time any degree of nausea or vomiting present; as, from the smallness of its bulk, it may pos- sibly be retained on the stomach, when every other purgative might be rejected. After these evacuations, and wheie there is no delirium present, an opiate wiil be found of great service in quieting the commotions induced either by the spontaneous or artificial discharges, and in enabling the patient to retain on his stomach both nourishment and medicines. In the remittent fevers of warm climates, as well as of temperate countries in the hotter seasons of the year, the best effects are to be derived from cold affusion, or throwing cold water over the patient; but it is to be understood that the height of the paroxysm is the proper time for the application of the remedy. The sensations of heat are then strong; the headach is violent, and delirium fre- quently runs high. By employing the remedy at an early period, we may be able either to arrest the disease precipitately, or bring about an early solution of the paroxysm ; but at the least we may for the most part so ameliorate its aspect, as that from an obscure remittent it will soon become an intermittent of a distinct and re- gular type. Where signs of congestion, or irregular action, pre- sent themselves in the abdominal or biliary system, and the disease is recent, it will be advisable, previous to having recourse to affusion, to premise proper evacuations. In the progress of the disease, where much debility has arisen, * 1. ft Potassa? Tartrat. 3tf- Infus. Sennac,f. ^jss. Tinct. Jalapae, VC[. xxx. M. ft. Haustus. Vel, 2. ft Pulv.Rhei, gr.x.—xv. Hydrargyr. Submuriat. gr. v. Syrup, q. s. M. Fiant Pilul. iv. pro dos. Vel, 3. ft Hydrargyr. Submur. gr. v. Pulv. Jalap, gr. xv. M. ft. Pulvis. * 1. Take Tartrate of Potass, two drachms Infusion of Senna, one ounce and a half. Tincture of Jalap, fifty drops. Mix them for a draught. Or, 2. Take Powdered Rhubarb, from ten to fifteen grains. Submuriate of Mercury, five grains. Common Syrup, as much as wilt form the mass, which divide into four pills, to be taken at once. Or, 3. Take Submuriate of Mercury, five grains. Powdered Jalap, fifteen grains. Mix. them, and take them for a dose. 24 P1REXLE, OR FEBRILE DISEASES- Class I. aspersion, or sponging the body over with cold water and vinegar, together with an internal use of wine, may be substituted for affusion or immersion. The general effects to be observed from affusion, where it can be practised with propriety, are a diminution of heat and anxiety, greater cheerfulness of countenance, improved recollection, ten- dency to sleep, the pulse becoming fuller and more uniform, and the skin moist, with now and then a distinct remission. To alter the type of the fever, and bring the remissions into per- fect intermissions, if possible, by promoting a gentle diaphoresis, it will be proper to give antimonials in small and frequently re- peated doses. They may be prescribed as mentioned under the head of Simple Continued Fever, or as below*; and to assist their effect, the patient should take frequent small draughts of some tepid diluting liquor. Where frequent vomitings prevail, antimonials will not be proper. In their stead, we may direct the saline medicine to be adminis- tered, so as that the effervescence shall take place in the stomach, with the addition of about ten drops of tinct. opii to each dose. Moreover, we may direct flannel cloths, wrung out in a warm decoction of chamomile flowers and bruised poppy-heads, with an addition of rectified spirits, to be kept constantly applied over the region of this organ. Should these means fail in procuring the desired effect, a large blister may be put immediately over the part, which will be found, in general, a very effectual remedy. The early application of a blister, even in cases where no great irritability of the stomach prevails, might in most instances be proper, as it will tend to pre- vent the determination to that organ. Blisters likewise prove highly serviceable in the latter stages of a remittent fever, when the spirits flag, and the pulse is low and fluttering, with insensibility or a disposition to coma. In such cases they may be applied be- tween the shoulders, or to the legs. Sinapisms of mustard may also be put to the soles of the feet. When a severe vomiting has arisen, the patient ought to swallow as little drink as possible, and should only now and then just moisten his mouth and throat; for whatever reaches the stomach is sure to be rejected shortly with considerable violence ; and each time it is thrown into these convulsive motions, the disease is strengthened and the person exhausted. Under such circum- stances, it will be better to support the strength by administering clysters composed of broths and other nutritious liquids, than to attempt, it by giving any thing by the mouth. When the stomach is not in an irritable state, and every thing is * 4. ft Pulv. Jacob. Ver. gr. iv. * 4. Take James's Powder, four grains. Camphor, gr. iij. Camphor, three grains. Coufect. Ros;i', q. s. M. Confection of Roses, a sufficiency ft. Bolus, 3tia veKla hora sumendus.~ to form them into a bolus or two pill*, to be taken every third or fourth hour. Order I. REMITTENT FEVER. 25 retained readily, the patient is to be supported by food of a light generous nature. During the remissions, a little wine may be mixed with it. As soon as the fever shows a disposition to yield, and a perfect remission takes place, we ought to give the bark of cinchona in substance, and in such doses as the stomach will easily bear : and if about twenty drops of the acidum sulphuricum dilutum are added to each dose, the effect will be increased. Should the cinchona in powder prove either disagreeable to the patient, or excite nausea, then a decoction or infusion of it must be substituted. If any of its preparations should occasion a purging, about ten drops of the tinctura opii, or a drachm of the tinct. catechu, may be added to each dose. In cold climates we may wait for a perfect and complete remis- sion before we give the cinchona ; but in warm climates we ought to administer it even on the most imperfect and short remission ; and although it may not prove sufficiently efficacious to prevent a fresh attack at first, yet it will seldom fail to mitigate the subsequent returns of the fever, and will at last bring about a regular and per- fect intermission. By neglecting to give the cinchona in the West Indies and other warm climates upon the first remission, the fever is apt to assume a continued form. Where danger is to be apprehended with every return of the paroxysm, and where the interval is likely to be short, we would give at least half an ounce of this bark at once, immedi- ately on the commencement of the intermission. During the rest of the intermission or remission, we may administer it in doses of about two drachms, repeated at such distances as that the patient shall take an ounce, or an ounce and a half, if possible, previous to the next accession. When the interval is pretty long, the remedy may be divided into smaller doses. To guard against a relapse, the cinchona should be continued for some days after a cessation of the attacks, and not to be too hastily left off, as is sometimes the case. The late Dr. Fowler found the most beneficial effects from the use of arsenic in the form of solution in this fever, as well as in in- termittents. From his report, published in the ninth volume of the Medical Commentaries, it appears that he experienced its virtues from repeated trials made of it on himself, having been visited by several attacks of a remittent between the years 1786 and 1T91. He took the solution as directed to be prepared under the title of liquor arsenicalis, in doses of from eight to ten drops twice a day, and always experienced the curative effects of the medicine, during each period of its administration, to be very pointed and successful. We are also informed by Dr. Ferrier*, that he has employed it in some very dangerous and tedious remittents, and always found it a safe and certain remedy. He observed that it generally lessened, * See the new edition of his Medical Histories and Reflections. 4 26 PYREXIA, OR FEBRILE DISEASES. ClaSS I. if it did not suspend, the second paroxysm after its being exhibited, and it effected the purpose without producing the slightest dis- turbance in the habit. To an adult, he usually gave five drops of the saturated solution every four hours, and seldom found it necessary to exceed this dose. The only sensible effects produced by it, Dr. Ferrier tells, are the removal of the crust on the tongue, the appearance of a sediment in the urine, and increased firmness of the pulse. Probably it might be best to administer this solution combined with the cinchona, either in substance, decoction, or infusion.—See Intermittents. Every thing that may have a tendency to bring on a fresh attack of fever is carefully to be avoided during the state of convalescence. A change of air and situation (particularly if it has been low and damp) may have a good effect in expediting the patient's recovery; and if the appetite does not return readily, he may take stomachic bitters with advantage.—See Dyspepsia for these. Gestation in the open air in wheel carriages is a remedy which has been strongly recommended by Dr. Jackson*, towards the close of the bilious remittent fever of warm climates, as well as of all others which have arisen from infection ; and he cites many instances which fell under his treatment and immediate observation, whilst he officiated as physician to the army, both on foreign stations and at home, in which it was employed not only with safety, but with the highest efficacy, particularly so in those where the diseased action had ceased, but where the healthy movement was slow* He observes, that although the good effects of gestation be in them- selves conspicuous, they are at the same time much increased by ablutions, by an entire change of clothes, and by frictions, both before the journey is undertaken, and after it is finished. In seasons and places where this fever is prevalent, it will be advisable, by way of preventive, to take a proper dose of the tinct. cinchonae composita about twice a day, but more particularly on an empty stomach in the morning. CONTINUED FEVERS. Fevers of this nature continue for several days with nearly the same violence, having evident exacerbations and remissions daily. SYNOCHUS, or SIMPLE CONTINUED FEVER. Synocha and typhus, blended together in a slight degree, seem to constitute this species of fever, as has before been observed; the former being apt to preponderate at its commencement, and the latter towards its termination. It is contagious, and is of more frequent occurrence in this country than any other kind of fever. —i — ■— . -_____________________________________________________________________________________________________________________________ * See his Exposition on applying Cold Water in I'ever, p. 398 Order I. simple continued fever. 27 Every thing which has a tendency to enervate the body, may be looked upon as a remote cause of fever; and accordingly, we find it often arising from great bodily fatigue, too great an indulgence in sensual pleasures, violent exertions, intemperance in drinking, and errors in diet; and now and then, likewise, from the suppression of some long-accustomed discharge. Certain passions of the mind (such as grief, fear, anxiety, and joy) have been enumerated among the causes of fever, and in a few instances it is probable they may have given rise to it; but the concurrence of some other power seems generally necessary to produce this effect. The most usual and universal cause of this fever is the application of cold to the foody, giving a check to perspiration ; and its morbid effects seem to depend partly upon certain circumstances of the cold itself, and partly upon certain circumstances of the person to whom it is applied. The circumstances which seem to give the application of cold a due effect, are its degree of intensity : the length of time which it i3 applied ; its being applied generally, or only in a current of air ; its having a degree of moisture accompanying it, and its being a considerable or sudden change from heat to cold. The circumstances of persons rendering them more liable to be affected by cold, seem to be debility, induced either by great fatigue or violent exertions ; by long fasting ; by the want of natural rest; by severe evacuations ; by preceding disease ; by errors in diet; by intemperance in drinking ; by great sensuality ; by too close an ap- plication to study, or giving way to grief, fear, or great anxiety ; by depriving the body of a part of its accustomed clothing; by expos- ing any one particular part of it while the rest is kept of its usual warmth ; or by exposing it generally or suddenly to cold when heated much beyond its usual temperature : these we may therefore look upon as so many causes giving an effect to cold, which it other- wise might not have produced. Another frequent cause of fever seems to be, the breathing air contaminated by the vapour arising either directly or originally from the body of a person labouring under the disease. A peculiar matter is supposed to be generated in the body of a person affected with fever, and this floating in the atmosphere, and being applied to one in health, will, no doubt, often cause fever to take place in him, which has induced many to suppose that this infectious matter is produced in all fevers whatever, and that they are all more or less contagious. The effluvia arising from the human body, if long confined to one place without being diffused in the atmosphere, will, it is well known, acquire a singular virulence, and will, if applied to the bodies of men, become a cause of fever. Exhalations, arising from animal or vegetable substances in a state of putrefaction, have been looked upon as another general cause of fever ; marshy or moist grounds, acted upon by heat for 28 pyrexiae, or febrile diseases. Class I. any length of time, usually send forth exhalations which prove a never-failing source of fever. Marsh miasma, as these exhalations are usually termed, have, undoubtedly, the peculiar effect of inducing fever on human bodies, exposed under certain conditions to their influence. From their denomination it is too commonly understood that marshes are the only sources whence these exhalations arise ; but they also proceed from moist earth, slime, mire or mud, in a great variety of situations and climates of inhabited, as well as unfrequented and uncultivated tracts of country, in almost every quarter of the globe. They are more powerful, concentrated, and virulent in hot climates and in warm seasons, than in temperate ones. It further appears, that the types, or periodical evolutions of the fever which they excite, are chiefly governed by the degrees of concentration which these exha- lations possess ; the type being more continued and less intermit- tent or remittent, in proportion to the power of the exhalation. Numerous are the writers, who, for upwards of a century, have successively exerted their talents in pointing out what each con- ceived to be the proximate cause, or essentia! nature of fever ; some supposing it to consist in a noxious matter, introduced into, or generated in the body, the increased action of the heart and arteries being an effort of nature to expel this morbific matter ; others offer- ing it as their opinion, that it consisted in an increased secretion of bile; and others again, that it is to be attributed to a spasmodic con- striction of the extreme vessels on the surface of fhe body, which, indeed, was the doctrine taught by the late Dr. Cullen. A modern writer*, however, tells us, that the local and primary seat of idiopa- thic fever is in the brain, and that it is nothing more or less than a species of phrenitis, or topical inflammation of the brain. Dr. Currie supposes debility of a peculiar kind to be the first ope- ration of the remote cause producing fever ; the necessary conse- quence or concomitant effect, is, he thinks, a spasm or contraction of the arteries, but more especially of the extreme vessels and capil- laries of the surface ; hence follows an accumulation of blood on the heart and lungs, the reaction of these organs, the separation of mor- bid heat, and morbid association. The ground of this theory is, indeed, nearly the same with that of Dr. Cullen, resting, however, more fully on morbid heat, and admitting into the chain of opera- tion an appendage of morbid association. To investigate these different hypotheses, would lead me into a train of theoretical and vague reasoning, inconsistent with the plaa of this publication ; I shall, therefore, proceed to point out the man- ner in which fevers usually come on, barely observing that the proxi- mate cause of fever is by no means, as yet, satisfactorily ascertain- ed, and that it is a disease, the whole of the appearances of which have not been accounted forf. * See Inquiry into the Seat and Nature of Fever, by H. Clutterbuck, M. D. ♦ See Dissertation on Fever, by Dr. George Fordyce. Order /. simple continued fever. 29 An attack of synochus is generally marked by the patient's being seized with a considerable degree of languor or sense of debility, together with sluggishness in motion, and frequent yawning and stretching ; the face and extremities at the same time become pale, and the skin over the whole surface of the body appears constricted: he then perceives a sensation of cold in his back, passing from thence over his whole frame ; and this sense of cold continuing to increase, tremors in the limbs and rigors of the body succeed. With these, there is a loss of appetite, want of taste in the mouth, slight pains in the head, back, and loins, and a small and frequent respiration. The sense of cold and its effects, after a little time, become less violent, and are alternated with flushings, and at last, going off altogether, they are succeeded by great heat diffused generally over the whole body ; the face looks flushed ; the skin is dry, as likewise the tongue ; universal restlessness prevails, with a violent pain in the head, oppression at the chest, sickness at the stomach, and an inclination to vomit. There is likewise great thirst and costiveness, and the pulse is full and frequent, beating, perhaps, 90, 100, or 120 strokes in a minute. When the symptoms run very high, and there is a considerable determination of blood to the head, delirium will arise. In this fever, as well as most others of the continued kind, there is generally an increase of the symptoms towards evening. If the disease is likely to prove fatal, either by its long dura- tion, or by the severity of its symptoms, then a starting of the tendons, picking at the bed-clothes, involuntary discharges by urine and stool, coldness of the extremities, and hiccups, will be observed : where no such appearances take place, the disease will go through its course, and at length cease. As a fever once produced will goon, although its cause be entirely removed, there can be no certainty as to its duration ; and it is only by attending to certain appearances or changes, which usually take place on the approach of a crisis, that we can form any opinion or decision on this head. It has, moreover, been asserted by some of our eminent teachers of medicine, but more particularly by Dr. Cullen and Dr. George Fordyce*, that the continued or fresh cause of fever neither will increase that which is already produced, nor occasion a new one ; but the soundness of this doctrine I am much inclined to doubt; for although a fever will run its course notwith- standing the cause which gave rise to it has ceased to exist, still the reiterated application of the cause, or continuance within the range of its influence may, I think, signally exasperate the fever in its progress. The symptoms pointing out the approach of a crisis, are, the pulse becoming soft, moderate, and near its natural speed ; the tongue losing its fur and becoming clean, with an abatement of thirst; the skin being covered with a gentle moisture, and feeling soft to the touch ; the secretory organs performing their several offices, and the * See his Treatise on Simple Fever. 30 pyrexiae, or febrile diseases. Class I. urine depositing flaky crystals of a dirty red colour, and becoming turbid on being allowed to stand any time. Many physicians have been of opinion that there is something in the nature of all acute diseases, except those of a putrid kind, which usually determines them to be of a certain duration ; and, therefore, that these terminations, when salutary, happen at certain periods of the disease rather than at others, unless disturbed in their progress by an improper mode of treatment, or the arising of some accidental circumstances. These periods are known by the appellation of critical days, and from the time of Hippocrates down to the present, have been pretty generally admitted. The truth of them, I think, can hardly be disputed, however they may be interrupted by various causes. A great number of phenomena show us, that both in the sound state and the diseased, nature has a tendency to observe certain periods : for instance, the vicissitudes of sleeping and watching, occurring with such regularity to every one; the accurate periods that the menstrual flux observes, and the exact time of pregnancy in all viviparous animals, and many other such instances that might be adduced, all prove this law. With respect to diseases, every one must have observed the defi- nite periods which take place in regular intermittents, as well those universal as topical, in the course of true inflammation, which at the fourth, or at the farthest the seventh day, is resolved, or after this period changes either into abscess, gangrene, or scirrhus : in exanthematous eruptions, which, if they are favourable and regular, show themselves on a certain and definite day; for example, the small-pox about the fourth day. All these appear to be founded on immutable laws, according to which the motions of the body in health and in disease are governed. The days on which it is supposed the termination of continued fevers principally happens, are the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth, and twentieth. A simple continued fever terminates always by a regular crisis in the manner before mentioned ; or from the febrile matter falling on some particular parts, it excites inflammation, abscess, eruption, or destroys the patient. Great anxiety, loss of strength, intense heat, stupor, delirium, irregularity in the pulse, twitchings in the fingers and hands, picking at the bed clothes, startings of the tendons, hiccups, invo- luntary evacuations by urine and stool, and such-like symptoms, point out the certain approach of death. On the contrary, when the senses remain clear and distinct, the febrile heat abates, the skin is soft and moist, the pulse becomes moderate and is regular, and the urine deposits flaky crystals, we may then expect a speedy and happy termination of the disease. It sometimes happens that the fever does not effect every part of the system equally ; the symptoms being less severe in one part of it than in another. This, which the young and inexperienced Order l. simple continued fever. Si practitioner, and the by-standers in a much greater degree, are apt to think it fortunate for the patient, is in fact the very reverse, as has been very judiciously observed by Dr. Fordyce*; there being nothing more dangerous in fever than its not affecting every part of the system in an equal degree. The usual appearances which are to be observed on dissection of those who die of this fever, are congestion, or an effusion within the cranium, and topical affections, perhaps, of some of the viscera. In fever all motion of the body should be avoided, especially that which requires the exercise of the muscles ; the patient ought therefore to be confined to his bed. The exercise of the mind proving a stimulus to the body, all impressions which lead to thought, especially those which may excite emotion or passion, are to be carefully shunned. A person labouring under a fever ought therefore to be kept as composed and quiet as possible, and his chamber should not be close and warm, as is too usually the case; but on the contrary, perfectly cool and sufficiently ventilated, taking care, however, that the air does not come in a direct stream or current upon him. He is likewise to be lightly covered with bed-clothes. The strict pursuance of an antiphlogistic regimen will be highly necessary to be observed in this fever, as well as in some others of the continued kind. That sort of aliment which gives the least stimulus will be the most proper: the food should be light, nour- ishing, and easy of digestion, consisting of preparations of barley, oatmeal, sago, vermicelli, tapioca, and the meal of Indian arrow- root, varying them now and then for panado, roasted apples, &c. Animal broths produce an increase of heat in the body, and are there- fore improper, unless the patient is in a state of convalescence. For drink he may take barley water, linseed tea, toast and water, milk whey, thin gruel, and lemonade, which may be varied now and then for an infusion of balm, and such other herbs, carefully shun- ning the use of any kind of spirituous or fermented liquor. In fever it is no uncommon occurrence for peculiar longings to arise, and when they do, should always be gratified in moderation, although they may seem not altogether proper. The stomach, and the rest of, the alimentary canal, are manifestly affected in many cases of fever in a higher degree than other parts of the body, and therefore emetics and purgatives are usually the first means which present themselves to the notice of the physician. In fever it will, therefore, be necessary to pay an early attention to the state of the stomach ; and if there are any crudities or corrupted humours, producing nausea or vomiting, to dislodge them by ad- ministering a gentle emeticf. To assist its operation the patient * See his fifth Dissertation on Fever. M. JJPulv. Ipecac, gr. xv. j t 1. Take powdered Ipecacuanha, fifteen 1 grains. Antimon. Tartarizat. gr. j. ] Tartarized Antimony, one grab. 32 PYREXIAE, OR FEBRILE DISEASES. Class I. should drink freely of lukewarm water, or an infusion of cha- momile flowers. To remove the feculent contents of the bowels some gentle laxa- tive* may be taken ; and throughout the remainder of the disease the body should be kept open, if necessary, by a repetition of some such medicine, administered as the occasion may require, or by means of aperient clystersf. Where the disorder seems to have arisen from, or to be kept up by a redundant secretion of bile, mild purgatives will still be more highly necessary, and, perhaps, the submuriate of mercury, joined with a few grains of jalap or cathartic extract, may best answer our purpose. Purgative medi- cines are sometimes combined with antimonialsj. In the simple continued fever it will seldom be necessary to have recourse to the lancet, particularly in warm climates ; but should the disease have arisen in a young person of a plethoric habit, and the attack of fever have been severe, with considerable flushing of the face, redness of the eyes, intense pain in the head, or delirium, and a full, hard, and obstructed pulse, or should there be symptoms of congestion in some important organ, we may then advise ^he taking away eight or ten ounces of blood from the arm. This quantity should be drawn off at once from a large orifice, and not by repeated bleedings, as by the former mode there will be greater temporary, but less permanent weakness induced by the evacuation. Under no other circumstances will it be advisable to resort to this operation. For the purpose of removing any pain of the head, the application of a few leeches to the forehead and temples will, in many cases, be quite sufficient ; and where these are not to be pro- cured, a blister on the nape of the neck may be found a valuable substitute. By bleeding unnecessarily at the commencement of this fever, such a degree of weakness may be induced as, added to the depres- sion of strength, which arises in its progress, might produce symp- Aq. Menth. Virid. f. |jss. M. ft. Haustus. * 2. & Potassae Tartrat. |ss. Manns Optim. |j. Aquae Fervent, f. ^iij. ----Cinnam. f. ?ss. M. ft. Solutio cujus sumatdiraidium,etrepeta- tur dos. post horas duas nisi alvus prius re- spondeat t 3. R Sodae Sulph. ^ss. Decoct. Malvae Composit. f. ^xij. Olei Olivae, f. |ss. M. ft. Enema. 14. g: Hydrargyri Submuriat. gr. v. Pulv. Antimonial. gr. j.—ij.M. ft. Pulvis. Mint Water, one ounce and a half. Mix these for an emetic draught. * 2. Take Tartrate of Potass, half an ounce. Manna, one ounce. Warm Water, three ounces. Cinnamon Water, half an ounce. Mix them, and of the solution take the half for a dose, which repeat after two hours, unless the bowels are sufficiently acted upon by the former. t 3. Take Sulphate of Soda, half an ounce. Compound Decoction of Mallow, twelve ounces. Olive Oil, half an ounce. Mix them for an aperient clyster. t 4. Take Submuriate of Mercury, five grains. Antimonial Powder, from one to two grains. Mix them. Order I. simple continued fever. 3§> toms of putrefaction in the second or third week of the disease, so as to prove fatal. By neglecting to bleed, however, when the pulse is full, hard, and quick, the respiration hurried, breath hot, skin dry, and the head highly painful, we shall commit a dangerous error, and endanger the life of the patient. Bleeding in fevers is strongly recommended by a late writer*, and he seems to value it far more highly than any of his cotempo- raries. In malignant fevers it has generally been considered as nearly inadmissible; but even in these, as well as the fevers of tropical climates, he deems it, on many occasions, to be an essential part of the preparation for his curative means. It is necessary, however, to observe, that he by no means considers bleeding as a debilitating process. Its effects, he says, are stimulative, relatively ac- cording to the circumstances of the subject, and they are extensive, for they are felt in all parts of the circulating system, and conse- quently through the whole extent of the animated machine. The abstraction of blood, by its express effect, diminishes the quantity of a body to be moved ; and, therefore, increases the power of the mover: it thus facilitates motion ; but this, we are told, is not all. The diminution of the quantity of blood, and change of movement in consequence of such diminution, is in some manner productive of a change of condition at the sources of life: motion is effected, changed, even suspended; diseased motions are arrested;, an opportunity is thereby furnished for the more effective action of those powers, which are provided and expressly calculated for the stimulation of the due action of health. Bleeding, as it is the most manageable power, so it possesses the most absolute influ- ence over animal movement, either as directly effective of a final purpose, or as preparatory to the action of other means necessary to insure the final purpose. Such is Dr. Jackson's mode of reasoning, and although plausible, still I conceive there will be found few among our modern physi- cians who will be ready to adopt his practice, but particularly those whose patients compose the higher classes in life, and whose ener- vated frames are ill calculated to bear copious depletion by vene- section. The stout, robust, and hardy British soldier and seaman (who, indeed, bear phlebotomy better than any class of people in private life) may undergo such a discipline with less injurious effects, and in cases of severe attacks, may undoubtedly require a free use of the lancet; but surely the remedy in question cannot be so uni- versally necessary as Dr. Jackson supposes. He moreover tells usf that a certain condition of susceptibility is necessary to insure the action of whatever means we may employ in fever, and that where this doesmnot exist naturally, it must be excited artificially, which is to be accomplished in some degree by applying fomentations to * See Dr. Jackson's Appendix to his Remarks on the Constitution of the Medical Department of the British Army. » Scohis Exposition on the Practice of applying Cold in Fevers 5 34 PYREXIA, OR FEBRILE DISEASES. CtaSS I. the legs and feet; or by immersing the lower parts, and even the whole of the body in a warm batb^ but principally by sub- stracting blood from a vein, the quantity of which is to be measured according to the circumstances of the case, and the effect which arises in the course of the progress, and not by any precon- ceived opinion of what may be sufficient; for few, he observes, can be supposed to possess such a knowledge of the nature of things, as to be capable of measuring it with exactness in the prescription- book. The effect to be looked for, and which is to decide the mea-' sure of the quantity, he notices, implies a remission of pains of all denominations, relaxation of the skin, freedom in all the secretory functions, and a change in the condition of the pulse, which, instead of being hard, tense, and tumultuously agitated, becomes free, open, and regular. Dr. Jackson is at the same time ready to admit, however, that many instances occur where the action of the fever is not principally manifested in the circulating system, either by increase or defect of action; consequently, where bleeding is not the remedy of chief dependence. If great heat with much thirst prevails, refrigerant medicines may be taken with advantage, and the most useful of this class is the nitrate of potass, which may either be joined with others*, or be added to whatever the patient uses for common drinkf. Acids of all kinds, when sufficiently diluted, are refrigerant reme- dies, well adapted to continued fevers. Those most in use are the sulphuric, muriatic, and vegetable, but more particularly the latter, such as the acid of tamarinds, oranges, lemons, mulberries, &c. As a refrigerant, cold water may likewise be drank. For the purpose of arresting the febrile course, and moderating or abstracting the morbid excess of heat, and restoring a healthy action, cold bathing has, of late years, been much employed in fevers. The practice of bathing in fevers appears, indeed, to be of great antiquity* for its use and management were well known to Galen, and are well defined by him. It farther appears, by the relation of travel- lers, to have been long used by several of the eastern nations. We have likewise indisputable proof that cold affusion had long age been employed by Dr. Wright of Jamaica, and some other physi- cians in the West Indies, particularly by Dr. Jackson. The notice which this remedy has attracted in England, has certainly, however, * 5. IJ: Succi Limon. f. ^ss. Potassae Subcarbon. 3j. vel q. s. ------Nitrat. gr. x. - Aq. Fontan. f. ^j. Syrup. ViolaM". 3j. M. ft. Haustus 3tia quaq. horn sumendus. t 6. ]J Decoct. Hordei, Oij. Potass® Nitrat. 3>j- ft. Potus. * 5. Take Lemon Juice, half an ounce. Subcarbonate of Potass, one scru- ple, or a sufficiency. After being saturated, add Nitrate of Potass, ten grains. Pure Water, one ounce. Syrup of Violets, one drachm. Mix them, and let the draught be takea every three hours. t 6. Take Decoction of Barley, two pints. Nitrate of Potass, two drachm?. Mix them for ordinary drink. Order I. SIMPLE CONTINUED FEVER. 35 been owing to the popular manner in which the subject has been treated by the late Dr. Currie of Liverpool. For the safest time, and most advantageous mode of employing cold affusion in fevers, I beg leave to refer the reader to the admonitions given under the heads of typhus mitior and typhus gravior. Under the present, I will only observe, that affusion with cold water, either by means of a large watering pot, so as to allow the streams to pour on the head and shoulders with some force, or by dashing it out of a pail, may be boldly and fearlessly resorted to at the commencement of the greater number of fevers of every climate, where no catarrhal symptoms or inflammatory affection of the lungs are present; but in the advanced stages, or latter periods of most, and where there is much debility, this remedy should be adopted with due caution, and a careful consideration of the attendant circum- stances. With a view to determine the circulation to the surface of the body, it will be right to resort to an early use of such medicines as possess this peculiar power. To excite a perspiration it will in many Cases be sufficient only to make the patient lie abed, and drink plentifully of diluting liquors; but should these simple means not prove efficacious, it will then be necessary to resort to more power- ful agents. Neutral salts, when taken into the stomach, soon produce a sense of heat on the surface of the body ; and if it be covered close, and kept moderately warm, a gentle sweat is often readily brought on. These, therefore, being possessed of the power of determining to the surface, are highly useful in fever, and may be prescribed as in the under-mentioned forms*. * 7. ftAmmon. Subcarbonat. gr. x. Succi Limon. f Jss. Aq. Menth. Virid. f. §j. Tinct. Lav. Comp. fll- vj. Syr. Althaea?, f.3'j-M. ft. Haustus. Vel, 8. ft Succi Limon. f. ^jss. , Potassae Subcarbon. 3j- vel q. s. Aq. Menth. f. ^j. ----Fontan. f. |iij. Antim. Tartarizat. gr. jss. ad ij. Syrup, f. 3ij M. ft. Mistura cujus capiat Cochl. ij. magna tertiis horis. Vel, ft Liquor. Amman. Acetatis. * 7. Take Subcarbonate of Ammonia, ten grains. Lemon Juice, half an ounce. Mint Water, one ounce. Compound Tincture of Lavender, ten drops. Syrup of Marshmallow, two drachms. Mix them for a draught. Or, 8. Take Lemon Juice, one ounce and a half Subcarbonate of Potass, about a drachm. After the effervescence has ceased, add— Mint Water, one ounce. Pure Water, three ounces. Tartarized Antimony, from one and a half grains to two grains. Common Syrup, two drachms. Mix them, and let the patient take two large spoonsful every three hours. Or, 9. Take a solution of Acetate of Ammo- nia. 38 PYREXIAE, OR FEBRILE DISEASES. ClttSS /, Emetic medicines, and particularly antimonials, given in small nauseating doses, have likewise a similar power of determining the circulation to the surface of the body, and of producing symptoms similar to those which take place in the crisis of fever: these are therefore advisable. They may either be combined with those of the before-mentioned class, or be given by themselves*. From the uncertainty with which Dr. James's powder and the pulvis antimonialis act, the tartarized antimony may be considered as preferable in many cases. To increase the diaphoretic effect of these medicines the patient should take frequent small draughts of some tepid liquor. Warm bathing, or fomenting the lower extremities, are reme- dies sometimes employed in fever to produce moderate sweating. Where these relieve delirium, induce sleep, and are easily borne by the patient, we may be assured of their propriety. Sweating, however, when excited in fevers by stimulant, heating, and inflam- matory medicines, is almost sure to prove hurtful. It likewise proves injurious, when excited by much external heat: as also where, instead of relieving, it rather increases the frequency and hardness of the pulse, the anxiety and difficulty of breathing, the headach, and delirium. When sweating is partial, and confined to the superior parts of the body, it will be more likely to prove hurt- ful than salutary. If a cough accompanies the fever, and a rawness and soreness in the faucus, together with a tightness at the chest, are present, then, Aquae Cinnam. aa f. |ss. ----Fontan. f. 3vi. Vini Antimon fn.. x. Spirit. Athens Nitrici, f. 3ss. M. It. Haustus 3tia quaq. hora sumendus. • 10. ft Pulv. Antim. gr. j. ad iij. Confect. Rosa?, gr. vj. M. ft. Bolus 4tis horis sumendus. ' Vel, 11. ft Pulv. Jacob. Ver. gr. v. pro dos. Vel, 12. ft Pulv. Ipecacuanhae, gr. iij. Confect. Cort. Aurant. gr.vj. M. ft. Bolus. Vet, 13. ft Antim. Tartarizat. gr. jss. Aq. Fontan. f. ^vj. Syrup. Croci. 3j- M. it Mistura cujus sum at Cochl. ij. magna 2da vel 3tia hora. Cinnamon Water, of each half an ounce. Pure Water, six drachms. Antimonial Wine, fifteen drops. Spirit of Nitric either, half a drachm. Mix them, and give this draught every three hours. * 10. Take \ntimonial Powder, from one to three grains. Confection of Roses, six grains. Make them into a bolus, to be taken every four hours. Or, II. Take James's Powder, five grains for a dose. Or, 12. Take Powdered Ipecacuanha, three grains. Confection of Orange Peel, six grains. Form them into a bolus, to be taken every four hours, as the former. Or, 13. Take Tartarized Antimony, one grain and a half. Pure Water, six ounces. Syrup of Saffron, one drachm. Of this mixture, give two table spoonsful every second or third hour. Order I. simple continued fever. 37 besides pursuing the antiphlogistic plan before advised, we may give demulcents* in frequent repeated doses. Should a vomiting arise in the course of this fever, and the irri- tation prove considerable, a saline draught may be taken in the act of effervescence, or it may be administered so as that this shall take place in the stomach. The manner of doing it is by giving the patient about half an ounce of lemon juice mixt up with a little mint water and syrup, and immediately afterwards, about a scruple of the potassae subcarbonas, dissolved in an ounce of common.water. If the irritation at the stomach is not abated by this mean, we may add a few drops of tinctura opii with a little aqua cinnamomi. In this fever partial evacuations, such as purging and sweating, which have no tendency to prove critical, often arise. When these happen, we should, by all means, put a stop to them. The former may be checked by astringents, as belowf, or as advised under the head of diarrhoea; and the latter, by keeping the patient cool, by washing his body frequently with a sponge dipped in cold water, and giving him refrigerants. We may distinguish critical evacuations from those which are not so, by attending to the appearances which take place in other parts of the system. For instance, if a purging should arise, and the tongue continue foul, and the skin dry, without any abatement of heat and thirst, then we may regard it as by no means critical; but if, on its taking place, the tongue becomes clean and moist, the pulse moderates, the febrile symptoms abate, and the skin has a gentle breathing sweat universally diffused over it, then a crisis may be expected. In the progress of this fever it sometimes happens that particu- * 14. ft Cetacei, 3U Vitel. Ovi, q. s. ad solut Aquae Pulegii, f ?iv. Aceti Scil. f. 3»j- Syrup. Tolutan. f. 3"j. M. ft. Mistura, cujus sumat paululum subinde. Vel, 15. ft Mucil. G. Acaciae. Aq. Fontan. aa §iij. Potassae Nitrat. 3j. Vin. Antimon. f\. xxx. Syrup. Limon- f. ^ss. M. ft. Mistura Cochl. ij. pro dos. tusse urgenti sumenda. t 16. ft Confect. Aromat. 3»j- Aq. Cinnam. f. |j. ----Fontan. f. ^"j- Tinct. Catechu, f. 3»j- M. ft. Mistura cujus sumat Cochl. ij. magna post singulas sedes liquidas. * 14. Take Spermaceti, two drachms. Yolk of an Egg, sufficiency to dissolve the former. Then add Penny Royal Water, four ounces. Vinegar of Squill, two drachms. Syrup of Tolu, three drachms. Mix them well together, and let the patient take a mouthful from time to time. Or, 15. Take Mucilage of Acacia. Pure Water, each three ounces. Nitrate of Potass, one drachm. Antimonial Wine, fifty drops. Syrup of Lemons, half an ounce. Mix them, and give about two large spoons- ful occasionally, as the cough is trouble* some. t 16. Take Aromatic Confection, two drachms. Cinnamon Water, one ounce. Pure Water, three ounces. Tincture of Catechu, two drachms. Mix them, and let two table spoonsful be taken after every liquid stool. 38 PYREXIA, 6R FEBRILE DISEASES. ClaSS I. lar parts of the body are much affected, and that there prevails either great oppression of breathing, or that violent pains in the head, stupor, or delirium ensue. In all such cases, the application of a blister near the part affected will be proper, and relief will often be quickly procured by it. Where there is any unusual coldness of the extremities, with a sinking pulse, blisters to the inside of the legs will likewise prove highly serviceable. Their efficacy in such cases may be increased by the application of stimulating cata- plasms* to the soles of the feet and palms of the hands. Camphor, ammonia, musk, and aether, are remedies which may be used at the same time, either separately or combined together; and the patient should be allowed a liberal use of wine, both in a diluted and undi- luted state. When we administer camphor in this or any other disease in a liquid form, in order to render it properly diffusive in water, and obtain its full effect, we should (instead of trusting to the mistura camphorae of the London Dispensatory, which contains but a small proportion of the resin) dissolve it in a little rectified spirit, or ex- pressed oil, and then triturate it well with mucilage of gum acacias previous to adding the water. By triturating camphor with milk, it is nearly as readily dissolved as with rectified spirit. The emulsio camphorata may be prepared agreeable to the annexed prescription!, and none of the camphor will be lost by precipitation. Severe pains in the head, accompanied with a throbbing of the arteries, or any degree of delirium, and which have not been sub- dued by leeches to the temples, or a blister to the nape of the neck, may possibly be relieved by the application of linen rags, moistened in cold water, to the forehead, and removed frequently. In synochus there is often a great interruption to sleep; and the more violent the fever, the greater in general is the interruption. It is unfortunate, however, that it cannot be procured with safety to the patient, as opium proves generally prejudicial in all fevers, except those of the typhus kind. To procure rest, therefore, in that which I am treating of, we must be contented in directing him to be kept as still and quiet as possible. If necessity obliges us to a use of sedatives, the spiritus aetheris nitrici, and Hoffman's liquor, will be the least exceptionable. Where this fever is kept up merely by weakness and irri- tability, opium, given in small doses, may be proper. If it is found to procure refreshing sleep, the dose may be repeated the * 17. ft Seminum Sinapeos Crass. Medulla; Panis, aa ft>ss. Aceti quantum satis sit. M. et fiat Cataplasma. *. 18. ft Camphorae, 3ss- solv. in Lactis Vaccinae, ^'j- dein. adde Aq. Purae, |vi. f. M. ft. Emulsio. * 17. Take Bruised Mustard Seed. Crumb of Bread, each half a pound. Vinegar, a sufficiency to form the whole into a Cataplasm. t 18. Dissolve Camphor, half a drachm, in Fresh Milk, two ounces, then add Pure Water, six ounces. Mix them so as to make the whole into a* Emulsion. Order I. simple continued fever. 39 ensuing night; but if the rest has been much disturbed, its use ought to be discontinued. By introducing opium into the system by means of friction, as advised under the head Cholera Morbus, it possibly might not be attended with any injurious effect. In this fever, as well as in all others, where we wish to procure sleep, and cannot have recourse to opium, on account of delirium being present, we may employ some of the preparations of the hop, or humulus lupulus, such as its extract or tincture. Hyoscyamus is now and then given under similar circumstances with benefit. This fever is, in some instances, continued and kept up solely by debility, as has been just mentioned. In such cases, if the symp- toms are mild, we may venture to prescribe a use of the cinchona bark; and as it will be more likely to sit easy on the stomach in the form of decoction* or infusionf, these preparations of it will here be preferable to giving it in substance. If, on a trial, the patient sleeps well, breathes easily, and does not find any increased heat, we may then venture to go on with it; but if, on the contrary, it pro- duces restlessness, difficulty of breathing, &c. its use should be omitted. In the continued fevers of warm climates, we should by no means wait for a complete crisis, in order to administer the bark of cinchona. In these it will be prudent to embrace even the least remission, let it be ever so imperfect, or of short duration, as likewise to give it in as large doses as the stomach will bear, and to repeat these frequently. The same attention must, however, be paid to the effects it produces, as have been mentioned, or may hereafter be noticed. In cold climates it is usual to wait for a regular intermission be- fore the cinchona is given. As a tonic, this medicine has acquired the greatest celebrity in all febrile cases, and is, therefore, usually preferred to all others; its effects are evidently more obvious when given in substance, than in any other form. About a drachm of the powder is a common dose, and this may be repeated every two or three hours, according to the exigency of the case. Teh or twelve * 19. ft Pulv. Cinchonas, |i. Aq. Fontan. Ojss. Coque ad Oj. et Col. dein adde Tinct. Columbaj.f. ^j. M. ftDecoctum, dequo sumat Cochl. iij. magna quartis horis. t" 20. ft Cort. Cinchonae in pulv. trit. ^ss. Aq. Bullient. f. ^vj. post horam Colat. adde Tinct. Cort. Aurant. f. 3ij. M. ft. Infusum, cujus sumat Cochl. iij. tertiis horis. 19. Take Powder of Peruvian Bark, one ounce. Pure Water, one pint and a half. Boil these slowly till reduced to one pint, then strain off the Kquor, and add Tincture of Columbo,one ounce. Mix them, and of the decoction let three table spoonsful be taken every four hours. t 20. Take Peruvian Bark, reduced to a coarse powder, half an ounce. Boiling Water, six ounces. Infuse them for an hour, strain off the li- quor, and add Tincture of Orange Peel, two drachms. Mix them, and let three table spoonsful be taken every three hours of this infusion. 40 PYREXIAE, OR FEBRIL^ DISEASES. CktSS I drops of the acidum sulphuricum dilutum may be added to each dose. The bark of cinchona is apt, at first taking it, to affect the bowels, and pass off by stool with many people. When this happens, five or six drops of the tinctura opii, or about half a drachm of the tinc- tura catechu, may be added to each dose. With some persons the cinchona bark will not sit easy on the stomach almost in any shape. In such cases we may substitute the use of quassia*, or any of the other astringent bitters noticed under the head of Intermittents. On a recovery from fever the patient should cautiously avoid any fatigue, exposure to cold, or improper food. As restoratives, a gen- erous diet, with a moderate use of wine, will be serviceable ; and if the season of the year will admit of cold bathing, it will likewise be advisable. A change of air, with moderate daily exercise, either in a carriage or on horse back, will prove powerful auxiliaries in en- abling the convalescent to regain his strength. Where the appetite is defective, we may prescribe stomachic bitters.—See Dyspepsia. SYNOCHA, or INFLAMMATORY FEVER. Synocha is a fever with much increased heat; a frequent, strong, and hard pulse; the urine red : the animal functions but little dis- turbed, although at an advanced age the sensorium is apt to be- come much affected. We may readily distinguish synocha from either typhus milior or typhus gravoir by its being attended with symptoms of an inflammatory nature. It makes its attack at all seasons of the year, but is most prevalent in the spring; and it seizes persons of all ages and habits, but more particularly those in the vigour of life, with strong elastic fibres, and of a plethoric con- stitution. It is a species of fever almost peculiar to cold and tem- perate climates, being rarely met with in very warm ones, except among Europeans lately arrived; and even then the inflammatory stage is of short duration, as it soon assumes the typhoid type. The exciting causes are, sudden transitions from heat to cold, the application of cold to the body when warm, swallowing cold liquors when much heated by exercise, too free a use of vinous and spiritu- ous liquors, great intemperance, violent passions of the mind, expo* sure to the rays of the sun, topical inflammation, the suppression of habitual evacuations, the drying up of old ulcers, and the suddenyt repulsion of eruptions. It may be doubted if this fever ever origi- nates from personal infection ; but it is possible for it to appear "21. ft Qu:issia», 3ij. Aq. Bulliout. f. \ vj post horam Colat. adde Tinct. Calumb. ----Card. Com. aa f. ^ss.M. ft. Mistura cujus capiat Cochl. ij. tertiie horis cum Acidi Sulphur. DilutifTL x. * 21. Take Quassia, two drachms. ' Boiling Water, six ounces. Strain off the liquor after one hour's infu-, sion, and add Tincture of Calumbo. Tincture of Cardamoms, each : half an ounce. Mix them, and take two table spoonsful every three hours, with fifteen drops of Di- luted Sulphuric Acid. Order 1. wplammatory fever. 41 pretty generally among such as are of a robust habit, from a peculiar state of the atmosphere. It comes on with a sense of lassitude and inactivity, succeeded by vertigo, rigors, and pains over the whole body, but more particu- larly in the head and back ; which symptoms are shortly followed by redness of the face, throbbing of the temples, great restlessness, in- tense heat, and unquenchable thirst, oppression of breathing, and nausea. The skin is dry and parched ; the eyes appear inflamed, and are incapable of bearing the light ; the tongue is of a scarlet colour at the sides, and furred with white in the centre : the urine is red and scanty, the body is costive, and there is a quickness, with a fulness and hardness in the pulse, not much affected by any pres- sure made on the artery. Its pulsations are from 90 to 130 in a minute, and when blood is drawn, it exhibits a yellowish or buffy crust on its surface, which is the coagulable lymph or fibrin. If the febrile symptoms run very high, and proper means are not used at an early period, stupor and delirium come on at a more advance j stage ; the imagination becomes much disturbed and hurried, and the patient raves violently. The disease usually goes through its course in about fourteen days, and terminates critically, either by a diaphoresis, diarrhoea, haemorrhage from the nose, or the • deposit of a copious sediment in the urine ; which crisis is usually preceded by some variation in the pulse. In some instances it, however, terminates fatally. Our judgment, as to the termination of the disease, must be formed from the violence of the attack, and the nature of the symptoms. If the fever runs high, or continues many days, with great action of the heart and arteries, flushed, turgid face, red eyes, intolerance of light, with vertigo, or early stupor and delirium, the event may be doubtful ; but if to these are added, picking at the bed-cloths, starl- ings of the tendons, involuntary discharges by stool and urine, and hiccups, it will then certainly be fatal. On the contrary, if the fe- brile heat abates, and the other symptoms moderate, and there is a tendency to a crisis, which is marked by an universal and natural perspiration on the body ; by the urine depositing a lateritious sedi- ment, and by the pulse becoming more slow or soft ; or by ahaimor- rhage from the nose ; diarrhoea supervening; or the formation of abscesses ; we may then expect a recovery. In a few cases, this fever has been succeeded by mania. On opening those who die of an inflammatory fever an effusion is eften perceived within the cranium : and now and then topical af- fections of some of the viscera are to be observed. From the symptoms which attend this disease, it is evident our endeavours should be early exerted to avoid the mischief that may ensue from general inflammation ; and as evacuation by bleeding is the chief mean we can confide in, it should be resorted to on the first of its attack ; and one large bleeding at this period will have a much better effect than repeated small ones afterwards. If the symptoms run high, therefore, and the person is young and pletho> 42 pyrexia, or febrile diseases. Ciass L ric, twelve or sixteen ounces may be drawn off at once from the arm through a large orifice. In repeating the operation, we are to be governed by the effect it produces on the pulse, and by the ap- pearance the blood puts on after standing some time. If the former continues full, strong, and tense, and the latter exhibits a buffy, sizy coat on its surface, the bleeding should be repeated by all means, but in smaller quantity than before. Blood-letting relaxes the vas- cular system, diminishes its action, and takes off plethora. The pulse, in this fever, is apt, however, to become fuller and stronger after bleeding, which may easily be explained ; for the plethora may be so great as to distend the vessels beyond their proper tone : in such cases the vessels cannot act fully, and the pulse is contracted; but when the plethora is taken offby copious bleeding, and the vessels are allowed to contract properly, the pulse becomes fuller, which shows that the remedy nas been proper, and should induce us to re- peat the operation if the case requires it. It may be difficult to determine whether drawing blood from the temporal artery ought not to be preferred in severe attacks to vene- section at the arm. Both, indeed, will relieve the headach, gid- diness, and stupor ; but I conceive that a more permanent benefit will be derived from the former. When the fever has been of several days' standing, and the head is much affected either with severe pain or delirium, topical bleeding, by the application of three or four leeches to each temple, may be preferable to any other mode of drawing blood. Applying linen cloths, wetted in cold water or aether, to the fore- head and temples, may be attended with some advantage in such cases. With a view of diminishing inflammation and general excite- ment, digitalis has been proposed as a remedy in this disease, after having employed proper venesection, and probably may prove serviceable. If any nausea prevails at the commencement of the disease, the stomach may be relieved by making the patient drink one or two cupsful of an infusion of the flores antheroidis ; but should these simple means not be attended with the desired effect, he may then take a table spoonful of an emetic solution*, every quarter of an hour, until sufficiently eased. To obviate costiveness, one or two motions should be procured daily, by means either of some aperient medic inef, or by laxative * 1. ft Antimon. Tartanzat. gr. ij. Aq. Fontanaj,f. ^iij. Syr. Croci. f. 3j- M. \ 2. ft Pulp. Tamarind, ^ss. Potassae Supertartrat. 3'j. Aq. Bullientis, f. §v. Colat. adde Aq.Cinnam. f. ^j. 1. lake Tartarized Antimony, two grains. Pure water, three ounces. Syrup of Saffron, one drachm. Mix them. t 2. Take Pulp of Tamarinds, half an ounce. Supertartrate of Potass, two drachms. Boiling Water, five ounces-, strain off the liquor, and add Cinnamon Water, one ounce. Qr3er I. inflammat©ry fever. 43 clysters*. In synocha, cathartics, particularly the saline ones, will prove singularly useful. If the stomach is in an irritable state, we can substitute a few grains of the hydrargyri submurias, made up into pills, with a small quantity ef cathartic extract, instead of the other laxative medicines. To abate thirst the patient should be directed to drink frequently of diluting liquors, acidulated with lemon juice or potassae super tartras. He may likewise take small and frequently repeated doses pf the nitrate of potassf; or as a refrigerant, he may be allowed to drink freely of cold water. For the purpose of moderating or ex- tracting the morbid excess of heat, various parts of the body should be sponged frequently with cold water. Cool air may be freely admitted also, as it has been found that a person in fever may be kept much cooler than one in health without uneasiness or harm. The acid fruits, such as oranges, &c. will be very proper. Sudorifics do not appear to be advisable in this fever, as they might bring on profuse sweating ; and it is not possible to keep the body warm without producing a considerable increase of heat. The neu- tral salts may be given in any of the forms advised under the head of Simple Fever, every two or three hours, joined with small nausear ting doses of tartarized antimony, or the like. A pediluvium at night may assist their effect. Should the breathing be oppressed, or should stupor or delirium arise, it will then be right to apply a blister in the neighbourhood of the part so affected. If the pulse sinks, and the extremities become cold, the application of sinapisms to the soles of the feet will be proper. Camphor, aether, ammonia, and cordials, will be proper remedies on such occasions. In this fever, as in most others, sleep is much interrupted, and from a want of this, delirium often arises; opium here would be an Antimon.Tartarizat.gr. j. M. Sumat Cochl. iv. et repetatur dos. poet horas tres nisi alvus prius respondeat. Vel, 3. ft Infus. Senna?, f. |jss. Magnes. Sulphat. 3»j- Mannae, Optim. 3uth we may employ a solution of alum in water (an ounce of the former to a pint of the latter), as a gargle, which will quickly take away the stench that arises frojo them, or we may substitute that which has been recommended in typhus mitior. In typhus gravior it is of the utmost consequence to procure rest, and therefore, where there is no great delirium, we may give an opiate towards bedtime. Combining it with some diaphoretic* will prevent any deleterious effects from it, and therefore it will be best to give in this way. A slight purging, attended with a gentle moisture on the skin, not unfrequently arises towards the close of this fever, and now and then assists in carrying it off; but where it does not seem to produce a critical effect, it ought to be stopped as quickly as pos- sible by astringentsf. When we succeed in removing the symptoms entirely by the means which have been pointed out, or in procuring a cessation of the fever, we are to endeavour to prevent its return by a free use of cinchona bark, the cortex cuspariae, infusions of gentian and orange-peel, and other stomachic tonics; and in order to recruit the strength, the patient should'be directed to use a nourishing diet, with wine in moderation; and he should take such gentle exer- cise as his state of convalescence will admit. Having pointed out the mode of treatment to be adopted when the disease actually takes place, it seems proper likewise to mention the precautions it may be necessary to pursue, in order to prevent its contagion from being communicated to others. When the disease arises, the sick ought to be removed to a clean and well aired room in the most remote part of the house, and as much separated from the rest of the family as possible; his bed* linen should be changed frequently ; his body be kept clean ; what- ever comes from him, be immediately removed and emptied; and his cha nber be well ventilated by allowing a free admission of fresli air into it; it may likewise be sprinkled frequently with warm * 10. Pi Liquor Ammon Acet. f. 3'U- Aquae Cinnam. f. |j. Tinct. Opii. fTJ,. xxv. Syrup Simpl. f. 3'j. M. ft. Haustus t 11. & Confect. Aromat. ^ss. Aq Cinnam. ----Pimentaj, ?ia f ^jss. ----Fontan. f. ^ij. Tinct Kino, f 3ij. ----Opii, fn.. xxx. M. it Mistura cujus sumat Cochl. ij. magna4tis horis. * 10. Take Solution of Acetate of Ammonia three drachms. Cinnamon Water, one ounce. Tincture of Opium, forty drops. Syrup, two drachms Mix them for a draught. t 11. Take Aromatic Confection, half a drachm. Cinnamon and Pimento Water,of each one ounce and a half. Pure Water, two ounces. Tincture of Kino, two drachms. --------Opium, fifty drops. Of this mixture, take two large spoonsftl every four hours. Order I. malignant and putrid fever. 69 vinegar, in which some of the aromatic herbs have been infused. No fire should be kept in the room. In summer the patiem should be covered only with a sheet, and in winter with a single blanket above the sheet. The good effects which arise from removing pa- tients in this fever from contaminated air, are particularly remark- able among the poor; for a great many of them will recover when brought to an hospital or ward of recovery, although they take little or nothing: whilst those who remain at their own houses, and have the best medicines and attendance, will sink rapidly. None but the necessary attendants should have any communication with the sick; and these, to guard against contagion, should avoid sitting down on the patient's bed; and they must likewise care- fully avoid inhaling the vapour arising immediately from his body. When near him, they may keep a sponge or handkerchief, moist- ened in camphorated spirit or vinegar, to the nose and mouth. In hospitals, camps, and on board of ships, where a number are unavoidably crowded together, so as to render it impossible to cut off the communication between the healthy and the diseased, these simple means will not prove sufficiently powerful for destroying the contagion, and therefore others must be adopted. In all such instances, besides well fumigating the apartments, clothes, beds, bedding, and hammocks of the sick, as hereafter advised, changing them frequently for fresh ones, paying the strictest attention to cleanliness in every respect, well ventilating every place where they are lodged by a constant and free admission of fresh air, we should oblige those in health, as well as those tainted by the con- tagion, to undergo daily ablution with cold water. Nitric acid has been used by Dr. Carmichael Smyth, as a fumi- gation, with the greatest success in this fever. In the year 1780, the disease broke out among the Spanish prisoners confined in Winchester castle; he embraced the opportunity of giving the remedy a fair trial, and obtaining the most decisive evidence of its happy power in preventing the spreading or farther commu- nication of the infection. He found he could use it without risk or inconvenience to respiration, and therefore thought it the most proper antidote to be applied, where persons are unavoidably obliged to be present. The doctor's mode of obtaining nitric acid, is by decomposing nitre by means of heated sulphuric acid, which may be done as follows: put half an ounce of this acid into a crucible, glass, china cup or saucer, and warm this over a lamp, or in heated sand, add- ing to it, from time to time, some niire: these vessels he directs to be placed at 20 or 30 feet distance from each other, according to the height of the ceiling and the virulence of the contagion. In hospitals and prisons, he advises, the lamps or vessels containing heated sand to be placed on the floor; but on board of ships, he recommends to hang them to the beams by waxed silk cords. From the well-known efficacy of the sulphuric acid in destroying contagion, he advises it to be employed as a fumigation for clothes 70 PYREXIA, OR FEBRILE DISEASES. ClOSS I and furniture, Sic.; but for purifying empty prisons, hospital wank, j and ships, he gives the preference to the nitric, its vapour being more volatile and penetrating, and not leaving the disagreeable smell which the sulphuric does, and thinking it at the same time equally efficacious. Monsieur Guyton Morveau, in his Treatise on the Means of pu- rifying Infected Air, claims the merit of being the discoverer of the power of the mineral acids to destroy contagion, and endeavours to establish the superiority of the muriatic acid over all others. Upon a full investigation of the matter it appears, however, that the power of the mineral acids to destroy contagion was known to Sir John Pringle as early as the year 1750, and their utility for that purpose was mentioned by Dr. Johnson in his pamphlet published in 1758, in which we are told that the vapour of muriatic acid was success- fully employed by him in correcting the contagion of a very ma- lignant fever, which had raged at Kidderminster two years before that period. Dr. Smyth has also claimed the having been the first who used the mineral acid gases in the apartments of the sick, and has alleged' that they never had been employed by Dr. Johnson but in places where no one was present, or whence the sick were removed. This opinion has been refuted by Dr. Johnson's son, and the invention of his father most incontestably established*. What Dr. Smyth seems therefore entitled to is, the merit of having brought the dis- covery into public notice, and of having applied and extended it to general use. It seems of little consequence whether we employ the nitric acid or the muriatic, in the form of gas, for the purpose of destroying contagion and purifying infected air, as the powers of both are ex- tensive and certain. The muriatic is, however, thought to be more diffusible than the other. When we give it the preference, it may be used in the following manner:—put one pound of common salt into an earthen vessel, and pour over it, from time to time, a small quantity of sulphuric acid, till the whole salt is moistened. If the air is foul and peculiarly offensive, apply a gentle heat under the vessel, to extricate a larger quantity of vapour; but in general, the simple addition of the acid to the salt will be found sufficient, un- less the apartment is very large. The most effectual, however, of all fumigations, is perhaps the following, but it requires some nicety. Take of manganese in powder two parts, the same of common salt, of sulphuric acid three parts, and of water one part. Put an ounce of the mixed mang^ nese and salt into a basin, add of water a large tea-spoonful, thenar drop in half a tea-spoonful of sulphuric acid, and repeat this till you have used a tea-spoonful and a half of the acid. In this manner keep up a sensible extrication of the fumes. On the appearance of typhus or any infectious disorder in a gaol, * See Dr. John Johnson's Reply to Dr. Smyth. Order I. YELLOW FEVER. 71 hospital, workhouse, garrison, transport-ship, or any other place where many persons are crowded together, we should not fail to advise one of these gaseous fumigations in every room, in addition to a free ventilation and the greatest cleanliness. The same steps should be adopted in academies, boarding-schools, and even our dwelling-houses. Of the YELLOW FEVER, or TYPHUS ICTERODES. This disease takes its name (improperly however,) from one par- ticular symptom; but which, although pretty general, is by no means universal, nor even essential to its existence. By Sauvages, it has been denominated typhus icterodes ; by Cullen, typhus cum fiavi- dine cutis ; by the French, la maladie de Siam, and fievre des mat- elots ; and by the Spaniards, vomito prieto. With respect to the origin of the yellow fever in America, there has prevailed a great difference of opinion ; some supposing it to have been introduced from the West Indies ; and others, that it took its rise from the exposure of putrid animal and vegetable sub- stances on the public wharfs of the city of Philadelphia ; which opi- nion is strongly supported by Dr. Rush, as he found that the streets adjoining to these wharfs were the first in which the disease made its appearance, and that in several instances it could clearly be traced from thence to other parts of the city. Let this be as it may, it is evident, from the report of Dr. Chisholme, and others who have written on the disease, that the fever which prevailed in Philadel- phia was exactly the same with that which raged in the West India colonies. Dr. Clarke informs us, that there appears to have been such an extensive and very peculiar deranged stale of the atmosphere in the towns of the West Indies and in North America, that it is more probable the disease was produced by this general cause breaking out nearly at the same time in these different places, than that it was carried from the one to the other, either by persons or in any kind of goods or merchandise. We are informed by Dr. Miller, of New-York, that the yellow fever in America always begins in the lowest part of a populous mercantile town near the water, and continues here without much affecting (he higher parts. It rages most where large quantities of new ground have been made by banking out the rivers, for the pur- pose of constructing wharfs. The appearance and prevalence of the yellow fever in low situations, have led to the belief, he tells u*, that the disease was imported by ships from the West Indies. But a person seized with this fever in an affected part of the town, and conveyed to one that is healthy, or carried info the country, does not communicate it, he asserts, to the neighbourhood, nor to those immediately around him. He therefore is of opinion, that the yellow fever is generated by the impure air or vapour which issues from the new-made earth or ground raised on the muddy and filthy bottom of 72 PYREXIA, OR FEBRILE DISEASES. Class I. rivers, and which deteriorate the air above it, in like manner as air becomes offensive and injurious when it approaches or passes over a body of vegetable or animal matter in a state of putrefaction. It appears that the shores of the rivers of New-York and Phila- delphia have undergone great and rapid alterations from their natural state within a few years, on account of the vast increase of commerce, and for the sake of making wharfs; and Dr. Miller mentions, it is only in such parts where these alterations have taken place, that the yellow fever has been produced The parts where little or no alteration has taken place on the east and north river, and which continue nearly in their natural stale, do not pro- duce the yellow fever. He adds, eighty new wharfs have been made since the war ; the consequence of which has been, that great quantities of filth and corruptible matter, deposited in the muddy bottom of the river contiguous to the shore, and which produced no ill effect while exposed to the air and washed twice every four- and-twenty hours, have been covered over several feet deepwithnew earth, and closely pent up so as to exclude the tide. It is in these places, and these only, that the yellow fever is produced, we are told. On the other hand, we are informed by Dr. Hosack, who is pto- fessor of the theory and practice of physic and clinical medicine in the university, New-York, as well as by many other physicians of eminence in America, that the yellow fever did not originate there from domestic causes, but was exclusively of foreign origin*, and contagious in a confined deteriorated atmosphere and unventilated situations. Dr. Bancroftf is of opinion that the only existing cause of yellow fever is the application of marsh miasmata to the human body, anil that the disease is really a marsh remittent fever. He thinks him- self justified, from repeated observations, in concluding that the joint influence of marsh miasmata, and of an atmosphere unusually and sufficiently heated, upon persons habituated to a cold or tem- perate climate, is, of itself, fully capable of causing an epidemic yellow fever, resembling that which has committed such ravages in the West Indies, the United States of America, and the South of Europe. We are told by him, that the common bilious remittent of hot climates, which is universally admitted to be the effect of miasmata, differs from the yellow fever only by being less violent; that at the utmost their symptoms only vary in degree, and conse- quently the danger being greater in the latter than the former, for the yellow colour appears in both. Some have imagined, that the fever, which has occasioned such devastation, is totally of a different nature from the yellow fever formerly met with in the West Indies and other tropical climates; but in my opinion, it seems to be the same, and that its only dif- ference consists in its having prevailed as an epidemic, from the subsisting vitiated state of the atmosphere, and from its having, * See American Medical and Philosophical Register. t See his Essay on the Disease raited Yellew Fever. Order 1. yellow fever. 73 from other concurring circumstances, acquired a degree of malig- nancy and virulence unknown before. During a residence of nine years in the West Indies, from 1776 to 1785, 1 had frequent opportunities of meeting with the yellow fever among seamen, and such new-comers as were imprudent on their first arrival; and although the disease never prevailed during that period epidemically, still I looked upon it as capable, under certain circumstances, of being communicated from one person to another. We ought to be aware that a fever, not'contagious at its commencement, may acquire that character from confined air, filth, and accumulation; then why deny that the same may take place during the prevalence of typhus icterodes. I think it ought to be admitted, that the fever which has prevailed of late years, both in America, the West Indies, and Spain, is a contagious or communi- cable disease in an impure atmosphere ; but where great cleanliness is observed, and the air preserved pure and free from noxious par- ticles and materials, its contagion may be counteracted. The ad- mission of this doctrine will readily account for the apparently contiadictory facts which have been brought forward by the advo- cates of the two opposing opinions. It is probable that marsh exhalations, and the effluvia arising from putrid vegetable and animal substances, under a concurring vitiated state of the atmosphere, were the causes which gave rise to this fever, and that it was afterwards kept up by contagion, heightened, by various accidental circumstances, to a pestilential degree of violence. Very hot and sultry weather, with a long drought, will greatly predispose to the prevalence of this fever as an epidemic, in all tropical climates ; and it may have a similar effect in America, where the summer months are intensely warm. It has been ascertained, from tables and records for the last twenty years, that in Philadelphia the yellow fever does not pre- vail when the months of June and July do not exceed 70° Fahr. ; but that in every summer since 1793, whenever the average heat of those months has exceeded 79°, then the fever has raged, and that it has been most mortal in those years in which the thermo- meter has indicated the greatest altitude. Dr. Rush, and a few others, are of opinion, that the yellow fever is not contagious in its simple state, and that it spreads exclusively by means of exhalations from putrid matters, which are diffused in the air : and Dr. Bancroft tells us, that of the many thousands, who in the West Indies, as well as at Charlestown, Norfolk, Bal- timore, Philadelphia, New-York, &c. were removed beyond the reach of marsh miasmata, whilst labouring under the disease or after having imbibed the poison, though in many of these the disorder appeared under its worst forms and proved fatal, still it has never been communicated to others. This point, however, has by no means been satisfactorily established; and some facts which have been brought forward by Sir James M'Gregoi*, and others, which * See his Medical Sketches- 10 74 PYREXIAE, OR FEBRILE DISEASES. ClttSS I. are inserted in the American Medical and Philosophical Register* very clearly show that this fever may be communicated by con- tagion. Moreover,, the Reports of Sir James Fellowes, lately pub- lished, tend completely to refute the very mischievous doctrine, that the pestilential fever of America and Spain, &tc is not contagious; No doubt ought now, in my opinion, to be entertained upon this point, so interesting to mankind. Contagion, perhaps, may not be necessary to originate the yellow fever, or it may not propagate the disease unless aided by exterior circumstances favourable to its agency ; but we want facts of a more positive kind, in order to prove that no virus is formed in the body of an individual labouring under this fever, capable of im- pregnating another with a certain quantum at least, if not kind of disease. By diffusion in the open air, the disease may rarely be commu- nicated from one person to another in country situations, where there is a constant circulation of fresh air ; but in confined and un- ventilated situations, where cleanliness is neglected, I am decidedly of opinion that its contagion may as readily be propagated as that of typhus gravior, the gaol, or hospital fever. The persons most liable to be attacked by it in the West India Islands, were the Europeans who had lately arrived ; and hence it was, that the troops sent out to recruit our armies, and the seamen to strengthen our fleet, fell its earliest victims. Women were ob- served to be less liable to its attacks than men, and children still less so than these ; and the people of colour were by no means so apt to be seized with it as the whites. When the disease did appear among them, it was always much milder, owing most likely to their necessary temperance. Those of a full plethoric habit, and that were intemperate in their mode of living, were much greater suf- ferers by it than those of a lax fibre, and who were guilty of no irregularity. Young people born in the West Indies, and educate* in Great Britain, and persons having resided some years in Eng- land, after they had passed a great part of their lives between the tropics, were observed to be liable to an attack of this fever on their return to the West Indies. There is evidently something peculiar to the constitution of people from a cold country, which renders them more obnoxious to fever in a warm climate than either the natives or those who have been assimilated to it by a long residence. Accordingly we find, that the same exposure to the causes, predisponent and occasional, will produce fever in a stranger, while the native or old inhabitant remains in good health ; and the symptoms will be tenfold more urgent in the one than the other, supposing both are attacked. Hence it happens, that long residents, and natives in general, are not very liable to the yellow fever in its continued and malignant form ; but when they are attacked with the remittent of the coun- try, the symptoms partake more or less of the nature of the * Volume II. page 22. Order I. YELLOW FEVER. 7,5 prevailing epidemic. In persons of the former class, the body, from long exposure to the influence of the climate, has become creolized, approaching to the conformation of the natives, by having their original firmness of fibre reduced to the appropriate standard for continuing the healthy action underexposure to preternatural heat. The heat of the body of new-comers in the West Indies has been noticed, by Dr. M'Kitrick, to be between three and four degrees above that of the temperature of the natives; and to this he ascribes in part, the predisposition of new-comers to the yellow fever. A disposition to take on an inflammatory action has been assigned, therefore, as the reason why Europeans, within the first few months after their arrival in the West Indies, are so obnoxious to this fever. Not only does the yellow fever invade Europeans newly arrived in the West Indies in preference to Creoles, negroes, and those who by a long continued residence have become acclimated, but even among those Europeans who happen to be susceptible, the most healthy and robust, and in general those who are earliest subjected to great exertions, and a high degree of temperature, are sooner seized, and more rapidly destroyed, than those of laxer fibres, or those who have had an opportunity of becoming more gradually inured to the climate. In North America it also happens, that the inhabitants who con- stantly reside in the most southern States, are seldom attacked with this fever in its violent form, while those of the north-east States are destroyed by it in great numbers; but even in these districts it has been remarked, that it more readily seizes strangers from Eu- rope, or peasants from the interior provinces, than the natives of the towns in which the disease prevails. The inhabitants of the southern States, from being subjected to constant heat, approach in constitution nearly to the Creoles or natives of the West Indies ; but those residing in the more northern States, although exposed to a high degree of heat during the summer, can never become creol- ized, (if the expression may be allowed), on account of the inter- vening winter, which annually renews the predisposition, and creates a susceptibility to the disease; still, from living during a part of the year in excessive heat, the inhabitants of the place where the disease prevails are in some degree less susceptible of the most malignant form of the fever than strangers from Europe, or peasants from the inland districts, whose more dense and rigid fibre renders them peculiarly disposed. It is therefore obvious, that the strongest men, those of the most dense and rigid fibre, are particularly subject, both in America and the West Indies, to the high degree of the yellow fever; and are most frequently and rapidly destroyed by it. Women, children, convalescents from former malady, and those who have been re- duced by the use of mercurial remedies, are less frequently the objects of its attack; and when it happens to seize them, it is usu- ally milder, and less rapid in its progress. In these classes, the state of the animal fibre, either from original conformation, or from 76 PYREXIA, OR FEBRILE DISEASES. ClaSS /. eventual circumstances, more nearly approaches to that of the Creoles and natives*1. This species of fever is excited into action by a variety of causes; the chief of which are, intemperance, excessive fatigue in the sun, checked perspiration by being exposed to a current of air, or sleep- ing exposed to the dews, costiveness, &c. In fact, whatever proves an exciting cause of fever in any country, is equally so in the West Indies, but it is not the same species of fever that is induced. Dr. Pinckard, who was a physician to the army in the West Indies, from having observed this fever exhibited such instability, and varied so incessantly in its character, that he could not dis- cover any one symptom to be decidedly diagnostic, has been in- duced to offer it as his opinion, that the yellow fever so called is not a distinct or specific disease, but merely an aggravated degree of the common remittent or bilious fever of hot climates, rendered irregular in form, and augmented in malignity, from appearing in subjects unaccustomed to the climate. Dr. Jackson also views this disease as only a modification, or very high degree of the common fever of the country. The yellow fever usually attacks with lassitude and weariness, chilly fits, listlessness of every thing around, faintness, giddiness, flushing of the face, redness of the eyes, pains in the eyeballs and lower part of the forehead, as likewise in the back, debility and. sighing, thirst, and a tendency to coma; the urine is high-coloured, small in quantity, and turbid; the perspiration is irregular, inter- rupted, and greatly diminished; the saliva is viscid; the tongue is covered over with a dark fur; the bile is secreted in unusual quan- tities, and thrown into the stomach, from which it is again speedily ejected ; and the skin is hot, dry, and hard. The disease continuing to advance, the eyes become of a deep yellow, the face and breast are tinged with the same hue ; an in- cessant retching and vomiting of frothy bile ensues; great costive- ness prevails, and a peculiar delirium arises, which is attended with a permanent dilatation of the pupils of the eyes. There is hardly ever an evident remission until the fever has en- tirely gone through its first stage, which is generally in thirty-qix or forty-eight hours; when there is often such abatement of the symptoms as to induce the patient to think himself tolerably well; but an early recurrence of the symptoms in an aggravated form, accompanied with extreme debility, soon convinces him of the contrary. In tile last stage of the disease, the greatest debility prevails, and symptoms of universal putrefaction arise; large patches of livid spots are to be observed on different parts; the tongue becomes dry and black, the teeth are incrusted with a dark fur, the breath is highly offensive, the whole body exhibits a livid yellow in many cases, but not in all, hemorrhages break forth from the mouth, ears, * See Noles on the West Indies,by George Pinckard, M. D. Letter LIV. Order J. YELLOW FEVER. 77 and nostrils, dark and fetid stools are discharged, hiccups ensue, the pulse sinks, and death follows very quickly. These are the usual appearances to be met with ; but great irre- gularities have been observed by different practitioners. t)r. Chis- holme mentions, that he often found patients, without any previous complaint, suddenly become giddy, lose their sight, fall down almost insensible, and remain in that state for half an hour or upwards ; the body then became overspread with a cold sweat, and this was succeeded by intense heat, a quick, small, hard pulse, violent pain of the head, particularly in the forehead, great anxiety about the prascordia; the eyes were much inflamed, watery, protruded, and wildly rolling ; the face was much flushed ; there was great heat at the pit of the stomach, with nausea, frequent retching and vomiting, as also severe pains in the small of the back and calves of the legs. During 12, 18, 24, or 36 hours, he found all these symptoms con- tinue to increase, except the quickness and hardness of the pulse, which were not materially changed, and that they were then suc- ceeded by general coldness, clammy sweats, and a greater or less degree of coma or delirium. Life, in this case, was lengthened out to sixty or ninety hours from the attack. A short interval of rea- son perhaps took place, the patient considered himself better, and flattered himself for the moment with the hope of recovery ; but a fit, as sudden and as unexpected as the first, came on, during which he rolled his eyes dreadfully, foamed at the mouth, and threw out and pulled back his extremities in violent and quick alternate suc- cession. Dr. Chisholme observed, that in general the patient ex- pired in this fit; but in a few instances he recovered from it, and continued rational for a short time, when another has ensued and carried him off. He noticed, that in a few instances the patient complained of violent pains in the testicles, and on examination, he perceived them much lessened in size and retracted, with an excoriation of the scrotum : now and then he found a remarkable change in the voice, and that it became weak and shrill ; in a few instances he could discover little or no yellowness of the skin. Dr. Rush says, the disease appeared with different symptoms in different people : he observed the premonitory signs of it were, costiveness, a dull pain in the right side, defect of appetite, flatu- lency, perverted taste, heat in the stomach, giddiness or pain in the head, a dull, watery brilliant yellow, or red eye, dim and im- pefect vision, a hoarseness, or slight sore throat, low spirits, a dis- position to sweat at nights or after moderate exercise, or a sudden suppression of night sweats. More or less of these symptoms fre- quently continued for two or three days before the patients were confined ; and in some they continued during the whole time of the prevalence of the fever in the city of Philadelphia, without pro- ducing the disease. Many went to bed in good health, and awoke in the night with a chilly fit; many rose in the morning after natural 78 PYREXIAE, OR FEBRILE DISEASES. and regular sleep, and were seized at their work, or after a walk, with a sudden and unexpected attack. He observes, that it frequently came on with a weak pulse, and often without any preternatural frequency or quickness ; and that, in some instances, it was so low as not to be perceived without pressing hard on the artery; in some cases, the pulse intermitted, and these intermissions occurred in several persons who were in- fected, but who were not confined by fever ; in others, there was a more than ordinary slowness of the pulse, whicli was now and then accompanied with a dilated pupil of the eye. Hemorrhages hap- pened at the commencement of the disorder, chiefly at the nose and uterus ; and as it advanced, the discharge of blood became more universal, and then issued from the gums, ears, stomach, bowels, and urinary passage. Many complained of a dull pain in the region of the liver, but few felt any soreness to the touch, or pain at the pit of the stomach ; in some, a determination of blood took place to the lungs, but the brain was chiefly affected with morbid congestion, which was indi- cated by the suffusion of blood in the face, redness of the eyes, dilatation of the pupils, pain in the head, hemorrhages from the nose and ears, by sickness or vomiting, and by an almost universal costive state of the bowels. With respect to the secretions and excretions, there appeared to be a preternatural secretion of bile, which was discharged from the stomach and bowels in large quantities, and of very different quali- ties and colours, being in some cases yellow, and in others black. The urine was sometimes plentiful and of a high colour ; sometimes it was pale, and at others it was small in quantity and turbid : more- over, sweats of a yellow colour, and highly offensive to the smell, often broke out. On the first and second day, the tongue was invariably moist and white ; but as the disease advanced, it became red, and put on a smooth shining appearance: towards the close, a dry black streak appeared in its middle, which gradually extended to every part of it. The effects produced on the nervous system were different, according as the fever affected the brain, the muscles, the nerves, or the mind. In a few instances, apoplexy was induced, which usually proved fatal; tremors of the limbs, and twitching of the tendons, were common ; delirium was a frequent symptom, but many passed through the disease without the least derangement of ideas : in some cases, the pain in the head was acute and dis- tressing, and the stomach, towards the close, was affected with burning or spasmodic pain of the most severe nature. The senses and appetites exhibited several marks of the ravages of this fever upon the body. Deafness and dimness of sight some- times took place. Thirst, and want of appetite, were present, as in most other fevers. The convalescence was marked by a sudden Order I. YELLOW FEVER. 79 renewal of the propensity to venery*. Swellings in the inguinal and parotid glands took place in a few instances, which did not pro- ceed to suppuration. In some cases, the skin was preternaturally warm ; in others, it was cooler than in health. The yellow colour was by no means universal; when it took place, it was seldom to be observed before the third day, but more frequently about the fifth or seventh from the first attack. The eyes seldom escaped a yellow tinge. There were eruptions of various kinds on the skin, and, in the latter stage, petechias were common; carbuncles also took place in a few cases. The disease ended in death in various ways. In some, it was sudden; in others, it came on gradually. The last hours of some were marked with great pain and strong convulsions; but, in many, death seemed to insinuate itself into the system with all the gentle- ness of natural sleep. In every case that came under Dr. Rush's care, there were evident remissions or intermissions of the fever, or of such symptoms as were substituted for it. The disease continued for 15, 20, or SO days in some people. He observed, that all were affected by it; but persons in the prime of life were most liable to it. Men were more subject to its attacks than women. He likewise observed, that the refugees from the West Indies universally escaped it; whereas the natives of France, who were settled in the city of Philadelphia, were much annoyed by it; and he found that the people of colour took the dis- ease in common with the white people, but in them it was usually much milder. Critical days were hardly ever distinguishable in this fever, nor was the crisis often very evident. Sometimes a copious perspiration put an end to it; and at others, the return of sleep, an hemorrhage from the nose, or sudden diarrhoea, carried it off. Dr. Fordyce is of opinionf that typhus icterodes ought to be regarded rather as an irregular semi-tertian than as a continued fever; for it often happens that a patient becomes greatly relieved, and appears to be recovering, when all at once a fresh attack takes place and carries him off. He thinks that the dark brown colour of the skin in this fever arises rather from a greater secretion of the matter secreted by the sebaceous glands of the skin, than owing to a quantity of bile getting into the blood-vessels. In support of this opinion, he observes, that the colour is very different from that which takes place in jaundice. The evacuations from the intestines have not that clay-like appearance which is common in jaundice. The secretion from the kidneys has not that dark yellow- ish brown, nor that thick sediment, which have almost always been noticed in those persons in whom the bile has got into the blood- vessels. The dark brown matter which the patient throws up by vomiting, * The same is frequently noticed on recovering from the plague. ' See his Fourth Dissertation on Fever. 80 PYREXIA, OR FEBRILE DISEASES. Class I. he thinks, has the appearance of the matter observed upon the tongue in very violent fevers, and that probably it is foimed on the surface of the stomach, and perhaps of the duodenum, or even on the beginning of the jejunum. The force of the exertions in vomit- ing, often occasions a greater quantity of bile to be secreted, and so to be thrown back into the stomach, and be brought up with the dark brown matter. When this happens, it gives to the matter thrown up, he observes, the taste and appearance of bile. At other times, however, there is no appearance of bile at all, but only of this dark brown matter. • Dr. Bancroft is of opinion*, that the black matter thrown up in this fever is merely blood which has been effused from some of the small arteries, ruptured in consequence of the suppuration of certain portions of the villous coat, and has coagulated within the cavity of the stomach, or on the surface over which it was effused, and having been afterwards detached and triturated by the violent and frequent contractions of that organ in the efforts to vomit, has had its appearance as a coagulum of blood altered, and its colour darkened by the gastric juice, or by some chemical decomposition, either spontaneous or produced by the action of the air, or other matters contained in the stomach. Dr. Jacksonf thinks that the black colour of the matters ejected from the stomach, or discharged by the anus in the latter stages of this form of fever in the West Indies, owes its origin to an admix- ture with diseased secretions from the mucous membranes of the whole gastric system, more particularly of the liver. He observes, the secretion is ropy and clear during the early periods of the disease, becomes brown or black in the latter; sometimes black as soot, more particularly in persons where the head and stomach are simultaneously affected, and where no strong vascular action takes place during the course of the disease. Concerning the nature of the black vomit, various opinions have indeed been entertained. Some have considered it as consisting of putrid bile; some as composed of a mixture of blood and bile; some of the villous coat of the stomach dissolved in the progress of inflammation, terminating in sphacelus, and others, of bile mixed with the septic acid contained in the alimentary canal. Dr. Cathrall of Philadelphia!, considers all these opinions as erroneous, and offers it as his, that the black vomit is an altered secretion from the liver. We are informed by him, that the black vomit, or matter so called, appears to be of two kinds; one consisting of a number of flaky particles, resembling the grounds of coffee; the other, of a dark-coloured inspissated mucus. From various and repeated experiments, he concludes, that the black vomit, besides a * See his Dissertation on the Yellow Fever. t See his Sketch of the History of Febrile Diseases, as they appear in the Wert Indies, among the Soldiers of the British Army. | See the New-York Repository of 1800, Cor his Memoir on the Analysis of Ihe Blatk Vomit, ejected in the last stnge of this IVrer. Order 1. YELLOW FEVER, 81 considerable proportion of water tinctured with resinous and mucilaginous substances, contains a predominant acid, which is neither the carbonic, phosphoric, or sulphuric, but hints it may be the muriatic. It appears from Dr. Cathrall's experiments, that the black vomit, when applied to the most sensible parts of the body, produced little or no effect. It likewise appears that large quantities of this fluid may pass through the stomach and bowels of quadrupeds and other animals, without apparently disturbing digestion, or affecting the health. This fact incontestably proves the inactivity of this fluid, and renders it probable that the speedy death which ensues after this discharge in yellow fever, is not from any destructive effect of this matter on the stomach and bowels, but most likely from the degree of direct and indirect debility which had been previously induced. Another fact which has been proved by this gentleman's experiments is, that an atmosphere highly impregnated with the odour of the black vomit recently obtained, would not produce fever, apparently under the most favourable circumstances. The yellow fever differs from typhus in the following circum- stances, viz. it usually prevails only during, or immediately after very hot seasons, in which typhus is soon extinguished, and it is in its turn completely annihilated upon the accession of cold weather, in which typhus is commonly most prevalent, particularly if accom- panied with humidity of the atmosphere. It attacks most readily and violently the young and robust, over whom typhus is allowed to have the least power; it begins wTith much greater exertions of the living power than typhus, is attended with many symptoms of a different nature, and it frequently changes into a regular remittent, and sometimes even to an intermittent fever, which true typhus is never observed to do. It differs from the plague, in that it prevails only in those coun- tries, and in those seasons, in which the heat is, or has recently been, so great as to destroy or stop the progress of the plague ; in the inter-tropical climates, therefore, so favourable to the existence of the yellow fever, the plague is unknown. The glandular and cutaneous affections called buboes and carbuncles, so constantly accompanying the plague, are not met with in the yellow fever. A violent febrile paroxysm is essential to the character of yellow fever; whilst, according to the best authorities, persons have been attacked by the plague without having the least febrile affection. In forming an opinion as to the event of the yellow fever, we must have in view the nature of the symptoms, the mode of attack, and the age and habit of the patient. Youth, and a plethoric state, are invariably circumstances of danger. A sudden oppression of all the functions at once; great debility; weak, irregular pulse; sighing; severe vomiting of dark matter; tremors of the body when moved, with a tendency to faint on the slightest exertion ; pensive sadness in the countenance; and a dilatation of the pupils 82 PYREXIA, OR FEBRILE DISEASES. ClaSS I. of the eyes, with coma; are signs of great danger. Very few recover from that stage in which a black vomiting is the prominent symptom. Black and fetid discharges by urine and stool, the breath being highly offensive, and the appearance of petechia;, portend almost certain death. The symptoms that we may regard as favourable are, a settled state of the stomach, lessened headach, eyes lively, appearance of an eruption on the skin, (known in tropical climates by the name of prickly heat), free perspiration, copious and high-coloured urine, bilious flux, and sound sleep. No disease, however, exhibits a greater variety of symptoms, and often less to be depended upon, than this; for sometimes it goes on with favourable appearances, then suddenly changes to the worst, and sometimes patients appa- rently almost in a state of convalescence, expire in a few hours. Dissections of the bodies of those who have died of the yellow fever have shown the coats of the oesophagus corroded; the stomach and intestines loaded with a black fetid matter, or both to be often much inflated, inflamed, and sphacelated ; the liver, in many cases, to be shrunk to less than half its natural size, very flaccid, and of a colour approaching to buff; and the gall-bladder to be flaccid and greyish, having but little bile contained in it. In some instances the lungs have been found inflamed ; and the bladder has been observed to be much thickened, and to contain a considerable quantity of urine. In those cases where there has been a dis- charge by vomiting of a black coagulated matter resembling the grounds of coffee, the gall-bladder and biliary ducts have been found distended with the like substance. Where an affection of the head has formed a prominent feature of the disorder,; the integuments of the brain have been observed more or less inflamed, the vessels of the dura and pia mater to be very turgid with blood, and occasionally there has been extravasation. Sometimes the volume of the brain has been found increased, and the substance of it more firm than usual. The same difference of opinion which arose among the profes- sional gentlemen of Philadelphia with regard to the origin of the disease, seems likewise to have subsisted between them as to the mode of treatment to be pursued; some recommending and adopt- ing the antiphlogistic plan, by bleeding, purging, and a low diet;. some, the stimulant plan, with a liberal use of the bark, wine, opium, and the cold affusion; and others, again, either purged moderately with calomel, or bled on the first or second day of the fever, and then resorted to a free use of bark, wine, laudanum, and aromatic tonics: and this practice they adopted on the supposition that the disease was inflammatory in its first stage, and putrid in its last. According to the report of Dr. Rush, this last mode of treatment was scarcely more successful than the tonic and stimulant one • and that which he found to succeed best was the antiphlogistic, pursued even to a degree of extreme rigour; for we are given to understand, Order I. YELLOW FEVER. 83 that although in some instances he allows of one or two moderate bleedings being sufficient, still, in most cases, he was in the habit of repeating the operation much oftener, and of drawing off a consi- derable quantity each time, even from the poor who resorted to his house for advice. Whether or not bleeding may be practised with advantage to the patient in America, or to what length it may be carried, I am not capable of determining, never having been on that continent; but being well acquainted with the climate of the West Indies, from a long residence there, and having often met with the disease, (although not under its very malignant form), I must concur with the objectors, who contend that, in tropical climates, vene- section resorted to among the natives, and such others whose bodies and constitutions have been perfectly assimilated to the climate by a long residence, cannot produce a good effect: the reduction of tone, which a certain period of residence occasions in the constitution of Europeans, as well as of the natives, renders it unnecessary; but when this fever has attacked new comers of a vigorous constitution and in rude health, but more particularly soldiers and seamen, (who bear phlebotomy better than any class of people in private life), then I am ready to admit, that the abstraction of blood soon after the seizure, or during the early stage, may be beneficial, if the quantity drawn off is in due pro- portion to the age, habit, and other circumstances of the patient. When the fever is completely formed, or is of a longer standing than 36 or 48 hours, it will bid defiance to depletion by the lancet, and then, instead of proving serviceable to the patient, will be highly injurious. Dr. Clarke, in his treatise on this disease, mentions, that no native recovered when the lancet had been used ; and Dr. Chisholme observes, that although the blood drawn, in the cases where this remedy was employed, appeared remarkably florid, and always threw up an inflammatory crust of greater or less thickness, and although the pains seemed to undergo a temporary mitigation, yet the consequence, at the expiration of a few hours, was always fatal, notwithstanding the patients were remarkably robust, florid, and generally in the vigour of life. Dr. Hector M'Lean, who has likewise published on this fever, is one of the few West India practitioners who approves of bleeding. —He observes, that the determinations to particular organs, which take place in the disease, and which constitute its greatest danger; the marks of inflammation, which dissections have shown in the stomach and biliary organs, evidently point out the propriety of this evacuation. He adds, that experience confirmed its utility; for his practice was much more successful after he had adopted blood-letting, than before. By way of caution, he mentions, however, that it is only in the very early stages he thinks it advisable to have recourse to the operation, and that if it is not 84 PYREXIAE, OR FEBRILE DISEASES. performed as early as the second, or at farthest the third day, he apprehends it will not be successful. Dr. Jackson, in his Exposition of affusing cold Water in the cure of Fever, tells us. that he holds a substraction of blood in large quantity to be a most decisive process in the more intense and con- centrated forms of the endemic fever of the West Indies, and that the remedy produces a condition susceptible of being more readily acted upon afterwards by cold affusion, and the other means we may employ. He adds, that whatever may be the precise quantity necessary to produce the effect, it must always be supposed to stand high, and seldom lower than thirty ounces; in strong athletic Euro- pean soldiers, recently transported to a tropical climate, sometimes far above it. In a work* of a later date he mentions, that he is fully warranted by long experience and attentive observation to say, that venesection, prescribed with consideration and conducted with management in execution, is both a safe and powerful remedy, either decisive of curing from its own effect, or preparatory of the curative effect of others. If there be no prohibitory circumstances in the case, one bleeding, he says, is to be preferred to repeated small ones: for although the latter diminish violence, and thereby avert the destruc- tion of organic structures, they do not prevent the diseased action from proceeding the regular process of what he terms coction, to a constituted period of formal crisis. He however readily admits, that bleeding in a large, or even in any quantity, is not invariably or uniformly either proper or safe. A late writerf on the yellow fever says, that it is only by a copious abstraction of blood employed while the fever is forming, or within a short time after it is formed, aided by purgatives, and by the cold affusion if indicated, that we can entertain any plausible expect- ation of arresting a disease where the morbid motions are of such rapidity and power. He very properly observes at the same time, that the ability with which men bear the" loss of blood will much depend upon the habit and locality, and its efficacy on the early stage of the disease. Dr. Bancroft is of opinion that bleeding may be resorted to in certain cases of the yellow fever, not only with safety but ad- vantage, and he quotes himself as an example; but, he says, that the propriety of the operation, and the quantity of blood to be taken away, must be determined by the circumstances of the patient. On a more intimate acquaintance with this species of fever than physicians possessed at first, many of those who have had most experience in attending patients labouring under the disease, now approve of venesection at the outset, or soon after its seizure. * See Dr. Jackson's Sketch of the History of Febrile Diseases among the Soldiers of the British Army in the West Indies. t See Treatise on the Causes of the Tropical Endemic or Yellow Fever by J H Dickson, M. D. ' ' Order L YELLOW FEVER. 85 To obviate the inflammatory diathesis which prevails during the first stage of the disease, and to take off the determination from the head, as well as to cleanse the prima? viae of acrid and offending humours, we may employ gentle purging, so as to procure one or two evacuations daily during the continuance of the fever; but as the stomach is seldom in such a state as to be capable of retaining those purgatives which are in common use, besides a triple dose being generally necessary, it has been found best to administer the hydrargyri submurias, either by itself, or combined with jalap or extract, colocynth. c. as below*. If the first dose does not operate in due time, it is to be repeated. At the end of six hours or so, if the purgative has not yet been attended with the desired effect, it ought to be assisted by an enema, giving at the same time by the mouth about an ounce of magnesiae sulphas dissolved in a little mint water. In no stage of typhus icterodes can emetics be administered with safety, owing to the disposition to vomit which usually prevails, and which it is often difficult to allay. Instead of prescribing emet- ics, we are to endeavour by every possible means to calm and allay the irritation of the stomach. As there appears to be a morbid determination of febrile or in- flammatory action in this disease upon the intestines, we may endeavour to counteract this disposition and produce an opposite determination by suitable diaphoretics, combined with opium in small doses, assisted in urgent cases by the warm bath, warm fomentations and a blister on the belly, faking care, at the same time, to promote sufficient evacuations by stool, in order to relieve the intestines as much as possible from all irritation and uneasiness which they might suffer by a retention of hardened faeces and other matters. Mercury being known to be a kind of specific in local inflam- mations of the liver, and their being evidently a great determi- nation of blood to this viscus in the yellow fever, practitioners have been induced to employ it likewise with the view of exciting a degree of salivation ; and where an incessant vomiting has pre- vented their using the submuriate of mercury in sufficient doses to effect this, they have substituted mercurial frictions. In some of the cases, where the hydrargyri submurias was administered with * 1. R Hydrargyri Submnr. gr. iv. Pulv. Jalap, gr. viij.—xvj. Syrup. Zingib. q. s. M. ft. Pulvis pro dos. Vel, 2. g; Hydrargyr. Submur. gr. vi. Extract. Colocynth. C. g. x. M. Fiant pilul. iij. 1. Take Submuriate of Mercury, four grains. Powder of Jalap, from eight to sixteen grains. Mix these for a dose. Or, 2. Take Submuriate of Mercury, six grains. Compound Extract of Colocynth, ten grains. Mix them together, and form the mass into three pills. 86 PYREXLE, OR FEBRILE DISEASES. IAOSS I. this view, its quantity was obliged to be increased to an almost incredible extent. Dr. Chisholme mentions a case, where 400 grains were given before the salivary glands were affected ; and in the Medical Commentaries for the year 1795, Dr. Duncan, of Edinburgh, takes notice that a correspondent in Jamaica had reported an instance where, within the space of a few days, the patient had taken 270 grains of it, and had rubbed in twenty drachms of the strongest mercurial ointment, from which the happiest effects were at last produced. On such authorities, and from the well-known efficacy of mer- cury in inflammations of the liver, it may, probably, be a proper and valuable remedy in typhus icterodes. To ensure its success, it should, however, be employed at the very commencement of the disease, and be so conducted as to affect the mouth before the dangerous symptoms of the second stage of the fever make their appearance. Dr. Currie, of Philadelphia, informs us*, that in every case in which he has seen mercury employed after the distressing and dangerous symptoms of the second stage had come on, it aggravated them and increased the danger ; and that when resorted to after signs of what is called putrescency have made their appearance, it has invariably accelerated the fatal event, notwithstanding the declaration of Dr. Chisholme to the contrary. In having recourse to mercury externally, we may direct half a drachm, or even a drachm of the strongest ointment to be rubbed into the thighs, hams, legs, and arms, every four hours; and we may give hydrargyri submurias internally, either by itself, or combined with opiumf, according to the state of the bowels. When a gentle ptyalism takes place, its use ought immediately to be omitted, and only nourishment and wine be given. That many patients have recovered by a mercurial treatment, if early adopted, appears from Dr. Chisholme's excellent work, as well as from the practice of the naval and military hospitals in the different West India islands, and the reports given in by various private practitioners. In typhus icterodes, possibly, there may be congestions in the liver, both from an accumulated and imperfect secretion of bile ; and mercury certainly possesses very stimu- lating and deobstruent qualities. We are told by Dr. Bancroft, however, that mercury admi- nistered so as to produce a salivation, appeared to him to be extremely equivocal in its operation. He is of opinion that the good effects of the mercurial treatment have been greatly ex- * See vol. ix.page 102, of the Med. and Phys. Journal. t 3 rx Hydrargyri Submunat. gr. ij.—iv. Opii, gr. s?. Confect. Rosse, q. s. M. ft. Pilula 4tis horis repetenda. t 3. Take Submuriate of Mercury, from two to four grains. Opium, half a grain. Confection of Roses, asufficiency to form a Pill, which is to be repeated every four hours. Order I. yellow fever. 87 aggerated; that many persons have died of this fever, although mercury administered externally or internally had produced a copious salivary discharge, and that in many others who have recovered, the discharge did not begin until after a solution or great mitigation, and therefore could not have been the effect of the salivation. He, however, deems the use of mercury as a purgative highly beneficial, and into this quality he is strongly disposed to believe its reported efficacy in all fevers is to be resolved. At the first commencement of typhus icterodes, it is not unusal for a frequent vomiting to prevail. In such cases, it may be advisable to wash out the stomach with an infusion of the flores anthemidis; but should it continue, stupes, wrung in a decoction of bruised poppy-heads, with an addition of one-third part of cam- phorated spirit, may be kept constantly applied to the region of the stomach, and the saline medicine may be administered (so as that the effervescence shall take place in the stomach) with an addition of about ten or twelve drops of tinctura opii to each dose. Sulphuric aether has been given, and even ardent spirits are some- times administered with partial relief, as the heat and vascular action subside. Warm clysters made of mucilaginous and aromatic vegetables infused in boiling water, with an addition of sixty or eighty drops of the tincture of opium, have been attended with the most imme- diate and sensible benefit in cases where vomiting, oppression about the praecordia, and great irritability appeared to be owing to exhaustion from too copious depletion. In cases of great irritability of the stomach, where excessive vomiting prevails, the early application of a blister immediately over the part may be attended with the best effect; but this re- medy is in general applied too late, and a determination to that important organ is suffered to take place before any attempt is made to counteract it, which at last proves too powerful to be removed. In some instances the vomiting has been known to cease upon the application of a large poultice of mustard-flour to the stomach and feet, which occasioned a very extensive and painful inflam- mation of the skin. By employing cold affusion on the first onset of typhus icterodes, we may, probably, in some instances, arrest its progress, and interrupt the morbid actions; and even in cases of some days' continuance we shall be able, by means of it, to abstract heat, induce sleep, and recruit the animal powers. In an advanced stage, it will be best to substitute aspersion, or ablution with a wet sponge. In all cases where there may be the smallest danger of arresting the movements of life by either affusion or aspersion, a glass of wine, or some other more powerful cordial, should be taken immediately after using the remedy. Cold water is certainly a very efficacious remedy in this fever, 88 PYREXIA, OR FEBRILE DISEASES. Class 1. and when applied externally, affords very great relief to the feelings of the patient, who is frequently distressed with a sensation of burning heat, the temperature of the skin, at the same time, being actually raised some degrees of Fahrenheit's thermometer above 'the natural standard. It is, however, only when the heat of the body is above the natural standard that cold water should be applied externally; and the period of its application and the frequency of its repetition must be determined by the feelings of the patient; for should he beco'me chilled by it, much mischief might ensue. To avoid any fatigue to the sick, which the usual mode of applying this remedy is apt to induce, a late writer* on this fever recommends as an useful substitute, that the patient should be covered as he lies in bed with a single sheet wetted with cold water, which by evaporation will gradually reduce the temperature of his body to a proper standard. Dr. M'Lean has seen the best effects to arise from cold affusion in this fever, and tells us, in order to heighten its power, that he often premised the warm bath, and while the patient was sitting in it he dashed two or three buckets of cold water suddenly on him. In those cases where the remedy was happily applied, the general effects observed from it Avere, an improved recollection, greater cheerfulness of aspect, a diminution of heat and anxiety, the pulse becoming more full and equable, a tendency to sleep, and sometimes a distinct remission. Some communications of Dr. O'Leary's, through the medium of the London Medical Journalf, further establish the good effects of the affusion of cold water in typhus icterodes. We are told by him, that he was ordered, soon after his arrival at Barbadoes from Europe, to attend the sick of the 70th regiment at Antigua, where, on his arrival, he found they amounted to about an hundred. They were chiefly affected with the yellow fever, and the mortality had been very great; but on his employing cold affusion judi- ciously, agreeably to the rules advised by Dr. Currie (see Typhus Mitior and Gravior), very few died afterwards. He mentions, that so sensible were the men of its efficacy being superior to any other remedy, and of the relief obtained from it. that in his absence they frequently entreated the officers, when duty led them to visit the hospital, to have it repeated on them. In a short history of the yellow fever which prevailed at Norfolk in America, and communicated by Drs. Selden and Whitehead to Dr. Miller of New YorkJ, further testimony in favour of an early use of the cold affusion is produced. From the great benefit which these physicians experienced iu their two or three first trials of it, they proceeded to recommend it afterwards with confidence. They have reported, that of all those patients to whom they had an opportunity of exhibiting this remedy on or before the second * See Dr. Bancroft's Essay on the Yellow Fever. t See vol. xvi page 490. i See vol. x.page 266, Med. and Phys. Journal. Order I. YELLOW FEVER. 89 day of the attack, they had the good fortune not to lose one; but after this period, when the fever had begun to subside, without symptoms of amendment, the affusion of cold water seemed to hasten the fatal catastrophe. In no instance did they employ the remedy in question without the exhibition of calomel at the same time. No disagreeable effect was produced by combining the use of calomel with the affusion of cold water; nor did the mercury occasion a salivation in a single instance, although the discharge from the bowels was scarcely as great as when it was used alone in the cure of the disease. In temperate and cold climates where we employ affusion, it will be sufficient to take the water fresh from the spring, pump, or the sea; but in warm climates, in order to command the full and ex- pected effect, it will be necessary that its temperature be reduced to a low degree (as about 40 of Fahrenheit's thermometer) by ex- posing it to the night air previously, or by adding some salt to it. Much benefit will probably be derived from cold water taken in- ternally as drink, small quantities of which, frequently repeated, have been observed to moderate the excessive heat of the body, as well as the violence of general febrile action and thirst: it is likewise efficacious in disposing the skin to perspire gently, and in preventing inflammation and irritation of the stomach. For reducing the temperature of the body to its natural and Jiealthy standard, and for producing a refrigerant effect in this and other fevers of the1 typhoid type, we have been informed by Dr. Cumming* that he has derived the highest benefits from either sprinkling or sponging the bodies of the sick with ardent or rectified spirits, and that he considers these to be in every respect superior to cold water. The effect, no doubt, will be quicker from using spirit, as the evaporation will be more rapid; but it has been questioned, and very properly, whether or not the great advantages which are derived from the cold affusion or washings, are to be attributed solely to the abstraction of heat in fever. Should proper means not have been adopted sufficiently early, or should they have failed in procuring the desired effect, and symptoms of putrefaction have made their appearance, our en- deavours must be directed towards slopping the putrid disposition of the fluids by the most powerful antiseptics. West India practitioners have of late administered the capsicum, in the form of pills, as a stimulant, and with very good effect. Spirituous baths have likewise been employed. The cinchona bark must be given in as large doses as the stomach will bear; and if it will not retain any quantity, either in substance, decoction, or infusion, it may then be given in the form of clyster. A pint of decoction, made by boiling an ounce of the powder in a quart of water, ______________________________________________________________—------—-----------.—k-x.---- * See Med. and Phys. Journal, vol. xviii p. 197. 12 90 PYREXIA, OR FEBRILE DISEASES. ClaSS [. until one half is evaporated, may be injected every three or four hours. Acid fruits may likewise be given liberally ; and the ordi- nary drink should be wine sufficiently diluted with water, and acid- ulated with lemon or orange juice. The mineral acids might likewise be serviceable in this fever, as well as in typhus gravior and scarlatina anginosa, and I much wish that a fair trial may be made of them, but more particularly the muriatic, in an early stage of the disease. The sooner it is ad- ministered, the more likely will it be to pr..ve efficacious. Its wonderful effects in other malignant disorders 1 have often witness- ed ; and typhus icterodes being evidently of this nature, is it not reasonable to suppose that its use might prove highly serviceable in this also ? Throughout the whole course of the disease, but more parti- cularly under the above circumstances, the strictest attention ought to be paid to c eanliness, by not only changing the patient's linen frequently, and immediately removing and emptying what- ever comes from him, but likewise by sprinkling his chamber every now and then with warm vinegar, and allowing a perfect and ree ventilation of air through it. To destroy contagion, and assist in correcting the fetor, the gaseous fumigations re- commended under the head of Typhus Gravior ought to be employed. The patient's strength is to be supported throughout the disease with preparations of barley, sago, tapioca, Indian arrow root, he. mixed with wine, and his thirst allayed by a liberal use of barley water, common water, or any other grateful beverage. Dr. MLean observes, that he always found opium to be injurious in the beginning of this fever, although restless nights and anxiety often tempted him to prescribe it in large doses. It procured no settled rest: for a time, the delirium was increased, to which stupor rather than sleep succeeded ; and the next day, languor, irritability, and weakness prevailed. When remissions had com- menced, and where a return was apprehended, he gave opium freely, and apparently with a good effect. It was likewise useful when convulsions took place, and to procure sleep towards the decline of the disease. When a severe headach, with great depression of spirits, is complained of, camphor and aether may probably be administered with some advantage. In cases where violent delirium prevails, the application of a blister to the neck or shoulders may be advisable; but where there is only coma, this remedy will not be necessary. When remissions are obtained, and the disease shows a dispo- sition to yield, the cinchona bark, joined with sulphuric acid, may be taken with advantage, and its use should be continued during the whole sta^e of convalescence, which is often tedious and long, owing to tin; great debility that is always left behind, and from which the patient cannot readily recover, unless by a change of climate. Order 1. YELLOW FEVER. 91 Quassia in a cold infusion is a valuable medicine during convales- cence, and here the cold bath may also be serviceable. The cortex cuspariae has likewise been found an useful medicine towards the close of this fever, when debility is the chief symptom. An infusion of it* sits easy on the stomach, and is attended with the most beneficial effects in restoring the strength and appetite. Other tonics may be used at the same time: for these, see Dys- pepsia. In recommending a use of the cortex cuspariae, it appears worthy of observation to guard practitioners against a spurious species of it met with in the trade, and which proves of a deleterious and poisonous nature. That of a safe nature and commonly used, is a thin smooth bark, of a yellowish colour in the fracture, and of a bitter aromatic taste. The poisonous kind is less thick, a white, or yellowish white bark; in the fracture grey, on the inner edge yellowish, partly approaching to brown, of an unpleasant bitter taste, and hardly possessing any aroma. The effects of the spurious and bitter cusparia, both on mankind and animals, are pretty much the same with those produced by the nux vomica. Not long ago a fever of a highly malignant nature made its ap- pearance at Gibraltar, as well as at Cadiz and Malaga, and destroyed som^ thousands of the inhabitants. By some practitioners it was sup- posed highly contagious f, by others again not so. Thus it appears that the same diversity of opinion prevailed on this head with respect to this disease, as with regard to the yellow fever, which indeed it very nearly resembles, and probably is the same. That which has been denominated the Bulam fever is also nearly alliedj. This seems to be merely tbe bilious continued, or bilious remittent, of warm climatesfj. It appears by the practice and writings of the most eminent physicians who have witnessed the Gibraltar and other parts of the Mediterranean fever, that the leading remedies were blood- letting, and purging by the submuriate of mercury and antimony; for upon opening many bodies after death, the brain as well as the abdominal viscera presented appearances demonstrative of a turgescence of the vessels of the former, and an inflamed state of some of the latter. In many, the stomach contained a dark or 'black slimy fluid, closely adhering to the internal coat. t See Reports of the Pestilential Disorder of Andalusia, Cadiz, and Gibraltar, by Sir James Fellowes. X See Observations upon the Bulam Fever, by Dr. Pym. || See Dr. Bancroft's Sequel to his Essay on Yellow Fever. * 4. ft Infus. Cort. Cuspariae, f. |v. Tinct. Cinchon. ----Calumb. aa f. gss. M. Capiat Cochl. magna ij. ter quaterve in die. cum Acid. Sulph. Dilut.tTl. xvj. * 4. Take Infusion of Angustura Bark, five ounces. Tincture of Peruvian ditto, ------ of Calumbo, each half ian ounce. Mix them The dose may be two table-spoonsful three or four times a day, adding about twenty- four drops of Diluted Sulphuric Acid. 92 PYREXI2E, OR FEBRILE BISEASES. ClaSS J. Where the disease breaks out in a garrison, the healthy should immediately be separated from the sick, and, it possible, be en- camped at a considerable distance. Subjecting the former to cold ablution daily might possibly enable them to resist the powers of contagion the better; for that it is of a highly contagious nature, I am perfectly convinced. In the apartments of the sick, fumigation (as advised under the head of Tyhpus Gravior) should be adopted. An attention to these, and other precautionary means, may be attended with the most happy effects: a neglect of them, with ruinous calamity and devastation, as was unfortunately experienced at Gibraltar on the first appearance of the disease. Mr. Jackson, in his account of the empire of Morocco, states it as his opinion, that the epidemic fever which made its appearance at Cadiz, and afterwards spread all along the southern shores of Spain, was really the plague, imported from the Barbary States, and suffering, after its passage to a Christian country, some variation, originating from the different modes of living, and other circum- stances. Having pointed out the most approved method of treating the yellow fever, it seems advisable to offer a few hints, by an attention to which Europeans may often be enabled to withstand its attack, or, if seized, to go through it with the least danger. The plethoric and robust being the subjects most liable to this malignant disease, all such, on their approach to the warm latitudes, ought to be bled in proportion to their strength; but should this have been neglected during the voyage, it may be done immediately on their arrival on shore. It will easily be understood here, that bleeding, as a pre- parative, will have a very different effect from what it would have in a curative intention; for in the former, it prevents morbid action, and gives time for assimilation; whereas, in the latter, it may induce debility, and morbid associations, very dangerous to life. After bleeding, if the patient is of a full and plethoric habit, the bowels are to be opened by some cooling purgative; and if he is naturally of a bilious habit, it may be advisable to premise a gentle emetic. Having adopted these steps, he may then begin a slight course of mercury, taking from two to four grains of hydrargyri submurias, according to his age and other circumstances, every other night, either in the form of a pill, or that of a powder, mixed in some thick vehicle, until the gums become somewhat affected. Should the medicine run through the bowels, a grain of opium, or a few drops of tinctura opii, may be added to each dose. When the mouth shows the mercurial action, a dose of cooling physic ought to be administered after one or two days' intermission of the medicine. In some constitutions, not easily affected by mercury, it will be necessary to persevere with steadiness, until the system be thoroughly impregnated, for thereon depends the safety of the patient. On his voyage being completed, and his landing, he must ob- serve the greatest temperance in his diet, and carefully guard Order f. YELLOW FEVER. 9$ against any exposure to the sun in the middle of the day, and to the cool aii- of the night, until he becomes somewhat habituated to the climate. The effects of temperance, as a prophylactic, are strikingly demonstrated by Dr. Chisholme, who observes, that while the yellow fever raged at the island of Grenada, the utility of this was remark- ably illustrated by the almost total exemption of the French inhabit- ants from the disease, whose mode of living, compared with that of the English, is temperate and regular in an uncommon degree. Dr. Clarke tells us, that new settlers who could be prevailed upon to undergo a gentle course of mercury, taking a few laxative medi- cines, afterwards confining themselves to a moderate use of wine, and living chiefly on vegetables and fruits for the first two or three months, may rely almost to a certainty on escaping this fever. The remark is, I think, well founded, excepting that, notwithstanding all these precautions, it may arise from contagion, and in this case its virulence, in all probability, will be greatly diminished. Europeans appear to suffer in point of priority and severity of attack by the yellow fever, precisely in the degree that they pos- sess bodily vigour, rigidity of fibre, and are of a sanguinous temper- ament ; and when relaxed by a long residence, or other causes, they become, like the Creoles and people of colour, (as they are termed) in a great degree exempt from the influence of this fever. It is the reduction of tone, which a certain period of residence oc- casions in the constitution of Europeans, that secures them in a great measure from the seizure of the yellow fever. It is a cor- responding (atonic) state of constitution which affords immunity to the native inhabitant. Having pointed out the means for enabling Europeans to with- stand an attack of this fever, I proceed to offer, from personal experience, a few admonitions or rules, by an assiduous attention to which they probably may be enabled to enjoy a long and unin- terrupted state of good health in warm climates, unassailed by any other disease whatever.. Men who exchange their native for a distant climate, may be considered in a light somewhat analogous to that of plants removed into a foreign soil, where the utmost care and attention are required to inure them to their new situation, and keep them healthy. Every European, in changing his own climate for a warm one, should, if possible, avoid arriving in his new situation during the rainy season of the year. This? with some small variation, com- mences in the month of August, and terminates in October. If he has it in his power to choose the place of his residence, he ought to prefer that situation which is somewhat elevated, dry, open to the air and 3un, and remote from woods, stagnant waters, or marshy grounds. Most of the towns in the West Indies, as likewise the factories on the coast of Africa, with some of our settlements in the East Indies, are, for the convenience of trade, situated on low grounds, either contiguous to the sea, or on the banks of some large river. Swamps and marshes, therefore, exist in their neighbour- 94 PYREXIA, OR FEBRILE DISEASES. ClaSS I. hood, and when acted upon by a powerful sun, particularly after heavy rains, they send forth noxious vapours and exhalations, which prove a never-failing source of intermittent and remittent fevers, fluxes, &c. to all descriptions of inhabitants, but more particularly to Europeans lately arrived. Persons of this description ought, therefore, to pass as little of their time as possible in such a situation ; and, where obliged by business to resort there by day, they should retire early in the evening to one that is elevated, and that has the advantages before described. If no such situation h to be p oeured without great inconvenience, sleeping on board a vessel in an open road or healthy harbour, will then be preferable to passing the night on shore. Where unfavourable circumstances do not admit of either of these advantages, and new-comers are obliged to remain con- stantly in an unhealthy spot, they will act prudently in adopting such means as will tend in some measure to lessen the danger to which they are exposed. The highest apartment in the house should be chosen 1o sleep in ; if furnished with a stove, a small fire should be kept in it; and the windows that front the swampy ground, if the house is to the leeward of this, are to be kept shut, admitting the light and air by the others. About half an ounce of the compound tincture of bark may be taken every morning on an empty stomach, repeating the dose again in the evening. Smoking tobac- co might also be serviceable in such a situation. A propensity to smoking is, however, too general anion;: Europeans and natives, in tropical climates; but it ought to be considered not only as a degrading but an injurious habit, as, during the process, the grog glass is in constant circulation. In particular places, where marshy or other deleterious exhalations abound, or during very moist damp weather, at certain seasons of the year it may be useful and al- lowable. The diet of Europeans, newly arrived in a warm climate, should consist of a greater proportion of vegetable food than of animal, avoiding such articles of the latter as are either salted or very highly seasoned. To all such, a free use of ripe sub-acid fruits will be highly proper, as th^y will not only assuage thirst, but serve to correct any tendency in the fluids to putrefaction. In the West Indies it is usual to take weak punch in the forenoon daily : sherbet, or an infusion of preserved tammarinds, in water, will be found, however, a grateful and more salutary beverage to allay thirst. The danger of drinking cold fluids of any kind when the body is much heated by exercise, and the perspiration profuse, cannot but be obvious to every person. The unbounded hospitality of the islanders in the Wrest Indies frequently proves a source of much evil and danger to new-comers ; for they are no sooner arrived, than they are engaged by invitation in a daily round of visiting and feasting, committing therein ex- cesses, which, together with an unavoidable exposure to the dews Order I. yellow fever. 95 of the evening, are not unfrequentl) productive of a severe attack of illness. To all new settlers 1 beg leave, therefore, to recommend a very moderate indulgence in the delicacies of the table ; a spare and temperate use of all kinds of vinous and spirituous liquors, giving wine the preference to spirits; a proper self-command in sensual gratifications; the carefully avoiding any exposure to a current of air, or moisture, particularly when the body is heated by exercise; their avoiding this in the heat of the day, taking it early in the morning and cool of the evening; their return eaily to their respective homes so as to avoid the night dews; their refraining from dancing and such other active amusements; and their cautiously obviating a costive habit, by taking from time to time some gentle cooling laxative, until they are able to establish a proper regularity in this point, by visiting the temple of Cloacina at certain hours every day, and soliciting natural evacuations. The custom of going early to bed, and rising betimes in the morn- ing, is conducive to health every where, but more especially so in hot countries. If gentle exercise, either on foot or horseback, be added in the morning, it will prove highly salutary; and should cold bathing be first used, the body would thereby be much invigorated, and rendered less susceptible of external impressions. Where the con- venience of a proper bath is not to be procured, water properly cooled, by having been exposed all night to the air in pots, or a tub, may be thrown over the body. Minor ablu'ions, at other periods in the day, may also have a good effect. Cold bathing is one of the most pow- erful means we possess for counteracting the injurious influence of a hot climate, and it connects the most grateful sensations with the most salutary effects, but it should be used in the mornings. The practice would, however, be injurious to those who labour under any visceral derangement: for such, a slight tepid bath may be substituted with advantage. The dress of new-comers should consist of coats made of thin woollen cloth, with waistcoats and breeches of dimity or nankeen, and they should clothe in proportion to the exposure. What is worn next to the skin should be made of cotton in preference to linen, as this last, when moistened with perspiration, in consequence of any severe exercise, is very apt to convey a sense of chilliness when the body becomes inactive again. Calico shirts will, thereforej be preferable to linen ones. Those who are afliicted with rheumatic pains may substitute a waistcoat of thin flannel next to the skin. New settlers should observe the greatest precaution in changing their clothes, of every kind, as soon as possible after getting wet; a circumstance too frequently made light of and neglected, and which often, therefore, proves the cause of an attack of some severe disease. In a few words, the preservation of the health of Europeans in tropical climates will very much depend on avoiding the various pre- disposing and exciting causes of disease, until the physical sensibililv of the system is reduced by habit to the climate. 96 PYREXIA, OR FEBRILE DISEASES. CkU8. I. The rules to be observed for preserving the health of seamen in warm climates, as well as in cold ones, are inserted under the head of Scurvy. ORDER II. PHLEGMASIA, or INFLAMMATIONS. The character of this order of diseases is synocha fever, with in- flammation or topical pain; the function of an internal part being at the same time injured; the blood upon venesection exhibiting a huffy surface. Before I proceed to speak of the different inflammatory diseases to which the human frame is liable, it seems proper to make a few observations on inflammation in general, and likewise to point out the different species of it which are to be met with in practice. In every inflammation there is an increased action of the blood- vessels, propelling forward a greater quantity of blood than usual into the part affected, by which means its sensibility and irritability are increased, its vessels distended beyond their natural tone, and the circulation of blood through them rendered more rapid. A variety of opinions have, however, been entertained with respect to the nature of inflammation. Hoffman, and Dr. Cullen, supposed the proximate cause to consist in an increased action of the blood- vessels, with a spasmodic stricture of their extremities; but as the beginning veins are in a state of over-distention in an inflamed part, as well as the arteries, it is evident that no such spasmodic stricture can exist. Dr. M'Bride's hypothesis on the nature of inflammation is, that, besides the action of the blood-vessels being increased, the resistance to the course of the blood is diminished; and a third doctrine has lately been advanced, which teaches, that instead of an increase of action in the vessels of the part, as is commonly suppo- sed, the direct contrary takes place, and that there is a deficiency of action and paralysis of the vessels affected, instead of spasm. The principal argument in favour of this hypothesis is drawn by its founder, Mr. Latta* from the swelling of the inflamed part, which he attributes to a partial stagnation of blood; but the great heat of the part, the throbbing pain, and, in many cases, the accelerated action of the whole sanguiferous system, clearly point out an increase of action in the vessels. When the inflammation is confined to one particular part, without producing any general affection in the system, it is called local or topical; but when it produces effects on the whole system, it is known by the name of general inflammation. Inflammation is properly of two kinds; viz. the phlegmonous * See his System of Surgery. Order II. inflammations. SH and erysipelatous. By the phlegmonous is to be understood an inflammatory circumscribed affection of the skin and cellular membrane, with a swelling rather prominent in the centre, and of a bright red colour, attended with pain and distention, and in which any effusion that happens to take place is usually converted into pus. By the erysipelatous is implied an inflammatory affection confined principally to the skin when seated outwardly, and to the mucous membrane when internally, with hardly any evident swell- ing, being of a mixed red colour, readily disappearing upon pres- sure, but quickly returning again, the redness being of no regular circumscription, but spreading unequally, with a pain like to that of burning, which gives rise to a number of small blisters, and terminating usually in a desquamation of the scarf-skin, and now and then in gangrene, but never in a suppuration, unless combined with phlegmon. Such a combination does frequently occur in practice, constituting what has been denominated erysipelas phleg- monodes. Besides the differences in the circumstances of these two kinds of inflammation, there is another very evident one, which is, that a phlegmon, when considerable, is generally accompanied with more or less of the symptoms of general inflammation ; whereas, erysipelas is usually attended with symptoms of irritation when perfectly pure ; from which circumstance it will be necessary to adopt a different mode of treatment in each of them. Of the erysipelas there are two cases : one, when it is merely an affection of the skin alone, with very little of the whole system, which is called erythema ; the other, when it is an affection of the system, and is named erysipelas. Persons in the prime of life, and in full health and vigour, and of a plethoric habit of body, are most liable to the attacks of phleg- monous inflammation : whereas those advanced in years, and those of a weak, irritable, and spare habit, are most apt to be attacked with erysipelatous or erythematic inflammation. The more moderate the different symptoms are, the better is the chance of the inflammation terminating by resolution. When it does not readily yield to proper reuiedies, and is unusually obstinate, or deep-seated, there is reason to believe that it will terminate by sup- puration. When the symptoms are very violent, especially if the inflammation is of the erythematic kind, there will be reason to fear gangrene. Resolution is always a favourable termination : suppuration is also favourable if the inflammation be external and the habit good ; but in internal inflammations we shall find it is generally to be dreaded. Internal gangrene is always fatal. It is only when the gangrene is external that medicine can avail, and then it often fails. »3 98 PYREXIAE, OR FEBRILE DISEASES. Cld&$ / PHLEGMON. This species of inflammation is occasioned by the application of stimulants, such as fire or burning ; by external injuries, either bruising, wounding, over-stretching, or compressing the parts ; by extraneous substances which have lodged, and either by their form; bulk, or quality, produce irritation; by the application of cold; and by any thing that determines an increased impetus of blood to the part. The chief seat of phlegmonous inflammation is the inner surface1 of the true skin and the cellular substance contiguous to it, from which it extends to the adjoining parts of the cellular membrane and skin ; so that the surface soon assumes a florid colour, the tumor, at the same time, extending both in depth and circumference. It comes on with an itching, dryness, redness, and increased heat and circulation in the affected part ; which symptoms are shortly succeeded by a circumscribed tumor, through which shooting and throbbing pains extend. If the inflammation runs high, and is of considerable extent, then an increased action of the heart and arteries takes place, the pulse becomes full, hard, and quick; the skin dry and hot; great thirst arises, and a feverish disposition ensues. Phlegmonous inflammation usually terminates either by resolu- tion, suppuration, effusion, and adhesion, or gangrene. By resolution we are to understand the natural cure or going off of the inflammation by a gradual cessation of all the symp-1 toms, the state and texture of the part remaining entire. By* suppuration is implied the conversion into matter, or pus, of the serum, or coagulable lymph and blood which have been effused in the adjoining cellular substance, in conse- quence of which a cavity, termed an abscess, is formed. When effusion takes place without terminating in suppuration, the matter exuded is frequently viscid, and unites the neighbouring parts together often in twenty-four or thirty hours. In some cases this takes place from a slow degree of inflammation, such as is not noticed at the time : hence, on opening bodies, adhesions between the pleura and lungs, or among the abdominal viscera, are often found. By gangrene is meant a mortification not yet actually formed, but approaching, being the intermediate state between the height of inflammation and sphacelus.1 Sphacelation implies the total loss of life in the part, an absolute derangement of its structure, the abolition of all its functions, and an utter incapacity of its being restored to any service in the animal economy. Many of the phenomena of gangrene seem to depend on a great violence in the action of the vessels, followed by a relax- ation, or loss of tone in them ; this, in many cases, being so complete, that the action cannot be restored, which occasions the part to be- come perfectly dead, or sphacelated. Such are the most common terminations of this species of inflam- Order II. phlegmon. 99 mat ion ; but in the schools a fourth has been noticed, which is in a scirrhus, implying an indolent, knotty hardness of the part, unat- tended by any discolouration, but accompanied with lancinating pains, the tumor after a time ulcerating and becoming cancerous. This termination of inflammation is, however, confined to glandular parts. When the patient is seized with reiterated shiverings; when the fever and inflammatory appearance cease quickly without any per- ceptible reason ; when a heavy, cold, and dull uneasiness is expe- rienced in the part affected, instead of acute pain ; when the most elevated portion of the tumor appears soft and white, while the rest has its redness increased; and when, at the same time, the sur- geon can feel the fluctuation of a fluid, we may be assured that a termination in suppuration has ensued. The latter symptom, how- ever, occurs only where the matter lies superficially : but a man endued with great nicety of touch may be able, in many cases, to perceive the undulations of matter, even when deeply lodged. In most instances, indeed, of this nature, the quick subsidence of all the inflammatory symptoms, the repeated rigors, and the sense of weight and coldness in the part, are the only obvious appearances ; but the patient being afterwards attacked with emaciation, noc- turnal sweats, and other hectic signs, very clearly point out that there is a hidden collection of matter. The symptoms which denote the termination of inflammation in incipient mortification are ; first, a sudden diminution of (he pain and sympathetic fever: secondly, a livid discolouration of the part, and which, from being yellowish, becomes of a green hue : thirdly, a detachment of the cuticle, under which a turbid fluid is effused : and fourthly, the swelling, tension, and hardness subsiding, while, at the same time, a crepitus is perceived on touching the part, owing to a generation of air in the cellular membrane. The term gangrene has been applied to the disease in this stage ; but when the pari has become black and fibrous, and destitute of natural heat, sen- sation, and motion, it is denominated sphacelus. In phlegmon, our prognostic should be drawn from the symp- toms which are present, as well as from the seat of the inflam- mation. If the inflammatory appearances cease suddenly, and blisters discharging a thin ichorous matter arise, together with the part affected losing its sensibility and becoming of a livid colour, then a gangrene will certainly ensue. On the contrary, a gradual abatement of the inflammatory symptoms by a termination, either in resolution, or a suppuration where proper pus is formed, may be regarded as prognosticating a favourable event. This re- mark holds good, however, only with respect to external suppura- tions, as internal ones areialways dangerous, and not unfrequently fatal. In the incipient state of a phlegmon, it will always be proper to attempt the cure by procuring a resolution of the tumor, if possi- ble ; and, therefore, an early attention should be paid to the removal 108 PYREXIAE, OR FEBRILE DISEASES. Cla$S I of the cause which has excited it, as likewise to obviate the phlo- gistic diathesis, either of the whole system, or of the particular part which is affected. If the inflammation has proceeded from a lodgement of some extraneous body, such as a bullet discharged from any kind of fire-arms, or has been occasioned by a thorn or splinter of wood,&c. it ought immediately to be removed, and, if necessary, the wound must be dilated to such a size as to admit of its being readily got at. In cases of local inflammation, the phlogistic diathesis may be obviated by drawing a proper quantity of blood immediately from the neighbourhood of the part affected, either by scarifications with the aid of cupping-glasses, or by the application of several leeches, which will be the preferable way if they can be procured; pro- moting the flow of blood by cloths dipped in warm water, and re- newing them as soon as they cool : but in internal inflammations, it will be advisable to draw blood from the system by opening a vein or artery, taking care to proportion the quantity drawn off to the age and strength of the patient, as well as to the severity of the symptoms. With a view of obviating the phlogistic diathesis, we may like- wise have recourse to purgative medicines. In inflammations of any of the external parts of the body, as likewise in those of the head and chest, a frequent use of purgatives will be attended with a good effect; but in a similar affection of the bowels, active pur- gatives should be administered with due caution. Those of a mild nature, together with emollient laxative clysters, deserve a preference. To assist these means, and terminate the inflammation by reso- lution, if possible, it will be right to make use of some discutient application, as remedies of this nature are, in some mild cases, of themselves sufficient to disperse an incipient phlegmon. In cases of violent contusion or fracture, where a considerable degree of tension prevails, a poultice of rye-meal, or crumbs of bread, moistened with the liquor plumbi acetatis, properly diluted with water (viz. about eighty drops of the former to about a pint of the latter), will be a very proper application; and this may be renewed twice or thrice a day, until the swel- ling and inflammation subside: but in a common phlegmon, or where the part is so tender and painful as not to be able to bear the weight of a poultice, we must be content to apply pieces of soft linen moistened in some sedative application*. It is 1. R Liquor. Amnion Acetatis, Aquae Distillat. Spirit. Rectific. aaf. ?ij. M. Vel, 2. H Amnion. Muriat. 3j- Acid. Acetic, dilut. f. |jj. * 1. Take Solution of Acetate of Ammonia, Distilled Water, •^Icohoi, each two ounces. Mix them, and use them as a wash. Or, 2. Take Muriate of Ammonia, on« drachm. Distilled Vinegar, two ounce's. Order H. phlegmon. 101 to be understood, however, that these remedies are to be applied cold, whether we use poultices, or wet pledgets, and that they are to be renewed as often as they become stiff, hard, or warm. The application of cold is indeed one of the most powerful means which we possess for abstracting heat and subduing inflammation; and it has been carried so far in some instances, that pounded ice and snow have been employed for the purpose. When these are not to be obtained, we may substitute, as a refrigerant, pieces of soft linen moistened in a solution of the nitrate of potass and mutiated ammo- nia in water, or even in simple cold water; but they are to be renewed frequently. In some cases of phlegmonous inflammation, particularly that which attends compound fractures, swelled testicle, &c. the pain is often so violent as to deprive the patient of his natural rest. When this happens, we may give opiates both with advantage and safety, provided sufficient evacuations have been premised, and that we after- wards obviate the costiveness produced by them by gentle aperients. The dose, however, should be considerable; otherwise opium, instead of proving serviceable, will have a contrary effect. About fifty or sixty drops of tinctura opii may be given to an adult an hour or two before bedtime, and in a like proportion to those of a younger age. Children at the breast may take a small quantity of the syrup, papa- veris, instead of the tinct. opii. When the inflammatory symptoms run so high as to affect the system, it is not unusual for a febrile disposition to prevail. In such cases we may order some febrifuge medicine to be taken every three or four hours, combined with the nitrate of potass*. If, notwithstanding these means,, the tumor should show an evident tendency to suppurate, we are then to accelerate its pro- gress by the application of warm emollient cataplasms, which ought to be renewed three or four times a day. If linseed can be procured, a poultice made of this, slightly bruised and boiled up with milk and Spirit. Camphorae, f. ^j. Liquor. Plumbi Acetat. til xv. M. ft. Lotio. * 3. R Potassae Nitrat. 3ss.—3j- Aq. Fervent. §viij. Antimon. Tartarizat. gr. ij. Syr. Violas, 3»j- M. ft. Mistura cujus sumat cochl. magna ij. pro dos. Vel, 4. R Haust. Salin. |jss. Potassae Nitrat. gr. x.—xv. Vini Antimon. iT\. xij. Syrup Simpl. 3j- M. ft Haustus 3tia quaque hora sumendus. Camphorated Spirit, one ounce. Solution of Acetate of Lead, twenty-four drops. Mix them for a wash. * 3. Take Nitrate of Potass, from half a drachm to one drachm. Hot Water, eight ounces. Tartarized Antimony, two grains. Syrup of Violets, two drachms. Mix them, and take two table-spoonsful for a dose. Or, 4. Take Saline Draught, one ounce and a half. Nitrate of Potass, ten or fifteen grains. Antimonial Wine, eighteen drops. Common Syrup, one drachm. Mix them as a draught, to be taken every three hours. 102 PYREXIA, OR FEBRILE DISEASES. ClaSS 1. water, will be preferable, on account of its emollient quality; but when it is not to be obtained, the white bread poultice, with a small addition of oil, may be used : previous, however, to the application of the poultice, the part affected should be well fomented with flan- nels wrung out of a warm decoction or infusion of emollient herbs*. In inflammatory tumors, which are slow in suppurating, stimulating poultices, composed of onion, garlic, galbanum, or ceratum resinae, mixed with the white of an egg, and the common poultice, may possi- bly forward the suppuration. Warm plasters of galbanum, or pix arida, applied to slow suppurating tumors, sometimes prove useful; and they have this advantage over poultices, that they do not prevent people from doing their ordinary business. When the suppuration is completed, and the tumor is become very soft to the touch, and is near the surface, it is to be opened, either with a lancet or a trocar, in the part which is most dependent, taking care to press the matter perfectly out; after which the wound is to be dressed with dry lint, and a pledget spread with the ceratum resinae to be laid over all. If the wound does not heal readily, the cincho- na, with other tonics, should be used till the patient is restored to health. To support the vis vitae, a full diet, with a moderate allow- ance of wine, will be requisite. In very large abscesses, particularly in that of the psoas muscle, it has been found a judicious practice to evacuate the matter by means of a seton, or by a flat trocar in a canula, which is to be in- sinuated between the skin and cellular membrane for some space, and then to be plunged in a slanting direction down into the ab- scess, leaving the canula, and withdrawing the trocar. The orifice in the skin, and deep-seated parts, by this means will not be in a di- rect line, and the severe constitutional symptoms which are apt to arise from the exposure of an extensive cavity to the air, are thereby avoided. In the like cases it will also be proper to direct the pa- tient to take at least an ounce of cinchona bark a day, in order to promote the production of proper pus; and to support his strength under the discharge, a nutritive diet, with a moderate use of wine, should be allowed. Good pus is of the consistence of cream, and of much the same colour; it has no smell, scarcely any taste, and six parts in seven appear to he water, but it is in general rather heavier than water. In the common heat of the atmosphere it does not unite with this liquid, but does so when exposed to heat. It contains in it some volatile matter, the peculiar properties of which have not been * 5. g; Flor. Antbemidis, Fol. Althaeas, aa |jj. Papav. Somnif. Exsiccat. ^j. Aq. Ferventis. Oiv. M. ft. Foinentum. * 5. Take Camomile Flowers, Marshmallow Leaves, each two ounces. Poppy Heads, bruised, an ounce. Boiling Water, two quarts. Infuse them for a proper time, then pour oft the liquor, and use it for fomentation. Order II. phlegmon. 103 fully explained: when examined by the microscope, it commonly appears to be flaky. Pus, when examined chemically, has the same general properties as the blood. The matter of an abscess is either absorbed or discharged, but more generally the latter; and in either case, if it is well condi- tioned, the cavity is gradually filled up by an operation of nature, which is termed granulation, from the new parts appearing in the form of small red grains. When this process goes on favourably, the granulations are of a florid red colour, and proceed in a regular manner till the cavity is accurately filled, its edges (if the matter of the abscess has been discharged externally) being even, or nearly so, with the sound skin. When the granulation is too languid, it is to be forwarded by the same means which promote a favourable secretion of .pus. It is, however, sometimes too luxuriant, forming irregular masses, which project beyond the lips of the wound. In such cases it will be ne- cessary to check the granulating process, and destroy the projecting parts by escharotics; but for more particular information on this head, I must refer to the works on surgery. It has been customary to treat inflammation, terminating in sup- puration, in the manner just detailed ; but in the treatment of such abscesses it has lately been recommended* to approximate the lips of the wound, immediately after the contents of the sac are dis- charged, by strips of adhesive plaster, then applying a compress, and securing the whole by a roller of sufficient length, applied some- what tight. The dressings are, at the same time, to be kept con- stantly moistened with a cold saturnine lotion. By proceeding thus, instead of in the usual way, the external air (if it really be pro- ductive of the evil commonly attributed to it) is effectually excluded ; adhesion, and obliteration of the sac, will certainly be obtained; the health of the patient will in nowise be injured either by the quantity or quality of the subsequent discharge, as the cutis vera approxi- mates closely; when the cure is affected, there is no waste of cuta- neous substance, which frequently renders the parts weaker after- wards than they were before; there will be no unseemly, or puckered cicatrices, so often observed on the site of large abscesses ; and, finally, instead of the curative process occupying weeks, nay, months sometimes, by this plan of treatment the cure is nearly effected in a few days; for when the cavity of the abscess is once obliterated by the adhesion of the investing integuments to the surface below, the cure may be considered as next to being completed, as the lesion then constitutes merely a simple wound. Should phlegmonous inflammation threaten to terminate in gan- grene, or already have shown symptoms denoting such a termination, we are then to step the progress of the mischief, and promote the speedy separation of the dead parts from the living. To effect this, * See Mr. Cunningham's Communication in vol. v. p. 272 of the Medico-Chirurgiral Journal. 104 PYREXIA, OR FEBRILE DISBA9ESJ. ClaSS I. it was formerly customary to make slight scarifications, and after- wards to apply warm antiseptic fomentations, and poultices: but modern practitioners, particularly Mr. Bell and the late Mr. John Hunter, have highly disapproved of this mode of proceeding, and recommend a reliance to be placed on a liberal use of the bark of cinchona, together with a nutritive diet, and such a quantity of wine as will be sufficient to keep up the pulse, and induce the necessary slight degree of inflammation. To give energy to the system, to restore vitality to the affected parts, and to lessen the morbid irritability in them, are the objects which we should keep in view in all cases of gangrene. In cases of gangrene, arising from external injury, and exposing the life of the patient to danger, Monsr. Larry* strongly advises that amputation should be performed, without waiting the appear- ance of the line of separation between the living and dead parts. Where gangrene arises from debility, opium frequently proves useful: and as it by no means counteracts the effects of the cinchona bark, it may be given along with it: indeed opium will prove gene- rally beneficial, and particularly in that variety of the complaint in which no previous inflammation existed, but which is accompanied by violent pain. The efficacy of the bark of cinchona is in every instance indeed much increased by its junction with opium in these affections, and therefore they cannot be too early employed in the curative plan of treatment conjoined together. In cases of gangrene, accompanied with convulsive spasms, or arising from any local injury, such as a fracture, &.C. producing irritation, a combination of musk with ammonia has been found by Mr. White, of Manchester, and other practitioners, on his recom- mendations, to have been attended with a happy effect in abating subsultus tendinum, stopping the progress of mortification, and occasioning the dead parts to separate from the living. A bolus, consisting of ten grains of musk, and the same quantity of ammo- nia, repeated every three hours, is what is advised on such occa- sions. Musk combined with the volatile salt of amber might probably prove a still more powerful remedy for checking the progress, of gangrene arising from any local injury producing irritation. By modern practitioners we are instructed to keep the parts cool, and that all applications to them ought to be cold instead of warm, as was formerly practised. As an application to parts in a gangre- nous state, there can be none better than a poultice made by stirring into an infusion of malt (such as may be readily obtained from the ale or porter brewers) as much oatmeal as is required to make it of a proper thickness, and afterwards adding about a spoonful of yeastf. In applying it, due care must be taken not to bind it on * See his Memoirs de Chirurgie Militaire. \ This is the Cataplasma Efferrescens of the Pharmacopoeia Chirurgica. Order II. PHLEGMON. 105 too closely, as the fermentation, a short time after its application, will be considerable, and its bulk of course so increased, as to put the cloths and bandages which confine it very much on the stretch. The cataplasma carbonis (which is prepared by mixing two ounces of wood charcoal, reduced to a very fine powder, with half a pound of the common farinaceous poultice) is another application which has lately been much used in gangrenous cases, as well as in sweetening fetid ulcers, and disposing them to granulate fa- vourably. By some communications through the medium of the Medical and Physical Journal*, we are given to understand that the pro- gress of mortification has been checked, and the offensive stench issuing from the wound entirely removed in a very short space of time, by'sprinkling the diseased parts thickly over with the nitrate of potass, pulverized very fine. In the instances alluded to, the dressing was renewed twice or thrice a day. When the diseased parts separate and slough off, dry lint is to be laid on the wound with a pledget, spread with some digestive oint- ment, applied over all. In the second volume of the Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, is inserted a paper from Dr. Harness, at that time a physician to the fleet, on the good effects of the application of the gastric fluid of gramini- vorous animals to parts in a gangrenous state. By this gentleman we are informed, that he found its application to succeed in more than a hundred cases of sphacelus in entirely removing the sloughs, and occasioning healthy granulations. As a gentle stimulus to parts in a state of gangrene, where any is thought proper, and in preference to warm gums, balsams, or rectified spirit, Mr. B. Bell advisesf the use of a weak solution of ammonia muriata in vinegar and water. We are informed by him that a drachm of the salt, to two ounces of vinegar and six of water, form a mixture of a proper strength for every purpose of this kind ; but the degree of stimulus can be easily either in- creased or diminished, by using a larger or smaller proportion of the salt. In similar affections of the toes and feet, Mr. PottJ very much disapproves of all stimulating applications, and in their stead re- commends soothing and emollient ones, and this with a view to avoid exciting pain. A case which some time ago came under my inspection has, in my opinion, decidedly established the superiority of the latter mode of treatment over the former. On meeting in consultation the professional gentleman who had the management of it, I strongly urged the necessity of soothing and emollient • See vol. xi. p. 206. t See his System of Surgery, vol. i. p. 112. X See his Chirurgical Works, pp. 799 and 800. 14 106 PYREXIA, OR FEBRILE DISEASES. ClaSS I. applications (the good effects of which 1 had before witnessed on other similar occasions); and these were adopted for a time with the greatest relief to the sufferings of the patient, as likewise arresting the progress of the mortification. Not happening to call again for three or four days, thi3 prudential mode of proceeding was discontinued by the chief surgeon, and a stimulant one was substituted, to which plan, as a disciple of the old school, he was strongly bigoted. The consequences were, that the pains, which had before been much alleviated, became highly aggravated, and the mortification which had been arrested in its progress, spread so considerably as to threaten the greatest danger. Being now thoroughly convince^ of his error, he was glad once more to have recourse to the soothing and emollient plan ; by a strict pursuance of which ; by administering opium to the amount of six or eight grains a day, so as to keep up a constant effect ; by allowing a liberal use of wine; and by giving the cinchona bark in substance, in the quantity of about an ounce a day, joined with camphor (which combination seems to possess strong antiseptic powers), the patient appeared for many weeks to have a great chance of recovering. The prospect, however, proved delusive ; for he soon afterwards paid the debt of, , nature. From his having been withdrawn from under my care during the last six weeks, I cannot speak as to the mode of treat- ment which was latterly pursued. It seems almost superfluous to observe, that it was found neces- sary to obviate the effect of the opium on the intestines by a fre- quent use of some mild laxative or emollient clyster, so as to procure one or two evacuations daily. In the early stage of the disease the cataplasma effervescens was employed, and seemingly with a most happy effect. In this species of mortification, Mr. Pott reports, he found the cinchona bark had little or no influence, but that opium in large doses, frequently repeated, proved an effectual remedy in many cases. To give the patient every possible chance of recovering, it will be best, I think, to administer both. It sometimes happens, particularly in military hospitals, when the wards are much crowded, and the air contaminated to a high degree with putrid miasma, that sudden and rapid mortification is apt to attack all the wounded who are lodged in such wards, and that several individuals die, notwithstanding the application of the curative means and treatment successfully resorted to in the other species of gangrene. The term hospital gangrene has, therefore, been applied to this species of the disease. It seldom falls under the observation of practitioners in civil life; it occurs most commonly among the wounded after an engage- ment, particularly when many are crowded together. When it supervenes upon a wound, its progress to a fatal termination is rapid, and all structures suffer from it. By an examination of its symptoms, it* would appear that this Order II. PHLEGMON. 107 gangrene is the effect of a general state of the system, which pro- duces a local affection on wounds or ulcers; an affection which, after having passed through different stages or periods, degenerates into mortification or gangrene, assuming all the symptoms of slow fever, and terminating very frequently by destroying the life of the patient. In most cases there is reason to suppose the contagion is spread through the atmosphere, and that the miasma, most probably, are applied immediately to the wound or ulcer; but there are some grounds, at the same time, for believing that hospital gangrene may also be produced by the inspiration of the deleterious matter. All who have described the disease, say, that it is communicable by the pus of ulcers which are affected with it, and particularly by what- ever may be impregnated by this pus, such as lint, linen, mattresses, sheets, blankets, &c.; and it has been thought by some of the Ger- man and French surgeons, as well as a few of the English ones, that the usual washing and bleaching of linen is not sufficient to annihilate the power of the contagious matter, as lint made from the old sheets of hospitals wherein this species of gangrene had existed, was found to give rise to the disease among those labour- ing under recent wounds or ulcers in other establishments wholly free from it. During the late war this malady very frequently made its appear- ance in the French hospitals; and in the treatment of it, we are informed by Mr. Cross*, that no reliance whatever was placed by the surgeons upon internal remedies, although acknowledged to be a constitutional and contagious affection. He states, that the topi- cal application of vegetable and diluted mineral acids was found by them to prove successful in mild cases, and in a few instances carbon; but that the actual cautery alone proved capable of arrest- ing the fatal progress of the more unfavourable. The iron is applied red hot by the French surgeons, so as to produce an eschar on every point of the surface of the sore. We are informed by Mr. Blackadderf that he experienced the progress of the disease to be completely arrested by keeping the sores constantly wet with the liquor arsenicalis diluted with an equal quantity of water, by means of lint dipped therein ; and with suitable topical applications the wounds soon got well without paying any attention to the constitutional affection, which soon disappeared of itself. To detach the slough, he says, it must be dressed with a detergent ointment, and be frequently washed with a solution of potass. On the detachment of this, the wound be- comes a simple ulcer, and is to be treated accordingly. No instance occurred in the practice of this gentleman during the time he was resident officer of a division hospital in Spain, in which this method of cure failed of success, when timely and properly employed. It * See his Sketches of the Medical Schools of Paris. See his Observations on Phagedeena Gangrenosa. 108 pyrexia:, or febrile diseases. Class I, appears also, that it was afterwards adopted in the hospitals of Belgium with the same results. Mr. Blackadder mentions, that the prejudices of the times are against the use of the actual cautery. In all cases of hospital gangrene, the strictest attention should be paid to cleanliness, and a free and perfect ventilation. The wounded patients, and those labouring under common ulcers, should be kept apart, and the wards of the hospital containing such patients be made to undergo frequent fumigations, as advised under the head of typhus. Cinchona, in conjunction with the mineral acids, may be considered as appropriate medicines. Carbuncle (Anthrax) is an inflammatory tumor which seldom suppurates perfectly, but discharges a thin acrid humour, as is usual in erysipelatous inflammation, and exhibits symptoms of approach- ing sphacelus. A generous diet, with a liberal use of wine and bark, in combination with snake root, together with opiates to alleviate pain and procure rest, will be the best internal remedies in this complaint; warm fomentations with bruised poppy heads, with an addition of a little rectified spirit and a cataplasm of bark and yeast over the whole tumor, (which ought to be renewed every four hours) are the best external applications we can employ. The termination of inflammation in a scirrhus is (as was before observed) confined to glands. Upon a gland becoming scirrhous, we should disperse it, if possible ; and if we cannot effect this, then we should endeavour to keep it stationary, and prevent its ulcerating and degenerating into a cancer. The means best cal- culated to answer these intentions are pointed out under the par- ticular heads of scirrhus and cancer. If the tumor, on a fair trial of these means, should not disperse, but, on the contrary, show an evident tendency to ulcerate, and degenerate into a cancer, then, in my opinion, the sooner it is ex- tirpated, the better will it be for the patient, as it is more than probable that the affection is not originally connected with the system, but is merely local, and that the constitution or habit does not become tainted until ulceration takes place. ERYSIPELAS. This disease is an inflammatory affection, accompanied usually with drowsiness, often however with delirium, when the face is affect- ed, and with a fever of a few days' continuance. When the inflammation is principally confined to the skin, and is unattended by any affection of the system, it is called Erythema; but when the system is affected, it is named Erysipelas* It sometimes happens that the inflammation extends to the cellular membrane beneath the skin, whence a real phlegmon and * In Dr. Cullen's nosological arrangement of diseases, erysipelas is placed among the Exanthemata, but 1 have thought it best.not to separate it from Erythema, that the t\v« species may thereby be seen at one view. Order II. erysipelas. 109 collection of matter become jointed to the erysipelas, which com- bination has been denominated erysipelas phlegmonodes; but this is mostly the case where there has been a previous scratch or injury of the skin. Every part of the body is equally liable to erysipelatous inflam- mation, but it more frequently appears on the face, legs, and feet, than any where else when seated externally; and it occurs oftener in warm climates than phlegmonous inflammation. Erysipelas does not often attack persons before the age of puberty : it is a disease of advanced life, met with more frequently among women than men, particularly those of a sanguine irritable habit. In many people there seems to exist a predisposition to the disease. Sometimes it returns periodically, attacking patients once or twice in the year, and in some instances much oftener, greatly exhausting the strength thereby. It is brought on by the several causes that are apt to excite in- flammation ; such as injuries of all kinds, the external application of stimulant acrid matters to the skin, exposure to cold, particu- larly during a course of mercury, obstructed perspiration, sup- pressed evacuations, or other causes inducing plethora, the presence of irritating matter in the prima? viae, he.; and it may likewise be occasioned perhaps by a certain matter generated within the body, and thrown out on its surface. A particular state of the atmos- phere seems sometimes to render it epidemical, as we often find the angina scarlatina, which is a species of internal erysipelas, prevail as such. It seems connected likewise with that peculiar state of the atmos- phere which occurs in hospitals, and crowded ships of war, occa- sioning the slightest wound to produce erythema. By the gene- rality of practitioners, erysipelas has not been considered as a contagious disease. In slight cases, where it attacks the extremities, it makes its appearance with a roughness, heat, pain, and redness of the skin, which becomes pale when the finger is pressed upon it, and again returns to its former colour when it is removed. There prevails likewise a small febrile disposition, and the patient is rather hot and thirsty. If the attack is mild, these symptoms will continue only for a few days, the surface of the part affected will become yellow, the cuticle or scarf-skin will fall off in scales, and no further inconvenience will perhaps be experienced ; but if the attack has been severe, and the inflammatory symptoms have run high, then there will ensue pains in the head and back, great heat, thirst, and restlessness ; the part affected will slightly swell; the pulse will become small and frequent; and about the fourth day a number of little vesicles, containing a limpid, and in some cases a yellowish fluid, will arise. In some instances the fluid is viscid, and instead of running out, as generally happens when the blister is broken, it ad- heres to, and dries upon the skin. In unfavourable cases these blisters sometimes degenerate into 110 PYREXIAE, OR febrile diseases. Class I. obstinate ulcers, which now and then become gangrenous. This, however, does not happen frequently ; for although it is not un- common for the surface of the skin, and the blistered places, to appear livid, or even blackish, yet this usually disappears with the other symptoms of the complaint. The period at which the vesicles show themselves is very uncer- tain. The same may be said of the duration of the eruption. In mild cases it often disappears gradually, or is carried off by spon- taneous sweating. In some cases it continues without showing any disposition to decline for twelve or fourteen days, or longer. The trunk of the body is sometimes attacked with erysipelatous inflammation, but less frequently so than the extremities. It is not uncommon, however, for infants to be attacked in this manner a few days after birth ; and in these it makes its appearance about the genitals. The inflamed skin is hard, and apparently very pain- ful to the touch. The belly often becomes uniformly tense, and sphacelated spots sometimes are to be observed. From dissections made by Dr. Underwood, it appears, that in this form of the dis- ease the inflammation frequently spreads to the abdominal viscera? —See infantile Erysipelas. Another species of erysipelatous inflammation which most usu- ally attacks the trunk of the body, is that vulgarly known by the name of shingles, being a corruption of the French word ceingle, which implies a belt. Instead of appearing an uniform inflamed surface, it consists of a number of small pustules, extending round the body a little above the umbilicus, which have vesicles formed on them in a short time. Little or no danger attends this species of erysipelas. When erysipelas attacks the face, it comes on with chilliness, succeeded by heat, restlessness, thirst, and other febrile symptoms, with a drowsiness or tendency to coma or delirium, and the pulse is very frequent and full. At the end of two or three days a fiery" redness appears on some part of the face, and this at length extends to the scalp, and then gradually down the neck, leaving a tume- faction in every part the redness has occupied. The whole face at length becomes turgid, and the eyelids are so much swelled as to deprive the patient of sight. When the redness and swelling have continued for some time, blisters of different sizes, containing a thin colourless acrid liquor, arise on different parts of the face; the skin puts on a livid appearance in the blistered places ; but in those not affected with blisters, the cuticle, towards the close of the disease, falls off in scales. No remission of the fever takes place on the appearance of the inflammation in the face ; but, on the contrary, it is increased as the latter extends, and both will continue probably for the space of eight or ten days. In the course of the inflammation, the disposi- tion to coma and delirium is sometimes so increased, as to destroy the patient between the seventh and eleventh days of the disease. When the complaint is mild, and not marked by a fatal event, the Order II. erysipelas. Ill inflammation and fever generally cease gradually without any evident crisis. If the disease arises in a gross habit of body, occupies a part pos- sessed of great sensibility, is accompanied with much inflammation, fever and delirium, and these occur at an early period, we may sup- pose the patient is exposed to imminent danger. The fever assuming the typhoid form ; the inflammation becoming of a purple colour; its suddenly receding from the surface, and attacking an internal part; livid vesications; great prostration of strength ; and a weak, rapid, irregular pulse, are to be viewed in a very unfavourable light. Erysipelas never terminates in suppuration, unless combined with a considerable degree of phlegmonous inflammation, which is however sometimes the case; but in a gross habit, the vesications are apt to sphacelate, in which case there will also be great danger. When the febrile symptoms are mild, and unaccompanied by delirium or coma, is not combined with typhus, and the inflammation does not run high, we need not be apprehensive of danger. Where the disease has occupied the face, and proves fatal, in- flammation of the brain, and its consequences, are to be met with in dissection. Great diversity of opinion has prevailed among the practitioners in medicine, concerning the mode of treatment to be adopted in erysi- pelas ; some pursuing the same antiphlogistic plan advised in phleg- monous inflammation; others, again, disapproving of all evacuations, and treating it as a disease dependent on irritability. To reconcile these jarring opinions, I shall consider the com- plaint as sometimes combined with phlegmonous inflammation (con- stituting what has been denominated erysipelas phlegmonodes), as now and then happens, when it arises in a full plethoric habit. In such a case, if the skin is hot and dry, the pulse full, strong, hard, and frequent, and the head affected with severe pain, stupor, or de- lirium, it will undoubtedly be proper to have recourse to bleeding, cooling purgatives, diaphoretic and refrigerant medicines, and the strict observance of an antiphlogistic regimen, as recommended in phlegmon. Topical bleeding, however, by means of leeches, which proves so useful in other varieties of inflammation, is not admis- sible in erysipelas, as the orifices by which it is drawn are very apt to become gangrenous, or to degenerate into those troublesome ulcers which the disease, when it terminates in effusion, sometimes produces. When we have occasion, therefore, to draw off bloor/, in order to counteract the inflammatory diathesis, we must do it ry opening a vein; and where the head is the part diseased, the jugu- lar will be the most proper. As to the quantity to be taken aw»y, we are to be regulated in this by the violence of the inflammatory symptoms, the appearance of the blood when allowed to cool, and the strength of the patient. From the excessive vascular action which the brain and the affected parts exhibit when the disease proves fatal by occupying the head, there can be no doubt, in such cases, of the propriety of the depleting plan: blood may be taken 112 PYREXIAE, OR FEBRILE DISEASES. ClaSS I. freely from the arm, and a constant evaporation from the inflamed parts be kept up by means of alcohol and water. In vigorous habits, the efficacy of this practice must be obvious; but in old or infirm constitutions, or where the disease is perfectly pure or local, does not affect the head, is unaccompanied with symptoms of ge- neral inflammation, and has arisen in a weak irritable habit, or is accompanied with a fever of the typhoid'kind, bleeding will be improper. The same observation will likewise apply to the making use of strong purgatives ; but although 1 disapprove of such medicines in the latter instance, still it will be right to keep the body open by gentle saline aperients, so as to procure one or two motions daily. Where the inflammation is of a phlegmonous nature, and the head is much affected, a liberal use of active purgatives will undoubtedly be advisable. In those cases where the fever and inflammation run high, dia- phoretic medicines will be proper, and they may be given conjoined with the nitrate of potass, as advised in phlegmon, or as directed under the head of Inflammatory Fever. As erysipelatous fevers often terminate by sweat, mild diaphoretics*, with plentiful dilution, become a necessary part of the treatment, and should never be neglected. In those cases where the head and face are affected, and coma prevails, the semicupium, together with sinapisms applied to the feet, will be highly advisable. The application of a blister between the shoulders may assist in affording relief towards the close of the disease. It has been observed, that when the disease has made some progress, vesicles of various sizes usually arise. The most proper application will be some dry mealy powder, such as starch, wheat-flour, oatmeal, or chalk; but oatmeal may perhaps be preferable to the rest, on account of its not being likely to cake and become hard by the humour which weeps from the parts affected. Probably external applications that reduce the heat of the skin might be employed with advantage. Some prejudices have indeed long existed against the use of cold applications in erysipelas. Cooling lotions have nevertheless been employed in this disease with great advantagef. I have myself frequently recommended linen cloths wetted with a cooling lotion t See Cooper's Dictionary of Practical Surgery, and also his First Lines of the Practice cf Surgery. * \. g; Mistura? Camphorae, f. ^s. Liquor Amnion. Acet. f. 3iij- -----Antimon. Tartarizat. TTJ.. xij Syrup Simpl. f. 3j M. it. Htastus quartis horis adhibendus. * 1. Take Camphorated Mixture, half aa ounce. Solution of Acetate of Ammonia, three drachms. ■----------Tartarized Antimony, eighteen drops Syrup, one drachm. Make them into a draught, to be taken every four hours. Order II. erysipelas. 113 of equal parts of the liquor ammon. acetatis, or of muriated ammo- nia dissolved in water, with the addition of a little vinegar and camphorated spirit in erysipelatous inflammation with much benefit and relief to the feelings of the patient, when the application of farinaceous powders has seemed indeed rather to aggravate than soothe his sufferings. No solution, either of lead, copper, or alum, should be employed, as these would be injurious. When effusion is found to have occurred in any considerable quantity, it ought to be discharged by making a small opening in the most dependent part. It has been usual to employ emollient fomentations and poultices in this state of the complaint, in order to bring on a proper suppuration; but the effusion which some- times happens in erysipelas not being of a nature to be converted into pus, as in the case of a pure phlegmon, they certainly cannot prove serviceable. The ceratum plumbi compositum, or ceratum plumbi superacetatis, will be the best applications. Erysipelas phlegmonodes is a species of inflammation which, we are informed by a late writer*, is very prevalent in the British navy, and ascribed by him chiefly to the nature of the diet of sailors, and the sudden alterations of temperature to which they are exposed. Its active influence is found more especially directed to the reticular or condensed cellular substance, forming the muscular aponeurosis, although it often primarily affects the skin, and is thence communi- cated to that membrane. When pus is formed, it more frequently appears beneath the aponeurosis, in contact with the muscles, and generally destroys that membrane rapidly. It has, however, been found occasionally to commence in the periosteum, detaching that membrane and insulating the bone. A peculiarity in the plan of treatment, recommended by the surgeon alluded to, consists in making free incisions with a scalpel on the inflamed surface, down to the muscles, previous to any secretion of pus having taken place. These are the means to be employed when erysipelas happens to be combined with phlegmonous inflammation. When it arises in advanced life, or a weak delicate habit, assumes the typhoid cha- racter, and is accompanied with symptoms of irritation, such as de- pression of strength, a quick small pulse, he. to take off the irrita- bility, and guard against a termination in gangrene, which some- times ensues, we should give the bark of cinchona, mineral acids, snake-root, camphor, aromatic confection, and wine. In those cases where the disease is confined to the trunk and extremities, and where there is considerable pain and irritation, the employment of opium seems advisable: indeed, I have used it on such occasions seem- ingly with much advantage. In erysipelas of the face, even without coma or delirium, from the tendency of this form of the disease to affect the brain, opium is to be regarded as a more doubtful remedy. Where a tendency to mortification becomes apparent, the above medicines, with wine and other antiseptics, will be the more neces- Si-e Surgical Observations by Mr. Copeland Hutcheson. 15 114 PYREXIA, OR FEBRILE DISEASES- ClaSS I sary—(See Phlegmonous Inflammation terminating in Gangrene). Ammonia joined with aromatic confection may be given internally, with some probability of advantage, in all cases of erys.pelatous inflammation of the extremities, or other parts, which threaten to terminate in gangrene. When erysipelas is accompanied with a ten- dency to the worst kind of hemorrhage, from being of a malignant nature, alum and the sulphuric acid are particularly indicated. If the disease is mild, and unaccompanied with febrile symptoms! it will be sufficient to keep the patient within doors, without con- fining him to his bed. In those cases where the inflammatory symptoms run high, the diet should consist of light nourishing things, such as preparations of barley, sago, tapioca, rice, Indian arrow-root, panado, and the like • and his drink should be lemonade, tamarind-beverage, or bar> ley-water, acidulated with some vegetable acid; but m those cases where symptoms of irritation prevail, a more generous diet, such as animal broths, and a moderate use of wine, ought to be allowed. For the treatment of the erysipelas with which infants are liable to be attacked, see the diseases peculiar to them at the end of this work. PHRENITIS, or INFLAMMATION of the BRAIN and its MEMBRANES. Phrenitis is an inflammation of the parts contained in the cavity of the cranium, and may effect either the membranes of the brain, or the brain itself. It is called primary, or idiopathic, when it exists independent of any other disorder ; and symptomatic when it arises in consequence of some other disease, as fevers and inflammaf tory affections; which species is that most universally met with, the other occurring but very seldom, at least in this country. In warm climates, it appears to be sometimes produced by exposure to the intense rays of the sun, and often proves quickly fatal. Its characteristics are vehement pyrexia, severe pain in the head, redness of the face and eyes, intolerance of light and sound, watch- fulness, and violent delirium. The causes which give rise to idiopathic phrensy, are such as di- rectly stimulate the membranes, or substance of the brain, or in- crease the impetus of the blood in its vessels : hence violent fits of passion, intense study, excessive venery, severe exercise, external violence of any kind, such as blows on the head, concussion, fis- sure or fracture, an immoderate use of vinous and spirituous liquors} a long-continued exposure to the heat of the sun, and the suppres- sion of accustomed eva< uations, as haemorrhois, menses, issues, milk drying up, &tc. may be regarded as the remote causes. Many acute diseases, and a long want of sleep, may give rise to sympto- matic phrensy. The idiopathic is usually preceded by long-continued, and almost constant watching, or frightful dreams, acute pains at first in the Order II. phrenitis. 115 neck and occiput, afterwards extending to the head, deep respira- tion, inability to recollect circumstances which have lately hap- pened, suppression of urine, and irregular pulse As the disease advances, the eyes sparkle, and are violently agitated; there is a ferocity in the countenance, with universal restlessness, deafness, great confusion of ideas, violent ravings, intolerance of light, evi- dent pulsation in the temporal and carotid arteries, and the most furious delirium. The tongue is dry, rough, and of a yellow or black colour, the face is of a deep red, and the pulse is small, quick, and hard. The symptomatic phrensy is constantly preceded by acute fever, or some inflammatory complaint, and is usually accompanied with inability to sleep, constant watching, delirium, picking at the bed- clothes, redness and fierceness of the eyes, wild look, and deep breathing. Phrenitis is distinguished from mania by the quickness of the pulse, and the attendant fever and pain in the head ; and from that species of delirium which occurs in low fevers, unaccompanied with inflammation, by the appearance of the countenance and eyes; for in true phrensy the face is red, the features are rather enlarged than shrunk, and the eyes protuberate and sparkle : whereas in the de- lirium supervening to low fever, the face is pallid, the features are shrunk, and the eyes pearly. It is to be distinguished from synocha by the state of the pulse; as in the latter it is strong and full, whereas in the former it is small, hard, and more rapid. In phrenitis, the delirium is the primary affection; but in synocha, it is consequent upon the general fever. Phrenitis, whether idiopathic or symptomatic, may always be regarded as a dangerous and alarming complaint: it often proves fatal between the third and seventh day; and if long protracted, is apt to terminate in mania, or great prostration of strength : it often terminates in stupor and insensibility. In children, an effusion of water between the membranes of the brain, or in the cavities of its ventricles, is a frequent consequence. Grinding of the teeth, white or ash-coloured faeces, suppression of urine, startings of the tendons, with convulsions, cold sweats, a fluttering pulse, and coma supervening on delirium, denote a fatal termination : on the contrary, when there is a copious hemorrhage from the nose, mouth, or lungs, or even from the urinary passages or hemorrhoidal vessels, or when diarrhoea ensues, when the delirium is relieved by sleep, and the patient remembers his dreams, when the perspiration is free and general, the deafness diminished or removed, the pulse less frequent, but fuller and soft, and the febrile symptoms become milder, there are hopes of a recovery. Dissections of persons who have died of phrenitis have shown the brain and membranes red and inflamed, the membranes consi- derably thickened and hardened, and in a few instances the pia jnater has been found as thick as the dura mater. In some cases. 116 FYREXLE, OR FEBRILE DISEASES. ClaSS L abscesses in the ventricles and adhesions of the dura mater to the skull have been perceived. On the first coming on of idiopathic phrensy, immediate recourse should be had to bleeding, proportioning the quantity that is drawn off to the age and constitution of the patient, and the severity of the symptoms. The orifice which is made with the lancet should be large, and the patient, if possible, ought to be placed in an erect posture. The blood drawn off is usually buffy and cupped upon cooling. Opening the jugular vein, or temporal artery, may be preferable to drawing blood from the arm; and taking away a con- siderable quantity at once, will certainly be better than drawing off only a little at a time, and repeating the operation frequently. Thirty or forty ounces of blood taken at one operation, will more decidedly stop the progress of the disease, than sixty or eighty drawn off by driblets of twelve or fourteen ounces at a time. A man who in a state of health would faint from the abstraction of a pound of blood, will, when an inflammatory diathesis is present, suffer the loss of two or three pounds, without any, or but trifling inconvenience. If the patient is perceived to be much reduced by the largeness of the evacuation, and the disease should nevertheless still continue with violence, the application of several leeches to each temple will be more advisable than any repetition of bleeding from the system. When leeches are not to be procured, blood may be abstracted by means of a cupping-glass and scarificator. The next proper step to be taken, will be to direct the head to be shaved, and to apply a large blister over it. Linen cloths wetted with vinegar and water, cold spirituous lotions, diluted aether, or iced water, may likewise be kept constantly to the temples and forehead; and they should be re-wetted as often as they acquire the temperature of the scalp by continuance. Topical cold over the region of the brain^by a wet towel, or other like medium, will in- deed, in many cases, prove more efficacious than the application of a blister, as this has been observed occasionally not only to acce- lerate the pulse, but likewise to render the patient more unma- nageable. With a view of obviating the inflammatory diathesis, and of di- verting the humours from the head, a strong purge* may be ordered; and this ought to be repeated every second or third day during the continuance of the complaint. Purgatives of the saline kind are * 1. g; Hydrargyri Submur. gr. viij.—x. Extract. Colocynth. gr. vj. M. fiantpilula? iij. pro dos. Vel, 2. g. Pulv. Jalapae, gr. xv.—3i. Hydrargyr. Submur. gr. vj. M. ft. Pulvis Catharticus. * 1. Take Submuriate of Mercury, from eight to ten grains. Extract of Colocynth, six grains. Form the mass into three pills for a dose. Or, 2. Take Powdered Jalap, from fifteen grains to one scruple. Submuriate of Mercury,six grains. Mix them, and let the cathartic powder be taken at once. Order II. PHREMTIS. 117 good antiphlogistics, and may be prescribed instead of others. When we cannot employ purgatives, laxative clysters may be used. In all inflammatory affections of the head, a copious discharge from the intestines will be found highly beneficial, and experience has indeed ascertained that venesection itself is often less powerful. To assist in diminishing the determination of blood to the head, the patient should be kept as near the erect posture as can easily be borne. Warm bathing of the lower extremities, and the application of rubefacients to them, for the purpose of revulsion, have been very generally employed in idiopathic phrenitis. By some physicians, and particularly by Dr. Cullen, they have, however, been regarded as ambiguous remedies; and it is probable that they will be likely to do harm, if employed before the excitement has been sufficiently reduced. From the well known power of digitalis in lessening the action of the heart and arteries, it is probable that small doses of it admi- nistered from time to time might prove beneficial. Opiates have not been thought advisable remedies in this dis- ease : hyoscyamus might however be serviceable, if we at the same time employ copious evacuations and alow diet. In symptomatic phrenitis, particular attention should be paid to the primary-disease which has given rise to it, and the treatment ought to be varied according to the nature and progress of the dis- order which has occasioned it. If it is in its first stage, and inflam- matory, copious bleeding from the system will be necessary; but if it has been of some continuance, drawing blood from the tem- ples, by means of leeches or cupping with scarifications, will be preferable. Symptomatic phrenitis will not require our using active purga- tives ; on the contrary, we should keep the body open only with gentle aperients, or laxative clysters, administered from time to time, as the occasion may require. In most cases, the application of a blister to the neck, or between the shoulders, will be proper. As a medicine, the patient may take in both species of phrenitis a diaphoretic bolus* every three hours, washing it down with two or three table-spoonsful of some febrifuge mixturef. * 3. & Camphorae, gr. iv. Pulv. Antimon. gr. ijss. Confect Ross, q. s. M. ft. Bolus. *4 4. g. Succ. Limon. f. ^jss. Ammonia; Subcarbonat. 3ss. vel q. s. ad ejus saturationem, dein adde Aq. Menth. Virid. f. |j. — Fontan. f. ^iv. Potassae Nitrat. 3j. Syrup. Rosae, f. 3'j- M. ft. Mistura. * 3. Take Camphor, four grains. Antimonial Powder, two grains and a half. Confection of Roses, a sufficiency to form the whole into a small bolus. t 4. Take Lemon Juice, one ounce and a half. Subcarbonate of Ammonia, half a drachm, or a sufficiency to satu- rate the acid, then add Mint Water, one ounce. Pure Water, four ounces. Nitrate of Potass, one drachm. Syrup of Roses, two drachms. Mix them. 118 PYREXIAE, OR FEBRILE DISEASES. ClttSS L If phrenitis arises in consequence of some suppressed evacuation or eruption, we muv endeavour to restore it by the proper means, which will be understood from the nature of the former discharge. During the whole course of ihe disease the patient ought to be kept cool, and as quiet and undisturbed as possible, excluding light from him; and his food should be mild and nourishing, consisting of preparations of barley, sago, gruel, Sic. Cold acidulated liquors should be allowed with freedom. In idiopathic phrenitis, every part of the antiphlogistic regimen will be necessary. OPHTHALMIA, ok INFLAMMATION of the EYE. Ophthalmia is of two kinds, viz. the idiopathic and sympto- matic ; the latter proceeding either from diseases of the eye, or parts in its neighbourhood, or from diseases of the system ; and the former from the causes assigned below. In ophthalmia, the inflammation is seated either in the mem- branes of the eye, its deep-seated parts, muscles, and the lachrymal gland, or in the sebaceous glands placed in the edges of the eyelids: but sometimes all these parts are affected in consequence of sympa- thy; and indeed it rarely happens that any of these suffer in a con- siderable degree without the inflammation extending further. It readily spreads along the conjunctiva, from the tarsi to the eye, or in the contrary direction. When the conjunctiva is much inflamed, the adnata soon partakes of the inflammation ; and if the complaint increases, it gradually spreads to the deep-seated parts. With some people there is a great tendency to a recurrence of the disease; and in many cases it has been observed to renew its attacks!, or to have regular exacerbations at a particular time of the day. The causes producing ophthalmia are, external injuries, such as blows, contusions, and wounds on the eyes; extraneous bodies, of an irritating nature, introduced under the eyelids; exposure to bleak winds and cold; little inflammatory tumors called styesj1 which rise on the eyelids; various acrid fumes acting as chemical stimuli, such as the smoke of pit coal, that of wood, turf, he.; too free a use of vinous and spirituous liquors, the suppression of ac- customed discharges, the long application of a strong light, or fixed attention to minute objects, and an acrimony prevailing in the mass of blood. To these causes we may, perhaps, add with some propriety the bare inspection of the eyes of a person when in an highly inflamed state; for although practical writers have not enumerated this among the causes of ophthalmia, yet I have occa* sionally met with cases which appeared to arise from this, as pre- vious to inspecting the diseased eyes the person made not the least complaint, but very soon afterwards complained of uneasiness in his own. The occurrence once happened indeed to myself, and the inflammation that ensued was very violent. Ophthalmia is sometimes symptomatic of other diseases, such as measles, small- pox, scurvy, scrofula, and syphilis. Order II. ophthalmia. 119 A very obstinate and dangerous species of ophthalmia of the purulent nature is now and then produced by the accidental applica- tion of gonorrheal matter to the eye, or eyes. A distressing case of this nature, wherein the patient, a very stout man, was for ever totally deprived of sight by imprudently washing his eyes with his urine, whilst labouring under gonorrhoea, lately came under my observation. Mons. Sonnini, in his Travels through Egypt, mentions, that ophthalmia is a complaint which is endemial in that country, and that eyes perfectly sound, or which are not swelled, are rarely to be seen. This he attributes to the excessive heat, the air being impregnated with noxious particles, and the acrid and burning dust which the winds scatter in the atmosphere. Another cause of the cecity so general at Cairo, he says, is the frequent watering of the streets and houses. Water, thrown abundantly and frequently upon a burning soil, containing a great many saline particles, produces, he observes, acrid vapours, which may be considered as one of the principal causes of blindness in Egypt. Sir Robert Wilson mentions* that the Egyptian ophthalmia is supposed to originate in the nitrous particles emitted from the ground by the force of the sun, which are of a quality so pungent and penetrating as to injure the fine vessels of the eye. The acrid and bur.iing dust flying continually in the atmosphere, irritates still more the already affected part; while the reflection of the soil, the heat of the air, and vivid light of the sky, tend to weaken the sight, at last occasioning excessive inflammation. According to the best information which we have received, this species of ophthalmia arises in the first instance soon after the over- flowing of the Nile, or rather on its recession, when a vast quantity of slimy mud is deposited on its banks and other places which were overflowed, and which being acted upon by a powerful sun, send forth miasma, or effluvia that excite inflammation in the eyes of this peculiar nature. The custom in Egypt of sleeping in the open air, possibly may increase the power of the cause. Ophthalmia has not been considered in Great Britain as a con- tagious disease, although it has often been known to appear as a prevailing epidemic at different times; but it is an undoubted fact, that the Egyptian species is highly contagious. During the cam- paign in Egypt our troops were dreadfully afflicted with it, and many returned with a total loss of sight; whilst others, still labouring under the disease, propagated it at Malta and Gibraltar, where they first landed; and from which places it was at length brought into this country. It seems to be established, I think, on the most indisputable evidence, that the Egyptian ophthalmia may be propagated by contagion, and that in this way it has been introduced into our united kingdom, and has spread in the same manner as in its * See bis History of the Expedition to> Egypt. no PYREXIAE, OR FEBRILE DISEASES. Class I. native soil. The influence of climate, and other local circumstance^ on the general character and progress of the disease, cannot, how- ever, be denied. In most of the instances in which this species of ophthalmia has prevailed in this country, it has appeared with mitigated symptoms, in comparison with the disorder as it occurs in Egypt; but it has nevertheless been observed, that where the patients were exposed to the influence of a marshy soil, it equalled in the severity of its symptoms the Egyptian ophthalmia. A modern writer* assures us, that its spreading is not owing to contagion in the ordinary sense of the word (that is, to any infectious matter thrown off from the system of those labouring under the disease^ and operating at a greater or less distance from its source), but to the actual conveyance of the purulent matter from the inflamed organ to the eye of a person in health. Dr. Edmonston has also pointed outf, that the sphere of action of this contagion is very limited, and that most of the cases which came under his observation arose from the direct application of virus from diseased to sound eyes. It has been indeed ascertained as a fact, that many soldiers, with the hope and view of obtaining a discharge from their regiments, absolutely inoculated their eyes with the contagious matter, therej^y inducing a loss of sight in one or both. Mr. Ware is of opinionj, that the disease which has appeared as a prevailing epidemic among soldiers since the return of our troops from Egypt, ought to be denominated the purulent ophthalmia in- stead of the Egyptian ; since one of its chief symptoms, and that which distinguishes it from any other, is the profuse discharge of a purulent coloured fluid, closely resembling the pus or matter that issues from an ulcerated surface. He also thinks that it great& resembles, in many respects, a disorder, which he has described with minuteness in his Observations relative to the Eye (see vol. i. p. 129 and 309j, under the title of the Purulent Eye of new-born Children, and in which, no less than in that under consideration, the discharge of matter is always profuse. The common ophthalmia usually comes on with a sensation as if some gritty particles had insinuated themselves under the eye-lids, accompanied with great heat, redness, and pricking, darting pains. As it increases, the parts swell, and the vessels of the eye become not only increased in size, and turgid, but appear more numerous than in the natural state. Great pain is excited upon the least motion of the ball of the eye ; the patient cannot bear the light, and an affusion of tears from the lachrymal gland ensues, which is of so acrid a nature as to excoriate every part on which it happens to fall. When the inflammation runs high, a slight febrile disp'o- * See an Account of the Ophthalmia which has appeared iu England since the return of the British Army, by J. Veiich, M. D. f See Edmonston's Account of an Ophthalmia which appeared in the 2d Regiment of Argylesliire Fencihles in 1802, with Observations ou Egyptian Ophthalmia. } See his Remarks on Purulent Opbthauoy. Order II. ophthalmia. 121 Bition often attends. These appearances, after some days' con- tinuance, gradually abate, and at length entirely cease ; but in some cases, a discharge of thick glutinous matter ensues, which collects in considerable quantities about the angles of the eye, par- ticularly during sleep. W7here only one eye has been affected, it is often succeeded by an inflammation of the other, particularly in a scrofulous habit. In the Egyptian ophthalmia, the symptoms which present them- selves are somewhat different from those of common ophthalmia. In the early stage of the former, the conjunctiva is red, swelled, and turgid ; the secretion of tears is copious, the patient complains of excessive pain, and roughness of the ball of his eye, and he cannot bear even a feeble light. The eyelids are red at their edges, and swelled, and there is often a sense of weight and scalding of the eye. Sometimes there is a soreness of the inte- guments of* the forehead and temples, with rigors, a quick hard pulse, headach, and other febrile symptoms. In a very short time, cedematous swelling and tension of the eyelids, and pro- digious tumefaction and turgescence of the conjunctiva, with a feeling as if the eye was to burst out of the head, succeed to the other symptoms. The least ray of light falling ons the retina gives acute pain, and excites in the patient the feeling as if some sharp instrument was thrust into his eye. In some cases the under eyelids are turned somewhat outwards j in others both eyelids are closed and swollen, and the skin of these parts has an efflorescent shining appearance. It is not unusual to see the eyelids open, and the conjunctiva so swelled and turgid as to protrude from the eye in the form of two or three folds. When the tumefaction of the conjunctiva is not very great, and the eye can be brought fully info view, the cornea sometimes appears pel- lucid, (he pupil is contracted, and the iris discoloured, or as it were full of spots. As the inflammation proceeds, a secretion of purulent-like mat- ter takes place from the surface of the conjunctiva and glands of the tarsi. This matter is pent up for some time within" the eyelids in those cases in which the tarsi come in contact; but in others, where they remain separated, it flows from the eye mixed with tears. It is so acrid as to irritate the eye exceedingly, and to \ excoriate the palpebral and cheeks in passing over them. In this stage of the disease the sufferings of the patient are excessive. He is hot and feverish, cannot remain long in one posture or situation, gets no sleep either by night or day, and describes his feelings, as if boiling water was poured into his eyes. If a sight of the ball of the eye can now be obtained, it is found bathed with the purulent matter ; the cornea is muddy in a part or the whole of its extent, or its surface is studded with small white spots. These appearances denote the commencement of a suppuration of the cornea. Sometimes the whole of the cornea is included in the suppuration, and destroyed, the iris is laid bare, 122 PYREXIA, OR FEBRILE DISEASES. ClaSS I the lens and vitreous humour are forced on the iris, or entirely evacuated, and even the form of the eye does not remain. At other times only a portion of the cornea suppurates, and the sight is more or less affected afterwards, according to the point at which the suppuration has taken place, and the extent to which it has gone. If the abscess be situated before the pupil, and if it pene- trate the whole depth of the cornea, the aqueous humour, in escaping, will carry with it a portion of the iris through the aperture in the cornea; and the pupil will be in general totally obliterated by the protrusion of the iris, and its subsequent adhesion to the sides of the ruptured cornea. During some violent paroxysm of pain, from the excessive in- creased volume of the whole compages of the eye, locked within the orbit, the coats of the eye at length give way. By this cir- cumstance, the tension in the parts is considerably diminished, the inflammation gradually subsides, and the state of the# eye begins to improve, unless in the melancholy instances in which the iris Continues to protrude. Such is the most violent form of the disease ; but even in slighter cases, where no rupture of the cornea takes place, on the discharge of pus ceasing, a number of granulations are sometimes perceived; to arise, on an inspection of the eye, from the interior of the eye- lids, and to present a shocking spectacle. With some, the Egyptian ophthalmia lasts only nine or ten days ; in others, the patients have suffered for months : and un- fortunately there is no security, we are informed, against a new attack, even after a perfect recovery. The common ophthalmia, when slight, and not symptomatic of any other disease, will readily give way to proper means ; but if it is very violent, or has continued for any length of time, it is apt to occasion specks, or to terminate in a dimness of sight or opacity of the crystalline lens. In some cases, the inflammation ter- minates in suppuration of the cornea and deep-seated parts. When it arises in a scrofulous habit, or is symptomatic of syphilis, the cure is often tedious. In the treatment of ophthalmia, its varieties of idiopathic and symptomatic, and of acute and chronic, ought duly to be con- sidered, and to form the basis of our practice. Our object there- fore should be, to determine with precision, how far each parti- cular case is to be referred to one or other of these kinds, and to adopt our plan accordingly. Those^who are engaged in an extensive practice, now and then meet with cases of idiopathic and acute ophthalmia, accompanied not only with a high degree of organic inflammation, but likewise with much systematic derangement, such as thirst, great heat of the body, fulness and frequency of the pulse, severe pains in the heat', and violent throbbing* of the temporal arteries. Such instances are, however, rare; but when they do occur, general bleeding or venesection ought not to be neglected ; and we should Order II. OPHTHALMIA. 123 take care to proportion the quantity we draw off to the existing circumstances, and quickly to repeat it, if necessary. In patients afflicted with violent ophthalmia, it will always be best to bleed from a large orifice as they stand erect upon their feet, as it sooner makes an obvious and great impression upon the circulation than in any other way, and thereby enables us to attain our object by a moderate abstraction of blood : the tunica adnata, which before venesection in this way had been intensely red, will often be found comparatively whitened after it, with a most sensible relief in almost every other respect. In the worst cases, the blood may be drawn from the jugular vein or temporal artery, in preference to taking it from the arm. In general, however, ophthalmia is only a local affection, accom- panied with little or no fever, except what is excited by the irrita- tion or pain in the organ, and this but trifling; and therefore it will not often be necessary to resort to general bleeding: the pre- ferable way will be to draw blood from the neighbourhood of the affected part, by applying several leeches round the eye ; which process we may repeat again and again, as long as the inflammation continues. They ought not, however, to be applied on the upper, but on the under lid. Where leeches cannot be procured, blood must be drawn from the temples by scarifying and cupping. If the inflammation runs high, so as to endanger vision, by pro- ducing an opacity, it will be advisable to make scarifications daily, with the edge of a lancet, on the turgid vessels of the adnata itself; which, if done by a steady hand, will be attended with no kind of danger, but, on the contrary, with infinite advantage. Its effects in diminishing inflammation are very great, even though no more than a few drops of blood be obtained, and the relief is frequently so considerable as to induce patients after once undergoing the ope- ration, to request its repetition. It is almost unnecessary to observe, that when ophthalmia has arisen from any extraneous body getting into the eye, as particles of sand, dust, lime, or metal, small flies, the hairs of the eyelids, he., the irritating cause ought immediately to be removed, and the part be defended from the light by the patient's wearing a deep shade of green silk, and sitting in a darkened room. Having adopted topical bleeding, we may then order some active purgative to be taken ; and this should be repeated every third or fourth day, as long as may be found necessary. A few grains of hydrargyri submurias, with a sufficient quantity of jalap, or a solution of any of the neutral salts, will best answer the intention. Where the complaint has arisen from exposure to cold, or other causes suppressing the perspiration, it is probable that the patient may receive benefit from small doses of some antimonial prepara- tion given so as to excite a proper diaphoresis.—(See Synochus.) The pediluvium may also be employed with the same intention. It was a common practice of the late Mr. Saunders, who was 124 PYREXIA, OR FEBRILE DISEASES. ClaSS I esteemed a very eminent oculist, to employ emetics, particularly a solution of tarrarized antimony, in the early stage of every variety of acute ophthalmia, so as to produce nausea or full vomiting, and the same practice has been adopted by Sir William Adams with the greatest success, especially in that species of it which has been denominated the Egyptian. To abate the inflammation and irritation, it is customary to have recourse to the frequent application of some cooling and astringent wash. Such remedies applied to the eye by means of an eye-cup, or by wet pledgets, prove, beyond a doubt, highly serviceable. Any of the undermentioned* may be used. Where the pain is very acute, forty or fifty drops of the vinous tincture of opium may be added to any of the foregoing applications, or the eyes may be bathed frequently with a decoction of bruised poppy-heads. In such cases, an internal use of opium will also be advisable; and it may therefore be taken in doses of a quarter of a grain, repeated every four or six hours. For the purpose of appeasing heat and inflammation in the eyes, some practitioners prefer warm collyiiums to cold ones ; and among this number, I think, is Mr. Ware. The fact is, that inflammation of the eyes sometimes yields to cold applications, and at. others, it resists them. In instances of the latter nature, the application of warm fomentations may be used. The alternate use of cold and hot applications has sometimes succeeded when neither of them singly appeared capable of putting an end to the diseased action. In inveterate cases of ophthalmia, where inflammation prevails in a high degree, it probably might be advantageous to drop into the eye a strong infusion of digitalis, or the extract of belladonna dissolved in water. The former, I understand, is much employed * 1. ft Zinc. Sulphat. Plumbi Superacet. aa gr. viij. Aq. Distillat. f. ^vj. M. ft. Collyrium. Vel, 2. ft Liquor Ammon. Acetatis, Aqua? Rosas, singul. f. ?ij. Misturae Camph. f. §j. M. Vel, 3. ft Alumnis Purif. 3ss. Aq. Rosae, f. |vj. Vel, 4. ft Aq. Rosae, f. §iij. Liquor Plumbi Subacetat.fll. xij. M Vel, 5. ft Zinc. Sulph. gr. x. Aq. Rosae, Mistur. Camphor, aa f. ?iij. M. * 1. Take Sulphate of Zinc, Superacetate of Lead, of each eight grains. Distilled Water, six ounces. Mix them for a Wash for the Eyes. Or, 2. Take Solution of Acetate of Ammonfc, Rose Water, of each two ounces. Camphor Mixture, one ounee. Mix them. Or, 3. Take Alum, half a drachm. Rose Water, six ounces. Mix them. Or, 4. Take Rose Water, three •unces. Solution of Subacetate of Lead, eighteen drops. Mix them. Or, 5. Take Sulphate of Zinc, ten grains, Rose Water, Camphorated Mixture, of each three ounces. Mix them. Order It ophthalmia. 125 by an eminent veterinary surgeon for the purpose of subduing violent inflammation in the eyes of horses, and with a very good effect. When ophthalmia is found not to yield to bleeding, both general and topical, duly repeated, purgatives, emetics, fomentations, and the other means which have been pointed out, it will be proper to put a blister at the back of the neck, or behind the ear on the side with the eye which is affected, supposing only one to be diseased ; and to promote a proper discharge, it ought to be dressed with some stimulating ointment*. In those cases where the disorder appears to be constitutional, or to be kept up by any acrimonious humour in the habit, issues between the scapulae, or the insertion of a seton in the neck, will be advisable. Errhines have been recommended in instances of habitual oph- thalmia, and probably may sometimes prove good auxiliary reme- dies. The pulvis asari compositus may be used on the occasion. The pulvis digitalis will likewise excite a copious excretion from the membrane which lines the nostrils, although not generally known to possess such a power. In chronic and strumous ophthalmia, the vinous tincture of opium is one of the best applications we can employ, and was much used by Mr. Ware in such cases. It has been mentioned, that in ophthalmia the eyelids are apt to be glued together (particularly during sleep) by a thick glu- tinous matter which is secreted. To prevent this inconvenience, their edges should be anointed with a little soft ointmentf every night, or every night and morning. In the ophthalmia tarsi, arising from a scrofulous habit, the unguentum hydrargyri nitrico- oxydi mixed with an equal quantity of adeps praeparata to render it milder, is one of the most powerful remedies we can employ. Red precipitate mixed with lard is sometimes used, and it seems to be serviceable by destroying the small ulcers that now and then appear on the edges of the eyelids. About fifteen grains of it to an ounce of adeps praeparata seems to be the strongest proportion that can be used with safety. It will seldom be necessary to use poultices for an inflammation of the eye, except it is of the purulent * 6. ft Cerat. Resinae, §i- ----Lytta?, 3iij. M. ft. Unguentum. Vel, 7. ft Cerati Sabinae, ?i. t 8. ft Tutiae Praeparat. 3j- Unguent Cetacei, |j. M. Vel, 9. ft Unguent. Adipis Praeparat ?j. Zinc. Sulphat. 3ss. M. Vel, 10. Ceratum Plumbi Superacetaris. * 6. Take Resin Cerate, one ounce. Cerate of Spanish Fly, three drachms. Mix them into the form of an ointment. Or, 7. Take Savine Cerate, one ounce. 18. Take prepared Tutty, one drachm. Spermaceti Ointment, one ounce. Mix them. Or, 9. Take prepared Lard, one ounce. Sulphate of Zinc, half a drachm. Mix them. Or, 10. Take Cerate of Superacetate of Lea8 126 PYREXIiE, OR FEBRILE DISEASES. Class I kind, in which case we may apply with advantage one made by stirring a lump of alum in the whites of two eggs, until (hey form a coagulum, and this is to be laid to the eye between two pieces of thin linen or muslin. Cold poultices of rasped pota- toes and turnips are often used on such occasions. Mr. Ware is of opinion that the purulent is very similar to the gonorrhoeal ophthalmia. He found the purulent eye, we are told*, most commonly to occur in the children of those women who have had an acrimonious discharge from the vagina at the time of delivery; and the purulent ophthalmia of adults,1 he thinks, is very generally found connected with some gonor- rhoeal affection. In public schools be noticed the disease to spread obviously, in consequence of the indiscriminate use of basins and towels among the children. Hence, he believes that the puru- lent ophthalmia arises from the direct application of some poison- ous matter to the eyes. Two or three cases of purulent ophthalmia in infants, and evi- dently arising from their mothers being afflicted with leucorrhcea at fhe lime of delivery, have lately been under my care; and I am apt to think that the reason why more children are not affected in the like manner, is owing to the careful ablution they usually undergo immediately after birth, and before they are dressed. The disease is found to prevail mostly among the lower classes of society, who, we may naturally suppose, are not so attentive to cleanliness as those in a higher sphere of life. Mr. Gibson, of Manchester, seems to have been the first to attri- bute this disease in new-born infants to the cause just assigned ; and he thinks it highly probable, from the frequent coincidence of fluor albus in the mother, and the puriform ophthalmia in the child, that these disorders «tand in the relation of cause and effect to each other : but, at the same time, he bj' no means wishes it to be under- stood, as supposing leucorrhoea to be the only cause of a puriform discharge from the eyes of an infant. In some cases, it possibly may arise from exposure to cold, or from a peculiar constitution of the atmosphere. Mr. Ware appears to have described and treated one of the symp- toms of purulent ophthalmia as if constituting it, and seems to have overlooked the relation between the inflammation and the dis- charge, of cause and effect. He states the first stage of the disease to be an increased discharge from the minute pores of the conjunc« tiva; and attributes the subsequent affection of the cornea to the eroding quality of the retained matter, joined to the pressure of the swollen eyelids. In conformity to this hypothesis, he thinks the indication of cure consists in immediately constringing the re- laxed vessels by strong styptic injections. The late Mr. Saundersf has stated the disease to consist in an inflammation of the conjunc- * See his Remarks on the purulent Ophthalmia. } See his Treatise on some Practical Points relating to the Diseases of the Eye. Order II. ophthalmia. 127 tiva, which is affected much in the same way as the membrane of the urethra in gonorrhoea: he therefore advises that a strict anti- phlogistic plan should precede the use of injections, and that when the activity of the inflammation has subsided, the injections should be of a mild nature. If ophthalmia is dependent on a venereal taint, mercury is the remedy we must rely on to remove it. When it arises in a scrofu- lous habit, affecting chiefly the tarsi, and is attended with ulcera- tions, as is often the case, cinchona bark, with alteratives, mineral waters, and sea-bathing, will be the most proper remedies. In these cases, hemlock, combined with cinchona bark, has sometimes proved serviceable. Cinchona, with the subcarbonate of soda, may also have a good effect. At the same time that we are employing these remedies, we ought not to neglect topical applications. The edges of the eyelids may be smeared every morning and night with a little ointment* composed of mercury or the sulphate of zinc. When a speck has ensued in consequence of previous inflamma- tion, which has destroyed some part of the transparency of the cor- nea, it may be touched with some gentle escharotic on the point of a fine camel's hair pencil twice a day. In employing escharotics for the removal of opacities of the cornea, much care and attention will, however, be requisite, otherwise they may prove more injurious than serviceable. That species of opacity which is seated on the external surface of the cornea, and accompanied with some growth, may sometimes be removed by the knife in a steady hand, or by dividing the blood- vessels going to it, but not always, as it is sometimes so much diffu- sed as to render the operation impracticable. A case of opacity, which arose from a local injury, and which extended nearly over the whole lucid cornea, lately fell under my observation, and was entirely removed by having a few drops of the liquor cupri ammo- niati admitted into the eye every day. In opacities of the cornea, the application of animal gall to the part has been found to be efficacious, when other remedies have failed. Being a stimulant, it ought never to be applied while the inflammatory action is increasing, but should not be delayed one minute after the inflammation is at a stand, as an indolent un- healthy state is apt to take place, which too often terminates in opacities, that no applications can afterwards remove. It may either be used pure, or diluted; perhaps the latter may be most * 11. ft Unguent. Hydrarg. Nitratis, Adipis Praeparata?, aa ?ss. M. ft, Unguentum. Vel, * 11. Take Ointment of the Nitrate of Mercury, Prepared Lard, of each half an ounce. Mix them. Or, 12. ft Zinci Sulphat. 3j. i 12. Take Sulphate of Zinc, one scruple. Adipis Praparat. Zj. M. J Prepared Lard, Qjie ounce. ! Mix them. 128 PYREXIAE, OR FEBRILE DISEASES. ClaSS I advisable at first, as it is apt to occasion a painful sensation; but this, however, soon goes off. Its effects seem to be similar to those of a weak solution of the argenti nitras. We are informed by Mr. Ware*, that he has had occasion to at- tend a considerable number of cases, in which an opacity of the crystalline humour was produced by some violence done to the eye; and in most of these, the opacity was dissipated, and the sight restored, during the external application of aether. He says, "In using this remedy, I have sometimes diluted it with a third or fourth of a weak solution of hydrargyri oxymurias; but m general, I have used the aether alone, which has been applied by means of a camel's hair pencil to the eye itself. The application of the remedy occasions a very pungent pain in the eye, with consi- derable redness in the tunica conjunctiva; but these go off in a few minutes, and leave the eye as easy, and the conjunctiva as pale, as they were before the aether was used." In all cases of ophthalmia it will be requisite to avoid every thing which might occasion irritation; for which reason the patient ought to be confined to a dark chamber, or, at least, he should wear a blind of green silk over the eye, to prevent a great glare of light; and he ought likewise to abstain from reading, writing, and from all food of a heating or stimulating nature, and a use of vinous or spirituous liquors. In severe cases the diet should be very spare and light, and the drink consist chiefly of some mild farinaceous decoction, which, while it allays thirst and supplies sufficient nourishment, tends both to moderate excitement and promote perspiration. After the removal of ophthalmia, it may sometimes be necessary to employ means to prevent its return, by continuing the use of blisters behind the ears, or the insertion of an issue. In some in- stances, however, it may be connected with a debilitated habit, and then the best means of preventing its return are those which tend to strengthen the vessels of the eye, or the system in general; and these will sometimes remove habitual ophthalmia when all others have failed. One of the most powerful of these means is the cold bath, which may be employed either by immersing the whole body, or by washing the head in cold water once or twice a day. The application of cold water to the eyes themselves, or of any astringent collyriura, by means of an eye-cup, twice or thrice a day, may likewise be service- able in preventing the return of ophthalmia, or removing it after it has become habitual. Cinchona, and other tonics, have also been resorted to with a good effect. In that species of the disease which has been denominated the Egyptian ophthalmia, a favourable termination will uniformly depend on our being able to moderate the inflammatory affection * See his second edition of Observations on the Cataract, &c. Order II. ophthalmia. 129- during its first stage, and therefore the first and great object of the surgeon should be directed to this end ; for, if this is not effected, the structure of the visual organ will be destroyed, or be so altered as to impede or annihilate its functions. By a prompt application of proper means at the commencement, every bad symptom most likely will be arrested. Bleeding to the amount of sixteen or twenty ounces, or more, according to the urgency of the case, and the strength of the patient, is the first step to be adopted, and perhaps it may be preferable to draw off this quantity of blood from one or both of the temporal arteries, as one or both eyes may be affected, in preference to taking it from the arm ; and to pre- vent secondary hemorrhage it may be advisable to secure the divided artery by the tenaculum, as the pressure of a tight bandage round the temples will, in severe cases, add to the tumefaction of the palpebiae, and increase the pain and inflam- mation. Should the inflammation of the organ not be greatly moderated in six or eight hours after this bleeding, it will then be necessary to take away more blood in the same manner as before, again regulating the quantity according to (he severity of the complaint. If our attempts to subdue the inflammation still prove ineffectual at the expiration of eight hours more, and the symptoms seem to require it, the operation ought to be repeated a third time in sufficient quantity. We are told by Dr. Veitch*, that the principal remedy which has been productive of any good effect in the ophthalmia that has prevailed among the British soldiers since their return from Egypt, and to which the name of Egyptian ophthalmia has been applied, is bleeding; but, in order to insure its full power, that it has been found necessary to carry this evacuation to a great extent, and with a freedom far beyond what we have Been accustomed to recom- mend. In short, he informs us that he found it absolutely neces- sary to draw off upwards of twenty ounces at a time, or rather to bleed the patient ad deliquium animi, and to repeat the operation pretty frequently to this extent. Immediately after the first bleeding in the Egyptian ophthalmia, a large dose of purgative salts is to be administered, and this should be repeated every second or third morning. A large blister is to be applied at the same time either over the whole of the head, or behind the ears and to the nape of the neck. The patient is to be lodged in a dark but well-ventilated room, and to be confined to a spare and antiphlogistic diet. A tardiness in the use of evacuants, particularly a sparing use of the lancet, or its not being early resorted to, may be con- sidered, in most instances, as the chief cause of subsequent disorganization and destruction of the eye, in the various shapes of suppuration, ulceration, sloughing, and rupture of the cornea, * Sec his Treatise on the Egyptian Ophthalmia. 17 13(1 PYREXIAE, OR FEBRILE DISEASES. ClttSB 1. adhesions x»f the iris, opacities, &c. which are met with in cases of Egyptian ophthalmia; and even if these bad result! do not occur, such omissions will tend to form and protract an obstinate chronic stage, from the debility induced in the ves- sels of the membranes, owing to previous excessive action and distention. In this species of ophthalmia, as well as in severe cases of the common kind, it may be advisable to make frequent scari- fications on the ball of the eye; but perhaps it may be the better way to carry the lancet along the inside of the lower lid, parallel to its edge, and not far distant from it. Scarifi. cations made in this way will be far preferable to pricking the eyelid repeatedly in quick succession, as is sometimes practised. The issue of blood from the scarifications may be assisted by gently averting the lid with the end of the finger; and it will be more useful to take off the finger occasionally, and then to apply it again, and thus renew the eversion, than to continue the finger steadily on the lid. Whilst, by large and sudden evacuations of blood from the system, as well as from the affected eye, we lessen the violence of the disease, and prevent either an opacity of the crystalline lens, or a rupture of the cornea from ensuing ; we are, at the same time, to moderate the external symptoms, and lessen the secretion by local applications — linen cloths, dipped in some cooling lotion, (see those before prescribed) should therefore be kept constantly to the eye, or eyes, if both are affected, and such applications as experience seems to have accommo- dated to the different stages of the disease ought to be care- fully dropt into the eye. The best appear to be the liquor plumbi acetatis, properly diluted ; solutions of alum, or sulphate of zinc, or the camphorated collyriuin, prescribed below*, or before mentioned. When we consider, however, that the morbid mucus is confined between the swelled conjunctiva that lines the eyelids, and that part of it which covers the globe of the eye, it must be evident that in order to bring the matter effectually away, the lotion must be pro- pelled over the eye with some degree of force ; and this cannot be better effected than by the use of a small blunt-pointed syringe, by means of which the medicated liquor may be conveyed over the whole surface of the eye, and the retained matter be each time entirely cleared away. The injection ought to be repeated at ' 13. ft Cupri Sulphat. Bol. Armen. aa gr. viij. Camphorae, gr. ij. Misce, affundc. Aq. Bullientis, f. |viij. Cum totio sit frigida, effundatur liquor limpi- dus,etsa>pissime injiciatur paululum inter oculum et palpedras omni hora. 13. Take Sulphate of Copper, Armenian Bole, of each eight grains. Camphor, two grains. Boiling Water, eight ounces. When the liquor is cool, pour it off clear ,and let a little of it he injected between the eye and eyelids every hour. Order II. OPHTHALxMIA. 131 least once an hour during the height of the disease ; but when the violence of the inflammation has abated, and the quantity of the discharge is decreased, a longer period may be allowed to intervene between the times of applying it. In those cases where the pain of the eye and tumefaction of the conjunctiva are very considerable, it may be advisable not only to make the lotion of a weak standard, and to leave longer intervals between the times of employing it, but occasionally to interpose the injection of merely tepid water. Under the like circumstances, the frequent application of hot water also, or of a warm decoction of poppy heads, by means either of a flannel or of a large sponge, may likewise prove serviceable. During the inflammatory stage of the disease, and when the irritation is great, a warm poultice of bread and milk ma\ be applied to the eye, renewing it frequently through- out the day. Possibly it might be of service to shave the head and keep cloths wetted with vinegar to it, the forehead, and temples. The introduction of the vinous tincture of opium by a few drops at a time into the eye, will have a very good effect when employed in the early stage of the disease. In the intermittent form of ihis and the other species of ophthalmia, where the pain observes periodical paroxysms, pro- bably the administration of cinchona, during the intervals, may be attended with a very good effect. Such are the means to be adopted in the treatment of this variety of ophthalmia. It sometimes happens, however, that in 3pite of our utmost endeavours to subdue the inflammation, we cannot succeed, and that there is great danger of a rupture of the cornea taking place, and discoverable by the cornea losing its transparency, and a white ring forming round its circum- ference. In such cases it will be highly advisable to evacuate the aqueous humour, by making a puncture with a common lancet into the anterior chamber of the eye. This operation, it appears, has been performed in several instances with perfect safety, and the highest advantage, by Mr. Wardrop* of Edinburgh, under the like circumstances; and he thinks it probable that the great and immediate relief afforded by it arises chiefly from the sudden removal of tension. Mr. Waref coincides with Mr. Wardrop on the propriety of puncturing the cornea to evacuate the aqueous humour when a rupture of it is threatened; and be very' properly observes, that by suffering this to happen spontaneously, it may take place in such a part of it as afterwards to impede the passage of light, but that, when the opening is made by a surgeon, it may be done in such a place as to obviate any impediment of the kind. * See vol. iii. of the Edinburgh Journal, p. 56 * See his Remarks on Purulent Ophthalmia, ISg PYREXIAE, OR FEBRILE DISEASES. CUtSS I. We are informed by Mons Larry* that in order to be secure from ophthalmia in Egypt, it will be necessary to wash the eyes, and, indeed, the whole of the head, frequently with warm water and vinegar; to avoid the direct impressions of light and dust during the day; at night, to be covered from head to foot; to put a bandage over the eyes; to avoid, as much as possible, damp and marshy places; and to keep up the perspira- tion, and encourage moderate sweating by a use of the Egyptian baths and exercise during the fine season. It will also be necessary to avoid strong liquors, and heating and indigestible aliments, fortify- ing the stomach by tonics, such as the bitter infusions. OTITIS, on INFLAMMATION of the EAR. Inflammations of the ear are for the most part unaccompanied by pyrexia, although the sufferings of the patient are sometimes very great; but in some instances they are attended with fever, as- sume a formidable appearance, coma, delirium, and convulsions su- pervene, and even a fatal termination has been the consequence. Otitis is produced by the same causes with other inflammations, but by none more readily than a partial exposure to cold. In the treatment of this complaint we should proceed on the same principles as in that of ophthalmia. While it is merely a local affec- tion, local remedies alone are necessary, if we except cathartics, for the purpose of dislodging the contents of the primae via?. Local blood-letting, the application of a blister behind the ear, and of warmth, are the means chiefly to be relied on. If the pain does not abate, but, on the contrary, should continue to increase, we may expect a suppuration to ensue. This we may then encourage by the application of emollient poultices and warm vapour; and when the abscess bursts, or is opened, we may syringe the ear from time to time with some mucilaginous and gently astrin- gent decoction. When otitis is accompanied with universal pain diffused over the whole head, fever, delirium, or coma, the most powerful general means are to be combined with the local ones, as recommended in phrenitis. Suppuration is generally the consequence of these violent forms of the disease, and then the structure of the whole internal ear is often destroyed, the bones being discharged through the meatus auditorius with much purulent and fetid matter. In such cases, the sense of hearing in the ear affected is wholly lost of course. Fistulous ulcers of the internal ear are now and then the consequence of suppuration, and prove very troublesome. * See his Memoirs of Military Surgery. Order II. inflammatory sore throat. 133 Ear-ach sometimes continues many days without any apparent inflammation, and is then frequently removed by filling the ear with cotton or. wool, wetted with tincture of opium or aether, or even with warm oil, or warm water. Sometimes a pain in the ear is the consequence of association with a diseased tooth, in which case the aether should be applied to the cheek over the suspected tooth, or a grain of opium, with a little camphor, be applied to the tooth itself. CYNANCHE TONSILLARIS, or INFLAMMATORY SORE THROAT. i In this complaint the inflammation principally occupies the glands, such as the tonsils ; but it often extends through the whole mucous membrane of the fauces, so as essentially to in- terrupt the speech, respiration, and deglutition of the patient. It is readily to be distinguished from cynanche maligna by the strength of the pulse, the greater difficulty of deglutition, the absence of ulcers in the throat, and the accompanying fever being synocha. The causes which usually give rise to it are, exposure to cold, either from sudden vicissitudes of weather, from being placed in a partial current of air, wearing damp linen, sifting in wet rooms, or getting wet in the feet, or coming out of a heated and crowded room suddenly into the open and cool air; all of which may give a sudden check to perspiration. It may also be occasioned by violent exertions of the voice, blowing wind instruments, acrid substances irritating the fauces, and by the suppression of accustomed evacuations. It principally attacks the youthful, and those of a full and plethoric habit, and is chiefly confined to cold climates, occurring usually in the spring and autumn ; whereas the cynanche maligna chiefly attacks those of a weak irritable habit, and is most prevalent in warm cli- mates. The former differs from the latter likewise in not being contagious. In many people there seems to be a particular tendency to this disease, as from every considerable application of cold it is readily induced. An inflammatory sore throat discovers itself by a difficulty of swallowing and breathing, accompanied by a redness and tumor in one or both tonsils, dryness of the throat, foulness of the tongue, lancinating pains in the parts affected, hoarseness of the voice, a frequent but difficult excretion of mucus, and some small degree of fever. As the disease advances, the dif- ficulty of swallowing and breathing becomes greater, the speech is very indistinct, the dryness of the throat and the thirst increase, the tongue swells and is encrusted with a dark fur, and the pulse is full, hard, and frequent, beating from 100 to 140 in a minute. In a few cases, small white sloughy spots are to be observed on the 184 PYREXIA, OR FEBRILE DISEASES. ClaSS I tonsils, and in very violent ones there is complete deafness. When the symptoms of cynanche are considerable, the whole face par- takes of it, the eyes are inflamed, and the cheeks florid and swelled, respiration is performed with difficulty, and the patient is obliged to be supported in nearly an erect posture to prevent suffocation. Even delirium and coma sometimes supervene. If the inflamma- tion proceeds to such a height as to put a total stop to respiration, the face will become livid, the pulse will sink, and the patient will quickly be destroyed. The chief danger arising from this species of quinsey is, the in- flammation occupying both tonsils, and proceeding to such a degree as to prevent a sufficient quantity of nourishment for the support of nature from being taken, or its wholly impeding respiration; but this seldom happens, and its usual termination is either in reso- lufion or suppuration. When proper steps are adopted early, if will in general readily go off by the former. Cynanche tonsillaris rarely terminates either in gangrene or scirrhus. Little fever, free respiration, deglutition not much impeded, the inflammation being of a vivid red colour, universal but gentle diaphoresis, and a copious ptyalism or moderate diarrhoea coming on about the fifth day, are to be regarded as symptoms which de- note a termination of the disease in resolution. When suppuration is likely to ensue, the parts affected become more pale and less painful, a sense of pulsation is felt in them, and there are slight rigors. The suppuration sometimes takes place at the lower part of the tonsils, and then the matter is discharged into the oesophagus, and passes into the stomach, and it is only known to have happened by the immediate relief which the patient expe- riences. Sometimes, however, it is brought up, and discharged. by the mouth, being of a very clotted appearance, often mixed wiuV blood, of a nauseating bitter taste, and fetid smell. The relief experienced by the discharge is often very remarkable from its suddenness ; for the person who a few minutes before was not able to swallow the smallest quantity of any thing, and who breathed with great difficulty, now feels perfect ease, and is able to eat and dnnk heartily. Sometimes, however, the disease does not terminate by a proper suppuration, but in several small abscesses, which produce trifling superficial ulcers, being of a white or grey colour, similar to aphtha?; whereas those in cynanche maligna are of a dark brown, or black colour. If gangrene is to take place, the parts affected lose their red and shining colour, and from being tense and tumid, they become flaccid, brown, and livid ; the pulse, from being strong, becomes small, weak, and irregular; the face assumes a cadaverous appearance ; cold clammy sweats break out; the extremities are cold ; eoma, and symptoms of debility, make their appearance, and destroy the patient. Where cynanche tonsillaris has proved fatal by suffocation little more than a highly inflamed state of the parts affected, with'some morbid phenomena in the head, have been observed on dissection. Order II. inflammatory sore throat; 135 In the treatment of this complaint, our first and chief endeavour should be to carry off the inflammation ; for which reason an anti- phlogistic plan must be pursued. If the inflammatory symptoms run high, the pulse be quick and hard, and the breathing some- what difficult, twelve or fourteen ounces of blood (supposing the patient to be an adult) ought to be drawn from the jugular vein, in preference to the arm; but if they do not, it will be sufficient to draw blood by the application of several leeches under the ears, particularly on the side most affected. Drawing blood from the tonsils by internal scarifications, is likewise a powerful remedy in this species of quinsey, and when employed with freedom on its first appearance, will greatly tend to abate the inflammation, and pre- vent a suppuration from ensuing. At the commencement of cynanche tonsillaris, and before the febrile symptoms are any way violent, the timely exhibition of aa emetic often proves extremely useful, and now and then checks its complete formation. To assist in removing the inflammatory diathesis, gentle evacua- tion from the intestines, by means of laxative medicines, should be advised occasionally. Saline cathartics, such as the potassae tartras, sodae sulphas, or hydrargyri submurias with jalap, may be most proper. In those cases where the inflammation is considerable, the early application of a blister or cataplasm of mustard round the throat, or to the back of the neck, will most probably be attended with a good effect; but in slight cases it will be sufficient to have these parts rubbed twice or thrice a day with some stimulating embroca- tion, such as the linimentum camphorae vel ammoniae, putting a. piece of flannel round them afterwards. In this complaint it is found of service to wash the mouth and fauces frequently with mild, astringent gargles* somewhat acidu- * 1. ft Confect. Ros. Gallic. |j. Aq. Bullient, Oss. Acid. Sulphuric, f. 3j. M. ft. Gargarisma. Vel, 2. ft Decoct. Hordei, f. ?vj. Mel. Rosas, f. zj. Acid. Sulphuric. Dilut. 1T1. xxx. Vel, 3. ft Aluminis Puri, 3j- Decoct. Hordei Oss. MeUis Rosae, f. §j. M. Vel, 4, ft Infus. Rosae, f. ^vj. Tinct. Myrrh, f. ^ss. Mellis SodeBorac. 3jj. M M. * 1. Take Confection of the Red Rose, one ounce. Boiling Water, half a pint. Sulphuric Acid, one drachm. Mix them for a gargle. Or, 2. Take Barley Water, six ounces, Honey of Roses, one ounce. Diluted Sulphuric Acid, fifty-five drops. Mix them. Or, 3. Take Alum, on* drachm. Decoction of Barley, half a pint. Honey of Roses, one ounce. Mix them. Or, 4. Take Acidulated infusion of Roses, six ounces. Tincture of Myrrh, half an ounce. Honey of Borax, two drachms. Mix them 136 PYREXIAE, OR FEBRILE DISEASES. Class I lated, and likewise to scrape and cleanse the tongue from the fur which is apt to collect on it. Gargles composed of a few grains of the plumbi superacetas have sometimes proved highly serviceable in abating the inflammation, when other remedies have failed; but from the general prejudice against the use of this preparation in the form of gargle, lest any of it should happen to be swallowed, it is seldom prescribed. When white sloughy specks are observed on the tonsils, we may substitute the gargles advised in cynanche maligna for those men- tioned here. If a tendency to gangrene should appear, we should immediately have recourse to those of an antiseptic nature, the best of which are composed of cinchona bark, myrrh, and Port wine, or of capsicum and vinegar.—See Cynanche Maligna. Gargling is the best means of washing the internal fauces; but its motion is sometimes so painful or irksome, as to prevent the patient from having recourse to it. In such cases, the medicine may be thrown into the fauces by means of a syringe. Frequently inhaling the vapour arising from warm water mixed with a little vinegar throughout the course of the day, will greatly assist the effect* of gargles; and where Mudge's inhaler cannot be procured for the purpose, we must be content to substitute a basin with an inverted funnel over it. When a febrile disposition prevails, it will be proper to employ diaphoretic medicines with the view of determining to the surface of the body. Any of those advised under the head of Simple Con- tinued Fever may be used; and to increase their effect, the patient should take frequent small draughts of whey, barley-water, or any other diluting liquor. Neutral salts, as recommended under the same head, will likewise be proper medicines, and therefore the saline mixture combined with tartarized antimony will answer the purpose. Where the symptoms run high, the patient ought to be confined to bed. Probably a pediluvium in the evening might have a good effect. If our endeavours to resolve the inflammation have proved fruit- less, and it seems likely to terminate in a suppuration, we ought then to hasten it by the frequent application of warm fomentations and emollient poultices to the throat, and by directing the patient to receive the vapour arising from warm milk and water into the fauces several times a day, in the manner before recommended. Warm gargles composed of a decoction of figs and barley-water may also be employed, and the best way of using them will be to permit as large a quantity as can conveniently be retained to lie on the part till it cools to the temperature of the mouth. When the matter is formed, if the tumor do not break readily, a lancet may be applied to it. During this stage of the disease, the passages to the stomach and lungs are sometimes so closed by the size and pressure of the tumor, as to endanger the life of the patient, either by suffocatioB, Order II. MUMP9. 137 or the want of nourishment. In the first case, recourse should be had in proper time to the operation of bronchotomy, in order to keep up respiration ; and in the last, the strength must be supported bv nutritive and mucilaginous clysters, consisting of animal broths, thick gruel, arrow-root, barley-water, or a solution of starch, which should be thrown up the intestines in a small quantity each time, as they will thereby be absorbed the more readily, and will not be so apt to pass off again, without affording any benefit. Before we resort, however, to bronchotomy, it may be worthy of a trial to endeavour to break the tumor, either by exciting vomiting, or by making the patient receive through an inhaler the steams arising from warm water, to which a sufficient quantity of sther has been added. The stimulus will prove so great as to succeed in many cases, particularly where the suppuration is nearly completed. In cynanche tonsillaris every part of the antiphlogistic regimen is necessary, and should be more or less strictly enjoined according to the degree of general excitement. Even where this is not very Considerable, all kinds of animal food and fermented liquors must be avoided, and the diet should be light and diluent, consisting of mild vegetable matters, such as roasted apples, boiled turnips, and subacid fruits. Any fresh exposure to cold, even in the slightest cases, ought carefully to be avoided, otherwise the disease may be lengthened out to a great degree, and perhaps terminate in pneu- monia. The tonsils sometimes become affected with permanent swelling and induration in consequence of an attack of cynanche, giving a good deal of uneasiness to the patient. In some cases the complaint will yield to astringents; but when it does not, and impedes his respiration or deglutition, there can be no impropriety in removing the diseased parts by a piece of wire with a noose at the end of it, or even by a pair of scissars. CYNANCHE PAROTIDiEA, or the MUMPS. This disease chiefly affects children, but particularly among the lower class of people; is often epidemic, and manifestly contagious. It is distinguished by an external moveable swelling that arises most commonly on both sides of the neck, but in some instances it is confined to one. These tumors occupy the maxillary and pa- rotid glands; are large, hard, and somewhat painful; and some- times they attain to such a considerable size, as greatly to impede the powers of respiration and deglutition, giving rise thereby to pyrexia. The swelling usually continues to increase till the fourth day; but from that period it declines, and in a feu days more goes off entirely, and then the febrile disposition likewise ceases. As the swelling of the fauces subsides, it not unfrequently happens that some tumors affect the testicles in the male sex, or the breasts in the female, but these generally go away in a few days. Some- 18 138 PYREXIA, OR FEBRILE DISEASES. ClaSS I times the tumor in the fauces becomes suddenly suppressed, and is not accompanied with the last-mentioned symptom ; or if so, this is quickly repressed; in which ease the fever becomes very consider- able, is attended with delirium, and at length proves fatal. In a few instances where the swelling has been very great, suppuration has taken place in the cellular membrane, and occasioned prodigious deformity; or by bursting inwardly, and discharging its contents into the larynx, has suffocated the patient. There is, however, seldom much danger from this disease, except when symptoms of congestion in the brain or its membranes arise. The mumps do not often require the assistance of medicine; and all that is in general requisite, is to keep the head and face warm, to avoid taking cold, and to open the bowels by the mildest cooling laxatives: but should the tumor in the neck suddenly disappear, and the febrile symptoms increase, so as to induce an apprehension that the brain will be affected, it will be advisable to promote and reproduce the swelling by warm fomentations and stimulating lini- ments*; and to obviate the fatal consequences that might ensue from its suddenly receding, by means of venesection, nauseating doses of emetic medicinesf, cathartics, and blisters, according to the violence of the disease. When the testicles become affected and are much swelled, every endeavour should be exerted to prevent suppuration from ensuing, and we are therefore to have recourse to bleeding, both general and topical, cathartics, cooling and discutient applications, and a suspensory bag. Much the same means are to be adopted when, on a retrocession of the tumor in the neck, the female breast be- comes indurated and swelled. _^_----------------------------- * 1. R Liniment. Ammoniae Fort. f. ?J. Vel, 2. 1$. Spirit. Camphorae, f. ?J. Liquor. Ammonias Subcarbonat. f.3ij Tinct. Lyttae, f. 3ss. M, ft. Linimentnm. t 3. R Potassse Nitrat. 3j. Antim. Tartarisat. gr. iss. M. ctin chartulasvj. divid.quarum,unam sumat 4tis horis. Vel, 4. IJ Haust. Salin. f. |jss. Vini Antimon. ITT. x.—xx. Syrup. Cort. Aurant. 3j- it Haustus 3tia quaque hora capieq/Ius. 1. Take Strong Liniment of Ammonia, one ounce. Or, 2. Take Camphorated Spirit, one ounce. Solution of Subcarbonate of Am- monia, two drachms. Tincture of Spanish Fly, half a drachm. Mix them for a Liniment t 3. Take Nitrate of Potass, one drachm, Tartarized Antimony, one grain and a half. Mix them together, and divide them in six papers, of which one is to be taken every four hours. Or, 4. Take Saline Draught, one ounce and a half. Antimonial Wine, from fifteen h> thirty drops. Syrup of Orange Peel,one drachm Make them into a draught, which is to be taken evpru tVirco !,«..,.,. Order II. PUTRID SORE THROAT. 13p CYNANCHE MALIGNA, or PUTRID SORE THROAT. The putrid sore throat is readily to be distinguished from Ihe inflammatory quinsey by the soreness and white specks or aphthae covering ulcers which appear in the fauces, together with the great debility of the system, a small fluttering pulse, and an eruption on the skin of the same nature with that of scarlatina, which are to be observed in the former ; whereas in the latter there is always great difficulty of breathing, a considerable degree of tumor, with a ten- dency in the parts affected to suppurate, and a hard full pulse. Moreover, in the former disease, the inflammation is seated prin- cipally in the mucous membrane of the mouth and throat, and the accompanying fever is of the typhoid type ; whereas in the latter, it chiefly occupies the glandular parts, and the fever is of the in- flammatory kind. The putrid sore throat often arises from a peculiar or humid state of the atmosphere, and so becomes epidemical, making its attacks chiefly on children, and those of a weak lax habit, principally about autumn and the beginning of winter. It is produced likewise by contagion, as it is found to run through a family, when it has once seized any person in it : and it proves often fatal, particularly to those in an infantile state. In some instances the symptoms of scarlatina and cynanche maligna are so blended together, that it is difficult to say of which disease they partake most: in a practical vie\v this is however of no importance, as both disorders require a similar treatment. By some physicians scarlatina and cynanche maligna have how ever been considered as distinct in their nature ; but from the ob- servations which I have made, I am induced to look on them merely as modifications of the same disease, for I have noticed it under all its different forms in the same epidemic, and even in the same family from the same contagion. The putrid sore throat sometimes attends on measles which are of a malignant nature. Cynanche maligna usually makes its attack with cold shivering?, anxiety, nausea and vomiting, succeeded by heat, restlessness, thirst, debility, and oppression at the chest; the face looks flushed, the eyes are red, and a stiffness is perceived in the neck, with a hurried respiration, hoarseness of voice, and soreness in the throat; and upon viewing the internal fauces, there appears a fiery redness in every part, with some slight degree of swelling in the tonsils, which, however, is by no means so great as to impede either respiration or deglutition. The inflammation, after a short time, takes a peculiar termina- tion ; for, upon a further inspection intp the throat, a number of sloughs of a shade between a light ash colour and a dark brown are to be observed on the tonsils, velum pendulum palati, and uvula ; the breath is highly offensive ; the tongue is covered with a thick brown fur ; and the inside ef the lips is beset with vesicles, 140 PYREXIA, OR FEBRILE DISEASES. Class I containing an acrid matter, which falling on the corners of the mouth and other parts, occasions excoriations. With these symp- toms there is likewise a coryza, whioh pours out a thin acrid matter, excoriating the nostrils. A purging often attends also, particularly in infants, and a thin acrid matter flows from the anus, excoriating this and the neighbouring parts. From the first attack of the complaint there is a considerable degree of fever, with a small, frequent, and irregular pulse; and every evening there occurs a manifest exacerbation, and in the morning some slight remission, together with debility and genera! loss of strength. In some cases the brain is affected with delirium of the low muttering kind, or coma. About the second or third day, large patches of a dark red colour make their appearance about the face and neck, which by degrees become dispersed over every part of the body, even to ihe extremities of the fingers, which feel swelled and stiff. These eruptions, after continuing for about four days, depart without producing any remission of the symptoms. The inflammation, as in the cynanche tonsillaris, sometimes spreads along the Eustachian tube to the internal ear, occasioning ulceration, and sometimes wholly destroying its structure. In other cases it extends to the parotid, maxillary, and other gland9 of the fauces, which become swelled and painful. The whole neck, indeed, sometimes swells, and assumes a dark red colour. As the sloughs spread, they generally become of a darker colour, the interstices at the same time assuming a purple hue; new specks arise, and the whole internal fauces are at length covered with thick sloughs, which, when they fall off, discover ulcers some- limes very deeply seated In the worst cases, the fauces appear quite black, the slougha corrode deeper and deeper, and spread throughout the whole of the alimentary tube, so as to terminate at last in ^ngrene; and the symptoms of irritation continuing to increase, together with a severe purging coming on, the patient is cut off; which event happens usually before the seventh day, and, in some cases, so early as on the third. Where there is a great increase of the evening paroxysm of fever, with vast debility, depression or irregularity in the pulse, early delirium, coma, much vomiting, diarrhoea or subsultus tendi- ng m, and these are accompanied with considerable swelling of the throat, and dark coloured spreading ulcers, with great fetor of breath petechia}, or hemorrhage, the disease will certainly termi- nate fatally; but where the pulse becomes more moderate and stronger, the respiration freer, the skin soft and moist the efflo- rescence copious on the surface of the body, the florid colour begins to return to the fauces, and a better matter to be discharged from the ulcers, with less acrimony in that which flows from the nares, we may expect a favourable termination. In slight cases, where the fever is of a less putrid nature, and the symptoms Order It putrid sore throat. 141 are moderate, and where the appearance of the efflorescence is succeeded by a remission, and this remission of the fever increases daily in the progress of the disease, we need not apprehend danger. Cynanche maligna generally arrives at its height about the fifth or sixth day, and in cases which terminate favourably declines in five or six days. It has, however, been observed to run through its course more slowly in adults than in children. Twenty or thirty of the latter for one of the former are destroyed by this disease, owing most likely to their not being able to wash off the acrid ichorous matter from the throat and fauces by gargling as adults do, and which, by passing down the oesophagus, produces affections of the stomach and bowels, as likewise excoriations about the anus. It sometimes happens that cynanche maligna appears without any affection or efflorescence of the skin, in the same manner as we meet with the scarlatina without any ulceration in the throat: in general, however, the affections of the throat and skin are combined, and seem wonderfully influenced by the state of each other. But while the absence of the sore throat in scarlatina always denotes a favourable prognosis, that of the eruption in cynanche maligna generally affords an unfavourable one. The eruption in cynanche maligna is seldom uniformly diffused, but comes out in blotches or small points scattered over the trunk and extremities, which are rarely of a florid red, but of a dark purplish or livid hue, and which terminate in but a very scanty desquamation. As in other eruptive fevers, the eruption in this sometimes suddenly recedes, and an alarming train of symptoms arise. The patient becomes dropsical, the countenance assumes a cadaverous appearance, and convulsions supervene, which ter- minate in death. The same consequence has ensued on the eruption suddenly assuming a very pale or livid appearance. A florid colour of the eruption, with a uniform diffusion of it over the body, and a copious desquamation, afford a favourable prog- nosis. From dissections it appears, that in this disease the fauces are inflamed, suppurated, and gangrenous; and that the trachea and larynx are likewise in a state of inflammation, and lined with a viscid fetid matter. In many instances the inflammatory affection extends to the lungs themselves. Large swellings of the lymphatic glands about the neck, occasioned by an absorption of the acrid matter poured out in the fauces, are now and then to be found. The same morbid appearances which are to be met with in typhus gravior present themselves in other parts of the body. Cynanche maligna, as it differs very much in its nature and appearance from cynanche tonsillaris, differs also very much in its treatment, and this difference depends upon the former being attended with a fever of the typhoid nature, and a strong dis- position to gangrene in the ulcerated parts, which prohibit the 142 PYREXLE, OR FEBRILE DISEASES- Class I. employment of those antiphlogistic remedies which we find proper and necessary in the latter, and call for others of a very opposite nature. In the treatment of cynanche maligna, we should abstain from all kinds of bleeding, either topical or general, as it would infallibly prove injurious by increasing the irritability, and likewise the debility, which naturally are very great. The same precaution is necessary with respect to the employment of active purgatives; and we are sufficiently deterred indeed from the use of them, by observing that a diarrhoea, arising even spontaneously, always does harm, and often proves fatal. The regular expulsion of the faeces is therefore to be solicited by gentle aperients and clysters, and even these are only to be had recourse to when nature is defective. It has often happened in this complaint, that from a want of due attention to this precaution, a cathartic has been followed by a retrocession of the eruption, and a train of the most alarming symp- toms. If active cathartics are ever admissible in cynanche maligna, they can only be so at its very commencement, or at the termination of those cases, where, although there is a healthy appearance in the throat, with an abatement of all the febrile symptoms, still the abdomen becomes swelled from a collection of putrid colluvies; or glandular obstructions are formed. In such instances a few grains of hydrargyri submurias with rhubarb may be administered with Caution. It has been proposed by Dr. Currie to extinguish the disease in the beginning (as in the first twelve or sixteen hours of its attack) by the copious affusion of cold water, and in some cases this plan may be adopted with success, equally as in scarlatina. After the affusion, it was Dr. Currie's practice to put the patient into bed, and to give him about eight ounces of wine, if an adult, and so in proportion to children; which plan, it appears, was very successful, for in fifty out of fifty-two cases, where he had adopted it very early in the disease, he succeeded. At the commencement of cynanche maligna it has been found of service to give a gentle emetic; wherefore a few grains of ipecacuanha may be taken. It will not fail to bring off a considerable quantity of acrid matter, which, by getting into the bowels, might induce a diar- rhoea; an affection to be avoided by every possible means, as always adding to debility, and endangering the life of the patient. During the first four-and-twenty hours, an emetic will in some cases cut short the progress of the disease, and in all it will be likely to break the force of it. At an advanced stage of the disorder, if we still wish or think it proper to evacuate the contents of the stomach, it may be done by an infusion of chamomile flowers in preference to ipecacuanha. The grand objects to be kept in view in this malignant disease, should be, to check or counteract the septic tendency which pre- vails; to wash off from time to time the acrid matter from the fauces, and to obviate debility. Should any particular symptoms Order II. putrid sore throat. 143 arise during its progress which may tend to aggravate it, such as diarrhoea, hemorrhage, he., they ought to be immediately at- tended to. In the year 1785, at which period I was in the West Indies, this disease prevailed in the island of Saint Christopher's, as an universal epidemic among children, and a vast number of them fell martyrs to it, in spite of the utmost endeavours of the profession to save them ; when at last the most happy effects were derived from the use of a remedy, the basis of which was Cayenne pepper. The medicine was prepared by infusing two table-spoonsful of this pepper and a tea-spoonful of salt, in half a pint of boiling water, adding thereto the same quantity of warm vinegar. After standing for about an hour, the liquor was strained through a fine cloth, and two table-spoonsful were given every half hour. The speedy and good effect produced by the use of this medicine in every case in wnich it was tried, evidently points out the utility of giving warm aromatics, which will bring on a timely separation of the sloughs, as well as other antiseptics, to correct the ten- dency in the parts to gangrene. Since the period above mentioned, many practitioners in the United Kingdom have become vouchers for the very beneficial effects which were derived in various instances of cynanche ma- ligna from this medicine. My own experience induces me to speak well of it also. To assist the effect of the pepper remedy, it will be highly ad- visable to give the bark of cinchona at the same time in doses of from two scruples to a drachm, every two hours; and if the inflammatory symptoms do not run high, it may be mixed in a little Port wine. Should the stomach not be able to retain the powder, we may then substitute the extract or strong decoction or infusion of it, adding to each dose about two drachms of the tincture. If the least degree of diarrhoea is produced by the use of the bark, a few drops of the tincture of opium may be added to each dose. With many children it may be impossible to prevail on them to take the cinchona bark in any form. In such cases it ought to be administered in a clyster. Two drachms of the fine powder may be given in four or five ounces of barley-water, every three or four hours, to young children; and about half an ounce, in a proportionate quantity of the liquid, to those of eight or ten years of age. Should the first clyster come away too soon, from five tr> ten or fifteen drops of the tincture of opium may be added to the subsequent ones. The extract of cinchona may be employed in the same way. In cynanche maligna, a junction of the muriatic acid with the bark of cinchona, as advised under the head of Typhus Gravior, or of the oxygenated muriatic acid, as noticed under that of Scarlatina, will be very proper. Where we give these acids in considerable doses, it may be necessary to add a few drops of 144 PYREXIA, OR FEBRILE DISEASES. CktSS I tinctura opii to each, in order to prevent any disagreeable effect on the stomach and«bowels from ensuing. To check the septic tendency in the parts, as well as to remove the acrid matter which is secreted, it will be necessary to wash out the fauces with some proper gargle*, making frequent use of the pepper remedy in the same manner ; but as young children cannot be prevailed on to gargle, it ought to be injected into the mouth and throat with a syringe. After washing the parts in this manner, the steams arising from warm vinegar and water may be received into the fauces by means of an inhaler. Oxygen gas may also be inhaled by adults. Where there is any difficulty in inducing the patient to sit up in bed to inhale this gas, or we are not furnished with the necessary apparatus, we may substitute the following method, which perhaps may answer equally well. Cause the windows and doors of the person's apartment to be closed, and then taking a chafing-dish with some live coals, throw into it half an ounce of purified nitre in powder, which will fill the room with a thick white cloud, that will continue for a considerable time. This process ought fre- quently to be repeated in the course of the day. Many judicious practitioners have thought that the greater fa- tality among children than adults, in such as have laboured under cynanche maligna, is in a great measure to be attributed to their swallowing the morbid secretion from the throat. This, beyond all doubt, induces vomiting, griping pains, and a purging of the * 5. & Mel. Rosae,.f. |j. Decoct. Hordei, f. |x. Tinct. Myrrh. f.J?ss. Acet. Optim. f. ^j. M. ft. Gargarisma. Vel, 6. r£ Decoct. Cinchonae, f. §vj. Acid. Muriat. f. 3j- Tinct. Cinam. Compos, f. ?ss. ----Myrrh, f. ^j. M. Vel, 7. g> Decoct. Hordei Compos, f. ^xij. cui inter coquendum adde Rad. Contrajerv. Contns. ?ss. Liquori col ato admisce Acid Acetic f. |ij. Tinct. Myrrh, f. ^j. Mel. Rosae, f. |ss. M. Vel, 8. ft Extract. Cinchon. 3j. Vini Rubr. Generos. f. |vj. Acid. Sulphur. Dilut. 3j. M. * 5. Take Honey of Roses, one ounce. Decoction of Barley, ten ounces Tincture of Myrrh, half an ounce. Vinegar, one ounce. Mix these for a gargle. Or, 6. Take Decoction of Peruvian Bark, six ounces. Muriatic Acid, one drachm. Compound Tincture of Cinnamon, half an ounce. Tincture of Myrrh, one ounce. Mix them. Or, 6. Take Compound Decoction of Barley, twelve ounces. Add during its boiling Bruised Contrajerva Root, half an ounce. To the strained liquor, add Acetic Acid, two ounces. Tincture of Myrrh, one ounce. Honey of Roses, half an ounce. Mix them. Or, 8. Take Extract of Peruvian Bark, one drachm. Port Wine, six ounces. Diluted Sulphuric Acid, one drachm. Mix them. Order II. PUTRID SORE THROAT. ttfr worst kind, by causing the complaint to spread along the alimentary tube ; and it is very frequently by these affections that children are destroyed. Possibly they might be prevented by removing the acrid matter from time to time by a small sponge fastened to the end of a quill or piece of wood ; and by means of another sponge at the other end, the ulcerated fauces may be touched with the remedies best calculated to promote their healing. This mode of proceeding will be the more necessary when gargling is not freely employed. No force whatever is to be used for occasioning a separation of the sloughs; and if, after a continuation of the gargles for some time, the sloughs should not begin to separate, all that can be done with safety is to touch them with a little alum, or the muriatic acid mixed with honey, &c. applied with a small piece of soft rag, or hair pencil. ... When any considerable degree of fever attends, and the skin is very dry, it may be advisable to give small and frequently repeated doses of some diaphoretic medicine; but as antimonials are apt to act downwards, and produce a purging, some caution will be necessary in administering them. To prevent this tendency, they may be combined with a small quantity of the aromatic confection* Small doses of the pulv. ipecac, comp. will however be preferable to any antimonial. They may be given with the mistura cam- phorae. Where cynanche maligna is conjoined with scarlatina, we may probably employ a solution of ammoniae subcarbonas in the propor- tion of two drachms to five ounces of water with some advantage, giving two tea-spoonsful every three or four hours, according to the urgency of the symptoms. For the purpose of prompting perspiration, the pediluvium has frequently been used in this disease; but at an advanced stage its effects would be too debilitating; and at all periods, if the symp- toms run high, the trouble attending its use would not be com- pensated by any good effect it might have. The pediluvium * 9. ftTulv. Antimonial. gr.j.—ij. Confect. Aromat. 3ss; M. ft. Bolus tertia hora sumendus. Vel, 10. ft Pulv. Ipecac. Comp. gr. iij.—vi. Vel, 11. ft Mistur. Camphorce, f. ^ij. Confect. Aromat. 3ss. Vin. Antimon. it[ xxv. Aq. Cinnam. |iij. M. Capiat rochl. magnum 3tia quaque bora. * 9. Take Antimonial Powder, one grain to two grains. Aromatic Confection, half ascruple. Make them into a Bolus, to be taken every three hours. Or, 10. Take of Compound Powder of Ipeca- cuanha, from three to six grains for a dose. Or, 11. Take Camphorated Mixture, two ounces. Aromatic Confection, half a drachm. Antimonial Wine, forty drops. Cinnamon Water, three ounces. Of this Mixture take a large spoonful every third hour. 146 PYREXIA, OR FEBRILE DISEASES. ClaSS / seems therefore advisable only in those cases where the efflores- cence becomes very pale, or suddenly recedes. Should a diarrhoea arise in the progress of the disease, immediate recourse must be bad to some powerful astringent*, to which maybe added a use of wine or brandy mulled up with spice. Every possible endeavour should be exerted to put an immediate stop to it, as in every period of the disease diarrhoea is a very dangerous symptom. Violent vomiting arising in the course of cynanche maligna is to be appeased by the saline medicine in the effervescing state; by opiates joined with camphor, and by applying linen cloths wetted with tinctura opii to the region of the stomach. It has been usual to apply blisters to the throat in this com- plaint, particularly when there is any considerable degree of tumor; but they are attended with some danger, as in a few instances where blisters were applied I have observed white specks shortly to arise on the part, which, from the prevailing dispo- sition to putrefaction, have soon degenerated into ulcerations,, that have become gangrenous, and at length have destroyed the patient. It may, however, be attended with a good effect to excite a slight degree of inflammation externally, by applying a cata- plasm of mustard moistened with a small quantity of camphorated spirit, or by rubbing the parts with rubefacients, as in cynanche tonsillaris. A suppression of urine sometimes arises in cynanche maligna, and then it is frequently a symptom of debility. In such cases the necessity of pushing as far as possible the invigorating plan is strongly indicated. Emollient fomentations, or cold applications over the region of the bladder, are the most advisable means for removing this affection; and where the patient has been long costive, some mild clyster may be expedient. When the sup- pression continues obstinate, the assistance of a surgeon will be necessary to draw off the water with a catheter. In the last or putrid stage of ihis complaint, it is not uncommoi for a hemorrhage to break forth from the nose, mouth, or ears, which never proving critical, but, on the contrary, threatening the greatest danger, ought always to be immediately stopped, if possible, by administering strong antiseptics internally, as advised under the head of Malignant Fever, and by the external appli- * 12. ft Confect. Aromat. 3j. Mistur. Crete, f. §ij. Aq. Cinnam. f. ^ijss. Tinct. Opii, TTl xx.—xxx. ------Catechu, f. 3j. M. ft. Mistura cujus sumat cochl. magna ij quartis horis. * 12. Take Aromat icConfection,one drachm. Chalk Mixture, two ounces. Cinnamon Water, two ounces and a half. Tincture of Opium, from thirty tt- fifty drops. ----------Catechu, one drachm Shake them, and of the mixture give two large spoonsful every four hours. Order II. CROUP. 147 cation of tents dipped in some powerful styptic, such as a solution of cupri sulphas*. Through the whole course of the disease the patient is to be supported with a sufficient quantity of liquid vegetable nutriment, such as gruel, barley-water, and preparations of tapioca, Indian arrow-root, rice, sago, and panado ; and his ordinary drink may consist of wine-whey, or Port wine negus acidulated with orange- juice, or some other acid, either vegetable or mineral. The quantity of wine allowed must be in proportion to the age of the sick, the violence of the febrile symptoms, the degree of de- bility that exists, or the tendency that there is to putrescency. The chamber should be kept sufficiently ventilated, and of a propet temperature, so as not to be too hot, nor at the same time to be so cool as to give any check to the perspiration, or efflo- rescence ; and it may be sprinkled several times a day with warm vinegar, in which rosemary or some other aromatic herb has been infused. The greatest cleanliness is moreover to be observed in removing, as soon as possible, whatever is voided by stool ; the pa- tient's linen, as also that of his bed, ought frequently to be changed, and the mouth and throat be repeatedly washed and kept clean. The putrid sore throat being highly contagious, especially among children, if will be prudent, on the first appearance of the disease, to separate the sick from the rest of the family : and in order to destroy the contagion, and render the attendants less susceptible of being infected, it may be advisable to fumigate with the nitric, or muriatic acid, as advised under the head of Malignant Fever. The capsicum medicine before mentioned has not only been used in the cure of cynanche maligna, but it ha$ likewise been advised for the prevention of it. By giving the attendants of the sick, and others who may unavoidably be exposed to infection, a tea-spoonful or two every three hours, using it at the same time as a gargle, the preventive effect of the remedy is said to have proved certain. It seems to act by producing and keeping up a regular excitement in the tonsils, uvula, and fauces, and thereby enabling them to resist the sedative effects of the poison which is inhaled. CYNANCHE TRACHEALIS, or CROUP. The croup is an inflammatory affection of the mucous membrane of the trachea and larynx, excited so high as to stimulate the ves- sels to throw out coagulated lymph, instead of inducing only an increased and altered secretion, according to the customary action of those membranes. In many instances it extends even to the 13. ft Cupri Sulphat. 3jss. Aluminis, 3ss. Aq. Pura?,f. ^vij. Spirit. Rectificat. f. 3j. M. ft Solutio. IMix them for a wash. 13. Take Sulphate of Copper, one drachm and a half Alum, half a drachm Pure Water, seven ounces. Alcohol, one ounce, 148 PYREXIA, OR FEBRILE DISEASES. ClaSS I. bronchial ramifications and surface of the lun.cs, producing an exu- dation 'hat appears partly in a membranous coating, und partly hi a fluid resembling pus, and is attended with a peculiar wheezing sonorous inspiration, compared by some to the crowing of a cock, a similar or stridulous sound in coughing and speaking, great diffi- culty of breathing, thirst, and other febrile symptoms, as likewise by some degree of spasmodic affection. Children are most liable fo attacks of this disease. Some physicians have judged it proper to divide croup into two species, %iz. idiopathic where the disease is primarily and exten- sively seated in the trachea, bronchia?, and surface of the lungs; and symptomatic, where it appears as the consequence of some previous disorder, such as the measles, scarlatina, or cynanche ma- ligna. The distinctions into spasmodic and inflammatory must be objected to, as the disease is always to be considered as arising from inflammation. The croup may be distinguished from acute asthma by the fol- lowing diagnostics :—in the former, the cough is frequently ringing in our ears, whereas in the latter there is little o*r no cough. In croup there is seldom or ever any remission, whereas in the acute asthma it is one of the most striking phenomena of the disease, and it is attended with some evacuation, such as belching, vomiting, or purging. In croup, the pulse is strong, with much febrile heat, the urine high coloured, and the voice shrill and small: in acute asthma, the pulse, although perhaps equally quick, is less full, the urine is limpid, and the voice is croaking and deep. The inflammation in the croup appears of a very peculiar and singular nature. If it was like that met with in common, we might expect to find the same kind of concretion on the surface of the trachea every day, as its mucous membrane is so frequently the seat of inflammation, attended with an increased secretion. The matter, however, of which this substance is formed, possesses dif- ferent properties from those of the mucus which is thrown out upon the membrane of the nose, or of the trachea, in common calarrhal affections. Most practitioners from thence have been induced to suppose, that the film which we find in the croup is not formed by a secretion from the mucous glands, but is an exudation from the exhalant arteries, and that it is analogous to the inflammatory exu- dation from the inflammation of other internal membranes, first described by the late Dr. Hunter. Upon this principle we can indeed more easily account for such a film not being found in com- mon catarrhal affections, in which the mucous glands are, perhaps, more the seat of the disease. The opinion now universally enter- tained is, that the new membrane formed in croup is nothing but coagulated lymph. The croup does not appear to be contagious, but it sometimes prevails epidemically. It seems, however, peculiar to some families; and a child having been once attacked, is very liable to its returns, at uncertain periods, from any slight exposure to cold, but then its Order II. CROUP. 149 attacks are usually less severe. It is likewise peculiar to children from the age of a year to eight or ten, particularly the ruddy and robust, and has rarely been known to attack a person arrived at the age of puberty. The application of cold seems to be the general cause which pro- duces this disorder, and therefore it occurs more frequently in the winter and spring, when the weather is stormy and blowing, than in the other seasons. It has been observed to be most prevalent near the sea-coast, where the air is loaded with moisture, and the changes of the weather are sensibly experienced ; but it is frequently met with in inland situations, and particularly those which are marshy. It is less known in the temperate than in the northern regions of Europe. A day or two previous to an attack of the disease, the child ap- pears drowsy, inactive, and fretful ; the eyes are somewhat suffused and heavy, and there is a cough, which from the first has a peculiar shrill sound : this, in the course of two days, becomes more violent and troublesome, and likewise more shrill. Every fit of coughing agitates the patient very much ; the face is flushed and swelled, the eyes are protuberant, a general tremor takes place, and there is a kind of convulsive endeavour to renew respiration at the close of each fit. As the disease advances, great difficulty of breathing pre- vails, accompanied with a swelling and inflammation in the tonsils, uvula, and velum pendulum palati, and the head is thrown back in the agony of attempting to escape suffocation. There is not only an unusual sound produced by the cough, but respiration is per- formed with a hissing noise, as if the trachea was closed up by some light spongy substance, and thought by some to resemble the sound of a piston forced up a dry pump, or the crowing of a cock. The cough is generally dry ; but if any -thing is spit up, it has either a purulent appearance, or seems to consist of films resem- bling portions of a membrane. Where great nausea and frequent retchings prevail, coagulated matter of the same nature is brought up. With these symptoms there is much thirst, an uneasy sense of heat over the whole body, a continual inclination to change from place to place, great restlessness, and frequency of the pulse. Very often the symptoms suffer considerable and sudden remissions and exacerbations. In an advanced stage of the disease, respiration becomes more stridulous, and is performed with still greater difficulty and some degree of spasmodic affection, being repeated at longer periods, and with greater exertions, until at last it ceases entirely. The croup is to be considered as a very dangerous disease, and which sometimes will destroy the child quickly by suffocation, in- duced either by spasm affecting the glottis, or by a quantity of mat- ter blocking up the bronchiae : but when it terminates in health, it is by a resolution of the inflammation, by a cessation of the spasms, by relief to the dyspnoea, and the voice becoming natural, with a copious and free expectoration of the matter exuding from the tra- 150 PYREXIAE, OR FEBRILE DISEASES. chea, or of the membrane formed there. The unfavourable symp- toms are, considerable difficulty of breathing, great anxiety, violent fever, frequent fits of coughing, no expectoration, the voice be- coming more shrill, and the pulse irregular and intermitting. The disease has, in a few instances, terminated fatally within twen'y-four or thirty hours after its attack ; but it more usually happens, that where it proves fatal, it runs on to the fourth or fifth day. Where portions of the membranous film, formed on the sur- face of the trachea, are thrown up, life is sometimes protracted for a day or two longer than would otherwise have happened. More than one half the cases of croup terminate fatally. The younger the patient, the greater will be the danger. On opening the bodies of children who have died of the croup, it is not unusual to find the lungs in a healthy state ; but in some in- stances the lungs are inflamed on particular points of their surface, and in others, adhesions to the pleura are discovered ; occasionally they are found full of dark-coloured blood and serum, and some- times a quantity of pus is met with. In tracing the bronchi* throughout their minute ramifications, they are usually found filled with mucus, but which is of a firmer consistence in the trachea, and as it were pasted on the surface of the tube, forming a membranous- like concretion of variable colour and texture. The upper part of the trachea is the most usual seat of deviation from the natural structure ; but this is sometimes observed also in the lungs, and ex- tending to the smallest ramifications of the bronchiae. It has been, and I believe still is, in a great measure the common opinion, that the inflammatory affection in croup is chiefly confined to the trachea and bronchiae ; but Dr. Baillie*, as well as Dr. Cheynef, have asserted the contrary, and have given a minute ac- count of several dissections of this disease, wherein the lungs were affected with deep-seated inflammation, and obvious from the firm- ness of these organs, from their not collapsing when the chest was exposed, and from a kind of purulent matter found within their cells. From the appearances on dissection, and the symptoms which attend the disease, there can be no doubt but that it is an inflam- matory affection of the mucous membrane of the trachea, larynx, and other parts immediately connected therewith, attended by a spasmodic contraction of the muscles in consequence thereof ; the treatment ought therefore to be managed accordingly. In the first or incipient stage of croup, our best and most strenuous endeavours should be exerted to lessen the increased action which prevails all over the mucous membrane of the trachea, larynx, and bronchiae ; and therefore bleeding, emetics, purgatives, and blistering, are to be resorted to. The first thing to be done should be, to take away blood, either from the jugular vein or arm, but a preference is due to the former, proportioning the quantity to the age and habit of • See his Morbid Anatomy, p. 91. i See Pathology of the Membrane of the Larynx, by J. Cheyne, M. D. Order II. CROUP. 151 the child, and continuing it so as nearly to produce fainting, where the difficulty of breathing is great. Should the symptoms not mi- tigate from the bleeding, or should they return after a little time, more blood ought to be drawn, by applying several leeches immedi- ately over the trachea; but previous general bleeding should never be omitted in any case. In those which are urgent, active deple- tion will be necessary. The use of the lancet has indeed been deprecated by a few prac- titioners ; and the tinctura opii, in doses proportionate to the vio- lence of the symptoms, recommended as being likely to give relief as speedily as venesection, or any other remedy. I think bleeding, with other antiphlogistic remedies, ought never to be neglected in the first stage of the disease. The prompt abstraction of blood at the commencement of croup, in such a quantity as effectually to lower vascular action upon the tracheal surface, before it has continued long enough to produce any exudation, or effusion of coagulated lymph, or whatever it may be that constitutes the adventitious membrane, is in my opinion the principal remedy from which any relief is to be derived; and it is only at this period, most probably, that bleeding can be useful. Immediately after bleeding it will be proper to apply a large blister all across the throat from ear to ear, keeping up a discharging surface after it is removed, by dressing it with a little of the ceratum sabinae. Having adopted these steps, we ought to give a gentle emetic of ipecacuanha, or tartarized antimony, in a dose proportioned to the age of the child, so as to produce sufficient vomiting. Great relief will be .afforded by the remedy, in consequence of a considerable quantity of ropy mucus being brought off. In all cases of the croup the child should be kept nearly upright in bed, to guard against suffocation. Throughout the whole course of the disease an antiphlogistic regimen will be necessary; and the body should be kept open by the frequent administration of some purgative. Brisk purgatives (in which the submuriate of mercury* may be an ingredient), when the bowels are inactive, are obviously proper. Their operation may be solicited by occasionally administering clysters. To assist the expectoration, and promote a determination to the surface of the body, we may employ diaphoretics, such as a few drops of vinum ipecac, or the solution of tartarized antimony. I usually give a preference to the latter, administered every two or * 1. ft Hydrargyri Submur. gr. iij. Pulv. Jalapae, gr. iv.—viij. M. ft. Pulvis catharticus. Vel, 2. ft Pulv. Rhei, gr. vj. Hvdrargyr. Submur. gr. ij. M. ft.-Pulvis. * 1. Take Submuriate of Mercury, three grains. Powdered Jalap, from four to eight grains. Mix these together for a purge. Or, 2. Take Powdered Rhubarb, six grains. Submuriate of Mercury,two grain* Mix them. 152 PYREXIAE, OR FEBRILE DISEASES. ClaSS I, three hours in such doses as to excite nausea. To increase the effect of this medicine, a warm bath of between 90 and 100 of Fahrenheit may be used. Possibly moderate doses of the pulvis antimonialis, combined with a small quantity of the submuriate of mercury, might prove very serviceable. Bv promptly resorting to the means which have been pointed out, the progress of croup may be frequently averted; but by ne- glecting these during the first day or two of the disease, and trust- ing to trifling remedies, thereby suffering the inflammatory action to proceed, the practitioner will be constrained to witness that dis- tress and loss of his patient which promptitude and energy might have prevented. In the course of the disease there is always a lodgment of lymph or mucus in the trachea, and therefore it will be advisable to pxcite vomiting* once or twice a day, in order that the effused fluid, or adventitious membrane formed thereby, may be dislodged if pos- sible, and brought off. Inhaling the vapour arising from warm water with a small addi- tion of aether, may possibly prove a good auxiliary, both in lessen- ing the violence of the spasms, and assisting expectoration. Some cases of this disorder have been successfully treated with the digitalisf. In these, the tincture was employed in the dose of five drops, repeated every four hours. Its good effects would appear to depend partly upon its operating quickly and powerfully on the arterial system, and thereby stopping the rapidity of the in- flammatory symptoms, and partly on its allaying the spasmodic irritation. I have myself employed it in two or three cases of croup, and with much seeming advantage, but I always premised general as well as local bleedings. After copious depletion, by bleeding both general and topical, vomiting, purging, and blisters, when the inflammatory symptoms have subsided, and the disease seems almost entirely spasmodic, we may venture to give a few drops of the tincture of opium every two or three hours, combined with the wine of ipecacuanha, or solu- tion of tartarized antimony, for the purpose of procuring rest and a remission of the spasms. Musk and assafoetida have been recom- mended as antispasmodics in this disease, but here they are not entitled to our confidence. From the report of some authors we should be induced to sup- pose, that the croup was a disease of long duration and easy ma- nagement ; as by one we are informed that mercury, employed so as to produce a salivation, effectually cures it: another is confident of the success of a lotion made with spiritus astheris sulphuric} t See Med. and Phys. Journ. vol. iv. p. 20. * 3. rj Antimon. Tarlarisat. gr. ij. Aq Purse, f. ^ij. Oxymel. Scillae, f. ?ss. M. Capiat cochl. duo minima subinde ad vomi- tum promovendum. * 3. Take Tartarized Antimony, two grains. Pure Water, two ounces. Oxymel of Squill, half an ounce Mix them together,and five (wo tea-spoons- ful from time to time until vomiting is ex- cited. Order* II. CROUP. 153 compositus; and a third places his reliance on a decoction of seneka: but such is the celerity of the dangerous symptoms, that few practi- tioners have, I think, witnessed a recovery from the croup, where an extravasation of coagulable lymph within the trachea and bronchial tubes had taken place in a high degree. In one or two mild cases of the disease, hydrargyri submurias has been indeed employed, on the recommendation of Dr. Rush, with some seeming advantage; but as the relief we obtain is always in pro- portion to the quantity of mucus brought up, it would appear that we" should never neglect exciting frequent vomiting, by means of tinctura scillae, vin. ipecacuanha?, or a solution of tartarized antimony, in order to have recourse to mercury. Dr. Hamilton, Professor of Midwifery in the University of Edin- burgh, is a strpng advocate for the use of the submuriate of mercury in the croup. He tells us*, that in every case where he has administered it previous to the occurrence of lividness of the lips and other mortal symptoms, he has completely succeeded in curing the disease. His mode of employing it is, having previously put the child into a tub of hot water heated to the ninety-sixth degree of Fahrenheit's thermometer, or wrapt it up in a blanket wrung out of hot water, to give it a dose of from one to five grains, according to the age, every hour, till the breathing is evidently relieved; when it is gradually discontinued, allowing at first two, then three, and finally four or five hours to intervene between each dose, according to the state of the symptoms. The submuriate of mercury, in moderate doses, may be a good remedy in the croup, and by establishing its mercurial influence, may possibly supplant that of the disease, but the Professor's mode of using it to the exclusion of other remedies, such as bleeding, both generally and topically, emetics, he. (with which it is not incompati- ble) I cannot recommend. Where the child is threatened with suffocation, it will be right to excite sneezing by introducing strong snuff, or the pulvis asari compositus, up the nostrils by means of a quill; as also to excite vomiting by a solution of tartarized antimony, if it can swallow: if not, a vein may be opened, and the solution be injected into it, as mentioned under the head of Vegetable Poisons. The operation of laryngotomy has been proposed as a last resource in those cases which threaten suffocation; but from the appearances on dissection, it does not seem that success would attend it; for although the upper part of the hardened membranous substance might be extracted by the forceps, still we should not be able to re- move the fluid portion, which fills the lower part of the trachea and bronchiae, and which is one of the chief obstacles to res- piration. * See his Treatise on the Management of Children in early Infancy. 20 15 i PVREXIA:, OR FEBRILE DISEASES. ClttSS I. CYNANCHE LARYNGiEA, or INFLAMMATION of thb LARYNX. Cynanche laryngaea is of a local nature, is acute, and of short duration, and affects the mucous membrane of the epiglottis, or rima glottidis, or, probably, both of these parts, and in which there exists a high degree of inflammatory action, occasioning impeded deglutition with difficult respiration. It is only of late that this fatal variety of sore throat has attracted the notice of practitioners, having commonly been confounded with croup. In many cases there may, indeed, arise some difficulty of forming a just diagnosis, but the following peculiarities will greatly assist us. In cynanche laryngaea the symptoms are, an uneasy sensation in the larynx, difficult and painful deglutition, partial swelling of the fauces, a supervening and perpetually increasing difficulty of breathing, nearly amounting to a sense of suffocation, the voice being extremely hoarse, or reduced to a scarcely audible whis- per, attended by inflammatory fever. In cynanche trachealis there is a difficulty of respiration without any swelling of the fauces, or painful deglutition : the expirations, especially in coughing, are very shrill, but the fever in this is also inflamma- tory. The usual cause of cynanche laryngaea is exposure to cold, which excites an inflammatory determination to the membrane investing the larynx. It comes on with chilliness, succeeded by beat and fever, which are soon followed with a hoarseness and indistinctness of voice, laborious respiration and pain, or, as it were, a stricture in the throat threatening suffocation; the pulse is quick and feeble, the eyes are suffused with blood, and somewhat protruding, the countenance has a livid or swollen appearance, the tongue is furred, the tonsils, uvula, and pharynx presenting a dark red appearance on inspection, and any attempt to swallow is succeeded by excruciating pain and difficulty. If the symptoms are not properly attended to, and subdued by an adoption of active and proper means, the patient is destroyed by suffocation. The morbid appearances to be observed on dissection of those who die of cynanche laryngaea are as follow: the mucous membrane invest- ing the epiglottis and margin of the glottis is inflamed, serum is effu- sed under it, or coagulable lymph on its external surface, by which the rima glottidis is narrowed, or actually closed. Sometimes there has been perceived an accumulation of mucus in the cells of the lungs, with a slight effusion of serum into their reticular texture. In some instances the pleura has been found partially adhered, with more fluid in the cavities than is natural. To control and manage the disease with success, a timely and active employment of an appropriate treatment is obviously necessary, and this must be directed to the subduing of the locsd Order II. inflammation of the larynx. 155 inflammation as quickly as possible. In the first stage of the inflam- mation (or first four-and-twenty or thirty hours of its commencement), when the patient feels uneasiness in the larynx, with difficult and painful deglutition, we should have recourse to copious blood-letting from the arm in a free stream, (such as from sixteen to twenty ounces if an adult) repeating the operation on the same day, and nearly to the amount of the same quantity should the breathing and deglutition not be very considerabl) relieved. After these, some active purga- tive, such as the submuriate of mercury, joined with jalap, or the compound extract of colocynth, ought promptly to be administered; and should it not act quickly and satisfactorily, a cathartic clyster may be injected The bleeding, as also the purgative, may be re- peated the succeeding day, if judged necessary, between the doses of which we may prescribe small nauseating doses of some antimonial preparation, such as the pulvis antimonialis, or solution of the anti- monium tartarisatum. Should the inflammatory action in the parts not be subdued by venesection and purging, we may advise the application of several leeches to the throat, and a large blister to be put on the chest, im- mediately under the throat. In addition to these means, the frequent use of an inhaler, filled with warm water and vinegar, may afford &ome relief, as may also gargling. Now and then suppuration takes place, and a copious discharge of matter is thrown up by a violent fit of coughing, produced by an effort at deglutition. Where suppuration exists, it might be advisable to excite vomiting, that the abscess may be ruptured and the matter be discharged by the mouth as expeditiously as possible, aqd thereby prevent suffocation.—See Croup. Where the disease resists our best endeavours, laryngotomy affords the only chance of escape from suffocation, by enabling the patient to breathe, till the inflammation, narrowing the aperture of the glottis, may have time to subside ; but this operation should not be delayed too long, as, at a late period, it may afford but little relief; whereas, when performed in an early stage of the complaint, the benefit to be derived from it will be of high importance. Mr. Bell has lately endeavoured to simplify and improve the operation of laryngotomy. He recommends the incision to be made with a small scalpel through the membranous space betwixt the thy- roid and crycoid cartilages, then to introduce the handle of the knife, and turn it so as to open the slit. J his will be sufficient if the occa- sion be temporary; but if a more permanent gap be required, the four corners left by the incisions may be snipt off*. * See Surgical Observations, &c. part i. p. 46, by Mr. Charles Bell, 15t> PYREXIAE, OR FEBRILE DISEASES. CYNANCHE PHARYNGJEA, or INFLAMMATION of the PHARYNX. This differs from cynanche tonsillaris only in the seat of the inflam- mation. It is of the same nature, is produced by the same causes, and re- quires a similar treatment. PLEURITIS, or PLEURISY. , Pleurisy is an inflammation of the membrane lining and envelop** ing the lungs, attended with an acute pain in the side, impeded respi- ration, fever, and a full, quick, and hard pulse. In some instances the inflammation is partial, or affects one place in particular, which is commonly on the right side; but in general a morbid affection is communicated throughout its whole extent. The disease is occasioned by exposure to cold, and by all the causes which usually give rise to other inflammatory complaints; and it at- tacks chiefly those of a vigorous constitution and plethoric habit. In consequence of the previous inflammation, it is apt, at its depart- ure, to leave behind a thickening of the pleura, or adhesions to the ribs and intercostal muscles, which either lay the foundation of future pneumonic complaints, or render the patient more susceptible of the changes in the state of the atmosphere than before. It comes on with an acute pain in the side, which is much aggrava- ted on making a full inspiration, and is accompanied by flushing in the face, increased heat over the whole body, rigors, difficulty of lying on the side affected, together with a cough and nausea; and the pulse is hard, strong, and frequent, and vibrates under the finger when pressed upon, not unlike the tense string of a musical instrument. If blood is drawn, and allowed to stand for a short time, it will exhibit a thick sizy or buffy coat on its surface, consisting of the coagulable lymph or fibrin. If the disease is neglected at its onset, and the inflammation pro- ceeds with great violence and rapidity, the lungs themselves become affected, the passage of the blood through them is stopped, and the patient is suffocated; or, from a combination of the two affections, the inflammation proceeds on to suppuration, and an abscess is formed. The prognostic in pleurisy must be drawn from the severity of the symptoms. If the fever and inflammation have ran high, and the pain should cease suddenly, with a change of countenance and a sinking of the pulse, great danger may be apprehended; but if the heat and other febrile symptoms abate gradually, if respiration is performed with greater ease and less pain, and a free and copious expectoration ensues, a speedy recovery may be expected. Empy- ema, or a collection of pus in the cavity ofthe thorax, is occasionally '" one of the terminations of pleuritis. Order IT. pleurisy. 157 The appearances on dissection are much the same as those mentioned under the head Peripneumony ; viz. an inflamed state of the pleura, connected with the lungs, having its surface crowded with red vessels, and a layer of coagulated lymph lying upon it; adhesions also of the substance of the lungs to the pleura. Besides these, the lungs themselves are often found in an -inflamed state, with an extravasation either^ of blood or coagulated lymph in their substance. Tubercles and abscesses are like- wise frequently met with. In the treatment of pleurisy our chief attention must be directed to the removal of the inflammation, by copious bleedings from the system at an early period of the complaint, taking the pulse for a guide, and giving the age and constitution of the patient proper consideration. While the pulse remains full, hard, and obstructed, the pain in the side acute, the breathing difficult, and the blood continues to exhibit a sizy crust on its surface when cool, so long ought we to repeat the operation, with this exception, that after a free expectoration has commenced, it will be injurious. Here it is proper to mention, that physicians have been struck at all times with the effect produced, by taking the blood from a large orifice* in inflammatory diseases ; and it is certainly a step which cannot be too strongly urged, but more particularly in pleuritis and pneumonia. It is true, that from a small orifice an equal quantity of blood may be taken as from a large one ; but the time of its flowing is so long, that the topical inflammation, which demands for its relief a sudden effect upon the system, is not much influenced by it, though^ the general strength is greatly reduced, which is an occurrence to be avoided as much as pos- sible in a disease that requires a repetition of the operation. Pleurisy and peripneumony are complaints in which an early and repeated application of the lancet is usually of the most urgent and indispensable necessity. If blood-letting be had recourse to at a proper period, and to a sufficient extent, (which of course must vary according to the symptoms of the disease, and the con- stitutional habit and age of the patient), it will seldom fail, with very little further aid, to remove a disease that otherwise might, and not unfrequently does, in a very short time terminate in death. From the well-known power which the digitalis possesses of di- minishing the action of the heart and arteries, it possibly may be employed in pleuritis with some advantage after copious general bleedings. To allay the pain in the side, and take off the inflammation internally, it will likewise be advisable to apply a large blister immediately over the part affected ; and to prevent the coming on of a strangury, the patient should be directed to drink plentifully of barley-water in which a small quantity of gum acaciae has been dissolved. If it heals up too quickly, and the pain is not relieved * «»n n.. *•«...!,...„>- r......i. r.: —.ation on l'ever, p. 60. 158 pyrexia, or febrile diseases. Class I by the first, a fresh one, ought to be applied as near to the former as possible. Where the pain is trifling, or the patient cannot be persuaded to submit to the application of a blister, flannel cloths, wrung out in a warm decoction of emollient herbs, or bladders containing warm water, may be applied in its stead. In pleurisy the application of cold on or near the part affected has occasionally been used with a salutary effect. Nitre, as being a powerful refrigerant, is likely to be a useful medicine in pleurisy as well as in peripneumony. It may be given in doses of ten grains, repeated every three or four hours. As strong purgatives are found to determine the flow of blood to internal parts, they are improper remedies to be used in pleurisy; and therefore when it is found necessary to obviate costiveness on the first attack of the disease, it will be best to do it by means of gentle laxatives, such as the neutral salts and manna, in an infusion of senna, and the body may afterwards be kept open by emollient clysters, administered so as to procure one or two stools daily. An early use of diaphoretics, particularly those of the antimonial class (as prescribed under the head of Simple Continued Fever); will be very proper in the cure of pleurisy ; as they not only de- termine the circulation to the surface of the body, but will likewise greatly assist in promoting an expectoration. They ought, however, to be given in 3uch small doses as not to excite vomiting (which might be attended with bad consequences), and to be repeated every two or three hours. To assist their operation, the patient should take frequent small draughts of some tepid liquor, such as bariey-water, or herb-tea. The pediluvium, or semicupium, frequently repeated, might prove a good auxiliary. A free expectoration being the mean which nature usually adopts to relieve herself of this inflammation, it ought therefore to be encouraged by every possible method, such as inhaling the steams arising from warm water and milk, or from a decoction of emollient herbs, and giving mucilaginous* and oilyf medicines * 1. g;Mucilag. Gum. Acaciae,f. |iv. Aq. Fontan. £ ^ij. Potassae .Nitrat. 3j. Vin. Antimon. u| xx. Syrup. Limon f. |j. M. ft. Mistura, cujus sumat paululum subinde, vel tusse urgenti. t 2. R 01. Oliv. Optimi, f. ^j. Mucil. Gum. Acaciae, f. |iv. Oxymel Scillas. f. 3'ij- Ammonias Subcarbonat. 3j. Aq. Pulegii, f. ^i.j. M, ft. Mistura. 1. Take Mucilage of Gum Acacia, four ounces. Pure Water, two ounces. Nitrate of Potass, one drachm. Antimonial Wine, thirty drops. Syrup of Lemons, one ounce. Of this mixture, when shaken, take a little from time to time, or when the cough is troublesome. t 2. Take Best Olive Oil, one ounce. Mucilage of Gum Acacia, four ounces, Oxymel of Squill, three drachms. Subcarbonate of Ammonia, one scruple- Penny-Royal Water, two ounces. Mix them together, and take a little oc casionally. Order II. PERIPNEUMONY. 159 frequently throughout the course of the day, as here advised, or recommended under the head of Peripneumony. These will like- wise serve to sheathe the throat, and other parts, from the acrimoni- ous mucus which is thrown out, and which provokes frequent fits of Couching. As opiates evidently tend to give a check to expectoration, they ought, if possible, to be avoided; but if it is absolutely necessary to have recourse to them by the patient being exhausted from the want of sleep, they may then be given, joined with some diapho- retic*. Throughout the whole course of the disease the patient is to ab- stain from animal food, and from all kinds of fermented and spirit- uous liquors, supporting his strength with gruel, sago, preparations of barley, and such-like vegetable productions. On his recovery, he is carefully to guard against any fresh exposure to cold, as a return of the complaint might be attended with worse consequences than the first attack. It has been mentioned that empyema, or a collection of pus, is one of the terminations of pleuritis: where this happens, and a fluctuation can be perceived, the thorax must be punctured to evacu- ate the matter. For the mode of performing the operation, see Bell's, or any other work on Surgery. PNEUMONIA, or PERIPNEUMONY. A peripneumony, or inflammation of the lungs, is denoted by a difficulty of breathing, obtuse pain in some part of the chest, cough, a frequent full pulse, vibrating under the finger like the tense string of a musical instrument, white tongue, high-coloured urine, and other symptoms of inflammatory fever. The disease is divided into the true and spurious peripneumony. When it arises from sizy blood obstructing the vessels of the lungs, it is Vel, 3. ft 01. Amygdal. Dulc. f. f j. Syrup. Althaea?, f. ^ss. Mucilag. G. Acaciae,f. ?jij. Aq. Fontan. f. ^Hj. Liquor. Amnion. Subcarbonat. 3ss. M. ft. Mistura. 4. ft Liquor. Amnion. Acetat. f ^ss. Aquae Menth. Viridis, f. |j. Vin. Antimon. flX xij. Spirit, either. Nitrici, H[ xx. Tinct. Opii, fU xxv. Syrup. Simpl. 3'j M. ft. Haustus hora decubitus sumendus. | Or, 3. Take Oil of Sweet Almonds, one ounce. Syrup of Marshmallows, half an ounce. Mucilage of Gum Acacia, tw« ounces. Pure Water, three ounces- Solution of Subcarbonate of Am- monia, half a drachm. Mix them. * 4. Take Solution of Acetate of Ammonia, half an ounce. Mint Water, one ounce. Antimonial Wine, twenty drops. Spirit of Nitric ./Ether, thirty drops. Tincture of Opium, forty drops. Common Syrup, two drachms. Mix them for a draught, to be taken *ti going to bed. 160 PVREXIiE, OR PEBRILE DISEASES. Class I, called by the former appellation; and when it proceeds from i thick viscid matter, producing a similar effect, it is known by the name of the latter. Pneumonia is sometimes met with combined with typhus gravior, and then appears under a different character from its usual one. The most general cause of peripneumony is, the application of cold to the body, which gives a check to the perspiration, and determines a great flow of blood to the lungs. It attacks principally those of a robust constitution and plethoric habit; hence it is more frequently met with in men than women, and occurs most frequently in the winter season and spring of the year; but it may arise in either of the other seasons, when there are sudden vicissitudes from heat to cold. Other causes, such as violent exertions in singing, speaking, or playing on wind instruments, by producing an increased action ot the lungs, have been known to occasion peripneumony. Severe exer- cise, external injuries, a free indulgence in the use of fermented liquors, intemperance, repelled eruptions, suppressed evacuations, and metastasis from other diseases, such as gout, rheumatism, 8tc. may also give rise to it. Those who have laboured under a former attack of this complaint, are much predisposed to reiurns of it, Pneumonia appears as a symptomatic affection in several diseases, as measles, catarrh, he. The true peripneumony comes on with an obtuse pain in the chest or side, great difficulty of breathing (particularly in a recumbent po- sition, or when lying on the side affected), together with a cough, dryness of the skin, heat, anxiety, flushing of the face, and thirst. The pain is prodigiously increased on coughing or making a full inspi- ration. At the first commencement of the disease, the pulse is usually full, strong, hard, and frequent; but in an advanced stage it is commonly weak, soft, and often irregular. In the beginning the cough is frequently dry, and without expectoration; but in some cases it„is moist even from the first, and the matter spit up is various both in colour and consistence, being often streaked with blood, but at which we need not be alarmed. jl0 If relief is not afforded in time, and the inflammation proceMi with such violence as to endanger suffocation, the vessels of t£e neck will become turgid and swelled; the face will alter to a pur- ple colour; an effusion of blood will take place into the cellular substance of the lungs, so as to impede the circulation through that organ, and the patient will soon be deprived of life. Should these violent symptoms not arise, and the proper means for carrying off the inflammation have either been neglected, or have proved ineffectual, although adopted at an early period of the disease, a suppuration may ensue, which event may happen in a few cases during the first week, but more usually in the second, when the disease continues, and is to be known by frequent slight shiverings; by an abatement of the pain, and sense of fulness in the part; by the patient being able to lie with greatest Order II. PERIPNEUMONY. 161 ease on the side which was affected; by a remission of the previous febrile symptoms and accession of hectic, and by the respiration being less painful but more oppressed. When the collection of matter has come to maturity, it sometimes bursts into the air-vessels and occasions instant suffocation; in some cases it will be spit up. I have known a patient spit up a considerable quantity in this way. This spitting often continues long, and the person falls into a state similar as in phthisis pulmonalis. Some- times the collection bursts into the cavity of the thorax and produces empyema, rather a hopeless case. Sometimes lymph is effused into the air-vessels, which, by filling up the cells of the lungs, produces suffocation ; or being effused into the cavity of the chest, gives rise to hydrothorax; at others, adhesions to the ribs are formed. Tubercles, or a hardened state of the lungs, have been said to occur in consequence of pneumonia, and in some cases it undoubtedly may be so, but not so often, I believe, as has been imagined. In my opinion, they are more frequently the cause of it, having previously existed in a scrofulous habit. In such cases they give great irritation to the lungs, produce dyspnoea,,cough, and congestions, and upon the application of any additional stimulus, pneumonia is apt to be induced. When peripneumony proves fatal, it is generally by an effusion of blood or lymph into the cellular texture of the lungs, so as to occasion suffocation, which usually happens between the third and seventh day; but it may likewise prove fatal, by terminating either iii suppuration or gangrene. The latter is a very rare occurrence. In those cases where it goes off by resolution, some very evident evacuation always attends it, such as a great flow of urine, with a r.onious sediment, diarrhoea, mild sweats diffused over the whole body, emorrhage from the nose; but the evacuation which most fre- ly terminates the complaint, and which does it with the greatest , is a free and copious expectoration of a thick white or yellow s; and by this the disease is carried off in the course of twelve irteen days, the pulse gradually abating in its frequency, and the of the body, with the other febrile symptoms, disappearing. 5 of pneumonia terminating in health without expectoration are rare. lr opinion as to the event is to be drawn from the symptoms h are present. A high degree of fever, attended with de- n, much difficulty of breathing, acute pain, a dry cough, or xpectoration of a dark black colour, sudden cessation of pain, f the expectoration, followed by a change or lividness of the and of the countenance, and sinking or irregularity of the e, denote great danger: on the contrary, an abatement of the ile symptoms, and of the difficulty of breathing, and pain ng place on the coming on of a free expectoration, or the pening of any other critical evacuation, such as a hemorrhage 162 PYREXIAE, OR FEBRILE DISEASES. ClaSS / from the nose, diarrhoea, or free diaphoresis, the urine at the same time depositing a copious sediment, promise fair for the recovery of the patient. When the inflammation terminates either in suppn. ration, or an effusion of lymph into the cellular substance of the lungs, or cavity of the thorax, it is always to be considered as highly dangerous. On dissection the lungs usually appear inflamed, and there is often found an extravasation either of blood or of coagulated lymph in their cellular substance. The same appearances likewise present themselves in the cavity of the thorax, and within the pericardium. The pleura connected with the lungs is also in an inflamed state, having its surface every where crowded with red vessels. Besides these, abscesses are frequently found in the substance of the lungs, as likewise tubercles and adhesions to the ribs are formed A quantity of purulent matter is often discovered also in the bronchiae. As in many cases of peripneumony the patient is destroyed in the course of a few days by the passage of the blood through the lungs being obstructed, effusion taking place, hemorrhage of blood ensuing, or the inflammation proceeding on rapidly to a suppuration, the antiphlogistic plan, in its most rigorous extent, ought to be adopted on the very first attack of the disease. A quantity of blood propor- tioned to the state of the pulse, the violence of the symptoms', and the vigour of the person, (for there is no fixing on the definite quantity) should be drawn from the arm, taking care to make the orifice large (see Pleurisy); and if the difficulty of breathing and pain are not relieved while it flows, the bleeding should be continued until the patient turns pale and seems likely to faint, as one copious evacuation will be far preferable to repeated small bleedings. It has often distressed me during the course of my practice, when called upon for advice in severe cases of pneumonia, to have observed many a life endangered, nay sometimes sacrificed, by a trifling abstraction of blood at the onset of the disease, and which most probably would not have happened had the medical attendant on first seeing the patient immediately drawn off a proper quantity. If a powerful impression is produced by the abstraction of a large quantity at first, the disease is suddenly corrected, and vrill often, in the course of a few hours, be converted from a most violent pneumonia into a simple catarrh ; or if the result is net so fortunate, the syn ptoms will become infinitely milder and more manageable, and may even not recur with such violence as to require a repetition of venesection. But the reverse of this picture deserves notice. If blood-letting has been too long deferred, or; from timidity in the practitioner or the patient, not largely em- ployed in the first instance, the disease generally proves violent, tedious, untractable, and often fatal. It appears to be a matter of indifference from which arm the blood is taken away, as the Order II. peripneumony. 163 operation is resorted to with the view of removing a stimulus, and not any expectation of causing revulsion. If the pain and difficulty of breathing continue violent, or return after a short interval (which they are very apt to do when the loss of blood is only trifling) the bleeding may be repeated the succeed- ing or even on the same day, and a proper quantity may again be drawn off, as the practitioner, in repeatedly abstracting blood, is not to be guided by the quantity, or even by the appearance of the blood, but by the relief procured. When the inflammatory disposi- tion is subdued, and the difficulty of breathing and pain are not very great (the patient complaining, perhaps, only of a rawness and sore- ness in the throat), it will not be necessary to have recourse to the operation a second or third time. It is according to the state of the symptoms, the effect produced upon the luiigs, and respiration being freely performed, taking into consideration, at the same time, the appearance which the blood exhibits when cold, that bleed- ing is to be repeated or not. After expectoration has taken place to any degree, it would be improper to bleed. Where there has been a considerable lapse of time, and the patient is old, or in a weak debilitated state, instead of repeating venesection a second or third time, we may apply several leeches, or the scarificator and cupping-glass to the chest, immediately over the part which is painful. To diminish the action of the heart and arteries, it has been pro- posed in this disease, as well as in pleurisy, to administer the digir talis. In addition to early and copious bleeding, this remedy may, probably, have a good effect, but it ought never to be relied on alone. Where much systematic debility and pulmonic irritation prevail, with frequent coughing, difficult respiration, dry heated «,r: , and a rapid hard pulse, notwithstanding we have bled freely le early stage of the disease, we may then give the foxglove, ?r in the form of powder or tincture. About half a grain of the er, or from fifteen to twenty drops of the latter, may be admi- red every four hours. laming the skin immediately over the part affected with pain, e application of a large blister, is the next proper step to be ed after bleeding ; and should it show a disposition to heal up a fresh one ought to be applied in the vicinity of the other, so keep up a constant effect ; which mode of proceeding will preferable to keeping the blistered parts open with any kind ulating ointment, as is often practised. Blisters may be used stage of the disease, and in many cases in which blood-letting be carried far enough, or cannot be employed at all : in ipneumonia notha of old people they prove very beneficial. Ilient fomentations and cataplasms are sometimes made use they evidently interfere with the application of a more 1 remedy, as a blister cannot be kept on at the same time y are employed. bowels require evacuation, strong purgatives ought not 164 PYREXIAE, OR FEBRILE DISEASES. Class L to be given, but gentle aperients of a cooling nature should be used, particularly at the commencement of the disease. It is a pretty- general opinion that purgatives are not proper remedies in pneumo- nic affection, because copious and frequent purging has a tendency to diminish expectoration, a point of the highest importance ; that drastic ones ought not to be administered, is obvious ; but, never- theless, we should not neglect giving those of a mild nature, such as a solution of the sulphate of magnesia, &c. as prescribed below*. A free expectoration being the means which nature most usually adopts for carrying off the inflammation, we ought, therefore, to promote it as much as possible, by giving such medicines as are supposed to have a power of promoting a secretion from the glands1 of the throat and bronchiae ; and likewise such as will serve to alleviate the cough, by sheathing the parts against that acrimony of the mucus which gives rise to it. It may be at the option o" (he practitioner to use any of the forms mentioned belowf, or to sub~ * 1. g. Mannae Optim. 3»j- Magnesia? Sulph. 3ij. Infus. Sennae, f. fiss. M. ft Haustus catharticus. Vel, 2. B- 01. Ricini, f. ^i. t 3. & Cetacei, 3»j- Vitell. Ovi,q. s. adsolut. et adde Aq. Pulegii, f. §iv. Potasses Nitrat. 3j- Oxymel Scillae, f. 3iij. M. ft. Mistura. Cochl. j. pro dos. subinde vel tusse urgenti sumendum. Vel, 4. U Mucilag. Gum. Acaciae, f. |v. Syrup. Limon.f. ?j. Tinct. Tolutan. f.~3j. M. Vel, ft. Mistura. 5. rj Gum. Ammon. 3j- solve in Aq. Puleg. f. ^v. et adde Acet. Scillae, f. 3iij. Syrup. Tolutan. f. ^ss. M. ft. Mistura. Vel, 6. R 01. Amygdal. Dulc. Syrup. Tolutan. aa f. ^j. Cetacei (Gum. Acac. permixt.)3ij Confect. Rosae Canin. ^ss. M. it. Linctus de quo saepe lambat aeger. I* 1. Take Manna, three drachms. Sulphate of Magnesia, two drachms. Infusion of Senna, one ounce and a half. Mix them for an aperient draught. Or, 2. Take Castor Oil, one ounce. t 3. Take Spermaceti, two drachms. Yolk of Egg, a sufficiency for solution. Then add Penny Royal Water, four ouncei. Nitrate of Potass, one drachm. Oxymel of Squill, three drachms. Mix them, and let a spoonful be taken occasionally whenever the cough is trou- blesome. Or, 4. Take Mucilage of Gum Acacia, five ounces. Syrup of Lemons, one ounce. Tincture of Balsam of Tolu, one drachm. Mix them. Or, 5. Take Gum Ammoniac, one drachm. Dissolve it in a mortar with Penny Royal Water, five ounc M- Then add Vinegar'of Squill, three drach;j- M. ft. Haustus. t 1. Take Infusion of Senna, one ouice and a half. Sulphate of Magnesia, three drachms. Tincture of Jalap, Syrup of Buckthorn, of each one drachm. Mix them for a draught. X 2. Take Saline Draught, one onnce and a half. Nitrate of Potass, from ten to fif- teen grains. Tartarized Antimony, the sixth of a grain. Syrup of Marshmallow, WO drachms. Mix them for a febrifuge draught. Order II. INFLAMMATION OF THE LIVER. 183 the disease is found not to give way, we should call in the aid of mercury. Some practitioners, particularly in the East and West Indies, have recourse to it on the first attack; but the most judicious do not in general use it to effect a mercurial operation until the urgent inflammatory symptoms have been somewhat subdued by an antiphlo- gistic treatment. In every inflammatory affection of the liver, and where febrile excitement is present, but more particularly in northern climates, although it may be advisable to employ mercury as a pur- gative at the commencement of acute hepatitis, still I am of opinion that we should not then use it with the view of promoting saliva- tion. The remedy in question, when properly used, is cer- tainly attended with wonderful efficacy, but it appears improper * on the first attack of acute hepatitis, which, like other visceral in- flammations, readily yields in Great Britain to the ordinary plan of depletion*. We may begin the mercurial course at the expiration of the fourth or fifth day of the disease. The most proper way of introducing mercury into the system will be, by rubbing in a small quantity of the ointment (perhaps about one drachm) in the neighbourhood of the part affected, every night, until a slight degree of salivation is excited, or rather until some very obvious effect is produced on the constitu- tion ; by which means we shall in general be able to disperse the swelling and hardness. It will be advisable to rub the ointment on the side, in preference to any other part, because some advantage may possibly be derived from the mere friction. If rubbing in the mercury in the neighbourhood of the part is at- tended with any pain or inconvenience to the patient, the unction may then be applied to the groins, taking care however not to carry it much beyond the point bordering on salivation. With the view of assisting the discussion of the inflammation, and obviating any severe effects from the use of mercury, some gentle purgative, such as a so- lution of any neutral salt in an infusion of senna, may be taken every third or fourth morning. A modern writer mentionsf, that it is by no means sufficient to ren- der the mouth sore by mercury j it must be carried to the extent of producing a copious salivation, as the disease never yields till the saliva flows freely. In this opinion I believe he is singular; but indeed the generality of the East India practitioners seem to carry the point too far. Should we wish the mercurial action to be soon effected, we may employ mercury internally as well as externally; and to make its effect the more certain, we may join small doses of opium with it, administering them in the form of a pillj. If we find the submu- * See Dr. Saunders's Treatise on Diseases of the Liver. t See Medical Sketches, by Sir James M'Gregor, M. D. t 3. B: Hydrargyr. Submur. J]. I j. 3. Take Submuriate of Mercury, one J drachm. Opii, ' Opium, 184 PYREXIA, OR FEBRILE DISEASES. Class / riate of mercury not to answer our wishes, we should substitute the pilula hydrargyri, the patient taking one or two every night at bedtime, as may be judged necessary. In hepatic derangements this remedy has of late years been very extensively and usefully employed in the United Kingdom. If the disease yields readily, a short course of mercury will be sufficient; but if not, its use ought to be continued for, perhaps, five or six weeks. When assistance has not been procured in due time, or the means which have been employed to carry off the inflammation in the liver have not been attended with the desired effect, and suppuration has ensued, ive must endeavour to promote the formation of proper pus, and the discharge of the abscess externally. To effect the first of these intentions, the patient should be directed to t ke a drachm of the powdered bark of cinchona every two or three hours, using at the same time a generous nutritive diet, with a mode- rate quantity of wine, which course ought to be continued until the suppuration is completed; and to promote the second intention, a large emollient poultice should be kept constantly over the part, well fo- menting it twice a day, previous to the application thereof. When the tumor points outwardly, and has become somewhat soft, with evident fluctuation, we should immediately open it in the most de- pendent part, taking care not to touch its adhesion with the correspon- ding portion of the peritoneum. The opening may be made through the external integuments with a scalpel, and on reaching the abscess it may either be touched with a lancet, or be pierced with a trocar, which may be the preferable way, as we shall thereby have it in our power to evacuate the matter slowly and gradually, which in large collections is a point of importance, and therefore deserving of atten- tion. The fluid discharge is most commonly of a greyish colour, but not invariably so. To facilitate the discharge of the matter, the patient ought to be placed in the most favourable position, and the belly be gradually compressed by means of a proper bandage. The dressings ought to be simple, and frequently renewed. Should the lips of the wound after some days seem disposed to close before the healing of the interior parts, a tent of soft lint, dipped in some digestive ointment, may be inserted into them. To the end of the cure, cinchona with stomachic bitters, wine, and a Camphorae, aa 3ss. Syrup. SimpI q. s. M. ft. massa in pilulas aequales xxx. distri- buenda, capiat j. vel ij. pro dos. Vel, 4. g; Hydrargyr. Submuriat. 3j- Opii Purif. 3ss. Antimon. Tartarisat. gr. v. Syrup. Simpl. q. s. M. ft. massa in pilul. xxx. divid. j. mane et nocte quotidie sumenda. Camphor, of each half a drachm. Common Syrup, a sufficiency to form the mass, which divide into thirty pills, and take from one to two for a dose. Or, 4. Take Submuriate of Mercury, one drachm. Opium, half a drachm. Tartarized Antimony, five grains. Syrup, a sufficiency to form the mass ; divide this into thirty pills, and lei one be taken night and morning. Order II. inflammation op the liver. 18S* generous diet, will be proper. Suppuration of the liver is a disease of such frequent occurrence in the East Indies and other warm climates, that the practitioners there are become very expert at this operation, and frequently perform it with safety when the tu- mor does not point at all, judging merely by the preceding progress of the case, and the degree of fulness in the hypo- chondrium. . Abscesses in the liver sooner heal when opened than similar affections in other parts of the body, and perhaps with less incon- venience ; and, therefore, whenever we have good grounds for suspecting that matter has formed in this viscus, we may advise an opening to be made into the abscess, whether situated on the convex part of it or not, in preference to suffering it to break internally, by which its contents must be evacuated into the abdomen, to the almost certain destruction of the patient. Should the abscess discharge itself into the cavity of the chest, and so form purulent empyema, the proper operation ought to be performed without any loss of time.—See Empyema. The common plan of cure in chronic hepatitis is by mercury, and it is certainly the most effectual practice. It should be given in small doses and slowly, so as to keep up a brassy taste in the mouth for a considerable time, as it promotes the secretion of bile, and excites the extreme vessels on the surface. To increase the latter effect, it has, however, been found useful to combine it with a small proportion of antimonial powder, as likewise of opium, to protect the bowela from irritation. The next most salutary process is to keep up the regular peris- taltic motion of the intestines, and excite the mouths of the excretory ducts of the liver. With this view one or two of the pills prescribed below* may be taken occasionally at bedtime, succeeded the ensuing morning by a draught composed of some neutral salt, as prescribed in the treatment of acute hepatitis. Our attention is at the same time to be directed to the cuticular discharge, which ought to be promoted by the most gentle means, such as moderate exercise and flannel next to the skin. When hepatic obstructions exist, with too great a determination to the bowels, keeping them in an irritable state, the utility of flannel is apparent. The assiduous and frequent application of the flesh brush, or friction with the hand over the hypochondriac region, will be found to excite the healthy action of the biliary organ in no slight degree. A tepid bath will be useful, but some caution * 6. \\ Extract. Colocynth. C. 3j- Hydrargyr. Submur. 3j, Antimon. Tartarisat. gr. iv. 01. Carui, fll v. Syrup. Simpl. q. ». M. it. Pilulffi xxs>. QA 5. Take Compound Extract of Colocynth, one drachm. Submuriate of Mercury, on« scruple. Tartarized Antimony, four grains. Oil of Carui seven drops. Common Syrup, a sufficiency to form the mass, which is to be made into thirty pills. 186 PYREXIJE, OR FEBRILE DISEASES. ClaSS I, will be requisite in avoiding subsequent chilliness. Warm mineral Waters may also be taken internally. When there is much local uneasiness, repeated blisters may be had recourse to with some advantage. General bleeding is never necessary in chronic hepatitis : in a few instances, topical may be serviceable. Among the local means, I beg leave to observe, that in those instances where the liver has been exceedingly enlarged, decided benefit has sometimes been derived from the application of a plaster of ammoniacum spread largely over the diseased surface, so as to act medically, as well as on the principle of a bandage in giving some support. In that species of diseased liver which arises from an immoderate use of vinous or spirituous liquors; a mercurial course has been ob- jected toby Dr. Trotter. In the tubercular or schirrhous liver, he tells us*, it had seldom appeared to him to be of any service, be- yond its action in keeping the bowels open, when costiveness was to be guarded against. My own experience, however, does not lead me implicitly to adopt this conclusion; on the contrary, in more than one instance of incipient scirrhous liver, slightly com- plicated with dropsy, I have seen mercury employed with advan- tage. Mercury, however, will not fail to prove injurious in those cases where the structure of this viscus is considerably destroyed. We have been informed, that of late the nitric acid largely diluted with water and mucilage of syrupf, has been used in the East Indies in chronical affections of the liver, and it is said with much benefit. As an auxiliary remedy, it certainly maybe employed with safety and advantage. Where the disease arises in a person of a scorbutic habit, there is no doubt that the use of mercury would be highly improper, as it would infallibly increase the symptoms, and hasten the fatal termination thereof; and in such casea, the nitric acid may be given with much advantage, as it will not only relieve the hepatic affection, but may likewise, in some degree, amend the scorbutic tendency. In the treatment of chronic inflammation of the liver, great commendation has been bestowed upon the taraxacum (dandelion) by a modern writerj, who tells us that he has seen the most decided advantage, both in incipient scirrhus of the liver, and also in several chronic derangements of the stomach, in the dose of * See his Essay on Drunkenness, and its Effects on the Human Body X Dr. Robert Pemberton's Treatise on Diseases of the abdominal Viscera, p. 42. ' 6. 1£ Acid. Nitric, fll vi.—x. Aq. Purse, f. 3*ij» Syrup. Cort. Aurant. f. 3'j. M it. Haustus ter quaterve die sumendus. t 6. Take Nitric Acid, from eight to fifteen drops. Pure Water, twelve drachms. Syrup of Orange Peel, twu drachms. Make them into a draught, whichisto ba taken three or four times a day. Order II. inflammation of the liver. 18? half a drachm of the extract twice a day. Either a strong decoc- tion, or the fresh expressed juice, in doses from two ounces to four, two or three times within the twenty four hours, will however be found more active preparations. Enlargements of the liver and spleen are sometimes the con- sequence of long continued intermittents, and they not unfre- quently resist the effects of mercury, although the salivary glands have been sufficiently excited. In cases of this nature we may make trial of the succus inspksatiis conii, probably with better success.—See Intermittents. The diet best adapted for persons labouring under chronic hepatitis, is such as is attenuant, nutritive, and easy of digestion ; avoiding salted meats and greasy substances. By degrees it may be improved by the addition of broths, light animal food, &c. until health is perfectly restored. He who labours under ob- structed liver, and hopes to prolong his existence, must abandon what are called the pleasures of the table, and observe a rigid temperance with respect to diet. If wine is drank, it ought to be diluted with water ; but in most cases this last alone will be the best beverage. Malt liquors will seldom agree, and spirituous ones ought to be shunned as poison. Late hours and night air ought to be cautiously avoided. Such as labour under chronic affections of the liver in India, or the West Indies, should never return to Europe in the winter. Those of the former who cannot undertake the long and expensive voyage to Europe, ought to change a continental for an insular situation. The most proper places will be Prince of Wales's Island, which enjoys a milder air and a lower range of tem- perature than any of the Presidencies ; or St. Helena, which approxi- mates more to the climate of Europe than that of any other inter-tropical situation. Those of the West Indies may go to America, and they will be likely to experience considerable benefit from the voyage and sea air. The complicated diseases which are often brought on by a long residence in warm climates, affecting the secretion of bile, the functions of the stomach and alimentary, canal, and which ge- nerally produce organic derangement in some part of the hepatic system, often receive much benefit from the Bath waters, if used at a time when suppurative inflammation is not actually present; and they will certainly prove a good auxiliary to other proper means. Cheltenham water may also be taken with singular advantage by those who labour under any chronic affection of the liver; and this spring is indeed the resort of most of those who have had their biliary organs injured by a long residence in a warm climate. This water, besides containing salts of a purgative nature, is likewise a chalybeate, and the iron is suspended by carbonic acid, of which gas the water contains about an eighth* 188 pyrexia, or febrile diseases. wass l. Its great efficacy, however, in chronic hepatitis, is owing to the gentle continued purging which it excites. Persons of a bilious habit, and who are at the same time costive, will find much benefit by taking two or three of ihe aperient pills here* recommended, at night, or in the morning;, as necessity may require. SPLENITIS, or INFLAMMATION of the SPLEEN. This disease comes on with rigors succeeded by heat, thirsty and other febrile symptoms ; there is an anxiety and,straitnesB in the prSKCordium, with difficult respiration, often conjoined with a cough without expectoration. The patient complains also of ex- ternal heat, tension, pains in the left side which sometimes extend through the whole region of the abdomen, or shoot through the diaphragm, and into the left shoulder. The pains are increased on pressure, and are pulsatory, pungent, and burning in various degrees. The pulse on the left side is sometimes partially sup- pressed, often intermittent, weak, and not quick. There is lassi- tude and loss of strength, watchfulness, and sometimes delirium. Dyspepsia, anorexia, vomiting of green bilious matter, and some- times difficulty of urine from affection of the kidney or bladder. Swelling in the region affected, representing the form of the spleen, faintings, and bleeding from the nostrils at the height of the disease ; but the most remarkable symptom which attends, is the bloody vomiting, which most authors have considered as peculiar, and have designated by various names. By the ancients it was termed atra bilis. At the commencement, the intestines are rather confined, but they soon become relaxed, and emit sub- stances somewhat coloured by black blood. Like the liver, the spleen is often attacked with chronic inflam- mation, and in time becomes enlarged and indurated. Sometimes suppuration ensues, and forms an abscess. The causes of the disease are most generally the same with those of other inflammatory diseases ; but enlargements of the spleen are frequently the consequence of long-continued inter- mittents ; and these, as well as indurations of the liver, are called ague-cakes. They arise, no doubt, from too great a determination of blood to these viscera during the several attacks of the cold fits. With respect to the prognosis in splenitis, it need only be ob- served, that, like other inflammations, it may terminate either in * 7. ft Extract. Colocynth. C. 3i. ------Jalapae, 3ss. Antimon. Tartarisat. gr. iv. Sapon Venet. 3j- 01 Essent. Carui, fll viij. Syrup Rhamni, q. s- M. ft. massa in pilulas xl. distribuenda. " 7. Take Compound Extract of Colocynth, one drachm Extract of Jalap, half a drachm. Tartarized Antimony, four grains. Soap, one drachm Oil of Carui, twelve drops. Syrup of Buckthorn, a sufficiency to form the mass into forty pills. Order II. inflammation op the kidneys. 189 resolution, suppuration, or scirrhus. Sometimes it is carried off by a vomiting of dark-coloured matter, resembling coffee-grounds; sometimes by a diarrhoea, and sometimes by a hemorrhage from the hemorrhoidal vessels. The vomiting of grumous matter is under common circumstances to be considered a favourable and critical evacuation, yet it sometimes proceeds to a fatal excess. Where splenitis terminates in suppuration, and the contents of the abscess are evacuated in the cavity of the abdomen, the event may prove fatal sooner or later; but a simple enlargement of the spleen is often supported for many years without any very great inconveni- ence or hazard to the patient. Dissections of dead bodies show that the spleen is inflamed and sometimes gangrenous, and that the surrounding viscera partake of the inflammation : occasionally an abscess is formed. The conclusions which have been drawn from a multitude of pathological as well as anatomical facts are, that the spleen is an organ peculiar to red-blooded animals; that it is of great importance in preparing and mixing the blood j and that its action is of great consequence to the liver. During the acute stage of splenitis we must adopt the antiphlo- gistic plan by general and topical bleedings, by purging frequently with the submuriate of mercury combined with jalap, and by the repeated application of a blister over or near the part affected. If the inflammation should terminate in suppuration, the abscess is to be encouraged to discharge its contents externally, by fomentations and poultices. Where its termination is in enlargement and in- duration, or scirrhus, we must employ mercury at an early period, both as a purgative and deobstruent, in the manner advised for the removal of chronic inflammation of the liver. The nitric acid may also be tried. If these remedies are not attended with success in removing the enlargements, although the salivary glands have been sufficiently excited, we may make trial of the succuss inspissatus conii, which has been found to answer when mercury has failed*.— See Intermittents. NEPHRITIS, or INFLAMMATION or the KIDNEYS. Nephritis, properly considered, appears to be of two kinds; the one arising from the general causes of inflammation, and being seated principally in the external membrane of the kidney; the other occasioned by the stimulus of gravel or a stone in the pelvis of it, and the inflammation occupying the interior parts. It is, however, only the first of these that I mean here to investigate; the other will be noticed under the head of Calculus. This species of inflammation may be distinguished from the colic, by the pain being seated very far back, and by the urine * See Essay on Hepatitis and other Bilious Complaint5 in India, -j- Pulv. Cort. Cinchonas, |j. —— Cinnam. Compos. 3iss Syrup. Cort. Aurant. q. s. M. ft. Electuarium, de quo capiat quantitatem juglaadis bis in die. 4. Take Infusion of Calumbo Root, four ounces. Compound Tinctureof Peruvian Bark, Cardamoms, of each, half an ounce. magna Of this mixture let the patient take two large spoonsful twice or thrice a day. Or, 5.Take Subcarbonate of Iron, two drachms. Powder of Peruvian Bark, one ounce. Compound Powder of Cinnamon, one drachm and a half. Syrup of Orange Peel, a sufficiency to form these ingredients into an electua- ry, of which the bulk of a walnut is to be taken twice a day. 208 PYREXIAE, OR FEBRILE DISEASES. CldSS I which proved suddenly mortal. Dr. Darwin likewise tells us, in his Zoonomia, that two cases of a fatal termination, from a long continued use of bitter medicines, fell under his observation. The daily use of hop in our malt liquors must, he thinks, add to the noxious quality of the spirit in them, and contribute to the pro- duction of apoplexy, or inflammation of the liver. It has indeed been observed by many other physicians of eminence, that a long continued and excessive use of bitter remedies seldom fails |o weaken the digestive power of the stomach, so as to produce a loss of appetite and impaired digestion, which has accelerate^ the death of those who had used them. The Eau Medicinale d'Husson is a remedy much in vogue at present in gouty attacks, and in some cases it appears to have considerably alleviated the paroxysm; but in a few others it haa produced alarming effects, such as syncope, cold sweats, extreme prostration of strength, excessive evacuations from the stomach and bowels, accompanied with a pulse scarcely perceptible, and a degree of insensibility that indicated approaching dissolution. Such consequences have, however, only ensued when an improper dose of the nostrum has been taken. Besides possessing the pro- perties of an emetic and a cathartic, it appears also to be endowed with the virtues of a narcotic, as in some instances it seems to act as an anodyne previous to any sensible evacuation taking place. The remedy consists of some vegetable of a bitter nauseoiia taste (supposed by some to be white hellebore ; by others gratiola, or hedge-hyssop, and again by others to be colchicum* or the common meadow saffron) infused in Spanish white wine, with an addition of tinctura opii. If the veratrum, colchicum, or gratiola, are riot the basis, probably the roots of betony (the taste of which is bitter and nauseous, and in a small dose will vomit and purge violently) may be the chief ingredient in the Eau Medicinale. In the stomachs of gouty people, a morbid acidity, accompanied by heart burn and flatulence, is usually to be met with, and even this has been thought to have the power of bringing on the disease. Antacids have therefore been found a useful and salutary class of medicines for gouty persons. Alkalies have been considered as of too acrid a nature, and therefore absorbents are preferred ; that most commonly used is magnesia, which proves both absorbent and laxative. To quicken its operation, if found necessary, we may combinef it with a small proportion of rhubarb. * Two ounces of the root of colchicum autumnale cut into slices, and macerated in four ouncesof proof spirit, until the latter is fully imbued with the properties of the tormer, is said by Mr. Want, to be the exact composition of the Eau Medicinale. t 6. ft Magnesias, 3i. Pulv. Rhei. gr. viij. ----Aromat. gr. v. M. fL Pulvis, pro re nata sumendus. Vel, R Magnesias, 3ss. 6. Take Magnesia, one drachm. Powdered Rhubarb, eight grains. Aromatic Powder, five grains. Mux them. This powder may be taken occa- sionally, as the case may require. Or, 7.Take Magncsia> half a drachm. Order II. eouT. 209 Alkalies in various forms, such as the fixed alkali both mild and caustic, lime water, and soap, have however been employed in gouty habits, and of late the alkaline aerated wafer has been much used. Since it became common to exhibit those medicines in nephritic calculous cases it has often happened that they were given to those who were at the same time subject to the gout ; and it has been observed, that under a use of these medicines, gouty persons have received relief, and been longer free from attacks of the disease than before. As a gentle aperient, rhubarb may be employed when costiveness is to be removed. If it disagrees, aloes may be given in the quan- tity of five or six grains combined with any aromatic*, the intent being not to purge, but to keep the bowels regular. In those cases where gout produces anomalous affections of the head, stomach, and bowels, the greatest benefit may be derived from the Bath water ; and it is here a principal advantage to be able to bring by warmth that active local inflammation in any limb which relieves all the other troublesome and dangerous symptoms. Hence it is, that this water is commonly said to produce the gout; by which is meant only, that where persons have a gouty affection, shifting from place to place, and thereby much disordering the system, the internal and external use of the Bath water will soon bring on a general increase of action, indicated by a flushing in the face, fulness in the circulating vessels, and relief of the dyspeptic symptoms ; and the disorder will at length terminate in a fit of the gout, which is the crisis to be wished for. In various cases of gout, especially where the high inflammation of particular limbs has gone off, and where if has left either a number of dyspeptic symptoms, or a rigidity or impaired action in the seat of the disease, an internal use of Buxton water has been recommended. As an external application in gout, it has also been found serviceable in restoring the functions to parts so diseased. In the sciatica or gout affecting the hip, we may recommend Pulv. Rhei,gr.x. Aq. Menth. Pip. f. |iss. M. ft. Haustus. Vel 8. RAq. Menth. Pip.'|vij. Tinct. Gentian, ^ss. Liquor Potassaj, AT, xx. M. Magnesia?, 3i. ft. Mistura. Sumantur cochlearia duo media bis terve in die. * 9. R Pulv. Aloes Spicat. gr. vi. ----Zingib. gr. iij. M. Syrup. Rhamni, q. s. ft. Massa in pilulas duas dividenda. 07 Powdered Rhubarb, ten grains. Peppermint Water, one ounce and a half. This draught may be taken whenever there is occasion. Or, 8. Take Peppermint Water, seven ounces Tincture of Gentian, half an ounce. Solution of Potass, thirty drops. Magnesia, one drachm. Of this mixture two dessert spoonsful may be taken twice or thrice a day. 9. Take Powder of Socotrine Aloes, six grains. ■--------Ginger, three grains. Syrup of Buckthorn, a sufficiency to form the mass, which divide into two pills. 21t PYREXIA, OR FEBRILE DISEASES. CklSS 1. frequent blistering along the course of the sciatic nerve, together with electricity. In severe attacks of atonic gout, some practitioners have ad- vised the application of blisters to the lower extremities; but they ought to be avoided in those cases which are attended with much pain in the parts. Sinapisms, pediluvium, together with wine and other stimulants, have also been recommended in atonic gout for bringing the disease to the extremities. The greatest attention should be paid to promote perspiration and avoid cold ; and this is most effectually done by warm clothing, joined to moderate exercise. A flannel shirt, with a pair of stout shoes, and thick woollen or fleecy hosiery stockings, will be ne- cessary articles of attire for those who cannot remove in the winter to a warmer climate. When the stomach or intestines become affected in consequence of retrocedent gout, immediate relief ought to be attempted by making the patient drink freely of wine, or even brandy, joined with aromatics. In affections of this nature, strong spirits impreg- nated with assafostida or garlic may also be given with much ad- vantage. Opiates* joined with aromatics, or with camphor, musk, or ammonia, may be of service. From one to four teaspoonsful of equal parts of camphorated tincture of opium, and aminoniated tincture of guaiacum, in any suitable vehicle, will be a proper medicine. iEther will likewise be a useful remedy. At the same time that we administer these medicines internally, warmth should be applied externally to the region of the stomach by hot cloths, fomentations, or a bladder filled with warm water, and hot bricki wrapped in flannel must be put to the feet. Frictions with brandy, or the linimentum ammonia? fortius over the stomach, will also be proper. If nausea and vomiting come on, the stomach is to * 10.&Opii,gr.j. Camphorae, gr v. Ammonias Subcarbon. gr. vj. Confect. Aromat. gr. v. M. ft. Bolus pro re nata adhibendus. Vel, 11. RMisturae Camphorae, f. ^jss. Ammonias Subcarbon. gr. x. Tinct. Opii, fTl viij. Spt. .Ether. Sulph. fll xx. M. ft. Haustus tertia quaque hora sumendus. Vel, 12. g; Moschi, gr. v. solve in Misturae Camphor. 3*. Spirit. Ammon. Aromat. 3ss. Tinct. Opii, iJ[ viij. M. ft. Haustus. * 10. Take Opium, one grain. Camphor, five grains. Subcarbonate of Ammonia, sis grains. Aromatic Confection, five grains. Make them into a bolus, to be taken whea requisite. Or, 11. Take Camphor Mixture, one ounce and a half. Subcarbonate of Ammonia, tei grains. Tincture of Opium, twelve drops. Spirit of Sulphuric .(Ether, thirty drops. Mix them. Take this draught every three hours. Or, 12. Take Musk, five grains ; dissolve it » Camphorated Mixture, teu drachms. Aromatic Spirit of Ammonia, halt a drachm. Tincture of Opium, twelve drops. Mix them for a draught. Order II. GOUT. 211 be relieved by taking a few draughts of wine, somewhat diluted with warm water, having recourse afterwards to opiates combined with camphor. In retrocedent gout, where the heart becomes affected, the above means may be adopted. » If there is a translation of the disease from the extremities to the head, so as to threaten apoplexy or palsy, a large blister ought to be applied to the back, as likewise 6mall ones to the inside of the legs, with cataplasms to the soles of the feet, and the patient must take from twenty-five to forty drops of the spiritus ammonia? aromaticus every three or four hours, or a combination of volatile alkali, aether, and aromatics, as specified in the formula? at the bottom of the preceding page, omitting the opium. Abut six drachms or an ounce of the tinctura aloes may also be taken as a gentle purgative. When the gout attacks the lungs, and produces asthma, blisters should be applied to the breast or back, and stimulating cataplasms to the soles of the feet, and opiates and antispasmodics should be administered internally. From twenty to fifty drops of aether may be taken every two or three hours in a glass of wine, and an opiate* may be repeated as the necessity of the occasion requires. In this particular retrocession of gout, where the attack is so severe as to threaten suffocation, as well as where there is a translation to the head, venesection might be resorted to with advantage. Where the disease attacks the kidneys, and imitates a fit of the gravel, the patient ought to keep warm fomentations, or bladders filled with warm water, constantly applied over the parts affected; he should drink freely of tepid diluting liquors; and an emollient clyster, with an addition of a small quantity of tinctura opii, ought * frequently to be injected. In order to alleviate the pain, thirty or forty drops of the same tincture may likewise be taken by the mouth in any kind of vehicle. During paroxysms of the gout, the treatment must be active and appropriate : after they have subsided, the remaining duty to be'per- formed, is the restoration of the healthy state of the digestive functions, and of due strength in the weakened limbs. In such cases and cir- cumstances as do not forbid tbe use of steel, from too much vascular fulness and action, the tincture of ammoniated iron may be taken advantageously in a little warm water in doses of twenty drops, grad- ually increased to about sixty. The gout imitates many diseases, as has already been observed; and by being mistaken for them and treated improperly, is often * 13. Take Aromatic Confection, half a drachm. Cinnamon Water, one ounce and a half. Tincture of Opium, thirty drops. 1 Mix them for a composing draught. • 13. R Confect. Aromat. 3ss. Aq. Cinnam. f. ?jss. Tinct. Opii, fllxx. M. ft. Haustus. 212 PYREXIA, OR FEBRILE DISEASES. Cla$S 1, diverted from its regular course, to the great danger of the person's life; for which reason, those who have had the gout ought to pay particular attention to any complaint that may happ< n to take place about the time they may have reason to expect another attack of it. Those likewise who never had the gout, but who, from constitution or manner of living, have reason to expect it, ought also to be very circumspect with regard to its first approach, as by any wrong conduct, or improper treatment, it might be diverted from its right course, and be thrown upon some vital part. To render the recurrences of gouty paroxysms less frequent, and their attacks less severe, we may rest assured that more is to be done by temperance in diet, cheerfulness and serenity of mind, a moderate exertion only of the intellectual faculties, an early hour of retiring to rest, obviating costiveness as the occasion may require, and by regular moderate exercise, than by any other means whatever, being at the same time attended with greater safety. The exercise must be suited to the condition of the patient. Walking will certainly be the best; but if he be unable to use it, he must employ some other kind, as riding on horseback, or in a carriage. Although walking may probably be irksome at first, and the feet feel tender, yet by perseverance it will become more agreeable, and great advantage will be derived. Where no exercise can be taken, some benefit may possibly arise from frictions. In those who have an hereditary disposition to gout, it is certain that it may often be prevented from taking place by paying an early and strict attention to regimen, temperance, and exercise ; and even after it has shown itself by a regular attack, its returns may possibly be prevented for tbe remainder of life : but it is only those who have sufficient resolution to observe a steady perseverance in such a course, that can have any reason to expect a cure. Exercise in persons disposed to the gout, not only strengthens the system, but tends likewise to prevent a plethora. To prove advantageous, it must, however, be constant, regular, and continued through life, and should only be moderate. In the beginning of the disease, when the disposition or tendency to it is not strong, exercise will often prevent an attack which might otherwise have taken place, and in the intervals it will always be proper as long as the patient retains the use of his limbs. In a more advanced stage of the disease, where there is an evident disposition to a paroxysm, much walking ought to be avoided, as it might tend to hasten its approach, by increasing the inflammatory disposition in the lower extremities. While the vigour of the system still remains unimpaired, either by intemperance or frequent attacks of the gout, an abstinence from animal food may be entered upon with safety, in order to prevent a recurrence of the disease; but if this abstinence shall not have been adopted until the constitution has been hurt by intemperance, frequent fits, or the decline of life, it certainly will prove injurious, and might tend to bring on an irregular attack. Order II. -RHEUMATISM. 213 A sudden change from a full to a spare and low diet, will in all cases whatever be highly improper; and whenever an alteration is made in the mode of living, it ought to be done in a gradual manner. Where an abstinence from animal food is to be observed, a diet con- sisting of milk and the farinaceous seeds will be the most proper, and all kind of spirituous and fermented liquors are to be avoided; but where custom or a declining state of the system has rendered them absolutely necessary along with a use of animal food, they are then to be used with moderation. Besides regimen and exercise, it will be necessary for the patient to observe universal temperance; he is to shun night studies, and any excess in sensual gratifications; he should go to bed betimes, and rise early ; and he should avoid all exposure to cold, but more particularly getting wet in the feet. In the gout, as well as in regard to all other diseases, the cardinal rules in preserving the health are founded on temperance and exercise, on the choice of all those means which are found by the individual to invigorate the system, and the shunning whatever injures and enfeebles it. Some persons much disposed to gout, who have been reduced to poverty and obliged to work hard and use alow diet, have been cured by it, which clearly demonstrates the efficacy of exercise, temperance, and a spare regimen. RHEUMATISMUS, or RHEUMATISM. The characteristics of rheumatism, as assigned by Dr. Cullen, are pyrexia, pain about the parts following the tract of the muscles, attack- ing the knees and larger articulations, in preference to those of the feet or hands, increased by external heat. The disease is distinguished into the chronic and the acute; being known by the former appellation when there is no great degree either of inflammation or fever present, but merely pains; and by the latter, when both fever and inflammation exist in a high degree. It may arise at all times of the year, when there are frequent vicis- situdes of the weather from heat to cold; but the spring and autumn are the seasons in which it is most prevalent; and it attacks persons of all ages; but very young people are more exempt from it than adults. Those whose employments subject them to alternations of heat and cold, are particularly liable to rheumatism. Although acute rheumatism somewhat resembles the gout, still in some respects it differs from it. It does not usually come on so suddenly as a fit of the gout, but for the most part gives the patient warning by a slow and gradual increase of pain. Neither is it fixed to one spot like the gout, but is distinguished by its frequent wanderings from place to place, accompanied by a sense of numbness. It seldom attacks the small joints, but is confined 214 PYREXIA, OR FEBRILE DISEASES. CUtSi I. chiefly to the larger, as the hip, knees, and shoulders. Acute rheumatism is generally attended with a continued fever; whereas the gout has periodical remissions. Like most of the pyrexiae, it is preceded by rigors, and a sense of cold. A febrile, quick, and hard pulse supervenes ; the veins near the part affected swell; and a throbbing pain is felt'in the arteries. By degrees the pain in- creases, and the patient suffers cruel torture, which is increased on the least motion. The sense of pain resembles that of a slow dilaceration of the parts, and commonly goes off by a swelling 0f the joint or joints. The rheumatism, moreover, is not precede! by dyspeptic symptoms, as is usually the case with the gout; neither do chalky concretions form about the small joints and fingers, as in the latter. Obstructed perspiration, occasioned either by wearing' wet clothes, lying in damp linen, sleeping on the ground or in damp rooms, or by being exposed to cool air when the body has been much heated by exercise, or by coming from a crowded public place into the cool air, is the cause which usually produces rheumatism. Those who are much afflicted with this complain't'are very apt to be sensible of the approach of wet weather, by finfling wandering pains about them at that period : in fact, some are living barometers. The proximate cause of the acute species of the disease at least, is supposed to be an inflammation of the membranes and tendinous aponeuroses of the muscles. Acute rheumatism usually comes on with lassitude and rigors, succeeded by heat, thirst, anxiety, restlessness, and a hard, full, and quick pulse; the blood, when drawn from a vein, exhibits an'inflam-' matory surface upon tooling, and the tongue preserves a steady whiter ness; after a shor,t time excruciating pains are felt in different parts of the body, but more particularly in the joints of the shoulders, wrists, knees, and ancles, or perhaps in the hip ; and these keep shiftingfrom one joint to another, leaving a redness and swelling in every part they' have occupied, as likewise a great tenderness to the touch. Towards eveping there is usually an exacerbation or increase of fever, and during the night the pains become more severe, and shift from one joint to another. Sometimes the pain is confined to a few joints; in other cases it affects many at the same time. In no disease do we meet with such' remarkable instances of metastasis, and no muscular part'is exempted' from the pain. The internal muscles, as the diaphragm and heart, have been said to be sometimes affected with metastasis. In these translations of rheumatic inflammation, the stomach is also sometimes attacked. The pain is met with in every degree of violence, and is highly aggravated by pressure or motion. The face in general is not flushed, there is seldom much headach, and in most cases there seems to be little tendency to delirium. The stomach generally is not af- fected, but the bowels are usually costive. Early in the course of the disease some degree of sweating Order II. RHEUMATISM. 215 usually occurs ; but it seldom removes the pains, or proves either salutary or critical; and it is somewhat singular that the pained limbs remain dry, when a sweat is on the rest of the body. In the begin- ning the urine is without any sediment; but as the disease ad- vances in its progress, and the fever admits of considerable remis- sions, a lateritious sediment is deposited ; but neither does this prove critical. Chronic rheumatism is attended with pains in the head, shoul- ders, knees, and other large joints, which at times are confined to one particular part, and at others shift from one joint to another without occasioning any inflammation or fever ; and in this manner the complaint continues often for a considerable time, and at length goes off, leaving the parts which have been affected in a state of debility, and very liable to fresh impressions on the approach of moist damp weather. Little danger is attendant on chronic rheumatism ; but a person having once been attacked with it, is ever afterwards more or less liable to returns of it, and an incurable anchylosis is sometimes formed in consequence of very frequent relapses. Neither is the acute rheumatism often accompanied with much danger, as it usually goes off spontaneously, or is removed by the timely employment of proper remedies ; but in some instances the patient has been de- stroyed by general inflammation, and now and then by a metas- tasis to some vital part, such as the head, lungs, heart, and stomach. Many cases of cardiac inflammation are indeed either combined or alternated with acute rheumatism. It has been observed, that per- sons subject to rheumatism are attacked more frequently than others with symptoms of an organic disease in the heart ; and that in some instances the lungs have been much affected with severe dyspnoea, no doubt from the disease being translated to these parts, occa- sioning real inflammation of these organs*. Acute rheumatism, although accompanied with a considerable degree of inflamma- tion in particular parts, has seldom been known to terminate in suppuration ; but a serous or gelatinous effusion sometimes takes place. A general, but not unnaturally profuse perspiration, the deposit of a lateritious or furfuraceous sediment in the urine, eruptions on the skin, or moderate hemorrhage of blood from the nose or other parts, may be regarded as favourable symptoms ; whereas the in- flammation becoming erysipelatous, and assuming a dark red or rose colour, and this followed by vesications, metastasis of the in- flammation to the head, chest, or abdominal viscera, producing the symptoms of the idiopathic diseases of these organs, are to be looked upon as unfavourable. Rheumatism seldom proving fatal, very few opportunities have offered for dissections of the disease. In the few which have oc- curred, the same appearances have been observed as those men- * See Medico-Chirurgical Transaction?, vol. i. 216 PYREXIJE, OR FEBRILE DISEASES. Ckut I. tioned under the head Inflammatory Fever. In the joints, thicken- ing of the membranes, ad.lesions, and gelatinous effusions, are the only phenomena to be met with. The principal thing to be attended to in the treatment of acute rheumatism, is to obviate the general inflammation which prevails, and this is to be effected by strictly pursuing an antiphlogistic regi- men, and by blood-letting in all cases where the vascular action is strong, the constitution robust, and the heat considerable, propor- tioning the quantity we take away to the violence of the symptoms, and the age, strength, and habit of the patient. If the pains con- tinue very severe, and the pulse full, hard, and quick, after bleed- ing, and the blood appears very sizy on becoming cool, we may with great propriety repeat the operation either on the same day or the next : but this mode of proceeding should be adopted only at an early period of the disease. The reduction of vascular action is, however, more particularly to regulate the repetition, than the huffy appearance of the blood, which in many cases continues to increase, notwithstanding the abstraction of blood, and is not diminished by bleeding. This circumstance should be attended to. To repeat bleeding until the pulse be reduced to 100 or a little below, may be a good rule. [n weak irritable habits, where no great degree of general inflam- mation prevails, and little or no fever attends, and where the in- flammation is chiefly local, or the pain not violent, topical bleeding, by means of several leeches applied to the part affected, may be substituted instead of using the lancet, and will often be found to afford essential relief. Moreover, they are not attended with the risk of causing translations of the disease. They may likewise be used with benefit where much inflammation prevails in the system, as well as in particular parts, provided that some general bleeding has been premised or adopted. When leeches cannot be procured, scarifying and cupping may be employed in their stead. It has been usual in acute rheumatism to rely principally on large and repeated bleedings at an early period, joined with an antiphlogistic regimen; and no doubt this evacuant plan of treat- ment has in some cases been carried to excess, and produced an alarming degree of debility. Having reflected much on this cir- cumstance, and well considered, the wonderful power which the digitalis possesses of diminishing the action of the heart and arte- ries, I have employed it in some severe cases of acute rheumatism after one or two bleedings from the system, and with much appa- rent advantage; for I found that its use rendered any further re- petiiion of venesection unnecessary. In the instances to which I allude, from ten to twenty drops of its tincture were given every four or six hours. In case of costiveness prevailing, one or two evacuations should be procured daily by making use of some gentle cooling purgative, such as the neutral salts, or by giving laxative clysters, which may be the preferable way when the disease is general and violent, as Order II. RHEUMATISM. 217 the motion occasioned by frequently getting up to stool would prove irksome and painful to the patient. Where the pain is chiefly confined to one part, and is unaccom- panied by much inflammation, the application of a blister will be likely to prove serviceable, or we may rub it with some kind of rubefacient liniment*; but where the pains are wandering, and there are frequent translations from one joint to another, neither of these remedies will be of much use. In acute rheumatism, warm fomentations ought never to be employed, as they are found to aggra- vate the pains instead of alleviating them. Where, on the sudden subsidence of the external pain and inflam- mation, some of the viscera or head are attacked, blisters should always be applied near those parts where the disease had originally existed, their power of counter irritation being useful on such an occasion. When any of the joints of the extremities swell very much, and are highly painful, we may, besides drawing blood from the part by means of leeches, make use of attenuating cataplasms, such as the cataplasma farina? compositumf of the Pharmacopoeia Chirur- gica, the ingredients of which being wrought into a paste with hot water, are to be wrapped round the part affected, and to be renewed morning and evening. The reduction of heat by keeping linen cloths wetted in cold water, or in a solution of muriated ammonia, with the nitrate of potass, constantly to the inflamed parts, may, I think, be adopted with safety and much advantage in acute rheumatism, although in gout the remedy ought certainly to be looked on as hazardous. During the summer of 1807 1 visited Russia for a few months, and understood that the physicians there are in the habit of recommend- * 1. Take Camphorated Spirit, two ounces. Solution of Ammonia, half an ounce. Oh" of Rosemary, fifteen drops. Mix them for a Liniment. Or, 2. Take Olive Oil, three ounces. Rectified Oil of Turpentine, one ounce. Sulphuric Acid, fifteen drops. Mix them. Or, 3. Dissolve Camphor, two drachms, in Olive Oil, two ounces, and add Tincture of Spanish Fly, one drachm. Solution of Ammonia, half an ounce. Mix them for a Liniment. t 4.Take Rye Flour, one pound. State Vinegar or Beer, four ounces. Muriated Natron, two ounces. Mix them for a cataplasm. * 1. ft Spirit. Camphorae, f. |ij. Liquor. Amnion, f. ?ss. Essent. 01. Rosmarin, fll x. M. ft. Linimentum. Vel, 2. R01. Olivas.f. §iij. — Terebinth. Rectif. f. |j. Acid. Sulph. TT1 x. M. Vet, 3. ft Oh Olive, f. jy. Camphorse, 3U- Solv. et adde Tinct. Lytta^fSj. ' Liquor. Amnion, f. ^ss. M. i 4. ft Farkiae Secalis, ftj. *' Fennenti Veteris Acris, f. ?iv. Natri Muriati, |ij. M. ft. Cataplasma. 28 218 PYREXIAE, OR FEBRILE DISEASES. ClaSS, I. i ing the application of snow or pounded ice in cases of this nature, and j often with a very good effect. When rheumatic inflammation is local and stationary, the aid of cold applications, or of the evaporating treatment as noticed under the head of Gout, will be likely to prove very beneficial; but when the inflammation quickly wanders from one part to another, almost eluding our pursuit, we must rely more confidently un constitutional means, and make our local treatment accordingly both more sub- servient and considerate. - i After the necessary evacuations have been made, diaphoretics may then be used, and either those of the antimonial kind, as ad- vised under the head of Simple Fever, may be prescribed in small and frequently repeated doses, or from ten to fifteen grains of the pulvis ipecacuanha? compositus* may be given every three or four hours. This indeed appears to be the best sudorific we can exhibit in acute rheumatism. Volatiles are employed b) some practitioners t in the cure of rheumatism, for the purpose of exciting a diapho- resis. With the same view camphor has been likewise adminis- tered. They may be given separately, or be combined together, agreeable to the formulae advised belowf, should the remedies before recommended not prove sufficiently powerful. To increase * 5. ft Pulv. Ipecac. C. gr. x. * 5. Take .Compound Powder of Ipecacu- anha, ten grains. Confect. Rosae, gr. xij. Confection of Roses,tweIve grains, Syrup, q. s. M Syrup,asufficiencyt»formaBolu», ft. Bolus 3tia vel 4ta hora sumendus, super- which may be takeii every three or four hours, washing it down with three large spoonsful of the following Mixture :— 6. Take Lemon Juice, one ounce and a half. Subcarbonate of Ammonia, one drachm. Pure Water, four ounces and a half. Nitrate of Potass, half a drachm. Syrup, half an ounce. Mix them. t 7. Take Subcarbonate of Ammonia, ten grains. Antimonial Powder, two grains. Confection ef Rose.; a sufficiency to form a Bolus, which may be taken every four hours. Or, 8. Take Wine Whey, ten ounces. Volatile Liquor of Hartshorn, thirty drops. Mix them, and let the patient drink the whole on going to bed. Or, 9. Take Camphor Mixture, one ounce. Solution of the Acetate of Ammo- nia, three drachms. Antimonial Wine, twenty drops. Mix them for a draught, to be repeated every four or six hours. did. cocin. hj iviisturae sequenus:— 6. ft Succ. Limon. f. ^jss. Ammonia; Subcarbonat. 3j- Aq. Fontan. f. ^ivss. Potassae Nitrat. 3ss. Syrup. Sinipl. f. ^ss. M. ft. Mistura. t 7. ft Ammonia? Subcarbon. gr. x. Pulv. Antimon. gr. ij. Confect Rosae, q. s. M, ft. Bolus 4tis horis sumendus. Vel, 8. ft Seri Lactis Vinos, f. ^x. Liq. Vol. Cornu. Cerv. HXxx. M. Bibat ajger hora decubitus. Vel, 9. ft Mistur. Camphorae, f. ^j. Liquor. Amnion Acetat. f. 3iij. Vin. Antimon. TH. xv. M. ft. Haustus 4ta vel 6ta quaque hora repe- tendus. Order II. rheumatism. 2\9 the effect of all these medicines, the patient should at the same time be enveloped in flannel, every article of linen being removed ; and as soon as he begins to sweat, and not before, lest vomiting be induced, he ought to drink freely of diluents, such as herb lea, barley-water, arid wine-whey. As an auxiliary remedy, warmth applied to the extremities, espe- cially to the affected parts, is of some consequence. It may be employ- ed either in the form of fomentations, or in a dry one, by warm bottles, or bricks wrapped in flannel. Sweating is an evacuation which is resorted to very generally both in the acute and chronic rheumatism, and in many instances with very essentia! benefit; but it has its inconveniences, for sometimes it comes out freely without producing any good effect, and when long continued it relaxes the skin, and makes the patient very susceptible of cold afterwards: to guard against which, it will be necessary for him to be confined to his chamber, and to wear a flannel shirt for some time. In the early stage of the disease it is desirable to procure perspi- ration by diaphoretics of the antimonial kind, or the compound powder of ipecacuanha joined to saline medicines, and in some cases material relief has been obtained thereby. If, however, obvious benefit does not ensue within forty-eight hours, we ought then to discontinue the use of diaphoretics, as being more likely to do injury than good. Every local means to increase perspiration ought also after this period to be avoided, whether by a use of flannels, hot appli- cations to the painful parts, or the warm bath. Instead of them, linen cloths dipped in camphor mixture and cold water, may be applied. Opiates combined with camphor are given by many practitioners in acute rheumatism ; but such a compound is not likely to prove efficacious; and the best way of administering opium in this disease when the pain is considerable, is by using the pulvis ipecacuanha? compositus, as has just been mentioned, or by giving it combined with antimony*. Other narcotics, such as conium, hyoscyamus, 10. ft Pulv. Antimonial. gr. ij.—iij. 10. Take Antimonial Powder, from two to three grains. Opium, half a grain. Confection of Roses, a sufficiency to form these into a pill,which is to be taken every six hours, washing it down with the common saline draught. Or, 11. Take Solution of the Acetate of Am- monia, three drachms. Mint Water, one ounce. Antimonial Wine, twenty drops. Tincture of Opium, thirty to forty- five drops. Syrup. Simpl. f. 3*j- M. Common Syrup, two drachms. ft. Haustus hora somni adhibendu*. |Mix them, and give the draught at bed ' time Opii, gr. ss. Confectionis Rosae, q. s. M. ft. Pilula 6ta quaq. hora sumenda cum haustu saliuo communi. Vel, 11. ft Liquor. Amnion. Acetat. f. 3uj. Aquae Menth. virid. f. ?j. Vin. Antimon. Vf[ xv. Tinct. Opii, 111 xx-—xxx. 220 PYREXIAE, OR FEBRILE DISEASES. ClttSS I.' aconitum, and digitalis, are sometimes employed with seeming advan- tage after the bowels have been freely evacuated. A new mode of treating every case of acute rheumatism by a liberal and early use of the bark of cinchona had been adopted, as well as recommended, by a late celebrated reader of Lectures on the Practice of Physic*. He informs us, in his Third Dissertation on Fever, that for the last fifteen years he had entirely left off bleeding in this disease, and that he had not lost above two or three patients, although he treated several hundreds who laboured under it in this way ; and he adds, that when he practised bleeding largely in acute rheumatism, metastases were very apt to take place, and to destroy the patient, which accident had rarely happened since he discontinued its use. With due deference to so high an opinion, I am however in- duced to think, that where the inflammation of the system is great, the pulse quick and full, and the person young and of a robust constitution, early venesection (the quantity of blood to be abstracted being duly proportioned to the circumstances of the case) is not only necessary in attacks of acute rheumatism, but that those who fall victims to it die frequently from its not having been adopted. Another advocate for a very early use of the bark of cinchona in this disease is Dr. Haygarth, who tells usf, that for several years his usual method of treating acute rheumatism has been to give either the an- timonial powder or tartarized antimony, generally the former, till the stomach and bowels are sufficiently cleansed : without waiting for any other evacuation or abatement either of the inflammation or the fever, he then orders the cinchona bark at first in small doses, and if they succeed, gradually in larger; but if it disagrees in any respect, or does not produce manifest relief of the symptoms, the bark is sus- pended, and the antimony again repeated till it shall have produced sufficient evacuations. After cleansing the stomach and bowels a second time, he administers the bark again, at first sparingly, and then more freely. He never continues it longer nor in larger quantity than what perfectly agrees with the stomach, the fever, and the rheumatic inflammation. Dr. Haygarth cautiously adds, however, that if doubts occur on any of these points it will be advisable to have recourse to bleeding by the lancet or leeches, or both, and to more evacuations by antimony. In such cases the cinchona is not to be again employed till the inflammatory symptoms are abated. Our author assures us, that with the exception of a very few cases, this bark has uniformly produced the most salutary effects. The pains, swellings, sweats, and other symptoms of inflammatory fever, manifestly and speedily abated, and gradually * Dr. George Fordyce. t See Dr. Haygarth's Clinical History of Acute Rheumatism Order II. rheumatism. 221 ceased, till health was perfectly restored. The evidence adduced by him is much in favour of the cinchona as a remedy in acute rheumatism. It appears that Dr. Haygarth began to administer cinchona in the acute rheumatism in 1772, at first cautiously, and, as it mani- festly produced salutary effects, more freely, upon the recommenda- tion and high authority of that very eminent physician Dr. John Fothergill*. In the last edition of his Clinical History of Acute Rheumatism, Dr. Haygarth has adduced the most respectable, testi- mony! in favour of this practice. The late Sir George Baker (who learned this method of treating the disease from Sir Edward Wilmot), Dr. Heberden (who quotes the recommendation of his fa- ther), Dr. Saunders, Dr. Willan, Sir Lucas Pepys, Dr. Lettsom, Sir Walter Farquhar, and Dr. Aikin, have all of them administered cinchona at an early period of acute rheumatism with very salutary effects. A late authorj also confirms the utility of this practice from his own observations. But this mode of treatment, Dr. Hay- garth observes, being directly contrary to medical theories, even successful experience by the most learned and sagacious physicians has not yet prevailed against established doctrines, and the prac- tice is but partially adopted. By most physicians the use of cinchona bark, during the inflam- matory state of acute rheumatism, has been disapproved of; and it is only after the inflammatory diathesis has been subdued by anti- phlogistic remedies, and where at the same time the exacerbations of the disease are periodical, with considerable remissions interposed, that its use has been thought proper. Since the first edition of this work appeared before the public, I have been much in the habit of administering the cinchona, joined with nitre^, in acute rheumatism, and generally with a very happy effect. I would therefore recommend this combination of medicine at an early stage of the disease, in preference to giving the bark separately ; but I do not advise the use of it even in this way until the inflammatory symptoms have been somewhat counteracted by the antiphlogistic remedies which have been pointed out. Where there are intermissions of pain, a clean and moist tongue, a per- * See Dr. Haygarth's Clinical History of Acute Rheumatism, pp. 59—72. t Ibid, pp.141—155. X See Granger's Medical and Surgical Remarks, pp. 240—267. <§ 12. ft Pulv. Cinchonas, 3ss—3j. Potassae Nitratis, gr. x. M. ft. Pulvis 4tis horis repetendus. Vel, 13. ft Decoct. Cinchon. f. ?js3. Potassae Nitratis, gr. xij. M. ft Haustus. § 12. Take Powder of Peruvian Bark, half a drachm to one drachm. Nitrate of Potass, ten grains. Mix them, and repeat this powder every four hours. Or, 13. Take Decoction of Peruvian Bark, one ounce and a half. Nitrates of Potass, twelve grains. 'Mix them for a draught, to be taken as the I former. 222 PYREXIA, OR FEBRILE DISEASE3. ClaSS / spiring skin, and a lateritious sediment in the urine, the use of this remedy is clearly indicated, and should no longer be delayed. In some cases I have of late employed it with much benefit, combined with the oleum terebinthina;*. Dr. Hamilton, of Lynn Regis, informs usf, that in those cases of acute rheumatism where blood-letting and sudorifics have been pushed as far as may be thought prudent, without being productive of the desired effect, and where a sufficient remission cannot be obtained so as to give the cinchona bark, very great benefit is often to be derived from the use of the submuriate of mercury, combined with opium, which combination he has frequently employed in the proportion of from five grains to one of the former, and from one to one-fourth of the latter, according to the age and strength of the patient, and administered every six, eight, or twelve hours, as the degree of inflammation, or the threatening aspect of the disorder, seemed to require. Along with this remedy he enjoins a plentiful dilution with barley-water, or any other weak tepid beverage. Early and moderate venesection, succeeded by gentle purgatives, calomel, opium, and antimony, is perhaps the best plan that can be pursued in acute rheumatism. In acute rheumatism the patient must be kept on a cool spare diet, as milk, whey, buttermilk, light vegetable matters, panado, ripe fruits, &c. : animal food and fermented liquors should be avoided. A different mode of treatment from what has been advised in acute rheumatism must be adopted in the chronic species. Here bleeding from the system will neither be necessary nor proper. Where the ligaments and membranes of the joints are the peculiar seat of the disease, or an enlargement of the extremities of the bones has taken place, the first attempt at relief, especially in young and vigorous subjects, should be directed to local bleeding, either by leeches, or what is to be preferred, the operation of scari- fying and cupping. When the pain and irritation are abated by repeated bleeding, no time should be lost in securing a drain from the part by the aid of issues, making them with caustic in preference to the knife. In hip cases of long standing, as well as in obstinate ones of sciatica, the same practice will be found highly beneficial. In most cases it will be advisable to rub the parts which are the seat of the disease several times a day with some rubefacient lini- ment, as prescribed in acute rheumatism, after which they are t See vol. ix. of the Edinburgh Medical Commentaries. * 14. ft Decoct. Cinchonae, f.|iss. Pulv. Ejusdem, 3j. 01. Terebinth. TTl xv.—xxv. M. ft. Haustus sextis horis adhibendus. * 14. Take Decoction of Peruvian Bark, one ounce and a half. Powder of the same, one scru- ple. Oil of Turpentine, twenty to five and thirty drops. Mix them., and give the draught every si* hours. Order II. rheumatism. 223 to be enveloped in flannel. The regular use of a flesh-brush, with electricity or galvanism, may be requisite in cases of long standing, and where there is any rigidity in the parts. Exercise either of the whole, body or of particular limbs will be highly important. As an exercise for the arm, the dumb-bells answer very well. For the lower extremities none will answer better than walking ; and although it may prove a little irksome at first in some cases, still by perseverance much benefit will soon be experienced. The want of exercise is apt to induce stiffness in the limb. Frictions with acetic aether on the painful parts have been em- ployed in France with much benefit, particularly in cases of scia- tica and lumbago. The remedy is reported* to posses? the advantage of producing an agreeable heat on the skin, and a very useful per- spiration, without augmenting the irritation or erethism in the parts. Camphor dissolved in aether, and applied externally in painful affection of the joints, has likewise afforded singular relief in a great variety of instances. The ointment and embrocation of tartarized antimony have the property of producing a crop of pustules wherever they are rubbed, and when this effect is procured, they ought of course to be dis- continued. Immersing the whole body in a warm bath, or applying it topi- cally, by pouring warm water upon the limb from a kettle several times a day, has, in many instances, proved very useful, together with proper exercise, either of the part itself, or of the whole body, if the patient is capable of taking it. A quarter of an hour, or twenty minutes, will be sufficient time to remain in the bath, the temperature of which may at pleasure be varied from 90 degrees to 114. This scale appears sufficiently extensive in all cases to insure the beneficial effects to be expected from the use of a tepid or hot bath. If the pains are of a recent date, and chiefly attack the muscles and thin membranous coverings, occasionally shifting from one part to another, and the strength is at the same time but little reduced, there can be no doubt that a moderate use of the warm bath may be serviceable ; but where it proves unsuccessful after two or three trials it ought to be discontinued. In soothing pain, relaxing the stiffened joints and rigid fibres, particularly in elderly patients whose strength has been much reduced by the length and violence of the disorder, a tepid bath of from 84 to 90 will often prove a useful auxiliary to the other means we employ. Both remedies however may, I think, be considered of inferior value in the cure of rheumatism, when compared with the topical, and sometimes general use of hot water in the form of vapour. Whenever the joints are very rigid, and the pain upon motion ex- * See Recueil Periodique de la Soeiete de Medecine de Paris, No. xlviii. 224 PYREXIAE, 6R FEBRILE DISEASES. ClaSS 1. quisitely severe, or where the muscles have become contracted and almost paralytic; and indeed in all protracted cases of the disease of the hip joint, lumbago, or sciatica, the vapour of hot water, locally and properly applied, will seldom fail, in conjunction with other proper topical applications, to prove a safe and successful remedy. The mode of applying it must be regulated according to circumstances. A large boiler with a pipe affixed to it forms a simple apparatus. With this the parts affected may be steamed for about half an hour at a time, repeating the process two or three times a day. A vapour bath constructed agreeable to the plan advised by the Honourable Basil Cochrane*, or in the Russian manner, would bet great acquisition in all infirmaries and hospitals. The latter is very simple. The building usually consists of a wooden house, situated, whenever it is possible, by the side of a running stream. In the bath-room is a large vaulted oven, which, when heated, makes the paving stones lying upon the top of it red hot; and adjoining to the room is a kettle fixed in masonry for the purpose of holding boiling water. Round about the sides of the room are a few rows of benches one above another like the seats of an amphitheatre. Little light is admitted, but here and there are apertures for per- mitting the vapour to escape, the cold water which is wanted being let in by small channels. The heat of the bath-room is usually from 32 to 40 degrees of Reaumur's thermometer, that is, from about 114 to 132 of Fahren- heit's. Warm water is thrown every five minutes or so upon the hot stones, by which means the heat is somewhat increased, espe- cially in the upper parts of the building. The bathers recline on the benches in a state of nature, and they perspire more or less in proportion to the heat of the humid atmosphere in which they are enveloped. To promote perspiration the better, and completely' to open the pores, they are at first well rubbed with the hands, and then gently flagellated with leafy bunches of birch. After remain- ing awhile, they quit the sweating bench, and wash the body with warm or cold water. During my stay at Petersburgh, I observed that many of the Russians threw themselves immediately from the bath-room into the adjoining river. In the winter they roll them- selves in snow, in a frost of ten or more degrees of Reaumur's ther- mometer, nor is the sudden change succeeded by illness, or product tive of the least inconvenience. > i Incases of chronic rheumatism, where great debility prevails with deep-seated pain, the warm bath frequently renders the patient hot and restless, and seldom or never relieves, unless it induces sweat. Now the advantage of the vapour bath is, that perspiration takes place at a much lower temperature in it than the other: the vapour bath need not to be heated above 96 degrees to produce a salutary perspiration, whereas a warm bath seldom produces this * See his pamphlet on Vapour Baths. Order II. RHEUMATISM. 226 discharge at a lower temperature than 100 degrees, and from that it is used up to 112 in some of the hot springs at Bath. Besides this increased heat applied to the skin when the exhalants are ready to yield their contents, the surrounding medium presses upon the cuticle, and in some measure prevents the flow of perspiration which it had brought on the surface : on the contrary, in the vapour bath the heat being applied to the body in an aeriform state, unites with the insensible perspiration as it arises by the exhalants, condenses upon the surface, and drops from the body by its own weight, meeting with no resistance' from the elastic vapour*. After exposing the diseased parts for a due length of time to the ac- tion of vapour, and diligently rubbing in some rubefacient liniment during the operation, we may immediately after employ electricity, either in slight shocks, or by draw ing sparks. Perhaps the latter may be the preferable way. The process being completed, the parts are then to be enveloped in flannel. Dr. Bardsley, in his Medical Reports, mentions, that he has seen at the Manchester Infirmary several hip cases of long standing yield to the persevering use of topical bleeding by means of cupping and scarifying, with the aid of issues; but in order to remove the rigidity and want of tone which remained in the parts after the subsidence of the more violent symptoms, he was obliged to have recourse to the aid of vapour and electricity. In some very obstinate cases of sciatica, which resisted all other means of relief, he has also witnessed the happiest effects from issues; but, he observes, that he often found it necessary to surround the joints with several of these drains, moderating the degree of irritation and discharge according to the obstinacy of the disease and the strength of the patient. The ahronic rheumatism in all its forms succeeding to the acute, and where the inflammation has been chiefly seated in moving parts, is often wonderfully relieved by bathing in the Buxton waters, and the healthy action is soon so far restored as to enable the patient to use the more powerful remedy of sea-bathing,or the common cold bath. On account of the slightness of the shock of immersion, very delicate and irritable habits, and especially parts weakened by disease, can gene- rally bear this degree of cold, and overcome it by a very small reac- tion ; to produce which appears to be often a most salutary effort of the constitution. Hence the Buxton bath is become almost a tech- nical term for any bath heated to the highest degree that is compat- ible with giving some sensation of cold when the body is first plunged into it. The power of the Bath water is chiefly confined to that species of rheumatism which is unattended by inflammation, or in which the patient's pains are not increased by the warmth of his bed. Cold bathing has been advised by some physicians, while * See Treatise on Warm and Vapour Baths, by Dr. Kentish. 226 PYREXIA, OR FEBRILE DISEASES. ClaSS I. others again have disapproved of it. In some instances it has certainly proved very beneficial. The cold bath is a stimulant, and promotes perspiration, and, by strengthening the body, prevents a relapse. While there are any febrile symptoms it should not be used. . Blisters are sometimes employed in this complaint; but they seem to be most serviceable in those cases where the disease partakes of the nature of acute rheumatism, or where the pain is fixed in any particular joint. With respect to the mode of their application, it seems proper to observe, that a repetition of fresh blisters will be far preferable to keeping up a constant sore by stimulating the vesicated parts with the unguentum lyttee; and in the former way we shall likewise produce greater effect upon the disease. In some instances it will be found more beneficial to apply the remedy at a little distance from the seat of the disease, than to lay it immediately on the affected part. Indeed, whenever the complaint seizes upon any of the larger and deep- seated muscles at their origin near the joints, applying blisters to the inferior extremities of such muscles, and near to the points of their insertion, will be found highly beneficial. Thus in recent and slight.cases of sciatica, the application of a blister to the inferior extremity of the thigh-bone often proves speedily useful. Compressing the large arteries by means of a tourniquet, as men- tioned under the head of Intermittents, is another remedy which has been employed with advantage* in some instances of severe rheumatic pains. Several cases of chronic rheumatism of great severity and long standing, and which had resisted all previous means, but which were promptly and effectually removed by bandages of flannel round the diseased limb, carried from below upwards, are recorded by Dr. Bal- four in the Edinburgh Medical and Surgical Journalf, as well as in a work published by him J. In applying them, he found it necessary id some instances, especially at the beginning, to roll them tighter thaa they could well be borne for any length of time, and in such cases the frequent removal of the bandages, with the aid of manual application of friction, and more especially of percussion in the intervals, he says, are indispensable. The practice of applying pressure by ban- dages, in his opinion, may prove an useful adjuvant or auxiliary to the other means, particularly warm bathing, for the removal of this painful disease. Where the knee or any other joint becomes enlarged from effusion, it ought to be diligently rubbed twice or thrice a day with about an ounce of the muriate of ammonia dissolved in twelve ounces of com- mon vinegar. * See Dr. Duncan's Annals of Medicine for 1801. t See No. xlii. t See New Method of Treating Rheumatism, by Wm. Balfour, M. D. Order II. RHEUMATISM. 227 The internal remedies which have been most generally recom- mended in chronic rheumatism are sudorifics and medicines of a stimulating nature, which abound in essential oils and resins ; and therefore volatile alkaline salts, guaiacum, turpentine combined with cinchona and the like, may be administered as in the under- mentioned formulae*. In the most aggravated instances of this species of rheumatism, where great torpor and debility prevail' guaiacum, in as large doses as the stomach will bear, often proves a powerful remedy when aided by topical applications. The am" moniated tincture of this medicine, joined to a strong decoctio11 of cinchona, often proves serviceable in very obstinate cases. In" ternal medicines, however, without the aid of the external means before noticed, will seldom or never effect a cure in severe and obstinate cases. Hydrargyri submurias and other preparations of mercury have " 13. g- 01. Terebinth, f. 3jss. Vitell. Ovi, q. s. Dein adde. Spirit. Junip. Comp. f. §j. Decoct. Cinchon. f. |v. M. ft. Mistura, cujus sumat. cochl. larg. ij quarta quaq. hora Vel, 16. i£ Tinct. Guaiac. Ammoniat. f. 3'j- Spirit. Cinnam. f. ^ss- Decoct. Cinchon. f. ^j. Via. Antimon. 1T[ xv. M. ft. Haustus bis terve die sumendus. Vel, 17. R Tinct. Guaiac. Ammoniat. f. 3'j. pro dos. in quovis vehiculo. Vel, 18. ft Gum. Guaiac. 3j. Ammonia? Subcarbonat. gr. x. Confect. Rosae, q. s. M. fl. Bolus mane et vespere adhibendus. Vel, 19. ft Gum. Guaiac. gr. xv. Pulv. Antimonial. gr. ij. Confect. Opii, gr. x. Syrup, q. s. M. ft. Bolus. Vel, 20. ft Gum. Guaiac. Pulv. 3j. Pulv. Ipecac. Comp. 3ss. ft. Pulvis, omni nocte capiendus. * 15. Take Oil of Turpentine, one drachm and a half. Yolk of Egg, a sufficiency to mix them. Then add Compound Juniper Spirit, one ounce. Decoction of BBrk, five ounces. Of this mixture, two table spoonsful may be taken every fourth hour. Or, 16. Take Ammoniated Tincture of Guaiac, two drachms. Spirit of Cinnamon, half an ounce. Decoction of Bark, one ounce. Antimonial Wine, twenty-four drops. Mix them for a draught, to be taken twice or thrice a day. Or, 17. Take Ammoniated Tincture of Guai- ac, two drachms for a dose. In any vehicle. Or, 18. Take Gum Guaiac, one scruple. Subcarbonate of Ammonia, ten grains. Confection of Roses, a sufficiency to form a bolus, which may be given morning and evening. Or, 19. Take Gum Guaiac, fifteen grains. Antimonial Powder, two grains. Opiate Confection, ten grains. Syrup, a sufficiency to make them into a bolus. Or, 20. Take Powdered Gum Guaiac, one scruple. Compound Powder of Ipeca- cuanha, half a scruple. Mix them for a dose, to ba taken every night at bedtime £28 PYREXIAE, OR FEBRILE DISEASES. ClaSS /. been given in this disease along with the decoctum sarsaparillat compositum; but they seem best adapted for those cases where we suspect it to be connected with a syphilitic taint. In palliating symptoms, and allaying pain and imtation, small doses of the antimonial powder and opium combined with the submuriate of mercury, sometimes prove useful. Some medicines of the narcotic class, as conium and aconitum, have also been administered in chronic rheumatism. In chronic rheumatism it will be absolutely necessary to per- severe for a considerable length of time in the use of whatever medicines we employ, otherwise but very little benefit can be da- rived from them. If in the course of the disease the patient's rest should be much disturbed throughout the night by the severity of the pains, an anodyne draught may be ordered for him, to be taken at bedtime*. Where the different combinations of guaiacum, opium, antimonyr and mercury, have proved ineffectual, very speedy and good effects have been derived from a cautious exhibition of the arsenical solu- tion, as noticed under the head of Intermittents. It may be given with an equal proportion of tinctura opii in doses of ten drops repeated twice or thrice a day in any convenient vehicle, and probably a decoction of the cinchona bark may be as good as any we can employ. It seems, however, to be pretty generally admitted, that it is chiefly in the protracted chronic rheumatism, where the vital powers are much diminished, and the ends of the bones, periosteum, capsules, or ligaments of the joints, are likewise partially affected, that the use of arsenic is likely to prove essentially serviceable, or successfulf. In such cases we can begin with the quantity before mentioned, and so increase the dose gradually according to the effect produced on the stom- ach and bowels. In some instances, a degree of erythema arise! on different parts of the body in consequence of administering this remedy; and in others, a soreness of the mouth and ptyalism are excited. Costiveness generally ensues; and this we must obviate by some proper laxative taken from time to time. It may be sometimes necessary to intermit its use for a day or two, and tbei return to it again. Arsenic will do little good in recent cases of rheumatism, and especially in young subjects: indeed it can rarely be preserved ii t See Dr. Bardsley's Medical Reports. * 21. ft Liquor. Ammon. Acet. f> 3»*j- Aq. Cinuara. f. ?j. Tinct. Opii, fll xxvi. Vin. Antimon. fllxvj. Syrup, Papav. Somniferi, 3»j- M. fiat Haustus. ■ * 21. Take Solution of the Acetate of Am- monia, three drachms. Cinnamon Water, one ounce. Tincture of opium, forty drops. Antimonial Wine, twenty-four drops. Syrup of Poppies, two drachms- Mix them for a draught. Order II. RHEUMATISM. 229 where the patient is not much reduced in strength, owing to the great- ness of its stimulating power; for which reason it succeeds best in old persons. As a mean of relief in chronic rheumatism, particularly in protract- ed cases, the cinchona bark may be employed. No change whatever will be necessary in the patient's ordinary mode of living in chronic rheumatism, unless it happens to be in- termixed with the acute, and then the diet should be cooling, light, and nutritive. In chronic rheumatism, mustard and horse-radish may be taken freely in their natural state. Weak wine-whey, or barley-water, with a small quantity of the supertartrate of potass dissolved in it, may be used for common drink. Those who are subject to either kind of rheumatism should wear flannel next to the skin. Where there are any suspicions of the disease being connected with a syphilitic taint, a long-continued course of mercurial alteratives (see Syphilis) must be entered upon. Chronic rheumatism sometimes affects the lumbar region, with an acute pain shooting down into the us sacrum, so that the patient cannot stand upright without suffering great pain; neither can he enjoy ease when in bed. This affection is known by the name of lumbago-. The disease sometimes fixes likewise in the hip-joint, and is then called sciatica. Both of these affections are to be treated nearly in the same manner as chronic rheumatism. From a paper inserted in the sixth volume of the Memoirs of the Medical Society of London, by Dr. Wm. Falconer, it appears that the external application of the Bath waters has proved a most valuable and efficacious remedy in innumerable instances of ischias or the dis- eases of the hip-joint. The following is the mode of proceeding which has been pursued. When the patient is tolerably strong, and the symptoms mode- rate, he is directed to bathe in a hot bath of about 105 degrees of heat. The usual time of continuing in the bath is from fifteen to twenty-five minutes, and it is generally repeated twice or thrice a week. After a few times bathing, the dry pump, as it is quaintly called, or pumping on the affected part without bathing, is advised ; and this is tried on the affected part on those days when the patient does not bathe. From fifty to two hundred strokes of the pump are usually given. The first good effects of the application are to abate the stiffness and pain of the joint, and to afford a greater latitude and extent of motion, which are often perceived after using it three or four times. As the effects of the remedy proceed, the soreness and swelling diminish; the nocturnal pain, which is often very distressing, abates; the power of supporting the body on the lower limbs on the affected side increases; the legs, whether shorter or longer, approach towards their proper dimensions; and the muscles, that were let down and wasted, regain their natural shape, firmness, and 280 PYREXIA, OR FEBRILE DISEASES. ClaSS I plumpness. Where a use of the waters seems to succeed thus favour- ably, there is no other remedy employed. It sometimes happens, however, that the waters will show their be- neficial effects to a considerable extent for a time, and then the amend- ment seem5! to be at a stand, but still without any accession of new morbid symptoms, or without any aggravation of the old. In such cases it is found requisite to suspend the use of the waters for a short period, and to apply a blister upon the seat of the pain; after the healing of which, the application of the waters may be repeated with advantage. Where it happens that the irritability of the nerves is much excited by a use of the bath, or that it causes profuse perspiration, much caution is required. In instances of the latter kind, unaccompanied by fever, a light infusion of cinchona with aromatics is generally ser- viceable : but the tendency to fever is most to be apprehended. If the spot where the uneasiness is felt be extremely sore, and tender to the touch, and the swelling and pain are considerable, then it will be necessary to be (in our guard. Cupping-glasses, with scarification^ are applied in such cases with advantage; or if the skin be too sore or tender to endui e without much pain the suction of a cupping-glass, a large number of leeches have been substituted in the place of the other, and by being repeatedly applied, have proved of great service. In aid of these applications, saline cooling purgatives, and the common febrifuge draught, with antimonials, are administered with advan- tage. For the relief of the pain, which often subsists without fever, it is found necessary to employ opiates; and a preference is given by Dr. Falconer to the pulvis ipecac, compos, in the quantity of from five grains to twenty, once or twice in the course of the day and night. If these means prove effectual in procuring an abatement of the symptoms, the bath is cautiously tried, and especially the cross-bath, which is cooler than the other, and this for a short time only. If it can be borne without aggravating the symptoms, but rather with a soothing effect, it is directed to be repeated after an interval of three or four days, interposing the purgative before mentioned occasionally. When the bath can be borne with ease, the use of the pump in the bath is recommended, as the impetus of the water thrown on the part affected is less than in the dry pump, by the stream being conducted to the part beneath the surface of the water of the bath. By these means, together with the assistance of a blister on the part, the application of the waters is rendered sufe, and often effectual, in cases, we are told, that seemed at first view not to allow their use. To reduce the swelling, and promote a re-absorp- tion of the effused fluid, when that can be safely done, Dr. Falconer directs a trial to be made of the lime poultice, composed of one part of quick-lime, fallen to powder in the air, and two parts of oatmeal, which being made ;nto a poultice with hog's-lard, and Order III. small-pox. 231 spread thick on a cloth, is to be applied temperately warm to the part. This poultice is to be repeated every night, but to be re- moved in the morning. It generally produces some degree of moisture or exudation under it, though without raising a blister : and this gradual local discharge is often an effectual though gradual method of reducing tumors both of the hip and of the knee. Those who are subject to rheumatic complaints ought carefully fo avoid all exposures to cold and wet, and they should go warmly clothed, and wear flannel next the skin. ORDER III. OF EXANTHEMATA, or ERUPTIVE FEVERS. Most of the diseases of this order are contagious, and attack a person only once in his life : they begin with fever, and at a definite time numerous and small eruptions are perceived scattered over the skin. In the nosology of Dr. Cullen, erysipelas is placed among this order, and although considered by some as contagious, still as it often affects the same person repeatedly, and in some becomes con- stitutional, it cannot be so arranged with propriety. In this volume it is placed with erythema among the preceding order of phlegmasia?. VARIOLA, or SMALL-POX. Small-pox is a disease of a very contagious nature, marked by a fever which is usually inflammatory, but now and then is of a typhoid nature, attended with vomiting, and upon pressure of the epigastrium, with pain ; succeeded after a few days by an eruption "of red pimples on different parts of the body, which in the course of time suppurate, and at length fall off, leaving frequently behind them little pits in the skin, and, in severe cases, scars. With regard to the history* of the small-pox, it appears from the researches of eminent writers, that this disease, as also the measles, had prevailed in China and Hindostan from remote antiquity, yet had not extended to the more western nations until the middle of the sixth century. About this period these maladies reached the southern coasts of Arabia, by vessels trading with India, and broke out near Mecca, during the war of the elephant, (as it has been termed) in the year 569, immediately before the birth of Mahomet. During the latter parts of the sixth, and whole of the seventh century, they were spread by the Arabians over the remaining countries of Asia, and all that part of Africa which is washed by the Mediterranean Sea. In the eighth century Europe was con- taminated in consequence of the Saracens invading Spain, Sicily, * See Mr. Moore's History of the Small-Pox, p. 110. isn PYREXIAE, OR FEBRILE DISEASES. Class!. Italy, and France, and the above diseases gradually extended to the north. They had reached Saxony, Switzerland, and England, in the ninth or tenth century. And lastly, in the beginning of the sixteenth century, twelve years after the death of Columbus, the infections were transported by the Spaniards to Hispaniola, and soon afterwards to Mexico, and diffused speedily over that hemi- sphere also. The small-pox attacks people of all ages, but the young of both sexes are more liable to it than those who are much advanced in life ; and it may prevail at all the seasons of the year, but in gene- ral is most prevalent in the spring and summer. It rarely happens that any person is attacked a second time with the disease, however he may be afterwards exposed to its infectioo, or even be repeatedly inoculated with variolous matter. A few in- stances to the contrary have now and then occurred however, and with a high degree of severity. Affirmations of this from the high* est authorities are on record. Dr. Jenner is of opinion, I believe, that the susceptibility to receive variolous contagion always remains through life, but under various modifications or gradations, from that point where it passes silently through the constitution, up to that where it appears in a confluent state, and with such violence as to destroy life. The small-pox is distinguished into the distinct and confluent, implying, that in (he former the eruptions are perfectly separate from each other, and that in the latter they run much into one another. The distinct may often be distinguished from the con- fluent before the eruption appears, by the mildness of its attack,*by the synochal type of the fever, the late appearance of the eruptnjfe- and the absence of typhoid symptoms. - Some anomalous varieties of small-pox occasionally occur in practice, viz. the crystalline, in which the fluid never becomes opake or purulent; the vesicular, in which small vesicles appear in the interstices of the pustules ; and some others ; but which are all merely different modifications of the same disease. Both the distinct and confluent small-pox are produced either by breathing air impregnated with the effluvia arising from the bodies of those who labour under the disease, or by the introduction of a small quantity of variolous matter into the habit by inoculation; and it is probable that the variety of the small-pox is not owing to any difference in the contagion, but depends on the state of the person to whom it is applied, or on certain circumstances concurring with the application of it. Many physicians of eminence are of opinion, (hat the variolous contagion is limited to a narrow sphere, and that it seldom, if ever, is conveyed by the wind to a distance, as some have imagined it capable of being. Dr. Haygarth, in his Sketch of a Plan to exter- minate the casual Small-pox from Great Britain, informs us, that certain facts appear to exhibit negative proofs that the open air is mot contaminated to a great distance from the patient; not to one Order III small-pox. 233 thousand five hundred feet, nor probably to one hundredth part of the space. He mentions, that very few cases have been adduced by those who have corresponded with him on the subject, in which clothes exposed to variolous miasma have been even suspected of conveying infection, and that several have given a negative testi- mony against this mode of communication. He further notices, that innumerable instances are to be produced where medical men, after exposing themselves to the miasms of an infectious chamber, in a very short time nearly approach persons liable to the distem- per, who are yet not infected by the interview ; and that inoculators are daily in this situation without communicating the casual small- pox. The period during which infection remains latent in the, body, he observes, is determined by the testimony of many to be, in the inoculated small-pox, from the fifth day to the sixteenth, seven- teenth, and even the twenty-third: in the casual or natural small- pox, a litde but not much longer than the common period in ino- culation. A variety of opinions have been entertained respecting the effect of the variolous infection on the foetus in utero; a sufficient number of instances, however, have been recorded, to ascertain that the dis- ease may be communicated from the mother to the child. In some cases the body of the child at its birth has been covered with pus- tules, and the nature of the disease has been most satisfactorily ascer- tained by inoculating with matter taken from the pustules. In other eases there has been no appearance of the disease at the time of the birth, but an eruption and other symptoms of the malady have appeared so early, as to ascertain that the infection must have been received previously to the removal of the child from the uterus. Moreover, some cases reported in the first volume of the Medico-Chirurgical Transactions of London*, by Dr. Jenner, point out the obvious infection of the fcetus before birth, and communi- cated through the mother, she being already secure from any visible occurrence of the disorder, which is indeed a very extraordinary occurrence. Four different states or stages are to be observed in the small- pox :^-first, the febrile; second, the eruptive ; third, the maturative ; and fourth, that of declination or scabbing, which is usually known by the name of secondary fever. When the disease has arisen naturally, and is of the distinct kind, the eruption is commonly preceded by a redness in the eyes, sore- ness in the throat, pains in the head, back, and loins, weariness and faintness, alternate fits of chilliness and heat, thirst, nausea, inclination to vomit, and a quick pulse. In some instances these symptoms prevail in a high degree, and in others they are very moderate and trifling. In young children, slartings and convulsions are apt to take place a short time previous * See page 271 30 234 PYREXIAE, OR FEBRILE DISEASES. CktSS I, to the appearance of the eruption, always giving great alarm to those not conversant with the frequency of the occurrence. About the third or fourth day from the first seizure, the eruption shows itself in little red spots (similar to flea-bites) on the face, neck, and breast; and these continue to increase in number and size foi three or four days longer; at the end of which time they are to be observed dispersed over several parts of the body. If the pustules are not very numerous, the febrile symptoms will generally go off on the-appearance of the eruption, or they will be- come very moderate. It sometimes happens, that a number of litde spots of an erysipelatous nature are interspersed among the pustules; but these generally go in again as soon as the suppuration commences, which is usually about the fifth or sixth day; at which period a small vesicle, containing an almost colourless fluid, may be observed upon the top of each pimple. Should the pustules be perfectly distinct and separate from each other, the suppuration will probably be completed about the eighth or ninth day, and they will then be filled with a thick yellow matter; but should they run much into each other, it will not be completed till some days later. When the pustules are very thick and numerous on the face, it is apt about this time to become much swelled, and the eyelids to be closed up ; previous to which, there usually arises a hoarseness and difficulty of swallowing, accompanied with a considerable discharge; of viscid saliva. About the eleventh day the swelling of the face usually subsides, together with the affection of the fauces, and is succeeded by the same in the hands and feet; after which the pustules break, and discharge their contents, and then becoming dry, they fall off ii crusts, leaving the skin which tbe\ covered of a brown red colour, which appearance continues for many days. In those cases where the pustules are large, and are late in becoming dry and falling off, they are very apt to leave pits behind them ; but where they are small, suppurate quickly, and are few in number, they neither leave any marks behind them nor do they occasion much affection of the system. In the confluent small-pox the fever which precedes the eruption is much more violent than in the distinct, being attended usually with great anxiety, heat, thirst, nausea, vomiting, and a frequent and contracted pulse, and often with coma or delirium. In in- fants, convulsive fits are apt to occur, which either prove fatal before any eruption appears, or they usher in a malignant species of the disease. The eruption usually makes its appearance about the third day, being frequently preceded or attended with a rosy efflorescence, similar to what takes place in the measles: but the fever, although it suffers some slight remission on the coming out of the eruption, does not go off as in the distinct kind ; on the contrary, it becomes Order III. SMALL-POX. 235 increased after the fifth or sixth day, and continues considerable throughout the remainder of the disease. As the eruption advances, the face being thickly beset with pus- tules, becomes very much swelled, the eyelids are closed up, so as to deprive the patient of sight, and a gentle salivation ensues, which towards the eleventh day is so viscid, as to be spit up with very great difficulty. In children, a diarrhoea usually attends this stage of toe disease instead of a salivation, which is to be met with only in adults. The vesicles on the top of the pimples are to be perceived sooner in the confluent small pox than in the distinct; but they never rise to an eminence, being usually flatted in; neither do they arrive to a proper suppuration, as the fluid contained in them, instead of becoming yel- low, turns to a brown colour. About the tenth or eleventh day the swelling of the face usually subsides, the hands and feet beginning then to puff up and swell, and about the same time the vesicles break, and pour out a liquor that forms into brown or black crusts, which upon falling off leave deep pits behind them that continue for life; and where the pustules have run much into each other, they disfigure and scar the face very considerably. Sometimes it happens that a putrescency of the fluids takes place a$ an early period of the disease, and shows itself in livid spots interspers- ed among the pustules, and by a discharge of blood by urine, stool, and from various parts of the body. In the confluent small pox, the fever, which perhaps had suffered some slight remission from the time the eruption made its appear- ance to that of maturation, is often renewed with considerable violence at this last-mentioned period, which is what is called the secondary fever; and this is the most dangerous stage of the disease. It has been observed, even among the vulgar, that the small-pox is apt to appear immediately before or after the prevalence of the measles. Another curious observation has been made relating to the symptoms of these complaints, namely, that if, while a patient labours under the small-pox, he is seized with the measles, the course of the former is generally retarded till the eruption of the measles is finished*. The measles appear, for instance, on the second day of the eruption of small-pox; the progress of this ceases till the measles terminate by desquamation, and then it goes on in the usual way. Several cases are however recorded in the Medical and Physical Journal, as likewise in the third volume of the Medical Commentaries, in which a concurrence of the small-pox and measles took place without the progress of the former being retarded. The only diagnosis that is necessary is between small-pox and chicken-pox. In the latter the pustules commonly go back without • See Dr. Duncan's Medical Commentaries, vol. i. 236 PYREXIA, OR FEBRILE DISEASES- Class I. coming to proper suppuration. Their number, size, appearance, and course, differ very essentially. There is great reason to suppose, however, that the one disease is sometimes mistaken for the other, which may account for many of the supposed failures of the vaccine inoculation. The distinction is sufficiently apparent between chicken-pox and the small-pox when each of these diseases appears in its proper colours; but when the latter is peculiarly mild, and the former extraordinarily violent, which is sometimes the case, then all the discriminating marks are obscured. The distinct small-pox is not attended with danger, except when the eruptive fever is very violent, or when it attacks pregnant women, or approaches nearly in its nature to that of the confluent; but this last is always accompanied with considerable risk, the degree of which is ever in proportion to the violence and permanence of the fever, the number of pustules on the face, and the disposition to putrescency which prevails. When there is a great tendency this way, the disease usually proves fatal between the eighth and eleventh day; but in some cases death is protracted till the fourteenth or sixteenth. The confluent small- pox, although it may not prove immediately mortal, is very apt to induce various morbid affections. Both kinds of small-pox leave behind them a predisposition to in- flammatory complaints, particularly to ophthalmia and pneumonia; and they not unfrequently excite scrofula into action which might otherwise have lain dormant in the system. The regular swelling of the hands and feet upon that of the face subsiding, and its continuance for the due time, may be regarded in a favourable light. Violent eruptive fever, delirium, stupor, severe vo- miting, dyspnoea, sudden disappearance of the eruption, subsidence of the swelling of the face or extremities, suppression of saliva, or de- pression of the pustules, followed by much prostration of strength, pallor of the skin, great anxiety, syncope, or convulsions, are appear- ances which denote the greatest danger. The disease in its progress assuming a malignant character and typhoid type, and the pustules becoming livid, or being interspersed with petechiae, portend a fatal termination. The dissections which have been made of confluent small-pox, have never discovered any pustules internally on the viscera. From them it also appears, that variolous pustules never attack the cavi- ties of the body, except those to which the air has free access; as the nose, mouth, trachea, the larger branches of the bronchiae, and the outermost part of the meatus auditorius. In cases of prolapsus ani, they likewise frequently attack that part of the gut which is exposed to the air. They have usually shown the same morbid appearances inwardly as are met with in typhus gravior, where the disease has been of a very malignant nature. Where the febrile symptoms have run high, and the head has been much affected with coma or delirium, the vessels of the brain appear, on removing Order III. small-pox. 23? the cranium and dura mater, more turgid, and filled with a darker coloured blood than usual, and a greater quantity of serous fluid is found, particularly towards the base of the brain. Under similar circumstances the lungs have often a darker appearance, and their moisture is more copious than usual. When a person who has never had the small-pox is attacked with febrile symptoms after having been exposed to infection, or in consequence of Ihe disease prevailing epidemically, we ought imme- diately to advise a strict pursuance of the antiphlogistic plan, de- barring him from animal food, impregnating his drink with cooling acids, keeping his body open with gentle laxatives, and above all, exposing him freely to cool air, as, beyond all doubt, there is not a more effectual remedy for moderating the febrile heat produced by this disease than the application of cool air ; and the more urgent the symptoms, the more will the patient stand in need of it; for where the ventilation is free, it is inconceivable how refreshing it proves, and how suddenly it is capable of reducing the pulse, and of moderating all the symptoms. The proper treatment of the pa- tient from the very first attack of the disease will have great in- fluence on the form which it assumes : if he be kept in a warm room, be loaded with bedclothes, and get warm drink, the fever will be severe and the eruption copious ; while by an opposite treat- ment the disease may be broken at the beginning. In the early stage of small-pox, and during the eruptive fever, when the symptoms run high, we may, in addition to exposing the patient freely to cool air, recommend washing the body partially or generally with cold water. As the quantity, as well perhaps as the quality of the pustules depends greatly on the violence and duration of the eruptive fever, and as by mitigating the one we render the other more favourable, it would seem really advisable, as soon as a person is seized with variolous fever, wherein the febrile symptoms are any way high, to have cold water thrown over the body every four or six hours ; which plan may be continued until the eruption is completed. The safety and utility of the remedy are recorded in the thirteenth number of the Edinburgh Medical Journal, and are confirmed by my own experience. When had recourse to on the attack of variolous fever, it usually mitigates the headach, pain in the back, and other febrile symptoms ; a slow and gentle perspiration succeeds, and a mild eruption takes place. Where it is resorted to after the small-pox have made their appearance, and by their quantity and the duration of the fever a confluent pock is expected, the cold bath seems not only to moderate the febrile symptoms, but likewise to diminish the number of the pustules, and in doing so, greatly to lessen Ihe danger of the disease. The temperature of the patient's chamber should always be such that he may experience no disagreeable degree of heat, but rather a sensation of cold ; and except he complains of being chilly, we need not be afraid of carrying the cool regimen too far. He should lie on a mattress covered only with a few bedclothes^ 238 PYREXIA, OR PEBRILE DISEASES. Class I. a feather-bed being apt to occasion too great an accumulation of heat. If convenient, he should have an apartment to himself, as the heat of a crowded room would be sure to prove injunous; and his body-linen, as well as that of the bed, should be shifted frequently. . , In many instances, little more will be requisite than to pursue the steps which have been advised ; but sometimes the fever and general inflammation run so high (particularly in adults of a ple- thoric and robust habit) as to be accompanied with great heat and dryness of the skin, redness of the face and eyes, considerable dif- ficulty of breathing, acute pain in the head, stupor, or delirium ; in which case it may be necessary to take away a little blood ; but in resorting to this operation, great prudence is necessary ; for should a fever of a malignant nature, or putrid tendency, accompany the disease, bleeding might prove highly injurious. Indeed it might perhaps be the best practice to recommend it only in those cases where the effects expected from it cannot be procured by other re- medies ; and even in these local blood-letting by scarification of the temples, or the application of leeches, ought to be preferred.- Where the eyes look red and fiery, or coma prevails, topical bleed- ing may prove a valuable remedy. The same caution should be observed with respect to a use of purgatives. For the purpose of diminishing excitement in the dis- tinct small-pox, they may prove serviceable if administered in mo deration ; but if the accompanying fever is of the typhoid kind in- stead of synocha, then these and other antiphlogistic remedies are by no means warrantable. To dislodge the contents of the intestinal tube in such cases where costiveness prevails, we should only em- ploy the most gentle laxatives, such as the neutral salts, with the occasional use of emollient clysters. On the coming on of the fever, the stomach in some cases is much disordered, aud a constant neasea, or frequent vomiting, is apt to arise : to obviate which, it will be proper to give a gentle emetic, working it off with a few draughts of camomile-tea. It is no uncommon occurrence for convulsive fits to attack children some short time previous to the appearance of the erup- tion, which are apt to alarm those who are not conversant with the disease. In this instance little more will be requisite, in general, thari to admit cool air freely to the child ; but should they occur at a very early period of the disorder, and be repeated frequently with any violence, they then are attended with considerable danger, and ought to be removed, if possible, by giving opium in doses propor- tioned to the age of the child. About five drops of the tinctura opii will be sufficient for a child of a year old, about eight drops for one of two years old, and so on in a regular gradation. Blisters are sometimes used in cases of this nature ; but from the great length of time which elapses previous to their producing any effect, they seldom prove serviceable. In those instances where the eruption does not come out kindly, Order III. small-pox. 239 it has been advised to immerse the whole body for a short time in a warm bath ; but perhaps it may be more proper only to put the feet and legs into warm water at first, using at the same time a more generous diet; and should these means fail, the other mode of proceeding may then be adopted. If there be great irritability and restlessness, opium in small quantities, either with the saline mixture, or a grain or two of anti- monial powder, will be serviceable. Where the febrile symptoms run high after the appearance of the eruption, we should give small and frequently repeated doses of antimonials, as advised under the head of Simple Continued Fever. With the same view of lessening febrile heat and excitement, we may employ refrigerant medicines, such as nitre and saline draughts, administering the latter in the act of effervescence. Cold diluents, auch as lemonade, imperial, &c, may be taken freely to allay thirst. It will likewise be proper to avoid heat, and to expose the body to cool air. The cool regimen, in its fullest extent,, is however by no means so necessary after the completion of the eruption, or where the fever has almost or wholly disappeared, as before. At the same time we must be careful to avoid the opposite and more dangerous extreme of relaxing too suddenly in the employment of the cool regimen. The use of laxative medicines, or clysters, as far as is necessary to prevent costiveness, is to be continued ; and with regard to the application of cold, it should at this period be regulated by the patient's feelings. If, on the other hand, the febrile symptoms continue considerable, notwithstanding the appearance of the eruption, the plan of treat- ment must not be relaxed. The continued use of gentle cathartics and the cool regimen is then necessary ; at an early period they are the best means of moderating the eruptive fever ; they are now the most effectual for preventing the appearance of the secondary, which is always to be feared where the remission on the comple- tion of the eruption is iuconsiderable. Wrhen a degree of cynanche is present, gargles and the inhalation of warm steam may be used. In those cases where the pustules contain a thin watery fluid, and are accompanied with great soreness, uneasiness, loss of strength, and lowness of the pulse, the cinchona bark should be given in large doses, and be frequently repeated ; and although it may perhaps increase the difficulty of breathing, and render the expectoration a little more difficult, still its good effects in obviating the symptoms of irritation, and the tendency to putrescency, will greatly overbalance the former. To assist the effects of this bark, a free use of wine-whey ought to be allowed. In the confluent small-pox, particularly where there is a putrid tendency, where the puslulea are filled with a bloody 2&0 PYREXIJE, OR FEBRILE DISEASES. ClaSS I, water, or where petechia? are interspersed among them, we must also have recourse to the bark of cinchona joined with wine, toge- ther with acids, all kinds of which have been much employed in this form of the disease, but more particularly the muriatic and sulphuric, as noticed under the head of Typhus Gravior. Where hemorrhages arise, we may give alum in addition to these remedies. If the eruptions, after having made their appearance, strike in suddenly, or if the disease has arisen in a person of lax fibres, and is attended with a weak low pulse, and a sinking in of the pustules, then, besides allowing a liberal use of wine-whey, we should apply cataplasms to the soles of the feet, and blisters successively to different parts of the body, paying no regard to their being covered with pustules. Camphor, ammonia, musk, and aromatics, will likewise be advisable medicines. The warm bath will also be proper. Where the suppuration in the pustules does not go on kindly, owing to the want of rest, it will be proper to give opiates. About forty drops of the tinctura opii may be administered to an adult every night at bedtime, and one or two teaspoonsful of the syrupus papaveris somniferi to young children. If opiates are given when the excitement is considerable, or if they are found to induce coma, their use will certainly be improper ; but in all other cases, more particularly during the maturating stage, in the confluent small-pox, a quantity of opium, sufficient to allay restlessness, provided care be taken, by administering gentii laxatives, to prevent its constipating effects, will be sure to prove beneficial. The secretion from the glands of the mouth and throat in the confluent small-pox, usually goes on without the help of medicines until near the time of the completion of the suppu- ration, so that it is only necessary to defend the parts from the matter secreted by giving mucilaginous drinks, such aa barley-water, linseed-tea, or a solution of Gum. acaciae ; but towards the time of its being completed, the secretion is apt to become so thick and viscid, as to be expectorated with the greatest difficulty, and often even to endanger suffocation. In this case we should give an emetic*, after which the mouth and throat must be washed out very frequently with some proper gargle as belowf, or as advised under the head of Inflammatory Quinsy. If the emetic does not afford a pernia- * 1. ft Antimon. Tartarizat. gr.jss. Aq. Foutan. f. ^j. Oxymel. Scillae, f. |ss. M. ft. Haustus. t 2. ft Infus. Rosae Gallic, f. ?vij. Md. Optim.f. *ss. ft. Gargarisma. M. * 1. Take Tartarized Antimony, one graii and a half. Pure Water, one ounce. Oxymel of Squill, half an ounce. Mix them for a draught. t 2. Take Infusion of Roses, seven ounce!" Honey, half an ounce. Mix them for a gargle. Order HI. SMALL-POX. 241 nent relief, we may then apply a blister to the external fauces with some prospect of advantage. When the swelling of the face begins to subside, if we should find that the extremities do not become puffy and swelled, as they ought to do, cataplasms and blisters may be applied to them, to excite inflammation. Determination to the head or chest, or other viscera, requires blis- ters, pediluvium, and sinapisms to the feet. If a strangury or suppression of urine should ensue in the course of the disease, as sometimes happens, it possibly may be relieved by making the patient walk barefooted several times across the floor, and by giving him small doses of nitre at the same time. Dashing cold water on the legs, as is sometimes practised to solicit the alvine discharge, may also be tried. Should these means fail in affording relief, we ought then to resort to the other remedies recom- mended under these particular heads. Obstinate vomiting, which in this disease often proves a very troublesome as well as dangerous symptom, is most effectually allayed by saline medicines, taken in the act of effervescence, and joined with opium*. Profuse diarrhoea is a troublesome occurrerce in the confluent small-pox, particularly in children : but unless this symptom produces a dangerous degree of debility, we should be cautious in checking it; and even when it does occasion considerable debility, the safest plan will be to endeavour to moderate it by very gentle as- tringents and tonics. There is perhaps no instance, except towards the termination of the disorder, in which the diarrhoea can be safely stopped by astringents, and then it is to be done cautiously ; and when these medicines, either conjoined with opium, or of themselves, produce too sudden an effect, it must be counteract- ed by gentle laxatives. In all cases where there is a propensity to sweating, after the eruptive fever has passed, a cool regimen will be particularly necessary. In the distinct small-pox there ensues little or no secondary fever; but it regularly attends on the confluent, and is always in proportion to the number of pustules, proceeding probably from an absorption of the matter. This being the case, it may be advisable to open every pustule as soon as the suppuration in it is completed ; and in order to moderate the fever, as well as to prevent hectic symptoms, and after-suppurations from arising, we ought to employ mild cathar- tics, so as to keep the bowels regularly open. *3.R Potassae Aerati, 3i. Aq. Cinnam. f. 3". ' Tinct. Opii, Til viij. Syrup. Cort. Aurant. 3j. M. ft. Haustus quarta quaque hora adliibendus in actu effervescentiae cum cochleare magna succi limotis. 31 *3. Take Aerated Potass, one scruple Cinnamon Water, ten drachms. Tincture of Opium, twelve drops, Syrup of Orange Peel, one drachm. Mix them, and let this draught be given every fourth hour with a table-spoonful of lemon juice daring the effervescence. 242 PYREXIAE, OR FEBRILE DISEASES. ClaSS I If at the approach of the secondary fever the pulse is quick, hard, and strong, the heat very great, the head much affected, and the breathing laborious, a quantity of blood, proportioned to the urgency of the symptoms, may probably be taken with safety, by means of scarificaiions or leeches applied to the part most affected; but a use of gentle cathartics, and other antiphlo- gistic means, seems much more advisable. If, on the contrary, the patient is faint, the pustules look pale and much indented, and the extremities feel cold, with other symp'oms of irritation, the fever is then to be considered as of the typhoid kind; and the proper reme- dies to be employed are cinchona bark, in whatever form it is found to sit easiest on the stomach, conjoined with wine and aroma- tics, together with mineral acids, opium, and artificially prepared pure air, or oxygen gas. To prevent the face from being marked after the confluent small- pox, it has been recommended to bathe if three or four times a day1 with warm milk and water, and on the seventh or eighth day to apply over its whole surface a mask made of fine cambrick, thinly spread with a soft liniment, composed of olive oil, white wax, and prepared lard, or with the unguentum cetacei, so as to exclude the external air; which application is to be renewed twice or thrice a day. When the pustules are numerous on the face, it sometimes* happens that the eyes become much affected, and that a loss of sight is the consequence. In those cases, therefore, where the face is much beset with pustules, the use of mild and gently astringent collyria, as advised under the head of Ophthalmia, should never be neglected. To prevent the eyelids from adhering together in such cases, it may be necessary to bathe them from time t-» time with warm milk, and to besmear them frequently with a little emollient ointment of any kind. The small-pox, particularly when it proves severe, is apt, in habits disposed to scrofula, to excite that disorder into action, when it other- wise might not have shown itself. Frequent instances of this nature occur in practice, and prove obstinate to the practitioner, as well as distressing to the patient. In all such cases we must resort to the means advised under that particular head. In the confluent small-pox, as well as the distinct, the patient's strength must be supported by food of a light nutritive nature, such as panado, bread-pudding, preparations of sago, arrow-root, roasted apples, he.; and for common drink he may take thin gruel or barley water gently acidulated, together with a little wine-whey now and then when the febrile symptoms do not run high. If the accompanying fever is of a typhoid nature, a liberal use of wine will be proper. Order 111, inoculation of the sjiall-pox. 243 Of INOCULATION. Experience has taught us that by applying variolous matter to a scratch or wound, so as to occasion an absorption, we shall in general procure fewer pustules and a much milder disease than when the small-pox is taken in the natural way. Notwithstanding these evident advantages, objections have been raised against inoculation, on the score that it exposes the person to some risk, when it is possible he might have passed through life with- out being attacked by the disease in question ; but in reply it may be urgf d, that he will be exposed to much greater danger from the inter- course which he must have with his fellow-creatures, by taking the disorder in the natural way. In objection to inoculation, instances have been adduced to support the probability of a person's being liable a second time to the small- pox, when produced at first by artificial means; but such instances are very rare indeed, besides not being sufficiently authentic ; and we may safely conclude, that in most of those cases the matter used was not variolous, but that of some other eruptive disorder, such as the chicken-pox, which, when severe, may be mistaken for the small- pox by those who are not very conversant with the difference between them. It has been computed that a third of the adults die who take this disease in a natural way, and about one-seventh of the children; whereas of those who receive it by inoculation and who are properly treated afterwards, the proportion probably is not greater than one in five or six hundred. Although inoculation for the small pox may have been beneficial to individuals by greatly lessening the chance of death, yet it may safely be asserted that it has proved of no benefit to the community at large, but the reverse ; which is evident by the bills of mortality, as they clearly prove that the disease of small-pox has increased in England since the introduction of inoculation, in the proportion of 19 in every 100. This has arisen in a great measure from the want of some laws of exclusion, analogous to those of quarantine, by which those who pro- duce the disease by inoculation should be prohibited from exposing the inoculated persons in the way of such as are liable to the infection. A recent decision in the Court of King's Bench, however, has shown, that such an exposure, where it produces the disease in others, is a misdemeanour by common law, and that those who thus trespass on the community, and are guilty of the act, are liable tq imprisonment. The practice of inoculating is generally supposed to have been in- troduced into Britain from Turkey, by Lady Mary Wortley Montague, about the year 1721, whose son had been inoculated at Con- stantinople during her residence there, and whose infant daughter was the first that underwent the operation in this country. Some 244 pyrexia, or febrile diseases. Class I. letters, however, of Dr. Williams, Mr. Owen, and Mr. Wright, which may be seen in the Philosophical Transactions for the year 1722, assert, that inoculation was well known in the south of Wales at that time, and had been of long standing. It seems likewise to have been practised in the Highlands of Scotland before its introduction into England. Mr. Mungo Park, in his Travels into the Interior of Africa, found that inoculation had long been practised by the negroes on the Guinea Coast, and nearly in the same manner, and at the same time of life, as in Europe. Where inoculation really originated is a matter of doubt, although it has been ascribed to the Circassians, who employed it as a mean for preserving the beauty of their women. It ig more than probable that accident suggested the expedient among the different nations to whom the small-pox bad long been known, independently of any intercourse they had with each other : and what greatly adds to the probability of this conjecture is, that in most places where inoculation can be traced back for a considerable length of time, it seems to have been practised chiefly by old women before it was adopted by regular practitioners. Many physicians held the practice of inoculation in the greatest contempt at first, from its supposed origin ; others again discredited the fact; while others, on the testimonies of its success in distant countries, believed in the advantages it afforded, but still did not think themselves warranted to recommend it to the families they attended; and it was not until after the experiment of it had been made on six criminals (all of whom recovered from the disease and regained their liberty), that it was practised in the year 1726 on the royal family, and afterwards adopted as a general thing. To ensure success from inoculation, the following cautions should strictly be attended to:— 1st, That the person should be of a good habit of body, and free from any disease apparent or latent, in order that he may not have the distemper and a bad constitution, or perhaps another disorder, te struggle with at the same time. 2dly, To enjoin a temperate diet and proper regimen; and where the body is plethoric, or gross, to make use of gentle purges, together with mercurial and antimonial medicines, as hereafter mentioned. 3dly, That the age of the person be as little advanced as possible; but not younger, if it can be avoided, than four months. 4thly, To choose a cool season of the year, and to avoid ex- ternal heat, either by exposures to the sun, sitting by fires,, or ia warm chambers, or by going too warmly clothed, or being much ia bed. 5thly, To take the matter from a young subject who has the small-pox in a favourable way, and who is otherwise healthy and Order III. inoculation of the small-pox. 245 free from disease ; and when fresh matter can be procured, to give it the preference. Where matter of a benign kind cannot be procured, and the patient is evidently in danger of the casual small-pox, we should not however hesitate a moment in recommending inocu- lation from any kind of matter that can be procured, as what has been taken in malignant kinds of small-pox has been found to produce a very mild disease. The mildness or malignity of the small pox appears therefore to depend little, if at all, on the inoculating matter. Variolous matter, as well as the vac- cine, by being kept for any length of time, particularly in a warm place, is apt, however, to undergo a decomposition by putrefaction, and then another kind of contagious material has been produced. In inoculating, the operator is to make the slightest puncture or scratch imaginable in the arm of the person, rubbing that part of the lancet which is besmeared with the matter repeatedly over it, by way of ensuring the absorption ; and in order to prevent its being wiped off, the shirt-sleeve ought not to be pulled down until the part is perfectly dry. In preference to either puncturing the arm, or scratching it in a direct line, it has been recommended to introduce the lancet armed with the matter obliquely beneath the cuticle, so as to wound very slightly, and occasion little or no flow of blood. This mode may probably be preferable ; but in withdrawing the point of the lancet, it will be right to press the wound with the finger, that the parts in contact with the matter may wipe it off the lancet, and thereby se- cure the success of the operation. W7hen inocu'ation is performed in any of these ways, the application of a plaster or bandage will be unnecessary. The matter of small-pox must be applied to a wound in order to induce the complaint. Dr. Rush informs us, he could not in- duce the small-pox by rubbing the matter on the entire skin ; and he likewise mentions, that a negro girl took some variolous matter mixed with a dose of physic, which produced no sensible effect. A singular circumstance attending inoculation is, that when this fails in producing the effect, the inoculated part nevertheless iomefimes inflames and suppurates, as in cases where the complaint is about to follow ; and the matter produced in such cases is as fit for inoculation as that taken from a person actually labouring under the disease. The same happens very frequently in inoculation for the cow-pox. If on the fourth or fifth day after the operation, no redness or in- flammation is apparent on the edges of the wound, we ought then to inoculate in the other arm in the same manner as before ; or, for greater certainty, we may do it in both. Some constitutions are incapable of having the disease in any form. Others do not receive the disease at one time, however freely exposed to its contagion, even though repeatedly inoculated 246 PYREXIJE, OR FEBRILE DISEASES. and yet receive it afterwards by merely approaching those labouring under it. Dr. Huxhain* makes mention of cases of this nature. His words are, " I know an old nurse, and one apothecary, who for many years attended persons, and a great number too, in the small-pox, and yet never had them ; nay, many that have indus- triously endeavoured to catch the infection, by frequenting the chambers of the sick, have done it without effect, and yet some of these persons, some months or years after, have been seized with the small-pox." On the coming on of the febrile symptoms, which is generally on the seventh day in the inoculated small-pox, the patient is by no means to be suffered to take to his bed ; but, on the contrary, must be constrained to keep up, and to be as much in the cool air as possible : and if thirsty, he may partake freely of some cooling antiseptic drink. As the number of pustules would probably be much increased by lying with another person, the patient should always have a bed to "himself. From the time that the matter is introduced into the system to the appearance of the eruptions, it will be "necessary to obseYve a total abstinence from all animal food, and to give some gentle pur- gative every second or third day, if the person is of a gross habit; and on the intervening ones, he may take a dose of the following preparative powder :—Mix a drachm of prepared chalk with twelve grains of hydrargyri submurias, and one grain of tartarized anti- mony, which for an adult may be divided into three doses, and for a child of a year old, into twelve. Some late experiments might induce us to believe that prepara- tion has little or no effect on the future eruption, and that the cause of its mildness, in the inoculated small-pox, is to be ascribed to the operation itself, independent of any thing else. Mons. Desserts, in the sitting of the French National Institute, is said, however, to have adduced a number of facts to prove that the na- tural small-pox is rendered much milder by the use of mercurial remedies, and probably the inoculated disease may likewise be influenced by them. Indeed, it appears from the experi- ments of Van Woensel, that the submuriate of mercury, given as an alterative for some days before inoculation, and till the eruptive fever commences, does with certainty render the disease mild. A singular circumstance, mentioned by the same author, is, that this preparation of mercury, triturated with variolous matter, incapacitates it from conveying the disease by inoculatioti. The mode of treating the small-pox being the same, whether it arises naturally, or from inoculation, a reference must be had to the plan which is laid down in the preceding pages; and as purging is not less necessary after the small-pox by inocula- tion than by the natural way, it ought by no means to be neglected. Various plans have been proposed with a view wholly to banish * See his Treatise on Fevers, Small-Pox, Sic. Order lit cow-pox. 247 the casual small-pox. Dr. Haygarth* has bestowed much attention on this subject ; and were the regulations pointed out by him to be rigidly enforced, there is reason to believe they would be found sufficient for the purpose. A surer and more effectual way, how- ever, fo eradicate the disease, is by inoculating with vaccine mat- ter every adult who never has had the small-pox; as likewise every child soon after its birth. It has frequently been attempted to communicate the small-pox and measles to quadrupeds by inoculation, but in vain. VARIOLiE VACCINAE, or COW-POX. In many of the dairy counties it has been long known that the cows are liable to an eruption on their paps or udders, which was occasionally communicated to the hands or arms of those who milked them, producing an ulcer, and some degree of fever ; and it had been observed by the people of those counties, that those who had gone through this disease, known by the name of cow-pox, were not liable to the small-pox. The disease had not, however, undergone any medical investiga- tion until Dr. Jenner, then of Berkley, in Gloucestershire, paid particular attention fo it. He very satisfactorily ascertained that it was a much milder disease than the small-pox, and that the fact was true, that in general it secured those who had been infected with it from afterwards being liable to variolous infection. He also ob- served, that the vaccine-pox is not infectious but by inoculation ; and that on this account it might be inoculated in a family without endangering others : a circumsfance of the greatest importance. On the suggestions of Dr. Jenner, many practitioners were induced to adopt the practice of substituting the one disease for the other, and its efficacy is in most cases now fully established. With respect to the origin of the disease in the cow, we are in- formed by Dr. Jenner, that he traced it fo the diseased heels of horses which had been affectejj with the grease ; and by the person appointed to apply the dressings to them not paying a due atten- tion to cleanliness, and incautiously bearing his part jn milking the cows, with some particles of the infectious matter adhering to his fingers, he has communicated the disease to them. From numerous experiments made, however, at an early period, by the late Dr. Woodville, and by Mr. Coleman, Professor at the Veterinary College, with the matter of grease, taken in the various stages of that complaint, no such effect has been produced upon cows. Neither were inoculations with this matter, nor with several other morbid secretions in the horse, productive of any effects upon the human subject, which by no means accord with the facts adduced by Dr. Jenner on this point. Some communications through the medium of the Medical g * See his Ske.tch of a Plan to exterminate the Casual Small-Pox from Great Britain. 248 PYREXIA, OR FEBRILE DISEASES. ClaSS I and Physical Journal (see vol. iv. pages 381 and 466), in consequence of still later experiments, seem however to give support to Dr. Jenner's opinion as to the origin of the disease. On its first investigation, some circumstances led to the supposi- tion that the cow-pox and small-pox were originally one and the same disease; the latter being derived from the animal at some remote period, and having undergone, in the lapse of years, and by the influence of various constitutions, the changes we now experience. Subsequent facts have, however, invalidated this opinion. From various experiments it appears that the vaccine disease and the small-pox are not susceptible of intermixture, but that each preserves its distinct character under all circumstances. At the Small-Pox Hospital it has been noticed, that when the vaccine and variolous fluids are mixed together, and thus inserted, sometimes the vaccine pustule, at others the variolous, has been produced, each of them retaining its characteristic marks throughout. Again, it has been found, that when the two fluids are inserted separately, and so near together that the two pustules which follow spread into one, by inocu- lating with the fluid taken from one side of it, the vaccine pustule alone will be produced, while the fluid taken from the other excites the genuine variolous pustule, with the general eruption of small- pox on the body. Another point of dissimilarity between the vario- lous and vaccine diseases is this: the inoculation of the former we well know supersedes the natural disease many days after exposure to infection. The effect produced by submitting persons to the influence of vari- olous and vaccine matter at the same time, is, that they both prove effective: for the vaccine vesicle proceeds to its acme in the usual num- ber of days, and the maturation of the variolous pustules is attended with a pustular eruption on different parts of the body; but when vari- olous matter is not inserted until the ninth day after the inoculation with vaccine matter, the action of the variolous seems to be wholly precluded. The variolous and vaccine fluids inoculated about the same time, restrain the action of each other. The vaccine vesicle, in this case, is smaller, and proceeds more slowly to its maturity, and the variolous pustules are small, hard, and shining, producing only a small particle of matter at their apices. The nipples of the cow being once affected, the disorder is commu- nicated to the dairy-maids, and other assistants employed in milking, and by them it is spread through the farm, until at last most of the cat- tle experience its consequences. The disease appears on the nipples of the cows in the form of irregular pustules, which on their first appearance are commonly of a colour somewhat approaching to livid, and are surrounded by an erysipelatous inflammation, according to the report of Dr. Jenner; but Dr. Woodville seems to think that it is rather an indurated tumefaction of the skin which surrounds the pustules, Order HI cow-pox. 249 than an inflammation of an erysipelatous nature. Unless proper remedies are applied in time, these pustules soon degenerate into phagedenic, ulcers, which prove extremely troublesome ; the animals then become much indisposed, and the secretion of milk suffers a considerable diminution. Inflamed spots now begin to appear on different parts of the hands and wrists of the domestics employed in milking, which run on quickly to suppuration, assuming at first the appearance of small vesications produced by a burn. Most commonly they come out about the joints of the fingers, and at their extremities; but whatever parts are affected, if the situation will admit, these super- ficial suppurations put on a circular form, with their edges more elevated than their centre, and of a colour distinctly approaching to blue. In consequence of absorption, tumors appear in each axilla, the system becomes affected, the pulse is quickened, and rigors, with general lassitude and pains about the limbs and loins, with a vomiting, come on. In some instances the head is much affected, and a delirium arises. These symptoms varying in their degrees of violence, usually con- tinue for three or four days, leaving ulcerated sores about the hands, which from the sensibility of the parts are very troublesome, and commonly heal slowly, becoming not unfrequently phagedenic, like those from which they sprung. The lips, nostrils, eyelids, and other parts of the body, are likewise affected sometimes with sores, in consequence of being heedlessly rubbed or scratched with the patient's infected fingers. Dr. Jenner informs us, that he had never met with any case of the cow-pox, either taken naturally, or produced artificially, which Eroved fatal; but by Dr. Woodville we are told, that out of five undred cases of inoculated cow-pox under his care, one proved fatal, which was a child at the breast, on the eleventh day after the matter had been inserted in the arm. From that occurrence, and a few cases in which the febrile symptoms ran high, this gentleman was at first very adverse to the vaccine inoculation; but from further trials he latterly gave it, with almost every other practitioner, a decided preference. The few instances of death which have occurred from vaccine inoculation, since it has been more generally practised, may probably be referred with much justice to some unknown pecu- liarities of the constitution; to intervening disorders independent of the vaccine, and to inflammation excited by accidental causes in young children, especially when they have been ill fed and badly nursed—circumstances not uncommon among very poor people. When the pustules are numerous, as sometimes happens where the disease has been received immediately from the cow, a con- siderable degree of fever attends: but when it has arisen from 32 250 PYREXIA, OR FEBRILE DISEASES. ClOS9, t inoculation, few or no pustules are to be observed, except immedi- ately round the wound in the arm ; and little or no inconvenience is experienced. A more general knowledge of the disease than what we had at first, has ascertained it to be an undoubted fact, that the vaccine virus is greatly modified, and rendered much milder, by passing through different habits; and that although the cow-pox has proved in many instances a severe disorder in those who received the infection immediately from the animal, still in a few instance* only have the symptoms run high, or has the least inconvenience been experienced, where proper matter taken from the human subject was used for inoculation. In the few cases which have been brought forward, where a numerous eruption, preceded by a fiery redness, took place, we should attribute it to something wrong in the habit of body; to the intervening of some other eruptive disease; or possibly ta the having inoculated with matter which had undergone a decom- position, in consequence of putrefaction, or some other cause not obvious. A use of medicine seems wholly unnecessary in the cow-pox, except in those cases of the natural disease where much febrile heat attends; and then the antiphlogistic plan ought to be pursued. The vaccine virus is certainly of a very singular nature, inasmuch as that a person who has been infected by it, is generally found to be for ever after secure from the infection of the small-pox; neither exposure to variolous effluvia, nor the insertion of the matter into the skin, being capable of producing the disease. Many direct experiments, made by innumerable practitioners, prove that the sus- ceptibility of the small-pox is in general totally destroyed by inocu- lating with the vaccine matter. The permanency of the effect was indeed a matter of some doubt, but that is now fully established. It appears from the Report of the Small-Pox Hospital in London, that up to December 1802, eleven thousand eight hundred patients and upwards had been vaccinated, of which number twenty-fife hundred were afterwards proved to be secured from the natural small-pox, by receiving a further inoculation with small-pox matter, while they were at the same time exposed in an hospital full of its infection, without effect. It was said at first, that although the cow-pox destroyed the susceptibility of the small-pox, still it possessed not the same power with regard to itself, as a person might have the disease more than once. Instances certainly have been adduced of the cow-pox taking place a second time; but they are of very rare occurrence, and should be looked on as irregular. The same has happened with the small-pox. In Dr. Jenner's first treatise he mentions that the small-pox if not always a security against the cow-pox, and that although the susceptibility of the virus of the cow-pox is for the most part lost m those who have had the small-pox, yet in some constitutions it Order HI «gw-pox. S51 is only partially destroyed, and in others it does not appear to be in the leasi diminished. A more intimate knowledge of the disease has con- finced us of the fallacy of this opinion. Soon after Dr. Jenner's first publication on the vaccine disease, a few instances were adduced, tending to invalidate his suppo- sition of the preventive power of the cow-pox with regard to variolous infection; but these he considers to have been cases of a spurious disease, and therefore not affecting his general conclusion. In using this term, he does not mean, however, to imply that there is a true and false cow-pox, but merely to express an irregularity or difference from that common form and progress of the vaccine pustule from which its efficacy is inferred. Those who perform vaccination ought therefore to be well instructed, and should have watched, with the greatest care, the regular process of the pustule, and learnt the most proper time for taking the matter. A few cases of still later occurrence have also been brought forward by Mr. Goldson* of Portsmouth, and others, with the view of proving that the inoculated cow-pox is not a permanent security against the infection of the small-pox ; but a failure in one or two cases out of more than thirty thousand, although ever so well substantiated, should be considered in no other light than as a casual irregularity, upon which no solid determination can, or ought to be grounded. Instances of the like nature have been known to occur likewise among persons inoculated with variolous matter, and when they are met with, ought to be looked on as anomalous. There can be little doubt, however, that some of the failures are to be imputed to the inexperience of the early vaccinators; and it is by no means unreasonable to expect that further observation will yet suggest many improvements that will reduce the number of anomalous cases, and furnish the means of determining with greater precision when the vaccine disease has been effectually received. Persons who have been vaccinated and passed through the cow-pox with all the usual accompanying symptoms, and who have afterwards taken the small-pox, of which a very few instances may have happen- ed, have generally imperfect pustules, which die away in a few days without exciting any constitutional complaint; but the matter taken from these pustules will communicate the small-pox. This circum- stance has been brought forward by the anti-vaccinisls as a proof that persons who have had the cow-pox, may afterwards take the small- pox by inoculation, and otherwise, not making the proper distinction between local and constitutional infection; or perhaps not understand- ing how any one can communicate a disease to others with which he is not himself infected. * See his Cases ef Small-Pox subsequent to Vaccination, 252 PYREXIAE, OR FEBRILE DISEASES. ClaSS / We are informed by Dr. Jenner that the sources of a spurious cow- pox are as follow:— 1st, That arising from pustules on the nipples or udder of the cow, which pustules contain no specific virus. 2dly, From the matter (although originally possessing the specific virus) which has suffered a decomposition either from putrefaction or from any other cause less obvious to the senses. 3dly, When the matter is taken from an ulcer in an advanced stage, which ulcer arose from a true cow-pox : and, 4thly, He supposes a spurious disease to arise from matter produced on the human skin, from contact with some peculiar morbid matter generated by a horse. The characteristics of the true cow-pox are as follow, viz. a circum- scribed, circular, elevated eruption, surrounded by a red halo or efflo- rescence; smooth surface; brown, black, or mahogany and tamarind- stone coloured, long adhering scab. From a chymical analysis of vaccine matter by some French phy- sicians, it was found to consist of water and albumen. The succeeding arguments have been urged in favour of inoculation for the cow-pox over that for the small-pox. 1st, Of several thousand persons who have had the inoculated cow- pox, only one or two have died. 2dly, Very few well-attested instances have been produced out of many thousands of the above persons, known to have had the inocu- lated vaccine-pox, and who were subsequently inoculated for the small-pox, of this disease being afterwards taken; although many of these were also exposed to the infectious effluvia of the natural small- pox. And traditionally, this fact has been established time immemo- rial with regard to the casual cow-pox. 3dly, It may safely be affirmed, that the inoculated cow-pox is ge- nerally a much slighter disease than the inoculated small-pox; and that the proportion of severe cases in the latter is to the former as at least ten to one. 4thly, It does not appear that the genuine vaccine-pox can be propagated, like the small-pox, by effluvia from persons labouring under it. Hence, if the vaccine inoculation should be univer- sally instituted in place of the small-pox, it is reasonable to con- clude, that this most loathsome and fatal malady will be extin- guished. 5thly, It does not appear that the vaccine poison, like that of the small-pox, can be conveyed so as to produce the diseases indirectly from diseased persons, by adhering to clothes, furniture, bedding, let- ters, &c. Hence no danger of its propagation in these channels is to be apprehended from the universal practice of the inoculation of the cow-pox. 6thly, It has been found, that a person whose constitution has distinctly undergone the vaccine disease, is in future unsuscep- tible of the same disorder. Hence no objection can be made to the new inoculation, as was once urged, on account of its being Order III COW-POX. 253 believed, that by the commutation of the small-pox for the vaccine- pox, an eruptive disease would be introduced, to which the same person would be repeatedly liable. 7ihly, It does not appear that those who have already gone through the small-pox are susceptible of the vaccine disease, as was at first believed. Hence no objection can be urged on the score of persons who have already gone through the small-pox being liable to a new infectious disease, by the introduction of the vaccine inoculation. 8thly, Experience shows, that there is no reason to apprehend the smallest chance of deformities of the skin from the vaccine inoculation. 9thly, The extensive practice of the vaccine inoculation, and the accounts of the disease in the casual way, do not show that any other disease will be excited subsequently, which is peculiarly imputable to the new practice. On a review of these arguments founded on facts, there can remain no doubt but that the vaccine inoculation will soon wholly supersede and do away the variolous. Could all parents be per- suaded to inoculate their children with vaccine matter soon after birth, the small-pox might be entirely eradicated in time. The introduction of this species of inoculation generally throughout both the army and navy, and its extension to France, Spain, Ger- many, and every part of the continent, as well as to both the Indies, fully stamp its value and efficacy, and give us reason to hope that it will shortly be adopted by every nation of the earth with whom we have the least communication. Vaccination has indeed penetrated to the remotest corners of the globe ; and wherever it has been introduced, the increasing experience of every year has only served to confirm pretty generally a con- fidence in its efficacy. It has been recommended and adopted by far the greatest and most respectable part of the profession, every where, but by a few individuals it has been obstinately opposed through interested motives. In inoculating for the vaccine disease, we should carefully attend to the following circumstances :— 1st, That the matter should not be taken later than the ninth day of the disease. 2dly, That the fluid should be perfectly transparent, as it is not to be depended upon if it has become in any degree opaque. 3dly, That the matter, if not used immediately, should be allowed to dry gradually and thoroughly before it is laid by for future use. 4fhly, That the punctures can scarcely be made too superficial, and on no account should more than one be made in each arm. 5thly, That attention should be paid to repress, as soon as may be, any excess of inflammation that may happen to arise ; and this is best done by cold and restringent applications. With respect to the operation of vaccination, it will be im- 254 PYREXIA, OR FEBRILE DISEASES. ClttSS 1 portant to ascertain that the vesicle has not acted locally, but effected the desired change on the constitution: hence has origfc nated the practice of testing by re-vaccinating during every period of the progress of the vaccine vesicle. From the report of the physicians of the Vaccine-Pox Insti- tution, it appears that the matter of a single pustule, being mixed with one quarter of an ounce measure of warm water, such diluted matter excited as distinct a vaccine-pox by inoculation, as an equal quantity of undiluted matter. A pox so excited was not attended with less inflammation, or constitutional affection, than that excited by a larger quantity of undiluted matter ; which point9 out an easy method of inoculating several persons from a single vaccine-pock — a great conveniency indeed, when the poor to be inoculated at one time are very numerous. VARICELLA, or CHICKEN-POX. This disease, like the small-pox, seems to depend upon a specific contagion, and affects a person but once during life. The eruption is sometimes preceded by chilliness, succeeded by flushings and heat, pains in the head and back, thirst, restlessness, and a quick pulse ; but at other times no such symptoms are perceptible. About the second or third day the pustules become filled with a watery fluid, which is never converted into yellow matter, as in the small-pox (to the milder species of which it seems, however, to bear some affinity) ; and about the fifth day they usually dry away, and are formed into crusts or scabs. No danger ever attends the chicken-pox. The small-pox and chicken-pox differ, in the eruption of the former being preceded by a fever of a certain duration, while that of the latter is either preceded by none, or one of uncertain conti- nuance ; in the vesicles appearing much earlier in the chicken-pox than in the small-pox, and about the second or third day being filled with serum ; in the matter of the former never acquiring the purulent appearance, which if always does in the distinct small-pox, and in the crusts which cover the pustules being formed about the fifth day, at which time those of the small-pox are not at the height of their suppuration. These distinguishing marks it will be necessary to attend fo, as there is great reason to suppose the chicken-pox has not only been sometimes mistaken for small-pox, but that its matter has been used for that of small-pox in inoculation, to which may be ascribed many of the supposed cases of small-pox having appeared a second time in the same person. In general it is only necessary to make use of a spare regimen on the first appearance of the eruption, and to give one or two cooling purgatives afterwards ; but should the febrile symptoms run high, it may then be advisable to make the patient take frequent small doses of some antimonial, with saline draughts and nitre, as advised Order III MEASLES. 255 under the head of Simple Fever, or the distinct Small-Pox, drink- ing plentifully at the same time of cold diluting liquors, and keep- ing the body open with gentle laxatives or emollient clysters. The like treatment will also be proper in the swine-pox, which is indeed only a species of the varicella. RUBEOLA, or MEASLES. This disease is an inflammatory infectious fever, attended by cough, sneezing, a defluxion of thin humours from the eyes and nose, and a determination of acrid matter to the surface of the body, showing itself in red spots over every part of it, but which never come to any suppuration, as in the former disorders, but go away in a small mealy desquamation of the cuticle after a few days continuance. In systems of nosology several varieties of the measles are men- tioned, but they may all be comprehended under two heads ; the benign and malignanf: the former attended with more or less of the symptoms of general inflammation, the latter accompanied by a putrid diathesis and typhoid fever. The scientific Willan* divides rubeola into three species, viz., rubeola vulgaris, rubeola sine catarrho, and rubeola nigra; in the tatter of which the papulae suddenly assume a black or dark purple colour. Scarlatina sometimes resembles the measles so exactly as not to be easily distinguishable ; though this is a matter of great import- ance, because the method of cure in the two diseases is extremely different. The redness of the scarlet fever is more equally diffused than in the measles, and is not in distinct spots with the natural colour of the skin interposed ; yet in a few cases it has been ob- served so. In the measles the eruption rises more above the skin, and occasions a manifest roughness to the touch, which is hardly observable in the scarlet fever, except a very little roughness some- times in the arms. In the scarlet fever there is seldom a severe cough ; the eyes do not water much, and the eyelids are not red and swoln ; all which rarely fail to attend the measles. The time of the eruption is likewise different, for it appears in the scarlet fever both in the face and arms on the second day; but in the measles it begins only about the third day to be visible on the chin and breast, and does not come to the arms and hands till the fourth or fifth day. The measles may prevail at all seasons of the year as an epidemic, but the middle of winter is the time they are usually most preva- lent ; and they attack persons of all ages, but children are most liable to them. They prove rather unfavourable to such as are of a plethoric or scrofulous habit. Like the small-pox, when genuine, they rarely affect persons but once, their contagion appearing to be •mmmrnm..: i i i i . ......,. * See his Description and Treatment of Cutaneous Disease* 256 PYREXIAE, OR FEBRILE DISEASES. ClaSS I. of a specific nature. A recurrence of the measles has been dis- puted by some, but a number of examples are recorded by different writers wiiere the measles took place twice*. From a number of cases lately observed at New-York, when the measles were very prevalent there, it appears that spurious forms of the disease, insufficient to protect the system from subsequent attacks, occur in a manner very analogous to the spurious appear- ances of the small-pox and of the variolae vaccmaef. For many persons, who on former occasions of the measles prevailing, and after exposure to their contagion, had exhibited certain irregular appearances of febrile, catarrhal, and eruptive symptoms, mistaken for the true disease, were afterwards attacked with measles in an exquisitely genuine form. The fact is likewise noticed by Dr. WillanJ, and he mentions that the rubeola sine catarrho appears to be an unusually mild form of the disorder, which does not destroy the susceptibility to an attack in future. Two instances of its re- currence happened among his own children, at an interval of two years. In a later publication^ he informs us, that he has since seen other cases of the same kind, wherein the efflorescence without fever or catarrhal symptoms having declined, there appeared, on the fourth day from its commencement, a new efflorescence, and violent disorder of the constitution. The eruption of benign measles is usually preceded by a chilli- ness and shivering, succeeded by heat, thirst, anxiety, pains in the head, back, and loins, heaviness, and redness of the face and eyes, with an effusion of tears, swelling of the eyelids, nausea, and pro- bably a vomiting of bilious matter; and with these symptoms there are a dry cough, hoarseness, hurried respiration, difficulty of breath- ing, frequent sneezing, and a discharge of acrid water from the nostrils. The pulse is at the same time frequent and strong. In alarming cases, spasms of the limbs, subsultus tendinum, deli- rium, or coma, supervene. This last symptom, however, so fre- quently attends the eruptive fever of measles, that by some prac- titioners it is regarded as one of its diagnostics. In measles, as in other febrile diseases, the symptoms generally suffer some remission towards the morning, returning however in the evening with increased severity. About the third or fourth day small red spots, somewhat similar to flea-bites, appear in clusters about the face, neck, and breast, and in a day or two more the whole body is covered with them. They do not rise into visible pimples, but by the touch are per- ceived to be a little prominent. The febrile symptoms do not however abate on the appearance of the eruption, as happens in the small-pox ; but, on the contrary, * See Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, vol. iii. t See the New-York Medical Repository, vol. v. No. 3. X See his Reports on the Diseases of London, 1799, p. 207. § See his Description and Treatment of Cutaneous Diseases, Order iii. Part I. Order HI. measles. 257 are usually much increased, and they do not cease till after the desquamation takes place. The cough, hoarseness, difficulty of breathing, and defluxion from the eyes and nostrils, seem likewise grea;ly aggravated. On the fifth or sixth day the spots from a vivid red are changed to a brownish hue, and they begin to dry away about the face, never having proceeded to any kind of suppuration ; about the eighth or ninth day they disappear on the breast, and other parts of the body, with a mealy desquamation of the cuticle. About this period it is no uncommon occurrence for a diarrhoea to ensue. The malignant form of the disease is accompanied with typhus fever, and with petechias and other signs of putrescency, as enume- rated under that head. Moreover, the eruption appears more early, and all the concomitant symptoms are in an aggravated form. The fauces not unfrequently assume the same appearance as in cynanche maligna, probably from a combination of the two diseases. Some cases of this nature have lately fallen under my care, two of which proved fatal. The febrile and other symptoms being mild, a gentle diarrhoea, a free and copious expectoration, a moisture on the skin at the ap- pearance of the eruption, and an early and free desquamation, de- note a favourable termination of the disease; but a high degree of fever, hot and parched skin, hurried and difficult breathing, flushed countenance, unusually hard pulse, the energy of the system not proving sufficient to throw out the eruption to the surface of the body, and the mucous membrane of the larynx, trachea, and bron- chial ramifications being invaded therewith, as happens sometimes in scarlatina, ulcerated fauces, severe diarrhoea, the vomiting con- tinuing after the eruption, great pain in the head and eyes after it, considerable degree of coma or delirium, the eruption becoming of a livid hue, with great prostration of strength, small intermittent pulse, petechias, and other marks of putrescency, point out the highest degree of danger. The existence of typhoid symptoms along with a severe pneumonic affection, always increases the danger. * The consequences attendant on the measles are frequently more to be dreaded than the immediate disease; for although a person may get through it, and appear for a time to be recovered, still pulmonary consumption and hectic fever shall afterwards arise and destroy him, or an obstinate ophthalmia will ensue. Measles, as well as the small-pox, not unfrequently call into action a disposition to scrofula, where such happens to exist in the habit. Another bad consequence of the measles is, that the bowels are often left by them in a very weak state; a chronic diarrhoea re- maining, which has sometimes proved fatal. Dropsy has also been known as a consequence of measles. A singular circumstance attending the contagion of the measles is, that if it be taken a sufficient time before inoculation for the 258 PYREXIAE, OR FEBRILE DISEASES. CUiSS 1. small-pox, so that the eruption may commence before the variolous fever conies on, it stops the progress of the small-pox in the inocu- lated wound, and delays it till the fever of the measles has finished its career. The morbid appearances to be observed on dissections of those who die of the measles, are pretty much confined to the lungs and intestines; the former of which always shows strong marks of in- flammation, with sometimes a tendency to sphacelus. Where the patient dies under the eruption, the trachea and larger branches of the bronchiae, as in the small-pox, are often found covered with it, which may account for the increase of the cough after the appearance of the eruption. In some instances the measles make their attack in a mild man- ner, and go through their natural course without medical aid; but in others the febrile symptoms run high, particularly after the ap- pearance of the eruption, and are accompanied with a strong pulse, much coughing, great difficulty of breathing, ami other symptoms of pneumonic inflammation; in which cases it will be proper to draw off a quantity of blood proportioned to the age and habit of the patient. We should, however, be careful never to draw blood unnecessarily, nor to take a greater quantity away than what may really be requisite. Topical bleeding by means of leeches to the chest or head, when symptoms of local inflammation in either of these are apparent, may be more advisable than venesection. So long as a considerable difficulty of breathing, a troublesome cough, or any other symptom indicative of inflammatory action in the lungs exists, the topical abstraction of blood from the chest by means of leeches, or the scarificator with cupping-glasses, may be repeated from time to time. In those instances where the pulse is weak, and from the nature of the epidemic we may have strong reasons to ap- prehend an accompanying fever of the typhoid kind, or a disposition to putrescency, venesection ought not to be adopted. During the whole course of the disease it will be highly proper to keep the body open; and, therefore, if costiveness prevails, it should be obviated by giving cooling laxatives, such as the neutral salts and emollient clysters. Should the difficulty of breathing and oppression at the chest not be relieved by the bleeding, and other antiphlogistic means, a blister may then be applied in the neighbourhood of the part or between the shoulders. In removing local inflammation, the application of a blister often proves a valu- able remedy. The cough being usually very troublesome, it will be necessary to make frequent use of some demulcent pectoral, either of an oily or mucilaginous nature, as advised under the heads of Catarrh, Pleurisy, and Puripneumony, which will sheath the throat, and ob- viate that rawness and soreness of it which are generally much felt. Besides using pectoral medicines, the patient may drink freely of barley-water, linseed-tea, or the decoctum hordei compositum, gen- tly acidulated with lemon-juice. Order III MEASLES. 259 Where the cough proves very troublesome, and is attended with great difficulty of breathing or soreness at the chest, inhaling the steam arising from warm water and vinegar may prove serviceable. A pediluvium might be a good auxiliary. If the febrile symptoms run high, and great heat, thirst, and restlessness prevail, small nauseating doses of antimonials may be given every two or three hours, as advised under the head of Simple Continued Fever, in order to determine to the surface of the body. Iii this, as well as in other cases of excitement, it will be advis- able to have recourse to nitre and saline draughts, along with anti- monials, whenever the inflammatory symptoms run high. When the cough harasses the patient much by night, so as fo deprive him of rest, it may be necessary to give him an opiate about bedtime. The tinctura opii may be used for adults, combined with some diaphoretic* ; but for children it will be better to sub- stitute the syrupus papaveris soroniferi. Opiates are, however, to be administered with great caution in this disease, as well as in all other inflammatory ones, and ought never to be employed where there is much fever present, with great difficulty of breathing. When these symptoms have been removed by timely bleeding, ape- rient medicines, &c. and the cough and watchfulness are those only which are urgent, opiates will prove both safe and efficacious. In formidable cases of measles, when the urgency of the cough, the quick, difficult, anxious,' or laborious respiration, with a high fever, denote a dangerous disease, but in which blood-letting, or the exhibition of opium, may be thought equivocal, we may recom- mend full doses of the tinctura digitalis. In such cases the fever is allayed, respiration relieved, and the bowels relaxed by its means ; whereas the very reverse is frequently the consequence of opium. Hence its superiority in many instances. If a severe purging should arise, we may moderate it by giving astringents joined with opium (see Diarrhoea) ; but as an open state of the bowels proves serviceable, it ought not to be suppress- ed, unless it is violent. * 1. rj Liquor. Arumon. Acetat. f. |ss. Aquae Purae, f. |j. Spirit. .Ether. Nitrici,fllxxv. Vin. Antimon. TT1 xv. Tinct Opii, Til xxv Syrup. Tolutan. 3'j- M- ft. Haustus. Vel, 2. g; Mistura? Camphorae, f 3*. Spirit. .Ether Nitrici, f. 3j. Tinct. Digitalis, fn, xv. Syrup. Papav. Somnifer. f. 3ij. M. ft. Haustus. * 1. Take Solution of Acetate of Ammonia, half an ounce. Pure Waler, one ounce. Spirit of Nitric jEther, forty drops. Antimonial Wine, twenty drops. Tincture of Opium, forty drops. Syrup of Tolu, two drachms. Mix them lor a draught. Or, 2 Take Camphor Mixture, ten drachms. Spirit of Nitric ./Ether, one drachm. Tincture of Foxglove, twenty-two drops. Syrup of Poppies, two drachms. Mix them for a draught. 260 PYREXIA OR PEBRILE DISEASES. ClaSS I. When the eruption of measles disappears before the proper period, and great anxiety, and delirium, or convulsions, take place, the indication will be to restore the eruption to Ihe skin. To effect this, immediate recourse must be had to the warm bath, blisters to the chest and legs, and the administration of wine properly diluted with warm water: ammonia, camphor, sether, and antimonialsj'will be the best medicines*. Should the symptoms manifest a malignant kind of the disease, and a putrid tendency prevail, we must then adopt a very different mode of treatment from what has been advised for the inflamma- tory. The'cure must be conducted on the general antiseptic plan by cinchona, wine, acid*, (particularly the mineral) and pure air, &c.—See Typhus Gravior. Throughout the whole course of the measles the patient ought to be confined to his bed, and to avoid any exposure to cold air, which might repel the eruption ; but in observing this precaution, he is not to run into the opposite extreme, and excite internal heat either by loading himself with bed clothes, or by not allowing a sufficient ventilation through his chamber. The degree of tempe- rature should be regulated by the patient's feelings. Rubeola does not either require or bear the free application of cold, which is so potent a remedy for the most distressing symptoms of scarlatina ; but nevertheless the propriety of coolness in the apartment and bed, as also in the drink of the patient, must be obvious. A diluent and antiphlogistic diet being one of the best means of obviating inflammatory complaints, we ought to recommend it in the early stages of measles : but in managing it properly, we should recollect its tendency to produce debility, and in weak habits be careful not fo push it too far. Where the disease shows a malig- nant and putrid tendency, a diet of this nature would be highly im- proper. In such cases a quantify of wine, proportioned to the a^e of the patient, the urgency of the symptoms, and the effect it pro- duces, ought to be allowed, in addition to the bark of cinchona, mineral acids, and opiates. After the disappearance of the eruption, it will be proper to * 3. U Pulv. Antimon gr. ij. Camphorae, gr. iij. Ammonias Subcarbonat. gr. iv. Confect. Cort. Aurant. q s. M. ft. Bolus quartis vel sextis horis adhi bendus. Vel, 4. R Liquor. Ammoniae Acet. f. §i. Mistura? Camphorae, f. ?v. Spirit. ^Ether. Sulph. C. f. 3ij. Liquor. Antimon. Tartarizat. fn. xx. M. ft. Mistura cujus sumantur cochlearia duo magna secunda vel tertia quaque hora *3. Take Antimonial Powder, two grains. Camphor, three grains. Subcarbonate of Ammonia, four grains. Confection of Orange PppI, a suf- iciency to form a bolus, which is to be :iven every four or six hours. Or, 4. Take Solution of Acetate of Ammonia, one ounce. Camphor Mixture, five ounces. Compound Spirit of Sulphuric ^Ether, two drnchms. Solution of Tartarized \ntitnoiiy, thirty drops : shake them. Of this mixture take two table-spoonsful every second or third hour. Order lit measles. 261 give one or two doses of some cooling purgative. This practice, although disregarded by many, seems nevertheless worthy of attention, as ophthalmia and olher troublesome complaints may probably be prevented by conforming to it. If a difficulty in breathing, pain in the side, and cough, should ensue in consequence of the measles, it w ill be advisable to take away a proper quantity of blood, in order to remove the inflammatory state of the system which has been induced by the disease; besides which, the patient must pursue the other steps advised under the head of In- cipient Phthisis Pulmonalis, making u 1. g; Hydrargyri Submuriat. gr. irj. H 1. Take Submuriate «f Mercury, three I grains. '268 PYREXIA, OR FEBRILE DISEASES. CUlSS 1. the remainder of the disease, if costiveness arises, it must be obviated by laxative clysters administered from time to time, as the occasion may require. These, as inducing no debility, will be far preferable to purgatives, when the disease has made some progress. Purgatives ought indeed carefully to be avoided, except on the first onset of scarlatina; and even then, whatever we employ, should be of the mild- est nature, lest we should induce diarrhoea, which is apt to occur of itself. This precaution, with respect to administering purgatives in scarlet fever, but more particularly in that species of it which has been de- nominated scarlatina anginosa, although sanctioned by the opinion of most of our eminent physicians, and ratified by my own experience, by no means accords with the directions of a modern writer*; for he tells us, that in treating scarlatina he has confided much in the use of purgative medicines, and that no variety of the disease has prevented him from pursuing out this practice to the extent he judged necessary. He indeed somewhat qualifies this mode of treatment, by afterwards acknowledging, that he wishes to limit their effects to the express pur- pose of unloading the bowels, and securing the complete expulsion of their contents, without inducing what he calls full purging. Bleeding from the system Will not be necessary in scarlatina mitis, even although a slight inflammatory diathesis may seem to prevail on its attack. In those cases of scarlatina anginosa where the tonsils are so much inflamed and swelled as to impede deglutition, or consider- ably interfere with respiration, it will be much safer to apply a few leeches under each ear, and draw blood in this way from the neigh- bourhood of the parts immediately affected, than from the system by venesection. Where the eyes look red and fiery, and a high degree of delirium prevails in scarlatina, the application of two or three leeches to each temple may be resorted to with safety, and possibly with some relief. The physicians on the Continent have indeed recommended drawing blood from the arm, or when the head is much affected, from the jugular veins; and it appears that Morton adopted the same practice in many of the cases he attended in London: but I think there will be found very few among our modern physicians who would advise it, particularly in scarlatina maligna, even at an early stage of the disease. Dr. Arriistrongf is, however, among the few who approve of venesection; and we are told by him that experience in scarlatina has induced him to abandon the stimulant plan of treatment, even in the most malignant forms of the com- plaint, from having ascertained its efficacy ; and that since he has had recourse to depletory measures of an active and decided kind, * See Observations on the Utility of Purgative Medicines, by Dr. Hamilton. t See his Practical Illustrations of the Scarlet Fever, fce. Pulv. Rhei, vel Jalapae, gr. vj.—xij. 1 Powdered Rhubarb, or Jalap, M. j from six to twe4ve grains. ft. Pulvis aperiens ex melle sumendus.* ' Mix them in a little honey. Order III scarlet fever. 269 he has practised in the disease with much more satisfaction of mind, arising from far greater evidence of success. Even in scarlatina maligna let the practitioner, he says, give a fair trial to the cold affusions as soon as the stage of excitement is developed, and if they should not effectually reduce the fever, let him not pause an instant longer, but open a vein in the arm or neck, or even a branch of the temporal artery, and allow the blood to flow until it is stopped by approaching faintness. If this should not give, he adds, a marked relief to the most prominent symptoms, a second but more moderate venesection should be tried in an hour or two afterwards. The putrid symptoms only occur, he says, in the stage of collapse, and are the products of the preceding stage of excitement. The head must be always raised very high, and after having been shaved, it should be repeatedly covered with folds of linen soaked in cold water. Im- mediately after the bleeding, the bowels are to be opened by large doses of submuriate of mercury and jalap, aided by the sulphate of magnesia, or some other neutral salt, and the purgative plan must be persisted in vigorously until there is a visible change for the better in every respect. It must however be recollected, he observes, that these powerftil proceedings must be solely confined to the stage of excitement, and that unless they are carried into effect within the first thirty hours of that stage, nothing decidedly beneficial is for the most part to be expected from tbem. To determine gently to the surface of the body, it may be advisa- ble to give the saline medicine from time to time with small doses of some antimonial*. Throughout the whole course of the disease, if there is either in- flammation or ulceration in the throat, it will be proper to make fre- quent use of some detergent gargle, as recommended under the heads of Cynanche Tonsillaris and Maligna, which in young children may be thrown into the fauces with a syringe, as they seldom can be prevailed on to gargle. A little of the linimentum ammoniae subcarbonatis may at the same time be rubbed twice or thrice a day externally, covering the parts afterwards with flannel. Where the throat is much affected, a mustard poultice may be applied, and kept on as long as it can be borne without producing too great a degree of irritation. When the fauces are in a sloughing or gangrenous state, a warm fomenta- tion of nitric acid largely diluted, together with the stimulating • 2. R Haust. Salin. Mistur. Camphorae, aa f. 3vj. Antimon. Tartarizat. gr. l-6th. Syrup. Cort Aurant. f. 3j. M. ft. Haustus 4tis horis sumendus. * 2. Take Saline Draught, Camphor Mixture, of each six drachms Tartarized Antimqny, sixth of a grain. Syrup of Orange Peel, one drachm Mix them as a draught, to be taken every four hours. 270 PYREXIAE, OR FEBRILE DISEASES. ClaSS I gargle of Cayenne pepper, as mentioned under the head of Cynan- che "Ualigna, will be likely to prove highly serviceable. Blisters have been employed by some practitioners in those cases where the deglutition is difficult, the head much affected, or a high degree of delirium has arisen; but they have too frequently been observed to prove detrimental, by rather increasing the irritation of the patient. Immersing the feet and legs in warm water might probably be attended with a good effect. Wnen blisters are applied under a tendency to putrefaction, they are apt to become gangrenous. In scarlatina maligna they never therefore should be used. To obviate inquietude and restlessness, opiates are sometimes re- sorted to; but where the head is much affecied, or there is delirium, they would prove injurious. JEther, and the spiritus aetberis com- positus, or H jffman's liquor, would be more suitable remedies on such occasions. In those cases of scarlatina which show a disposition to malignancy or putrescency, it will be advisable to give the bark of cinctiona in substance', decoction, or infusion (as shall be found to sit easiest on the patient's stomach), along with the mineral acid^, (particularly the muriatic), wine, and other antiseptics, from the first commencement of the disorder.—See Typhus Gravior. As an antiseptic, carbonic acid gas has sometimes been used in this species of the disease with advantage. The best way of giving it is, by administering the neutralized medicine in sucti a manner as that the evolution of the gas may wholly take place in the stomach, which is to be done by the patient's taking the potassae subcarbonas and lemon-juice in separate draughts immediately after each other. The oxygenated muriatic acid is a remedy which has been much employed of late in scarlatina anginosa, and in many instances with a very beneficial effect, even at an advanced stage of the disease. The proper quantity for persons from fourteen to twenty years of age, will be about one drachm of it in the course of twelve hours, divided into small doses, and given at proper intervals. For younger patients a less quantity will be sufficient. As a vehicle to admi- nister the oxygenant remedy in, we may use common water or a weak infusion of calumbo; and to prevent the disoxygenating in- fluence of the light, the medicine should be placed in a dark situa- tion, wrapped in paper. In administering it to the patient, it will be necessary to caution the nurse or other attendant not to employ a spoon, lest a poisonous fluid be thereby conveyed into the stomach, by the oxygen rapidly oxydating the metal of which it is composed. We may also employ the oxygenated muriatic acid in the form of gargle* in scarlatina anginosa. *3. RAO. Hordei, f. ?vij. Mollis Rosae, f."zi. Acidi Muriat. Oxygenat.f. 3i. *3. Take Barley Water, seven ounces. Honey of Roses, one ounce. Oxygenated Muriatic Acid, one drachm. Order 111. scarlet fever. 271 It may not be improper to mention, that camphor is a medicine much employed in scarlatina, and often with a seeming good effect j but more particularly in those cases where the pulse is very low, or the efflorescence disappears suddenly. In these instances ammonia, the aromatic confection, warm bathing, and wine, will likewise be ad- visable. A solution of the subcarbonate of ammonia, in the proportion of two drachms to five ounces of water, of which two tea-spoonsful are to be taken every two, three, or four hours, according to the urgency of the symptoms, is another remedy which has been found highly benefi- cial in this disease*. My usual plan of proceeding in both scarlatina anginosa and scar- latina maligna is, to give a decoction of the bark of cinchona, with an equal quantity of wine and a few drops of oxygenated muiiatic acid, and in two or three hours afterwards the draughtf of camphor and am- monia, and so on alternately; which mode of proceeding I have found very successful. If a purging arises in scarlatina anginosa, it ought to be suppressed as soon as possible, by astringents joined with aromatics, opium, and wine.—See Diarrhoea. The ©edematous disposition which ensues after some cases of scar- latina anginosa is to be removed by diuretics, joined with tonics and a generous diet, as advised under the head of Anasarca, giving at the same time some gentle laxative occasionally. In all cases of scarlatina, when the fever has subsided, the cinchona, stomachic bitters, chalybeates, the mineral acids, wine, a nourishing diet, pure air, and gentle exercise, will greatly accelerate the reco- very of the patient. Scarlatina being of a very contagious nature, and never failing * See Dr. Peart's Treatise on the Malignant Scarlet Fever and Sore Throat. Tinct. Myrrh, f. |ss. M. ft. Gargarisma. Vel, 4. g; Piperis Indici. 3i. Aq Ferventis, f. |v. Macera et eo laturae adde Decoct Cinchon. f. |iij. Acid. Muriat. Oxygenat. f. 3i- M. ft. Gargarisma. t i. & Camphorae, gr. r. Solve in Spirit. Rectif. f. 3ss.et adde Aq. Puraj, — Cinnam. aa f. 3*. Ammonite Subcarbonat gr. K. Syrup. Cort. Aurant f. 3j. ft. Haustus 4tb horis oapiendus. Tincture of Myrrh, half an ounce. Mix them, and use them as a gargle. Or, 4. Take Cayenne Pepper, one scruple. Hot Water, five ounces. Let them infuse, and to the strained liquor add Decoction of Peruvian Bark, three ounces. Oxygenated Muriatic Acid, one drachm. Mix them for a gargle. f 5. Take Camphor, five grains. Dissolve it in Alcohol, half a drachm, then add Pure Water, Cinnamon Water, of each fi?e drachms. Subcarbonate of Ammonia, ten grains. Syrup of Orange Peel, one drachm Mix them, and let this draught he taken every four hour* 272 PYREXIA, OR FEBRILE DISEASES. Class I. to excite the greatest consternation and anxiety when it breaks out in schools and families, it seems right to notice the means which have been recommended*, under such circumstances, for checking its pro- gress, and attempting its total extinction. So long ago as 1779, Dr. Haygarthf preserved 37 boys from the scarlet fever in a boarding-school at Chester, by confining a patient ill of it to a violent degree, in a separate room of the same house, and by attention to perfect cleanliness. In a boarding-school at Bath, in 1805, two young ladies had a scarlet fever and a malignant ulcerated 'sore throat, one of them dangerously. The governess visited the patients, and assisted to syringe their throats frequently in the day. After washing her hands, and with other strict attention to perfect cleanliness, so as carefully to avoid conveying any conta- gious dirt out of the sick chamber, but without changing her garments, she went among 65 of her scholars in the adjoining rooms of the house to hear their lessons and examine their work: not one of these young ladies was infected with the fever, as Dr. Haygarth was informed by the physician who attended these patients. The testi- mony of such numerous facts proves, beyond all controversy, that contagious miasms, in his opinion, do not adhere to clothes so as to infect others closely exposed to them. Hence typhus, scarlatina, he. are always caught either by miasms issuing from the patient, or by miasms issuing from the contagious poison in a solid or liquid form discharged from the patient: but not by miasms adhering to clothes, &c. It completely confirms the fourth law of contagion mentioned under the head of Typhus, which is of very great import- ance, being highly conducive to the simplicity, facility, and certainty of the rules of prevention. If, in future, a patient ill of either typhus or the scarlet fever, be permitted to infect the family, where there is a room in the house for the separation of the sick, it will be justly imputed to the want of knowledge or the want of care in the attendants. All masters and mistresses of boarding-schools ought for their own sakes, as well as for the interest of the children committed to their care, to be provided with one or more separate apartments, in proportion to the size of the establishment, for the reception of inva- lids. These should be so contrived that the communication between the rooms appropriated for the sick and the rest of the house may be speedily and completely cut off at any time. If the establishment be too small to admit of such appendages under the same roof, a proper lodging should be reserved in the neighbourhood, to be always in readiness, whenever the occasion might require to resort As soon as the fever manifests itself in one subject, the person so affected should be separated without delay from all the rest. The next essential step to be taken is to subdue unnecessary alarm and * See Dr. Blackburne's Observations on Scarlet Fever. t See Dr. Haygarth's Sketch of a Plan to exterminate the Small-Pex, p. 247. Order III thb plague. 273 consternation ; in the performance of which duty the parent or guardian must co-operate fully with the instructer. Where Ihe scholars are numerous, and the extent and disposition of the pre- mises admit of if, the best plan is not to disperse the school; for by dismissing the children, those in whom the infection is latent, and to be afterwards produced, thereby convey it to their respective families, and so promote the further propagation of the disease, to the great injury of the junior branches in particular, who are more susceptible of the contagion than adults. Having ascertained and cut off the source of infection; having separated the originally tainted as soon as they begin to sicken, and while they yet remain incapable of imparting disease ; having disposed of them in proper apartments, and strictly enforced the rules of prevention ; the evil may be crushed in its infancy. The extent and magnitude of the mischief will thus be accurately measured and totally obviated. But if the accommodations of the establishment be too limited for the complete execution of this scheme, or parents be unwilling to commit their offspring to any other than their own inspection in the time of illness, it is a sacred duty imposed on them not to admit even a suspected child, much less a diseased one, into family intercourse with themselves, their other children, or their servants. A separate apartment, where circumstances allow of such a con- venience, ought to be in readiness, or in a state to be made ready, for accidental sickness. Here a strict quarantine should be per- formed, whether the subject be suspected or convalescent, the period of which may be regulated, partly by what is already known on the subject, and finally determined by future observation and the result of aggregated facts. If the child be really infected, im- mediate separation, with a suitable regimen, should be adopted. To annihilate the powers of contagion, we may employ fumiga- tions with manganese, salt, and sulphuric acid, as advised under the head of Dysentery; or we may have recourse to those of the mu- riatic or nitric acid, as noticed under that of Typhus Gravior. In regard to prevention, it is obvious that an improvement of the diet in such as live low, moderate exercise in the open air, cold bathing, and in short every mode of strengthening the constitution, with great attention to cleanliness and ventilation, must have a tendency to ward off the disease. Those who are in attendance ought as much as possible to avoid inhaling the breath of the «ick, as it is clear that scarlatina, as well as some other diseases, may be so received. By using a gargle of capsicum frequently, as noticed under the head of Cynanche Maligna, they probably may be enabled to resist contagion the better. PESTIS, on the PLAGUE. The plague is a fever of a putrid and very contagious nature, in Ihe progress of which, extreme debility, buboes, carbuncles, pete- chias, hemorrhages, colliquative diarrhoea, and such other svniptoros 274 PVREXIiE, OR FEBRILE DISEASES. Class I. arise. The contagion of the plague is of a specific nature, giving rise to febrile symptoms, and particularly affecting the nervous and glandular systems. Sir James M'Gregor, in his Medical Sketches of the Expedition from India to Egypt, notices, that the, plague is subject to consi- derable varieties in different seasons and circumstances. In the Indian army, he observed, that when the disease first broke out, the cases sent from the crowded hospitals of the 61st and 88th re- giments were from the commencement attended with typhoid or low symptoms. Those which were sent from the Bengal volunteer battalion and from the other corps, when the army was encamped near the marshy ground at El-Hammed, were all of the intermittent and remittent type. The cases which occurred in the cold rainy monlhs of December and January, had much of the inflammatory diathesis : and in the end of the season, at Cairo, Ghiza, Boulac, and on crossing the isthmus of Suez, the disease wore the form of a mild continued fever. The appearances of the plague have been arranged by different authors in different ways. The French writers on the subject have specified five varieties ; Dr. Russel has extended them to six; but the arrangement ot Sir Brooke Faulkner*, drawn from exten- sive observation during the late appearance of that complaint in the island of Malta, which admits only of three species, appears to be the most judicious ; and this I shall therefore adopt. The pro- priety of distinguishing the plague into three species is also sanc- tioned by a small Tract from the pen of Dr. Pearsonf. The plague is by most writers considered as the consequence of pestilential contagion, which is propagated from one person to another by association, or by coming near infected materials. Some, however, have doubted whether the disease is really con- tagious or not. The fact that it is evidently contagious is fully established in Sir James M'Gregor's opinion ; but the laws of its transmission are not more accurately known than the specific nature of the contagion. Dead bodies, we are told, did not seem to convey it; the heated animal body, and still more with a febrile moisture on the skin, appeared to transmit it most readily. Among the most obvious causes which contribute to induce the plague besides con- tagion, may be enumerated the following, viz. corrupt or damaged gram, putrid fish or other animal substances, noxious exhalations arising from stagnant waters or slimy mud, a residence in confined situations where the current of air is obstructed, and the want of due cleanliness. In some eastern countries, but more particularly Persia and Japan, this disease is wholly unknown. In those where it is pre- valent, it rages most violently during the summer ; its effects are somewhat diminished in autumn ; and during the winter it is greatly * See his Essay on the Plague, inserted in the Edinburgh Medical and Physical Journal, vol. x. \ ?39e hii Brief Description of the Plague. Order III THE PLAGUE. 275 reduced or totally suppressed : this is more particularly the case in European countries. It attacks persons of all ages and both sexes indiscriminately ; but women, young people, and infants at the breast, have been observed in general to resist infection more than robust men. Those who were exposed to vicissitudes of heat and cold, such as bakers, cooks, and smiths, were noticed, during the campaign in Egypt, to be more particularly attacked with it. The plague is said to be most prevalent in that country soon after the inundation of the Nile, or lather its recession; for a quantity of slimy mud being deposited on the banks of the river and other places it has overflowed, occasions humid mephitic exhalations to arise, and which are supposed to produce the disease. From Sir, Robert Wil- son's account of the diseases of Egypt*, there is great reason to suppose that a humid state of the atmosphere is favourable to the production of the plague; for the English and Turkish armies which marched to Cairo escaped contagion, notwithstanding almost every village was infected; while the troops that remained stationary on the moist shore of Aboukir were severely affected, and lost many men. A dry atmosphere appeared to him not only to be a preventive of the plague in some degree, but likewise to act as a remedy; for we are told that several men, confined with this disorder in the hospital at Jaffa, escaped into the desert, and endeavoured to reach the army; but finding the attempt impracticable, they returned in three days perfectly recovered. Baron Larreyf observed that the plague put on a more formidable appearance during the continuance of the south winds than during the winds from the north or north-east. When the latter prevailed, its effects were diminished; and if it continued for any time, the disease disappeared altogether. On the return of the south winds, (or khamsyn) it appeared again with as much violence as ever. A curious observation made by this gentleman was, that the plague rarely attacks wounded men whose wounds were in a state of plen- tiful suppuration; but as soon as the wounds were skinned over, a great many were seized, and few escaped death. He observed the same thing among the inhabitants of the country who had issues open. Galen, and many other celebrated writers, have also noticed, that in countries which they have seen ravaged by the plague, it had spared all those who had issues plentifully discharging. It has been observed, that the plague generally appears as early as the fourth or fifth day after infection; but it has not yet been ascertained how long a person who has laboured under the disease is capable of infecting others; nor how long the contagion may lurk in an unfavourable habit without producing the disease, and may yet be communicated, and the disease excited, in habits more sus- ceptible of the infection. It has generally been supposed, however, that a quarantine of forty days is much longer than is necessary for * See his History of the Expedition to Egypt. t See his Memoirs of Military Surgery. 276 PYREXIAE, OR FEBRILE DISEASES- ClaSS I. persons, and probably for goods also. Experience has not yet de- termined how much of this term may be abated. If I mistake not, the Board of Trade has, however, under the sanction of the College of Physicians, somewhat abridged it. ' In the first species of the plague, according to the arrangement of Sir Brooke Faulkner, the energy of the brain and nervous sys- tem is greatly impaired, indicated by coma, slow, drawling, or in- terrupted utterance; the tongue is white, but little loaded with sordes, and usually clean, more or less, towards the centre and ex- tremity, the anxiety is great, countenance pale, stomach extremely irritable, and the strength much impaired. Rigors and pain in the lower part of the back are among the early precursors of the other symptoms. This was observed by Sir Brooke Faulkner and the other physicians at Malta to be the most fatal species of the plague, and prevailed chiefly at the commencement of the late disaster. Those who were affected sometimes died in the course of a few hours, and with petechia?. In the second species, the state of the brain is the reverse of what takes place in the former, the symptoms generally denoting a high degree of excitement; the pain in the head is intense, thirst fre- quently considerable, though sometimes wanting, countenance flushed, and utterance hurried. The attack is ushered in by pain in the back, and rigors, as in the first species. Epistaxis not un- frequently occurs in this. Glandular swellings come out tardily, and after appearing, recede again without any remission of the general symptoms. Carbuncles arise over different parts of the body or extremities, which are rapidly disposed to become gan- grenous. The delirium continues extremely high and uninterrupted, and the patient perishes in the course of two or three days. Some- times he lingers on to the seventh, yet rarely beyond this period, without some signs of amendment. Sir Brooke Faulkner found the instances of this second species very numerous, and they were nearly as fatal as the preceding. In the countenances of some of the sick, just previous to the accession of the more violent symp- toms, there is an appearance of despair and horror which baffles all description, and can never well be mistaken by those who have once seen it. The third species is somewhat akin to the last, only the symp- toms are much milder, and the brain comparatively is little affected. The buboes and other tumors which make their appearance go on more rapidly and kindly to suppuration; and by a prompt and early employment of remedies to assist the salutary operations of naturej the patient has a tolerable chance of surviving. Cases of this kind are often so mild, that persons have been known to walk about in speming good health, and without any evident inconvenience from the buboes. Such are the characteristic symptoms of this malignant disease, the varieties of which seem to depend in a great measure on the constitution or state of the air at the period of the epidemic pre- Order III SHE PLA6UE. 277 vailing, and on the habit of body of the patient at the lime of the attack. In no disease do patients bear motion worse than in this. The least motion has been known to induce syncope, and even death, particularly in the last stage of the complaint. The plague is always to be considered as attended with imminent danger, and when it prevailed in this country about two hundred years ago, proved fatal to most of those who were attacked with it. It is probable, however, that many of them died from want of care and proper nourishment, the infected being forsaken by fheir nearest friends ; because in Turkey and other countries where attention is paid to the sick, a great many recover. Of the French army that invaded Egypt, little more, however, than one third of all that were attacked with the plague recovered, as appears by the report made by Dr. Desgenettes*, who was the chief physician to that army. The duration of the disease is various. In some instances the effect of the pestilential contagion is the immediate extinction of life ; and cases have occurred wherein the patient has survived but a few hours the first sensation of illness. In other instances again, he has lived till the thirteenth, and even the seventeenth day of the disease. Where the plague is ushered in by fever and delirium, it is seldom that the patient recovers : in spite of every endeavour, he is generally deprived of life within forty-eight hours, or on the third day at furthest. If the fever does not occur until the second day from the attack of the disease, there is less danger, as time is thereby given to obviate the consequent symptoms. When the plague is unattended by buboes, it runs its course more rapidly, and is more generally fatal, than when accompanied by such inflammations. The earlier they appear, the milder usually is the disease. When they proceed kindly to suppuration, they usually prove critical, and ensure the patient's recovery. Sudden death has, however, been known to happen even when the violence of the constitutional disturbance appeared to have been subdued, when buboes have made their appearance, were suppurating, and the patient considered convalescent. It is generally a favourable sign when the bubo does not adhere, but shakes on its base. A gentle diaphoresis, arising spontaneously, has been known in many instances to prove critical. When carbuncles show a disposition to become gangrenous, the event will be fatal. Furuncles, pete- chia?, hemorrhages, severe vomiting, and *a colliquative diarrhoea, denote the same termination. The worst forms of the disease are always accompanied with the usual symptoms of putridity and malignity; and such rarely ter- minate favourably. It has-been remarked, that if a patient, after an access of delirium, was suddenly restored to his senses, he * See his Histoire Medicale del'Arraee del'Orient. '27b' PYRKXI.K, OR FE13 RILE DISEASES. Class I Seldom recovered. Most cases terminate fatally wherein the pa- tient is comatose from the beginning. The typbo-mania may be regarded as a more fatal form of delirium than the inflammatory. Dissections of the bodies of those who have died of the plague iiave discovered the omentum, stomach, and intestines gangrenous in some places ; the liver in a state of congestion and considerably enlarged, the gall bladder filled with black fetid bile, and the pericardium with a bloody fluid*. Proofs of inflammation and gangrene have also been found in the brain and its investing mem- branes, in the lungs, and kidneys. In many instances the glandu- lar system has been found in a very diseased state, and the blood black and loose in its texture, similar to what occurs in putrid fever. Under the supposition that a person has been exposed to the con- tagion of the plague, and in consequence of this becomes much in- disposed, the first step to be adopted is to give him an emetic, par- ticularly where nausea or vomiting ensues. If a severe retching should prevail after the operation of the emetic, this may possibly be relieved by administering the saiine medicine in the act of effer- vescence ; but if it should not, we may make an addition of a few drops of tinctura opii to each dose. To obviate costiveness; and draw off any putrescent matter which may be lodged in the bowels, it will be necessary to mrke use of some gentle laxative : but large evacuations, by the aid of strong purgatives, would be very improper. In an advanced stage of the disorder, emollient clysters would be most advisable, as being less apt to excite diarrhoea, which, when it arises towards the close, generally destroys the patient So careful are the Eastern nations in avoiding this occurrence, that they most com- monly make use of suppositories only. When a diarrhoea does occur, either spontaneously or from an improper use of cathartics, it should be suppressed as quickly as possible by astringents, opiates, and every other means we can employ. We are informed by Dr. Russell, that many, particularly the Asiatics, make it a rule to let blood in all cases of the plague, if they see the patient at an early period ; and some recommend it as late as the fourth, fifth, sixth, or seventh day; and even some European practitioners have gone nearly as far. To him it ap- peared that very plentiful bleeding at the first appearance of the disease was of great service. Dr. Buchan was in the habit of occasionally resorting to bleeding* we are told by Sir James M'Gresror, and that during the first season he had met with several cases where the operation proved of the greatest service. The Turks, we are informed, employ local instead of general blood-letting, most commonly, and in the latter they draw off only a very small quantify. • * See Memoirs of Military Surgery, by Baron Larrey, abridged from the French by J. Waller. Order HI THE PLAGUE. 279 Syddenham considered the plague as an inflammatory affection, and speaks of the efficacy of bleeding in the warmest terms; and Dr. Mead* not only advises venesection, but declares that we must draw blood with a more liberal hand than in other cases, if we are to expect sm cess from it in this complaint. In opposition to the opinion entertained by most modern physicians, who have considered the plague as an affection of direct and excessive debility, a late writerf asserts, on the contrary, that it is one of excitement and congestion, and of course he advocates the necessity of employing the lancet in its treatment. The advantages of blood-letting in this disease appear to be of a very dubious nature; for we are given to understand that Dr. Whyte, one of the physicians to the forces in Egypt, used the lancet very free- ly, but that every one of his patients died. In the first stage of the disease, where there exists congestion or turgescence in any part of the body, the application of cupping-glasses, with previous scarifica- tion, may probably be a safer remedy than venesection. It has been observed that a gemle diaphoresis sometimes: proves critical, and carries off the disease, but more particularly when it arises spontaneously. To assist nature in throwing off the morbid matter hy the pores, if possible, it will be right to employ diaphoretics, such as the neutral salts, small doses of antimonials, or the pulv. ipe- cac, compos, as advised under the head of Simple Fever; the effects of which may be increased, by directing the patient to drink plenti- fully of diluent acidulated liquors; and where the heat of the body is not very considerable, his strength may be supported under this operation by means of a little wine. Profuse sweating is, however, by all means to be avoided, as by inducing debility it would prove. injurious. Dr. Falconer of Bath, in his Essay on the Plague, seems to insinuate, that no small share of the mortality foimerly observed in this disease may be attributed to the sweating regimen, then commonly employed for its cure. Instead of adopting this plan, he advises the avoidance of a warm bed, and indeed of a bed altogether, if possible, in the day time; a circulation of free and cool air, light clothing, cool drinks, and particularly cold water; and he mentions, that if any benefit is to be expected from the use of this regimen, it must be tried largely and steadily; not as if cold liquor were an indulgence permitted or allowed, but as a remedy enjoined, on which the principal dependance was to be placed. In addition to these means Dr. Falconer recommends the external use of cold water in the manner pointed out by the late Dr. Currie of Liverpool, and noticed under the head of Typhus Gravior. Savary, in his Letters on Egypt, mentions an anecdote which is considered by Dr. Falconer as much to his purpose. The captain * See his Works. •+ See Illustrations of Typhus and other Febrile Diseases, by J. Armstrong, M 1 j 28& PYREXIA, OR FEBRILE DISEASES. ClaSS /. of a ;ship, whose sailors had contracted the plague at Constantinople, caught it himself by attending on them: be felt, as he expressed him- self, excessive heat, which made his blood boil: the disease seized his head, and he perceived (as he thought) that he had only a few mo- ments to live The little remaining reason he had, taught him to at- tempt an experiment: he laid himself down quite naked on the deck: the heavy dews that fell, penetrated, according to his sensations, to bis very bones. In a few hours he could breathe better; his agitated blood became calm, and bathing the morning after in the sea, he was perfectly cured. This case brings to my recollection another of a French soldier, and reported by Dr. D'sgenettes, who being afflicted with the plague, threw himself into the Nile under a high degree of delirium, and oh being taken out of the water after a short lapse of time, soon recovered from the disease, seemingly in consequence of his immersion. A similar (rase is brought forward of the good effects derivable from the sudden application of cold water by Sir Brooke Faulkner, in his Ob- servatio ns on the Plague*. Spunging the body with vinegar or citric apid has been found a use- ful reinrdy. Camphor is a medicine which has been much recommended in the plague. For t he purpose of allaying irritation and procuring sleep, opiates are advi sable, and when used have by no means been found to produce coma. They seem equally proper as in typhus. If we are so fortunate as to procure a crisis by the remedies which have be en advised-, the bark of cinchona should be given in as large doses as the stomach will bear, and be repeated every two hours; but if there is no chance of obtaining this desirable end, then, besides this bark, we should adopt the other means recommended under the head of Malignant Fever, with the view of obviating extreme debility and the disp osition to putrescency. A fre e use of both vegetable and mineral acids seems advisable in the plague as well as in typhus gravior. Acidulated drinks will be highly jproper. Sir James M'Gregor, in his tract before mentioned, indeed hints that he found the nitric acid, and other irregular reme- dies, to be serviceable. He likewise employed mercury, as he though t, with some advantage; and when the mouth was speedily made s ore by it, recoveries oftener took place in the same manner as in yellow fever, than when the system proved unsusceptible of the mercurial action. It appears from this gentleman's report, that some patients were kept winder the influence of wine and opium for a time, according to th(; Brunonian theory, but that the practice never proved success ful. Whe re the patient survives the disease, the treatment of the carbun cles or buboes becomes the province of surgery. Their de- ' * See Edinburgh Medical and Surgical Journal for April 1814, p. 1»1 Order III THE PLAGUE. 281 velopement at an early period ought to be assisted by stimulants and rubefacients. OF THE MODE OF PREVENTION. It is well known that the pestilential virus which emanates from the human body may adhere for a long time to other substances, and preserve its power of producing and propagating future infec- tion; and that in this manner it may be conveyed from the Eastern countries into any other; the persons first attacked by being exposed to the contagion, then becoming the source of infection to others. This fact being well established, it has been judged proper by the legislature of this kingdom and of some others, to oblige ships, per- sons, and all kinds of merchandise coming from places apt to be in- fected with the plague, to procure bills of health, or to undergo a certain quarantine, during which period the goods are, or ought to be, properly ventilated. An adherence to these regulations has of late years prevented the importation of the disease; but should it unfor- tunately ever be introduced, the following steps must be pursued for destroying the infection, and preventing its further propagation. 1st, The infected should be confined in lazarettos, surrounded by strict guards, aod no kind of communication be held with them, except by such attendants as may be absolutely necessary. 2dly, The nurses or others employed in attending the sick, must take care to come in actual contact with them as seldom as pos- sible, or place themselves in such a situation as that a stream of air may carry the effluvia towards them*. They should likewise pay an unrelaxing attention to personal cleanliness. Dresses of oiled silk have been strongly recommended by Sir Brooke Faulkner, as an invaluable armour to such persons as are constantly obliged to be about the sickf. One of these he wore himself, as did also the attendants in the military plague hospital at Malta, during the * It is a fact well known, that the pestilential poison, unlike other ordinary epidemics, is confined to the vicinity of the affected body, and becomes so dilute at the distance of a very few paces, as to be incapable of further action. Mous. Samoilowitz, a celebrated Russian physician, and author of a very good Memoir on the Plague, insists that this disease exists neither in the air, nor is communicated by the air, but by contact alone : and Mons. Sonnini tells us, that it is suflicieut for Europeans settled in Turkey to shut themselves up in their houses in order to be preserved irom the contagion, even whea it makes the greatest ravages in towns which they inhabit, and although they draw from without their provisions and daily food. The report made by Sir James M'Gregor likewise shows how very limited in extent is the action of contagion in the plague. Thirteen of the medical gentlemen of the army of Egypt were directly in the way of contagion, for it was their duty to come into contact with the infected; of these, seven caught the infection, and four died. To the atmosphere of the disease, all the medical men of the army were exposed, as they saw and examined the cases in the first instance; but, except from actual contact, there never appeared to be any danger of contagion. Although the disease is communicated chiefly by contact, yet it appears to me that authors go too far when they infer that it is not communicable by an atmosphere strong- ly tainted with pestilential miasmata. t See Edinburgh Journal for April 1814. 36 ■28% PYREXIA, OR FEBRILE DISEASES. ClasS. L extensive prevalence of the disease, in the year 1813, in that Island. Medical attendants will act prudently in changing thew linen and clothes, and in well washing their whole body, but more particularly their hands, with warm water and vinegar, as soon as they quit the lazaretto. 3dly, All substances capable of being impregnated with the effluvia, or of vitiating the atmosphere, ought to be removed from the apart- ments of the sick to situations where the healthy cannot suffer by them, and where they miy undergo a proper purification by exposing them to a heat of about 120 of Fahrenheit, and then freely ventilating them. The linen and other clothes of the patient should be burnt. The dead should be immediately interred: probably combustion would be preferable to inhumation. 4thly, The atmosphere surrounding the infected ought to be kept as pure as possible, so thf»t neither the patient nor his attendants may suffer from the exhalations : with which view, the strictest at- tention should be paid to cleanliness, a free ventilation, and fumiga-, ting with the nitric or muriatic acid, as advised under the head of Malignant Fever. A long stay in pestilential apartments that are but little aired, ought carefully to be avoided, as also the exhala- tions from the dead bodies, or from patients in the last stage of the disease. 5thly, To avoid whatever weakens the body, by giving way to intem- perance or sensuality, or making use of a poor diet, great fatigue, or considerable evacuation. 6lhly, To keep the mind cheerful, and as free from care, anxiety, fear, and lowness of spirits, as possible. 7thly, As it is supposed that by strengthening the bodies of men we can thereby enable them to resist contagion the better, some advantages may probably be derived from using cold bathing, with wine, bark, and other tonic medicines, with a generous diet. Wbere access to the sea cannot be had, and uater is scarce, the substitute proposed by a late writer* is, that a shirt be dipped every morning in a saturated solution of common salt in cold water, and after being well wrung out to be put on wet and cold, keeping the body in motion for sometime afterwards by moderate' exercise. Those who 'cannot keep themselves isolated from the contagion will act prudently, in conformity to the observations of Baron Larrey and other writers, in opening a large issue, or perpetual blister? In Dr. Duncan's Annals of Medicine for 1797, is inserted an ar- ticle relating to the cure and prevention of the plague by frictions of the whole surface of the body with olive-oil, and communicated, as we are given to understand, by George Baldwin, Esq. at that period his Britannic Majesty's agent, and consul-general in Egypt. It is mentioned, that there is no instance of a person rubbing a patient having taken the infection; but, by way of precaution, it is * See Description of the Plague, kc. by Richard Pearson, M. D. Order III «ie plaque. 28S advised to anoint himself all over with oil, and to avoid receiving the breath of the infected person into his mouth and nostrils. The prevention to be used in all circumstances, is that of carefully anointing the body, and living upon light and easily digestible food. A striking observation made by Mr. Baldwin is, that among opwards of a million of inhabitants carried off by the plague in Upper and Lower Egypt, during the space of four years, he could not learn that a single oilman, or dealer in oil, had suffered*. Mr. Jackson, in his Reflections on the Commerce of the Mediterranean, likewise informs us, that in the kingdom of Tunis, where the plague frequently rages in the most frightful manner, destroying some thousands of the inhabitants, there never wai known an instance of any of the coolies, or porters, who work in the oil-stores, being in the least affected by this disorder, their bodies being always well smeared with the oil, as well as their clothes being imbued with it. It has been considered as pretty certain that in the generality of instances the contagion of the plague enters the body through the medium of the cutaneous lymphatics, and thence produces the dis- order of the lymphatic glands. This idea is illustrated by the pro- bability that the external use of oily frictions lessens the sus- ceptibility of infection ; and Sir James M'Gregorf mentions a fact which much favours the opinion, by observing, that the men who were employed in applying oily friction to the camels for some epidemy affecting them, escaped the plague. The evidence produced in behalf of the plan communicated by Mr. Baldwin, seems more satisfactory as to the preventive powers of the application, than as to its sanative properties after the disease has once taken place. It seems, however, right to notice, that Dr. Assalini, who was a medical officer in the French army which invaded Egypt, makes a favourable mention of oily frictions in his Observations on the Plague, as being generally followed by copious sweating; and to this, he thinks, their beneficial operation is to be attributed. We are also told by Mr. JacksonJ, that he recommended the remedy to several Jews and Mussulmen during the time that the plague was depopulating West Barbary, in 1T99 and 1800, and no instance of its failure, when duly per- severed in, even after infection had manifested itself, had come to his knowledge. Inoculation for the plague has been tried by some physicians, in order to discover if this malady could not.be checked or rendered less virulent thereby; and it appears from Sir Robert Wilson's History of the Expedition to Egypt, that Dr. Whyte, resolving to * It has been said, that when the plague raged in London about two hundred years ago, the dealers in pitch, tar, and tobacco, were particularly observed to escape the contagion. i See bis Medical Sketches. } See hie Account of the Empire of Morocco. 284 PYREXIAE, OR FEBRILE DISEASES. CUlSS I become the patient of his own speculation during the time this disease raged at Rosetfa, inoculated himself with matter taken from the buboes of an infected person. The attempt failed twice ; the third proved fatal in three days after the symptoms showed themselves. It likewise appears, that Dr. Desgenettes, in order to lessen the general alarm, and to inspire confidence among the French troops, inoculated himself both in the groin and arm-pit, with a lancet dipped in the pus of a bubo in a convalescent patient. The inocu- lation, however, failed ; and the only consequence was a slight inflammation on the inoculated parts, which continued for more than three weeks. As the future susceptibility to the disease is by no means, how- ever, destroyed, for the same person may be afflicted with it repeatedly, and even may be attacked twice in the same season with it, as Dr. Desgenettes experienced, (many of the convalescents from the plague, who were appointed to take care of the sick, having been, he observes, seized a second time), this experiment would not be advisable, unless it could be ascertained that the disorder is rendered milder by the inoculation. This is a point not yet, however, established : indeed, the information afforded us by Mons. Sonnini* seems to lead to a contrary conclusion ; for he mentions, that a Russian surgeon, who was a prisoner at Constantinople, with a number of his countrymen, took it into his head to inoculate these unfortunate men with the plague, under the supposition of render- ing the contagion less destructive ; but by doing so, he killed two hundred of these prisoners : and fortunately for the rest, the inoculator, after having performed the operation on himself, soon died of his own treatment. By a paper read before the Royal Society of London, on the 27th of June, 1816, it appears, from comparative experiments on the disinfecting powers of vinegar, chlorine, and the fumes of sulphur, that the best and most efficacious method of disinfecting letters coining from places supposed to be visited by the plague, is to expose them to the fumes of burning sulphur, mixed with nitrate of potass. MILIARIS, or MILIARY FEVER. This fever takes its name from the small pustules or bladders which appear on the skin, resembling in shape and size the seeds of millet, being in general numerous on the breast, back, and other parts where there is most moisture on the skin. It may be distinguished from the other exanthemata by its pathognomic symptoms, the peculiar sour and rank odour of the sweat, attended with dejection of spirits, oppression, and sense of constriction about the precordia, anxiety, and frequent sighinsr. * Travels into Greece and Turkey, p. 497. Order III. MILIARY FEVER. 285 Many of our modern physicians seem to think that the disease is never a primary one, but arises in consequence of some other; parti- cularly where much sweating has been excited, either by keeping the patient too warm, or by giving heating medicines. All debilitating powers, such as a lax habit of body, weakness, how- ever induced, excessive evacuations, the presence of irritating matter in the prima? viae, the period of child-birth, long continued menstrua- tion, &c. may be regarded, most probably, as predisposing causes, while the hot regimen is to be looked upon as the principal exciting cause of the eruption. This conclusion seems justifiable, as it is found, that whatever the state of the patient may be, miliary eruption is very generally avoided by exposure to cool air, and administering cold liquors. It has been observed to affect both sexes, and persons of all ages and constitutions, but that females of a delicate habit are most liable to it, particularly in child-bed.' It is, however, by no means a contagious disease, and has rarely, if ever, been known to prevail epidemically. Moist variable weather predisposes most to this eruption, and its occurrences are more usual in the spring and autumn than in the other seasons. Winter is the least favourable to its appearance. Miliary fever makes its attack with a slight shivering, succeeded by heat, restlessness, loss of strength, depression of spirits, anxiety, sighing, difficulty of breathing, oppression at the chest, and a low quick pulse.* The tongue appears white, the mouth is dry, the body costive, and when the disease is violent, coma or delirium is apt to arise. Great dejection of spirits and anxipty, with fetid sweats, are, however, the most common forerunners of the miliary eruption. The patient after a short time feels an itching or pricking pain under the skin, soon after which innumerable small pustules, of a red colour, and of the size of millet seeds, come out, first upon the neck and breast, thence gradually extending to the trunk and extremities; their prominence is imperceptible to the sight, yet evident to the touch ; they often lose their redness, and appear of the ordinary colour of the skin. They are usually distinct, but now and then we may perceive them clustered together. About the second day after the appearance of the eruptions a small vesicle may be observed on the top of each pimple, and in two or three days more they break, and are succeeded by small crusts, which fall off in scales. Sometimes it happens, that when one crop of erup- tions has disappeared, another will succeed it. On the eruption being visible, most of the foregoing symptoms are usually relieved. The sweating is apt, however, to continue, unless proper means are used to check it, and to be attended for many days with a fresh crop of eruptions. The eruption being steady, and not disappearing after having come out; the fever inclining more to the nature of synocha than typhus; and there being a considerable remission of the symptoms 286 PYREXIAE, OR FEBRILE DISEASES. ClttSS I. upon the appearance of the eruption, denote a favourable issue; whereas great anxiety, dejection of mind, vast prostration of strength, difficulty of breathing, fldcridity of the parts covered by the eruption, its sudden disappearance, a rapid, weak, and intermitting pulse, vio- lent vomiting, profound coma, delirium, convulsions, petechia? and other symptoms of putrescency, are to be considered as prognostica- ting a fatal termination to the disease. The appearances to be observed on dissection will depend on the aature of the fever which accompanies the eruption, and which most usually is of the typhoid kind. As the disease is evidently brought on by the application of too much heat, an early attention ought to be paid to the means of pre- venting it from appearing in those affections which it is apt to accompany. With this intent, the patient should not be covered with too many bedclothes; neither ^should the chamber be kept hot by means of too much fire, or by being closely shut up; on the contrary, a sufficient ventilation ought to be allowed, so as to keep it of a proper temperature. In doing this, we are, however, to take care not to run into the opposite extreme, and allow too free an admission of cold air. Sweats which are not followed by an abatement of the febrile symp- toms, cannot of course prove critical, and may therefore be safely and advantageously checked, by keeping the patient's apartment cool, by covering him lightly and loosely with bedclothes, by making him lie with his arms exposed, and by giving him whatever be drinks perfect- ly cold; but in sweats which are likely to be critical, the practitioner must take care to regulate the admission of air, so as that it shall not prove prejudicial. By adopting these precautions at an early period, we may often pre- vent miliary eruptions, which might otherwise have appeared; and after they have made their appearance, we probably may be able to moderate them, by using the same means. Miliary eruptions sometimes accompany inflammatory affections; in which case it will be necessary to have recourse to gentle aperients, or laxative clysters; but bleeding ought never to be used. They are found to attend more usually on diseases where much debility prevails, or where there is a disposition to putrescency; in which instances the patient's strength must be supported with wine, and a nutritive diet; making use at the same time of tonics, the cinchona bark, mineral acids, and other antiseptics, as advised under the head of Typhus Gravior. Whatever debilitates, is, in most cases of miliary fever, pernicious ; whatever supports the vigour of the sys- tem, beneficial. Great sickness at the stomach is apt to precede any fresh erup- tions that come out in the course of the disease, and to prove very dis- tressing. To allay it, we may order small and frequently repeated doses of the mistura camphorae. Where delirium or coma comes on, blisters will be proper. When a retrocession of the eruption happens, our principal view should be Order HI pemphigus. 28? to bring out and support a sweat by powerful diaphoretics, cam- phor, ammonia, frictions to the skin, external warmth, pediluvium, he. Where any considerable evacuation ensues on a retrocession, we must be careful not to check it hastily. Should convulsions supeivene thereon, musk and opium are particularly recommended. To prevent the disease from arising in pregnant women, costive- ness ought carefully to be guarded against ; and when in child-bed, they should strictly observe a cool regimen, and keep their chamber of a proper temperature, being at the same time lightly covered with clothes. PEMPHIGUS, on VESICULAR ERUPTION. This disease consists in eruptions dispersed over different parts of the body, internal as well as external, which gradually rise up into vesicles of about the size of a large nut, containing a yellow, serous fluid, that is in some instances of an ichorous nature, and which again disappear in the course of three or four days. By some authors it is described as being attended both by fever and contagion ; and by others as being accompanied by neither. It is therefore supposed that there are two species of it, the chronic and the acute. The disease is, however, of very rare occurrence. Dr. Willan* describes three varieties of it, viz. pemphigus vulgaris, pemphigus contagiosus, and pemphigus infantilis; but he has never seen any instance of the two first. The last, he says, occurs sometimes in weak, emaciated children, who are de- stroyed by the pain and irritation of the successive vesications and ulcerations. By the generality of the physicians who have favoured us with their opinions, the principal of whom is Dr. Dicksonf, it has not been considered as contagious. The gentleman saw six cases of the complaint, in none of which it was received by contagion, nor communicated to those who attended the sick. Dr. Cullen informs us, that the blisters are filled with a thin ichor, which is discharged, not absorbed, as mentioned by Dr. Dickson ; but during his whole practice it appears that he met only with a single case of pemphigus. Some slight degree of lassitude, sickness, and headach having prevailed for a day or two, small vesicles of about the size of a pea make their appearance over different parts of the body, and not unfrequently in the mouth, and other portions of the alimentary canal; and these gradually increase till they become as large as a nut or almond. Now and then they are to be met with of the size of a walnut. They are surrounded by an inflamed margin, or areola, and distended with a faintly yellow serum. They often are accompanied with difficulty of deglutition, nausea, * See his Treatise on Cutaneous Diseases. t See his Paper on Pemphigus, ia the Transactions of tho Royal Irish Academy in US7 288 PYREXIA, OR FEBRILE DISEASES. Class I vomiting, a sense of soreness in the abdomen, and intense heat of the skin. Sometimes they are so numerous as to run into each other. The pulse during this ti;ne is small and frequent, and the patient is sensible of a considerable degree of debility. An intense burning heat of the skin appears to be a prominent feature of the disease ; and in no other exanthematous fever is there usually felt so strong a sensation of heat ; the vesicular eruption appearing to be the consequence of extreme action of the capillary vessels, thereby generating an increased evolution of heat, and augmenting the virulence of the discharge. The sensation it con- veys to the patient is somewhat similar to a common scald, with a train of concomitant febrile symptoms. After the vesicles have remained for some days, they either break and discharge their contents, or they begin to shrink, and so dis- appear. This seems to be the most favourable termination, as they have been known to leave troublesome ulcers behind them when they broke. Pemphigus resembles the small-pox, in frequently leaving pits ia the skin, and in the parts which the vesicles occupied remaining of a dark colour for a considerable time afterwards. In the third volume of Medical Facts and Observations, Dr. Winterbottom takes par- ticular notice of this occurrence. We are to be influenced in our prognosis by the seat and appearance of the vesicles. When they appear only on external parts, and are not numerous, they demand little attention ; when they are numerous, when they attack the alimentary canal, and are attended with a small hard pulse, and great prostration of strength, the danger is considerable. The danger is likewise very great when the ulcers left by the vesicles show a tendency to gangrene by becoming livid ; which seldom happens, however, unless a fever of the true typhoid kind has accompanied the eruption. On taking a comprehensive survey of what has bsen recorded by eminent writers on the subject, (and in addition to those already referred to, I beg leave to add Dr. liall*,) we must, I think, conclude, that pemphigus is an affection merely sporadic, and not of a con- tagious nature ; that it is connected with a statp of debility; and that the symptoms accompanying one or other instances of this af- fection are those which attend febrile diseases, whether inflammatory or putrid. The most important distinctions necessary to be ascer- tained appear therefore to be, 1st, Whether the fever is of an inflammatory nature, and accom- panied with a strong and increased action of the vascular system; or, 2dly, Whether the fever has a tendency to the typhoid type, and is marked by great debility, and other symptoms which denote a * See Essay on Pemphigus, by Dr. Hall, in volumes 3d uud 4th of the Edinburgh Annals of Medicine. Order III NETTLE-RASH. 289 tendency of the fluids to putrefaction. It will be obvious, that in the first case evacuation and other antiphlogistic remedies will be proper; and that in the second it will, on the contrary, be necessary to shun all evacuations, and to employ those remedies alone which support the strength, and give tone and vigour to the system. In most cases the disease seems to be connected with a cer- tain state of debility, and a tendency of the fluids to putrefaction, and therefore the indications of cure are obvious. Having cleansed the stomach by a gentle emetic, where nausea prevails, and dislodged the contents of the intestines by some mild laxative, such as the saline purgatives, or small doses of the sub- muriate of mercury with jalap, we may then give the cinchona bark either ih infusion, decoction, or powder, along with wine. The mineral acids, in a state of proper dilution, if administered early, will likewise be of service in obviating the effects of debility, and any tendency to putrefaction. On the first accession of the disorder, if the skin is hot and dry, it may be of service to give the saline medicine, with small doses of some mild antimonial, in order to excite a gentle diaphoresis; but these should not be continued long. To diminish the effects of irritation, opiates combined with sulphu- ric aether will be proper. Where vesicles arise vin the mouth, and break, so as to become ulcers, we should then employ detergent gargles, as advised under the head of Cynanche Maligna. If there is reason to apprehend that the eruption has extended to the alimentary canal, it will be necessary to order copious draughts of some mucilaginous decoction, as mentioned under the head of Aphtha Chronica. When obstinate ulcers are formed on any exterior part of the body in consequence of the vesicles breaking, the assistance of a surgeon will be requisite. Some practitioners are in the habit of opening the larger vesicles, but the propriety of this step is not yet fully established. On recovery, the patient's strength is to be recruited by tonics and other auxiliaries, as noticed under the head of Dyspepsia. URTICARIA, or NETTLE-RASH. This disease takes its name from its being attended by an eruption on the skin, similar to what is produced by the stinging of nettles, and terminates in a desquamation of the cuticle. Dr. Willan, in his treatise on Cutaneous Diseases, notices six varieties of it.—See Order III. In some instances a slight degree of fever either precedes or attends the eruption: this is not confined to any particular parts of the body, but is somewhat dispersed, being always accompanied with a considerable degree of heat and itching. In some persons 37 290 PYREXIAE, OR FEBRILE DISEASES. ClaSS 1. it lasts only a few days, in others many months, appearing and disap- pearing at intervals. It usually disappears in the day-time, and in the evening breaks forth again, accompanied sometimes with slight febrile symptoms. In some cases urticaria is characterized by large wheals or bumps, which on pressure appear of a solid nature, without any cavity or head; nor do they contain any kind of fluid. The causes of urticaria are by no means obvious, but it has been supposed to arise from suppressed perspiration, or some irritating matter in the stomach. A disease very similar to febrile urticaria is produced in particular constitutions by substances received into the stomach, which proves offensive, such as almonds, mushrooms, crab-fish, muscles, lobsters, herrings, he. When a person is poisoned by fish of a deleterious nature, it frequently shows itself as a consequence thereof. (See Animal Poisons). The effect is rapid, and the symptoms are violent for some hours. In conse- quence of such circumstances, physicians have been induced to con- clude that urticaria, attended with fever, originates generally from indigestion, or from some substance of a noxious quality taken into the stomach. The nettle-rash readily gives way in general to a cool regimen, and keeping the body open with mild laxatives, such as the potassae supertartras, or any of the neutral salts. When it has arisen from any thing noxious being eaten, an emetic should be administered at the commencement of the attack. If it proves obstinate, we may resort to small doses of the submuriate of mercury and nitric acid.. An infusion of serpentaria, made in the proportion of two drachms to a pint of water, is spoken very favourably of by a late writer* on chronic urticariaf. ORDER IV. HEMORRHAGIC, or INVOLUNTARY DISCHARGES of BLOOD. Under this title are comprehended active hemorrhages only, that is, those attended with some degree of symptomatic fever, and which depen ! upon an increased impetus of the blood in the vessels from which it flows, chiefly arising from an internal cause. On venesection the blood appears as in the cases of phlegmasia?; that is, the glutten separated, or a crust formed. The general remote causes of hemorrhages of this nature are, external heat, a sanguine plethoric habit, whatever increases the * See Mr. Cook's Practical Treatise, 8tc. p. 209. t According to the nosological arrangement of Dr. Cullen, Aphtha should have follow- ed next as one of the Exanthemata; but being more frequently met with among infants than persons of a mature age, it has been inserted among the diseases of the infantile state Cachexia aphthosa, or chronic thrush, not being an idiopathic disease, hut sympto- matic of seme other, such as general debility, is placed in the class Cachexia?. Order IV. involuntary discharges of blood. 291 force of the circulation, as violent exercise, strong exertions, anger, and other active passions, particular postures of the body, ligatures producing local congestion, a determination to certain vessels, rendered habitual from the frequent repetition of hemor- rhage, the suppression of accustomed evacuations, external violence, and exposure to cold. Hemorrhages may be occasioned either by foo copious a production of the vital fluid, by some partial accumulation of it, or by the lax- ity or tenuity of the vessels which contain it. Hemorrhage seldom, however, comparatively speaking, arises from a more than ordinary mass, or impetus of blood, but in general from a want of that contractile power in the artery which is necessary to resist its tendency to effusion. The general treatment of hemorrhages must consist in putting a stop to the discharge of the blood ; in preventing its recurrence, by removing the causes by which they were excited, and by de- stroying the inflammatory diathesis when any exists. These means remain to be pointed out under each distinct hemorrhage, as in the subsequent pages. EPISTAXIS, on HEMORRHAGE from the NOSE. In the nose there is a considerable net-work of blood-vessels expanded on the internal surface of the nostrils, and covered only with a thin tegument : hence upon any determination of a greater quantity of blood than ordinary to the vessels of the head, those of the nose are easily ruptured. In general the blood flows only from one nostril ; but in some cases it is discharged from both, then showing a more considerable disease. Persons of a sanguine and plethoric habit, and not yet ad- vanced to manhood, are very liable to be attacked with this complaint ; females being much less subject to it than males, particularly after menstruation has commenced. Peculiar weak- ness in the vessels of the part, and the decline of life, may also be considered as predisposing causes. Great heat, violent exertion, external violence, particular postures of the body, and every thing that determines the blood to the head, are to be looked upon as its exciting causes. Epistaxis comes on at times without any previous warnings ; but at others, it is preceded by a pain and heaviness in the head, vertigo, tinnitus aurium, flushing in the face, heat and itching in the nostrils, a throbbing of the temporal arteries, and a quickness of the pulse. In some instances, a coldness of the feet, and shivering over the whole body, together with a costive belly, are observed to precede an attack of this hemorrhage. The complaint is to be considered as of little consequence when occurring in young persons, being seldom attended with danger; but when it arises in those who are more advanced in life, flows profusely, and returns frequently, it indicates loo great a fulness of 292 PYREXLE, OR FEBRILE DISEASES. Class I. (he vessels in the head, and not unfrequently precedes apoplexy, palsy, &c, and therefore in such cases is to be regarded as a dan- gerous disease. When this hemorrhage arises in any putrid disorder, it is to be considered as a fatal symptom. As a bleeding from the nose proves salutary in some disorders, such as vertigo and headach, and is critical in others, such as phrensy, apoplexy, and inflammatory fever, where there is a deter- mination of too great a quantity of blood to the head ; we ought properly to consider at the time it happens, whether it really is a disease, or intended by nature to remove some other. When it arises in the course of some inflammatory disorder, or in any other where we have reason to suspect too great a deter- mination of blood to the head, we may suppose that it will prove critical, and therefore we should suffer it to go on, at least as long as the patient is not weakened by it. Neither should it be suddenly stopped, when it happens to per- sons in good health, who are of a full and plethoric habit. In short, where a bleeding at the nose relieves any disagreeable symptom, and does not proceed so far as to induce debility, it ought not to be hastily checked. When it arises in elderly people, or reti-ns too frequently, or continues till the patient becomes faint, if ought to be put a stop to as quickly as possible : to effect this, the person is to be ex- posed freely to cool air, and to be placed nearly in an erect position, with his head somewhat inclined backwards ; to drink freely of cold liquors, and to make use of an antiphlogistic regimen. Besides these means, he may immerse his head in water impregnated with ammonia muriata, or common salt, and snuff vinegar and water frequently up the nose, or he may throw some astringent wash* repeatedly up the nostril from which the hemorrhage pioceeds, by means of a syringe. * l.ft Zinc. Sulphat. 3j- Plumbi Superacet. gr. x. Aqua? Distillat. f. |x. M. ft. Inject io. Vel, 2. ft Aluminis in pulv. trit. 3y. Aq. Rosae,f. |vj Acidi Acetici, f. ?j. M. Vel, 3. R Tinct. Ferri Muriatis, f. 3iss. Aq. Distillat. f. |vj. M. Vel, 4. R Acid. Sulph. Dilut. f. 3iss—f. 3»j- Aq. Pura?, f. |ijss. M. 1. Take Sulphate of Zinc, one drachm. Superacetate of Lead, ten grains. Distilled Water, ten ouuces. Mix them for an Injection. Or, 2. Take Powdered Alum, two drachma. Rose Water, six ounces. Distilled Vinegar, one ounce. Mix them, and use the liquor as a wash or injection. Or, 3. Take Tincture of the Muriate of Iron, one drachm and a half. Distilled Water, six ounces. Mix them. Or, 4. Take Diluted Sulphuric Acid, a drachm and a half or two drachms. Pure Water, two ounces and a half. Mix them. Order IV. hemorrhage from the nose. 293 Should the bleeding nevertheless continue, a dossil dipped either in a solution of the sulphate of copper in water, the sulphate of iron in brandy, or in Ruspini's styptic, may be introduced up the nostril. A tent wetted with the compound tincture of benzoin, and afterwards rolled in equal parts of alum and sulphate of zinc, may be tried upon a failure of the former. One of the most powerful styptics, however, which we can use, is powder of charcoal. In.epistaxis, it may be ap- plied by means of tents, first moistened with water, and then dipped in this powder; but in slight cases, it will answer by being taken like snuff. To assist the effect of all such applications, a little cold water may be sprinkled with the fingers on the patient's face, and the genitals of a male be immersed now and then in the same fluid. Dr. Darwin mentions in his Zoonomia the case of a lady who had a continued hemorrhage from her nose for several days; the ruptured vessels was not to be reached by plugs up the nostrils, and the sensibility of her fauces was such, that nothing could be borne behind the uvula. After venesection, and other common applications, she was directed to immerse her whole head in a pail of water, which was made colder by the addition of several handsful of salt; in consequence of which, the hemorrhage immediately ceased, and returned no more; but her pulse continuing hard, she was necessitated to lose blood from the arm on the succeeding day. In epistaxisthe application of pressure to the mouth of the bleeding vessel is often attended with a good effect, when other means prove unsuccessful: to effect which, a piece of hog's gut that has been pre- viously dried, and moistened again, may be used. One end of it being firmly tied with a bit of small packthread, is, by means of a probe, to be pushed along the course of the nostril from which the blood is dis- charged to the upper part. The gut is then to be filled with cold vinegar and water by means of a syringe inserted at the end banging out of the nostril, and as much injected as the gut will admit, the whole is to be pressed up as far as possible, and to be then secured in this situation by a proper bandage. While we are pursuing these steps, we are at the same time to open the body, if necessary, with cooling purgatives, in order to make some derivation from the vessels of the head; and the patient is carefully to avoid all those circumstances which might either determine the blood to the head, or prevent its free return from it. Refrigerants, such as the saline medicine, with nitre, may be advised every hour or so, the patient drinking cold acidulated liquors, and ex- posing himself freely to cool air. Astringents, such as the sulphate of zinc, alum and plumbi su- peracetas, with opium, are sometimes given internally; but their effect seems doubtful, as they seldom have time to act. When the 294 PYREXIAE, OR FEBRILE DISEASES. Class I. eomplaint is of long duration, they may be used as below*. Alum, catechu, and gum kino, are astringents more applicable for hemor- rhages from the lungs, stomach, and intestines, than for epistaxis. In this hemorrhage, as well as in all other active ones, the tincture of digitalis, given in doses of thirty drops from a two- ounce phial (the size will make some difference in the drops) every six hours for four or five doses, may prove an efficacious remedy, particularly in full robust habits, or where there is a quickened circulation. In obstinate cases, the application of a blister to the neck has occasionally produced a good effect. After the bleeding has ceased, the patient must be careful not to remove the tents or clotted blood, but should allow them to come away of themselves; and in order to avoid any return of the hemor- rhage, he must be kept as still and quiet as possible, taking care not to apply any thing of a stimulating nature to the nose. It sometimes happens, that when the bleeding is stopped out- wardly, it nevertheless continues inwardly, and prevails in so high a degree as to threaten suffocation, particularly when the person falls asleep. In such cases the passage may be stopped by intro- ducing a pliable probe up the nostril, through the eye of which some strong threads have been passed, and so bringing it out at the mouth, then fastening pieces of sponge to their extremities, * 5. IJ. Infus. Rosae Acid, f. ?vj. Potassa? Nitrat. 3j. M. £t. Mistura, cujus sumat cochl. larg. iij tertia quaq. hora. Vel, 6. ft Acid. Sulph. Dilut. TTl xvi. Aq. Font. f. ^jss. Syrup. Rosas, f. 3y. Tinct. Opii, til x. M. Pro haustu ter quaterve die sumendo. Vel, 1. ft Zinc. Sulphat. gr. \—h- Aluminis, gr. x. Infus Rosae, f. ^jss. Syrup, ejusdem, f. 3j^ M. ft. Haustus 6tis horis adhibendus. Vel, 8. ft Aq. Distillat. f. |jss. Plumbi Superacet. gr. j.—ij. Tinct. Opii, 1t[ x.—xij. Syrup. Rosae, f. 3j. M. -ft. Haustus sexta quaque hora capiendus * 5. Take Infusion of Roses, six ounces. Nitrate of Potass, one drachm. Shake them together, and of this mixture take three large spoonsful every third hour. Or, 6. Take Diluted Sulphuric Acid, twenty- four drops. Pure Water, one ounce and a half. Syrup of Roses, two drachms. Tincture of Opium, fifteen drops. Mix them for a draught, to be taken three or four times a day. Or, 7. Take Sulphate of Zinc, one quarter or half a grain. Alum, ten grains. Infusion of Roses, one ounce and a half. Syrup of the same, one drachm. Mix them for a draught, to be administered every six hours. Or, 8. Take Distilled Water, one ounce and a half. Superacetate of Lead, from one to two grains. Tincture of Opium, fifteen to twenty drops. Syrup of Roses, one drachm. This draught may be taken every si* hours. Order IV. SriTTING OP BLOOD. 2B5 afterwards drawing them back, and tying them on the outside with a sufficient degree of tightness. Where epistaxis arises in adults of a full plethoric habit, a fre- quent use of cooling purgatives, and an antiphlogistic regimen, may probably prevent any return of the complaint. W hen occa- sioned by too great a determination of blood to the head, topical bleeding, by means of leeches to the temples, will be advisable. When it is occasioned by the suppression of some accustomed evacuation, such as the menstrual or hemorrhoidal flux, this is to be restored if possible ; but if we do not succeed, some other discharge, by means either of an issue or seton, must be substituted. HEMOPTYSIS, on SPITTING of BLOOD. In haemoptysis there is a discharge of blood of a florid colour, and often frothy, from ihe mouth, brought up with more or less of cough- ing or hawking, and preceded usually by a saltish taste in the saliva, a sense of weight about tbe precordia, difficult respiration, and a pain in some part of the thorax. ft is readily to be distinguished from haematemesis, as in this last the blood is usally thrown up in considerable quantities, is more- over of a darker colour, more grumous, and mixed with the other contents of the stomach, and is unattended by any cough ; whereas blood proceeding from the lungs is usally in small quantity, is of a florid colour, fluid, mixed with a little frothy mucus, and brought up by coughing. A spitting of blood arises most usually between the ages of six- teen and twenty-five, and may be occasioned by any violent exer- tion, either in running, jumping, wrestling, singing, speaking loud, or blowing wind-instruments; as likewise by wounds, plethora, pneumonia, weak vessels, hectic fever, coughs, irregular living, ex- cessive drinking, or the suppression of some accustomed discharge, such as the menstrual or hemorrhoidal. It may likewise be oc- casioned by breathing air which is too much rarefied to be able pro- perly to expand the lungs. Persons in whom there is a faulty proportion either in the vessels of the lungs, or in the capacity of the chest, being distinguished by a narrow thorax and prominent shoulders, or who are of a delicate make and sanguine temperament, or who have had previous af- fections of the same disease, seem much predisposed to this hemorrhage ; but in these the complaint is often brought on by the concurrence of the various occasional and exciting causes before mentioned. A spitting of blood is not however always to be considered as a primary disease. It is often only a symptom ; and in some disorders, such as pleurisies, peripneumonies, and many fevers, often arises, and is the presage of a favourable termination, if only very slight. Sometimes it is preceded (as has already been observed) by a 296 PYREXIA, OK FEBRILE DISEASES. ClttSS I sense of weight and oppression at the chest, a dry tickling cough, some slight difficulty of breathing, and a hard jerking pulse. At other times if is ushered in with shiverings, coldness of the extre- mities, pains in the back and loins, flatulency, costiveness, and lassitude. The blood which is spit up is sometimes thin, and of a florid red colour; and at other times it is thick, and of a dark or blackish cast : nothing, however, can be inferred from this circum- stance, but that the blood has lain a longer or shorter time in the chest before it was discharged. An haemoptoe is not usually attended with danger, where no symptoms of phthis.is pulmonalis have preceded or accompanied the hemorrhage ; where it leaves behind no cough, dyspnoea, or other affection of the lungs ; or where there is no malconformation of the pulmonary system: nor is it dangerous in a strong healthy person of a sound constitution, unless the hemorrhage is very great; but when it attacks persons of a weak lax fibre and delicate habit, it may be difficult to remove it. It seldom takes place to such a degree as to prove fatal at once ; but when it does, the effusion is from some large vessel. The danger, therefore, will be in proportion as the discharge of blood comes from a large vessel or a small one, and as the quantity is profuse or trifling. When the disease proves fatal in consequence of the rupture of some large vessel, there is found on dissection a considerable quantify of clotted blood between the lungs and pleura, and there is usually more or less of an inflammatory appearance at the rup- tured part. Where the disease terminates in pulmonary consump- tion, the same morbid appearances are to be met with as described under that particular head. In an haemoptoe the effusion is to be moderated by a strict ob- servance of the antiphlogistic plan ; by carefully avoiding heat, and every kind of bodily exertion, and where the hemorrhage is severe, even speaking ; by employing occasionally cooling pur- gatives*, such as manna, tamarinds, phosphorated soda, sulphate of potass, &c. and by making use of a light vegetable diet, with ice and other refrigerantsf. Cold acidulated liquors should be * 1. Take Infusion of Roses, one ounce and a half. Sulphate of Magnesia, three drachms. Mix them, and take this draught twice in the day. I 2. Take Infusion of Roses, one ounce and a half. Nitrate of Potass, fifteen grains. Tincture of Opium, fifteen drops. Mix them for a draught, to be taken every four hours. Or, 3. Take Supertartrate of Potass, three drachms. * 1. ft Infus. Rosae, f. ^iss. Magnes. Sulphat. 3"j. M. ft. Haustus bis in die adhibendus. t 2. ft Infus. Rosae, f. |iss. Potassae Nitrate, gr xv. Tinct. Opii 1f[ x. M. ft. Haustus 4tis horis sumendus. Vel, 3. ft Potassae Supertart. 3»j. Order IV. SPITTING OF BLOOD. 297 taken for ordinary drink. Dr. Darwin is of opinion, that one immersion in cold water, or a sudden sprinkling all over with it, might probably stop a pulmonary hemorrhage. Indeed the appli- ca.ion of cold t> the genitals, or immersing the feet, and even the lower part of the body, ought in no case of haemoptysis to be neglected. If the patient is hot and feverish, youthful, or of a plethoric habit, and has a hard jerking pulse, bleeding from the arm may be used with advantage, and the operation be repeated according to circumstances; but on the contrary, where there are marks of debility and laxity, and the blood is of a dark colour, depletion will be improper. In all cases where the hemorrhage is considerable, besides re- sorting to cooling purgatives and refrigerant medicines in the manner before mentioned, we ought to give astringents*, in order to stop it as quick as possible; and if we find mild ones to fail, we must then employ others of a more powerful naturef, taking care ft. Potassae Nitrat. 3'j- Pulv. capiat asger 3ss cyatho parvo decocti hordei vel aquae frigidse. Vel, 4. ft Acid Sulph. Dilut. fll xv. Aq. Fontan f. ^jss. Tinct Opii,fll xiij. Syrup. Rosae, 3j- M. ft. Hatjstus. * 5. ft Aluminis, gr viij. Extract Catechu, gr. x. Conlect. Rosae, q. s. M. ft. Bolus 4ta. quaq. hora sumendus super- bib, cochl. iy. magna Infusi Rosae. Vel, 6. ft Tinct. Kino ----Catechu, aa f. ^ss. M. | Nitrate of Potass, two drachms. pro dosi exj Mix them, and let the patient take half a ---Opii, 3ij. M. Capiat fll xx —xxx. pro dos. ter quaterve in die. t 7. ft Zinci Sulphat. gr. ss__ij. Gum Kino, gr. viij. Opii, gr. ss Confect Rosae, gr. x. M. ft. Bolus, ter de die adhibendus. Vel, 8. ft Sulphat. Cupri. gr. v. solve in Aq. Rosae, f. gviij. et adde Tinct. Opii, fll xl. M. ft. Mistura, cujus sumat aeger cochlear, j 4tis borrs. i 38 drachm of the powder dissolved in a teacupful of barley-water, or cold water. Or, 4. Take Diluted Sulphuric Acid, twenty- five drops. Pure Water, one ounce and a half. Tincture of Opium, twenty drops. Syrup of Roses, one drachm. Mix them for a draught. * 5. Take powdered Alum, eight grains. Catechu, ten grains. Confection of Roses, a sufficiency to form a bolus, which may be taken every four hours, washing it down with three table-spoonsful of the Infusio n Roses. Or, 6. Take Tineture of Kino, --------Catechu, of each half an ounce. --------Opium, two drachms. Mix them well, and take from thirty to forty drops for a dose three or four times a day. 1 7. Take Sulphate of Zinc, from half a grain to two grains. Gum Kino, eight grains. Opium, half a grain. Confection of Roses, ten grains. Make them into a bolus, to be given three times a day. Or, 8. Take Sulphate of Copper, five grains. Dissol\e it in Rose Water, eight ounces, and add Tincture of Opium, sixty drops. Of this mixture let the patient take a large spoonful every four hours. 298 PYREXIAE, OR FEBRILE DISEASES. ClaSS I. to exhibit some laxative, such as the oleum ricini, now and then, to prevent their having any deleterious effect. The superacefate of lead has been used freely, and with great ad- vantage, in haemoptysis. One grain every four or six hours may be employed with perfect safety, fn cases attended with imminent dan- ger, we may venture on two or even three grains. It may be given in an infusion of roses, with a few drops of tinctura opii, or in the form of a pill if more agreeable. The remarkable operation of digitalis in retarding the pulse has suggested its use in cases of active hemorrhage, and particularly in haemoptoe, in which disease it has been used by many practitioners, and repeatedly by myself, with a very happy effect. It may be given in small doses, repeated twice or thrice a day, as prescribed here*. Should these remedies prove ineffectual in putting a stop to the hemorrhage, we may make trial of Ruspini's styptic: but as it appears to possess very active powers, the full dose advised in the printed directions should not be continued after the bleeding stops. If its use is persevered in to prevent a return of the disease, the dose should be reduced to one half, and be repeated at longer intervals. If the hemorrhage resists all the means which have been advised, Vel, 9. ft Infus. Rosae, f. ^jss. Aluminis, gr. x. Zinci Sulphat gr. \. Tinct. Opii fll x. Syrup. Simpl. f. 3j. M. ft. Haustus 4tis horis capiendus. Vel, 10. ft Plumbi Superacet. gr. iss.—iij, Opii, gr. ss. Conject. Rosae, q. s. M. ft. Pilula, quarta vel sexta quaque hora sumenda. 11. ft Pulv. Digitalis Purp. gr. j. Confect. Rosae, gr. x. M. ft. Bolus mane, hora meridiana, et vespere sumendus. Vel, 12. ft Infus. Digitalis, f. 3vi. Plumbi Superacet. gr. ij. Tinct. Opii, fll viij. M. ft. Haustus 6ta quaque hora adhibendus. Vel, 13. ft Infus. Rosae, f. ^jss. Tinct. Digitalis fll x. ----Opii, fll xii M. it. Haustus 6tis horis capiendus. Or, 9. Take Infusion of Roses, one ounce and a half. Alum, ten grains. Sulphate of Zinc, half a grain. Tincture of Opium, fifteen drops. Syrup, one drachm. Mix them for a draught, to be taken every four hours. Or, 10. Take Superacetate of Lead, one gram and a half to three grains. Opium, half a grain. Confection of Roses, a sufficiency to make them into a pill, which may be taken every fourth or sixth hour. * 11 lake Powdered Purple Fox Glove, one grain. Confection of Roses, ten grains. Form a bolus, to be taken morning, noonj and evening. Or, 12.Take Infusion of Fox Glove.six drachms. Superacetate of Lead, two grains. Tincture of Opium, twelve drops. Mix them foe a draught, to be token every. six hours. Or, 13. Take Infusion of Roses, one ounce and a half. Tincture of Fox Glove, fifteea drops. ------Opium, eighteen drops. Mix them for a draught, to be taken every six hours. "Order TV. vomiting of bloob. 299 and there is reason to fear that the patient may sink under the loss of blood, it will be proper to apply a blister to the chest: which remedy has often been attended with much advantage in cases of this nature. Dr. Rush tells us, that a table-spoonful or two of common salt is often successful when other means will fail. When much coughing attends on haemoptoe, it will be necessary to have recourse to »pium, exhibited in small and frequently repeated doses along with the other remedies. Different preparations of the hyoscyamus have been successfully employed in haemoptoe by the German physicians*; but being in the possession of so active a remedy as the digitalis for suppressing pul- monic hemorrhage by diminishing the action of the heart and arteries, it seems unnecessary to resort to this, except in those cases where we give it the preference to opium with the view of tranquillizing the rough. After the effusion is stopped, we are to use every possible means for preventing its return. If the complaint has arisen from predis- position, and where an inflammatory diathesis prevails, it may be necessary to obviate this by small bleedings, repeated according to the urgency of the symptoms; besides which, we may employ re- frigerants and cooling purgatives occasionally, the patient at the same time adhering strictly to an antiphlogistic regimen, and avoid- ing all vigorous exertions of the body, agitations of the mind, and Other occasional causes. Sailing, travelling in an easy carnage, swinging, and riding gently on horseback, will be the most proper exercises. Where the disease arises in persons of a lax fibre and delicate habit, it has been customary to exhibit the bark of cinchona and chalybeates. These seem, but more particularly the latter, to be unsafe medicines in all cases of active hemorrhage, and have been experienced frequently to prove prejudicial in haemoptoe, by increas- ing the phlogistic diathesis. Whenever there is a fixed pain in the chest, a blister may be ap- plied over the part with considerable advantage. IL&MATEMESIS, or VOMITING of BLOOD. A hemorrhage of blood from the stomach is readily to be dis- tinguished from one which proceeds from the lungs, by its being Msually preceded by a sense of weight, pain, or anxiety in the region of the stomach ; by its being unaccompanied by any cough ; by its being discharged in a very considerable quantity ; by its being of a dark colour, and somewhat grumous; and by its being mixed with the other contents of the stomach. The disease may be occasioned by any thing received into the stomach which stimulates it violently or wounds it; or may pro- * See Extracts from Hufeland's Journal, in vul. iii. p. £76, tf Ae Medical and Physfc cat Journal. 30<3 PYREXIA, OR FEBRILE DISEASES. ClaSS I. ceed from blows, bruises, or any other cause capable of exciting inflammation in this organ, or of determining too great a flow of blood to it: but it arises more usually as a symptom of some other disease (such as a suppression of the menstrual or hemorrhoidal flux, or obstructions in the liver, spleen, and other viscera), than as a primary affection. Towards the close of scarlatina maligna, typhus gravior, and other disorders of a like nature, where symptoms of putrescency prevail in a high degree, a hemorrhage from the stomach is very apt to arise. Haematem*>sis is seldom so profuse as to destroy the patient sud- denly ; and the principal danger seems to arise either from the great debility which repeated attacks of the complainl induce, or from the lodgment of blood in the intestines, which by becoming putrid might occasion some other disagreeable disorder. The appearances to be observed on dissection, where it proves fatal, will depend on the disease of which it has been symptomatic. Where this complaint has arisen in a plethoric habit, and is attended with febrile symptoms, or such as indicate an inflamma- tory diathesis, it may be necessary to take away a small quantity of blood from the arm ; but the great debility which the disease produces of itself will not admit of this operation under any other circumstances. In moderate attacks of the disorder it may be sufficient to make use of refrigerants, as advised under the head of Haemoptysis, toge- ther with small doses of opium repeated twice or thrice a day, con- fining the patient at the same time to food of a light nutritive na- ture, and directing him to take some kind of cool acidulated beverage for his ordinary drink : but if these means do not quickly allay the hemorrhage, we ought then to employ powerful astringents and sedatives, as advised under the last-mentioned disease. During the use of these medicines, it will be necessary, however, to give some gentle laxative (such as the oleum ricini) now and then, in order to obviate costiveness and prevent any deleterious effects. In haematemesis I have the strongest reasons for presuming that there is not a m ire eff^ciual astringent than the tinctura ferri muria- tis; for by being applied here immediately to the mouth of the bleeding vessel, it acts as a styptic. It may be given in doses of twenty or thirty drops in a little cold water, and be repeated every hour or two till the hemorrhage ceases. Should it resist this medi- cine we may make use of Ruspini's styptic. It is said that large doses of spermaceti have been given in this disorder with success ; but its use seems more likely to prove bene- ficial after the hemorrhage has ceased than during its continuance, particularly, where the effusion is considerable. If the practitioner is disposed to make a trial of it in mild cases, he can give it as below*. * 1. R Cetacei, ^ss. I * 1. Take Spermaceti, half an ounce. Vitel. O'vi, 4■ s. Terantur in mortar. I Yolk df Egg, a sufficiency. Let marmoreo, et adde I them be mixed in a marble I mortar, and then add Order IV. VOIDING OF BLOOD BY URINE. 301 The application of a blister to Ihe abdomen in severe attacks is sometimes attended with a good effect. When the hemorrhage has stopped, it will be advisable to dis- cover, if possible, the cause from which it proceeded, and by re- moving that or the primary disease, to prevent any return of the complaint. ' Where hasmatemesis arises in putrid diseases, we must have re- course to the most powerful antiseptics.—See Typhus Gravior.— Where scirrhous tumors of the liver or spleen exist, and seem to have given rise to the hemorrhage, we must resort to bydrargyrus, conium, and the other means advised in chronic hepatitis and splenitis. A modern writer* informs us, that he has met with a variety of this disease in females from eighteen to thirty years of age, and by no means originating in organic affection of the stomach or viscera connected with it, that resisted the usual routine of treatment with cold acidulated liquors and different emmenagogues, but which readily gave way, by procuring copious and free alvine evacuation, by the exhibition of purgatives. HEMATURIA, or VOIDING of BLOOD ur URINE. This disease is sometimes occasioned either by falls, blows, bruises, or some violent exertion, such as hard riding and jumping ; but it often arises from a small sfone lodged either in the kidney or ureter, which by its size or irregularity wounds the inner surface of the part it comes in contact with ; in which case the blood dis- charged is most usually somewhat coagulated, and deposits a sedi- ment of a dark brown colour, resembling the grounds of coffee. It is rarely, if ever, an idiopathic disease. A discharge of blood by urine, when proceeding from the kidney or ureter, is commonly attended with an acute pain and sense of weight in the back, and some difficulty of making water, the urine which comes away first being muddy and high-coloured, but to- wards the close of its flowing becomes transparent, and of a natural appearance. When the blood proceeds immediately from the bladder, it is usually accompanied with a sense of heat and pain at the bottom of the belly. It is distinguished from the high coloured urine attendant on many diseases, by the deposite of a coagulum to the bottom of the vessel, and by its staining linen of a red colour. The voiding of bloody urine is always attended with some danger, * See Observations on the Utility of Purgative Medicines, by Dr. Hamilton, page 109 Aq. Pulegii, f. f j. — Fontan f. ^v. Potassae Nitrat 3j. Tinct. Opii, fT\ xl. M. ft. Mistura, cujus sumat cochl. larg. iij. 3tia vel 4ta quaq. hofst. Penny Royal Water, one ounce. Pure Water, five ounces. Nitrate of Potass, one drachm. Tincture of Opium, sixty drops. Of this mixture, let three large spoonsful be taken every three or four hours. 302 P1REXI.K, ©R FEBRILE DISEASES. ClaSS t particularly when mixed with purulent matter. When it arises iu the course of any malignant disease, it shows a highly putrid state of the blood, and always indicates a fatal termination. The appearances to be observed on dissection will accord with those usually met with in the disease which has given rise to the complaint. In the treatment of haematuria we must be guided by the cause which has occasioned it. If it has.arisen in consequence of some external injury, such as a blow or fall, or the patient is of a full plethoric habit, it may ' then be proper to make use of evacuation by bleeding, giving him a couple of table-spoonsful of an infusion of roses, with a small quantity of nitre dissolved in it every two or three hours, and employing some gentle purgative, such as the oleum ricini, mag- nesia? sulphas, or sodae sulphas, every second or third diy, to keep the body open. If the hemorrhage should continue after these steps have been taken, we must resort to astringents, as noticed under the former heads, beginning with those of the milder kind. To allay irritation, we may also give opium in sinaM doses every four or six hours. Where there is any deposite of a muco-purulent matter in the urine, about half a drachm of uva ursi in powder, three times a day, may be of service, the patient taking the double acidulated soda water for common drink. When haematuria proceeds from a stone either in the kidney, ureter, or bladder, it is only to be cured by removing the cause ; but as this may not be always practicable, we must then be con- tented to moderate the symptoms by making the patient drink plentifully of mucilaginous liquors, such as thick barley-water, solu- tions of gum. acaciae, or a decoction of marsh-mallows, sweetened with honey ; by giving him repeated small doses of opium joined with refrigerants, as advised under the head of Haemoptysis, and by throwing emollient clysters frequently up the intestines. A case of haematuria is recorded in the eighth volume of Medical Facts and Observations, which had resisted repeated bleedings and warm bathing, saline purgatives, emetics of different kinds, cam- phor and opium in large doses, uva ursi, mephitic alkaline water, &c. and which was quickly and effectually removed by giving the patient a pint a day of a decoction of peach-leaves. This was pre- pared by boiling an ounce of dried leaves of the peach-tree (Amyg- dala Persica, Linn.) in a quart of water, till it was reduced to a pint and a half. When haematuria is symptomatic of some malignant disease, aa putrid fever, &c. powerful antiseptics must be administered. MENORRHAGIA, or IMMODERATE FLOW of the MENSES. A flow of the menses is to be considered as immoderate when it either returns more frequently than what is natural, continues Order TV. immoderate flow of the menses. 303^ longer than ordinary, or is more abundant than is usual with the same person at other times. With the extraordinary flux of this secretion there are usually pains in the back and belly somewhaC like those of child-birth. The usual period of its visitations is from twenty-seven to thirty days. As to the time of its continuance, this is various in different women ; but it seldom continues longer than six days, or less than three, and does not cease suddenly, but in a gradual manner. The quantity generally discharged in a healthy and regular woman is from four to six ounces at each visitation. Those of a lax and de- licate constitution have, however, a more copious and longer con- tinued discharge than persons of a robust habit: thus the full bloom- ing country girl does not discharge half the quantity that the pale- faced lady of qualify does. The quantity of the menstruous fluid is greater in warm than in cold climates ; so if a woman lives in an atmosphere artificially warmed, much the same effect is produced. For practical purposes, it is of consequence to observe, that menstruation is a secretion, and not an effusion of pure blood either from the arteries or veins. All blood from the sanguiferous vessels (with very few morbid excep- tions) coagulates, whilst the fluid of the catamenia does not, whe- ther it comes away in a dropping manner, or is retained in any con- siderable quantity, as in the case of imperforate vagina. For other observations on menstruation, see Amenonhcea. The causes of menorrhagia may be referred fo, 1st, A plethoric state, or general fulness of habit. 2dly, Accidental circumstances determining the blood more copiously and forcibly into the uterine vessels, as violent exercise in dancing, strokes or contusions on the belly, strains and violent passions of the mind. 3dly, Irritations acting particularly on the uterus, as great cos- tiveness obliging the person to much straining at stool ; "excess in venery, particularly during menstruation, or the application of wet and cold to the feet, which may determine a greater flow of blood than natural to the uterus. 4thly, Laxity and debility of the organ, arising from frequent: child bearing, difficult and tedious labours, or repeated miscarriages. 5thly, Those which induce debility of the whole system, as a sedentary and inactive life, indulging much in grief and despon- dency, living upon a poor low diet, drinking freely of warm ener- vating liquors (such as tea and coffee), and living" in warm cham- bers ; and, 6thIy,Organic affections, such as scirrhus, polypus, ulceration, Sec. An immoderate flow of the menses arising from plethora is often preceded bty headach, giddiness,-or dyspnoea, and is afterward* attended with pains in the back and loins, some degree of thirst, universal heat, and a frequent, strong, hard pulse ; but where it arises in consequence of a laxity of the organ, or of general debility, and such attacks are frequently repeated, the symptoms whicli 304 pyrexias, or febrile diseases. Class I. attend are, paleness of visage, chilliness, laxity and flabbiness in the muscular fibres, unusual fatigue in exercise, a hurried respi- ration on the slightest effort, paius in the back on remaining any length of time in an erect posture, and coldness of the extremities, together with loss of appetite, indigestion, and a long train of nervous complaints. If the disease has induced much debility by frequent and severe attacks, it is no uncommon occurrence for the feet to be affected with oedematous swellings, particularly towards the evening, and for a leuco-phlegmatic habit to take place. In forming our prognostic in this disease, we must be directed by the nature of the cause which has given rise to it. If occasioned by plethora, or a general fulness of the system, we need apprehend no danger, as a temporary debility will be the only inconvenience the woman will experience ; but where it is produced by a laxity of the vessels of the organ, and is profuse, long continued, and of frequent occurrence, there will always be a risk of its inducing much general debility, and a leuco-phlegmatic habit. Leucoirlicea is a common consequence of it. Where it arises from an organic affection of the part, which is sometimes the case after the age of forty-five, it is usually deemed incurable. When menorrhagia proves fatal in consequence of a scirrhus of the uterus, this organ is observed on dissection to be much in- creased in size, and its substance to be thick and hard, and when cut into, shows a firm structure intersected with membranous septa. The internal surface is at the same time usually ulcerated, and beset with ragged processes, and from these ulcerated parts the hemorrhage proceeds. If polypi are the organic affection, these on dissection are gene- rally to be found adhering to some part near the neck of the womb, and they are surrounded wilh varicose vessels, which throw out the blood in considerable quantity when a rupture of any of them happens to take place. Where a profuse flow of the menses is attended with pains in the back, and the patient is of a full and robust habit, with pyrexial symptoms, it may be proper to draw offa few ounces of blood ; but in other instances, venesection may very safely be omitted. In general it will be sufficient to employ the other antiphlo- gistic means, such as keeping the body gently open with lax- ative medicines that give but little stimulus* ; administering * l.ft Potassae Tartrat. ^ss. Mannae Oplim. 3*»j- Aq. Fervent. ?iij. Tinct. Lav. C. 3ss. M. ft. Mistura, cujus sumat dimidhim pro dos. Vel, 2.& Magnes. Sulphat. |ij. Aq. Fervent. |vj. * 1. Take Tartrate of Potass, half an ounce- Manna, three drachms. Warm Water, three ounces. Compound Tincture 01 Lavender, half a drachm ? Shake them, and of this mixture take the half for a dose. Or, 2.Take Sulphate of Magnesia, two ounces. Warm Water, six ounGes. Order IV. immoderate flow of the menses. 305 refrigerants*, such as nitre; making use of a spare regimen ; drink- ing freely of cool acidulated liquors, such as lemonade or tamarind beverage, and keeping the chamber of a moderate temperature, and the bed, or mattress (which will be more proper) lightly covered with clothes. Besides adopting these means, the patient is to avoid an erect posture, and all such things as might prove exciting causes. By avoiding these, and moderating the first beginnings of the disease, it is probable that women might, in most cases prevent that debility which repeated and severe attacks are apt to occasion. When no symptoms denoting an increased action in the vessels of the uterus are present, and we suppose that the augmented secre- tion has arisen in consequence of a laxity of the vessels, besides keeping the woman in a recumbent posture, shunning much external heat, making use of refrigerants internally, and avoiding venery, cos- tiveness, and the other remote causes, we? should have recourse to sedatives and astringents, both of which may be used externally as well as internally. After these we should prescribe tonics and stimulants. Linen cloths dipped in vinegar and water, and kept constantly applied to the back and private parts, have a powerful effect in many cases of uterine hemorrhage. These means ought therefore always to be employed in those instances where menstruation is profuse. Opium has been much used internally in menorrhagia; and where the patient experiences spasmodic pains in the uterus, it undoubt- edly will prove a very valuable and useful medicine. On such oc- casions it may be given in small and frequently repeated doses, combined either with refrigerants or astringents; but as opium possesses the power of greatly relaxing the system when used libe- rally, it ought not to be administered in cases of general debility, unless under the circumstance just mentioned. The astringents most employed in this disease are, alum, catechu, Tinct. Sennae C. ^ss. Compound Tincture of Senna, half an ounce. Syr. Rosae, 3ij. M. \ Syrup of Roses, two drachms. Cochl. larg. iv. pro dos. sumenda. | Of this mixture let four table-spoonsful be * 3. R Potassae Subcarbonat. 3j. Succ. Limon. f. ^ss. Potassae Nitrat. gr. xv. Aq Font. f. ?jss. Syr. Simpl. f. 3ij. M. ft. Haustus 3tia hora capiendirs. Vel, 4. g; Infus. Rosae, f. |iss. Potassa* Nitrat. gr. x. Adde, pro re nata, Tinct. Opii, fn. x. M. It. Haustus 4tis horis repctendus. taken for a dose. 3. Take Subcarbonate of Potass, one scruple. Lemon Juice, half an ounce. Nitrate of Potass fifteen prains. Pure Water, one ounce and a half. Common Syrup, two drachms. Mix them, and take the draught every three hours. Or, 4. Take Infusion of Roses, one ounce and a half. Nitrate of Potass, ten grains. Adding, if necessary Tincture of Opium.fifteen drops. Mix them, and repeat this draught every four hours. ^Q 606 pyrexia:, or febrile diseases. Class 1. gum kino, and Armenian bole, which may be given as advised below*, or as prescribed under the heads of Haemoptysis and Abortions. The sulphate of zinc, and superacetate of lead, may be substituted in cases of profuse hemorrhage.—(urs, according to the urgency of the symptoms. In those cases where the hemorrhage is profuse, and resists the means already recommended, it will be proper to throw up astrin- gent injections into the uterus from time to time. Any of those heref prescribed may be used on the occasion. Where symptoms denoting an increased action in the vessels of the uterus are observable, it would probably be right to give the digi- talis, as advised under the heads of Abortions and Haemoptysis. In a few cases of this nature I have employed it with a good effect. Where menorrhagia proceeds from a scirrhous or ulcerated state of the uterus, all that can be done is to afford a temporary relief by administering opium in considerable doses. A combination of it with the extract of hemlock might possibly add somewhat to its pallia- tive effect. Hyoscyamus may likewise be tried. In those cases where menstruation becomes profuse, continues * 6. ft Aluminis, gr. xij. Gum. Kino, gr. viij. Confect. Rosae, q. s. M. ft. Bolus 3tia vel 4ta hora dus. Adde, pro re nata, Opii, gr. ss. Vel, 6. ft Extract. Catechu, gr. xij. Aluminis Purif. gr. x. Confect. Rosae, q.s. M. ft. Bolus. Vel, 7. ft Decoct. Cinchon. f. ?is6. Aluminis, gr. xij. Tinct. Kino, f 3j. ----Opii, fTlx. M. ft. Haustus 4tis horis sumendus. 18. ft Decoct. Cort. Querc. f. |vj. Aluminis, 3jss. M. ft. Injectio. Vel, 9. ft Zinc. Sulphat. gr. xv. Plumbi Superacet. 3j Aq. Distillat. Oj. M. Vel, 10. ft Aluminis, 3iv. Zinc. Sulphat $r x. Aq. Rosae, ^viij. M. Vel, 11. ft Infus. Galue Contus, Oj. 5. Take Alum, twelve grains. Gum Kino, eight grains. Confection of Roses, a sufficiency to form a bolus, which is to be, taken every third or fourth hour. Occasionally add Opium, half a grain. Or, 6.Take Extract of Catechu, twelve grains. Alum Purified, ten grains. Confection of Roses, a sufficiency to form a bolus. Or, 7. Take Decoction of Peruvian Bark, one ounce and a half. Alum, twelve grains. Tincture of Kino, one drachm. -------- Opium, fifteen drops. Mix them, and take the draught every four hours. 18. Take Decoction of Oak Bark, six ounces. Alum, one drachm and a half. Mix them for an injection. Or, 9. Take Sulphate of Zinc, fifteen grains. Superacetate of Lead, one drachm Distilled Water, one pint. Mix them. Or, 10. Take Alum, four scruples. Sulphate of Zinc, ten grains Rose Water, eight ounces. Mix them. Or, 11. Take Infusion of Oak Galls, one pin' Order IV. immoderate flow of the menses. 307 longer than ordinary, or returns more frequently than what is natural, in consequence of general laxity in the system, and not from inflammatory action, it will be proper for the patient, during its intervals, to enter on a course of Ionic medicines, such as cin- chona, the cortex cuspariae, myrrh, and preparations of steel, which may be given as advised below*, or under the head of Dyspepsia. To assist the effect of these remedies, she may make use of cold bathing, together with gentle horse exercise and a generous nutri- tive diet with wine. Where chalybeate springs can be resorted to with convenience, a use of these waters will be likely to afford much benefit. When, from great weakness, and relaxation in the uterine parts, the patient is troubled with a profuse menorrhagia, or with fluor albus, she will often experience great relief from Tunbridge water, or any other such chalybeate spring ; and as this state of local debility is very frequently a cause of abortion or barrenness, these waters have often been the means of removing such un- pleasant circumstances. With regard, however, to hemorrhagy from the uterus, it is often acompanied with a degree of general fever, pains in the back and loins, and local irritation, when every internal stimulant medi- cine would aggravate the disorder ; and therefore the use of chaly- beate waters in these cases requires much judgment and a proper discrimination. To repress the too great or permanent menstruation, which occurs in weak constitutions at the time of life when it ought to cease, we should have recourse to chalybeates, alum, bitters, and opium, the last of which may be administered in the dose of a grain every night, with about five grains of rhubarb. * 12. ft Gum. Myrrh. 3j- solve in Mortario cum. Aq. Distillat. ^vj. et adde ----Cinnam. f. ?j. Potassae Subcarbonat. 3ss. Ferri Sulphat. 3j. Syrup Simpl. f. 3y. 12. Take Gum Myrrh, one drachm. Dissolve it in Distilled Water, six ounces ; and add Cinnamon Water, one ounce. Subcarbonate of Potass, half a drachm. Sulphate of Iron, one scruple. Common Syrup, two drachms. ft. Mistura in Haustus" iv. distribuenda,'Mix them, and divide the whole into four quorum sumat j. mane, hora quinta post meridiem, et hora decubitus. Vel, 13- ft Decoct. Cort. Cinchonae, f. ^jss. Tinct. Cort. Cuspariae, ----Card. C. aa f. 3j. M. ft. Haustus ter in die capiendus. Adde, pro re nata, Acid. Sulph. Dilut. fll xij. draughts, of which take one every morn- ing, at five in the evening, and at bed-time. Or, 13. Take Decoction of Peruvian Bark, one ounce and a half. Tincture of Angustura Bark, Compound Tincture of Cardomoms, of each one drachm. Mix them for a draught, to be taken thrice a day, adding occasionally Diluted Sulphuric Acid, eighteen drops. 308 pyrexia, or febrile diseases. Class / H^EMORRHOIS, or PILES. The piles consist of small tumors situated on the verge of the anus, which are sometimes separate, round, and prominent, but sometimes the tumor consists only of one tumid or varicose ring surrounding it. In some cases there is a discharge of blood from these tumors, particularly when the patient goes to stool, and then the disease is known by the name of bleeding piles ; and in others there is no discharge, when it is called blind piles. These affections may be occasioned by habitual costiveness, plethora, hard riding, excesses of various kinds, the suppres- sion of some long accustomed evacuation, and by a use of strong aloetic purges ; and are most apt to arise in those of a robust habit, and who lead a sedentary life. Pregnant women are frequently afflicted with the piles, owing to the pressure of the uterus upon the rectum, which interrupts the return of venous blood from that part, and the costive habit to which such women are usually liable. The piles are sometimes accompanied by a sense of weight in the back, loins, and bottom of the belly, together with a pain or giddi- ness in the head, sickness at the stomach, and flatulency in the bowels. On going to stool, a pungent pain is felt in the funda- ment, and small tumors are perceived to project beyond its verge. If these break, a quantity of blood is then voided, and a consider- able relief from pain is obtained ; but if they continue unbroken, the patient in that case experiences great torture every time he goes to stool, and feels an inconvenience even in sitting down on any hard seat. The tumors are sometimes considerable, and from pressure upon the bladder, produce much irritation and even pain in voiding urine. Hemorrhoids are by no means dangerous, but they often prove both troublesome and disagreeable. In some instances they are to be regarded as a salutary evacuation. Hemorrhoidal tumors are sometimes attended with a considerable degiee of inflammation, which proceeding to a suppuration, terminates in sinuous ulcers, or fistula. Dissections of piles show that the tumors consist partly of the fine skin round the anus on the outside, and partly of the internal membrane of the gut. In general they are entire, but they some- times have srn.11 openings in them through which the blood issues. In the treatpient of piles due attention should be paid to the cause from which they have arisen : and as costiveness is one of the most frequent, the bowels ought to be kept ope" and regular by medicines which will prove gently laxative** * 1. ft Confect. Sennae, ^ij. Pulv. Jalap. 3ij. Potassae Mtrat. 3jss\ * 1. Take Confection of Senna, two ounces. Powdered Jalap, two drachms. Nitrate of Potass, one drachm and a half. Order IV. piles. 309 without irritating the rectum; and as a habit may be acquired, it will be right for the patient to observe stated times in the day for endeavouring to obtain motions. When the tumors are attended with much pain, and a considerable degree of inflammation, it may be advisable to apply a few leeches; after which, pledgets wetted in a solution of the superacetate of lead, or sulphate of zinc, may be laid on, the patient taking care after each stool to anoint the parts with some kind of emollient ointment*. In these cases fomentations and poultices are likewise employed ; but the former are preferable, except in those cases where a suppuration has commenced. This however should be prevented if possible, as a fistula is sometimes the consequence thereof. Injections of cold water up the rectum have sometimes afforded great relief when even leeches and opiates have failed. In a plethoric habit small doses of nitre may prove serviceable, par- ticularly if mixed with sulphur. Balsam of copaiba, given to the extent of forty or fifty drops morning and evening, often relieves the pains so frequently produced by piles. In some cases where the tumors are numerous and tumid, relief may be obtained by making a firm and gentle pressure of each pile between the finger and thumb. In a most violent case of external and internal hemorrhoidal Syr. Rhamni, q. s. M- ft. EIecruarium,de quo sumat magnitudinem juglandis pro re nata. Vel, 2. ft Sulph. Sublimat. §j. Confect. Sennae, -ij. Potassae Supertarf! 3"j- Syrup. Rosae, q. s. M. ft. Electuarium. Vel, 3.ft01.Rtcini,f.3vj.—|j. Vel, 4. ft Pulv. Jalapa?, 3j. Potassae Supertartrat 3ij. M. ft. Pulv. pro dos. * 5. ft Unguent. Cetacei, ?ij. Opii, 3j. M. ft. Unguentum. 6. ft Cerati Plumbi Superacet. |ij. t Opii, 3ij. M. Vel, Vel, 7. ft Cerati Cetacei, ----Plumbi Superacet. aa ?ss. Pulv. Opii, 3ss. M. Syrup of Buckthorn, a sufficiency to form an electuary, of which take the bulk of a Walnut occasionally. Or, 2. Take Sublimed Sulphur, one ounce. Confection of Senna, two ounces. Supertartrate of Potass, three- drachms. Syrup of Roses, a sufficiency to make the whole into an electuary. Or, 3. Take Castor Oil, six drachms to one ounce. Or, 4. Take powdered Jalap, one scruple. Supertartrate of Potass, two scruples. This powder to be taken as a dose. * 5. Take Spermaceti Ointment,two ounces Opium, reduced to powder, one drachm. Mix them, and use the ointment. Or, 6. Take Cerate of Superacetate of Lead, two ounces. Opium, two drachms. Mix them. Or, 7. Take Spermaceti Cerate, Cerate of Superacetate of Lead, of each half an ounce. Opium in Powder, half a drachm Mix them. 310 PYREXIA, OR FEURILK DISEASES. CIUSS / affection, which had resisted judicious treatment for five weeks, Dr. M'Lean mentions*, that almost immediate relief was obtained by giving the patient forty drops of the tinctura digitalis, and :hata rapid recovery was effected by repeating thirty-fire drops evening and morning. It is observed, that when he first applied for advice, his countenance was pale and sallow, his strength and flesh much exhausted, he walked with extreme pain and difficulty, his pulse was quick and small, and his appetite impaired : in a week the contrast was very striking. If a prolapsus ani attends the piles, the part is carefully to be re- placed each time after going to stool, by laying the patient in a horizontal posture, and pressing gently with the fingers till the reduc- tion is affected. Its return is to be prevented by avoiding the occa- sional causes as much as possible; and where it proceeds from a laxity of the rectum, besides applying a proper bandage, we may employed astringents both internally, as advised under the heads of the preceding hemoirhages, and also externally. Pledgets dipped in a strong decoction of galls, or oak bark, may be kept constantly to the parts as an external astringent, and they may be anointed from time to time with an ointmentf possessing similar virtues. As a general tonic cold bathing may be employed with advantage. It has been noticed that hemerrhoids are to be regarded in some instances as a salutary evacuation. In all such, therefore, the hemor- rhage should not be stopped. In those cases where it is so profuse as to occasion great loss of strength, we must have recourse to astringents both internally and externally, as has just been advised, taking care to obviate costiveness by some gentle laxative. Confinement to an horizontal posture will be advisable in such cases. Where the hemorrhage has been very considerable, good effects have been derived from the early application of pressure, made by introducing up the rectum a piece of sheep's or pig's gut tied at one end, and by filling it at the other extremity with any cold liquid, such as vinegar and water, forcing up the liquid so as to increase the degree of pressure, and then securing it with a proper bandage. When the hemorrhage proceeds from tumors seated high up * See Medical and Physical Journal, vol. iv. p. 134. * 8. ft Adipis Praeparat. |j. Pulv. Gallarum, 3»j- Opii, 3j- M. ft Unguentum. Vel, 9. ft Cerat. Plumbi Superacet. |j. Pulv. Gallar. 3ij. M. t 8. Take Prepared Lard, one ounce. Oak Gall, in fine powder, two drachms. Opium, one drachm. Mix them. Or, 9. Take Cerate of Superacetate of Lead, one ounce. Oak Gall, in powder, two drachms. ' Mix them. Order IV. PILES. 311 in the rectum, and is so severe as to induce great debility, we. may throw up some astringent injection*, if it cannot be stopped by the means just recommended. In those cases where the discharge has become habitual, arising from plethora, this state of fulness must be prevented by moderate exercise on foot, or in a carriage, by the use of a spare diet, by taking cooling purgatives from time to time, and by carefully avoiding all strong liquors. An internal use of Harrowgate water is a remedy from which great benefit is derived in the pdes. The advantages of sulphur as a mild unirritating purgative, and one which seems to continue its operation through the whole of the intestinal tube, has long esta- blished its virtue in those hemorrhoidal affections that require this evacuation; and the neutral salts, with which it is united in this mineral water, cannot but contribute to its efficacy. Those who are afflicted with piles should shun all such causes as may either increase the determination of blood into the hemorrhoidal vessels, or prevent its return back from them, but more particularly riding on horseback. During the continuance of this complaint the diet should be cool and nutritious, consisting principally of vegetables, ripe fruit, jellies, broths', &c. Fermented and spirituous liquors will be hurtful, and therefore the patient should only drink cooling acidulated liquors, water, or toast and water. Where piles have been of long standing, the intestinal varicose tu- mors or hemorrhoidal excrescences sometimes become so troublesome as to render their extirpation necessary either by ligature or excision. Under certain and prudent limitations the latter has been strongly re- commended by Mr. Waref, and by Sir James EarleJ, their removal has been powerfully urged ; but very serious consequences have, how- ever, now and then resulted from both modes. Their removal by the knife appears far preferable to doing it with ligatures, as peritoneal inflammation, convulsions, suppression of urine, and even tetanus, have ensued from the latter mode of treatment. t See his Remarks on Fistula Lachrymalis, with Observations on Hemorrhoids. X See Observations on the Hemorrhoidal Excrescence.—Pott's Works, by Sir James Earle, vol. iii. '^ * 10. ft Cort. Querc. Contus. |j. Aq Fontan Oij. Coque ad Oj. Colatura adde Aluminis, 3>j- Tinct. Opii, f. 3j. M. ft. Injectio. Vel, 11. ft Zinc. Sulphat. 3j. Aq Rosae, Oj. M. Vel, 12. ft Gallae Contus. |ss. Aq. Fervent. Oij. Col. 10. Take Decoction of Oak Bark,one pint Alum, two drachms. Tincture of Opium, one drachm. Mix them for an injection. Or, 11. Take Sulphate of Zinc, one drachm. Rose Water, one pint. Mix them. 12. Take Bruised Oak Gall, half an ounce Hot Water, two pints. Infuse them, and strain off the liquor. 312 PYREXI2E, OR FEBRILE DISEASES. ClaSS / If the disease is recent, it may sometimes be relieved by milder means, such as the introduction of a large-sized bougie up the rectum. Where the radical operation is not thought advisable, or there may be any other objection to its performance, we ought to make trial of the bougie, as it promises, nay, has been found* very considerably to re- lieve strictures in the rectum and such like inconveniences produced by hemorrhoidal excrescences. When, in consequence of piles, the rectum becomes so much af- fected as to threaten the patient with a fistula, we may recommend a use of Dr. Ward's celebrated pastef, as inserted in the Pharmacopoeia Chirurgica, which is to be prepared in the following manner:—The three first ingredients are to be finely powdered and well mixed ; afler which, the honey and sugar melted together over the fire, and formed into a clear syrup, are to be added, and the whole beaten together into a mass. —«s=)l»l«i®®l®l®IC=s=— ORDER V. PROFLUVIA, or FLUXES, with PYREXIA. Pyrexia, with an increased excretion, not naturally bloody, con- stitutes this order of diseases. CATARRHUS, or CATARRH. A catarrh consists in an increased excretion of mucus from the membrane of the nose, throat, and bronchiae, accompanied with a slight degree of fever, and other symptoms usually attendant thereon. It attacks persons of all ages and constitutions, but more particu- larly the young, and those who have had any former affection of the lungs ; and it may take place at any time of the year when there are sudden changes of the weather from heat to cold, and vice vers&. In the former instance, the application of cold to t|£ body seems evidently to be the remote cause of the disease: and in the latter it appears to depend on a specific contagion, having, in the years * See Observations on the Diseases of the Rectum and Anus, by T. Copeland. t 13. Take Elecampane Root, in powder, Black Pepper, of each half a pound. Fennel Seed, powdered, one pound and a half. Clarified Honey, White Sugar, of each ons pound. ft Pasta, de qua capiat quantitatem nucis Make them into a pas'te,of which let the bulk moshatae bis terve tie die. ' ofanutmegbetakentwiceortbricedaily- I 13. ft Rad Enul.Campan. Pulv. Piperis Nigri singul foss. Seminum Faenicul. Pulv. fljjss. Mellis Despumati, Sacchar. Purificat. singul. Jbj. M Order V. catarrh. 318 1732 and 1733, spread in a progressive manner over the whole of Europe, and part of America, and in 1785 and 1803, over the whole of Britain. When Ihe disease has prevailed epidemically in this manner, the term of influenza has been applied to it. The proximate or immediate cause of catarrh, seems fo be an increased afflux of fluids to the mucous membrane of the nose, fauces, and bronchia, in consequence of some degree of inflammation in these parts. Catarrh is to be distinguished from the measles by the great mild- ness of the febrile symptoms, and by the absence of many of the symptoms accompanying the latter. The disease usually comes on with a dull pain, or sense of weight in the forehead, a redness of the eyes, and a fulness and heat in the nostrils, which symptoms are soon followed by the distillation of a thin acrid fluid from these parts, together with a soreness in the trachea, hoarsness, frequent sneezing, some difficulty of breathing, a dry cough, loss of appetite, general lassitude over the whole body, and chilliness ; towards evening the pulse becomes considerably quickened, and a slight degree of fever arises. In the progress of the disorder the cough is attended with an excretion of mucus, which at first is thin, white, and expectorated with some difficulty ; but becoming gradually thicker and of a yellow colour, is at length brought up with greater ease and less coughing. Even where there is not much affection of the system, it often happens that (he natural evening paroxysm is considerably increased; and from restlessness, and frequent coughing, the patient is prevented from sleeping till the morning, at which time a crisis takes place for the present, and he then remains tolerably easy until the return of the evening paroxysm. When the secretion of mucus ceases, the inflammation goes off also, so that a natural cure almost always arises in the disease. Catarrh is seldom attended with fatal consequences, except when it either arises in elderly persons, attacks those of a consumptive habit, or has been much aggravated by some fresh application of cold, or by improper treatment ; and it usually terminates in the course of a few days, if not neglected, either by an increased expectoration, or a spontaneous sweat. In some instances it how- ever lays the foundation of phthisis pulmonalis, or gives a ten- dency to asthma and hydro-thorax. In others it becomes habitual, and is accompanied by severe dyspnoea, particularly in the winter : such patients often suffer fatally from the accession of a sharp frost; their usual complaint immediately attacks them, and passes on to the peripneumonia notha on the one hand, in which they are suf- focated by the profuse effusion of viscid phlegm into the air cells and tubes; or on the other, it puts on the more active form of common peripneumony. Very old persons are apt to be carried »ff by comparatively moderate attacks of catarrh, which seemed 40 314 PYREXIAE, OR FEBRILE DISEASES. Class I. (o wear out their feeble portion of vitality merely by the Blight interruption to the function of respiration, which the phlegm secreted in the bronchial passages occasioned, and they quietly sink into the sleep of death, without any urgent symptom or appearance of distress. The inner membrane of the trachea usually appears on dissection, in fatal cases of catarrh, to be much inflamed, and its cavity to be filled with a considerable quantity of mucous fluid. The same morbid state is likewise communicated to the lungs, which seem loaded with matter of a similar nature, producing suffocation. In mild attacks of this disease it may not be necessary to have recourse to the aid of medicine. In general it will be sufficient to confine the patient in bed, and to make him use an abstemious regi- men, and drink plentifully of warm diluent mucilaginous liquors, such as barley-water, thin gruel, &c, acidulated with a small quan- tity of lemon-juice, or crystals of tartar ; but in violent attacks, where there is a great difficulty of breathing, much febrile heat, and a full, frequent pulse, it will be necessary, besides adopting these means, to guard against the effects of general inflammation, by em- ploying various remedies. In those cases, therefore, where there is much general affection of the system, and the inflammatory diathesis is great, we should have recourse to the lancet, and other antiphlogistic remedies, pro- portioning the quantity of blood which we draw off to the violence of the symptoms and the age of the patient. If the difficulty of breathing and oppression at the chest are net aoon relieved by venesection, local blood-letting will be advisable, after which it will be proper to apply a blister over the part affect- ed ; which application will seldom fail to afford relief, if employed early in the disease. To encourage a determination to the surface of the body, and promote expectoration, if will be necessary to administer small and frequently repeated doses of antimonials, as advised under the head of Simple Continued Fever, or other diaphoretics, as prescribed below* ; the effect of which may be assisted by making the patient * 1. ft Succ. Limon. f. |js,s. Ammon. Subcarbonat. 3ss. Aq. Fontan. f. ^v. Antimon. Tartarizat. gr. jss. Syrup. Tolutan. f. |ss. M. ft. Miskira, cujus sumat cochr. larg. ij. tertiis hoi is. Vel, 2. ft Liquor Ammon. Acetat. f. |ss. Mistur. Camphors, f. |j. * 1. Take Juice of Lemon, one ounce and a half. Subcarbonate of Ammonia, half A drachm. Pure Water, five ouncei. Tartarized Antimony, one grail and a half. Syrup of Tolu, half an ounce. Of this mixture two large spoonsful are to be taken every three hours. Or, 2. Take Solution of Acetate of Ammonia. half an ounce. Camphorated Mixture, on« ounce. Order V. CATARRH. 313 drink plentifully of mucilaginous diluent liquors acidulated, and confining him to bed. Ammonia is a very powerful diaphoretic, and particularly if ad- ministered in wine-whey. Twenty or thirty drops of liquor vol. corn, cervi, in half a pint of. wine-whey, if the patient is kept in a moderately warm bed, will soon elicit a profuse sweat. Neutral salts promote insensible perspiration when the skin is.not warmed much externally. When these are sufficiently diluted with water, and given, a copious perspiration is procured. Half an ounce of vinegar saturated with ammonia (as in the liquor ammon. acetatis), and taken every two or three hours, will answer this purpose very well. Nitre is a medicine which is often given in this disease, as well as in gonorrhoea. In the latter it will be sure to augment the pain by its stimulus on the excoriated or inflamed urethra; and in the former, where the discharge is too thin or saline, it cannot fail to increase the coughing. The secretion of mucus in the lungs and fauces may likewise be assisted by administering pectorals of the attenuating class, such as squills, gum ammoniac, &c.*, and by apply-ng to them repeatedly throughout the course of the day the steams arising from warm vine- gar and water, by means of Dr. Mudge's inhaler. When the cough is troublesome, and there h great soreness and rawness in the fauces, demulcent's! may be used with advantage; Liquor. Antimon. Tartarizat. TTT. xii. Syr. Althaea?, 3ij. M. ft. Haustus, quartis horis adhibendus. Vel, 3. ft Camphorae, gr. iv. Pulv. Antimon. gr. ij. Confect. Rosae, q. s. M. ft. Bolus. * 4. ft Mistura? Ammon. f- ^vss*. Oxymel. Scillae, f. ^ss. M. ft. Mistura, cujus sumat cochl. media ij subinde vel tusse urgenti. t5. ftMucilag. Gum. Acaciae, f. ^v. 01. Amygdal. D. f. f j. Syrup. Tolutan. f ?ss. Liquor. Ammon. Subcarbooat. f. 3ss. M. ft. Emulsio, cujus saepe sumat cochl. larg. j. Vel, 6.ft Cetacei, 3iss. Vitellum Ovi unius. Misceantur bene in mortario, et adde Solution of Tartarized Antimony, eighteen drops. Syrup of Marshmallow, two drachms Mix them as a draught, to be given every four hours. Or, 3. Take Camphor, fourgrains. Antimonial Powder, two grains. Confection of Roses, a sufficiency to form a bolus, which may be taken as fre- quently as the former. * 4. Take Mixture of Ammoniac, five oun- ces and a half. Oxymel of Squill, half an ounce. Of this mixture two dessert spoonsful may be taken now and then, or when the cough is troublesome. t 5. Take Mucilage of Gum Acacia, five ounces. Oil of Sweet Almonds, one ounce. Syrup of Tolu, half an ounce. Solution of the Subcarbonate of Ammonia, half a drachm. Mix them, and of this emulsion the patient may take a large spoonful frequently. Or, 6. Take Spermaceti, one drachm and a half. The yolk of an Egg. Mix them well together in a mortar, than, add 316 PYREXIA, OR FEBRILE DISEASES. ClaSS I and after the inflammatory symptoms have abated, opiates will affoid effectual relief, and may be joined with the former Where the patient's rest is particularly disturbed in the night, an opiate* at bed-time will be highly necessary, but it should be combin- ed always with some diaphoretic. If costiveness prevails in the course of the disease, it ought to be removed by gentle laxatives. When the mucous membrane of the nose is much affected, it maybe smeared from time to time with a little tallow, or spermaceti ointment. The diet of the patient should be cooling and spare, as water- gruel, chicken-broth, beef-tea, vegetables, he. Such is the treatment which should be adopted during the first stage of the disease : but it often happens, that after the inflammatory symptoms have subsided, a weaknes* remains, and there is an in- creased secretion from the lungs, which perhaps continues for many months, without the least appearance of purulence. In such cases the patient is carefully to avoid all fresh exposures to cold, and he should defend himsplf by g"ing warmly clothed. Where the dis« ase runs on for any length of time, or has become habitual, the patient should continue long in bed in the morning, so that the natural evening paroxysm of fever may be entirely carried off there, and he should go early to bed at night. He is likewise to abstain from wine, and all food which is bard of digestion ; to breathe as pure open air as possible; and to use gentle exercise daily on horseback: which will take off the blood from the interior parts, and thereby diminish the internal secretions. Much benefit has been derived in some cases of chronic catarrh by using a warm bath, but particularly the vapour-bath, as by the latter we have the power of introducing into the chest soothing, or Syrup. Tolutan. f. ^ss. Aq. Distillat. ----Pulegii, aa f. ^iij. M. ft. Mistura, cujus capiat aeger cochleare magnum frequenter. Vel, 7. ftMel.Optim. 01. Amygd D. aaf. ^ij. Sue Limon. f. |j. Syrup. Tolutan. f. 3'ij. M. ft. Linctus, de quo saepe lambat aeger. * 8. ft Liquor Ammon. Acetat. f. 3"j- Mucilag. Gum. Acaciae, f ^j- Syrup. Tolutan. f. 3j- Tinct. Opii, TTj. xxvi.' M. ft. Haustus, hora decubitus sumendus. Vel, ¥ 9. ft Pulv. Ipecac. Comp. gr. xij. ft. Pulvis sudorificus. Syrup of Tolu, half an ounce. Distilled Water, Pure Water, of each three ounces. Shake them together, aud let the patient take a large spoonful frequently. Or, 7. Take Clarified Honey, Oil of Sweet Almonds, of eack two ounces. Lemon Juice, one ounce. Syrup of Tolu, two drachms. Mix them, and of this linctus let the patient take a little often. ' 8. Take Solution of Acetate of Ammoniaj three drachms Mucilage of Gum Acacia, one ounce. Syrup of Tolu, one drachm. Tincture of Opium, forty drops. Mix them for a draught, to be taken ob going to bed. Or, 9. Take Compound Powder of Ipeca- cuanha, twelve grains. Order V. ©ATARRH. 317 stimulant vapours, which act immediately on the seat of the disease. When the secretion from the chest is greatly lessened, and debility alone remains, we may alternate the vapour-bath with the'cold one, using the latter twice a week, and the vapour-bath once. By paying a proper attention to the means which have been advised, by keeping up a constant inflammation on the breast by plasters of Burgundy pitch or pix arida, and blisters, and by em- ploying opiates to mitigate the cough, and tonics, we shall in general be able to remove all consequences of the disease. If, notwithstanding these means, the cough should be dry, or be unattended with proper expectoration, and, together with a sore- ness, produce shooting pains through the breast and between the shoulders, accompanied with difficulty of breathing, flushing in the cheeks after meals, a burning sensation in the hands and fe et, and other symptoms of hectic fever, no time should be lost, as there is reason to fear that tubercular suppurations will follow. Under such circumstances the steps advised in the treatment of phthisis pulmonalis ought immediately to be adopted. ^, It is necessary here to notice a species of catarrh, with which persons advanced in life, and who have had frequent attacks of such affections, are apt to be afflicted. They are seized with a cough, which at length becomes habitual and chronic, and con- tinues for many years, proving extremely distressing. Its attacks are most common early in the morning, and the ill-fated patient, otherwise in good health, is thrown into fits of coughing, which last along time, and are only terminated by a free expectoration taking place, when relief is immediately obtained. Next morning, however, the same distressing symptoms again seize the enfeebled patient, and thus the little strength he may have to support him through the fatigues of the day is nearly exhausted. In nothern climates in particular, this species of catarrhal affection is very frequently to be met with among elderly people; and it seems to arise from an unusual quantity of mucus secreted in the bronchiae and perhaps in the lungs themselves, which by impeding respi- ration, or mechanically irritating these parts, produces the cough. When the complaint is protracted, or occurs in aged people who are much exhausted, the expectoration possibly ceases, while at the same time the bronchial secretion goes on, the skin is cold, the pulse is small and fluttering, the patient becomes drowsy, the face is tumid and discoloured, the lips livid, and the breathing is more and more difficult, tiil at last the bronchiae are so replete with mucus that the admission of a sufficient quantify of air to support life becomes impossible, and suffocation ensues, as happened in a late instance which came under my care. A combination* of squill r 10. ft Pulv. Gum. Myrrh. 3j. Gum. Ammoniac. 3ss. Scillae Pulv. gr. x. Syrup. Tolutan. q. s. M * 10. Take Gum Myrrh in powder, one drachm. ----Ammoniac, half a drachm. Powdered Squill, ten grains. Syrup of Tolu, a sufficiency to 318 PYREXIA, OR FEBRILE BISEASES. CUiSS I and gum ammoniac will be proper in this species of catarrh. Tonics appear likewise advisable, and therefore we may recom- mend the sulphate of iron, with subcarbonate of potash and myrrh, as noticed under the head of Phthisis. Opium, by checking the expectoration, might prove prejudicial. Digitalis* will be very likely to produce much benefit also in chronic coughs accompanied with dyspnoea, great secretion of viscid phlegm, and any tendency to effusion into the cells of the lungs. The catarrhal fever, known by fhe name of influenza, which pre- vailed so universally in most parts of this kingdom in 1803, as well as in France, where it was called la-gripe, first showed itself in London towards the latter end of the month of February, when a damp and mild slate of the atmosphere had succeeded to severe cold, and when this again had been followed towards the beginning of March by frost and keen easterly winds. Like preceding epidemics of the same kind, this disease ex- hibited various degrees of morbid affection, having been in some instances so^slight as not to incapacitate persons from following their ordinary occupations and pursuits, and scarcely to require the aid of medicine ; while in others the attack was of so severe a nature as to endanger life, and even to destroy it. To young children and elderly people it proved very fatal indeed, but more particularly so to the latter. Those likewise of a middle age, who either laboured under habitual asthma, or had any predisposition to phthisis, experienced its-dire effect. It was generally preceded by chilliness and shiverings, which were succeeded by some degree of heat, pains in the head, a dis- charge from the eyes and nostrils, severe sneezing, hoarseness, and cough. In the course of a few hours the headach became much increased, as well as the heat; the pulse was quickened, but small; the breathing was difficult and oppressed, or transitory stitches across the chest were felt. Some patients complained of pains in ft. Massa in pilulas, gr. v. dividenda. Capiat ij. pro dos. omni mane et nocte Vel, 11. ft Gum. Myrrh. 3ss. Solve in Aq.Purae, ^j. etadde Mistur. Ammoniac. ?v. Oxymel. Scillae, ?ss. Tinct. Camphorae Compos. 3ij- M Capiat cochl. amplumprodos bis terve in die. 12. ft Vlisturae Ammoniac, f. |v. Oxymel. Scillae, f. |ss. Tinct. Digitalis, fll xxv. M. Sumat cochl. amplum subindc, vel tusse, aut dyspnoea urgentL form the mass, which is to be divided into pills of five grains each, and two to be taken morning and night. Or, 11. Dissolve Myrrh, half a drachm in Pure Water, one ounce, then add Mixture of Ammoniac, five ounces. Oxymel of Squill, half an ounce. Compound Tincture of Camphor, two drachms. Mix them, andtake alarge spoonful twica or thrice a day. 12.Take Mixture of Ammoniac, five ounces. Oxymel of Squill, half an ounce. Tincture of Fox Glove, forty drops. Mix them, and let a large spoonful be taken from time to time, when either the cough or shortnessof breath is troil? blesome. Order V. CATARRH. 319 the shoulders and limbs, very much resembling chronic rheumatism, and there were instances in which the difficulty of breathing might be, in part, attributed to a similar affection of the intercostal muscles. The tongue was usually white; the thirst considerable; the bowels were costive; the urine was high-coloured and clear; and very frequently there was nausea at the stomach, with more or less of vomiting. Towardsthe second or third night the cough became greatly aggra- vated, and was strong and almost incessant, being usually accompanied, even on its first coining on, with an expectoration of thin sharp mucus. The evening paroxysm of fever was likewise more severe, being at- tended with extreme anxiety and restlessness, as well as considerable heat, and often with a great confusion in the head, and rambling. At this stage of the disease the pulse was usually from 100 to 120 strokes in a minute. Towards the morning there was commonly a remission of the febrile symptoms, but the cough continued urgent, and greatly interfered with the patient's getting any sleep after this time. Where gentle perspirations came on early, and the bowels were kept open, the fever usually declined about the fifth or sixth day, and the urine, which was before high-coloured and clear, now became turbid, or deposited a copious sediment; but the cough continued for many days, the sputum being however of a milder quality and thicker consistence, and the expectoration more free. Depression of spirits, languor, and debility, which were universal attendants on this epidemic, together with restless nights, harassed the patients for a considerable length of time after the decline of the fever. Such was the common form of the disease, but its modifications were extremely numerous; for in some instances there was a violent headach with a swelling of the eyes or inflammation of the conjunctiva, or pains in the limbs with but little catarrhal affection; in others, the throat was principally affected ; and in others again, a peripneumonic condition existed. In a few instances the fever assumed the typhoid type. In the treatment of the influenza bleeding was not much employed, and it was only had recourse to in those cases where the symptoms of pneumonia were very urgent, and the patient complained of great difficulty of breathing or an acute pain in the side. Where dyspnoea prevailed, the application of a blister to the chest usually afforded considerable relief. If nausea was complained of at the commencement, a gentle emetic proved serviceable ; and where costiveness existed, as was usually the case, it was necessary to give some gentle laxative. When there was no great degree of heat or fever present, it was by no means requisite to keep patients in bed: in such cases, con- finement to their chamber, with plentiful dilution, and a spare regimen, was sufficient; but when the febrile symptoms ran high, it was necessary to keep them in bed, and to administer diapho- 320 PYREXIA, OR FEBRILE DISEASES. ClaSS I retics. Small doses of the pulvis antimonialis, assisted by a solution of. some neutralized salt, and given every three or four hours, seldom failed to excite a gentle deteimination to the surface of the body. Further than this was not proper; for immoderate sweating, and particularly at the decline of the disease, was sure to prove injurious, by adding to the languor and debility. Some advantages were derived from a free use of the compound decoction of barlpy, and solutions of gum. acacise, with the addition of a little syrup of lemons, in those cases where the fauces and throat were affected by rawness and sort ness. Towards the decline of the disease, where the expectoration was both viscid and difficult, squills were employed with benefit. Where the cough proved very troublesome, and the febrile symptoms had subsided, and anodyne at night bad a very good effect. To counteract the languor and debility which invariably attended this epidemic, it was necessary, during a state of convalescence, to have recourse to tonics; such as a decoction of the bark of cinchona, with the mineral acids; or some preparation of myrrh, with an infusion either of calumbo root or gentian, various formulae of which are inserted under the head of Dyspepsia. At the commencement of the disease, a spare, mild, and vegetable diet was most advisable; but at its decline, a generous one, with a moderate quantity of wine, was proper. Many persons seemed to have relapses, and therefore it was found necessary to guard carefully against any fresh exposure to Cold. In many instances the period of convalescence was much protracted ; and during the debility which prevailed in consequence of it, patients were liable to the attack of some chronic disorder that proved obstinate and tedious, but more particularly to chronic rheumatism. By some physicians the disease was supposed to be contagious; by others not so: indeed its wide and rapid spread made many suspect some more generally prevailing cause in the atmosphere as alone capable of accounting for its extensive and speedy diffusion. It arose probably at first from a peculiar state of the atmosphere, like other epidemics, and was afterwards kept up and propagated by contagion. DYSENTERIA, or DYSENTERY. The dysentery is a disease in which there is an inflammation of the mucous membrane of the intestines, accompanied with frequent stools, severe griping pains, a tenesmus, and some degree of fever; the stools, although frequent, being small in quantity, and without any natural faeces intermixed, but consisting principally of mucus, which is sometimes streaked with blood. When the natural faeces do appear, they are usually under the form of small, compact, hard substances, known by the name of scybala. In the medical schools of Europe, it has been taught that Order V. DYSENTERY. 321 dysentery is of a highly contagious nature, and it undoubtedly is so where the sick are over accumulated, and cleanliness and ventilation are not properly attended to ; but it seems probable that the disease itself, under all ordinary circumstances of accommodation, is not of an infectious nature. Dysentery occurs chiefly in the autumn, and is often occasioned by cold or moisture succeeding quickly to intense heat or great drought, whereby the perspiration is suddenly checked, and a deter- mination made to the intestines. It is likewise occasioned by a use of unwholesome and putrid food, and by noxious exhalations and vapours : hence it appears often in armies encamped in the neighbour- hood of low marshy grounds, spreads rapidly, and proves highly de- structive, particularly where there is an undue accumulation of sick, and a neglect of cleanliness and due ventilation. From the same causes it occurs frequently on board ships of war, and vessels tran- sporting slaves from the coast of Africa, proving equally fatal. The free use of fruits has been assigned as one of the causes productive of the disease in warm climates; but very erroneously, for they have quite the opposite effect, and tend to preserve those from it who partake freely of them when perfectly ripe. A particular dispo- sition in the atmosphere seems often to predispose or give rise to the dysentery, in which case it prevails epidemically. It frequently occurs about the same time with autumnal inter- mittent and remittent fevers, and with these it is often complicated. It is likewise frequently combined with typhus. A late writer* supports the proposition that the simple dysentery is of itself never contagious, nor the intermittent and remittent forms of the disease; that the combination with typhus is alone possessed of that pro- perty ; and this, he insists, originates not in the virus specific to the dysentery, but in the contagion of fever. Others have however given it as their opinion, that the contagion arises from the effluvia of the fasces of dysenteric patients, and not from their febrile perspi- ration or breath. The dysentery is much more prevalent in warm climates than in cold ones; and in the months of August, September, and October, which is the rainy season of the year in the West Indies, it is apt to break out, and to become very general among the negroes on the different plantations in the colonies. It likewise prevails much in the unhealthy parts of the East Indies, and in our factories on the coast of Africa, both during the wet season and some time after it. The body having been rendered irritable by the great heat of the summer months, and being exposed sudd. n!y to cold or moisture with open pores, the blood is thereby thrown fi\»m the exterior vessels upon the interior, so as to give rise to dysenteries. The dysentery of tropical climates is usually found connected in some way or other with derangement of the liver; but whether the one is a cause or a consequence of the other, observation * Sec Obse:vafioris on si:nple Dysentery and its Combinations, by William Harty, M. D. 41 32£ PYREXIAE, OR FEBRILE DISEASES. ClttSS I has not accurately determined; for sometimes hepatitis precedes the rise of Indian dysentery, at other times it follows in succession, and in some instance- there are evident Symptoms of both diseases existing from the commencement to the termination of the case. Dysentery may readily be distinguished from the diarrhoea by the absence of fever and tenesmus in the latter: the appearance of the stools, and the other symptoms, will further assist us. An attack of dysentery is sometimes preceded by loss of appetite, costiveness, flatulency, sickness at the stomach, and a slight vomit- ing, and comes on with chills succeeded by heat in the skin, and frequency of the pulse. These symptoms are in general the fore- runners of the griping and increased propensity to stool which after- wards occur; but it sometimes happens that the local affection is perceived first. When the inflammation begins to occupy the lower part of the intestinal tube, the stools become more frequent and less abundant, and in passing through the inflamed parts they occasion great pain, so that every evacuation is preceded by a severe griping, as also a rumbling noise, and there is unusual flatulence in the bovvels. The motions vary bnth in colour and consistence, being some- times composed of frothy mucus streaked with blood, and at other times of an acrid watery humour, like the washings of meat, and of a very fetid smell. Sometimes pure blood is voided ; now and then lumps of coagulated mucus, resembling bits of cheese, are to be observed in the evacuations, and in some instances a quantity of purulent matter is passed. Sometimes what is voided consists merely of mucous matter, with- out any appearance of blood, exhibiting that disease which is known by the name of dysenteria alba, or morbus mucosus. While the stools consist of these various matters, and are voided frequently, it is seldom that we can perceive any natural faeces among them, and when we do, they appear in small hard balls, called scybala, which being passed, the patient is sure to experience some temporary relief from the griping and tenesmus. It frequently happens from the violent efforts which are made to discharge the irritating matters, that a portion of the gut is forced beyond the verge of the anus, which in the progress of the disease proves a troublesome and distressing symptom, as does likewise the tenesmus, there being a constant inclination to go to stool, without the ability of voiding any thing, exeept perhaps a little vitiated mucus, or a small quantity of blood. More or Jess of pyrexia usually attends with the symptoms which have been described throughout the whole course of the di-ease, where it is inclined to terminate fatally, and is either of an inflam- matory or putrid tendency. In the other case the febrile state wholly disappears after a time, while the proper dysenteric symptoms prob' bly will be of long continuance. When the symptoms run high, and are accompanied with violent Order V. DYSENTERY. 323 irritation of the whole intestinal tube, great prostration of strength, strangury, and hiccup, or with a putrid tendency, and fetid and involuntary discharges, the disease often terminates fatally in the course of a few days : but when tbey are more moderate, if is fre- quently protracted to a considerable length of time, and induces great emaciation and debility, but goes off at last by a gentle per- spiration diffused over the whole body ; the fever, thirst, and griping then ceasing, and the stools becoming of a natural colour and con- sistence. When the disease is of long standing, and has become habitual, it seldom admits of an easy cure; and when it attacks a person labouring under an advanced stage of scurvy or pulmonary consumption, or whose constitution has been much impaired by any other disorder, it is sure to prove fatal. It sometimes appears at the same time with autumnal intermittent and remittent fevers, as has before been observed, and is then more complicated and difficult to remove. A great degree of tenesmus, severe griping pains, frequent incli- nation to go to stool and but little voided, much depression of strength, fetor of the evacuations, a tense abdomen, violent pyrexia, cold clammy sweats, coldness of the extremities, aphthae, hiccup, petechia?, and a weak irregular pulse, are to be regarded as very unfavourable symptoms. Whereas a gentle and universal diapho- resis, moderate pyrexia, the evacuations becoming less frequent and more of a natural consistence, and a gradual diminution of the griping and tenesmus, are favourable appearances. The disease is rery liable to a relapse from any exposure to cold, wet, or fatigue. Upon opening the bodies of those who die of dysentery, the in- ternal coat of the intestines (but more particularly of the colon and rectum) appears to be affected with inflammation and its conse- quences, such as ulceration, erosions, contractions, scirrhosities, and gangrene. The peritonaeum and other coverings of the abdomen, in many instances, have likewise an inflammatory appearance. Two different stages seem evidently to exist in the course of this disease ; wherefore, to treat it properly, due attention should be paid to that which is present at the time when advice is applied for. An important point to be attended to, is not to neglect it at its commencement. In its first stage, if the patient is young and plethoric, and the disease is accompanied by acute inflammation of the villous coat of the intestines, and a considerable congestion of blood, or inflam- mation of the liver, as is sometimes the case in warm climates, early blood-letting may be requisite ; but otherwise venesection will not be necessary, particularly as the fever which accompanies dysentery is very apt in the course of the disease to assume a typhoid type. It has been a matter of doubt with some physicians whether to consider the inflammation that attends on dysentery as the conse- quence or cause of the disease. My own opinion is certainly in favour cf the latter ; but nevertheless, I do not recommend an 324 PYREXIA, OR FEBRILE DISEASES. ClaSS 1. indiscriminate use of the lancet, but, on the contrary, a very cautious one. In most cases, we may begin the cure by giving a gentle emetic in the evening, and the next morning we may administer some saline purgative*, which should be repeated every second or third day, in order to procure an evacuation of natural faeces, which seldom pass off in any quantity, unless by artificial means. Should those which are prescribed below not procure copious stools, we must then employ stronger purgativesf. Some practi- tioners are in the habit of combining emetic and purgative medi- cinesj, such as some of the mild neutral salts, with tartarized anti- mony, and often with a very good effect. With the view of determining the circulation to the surface of the body, small doses of so ne diaphoretic|| may be taken every three or four hours, after proper evacuations, so as fo produce and keep up a gentle perspiration without exciting much nausea. A setni- cupiuni may possibly assist. By these means we may be able sometimes to cut the disease abruptly short, and arrest its progress. Cerated glass of antimony has been much extolled by Sir John Pringle for its great efficacy in the cure of dysentery, and may therefore be given if the other medicines are not found to answer. 1. ft Sodae Sulphat. 3vi. Manna; Optim |ss. Aq. Fervent, f ^iss. Tinct. Senna? C. 3'j- M. ft. Haustus. Vel, 2. ft 01. Ricini, f. ?j. pro dos. Vel. 3. ft Magnes. Sulphat. ^i. Manna? Optim. ^s«s. Aq. Fervent — Menth. Pip. aa f. ^iis. Ti.tct Rhei, f. 3U- M. Cujus sit dosis cochlearia quatuor pro re nata t 4. Hydrargyr. Submuriat. gr. iij. Pulv. Jalapa?, 3j. Syr. Rhamni, q. s. M. ft. Mass. in pilulas v. pro dos. dividenda. X 5. ]J Infus. Senna?, f. %v. Potassae Tartrat ?j. Antimon Tartar, gr. ij. Solv. Hujus misturw sumantur cochl. iv. quo libet trihorio, donee venter rite solutus fuerit. |J 6. ft Pulv. Ipecac. Com. gr. iij. Confect. Aromat. gr. x. M. ft. Bolus 4tis horis sumendus. 1. Take Sulphate of Soda, six drachms. Manna, half an ounce. Warm Water, one ounce and a half. Compound Tincture of Senna, two drachms. Mix them as a purgative draught. Or, 2. Take Castor Oil, one ounce for a dose. Or, 3. Take Sulphate of Magnesia, one ounce. Manna, half an ounce. Warm Water, Peppermint Water, of each two ounces and a half. Tincture of Rhubarb, two drachms. Of this solution four large spoonsful may be taken occasionally. 14. Take Submuriate of Mercury, three grains Powdered Jalap, one scruple. Syrup of buckthorn, a sufficiency. Form the mass into five pills, to betaken for a dose. X 5. Take Infusion of Senna, five ounces. Tartrate of Potass, one ounce, Tartarized Antimony, two grains. Dissolve them, and of this mixture four large spoonsful may be taken every three hours, until the bowels are suffi- ciently moved. 6. Take Compound Powder of Ipecacu- anha, three grains. Aromatfc Confection, ten grains. Make them into a bolus, to be taken every four hours. Order V. DYSENTERY. 325 The dose for an adult is about eight grains ; but it will be most advisable fo begin with four or five grains, increasing the quantity according fo flie effect produced. A novel method of using emetic medicines in dysentery has been recommended by a late writer* ; and we are assured by him, that he has found the practice highly successful. This is in the form of a clyster ; and that which he has experienced to answer best, has been about three drachms of ipecacuanha loot, bruised and boiled in a quart of water down to a pint, which he repeats twice or thrice in twenty-four hours. If dysentery is accompanied wilh violent retchings or a severe vomiting on its attack, so as to threaten the patient with cholera morbus, neither emetics, purgatives, noi diaphoretics, will be ad- visable at first. In such cases the stomach must be evacuated of its contents by the gentle stimulus of large draughts of chamomile- tea. The same, or weak broth, may be thrown up the intestines in the form of clysters until these are cleansed; after which an opiate should immediately be given. If the opium is rejected, a double quantity of it is then to be administered in a clyster. Should the vomiting continue very obstinate notwithstanding these means, the safety of the patient will then depend on bathing the region of the stomach well with tincture of opium and cam- phorated spirits ; on repeating the clysters frequently with a proper quantity of opium in each ; and on adopting the other steps advised under the head of Cholera Morbus. A blister applied over the stomach may sometimes be useful. In dysentery, when the abdomen is hard, tense, and painful to the touch, and the gripings are frequent and severe, the application of flannels, wrung out in a warm decoction of chamomile-flowers and poppy-heads, with a small addition of camphorated spirits, to the part, may afford considerable relief: but should fomentations not procure fhe desired effect, a blister ought to be put on. Most cases of dysentery, and particularly during the acute stages of the disease, may be relieved by immersing fhe patient in a warm bath of a moderate temperature, and keeping him in it for some time. Per- haps rubbing the abdomen with some wTarm and stimulating embroca- tionf on his being taken out of the bath, might increase its effect. To defend fhe inner coat of the intestines from the acriwiony of its contents, and to counteract the vain attempts at evacuation, it will be necessary to give something to be discharged. Here then we should not only administer mucilaginous substances, such as solutions of gum acacia in milk, preparations of barley, rice, arrow- * See Observations on the Nature and Cure of the Diseases of the East and West Indies, by Thomas Clarke, Surgeon. t 7. ft Liniment. Saponis,f. ?iss. Tinct. Opii, f. Zss. Olei Rosmarin. f. 3»- M. ft. Embrocatio. t 7. Take Soap Liniment, one ounce and a half Tincture of Opium, half an ounce. Oil of Rosemary, one drachm. Mix them for an embrocation. 326 PYREXIA, OR FEBRILE BISEASF.S. Class I. root, he.* by the mou'h; but we should likewise injfct a clyster of a similar naturef three or four times in the course of the day. All vain attempts to go to stool, as also all violent strainings in evacuating the contents of the bowels, ought carefully to be avoided by trie patient throughout the disease, for if obedience be paid to every seeming call of nature, the straining which ensues will be highly detrimental, as little or nothing, except mucus and blood, comes away in four out of five efforts. If the fundament becomes inflamed or excoriated, the parts should be anointed with a little soft pomatum or prepared lard, after each evacuation. In the cure of Indian dysentery, mercury is the remedy now much relied on, but it is to be employed in an early stage of the disease. The plan recommended is, to give the hydrargyri sub- murias in a considerable dose night and morning without interrup- tion, accompanied bv a mercurial friction of the abdomen until the mouth becomes sore. If diarrhoe.i ensues, this symptom is n»t to be interfered with, but rather encouraged by an occasional purga- tive of the sulphate of soda or rhubarb. I am much inclined to doubt, however, whether mercury so employed as to produce sali- vation will be found useful, or even innocent, in the cure of real dysentery. Indeed 1 should think it could not fail in many in- stances to prove hurtful, and particularly in the doses which are mentioned. When given, it probably might be found best to com- bine it with ipecacuanha, as, for instance, half a grain of calomel with one of ipecacuanha every two hours, until the gums are affected, or we may administer it combined with antimonial powder and opium. Where there exists a disease of the liver, or any diseased actioi of the biliary system in dysentery, mercury has certainly been found highly useful; and it is from its singular utility in this combination of disease, that the practice has become in warm climates so general of treating it, in all its stages, by this remedy; a treatment, "however, which must in many cases be improper. The connexion between dy-entery and the deranged functions of the skin and liver has been illustrated by Dr. Johnson, who is a great advocate • 8. ft Gum. Acacias, Zij. Solv. in Decoct Hordei, Oij. et adde Syrup. Cort Aurant f. ?ij. Bibat aeger pro potu ordinario. Vel. 9. ft Mistune Corn. Usti Oj. in die. , 10. RDf-coct. Aniyli,f. ?v. 01.0liv;p, f ?ss M. ft. Enema ; addr pro re nata, Tinct. Opii, f. 3ss—3'. * 8. Take Gum Acacia, two ounces. Dis- solve it in Barley Water, two pints, and add Syrupof Orange Peel, two ounces. The patient may take this for ordinary drink. Or, 9. Take Mixture of Burnt Hartshorn, one pint daily. 110.Take Decoction of Starch, five ounces. Olive Oil, half an ounce. Add occasionally Tincture of Opium, half a drachm to one drachm. Mix them for a clyster. Order V. dysentery. 327 for scruple doses of hydrargyri submurias, combined with small portions of opium. We are also told by a modern writer* thai! a proper combination of these two medicines has a surprising effect in restoring the natural balance of the vascular system, and in pro- moting the free secretion of bile. He says, that when it fails in acting forcibly on the skin in dysentery, small doses of the pulvis antimonialis and camphor may perhaps be added with advantage, the warm bath being occasionally used at the same time to equalize the circulation. There are some grounds for presuming that the disease which the authors here quotedf have called the dysentery of India, is in its nature, symptoms, and causes, and likewise in its method of treatment, very different from that which is described under this name in other coun- tries; that it differs in nothing from the bilious fluxes so commonly to be met with there, and arises from an affection of the liver; for they describe the stools as being copious and liquid, frequently bilious, and seldom or never as containing scybala—symptoms by no means cha- racteristic of true dysentery. In the secondary attacks of Indian dysentery, where the relaxed and weakened stale of (he bowels seemed to keep up the disease, the nitric acid, in the quantity of about two drachms in the day, in barley- water, has proved an useful adjunct in the cure. In similar states, an infusion of quassia, calumbo, or cascarilla, may be administered till the stomach and bowels have recovered their vigour and proper tone. At the commencement of the dysentery it would be improper to employ either opiates or astringents; but in the second stage, where the patient's strength is exhausted by frequent returns of the com- plaint, proceeding rather from a weak relaxed state of the bowels, than from any remains of malignancy, a use of these remedies will prove both proper and beneficial, taking care to obviate costivpnes*, and evacuate the contents of the intestines from time to time, b) adminis- tering a few grains of rhubarb, or some such gentle laxative. In this stage of the disease, should the patient's rest be much dis- turbed throughout the course of the night from the frequency of the motions, we may direct an opiatej to be taken at bed time. * See Practical Illustrations of Typhus and other Febrile Diseases, by J. Arm- strong, M. D. t See .MGregor's Medical Sketches; Clarke on the Diseases of Warm Climates; Milne's Account of the Diseasesthat prevailed during two Voyages lo the East Indies; and Essay ©n the Influence of Tropical Climates on European Constitutions, by J. Johnson, M. D. f 11. ft Aq. Cinnam. f 3vi. Spirit. Pimento;, f. ^ss. Syrup Zingib. f. 3i. Tinct. Opii, fll, xxv. M. ft. Haustus. Vel, 12. ft Opii,gr.j_ij. Pulv. Antim. gr. j. Confect. Aromat. q. s. M. ft. Pilula. X 11. Take Cinnamon Water, six drachms- Spirit of Pimento, half an ounce. Syrup ot Ginger, one drachm. Tincture of Opium, forty drops. Mix them as a draught. Or, 12. Take Opium, one grain to two grains. Antimonial Powder, one grain. Aromatic Confection, a sufficiency to form a pill. 328 PYREXIA, OR FEBRILE DISEASES. ClaSt /. The hyoscyamus (henbane), by its anodyne and gentle laxative qualities, seems a medicine well adapted to this disease, and may be tried when we cannot venture on opium. In chronic and habitual fluxes, which are complaints frequent with those who have suffered much sickness in tropical climates, it is seldom, indeed, that relief can be obtained without the aid of opium, and it is often found necessary to add it to all the other medicines we admi- nister. Opiates, especially those of the wanner kind, such as the con- fectio opii, he. are as valuable in these cases as the bark of cinchona is in intermittents. When the bowels have been effectually relieved, it often happens, after the disease has continued for some time, from the tender state of the rectum, that a severe and troublesome tenesmus remains. Under such circumstances, or in the advanced stage of the disease, soothing and anodyne clysters are much used by professional men ; but in some instances the irritation produced by introducing the pipe more than counterbalances the soothing effects of the injections. As a commo- dious substitute for anodyne clysters, we may therefore direct the pa- tient to insinuate into the anus a pill of about two grains of opium, previously somewhat softened betwixt the fingers. We may also cause warm fomentations to be applied to the parts, and a bladder filled with hot water to the hypogastric region. These will be likely to afford great relief to the patient. We are told that opium, combined with the nitric acid, agreeable to the prescription* here advised, has, on various trials, been found to have been attended with the best effects in the advanced stage of dys- entery, when all other remedies have proved ineffectual, and even in cases where death seemed almost inevitablef. The astringents best adapted for the cure of a dysentery, are the different preparations of catechu, gum kino, logwood, he. which may be given as belowj, the patient at the same time taking Port t See Observations on the Effects of Nitric Acid and Opium in the Cure of Dysentery, in vol. iii. p. 413 of the Medical and Physical Journal. * 13. ft Acid Nitrici, f. 3ij. Tinct Opii, fll xxx. Aq. Purae, f. ^iij. M. Capiat cochleare minimum ter quaterve die in qnovis vehiculo. X 14. ft Extraca. Lign. Campech. 3j- Mist. Creta, f. |iv. Tinct. Catechu, f. 3'j. Spirit. Myristicae, f. ^j. M. ft. Mistura, cujus sumat cochl. larg. ij quartis horis. Vel, 15. ft Confect. Aromat. 3j. Aq. Cinnam. f. |v. Spirit. Pinienla;, f. 2j, Tinct. Kino. f. 3'j- M. • 13. Take Nitric Acid, two drachms. Tincture of Opium, forty-five drops. Pure Water, threp ounces. Mix them, and take about a tea-s|ioonful three or four times a day. t H.Take Extract of Logwood.one drachm Chalk Mixture, four ounces. Tincture of Catechu, two drachms. Spirit of Nutmeg, one ounce. Of this Mixture take two table-spoonsful every four hours. Or, 15. Take Aromatic Confection, one drachm. Cinnamon Water, five ounces. Spirit of Pirnenta, one ounce. tincture of Kino, two drachms Order V. DYSENTERY. 329 wine properly diluted with water for his ordinary drink. Lime- water mixed with an equal proportion of milk has been much re- commended as a useful remedy in the latter stage of the disease. During my residence in the West Indies I was in the habit of re- commending a strong decoction of logwood with the barks of pomegrenale-fruit and the cushew cherry tree, or anacardium, as an astringent drink, from which my patients seldom failed to expe- rience a good effect. In the advanced and chronic stage of the disease, as acidity at the stomach is apt to prevail, absorbents, such as the mistura creta&, pulvis cretae compositus, liquor calcis, &c. combined M*ith opiates, will be useful.—See Dyspepsia for formulae of these medicine's. Where there exists an extreme degree of atony, and a frequent discharge of faxes without pain, small doses of zinci sulphas com- bined with opium have proved of singular utility in many instances. The impaired tone of the intestines is likewise to be restored by a use of tonics and bitters*, together with a light nutritive diet and ft. Mistura. Adde pro re nata singul- dosi Tinct. Opii, fll x. Vel, 16. ft Confect. Opii, gr. X. Aq. Cinnam. f. 3>jss. Tinct. Catechu, f. 3jss. M. ft. Haustus quartis horis sumendus. Vel, 17. ft Elect. Catechu, gr. xv. Aq. Pimentae, f. ?jss. Tinct. Kino, f 3j. ----Opii, f)\ x. M. ft. Haustus. * 18. ft Cort. Simaroubae, contus. ----Cascaril. aa ^ss. coque ex Aq. Bullient Oj. ad |viij. colat adde Spirit Cinnam. f. ?ij. Tinct. Opii, fll xxx. M. Cap iat cochl. larg iij quarta quaque hora, Vel, 19. ft Infus. Cort. Cuspariae, f. |vj. Tinct Calumbae, f. "j. ----Catechu, f. 3ij" Acid. Nitric, f. 3i. M. ft. Mistura, cujus sit dosis cochlearia magna iij. ter in die. Vel, 20. ft Decoct. Cort. Cinchonae, f. |jss. 42 This mixture may be taken as the former, adding occa- sionally to each dose Tincture of Opium, fifteen drops. Or, 16. Take Opium Confection, ten grains. Cinnamon Water, one ounce and a half. Tincture of Catechu, one drachm and a half. Mix them, and take this draught every four hours. Or, 17. Take Electuary of Catechu, fifteen grains. Pimenta Water, one ounce and a half. , Tincture of Kino, one drachm. —■----— Opium, fifteen drops. Mix them for a draught. 18. Take Simarouba Bark, bruised, Cascarilla Bark, of each half an ounce. Boil them in a pint of water until reduced to eight ounces, strain off the liquor, and add Spirit of Cinnamon, two ounces. Tincture of Opium, forty-five drops. Mix them, and let the dose be threp table.- spoonsful every four hours. Or, 19. Take Infusion of Augustura Bark, six ounces. Tincture of Calumba, one ounce, ------- Catechu, two drachms. Nitric Acid, one drachm. Of this mixture the dose may be three table* spoonsful thrice a day. Or, 20. Take Decoction of Peruvian Bark, one 9unce and a half. 338 PYREXIAE, OR FEBRILE DISEASES. ClaSS I moderate exercise. The application of cold water to the abdomen, and particularly to the lower parts of it by means of cloths or sponges ; or the immersion of the lower part of the trunk in a tub of water, may probably prove a good auxiliary mean. The fever accompanying this disease sometimes appears under an intermittent or remittent form, and is protracted much longer than it otherwise would have been in consequence of its being so complicated. In such cases its treatment is to be regulated at directed under these heads, by a use ef the bark of cinchona, &c. In those instances where a dusky sallow hue of the countenance, tenderness upon pressure over the region of the liver, and a clayey appearance in the faeces which happen occasionally to be voided, manifest the presence of a diseased or obstructed state of the liver ; we should resort to mercury, pushing it to such an extent as to keep up a gentle affection of the mouth until the symptoms are mitigated. We may give the nitric acid at the same time. In the first stage of dysentery, a use of ripe fruits will be proper; but in a more advanced period, where any morbid acidity seems to prevail in the stomach, they should not be recommended. Every sort of food which readily tends to putrefaction ought carefully to be avoided throughout the whole course of the disorder, as also all kinds of fermented and spirituous liquors, supporting the patient's strength with preparations of barley, rice, sago, flour, panado, Indian arrow-root boiled in milk, occasionally varied for gelatinous broths. During the stale of convalescence, Port wine or Madeira, or even a moderate quantity of brandy, properly diluted with water, may be allowed. Persons recovering from a dysentery should observe the greatest caution and regularity in their mode of living, and they should go warmly clothed, as the disease is very liable to relapse from any fresh exposure to cold, wet, damp night-air, or sudden atmospherical yicissitudes. The importance of warm clothing, both in the prevention and Tinct. Calumb. Tincture of Calumbo, ----Cort. Aurant. aa f. 3jss. -------- Orange Peel, of each ----Kino, fll xxv. M. ft. Haustus ter quaterve die sumendus. Vel, 91. ft Extract.Gentian. ------Lign. Camp, aa 3j. ' Ferri Sulphatis, Gum. Myrrh, aa 3s». Syrup. Zingib. q. s. M. Fiant pilula; xl. quarum iij. sumat terin die one drachm and a half. Kino, forty drops. Mix them for a draught, to be taken three or four times a day. Or, 21. Take Extract of Gentian, --------Logwood, of each one drachm. Sulphate of Iron, Gum Myrrh, of each half a drachm. Syrup of Ginger, a sufficiency t« 'form the mass, which is to be divided inta cum Decoct. Simaroub. aut infusi Caeca- forty pills, and of these three are to be rills, f. ?ij. itaken morning, noon, and night, washin{ them down with about two ounces of • decoction of Simarouba Bark, or an infu- sion of Cascarilla. Order V, BTSENTERY. 351 *ure of bowel complaints, is too obvious to require my saying much on the subject; I will therefore only observe, that warmth ought not to be a secondary object ■; on the contrary, it ought to be the first; for if a patient only wears his ordinary clothing, he will re- ceive comparatively little benefit from any medicine. A waistcoat of flannel or fleecy hosiery next to the skin ought always to be worn, as likewise sliders of the same; and these should be laid aside with caution, and by slow degrees. The writer* of a small tract on dysentery lays much stress on swathing the abdomen with flannel bandages, as being> the best mode of confining a certain degree of heat over that part of the body which is the seat of the disease ; and this practice is reported by Sii James M'Gregorf to have been found very serviceable in many cases, both as affording an equal support, and keeping up a due degree of warmth on the surface of the abdomen. Dysentery being by most considered of a very contagious nature, every precaution should be taken, particularly in situations where many people are crowded together (as in camps, and on board of ships), to prevent the disease from spreading. The sick ought imme- diately to be separated from those in health, or who labour under any other disorder; they should be lodged, if possible, in distinct rooms or tents, and the strictest attention should be paid to cleanli- ness, taking care to remove the stools as soon as voided, and to have them quickly buried: to ventilate the chamber sufficiently, and sprinkle i: now and then with a little warm vinegar; and to change the linen both of the body and beds frequently. In addition to these means, the fumigations advised under the head of Typhus Gravior may be resorted to. For the destruction of contagion of every species, where a num- ber of persons are collected together, Dr. Rolloj, in addition to free ventilation and cleanliness, recommends the following as being an easy, safe, and very effectual method, and which is pursued at the Royal Artillery Hospital. Take of pulverized manganese, two parts; common salt, four parts; sulphuric acid, three parts; water, one part. A suitable proportion of this mixture is to be put into an earthen vessel, and suffered to remain until no vapours arise from it, or its peculiar smell is not perceptible. He mentions, that when a patient is admitted with an infectious disease, one or two gallipots are placed in the wards with about three ounces of the manganese and salt, to which is added half an ounce of water, and then is gradually poured on the whole a part of the ounce of sulphuric acid, the remainder occasionally. These quantities are according to the proportions previously stated, and they answer the consumption of a day. A pot or two * See H. Dewar's Observations on Diarrhoea and Dysentery,as those Diseases appear- ed in the British Army during the Campaign in Egypt in 1801. I See Medico-Chirurgical Observations, vol vi p. 433. J See his Aecount of the Royal Artillery Hospital at Woolwich. 332 NEUROSES, OR NERVOUS DISEASES. ClaSS II. is placed, we are informed by the Doctor, on the outside of the doors of the same wards in the gallery. The vapour is diffused over the whole ward, penetrates every where, and destroys every other smell than what itself conveys. Even the contagion of the small-pox has been noticed to be destroyed by this vapour, and of course it is likely to prove destructive of other contagions. In the manner here descri- bed, it can be used with due effect, and without the least prejudice to the sick. Its application, besides annihilating contagion, may also prevent its formation : and its use is recommended by Dr. Rdtlo in all situations where a number of persons in health are coufined together, as on board of transports, especially in bad weather. Two or three gallipots, with the quantities before mentioned, he says, would be sufficient, and it would not be necessary to use them oftener than twice or thrice a week. It has been recommended to make trial of the remedy in marshy situations, where there may be an unavoidable exposure: in these pla- ces the gallipots with the materials should be placed in the inside of the windows and doors of the habitations next to the marshes. CLASS II. NEUROSES, or NERVOUS DISEASES. The character assigned to this class of diseases is, preternatural affection of sense and motion, without idiopathic or primary pyrexia, and without local disease. ORDER I. COMATA. Diminution of voluntary motion, with sleep, or a suspension of sense, is the character of this order of diseases. APOPLEXIA, or APOPLEXY. This disease consists in a sudden diminution or abolition of all the senses, external and internal, and of all voluntary motion, while at the same time the heart and lungs continue to perform their action. The state of the pulse, difficult respiration, stertorous breathing, profound sleep, and the affection of all the powers of volition, will distinguish apoplexy from palsy: the slertor, sopor, diminution of the power of volition, and the absence of convulsions, will distinguish it from epilepsy. In general it may readily be distinguished from intoxication by the patient not being roused by shouting in his ear, by applying volatile spirits to his nostiils, nor by shaking or pinching him. His respiration is low, labouring, and Order I. apoplexy. 353 irregular, his countenance flushed, the pupils of his eyes often con- tracted, and his breath not tainted with the smell of wine or spirituous liquors. The extreme of insensibility from intoxication is sometimes, however, with difficulty to be distinguished from apoplexy, but its duration seldom exceeds ten or twelve hours at the utmost. Apoplexy makes its attack chiefly at an advanced period of life, and most usually on those who are of a corpulent habit, with a short neck and large head, and who lead an inactive life, make use of a full diet, or drink to excess. Young subjects are not, however, exempted from apoplexy, but it is very rare when compared with persons ad- vanced in the vale of years. The immediate cause of apoplexy is most generally a compres- sion on the brain, produced either by an accumulation of blood in the vessels of the head, and distending them to such a degree as to compress the medullary portion of the brain; or by an effusion of blood from the red vessels, or of serum from the exhalants, which fluids are accumulated in such a quantity as to occasion compres- sion; but it takes place sometimes without congestion, extravasa- tion, exudation, or effusion in the head being the consequence, as in-many instances we see patients recovering quickly from a fit of apoplexy without any paralytic affection being left behind, which could not happen if either of these had existed. Such cases have by some physicians been supposed to originate in a peculiar con- dition of the brain and nerves alone, unattended by any discoverable alteration in their anatomical structure. Possibly a particular con- dition of the stomach and local irritations will produce this state. When the disease arises from an accumulation of blood in the vessels of the head, or by an effusion of blood from the red vessels, it is called sanguineous apoplexy, and when occasioned by serum from the exhalants, it is known by the name of serous apoplexy. The states of over distension and effusion may be brought on by whatever increases the afflux and impetus of the blood in the arte- ries of the head; such as violent fits of passion, mental anxiety, in- dolence, great exertions of muscular strength, severe exercise, excess in venery, gluttony, drunkenness, intense study, stooping down for any length of time, wearing any thing too tight about the neck, long exposure to intense cold or a vertical sun, the sudden suppression of any long-accustomed evacuation, the application of the fumes of cer- tain narcotic and metallic substances, such as opium, alcohol, charcoal. mephitic airs, mercury, &c.; and by blows, wounds, and other exter- nal injuries. In short, apoplexy may be occasioned by whatever fills, distends, obstructs, ruptures, lacerates, corrodes, or compresses the vessels of the brain and its meninges too much, and thereby urges, retards, or entirely impedes the flow of blood through the same; or in any manner destroys the intimate fabric and structure of the brain. A loss of vitality in the brain has been assigned as a cause of o34 neuroses, or nervous diseases. Class II. apoplexy in those cases where neither extravasation, exudation, nor effusion, are to be discovered on dissection. The circumstances disposing to sanguineous apoplexy are a full and luxurious mode of living, with but little e*xercise, a sanguine temperament, a full habit, middle age, short neck, suppressed eva- cuations, and warm weather. Those which dispose to serous apo- plexy are a phlegmatic temperament, cachetic habit of body, poor living, depressing passions of the mind, much study, watching, and old age. Sanguineous apoplexy is sometimes preceded by giddiness, dim- ness of sight, drowsiness, loss of memory, or faltering of the tongue in speaking; but it more usually happens, that without much pre- vious indisposition, the person falls down suddenly, the face is red, and appears puffed up, the veins of the head, particularly of the eyes, temples and neck, seem turgid, the head feels hot, the eyelids are half open and rigid, the eyes are prominent and fixed, the breathing is difficult and stertorous, and for the most part the pulse is strong, regular, and generally less frequent than what is natural. In a few instances, a grinding of the teeth, with slight convulsive motions, are observable. When the disease continues for any length of time, the pulse becomes languid, weak, and slow, and the breathing is shor- tened, until at length it ceases altogether. In serous apoplexy the attack is more gradual in general, the face is pale and tumid, the veins are depressed, the pulse is small, weak, irregular, and intermittent, respiration is impeded and stertorous, and the extremities are cold and flaccid. Sometimes these appearances are preceded by vertigo, torpor, and an impediment in the speech, together with a failure of memory. Although the whole body is affected with the loss of sense and motion in apoplexy, it takes place nevertheless very often more upon one side than the other, which is called a hemiplegia, and in this case the side least affected with palsy is somewhat convulsed. In some few instances of apoplexy the patient lies for several days insensible and motionless, and yet gradually recovers the use of his understanding, and his muscular strength ; but for the most part he is permanently deprived of the command of one side of his body, or he regains it imperfectly after a time; his mind sustains a shock which is never recovered from; his sensations and perceptions becoming less accurate, and his memory and powers of combining being much weakened, or at least his faculty of expression : for even while his memory and imagination are unimpaired, he is not always ahle to find appropriate words to express the notion which is excited in his mind. In forming our opinion as to the event, we must be guided by the violence of the symptoms, and according as the vital functions are more or less disordered. If the fit is of long duration, the respiration laborious and stertorous, the deglutition continues to be Order I APOPLEXY. 33o impeded, the pulse quick and hard, the extremities cold, and the per- son advanced in years, the disease in all probability vyill terminate fa- tally. In some cases it goes off entirely, either by diarrhoea, hemor- rhage, return of the hemorrhoidal or any other habitual discharge, and sometimes by the appearance of fever; but more frequently it leaves a state of menial imbecilily behind it, or terminates in a hemiplegia, or in death. Even when a person recovers from an attack of this dis- order, it is very apt to return after a short period of time, and in the end to prove fatal. Wiiere there is extravasation, the patient's recovery will be slow and difficult; for the power of absorption cannot be equal to its being immediately taken up. When the person's recovery is immediate, it is a presumptive evidence that there has been neither extravasation, effusion, nor exudation, but that the compression arose from a reple- tion in the vessels of the brain. The sanguineous apoplexy is more dangerous than the serous. Dissections of those whe have died of sanguineous apoplexy offer ample proof of the arterial as well as the venous system being in a remarkable state of repletion. When the scalp is divided, there is sometimes a considerable flow of blood from the occipital and frontal veins; indeed, during the dissection the venous blood flows from all parts of the head. The dura mater is sometimes thickened and bound to the cranium by strong adhesions: some- times the tunica arachnoides loses its transparency, is opaque and much thickened. The pia mater is often remarkably vascular; the reins are turgid with dark blood, and in particular parts of this membrane there appears high arterial action: the whole surface sometimes acquires a bright vermilion tint. Between the pia mater and tunica arachnoides there often is to be observed a serous effusion, which in some bodies is colourless; in others, turbid, bloody, or even mixed with streaks of coagulable lymph. With respect to the substance of the brain, it is frequently found unu-ually firm, and when cut into, the numerous points of blood show that the divided ressels are enlarged. A considerable quantity of serous fluid is often found in the ventricles, and these are much enlarged. For the most part, extravasated blood is met with in the cranium, sometimes between the membranes, and sometimes in the substance of the brain, and sometimes in the ventric les. Dissections have confirmed the observation, that the blood is generally found extrava- sated in the hemisphere opposite to the side of the body which was paralyzed. In most instances the extravasation of blood is confined to the cerebrum, but it has not unfrequentl) been observed in the cerebellum*: we do not always discover extravasation of blood, but we never fail to find the remains of greatly increased action, and reat congestion in the arterial and venous systems of the brain. ometimes the longitudinal and lateral sinuses are swelled and distend, d. * See Cases of Apoplexy, by J. Cheyne, M. D 336 NEUROSES, OR NERVOUS DISEASES. ClaSS II. In those who die of serous apoplexy, dissections show the cerebral arterial system nearly empty, their veins contain more blood, but less than in the sanguineous apoplexy; the brain is somewhat flaccid and soft, with perhaps a little watery effusion on its surface, between the convolutions or in the ventricles; the left cavities of the heart, as well as the arteries, are empty ; the right cavities contain some coagula of black blood ; the pulmonary organs are full; frequently the digestive passages are impeded, and in a state of remarkable plenitude. In some dissections of serous apoplexy, venous turgescence, as well as effusion of serum, has been discovered ; and in others, there were sa- tisfactory proofs of increased arterial action having existed shortly be- fore death. In the cure of sanguineous apoplexy no time should be lost in em- ploying powerful remedies. On the person's being seized, due care must be taken to remove all compression from about the neck, to sup- port him in as erect, a position as possible, and fo allow a free admis- sion of cool air. These steps being adopted, sixteen or eighteen ounces of blood should immediately be taken away, and if it can be drawn from the jugular vein instead of the arm, it will be the more likely to be attended with a good effect. When any branch of the temporal artery seems so turgid as to admit of being easily opened, drawing blood from thence may probably prove a still more effectual way of unloading the vessels of the brain. In those cases where one side of the body is perceived to be more affected with loss of motion than the other, the bleeding should be made, if possible, on the opposite side to that affected, as dissections show that the congestions producing apoplexy are generally on the side which is not affected. If the first bleeding has not been of service, and the disease is une- quivocally established, the operation should be repeated a second time; and if it is ascertained that this also is ineffectual in stopping the progress of the disease, a third bleeding ought to follow, as blood- letting is to be regarded as the most effectual remedy we can employ in sanguineous apoplexy. The quantity of blood to be drawn off must be regulated by the appearance and habits of the patient; by the circumstances of the attack; its violence and duration; the effects of the previous evacuations; the appearance of the blood, which is often sizy; and the state of the circulation; particu- larly the relief of the pulse and breathing, and the reduction of the complexion. After general bleeding, leeches may be applied if necessary to the temples, or the scarificator and cupping-glass to the occiput; and when sufficient evacuations have been procured by these means, we may then apply a large blister to the nape of the neck, and small ones to the extremities, together with cataplasms to the soles of the feet, or warm fomentations. Should apoplexy appear in a gouty constitution, or after symp- toms of the gout, the lancet, I think, may be used with safety and advantage. Order 1. APOPLEXY. 337 If the power of swallowing remains, some active purgative* should be given by the mouth in divided portions, and at proper intervals, so as not to excite any vomiting ; but if not, the con- tents of the intestines are to be dislodged by a strong clysterf, or one composed of a solution of soap, which is fo be repeated every three or four hours, until a sufficient effect is procured. Emetics are made use of by some practitioners. Where the disease has been brought on by intoxication, or by a large* indi- gested meal distending the stomach, pressing upon the aorta descendens, obstructing the free expansion of the lungs, and thus crowding the arteries of the head with more blood than ought to be there, the exhibition of a gentle emetic may be ad- missible and proper, provided it has been preceded by copious venesection ; or should vomiting arise naturally, the stomach may- be relieved by washing it out with a little chainomile-tea; but where the disease arises spontaneously, and is occasioned by an extravasation either ot" blood or serum on the brain, more par- ticularly Ihe former, it cannot be denied, I think, that an emetic would be a very hazardous remedy. A supposed case of apoplexy which fell under the care of Dr. Langslow, of Halesworth, and Mr. Crowfoot, of Beccies, gave rise to much controversy with 1. U Infus. Sennse, f. |iv. Potassae Tartr.itis, 3vj. Tinct. Jalapaj, f 3'j- Syrup. Rhamni, f. 3iij. ©apiat dimidium pro dos. Vel, 2. g. Gum. Gambog gr. iij. Terito bene cum Tinct. Sennas C f. |j. et adde ----Jalapae, f. 3j. M. ft. Haustus. Vel, 3. & Hydrargyr. Submuriat. gr. vj. Extract. Colocynth. C. gr. xv. M. Fiant Pilulae iv pro dos. f 4. ft Fol. Sennae, 3iij. Aq. Fontan. Oj. Coque leniter ad Oss. Colat. adde Soda; Sulphat. ?j. 01. Ricini, f.?jr M. ft. Enema. Vel, 5. R Extract. Colocynth. C. 3ss—3i. Infus. Sennae, f. ?xi. 01. Ricini, f. Ij. M. ft Enema statim injicicndum. 43 * 1. Take Infusion of Senna, four ounces. Tartrate of Potass, six drachms. Tincture of Jalap, two drachm';. Syrup of Buckthorn, three drachms. Mix them, and let the half be taken for a dose, to be repeated after an hour or two, if necessary. Or, 2. Dissolve Gamboge, three grains in Compound Tincture of Senna one ounce, and add Tincture of Jalap, one drachm. Mix them for a draught. Or, 3. Take Submuriate of Mercury, six grains. Compound Extract of Colocynth, fifteen grains Make them into four pills, to be taken for a dose. t 4. Take Senna Leaves, three drachms. Pure Water, one pint. Boil them slowly until reduced to half a pint, strain off the liquor, and add Sulphate of Soda, one ounce. Castor Oil, one ounce. Mix them for a clyster. Or, 5. Take Compound Extract of Colocynth, half a drachm to a drachm. Infusion of Senna, eleven ounces. Castor Oil, one ounce. Mix them, and inject this clyster imme- diately. J3S NEUROSES, OR NERVOUS DISEASES. ClttSS II. respect to the propriety of administering emetics in this disease. Those who wish to peruse the arguments which have been brought forward on the occasion by these gentlemen, as well as by many other practitioners, will find the subject amply discussed in the sixth and seventh volumes of the Medical and PhysicialJournal. When the fit eoes off, we may advise some of the cephalic and nervous medicines recommended under the head of Palsy ; and in order to obviate any costiveness that may happen to arise, a little tincture of rhubarb may be taken occasionally. In serous apoplexy, blood-letting may be more sparingly used than in the sanguineous. To promote an absorption of the effused serum, after bleeding proportionate to existing circumstances, it will be proper to have recourse fo warm purgatives, sternutatories*, and a free application of blisters to the head, back, and extremities, and of sinapisms to the soles of the feet. Electricity is sometimes resorted to, and slight sparks passed through the head, but it ia only under a failure of the other remedies that this should be employed. Emetics in (his species of apoplexy, as well as the former, seem of doubtful effect. Stimulants of various kinds, such as volatile salts, cephalic elixirs and cordials, have been much employed in serous apoplexy; but as they determine the circulation to the head, their use appears ■not altogether advisable. Wiien they are employed, sufficient evacuations should always precede their use. Out of a fit of serous apoplexy, the cephalic and nervous medi- cines, advised under the head of Palsy, will be proper, taking some stomachic purgative now and then. When apoplectic symptoms proceed from opium, or any other narcotic poison taken into Ihe stomach, the offending matter ought to be got rid of as soon as possible, by exciting vomiting, with tartarized antimony or sulphate of zinc, should none have arisen spontaneously. Having procured its discharge, we are to have recourse to bleeding, and the exhibition of acrid clysters, with the view of relieving the congestion in the brain and lungs, together with the other means recommended under the head of Vegetable Poisons. Although stimulants are improper in apoplexy arising from other causes, still they may be employed with great safety and utility in those cases where it proceeds from any narcotic poison taken into the stomach, or otherwise applied to the body ; but here too, pro- per evacuations should be premised. The external stimulants ia general use, are volatile spirits applied to the nose and temples, rubefacient ointments to the breast and back, blisters, sinapisms with horseradish, and warm fomentations to the extremities, to- gether with frictions with flannels or a flesh-brush, impregnated with flour of mustard, and throwing cold water over several parts of the body, which in general proves one of the most effectual * 6. Pulv. Asari Compos. f * 6. Compound Powder of Asarabacca Order t APOPLEXY. 33fc means of rousing apoplectics of this kind, particularly if the person is first carried out into the open air. The internal stimulants to be employed, are the volatile alkaline salts or spirits, white mustard- seed, horseradish, white scurvy-grass, and various aromatics, such as rosemary, lavender, &c. used either in substance, tincture, or in their essential oils. If the disease arises in consequence of the suppression of piles, leeches should be applied to the hemorrhoidal veins, fomentations must be employed, and the intestines be stimulated by means of aloe tic purges. Those who from a plethoric state of the blood-vessels of the head are predisposed to an attack of apoplexy, will act prudently in con- fining themselves to a very spare diet, carefully abstaining from strong liquors, from all high-seasoned food, and from meat suppers. A limitation of the use of fluids in habils predisposed to plethora and apoplexy will likewise be worthy of attention. Dr. Mossman tells us* he is taught by long observation and experience fo expect effects highly beneficial from the adoption of this plan ; for he con- stantly noticed the phenomena of plethora and obesity are referri- ble, not to Ihe taking in of solid but of liquid nutriment. Persons predisposed to apoplexy should likewise be careful to keep their body open by some gentle laxative, taken occasionally, and such moderate exercise ought to be used, as will support the perspira- tion without hurrying respiration, or exciting heat. Nothing tight should be worn round the neck ; and when in bed, the head ought fo be supported of a proper height. The feet should be kept warm and dry, and the extremes of heat and cold must be avoided. Nothing has a better effect in preventing apoplexy in those who are predisposed to its attacks, than a perpetual issue between the shoulders, or a seton in the neck ; but great care must be taken not to allow them to dry up without opening some other drain in their stead. When an alfack of apoplexy is immediately threatened, blood- letting is the remedy most to be relied on, and the blood should be drawn either from the jugular vein or temporal artery, as before advised. The extent of the bleeding can only be determined by the nature of the case. Under doubtful circumstances, where fhe symptoms are not very urgent, the application of several leeches to the temples, or scarifications with cupping at the back of the head or neck, may prove amply sufficient. Where a lethargic disposition prevails, we should advise bleed- ing, but particularly topical, from the temples by means of leeches, or from the nape of the neck by the scarificator and cupping. We should also administer cathartics frequently, and direct a blis- ter to be applied to the head or in the immediate neighbourhood of it. Every thing which may tend to stimulate the brain, such as ardent spirits, strong wines and tobacco, ought to be avoided. * See Med. and Phys. Journal, vol. «. p. 412r 34« NEUROSES, OR NERVOUS DISEASES. Class II. Where lethargy has been induced by great excitement of the mind, a change of scene, travelling by easy stages, cheerful company, the amusements of watering places, and a course of those mineral waters which relax the bowels (such as those of Cheltenham) are worthy of a trial. The coup de soleil, or stroke of the sun, which so frequently occurs in warm climates to those who are long exposed under its immediate influence, seems evidently to be an attack of apoplexy, and is to be treated in the same manner as pointed out in the pre- ceding pages. The application of linen cloths wetted in cold vine- gar and water to the temples, may likewise be tried. It may not be improper to remark here, that as the vital principle frequently remains in a latent state for some time, and as we are yet unacquainted with any certain criterion between positive and apparent death, besides that of putrefaction, some appearances of incipient decomposition should therefore be allowed to take place, in every case of sudden decease before interment. In warm countries, where it is customary to bury the body within four- and-twenty hours, I have great reason to fear that premature interment sometimes happens. PARALYSIS, or PALSY. Palsy is a diminution or total loss of the powers of motion and sensibility in certain parts of the body, often attended with drowsi- ness. In some instances the disease is confined to a particular part, or set of muscles, but it more usually happens that one entire side of the body, from the head downwards, is affected, which is known by the name of hemiplegia. * If the power of motion and sense of feeling in the half of the body taken transversely be impaired, the complaint is denominated paraplegia. Palsy may arise in consequence of an attack of apoplexy, and like it may be occasioned by any thins; that prevents the flow of Ihe nervous power from the brain into the organs of motion ; hence tumors, over-distention and effusion, dis.'ortions of the spine, and a thickening of fhe ligaments that connect the vertebrae together, often give rise to it. It may also be occasioned by translations of morbid matter to the head, by fhe suppression of usual evacuations, and by pressure made on the nerves by luxations, fractures, wounds, or other external injuries. The long continued application of se- datives will likewise produce palsy ; as we find those whose occupa- tions subject them to the constant handling of white-lead, and those who are much exposed to the poisonous fumes of mffaw or minerals, are very apt to be attacked with it. Whatever tends to relax and enervate the system, may likewise prove an occasional cause of this disease : hence those who lead a sedentary or luxurious life ; those who are guilty of frequent irregularities, of great debaucheries ; those who are engaged iu intense studies during the 9rder I. PALSY". 341 night, or labour under great distress of mind or anxiety, are very subject to this malady. It has very properly been doubted by some writers* whether palsy of the lower extremities alone, or of one single part, has so often its cause in the brain as it is said. The cause may, it is thought, also reside either in the nervous cord of the spine, or in the abdominal viscera, or in the affected limbs themselves. The spinal cord i$ certainly composed of a nervous mass, and has the same membranes as the brain; hence it may be affected by the same dis- eases, such as inflammation, suppuration, induration, tumor, con- gestion, or ossification of the blood vessels, collection of any fluid, by irritation, weakness, or exhaustion of the nervous mass. The spinal cord may also be injured, or compressed by the deviation of any of the vertebra?. It is to inflammation of a more chronic form in that part, that we impute those shaking pabies which are attended with pain. All the varieties of palsy more generally appear in the aged and infirm than in the young and robust. The left side is more frequently affected than the right. A decline of energy is often to be regarded as a commencement of palsy. In the premature diminution of the capacity of either bodily or mental exertions, there may be in many cases a well-tound- ed fear of ultimate paralysis, unless the tendency to it be in due time counteracted by the relinquishment of pernicious habits, or the administration of appropriate remedies. Palsy usually comes on with a sudden and immediate loss of the motion and sensibility of the parts; but in a few instances it is pre- ceded by a numbness, coldness, and paleness, and sometimes by slight convulsive twitches. When the head is much affeeted, the eye and mouth are drawn on one side, the memory and judgment are much impaired, and the speech is indistinct and incoherent. If the disease affects the extremities, and has been of long duration, it not only produces a loss of motion and sensibility, but likewise a considerable flaccidity and wasting away in the muscles of the parts affected. It has been mentioned that a curvature of the spine, owing to one or more of the vertebrae being displaced, sometimes induces paralytic affections of the lower extremities, from the pressure that they make upon the nerves of those parts, and that sometimes the disease appears to arise solely from a thickening of the ligaments that connect the vertebras together, without any particular affection of the bones. When one of the vertebrae only is diseased, it is ob- served that the patient is more completely deprived of the power of his limbs than when two or more of them are displaced, owing, as Mr. Bellf thinks, to the angle being more acute, and consequently the pressure on the medulla spinalis greater, when one bone only is * See Observations on Deranged Manifestations of the mind, by Dr. Spurzheim, p. 28 I See his System of Surgery, vol. vii. p.213. 312 NEUROSES, OR INERVOUS DISEASES. CldSS H. thrown out of the range. This also accounts for the paralytic symptoms in some being less remarkable in the more advanced stages of the disease than they were at first; for although one bone only is displaced a1 first, yet one or both of the contiguous vertebrae almost constantly yield at last; and the difference arising from this is so great, that patients almost always linger and die in the course of a year or two, often in a less time, when one bone only is deranged; while they live for a great length of time, frequently as long as if no such circumstance had occurred, when the curvature of the spine becomes more extended. Paralytic affections from distortions occur in all ages; but more frequently about puberty than at any other period, and more commonly in girls than in boys. In general the effects that result from them are observed before the cause is suspected, for there is seldom much pain in the part immediately affected. When distor- tion of the spine occurs during infancy, the patient appears to be suddenly deprived of the use of his limbs; but at more advanced periods, he complains first of feebleness and languor, and of numb- ness or want of feeling in the lower extremities. By degrees this want of sensibility is found to increase, and he is often observed to stumble, and to drag his legs, instead of lifting them properly; nor can he stand erect for any length of time without much difficulty. At last he loses the use of his legs entirely, which become altogether paralytic; and when the spine is distorted much forward, so as to compress the thoracic and abdominal viscera, he becomes distressed with dyspnoea, or with complaints in the stomach and bowels, accor- ding to the part of spine that is diseased. Palsy is to be distinguished from apoplexy by the pulse, which ia the former disease is soft and slow, by the loss of sense and motion being only partial, by the absence of stertor, and likewise by the other symptoms. When palsy attacks any vital part, such as the brain, heart, or lungs, it soon terminates fatally. When it arises as a consequence of apoplexy, it generally proves very difficult to cure. Paralytic affections of the lower extremities ensuing from any injury done to the spinal marrow, by blows and other accidents, usually prove in- curable. Palsy, although a dangerous disease in every instance, particularly at an advanced period of life, is sometimes removed by the occurrence of a diarrhoea or fever. A feeling of warmth, and a slight pricking pain as if stung by ants in the parts affected, with returning sensation and motion, are favourable symptoms. The morbid appearances to be observed on dissection in palsy are pretty similar to those which are to be met with in apoplexy: hence collections of blood, and of serous fluids, are often found effused on the brain, but more frequently the latter, and in some instances the substance in this organ seems to have suffered an al- teration. In palsy, as well as in apoplexy, the collection of extrava- sated fluid is generally on the opposite side of the brain to that which is affected. Order I. PALSY. v343 When this disease arises in a young person of a full, plethoric habit, comes on suddenly, and the head appears to be much affected, or seems to arise from the causes producing apoplexy, it will be ad- visable to take away some blood, by opening the jugular vein or tem- poral artery ; after which it will be proper to give an active purgative, as advised under the head of Apoplexy; but in old age, or where palsy arises in a debilitated constitution, neither bleeding uor purging. should be resorted to. Where costiveness prevails, in such habits- it may be obviated by some stomachic laxative, such as the tinctura rhei composita. In most cases, but particularly where the disease has arisen in aged or decrepit persons, the external application of stimulants will be highly proper; wherefore the parts affected, as well as all along the spine, may be rubbed several times a day with flannels, or a flesh- brush impregnated with flour or essence of mustard, or else with the palms of the hand, and some kind of rubefacient liniment* : and in addition to these remedies we may recommend the application of warm fomentations, blisters, and sinapismsf to the palms of the hands and soles of the feet. As a gentle stimulus to parts affected by paralysis, urtication may sometimes be used. Warm bathing is a remedy which has been much employed in most cases of palsy, as an external stimulant. In those, however, which arise in sanguineous habits, from a congestion of blood in the vessels of the brain, its use would in all probability prove inju-^ * 1. $01. Olivae, f. ?ij. — Terebinth, f. |j. M. ft Linimentum. Vel, 2. $ Spirit. Camphora?, f. |j. Tinct. Lytta?, 1. 3ij- Liquor. Amnion. Subcarb. f. |ss. M Vel, 3. ft Liniment Ammon. Subcarbonat f 3*ij. 01. Terebinth, f. 3iij. M. ft. Linimentum. Vel, 4. f£ Liniment. Camph. Comp. f. ?i. Tinct. LyUse, f. 3j- M. t 5.5-Semin Sinap. Pulv. Rad. Armoracia? Contus. aa ^j. Micae Panis aut Farin. Sera. Lini. |ij. Acidi Acetic, q. s. M. ft Cataplasma plantis pedum applicandum. * 1. Take Olive Oil, two ounces. Oil of Turpentine, one ounce. Mix them for a liniment. Or, 2. Take Camphorated Spirit, one ounce Tincture of Spanish Fly, t\v<* drachms. Solution of Subcarbonate of Am- monia, half an ounce. Mis them. Or, 3 Take Liniment of the Subcarbonate of Ammonia, twelve drachms. Oil of Turpentine, three drachms Mix them. Or, 4. Take Compound Camphor Liniment, one ounce. Tincture of Spanish. Fly, one drachm. Mix them. t 5. Take Mustard Seed, in Powder. Horseradish, bruised, of each ait ounce. Crumb of Bread, or Linseed Meal, two ounces. Acetic Acid, a sufficiency to form. a cataplasm, which is to be applied to the soles of the feet 344 NEUROSES, OR NERVOUS DISEASES. ClaSS II. rims, both by stimulating the solids and rarefying the fluids, and thereby becoming a stimulus to the sanguiferous system ; but iu those cases where palsv has arisen in consequence of the application of narcotic powers, diminished vital heat, or an enfeebled constitution, the use of warm bathing will be likely to prove highly beneficiai. In palsy we oua;ht therefore most cautiously to ascertain whether an in- creased or diminished degree of vital heat or action in the sanguif- erous vessels is the cause of the di ease. Whether the natural baths, sti'-.h as those of Bath, in Somersetshire, &c. possess more effica- cious qualities than the ordinary warm ones, seems a matter of doubt with many practitioners, as the substances with which the former are impregnated are but trifling in point of quantity. The late Dr. Heberden thought these waters are neither in any way detrimental, nor of the least use in palsy. Bath has indeed been for a great length of time a favourite place of resort for the paralytic, whether made so by debauchery, or any other cause of premature decay; but it is highly probable the fashionable springs of that crowded mart of health are not impregnated with the power of res- toring lost energies, or bringing back the tide of ebbing animation*. Wuen a natural warm bath cannot be resorted to, an artificial one may be substituted ; and this may be made by dissolving a pro- per quantity of the ferri sulphas in the water, and impregnating it with fixed air. Electricity, both by sparks and shocks, is another remedy which is universally employed in the cure of the palsy as an external stimulant, and often with the most happy effect: but in using it proper care should be taken to apply it only with a moderate force, as more is to be expected from its repetition than from employing it with violence, and likewise to confine its application to parts which are somewhat remote from the bead, as in those cases which depend upon a com- pression of the brain, it might do injury, by acting on the vessels of this organ. Galvanism is also a remedy from which advantages might probably be derived Indeed some practitioners have gone so far as to declare, that they have experienced its effects in palsy to be superior to elec- tricity. Dr. Bardsley tells usf, he has found it to succeed when the latter has failed. When the disease affects several different parts of the body, as in hemiplegia, or paraplegia, we should use stimulants inter- nally as well as externally. Those in most general use are mustard- seed, horseradish, garlic, and volatile alkaline sails, or spirits, and aether, which may be taken agreeably to the prescriptions advised belowf. Tlie arnica moutana (leopard's bane) is a * See Essay on Nervous Diseases, by John Reid, M. D. f See his Medical Reports and Cases, p. 183. J 5. RSem. Sinap. Alb. Zj. Capiat ajger cochl min. ij. ex. Aq. Frigid. Cyatho bis terve die f 5. Take White Mustard Seed, two lea- «|»oonsfuI twice or tluice a day, washing them down with a little cold water. Order I PALSV. 3-15 remedy* much recommended, and great advantages have been derived from i; in paralytic and other affections depending upon a want of nervous energy. Vel, 7. ft Sem. S'map. Alb Contus. Rad. Arinoraciae, aa |ij. Cort. Aurant. ?ss. Aq. Fontan. Oij. Coque ad Oj €ol. Fiat Decoctum cujus sumat Cyath. j amplum ter in die. Adde pro re uata Tinct. Valerian. Ammon. fll xx. Vel, 8. ft Spirit. Ammon. Aromat. f. 3J. Sumat fn, x.—xx. pro dos. tor in dip. Vel, 9. ft Tinct. Lav. Comp. f. 3ij. Spirit Ammon. Foetid. ?ss. M Capiat fll xvj.—xxvj. in quovisvehiculoap propriato. Vel, TO. ft Spirit. Armoraciaj Compos, f. 3>j. ------Ammon. Fceiid. fll xvj. Tinct. Valerian, f. 3'j. Aq. Anethi, f. ^j. M. ft. Haustus ter in die sumendus. Vel, \\. ft Ammon. Subcarbon. gr. vj. Tinct. Cardam. Comp. f. 3U- Aq. Menth. Virid. f. £j. ss. M. ft. Haustus 6ta hora capiendus. Vel, 12. ft Spirit. Ammon. Aromat. f. 3ss. Aq. Pimentae, f. 3*- Tinct. Cinnam. C. f. 3ij. M. ft. Haustus sextis horis adhibendus. * 13. ft Flor. Arnica; Mont.3'ij.—3iij. Aq. Bullient. f. ^x. Macera per horam in vase clauso et cola. AA Or, 7. Take of Bruised Mustard Seed, Horseradish Hoot, of each two ounces Orange Peel, bruised, half an oun^e. Pure Water, two pints. Boil them slowly until reduced to one pir.t, then strain off the liquor, and let the pa- tieut take a wine-glassful three times a day, adding occasionally Ammoniated Tincture of Vale- rian, thirty drops. Or, 8. Take Aromatic Ammoniacal Spirit, one ounce. Of this, from fifteen to thirty drops may be given for a dose thrice a day. Or, 9 Take Compound Tincture of Lavender, two drachms. Feet id Spirit of Ammonia, half an ounce. Mix them. and take from twenty-four to fifty drops occasionally, in any suitable ve- hicle. Or, 10. Take Compound Spirit of Horsera- dish, two drachms. Fcetid Spirit of Ammonia, twen- ty-four drops. Tincture of Valerian, two drachms Dill Seed Water, one ounce. Mix them for a draught, to be taken three times a day. Or, 11. Take Subcarbonate of Ammonia, six grains. Compound Tincture of Carda- mom, two drachms. Mint Water, one ounce and a half. Mix them, and let this draught be taken every six hours. 12. Take Aromatic Ammoniated Spirit, half a drachm. Pimenta Water, ten drachms. Compound Tincture of Cinna- mon, two drachms. Make these into a draught, to be taken as frequently as the former * 13. Take Flowers of Leopard's Bane, two or three drachms. Boiling Water, ten ounces. Let them infuse for an hour in a covered vessel, then strain off the liquor. 34(5 ?s£lTROSES, OR NERVOUS DISEASES. CktSS It Resinous substances, such as guaiacum and the turpentines, have sometimes been employed with advantage in pa^y: but from being apt to prove too inflammatory, their use is by no means general in this disease. When palsy has arisen in consequence of the system being ener- vated by any debilitating cau^e, besides applying stimulants exter- nally, and likewise administering them internally, we should make Use of tonics joined with aromatics, as advised under the head of Dyspepsia. The arsenical solution is a remedy which promises some benefit in this disease, particularly when confined to particular parts. In that palsy of the lower extremities which is occasioned by a deformity of the spine, or which arises from a thickening of the liga- ments that connect the vertebra? together, without any particular affection of the bones, the insertion of issues conjoi.icd with a recum- bent position (see Scrofula) have proved advantageous in many cases. The late Mr. Pott, to whom we are much indebted for his observa- tions on this subject, speaks highly of the effects of drains placed as near as possible to the tumor. He recommends an issue to be opened with caustic on each side of the swelling, large enough to admit of a kidney-bean, and the bottom of the sore to be sprinkled from time to iime with powder of cantharides. My advice was sometime ago requested on the case of a young lady about seventeen years of age, who had gradually lost all sense of feeling as well as motion in her lower extremities. The disease had then been of two years' standing; she had consulted two or three practitioners, and had gone through a course of the usual me- dicines, together with blistering and other stimulating external applications, and she had made trial both of warm and cold bathing; but all without avail. Independent of the paralytic affection in the lower extremities, she seemed to suffer no inconve- nience ; her countenance was healthy, and her appetite good; she slept well, and felt no pain. She rode on horseback every day when the weather permitted, and when it did not, she went out ia a carriage for the benefit of the air. Upon being informed of the history of the ca?e, I immediately suspected that the disease was occasioned by some injury done to the spine, or that there was a thickening of the ligaments that connect the vertebrae together; and in this supposition 1 was confirmed by passing my hand down the lower extremity of the spine. I ordered issues to be inserted in the manner ju^t advised, and had the satisfaction to see my patient soon recover the feelings in her feet, so as to be sensible when they ft Colati Liquoris, f. 3*. Tinct. Card. C. f. 3ij. Syrup. Zingib f. 3j- M ft. Haustus ter ia die sumendus Take of the strained liquor, tei. drachms. Compound Tincture of Carda- mom, two drachms. Syrup of Ginger, one drachm. Mix them, and let this draught betake* th rice a day. Order 1. PALSY. 341 touched the ground, and at the end of about three months she was capable of walking alone. I have evtr> reason however to conclude, that the disease was in the ligaments only, and that the bones of the spine were not affected. When the vertebrae are diseased, a complete cure, I am afraid, can seldom be obtained; but the symptoms may certainly be greatly mitigated, and the pressuie upon the spinal marrow diminished, by exciting a discharge in the neighbourhood of the parts, and keeping the patient in a recumbent position.—See Scrofula. Dr. Clutterbuck informs us, in a pamphlet published not very long ago, that he had found mercury to be an excellent antidote to lead, and that he had used it with the most happy effects in many instances of paralytic affections which had arisen among those who were em- ployed in manufacturing the several preparations of lead, and in ap- plying them to their respective uses. In confirmation of the success of the remedy, he has recited several cases which seem clearly to prove its utility ; and he has likewise added a letter from the late Dr. Bradley, physician to the Westminster Hospital, bearing testimo- ny in favour of the u^e of mercury iu such cases. In the removal of those distressing and terrible symptoms which frequently result from exposure to saturnine emanations (see Colica Pictoru'ti), the nitrate of silver has been in some cases employed with success*. The remedy was administered in doses of from one to five grains three or four times a dav, preceded by a dose of castor oil. From the activity of its operation on the bowels it may be necessa- ry to combine it occasionally witi) opium. The paralysis, or loss of nervous power in particular limbs, which arises as a consequence of that painful and obstinate colic produced by the poison of lead, is found to be peculiarly relieved by a use of the Bath waters, more especially when applied externally, either generally or upon the part affected. In the treatment of that species of palsy of the hands which is produced by the poison of lead, the use of an ingenious mechanical contrivance adapted to place the muscles in a favourable state is highly recommended by a late writerf, and it appears also to have been employed by him with much advantage. It is a splint, made somewhat in the form of a battledore, to be fastened under the fore- arm, and continued to the extremities of the fingers. The object of th? instrument is to take off the weight appended to the extremities of the muscles, under the idea that this weight is a principal object to the restoration of the muscular power. In the first trial which our author made, the splint was applied to the right arm only, and the re- sult, we are told, was as follows:— In one month from the first application he had, the satisfaction to find that the right hand was able to raise an eight ounce weight into * See London Medical Transactions of the College of Physicians, vol. v. art. 4th. * t See Dr. Pemberton's Treatise ou the Diseases of the Abdominal Viscera. 348 NLl ROSES, OR NERVOUS DISEASES. ClaSS 11 a line with the fore-arm by the power of the extensor muscles ; where- as at this lime the left hand remained as perfectly paralytic as be- fore. In five weeks more the extensor muscles of the right hand had regained their natural strength, but the left hand continued paralytic. For the purpose of ascertaining how far this improvement cotdd be conceivtd to have arisen from any change of the constitution, and not from the local mean which was used, it appears that he discharged the patient from under his care for one month, at the end of which time he returned to him with the left hand still per- fectly paralytic, but the right hand enjoying its full and natural powers. The splint was then applied to the left hand, and in seven weeks the power of the extensor muscles of that hand was also per- fectly restored. The result of the experiment certainly places the use of this me- chanical contrivance in a*favourable light; but it is proper to observe, at the same time, that it failed in producing the desired effect in some cases of palsy which were not occasioned by the poison of lead. In palsy the diet should be light, nutritive, and of a warm aro- matic nature. If the patient is able to waik, he should take such daily exercise as his strength will admit; but if deprived of the use of his legs, he ought then to be carried abroad in a carriage, or on horseback: and frictions, with strong stimulants, should frequently be applied to the parts affected. Flannels should be worn next to the skin, and all exposures to cold, damp, and moist air, ought carefully to be avoided. If possible, a warmer climate should be resorted to. In those cases where the appetite fails, and the person sinks into a state of debility from the long continuance of the disease, it will be proper to employ the bark of cinchona, stomachic bitteis, and other tonics to strengthen the system, as advised in Dyspepsia. The inhabitants of the East Indies are very subject to a species of palsy which is called baibiers, but known by the natives under that of beriberii, a word signifying a sheep. The disease probably has re- ceived this denomination, because those who are seized with it have a tottering of the knees and a peculiar manner of walking, exhibiting to the fancy a representation of the gait of that animal. It attacks both natives and strangers, especially dining the rainy season, commencing in November and terminating in March or April, but is most violent on the Malabar coast. Duiing this reason the land winds issue every morning about sunrise from the neighbour- ins; mountains with remarkable coolness; and such as are templed by the serenity of the atmosphere to sleep exposed to these winds-, are often suddenly seized with the disease. Among the chief symptoms by which it is characterized, is a lassi- tude ov*r the whole body. The motion and sensation, especially of the hands and feet, are languid and depraved. Sometimes only a Order 11. PALSY. 349 part of the extremities are affected, and at others the whole of them. The speech is now and then so much obstructed, that the patient can scarcely pronounce a syllable articulately. The disease seldom proves fatal; but the cure is generally tedious, and notwithstanding a use of the most powerful medicines, is said* seldom to be effected till after the shifting of the monsoons, unless the patients are removed to the coast of Coromandel, or to any place to the eastward of the Balagat mountains, where, by a change of air, they quickly recover. The means principally employed by the native practitioners, how- ever, are fomentations and baths made of aromatic herbs, together with strong frictions. The Indians likewise adopt earth bathing by putting the patient into a hole dug in the ground, and covering him with sand up to his neck. This is performed in the middle of the day, and he remains there as long as he can bear the heat of the sand. Where the disease is chronical, and of long standing, sudorific medicines are proper ; and therefore camphor, volatile sails, and gum guaiacum, are frequently given. To obviate costiveness, aloetic purges must be interposed. Due exercise, either on horse- back or by walking, will be necessary to restore the action and strength of the extremities, together with warmth, and friction* with rubefacients. --—'^S^^9999>99^>^SS-J ~ ORDER II. ADYNAMIC. A diminution of the involuntary motions, whether vital or natural, is the character of this order. SYNCOPE, or FAINTING. This disease consists in a decreased action, and sometimes total cessation of the pulse and respiration. It is sometimes preceded by anxiety about the prascordia, a sense of fulness ascending from the stomach towards the head, vertigo, or confusion of ideas, dim- ness of sight, and coldness of the extremities. Attacks of syncope are frequently attended with, or end in vomiting, and sometimes in convulsions, or in an epileptic fit. The causes of this affection are sudden and violent emotions of the mind, pungent and other kinds of odours, derangement of the prims via?, debility from preceding disorders, defect of the stimu- lus of distention, as after blood-letting, hemorrhage, or the opera- tion of paracentesis in ascites ; organic affection of the heart, or of * See Dr.Lind on the Diseases of Warm Climates, p. 286. -350 KEUROSES, OR NERVODS DISEASES. Class 11 the parts immediately connected with it, such as aneurism either of the heart itself, or of the arch of the aorta ; ossification of the valves of the heart, or its large blood vessels, or polypi. During the paroxysm, the nostrils are to be stimulated with vola- tile spirits or salts, and the face to be sprinkled with cold water. Where the disease arises as the consequence of an hemorrhage, fhe patient should be placed in a recumbent posture, and in all cases a free admission of pure cool air should be allowed. If the disease arises as the consequence of debility or defective excitement, the system should be strengthened by the use of cinchona, sulphuric acid, stomachic bitters, and chalybeates, together with cold bathing.— (See Dyspepsia). It need hardly be added, that avoiding the oc- casional causes, and removing them, if in our power, is a matter we should always keep in view. VERTIGO, or GIDDINESS in the HEAD. Vertigo proceeds most usually either from too great a fulness of blood in the vessels of the head, or is symptomatic of dyspepsia, hypochondriasis, or hysteria. The patient is seized on a sudden with a swimming in the head; every thing appears to him to go round, he staggers, and is in danger of falling down. , This complaint is attended with no danger, when it arises as a symptom of hysteria, or any other nervous disease ; but when it takes place in consequence of an over-fulness of blood in the vessels of the head, and is not timely relieved by proper evacuation, it may terminate in apoplexy or palsy. Where vertigo prevails as a symptom of some nervous disease, recourse must be had fo the medicines and remedies which are most suitable to the removal of the primary affection ; (see Hysteria and Dyspepsia) but where it is occasioned by an over-distention of the vessels of the head, either general or topical bleeding by the ap- plication of several leeches to fhe temples, or the scarificator and cupping-glass to the nape of the neck, the latter being the most certain ; together with a frequent use of cooling purgatives, and a spare regimen, ought to be employed. Should the complaint not Jbe removed by these means, scapulary issues will be advisable. DYSPEPSIA, or INDIGESTION. This disease»chiefly arises in persons between thirty and forty years of age, and in principally to be met with in those who devote much time to study, or who lead either a very sedentary or irre- gular life. A great singularity attendant on it is, that it may, and often does continue a great length of time, without any aggrava- tion or remission of the symptoms. The disease is a frequent attendant on chronic weakness. Order II INDIGESTION. 351 In Dr. Parry's opinion*, idiopathic dyspepsia consists in a morbid fulness of the vessels of the villous coat of the stomach. Great grief and uneasiness of mind, intense study, indolence, profuse evacuations, excess in venery, hard drinking, particularly of spirituous liquors; irregularity of life, too frequent a use of warm diluent liquors, and of tea, tobacco, opium, and other narcotics, immoderate repletion, and over-distention of the stomach, very frequent rejection of the sal- iva, in consequence of smoking or chewing tobacco, or a diminution or interruption of the due secretion of it, a deficiency in the secre- tion of the bile, pancreatic, or gastric juice, diseases of the liver, and spleen, hysteria, hypochoi!driasis,and exposure to moist and cold air, when without exercise, are the causes which usually occasion dys- pepsia. Unless where dyspepsia arises either from a sedentary life, excess of study, or the depressing passions, it is almost universally sympto- matic of organic affection of the liver or spleen, and not an idiopathic disease, of which the practitioner may be convinced by paying due attention to the colour of the alvine and renal discharges; to the pasty or doughy feel of the skin, and the dingy pale hepatic hue of the countenance that generally attend dyspepsia. Scirrhus in the pyloric ori6ce, or outlet of the stomach, is very apt to take place in those who addict themselves to ardent spirits; and there are numerous glands at this part, which, from such a practice,. are liable to be affected, giving rise to a high degree of acidity in the stomach. Many, perhaps most of the diseases of the digestive organs, cau-ed by various circumstances, consist in a weakness or alony of the affected parts, accompanied by a deficiency or depravity of the fluid* secreted by them, and upon the healthy qualities of which a right performance of the functions depends. The state of the tongue is in general a pretty good criterion of a disordered state of the stomach, but it does not point out the kind and degree of that disprder. With a furred tongue, there is perceived a disagreeable taste in the morning, and the breath in most instances, notwithstanding the greatest care that can be taken, acquires an of- fensive smell. In consequence of continued disease, the cuticle of the tongue sometimes appears to have lost its usual colour, and to become permanently white. In some states of depraved digestion, there is nearly a complete disrelish for food; but still the appetite is not greatly impaired, as at the stated peiiods of the patient's meals he can eat heartily, al- though without much gratification. With hard drinkers nausea and vomiting frequently occur in the morning; and in ruined constitu- tions, there is an almost constant thirst, with feverishuess, loss of ap- petite and strength, shortness of breath, paleness of the countenance, languor, and towards the close, anasarcous swellings. * See his Elements of Pathology and Therapeutic* 352 NEUROSES, OR NERVOUS DISEASES. ClaSS II. In stomach complaints, in addition to defective appetite, indiges- tion, flatulency in a high degree, acidity and cardialgia, the parent is often afflicted with costiveness, vertigo, pain in the balls of the eyes, imperfect vision, ringing in the ears, and palpitations. The mind in such cases is frequently irritable and desponding, and great anxiety is observable in the countenance. The pulse is usually fee hie and fre- quent, and slight exercise produces considerable fatigue and perspira- tion, ilesdessness prevails at night, tho sleep is disturbed by fright- ful d-eams and starting, not affording much refreshment, and occa- sionally there i- much moaning, with a sense of a heavy weight on the chest, or what has been denominated the night-mare. In some in- stances, the disease is complicated with gastrodynia, or severe pain in the stomach itself, and now and then with pyrosis. Although dyspeptic complaints, when they exist in consequence of debility of the stomach, may be alleviated, or be entirely removed by timely desisting from bad habits, and taking proper medicines, still when they have been of long continuance, so as to produce great de- bility, and pass into some other disease, such as dropsy ; or when they originate from an organic affection, such for instance as a scirrhus of the pylorus, they will be sure to prove fatal. The morbid appearances to be observed on dissections of this dis- ease are principally confined to liver, spleen, and that part of the stomach which is called the pylorus, this being often found either in a contracted, scirrhous, or ulcerated state, in every distance the stomach is perceived to be considerably distended with air. In the treatment of the disease, three indications must be attend- ed to :— The first is to avoid or remove the remote causes which have been enumerated. The second is to obviate the symptoms which contribute to continue or aggravate the disease. The third is to restore the tone of the organ. To effect the first of these intentions, it must be the business of the physician to point out to the patient the indispensable necessity of renouncing such habits or pursuits as may have tended to give rise to the disease, as the continued application or frequent repetition of these causes may defeat the use of whatever remedies are em- ployed. If he leads a fashionable life, it will be necessary for him to forsake the haunts and habits of dissipation; to leave the crowded city, and its alluring amusements, conducted in rooms, where the air he breathes is vitiated and contaminated by the great nunher of persons collected together; to shun luxurious tables, indolence, and late hours; tore- trace the footsteps by which he had deviated from simple nature, and to court the country, pure air, moderate exercise, early rising, simple diet, the society of a few select friends, and pleasing occupations. To accomplish the second intention of obviating the symptoms Order H. indigestion. 353 which contribute to continue or to aggravate the disease, it will be necessary to remove the crudities in the stomach by giving a gentle emetic. It will also be necessary to correct the moibid acidity in the organ by alkalies and absorbents*, as the potassae subcarbo- nas, soap, liquor calcis, magnesia, chalk, he.; to assuage the pain and flatulency in the stomach and inteslines by carminativesf, antispasmodics!, and opiates; and lastly, to obviate costiveness, by a use of such gentle laxatives||, joined with aromatics, as will promote a ready discharge of the contents of the intestines, * l.rjL Liquoris Calcis Oj. Capiat aeger, f. Zy.—Ziv. bis in die Vel, 2. ft Liquor. Potassae, f 3j- ■ Calcis, f. |vij. M ------,.. ^ .v. „». Capiat a?ger cochleare magnum bis in die ex poculo jusculi bovini. Vel, 3. ft Magnesiae, 3"j. Pulv. Rhei, 3j. Aq. Fontan. I. ?iv. ----Cinnam. f. rj. Tinct. Lavend. C f. 3ss. M. ft. Mistura, cujus sumat cochl. ij. terin die Vel, 4. ft Cretaj Praeparat. gr. xv. Spirit. Myrioticae, f. 3j. Aquae Fontan. f. |jss. Liquor. Potassae, fT^x. Syrup. Zingib. f. 3'j. M. ft. Haustus bis die sumendus. Vel, 5. ft Magnesiae, 3y*. Pulv. Rhei, gr. v. ----Nuc. Mosch. gr. iij. M. ft. Pulvis mane et vespere sumendus. t 6. ft Cret. Praeparat. gr. xij. Aq. Menth. Pip. f. ?ss. ----Font. f. §j. Spirit. Pimentae, f. 3U- Tinct. Opii, fll x.~ M. ft. Haustus ter die sumendus. {7. ft Aq. Anethi,f fiij. Spirit. Cinnam. f. ^j. Tinct. Valerian. Ammon. f. 3ij. ----Opii, fll xxv. iEther. Sulphuric, f. 3j. M. Supiat cochl. larga ij. bis terve in die, vel dolore ventriculi urgente. [! 8. ftPil. Aloes cum Myrrh, gr. xv. in Pilulas iij. pro dos. divid. 45 1. Let the patient take from two to four ounces daily of Lime Water. Or, 2. Take Solution of Potass, one drachm. Lime, seven ounces. Mix them, and take a tabie-spoonful twice a day in a little beef-tea. Or, 3. Take Magnesia, three drachms. Rhubarb in powder, one sciuple, Pure Water, four ounces. Cinnamon Water, one ounce. Compound Tincture of Lavender, half a drachm. Of this mixture two table-spoonsful may be taken three times a day. Or, 4. Take Prepared Chalk, fifteen grains. Spirit of Nutmeg, one drachm. Pure Water, one ounce and a half. Solution of Potass, fifteen drops. Syrup of Ginger, two drachms. Mix them, and let this draught be taken twice a day. Or, 5. Take Magnesia, two scruples. Rhubarb in powder, five grains. Powdered Nutmeg, three grains. Mix them. This powder may be taken morning and evening. 16. Take Prepared Chalk, twelve grains. Peppermint Water, half ail ouuce. Pure Water, one ounce. Spirit of Pimenta, two drachms.1 Tincture of Opium, fifteen drops. Mix them. This draught is to be taken three times a day. X 7. Take Dill Water, three ounces. Spirit of Cinnamon, one ounce. Ammoniated Tincture of Valerian, two draehms. Tincture of Opium, forty drops. Sulphuric .fcther, one drachm. Mix them, and let two table-spoonsful be taken twice or thrice a day, or whenever the pain in the stomach is severe. || 8. Take Aloetic Pills with Myrrh, fifteen grains. Divide the mass into three pills for a dose. 354 NEUROSES, OR NERVOUS DISEASES. without hurrying their action, or increasing the excretions made into their cavity. An habitual attention to the removal of costiveness by instituting a regular custom of periodically soliciting an evacuation by volun- tary and persevering efforts, will powerfully aid the beneficial effects of the other means we employ. The morning is the proper time for the attempt; and the trial should be prosecuted during at least fifteen minutes, if the peristaltic be not earlier excited to adequate motion. Perhaps a week may be unavailingly employed in this endeavour, but the proposed effect will probably be attained within a month : one month has indeed in numerous instances fully established an habitual call to intestinal evacuation, under circum- stances that previously required the almost daily use of aperient medicines. Where dyspepsia is occasioned by defective biliary secretion, and is combined with a diseased state of the liver, spleen or biliary ducts, the stools indicating a want of due mixture of bile with them, we should employ the submuriate of mercury. A pill con- taining about two grains of this may be taken every third night, succeeded the next morning by an aperient draught composed of one ounce and a half of infusion of senna, with two or three drachms of sulphate of magnesia. For the removal of cardialgia and vomiting which attend on dyspepsia, the application of a blister over the stomach often proves serviceable. In such cases, blisters invigorate the exertions of the arterial and lymphatic vessels of the skin, produce an in- Vel, Or, 9. ft Aloes Spicatae Extract. 9. Take Soccotrine Aloes, Pulv. Rhei, aa 3j. Powdered Rhubarb, of each one dnichm. ■----Cinnam. Comp. 3j. Compound Powder of Cinnamon, one scruple Sapon. Venet. 3=s. Hard Soap, half a drachm- Syrup, q. s. M. Syrup, a sufficiency to form tat Fiat ma=sa in pilulas 1. divenda, quarum mass, which is to be divided into fifty pilli, ij. sumat pro dos. of which two will be a sufficient dose. Vel, Or, 10. ft Confect. Sennae, |ij. 10. Take Confection of Senna,two ounces. Pulv. Jalapae, 3ij- Jalap in Powder, two drachms. ----Cinnam. Comp. 3j. Compound Powder of Cinna- mon, one scruple. Potassae Supertart. 3j- Supertartrate of Potass, one drachm. Syrup. Zingib. q. s. M. Syrup of Ginger, a sufficiency ft. Electuarium, cujus capiat quantitatem to form an electuary, of which lake the juglandis hora somni. bulk of a walnut at bed-time. Vel, Or, 11. ft Tinct. Rhei, f. 3vj. pro dos. 11. Take Tincture of Rhubarb, six drachms for a dose. Vtl, Or, 12. ft Pulv. Rhei, 3j. 12. Take Powdered Rhubarb, one sere pie. ----Zingib gr. v. --------Ginger, five grains. Magnesia?, 3ss. M. Magnesia, half a drachm. ft. Pulvis, pro re nata suineadusv Mix them, aud take this powder when ne- cessary. Order II. INDIGESTION. 355 crease of insensible perspiration and of cutaneous absorption, and augment the action of the stomach, and consequently its power of di- gestion. To accomplish the third intention of restoring the tone of the sto* mach, the loss of which is to be considered as the chief and immedi- ate cause of dyspepsia, we are to en ploy such medicines as operate directly on this organ, and such remedies, and other means, as have a tendency to strengthen the system in general. The medicines best calculated to restore the tone of the stomach are aromatics and astringent bitters*, as likewise the cinchona barkf, » 13. ft Infus. Gentian. C. f. |jss. Tinct. Card. C. f 3»j. ----Myrrh, f. 3j. M. ft. Haustus bis terve de die adhibendus. Vel, 14. ft Infus. Rad. Calumb. f. 3*. Tinct. Cascaril. ----Cort. Aurant, aa f. 3j. M ft. Haustus. Vel, 15- ft Quassiae, 3U- Aq. Fervent, f. ^v. Colat. adde Tinct. Calumb. ----Card. C. aa f. ?ss. M. Capiat aeger cochl. iij. ter in die. Adde pro re nata Acid. Sulph. Dilut. fll xiij. Vel 16. ft Infus. Gentian. C. £ |v. Tinct. Cinnam. C. f. |j. ----Lavend. C. 3i. M. ft. Mistura. Vel, 17. ft Rad. Gentian. Contus. |ss. ----Calam. Aromat. C. Cardam. Sem. Contus. aa 3iij. Cort. Aurant. Sic. C 3ij. Vin. Alb Hispan. Oij. Infundan- tur per dies octo. Hujus Infusi capiat cochl. ij bis quotidie. t 18. ft Decoct. Cinchonas, f. |jss. Tinct. Calumb. f 3ij. ----Myrrh, f. 3j. M. ft. Haustus ter in die sumendus * 13. Take Compound Infusion of Gentian, one ounce and a half. ------------Tincture of Carda- mom, two drachms. Tincture of Myrrh, one drachm Mix them. This draught is to be given thre« times a day. Or, 14. Take Infusion of Calumbo Root, ten drachms. Tincture of Cascarilla, --------of Orange Peel, of each one drachm. Mix them for a draught. Or, 15. Take Infusion of Quassia, five ounces. Tincture of Calumbo Root, Compound Tincture of Carda- mom, of each half an ounce. Of this mixture let the patient take three table-spoonsful three times a day, adding occasionally twenty drops of Diluted Sul- phuric Acid. Or, 16. Take Compound Infusion of Gentian, five ounces. ---------Tincture of Cinnamon, one ounce. ------ ■ Lavender, one drachm. Mix them. The dose the same as the former. Or, 17. Take Gentian Root bruised, half an ounce. Sweet Flag Root, sliced, Cardamom Seeds, bruised, of each three drachms. Orange Peel, dried, two drachms. White Wine, two pints. Infuse them for eight days, and let the patient take two table-spoonsful twice a day. t 18. Take Decoction of Peruvian Bark, one ounce and a half. Tincture of Calumbo,two drachms. ------Myrrh, one drachm. Mix them, and take this draught thrice a day. 356 NEUROSES, OR NERVOUS DISEASES. ClaSS II. the mineral acids, and chalybeates*. The latter, in particular, are of eminent service in an impaired or capricious appetite, and weakness of the assimilating organs, irregular digestion, flatulent distention o/" the abdomen, anxiety about the praerordia, difficult respiration from sympathy with the stomach, and occasional vomiting of viscid mucus. Vel, 19. ft Pulv. Cinchonae, 3j. Aq. Cinnam. f. ^jss. Tinct. Gentian. C. 3ij. Acid. Sulph. Dilut. fll xiij. M. ft. Haustus. Vel, 20. ft Infus. Cinchonae, f. ^v. Tinct. ejusd. C. ----Card. C. aa f. ^ss. M. Sumat cochl. iij ter in die. Adde pro re nata Acid. Sulph. Dilut. fll xiij. * 21. ft Tinct. Ferri Muriat. f ^ss. fll x—xv. ter die sumendae in quovis vehiculo. Vel, 22. Aq. Chalybeatce. Vel, 23. ft Vin. Ferri, f 3U- Infus Gentian, f. ^jss. Tinct. Cascaril. f 3j. M. Pro haustu bis terve in die sumendo. Vel, 24. ft Pulv. Myrrh. 3ss. Solve in Spirit. Cinnam. f. 3'j- et adde Aq. Pimentee, f. ^j. Ferri Sulphat. gr. iij.—vj. Potassae Subcarbon. gr. x. M. ft. Haustus ter die sumendus. Vel, 26. ft Extract. Cinchonae, ------Gentian, aa 3j> Ferri Sulphat 3ss. Pulv. Myrrh. 3j- Syrup. Zingib q s. M. Fiant piluhe lx. quaruin iij. sumat bis terve in die cum Infus. Cascarilhe Cort. f. |ij. Or, 19. Take Powder of Peruvian Bark, one drachm. Cinnamon Water, one ounce and a half Compound Tincture of Gentian, two drachms. Diluted Sulphuric Acid, twenty drops Mix them for a draught. Or, 20. Take Infusion of Peruvian Bark, five ounces. Compound Tincture of the same, -------------------Cardamoms, of each half an ounce. Of this mixture three large spoonsful maybe taken thrice a day, adding occasionally of Diluted Sulphuric Acid, twenty drops. * 21. Take Muriated Tincture of Iron. fif. teen to twenty-five drops thrice a day in any vehicle. Or, 22. Chalybeate Waters. Or, 23. Take Wine of Iron, two drachms. Infusion of Gentian, one ounce and a halt. Tincture of Cascarilla, one drachm. Mix them for a draught, to be taken twice or thrice a day. Or, 24. Take Myrrh, half a drachm. Dissolve it in Spirit of Cinnamon, two drachms, and add Pimenta Water, one ounce. Sulphate of Iron, from three to six grains. Subcarbonate of Potass, ten grains. Mix them, and let this draught be taken three tim^s a day. Or, 25. Take Extract of Peruvian Bark, ---------- Gentian, of each one drachm. Sulphate of Iron, half a drachm. Powdered Myrrh, one drachm. Syrup of Ginger, a sufficiency to form the mass, out of which sixty pills are to be formed, of which three are to be taken twice or thrice a day, washing tbem down with about two ounces of an Infu- sion of Cascarilla Bark. Ordtr II. INDIGESTION. 357 Beside the vegetable bitters that we have long been accustomed to, two others have very lately been recommended aud brought forward as deserving our notice. The one is the humulus lupulus, or common hop, different preparations of which, such a-, the powder, extract, and tincture, are to be procured at the shops of many druggists; the other is the radix rhataniae, or rhatany root. This last, we are told by Dr. Reece* who seems to have been the first to give it notoriety, has been found to invigorate the digestive organs, produce a relish for food, and promote digestion. He further mentions, that it is more grateful to the palate than cinchona bark, and that he has found it to succeed better. This has not, however, been the case in the trials which I have made of it; neither has it answered the expectations of most others who have administered it. An aromatic tincturef of it seems to be its best preparation. In cardialgia, gastrodynia, pyrosis, and such other complaints of the stomach, the oxyd of bismuth is a remedy which has been employed with considerable advantage in a variety of instances^. The proper dose is from three to ten grains, with about twenty-five grains of gum tragacanth, repeated three times a day. It will be best, however, to begin with a dose of only three grains, increasing it gradually. The remedy is perfectly safe as well as useful. As a diminution of the due quantity of gastric juice is sometimes a cause of dyspepsia, it may not be improbable that in such cases the symptom may be relieved by supplying the patient with the gastric liquor of those animals whose food is most similar to that of man. Dr. Scott, in a thesis published some years ago, makes men- * See his Treatise on the Rhadix Rhataniae. X See Memoirs of the London Medical Society, vol. v. ----Medical Reports, by Dr. Bardsley. Vel, 26. ft Pulv. Cinchonae, |j. ----Myrrh 3'j- ----Cinnam. C. 3ss. Ferri Subcarbonat. 3*j- Syrup. Cort. Aurant q. s. M. ft. Electuarium, cujus sumat quantitatem juglandis ter in die cum Infus. Quassia;, i'j- > 27. ft Rad. Rhatan. Contus. |ij. Cort. Aurant. Sic. C. ?ss. ----Canel. Alb. C. 3jss. Spirit Rectificat. Ten. Oij. Digere per dies decern et cola. .Sit dosis cochl. ij. minima bis in die ex cyatho aqua? pura>. I Or, 26. Take Powder of Peruvian Bark, one ounce. --------Myrrh, two drachms. Compound Powder of Cinnamon, half a drachm. Subcarbonate of Iron, two drachms. Syrup of Orange Peel, a suffi- ciency to form an electuary, of which the bulk of a walnut may be taken three times a day, with two ounces of an Infusion of Quassia. I 27. Take Rhatany Root, bruised, twe ounces. Orange Peel, dried, half an ounce. Canella Bark, bruised, one drachm. and a half. Proof Spirit, two pints. Infuse them for ten days, then strain off the liquor. The dose may be two tea- spoonsful twice a day in a glass of water. .358 NEUROSES, OR NERVOUS DISEASES. ClaSS 11 tion, that an Italian physician, finding every thing else fail in a dys- peptic case, had recourse to the gastric liquor of brutes, which proved completely successful. To strengthen the system, whereby the powers of the stomach will be made stronger, the patient should take daily exercise on horse- back, which will be preferable to walking, as being less fatiguing; he should breathe a purL*, dry, and temperate air, rnc early every morn- ing, go soon to bed at night, lead a temperate life, use light animal food for his diet, but avoid farinaceous vegetables, adapt his dress to the climate and changes of the weather, and bathe frequently in cold water. The use of a tepid bath of about 96 or 98 degrees of heat for half an hour every other day fir two or three months, has likewise in many instances proved of great service to dyspeptic persons. Indeed it would be best to begin with tepid bathing, and so reduce the temperature gradually. Tepid bathing communicates heat to the system, and it likewise stimulates it, and causes absorption more than exhalation. The mind is to be amused at the same time that the body is em- ployed ; hence it is that mineral waters, and places of public re- sort, have always been found very efficacious in removing dyspeptic complaints. Mineral waters are indeed of themselves powerful remedies in cases of dyspepsia; but their efficacy is greatly in- creased by drinking them at the spring, where the patient's mind being constantly engaged by the company and a great variety of amusements, he is sure to receive both hope and entertainment. The advantages of air, exercise, particularly on horseback, and agreeable prospects, admirably coincide, in most cases, with the general curative effect of the spring itself. Buxton water is found of considerable service in removing many of the symptoms of defective digestion and derangement of the alimentary organs consequent to a life of high indulgence and in- temperance. A judicious use of this simple remedy, Dr. Saunders* observes, will often relieve the distressing symptoms of heart-burn, flatulency, and sickness; and if persevered in, will increase the ap- petite, render the secretions more regular, and improve the general health and spirits, that are so intimately connected with the func- tions of the digestive organs. A spontaneous diarrhoea is some- times a consequence of its use at first; but it is more common, especially in habits where the action of the bowels is naturally sluggish, for costiveness to come on during a course of this water, which must be remedied by laxative medicines. In dyspeptic affections, spasms of the stomach, or intestinal canal, and similar disorders, great benefit is derived from a use of Bath water; but it ought to be persisted in for a considerable length of time. Dyspepsia, foulness of the stomach, bilious vomiting, acidity, * See his Treatise on .Mineral Waters. Order II. indigestion. 359 heart-burn, and spasmodic pains in any part of the alimentary canal, are complaints in which a use of Seltzer water affords likewise the greatest relief. Pyrmont water is another remedy which may be advantageously used in all cases of debility, where the constitution requires an ac- tive tonic, and which at the same time does not excite a permanent heat. It increases fhe secretion of urine, and sometimes occasions a temporary eiuption on the skin. It is of an agreeable, though strongly acidulated taste, and emits a large portion of gas, which affects those who drink it with a sensation somewhat resembling that produced by intoxication. The dose must vary according to circumstances, and the nature of the patient's complaint, but in general the quantity to be taken ought not to exceed three pints per day. If a person residing in a warm climate should labour under chronic weakness for any length of time, he will act prudently in removing to a colder one before the disease becomes inveterate, and lays the foundation of some dangerous complaint. If his circum- stances or business will not admit of such a change, he ought then to remove to the coolest situation that can be procured ; or, in pre- ference to remaining on shore, he may sleep on board of some vessel; and as often as opportunities offer he should make short voyages, as wonderful recoveries have been effected by sea air in cases of this nature. The diet in dyspepsia ought to be nutritive and generous, con- sisting chiefly of animal food, on account of fhe disposition to aces- cency ; and it should be taken every three or four hours, and never exceed a few ounces at any one time. Moreover, due care is to be taken fo masticate it properly, in order that it may be reduced by comminution and salival commixture to a semi-fluid state. Instead of fermented bread, the patient should eat biscuit with his food. No diluent fluids should be taken at his meals, nor until some lime after each repast, lest the solvent property of fhe mixed saliva should thereby be diminished ; nor should the quanlify of fluid taken at once ever exceed half a pint, nor be repeated oftener than at intervals of three hours. About half an hour before swallowing the portion of aliment proposed, brisk friction should be performed with a flesh-brush over the region of the stomach during some minutes, and a similar operation may follow the meal. A moderate use of wine, such as Madeira or Sherry, ought to be allowed : but should these disagree with the patient and become acid on his stomach, weak brandy and wafer may be substituted for ordinary drink. Under no other circumstances should a use of ar- dent spirits be resorted to, as by an indulgence in ihem, a habit im- perceptibly steals on before the person is aware of (he consequences to which it leads. By too free a use of spirituous liquors, obstruc- tions in the principal organs ensue, the nervous system becomes blunted and depraved to every feeling, the energies of the mind snfFer, loss of memory takes place, a train of nervous disorders 360 NEUROSES, OR NERVOUS DISEASES. ClttSS 11. eome on, and an attack of jaundice, dropsy, or consumption, at length terminates existence. In this progress even the passages to the stomach lose their feeling, become indurated and callous; and the organ itself, taking on the same state, has its digestion impaired, and becomes unfit to prepare nourishment for the body. Pure wine in a moderate quantity gently stimulates, increases the action o1' the heart and aneries, and augments the nervous energy over the whole body, communicates a serenity and ease of mind, a liveliness of imagination, and a powerful ex* ition of every faculty : but, on the other hand, if taken immoderately, these favourable appearances are changed, the powers of the nervous system are weakened, the mind is deranged, and in the end both motion and sensation are much impaired, if not lost. In that species of chronic debility which is brought on by drinking spirituous or fermented liquors to excess, there is not much reason to expect a return to healthful vigour, where the power of digestion is considerably desiroyed ; but in other cases, the person may probably recover his health by a prudent and gradual diminution of the quantity of spirits. In such a case, he should at first omit one-fourth of the quantity of spirit he has lately been accustomed to, and if in a fort- night his appetite increases, he should be advised to omit another fourth ; but if he perceives that his digestion becomes more impaired from the want of the usual quantity of spirituous potation, he should then be advised to continue as he is, and rather bear the ills he has, than risk the encounter of greater. Animal food, with or without spice, is at the same time to be recommended, as likewise the cinchona bark with myrrh and steel between his meals. At night he may take half a grain or a grain of opium, with five or eight grains of rhubarb. Nervous persons are apt to complain of atoms floating before the eyes, or what are termed rauscse volitantes : but for the treatment of these, I beg leave to refer to the succeeding disease. HYPOCHONDRIASIS, or HYPOCHONDRIAC AFFECTION. This disease, known likewise by the name of low spirits, or the vapours, is a certain state of the mind along with dyspepsia, wherein the greatest evils are apprehended upon the slightest grounds, and fhe worst consequences imagined from any unusual feeling even of a trifling kind ; and in respect to such apprehensions and feel- ings, there is always the most obstinate belief and persuasion. Hypochondriasis bears a strong resemblance to dyspepsia ; but there is this difference between them, that the former prevails at an advanced period of life, and is more an affection of the mind than of the body ; whereas the latter occurs principally from the age of puberty to that of 35, and depends chiefly on debility. Hypochon- driasis may moreover be distinguished from dyspepsia by the lan- guor, listlessness, want of resolution and activity, fear of death, and Order II. hypochondriac affection. 361 suspicious disposition being always present, and by the dyspeptic symptoms being often absent, or when present, they are in a much slighter degree. Men of a melancholic temperament, whose minds are capable of great attention, and whose passions are not easily moved, are at an ad- vanced pe» iod of life must liable to be attacked with this disease; and when it has once taken place, it goes on increasing as life advances, being usually most troublesome in the autumnal and winter seasons, which accounts for more acts of suicide being committed at these times of the year than any other. The English have been accused as the nation of all others which is addicted to suicide; and perhaps this proneness ought more reasonably to be attributed to an indulgence in unhappiness and domestication of misery, from trivial circumstances, ithan to the influence of fogs, or the physical effects of coal fires, as have been assigned by foreigners. Hypochondriasis seems to depend on a loss of energy in the brain, or on a torpid state of the nervous system, induced by various remote causes, such as close and intense study, long and serious attention to abstruse subjects, the constant remembrance of some material loss or disappointment which has occurred, great anxiety of mind, leading an inactive, indolent, or sedentary life, immoderate venery, or a use of crude, flatulent, or unwholesome food, being guilty of great irregu- larity and intemperance, as likewise by obstructions in the viscera^ and by long-continued evacuations. Hypochondriasis and other nervous complaints are, through the medium of sympathy, scarcely lrss infectious (it is probable) than febrile diseases; and even persons naturally of a cheerful temper, by being long domesticated with those of a melancholic desponding cast, have been known to become decidedly and often deplorably dejected. The hypochondriac affection is attended with inactivity, a want of resolution with respect to all undertakings, lowness and dejection of spirits, great despondency, and apprehension of evil upon the slightest grounds, and a dread of danger from any unusual feeling even of a trifling kind, together with flaiulency in the stomach and bowels, acid eructations, costiveness, a copious discharge of pale urine, spasmodic pains in the head and other parts of the body, giddiness, dimness of sight, and palpitations. In short, it is attended with such a long train of symptoms, that it would fill many pages to enumerate them all, as there is no function or part of the body that does not suffer in its turn by its tyranny : the miserable patient in- dulges wild imaginations, and fancies that he labours under almost every disease; and with respect to these feelings and apprehensions, he entertains the most obstinate belief, being highly displeased if any attempt is made to reason with him on the absurdity of his per- suasions. There are few examples of hypochondriacal people who find themselves worse at night than in the morning : the generality ef 4fi 362 NEUROSES, OR NERVOUS DISEASES. ClaSS II them, like most of those who are afflicted with any of the com- plaints styled nervous, are seemingly hurt by their sleep, little as it is; and the longer they happen to sleep the worse they are: they awake out of it with confusion, and do not come immediately to themselves; and when they do, they can think only of melan- choly subjects, and feel the worst horrors of their disorder. This state continues till dinner, with very little abatement; after dinner they feel themselves a little revived ; and at night the tide of their spirits returns, which being desirous to enjoy, and dreading their certain ebb when they lie down, they go late and with reluctance to bed. In hysterical women the operations of the animal powera seem to be the most disturbed and perverted ; but in men the mind is most affected; involuntary exclamations, faintings and convulsions of all sorts, being most common in women, and silent despair in men. Hence, perhaps, suicide occurs more frequently with men than among women. As to the prognostic, the disease, if recent, is rather to be regarded as troublesome than dangerou-s; but if long continued, it is apt to pro- duce scirrhi of the viscera, cachexy, dropsy, incurable melancholy, or madness. On dissections of hypochondriacal persons, some of the abdominal viscera (particularly the liver and spleen;, are usually found consider- ably enlarged. In some few instances, effusion, and a turgescence of the vessels, have been observed in the brain. The indications of cure in this disease seem to be, 1st, To excite the nervous energy which has been depressed, and that particularly by attending to the state of the mind. 2dly, To remove or alleviate the symptoms which serve to continue and aggravate the disease. 3dly, To strengthen the alimentary canal and promote the secre- tions. To answer the first of these indications, the patient's attention i* to be engaged and diverted to other objects than his own feelings; he is to be directed to vary the scene frequently by going from one place to another; to associate as much as possible with agreeable cheerful company; to engage in such pursuits as will afford him moderate exercise in the open air, which gardening, riding on horseback, and field sports, as hunting and shooting, are particu- larly calculated to do ; and by all means to avoid absolute idleness: but in doing this, all application to former studies, especially pro- fessional ones, is to be forbid : entertaining books will, however, be serviceable, as assisting to divert the mind from itself. Gardening is a pursuit highly proper for hypochondriacs, as it will keep the mind alert and the body in exercise. Such as live in the country should therefore engage in it. In cities or large towns where this healthy recreation cannot be enjoyed, no better substitute can be employed than that of fitting up an apartment as a work-shop. Working in a cool and free atmosphere would prove a deliverance Order 11. HYPOCHONDRIAC AFFECTION. 363 from that chilliness which for above half of our year so miserably persecutes the tender, and it might act equally as a charm on the ruffled spirits. Hypochondriasis is far from being a metropolitan disease, as the multiplicity of external objects, which in a large capital are con- tinually giving a new direction to the current of thought, is of course unfavourable to the uniformity and self-absorption of the melancholy. A residence therefore even in a large city which affords objects of interest and motives of exertion, ought to be recommended to hypo- chondriacal or nervous patients, in preference to the most healthy situation in the country, where there is not enough to rouse the slug- gishness or fill the vacuity of the mind. Compassion, and not raillery, is to be bestowed on the hypochon- driac, as the firm persuasion which he entertains will not allow his feelings to be treated as imaginary, nor his apprehension of danger to be considered as groundless, however the Physician may be of opinion that it is the case in both respects. To gain his con- science, it will be necessary to attend to his complaints, as if they were all real: and to satisfy him, it will by all means be advisable to give him some kind of innocent medicine or placebo, changing it from time to time whenever he expresses any disappointment of relief. In the absence of every other diversion, even the swallowing of medicine may be a source of amusement. The timesfor taking the different draughts or doses, are so many epochs in the chronology of an hypochondriac, which by dividing, help to conquer the tedium ef his day. However sceptical a physician may be with regard to the inherent or permanent qualities of any medicine, it is his duty, perhaps, to take advantage of the tide of opinion, and he may honestly make use of his patient's credulity, in order to relieve him from the pressure of his disease, and render the partial weakness of his mind instrumental to the general restoration of his corporeal strength*. The complaints of hypochondriacs should be treated by the phy- sician as of real existence; and from whatever cause they may arise, it is his province to employ his art to subdue it; not to ruffle an irritable mind by unseasonable levity, or expose a morbid sensibility, to insult and reproach. From the slow evacuation of the stomach in melancholic tempera- ments, acidity often prevails in a high degree with hypochondriacs; to obviate which, and answer the second indication of cure, it will be necessary for the patient to make use of absorbents and alkalies, as advised under the head of Dyspepsia. Vomiting, though sometimes employed, is by no means suited to this disease. Costiveness, which is another frequent symptom in hypochon- * See Essay on Nervous Diseases, By John Reid, M. D. 364 NEUROSES, OR NERVOUS DISEASES. ClaSS II driasis, is to be obviated by instituting a regular custom of periodi- cally soliciting an evacuation by voluntary and persevering efforts once or twice a day at certain hours : and until the desired intention can be established in this way, some gentle laxative may be taken occasionally, as mentioned under the head of Dyspepsia. Harrowgate water may be used with a fair prospect of advantage in correcting the obstinate costive habit of body that accompanies hypochondriasis; and this habit, when removed by mineral waters, appears to be less liable to return than when only the resinous and drastic cathartics are employed. Flatulency is another constant attendant, and is to be prevented by making use of carminatives, essential oils, and spices, formulae of which will likewise be found under the head of Dyspepsia. Besides these affections, hypochondriacs are apt to be troubled with spasmodic pains in the head and stomach : to relieve which, it may be proper to employ such medicines as aether, musk, and opium, either given separately or combined together*. Asafoetida, castor, camphor, valerian, volatile salts, salt and oil of amber, are medicines which are likewise much employed in the cure of the disease: and therefore when the patient loses a confidence in the one, we can readily substitute another, hypochondriacs being seldom satisfied, unless they are liberally supplied with some drug or other. Various forms of these remedies will be found under the heads of Hysteria and Epilepsy. Nervous people are apt to be troubled with what are termed muscae volitantes (atoms flying before the eyes), which, though * 1. J3L Spirit. ./Ether. Sulph. f ^jss. Capiat fll xx —xxx. pro dos. Vel, 2. IJ; Misturae. Moschi, f. ^iss. Spir. ./Ether. Sulphur, fll xx. M. ft. Haustus ter in die sumendus. Vel, 3. R Infus. Gentian. C. f. gjss. Tinct. Card. C. f. 3ij. Spirit, ..Ether. Sulphur, fll Xiij. Tinct. Opii, fll xj. M. ft. Haustus. Vel, 4/rxSpt. Carui, f fss. Misturae Camph. f ?v. Spir. ./Ether. Sulph. f. 3j. Tinct. Opii, fll xxv. ----Lavend. C. f. fll xxx. ft. Mistura, cujus sumat cochl. larg. ij. ter nuatervedie. * 1. Take Spirit of Sulphuric JElher, from thirty to fifty drops, for a dose. Or, 2. Take Musk Mixture, one ounce and a half. Spirit of Sulphuric ./Ether, thirty drops. Make them into a draught, to be taken three times a day. Or, 3. Take Compound Infusion of Gentian, one ounce and a half. -------- Tincture of Carda- moms, two drachms. Spirit of Sulphuric .'Ether,thirty- five drops. Tincture of Opium, sixteen drops. Mix them for a draught. Or, 4. Take Spirit of Carraway, half an ounce. Camphor Mixture, five ounces. Spirit of Sulphuric .Ether, one drachm. Tincture of Opium, forty drops. Compound Tincture of Lavender, forty-five drops. Mix them, and let two large spoonsful be taken three or four times a day. Order 11. HYrocHONDRLve affection. $65 harmless and slight, often excite alarm and apprehension on the part of such patients, and may be mistaken for amaurosis, or inci- pient cataract: but whenever the appearance of muscae volitantes is unaccompanied with the sensation of a mist, which more or less obscures the appearance of objects, we may safely conclude that it is not a symptom of cataract ; and whenever this appearance is not accompanied with a fixed state of the pupil, it may be safely inferred that it is not a symptom of gutta serena*. The plan of cure for these muscae volitantes is to relieve the mind from intense application, and from objects of anxiety ; to clear the bowels by a brisk purgative, and then to give volatile medi- cines. Local bleeding, or any other debilitating treatment, is com- monly injurious. In hypochondriasis, as well as in most other nervous diseases, it is too much the custom with many to addict themselves to a fre- quent and immoderate use of opium, in some form or other: but this remedy should be carefully shunned, unless on urgent occa- sions ; for although it may afford some little relief for the present, it will nevertheless, by a constant use, greatly add to the disease. The immediate effect produced by opium upon such as addict them- selves to its use is, that with an increase of the frequency of the pulse the heat of the body is generally somewhat augmented, so as to produce very often flushings in the face; and from a depressed state, they become active and alert with an exhilaration of spirits; but after the operation of the remedy is over, depression of mind ensues, the body is cold and heavy, and in this dull and indolent condition it remains until the dose is repeated ! The peculiar power which the citric acid possesses of counteract- ing the noxious effects of opium is deserving of attention by those who accustom themselves to a regular use of this drug ; and it has indeed been recommended by some physicians, that with every dose of opium a proportion of the juice of lemons, or oranges, in the quantity of two ounces to the grain of opium, should be taken : by this means the uneasiness which the medicine often occasions will be prevented, its depressing consequences avoided, and the ten- dency to constipation obviated. To a very free u-e of the vegetable acids is ascribed the slight effect which opium produces on the Turks, and not to the influence of coffee, as has been alleged by- some. These people, as well as others of the eastern nations, are in the habit of drinking daily large quantities of sherbet, which is a liquor composed of the juice of lemons or oranges, mixed with water and sugar. From the quantity of acid in the composition of the black drop, a preparation of opium now much used, it will often stay upon the stomach when other preparations of this drug will not, and a long continued use of it may perhaps be less injurious to the constitu- Soe Medico-Chirurgical Transactions of London, vol. v. Essay 18th. 366 neuroses, or nervous diseases. Class II. tion from the same cause. The original recipe for the black drop (see Dr. Armstrong's Practical Illustrations of Typhus) is given below*. Many of those who labour under a lowness of spirits have re- course to wine, or other fermented liquors, and what is still worse, to spirituous ones, in order to raise them. The momentary relief so obtained is much too dearly bought by the far greater languor which succeeds : and the necessity of increasing the quantity of these liquors in order to obtain the same effect, irrecoverably ruins the health, and this in the most miserable manner, as has been noticed under the bead of Dyspepsia. It is remarked by the judicious writerf before alluded to, that the best way of attempting to conquer the vice of intemperance in another, especially when it has been induced (as very frequently is the case) by some permanent or weighly cause of sorrow, is to picture to the mind of the patient the agreeable change in his situation which would be likely to arise from an alteration in his mode of life, rather than to present to him those deeper shades which must successively ensue from a continuance of his ignomi- nious servitude and habits of fatal indulgence. The latter, though the more common mode of endeavouring to effect the reformation of an unfortunate inebriate, is in general calculated only to confirm and aggravate the evil, by sinking his spirits lower, and in some instances, perhaps, converting the languor of dejection into the mental palsy of despair. It is not easy to determine whether the use of opium or of strong fermented liquors is most detrimental to the human consti- tution : unluckily the victims who addict themselves to either are insnared by a habit which they find it impossible to relinquish, because the constitution, when habituated to a strong stimulus, becomes incapable of carrying on the functions of life without continual excitement, which of itself brings on debility and pre- mature decay. Grievous, however, as is the depression which takes place, as the second effect of all fermented liquors, that which succeeds to the excitement produced by opium in any shape is still more into- lerable. It is of course a task less difficult to refrain from the former than the latter, when tbe latter has been regularly applied to for temporary comfort or support, on a desertion or prostration of the spirits. To answer the third indication of strengthening the alimentary * Take half a pound of opium sliced, three pints of good verjuice, one ounce and a half of nutmegs, half an ounce of saffron. Boil these to a proper thickness; then add a quarter of a pound of sugar, and two spoonsful of yeast. Set the whole in a warm place near the fire for six or eight weeks ; then place it in the open air until it becomes like a syrup. Lastly, decant, filter, and bottle it, adding a little sugar to each bottle. These ingredients, when properly mixed, should yield about two pints of Ihe strained liquor. Oiu> drop of it is supposed to be equal to three drops <n the liver, spleen, and pancreas, which are often found in a hard, scirrhous, or other diseased state. Another very material difference might be pointed out between these two diseases, which is, that hysteria is much relieved by advancing in age, whereas hypochondriasis usually becomes aggravated. The two diseases have been often confounded together; but from considering the foregoing circumstances, it appears that a proper line of distinction should be drawn between them. The hysteric passion likewise differs from a syncope, as in this there is an entire cessation of the pulse, a contracted face, and a ghastly countenance ; whereas in the uterine disorder there is often something of a colour, and the face is more expanded ; there is like- wise a pulse, though languid ; and this state may continue two or three days, which never happens in a syncope. It also differs from apoplexy, in which tl e abolition of sense and voluntary motion is attended with a sort of snoring, great dif- ficulty of breathing, and a quick pulse; which do not take place in hysteric cases. It differs from epilepsy, in that this is supposed to arise in conse- quence of a distention of the vessels of the brain ; whereas in hys- teria, the spasmodic and convulsive motions arise from a turgescence of blood in the uterus, or in other parts of the genital system. Hys- teria may be distinguished from epilepsy by the globus hystericus, by the great flow of limpid urine, by the sudden transitions from laughing to crying, and by the fear of death preceding and succeed- ing to the paroxysm. However dreadful and alarming an hysteric fit may appear, still it is seldom accompanied with danger, and the disease never termi- nates fatally, unless it changes into epilepsy or mania, or the patient is in a very weak reduced state. In the cure of hysteria two indications are to be attended to. The first is to allay the spasmodic symptoms which consti- tute the fit ; and The second, to lessen the excitability of the nervous system. Order HI. hysteric disease. 371 and strengthen the whole frame during the intermissions of the paroxisms. The first of these indications is to be answered by bleeding, if the patient is young and plethoric, the pulse full, and the attack quite of a recent nature; but in wfak and delicate constitutions, or where the disease has bi en of long standing, we should never have recourse to this operation. During the fit it will be the safest practice to rouse the patient by applying burnt feathers, asafcetida, or volatile salts or spirits, to the nose; by rubbing the temples with aether, and by putting the feet into warm water. Dashing cold water over the extremities and face is sometimes attended with a good effect. In case of costiveness, a laxative clyster, with an addition of asa- fcetida or castor, may be thrown up into the intestines. AVhere the fit continues for any length of time, I have seen very speedy and effectual relief afforded by administering clysters composed of turpentine*. We may at the same time apply a small blister to the inside of^each leg. During the fit, due care is to be taken that the palient sustains no injury from the violence of her struggles. As soon as she is perceived to be capable of swallowing, some antispasmodic, as asafcetida, castor, ammoniated tincture of valerian, aether, &c. should be given to her frequently. Such medicines may either be administered separately, or be combined together, as in the formula? belowf. In those cases where the spasms are very * 1. ft 01. Terebinth f. 3i»j- Mucilag. Gum. Acac. f. ^ss. Misceantur bene simulin mortario, et adde *. Decoct. Avenae, f. ^xi. ft. Enema. t 2: ft Mistura? Asafcetid. f. %vj. Tinct. Valerian. Ammon. f 3'j- Spir. MWitr. Sulphuric, f. 3j- M ft. Mistura, cujus sumat aegra cochl. ij. eex- tis horis. Vel, 3. ft Tinct. Valerian. Ammon. f. 3j- ----Lavend. C. f. 3'j- Spirit. Cinnam. f. 3"j- Aq. Purae, f. |vj. M. ft. Mistura, capiat, cochl. ij. pro dos tei quaterve in die. Vel, i, ft Aq. Cinnam f. |jss. Tinct Castor, f. 3j. Spirit. Ammon. Foetid, fllxjv. ' 1. Take Oil of Turpentine, three drachms. Mucilage of Gum Acacia, half an ounce. Mix them well together in a mortar, and add Thin Gruel, eleven ounces, for a clyster. f 2. Take Mixture of Asafcetida, six ounces. Amraoniated Tincture of Valerian, two drachms. Spirit of Sulphuric iEther, one drachm. Of this mixture the patient may take two table-spoonsful every six hours. Or, 3. Take Ammoniated Tincture of Valeri- an, one drachm. Compound Tincture of Lavender, two drachms. Spirit of Cinnamon, three drachms. Pure Water, six ounces. Mix them, and let the dose be two table- spoonsful three or four times a day. Or, 4. Take Cinnamon Water, one ounce and a half. Tincture of Castor, one drachm. Fetid Spirit of Ammonia, twenty drop5. 372 NEUROSIS, OR NERVOUS DISEASES. ClaSS It violent, and the fit of long duration, opium may be employed in addi- tion to other antispasmodics. In common cases it will, however, be best to avoid its use, as it seldom fails to leave the patient remarkably low, particularly if long continued. In cardialgic paroxysms of the hysteric kind, the liquor potass© subcarbonatis in doses of twenty drops, frequently repeated, has been found an excellent palliative remedy, and may therefore be pre- scribed. The second indication is to be answered by giving medicines during the intermissions of the paroxysms to strengthen the system, such as the cinchona bark, and other bitters, with the sulphuric acid, and cha- lybeates ; proper formulae of which have been inserted under the bead of Dyspepsia ; but if more agreeable to the practitioner, those men- tioned below* may be substituted. Mineral waters are found to be very efficacious in hysteric affections, and their powers may greatly be increased by proper exercise, parti- cularly riding on horseback, together with early rising, a generous nu- tritive diet, cool dry air, and cold bathing. ^ In addition to these, the mind is to be kept constantly easy and cheerful, and, if possible, to be always engaged in some agreeable and interesting pursuit; for which reason watering places are well adapted for those who are subject to hysteric affections, and particularly where they have taken their origin from grief, anxious thoughts, or other dis- tresses of the mind. If the stomach is affected at any time with phlegm, so as to excite Spirit. jEther. Sulphuric. V\ xx. M ft. Haustus 4ta aut 6ta quaq. hora sumendus. Vel, i. ft Spirit. Ammon. Foetid, i. ^ss. AT. xv. —xx. pro dos. Vel, 6. ft Spirit. jEthcr. Sulphuric, f. ^ss. Capiat V\ xx.—xxx. in quovis vehiculo. "' 7- ft Ferri Subcarbonat. gr vj". Extract. Cinchonae, 3j. Syrupi, q. s. M. ft. Bolus bis in die sumendus cam Infus. Quassia?, f. ^ij. Vel, 8. ft Extract. Cinchonae, Pulv. Myrrh, aa 3j- Ferri Sulphat. 3»s. OJ. Carui, fll v. Syrup. Zmgib. q. s. M. Fiant pilula; xxxvj. quarum ij. capiat aegra ter quaterre in die; superbibendo Infus Gentian. C. f. ||j. Spirit of Sulphuric ./Ether, thirty drops. Mix then for a draught, to be taken every four or six hours. Or, 5- Take Fetid Spirit of Ammonia, from twenty-two to thirty drops for 1 dose Or, G. Take Spirit of Sulphuric ;Ether, from thirty to forty-five drops in any vehicle. * 7. Take Subcarbonate of Iron, six grains. Extract of Peruvian Bark, ont scruple. Common Syrup, a sufficiency t» form a bolus, which may be taken twice a day, washing it down with about two ounces of an Infusion of Quassia. Or, 8. Take Extract of Peruvian Bark, Powdered' Myrrh, of each one drachm. Sulphate of Iron, half a drachm. Oil ef Carraway, eight drops. . Syrup of Ginger, a sufficiency t» form the mass into thirty-six pills ,of whick the patient may take two, three or four times a day, wash ing them down with twe ounces of the Compound Infasion of Gentian. Order HI. hysteric disease, 37S nausea, a gentle emetic may be taken to remove it; ©r if there is a tendency to costiveness, it may be obviated by some gentle laxative^ as advised under the head of Dyspepsia. When hysteric affections arise from a suppression or obstruction of the menses, these evacuations must again be promoted by adopt- ing the means recommended under those particular heads. Hysterical women are often afflicted with slight spasmodic affec- tions in various parts of the body, and particularly with cramps, which are most apt to seize them in bed, and when asleep. In mild cases of this nature, immersing the feet and legs in warm water will often be sufficient to remove them ; but where the spasms are violent, and of some duration, we must attempt the cure by opiates, musk, Kther, camphor, &c. internally, and by the warm bath, and friction* with anodyne liniments externally.—See Tetanus. In those cases where the stomach becomes affected with cramp,. we must have recourse to considerable doses of aether combined with opium*. Its external region may likewise be anointed with a liniment of the same naturef. If the feet are cold, bottles filled with warm water should be applied to them. Throwing up an emollient clyster into the intestines may also be proper, particu- larly where costiveness accompanies the spasmodic affection of the stomach. To lessen the irritability or excitability of the system, and pro- duce permanent effects, some physicians have recommended a use of antispasmodics along with tonics. The under-mentioned formulas J * 9. ft Aq. Cinnam. f. |j. Spir. ^ther. Sulphuric, f. 3j. Spirit. Carui, f. |ss. Tinct Opii, ffl. viij. ------Castor, f. 3ss. ft. Haustus ter quaterve die capiendus. t 10. ft Spirit Camphorae, f. |ij. Tinct. Opii, f. |ss. Spirit. .ZEther. Sulphuric, f, M. ft. Embrocatio. ^ ll.ft Moschi, gr. vi. Camphorae, gr. iij. Extract. Cinchon. 3ss. Syrup, q. s. M. Q. Bolus bis terve die sumendus. Vel, 13. ft Pulv. Myrrh. Castor, aa 3j. Ferri Sulphat. 3g. Extract. Anthemidis, 3s? 01. Succin. tit* 3iij. * 9. Take Cinnamon Water, one ounce. Spirit of Sulphuric v£ther, one drachm ——Carraway, half an ounce. Tincture of Opium, twelve drops. --------Castor, half a drachm. Mixthem,and let the draught be taken three or four times a day. f 10. Take Camphorated Spirit, two ounces. Tincture of Opium, half an ounce. Spirit of Sulphuric ./Ether-, three drachms. Mix them for an embrocation. X U. Take Musk, six grains. Camphor, three grains. Extract of Peruvian Bark, ten grains. Syrup, a sufficiency to form & Bolus, which is to be taken twice or thrice. a day. Or, 12. Take Powdered Myrrh, Castor of each one drachm. Sulphate of Iron, one scruple. Extract of Chamomile, haft' a drachm. Oil of Amber, eight drops. 374 NEUROSES, OR NERVOUS DISEASES. ClaSS II may be advised on the occasion, the patient washing them down with a little valerian tea. From the great disposition of the stomach to acescency in this dis- ease, as well as in hypochondriasis, a diet of animal food will be most proper. Wine diluted with a sufficient quantity of water should be preferred to all other liquors for common drink. EPILEPSIA, or EPILEPSY. This disease consists in a sudden deprivation of the senses, ac- companied with a violent convulsive molion of the whole body. If attacks by fits, and after a certain duration goes off, leaving the person most commonly in his usual state ; but sometimes a consi- derable degree of stupor and weakness remains behind, particularly where the disease has frequent occurrences. It is oftener met with among children than grown persons, and boys seem more subject to its attacks than girls. Its returns are periodical, and its paroxysms commence more frequently in the night than in the day, being some- what connected with sleep. It is a disease sometimes counterfeited) in order to extort charity or excite commiseration. Occasionally we meet with epilepsy in combination with mania. Epilepsy is properly distinguished into sympathic and idiopathic ; bein< considered as sympathic, when produced by an affection in some other part of the body, such as acidifies in the stomach, worms, teething, &c. ; and idiopathic, when it is a primary disease, neither dependant on, nor proceeding from any other. The causes which give rise to epilepsy are blows, wounds, frac- tures, and other injuries done to the head by external violence, to- gether with plethora of the vessels of the head, lodgements of water in the brain, tumours, concretions, polypi, and a deformity in the shape of fhe bones in any part of the skull. Epilepsy has also beea known fo arise from an affection of the spinal marrow ; and it is to inflammation in that part of a more chronic form that those shaking palsies, which are attended with pain, have been imputed. Violent affections of the nervous system, sudden frights, fits of pas- sion, great emotions of the mind, frequent intoxications, acute pains in any part, worms in the stomach or intestines, teething, the sup- pression of some Ion^-accustomed evacuation, too great emptiness or repletion, and poisons received into the body, are causes which likewise produce epilepsy. Sometimes it is hereditary, and at others it depends on a predisposition arising from a mobility of the sensorium, which is occasioned either by plethora or a state of debility. Syrup. Simpl. q. s. M. Common Syrup, a sufficiency to Fiant pilul. xxxvj. quarum capiat aegra iij. form the mass. Divide this into thirty-six mane et hora decubitus cum cochl. ij. pills, and let the patient take three night magnis InfusiRad. Calumba?. and morning, with two table-spoonsful •* an Infusion of Calumbo Root. Order III EPILEPSY. 375 We are told by Dr. Parry*, that whatever may be the primary cause of epilepsy, it usually depends immediately on excessive im- petus of blood in the vessels of the brain. An attack of epilepsy is now and then preceded by a heavy pain in the head, dimness of sight, noise in the ears, palpitations, flatu- lency in the stomach and intestines, weariness, and a small degree of stupor, and in a few cases there prevails a sense of something like a cold vapour or aura rising up to the head ; but it more gene- rally happens, that the patient falls down suddenly without much previous notice ; his eyes are distorted or inverted, so as that only the whites of them can be seen ; his fingers are closely clenched ; his limbs and the trunk of his body, particularly on one side, are much agitated ; he foams at the mouth, and thrusts out the tongue, which often suffers great injury from the muscles of the lower jaw being also affected ; he loses all sense of feeling, and not unfre- quenlly voids both urine and faeces involuntarily. After a continuance of the convulsions for some time they abate gradually, and the patient continues for a short period in a state of insensibility, but on coming to himself, feels very languid and ex- hausted, and retains not the smallest recollection of what has passed during the fit. When the disease proceeds either from tumors, polypi, concre- tions, or a deformity in the bones of the skull, the case is hopeless. When it arises from an hereditary disposition, or comes on after the age of puberty, or where the fits recur frequently, and have become habitual, or are of long duration, it will be very difficult to effect a cure ; but when it attacks at an early age, and is occasioned by worms, or any accidental cause, it may in general be removed. In some cases it has been entirely carried off by the recurrence of a fever, or by the appearance of fhe menses, or of a cutaneous erup- tion. It has been known to terminate in apoplexy, and in some instances to produce mental derangement, or a loss of the powers of the mind, and so to end in idiotism. Epilepsy has been perceived to disappear suddenly about the age of puberty where it has attacked children of five or six years old, and where no treatment has had any effect. The number of fits are always increased by parturition, and by every other thing which*- has a tendency to debilitate the system. The appearances usually to be observed on dissection, are serous and sanguineous effusion, a turgid tense state of the vessels of the brain without any effusion, a dilatation of some particular part of the brain, excrescences, polypi, and hydatids adhering to it, and obstructing its functions, and likewise ulcerations, In some in- stances the pituitary gland is found in a diseased state, even when every other part of the brain has appeared nafura:. In epilepsy (he intentions of cure should vary according to the cause which occasions the disease. * See his Elements of Pathology and Therapeutics. ^76 &EUROSES, OR NERVOUS DISEASES. ClaSS III When it is sympathic, and arises from worms, medicines pos- sessed of the power of destroying or dislodging these vermin ought to be employed. As an anthelmintic, the oil of turpentine in doses of from half an ounce to one ounce has been found a very useful medicine in some cases of epileptic fits. When they proceed from teething, that part of the gum which appears to be inflamed should be deeply scarified, the body should be kept open by laxative medi- cines or emellienf clysters, and the feet be bathed in warm water. When cases occur without any symptom of direct pressure on the brain, and there is occasional sickness, attended with flatulency, dis- turbed sleep, and other marks of disordered digestion, either preceding or following epileptic paroxysms, it will be right, especial- ly in the former case, to evacuate the contents of the stomach fey an emetic, consisting of a solution of the sulphate of zinc in an aqueous infusion of ipecacuanha, and to repeat it in six, eight, or ten days, according to circumstances*. The dose must vary according to the age of the patient, and the different degrees of irritability of the stomach, as no general rule can apply to every case. Afterwards, if the stomach should exhibit marks of weakness, light bitter infusions may be given, assisted by some active stimu- lant, as ammonia or oleum cajeputi. When there is a great prevalence of acid, from the imperfect digestion of vegetable food, soda, liquor potassae, or liquor potassae subcarbonatis, may be combined with the bitter. If the bowels are confined at the same time, magnesia may be employed advantageously. On the contrary, if too much relaxed, which is seldom the case, cretaceous preparations may be resorted to. If epilepsy appears to proceed from any suppressed discharge, in particular the bleeding piles, leeches should be applied to the hemorrhoidal vessels, together with fomentations, and we should at fhe same time administer aloetic cathartics. Where it attacks children of a costive habit, and seems to take jfs rise merely from a foulness of the bowels, active purgatives should be employed. A combination of the submuriate of mercury and jalap will be very proper. If it arises from any stimulus, which by exciting pain occasions the complaint, this ought to be removed as quickly as possible. If it is a case of sympathic epilepsy, and is accompanied with the aura epileptica, we should then endeavour to destroy the part, either by cutting it out, or by applying caustic to it; and when these means cannot be adopted, we ought then to endeavour to correct the morbid affection in it, either by blisters, or by inserting an issue in fhe part. Should the disease seem to proceed from the partial division of a nerve, and it can be got at readily, we ought to cut through it * See Dr. J. Clarke on the Diseases of Children. Order HI. EPILEPSY, 377 in the same manner as in tetanus. Cutting off the communication with the brain has likewise been attempted by the application of ligatures upon the limb, above the part from which the aura 8 T case which was successfully treated in this way, is recorded by Mr Adolphus T. Leoffler, Professor of Altona, in his Observations on Medicine and Surgery. An epileptic patient felt, on every attack, a sense of coldness at the sole of the foot, and which gradually ascended till it reached the head. It occurred to tbe Professor to make a strong ligature above the knee of the affected limb, before the cold sensation had proceeded so high. The method succeeded ; and as often as he took this precaution sufficiently early, he prevented the attack from taking place. # In the idiopathic epilepsy, the cure consists in avoiding the occa- sional causes, and in removing or correcting those which predispose to it. . The occasional causes which are to be avoided, are over distention, turgescence, intoxication, fits of passion, and all other emotions of the mind; and as the disease is confirmed by repetition and habit, so the avoiding frequent recurrences of it is of the utmost im- portance. It is a fact well supported, that in some instances the disease has been found to continue from custom alone, after the original cause had long eeased to act. In such cases, our endeavours should be exerted to make nature discontinue this custom if possible. When an attack can be foreseen, no medicine, perhaps, under such circumstances, will be more likely to prevent an epileptic fit, than an emetic given about an hour before its approach. Removing to another country, and changing former habits and the manner of living, may likewise be serviceable in such cases. If the predisposition to the disease has arisen from a plethoric state of the system, or from a turgescence in the vessels of the head, this is to be obviated by bleeding, both generally and topically, but more particularly the latter; by an abstemious diet and proper exercise, and by issues between the scapulae, or a seton in the neck. These last may not only be supposed to be good remedies for obviating the plethoric state of the system, but may likewise be the means of determining occasional tumescences to such places, and therefore of diverting them, in some measure, from their action upon the brain. In those cases where, from frequent parox- ysms, a morbid condition of the encephalon has prevailed, the in- sertion of a seton in the neck has been attended with a very happy effect. In some cases of epilepsy, the patient lies in a comatose state after the paroxysm of convulsion has ceased, owing to a violent determination of blood to the head, his breathing is stertorous with foaming at the mouth, and the pulse is full* hard, and beating one hundred in a minute. In such cases, bleed to the extent of twenty ounces or more, order cold applications to the forehead, temples, 48 378 .NEUROSES, OR NERVOUS DISEASES. ClttSS II. and head, and evacuate the bowels freely by a powerful dose of some active purgative, assisted by an enema of the same nature. If these means do not restore the patient to a stale of sensibility, repeat the bleeding again, apply leeches to the temples, and a large blister to the neck, or between the shoulders. Epilepsy is one of the diseases in which the digitalis has been found serviceable, but most so in those cases where a plethoric state or turgescence in the vessels of the head prevails. To produce, how- ever, a permanent effect, the constitution must be kept under its influence for some weeks, by giving from half a grain to one grain of the powder, or from fifteen to thirty drops oP tbe tincture, three or four times a day. Under the head of Mania, I have mentioned a severe case of epilepsy in a middle-aged married woman, ac- companied with mental derangement, wherein, by administering the digitalis in the manner just noticed, and carefully guarding against the exciting cause (frequent intoxication), a complete cure was effected. When the predisposition is owing to a state of debility, which is most usually the case, we are to obviate and prevent its effects by recom- mending the patient to breathe a cool air, to make use of a generous nutritive diet, to take daily exercise adapted to his strength, particu- larly on horseback, and to go frequently into a cold bath; and besides adopting these steps, he may enter on a regular course of antispasmo- dic, astringent, and tonic medicines. The antispasmodics in most general use are, valerian, castor, musk, aether, oil of amber, oleum cajeputae, arnica montana, belladonna, hyoscyamus, digitalis, and opium, all of which may be given, as advised under the heads of Hysteria, Hypochon- driasis, and Palsy, or as prescribed below*. A combination! of opium and valerian, or of opium and musk, will be likely to prove * 1. R Aq. Anethi, f. ^jss. Tinct. Valer. Ammon. TH, xx. ----Castor, f. 3j. Spirit. iEther. Sulphuric. TTl xx. M. ft. Haustus bis terve die sumendus. Vel, 2. I£ Infus. Cort. Cascaril. f. |jss. Tinct. Valerian. Ammon. TTl xx. ----Calumb f. 3*j- ----Hyoscyami, TTl xv. M. ft Haustus t 3. R Moschi, CYstorei, aa gr. x. Opii, gr.ss Confect. Rosae, q. s. M. ft. Bolus 6ta quaq. hora capiendus. * 1. Take Dill Water, one ounce and a half. Ammoniated Tincture of Valerian, thirty drops. Tincture of Castor, one drachm. Spirit of Sulphuric iEther, thirty drops. Mix them for a draught, to be taken twice or thrice a day. Or, 2. Take Infusion of Cascarilla Bark; one ounce and a half. Ammoniated Tincture of Valerian, thirty drops. Tincture of Calumbo,tno drachm*.. --------Henbane, twenty drops. Mix them for a draught. t 3. Take Musk, Castor, of each ten grains. Opium, half a grain. Confection of Roses, a sufficiency to form a bolus, which may be takes every six hours. Order III ,EPILEPSY. 379 valuable remedies. In particular, they should be given a short time before the expected return of the paroxysm, and be repeated at proper intervals, increasing the dose in a gradual manner in propor- tion to the violence or frequent recurrence of the fits. Where thedisease depends upon a plethoric state, it would be highly improper to give opium; but where no plethora exists, and it seems to depend upon irritation, or upon increased excitement, opium will prove a safe and powerful remedy. When given in a large dose, such as two grains in substance, or sixty or seventy drops in tincture, on the approach of a fit, it has been known to prevent it altogether; but should it even fail in this, it will infallibly be found to lessen its violence. . If the stomach rejects the internal use of opium, its external ap- plication may possibly be resorted to with much advantage, and it may likewise be employed in this way during the convulsions. The whole spine of the back may be moistened with tinctura opii, or a liniment consisting of six grains of pure opium, well triturated with a little prepared lard, may be rubbed in. The astringent medicine most celebrated formerly in the cure of epilepsy, was the misletoe, or viscus quercinus. It was given in doses of frcru half a drachm to a drachm of the powder, or about an ounce o: the infusion repeated twice a day. It was indeed looked upon by many more as an object of superstition than of real utility, and for many years past has experienced almost total neglect. A modern writer on epilepsy* speaks, however, highly in its favour, and has recited several cases which were radically cured by it. As a tonic, the cinchona bark has been much employed in the cure of this disease. Its use seems, however, best adapted to those epi- lepsies which recur at certain periods, and which are without pletho- ra : in which cases, if it is given in a considerable quantity some little time before the expected recurrence, it will be very likely to prove serviceable. When taken for a constancy, it may be combined with valerian, he. as belowf. Metallic tonics having been found more powerful than the ve- getable ones, have therefore been more generally employed. The " See Dr. Henry Frazer's Treatise on this Disease. Vel, 4. U 01. Succin.f. ^ss. Tinct. Opii, f. 3>'j. M. Guttie viginti bis terve in die sumendae ex cyatho aqua? purse. f 6. R Decoct. Cinchon. f. 3x. Tinct. cjusdem C. f. 3ij. ----Valerian. Ammon. f. 3ss. M, Pro haustti ter in die sumendo. Or, 4. Take Oil of Amber, half an ounce. Tincture of Opium, two drachms. Mix them, and take twenty drops twice or thrice a day in a little water. 16. Take Decoction of Peruvian Bark, ten drachms. Compound Tincture of the same, two drachms. Ammoniated Tincture of Valerian, thirty drops. Mix these for a draught,, to be taken thrice a day. 380 NEUROSES, OR NERVOUS DISEASES. CUlSS 11 preparations of iron most used are, the ferri sulphas, the ferrutn ammoniatum*, and the ferri carbonas. Those of copper are the cuprum ammoniatum of the Edinburgh Dispensatory, and the cupri sulphas, whiclif may De g.ven in small doses at first, repeated twice a day, increasing them gradually to as much as the stomach will bear. The pulvis stanni, and other preparations of tin, have likewise been used in the cure of epilepsy; but their effects seem doubtful. The oxyd of zinc has been much extolled for its virtues in this disease. The dose is from one grainj to three, four, or five. It will always be the best way to begin with a single grain, repeated three or four times a day, and so to increase the dose gradually according to the effect it produces on the stomach. The sulphate of zinc is another metallic tonic much recommended in this disease we may give half a grain of it thrice a day, and increase the dose gradually. Arsenic has likewise been employed in the cure of epilepsy with * 6. ft Ferri Ammoniat. gr. x —xv. Extract. Gentian, gr. x. Syrup, q. s. M. ft. Bolus ter in die sumendus. Vel, 7. ft Titict. Ferri Ammoniat. f. ^j. Capiat nT, xv. bis terve die in aquae frigid. cyatho. t 8. ft Cupri Ammoniat. gr. j.—iv. Confect. Aurant. gr. x. M. ft. Bolus bis in die adhibendus. Vel, 9. ft Cupri Sulphat. gr. iij. Extract. Cinchonae, gr. xij. Opii, gr. ij. Syrup Misceantur bene in massam et in pilulas vj. divid. quarum ca piat aeger unam vel duas ter in die. X 10. ft Zinc. Oxydi, gr. xij. Pulv. Cinnam. Comp. gr. xv. ----Cinchonae, 3j- M. et in chartul. xij. divide, quarum nnarn sumat ter in die. Vel, 11. ft Zinc. Oxydi, gr. xxiv. Extract. Gentian. 3ss. Syrup, q. s. M. ft. Massa in pilulas xij. dividenda, quarum j.. sumat mane et vespere cum Decocti Cic chouse, |isj. * 6. Take Ammoniated Iron, ten to fifteen grains Extract of Gentian, ten grains. Syrup, a sufficiency to form • bolus, which may be taken thrice a day. Or, 7. Take Ammoniated Tincture of Iron, twenty two drops twice or thrice a day in a glassful of water t 8. Take Ammoniated Copper, one enup, gradually increasing :* ».o four grains Confection of Orange Peel, ten grains. Make them into a bolus, to be taken twice a day. / Or, 9. Take Sulphate of Copper, three grain*. Extract of Bark, twelve grains. Opium, two grains Syrup, a sufficiency. Divide the mass into six pills, of which one or two may be taken thrice a day. X 10. Takt Oxyd of Zinc, twelve grains. Compound Powder of Cinnamon, fifteen grains. Powder of Peruvian Bark, one drachm. Mix them, and divide the Powder into twelve papers, of which take one three times a day. Or, 11. Take Oxyd of Zinc, t wenty-fourgrains. Extract of Gentian, half a drachm. Syrup, a sufficiency to form the mass, which divide into twelve pills, whereof two may be taken morning and evening, with one ounce and a half of a Decoction of Peruvian Bark. Order III epilepst. 381 some success. If will be best administered in the form of solution* as recommended under the head of Intermittent Fever. Some instances of the cure of epilepsy having occurred from am accidental use of mercury, this also has been proposed as a remedy. The nitrate of silver* has been found to be a valuable medicine in the cure of epilepsy, even where the disease has been of many- years' standing. Two cases of this nalure are recorded in the Medical and Physical Journalf. It will be best to begin wilh a quarter of a grain thrice a day, which dose will be sufficient for an adult. A singular occurrence attendant on a long course of this medi* cine is, that the skin of the patient has been known to contract a blue colour over the whole of the bodyj without there being the least disease of the heart, and where neither the circulation nor respiration were in the least affected. As the blood in these pa- tients is always of the natural hue, it cannot be doubted, I think,. with others, that the blue colour must be looked for in the reticula malpighiana, in which it is produced by the nitrate of silver. In some of the worst cases of epilepsy, in which the fits were long and violent, as well as frequent throughout the course of the day, and where the disease had been of some standing, electricity has been found to render fhem weaker, and to reduce their number very materially in a short space of time. When other means fail to- procure the desired effect, we ought therefore to have recourse to this remedy, or galvanism. The oleum terebinthinae has lately been used in some cases of epilepsy with success||, as well as in a few other spasmodic dis- eases : fhe dose should be considerable to produce any effect, viz, one ounce for a delicate female, an ounce and a half for a robust female or small man, and about two ounces for a robust man. The best vehicle for it appears to be milk. The most proper time for administering it will be early in ihe morning, on an empty stomach. It must be obvious, however, that this remedy can only be em- ployed efficaciously in cases depending upon a cause unconnected with diseased organization, and which is producing loo great an ex- citement in the nervous system. In cases connected wilh diseased organization of the brain, the administration of turpentine would in all probability only aggravate the malady by exciting activity in the t See vol. i p. 184, and vol. ii p. 70. X See Medico-Chirurgical Transactions, vol vii. part i p. 279. II See Edinburgh Medical and Surgical Journal, No. 35. * 12. ft Argent. Nitratis, gr. iij. Solve terendo in Aquae Distillatae, fll aliquot, et adde Mica; Panis, q s. ft. Massa in pilulas viginti distribuenda. Unara vel duas sumat bis terve in die. * 12. Take Nitrate of Silver, three grains. Dissolve it in a few drops of Distilled Water, then add Crumb of Bread, a sufficiency to form a mass, which is to be made into twenty pills. The dose may be from one to two twice or thrice a day. 382 NEUROSES, OR NERVOUS DISEASES. ClaSS II. vessels of the morbid organ, which it should be the endeavour of the physician rather to arrest and tranquillize. The diet in epilepsy should consist of such things as are light, nutritive, and easy of digestion, taking care to avoid whatever is apt to prove flatulent. During the intervals, the patient is to keep him- self as cheerful and tranquil as possible, carefully guarding against all violent passions or other emotions; and he should take care never to put himself in a hazardous situation, lest a fit should happen to attack him at that period. When it is present, due care must be taken to prevent him from bruising himself in his struggles; and especially that he does not get his tongue between his teeth. Rubbing the nose, temples, and pit of the stomach with aether, may possibly help to abbreviate the fit by its action on the olfactory organ. A smaller degree of epilepsy is where the sensibility and irritabi- lity remain, but there are spasmodic contractions of the muscles; hence we see many persons affected with twitchings of the face. There are also certain spasmodic pains that come on by paroxysms, which seem likewise of the epileptic kind. When any of these arise as sympathic affections, they are only to be cured by removing the primary disorder upon which they depend; but where they take place independent of any other disease, they are to be treated in the manner just recommended to be pursued in the cure of epilepsy. CATALEPSIS, or CATALEPSY. Catalepsy is that state of the muscular system in which the patients, without fever, lose voluntary motion, and commonly the fuctions of the five senses, but preserve the mobility of the mus- cles, and keep the exact position wherein they are attacked, or arbitrarily placed by other persons. The causes of catalepsy seldom appear to be local, but mostly general. There have been examples where plethora has produced this singular disorder, and where it has been removed by a spontane- ous hemorrhage. Suppressed catamenia, worms, and painful emo- tionsof the in'nd, as terror,grief, disappointment, profound meditation, anger, he. have all occasioned attacks of catalepsy. Women are more frequently attacked by it than men. It sometimes changes into epilepsy, apoplexy, or melancholia, and has been known occasionally to terminate fatally in a few days. We should, in treating the disease judiciously, endeavour to find out the occasional cause, and adapt our remedies accordingly. If supposed to proceed from plethora, we should unload the vessels by cupping at the back of the neck, cathartics, blisters, seton, or an issue. When arising from causes of a debilitating nature, tonics joined with antispasmodics will be proper. During the paroxysms, stimulating cataplasms may be applied to Order 111 DANCE OF ST. VITUS. 388 the palms of the hands and soles of fhe feet. Internally we may administer musk joined with volatiles*, &c. CHOREA SANCTI V1TI, or DANCE of ST. VITUS. This disease is marked by convulsive actions, most generally con- fined to one side, and affecting principally the arm and leg. When any motion is attempted to be made, various fibres of other muscles act which ought not, and thus a contrary effect is produced from what the patient intended. It is chiefly incident to young persons of both sexes, but particularly those of a weak constitution, or whose health and vigour have been impaired by confinement, or by the use of scanty and improper nourishment, and makes its attacks between the age of ten and fifteen, occurring but seldom after that of puberty. By some physicians it has been considered rather as a paralytic affection than as a convulsive disorder, and has been thought to arise from a relaxation of the muscles, which being unable to per- form their functions in moving the limbs, shake them irregularly by jerks. Chorea sancli viti is occasioned by various irritations, as teeth- ing, worms, acrid matter in the bowels, offensive smells, poisons, &c. If arises likewise in consequence of violent affections of the mind, as horror, fright, and anger. Occasionally it depends upon excessive impulse of blood in the brain, and in such cases it is greatly aggravated by whatever increases the action of the heart, and of course relieved by means that lessen this. In many cases it is produced by general weakness and irritability of the nervous system, and in a few it takes place from sympathy at seeing the disease in others, or by imitating them; hence it not unfrequently spreads in public seminaries, particularly among girls, if its progress is not checked by separation. The fits are sometimes preceded by a coldness of fhe feet and limbs, or a kind of tingling sensation that ascends like cold air up the spine, and there is a flatulent pain in the left hypochondrium, with obstinate costiveness. At other times the accession begins with yawning, stretching, anxiety about the heart, palpitations, nausea, difficulty of swallowing, noise in the ears, giddiness, and pains in the head and teeth, and then come on the convulsive motions. These discover themselves at first by a kind of lameness or insta- bility of one of the legs, which the person draws after him in an * 1. & Mistur Moschat. |iij. Aq. Pulegii, ?ij. Spirit, Ammon. Foetid. 3>j- Tinct. Valerian. |ss. M. ft. Mistura, cujus sumat cochl. ij. secundis vel tertiis horis. \ taken every two or three hours 1. Take Musk Mixture, three ounces. Penny Royal Water, two ounces. Fetid Spirit of Ammonia, two drachms. Tincture of Valerian, half an ounce. Mix them, and let two table-spoonsful be <384 NEUROSES, OR NERVOUS DISEASES. CUlSS //. odd and ridiculous manner, as if it was paralytic ; nor can he hold the arm of the same side still for a moment; for if he lays it on his breast, or any other part of his body, it is forced quickly from thence by an involuntary convulsive motion. If he is de-irous of drinking, he uses many Angular gesticulations before he can carry the cup to hi- liead, and it is forced in various directions, till at length he gets it to his mouth, when he pours the liquor down his throat with great haste, as if he meant to afford amusement to the by-standers. Sometimes various attempts at running and leaping take place, and at others the head and trunk of the body are affVcted with convulsive motions. The eye loses \i< lustre and intelligence, and the countenance is pale and expressive of vacancy ; deglutition is occasionally performed with difficulty, and artieuhtion is ofien impeded, and sometimes completely suspended. In the advanced periods of the disease, flaccidity and wasting of the muscular flesh lake place, the con- sequence of constant irritation, of abated appetite, and impaired digestion. In many instances the mind is afflicted with some degree of fatuity, and often shows the same causeless emotions, such as weeping and laughing, which occur in hysteria. When the disease arises in children, it usually ceases again before tbe age of puberty, and in adults is often carried off by a change from the former mode of life. Unless it passes into some other disease, such as epilepsy, or its attacks are very violent, it is not attended with. danger. Where chorea arises in those of a weak irritable habit, and is wholly unconnected with any species of irritation, either of teething, worms, or acrid matter in the first passages, we should not employ evacuants, but have recourse to strengthening remedies, with the view of increas- ing t he tone of the muscular system. Cinchona bark in large doses, with the assistance of cold bathing, has often effected a cur^ ; but the metallic tonics wliich have been advised under the head of Epilepsy, will be more likely to prove efficacious than those of the vegetable class. To tonics we may join antispasmo- dics, such as opium, musk, and camphor, as prescribed under the same head. Hyoscyanms and belladonna are medicines sometimes em- ployed in chorea with success, when all others have proved ineffectual, particularly the latter. When givt n to children, we may begin with about a grain daily, in divided doses, and gradually increase the quan- tity to one grain and a half. During a use of these medicines, if costiveness prevails, it should be removed by some gentle laxative. Should the disease resist these means, it probably may be carried off by strong electrical shocks directed through the whole body. Ter- ror suddenly excited has been known to effect a cure. The application of a perpeiual blister to the os sacrum has in addiiion to electricity been found a valuable remedy. Dry cupping bas in some instances been thought to have proved useful. In some cases of chorea, where from the frequency of the paioxysms a Order III. DANCE OF ST. VITUS. 385 morbid condition of the brain has arisen, the insertion of a seton in the neck, and kept open for a considerable time, has been attended with a happy effect. . Chorea has pretty generally been considered by systematic writers as a disease of debility, and this opinion has been almost univer- sally adopted by practical physicians, inducing them to employ tonics, stimulants, and antispasmodics for its cure; but in many cases this has proved very difficult; and when not i emoved by the change which the system undergoes al the age of puberty, the dis- ease has continued to harass the wretched sufferer ever afterwards. This fact being well established, we should undoubtedly regaro the symptoms of chorea as sometimes depending on local irritation and not on debility; and in such cases they are to be obviated by re- moving the causes of irritation, by scarifying the gums, by expelling worm.-, or by a use of brisk purgatives. From some cases reported in the first number of the Edinburgh Medical and Surgical Journal, and which were received into the Koyal Infirmary of that city, it appears that very complete cures were effected by the frequent ex- hibition of drastic purges, consisting of mercury and jalap. Irrita- tion in the first passages no doubt had occasioned the chorea in these instances. A modern writer tells us*, that having met with many cases of cho- rea which he treated in the usual way, but without success, he was induced to desert the practice, and to consider the disease in a differ- ent light from that in which it had been commonly viewed. He conceived that the debility and spasmodic motions hitherto so much considered, might not be the leading symptoms of the disease, but might depend upon previous and increasing derangement of health, as indicated by irregular appetite and constipation of the bowels. Under this impression he resolved to alter the mode of treating the disease, and began trying the effects of purgative medicines, given regularly in moderate doses. The success of the new practice established, he mentions, the justness of his opinion, and encouraged him to persevere with steadi- ness and activity. To procure a discharge of the indurated and fetid feces, he found it necessary to employ active and strong purgatives in the confirmed stage of the disease, given in successive doses, in such a manner that the latter doses might support the effect of the former; but in the first stage of chorea, while the intestines yet retain their sensibility, and before the accumulation of fsces is great, gentle purgatives, repeated as the occasion may require, he experienced readily to effect a cure, or rather prevent tbe full for- mation of the disease. He mentions, that an occasional stimulus from purgatives will be requisite to support their due action, and to restore their healthy tone, even after a regular appetite for food, a more intelligent eye and lightened countenance, cheerfulness, increas- ing aptitude for firmer motions, the restoration of articulation, and * See Observations on the Utility of Purgative Medicines, by Dr. Hamilton. 3T56 NEUROSES, OR NERVOUS DISEASES. ClaSS II. the power of deglutition, and a renovation of flesh and strength succeed each other. The oleum ferebinthinae in considerable doses has been administer- ed with decided advantage in some cas perceived about the chest, with a pain at the ex- tremity of th° sternum shooting into the back. A stiffness also takes place in the jaws, which soon increases to such a height that the teeth become so closely set together as not to admit of the smallest opening. When the tetanic affection is confined to the jaws, the disease is called trismus. In some cases the spasmodic affection extends no farther; in others, the spasms at this stage of the disease returning with great frequency, become likewise more general, and now affect not only the muscles of the neck and jaws, but likewise those of the whole of the spine, so as to bend the trunk of the body very forcibly backwards, and this is what is named opisthotonos. Where the body is bent forwards, the disease is called emprosthotonos. During the whole course of the disorder the abdominal muscles are violently affected with spasm, so that the belly is strongly retracted, and feels very hard, most obstinate costiveness prevails, and both the flexor and extensor muscles of the lower extremilies 388 NEUROSE?, OR NERVOUS DISEASES. Class II. are commonly affected at the same time, so as to keep the limbs rigidly extended. The flexors of the head and trunk become at length so strongly af- fected as to balance the action of the extensors, and to keep the head and trunk so rigidly extended and straight as to render it incapable of being moved in any direction. The arms, which were little affected before, are now likewise rigidly extended, the tongue also becomes affected with spasm, and being convulsively darted out, is often much injured by the teeth, the jaws at that moment snapping together. It is to this state of the disease that the term of tetanus has been strictly applied. The spasms which recur at first every ten or fifteen minutes, besides being brought on by slight movements of the body and pressure on the abdomen, are, in the advanced stages, excited by the presentation of any subs'ance. solid or fluid, to the lips, so as at first view nearly to re- semble those in a person affected with rabies. Tetanus is seldom at- tended with either nausea or vomiting, or with any fever, but always with most violent pain. The disorder continuing to advance, every organ of voluntary mo- tion becomes affected, the eyes are rigid and immoveable in their sockets, the countenance is hideously distorted, and expresses great distress, the strength is exhausted, the pulse becomes irregular, and one universal spasm puts a period to a most miserable state of existence. With regard to the duration of tetanus, when it proves fatal it generally carries off the patient before the tenth day, but some- times before the fifth ; and the younger the subject the more rapid the disease. When tetanic affections arise in consequence of a wound, puncture, or laceration, tbey are almost sure to prove fatal, as I never but once met with a recovery under such circumstances, during a very exten- sive practice and long residence in the West Indies. The locked-jaw arising in consequence of an amputation, or gun-shot wounds, like- wise proves usually fatal. When these affections are produced by an exposure to cold, they may in most cases be removed by a timely use of proper remedies, notwithstanding a considerable spaee will probably elapse before the patient will be able to regain his former strength. Although there is sometimes a great abatement of the spasms in tetanus, still they are apt to return with renovated force. Dr. Parry* has remarked, that if, in an adult, the pulse by the fourth or fifth day does not reach 100 or 110 beats in a minute, he believes the patient almost always recovers: if, on the other hand, tbe pulse on tbe first day is 120 or more in a minute, few instances, he apprehends, will be found in which he will not die. This observation respecting the acceleration of the pulse has not, however, been confirmed by other practitioners. * See bis Cases of Tetanus and Rabies Contagiosa, p. 18. Order 111 cramp. 889 On dissections of this disease, slight effusions within the cranium have been observed in a few instances; but in by far the greater number nothing particular has been discovered either in the brain or any other organ. In some instances, however, tbe blood is not found in coagula, but fluid like molasses, as in animals killed by lightning, appearing to indicate that the whole muscular fibres of the arterial system had partaken of the general spasmodic action. The bodies of tetanic patients run rapidly into putrefaction after death. It is stated by Baron Larrey, that in his examination of bodies of persons who have died of tetanus, he found the pharynx and ceso- phagus much contracted, and their internal membranes red, in- flamed, and covered with a viscid reddish mucus. Others have discovered the intestines much inflamed, and in a few instances a yellow waxy fluid of a peculiar offensive smell covering their in- ternal surface*; but whether the inflammation was primary, or only a consequence of the pressure of the abdominal muscles, which contract so violently in this disease, has not been decided. The inflammation in tetanus is however different from that observed in enteritis: in the latter, the intestines often adhere to one another by layers of coagulable lymph, recently thrown out; flakes of a curdled matter are frequently found, and pus is sometimes formed. In the inflammation attending tetanus, there are no adhesions ; nor is there any formation of pus. The nerves of tetanic patients have been examined after death, from the place of injury to their central termination, but no in- flammation has been observable in any part of their course : the supposition, therefore, of an inflamed nerve being the cause of tetanus, ought to be rejected. Although our endeavours may not be crowned with success, where tetanus or trismus arises from a lacerated wound, or puncture in some tendinous part, still we should by no means suffer the patient to remain in so miserable a state of existence without making some efforts to afford even a temporary relief or alleviation of hi>* sufferings. On being applied to for advice, tbe practitioner should endeavour in the -first place to find out the cause which has given rise to the disease. If supposed to proceed from a wound or puncture, he ought carefully to examine the injured part, and to extract, as quickly as possible, any extraneous body that may have lodged therein, taking care at the same time to dilate or freely lay open the woundv Thestf steps being taken, it may possibly be attended with some advantage to pour a small quantity of a strong solution of opium into the wound, dressing it afterwards with a little lint dipped in the same, and laying a pledget spread with some digestive ointment s Sec MecUco-Chirargical Transactions, vol. vii.part ii. p. 459. ^90 NEUROSES, OR NERVOUS DISEASES. Class II. over the whole. Every time the dressings are renewed, the wound is again to be wetted with the solution. The partial division of a nerve being sometimes supposed to oc- casion tetanic affections, the practitioner ought, when this is sus- pected to be the case, to make a deep incision into the part which has been injured, so as to divide the tendinous and nervous fibres entirely, after which he should adopt the mode of treatment that has just been recommended. Pencilling the wound freely with lunar caustic, and afterwards covering it with a poultire of bread and milk, with ibe view to obtain suppuration as soon as possible, is another mode of proceeding which has been pursued in tetanus arising from external injury. Barron Larrey has recommended the application of a hot iron in these cases, promoting suppuration afterwards as speedily as possible by stimulant dressings*. Dr. Darwin recommends-)- the wound to be dilated, and then to fill it with lint moistened with spirits of turpentine, which brings on an inflammation in it, and thereby cures or prevents the convul- sions. A case of trismus, which was successfully treated by Dr. Stevenson, of Baltimore, America, in this manner, is recorded in the 3d No. of the New Medical and Physical Journal, p. 220.—S. P. a stout ple- thoric black woman, aged about thirty-five years, in walking barefoot, chanced to tread upon a piece of glass, which wounded her foot near the first joint of the little toe. It bled copiously, and no attention was paid to it. It healed, as usual, in a few days after the accident. At the expiration of three weeks she was suddenly seized with a spasm in the muscles of the lower jaw, accompanied with intolerable pain, particularly near the coronoid and condyloid processes. This, in spite of large quantities of opium, increased, and a rigidity of the jaw superseded to such an extent, that she could not mas- ticate her food, Two grains of opium were given every two hours without any alleviation of the symptoms. In this dreadful state the Doctor made an incision about half an inch deep, and an inch and a half in length, immediately above the cicatrix, in a trans- verse direction, and then poured strong spirits of turpentine into the wound. In a few minutes violent pain was created in the part; in half an hour the spasms left the jaw ; and in a few hours more the rigidity entirely vanished. The pain in the wound became excessive, and continued so for four or five hours; but the trismus was completely removed, nor did it ever recur. Little or no suppu- ration ensued, the wound healing by the first intention, or adhesive in- flammation. Opium is the medicine which has been employed with the best effect in cases of tetanus; but it should always be given in moderate doses at first, and so be increased gradually. In administering * Sep his Military Surgery. t See Zoenomia,, vol. iv. pa^t 47. Order III cramp. 391 opium in this disease, the attention must, however, be directed to the effect that it produces on the patient, and not to the quantity which is taken, as many cases are on record, where an ounce of it in substance has been given in the course of twenty-four hours, the spasms having been very frequent and violent. By many it has been supposed that joining it with musk, cam- phor and aether, has greatly added to its effect. A combination of these medicines (as in the formulae below*) had therefore best be used, taking care fo increase the quantify of opium in each suc- ceeding dose. The good effects of opium combined with James's powder, as also with ipecacuanha in some cases of tetanus arising from wounds, are attested by Dr. Latham, in the 4th volume of the Medical Transactions of the London College of Physicians. Giving the mild alkali internally, and administering opium at the same time in alternate doses, together with the use of a hot bath impregnated with potass, and a few ounces of quick-lime, is a mode of treatment much recommended by Dr. Stutz, of Suabia, in teta- nus and trismus traumaticusf. An alternate internal use of opium and carbonate of potass is said to have been employed in the hospitals of Germany among the wounded soldiers in the late war with a most happy effect. The remedy is, therefore, worthy of our attention in tetanic af- fections. In those cases where the jaws are so firmly locked together as to prevent a spoon from being introduced between them, and where the teeth are quite perfect in front, it will be necessary to extract some of them, for the purpose of giving the patient his medicines and food. When he loses the power of deglutition, opium is then to be administered in clysters. Besides giving opium internally, it may likewise be employed externally, by rubbing the parts frequently which are most affected by spasm with equal parts of the linimentum saponis and tinctura opii, or with the ointments prescribed below J. t See Medical and Physical Journal, vol. jii. p. 572, and vol. w p. 472. ' 1. U Moschi,gr x. .* 1. Take Musk,, ten grains. Spirit. Cinnam. f. 3'j I Spiritof Cinnamon, two drachma Camphor Mixture, one ounce. Tincture of Opium, forty drops. Mix them for a draught, to be taken every third or fourth hour. Or, 2. Take Camphor Mixture, six ounces and a half. Compound Spirit of ^Ether, half an ounce. Tincture of Opium, two drachms. )f this mixture the dose may be two table- spoonsful every three hours. 3. Take Opium, reduced to a powder, out drachm. Camphor, fifteen grains. Prepared Lard, half aa ounce. Mis them as an ointment. iviisiur. campnorae, t. jj. Tinct. Opii, V\ xxvj. M. ft. Haustus 3tia vel 4ta hora sumendus. Vel, 8. U Misturae Camphorae, f. %r$sa. Spirit. Miher. C. f. |ss, Tinct. Opii, f. 3ij. M. ft. Mistura, cujus sit dosis cochlearia duo magna tertiis horis. I 3. & Opii Purif. Pulv. Subtilis, 3j. Camphora*, gr. xv. Adipis Praeparat. |98, M. ft. Uaeuentum. 392 NEUROSES, OR NERVOUS DISEASES. dttSS II. This mode of introducing opium into the system will more par- ticularly be necessary where the patient loses the power of swallow- ing ; and by being applied to tbe parts immediately affected, pro- mises fair for affording essential relief. Dr. Mosely asserts*, that opiates applied externally are not of the smallest utility either in the prevention or cure of tetanus. In this I musl beg leave to differ from him, as, during my practice in the West Indies, I met with many instances where the most evident advantages were derived by using it in this way. To procure a relaxation of the spasms, it has been customary to make use of a warm bath in conjunction with anodyne frictionS| and occasionally a clyster of tobaccof has been administered about twice a day with success : but in all the instances of a recovery from tetanus which have taken place under my care, the cold bath was substituted instead of the warm. These, however, were cases (one excepted) which arose from exposures to cold. ' The plan generally pursued was, to throw a large pail-full of cold water every two hours on the patient, after which he was wiped dry, and again put into bed ; an opiate draught, similar to what has been advised, was then given to him, and the parts most affected were well rub- bed with a strong anodyne liniment. When he was so far re- covered as to be able to swallow with facility, the cinchona bark was also given to him with a very free allowance of wine ; which course was pursued for a considerable time after the spasmodic affection had ceased. It has been recommended by some physicians to endeavour to excite a salivation by using mercury both internally and externally ; but I must say, i never found it answer. My trials of it were, however, few ; for having experienced the method which I have recommended to be so very successful, in almost every instance where the disease arose from an exposure to cold, I should not have thought myself justified in losing time by using any remedy which was attended with uncertainty. Where mercury is employed in the cure of tetanus with the view of exciting a salivation, tile patient should be put now and then into a warm bath ; and that he may have every chance of recovering, I would recommend a joint use of opium at the same time. In the Transactions of the College of Physicians of Philadelphia, vol. i. part i. is inserted a case of tetanus, from the extraction of two teeth, which was successfully treated by Dr. Rush, by a use of mercury and wine; and others are elsewhere recorded pn indisputable authorities. * See his Treatise on Tropical Diseases, p. 494. t See the Edinburgh Med. and SnrgicalJournal, No. 42, p. 198. Vel, —————— Or, 4. R Adipis Praeparat. Jj. 4. Take Prepared Lard, one ounce. Olei Succin. f. ^ss. Oil of Amber, half an ounce. Opii Pulverisat. 3ij- M: Opium, pulverized, two drachms Mix them. Order III CRAMP. 39S In the New-York Medical Repository for 1779, is mentioned another case of tetanus arising from the puncture of a pin in the wrist, wliith was successfully treated by Dr. Hossack with wine (Madeira) alone ; the woman having taken three gallons in a few- days, in doses of a wine-glassful (containing about two ounces) every hour. It seems necessary to observe, however, that in this case the wound was freely pencilled with lunar caustic, after which it was covered with an emollient poultice. In those affections where inflammation of the system might be of service, Dr. Darwin thinks wine might be preferable fo opium. He mentions, thai he has observed a mixture of rectified spirit and warm water, given alternately with the doses of opium, has soonest and most certainly produced that dt-gree of intoxication which was necessary to relieve the patient in the epilepsia dolorifica*. In most cases of tetanus arising* from wounds in the limbs, it probably would be the best practice to amputate as soon as the symptoms appear. This plan is strongly recommended by Baron Larry, who acted as surgeon-in-chief to the French army in E.ypt and Syriaf ; for he found that it succeeded in some instances after opium, camphor, and other remedies had been used in vain. Even where the case terminated fatally he found that the operation relieved the symptoms very considerably. When tetanus has proceeded from an exposure to cold, it is apt to be attended with some slight inflammatory symptoms; to re- move which, bleeding is sometimes had recourse (o, but it usually proves injurious instead of beneficial. As costiveness is a constant attendant on tetanus, it should be obviated by the frequent exhibition of some active aperientj while the power of swallowing remains ; and after it has ceased, by the regular exhibition of clysters. Of fhe utility of purgatives in cases of tetanus, whether idiopathic or occurring after wounds, there can be no doubt, and their efficacy is strongly enforced by Dr. Hamilton|J. The torpor of the intestines which precedes and accompanies this disease, is highly deserving of attention. In many instances the evacuations have not the appearance of faeces, but are nevertheless of a highly offensive nature. Among the remedies for tetanus, it may be proper to mention the oleum petrolei, or Barbadoes tar, which, by being taken internally, has been said in some instances to have effected a cure. Electricity is reported to have lately been employed in some cases* * See Zoonomia, vol. ii. p. 431. t See Relation Hislorique et Chirurgicale de 1'Expedition de l'Arm6e d'Orient en Egypte et en Syrie, par D. J. Larry. || See his Treatise on Purgatives. X 5. R Infus. Senna?, f. |jss. Sodae Sulph. f. |ss. Tinct. Jalapae, f. 3ij- Syrup. Rhamni, f ft. Hanstus. 3j. M. 50 5. Take Infusion of Senna, one ounce and a half. Sulphate of Soda, half an ounce. Tincture of Jalap, two drachms. Syrup of Buckthorn, one drachm. Mix tbftio ior a draught. 394 NEUROSES, OR NERVOUS DISEASES. Class II. of the locked-jaw with a happy effect. The remedy seems there- fore deserving of further trials. Throughout the whole course of all tetanic affections, the pa- tient's strength is to be supported by wine, mixed with such things as he can easily swallow ; and where this power ceases, nutritive clysters must be substituted. The trismus nascentium is a species of tetanus ; but this is in- serted among the diseases peculiar fo infants. Dr. James Clark, in his Treatise on West-India Diseases, informi us, that, being unable to cure the symptomatic tetanus, he en- deavoured to prevent it ; and for this purpose, after wounds and punctures, he gave two or three grains of calomel twice a day till a gentle salivation came on, and he pursued the same plan after operations. Out of fifteen patients, after amputation, that were treated in this way, only one died, and he was in so irritable a state before, that bad consequences were dreaded. In those who had been wounded or punctured, the success was greater ; two only having been lost out of a great number since this mode of practice was begun. To prevent tetanic affections from arising after wounds and chirurgical operations, I understand it is almost an universal prac- tice on board of ships of war to mix tincture of opium with the dressings, and that since this practice has been adopted these complaints seldom occur. As a prophylactic, I should be much inclined to adopt this mode of treatment in preference to that proposed by Dr. Clark. SINGULTUS, or HICCUP. Hiccups are a spasmodic affection of the stomach and dia- phragm, arising from some peculiar irritation. They are in ge- neral symptomatic, but in some instances they appear as a primary disease. When they are idiopathic, they usually arise from an error in diet or from an acidity in the stomach. When symptomatic, they either come on towards the termination of some acute disease, attend on injuries done to the stomach and other viscera, or prevail as an affection attendant on hysteria. Hiccups prevailing as a primary affection, are never attended with danger, and are in general easily removed ; but when they arise in any acute disorder, or after a mortification has taken place, they may always be looked upon as the forerunners of death. The appearances on dissection will depend entirely on the disease of which they have appeared as a symptom. A common hiccup is offen removed by taking a few small vdraughts of ccld wafer, in quick succession, or by a sudden ex- citement of some degree of fear or surprise. When these simple means do not answer, recourse must be had to antispasmodics, the most useful of which for this disease seem to be aether> musk, and Order HI. whooping cough. 396 opium. Ttiese may either be combined together, or be given separately. In the accidental hiccup of youth or of very old people, a pretty certain remedy is a smail quantity of any powerful acid, sueh as a tea-spoonful of vinegar or lemon-juke, or a little peppermint-water acidulated with a few drops of sulphuric acid. Where hiccups prove violent as well as obstinate, the application of a large plaster of Venice treacle to the patient's stomach some- times affords relief; but should it fail, a blister may then be sub- stituted. Hiccups sometimes proceed from an acidity in the stomach, and hence it is that infants are very apt to be affected with them. When they arise from this cause, a little prepaied chalk or magnesia joined with some carminative, such as the oleum anisi, will be the most proper medioine. When hiccups arise at the close of any acute or malignant disease, or in consequence of a mortification, no advantage can be obtained from medicine, or any other means whatever. PERTUSSIS, or WHOOPING COUGH. Pertussis is a convulsive cough, interrupted by a full and sona- rous inspiration, and returning in fits that are usually terminated by a vomiting or expectoration. In its first stage, it may be considered as a febrile disease. Children are most commonly the subjects of pertussis, and it seems to depend on a specific contagion, which affects them but once in their life. The disease being produced, the fits of coughing are often repeated without any evident cause; but in many cases the contagion may be considered as only giving the predisposition, and the frequen- cy of the fits may depend upon various exciting causes, such as violent exercise, a full meal, the having taken food of difficult digestion, and irritation of the lungs by dust, smoke, or disagreeable odours. Emotions of the mind may likewise prove an exciting cause. Pertussis often prevails epidemically, but does not, in this respect, appear to be influenced by any particular season of the year. It has however been observed to be much milder in warm climates-than in cold ones; and it would seem, in conformity to this law, that the disease is found to be more severe in this country during autumn and winter, than during spring and summer. It arises generally from contagion, it is true; still it must be allowed that there is a principle independent of contagion capable of producing the complaint, and that this principle undoubtedly exists in the atmosphere, which it pervades to a certain extent; but what it is, and how formed, remains a curious subject for physical research. The proximate or immediate cause of pertussis seems to be a viscid matter or phlegm lodged upon the bronchia, trachea, and fauces, which sticks so close as to be expectorated with the greatest 396 neuroses', or nervous diseases. Class 11. difficulty. Some have supposed it to be a morbid irritability of the stomach, with increased action of its mucous glands ; but the affec- tion of the stomach which takes place in the disease, is clearly only of a secondary nature, so that this opinion must be erroneous. The whooping cough usually comes on with an oppression of breathing, some degree of thirst, a quick pulse, and othei slight febrile symptoms, which are succeeded by a hoarseness, cough, and difficulty of expectoration. These symptoms continue perhaps for a fortnight or more, at the end of which time the disease puts on its peculiar and characteristic form, and is now evident, as the cough becomes convulsive, and is attended with a peculiar sound, which has been named a whoop. When the sonorous inspiration has taken place, the coughing is again renewed, and continues in the same manner as before, till either a quantity of mucus is thrown up from the lungs, or the con- tents of the stomach are evacuated by vomiting. The fit is then terminated, and the patient remains free from any other for some time, and shortly afterwards returns to the amusements he was em- ployed in before the accession of the fit, expresses a desire for food, and when it is given to him, takes it greedily. In those cases, how- ever, where the attack has been severe, he often seems much fatigued, makes quick inspirations, and is rather faint. On the first coming on of the disease there is little or no expecto- ration, or, if any, it consists only of thin mucus; and as long as this is the case, the fits of coughing are frequent, and of consider- able duration; but on the expectoration becoming free and copious, the fits of coughing are less frequent, as well as of shorter continuance. By the violence of coughing, the free transmission of blood through the lungs is some \ hat interrupted, as likewise the free return of the blood from the head, which produces that turgpscence and suffusion of the face which commonly attend the attack, and in some instances brings on a hemorrhage either from the nose or ears. The disease having arrived at its height, usually continues for some weeks longer, and at length goes off gradually. In some cases it is however protracted for several months, or even a year. Although the whooping cough often proves tedious, and is liable to return with violence on any fresh exposure to cold, when not entirely removed, it nevertheless is seldom fatal, except to very young children, who are always likely to suffer more from it than those of a more advanced age. The danger seems indeed always to be in proportion to the youth of the person, and the degree of fever and difficulty of breathing which accompany the disease, as likewise the state of debility which prevails. It has been known in some instances to terminate in apoplexy and suffocation In some it lays the foundation for asthma and phthisis pulmonalis. If the fits are put an end to by vomiting, it Order HI whooping cough. •■ 397 may be regarded as a favourable symptom, as may likewise the taking place of a moderate and free expectoration, or the ensuing of a slight hemorrhage from the nose or ears. Dissections of those who die of the whooping cough usually show the consequence of the organs of respiration having been affected, and particularly those parts which are the seat of catarrh ; hence the mucous membrane of the trachea and bronchiae are commonly found in a morbid state. In many instances the lungs have exhibited highly morbid appearances, the trachea and its ramifications bearing vestiges of recent inflammation, and the air-cells and the bronchia?, near to their bifurcation, filled with a whitish purulent looking mucus. Serous accumulation in the pericardium is also frequently met with. In some instances the lungs have been found adhering to the pleura. When the disease has been long protracted, or has degenerated into pulmonary consumption, asthma, or visceral obstructions, the glands of the messentery are found in a hard and enlarged state. In the treatment of pertussis, we are, in its first or early stage, to moderate its violence, and palliate the urgent symptoms; and at an advanced period, to arrest its progress, and put a stop to it by suitable remedies sooner, perhaps, than it would spontaneously have ceased. In all severe cases of pertussis, where the cough is accompanied with a difficulty of breathing, or full pulse, much heat, and other febrile symptoms, early venesection ought never to be neglected* particularly in children of a full plethoric habit. As soon as the cough becomes severe we should draw off blood liberally at one time, which will often enable us to prevent mischief, and render the disease mild in its progress; but upon the accession of febrile paroxysms and a hurried respiration, which indicate a consider- able degree of inflammation in the mucous membrane, or where the inflammation has extended to the substance of the lungs, and thus produced, in combination with those of the whooping cough, symptoms of pneumonia, this remedy becomes indispensable to the safety of the patient. Under these circumstances we must not be satisfied with a single bleeding; it should be repeated in sufficient quantities until the symptoms are under control, or we are convinced that amendment is beyond its power. The failure of venesection in pertussis may very often be attributed to its being resorted to at too late a period, or its being too sparingly used. In milder attacks of the disease, where the cough and difficulty of breathing are more moderate, it may be advisable to take away some blood by applying a sufficient number of leeches to the chest, instead of resorting to venesection ; and if the dyspnoea is not lessened in due time, the application should be repeated. In com- * See Dr. Watts's Work on Pertnssis. 398 neuroses, ©r nervous diseases. Class IT. mon cases of pertussis, unattended by febrile paroxysms or dyspnoea, bleeding of any kind will be unnecessary. Where there is much difficulty of breathing, the application of a blister to the chest will be highly proper at the commencement of the disease. Some practitioners have recommended the lower region of the sto- mach to be rubbed very frequently with a stimulating embrocation*, covering the part afterwards with flannel. Inhaling the steam of warm water with an addition of vinegar or aether twice or thrice a day, may be of service. The body being usually very costive, it will be necessary to have re- course to gentle laxatives, such as an infusion of senna with manna, he. to remove it. In many instances an attention to diet may pro- bably be sufficient to answer the purpose of removing or preventing this symptom; and therefore stewed prunes, roasted apples, he. may be given, which ttiiigs children take very readily. Emetics administered frequently, have been found the most useful of. all remedies in whooping cough, for which reason they ought never to be neglected ; and as children may easily be deceived by what has no appearance of medicine, a solution of tartarized antimo- nyf, seems the most proper for the occasion. The best way, how- ever, will be to give about a table-spoonful every fifteen minutes or so, until it takes effect, as dangerous consequences might ensue from the medicine happening to operate harshly, and producing much vomiting, which in some cases a very small quantity of it is apt to do. Where the patient is grown up to an adult state, an emetic of the wine of antimony or ipecacuanha, or of oxymel of squills, may be substituted. A medicine composed of opium, ipecacuanha, and the carbonate of soda, is recommended by Dr. PearsonJ to be given in pertussis after the accumulated phlegm has been brought away by an antimo- nial emetic. He advises it in the following proportions to a child between one and two years, viz. one drop of the tincture of opium, five drops of ipecacuanha wine, and two grains of the carbonate of soda, which may be made up into a small draught with syrup and water, and be repeated every fourth hour for several days, taking «are to remove costiveness, whenever it occurs, by submuriate of X See Medico-Chirurgical Transactions, art. 3d. * 1. g; Antimon. Tartarizat. 3j. Aq. Purae, f. |ij. Tinct. Lyttae, f. §ss. M. ft. Embrocatio. t 2. I£ Antimon. Tartarizat. gr. iij. Aq. Purae, f. ?vj. Syr. Simpl. f." jij. M it. Solutio. * 1. Take Tartarized Antimony, one scruple. Pure Water, two ounces. Tincture of Spanish Fly, half aa ounce. Mix them for an embrocation. t 2. Take Tartarized Antimony, three- grains. Pure Water, six ounces. Common Syrup, two drachm? Mis them. Order HI whooping cough. 399 mercury and rhubarb. Dr. Pearson is of opinion, that without the soda the preparations of ipecacuanha and opium would not be equally efficacious, and was led to employ it by the sour smell of the slimy fluid brought up by vomiting ; but he suspects that it has an influence beyond that of correcting acidity. Bathing the feet frequently in warm water has been supposed to afford relief in many cases. A tepid bath is sometimes- serviceable. The superacetate of lead has been lately recommended in the whooping cough, and is said to relieve the symptoms of the disease very speedily, without producing any bad effects on the stomach and bowels. It may be given as in the formula inserted below*. Exciting a slight degree of strangury has been attended with a good effect in some instances of pertussis. A combination of tinc- tura lyttse, and tinctura camphorae compositaf, may be used for this purpose, giving it in doses of about fifteen drops repeated every three or four hours, unlil some slight effect of this nature is pro- duced, when the dose may either be lessened, or be given at longer intervals. Its efficacy most likely is owing to the counter-irritation which it excites. For obviating the fatal tendency of the disease, and putting it into* a safe train, the remedies which have been advised are evidently the most proper; but in its second stage, where it may be considered as continuing from the power of habit alone, all danger and violence being over, we must alter the plan of treatment, and have recourse to antispasmodics and tonics. Of the first class, musk, castor, asafcetida, oleum succini, cam- phor, and opium, have principally been used ; but their effects seem rather doubtful ; and as they are all nauseous medicines, particularly the three first, it may not be easy to persuade children to take them. The uncertainty of the dose of opium, as well as the inconvenient * 3. B: Plumbi Superacet. gr. ij.—v. Aq Rosae, f. ?ij. Syrup Violfie, f. 3ij. M. ft. Mistura. Capiat cochl. parvulum 4ta vel 5ta quaque hora 14. £]L Tinct. Camphorae Compos, f. 2j. ----Lyttae, f. 3ij. M. Vel, 5. ft Decoct. Cinchon. f. |iijss. Tinct. Lytta;, fn. xxvj. ---- Camphor. Compo3. f. |ss. M Capiat cochleare medium quartis horis. *3. Take Superacetate of Lead, two to five grains. Rose water, two ounces. Syrup of Violets, two drachms. Of this mixture a tea-spoonful may be take» every fourth or fifth hour. t4 Take Compound Tincture of Camphor, one ounce. Tincture of Spanish Fly, two drachms. Or, 5. lake Decoction of Peruvian Bark, three ounces and a half. Tincture of Spanish Fly, forty drops. , Compound Tincture of Camphor, half an ounce. Of this mixture let a dessert-spoonful be la ken everv four hours. 400 NEUROSES, OR NERVOUS DISEASES. effects produced by it on children, operate somewhat against the in- ternal use of this drug, but its external use promises much benefit. In order to disguise tincture of opium, a few drops of aether may be added, and in this way it may be employed as an embrocation twice or thrice a day over the chest and stomach. Artificial musk is a medicine which is reported to have been given in the whooping cough with the most decided advantage, even when other remedies have failed. A small quantity may be dissolved in a lit Je rectified spirit, and about three or four drops be given twice a day, gradually increasing the dose to six, thrice in the twenty- four hours. Hemlock has been administered in this disease as a narcotic, and frequently with success. In a few cases w iere I made trial of it, some advantage seemed to be <>b ained from its use; but as I gsve it combined with other remedies as below*, probably it was not en- title! to the whole merit. The tincture of digitalis is another medicine which has of late been recommended in the whooping cough. I have prescribed it in a few cases with seeming advantage. Combining it with opium might perhaps increase its efficacy. Hyoscyamus has likewise been proposed as a remedy in pertussis. It may be given combined with the antimonial solutionf, regulating the dose by the age of the child. We may begin with four or five drops, repeated four times a day, gradually increasing the quantity till a slight degree of nausea takes place. Belladonna has been much employed on the continent by Hufe- land, and others, in pertussis, and is said by them to have produced most excellent effects, by greatly diminishing the force, violence, frequency, and duration of the accessions of this distressing cough, and by entirely removing the disease in a very short space of time. The dose is a quarter of a grain of the powdered root, with a few grains of sugar morning and night to children under one year; to those from two to three years of age, half a grain twice in the twenty- * 6. ft Extract. Conii, gr. j.—ij. Decoct. Cort. Cinchon. f. ^j. Tinct. Opii,fll iij M. Fiat haustus ter in die sumendus. Vel, 7. ft Extract. Cinchon. gr. xxxvi. ------ Conii, gr. xij. Syrup, q. s. M. ft. Massa iu pilulas xij distribuenda quarum unam capiat bis terve in die. t 8. ft Liquor. Antimon. Tartarizat. f. ^i Extraet. Hyoscyami, 3y. Solve.' * 6. Take Extract of Hemlock, one to two grains. Decoction of Peruvian Bark, oni ounce. Tincture of Opium, five drops. Mix them, to be taken as a draught three times a day. Or, 7. Take Extract of Bark, thirty-six grains. ---------Hemlock, twelve grains. Syrup, a sufficiency to form the mass, which is to be divided into twelve pills, whereof one is to be taken twice or thrice a day. t 8. Take Solution of Tartarized Antimony, one ounce. , Extract ef Henbane, two scru- ples. Dissolve the latter in the former. Order lit Water-brash. 401 four hours ; and to those from four fo six years of age, a grain and a half in the same 'time. The dose may be enlarged every two or three days until the increase equals half of the first dose. To lake off the irritation from the mucous membrane, which ia the principal seat of tbe disease, as well as to strengthen the general habit, it will be advisable to employ the bark of cinchona. It may be given joined with the other remedies ; but as it is often impossi- ble to persuade children to take it in substance, we must be con- tent with substituting a decoction or strong infusion of it. Other tonics, such as the various preparations of steel, zinc, &c. may . likewise be administered. Arsenic has lately been recommended in pertussis by Mr. Sim- mons, of Manchester* ; and he asserts that it is attended with the most salutary effects, moderating the symptoms in a few days, and generally making a complete cure in the space of a fortnight. It has been given to children of a year old with safety in the doses re- commended by the late Dr. Fowler, of Stafford, (see Intermittents), whose solution was used. It appears, however, that Mr. Simmons employed venesection and emetics occasionally ; and he recom- mends, after the solution has been omitted for a week, to repeat it, in order to guard against a relapse. A frequent change of air having always been found very serviceable in this disease, ought therefore to be advised. A flan- nel waistcoat should be worn by the patient, as no doubt it pro- motes absorption, and prevents the vicissitudes of the climate taking that effect on the skin, which we know it does, acting there- by as an exciting cause of coughing. Young children should lie with their heads and shoulders raised, and should be cautiously watched, that when (he cough occurs they may be held up, so as fo stand upon their feet, bending a little forward to guard against suffocation. Their diet should be light, and of easy digestion, and mucilaginous diluents should be taken freely. PYROSIS, or WATER-BRASH. A discharge of a thin, watery, or glairy fluid from the stomach, with eructations, and likewise a sense of burning heat in the epi- gastric region, are the chief characteristics of this disease. It principally attacks those of a middle age, and more frequently affects females fhan males, particularly the unmarried. Those who are afflicted with fluor albus have been found to be much predisposed to it. Being a disease not much known, and occurring but seldom, its causes have not been properly ascertained, but a low diet has been ascribed as being apt to give rise to it. The application of cold to * See Annals of Medicine for 1797. 51 402 NEUROSES, OR NERVOUS DISEASES. Class 11. the lower extremities, and violent emotions of the mind, are like- wise enumerated among its occasional causes. The fits of pyrosis usually come on in the morning and forenoon, when the stomach is empty ; and the first symptom which the pa- tient perceives is a pain at the pit of the stomach, with a sense of constriction, as if it was drawn towards the back, and this is usually much increased by an erect posture. The pain, after proving severe, and continuing for some time, is followed by eructations and the discharge of a considerable quantity of a thin watery fluid, sometimes of an acid taste, but often quite insipid. In some in- stances, however, it is very ropy, and of an appearance somewhat similar to the white of an egg, as happened in a case which some time ago came under my observation. On a frequent repetition of the eructation and discharge the fit at length goes off. This disease never proves fatal, but is often tedious and trouble- some to remove, being apt to recur occasionally, a long time after it has once taken place. For its cure no certain method has yet been proposed ; but its fiti are relieved by antispasmodics, such as aether, musk, castor, ammo- nia, oleum cajeputae, opium, and the chewing or smoking of tobacco. In tye intervals the cinchona, with the acidum sulphuricum, chalybeates, and other tonics, will be advisable. To carry off 'he offending fluid or mucus, I am of opinion that we may employ purgatives* about twice a week with advantage. As adjuvants will be occasionally serviceable, magnesia and alkalies (especially ammonia) will correct acidity, and relieve heartburn and other dyspeptic symptoms. In pyrosis, as well as in gastrodynia and other like affections of the stomach, the oxyd of bismuth has been found to affoid much relief, interposing now and fhen gentle aperients. It appears to be a remedy recommended on the ground of safety as well as utility. An adult may take five grains of it with about a scruple of gum tragacanth three times a day. A case of pyrosis, accompanied by gastrodynia of a year's stand- ing, is recorded in Dr. Bardsley's Medical Reports, which was effectually removed by the oxyd of bismuth in a very short time. The complaint had been so constant and severe as fo prevent the patient from following his occupation as a weaver. The pain was fixed and dull, and the quantity of acid discharged from the stom- ach, in a watery form, was abundant. After clearing the stomach * 1. ft Hydrargyr. Submur. gr. ij. Pulv. Antimon.gr. j. Extract. Colocynth. gr. x. Syrup. Rhamni, q.s. M. Piant pilula; iij. pro dos 1. Take Submuriate of Mercury, tw« grains. Antimonial Powder, one grain. Extract of Colocynth, ten grains. Syrup of Buckthorn, a sufficiency to form the mass, which is to be formed into three pills, and token at once. Order III. ANGINA PECTORIS. 406 with an active emetic, the bowels were emptied by castor oil, and the patient then entered upon the bismuth. He took twenty grains of a powder consisting of one part of the oxyd and five of gum tragacanth thrice a day for the space of a week, and then increased the dose gradually to forty grains. A short time eifected the removal of the pyrosis. The bismuth was then discontinued, and the cinchona with sulphuric acid substituted, which soon completed the cure. It appears likewise that some other cases of pyrosis, accompanied with spasmodic pains, were treated wilh uniform suc- cess. An obstinate case of the disease, accompanied by gastrodynia, lately came under my care, and was perfectly cured by the oxyd of bismuth in conjunction with stomachic bitters. Linnaeus, by whom pyrosis seems first to have been noticed, recommends a use of the nux vomica : the dose is from ten grains to a scruple three times a day. The case to which I have alluded in the preceding page, and in which there was a discharge of a ropy fluid, was at first treated with antispasmodics ; but these being attended with no good effect, the physician who was called in advised the use of the sulphate of zinc combined with opium and the extract of cinchona bark, which seemed at first to be wonderfully efficacious ; but the disease shortly afterwards returned, and the patient having lost confidence in the remedy, it was discontinued. ANGINA PECTORIS. An acute constrictory pain at the lower end of the sternum, inclining rather on the left side, and extending up into the left arm, accompanied with great anxiety, violent palpitation at the heart, laborious breathing, and a sense of suffocation, are the character- istic symptoms of this disease. Angina pectoris appears in general to be connected with a full habit, and an accumulation of fat in the cellular membrane. It has appeared in some instances to have a connexion with suppressed discharges. Mental emotion seems to be a powerful predisposing cause of the disease. It is found to attack men much more frequently than women, particularly those who have short necks, who are inclinable to corpulency, and who at the same time lead an inactive or sedentary life. In most instances the attacks are sudden, and occur in those who have previously enjoyed good health. In a few cases, spasms of the stomach, indigestion, and pains in the limbs, are not unusual, which are for the most part removed, or greatly diminished in violence on the appearance of the disease. Although angina pectoris is sometimes met with in persons under the age of twenty, still it more frequently occurs in those who are between forty and fifty. In slight cases, and in the first stage of the disorder, the fit comes •n by goinig up hill, up stairs, or by walking at a quick pace after a 404 NEUROSES, OR NERVOUS DISEASES. ClttSS It, hearfymeal ; but as the disease advances, or becomes more violent, the paroxysms are apt to be excited by certain passions of the mind, by repletion of the stomach, by walking, by riding on horse- back or in a carriage, or by sneezing, coughing, speaking, or straining at stool. In some cases they attack the patient from two to four in the morning, or while sitting or standing, without any previous exertion or obvious cause. On a sudden he is seized with an acute pain in the breast, or rather at the extremity of the sternum, inclining to the left side, and extending up into the arm as far as the insertion of fhe deltoid muscle, accompanied by a sense of suffocation, great anxiety, and an idea that its continuance or increase would certainly be fatal. The paroxysm seems to consist very much in an impediment or suspension of the vital action of tbe heart. In the first stage of the disease the uneasy sensation at the end of the sternum, with the other unpleasant symptoms which seemed to threaten a total suspension of life by a perseverance in exertion, usually go off upon the person's standing still, or turning from the wind ; but in a more advanced stage they do not so readily recede, the paroxysms are much more violent, and in a few cases have continued for several days. During the fit the pulse sinks in a greater degree, and becomes irregular, but in some instances it is not much disturbed ; the face and extremities are pale, and bathed in a cold sweat, and for a while the patient is perhaps deprived of the powers of sense and voluntary motion. Sometimes the stomach is morbidly affected, becomes unusually irritable, and re- jects whatever is swallowed. The disease having recurred more or less frequently during fhe space of some years, a violent attack at last puts a sudden period to his existence. He dies after having suffered all the agonies of dissolution ; for this is a complaint in which, during the fit, there are the most overwhelming sensation! and apprehensions of instant death. Angina pectoris had passed unnoticed among practitioners until Dr. Heberden published a description of it about fifty years ago in the Transactions of the College of Physicians of London ; since which many gentlemen of eminence in their profession have attempted to investigate its nature, and have obliged us with their observations, particularly Drs. Percival, Fothergill, and Wall. By many of them it has been judged spasmodic. Dr. Parry, physician to the Bath General Hospital, who has published* his sentiments on it, is of opinion, however, that it is in reality a case of fainting or syncope, which Dr. Cullen defines " mot us cordis* imminutug, vel aliquamdiu quiescens," and as differing from the common syncope only in being preceded by an unusual degree of anxiety or pain in tbe region of the heart, and in being readily excited* during a state of apparent health, by any general exertion of the muscles, more especially than of walking. The supposed cause of " See his Treatise on Angina Pectoris. Order HI. angina pectoris. 405 angina pectoris) for which he has thought proper to substitute the name of syncope anginosa) is referred by him to a diseased state (generally ossification) of the coronary arteries of the heart. The rigidity of the coronary arteries thus induced may act, he thinks, proportionably to the extent of the ossification, as a mechan- ical impediment to the free motion of the heart; and though a quan- tity of blood may circulate through these arteries sufficient to nourish the heart, as appears in some instances, from the size and firmness of that organ, yet there may probably be less than what is requisite for ready and vigorous action. Hence, though a heart so diseased may be fit for the purposes of common circulation, during a state of bodily and mental tranquillity, and of health otherwise good; yet when any unusual exertion is required, its powers may fail under the new and extraordinary demand. In conformity with this notion, Dr. Parry endeavours to show that the chief symptoms of the disease are the effect of blood retarded and accumulated in the cavities of the heart and neighbouring large vessels; and that the causes exci- ting the paroxysms are those which produce this accumulation ; either by mechanical pressure, or by stimulating in an excessive degree the circulating system j in consequence of which the heart, weakened by the mal-organization, readily sinks into a state of quiescence, while the blood continues to advance in the veins. After this quiescence has continued for a certain period the heart may recover its irritability, so as again to carry on the circulation, in a more or less perfect degree, from the operation of the usual stimuli; or death may at length ensue, from a remediless degree of irritability in the heart, Such is Dr. Parry's theory. In ray opinion, the primary or original cause of angina pectoris in most cases is either ossification of the coronaries, or some organic lesion (usually of an osseous nature) existing at the origin of the circulation. In some instances an ossification, more or less com- plete, of the cartilages of the ribs also accompanies. The disease in question has been considered by some German writers, as also by Dr. Darwin, as a species of asthma; by the latter of whom it has been named asthma dolorificum. Dr. Hosack, Professor of Physic and Clinical Medicine in the University of New-York, is of opinion that the disease proceeds from plethora of the blood-vessels, more especially from a disproportionate accumu- lation in tbe heart and large vessels*. The vast accumulations of fat, the effusion of water in the thorax, the distended state of the vessels, and even the bony deposits occasionally met with in the valves and vessels of the heart, he is induced to consider as the effects of such plethora. We should always consider angina pectoris as attended with a considerable degree of danger at an advanced period of life, and where the paroxysms are frequent or violent: and it usually hap- * See American Med. and Phil. Register, vol. ii p. 366. 406 neuroses, or nervous diseases. Class II. pens that the person is carried off suddenly. When it really depends upon an ossification of the coronary arteries, or any organic lesion existing at the origin of the circulation, it is evident that we can never expect to effect a cure. In young persons, and 1 when the disease is gradual in its progress, a hope of recovery may I be entertained. ' In some instances, on inspecting the body after death, the cellular membrane has been found loaded with fat; in the bags j of the pleura, and that of the pericardium, a considerable quan- tity of water has been lodged ; and in others the heart itself has been discovered covered with fat, large, flabby, and soft. On the internal surface of the aorta, near its origin, osseous scales have been perceived, and in many instances the coronary arteries are ossified nearly throughout their whole extent. There are four cases recorded in the seventh volume of the Medico-Chirurgical Transactions, in every one of which there was an ossification more or less complete of the cartilages of the ribs, which circumstance is curious, and would almost indicate the existence of an ossific diathesis, showing its influence beyond the limits of the arterial system. Daring the paroxysms of angina pectoris, the patient is to be laid in a recumbent posture, and if there be a great degree of op- pression and constriction about the chest, we are, even although the pulse be faultering and weak, to draw off a few ounces of blood; for in some cases we find that the heart is prevented from beginning to act again by the blood with which it is overloaded. Under this situation, by opening the jugular vein, and gently pressing on the chest, we are to endeavour to expel a portion of the blood from the right side of the heart, and for the same reason that the lancet is sometimes used in suspended animation. Our decided object should be to allow the heart slowly to recover its lost energy. Every circumstance in the pathology of angina pectoris evinces that the paroxysm is brought on rather by an accumulation of blood about the heart than by any unusual weakness of the organ at tbe moment; and therefore venesection appears to be the first remedy that should be tried, and this may be followed up by exciting vomiting, which we know powerfully diffuses the blood from the centre to the surface of the body. It has been observed by Dr. Parry, and justly, that the extreme weakness of the pulse and coldness of the skin do not contra- indicate bleeding. He is of opinion, that in the paroxysms blood should be taken from a small orifice, the patient being placed m the horizontal position, while the physician is to keep his finger on the pulse, to decide the limits to which venesection is carried. During the paroxysm we may employ rubefacient frictions and external heat to the lower extremities, as being preferable to ■timulants administered internally, which should be used with caution, and only to remove flatulency from the stomach. The Order HI. angina pectoris. 407 carminative medicines, agreeable to the annexed formulae*, may be prescribed for this purpose, when judged necessary. Possibly a tepid bath, by eliciting tbe blood to the surface of the body, might prove useful in relieving the central organ of circulation from the load with which it is oppressed. If the cessation of the vital principle continues long, or appears very complete, the application of a large blister to the chest will be very advisable. In very desperate cases we may venture to pass slight elec- tric shocks through it, rubbing the limbs at the same time with stim- ulating embrocations. Our exertions are to be continued on such oc- casions until unequivocal signs of real death are obvious, or the patient is reanimated. With the view of rousing the patient during a state of fainting, or whilst he is just recovering from this condition, wine and other cordials have been administered by some practitioners, but there is reason to doubt if they have proved beneficialf. In the case of the late Mr. John Hunter, and reported by Sir Everard Home, it was evident that stimuli were not attended with a good effect. Both at the com- mencement of the spasm, and while it was on him, it appears that re- course was had to the camphor julep, but no relief was obtained. He tried Huffman's anodyne liquor in the dose of a tea-spoonful, but not finding it to answer alone, joined it to tbe camphor julep. The spasms however seemed to be more violent. One night he took twenty drops of the tincture of opium, which occasioned his head to be greatly confused the next day, but did not at all abate the spasms. Not having drank wine for four or five years, be was advised to try it, which he complied with, but found the spasms more readily brought on after using it, than on those days in which he drank none. After eating a hearty meal they were more readily produced. Where the sleep is interrupted considerably, the extract of hyoscya- mus, or some of the preparations of the humulus lupulus, (see Mania) may be tried instead of opium, should this drug produce an injurious t See Observations on Diseases of the Heart, by Mr. Allen Burns. * 1. £ Aq Menth. Pip. Spirit. Carui, aa f. ^ss. ----^ther. Sulph. fll xx. Tinct. Lav. C. fll x. M. ft. Haustus. Vel, 2 & Aq. Pimentae, f. 3vj. Tinct. Card. C. f. 3jj. ----Cinnam. C. f. 3i. Spirit. Ammon. Aromat. fll x, M ft. Haustus. * I. Take Peppermint Water, Spirit of Can-away, of each half an ounce. ------Sulphuric JEther, thirty drops. Compound Tincture of Lavender, fifteen drops. Mix them for a draught. Or, 2. Take Pimenta Water, six drachms. Compound Tincture of Carda- mom, two drachms. --------■-----------Cinnamon, one drachm. Aromatic Spirit of Ammonia, fif- teen drops. Mix them to be takan as a draught. 408 NEUROSES, OR NERVOtJS DISEASES. ClaSS H It hasbpen observed, that angina pectoris is a disease always attend- ed with considerable danger, and in many instances has proved fatal under every mode of treatment. We are given, however, to under- stand, by Dr. Macbride*. that several cases of it have been treated with great success, and the disease radically removed by inserting a large issue in each thigh. These, therefore, or instituting a sufficient and permanent drain from the region of the heart, should never be neglected. In one case, with the view of correcting or draining off the irritating fluid, he ordered instead of issues a mixture of lime water, with a little of the spiritus juniperi comp. and an alterative proportion of Huxham's antimonial wine, together with a plain* light, perspirable diet. From this course the patient was soon apparently mended; but it was not until after the insertion of a large issue in each thigh that be was restored to perfect health. Dr. Darwin likewise makes mentionf, that four patients who laboured under the angina pectoris in a severe degree, were all recovered, and continued well three or four years, by the use (as he - believes) of issues on the inside of each thigh, being large enough at first to contain two peas each, but afterwards only one. They took besides some slight antimonial medicine for a short time. i Two remarkable cases of this disease are recorded in the sixth volume of the Medical and Physical Journal, which were cured by i applying pieces of calico to the sternum, wetted with a solution of tar- tarized antimony in the proportions mentioned belowj, several times a day. The stimulus from this application produced an uncommon and violent eruption on the skin in a short time, having the peculiar malignant appearance of carbuncles, itching and smarting excessively, many of which suppurated, while hundreds w re continually rising op, some as large as peas, others as small as pins' heads. As soon as the eruption appeared, considerable relief from the spasmodic af- fections was obtained in both instances, and the patients went on grad- ually recovering, after continuing the remedy two or three times a day for about a month. Having pointed out the best means for moderating and removing tbe paroxysms of angina pectoris, it is proper to notice those from a rigid j and steady adherence to which, such as are subject to its attacks will j experience much benefit, and these be prevented from proceeding to any alarming extent. The patient should sedulously shun every source of mental in- quietude and irritation, and the circulation be vigilantly guarded from the influence of sudden gusts of passion* Moderate exercise in tbe open air should daily and regularly be taken, but no violent j * See Medical Observations and Inquiries, vol. vi. f See Zoonoraia, vol. iv. p. 43. i 3. ri Antimon. Tartar. 3j. \X3. Take Tartarized Antimony,onedrachm- Aq. Fervent. Oj. Warm Water, one pint. Spirit. Camphorae, f. ?ss. M. Camphorated Spirit,half an onw* ■ i Mix them. Order III PALPITATION. m or long continued corporeal exertion should be attempted ; nor should rising ground ever be ascended without the utmost delibe- ration and care. Plain food, easily digestible, and not prone to fermentation in the stomach, should be made use of m small quantities at a time, being carefully masticated, and deliberately swallowed. All fermented liquors will be improper. Gastric dis- tention is indeed a very frequent concomitant upon organic diseases of the heart, and a source of great uneasiness and distress to those who labour under them. The occurrence of this symptom may, however, be obviated by abstinence from fermentable aliment; and when existing may be palliated, or removed by the judicious ex- hibition of the mineral acids, by the carbonate of soda or potass, and by the aromatic spirit of ammonia in combination with bitters. Whenever the patient perceives any tendency to plenitude in the rascular system, he should rigidly adhere to an antiphlogistic re- gimen, and occasionally take some purgative, such as tbe sub- muriate of mercury and jalap, conjoined with a little ginger or any other aromatic. At all times the bowels should be kept regular, and one or two daily evacuations be procured. Some relief pos- sibly may be obtained by keeping up a permanent counter-irrita- tion and discharge on the surface, as near as possible to the seat of the disease, by means of a perpetual blister, or by a seton passed through the integuments over the region of the heart. Warm bathing and friction of the extremities might also prove useful, by promoting circulation in the limbs, and determining to the surface of the body, thereby diminishing the fulness of the heart and large vessels. As a medicine, pills composed of carbonate of soda, sulphat of iron and extract of gentian, may be taken twice a day with an infusion of ginger. PALPITATIO, or PALPITATION. This disease consists in a vehement and irregular motion of the heart, and is induced by organic affections, a morbid enlargement of the heart itself, or of the large vessels, a diminution of the cavities of its ventricles from inflammation or other causes, polypi, ossification of the aorta or other vessels, plethora, debility or mobility of the system, mal-conformation of the thorax, and many of the causes inducing syncope. During the attacks the motion of the heart is performed with greater rapidity, and generally with more force than usual, which is not only to be felt with the hand, but may often be perceived by the eye, and in a few instances even be heard ; there is frequently dys- pnoea, a purplish hue of the lips and cheeks, and a great variety of anxious and painful sensations. In some instances the complaint has terminated in death, but in many others it is merely symptomatic of hysteria and other nervous disorders. In the treatment of this disease, it should be our study, if por- 52 410 NEUROSES, OR NERVOUS DISEASES. Class II sible, to find out the exciting cause, and to remove this. If it arises from plethora, bleeding with purgatives and the rest of the antiphlo- gistic course should be adopted : if from debility, bitters with chaly- beates and cold bathing, he. will be proper; when symptomatic of anv nervous disorder, at her, castor, musk, and other antispasmodics, conjoined with tonics, will be advisable. As the disease, however, arises from an organic affection of the heart hself in many instances, or of the aorta, or other large vessels con- nected with it, all that may be in our power in >ucb cases will be to caution the patient against exposing herself or himself to such circum* stances as may increase the action of the sanguiferous system, parti- cularly fits of passion, sudden surprises,, violent exercise, or great ex- ertions of the body. ASTHMA. This disease is a spasmodic affection of the lungs, which comes en by paroxysms most generally at night, and is attended by a frequent, difficult, and short respiration, together with a wheezing noise, tightness across the chest, and a cough; all of which symptoms are much increased when the patient is in an horizontal position. Asthma rarely appears before tbe age of puberty, and seems to at- tack men more frequently than women, particularly those of a full habit, in whom it never fails, by frequent repetition, to occasion some degree of emaciation. Dyspepsia always prevails, and appears to be a very prominent feature in tbe predisposition. Its attacks are most frequent during the heats of summer, and in winter when heavy fogs or sharp cold winds prevail. When the disease is attended with an accumulation and discharge of humours from the lungs, it is called the humid asthma; but when it is unaccompanied by any expectoration, it is known by the name of the dry or spasmodic asthma. On the evening preceding an attack of asthma, the spirits are often much affected, and the person experiences a sense of fulness about the stomach, with lassitude, drowsiness, and a pain in the head. On the approach of the succeeding evening he perceives a sense of tightness and stricture across the breast, and a sense of straightness in the lungs impeding respiration. The difficulty of breathing continuing to increase for some length of time, both in- spiration and expiration are performed slowly, and with a wheezing noise; the speech becomes difficult and uneasy, a propensity t« coughing succeeds, and the patient can no longer remain in aa horizontal position, being as it were threatened with immediate suffocation. These symptoms usually continue till towards the approach of morning, and then a remission commonly takes place; the breathing becomes less laborious and more full, and the person spealtt and coughs with greater ease. If the cough is attended with ae Order HI asthma. 411 expectoration of mucus, he experiences much relief, and soon falls asleep. When he awakes in the morning he still feels some degree of tightness across his breast, although his breathing is probably more free and easy, and he cannot bear the least motion without rendering this more difficult and uneasy; neither can he continue in bed, unless his head and shoulders are raised to a considerable height. Towards evening he again becomes drowsy, is much troubled with flatulency in the stomach, and perceives a return of the diffi- culty of breathing, which continues to increase gradually till it becomes as violent as on the night before. After some nights passed in this way, the fits at length moderate, and suffer more considerable remission?, particularly when they are at- tended by a copious expectoration in the mornings, and that this con- tinues from time to time throughout tl e day ; and the disease going off at last, the patient enjoys his usual rest by night without further disturbance. During tbe fits the pulse is not usually much affected, but in a few cases there is a frequency of it, with some degree of thirst, and other febrile symptoms. In some persons the face becomes turgid and flushed during the continuance of the fit, but more commonly it is pale and shrunk. Urine voided at the beginning of a fit is generally in considerable quantity, and with little colour or odour ; but after the fit is over, what is voided is in the ordinary quantity, of a high colour, and sometimes deposits a sediment. Asthma, but more particularly the spasmodic, is brought on by almost every thing which increases the action of the heart; and which stimulates and fills the vessels of the mucous membrane. Thus it is produced by intense heat, by lightness of air, by severe exercise, by full meals, by stimulating drinks, by exposure to cold, and by certain effluvia, as those of hay, whether new or old, of sealing wax, and other burning substances. * Congestions of blood, or of serous and pituitons humours in the lungs, noxious vapours arising from a decomposition of lead or arsenic, impure or smoky air, cold and foggy atmosphere, sudden changes of temperature, scrofulous, rheumatic, gouty, psoric and scorbutic acri- mony ; dyspepsia or irritation in some of the abdominal viscera, but particularly in the stomach ; irritation of tbe bronchial system by serial acrimony or other causes, suppression of long accustomed evacuations, frequent catarrhal attacks, general debility, water in the chest, aneurisms, polypi, or concretions of grumous blood in tbe large vessels, and the like, are the causes from which this formidable disease may arise in different individuals. In some instances it proceeds from an hereditary predisposition, and in others from mal-conforma- lion of the chest. Asthma having once taken place, its fits are apt to return pe- riodically, and more especially when excited by certain causes, such as by a sudden change from cold to warm weather, or from a 412 NEUROSES, OR NERVOUS DISEASES. CUtSS II. heavier to a lighter atmosphere; by severe exercise of any kind, which quickens the circulation of the blood; by an increased bulk of the stomach, either from too full a meal or from a collection of air in it; by exposures to cold, obstructing the perspiration, and thereby favouring an accumulation of blood in the lungs; by violent passions of the mind; by disagreeable odours; and by irritations of smoke, dust, and other subtile particles floating in the air. "• A consequence of convulsive motions is the habit of repetition, the muscles have contracted by laws peculiar to the animal economy ; so asthma is believed to depend frequently upon this cause. The proximate or immediate cause of the disease has by Dr. Cullen, and most other writers, been supposed to be a preternatural or spas- modic constriction of the muscular fibres of the bronchiae, which not only prevents their being so dilated as to admit of a free and full in- spiration, but also gives them a rigidity, which interferes with a free and full expiration. This doctrine has, however, been disputed by Dr. Bree, who, in a very ingenious treatise on this disease, offers it as his opinion, that ir- ritation seated within the air-cavities, and arising either from an effu- sion of serum, or from aerial acrimony, is the true proximate cause of convulsive asthma. The mucus which is excreted in tbe course of the disease, and which has been looked upon''by Dr. Cullen and others as only an effect, Dr. Bree views as a prominent cause of the parox- ysm ; or, when it is absent, only yielding to a different cause equally irritating to the organ, and exciting spasmodic contractions of the respiratory muscles. Dr. Darwin says, that whatever may be the remote cause of the paroxysms of asthma, the immediate cause of the convulsive respi- ration, whether in the common asthma, or in what is termed the con- vulsive, which are perhaps only different degrees of the same disease, must be owing to violent voluntary exertions to relieve pain, as in other convulsions; and the increase of irritability to internal stimuli, or of sensibility during sleep, must occasion them to commence at this time. Asthma usually diminishes as soon as a mucous secretion begins to take place, and is more speedily and effectually relieved by a spitting of blood. These facts are convincing proofs of a preternatural fulness of tbe vessels of the mucous membrane of the bronchiae, so as to im- pede free respiration, and to produce all the symptoms of spasmodic asthma. The sudden accession of the paroxysms generally after the first sleep, their returning at intervals, and the sense of constriction about the diaphragm, occasioning the patient to get into an erect posture, and to fly for relief to the cold air, will readily distinguish asthma from other diseases. If the attacks of asthma are neither frequent nor severe, tbe constitution unimpaired, and the patient is young, there may be a possibility of removing the disease entirely; but where it comes on Order 111 asthma. 413 at an advanced period of life, has frequent paroxysms, and pro- ceeds either from an hereditary predisposition, or from a condition of the body subject to serous defluxions, it will be impossible to eradicate it. By changing into other diseases, as consumption and hydrothorax, or by occasioning an aneurism of the heart, or of some large vessel, it is apt to prove fatal; but without such occur- rences it is by no means attended with much danger, although it may seem in many instances to threaten almost immediate death by suffo- cation. Anasarcous swellings of the lower extremities, and some degree of diabetes, are complaints which frequently attend on asthma, where it has been of long duration. The respiration becoming suddenly quick and short, the pulse weak and irregular, paralysis of the arras, great depression of strength, a scanty secretion of urine, and frothing at the mouth, indicate . extreme danger. The inspection of dead bodies has thrown but little light either on the nature or cause of this disease. A series of observations from Morgagni, and the works of many other anatomists, have how- ever proved the existence of extravasated serum in the vesicles of the lungs of asthmatics, in most instances. Where the disease has l>een of long continuance, various morbid affections of the system have been discovered on dissection. In the treatment of asthma we should endeavour to moderate the violence of the paroxysms, and when they are subsided, to hinder their recurrence. With the view of preventing any danger from the difficult transmission of blood through the lungs, and of obviating the plethoric state of the system, which might be supposed to have a share in producing a turgescence of the blood in the lungs, it is- a frequent practice to draw off blood during the paroxysm; but bleeding has proved highly injurious in almost every instance of the disease, by delaying the expectoration, and is certain to be attend- ed with bad consequences, where asthma has arisen in elderly persons, or has been of long standing. In full plethoric habits, possibly cupping, or applying several leeches to the chest, might afford some relief. On blood-letting, Dr. Bree makes the following judicious obser- vations :-—"Many doubts," he says, "occur on the propriety of bleeding in any species of this disease. Before the pulmonary ves- sels have attempted to relieve themselves by their exhaling orifices, blood may possibly be drawn with advantage; but when effusion has taken place, a certain debility is indicated, and a loss of con- tractile power in the coats of the vessels, which prudence will rather submit to during the fit, and attempt to remedy in the inter- mission. In this state of the disease, nature pursues the path best adapted to her circumstances: the escape of serous fluid gradually relieves the vessels, and respiration and absorption must be relied on, with a salutary cough, to clear the air-cells of the lymph. If evacuations of blood are directed, the sudden depletion of the ves- sels will leave their coats without the stimulus necessary to pro- 414 NEUROSES. OR iNF.RVOUS DISEASES. CtaSS II. m time to time. Ipecacuanha being milder and more certain in its operation than any of the preparations of anti- mony, should have a preference given to it. A dry and settled atmosphere is most friendly to asthmatical people, not only because it is free from impure vapours, but also as having more elasticity to press upon the vesicles of the lungs. While some asthmatical persons cannot live, however, with any comfort in the atmosphere of large cities, there are others again who feel them- selves better in an air replete with gross effluvia, and breathe with greater ease in a crowded room where there are candles and a fire. Indeed the removal from a cold to a warm climate is sometimes found beneficial. In every species of asthma the patient's diet should consist of such things as are light, and easy of digestion, carefully avoiding at the same time whatever may tend to generate flatulency: and as many kinds of vegetables are apt to be attended with this effect, they are almost all improper. Animal food of tbe lightest kind, taken in a moderate quantity, so as not to overload the stomach, will be the most proper for asthmatics; and for ordinary drink tbey may use toast and water, or other cool watery liquors. All vinous, spirituous, and fermented liquors, will be injurious to them. Tea will likewise bj improper, from its being usually drank warm, and from its supposed power of weakening the nerves of the stomach. C'iffee has been employed in asthma with much advantage when tak-n in a powerful dose. In the pure spasmodic kind, if made so strong as an ounce to the cup, without milk or sugar, and repeated, if necessary, at the distance of a quarter or half an hour, the fit has Order III eANINE MADNESS. 421 been entirely removed ; and this practice has been continued by patients labouring under the disease for years, affording certain relief to their paroxysms. Some practitioners have, however, dis- approved of fhe use of coffee. Garlic is a vegetable production which is found of service to asthmatical people. Acids usually agree with them. HYDROPHOBIA, RABIES, or CANINE MADNESS. The commencement of hydrophobia is marked by unusual anxiety, timidity, and sighing, severe pain in the epigastric region, difficult and painful deglutition of all liquids, accompanied by a sense of suffocation, dryness of the tongue and fauces, a small weak pulse, and slight pyrexia : its progress and close, by con- tinual watching, laborious respiration, intolerance of light and the motion of air, a discharge of viscid saliva from the mouth, and not unfrequently by convulsions. * The disease arises from the introduction of a small portion ofthe poison by the bite of a rabid animal, and that commonly of the canine or cat kind, as being those which are most domesticated. Some ofthe old writers have asserted, that it has occurred from the contact of fhe saliva, without the intervention of the poison of a rabid animal with the skin, independently of any bite, or the inflic- tion of any apparent injury : but the possibility of this 1 much doubt. At any rate, the occurrence is to be considered as very rare indeed. There can be no doubt, however, but that symptoms exactly resembling those of fhe genuine rabies canina have arisen in fhe human body from other causes. Local irritation from wounds in irritable habits, especially when conjoined with a perturbed state of the passions, and also violent affections of the mind, independently ot corporeal injury in hysterical and hypochondriacal constitutions, have at limes produced all the pathognomic symptoms of canine madness. Violent alternations of heat and cold, and all other causes which induce great debility, and at the same time increase the irritability of the system, have also at times proved adequate to the production of symptoms exactly corresponding with those of rabies. Such cases have been denominated by medical writers, spontaneous hydrophobia. A few have gone so far as to doubt the existence of this affection, as arising from the bite of a rabid animal, and an absorption of the virus, contending that all the phenomena witnessed in this terrific malady may be referred to nervous irritation, from terror and apprehension of its occurrence, and are wholly independent of the saliva, erroneously, they think, considered poisonous : but the fallacy of this hypothesis has been most satisfactorily ascertained. Many have doubted whether madness can arise in animals with- out preceding contagion. Some cases recorded by M. Rossi in the Mem. de I'Acadeuiie de Turin, lom. 6th, evidently demonstrate, however, that animals previously healthy become capable, when 422 NEUROSES, OR NERVOUS BISEASES. ClaSS II. enraged or irritated to a high degree, of communicating disease by their bite ; a circumstance which, although long credited by the vulgar, wanted the support of direct evidence to establish it satisfactorily. The fact of rabies sometimes arising spontaneously, appears to be decisively established by Mr. James Gillnian*, tor he recordi an instance where a dog that was chained in a yard, without any kind of intercourse with animals capable of inoculating the disease upon him, had it in its genuine form, which was verified by the effect produced by bis saliva. Food of a highly putrid nature, a deficiency of water to assuage thirst, severe exercise during very sultry and dry weather, and a certain state or peculiarity in the atmosphere similar 1o what pro- duces epidemics of other kinds in (he brute species, may possibly be capable of giving rise to madness in the canine and cat species, as well as a long continued worrying of the animal. Some physi- cians, however, are disposed lo dispute the efficiency of these remote causes, and maintain the actual infection from a diseased animal, by an inoculation of the poison, to be the sole exciting cause. There are, however, strong presumptive proofs that rabies does originate spontaneously in some quadrupeds ; and carnivorous animals seem most, if not alone, liable to it as a spontaneous disease. It does not appear, however, that madness is so prevalent among dogs in warm climates as in cold ones; for during a residence of many years in the West Indies I never met with a single occurrence of the kind* We are also informed by various writers, that canine madness is a stranger to South America; and according to the testimony of Volneyf it is equally unknown in Egypt and Syria. Mr. Barrow| also tells us, that notwithstanding the heat of the climate at the Cape of Good Hope, and though the dogs are fed in the interior hy the Kaffers on meat in a highly putrid state, still the disease is un- known there. Rabies seems to arise from a specific contagion, which being once produced by causes unknown, continues to be propagated by the intercourse which dogs have with one another. It is alleged that the distemper is not communicable from one hydrophobous person to another, by means of a bite or any other way; but this seems to require further confirmation. The possibility of reproducing this disease by inoculation of the quadruped with virus secreted in the human system, had long re- mained a doubtful fact, having often been tried without success j but this point seems now determined by Messrs. Magendie and Bresslet|| having succeeded in affecting a dog with rabies, by ino- culating him with the saliva of a man under that disease. * See his Dissertation on the Bite of a Rabid Animal. i See his Travel*, vol. i. X ------■.--------into the Interior of Africa from the Cape of Good Hope. ?i See LonUou Medical Repository, vol. iv. p. 35. Order III canine madness. 42# We have no proof that any of the secretions of a rabid animal but the saliva can excite hydrophobia. It is known to a certainty^ that the specific poison of rabies exists in the saliva, but it has been a question how far the fluids and solids have been generally con- taminated. The experiments of Mr. Gillman have furnished results which go far to prove that the infecting material of rabies is hardly to be found but in the saliva. A large portion of such persons as have really been wounded by the bite of a rabid animal are never affected with the disease Mr. Hunter mentions an instance of twenty persons being bitten by the same dog, and only one was seized with it. It is therefore obvious, that different persons are not alike predisposed to be acted upon by the same contagion, and likewise that the predisposition to receive contagion varies in the same person at different periods. The de- pressing passions, as well as other causes producing debility,, pro- bably may predispose the system to the action of this virus. In the canine and cat species, about seven or eight days may be considered as a fair average of the shortest period in which rabies shows itself after the animal is bitten, and six or seven weeks the longest period from the date of fhe bite. In the human species, only a few days have in some instances elapsed previous to the symptoms showing themselves ; but the most common time of their appearance is from twenty to forty days after the bite. There are no well-authenticated instances of the poison lying dormant longer than eleven or twelve months; and we may therefore consider a person pretty safe at the expiration of a year without any symptom appearing. In the cases quoted by authors where canine madness is said t© have occHrred at the distance of many years from the communica- tion of the supposed poison, we may justly consider them either as instances of spontaneous hydrophobia, as before mentioned, or as such other diseases as occasionally exhibit the anomalous symptoms of an inability to swallow fluids, and an aversion fo the sight of them : the poison of a rabid animal has had no share in their production. The frequent occurrence of an aversion to fluids, and of great dif- ficulty in swallowing them in women affected with hysteria, have been noticed by many writers, and some of fhese facts demonstrate- that all the symptoms of canine madness have been brought on by violent affections of the mind in irritable and delicate habits. The fatal termination of some of these instances, tends further to confirm the strictness of analogy between rabies and hysteria. Possibly some cases also of tetanus, in which there has been much local irri- tation in an excitable habit, conjoined with a perturbed state of the passions, may have been mistaken for hydrophobia, by exhibiting symptoms exactly corresponding with those of rabies canina. Rabies in a dog is attended with the following appearances :-<- he generally shows some marked deviation from his accustomed habits. In fhose which are domesticated, as lap dogs, some strange peculiarities have been observed, as the picking up of the different1 124 NEUROSES, OR .NERVOUS DISEASES. ClaSS II. little objects, such as paper, thread, straw, &c/ or any thing which may happen to be presented to their notice. Sometimes they show a depraved appetite, and eat their own excrement, or lap their own Urine. Still, however, in this stage they seldom attack any person unless irritated to it. Although a diseased dog often ob- serves the usual obedience to his master, and evinces the s;une attachment, still he is usually extremely irritable, and alwayi treacherous, suffering any one to fondle him, but suddenly snaps or bites with the smallest provocation. In the progress of the disease, his eyes sometimes become inflamed, a purulent dis- charge issues from the lids. Instead of barking, he often makes a dismal howl, and has usually a listless and melancholy appear- ance. The term hydrophobia, as applied to dogs, is highly exceptiona- ble, as the animal, instead of showing any dread of water, which has generally and popularly been considered as marking fhe disease, seeks it in most instances with avidity, and laps it incessantly. A late writer* on the diseases of dogs very justly notices the evil that this opinion has led to in lulling info dangerous security per- sons bitten by dogs actually rabid, and in particular refers to an instance in which an eminent physician, on being consulted by a person who had been bitten, recommended that no precautions might be taken, because he was informed the dog could drink. Another absurd popular error noticed by this writer, is the opinion that the worming a dog, which is merely removing the frsenum from the tongue, will prevent his becoming rabid at any future time. As rabies advances, the animal becomes extremely anxious and impatient, and has an inordinate desire fo gnaw every thing around him. When chained, or confined, he uses his utmost endeavours to break loose, and if he succeeds, he wanders about seeking other animals to bite, particularly some of his own species. It has before been observed, that frequently he does not avoid water, but laps it greedily ; still in this stage of the disease he is often deprived of the power of swallowing it. Very often he has the appearance of being paralytic behind, and labours under an inflammation in his bowels, which occasions him to sit on his rump, seemingly in great pain. In the last stage, all the preceding symptoms are highly aggravated : he now becomes very feeble, his jaws drop as if paralyzed, and the saliva runs from his mouth, he wanders or rather staggers about with scarcely the power of biting, and at length being exhausted by disease, generally dies on the fourth or fifth day from its commencement. Few dogs survive the seventh. In the human species, the general symptoms attendant upon the bite of a mad dog, or other rabid animal, are :— The part bitten, after some time, begins to be painful ; then come on wandering pains, with an uneasiness and heaviness, dis- * See Canine Pathology, by Mr. Delabere Blaine, Professor of Animal Medicipe Order III ganine madness. 4Qu turbed sleep and frightful dreams, accompanied with great rest- lessness, sudden startings and spasms, sighing, anxiety, and a love of solitude. These symptoms continuing to increase daily, the cicatrix of the wound becomes hard and elevated, a peculiar tingling sensa(ion i-> felt in the part, and pains begin to shoot from the place which was wounded, all along up to the throat, with a straimess and sensation of choking, and a horror and dread at the sight of water and other liquids, together with tremors. The person is, however, capable of swallowing any solid substance with 'olerable ease ; but the moment that any thing in a fluid form is brought in contact with his lips, it occasions him to start back with much dread and horror, although he labours, perhaps, under great thirst at the time. This appears to be a circumstance peculiar to the human race; for rabid animals do not evince any dread at water. It has indeed been remarked by a late writer*, (and very justly in my opinion) that the dread expressed, is not of the water, but of the act of deg- lutition. It miy, however, be said, that the very sight of water produces this dread ; but in that case the sight of tbe water associates with it the idea of deglutition. Many other practitioners are also of opinion that this peculiar sjuipiotn or starting bark with horror at the sight of water and other fluids, does not proceed from any dread of them, but from tiie fear of swallowing them, owing to tbe diseased state of the parts in consequence of inflammation. To swal- low liquids, a greater contraction of the muscles of deglutition is requisite than to get down -olids, and of course it produces a higher degree of pain and spasm, which explains the greater capability in the patient of being able to swallow solid substances than fluids. Dr. Vaughan, who has favoured tbe public with his opinions on hydrophobia, denies, however, that the excruciating pain, which never fails to attend eveiy attempt to drink, is felt in the fauces and throat. He says, that it is the scrobiculus cordis which is principally affected, this being the part to which the patient always applies his1 hand. From this circumstance, therefore, from the presence of risus sardonicus, from the muscles of the abdomen being forcibly contracted, and from the sense of suffocation which seems to threaten almost immediate death, he is led to think, that in hydrophobia a new sympathy is established between the fauces, the diaphragm, and tbe abdominal m-is les. Dr. Rush, from some appearances which he observed on dis- secting a boy who died of hydrophobia, from the bite of a mad dog, has been induced t6 suppose that it is the temporary closure of tbe glottis which produces the dread of swallowing liquids; hence the reason why they are taken in suddenly and at intervals. Ihe same danger and difficulty attend swallowing the saliva; and * See Dr. Marshall's Anatomy of the Brain, p. g§. 54 426 NEUROSES, OR NEVOUS DISEASES. ClaSS It hence, he thinks, the symptom of spitting proceeds, which has been so often noticed in hydrophobia. In the case here alluded to, the morbid appearances were as follow: the epiglottis was in- flamed, and the glottis so thickened and contracted, as barely to admit of a probe of the common size. The trachea below it \»as likewise inflamed and thickened, and contained a quantity of mucus in it. The oesophagus exhibited no marks of the disease, but the stomach had several inflamed spots upon it. Dr. Pany is of opinion*, that the part which is primarily af- fected, so as to give rise to the symptom denominated hydrophobia, is not the pharynx, oesophagus or stomach, but the upper portion of the trachea, together with other parts of the apparatus concerned in the function of respiration. In the course of the disease a vomiting of bilious matter comes on, and an intense high fever ensues, attended with continual watching, great thirst, dryness and roughness ef the tongue, hoarseness of the voice, and the discharge of a viscid saliva from the mouth, which the patient is constantly spitting out; together with spasms of the genital and urinary organs: in consequence of which the evacuations are sometimes forcibly ejected. In general he is incapable of enduring light, or the motion of air; bis respi- ration is laborious and uneasy, but his judgment is unaffected, and as long as he retains the power of speech his answers are distinct. In some few instances a severe delirium arises, and closes the tragic scene; but it more frequently happens, that the pulse be- comes tremulous and irregular, that convulsions arise, and that nature, being at length exhausted, sinks under the pressure of misery. Our prognostic in this disease must always be unfavourable, a6 in mo-t instances all means whatever have proved ineffectual. Death commonly takes place about the third -or fourth day from the first appearance of the symptoms. The appearances to be observed in the human species on dissec- tion in hydrophobia are unusual aridity of the viscera and other parts; marks of inflammation in the lower portion of the oesopha- gus and cardiac extremity of the stomach, and even in the stomach itself. Some marks of inflammation are likewise to be observed in the brain, consisting in a serous effusion on its surface, or in a red- ness of the pia mater; which appearances have also presented themselves in the dog. Now and then we meet with an accumu- lation or effusion of blood in the lungs. In some cases of dis- section, not the least morbid appearance has been observed either in the fauces, diaphragm, stomach, or intestines. The poison has therefore been conceived by some physicians to act upon the nervous system, and to be so wholly confined to it, as to make it a matter of doubt whether the qualities of the blood are altered by it or not, or whether the poison at all enters the system by the "See his Cases of Rabies Contagiosa and Tetanus. Order III canine madness. 427 absorbents. As far as my knowledge extends, tbe lymphatic glands in the course of absorption have never been found diseased. On the developement of the symptoms of hydrophobia, tbe pain beginning in the bitten part appears indeed to follow rather the course of the nerves than that of the absorbents. On opening rabid animals, slight marks of inflammation about the epiglottis and pylorus, with occasionally some livid marks in the villous coat of the stomach, are now and then to be observed, but sometimes no appearances of inflammation either in the stomach or elsewhere are to be observed on inspecting the bodies of these animals. As in rabies, when once manifested in the system, the power of medicine and all human skill have failed in most instances, our views should be early directed to prevent the accession of the disease; and for this purpose the most effectual is excision of the wounded part, with free ablution and scarifications. Immediately, therefore, on the infliction of the bite, or as soon afterwards as possible, ablution with water and soap should be had recourse to, and be continued until professional aid is. procured. On the arrival ofthe surgeon, a free and complete excision of the bitten partis to be made, taking cate to carry the knife to a sufficient depth, so as to ensure its complete removal. The excised part being removedj ought carefully to be examined to see if there is any place in the piece through which the dog's teeth appear to have passed; and m case there is, the excision ought to be carried still deeper than be- fore. Should the knife, on a close examination, appear to have entered the wound made by the dog's teeth, it may be advisable to recommence the operation with a clean knife, lest the other should be contaminated by its having entered the wounded parts, and by which the sound ones might become inoculated with the canine virus. The sooner that the wounded part is extirpated after the accident the better; but it will be right to do it even at the distance of several days, or even at any time prior to the developement of the disease, rather than that the person should be debarred ofthe chance which excision affords, as there is great reason to presume that the canine poison does not enter the system so quickly as a variety of others are perceived to do*. This conclusion we are somewhat authorized to draw, as in several well-attested cases, many weeks, nay months, have intervened between the accident of being bitten, and the appearance ofthe disease. Dr. Darwin observesf, that if the patient is bitten in a part which could be totally cut away, as a finger, even after the hydro- phobia appears, it is probable it might cure it, as he suspects the cause still remains in the wounded tendon, and not in a diffused infection tainting the blood. Hence there are generally uneasy ——————————— . ,ltl * See Mr. Gillman's Prize Dissertation on the Bite of a Rabid Animal. t See ^oonomia, vol. iv. p. 50. 428 NEUROSES, OR NERVOUS DISEASES. ClttSS II. sensations in the old cicatrix before the hydrophobic symptoms commence. Even in cases where assistance has not been requested until the consequent disease has already appeared, I am of opinion that the wounded parts should be excised : for if the excision of the part, in which the virus of small-pox, syphilis, or any similar disease is deposit- ed, after the local action has evidently commenced, prevents absorp- tion, and consequently the complete formation of the general disease} what reason is there for supposing that the same effect would not result from this operation, at the same period, in the case of the bite of a rabid animal, if the poison enters the system by the absorbents. After excision, ablution is again to be performed with a solution of volatile alkali in water, and when the flow of blood begins to cease, suction with the cupping-glass may be resorted to. The alternate employment of ablution and the exhausted receiver may be continued for some hours. Having proceeded thus far, caustic, such as the ar- genti nitras, or potassa fusa, may be applied to the wound, so as to produce a slough in the first instance, and afterwards a purulent dis- charge for some weeks. By this mode of treatment many persons have been known to escape the disease ; while others who have been bitten by the same animal, and who neglected these means, have be- come affected. It sometimes happens that the wounded or bitten part is so situated as not to admit of excision, or from the timidity of the patient he cannot be persuaded to submit to the operation. Under this dilem- ma we must be content to have recourse to a careful and persevering ablution, and afterwards to scarification and rupping, bathing the parts with warm water to promote a free flow of blood, in order to assist in washing away any remaining particle ofthe poison. With respect to the fluid to be employed at first in the ablution, a weak solution of volatile alkali, in the proportion of one part of the alkali to four of water, may be as proper as any we can use. Wilh this solution, which is fully capable of dissolving the saliva, the wounded part should be freely washed, and injections with a syringe forcibly be made into the wound. After this, water may be substituted to assist in washing away any remaining particles of the canine poison. Having washed the wound for a considerable time, it may be touched with caustic, the argenti nitras, or the potassa fusa. Ligatures above and below the wounded part have been recommended during the ablutions by Dr. Percival, when they can be put on. The bitten part must be destroyed to the bottom, by repeated appli- cations of the caustic. To assuage the inflammation caused thereby, the wound is to be dressed for some time with poultices ; and after- wards with acrid dressings and hot digestives, to remove the eschar, ereate a discharge, and drain the injured parts. Where there has been any delay after the accident, the wound should thus be kept open for two or three weeks, or even longer. Order III canine madness. 429 From some experiments made by Dr. Linke, of Jena, with the saliva taken from a mad dog after it was dead, and that had bitten other animals with a fatal effect, the external application of a strong solution of white arsenic in water to wounds besmeared with the poison, appears to have been attended with the happy effect of des- troying the viius, and of preventing the disease from taking place. The remedy seems therefore worthy of further trials in wounds made by rabid animals. Under the head of Animal Poisons it is mentioned that the exter- nal application, as well as the internal exhibition of the liquor ammo- nite, was found on many trials entirely to do away the injurious con- sequences arising from the bite of the cobra de capello, a snake of the most venomous kind, and productive of symptoms pretty similar to those arising from a rabid animal. The same remedy would therefore seem worthy of a trial in cases of hydrophobia; but as there would be great difficulty in administering caustic volatile alkali in a state necessarily diluted with some mild bland liquor, where the increased sensibility of the fauces and the dread of liquids are so strongly felt, we might convey it into the stomach in the manner practised by Mr. John Hunter, and herein after mentioned, or we might mix the volatile alkali with crumbs of bread, and form the mass into pills, or a bolus. Tn addition to these modes of prevention, it has strongly been recommended to commence, very speedily, a course of mercurial unction, which is to be continued regularly, and to be applied in a considerable quantity at once, so as to occasion some degree of salivation ; to expedite which, tbe submuriate of mercury may be given internally night and morning, and warm bathing be used oc- casionally. Mercurial fumigations may also assist. With the design of exciting a rapid salivation in hydrophobia, Dr. Darwin has suggested that one grain and a half of the hy- drargyri oxymurias dissolved in half an ounce of rectified spirit may be given frequently to the patient with a prospect of advantage. From a paper by Mr. Addington, of West Bromwich, inserted in the Contributions of Medical Knowledge published by Dr. Beddoes, it appears that a similar mode is adopted by him for the cure of gonorrhoea virulenta, and that he has cured hundreds in a very- short time in this manner without the least disagreeable conse- quence. He directs us to proceed as follows: three grains of hydrargyri oxymurias are to be dissolved in one ounce of rectified spirit. Half of this mixture is to betaken undiluted at going to bed; it produces a copious salivation for an hour and a half, or longer, during which the patient spits about a quart. Some aperient salts are to be taken on the second day after this opera- tion, and on the evening of that day he is to repeat the draught, and the salts on the day but one following. Dr. Thomas Reid, in a pamphlet which bears the title of Obser- vations on the Application of warm and cold Sea-bathing, recites a case which strongly attests the preventive effect of mercury. 430 neuroses, or nervous diseases. Class 11. He makes mention, that a man, a woman, and several dogs, were bitten by a supposed mad dog, who was soon after destroyed. A fortnigh after the accident, he saw them ; the woman was slightly wounded in the little finger, a black scab remained on the punc- ture : she had great pain in the arm, shooting up to her u*ad, particularly in the night, with disturbed and frightful dreams, and great depression of spirits. Tbe man had been bitten in the hand also, but had not so much pain. He directed mercury for them in tbe manner published by Dr. James. In a few days the symp- toms abated; and as the woman's mouth was sore, she desisted from using it. The pain, however, returned very soon, greatly augmented, and affected her head ; she resumed the medicine, and every symptom vanished ; they both remained perfectly well. Had my return of the disease taken place, he is certain he would have been informed of it.. Dr. Reid further mentions, that the same medicine was given to dogs ; but by some accident one of them was forgotten, and took none ; he became raving mad the thirtieth day, and in that state he had him shot; all the other dogs remained well, except a small lap-dog, which died of the salivation. Neither the man nor woman supposed the dog to have been mad, until they began to take tbe medicine; the mind had therefore no influence in pro- ducing the symptoms that ensued. These facts seem well authenticated, and strongly attest the good effects of mercury, when used at an early period. During the aciual presence of the disease, its inutility has been proved in numberless instances. Dr. Mosely* has, indeed, recorded a case of recent hydrophobia, and timely discovered, which was successfully treated by exciting a rapid and plentiful salivation by means of an ounce of strong mercurial ointment rubbed into different parts of the body at four frictions within forty-eight hours. Dr. Richard Pearson, of Birmingham, in his Treatise on Hydro- phobia, offers it as hi- opinion, that if the disease has ever been cured by mercury, it has been in consequence of a counter-impression communicated to the whole system, and not in consequence of the salivation; for a salivation is a constant symptom of the disease, so that if it were curable by a flow of spittle, it would cure itself. This seems, however, a vague mode of reasoning. Although medicine has hitherto proved ineffectual in most of the cases where the disease had fully established itself, still it is neces- sary to mention the plan which has usually been pursued on such occasions. From certain symptoms which attend on hydrophobia, such as heat, thirst, restlessness, fever, difficulty of breathing, priapism, watchfulness, and furor; from the inflammatory appearances usually observed on dissection, and from the successful employment of * Sec his Dissertation on Canine Madness, Order III canine madness. 431 venesection in some supposed cases of rabies, this remedy has been much used by many practitioners. Where the *rue characteristics ofthe disorder were really present, it had not heretofore afforded relief; but two successful cases have lately been reported in the 167th No. of Philips's Medical Journal, by Dr. Shoolbred, of Calcutta, in which bleeding ad deli- iquuim animi, and repeating the operation at intervals as long as firmness of arterial action or the symptoms of hydrophobia remain- ed, completely removed the disease. In these instances, vene- section was resorted fo immediately on the disorder becoming apparent. The cure in these cases, although attributed by Dr. Shoolbred fo blood-letting alone, has by some been supposed to be owing to the combined use of mercury at the same time. The trials which have as yet been made of the depletory prac- tice in Europe are too limited and defective to admit of their being received as decisive of the question as to tbe utility of copious bleeding at the onset of rabies. The operation should be performed as soon as the wound reassumes an inflamed appearance, or an aversion from drinking is manifested: the orifice ought to be a large one, and the bleeding be continued till actual fainting is induced, for it is not the quantity of blood lost, but the suddenness with which it is abstracted, and the fainting, that determine its efficacy. The inflammatory diathesis, which has been supposed to exist in this disease, has of late been disputed, and particularly by Dr. Pearson. He observes, that some of the symptoms are merely accidental, others scarcely perceptible, and some, even if present, would not denote the disease to be of a nature requiring venesection. Dr. Parry says, that with respect to the proximate constitutional character of rabies, there cannot be a greater mistake fhan to Suppose either that the fever consequent on the disease is of the inflammatory kind, or that its peculiar symptom arises from local inflammation of the fauces, fhe cardia, or any other part. Under the idea that rabies is an inflammatory disease, warm bathing, and the rest of the antiphlogistic plan, have been much used in its treatment ; but these means proving ineffectual, and from a fancied analogy between (etanus and rabies, some prac- titioners have been induced to recommend gold bathing, with a free use of wine. Dr. Russell makes mention that wine in large quantities has been administered with success against the bites of venemous serpents ; between which disorder and rabies we can readily allow some de- gree of affinity. Wilh respect to cold bathing, this has been found to aggravate the disease when it has once absolutely taken place, by exciting convulsions ; but before it has shown unequivocal symp- toms, and is apparent, this remedy may probably be used with advantage. That cold bathing possesses a degree of preventive power againBt the effects of canine poison, is an opinion 432 neuroses, or nervous di&eases. Ciuss It handed down by ancient writers, and is still entertained by many of the moderns. From considering that the poison of a rabid animal produces an excessive increase, or morbid alteration of the natural sensibility, and that those who are bitten by a mad dog, or other animal so diseased, are in a perpetual state of restlessness, from the beginning of the attack to the end, that they can ill bear the impression of objects upon the senses, that the least noise is offensive, and that all feeling is painful, opium has been much employed; and consid- ering that the poison produces these effects, we might be induced to suppose that it would have proved a valuable and powerful remedy. Many cases are however on record, where, although it was given to the quantity of 180 grains in the space of fourteen or fifteen hours, it failed to produce any good effect*. Whenever opium is administered the dose ought to be pretty con- siderable, and its repetition should be regulated by the effect it occasions, without much attention to the quantity. Might not the external application of it, as advised under the head of Tetanus, be worthy of a trial ? Where the patient loses the power of degluti- tion, introducing opium into the system by means of friction, appears to be a very eligible plan. Mr. Ward, of Manchester, was, I believe, the first who suggested its being employed in hydrophobia in this manner. Indeed, as the throat appears in this disease always to be affected with spasmodic contractions, it would seem that no remedy we can employ promises better effects than the rubbing in (and particularly about the throat and chest), opium in the form either of liniment or ointmentf. Dr. Stutz, of Suabia, very much recommends a tr;al of the vegetable alkali in this disease, alternately administered with opium, together with its external application in a warm bath. Besides opium, other antispasmodics, such as musk, have been employed in the treatment of hydrophobia, but without much ad- vantage. The best plan will be to unite their powers, by giving them combined as below.J * See Medical Record and Researches, art. viii. p. 117. » 1. ft Tinct. Opii, f. |j. Spirit Camphorae, f. ?ss. Liquor. Ammonias, f. 3>j- M. (t. Linimentum. Vel, 2. g; Adipis Praeparat. ^i. Opii in Puiv. subtilis. trit. 3i>j. M ft. Unguentum. X 3. Moschi, gr. xij. Camphorae, gr. v. Opii, gr. iij —x. Bals. Peruv. q.s. M. ft. Bolus 4tis horis sumendus. t 1. Take Tincture of Opium, one ounce. Camphorated Spirit, half an ounc« Solution of Ammonia, two drachms. Mis them, and use thero as an embrocation. Or, 2. Take Prepared Lard, one ounce. Opium, in fine powder, three drachms. Mix them into an ointment. { 3. Take Musk, twelve grains. Camphor, five grains. Opium, three grains to ten. Balsam of Peru, a sufficiency to form a bolus, which may be taken evsry four hours. Order 111 «anine madness. 438 As ipecacuanha in small doses proves serviceable in some spas- modic diseases, it perhaps might be useful to give it in this. It should not, however, be administered so as to provoke vomiting, but only in such doses as will be sufficient to promote a copious perspira- tion, by exciting a slight degree of nausea. It is probable that the pulvis ipecacuanha? compositus (in which there is a portion of opium) ought to be preferred to the simple powder, as being usually attended with a more certain diaphoretic effect. It has been recommended to make a trial ofthe spirit of turpen- tine in the form of clyster, during the convulsive stage of the dis- ease, from its efficacy in some other spasmodic affections, but more particularly hysteria. The hint seems worthy of attention. It is asserted that some cures have been performed by a liberal use of vinegar. We have likewise been assured, that anointing the body freely with sweet oil, and pouring repeated draughts of it forcibly down the throat, has lately been discovered to be a success- ful remedy in hydrophobia. The dread of fluids is said to diminish in proportion to the quantity of oil which is swallowed. A method of preventing the plague, somewhat similar to this, has been noticed under the head of that disease. Among the medicines celebrated for their virtues in hydrophobia are to be enumerated the Ormskiik powder, the Tonquin remedy, and the Carnatic pill. The former of these seems perfectly inert, and on a careful analysis was found to consist of about half an ounce of prepared chalk, ten grains of alum, three drachms of arme- nian bole, one drachm of powdered elecampane root, and a few drops ofthe oil of aniseeds. The principal ingredient in the latter is arsenic. This mineral is much employed by the Hindoo physicians as an antidote to hydrophobia. It enters into the composition of the East India snake-pill, a medicine communi- cated to the presidency of Madras by a native of Tanjore, and which, we are told by Dr. Simmons, (one ofthe Company's surgeons) he has administered with apparent success to persons bitten by mad dogs. In Dr. Hamilton's Treatise on Hydrophobia, it is in- deed much recommended to try the effects of arsenic in this disease. As strong epileptic paroxysms have been stopped by administering the arsenical solution, possibly it might have a good effect in rabies. A combination of arsenic and opium has been proposed by Dr. Blane*, as a prophylactic for the bite of a mad dog. The oxyd of zinc, and the cuprum ammoniatum, are other mineral preparations which have been named, as well adapted to the disease. The Tonquin medicine consists of twenty-four grains of native cinnabar, with the same quantity of factitious, made into a powder, with sixteen grains of musk. It is directed to be taken in a tea-cupful of arrack or brandy, and is said to secure the patient for thirty days, at the expiration of which it is to be • See Transactions of a Society for tbe Improvement of Medieal and Knowledge. 55 434 NEUROSES, OR NERVOUS DISEASES. Class II. repeated; but if he has any symptoms of the disease, it must be re- peated in three hours. The first dose is to be taken as soon after the bite as possible. The aligma plantago, reduced to powder, and given to the person bitten, is reported to be much used among the Russians with a happy effectdn hydrophobia. Notwithstanding the various nostrums that have in all ages and different countries been extolled as antidotes to the poison of rabid animals, we may rest assured that the only remedy on which we can place a confidence is excision or cauterization, but particularly the former. Even in wounds completely healed, perhaps it would be advisable to adopt one or other of these, and thereby expose the part within reach of the animal's teeth. If the remedy is resort- ed to before lancinating pains and uneasiness begin to show them- selves about the cicatrix, we may be more likely to succeed by our preventive means, as such symptoms indicate the passage of the virus through the absorbents, or along the course of the nerves. Dr. Pearson is of opinion, that the exciting some degree of fever and inflammation may have a salutary effect in canine madness. He observes, that there is no instance of a person having recovered from an animal poison introduced into the system without more or less inflammatory action. The poison which produces the plague is often most fatal when it is accompanied with the least degree of fever; and swelling and inflammation of the bitten part, together with in- creased heat over the whole body, are the usual forerunners of recov- ery in cases of viper bites. On these grounds he is induced to presume that wine, ardent spirits, and aromatics, may have a beneficial effect in rabies, provided the aversion to liquids is not so strong as to render the exhibition of wine impracticable. He says, that perhaps the nitric or other mineral acids or vinegar (as mentioned by Dr. Ferriar), might be advantageously mixed with the wine. Besides giving wine and vinegar by the mouth, he tells us they should likewise be injected up the rectum. These things are to be administered on the first appearance of the symptoms characteristic of rabies; for as the disease advances, neither wine nor any other liquid can be swallowed in quantities sufficient to produce a powerful effect; and there is sometimes an equal impediment to the administration of clysters. Even in this state of things, he mentions, we are not without re- source. Some of the concrete acids, such as the essential salt of tartar, the essential salt of lemons, or even the acidum benzoicum, may be given joined with about half as much powdered capsicum, or other strong aromatic, and divided into small portions, to be enveloped in wafer-paper, and formed into ooluses. Not less than 20 or 30 grains of the concrete acid*, nor less than 8 or 10 grains of the capsicum, should be given for a dose. Dr. Pearson further observes, that while these things are administered internally, topical applications are not to be neglected. Where the bite is in a Order 111 CANINE MADNESS. 43£ part that will admit of it, a ligature, as proposed by Dr. Percival, should be applied above tbe cicatrized wound. This will prevent far- ther absorption At the same time the bitten part may be opened or destroyed by the application of lunar caustic, or concentrated mineral acids. After the corrosion of the cicatrized wound by the means just mentioned, the ligature which had been passed round the limb should be removed. Such is the plan proposed by Dr. Pearson, which being novel, it seemed right to notice. Whether stimulants are really useful and powerful remedies in the treatment of hydrophobia or not, can only be determined on trial, and nut on any previous view ofthe nature of the disease which theory may suggest. It now remains only to observe, that during the furious stage of the disease the greatest care must be taken that the patient is so confined by means of a strait waistcoat, as to be rendered incapable of doing any injury either to his attendants or himself. As long as he can swallow, his strength is to be supported by things that are light and nutritive, and when deprived of this power, clysters of animal broths must be injected. To assuage his thirst, wine and water may be poured down his throat from the spout of a tea-pot; but if his dread at liquids and act of deglutition are insurmountable, a sponge dipt in hot vinegar may be kept constantly to his mouth and nostrils. If great costiveness prevails at any time in the course of the disease, it should be removed by a laxative clyster. If this fails in procuring the desired effect, the purgative pills advised below* may be given. Dr. Rush has suggested that it might be proper, in cases of hy- drophobia, to make an artificial opening into the windpipe, obviating by this means the most fatal symptom, and giving time for the employment of other remedies, according to the state of the system ; or fluids might be conveyed into the stomach in the manner prac- tised by the late Mr. John Hunter in a patient who was afflicted with a paralysis of the oesophagus, and consequently unable to swallow any nutrimentf. The instrument made use of was a fresh eel-skin, of rather a small size, drawn over a probang, and tied up at the end where it covered the sponge, and tied again close to the sponge where fastened to the whalebone, a small longitudinal slit being made into it just above this upper ligature. To the other end of the eel-skin was fixed a bladder, and a wooden pipe, similar t See Transactions of a Society for the Improvement of Medical Knowledge, vol. i. * 3. ft Extract. Colocynth. C. 3j, Hydrargyri Submuriat. gr. v. 01. Carui, til iij- M. ft. Mnssa in pilulas vj. dividends. *3. Take Compound Extract of Colocynth, one scruple. Submuriate of Mercury, five grains. Oil of Carraway, four drops. Mix them, and divide the mass into six pilr% 436 NEUROSES, OR NERVOUS DISEASES. ClttSS II. to what is used in giving a clyster, only the pipe being large enough to let the end of the probang pass into the bladder without filling up the passage. The probang thus covered, was introduced into tbe stomach, and both food and medicines being put into the bladder were squeezed down through the eel-skin. As cases however of this kind may occur where eel-skins cannot be procured, a portion of the gut of any small animal will make a good substitute. By this mode, whatever fluids are administered would not come in contact with the irritable parts of the gullet. COLICA, or COLIC. Colic is a painful distention of the whole of tbe lower region of the belly, with a twisting round the navel in particular, often accom- panied with vomiting, costiveness, and a spasmodic contraction of the muscles of the abdomen. The disease is produced by various causes, such as crude and aces- cent food, flatus, a redundance of acrid bile, long-continued costive- ness, hardened faeces, certain metallic poisons, derangement of the prima? vise, metastasis of gout or rheumatism, hysteria, the application of cold and moisture, worms in the intestinal tube, and the having. swallowed poisonous substances. It has commonly been considered as being of different species, and has been variously denominated, ac- cording to the cause which has given rise to it, as the biliuus, the flatulent, and the hysteric : but in all of them the proximate cause seems to be the same, viz. a spasmodic constriction of some put of the intestines. Ifc the bilious colic there is loss of appetite, bitter taste in the mouth, thirst, febrile beat, costiveness, and a vomiting of bilious matter, attended with an acute pain all round the region of the navel; and as the disease advances, the former becomes more fre- quent, and the latter more severe and lasting. In the flatulent colic there is great costiveness, attended with pain, soreness and griping of the bowels, a rumbling noise, distention of the stomachj an inclination to throw up, and coldness of the extremities. Iu the hysteric colic there is nausea and sickness at the stomach, accompanied with severe spasms, costiveness, and dejection of spirits. The disease, when rising to a violent height, and attended with a stercoraceous vomiting, obstinate costiveness, and an evacuation of faeces by the mouth, constitutes what is called the iliac passion. Ii this, as well as in intus susceptio, the peristaltic motion is inverted, and a high degree of inflammation is the consequence. The colic is to be distinguished from enteritis by the spasmodic contraction ofthe abdominal muscles, by the absence or trifling de- gree of fever, by the state ofthe pulse, and by the diminution ofthe pain upon pressure of the abdomen. Order III COLIC. 43f When tbe pain remits, or shifts its situation, not being obstinately confined to one place, and when the patient experiences considerable ease after a discharge either of wind or faeces, and stools are obtained, we may have reason to expect a favourable termination to the disease; but the sudden cessation of pain, with the costiveness remaining ob- stinate, cold sweats breaking out, a weak tremulous pulse, frequent syncope, and the ensuing of hiccups, denote supervening inflammation terminating in gangiene. When the disease proves mortal, the usual appearances to be ob- served on dissection are, inflammation on the surface of tbe intestines* distention and irregular contraction of some particular part of the tube, or a passing of one portion of it within another to a considerable extent, the part received within the other being in a contracted state> or probably gangrenous. In all cases of colic, where the patient is young and vigorous, and the symptoms proceed with such violence as to endanger the ensuing of an inflammation of the intestines, it will be advisable to take away some blood, being regulated as to the quantity by the state of the pulse and the appearance of what is drawn off." In repeating the operation we are to be guided by the severity of the attack, the con- tinuance of the constriction on the intestines, the habit of the patient, and the state of the pulse. In the bilious colic, if there is great irritation at the stomach with frequent vomiting, we may direct a saline draught to be taken every two or three hours in tbe act of effervescence, with an addi- tion of about five-and-twenty drops of tinctura opii; but if only a nausea prevails, the patient may be made to drink plentifully of chamomile-tea. Externally we m*y apply flannel cloths wrung out in a warm decoction of emollient herbs, or a bladder filled with hot water, interposing between the paroxysms frictions with anodyne liniment. When the nausea and vomiting have ceased, he should take some active purgative* to carry off the offending matter, tbe operation of which may be assisted by a free use of diluent liquors, such as thin gruel and animal broths. Should the purge be rejected by the moulhr or not operate quickly, we must then attempt to diJodge the contents of the intestines by clysters, making use of mild laxative ones at first* and afterwards resorting to those which are more powerful, if necessary; and these are to be repeated until a sufficient effect is produced. In the flatulent colic we may begin the cure by giving a wine-glass * I. Take Powder of Jalap, half a drachm. Submuriate of Mercury, five grains. Syrup of Buckthorn, a suffi- ciency. ' Form the mass into five pills, to be taken for a do«r. v I. R Pulv. Jalapae, 3ss. Hydrargyr. Submur. gr. v, Syr. Rhamni, q. e. M. Fiant pilula; v. pro dos. 438 NEUROSES, OR NERVOUS DISEASES. Class ff. of some aromatic cordial combined with an opiate*. If relief is not soon obtained, a carminative clysterf may be injected every three or four hours, and warm fomentations, with an addition of rec- tified spirit, be applied over the whole region of the belly. Should clysters not procure a copious evacuation of faeces and wind, some stomachic purgativef may be administered by the mouth. Am- monia, joined with carminatives, will be very proper in the flatulent colic. If the disease continues to increase with violence notwithstanding these means, so as to threaten the approach of an inflammation in the bowels, we must then resort immediately to bleeding, the warm batb, and blistering over the part more particularly affected. On appre- hending a similar consequence in the bilious colic, we may adopt tbe same means.—See Enteritis. * 2. R Aq. Menth. Pip. f. §j. Spirit. Carui, f. ?ss. Tinct. Lay. C. f. 3j- ----Opii, tTl xx. M. ft. Haustus. Vel, 3. Tinct. Cardam. C. f. 3iij. ----Opii, TTl xxv- Aq. Menth. Pip. f. ^iss. M. ft. Haustus. t 4. R Seni. Anis. Contus. Flor. Anthemidis, aa |ss. Coque ex Aq. Fontan. Ojss. ad. ^xj. et colatura: adde Sodae Sulphat 3vj. 01. Ricini, f. |j. M. ft. Enema. Vel, 5. R 01 Terebinth f. 3iij. Vitel. Ovi, q.s. Misceantur in mortario marraoreo, dein adde gradatim Decoct. Avenae, f. Jxij. ft. Enema. X 6. ft Tinct. Sennae C. f. ?j. ft. Haustus. ■ Jalapae, f. 3j- M. Vel, ax Tinct. ejusd. 7. R Infus. Sennae, f. ?v. i.C.fT3vj. Magnes Sulphat. |j. Syrnp. Zii.^ib. f. ^ss. M. ft. Mistura, cujus capiat aeger cochleariatria magna omni bihoria donee alvuspurgetur. 2. Take Peppermint Water, one ounce. Spirit of Carraway, half an ounce. Compound Tincture of Lavender, one drachm. Tine! ure of Opium, thirty drops. Make them into a draught. Or, 3. Take Compound Tincture of Carda- mom, three drachms. Tincture of Opium, forty drops. Peppermint Water, one ounce and a half. Mix them for a draught. t 4. Take Aniseed, bruised, Chamomile Flowers, of each half an ounce. Pure Water, one pint and a half. Boil them slowly until the water is re- duced to eleven ounces, and to the strained liquor add Sulphate of Soda, six drachms. Castor Oil, one ounce. Mix them for a clyster. Or, 5. Take Oil of Turpentine, three drachm.-. Yolk of Egg, a sufficiency Mix them well together in a marble mortar, then slowly add Thin Water Gruel, twelve ounces Mix them for a clyster. } 6. Take Compound Tincture of Senna, one ounce. Tincture of Jalap, one drachm. Mix them for a dose. Or, 7. Take Infusion of Senna, five ounces. Compound Tincture of the same, six drachms. Sulphate of Magnesia, one ounce. Syrup of Ginger, half an ounce. Of this stomachic purgative let the patient take three table-spoonsful every two hours until the bowels are well moved. Order HI. COLIC. 439 In the hysteric colic it will seldom be necessary to make use of evacuation ; but should obstinate costiveness prevail, it will be proper to give some gentle laxative*, administering at the same time every four or six hours the clyster of turpentine recommended in the flatu- lent colic, as I have known it in many instances to have been attended with much benefit, and this almost immediately. If a vomiting at- tends, the stomach may be cleansed by drinking one or two cupsful of chamomile-tea, after which the patient may be ordered some an- tispasmodic medicinef. When a colic of any kind proceeds with great violence, and ter- minates in an inversion of the peristaltic motion, or iliac passion (as it is usually called), notwithstanding the means which have been recommended have all been employed, it then becomes advisable to have recourse to the injection of tobacco clysters, which herb may be used either in the form of infusionj or that of smoke. Where even these fail, it has been customary to attempt a mechanical dila- tation of the intestines, by giving a large quantity of quicksilver by the mouth. The practice seems, however, attended with a consider- able degree of danger; for should the inversion of the peristaltic mo- tion have arisen in consequence of intus-susceptio, the complaint, instead of being relieved by the remedy, would certainly be increased by it. A surer and much safer method of employing mechanical dilata- tion is by injecting a large quantity of tepid water by a proper syringe, which will throw it into the rectum in a continued stream, and with some force, the patient drinking copiously at the same time. Some persons have borne two gallons to be injected in this way, and the cases were attended with tbe desired success. In those instances where there is an accumulation of hardened fasces in the colon, these large injections seem to be a powerful remedy, as they serve the two intentions of dilating the passage, and of softening the faces. * 8. R Pulv. Rhei, 3j. Spirit. Anisi, f. ^ss. Aq. Cinnam f. ?j. Tinct. Jalapaj.f. 3j. M. ft. Haustus statim sumendus. 19. R Aq.Anethi,f. |ivss. Spirit. jEther. Sulphur, f. 3j. ----Ammon. Foetid, f. 3ss- Tinct. Opii, fll xxxiij. ----Castor, f. ^ss. M. (t. Mistura, cujus sumat cochl. magna ij. tertiis vel quartis horis. t 10. R Fol. Tabaci, 3ss.—3ij. Aquae Bullient. f. ^xij. Post semihoram col. pro enemate. * 8. Take Powdered Rhubarb, one scruple. Spirit of Aniseed, half an ounce. Cinnamon Water, one ounce. Tincture of Jalap, one drachm. Make them into a draught, which is to be taken immediately. t 9. Take Dill Water, four ounces and a half. Spirit of Sulphuric JCther, one drachm Fcetid Spirit of Ammonia, half a drachm. Tincture of Opium, fifty drops. --------Castor, half an ounce. Of this mixture two large spoonsful may be taken every three or four hours. X 10. Take Tobacco, half a drachm to two scruples. Roiling Water, twelve ounces. Afterinfusing for half an hour, strain off the "iquor, and administer theclyster. 440 NEUROSES, OR NERVOUS DISEASES. CtaSS II. Obstinate constipations, arising fr >ra an accumulation of indurated faeces in the rectum, and attended vi li severe colic pains which re- sisted the usual means of relief, have been removed by introducing the finger, or scoop used in lithotomy, in ano, and then breaking and loosening the scybala. Two cases of this nature are recorded in the Edinburgh Medical Commentaries for the year 1795, which undoubt- edly suggest an important caution ; to advert to the cause above pointed out, in cases of obstinate costivene-s and colic, where the usual means of aperient medicines and clysters have had a reasona- ble trial, without the desired effect. Throwing cold water on the extremities, or applying pounded ice, snow, or towels wetted with a solution of ammmia muriata and nitre in cold water to the region of the belly, have been found, in some cases of obstinate constipation, to have been attended with a good effect, where all other remedies have failed. Those who are subject to attacks of tbe colic should cautiously abstain from all kinds of crude, flatulent food, and from fermented liquors: they should also avoid, as much as passible, any exposure to wet and moisture, taking due care to obviate costiveness by a timely use of some gentle laxative. COLICA PICTONUM, or the DRY BELLY-ACH. The characteristics of this disease are, obstinate costiveness, with a vomiting of acrid or porraceous bile, pains about the region ofthe navel, shooting from thence to each side wilh excessive violence, strong convulsive spasms in the intestines and abdominal muscles, with a tendency to a paralysis of the extremities. It is occasioned by long-continued costiveness; by an accumula- tion of acrid bile; by cold applied either to tbe extremities or to the belly itself; by a free use of unripe fruits; by great irregularity in the mode of living; by acrid food or drink, such as sour wines or cider; and by the inhalation of vapours arising from a decomposition of lead, or frequently handling some of its chemical preparations; hence painters and glaziers are frequently attacked by it. From the disease occurring frequently in Devonshire and other cider counties, it has generally been supposed, to arise from an impreg- nation of lead received into the stomach : but as the colica picto- num is a very prevalent disease in the West Indies likewise, where no cider is made, and where there is only a very small quantity of lead in the mills employed to extract the juice from the sugar-canes, this cause cannot be so general a one as has been imagined. It is true, ho.vever, that the effect of some metals in destroying or pre- venting the acidity of ci ler or wine, often induces dealers in these ar- ticles to employ some ofthe preparations of lead for this purpose. A dreadfil disease of a similar nature with the colic, under investi- gation, and caused by the destructive fumes of melted lead, is known to be very prevalent among those who are employed i» Order HI. dry belly-ach. 441 smelting or preparing this metal, and is said to attack even those who live near the furnaces. It passes in many places under the name of the mill-reek. C«»lica pictonum comes on gradually with a pain at the pit of the stomach, extending downwards to the intestines, particularly round tbe navel, accompanied, by eructations, slight sickness at the stomach, thirs., anxiety, obstinate costiveness, a frequent but ineffectual desire to evacuate the contents of the bowels, and a quick contracted pulse, but seldom exceeding one hundred in a minute. After a short time the pains increase considerably in violence, the whole region of tbe belly is highly painful to the touch, the mucles of the abdomen are contracted into hard irre- gular knots or lumps, the intestines themselves exhibit symptoms of violent spasm, insomuch that a clyster can hardly be injected from the powerful contraction of the sphincter ani ; and there is constant restlessness, with a frequent vomiting of an acrid or porraceous matter, but more particularly after taking either food or medicine. Upon a further increase of the symptoms, or their not being quickly alleviated, the spasms become more frequent as well as violent, the costiveness proves invincible, and an inflammation of the intestines ensues, which soon destroys the patient by terminating in gangrene. In an advanced stage of the disease it is no uncommon occurrence for dysuria to take place in a very high degree. The severity of the pain round the naval, the retraction of the belfy, the costiveness, the pulse, and the preference given by the patient to a bent position of the body, will readily distinguish this from every other disease of the abdomen. The palsied and dropping hand, and slightly contracted fingers, oinaccompanied by spasm in the upper extremities, or by any af- fection of the lower, supervene with remarkable uniformity in the saturnine colic. Colica Pictonum is always attended with some degree of danger, but which is ever in proportion to the violence of the symptoms and the duration of the disease. Even when it does not prove fatal, it is too apt to terminate in palsy, and to leave behind it contractions of the hands and feet, with an inability in their muscles to perform their office; and in this miserable state of existence the patient lingers out many wretched years. Such consequences are very frequent in warm climates, and many fell T iirmy ,mmed,ate care and observation during my practice in the West Indies. When this colic is induced by lead, it is more obstinate and longer protracted than when brought on by other causes. ° J Dissections of this disease usually show the same morbid appear- ances as in common colic, only in a much higher degree. In all complaints of the intestines partaking of the nature of 4. Take Powder of Calumba, ten grains. -------- Ginger, Subcarbonate of Iron, of each five grains. Syrup of Roses, a sufficiency to form a bolus, which is to be taken twice every day. 450 NEUROSES, OR NERVOl S DISEASES. ClaSS //. There are some people who are subject to periodical attacks of cholera, returning by intervals of a few weeks, producing for two or three days sickness and vomiting, increased heat of the skin, and quickness of the pulse, white tongue, and thirst. Sometimes, however, the bowels are torpid. Heaviness of the eyes and great disposition to drowsiness are commonly the precursors to tbe attack; and if a dose of hydrargyri submurias joined with some gentle purgative be then given, it will either considerably lessen its violence, or altogether pre- vent it. Exercise, particularly on horseback, tonics, and tbe Bath or Chel- tenham waters, are well calculated to afford relief, and prevent lecurrences of the complaint in all such cases. DIARRHOEA, or LOOSENESS. DiARRiiffiA consists in frequent and copious discbarges of feculent matter by stool, accompanied by griping, and often at first with t slight degree of vomiting, but unattended either by inflammation, fever, or contagion. Tbe presence of these, with tenesmus and an evacua- tion of blood and purulent mucus with hardened balls or scybala, instead of natural faeces, which prevail in dysentery, will always enable the practitioner readily to discern the two diseases from each other. It is to be distinguished from cholera morbus by the discbarge not being very bilious, and also by there being no vomiting of bile. In diarrhoea there is evidently a moi bid increase of the peristaltic motion ; which morbid increase is the effect of a variety of causes applied either to tbe body in general, or acting solely on the parts affected. Of the former may be noticed the application of cold to the sur- face of the body, so as to give a check to perspiration, and thereby determine tbe flow of blood more to the interior parts; as likewise passions of the mind, and certain diseases, as dentition, retrocedent gout and rheumatism, fever, &e. Of the latter may be enumerated, first, matters taken into the stomach, and acting either from their quantity, as in the case of over- charging the organ, or from their nature, on the state of the stomach itself, producing fermentation, as acid fruits, as also oily and putrid substances, and purgative medicines ; secondly, matters generated in the body and thrown into the intestines, as acrid bile, pancreatic juice, purulent matter, water in dropsy, worms, &c.: thirdly, mucous matter poured from the mucous follicles of tbe intestines them- selves, in consequence of an increased excretion, and producing wbaf. is known by the name of diarrhoea mucosa. In dianhoea, each discharge is usually preceded by a murmuring noise and flatulence in the intestines, together with a sense of weight and uneasiness in the lower part of the belly, which cease on tbe discharge taking place, but are again renewed before tbe Order III diarrh 8. Take Subcarbonate of Ammonia, ten grains. Peppermint Water, one ounce and a half. Tincture of Opium, fifteen drops. Syrup of Roses, one drachm. Mix them, and let this draught be taken twice a day. Or, 9. Take Magnesia, two scruples. Powder of Rhubarb, eight grains. Compound Powder of Cinnamon, ten grains. Mix them, and take this powder night and morning. Or, 10. Take Compound Powder of Chalk with Opium, fifteen grains. Confection of Roses, a sufficiency to form a bolus, which may be takes twice a day. 454 NEUROSES, OR NERVOUS DISEASES. Class II. some stomachic purgative, such as the tinctura rhei compos, may be given; after which the absorbent mixture just recommended may be used in frequently-repeated doses, with an addition of ten or twelve drops of tinctura opii to each. Should diarrhoea be occasioned by worms, which may be known from the sliminess of the stools, mixed with pieces of the decayed worms, medicines must be given to destroy and carry off these ver- min, as advised under that particular head. When it proceeds from an use of unwholesome water, and the sit- uation of the person will not admit of its being changed, the addition of a small quantity of quick-lime, chalk, or the like, possibly may correct this effect. The diarrhoea which attends on dentition should never be checked, unless it prevails in so high a degree as to prove hurtful to tbe child: in which case four or five grains of toasted rhubarb, with about eight or ten of prepared chalk or magnesia, may be given. This, if re- peated three or four times, will generally correct the acidity, and put a stop to the griping stools. If it fads we may make trial of the mixture advised beb»w*. Should purgings return frequently in the time of teething, or upon the striking in of some eruption on tbe skin, it will be very useful to procure a small discbarge behind the ears, or to apply a plaster of pix arida to the back. For the former purpose, some finely powder- ed Spanish flies may be rubbed on the part till a proper excoriation is produced, or we may draw a bit of narrow tape through a piece of the emplastrum lyttae, and lay it close behind the ears. A diarrhoea that is likely to prove critical or salutary, is by no means to be rashly stopped ; but when it attacks pregnant women, the most powerful remedies ouglit immediately to be employed. To answer the second indication in the cure of diarrhoea, viz. that of suspending the increased action which constitutes the disease, it will be proper to have recourse to opiates, which may either be given separately, in small and repeated doses, so as to keep up a constant effect, or be combined with whatever other medicines} we admin- ister. 11. ft Pulv. Rhei, gr. xv. Magnes. Carbonat. 3s& Aq. Auethi,f. ~ij. Spirit. Ammon. Aromat fll xv. Tinct. Opii, fll xij. M. ft. Mistura cujus sumantur cochl. ij. vel iij minima bis terve in die, vel ut opus sit. i V2. ft Confect. Opii, gr. xv. 11. Take Powdered Rhubarb, fifteen grains. Carbonate of Magnesia, half a drachm. Dill Water, two ounces. Aromatic Spirit of Ammonia, twenty-four drops. Tincture of Opium, twenty drops. Of this mixture two or three tea-spoonsful are to be taken twice.or thrice daily, as may be judged necessary. ! 12. Take Confection of Opium, Ifteen grains- Order III DIARRHOEA. 455 The third indication is to be effected by an use of astringents, joined with aromatics and tonics. These, remedies are especially adapted to those cases where the irritability of the intestines depends upon a loss of tone, and which may occur, either from debility ofthe whole system, or from causes acting on the intestines alone. The astringents in most general use are, alum, logwood, catechu, and gum k:no, which may be administered in any of the forms ad- vised below*. In habitual and long-protracted diarrhoea, some pa- tients have derived much benefit from drinking about a pint of lime- water a day, mixed with an equal quantity of milk, in which an ounce of gum. acaciae has been dissolved. The tonics which are most likely to prove useful are, the cinchona, cusparia, simarouba, quassia, and cascarilla barks, calumba-root, pre- parations of iron, and chalybeate waters, together with a proper quantity of Port wine taken daily. Where this becomes acid on tbe stomach, Madeira, sherry, or weak brandy and water, may be substi- tuted. The above medicines may be administered as here recom- mended-)-, or as prescribed under the head of Dyspepsia. Aq. Cinnam. — Pimentae, aa f. 3"j- Tinct. Kino, f.3j- ----Lav C. f 3ss. M. ft. Haustus 4ta vel 6ta quaq.hora sumendus. * 13. ft Aluminis Pulv. Catechu Extract, aa gr. x. Opii, gr. ss. Confect. Ros. q. s. M. ft. Bolus ter quaterve die capiendus. Vel, 14. ft Misturae Cretae, f. %r. Extract. Haematoxyli. 3ss. Aq. Pimentae, f. |ij. Tinct. Kino, f. 3j. Syr. Zingib. f. 3ij. M. ft. Mistura cochl. ij. magna ter quaterve in die adhibenda. Vel, 16. ft Confect. Aromat. 3j. Aq. Cinnam. f. |ij. — Fontan. f. |iv. Tinct. Catechu, f. 3»j. ----Opii, fll xixiv. M. ft. Mistura. r 16. ft Cort. Cascaril. Contus. ----Simaroub. C. aa 3ij. Coq. ex Aq. Fontan. Oj. ad f. ?viij Colat.adde * Cinnamon Water, Pimenta Water, of each sis drachms. Tincture of Kino, one drachm. Compound Tincture of Lavender, half a drachm. This draught may be taken every fourth or sixth hour. • 13. Take Powdered Alum, Catechu, of each ten grains. Opium, half a grain. Confection of Roses, a sufficiency to form a bolus, which is to be taken three or four times a day. Or, 14. Take Chalk Mixture, five ounces. Extract of Logwood, half a drachm. Pimenta Water, two ounces. Tincture of Kino, one drachm. Syrup of Ginger, two drachms. Of this mixture the dose may be two large spoonsful three or four times a day. Or, 15.Take Aromatic Confection, one drachm Cinnamon Water, two ounces. Pure Water, four ounces. Tincture of Catechu,two drachms. ------Opium, fifty drops. The dose of this mixture to be the same as the former. f 16. Take Cascarilla Bark, bruised, Simarouba Bark, bruised, of each two drachms. Pure Water, one pint. Boil them slowly until reduced to eight ounces, strain off the liquor, and add 456 NEUROSES, OR NERVOUS DISEASES. ClaSS II. From whatever cause a diarrhoea proceeds, whenever it is found necessary to check it, the diet ought to consist of rice boiled with milk, and flavoured with cinnamon, together with preparations of sago or Indian arrow-root, and the lighter sorts of meats roasted, as veal, Iamb, or chickens. Weak brandy and water, or diluted wine, may be substituted for malt liquor as common drink. Those who are liable to frequent returns of this disease, either from a peculiar weakness, or too great an irritability of the bowels, should live temperately, avoiding crude summer fruits, most kinds of vegeta- bles, all unwholesome food, and meats of hard digestion. They ought likewise to beware of cold, moisture, or whatever may obstruct the perspiration, and they should wear flannel next to the skin. DIABETES. Weariness and disinclination to motion or exertion, with the feelings of weakness, dryness and harshness of the skin, costive- ness, great thirst, a voracious appetite, accompanied by an ap- parent defect in the process of chylification, gradual emaciation "f the whole body, and a frequent discharge of urine, containing a large proportion of saccharine and other matter, which is generally voided in a quantity far exceeding that of tbe aliment or fluid Spirit. Cinnam. f. ?j. Tinct.Kino, f. 3ij. M. ft. Mistura cujus sumat cochl. magna iij. ter quaterve in die. Vel, 17. ft Infus. Cort. Cuspariae, f. ^vj. Tinct. Calumb. f. §j. ----Catechu, f. 3ij- Spirit. Pimentae, f. ?ss. M. Vel, ft. Mistura 18. ft Cort. Granat. Contus. 3ij. Rad. Simaroub. C. ?ss. Aq. Ferventis, f. |xvj. macera per horas duas, et colaturae adde Confect. Aromat. 3j- Tinct. Card. Comp. f. §j. M. ft. Mistura cujus sumantur cochlearia larg. tres ter quaterve in die. Vet, 19. ft Decoct. Cinchonae, f. ^jss. Tinct. Ejusd. C. f. 3y. ----Kino, f. 3j- ----Opii, fl], vi. M. ft. Haustus 4lis aut 6tis horis sumendus: Spirit of Cinnamon, one ounce. Tincture of Kino, two drachms. Of this mixture let three large spoonsful be taken three or four times every day. Or, 17. Take Infusion of Cusparia Bark, six ounces. Tincture of Calumba, one ounce ------Catechu, two drachms. Spirit of Pimenta, half an ounce. Mix them. Or, 18. Take Pomegranate Bark, bruised, two drachms. Simarouba Bark, bruised, half an ounce. Boiling Water, sixteen ouncei. Let them infuse for two hours, strain off the liquor, and add to it Aromatic Confection,one drachm Compound Tincture of Carda moms, one ounce. Of this mixture three large spoonsful are to be taken three or four times a day. Or, 19. Take Decoction of Peruvian Bark, one ounce and a half. Compound Tincture of the same. two drachms. Tincture of Kino, one drachm. --------Opium, ten drop*. Mix them for a draught, to be taken ever* four or six hours. Order 111 diabetes. 457 introduced, are the characteristics of this disease. It has been usual to apply different names to it, as the diabefes mellitus, wherein the urine is of a fragrant smell, and of the colour and taste of honey, and the diabetes insipidus, with limpid urine, not sweet; but some have considered this division as more fanciful than real, and more systematic than useful. Those of a shattered constitution, and those who are in the de- cline of life, are most subject to its attacks. The few cases Avhich have occurred to me in practice, all arose in persons who had ad- dicted themselves to spirituous liquors, and who at the same time fared hard, and were much exposed to cold. It not unfrequently attends on hysteria, hypochondriasis, dyspepsia, and asthma; but it is always much milder when symptomatic, than when it appears as a pri- mary affection. Diabetes may be occasioned by a use of strong diuretic medicines, intemperance of life, and hard drinking, excess in venery, severe evacuations, immoderate use of acid drinks, excessive labour joined to a poor vapid diet, and the depressing passions, or by any thing that tends to produce an impoverished state ofthe blood, or general debil- ity. Some individuals have an hereditary disposition to the disease, as has been noticed in a communication from Dr. Storer to Dr. Rollo. In some cases it has arisen from an exposure to cold and suppressed perspiration. It has however taken place, in many instances, without any obvious cause. That which immediately gives rise to the disease, has ever been considered as obscure, and various theories have been advanced on the occasion. It has been usual to consider diabetes as the effect of relaxation of the kidneys, or as depending on a general colliqua- tion of the fluids. Dr. Richter,' professor of medicine in the university of Gottingen, supposes the disease to be generally of a spasmodic nature, occasioned by a stimulus acting on the kidneys; hence a secretio aucta urinae, and sometimes perversa, is the con- sequence. Dr. Darwin thinks that in diabetes there is another passage from the intestines to tbe bladder, besides' that of the sanguiferous system, through the kidneys, anoV supposes it is ef- fected by the retrogade motions of the urinary branch of the lymphatic system; which doctrine, although it did not escape the censure of the best anatomists and experimental physiologists, met nevertheless wilh a very favourable reception on its being first announced. The late Dr. Cullen offered it as his opinion, that the proximate cause of this disease might be some fault in the assimi- latory powers, or in those employed in converting alimentary matters into the proper animal fluids; wLicli theory has since been adopted by Dr. Dobson, and still later bv Dr. Folio, su.ccon- general to the royal artillery. The liver ha,' been thought by ^ome to be the chief source of the disease; but dit.bet;-s is seldom at- tended with any affection of this organ, 'as h:»s bee-» proved bv frequent dissections, and when observed, it is .0 be considered as accidental. 458 neuroses, or nervous diseases. Class II. My own opinion as to the cause of diabetes ine'litus is, that it consists in a perverted or deranged action of the kidneys, and that it is by virtue of this action that the saccharine matter in the urine is produced. The primary seat of the disease is far from being absolutely deter- mined in favour of any hypothesis yet advanced ; but from an attentive consideration of all the circumstances, the weight of evidence ap» pears to induce the majority of practitioners to consider diabetes as depending on a primary affection of the kidneys. The morbid state in which these organs are usually found on dis- section, certainly strengthens the opinion that they are the primary seat of the disease. From the peculiar matter which is elaborated by the kidneys being secreted in twice its usual quantity, we are at least induced to conclude that their action is very considerably increased. It must, however, be acknowledged, that the excessive increase of appetite, accompanied with an apparent defect in the process of cbylification, which are the usual attendants on diabetes, seem to de- monstrate that some derangement exists also in the digestive organs. Possibly this may be secondarily. Dr. Rollo informs us in his ingenious publication, that from having duly investigated the most remarkable circumstances and changes which took place during the cure in several cases of this disease, he thinks himself authorized to draw the following in- ferences:— 1st, That the diabetes mellitus is a disease of tbe stomach, &x. proceeding from *ome morbid change in the natural powers of di- gestion and assimilation. 2d, That the kidneys, and other parts of the system, as the head and skin, are affected secondarily, and generally by sympathy, as well as by a peculiar stimulus. 3d, That the stomach affection consists in an increased action and secretion, with a vitiation of the gastric fluid, and probably in too active a state of the lacteal absorbents. 4th, That the cure of the disease is accomplished by regimen and medicines preventing the formation of sugar, and diminishing the in- creased action of the stomach. 5th, That confinement, an entire abstinence from every species of vegetable matter, or a diet solely of animal food, with emetics, bepati- zed ammonia, and narcotics, comprehend the principal means to be employed. 6ih, That the success of the treatment in a variety of cases, in a great measure establishes the five preceding inferences. 7th, That the saccharine matter ofthe disease is formed in the stom- ach, and chiefly from vegetable matter, as has been shown by tbe immediate effects produced by the abstinence from vegetable matter an 1 the use of animal food solely. 8th, That acescency is predominant in diabetic stomachs, which continues even some time after the entire abstinence from vegetable matter, and after the formation of sugar; and that whrle such Order 111 DIABETES. 459 acescency remains, the disposition to the disease may be supposed to continue. 9th, That the saccharine matter may be removed in three days, and, by avoiding vegetable matter, will not again be re-produced ; but when fhe disease and the disposition to it will be finally re- moved, cannot be stated with accuracy. Such knowledge may, however, be acquired in those cases where the "patients adhere correctly to rules. 10th, That there are two circumstances fo be considered in this disease, which we may separate in the progress of fhe treatment ; as it has been shown, that though the formation of sugar was pre- vented, yet the increased action of the stomach remained, and maintained the defect of assimilation, which prevented nutrition. Hence two objects occur in the cure; for it is not yet determined whether the preventing the formation of sugar by an entire absti- nence from vegetable niatler, and the use of animal food with fats, if properly persevered in, might not ultimately comprehend the other, namely, the removal of the morbid action of the stomach. 11th, That the lungs and skin have no connexion with the pro- duction of the disease. 12th, That the quantity of urine is probably in proportion to the quantity of liquids taken in, and has but little dependance on an absorption of fluids from the surface of either skin or lungs. 13th, That though the disease has been shown (o consist in an increased moibid action of the stomach, and probably too great a secretion, with vitiation of fhe gastric fluid ; yet the peculiar or specific condition of either, as forming the disease, is acknowledged fo lie in obscurity, and must remain so, until the physiology of healthful digestion is properly explained and established. The following are the objections which have been made fo Dr. Rollo's theory of diabetes : 1st, That saccharine matter has not been detected in the blood, or in the stomach. 2dly, That the disease often shows symptoms of dyspepsia or weakness of digestion. 3dly, That the stomach affection may be sympathetic of diseased kidney, from the intimate consent between both : and, 4thly, That fhe kidneys may be capable of forming or se- creting matter under a peculiar action, similar to the breasts of women. In answer fo the first of these objections, Dr. Rollo has replied, that it is difficult fo ascertain fhe exact period in the piocess of digestion, when this change may be looked for, and therefore an emetic might fail in affording the necessary contents. Willi respect to fhe blood, Dr. Dobson affirmed the existence of saccharine matter in diabetic blood. In several instances, fhe serum was turbid and wheyish, and it did not, on standing, undergo the usual changes of animal matter. To the second objection which has been made to Dr. Rollo's 460 neuroses, or nervous diseases. Ulass if. doctrine, he answers, that the increased action of the stomach is of a morbid kind, and connected with debility : being, therefore, irregular and imperfect, it does not accomplish digestion. To the third objection, Dr. Rollo has replied, that the stomach affections which exist in diabetes, are entirely different from those which take place in consequence of primary morbid conditions of the kidney. He observes, besides, that most cases of the disease have been preceded by stomach derangement, or have been pro- duced by causes immediately operating on the stomach. To the fourth objection he observes, tint the kidneys are not se- creting organs, but separating only, and that a much greater change in their structure than has ever been found must take place before they could become capable of secreting saccharine matter. He further notices, that in some instances of diabefes the structure of the kidneys has not been visibly changed. In support of the doctrine which Dr. Rollo advances, he has used the following arguments :— 1st, The fact, that the stomach affection generally precedes the urinary characteristic symptoms of the disease. 2ndly, The fact, that a stomach affection always attends the disease, which materially differs from that sympathetic of primary kidney affection. 3dly, The fact, that a diet of animal food, with an entire absti- nence from vegetable or other matter capable of forming sugar in the stomach, removes speedily the general symptoms, the saccha- rine matter, the quantify of urine, and its unnatural state. 4thly, The fact, that dissection has shown no morbid condition of the kidneys, but what may be referrible to a continuance of increased action from the application of a simple stimulus, and probably sympathy, augmenting merely the capacity of their vessels. Such are the arguments brought forward by Dr. Rollo in favour of his theory ; but a still stronger than any of these is the success which has attended his mode of treatment, and which, on his recommendation, has been pursued by other practitioners with a happy effect in some cases of this disease. Diabefes sometimes comes on slowly and imperceptibly without any previous disorder, and it now and then arises to a considerable degree, and subsists long without being accompanied with evident disorder in any particular part of the sysfem, the great thirst which always, and the voracious appetite which frequently occur in it, being offen the only remarkable symptoms ; but it now and then happens, that a considerable affection of the stomach precedes the corning on of the disease, and that in its progress, besides fhe symp- toms already mentioned, there is great dryness of the skin, with a sense of weight in the kidneys, and a pain in the ureters, and the other urinary passages. The temperature of fhe body is usually below the standard of health. The spirits are depressed, Ihe dispo- sition is equally indifferent to study or amusement, and there is Order III. diabetes. 461 evidently a decline of mental energy, with a loss of the power of virility. Ulceration of the tongue and gums are of frequent occur- rence in diabetes, owing probably to the derangement of the digestive functions. Some morbid change in the alvine excretion always ac- companies the diabetic habit, and costiveness is perhaps the most common of these: for in some instances the bowels have been so re- markably torpid, that even the most powerful medicines', in large doses, produced but a trifling effect. Very frequently some degree of in- flammation and swelling about the external orifice ofthe urethra is to be observed*. It has been remarked, that diabetes is often preceded or accompa- nied with a pulmonic affection ; and we are told by Dr. Bardsleyf, that he does not recollect an instance of the disease which was not attended with some affection of the chest. Under a long continuance of the disease, the patient becomes much emaciated, the feet oedematous ; great debility arises, and an obscure fever, with all the appearances of hectic, prevail. In point of number the pulse is very much diversified: in most cases it is quicker than natural, but sometimes it is below the common standard; but whether it be quick or slow, it is generally such as to denote great debility in the system. In some cases vision becomes very indistinct, and the patient is troubled with vertigo. The urine, in diabetes, from being at first insipid, clear, and colour- less, soon acquires a sweetish or saccharine taste, its leading characte- ristic in many instances. From some experiments which were made on diabetic urine, the following conclusions have resulted :—1st, That it contains neither urea, nor the earthy phosphates. 2dly, That it does contain a con- siderable quantity of a brown extract, united with a proportion of sugar : and, 3dly, That when the sugar is absent, its place is some- times supplied by a bitter principle. In some instances the quantity of urine is much greater than can be accounted for from all the sources united. Cases are recorded in which from twenty-five to thirty pints were discharged in the space of a natural day for many successive weeks and even months ; and in which tbe whole ingesta, as was said, did not amount to half the weight of the urine. To account for this overplus it has been alleged that water is absorbed from the air by the surface of the body, as also that an extraordinary quantity of water is compounded in the lungs themselves. Dr. Darwin is of opinion, that in the aqueous diabetes the cuta- neous absorbents frequently imbibe an amazing quantity of atmo- spherical moisture; and although it has been mentioned by Dr. Rollo, that one patient whom be weighed, after being ten minutes in a warm bath, did not weigh heavier on his leaving it, still he sus- pects that if the bath be made very hot, perhaps much above animal heat, the bather may perspire more than he absorbs, and become in * See Cases of Diabetes, by R. Watt, p. 159. t See his Medical Reports. 462 NEUROSES, OR NERVOUS DISEASES. ClttSS 11. reality lighter. In a bath of moderate heat, provided tbe patient has been previously exhausted by abstinence or fatigue, he may be likely, Dr. Darwin thinks, to absorb much; but if his system be already full of fluids, from the food and liquids which be has previously eaten and drank, he may not then absorb any thing. That the cutaneous absorbents can imbibe such a quantity of atmo- spheric moistufe as to account for the surplus of urine over the ali- ment and fluids which are taken, I am by no means inclined to admit. It has been usual to regard this disease as always attended with great difficulty of cure, and no inconsiderable degree of danger, par- ticularly where it attacks persons advanced in years, or whose consti- tutions have suffered much by any debilitating cause whatever, espe- cially hard drinking; but if we are to credit Dr. Rollo's report, which seems both candid and ingenuous, and has indeed been confirmed by tbe testimony of other practitioners who have adopted the mode of treatment he recommends, we may presume that it need not in future be regarded in so unfavourable a light, and that cures may be effected under the most unpromising circumstances, provided a rigid compli- ance with his plan is observed. Great abatement of the thirst, and extraordinary desire for food, the skin becoming soft to the touch and perspirable, the bowels more lax or regular, the urine being voided less frequently, and in smaller quantity each succeeding day, being at the same time of a more natural colour, taste, and smell, the dyspeptic affection being much diminished, and the bodily strength somewhat recruited, together with a return of mental energy, are to be regarded as very favourable symptoms j whereas the contrary denote a fatal termination sooner or later. Dissections of diabetes have usually shown the kidneys to be much affected. In some instances they have been found in a loose flabby state, much enlarged in size, and of a pale ash colour; in others they have been discovered much more vascular than in a healthy state, approaching a good deal to what takes place in inflammation, and containing in their infundibula a quantity of whitish fluid, somewhat resembling pus, but without any sign of ulceration whatever. At the same time that these appearances have been observed in their interior, the supeificial veins on their surface were found to be much fuller of blood than usual, forming a most beautiful net-work of vessels, the larger branches of which exhibited an absorbent appearance. In many cases of dissection the whole of the messentery has been discovered to be much dis- eased, and its glands remarkably enlarged; some of them being very hard, and of an irregular texture; others softer, and of an uni- form spherical shape. Many ofthe lacteals have likewise been seen considerably enlarged. The liver, pancreas, spleen, and 9tomach, are in general perceived to be in a natural state; when they are not so, the occurrence is to be considered as accidental. The bladder is now and then found to contain a quantity of muddy Order III diabetes. 463 urine • in some cases its coats are much thickened, and its size less than natural. The fat within the thorax, abdomen, anil pelvis, in some instances has seemed entirely converted into a gelatinous-like matter, some- what of an amber colour, and when slightly pressed between the fingers did not appear unctuous. The subcutaneous fat is found in general much diminished. The treatment of diabetes has hitherto been conducted on the principles of diverting the increased discharge elsewhere, and after- wards of restoring the tone of the parts. The first indication has been attempted by a use of remedies which open the pores, such as emetics exhibited occasionally, diaphoretics, the warm bath of about 96 or 98 degrees of heat, additional clothing, or the removal to a warm climate. As diaphoretics, the pulvis ipecac. compos, and antimonials combined with opium, have principally been employed. For the purpose of diverting the increased discharge, blisters are sometimes applied over the region of each kidney in suc- cession, and the ulcerated parts kept open afterwards by the unguen- tum lyttae, or ceratum sabinae. The second indication has been aimed at by astringents and tonics. The astringents which have been most used are, alum, zinci sulphas, gum kino, catechu, and the sulphuric and nitric acids, but the first and second seem to be the most efficacious, and may be combined together as below*, or be given separately. The tonics generally employed are the, different preparations of cinchona, myrrh, and chalybeates, as advised under the head of Dyspepsia, together with cold bathing. The Bristol Hot-well waters, when drank at the fountain head, have long been celebrated for their good effects in this disease, and have by many been looked on as a kind of specific ; they may there* fore be resorted to, if the situation and circumstances of the patient will admit of it; but if not, he must be content to substitute lime- water, which maybe taken in the quantity of a pint or quart a day, mixed with an equal proportion of milk. By dissolving about half an ounce of gum. acaciae in each pint of milk, some further advantages may possibly be derived. The mephitic alkaline water has been much recommended in this disorder, and it is probable that Schweppe's soda-water may be of service, as it is well calculated to relieve acidity in the stomach. The soda will be preferable to the vegetable alkali, as being less likely to act on the kidneys. * 1.1£ Aluminis, gr. xij. Zinc Sulphat. gr. ij. Opii, gr ss. Confect Rosae, q. s. ft. Bolus ter quaterve die sumendus super bibendo Liquor. Calcis, f. |iv. * 1. Take Alum, twelve grains. Sulphate of Zinc, two grains. Opium, half a grain. Confection of Roses, a sufficiency to form a bolus, to be taken three or four times a day, washing it down with about four ounces of Lime Water 464 NEUROSES, OR NERVOUS DISEASES. ClaSS II Administering large doses of opium has occasionally been found highly useful in this disease. Some cases recorded in the 4th vol- ume of the Medical Transactions of the London College of Physi- cians, by Dr. Warren, clearly show the very great influence which opium is capable of exerting over the morbid secretion ofthe kidneys in this disorder, and point it out as a remedy worthy of attention in addition to animal regimen. The tinctura lyttae is a medicine which has sometimes been era- ployed in diabetes. Rubbing the skin with oil, or any adhesive liniment, so as to put a stop to the supposed absorption of fluids thereby, has been much recommended in diabetic cases. From experiments made by Dr. Gerrard, of the Liverpool Infirmary, as well as by Dr. Rollo, it does not appear however that there is any absorption of fluids by tbe skin in this disease, for the body gained nothing by immersion in a warm bath: this remedy seems therefore of a doubtful nature. To assist the effects of the means which have been advised, gentle exercise on horseback, along with frequent friction over the kidneys by means of a flesh-brush or flannel, when not in a blistered state, to- gether with warm clothing next to the skin, ought to be used. The patient is at the same time to abstain from all strong drink, to make use of animal food as much as possible instead of vegetable, and by all means to avoid external cold, as any thing that checks the perspi- ration cannot fail to determine a large quantity of fluid to the kidneys. While we pursue these steps we are to obviate costiveness, and keep the body perfectly open, either with rhubarb or an infusion of senna. When diabetes is symptomatic of hysteria, hypochondriasis, or asthma, the proper remedies for the primary disease should be ad- ministered. The mode of treatment which has just been laid down is, with some small improvement, that which has been pursued by most prac- titioners, but it must be acknowledged to have proved in many instances very ineffectual. This being the case, it is proper to make mention ofthe plan recommended by Dr. Rollo, which is said to have often . performed a cure under the most unpromising cir- cumstances. The indications to be attended to, he supposes to be, to destroy tbe saccharine process going on in the stomach ; to promote a healthy assimilation ; to prevent a supposed increased absorption by the sur- face ; to diminish the increased action, and to change the imagined derangement of the kidneys. To answer these indications Dr. Rollo enjoins a diet consisting wholly of animal food, abstaining rigidly from every kind of vegetable matter from which sugar may be produced; he likewise enjoins hepatized ammonia to be taken daily in the doses here- after to be mentioned ; the skin to be anointed with prepared lard ; exercise to be avoided; antimonial wine with opium to be taken at Order 111 DIABETES. 465 ■ieht; an ulceration about the size of half-a-crown to be formed opposite to each kidney, and the bowels to be kept open by aloes and soap. . Dr. Rollo at first was in the habit of using the potassa? sulphure- tum* ; but was induced to substitute the hepatized ammonia, under the supposition that the alkali of the former had an improper effect on the kidneys. Weareimformedby Mr. Cruikshank, chemist to the Ordnance, in some observations added to Dr. Rollo's publication, that the hepa- tized ammonia, which promises to be a valuable medicine, is easily prepared by making a stream of pure hepatic gas pass through the liquor ammoniae subcarbonatis Pharm. Londinensis, until no fur*- ther absorption is perceived, or until the alkali is saturated. The hepatic or sulphurated hydrogene gas should be obtained for this purpose from artificial pyrites, or sulphuretof iron, and the muriatic acid. We are further informed, that the easiest method of making the artificial pyrites, is to raise a piece of iron in a smith's forge to a white heat, and then to rub it against the end of a roll of sulphur : the iron, at this temperature, immediately combines with the sulphur, and forms globules of pyrites, which should be received into a vessel filled with wafer. Those globules are to be reduced into powder, and introduced into the proof, to which a suf- ficient quantity of muriatic acid is to be added. The dose to an adult should not at first exceed three or four drops, three or four times a day, and this dose is to be gradually increased so as to pro- duce slight giddiness. It should be dropped from the phial at the time of using it into a little distilled water, and be taken immediately. When we cannot procure hepatized ammonia, we must be content to substitute the subcarbonate of ammonia, which may be given in the form of pills, ordering about twelve to be taken daily, each con- taining about four grains ofthe ammonia. A case of diabefes mellitus is recorded in the thirteenth volume of the Medical Journal, by Mr. Earnest, surgeon to the Sheffield Ge- neral Infirmary, which was successfully treated by putting the patient on a diet consisting principally of animal food, with a generous allowance of porter, giving at the same time the nitric acid in the proportion of from one to three drachms of the acid to two pounds of wafer, with about an ounce of sugar daily. We are further informed by him, lhat in three other cases of excessive polydipsia he had known the nitric acid essentially useful. Under the failure of • 2. ft Potassae Sulphuret. gr. x. Confect. Rosae, q. s. M. ft. Bolus ter in die sumendus. Vel, 3. ft Potassae Sulphuret. gr. j. Aq. Menth. f. ^iss. Syrup. Zingib. f. 3i. M. ft. Haustus terin die capiendu?. W • 2. Take Sulphuret of Potass, ten grains. Confection of Roses, a sufficiency. Form them into a bolus, which may be taken three times a day. Or, 2. Take Sulphuret of Potass, ten grains. Mint Water, one ounce and a half, Syrup of Oinger, one drachm. This draught is to be taken thrice a day. 466 NEUROSES, OR NERVOUS DISEASES. ClttSS 11. fhe other means which have been noticed, it will therefore be ad- visable to pursue this plan. The nitric acid no doubt is productive of considerable ad- rantagfe in mitigating the thirst and heat, and thereby lessen- ing the quantity of urine ; but of itself it ought to be considered as incompetent to destroy the saccharine impregnation of this fluid, or to arrest the other characteristic symptoms of the disease. A total abstinence from all vegetable food is likewise absolutely necessary. Numerous indeed are the cases now recorded by different medical writers very clearly demonstrative of the great efficacy ofthe animal regimen in diminishing the quantity and changing the properties of diabetic urine, and in relieving the concomitant circumstances; and from the repeated observations and experiments which have been made by some of our most eminent physicians, we may, I think, be justified in drawing the inference, that an abstinence from vegetable, and the employment of animal food, together with the nitric acid, opiates, blisters to the loins, and the warm or iepid bath, comprehend the general and most successful method of cure, and are capable of removing tbe disease in question in its incipient state, when unaccompanied with any dangerous organic affection ; and that even in the most acute and aggravated instances of the complaint, a steady perseverance in the proper regimen will arrest the progress ofthe diabetic symptoms, and bring the pa- tient into a state of convalescence ; but that the cinchona, astrin- gents, and alkalies, either alone, or combined with sulphur, (soch as the hepatized ammonia), afford little assistance in subduing dia- betes, or even arresting the progress of its characteristic symptoms. We are informed, however, by Dr. Ferriar*, that he has cored three confirmed cases of this disease by a combination of cinchona, uva ursi, and opium, taken three times a day, in the proportion of a scruple of each of the former to half a grain of the latter; and that from the great success he had met with from this medicine he found it unnecessary to try Dr. Rollo's plan. The doses were taken with lime-water, which was also directed for the patient's common drink. In order to restore the patient to general health and strength, an admixture of vegetable and animal food is to be gradually and cautiously entered upon, as soon as ever the saccharine impregna- tion of the urine and the voracious appetite have disappeared. After the cessation of the diabetic symptoms, great attention should be paid to the state of the prinise via?, as the tone of the stomach remains for some time much impaired, and the bowels also become torpid, and are liable to inflammation if evacuations be not speedily procured. The phenomena which diabetes mellitus exhibits in its progress, and the great degree of vascularity and enlarged size of the kid- neys which are observed on dissection, have induced some to sup- * See the new edition of his Medical Histories and Reflection* Order 111 DIABETES. 467 pose that an inflammatory action takes place in these organs ; which Tiew of the disease, if well founded, would evidently direct to a mode of treatment the very reverse of what has hitherto been pursued. Instead therefore of tonics, astringents, cold bathing, and a stimula- ting diet of anim \\ food, a mild antiphlogistic regimen, with occasion- al evacuations, and topical remedies, suited to the habit of the patient and the degree of local affection, would promise, they think*, to fulfil the intentions of the practitioner with success. Several cases of diabetes which were treated successfully by an antiphlogistic regimen, and very copious depletion by venesection, employed under the most unpromising circumstances, such as a feeble low pulse, loss of strength and spirits, cold and oedematous extremi- ties, Stc. are recorded by a late writerf; and they seem to support the ojiinion, that an inflammatoiy action does really take place in the kidneys of those labouring under this disease. In the second of these cases, it appears that the operation was repeated again and again, until above 180 ounces of blood had been abstracted ; and the result was a perfect restoration of health. During this time the animal diet was employed, but not rigidly : various medicines were also occasionally interposed ; but the great agent, and that to which the attention was almost exclusively directed, was bleeding. A very visible change was observed in the appearance of the blood during this process; at first it was black and had only a very small proportion of crassamentum; but as more and more of it was taken away, it gradually acquired the ap- pearance which it exhibits in persons who labour under inflamma- tory fever. The same practice was followed with the same result in all the succeeding cases; the condition of the blood was changed, and the health was restored as in the former instance; and it is to tbe bleeding alone that any essential benefit is attributed. A case is also recorded in one ofthe numbers of a periodical workf, which was treated by venesection frequently repeated in an elderly man of seventy-two with success. There is a paper in the fifth volume of the Medical Transactions of the London College of Physicians, giving a detail of several cases of diabetes which were successfully treated by tbe late Dr. Sat- terley, and which illustrate in a very satisfactory manner the advan- tages to be derived from a judicious employment of the lancet, as proposed by Dr. Watt. In the first in particular, the symptoms were strongly marked, and the progressive beneficial effects of the succes- sive bleedings so evident, as to induce the patient to desire a more frequent repetition of the remedy than was deemed prudent. In all the cases the first drawn blood had the appearance of a homogeneous black mass, possessing no firmness, but resembling treacle, and not separating by rest into serum and crassamentum. After each bleeding, however, it became firmer and more natural in * See No 67 of the Medical and Chirurgical Review. t See cases of Diabetes, by Dr. Robert Watt, of Glasgow. i See No. 29 of the Edinburgh Medical and Surgical Journal. 468 NEUROSES, OR NERVOUS BISEASES. OlaSS II. appearance ; and in the first ofthe cases, after the fourth venesection, the crassamentum was covered with a membrane analogous to the buffy coat, but of an intense bright scarlet colour. The quantity of saccharine matter also yielded by each quart of water was found tt diminish in proportion as the urine itself was diminished ; but even when it was reduced to two quarts daily, sugar was found in it. At seven different times, from February the 19th to March the lltb, one hundred and twenty-six ounces of blood were drawn in this case from the arm, with great and almost uninterrupted mitigation of the symp- toms, terminating in a perfect recovery. ORDER IV. VESANLE. Impaired judgment, without pyrexia or coma, is the character of this disorder. MANIA, or MADNESS. The definition of mania which has hitherto been generally givei, is delirium unaccompanied by fever; but this does not seem alto- gether correct, as delirium may prevail without any frequency of the pulse, or fever, or without mania, as happens sometimes with women in tbe hysteric disease. Some have attempted to give a definition of mania by making it consist in the raising up in the mind images not distinguishable from impressionson the senses; or, as it may be expressed, intensity of idea, converting imagination into implicit belief, and producing incorrect- ness of association, incoherence of expression, or incongruity of action. I think mania may be termed a false perception of things, displayed most generally in the opinion formed by the patient of his nearest friend?; in a want of due connexion of tne train of thought, marked by an incoherence or raving; and in a resistance of tbe passions to tbe command of the will, accompanied, for the most part, with a violence of action and furious resentment «t restraint. Tne incapacity of dis- tinguishing the diseased functions of the mind and the irritability of our actions, in the opinion of Dr. Spurzheim*, constitute insanity. In mania the mind is not perfectly master of all its functions; it receives impressions from the senses which are very different from those produced in health; the judgment and memory are greatly impaired, .if not wholly lost; and the irritability of the body is much diminished, maniacs, it is supposed, being capable of resisting the usual morbid effects of hunger and watching. It has also been a generally received opinion, that they can likewise resist the mor- bid effects of cold ; but we are assured by Mr. Haslamf, late apothe- * See bis Observations on Insanity. i See his Observations on Madness^ Order TV. MADNESS. 469 cary to Bethlem Hospital, that they possess no such exemption. He tells us, that those under strict confinement in that receptacle, are particularly subject to mortifications ofthe feet; and that those who are permitted to go about in the hospital are always to be found as near to the fire as they can get during the winter season. Mr. Haslam's observation is confirmed by Professor Pinel*; and we ire cautioned by him against the belief, that the power of resisting cold is universally great. He affirms, that seldom a year has passed during which no fatal accident has taken place, from the action of cold upon the extremities, at the Asylum of Bicetre, in Paris, to which he is physician. Great insensibility certainly prevails in some states of madness, and a degree of cold which would create much uneasiness to persons of sound mind, might not incommode maniacs; but experience has shown that they suffer equally from any severity of weather. Some indeed refuse all covering; but these occurrences are not common; and it jnay be presumed, that by a continued exposure to the atmosphere, such persons might sustain with impunity a low temperature which would be productive of serious injury to those who are clad according to the exigencies of the season. Such endurance of cold is probably more the effect of habit than of any condition peculiar to insanity. Some writers contend, that insanity is a disease wholly of the mind, and not of the body; whereas others suppose that mania in general depends on a physical origin, or arises from disorganization, or morbid action of some part of the body, derangement of the intellectual fac- ulties being only theeffectf; which supposition is somewhat sup- ported by the appearances frequently to be observed in the head on dissection. But every species of madness, whether it has originated in the mind or the body, becomes the same by continuance. In mad- ness, both the mind and the body must ultimately be diseased; for a disease ofthe mind soon produces one in the body. There are two species of madness, viz. the melancholic, and furious. In both these states the association of ideas is equally incorrect. Be- tween melancholic and furious madness there seems however to exist an intermediate species of the disease. Great eccentricity or singularity, dejection of spirits, and violent tendency to immoral habits, notwithstanding the inculcation of the most correct precepts, and the force of virtuous example, may be regarded as only slighter shades of the disorder. By some writers the disease has been distin- guished into many varieties ; but probably the best division would be into chronic and acute, periodical and habitual. Madness is occasioned by affections of the mind, such as anxiety, grief, the love of an absent object, the pain of jealousy, sudden frights, violent fits of anger, the disappointment of ambition, the * See his Treatise on Insanity. i See.ObservaMuns on Insanity, by Dr. Spurzheim. ------■-------,De Pathology of Insanity, by (J. M. Burrows, M. D. 470 NEUROSES, OR NERVOUS DISEASES. Cl0S8 //. haughtiness of pride, prosperity humbled by misfortune, religious terror or enthusiasm, the frequent and uncurbed indulgence of any passion or emotion, and by abstruse study. In short, it may be produced by any thing that affects the mind so forcibly as to take off its attention from all other affairs. A very frequent cause of insanity arises from the pain of some imaginary or mistaken idea, which may be termed the hallucinatio maniacalis. Violent exercise, intemperance of every kind, and especially in the use of spirituous liquors, a sedentary life, tbe suppression of periodical and occasional discharges and secretions, repelled eruptions, injuries and ma Icon- formation of the head, excessive evacuations, mercury largely and injudiciously administered, and paralytic seizures, are likewise enumerated as remote causes. Mania sometimes arises in con- sequence of painful protracted parturition. Certain diseases of the febrile kind, particularly phrenitis, have been found to occasion madness, where their action has been very violent, or accompanied by delirium. That insanity originates more generally in a corporeal cause than is allowed, must, I think, be admitted ; and perhaps is not unfrequently connected with hepatic derangement. Possibly it may now and then arise from sympathy with parts morbidly excited, and distant from the brain, and this action may be reciprocally exerted. In some cases mania proceeds from an hereditary predisposition or constitutional bias; and of all the maladies to which the human frame is liable, and which can be entailed on posterity, mental derangement is surely the most deplorable. It is an indisputable fact, that the off- spring of insane persons are more liable to be affected with insanity, than those whose parents have enjoyed sound minds; which shows that a predisposition or constitutional bias to the disease may be en- tailed by either parent. Moreover, it frequently occurs that the descendants from an insane stock, although they do not exhibit the broad features of madness, shall yet discover propensities equally disqualifying for the purposes of life, and destructive of social hap- piness. Some late writers on mania have, however, presumed to deny the fact of hereditary predisposition, or constitutional similarity between parent and progeny*; but this surely is to fly in the face of truth, and to inculcate a doctrine very injurious to society, by throwing individu- als off their guard, and encouraging them to intermarry with the des- cendants or offspring of insane persons. One who is aware of a decided bias in his own person towards mental derangement, ought to shun the chance of extending and of perpetuating the ravages of so dreadful a calamity. A man so situated, in incurring the risk of becoming a parent, involves him- self in a crime which may not improbably project its lengthened shadow, a shadow too which widens in proportion as it advances, * See Dr. Adam's Treatise on Hereditary Diseases. — Essay on Insanity, by George N. Hill. Order TV. MADNESS. 471 over the intellect and the happiness of an indefinite succession of beings*. When, as it sometimes happens, an hereditary disposition or bias to this disease appears to sleep through one generation, it will often be found to awaken in the next with even aggravated horrors. Should the child of a maniac escape his parent's malady, the chance is small that the grandchild will be equally fortunate. The continued stream of insanity, although it occasionally conceal itself for a time, may soon again emerge to our view. Strictly speaking, however, it is only the tendency to insanity that is in- herited ; or, in other words, a greater facility than ordinary to be acted upon by those external circumstances that are calculated to produce the disease. Such is the proper light in which we should view what are termed hereditary predisposition and hereditary disease. From the predisposition or bias entailed by persons of an insane stock on their children, and the great pressure of the times, the enthusiasm of certain sectaries, but more particularly the method- iats, and the various exciting causes which have been enumerated, mania appears to be a disorder of much more frequent occurrence than formerly. All inquiries respecting the proximate cause of mania are in- volved in such a cloud of obscurity, that I shall not venture to ad- vance any opinion on if. Many physicians have attempted indeed to account for the production of insanity from the morbid appear- ances observed on dissection ; but these vary exceedingly in differ- ent cases; and even when they are the most marked and constant, they only serve to denote the progress and ultimate effects, rather than the actual condition wherein the disorder consists. We only know for certain, that in the majority of maniacal persons that have been opened after death, more or less organic injury of the brain has been discovered, and that the said organic injury seems to be, for the most part, the consequence of an inordinate determination of blood to the head. Two constitutions are particularly the vicfims of madness, the sanguine and melancholic : by the difference of which, its appear- ance is somewhat modified. It attacks persons of all complexions and colours of hair ; but out of 265 patients who were examined by Mr. Haslamf, at Bethlem Hospital, 205 were of a swarthy com- plexion, with dark or black hair ; the remaining 60 were of a fair skin, and light brown or red haired. A particular species of in- sanity as sometimes occurring about the age of puberty, especially in those who have possessed a good capacity and lively disposition, and among females more than men, is noticed by this gentleman : they become by degrees listless and inactive, and the faculties are gradually obliterated, until at last complete and incurable idiotism ensues. • See Essays on Nervous Affections, by John Reid, M. D. + See his Observations on Madness. 472 NEUROSES, OR NERVOUS DISEASES. ClaSS It. Children, and persons of weak intellectual powers, are never sub- ject to madness ; for how can a person despair who cannot think*? On this subject Mr. Locke has a beautiful distinction. The dif- ference, he says, between a madman and a fool is, that the former reasons justly from false data ; and the latter erroneously from just data. The most common form of insanity is the intermitting, or that in which the paroxysms of the disease are divided by lucid intervals. The accession of the paroxysms is far from being regular, but most usually they begin soon after the summer solstice, continue with more or less violence during the heat of summer, and termin- ate towards the decline of autumn. Mania comes on at different periods of life ; but in the greater number of cases it makes its first attack between thirty and forty years of age, probably because people at this period are more liable to be acted upon by the re- mote causes of the disease, or that a greater number of such causes are then applied. At this age people are generally established in their different occupations ; are probably married, and have fami- lies ; their habits are strongly formed, and tbe interruptions of them are consequently attended with greater anxiety and regret. Under these circumstances they feel the misfortunes of life more exquisitely. Sometimes mania, however, instead of being only temporary, or occurring in paroxysms, which go off and return again at certain periods, continues during the whole of the person's life without any intermission, and the patient sinks at last under the violence of the conflict, without any abatement of the symptoms ; or a state of perfect idiotism ensues. In no two patients is the disease ushered in, or continued, with precisely the same appearances ; for the different propensities and habits of different patients lead of necessity to a difference of idea and of expression nil each. The precursory symptoms of a mania- cal paroxysm are, however, very frequently as follow. The patient complains of a sense of tightness at the region of the stomach, want of appetite, costiveness, and a sensation of heat in the bowels. He is subject to a kind of uneasiness, which he cannot describe or a* count for; experiences a degree of fear that sometimes amounts to terror, and feels either little disposition or absolute incapacity to sleep. Soon after these appearances, incoherence and incongruity of idea are betrayed in his outward conduct, by unusual gestures, and by extraordinary changes in the expression and movements of his countenance. He generally holds his head erect, and fixe9 his eyes and attention upon the heavens. He speaks with a deep hollow voice, walks with a quick and precipitate step, then stops suddenly, as if arrested by the most interesting and profound con- templations. Some maniacs are remarkable for good humour and mirth, which they express by fits of loud and immoderate laughter. * See Philosophy of Humau Nature, by John Duncan, M. D. Order IV MADNESS. 473 There are others again, whose taciturnity is perpetual; who express their afflictions by tears, or who sink, without a tear, UDder the dis- tressing influence of solitary anxiety. This happens in melancholia, to which there are usually added, fondness for solitude, timidity, fick- leness of temper, great watchfulness, flatulence in the stomach and hovels, costiveness, and a small weak pulse. Furious madness is marked by severe pains in the head, redness of tbe face, noise in the ear*, wildness of the countenance, rolling and glistening of the eyes, grinding of the teeth, loud roarings, violent exertions of strength, absurd incoherent discourse, unaccountable malice to certain per- sons, particularly to the nearest relatives and friends, a dislike to such places and scenes as formerly afforded particular pleasure, a diminution of the irritability of the body with respect to the morbid effects of cold, hunger, and watching, together with a full quick pulse. Insane persons are said to be usually worse in the morning; but perhaps this is not so generally the case as has been supposed. In many instances, at the commencement of tbe disease, they are more violent in the evening, and sometimes so the greater part of the night. It is indeed well known, that the majority of patients of this descrip- tion have their symptoms aggravated by being placed in a recumbent position. They seem of themselves to avoid the horizontal posture as much as possible when they are in a raving state, and when so con- fined as that they cannot be erect, will support themselves on the breech. Of the organs of sense which become affected in those labouring un- der insanity, the ear has been observed particularly to suffer: few luna- tics become blind, but numbers were noticed by Mr. Haslam to be deaf; and those who were not actually deaf, were troubled with diffi- culty of hearing and tinnitus aurium. Mania is to be distinguished from phrenitis by the absence of pyrex- ia and headach; and from delirium, by the state ofthe pulse, and not being conscious of external objects when roused, and even then the person soon relapses into a state of inattention ; whereas in mania he is frequently sensible, and is often planning tbe means of preventing or revenging supposed injuries. A modern writer* thinks that insanity is distinguished from delirium by the derangement ofthe intellectual faculties not being connected with bodily disorder, and that it is this circumstance which constitutes the distinction between the two maladies. An intermittent fever supervening madness of long standing has been known m some instances to have proved a cure for the disease; the senses have returned when the fever terminated. When mad- ness has arisen in consequence of some other disorder, and when its attacks are slight, and do not return very frequently, a radical cure may possibly be effected; but when it takes place in conse- quence of an hereditary disposition, or is attended with great melancholy, and a fixed attention to one particular object, be it love See Practical Remarks on Insanity, by Mr. CrowAer. 68 474 NEUROSES, OR NERVOUS DISEASES. ClttSS 11. or religion, we should not entertain much hope. The difficulty of relieving religious madness is acknowledged by all authors, and many cases have been evidently derived from Methodism in its various forms. It is indeed very obvious that those sects which are most accustomed to call up all the human passions in order to assist the propagation of their doctrines, must be most exposed to the inconveniences which result from the too violent operation of those passions. In those cases where mental derangement has originated from a physical state that exists only for a short period, or from the sudden impression of an unlooked for calamity, an expectation of cure may for the most part be not unreasonably entertained: but when, on tbe other hand, by a life of debauchery, or the corroding operation of any chronic passion, the mind has been disorganized, there is in general little hope, from either medical or moral regimen, of an entire and permanent restoration. Where there is a predisposition to mental derangement from an hereditary bias, external and accidental causes act with more violence upon it, and more readily overset reason, and such cases are usually most difficult to cure. Patients who are in a furious state recover in a much larger propor- tion than those who are melancholic. Insane persons are found to re- cover in proportion to their youth. Under every form of tbe disease, the hope of a recovery is usually proportionate to the time which has elapsed from its actual commencement, to the period of its being sub- jected to a regular treatment; advanced age always rendering the prognosis more unfavourable; for a radical cure has scarcely ever been effected in the instance of a hoary-headed maniac. The probability of recovery is comparatively small after the insanity shall have lasted longer than twelve months, as by this time the morbid action seems for the most part to tend towards morbid structure, which when carried to any extent will prove beyond the reach of medicine, or medical treat- ment. Where insanity supervenes on epilepsy or palsy, a cure is sel- dom effected. Madness from inebriety is rarely cured, because per- manent abstinence is seldom if ever attained in habitual drunkards. When the furious state is succeeded by melancholy, and the violent paroxysm returns after this shall have continued a short time, the hope of recovery is but small. A person labouring under furious madness who is attacked with small-pox is generally destroyed. By the books of Bethlem Hospital it appears that not quite a half, but rather more than a third of its patients are discharged cured of their insanity. Insanity, after continuing for a longer or shorter period without relief, commonly terminates in fatuity. This destruction of mind is almost always incurable. Sometimes, however, young persons, after having remained in a state of complete fatuity for months, or even years, are suddenly seized with a paroxysm of insanity, on the cessation of which they are restored to reason. It has been observed by those who superintend mad-houses, that the number of females annually brought in considerably exceeds the number of males. The natural processes which women undergo. Order IV. MADNESS. 475 of menstruation, parturition, and of preparing nutriment for the infant, together with the diseases to which fhey are subject at these periods, and which are frequently remote causes of insanity, as likewise the sedentary life they usually lead, and the exquisite- ness of their feelings, may perhaps serve to explain their greater disposition to this malady. W;omen affected with mania in conse- quence of a puerperal state, recover in a larger proportion than patients of any other description : indeed the insanity subsequent to parturition is generally curable, if the curative attempts be rational. From whatever cause fhe disease may be produced in women, it is to be considered as unfavourable to recovery if they are worse at the period of menstruation, or have their catamenia either in very small or immoderate quantities. A curious circumstance attending mania is, that by its access other diseases are often cured. Some Cases of anasarca, which were removed by an attack of mania, are mentioned by Dr. Dar- win*, all of which (he thinks) were affected by the increased energy of some parts of the system, owing to the addition of volition to the sensorial powers of irritation, or association. The morbid appearances most generally to be observed on open- ing the heads of maniacal subjects are, an opacity of the arachnoid membrane, and occasionally a thickening thereof; a preternatural determination of blood to the membranes as well as the substance ofthe brain itself; together with an effusion of water info the ven- tricles, and between its membranes and convolutions. Exclusively of these, ossification of some of the arteries, or a preternatural hardness of the substance of the brain, is. occasionally observed. Sometimes the pineal gland has been discovered charged with sabu- lous matter. Mania has ever been found on dissection to be con- nected with a morbid state of the brain and its membranes ; but whether this peculiar state ought to be regarded as the cause or effect of the disease, is a point not yet satisfactorily ascertained. From the anatomical observations of Dr, Greding, it appears that the greater number of insane people fall into a state of atro- phy or decay towards the close of their life, as it was observed that of one hundred maniacs sixty-eight died in this way. Of all dis- eases, hydrothorax appeared to be that to which maniacs are most subject, for out of one hundred of them, seventy six laboured under it. We are informed by the same gentleman, that consump- tion from an ulcerated state of the lungs appears to be another disease which frequently terminates the existence of insane people, as it was found that of one hundred maniacs there were forty who laboured under phthisis pulmonalis. Mr. Haslam has observed that maniacs are more liable to attacks of apoplexy and palsy than other diseases. Insane people are very subject to mortification of the toes, feet, and nates, when closely confined, which shows their susceptibility * See toI. iii. page 175, of his Zoonomia. 476 NEUROSES, OR NERVOUS DISEASES. Class II to the effects of cold. The helpless insane and bed-ridden patients are verv liable to be attacked with a mortification of the buttocks. It therefore appears a most advisable point that all asylums for the insane should be warmed by means of flues and heated air. In the internal economy of all such buildings this would be an important and humane improvement. The treatment of mania consists m the management of the patient, in humouring the subject of the mental disease, and the aid which medicine may afford ; but although the first is of great consequence, still where the mental faculties are only partially affected, the assistance of medicine is of high importance. That maniacs require medical aid in the first stage of the disease, cannot, I think, admit of a doubt ; and very likely the recovery of such persons will depend in a great degree upon early medics* attention and assistance : without it the chance of a cure wil be much lessened. When the disease arises in women, which . is apt to do between the ages of sixteen and forty,) moral reatnicnt alone, let the management be ever so proper, will not be likely to recover them without the aid of medicine. In the management ofthe insane, the great objects to be aimed at are, in the first place, that the invalids be separately and properly classed, both in respect to their ages, sexes, condition in life, and kind or degree of their disorder. Secondly, free ventilation, so insured as to guard against undue exposure to the inclemencies of the weather. Thirdly, a rigid system of cleanliness JourUily, such a judicious regulation both of mental and bodily e.emse as shall excite without fatigue, and exhilarate without exhaustion; and lastly, a combination of tenderness, lenity, and conciliation, with proper firmness, at the same time, on the part ot the keepers. It should always be the object of the superintendant and keeper to gain the confidence ofthe patient, and to awake m him proper respect and obedience, which is to be effected by d»cipl.iie of temper «nd dignity of manners. Tyrannical seventy may excte fear in the lunatic, but it will be mingled probably with contempt. In the management of insane persons, the superintendant must endeavour to obtain a complete ascendancy over them. W hen (his is once effected, he will be enabled on all future occasions to direct and regulate their conduct according as his judgment may suggest. He should possess firmness, and, when occasion "ay require, should exercise his authority in a peremptory manner. He should never threaten but execute, and when the patient has misbehaved should confine him immediately; and as example operates ,nor forcibly than precept, it will be best to order the delinquent to be confined in the presence of the other patients, be the institution a public or privatise. Such a conduct will display authority ; and fhe person who has misbehaved becomes awed by the spectators and more readily submits. When the patient is a powerful and strong man, two or more keepers should assist m securing hun, for when the maniac finds his strength or skill in the contest pre- Order IV. SfADNESS. 477 vail he is sure to make the most of such an advantage, and the con- sequence of his victory has sometimes proved fatal to the keeper*. When coercion is absolutely necessary, such an overpowering force ought to be employed as to preclude all possibility of successful resistance, by which means every idea of making any at all will most commonly be extinguished. The keeper should convince the maniac that all impropriety of conduct will be restrained. A prudent and vigorous coercion will generally restrain the fury, and sometimes restore rationality very speedily. He must then be treated with lenity and kindness, and with the manners due to his station in life, which will insure the respect of tbe pupil to his master, upon which every indulgence consistent with sa'ety and propriety may be allowed. It is obvious, therefore, that a system of intimidation without cruelty, of restraint without indignity, of rigid order and discipline, combined with lenity and conciliation, is the only rational and successful method of com- bating the extravagances of lunatics. To obtain a salutary influence over the wanderings of a maniac, we ought first to secure his confidence. This cannot be done with- out behaving towards him with a delicacy due to his unfortunate state, which for the most part ought to be regarded not as an aboli- tion, but as a suppression merely ofthe rational faculties. There is indeed ground to apprehend that fugitive folly is too often converted into a fixed and settled frenzy; a transient guest into an irremoveable tenant of the mind; an occasional aberration of intellect into a con- firmed and inveterate habit of dereliction, by a premature and too precipitate adoption of measures and methods of management, which sometimes indeed are necessary, but which are only so in cases of extreme and ultimate desperation. At some asylums for the reception of insane persons, but more particularly those of a public nature, we have just reasons for ap- prehending that severe and harsh treatment is not unfrequently re- sorted to, and the strong principle of fear sternly applied by blows, the strait waistcoat, or chainsf, to be the most usual means adopted for correcting the wanderings of reason, or the diseased ebullitions of passion; as it is less trouble to fetter by these restraints than by the assiduities of sympathy or affection. Nothing, however, has a more favourable and controlling influence over one who is disposed to or actually affected with melancholia or mania, than an exhibition of friendship or philanthropy, excepting, indeed, in such cases and in that state of the disease in which the mind has been hardened and almost brutalized by having already been the subject of harsh and humiliating treatmentj. By an experiment made in an asylum near York, named the Retreat||, it has been ascertained that the best effects have re- * See Observations on Madness, by Mr. Haslam. t See Report of the Evidence before a Committee ofthe House of Commons. X See Essays on Nervous Affections, by John Reid, M. D. || See Description of the Retreat, near York, by Samuel Tuke, 47b* rsEURosEs, ok nervous diseases. Class II. suited from a system, the prevailing feature of which is kindness, and even certain degrees of indulgence; and that the proportion of old or hopeless cases which have been discharged from thence cured, very far exceeds that from St. Luke's or Bethlem. At the Retreat, the convalescents of every class are frequently introduced into the society of the rational parts of the family. They are also permitted to sit up till tbe usual time for the family to retire to rest, and are al- lowed as much liberty as their state of mind will admit. Although the effect of fear is not excluded from this institution, when indispen- sably necessary, yet the love of esteem is considered as a still more powerful principle. At Laverstock, in the immediate vicinity of Salisbury, there is an asylum for the reception of lunatics, under the direction of Dr. Finch, and which is conducted with great kindness and lenity to those placed under his care. The house is pleasantly situated, commands an extensive prospect over a fine open country, and has a considera- ble portion of ground attached to it, where the patients are aired, and take exercise without being exposed to the view of any persons passing by. The paupers are kept distinct from the others, and the sexes separate, and throughout the whole institution the strictest at- tention is paid to cleanliness, and the keeping up a free ventilation. The patients are welt fed, are treated with kindness and conciliation, and are allowed every indulgence and recreation consistent with their safety and welfare. As amusements within doors, billiards, cards, books, &c. are supplied them : bowls, cricket, greyhounds, walking, riding on horseback, and in a carriage, are the out-door amusements; but the two latter, of course only to those whose fortunes will admit of such expense. The pauper patients are employed in his garden. Bodily restraint is never used except on the most urgent occasions, and then tbe mildest only is employed. Tbe very high and favoura- ble opinion I entertain of the humane kind, and benevolent manner in which Dr. Finch conducts this Asylum, has been strongly corrob- orated by the testimony of Mr. Whitefield, on his examination be- fore a Committee of the House of Commonsf, who says, that no words can characterize it in too high terms. Under slight attacks of mania where the degree of irritation is trifling, as well as during a state of convalescence, it will not be necessary to confine the patient within doors in fine weather; taking care, however, at the same time, to put it out of his power to escape, or do any injury either to himself or others. His mind is to be soothed and his attention diverted as much as possible, by getting him to engage in some exercise or amusement, that will employ both body and mind at the same time, and that will divert the latter from pursuing any train of thought. He should be recommended to avoid as much as possible thinking upon questions of a perplexing and intricate nature. In melancholia, this plan * See Report of the Evidence before them. Order IV. madness. 479 will be doubly necessary, and we may likewise allow entertaining books, cheerful company, amusing scenes, music of fhe exhilarating kind, playing at billiards, or even cards. If the patient is fond of gardening, the employment of some portion of his time in this way will prove both healthy and agreeable. It has been observed, that in all institutions for the insane, the male patients, who assist in digging, planting, weeding, wheeling, wood cutting and making fires, &c, and the females who are em- ployed in washing, ironing, and scrubbing floors, often recover ; while persons, whose rank exempts them from performing such services, languish away their life within the walls. In the management of insane persons, the value of exercise and employment is to be highly estimated. Female patients may be employed in sewing, knitting, or domestic affairs, and many of the convalescents may assist the attendants. Of all the modes by which patients may be induced to restrain themselves, regular em- ployment is perhaps the most efficacious, and those kinds of it ought doubtless to be preferred, both on a moral and physical account, which are accompanied by considerable bodily action; that are most agreeable to the patient, and which are most opposite to the illusions of his disease, or the hallucination possessing the mind. At the Lunatic Hospital, at Charenton, in France, the experiment has been made to induce the patients to act plays for their amuse- ment. To these exhibitions their friends were invited, and a be- neficial effect was produced thereby*. It has been asserted, that some maniacs have been cured by being compelled to constant, and even hard labour ; and as a forced attention to the conduct of any bodily exercise is a certain mean of diverting the mind from pursuing any train of thought, it is probable that such exercise may be useful in many cases of mania. Monsieur Pinel, in his Treatise on Insanity, tells us, that at the principal hospitals in Spain, but more particularly the one established at Saragossa, the maniacs capable of working are distributed every morning into separate parties. An overlooker is appointed for each class, who apportions to them all, individually, their respective employments, directs their exertions, and watches over their conduct. The whole day is thus occupied in salutary and refreshing exercises, which are interrupted only by short in- tervals of rest and relaxation. The fatigues of the day prepare the labourers for sleep and repose during the night. Hence it happens, that those whose condition does not place them above the necessity of submission to toil and labour, are almost always cured ; whilst the grandee, who would think himself degraded byexercises of this description, is generally incurable : by retaining his privi- leges, he retains his lunacy. In violent states of mania, the patient should be confined alone k ^ee Paris, par Monsr. Sangur. 480 neuroses, or nervous diseases. Class 11. in a dark and quiet room, so that he may not be affected by the stimuli of light and sound, such abstraction more readily dis- posing to sleep. To prevent him from committing any violence, his hands ought to be properly secured with manacles, and he may likewise be confined by one leg, or he may be strapped by the hands and legs in a large ch?ir fastened to the floor. As an horizonal posture tends to increase the fulness of the vessels in the brain, this should be avoided in the day-time. The strait waistcoat is another mode of confinement well calculated to prevent maniacs from doing any injury either to themselves or others; but in the furious state, and particularly in warm weather, it is apt to irritate and increase that restlessness which patients of this description usually labour under. Where malevolence forms a prominent feature, and the person is very furious, close confinement in the manner just detailed is doubly necessary; but chains are not to be used on any occasion. In some asylums, but more particularly in the Ward at Guy's Hospital, appropriated to insane persons, where bodily restraint is deemed absolutely necessary, insiead of the strait waistcoat, in hot weather, a strong leathern belt is substituted, which is girded round the body with a small strap round each arm ; and this allows the patient the use of his hands without occasioning heat, as the strait waistcoat does. This mode of restraining violent patients appears therefore decidedly preferable to the other. The straw on which such persons lie as are insensible of the calls of nature, ought to be changed, very frequently, and the strictest at- tention paid to their bodily cleanliness and that of their apartments, by frequent washings, and proper ventilation throughout tbe day. The wet patients at Guy's are lodged on bedsteads lined with lead and sloping to one corner, which occasions the urine to run off without any offensive smell remaining, as is the case in other houses. In slighter cases, where the patient is in a condition to be sen- sible of restraint, he may be punished for any improper behaviour by confining him to his room; by degrading him, and not allowing him to associate with the convalescents, and by withholding those indulgences be has been accustomed to enjoy : the infliction of corporeal chastisement ought never to be resorted to. All violence and harsh treatment on the part of domestics should strictly be proscribed, being a law of fundamental importance, and highly essential to the prudent and successful management of all insti- tutions for insane persons. Moreover, any confinement of tbe patient beyond what is absolutely necessary, will inevitably tend to create such an irritation of mind as might greatly iuterfere with the cure. In most of the public asylums there is an insufficiency of the number of keepers in proportion to the number of persons intrusted to their care, which unavoidably leads to a pioportionably greater degree of restraint than the patients would otherwise be under, Order IV. MADNESS. 481 and this unnecessary restraint must greatly tend to retard recovery. Another evil by which the recovery of patients is not unfrequently retarded, is, that many of such asylums receive a greater number of insane persons than can comfortably be accommodated, in con- sequence of which several are lodged in the same room, and not unfrequently two or more are put into the same bed*. Moreover, in some of the asylums they do not pay proper attention in se- parating those patients who are violent and outrageous from those who are quiet and inoffensive; nor those who are insensible to the calls of nature, from those who are cleanly and orderly. The con- gregating insane persons together in this promiscuous way, is cer- tainly an evil of pernicious tendency ; and therefore I repeat, that the separating and properly classing such invalids, both in respect to their sexes, ages, condition in life, and kind or degree of their disor- der, is a point of high importance in their management within all lunatic asylums. Persons in a state of convalescence ought always to be kept apart from those who are labouring under a paroxysm of the disease; for by having constantly before their view those who are suffering under the disgusting or affecting symptoms of the malady, their cure would probably not only be retarded, but be ultimately prevented. Insane persons should be made to rise early, to take such exercise as their condition will admit of, and have their food served up to them at stated times. Independently of such regu- larity contributing to health, it also renders them more manage- able. In all cases of madness it will be proper to remove the patient from those objects with which he was formerly acquainted, as these might call up ideas and the various associations; and on this account, a change of situation, and removal from his friends, will be advisable; for it is a fact well known to those who superintend lunatics, that patients are seldom or never recovered at home. It not unfrequently happens, indeed, that maniacs, who have been brought immediately from their families, and who are said to be in a violent and ferocious state at home, become suddenly calm and tractable when placed in a lunatic asylum. On the other hand it is equally a fact, that there are many patients, whose disorder speedily recurs after having been suf- fered to return to their families, although they have for a length of time conducted themselves, under confinement, in a very orderly manner. The restraint, cunning, and dissimulation, which many insane persons are capable of, are well known to those who are conversant with them ; but the ignorant are apt to cry out against secluding them from society, because they probably happen to conduct themselves with propriety before strangers, and in short conversations appear coherent and rational. To attempt the complete seclusion of a maniac in a furious * See Report from the Committee on the House of Commons on Madhouses in England. 61 482 NSUROSBS, OR NERVOUS OISEASES. ClaSS II. state at his own house, in the bosom of his family, is by no means desirable ; and indeed it is seldom practicable ; for a patient confined at home naturally feels a degree of resentment when those whom be has been accustomed to command, refuse to obey his orders, or attempt to restrain him. If, however, a patient be rich, quiet, and manageable without coercion, the attendance of an affectionate wife, or husband, brother, sister, or friend, may with proper instruction, be able to do much more than can be expected where a great number are t« be attended to. Various objections have indeed been raised against sending maniacs to a place of confinement, both among the highest and lowest classes of society. A principal one is, the fear of severe and cruel treat- ment, and the hazard of rendering the disorder permanent: but these apprehensions appear groundless; for there must be some grievous defect in the mode of amending the disordered mind, if correct sentiments and rational and orderly behaviour are not inculcated by the habit of self-denial and strong efforts of the will. Let the appeal be fairly made by visiting a maniac at his own house, or at an establishment appropriated for tbe reception of such persons. To endeavour to refute the notions of lunatics will be labour it rain : it will be best to coincide with their extravagancies, and appa- rently to humour the prevailing hallucination. The skilful physician will always endeavour to investigate the maniacal idea or hallucination, as it may not only acquaint him with the probable designs of the patient, from whence may be deduced the necessity of confinement, but also may sometimes lead to the most effectual plan of cure. A late writer* o'n mania, who has long kept an establishment for the reception of lunatics of both sexes, has recorded a number of striking examples, where, by humouring the subject of the mental disease, tbe most happy effects ensued, and the patients were perfectly restored to reason and health. To assist the young practitioner in applying a judicious moral treatment under similar circumstances, I transcribe one of tbe cases, which is as follows: Case 2d. Mr.-----, aged 40, of a spare and melancholic tempe- rament, remarkable for general and almost universal acquired knowledge, and always possessing singular equanimity, had injured his health by too close an attention to extensive mercantile con- cerns. At length he was observed to be very attentive to every feeling, of which he made minute descriptions to his family: this increasing, he became a prey to empiricism, read several ridiculous popular pamphlets, and was soon worked up to a belief that his body was the common receptacle of disease: pills, potions, pow- ders, unctions, lotions, and mercurial girdles, were employed and dismissed in succession. The metallic tractors for a time amused * See Practical Observations on Insanity, By J. M. Cox,M. D. Order IV. MADNESS. 48* him, till it was proved to tbe patient and to his friends who witnessed tbe experiments, that these expensive baubles possessed no more pro- perties than a rusty nail. All the fears of the patient became at length concentred in one ; from the contemplation of, and conversation on which, no arguments could divert him : he believed all his sufferings arose from repelled itch. A formal consultation of medical men was therefore determined on, who having previously agreed on the pro- priety of humouring the subject of the mental disease, were unani- mously of opinion the conjecture of tbe patient was just. A medical plan was laid down ; some rubefacient applications to different parts ofthe body occasioned crops of eruptions from time to time, which were washed with some simple preparation. This farce continued a few weeks, and the patient at length was perfectly restored to health and reason. A number of cases tending to show the great utility of investigating the maniacal idea or hallucination are likewise reported by Dr. Darwin in the 4th volume of his Zoonomia, page 66. With regard to the diet of maniacs, it is only necessary to observe, that it should be conformable to the general curative plan. If the whole treatment is antiphlogistic or lowering, the diet must be similar: if the curative plan be tonic, the diet must correspond; and if at the same time tonics combined with aperients are indicated, the diet ought not to be in opposition. Although temperance is strictly to be enjoined, still wine may be allowed in moderation during a state of convalescence in melancholia. The criterion ofthe proper quantity should be that which does not affect the temper ofthe patient, nor exasperate his aversions. Maniacs who are paralytic, require to be kept warm, and to be allowed a more nutritious diet, and cheering beverage, than insane patients of any other description. In the winter months they suffer extremely. Lunatics sometimes refuse all food for many days, so as to endan- ger their lives. In private receptacles it is usual, Mr. Haslam says, to have recourse to the operation of what is called spouting, whereby the front teeth are commonly broken and destroyed. To prevent this, he recommends an instrument*, by which food may be conveyed into the stomach with great facility, and without any injurious consequences to tbe teeth. Bleeding has been much employed in mania. In paroxysms of madness, which are preceded by a heightened complexion, wild- ness and prominence of the eyes, and exuberant loquacity, or where there is obvious plethora, or evident determination and congestion about the head, a free use of the lancet, no doubt, is often attended with a happy effect; but bleeding, practised as it frequently is, without rule or bounds, among maniacs, often exasperates the complaint, and reduces the patient to a state of extreme debility, occasioning periodical and curable mania to degenerate into idiotism. Where absolutely necessary, drawing * See his Observations «n Madness. 484 NEUROSES, OR NERVOUS DISEASES. ClaSS II. blood from the jugular veins will be preferable to taking it from the arm, or we may draw it from the head, by applying six or eight cup- ping-glasses to the scalp, after having it shaved. From eight to six- teen ounces may be drawn off in this way, and the operation be re- peated as circumstances may require. Against mere insanity, unaccompanied by bodily derangement, me- dicine appears to be almost powerless; but where an insane person happens to be diseased in body as well as mind, medicine, or more strictly medicinal treatment, is not only of as great importance to him as to any other person, but much greater, as diseases of the body are commonly found to aggravate those ofthe mind. In acute cases of mania, patients require speedy as well as regular assistance to prevent that disorganization which might lead to protracted or incurable insanity. For the purpose of obviating the fulness and tension of the vessels of the brain, purging is generally adopted, and medicines of the drastic kind, such as hellebore, are often made use of; but more advantage will be derived from a frequent exhibition of the potassa? tartras and other saline cooling purgatives, which are the principal medicines to be depended upon in mania. It is an assiduous, a continued, an alternating and alterative use of cathartic and opening medicines, the operation of which is gentle, that promises, and in reality has proved, to be beneficial in cases of madness and melancholy. When tbe nervous system is so much de- ranged as the cases in question suppose, there is almost invariably a tendency to faulty action in the first passages, and their immediately connected viscera. This state of the stomach and bowels comes in the course of time to react as it were upon the nervous system, and te prove an occasion for the continuance of that derangement of which it was at first a mere consequence. Cathartics* are of the utmost importance therefore in tbe treatment of insanity, but more particularly when the excitement is great; and as constipation is a common occurrence with maniacs, those who have their supwintendance should regularly inquire into the state of their bowels. In obstinate cases the submuriate of mercury joined with a few grains of the extract, colocynth. c. may be used. In periodical mania, the paroxisms are usually preceded by obstinate costiveness; and a dose or two of some purgative medicine, at an early period, will frequently put a stop to the progress of the attack ; which fact ought to have due weight. Moreover, it has frequently happened, that a speedy convalescence has ensued in mania after the coming on of a-diarrhoea, and in a few instances it has proved a cure. * 1. B; Infus. Senna?, f. |jss. Potassa; Tartrat. 3»j- Tinct. Jalapae, f. 3'j- Syrup. Rhamni, f. 3j- M. ft. Haustus catharticus. * 1. Take Infusion of Senna, one ounce and a half. • Tartrate of Potass, two drachms. Tincture of Jalap, two drachms. Syrup of Buckthorn, one drachm- Mix them, for a cathartic di aught. Order IV. madness. 485 At the commencement of the paroxysms of furious madness, where the eyes look wild and rambling, and there is high excitement, both purging, venesection, and the topical abstraction of blood from the head, by means of several leeches, or the application of cupping- glasses preceded by scarification, will undoubtedly be proper, in addition to having the bead shaved, and linen cloths, wetted in some evaporating lotion, kept constantly applied to it: but in melancholia, where there is extreme depression both of strength and spirits, neither active purging nor bleeding should be adopted. In such cases, all debilitating means ought to be avoided, as tending to aggravate tbe symptoms ofthe disease, and to increase tbe probability of superven- ing idiotism. Emetics have been recommended by some physicians* in mania, but by the generality of them they have been disapproved of, as being likely to increase the determination to the head, and occasion apo- plectic or paralytic attacks. We are told by Mr. Haslam, that from many years' observation and administration of many thousand emetics to insane persons at Bethlem Hospital, he has not been enabled to place any confidence in this class of medicines, as a cure for insanity; admitting, at the same time, that the lunatic, whose stomach was in a disordered state, has been equally benefited with a person in his senses by the operation of a vomit. In my opinion, emetics ought not to be administered, except with the view of removing symptoms that may be concomitant with mania. Small and frequent doses of the antiuionium tartarizatum, so as to excite a slight degree of nausea, and thereby determine to the surface of the body, may however be serviceable in those cases where there is a high degree of excitement. Cold bathing, by diminishing irritation, is a remedy by which ma- niacs have been relieved, and sometimes entirely cured, especially when applied in a certain manner. This consists in throwing the person into cold water by surprise, by detaining him in it for some length of time, and pouring water frequently on his head, while the whole ofthe body except the head is immersed ; and thus managing the process sov as that, with the assistance of some fear, a refrigerant effect may be produced. That the external application of cold may be of service, we have full experience, from the benefits which have been received in some maniacal cases from the application of ice and snow to the naked head. Mr. Haslam, however, mentions, that he has known in many in- stances paralytic affections to have ensued in a few hours after cold bathing, especially where the patient has been in a furious state, and of a plethoric, habit. In other cases, he has known vertigo, or a con- siderable degree of fever, to ensue after a cold immersion. In all cases of furious madness connected with plethora there can exist no doubt that a cold bath will prove prejudicial. *. See Observations on Insanity, by J. Cox, M. D. ■—.Essay on the Cure of Insanity, by G. N. Hill. 486 NBUROSES, OR NERVOUS DISEASES. CUlSS 11, Warm bathing has been recommended by some physicians, and others again have disapproved of it. Probably it may be most useful to those of a rigid melancholic temperament. The late Dr. Willis was of opinion* that warm bathing might be useful to lunatics, bat that cold bathing could seldom be required. Indeed warm bathing, and the judicious administration of cathartics, appear to be the best physical agents we can employ upon mental disorder: the effects of the former in calming nervous irritation are often abundantly con- spicuous. At the Retreat, or asylum at York for the reception of insane persons, warm bathing has been used for several years, and is still considered of greater importance and efficacy, in most cases of melancholia, than all the other medical means which have been employedf. In the lunatic hospital in Paris, denominated La Salpetriere, and which is under the superintendance of Dr. Pinel, great stress is laid upon tbe tepid bath as a remedy for mania; to which is added, when the patient is riotous, a douche, or pumping of cold water, falling several feet on the head. A novel method of treating insanity is practised by Messrs. Lucett and Delahoyde, at their reception for insane persons at Sion Vale. The process employed by these gentlemen is however kept conceal- ed from the public; but it appears from the statement of a Mr. Tar- dy, that he was engaged in the management and employment of this process with Mr. Lucett prior to the latter's connexion with Mr. De- lahoyde, and that during this they treated some cases of mental derangement with variable effects, but striking enough to countenance and encourage further inquiry. The great influence which the pro- cess was proved to effect upon the circulation and pulse, was, as far as we can trust to the correctness of our information, caused by the immersion of the patient's body in warm water, and at the same moment pouring a stream of cold water on the naked head. The bath was at first 90 degrees, and subsequently increased to 108. The patient was kept in the bath about four minutes on the first trial, and afterwards from 30 to 40 minutes. The effects produced were a decrease of the velocity, but an increase of fulness of the pulse ; a quieting of disturbed and erratic mental action, followed by calm sleep of several hours' continuance. Opium, when administered to madmen during a violent paroxysm, has hardly ever been found to procure sleep ; but, on the contrary, has rendered those who have taken it much more furious; and where it has for a short time procured rest, the patient has, after its operation, awoke in a state of increased violence. Opium, to prove serviceable in maniacal cases, ought to be administered in very large doses, such as about two hundred drops of its tincture. It seems however at best to be but a doubtful remedy. * See Report ofthe Select Committee appointed to inquire into tbe State of Lunatic* t Description of the Retreat, by Samuel Tuke. Order IV. BADNESS. 487 An extensive friction, with a liniment consisting of six or ten grains of opium well triturated, with a small quantity of prepared lard, has been recommended for the purpose of inducing sleep in maniacs where its internal administration might be prejudicial. Where frictions fail we might possibly employ opium in the form of fumigation with some advantage. Where the patient appears much reduced from the want of sleep, but still we dare not give opium from having found it prejudicial, we may make trial of the extractum papav. albi, or the extractum hyos- cyami in the dose of four or five grains*. With regard to tbe medical properties of the hop, or lupulus com- munis, the experiments made on it show that it is evidently narcotic, inducing sleep like opium; but it seems rather to dispose to laxity of the bowels than costiveness. In this disease, as well as in some painful cases where an opiate is greatly wanted, hut where it cannot be exhibited in any of the usual forms without pro- ducing untoward symptoms, a strong infusion of the hop used both internally and externally, has frequently, it is said, been found to sooth pain, and finally to procure a calm, tranquil sleep. The best preparation however of the hop appears to be the tincture, made by digesting four drachms of the lupulus communis in ten ounces of rectified spirit. The dose may be from forty drops to one hundred. The sedative effects of the digitalis point it out, we have reason to presume, as an useful and powerful remedy after frequent purging and phlebotomy in cases where great excitement and increased tone prevail in the nervous and arterial systems. It has therefore been used in mania, and not unfrequently with successf. When the de- rangement is accompanied, and in some degree regulated by an accel- erated circulation, a use of foxglove will be highly proper. A few drops of the tincture, or half a grain of the powder, are to be given at first, and the dose to be gradually increased till the desired effect is produced. To make this permanent it will however be necessary to keep the constitution for some length of time under the influence of the medicine. A case of mania, preceded by strong epileptic fits of frequent recur- rence, and induced by along and intemperate use of spirituous liquors, some time ago came under my care, wherein, by adopting this plan, the mental affection, as well as the spasmodic, entirely ceased. On discontinuing a use of the digitalis, the patient commenced a course of the oxyd of zinc, joined with stomachics, which completed the cure. t See Observations on the Digitalis Purpurea, by Dr. Currie, vol. iv. article GC°N H°ll 01™ 6 Medical Society of London—See Essay on Insanity, by * I. Take Camphor, ten grains. Extract of Henbane, five grains. Syrup, a sufficiency. Let the mass be formed into three pills, which may be taken every six hours. i. u Vyampnorae, gr. x. Extract. Hyoscyami, gr. v. Syrup, q s. M. Fiant pilulae Iij. pro dos. sextis horis su-, mendae. 488 NEUROSES, OR NERVOUS DISEASES. ClaSS It Camphor is a medicine which has been much recommended by some physicians in mania, while by others it is said to be useless. I understand that Dr. Willis gave the camphorated mixture at the same time with the extracts of conium, hyoscyamus, and other narcotics. Might not a combination of it with digitalis prove advantageous ? Blisters and other drains, such as issues or a seton, have likewise been employed in this disease ; and when recent, may probably have a good effect. In cases of long standing they have been found in- effectual. Dr. Monro, in his Observations on Mania, mentions, that a blis- ter, when applied to the head itself, seldom proves useful: and tbe same circumstance has been noticed by other physicians. When we hare recourse to blisters, it will be most advisable therefore to apply them to the neck or back. To keep up a sufficient discharge from them, I have found the ceratum sabinae far preferable to the ungu- entum lyttae. In the cure of insanity, quietness, and the abstraction of all stimuli, are in general to be enjoined ; yet there appears to be exceptions, Dr. Cox* very judiciously observes, both with regard to light and other stimuli; for in some cases total darkness aggravates all the symptoms, excites fear, dread, and apprehension; though in others it may be had recourse to with an intention of producing these effects. It appears a curious circumstance that the conversion of religious melancholy into furious madness is an occurrence that sometimes happens, and when it does, is generally followed by re- covery, which has suggested the propriety, in some cases that have resisted more common means, of producing a degree of excitement by means of stimuli; in fact, keeping the patient for some reces- sive days in a state of intoxication. This plan, we are told, has often occasioned an alleviation of symptoms, and sometimes restored the sufferers to reason. In cases of mental derangement, originating from the passions of grief, sorrow, or religious fear, and in which the system has sunk into apathy and dulness, the stimulus of galvanism, or of gentle electricity, affords some prospect of relief, more especially if the patient be not very far advanced in life. When we have recourse to the first of these remedies, it will be best to employ a pile consisting only of a few plates at first, that the brain may not be subjected to too violent an action. The same must be carefully guarded against when we resort to electricity. Dr. Cox speaks highly of swinging as a remedy in mania, and he recites many cases where the happiest effects were derived from making use of it. We are told by him, that it may be employed in the common oscillatory way, or in a circular manner of whirl; the patient at the same time sitting erect, or lying horizontally. On persons in health he observed these swings to produce only the common effects; but in proportion to the motion communicated, * See his Observations on Insanity. Order IV. madness. 489 and sooner by the circular than by the oscillatory, and in the hori- zontal than in the perpendicular position. In some maniacal cases, independent of these more obvious effects, he noticed that swinging, often repeated, had the singular property of rendering the system sensible to the action of agents whose powers it before resisted. One of its most valuable properties was, its proving a mechanical anodyne. This effect 1 have myself observed. After a very few circumvolutions, Dr. Cox has witnessed its sooth- ing, lulling effects : the mind has become tranquil, and the body quiescent: a degree of vertigo has often followed, and this has been succeeded by the most refreshing slumbers; an object the most de- sirable in every case of madness, and procured with the utmost diffi- culty in general. Maniacs, he has noticed, are not usually sensible to the action of the common Oscillatory swing, although it affords an excellent mode of secure confinement, and of harmless punishment. By the protracted action of the circular swing or whirl, he has some- times seen the patient almost deprived of his locomotive powers; and although it required the combined strength and address of several experienced attendants to place him in it, still he has been taken out of it by a single person : the most profound sleep has followed, and this has been succeeded by convalescence, and a perfect recovery, without the assistance of any other means. One of the most con- stant effects of swinging is a greater or less degree of vertigo, attend- ed by pallor, nausea, and vomiting, and frequently by an evacuation ofthe contents ofthe bladder. Where insanity attacks patients of a delicate habit, with previous consumptive or pulmonic symptoms, swinging has in many instances proved highly beneficial. It has been mentioned in the preceding pages, that insane people, when closely confined, are very subject, in wiuter, to a mortification of Jhe toes, feet, and nates, and that the helpless and bed-ridden patients are very apt to be attacked with a mortification ofthe buttocks. In all cases of this nature, we are told by Mr. Crowther*, who was, until lately, surgeon t«» Bethlem Hospital, that the treatment usually adopted (consisting of hot fomentations, lint dipped in stimulating liniments applied warm, and over the whole a poultice of the grounds of stale beer and oatmeal) invariably failed; whereas by substituting an embrocation of rectified spirit, lowered with water according to the degree of sensibility of the parts, and afterwards covering them with soft lint spread with the ointment heref prescri- • See his Practical Remarks on Insanity. f 2. R Unguent Resinos. Empl. Resins, aa ?ij. Bals. Terebinth, ri. M. t 2. Take Resinous Ointment, Resin Plaster, of each two ounces. Terebinthinate Balsam,one ounce. Mix them. 490 NEUROSES, OR NERVOUS DISEASES. OlttSS It bed, not a single death arising from a mortified state of the nates afterwards happened. When madness has taken place in consequence of great debility and weakness, as sometimes happens at the close of typhus initior, all evacuations whatever ought to be avoided, a nutritive and resto- rative diet should be allowed, and a regular course of the cinchona bark and other bitters, together with chalybeates, be entered upon ; the patient taking at the same lime such daily exercise in the open air, either in a carriage or on horseback, as his sfrength will admit. The mind is apt to be much affected, both after abortion and delivery, and in some instances the woman becomes either melan- cholic or mad, the latter being more frequent. This mania is in general sudden in its attack, and is often preceded by great palpita- tion and some other nervous affection. The disease, although frequently tedious in such cases, is oftener got the better of than any other species of mania. In puerperal mania venesection would be likely to prove inju- rious. Where there is furious delirium, the best practice is fo apply leeches to the temples, open the bowels freely, determine gently to the surface of the body by saline jalap, and afterwards allay irritation with liberal doses of camphor combined with aether. Opium appears to be a very doubtful remedy at an early period of the disease ; but in the wane it probably may be productive of be- nefit. The extract urn hyoscyami will be more appropriate during the early .stage. Blisters are usually considered inefficacious and detri- mental. The patient should be kept as quiet as possible. Should there be any difficulty in confining her in bed, we may have recourse to the strait waistcoat, or strong leathern belt, as before mentioned, by which she will be restrained, and obliged to exercise self-eon- trol. In the progress of the disease due altention must be paid to fhe bowels, and it must be borne in mind, that often the patient voids both urine and faeces, not from being unable to retain them, but from inattention or perversity. In a state of convalescence the mind and attention are to be occupied by cheerful conversation, music, light reading, and afterwards by a change of scene, and regu- lar exercise daily in a carriage or on foot. Melancholy madness comes on laler than furious delirium. The disease differs nothing in appearance or symptoms from melancholy occurring at other times. It is however frequently obstinate, but in common goes off after the child is weaned, and the strength has returned. Sending the patient into the country, if resident in town, will therefore be advisable, as soon as possible removing the child also from sucking her. Insanity has sometimes been pretended for the purpose of evad- ing justice after the perpetration of murder. The principal means for the detection of such pretenders to madness are, a consideration of their probable motives for counterfeiting fhis state; a strict exami- Order IV. night-mare. 491 • nation of their conduct when they suppose themselves to be alone and not overlooked, contrasted wilh their behaviour when they are conscious of being observed ; the existence of that peculiar fetor in the exhalations which so generally accompanies the true maniacal state ; and the manner in which the subject is affected by the admi- nistration of drastic drugs. INCUBUS, or NIGHT-MARE. In this disease there is such a weight and oppression felt as to impress the patient with the idea of some living being having taken its position on the chest, inspiring terror, impeding respiration, and paralyzing all the voluntary muscles. Incubus will sometimes occur in the healthiest person when any indigestible food happens to be in his stomach or the upper portions of- the alimentary tube during sleep ; but a peculiar habit of body is necessary to render a person liable to it. Those of a contempla- tive disposition, and of that particular temperament which disposes to hypochondriasis and other nervous diseases, are very subject to its attacks. Sedentary employments, confinement within doors, literary.studies, anxiety of mind, &c. all predispose to visitations of incubus. Sailors have been observed to be very liable to this disease*. Hypochondriacs and pregnant women are also its victims, but the male sex more frequently than the female. In advanced life it is not often met with, except where corpulency, asthma, or a tendency to lethargy exists. The disease always attacks during sleep : if this be profound, the first approach of the fiend is usually in the shape of a disagree- able dream. The patient imagines himself exposed to some danger, or pursued by an enemy whom he finds it impossible to avoid. He frequently feels as if his limbs were tied, or deprived of motion : at other times he fancies himself confined at the bottom of a cavern or vault, and in danger of suffocation. This is often the whole of the sensation which the disease produces, when it goes off either by an oblivious sleep or dream. Here incubus is not fully formed, the predisposition is only evinced. When the paroxysm actually takes place, the uneasiness of the patient in his dream rapidly increases, till it ends in a kind of consciousness that he is in bed and asleep, but he feels oppressed with some weight which confines him on his back and prevents his breathing, which is now become extremely laborious, so that the lungs cannot be fully inflated by any effort he eau make. The sensation is now the most painful that can be conceived : the person becomes every instant more awake and conscious of his situation ; he makes violent efforts to move his limbs, especially «his arms, with the view of throwing off the incumbent weight, but uot a muscle will obey the impulse of the will; he groans * See Mr. Waller's Treatise on Incubus. 492 NEUROSES, OR NERVOUS DISEASES. CktSS 11 0 aloud if he has power to do it, while every effort he makes seems to exhaust the little remaining vigour. The difficulty of breathing goes on increasing, so that every breath he draws seems to be almost the last thai he is likely to draw ; the heart generally moves with increased velocity, sometimes is affected with palpitation, the countenance appears ghastly, and the eyes half open. The patient, if left to himself, lies in this state generally about a minute or two, when he recovers all at once the power of volition, upon which he either jumps out of bed, or in- stantly changes his position, so as to awake himself thoroughly. If this be not done the paroxysm is very apt to recur again imme- diately, as the propensity to sleep is almost irresistible ; and if yielded to, another paroxysm of night-mare is, for the most part, inevitable. Where the disease is established, some confusion of the head, singing in the ears, and spectra before the eyes, will often remain for a time after being roused. There is often also a sense of weight at the stomach, an unpleasant taste in the mouth, acceleration of pulse, and palpitation of the heart. When the paroxysm goes off, as frequently happens without the patient awaking, strange hallucinations are occasionally produced, which give origin to reputed visions and supernatural visitations even among people of great intellectual cultivation. The degree of consciousness, during a paroxysm of night-mare, is so much greater than ever happens in a dream, that the person who has had a vision of this kind cannot easily bring himself to acknowledge the deceit unless he awakes out of his paroxysm, and finds some incongruity in respect to time or place, which proves the transaction to be an illusion*. Spasmodic constriction of the diaphragm and muscles of the chest has been assigned by some as the proximate cause of incubus. The disease is not attended with danger. The complaint seems to be altogether dependent on a state of dys- pepsia, and is usually accompanied with a distention of the sto- mach and bowels; by flatus, constipation, and acid eructations. Whenever the dyspeptic symptoms are urgent, we may administer one of the draughts prescribed belowf, repeating if as the occasion may require. Costiveness is to be guarded against by some gentle aperient, such as a few grains of rhubarb with magnesia. Where there is much languor and debility, with loss of appetite, we may recommend the pilula ferri cum myrrha, together with either the * See Mr. Waller's Treatise on Incubus for various deceptions of this kind. t 1. Take Subcarbonate of Potass, twelve t 1. & Potassae Subcarbon. gr. xij. Aq. Menth. Pip-f.^i. Tinct Card. Comp. f. 3»j- Syrup. Zingib. f. 3i- ft. Haustus. grains. Peppermint Water, one ounce. Compound Tincture of Cardamom*. three drachms. Syrup of Ginger, one drachm- Mix them for a draught. Order 1. ATROPHY. 493 decoctum cinchona?, infusum gentian, comp. vel quassias, or any other agreeable bitter, various formulae of which may be found under the head of Dyspepsia. The carbonate of soda, mixed with ale or porter, will form a pleasant beverage for those who are liable to dyspeptic symptoms and incubus. Persons subject to incubus ought carefully to shun all kinds of food likely to prove flatulent or of difficult digestion, particularly for supper; they should be guilty of no intemperance whatever, and should avoid gloomy contemplations, a sedentary life, and particularly intense study, with late hours. Moreover, they should always have some person to sleep near them, so as to be immediately awoke by their groans and struggles ; for the sooner a person is roused from a parox- ysm of the night-mare the better, as when, in a very high degree, it differs little from a fit of epilepsy. Where medicine is not at hand, a glass of any cordial will frequently dispel flatulence, and prevent the paroxysm of incubus. ———^d^® 9Q 9 9 ®® ^s^"~~—' CLASS III. CACHEXIA, or CACHECTIC DISEASES. A depraved state of the whole, or greater part of the body, with- out any primary febrile or nervous affection, constitutes this class. iiSI»»|^|»l»IC, ORDER I. MARCORES. Emaciation of the whole body is the character of this order. ATROPHIA, or ATROPHY. This disease is marked by a gradual wasting of the body, unac- companied either by a difficulty of breathing, cough, or any evident fever at first, but usually attended with a loss of appetite and im- paired digestion, depression of spirits, and general languor. The causes which commonly give rise to it are. a poor diet, un- Vel, 2. & Ammonia, gr. x. Aq. Cinnam. f. 3*. Tinct. Capsic.f. 3i. Syrup. Crori. f. 3iss. M ft. Haustus. Or, 2. Take Ammonia, ten grains. Cinnamon Water, ten drachms. Tincture of Capsicum, one drachm. Syrup of Saffron, one drachm and a half. Mix them as a draught. 494 CACHEXIA, OR CACHECTIC DISEASES. CUlSS III. wholesome air, excess in venery, scrofulous disposition, fluor albus, severe evacuations, continuing to give suck too long, a free use of spirituous liquors, mental uneasiness, and worms; but it frequently conies on without any evident cause. Young persons of both sexes, who are of a delicate makt, and at the same time grow very fast, are apt to be attacked with this complaint before they arrive at the age of puberty. It is particularly prevalent in large and populous cities, where children are deprived of ready access to exercise in pure air, or where they are confined in crowded school-rooms. Children also who are employed in manufactories, where their occupation and confinement are such as to weaken and enervate them, are very likely to be attacked with it. Emaciation of the body very frequently arises from a morbid state of the mesenteric glands, induced by scrofulous inflammation, to which they appear peculiarly liable. Whatever may be tne effect of diseased mesenteric glands upon the cbyle, we are warranted in assigning this as the most frequent cause of bodily emaciation in children, seeing that the two states are almost invariably associated. Sluggishness, lassitude on the slightest exertion, depravity, and loss of appetite, wasting ofthe muscular flesh, paleness ofthe coun- tenance, with bloating, swelling, and prominence of the belly, oedema of the lower extremities, an irregular and generally costive state of the bowels, a change in the colour and odour of the faeces, and fetid breath, mark the beginning of the disease. When these symptoms have continued for a little time, they are followed by al- ternate paleness and flushing of the countenance, heat, and dryness of the skin, a feeble and quick pulse, thirst, fretfulness, great debi- lity, and disturbed sleep. Atrophy, arise from whatever cause it may, is usually very diffi- cult to cure, and not unfrequently terminates in dropsy. In attempting however to effect this, we should endeavour to find out the cause from which it has originated, and to remove it, if possible. If occasioned by worms, these must be destroyed by tbe vermifuge medicines advised under that particular head ; if by sensual excesses, or the continuing to give suck too long, these must wholly be discontinued; if from severe evacuations, these must be suppressed; if from an impoverished diet and unwholesome air, these must be quickly changed; if from a scrofulous disposition, deobstruerits, purges, and tonics must be had recourse to in due turn ; (see Scrofula) and if from a venereal taint, which is sometimes the case, we must then resort to a use of mercury, with the decoctum *arsje, and other auxiliaries, as recommended under tbe head of Syphilis, together with a milk diet. In all cases of atrophy the patient should make use of food that is nutritive and easy of digestion, and it should be taken frequently, but in a small quantity at a time. He should likewise breathe a Order 1. atrophy. 495 pure, dry, and wholesome air; taking such moderate exercise every day as bis strength will admit, particularly on horseback. To assist the digestive powers it will be proper to put bim under a course of stomachic bitters, cinchona, and chalybeates. Due evacu- ations by stool ought to be strictly attended to. Mild laxatives, repeated at certain intervals, will therefore be necessary. They will preserve the bowels in proper action, carry off faeces which had begun to be offensive and hurtful, and prevent accumulation. Gentle vomitings, with the cupri sulphas, as mentioned under the head of Phthisis Pulmonalis, might possibly, by their stimulus, prove of infinite service. The myrrh mixture, recommended in the cure of the same disease, would be likely to produce a good effect. In this complaint cold bathing will be proper; but the patient should begin with a tepid bath, reducing it gradually to a cool, and at length to a cold temperature. When there is a disposition to oedematous swellings of the legs and feet, we should combine diuretics with whatever tonics we administer, as advised in Anasarca. In children of a scrofulous habit atrophy is often accompanied with an enlargement of the mesenteric glands; and then indiges- tion, costiveness, or purging, irregular appetite, flushed cheeks, or a total loss of colour, impaired strength and spirits, remit- ting fever, and a hard and tumid bejly, with emaciated limbs, prevail. In a general way, the principal indications in such cases are to remove the obstructions in the lymphatic system, and effect a reso- lution of the indurated glands of the mesentery; to carry off the viscid matter; and, lastly, to strengthen the system and esta- blish a good digestion, as well by means of proper diet as by medicines. Among the first, and as general deobstruents, are mercurial and an- timonial remedies, neutral salts, soap, steel, and hemlock, to which perhaps may be added with propriety, frictions to the abdomen, and the employment of a tepid salt water bath. The hydrargyri submu- rias is the best mercurial we can employ, and may be joined with some purgative medicine, such as rhubarb: this combination may be con- tinued in small doses daily, or every other day, till there shall be some favourable change in the feel and size of the belly. When we do not like to have recourse to mercury, we may administer rhubarb, joined with potassae tartras, as a purge. Occasional gentle emetics may be good auxiliaries. The emaciated state to which the patient is generally reduced, even although we should be fortunate enough to remove the ob- struction, will require the aid of tonic remedies. To strengthen the stomach and alimentary canal, and promote a good digestion, the only means by which a nutritious chyle can be obtained, and the body kept in a healthy state, we should have recourse to bitter 496 CACHEXIA, or cachectic diseases. Class III. infusions*, joined with aromatics, cinchona, and steclf. To these may be joined daily frictions of the belly, limbs, and spine. Where the obstructions are removed, the cold bath will be a proper remedy. Where atrophy arises as a consequence of suckling, the curative indications are to restore the wasted strength, to relieve the affection of the lungs, and to quiet or remove the fever. The first point then is, for the woman to avoid the exciting cause, and therefore the child must be weaned immediately: she must live on milk, broths, jellies, sago, blanc-mange, salep, Indian arrow-root, and tapioca, with eggs, and a moderate quantity of animal food for dinner. Wine in modera- tion will likewise be proper. To add to the effects of a restorative diet, a course of the cinchona or other bitters, wilh the sulphuric acid, myrrh, and chalybeates, as advised for dyspepsia, may be entered upon * 1. R Infus. Gentian, f. |iijss. Tinct Cardam. f. ^ss. Potassae Subcarbonat. 3ss. M. Capiat cochl. j. infantis bis terve in die. Vel, 2. Infus. Cinchonae, f. ^ijss. Tinct. Calumb. f. 3iij. Potass® Subcarbonat. 3j. M. Cochl. j. bis in die sumendum. Vel, 3. R Rad. Calumb. Contus. 3»j. Aq. Bullientis, f. |iv. Post horas tres cola, et adde Tinct. Cinnam. C. f. ^ss. Sodas Subcarbonat. 3ss. M. t 4. U Ferri Subcarbonatis, gr. ij. ad. v. Pulv. Calumb. gr. viij. M. ft. Pulvis mane et vespere capiendus. Vel, 5. ft Pulv. Cinchon. gr. x. ad 3ss. Ferri Sulphat. gr. j. ad iij. ft. Pulv. pro dos. bis in die repetendus. ' 1. Take Infusion of Gentian, three onncei and a half. Tincture of Cardamoms, half an ounce. Subcarbonate of Potass, half t drachm. Mix them, and let a child's spoonful be ta- ken twice or thrice a day. Or, 2. Take Infusion of Peruvian Bark, two ounces and a balf. Tincture of Calumba, .three drachms. Subcarbonate of Potass, one scruple Of this mixture a child's spoonful may be taken twice daily. Or, 3. Take Calumba Root, bruised, three drachms. Boiling Water, four ounces. Let them infuse for three hours, strain off the liquor, and add Compound Tincture of Cionamon, half an ounce. Subcarbonate of' Soda, half » drachm. , Mix them. The dose may be the same as of the former. t 4. Take Subcarbonate of Iron, two to five grains. Powder of Calumba, eight grains, Mix them, and let this powder be taken morning and evening. Or, 5. Take Powder of Peruvian Bark, ten grains to half a drachm, *c- cording to the age". Sulphate of Iron, one grain to three. Mix them. This powder may l*e repeated twice a day. Order I. pulmonary consumption. 497 If the affection of the lungs appears to be of an inflammatory na- ture, and marked by hardness ofthe pulse, oppressed breathing, or a fixed pain in some part of the thorax, bleeding to the amount of three or four ounces may be necessary, which ought to be drawn from as near the painful part as possible by means of leeches ; but if none of these symptoms are present, we should be content with applying a succession of blisters about the thorax. Where there is any inflammatory action, the diet must be confined fo vegetables and milk, omitting the cinchona and other medicines, and substituting laxatives, and the saline mixture with nitre, combined with small nauseating doses of tartarized antimony. The fever is to be removed by shortening fhe paroxysms when they come on, and during the intervals by preventing their recur- rences by the means pointed out under the heads of Intermittent and Remittent Fevers. The atrophia ablactatorum belongs to the order of Marcores, but is inserted among the infantile diseases. PHTHISIS, or PULMONARY CONSUMPTION. ^ Pulmonary consumption is accompanied wilh general emacia- tion, debility, pain in the side or chest, some degree of dyspnoea after walking or speaking, and a cough, which usually proves most troublesome towards morning. In an advanced stage, purulent expectoration ensues, with hectic fever and diarrhoea. Pulmonary consumption does not often occur until after the age of puberty, but in some cases it is evidently formed before that period by tubercles arising. Women are more subject to it than men, as well from their going more slightly clad, as from the greater delicacy of their organization. The causes which predispose to this disease are very numerous ; the following are, however, the most general: hereditary disposi- tion ; particular formation of the body, obvious by a long neck, prominent shoulders, and narrow chest; scrofulous diathesis, indi- cated by a fine clear skin, fair hair, delicate rosy complexion, large veins, thick upper lip, a weak voice, and great sensibility : certain diseases, such as catarrh, pneumonic inflammation, hcemoptoe, syphilis, scrofula, srnall-pox, and measles ; particular employments exposing artificers to dust, such as needle pointers*, stone-culters, millers, &c. or to the fumes of metals or minerals under a confined • In the fifth volume of Memoirs ofthe Medical Society, we are informed by Dp. Johnson, that persons employed in the pointing of needles, by dry-grinding them, are quickly affected by pulmonary complaints, such as cough, and purulent and bloody ex- pectoration ; and that they scarcely ever attain the age of forty years. We are also told by Dr. Willan in his Reports, that hair-dressers, bakers, masons, brick-layers, labour- ers, laboratory men, coal-heavers, and chimney-sweepers, are very liable to obstinate pulmonic diseases, as are likewise in an equal degree, the dressers of flax, and feathers, and workmen in the warehouses of leather sellers. Many persons thus engaged struggle w.th a hard tormenting cough until it terminates in consumption, whereas by a timely removal into pure air, and having recourse to a suitable regimen, they might soon have been restored to health 6 63 498 CACHEXIA, OR CACHECTIC DISEASES. . CktSS III and unwholesome air* ; violent passions, exertions, or affections of the mind, as grief, disappointment, anxiety, or close application to study, without using proper exercise ; playing much on wind in- struments ; frequent and excessive debaucheries, late watching, and drinking freely of strong liquors ; great evacuations, as diarrhoea, diabetes, excessive venery, fluor albus, immoderate discharge of the menstrual flux, and the continuing to suckle too long under a debilitated state ; and lastly, the application of cold, either by too quick a change of apparel, keeping on wet clothes, lying in damp beds, or exposing the body too suddenly to cool air, when heated by exercise ; in short, by any thing that gives a considerable check to the perspiration. In enumerating the causes of phthisis, a late writer mentionif, that moist air is a very frequent one ; be supposes it to operate by occasioning general relaxation and debility, and observes, that the frequency ofthe disease in Holland has been attributed to this cause. It has not however been satisfactorily proved that phthisis is really frequent among the Dutch. The re\ erse indeed has been stated ; for Dr. Beddoes, in his Essay on Pulmonary Consumption, quote« Dr. Cogan, a physician who practised many years in Holland, as remarking on the infrequency of coughs and colds in that country, in comparison with England; and consumption has been said to be much more rare in the fenny parts of Lincolnshire than in the high lands in the same county. The more immediate or occasional causes of phthisis are haemop- tysis, pneumonic inflammation proceeding on to suppuration, catarrh, measles, asthma, and tubercles, (which in nineteen cases out* of twenty depend on a scrofulous habit), fhe last of which is by far the most general. The connexion between scrofula and pul- monic consumption is obvious, and generally acknowledged ; the latter being often no more than constitutional symptoms ingrafted upon the scrofulous diathesis. At the time when scrofula disap- pears from the surface ofthe body, it frequently falls upon the lungs. Various causes have indeed been assigned for the increasing prevalence at the present time of this distressing disease in the United Kingdom : and among others, the disuse of wood fires, and the general adoption of mineral coal for fuel, baa of itself been thought sufficient by some persons to account for it. But the great and sudden changes of temperature or variableness to which our climate is subject, ought properly to be considered as the real cause of the frequency and prevalence of this disease; and there is great reason to suspect that the warmth and closeness of our apartments, together with the present scanty, light, and flimsy attire of our modish females, very much increase the liability to this * Mr. Polwhele, in his History of Cornwall, mentions, that the miners there are verj subject to consumption, and that more than one half of their population fall a sacrifice to it, owing, as he supposes, to their working in what are termed damps, in which the air Is mephitic, or unfit for respiration. t See Dr. Wilson's Treatise on Febrile Diseases, vol.iv- Order I pulmonary consumption. 499 complaint. In an economical point of view, as saving an expenditure of fuel the ingenious contrivances of Count Rumford and others un- doubtedly are very efficacious for the purpose; but in the winter, when we leave such apartments to go into the open air, the sudden change of temperature which we experience often amounts to 25 or 30 degrees; the entrance to the lungs and glottis consequently falls into torpor, from the stream of cold air which is constantly passing between them for the purpose of respiration; and when we re-enter our apartments, the blood rushes with violence into these vessels previously rendered torpid by the cold ; and like the pain our hands experience on coming near a fire after being exposed to cold, we feel a sensation of heat about the glands of the throat: this local in- flammation spreads, and we experience all the usual symptoms at- tendant on a recent catarrh. In noticing the causes of the vast prevalence of phthisis pulmo- nalis, 1 think I may put down the increase of scrofula among us, and we therefore meet with more cases of tubercular consumption than of any other kind. The predisposition to scrofula is inherited by children from their parents, and at some period or other of their life the disease shows itself either in inflammation of some gland that suppurates and breaks externally; or in tubercles in the lungs that proceed to suppuration and ulceration, and terminate in consumption. That consumptive mortality has very considerably increased in Great Britain within the last century, cannot be denied; and accor- ding to the calculations of a modern writer* the annual victims to consumption in this island are not less than fifty-five thousand persons out of a population of eleven millions. By attending to the thick purulent expectoration connected with hectic fever, the disease may readily be distinguished from all others. All over the Levant, not only the natives, but also tiie physicians entertain an opinion that phthisis is a disease of a contagious nature; and in the Venetian states there is a law, I understand, which directs the clothes and even furniture of those who have died of consump- tions to be burnt. Under the same idea, it is customary among the Sicilians to desert the consumptive patient, and when he dies, they burn his bed and bed clothes, and well ventilate and fumigate the apartments in which he lay. It does not seem probable, however, that phthisis pulmonalis is infectious, at least it is not regarded so among us at present, although Morgagni, Van Swieten, and of a still later date, Mortonf were of that opinion ; but it often occurs in a family from an exposure to the same occasional causes, or from a similarity of constitution and hereditary predisposition. The only way in which I conceive the disease can be conveyed from one per- son to another, if at all possible, is by sleeping constantly in the same bed with one who labours under it, in its ulcerative stage, accompa-' * See Remarks on the Progressive Increase ef Consumption, ke. by W. Wool- combe, M. D. t SeePhthisolog. lib. ii. cap. 1. 500 cachexia, or cachectic diseases. Class 111. nied with fe.tid expectoration and cadaverous-smelling night-sweat*. and so inhaling his breath. Two or three seemingly well-marked cases of this nature have fallen under my own observation. Respect- ing the question of contagion in this disease, the late Dr. Hebeiden observes*, that he has not seen proof enough to say that the breath of a consumptive person is infectious ; and yet he has seen too much appearance of it to be sure that it is not; for he has observed several die of consumptions, in whom infection seemed to be the most probable origin of their illness, from their having been tbe constant companions, or bedfellows, of consumptive persons. Viewing the subject in this light, it would therefore be advisable to avoid being too closely inmated with patients in the last stage of pulmonary con- sumption. The proximate cause of phthisis is supposed to be an ulcer in the lungs. Climate, occupation, and temperament, will diversify the form of phthisis; but for practical purposes, it may be sufficient to distin- guish carefully between pulmonary consumption which occurs in persons ofthe strumous temperament, and that which attacks consti- tutions of a different description from accidental causes, such as an exposure to cold, or as the consequence of other diseases. The most common and most destructive form of the disease is, the strumous or tubercular phthisis. The incipient symptoms of phthisis will vary with the cause ofthe disease ; but when it arises in persons of a strumous temperament, or from tubercles, it is mostly thus marked : it begins with a short dry cough, that at length becomes habitual, but from which nothing is spit up for some time, except a frothy mucus that seems to proceed from the fauces. The breathing is at the same time somewhat im- peded, and upon the least bodily motion is much hurried; a sense of straitness, with oppression at the chest, is experienced ; the body becomes gradually leaner, and great languor, with indolence, dejec- tion of spirits, and loss of appetite, prevail. In this state the patient frequently continues a considerable length of time, during which he is however more readily affected than usual by slight colds; and upon one or other of these occasions the cough becomes more troublesome and severe, particularly by night,, and is at length attended with an expectoration, which towards morning is more free and copious. By degrees the matter which is expecto- rated becomes more viscid and opaque, and now assumes a greenish colour and purulent appearance, being on many occasions streaked with blood. In some cases a more severe degree of haemoptysis attends, and the patient spits up a considerable quantity of florid frothv blood. The breathing at length becomes more difficult, and the ema- ciation and weakness go on increasing. With these the person * See his Commentaries on the History and Cure of Diseases. Order I. pulmonary consumption. 501 begins to be sensible of a pain in some part of the thorax, which, however, is usually felt at first under the sternum, particularly on coughing. At a more advanced period of the disease a pain is sometimes per- ceived on one side, and at times prevails in so high a degree as to pre- vent the person from lying easily on that side; but it more frequently happens, that it is felt only upon making a full inspiration, or coughing. Even where no pain is felt, it often happens that those who labour under phthisis cannot lie easily on one or other of their sides, without a fit of coughing being excited, or the difficulty of breathing being much increased. At the first commencement of the disease the pulse is often na- tural, or perhaps is soft, small, and a little quicker than usual: but when the symptoms which have bern enumerated have subsisted for any length of time, it then becomes full, hard, and frequent. At the same time the face flushes, particularly after eating; the palms of the bands and soles of the feet are affected with burning heat; the respiration is difficult and laborious, evening exacerbations become obvious, and by degrees the fever assumes the heetic form. This species of fever is evidently of the remittent kind, and has in many cases exacerbations twice every day. The first occurs usually about noon, and a slight remission ensues about five in the afternoon. This last is, however, soon succeeded by another exa- cerbation, which increases gradually until after midnight; but about two o'clock in the morning a remission takes place, becoming more apparent as the morning advances, and in the advanced stage of the disease terminating in a profuse sweat, which however is usually partial. During the exacerbations the patient is very sensible to any coolness of the air, and often complains of a sense of cold, when his skin is, at the same time, preternaturally warm. Of these exacerbations, that of the evening is by far the most consi- derable. From the first appearance ofthe hectic symptoms, the urine is high- coloured, and deposits a copious branny red sediment. The appetite, however, is not greatly impaired, the tongue appears clean, the mouth is usually moist, and the thirst is inconsiderable. As the disease advances, the fauces put on rather an inflamed appearance, and towards the termination are often beset with aphtha*, and the red vessels of the tunica adnata become of a pearly white. During the exacerbations a florid circumscribed redness appears on each cheek; but at other times the face is pale, and the countenance some- what dejected. At the commencement of hectic fever the belly is usually costive; but in the more advanced stages of it a diarrhoea often comes on, and this continues to recur frequently during the remainder of the disease : colliquative sweats likewise break out, and these alternate with each other, and induce vast debility. The degree of heat in which the patient is kept has often a great effect on the diarrhoea; 302 cachexia, or cachectic diseases. Class III. for by exposing him to cool air in the morning, the sweat may be much diminished, but the diarrhoea will be increased ; and on the other hand, if the diarrhoea be relieved by opiates and astringents, the sweating will be aggravated: thus they frequently alternate for a long time, bu! in a few instances they are both severe at once. In the last stage of phthisis the emaciation is so great that the patient has the appearance of a walking skeleton; his countenance is altered, his cheek bones are prominent, his eyes look hollow and languid, his hair falls off, his nails are of a livid colour, and much incurvated, and his feet and ankles are affected with cedematous swellings. To the end of the disease the senses remain entire, arid tbe mind is confident and full of hope. It is indeed a happy circumstance attendant on phthisis, that those who labour under it are seldom apprehensive or aware of any danger; and it is no uncommon occurrence to meet with persons labouring under its most advanced stage, flattering themselves with a speedy recovery, and forming distant projects under that vain hope. Shortly before death the extremities become cold. In some cases a delirium precedes that event, and continues until life is extin- guished. The cause of hectic fever is generally supposed to be the absorption of vitiated purulency, but possibly it may proceed from other causes. It appears, however, that hectic fever generally attends an extensive suppuration, and it is of little consequence whether it be occasioned by the absorption of pus, or by the inflammation which precedes the suppuration. As an expectoration of mucus from the lungs may possibly be mis- taken for purulent matter, and may thereby give us reason to suspect that the patient labours under a confirmed phthisis, when he really does not, it may not be amiss to point out a sure criterion, by which we shall always be able to distinguish mucus from pus. The physical world are indebted to the late Mr. Charles Darwin for the discovery, who has directed the experiment to be made in the following man- ner :— . Let the expectorated matter be dissolved in sulphuric acid ana in caustic lixivium, and add pure water to both solutions. If there is a fair precipitation in each, it is a certain sign of the presence of pus; but if there is not a precipitation in either, it is certainly mucus. The oxymurias hydrargyri he found to coagulate mucus, but not pus. Sir Everard Home, in his-Dissertation on tbe Properties of Pus, informs us also of a decisive mode of distinguishing accurately be- tween this and animal mucus. Pus, he observes, is of the consistence of cream, its colour is whitish, and it has a mawkish taste. When cold, is inodorous; when warm, it has a peculiar smell. Examined by the microscope, it consists of semi-opaque globules, and a transparent colourless fluid, which is coagulated by muriate of ammonia. Pus may be Order I pulmonary consumption. 503 evaporated to dryness without coagulating. Its specific gravity is greater than that of water. It does not putrefy readily; nor is it easily diffused in cold water, but in warm water it is speedily dif- fused, and remains so after it cools. Animal mucus, and all chemi- cal combinations of animal substances, appear in the microscope to be made up of flakes. This property was first noticed by the late Mr. John Hunter. Pulmonary consumption is in every case to be considered as attended with much danger; but it is more so when it proceeds from tubercles than when it arises in consequence either of haemoptysis, or pneumonic suppuration. In the last instance the risk will be greater where the abscess breaks inwardly, and gives rise to em- pyema, than when its contents are discharged by the mouth. Even cases of this nature have nevertheless been known to terminate in immediate death. The impending danger is generally to be judged of, however, by the violence ofthe hectic symptoms ; but more par- ticularly by the fetor of the expectoration, the degree of emaciation and debility, the colliquative sweats, oedema of the legs, aphthae, and diarrhoea. An insulated ulcer of the lungs, whether arising from inflamma- tion of the bronchial membrane, the rupture of a blood vessel, or deep seated suppuration, may, and does indeed sometimes, even under circumstances apparently hopeless, admit of a cure ; but that a recovery can be permanently established when the substance of the lungs is studded by tubercles in a state of suppuration, or pro- ceeding rapidly thereto, would require more confidence in the power of nature and art than tbey are entitled to. The unkindly nature and secretion of these ulcers, their number, their inaccessibility to any direct application, the impossibility of excluding the atmos- pheric air from them, or obviating its influence, and lastly, of preserving the morbid lungs in a state of quietude, constitute a chain of cir- cumstances through which the arm of science, however ably directed, will never break. Phthisis pulmonalis has in many cases been found to be con- siderably retarded in its progress by pregnancy, but when this is over, is hastened to a rapid termination; and in a few has been alleviated by an attack of mania. Some people get a little better in summer, and relapse in winter. The morbid appearance most frequently to be met with on the dissections of those who die of phthisis, is the existence of tubercles in the cellular substance of the lungs. These are small tumours, which have the appearance of indurated glands, are of different sizes, and are often found in clusters. Their firmness is usually in proportion to their size : and when laid open in this state, they are of a white colour, and of a consistence nearly approaching to car- tilage. Although indolent at first, they at length become inflamed, and are at last changed into little abscesses, or vomicae, which break- ing, and pouring their contents into the bronchiae, give rise to puru- lent expectoration, and thus lay the foundation of phthisis. 304 CACHEXIA, OR CACHECTIC DISEASES. ClttSS 111 Such tubercles, or vomicae, are most usually situated at the upper and back part of the lungs; but in some instances tliey occupy the outer part, and then adhesions to the pleura are often formed. When the disease is partial, only about a fourth of the upper and posterior part of the lungs is usually found diseased; but in some cases life has been protracted till not one twentieth part of them ap- peared, on dissection, fit for performing their function. A singular observation, confirmed by the morbid collections of anatomists, is that the left lobe is much oftener affected than the right. Experience having taught that it is only in the early stage of phthi- sis that remedies are likely to be employed with success, we ought by all means to pay the greatest attention to the first appearance of the symptoms. Where a spitting of blood occurs in a person of a phthisical habit, or in one born of phthisical parents, we are to endeavour by every possible means to prevent ulceration from taking place, which is to be done by employing the mpans for moderating the hemorrhage, and likewise preventing any future return of it, as advised under the head of Haemoptysis ; and these means and precautions ought to be continued, and extended beyond the period at which phthisis proves chiefly fatal, which is usually between the twentieth and thirtieth year of his age. The phthisis which ensues from pulmonic inflammation proceed- ing on to suppuration, is only to be prevented by pursuing the means that will procure a resolution of sucb inflammation. Of these particular mention has been made in the cure of peripneumony, to which head I beg leave to refer the reader. When a person of a phthisical habit, or born of parents who have had the same disposition, is about the age of twenty, or sooner, attacked in the spring of the year, or summer, with the symptoms which have been enumerated in the first stage ofthe disease, and this even in the very slightest degree, we have just grounds to apprehend that tubercles have either formed, or are about to form, in the lungs; in such a case we are to exert our utmost endeavours to prevent their formation, and consequent inflammation and suppuration ; foi by so doing the disease may be kept under for many years, if not entirely subdued. To effect these purposes, we must have recourse to a strict pur- suance of the antiphlogistic plan, such as bleeding from the arm, as well as topically from the chest, by means either of leeches or cup- ping, keeping the body open with gentle laxatives, and the use of a spare regimen. The propriety of the first of these remedies, viz. blood-letting, has, however, of late years been much disputed, and it has indeed fallen a good deal into discredit. Blood-letting, and the rest ofthe antiphlogistic plan, may formerly have been carried much too far in many cases, I readily admit; but certain il is, that for some years past the opposite system has been carried to an equally hurtful ex- cess. Order I. PULMONARY CONSUMPTION. 505 In the inflammatory and first stage of phthisis, where the patient complains of a difficulty of breathing with pain in his breast or side, has hot restless nights, with a hard contracted pulse, and a cough, there can be no doubt but that bleeding may be of infinite service, provided the quantify taken away bears a just proportion to his strength and habit, and to the severity ofthe symptoms ; but having recourse to it under the stage of ulceration, where the expecto- ration has become purulent, and where great debility prevails, with night-sweats, and repeating the operation frequently, even in small quantities at a time, as was formerly practised, must evidently prove highly injurious. At an early period, we have in view to procure a resolution of the inflamed tubercles ; but in confirmed phthisis this hope no longer exists. During the first and inflammatory stage of the disease it will be advisable, in compliance with the antiphlogistic plan, to employ gentle laxatives, should the bowels be costive. When there is any febrile heat, with a cough or pain in the chest, we may give diaphoretics, such as small doses of tartarized anti- mony or the pulvis antimonialis, repeated three or four times a day, together with the saline mixture and nitre. It will be necessary to pay a proper attention fo regimen. The diet should consist of such things as are nutritive and easy of diges- tion ; as preparations of the different farinacea with milk, most kinds of vegetables and fruits, poached eggs, light puddings, cus- tards, jellies, and animal broths. The different kinds of shell-fish (but more particularly oysters, lobsters, crabs, prawns, and cray- fish) may also be proper. Where the symptoms are but trifling, and fhe patient cannot well refrain from animal food, he may then. be allowed such as is ofthe highest nature, and most easily digested. All fermented liquors, but more particularly spirituous ones, are to be avoided. Milk of itself is a valuable remedy in phthisis. That ofthe ass is usually preferred to any other ; but it cannot always be obtained: besides, it is generally taken in a very small quantity; whereas, to produce any effect, it ought to make a considerable part of the patient's diet. Instead of taking half an English pint night and morning only, as is usually practised by phthisical patients, they ought fo take it at least four times a day, eating a little bread with if, so as to make it a kind of meal. If the milk should happen to purge, it may be mixed with a little of the powder of prepared chalk, or with a small quantity of the confectio rosae Gallicae. The best effects have been known to proceed from a long-conti^ nued use of women's milk, which is indeed the best of all others for consumptive persons : but as it is not to be obtained in a sufficient quantify, we are generally obliged to substitute either asses' milk, or that of cows. The milk of cows, although not so easily digested as that of asses 64 606 CACHEXIA, OR CACHECTIC DISEASES. CIOSS 111 or mares, may be rendered much lighter by allowing it to stand for some time, and then taking off the cream. In cases of incipient phthisis, a free use of butter-milk has fre- quently been attended with much advantage. In order to make it sit easy on the stomach, it should at first be taken sparingly, and the quantity gradually be increased. To assist in preventing an inflammation of the* tubercles in the hings, it will be necessary that the patient avoids any particular irritation of the part affected, which may arise from the violent exercise of respiration, as in singing, playing on wind instruments, or making long and loud declamations : he is likewise to avoid going info crowded rooms, the air of which, from being inhaled by f many different people, becomes at length very unfit for respiration, particularly in those whose lungs are already in a weak and irrita- ble state ; he is to refrain from placing his body in such a position, either in reading, writing, or following his ordinary occupation in rife, as that the capacity of the thorax shall be the least straitened in consequence of pressure against it : he is to shun all kinds of bodily exercise which require much exertion, and in particular, he is carefully to guard against any exposure to cold, which never fails to determine a greater quantity of blood to the lungs and other internal parts than what is natural. With the view of guarding against any diminution of cutaneous perspiration, in consequence of the application to cold, he should wear a flannel waistcoat next to his skin, together with sliders of the same, and stockings of cotfon or worsted. Such a dress may be found a little irksome at first; but time soon reconciles it, and in the end renders it truly desirable and comfortable. Where the patient cannot bear flannel next the skin, he may make trial of calico, which will keep up a more equable tempera- ture on the surface of the body than linen, and guard against fhe action of external cold. He is by all means to avoid exposing himself to the piercing north-east winds of this country. In our climate, tubercles are evidently induced and accelerated in winter, and retarded in summer. A person gets a dry cough in winter or spring, which goes off as the summer advances, and wai regarded! as a catarrh, but tubercles were forming: if therefore such a person could be removed to a warm elimate before the winter comes on, he might escape an attack at this period, and by conti- nuing there for a few years, may be perfectly recovered. Going to a warm climate is not merely avoiding what might be hurtful; it is applying a remedy which has the best chance to prove bene- ficial. It may justly be admitted, that the cold and variable temperature of the winters in England is the great source of phthisis in this country, and when the disorder is once formed, greatly contributes to its fatal termination ; and that a warm and equable temperature in some measure prevents the formation of the disease, and when Order I. pulmonary consumption. 507 it has taken place in only a slight degree, possesses some power in retarding its progress. In tbe early stage of consumption, that is to say, when suppuration and ulceration have not yet taken place, it appears from the report of Sir James Macgregor, that tbe disease was checked by the climate of the Peninsula* among those of the army affected with phthisis; but that when suppuration and ulceration had taken place, it run even a more rapid progress than in England, and the same remark has been made in regard to the East and West Indies. If the patient's circumstances will admit of his removing in due time from this climate to one in which the temperature is warm during winter, he ought to comply therewith. The islands of Madeira, Malta, Lisbon, Italy, or the south of France, have been recommended as proper places. To persons liable to catarrhal or consumptive complaints, the most important properties ofthe climates of other countries are warmth and equability of temperature, especially in the winter months. The islands of Madeira and Malta present, numerically, a mean tempera- ture for the winter months, as favourable for an invalid as can possibly be desired. A female writerf of some celebrity informs us, she is convinced by experience that the lives of many consumptive patients might be saved were they sent by sea to Leghorn, advised to winter at Pisa, caution- ed against travelling much by land, and above all things, interdicted from crossing the Apennine and Alps, which people very frequently do, in order to spend the summer months in Swisserland, one of the most unequal climates in Europe. She thinks that in pulmonary complaints, Pisa is entitled to a decided preference over Nice, Massa, Florence, Rome, or Naples, or indeed to any other place in Europe, from the beginning of October till tbe end of April. She was advised to travel over-land to Italy, and therefore she passed over to France. Nice was recommended to her as the best winter climate, and she therefore spent many months in that city : but experience soon con- vinced her that she might have adopted a more eligible plan ; for long journeys over-land on the continent are to consumptive persons dangerous experiments, owing to the accommodations being so very indifferent that it is scarcely possible for an invalid to sleep at an inn out of a great town without suffering. To consumptive persons and invalids in general, she therefore recommends the going to Italy by sea in a vessel bound to Leghorn, and so wintering at Pisa. When the patienfs circumstances or business will not admit of his removing to a more temperate climate, he must endeavour to pass his winter in some place which is dry and well sheltered from cold bleak winds, where the air is free and pure, and the soil of a ♦See his Sketch of the Medical History ofthe British Armies in the Peninsula of >ain and Portugal, in vol. vi.of the Medico-Cairurgical Transactions. t See Stark's Letters, vol. ii. p. 261. 508 CACHEXIA, OR CACHECTIC DISEASES. ClttSS HI. gravelly nature. The mild and sheltered vales of Devonshire, bat more particularly Sidmouth, and Penzance in Cornwall, offer desire* ble situations of this nature. In the summer the person may remove to a more elevated situation. With the enjoyment of a free and pure air, he should take daily moderate exercise either in a carriage or on horseback, but more par- ticularly the latter. By taking it in progressive journeys through different parts ofthe country in fair and settled weather, the efficacy ofthe remedy, great as it may be at other times, would be much in- creased ; for in such a tour the mind would find an ample store of amusement, ami be diverted mm any train of unpleasant thought. The pursuit of some object at the same time might probably add to the effect. All violent exertions, such as dancing, he., liberties in diet, and going to crowded public places, are most cautiously to be avoided. If the disease has made considerable progress, and the patient is thereby prevented from exposing himself out of doors during the winter and spring, he must be contented to live in chambers subject to very little change from tbe atmosphere, and heated from 62 to 65 degrees, which temperature will be most suitable. A stove may be employed for the.purpose, and a preference should be given to one of porcelain (like the Gorman and Russian stove), over one of iron, as a very unpleasant smell is occasioned by the latter. Dr. Buxton* is of opinion that in the common shop stove, or ironing stove used in laundries, >ve possess all that is necessary for the purpose of the propo- sed remedy. Under the principle of amusing the mind, and at the same time of having a desirable end to be obtained, many phthisical patients are yearly sent to the Hot-wells at Bristol. The waters of these wells have long been extolled for their supposed good effect in consumptive cases ; but in my humble opinion they are by no means deserving of tbe credit ascribed to *hem, as, during a residence of some time at and near these wells, I cannot charge my memory with a single in- stance where any person labouring under a confirmed phthisis expe- rienced much relief from their use alone. That many persons who have been of a phthisical habit have derived benefit from resorting to the Bristol Hot-wells, I am ready to admit; but this should not be attributed wholly to the waters. The horse exercise, which is taken daily by such patients, on a fine airy down, where most beautiful views and rich landscapes are presented to the eye on every side; the salubrity of the air; the healthfulness of the situation, and the frequent attendance on the different amusements which are furnished at these wells, and those at Cliftm, prove beyond all doubt most powerful auxiliaries. Places of public resort are food to the mind of convalescents, and serve to keep it in the same active state that exercise does the body, preventing thereby that indulgence in gloomy reflection, to which * See his Essayou the Use of a regulated Temperature in WinterCough and Consumption. Order I PULMONARY CONSUMPTION. 509 the want of cheerful scenes and agreeable company is apt to give rise in those who are in an indifferent state of health. The opinion which I have here offered on the efficacy of the Bristol Hot-wells waters, seems however by no means to accord with that entertained of them by a gentleman who some time ago pub- lished a dissertation on their chemical and medical properties*. On the subject of pulmonary consumption, he observes, that the utility of a journey to Bristol, undertaken while a cure is yet practicable, is de- monstrated by hundreds of examples annually, where the disease is prevented in many, and suspended or mitigated in others. I agree, however, with Dr. Beddoesf, that tbe fine things which medical men put into their pamphlets about the water of the places where they constantly or occasionally reside, are to be received with a large share or weight of allowance. Nay, I am decidedly of opinion, that at least three-fourths of the cures attributed to all mineral waters, ought rather to be placed to the account of a difference in air, ex- ercise, diet, amusement of the mind, and tbe regulations productive of greater temperance, than to any salutary or efficacious properties in the waters themselves. Respecting the composition of the Bristol water, it appears, from Dr. Carrick's experiments, to consist ofthe following principles : a wine gallon of 231 inches is impregnated with Muriated magnesia----------------7 1-4 grains Muriated soda---------------- — 4 Vitriolated soda----------------11 1-4 Vitriolated lime-------------------11 3-4 Carbonated lime---------------13 1-2 Making together of solid matter 47 3-4 grains. Carbonic acid gas..........30 cubic inches Respirable air---------------------3 Making together of gaseous fluids 33 cubic inches. On the supposed virtues of this water in phthisis, there has in- deed prevailed much diversity of opinion, and many have denied that it possesses any peculiar power superior to simple water. Dr. Saun- dersf thinks, that although it is by no means a cure for consumption, still it will be found to alleviate some of the most harassing symp- toms in this formidable disease. He observes, it is particularly effi- cacious in moderating tbe thirst, the drv burning heat of the hands and feet, the partial night-sweats, and the symptoms that are pecu- liarly hectical; and thus in the early stages of phthisis it may proba- bly contribute to a re-establishment of health; and even in the D!,S?efIDr Camck's Dissertation on the Chemical and Medical properties of the Bristol Hot-well Water. t see his Manual of Health, p. 337. t See his Treatise on Mineral Waters, p. 125. 510 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III latter periods it may considerably relieve, when the prospect of a cure has long been doubtful, if not hopeless. Short voyages on sea have been much recommended to consump- tive persons, under the idea that sailing is of all modes of exercise or conveyance the smoothest and ra »st constant. The good effects produced by sea voyages seem to depend, however, chiefly on the purity of the air, assisted somewhat probably by the occasional vomiting, which persons unaccustomed to be on board of a ship usually experience. Swinging is another species of exercise much recommended to phthisical patients. The use of what are called dumb bells might perhaps likewise prove serviceable. To remove inflammation from the lungs, and prevent the tuber- cles from proceeding to suppuration, the application of a blister will be highly proper; and that it may be rendered perpetual, it should be shifted from the chest to the side, and from the side to the chest, whenever the discharge ceases to be plentiful. Issues or a seton are frequently inserted in the side, or between the scapulae; and in cases of incipient phthisis sometimes produce a good effect. Topical bleedings, by means of leeches and cupping, might likewise be resorted to with advantage in this stage of the disease. Both blisters and topical bleedings will afford considerable relief where there is a fixed pain in the breast or sides, which is increased upon coughing. Previously to the tubercles becoming much inflamed, perhaps they may be relieved, or be entirely removed by a solution of the muriate of lime, beginning with a drachm a day, and gradually increasing the dose. On the recommendation of Dr. Beddoes, factitious airs some years back were employed in the early stage of phthisis, and as auxiliaries, they undoubtedly proved serviceable ; but from their virtues having been overrated, and an almost sole dependance placed upon them in many cases, they fell into disrepute, and other remedies have been substituted in a very rapid succession. Oxygen reduced by an addi- tion of hydrogen, and other aerial fluids, with carbonic acid gas, are those which were chiefly used. With these the air of a room may easily be impregnated by means of the apparatus invented by Mr. Watt, of Birmingham. Where there is any difficulty in procuring the proper apparatus and materials, so as to prevent the possibility of adopting the most expeditious, or, upon the whole, the most advantageous methods of procuring the aerial fluids, the practitioner will do well in consulting Tiberius Cavallo's Essay* on the Medical Properties of Factitious Airs, in which a substitute is recommended. The following are his observations on the gases, and they are high- ly judicious:— " In the use of oxygen," he says, " we have a singular stimulus, ----,----_---------------------------------------;-------f-- " * See chapter the first Order I. PULMONARY CONSUMPTION. 511 which admits of its being rendered more or less active by dilution with various proportions of common air. In its pure or nearly pure state, it is a powerful exciter of suspended animation, and when di- luted #with a considerable quantity of common air, it is a gentle stimulus, which, by invigorating the various parts of the animal body, by communicating firmness to the solids and energy to the fluids, does frequently obliterate the causes of morbid habits. " The use of azotic gas, and of the various species of hydrogen- gas, produces a diminution of the irritability of the animal fibre to any degree, and hence it becomes useful in a variety of those disorders which depend on an increased irritability, such as inflam- mations, coughs, spasms, &c. In the use of carbonic acid gas we have a powerful antiseptic, and, in certain cases, a solvent of con- siderable efficacy. "The use of pure oxygen air is confined to the purpose of exci- ting the dormant powers of suspended animation, and it is therefore to be administered to children born apparently dead or overlaid ; to persons suffocated by drowning, by steam of charcoal, by foul air, &c. whenever the circumstances ofthe case may indicate a possibility of recovery. " Those cases excepted, the respiration of pure or nearly pure oxygen air is almost always attended with unfavourable symptoms, such as a preternatural heat, especially about the region of the lungs ; a quickened and feverish pulsation, inflammation, he. And these symptoms come on after a longer or shorter use of the oxygen air, according to the particular constitution of the experimenter, and the purity of the gas. " But when the oxygen is diluted with much common air, viz. in the proportion of one to eight, and even as far as one to twenty, it then is a safe and useful remedy, whose principal action consists in giving tone, elasticity, and consistence to the fluid as well as to the solid parts of the body, and of course it promotes all the natural consequences of those effects, viz. it quickens languid circulation, it strengthens the organs of digestion, promotes secretions, invigorates debilitated habits, and assists nature in throwing off bad humours, and other lurking causes of diseases." Our author concludes with the following observations :— " After a careful consideration of the preceding general and com- prehensive prospect of tbe medicinal use and efficacy of the aerial fluids, we may easily regulate the measure of our hopes by tbe stand- ard of reason and experience. The idea of finding in them a remedy capable of curing consumptions in their various stages must be laid aside, and the hope of healing all sorts of internal ulcers will naturally vanish. A use of reduced atmosphere does undoubt- edly diminish tbe irritability of the fibre, and a diminution of irritability favours the healing of certain ulcers, but by no means of them all: nay, in some cases it will even produce the contrary effect. The* use of oxygen air has been found advantageous in many of those disorders that are called nervous, and it has un- 512 CACHEXIA, OR CACHECTIC DISEASES. CklSS III doubtedly strengthened and invigorated debilitated or emaciated habits; but it would be absurd to expect that it should prove bene- ficial in all cases of emaciation and debility, since those visible effects are often produced by causes that may be rather fomented" than checked by the use of oxygen air." The only remark I have to add to these judicious observations, now fully established by the repeated trials of others, is, that the confidence placed by certain practitioners in the efficacy of artificial atmospheres seems entirely to be done away. The vapour of spiritus aetheris sulphurici dropped into warm water, has, in some cases of phthisis pulmonalis, been inhaled with considerable advantage to the patient. Earth-bathing, and stabling with cows, have been recommended by Dr. Beddoes in cases of incipient phthisis. Having had no experience of these remedies, I must beg leave to pass them over, it being sufficient that I have mentioned them. The former of these, we are given to understand by Van Swieten, in his Com- mentaries of Boerhaave, is much adopted in Granada, Andalusia, and other parts of Spain, in the cure of phthisis pulmonalis, and was first used in this country by the late well-known empiric Dr. Graham. One of the latest remedies which has been introduced into prac- tice for the cure of phthisis, is the digitalis purpurea. To speak properly, it is however rather the revival of an old remedy Jong laid aside, than a new one. Concerning the virtues and mode of operation of this medicine, a variety of opinions have been enter- tained ; some attributing to it the power of diminishing secretion, and of exciting the action of the absorbents; and others again looking upon it as only useful from the power it possesses of lessening the action of the heart and arteries. Foxglove has indeed be<^n generally considered as a direct sedative ; and by this power, producing a rapid diminution in the frequency of arterial pulsation. A modern writer* contends, however, that it is a powerful stimu- lant; that it increases the strength and frequency of the pulsetand if continued sufficiently long, produces flushed face, headach, hot skin, restlessness, and other symptoms of febrile action. These are effects which indeed we have never before heard attributed to this drug, being diametrically opposite to what they are by all otheB believed to be. The chief advocates of foxglovef are men of considerable emi- nence in their profession, and their report is certainly highly in it» favour. They seem however to be too confident of having discovered a specific (if I may be allowed the term) for this dreadful disease; and until it is determined that the digitalis alone, and not conjointly with other medicines, has uniformly cured pulmonary consumption, and that it produces effects on the human system * See Dr. James Saunders on Fulmonary Consumption. t Dr. Fowler, of Stafford, Dr. Drake, Dr. Beddoes, Dr. Mossman Order I PULMONARY CONSUMPTION. 513 different from all others of tbe same class, we are by no means author- ised to consider it in so very favourable a light. Dr. Beddoes, in his Essay on Consumptions, afterhavmg informed us that his own experience has fully verified the observations of the two first gentlemen mentioned in the preceding page, uses the follow- ing forcible words:— " I daily see many patients in pulmonary consumption advancing towards recovery with so firm a pace, that I hope consumption will henceforward as regularly be cured by the foxglove, as ague by the Peruvian bark. Could we obtain a single auxiliary for foxglove, such as we have in many instances for the bark, I should expect that not one case in five would terminate as ninety-nine in an hundred have hitherto terminated. But I believe a majority of cases will yield to simple fox- glove. It is evident that no new cases need be suffered to advance beyond the first stage, without the application of this medicine, and few into it." Dr. Drake speaks of it thus*: {: It has for several years been given in pulmonary hemorrhage with effect, and certainly will con- tinue to be, with the intelligent, whatever may be the result of its trial in phthisis. I am happy however to say, that the success which has hitherto attended the exhibition of the digitalis in phthisis has been very considerable; several patients, in its confirmed state, have been cured by this remedy; almost all have been relieved ; life has even been protracted by it; and when death has taken place, whilst tbe system was under its influence, it has been free from pain or struggle; my expectations have been answered, and Dr. Fowler, I understand, from further trials, is fixed in his former favourable opinion." Dr. Mossman saysf, " I have prescribed the digitalis very exten- sively for upwards of twelve months, and during the last six of that period I have had very ample experience of its powers. I am now fully persuaded, that by a judicious management of the plant, various- ly combined, I can obviate pneumonic inflammation with as much certainty as I can arrest the progress of an intermittent fever by means of the bark of cinchona. Again, I am persuaded, that if pulmonary consumption be divided into four stages, the digitalis will very certain- ly cure the three first, and as certainly alleviate the distressing symp- toms of the last." In the primary stages of the complaint, Dr. Mossman is of opinion that this remedy approximates to a specific. He thinks that it possesses in itself J a power directly sedative, and that the application of this power, by lessening the irritability ofthe muscular fibre, will explain its salutary operation in the cure of pulmonary consumption. From the observations of all these gentlemen, as well as from • See Medical and Physical Journal, vol. ii. p. 418. t See hi? Essay on Glandular Consumption. t Ibid. voK iv. p. 309. 66 514 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III those of other physicians*, the digitalis must certainly be admitted to be a very powerful remedy in phthisis; and although it is by no means to be regarded as a specific, still it must be allowed to have, in many instances, procured the most beneficial effects. In its early stage, when tbe powers of the system are not broken down, it promises to be productive of very essential service, by mode- rating the pulse, and by diminishing the hectic fever, tbe most distress- ing of all the symptoms, and that which seems to hurry on the patient to a fatal termination. After the purulent stage is completely formed, it has appeared to me however not to produce any considerable or permanent good effects; but even in this stage of phthisis it has been thought by some physicians to alleviate the sufferings of the patient. It does not seem that any evil of magnitude can arise from its use in tubercular consumption, if properly exhibited; that is to say, if givei in moderate doses about twice a day, and increased in a gradual man- ner until it produces a sensible effect on the system. The most unpleasant symptoms consequent on a liberal and long- continued use of this medicine, are vertigo, nausea, and sickness. In one case where the stomach and bead were soon disordered by even a small dose, we are informed by Dr. Drakej-, that a little lemon-juice produced an immediate good effect, removing both the sickness and vertigo, and enabling him to throw in a larger quantity of the tinc- ture with ease and safety. A few drops of tinct. opii with each dose of the tincture of digitalis, he mentions, will sometimes prevent the rejection of the latter from the stomach ; but he has not found it very effectual in removing the sensation of languor, or the affection ofthe head. The preparation of the digitalis used by the late Dr. Fowler, of Stafford, is a decoctionj, of which he directed his patients to take half an ounce, twice, thrice, and, in a few instances, four times in the twenty-four hours. That used by Dr. Drake was the saturated tine- * See Dr. Kinglake's Remarks on the Effects of Digitalis, vol. iii. p. 120, ofthe Medi cal and Physical Journal. t SeeMedical and Physieal Journal, vol. ii. p. 419. t 1. ft Fol Digital. Purpur. Recent. §ij Coque ex Aq. Purae, Oj. ad Colat. |vijss. el adde Tinct. Cardamom, f. |ss. M. Vel, 2. ft Fol. Digitalis Purp. Siccat. 3j- Infunde in Aq. Pur. Bullient. f. ?viij. et post horam cola. ft. Infusum. Dos. f. ^ss.adf. 3vj. X 1. Take Fresh Leaves of Purple Fo* glove, two ounces. Pure Water, one pint. Boil it down to seven ounces and a half Strain off the liquor, and add Tincture of Cardamoms, half an ounce. Mix them. Or, 2. Take Dry Foxglove Leaves, one drachm. Boiling Water, eight ounces. Infuse them for an hour, then strain off the liquor. The dose of this may be from half an oance to six drachms. Order I PULMONARY CONSUMPTION. 515 ture, in tbe proportion of five ounces of proof spirit to one ounce of the leaves coarsely powdered, without any dilution of the colour or diminution of strength or tastf. Of this saturated tincture he at first gave his patients from fifteen to twenty drops twice a day, which, in some cases, he gradually increased to ninety or an hundred drops with safety, even in patients greatly debilitated, before either sickness or irregularity of tbe circulation took place. Dr. M'Lean, of Sudbury, in Suffolk, is another gentleman who has favoured us with his sentiments on the foxglove ; and although he does not speak of it in such high terms as those of whom I have made mention in the preceding pages, and allows its powers to be limited even in the very early stages, still he is ready to acknowledge that he found it a valuable remedy in consumption*. He says, " It will sometimes cure when the most approved remedies fail. When of itself it is insufficient to subdue the disease, it will prove a valuable auxiliary to other means. It has always with me quieted and soothed tbe sufferings of tbe patient more or less; and where it ultimately failed, it lengthened the duration of life, and smoothed the avenues to death." He goes on with observing, " This is all I apprehend it will be found capable of performing; but this is doing a great deal. Those who expeot wonders from it, or that it will in general cure consumption, will be disappointed." The preparation of the digitalis, recommended and used by Dr. M'Lean, is that of the tincture made according to the formulaef here advised ; but he gives the preference to the Jast, as having the plant in its perfect state. He begins with from ten to fifteen drops three times a day, increasing two drops every second day, until the habit feels its influence. He then desists, and afterwards dimi- nishes in the same gradual manner, or augments the dose according to the effect. By these means, he observes, the body may, with the greatest safety, be kept under its influence for weeks, and even months. From Dr. M'Lean's report it appears, however, that he never was able to exceed a greater dose than thirty drops, repeated three times a day. With respect to the supposed mode of action of the digitalis, instead of allowing, with Doctors Darwin, Fowler, and Drake, that its good effects depend always upon its power of diminishing secre- tion, and promoting pulmonary absorption, he observes, that it * See Medical and Physical Journal, vol. ii. p. 117. 13. ft Folior. Digital. Purp. exsic. ?j. Spirit. Ten. f. |viij. M. Digere leni calore per dies septem,dein cofa. Vel, 4. ft Folior. Digital. Purpur. recent. ?iv. Spir. Rectif f §v. M. Digere per dies septem leni calore, dein cola. t 3. Take dry Leaves of Purple Foxglove, one ounce. Proof Spirit, eight ounces. Let them stand in a warm place for seven days, theu strain off the liquor. Or, 4. Take fresh leaves of purple Foxglove, four ounces. Rectified Spirit, five ounces. Let them stand for seven days in a gentle warmth, then strain off the liquor- 516 CACHEXIA, OR CACHECTIC DISEASES. ClOSS IIJ. is equally, and indeed more efficacious in cases where there is no increase of mucus or pus. He attributes the good effects of the remedy in question to its power of correcting the diseased condition of the whole frame, and the train of morbid phenomena resulting from it. His words are: " It is to these I have been disposed to attribute, in a great degree, its salutary effects in this deplorable malady. If it frequently possesses such a control over the heart as to reduce its contractions from 120, and even 140, to. fifty in a minute; if it allays, as it does in a most extraordinary manner, the cough and irritation of the lungs, and indeed of every part, the advantages thence resulting will be incalculable. The vessels ofthe diseased lungs will be placed in a condition of secreting bland healthy fluids ; every organ in a state of performing its healthy func- tions ; and thus the unison and harmony which constitute the healthy standard will be established throughout the body." In opposition to the theories of Doctors Drake and Fowler, and to that of Dr. M'Lean, with respect to the mode of action of tbe digitalis, there are some practiiionerswho allow of its having no other powers than those of a sedative nature. This opinion seems by no means to be well founded. The modus operandi of this plant does not seem however to be clearly understood as yet. Let its powers depend upon what they may,, certain it is that its success is proportioned to its early exhibition; and that therefore in every case where the disease arises in a phthisical habit, or is dearly marked, it ought to be had recourse to without any further loss of time. As the saturated tincture, recommended by Dr. M'Lean, appears to be its best preparation, we should give it tbe preference. In administering foxglove it will be necessary to attend to tbe state ofthe pulse under different positions of the body; for it appears by the report of some physicians, that there is a considerable differ- ence of its velocity in the erect and recumbent postures. A case is recorded in the third volume of the Edinburgh Medical Journal, page 271, in which, after taking this medicine, the pulse was not lessened in frequency when the patient stood erect, being upwards of an hundred. When he sat down it fell considerably, and when lying on his back it fell much mure. When sitting it was reduced to seven- ty-five, and when lying to forty. The experiment was repeated many times, and always with the same effect. The like singularity is no- ticed by Dr. Hamilton in his Treatise on Digitalis. Hemlock is a remedy which has been much recommended in glan- dular affections. As a narcotic it may be useful in some cases of tu- bercular consumption, but opium most likely will answer this purpose better. It may be given, conjoined with myrrh, in the form of pills* when we wish to make trial of it. •5. Extract. Conii Gum. Myrrh, pulv. aa 3*«- • 6. Take Rxtract of Hemlock, Gum Myrrh, in powder, of each half a drachm. Order I pulmonary consumption. 517 Muriate of barytes is another remedy which has been much recommended by some physicians in incipient phthisis, as well as scrofula. It is best given in the form of the solutio muriat is baryfa;, at first in doses of five or six drops, which may afterwards be increased to twenty, twenty-five, or thirty, twice or thrice a day. In that variety of the disease which appears to be occasioned by an enlarged and indurated state of the abdominal viscera, or the lymphatic glands of the mesentery, we are told by Dr. Wilson* that lie found mercury a valuable remedy, and that he has seen the patient saved by it even at an advanced stage. Mercury is, indeed, a remedy which has been much recommended, and sometimes em- ployed in the early stages of phthisis pulmonalis by a few physi- cians in America, but more particularly by Dr. Rush. I think, how- ever, it promises no relief except in the cases Dr. Wilson used if. In all others it may be more likely to aggravate the disease than amend it. In the early stage of phthisis, the exhibition of an emetic every second or third day is usually attended wilh a very happy effect, and seems indeed to be one ofthe most powerful remedies we know of. As such it should never be neglected, with an exception to pregnant women. From the cupri sulphas having been found to excite vomiting readily and easily, without relaxing tbe stomach, irritating the intestines, or greatly fatiguing the patient, it has been more generally used in phthisical cases than any other medicine of the same class. The dose is from three grains to ten or fifteen, in proportion fo the age ofthe patient, dissolved in two or three ounces of water. A vomiting is excited soon after it is received into the stomach, on which fhe patient may drink a pint of water. Dr. Marryattf seems fo have been one of the first who recom- mended the employment ofthe cupri sulphas as an emetic in phthi- sical cases. He advises it fo be combined with tartarized antimony in the proportion of seven grains of each, which he directs to be divided into three powders, one of which is to be given twice or thrice a week. When any diarrhoea attends, he gives one grain of tbe cupri sulphas with five grains of ipecacuanha. During the ope- ration ofthe medicine he advises nothing'to be drank, for which reason he calls it the dry vomit. Dr. Senter, in his RemarksJ on Phthisis Pulmonalis, as- sures us, that he has restored more persons labouring under hectic fever from glandular suppuration by vomiting every * See his Treatise on Febrile Diseases, vol. iv. t See his Therapeutics. t See Transactions of the College of Physicians of Philadelphia, vol. i. part i. Mucilag. Gum. Acac. q. s M. ft. Massa in pilulas viginti distriboenda qua- rum duas sumat bis terve in die. Mucilage of Gum Acacia, a suffi- ciency to form the mass, to be divided into twenty pills, of which take two twice or thrice a day. £18 cachexia:, or cachectic diseases. Class lit second or third day with the supri sulphas, and giving in the intervals as much as the stomach would bear of Dr. Griffith's myrrh mixture (hereafter to be mentioned), than by all other methods he has ever read of or tried. He looks upon the sulphate of copper to be one of the most safe and efficacious emetics, joined with ipecacuanha, that the materia medica fur- nishes us with, and advises from seven to ten grains of each, made up into pills, to be taken in the morning fasting, with- out drinking any thing afterwards. To the good effects of the mode of treatment pursued by Dr. Senter I can bear ample testimony, having adopted it in many cases of incipient phthisis with infinite advantage. As the cough often proves troublesome in the first stage of the disease, as well as in the last, it may be found necessary to make use of some pectoral*. In such cases the patient, besides using these medicines as necessity may render needful, should take for ordinary drink what is heref recommended. In this stage of the disease opiates would be likely to prove prejudicial, and we should resort to them only in those cases where the rest at night is much disturbed. The extractum papaveris in doses of five grains or more should be preferred to opium. The digitalis, by allaying 6. Take Mixture of Ammoniac, sii ounce! and a half. Vinegar of Squill, two drachmi. Syrup of Tolu, three drachms. Compound Tincture of Camphor, two drachms. )f this mixture let the patient take a larep spoonful whenever the cough is trouble- some. Or, 7. Take Almond Mixture, six ounces. Oxymel of Squill, three drachmi. Compound Tincture of Camphor, two drachms. Tincture of Foxglove, thirty drops. •fix them, and take a mouthful from timt to time. Or, 8. Take Spermaceti, two drachms. Folk of Egg, a sufficiency for solu- tion, Then add Pennyroyal Water, five ounces. Nitrate of Potass, one scruple, Tincture of Foxglove, forty drops. Syrup of Tolu, half an ounce. fix them. 9. Take Decoction of Barley, two pints. Gum Acacia, three drachms. Syrup of Lemons, one ounce and • half. fix them for ordinary drink: * 6. Misturae Ammon. f. jtiss. Acet. Scillae, f. 3«.j- Syrup. Tolutan. f. 3»J- M- Tinct. Opii Camphor, f. 3ij- ft. Mistura, cujus sumat cochl. j. larg. tusse urgenti. Vel, 7. ft Mistura? Amygdal. ^vj. Oxymel Scillae, 3»J- Tinct. Opii Camph. 3>j- ----Digitalis, fll xx. M. Sumat paululum subinde. Vel, $. ft Cetacei, 3ij- , ,, Vital. Ovi, q. s. ad Solut. et adde Aq. Pulegii, f. ^v. Potassae Nitrat. 3j. Tinct. Digitalis, nT. xxvij. Syrup. Tolutan. f. ^ss. M. t 9. ft Decoct. Hordei, Oij. Gum. Acacias, 3"j- Syrup. Limon. f. 3JSS. M. Pro potu ordinario. Order I pulmonary consumption. 5t$ the irritation ofthe lungs, in consequence of its retarding the circu- lation through them, may be of much advantage in appeasing the cough. Hyoscyamus and the humulus lupulus have been employed wilh advantage where opium cannot be administered ; but we are told by Dr. Duncan, senior*, that of all the substitutes for opium which he had ever used in practice, he had found none of so much benefit, in phthisis particularly, as the preparations formed from the inspis- sated white juice of the common garden lettuce, or lactuca sativa of Linnaeus. Dr. Duncan thinks favourably of the effect of inhaling the vapour of sulphuric aether in which the dried leaves of conium maculatum have been maceiated; and be recommends it as particularly relieving the cough and dyspnoea, and promoting ex- pectoration. The lichen Islandicus is a favourite remedy with the continental physicians, and is daily employed by them in the routine of phthisical cases. The most usual form of exhibiting it is in that of a decoction with milk ; or, when this disagrees with the stomach, in water. It is not used however indiscriminately in every species of phthisis, nor in every stage of that disorder. It is chiefly recommended in those in- stances where the cough is attended with purulent expectoration ; in cases preceded by, or accompanied with haemoptysis; in incipient phthisis, where from relaxation there is an increased discharge of mucus from the bronchia; in the sequelae of measles attended with a quick small pulse, pain of the breast, emaciation, violent cough, and purulent expectoration. Of late the lichen Islandicus has be- come a fashionable remedy likewise among our own physicians, and I have myself prescribed it in several cases of phthisis, but without any evident beneficial effect. It seems indeed better calculated for an article of diet than a medicine. Such are the means which should be had recourse to during the first stage of phthisis. In the second and latter stages we are to counteract, if possible, the effects of the absorbed matter; to miti- gate the most distressing symptoms, such as the cough, diarrhoea, and colliquative sweats; and lastly, to put the body into as good general health as possible, by air, moderate exercise, and a proper course of mild nutritive food. No antidote against the poison which especially operates here having been found out, and it appearing that too great a degree of inflammation may have a share in preventing the ulcer from heal- ing, and in urging on its fatal consequences ; it has been proposed to employ means for moderating tbe inflammation in this stage of the disease, as well as in tbe first. With this view, small bleedings frequently repeated have been advised by some physicians. Draw- ing off blood, when this disease has arrived at the stage of ulcera- tion, is in my opinion exhausting the vital stream very unneces- * See his Observations on Pulmonary Consumption. 420 CACHEXIA, OR CACHECTIC DISEASES. ClttSS HI sarily; it is adding to debility, and most therefore t>e very improper. The same reasoning will hold good against a use of purgatives. When we want to lessen the action of the heart and arteries, from the pulse being very frequent, and the patient much troubled with flushing heats, in consequence of hectic fever, we should employ the digitalis, instead of having recourse to such debilitating means; this having been found capable, as has already been observed, of reducing the pulse from 120, and even 140 strokes in a minute, to something below the natural standard. Dr. Bourne, of Oxford, has published some cases of pulmonary consumption, in which he made trial of the uva ursi; and the dose in which he mostly exhibited it to his patients, was from eight to fifteen grains of the powder three times a day. He is of opinion that it has a very sensible effect in diminishing the hectic fever, and in abating the increased frequency ofthe pulse dependant thereon. It appears that he was first induced to make use of it in phthisis from having re- marked its good effects in a disease of the urinary organs, attended with a discharge of muco-purulent matter along with the urine, and accompanied with all the usual characteristics of hectic fever. The uva ursi is possessed of considerable astringency, and to the taste is slightly bitter; but neither its sensible properties nor its immediate effects on the system point it out as a medicine of great activity, par- ticularly in phthisis pulmonalis. In the second stage of the disease, the employment of emetics must be duly persisted in, every second or third morning, in the manner advised during tbe first stage. As detergents, different balsamics have been much used in the ul- cerated stage of the disease. Balsam of copaiba, in the dose of from twenty to thirty drops twice or thrice a day, may be tried. Myrrh is, however, tbe medicine which is employed with the greatest suc- cess in those cases of hectic fever which are unattended by any great degree of heat or thirst, and which do not show manifest signs of in- flammation. The preparation* used by the lale Dr. Moses Griffith* seems to be preferable to all others. If at anytime it should be thought too heating, the spirituous water may be omitted, as the solution may be made without it; but it is a doubt if it will agree so well with the stomach of patients in general. * 10. ft Myrrhae, 3j. Solve terendo in mortario cum Spirit. Pimentae, f. 3vj. Aquae Distillat. f. |vjss. Dein adde Potassa? Subcarbon. 3ss. Ferri Sulph at is, gr. xij. Syrup, f. 3ij- M. ft. Mistura, in haustus quatuordistribuenda, quorum unum capiat mane, hora quinta post meridiem, et hora decubitus. * 10. Dissolve of Myrrh, one drachm, iu a mortar, with Spirit of Pimenta, six drachms. Ditilled Water, six ounces and a half. Then add Subcarbonate of Potass, half a drachm. Sulphate oflron, twelve grains. Syrup, two drachms. Mix them, and divide the whole into four draughts, of which one is to be taken every morning, another at live in U»8 evcuing, and one at bedtime. Order 1. PULMONARY CONSUMPTION. 521 The myrrh may gradually be increased to seventeen or eighteen grains for a dose, the potassae subcarbonas to ten, and the ferri sul- phas to four. But it is always best to begin with small doses, and as the symptoms abate, to give two draughts a day, containing eight- teen or twenty grains of myrrh, twelve of the potassae, and five or six o, the ferri sulphas, which is the largest dose that should be taken. This medicine, although a little nauseous at first, is never- theless seldom rejected by the stomach, or excites any kind of dis- turbance in the habit afterwards. Where hectic heats and flushings prevail in a high degree, and the pulse is very frequent, it probably might be most advisable to omit the last article entirely. Dr. Beddoes has expressed a wish that we could obtain a single auxiliary to foxglove; as that then he should expect that not one case in five would terminate as ninety-nine in an hondred have hitherto done. I would propose this myrrh mixture of Dr. Griffiths, and vomiting twice a week, with the cupri sulphas, as mentioned in the preceding pages. A proper dose ofthe tincture of digitalis may be added to each of the myrrh draughts, and so be given toge- ther. This plan of proceeding I have adopted in several cases, and with mueb seeming advantage. Should the mixture not sit easy on the stomach, or be objected to on account of its nauseous taste, we may then form the myrrh and other ingredients into pills* and give the digitalis in about an ounce of the infusion of quassia or cascarilla. The cinchona bark has been employed in the ulcerated stage of phthisis ; but if ever it proves serviceable, it can only be when the morning remissions of the fever are considerable, and the noon exacerbations well marked. In all other cases it will be likely to prove prejudicial. The reason why pulmonary ulcers are prevented from healing is their being constantly exposed to the air. It is remarkable that matter produced by suppuration may be concealed in the body many weeks, or even months, without producing hectic fever; but as soon as the wound is opened, so as to admit air to the surface of the ulcer a hectic fever very quickly supervenes. 3 The suckling of children longer than is consistent with the mothers ability, is sometimes a cause of pulmonary consumption : but more particularly among the lower class of females who are of *IL ^SK' it * "■ T«akr ^nhr Powder> twod,achmS. * ™ Sulphate of Iron, one scruple. Subcarbonate of Potass, one drachm. Extract of Gentian, one drachm and a half. Potassae Subcarbon. 3j. Extract. Gentian. 3jss. Syrup. Simpl. q. s. M. ft. Massa in pilulas lxx. distribuenda, qua rum sumat iij—iv ter in die. 66 Syrup, a sufficiency to form th» mass, which is to be divided into seventy pills, whereof three or four are to be taken thrice a day. 522 CACHEXIA, OR CACHECTIC DISEASES. ClaSS HI a tender and delicate constitution. In such cases the cinchona bark given early in moderate doses, and merely as a tonic, is often attend- ed with tbe best effect. Where a disposition to consumption arises in consequence of any enfeebling evacuation, such as a considerable abscess, fluoi albus, or the like, without any inflammation of the lungs having yet taken place, cinchona will likewise prove serviceable, and may be given as advised below*. After inflammation has come on, or ulceration has commenced, it would not fail to prove injurious, by increasing the cough and the tightness and oppression of breathing. To counteract the effects of absorption, vegetable acids, such as oranges, and other fruits yielding an acid but not acrid juice, have been much recommended. When they do not affect the bowels they may be given freely with the powder of sarsaparilla. Fresh subacid fruits, although supposed to be usually laxative, are often useful in the diarrhoea of hectics, by their antiseptic quality. When the diarrhoea of hectic is accompanied with pain, and resists the action of astringents and anodynes, small doses of the submuriate of mercury have been found useful. In this stage of the disease, as well as in the incipient, we are to obviate inflammation, and divert the matter, if possible, by means of blisters, issues, or a seton. To palliate the cough, which is very apt to prove troublesome, and to assist the expectoration, we ma) have recourse to demulcents, as before advised. If the patient's rest is much disturbed by night, we may employ opiates; and although they are supposed to increase the phlogistic diathesis, and in some degree to check the expecto- ration, still they amply compensate for these by tbe ease and sleep they procure. In the tubercular or true scrofulous phthisis, Dr. Crichton, of Petersburgh, has seen very great benefit derived from a use of tar fumigation. He found that it heals the ulcers and subdues the inflammation of the tubercles ; but where there are large abscesses, or vomicae, in sanguineous habits, and in cases of suppuration suc- ceeding active hemorrhages, accompanied with fever, in young persons, little or no advantage was derived from the remedy. It is also of importance to know that the use of the fumigations should not be continued after the cough, expectoration, and hectic syrop- * 12 ft Potassae Subcarbon. 3'ij. Succ. Limon. f. ^j. Decoct. Cinchon. f. |v. M. ft. Mistura, cujus capiat cochl. ij. bis terve in die. Vel, 13. ft Decoct. Cinchon. f. ^v. Liquor. Ammon. Acetat. F. |j. M. ft. Mistura. 12. Take Subcarbonate of Potas*, tw» scruples. Juice of Lemons, one ounce. Decoction of Peruvian Bark, five ounces. Of this mixture let the patient take two table-spoonsful twice or thrice a day. Or, 13. Take Decoction of Bark, fiv« ounces. Solution of Acetate of Ammonia. one ounce. Mix them. Order I. PULMONARY CONSUMPTION. 536 toms are greatly subdued, and that patients should not again expose themselves hastily to a cold air. The simplest and best manner of filling a room with the vapour from tar, is to place the vessel containing it over a spirit lamp, taking care that it boils slowly and does not burn. The vessel should be well cleansed every day, and the fumigation be repeated every three hours. Some of the subcarbonate of potass (in the proportion of one ounce to the pound of tar) is to be added, in order thai the pyroligneous acid, as Dr. C. terms it, (perhaps more properly the empyreumatic acetic acid), may be destroyed. With respect to th* treatment of phthisis by bituminous vapour, the subject is not altogether new, as similar good effects have resulted from fhe vapour of melted rosin ; a case of which nature^ that occurred in the year 1771, is reported in the 53d No. of the London Medical Repository, page 400. In slow hectic fever, attended with frequent flushings and profuse night-sweats, and with much coughing and fetid purulent expecto- ration, Seltzer water will often in a high degree check the violence of perspiration, diminish the discharge from the lungs, and correct its fetor ; and under the operation of this medicine the patient will for a time be able fo gain quieter nights, and a better appetite. Seltzer water mixes well with milk, and will not soon coagulate it; which mixture has been strongly recommended in cases of hectic fever wilh expectoration. In very irritable habits it may be highly necessary to dilute the water in this way, as in its simple state it might prove too powerful. When the sweats are profuse, the infusum toses, with a sufficient quantity of diluted sulphuric acid, will be a good medicine to check them, and may answer instead of Seltzer water. The nitrate of silver, in doses of an eighth or fourth of a grain twice or thrice a day, has been administered with a happy effect in some cases of profuse sweating, accompanied by purulent expectoration. When a diarrhoea arises, it is to be stopped by astringents com- bined with opium, as recommended under that head. For common drink, tbe patient may take the mistura cornu usti, and arrow-root. By the consent between the intestines and skin, twenty grains of Armenian bole given on going to bed to hectic patients, will fre- quently check their tendency to sweat as well as to purge, and the more certainly if joined with one grain of opium. Where a spitting of blood arises in persons labouring under phthisis, the internal use ofthe superacetate of lead conjoined with opium, together with the other means advised under the head of Haemoptysis, must be resorted to. • The aphthous sores in the mouth which frequently arise in the latter stage of phthisis, are to be cleansed by washing or rincing the fauces often with an infusion of cinchona, having a little borax dig- solved in it.— See Cachexia Aphthosa. The strength is to be supported by food of a light nature, but which is at the same time highly nutritive ; and the different exer- 524 CACHEXIiE, OR CACHECTIC DISEASES. CktSS HI. cises, such as sailing and riding in a carriage or on horseback, but more particularly the latter, should be taken daily in fine weather. When the inflammatory diathesis is subdued, chalybeates, com- bined with myrrh and the subcarbonate of potass, may be given With much advantage. The liquor calcis will be a good menstruum for dissolving the myrrh. Should we be so fortunate as to subdue the disease by the means which have been pointed out, it will be indispensably necessary to* the patient to persevere in employing the regimen recommended in the treatment of this complaint, for a considerable length of time after every symptom has disappeared ; and he should return to his former manner of living with fhe utmost caution. Some practitioners, from considering pulmonary consumption as entirely of a scrofulous nature, disapprove hig-hly of the antiphlo- gistic plan, by bleeding and a spare diet even in the first stage of the disease. Instead of these, they recommend a nutritious diet, consisting of shell-fish and animal food ; the use of conitun and sarsa in powder as medicines ; warmth in the dress, by wearing flan- nel next to the skin, and at the same time heating the patient*s room to the West India point, when he cannot remove to a warmer climate ; the application of blisters, and frequent smart riding on horseback by way of exercise. With regard fo the remedies usually employed in the freatment of phthisis, Dr. Ferriar has observed that the digitalis, with the ferri sulphas, myrrh, cinchona, and other tonics, may be most proper in those cases of consumption which arise from scrofula ; while fhe digitalis with opium, mucilaginous medicines, and diuretics, may be opposed to the florid consumption. CACHEXIA AFRICANA, or NEGRO CACHEXY. This disease, known by the name of mal d'estoraac among the French, and by that of dirt-eating in our West India colonies, is frequently to be met with among negroes, but more particularly those imported from Africa. Mons. Sonnini makes mention, in bis Travels through E^ypt, that a propensity for eating earth is a dis- ease frequently to be met with likewise among the Egyptians. Between it and chlorosis there is in many respects a great similarity ; but they differ in this circumstance, that the latter only affects females, and that principally about the age at which menstruation ought to commence ; whereas the former affects males as well as females, and is often to be met with in children of six or seven years old, as I have seen happen in various instances. Cachexia Africana evidently arises from a want of due energy or vigour in the system, induced by various debilitating causes, as grief and despondency, occasioned by their being separated from their families and friends, and reduced to a state of bondage ; by poor diet, hard labour, and harsh treatment. With some fhe dis- ease is however constitutional, and proceeds from general relaxa- Order I. negro cachexy. 525 tion, a vitiated state of the stomach, and bad digestion. Negroes imported from the coast of Africa, who are of an inactive indolent habit, and children of lax fibres, and who have been badly nursed and afterwards neglected, are most liable to its attacks. Nostalgia, in which there prevails an unaccountable desire of re- turning to one's own country, is a disease somewhat similar to the negro cachexy. The Swiss are said to be particularly liable to it, and when taken into foreign service, very frequently desert from this cause. Its effects on the Africans are more violent, and not unfre- quently impel them to dreadful acts of suicide. Sometimes it plunges them into deep and incurable melancholy, which induces the unhap- py sufferers to end a miserable existence by a more tedious, though equally certain method, that of dirt-eating. Cachexia Africana shows itself by a fondness for solitude, and an indulgence in grief and despondency, together with a loss of appe- tite, constant pain in the stomach, difficulty of breathing upon the least bodily exertion, paleness of the face and palms of the hands, whiteness of the tongue, with an appearance like stains of ink upon it, whiteness of the lips, drowsiness, inactivity, unwillingness to at- tempt and inability to perform motion, and general debility. The tunica adnata is of a glassy whiteness, the skin of an olive complex- ion and cold to the touch ; the eyelids, face, and extremities, show- evident signs of an extravasation of water in their cellular membrane; and the unhappy sufferer can only breathe in an erect posture, from water being likewise collected in the chest and cavity of the abdo- men. The stools are at the same time of a white or clay colour, the urine is scant}', and the pulse is always small, and generally be- comes quicker as the night approaches. In consequence of the vitiated state of the gastric juice and im- paired digestion, a morbid acidity prevails; and a symptom arises from this cause, which with some has given name to the disease, viz. a habit of eating dirt, chalk, or whatever will obtund acrimony. This vitiated action is propagated throughout the whole aliment- ary canal ; the lacteals are abraded by acrimonious fluids, and no longer possess the power of absorbing healthy chyle; hence the lymphatic glands become indurated and inflamed ; the liver also is enlarged and of a scirrhous hardness; the blood poor, vapid, and colourless, no longer stimulates the heart and arteries to action: hence asphyxia and sudden death. Fatal consequences usually attend this disease. On dissection. the. stomach is often found much enlarged and thickened in its coats; the liver is of an increased size, scirrhous, and always pre- ternaturally white; biliary concretions are sometimes met within the gall-bladder ; the bile is never of a healthy appearance, but usu- ally of a thin watery consistence, and of a slightly yellow or fresh colour; the mesenteric glands are indurated and scirrhous, and po- lypous concretions are occasionally found in the heart. The proper indications of cure seem to be, first, to strengthen the 526 cachexia, or cachectic diseases. Class III general system, and give due energy to the constitution; and second- ly, to correct the morbid acidity which prevails. To answer the first of these purposes, the patient must be allowed a generous and nutritive diet, consisting principally of animal food and wine, or weak fermented liquors. Cane juice boiled to the con- sistence of a thin syrup (as in the fir^t process of sugar making) is also of a very restorative nature, and ought during cmp-tinie to be allowed liberally. With a generous diet, the patient should be made to take moderate exercise daily, as a want of this will not fail to in- crease the general debility, and add to the disease. Warm clothing, with occasional frictions by means of flannels, will likewise be proper. To assist the effects of these means, we must put the patient under a course of stomachic bitters, joined with aromatics, different prepa- rations of the cinchona bark, with myrrh and chalybeates, as advised under the head of Dyspepsia. The antihectic mixture of Dr. Griffiths (see Phthisis) will be likely to prove a most valuable remedy in this disease. The second indication is to be answered by alkalies and absorb- ents, as likewise recommended under the head of Dyspepsia. The exhibition of an emetic of the cupri sulphas once or twice a week, as advised in phthisis, seems likewise proper. When costiveness prevails, it ought to be removed by an use of some warm stomachic laxative, such as the tinctura rhei composita, or tinctura aloes composita. If the disease has been of such standing as to be attended with anasarcous swellings, besides using the means already recommended, we must have recourse to diuretics, as advised in dropsy. Where it is accompanied with a retention ofthe menses, we must endeavour to promote these by calling in the assistance of emmena- gogues.—See Chlorosis. In order that the depravity of appetite may not be indulged, the patient should be lodged in a room which has a boarded floor, and where he cannot possibly get any dirt; and when he goes out for ex- ercise, he should be accompanied by an attendant, who will not permit him to eat it. Dr. Chisholme, in bis ingenious Essay on this disease*, says, it is remarkable that negroes who are subject to it have been much benefited by living in a low situation, near marshes, which quickly prove fatal to whites; and he had long observed this before he formed any theory on the subject. He adds, perhaps the hydro- carbonic air may act as a cordial; it is perhaps the nervous aether itself. It has been remarked by medical writers, that the attack of remittent marsh fevers is frequently preceded by an unusual flow of spirits. From my own observations, during a long residence in the West * See the New-York Medical Repository. Order 1. chronic thrush. 527 Indies, I am ready to admit with Dr. Chisholme, that mountainous situations do not agree with cachectic negroes so well as low ones; but I cannot with him attribute the effect to the influence of marsh effluvia. Noxious vapours arising from stagnated waters and maishy grounds, acted upon by a powerful sun, prove, in warm climates, a never-failing source of disease under all circumstances, and under every condition ofthe body. The cachectic negro cannot endure the cold, chilling, and damp air of a mountainous situation ; but in a low one (the more remote from marshy grounds or stagnant waters the better), he feels warm and comfortable, and breathes a pure dry air, moderated in its temperature by the refreshing aud reviving breezes which come off the sea. CACHEXIA APHTHOSA, on CHRONIC THRUSH*. Chronic thrush is a disease very frequently to be met with among the inhabitants of our West India colonies, many cases of it having occurred during my practice there, but which is likewise apt to prevail in those northern countries where the cold is combined with a consi- derable degree of moisture, or where the soil is of a very marshy na- ture. It may in some cases be considered as an idiopathic affection, but it is more usually symptomatic. It is dependant on a cachectic state of the whole system, characterized by ulceration of the mouth, tongue, fauces, and intestinal canal. It shows itself at first by an uneasy sensation or burning heat in tbe stomach, which comes on by slow degrees, and increases gradually in violence. After some time, small pimples, of about the size of a pin's head, appear on the tip and edges of the tongue, and these at length spread over the whole inside of the mouth, and occasion such a ten- derness and rawness of the parts, that the patient cannot take any food of a solid nature; neither can he receive any vinous or spirituous li- quor into his mouth, without great pungency and pain being excited : little febrile heat attends, although there is some thirst, but the skin is always remarkably dry, rough, and without the least moisture on it; the countenance is of a pale olive colour, the pulse is smaller and more languid than in health, general coldness is felt over the whole body, but more particularly in the extremities, and the urine is small in quan- tity, and sometimes exhibits a milky or wheyish turbidness. These symptoms will continue probably for some weeks, the general health being sometimes better and sometimes worse, and then the patient will be attacked with acid eructations, and a vomit- ing of acrid phlegm, as likewise with a severe purging, which greatly exhausts his strength, and produces considerable emaciation of the * The common species of Aphtha, as principally affecting infants, is included among the diseases peculiar to them; but in Dr. Cullen's nosological arrangement it stands among the Exanthemata. 528 cachexia, or cachectic diseases. Class 111 whole body. The stools indicate a defective biliary secretion, strongly resembling thick oatmeal gruel in an incipient state of fermentation; but there is no pain or enlargement of the liver, nor jaundice, although the complexion is somewhat of the olive colour. After a little time, the symptoms cease, and he again enjoys better health ; but sooner or later the acrid matter shows itself once more in the mouth, with greater virulence than before, and makes frequent translations to the stomach and intestines, and so from these to the mouth again, until at last the patient is reduced to a perfect skeleton. Death in its approach still lingers, and seems as it were unwilling to overtake its languid victim, until worn down with fatigue and inquietude, he sinks into a state of exhausted apathy, and life at length is ex- tinguished. General relaxation, exposure to cold combined with great moisture, obstructed perspiration, and an acrimony ofthe humours, are suppo- sed to be the causes which give rise to the chronic thrush. Elderly people and persons with a shattered constitution are most liable to its attacks. It often admits of palliation from the resources of medicine, but it is seldom cured, even at an early stage ofthe disease. When engen- dered beneath the influence of a tropical sun, or it has been neglected,. is of long standing, or has made its attack in an advanced period of life, it will terminate fatally. The principal appearances to be observed on dissection are the aphthae, which extend through the whole of the alimentary canal^ The muscles throughout the body are relaxed and flaccid, and their( connecting cellular membrane is divested of any fat. It will in all cases be advisable to begin the cure with giving a gentle emetic, to dislodge the acrid phlegm with which the sto- mach is usually loaded; and if any acidity prevails afterwards (which may be known by sour belchings attended with a degree of heat and pain), a little magnesia, or a small quantity of the absorbent mixture* here recommended, may then be taken oc- casionally. Wherever we suspect the disease to have arisen, or to be kept up from the ingesta, then, besides an emetic, it may be right to cleanse the primae viae by some gentle cathartic; as the irritating matter, when permitted to accumulate in the alimentary canal, in- creases the morbid affection of the intestines. A combination of rhubarb with magnesia, or the submuriate of mercury, will be a proper laxative. Medicines of this nature are however to be ad- « 1. ft Magnesiae, 3j. Aq. Purae, f. ^vss. Spirit. Cinnam. f. 3»jj- Liquor. Ammon. f 3j- M. Capiat, cochl. ij. larg. pro re nata. * 1. Take Magnesia, one drachm. Pure Water, five ounces and a half. Spirit of Cinuamon,three drachms. Solution of Ammonia,one drachm. Of this mixture take two table-spoousful occasionally. Order I. chronic thrush. $29 ministered only in the first stage of the disease, as the risk of indu- cing excessive purging more than counterbalances the chance of ad- vantage from them. In an advanced stage of the disease, where it is found necessary to evacuate the intestines, emollient clysters may be employed. When a purging arises, we should have recourse to astringents joined with opiates, agreeable to the prescriptions below*, or as advised under the head of Diarrhoea; besides which, the patient should drink about a pint a day of the mistura cornu usti, or the same quantity of lime-water with an equal proportion of milk. Where there is no tendency to excessive purging, opiates perhaps may be omitted, unless they be necessary to procure sleep or allay irritation. In mitigating the pain, exhaustion, and despondency which sig- nalize the ravages of the disease towards its fatal termination, opium is indeed the remedy principally to be relied on. With the view of determining the humours to the surface of the body, it will be right to give frequent stnall doses of some diaphoi etic, such as the pulv. ipecac, compos.; and to assist their operation, flannel should be worn next to the skin. Should these fail in exci- ting a proper perspiration, and the patient continue to waste in flesh, a tepid bath may prove serviceable, and where a natural one can be procured, it ought to have the preference. To remedy the inconvenience arising from the soreness of the mouth and tongue, these should be washed frequently with some kind of healing astringent garglef. When the rectum is affected, mild injections are proper, and • 2. ft Confect. Catechu, 3'j. Aq. Cinnam f ^ij. — Purae, f Ziij. Tinct. Kino, f. 3'j- ----Opii, fll xxv. M. ft. Mistura, cujus sumat cochl. ij. vel iij. in die. Vel, 3. ft Mistur. Crets, f. ^iv. Spirit. Cinnam. f. Jj. Tinct. Catechu, f. 3y- ----Opii, TTl xxvj. M. I 4. ft Infus. Rosae, f. ^vj. Aluminis, 3jss. Mel. Optim. f. Zj. Liquor. Plumbi" Subacet. 1t[ i. ft. Gargarisma. Vel, 5. ft Zinc. Sulphat. gr. x. Aq.Rosa;, f. ^viij. Tinct. Myrrh, f. *i. M. 67 ter 2. Take Confection of Catechu, two diaclims. Cinnamon Water, two ounces. Pure Water, three ounces Tincture of Kino, two drachms. --------Opium, forty drops. Of this mixture let two or three table-. spoonsful be taken thrice a day. Or, 3. Take Chalk Mixture, four ounces. Spirit of Cinnamon, one ounce. Tincture of Catechu, two drachms. ------— Opium, forty drops. Mix them. The dose may be tbe same as the former 1 4. Take Infusion of Roses, six ounces. Alum, one drachm and a half Honey, one ounce. N Solution of Subacetate of Lead; fifteen drops. Mix them for a g«rgle. Or, 5. Take Sulphate of Zinc, ten grains. Rose Water, eight ounces. Tinctnn? of Myrrh, one ounce. Mix them. 530 CACHBXI.fi, OR CACHECTIC DISEASES. ClttSS III. produce effects similar to those of gargles in the fauces; they should consist of mild mucilaginous and gently stimulating decoctions, such as veal broth, boiled with rice and bruised turnips, or turnip radishes, which will likewise prove an excellent article of diet. In mild cases of the disease, a decoction of the cinchona bark combined with the subcarbonate of soda, is often used internally, and with much advantage. In those cases where it puts on an alarm- ing appearance, this preparation should be employed as a gargle, and the powder be administered in as large doses as tbe stomach will bear. If it excites a purging, a few drops of tinct. opii may be added to each dose. In its first or simply dyspeptic state, the disease may often be re- moved in northern climates by a few doses of calomel, and some bitter infusion combined with magnesia or rhubarb. Occasionally mercury has been used both externally and internally in this disease with advantage: externally, in the form of ointment or plaster to the hepatic region; internally, in that of the hydrargyri submurias com- bined with opium. The diet in cachexia aphthosa should consist only of such things as are light and nutritive, as milk, mucilaginous soups, jellies, prepa- rations of barley, sago, rice, Indian arrow- root, plantains, bananas, &c; lime-water mixed with milk may be used for ordinary drink. It will be best to abstain from wine, spirits, and all fermented or fermenting liquors. If any is used, Port wine diluted with water may be the least injurious. , To restore the lost vigour and tone of the system, astringent bit- ters, such as infusions of cascarilla and cinnamon bark, of lemon and pomegranate rind in lime water, with chalybeates, myrrh, and other tonics, may be used, as advised under the head of Dyspepsia, together with such moderate daily exercise in tbe open air in mild weather, as the strength will admit of. If the patient's circumstances will al- low of his removing from a warm climate to a cold one, where the air is dry, he should do it before the disease becomes inveterate. Vel, 6. ft Decoct. Hord.f. §vj. Mel. Rosae, f. |j. Aluminis, 3j- Tinct. Myrrh, f. |ss. M. Vel, 7. ft Sodae Sub-borat. 3jss. Aq. Fervent, f. ^v. Mellis Rosa;, ?J. Tinct. Opii, fll xxvj. M Or, 6. Take Decoction of Barley, six ounce? Honey of Roses, one ounce. Alum, one drachm. Tincture of Myrrh, half an ounce Mix ihem. Or, 7- Take Borax, one drachm and a half Warm Water, five ounces. Honey of Roses, one ounce. Tincture of Opium, forty drops Mix them. Order II. CORPULENCE. 53} ORDER II. INTUMESCENTLE. Swelling of the whole or a great part of the body externally. I.—INTUMESCENT1.E ADIPOS.fi, or FATTY SWELLINGS. POLYSARCHIA, or CORPULENCE. Corpulence, when it arrives at a certain height, becomes an absolute disease. The increase of the omentum particularly, and the accumulation of fat about the kidneys and mesentery, swell the abdomen, and obstruct the motions of the diaphragm ; whence one reason of the difficulty of breathing, which is peculiar to corpulent people : while the heart and the large vessels connected therewith are in like manner so encumbered, that neither the systaltic nor subsultory motion can be performed with sufficient freedom, whence weakness and slowness of the pulse ; but when the whole habit.is in a manner overwhelmed with an oily fluid, fhe enlargement of the cellular interstices will necessarily interrupt the general distribu- tion and circulation throughout the nervous and vascular systems, impeding the action of muscular fibres, and producing insensibility, somnolency, a disposition to apoplexy, and death. The general exciting cause of obesity, independent of peculiarity of habit, is certainly a free indulgence of the appetite in the use of nutritive food and fermented liquors, since it is only among those who enjoy the means of obtaining the comforts of life without hard labour that this state is observed. The citizen in easy circum- stances, the indolent rector, the opulent farmer (and especially their wives, who enjoy their feeding without anxiety or much exercise), the masters and mistresses of well frequented inns, and the sergeants of regiments in peaceable quarters, or ofthe militia, &c. are those whose rotundity of belly marks the superabundance of their ingesta, and who upon the least exertion perspire and wheese under a load with which they have voluntarily encumbered themselves. When a person of a constitution which is predisposed fo obesity is enabled to indulge in good feeding, leads a calm indolent life, free from mental inquietude, and sleeps much, corpulence generally ensues. The causes of corpulence being thus well understood, the means of prevention and removal are not less obvious : in this the patient must, in a great degree, minister to himself: the prevention and cure will depend upon the proper regulation of his diet, exer- cise, and sleep. Medicine will only be necessary to obviate par- ticular symptoms, or diseases arising from or connected with if. The disease frequently, however, steals on so imperceptibly, fhat it becomes inveterate before people begin (o think of pursuing any means for obviating it. 532 CACHEXIA, OR CACHECTIC DISEASES. CUtSS til To get rid of loo much fat without any injury to the constitu- tion, the palient should, in a very gradual manner, diminish Ihe usual quantity of his aliment, taking less nutritious substances for food ; he should drink as little as he can with ease to his sensa- tions, and particularly of malt liquors ; he should use regular and daily active exercise, abstain from suppers, take short rest, sleep but few hours, and rise early every morning. To assist these means, and compress the bowels (increasing their absorption pro- bably thereby), be may put a proper bandage on tbe belly, so that it can he tightened or relaxed with ease. An under-waistcoat with two or three rows of buttons will answer this purpose very well. By a rigid pursuance of these means for a due length of time, I have no hesitation in affirming, that fhe most corpulent and unwieldy man or woman may be reduced within moderate bounds with an acquisition of health, strength, and vigour, both of body and mind. Newmarket affords abundant proofs how much may be clone by active exercise and a spare diet, as jockies have been knov.n to redure themselves a stone and a half in the space of a ween or two. To fhe question proposed fo a person* well versed in fhe business of training, " Would he recommend a similar piocess to reduce corpulency in other people, whether male or female ?" the answer was in the affirmative, as he had perceived from experience that the constitution does not appear to be injured by it. It will, however, be most prudent in all cases to reduce obesity in a grad- ual manner, which may be done effectually by keeping the eyes open, the mouth shut, and the legs in motion; or, in other words, by eating and drinking sparingly, by sleeping little,- and taking much exercise. The case of Mr. Thomas Wood, miller, which is published in Vol. 2d of Medical Transactions of tbe College of Physicians, is likewise strongly illustrative of what may be accomplished in cir- cumstances of the greatest corpulence, and diseases consequent fbereon, by a rigid adherence to the plan just recommended. As medicines, diaphoretics, with an occasional use of moderate purging, have been employed. Soap is recommended fo melt down and facilitate the absorption of the fat in corpulent people; but probably the potassae subcarbonas would be more powerful. Diuretics might possibly be used with advantage. The aerated alkaline water, which is supposed to render the fat more fluid at the same time that it determines to the kidneys, may be taken by the pafient for his ordinary drink. Vinegar and lemon-juice are too frequently used by young women to reduce corpulence ; but an excessive use of acids is apt to destroy the digestive powers, and in the end to bring on a train of dyspeptic complaints. * See Code of Health, by Sir John Sinclair. Order II. tympany. 533 II.—LNTUMESCENttJE FLATUOS^, or FLATULENT SWELLINGS. EMPHYSEMA. This disease consists in a collection of air in the cellular membrane. In general it is confined to one place; but in a few cases it spreads universally over the whole body, and occasions a considerable degree of swelling. It sometimes arises spontaneously, which is however a rare occur- rence, or comes on immediately after delivery, without any evident cause ; but it is most generally induced by some wound or injury done to the thorax, and that affects the lungs ; in which case, the air passes from these through the wound into tbe surrounding cellular membrane, and from thence spreads sometimes over the whole body. Emphysema is attended wilh an evident crackling noise, and elas- ticity upon pressure; and sometimes with much difficulty of breath- ing, oppression, and anxiety. We are to consider it as a disease by no means unattended by danger : but more probably from tbe causes which give rise to it, than any hazard from the complaint itself. The intentions of cure which we should have in view must be, first, to remove the cause of the disease ; secondly, to relieve the urgent symptoms; and, thirdly, to evacuate the collected air. To answer tbe first of these, the assistance of surgery will be ne- cessary as arising most commonly from a wound or other injury done to the thorax, which at the same time affects the lungs, as in the case of a fractured rib, the ragged edges of which penetrate the pleura and substance of the lungs, and thereby admit of an extravasation of air into the cellular membrane. In such cases the air is to be evacuated by scarifications into the cellular membrane in different parts of the body, as circumstances may require, assisted by proper pressure wilh the hand. Violent dyspnoea and anxiety are to be relieved by bleeding and lax- atives; and the pain and uneasiness arising from the distention, by re- laxing applications to the skin, such as the unguentum cetacei, he. TYMPANITES, or TYMPANY. Tympany consists in a violent distention either of the intestines, or cavity of the abdomen, by wind. In tbe former instance, it has been supposed to arise from the sudden suppression of diarrhoea or dysentery, or as a consequence of febrile diseases, or tbe sudden drying up of long-continued discharges; from cutaneous eruptions, r; or a use of crude vegetable aliment; and in the latter from an erosion of the intestines, the effect also of preceding complaints. Tympanites inteslinalis sometimes conies on suddenly, at others it is more slow in its progress, and preceded (be the cause what it may) by great flatulency, borborygmi, and a frequent expulsion of the air upwards and downwards, attended with colic pains. 534i eACHBXIvE, OR CACHECTIC BISEASES. CUlSS III As it advances, the abdomen becomes considerably distended, and retains the same figure under every variation of position. Tbe swelling does not yield much to pressure, and in what it does, it soon recovers its former state ; it feels very elastic, but no fluctua- tion can be perceived. The urine at first is not altered either in quantity or quality; but in the advanced stage of the disease a change takes place in both respects, and dysuria and even ischuria sometimes come on. The body is usually very costive, the appetite isjmpaired, thirst, heat, and pyrexia attend, and general emaciation ensues. In time the respiration becomes difficult, with much anxiety and cough; the strength is exhausted, the belly is enormously swelled, and the patient is not unfrequently destroyed in consequence of su- pervening gangrene. In tympanites abdominalis the swelling is more equal than in the former species, the tension greater; it is more elastic, and, upon percussion, sounds like a drum or bladder filled with air. Moreover, there are no discharges of flatus. Tympanites is easily to be distinguished from ascites by the ab- scence of fluctuation, by the tense feel of the abdomen, by the quick reaction of the parts after removing the pressure of the finger, by the frequent desire to belch, and by the state of the bowels and urine at the commencement of the disease. It is, almost in every instance, an obstinate and dangerous disease, slow in its symptoms, marking a total relaxation of the system; and therefore it frequently terminates in dropsy, showing tbe same emaci- ation of countenanee, dry cough, and hectic state, in the end. An unimpaired constitution with frequent explosions of flatus, showing that the air is contained within the intestines, may be regarded in a favourable light. When the wind is confined within the intestines, its evacuation is to be attempted by introducing an unarmed clyster-pipe up the rectum, and keeping it there for some time, so as to take off the resistance of the sphincter: and by giving carminatives, essential oils, spice, and stomachics, which may be joined as in the fol- lowing forms*, or as advised under the head of Dyspepsia; and * 1. rxPiilv. Cinnam. Comp. * 1. Take Compound Powder of Cinnamon, Extract. Gentian, aa gr.x. Extract of Gentian, of each ten grains. 01. A nisi, fl| iij. Oil of Aniseed, five drops. Syrup. Zingib. q. s. M. Syrup of Ginger, a sufficiency to it. Bolus 4tis horis sumendus cum cochl. form a bolus, which may be taken every magnis duobus mistura; sequentis. four hours with two table-spoonsful of tbe following mixture :— 2. R Aq. Menth. Pip. 2. Take Peppermint Water, Misturae Camphorae, aa f. ^ijss. Camphor Mixture, of each two ounces and a half. Spirit. jElheris. Sulph. f. 3«ss. Spirit of Sulphuric jEther, one drachm and a half. Tinct. Card. C. f. |ss. M. Compound Tincture of Carda- mom, half an ounce. ll Mistura, capiat cochl. ij. pro dos. Mix them. The dose may be two tabic spoonsful. Order II. tympany. 535 when costiveness prevails, by an occasional use of laxative medicines, joined wilh aromatics and essential oils, or clysters* frequently re- peated. Should these gentle means fail in procuring sufficient evacuations, we must then employ active purgativesf; and where there is great ir- ritability ofthe stomach, with nausea and frequent vomiting, it will be advisable to give them in the form of a pill, as being most likely to be retained. If the disease resists all our endeavours, and the bowels continue obstinately costive, with increasing distention, thirst, heat, and other symptoms of pyrexia, we should then have recourse to the lancet, in order to guard against supervening inflammation and its con- sequences. It is only in acute attacks, however, that we need dread such a termination. Antispasmodics of the strongest kinds, such as asafcetida, aether, &c, with infusions of horseradish and ginger, together with chalybe- ates, are remedies which have sometimes proved useful in tympanites, and therefore should not be neglected. To excite tbe action of tbe distended intestines, it has been recommended, along with these remedies, to apply cold substances, Vel, I Or, 3. fy Infus. Cort. Cinchon. f. |j. | 3. Take Infusion of Peruvian Bark, one ounce. CompoundTincture of Cardamom, Spirit of Pimenta, of each two drachms. Compound Spirit of Lavender, half a drachm. Mix them, and take this draught three or four times daily. Or, 4. Take Tnfusion of Cascarilla, one ounce. Tincture of Calumba, one drachm. Spirit of Carraway, ------Aniseed, of each one drachm and a half. Mix them for a draught. * 4. Take Aniseed, bruised, three drachms. Chamomile Flowers,half an ounce. Pure Water, one pint and a half. Boil them until reduced to twelve ounces, and to the strained liquor add Sulphate of Soda, half an ounce. Oil ot Turpentine, two drachms or half an ounce. Mix them for a clyster. t 5. Take Compound Tincture of Senna, one ounce. Tincture of Jalap, two drachms. Mix them as a purgative draught. Or, 6. Take Compound Extract of Colocynth, fifteen grains. Submuriate of Mercuiy, fiva grains. Oil of Carraway, a sufficiency to form the mass, which divide into four I pills, to be taken at once. Tinct. Cardfcm. C. Spirit. Pimentae, aa f. 3»j- ----Lav. Comp. f. 3ss. M. ft. Haustus, ter quaterve in die sumendus. Vel, 4. R Infus. Cort. Cascaril. f. ?j. Tinct. Calumb. f. 3i. Spirit. Carui, —— Anisi, aa f. 3>ss. M. ft. Haustus. * 4. g; Sem. Anis. Contus 3»j- Flor. Anthemidis, |ss. Coque ex. Aq. Fontan. Ojss. ad f. |*ij Colat. adde Sodae Sulphat. ?s»-. 01. Terebinth, f. 3ij—^ss. M. ft. Enema. t 6. {$: Tinct. Sennae Comp. f. ^j. ----Jalapae, f. 3>J- M. ft. Haustus catharticus. Vel, 6. & Extract. Colocynth. C. gr. xv. Hydrargyri Submur. gr. v. 01. Carui, q. s. M. ft. Massa in pilulas iv. divid. pro dos. 536 «ACHEXI£, OR CACHECTIC DISEASES. ClaSS 111 such as iced water or snow, to the belly, after which it is to be ban- daged tight with flannel. A case of severe tympanites, s- »me time agd, came under my care, wherein very great bi nefit was derived front* the frequent application of pounded ice to the abdomen. It is probable that frictions with turpentine, oils, the linimentum ainmoniae fortius, or the linimentum camphorae, and the hand, might afford some relief, and excite tire intestines, when assisted by pressure and other proper means, to discharge the accumulated air. The application of a warm stimu- lating plaster, ot even a blister, may be tried if these means fail. Mercurial frictions upon the surface of the abdomen, with active pur- gatives, sometimes prove useful in tympanites. It has been proposed as a query*, Whether tbe co*d bath contin- ued long enough to become antispasmodic and relaxant, might not produce good effects in this disease as well as in trismus ? To afford relief in desperate cases, where the air is diffused in the cavity of the abdomen, it may be necessary to have recourse to the operation of paracentesis, or tapping with a small trocar. In tbn case, tonics will likewise be advisable. During tbe continuance of the disease, that aliment which is least apt to prove flatulent should be taken, and such things be given as will check the fermentation of the food. The mineral acids and small quantities of ardent spirits will have this effect. Should we be so fortunate as to remove the disorder, the patient must pay particular attention to his diet, avoiding all food of a flatulent nature, and using only such as is light and easy,of digestion. He is at the same time to guard against costiveness, by an occasional use of some stomachic aperient, and to invigorate bis body by gentle exercise, and the other tonic means advised under the head of Dyspepsia. III.—INTUMESCENTI^E AQUOSiE, or WATERY SWELLINGS. HYDROPS, on DROPSY. Dropsy is a preternatural or morbid accumulation of a serous or watery fluid in some part of the body, impeding or preventing the functions of life, and receives different appellations, according to the particular situation in which it is lodged. When it is diffused through the cellular membrane, either generally or partially, it is called anasarca. When it is deposited in the carity of the cranium, it is called hydro- cephalus. When in the chest, hydro-thorax, or hydrops pectoris. When in the cavity ofthe abdomen, ascites. In the uterus, hydrometra; and within the scrotum, hydrocele. ' Water is likewise encysted in the ovarium now and then, and is named ascites ovarii. " See Dr. Temple's Practice of Physic, p. 234, Order 11 dropsy in the cellular membrane. 637 Infants, youth, and adults, are equally liable to these effusions in the various cavities of the body. A modern writer* having remarked, that in many cases of dropsy the urine possesses the piopetty of being coagulaled by heat, instead of classing dropsical affections according to their situation, has divided thein into those with coagulable, and those with uncoagulable urine. The causes of these diseases are, a family predisposition thereto, frequent salivations, excessive and long-coniinued evacuations, a free use of spirituous liquors, (which never fail fo destroy the diges- tive powers), scirrbosities of the liver, spleen, pancreas, mestnteiy, and other abdominal viscera ; preceding diseases, as the jaundice, diarrhoea, dysentery, phthisis, asthma, gout, intermittents of long duration, scarlet fever, and some of the exanthemata ; a suppres- sion of accustomed evacuations, the sudden striking in of eruptive humours, ossification of the valves of the heart, polypi in the right venfricle, aneurism in the arteries, tumors making a considerable pressure on the neighbouring parts, permanent obstruction in the lungs, rupture of the thoracic duel, exposure for a length of time to a moist atmosphere, laxity of the exhalants, defect in the absorbents, topical weakness, general debility, and whatever powerfully disposes the body to a state of relaxation. Diminished absorption and increased effusion, or both united, may be considered as the proximate causes of the different species of watery swellings. ANASARCA, or DROPSY in the CELLULAR MEMBRANE. This species of dropsy shows itself at first with a swelling ofthe feet and ankles towards evening, which for a lime disappears again in the morning. The tumefaction is soft and inelastic ; and when pressed upon with the finger retains its mark for some time, the skin becoming much paler than usual. By degrees the swelling ascends upwards, and occupies the thighs and trunk of the body, and, at last, even the face and eye- lids appear full and bloated. When it has become pretty general the viscera are afiecled in a similar way ; the cellular membrane of the lungs partakes the affection, the breathing then becomes diffi- cult, and is accompanied by cough, and the expectoration of a watery fluid ; the urine is small in quantity, high-coloured, and deposits a reddish sediment; sometimes, however, it is of a pale whey colour, and more copious; the belly is costive, the perspira- tion much obstructed, the countenance yellow, and a considerable degree of thirst, with emaciation of the whole body, prevails. To these symptom* succeed torpor, heaviness, and a slow fever. In some cases the water oozes out through the pores of the. cuticle ; in others, being too gross to pass by these, it raises the * See Observations on the Nature aud Cure of Dropsy, bv J. Blaekall, M. D. 68 588 CACHEXIA, OR CACHECTIC DISEASES. GlftSS III cuticle in small blisters ; and sometimes the skin, not allowing the water to escape through it, is compressed and hardened, and is at the same time so much distended, as to give the tumor a con- siderable degree of firmness. The disease is always to be regarded as admitting more readily of a cure when if arises from topical weakness or general debility, than when it has been occasioned by visceral obstruction ; as like- wise when recent, than where it has been of long continuance. The skin becoming somewhat moist, with a diminution of thirst, and an increase in the flow of urine, are to be regarded as very favourable symptoms. In some few cases nature makes powerful efforts of her own accord, and the disease goes offby aspontaneoiu crisis, either by a vomiting, purging, or an unusual discbarge of urine ; but this does not often happen. Concomitant organic dis- ease, great emaciation, erysipelatous inflammation, much drowsi- ness, petechia? and ecchymosis, hemorrhage, febrile heat, great thirst, and a quick small pulse, are very unfavourable symptoms. > On opening the bodies of anasarcous persons after death, the whole of the cellular membrane is found distended with an aqueous fluid ; the glands, spleen, and fhe liver indurated, and often suppurat- ed ; and there are ossifications, as well as polypi, in the larger blood- vessels. The consistence ofthe blood itself is more or less altered, according fo the degree of ihe disease, and the intensity of ifi causes. The effused fluid is for Ihe most part serous. In the cure of anasarca we are to keep in view the three follow- ing indications :— 1st, To remove the remote causes of the disease : 2dly, To evacuate the serous fluid already collected : and, 3dly, To restore the tone of the system, and strengthen the general habit. In dropsical cases we should always carefully investigate whe- ther the disease is an original one, or prevails as a symptom of some other ; for by removing the cause we shall often be enabled fo perform a cure. For instance, if it has arisen as (he consequence of intemperance, a free use of spirituous liquors, exposure to a moist atmosphere, or the having had recourse to large evacuations, particularly by bleeding, these ought carefully to be avoided in fuflire ; or if it has proceeded from long-continued intermittents, obstructions in the abdominal or thoracic viscera, and the like, these should be obviated. In the treatment of anasarcous swellings, arising from the pres- sure of a tumor on some large lymphatic, the only thing that can be done is to remove if. When weakness of a limb, in consequence of a sprain or some contusion, has given rise to these swellings, fhe best method of cure will be to support the weakened parts, either with a laced stocking or a flannel roller, to prevent their yielding fo distention, till in the course of time, and by fhe effects of cold bathing and moderate frictions, they recover their natural tone. When cedematous swellings come on in consequence of any of Order 11 dropsy in the cellular membrane. 539 the lymphatic vessels of a limb being cut, as sometimes happens in extirpating indurated glands from the axilla, small punctures made if* the' under part ofthe limb will afford immediate relief. The treatment of the diseases on which dropsy may depend, has already been pointed out in various parts of this treatise, each fonder its distinct head; but unfortunately it may, and does sometimes depend on diseases which are incurable, such as polypi ofthe heart,- ossifications of its valves and great vessels, erosions of the thoracic duct, and scirrhosity of the liver, spleen, &c. In such cases, medi- cine will avail but little. To answer the second indication, of evacuating the serous fluid already collected, we must either have recourse to openings made immediately into the cellular membrane, or we must endeavour to excite certain serous excretions. The openings most frequently used in anasarca are either slight scarifications or small punctures. In having recourse to these, we should however take care to avoid them in parts that are dependent, and they should be made so superficial as to extend to no greater depth than the cellular membrane, as deep incisions in dropsical parts are very apt to become gangrenous. To promote a discbarge of the water by the several orifices, the parts may be bathed three or four times a day with some kind of emollient fomentation*. rAt an early stage of dropsy, issues made with caustic below one or both knees, have sometimes been employed to evacuate the water from the upper parts; but they are by no means so safe as smajl punctures or slight scarifications, and if inserted in parts that have lost their tone, might terminate in gangrene. With the like intention of drawing off the water from anasarcous limbs, blisters have sometimes been applied ; but the objection which has been urged against the use of issues applies equally to these, and therefore they should be resorted to with great circumspection and caution. The application of colewort-leaves to the legs and feet of anasar- cous persons, is another way which has been proposed for drawing off' the water; but although they become imbued with moisture, still their effect is too trifling to be depended upon. An excitement of the different excretions is the other mode which has been proposed for carrying off the fluid diffused throughout the cellular membrane. This is to be done by emetics, purgatives, dia- phoretics, and diuretics, all of which, by their evacuating effects, tend to increase the power of the absorbents. Emeticsf have been much administered in dropsical cases, under ' 1. ft Fol. Mai vie, L * 1. Take Marshmallow Leaves, Flor. Anthemidis, aa ?jss. Chamomile Flowers, of each one ounce and a half. Aq. Fontan. Oiv. Paulisper coque, Pure Water, two quarts. Boil et cola pro fotu. them slowly for some time, then strain oil the liquor and use it for fomentation. f 2. & Oxymftl. Scillae, f. 3vj. t 2. Take Oxymel of Squill, six drachm?. Vin. Ipecac, f. |ss. M. Wine of Ipecacuanha, half au ounce. t Haustus emeticus Mix them for an emetic draught. o4rJ CACHEiUifc, OR CACHECTIC tflSEAStiS. CHaSS 111. the supposition that they greatly promote absorption, and in many instances they have certainly been attended with a very g»od effect. To e tiploy them, however, with advantage, we ooght to repeat them frequently. If they are found to weaken the patient, without procur- ing any mitigation of the disorder, we should then desist from using them. An emetic of the cupri sulphas, as advised under the head of Phthisis, or below*, appears to be the most proper, as having less tendency to exhaust than any other used in common. Purgatives are likewise much employed in dropsical cases, with the view of carrying off a portion of the water by stool, and of exciting absorption; and as the stimulus of those which are of a drastic naturef is most readily communicated to fh»* system, so these are more generally used than those of a mild kind. The potassae supertartras is, however, a purgative of this nature, which has been giv«n with considerable success, bnt it is more usual to combine it with some of the drastics, such as jalap, elaterium, Vel, 3. R Oxymel. Scills, f. |j. Aq. Menth. f. ^ss. Antimon.,Tartarisat. gr. j.—ij. M, ft. Haustus. * 4. 3- Cupri Sulphat. gr. v. ad x. Fulv. Ipecac, gr. v. M. ft. Pulv. seeundo vel tertio quaq. mane sumendus. t 5. ft Scammon. gr. xij Hydrargyr. Submur. gr. v. Pulv. Zingib. gr. vi. M. ft. Pulvis pro dos. Vet, 6. g. Pulv. Jalaps, ----Scammon. aft gr. xij. ft. Pulvis. Cinnam. Comp. gr. x. M. Vel, 7. ft Gum. Gambog gr iij. Terito bene cum Tinct Sennae Comp. f. |ss et adde ----Jalapse, f 3>.l- Syrup Zingib. f. 3"j- M. , ft. Haustus Vel, ' 8. ft Pulv.Elaterii, g. j. ad iij. ----Zingib gr. x. 01. Jump fll iij. Syrup Simp q- »• M. ft. Bolus, aul in pitdlas iv. divid. pro dos. Or, 3. Take Oxymel of Squill, one ounce. Mint V\ater, half an ounce. Tartarized Antimony, one to two grains. Mix them. * 4. Take Sulphate of Copper, from five to ten grains. Powder of Ipecacuanha, five grains. Mix them, and let this powder betaken every second or third morning. t 6. Take Scammony, twelve grains. Submuriate of Mercuryi five grains. Powdered Ginger, six grains. Mix them for a dose. Or, 6. Take Powdered Jalap, ----------Scammony, of each twelve grains. Compound Powder of CiniiaooB, ten grains. Mix them. 7. Take Gamboge, three graini. U«- solve it in Compound Tincture of Senna, half an ounce *. and add Tincture of Jalap, two drnchms. Syrup of Ginger, three drachms. Mix them for a draught Or, 8 Take Powder of Wild Cucumber, one grain to three. Ginger in powder, ten grains. Oil of Juniper, five drops Syrop, a sufficiency to form » bolus, or to divide the mass into four pills for a dose. Order li. dropsy in >the cellular membrane. 541 scammony., and gamboge* than to give it alone. Evacuants, par- ticularly of the drastic kind, are, however, only admissible and useful where ihe habit is indolent, and the dropsy extensive, without much local d**termination. To administer purgatives with the greatest advantage, they ought to be repeated at as short intervals as the patient can bear; for, when purging is not carried to the degree of quickly exciting absorption, the evacuation weakens the system, and thereby increases the afflux of fluids to the hydropic parts. Diaphoretics are another class of medicines which have been era- ployed in dropsy. In a few instances sweating may, perhaps, have produced a good effect; but in general it proves inefficacious, and only tends to add to general debility. On this account diaphoretics are not much employed in dropsical cases, particularly where there is great weakness and general relaxation of the system. Should the practitioner wish to make trial of them under the failure of other remedies, be can administer them as heref advised, directing the patient at the same time to be laid between blankets, with a shirt and trowsers of flannel next to his skin, and to drink plentifully of tepid liquors, of which none probably may be more proper than mustard- whey. Another method of promoting a diaphoresis, and of thereby in- creasing absorption from the cellular membrane, is by warm air, or by warm steam. If the swelled legs of a dropsical patient are en- closed in a box, the air of which is made warm by a lamp or twd, a copious sweat is soon produced by tbe increased action of the capillary glands, which is seen to stand on the skin, as it cannot * 8. ft Potassae Supertart. 3"j- Gambog. gr. ij. Pulv. INuc. Moch. gr. x. M. ft. Pulvis. Vel, 10. ft Pulv. Elaterii, g. i.—ij. Potassae Supertart. 3'j- Pulv. Cinnam. C. gr. v. M. ft. Purvis pro dos. sumendus. t 11. ft Camphorae. gr. v. Pulv. Antimonial. gr. ij. Confect. Aromat. gr x. M. ft. Bolus, hora decubitus sumendus. Vel, 1*2. ft Liquor. Ammon. Acetat.f. ^ss Aqua; Pure, f. §j. Vin. Antimon. iTj, xvj. Spirit. Ammon. Aromat. AT, x. Syrup. Zingib. 3'j- M. ft. Haustus. 9. Take Supertartrate of Potass,| three drachms. Gamboge, two grains. Powdered Nutmeg, ten grains. Mix them. Or, 10. Take Powder of Wild Cucumber, one to two grains. Supertartrate of Potass, two drachms. Compound Powder ol Cinnamon. five, grains. Mix them for a dose. 111. Take Camphor, five grains. Antimonial Powder, two grains. Aromatic Confection, ten grains. Make them into a bolus, to be taken at bed-time. Or, 12. Take Solution of Acetate of Ammo- nia, half an ounce. Pure Water, one ounce. Antimonial Wine, twenty-four drops. Aromatic Spirit of Ammonia, fif- teen drops. Syrup of Ginger, two drachms Mix them as a draught. $.i- CACHEXIA;, OR CACHECTIC DISEASES. ClaSS 111. readily exhale in so small a quantity of air, which is only changed so fast, as may be necessary to permit tbe lamps to burn. At the same time tiie lymphatics ofthe cellular membrane are stimulated by the heat into greater action, as appears by the speedy reduction of the tumid legs. Possibly it might be well worth trying an experiment upon a person labouring under a general anasarca, by putting him into a room filled with air heated to about 120 degrees, which would pro- bably excite a copious general diaphoresis, and an universal cellular absorption, both from the lungs and every other part. That air of so great heat may be borne for many minutes without much incon- venience, has been demonstrated by the experiments made in heated rooms by Dr. Fordyce. Another experiment of using warmth in anasarca and other dis- eases, might be by immersing the patient in warm air, or in warm steam, received into an oil-skin bag, or bathing-tub of tin, so mana- ged that the current of warm air or steam should pass round and over the whole of the body, except the head, which might not be exposed to it: and thus the absorbents ofthe lungs might be in- duced to act more powerfully by sympathy with the skin, and not by the stimulus of heat*. By employing stimulants, we sometimes are able to increase the action of the absorbent vessels, and thereby occasion watery fluids to be absorbed from their cavities. As such, mercury has some- times been made use of; but it is apt to leave a great degree of weakness behind it, and to prove thereby highly prejudicial. If mercury will cure the disease on which dropsy depends, then it will be a proper remedy, but not otherwise. The parts affected with dropsy have been stimulated by rubbing them very well every morning with warm dry flannels; and the practice is certainly productive of a very good effect. Ammoniated liniment, and such other stimulating applications, can only prove useful in partial dropsies. To remove swellings of the legs proceeding from a deficient action of the absorbents of the lower extremities, a warm saline pediluvium has often been used with success. Tbe quantity of sea-salt should be about one-thirtieth part of the water, which with about one- eightieth part of the sulphate of magnesia, or bitter cathartic salt, constitutes the medium strength of the sea-water round this island. In such a pediluvium, the legs should be immersed for half an hour every night for a for;nigut, at the heat of about 96 or 98 degrees. Dr. Reid, in his Treatise on Sea-bathing, recommends an uni- versal warm bath of sea-water in cedematous swellings, and appa- rently has employed it with success. He advises friction at the same time to be diligently used in the bath on the tumid limbs, * This and the former experiment have been proposed by the late Dr. Darwin. See vol. ii. of his Zoonomia, article iv. Sorbealia. Order II. dropsy in the cellular membrane. 543 taking care always to rub them from their extremities towards the trunk of the body, and not in the contrary direction, as in this way the progress of the fluids in the absorbent system must be most facili- tated, though these vessels are furnished with valves to prevent its return. In a warm bath of sea-water the stimulus of the salt is added to that of the heat. The evacuation which will be attended with the least danger of inducing debility, and at the same time with the best effect, is the excretion by the kidneys; and it is on this account tbat diuretics are more generally employed in all cases of dropsy, than any other class of medicines. Even these often fail, however; but not un- frequently, we may presume, from their use being discontinued too soon. Of the class of diuretics, none seems to be more active than the digitalis. Its power of increasing the discharge from the kidneys, and of succeeding in effecting a cure of dropsical affections, in consequence of the increased evacuation produced by it, has of late been clearly ascertained in a great variety of instances. On account of its acting powerfully on the nervous system, destroying its mo- bility, and weakening the vital powers by repressing arterial action, it has, however, by some practitioners, been thought an improper remedy in dropsy; but even large doses of it have been given in this disease without any of those uncontrollable and dangerous effects, which are said to deter many from its use, being observed to ensue. It is a circumstance of curious and interesting moment, not perhaps very generally known, that a relaxed, weakened, and de- pressed state of the system, is the most favourable for displaying the full effects of digitalis. Dr. withering* had early pointed out the fact, tbat in persons of tense fibres and great natural strength, labouring under ascites or anasarca, the digitalis seldom succeeded ; and that, on the contrary, where the pulse was found feeble, or intermitting, the anasarcous limbs and body soft and yielding, the countenance pale, and the skin cold, the diuretic powers of the plant were more conspicuous. We are informed by Dr. Macleanf that these observations fully accord with those which he made ; and. he adds, that it seldom suc- ceeds in those of a fat corpulent habit with a dull sluggish irritable fibre, while it speedily relieves those of a weak, delicate, irritable constitution with a thin, soft, smooth skin, which in the anasarcous limb is transparent. When the urine is not serous, I have perceived that digitalis usually .fails of success; on the contrary, 1 have found it to succeed where the habit was not entirely depraved, or the substance of the viscera not -affected. When the organs of digestion fail, and there is frequent sickness or diarrhoea, and the bad habit of body * See his Essay on Digitalis, p. 189. 1 See his Inquiry into the iNature, kc. of Hydrothoras, p. 251. 544 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III is more remarkable than the extent or seat of the dropsy, its use ha3 appeared to be injurious. It may not here be unworthy of notice, that where Ihe foxglove is given in such doses as to excite nausea, or to produce an evident narcotic effect, it does not then operate as a diuretic. In a long use of it, its narcotic etfect seems to preclude its action as a diu- retic. A diarrhoea supervening on the use of this remedy, is like- wise found to stop its diuretic etfect. If the digitalis does not answer within the first fortnight, the best way will be to change it for some other diuretic ; as it not unfre- quently happens, that where we have failed with one remedy of this class, we shall be successful with a second or a third. No class of medicines is so uncertain in their etfect as this ; and it will often occur that a diuretic of very inferior expectation will procure the effect we wish, after a failure of those which rank highest in power. In employing the foxglove in dropsy, we may give it either in infusion* or saturated tincture, as mentioned under the head of Phthisis ; or we may give il in substance, washing it down with a teacupful of any diuretic infusion. The digitalis lutea has been found by Dr. Careno, of Vienna, te possess stronger diuretic powers than the digitalis purpurea, and without producing any of the usual noxious effects. He tells usf that he has succeeded in curing many dropsies with the digitalii lulea after the other species had failed. The potassae supertartras is another diuretic which is often em- ployed in dropsical affections with a very happy effect. As pos- sessing no deleterious qualities, and being easily managed by prac- titioners of the smallest judgment, a preference over the digi- talis has been given to it by some. Whether it possesses as great an anti-hydropic power, has not been satisfactorily ascertained. The experiments of Dr. Home J and Dr. Ferris || seem to assure us that it does ; but from my own experience 1 am induced to conclude that it does not. In some cases, however, the potassae superlartras diminishes Ihe swellings very speedily. It produces an increase of urine with watery stools ; and for the most part lessens the patient's size more quickly than the increase of urine would lead us to expect. When it is likely to prove successful, it usually operates very early, pro* ducing, in general, an increased Row of urine within tweuty-four hours ; but its salutary effects have been known to have been t See Memoirs of the Royal Academy of Berlin, for 1794—5. • X Clinical Observations, Experiments, &c. p 349. || Medical Histories and Reflections. * 13. ft Infus. Digital. Purp. 3vj. Confect. Aromat. gr. x. Sp jElher. Nitr. 3«- M. ft. Haustus bis in die sumendus. • 13. Take Infusion of Purple Foxglove, six drachms. Aromatic Confection, ten grains. Spirit of Nitric jElher, one drachm. Mix them, and take this draught twice a day. Order II. dropsy in the cellular membrane. 545 delayed to the end ofthe third or fourth week. It is given in doses of from two drachms to one or two ounces a-day, as by habii it loses a great deal of its effect. When the quantity is considerable, it will be best to divide it into three or four doses, instead of taking it all at once, which few stomachs will bear. In conjunction with gamboge, as before advised, it forms a powerful medicine, and according to circumstances, may be made either to assist or take the lead of the digitalis. From a junction of the potassae supertartras with digitalis or squills* 01 both, (see Hydro-thorax) interposing purgatives occasionally, the greatest advantages have been derived in some cases which occurred in my practice. A total abstinence from drink has long been considered as highly necessarv in all cases of dropsy : but in many instances the practice has been carried to a considerable length without any advantage. It semis, however, to have fallen a good deai into discredit, as large quantities of watery liquors are often now allowed, where diuretics, but more particularly the potassae supertartras are given. This mode of treatment seems indeed by far more proper than the former, as these medicines can hardly be carried in any quantity to the kidneys, without being accompanied with a large poilion of water. When, upon a fair trial, the quantity of urine is not found to be increased by drinking water or other watery liquorsf, their uso may in that case be discontinued. Beer boiled with juniper berries is much used as a diuretic drink by the German physicians. " 14. ft Potassa? Supertartrat. 3'j. Pulv. Cinnam. Comp. gr. v. ----Digitalis, gr j. M. ft. Pulvis bis terve in die sumendus. Vel, 15. ft Pulv. Digitalis, gr. ss—j. ----Scillae, gr. j. Potassae Supertart. 3'j. M. it. Pulvis terin die adhibcndus. * 16. ft Rad. Armoraciae Incis. Sem. Sinap. C. aa |ss. Aq. Bullient. Oj. Infund. perhoras xij. et adde Liquori colat. Potassae Acetat. 3"j Spirit. Junip. Comp. |ij. M. Bibat aeger cyathum ter quaterve in die. Vel, J7. ft Decocti Gcnistae Recent, ?xi xij. 69 * 14. Take Supertartrate of Potass, two drachms. Compound Powder of Cinna- mon, five grains. Powder of Foxglove, one grain. Mix them. It may be taken twice or thrice a day. Or, 15. Take Powder of Foxglove, half a grain to one grain. ------Squill, one grain. Supertartrate of Potass, two drachms. Mix them, and let this powder be given thrice a day. t 16. Take Horseradish Root, sliced, , Mustard Seed, bruised, of each halt an ounce. Boiling Water, one pint Infuse them for twelve hours, and to the strained liquor add Acetate of Potass, three drachms. Compound Spirit of Juniper, two ounces. Mix them, and let the patient drink a wine- glassful Ihree or tour times a day. Or, 17. Take I)f the disease, or that in which the water is not confined within the ventricles, being cured by incision after the application of the trephine. HYDRO-THORAX, or DROPSY of the CHEST. Oppression of breathing, particularly on motion and when in an horizontal posture, difficulty of lying on the side where effusion does not exist, sudden startings from sleep, with anxiety, and palpitations at the heart, irregularity of the pulse, cough, occasional syncope, pale- ness of visage, anasarcous swellings of the lower extremities, thirst, and a diminution of urine which is high coloured and on cooling de- posits a pink or red sediment, are the characteristic symptoms of hydro-thorax ; but the one which is more decisive than all the rest, is a sensation of water being perceived in the chest by the patient on certain motions of the body, or as if the heart were moving in a fluid. By percussion with the hand upon the chest, when the patient is in an erect position, and also by pressure upon the abdomen, which con- siderably aggravates the sense of suffocation for the moment, as well as the other symptoms which attend on hydro-thorax, we may be able in many cases clearly to ascertain the accumulation of water in the chest. The former is strongly recommended as a test by Covissart, and the latter by Bichat, both of them being men of eminence. By combining both means we may be able to determine more decisively than by adopting either singly. The diseases with which hydro-thorax is most likely to be con- founded are, empyema, angina pectoris, asthma, and organic affec- tions of the heart, or aneurismal dilatations of the large vessels connected with it; but by a close attention to the symptoms which ' See London MedicaL Repository, vol. iv. p. 369. 564 cachexia, or cachectic diseases. Class III have been pointed out under these beads, we shall be able to distin- guish between them with tolerable accuracy. The causes which give rise to the disease are pretty much the same with those which are productive of the other species of dropsy. In some cases it exists without any other kind of dropsical affection being present, but it prevails very often as a part of more universal dropsy. Hydro-thorax is frequently a disease of advanced life, and like other dropsical affections, it often succeeds debility, however induced. It is, however, the consequence now and then of previous inflammation in the thorax. It chiefly attacks males who have addicted themselves to free living, especially to potations of any intoxicating liquor. Such as have long suffered from gout and asthma, are peculiarly liable to it. It frequently takes place to a considerable degree before it becomes very perceptible ; and its presence is not readily known, the symp- toms, like those of hydrocephalus, not being always very distinct. In some instances the water is collected in both sacs of the pleura, but at other times it is only in one. Sometimes it is lodged in the pericardium alone ; but for the most part it only appears there when at the same time a collection is present in one or both cavities of the thorax. Sometimes the water is effused in the cellular texture of tbe lungs, without any being deposited in the cavity of the thorax. In a few cases the water that is collected is enveloped in small cysts of a membranous nature, known by the name of hydatids, which seem to float in the cavity ; but more frequently they are connected with and attached to particular parts of the internal surface of the pleura. Hydro-thorax often comes on with a sense of uneasiness at the lower end ofthe sternum, accompanied by a difficulty of breathing, which is much increased by any exertion or motion, and which is always most considerable during night, when the body is in an horizontal posture. Along with these symptoms there is a cougb that is at first dry, but which, after a time, is attended with an ex- pectoration of thin mucus. There is likewise a paleness of tbe complexion, and an anasarcous swelling of the feet and legs, together with a considerable degree of thirst and a diminished flow of urine; occasionally the face swells and pits upon pressure, especially in the morning; and these signs of disease are accompanied by debility and loss of flesh. Under these appearances we have just grounds to sus- pect that there is a collection of water in tbe chest. The symptoms which have been described gradually increase, but their progress is slow, and a considerable time elapses before the disorder is fully formed. The difficulty of breathing at length becomes excessive. The patient can seldom remain in a recumbent posture for any time, and the head and upper part of the trunk mu^t be supported almost erect. The sleep is frequently interrupted on a sudden by alarming dreams, out of which the patient quickly starts up in bed, with a Order II DROPSY OF THE CHEST. 565 sense of impending suffocation. Convulsive efforts of the muscles subservient to respiiaiion, resembling an attack of spasmodic asthn.a, with violent palpitations of the heart, generally accompany the par- oxysms, which are also frequently excited by the most trifling volun- tary motion, or by a fit of coughing. When afflicted with these distressing symptoms, the patient is under the necessity of continuing erect, with his mouth open, and he betrays the utmost anxiety for fresh air. His face and extremities are cold : the pulse, with little exception, is feeble, irregular, and in- termits in a degree seldom ^experienced in other disorders, and a pain or sensation of numbness frequently extends itself from the heart towards the insertion of the deltoid muscle of one or both ai ms, Ex- cepting a livid hue of the lips and cheeks, the countenance is pale, and indicates a peculiar anxiety and ghastliness of appearance, and together with the upper parts of the body is usually covered with a profuse clammy sweat. Drowsiness, coma, or delirium, occasioned by the difficult transmission of the blood through tbe lungs, and want of sleep, frequently attend the latter periods of hydro-thorax, and from the same cause the expectoration is sometimes bloody. Now and then a sensation of water floating about can be distinctly per- ceived by the paiient, on any sudden change of posture. No person has yet been able to point out the individual signs by which we can with certainty ascertain in which cavity of tbe chest the water is lodged, but some ingenious observations or data on this head have been offered by a late writer* on hydro-thorax. Our prognostic in hydro-thorax must in general be unfavourable, as it has not been often cured, and in many cases will hardly admit even of alleviation, the difficulty of breathing continuing to increase, until the action ofthe lungs is at last entirely impeded by the quan- tity of water deposited in the chest. In some cases the event is sud- denly fatal, but in others it is preceded, for a few days previous to death, by a spitting of blood. Now and then hydro-thorax ends in general dropsy, by which it is indeed sometimes accompanied from the beginning. But it more commonly impedes the action of the heart or lungs before universal dropsy has taken place, and destroys the patient apparently by suffocation in consequence ofthe increased pressure of the accumulated fluid on the lungs, or by apoplexy from the pressure of dark venous blood on the brain, not unfrequently ac- companied with serous effusion, either on its surface or in its ven- tricles Dissections of this disease show that in-some cases the water is either collected in one side of the thorax, or that there are hydatids formed in some particular part of it; but they more frequently dis- cover water in both sides of the chest, accompanied by a collection in the cellular texture and principal cavities of the body. The fluid is usually of a yellowish colour, possesses properties similar * See Dr. L. Maclean's Inquiry into the Nature, Causes, and Cure of this Disease, p 63. -366 CACHEXIA, OR CACHECTIC BISBASES. CUtSS HI to serum, and, with respect to its quantity, varies very much, being from a few ounces to several quarts. According to the quantity, so are the lungs compressed by it; and wh*»re it is very considerable, they are usually found much reduced in size. When universal anas- arca has preceded the collection in the chest, it is no uncommon oc- currence to find some of the abdominal viscera in a scirrhous state. The treatment of hydro-thorax is to be conducted on the same general plan with that of anasarca; viz. by emetics, purgatives, and diuretics. With respect to emetics, they do not seem, however, well calculated to afford any considerable degree of relief; and as the great desideratum in the cure of this disease is to evacuate the water without increasing the weakness still farther, purgatives, particularly those of a drastic nature, such as scammony, gamboge, he. are not advisable. If the bowels are confined at any time, aperients of tbe saline class may be given from time to time as the occasion may re- quire. Possibly a combination of potassae supertartras and hydrar- gyri submurias* taken at night, with something of a more active na- turef in a liquid form the following morning, if necessary, would produce very beneficial effects. The medicines most to be relied upon in hydro-thorax are diure- tics; and that which formerly was chiefly employed in this species of dropsy is the squill, because, besides its diuretic effect, it pos- sesses that of promoting an evacuation from the glands of the lungs ; in administering it, we should push it to as large a quantity as the stomach will bear without excifing nausea. Any of the forms recommended under the head of Anasarca may be prescri- bed ; and besides the powder, we may try either the oxymel, vine- gar, or tincture : the ingredients indeed with which the squill is combined in the two former may, perhaps, add to its virtues. If after a sufficient length of time we should fail to procure any good effects from a use of the squill, we ought then to make trial of the digitalis, as advised under the same head and that of Phthisis. Dr. Maclean offers it as his opinionj that digitalis exerts no diuretic operation on the urinary organs, but that as a successful X See pp. 158 and 160 of his Inquiry into the Nature, Sic. of Hydro-thorax. * I-ft Potassa Supertarlrat. g. x—xx. Hydrargyri Submur. gr. ijj—iv. Pulv. Zingib. gr. v. Syrup. Simpl. q- s. M. ft. Bolus hora decubitus sumendus. t 2. ft Infus. Sennas, f. 3*- Potassae lartrat. 3j- Tinct. Jalapffi, f. 3'ij •1. Take Supertartrate of Potass, from tea to twenty grains. Submuriate of Mercury, two to four grains. Powdered Ginger, five grains. Syrup, a sufficiency to form a bolus, which may be taken on going to bed. f 2. Take Infusion of Senna, ten drachms. Tartrate of Potass, one drachm. Tincture of Jalap, two drachms. Syrup Rhanini, f 3,i- M. ! Syrup of Buckthorn, one drachm. ft. Haustus primo mane adhibeudus si opus Mix them, and let this diaught be taken in fuerit. I tbe morning, if necessary. Order II. dropsy of the chest. 557 agent in dropsy its effects are confined to fhe absorbents, and pro- bably in a certain degree extended to the exhalants. When it increases the urinary secretion with promptness in dropsy, he thinks it may be attributed wholly to its restoring the impaired or lost function of tbe absorbing lymphatics, and probably by lessening se- rous effusion at tbe same time. In administering this medicine the principal circumstances to be regarded, are the age, strength, peculiar habit of the patient, stage of tbe disease, and degree of urgency of the symptoms. If the disease be far advanced, and immediate danger is indicated, the dose should be such as to produce a speedy effect. In general a grain of the powder, or an ounce of the infusion* taken three times a day, viz. morning, noon, and night, may be regarded as a full dose for an adult of moderate strength. If the herb be in perfect preservation and genuine, the habit will most likely feel tbe influ- ence of this quantity in a few days. In female constitutions, or in males whose strength has been much reduced, this quantity should not be given oftener than twice in the day, evening and morning, and in young subjects tbe dose ought to be reduced still farther in proportion to the age. Perhaps M would be best not to continue the use of digitalis for any length of time, but to stop for certain short intervals, as we shall thereby guard against its producing any deleterious effects, and prevent its disordering the stomach, or habit at large. During a course of this medicine, the state of the pulse, the stomach, the bowels, and sensorial functions, ought to be watched attentively. If it acts powerfully on the bowels, and produces either pain, griping, or a number of copious watery evacuations following one another in quick succession, attended with extreme faintness, languor, and prostration of strength, its use must be discontinued for a day or two, and from ten to fifteen drops of the tincture of opium be given in some cordial water, repeating this dose at proper intervals, accor- ding to the frequency of the evacuations and the consequent debility. A lax state of tbe bowels has, however, been observed to be vpry favourable to the successful exhibition of digitalis and other diuretic medicines. * 3. ft Fol. Digit. Purp. Contus. 3iss. Cane]. Alb. Contus. 3j. Aq. Fervent, f. |viij. Infunde per horas quatuor in vase aperto, dein liquorem cffuude. ft. Infusum. Vel, 4. ft Infusi Digitalis Purp. f. gss— ^j. Aq. Menth. Pip. f. 3iij. Potassae Acetat. gr. xv. Spirit. jEther. Nitrici, f. 3i. M. ft. Haustus bis terve de die capiendus. * 3. Take Leaves of Purple Foxglove, bruised, one drachm and a half. Canella Bark, bruised, one scruple. Boiling Water, eight ounces. Let them infuse for four hours in a covered vessel, then strain off the liquor for use. Or, 4. Take of this Infusion of Foxglove, half an ounce to one ounce. Peppermint Water, three drachms. Acetate of Potass, fifteen grains. Spirit of Nitric jEtherj one drachm. Mix them, and let this draught be taken twice or thrice a day. 568 CACHEXIA, OR CACHECTIC DISEASES. Class III When foxglove disorders the stomach, and in consequence of its unguarded or injudicious use, produces alarming symptoms, frequent doses of the confectio opii in small bulk, as in that of a pill, with warm cordials in very small quantity, (for the stomach immediately rejects every thing in large draughts) warm volatile anodyne embro- cations to tbe epigastrium, and spirituous fomentations to the feet, will be found in general effectual means. If the stomach rejects ev- ery thing, rich broth glysters in small quantity, with from 80 to 150 drops of tinctura opii, may be thrown up, and repeated according to circumstances. When, after a fair trial of both squill and digitalis, the flow of urine is not increased, although these medicines have been em- ployed in increased doses, we must have recourse to diuretics of another class, such as the saline. Those in ordinary use are the potassae subcarbonas, potassa? acetas, broom-ashes, and potassae supertartras, the latter having been much used of late years, and frequently with great success in several species of dropsy—(See Anasarca). We may give this drug either by itself, or combine it with squill and digitalis*, or with the other diuretics noticed under the head just referred to. At the same time that we have recourse to these means, we should apply blisters to the chest, shifting them from one side of it to the other, whenever they show a disposition to heal up; to pre- vent which, they ought to be dressed with some kind of stimulating ointment, such as the ceratum sabinae. The breathing will not only be somewhat relieved by the fre- quent application of a blister, but the irritation excited by it in tbe * 5. ft Fol. Digital. Purp. ExsicCat. Pulv. gr- vj. Potassae Supertart. 3yj. Pulv. Cinnam. Comp. 3j. M. ft. Pulv. in chartulas vj. distribuend. qua rum unam sumat bis terve de dieexlnfusi Baccarum Juuiperi Cyatho. Vel, 6. ft Pulv. Digitalis Purp. ----Scillae, aa gr. ix. Extract. Gentian. 3j. 01. Junip. tTl, viij. Syrup.Simpl. q.s. M. ft. Massa in pilulas xij. distribuenda, quarum unam capiat ter de die cum haustu se- quent!. 7. ft Fotassa? Supertart. 3'-—3'j- Aq. Fervent, f. |iss. Spirit. Junip. Comp. f. 3'j- Tinct. Cinnam. C f. 3i. M. ft. Haustus \ Mix them. * 5. Take Powder of Foxglove, six grains Supertartrate of Potass, six drachms. Compound Powder of Cinnamon, oue scruple. Mix them, and divide them into six papers, of which take one dose twice or tnnce a day, mixed in a small tea-cupful of an Infusioii of luniper Berries. Or, 6. Take Powder of Foxglove, ------Squill, of each nine grains. Extract of Gentian, one scruple. Oil of Juniper, twelve drops. Syrup, a sufficiency to form the mass, which is to be divided into twelve pills, of which let one be taken thrice a day with the following draught. 7.Take Supetartrate of Potass, from one to two drachms. Warm Water, one ounce and half. Compound Spirit of Juniper, two drachms. ■ — Tincture of Cinnamon, one drachm Order II. dropsy of the chest. 369 urinary passages may possibly tend to facilitate the operation of the diuretic medicines. Where hydro-thorax is complicated with convulsive breathing resembling the commou periodic asthma, it may be relieved by giving a grain of opium every hour for two or three doses, with about a drachm of aether in cold water, continuing the digitalis as before recommended. When the accompanying cough is so urgent as to prevent sleep and aggravate every other symptom, as sometimes happens, opiates combined with squills and other expectorants may be administered. If the patient is far advanced in life and his strength much exhausted, or if the disease has been of any standing, and con- siderable debility has ensued, it will be necessary to administer tonics, combined with diuretics, as recommended in the treatment of anasarca, or as prescribed below*. For preventing farther accumulation when the water has been removed, and giving strength and energy, they will also be proper. In a letter from Mr. Barr, of Birmingham, to Dr.. Beddoesf, we are informed of the happy effects which were derived in a case of hydro-thorax from the aid of pneumatic medicine in conjunction with other remedies, which of themselves had availed nothing. He states, that his patient's face was become pale and emaciated, his eyes started as if taking a last conscious view of their objects, his legs were swelled to such a degree that the skin was become much inflamed, and in danger of bursting; he had a continued tenesmus, and made very little urine; he could not endure a horizontal posture for a moment, but was under the necessity of being bolstered upright in bed through the night; even then he slept little, and that little was disturbed and unrefreshing, for he frequently started from his sleep, under an impression of im- mediate suffocation. t See his Considerations on the Medicinal Use and Production of Factitious Airs, * 8. ft Myrrh. 3ij. Ferri Sulphat. Potassa? Subcarbonat. aa 3ss. Extract. Anthemidis, 3j. Syrup. Simpl. q. s. M. ft. Pilula? xxxvj. capiat ij. ter in die cum cochl. magnis duobus mistura? sequentis. $• ft Infus. Gentian. Compos, f. £v. Potassa? Acetat. 3ss. Spirit. Junip. C. ------Armoraciae, C. aa f. ^ss. ------Mther. Nitric, f. 3y. M. ft. Mistnra 72 * 8. Take Myrrh, two scruples. Sulphate of Iron, Subcarbonate of Potass, of eaeh half a drachm. Extract of Chamomile, one scruple, Syrup, a sufficiency to form the mass. Divide this into thirty-six pills,and let two be taken three times a day, with two table-spoonsful of the following mixture. 9. Take Compound Infusion of Gentian, five ounces. Acetate of Potass, half a drachm, Compound Spirit of Juniper, -------------Horseradish, of each half an ounce. Spirit ot Nitric iEther, two drachms Mix tbem. OlO CACHEXIA, OR CACHECTIC DISEASES. ClaSS ill One quart of oxygen, mixed with nineteen of atmospheric air, was directed to be inhaled every day ; but as the symptoms were very urgent, it was thought right to join the use of those active medicines which had been prescribed for him before to no effect. He was ordered to take half a grain of digitalis in substance every evening, and four ounces of a decoction of the cortex cuspariae in the course of each day. On the third night after inspiring the factitious ah* he found himself more composed, he could remain longer in one posture, and the startings during sleep seemed both less frequent and less violent. Every night he was sensible of amendment; in ten days he could bear the removal of several of the pillows that bolstered hirn up in bed, and be could sleep for (hree or four hours without one starling fit. The swellings of his legs began now to subside, the tenesmus was entirely removed, the quantity of urine was considerably increased, and he could walk up stairs with much ease ; his appetite and cheerfulness began to return, and fhe pale face of disease to give place to the florid countenance of health. In the course of the second week the quantity of oxygen bad gradually been increased fo two quarts a day, diluted as before. In four weeks from the patient's beginning to inspire the vital air not a vestige of the disorder remained, except weakness ; he could lay his head as low in bed as when in perfect health, and sleep the whole night ; no swelling of the legs remained, no difficulty of breathing upon ordinary exertion, and every function was per- formed with regularity and ease. He discontinued the use of all medicines, except a laxative pill occasionally ; and at the age of sixty seemed to possess uncommon strength, agility, and vivacity. Such is the report made by Mr. Barr of the effects of vital air in hydro-thorax ; which, from having proved so highly beneficial, we may employ as an auxiliary mean. That aliment which contains the greatest quantity of nutriment in fhe smallest bulk, and which requires, at the same time, the least effort of the digestive organs to convert it into animal juices, reason and experience point out as the best in hydro-thorax. The food should be well masticated, and- fhe free motion of fhe diaphragm never interrupted by a full meal. During a course of diuretic medicines the patient should drink freely of liquids, and particularly of such as are supposed to increase the flow of urine. —See Ascites. If all our endeavours fo carry of£ the water, or promote its re- absorption, prove fruitless, and a fluctuation is evidenlly per- ceptible, and particularly when lodged iu the pericardium, we should then perform a paracentesis of the thorax. Where it is loose in the sacs of the pleura or in the pericardium, we may, wilh the assistance of diuretics joined with tonics,' possibly effect a cure by means of this operation ; but where it is accumulated in hyda- tids, or in the cellular texture surrounding the bronchiae, we shall derive no advantage from it. Order II rickets. 81i The practice of evacuating water, contained in the thorax by an incision, is of as ancient a date as the days of Hippocrates. For 4he mode of performing the operation, I beg leave to refer to Mr. Bell's System of Surgery. Before the evacuation ofthe water, the patient's situation seldom admits of much bodily exertion. Somewhat, however, may be done by the frequent and diligent use of a flesh-brush, or by friction with flannel all over the body, but especially over the chest, and as near tbe seat of the complaint as possible. From the circulation of blood being very languid in tbe feet and legs, these parts are in gen- eral very cold, and ought therefore to be enveloped in worsted or fleecy hosiery stockings, being well rubbed every morning and night. The great coldness of the bodies of dropsical subjects, and the total want of perspiration, evidently point out the necessity of warm clothing; and there are no cases in which a flannel covering will prove more beneficial, or more grateful to the sensations of the patient. As soon as the evacuation of the water, or the relief of urgent symptoms, will permit, no day should elapse without the patient either walking, riding on horseback, or in an open carriage; for the frequent but gentle agitation of the body, and the moderate exertion of the muscles, together with the salutary influence of a pure healthy atmosphere, will assist greatly in giving tone, vigour, and energy to the whole frame. The lungs of some persons who labour under hydro-thorax are, however, extremely susceptible of a cold frosty air; it being no sooner respired, than they are seized with a cough and wheezing, and experience a painful sense of con- striction about the chest. Under such circumstances it will be bet- ter to keep within doors. IV.—INTUMESCENTIA SOLIDS, or SWELLINGS of the SOLID PARIS. RACHITIS, or RICKETS. The characteristic marks of this disease are, an uncommon size •of the head, swelling of the joints, flattened ribs, incurvation of the spine, distortion of the cylindrical bones, protuberance of the belly, and general emaciation. Rickets is an hereditary disease in some families, though parents that have been affected with it have sometimes a healthy and robust offspring. In some instances, I think, it can be traced to a venereal taint, which, though not the immediate cause, is very often an exciting one of it and scrofula. A.t least, it is certain tbat syphi- lis, transmitted from parents to their children, appears in the latter in a manner very different from that in which the former are affected. We find that the children of the indigent and profligate are those most generally afliicted with rickets 5 but at the same timp 572 CACHEXIA, OR CACHECTIC DISEASES. ClaSS HI. it must be allowed that there are many circumstance*) which conduce to this disease ; such as a damp and cold residence, impure air, inattention to cleanliness, bad nursing, want of due exercise, a deficiency of food and debility. Difficult dentition, and the pain and bowel complaints arising from it, may favour, in a powerful manner, the action of the exciting causes of rickets. The proximate cause of fhe disease is now supposed to be a deficiency of the phosphate of lime, or animal gluten in the bones; hence the latter are deprived of that necessary strength and soli- dity in consequence ofthe prevailing debility in the vessels, so that the former, instead of being conveyed to the bones, is deposited in other parts of the body. Thus we find particles of lime often eva- cuated in the urine of rickety children. Tbe disease seldom appears before the ninth month, and very rarely shows itself after the second year of a child's age. It is more frequently met wilh among the children of the poor than in those of higher rank, and seems to be almost solely confined to cold climates where much moisture prevails, which seems fo indicate fhat a peculiar atmosphere has a great share in giving rise fo it. It usually comes on slowly, and fhe first appearances of it to be observed are, a flaccidity of the flesh, emaciation ofthe body, pale- ness, and loss of colour in the cheeks, if they have been rosy, and a slight degree of tumefaction ofthe face. The head at fhe same time appears large with respect to the body, and the sutures and fonfanelle are preternaturally open. The head continuing fo in- crease in size, the forehead becomes at length unusually prominent, and the neck appears very slender in proportion fo the head. Dentition is at the same time very slow, and much later thari usual, and the teeth thai do appear soon spoil, and are apt fo fall out. The ribs lose their convexity, the sternum protrudes in the form of a ridge, the spine is incurvated, and the epiphyses at the several joints of the limbs become swelled, while at the same time the limbs between fhe joints appear to be more slender than before, and from their inability fo support the weight ofthe body, become somewhat flexible, and at last much distorted. With these symptoms the child experiences a great diminution of its strength, is averse to making fhe least exertion, and is unable to walk. Its appetite is not often much impaired, but its stools are usually frequent and loose, and its abdomen appears uncommonly full and tumid. With regard to its mental faculties, the understan- ding is most generally very mature, but in a few cases stupidity or fatuity ensues. At the commencement of the disease there is no fever present; but in its more advanced stage, a frequent pulse, with other febrile symptoms of a hectic nature, attend. In some cases the disease proceeds no further, and the child gra- dually recovers its health and strength, the limbs bein? left how- ever in a distorted state. In others it continues to increase, till at last every function of the animal economy becomes affected, and the tragic scene is closed by death. Order 11. RICKETS. 573 Cretinism (which is to be met with very generally among the inhabitants of that part of Switzerland nearest to Italy, in the deepest valleys of the Alps, where the atmosphere is extremelv humid, in cousequence of numerous waterfalls and rivulets that emit powerful exhalations through tbe influence of tbe sun's heat, while they are secluded from the access of every drying wind) is a disease which has been supposed to be only as high a degree of rachitis as human nature can possibly sustain*. This opinion is cor- roborated by an observation that the different stages or degrees of the evil correspond with the variations in the atmosphere. Those, for example, who inhabit the deepest and most recluse valleys are redu- ced to the lowest state of imbecility and idiotism; in those who are somewhat more elevated, tbe mental powers are not so completely ob- tunded; and others still more elevated, and of course less exposed to exhalations, will probably be deformed merely with wens or swell- ings about the joints, and other symptoms of rachitis. Those who are nearer to the summits are perfectly exempt from all these appearances. Cretinism is, in many instances, connected with goitre or bron- chocele (see this disease). An enlargement of the thyroid gland is indeed a striking feature in the unsightly aspect of the cretin, but it is not a constant attendant; for cretinism is frequently observed without any affection of the thyroid gland, and this gland is often much enlarged without any affection of the intellectual faculties. The production of cretinism by the bad quality ofthe air and food, the neglect of moral education, and other evils attendant upon pover- ty and indigence, and the deformity becoming so general in those re- gions by a seclusion from the rest of mankind, and by perpetual inter- marriages, is supported by facts so strong and pointed, that the greater number of cases in mountainous districts may safely be ascribed to these causes, instead of to the use of snow water, as a few have supposed. That a use of snow water produces either goitre or cretinism, is an absurd idea, for persons born and living in places contiguous to the Glaciers, who drink no other water than what flows from the melting of snow and ice, are not afflicted with these disorders, and they are observed frequently in places where snow is unknown. The causes of cretinism begin to operate upon the system soon after, and perhaps even before birth; the want of energy in the parent is communicated to the offspring, the children become deformed and cachectic very early in life, the growth and develop- ment ofthe body are impeded, the abdomen becomes enlarged, and tbe glands swelled in various degrees; moreover, the powers of the mind remain dormant, and are at length obliterated, partly from * See Dr. J. F. Akerman's Inquiry into the Causes of a Singular Deviation from the Human Species in the Alps. 574 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III the want of proper organization, and partly from tbe total neglect of every thing like education. The head of the cretin is deformed, his stature diminutive, hit complexion sickly, his countenance vacant and destitute of meaning, his lips and eyelids coarse and prominent, his skin wrinkled and pendulous, his muscles loose and flabby, and frequently he is affected with an enlargement of the thvroid gland or goitre, which greatly adds to his unsightly aspect. The qualities of his mind correspond to the deranged state of his body, and the disease prevails in all the intermediate degrees from excessive stupidity to complete fatuity. Cretinism was observed in Chinese Tartary by Sir George Staunton, in a part of that country much resembling Savoy and Switzerland in its Alpine appearance. Dr. Abercrombie mentions*, that many cases of it are to be met with in the Pyrennees, and les Cevennes of France. A race of Cretins existing in the South of France has lately been presented to the notice of the professionf under the appellation of Cagotts. In this part of France this degraded race is widely exten- ded : the individuals of it, deformed with bronchocele, have an indis- tinct articulation, an air of stupidity, a sallow complexion, and an ex- treme apathy to all external objects. The Cagotts are pretty muck the same as the Cretins ofthe Alps; they both present the same de- gree of imbecility, the last remains of the intelligence of man, together with the last traces ofthe human form. The rickets, although attended with much distortion of the bones, and various other unpleasant symptoms, very seldom proves fatal; * and we are only to regard it as attended with danger where the distortion becomes so great as to affect the office of the lungs and other organs; or where the enlarged size of the head shows that it contains a considerable quantity of water within it; or where the food is passed unchanged by digestion, which denotes a highly dis- eased state of tbe mesenteric glands. Children at the breast are more exposed to peril than those that have reached three or four years. Various morbid affections of the internal parts are to be observed on opening the bodies of those who have died of this disease. The brain has commonly been discovered in a flaccid state, with effu- sions of a serous fluid in its cavities. The lungs have been found in a morbid jcondition, seemingly from some inflammation that had come on towards the close of the disorder; the spleen and liver are flaccid and enlarged; the intestines are pale, or rather whitish; all the lymphatic glands, especially those of the mesentery and bron- chia, are enlarged, and tbe latter sometimes suppurated; tbe bones, reduced to a fibrous state, are flexible, bent in several directions, and easily cut. With respect to the muscular parts, they * See his Inaugural Dissertation on Alpine Idiotism. t See the Translation of Travels in the Pyrennees, by Mons. Ramond Order II rickets. 575 have been found very soft and tender, and the whole of the dead body without that degree of rigidity which is so common in almost all others. Mons. Leveille has paid some attention to the structure of a soft rickety bone, and it is described* as having been exceeding light, yielding with facility to the scalpel, and presenting throughout a cellu- lar and spongy texture. Concerning the condition of the bones in rickets, Bichat remarks, tbat in this disease the solid structure form- ing the walls of a long bone entirely disappears: the whole of its in- terior presents a homogenous appearance and cellular texture through- out : the periosteum is much thickened. In some instances the bones in rickets have been observed^ to be nearly of the consistence of common cartilage; have presented throughout an areolated texture, the cells being in some parts large, and containing a brown gelatinous substance. In the cure of the rickets we should proceed on the plan of invi- gorating the system by bracing the solids and promoting digestion and the formation of good chyle. For this purpose, we must have recourse to such medicines as possess a tonic power, together with fre- quent immersion in cold water, the effects of which may be much increased by frictions with flannels, a free, open, and dry air, a gener- ous nutritive diet with wine, and proper exercise by carrying the child in an horizontal posture. An erect one might be apt to increase the deformity. As children cannot easily be prevailed upon to take the cinchona bark or any kind of bitters, for the purpose of invigorating the system, myrrhj and the metallic tonics must be employed. The most proper of these are the ferri carbonas, ferrum ammoniatum, and zinci oxydum, which may be given as advised below||, together * See Memoiros de Physiologie et de Chirurgerie Pratique, par Scarpa et Leveille. t See Medico-Chirurgical Transactions, toI. vii. part ii. p. 407. ? L R Myrrh. Optim. Pulv. Calumb. aa gr. v.—x. Ferri Sulphat gr. iss. M. ft. Pulvis, ex pauxillo syrupi bis quotidie ca piendus. || 2. & Vin. Ferri, f. 3j —3"j. ex cochl. ij. Decoct. Cort. Cinchon. bis in die. Vel, 3. g: Ferri Subcarbonat. gr. vj. Pulv. Rhei, gr. iv. Sacch. Alb. Pulv.gr. viij. M. ft. Pulv. mane et vespere sui .erdus. Vel, 4. ri Tinct. Ferri Ammoniat. f..^j. Capiat. AT. xx.—Ix. ex aqua; trigidee cyatho bis in die X I. Take Myrrh, Powder of Calumba, of each from five to ten grains. Sulphate of Iron, one grain and a half. Mix them, and let this powder be taken twice daily, mixed in a little syrup. || 2. Take Wine of Iron, from one drachm to lhree drachms twice a day with two table-spoonsful of a Decoction of Peru- vian Bark. Or, 3. Take Subcarbonate of Iron, six grains. Powdered Hhubarb, four grains. White Sugar, powdered, eight grains. Mix them. This powder may be taken morni.ig and evening. Or, 4. Take Ammoniated Tincture of Iron, from thirty drops to ninety twice a da/ in a glass of cold water. 576 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III with a few grains of rhubarb. The quantity of this is to be in- creased or diminished according to its effect*; and the dose of tbe ferri carbonas, ferrum ammoniatum, and zinci oxydum, may be aug- mented gradually. Where the child can be persuaded to take the cinchona, we may give it at the same time with the metallic tonics, either in substance, decoction, or infusion, or we may try the extract dissolved in a little Port wine. To assist the effect of these remedies, a gentle emetic should be given occasionally, but more particularly in those cases where the appetite and digestion are considerably impaired. The moderate agitation of the abdominal viscera produced by this medicine will greatly tend to remove the obstructions of the mesenteric glands. The bowels are to be kept gently laxative with rhubarb joined with a small quantity of any neutral salt. When the rickets are accompanied with mesenteric obstructions, deobstruents, with small doses of rhubarb, and repeated frictions on the abdomen, will have a beneficial effect.—See Scrofula and Atrophia. In cases of difficult dentition we should resort to the means ad- vised under this head, and in those of worms to vermifuge medi- cines. In venereal taints we may prescribe tonics combined with mercurials. Absorbents have been employed in rachitis by some practitioners, it is said, with considerable success, and may therefore be combined with the tonics before recommended. In rickets the principal advantage is to be derived however from gen ral treatment: the patient, if a resident in a city, is to be removed to the country, where an elevated and dry situation should be chosen ; he is to be supplied with a nourishing diet, and a moderate quantity of wine. But as the poor, amon& whom the Vel, 5. IJ; Ferri Ammoniat. gr. iij.—xv. Extract. Gentian, gr. vj. Syrup, q s. M. ft. Bolusaut pilul. bis'erve indie capiendus. Vel, 6. g; Tinct. Ferri Muriat. fit iii.—x. Infus. Cort. Cascaril. f. ^i. M. ft. Haustus ter in die adhibendus. Vel, 7. R Zinci Oxydi, gr. xij.—xxiv. Pulv. Cinnam. C. 3j. Sacch. Alb. 3ij. M. ft. Pulv. in chartul. xij. dividend, quarum unam capiat hora decubitus et mane quo tidie. Or, 5. Take Ammoniated Iron, from three grains to fifteen. Extract of Gentian, six grains. Syrup, a sufficiency to form th«m into a bolus or pills for a dose to be taken twice or three times a day. Or, 6. Take Muriated Tincture of Iron, from five to fifteen drops. Infusion of Cascarilla Bark, one ounce. Mix them, and give this draught thrice » day. Or, 7. Take Oxyd of Zinc, from twelve graim to twenty-four. Compound Powder of Cinnamon, one scruple.' White Sugar, two scruples. Mix them, and divide the whole into twelve papers, of which let one dose be taken night and morning. Order II. RICKETS. 577 disease is most frequently observed, cannot change their residence, .they should be placed in the highest apartment of the house, which should be kept well ventilated. The bed on which a ricketty patient lies, should consist of a hair mattress or oaten chaff, or it might be made of dried fern leaves, among which some aromatic herbs were mixed. Such beds are better than those made of feathers ; for they do not yield to the weight of -the body, and they are much drier. If the patient be very young he should be placed on his back, so tbat the weight of bis body may have as little influence as possible on the bones; but as it is painful fo remain constantly in this position, he may be allowed to sit up now and then, but not on a soft chair: he is to be placed on a seat capable of making a uniform resistance, with a high straight back, and without arms. He should not be allowed to walk for a consi- derable time; at first he will be incapable of doing so without assistance, and the strings and ribands necessary for supporting him .contribute, by pressing on the parietes of the thorax, to deform that cavity. Mechanical means have been proposed for obviating the effects of this disease, but it is nearly fruitless to attempt using any machines with very young children, and it is also impossible to confine them on their back in bed; besides, it would be extremely injurious to keep them constantly in this posture : the continued extension of the limbs, and the inactivity of the muscles, would add to the general debility, and consequently increase the disease. Splints applied to the limbs, strong leather boots, and the apparatus for the spine, are really useful only in those cases where the patient is of a certain age, and when the progress of the disease is gradual, and the strength not too much ex- hausted ; and even in most of these cases the inactivity necessarily occasioned by these machines is productive of disadvantages which are not compensated by their good effects. Apparatuses of this kind may probably therefore be fitter for correcting vicious attitudes contracted by children of a weak frame, than deformity arising from rickets. Mr. John Veirac, surgeon at Rotterdam, in his Treatise on the Rickets, which obtained a premium from the Society of Arts and Sciences at Utrecht, asserts, that the acidity of tbe milk in the stomachs of infants is incorporated with the mass of blood, and insin- uates itself into the very substance of the bones. We are informed by him, that the blood in these cases after death effervesces with the liquor ainmoniae subc. The cure he recommends corresponds with this theory, and consists in the exhibition of alkaline medicines. Mons. Bonhomrne, of Paris, in his Memoir on the Nature and Cure of Rachitis*, advises a similar mode of treatment. Accord- ing to this gentleman, the disorder arises on the one hand from the development of an acid, approaching in its properties to the vegetable acids, particularly the oxalic, and on tie other, from ^_______________________________________*__________ _ * See Dr. Duncan's Annals of Medicine for 1797 73 578 ©ACHEXI^S, OR CACHECTIC DISEASES. CiaSS lit. the defect of phosphoric acid, of which the combination with animal calcareous eajrth forms the natural basis of the bones, and gives them their solidity. From this opinion be infers, that the proper treatment of rachitis must turn on two principal points, viz. to prevent the de- velopment ofthe oxalic acid, and to re-establish the combination of the phosphoric with the basis of the bones. These intentions, he thinks, may often be accomplished by tbe in- ternal use of phosphate of lime: and phosphate of soda, and by the ex- ternal use of alkaline lotions. In this Memoir be relates several cases in which these practices were apparently attended with the best ef- fects. A powder was formed of equal parts of phosphate of lime and phosphate of soda, and taken by infants twice a day to tbe extent of a scruple for a dose. The alkaline solution was made by dissolving half an ounce of common potass in a pound of very pure spring water. When this solution is to be used, the skin must first be rubbed witb a dry cloth, or a piece of fine flannel, After this precaution, the dis- eased parts are to be washed carefully with the warm solution, and at length wiped sd as to leave no trace of moisture. This wash'must be repeated at least twice a day. We are further informed by Monsieur Bonhomme, that be has seen various instances of children cured of their disposition to rachitis merely by washing with the alkaline liquid ; but he considers the in- ternal remedies as possessing superior efficacy. He contends, that the calcareous phosphate taken internally is really transmitted by the lymphatic passages, and contributes to ossification; and that the internal use of the calcareous phosphate, whether alone or combined with the phosphate of soda, powerfully contributes to res- tore the natural proportions in the substance of the bones, and thereby accelerates the cure of rachitis. In support of these opinions, he re- lates various experiments made on youngjbwls, some of which took a proportion of calcareous phosphate with their food. After an exact comparison, there could (he tells us) be no doubt of the efficacy of calcareous phosphate in favouring the progress of ossification. ORDER III. IMPETIGINES. A depraved habit producing preternatural affections of tbe skin, or external parts of the body, characterises this Order. SCROFULA. Scrofula consists in hard indolent tumors of the conglo- bate glands in various^.parts of the body; but particularly in the neck, behind the ears, and under the chin, which after a time suppurate and degenerate into ulcers; from which, instead Order III. scrofula. 579 of pus, a white curdled matter, somewhat resembling" fhe coagulum of milk, is generally discharged. The first appearance of the disease is most usually between fhe third and seventh year of the child's age, but it may arise at any period between these and the age of puberty ; after which it sel- dom makes its first attack. It most commonly affects children of a lax habit, wifh a smooth, soft, and fine skin, fair hair, rosy cheeks, and a delicate complexion ; but it is occasionally met with in those of a dark one. It likewise is apt to attack such children as show a disposition to rachitis, and marked by a protuberant forehead, enlarged joints, and a tumid abdomen. Scrofulous persons are offen comely and handsome, and rather distinguished for acufeness of understanding and precocity of genius. They are however seldom robust, or able to endure much fatigue without having tbeir strength greatly exhausted, and fheir flesh much wasted ; but when they once begin to regain these, their convalescence is usually rapid. Scrofula prevails most in those climafes where the atmosphere is cold and humid, where the seasons are variable, and tbe weather unsteady. From latitude 45 to 60 is the principal climate of this disease. A long continuance of inclement weather may increase any predisposition fo scrofula ; and in persons already much predisposed to it, any uncommon, though temporary exposure to wet and cold, is sometimes an exciting cause of an immediate attack. Besides climate and exposure fo moist air and atmos- pherical vicissitudes, every other circumstance which weakens the constitution and impairs the general strength of (he system predisposes to scrofula; thus breathing impure tainted air unfit for respiration, and living upon food of an unwholesome and indi- gestible nature, which does not afford true nourishment to the body, favours an attack of scrofula by reducing tbe strength of fhe system, and making the person weakly. Tbe neglect of due per- sonal cleanliness, and of salutary exercise, indolence, inactivity, the want of warm clothing, confinement in cold damp habitations, &c. may all be regarded as so many exciting causes, and satisfactorily account for the prevalence of fhe disease among children employed in large manufactories, as at Manchester, &c. Scrofula is by no means a contagious disease, but beyond all doubt is of an hereditary nature, and is often entailed by parents on their children. The patient, it is true, is not born with the disease, but only with a greater aptitude to revive certain moibid impressions which may bring the lafent dispo- sition into action. There are indeed some practitioners who wholly deny that this* or any other disease can be acquired by an hereditary right; but that a peculiar temperament of body, bias, or predisposition in fhe constitution to some diseases may extend from both father and mother to their offspring r See Essay on the Diseases of the Absorbent System, bj W. Goodlad, 580 CACHEXIA, OR CACHECTIC DISEASES. ClOSS III is, I think, very clearly proved ; for example, we very frequently meet with gout in young persons of both sexes who could never have brought it on by intemperance, sensuality, or improper diet, but must have acquired the predisposition to it in this way. A predisposition to become affected by certain diseases on fhe application of exciting causes does certainly exist in the human race, and particularly so (there is every reason to presume) in scro- fula, gout, and mania. In some instances it is more strorHy marked than in others, but predisposition is inert, and of itself insufficient to produce disease. It requires for this purpose the application of an exciting cause. This is the proper light in which we should view what are termed hereditary predispoaition and hereditary disease. A remarkable circumstance attending the transmission of scrofula is, that although it is an hereditary disease, it does occasionally pass over one generation and appear again in fhe next, so that the grandfather and grandson (the first and third generations) shall both be scrofulous, while the intermediate one, which holds the more intimate relation of father and son, and connects the two others together, shall be exempted from any attack of the disease. The matter which scrofulous sores generate does not seem to possess much acrimony; for if fhe sore be of limited extent, the system does not suffer by its continuance ; nor do the neigh- bouring parts seem to be much affected by its vicinity. Neither is it contaminating, as has been proved by Mr. Kortuin*, who atlempted to transfer scrofula from one person to another by inoculation : but although he took great pains to insert the matter completely, and although he repeated the experiment frequently, yet all his attempts failed of success; as no disease was communicated, nor even any evident irritation excited at the place where the matter was inserted. All apprehension of scrofula being propagated by contagion or contact, appears therefore to be a groundless prejudice. The late Dr. Cullen supposed scrofula to depend upon a peculiar constitution of the lymphatic system. One of the most frequent symptoms of this disease is undoubtedly an enlargement of fhe lymphatic glands, and the frequency, and offen universality of such swellings, have induced some physicians to suppose scrofula as depending upon a morbid affection of the lymphatic system ; but many other parfs of the body which show little of a glandular structure are very often the primitive seats of scrofula. A modern writerf considers scrofula as a disease arising from and generated by disorders of the digestive organs, but this opinion is ill founded. Some writers have attributed much influence in its production to the habitual use of impure water, among whom is the late Dr. • De Vitio Scrofuloso,p. 218. 1 See Essay on Scrofula,by Mr. Richard Carmichael, p. 26. Order III. SCROFULA. 581 Heberdeen. In my opinion, scrofula is a disorder closely connected with a delicate constitution, lax fibres, and debility. It is a disease of very frequent occurrence in this country, partic- ularly in large manufacturing towns, appearing under various forms, and in different degrees of severity, from a state of mildness, which hardly betrays any perceptible external symptoms, to a state of vio- lence, which produces the must miserable objects of human wretch- edness; and whenever it mingles with any accidental or local com- plaint, it makes all the symptoms worse and more difficult to cure : this happens particularly in syphilis. The attacks of scrofula setm much affected or influenced by the periods of the seasons. They begin usually some time in the winter and spring, and often disappear, or are greatly amended, in sum- mer and autumn. The first app> arance of the disorder is com- monly in that of small oval or spherical tumors under the skin, unattended by any pain or discolouration. These appear in general upon the sides of the neck, below the ear, or under tbe chin ; but in some cases the joints of the elbows or ankles, or those of the fingers and toes, are tbe parts first affected. In these instances we do not, however, find small moveable swellings, but, on the contrary, a tumor almost uniformly surrounding the joint, and interrupting its motion. \ After some length of time, the tumors become larger and more fixed, the skin which covers them acquires a purple or lived colour, and being much inflamed, they at last suppurate and break into little holes, from which at first a matter somewhat puriform oozes out; but this changes by degrees into a kind of viscid serous discbarge, much intermixed with small pieces of a white substance, resembling the curd of milk. The tumors subside gradually, while the ulcers at the same time open more, and spread unequally in various directions : after a while some of the ulcers heal; but other tumors quickly form in different parts of the body, and proceed on in the same slow manner as the former ones to suppuration. In this way the disease goes on for some years, and appearing at last to have exhausted itself, all the ulcers heal up, without being succeeded by any fresh swellings ; but leaving behind them ugly puckerings of tbe skin, and scars of con- siderable extent. This is the most mild form under which scrofula ever appears. In more virulent cases the eyes are particularly the seat of the dis- ease, and are affected with ophthalmia, giving rise to ulcerations in the tarsi, and inflammation of the tunica adnata, terminating not unfre- quenlly in an opacity of the transparent cornea. In similar cases the joints become affected; they swell, and are incommoded by excruciating deep-seated pain, which is much increased upon the slightest motion. The swelling and pain con- tinuing to increase, the muscles of the limb become at length much wasted. Matter is soon afterwards formed, and this is discharged at small openings made by the bursting of the skin. 5&Z CACHEXIA, OR CACHECTIC DISEASES. CluSS 111 Being however somewhat of an acrimonious nature, it erodes the ligaments and cartilages, anil produces a caries of the neignbounng bones. By an absorption of the matter into the system, hectic fever at last arise-, and in the end proves fatal. The bones al-o of scrofulous persons partake of the general dis- ease in the constitution : tliey seem to contain a smaller proportion of animal earth, and a larger of gelatinous matter, than what ac- cords with the composition of a healthy bone, on which account they are exceedingly susceptible of a morbid action. The diseases to which they are most liable, are general and partial enlargement, inflammation, suppuration, and exfoliation. They are also easily fractured, which facility is much increased, especially in the long bones, by the deficiency of solid substance; for the cylindrical shell is preternaturally thin, and therefore mechanically weak, so that the bone breaks upon the application of an inconsiderable force. A diseased state of the vertebrae, which in consequence of the softness of their bodies occasions a protrusion of their spinal pro* cesses, and a compression of the medulla, is generally allowed to be closely connected, with scrofula. The primary attacks of scrofula often admit of an apparent cure, while their sequelae are secretly laying tbe foundation of diseases which undermine the patient's constitution, and unexpectedly manifest their insidious effects at a distant period of time, when no suspicion was entertained of their existence. When scrofula is confined to the external surface, it is by no means attended with danger, although, on leaving one part, it is apt to be renewed in others; but when the ulcers are imbued with a sharp acrimony, spread, erode, and become deep, without showing' any disposition to heal; when deep-seated collections of matter form among the small bones of tbe hands and feet, or in the joints ; or tubercles in the lungs, with hectic fever, arise, the consequences will be fatal. On opening the bodies of persons who have died of this disease* many of the viscera are usually found in a diseased state, but more particularly the glands of the mesentery, which are not only much tumefied, but oftqn ulcerated. The lungs are frequently discovered beset with a nu nber of tubercles or cysts, which contain matter of various kinds. Scrofulous glands, on being examined by dissection, feel somewhat softer to the touch, than in their natural state; and when laid open, they are usually found to contain a soft curdy matter mixed with pus. Examinations after death of those who have la- boured under a diseased state of the spinal column have shown that almost all the glands are found in an enlarged, diseased, and often suppurated condition, and that cysts are also discovered, connected with the diseased vertebrae, that contain curdy, purulent, and other matter of unequal consistence. Scrofula is a disease, the cure of which is of acknowledged «lj$culty. Its tjjgatment naturally divides itself into two periods. Order HI scrofula. 583 The first is, that in which, without any local sore or other marked symptoms of disease, there is sufficient evidence of a scrofulous predisposition prevalent in the system. The other is, that in which some local sore, or other scrofulous symptom, which re- quires appropriate management, that may either concur wifh the general treatment of the constitution, or interfere with it, has actually taken place. As scrofula is greatly promoted by the slow operation of a number of circumstances which produce a gradual change in the constitution, there is great reason to expect benefit frdm placing fhe patient in a different situation of circumstances. If, for in- stance, tbe continuance of improper diet has seemed to favour the appearance of the disease^ an amelioration of it will naturally counteract this tendency. A similar advantage will be derived from substituting the respiration of pure salubrious air, instead of what is tainted and unwholesome ; and in like manner exerf management conducive to health, and that will invigorate the body, will contribute fo correct fhe disposition to scrofula. The languor and debility which prevail in scrofula, naturally indicate the necessity of employing a plentiful supply of wholesome nourishment, in such quantity as the stomach can bear without being overloaded, and of this light animal food ought to form a fair proportion. The quantify must be regulated by fhe appetite and powers of digestion. Milk, puddings, rice, and ofher fari- naceous substances, ought to constitute the remainder of the patient's diet. Where there is occasional atony in the stomach and languor, a moderate allowance of wine will be likely to prove salutaVy, but it will be best to give it between meals, with a bit of bread or cake. To ward off an attack of the disease in those who show a pre- disposition to it, it will be advisable that they take every day regular and moderate exercise, continued sufficiently long to dispose them to rest, without inducing any degree of fatigue. When the patient is either too young or too weakly to take sufficient exer- cise, by exertions of his own, external frictions assiduously applied, and persisted in for a length of time, are usually substituted, and, in young children in particular, have been practised in many cases with a very good effect. Another highly important external application is bathing the body. The bath may be either warm or cold, simple, or impreg- nated with various medical substances. Cold bathing, especially in the sea, is a remedy universally employed in scrofula, and apparently with the greatest advantage in many cases; for it appears not only to improve the person's health and strength, but likewise to promote the dispersion of enlarged glands, and. the resolution of indolent swellings in the joints, even after they have attained a considerable size. But in order that cold bathing may be practised with safety and advantage, the constitution should have vigour to sustain the shock of immersion without 684 CACHEXIA, OR CACHECTIC DISEASES. ClaSS 111 inconvenience. If the immersion be.succeeded by a general glow over the surface of the body, and the patient feels cheerful, and has a keen appetite, we may conclude that the bath agrees with him ; but if he shivers on coining out of the water, continues chilled, and becomes drowsy, we may be assured that the cold bathing will not prove serviceable, and ought therefore to be discontinued. In all weakly patients the immersion should be momentary. When any doubt is entertained with regard to fhe probable effects of cold bathing, it will be a prudent precaution to premise the use of a warm bath, which is often serviceable in those cases of scrofulous weakness wnich forbid the employment of a cold one. One great advantage of warm bathing is to relieve a certain dryness ofthe skin, which often accompanies scrofulous emaciation and weakness, and occasions much oppression and distress. A small number of immersions is, in general, sufficient to accomplish the object, and to prepare the patient for the safe and beneficial use of the cold bath ; though, when a great degree of scrofulous debility prevails, it may be necessary to continue the warm bathing, at the rate of two or three immersions a week, for some time. At the commencement of a course of warm bathing, an immer- sion from twelve to twenty minutes, with a temperature of water varying from 90 to 100 of Fahrenheit's thermometer, may be recommended ; but persons much accustomed fo the practice of warm bathing in general remain longer at a time in the bath, and use a higher temperature of heat. To promote the efficacy of tiie warm bath, frictions with some stimulant substance are often employed, and with advantage, particu- larly in certain cases of scaly scrofulous eruptions, and some of the more solid kinds. The clothing of scrofulous patients ought to be of such a nature as completely to protect the wearers against any inclemency of the weather, and to keep them comfortable and warm : a flannel dress ought therefore to be worn next to the skin in cold weather. The reason why weakly people so sensibly feel the vicissitudes of weather in this country is, that in general they are too thinly clad, and this inconvenience has been much increased of lafe by the airy and light modern attire adopted by our fashionable females. In very bad cases, a change of climate may be advisable ; but where circumstan- ces will not admit of this, artificial warmth by fires or a stove must be substituted. Every weakly scrofulous person, who wishes to recruit his health and strength, should retire to bed betimes each night, rise earl) in the morning, and, if possible, select for his residence a situation where the air is pure and dry. It is indeed the unavoidable lot of the poor in large towns, and particularly in manufacturing one6, to inhabit cellars, or other cold, confined, damp, and ill-ventilated places. It is generally recommended to scrofulous persons, who use Order III scrofula. 585 sea-bathing, to drink a little of the water daily, that it may act as a gentle purgative, and empty the intestinal tube of all feculent mat- te! s. When not at the sea-side, a solution of any of the neutral salts, such as the potassae tartras, potassae sulphas, he. may be substi- tuted. The submuriate of mercury is, however, by far the most celebrated of all the purgative medicines which have been employed in the treat- ment of scrofula, and it is undoubtedly a serviceable remedy in many stages ofthe disease. To enjoy its beneficial effects, however, with safety, we must be careful to avoid giving it in so large a quantity as to produce the specific effects of mercury to any extent; for it is well known that any deep mercurial impression on the system aggravates every symptom of scrofula. The hydrargyri Submurias,.however, when given cautiously in moderate doses, so as to act merely as an alterative, or gentle purgative, agrees well with scrofulous complaints, and greatly contributes to discuss tumors and resolve indurations of such a nature. But to produce the desired effect, this alterative course must be continued for a sufficient length of time, carefully watching its effect, lest it should exceed the prescribed bounds, and produce any ptyalism or severe purging. The dose must be regulated by the age of the patient and other circumstances. A few weeks' trial will be sufficient to determine the probability of its removing or relieving the complaint. In recent cases of obstruction, the submuriate of mercury joined with tartarized antimony*, has been used with benefit; and during the progress of tbe disease, where there is much irritation, or where there are deep-seated affections of the joints, opium has been added. Other alteratives, such as the hydrargyrus cum sulphuret, Plum- met's pill|, as likewise antimonials, with decoctions of guaiacum, * 1..R Pulv. Cretae Praeparat. 3j. Hydrargyri Submuriat. gr- iij.—vj Antimon. Tartarizat. gr. ij. M. ft. Pulvis in chartulas xij. dividend, quarum sumat. j. bis in die. t 2. IJ; Sulphuret. Hydrargyr. Nigr. gr. xv. Pulv. Antimon. gr. j. M. ft Pulv. nocte et mane sumendus. X 3. g: Hydrargyr. Submuriat. Antimon. Sulphuret.Praecip.na 3ss. / Gum Gaiac. pulv. 3j. . Syrup, q. s. M. ft. Massa in pilulas xxx. dittribuenda, quarum capiat j. omnl nocte et mane. 74 • 1. Take Prepared Chalk, pulverized, one drachm. Submuriate of Mercury, from three to six grains. Tartarized Antimony, two grains. Mis them, and divide the whole into twelve papers, of which let a dose be taken iwice a day. t 2. Take Black Sulphuret of Mercury, fifteen grain*. Antimonial Powder, one grain. Mix them. Take this powder night and morning. X 3. Take Submuriate of Mercuiyy Precipitated Sulphur of Anti: mony, of each half a drachm. Gum Guaiac, in powder, one drachm. Syrup, a sufficiency to form the R&ass, which is to be divided into thirty pilhj', one of which is to be taken night and morning. 586 -CACHEXIJE, OR CACHECTIC DISEASES. CUtSS III sarsaparilla, sassafras, dulcamara, and mezereon, together with the Lisbon diet-drink (which is a combination of these), have like- wise been much employed, but usually without any seeming ad- vantage. Muriated barytes is said to have been given in some cases of scrofula with success. The proper dose is from three to ten or twelve drops twice a day, according to the age of the person. Beyond a certain dose it is apt to occasion sickness, tremors, and a loss of power. The muriate of lime, we are given to understand by Dr. Wood* has been much employed at the Newcastle Infirmary in lieu of the muriate of barytes, and with two great additional advantages; viz. its action was more immediate, and no bad consequences at- tended an over-dose, while at the same time its efficacy was decisive. He used it at first in the form of crystals, by dissolving three grains in an ounce of water; but he found the process of crystallizing the salt to be too tedious and difficult for general use, and that it did not possess any advantage over a fltiid solution of the carbonate of lime in muriatic acid. Of the solution prepared agreeably to the Edinburgh Phaimacopceia, about a drachm for adults, and thirty drops for children, given in water twice or thrice a day, will be a sufficient dose. A late writer on scrofulaf tells us, however, tbat the muriate of lime had been employed by his colleague, Professor Thomson, of Edinburgh, in various cases of this disorder, without having derived benefit from it in a single instance. I can say little in its praise, as in the cases I have employed it no evident amendment or advantage was derived from it. Medicines of the narcotic tribe, but more particularly hemlock, have also been used for tbe cure of scrofula, both in the stage of swelling, and that of ulceration. From rny own experience of hem- lock, as well as tbe report made of it by others, it appears, when administered internallvj, to prove often serviceable in discussing swpjlings of this nature; and it likewise appears, in some cases of ulceration, to have afforded relief by being employed externally either in the form of poultice, or fomentation, or both. As an in- ternal remedy in the ulcerated stage of scrofulous tumors, it seems to be inefficacious. It has, however, been considered by a modern writer|l as an useful auxiliary in cases of great irritation, partrcu- * Seethe Edinburgh Medical Journal,vol. i. p. 147. t ------Treatise on Scrofula, by Mr. J. Russell, p. 85. ||------ Essay on the Diseases of the Vessels and Glands of the Absorbent System. by W. Goodlad. t 4. IJ; Extract. Cinchon. 3«j- ------Conii, 3j- M. Fiant prim" xl. quarum sumat ij.—iij.bis vel ter de die. X 4. Take Extract of Peruvian Bark, twe drachms --------Hemlock, one drachm. Mix them, and make forty pills out of the mass, of which from two to three may be taken twice or thrice a day. Order til scrofula. £87 larly if it be combined wilh calomel or preparations of iron, when either of these remedies is indicated. To enjoy the full benefit of the curafive powers of hemlock, it will be necessary fo give it to the full extent that fhe constitution can bear wilh impunity. The limit of the dose, fherefdre, is to be measured by its effect in producing incipient symptoms of giddiness or nausea, which disturb the functions of the head and stomach. The course requires to be continued many weeks, before the good effects of its operation are perceptible. The juice ofthe fresh leaves ofthe tussilago, or coltsfoot, is said to have been given with some advantage. When it cannot be pro- cured in fhe fresh stale, a strong decoction of the dried leaves may be substituted. Lime-water and alkalies, as the sodse subcarbonas, subcarbonate of ammonia, &c, are enumerated among the remedies often used in this disease, and administered, no doubt, under the supposition of an acid acrimony prevailing in the fluids. In some instances, a junction of soda with cinchona has been attended with a very good effect. In a small work* lately published, the successful treatment of several severe cases of scrofula, by means of the internal use of caus- tic alkali in doses proportioned to the age of the patienf, with the external application of small quantities of mercurial ointment at the same time, and which are mentioned fo have resisted all other remedies, is laid before the public. The annexed formulaf is what was employed. The wafer is directed to be boiled in a tin kettle, adding the lime by a little at a time ; the whole being prop- erly slacked, the pearl ashes are to be put in, the whole fo be well stirred together, and then fo be put into an earthen jar or pot well glazed on the inside, with a wooden spicket and faucet fixed in it to draw it off when wanted. The dose is a small tea-spoonful, or a drachm by measure, for children from four to six years old ; one tea-spoonful and a half for those from six fo eight; two lea-spoons- ful for those from eight to fifteen ; and in the like proportion to those of niore advanced age. The medicine is to be taken twice a day in a little malt-lea, barley-water, or thin gruel. Burnt sponge is another remedy which has been much adminis- tered in scrofula, and frequently with advantage. It may be given either in the form of a bolus or draught J. A more active medi- • See Observations on Scrofula, by Mr. J. Braudish. t 6. R Calc. Viv. Recent, ftij. Ciner. Clavellat. American, fovj. ----Ligni Combust, ftjij. Aquae Bullient. cong. vj. M. i 6. & Spong. Ust. 9j.—3ss. Pulv. Rhei, gr. iij. Mcl.Opthn. q.s. M. ft. Bolus bis in die sumendus. t 5. Take Quick Lime, two pounds. American Potass, six pounds. Wood-ash, two pounds. Boiling Water, six gallons. Mix them. X 6. Take Burnt Sponge, from a scruple to half a drachm. Powder of Rhubarb, three grains. Honey, a sufficiency to form a bolas. Let this be taken twice a day. 588 CACHEXIA, OR CACHECTIC DISEASES. Class III. cine, however, is the soclie carbonas, which is now employed in lieu of the former, of which, indeed, it is the basis. I he dose, hi these cases, is from ten or twenty grains to a drachm, twice or thrice a day*. . , . To invigorate the constitution, it will be necessary in fhe cure of scrofula to employ such medicines as are supposed to impart strength to the body. Of the vegetable class the cinchona is tbe most esteemed ; but previous fo its use, and to insure the full benefit from if, the bowels must be previously cleared of any morbid accu- mulation of faeces, either by the submuriate of mercury or neutral salts, in the manner before mentioned. The cinchona seems, how- ever, best suited to those cases where there are extensive ulcers or large abscesses, with copious exhausting discharges of purulent matter ; and in general to communicate that degree of energy to the actions of the system which tends to support and confirm the patient's strength. If the stomach will bear the powder, It v ill be the best mode of exhibiting it ; but should it disagree, fhen either a decoction or infusion of it may be Substituted, or we may try the extract properly dissolved. If none of these preparations agree with the patient, or we wish after a time to change the medicine, some of the other vegetable tonics, such as calumba, cascarilla, gentian, myrrh, &c. (for various Vel, 7. ft Spong. Ust. 3j. Confect. Aromat gr. x. Aq. Menth. f. §j.—^jss. M. ft. Haustus. Capiat bis in die. • 8. ft Sodae Carbonat. 3»j ■ Pulv. Cinchonae, ^jss. Mucilag. Gum. Acaciae, q. s M ft. Electuarhim, cujus sumat quantitatem nuc. moschatae ter in die. Vel, 9. ft Decoct. Cinchon. f. 3«- Tinct. Card. C. f. 3'iss. Sodae Carbon, ep xv. M. ft. Haustus bis terve de die sumendus. Vel, 10. ft SodaeXJarbonat. 3>j- Infos. Cinchon.f.'^iv. Tinct. Cinnam C. f. Jss. Syrup. Cort. Aurant. f. 3"j • M. Capiat cochl. larg. ij. ter quarterve in dje. Or, 1. Take Burnt Sponge, one scruple. Aromatic Confection, ten grafcli. Mint Water, one ounce to oae ounce and a half. Mix them as a draught, and let this be taken twice a day. 8. Take Carbonate of Soda, three drachms. Powder of Peruvian Bark, oae ounce and a half. Mucilage of Gum Acacia, a suffi- ciency to form an electuary, of which let the bulk of a nutmeg be taken thricea day. Or, 9. Take Decoction of Peruvian Bark, ten drachms. Compound Tincture of Carda- moms, one drachm and a half. Carbonate of Soda, fifteen grains. Mix them, and let this draught be taken twice or thrice a day, Or, 10. Take Carbonate of Soda, two drachms. Infusion of Peruvian Bark, four ounces Compound Tincture of Cinna- mon, half an ounce. Syrup of Orange Peel, two drachms Of this mixture two large spoonsful are to be taken three or four times a day. Order HI SCROFULA. 589 formula? of tfeese see Dyspepsia), may be given ; and to add to their efficacy, we may conjoin some agreeable aromatic, such as the tinc- tura cardamouu, or tinctura cinnaraomi composita. Of the mineral tonics, iron and the sulphuric and nitric acids are most valued for their virtue in the cure of scrofula. The latter are palatable, grateful to the stomach, and agree with all forms and stages of the disease, being peculiarly adapted to tbat state of fever which is connected with tbe putrid sloughs that are often formed on the inside of large tumors when first exposed to tbe air, and to that state of weakness which disposes to copious perspiration upon any moderate degree of exercise. Dr. Mosman informs us*, thai he found muri- ated barytes and the nitric acid to increase the appetite, and impart vigour to the system ; but he never saw them exhibit any beneficial effect on the morbid glands. A few drops of either of the acids may be given with each dose of the cinchona, or other vegetable tonics. Of the preparations of iron, the subcarbonate, ferrum ammoniatum, and muriated solution, .have been found most efficacious. We may give doses of these proportioned to the age of the patient, tw ice or tbrioe a day. To derive the full benefit from tonic medicines m scrofula, it will be advisable occasionally to administer the vegetable and mineral at the same time in combination.—(See formulas thereof under the head of Dyspepsia). About ten grains of the ferrum ammoniatum, in the space of twenty-four hours, will be sufficient for an adult, and so in proportion for children. Iron is less liable than cinchona to oppress the stomach with indigestion, or to produce accumulation in the bowels, and on these accounts is a more unexceptionable medicine in scrofula than the latter. During the use of tonics, a few grains of rhubarb, with one or two of the submuriate of mercury, may be given now and then. Mineral waters of the sulphureous and chalybeate class may likewise prove serviceable in the treatment of the disease under in- vestigation. Arsenic is another mineral production which has been employed in scrofula with some advantage, and is said to contribute greatly to the cure of scrofulous ulcers. From one to five drops of a solution of this (see Intermittents) may be given to children twice or thrice a day, according to their age ; and from five to ten, or more, to grown persons, diminishing the quantity if it affects the bowels. Besides employing medicines internally to correct tbe cachectic state of the fluids and strengthen the system, we are often obliged likewise to make use of external applications. Upon the first appearance of any tumor, it will always be ad- visable to disperse it, if possible, as we shall thereby relieve the patient from the risk of some very troublesome consequential symp- toms. The discutients commonly employed are, different saturnine ■ " See his Essay on the Nature, Origin, and Connexion of Scrofula and Glandular Consumption. 590 CACHEXIAS, OR CACHECTIC DISEASES. ClttSS III, application^, the liquor ammonia; acetatis, solutions of the muriate of ammonia, camphorated an I ammoniated oils,, a mixture of fresh bile with saponaceous linimen'., plasters of soap, ammoniacum, and mercury, sea-water poultices, hemlock, mercurial ointment, electrici- ty, and likewise blisters. Tne quercus marinus or sea-tang, bruised, and made into a poultice, is an application much recommended. These may be tried in rotation, and a*here one fails, another may pro- bably succeed. YVhpre sea-bathing can be obtained, it will prove the most efficacious of all remedies. It is only, however, in the incipient stages of the attack, and before effusion has attained a stationary state, that any benefit is to be ex- pected from discutient applications; for after the parts have lost their activity, and have become indolent, these remedies will have little or no power over them. The topical detraction of blood, by means of leeches, will prove a powerful mean in those cases of large glands which lie super- ficially, or adhere to the surface, and which are attacked with in- flammation ihat threatens to terminate in suppuration; but it is only under such circumstances that local detractions of blood are advi- sable. During the incipient or inflammatory stage of scrofulous glandu- lar swellings, an occasional gen'le purgative to keep tbe bowels soluble, and consisting of a few grains of rhubarb joined with calomel, may prove serviceable. In a case of some years' standing, in which the glands ofthe neck bad become enormously enlarged, and the tumor was attended with excruciating pains, much relief was obtained by anointing the parts morning and night with an ointment composed of one drachm of tar- tarized antimony rubbed with an ounce of lard, even after considera- ble doses of opi'im administered internally had failed to alleviate the pain. After using the ointment a few days, several pustules of a con- siderable size appeared on the tumor, being the usual consequence of its application. Galvanism and smart electrical shocks passed through scrofulous tumors of an indolent nature, particularly when occupying glands in the neck, have in some instances had a good effect in dispersing them. Repeated frictions simply with the hand without any substance in- terposed, except perhaps a little flour to prevent the abrasion of the skin, and continued for a considerable length of time each day, have been much recommended in indolently enlarged glands, and in some instances apparently with a very good effect. A case of this nature in a young lady, whose knee became much enlarged after an attack of scarlatina, and which had resisted the repeated applications of leeches, and tepid water poured over it, while the submuriate of mercury, hemlock, lime, &ic. were given internally without the least advantage, and which was at last effec- tually cured under the care of Mr. Grovenor, of Oxford, by assi- duous frictions with the bare hand, exercise on foot, and an occa- Order III. SCROFULA. 591 sional use of calomel, is recorded in the 29th No. of the Edinburgh Medical and Surgical Journal. The application of blisters to glandular swellings of this nature has sometimes proved effectual in occasioning them to suppurate quicker than they otherwise would have done. Where the activity of the inflammation is on the decline, and the swelling of a gland has become indolent and stationary, the stimulus of a blister imparts fresh vigour of action, which possibly may dispose the swelling to sup- purate. In some instances both blistering and electricity have, how- ever, been attended with a direct contrary effect, and have occasioned ihem to disperse. When we fail in our attempts to disperse scrofulous swellings, and a suppuration has commenced, we are to promote and expedite this as much as we can. Poultices and other warm applications have lit- tle effect, however, in bringing foiward these kind of tumors, and when long used, they tend to weaken and relax tbe parts so much, that the sores which ensue are rendered difficult of cure. Washing the parts with strong brine has sometimes been employed with success, and has expedited the formation of matter in scrofulous swellings. Where the process of suppuration is unavoidable, and is sufficiently advanced, the contents of the abscess are to be»evacuated by a lancet at once, if the collection be not large; if otherwise, by repeated puncture at proper intervals, and the access of external air prevent- ed by careful closure of the orifice, similar to what has been long practised by tbe most skilful surgeons in the treatment of lumbar abscess. To correct tbe discharge, repress or destroy any luxuriant fungous growth, promote a proper suppuration, and dispose the ulcers to heal, it is usual to employ gentle escharotics, such as the hydrag.. nitrico oxyd urn, verdegris, and burnt alum, which may either be sprinkled over them, or be applied mixed up with some mild ointment, as tbe unguentum cerae. Where there is a languid action in any sore, which suspends its progress towards amendment, and renders it stationary. the use of gentle stimulants will be proper. A solution of the neutral or metallic salts, as the muriate of ammonia, oxymuriate of mercury, nitrate of silver, or the sulphate of zinc, will stimulate the ulcer to shoot forth granulations. A solution of the latter, in the proportion of from half a drachm to one drachm to about eight ounces of water, is considered by Mr. Goodlad* to be the best application that can be made to scrofulous sores that have suppurated and opened. Scrofulous abscesses have been punctured, and the cavjty after- wards injected with a solution of the sulphate of zinc in the propor- tion of about eight grains of the latter to an ounce of the former, with the best effectsf, as healthy inflammation has supervened, * Set his Tract on Scrofula. ♦ See Praciical Obsen^tiiyis.in Surgery, ke. by Mr. J. Howsbi;). 592 cachexia;, or cachectic diseases. Class III whioh terminated in adhesion, without any return of tbe corn- plaint. The application of linen cloths dipped in cold water, sea-water, or lime-water, and renewed as frequently as they become dry throughout tbe course of the day, with tbat of some mild plaster or ointment, such as the ceratum plumbi superacetatis, spreadupon fine lint by night, is a mode of treatment much recommended in scrofu- lous ulcers. If these fail in healing the ulcers, the linen rags may be moistened with a solution of two drachms of the plumbi superacetas in a pint of water, from which application I have seen very good effects derived. Dr. Darwin used powdered oak-bark mixed with white lead. Scrofulous ulcers which had resisted many other remedies) hare healed under a weak solution of nitric acid in water. In sores which are spreading and irritable, the application of an aqueous solution of opium or of hemlock, and afterwards of a solu- tion of zinc, may be beneficial. Where the granulations rise above the surface, and are broad and flabby, and where pressure cannot be applied, the sorrel poul- tice has proved useful. The topical employment of bruised sorrel leaves (rumex acetosa), has been strongly recommended as contributing very much to the cicatrization of indolent scrofulous ulcers. In sores of an ugly, gleeting, and ill-conditioned appearance, much benefit has been obtained by the application of a poultice made with crumbs of bread moistened with a solution of about an ounce of the crystals of soda in a quart of water. Tbe sub-borate of soda in the proportion of half a drachm, or one drachm mixed in an ounce of ceratum cetacei or ceratum calamine, has been found, a useful and efficacious application to scrofulous ulcers; and by such dressings they have frequently been healed in a short space of time, after having resisted other modes of treatment. Painful and deep-seated ulcerations, the consequence of a scrofo- lous habit, and which are attended with much local irritation, have been relieved by a use of the Malvern water. Applied to the sore, it moderates the profuseness of the discharge, corrects the fcetor which so peculiarly marks a caries of the bone, promotes the gra- nulating process and a salutary exfoliation of the carious part, and by a long perseverance in this course, very dangerous and obstinate cases have' at last been entirely cured. Inflammation of the eyes, especially the ophthalmia, which is so troublesome in scrofulous habits, often yields to this simple application*. It has already been observed, that diseases of the vertebrae, which in consequence ofthe softness of their bodies occasions a protrusion of their spinal processes, and a compression: of the medulla, are frequently connected with-scrofula. In such cases Mr. Pott de- * See Dr.Saunders's Treatise on Mineral Waters. Order III. diseased mesenteric glands. <593 pended principally on a drain by issues applied on each side ofthe pro- jecting spinal piocess, and in some of them succt ssfully treated in this manner, confinement to an horizontal position was unavoidable. Sir James Earle, fully aware that issues were ineffectual unless the super- incumbent weight was removed from the morbid part, and objecting to the horizontal position fnon its being irksome to the patient, " weakening and relaxing, and consequently retarding the cure," as he expresses it, endeavoured to substitute a mean betwixt the con- finement to bed and the pressure from an erect position. He there- fore recommended and employed a form of machinery, which should take off the incumbent weight from the diseased vertebrae and transfer it to the pelvis. Mr. Baynton*, (who is tbe latest writer on diseases ofthe spine), having compared the opinions and practice of Mr. Pott and Sir James Earle, and from facts collected from the writings of other surgeons of eminence, has been induced to conclude, that a system of resting in an horizontal position, regulated by scientific principles, will accomplish the cure of diseases of the spine, after the failure of drains and machinery steadily continued a number of years under the direction of skilful surgeons; and to substantiate the efficacy ofthe mode of treatment which he advises, he has recited the history of some cases which fell under his care. He is induced to suppose that the success which attended the cases treated by Mr. Pott, by issues made with caustic, conjoined with an horizontal position during the greatest part of the cures, as the patients could not bear to remain upright, was more owing to the uninterrupted rest they enjoyed than to the effects of the drains from the neighbourhood of the diseased portion ofthe spine. Great doubts have indeed been entertained by other practitioners respecting tbe efficacy of caustics in caries of the spine, and they have recommended in their stead occasional cupping, repeated blisters, ape- rients, the muriate of lime, a milk diet, and long-continued repose in an horizontal position, and particularly at the commencement of the disease. DISEASED MESENTERIC GLANDS. Children of a scrofulous habit are very often affected with a diseased state of the mesenteric glands, the little patient usuallv complaining of a deep-seated lancinating pain within the abdomen, which gradually enlarges, while the other parts of the body are emaciated.—-(See Atrophia).—The countenance becomes altered the eyes seem glassy and sunk in their sockets, the nose is sharp- ened, the cheeks are of a marble whiteness, unless when they are flushed with hectic fever, and the whole body is indeed of the same hue. Sometimes the lips are swelled and of a deep red colour and sometimes the angles of the mouth are beset with small ulcers! * See his Acrountof a successful Method of treating Diseases of the Spine 75 o94 cachexia, or cachectic diseases. Class III The state ofthe bowels is variable, though more commonly relaxed than otherwise. When they are relaxed, the stools consist chiefly of frothy mucus tinged with bile, by which discharge an excoriation of the verge of the anus is now and then produced. Although the appetite is tolerably good, nay often voracious, in chil- dren whose mesenteric glands are thickened and diseased, neither health nor strength result from it; the more food that is taken the worse the child is generally, as it oppresses without nourishing the system. Until the obstructions are removed, no healthy appearance can therefore take place. In the advanced stage of the disease the child is fretful, peevish, and inactive. There is usually an accession of fever towards the even- ing, the pulse being at that time generally about 120, while at other times of the day it is seldom less than 100 in a minute. There is but little thirst, and the tongue suffers no change, except perhaps being now and then streaked with white at the sides. The skin is dry to the touch and rough, and the cuticle is not unfrequently thrown off in scales. This diseased state of the mesenteric glands is to be distin- guished from enteritis by there being no vomiting or difficulty in procuring evacuations with the ordinary quantity of medicines, and but little pain being perceived on pressure; and it may be known from the febris infantum remittens, by the accession of fever being attended with restlessness rather than an inclination to sleep; by the excretions not being particularly changed from their natural ap- pearance; by the accession of fever occurring only in the evening; and by the duration of the complaint: whereas in the remitting fever the paroxysms are attended with drowsiness; the evacuations are unnatural both in smell and colour; the accessions of fever are very irregular, as well in their recurrence as in their duration; and the disease has more the character of an acute than of a chronic one. The disorder attacks children from the age of a few months to ten or twelve years; and the earlier it appears the greater will be the danger. In all ages the prognostic should be guarded, and for the most part be unfavourable; for the disease is generally far advanced before it becomes an object of medical attention, owing to its gradual progress, and being attended with scarcely any pain at first. An im- provement of the colour and look of the countenance, the evening accession of fever being le*s severe, and its duration shortened, in- crease of the flesh and appetite, and a diminution of the size of the abdomen, are to be regarded as favourable signs. The most unfavour- able symptoms are, a rapid increase of the emaciation, the evening accession of fever being severe and continuing through most of the night, the abdomen being much enlarged and tense, and the cuticle peeling off. In the treatment of this diseased state of the mesenteric glands, gentle action upon the intestines by aperients will be highly proper, and therefore it will be necessary to give one ofthe submu- Order III BISEASBD MESENTERIC GLANDS. 595 riate of mercury* in a dose proportioned to the age of the child twice every week. On the intermediate days, some slight tonic may be administered twice or thrice a day.—(For these, see Atrophia).— If the bowels are confined between the doses of aperients, they ought to be opened with a solution of some ofthe neutral salts; but we are at the same time to be cautious not to exhaust the strength of the patient by the exhibition of active purgatives. The less severe the evening accession of fever appears, the more free we may be in the exhibition of tonics, and the less necessity will there be for the use of purgatives: on the other hand, the more severe the evening parox- ysm, the greater caution will be necessary in the exhibition of tonics, and the less restraint be required in the use of purgatives. It is of the utmost importance in cases of diseased mesenteric glands to ensure the healthy state of the chylopoietic viscera, and tbe proper digestion of the food. By such treatment we remove a concurring cause to the prejudicial effects of this state of the glands upon the constitution ofthe patient. We thereby afford an opportu- nity for as much nutritious matter to be carried into the system as is compatible with the existing disease. Exciting the surface of the body to healthy action by warm bathing every second or third night, and employing frictionsf night and morning with the hand over the whole of the abdomen, will greatly assist and expedite the cure. The diet should be milk, gruel, sago, and other kinds of farina- ceous food, with an admixture of dressed vegetables. Provided the patient exceeds the age of two or three years, a small quantity of animal food may be allowed. Animal broths, jellies, he. may be given to all that are weaned. Exercise in the open air should be especially recommended, and as that of the sea usually proves beneficial to such patients, where a residence near the coast is practicable it should be adopted. Where the disease gives way, and a decided diminution of the fever, pain, and enlargement of tbe abdomen, has taken place, we may recommend sea-bathing at first with a bath heated to about 80 degrees, and so reduce the heat gradually, until at last * 1. IJ; Hydrargyr. Submuriat. gr. ij.—iv. * 1. Take Submuriate of Mercury, two to four grains Pulv. Rhei, gr. iv.—x. M. ft. Pulvis catharticus. Vel, 2. fy Hydrargyri. Submur. gr. ij.—iv. Potassae Tartrat. gr. viij.—3j. M. Powder of Rhubarb, four to ten grains. Mix them as a cathartic. Or, 2. Take Submuriate of Mercury, two to four grains Tartrate of Potass, eight grains to one scruple. Mix them. 3. g; Liniment. Saponis Comp. pro em-4 3. Take Compound Soap Liniment for an brocalione. I embrocation. Vel, | Or, 4. $ Liniment. Camphor. Comp. 4. Take Compound Camphor Liniment. 596 CACHEXIA, OR CACHECTIC DISEASES. Class 111. the patient can safely bear the sea-water at its usual temperature. If it should be winter, the water may be heated to about 65 or 70 degrees. SYPHILIS, or the VENEREAL DISEASE. The part of the world where this disease first originated has been much disputed, some looking upon it as of French extraction, and others supposing it to have been brought from America by the sol- diers of Christopher Columbus. Be this as it may, it is certain that it was first ohserved at the siege of Naples in the year 1493, and that from thence it spread very rapidly throughout France, Spain, Germany, and other kingdoms. The syphilitic pois-m is peculiar to the human species, and pro- duces no effect whatever on any ofthe brute creation, as has incon- testibly been proved by repeated experiments, from whence we might infer that it was intended not only as a check against any deviation from the rules of connubial chastity, but likewise as an incentive (if I may be allowed the expression) to the gay and young, to form, at an early period of life, a satisfactory and honourable alliance, by which tbey may be enabled to gratify the passions implanted in them by nature, and propagate the species, without the risk of disease. Syphilitic poison cannot, as happens in other eruptive complaints, such as the small-pox^ measles, he. be conveyed in the form of va- pour, or, in other words, by breathing air which is contaminated by a person labouring under it. To give rise to syphilis, it is neces- sary tbat tbe matter or poison should be applied to some part which is soft or covered with a mucous membrane, or else to some place where there exists eilher an excoriation, ulcer, or wound. It has been doubted whether it is possible for the disease to be communicated from the mother to tbe infant in utero. However rare such an occurrence may be, still it is very possible, and many well-authenticated cases are on record to substantiate this fact. Venereal matter is always sure to occasion a conversion of the mucus of the part, or of the fluids of the wound or ulcer to which it has been applied, into matter similar to itself; and when a sufficient quantity has beep produced, it excites an inflammation in the mu- cous membrane or glands, or in tbe wound or ulcer, and is then absorbed into the system, and but very seldom before. Instances have indeed occurred in practice where absorption has taken place without any apparent effect of this kind being produced : they are however very rare. The infection is almost always sure to show itself first in that part to which the matter is applied ; and as syphilis most ge- nerally arises in consequence of an intercourse between the sexes, so the symptoms usually show themselves first in or about the organs of generation. Where a child at the breast communicates Order III venereal disease. 597 the contagion to its nurse, ber nipples and breasts will be the parts first affected ; and on the contrary, where it is the nurse that infects the infant, then its lips and other parts of its mouth will show the first symptoms of the disease. In like manner if the infection is convey- ed to an accoucheur, in consequence of having a slight scratch on any of tbe fingers of tbe hand with which he officiates, the wounded part will show the first appearance ofthe disease by becoming inflamed, soon after which the glands in the axilla of the same side will swell, be painful, and indurated. Syphilitic matter, by being applied to the body, produces in the course of time either a local or a constitutional disease. By the former is meant, an affection confined solely to those parts to which the poison was first applied; and by the latter is to be understood, a general taint of the whole system and mass of fluids. Syphilis is therefore generally sure to show itself in both sexes, either as a local affection under the form of a gonorrhoea or chancre, or else as a constitutional one, under that of a confirmed lues venerea. Between a local and a constitutional affection there are, however, certain appearances which are apt to take place in the absorbent vessels and glands nearest in situation to the parts affected with ul- ceration, and produced, no doubt, by tbe passage of the venereal mat- ter through them. When the former become affected, a hatfd, red, inflamed line, somewhat similar to a cord, may be felt running all along the back of the penis; and when the latter are affected, which more usually happens, an induration, swelling, and inflammation of the glands themselves will take place, and a bubo will be the conse- quence. As in most instances the matter is applied first to the parts of generation, in consequence of an intercourse between the sexes; so, of course, the glands of the groins are most usually the seat of this symptom. By a gonorrhoea virulenta, or clap, is to be understood a secretion and discharge of matter from the mucous membrane and glands of the urethra, in consequence of the application of syphilitic matter to them. By a chancre is meant a venereal ulcer, the nature of which is to be much inflamed, to be very sore and painful, to be une- qual at the bottom, to have prominent edges of an ash colour, and to show no kind of disposition whatever to heal when left to itself, but, on the contrary, to spread very much ; and by a lues venerea is implied an affection of the whole habit and mass of fluids, in conse- quence of an absorption of the poison into the constitution, which produces certain effects on various parts of the body while diffused in the circulation. Although a gonorrhoea and a chancre are both of them local affec- tions on their first appearance, still there is this material difference between them, that, as in the first there is a formation of matter without any breach in the solids, and in the latter there is always a breach, so the first may go on for some time without degenerating into an affection of the whole system, and may at last effect its own 598 GACHEXIiL, UK VACIIJCCTie DISEASE?. CHaSSjIl cure; whereas the latter is never atlended with this happy effect; but, on the contrary, affords great reason to fear, that in those cases where the virus is not corrected by a timely use of proper an'idotes, an absorption of the matter will take place, and in due time give rise 4o a confirmed lues. In mentioning this distinction between a clap and a chancre, I wish not, however, to be understood to mean, that the former never terminates in, or occasions a taint of the whole system. In some cases, where a gonorrhoea has been of long standing, it has been attended with this effect, owing most probably to the forma- tion of some little ulcer in the urethra; not but that I conceive it possible for absorption to take place without ulceration. The application of venereal matter for any considerable length of time to a part that is of a soft and spungy nature like the glans penis, may in some instances, I apprehend, be productive of a con- stitutional taint without the existence of any previous ul- ceration. It has been disputed whether or not the matter secreted in a clap is of a similar nature with that secreted from a chancre, and whether or not it is possible for a person labouring under the one or the other to communicate to a healthy subject a different species of the disorder from that with which he is infected. That a gonorrhoea, chancre, and confirmed lues, all arose from the same original infection, may, I think, readily be admitted; and that the matter produced both in gonorrhoea and chancre is of the same nature, ought not to be doubted, as daily observation must convince those who are frequently consulted in venereal cases, and who have given themselves the trouble to investigate the nature of the complaint which the person laboured under who propagated the infection, that the matter from a gonorrhoea may and often does give rise either to a clap, chancre, or confirmed lues, and tbat the matter secreted from a chancre w ill do the same. The event depends, most assuredly, on the state of the parts and the constitution of the patient, together with other accidental circumstances at the time the poison is applied, and not on any difference in the nature of the matter secreted in the one or the other affection. I am aware that the doctrine I have here supported by no means accords with that which has been advanced by Mr. Ben- jamin Bell, and a few other modern practitioners of eminence; for these gentlemen consider gonorrhoea and lues as arising from different specific contagions. By the greater number of the pro- fession, however, they are still considered as the same; and it appears by Mr. Cross's Report* that the French surgeons are still of opinion tbat lues may arise from gonorrhoea, and therefore that the poisons of both are identically the same. When facts, * See bis Sketches ofthe Medical Schools of Paris. , Order HI. venereal disease 599- supporfed by accurate experiments and observation, are brought forward to convince me that they are separate poisons, I shall be ready to adopt the new opinion, but not until then. When a person labouring under the venereal disease form3 a connexion wilh another who is free from it, and who happens to have any little excoriation, ulcer, or wound, about the parts of generation, it is probable, that if the poison is conveyed to the healthy subject, it will be most likely to show itself under the form of a constitutional affection ; as in this case the matter is applied so as readily to be absorbed info the system, in a manner similar to what happens in the small-pox ; whereas if it is applied to a part that is spungy, or to a surface covered with a mucous membrane, and where neither excoriation, ulcer, nor any wound exists, then the most probable consequence will be either a gonor- rhoea or a chancre. In offering this as my opinion, I wish not to be understood that I mean to assert this will invariably be the case. Much (as has already been observed) will depend on the state and irritability of the parts at the time the poison is applied, as also on the habit of the person, and other accidental circumstances. Another remark which may be added on the nature of the vene- real poison is, that there seems to prevail in some constitutions a greater liability to be infected by it than in others, as two men having been connected with a diseased woman within a very short space of time, one of them shall contract infection from her, and the other shall escape with impunify. GONORRHtEA VIRULENTA* No cerfain rule can be laid down with regard to the time that a clap will take before it makes its appearance after infection has been conveyed. With some persons it will show itself in the course of three or four days; while with others there will not be fhe least appearance of it before the expiration of some weeks. It most usually is perceptible, however, in the space of from si* to fourteen days, and in a male begins with an uneasiness about the parts of generation, such as on itching in the glans penis, and a soreness and tingling sensation along the whole course of the urethra ; soon after which, the person perceives an appearance of whitish matter at its orifice, and also some degree of pungency on making wafer. Here it may be" proper to mention, that it is necessary to dis- tinguish accurately true gonorrhoea from that discharge that sometimes takes place from the internal surface of the prepuce, and produced by any thing causing irritation there, or behind the corona glandis, as a want of due cleanliness^ warts, &c. * This disease belongs to Class IV Locales, Order IV. Apocenoses, in the systematic arrangement of Dr. Cullen ; but I have judged it preferable not to separate tbe varieties of the venereal disease from each other. 600 CACHEXIA, OR CACHECTIC DISEASES. ClttSS HI. In the course of a few days the discharge of matter in go- norrhoea will increase considerably, will assume most probably a greenish or yellowish hue, and will become thinner, and lose its adhesiveness ; the parts will also be occupied with some degree of redness and inflammation ; in consequence of which, the glanspenis will put on the appearance of a ripe cherry, the stream of urine will be smaller than usual, owing to the can d being made narrower by the inflamed state of its internal membrane, and a considerable degree of pain and scaldiug heat will be experienced on every attempt to make water. Where the inflammation prevails in a very high degree, it pre- vents the extension of fhe urethra on the taking place of any erection, so that the penis is at that time curved downwards with great pain, which is much increased if attempted to be raised towards the belly, and the stimulus occasions it often to be erected, particularly when the patient is warm in bed, and so deprives him of sleep, producing in some cases an involuntary emission of semen. The above symptoms denote the presence of a chordee. In consequence of the inflammation it sometimes happens, that at the time of making water, owing to the rupture of some small blood-vessel, a slight hemoirhage ensues, and a small quantity of blood is voided. In consequence of inflammation, the prepuce likewise becomes often so swelled at the end that it cannot be drawn back ; which symptom is called a phymosis : or that, being drawn behind the glans, it cannot be returned ; which is known' by the name of paraphymosis. Now and then, from the same cause, little hard swellings arise on the lower surface of the penis,' along the course of the urethra ; and these perhaps suppurate, and form into fistulous sores. The adjacent parts sympathizing with those already affected, the bladder becomes irritable, and incapable of retaining the urine for any length of time, which gives the patient a frequent in- clination fo make waler, and he feels an uneasiness about the scrotum, perineum, and fundament. Moreover the glands of the groin grow indurated and enlarged, or perhaps one of the testicles becomes swelled and inflamed ; in consequence of which he ex- periences excruciating pains, extending from the seat of the com- plaint up into the small of the back, he gets hot and restless, and a small symptomatic fever arises. Where the parts are not occupied by much inflammation, few or none of fhe last-mentioned symptoms will appear, and only a discbarge, with a slight heat or scalding in making water, will prevail. In consequence of the inflammation of gonorrhoea extending along the urethra, it sometimes happens that the mucous mem- brane of fhe bladder becomes thickened, indurated, and ulcer- ated, and pours out a considerable quantity of muco-purulent matter, which added (o the urine, gives to it the appearance of whey. Order III. VENEREAL DISEASE. 601 If a gonorrhoea is neither irritated by an irregularity of the patient, nor prolonged by the want of timely and proper assistance, then in the course of about a fortnight or three weeks the discharge, from having been thin and discoloured at first, will become thick, white, and of a ropy consistence, and from having gradually begun to dimi- nish in quantity, will at last cease entirely, together with every inflam- matory symptom whatever : whereas, on tbe contrary, if the patient has led a life of intemperance and sensuality, has partaken freely of the bottle and high-seasoned meats, and has at the same lime neg- lected to pursue the necessary means, it may then continue for many weeks or months, and on going off may leave a weakness or gleet behind it, besides being accompanied with the risk of giving rise, at some distant period, to a constitutional affection, especially if there has been a neglect of proper cleanliness ; for where venereal matter has been suffered to lodge between the prepuce and glans penis for any time, so as to have occasioned either excoriation or ulceration, there will always be danger of its having been absorbed. Another risk arising from the long continuance of a gonorrhoea, especially if it has been attended with inflammatory symptoms, or has been of frequent recurrence, is the taking place of one or more strictures in the urethra. These are sure to occasion a considerable degree of difficulty as well as pain in making water, and, instead of its being discharged in a free and uninterrupted stream, it splits into two, or perhaps is voided drop by drop. Such affections become, from neglect, of a most serious and dangerous nature, as thev not unfrequently block up tbe urethra, so as to induce a total suppression of urine. We may rest assured that inflammation in the urethra is the usual source of all strictures, and for most part this is excited by gon- orrhoea; occasionally it has, however, arisen from some other cause producing continued irritation in the parts, as, for instance, from some previous disease in the bladder or prostrate gland. Most commonly the course ofthe complaint is this. The gonorrhoea has arisen and gone on unchecked until the inflammation being at its height, there is a purulent secretion, and probably cbordee : the disease which was at first seated near the orifice of the canal has spread back- wards; but by the use of appropriate remedies, the pain and other inconvenient symptoms which the patient had experienced are ame- liorated ; still, however, the irritation does not entirely subside. Some pain and heat in voiding urine are still perceived, and from time to time there flows a gleety discharge ; but this gleet is not the effect of mere relaxation of the vessels allowing a profuse discharge, as is too often supposed ; it is the vestige of inflammation in a milder and more chronic form. When this state of the parts is allowed to continue, a pretty firm stricture will at length be formed. The degree and firmness of the contraction will hold a strict relation 76 602 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III to the length of time, and the frequency of the occasional increase ofthe irritation, pain, and discharge. Where a gonorrhoea has been oflong standing, warty excrescences are likewise apt to arise about the parts of generation, owing to the matter falling and lodging thereon ; and they not unfrequently prove both numerous and troublesome. Having noticed every symptom which usually attends, on go- norrhoea in the male sex, it will only be necessary to observe, that the same heat and soreness in making water, and the same discharge of discoloured mucous matter, together with a slight pain in walking, and an uneasiness in sitting, take place in females as in tbe former; but as the parts in women which are most apt to be affected by the venereal poison are less complex in their nature, and fewer in number, than in men, so of course the former are not liable to many of the symptoms which the latter are ; and from the urinary canal being much shorter, and of a more simple form in them than in men, they are seldom, if ever, incommoded by strictures. With women it indeed oftens happens that all the symptoms of a gonorrhoea are so very slight tbat they experience no other inconven- ience than the discharge, except perhaps immediately after menstru- ation, at which period it is no uncommon occurrence for them to perceive some degree of aggravation in the symptoms. Women of a relaxed habit, and such as have had frequent miscar- riages, are apt to be afliicted with a disease known by tbe name of fluor albus, which it is often difficult to distinguish from gonorrhoea virulenta, as the matter discharged in both is, in many cases, of the same colour and consistence. The surest way of forming a just con- clusion in instances of this nature, will be to draw it from an accurate investigation both of the symptoms which are present, and those which have preceded the discharge ; as likewise from the concurring circumstances, such as the character and mode of life ofthe person, and the probability there may be of her having had venereal in- fection conveyed to her by any connexion in which she may be engaged. Not long ago it was generally supposed that gonorrhoea depended always upon ulcers in the urethra producing a dis- charge of purulent matter; and such ulcers do indeed occur in consequence of a high degree of inflammation and suppu- ration ; but many dissections of persons who have died while labouring under a gonorrhoea have clearly shown that the dis- ease may, and often does exist, without any ulceration in the urethra, so that the discharge which appears is usually that of vitiated mucus thrown out from the mucous follicles of tbe urethra. On opening this canal, in recent cases, it usually appears red and inflamed, its mucous glands are somewhat enlarged, and its cavity is filled with matter to within a small Order III. VENEREAL DISEASE. 603' distance from its extremity. Where the disease has been of long continuance, its surface all along, even to the bladder, is generally found pale and relaxed, without any erosion. In the cure of a gonorrhoea we are to be directed by the symptoms which are present, and by the state of the disease at tbe time that ad- vice is applied for. If at the commencement of tbe complaint the patient should experience much pain, heat, and difficulty in making water, together with other inflammatory symptoms, and he is at the same time of a full plethoric habit, it may be advisable to have recourse to antiphlogistic means, as bleeding, keeping the body open with gentle purgatives, allaying irritation by means of sedative injections*, drinking copiously of mucilaginous diluting liquors, such as barley- water, linseed-tea, or solutions of gum. acaciae in milk; making use of a very spare regimen; abstaining from all kinds of fermented and spi- rituous liquors, and avoiding exercise : but if an inflammatory diathe- sis does not exist, nor any great degree of ardor urinae prevail, it then will be unnecessary to have recourse either to general bleeding from the system or to purging. In avoiding purging, when not necessary, we are however to take care not to run into the opposite extreme by suffering costiveness to prevail, as the lodgment of indurated faeces, as well as the voiding of them, might prove a stimulus to the urethra. In every stage of * 1. ft 01. Amygdal. f |iv. Liquor. Plumbi Subacet. Til xiii. M ft. Injectio. Vel, 2. ft Aq. Fontan. f. ^iv. Tinct. Opii Vinos, fll xxv. M. Vel, 3. ft Liquor. Plumbi Subacet. fll xiii. Aquae Rosas, f. |viij. M. Vel, 4. ft Infus. These Virid. Herb. f. f vj. Liquor. Plumb. Subacet. TTl xiii.M. Vel, 5. ft Mucilag. Gum. Acaciae, f. ^iij. 01. Olivae, f. f j. M. et adde Tinct. Opii Vinos. TTl "* M. Vel, 6. ft Liquor. Ammon. Acetat. f. ^j. Aquae Fontan. f. %ir. M. i * 1. Take Oil of Almonds, four ounces. Solution of Subacetate of Lead, twenty drops. Mix them. Or, 2. Take Pure Water, four ounces. Vinous Solution, of Opium, forty drops. Mix them. Or, 3. Take Solution of the Subacetat* of Lead, twenty drops. Rose Water, eight ounces. Mix them. Or, 4. Take Infusion of Green Tea, six ounces. Solution of Acetate of Lead; twenty drops. Mix them. Or, 6. Take Mucilage of Gum Acacia, three ounces. Olive Oil, one ounce. Mix them. And add Vinous Solution of Opium, forty- five drops. Or, 6. Take Solution of Acetate of Ammonia, one ounce. Pure Water, four ounce?. Mix them. 604 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III gonorrhoea it therefore will be advisable to keep the body perfectly open by a regular use of some mild laxative* that is not of an irritating or drastic nature. Nitre is a medicine which is often employed where there is any heat of urine ; but this is very erroneous, for it cannot fail to increase the pain in making water by its stimulus on the excoriated or inflamed urethra. Among the symptoms attendant on gonorrhoea, it has been men- tioned that phymosis and paraphymosis are sometimes present. In such cases it will be necessary either to immerse the penis frequently in warm water, or to have recourse to emollient fomentations, with the after application of poultices, composed of linseed-meal, or crumb of bread, mixed up with a solution of the plumbi superacetas or a suf- ficient quantity of the liquor plumbi subacetatis diluted with common water, which are to be laid on cold ; and the patient is at the same time to keep as much as possible in a recumbent position ; or, if obli- ged to walk about, he should support the penis up to the belly by means of a proper bandage. In those cases, both of phymosis and paraphymosis, accompanied by considerable inflammation, it will be advisable, previous to adopting the foregoing steps, to draw blood freely from the arm, to administer cooling purgatives every other day, and to observe a strict antiphlogis- tic regimen, with rest. Local blood-letting, so useful in other inflam- mations, would not be advisable here; for if the matter which flows from beneath the prepuce should happen to come in contact with tbe wounds inflicted by the leeches, troublesome sores might ensue. In phymosis, besides pursuing the plan just recommended,: it will be advisable every now and then to inject a little * 7. ft Confect. Sennae, ^jss. Potassae Supertart. 3U- Pulv. Jalapae, 3ss. Syrup. Simp q. s. M. ft. Electuarium, cujus surnat cochl. j. mane et vespere pro re nata. Vel, 8. ft Manna* Optim. |ss. PotasstD Tartrat 3"j. Aq Fervent, f. Sjiss. Tinct. Jalapae, f 3<- M. ft. Haustus pro re nata tapiendus. Vtl, 9. ft Magnes. Sulphat. ^ij. Aq Frrvent f. §vij. Tin t S noae C. f. |j. M. Capiat cochl. magna iv. pro dos. * 7. Take Confection of Senna, one ounce and a half. Supertartrate of Potass, two drachms. Powdered Jalap, half a drachm. Common Syrup, a sufficiency to form an electuary, of which let a tea- spoonful be taken morning and evening as the occasion may require. Or, 8. Take Manna, half an ounce. Tartrate of Potass, three drachms. Warm Water, one ounce and a half. Tincture of Jalap, one drachm. Mix them for a cathartic draught, to be ta- ken occasionally. Or, 9. Take Sulphate of Magnesia, two ounces. Warm Water, seven ounces. Compound Tincture of Senna, one ounce. ,' Of this mixture let four table-spoonsful be taken for a dose. Order III VENEREAL DISEASE1. 605 w:irm milk and water between the prepuce and glans penis for the purpose of washing off any matter that may have lodged there, and which, if suffered to remain for any length of time, might produce ulceration. Where phymosis is accompanied with chancres it will be proper to inject mercurials (such as the oxy- muriat, in the proportion of one grain to an ounce of water) inside the prepuce. Indeed in most cases of confirmed phymosis, whether congenital or the result of inflammation, tbe division of the prepuce with a knife appears to be expedient. The surgeon's attention should be directed to the early stage of the complaint, and it should be a general rule to examine the naked glans before entering on a con- stitutional use of mercury, as not only warts and chancres are apt to be formed, but now and then extensive inflammation, terminating in ulceration and sloughing, occasionally takes place. Where ul- ceration is threatened, to prevent extravasation and preserve the urethra during healing, great advantage may be derived from the introduction of a small elastic gum catheter. Where erysipelatous inflammation of the penis supervenes either on phymosis, paraphymosis, or chancre, no preparation of mercury should be employed either internally or externally until this subsides. If a chordee attends on gonorrhoea, rubbing- the parts with a strong solution of opium or the tinctura opii, and keeping linen pledgets, dipped in the same, constantly applied (taking care to renew them however as often as they become warm), will greatly tend to remove both the pain and the spasmodic contraction. The most certain method of preventing this unpleasant symptom is to give the patient an opiate draught at bed-time, consisting of at least fifty or sixty drops of the tincture of opium in one ounce of camphor mixfure. In consequence of the inflammation running high, and extending a considerable way up the urethra, a tumor sometimes forms in the perinaeum. In this case we should endeavour to disperse it by means both of general and topical bleedings, but more particularly the latter ; by the application of saturnine poultices, such as before mentioned ; by frequently administering laxative medicines, and by making use of a very spare regimen. Rubbing mercurial ointment on the part has been advised in cases of this nature ; but it is seldom attended with a good effect. Where the inflammation shows no disposition to remit from adopting these means, but on the contrary seems to proceed wilh baste to a suppuration, the evacuation of the matter externally should be promoted, to prevent its making sinuous openings into the urethra, and thereby terminating in fistula in perineo, which can only be removed by the proper surg.'cal operation. Sometimes the bladder becomes affected in consequence of the inflammation extending to it ; in which case the patient is troubled with a frequent inclination to make water without fhe ability of voiding it, together with pain in the organ itself, and a consider- 606 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III. able degree of tension over the os pubis. To remove this affection it will be necessary to have recourse to general bleedings, copious dilution, and emollient fomentations and clysters, &c. as advised under the head of Ischuria. In some cases of an obstinate sup- pression of urine, and where the endeavour to draw it off has failed, by placing the patient in a warm bath, and bleeding him ad deliquium animi, the surgeon has been enabled to pass the catheter with great ease. If these means prove unsuccessful, throwing up an enema of an infusion of tabacco (see Ischuria) will sometimes be attended with a decisive effect. The tinctura tabaci administered in a little linseed-tea in doses of thirty drops, repeated twice or thrice a day, has proved an ex- cellent remedy in dysuria arising in gonorrhoea, either from too early an use of astringent injections, or any other cause. It has already been mentioned, that in consequence of the inflam- mation of gonorrhoea extending along the urethra, the mucous membrane ofthe bladder sometimes becomes thickened, indurated, and ulcerated, so as to occasion it to pour out a considerable quan- tity of muco-purulent matter, which, added lothe urine, gives it the appearance of whey; and moreover, that there is often a dis- charge of blood also. An obstinate case of this nature came lately under my care, and arose from an imprudent use of strong astrin- gent injections, and an internal one of the tinctura lyttae. The cure of this chronic species of inflammation is to be effected by injecting the bladder with emollient decoctions and oil*; by the use of uva ursi taken in the dose of a drachm three times a day ; by balsamicsf ; and by a regular course of soda water.—See Cystitis. * 10. ft Infus. Sem. Lini, f.J?v. * 10. Take Infusion of Linseed, five ounces. Tinct. Opii Vinos, f. 3ss. M. Vinous Solution of Opium, half a drachm. ft. Injectio. Mix them for an injection. Vel, Or, 11. ft Liquor. Calcis. f. ^iv. 11. Take Lime Water, four ounces. 01. Lini Recent, f. 3ij. Olive Oil, two drachms. • Liquor. Plumbi Subacetat. tTl xij. Solution of Subacetate of Lead, M. eighteen drops. Mix them. t 12. ft Terebinth. Canadensis, \ 12. Take Canada Turpentine, Bals. Copaib. aa f. 3j- Balsam of Copaiba, of each one drachm. Sacchar. Alb. ^ss. Misceantur in White Sugar, half an ounce. mortario Dein adde paulatim Let them be well mixed in a mortar, and then add by degrees Aq. Distillat. f. ^viij. Distilled Water, eight ounces. Tinct. Opii, tTl xx. M. Tincture of Opium, thirty drops. ft. Emulsio, de quo sumat aeger cochlearia iij. Of this emuMon let the patient take three masruater in die. large spoonsful thrice a day Vel, Or, 13. ft Terebinth. Cuiae.gr. iij. 13.Take Cyprus Turpentine, three grains. Sa)ionis Hispanic gr. v. HarH Soap, five grains. Pulv. Gentian, q. s. M. Powder of Gentian, a sufficiency Fiant pilulae iij. ter in die sumenda?. to form the mass, out of which let three pills be made, to be taken three times a day Order III. VENEREAL DISEASE. 607 The prostrate gland as well as the bladder is sometimes affected also in consequence of gonorrhoea, and an inflammation arises in it, which is known by a pain and heat in the perinaeum extending into the rectum, and a frequent desire to make water, without the ability of voiding more than a few drops at a time. To obviate this we should make use of topical bleedings, by the application of several leeches to the perinaeum, together with a warm hip bath and emollient fomen- tations and poultices, and we should keep the patient's body open with laxative medicines and clysters. Where there is great pain and irri- tation we may employ anodynes, both by the mouth and by adding them to the clysters. In most cases of urinary irritation the best mode however of ex- hibiting opium is that of enema. Sixty or eighty drops of the tinc- ture may be administered in thin gruel with a table-spoonful of olive- oil. Occasionally we may introduce opium into the rectum in substance, and formed into a pill containing two or three grains. The extract of hyoscyamus, as also of aconitum, are sometimes employed as substitutes for opium where its preparations confine the bowels; but if pain be the symptom to which our attention is directed, nothing but opium can be relied upon. In those deplorable cases where a total suppression of urine arises, and we are unable to draw it off either by a catheter or hollow bougie of elastic gum, we should puncture the bladder. The most approved method of doing this appears now to be through the rectum. It seldom happens that a hemorrhage of any consequence takes place in gonnorrbcea ; but when there does, it is to be suppressed by injecting sedatives and astringents into the urethra, such as a solution of plumbi superacetas, alum, or zinci sulphas, in rose- water ; by the application of pledgets dipped in the same externally, and by keeping the body at rest. Where these means prove in- sufficient to stop the hemorrhage, we must apply a sufficient pressure. Practitioners who aim at popularity by endeavouring to make hasty cures of gonorrhoea, are much in the habit of employing astringent injections on its first appearance. A frequent conse- quence however of this mode of practice is, that although the dis- charge is, perhaps, speedily suppressed, the person is soon after- wards attacked with an inflammation and swelling in one or both of tbe testicles. Such a consequence being observed too frequently to arise from Vet, 14. ft Extract. Conii, gr. iij. Resin. Flavae, gr. vj. Bals. Copaib. q. s. M. Fiant pilulae iij. omni mane, hora meridia- na et vespere capienda?. ( Or, 14. Take Extract of Hemlock, three grains. Yellow Resin, six grains. Balsam of Copaiba, a suffi- ciency. Divide the whole into three pills, which dose may be taken morning,, noon, and evening. 608 CACHEXIA, OR CACHECTIC DISHA3E3. CUtSS 111. this treatment, it seems proper to notice, that previous to a use of astringent injections, we should take care to remove every inflamma- tory symptom whatever by a strict pursuance of the antiphlogistic plan; and that in employing them after we have effected this, we ought to make them only of a moderate degree of astringency at first. During the inflammatory stage it will be most proper to employ those of a sedative nature, as before advised; but on its going off, any of the astringent ones* here recommended may be substituted. An injection of the sulphate of zinc in the proportion of about a grain or two to each ounce of water, though perhaps one of the most active and successful of any we usually recommend, is apt, in persons of an irritable habit, to produce occasionally great pain, an increase of the discharge, and a peculiar .liability to swelling of the testicles. Under such circumstances, we are informed by Mr. Henryf, that he was induced to make trial of an injection composed of eight or ten grains of the acetate of zinc, dissolved in four or six ounces of water, or of a thin mucilage of quince-seeds, or a decoction of linseed or of barley, the success of which exceeded his expectations, and far surpassed that of any, the use of which he had ever witnessed. t See Medical and Physical Journal, vol. ix. p. 53. * 15. ft Zinc. Sulphat 3j.—3ij. Aq. Rosae, f. ^viij. M. ft. Injectio. Vel, 16. ft Plumbi. Superacetat. gr. xv. Zinc. Sulphat. gr. x. Aq. Distillat. f. ^viij. M. Vel, 17. ft Aluminis, 3j- Aq. Rosae, f. ?vj. M Vel, 18. ft Cupri Sulphat. gr. viij. Aq. Fontan.f. %vuj. M. Vel, 19. ft Calaminae Praepar. 3js«. Bals. Copaib. f. 3'ij. Mucilag. Gum. Acaciae, f. |ij. Aq. Distillat. f. |vj. M. Vel, 20. ft Bals. Copaib. f. 3»j- • Mucilag. Gum. Acaciai, f. |ss. Misceantur simul, et adde Liquor. Calcis. f. |vj. * 16. Take Sulphate of Zinc, from one to two scruples. Rose Water, eight ounces. Mix them for an injection. Or, 16. Take Superacetate of Lead, fifteen grains. Sulphate of Zinc, ten grains. Distilled Water, eight ounces. Mix them. Or, 17. Take Alum, one drachm. Rose Water, six ounces. Mix them. Or, 18. Take Sulphate of Copper, eight grains. Pure. Water, eight ounces. Mix them. Or, 19. Take Prepared Calamine, one scruple and a half. Balsam of Copaiba, two scruples. Mucilage of Gum Acacia, two ounces Distilled Water, six ounces. Mix them. Or, 20. Take Balsam of Copaiba/two drachms Mucilage of Gum Acacia, half an ounce. Mix them well together, and add Lime Water, six ounces Order til TENEREAL DISEASE. 609 The following is one of the methods advised for preparing the acetate of zinc :—• To a solution of zinci sulphas in six or eight times its weight in water, add a solution ofthe acetate of lead in twice its weight in water as long as any precipitation ensues, or a little longer, in order to ensure the complete decomposition of the sul- phate of zinc ; throw the whole upon a linen strainer, and wash off the soluble part by repeated affusions of distilled water, then eva- porate and crystallize. Some Burgeons are much in the habit of employing injections of a mercurial nature ; but in recent cases, and during the inflammatory stage of gonorrhoea, they are equally as improper as those of the astringent kind. When the inflammation has somewhat abated, and the discharge still continues in a virulent form, as like- wise in those cases where there is reason to suspect that there are ulcerations in the urethra, mercurial injections* will be likely to be attended with a very good effect by easing the ardor urinae, lessening the discharge, and shortly removing the complaint altogether. There are a few who totally deny that gonorrhoea has a venereal origin ; and there are others again who contend that it is a peculiar species of the venereal disease ; but at the same time they look on it as a local complaint, in which there is no danger of the system becoming affected by an absoption ofthe matter. They moreover regard it as a disease which will be sure to wear itself out, and at last effect its own cure, and therefore they neglect giving any medicine with the view of counteracting or destroying the syphilitic virus. The impropriety of proceeding in this manner, and the many injurious consequences which frequently result from it, must be too apparent to require my dwelling on them. Expe- rience must have convinced the prudent surgeon, that in order to guard against any disagreeable consequences, and ensure a perfect cure, it will be advisable, in most cases ef gonorrhoea, to make use of a proper quantity of mercury, in some shape or other. In making this observation, I by no means wish to infer, * 21. ft Hydrarg. Oxymuriat. gr. ij. * 21. Take Oxymuriate of Mercury, tws grains. Dissolve it in Rectified Spirit, two drachms. And add Distilled Water, eight ounces. Muriate of Ammonia, six grains. Mix them. Or, 22. Take Mucilage of Gum Acacia, two ounces. Submuriate of Mercury, one scruple. Terantursimul in mortario, etaddej Let them be rubbed together in a mortar; j. and add Aq. Calcis, f. svj. t Lime Water, sis eunces 77 Solv. in Spirit. Rectif. f. 3y. et adde Aq. Distillat. f. "viij. Ammon.MuriafTgr. vj. M. Vel, 22. ft Mucilag. Gum. Acaciae, f. |ij. Hydrargyr. Submur. 3j. 610 CACHEXIA, OR CACHECTIC DISEASES. CHaSS III however, that a clap can in no instance effectually be removed without mercury. In those cases where the disease is recent and perfectly mild, and where neither excoriation nor ulceration has taken place, it probably may continue a local affection, and at last effect its own cure; but as we cannot discriminate those cases in which the matter will not be absorbed into the system, from those in which it will, it appears to be the safest and most advisable plan to have recourse to mercury in all severe cases of gonorrhoea, as by so doing we shall guard against any unpleasant consequences, which, whenever they ensue from neglect, will be sure to hurt the practitioner in the esteem of his patient. As soon, therefore, as we can procure an abatement of fhe in- flammatory symptoms, we may begin with an use of mercury, as well as of astringent injections, regulating the dose according to tbe effect it produces. If we give the pilula hydrargyri, in prefer- ence to any other preparation of this medicine, we may begin with one, consisting of about five grains every night, which is to be continued until either a coppery taste is perceived in the mouth, or the gums become slightly affected. On the event of either of these, the pill is to be taken only every second or third night, which will be sufficient to saturate the system, and effectually destroy the syphilitic virus. If the pilula hydrargyri occasions a purging, we may substitute one composed of a combination of the submuriate of mercury and opium*, or of the hydrargyri oxydum rubrumf, as advised here1, or directed in the treatment of confirmed lues. If these likewise purge, we must then have recourse to mercurial ointment, half a drachm of the strongest kind of which should be rubbed into the hams and groins every night, till the mouth becomes affected in either of the ways before mentioned. Whatever preparation of mercury we may employ, it ought by all means to be continued for some short time after the disappearance of every symptom, during the whole of which period the patient is cautiously te avoid any exposure to cold. In the Contributions of Medical Knowledge, published by Dr. Beddoes, there is a curious paper by Mr. Addington, of West Bromwich, on the cure of gonorrhoea virulenta, by large doses of • 23. ft Hydrargyr. Submur. Camphorae, aa 3j. Opii, gr. xij. Syrup, q. s. M. Fiant pilul. xx. quarum sumat j. vel ij mane et nocte quotidie. t 24. ft Hydrargyr. Oxydi rnbri, 3ss. Opii, gr. v. Extract. Cascaril. 3j. Syrup, q. s. M. Fiant pllnl. xij. capiat j. vel Ij. bis in die. 23. Take Submuriate of Mercury, Camphor, of each one scruple. Opium, twelve grains. Syrup, a sufficiency. Let twenty pills be made out of the mass, of which one or two may be taken every morning and night. t 24. Take Red Oxyd of Mercury, half a scruple. Opium, five grains. Extract of Cascarilla, one scruple. Syrup, a sufficiency. Mix them, and form them into twelve pills'. 1 Let one to two be taken twice a dav. Order III venereal disease. <>1J the oxymuriate of mercury. Three grains ef this are dissolved in an ounce of rectified spirit of wine; half of this solution is taken undiluted at going to bed; it produces a copious salivation for ao hour and a half, or longer, during which the patient spits a quart. Some aperient salts are to be taken on the second day after this operation, and on the evening of that day he is to repeat the draught, and the salts on the day but one following. Mr. Addington witness- ed that three or four doses frequently removed a veneral gonorrhoea in a few days without any disagreeable consequence, and was in- formed that hundreds have been cured by it. It will be difficult to account for the action of this medicine in any other way, than by supposing it to be owing to the consent of parte between the throat and the urethra. Upon tbe plan of diminishing tbe irritability of the system, as well as of the parts particularly affected, opium has been much used in gonorrhoea, not only by injecting a watery solution of it frequently up the urethra, throughout the course of the day, but likewise by giving it by the mouth every night towards bed-time. This practice is certainly attended with very good effects, and ought therefore to be adopted more generally than it is. In consequence of a sympathy of the parts affected, or the having imprudently used any severe exercise, or had too early recourse to strong astringent injections, it sometimes happens that inflammation and swelling attack one of the testicles, showing themselves at first by a similar affection of the spermatic vessels and epididymis. In these cases we must rigidly pursue an antiphlogistic mode of treatment, by bleeding from the system, where an inflammatory diathesis seems to prevail, and by topical bleeding by means of seve- ral leeches where it does not; besides which, we should give the patient a brisk purge* every third or fourth day, and confine him to a very spare regimen, and to a recumbent posture. To abate the swelling and inflammation* the parts may be bathed several times a day with some discutient and refrigerant lotionf, and afterwards be covered with small pledgets dipped in * 25. ft Pulv. Jalapae, 3ss. Hydrargyr. Submuriat. gr. v. M. ft. Pulvis. t 2(5. ft Ammon. Muriat. 3'j- Acid. Acetic, f. §ij. Spirit. Camphorae, i. ^j. Liquor. Plumbi Subacet. f. 3ss. M ft. Lotio. Vel, 27. ft Liquor. Ammon. Acetat. Spirit. Rectif. Aq. Distillat. aaf. |ij- M. * 25. Take Powder of Jalap, half a dracbm. Submuriate of Mercury, five grains. Mix them for a dose. f 26. Take Muriate of Ammonia, two drachms. Distilled Vinegar, two ounces. Camphorated Spirit, one ounce. Solution of Subacetate of Lead, half a drachm. Mix them for a lotio n. Or, 27. Take Solution of Acetate of Ammo- nia, Rectified Spirit, Distilled Water, ef each twe ounces. 612 CACHEXIA, OR CACHECTIC BISEASES. Class III the same, h Inch are to be renewed as often as they become dry or warm. By night a poultice of linseed or rye-meal, moistened with a solution ofthe plumbi superacetas, may be kept to the part; but it is also to be applied cold; and in order that the testicles may not at any time hang by their own weight, the scrotum should be supported by a suspensory bandage. Djringthe continuance of die inflammation and swelling, it will be advisable to omit the use of mercury, and to employ in its stead cooling medicines, such as the nitrate of potass*; and in order to allay irritation, we should give an opiate every night at bed-time. Emetics have been much administered in inflammation of the testicle, but they seem to afford most relief in those cases where the swelling is unaccompanied by any hardness. Indeed, so powerful is the effect of emetics in some cases of swelled testicle, that they have been frequently found efficacious, when the repeated applica* tion of leeches, purgatives, and discutient lotions have failed. The cupri sulphas may be employed as advised under the head of Phthisis, when we judge vomiting to be proper, or we may give tartarized antimony twice a day in such doses as to produce some degree of vomiting. Where a hardness remains after the inflammation and swelling have subsided, poultices of hemlock, and its use internally joined with the cinchona bark, together with the application of mercurial unction every night, will be the most likely remedies to remove it. Almost every case of inflamed testicle will terminate favourably, by paying proper attention to this plan ; but when, either from improper treatment, neglect, or any untoward circumstance, a sup- puration has ensued, the matter must be discharged by making an opening into the most dependant part ofthe abscess, and the remain- der of the treatment must be the same as in collections of pus in other parts of the body. Vel, 28. ft Plumbi Superacet. 3s& Aq. Rosae, f. ?iv. Tinct. Opii, f. 3ij. M. * 29. ft Potassae Subcarbonat. 3j. Succ. Limon. f.|sS. Aq. Fputan. f. ?j. Potassa? Nitrat. £r. xv. Vin. Antimon fn x. Syrup Simpl. f. 3'j- M. fjt. Haustus ter de"die sumendus. Vel, Or, 28. Take Superacetate of Lead, half a drachm. Rose Water, four ounces. Tincture of Opium, two drachms. 29. Take Subcarbonate of Potass, oo« scruple. Lemon Juice, half an ounce. Pure Water, one ounce. Nitrate of Potass, fifteen grains. Antimonial Wine, sixteen drops. Syrup, two drachms. Mix them for ft draught, to be taken thrice a day. Or, 30. ft Potassae Supertart. 3"'j- j 30. Take Supertartrate of Potass, three drachms. Nitrat. 3'j- M. Nitrate of the same, two drachms. et in dos. x. divid. quarum unam sumat ter Mix them, and divide the whole into ten quarterve in die ; doses, of which let oae be taken three ojr jfour times a day. Order Iff. venereal disease*. 61S The matter discharged in gonorrhoea, being in some instances of an acrid and virulent nature, is apt, by lodging between the prepuce and glans penis in men, and on the labia pudendi in women, to occasion an excoriation and ulceration in these pans. To prevent such con- sequences, it will be right to pay strict attention to cleanliness, by washing them at least twice a day. When they take place we must employ lotions* of plumbi superacetas, or the liquor plumbi subacetatis, sufficiently diluted with water, suspending the penis at the same time to the abdomen, by means of a proper bandage. Warty excrescences now and then appear about the external organs of generation in both sexes, as a consequence of gonorrhoea and chancres. They are of various sizes, appearance, and con- sistence, adhering sometimes by a narrow base and sometimes by a broad one. VVherever a ligature cannot be applied round them, from the broadness of their base, or their being very numerous, they may either be touched with caustic, or be destroyed by the frequent application of other stimulants, such as acetic acid—(see Lues), a solution of the oxymuriate of mercury, ammonia muriata, or savine powder. This last has been found to succeed when all the other usual remedies have failed. It acts by producing a considerable discharge from the surface, by which the excrescence is gradually wasted without causing an eschar like a caustic application. More- over, it gives little or no pain, and is never productive of inflam- mation, which not unfrequently follows the use of either a solution of the oxymuriate of mercury, or pure potass, or any of the potent caustics. In consequence of inflammation, certain parts of the urethra are apt to become contracted, and to occasion strictures, which cause the urine, instead of flowing in a free and direct stream, to split into two, or to be voided drop by drop. The most usual way to remove these is, by a regular and long-continued use of a bougie; and if made of the elastic gum, bent like a catheter, will be preferable to those in common use. Were all such as are afflicted with these complaints not to neglect this remedy, we should seldom, if ever, meet with those dreadful cases of suppressed urine which occur in practice. In making use ofthe common bougies, it will, however, be necessary to attend to the following rules :— 1st, To begin with one of a moderate size, and so to increase it very gradually; but previous to its introduction, I would recom- mend it to be held near a fire for a short time, so as to soften it, and then to bend it, in the shape of a catheter, so as to adapt it *■■ 31. ft Spirit Camphorae, f. 3ij. Liquor. Plumbi Subacet. ft. 3j. j «. ■-.. Aqtwe Distillat. Oj. M, ft. Lotio. *31.Take Camphorated Spirit,two drachms Solution of Subacetate of Lead, one drachm. Distilled Water, one pint. Mix them for a lotion. t)14 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III to the curvature of the urethra, by which means its passage will be greatly facilitated. 2dly, To employ no force in introducing it; but where we meet with great resistance, to be content with merely suffering its point to press against the stricture for a short time each day, with the hope that by a perseverance in this plan a dilatation of the contracted part may at last be effected. 3dly, To wear it at first, only for about half an hour, gradually in- creasing the time as tbe parts can bear it without irritation. 4thly, Never to pass it into the bladder, except at first to ascertain the extent of the disease, but merely to carry its point some small distance beyond the stricture or strictures. Sthly, To guard against its slipping into the bladder, by bending its end, and tying it with a cotton thread fastened to the penis. 6thly, To avoid all exercise during its introduction; and, 7thly, To continue its use for a considerable length of time after the disappearance of the stricture, and again to have recourse to it on the least return of obstruction. English surgeons almost invariably adopt these ppident and cautious rules in the treatment of strictures, whereas those of France seem to consider stricture as a disease to be cured by m;»in force, the gum elastic bougie or the conical catheter* being the only means employed by them for its removal; when the case admits of either of these instruments being made to reach the bladder. In those cases where a bougie even of the smallest size cannot be passed, as likewise in those which are of such long standing as to preclude the hope of a perfect recovery from its use, it has been pro- posed to make use of caustic. This was first advised by the late Mr. John Hunter, and since his time has been much urged by Sir Everard Home. It appears from the report of this gentleman, that Mr. Hunter, fully sensible of tbe many inconveniences which attended the application of caustic to strictures in the urethra, by means of a eanula, as at first practised, had for some years previous to his death adopted a more improved mode of applying it; and that he himself has continued to make use of it ever since, without having ever found it (as we are informed) to be attended with dis- advantage. This improved mode of applying the caustic is thus managed : take a bougie, of a size that can readily be passed down to the stricture, and insert a small piece of lunar caustic into the end of it, letting tbe caustic be even with the surface, but surrounded every where laterally by the substance of tbe bougie. This should be done some little time before it is required to be used; for the materials of w hich the bougie is composed become warm and soft by being handled iu inserting the caustic; and therefore the hold Sec Sketches of the Medical Schools of Paris, . Ill, by Mr. Cross. Order III. venereal disease?. 6<1o the bougie has of the caustic is rendered more secure after it has been allowed to cool and harden. This bougie, so prepared, is to be oiled and made ready for use j but previous to passing it a common bougie of the same size is to be introduced down to the stricture to clear the canal, and to measure exactly the distance of the stricture from the external orifice; this distance being marked upon the armed bougie, it is to be passed down the stricture immediately upon withdrawing the other. When it is found in contact with the obstruction, it is to be steadily retained there, with a moderate degree of pressure at first, and less as it is longer continued, since the bougie becomes soft by remaining in the urethra, and readily bends if the pressure is too great. The time it is to remain must depend a good deal upon the sensations of the patient, and the length of time the parts have been diseased ; but on the first trial, it should not be for more than a minute, as it then gives greater pain than on any future application. The pain produced by the caustic is not felt so immediately as it would be natu- ral to expect: the first sensation arises from the pressure of tbe bougie on the stricture, a little after there is the feeling of heat, and then the parts become painful. As soon as the caustic begins to act, the surgeon who applies it is made sensible of it by the smaller arteries of the parts beating with unusual violence, which is very distinctly felt by the finger and thumb tbat grasp the penis. After the caustic has been withdrawn,'it is desirable that the patient should make water, as in that way any of the remains of the dissolved caustic are washed off; but it sometimes happens that no water will flow at the first effort. When that is the case, it should not be urged, as it is not of any great consequence. It happens not unfrequently, that at the first time of making water some blood passes along with it; this is also of no bad consequence, but is rather favourable ; as when it has occurred, the stricture usually proves to be so far destroyed, that at the next trial the bougie passes on to the bladder. Every other day appears, in general, to be as often as it is prudent to apply the caustic. By this mode of arming the bougie, strictures in the membranous part of the urethra may have caustic applied to them, which cannot be done by a silver catheter, unless made flexible, and even in that state it is liable to many objections. It appears that Mr. Hunter made use of caustic only in cases of impervious stricture; but Sir Everard Home, from a number of facts, thinks it established as a general principle, that the irritable state of a stricture is kept up, and even increased, by an use of the bougie, but lessened and entirely destroyed by the application of lunar caustic: hence he recommends the use of the caustic in many cases likewise of spasmodic stricture, in preference te 616 CACHEXIA', OR CACHECTIC DISEASES. ClasS III the bougie. In speaking of the comparative effects of the bongie and caustic, be observes, that from what he has seen, he thinks he may safely infer, that the caustic is a mode of cure more extensively useful, milder, quicker, more effectual, and more permanent than tbe bougie. So general and indiscriminate an use of caustic, as is her*S recommended by Sir Everard Home, appears to me to be inju- dicious, and likely, in many instances, to be productive of injurious effects. No doubt the caustic bougie may be, and often is, applied to stric- tures without exciting any particular inconvenience or trouble, but still the application of so active a remedy to so delicate an organ, will sometimes give rise to disagreeable symptoms; and accordingly, during the employment of it, various circumstances will frequently occur to embarrass, or even disappoint our hopes of a cure. Most commonly the pain excited is not very acute, but occasionally it is severe, owing to a degree of inflammation and tenderness in the urethra at the time the caustic is applied. The best means to remove any unpleasant symptoms will be alight diet, rest, opiates, injections, cooling laxatives, and the warm bath. Should a suppression of urine be the consequence of the application of ihe caustic, the same means ought to be resorted to. Should a swelling of the testicle arise, it will be proper to desist from the reme- dy, and ti> employ the usual means for reducing this affection, such as topical bleeding with several leeches, rest, an antiphlogistic regimen, cooling laxatives, and saturnine applications, with a suspension of the parts. Bit one of the most troublesome circumstances attending tbe employment of caustic for the cure of strictures, and which is apt more or less to embarrass the surgeon, and to alarm the patient, is a profuse hemorrhage. The quantity of blood lost is sometimes very considerable, and the hemorrhage may return from time to time, for several days. Nothing, however, is to be apprehended from the quantity lost, except a temporary faintness and debility. To check its profuseness, we may employ cold applications, rest, inter- nal astringents, and laxatives. Gende pressure in the perinaeum will frequently put a stop to the discharge, and in severe cases we can use some slight styptic injection, such as a solution of alum, or the sul- phate of zinc. Where a paroxysm of fever attends the application of the caustic bougie, and the patient is seized with rigors, succeeded by heat and profuse sweating, as now and then occurs, the only treatment neces- sary is the administration of a smart purge, followed perhaps by a full dose of opium, and exciting and keeping up a free perspiration by the use of warm diluent drinks. In very irritable habits, it might probably be a good plan to give a full dose of opium an hour or so previous to the application of caustic to the strictured parts. The practice of applying caustic should, I think, be confined to Order III. venereal disease. 017 such strictures of the urethra as are either utterly impervious, or so contracted as to be incapable of dilatation by the common or gum bougie ; for the urethra, even in its healthy state, being tender and irritable, and connected with parts of great importance in the system, all violent remedies ought to be applied to it with the greatest cau- tion. The invariable rule to be followed, should be to endeavour to dilate all strictures by means of an elastic gum or common bougie, before any attempt is made to effect their removal with caustic. The bougie armed with caustic should be kept as a remedy of re- serve to be employed in those more difficult and complicated cases in which the former has failed, or to which it is inapplicable. It must, however, be admitted, that the dilatation effected by the unarmed bougie is seldom more than a temporary cure, particularly in strictures of long standing ; for although the passage may be dilated sufficiently for the urine to pass, yet there remains the original tendency for contraction, which generally returns sooner or later on any exposure to cold or act of intemperance. Two other methods of applying caustic to strictures in the ure- thra, where such an application seems necessary, have been pro- posed, the one by Mr. Cartwright, and the other by Mr. Whately, and these were fully noticed in the first edition of this work ; but as after a fair trial they have been found to possess no superior advantages over the method recommended by Sir Everard Home, and are more complicate, I have thought it unnecessary to give a particular detail of them here. In a second tract more lately published by Mr. Whately on stric- tures in the urethra, he tells us that he has discovered a more effi- cacious, and at the same time a less hazardous and painful remedy for the disease in question than lunar caustic. It is the potassa fusa ; and with this he directs a bougie to be properly armed, but much in the same manner as recommended by Sir Everard Home. This innovation has not, however, been looked upon by the best surgeons as an improvement ; for whatever tends to weaken the action of the caustic, will at the same time destroy or lessen its effects on the stricture. It has been considered by one or two practitioners as an import- ant distinction between the use of the potassa fusa and of the argenti nitras, that a certain lubricity is given to the urethra by the solution of the first forming a soap with tbe secretions, so as readily to admit the bougie into the narrow part of the canal; whereas the argenti nitras coagulates the secretions, and when it has been ap- plied to a stricture with the intention of burning it, and acting as a caustic, the part touched by it becomes dead, rough, and no longer smooth and lubricated. Caruncles and excrescences in the urethra sometimes arise as a consequence of gonorrhoea, but they are usually situated towards its extremity, and never any length within it. They are to be removed by fhe bougie and caustic, as well as strictures. Where a spasmodic constriction of the urinary passage ensses in 7% 618 CACHEXIA, OR CACHECTIC DISEASES. ClaSS 111 gonorrhoea (which is known by its suddenly taking place without any previous appearance of interruption, and its being as suddenly removed), we must have recourse to emollient applications, such as fomenting with flannel cloths rung out in a warm infusion of cha- momile-flowers and bruised poppy heads, and rubbing the penis with tinctura opii and asther combined. Where these fail, a warm bath, together with the internal use of opium, in considerable doses, by the mouth as well as in clysters, must be employed. A com- bination of the submuriate of mercury with opium has been attended with a very happy effect in many cases of a retention of urine in gonorrhoea from spasmodic strictures in the urethra. Two grains of the former, with one of the latter, may be given every second hour for six hours, unless the desired effect is produced sooner. To prevent any return of the complaint, a pill of the same nature may be continued night and morning for a few days. In suppressions of urine arising from spasm, it is observed under the head of Ischuria, that the profession is indebted to Mr. Cline for the discovery of a very efficacious remedy. This is the tinctura ferri muriatis, which we are instructed to give in doses of ten drops, repeated every ten minutes, until some sensible effect is produced. After six doses the urine usually flows freely, the patient pre- viously becoming a little sick and faint. If we are foiled in overcoming the spasmodic contraction by these means, we may endeavour to introduce an elastic gum ca- theter, but no violence should be used in passing it. In spasmodic stricture, where the irritability of the urethra is so considerable as to forbid the introduction of a common bougie, lhis may be readily lessened by touching the point of the instru- ment slightly with liquor potassae, after it has been oiled and is ready for introduction. The effect of potass employed in this manner upon an irritable urethra is offen astonishing, and a full- sized bougie may be thus easily got info the bladder, which had been previously regarded as impracticable. The enema nicotianae* has proved eminently useful in many cases of suppressed urine arising from spasm, where all other means have failed : the effect is often powerful and decided ; the patient be- comes faint and sick, the pulse sinks, his whole body is bathed in perspiration, and in a few minutes the urine will often flow in a moderate stream. In consequence of the repeated attacks of a gonorrhoea, and the debility of the parts occasioned thereby, it not unfrequently happens that a gleet or small discharge remains behind, after all danger of infection has ceased. In recent cases, the disease may in general easily be removed ; but in those of long standing, where the * 32. ft Fol. Nicotian. 3»s.—3j- j* 32. Take Leaf Tobacco, half a drachm to one drachm. Aq. Bullient. f. |xj. Cel. post Boiling Water, eleven ounces. semiheram- Infuse them for half an hour, and strain ofl ft. Enema. the lipuor for a clyster. Order III venereal disease. 819 mucous glands have suffered much relaxation, or where there is either a stricture or callosity, it may continue for life in spite of our best en- deavours to cure it, having however certain intervals. This is, nevertheless, to be attempted by a frequent use of astringent injections, and even by those of a stimulant nature, as acrid solutions of ammonia muriata, mercury, verdigris, balsam of copaiba, he.*, employing the last class more seldom, however, than the former ; as likewise by forming an issue, or putting a seton in or near the perinae- um, thereby diverting the discharge elsewhere.. Besides using injec- tions, we may employ remedies internallyf. To give vigour to the whole system, and restore the tone of tbe parts at the same time, the patient sliould enter on a course of chalybeates, as advised under the head of Dyspepsia, assisted by cold bathing, country air, and a restor- ative diet. The tinctura ferri muriatis, when steadily employed, frequently pro- duces very permanent benefit in gleets. From twenty to thirty drops may be given for a dose thrice a day in an ounce of the decoctum cinchonae. No remedy proves more efficacious, however, than the prudent administration of cantharidesj. In every case where the disease is obstinate and stricture suspected, * 33. ft Hydrargyr. Oxymuriat. gr. ij. Ammon. Muriat. gr. x. Aq. Distillat. f. fx. M. ft. Inject. Vel, 34. ft Bals. Copaib. f. 3ij- Mucilag. Gum. Acaciae, f. ?j. Misceantur in mortario, et adde Liquor Calcis, f. §v. Tinct. Lytta?, fll viij. M. ft. Inject. t 35. ft Bals. Copaib. f |j. Capiat cochl. min. bis terve in diepaux sacch. albi. Vel, 36. ft Terebinth. Canadensis, f. 3ij. Hydrargyr. Submuriat. 3j. Pulv. Cincbon. 3j. M. Fiant pilul. xl. Capiat iij. vel iv. mane et vespere. Vel, 37. ft Zinc. Sulphat. 3j- Pulv. Rhei, 3j. Terebinth. Chiae, q. s. M. Fiant pilulae xx. quarum sumat j. vel ij. main et nocte. #> X 38. ft Tinct. Lyttae, f. fi. Sit dosis TTl *v- j- ter die ex quovis vekiculo. * 33. Take Oxymuriate of Mercury, two grains. Muriate of Ammonia, ten grains. Distilled Wa'er, ten ounces. Mix them for an injection. Or, 84. Take Balsam of Copaiba, two drachms. Mucilage of Gum Acacia, one ounce. Mix them in a mortar, And add Lime Water, five ounces. Tincture of Spanish Fly, twelve drops. To be used as an injection. t 35. Take Balsam of Copaiba, a small tea-spoonful twice or thrice a day, upon white sugar. Or, 36. Take Balsam of Canada, two drachms. Submuriate of Mercury, one scruple. Powder of Peruvian Bark, one drachm. Mix them, and form the mass into forty pills, of which three or four may be taken morning and evening. Or, 37. Take Sulphate of Zinc, one drachm. Powder of Rhubarb, one scruple. Cyprus Turpentine, a sufficiency to form the mass. Divide this into twenty pills, whereof let one or two be taken morning and night. X 38. Take Tincture of Spanish Fly, one ounce. The dose may be twenty-four drops thrice a day, in any vehicle. 629 CACHEXIA, OR CACHECTIC DISEASES. ClaSS 111 the introduction of a bougie will be properto ascertain it; and when satisfied as to its real existence, we ought to advise a perseverance in the use of bougies. The caustic in the manner practised by Sir Eve- rard Home may be resorted to as the final resource, should these not prove effectual. CHANCRES. The second local form under which the syphilitic poison has been mentioned to show itself, is that of a chancre: this is distin- guished by a want of disposition t<> heal, a thickened base and cir- cumscribed inflammation, with other characteristic marks already noticed. The parts most apt to be affected with these ulcerations in men, are the prepuce, the fraenum, at the orifice of the urethra, and in the angle between ihe glans and body of the penis; and in women, about the labia, nymphae, and clitoris; but in some instances they have extend- ed into the vagina, and even so far up as the os uteri. Syphilitic matter, by being applied to other parts of the body covered with a mucous membrane, such as the lips, nostrils, &c. may give rise to chancres there also; but being most usually applied to the organs of generation, in consequence of an intercourse between the sexes, these are generally tbe seat of such ulcers. A chancre makes its appearance either with a slight inflammation, which afterwards ulcerates; or there arises a small pimple or pustule filled with a transparent fluid, which soon breaks and forms into a spreading ulcer. The period at which it makes its appearance after infection is very various, being most commonly in five or six days, but in some cases not till after the expiration of as many weeks. As there is always a risk that an absorption of matter may take place from a chancre, and possibly very speedily, it will not only be necessary to attend to the ulcer, but likewise to secure the constitution by a use of such remedies as are well known to possess the power of counter- acting the syphilitic poison. In cases of a very recent nature, chancres may often be removed by the application of caustic, or by washing them with a weak solution of hydrargyri oxymurias in rectified spirit diluted ; but where they are extensive, and have been of some standing, it will be necessary to dress them daily with ointments composed of hydrargyri nitrico oxy- durn,orthe submuriate of mercury spread upon fine lint. When much pain and irritation prevail, opiates will have a good effect. In some cases of obstinate chancres of an inveterate and corroding nature, which have not benefited by the dressing* just advised, much advantage has been derived fioiu the application of a poultice composed of the inner soft part.iaf. a loaf of wheaten bread, moistened with a solution of the s'drphate of soda in boiling water, in the proportion of one ounce of the former to four pounds of the latter. To give chancres a disposition to heal kindly, it will be highly necessary to attend strictly to cleanliness. Mr. John Hunter, in Order III TENEREAL DISEASE. 621 his Treatise on the Venereal Disease, seems however to have thought this unnecessary ; for he says be is inclined to believe that no matter of whatever kind can produce any effect on the part that formed it; neither can the matter of any sore, let it be what it will, ever do hurt to that sore; and from thence he draws the conclusion, that the wiping or washing away matter under the idea of keeping the parts clean, is in every case absurd. Where chancres exist along with phymosis, the cure will be both tedious and uncertain, and cannot often be effected by simply throw- ing up injections of a cleansing nature from time to time between the prepuce and glans. The more certain method will be, to make an inci-ion through the former, or to perform the operation of cir- cumcision. Chancres sometimes appear on the nipples of women who suckle infected children, and excite much pain. To lessen the irritability ofthe parts that are diseased, it will be proper to bathe the ulcers twice or thrice a day with a strong solution of opium in water, and afterwards to dress them with the unguentum cetacei, to which a proper quantity of hydrargyri submurias has been added. Besides topical applications, it will be necessary to secure the constitution from becoming affected at some after-period in con- sequence of an absorption of the matter from the ulcers, by having recourse to mercury, which must be used either externally or inter- nally, as shall be found most suitable to the constitution and convenience of the patient. In employing it we are however to avoid exciting any degree of salivation, and therefore we are to introduce it gradually into the system, carefully watching its effects. The length of time it ought to be used will depend on the virulence of the disease and other accidental circumstances ; but at any rate we should never totally desist from its use until the expiration of several days after the disappearance of the ulcers. Where erysipelatous inflammation of the penis supervenes to chancre, mercury should neither be exhibited internally or be used externally in any form whatever until it has subsided. In consequence of the irritation of venereal virus in a de- bilitated constitution, aggravated perhaps by an excessive or injudicious exhibition of mercury, more particularly in a crowded hospital, it not unfrequently happens that chancres become phage- denic. They commence with a livid redness of the part, succeeded speedily by vesication and ulceration, which extends laterally and sometimes penetrates deeply. The ulcer has a corroding appear- ance, is highly painful, discharges a great quantity of matter, and is often attended with fever. In all such cases stimuli would be in- jurious, and when used have been known to re-excite the morbid actions of the sore in such a degree as to occasion the death of the patient: mercury must therefore be omitted. The ulcerated parts should be well fomented morning and even- 622, CACHEXIA, OR CACHECTIC DISEASES. ClaSS III ing with flannel cloths wrung out in a decoction of bruised poppy- heads and the powder bark of cinchona, and afterwards be covered with an emollient poultice mixed with carbon (see Gangrene). Internally we may give opium freely, and at stated intervals, as likewise some light preparation of cinchona bark joined with sar- saparilla and a mineral acid. Wine in moderate qjantities will also be proper. The patient, if in an hospital, should be removed to a purer atmosphere. A peculiar eruptive disease arising from the exhibition of mercury has lately attracted the attention of some practitioners in Ireland*; and although of frequent occurrence, no doubt, in the London hos- pitals, it does not appear to have been particularly noticed by any surgeon belonging thereto, except by Mr. Pearsonf. Mr. Benjamin Bell, indeed, in his treatise on the Venereal Disease, very ac- curately describes itj, although, from tbe manner in which he speaks of it, the cases he had seen could not have been of a severe nature. The disease is generally supposed to be produced by exposure to cold while the system is under the influence of mercury ; yet as its occurrence is infinitely too rare to be the necessary consequence of so common a cause, probably a peculiar idiosyncrasy, or unknown state of the constitution of the person affected, may be necessary fot its production. It seems nearly allied to the genus erysipelas, and has by some been named the erythema mercuriale. This complaint sometimes shows itself by a heat and itching about the scrotum, and the upper and inner parts of the thighs, which on examination appear faintly red, and are somewhat rough. On other occasions, the heat, redness, and roughness, are first to be observed in the groins, and at the bend of the arms. Id most cases the anterior parts of the body are affected before the posterior, and the lower extremities suffer prior to its appearance on the trunk of the body; yet there is not so much of constancy and regularity in the order in which it proceeds, tbat the upper extremities are not occasionally attacked as early as the thighs. The redness beginning on the extremities makes a slow and gra- dual progress over the whole body, no part being exempted from it. Its increase is attended with great tenderness of the skin, a troublesome itching, and an evident tumefaction of the parts affected. The swelling is not unlike that which attends erysipelas, and it has been as considerable as that which accompanies the small-pox. The temperature of the skin is increased, tbe tongu*. is white, and the pulse frequent; but neither the functions of the sto- mach, nor of the sensorium commune, are evidently disturbed by this,,, complaint. * See a Dn= cription of tbe Mercurial Lepra, by Dr. Moriarty ; and an Essay on a pe>- culiar Eruptive Disease arising from the Use of Mercury, by George Alley. t See Observations on the Cure of Lues Venerea. X See his Treatise on Gonorrhoea Virulenta and Lues Venerea, vol. ii. p. 288. Order III. venereal disease. 6^3 The lepra mercurialis is always a vesicular disease, although the vesicles, which contain a pellucid fluid, are, at their first appear- ance, so small that they cannot easily be distinguished from papulae without the aid of a convex glass: they are then seen to be distinct, each vesicle surrounded by a circle of redness; and if they are not ruptured at an early period, fhey acquire the size of a large pin head, at which time the contents are opaque. The rupture of the vesicle is succeeded by the discharge of a thin acrid fluid that irritates the surface which it touches, and greatly increases the patient's sufferings, and as the disease proceeds, he is excoriated almost from head to foot. The quantity of the discharge is in proportion to the extent of the excoriated surface ; it is always considerable, and renders the linen which absorbs it stiff and unyielding. As the fluid discharged becomes thicker and more adhesive, it emits an offensive scent similar to that which arises from the secretions of the sebaceous glands when under the influ- ence of the disease. The lepra mercurialis does not invade the whole surface of the body at once, but occupies the different parts of it successively, so the several portions of the skin affected by it exhibit a more or less advanced state of the disease at the same time : hence while the part first attacked is discharging the adhesive matter, the thin acrid fluid may be flowing from another portion. From this repre- sentation it must be obvious that the exact period observed by this disease cannot be easily ascertained; nor indeed does it appear to be limited by any regular term of duration. When it has affected but a small part of the body it often terminates in ten or twelve days ; but when it has been universal, the patient seldom recovers completely in less than six, eight, or ten weeks. Wrhen the discharge ceases, the loosened cuticle acquires first a pale brown colour, and then becomes nearly black, separating in large flakes, and leaving a faint redness on the exposed surface. The first desquamation is often succeeded by a second, or even a third ; but in these latter desquamations the cuticle is more of a white colour, and separates in farinaceous-like scales, so that the surface of the skin appears as if it were covered with a white powder. The effects ofthe lepra mercurialis are not however con- fined to the destruction ofthe epidermis. All the hair ofthe body, the beard, the hair under the axilla?, and on the regio pubis, and the greater part of the eyebrows, and hair of the head, have been known to separate, and leave the parts as smooth as in a state of infancy. The disease ceases after a time, but it is doubtful wheth- er any remedies have the power of interrupting its regular course, er of abridging its duration. The mode of treafment however which has been recommended consists in desisting from the further use of mercury, and in em- ploying such remedies as will serve to support the patient without increasing fever, and such topical applications as may lessen the irritation arising from the perpetual loss of skin. Keeping the 624 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III bowels open with saline purges ; exciting a gentle determination to the surface of the body by diaphoretics ; allaying irritation by means of an opiate at night; and frequent warm bathing will be proper in most cases. Where the disease assumes a putrid type, the bark of cinchona, with wine and some ofthe mineral acids, may be necessary. Starch powder, meal or flour, will be the best topi- cal applications. The use of saturnine applications to so large an exposed surface might be injurious. A case which is recorded in the 18th No. of the Edinburgh Medical and Surgical Journal, by Dr. Rutter, of Liverpool, evidently shows however that mercury does not appear to be the sole cause of erythema in a hi^h degree, for an eruption exactly of a similar nature took place when his patient had neither taken or used in any manner whatever a single particle of mercury. We have hitherto been accustomed to look upon mercury as the only certain antidote against the venereal poison ; but the nitric acid has been recommended as possessing a similar power. Dr. Scott, late of Bombay, seems to be the first who employed it in syphilis. He tells us, he has had such extensive experience of its good effects, that he looks upon it to be by no means less effectual than mercury in removing that disease in all its forms, and in every stage of its continuance ; and from its not producing many of the inconveniences that arise from an use of that metal, he thinks it may in some respects be preferable. He observes, that mercury introduced into the circulation is attended by many disagreeable effects that render it often necessary to give over its use before it has answered the desired intention ; but that the nitric acid may be taken a long time without any material injury to the health, and without producing inflammation and a flow ot saliva, as from an use of mercury, but merely a temporary soreness in the gums and teeth. On the recommendation of this gentleman, many practitioners have been induced to employ the nitric acid in the primary affec- tions of syphilis, such as chancre, gonorrhoea, &c. and with some success. A few however have not made a favourable report of its effects ; but more particularly Mr. Blair, surgeon to the Lock Hospital. The nitric acid af any rate may assist the use of mercurials as well as opium in the cure of venereal ulcers, although it should not be solely depended upon. A matter of much importance, and worthy of notice, is, that the nitric acid has not been perceived to excite the action of other dis- eases, more especially scrofula, one ofthe greatest inconveniences attending a mercurial course, and by which many have had their constitution ruined, and others have lost their life. The sensible effects generally produced by a use of this acid are an increase of the appetite, costiveness, the mouth and tongue becoming moist and white, with a slight soreness in the gums, the Urine being of a light straw colour, clear, and increased in quantity; Order III venereal disease. • 6215 and the blood when drawn exhibiting the same appearances as under active inflammation, the coagulum being covered with a lough coat of coagulable lymph. In a few instances a burning sensation in the stomach has been observed ; but this has only happened where the dose has been too great. The mode of administering the nitric acid is to give one drachm of it diluted in a quart of an infusion of lemon-peel in warm water every day; and where this quantity does not seem to pro- duce the desired effect, to increase it gradually to two or more drachms. A course of this medicine requires no particular regimen nor confinement. Nitric acid is known to contain about four parts of vital air united to one of azote, with a certain proportion of water, and is supposed to remove the symptoms of syphilis by oxygenating the body to a considerable degree, producing thereby a general increased action of the whole system. In a work* lately published, Dr. Scott has inserted a paper ex- plaining the reasons of the failure of this remedy in this country, and under the direction of other practitioners. He therein states, that the acid he employed was not pure nitric acid, but an impure acid containing an admixture of muriatic acid. He therefore now recommends the use of a compound acid containing equal parts of nitric acid and of the muriatic, which he administers internally, and also applies externally either as a wash or bath, largely diluted, (say eight ounces of the acid to forty gallons of water), until the gums are affected and ptyalisra produced. He conceives every trial as quite inconclusive unless these constitutional effects occur. We are informed by Dr. Scott, that he found this acid particularly useful, even in this country, in that description of syphilis which is termed pseudo-syphilis, and which he considers as real syphilis combined with scrofula, called into action by the mercury employed for the cure of the syphilitic affection, and consequently not curable by mercury, although syphilis be still in the habit, but undoubtedly not produced by that remedy. It appears also, that sponging the skin with a solution of chlorine (water saturated with the nitro-murialic acid) is attended with the same effects exactly as arise from the union of the acids, and employed in the same way. Dr. Scott gives no explanation of the modus operandi of the acids in conjunc- tion, but thinks the power depends on the chlorine, as Sir H. Davy terms itf. A BUBO. ' It has already been observed, that between a local and constitu-. tional affection there often arises a kind of intermediate state, and that in consequence of an absorption of venereal matter from * See Journal of Science and the Arts of India, vol. i p. 205—11. \ See Sir II. Davy's Theory of Chlorine, London Med and Physical Journal, vel *\xv p. ill 79 626 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III some surface to which it has been applied, tbe glands situated nearest to the parts thus affected are apt to become indurated, swelled, and inflamed, and so to give rise to a bubo; and the parts of generation usually coming first in contact with the matter, so the glands in the groins are the most general seat of this particular symptom. In most cases the syphilitic virus is absorbed from a chancre or ulcer in the urethra; but instances, have occurred where a bubo has arisen without either gonorrhoea or any kind of ulceration, and where the matter appears to have been absorbed without any evident erosion of the skin or of the mucous membrane. A bubo comes on with a pain in the groin, accompanied with some degree of hardness and swelling, and is at first about tbe size of a kidney-bean, but continuing to increase, it at length becomes- as large as an egg, occasions the person to experience some difficulty in walking, and is attended with a pulsation and throbbing in the tumor, and a great redness of the skin. In some cases the suppura- tion is quickly completed; in others it goes on very slow; and in others again, the inflammatory appearances gooff without any forma- tion of pus. In a few instances the glands have been known to become scirrhous. As many other swellings in the groin, such as a rupture, aneu- rism, lumbar abscess, and scirrhous affection of the glands, may be mistaken for a bubo, it will always be advisable in doubtful cases to inquire whether or not the patient has lately been afflicted either with a gonorrhoea or chancre ; and whether or not he has lately laboured under any other complaint that might have given rise to the swelling, It may likewise be advisable to attend to the progress which the tumor has made. By a due consideration and investigation of these circumstances we cannot fail to form a just conclusion as to the real nature of the disease. The following are the characteristics of a venereal bubo : the swel- ling is usually confined to one gland ; the colour of the skin where in- flammation prevails is of a florid red; the pain is very acute; the pro- gress from inflammation to suppuration and ulceration is generally very rapid; the suppuration is large in proportion to the size ofthe gland; and there is only one abscess. A bubo is never attended with danger where the inflamed gland proceeds on regularly to suppuration; but in particular cases it acquires an indolence after coming to a certain length, arising from* a scrofulous taint; or, by being combined wilh erysipelas, it termi- nates in phagedenic ulceration, and occasions a great loss of sub- stance. This termination is however more frequently met with in hospitals than in private practice, and may partly be attributed to the contaminated state of the air of the wards wherein syphilitic pa- tients are lodged. The many inconveniences that ensue from allowing a venereal bubo to suppurate, should induce the practitioner to exert his utmost endeavours to prevent it from proceeding to such a state* Order III venereal disease. 627 and to occasion its speedy resolution or dispersion, if possible. To effect this, it will be proper, where the skin is occupied by much red- ness and inflammation, and the tumor by a throbbing, to draw off a suflicient quantity of blood immediately from the neighbourhood of the inflamed part during the first days ofthe disease by means of four or five leeches; the patient at tbe same time keeping his body open with iiome gentle laxative, using a very spare diet, and avoiding ex- ercise. After the leeches have ceased to bleed, the parts may be wet- ted frequently throughout the course of the day with linen pledgets dipped in any of the sedative lotions advised for a swelling of the tes- ticle, and by night be covered with a poultice of linseed or rye-meal, moistened either with a diluted solution of plumbi superacetas, or the liquor plumbi subacetatis. If the tumor is unattended by any inflammatory symptoms, then topical bleeding may not be necessary, as probably the timely appli- cation of mercurial ointment will be sufficient to disperse it. To give this its due and proper effect, it should not however be applied imme- diately upon the tumor, but be rubbed in on the inside of tbe thigh which is affected. With regaid to the quantity to be used, no express rule can be laid down, as some constitutions are readily affected by mercury, and others again are neither very quickly nor sensibly operated upon by, it. In all cases it will be most advisable to begin with a small quantity of about the size of a hazel-nut, and so to increase it daily, until it comes to that of a moderate-sized walnut; which course is to be pursued every night until tbe tumor and induration have entirely subsided. Indeed if it is continued for some little time after the disappearance of both, it will be attended with a more certain effect. Should the salivary glands become affected from an use of the unction, and any degree of salivation ensue, the patient ought imme- diately to discontinue it for some days, keeping his body open with gentle laxatives, and washing his mouth and throat frequently with a gargle composed of borax and honey* dissolved in water. The borax will not only act as an astringent, but will diminish the irritable state of the glands by its sedative power. To assist in lessening the irrita- tion, it will be advisable, during a course of the unction, to give an opiate every night at bed-time. If a bubo is too far advanced to be dispersed at the time that assistance is applied for, or obstinately continues its course to sup- * 39. R Sodae Sub-boratis, 3ij. Mel. Rosae, f. ^j. Aq. Fervent, f. |viij. M. ft. Gargarisma. Vel, 40. IJ Aluminis, 3'j- Decoct. Hordei, Oij. Melfis Rosae, f. |ij. M. • 39. Take Sub-borate of Soda, two drachms. Honey of Roses, one ounce. Hot Water, eight ounces. Mix them for a gargle. Or, 40. Take Alum, two drachms. Decoction of Barley, two pints. Honey of Roses, two ounces. Mix them. 628 CACHEXIA, OR CACHECTIC DISEASES. ClaSS 111 puration, in spite of our best endeavours to prevent it, we are then to assist the formation of proper pus by a full diet, and the application of emollient poultices. When this is formed, the tumor may be opened by a lancet or caustic, and the ulcer be brought to a proper digestion by suitable dressings and the internal use of mercury, taking care, however, not to carry it to the extent of producing salivation. In those case* where there prevails a scrofulous disposition, it frequently happens that the sore does not heal kindly, but. on the contrary, spreads from the glands to tbe cellular substance, in- flames the skin and contiguous parts, assumes a foul spongy appearance, and is accompanied by much pain and a discharge of an highly acrid matter; or should the ulceration heal in one part, it shortly afterwards breaks out in another, and becomes extensive. Cases of this nature have been most successfully treated by fomenting the ulcerated parts twice a day with a strong decoction of the leaves of hemlock or of bruised poppy-heads, and then covering them with some emollient cataplasm, or that advised for chancres of a corroding and phagedenic nature. Where the ulcers have a fungous appearance, and discharge a thin acrid ?anies, a little .of the hydrargyri nitrico oxydum may now and then be sprinkled over them, which will seldom fail to promote proper pus, and will by no means excite pain. As internal medicines, we may administer the bark of cinchona joined with the nitric acid, together with a de- coction of mezereon, which may be taken in the quantity of a quart daily. Opium has been much employed in these untoward cases, partly on the supposition of its being possessed of some specific power in the cure of syphilis; but its utility seems to depend entirely on its narcotic quality, and its allaying the*pain and irritation with which such sores are uniformly accompanied when the discharge is thin and acrid. Hemlock has likewise been resorted to in these cases, and sometimes with advantage ; it may therefore be taken internally. We may begin with about two grains of its extract in the form of a pill, and so increase the quantity daily, until it shows its effects on the system by producing a slight degree of giddiness. Buboes in scrofulous habits, or when accompanied with erysipe- latous inflammation, are very apt, particularly in' hospitals win re the air of the ward is much contaminated by many mercurial breaths, to degenerate into phagedenic ulcerations, which extend in a short time over a considerable space, and not unfrequently lay bare a large portion of the thigh and lower part of the abdomen, and even the testicles themselves. In cases of this nature the ulcerated parts should be well fomented two or three times a day with flannel cloths wrung out in a warm decoction of bruised poppy- heads and the cinchona bark, and afterwards be covered with an emollient poultice, and occasionally wilh the cataplasma carbonis Order lit VENEREAL DISEASE^ 629 mentioned under the head of Gangrene. The use of mercury should immediately be desisted from, employing in its stead large and frequently repeated doses of the bark of cinchona, joined with sarsaparilla, together with opium so as to keep up a con- stant effect. The patient is at the same time to be supported with a generous diet and wine, and if possible to be removed into a purer air, without which our endeavours may not be crowned with success. In all cases of bubo, as well as of chancre and gonorrhoea, where mercury is used either internally or externally, it will be necessary for the patient to abstain from food of a high-seasoned and salted nature, and from all kinds of spirituous and fermented liquors ; and as any exposure to cold, while under a course of this medicine, is very apt to bring on a salivation when it would not otherwise have arisen, he ought most carefully to avoid getting wet, or ex- posing himself to moist cold air, taking the precaution at the same time to adapt his clothing to the season ofthe year. THE CONSTITUTIONAL DISEASE. A constitutional taint is the third form under which it has been mentioned that the syphilitic poison is apt to show itself, and which always arises in consequence of the matter being absorbed, and carried into the circulating mass of fluids. The absorption of it may however take place in three ways :— 1st, It may be carried into the circulation without producing any evident local effect on the part to which it was at first applied : 2dly, It may take place in consequence of some local affection, such as either gonorrhoea, chancre, or bubo : and, 3dly, It may ensue from an application of fhe matter to a com- mon sore or wound, similar to what happens in inoculating for the small-pox. The most general way, however, in which a constitutional taint is produced, is by an absorption ofthe matter, either from a chancre or bubo. When syphilitic matter gets into the system, some symptoms of it may often be observed in the course of six or eight weeks, or probably sooner ; but in some cases it will continue in fhe circula- ting mass of fluids for a few months before any visible effects are pro- duced. The system being completely contaminated, it then occa- sions many local effects in different parts ofthe body, and shows itself under a variety of shapes, many of which put on the appear- ance of a distinct disease. We may presume that this variety de- pends wholly on fhe difference of constitution, the different kinds of parts affected, and the different state these parts were in at the time the matter or poison was applied. • The first symptoms usually show themselves on the skin, and in the mouth and throat. When the matter is secreted principally in the skin, reddish and brownish spots appear here and there on its 630 cachexia:, or cachectic diseases. Class 111 surface, and eruptions of a copper colour are dispersed over differ- ent parts ofthe body, on the top of which there soon forms a thick scurf or scale. This scurf falls off after a short time, and is suc- ceeded by another ; and the same happening several times, and at length casting off deep, an ulcer is formed which discharges an acrid felid matter. When the poison is secreted in the glands of the throat and mouth, the tongue will often be affected, so as to occasion a thick- ness of speech ; and the tonsils, palate, and uvula, will become ulcerated, so as to produce a soreness and difficulty in swallowing, and likewise a hoarsness in the voice. The tonsils are more usually affected with syphilitic ulceration than the uvula or* velum palati, though the affection may spread fo these from the tonsils. The ulcer of the latter is an excavation, as if a piece was scooped out; the sore has an uneven, jagged, foul appearance, with an erysipelatous redness on a hard, elevated, de- lined border ; the ulcer is commonly covered with a whitish or brown slough ; it is progressive, and like the rest of the syphilitic symptoms, it is not curable by the powers of the constitution. Generally there is not much pain nor much enlargement attendant on this form ofthe disease ; in other respects the sensations do not materially differ from those produced by ulceration of the throat proceeding from other causes. If the disease affects the eyes, obstinate inflammation, and some- times ulceration, will also attack these organs. The matter sometimes falls on deep-seated parts, such as the tendons, ligaments, and periosteum, and occasions hard, painful swellings to arise, known by the name of nodes. When the disease is suffered fo proceed, and is not counteracted by proper remedies, the patient will.in the course of time he afflicted with severe pains, but more particularly in the night-time : his countenance will become sallow ; his hair will fall off; he will lose his appetite, strength, and flesh ; his rest will be much dis- turbed by night, and a small fever of the hectic kind will arise. The ulcers in the mouth and throat being likewise suffered to spread, and to occasion a caries of the bones of Ihe palate, an opening will be made from fhe mouth to the nose ; and the cartilages and bones pf the nose being at length corroded away, (his will sink on a level with the face. It now and then occurs that primary symptoms followed by secondary ones present themselves, all closely imitating syphilis in its primary and secondary stages, and yet are not venereal. Symp- toms resembling the secondary appearances of syphilis occur also without any preceding primary symptom, and turn out not to be venereal. In some of the cases the symptoms go off, and the patient gets well without any remedy : in others, common altera- tives, such as a decoction ofthe woods, has subdued the complaint. These complaints resembling the venereal disease have been called Order III venereal disease. 681 by the name of cachexia syphiloidea, or pseudo^sypbilis. Mr. Hunter* has remarked, that undescribed diseases resembling the venereal one were numerous, and Mr. Abernethyf has drawn the attention of medical men by his remarks on diseases resembling syphilis. Some constitutions will bear up for a considerable time against the disease, while others again will soon sink under the general weakness and irritation produced by it. If the disorder is recent and the constitution not impaired by other diseases, a perfect cure may easily be effected ; but where it is of long standing, and accom- panied with the symptoms of irritation which have been mentioned, the cure will prove tedious, and in many cases uncertain, as the constitution and strength of the patient may not admit of his going through a course of medicine sufficient to destroy the poison ; or his health may be in such a state as that only a very small quantity of mercury can be administered, even at considerable intervals. The general appearances to be observed on dissections of those who die of lues, are caries of the bones, but more particularly those of the cranium, often communicating ulceration to the brain itself • together with enlargements and indurations of the lymphatic glands' scirrhus of several ofthe organs, particularly the liver and lungs, and exostosis of many ofthe hardest bones. We have always been accustomed to consider mercury as the most certain antidote which we are acquainted with, to the syphilitic poison, if judiciously employed or administered ; from whence it is evident, that it will be necessary to have recourse to it in all cases where the system becomes tainted. A class of practitioners has indeed lately started up, but particu- larly among regimental surgeons, to propagate the practice of curing syphilis and pseudo-syphilis in all their Protean forms without any mercurial preparation whatever; but I here beg leave to warn my readers against this new doctrine of trusting the cure of syphilis to sarsaparilla and such like remedies, in exclusion of mercury, as by such a practice we can never ensure the patient against secondary appearances of tbe disease. The manner in which mercury removes syphilis is not yet satis- factorily ascertaihed ; but in the opinion of some physicians, its ac- tion has been supposed to be chemical, the remedy combining with and destroying the virus ; for it has been found that venereal matter applied by inoculation readily propagated chancre, but if mixed with a variety of mercurial preparations, no infection followed. The same effect of mercury over variolous matter has been noticed under the head of Inoculation for the Small-pox. A few who rank as regular practitioners, besides those who act as quacks, fully sensible of the credulity of mankind, have endeavoured to make the vulgar believe, that by repeated examinations of the • See bis Treatise on tbe Venereal Disease f Sec his Surgical Observation*. 632 cachexia, or cachectic diseases. Class 111 various productions of nature, they have each of them been able to discover a specific of a milder and more innocent nature than,mer- cury for the venereal disease ; and puffing handbills and advertise- ments daily announce that they can perforin a radical cure without giving one grain of this mineral. A fair analysis of such of these nostrums as have been found at all serviceable in cases of this nature, has, however, clearly detected the falsity of these men's assertions, and proved beyond a possibility of doubt, that their new-discovered specifics are but some active preparation of mercury under a dis- guised shape. Mercury may be introduced into the system in two ways, viz. either by an external application of it in the form of unction, or by giving some preparation of it internally ; and it may be used to such an extent as to excite a salivation, or with such moderation as only to jive a tendency that way, without suffering it to proceed so far, which in all cases will be the safest and most advisable plan. A third method, or alterative course, has been adopted by some practition- ers; but although this may answer in primary affections, still it is by no means calculated to cure a confirmed lues. There are some persons who are but little affected by mercury when applied externally to the body in the form of unction, as the absorbent vessels will not readily receive it; and there are others again whose internal absorbents will not take up a suflicient quan- tity to produce much effect either on the disease or the constitution; in which case the medicine passes off by the bowels, occasioning eickness at the stomach and griping pains. To administer mercury judiciously, it ought therefore to be used in the way that is most suitable to the constitution of the patient. If on a trial the external application of it should produce no effect, either on the disease or constitution, then it should be administered inwardly: on the other hand, if its internal use fails, or produces any disagreeable effect on the stomach and intestines, then the external application ought to be substituted. Indeed, the skin not be- ing so essential to life as the stomach, is capable of bearing the application of mercury to it much better than the latter. Although the quantity of mercury to be introduced into the system for the cure of a lues must always be in proportion to the virulence of the disease, still in throwing it in we should neither proceed with haste or violence, nor administer it in large or too frequent doses. In all cases it will be most prudent to begin with a small quantity, whether given internally or applied externally, and to increase it gradually, so as that the system shall be inured imperceptibly to the remedy; and as soon as the patient perceives a copperish taste in his mouth, with a great foetor of breath, and a more than ordinary secretion of saliva, he ought then to proceed cautiously, and where necessary, wholly to desist from its use for a day or two, returning to it how- ever as soon as these sensations have somewhat abated. To use the medicine so as to give a tendency to salivation, with- Order III venereal diseass. 66@ out proceeding any length, and to keep it constantly at that point during tbe whole course, is what he is to aim at. Mercury when introduced hastily and in large doses into the consti- tution, is apt to produce sensible and disagreeable effects upon partic- ular parts ofthe body. It often occasions a swelling and inflammation in the mouth, tongue, and salivary glands, and thereby produces a profuse salivation. It likewise affects the stomach and intestines, and excites nausea, griping pains, and diarrhoea; and in some instances it produces profuse sweats and greai debility. Introducing mercury into the system, so as to give rise to any of these effects, will therefore be highly improper. Unless the disease is proceeding so fast in its course as that it might be attended with some risk to the patient to wait until it was checked by introducing it grad- ually ; or unless he is so irritable to the effects of mercury, as tbat even the smallest quantity used internally, or applied externally, affects his mouth, it will be wrong to occasion a salivation, as the cure will in general be rendered thereby more tedious, as well as uncertain, in- stead of being hastened. To prevent a salivation it will be necessary, besides beginning with small doses of mercury and proceeding gradually, tbat the patient sliould take care not to stimulate the salivary glands, either by rubbing the skin over them, and keeping it too warm with flannel; or by apply- ing any thing of a stimulating nature to the mouth ; and he should likewise avoid as much as possible any exposure to cold ; for this being applied while the body is in an irritable state from the use of mer- cury, is likewise apt to occasion inflammation and tumefaction of these glands, and so to give rise to a salivation. In a warm and well regula- ted temperature, a mercurial course is more under the command of the practitioner, the remedy produces its effects with more certainty and safety, the malady yields more pointedly to its operation, and the several dangerous effects of incautious exposure to cold and damp are avoided. The person who is under a course of mercury should abstain from all salted and high-seasoned meats, confining his diet to plain animal food that is of light digestion, to thin broths, preparations of sago, barley, and rice,custards, light puddings, milk, vegetables, ripe fruits, &c. He should avoid all spirituous liquors and acids; and if he drinks wine the quantity ought to be very small, and always diluted with a proper proportion of water. The late Mr. John Hunter seems, however, to have thought an attention to diet, under such circumstances, wholly unnecessary; for in his Treatise on the Venereal Disease, he says, that the man- ner of living under a mercurial course need not be altered from the common, because mercury has no action upon the disease, which is more favoured by one way of life than another; and he adds, " I see no reason why mercury should not cure the venereal dis- ease under any mode whatever of regimen." He asks, What effect eating a hearty dinner, and drinking a boitle of wine after it, can have over the action of mercury upon a venereal sore, either to 80 634 cachexia, or cachectic diseases. Class lit make it affect any part sensibly, as falling -on the glands of the mouth, or prevent its effect on the venereal irritation ? In answer thereto, 1 have only to say, that a use of mercury never fails to render the body irritable ; so any thing of a stimulating nature ap- plied to tbe salivary glands while under a state of increased sus- ceptibility and irritability, will be likely to occasion an inflam- mation and tumefaction in these parts, and thereby provoke a salivation; an event which should ever be avoided when it can possibly be dispensed with. When we make use of unction for the cure of syphilis, without intending to excite a salivation, we may direct the patient to rub thoroughly into the hams and thighs about half a drachm of the unguentum hydrargyri fortius* every night; and this course he is to continue until a coppery taste is perceived in the mouth, with somewhat of an increase of saliva. As soon as these are percep- tible, he must go on gradually, and should they seem to proceed to a greater height than what is intended, instead of using the oint- ment every night, he ought then to have recourse to it only every other night. On the contrary, should the quantity of ointment here directed be insufficient to produce any apparent effect on the mouth, he must then increase it gradually every night, until he caa attain the desired point. If we employ mercury internally, with the same view of not bringing on a salivation, we may then give one or two of tbe pilula hydrargyri every night at bed-time; or instead of these, we may recommend some of the other active preparations of mercury,- such as the hydrargyri submuriasf, the hydrargyri oxydum rubrumj, * By putting six ounces of quicksilver into a proper sized mortar, with about two oun- ces of strong mercurial ointment (if rancid the better), and rubbing them briskly togeth- er, tbe globules of quicksilver disappear in a few minutes; and by continuing to rub it well for five or six minutes longer, an union will be so far accomplished tbat the lard may be gradually added. By this simple process a pound of strong mercurial ointment may be well made in ten or twelve minutes, which according to tbe usual method requires at many hours. A knowledge of this fact may prove of high utility to apothecaries and druggists.—See No. 7 ofthe Medical, Surgical, and Pharmaceutical Repository, p. 53. f 41. IJ; Hydrarg. Submur. Camphorae, aa 3ij. Opii,gr. x. Mel. Optim. q. s. M. liant pilul. xx. quarum j. vel ij. sumat mane et nocte quotidie. Vel, 42. ft Hydrargyr. Submur. 3j- Antimon. Tartarizat.gr. v. Opii Purificat. gr. x. , Mel. Optim. q. s. M. Fiant pilul. xx. capiat ij. bis in die. X 43. R Hydrargyr. Oxydi Rabr. Camphorae, aa 3j. Opii, 3j. I 41. Take Submuriate of Mercury, Camphor, of each two scruples. Opium, ten grains. Honey, a sufficiency. Mix them, and out of the mass let twenty pills be formed, of which take from one to two morning and night daily. Or, 42. Take Submuriate of Mercury, one drachm. •Tartarized Antimony, five grains Opium, ten grains. Honey, a sufficiency to form the mass. Out of this let twenty pills b« made, of which take two twice a day. X 43. Take Red Oxyd of Mercury, Camphor, of each one drachm Opium, a scruple. Order III VENEREAL DISEASE. 685 or hydrargyri oxymurias* which may be taken ia small doses at first, and so be augmented gradually, as may be found necessary. Along with these remedies we may recommend the patient to drink about a quart a day of the decoctum sarsaparilla? compositum, which will tend to carry off the mercury by the skin and kidneys. Where any of its preparations affect the bowels, and excite either a purging or griping, a sufficient quantity of opium should be given at the same time to prevent these consequences. When, from the urgent nature of tbe case, we are obliged to employ mercury so as to excite a salivation, we must introduce it into the sys- tem in a gradual manner, by beginning with a small quantity, and augmenting it daily, taking care to observe its effects with great atten- tion. If we use unction (to which a preference ought always to be given where we mean to excite a salivation), we may direct the patient to rub in, as has before been advised, about a drachm of it every night previous to his going to bed. If the salivary glands do not become affected after a few days' application of the ointment, he can then increase the quantity each night, until a sufficient flow of saliva is procured- During the continuance of the spitting, the pulse should never ex- ceed 95 or 100 in a minute; neither should the quantity ofthe saliva which is discharged be greater than two or three pints in twenty-four hours. Under such a course, the body is to be enveloped in flannel, and the patient to drink plentifully of diluent liquors. To alleviate the soreness of his mouth and gums, he may use some soothing gar- glef three or four times a day. From the report of a modern writerj it appears that mercurial frictions are hardly ever employed by the French surgeons in hospitals, although sometimes in private practice they adopt them, and the most common preparation used internally by them in most cases is the oxymuriate of mercury. This is usually given by them either in a simple solution in water and a little spirit, or under the form of Van Swieten's liquor. The usual quantity daily taken by a patient is half a grain, which is administered at | See Sketches of the Medical Schools of Paris, by Mr. John Cross. Syr. Simpl. q. s. M. Fiant. pilul. 1. quarum sumat aeger j. vel ij. omni nocte hora decubitus. * 44. ft Hydrargyri Oxymuriat. gr. viij. Solve in mortario vitreo cum Spiritus Ten. Oj. ft. Solut. cujus capiat semi unciam mane et vespere. t 45. ft Decoct. Hord. f Jvj. Sodae Sub-borat. 3j. Mel. Rosae, f. §j. Tinct. Opii, f. 3j. M- ft; Gargarisma. Syrup, a sufficiency. Let the mats be divided into fifty pills, of which the patient may take from one to two every night on going to bed. * 44 Take Oxymuriate of Mercury, eight grains. Dissolve it in a glass mortar with Proof Spirit, one pint. Of this solution let half an ounce be taken morning and evening. t 45. Take Decoction of Barley, six ounces. Sub-borate of Soda, one drachm- Honey of Roses, one ounce. Tincture of Opium, one drachm. ■■ Mix them for a gargle, 636 CACHEXIA, OR CACHECTIC DISEASES. CtasS III a single dose, that the surgeon may see it given. They begin, how- ever, with as much of the solution as contains a sixteen.h, or an eighth of a grain, and so increase it. When the constitution indicates tbe necessity of divided doses, it is given morning and evening, and some- times in tbe form of pills. If we give mercury internally, with the intention of exciting a sali- vation, we must proceed in the same cautious manner as when under a course of mercurial frictions, increasing or diminishing the dose ac- cording to the effect produced. When a salivation comes on quicker, or proceeds with greater violence than we could wish, notwithstanding all our precautions, we must not only lessen the quantity of mercury, but we must also give one or two gentle purges, and keep the chamber some- what cooler than before. Sulphur has generally been supposed to possess a power of checking the rapid effects of mercury; and therefore where a salivation comes on with great rapidity and violence, we may have recourse to it in doses of from half a drachm to one drachm twice a day, besides taking the steps just mentioned. In mild cases of syphilis it probably will require from four to six weeks' perseverance in the use of mercury to effect acure ; but in cases of long standing, and a more confirmed nature, it may be necessary to continue it for eight or ten weeks, or even longer. Whether we at- tempt the cure by salivation, or in the milder way, by giving a tenden- cy to it, without proceeding tbat length, we should always recommend the patient to persevere in the plan, even for some short time after the departure of every symptom, in order that he may be ensured a per- fect cure ; for the venereal action may to appearance be stopped, and the symptoms vanish, and yet all return again; the virus not having been completely subdued. As soon as the use of mercury is left off, the diet may be amended, a purge or two be exhibited, and a return to the free air be gradually made ; after which, tonics, with country air and exercise, will greatly tend to recruit the strength. In the progress of the disease, it is often found necessary, besides employing mercury in order to counteract or destroy the virus in the system, to attend to particular symptoms; for tbe removal of which, a topical treatment may likewise be requisite. The tonsils, uvula, and other parts of the fauces, as likewise the nose, are frequently discovered in a state of ulceration, where the disease has been of long standing. In such cases, the parts should be well cleansed by washing them twice or thrice a day wilh some proper gargle*; after which, the fumes arising from myrrh and the v 46. ft Hydrarg. Oxymuriat. gr. v. Solve in inortario vitreo cum Spirit Rectif. f. |ss. et adde Decoct. Cinchon. f. ?vj. 46. Take Oxymuriate of Mercury, five grains. Dissolve it in a glass mortar with Rectified Spirit, half an ounce, and add Decoction of Bark, six ounces 'Order iff. VENEREAL DISEASE. 637 hydrargyri sulphurctum rubrum thrown upon a hot iron, may be brought into contact with them by means of an inverted funnel. When eruptions ulcerate, washing them with submuriate of mer- cury and water, or the hydrargyri oxymurias and liquor calcis, and dressing them with mild mercurial ointment, will be most proper ; making use, at the same time, of a decoction of mezereon-ioot, as advised in those cases where nodes arise. Venereal pains, blotches, and scaly eruptions will be removed most readily, by employing sudorifics at the same time with mer- cury. About a quart of the decoctum sarsaparilla? compositum, or of the Lisbon diet-drink*, the qualities of which have been the sub- ject of so much encomium, may therefore be drank daily with this view. In preparing this last, the powdered antimony and pumice- stone are to be tied in separate pieces of rag, and boiled along with the other ingredients. It is probable that the operation of these medicines, where the patient is not under a salivation, may be assist- ed by going into a warm bath now and then; but in having recourse to this remedy, the patient must observe the greatest precaution not to take cold, by wrapping himself up in very warm clothing on his coming out ofthe bath. If the pains are so severe as to interrupt his rest by night, be should take an opiatef on going to bed. Nodes on the bones are to be relieved by rubbing them every night with a small quantity of mercurial ointment, or by wearing a plaster of the same nature over them, assisted by a decoction of tbe woods, or mezereonj, together with opiates, where the pain is great. Tinct. Myrrh, f. ?j. Mel. Rosae, f. ^ss. M. ft. Gargarisma. * 47. ft Sarsaparillae Concis. Rad. Chinas, aa |j. Nucum Juglandis cortic. siccatarum xx. Anlimonii, |ij. Lapid. Pumicis Pulv. |j. Aq. Distillat. Ox. Coqueaddimidium et cola. t 48. ft Liquor. Ammon. Acetat. f. |ss. Aqua? Menth. Virid. f. ^j. Vin. Antimon. fll xvj. Tinct. Opii, flT. xx. Syr. Papav. Somnif. f. 3j- ft. Haustus. t 49. ft Rad. Mezerei Contus. 3'j. M. ----Glycyrrhizae, ^j. Aq. Distillat. Oij. Coque ad dimidinm et col. bibat Oss. ad Oj, in die. Tincture of Myrrh, one ounce. Honey of Roses, half an ounce. Mix them for a gargle. * 47. Take Sarsaparilla, sliced, China Root, of each one ounce. Dry rind of twenty walnuts. Antimony, two ounces. Powder of Pumice Stone, one ounce. Distilled Water, ten pints. Boil it slowly until the liquor is reduced one half, then strain it. 1 48. Take Solution of Acetate of Ammo- nia, half an ounce. Mint Water, one ounce. Antimonial Wine, twenty-four drops. Tincture of Opium, thirty drops. Syrup of Poppies, one drachm. Mix them for a draught. J 49. Take Mezereon Root, bruised, two drachms. Liquorice Root, one ounce. Distilled Water, two pints. Boil them until the liquor is reduced to a half, and then strain it off. From half a. pint to a pint may be drank daily. f>38 cachexia;, or cachectic diseases. Class III In inveterate case*, where the surface of the bone becomes cari- ous, it will be found necessary either to make an incision through the integuments and periosteum the whole length of the diseased part, or to apply a caustic to it for tbe purpose of procuring an exfoliation ; but this last will require great caution and skill, and in applying it some expertness will be requisite, to prevent it from spreading to a greater extent than what is intended, or may really be necessary. Acetic acid will remove corns in one or two applications with the greatest certainty, and, if not carefully managed, the surround- ing cuticle also which it happens to touch. To large verruca or warts with broad bases, the same application will be effectual. Those that are pendulous with narrow necks may be removed with scissors; and after the oozing of blood has ceased, they may be touched with the sulphate of copper, or a solution of lunar caustic. See Gonorrhoea. Inflammation of the iris, although frequently met with in syphilis where mercury has not been exhibited so as to affect the system, still its occurrence is more frequent as consequent upon the use of it than arising as an idiopathic disease. Under these circum- stances it is not surprising, that some surgeons of reputation should be disposed to deny that the inflammation of the iris is a venereal inflammation, and should consider it as belonging to that class of symptoms which resemble, or are grafted upon the syphilitic, and that others should regard it as an inflammation produced by the poi- son of mercury*. In the early and active stage of acute inflammation ofthe eyes, and previous to any mercurial action being induced, it will always be advisable to have recourse to blood-letting, both from the arm, and topically by the application of several leeches to the temples. It will likewise be necessary to give one or two doses of some cooling pur- gative. Besides these means, the eyes may be bathed two or three times a day with some cooling collyrium, as advised under the head of Ophthalmia, and the irritation of light be avoided, either by confin- ing the patient to a dark room, or obliging him to wear a large green shade over his eyes. Should the pain and inflammation not abate in due time by this mode of treatment, the application of a small blister behind each ear, or of a large one to the nape of the neck, will be proper. When the inflammation is reduced, we may begin with a use of mercury. Where syphilis falls on the bones of the nose, besides making use of mercury with the decoctum sarsaparillae compos, or the Lisbon diet-drink, we should employ detergent lotionsf, which • See Surgical Essays by Mr. Astley Cooper and Mr. Travers, vol. i. p. 60. v 50. ft Hydrarg. Oxymuriat. gr. iij. Solve t 50. Dissolve Oxymuriate of Mercury, in mortario vitreo cum three grains in a glass mortar, with Spir. Rectif. f. ^ss. etadde Rectified Spirit, half an ounce., \ and add Order III. VENEREAL. DISEASE, to may be applied to the parts by means of a syringe. When com- bined with ulcerations of the tonsils, palate, or uvula, we must likewise make use of fumigations and gargles, as before recom- mended. In those cases where ulcers of a phagedenic nature present themselves, we must omit the use of mercury for a time, and have recourse to the cinchona bark, with wine and a nutritive diet, removing the patient at the same lime into a pure air, if his situation is any way close or confined. Occurrences of this nature happen more frequently in hospitals than in private practice, and are owing, in a great measure, to the vitiated air which prevails in tbe waids set apart for venereal patients, as has already been men- tioned. In several cases of phagedenic ulceration, which had resisted the usual means employed by surgeons, tbe application of lint, moisten- ed in the balsam of Peru, has been attended with happy effects, occasioning in a few days the sphacelous parts to slough off, the face of the sore to become clear, and healthy granulations to extend over its surface. In broken constitutions, where cedematous swellings of the legs have begun to manifest themselves, a perseverance in a mercurial course ought not be pursued. In such distressing cases, a gene- rous diet, country air, and regulated exercise, are the best remedies, entirely omitting the use of mercury till the constitution is renovated. Where dropsy has actually taken place, nitric acid, given in as large doses as the stomach and bowels can bear, conjoined with digitalis or squill, may be of great service. Other remedies have been recommended in possessing specific effects in syphilis besides mercury. These are the oxygenated muriate of potass and the different acids, but more particularly the nitric, which has been noticed in pointing out the proper treat- ment of chancres. It remains further to observe, that from the trials I have made of it, it appears to be well calculated to re- move many of the primary symptoms of this disease, and may therefore be used in all such cases with safety, and most likely with the assurance of much advantage; but in a confirmed syphilis it ought never to be solely relied on. Its inefficacy in all such cases has been fully substantiated not only by Mr. Blair* but by various other practitioners of eminence. Many allow it, however, to possess a palliative power, and almost all admit its salutary effects in reme- dying the disordered state of the system arising from the excessive use of mercury. • See his Essay on the Venereal Disease, part iii. Decoction of Peruvian Bark, six ounces. Tincture of Myrrh, two drachms. Honey of Roses, half an ounce. Mix them for a lotion. Decoct. Cinchon. f. |vj. Tinct. Myrrh, f. 3ij. Mel. Rosae, f. ^ss. M. ft. Lotio. 640 CACHEXIA*, OR CACHECTIC DISEASES. ClaSS III. The lobelia, or blue cardinal, is another new remedy which of late has been recommended for the cure of syphilis ; but its effects are by no means sufficiently established to place any great dependance upon it. It is given in the form of decoction*, the patient beginning with half a pint twice a day. After some little time the same quan- tity is to be taken four times a day, and to be continued so long as its purgative effect is not too considerable. When the case is otherwise, it is to be discontinued for three or four days, and then to be had re- course to again till the cure is completed. The effects of this decoction are evidently purgative, as will be observed from what lias just been mentioned. Another new remedy is the decoctum astragali-}-, which has been very extensively used in Germany, and is said to possess powerful effects as an aniisyphilitic. For a more particular account of its vir- tues, I must beg leave to refer the reader to the London Medical Journal. The decoctum dulcamaraej is likewise another new remedy which is highly spoken of in anomalous diseases originating in lues vene- rea. The dose is half a pint in twenty-four hours, mixed with an equal quantity of milk. The treatment of syphilis in infants is noticed among the other diseases to which they are subject. SIBBENS. Sibbens or sivvens, is a disease which was first noticed by Dr. Gilchrist ; and we are told by him, that it was then confined to the west of Scotland. He supposes that its spreading is chiefly owing to a neglect of cleanliness; but from the report of others we are in- formed, that it is commmonly got by drinking from the same cup, smoking tobacco from the same pipe, sleeping in the same bed, or handling the sores of such as labour under it. The first appearances of the disease are usually to be observed in superficial ulcerations on the tonsils and uvula, together with an aphthous eruption in the inside of the mouth, cheeks, and lips. * 51. ft Rad. Lobeliae Syphilitic. Sicca?, manip.j. Aq Distillat. Oxij. Coque ad Oviij. f 52. ft Rad. Astragal. Excapi, ^j. Aq. Fontan. Oiij. Coq. ad Oij. Bibat. in die. I £3. ft Stipitum Dulcam. Recent, ^ij. Aq. Fontan. Oiv. Coq. ad Oij. et trotf. " 51. Take Dry Rootsof Blue Cardinal, one handful. Distilled Water, twelve pints. Boil them down to eight pints. t 52. Take Stemless Milk Vetch Roots,one ounce. Pure Water, three pints. Boil them to two pints, and let this quantity be drank daily. X 63. Take Fresh Bittersweet, two ounces. Pure Water, four pints. Boil it down to two pints, and rain off the liquor Order HI. sibbens. 641 Sometimes a hoarseness attends this state of the parts, and excres- cences, similar to a raspberry, arise from them. From these the name of sibbens is derived. Soon after the affection of the mouth has taken place small pus- tules are to be discovered on the skin, which break after a time, and leave behind them dry livid crusts, beneath which ulcers form that bear some resemblance to a chancre, as they spread more in depth than in breadth. Instead of ulcerations collections of matter in the form of boils or critical abscesses, sometimes appear in different parts, which degenerate into sores of a superficial kind, discharging a thin acrid secretion. These are soon filled up with fungous excrescences which shoot up in the form of a raspberry, like those of the mouth and throat. It is seldom that the bones become affected in consequence ofthe sibbens ; but in those cases the gristly parts of the nose have suffered by erosion. By the natives the disease has been supposed fo have some con- nexion with the itch ; by others it has been thought to bear a great affinity to syphilis ; but undoubtedly it has a greater resemblance to the yaws than to any other disease whatever, and possibly might have been introduced into the west of Scotland by some persons from the coast of Africa or the West Indies, where the yaws is a very prevalent disorder, being however chiefly confined to negroes, mulattoes, and others of a mixed race ; but white people are sometimes attacked by it. I am indeed firmly of opinion that sibbens is not a distinct disease from the yaws, but merely a variety ; and that the trifling dissimilitude which may be observed between them is wholly to be attributed to the difference of climate, mode of living, diet, colour of the skin, &c. A late friendly communication from Dr. Colling- wood, of Sunderland, has strongly corroborated this opinion. He informs me, that about the year 1769, a West Indian vessel was wrecked on the coast of Wigton, in Cumberland, some of the crew of which were saved, and hospitably received into the houses of those who resided near the spot* and that very soon afterwards the disease in question was communicated to the inhabitants, and be- came frequent. Dr. Collingwood being then a resident at Wigton, was called upon for advice, and he treated every case as had been recommended in the yaws by men of experience, and with the greatest success. I am further informed by Dr. Collingwood, that a few years ago he made a tour of the south-west of Scotland for near 150 miles, and that he repeatedly inquired for the sibbens among the practitioners, the younger of whom had never seen such a disease, while those.of more advanced years assured him that it had wholly disappeared. Dr. Adams, in his Observations on Morbid Poisons, informs us, j. Syrup. Simpl. q. s. M. Fiant pilula Ix. Capiat j.—iv. omni nocte hora decnbitus. " 1. Take Submuriate of Mercury, Precipitated Sulphur of Antimony, of each half a drachm. Gum Guaiacum, two drachms. Syrup, a sufficiency. Form sixty pills out of the mass, and let from one to four be taken every night at bedtime. Order III. LEPROSY. 65& chona bark, with the mineral acids, might be of service. Possibly the oxygenated muriate of potass may be a good auxiliary. If tried, it ought to be given in the form of so- lution. To counteract the corrosive effect of the matter discharged from- the sores, as well as to lessen tbe disagreeable sensation in the skin, the surface of the body should be washed frequently with some saponaceous solution, or with lime water in a tepid state. The ulcers ought to be regularly dressed with some absorbent ointment. To prevent the leprosy from spreading, it will be necessary to avoid any kind of close communication with persons who are infected. It is too customary with proprietors and managers of estates in the colo- nies to turn such negroes adrift on tbe public, and being thus exoner- ated from labour and servitude, they range about, and infect all those with whom they either cohabit or associate. It is true, indeed, that the legislative body in many ofthe islands has enacted laws for the pre- vention of this evil; but, from a neglect in the magistrates and consta- bles to enforce them, they are wholly disregarded, and the disease has become a very frequent one. The mild species of leprosy met with in cold climates is lo be removed by small doses of mercury conjoined with antimony, as in Plumer's pill, given so as to produce an alterative effect, assisted by warm bathing and a decoction of the woods, mezereon, lobelia sy- philitica, and tbe decoct, dulcamara? or decoct, astragali, as mention- ed under the head of Syphilis. These will cleanse and soften the skin. The minereal solution may prove a good remedy in many cases of lepra, and we may add the nitric acid as an auxiliary to it. The conjoint effect of these medicines possibly may accomplish what either separately would not. A gentle aperient of the saline class ought to be repeated at due intervals during the progress ofthe cure. As a vehicle for both the mineral solution and nitric acid, we may employ tbe decoctum ulmi, of which the patient may drink a pint daily. It sometimes happens that the skin of leprous persons in this country is so tender and irritable as to be disagreeably affected by even the mildest applications. In these instances, a strong infusion of the bruised leaves of fresh digitalis, with a small proportion of the liquor plumbi subacetatis dilutus, has proved highly soothing and curative. Harrowgate water has been found very serviceble, not only in a great variety of cutaneous complaints of a trifling nature, but like- wise in many of the more obstinate and painful disorders of the skin, such as the elephantiasis and leprous eruption. These com- plaints receive material advantage by employing the warm bath which accordingly makes part of the plan of cure; and during its use very moderate doses of the water warmed, and repeated at proper intervals, will materially assist in keeping up that full per- spiration which is promoted by the bathing, and always continued 654 «ACHEXLL, OR CACHECTIC DISEASES, for some hours, by confining the patient in bed after immersion wrap- ped up in flannel. In this respect, however, the cold sulphureous waters are not so advantageous as those which are naturally hot; lor the former, in being artificially warmed, must lose some of the sul- phureous gas, on which part of their efficacy, even when applied externally, must depend ; but we have no natural springs of this kind in our country. They are, however, to be met with at Aix-la-Cha- pelle, in Germany, and in our two colonies, the islands of Jamaica a id Nevis. Persons resident in these places, who labour under le- prous eruptions, should not fail to avail themselves of the advantages to be derived from these waters. We are informed by Dr. Kinglake*, that, in several cases of chronic eruption on the cuticular surface, which had resisted the warm bath, the internal and external use of the oxymuriate of mercury, antimonials, guaiacum, and likewise the nitric acid, he performed complete cures by giving the patient ten drops of the sulphuric acid three times a day in a teacupful of pure water, and by washing the eruptions with a solution of the same mixed in water, in the proportion of half a drachm of the former to one pint of the latter. This was done by dipping a small piece of linen in the liquid, and moistening with it the parts affected:! He observed that the external application was productive of severe pain at first, but this inconvenience daily diminished. The dose of sulphuric acid above mentioned is calculated for a child of three years of age, but adults may take thirty drops thrice a day in half a pint of water, gradually increasing the quantity to a tea-spoonful or two. If attended with any purgative effect, a small addition of tinc- tura opii may be made. PLICA POLONICA vel TRICHOMA, or PLAITED HAIR. Plica Polonica is a disease in which a morbid matter is de- posited upon the hair, and binds it together in such a manner, that to unravel it is impossible. In Poland, Lithuania, Hungary, Tran- sylvania, Prussia, Russia, and Tartary, it is endemial; but the scalp is not its only seat, for it sometimes extends to the hairs of tbe pubes. The exciting causes of the disease are uncertain, as neither the air, water, nor food seem to have any effect in producing it; nor are cleanliness, and regular combing of the hair, it is said, any de- fence against it. Certain it is, however, that it prevails only among the lower class of people, from whence many have con- ceived that it is to be considered merely as a consequence of uncleanliness. From some observations made by Mr. Frederick Hoffman, surgeon to the Prussian army, it appears tbat a pre- disposition to it may be transmitted from parents to their offspring; * See Medical and Physical Journal, vol. ir. p. 482 Order III PLAITED HAIfi. 655 and he observes*, that as no other cause can be assigned for the disease, it is probable that it arises, according to the general opinion, from contagion ; a contagion which, like that of psora, can be communicated by contact only. I confess that I look on plica polonica as a mere local disorder arising from a great length of hair, and neglect of combing it, and produced evidently by sweat, dirtiness, and vermin ; for the hair, when kept short, and due cleanliness is observed, never contracts plica, as I am informed. The military police enforces this on the Polish militia and recruits every year ; and if any of them happen to have the plica, their locks are cut off, and their heads shaved without scruple or danger. We are told by Mons. Alibert, physician to the Hospital of St. Louis, at Parisf, that as the Poles rarely comb, and scarcely ever wash or clean their hair, and as they wear warm fur caps, the disease in question is much favoured thereby. By the heat, he says, an afflux of humours is determined towards the head, which thus becomes a common sewer to all the organs of the body, whilst by its nastiness the pores are so obstructed, that the exuberant fluids are forced through the canals ofthe hair. He observes, that plica is sometimes communicated by contagion, and sometimes by suckling, but he has noticed at the same time that strangers are but little liable to be affected by it. The nature of this disease was narrowly investigated by Baron LarreyJ, Inspector General ofthe French Army, when at Warsaw, and he was fully satisfied that it is a local and factitious complaint, produced by dirt and neglect ; likewise that it is not contagious, and may be cured with facility, notwithstanding the absurdities which prejudice has set forth to the contrary. According to Monsieur de la Fonfaine||, an eminent physician at Warsaw, the proximate cause of the disease seems to be a pe- culiar morbid matter, which is clammy and acrid, has its seat in the lymph, and is deposited critically upon the hair. An opinion universally prevalent with the Polish peasants is, that the disease is a salutary effort of nature to expel a morbid matter from the body, and that to interrupt the course of it would be productive of danger ; hence they make no attempt to cure or even palliate the complaint. This opinion is, however, erroneous, as will appear from what I have already mentioned, as well as from the occurrence afterward recited. Both sexes have been observed to be equally liable to the atfacks of plica. It more usually comes on during infancy than after the age of puberty. Besides the human species, other animals, such * See his Observations on Plica Polonica, vol. iv. part ii. of the Memoirs ofthe Lite- rary and Philosophical Society of Manchester. t See his Description des Maladies dela Peau. t See his Memoires de Chirurgie Militaire et Campagnes. || See article the first, vol. the 1st; of the Annals of Medicine for the Year 1796, bv Andrew Duncan, M. D *J56 «AeHEXi.E, or gaghecwic diseases. Class III as fhe horse, and those of the canine species, as dogs, wolves, and foxes, are said to be subject to this complaint. The accession of the disease, we are told, is commonly preceded by general lassitude and heaviness, pains in different parts of the body, particularly in the bead and eyes, and some degree of febrile affection, all of which diminish or cease immediately on the ap- pearance of the plica. Most usually the hairs of the head are alone affected, and that only in particular parts. In these the hairs grow considerably longer than in the rest, they often seem greatly enlarged in their diameter, and are much knotted and entangled ; being also covered with the viscid matter which issues from their roots, and which assists in glueing them together. In proportion as the quantity of this gluten, and the implication of the hair increase, it is still more and more difficult to clean and comb it ; hence a degree of phthiriasis is produced, and the head contracts an extremely fetid smell, to which, however, the Polish peasants are so much accustomed, that they, endure it without complaint or any manifest inconvenience. In consequence of frequent scratching, the nails of the fingers being imbued in the matter, now and then become diseased : they increase in thickness, change their colour, and are unequal on their surface. The disorder frequently continues for life, when neglected ; but is not found to be attended with fatal consequences, except perhaps from an injudicious mode of treatment. In the beginning of the disease, we are recommended by Mons. de la Fontaine to employ resolvent, attenuant, saponaceous, de- mulcent, and emollient remedies, to prepare tbe morbid matter for a crisis. If these be not sufficient, he adds extract of aconite, or hemlock, tbe submuriate of mercury, or some antimonial. In general, he says, antimony is a specific in this disease. If it be complicated with lues, muriated mercury in small doses produces the very best effects, but salivation is highly detrimental in every case. These remedies can only be employed when no fever is present; in this case blood-letting and evacuants must be used very cautiously. Mons. de la Fontaine compares tbe disease to the small-pox, and observes, that when the fever is too weak to pro- duce the eruption, it must be increased ; when it is too violent, it must be diminished. Hence the strength of the patient must often be supported with a generous diet. To bring about a crisis, we are advised to make use of sudorifics. If the morbid matter be deposited on the surface of the body, it occasions malignant and obstinate sores, which give a great deal of trouble. Antimony should always be an ingredient in whatever medicine we administer. When our endeavours prove inadequate fo produce fhe crisis, inoculation of the disease will often, it is alleged, effect it. This is performed by putting on a cap which has just been worn by Order III SCCRVY. 65? one who has a recent plica. After a complete crisis, the plica separates from the head, and remains attached only by the sound hair. If it has become dry, and all symptoms have ceased, it may be cut off. External remedies are always proper and necessary ; such as the application of warmth to the head in the form of vapour, warm bath, or fomentation : washing the head with a warm solution of soap will likewise prove serviceable. Hair-powder rubbed with mercury will be a good remedy to destroy the vermin. Where the patient is much incommoded by a headach, tbe application of a blister to the neck or between tbe shoulders may possibly relieve it. It has before been stated tbat the opinion generally entertained in Poland, that there is danger in cutting off the hair in this dis- ease, and promoting the cure by external remedies, is wholly erroneous. The following fact, which occurred at Breslaw, and communicated by Dr. be Cairo, of Vienna, in a letter to the Editors of the Bibliotheque Britannique, fully establishes this assertion. " Some years ago one third of the recruits of the regiments of artillery brought from South Prussia, were attacked with plica polo- nica. An order was received from Berlin to send to that city all those that were infected, and to take care that the disease was not communicated to others. This order, it appears, was not agreeable to the commanders of companies, as it would have occasioned the loss ef at least two hundred young soldiers. M. Hoenel, surgeon- major to the artillery regiment, became mediator in the cause ; he made the recruits be brought on the ramparts, and ordered that a general shaving should be made. In a little time, a pile of plica was accumulated ; these trophies were then cast into a ditch, and the heads ofthe men carefully washed with soap and water daily for some week*; by this simple method those dirty Polanders were speedily transformed into good soldiers, without having in the least suffered by the loss of this precious ornament of their heads." This statement clearly points out the absurdity of tbe opinion en- tertained by the generality of the Polanders, and shows that the dis- ease in question may be cured with as much safety as tinea, capitis. It likewise evinces that many of the exteinal remedies which have been advised in the latter may be employed witb advantage in the former: indeed tinea capitis and plica polonica seem, I think, to be very similar diseases. SCORBUTUS, on SCURVY. The characteristics of this disease, as affixed by Dr. Cullen, are debility; bleeding of the gums; spots of different colours on the skin., for tbe most part livid, particularly at the roots of the, hairs 83 v- G58 cachexia:, or cachectic diseases. Class III occurring in cold countries, after living on putrescent salted animal food, with a deficiency of recent vegetable matter. The scurvy is a disease of a putrid nature, much more prevalent in cold climates than in warm ones, and which chiefly affects sailors, and such as are shut up in besieged places, owing, as is supposed, to their being deprived of fresh provisions, and a due quantity of aces- cent food, assisted by the prevalence of cold and moisture, and by such other causes as depress the nervous energy, as indolence, con- finement, want of exercise, neglect of cleanliness, much labour and fatigue, sadness, despondency, h<\ These several debilitating cau- ses, with tbe concurrence of a diet consisting principally of salted or putrescent food, with foul water, will be sure to produce this disease. It seems, however, to depend more on a defect of nourishment than on a vitiated state; and the reason that salted provisions are so pro- ductive ofthe scurvy, is, most probably, because they are drained of the nutritive juices, which are extracted and run off in the brine. As the disease is apt to become pretty general among the crew of a ship, when it has once made its appearance, it has been supposed by many to be of a contagious nature ; but the conjecture seems by no means well founded. The circumstance arises most probably from the men being alike exposed to the exciting causes of it. A preternatural saline state of the blood has been assigned as its proximate cause. It has been contended by some physicians; that the primary morbid affection in this disease is a debilitated state of the solids, arising principally from the want of aliment. Various theories have indeed been advanced with respect to scurvy. By Sir John Pringle it has been supposed to be owing to a putrescency of the blood. By Dr. Lind, Dr. Blane, and Dr. Millman, it has been looked upon as a disease of debility, having its origin in the weaknees of the organs of digestion, or in tbe gradual diminution of the vital power by the remote causes; or that it is owing rather to a defect of nourishment than to a vitiated state of it. Dr. Trotter, reasoning from the experiments of Dr. Goodwin concerning the action of dephlogisticated air on the blood, infers that the black colour of this in scurvy is owing to the abstraction of this principle (dephlogisticated air), and that fresh vegetables cure the disease by restoring to the blood this lost principle. Dr. Beddoes supposes scurvy to be owing to a gradual abstraction of oxygen from the whole system, just as death is pro- duced in drowning, by withholding all at once the same substance from that blood which is to pass the posterior cavities of the heart. Of the two causes of scurvy, want of fresh vegetables, or want of air sufficiently furnished with oxygen, Dr. Beddoes thinks the latter is by far the most powerful. Captain Cook's unex- ampled success in preserving his crews from the scurvy during his two last voyages, seems to have been owing in a great measure to his extreme care in keeping every part of the ship, well ven- Order III scurvy. 659 tilaied. The crew on many occasions were reduced to salt provisions, and much longer out of sight ofthe land than many other ships which have been dreadfully afflicted with the scurvy. In his last voyage there did not appear among the u.en any swnptom of this disorder; and in his second, only one man bad it in any considerable degree. The scurvy comes on gradually, with heaviness, weariness, and un- willingness to move about, together with dejection of spirits, anxiety, and oppression ai the praecordia, considerable loss of strength, and de- bility. As the disease advances in its progress, the countenance be- comes sallow and bloated, respiration is hurried by the least motion, the teeth become loose, the gums are spongy, swelled, and bleed upon the slightest touch, the breath is very offensive, livid spots appear on different partsof the body, old wounds which have been long heal- ed up, break out afresh ; severe wandering pains are felt, particularly by night; the skin is dry ; the urine small in quantity, turning blue ve- getable infusions of a green colour; and the pulse is small, frequent, and towards the last, intermitting ; but the intellects are for the most part clear and distinct. In some cases of scurvy, and even in its inci- pient stage, nyctalopia has been observed as one of the attendant symptoms*. By an aggravation of the symptoms, the disease in its last stage ex- hibits a most wretched appearance. Tbe joints become swelled and stiff, the tendons of the legs are rigid and contracted, general emacia- tion ensues, hemorrhages break forth from the nose, ears, anus, and other parts ofthe body, fetid evacuations are discharged by stool, and a diarrhoea or dysentery arises, which soon terminates the tragic scene. Scurvy, as usually met with on shore, or where the person has not been exposed to the influence ofthe remote causes before enumerated, is unattended by any violent symptoms ; as slight blotches with scaly eruptions on different parts of the body, and a spunginess cf the gums, are the chief appearances to be observed. In forming our judgment as to the event of the disease, we are to be directed by the violence of tbe symptoms, by tbe situation of the patient with respect to a vegetable diet, or other proper substitutes, by his former state of health, and by his constitution not having been impaired by previous disorders. The person being capable of muscular motion with little reduction of strength, the health not injured by previous disease, the skin moist, tbe pulse slow, a gentle bilious diarrhoea, tbe absence of ulceration, and tbe petechia?, if any appear, being of a bright red colour, are to be looked upon as favourable circumstances ; whereas great prostration of strength, flushed countenance, quick weak pulse, extreme oppression at the praecordia, fetid and involuntary evacuations, petechias and maculae of a dark livid colour, and pro- * See Dr. Blane's Work on the Diseases of Seamen. 660 CACHEXIA, OR CACHECTIC DISEASED. ClaSS III fuse hemorrhages of dissolved blood, denote the highest degree of danger. Dissections of those who die of scurvy have always discovered the blood to be in a very dissolved state. The thorax usually contains more or less of a watery fluid, which in many cases possesses so high a degree of acrimony, as to excoriate the hands by coming in contact with it. The cavity of the abdomen contains the same kind of fluid. The lungs are black and putrid ; and the heart itself has been found in a similar state, with its cavity filled with a corrupted fluid. In many instances, the epiphyses have been found divided from the bones, the cartilages separated from the ribs, and several of the bones themselves dissolved by caries. The brain seldom snows any marks of dis- ease. From experiments made on the blood and urine of scorbutic pa- tients, it appears that three ounces of blood, on cooling, consisted of two ounces of coagulum and one of serum. The coagulum was com- posed of two parts ; that on the t»p, about the sixteenth of an inch, was of a florid red, and tough ; that in the bottom, of a deep red, ap- proaching to black, and easily divided. TIip scrum, with respect to colour, was not uncommon Vinegar did not alter the colour of the black part of the coagulum. By the addition of lemon-juice it be- came somewhat lighter; on the admixture of a solution of nitre in vinegar it became of a florid red : the same took place with nitre and lemon-juice. By the subcarbonate of ammonia and diluted sulphuric acid, the coagulum was turned black, and was again ren- dered florid by the addition of nitre in the juice of lemons, and in vinegar. To counteract the principal remote causes ofthe disease, viz. the effect of salt provisions, and the want of fresh meat, and vegetables, every ship bound on a long voyage should be supplied witb an ample store of flour, eggs for puddings, pearl barley, groats, peas, oatmeal, rice, sago, vermicelli, portable soup, potatoes, and other vegetables in season, sour krout (which is cabbage fermented with vinegar), raisins, currants, prunes, and other dried and fresh fruits, various spices, many kinds of medicinal herbs, as balm, mint, penny-royal, sage, &c.; to- gether with tea, coffee, cocoa, sugar, treacle, honey, Seville oranges made into marmalade, essence of spruce, and fresh wort. High en- comiums have indeed been passed on tbe efficacy of this last by all the navigators who have made trial of it, and they seem by no means to have been unworthily bestowed ; but as its salubrious qualities are greatly impaired by becoming damp and mouldy, every possible care should be taken to prevent this from happening. Besides the articles which have been enumerated, tbe ship should likewise be supplied with a suflicient store of spirituous and fermented liquors, as rum, brandy, beer, and porter, to- gether with wine, cider, vinegar, and other acids, but more par- ticularly the concrete juice of lemons, limes, and oranges, together -with these fruits in their natural state. If possible, a milch Order Tit SCURVY*. 66l cow should be embarked, and there ought to be an abundance of live stock. If it can be avoided, salted provisions should by no means be con- stantly served out to the crew; but fresh animal food, with a due proportion of such farinaceous substances as the ship is supplied with. or of such fresh vegetables and fruits as have been procured at what- ever ports it may have touched, ought to be delivered out to the men. t The vegetable food with which seamen are principally supplied, consists of flour, biscuit, and peas, and it very frequently happens tbat a great deal of the former which is served out to crews on board of his Majesty's ships, is in a decayed state, and by no means equal to the support of their strength. The biscuit likewise which is fur- nished them is often too old, is worm-eaten, and has lost much of its nutritive quality. The health of seamen may be supposed to depend considerably on the goodness and purity of the water which they drink, as well as on the nutritive quality of their food ; but it too frequently happens, by an inattention in laying in tbe store of this necessary article, that it very soon becomes both putrid and offensive, and in this state they are obliged to make use of it. Nothing has been found so effectual for preserving water sweet at sea, during long voyages, as well char- ring the insides of the casks before they are filled; and certainly it would be highly advisable for our Admiralty Board to issue orders for the universal adoption of this process throughout the navy. Care ought at the same time to be taken that the casks should never be filled with sea water, as sometimes happens, in order to save the trouble of shifting the ballast, because this tends to hasten the corruption of the fresh water afterwards put into them. When the water becomes impure and offensive at sea, from being ignorant of the preservative effect produced on it by charring tbe casks pre- vious to their being filled, it may be rendered perfectly sweet by putting a little fresh charcoal in powder into each cask before it is tapped, or by filtering it through fresh burnt and coarsely pulverized charcoal. Mr. Williams, of Portsmouth, one of the gentlemen entrusted by the Admiralty Board with making trials as to the best method of preserving water during long sea voyages, has experienced that of all the remedies tried during a course of many years' observation, none has answered better than the practice of charring the water casks on their inside. We are informed by him, that he has seen three casks of water in one of his Majesty's dock yards, of three years' standing, and perfectly sweet. There is, therefore, little doubt that water may be preserved fresh and fit for drink any length of time in charred barrels. It has generally been supposed that tbe putrefaction to which water is liable, arises from its containing organic matter ; but this is not so much the case as a real decomposition ofthe water being effect- ed by the chemical action of the wood, to which it is constantly exposed. To preserve seamen in health, and prevent the prevalence of 662 CACHEXIA, OR CACHECTIC DISEASES. CHaSS III scurvy, and other diseases, it will further be necessary to keep the ship perfectly clean, and to have the different parts of it daily purified by a free admission of air, when the weather will admit of it, and likewise by frequent fumigations, agreeable to the plan mentioned under the head of Typhus Gravior. This precaution will more par- ticularly be necessary for the purification of such places as are remark- ably close and confined. The coldness and moisture of the atmosphere are to be corrected by sufficient fires. Cleanliness on board of a ship is highly necessary for the preservation of the health of seamen; but the custom of frequent swabbings or washings between the decks, as is too frequently practised, is certainly injurious, and greatly favours the produc- tion of scurvy and other diseases, by a constant dampness being kept up. The removal of all offensive substances by scraping and sweeping, has indeed been more accurately attended to during the late war than was formerly the case in the navy ; and the washing of decks, particularly in cold and damp weather, has been much less prac- tised. Dryness so essential to health and comfort is now more studied, and rubbing with hot sand, scraping, and portable fires have been found much more salutary operations than frequent washing. Gravel, sand, and other earthy substances which bav* hitherto proved prolific sources of foul air, by absorbing the putres- cent matters on board of ships, have lately been dispensed with throughout the navy ; and what are called iron tanks are now pretty generally substituted for the lower tier of water casks, and placed over the iron ballast. The men should be made to air their hammocks and bedding every fine day ; they should wash their bodies and apparel often, for which purpose an adequate supply of soap ought to be allowed, and they should change their linen and other clothes frequently. In rainy weather, on being relieved from their duty on the deck by the succeeding watch, they should take off their wet clothes, instead of keeping them on, and.lying down in them, as they are too apt to do. Two sets of hammocks ought to be provided for them. In fine pleasant weather, and aftertheir usual duty is over, they should be indulged in any innocent amusement that will keep their minds, as well as bodies, in a state of pleasant activity, and perhaps none is more proper than dancing ; which makes a fiddle, or a pipe and tabour, desirable acquisitions on board of every ship bound on a long voyage. No seaman labouring under any disease, especially one of a contagious nature, should be suffered to remain among those that are in health. On the contrary, he ought quickly to be removed to the hospital or sick room, a place which every ship that has a number of men on board should by all means be furnished with; and this should be situated in an airy and dry part of it. Order III SCURVT. 66* While speaking of the means of preserving the health of seamen, it may not be improper to observe, although not immediately rela- ting to the disease I am here treating of, that in warm climates the crews of ships are healthier at sea, when the air is dry and serene, and the heat moderated by gentle breezes, than when rainy or damp weather prevails; and they usually enjoy better health when the ship is moored at a considerable distance from the shore, and to windward of any marshy ground or stagnant waters, than when it is anchored to leeward of these, and lies close in with the land. Mas- ters of vessels, stationed at or trading to any parts between the tropics, will therefore act prudently, when they have arrived at their destined port, to anchor a considerable distance from the shore, and as-far to windward of all swamps, pools, and lakes, as can conveniently be done, as the noxious vapours which will be wafted to the crew, when the ship is in a station of this nature, will not fail to give rise to diseases among them. When unavoidably obliged to submit to such an inconvenience, some means ought to be adopted to prevent disagreeable conse- quences from ensuing. For this purpose a laige sail sliould be hoist- ed at the foremast or most windward part ofthe ship, so as to prevent the noxious vapours from coming abaft; the cabin, steerage, and between the decks should be fumigated now and then, and the sea- men be made to smoke tobacco freely. Unless absolutely necessary, it will be improper to permit any of the crew to sleep from on board, when stationed off an unhealthy shore ; but when necessity obliges them to do so, for tbe purposes of wooding or watering, a tent or marquee sliould be erected, if a proper house cannot be procured, and this should be pitched on the driest and highest spot that can be found, being so situated as that the door shall open towards the sea. Under cover of this, a sufficient number of hammocks are to be suspended for the accom- modation ofthe men by night, as they should by no means be suffer- ed to sleep on the ground. If the tent happens unfortunately to be in the neighbourhood of a'morass, or has unavoidably been pitched on flat moist ground, it will be advisable to keep up a constant fire in it by day as well as by night; and as a further preventive against those malignant disorders which are apt to arise in such situations, the men should be directed to smoke freely of tobacco, and to take a wine-glassful of the tinc- tura cort. cinchonae composita every morning on an empty stomach, and the same quantity again at night. In tropical climates, the healthiness of seamen will much depend upon avoiding undue exposure to the sun, rain, night air, famine, intemperance, unwholesome shore duties, especially during the sickly season, and upon the attention paid to various regula- tions and preventive measures. The bad effects of remaining too long in port at any one time, and independent of irregularities, of harbour duties, particularly after sunset, as well as during hi? 664 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III. meridian power, cannot be too strongly adverted fo by the com- mander of every ship ; and therefore a measure of the highest im- portance in the British navy is the employment of negroes and natives of the country, or at least m<*n accustomed to the torrid zone, in wooding, watering, transporting stores, rigging, clearing, careening ships, Sec.; and, in fine, in all such occupations as might subject the^i to excessive heat or noxious exhalations, which cannot fail to be highly dangerous to the health of the unassimilated European. The practice of heaving down vessels of war in the Wrest Indies, in the ordinary routine of service at least, cannot be too highly deprecated, as well from the excessive fatigue and exertion it de- mands, as because it is a process which requires for its execution local security, or, in other words, a land that is locked, and there- fore generally an unhealthy harbour. The instances of sickness and mortality from the effects of clearing a foul hold in an un- healthy harbour, are too numerous to be specified, but Dr. Bin* croft* makes mention of a particular one, on the authority of Dr. Dickson, in speaking of the production of the yellow fever, ac- companied in a great many cases with black vomit and conse- quent death on board the Circe frigate, principally from fhe duties of clearing the hold, and heaving down, by which so many of the ship's company were soon after attacked with this fever, that one hundred and forty-six men were obliged to be sent to the hospital at Antigua. A very productive source of disease in warm climates among seamen, is an immoderate use of spirituous and fermented liquors, as they are too apt, while under a state of intoxication, to throw themselves on the bare ground, where perhaps they lie exposed for many hours to the influence of the meridian sun, the heavy dews of the evening, or the damp chilling air of the night. The commander of a ship who pays attention to the health of his crew, will therefore take every possible precaution to prevent his men from being guilty of an excess of this nature ; and likewise that fhey do not lie out in the open air, when overcome by fatigue and hard labour. The different voyages of that celebrated navigator, Captain Cook, as well as that of the unfortunate La Perouse, incontesfably prove that by due care and a proper regimen, seamen may be pre- served from the scurvy and other diseases which have formerly been inseparable from long sea voyages ; and that they can support the fatigues of the longest navigations in all climates, in all latitudes, in the midst of fogs, and under a burning sun. In all long voyages it ought to be our object not only to find out and employ the most effectual means to cure the disease when It shows itself, but likewise to prevent its arising at all, as the taint never fails to give a fatal or malignant tendency lo the other * See his Sequel to an Essay on Yellow Fever. Ordet 111 9CURV*. eea disorders incident to seamen, such as ulcers, dysentery, he.; and with this view, our preventive plan ought to commence from the first day on which the sailing stock of fresh vegetables and ship's beer is expended ; since from many experiments it appears, that much greater success is likely to attend our endeavours in this way than by reserving them for the period in which the marks of a scorbutic dia- thesis begin to manifest themselves. When, from a want of tbe proper precautions before pointed out, the scurvy makes its nppearance among a number of men, be it on board of a ship or in a close garrison, we are then to counteract its effects, first by obviating the putrid state ofthe system, and secondly by restoring it to its former vigour. The first of these is to be accomplished by a diet of fresh animal and vegetable food, but more particularly the latter, consisting of garden and water-cress, mustard, horseradish, common radish, scurvy- grass, celery, endive, and lettuces, all of which may be eaten in their crude state, together with spinach, beet, carrots, turnips, cabbages, cauliflowers, brocoli, asparagus, tbe young shoots of hops, &c, which may be prepared by any common process of cookery. To these may be added, a free use of ripe fruits, especially those of a subacid kind, such as oranges, shadocks, and others of this class. For ordinary drink, the patient may use milk, or its pro- ductions, as whey, butter-milk, he. or else an infusion of malt or spruce. Such things are however only to be procured on shore, and there- fore cannot be obtained for a ship's crew, unless they remain in port* When at sea, other substitutes mu?t be resorted to. One of the most effectual of this kind has been found to be lemon- juice, with which most ships belonging to Government, and bound on a long voyage, are, I understand, now supplied ; and I am informed that the daily regulated allowance is now one fluid ounce, mixed with one ounce and a half of sugar. Where fresh vegetables are not to be obtained, we ought to have recourse to this. To render its effects more certain, and prevent it from irritating tbe bowels, we should mix it with a sufficient quantity of water and sugar, which will make a pleasant drink Usually known under the name of sherbet. If a due proportion of wine is added, it will render it still more antiseptic. The quantity of juice used during the first three or four days, ought not to exceed two ounces daily, but it may afterwards be increased to three or four per diem. In Dr. Trotter's Medicina Nautica is inserted a letter from Mr. A. Baird, surgeon to the Hector ship of war, communicating to him the wonderful benefit derived from the use of lemon-juice in a voyage to and from the East Indies, during which, although the scurvy became very prevalent, he did not lose a single man. His words are, " When I consider the alarming progress which the scurvy was making among the Hector ship's company previous to the ad- ministration of lemon-juice as a preventive, the sudden check 84 666 CACHEXIA, OR CACHECTIC DISEASES. CtasS HI. that disease met with afterwards, and the powerful effect ofthe acid in very bad cases, I think I shall not be accused of presumption whei I pronounce it, if properly administered, a most infallible remedy both in the cure and prevention of scurvy." Where the fresh juice cannot be procured we may substitute with the greatest advantage the citric acid in a concrete form, at first prepared by Mr. Coxwell. We are informed by Dr. Trotter*, that he has experienced its powers against scurvy to be equal to any effect he has ever observed from the recent fruit in its most perfect state. Other practitioners have. reported alike fav< urably of it. It takes from sixteen to eighteen parts of water to bring, the concrete acid to the standard of lemon-juice. It is obtained after the manner of Scheelef, by combinmgthe fresh vegetable acid with lime, and then precipitating by means of the sulphuric acid. Dr. Trotter observes, that Government mistake in making their contract for lemon-juice for the use of the navy, as what is furnished is often adulterated with the acetous acid, and sometimes contains the pulp, which render it liable to ferment. Lemon and lime-juice, he says, should be procured in Portugal and tbe West Indies, and in each place be combined with calcareous earth. It may be im- ported in barrels, and in that state be sent to sea, when tbe separation of the liquid acid is so easy a process as to require no trouble, and the medicine will be always in the best state. Combined with cal- careous earth, the acid will remain unchanged for a great length of time. It has been common to employ tbe fossil acids in this disease; but there is some reason to doubt if they are of any service, and it is certain they are not effectual remedies. Moreover, they can hardly be thrown in, in such a quantity as to be useful anti- septics. In a treatise on Scurvy, by Mr. D. Patterson, surgeon in the navy, we are informed, that from certain reasons, he was induced to try a solution of the nitrate of potass in common vinegar in several cases of this disease, which, with inexpressible pleasure, he saw to succeed in every one of them ; and from frequent trials of it he is convinced that the scurvy may be cured at sea without the assistance of recent vegetable matter. If this turns out as- stated, the discovery will indeed prove of great national ad- vantage. Mr. Patterson supposes that the good effects of the nitrate of potass in mitigating or removing the disease, are to be accounted for solely from the dephlogisticated or vital air it contains, and tbat it may be rendered more active by being combined with an acid. He allows common vinegar to be of * See Medical and Physical Journal, vol. iv. p. 164. t See Crell's Journal for 1784. Order III sttjRrr. <•. m little or no utility when giren by itself; yet supposes, that if it was charged with dephlogisticated or oxygen air it might prove highly beneficial; and this he presumes to be effected by the addition ol nitre. The following is his method of preparing this new remedy, and making use of it. , At first he dissolved two ounces of nitre in one quart of the ship s vinegar, and gave half an ounce of the solution (which he named aeidutn nitrosum, or nitric vinegar) to some twice, to others thrice in ttie .lay, and as frequently bathed their blotched and ulcerated limbs with the same. From the good effect it had, and from its not producing the smallest degree of nausea, colic, or diarrhoea, he was induced to augment the dose to an ounce, and to repeat it as often as before. . Finding by far the greater number of scorbutics who were under his charge bore the increased dose ofthe medicine without expressing the least uneasiness, he now, instead of two, dissolved four ounces of nitre in one quart of vinegar, and gave from half an ounce to two ounces of this strong solution twice, thrice, or four times in the day, if they were either blotched, stiff, or ulcerated. In this manner, we are informed, he continues to use it. He adds, " Some patients cannot bear the nitric vinegar without the addition of water; while others, without the least inconveniency, bear it undiluted. The discharge by stool, or the presence of gripes and nausea, guide me with respect to increasing or diminishing the dose ofthe nitric vinegar; but at the same time it is not a slight de- gree either of nausea, colica, or diarrhoea, that renders an alteration in the quantity of the medicine necessary. To a great number of scorbutic patients eight ounces of this strong solution, containing one ounce of nitre, have in the course of the day, as long as such a quan- tity wasnecessary, been administered to each with the greatest success. Also, a circumstance no less curious than pleasing, large and frequently repeated doses of this medicine have been given in cases of dysenteria scorbutica, and instead of increasing I have always found it remove the disease. Sometimes, notwithstanding the free use of the nitric vinegar, I have known constipation take place to a considerable de- gree; in which easel have found intermediate doses ofthe potassae su- pertartras necessary and highly advantageous. This very constipated state generally occurred where the disease was far advanced ; but in a few particular cases in delicate habits, and where the disease was not far advanced, I perceived even small doses of the nitric vinegar ruffle the stomach and intestines; to prevent or remove which I have found two, three, or four grains of camphor, with each dose of the medicine, very effectual." The effects of this medicine are as follow : " During a course of the nitric vinegar the belly in general is kept gently lax ; the dis- charge of urine is increased, and changes from an alkaline to a healthy nature ; the skin becomes open and more agreeable to tbe touch; the chilliness is changed to a pleasing warmth,; and 668 cachexia, or cachectic diseases. Class III the pulse acquires steadiness and healthy strength. Sleep comes to be more and more natural. The sallow and the gloomy is gra- dually changed into a clear and cheerful countenance. By degrees the inflammation of the inoudi and nose subsides; the gums heal and get firm. The lower extremities lose faster than could have been supposed their livid hue ; they gradually become softer, less painful, and m-»rp flexible, and ulcers put on a healthy appearance and skin over. The great oppression about the breast and stomach gives way, and the cough and the breathing become less laborious. The appe- tite and the sense of taste are restored ; tbe depression of spirits and the lassitude are not remembered ; the strength increases, and at last health returns." Mr Patterson, in comparing the effect of vegetable acid with tbat of the nitric vinegar, writes as follows :—" In the month of July, 1794, at sea, a small quantity of limes were purchased by order of Admiral Murray, for the u«e of the scorbutics at that time on board; but instead of depending altogether on their power, I gave them only to a certain number, on purpose to compare their effect with that of the nitric vinegar, which was more generally administered; and from what I have seen of both, and after having weighed all circumstances, I am at present inclined to decide in favour of the latter." Such is the report made by Mr. Patterson on the effect of these two acids; and as be seems to attribute the good effect ofthe remedy which he most approves of to the nitre it contains, and not to the vinegar, I beg leave to propose the following query : Might not a solution of the nitrate of potass in lemon or lime-juice (which of themselves are powerful remedies in scurvy) be preferable to a solution of it in vine- gar, or even to these acids given by themselves ? By the means which have been pointed out, together with some Other auxiliaries, such as spruce-beer, fresh infusions of malt or wort, sugar, and the succus cochleariae compositus, we are induced to sup- pose that we shall in most cases, even in those of a desperate nature, be able to obviate the putrid tendency of the system, and effect a cure. Introducing oxygen into the system by any kind of means may likewise prove a good auxiliary. It appears that the gases were used by the celebrated navigator La Perouse in his voyage round the world ; but he very wisely ob- serves, that bottles-full of them might be swallowed without doing seamen a thousandth part of the good they receive from good slices of roast beef, turtle, fish, fruit, herbs, he. In the course of the disease particular symptoms may arise which will require a separate treatment. Pains of the belly are to be allayed by emollients and opiates ; oppression at the chest and impeded respiration by blisters, for bleeding is never to be used; contractions of tbe hams and calves of the legs are to be relieved by fomenting the parts with warm vinegar and water, and by the application of emollient poultices and friction; sponginess of Order III scurvy. 669 tbe gums and looseness of the teeth are to be obviated by washing the mouth frequently with gargles of an astringent and antiseptic nature* ; and foul ulcers are to be cleansed and healed by washing them with lemon-juice, or a tincture consisting of equal parts of tbat of myrrh and cinchona bark, and then dressing them with some kind of digestive ointment, or a poultice of sorrel (see Ul- cers). Some navy surgeons report that they have known the most obstinate ulcers of a scorbutic nature cured by applying a paste of oatmeal and water to them, the surface being sprinkled with the liquor plumbi subacetatis. In very bad cases of ulceration it is probable that the application either of the cataplasma effervescens, or cataplasma carbonis, as mentioned under the head of Gangrene, might be attended with a very good effect. Dr. Harness, physician to the British fleet in the Mediterranean some years ago, informs usf, that after the failure of other reme- dies in the cure of scorbutic ulcers, and those where there was a tendency to mortification, he found the application of the gastric fluid of graminivorous animals to have been productive of the hap- piest consequences. If in the course of the disease the bowels should not be loosened by the use of fresh vegetables, and costiveness prevail, we may then advise the taking a decoction of tamarinds with a little ofthe potassae supertartras to obviate it. Where the skin is dry and parched, a gentle diaphoresis may be excited by a decoction of the woods joined with antimony, as advised in lues venerea, or by cam- phor combined with the pulvis ipecacuanha? compositus. To answering the second indication of restoring the former vigour of the system, fhe patient should be put under a course of cinchona bark, with the mineral acids, chalybeates, and other tonics, as di- rected under the head of Dyspepsia. He should at the same time breathe a pure, temperate, and dry air; take such daily exercise as his strength will admit of, use a generous nutritive diet of fresh animal and vegetable food, and lead a life of great regularity and temperance. It has been generally supposed that scorbufic patients require land air, and land recreations, for their more speedy and effectual recovery. Dr. Trotter, in his Medicina Nautica, endeavours to controvert this opinion. His words are, " There is not at present t See Dr. Duncan's Annals of Medicine for 1797. * 1. B Infus. Rosae, f. ^vj. Aluminis, 3jss^ Mel. Optim. f. 3j. M. ft. Gargarisma. Vel, ~. 3: Decoct. Cinchonae, f. |vj. Tinct. Myrrh, f. ^jss. Acid. Muriatic, fll xij.—rt. M. * 1. Take Infusion of Roses, six ounce?. Alum, one drachm and a half. Honey, one drachm. Mix them for a gargle. Or, 2. Take Decoction of Peruvian Bark, six ounces. Tincture of Myrrh, one ounce and a half. Muriatic Acid, from twenty to thirty drops. t>7fc* CACHEXIA, OR CACHECTIC DISEASES. CklSS Iff an officer in the fleet, fhat, in doing justice to either his people or his country, would prefer the cure out of a ship. Nay, there is often the most urgent necessity for keeping them on board till they acquire a certain degree of strength. In the very weak stage a scorbutic patient cannot bear the external air, which has been long observed, and recently confirmed by five men dying in the boat belonging to the Prince of Wales ship of war, between the Downs and Deal hospital." An instance is mentioned in Mons. Charpentier Cossigny's Voyage to Canton, of a German soldier of twenty-eight years of age who expired suddenly when the crew came in sight of the island of Roderigo, and who, although he had some slight symp- toms of the scurvy, was not so ill as to be entered on the sick list. M. Cossigny observes, that he has seen other scorbutic patients on inspiring the land air lose all their strength, and die while they were carrying to the hospital. He conjectures, that the density of tbe land air stifled the German soldier, his lungs having lost their elasticity, &c. Dr. Trotter's sentiments are corroborated by this gentleman's remarks. In those painful affections'of the skin, ofthe kind usually termed scorbutic eruptions, that rise often without any very obvious cause, that chiefly depend on the habit of body, and make their appear- ance at stated intervals in painful ulcerations of the skin, producing a discharge of lymph, and an abundant desquamation, a long-con- L'nued course of Cheltenham water is often attended with a very good effect. Where the disease is inveterate, it may be necessary to have recourse to alterative medicines, such as a combination of mercury with antimony (see Herpes), together wilh the decoctum ulmi, nitric acid, spruce-beer, &c. and a diet consisting chiefly of vegetables and milk. Sea-bathing will also be proper. ICTERUS, or JAUNDICE. Jaundice is characterized by a yellowness ofthe skin, more especially observable in the tunica conjunctiva of the eyes, a bitter taste in the mouth, a sense of pain or uneasiness in the right hypo- chondrium, whitish or clay-coloured faeces, and the urine obscurely red, tinging things dipped into it of a yellowish colour. It takes place most usually in consequence of an interrupted ex- cretion ofthe bile, from an obstruction in the ductus communis cho- ledochus, which occasions its passing again info the blood-vessels. In some cases it may however be owing to a redundant secretion of the bile. The causes producing fhe first of these are, the presence of bili- ary calculi in the gall-bladder and its ducts ; inspissated bile ; spas- modic constriction of the ducts themselves ; and lastly, the pressure made by tumors situated in adjacent parts : hence jaundice is often an attendant symptom on an inflammation or scirrhosity ofthe liver, pancreas, &c, and frequently likewise on pregnancy. The proxi- Order III Jaundice. 671 mate cause of icterus is absorption or regurgitation of the bile info the vascular system. Chronic bilious affections are frequently brought on by drinking freely, but more particularly of spirituous liquors ; hence they are often to be observed in the debauchee and the drinker of drams. They are likewise frequently met with iu those who lead a seden- tary life, and who indulge much in anxious thoughts. A slight degree of jaundice often proceeds from a redundant secretion of the bile, and a bilious habit is therefore constitutional to some people, but more particularly to those who reside long in a warm climate. By attending to the various circumstances and symptoms which present themselves, we shall in general be able to ascertain with much certainty the real nature of the cause which has given rise to the disease. We may be assured by the long continuance of the complaint, and by feeling the liver and other parts externally, whether or not it arises from any enlargement or tumor in this viscus, the pancreas, mesentery, or omentum. Wrhere passions of the mind induce fhe disease without any hard- ness or enlargement of the liver or adjacent parts, and without any appearance of calculi in the faeces, or on dissection after death, we are naturally induced to conclude that the disorder was owing to a spasmodic affection of the biliary ducts. Where gall-stones are lodged in the ducts, acute lancinating pains will be fejt in the region ofthe parts, which will cease for a time, and then return again; great irritation at the stomach, and frequent vomiting will attend, and the patient will experience an aggravation of the pain after eating* A pain at the top of the shoulder or right arm is another diagnostic of concretions in the gall-bladder and ducts. When calculi are passing through the common duct into the duo- denum the symptoms are not so obscure and uncertain as when lodged in the gall-bladder. Sometimes the attack is preceded by or accompanied with a sense of coldness in the back and lower ex- tremities. The person is seized with a sudden violent pain exactly where the common duct enters the intestine. The pain is often so circumscribed, that the patient is apt to say he can cover the extent of it with a finger, and sometimes it shoots through the back, and extends up between the shoulders. Persons thus seized cannot endure a recumbent posture, but are obliged to sit up with the body bent forward, which seems to affoid a slight mitigation of the pain. In most cases the stomach is so irritable that every thing is immediately rejected. Sometimes bile is brought up, -but not always; neither is vomiting a constant attendant. The intes- tines are invariably constipated ; indeed the whole canal appears to share in the spasmodic state induced on the duodenum by the irritating cause. If the bile is completely obstructed in its passage into the intes- 672 CACHEXIA, OR CACHBCTlC DISEASES. Class III. tine, the fasces will be of a light clay-colour, and the skin and eyes become yellow, from a regurgitation of the bile into the system. Although the pain is more exquisite than in hepatitis, and is some- times accompanied with great disturbance in the general system, such as heat ofthe skin, quickness of the pulse, thirst, white tongue, high coloured urine with a dark-coloured lateritious sediment, still inflammation seldom occurs. Sometimes the disorder continues several hours, and then a remission of pain ensues, either in conse- quence of the calculus entering the duodenum, or otherwise falling back into either of the ducts or gall-bladder. After an interval of some days, or perhaps weeks, the paroxysm possibly returns again, indicating that the obstructing cause has not been removed. Biliary calculi are of various sizes, from a pea to that of a walnuf, and in some cases are voided in a considerable number, being, like the gall, of a yellow brownish or green colour. They \ary also with regard to their figure and hardness. Some are very rough and angular ; at other times they are oval or round, and their surface smooth. Although these concretions have been generally found in the gall-bladder and ducts, yet they are sometimes met with in the pori biliarii and parenchyma or spongy and cellular substance of the liver. The experiments made by Dr. Saunders on biliary calculi prove them to consist chiefly of a resinous matter with a little earth (ap- parently calcareous) combined with the mineral and volatile alkali. The jaundice comes on with languor, inactivity, loathing of food, flatulency, acidities in the stomach and bowels, and costiveness. As it advances in its progress, the skin and tunica conjunctiva of the eyes become tinged of a deep yellow ; there is a bitter taste in the mouth, with frequent nausea and vomiting ; the urine is very high coloured, and tinges linen yellow ; the stools are of a grey or claVey appearance, and a dull obtuse pain is felt in the right hypo- chondrium, which is much aggravated by pressure with the fingers. Where the pain is very acute, the pulse is apt to become hard and full, and other febrile symptoms to attend. The disease, when of long continuance and proceeding from a chronic affection of the liver or other neighbouring viscera, is often attended with anasarcous swellings, and sometimes with ascites. Petechia? and macula? sometimes appear in different parts of the body; the skin, before yellow, turns brown or livid ; even passive hemorrhages and ulcerations have broken out, and the disease has in some instances assumed the form of scurvy. Where jaundice is recent, and occasioned by concretions ob- structing the biliary ducts, it is probable that by using proper means we may be able to effect a cure ; but where it is brought on by tumors of the neighbouring parts, or has arisen in conse? quence of other diseases, attended with symptoms of obstructed viscera, our endeavours, most likely, will not be crowned with success. Arising during a state of pregnancy, it is of little con- sequence, as it will cease on parturition. A giadual diminution Order III. jaundice. 673 of the sense of Weight and oppression about the praecordia, a return of appetite and of the digestive powers, the stools becoming copious and easily procured, the urine being secreted in a larger quantity, and ceasing to tinge linen of a yellowish colour, are to be regarded as fa- vourable circumstances. A violent pain in the bypochondrium or epi- gastrium, attended with a quick pulse, loss of strength and flesh, with anasarcous swellings ofthe extremities, chilliness, watchfulness, me- lancholy, or hiccup, denote great danger. On opening the bodies of those who die of jaundice, the yellow tinge appears to pervade even the most interior part of the body; it is diffu- sed throughout the whole ofthe cellular membrane, in the cartilages and bones; and even the substance of the brain is occasionally colour- ed by it. A diseased state of the liver, gall-bladder, or adjacent vis- cera, is usually to be met with. Calculi are sometimes found in the biliary ducts. As jaundice occurs in almost every morbid condition of the liver, and as its occurrence evidently does not depend upon a specific morbid action of that organ, some physicians have been induced to consider it only as a symptomatic affection. Under the general appearance of jaundice, we ought therefore by a careful investigation to ascertain, as far as we are able, the real condition ofthe liver 5 for certainly such a discrimination must appear indispensably necessa- ry, when it is considered that the mode of treatment must be varied according to the cause by which such an appearance is induced. The cure of the disease, unpromising as it may at times appear, is nevertheless to be attempted, first, by restoring the interrupted passage ofthe bile through the duct; secondly, by carrying it off by the intes- tines ; and thirdly, by relieving the particular symptoms. Whether the passage of the bile is obstructed by biliary concretions, or by spas- modic constriction of the ductus communis choledochus, the same plan nearly must be adopted. Concretions, when of a large size, frequently excite by their great distention ofthe biliary duct in their passage through it, not only acute pain, but very often a considerable degree of inflammation likewise. When this is the case, much fever is apt to attend. To guard against guch consequences, it will therefore be advisable in full plethoric habits where the symptoms run high, to take away a quantity of blood, proportionable to the state of the pulse, the severity of the pain, and the age of the patient. Having adopted this step, we should next direct him to be put into a warm bath, in which he may be allowed to continue until some de- gree of fainting is excited; he is then to be removed to bed, and to lake an opiate, which may be repeated every four or six hours until ease is procured ; and as the stomach is generally so irritable during the attack, tbat every thing taken into it Ts immediately rejected, es- pecially fluids, it will perhaps be the best way to administer it in a solid form, as that of a pill. Besides these mean15, we may advise the 85 674 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III constant application of a bladder filled with warm water immediately over the region of the part which is most painful. Throwing up emollient clysters may serve as internal fomentations. Small nausea- ting doses of antimonials, or of the pulvis ipecacuanha? compositus, together with a free use of diluting liquors, might probably afford some relief. With the intention of pushing forward biliary concretions, vomiting has been much employed in jaundice. In recent cases, where we have no reason to suspect the concretion to be of any great magnitude, and where the pain is not acute, this remedy may be attended with a good effect, by compressing, during its operation, the distended gall- bladder and biliary vessels; but in cases attended with acute pain and a considerable degree of fever, by which we are made acquainted with the presence of inflammation, vomiting would certainly be very likely to prove injurious. An interesting case of inflammation of the gall-bladder proceeding from biliary calculi and terminating in suppuration, which at length pointed 'externally, came under my observation some years back. The patient was a woman of about forty years of age, who for a con- siderable time had been severely afflicted with pain in the stomach, febrile heat, faintings, and a purging. After a month or so there arose a swelling near the navel, which upon being opened discharged a quan- tity of yellow matter for many days. The pain becoming very acute in the tumor, the surgeon was induced to introduce his probe into the orifice ofthe wound, when to his astonishment he found a hard gritty substance at the bottom of it, which upon being discharged a few days afterwards, prove to be a gall-stone of the size of a common nut. This was shortly succeeded by another, and in due time the woman's health was perfectly restored. In many instances it seems probable that there is not much pain produced whilst a calculus of a moderate size is lodged in the gall- bladder, or even in the biliary ducts, until it arrives at that part where the common duct perforates the intestine; which opinion seems confirmed from cases reported by writers of the first respecta- bility, where biliary calculi have been met with on dissection in the gall-bladder of persons who never were incommoded during their lifetime with any symptom's that indicated the presence of such a complaint. Purgatives have been much used in the jaundice, not only with tbe view of obviating costiveness, but also with that of exciting the action of the biliary ducts by increasing that of the intestines. Some physi- cians have, however, judged them useful only where there is a slow and bound belly; while others again assure us, that drastic purges, whose action is both brisk and of long continuance, have proved highly serviceable. Regular stools, with a soluble state of the bowels, are certainly necessary to a person afflicted with tbe jaundice ; and in more than Order III JAUNDICE. 615 one or two instances I have known it to be completely removed by a diarrhoea supervening of its own accord. Where the disease proceeds either from calculi or from spasmodic stricture, it seems rational therefore to presume, that after having pursued the steps before recommended, we may make use of purga- tives* with much advantage ; and in these cases I have certainly ex- perienced their beneficial effects very frequently ; but where jaundice arises in consequence of some chronic affection of the liver or other adjacent viscera, active purgatives would be likely to do harm by in- ducing much debility. In instances of this nature we may substitute aperients, such as any of the neutral salts. Wilh the intention of dislodging biliary concretions, gentle ex- ercise, but more particularly that of riding on horseback, together with frictions, have been much advised, and certainly will be very proper, except during the paroxysms. Electrical shocks passed through the liver in the course of the common duct, may likewise prove a good auxiliary in promoting the passage of the calculus. The warm bath and anodynes, by their relaxing and antispasmodic powers, have proved highly useful in tbe jaundice when proceeding either from calculi or spasmodic strictures; and therefore when either of these causes is suspected to have given rise to it, they should by no means be neglected. When a biliary concretion remains stationary in spite of all our endeavours to dislodge it, and promote its being voided by stool, * l.RPulv. Rhei, 3j. Sapon. Alb. 3ss. Hydrargyr. Submur. gr. xij. Syrap. q. s. M. Fiant pilul. xxiv. Capiat, ij. vel iij. hora decubitus. Vel, 2. IJ Hydrargyr. Submur. gr. v. Pulv. Jalapae, 3ss. Mel. Optim. qs. M- ft. Bolus, pro re nata capiendus. Vel, 3. IJ Pilul. Aloes cum Myrrb. gr. xv. Hydrargyr. Submuriat. gr. iv. Syrup. Zingib. q. s. M. Fiant pil. iv. pro dos. Vel, 4. U Gum. Scammon. Pulv. gr. v.—*. Potassae Superfartrat. Pulv. Zingib. aa gr. xij. ft. Pulvis pro dos. * 1. Take Powdered Rhubarb, one scrapie. Hard Soap, half a drachm.. Submuriate of Mercury, twelve grains Syrup, a sufficiency. Divide the mass into twenty-four pills, and take from two to three at bed-time. Or, 2. Take Submuriate of Mercury, five grains. Powder of Jalap, half a drachm. Honey, a sufficiency to form n bolus, which may be taken occasionally Or, 3. Take Aloetic Pills with Myrrh, fifteen grains. Submuriate of Mercury, four f grains. Syrup of Ginger, a sufficiency. Divide the mass into four pills for a dose. Or, 4. Take Scammony reduced to Powder, five to ten grains. Supertartrate of Potass, Powdered Ginger, of each twelve grains. sMix them for a dose. 676 CACHEXI.fi, OR CACHECTIC DISEASES. CIOSS III we may attempt its solution, however unsuccessful or inadequate the means may prove. Dr. Darwin* made experiments on some fragments of a bile-stone with weak spirit of marine salt, a solution of mild alkali, a solution of caustic alkali and oil of turpentine, without being able to dissolve them. After s:>me time these were all put into boiling water, and then the oil of turpentine dissolved the fragments, but no alteration, was produced upon those in the other fluids, except soim little change of their colour. Upon putting some other fragments of the same bile-stone into sulphuric aether, they were quickly dissolved with- out additional heat. Dr. Darwin therefore asks, Whether aether mixed wilh yolk of egg or honey, might not be given with advan- tage in bilious concretions? We are informedf thai a mixture of aether and spirit of turpen- tine is a remedy which has been employed by many practitioners. on the continent as a solvent of biliary concretions with the most decided success; but more particularly by Monsieur Durande, who affirms that of late he has cured all whom he met with suffering from gall-stones. The plan adopted by him is, after having conti- nued the use of emollient and aperient remedies, to give his patients a mixture of three parts of sulphuric aether and two of spirit of tur- pei tine in the dose of two scruples or a drachm every morning; and upon this he directs them to takp some emollient drink, such as milk-whey, veal-broth, &ic. &ic. We are told in the publication alluded to, that M. Durande has seen biliary concretions perfectly dissolved, and discharged by stool in the form of a yellow matter resembling peas by this method. As the remedy, however, is apt sometimes to occasion nausea and other distressing symptoms, it should be administered with due caution, lest tbe pain f-hould be increased by it ; and before having recourse to its aid, the proper steps for obviating inflammation ought assiduously to be adopted. Sliould we discover that jaundice has arisen in consequence of an inflammatory affection of the liver, we must, at an early period, have recourse to the usual means for carrying it off by resolution; viz. by venesection, topical bleedings, the exhibition of cowling sa- line purgatives from time to time, and the application of a blister over the part, which ought to be renewed in a quick succession if the disease does not soon abate ;—(see Acute Hepatitis) but where these have either fa/iled or been neglected, and it has proceeded on to a chronic state of enlargement and scirrhosity, pressing thereby on the biliary ducts, we must then resort to a use of mercury both externally and internaJhy, as advised under the bead of chronic in- flammation of that viscus. In cases of this feature, as well as in those of jaundice arising from biliary concretions, it has been much the practice to employ ** See Zoonomia, vol. ii- p. 4 t See Soemmering de Concretione Bilfe. Order III JAUNDICE. 677 neutral salts*, together with alkaliesf, soap, and other deobstruentsj. Soap has, indeed, been looked upon as a kind of specific in jaundice, and has therefore been employed in considerable quantities. Hem- lock has also been used, but most probably without any good effect* Combining it either with cinchona bark or mercury || might possibly make it more efficacious. The symptoms which usually prove most distressing in this dis- ease are, the pain in the epigastrium, sickness at the stomach, and costiveness. *• 5. R Infus. Gentian. C f. ^jss. Tinct. Cinchon. f. 3>j- Potassae Tartrat. gr. xv. Pulv Rhei, gr. v M. ft. Haustus mane, hora meridiana et vespere sumendus. t 6. IJ Sodae Subcarbonat. 3y- Pulv. Cinchonae, |j. ----Rhei, 3as. Mucilag Gum. Acaciae, q. s. M ft. Electuarium, cujus sumat nucis moschatae quantitatem ter in die. Vel, 7. rj Decoct. Cinchon. f, Zx- Tinct. Calumb f. 3»j- Potassae Subcarbonat. gr. xij. M ft. Haustus mane iterumque hora meridiana et vesperi sumendus. X 8. R Gqm. Ammoniac. Sapon. Dur. aa 3j- 01. Junip. fll v. Syrup. Zingib. q. s. M. Fiant pilula? xxiv. quarum sumat iv. vel v. bis in die. Vel, fi. & Pulv. Rhei, 3j, ----Cjnnam.C. 3ss. Sapon is Dur. 3'j- 01. Juuip. fll v. , j_ Syrup. Sirupl. q. s. M. If Massa, in pilulas I dividenda, quarum sumat iij. vel iv. mane et nocte. || 10. ]£, Extract. Cinchon. ------Conii, aa 3y. Syrup. Zingib. q s. M.. Fiant pilul. lx. Sumat iij.—xy.in dftj. * 5. Take Compound Infusion of Gentians one ounce and a half Tincture of Peruvian Bark, two drachms. Tartrate of Potass, fifteen grains. Powdered Rhubarh, five grains. Mix them This draught is to be taken morning, noon, and evening. t 6. Take Subcarbonate of Soda, two drachms. Powder of Peruvian Bark, one ounce. Rhubarb, half a drachm. Mucilage of Gum Acacia, a suffi- ciency to form an electuary, of which let the bulk of a nutmeg be taken thrice a day. Or, 7. Take Decoction of Peruvian Bark, ten drachms. Tincture of Calumba,! wo drachms. Subcarbonate of Soda, twelve grains. Mix them, and let this draught be taken every morning, again at noon, and in the evening. X 8. Take Gum Ammoniac, Hard Soap, of each a drachm. Oil of Juniper, eight drops. Syrup of Ginger, a sufficiency to form the mass, out of which make twenty- four pills, and let four or five be taken twice a day. Or, 9. Take Powdered Rhubarb, one drachm. Compound Powder of Cinnamon, half a drachm. Hard Soap, two drachms. Oil of Juniper, eight drops. Common Syrup, a sufficiency. Divide the whole into fifty pills, of which three or four are to be taken morning and night || 10. Take Extract of Peruvian Bark, ---— Hemlock) of each two drachms. Syrup of Ginger, a sufficiency. Let sixty pills be formed out of the mass, and from three to twelve be taken in the, course of the day. ~ 6^8 CACHEXIA, OR CACHECTIC DISEASES. ClaSS III The two former of these will generally be relieved by bleeding, the warm bath, fomentations applied to the part, the exhibition of emolli- ent clysters, and opiates, as before advised. Where they fail, the ap- plication of a large blister may possibly be attended with a better effect. Should the nausea and vomiting continue in spite of these means, we may then give the saline medicine in the act of efferves- cence, or something of a cordial antispasmodic* nature, that may be likely to abate the irritation in the stomach. Costiveness is to be removed by gentle laxatives, such as are here advised-f. When the disease is of a chronic nature, and attended with anasar- cous swellings, it will be proper to employ diuretics, as recommended under the head of Dropsy, strengthening the general system at the same time with astringent bitters, chalybeates, mineral waters, a nutri- tive generous diet, and gentle daily exercise, but more particularly on horseback. Moderate quantities of both soda and Seltzer waters will be proper. In the progress of the disorder, it sometimes happens that a Vel, 11. R Pilul. Hydrargyri, 3ss. Extract. Conii, 3U- M. "Riant pilul. 1. quarum iij. sumat mane et nocte. * 12. ft Confect. Aromat 3j- Aq. Fontan. f. |vss. Spirit. Pimentae,f. ^ss. ----Ammon. Aromatic, f. 3ss. Tinct Opii, fll xxv. M. It. Mistura, cujus capiat cochl. ij. vel iij urgenti nausea. i 13. ft 01. Ricini, f. ^ij. Mucil. Gum. Acacia, f |j. Misceantur simul in mortario, et adde Aq. Anethi, f. §j. Tinct Jalapae, f. 3'ij- M. (lapiat dimidium pro re nata. Vel, N ft Pulv. Jalapae, 3i. Potass.e Supertart. 3y. ft. Pulvis pro dos. Vel, 15. Bs Aloes Spicat. 3j«- Sapon. Venet. 3j- Potassae Subcarbonat. 3*s. Syrup. Rhamni, q. p. M. Fiant pilul. xxxvj. capiat iij. vel iv. hora decubitus. Or, 11. Take Mercurial Pills, half a drachm. Extract of Hemlock, two drachms. Mix them, and divide them into fifty pills, of which three may be taken morning and night. * 12. Take Aromatic Confection, one drachm. Pure Water, five ounces and a half. Spirit of Pimenta, half an ounce. Aromatic Spirit of Ammonia, half a drachm. Tincture of Opium, forty drops. Of this mixture let two or thr.".e table- spoonsful be taken when the nausea and sickness are urgent. f 13. Take Castor Oil, two ounces. Mucilage of Gum Acacia, one ounce. Mix them in a mortar, and add Dill Water, one ounce. Tincture of Jalap, three drachms. Take the half for a dose as the occasion may require. Or, 14. Take Powder of Jalap, one scruple. Supertartrate of Potass, two scruples.* Mix them for a dose. Or, 15. Take Soccotrine Aloes, one drachm and a half. Hard Soap, one drachm. Subcarbonate of Potass, half a drachm. Syrup of Buckthorn, a sufficiency. Let thirty-six pills be formed out ofthe mass, and three or four be taken at bed-time. Order III jaundice. 61$ spontaneous diarrhoea arises, and prevents the future absorption of the bile into the mass of fluids. As long as it continues moderate, and induces no debility, it may be allowed fo go on ; but where it attacks with violence, or takes place in a constitution much injured and enfeebled, it should be checked by having recourse to the means advised under that particular head. When a putrid disposition shows itself, this must be counteracted by proper antiseptics.—(See Scurvy). In jaundice arising from a scirrhosity of the liver, we must adopt the steps recommended in chronic hepatitis. A variety of other different remedies have been mentioned as possessing#a good effect in jaundice, but many of them have been found on trial to be perfectly inert. Among the rest, raw eggs have been proposed as a solvent. Dr. Darwin mentions the case of a gentleman hetween forty and fifty years of age, who had laboured under the jaundice about six weeks without pain, sickness, or fever, and had taken emetics, cathartics, mercurials, bitters, chalybeates, aether, Sec, without any apparent advantage. On a supposition that the obstruction of the bile might be owing to a paralysis or torpid action of the com- mon bile-duct, and the stimulants taken into the stomach seeming to have no effect, he directed half a score of smart electric shocks from a coated bottle, which held about a quart, to be passed through the liver and along the course of the common gall-duct, as near as could be guessed, and on that very day thejstools became yellow ; the electric shocks being continued a few days more, the patient's skin became gradually clear. In cases where we have reason to suspect the obstruction on the bile to be owing to a torpid action of tbe bile-duct, and where other means have failed in promoting the desired intention, we should therefore make trial of electricity. Jaundice which arises from simple obstruction of the gall-ducts, is often removed by the internal as well as external use of Bath waters. The complicated diseases which are brought on by a long resi- dence in hot climates, affecting the secretion of bile, the functions ©f the stomach and alimentary canal, and which generally produce erganic derangement in some part of the hepatic system, likewise receive much benefit from the Bath water, if used at a time when suppurative inflammation is not actually present. Whenever there is an increased heat of the skin and quickness of the pulse during the paroxysms excited by biliary concretions, these waters should not be taken until the acufe symptoms subside. Cheltenham water is another remedy which has been found of essential service in obstructions of the liver, and the other organs connected with the functions of the alimentary canal. Persons who have had their biliary organs injured by a long residence in warm climates, and who are suffering under the symptoms either of excess or deficiency of bile, and an irregularity in its 680 LOCAL DISEASES. ClaSS IV secretion, receive remarkable benefit from a course of this water judiciously exhibited. lis use may be here continued even during a considerable degree of debility ; and from the great determina- tion to the bowels, it may be employed with advantage to check the incipient symptoms of dropsy and general anasarca, which so often proceed from an obstruction in the liver. In full sanguine habits, the water of the saline spring only should be drank. Dr. Saunders recommends drinking it warm*. Cheltenham water, besides, containing salts of a purgative nature, is likewise a chaly- beate. The iron is suspended entirely by carbonic acid, of which gas the water contains about an eighth of its bulk. A diet consisting chiefly of vegetables appears to be "best calcu- lated for persons labouring under jaundice, or in whom bilious con- cretions are apt to form. Together with a use either of fhe Bath or Cheltenham waters, great advantage may be derived from regular and sufficient exercise daily, particularly on horseback, as nothing will tend more to pre- vent the bile from stagnating and becoming inspissated, which it is apt to do in those persons who lead a studious or sedentary life. -——•^^^&99Q9>&q9'^S^ CLASS IV. LOCALES, or LOCAL DISEASES. Affection of a part, not of the whole body, characterizes this Class. ORDER I. THE DYSESTHESIA. Deprivation or loss of some sense, from the fault of the exter- nal organ. • I i NYCTALOPIA, or NIGHT BLINDNESS. Itr this disease the sight is perfectly clear and distinct in the day-time, but a total blindness takes place by night, from which occurrence it derives its name. The disorder is peculiar to the inhabitants of tropical climates, and the southern parts of Europe, being rarely, if ever, met with in cold ones ; and has been supposed to proceed from torpor ofthe retina and optic nerves, which suffer so much from the strong reflected rays of the sun by day, as not to be susceptible of the * See hi= Treatise on Mineral Water5 Order I 6UTTA SERENA. 661 feint or weak light which the night furnisfees. It is a frequent concomitant fo scurvy between the tropics. In some cases, it is symptomatic of derangement in the chylopoetic organs, but more particularly in the hepatic system. It becomes apparent towards evening with a dimness of sight, tvhich gradually increases as the night approaches ; and the darker it gets, so much the more indistinct does vision become. It is in general unattended by any other symptom, except that perhaps a more than ordinary sense of fulness is now and then perceived in the fore-part of fhe head and over the eyes. Nyctalopia seldom proves a disease of much importance, or of lon^ duration ; but, on the contrary, generally admits of an easy cure. Evacuation, both by bleeding and purging, has been recom- mended by such writers as have taken notice of this disorder ; but as it is supposed to depend upon a relaxed state ofthe optic nerves or paralyzed condition of the retina, these remedies appear to be improper, and those we employ ought to be such as will strengthen fhe tone of the parfs. With this view, the eyes should be washed several times a day by means of an eye-cup, with cold water, or some gentle astringent collyrium* ; the patient at the same time wearing a green silk blind over his eyes, and avoiding all exposures to the sun or any great glare of light. Blisters applied to the temples, tolerably close fo the external canthus of the eye, and repeated several times, will expedite the cure, unless depending on scurvy, in which case they will have little effect until that complaint be removed. If the internal use of any medicine is necessary in nyctalopia, not dependent on scurvy, or on any derangement of the chylopoetic organs, but merely on a peculiar state of the optic nerves or retina, it is probable that the cinchona bark, joined with valerian and chalybeates, might be the most proper. GUTTA SERENA, AMAUROSIS, or DIMNESS ofSIGHT. Gutta Serena (a species of blindness, wherein the eyes remain fair and seemingly unaffected) consists in a dimness of sight, whether the object be near or at a distance, together with the representation of flies, dust, &c. floaling before the eyes ; and the pupil is generally deprived of its power of contraction. It is supposed fo depend on some affection of the optic nerves j but its causes are nevertheless said to be various ; some of which are, from their nature, incapable of being removed. Thus in one case the blindness has been found to be occasioned by an encysted * L R; Zinc. Sulphat. gr. viij—xv. Aq. Rosae, f. ?W. M 36 * l.Take Sulphate of Zinc, eight to fifteen grains. Rose Water, four ounces. Mix them. 682 LOCAL DISEASES. Class IV. tumor which was situated in the substance of the cerebrum, and pressed on the optic nerves near their origin ; in a second, by a cyst, containing a considerable quantity of water, and lodging itself on the optic nerves at the part where they unite ; in a third, by a caries of the os frontis, occasioning an alteration in the optic foramina ; and in a fourth, by malformation of the optic nerves fheniselves. In some cases the defect of vision has been attempted to be accounted for by supposing a defect in fhe optic nerves, disquali- fying them for conveying the impression of objects through the eyes to the brain, as, npon the minutest inspection by dissection, nothing has been discovered either in the structure of the eyes, or in the state of any of the component parts contributing to the faculty of vision, which could at all obstruct the performance of their proper office. Mr. Ware, in his treatise on this disease, mentions, that a dila- tation of the arterial circle surrounding the cella turcica (which is formed by the carotid arteries on each side, by branches passing from them to meet each other before, and by other branches passing backward to meet branches from the basilary artery be- hind), may likewise be a cause of gutta serena. The anterior portion of this circle passes over the optic nerves, which un- doubtedly may therefore become compressed when any enlarge- ment ef these vessels takes place. A dilatation of the artery which passes directly through the centre of the optic nerve to the retina, may, it is presumed, like- wise become a cause of defective vision. The proximate cause of amaurosis is generally allowed to be the insensibility of the retina. Violent contusions of the head ; apoplectic fits ; sudden flashes of lightning ; frequent exposure to the rays of the sun ; severe exercise and strong passions, especially terror and anger ; drunken- ness ; immoderate venery ; and all those causes which predispose lo nervous and paralytic affections, may give rise to amaurosis. An over distention of the blood-vessels of the brain, or of the immediate organ, has sometimes been a ciuse ofthe disorder. Gutta serena, although considerably relieved in some instances, proves generally an incurable disease. Its treatment is usually regulated on the plan of stimulating either the parts themselves, or the system in general. The first is to be done by applying blisters and issues behind the ears or at the back of the neck, and continuing them for a considerable length of time ; by promoting a discharge from tbe nose by means of errhines*, and by sfimulant collyriums. * 1.B-Pulv. Asari Cempoait. Pharmacop. ' 1. Take Compound Powder of Asarabacca Londinensis. Vel, Or, 2. R Hvdrargyr. Sulphat. gr. j. 2. Take Sulphate of Mercury, one grain Pulv. Glycirrhiz. gr. vj. Powdered Liquorice, sii grains Order 1. GUTTA SERENA. 68$ Electricity has been employed in some cases with the happiest effect, when other remedies have failed, by passing very slight shocks through the forehead twice a day, and afterwards drawing sparks from the parts surrounding the eye or eyes; which plan ought to be persevered in for a proper length of time. Galvanism has likewise been resorted to with advantage. Dr. Darwin records* the case of a lady who laboured under gutta serena, and whose sight was restored by these means. He adopted the experiment of Volta, by employing two rods, one of them of zinc, about the size of a writing pencil, ?nd the other a silver pencil-case, about the same size ; and by putting the end of the zinc rod in contact with the external corner of one eye, and the end of the silver pencil case in contact with the external corner of the other eye, and then re- peatedly making the other ends touch each other; sparks were visible in the eyes both at the time of contact and at the time of separating the two rods. He mentions that she took valerian and calumba at the same time, and perfectly regained her sight in about three weeks. Mr. Ware informs us, that in several instances of common gutta serena he observed considerable relief to be obtained by the use of a snuff composed often grains of turbith mineral, with about a drachm of the pulvis sternutatorius ; or in the place of that, the glycirrhiza, or saccharum commune. Stimulants have been applied immediately to the' eyes, in some cases of gutta serena, with aguod effect, but more particularly in those which seem to depend upon an irritability of the optic nerve. In such cases, an infusion of dried capsicums in water, in the proportion of one grain to the ounce, may be made use of, dropping a few drops into tbe eyes morning and evening. The severity of the pain may be great at first from this application, but, by perseverance, it will be found to abate. The vapour arising from warm rectified spirit passed through a tube and received into the eyes, has sometimes produced a good effect. To stimulate the system, it is customary to have recourse to mercu- ry, which is to be used and to be continued until it produces some sensible effect. In tbat form of the disease which is accompanied with a contracted state of the pupil, and which has been produced, probably, by an internal ophthalmy, Mr. Ware is of opinion, that it may best be relieved by the internal use of the hydrargyrus oxymu- riatus, a quarter of a grain for a dose. Where the disease seems to arise from a dilatation of the anterior portion of the circulus arteriosus, as before mentioned, he thinks the cause may often be removed by topical bleeding, purging, blistering, &c. but unfortunately we have no criterion to dis- * See Zoonomia, vol. iii. class 1, 2,3,5. Pu Iv. Rad. Veratri, gr. ij. M. Powdered White Hellebore Root; two grains. Mix them, and use the powder as snuff. 684 LOCAL DISEASES. Class IV. inguish this from other causes ; and this state of tbe parts can only be inferred from a plethoric habit of body in the patient. In those cases which seem to depend upon a relaxation of the optic nerve, the means advised under the head of Nyctalopia may be proper. We are informed by Dr. Ricbter, professor of medicine in tbe university of Gottingen, in a publication which bears the title pf Medical and Smgical Observations, that he has lately restored to sight several patients who laboured under gutta serena. In all those cases, he thinks tbe cause of the disease seemed to be seated in the abdominal viscera ; for he cured them all, he says, by means of medicines which remove obstructions in the viscera and evacuate. He affirms, that in this way he has not unfrequently performed a complete cure, in cases where be hardly expected it, and in some where the disease bad actually continued for several years. After vomiting he recommends the pills mentioned below* j and he says, it is often necessary to persevere in the use of these reme- dies six or eight weeks before any amendment is perceived. A gradual increase of the dose is also requisite. A disappearance of the fiery sparks from before the eyes, and of the sensation of tension in their balls, are the first symptoms he observes of amend- ment which gives reason to hope for success in the cure of gutta serena. Costiveness should carefully be obviated in all cases of amaurosis. The disease is almost universally admitted to consist in an im- paired or total loss of sensibility of the nerve appropriated to the sense of vision, the tonics and humours of the organ retaining their natural transparency. Whatever causes are capable ef deranging the function of the optic nerve, by acting directly on its origin in the brain, or its expanded termination in tbe retina, or, lastly, by its sympathy with some remote viscus, as the stomach, may become the exciting cause of amaurosis; but as these are various, so must be the modes of treatment. Hence it follows, ihat to attempt the cure in all instances by stimulants and nervines, on the supposition that tbe disease arises from a weakness or topor of the nerve, must be irrational as well as unavailing. When an over distention of the blood-vessels is suspected to be the cause, active general and topi- 3. B- Gum. Ammon. ----Assafmtid. Puly. Rad Valerian —— Summitat. Arnic. Sapon. Venet. aa 3ij. Antimon. Tartarizat. gr. iviij. 3.Take Gum Ammoniac, ----■. Assafa^tida, Powder of Valerian, Tops of Leopard's Bane, Venetian Soap, pf each two drachms. Tartarized Antimony, eighteen grains. Syrup, q s. M. Syrup, a sufficiency to form the ft. Pilul. pond. gian.'V. quarum sumat iij. ter I mass, out of which let pills of Ive grains leach be formed, and of these three are to be taken thrice a day. in die. Order I. DEAFiNESS. 685 cal depletion will be the most proper means to obtain a restoration of sighi. Some cases successfully treated in this way have lately been transmitted to the Medical Society of London*. PARACUSIS, or DEAFNESS. Deafness is occasioned by any thing that proves injurious to the ear, as loud noises from the firing of a cannon, violent colds, particu- larly affecting the head, inflammation or ulceration ofthe membrane, hard wax or other substances interrupting sounds; too great a dryness, or too much moisture in the parts; or by atony, debility, or paralysis of the auditory nerves. In some instances it ensues in consequence of preceding diseases, such as fever, syphilis, &c.; and in others it depends upon an original defect in the structure or formation of the ear. In the last instance the person is usually not only deaf but like- wise dumb. It is often difficult to remove deafness, but more especially where it prevails as a consequence of a wound, ulcer, or inflammation of the tympanum. Where it proceeds from malconformation it admits of no cure. When deafness is occasioned by wax sticking in the ear, or by any defective or diseased actions of the glanduke ceruminae, a little of either of the remedies heref advised may be dropped into it; or be applied at the end of a small dossil of cotton every morning and night, previously syringing it with a little warm milk and water, or soap and water. If a thin acrid or fetid discharge accompanies the difficulty of hearing, it will be advisable to apply a small blister behind the ear, and to render it perpetual by dressing it with the unguentum lyttae. When the disease proceeds from cold particularly affecting the head, the patient should be careful to keep this warm by night; the effects of which may be increased by putting the feet into warm water previous to his getting into bed, and taking some proper diaphoretic. Indeed, from whatever cause the disorder may originate, it will always be proper to keep the head warm. If deafness seems to be owing to a debility of some part of the organ, or arises in consequence of any nervous affec- • See Mr. Stevenson's Oration before this Society, inserted in the Medico-Chirurgi- cal Transactions for May 1817. I 4. ft Fellis Bovis, f. 3»j Balsam. Peruv. f. 3j- M, Vel, 8. R Sodae Muriati, 3j- Aqnap Distillat. q.s. ad solationem t 4. Take Ox Gall, three drachms. Balsam of Peru, one drachm. Mix them. Or, 5. Take Muriate of Soda (sea salt,) one drachm. Distilled Water, a sufficiency to dissolve the former. 686 l.WCAL DISEASES. Class IV. tion, it is then to be removed by stimulants* dropped into the ear; by drawing spark-; with an electrical machine ; by galvanism, and by cold bathing. zEtlier dropped into the ears of some people who are deaf seems lo possess a twofold effect: one, of dissolving the in- durated wax ; and the other, of stimulating the torpid organ : but it is liable to excife some degree of pain unless it be freed from the sulphuric acid, some of which arises along with it in distil- lation. To putrify it from this it should be rectified from man- ganese. In that particular species of deafness which depends on a defective energy of the auditory nerve, we are told by Mr. Wilkinsonf, that galvanism is capable of effecting a cure. He observes, that this species of deafness is ascertainable by the common practice cf placing a sonorous body in contact with the teeth. If the communication of sound should not be thus rendered more dis- tinct, we may conclude that the defect originates in the nerve: seeing tbat, provided the deafness has been owing to any derangement of the other parts of the ear, the sound transmitted by the medium of the teeth through the connecting bony substance to the seat of hearing would have been distinctly per- ceived. In several cases where the deafness seemed to have arisen from a relaxation of the membrana tympani, attended by a diminished secre- tion of cerumen, Mr. Wilkinson experienced good effects from the employment of galvanism, which not only induced a grateful warmth in the meatus, but also considerably augmented the secretion ef wax. Where the disease is the effect of fever it usually goes off as the patient regains his strength. To assist the hearing of persons who are deaf in a high degree, we may recommend the use of an ear-trumpet, vulgarly so called. Tobacco smoke is a remedy which has been employed in some eases of severe and long-continued deafness, but more particularly by Mr. Grosvenor, of Oxford, surgeon, with great success and t See his Elements of Galvanism. • 6. ft 01. Amygdal. Dulc. |ss. — Terebinth. TT[ xxvj. Vel, 7. R 01 Olivae, §ss. Liquor. Ammon. TTl, xx. M Vel, g. R 01. Amygdal. |i. Camphorae, 3'- Solve. Vel, 9. R Spirit. .Ether. Sulph. * 6. Take Oil of Sweet Almonds, half an ounee. --------Turpentine, forty drops. Or, 7. Take Olive Oil, half an ounce. Solution of Ammonia, thirty drops. Or, 8. Take Oil of Almonds, one ounce, Camphor, one drachm. Dissolve it. Or, 9. Take Spirit of Sulphuric iEther Order I DEAFNESS. 687 efficacy. The mode of using it is to fill the mouth wilh the smoke of the strongest tobacco, instantly to close the mouth and nose, and then for the person to make all possible effort as if he meant to force the smoke through the nose, which must be prevented by holding the nostrils very tight: this forces the smoke through the Eustachian tube into the ear. The efforts are to be repeated till one or both ears give a seeming crack, immediately on which the hearing returns. We are informed by Mr. Grosvenor*, who had been exceeding deaf for a long time, that the first night he made trial of tobacco smoke, after the third effort, the right (which was his best) ear, gave a violent crack or pop, and to his great asto- nishment, he immediately heard. He repeated the process every evening till the right ear regularly cracked, when the hearing always improved. After some evenings the left ear cracked also, and he now hears tolerably well with it: whereas, before it was scarcely possible to make him hear, even with the assistance of a trumpet. He has found that as he continues the practice each evening it is longer before the effect takes place. In addition to deafness, Mr. Grosvenor, it appears, was troubled with an incessant noise in the head and ears, which he found to decrease as bis hearing improved. Before using the tobacco smoke he could not hear the clock strike the hours, whereas he now hears every tick it makes. Mons. de Saissy, surgeon at Lyons, has been successful in some cases of deafness by making injections into the hollow ofthe tympa- num through the Eustachian tube. In that species of deafness which arises from an obstruction of the Eustachian tube, Mr. Aitley Cooper recommends the puncturing of the membrana tympanif. He was led to this operation by reflecting tbat as an aperture in this membrane did not appear to injure the power of the ear, and a small opening would be sufficient to admit a free passage of air to and from the tym- panum, perhaps a substitute might be thus easily found for the Eustachian tube, and tbe membrane by such an aperture be restored to its natural functions. He observes, that there are several causes by which a closure of the Eustachian tube may be produced. It may arise, first, from a common cold affecting the parts conti- guous to the orifices of the tube, and thereby preventing the free passage of air into the tympanum. The deafness thus produced, however, is often only temporary ; but the frequent recurrence of such attacks may produce a permanent enlargement of the tonsils, which by their pressure on the Eustachian tubes will occasion a con- stant deafness. Secondly, the scarlet fever causes ulcers in the throat, which in * See Supplement to vol. Ixxxiv. part i. of the Gentleman's Magazine. f See Philosophical Transactions of the London Royal Society for 1801 688 LOCAL DISEASBS. Class IV. healing frequently close the Eustachian tube, thereby producing lasting deafness. Thirdly, A venereal ulcer in the fauces by the cicatrix it pro- duces, often occasions a closure of the Eustaclran tube, caus- ing a deafness which nothing but the operation here spoken of can relieve. Fourthly, He has known the closure of the tube produced by an extravasation of blood in the cavity ofthe tympanum. Lastly, He met with one instance of a stricture in the tube, which although it did not emirely obstruct the passage of the air, yet rendered it extremely difficult. In this the gentleman who was tbe subject of the disease, in order to enable himself to hear, was under the necessity of forcing air from the mouth into the cavity of the tympanum, which pressed the mernbrana tympani towards the meatus; then by pressing gently on the ear, he forced out a part of the air which the tympanum contained; thus giving the membrane liberty lo vibrate, and producing an immediate increase in the power of hearing. As the operation will not afford relief in any cases of deafness, except such as arise from a closed Eustachian tube, Mr. Astley Cooper is anxious that it should be performed in those only which are clearly of that description. The criteria by which he judges whether the tube is closed or open are the following :— " First, If the person in whom it is suspected to be closed should feel, in blowing the nose violently, a swelling in the ear from the membrane being at that time forced outward, the tube is open ; for when closed no'sensation is produced. " Secondly, The Eustachian tube may be closed, yet the beating of a watch may be heard if it be placed between the teeth or pressed against the side ofthe head ; and if it cannot be heard when it rests upon the teeth, this operation cannot relieve, as the power of the auditory nerves must have been destroyed. " Thirdly, It is right to inquire if the deafness was immediately preceded by any complaint in the throat. " Lastly, In a closed Eustachian tube there is no noise in the head like that which is known to accompany nervous deafness. This species of deafness generally approaches in a gradual manner; the person hears better at one time than another; a cloudy day, a warm room, agitated spirits, or the operation of fear, produce a considerable diminution in the powers of the organ. In the open air the hearing is better than in a con- fined situation ; in a noisy than in a quiet society; in a coach when it is in motion, than when it is still. A pulsation is often felt in the ear: a noise resembling sometimes the roafhjg of the sea, and others in ringing of distant bells is heard. This deafness begins generally in a diminished secretion of the wax of tiie ear, which the patient attributes to some un- Order II. canine appetite. vo* usual exposure of the head to cold; and this continues as long as the disorder remains." ORDER II. DYSOREXLE. False or defective app etite. BULIMIA, on CANINE APPETITE. This disease is the direct opposite of anorexia, as the patient is affected with an insatiable and almost perpetual desire of eating, in which if be is not indulged he is apt to fall into fainting fits. With its real causes we seem not to be very well acquainted. In some cases it has been supposed to proceed from an acid in the stom- ach ; and in others from too great a sensibility or peculiar affection of its nervous coat. In most instances it ought, in my opinion, to be considered as depending more frequently on monstrosity than disease. In the third volume of the Medical and Physical Journal* is report- ed an extraordinary and well attested case of this nature in a French prisoner, who in one day consumed of Raw cow's udder 41bs. Raw beef-.....10 Candles.......2 Total----161bs. Besides five bottles of porter. It appears from Dr. Cochrane's report of this case, as inspector and surgeon of the prison in Liverpool, where this cannibal was confined, that the feces were by no means in proportion to the ingesta, and indeed seldom exceeded those of other men, and that with the ordinary allowance of drink, the quantity of urine was not more than a quart a day : neither was it more offensive than that of other men, but there was a constant propensity to exhalation from the surface of his body, and soon after his getting into bed he was usually attacked with such a profuse sweating as to oblige him to throw off his shirt. In this case it is therefore evident that the recrementitious parts of the aliment were evacuated principally by the skin; and the same may probably happen in most cases of bulimia. Another singular case of voracious appetite has been reported to the National Institute by M. Percy, a surgeon in chief to the * See page 209. 87 690 LOCAL DISEASE*. Class IV, French army. A young man from the neighbourhood of Lyons, named Tarare, and who early in life belonged to a troop of strolling jugglers, accustomed himself to swallow flints, enormous quantities of broken victuals, baskets-ful of fruits, and even living animals. The most alarming symptoms endured in con*equence were not suffi- cient to overcome this dangerous habit, which became at last an im- perious necessity. Enrolled at the commencement of the late war in one of the bat- talions of the army of the Rhine, he sought for the necessary supply of food around the moveable hospital. The refuse of the kitchen, the remains of the messes, the rejected matters, or corrupted meats, did not suffice him. He often disputed with the vilest animals their filthy and disgusting meal: he was perpetually in search of rats, dogs, and even serpents, which he devoured alive. He was obliged to be driven by force or threats of punishment from the dead room and the places where the blood drawn from the sick was deposited. It was in vain attempted to cure his ravenous appetite by giving him fat, acids, opium, and even pounded shells. The disappearance of a child of sixteen months' old gave birth to horrible suspicions of him, and he fled. Five or six years afterwards he was admitted into the Infirmary of Versailles in a consumptive state, which succeeded his enormous appetite. He soon after died. Mons. Tessier, chief surgeon of tbe Infirmary, examined the body, notwithstanding an abominable odour exhaled from it. The stomach was of an extraordinary capacity, the intestines were ulcerated and remarkably distended, and tbe gall-bladder was of a very large size. Tarare was small in stature, flabby, and weak; his countenance had nothing ferocious in it. When he had fasted for a time the skin of his belly could be almost wrapped round him ; and when full he appeared as if dropsical. A thick vapour issued in torrents from his mouth ; all his body smoked; the sweat flowed abundantly from his head; and like all other voracious animals, he slept during the time of digestion. A case of fever attended with inordinate appetite is recorded in the 5th volume of the Medical Transactions of the London College of Physicians. The patient was a young gentleman sixteen years of age, who, with all the other symptoms of fever, attended at first with a powerful determination to the bead, showed the usual want of appetite and dislike to food (owing to the deprivation of the powers of digestion attendant on almost all pyrexial diseases) until tbe fifth day, when the most insatiable craving for food came on, and .continued during the whole period of the disease, which was extended to upwards of thirty days, with all the ordinary characteristics of typhus. The desire for food came on regu- larly with the paroxysm of fever, and continued unabated until tbat subsided, when he usually fell into a profound sleep. A remarkable circumstance in this case was, that the digestive Order II #ymph©wania. 691 powers of the stomach were equal to the supply of food, and by the aid of active purgatives six or seven copious stools were daily procured, equal in bulk and consistence to those of a strong healthy adult. When a ravenous appetite is occasioned by an acidity in the sto- mach this ought to be corrected by an emetic, with the after-use of alkalies. Where the power of the stomach in quickly dissolving, assimi- lating, and disposing of the aliment, is so great as in the cases just mentioned, we probably may be able to allay its contractile force by oil, fat meats, opiates, and a free use of tobacco, which may both be chewed and smoked. The liquor potassa? administered in doses of about five-and-twenty or thirty drops in a little veal broth, and repeated twice or thrice a day, might probably have a good effect. A medical friend has communicated a case of bulimia to me which was cured by confining the patient to a diet consisting wholly of eggs boiled fo a very hard consistence; and these he carried constantly about with him in order to satiate his appetite whenever it became craving. FUROR UTERINUS, or NYMPHOMANIA. This disease comes on with melancholy, lascivious casting about of the eyes, and frequent sighing ; and as it increases the face becomes red and flushed, and the woman makes use of libi- dinous gestures and speeches, and shows an immoderate desire for coition. ' It frequently arises either from inflammation of the pudenda, or from an acrimony in the fluids of the parts. In most instances it ought to be considered as a high degree of hysteria, or as a species ef madness. When the disease is the consequence of local inflammation, we must resort to bleeding and cooling laxative medicines, together with refrigerants, such as nitre, and the topical application of sedative lqtions*. Internally we may likewise employ camphor » 1. ft Aq. Distillat. f f iv p. Takft D;stj|led w f Liquor. Plumb, Subacet. m xvj. | Solution of Subacetate of Lead, twenty-four drops. Tinct. Opii Vinos. AT, xxv. M. Vel, 2. g. Liquor. Ammon. Acetatis, Aqua* Distillat. t,.. Spirit. Rectif. aa f. §ij. Tinct. Opii Vines. il\ «i. M. Vinous Tincture of Opium, forty drops. Mil them. Or, 2. Take Solution of Acetate of Ammonia, Distilled Water, Alcohol, of each two ounces. Vinous Tincture of Opium, forty- five drops. Mix them. 692 LOCAL diseases. €hss If. combined with opium*, or the extract of belladonna. If these fail, small doses of fhe plumbi superacetas. If it proceeds from acrid matter, the patient must drink plenfi* fully of cooling demulcent liquors. Injections of the same nature may also be thrown up the vagina ; I he parfs be washed with a Sedative lotion as ju*t advised, or be anointed with some soothing linimentf; and opium be administered in small and frequently repeated doses. The diet is to be cooling and light, consisting principally of ve- getables and milk ; and every thing that might prove an additional stimulus should be avoided. As the clitoris is the seat of pleasure during the act of coitus, nymphomania might possibly be cured by extirpating this organ. The following case, which is recorded by a French writer J, is much to the purpose. A young woman was so addicted to masturbation that she was nearly exhausted by marasmus: sensible of the danger of her situation, yet not possessed of sufficient fortitude, or else irresistibly impelled by the pleasurable sensations to which she yielded, she could not command herself, and excited piofuse emissions. Her parents took her to Professor Dubois, and upon the authority of Levret, he thought it advisable to propose ampu- tation of the clitoris, which the patient and her parents agreed to. The organ was removed with one stroke of a bistoury, and the bleeding prevented by an application of the cautery. The opera- tion completely succeeded, and the patient was cured of her fata) habit, quickly recovering her health and strength. X See Nosographie Chirurgicale, par Anthelme Richerand, M. D. &c. *3. & Camphoree, gr. vj—xij. Potassae Nitrat. gr. x. Opii. gr js. Confect Rosee, q. s. M. ft. Bolus ter quaterve die sumendus. Vel, 4. g; Extract. Belladon. gr. i—iss. Misturae Camph. f. 3*. M. ft. Haustus bis terve in die sumendus. i 5. fj;Unguent. Celacei, Cerati Plumbi Superacet. aa |ss. Vel, 6. Q. Zinci Sulphat. Plumbi Superacetat. aa gr. xv. Adipis Praeparat. |ss. Opii Pulv. 3ss. M M 3. Take Camphor, six to twelve grains. Nitrate of Potass, ten grains. Opium, half a grain. Confection of Roses, a sufficiency to form a bolus, which may be taken three or four times a day. Or, 4. Take Extract of Belladonna, one gran to one and a half. Camphor Mixture, ten drachms. Mix them, and let this draught be taken thrice a day. t 5. Take Spermaceti Ointment, Cerate of Superacetate of Lead, of each halt an ounce. Mix them. Or, 6. Take Sulphate of Zinc, Superacetate of Lead, of each fifteen grains. Prepared Lard half an ounce. Opium, reduced to fine powder, half a drachm. Mix them. Order 11 impotency. 693 DEFECTIVE APPETITES. ANOREXIA, or LOSS of APPETITE. A want of appetite and loathing of food is not usually an original affection, but prevails as a symptom of some other disease, such as dyspepsia, and is therefore lo be obviated by aromatics, bitters, cin- chona joined wth sulphuric acid, chalybeates, he. as advised under that bead. In spontaneous anorexy, where the stomach is loaded with bile or crudities, an emetic in the evening, with some kind of stomachic purgative the next morning, will seldom fail to effect a cure. ANAPHRODISIA, or IMPOTENCY. In some cases this disease is owing to an original defect in the organs of generation ; but it more usuail) arises either from topical weakness, brought on by excess in venery or onanism ; or from great debility in the system, produced by severe evacuations, preceding diseases, or the want of nutritive food. In a few instances it may be occasioned probably by a want of suflicient confidence, or a de- gree of fear at the time of coition. Where the disease proceeds from an original defect in the organs of generation, it will not be possible to effect a cure. When it de- pends upon some disease of the parts, this must be removed by the means which have been pointed out as most proper. If it arises in consequence of general weakness, the system is to be strengthened by a generous nutritive diet; by cold bathing, both general and topical ; by tbe cinchona bark, myrrh, chalybeates, and other ionics, as advised under the head of Dyspepsia. Stimulants, such as the tinctura lyttae*, might likewise be of service if given in small doses. " 1. ft Pulv. Lyttae, gr. xviij. Opii, Camphorae, aa gr. xxxvj. Confect. Rosae Caninae, q. s. M Fiant pilulse xxxvj. Capiat j.—ij.omni nocte hora decubitus. Vel, 2. R Decoct. Cinchon. f. ^j. Tinct. Cinnam. C. f. 3'j- ----Lyttae fll xij—xx. M. ft. Haustus bis iu die sumendus. 1. Take Powder of Spanish Fly, eighteen grains. Opium, Camphor, of each thirty six-grains. Confection of Dog Rose, a suffi- ciency to form the mass, out of which let thirty-six pills be made. From one to two may betaken every night on goingto bed. Or, 2. Take Decoction of Peruvian Bark, one ounce. Compound Tincture of Cinnamon, two drachms. Tincture of Spanish Fly, twenty to thirty drops. Mix them. This draught is to be takes twice a day. 094 LOCAL DISEASES. CIOSS TV. ORDER IU. DYSCINESIiE. Obstructed or depraved motions, from fault in the organs, STRABISMUS, or SQUINTING. Squinting is generally owing to one eye being less perfect than the other ; on which account the person endeavours to hide the worst eye in the shadow ofthe nose, that his vision by the other may not be confused. Sometimes the habit is acquired, and cannot afterwards be easily corrected. Where squinting has not been confirmed by long habit, and one eye is not much worse than the other, we are told* the defect may often be obviated by making the child wear, for some hours every day, a piece of gauze stretched on a circle of whalebone over tbe best eye, in such a manner as to reduce the distinctness of the vision cf this eye to a similar degres of imperfection with the other ; or the better eye may be totally darkened by a tin cup covered with black silk for some hours daily, by which means it will be gradually weakened by the want of use, and the defective eye will be gradual]; :' strengthened by using it. In most cases of strabismus we shall be enabled to afford es- sential relief by the simple process of binding up the sound eye every day for two or three hours, so as to oblige the patient to make '"' use of the debilitated organ, and according as it is more or less in- disposed, to keep the other more or less veiled, continuing tbe process until the diseased eye can fully and properly perform its functions. ORDER IV. APOCENOSES. Unusual flux of blood or other humours, without pyrexia, or increased impetus of the fluids. EPHIDROSIS, or IMMODERATE SWEATING. This is usually a symptomatic affection, but it nevertheless some- limes prevails as an idiopathic disease, and then is commonly]' ©wing to general weakness and debility, accompanied with a preTj-^q ternaturd determination to the surface of the body. It is generally to be met with in the last stage of pulmonary consumption. The cure is to be effected by covering the body lightly with ap^ ,.? parel and bed-clothes; by keeping the chamber of a'moderate . * See Darvin's Zoonomia, vol. iii. class Ij 2, 4, 5. Order lV. incontinenct of urine. 6Q5 temperature ; by determining from the surface of the body, by means of diuretics and gentle laxatives: and lastly, by strengthening the system by chalybeates and other tonic medicines, cold bathing, and the means advised under the head of Dyspepsia, avoiding at tbe same time too long an indulgence in bed, and a use of warm slops. In the colliquative sweating which attends hectic fever and phthisis pulmonalis, the diluted sulphuric acid is much employed. ENEURESIS, on INCONTINENCY OF URINE. This disease usually proceeds either from relaxation or a paralytic affection of the sphincter ofthe bladder, induced by various debilita- ting causes, such as too free a use of spirituous liquors, masturbation, ana excess in venery; or it arises from compression on the bladder, from a diseased state of the organ, or from some irritating substance contained in its cavity. When it prevails in consequence of relaxation in the parts, tbe cure is to be attempted by general and topical cold bathing, but more par- ticularly the latter; by blisters applied to the perinaeum, and by an internal use of chalybeates and other tonics, as advised under the head of Dyspepsia. The uva ursi taken from a scruple to half a drachm twice or thrice a day, drinking about half a pint of lime-water after each dose, may likewise be of some service. Should the disease be owing to a paralysis of the bladder, besides applying a blister to the perinaeum and making use of electricity to the parts, we should give the patient medicines of a stimulating nature, such as the tinctura lyttae. External pressure applied in perinaeo on a line parallel with the urethra, has in some cases of eneuresis arising from paralysis of the sphincter, effected a complete cure. A bandage might be so contrived as to answer this purpose, and would be of easy ap- plication. When it is occasioned by an extraneous substance lodged in the bladder, such as a stone, we cannot effect a cure but by removing this. As arising from pregnancy, it is only to be relieved by delivery; but . possibly it may be palliated by confining the woman as much as possi* ble to an horizontal posture. To prevent in men the urine from galling and excoriating ihe parts it will be necessary for the patient lo wear some vessel adapted to the penis that will receive it as it drops; or he may employ a jugum penis, which will obviate its being evacuated in- voluntarily. Women may use a sponge so fastened as to absorb the moisture: 696 LOCAL DISEASE*. tias/lf. GONORRHOEA DORMIENTIUM, or INVOLUNTARY EMISSION of the SEMEN. An involuntary emission of semen during sleep sometimes pro. eeeds from general debility, but is more usually the effect of a weak- ness of the seminal vpssels in consequence either of excessive venery or onanism. In a few instances it may probably be occasioned by a repletion of these vessels. The disease is often difficult to remove, and in many cases proves incurable. Its cure, however, is to be attempted by the patient's abstaining from the remote causes depending upon his will; by a generous and nutritive diet; by cold-bathing both local and general; by balsamst; by chalybeatesf, the cipchona bark, and other astringent bitters, as advised under the head of Dyspepsia; and by the application of a blister to the perinaeum. In preventing an involuntary discharge of semen, and obvlatiabthe debility of the parts, a use of Spa water has often proved very service- able. It is a strorigjy acidulous chalybeate water, containing more iron, and especially more carbonic acid, than any we have in this country. " 1. B Bals. Copaib. f. 3ij Vi^el. Ovi Uni Misceantur in morlario marmor. et addegradatim, Aq. Fontan. f. 3VSS. Tinct. Cinchon. f. |j. Syrup. Althaeas, f gss M. ft. Mist, cujus sumat cochl. ij. ter quaterve in die. I 2. ft Gum. Myrrh. Extract. Cinchon. aa 3j- Ferri Sulphat 3j. Bals Copaib q. s. M. ft. Massa in pilul. xl. distribuenda, quarum sumat iv. terin die. Vel, 3. ft Zinc Sulphat.gr. xxiv. Extract Anthemidis, 3as. ------Cinchon. 3j- Syrup q. s. M. Fiant pilul. xxiv. capiat j—ij mane et nocte quotidie. * 1. Take Balsam of Copaiba, two drachms. 'The yolk'ot»» Egg- Let them be well mixed in a marble mor- tar, and add gradually, Pure Water, five ounces and il half. Tincture of Peruvian Bark^.om ounce. Syrup of Marshmallow;'half an ounce. Of this mixture let two table spoonlful be taken three or four times a day. t 2. fake Gum Myrrh. Extract of Peruvian Bark, 0/ each oncdrhchrn. Sulphate of Iron, one scruple. Balsam of Copaiba, a sufficiency to form Ihe mass, which is to be divided into forty pills, of which four may be taken three limes a day. Or, 3. Take Sulphate of Zinc, twentjfr'four grains. Extract of Chamomile, half a drachm. ————— Peruvian Bark, one drachm. Syrup, a sufficiency. Mix them and form them into twenty-fcur pills. Take one to two morning and ni^bt, daily. Order IV. WHITES. 697 LEUCORRHCEA, FLUOR ALBUS, on WHITES. This disease is marked by the discharge of a thin white or yellow matter from the uterus and vagina, attended likewise with some de- gree of foetor, smarting in making water, pains in tbe back and loins, anorexia, and atrophy. In some cases the discharge is of so acrid a nature, as to produce effects on those who are connected with the woman, somewhat similar to venereal matter, giving rise to excoria- tions about the glans penis and prepuiium, and occasioning a weeping from the urethra. To distinguish leucorrhcea from gonorrhoea, it will be very neces- sary to attend to the symptoms. In the latter the running is constant, but in a small quantity ; there is much ardor urinae, itching of the pudenda, swelling of the labia, increased inclination to venery, and very frequently an enlargement of the glands in the groin ; whereas in the former, the discharge is irregular, comes away often in large lumps, and in considerable quantities, and is neither pre- ceded by, nor accompanied with any inflammatory affection of the pudenda. Immoderate coition, injury done to the parts by difficult and tedious labours, frequent miscarriages, immoderate flowings of the menses, profuse evacuations, poor diet, an inactive and sedentary life, and other causes giving rise to general debility, or to a laxity ofthe parts more immediately concerned, are those which usually produce the whites, vulgarly so called, from the discharge being commonly of that colour. Fluor albus in some cases indicates that there is a disposition to disease in tiie uterus, or parts connected with it, especially where the quantity of discbarge is very copious, and its quality highly acrimonious. By some the disorder has been considered as never arising from debility of the system, but as being always a primary affection of the uterus, or produced by a change in the structure, position, or actions of the neighbouring parts, such change being the effect of natural or morbid causes*. Delicate women with lax fibres, who remove from a cold climate to a warm one, are, however, to my knowledge, very apt to be attacked with it, without the parts having previously sustained any kind of injury. The disease shows itself by an irregular discharge, from the uterus and vagina, of a fluid, which in different women varies much in colour, being of a white, green, yellow, or brown hue. In the beginning it is however most usually white and pellucid, and in the progress of the complaint acquires ihe various dis- colourations, and different degrees of acrimony; frem whence proeeeds a slight smarting in making water. Besidef? the discbarge, the patient is frequently afflicted with severe and constant pains in ♦■ See Observations on the Diseases of Females, !>v C M. Clarke, 88 608 LOCAL DISEASES. £/0S4 IV. the back and loins, loss of strength, failure of appetite, pain in the stomach, dejection of spirits, paleness ofthe countenance, chilliness; and languor. The sleep is disturbed by fearful dreams, and affords btft little refreshment. The woman becomes pale and emaciated, her eyes are dull, and a flushing of the face is alternated by a ghastly pale- ness. In process of time the feet and ancles swell, palpitations, and a difficulty of respiration are experienced, the mind is dejected, ap* prehensive, and occasionally affected with melancholy. Very fre- quently the functions of generation are greatly injured, and sterility is often the consequence thereof. Hysteria also in a greater or lettf degree, is generally a concomitfnt of leucorrhcea, the urine is turbid, and the menstrual discharge is sometimes scanty, and even sup- pressed : at others, it is too copious, irregular, or attended with much pain. The disease is seldom removed but by artificial means, and where these are long deferred, it proceeds to waste the constitution with accumulating mischief. Every symptom becomes highly aggravated, the eyelids and face swell, are bloated and disfigured, the body is wasted and debilitated, and hectic fever, with its doleful train, and dropsy in every form supervene, and terminate a miserable exist- ence. In some cases prolapsus uteri, and ulcerations are to be met with. Where leucorrhosa terminates in death the internal surface of the uterus appears on dissection to be pale, flabby, and relaxed; and where organic affections have arisen, much the same appear- ances are to be met with as have been noticed under the head of Menorrhagia. The proper indications of cure to be observed in fluor albus seem to be to increase the action of the absorbents of the uterus and vagina by restoring the tone of the parts; to correct the acri- mony of the discharge, diminish its quantity, and alleviate other urgent and distressing symptoms; and thirdly, to strengthen the system when the disease is complicated with general debility and relaxation. The first of these intentions is to be effected by astringents administered by the mouth, and likewise thrown up into the vagina and uterus in the form of injections*. A'um, sulphate of zinc, gum kino, and catechu, are the astringents which are most em- ployed as internal remedies; and these may be given either sepa- * 1. & Zinc. Sulphat. f. 3j- Plumbi Superacet. gr. x. Aq. Distillat. Oj. M. ft. Inject. Vel, 2. IJ- Decoct. Cort. Quercus, Oj. Aluminis, 3j- M. Vel, 3. g- Gall. Contus. |ss. Aq. Fervent. Oij. M. * 1. Take Sulphate of Zinc, one drachm. Superacetate of Lead, ten grains. Distilled Water, one pint. Mix them for an injection. Or, 2. Take Decoction of Oak Bark, one pint. Alum, one drachm. M xthem. Or, 3. Take Oak Gall, bruised, half an ounce Hot Water, two pints. Order IV. WHITES. 699 wtely or combined with some tonic, such as the cinchona, bitters, chalybeates, and the sulphuric acid, as advised below*, or recom- mended under tbe head of Menorrhagia; together with partial cold bathing, by sprinkling or sponging the loins and thighs with Cold Water. Besides astringents, it has been usual to employ in this disease such stimulating medicines as are most commonly deter- mined to the urinary passages, which, from their vicinity to the uterus, have often been found to afford considerable relief. Tur- pentine and other balsams, such as bals. copaibae, terebinthina Cana- densis, with many more of a like nature, have been used on the oc- casionf. The tinctura lyttae has likewise been much administered with the same view; and indeed in several obstinate cases I have "4.R Aluminis Pulv. 3'j- Ras. Nuc. Mosch. 3ss- Catechu Pulv. 3j. Pulv. Cinchon. |ss. Syr. Zingib q. s. M. ft. Electuarium, cujus sumat quantitatem juglandis ter in die. Vel, 5. R Alum Pulv. gr. x. Catechu, gr v. Zinc. Sulphat gr. j. Confect Rosae. q. 6. M. ft. Bolus terin die sumendus. Vel, 6. R Extract. Cinchonae, Gum Kino, aa 3j. Aluminis, 3SS- Ras. Nuc. Mosch. 9j. Syrup. Simp. q. s. M. ft. Massa in pilul. xxxvj. divid. quarum so mat iij. bis terve in die ex cyatho aquae calcis. 17. R Terebinth. Vulg. f. 3ij. Pulv. Cinchon. 3vj. ----Gentian. 3y. Mel. Optim. fj M. ft. Electuarium, capiat magnitudinem nucis moschatae pro dos. bis terve in die. Vel, 8. R Terebinth. Canadens. f. 3ij. Pulv. Rad. Rhei, 3j. — Cinnam. C. 3ss. M. Fiant pilul. I. quarum sumat aegra ij. ad iij. bis in die. ' 4. Take Alum, powdered, two drachms. Raspings of Nutmeg, half a drachm. Catechu, powdered, one drachm. Powder of Peruvian Bark, half an ounce Syrup of Ginger, a sufficiency to form an electuary, of which let the bulk of a walnut be taken thrice a day. Or, 6. Take Alum, pulverized, ten grains. Catechu, five grains. Sulphate of Zinc, one grain. Confection of Roses, a sufficiency to form a bolus. This may be taken three times a day. Or, 6. Take Extract of Peruvian Bark, Gum Kino, of each a drachm. Alum, half a drachm. Raspings of Nutmeg, one scruple. Syrup a sufficiency to form the mass. Divide this into thirty-six pills, and let three be taken twice or thrice a day, washing them down with a tea-capful of lime water. t 7. Take Common Turpentine, two drachms- Peruvian Bark, six Powder of drachms. Gentian, two drachms. Honey, one ounce. Make them into an electuary, and take the bulk of a nutmeg twice or thrice a day. Or, 8. Take Canada Turpentine, two drachms. Powder of Rhubarb, one drachm. Compound Powder of Cinna- mon, half a drachm. Mix them together, and let fifty pills be formed out of the mass, of which Ihe pa- tient may take from twa to three twice a day. ?O0 LOCAL DISEASES. ClttSS IV. given it with much advantage. It may be joined with balsam copai- ba* or some tonicf. The application of a blister to the sacrum has in some cases been attended with advantage. Stimulating the intestines and rectum by giving small doses of rhubarb, or the pilula? aines cum myrrha, every night on going to bed, for a considerable length of time, has likewise been found serviceable. Gentle emetics have also been supposed to be of singular ntilitv ia fluoralbus. not only by cleansing the stomach and bowels, and making a revulsion of the humours from the inferior part of the body, but likewise by their exciting all the powers of the constitution to a more vigorous action. To answer the second intention, of correcting the acrimony of tbe discharge and lessening its quantity, a diligent attention mu*t be paid to cleanliness by washing the parts frequently with cold water, or a little milk and water, and then throwing astringent injections up the vagina. These may consist of a strong infusion of green tea, or a solution of alum, or sulphate of zinc, in the proportion of a drachm of-the latter to a pint of water, or the decoctum quercus, or infusum cortiei* granati. When there are excoriations either externally or internally, the liquor plumbi subacetatis, diluted sufficiently with water, may be employed as a wash. ; Injecting frequently with the same in those cases when any of the symptoms of an inflammatory action are present, or where a cancerous state of the uterus is suspected, will be attended with considerable advantage. Vel, 9. R Zinc Sulphat. 3ss. Pulv. Catechu, 3'j- Bals. Copaib q. s. M. ft. Pilul. xl. capiat ij. vel iij. mane et vespere • 10. R Bals. Copaib. 3ij. Vitell Ovi. Un. Misceantur iu mortario marmor. etadde gradatim, Aq. Fontan. |vij. Mellis De-pum. |ss. Tinct. Lyttae, 3j M. Capiat cochl. med. ij. ter in die. 111. R Infus. Gentian. C. f. |j. Tinct. Cinchon. f. 3'j- ----Lyttae, gut. x —xv. M. ft. Haust. bis terve in die sumendus. Or, 9. Take Sulphate of Zinc, half a drachm. Powdered Catechu, two drachms. Balsam of Copaiba, a sufficiency. Form forty pills, and let two or three be taken morning anil evening. * 10. Take Balsam of Copaiba, two drachms. The Yolk of an Egg. Let them be well mixed together in a marble mortar, and gradually add Pure Water, seven ounces. Clarified Honey, half an ounce. Tincture of Spanish Fly, one drachm. Mix them, and take two dessert-spoonsful thrice a day. I 11. Take Compound Infusion of Gentian, one ounce. Tincture of Peruvian Bark, two drachms. -------i— Spanish Fly, fifteen drops to twenty-four. Mix them. This draught may be taken three times a day. Order V> COSTIVENESS. 70! The pains in fhe back and loins are lo be relieved by enveloping them with the euiplastrum picis compos, spread upon coarse linen or leather, and by avoiding a standing posture of long continuance, much walking, dancing, or any other violent exertion. Languor, debility, and faintings, are to be obviated by a ge- nerous nutritive diet, consisting of milk, with isinglass boiled up in it, blanc-mange, jellies, eggs, sago, gelatinous broths, and light meats, together with cordial medicines, but more particularly Port wine. To strengthen the general system where the disease is com- plicated with universal debility, besides the restorative means just mentioned, we must have recourse to bitters of an astrin- gent and stomachic nature, the cinchona bark, preparations of steel, the use of mineral waters, cold bathing both topical and general, and other tonics, as advised under the bead of Dyspepsia. Women that are afflicted with fluor albus should avoid all the remote causes of the disease, and by no means indulge in the use of tea and other warm slops of a relaxing nature : they should lie on a mattress in preference to a feather-bed ; they should avoid too free an indulgence in sensual gratification, and they should rise early, and take such daily exercise as their strength will admit, particularly on horseback. Where there is much languor, with a considerable degree of chilliness, it is probable that frictions with flannels might afford some relief. In winter they ought to wear a flannel shift or sliders. aWKMEWig ORDER V- EPISCHESES. Suppression of excretions. OBSTIPATIO, or COSTIVENESS. Costiveness is to be considered either as constitutional or symptomatic ; but in general it prevails as the latter. The word implies a retention of the excrement, accompanied with an unusual hardness and dryness, so as to render the eva- cuations difficult, and sometimes painful. Sedentary persons are peculiarly liable to this complaint, espe- cially those of a sanguineous and choleric temperament; or who are subject to hypochondriac affections, the gout, acute fevers, and a diseased state of the liver and spleen. Costiveness is frequently occasioned by neglecting the usual time of going to stool, and checking the natural tendency to those salu- tary excretions ; by an extraordinary heat of the body, and 702 LOCAL DISEASES. ClttSS IV. copious sweatb ; by receiving into the stomach a larger proportion of solid food than is proper for the quantity of fluids swallowed ; by a free use of opium, and by taking food that is dry, heating, and difficult of digestion. Drinking freely and frequently of Port wine may likewise occasion costiveness. With the defect of stools there sometimes exists nausea, want of appetite, flatulency, pains in the head, and a degree of febrile heat. The disease is to be obviated by an attention to diet; by observ- ing certain regular periods for soliciting motions ; and where these fail, by having recourse fo laxatives. The diet of such as are of a costive habit ought to consist a good deal of vegetables and ripe fruits, and their ordinary drink of malt liquors. With respect to the second object to be attended to, a habit of regularity should be endeavoured to be established by the person's going at a certain hour or hours each day, and making proper efforts at each period for promoting an evacuation. If a natural inclination arises at any time this ought [ likewise to be encouraged. The laxatives most proper for obviating costiveness are those which afford the least irritation*', but which will at the same time procure one or two motions daily. Persons of a costive habit of body, and particularly pregnait women, are very apt to make use of Anderson's pills which are * 1. ft Potassae Tartratis, |ss. V Mann. Optim. 3>.|- Aq. Fervent, f. ?iij. Tinct. Jalapae, f. 3ij. M. Capiat dimidium pro dos. Vel, 2. ft Infusi Sennae, f. ^v. Magnes. Sulph |ss. Syrup.'Rhamni,f. 3ij. M. Sumat ^ij. pro dos.et repetatur post horas tres, si sit necessitas. * 1. Take Tartrate of Potass, half an ounce. Manna, two drachms. Hot Water, three ounces. Tincture of Jalap, two drachms. Mix them, and let the half be taken for a dpse. Or, 2. Take Infusion of Senna, five ounces. Sulphate of Magnesia, half an ounce. Syrup of Buckthorn, two drachms. Mix them. Three table-spoonsful may be taken for a dose, and the same quantity be repeated in three hours if the bowels are not sufficiently moved. Or, 3. Take Castor Oil, six drachms for ■ dose. Or, 4. Take Electuary of Senna, two ounce*. Supertartrate of Potass, tw« drachms. Powdered Jalap, one drachm. Syrup pf Ginger, a sufficiency t» form an electuary, of which let the balk of a walimt be taken occasionally at bed-time. Or, 5. Take Compound Rhubarb PHls, fif- teen grains, divided into three pills for a dose. Vel, .3. ft 01. Ricini, f. 3vj. pro dos. Vel, 4. ft Elect. Sennae, %\]. Potassae Supertart. 3'j- Pulv Jalapae, 3j- Syrup. Zingib q. s. M. it. Electuarium. cujus quantitatemjuglandis borassmni sumat. Vel, 5. ft Pilul. Rhei Comp. gr. xv. in pilul. iij. pro dos. dividend. Order V. SUPPRESSION OF URINE* 703 composed wholly of aloes, with a little oil of aniseed to prevent the griping effect of the former ; and indeed these pills have acquired an extensive reputation. In phlegmatic constitutions they may indeed be used occasionally with some advantage possibly ; but in pregnant women, or those of a bilious habit, where the bowels are naturally irritable, they cannot fail fo do harm. Their operation is* confined in a great measure to the lower part of the rectum, and they are thereby apt to induce piles. The use of every purgative medicine moreover creates a necessity for its repetition, and by this repetition the bowels lose their energy, their delicate nervea become torpid to the stimulus of the food and drink, and the se- cretions formed from fhem. A natural discharge of the contents of the bowels ought therefore to be solicited by those of a costive habit, in preference to the habitual use of any kind of purgative whatever. In those cases where inveterate costiveness has once taken place, and the usual simple remedies have proved abortive, carbon or charcoal divested of heat has been administered with some success. It is reported to have procured the desired relief in every instance. Three drachms of it finely levigated may be mixed with three ounces of the electuarium senna?, adding about two drachms of the carbonate of soda. Of this mixture, from half an ounce to one ounce may be taken as ciicumstances require. In some cases of very obstinate costiveness, where every variety of purgatives, both by the mouth and clyster, fomentations to the abdomen, the warm baih, and pure quicksilver have failed, the spi- ritus turbinthinae has been known to remove the obstruction and act freely on the bowels. ISCHURIA et DYSURIA, or a SUPPRESSION and DIFFICULTY of URINE. When there is a frequent desire of making water attended with much difficulty in voiding it, the complaint is called dysuria or strangury; and when there is a total suppression of urine, it is known by the name of ischuria. Both ischuria and dysuria are distinguished into acute when arising in consequence of inflamma- tion, and chronic when proceeding from any other cause, such as calculus, &c. The causes which give rise to these diseases are, an inflammation of the urethra, occasioned either by venereal sores or by a use of acrid injections, inflammation of the veru-montanum, bladder, or kidneys, considerable enlargements of the hemorrhoidal veins, a lodgment of indurated fasces in the rectum, spasm at the neck of tha bladder, the absorption of cantharides applied externally or taken internally, excess in drinking either spirituous or vinous liquors, or particles of gravel sticking in the neck of the bladder, or .lodging in the urethra, and thereby producing irritation. Gout, by being translated to the neck rof the bladder, will sometimes 704 local diseases. Class IV. occasion these complaints. In many instances the obstruction to the flow of urine is in a great measure owing to a diseased action of the muscles; in some of them it is entirely to be attributed to this cause. A very frequent caise however of both dysuria and ischuria is, an enlargement or other diseased state of the prostate gland, a com- plaint with which men in advanced life are very apt to be afliicted. It is usually excited by full living of every kind, inebriety, indulging to excess with women, or producing frequent excitement in tbe seminal vessels by masturbation, severe attacks of gonorrhoea, a confined state of the bowels, and exposure to cold. Indeed, what- ever increases the circulation ofthe blood in these parls beyond the healthy standard may become a cause of inflammation in this gland, the blood vessels of which lose their tone in an advanced period of life. From various dissections made by Sir Everard Home*, he is of opinion, that when the prosiate gland becomes diseased, it is not its body or lateral portions which in general are principally enlarged, but its middle lobe, which gradually becoming of an increased size, presses inwards towaids the cavity of the bladder in the form of a nip- ple, pushes the internal membrane ofthe bladder before it, obstructs the flow of urine, and gives rise to dysuria and tenesmus, with many constitutional symptoms. Dissections, however, by other surgeons have demonstrated, and seemingly very satisfactorily, that the part projecting into the bladder, and forming the valve, is not the third lobe, but a more anterior part of the gland. It has also been ascertained, that whenever this val- vular projection from the prostate takes place, the muscles of the ureters are enlarged, and will be found inserted at the root of the tumor. In dysuria there is a frequent inclination to make water, attended with a smarting pain, heal, and difficulty in voiding it, together with a sense of fulness in the region of tbe bladder. The symptoms often vary, however, according to the cause which has given rise to it. If if proceeds from a calculus in the kidney or ureter, besides the affections mentioned, it will be accompanied with nausea, vomiting, and acute pains in the loins and region of the ureter and kidney of the side affected. When a stone in the bladder or gravel in the urethra is the cause, an acute pain will he felt at the end of the penis, particularly on voiding the last drops of urine, and the stream of ^ater will either be divided into two, or be discharged in a twisted manner, nut unlike a cork-screw. If an enlargement or scir- rhus of the prostate gland has occasioned the suppression or difficul- ty of urine, a hard indolent tumor, unattended wilh am acute pain, may readily be felt in the perinaium, or by introducing tbe finger in ano. * See Philosophical Transactions for I80rt, part i. art. 8th. — Practical Observations on tbe Diseases of the Prostate Gland. Older V. SUPPRESSION OF URINE. 705 * Uyauria is seldom attended with much danger, unless by neglect it should terminate in a total obstruction. Ischuria may^ affrays'be regarded as a .dangerous complaint when it continues for any length of time, from the great distention of the bladder, and often consequent inflammation which ensue* In those cases where nei- ther a .bougie nor a catheter can be introduced, the event in all probability will be fatal, as few patients will submit to the only re- maining means of drawing off the urine before a considerable de- cree of inflammation and tendency to gangrene have taken place. v When dysuria has arisen in consequence of the application of a bhVferi as sometimes happens, nothing more will be necessary than to 'direct the patient to drink plentifully of warm diluent liquors, such as a thin solution of gum. acaciae, linseed-tea, or barley-wate*. When it proceeds from any other cause, and the symptoms are violent, besides the means just.mentioned, flannel cloths wrung out in a warm decoction of emollient herbs, or a bladder filled with warm water, should be kept constantly applied over the region of the pubes, and emollient clysters should be injected frequently, ' both with a view of acting as an internal fomentation, and of dis- lodging any indurated faeces that may be collected, and which by their pressure and stimulus will of themselves often produce a fefrancrury, or difficulty of making urine. In ischuria it will always be advisable to guard against the taking ' place"of any degree of inflammation, by drawing off, front the arm a quantity of Wood proportionable to the age and habit of the ' patient, at an early period ofthe complaint, besides having recourse to emollient fomentations and laxative clysters. Where inflammation is supposed already to exist at the neck of the bladder or prostate gland, it will Iikewise.be proper to make use of topical bleeding by applying several leeches to the perinaeum. If the suppression does not give way to these means, the patient ' should be put info a warm bath, and having kept him in it for about ' ten minutes or a quarter of an hour, he is then to be taken out, and , the introduction of a metal catheter or one of flexible gum (which is preferable) to be attempted. Where an oval tub can be procur- , ed for the purpose of bathing him, it ought to be preferred, as then , the introduction of the catheter may be attempted in the bath, and } possibly with a more decisive effect. In some obstinate cases of ischuria, and where every endeavour to draw off the urine has failed, by placing the patient in a warm bath and bleeding him ad deliquium animi, tbe surgeon has sometimes been enabled to pass a catheter with the greatest ease imaginable. In all cases it will be necessary to introduce the catheter with , gentleness ; even a moderate force improperly directed is capable ■of'injuring the urethra in such a manner'as to render the operation --almost impracticable ; and it must be obvious to every surgeon, that long-continued and violent attempts have a tendency to increase * the inflamed state of the urethra; but besides this, a 30 706 LOCAL DISEASES. Class IV. laceration of its membranous parts is apt lo arise so as to endanger the making of an artificial passage by the catheter. In a retention of urine proceeding from an enlarged or diseased state ofthe prostate gland, and where there is a fulness, in the region of the bladder, with a turgidness of the parts, having pre- mised copious bleeding both general and topical, no time should be lost in introducing the catheter and drawing off the water. . In doing this, three things are, however, to be attended to :—1st, T» avoid bringing on spasms of the urethra ; 2dly, To conduct the point of the instrument over the prominence at the neck of the bladder ; and 3dly, To employ an instrument that is fitted to be retained in the bladder should much difficulty have occurred in the introduction, as less disturbance is likely to arise from an instru- ment remaining therein, than will be produced by repeating the .operation of introducing if, where any degree of violence is com- mitted upon the parts. The instrument should be soft and smooth, rounded at the point, and as large as the canal will easily admit, that it may more readily disengage itself at the turn into the bladder : the apertures in its side should be wide, to render them less liable to be clogged with mucus or blood, and it should be pliant, that it may adapt itself to the form of the parts, and give little disturbance while retained; another desirable property for it to possess, we are told by Sir Everard Home*', is a permanent curvature at the point, even to a greater degree than is usually given to the common silver catheter. The only instrument which possesses these requisites is the elastic gum catheter. To acquire the proper curvature, it should be kept upon an iron stilet of a proper shape. In some cases of an enlargement of the lobes of the prostate gland, even a flexible gum catheter with a stilet cannot pass along the urethra on account of spasm, but by having given it a consi- derable curvature by its being kept a sufficient time upon a stilet! and then introducing it in a flexible state without the stilet, we shall succeed, and be able to draw off the water. Hard metallic instruments should never be employed in cases of diseased prostate when the others will answer the purpose. Sir Everard Home gives the following directions for passing the catheter in cases of diseased prostate. It should be introduced either towards the left or right side with the handle nearly in an horizontal line, and when it reaches the membranous part of the urethra, the handle should be gently and gradually brought towards the perpendicular line, the point all the time being kept in motion; and when it is nearly upright, the handle should be depressed. When the flexible catheter has no stilet, a good deal of dexterity is often required. If the catheter without the stilet cannot be made to pass, it ought to be tried with one, and if it is still prevented from going * See his Observations on the Diseases ofthe Prostale Gland. Order V. suppression of urine* 707 on, by introducing a finger into the rectum, and pressing upon the curved point of the catheter, we may give it a right direction, so as to guide it into the bladder. When necessary to introduce the finger in anb, a recumbent posture must be employed; but in other instances Sir Everard Home prefers the standing position. In every instance of the complaint, whether arising from stricture, gravel, inflammation, or spasm, opiates will prove highly serviceable, and ought therefore to be administered not only by the mouth along with diuretics* of a mild or bland nature every four hours, but like- Wise in clysters repeated frequently-]-. Injecting sweet oil, or even warm milk and water, frequently up the urethra, will often afford relief, especially if the suppression has been occasioned by a small piece of gravel which has stuck in the canal. In both ischuria and dysuria, arising from gravel or a stone in the bladder, besides adopting this step, we should have recourse to the. means advised expressly undet these heads. Making the patient stand on a cold stone floor, and apply- ing snow or ice to the region of the pubes, have been known to remove a suppression of urine when other remedies have failed. * 1. ft Mucilag. Gum. Acaciae, f. |j. Ol.Olivae.f. 3ij- Terantur simul in mortario, et adde Spirit, .ffither. Nitrici, f. 3X Tinct. Opii, Til xv. Aq. Foenicul. gss. M. ft. Haustus. Vel, 2. ft Potassae Acetat. 3j. Aq. Foenicul 3sj- Tinct. Opii, fn. x. Syrup. Altheeae, f. 3y- ft. Haustus. 4 3. ft Bals. Copaib. f. 3ij. Vitel. Ovi, q. s. ad solut. et adde Decoct. Malve Compos, (. |xj, 01. Ricini, f. fss. Tinct. Opii, Til xxx,-r\v. M. Pro enemate. Vel, 4. ft Terebinth. Vulg. f. 3"j. Vitel Ovi, q. s. ad solut. et adde Deeoot- Malvae Compos, f. |xjL 01. Olivae, f. ^ss. Tinct. Opii, 1t\ xxx. M. 'ft. Ejiema.' H 1. Take Mucilage of Gum Acacia, one ounce. Olive Oil, two drachms. Let them be well mixed in a marble mor? tar, and then add Spirit of Nitric ^Ether, one drachm. Tincture of Opium, twenty-three drops. Fennel Water, half an ounce. Mix them for a draught. Or, 2. Take Acetate of Potass, one scruple: Fennel Water, eleven drachms. Tincture of Opium, fifteen drops. Syrup of Marshmallow, two drachma. Mix them for a draught. ,t 3. Take Balsam of Copaiba, two drachm?. Yolk of Egg, a sufficiency. Then add Compound Decoction of Marsh- mallows, eleven ounces. Castor Oil, half an ounce. Tincture of Opium, from fifty to eighty drops. Mix them for a clyster. Or, 4. Take Common Turpentine, three drachms. Yolk of Egg, a sufficiency.. And add Compound Decoction, of Marsh- mallows, eleven ounces. Olive Oil, half an ounce. Tincture of Opium,, fifty drops» Mix them for a clyster. 708 LOCAL DISEASES. Class li. Throwing a little cold water on tbe thighs has sometimes enabled the person to pass urine in a tolerable stream, although before suppressed. >* When all these means prove unsuccessful, an enema of an infusion of tobacco* will often be attended with a powerful and derisive effect in cases arising from spasmodic affection, as I have experienced in two or three instances; the patients became fain* and sick, the pulse sunk, a profuse perspiration broke out, and soon afterwards the urine flowed in a small stream. From the great depression of the powers of life which tobacco clysters are apt to occasion, (even to an alarming .degree sometimes) due caution must be observed in repeating theua. A bougie , medicated with tobacco, is reported by Dr. Shaw, of Philadelphia, to have been employed by him with great Miccess in several cases of retention of urine arising from stricture. In cases of retention arising, from spasm i combined with stricture, the injection of warm olive oil into the. urethra las sometimes proved beneficial. The tinctura labaci administered iu doses of thirty drops twice or thrice a day in a tea-cupful of linseed-tea has proved an excellent remedy in many cases of-i dysuria. The tinctura ferri muriatis is a remedy which often proves efficacious in suppressions of urine arising firm spasm ; and sliould the tobacco clyster fail in produoing the desired effect, it may be given in doses of ten drops, repeated every ten minutes, until some sensible effect is obtained. After six doses the urine usually flows*. freely. To the good effect of this medicine I can myself bear testi- mony, having tried it in some cases of spasmodic suppression with1 success. .n In ischuria, particularly where it is of a chronic nature, camphor ' has been found a very valuable medicine, and may be given as advised belowf, administering a dose of the oleum ricini now and then. » 6. ft Tabaci, 3ss —3i. Aq. Fervent, f. %x. Col. pott semi noram. Pro eijemate. t 6. ft Camphor, gr. v. Hydrargyr. Sqbmuriat. gr. ss —j. OphVgr.j. Confect Aurant. q. r. M. ft. Bolus bis in die sumendus. Vel, ■•:' 7, ft Camphorae, gr. vj,fi-x. Solve in Lactis Vaccinae, f. |iss.et adde Tin«t Opii, m, U. M. ft. Haustus. Capiat tertia quaque hora. * 5. Take Common Tobacco, half a drachm to one drachm. T ' Warm Water, ten ounces. After half an hour's infusion, strain off the liquor for a clyster. t 6. Take Camphor, five grains. Submuriate of Mercury, half 8 grain to one gram. Opium, one grain. Confection ofOrangp, asufficiencf., to form a bolus, which is to be taken twic§ a day. Or, 7. Take Camphor, six, to ten grains. Dissolve it in Fresh Cow's Milk, one ounce ana1 a half, and add Tincture of Opium* fifteen droM« ^ .■ Mix them. This draught may be taken every three hours- Order V. suppression of urine. 709 In morbid conditions of the bladder, in which a suppression ofe urine is apt to ari*e, and lo recur frequently, the extract of hyoscyamus may' prove a good medicine, beginning wilh doses of four or five grains, ami so gradually increasing the quantiiy according to the state of the distress, and the effect pro- duced;1 When a 'diseased condition of the bladder is supposed to'be connected with, or dependant on scrofula, possibly hemlock maybe of some service ; but to derive benefit from it in such cases it stiould he used in as large doses as possible. Gentle courses of mercury, conjoined with hemlock, have sometimes been beneficial in tbe like cases; but where, under a morbid condition of the blad- der, tbe inflammation and irritation are great, and verging to a state of scirrhus or ulceration, mercury would certainly be injurious. —See Cystiiis. In desperate cases where all the means which have been advised prove ineffectual, where no catheter can be passed, and where im- minent danger is lo be apprehended from the vast distention of the bladder, recourse is to be had, before it is too late, to the opera- tion of puncturing it with a trocar ; and the mode of doing this now most generally adopted by surgeons is (I believe) through tbe rectum.- Those who are subject to the affections here treated of ought carefully to guard against all exposures to cold, and particularly getting wet in the feet : they should lead a temperate life, avoid all severe exercise, especially on horseback ; and they sliould use every precaution against receiving any venereal taint. Those who are lia- ble to a suppression or difficulty of urine, either from strictures or ca- runcles in the urethra, will act prudently in wearing a bougie for an hour or two every day. In the first stage of an enlargement of the prostate gland, the best means to resort to are frequent bleedings from the perinaeum by means of leeches, or from ^the loins by cupping, assisted by cooling purgatives from time to time, opiate clys- ters^ and the use of a tepid hip bath of 94 or 95 degrees of temperature once in the twenty-four hours. Quietness, absti- nence, and all the other common means for allaying irritation, are to be employed at the same time. On no account should bougies or catheters, particularly of the metallic kind, be in- troduced ; since when done in the most adroit manner they cannot fall to produce some disturbance which the parts are not in a state to bear, and if an instrument is unskilfully passed, it will increase the swelling, and probably bring on a complete retention of Urine. In a more- advanced stage of the disease the treatment should consist in keeping the urine in a state of dilution by means of watery mucilaginous drinks, tbe bowels open by gentle aperients, the diseased parts soothed by suppositories and clysters of warm water, and medicines of tbe narcotic kind administered internal- 710 LOCAL DISEASES. Olast IV. ly*. Of these, opium, the compound powder of ipecacuanha, hem- lock, and hyoscyamus, are most to be depended upon. A tempora- ry relief may be experienced by a hip bath of common salt or wa- ter at a low temperature. The insertion of a seton or issue in peri- naeo might perhaps retard the progress of the complaint. The pa- tient should abstain from every kind of food and liquor of a stimulant nature ; he should carefully avoid horse exercise, or violent exertion of any kind, and he should sit on a chair with a cushion which is hollowed out in the centre ; moreover, he never should retain bis urine for any length of time so as to distend the bladder by an accu- mulation of it. Where ulceration takes place in the prostate gland*, the case is marked by an increased secretion of every viscid mucus mixed with pus, and sometimes with blood; a frequent desire to make water, and more or less with a stinging pain at the neck of tbe blad- der and glans penis. Ulceration of this gland is usually tbe conse- quence either of small irregular pieces of gravel escaping from the bladder, but entangling themselves just behind the veiu-montanum, so that the sharp points wound the membrane, and by degrees sink deeper into the substance of the gland, and become fixed in that situation ; or of the incautious use of instruments, more especially ofthe metallic kind, in attempts to pass them into the bladder, i or it ensues in consequence ofthe formation of an abscess in the sob- stance of the gland. ■ Cases of ulceration in the prostate gland are truly deplorable, and all that can be done is to mitigate tbe sufferings of the patient by narcotics, &c. recommending him at the same time strictly to follow the plan already detailed. AMENORRHEA, or INTERRUPTION of the MENSTRUAL FLUX. Amenorrhea is to be considered as of two kinds : the one where the menses do not begin to flow about the period of life at which they generally appear; and the other where, after having made their appearance, they cease to return at their usual periods from other causes than conception. The term of retention has been applied to the former, and that of suppression to the latter. Menstruation seems evidently to give a disposition to the female organs of generation to be acted upon by the male semen so as to fit them for impregnation, as women seldom, if ever, bear children before they have menstruated, and few or none ever become preg- nant after the total cessation of this discharge. Whether or not the blood which should have passed off by menstruation contribute* * 8. rx Opii, gr. iij. I * 8. Take Opium, three grains. Extract. Conii, gr.iv. M. Extract of Hemlock, four grains. ft. PUuia iu ano iutroducta. I Make them into a pill, and insert it op tfca { anus. Order V. RETENTION OF THE MENSES. 711 to the formation and nutriment of the foetus in utero, is looked upon as a matter of doubt : that it does not, is the opinion most generally entertained. An ingenious solution of the problem, Why nature should have doomed the human female to the menstrual discharge ? has been offered by Mr. Abernethy*. It can only be solved, he remarks, by supposing that it relieves uterine irritation, and mitigates the ex- treme of sexual desire, thus enabling a woman to conform to the laws of morality, and the social compacts that are established* between us. In warm climates menstruation fakes place at a much earlier period of life than in cold ones, as in the former it often makes its appearance at the age often or eleven years ; whereas in the latter it is seldom to be observed before fifteen or sixteen. It also ceases much sooner with women who reside in warm climates than it does with those who are inhabitants of cold ones : as in the former, men- struation is not often to be observed after the age of forty ; whereas in the latter it seldom stops before that of forty-five, and is in many instances extended to fifty years. - Some women begin to menstruate without any previous indispo- sition ; but with most of them the first appearance of the discharge is preceded by a swelling or enlargement of the breasts, together with a sense of fulness at the lower region ofthe belly, pains in the back and inferior extremities, and some slight hysteric affections, all *f which cease as soon as fhe flow of blood takes place. For the two or three first fimes of its appearing it is apt to be somewhat irregular, both as to the quantify of blood which is dis- charged and the period of its return ; but after these it usually observes stated times, and nearly the same quantity is lost at each visitation, unless some irregularity ensues. To ascertain tbe>q1uainfum generally discharged with exactness is impossible, as this varies in different women, and greatly depends on ^he constitution. Those of a delicate habit and lax fibre have a more copious and a longer continued discharge than women of a robust constitution. In general, however, the menses continue .fo flow from four to six days, and the quantity of blood discharge.; is about five ounces. Pregnant women, and those that suckle children, do not usually menstruate during such processes. CHLOROSIS, or RETENTION op the MENSES. The cause of this disease aeeuis to be a want of power in the system arising from weakness to propel fhe blood into the uterine vessels with a force sufficient to open their extremities, so as to allow of a discharge of blood from them; but the origin of the **■ See his Physiological Lectures delivered before the Royal College of Surgeons in tie year 1817. 712 LOCAL pfSEASES. Clans IV. weakness which appears at this particular period of life we are wholly unacquainted with. Some have referred it to a certain state or affection of the ovaria, between which and the uterine vessels there is a seeming connexion. The mere want of the discharge may not produce the diseasp, for frequently it does not appear until seventeen or nineteen y«irs of age without producing any morbid affection. Tli-is is not to be con- sidered as m irbid unless ihe system is evidently dwranged thereby. In many cases, however, morbid'symptoms do appear, which are evidently connected with the defect of the menses, and go off upon its discharge. The supposed connexion of chlorosis with defective menstruation as its cause, and with the restraints imposed by the laws of society on certain natural appetites and pa-'sions, has been combated by a late writer*, and he thinks that the leading symptoms may be rea- dily explained by a reference to the state of the prims vne. Cos- tiveness always precedes and accompanies the other symptoms. This induces, he says, the feculent odour of the breath, disnrdeitd stomach, depraved appetite, and impaired digestion, which preclude a sufficient supply of nourishment at a period of growth when it is most wanted. In reporting this gentleman's ideas on the subject of chlorosis, I cannot avoid observing, at the same time, that since the publication of his work on the utility or purgative medicines, it has become too prevalent to attribute a long catalogue of diseases as consequential affections upon a disordered state of the digestive organs, or chylo- poetic vsicera ; many of which, in my humble opinion, arise from other causes. Heaviness, listlessness to motion, fatigue on the least exercise, palpitations at the heart, pains in the back, loins, and hips, fla- tulency, and acidities in the stomach and bowels, costiveness, a pre- ternatural appetite for chalk, lime, and various other absorbents, together with many dyspeptic symptoms, usually attend on chlorosis. As it advances in its progress the face becomes pale, and after- wards assumes a yellowish hue, even verging upon gr*en, from whence it has been called green sickness ; the lips lose their colour; the eyes are encircled with a livid areola ; the whole body has a Ieucophlegmatic appearance, with every indication of a want of power and energy in the constitution ; the feet are affected with cedematous swellings; the breathing is much hurried by any vigo- rous exertion of the body; the pulse is quick, but small; and the person is apt to be affected with a cough, and with many of the symptoms of hysteria. Sometimes a great quantity of pale urine is discharged in the morning, and not unfrequently hectic fever attends. * See Observations on the Utility of Purgative Medicines in several Disease?, by Dr. James Hamilton, of Edinburgh. Order V. retention of the menses. 713 To procure a flow of the menses proves in some cases a very difficult matter ; and where the disease has been of "long standing, various morbid affections of the viscera are often brought on, which at length terminate fatally. By maniage, and a change in the mode of life, the disorder has in several instances been removed. Dissections of those who have died of chlorosis, have usually shown the ovaria to be in a scirrhous or dropsical state. In some eases, the liver, spleen, and mesenteric glands, have likewise been found in a diseased condition. The cure of the disorder is to be regulated on the plan of increas- ing the tone ofthe general system, and of exciting the action of the uterine vessels by stimulants. The first of these is to be effected by a generous nutritive diet, with a moderate use of wine; by gentle and daily exercise, but more particularly on horseback; by associating with agreeable com- pany, so as to keep the attention engaged, and the mind tranquil and amused ; by inhaling dephlogisticated air or oxygen gas ; and by a regular use of tonic medicines, as the cinchona, infusum gen- tians compositum, infusum quassias, &c. together with chalybeates,* * l.ft Myrrh. Pulv. 3ss. Ferri Sulphat. 3j. Sodae Subcarbon. gr. xv. Extract. Cinchon. 3j, Syrup. Zingib. q. s. M. ft. Massa in pilulas xxiv. dividenda, quarum duas sumat bis terve de die cum cochl. magnis duobus misturae sequentis ;— 2. R Infus. Gentian. Comp. f. §vj. Tinct. Cinchon. C. ----Cardam. C. aa f. |ss. M. (t. Mistura. Vel, 3. ft Tinct. Ferri Muriatis, f. §j. Sujus sumantur tTl decern terdedieex cy- - atho aquae frigidae aut Decocti Cinchonas Vel, 4. ft Pulv. Myrrh. 3i. Solve in Spirit. Cinnam. f. 3ij-etaa,de Aq. Pimentae, f. 3*- Ferri Sulphat. gr. v. Potassae Subcarbonat. gr. viij. 1. Take Powdered Myrrh, half a drachm. Sulphate of Iron, one scruple. Subcarbonate of Soda, fifteen grains. Extract of Peruvian Bark, one scruple. Syrup of Ginger, a sufficiency to form the mass, which is to be divided into twenty-four pills, and two to be taken twice or thrice a day, washing them down with two table-spoonsful of the following mixture:— 2. Take Compound Infusion of Gentian, six ounces. ----------Tincture of Bark, Cardamoms, of Mix them. each half an ounce. Or, Ryrup Simpl. f. 3>- M. ft Haustus ter in die adhibendus. 90 3. Take Tincture of Muriate of Iron, one ounce. The dose may be fifteen drops thrice a day in a glassful of cold water, or a De- coction of Peruvian Bark. Or, 4. Take Myrrh, one scruple. Dissolve it in Spirit of Cinnamon, two drachmas. And add Pimenta Water, ten drachms. Sulphate of Iron, five grains. Subcarbonate of Potass, eight grains. Common Syrup, one drachm. Mix them. This draught is to be taken thrice a day. 714 LOCAL DISEASES. (%SS IV. various forms of which will also be found under the head of Dys- pepsia. Previous to a use of these medicines it may however be advisa- ble to give a gentle emetic for the purpose of cleansing the stomach, and freeing it from acidities and inactive fluids. Chlorosis (a disease which is at all tiroes much relieved by steel, and will bear it even where there is a considerable degree of feverish irritation) is often entirely removed by a course of Bath water; and its use as a warm bath will greatly contribute to remove that languor of circulation and obstruction of the natural evacuations which constitute the leading features of this troublesome disorder. Women of an irritable habit sliould not however drink more than a pint a day. Tunbridge-well water is another chalybeate which frequently proves serviceable to chlorotic women. To those of a weak irritable stomach the frpsh-drawn water is apt to prove too cold, and to occasion a nausea or sickness which always defeats the general intention of the medicine. This inconvenience is to be prevented by giving the water a tepid warmth ; and to do this it is by far the best method to put it. into a bottle closely corked, and to immerse the whole in hot water, for by this means but little of the carbonic acid escapes. During a course of this water, as well as of the for- mer, it will be advisable to employ the warm bath occasionally; the propriety of which practice is proved by daily experience. A bath of about eighty degrees will be highly serviceable; a colder one might do injury. Pyrinont and Spa waters may likewise be found useful in this disease. As the former of these is very strong, and contains a large excess of carbonic aci 1, it will bear dilution with boiling water sof- ficient to bring the whole to a moderate temperature ; but with the mild weak chalybeates, such as that of Tunbridge, the method of warming it in the manner before mentioned is by far the best. In using the Spa water, it will be most advisable to begin with a moderate quantity, not more than half a pint for a dose, which may be repeated three or four times in the day, and be gradually increased till some effect is produced on the secretions. Many patients, but more particularly those on the spot, are in the habit of diluting with this water tbe wine that forms their common drink, which makes a pleasant and salutary beverage. The second intention of cure (viz. of exciting the action of the uterine vessels) is to be premoted by the exercises of walking, dancing, and jumping, by frequent friction, by putting the feet often into warm water, by heat applied to the organs of genera- tion and lower region of the belly, in the form either of steam or stupes, by compression of the iliac arteries in obstinate cases, and by electric shocks passed through the pubic, hypogastric, and lum- bar regions; the last of which, by being used at the same time, is more likely to be attended with a good effect. In all cases venery is however the most certain and natural remedy. Order V. retention of the menses. 714) Stimulating the rectum by purgatives is a mean which is likewise usually employed in chlorosis to excite the action of the uterine vessels. Those most in use are the drastic resins, such as aloes, he. which may be given as advised below*. Mercury is sometimes employed as a stimulant and deobstruent in this disease, and the preparation of it most used is the hydrargyri submurias ; but it is by no means universally approved of as a safe medicine. When given in cases of this nature it ought to be combined with some drasticf. Some practitioners are in the habit of giving these stimulating purgatives twice a week; but the preferable way seems to be that of employing them in a small but suflicient dose every night when the patient retires to rest, so as to keep up a regular and sufficient alvine evacuation. The author of tbe observation before quoted, tells us, that he has found the purgative plan very successful in chlorosis, but that it requires great assiduity and perseverance frequently to accomplish the end desired. The formation of this and many other diseases, he thinks, may be prevented wholly by promoting at all times, where nature is defective, a regular and sufficient alvine evacuation. Besides purgatives, other stimulants, under tbe name of emmena- gogues, such as savin, be. have been employed in the cure of chloro- sis ; but they seem better calculated for a suppression of tbe menses than for a retention of them, as in this disease tonics and chalybeates are the most advisable. Should the practitioner, however, be disposed to make trial of them, he will find various forms of the same under the succeeding head. If the desired effect is not produced by these remedies, we may, * 5. ft Pilul. Aloes com Myrrh. 3j- In pilulas xij. divid. quarum sumat iij. vel. iv. pro dos. Vel, . ft Pilul. Galban. C. Aloes Spicat. aa 3j- Syr Rhamni, q. s. M. ft. Massa in pilulas xxiv. distribuenda, qua- rum capiat iij. vel. iv. hora decubitus. Vel, 7. ft Tinct. Aloes Comp. f. 3ij.—f. |ss, pro dos. 1 8. ft Pulv. Scammon cum Hydrargyri Submuriate, 3j- Syrup, q. s. M. ft. Massa in pilul. xij. distribueaia. iij.pro af misery and pain, or he is cut off by a total suppression of urine. Tbe cancer with which chimney-sweepers are sometimes attacked generally begins in the rugae of the scrotum in the form of a wart. This, from tbe itching and uneasiness it at first occasions, and from the part being frequently rubbed in the act of climbing and descend- ing the chimneys, is often scratched and otherwise irritated : thus a constant stimulus is applied in addition ito the action of the soot on the part. If the head of the wart is picked or rubbed off, another is soon formed, and at length there is not only a horny crust, but a thickened base beneath, proceeding inwards, until a large fungus or Order VI. scirrhus and canger. 724 a spreading ulceration is produced, which at length occasions the testicle also to become affected. Cutaneous cancer is most frequently observed to occupy the lower lip, the angles of the eyes, the alae nasi, and penis. At its commencement it usually appears under the form of a small preter- natural enlargement or elevation of the skin. Sometimes it is so hard to the touch and in consistence as nearly to approach to the nature of horn, while on other occasions it will bear a much nearer resemblance to a common wart. In a few instances it will put on the appearance of a small discoloured pimple. Under whatever form the disease may first appear, a degree of surrounding-hardness will invariably be found to take place. Some degree of shooting pain from time to time is likewise experienced in the part. In many cases ulceration seems to be materially acce- lerated by the accidental irritation of the patient's fingers, which are often although unconsciously applied in the vicinity of the dis- ease. Sometimes, however, a sort of scale is generated so as to form a covering to tbe little tumor, and this will be removed and again be renewed several times in succession before ulceration is "perfectly established. " When the part has once arrived to a state of ulceration, it quickly ^rats on those characters of malignity which have occasioned it to oe classed as a species of cancer. The surface of the sore pos- sesses, indeed, the common appearance of carcinomatous ulceration, and there is a discharge from it of sanious or other ulcerated matter. In cutaneous ulcer it seldom happens that the lymphatic glands begin to enlarge or grow painful till after the diseased part has been in a state of ulceration for a considerable time, which forms a striking point of difference between this disease and that which has fys seat in glandular structures. *-' In a very great number of cases of cancer of the pepis, it has been'remarked, that phymosis had naturally existed ; hence it has been inferred by some surgeons, that phymosis may generate a predisposition to this affection. A review of the cases published by the authors referred to*, and in which amputation of the penis was performed, seems to countenance the opinion that cancer ofthe penis is an affection purely local, and hence less frequently repro- duced Ihan cancer of other parts. Cancer of the tongue, like cutaneous cancer, seems to admit of a pertain degree of variability in its appearance, which is, however, most commonly that of a small hart! tumor situated on the upper surface of the tongue, and at no great distance from its anterior extremity. The tumor usually possesses a firm connexion with tj- M. Vel, 3. ft Cerat. Plumb. Superacet. ^»- Opii in pulv. trit. 3ss. M. ft. Unguentum. Vel, 4. ft Erapl. Plumbi Oxydi-. I" 1. Take Solution Of Acetate of Ammonia^ one ounce. --------Subacetate of Lead, thirty drops. Pure Water, one ounce. Tincture of Opium, one drachm and a half. Mix them for a lotion. Or, 2. Take Camphorated Spirit, half an ounce. Distilled Vinegar, one ounce. Solution of Subacetate of Lead/ one drachm. Tincture of Opium, two drachms. Or, 3. Take Cerate of Superacetate ef Lead; one ounce. Opium, rubbed into a powder, half a drachm. Mix them into the form of an ointment. Or, 4. Take a Plaster of the Oxjrdfof Leafy and apply K to the tumor. Order VI. SCIRRHUS hND CANCER. 729 Hemlock'ts a medicine which, since the days of Stork, has been much employed in every stage of cancer, and there is reason to sup- pose sometimes with advantage. To derive this with the greater certainty, however, we should make use of it during the occult or scirrhous state, and before ulceration has commenced. In admi- nistering hemlock we ought always to begin with a Small dose, and so augment it gradually till the patient experiences some little in- convenient effects on the head and stomach, such as nausea and vertigo, when the quantity is to be lessened, or the medicine wholly be desisted from for a short time. The extract is the most active preparation, and this may be given in pills of two grains each, in the number of from one to ten or twelve in the twenty- four hours. Bella-donna and hyoscyamus are rhedicines of the same class with conium, and the timely use of these has sometimes proved advantageous in glandular tumors and indurations that are likely to become cancerous. Where no advantage seems fo be derived from any of the means which have been advised, but, on the contrary, the tumor is pro- * dSfeding hastily on to ulceration, the only effectual remedy then left is the complete removal with the knife, not solely of the indurated • part, but ofthe whole glandular substance of the breast, so as to secure against a relapse ; and this we should not fail to enforce most strenuously to the patient, provided the tumor is moveable and not attached to bony parts, and its local situation does not render the operation improper. If there be one or more enlarged lymphatic glands in the direction of the axilla, these are also to be cautiously removed. The causes of the failure of operations for the removal of scirrhi proceed either from the constitution having been already involved in those diseased actions which were local in their origin, or from the diseased parts not having been perfectly and entirely removed by the surgeon. All carcinomatous tumors ought therefore to be removed at an early stage when the usual remedies fail in arresting the disease ; and in performing the operation, the surgeon should net be contented merely to dissect away the diseased part from its neighbouring connexions; but a portion even of these should be cut away, so as to secure the patient against a recurrence of the disease. To destroy the living powers of the morbid growth in scirrhous tumors, and to effect its consequent separation from the sound parts which are immediately adjacent, caustic applications, and particularly those composed of arsenic, have been much employed by itinerants and quacks ; but when we seriously reflect on the c 4%nger and uncertainly which necessarily attend their operation, tliey must be held cheap in the estimation of the profession, and a decided preference be given to the knife. As the female breasts are liable to enlargements and induratiorrs 92 730 LOCAL DISEASES. ClaSS IV. from external injuries, exposures to cold during a puerperal state, and such other causes as by inattention might possibly be mis- taken for a scirrhus, it will certainly be necessary in all doubtful cases to scrutinize minutely into the rise of the tumor, the symp- toms and appearances with which it is attended, and the progress that it has made, in order that we may ascertain the real existence of the disease in question, previous to our having recourse to an operation. Where this has been neglected, and the inflammation has pro- ceeded on to suppuration and ulceration, we are then to endeavour to correct the foetor and acrimony of the discharge ; to defend the adjacent parts from its effects ; and to quiet the pain and lessen the irritability of the sore. The first of these intentions is to be answered by washing the ulcer with the dephlogisticated muriatic acid diluted with three times its weight, or more, according to the irritability of the sore, and the smarting it occasions, as recommended by Dr. Crawford ; and then applying a carrot poultice, or one composed of an infusion of malt, oatmeal, and yeast, as directed under the head of Gangrene. Tbe cataplasma carbonis (which is composed of about half a pound of fhe common bread poultice, with two ounces of wood charcoal in very fine powder) is another application which has likewise been found highly useful in sweetening fetid ulcers, and obtunding the acrimony, and may perhaps be preferable to the fermenting cata- plasm, as this, by lying on the part some hours, becomes more of- fensive than the smell it was intended to correct. The charcoal should be taken fresh from the fire, and powdered very fine as soon as cool ; when it is immediately to be put into a bottle and corked, in order that it may not be exposed to the air. The application of carbonic acid gas, or air in its elastic state, has been much used in the ulcerated stage of the disease, and often with a seeming happy effect, as we are informed by Dr. Ewart*, of Bath, who employed it agreeably to the following process :— The neck of a bladder was cut off, so as to make a circular aper- ture in if, of such dimensions as to correspond nearly with the size ofthe ulcer ofthe breast. A round hole ofthe same size was cut Ia a piece of soft leather, spread with adhesive plaster, and large enough to surround the ulcer : the cut end of the bladder was introduced through the hole in the leather, and its edges folded hack, and stuck to the plaster on the opposite side, forming some- what of the shape of a round hat, the plaster resembling the rim, and the bladder, when distended, the crown. In order more effectually to cement the adhesion of fhe bladder to the plaster, and to make it air-tight, narrow circular strips of plaster were applied round their junction both inside and without. The large plaster was then fixed on the mamma, the aperture in its centre>s » See his History of two Cases of ulcerated Cancer ofthe Mamma, one of which ha«- been eared, the other much relieved, by a new method of applying carbonic acid gas. Order VI. scirrhus ai*d cancer. 731 with the bladder attached to it, being placed exactly over the ulcer, no-part of which was touched by the plaster. A small orifice was made at the fundus ofthe bladder, sufficient to admit a tube of about a quarter of an inch diameter, which communicated with tbe top of an inverted cylinder, suspended upon water, which cylinder was filled with carbonic acid gas. The bladder being closely squeezed, to expel from it the atmospheric air it contained, and the above-mentioned tube being inserted into the orifice formed to receive it, and tied by a ligature passed over the bladder, the inverted cylinder was pressed do*n in the water, so that the carbonic acid air was made to rush through the tube and distend the bladder; the tube being then with- drawn, the orifice of the fundus of the bladder was tied, to prevent the escape of the carbonic acid air, which was thereby kept in contact with the ulcer. As often as the bladder collapsed, so as to show that much of this air had got out, it was filled in the same manner as before ; and this operation was repeated sometimes twice, sometimes three times a day, according as it appeared neces- sary. A proof of this simple apparatus fully answering its purpose, was, that tbe bladder, when filled at night, was for the most part found to contain a considerable quantity of its air the following morning. The second indication of defending the adjacent parts from being acted upon by the acrimony ofthe discbarge, is to be effected by the strictest attention to cleanliness, and by dressing or covering them with mild cerates, composed of calamine, or the superacetate of lead: and The third indication, of quieting the pain, and lessening the irritability of the sore, is to be answered by fomenting it with a decoction of poppies, and then applying a cataplasm of hemlock, as likewise by an internal use of opium or hyoscyamus at the same time. If the part affected will admit of it, the tumor should be suspended, so as to keep it as easy as possible night and day. It should be kept neither too warm nor too cold, as both extremes would be injurious. Henbane, nightshade, and others of the narcotic class, have also been employed in external applications as well as hemlock. When used in this way, tbe leaves may be boiled in milk, so as to form a decoction sufficiently strong, and with this the part must be frequently fomented. The gastric liquor of graminivorous animals applied to putrid and cancerous ulcers, has sometimes been attended with benefit. As a topical application in external cancer, such as of the lip, mamma, &c. lint dipped in a solution of the sub-borate of soda* * 5. ft Sodae Boratis, 3i'j * 5. Take Sub-borate ot'Soda, three drachma. Extract. Hyoscyam. 3'j- Extract of Henbane, two drachms. Aq. Distillat. tepid. Jviij. M. Distilled Water made warm, eight ounces. V3t LOCAL DISEASES. Class IV. and applied to the ulcerated surface, renewing it as often as it becomes dry, has not unfrequently been attended with a good effect, occasioning the discbarge to assume a comparatively healthy and purulent appear- ance, the size of the ulcer to be much reduced in a short time, and the pain to be rendered trifling. Applications of a caustic nature have been much used in the ulcera- ted stage of cancer, and they have been employed under a variety of forms; but their principal ingredients are well known to be either arsenic or the oxymuriate of mercury. The most noted are the Arundel powder, Guy's powder, and Plunket's powder*, the last of which is a composition of crow's-foot, dog's-fennel, and arsenic. It is prepared and applied as follows :—the crow's-foot and dog's-fennel being fresh gathered and bruised, the other ingredients are to be added, and the whole beaten into a paste. This is to be formed into balls, and dried in the sun. When used, they are to be powdered, mixed with the yolk of an egg, and applied, on a piece of pig's bladder, to the surface of the cancer. In this state tbe caustic is to remain, till the eschar separates spontaneously. When this remedy is used in cancers of tbe nose or lips, the greatest circum- spection will be necessary, lest a portion of the arsenic should be swallowed. A caustic composed of one ounce of powdered antimony and half an ounce of powdered arsenic, fluxed together in a crucible, and afterwards reduced to powder, was very extensively used by tbe late Mr. Justamond in his treatment of cancers, and often with a most happy effect. By an addition of powdered opium, this re- medy may be reduced to any degree of mildness. Equal parts of white arsenic and sulphur form a caustic application tbat is very powerful. The paste arsenicale is a favourite application of many ofthe most eminent French surgeons in cancerous affectionef. This is compo- sed of seventy parts of cinnabar, twenty-two of sanguis draconis, and eight ofthe oxyd of arsenic, which are made into a powder, and formed into a paste with saliva at the time of applying it. A good method of using arsenic is by mixing about two or three grains of it with a drachm of pulvis calaminae, and strewing a little of the powder on the cancer every day till the whole is destroyed and sloughs off. Whenever caustic is applied, it will be necessary to give considera- ble doses of opium to allay tbe irritation and pain it occasions; and we should also use anodyne fomentations, composed of a decoction of bruised poppy heads. f See Sketches of the Medical Schools of Paris, p. 45, by Mr. J. Cross. * 6. ft Ranunculi Acris Fol. Flammulae Vulg. Fol.fia |j. Arsenic. Alb Lajvigat. 3j- Sulphuris Sublimali, 3v. M. • 6. Take Meadow Crowfoot, Dog's Fennel, of each one ounce. Arsenic, one drachm. Sublimed Sulphur, five scruples. Mix them. Order VI. SCIRRHUS AND CANCER. 733 Arsenic seems to possess in cancer powers which are peculiar and distinct from those of other caustics. If applied to the skin it will not affect it; but if this is abraded, it will produce an eschar to a certain degree, but it will be superficial. When continued for any length of time, the eschar will not be increased, yet the parts beneath the eschar will be found sloughed to a degree and extent proportionable to the strength in which the mineral has been applied : in short, to accomplish this end by the application of arsenic, it is not necessary tbat it should be in contact with the whole of the part it is intended to destroy. Arsenic, besides being applied externally in cancers, has likewise been administered internally, and sometimes with a seeming good effect. Where the practitioner is desirous of making a trial of it, he can give it in a solution, as mentioned under the head of In- termittent Fever. A poultice made with crumb of bread, and moistened with some of this solution, diluted to the proportion of one grain of arsenic to a quart, might probably prove a very good external application, as well as the former, which have been noticed. A saturated solution of muriated barytes, in doses of from three or four to ten or twelve drops twice a day, in any convenient vehicle, has been recommended by Dr. Crawford in cancerous and scrofulous affections. In tbe early stage of cancer, it seems to have been frequently used with some advantage, but never in its last stage. Some cases of cancer were published a little time back by Mr. Carmichael*, wherpin he had employed different preparations of iron with some success, and which under a failure of other means may therefore be tried. For internal use, he is inclined to prefer the sub-oxyphosphate of iron to tbe carbonate, which like all the other salts of this mineral, answers best when given in small doses, and frequently repeated; and he thinks the best manner to exhibit this preparation, is to blend it with white of egg, and to add a small portion of pure fixed alkali, which will render the iron more soluble in the stomach, afterwards forming the whole into pills with a little powdered liquorice. When the carbonate of iron is em- ployed, it may be given in doses of five grains, repeated every four or five hours. Alter trying a variety of cathartics for the purpose of obviating the costiveness which a course of ferruginous medicines is apt to occasion, Mr. Carmichael discovered that aloes answered the best; and moreover thai this cathartic, in combination wilh iron, bas a far greater effect than if given in a more considerable quantity alone. He experienced that half a grain of aloes, combined with four grains of the carbonate of iron in the form of a pill, and taken three times a day, was perfectly sufficient to keep the bowels free and open. " See his Essay on the Effects of Carbonate and other Preparations of Iron upon Cancer. 734 local diseases. doss IV. The preparations of iron which Mr. Carmichael had used exter- nally in ulcerated cancers are the carbonate, the phosphate, oxy- phosphate, acetate, and arseniate. He says, that the best mode of applying these preparations of iron possibly may be to blend tbem with water to the consistence of a thin paste, with which the surface of the ulcer should be covered, and the application in general be re- newed in twenty-four hours. In occult cancers, he has used a solu- tion of tbe sulphate of iron as an external application, and commonly in the proportion of an ounce of the salt to a pint of water ; he pre- fers, however, the acetate of iron diluted with eight or ten times its weight of water. These embrocations are applied by means of folded linen, over which a piece of oiled silk should be placed to prevent the fluid from injuring the clothes. Fro n the use of arseni- ate of iron Mr. Carmichael has also found considerable advantage. It has indeed been doubted, by some practitioners of eminence, if the cases reported by Mr. Carmichael, in which the preparations of iron have been successful, were truly cancerous. We are told, however, by Mr. Denman*, that there is scarcely a class of medicines in the Materia Medica with some of which he has not made repeated trials in all the different stages of cancer, but the benefits derived from the use of any of them have been very little indeed, if compared with those obtained by the use of preparations of iron, and generally that all other medicines have been wholly unavailing. The common effects of iron, when used in cases of ulcerated cancer, are a speedy mitigation of pain, an amendment in the ap- pearance ofthe sore, and the correction of the foetor, with a diminu- tion in the quantity of discharge. Even in hopeless cases it renders the progress of the malady less horrible and distressing, we are told, than when it is treated in any other manner. Carcinomatous ulcers ofthe tongue have been successfully treated by a course of the nitric acid. A case of this nature, where the ulceration was of considerable magnitude, is reported in the 141 No. of the London Medical Journal, which, after having resisted various remedies, was completely cured by nitric acidf. An opiate was given at night, and to prevent the acid from corroding the teeth it was directed to be sucked through a tube. In fourteen days after the exhibition of this medicine, healthy granulations were perceived to shoot out at the bottom of the ulcer, which gradually healed from this time, and in the course of three months, although half the tongue had been in a state of ulceration, it was perfectly healed. Nothing was applied to the diseased part but • See his Observations on the Cure of Cancer, p. 77. t 7. ft Acid. Nitric Dilut. f. |j. MeMis, f. |ij. Aq. Purae, Oij. M. Capiat cochlear, iij. saepe in die. t 7 Take Diluted Nitric Acid, one ounce. Honey, two ounces. Pure Water, two pints. Mil them. Three table-spoonsful are to be taken frequently throughout the day. Order Vl SCIRRHUS AND CANCER. 7S£ a lotion composed of extractum conii, spt. rectificatus et aqua pura, to which little or no efficacy was ascribed. In cancerous ulcers of the face the expressed juice of the carduus tomentosus Linn, (the woody-headed thistle or friar's crown) has been employed with much advantage by the continental physicians, and particularly by Dr. Handel. He ordered his patients lo anoint the parts affected with the fresh juice six or eight times every day, and he found that in the course of a fortnight it checked the progress of a most malignant cancer of the face, but it produced no relief whatever where the female breast was affected with that loathsome disease. In the cancer, scroti, to which chimney-sweepers are peculiarly subject, extirpation bids fair for effecting a complete cure, if done before the virus has seized the testicle and the habit is tainted. A case of this nature sometime ago came under my care, in which the diseased part was removed by ligatures; the patient having been, some months before bis application to me, discharged from the Winchester Hospital, for refusing to submit to an extirpation ef the part with a knife, to which, undoubtedly, a decided pre- ference was due. The cure, however, proved as complete a one as I ever witnessed, although the case was somewhat deplorable, the' patient being far advanced in life, and much emaciated by disease, pain, and poverty. In every species of open cancer, the air should be excluded as much as possible; a covering of double oiled silk may therefore be applied over the dressings. A new process by mechanical pressure has lately been suggested, and indeed practised with some success, for the cure of scirrhus and cancer, by Mr. Samuel Young*, and the means employed by him to effect the pressure have been plaster straps, sheet lead forming shields of various thickness, tin plates, linen compresses, and the use of appropriate rollers. The strength of the application is to be progressive, commencing in most cases with the use of straps only, in some by single, and in others by double layers; the force of theii application controlled by the existing circumstances, and the sensa- tions of the patient. Scirrhus of ihe breast may be specifically com- pressed by the use of the pressure plates, and the adjustment of the linen compress, including at the same time a general pressure of the whole. In cases of open cancer the wound is to be filled with pow- dered chalk, and the surface well dusted with hair-powder, after which the pressure is to be applied as in the case of scirrhus. Irrita- ble parts should be defended by some goldbeater's skin. The beet composition for the straps was found by Mr. Young in equal parts of common strengthening and soap plasters, mixed and spread somewhat thinly on linen. The plaster should be uniformly smooth; and in the application * See Cases of Cancer and Cancerous Tendency successfully treated by Mr. Saraael Voting, Surgeon. 736 LOCAL diseases. Class IV. of the straps, which ought to be long and commanding, it is of the first importance that all wrinkles should be avoided, and that an equal surface of resistance should be given. In the direction of specific pressure on the diseased part all sorts of partial stricture ought to be avoided. The effects produced by Mr. Young's plan of treatment are cer- tified by some other practitioners who have been eye witnesses to ity that there is a very rapid stop put lo the ravages of the disease whether in a state of scirrhosity or ulceration ; the discharges are gradually lessened, and from being of a most acrimonious kind become bland and salutary. Besides there is evidenlly a gradual decrease of the tumefaction and induration, and the whole not only assumes an ap- pearance of amendment, but a promise of recovery. These are indeed very great advantages. In a case which lately occurred at the Middlesex Hospital, Mr. Young's plan of treatment was adopted, aud was found to have ex- ceeded the expectations of the most sanguine. Further experience has not however sanctioned it. FUNGUS H^MATODES, or MEDULLARY SARCOMA. A disease has of late attracted the attention of some surgeons, and has been pretty generally classed and treated as a cancerous affection in whatever parts of the body it may have been known to occur; but although in its history it has some analogy to cancer, still its symptoms and appearances on dissection are so different from those of cancer, that it cannot, I think, with propriety be considered as a disease arising from the same morbid alteration of structure. By some writers* it has been named the fungus baernatodes ; by othersf, the medullary sarcoma ; and others again have given it the appellation of spongoid inflammation. Mr. BurnsJ, who has adopted the latter name, mentions it as appearing only in the superior and interior extremities; but this probably from his not having met with any other cases of it; whereas the other writers describe it as occurring like- wise in tbe ball of the eye, testicle, liver, lungs, uterus, female breasts, and other parts. A great difference of opinion seems to exist between the English and French pathologists respecting the precise application of fungus haematodps. Mr. Roux asserts||, that most of the cases pointed out to him, when in London, as specimens of this affection, were merely a variety of carcinoma, the soft fungous cancer ; not preceded, like the more common form, by a state of scirrhus. He denies the existence of what we call fungus baernatodes as a specific or peculiar malady. The progress of fungus baernatodes, as well as of cancer, is * See Practical Observations on Surgery, by Mr. Hey, of Leeds, 1803. > ; | — General Observations on Fungus Haeraatodes, by Mr. J. Wardrop. of Edinburgh t See Surgical Observations, 1804, by Mr. Abernethy. t See his Dissertation on Inflammation. || Sse his Parallel of Trench and English Surgery. ' Order VI. SCIRRHUS AND CANCER. 737 generally slow. When ulceiafion has taken place neither of them discharge a purulent mailer, but a thin fetid ichor, and occasionally they bleed profusely. They both sometimes assume a fungous ap- pearance, and during their progress contaminate the absorbent glands which are in the course of circulation : they are also equally destructive, communicating the disease to the neighbouring parts, whatever fhe nature of these may be, whether cellular membrane, skin, muscle, periosteum, or bone. Fungus haematodes is generally a disease of early life, whereas cancer is usually confined to those who are advanced in years. Canter, moreover, seems to be confined to a very few organs of the body, and to a lew textures, whereas fungus baernatodes has been detected in parts where no true scirrhous structure has been ever met with. On dissection, fungus haematodes presents a very different series of phenomena from the scirrhous tumor. When it appears on the external parts ofthe body, and has not yet acquired a considerable bulk, instead of being hard and unyielding it is soft and elastic, and has a tolerably equal surface. Its form, when removed from the body, is accurately circumscribed, having generally a distinct covering of condensed cellular membrane. In place of the hard, /fibrous looking substance (the principal component part of scir- rhous tumors) the morbid growth in fungus haematodes consists of a soft pulpy matter, which mixes readily with water, and is some- what hardened by acids, and by being boiled in wafer. It has been compared to medullary matter in consistence and colour. When the skin or covering of fungus haematodes has been eroded in the progress of the disease, instead of the morbid growth being de- stroyed by ulceration, a fungus arises from it, and the tumor seems fo increase more rapidly in bulk. If the fungus haematodes is not interrupted in its progress, both the original lumor and the fun- gous mass growing from it, attain a considerable size, and the 1 fungas, which is of a dark red or purple coloured mass, of an irre- gular shape and of a soft texture, is easily torn, and bleeds . pro- fusely when slightly pressed, or otherwise injured. A want of success has generally attended all efforts in the cure of fungus haematodes in whatever part of fhe body the disease has existed. One successful case of it came however under my care some years ago, during my residence at Guildford, in Surrey. The patient was a man of about forty years of age. The fungus bad attained the size of a small cauli flower, and at times bled pro- fusely. It had been of some months' standing when I first saw it, ^ was of a deep red or purple colour, discharged a fetid, ichorous 'matter, and was seated in the left hypochondrium. The tumor and excrescence were removed by one or two applications of arsenic reduced to powder, and combined with sulphur and opium, and the uound healed up kindly in due tiinetiy the common and usual dressings. About a year after the man was carried off, as I have 738 LOCAL DISEASES. ClaSS IV. since understood, by some complaint seemingly unconnected with his former disease. Where the fungus has a narrow pedicle, and we are enabled to apply a ligature with tolerable ease, possibly it may be most advi- sable to resort to it in the first instance, taking care to make it only of such a tightness as not to cut the vessels, but merely impede their circulation. When the fungus with the surrounding ligature falls off, should any slight hemorrhage ensue, a saturated tincture of galls or some other styptic may be employed to suppress it. Should the surface show any disposition to renew the fungus, the part may be sprinkled with arsenic combined with opium, as before mentioned, which application may be renewed a second time after the-slough is thrown off, if requisite. Op BRONCHOCELE. This disease is marked by a tumor on tbe forepart of the neck, and seated between the trachea and skin. In general it has been supposed principally to occupy the thyroid gland. It is a very common disorder in Derbyshire, but its occurrence is by no means frequent in other parts of Great Britain or in Ireland. Among the inhabitants of the Alps, and other mountainous coun- tries bordering thereon, the Valois, the Valteline, at Lucerne, Berne, Fribourgh, in some parts of Piedmont, in the valleys of Savoy and at Milan, it is a disease which is very often met with, and is there known by the name of goitre. The cause which gives rise to it is by no means certain, but by some writers it has been attributed to a use of snow water. From its having been observed that tbe inhabitants of districts abounding with saline and mineral springs are more frequently af- fected with diseases of this sort than, persons living in other situa- tions, it has been supposed that the waters descending from these mountains, with which the dissolved snow mixes itself, may also/be impregnated with some saline or mineral ingredients capable of pro- ducing this singular affection in tbe throat. Dr. Saunders observes*, that snow water has long lain under the imputation of occasioning those strumous swellings in the neck which deform the inhabitants of many of the Alpine valleys; but that this opinion is not supported by any well-authenticated indis- putable facts, and is rendered still more improbable, if not entirely overturned, by the frequency of the disease in Sumatra, where, ice and snow are never seen ; and its being quite unknown at Chili and in Thibet, though the rivers in these countries are chiefly supplied by the melting of the snow with which the mountains are always covered. Certain experiments have moreover proved, that the * See his Treatise on Mineral Waters. Order VI. BRONCHOCELE. 739 water of dissolved snow is perhaps the purest of any that can be procured. A modern writer*, in his History of Java, mentions, tbat there, as well as in Sumatra, there are certain mountainous districts in which the people are subject to those large wens in the throat termed in Europe goitres, and the cause assigned by the natives is the quality of the water, but that there seems good ground for concluding that it is rather to be attributed to the atmosphere. In proof of this he tells us, tbat there is a village near the foot of the Teng'gar mountains in the eastern part of the island, where every family is afflicted by this malady, while in another village, situated at a greater elevation, and through which the stream descends which serves for the use of both, there exists no such deformity. He also mentions, that these wens are considered as hereditary in some families, and thus seem indepen- dent of situation. The disease in question is evidently of too local a nature to be attributed solely to an habitual use of snow water, nor can it be brought on by using water impregnated with calcareous earth, as some have imaginedy; for the same effects are not uniformly pro- duced where such water is used. A. predisposition to bronchocele is, I think, often entailed by parents upon their children, as well as that glandular affection known by the name of scrofula; which fact is corrbborated by the strongest evidence, as I know a family con- sisting of seven, all of whom were attacked with it before they arri- ved at the age of puberty; the father having been afflicted with it at an early period in life. This family resided at Crondall, in Hampshire, and were the only persons in the place who laboured under it. The predisposition to the disease must therefore have been entailed on the children by the parent. Where we meet with the disease in particu- lar districts, may we not therefore with good reason attribute its fre- quency of occurrence ratber to the inhabitants of those regions being somewhat secluded from the rest of mankind, and intermarrying among each other, thereby entailing the predisposition to it on their offspring, than to any peculiarity in the articles used for diet ?—See Cretinism. In those situations in the vicinity of mountains where the disease i9 found to be endemial, it has been attributed by some to a peculi- arity in the air, and it has indeed been found more generally prevalent among the lower class of people and those who are most exposed to the unguarded influence of the weather, and various changes that take place in the air of such situations. The swelling in bronchocele is at first without pain or any evident fluctuation, and the skin retains its natural appearance; but tfs the tumor increases in size it grows hard and irregular, the skin acquires a yellow colour, and the veins of the neck become varicose ; the face is subject to flushings, and the patient complains • See History of Java, vol. i. page 60, by T. S. Raffles, late governor thereof. i See Cone's Account of Switzerland. im LOCAL DISEASES. Glass TV. pf frequent beadapbs, and likewise of pains darting through the bady ofthe tumor. When the disease is of long standing, and the swelling considera- ble, we shall find it in general a very difficult matter to effect a cure by medicine or any external application; and it might be un- safe to attempt its removal with the knife on account of the enlarged state of its arteries and its vicinity to the carotids; but in an etrly stage rof the disease we may often be able by the aid of medicine to effect a cure, particularly if assisted by frequent frictions over the tumor. Bronchocele has by some practitioners been supposed to be a dropsical affection of the thyroid gland; and it is true that a great number of capsules filled with water have in one or two instances been found in it on dissection, but in general no such appearances are to be observed. In two cases examined by Mr. Benjamin Hell, this gland was evidently much diminished in size from the com- pression of the tumor, which was chiefly composed of condensed cellular substance, with effusions of a viscid brown matter in different parts pf it. To me the tumor appears to be of a steatomatous nature. To treat bronchocele judiciously, I am of opinion we ought at the same time that we give appropriate medicines internajlyy! to employ local remedies, but particularly friction with the hand for at Leas,t half an hour three times a day, the efficacy of which may pro- bacy be assisted by the joint use of such applications* as are calcu- lated to excite the action of the absorbent system. Should the size of the tumor not be diminished after a due time by means of fric- tion, we may.then recommend tbe application of a blister or of a plaster of ammoniacum with mercury. Slight electrical shocks may occasionally be passed, through it. If the tumor is at any tibie highly painful, topical bleeding by means of a few leeches may pruve beneficial. > Possibly pressure on the diseased part might prove a powerfol auxihary. to topical bleeding and tbe other means. Tim medicine which has proved most efficacious internally in' this disease is burnt sponge, and the form under which it is usaaHjft administered is [that of a lozenge. Many persons labouring under bronchocele have been cured by this remedy, some of whom began to suffer much, and to be seriously alarmed on account of the diffi- * 1. R Liniment. Sapon. Comp. Vel, -■ g- Liniment. Camphor Comp. ^i. • ■ , i .. Liquor. Potassae, TTl xx. M. <-. ,...-,!• , I'd,-- - - 3. & Unguent. Hydrargyr. fort. gr. x. Tnwogator supra partemlmnidam omui mane * 1 Take Compound Soap Liniment. Or, 2. Take Compound Camphor Liniment, one ounce. Solution of Potass, thirty drop?. Mix them for an embrocation. Or, 3. Take strong Mercurial Ointment, ten grains. ■ '' This quantity may be rubbad in monn'nt et nocte. I and night o\tr the tumor. Order VI: BRONCHOCELE. 741 c«lty of deglutition and respiration with which their complaints were attended: but whether it cures in a shorter space of lime by being administered in the form of a lozenge, so as to allow of its gradual solution, in preference to being swallowed at once, is a point not yet fully ascertained. .Dr. Cheston, of Gloucester, has found burnt sponge to succeed in various cases when employed agreeably to the annexed formula* and subject to the following regulations, which appear to be an im- provement on the methods recommended in the Coventry receipt under the sanction of Dr. Batesf. When the tumor appears about the age of puberly, and before its structure has been too morbidly deranged, a pill, consisting of a grain or two of the hydrargyri submurias, must be given for three successive nights, and on the fourth morning a saline purge. Every night afterwards for three weeks one of the troches should, when the patient is in bed, be put under the tongue, suffered to dissolve gra- dually, and the solution be swallowed. The disgust at first arising from this remedy soon wears off. The pills and purge are to be re- peated at tbe end of three weeks, and the troches had recourse to as before ; and this plan is to be pursued till the tumor is entirely dis- persed' It appears to me, that we should stand a better chance of effecting both a speedier and more certain cure by administering the remedy more frequently than is here recommended by Dr. Cheston, and likewise in more considerable doses than are contained in the Co- ventry receiptj; for instances have occurred where one lozenge was taken even twice a day for a length of time to no purpose; but when the number was increased to three a good effect was soon evident. The formula inserted below||, is the preparation of calcined sponge, which I have been in tbe habit of employing, and generally with the desired success. Care must be taken that no more syrup be used :than is absolutely necessary to make the dry ingredients cohere; for which reason it must be added slowly, and the mass must be well beaten. The lozenges are to be dried before the fire on a plate that has been slightly oiled to prevent them from sticking, and must be kept in some vessel tied over with bladder. t See the Pharmacopoeia Chirurgica, p. 139. t The quantity of calcined sponge in each bolus is only ten grains. * 4. gj Spongiaj Ustae, 3ss. Mucilag. Acaciae Gummi, q. s. Fiat Trochiscus. (|5-ftSpongiaeUst.3vj. Pulv. Gum. Acaciae, 3j- ----Zingib. 3ss. Syrup. Simpl. q. s. M. ft. Massa in tronchiscos duodecim distribu «nda, quorum unusdetineatur sublinguam donee iiquescati. *4. Take Burnt Sponge, half a drachm. Mucilage of Gum Acacia, a suffi- ciency to form a lozenge. || 5. Take Burnt Sponge, six drachms. Powdered Gum Acacia, one drachm. —------Ginger, half a drachm. Common Syrup, a sufficiency. Mix them, and divide the mass into twelve lozenges, of which one is to be kept under the tongue until it dissolves.. 742 LOCAL DISEASES. Class IV. One of them is to be placed under the tongue morning and night.so as to admit of its gradual solution; and if, after a short time, no ap- parent benefit seems to be derived, the same may be repeated' thrice or even four times a day. Sulphurated potash dissolved in water (in the proportion of thirty grains lo a quart daily) is a remedy which has been employed by Dr. Hichter with success in some cases where calcined sponge failed. Oc- currences of this nature will rarely happen, however, if the disease is counteracted in time. We are informed by the Rev. Joseph Townsend, in his Guide t6' Health, that the disease is very frequent in the vale of Pewsey, and that during thirty years he never failed to cure it in all those who applied to him for advice. He mentions, that he formerly gave lozenges of burnt cork, burnt sponge, and pumice-stone, in equal parts, similar to Mr. Bates's Coventry remedy, and always found this sufficient without any other medicine or application ; but latterly, considering tbat it is the alkali of these lozenges which combines' with the fat collected on the thyroid gland, and making a soap, he has confined himself wholly to burnt sponge, which abounds with soda. Whether burnt sponge administered in the form of lozenge, or swallowed at once, acts locally, and if it acts locally, whether it is conveyed to the thyroid gland by means of absorbents not hitherto ■ discovered ; or whether tbe thyroid gland is a mucous gland, and is'1 stimulated to excretion by the action of this medicine on the neigh- bouring parts, has not been ascertained. Such theories have however been suggested. ■<; From the remedy in question having been so frequently employed1! in scrofulous cases with advantage, I am induced to suppose that its effects are by no means of a local nature. It has been observed, under the head of the last-mentioned dis-' order, that the sodae subcarbonas being the basis of burnt sponge,' is now frequently employed instead of it, and it is indeed a more ' active medicine. In bronchocele it may likewise be substituted instead of calcined sponge, and may be made up into lozengetil in. the same proportion and manner as have been advised with the" latter. -i! The functions of the intestinal canal are to be regulated through- out the course of the disease by some gentle cathartic, such as a few grains of the hydrargyri submurias, joined with rhubarb or jalap. A case is recorded in tbe 13th volume of the Medical and Phy- sical Journal, p. 13, which resisted a long-continued course of burntr sponge, and was at last removed by a slight mercurial course. Under a failure of the means which have been mentioned, it may therefore be right to make a trial of tbe latter, directing a small quan- tity of the unguent, hydrargyr. fortius likewise to be rubbed in over the diseased part every night, as the friction is to be considered as a powerful auxiliary. Order VI. guinea-worm. 743 DRACUNCULUS, or GUINEA-WORM. 'This disease consists in a small round worm, very much re- sembling the string of a violin, and of a white colour all over, except fhe head, which is black, that is discovered in different parts of the body, immediately between the muscles and cellular membrane. The arms, legs, and thighs, are however the most general seats of it, in which parts it is often found of the length of one or two feet. It is a disease chiefly to be met with among negroes that are brought from the coast of Africa, or sailors who are lately returned from thence, and has generally been supposed to arise from drink- ing or bathing in the waters of stagnant ponds or wells, where the animalcules or embryo worms are deposited. It is said also to be a common complaint at Bombay, and all over that part of the coast of India*, particularly during the rainy season. Sir James M'Gregor reports, in his Medical Sketches, that this malady prevailed very much on the voyage from India to Egypt, both among the troops and seamen ; and it was only by separating the sick from the sound, and by a very strict attention to cleanli- ness, ventilation, and fumigation, that he was able to arrest its progress. He by no means, however, attributes its appearance to the water which was drank, as this came from different quarters, Bombay, Ceylon, and Madras ; for the officers of the 88lh regi- ment, as well as the artillery, drank the same water, he mentions, and yet escaped. It is obvious, therefore, that the embryos of the worm must have punctured through the skin, and lodged in it among the men previous to their embarkation. The most probable way, indeed, of accounting for the rise and production of these worms, is by supposing, that in a minute or embryo state (similar to what happens with the chigre) they pe- netrate the skin of persons who go exposed without any covering than perhaps a hat, shirt, or trowsers ; as those who are properly clad, and wear stockings and gaiters, or boots, are never attacked : hence common seamen are liable to them, whilst their officers seldom or never suffer from them. This in my opinion clearly establishes the origin of this affection. Intestinal worms possibly may be produced by an internal use of certain waters, or mucilaginous vegetables, but that those in question can arise from such a cause cannot readily be admitted ; for after being received info the stomach by drinking the water in which they are contained, they must become mixed with the chyle, enter the blood in a living state, and finally be deposited in the cellular membrane and interstices of the muscles, to be afterwards hatched, and produce the living dracunculi. In my opinion they can only be caused by the embryo worms insinuating themselves * See No. xiii. of the Edinburgh Medical and Surgical Jonrnal, p. 151. 744 LOCAL DISEASES. ClttSS IV. into different parts of the body, and having formed a nidus, in due timo* acquire a considerable size. Several persons being exposed to their influence may become diseased, and induce us to suppose that the complaint is of an infectious nature, but which certainly is not tbe case. The patient is usually sensible of an itching in the part or parts at first, and on a narrow inspection a small bladder or blister may often be observed. The Guinea-worm does not produce, however, any acute pain, until it is near a state of maturity, at which period the part in which it is lodged becomes swelled, inflamed, and very painful to the touch, and bears a strong resemblance to a boil which is not much disposed to suppurate. The tumor, after having remained in an indolent state for a considerable length of time, breaks at last, and then the head of the worm may be perceived protruded from the orifice, which continuing to push a little forward every day, may at last be laid hold of with ease. No injurious consequences attend on the disease when properly treated, although, when tbe inflammation is very considerable, there is often much fever present; but by breaking the worm, from being in too great a hurry to extract it, large abscesses and ill-conditioned ulcers are sometimes formed. In a few instances mortification has ensued, and very large sloughs have been cast off; alarming hemor- rhages have also occurred. Frequently after extracting one worm from a patient, a second, or third, or even a fourth will appear ; and after getting one out of the leg, another may be observed in one or both hands, or in the other leg. While the tumor remains in a hard indolent state, it will be neces- sary to keep an emollient poultice constantly applied to it, in order to bring it to a speedy and proper suppuration. When it breaks, and the head of the worm protrudes so far as that it can be laid hold of with ease, a piece of cotton rolled up like a quill is then to be tied to it, and as it advances it is to be daily twisted gently round, until the whole is extracted, using at the same time the greatest precaution that it may not be broken. The wound is then to be covered with dry lint, over which is to be laid a pledget of tow, spread with tbe ceratum resins. We are informed by Sir James M'Gregor that the native practitioners are much more successful in getting out tbe worms than Europeans, After long feeling with their fingers for the body ofthe worm, they" make an incision as nearly as they can judge over its middle, ana pulling the worm by a duplicature of it, draw out both ends at on© time. In the treatment of the Guinea-worm mercurial ointment has been rubbed on the parts affected by some surgeons, and electrical shocks have been passed through the tumors, but without any good effect. An internal use of medicine is necessary only where the inflammatory symptoms run higb, and then cooling purgatives, with the rest of the antiphlogistic plan, must be resorted to. We Order Vll HEADACH. -745 are told by Dr. Chisholm*, that an internal use of mercury is highly necessary ; and in order to destroy the insect or its ova, the remedy must be employed so as to pervade the system. In the many cases which came under my care during my practice in the West Indies, perfect cures were, however, effected without the use of mercury. As the malady has been said to spread from a neglect of cleanli- ness, the greatest attention should be paid to ventilation, and fre- quent washings and fumigations, in all situations where it makes its appearance. Those who may be unavoidably exposed to its in- fluence should bathe often in the sea or some river. ai»teigME|»i«is ORDER VII. DOLOROSl. PAINFUL AFFECTIONS. CEPHALALGIA, or HEADACH. This affection is, in some instances, general over the whole of the head ; at other times it is confined to a particular side ; and now and then cases occur where the pain occupies so small a part, that it may readily be covered with the end of the finger, which has been called clavis hystericus. The causes which give rise to the headach are most usually indi- gestion, foulness of the stomach, the hinderange of a free circula- tion of blood through the head, long exposures to the sun, transla- tions of gouty and rheumatic matter from other parts of tbe body, the stoppage of some long-accustomed evacuation, inebriety, and lastly, too great a determination of blood to (he head. Headach is, however, more frequently a symptomatic affection than a primary one, and often arises in consequence of a fever, or of hypochondri- asis, hysteria, or some other nervous disease. The symptoms which attend on a pain in the head usually vary according to the cause which has produced the complaint. Where a headach is symptomatic of some other disease, it will be likely to cease on a removal thereof, as in the case of fever. Where fhe pain comes on suddenly, is acute, and attended with a noise in the ears, giddiness, and a loss of speech, it denotes an attack of apoplexy or palsy. When it arises in hypochondriacal or hysterical persons, is very acute, and accompanied with much throbbing of the temporal arteries, it is apt to terminate in madness. A headach proceeding from some fixed nervous affection, is diffi- cult to be removed entirely, and the patient is liable to frequent returns of it. Between the head and stomach there is a great sympathy ; where- fore it happens, that where there is a foulness in tbe stomach, the » Seethe Edinburgh Medical and Physical Journal, No. xlh". 94 74(i LOCAL DISEASES. Class IV. head is frequently affected with pain. Where such a cause is ap- prehended to exist, it will by all means be advisable to give a gentle emefic ; and if any costiveness prevails, this should be removed by some proper laxative. Where the disease proceeds from an over-fulness ofthe vessels, or from too great a determination of blood to the head, a proper quantity may be drawn off by opening the jugular vein on the side most affected, or by the application of leeches to Ihe temples ; the patient afterwards taking care to use a spare regimen, to keep hii body perfectly open, and to wear nothing tight about his neck. Those who are of* a full plethoric habit of body, and who are troubled with severe and frequent attacks of the headach, will act prudently in having recourse to scapulary issues. To alleviate the pain at the time, linen cloths wetted in vinegar and water, or in camphorated spirits, may be applied to the forehead and temples. When a headach arises from a translation of gout or rheumatism from some other part, it will be advisable to excite a slight inflam- mation in fhe extremities by the application of small blisters, and at the same time to open the body by administering some stomachic purgative, as the tinctura rhei composita. If a venereal taint is fhe cause of the headach, recourse must be had to mercury, as advised in syphilis. In the headach which arises as a consequence of some nervous affection, the most proper medicines will be valerian, castor, asafcetida, and aether, together with cinchona bark and steeL which may be administered as recommended in hypochondriasis, hysteria, and dyspepsia. Rubbing the temples from time to time with a little aether may also have a good effect. The habit is to be rendered at the same time more robust by gentle and regular exercise every day in the open air; by a diet consisting chiefly of animal food, with a moderate quantify of wine, and by great regularity as to the hours of rest and rising, and likewise of meals. Where a headach is attended with great pain, long want of rest, and a slight delirium, we may venture to give opiates in a consi- derable dose, provided proper evacuations have been premised. Should we have reason to suppose that the headach has pro- ceeded from a stagnation of serum in the vessels, or on the mem- branes of the head, perpetual blisters, issues, and mercurial purges, will then be necessary ; and along with these we may employ err- hines, such as the pulvis asari compositus. In periodical headachs, we are informed by the late Dr. Fowler, t of Stafford, that he experienced the most happy effects from giving the solution of arsenic, as mentioned in the treatment of intermittent fevers. The best way in such cases will be, to begin with about three drops repeated twice a day, and so to increase the number gradually to eight or ten. The extractum bella-donnag has proved singularly successful in a Order VII. TOOTHACH. -741 great number of complaints of the head, whether resembling tic dou- loureux, or partaking of an intermittent form. Small doses of one or two grains, repeated every two hours, during a continuance of the pajp, have been sufficient. Tbe patient should always be apprized of the probable consequences to vision, and the other faculties which may ensue from a use of this medicine.—See p. 751. ODONTALGIA, or TOOTHACH. The toothach consist^ in an acute pain in one or more of the teeth ; but most generally it originates in one, and from that is diffused to ihe adjacent parts. A caries of the tooth itself, acted upon by different irritating causes, such as the application of cold, or some acrid matter, is the most usual cause of this complaint; but in some cases it would seem to proceed from a rheumatic affection of the muscles and membranes of the jaw; and here the whole side ofthe face will be affected. When it takes place in pregnancy, it is to be considered as arising either from an in- creased irritability or from sympathy. It may be presumed, that the acrid matter which occasions the toothach is produced by some vice that originates in the tooth itself. In some instances the caries appears first upon the external surface or enamel of the tooth, in one or more spots which are super- ficial ; but in others it commences in the internal surface, or bony part: the former, is, however, by far the most frequent. The caries, by spreading and corroding deeper, at length penetrates the sub- stance of the tooth ; and the external air, and other matters, get- ting into the cavity, stimulate the nerve, and thereby excite the toothach. The most effectual cure for this disease is extraction of the carious tooth: but as this in some cases may not be advisable, and in others might be strongly objected to by the patient, it will often be necessary to substitute palliative means. To relieve the urgency of pain in those cases where there is an opening made into tbe substance of the tooth by the caries, it is usual to introduce either cotton impregnated with substances of a caustic nature, such as the essential oil of cloves, cajeput, nutmeg, he. toge- ther with sulphuric or other mineral acids, or a small pill composed of opium and camphor. In some instances the actual cautery has been employed to destroy the sensibility of the nerve. To prevent a return of the pain when it has ceased, the hole in the tooth should be widened within by a proper instrument, and then be stopped with leaf gold, or leaf lead, by which operation it may often be preserved for many years without any further inconvenience to the person. These are the remedies and means to be made use of when the disease is confined to a single tooth ; but when the neighbouring ¥4o LOCAL DISEASES. Class IV. parts become likewise affected, or there is no access for such an appli- cation to tbe nerve, in consequence of the tooth having no cavit) in it, other measures are to be adopted. Exciting an irritation in the neighbouring parts, by means of blisters applied behind the ears, or by rubbing -he jaws with some kind of ru- befacient liniment*, and afterwards keeping them warm with flannel, has often afforded much relief, in cases where the pain is somewhat diffused. Promoting an increased excretion from the salivary glands, by means of pungent masticatories, such as horseradish, scurvy-grass, ginger, and pelhtory-root, has likewise been adopted in similar cases with much advantage. In those rheumatic affections ofthe maxillae, to which niany persons are subject under certain states of the atmosphere, and in which the pain is not confined in any one tooth, but occupipsthe whole jaw. tbe pyrethrum has often been peculiarly useful. When the tenderness or tumor of the gums renders the mastication of the root impractica- ble, a piece of lint, moistened in the tincture, prepared a> belowf, may then be applied to tbe mo*t painful part, renewing it as the occa- sion may rpquire ; or one of the pills here J advised may be held in the mouth until dissolved. Washing tbe teeth every morning with a soft brush or piece of sponge dipped in clear water, requently removing the tartar from off them, and making use of some absorbent testaceous powder|| reduced to a very fine consistence, twice or thrice a week, are the best means for preserving the teeth. Where tbe patient is of a * 1. ft Liniment. Ammon. Fort. f. |j. Vel, 2. 3- Spirit. Camphora;, f. |j. Liquor. Ammon. i'. 3"j- Essent. 01. Bergam. tTl *• M. t 3. B; Pulv. Bad. Pyrethri, 3". Spirit Rectif. Oj. Infund. per dies decern et Cola. Postea adde Camphorae, |j. Ot. Rorismarin. f. 3ss- Tinct. Opii, f. 3«j- M. Fiat tinctura. } 4. ft Pulv. Rad. Pyrethri, 3j- Mucilag Gum- Acacia?, q. s. M. Fiant pilulas xij. || 5. ft Bol. Armen. Corn. Calcinat. aa 3'j- M. * 1. Take Strong Liniment of Ammonia, one ounce. Or, 2. Take Camphorated Spirit, one ounce. Solution of Ammonia, three drachms. Essential Oil of Bergamot, fiffeea drops. Mix tbem. 13. Take Pellitory of Spain, powdered, ten drachms. Rectified Spirit, one pint. Let them infuse for (en days, then add Camphor, one ounce Oil of Rosemary, half a drachm. Tincture of Opium,two drachm*. Mix tbem X 4. Take Powdered Pellitory of Spain,on« drachm. Mucilage of Gum Acacia, a suffi- ciency. Mix them, and form twelve pills therefrom || 5. Take Bole Armenic, Burnt Hartshorn, of each twr drachms. Mix them for a dentrifice. ■Older VII. painful affection of the face. 749 scorbutic habit, and the gums inclining to softness and sponginess, they may be washed now and then with what is here* advised. Charcoal reduced to a fine powder is an excellent dentrifice, and by washing the mouth with a little of it diffused in water, ii imme- diately takes away the bad smell from decayed teeth. A lump of the charcoal should be put a second time into the fire till it is red-hot, and when it becomes cool again, the external ashes are to be blown off, and it is to be immediately reduced to a fine powder in a mortar, and kept close stopped in a phial for use. Tinctures composed of mineral acids diluted, and concealed under various artifices and gritty substances, tinged of divers colours, are vended in the shops under pompous names, as denlri- fices; but although they give a whiteness to the teeth, they never- theless prove highly pernicious to the enamel, and ought therefore to be used with great caution. FACIEI MORBUS NERVORUM CRUCIANS, or PAIN- FUL AFFECTION of the NERVES of the FACE. This is one of the most painful chronic complaints to which the human frame is subject ; and although of rare occurrence, still practitioners have now and then the misfortune to meet with it, and to deplore the severe sufferings of the patient and the inefficacy of any aid from medicine. It is the trismus dolorificus of Sauvage, or tic douloureux, by which name it is vulgarly known ; but as the one which has been applied to it by a late writerf is more accurate and expressive of its real nature, I have been induced to adopt it. The term neuralgia fascialis has been employed by % French nosologist of the present day, which indeed indicates with accuracy and precision the leading characters of the disease, an d is at the same time consistent with a correct and philosophic nomenclature. The late Dr. FothergillJ seems to have been the first author who noticed the disease ; since which we have been furnished with some remarks on it by Dr. Haighton, in a paper inserted in the Medical Records and researches, as likewise by Darwin in his Zoonomia. By some it has been supposed to be owing to a can- cerous acrimony, but we may with greater reason attribute it to a diseased state of the nerves of the face or their covering. Its true cause has not however been satisfactorily ascertained, but it is generally supposed that the several ramifications of the second branch of the fifth pair of nerves are the parts chiefly affected by it. t See a Systematic Account of this Disease, by S. Fotbergill, M. D. X Medical Observations and Inquiries, vol. v. * 6. ft Tinct. Cort. Cinchona;, f. ^ij. * 6. Take Tincture of Peruvian Bark, twe ounces. ----Myrrh, f. ?ss. M. --------Myrrh, half an ounce Mix them 759 LOCAL DISEASES. (Mass IV. Rheumatic and gouty irritation may sometimes be the real source of neuralgic affections. The most frequent seat of the affection is the nerves over the cheek-bone, just below the orbit; the alae of the nose, upper lip, teeth, and gums. When this is the case, it will be found to proceed from the second branch of the fifth pair of nerves, the superior maxillary nerve, which passes through the foramen rotuuduin, and whose branches are chiefly distributed to those parts. Sometimes the forehead an 1 temple and inner canthus of the eye, and even tbe globe of the eye itself, are first affected, from the first branch of the fifth pair, the ophthalmic branch being the subject of the disease; and as there are some cases recorded in which tbe patient suffered raicli from an effusion of tears, it might probably arise from that branch of the ophthalmic which goes to the lachrymal gland being the seat of the disorder. Wiien the lower jaw and tongue are affected in addition to the parts already named, the third branch of the fifth pair, or lower maxillary nerve, is diseased. Perhaps as frequently as any of these nerves is the portio dura of the seventh pair diseased; it gives off branches to most parts of the face, and they communicate with several of those of the fifth pair. The distinguishing mark of its being affected is, that besides the parts already enumerated, we find pain in the ear, the mastoid process, and the angle of the lower jaw. The disease is then chiefly confined to tbe fifth pair of nerves, of which most frequently the second branch only is affected, and the branches of the portio dura of tbe seventh pair. From the intimate connexion, however, of most of the branches of these nerves with each other, the disease seldom continues long without extending its ravages; and in very inveterate cases, all the nerves may possibly be affected. The only diseases with which tic douloureux can be confounded are, rheumatism, hemicrania, and toothach. It is to be dis- tinguished from the first of these by a paroxysm being excited by the slightest touch, by the shortness of its duration, and the ex- treme violence of the pain: neither are the symptoms similar, for in rheumatism, if acute, there is fever with redness and increased heat in the affected part, and generally some degree of swelling; if chrunic, the pain is obtuse, long continued, and often increased at night; whereas none of these symptoms usually occur in the mor- bus crucians faciei. From hemicrania it may clearly be distinguished by the circum- stance of the pain in tic douloureux accurately following the ramifi- cations of the affected nerve ; and It may be known from the toothach by the shortness of the paroxysm and the rapidity of its succession, and during the in- terval an entire freedom from all pain; the seat of the pain, and its darting in several directions, according to the particular nerve affected, with an acuteness and poignancy differing from that of the toothach, which seems to strike deep, while the pain of the mor- Order VII. painful aefection of the face. 751 bus crucians faciei is always more superficial and infinitely more lancinating; and lastly, the convulsive twitchings, which though not always present are very frequent, and are never experienced in odontalgia. Neuralgia fascialis commonly arises in persons of a delicate irritable habit at that period of their lives when the bodily strength begins to give way; for the most part between the fortieth and fiftieth year, and is excited into action by exposure to a cold and humid atmosphere, by great fatigue, by external violence, and by uneasiness of mind. Stimulating and anodyne embrocations, blisters, topical bleed- ing by means of leeches, frictions with mercurial ointment*, prepa- rations of quicksilver, particularly the submuriate, given in combi- nation with opium in doses sufficient to exhibit a decided constitu- tional influencef, and electricity, have been resorted to in the pallia- tive treatment of neuralgia fascialis; and the arsenical solutionr extracts of hemlock, hyoscyamus, and opium, in considerable doses, frequently repeated, as well as being applied externally in the form of finiment, the bark of cinchona, and the different medicines usually administered in nervous complaints, have at the same time been given internally with some temporary relief. It appears, however, from the report of a late writer^, that the most certain and powerful remedy which has been employed in this excruciating disease is bella-donna. In many cases recorded by him which were attended by excessive pain, and which had resisted every means before tried, this medicine proved effectual. From two to three grains of the extract, or from twenty to forty minims of the tincture, in any vehicle, were administered every four or five hours during the severity of the paroxysms to adults, but tbe dose was considerably lessened when ease was procured. It appears that the use of bella-donna is, however, accompanied by some distressing symptoms, such as giddiness in the head, impaired vision, numbness, tightness in the chest, arid a sense of dryness in the throat and suffo- cation when given in such doses as lo produce a certain effect; but these soon cease again on diminishing the dose or wholly discontinu- ing the medicine. It appears, then, that bella-donna exercises a striking and powerful influence over those chronicle sympathetic irritations tbat particu- larly belong to the head and face, which harrass and distress the sufferer to an almost interminable length, and which hitherto - had shown nearly an unyielding obstinacy to the power of every other medicine than bella-donna, but which has proved a most potent auxiliary in the cure of this excruciating disease. Besides * Sea vol. iii. p. 272, of the Edinburgh Journal for a case of tic douloureux success- fully treated with mercurial ointment so as to excite a copious ptyalism. t See vol. iv. p. 306, of the same Journal. — vol. vii. p. 381, of the new Med. and Phys. Journal. t See Observations on the Use of Bella-donna in Painful Disorders of the Head and Face, by Mr. John Bailey "752 LOCAL DISEASES. ClttSS IV. its internal use, a tincture of it has been employed as an external application in some cases with advantage. It has been attempted to exterminate this painful affection in some instances by a division of the nerve, and the operation is fully justified by the extreme acuteness of the disorder, and by the con- siderable degree of success that has attended this mode of treat- ment. It is well known, however, that the operation, although a radical cure in the part immediately affected, does not always prevent a recurrence of the pain in the collateral branches of the nerves ; and therefore, previous to having recourse to it, we should consider whether the nerve or nerves can be divided between the- part where the pain originated, and the parts to which it afterwards extended. When this can be done, there will be a probability of opera!ing with success; but when several parts are attacked at the same time, or where the pain extends in several directions from the part primarily impressed, there will be but little reason to expect ad- vantage from an operation. When the portio dura ofthe seventh pair (which is distributed very extensively upon the face under the name of pes anserinus) is the seat of the disease, and which may be ascertained by the patient complaining of a pain that begins in the forepart of the cheek, some- times as high as the forehead, and extends itself in the direction of the ear, no relief whatever can be obtained by dividing the second branch of the fifth pair, as such a division cannot possibly give any interruption to the communication between the scnsorium and the seat of irritation. Paralysing the nerves by the application of cerussa, succeeded in a case* under the care of Mr. Astley Cooper, that had resisted every other remedy, and even the knife. Two scruples of this formed into an ointment were rubbed in the morning on the affected cheek, about an hour before the paroxysm was expected. The application was continued tor a month or more, and the patient (who was a man) left the hospital apparently perfectly cured. The effect of the lead is reported to have been rapid and striking, the person being rendered comparatively comfortable in a short time, from a state of excruciating torment. No particular effect was produced by the cerussa on the stomach or bowels. It has already been observed, tbat tic douloureux is pretty gene- rally supposed to be primarily seated in the nerves of the face; but a modern writer thinks, however, that it has its origin in the brain, to which tbe affection of tbe face merely stands in the relation of an effect. This opinion, he saysf, has been impressed upon his mind by a careful examination of the cases which have fallen under his eyes, in the whole course of which, tbe affection of the face was preceded and attended by clear manifestations of cerebral disease, * See Mr. Bedingfield's Compendium of Medical Practice, chapter xii. t See Practical Illustrations of Typhus and oUier Febrile Diseases, p. 212, by Dr Armstrong. Order VII pain in the stomach. 753 such as pain, giddiness in the head, confusion, or some other un- easiness in the head, more or less disorder in the functions of some ofthe external senses, with symptoms of congestion, or of increas- ed action in the vessels of the brain, and sometimes the stomach and liver were simultaneously or sympathetically affected, a cir- cumstance not uncommon in many diseases of the sensorium. Forcibly struck with the appearances that indicated the seat of the malady in question to be in the brain, the physician alluded to resolved to try the power of decided bleeding, both general and local, and purging. In many cases of a recent nature this plan, we are fold, succeeded without any other aid. In one of much longer standing, the plan was followed up by opium and the submuriate of mercury combined together. The occasional application of a blister either to the scalp or nape of the neck, might be likely, he supposes, to assist the use of purgatives, and the depletion by- general and topical bleeding. From a consideration of all the circumstances attendant on tic douloureux, Dr. Parry* has likewise been induced to attribute this painful affection to increased vascularity, or determination of blood (amounting perhaps to inflammation), to the neurilema or vascular membranous envelope of the fascial nerves, or of the second or superior maxillary branch of the trigeminus. Of course the plan of treatment advised by him is depletion by general and local bleedings. GASTRODYNIA, on PAIN in the STOMACH. This disease often occurs in those who are afflicted with dys- peptic symptoms, such as heartburn, eructations, flatulency, &c. In addition to what has been mentioned of these complaints under the head of Dyspepsia, it may be proper to notice that cardialgia and gastrodynia originate from an inactivity ofthe stomach, whence the aliment, instead of being concocted by digestion, and converted into chyle, runs into fermentation, producing acetous acid. Somelimes the gastric juice itself becomes so acid as to give pain to the upper orifice of the stomach; and it is probable that violent cardialgia is more frequently owing to an increase of the acidity of the gastric juice than to the acetous acid produced by fermenting aliment. The heartburn, as arising from indigestion, is often an afflicting and pertinacious complaint, being not unfrequently attended with an emaciation of the body from the want of suflicient chyle. To obtain a temporary relief we must have recourse fo antacids, calcareous earths, alkaline salts, the aerated alkaline water, or Seltzer water. To check the fermentation in severe cases, we may employ the sulphuric acid in a diluted state, together with a due quantity of brandy or other spirit lowered with water : but for the purpose of procuring a permaneut relief, we should endeavour to strengthen the digestion by the stimulus of a blister externally, and * Sue hi? Elements of Pathology and Therapentics 95 754 LOCAL DISEASES. Class IV. by the use of aromatics, bitters, and chalybeates internally^ as ad- vised under the head of Dyspepsia. The diet should consist of such things as do not easily ferment, such as animal food, shell-fish, and biscuit. It appears by the experiments of Pringle and M'Bride, that the saliva swallowed along with our food greatly prevents its fermentation ; and there- fore dyspeptic persons should be particularly careful in well mas- ticaling what they eat. Flatulency is to be obviated by carminatives and a due observ- ance of the means just mentioned. Perhaps a waistcoat made so tight as slightly to compress the stomach and bowels, might prove serviceable in assisting he digestive process. In gastrodynia attended with acute pain in the organ, we must have recourse to antispasmodics, particularly aether and opium in combination with stomachic bitters and chalybeates. The oxyd of bismuth is a remedy which is reported to have been employed with considerable advantage in gastrodynia—(see Dyspepsia). The proper dose is from three to ten grains, with about twenty five grains of gum tragacantb, repeated three times a day. We had better, however, begin with a dose of three grains, and so increase it gradually. I have myself used it with advan- tage in some cases. SPRAINS. Accidents of this nature happen most frequently in the wrists, knees, and ankles ; and are usually occasioned by a slip, or some sudden effort or violent exertion. Sprains of the tendons and ligaments are usually productive of an immediate painful and inflammatory swelling. In severe sprains there is often not only an increased action of the arteries in the inflamed part, but there is likewise an instantaneous effusion from the rupture of some of the small vessels. In general, we may suppose the effusion to be of the serous kind, as the skin is not altered in colour for some time after the accident ; but it sometimes happens that the tumid parts are either of a deep red or leaden colour from tbe very first, owing to blood being extravasated from the ruptured vessels. In the treatment of sprains, two circumstances are principally to be attended to : the first,, to prevent, by all possible means, the swelling from arriving at any considerable magnitude ; the second, to employ those remedies which are known to be powerful in re- moving inflammation. To answer the first of these intentions, restringent applications, such as vinegar, ardent spirits, and the lees of red wine, may be made use of. By immersing the injured part in any of these immediately on receiving the injury, the effusion will be rendered much less than it otherwise would be, and may perhaps be alto- gether prevented. Plunging the sprained limb into the coldest Order VII gravel and stone. 755 water that can be procured as soon after the accident as possible, is often attended with the best effect, and may be advised as the first step, till one or other of the articles just mentioned can be procured. To answer the second intention, of removing inflammation, we may have recourse to local blood-letting by the application of seve- ral leeches to the tumid part; and if the pain and inflammation do not subside readily, they may be applied again the next day. Should any degree of fever attend in consequence of the violence of the sprain, opiates, together with refrigerants, and the remedies which prove useful ia other inflammations producing fever, ought to ;be administered. In cases where the accident is trifling, or after blood has been drawn off from the part affected, we may apply a solution of the plumbi superacetas or liquor plumbi subacetatis properly diluted, by keeping linen cloths dipped in either of them constantly to it throughout the course of the day. At night, a poultice consisting of oatmeal and linseed-meal mixed up with vinegar, may be laid on. This last, however, will not be essentially necessary, except where much tension and pain are present. With these and such other discutient applications*, proper rest will be necessary for the limb, which never should be kept in a pendent position. Where a weakness remains in consequence of a sprain, pumping cold water upon the part every morning, and wearing a calico bandage for a considerable length of time, as a support to it, will be the best means to pursue. LITHIASIS, or THE GRAVEL and STONE. These diseases depend upon a peculiar disposition of tbe fluids, and more particularly the secretion of the kidneys, to form a cal- * l.rx Liquor. Ammonia; Acetatis, Liniment. Saponis, aa f. |j. M. Vel, 2. g; Liniment. Camphorae, Liquor. Ammon. Acetat. aaf. zj- Tinct. Opii, f. |ss. M. Vel, 3. rj: Ammonia: Muriat. 3'j- Acidi Acetici dilut. Spirit. Rectif. aa Oss. M. Vel, 4- R Olei Succin. Tinct. Opii, aa f. ^ij. Adipis Praepar. 3j- M-. ft. Linimentum. * 1. Take Solution of Acetate of Ammonia Soap Liniment, of each one ounce. Mix them. Or, 2. Take Camphor Liniment, Solution of Acetate of Ammonia, of each one ounce. Tincture of Opium, half an ounce. Mix them. Or, 3. Take Muriate of Ammonia, two drachms. Distilled Vinegar, Rectified Spirit, of each half a pint. Mix tbem. Or, 4. Take Oil of Amber, Tincture of Opium, of each two ounces. Prepared Lard, one drachm. Mix them. To be used as a liniment. 756 LOCAL DISEASES. Class IV. culous matter, and have been supposed to be owing to tbe presence of an acid principle in tbem, termed the uric acid, which seems con- firmed by the benefit derived from a course of alkaline medicines. A long use of fermented liquors, and of wines abounding with tatar, may possibly in some constitutions prove occasional causes of the, gravel and stone. It has also been long supposed that water impregnated with sulphate and carbonate of lime, constituting what is called hard water, predisposes persons to be afflicted with the gravel and stone ; but Dr. Henry, in his excellent thesia, looks upon this opinion as an unfounded prejudice. Instances have been adduced where a stone has arisen from the accidental introduction of some substance in the bladder, thereby forming a nucleus. That a morbidly increased secretion of gravelly matter frequently occurs independent of external causes, we have the most satisfactory proof in the hereditary disposition of many families to this complaint. The real causes of the formation of calculi remain, however, still un- known. An excess of uric acid is generally supposed to be tbe proxi- mate one. Those who are in the decline of life, and who have been raueh engaged in sedentary employments, as likewise those who are much afflicted with the gout, are in general very subject to nephritic com- plaints ; but it is a matter of notoriety that the period of life from in- fancy to about fifteen years, is most subject to the formation of calculi in the bladder, and that the children of the poor are afflicted in a greater proportion than those of the opulent. From the difference in the structure of the urinary passages in the sexes, men are much more liable to them than women. In warm climates we seldom meet with instances of calculous concretions forming of any size either in the kidneys or bladder, as the particles of sand deposited from the urine usually pass off before they can adhere together, owing to the relaxed state of the parts, but in those that are cold they are found frequently of considerable magnitude. A very interesting case is reported by Sir James Earle, in the Philosophical Transactions of the Royal Society for 1809, in which a calculus was found in the bladder larger than any of which, we have an equally well-authenticated account. About ten years after the symptoms of calculus were experienced, lithotomy was per- formed, and the extraction attempted by Mr. Cline, at the par- ticular request of tbe patient. A considerable quantity of fragments was removed, but the great mass of the calculus could not be extracted, and after a few days death ensued. On dissection, the bladder was found entirely filled, and even distended by the stone: it weighed forty-four ounces, and was sixteen inches in length. It seemed to have completely occupied the cavity of the pelvis, and to have projected beyond, and rested upon the pubes. The pelvis of the kidneys and ureters urere much enlarged, and the latter appeared to have been the receptacles of the urine. The stone, on being analyzed, was found to consist of the triple pbos- Order VTT. gravel and stone. 757 phate of ammonia and magnesia, with phosphate of lime mixed with an unusually large quantity of animal matter. A fit of the gravel is attended with a fixed pain in the loins, numbness of the thigh on the side affected, nausea and vomiting* and not unfrequently with a slight suppression of urine. As the irritating matter removes from tbe kidney down into the ureter, it sometimes produces such acute pain as to occasion faintings and convulsive fits. The symptoms often resemble those of nephritis, but tbe deposition of reddish brown sand, or very fine powder of the same colour in the urine on becoming cold, will demonstrate the difference. One of the principal diagnostic symptoms of calculus in the kidney, however, is the dark appearance of tbe urine, as if it were mixed with coffee grounds, evidently depending on broken down particles of blood, proceeding from the obscure but continued irritation of the kidney. When this occurs in conjunction with a dull heavy pain in the loins, there can be very little doubt of the presence of calculus in the kidney. In mere inflammation of this organ, where no calculus is present, the urine does not put on the above appearance. Disordered affections of the prostate gland are those which without proper attention are most likely to be confounded with the stone in the bladder. One mark of distinction which the young practitioner will do well to attend to* is, that in the prostate affection the pain ex- perienced in making water will be always in the commencement of micturation, while on the contrary, it is most usually during the pas- sage of the urine, or when the bladder is nearly emptied, tbat pains and obstructions are perceived in cases of calculus. Another import- ant diagnostic of stone is, that the irritation which it induces does not much affect the general health as the same degree of local disturbance from other causes. The symptoms which attend on a stone in the bladder are a fre- quent inclination to make water, which flows in a small quantity, is often suddenly interrupted, and is voided towards the end with pain in the glans penis. The patient, moreover, cannot bear any kind of rough motion ; neither can he make use of any severe exercise, with- out enduring great torture, and perhaps bringing on either a discharge of bloody urine, or some degree of temporary suppression. With these symptoms he experiences pain in the neck of the bladder, te- nesmus, itching and uneasiness in the anus,frequent nausea, and some- times a numbness of one or both thighs, with a retraction of one of tbe testes. As all attempts to dissolve a calculus in the kidnej's or bladder have hitherto proved ineffectual (whatever certain persons actuated by selfish motives may have alleged to the contrary), we are to consider the disease as capable of being removed in males only by lithotomy; an operation always attended with much danger; but * See Dr. Hebexden's Commentaries ;58 local diseases. Class IV. more particularly so where the patient is advanced in years, the disease complicated with any organic affection of the parts, and the genera] health considerably impaired. Under such circumstances it indeed never should be attempted. In females, calculi of a moderate size, as likewise extraneous substances which have accidentally escaped from the urethra into the bladder, have been extracted therefrom* by gradually distending the former by means of a bougie, observing to increase its size every day until the urethra has become sufficiently distended to allow the intro- duction of a pair of forceps. The knowledge of this fact I have deemed worthy of being recorded, as it may induce many to make trial of a mild mean, instead of resorting hastily to a severe operation. One great advantage of this mode is, that it may be employed as soon as a small stone is discovered in tbe bladder, when it may be ex- tracted with great ease, and at a time tbat a more dangerous, painful, and important operation would be hardly proposed. When the preference is given to a palliative mode of treatment in males, instead of resorting to lithotomy, we must in that case have recourse to lithontriptics. These will prevent the farther accu- mulation of calculous matter. Of the class of lithontriptics, the fixed alkali seems to be tbe most powerful, and has indeed been most generally employed. It may be used both in its causticf and mildj .state. It has been satisfactorily ascertained tbat in the majority of cases the nuclei of calculi originate in the kidneys, and tbat of these nuclei, by far the greater number consist of uric acid : the good effect therefore so frequently observed from the use of alkalies, arises, not from any actual solution of calculous matter, but from the power which they possess of diminishing the secretion of uric acid, and thereby preventing the enlargement of the * See the 138th No. ofthe London Medical Journal, p. 147. — Medico-Chirurgical Transactions, vol. viii. p. 427. I 1. & Liquor. Potassae, fll xij—xx. jusculi cyatho ter in die. Sensim augeatur dosis. | 2. ft Sodas Subcarbonat. 3J—3J- bis terve m die. Vel, 3. ft Potassae Aerati, 3>jbis die in Aquae Distillat. Oss. solut. Vel, 4 ft P'dul. Sapon. gr. i. pro dos. mane et nocte Vel, *. R: Liquor. Calcis Oj. in die cum Lacte Vaccinas permixt. Vel, 0. ft Aq. Supercarbon. Sodae, Oss. bis tti've in die. t 1. Take Solution of Potass, from twenty to thirty drops three times a day, in a tea-cupful of broth. The dose maybe somewhat increased gradually. X 2. Take Subcarbonate of Soda, from one scruple to a drachm twice orthiiceaday. Or, 3. Take Aerated Potass, two drachms, twice a day, dissolved in half a pint of Distilled Water. Or, 4. Take Soap Pills, ten grains for a dose, morning and night. Or, 5. Take Lime Water, one pint in the day, mixed with milk. Or, 6. Take Soda Water, half a pint twice ot thrice a day. Order VII. GRAVEL AND STONEf. 775 calculus, so that while of a very small size, it may probably be voided by the urethra. The alkaline aerated water is a preparation of the mild kind, which has been much extolled for its virtues in calculous and nephritic complaints, and is indeed pretty generally substituted in- stead of the liquor potassae, and other active lithontriptics, the long exhibition of which is commonly attended with injurious con- sequences. The quantity ofthe aerated alkaline water usually taken is about a gill thrice a day, viz. before breakfast, dinner, and supper. When the stomach will bear a greater quantity, an English pint may be taken in a day. If it proves cold to the stomach, or occasions flatulency, a tea-spoonful or two of brandy may be added. Should the irritation of the urinary passages be great, it probably may be of use to take a few drops ofthe tincture of opium with each dose ; but this ought to be discontinued as soon as there is an abatement of the pain. No particular diet or regimen is necessary to be observed while using this medicine, farther than abstaining from acids, butter, and fat meats. Alkaline salts, although possessed of acrimonious properties in their separate state, are nevertheless rendered perfectly mild and inoffensive to the system by combining them with fixed air, as in the aerated water, and they are found by no meas to lose their solvent quality. ^ For the introduction of this water info medical practice, the world is indebted to Mr. Colbourne, of Bath ; since which, its beneficial effects have been noticed, and strongly recom- mended by Dr. Falconer, Dr. Percival, and other writers. When the machine for preparing the aerated alkaline water, invented by Dr. Nooth, is not at hand, a medicine nearly similar may be prepared in the following manner : Dissolve grs. 20 ofthe sub-carbonate of potash in two or three table-spoonsful of water, and add to the solution a table-spoonful of the juice of lemons. This mixture should be swallowed immediately, and is the proper dose, which may be repeated three or four times a day. It may, however, be doubted if the effects of this would be as powerful as the other. The method of preparing the aerated alkaline water with the machine invented by Dr. Nooth differs from that just mentioned, in adding to each pint of water in the middle of the glass of the machine, a quarter of an ounce of the fixed vegetable alkali. The potassa aerata is a preparation somewhat of a similar nature, which is now used at St. Bartholomew's, and other hospitals, as a lithonfriptic, and is given in the dose of two drachms dissolved in a pint of distilled water twice a day. It consists of half an ounce of the subcarbonate of potass, five drachms of dis- tilled water, and one drachm of subcarbonate of ammonia. The potass being dissolved in a water bath, the ammonia is to be added, and when the effervescence is at an end, the mixture is to he set by to crystallize. Dr. Duncan is of opinion that a solution of the super-carbonate 760 LOCAL DISEASES. (Hass IV. of soda in pure water (in the proportion of four scruples to a pint), is preferable to the aerated soda water, on account of the carbonic acid gas not being disengaged on exposure to the atmosphere. On the addition of a small quantity of lemon or tartarous acid, a very pleasant effervescence is produced. The carbonate of soda, by being combined with an excess of carbonic acid gas in this preparation, is rendered not only morp pleasant to the taste, but less liable to offend the stomach ; and Dr. Duncan thinks it is the only form in which the soda can be exhibited in suflicient doses, and for so long a continuance as to derive much benefit from its use in calculous complaints. Where alkalies fail to relieve the increased secretion of uric acid, and to prevent its forming calculi in the kidneys, and where they disagree with the stomach, magnesia has been found* generally effectual, and it may be persevered in for a considerable time without inconvenience, where the tendency to form uric acid remains. Muriatic acid given in doses of twenty or thirty drops three or four times a day, diluted with water, has been found in several cases where gravel was expelled from the bladder, to afford much benefit, and to appease the pain in micturitionf. It is moreover said to have proved a powerful lithontriptic. Tbe constant and uniform effect of the medicine after a few doses, is stated to be the appearance of a considerable quantity of calculous sediment in (he urine. In one instance two ash-coloured concretions were passed from the bladder. In both the fusible and bone-earth calculus it will certainly prove an excellent remedy, but will be of no use in the uric acid calculus, as the reader will observe by perusing a little further. It has long ago been observed, that gravelly or sabulous matter forms a constituent part of all urine : that it is kept in chemical solution in this fluid, and is eliminated by it out of the system. This matter was proved by chemists to be of an acid nature, and to be possessed of peculiar properties. By Scheele it was deno- minated lithic acid, but more significantly by Dr. Pearson, uric acid, as pointing out its origin. The composition of different calculi, however, has been shown to be very different. Dr. Wol- laston has particularly designated four species: 1st, the fusible calculus, consisting of phosphoric acid, magnesia, and volatile alkali, and hence called by Fourcroy the ammoniaco-magnesian phosphate; 2dly, the mulberry calculus, consisting chiefly of the oxaiite of lime; 3dry, the bone-earth calculus, made of pho-phate of lime or animal earth; and 4thly, the uric acid calculus. Calculi ofthe latter kind are, however, of far more frequent occurrenca than the other sorts. The uric acid, or gravelly matter contained in urine, is partly deposited on cooling ; but (unless where it is in * See Observations on this subject in the Philosophical Transactions, By Mr. Brando. t See Memoirs of the Medical Society, vol. v. article 8. aud vol vi. article 80. Order VII. gravel and stowe. 761 unusual quantity) commonly requires for the purpose, one, two, or three days, or tilt a beginning decomposition takes place. The nucleus of a calculus from the bladder is most usually formed of uric acid, proving it of renal origin : more rarely the nucleus is agglutinated ammoniaco niagnesian phosphate. The most rare is the mulberry calculus, frequently consisting throughout of the oxaiite of lime, as has already been observed. Where an ex- traneous body forms ihe nucleus, the surrounding depositions are generally mixtures of the phosphates. Those calculi that are formed of uric acid, are distinguished by their red, or dark yellow colour, being sometimes smooth, but generally rough surface. Those composed of a combination of uric acid, with ammoniaco- magnesian phosphate, are of a pale or grey colour, smooth, not unfrequently crystalline surface. Thuse composed of oxilate of lime are known by the protuberances and irregularities of surface, (whence the name of mulberry calculi) superior compactness, weight, and dark colour. Dr. WoHasion, in noticing four species of calculus, has, at the same time, pointed out the means of distinguishing one from the other, when even a small fragment can be procured for chemical examination*. The uric acid calculus is soluble out of ihe body in very weak alkaline preparations, and also in lime water, but not acted upon by muriatic acid. The fusible calculus is partly soluble in water, highly so in the carbonic acid, and consequently more so in the weakest possible acid impregnations that can be employed ; nothing more being necessary for the purpose than the addition of so many drops of weak muriatic acid as will scarcely impart an acid taste. The moriform calculi are the most difficult of solution, and are not acted upon by alkaline solvents; but Fourcroy found that nitric acid diffused in water, in time dissolves them almost entirely, except the animal matter. The bone-earth calculi are soluble in muriatic acid. In recommending the use of lithontriptics for calculi in the urinary organs, the physician ought therefore to endeavour to ascertain the nature of the concretion wilh which the patient is afflicted. Possi- bly some advantages might be derived, and the solution of a stone in the bladder attempted by means of injections through the urethra, consisting of the substances found to dissolve calculi out of the body, and the operation of lithotomy thereby be avoided. In violent paroxysms of pain recourse must be had to fomenta- tions, consisting of equal parts of the decoction of poppey heads and the compound decoction of mallow, applied externally and internally by clystersf; and where these prove ineffectual, the pati< nt should * See vol. iv. p. 486, and vol. v p. 3C6, of the Medical,and Chirugical Review, for an account of the varieties of the urinary calculi, and the valuable experiments ot Dr. Wollaston and Dr. G 1'carson on the subject. ' 7. ft 01. Terebinth, f. 3j- [11. Take Oil of Turpentine, one drachm. . Ovi Vitell. t\. s. | Yolk of Egg. a sufficiency. 96 "62 •LOCAL DISEASES. Class TV. be put into a warm bath. With these means he should drink plen- tifully of diluting mucilaginous liquors, and take some proper opiate*, which he ma'y repeat according to the urgency of the symptoms. • In cases of gravel the solution of tbe calcareous matter is to be attempted by the same means which have been recommended for a stone in the bladder. In those diseases which arise from a relaxa- tion of the kidneys and bladder, the uva ursif with the alkaline aera- ted water will be likely to prove highly serviceable. Some inquiries by Sir Everard Home into the functions of tbe stomachj, led him to consider, that the generality of calculous complaints might possibly be prevented by introducing into this organ such substances as are capable of preventing the formation of uric acid, and that this mode of treatment would have many advantages over the usual method, which consists i See the Philosophical Transactions for 1810. Miiceantur, et adde Decoct. Avenae, f. |xij. Tinct. Opii, TTV xx.—xl. M. ft. Enema. Vel, 8. ft Decoct. Sem. Lini, f. |xy- Sodae Sulphat. ?ss. 01. Ricini, f. 3«ij —f- ?j- Tinct. Opii, f. 3ss.—f. 3j- M. ft. Enema. * 9. ft Aq Foenicul. f. ^ jss. Liquor. Potassae Subcarbonat. fll xij Spirit. jEtber. Nitrici, f. 3ss. Tinct Opii, fll xij.—xx. M. ft. Haustus ter in die sumendus. MO. ft Pulv. Fol. Uva? Ursi, 3j.—3ss. Aq. Purae, f. |jss. Spirit. Junip. f. 3j- Syrup. Cort. Aurant. f. 3'j- M. ft. Haustus ter in die sumendus. Vel, 11. ft Pulv. Fol. Uva? Ursi, |ss. Pulp. Prun. Gallic, %}. Syrup Althaeae, q 9. M. _ , ft. E'.eetuarium, cujus sumat quant, nucis raoscuatae ter in die. Mix them, and add Oatmeal Gruel, twelve ounces. Tincture of Opium, thirty to sixty drops. Mix them lor a Clyster. Or, 8. Take Decoction of Linseed, twelve ounces. Sulphate of Soda, half an ounce. Caster Oil, three drachms to one ounce. Tincture of Opium, half a drachm to one drachm. Mix them for a Clyster. * 9. Take Fennel Water, one ounce and a half. Solution of Subcarbonate of Po- tass, twenty drops. Spirit of Nitric iEther, half a< drachm. Tincture of Opium, twenty t« thirty drops. Mix them. This draught is to be taken three times a day. 110. Take Powder of the Leaves of Bear- berry, (or trailing arbutes) one scruple to half a drachm. Pure Water, one ounce and a half. Spirit of Juniper, one drachm. Syrup of Orange Peel, t*o drachms. Mix them, and take this draught thrice daily Or, 11. Take Powder of Bearberry, half an ounce. Pulp of Prunes, one ounce. Syrup of Marshmallow, a suffi- ciency. Of this electuary, the bulk of a| jnutmeg may be taken three times a day Order VII. GRAVEL AND STONB. rm in attempting to dissolve the uric acid after it is formed. Magnesia was supposed by Sir Everard Home, from its insolubility in water, to be well adapted to this purpose, as it would remain in the stomach until it should combine with an acid, or be carried along with the food towards the pylorus. Upon putting this theory to the test of experiment, it was found by a very careful examination of the urine, that in several instances where there was an increased formation of uric acid, magnesia diminished it in a much greater degree than had been effected in the same patient by a very liberal use of alkalies. It is indeed now satisfactorily ascertained, that the tendency to form uric acid is best obviated by magnesia, which corrects those stomach complaints connected with the evolution of gravel or stone. If continued, however, beyond the proper maik, an oppo- site evil is generated, viz. a deposition of the phosphates. The preponderances are therefore to be watched, and magnesia and muriatic acid to be had recourse to as either extreme predomi- nates. Carbonic acid is also useful, not from preventing the for- mation of the phosphates, but by holding them in solution in the urine. During an acute fit of the gravel, where nephritis ensues, or is to be apprehended, we should draw off a quantity of blood propor- tionable to the age of the person, after which he ought to be put into a warm bath. When taken out of it, flannel cloths wrung out in a warm infusion of emollient herbs, or bladders filled with warm water, may be applied immediately over tbe part: emollient and anodyne clysters* may be injected frequently, as advised for the stone, and opiatesf be administered repeatedly until the pain and irritation are removed. To assist these means the patient should drink freely of mucilaginous diluting liquors, such as linseed-tea, solutions of gum. acacia;, and a decoction of • 12. ft Decoct. Malvae C. f. |xi. 01. Olivae, f. ?ss. Tinct. Opii, fit xl. M. Pro enemate. t 13. ft Opii Purificat. gr. j. Extract Glycyrrhiz. gr. ij. M. ft. Pilula 4tis vel 6tis horis repetenda. Vel, 14. ft Mucilag. Gum. Acaciae, f. ^ss. Aq. Foenicul. f. ^j. Spirit. ^Stheris Nitric, f. 3ss. Tinct. Opii, fll xij. Syrup. Althaeoe, 3j. M. ft. Haustus quartis horis sumendus. 112. Take Compound Decoction of Mallow, eleven ounces. Olive Oil, half an ounce. Tincture of Opium, sixty drops. Mix them for a clyster. t 13. Take Opium, one grain. Extract of Liquorice, two grains. Make tbem into a pill, which is to be re- peated every four or six hours. Or, 14. Take Mucilage of Gum Acacia, half an ounce. Fennel Water, one ounce. Spirit of Nitric iEther, half a drachm. Tincture of Opium, twenty drops. Syrup of Marshmallow, one drachm. Mix them, and let this draught be taken every four hours. 764 L©CAL DISEASES. Glass IV. barley ; to which may be added a small quantity of tbe nitrate of potass if much febrile heat prevails, or there seems any tendency to inflammation. If the pain and heat in the region of the kidney do not abate in twelve hours, and the pulse remains equally hard and frequent, the ve- nesection may be again repeated. When the pain has somewhat subsided it will be right to give some opening medicine, such as the oleum ricini; but if the stomach should reject this, about two drachms ofthe sulphate of magnesia in linseed- tea, with or without four or five drops of the tincture of opium, may answer tbe intention. Diuretics and blisters would be improper. In local pains, from the stimulus of any extraneous body, as in gravel descending along the ureter, the application of cold on or near tbe part affected may often be used with a very salutary effect. Dr. Darwin mentions a case of this nature where a gentleman who had laboured under excessive and continued pain from gravel in the ureter, found instantaneous relief very frequently in tbe day by applying on the painful part a bag of snow or pounded ice, and suffering it to dis- solve. When these cannot be procured, cold may be generated by allowing aether to evaporate on the part so as to render the vessels torpid or inactive. In cases of renal hemorrhage which are moderate; rest, cool air*, som^ of the acids, vegetable balsams, and sedatives, must be employ- ed : but when the loss of blood is very considerable, alum, superace- tate of lead in moderate doses, and opium, are the surest means of arresting the flow. The diet of those who are afflicted either with the stone or gravel should be light and nutritive, carefully avoiding fermented liquors, wines abounding with tartar, and all acids. Spring or soft water will be preferable to pump water. The alkaline aerated water will be very proper for those who are afflicted either with stone or gravel. From various experiments we seem authorized in concluding, tbat acids are prejudicial, and give rise, in those disposed to these complaints, to tbe formation of gravelly and calculous concretions, by causing a separa- tion and crystallization ofthe uric acid contents ofthe urine within the body. It is indeed a matter of common observation, that calcu- lus and gravelly complaints are aggravated by acid and acescent drinks of all kinds, and tbat alkaline substances alleviate these disorders. Seltzer water has sometimes been employed with much advan- tage in diseases of the urinary organs, especially those which are attended w.ith the formation of calculi. What solvent power it may exercise over these concretions is not yet determined ; but it is certain that under the use of this remedy the mucous, sabulous, and often purulent discharge which accompanies the urine, is rendered less painful ; and in general micturition is much les^ difficult. Order VIII. VLCER. 165 Painful complaints of tbe kidneys and bladder, connected with the formation of a calculus, are said to be much relieved by an inter- nal use of tbe Buxton water, and its use as a bath is found greatly to assist its employment as an internal medicine. Many who have been much incommoded with gravelly complaints have experienced relief by using the garden leek prepared in the following manner:— Take a handful of the roots or fibrous parts, with a few sprigs of fennel, and boil them in two quarts of water over a gentle fire until the half is evaporated ; then pour off the remainder, strain it, and drink about a pint a day. susllft&WOIc. ORDER VIII. DYALYSES. Discontinuity of a part manifest to the sight or touch. —«K3CO*»— ULCUS, on ULCER. In including ulcers among the other diseases it is by no means my intention to interfere with what belongs to the province of sur- gery, and only a few remarks will therefore be made on such as are accompanied by an affection of the system, taking notice at the same time of Mr. Baynton's new method of treating those of an obstinate nature. Ulcers usually proceed from some external injury, such as a wound or bruise, being afterwards kept open by neglect or an improper mode of treatment; or they arise in consequence of inflammation, syphilis, scurvy, or some other disease. When an ulcer is of long standing, and has become habitual, or seems to serve as a drain in canning off some peccant humour from the body, it should by no means be healed up without substituting an artificial discharge in its stead by means of one or more issues, as many have fallen martyrs to imprudences of this nature, but more particularly those who have been somewhat advanced in life. Where an ulcer is of a recent nature it ought to be healed up as expeditiously as possible, with the assistance of precipitate and light bandages car- ried from the foot and ancle upwards. Where the granulations rise above the level ofthe skin, the.sujphate of copper may be substituted, as repressing them, and leaving the surface more disposed for cicatrization. Sir Everard Home recommends the application of rhubarb in these cases, but its powers seem of rather too feeble a nature. To sweeten fetid and foul ulcers, and dispose them to granulate ri-66 LOCAL DISEASES. ClaSS IV. favourably, a poultice composed of half a pound of the common farinaceous cataplasm, and two ounces of wood charcoal, well mixed together, is often employed with a bappy effect. Carrots boiled a sufficient length of time, and then mashed into a pulp, so as to form a poultice of a proper consistence, are also used in cases of this nature with similar efficacy: their power possibly may be con- siderably increased by well washing or fomenting the ulcerated part with the liquor in which the carrots have been boiled. In ulcers requiring to be treated with powerful antiseptic remedies, the cataplasma effervescens ofthe Pharmacopoeia Chirurgica, (as directed to be prepared under the head of Gangrene), will be the most proper application. The powder of the bark of Xanthoxylon (known in the West Indies by the name of Hereules's club) applied to the surface of inveterate ulcers, has lately been found to be a powerful remedy in cleansing and rapidly promoting the healing action after the sloughing process in them has been corrected. In ulcers of long standing, and where the habit of body is vitiated, besides attending to the local affection, it will be right to endeavour to amend the depravity of constitution by administering medicines of an alterative nature, such as the pilul. hydrargyr. submur. compos, a solution of the oxymuriate of mercury, and a decoction of the woods. Where we have reason to expect a venereal taint to be lurking in the constitution, these medicines will be indespensably necessary.—See Syphilis. In the malignant, foul, and fetid ulcers of seamen, warm cataplasms and emollient greasy applications usually produce pernicious effects; but stimulants very ben ficial ones. The remedies of this description from which most advantage is usually derived are diluted rectified spirit, or diluted rum or brandy, weak solutions ofthe nitrate of silver, ofthe sulphate of copper, red oxyd of mercury, he. Lemon juice is strong- ly recommended by Dr. Blane, and is used by navy surgeons with an excellent corrective effect in foul, dark coloured, fetid, or scorbutic ulcers. The dressings to such sores should always be removed at least twice a day. A tight and well applied bandage of calico will greatly contribute to the cure. Where ulcers arise in consequence of scurvy, the remedies advised under that head must be resorted to besides attending to ■ the sores. It not unfrequently happens, tbat a combination of the different *" kinds of ulcer takes place,, and that the callus is attended with a spe- cific morbid action. The latter may be removed, and yet the ulcer may be intractable from assuming the former character. Whatever plan qf treatment be adopted it appears evidently the intention to reduce! the sore to a state of a simple ulcer. Whether in this form, or attended wilh callous edges, the plan of treatment recommended by Mr. Bayuton will be proper. He advises as follows :— The parts should be first cleared of tbat hair which is sometimes found in considerable quantities upon the legs by means of a razor, Order VIII. ulcer. 167 that none of the discbarges, by being retained, may become acrid and inflame the skin, and that the dressings may be removed with ease at each time of their renewal, which in some cases where the discharges are very profuse and the ulcers irritable, may perhaps be necessary twice in twenty-four hours, but which 1 have, (he says) in almost every instance, been only under the necessity of performing once in that space of time. The plaster should be prepared for spreading by melting in an iron ladle over a slow fire four ounces of common plaster of dia- chylon wilh half a drachm of yellow resin : when melted it should be stirred till it begins to cool, and then be spread thinly upon slips of smooth porous calico of a convenient length and breadth, by sweeping it quickly from the end that is held by the left hand of (he person who spreads it, to tbe other end that must be beld firmly by another person, with the common spatula that is used by apothecaries : the uneven edges must be then cut off, and the pieces so prepared cut into slips of from two to three inches in breadth, and of a length that will,, after being passed round the limb, leave an end of about four inches. The middle of the piece so prepared should then be applied to the sound part ofthe limb that is opposite to the inferior part of the ulcer, so that the lower edge of the plaster may be placed about an inch below the edge of the sore, and the ends should then be drawn over the ulcer with as much gradual extension as the patient can well bear ; other slips should be secured in the same way, each above the other, until the whole surface ofthe sore and the limb are completely covered with the plaster at least an inch above and below the diseased part. The whole of the affected parfs should then be defended with a nieces of soft calico, three or four times doubled and very evenly p applied ; and a calico bandage of about three inches in breadth and four or five yards in length, or rather as much as will be suffi- cient to support the limb from the foot to the knee, should be ap- plied with as much firmness as can be borne by the patient, and as much evenness as can be obtained by the attention ofthe surgeon, bypassing it first round the leg at the ancle joint, then once or . twice round the foot, and afterwards up the limb fill if reaches the knee, observing that each turn of fhe bandage should have its lower edges so placed as to be about an inch above the lower edge ofthe fold next below. •? The whole of the parts that are at all affected should then be well moistened with cold spring water poured from a large tea-pot ; and it should, if the parts be much inflamed, pr the discharge either acrid or profuse, be renewed as often as the beat of the parts may indicate, or perhaps at least once iii. every hour. The patient may then fake what exercise he pleases, " as I have," Mr. Baynton says, " been generally told by mine that they have been easier when they walked much ;'" and have generally found that their cures have not been re 76*8 local diseases. Class IV. tarded buf, on the contrary, most times accelerated by their exer- tions in that way ; and I think it will be obvious, that cures which are obtained under such treatment will be much more lasting lhan those that are accomplished in any way where the patient is con- fined to his bed. Mr. Baynton adds, " I have chosen to apply the means here recommended to those cases that have fallen under my care at aa early hour in the morning ; that is, before the oedema has come on which so frequently attends such cases ; first, with a view to restore the tone of the refluent vessels by supporting their sides when in a natural state ; and, secondly, with the expectation of being able to bring the divided edges nearer together whilst the parts are in that situation, and the skin relaxed, than it would be possible to do when tbe parts are distended by tumefaction. " I have also preferred the use of calico to linen, from much experience of its superiority in many respects : it does not subject the parts to that inconvenient and undue stricture that is expe- rienced in the use of linen ; it is more pervious, and consequently prevents the formation of sinuses, which might be occasioned by a complete retention of the discharges, if accompanied by the pressure so much recommended ; it appears to possess more ofthe accommodating properties of the true skin, and by its elasticity is well calculated to yield a little to muscular action, whilst it affords sufficient support to the parts; and, lastly, it is much cheaper. I have before said, that porous calico will be found most useful, and I prefer that which being smooth and free from inequalities, is to be bought at about a shilling a yard, to that which is more expensive, and less pervious. As a bandage, too, I think it much preferable to either linen or flannel ; it is more elastic, soft, and accommodating than the former ; and besides being less cumbrous^ and more cleanly than fhe latter, possesses the additional advan-^ tage of being a much better conductor of that morbid heat which so constantly affects inflamed parts, and which it is essential to re- move." The many cases cited by Mr. Baynton in his tract*,seem clearly to establish the superiority of this method of treatment over every other that has yet been adopted, and to prove that speedy cures may be obtained in the worst and oldest ulcers, of the poorest people, even where the true skin cannot be brought forward so as in any degree fo cover the denuded parts. Mr. Baynton asks, To what circumstances are we to ascribe these facts ? and goes on to say, they cannot surely be referred to the ingredients of the adhesive plaster, to fhe effects of the bandage, to the exercise that is used, nor to any constitutional interferenee, as the same effects have always followed the application of these principles, whether the patients have been young or old, robust or emaciated, temperate or disorderly; whilst ointments, composed * See his Descriptive Account of a new Method of treating old Ulcers of the Legs Order VIII SCALDS AND BURNS. 769 of the same ingredients as the adhesive plaster, bandages, exercise, and all the means except the endeavour to bring the divided parts together, to which it may be supposed ihe cures can be attributed, had been tried in every way in most cases without any such advantages being tained. This question Mr. Baynton answers himself, by referring to Mr. Hunter's doctrine on this subject, which teaches that sores, in their progress of healing, are lessened in their extent, by a contraction of the newly formed granulations, and that this contraction is assisted by the mechanical effects of the adhesive plaster applied in the way just mentioned. Another theory, as to the modus operandi ofthe remedy, has been sugges'ed by Mr. Simmons*, surgeon to the Manchester Infirmary, who approves highly of the employment of adhesive plasters, as re- commended by Mr. Baynton, and seems to consider it as one of the greatest improvements in modern surgery : he has found, that more can be accomplished by it in one week, than could be effected in se- veral accoiding to the old method. l\Jr. Baynton, he observes, considers the efficacy of his plan as de- pending on the endeavour to bring the divided parts nearer together. But whoever attends to its effect, on an extensive old ulcer, on the in- terim part of the leg, for example, will see the impossibility of bring- ing the original skin to approximate. Admitting his facts, the benefit may be produced in two ways: first, by acting as a bandage, giving tone, and removing induration ; and, secondly, by keeping the ulcera- ted surface level with the surrounding skin. The process of skinning resembles the freezing of water, or the crystallization of salts, both of which are facilitated by an even surface, which is essential to the due configuration of the crystals. On the same principle it is, that the ad- hesive plasters are so efficacious. Such are this gentleman's sentiments on the modus operandi of the method proposed by Mr. Baynton, and they seem very plausible. SCALDS and BURNS. In all accidents of this nature, it seems to be of the utmost im> portance to apply a remedy at the instant; for by this means the violent anguish is allayed, and vesication, which in scalds at least is usually so considerable as to lay the foundation for a tedious curative process, is in a great degree prevented. Of the remedies most quickly to be procured on such occasions, plunging the part which has sustained the accident, without a moment's delay, into very cold water, or pumping upon it, is of the greatest service. The transition from torture to ease will be truly rapid. Water is always at hand, and after proper immersions in it for a due length of time, it may be sufficient to cover the injured parts with * See Dr. Duncan's Annals of Medicine for 1797. article the Hthf 07 770 LOCAL DISEASES. Class IV. linen rags moistened therewith, passing over them from time to time streams of air by means of a small tube or bellows, until a sense of freezing or a considerable degree of cold arises. By this simple process, a large piece of skin that has been burned to the appearance of charring, and surrounded by a high degree of inflammation, has been perfectly cured in the course of a very short time, no sloughing or ulceration taking place, but the crust coming off dry, and leaving a sound surface. Of late, tbe application of ice has been much recommended by Sir James Earle and a few other practitioners of eminence. It has long been the practice of St. Thomas's Hospital, in cases -of burns or scalds, to smear the parts well with a feather (lipped in the oily liniment inserted below*; but it seems a very inefficacious application; and I think it will be more advisable to apply line* cloths wetted with either cold water, or what is heref recom- mended, as long as the parts are occupied by heat and inflam- mation. When these subside, the liniment may be used, or we may employ the unguentum cerae spread on fine lint as the dressing. lEther, or rectified spirit, applied in such a manner as to favour its speedy evaporation, and thereby the abstraction of heat, may be still more efficacious than the remedies already mentioned. When there is no exposure from a separation of the cuticle, the aether or rectified spirit somewhat diluted, may be evaporated from the skin, by keeping a piece of thin linen cloth wetted therewith over the parts aggrieved, and moistening it from time to time; but when the injured parts have been deprived of their natural covering, it will be advisable tolay im- mediately over tbem a piece of thin bladder, and then the linen cloth, as before, keeping it continually moist by squeezing a sponge wetted with the evaporating liquid over it. As long as the pain and heat last, this process should be continued; but as soon as the inflammation is subdued, the process of evaporation must be discontinued, lest we should occasion a greater abstraction of caloric than is consistent with health. * 1. ft Olei Olivae, f. ^iij. Liquor. Calcis, f. |vj. M. ft. Linimentum. f 2. ft Spirit. Rectif f. ^ij. Liquor. Calcis, Oss. M- ft. Lotio. Vel, 3. ft Liquor. Plumbi Subacet. f. 35< Spirit. Camphor, f. 3»ij- Aq. Distillat. Oj. M. Vel, .4. ft Liquor. Plumbi Subacet. f. 3j- Aquae Distillat. Oj. Spirit. Rectif. f. ^ssv M * 1. Take Olive Oil, three ounces. Lime Water, six ounces. .Mis them. I 2. Take Rectified Spirit, two ounces. Lime Water, half a pint Mix them. Or, 3. Take Solution of Subacetate of Lead, one drachm. Camphorated Spirit,tbree drachms. Distilled Water, one pint. Mix them. Or, 4. Take Solution of Subacetate of Lead, one drachm. Distilled Water, one pint. Rectified Spirit, half an ounce. Mi* them. Order VIII. SCALDS AND BURNS. 771 To alleviate pain and procure rest, in cases where the injury is ©f an extensive nature, it will be right to have recourse to opiates. When much febrile heat ensues, we should employ gentle laxa- tives and refrigerants; in short, the antiphldgistic plan should be strictly pursued. If the parts become livid and black, so as to threaten the coming on of a mortification, then the cinchona bark and wine, with the other means advised under that particular head, must be resor- ted to. Instead of the application of cold water, ice, and the other soothing means just mentioned, a plan of a directly opposite nature has lately been recommended by Dr. Kentish*. He advises to apply stimulants externally, such as spirits of turpentine, the liquid volatile alkali, and aether so managed as to avoid the cooling process of evaporation. In their application, we are diiected to proceed as follows:-— The injured parts are to be bathed two or three times over with rectified spirit, camphorated spirit, or spirit of turpentine, heated by standing in hot water. After this, a liniment is to be applied on soft cloth, composed of the ceratum resinae, softened with spirit of turpentine. This liniment is to be renewed only twice in twenty- four hours, and at the second dressing the parts are to be washed with proof spirit, or tinctura opii made warm. When a secretion of pus takes place, milder applications must be made, till the cure is effected. To excite the system at the same time, he recommends the inter- nal use of aether, brandy, opium, and other stimulants, which are to be given in proportion to the degree of injury, immediately after the accident, and to be repeated once or twice within the first twelve hours, and afterwards wine or ale till suppuration takes place, when it will be no longer necessary to excite the system. On this mode of treatment so highly spoken of by Dr. Kentish, I have to remark, tbat it requires further experience, and the con- current testimony of other practitioners. Mr. Bell has indeed lately favoured us with some observations!, which tend greatly to recom- mend it. His words are, " The superiority of the stimulating prac- tice is manifested in this; that when the essential oil of turpentine is applied to a scalded or burned part, relief is, in most cases tbat I have seen, produced within half an hour, provided that the remedy is made use of as soon after the accident as possible; nor have 1 observed any case, under the above circumstances, where the pain was protracted more than two hours. " In several slight cases where I have seen cold water made use of, it always required six, and not unfrequently eight hours, to free the sufferer from agony; for the moment the application of cold water ceased, the pain returned with much greater riolence. * See his Essay on Bums. X See Medical and Physical Journal, vol. iii. p. 208. 772 Lec\L diseases. Class IV. He adds, " I recollect a case whic-.. an eminent surgeon in Newcastle, Mr. Anderson, communicated to Dr. Kentish more than two years ago, and which is most decidedly in lavour of what is here advan- ced. A lady had both her arms severely scalded with boiling water, from above the elbows down to the finger ends. The ol. terebinth. was applied to one arm soon after the accident, and the other plun- ged into cold water, which was renewed as often as it became warm. That arm to which the ol. terebinth, was applied, became perfectly easy in about half an hour; the other continued to give pain, when taken out of tbe water even for an instant, for more than six hours: and, as far as I recollect, it required a much longer time for its cure than the other." By further information from Dr. Kentish*, we are given to un- derstand that the faculty in his neighbourhoodf have almost all adopted his mode of practice on the fullest conviction of its efficacy. It appears likewise that Mr. S. Hammick, jun. of the Royal Naval Hospital at Plymouth, has favoured him with his opinion of its su- perior merit to every other means used in that extensive institution, where he has an ample field for experiment, from the frequent explosions of gunpowder on board his Majesty's ships. His words are, " I am decidedly of opinion that the practice of applying im- mediately to burns the spirit of turpentine, is the best I have ever yet seen adopted, as the process to suppuration is, in general, more rapid, and those irregular marks, or seems, found after other applications, re not to be met with after the turpentine ; neither is the skin so disposed to crack, or break open again, as was formerly too often the case, producing the most troublesome and irritable sores." In Dr. Kentish's second Essay on Burns, in which he attempts to refute the opinion of Sir James Earle, on the supposed benefit of the application of ice in sueh accidents, a number of additional proofs are brought forward to establish the superiority of his sti- mulant mode of treatment over that of cold applications. In the detail of practice he has however been induced to make some alte- rations from his original plan, notwithstanding that he therein pursues the principle of treatment recommended in his first Essay. His words are, " In the first species, where the action of a part only is increased, I have not found any thing better for the first ap- plication than the heated ol. terebinth, and the digestive thinned with the same. In superficial burns, when the pain has ceased, it will be advisable to desist from this application in about four- and-twenty hours, as that time, in many cases, will be sufficient, and at the second dressing, a digestive sufficiently thinned with common oil, will be adequate to tbe case, and on the third day to begin with tbe ceratum calaminae. I have frequently seen se- condary inflammation excited by the remedy, which in tbe first * See Medical and Physical Journal, vol. iii. p. 262. t Newcastle-upon-Tyne. Order VlH. scalds and burns. 773 instance puzzled and perplexed me considerably. I have likewise been informed of this consequence by several gentlemen. The most certain remedy for this unpleasant symptom is to apply a plaster with digestive, thinned with oil, or a plaster of cerate, and over that a large rvarm poultice. This most effectually fakes off the irritation of the part, and the cerate will finish the cure. Should there be much uneasiness of the system, an anodyne pro- portioned to the age of the patient should be given." Mr. Parkinson, of Leicester, is another advocate for the stimu- lating plan, and speaks highly of the efficacy of rectified spirit in relieving the pain and inflammation occasioned by burning or scalding any part of the body*. The mode of treatment he re- commends is to cover the parts with pieces of bladder, softened by dipping them in warm water, keeping the outer surface con- stantly wetted with the spirits. He mentions, that the pain usually ceases in half an hour, but in deep and extensive burns the appli- cation must be continued for twelve or twenty-four hours, at the end of which lime the inflammation will be found to be entirely removed. To heal the ulcer, a cerate of wax and oil may be applied. In the second volume of Medical Facts and Observations, the late Mr. John Hunter has stated the communications of an eminent brewer at Edinburgh (Mr. David Cleghorn) on the subject of burns and scalds, which accidents have been very successfully treated by applying vinegar. The good effects of vinegar in these cases Dr. Kentish is inclined to attribute to the alcohol it contains. Between the advocates for the adoption of a cooling treatment and those who recommend a stimulating one, there seems indeed a perfect opposition both in theory and practice. My opinion is, that the cooling treatment will be most advisable while the sen- sation of heat and pain exists ; but when these are removed, and symptoms of debility occur, or when they primarily appear, I think fhe stimulant plan ought to have the preference. Much certainly depends on the constitutional variety of the subjects, as well as on the different stages or degrees of the acci- dent. Perhaps if no other inconvenience than a slight vesication of the injured parts is sustained, no remedy can be more aptly resorted to than the refrigerant application of cold water: but when the integuments are so burned that the cuticle is entirely destroyed, and the parts are affected with great vesication and pain, and there is at the same time inaction in the system, with symptoms of irritation, then the stimulant qualities ofthe terebin- thinate application will certainly be preferable, as the sedative effects of cold under such circumstances might extinguish the vital principle. * Sre Memoirs of tiie Medical Society, vol. v. article 7. 774 local diseases. Class IV* HERPES. HerpEs consists in an eruption of broad itchy spots dispersed here and there over the skin, of a whitish or red colour, which at length run into each other, discharge a thin serous fluid, and either form extensive excoriations or ulcers. After a certain time scurfy scales appear, which peel off, and leave the under surface red ; the same appearances are, however, renewed in a successive series, till the disease is either cured, or goes off spontaneously, which is indeed rarely the case. Being a complaint confined to the skin, it seldom happens that the general health suffers any great change. Its causes may be referred to a want of cleanliness, a low diet, and a damp situation ; but certain constitutions seem nevertheless particularly predisposed to herpetic eruptions. The best remedies for these eruptions are ointments prepared from the oxyd of zinc*, and the white precipitate of mercury, with a small quantity of hydrargyri oxymurias, and lard, making use at the same time of lotions somewhat of a similar nature, as recom- mended in psora ; or as here prescribed!, being somewhat similar to the nostrum sold under the name of Gowland's lotion. I have frequently found a strong decoction of the fresh leaves of digitalis to be a very good wash for herpetic eruptions of a troublesome and extensive nature. Where the disease is inveterate it may be necessary to have recourse to the internal use of medicine, such as pills of the submuriate of mercury and antimonyj, a solution of hydrargyri * L ft zinci Oxydi, 3ss. Adipis Praeparat. xj. M. ft. Unguentum. Vel, 2. ft Unguent. Hydrargyr. Praecipit. Alb Vel, 3. ft Unguent. Hydrarg. Nitratis. I 4. ft Amygdal. Amar. Decort. ^ij. Contunde in mortario mannoreo, dein bene terens graditim adjice Aq. Distillat. Oj. et Cola. Liquori colatas adde Hydrargyr. Oxymur. gr. xij. in Spiritus Rectificat. f. 3'j- Prius somt M. ft. Lotio. *, 5.ft Hydrargyr. Submuriat. Antim. aulphuret. Pracip. aa 3j. Guaiac. Gummi Resinae, 3'j- * 1. Take Oxyd of Zinc, half a drachm. Prepared Lard, one ounce. Mix them. Or, 2. Take Ointment ot the White Precipi- tate of Mercury. Or, 3. Take Ointment of the Nitrate of Mer- cury. t 4. Take Ritter Almonds, blanched, two ounces. Bruise them in a mortar, then gradually add Distilled Water, one pint. Strain the liquor, and make an addition to it of Oxymuriate of Mercury, twelve grains. Which has been dissolved in Rectified Spirit, two drachms. Mix them together for a lotion. } 6. Take Submuriate of Mercury, Precipitated Sulphur of Antimony, of each one drachm. Guiaicum Resin, in powder, two drachms. Order VIII. SCALLED head. 115 oxymurias, the liquor arsenicalis in the dose of six drops three times a day, increasing it gradually to twelve or fifteen; a decoction of elm-bark, sarsaparilla, or guaiacum, or the mineral acids*, together with a vegetable and milk diet, at least avoid- ing all salted meats. Some gentle aperient may be taken occa- sionally. A severe case of herpes lately came under my observation which> had resisted various means, but which was at last perfectly removed in a comparatively small period, by giving the patient twenty drops of tbe oxygenated muriatic acid internally three times a day, gradually increasing the dose ; using at the same time frequently throughout the day, a lotion composed of two drachms of the solution of potass in a pint of water. Its strength was at last augmented to three drachms. The effects of a tepid bath in promoting the natural excretions by the skin, render it very serviceable in curing herpetic eruptions : indeed in all cases of cutaneous foulness it will be found a most important aux- iliary to internal remedies. A bath prepared from, or saturated with the sulphuret of potass, has been employed with great success in the cure of herpes. TINEA, on SCALLED HEAD. This disease consists in a chronic inflammation of the skin of the head, productive of a secretion of matter peculiar in its nature, and capable of propagating the complaint, if applied to the scalp of a healthy subject. At first the eruption is confined, probably, to only a small portion of the head ; but by degrees its acrimony is extended to the neighbouring parts, and at length the whole of the scalp is eroded, and beset with a scabby eruption. Dr. Willan has Bals. Copaib. q. s. M. Fiant Pilul. Ix. Capiat j.—iij. omni nocte hora decubitus. Vel, 6. ft Pilul. Hydrargyri, Pulv. Antimonial. aagr. ij, Opii, gr. ss. Syrup. Simpl. q. s. M, ft. Pilula omni nocte sumenda. * 7. ft Acid. Sulphuric, f. 3ij. Aq. Fontan. f |jss. Post efferves- centiam adde Syrup. Simpl. f. 3>j- M. Capiat f. 3j. vel f. 3'j- D's terve in die ex Aquae Purse cyatho. , Balsam of Copaiba, a sufficiency to form the mass. Let sixty pills be made out of this1, of which from one to three may be taken every night at bed-time. Or, 6. Take Mercurial Pill, Antimonial Powder, of each two grains. Opium, half a grain. Syrup, a sufficiency to form a pill, which is to be taken every night. * 7. Take Sulphuric Acid, two drachms. Add gradually Pure Water, one ounce and a half. After the effervescence has ceased, make an addition of Common Syrup, two drachms. Mixthem. Of this let the patient take from sixty to one hundred and twenty drops twice or thrice a day in a tea-cupful of water. 776 LOCAL DISEASES. Class IV. substituted the term porrigo for that of tinea, as being less objectionable, and considers this genus as consisting of several varieties*. Children are principally affected with it, particularly those of the poor; hence it evidently arises from uncleanliness, from the want of a due proportion of wholesome nutritive food, and possibly from bad nursing. At any rate these will very much aggravate the disease. In many instances it is propagated by contagion, either by using a comb imbued with the matter from the head of a person labouring under it, or by putting on his hat or cap. When prop.-r means are early adopted the disease seldom proves difficult of cure. The treatment consists in shaving the head close, and afterwards covering it with an ointment made of sulphur and pitch, or muriated mercury and pitch, previous to the daily application of whichf it may be washed with a little of either of the lotionsj here advised. If these should fail we may substitute astringent or stimu- lating applications, paying a cautious attention at the same time to the 5"nf»ral health. As a covering for the head we may use the oiled silk cap. in those scurfy eruptions of the head which are observed in chil- dren, and where a thin ichor pervades the cuticle and excoriates the parts, the application of a little of either of the ointments marked * See his Treatise on Porrigo and Impetigo. t 1. ftPicis. Liquid. Oss. Cera; Flav. ?ss. Sulph. Sublimat. ^ij. Solv. ft. Unguentum. Vel, 2. ft Unguen. Picis Liquid, ^ij. Hydrargyr. Oxymuriat., gr. vj M. ft. Ungueutum. Vel, 3. ft Unguent. Pic. Liquid. |i. ------Hydrargyr. Nitrat. |ss. M X 4. ft Tabaci. 3«j. Aq Fontan. Oj. coq. ad Oss. el Colatura; adde Liquor. Potassa: Subcarb. f. 3j- M ft. Lotio. Vel, 5. ft Potassa; Sulphuret. ^ss. Liquor. Calcis. Oj. Liniment. Saponis Comp. f. ^j. M (6. Lotto: f 1. Take Tar, half a pound. Yellow Wax, half an ounce. Sublimed Sulphur, two ounces. Mix them over a lire. Or, 2. Take Tar Ointment, two eunces. Oxymuriate of Mercury, six grains. Mix them. Or, 3. Take Tar Ointment, one ounce. Ointment, of Nitrate of Mercury, half an ounce. Mix them. X 4. Take Tobacco, two drachma. Pure Water, one pint. Boil it down to half a pint, strain off the liquor, and add to it Solution of Subcarbonate of Po tass, one drachm. Mix them for a lotion. Or, 5. Take Sulphuret of Potass, half an ounce. Lime Water, one pint. Compound Soap Liniment, ojh ounce. Mix tbem. Order VIII. SCALLED HEAD. 777 thus* will be found of considerable utility, and will indeed seldom fail of effecting a radical cure. It should be applied every night, covering the parts wiih a bladder or linen, and again be washed off in the morning wilh soap and water. In the cure of tinea capitis, cutting off the hair as close as possi- ble, well washing the parts with warm soap and water, and afterwards sprinkling them pretty thick with powdered charcoal night and morning, has proved very efficacious. For the removal of tinea capitis many of the French surgeons after applying emollient applications to remove the scabs, have then recourse to shaving the head, which is repeated every two or three days, applying daily an ointment composed of the hydro- sulphuret of potass : others, after the application of a poultice, resort to an ointment made of caustic potass, mixed with lard or oil, which in a few days makes the hairs fall off, or allows them to be pulled out with little force and without pain. When the hairs have been removed by fhe caustic application and the cure effected, they grow plentifully again. The hairs are only taken off by the caustic application in those patches where the tinea existsf. Besides these external applications, it may sometimes be neces- sary to administer alterative medicines;"; at the same time. The doses must be varied according to the age, constitution, &c. of* the patient ; and if acidity abounds in the primae via;, some absor- bent, such as the creta praeparata, or magnesiae carbonas, ac- cording as the bowels may be more or less affected, should be t See Sketches ofthe Medical Schools of Paris, by Mr. J. Cross. * 5. ft Hydrargyr. Praecipitat. Alb. 3j. Plumbi Superacet. 3ss. Unguent. Hydrargyr. Nitratis, 3 ft. Lotio. || 7. ft Hydrargyr. Praecipit. Alb. 3j- ——----Submur. 3ss. Sulphuris Sublimat. Z»j- Adipis Praeparat. ^ij- M. ft. Unguentum omni nocte bora decubitus applicandum. * 1. Take Oxymuriate of Mercury, six grains. Muriate of Ammonia, ten grains. Distilled Water, twelve ounces. MU them for a wash. Or, 2. Take Oxymuriate of Mercury, ten grains. The Yolk of an Egg. Prepared Lard, two ounces. Make these into an ointment. t 3. Take Sulphuric Acid, half a drachm- Prepared Lard,one ounce. Mix them, and use this as an ointment. X 4. Take Powder of White Hellebore, one ounce. Prepared Lard, four ounces. Mix them for an ointment. Or, 5. Take White Hellebore Root, bruised, one ounce. Pure Water, two pints. Boil it down to one pint, and add to the strained liquor when cool Rectified Spirit, two ounces. Mix them, and use this lotion frequently. Or, 6. Take Decoction of White Hellebore, twelve ounces. Oxymuriate of Mercury, twelve grains. Muriate of Ammonia, one drachm. Mix them for a lotion. || 7. Take White Precipitate of Mercury, one drachm. Submuriate of Mercury, half a drachm. Sublimed Sulphur, two drachms. Prepared Lard, two ounces. Mix them, and let some of this ointment be rubbed in every night about bed-lime. 780 local diseases. Class IV. That species of the itch which consists in small ulcers in the skin is readily cured by an internal use of the acid of sulphur, which increases the cutaneous absorption. The external applica- tion of sulphur, mercury, and acrid vegetables, acts on the same principle. In that species of tbe disease which has been denominated psoria- sis diffusa, the most beneficial effects have been derived from exhibit- ing the liquor arsenicalis, using warm bathing at the same time. The dose may be six drops three times a day, increasing it gradually to twelve or fifteen. Such as are afflicted with the itch should be debarred the use of high-seasoned dishes, salted meats, fish of all kinds, and heating liquors; their diet consisting principally of vegetables and milk, with a small proportion of animal food. They should shift their linen frequently, and pay the greatest attention to cleanliness. When the unguentum acidi sulphurici is used, the parts to which it is applied should be covered with flannel instead of linen, on account of the destructive effects of the acid on vegetable substan- ces. In a paper read to the Medical Society at Paris, a new method of treating the itch has been proposed by Mons. Jadelot, of the L'Hopital des Enfans Malades, which is by employing a bath pre- pared by adding to twenty gallons of water heated to about 98 of Fahrenheit's thermometer, four or five ounces of the sulphuret of potass. This bath is to be used once every day for five or ten days successively, according to the severity of the disease, the patient remaining in it nearly an hour each time. If used twice as often, bad cases may be cured in four or five days. Considerable advan- tages are regarded by Mons- Jadelot as attached to this plan, which is much adopted in tbe French hospitals*. The disease, he thinks, will be more expeditiously removed and the rure more certain. It is less offensive, because the linen is not soiled with ointment, no sulphu- reous exhalation takes place from the patient, and the general habit is less impaired. Fumigation has also been employed at Paris, by Dr. Gale, with success in the cure of psora, and this mode he prefers to all others, particularly in very bad cases. The fumigation is produced by throwing half an ounce of sulphur mixed with two drachms of nitre * See Sketches of the Medical Schools of Paris, by J. Cross, p. 175. Vel, 8. ft Hydrargyr. Praecipilat. Alb. 3'j- Plumbi Superacetat. Potassae Subcarbonat. aa gr. x. Adipis Praeparat. ^ij. Essent Bergamot. fll xx. M. it. Unguentum. Or, 8. Take White Precipitate of Mercury. two drachms. Superacetate of Lead, Subcarbonate of Potass, of each ten grains. Prepared Lard, two ounces. Essential Oil of Bergamot, twenty drops. Mis them for an ointment, and use it in the same manner as the former. Order VIII. RING-WORM. 781 into a warming-pan of hot coals, which is to be employed in the usual manner of warming a bed. The patient is then to strip naked and get under the clothes, which are to be closely tucked round his neck and shoulders, so as to prevent as much as possible the escape of the gas. The process is continued about seven nights, and even the worst cases may be cured in this way, Dr. Gale says, without any inconvenience to the patient, who will usually sleep sound. IMPETIGO, on RING-WORM. This is a cutaneous disease, chiefly occupying the scalp, but some- times other parts of the body, and arises most frequently from coming in contact or using the same comb, cap, or bat, with those already affected by it; but in some habits there seems a predisposition to it. It is a disorder more frequently met with in warm climates than in cold ones, is of a very contagious nature, and in inveterate cases is very difficult to eradicate. It shows itself in small red pimples, which break out in a circular form, and contain a thin acrid fluid. When the body is heated by exercise these itch intolerably, and upon being scratched discharge their contents, which by falling on the neighbouring parts spread the disease to a considerable degree. The original size of the circle form- ed by the pimples is usually about that of a sixpenny piece; but in pro- cess of time it will become, by neglect, as large as the palm of the hand. In some cases the disease is so universal that the habit becomes tainted; the skin puts on a leprous appearance, is much disfigured with blotches, and the unhappy patient enjoys not a moment's ease from the intolerable itching and painful excoriations. Where the disease is not of an inveterate nature it may easily be removed by washing the parts affected with some kind of astringent lotion*; and where this fails, recourse may be had to the remedies ad- vised for the cure of herpes. The application of mushroom catsup to the pimples is reported to be a very efficacious remedy. A poultice of the flowers of the ring-worm bush, French guayava tree (cassia alata), is much employed in the West India islands, as are also lime juice and gunpowder. It seldom happens that an internal use of medicine is necessary. Where the disease is very inveterate, some gentle alterative, such as the pilul. hydrargyr. submur. compos, with a decoction of the woods, may probably be most proper.—See Herpes. 1. ft Zinc. Sulphat. 3ss.—3i. * 1. Take Sulphate of Zinc, half a drachm to a drachm. Plumbi Superacet. gr. xv. Superacetate of Lead, fifteen grains. Aq. Distillat. f. *vj. M. Distilled Water, six ounces • Mix them for a wash. >7o*i LOCAL DISEASES. Class IV. Many of the schools in the vicinity of London, and indeed through- out the whole kingdom, have of late been much annoyed by the ap- pearance of this disease among their youth under a very inveterate form, and chiefly occupying tbe scalp. This peculiarity is owing, no doubt, to using the same comb for the infected and the healthy ; and in this way it may very readily be communicated. By an inattention to this circumstance, I was once a witness of the disorder being very ge- nerally propagated through a large school of boys. They were in fact inoculated with the teeth of the comb imbued with matter from the head ofthe boy who was first affected, and who was an Indian or Creole lately arrived from the West Indies. A modern writer* has treated on this disease under the name of tinea capitis contagiosa, but in my opinion it is distinct from tinea. The ring-worm generally appears on the head in a small circle of redness, which increases in diameter by degrees, and contracts a bran- ny scurf, the hair separating at the roots from tbe slightest touch. After one circle has made its appearance, other similar circles may be expected soon to show themselves, till they reach one to another, and at length occupy the whole ofthe scalp. Unless proper means are resorted to in time, glandular swellings will ensue, and sometimes ul- cerations. When the scalp is much affected, the treatment to be adopted should be to shave the head every four or five days; to bathe it twice or thrice a day with a lotion of the sulphate of zinc ; and to apply every night a little of the unguentum hydrargyri nitratis, washing this off again the next morning with warm water and soap and a bit of flannel. In inveterate cases, where glandular swellings or ulcerations attend, we may advise alteratives internally, such as the hydrargyri sub- murias. ACNE, or BLOTCHED FACE. According to Dr. Willan's arrangement, acne belongs to the Order Tubercula, and the genus is characterized by an eruption of distinct, hard, inflamed tubercles, which are sometimes per- manent for a considerable length of time, and sometimes suppurate very slowly and partially. They appear on the face, especially on the forehead, temples, and chin, and sometimes also on the neck, shoulders, and upper part of the breast; but never descend to the lower parts of the trunk, or to the extremities. As the progress of each tubercle is slow, and they appear in succession, they are gene- rally to be observed at the same time in the various stages of growth and decline ; and in the more violent cases are intermixed with the marks and vestiges of those which have subsided. The erup- tion occurs mostly in persons of the sanguine temperament, and in the early part of life, from the age of puberty to thirty or thirty- * See Mr. Wra. Cooke's Treatise on Tinea Capitis Contagiosa. Order VIII. BLOTCHED FACE. 783 five. It is common to both sexes, but the most severe form of it is seen in young men. Dr. Willan has noticed four varieties of this eruption, which he designates by the titles of acne simplex, punctata, indurata, and rosacea. The acne simplex is an eruption of small vari which appear singly, and are not very numerous, nor accompanied by much in- flammation, nor by any intermediate affection of the skin. Many of the tubercles do not proceed to suppuration, but rise gradually, become moderately inflamed, and again slowly subside in the course of eight or ten days, leaving a transient purplish red mark behind; but others go on to a partial suppuration, the whole process of which occupies from a fortnight to three weeks. The eruption recurs frequently at short intervals in some individuals ; but in those who are more predisposed to it, it is more extensive, and perhaps never wholly disappears: at uncertain periods it is, however, more or less troublesome. Such persons often enjoy good health otherwise, and cannot refer the cutaneous complaint tc any obvious exciting cause. The affection being generally local, is to be treated by external applications, and the most proper are those of a gentle stimulating nature, such as lotions containing alcohol reduced or strengthened according to circumstances, by the addition of any distilled water, such, for example, as equal parts of spiritus tenuior and of rose or elder flower water. If the tubercles are much inflamed, and many of them pustular, the effect of a very acrid lotion would be to render them more confluent, and to produce the formation of a crust of some extent, as well as to excite an inflammatory redness in the ad- joining skin. As the inflammatory disposition subsides, an additional stimulus is often useful, such as from half a grain to one grain, or even more, of the muriate of mercury dissolved in each ounce of the spirit, or one drachm or more of the liquor potassae, or of muriatic acid in six ounces. Acetous acid and the liquor ammonia? acetatis afford also an agreeable stimulant in proper proportions. Sulphur yields a small portion of its substance to boiling water poured upon it, and allowed to infuse for twelve or fourteen hours, a quart of water being added to about an ounce of broken sulphur. In slight cases a lotion of this nature has been found advantageous, and especially in removing the duskiness and roughness in the face connected with the disease. Acne punctata. In this variety of the disorder the eruption con- sists of a number of black points, surrounded by a slight border of cuticle. These are vulgarly considered as the extremities of small worms or grubs, because when they are pressed out, a sort of worm-like appendage is perceived attached to them, but in reality fhey are only concreted mucus or sebaceous matter, moulded in the ducts of the sebaceous glands into this vermicular form, the ex- 784 LOCAL DISEASES. Class IV. tremity of whi^h is blackened by exposure to the air. In conse- quence of the distention of the ducts, the glands themselves some- times inflame and form small tubercles with little black points on their surface, which suppurate partially, as in the foregoing species; but many of them remain stationary for a long period, without ever pass- ing into an inflammatory state. These concretions may be extracted by pressing on both sides of the specks with the nails, until the hardened mucus is sufficiently elevated to be taken hold of. When the puncta are removed, the disease becomes acne simplex, and requires the same treatment wilh that species. Dr. Underwood* has recommended the use of a solution of the subcarbonate of potass internally in these cases, and Dr. Willan was in the habit of occasionally prescribing the oymuriatic acid. One or two tea-spoonsful of this liquid, taken in a glass of water three times a day, for a considerable period, has sometimes appeared to benefit the health, and improve the colour and smoothness of the skin; but medicines of this nature are seemingly more adapted to the subsequent species of the complaint, particularly the acne rosacea. Acne indurata. The tubercles are larger as well as more in- durated and permanent in this species than in acne simplex. They are of a conical canoidal form, and are occasionally somewhat acuminated, as if tending to suppuration, being at the same time of a bright roseate hue; but many of them continue for a great length of time in a hard elevated state without any disposition to suppurate. Others, however, pass on slowly to suppuration, the mailer not being completely formed in them for several weeks, and then only a few of the tubercles are removed by that process. They are frequently very numerous; sometimes two or three coalesce, forming a large irregular tubercle, which occasionally suppurates at the separate apices, and sometimes only at the largest. In whatever mode they proceed, the vivid hue of the tubercles gradually becomes purple or even livid, especially in those which show no tendency to suppurate. Upon the suppurating tuber- cles slight crusts form, which after a time fall off, leaving small scars surrounded by hard tumors of the same dark red colour; and these sometimes suppurate again at uncertain periods, and some- times slowly subside and disappear, leaving a purple or livid discol- ouration, and occasionally a slight depression, which is long in wear- ing off. The tubercles, even when they do not suppurate, but especially while they continue highly red, are always tender to the touch, so that washing the face, shaving, the friction of the clolhes, &c. pro- duce pain. The disease in its most severe form exhibits the * See his Observations relative to Grubs in his Treatise on the Diseases of Children, vol ii. p. 1G7, 5th edition. Order VIII BLOTCHED FACE. 786 eruption nearly covering the face, breast, shoulders, and top of the back, but does not descend lower than the ordinary tippet in female dress. The general health does not usually suffer even under this aggravated form of the eruption. Many persons, however, who are affected with the eruption are liable tQ disorders of the bowels and stomach, to haemorrhoids, and some to phthisis pulmonalis. lis first appearance too is frequently ascribed to some irregularity of diet, or to some cold substance swallowed when the person had been overheated and was in a free perspiration. Hence the appearance of the first eruption is not unfrequently somewhat sudden. By a steady use of external stimulants, combined with a proper regulation of diet and exercise, the acne indurata is often greatly alleviated, and sometimes entirely removed. Even from the be- ginning the eruption will bear a more acrid stimulus lhan in the inflamed acne simplex. A spirituous lotion, at first a little diluted, and containing the oxymuriate of mercury in the proportion of a grain, or somewhat Jess, to the ounce of the vehicle, is often ex- tremely beneficial. An emperical preparation, vended under the name of Gowland's lotion, which is generally supposed to conlain this mercurial salt in an emulsion of bitter almonds, has been much used, and where its strength happens to accord wilh the degree of irritability in the eruptions, it is doubtless beneficial in this species of the disease. Many other stimulants* may be substituted with a similar effect. In general it will be found requisite to augment the activity of all these applications in the progress of the treatment, partly in consequence of the diminished effect of an accustomed stimulus, and partly on account of the increasing inertness of the •l.ROl. Amygdal. f. ^i. Liquor. Potassa?, f. 3'j- Aq. Rosae, f. ^viss. M. ft. Lotio ter quaterve in die utenda. Vel, 2. g, Misturae Amygdal. Amar. f. 3-vss (Vide Herpes). Spirit. Camphora;, f. ^ss. M. ft. Lotio. Vel, 3. g; Mistura? Amygdal. Amar. f. f vj. Hydrargy. Oxymuriat. gr. iv. Solut. in Spirit. Rorismar. f. |i. M. ft. Lotio partibus affectis ter in die adpli- canda. 99 * 1. Take Oil of Almonds, one ounce. Solution of Potass, two drachms. Rose Water, six ounces and a half. Mix them. Let this wash be used three or four times a day. Or, 2. Take Mixture of Bitter Almonds, (see Herpes), five ounces and a half. Camphorated Spirit, half an ounce. Mix them for a wash. Or, 3. Take Mixture of Bitter Almonds six, ounces. Oxymuriate of Mercury, four grains. Dissolved in Spirit of Rosemary, one ounce. Mix them. Let the parts affected be wash- ed with a little of this lotion three times a day. 786 LOCAL DISEASES. Class IV tubercles, as the inflammatory state subsides, which must be deter- mined by the appearances. Frequent purgatives, which are often resorted to, are of no ad- vantage, but on the contrary only tend to augment tbe disease in feeble habits. The copious use of crude vegetables in diet, which the misapplication of the term " Scurvy" has introduced, is like- wise to be deprecated as well as the free use of vegetable acids, especially in constitutions predisposed to indigestion. It is a fact not easy to explain, that under many modifications of cutaneous inflammation, especially about the head and face, inflammation is immediately increased in sympathy with the offended stomach, when these substances are taken. In cases of acne indurata, the diet should be good, light, and nutritious, but not stimulating, consisting of animal food, with well dressed vegetables, and the farinaciae, wine and fermented liquors being omitted, or taken with great moderation. Internally medicines are generally supposed to effect very littler but in some inveterate cases an increased amendment* has been observed, when, in addition to the external treatment already noticed, small doses of soda, sulphur, and antimonyf, were at the same time administered, and by whieh plan, duly persevered in, fhe skin has been perfectly cleared. Acne rosacea. This species of acne differs in many respects from the preceding. In addition to an eruption of small suppurating tubercles, there is also a shining redness, and an irregular granula- ted appearance of the skin in that part of the face which is affec- ted. The redness commonly appears first at the top of the nose and afterwards spreads from both sides to the cheeks. At the commencement it is not uniformly vivid, but is paler in the mor- ning, and readily increased to a deep and intense red after dinner, or at any time, if a glass of wine or spirits be taken, or the patient be heated by sitting near the fire, or by active exercise. After some continuance in this state, the texture of the cuticle be- comes gradually thickened, and its surface uneven or granulated, and variegated by reticulations of enlarged cutaneous veins, with * See Dr. Bateman's Practical Synopsis of Cutaneous Diseases, p. 288,3d* edition. t 4, Take Washed Sulphur, half a drachm. Subcarbonate of Soda, one sc ruple to half a drachm. Tartarized Antimony, the six th ol a grain. Mix them This powder is to betaken morning and night. Or, 5. Take Subcarbonate of Soda, twenty- five grains. Sulphur. Loti, ^)ij. Washed Sulphur, two scruples. Polv. Antimon. gr.i. M. J Antimonial Powder, one grain. ft. Pulvis bis in die adhibendus. f Vlix them, and take this powder twice daily I 4. JJ. Sulphur. Loti, 3ss. Sodae Subcarbon. 2)1—-3«s- Antimon. Tartarizat. gr. l-6tb, M ft. Pulvis mane nocteque sumendus. Vel, 6. B; Sods Subcarbon. gr. xxv. Order VIII BLOTCHED FACE. 787 smaller red lines stretching across the cheeks, and sometimes by the intermixture of small suppurating tubercles, which successively arise on different parts of the face. Acne rosacea does not often occur in early life, except where there is a great hereditary predisposition to it: in general it does not appear before the years of five and thirty or forty; but it may be produced in any person by the constant immoderate use of wine and spirituous liquors. In such cases the greater part of the face, even the forehead and cheeks are often affected, but the nose especially becomes tumid, and of a fiery red colour; and in an advanced life it now and then en- larges to an enormous size, the nostrils being distended, or the alae fissured, as it were divided into separate lobes. At this peiiod of life too the colour of the acne rosacea becomes darker and more livid ; and if suppuration takes place in any of the tubercles they are apt to put on an unfavourable appearance, and do not readily assume a heal- ing disposition. In young persons, however, who are hereditarily predisposed to this complaint, irregular acrid patches not unfrequently appear in the face, which are often smooth and free from tubercles, and sometimes throw off slight exfoliations at intervals. If great tem- perance both in food and drink be not observed, these patches may be gradually extended until the whole face assume a preternatural redness. No danger, and but a trifling inconvenience accompanies acne rosacea, but those afflicted with it are usually solicitous to have it removed. For this purpose strong restringents and sedatives, such as a solution of the plumbi superacetas, are often employed; but although these succeed in repressing the eruption, they are apt to aggravate the internal disorder, and to give rise to severe headach and $ther unpleasant complaints. Moreover, tbe stimulants which are beneficial under proper regulations in most of the other forms of acne are generally prejudicial in this, by greatly aggravating it. Where restringents are applied externally to the patches of reticulated veins, such only as very dilute spirituous or acetous lotions, with or without a small proportion cf the superacetate of lead ; or simple ointments combined with alum, superacetate of lead, &c. in very small quantities, should be used. The perfect cure of this species of acne is seldom accomplished j for whether it originates in a strong hereditary predisposition, or from habitual intemperance, tbe difficulties in the way of correct- ing the habit of body are nearly insurmountable. Tbe regu- lation, however, of the diet is important in both : when the stomach, or liver is disordered, the symptoms may sometimes be palliated by the liquor potassa? or other antacids, such as soda, &c. which seem also to have some influence in lessening inflammatory action in the skin. It will be advisable to keep tbe bowels regular and open by some gentle laxative, if they are torpid. A slight course of the submuriate of mercury, joined with antimony, as in the pilulas hydrargyri submuriatis, with a decoction of sassafras or elm 788 LOCAL DISEASES. ClaSS IV. bark, might in some cases possibly prove serviceable. Tbe liquor arsenicalis has sometimes been found beneficial ; the patient may begin with eight drops twice a day, gradually increasing the dose to fifteen or twenty. Should a severe headach, impaired sight, or other ill effects arise from a recession of the cutaneous eruption in consequence of restrin- gents bring applied externally, the insertion of an issue of one or two peas between the shoulders might be advisable. CHIGRE. The chigre is a kind of small sand-flea which proves very trouble- some in the West Indies by insinuating itself into the soft and tender parts of the fingers and toes more usually than into other parts of the body, particularly under the nails, where it continues to increase in size, causing no further pain than a disagreeable itching and heat. In process of time, however, a small bag or bladder is formed, in which are deposited thousands of nits or ova, that become so many young chigres, and if not speedily extracted, create running ulcers. Some people have lost their limbs by amputation, nay, even their lives, by having neglected to root out these vermin in proper time. Tiie moment, therefore, that an itching, redness, and heat more than usual are perceived in any part affected with a chigre, it will be advisable to extract it. This is usually done with a sharp-pointed needle by some dexterous negro, who picks out the insect, and if a cyst is formed, endeavours to take out this whole also; for by breaking it troublesome ulcers are sometimes formed. The cavity is then usually filled up with tobacco-ashes or snuff. In very inveterate cases, where from neglect either the hands or feet are much beset with chigres, it may be necessary, after the ex- traction of the several cysts, to wash the parts wilh a strong decoc- tion of tobacco, or a solution of the sulphate of copper. PERNIO, or CHILBLAIN. Chilblains are painful inflammatory swellings of a deep purple or leaden colour, to which the fingers, toes, heels, and other extreme parts of the body are subject on being exposed to a severe degree of cold. The pain is not constant, but rather pungent and shooting at particular times, and an insupportable itching attends. In some in- stances the skin remains entire, but in others it breaks and discharges a thin fluid. When the degree of cold has been very great, or the application long continued, the parts affected are apt to mortify and slough off, leaving a foul, ill-conditioned ulcer behind. Children and old people are more liable to be troubled with chil- blains than those of a middle age; and such as are of a scrofulous habit are remarked to suffer severely from them. worms. 789 The best mode of preventing these affections is to avoid with much care any exposure to wet or cold ; wherefore those who are subject to them should be cautious, on the approach of winter, to cover the parts which are apt to be injured with woollen gloves and stockings, and not expose the hands or feet too precipitately, when cold, to a considerable degree of heat. Iu common cases of chilblains, as soon as any part is perceived to be affected, it will be proper to rub it well with warm spirits of rosemary, to which a small addition of spirits of turpentine has been made ; after which we may apply pieces of soft linen, moist- ened with camphorated spirits or any of the embrocations here ad- vised*, and they are to be kept on constantly. When the swellings break and discharge a thin matter, or ul- cerate, poultices and emollient ointments may be applied for a few days; but as these are apt to induce fungous excrescences over the sores which it will be difficult afterwards to remove, they should not be persisted in long. The occasional application of caustic to the edges, and dressing the sore daily with the unguen- tum hydrargyri nitratis, will effectually prevent any luxuriancy of granulation. Should (his be found of too escharotic a nature, its strength may easily be reduced by a small addition of the unguen- tum cetacei. = l»]»lff»i«l»ICJ DISEASES NOT REFERRIBLE TO ANY PARTICULAR CLASS. VERMES, or WORMS. The human body«is infested by three kinds of worms, viz. the ascarides, or small white wor n : the teres, or round worm, * 1. ft Aluminis, 3'j- Acid. Acetici, Spirit. Tenuior. aa Oss. M. Vel, 2. ft Liniment. Camph. C. --------Saponis, aa f. ^ss. 01. Terebinth, f. 3«j- M. Vel, 3. ft Liniment. Sapon. Comp. f. ^iss. Tinct. Lyttae, f. 3>j- M. Vel, 4. ft Liniment. Sapon. Comp. Liquor. Ammon. Acetat. aa f. |j. M 1. Take Alum, two drachms. Distilled Vinegar, Proof Spirit, of each half a pint. Mix them. Or, 2. Take Compound Camphor Liniment, Soap Liniment, of each half an ounce. Oil of Turpentine, three drachms- Mix them. Or, 3. Take Compound Soap Liniment, one ounce and a half Tincture of Spanish Fly, two drachms. Mis them. Or, 4. Take Compound Soap Liniment, Solution of Acetate of Ammonia., of each one ounce. Mix them. 790 WORMS. and the taenia, or tape worm, which is flat, consists of many joints, and is usually of a considerable length. The last is, however, more rarely met with in this country than the others : but in Germany and Switzerland the inhabitants are much trou- bled with it. Different situations of the intestines have been mentioned as being occupied by each kind, particularly the rectum as the seat of the ascarides, where they are observed always in- volved in mucus ; the teres occupy tbe small intestines, and some- times the stomach; the taenia the whole intestinal tube, more espe- cially the ilium. Unwholesome food, with a bad digestion, seems to be the prin- cipal cause of worms. They appear most frequently in those of a relaxed habit, and whose bowels contain a preternatural quantity of mucus or slimy matter. Hence it is a disease most common to children ; but they sometimes prevail in adults to a very high degree, particularly in those who live chiefly on a vegetable diet. The tape worm is not often met with in infancy or childhood ; in- stances of it do, however, now and then occur. Worms may readily be distinguished by the following symptoms, viz. variable appetite, fetid breath, acid eructations, and pains in the stomach, grinding of the teeth during sleep, picking of the nose, paleness of countenance, hardness and fulness of the belly, slimy stools, with occasional griping pains, more particularly about the navel,'heat and itching about the anus, short dry cough, emacia- tion of the body, slow fever, with evening exacerbations, and irre- gular pulse, and sometimes convulsive fits. It is often a very difficult matter to expel worms from the body, but more especially the taenia. When they prove fatal it is by their erosion of particular parts, and their inducing a tabid state. In the cure of this disease we must have in view, first, the effect- ing the destruction and discharge of the worms ; and, secondly, the preventing their future generation. The first of these is to be accomplished by certain remedies known by the name of vermifuges, which all act in one ofthe three following ways :— 1st. By simple evacuation or purging, as mercury, rhubarb, jalap, and aloes ; as also the different strong bitters, as rue, tansy, and wormwood. 2dly. Mechanically, as the pulvis stanni, cowhage, &c. or, 3dly. Chemically, as lime-water, which loosens their adhesion lo the intestines by dissolving the mucus in which they are involved. We may begin with those which act mechanically*, and which have been found the most powerful ; and after continuing them for * J. ft Stanni Limatur. Confect. Cassiae, aa ^ss. Syr. Simpl. cj. 8. M. it. Electuarium. cujus sumat wagnitud jiucis inoscbatae bis in die. l.Take Filings of Tin, Cassia Confection, of each half an ounce. Syrup, a sufficiency. Mix them. Of this electuary the bulk of* nutmeg may be taken twice a day. WORMS. 791 two or three days we may have recourse to those which have a purgative effect*, changing both after a continuance of some time for those which act chemicallyf. A long with those which act mechanically it will be proper to employ some kind of bitter infusion f. If these means prove ineffectual we may then make use of the Indian pink root, or spigelia, which has on many occasions been found a very powerful medicine. About ten grains of the powder may be given morning and night to a child of eight 01 ten years old, to which age the doses of the preceding remedies are adapted. The spigelia is without doubt a poisonous and narcotic vegetable, and it is in all probability by virtue of this poisonous quality that it proves so beneficial in cases of worms. By a proper use of stizolobium or cowhage, (the dolichos pru- Vel, 2. ft Stizolobii aut Dolichi Pub. gr. vj.—x. Limatur. Stanni, gr. x. M. ft. Pulvis, mane et nocte capiendus cum sy rup. aut melle permixtus. Vel, 3. ft Stizolobii, gr. vj.—x. Mel. Optim. vel Theriao. q. s. M. ft. Bolus bis in die adhibendus. Vel, 4. ft Stizolobii, 3j. Syrup. Simpl. q. s. M. ft. Electuarium Capiat cochl. minimum mane primo per dies tres. *&. ft Hydrargyr. Submuriat. gr. iij.—v. Pulv. Rhei, gr. x. M. Quarto mane sumendus. Vel, 6. ft Pulv. Jalapae, gr. x. ruiv. jaiapae, gr. x. Hydrargyr. Submuriat. gr. iij. M Vel, 7. ft Olei Ricini, f. |ss.—f. |j. pro dos. 18. ft Liquor. Calcis, Oss. in die. f 9. ft Rad. Gentian. Contus Fol. Absinth. ----Rutee, Cort. Limon. aa 31j. Aq. Ferventis, Oj. I Macerper horam unam, et cola. Hujus in fusi sumat cochl. magna iij. bis terve in die. Or, 2. Take the Down of Cowhage, six grains to ten. Filings of Tin, ten grains. Mix them. This is to be taken night and morning, mixed with a little syrup or honey. Or, 3. Take the Down of Cowhage, six to ten grains. Honey or Treacle, a sufficiency to form a bolus, which is to be given twice a day. Or, 4. Take Down of Cowhage, one drachm. Common Syrup, a sufficiency. Form an electuary, of which take a tea- spoonful every morning for three days on an empty stomach. *6. Take Submuriate of Mercury, three ta five grains. Powdered Rhubarb, ten grains. Mil them. This purgative powder is to be taken on the fourth morning after any of the preceding vermifuge medicines. Or, 6. Take Powder of Jalap, ten grains. Submuriate of Mercury, three grains. Mix them for a cathartic. Qr, 7. Take Castor Oil, half an ounce to one ounce for a dose. t 8. Take of Lime Water, half a pint in the day. X 9.Take Gentian Root, bruised, Wormwood Leaves, Rue Leaves, Lemon Peel, of each two drachms. Warm water, one pint. Infuse them for an hour, and then strain off the liquor. Of this infusion three table- spoonsful may be taken twice or thrice * dav. 792 WORMS. riens of Linnaeus), with the submuriate of mercury combined with jalap, or the oleum ricini every third or fourth morning as a purga- tive, we seldom, however, shall have occasion to seek relief from any other medicine, as in several hundred cases where I had used it, during my piactice in the West Indies, I never knew it once to fail. It appears to have been but very lately introduced into this country, which, considering its wonderful vermifuge powers, is somewhat surprising. The stizolobium or dolichos is a plant like the vine, long, slender, and creeping. The leaves are thin, pointed, and covered with a down. The flowers grow in clusters, and are followed by a pod, somewhat similar to the common pea in shape and size, and containing several purple beans. The pods are thickly covered by very fine stiff pointed hairs, which, upon being applied to the skin, produce an intolerable itching, and it is only this downy portion of the plant that is employed to destroy worms. A decoction of the Geoffra-a inermis, or cabbage bark, is another remedy much used in the West Indies, but more particularly in Jamaica, for destroying worms, and often wilh a very happy effect. For the destruction of ascarides it is very usual to throw up injections into the rectum that will prove obnoxious, and there- by dislodge them. Any of those recommended below* may be tried. ■* Turpentine has been used also wilh success in the form of glysffer. About two drachms of it, blended with a decoction of oatmeal, may be thrown up at a time. An injection of the down or hairy part of the stizolobium, mixed • 10. ft Liquor. Calc. tepid, f. ^x. pro ene mate. Vel, 11. ft Fol. Ruta>, ----Absinth, aa *|ss. Coq. ex Aq. Pura;, Oj. ad ^x. Colat. adde 01. Ricini, f. *"jss. M. ft. Enema. Vel, 12. ft Spicul Stizolobii. gr. x. Decoct. Avenae, f. ^vj. M. ft. Enema. I'd, 13. ft Aloes Vulgaris Extract. 3j- Decoct. A vena;, f. ^s. Vel, 14.ft Tabaci, 3j—Sss. Aq. lYrvent.f. "\. Post ?emiho)\im col. * 10. Take Lime Water of a tepid warmth, ten ounces for an injection. Or, 11. Take Rue leaves, Wormwood Leaves, of each half an ounce. Boil them in a pint of water until reduced (o ten ounces, strain off the liquor, and add Castor Oil, half an ounce. Mix them for a clyster. Or, 12. Take Down of Cowhage, ten grains. Thin Gruel, six ounces. Mix them for a clyster. Or, 13. Take Common Aloes,one drachm. Thin Gruel, ten ounces. Mix them for a clyster. Or, 14. Take Tobacco Leaves, from one scruple to half a drachm. Warm Water, ten ounces Infuse them for half an hour, and (lien strain oft* Ihe liqno/.ior a clyster. WORMS. 793 in a little thin gruel, might possibly have a very good effect. Dr. Darwin has proposed fhe introduction of a piece <>f candle up the rectum, well smeared with mercurial ointment, as a likely method to destroy ascarides. A peculiar mode of employing tobacco in cases of worms has been recommended by Dr. Barton*, and which we are informed by him has in many instances produced very happy effects. The leaves are pounded with vinegar, and applied in the shape of a poultice to the region of the stomach or abdomen. " In consequence of this application, worms are often discharged," he mentions, " after pow- erful anthelmintics have in vain been administered internally." A similar practice 1 know is adopted in the West Indies, where it is usual to apply a cataplasm of the expressed juice of the aloe-tree to the abdominal region, for the purpose of dislodging worms, and I have observed that in many cases the remedy seemed to prove a powerful auxiliary to other means. Its efficacy has extended how- ever only to cases of the round worm. The male fern, or filix mas, which forms the basis of Madame Noufler's celebrated remedy, is a medicine which has been much extolled for its destructive powers to the tape-worm, which, of all others, proves the most difficult to expel from the body. The dose for an adult is from one to two drachms. After two doses, it will be right to give a purge ofthe submuriate of mercury and jalap, in about the proportion of five grains of the former to five-and-iwenty of the latter. The common spirit of turpentine, it appearsf, has recently been administered with a very good effect in some cases of tape-worm, having caused many feet in length ofthe animal to be brought away, or expelled. For a delicate female, the proper dose will be an ounce ; for a robust female or small man, an ounce and a half; and for a robust man, two ounces. The best vehicle for it appears lo be milk. It should be taken early in the morning on an empty stomach. Purg- ing will be produced by it, and this speedily. When the dose is considerable, it may be advisable to direct the patient to drink plen- tifully of emollient liquors with the view of sheathing the stomach and kidneys. The pomegranate root has been found a very effectual remedy} for destroying the tape-worm. Sulphureous waters, such as those of Harrowgate, in this coun- try, and of the Islands of Jamaica and Nevis, in the West Indies, have been found, when drank upon the spot, to be very good anthel- mintics. Harrowgate water is "a safe and powerful remedy against the * Reporled in vol. \ iii- p. 428 of the Medical and Physical Journal. t Reported in No. 181 and 132 of the Medical and Physical Journal; — See Transactions of the London Medical Society, vol. i. % See Edinburgh Medical Journal for January 1807. 100 794 MINERAL POISONS. round worm and ascarides, when taken in such a dose as to prove a brisk purgative ; and in the latter case, when used likewise as a clys- ter, the ascarides being chiefly confined to the rectum, and therefore within reach of this form of medicine. Common salt was administered by Dr. Rush as an anthelmintic remedy, with some success; and by some other physicians it has been thought to possess a power destructive to worms. Those who do not make use of it with their food, have been observed to be much predisposed to these vermin. Such as are afflicted with worms should abstain from all crude ve- getables and unripe fruits, making their diet consist chiefly of animal food that is light, nutritive, and easy of digestion. After a proper course of the vermifuge medicines which have been advised, we should employ such others as have a tendency to strengthen the stomach and intestines, in order to prevent any worms from being generated in future ; a relaxation of these parts being a constant attendant on the disease. The most proper tonics are the cinchona bark, astringent bitters, and chalybeates; various forms of which will be found under the head of Dyspepsia. O* POISONS. Poisons are of four kinds—mineral, vegetable, aerial, and animal. Mineral poisons are to be distinguished from vegetable ones by their action. The former corrode, stimulate, or inflame ; the latter gen- erally stupify, and leave no marks of inflammation. None ofthe min- eral poisons terminate life, till after a most excruciating operation of two or three hours at least; whereas some of the vegetable class destroy it in a few minutes. From the animal poisons the distinc- tion is as striking ; for although in the plague the mouth and throat are frequently affected in the same way, yet the local disease of the stomach is never present. The aerial poisons operate still more quickly than any of the other classes, and their action on respiration is so peculiar, that it can never be mistaken. Of the MINERAL POISONS. The chief of the mineral poisons are arsenic, oxymuriate of mer- cury, and lead. Where arsenic has been administered, or taken perhaps in a mistake for some other medicine of a similar colour, a pricking and burning sensation will soon be experienced in the stomach, sudden and excruciating pains will be felt in the bowels, a severe vomiting will arise, the tongue, mouth, and throat will become rough and parched, and an unquenchable thirst will prevail, with much anxiety and restlessness. If the dose has been considerable, and proper antidotes have not been employed in time, an inflammation of the stomach and intestines will be the consenuence. which will MINERAL POISONS. T95 soon terminate in gangrene, giving rise to much distention of the abdomen, coldness of the extremities, fetid vomiting and stools, hic- cups, and lastly, the death of the person. A case reported in the Sth volume of the Medical and Physical Journal, p. 543, shows, tbat arsenic, as well as some other metallic poisons, may be taken into the system by the absorbents, and thereby produce very baneful effects on the constitution. There are two theories entertained with respect to tbe mode in which arsenic operates : the one is, that its deleterious properties are owing to the action of its sharp spiculae on the stomach ; the other, that it has a peculiar action on the nervous system. Neither of these seems, however, to be true to the extent meant to be inculcated. The effects produced by swallowing oxymuriate of mercury in a considerable dose are pretty similar to those occasioned by arsenic. The effects of lead introduced into the stomach and bowels have already been noticed under the heads of Colica Pictonum and Palsy. From poisons of all kinds, more or less danger is always to be ap- prehended ; but the degree will ever be in proportion to the quantity which has been swallowed, and to the time which has elapsed previous to any assistance being given. Dissections of those who have died in consequence of any mineral poison, such as arsenic, or the oxymuriate of mercury, show, that the alterations of structure occasioned by them are, that tbe mouth, stomach, and intestines are usually inflamed; that the stomach and duodenum sometimes present gangrenous spots, eschars, and per- forations of their coats; that the villous coat of the stomach now and then appears as if destroyed, and reduced to a state of a reddish brown dough; finally, that all the other viscera are more or less inflamed. It is said that arsenic produces a resistance to pu- trefaction, as some bodies, which have been examined many days after the persons had been poisoned, discover neither putrescence nor foetor. When an animal is killed by arsenic or the oxymuriate of mercury taken internally, the stomach is usually found to bear marks of inflammation, as has just been observed ; and it is a very general opinion that this inflammation is the cause of death, and that it is tbe consequence of the actual contact of the arsenic with the internal coat of the stomach; but we are told by Mr. Brodie*, that as a general proposition, the first of these opinions is incorrect, as he has found in several cases the inflammation of the stomach so slight, that on a superficial observation it might have been easily overlooked, and that in most of his experiments with the poison of arsenic, death has taken place in too short a time for it to be considered as the result of inflammation. He is * See his Observations on the Action of Poisons on the Animal System, which were read before the Royal Society in February 1812. 796 MINERAL POISONS. of opinion that vegetable substances, when applied to wounded sur faces, affect the system by passing into the circulation through the divided vein«; and he thinks that arsenic, in whatever way it is admi- nistered, does not produce its effects on the stomach until it is carried into the blood. In short, that the symptoms produced by arsenic may be referred to the influence of the poison on the nervous system, tbe heart, and alimentary canal. In all cases of poison arising either from arsenic, oxymuriate of mercury, or any other mineral, it will be necessary to procure as speedy and quick an evacuation upwards as possible, by means of a strong emelic*; drinking freely afterwards of diluting liquors, such as a decoction of barlev, with gum. acaciae, mutton and veal broths, linseed-tea and milk, in order lo sheathe the parts, and prevent their being acted upon by the particles of the poisonous matter. With the same intention, oil is not only frequently administered by the mouth, but likewise thrown up into the intestines in the form of clyster, mixed with a decoction of emollient herbs. It appears, however, from numerous Trials, that when arsenic is given to animal^ combined with oil, butter, or other fatty substances-, they are destroyed much more quickly than when it is given in an aqueous vehicle. The use of fat bodies ought therefore to be interdicted during the first moments in cases of such a poison, and mucilaginous and gelatinous substances be employed in their stead. Alkaline salts have been found to diminish tbe injurious effects of mineral poisons, and therefore in accidents of this nature it will always be advisable to make use of them without loss of time. For this purpose, dissolve about an ounce of the subcarbonate of potass in half a gallon of water, and give the patient a tea-cupful frequently. Where none of these salts are at hand, then a small quantity of wood- ashes, mixed up with boiling water, so as lo make it of a sufficient strength, may be substituted, suffering the liquor to stand until it set- tles, and then filtering it through linen for use. Fresh charcoal powdered fine has (it is affirmed) been found an efficacious medicine in obviating the deleterious effects of arsenic on the stomach and intestines. The carbonate of magnesia has been recommended as a good * 1. R Zinc. Sulphat. gr. xv.—3ss. Pulv Ipecac gr. x. M. ft. Pulvis slatim sumendus. Vel, 2. R Antimon. Tartarizat gr. ij. Zinc. Sulphat. gr. xv.—j)j. Aq Pura-. ~\. M ft. Haustus Einet'cus. * 1. Take Sulphate of Zinc, fifteen grains to half a drachm. Powder of Ipecacuanha, ten grains. Mix them, and let this powder be taken immediately. Or, 2. Take Tartarized Antimony, two grains. Sulphate of Zinc, fifteen grains to one «rrup)e. Pure Water, one cunce. Mix them for an emetic draught. MINERAL POISONS. 797 remedy to counteract the deleterious effects of arsenic ; but from some experiments reported in the London Medical Repository*, it appears that calcined magnesia does not decompose the white oxyd of arsenic, but on the contrary, that it combines with if, and forms a soluble ai>enife of magnesia, which has not a feeble action on Ihe human frame, as is loo generally supposed. From these experiments, it also appears that chalk, and also lime water, destroy the deleterious etfects of an overdose of a solution of the white oxyd, if taken in time, and are likely even to suspend or greatly lessen the action of the poison swallowed in a solid form, if aided by plentiful dilution. Lime water is recommended by Orfilaf, who proved by experiments that the arsenite of lime (formed by pouring lime water into a solution of white oxyd of arsenic) is insoluble, and when swallowed, is not poisonous. Of all antidotes to the poison of the oxymuriate of mercury, we are informed by the French writerj before referred to, that he found albumen (which is only the white of egg dissolved in water and filtered) to be the most powerful and efficacious. It is to be properly diluted with water previous to use. On the principle of removing inflammation in cases of mineral poisons, it may be advisable to employ copious bleeding, together with the application of a large blister to the epigastric region, keeping the bowels open at the same time with frequent doses of the oleum ricini. A successful case of this nature is recorded in the 2d volume of the London Medieo-Chirurgical Transactions. Indeed when inflammation is only commencing from the absorp- tion of the mineral, and the morbid symptoms have not yet reached to any alarming height, it would appear, that after having adminis- tered an emetic to clear the stomach of the poisonous particles, and then an active purgative to evacuate the bowels, blood-letting is a remedy obviously pointed out. In cases where the poison of verdigris has been recently swal- lowed, emetics should first be given, and afterwards cold water, gently alkalized, ought to be drank in abundance. By experiments made on animals by the French writer just quoted, it was ascertained that sugar exercises a chemical action on verdigris, and renders it insoluble in water. It was therefore used by him and olhers as an antidote to verdigris, and was found in all cases of this poison fo allay the pain and other alarming symptoms, and to produce an immense quantity of liquid stools. Those who have eaten provisions prepared in a copper vessel badly tinned, are occasionally attacked a short time afterwards with symptoms characteristic of the poisonous effects of the metallic substance, in which cases the exhibition of charcoal has proved highly beneficial when other remedies have failed||. * See No. 44, p 157. t See Trait6 des Poisons, par M P. Orfila, Docteur en Medecine, torn. i. partie i. X — The same. II See Journal Gen. de Medecine for April 1815. 798 MINERAL POISONS. To obviate the deleterious effects of lead introduced into the stomach and bowels, the means which have been advised under the head of Colica Pictonum must be adopted. 1 would, however, mention here, that the sulphates of soda and magnesia are anti- dotes to the salts of lead and barytes. Muriate of soda counteracts the corrosive effects of nitrate of silver. Milk is the real antidote of muriate of tin, by which it is com- pletely coagulated. The coagulum contains muriatic acid and oxyd of tin, and is not deleterious. Acetic acid is the best antidote against the effect of alkalies. The success of the treatment of all cases of mineral poisons will depend in a great measure on the sort of regimen the patient observes during his convalescence, which is frequently long and painful. He ought to be principally nourished by milk, gruel, farinaceous preparations, and nutritive broths. Great thirst usually accompanies such occurrences, which may be allayed by frequently washing the mouth with cold water, this being preferable to drink- ing any great quantity of watery liquors, lest vomiting should be excited or kept up thereby. The following are the tests by which arsenic may be discovered in the contents of the stomach, where it has been administered at a poison. First, if a few grains of it are thrown on a red-hot iron, a smell like garlic will be perceived. 2dly. If a few grains are placed between two plates of copper, and subjected to a red heat, the copper becomes whitened. 3dly. Where the quantity is suffi- cient, some wheat may be steeped in a solution of it, and which, if given to chickens or small birds, will destroy them. A simple and efficacious mean for detecting tbe presence of arsenic is that of Bergman. It consists in infusing a portion of the suspected matter in a solution of vegetable alkali : after stand- ing an hour or two, pour upon it a solution of the sulphate of copper. If any arsenic is present, the copper will be immediately con- verted into a beautiful green, and will soon be precipitated. In this way water, or the contents of a stomach supposed to contain arsenic, may be examined. The precipitation of arsenic from any fluid in which it is dissolved, may also be made by an alkaline hydro-sulphuret. Another piocess for discovering the presence of arsenic is by combining it with silver. This test has been strongly recommended by Mr. Hume, of Long Acre, under the title of the ammoniaco- nitrate of silver, and is thus prepared: Dissolve a few grains, say ten, of the nitrate of silver, called lunar caustic, in about nine or ten times its weight of dislilled water ; to this add, by a drop at a lime, a solution of ammonia, till a precipitate is formed. Con- tinue to add the ammonia, now and then shaking the bottle, till the precipitate shall be taken up, and tbe solution again become transparent, or nearly so, as the ammonia need not be in great excess, if in any ; for, a solution of ammonia being lighter than MINERAL POISONS* 799 water, the superfluous portion would remain on the surface of any- fluid fo which this test liquor may be applied. This simple liquid, if kept in a phial with a glass stopper, will not easily spoil. Its application is yery simple ; for nothing more is required than to dip a strip of glass into this liquor, and apply it to the solution containing arsenic. Should the material suspected to contain arsenic be of a dry nature, such as a mixture of sugar, meal, bread, meat, or any other kind of food, let some boiling water be poured on the suspected substance, and filtrate the so- lution through paper. If a bright yellow colour appear on pre- senting the nitrate of silver, we may conclude, without reserve, that there is arsenic in the mixture under examination. It is said by Mr. Hume, that this test, by proper management, will prove the existence of white arsenic, even if dissolved in more than four hundred thousand times its weight of water. It is of great importance to employ boiling water in examining the vomited matters and contents of the stomach, in cases of poisoning by arsenic. By Klaproth's experiments, it appears, that one part of the white oxyd requires four hundred parts of water, at 59 Fah. for its solution ; although one hundred parts, which had been boiled on white oxyd of arsenic and cooled down to 59° retain three grains of Ihe oxyd in solution. This is contrary to Bergman's opinion, and adopted by many chemical writers, which states, that one part of white oxyd is soluble in fifteen parts of boiling water, and in eighty of cold. For the discovery of the oxymuriate of mercury, the methods almost exclusively resorted to are its precipitation by means of one of the carbonated fixed alkalis, or by lime water, which detach it under the form of an orange coloured, or orange yellow, sedi- ment. Dr. Bostock has lately recommended muriate of tin. The presence of lead may be detected by adding a little sulphuric acid, which will precipitate the mineral in the form of a white powder. Sulphuret of potass, or lime, may also be employed, which will occasion a blackish deposit. When copper is taken into the stomach, the beautiful blue colour produced in its solutions by pure ammonia, is the most decisive and satisfactory evidence that can be required. Such are the tests by which the practitioner will be enabled to form his opinion with tolerable accuracy, if called upon to appear before a court of judicature in most cases of supposed poison by anv mineral. In those which admit of the smallest doubt, we should never fail to attempt a reproduction ofthe mineral, by evaporating fhe fluid with which it may be supposed to be mixed or held in so- Jution, this being the surest and most accurate. All other tests are liable to some distrust, in as much as it has been clearly demon- strated, that similar results will be obtained from them where it is obvious no arsenic could be present*. * See Edinhurfrh Medical anflPh«;™l Ttiotinniry, unc{er the head Arsenic. 800 VEGETABLE POISONS: The following mode of reproducing the w:.ite oxyd of arsenic ia simple and easy, but it'is necessary to have a quantity that is tangilde. When white arsenic is mixed with carbonaceous or unctuous matter, and then exposed lo a red beat in a glass tube closed al the end, it will be sublimed in the form of shining metallic scales; and then exposed to the air under the heat of ignition, will burn with a blue flame, and revert to tiie common white oxyd*. Before I quit this subject, it may not, however, be amiss to notice a peculiar appearance which is now and then met with in the stomach on diss ction, and which, in a case of judicial investigation, might be mistaken by the inexperienced practitioner for the effect of some mineral poison. I allude to the dissolved or eroded state in which a portion of this organ is at times found on anatomical inspections, and solely occasioned by the gastric juice. Several well authenticated insiances have lately been brought forward, proving satisfactorily a solution of the coats of the stomach, either partly or wholly, by ihis secretion. Such a solution is most frequently met with in those who have been suddenly deprived of life when in full health, a circum- stance first noticed by the late Mr. J -fin Hunter; but still the occur- rence is not confined to such cases alone ; it has been found in those who have died of lingering and debilitating diseasesf. This, however, is in contradiction to the opinion of some practitioners who have written on the subject; for they hardly conceive it possible that the coats of the stomach can be dissolved in a person labouring under a state of debility at the time of death by the gastric juice. The fact appears, nevertheless, incontrovertible. In the case of tbe young woman at Liverpool, whose body was opened under the supposition of being poisoned, and for which a trial was inslituted, a hole of considerable size was discovered in the stomach ; but as no particles of any metallic poison were found, and one of the physicians who was examined as an evidence sug- gested fhe possibility of the erosion being occasioned by the gas- tric juice, the prisonerj was acquitted. The case and result gave rise to much medical controversy at the lime. Of VEGETABLE POISONS. Some species of fungi, particularly the small agaric, denominated champignon by the French, nearly resembling mushrooms, as well * See Marshall on Arsenic. t See Mr. Burne's Observations on Digestion of Ihe Stomach after Death, in the 22d Number of the Edinburgh Mediciil and Surgical Journal. X Several experiments made by Dr. Bostock, of Liverpool, in consequence of the ac- quittal of this person, and recorded iu the 17lh .Number of the Edinburgh Journal, ought to have some influence in all judicial proceedings, where the question of poisoning »■ agitated. He found that an a'liinal may be suddenly killed by receiving a metallic p»H- son into the stomai.h,and yet that the nicest tusts may not be able to dcteit any portion ofthe poison, idler death, in the contents ofthe stomach. A poson may, I think, produce fatal effects, mid yet be so completely evacuated by vomilimjand purging as to leave no trace, discoverable, by chemical analysis, in the contents ofthe alimentary canal. A case reported in the 2oih Number of the Edinburgh Journal, by Dr. Henry, coufirms this opinion. VEGETABLE POISONS. 801 as laurel water, hemlock, nightshade, foxglove, and other plants of the narcotic tribe, by being taken through mistake, often prove a source of poison. In the West Indies similar accidents frequently happen from using the cassava root in its crude state. In this state it acts as a most deadly poison ; but by having its acrimonious juice carefully expressed, and being afterwards baked into thin cakes, it becomes a wholesome and nutritive kind of bread, much used in roost of the islands, as also in Africa. Such is the wonderful effect produced by fire over this plant. The following are the indications by which the mushroom tribe that are of a suspected nature may be distinguished. All those may be regarded as suspicious and of a dangerous quality which grow in marshy shady places, as thick forests, where the sun has no access : their substance is softer, more open, more porous, and moister than edible mushrooms. They have besides a more disagreeable appear- ance, and a more or less humid and dirty looking surface. Those also which are dusky and change colour when cut, or which exhale a strong unpleasant odour, or have a gaudy colour, or many very distinct hues, particularly if they have been originally covered by an envelope, and aie found in shady places, ought not to be eaten. Those which have short bulbous stalks, or fragments of skin ad- hering to their surface, or which grow rapidly and corrupt very quickly, should also be rejected. It has generally been supposed that fungi lose their deleterious properties by being dried ; but this is a rule to which there are many exceptions, and which ought therefore to be very cautiously admitted*. The symptoms occasioned by all poisonous substances of the Vegetable class are, giddiness, confusion of sight, wildness ofthe eyes, palpitations, loss of memory and voice, stupor, nausea, vomiting, great distention of the stomach, universal twitchings and con- vulsions. Under accidents of this nature we must attempt tbe immediate evacuation of the offending matter; but it is only quickly after the narcotic has been taken, and before it has excited its peculiar symptoms, that an emetic can be advantageously given, as the efforts to vomit might increase the dangerous determination of blood to the bead. The most proper emetic will be a strong solution of tbe sulphate of zinc with tartarized antimony, as advised under the head of Mineral Poisons. A very singular case is related in the French Dictionary of Me- dical Sciences, among the Cas Rares, of a man 60 years of age who swallowed a piece of meat which stuck in the oesophagus, near the lower end of the tube. Alarming symptoms followed quickly, but the surgeon could not displace the foreign body. He opened the median vein in the arm, and injected four grains of tartarized antimony dissolved in an ounce of water. About a minute after- wards the patient vomited up the piece of meat. Query}- Might ' See Traite des Poisons, &c. n-ir Mon-5 Orfila. 101 802 VEGETABLE POISONS. not the same plan be adopted with advantage in cases of poison from opium and other powerful narcotics, where the patient is deprived of sensibility or the power of swallowing, or where there prevails very great torpidity ofthe stomach f To counteract the effects of the poison, the patient should be made to drink, after vomiting has been excited, but not before, if possible, of liquors strongly acidulated with the juice of lemons, vin- egar, or sulbhuric acid, giving the preference however to the former. These fluids should be given in small doses, and be repeated every ten minutes. Contrary to the generally received opinion that vinegar and the vegetable acids are antidotes to the poison of opium, a French writer* concludes, from the results of a series of experiments upon dogs, that these acids aggravate the symptoms of poisoning by opium, by dissolving the greater quantity, and thereby increasing its narcotic power, when the poison has not been rejected by vomiting; but he found if the poison has been vomited, that then vinegar and vegetable acids possess the property of diminishing the symptoms of the poison, and even altogether overcoming them. No experiments, however, have been made upon the human body of the like nature, to prove whether a similar result would ensue. It will, however, be most advisable to excite vomiting by a powerful emetic previous to a use of acids. In urgent cases of persons of a robust and plethoric habit suffering under the influence of opium, opening the jugular vein in preference to any other will be advisable, as by this means only can the danger- ous accumulation of blood in the brain be relieved. Bleeding unne- cessarily might however not only retard, but endanger the recovery ofthe patient. For the purpose of rousing the system from a state of torpor, particularly in cases where an immoderate dose of laudanum or opium has been taken, the patient is to be kept in constant motion on his legs, if capable of standing; but if not, by frequently shaking and moving his body. We may at the same time assiduously rub different parts of it with warm salt and other stimulating applica- tions. If these means fail, water of the temperature of about 106 or 110 degrees may be dashed over the patient every now and then : this will sometimes rouse him (at which time we may be enabled to give him a strong emetic or any other proper medicine), when even violently shaking him could not keep him awake. To assist in pioducing such a degree of irritation as shall coun- teract tbe soporific quality ofthe poison, a large blister may be put between the shoulders, and sinapisms, to the palms of the hands and soles of the feet. The nostrils may be irritated from time to time with a feather dipped in the liquor vol. cornu cervi. With the like view of obviating the torpor ofthe stomach, and stimulating the whole system, it would appear advisable to give * See Traite des Poisons, 8ic. par Mons. Orfila. VEGETABLE POISONS. 80S considerable doses of ammonia. Indeed we are informed by a mod- ern writer*, that be has obsened where any of the narcotic poisons, particularly opium or hyoscyamus, has been swallowed, and an alarming stupor has continued for many hours, notwithstanding every effort made by the by-standers, a spoonful of a strong solution of ammonia has awakened tbe patient, and enabled him by words to express the benefit he has received from it; and by a repetition of the medicine, as tbe stupor returns, the sensibility and irritability have been gradually restored. There can be no doubt but that strong stimuli will be necessary as soon as the effects of the one constituting the disease are observed to be subsiding, and the system discovers marks of sinking. In this state we ought therefore not only to employ frictions externally with salt, as have been directed, and excite the action of the intestinal tube by irritating clysters, but we should give ammonia, with as much brandy as can be got down into the stomach, even by tea-spoonsful at a time. Where the cause of death is the cessation of the functions of the lungs, as in cases of suffocation, inflating these organs is generally recommended. Possibly the same mode of treatment might be employed wilh advantage as an auxiliary for the recovery of persons labouring under the effects of opium and other vegetable poisons. Cases of poisoning by henbane, and other vegetable narcotics, require much the same kind of treatment as those by opium or its preparations. In cases of poisoning by fungi, Mons. Orfila advises that the stom- ach and bowels should be first cleared as quickly as possible by a mixture composed of three or four grains of tartarized antimony, twenty-four grains of ipecacuanha, and from six drachms to one ounce of the sulphate of soda, with a proportionate quantity of water. Castor oil may afterwards be given, and likewise purgative clysters. The poison being freely evacuated, spoonsful of a potion containing a large dose of aether should then frequently be swallowed, and re- course be had to mucilages and other demulcents, should the patient complain of any pain in the abdomen. If the poison, however, has been taken long before the assistance of the practitioner is required, and inflammation has already come on, then such evacuants would not be proper: bleeding and other antiphlogistic means must be re- sorted to. Vinegar is useful only when the poisonous fungus has been ex- pelled by vomiting; but as long as it remains in the stomach ihe reverse is said by this able writer to be the case, as the acid dis- solves the poisonous principles, and thereby facilitates its absorp- tion. Muriate of soda (common salt) acts in the same manner as vinegar, and therefore requires to be employed under the same * See Dr. Stone's Treatise on the Diseases oi" the Stomach 804 AERIAL POISONS. limitations. Sulphuric aether, as it also takes up the poisonous part of the fungi, should not be used previous to the evacuation of the stomach, but afterwards it will be of great utility. Volatile alkali is more hurtful than salutary, and oil, butter, and milk, are useless in this kind of poison. Several cases of accidental death have of late occurred from taking oxalic acid in a mistake for common purging salts, to which it indeed bears a strong resemblance. This acid is used in various domestic purposes, particularly for cleaning boot tops and other articles of leather, and persons using it are too apt to leave it about in a careless manner. The appearances on dissection of those who are destroyed by this poison are as folio-v : the cuticular coat of the oesophagus peels off with the slightest effort; the blood-vessels of the inner coat of the stomach appear as if injected with a carbonaceous substance; the stomach itself is in some cases so perforated that its contents escape into tbe cavity of the abdomen, whilst the other part is so tender that it tears with the slightest force : the spleen and other parts contiguous to the stomach, by the acid falling upon them, also become in part destroyed. From some experiments made by Dr. Thomson* it appears, that oxalate of lime does not produce any deleterious effect when swal- lowed; and that a mixture of chalk and water, if taken, by produ- cing oxalate of lime in the stomach where oxalic acid has been pre- viously swallowed, may be regarded as the antidote of that acid, when exhibited very soon after the poison has been swallowed. Of AERIAL POISONS. The external appearances of persons suffocated by the deleterious fumes arising from charcoal, various metals, such as copper, lead, antimony, mercury, &c. as well as in consequence of sleeping in un- ventilated apartments, or respiring the foul air of wells, caverns, and mines, are as follow :—the head, face, and neck are swoln ; the eyes are propelled from their sockets; the tongue is protruded at one side of the mouth ; the jaws are firmly closed; the face is of a livid, and the lips are of a deep blue colour ; tbe abdomen is inflated ; the body is insensible to pain, and the person appears to be in a profound sleep. The first symptoms which the patient experiences on inhaling air vitiated with these deleterious fumes are, giddiness, headach, lethargy, fainting, convulsions, and general torpor. Immediately on discovering a person who has been suffocated by any kind of deleterious fume, the windows and doors ought to be thrown open, and the body be undressed and exposed freely to cool air, being supported at the same time in a leaning posture on a * See No. 17, p. 388, of the Londou Medical Repository. AERIAL POISONS. 805 chair : after a little time it must be covered with flannel or blankets, the face be sprinkled with vinegar, and the pit of the stomach with cold water. The legs may also be put into a cold bath; and as it is a well-known fact, that the recovery of the dogs which are made the subjects of experiment in the Grotto del Cani, is much favoured by their being plunged into a neighbouring lake, possibly a sudden im- mersion of the whole body in cold water might be of service. After each application of vinegar and water, the skin ought to be rubbed with flannel or a soft brush, the temples and inside of the nostrils be stimulated by applying volatile spirits, and bottles filled with warm water be laid to the soles of the feet, then leaving the person for a few minutes in an undisturbed state. Farther, clysters consisting of vinegar and water will be useful; and on the return of life an incli- nation to vomit should be promoted by a feather dipped in oil, while gentle friction is to be continued at intervals. The first symp- toms indicaling this happy change will be, foaming at the mouth and shivering of the whole body, especially after affusions of cold water. Where the means which have been mentioned fail in reanimating the patient, it will be advisable to employ the united powers of elec- tricity or galvanism : repeated shocks of either of which, particularly the latter, may be passed through the chest. Blood-letting, and the artificial introduction of air into the lungs by means of a pipe or bel- lows adapted for the purpose, are also to be tried. If these efforts prove successful, so that the patient seems again to breathe, he may then inhale oxygen gas. When he is able to swallow, the most proper drink will be vinegar and water, or some other acidulated liquor. In Russia tbe common people are frequently deprived of sensa- tion by vapours arising from the following cause :—Persons of rank in that country have double windows to their houses in winter, but those ofthe poorer classes are only single. During frosty weather, an incrustation is formed on the inside of those windows, from a con- densation of the breath, perspiration, he. of a number of persons living together in tbe same room. This mephitic crust is mixed with the noxious fumes of candles, and of the stove with which the chamber is heated. When a thaw succeeds, and this plate of ice is converted into water, a deleterious principle is disengaged, which produces effects similar to those arising from the fumes of charcoal. The method of recovering persons affected by this effluvium is as follows :—They are immediately to be carried out of doors and placed on the snow, with no other covering but a shirt and linen drawers. Their temples and the region of the stomach are then to be well rubbed with snow, and cold water is to be poured down their throats. The friction is to be continued till the livid hue of the skin disappears, and the surface acquires its natural odour. 806 ANIMAL POISONS. Of ANIMAL POISONS. Several of these have already been mentioned, and their mode of operation noticed under the heads of Hydrophobia, Syphilis, Cancer, and Contagion. It only therefore remains to treat of the poison of venemous snakes, the viper, and some peculiar kinds of fish, the last of which in warm climates is frequently attended with fatal con- Sequences. In many parts of India persons working in the fields are often bitten by venemous serpents; and as no puncture is to be observed very frequently, the poor fellows* are apt to attribute the uneasiness at first to the pricks of thorns, thistles, he. A few minutes, however, never fail to exhibit the real state ofthe case; the unfortunate victim becoming sick, with cold sweats and stupor, and gradually sinking, perhaps occasionally convulsed, into the arms of death. Few, we are told, survive more than half an hour, and some die within a few minutes. The symptoms which attend on the introduction ofthe poison ofthe rattlesnake into the blood are ;—nausea; a full, strong, agitated pulse; swelling of the whole body; eyes much suffused with blood; sometimes copious bloody sweats; and often hemorrhages from tbe eyes, nose, and ears; the teeth chatter; and the pains and groans of the sufferer indicate approaching dissolution. The poison of this reptile is generally of a yellowish, somewhat greenish colour, which becomes darker in hot weather. During the coupling season it is observed to be more active or virulent than at any other. So deadly are its effects that it has been known to kill a dog in a few minutes. When a person has been wounded by a venemous snake, the first step to be adopted is, to pass a tight ligature above the injured part (where capable of such an application), so as to prevent the further absorption of the virus into the system, and then to evacuate that which has already been admitted by sucking the wound, as practised by the Creek Indians with impunity, and by afterwards promoting discharges of blood and serum from it by means of scarifications, cupping, excision, or the application of caustic. In bites of the rattlesnake, cobra capello, he. cutting out the wounded part as quickly as possible, and afterwards immersing the limb in warm water so as to encourage the bleeding, together with the internal use of opium to allay irritation and pain, have in some instan- ces proved a successful mode of treatment. Soap-lees, volatile alkali, and the spiritus ammonia? succinatus, and eau de luce, have all been found excellent applications to wounds inflicted by the rattle and other venemous snakrs, provided they have been used immediately after the accident. The last re- medy is likewise used internally in the East Indies in the proportion • See Oriental Field Spoils. ANIMAL POISONS. 807 pf a tea-spoonful to a wine glass-ful of water, and by being repeated a few times, is said to be attended with a happy effect. The fresh juice of the rattlesnake-plantain, applied to a wound of this nature, is said to be a powerful antidote against the poison of this reptile. We are told by Captain Carver, in his T#avels through North America, that so conduced are Ihe Indians of the power of this antidote, that for a trifling bribe of spirituous liquor they will at any time permit a rattlesnake to drive his fangs info their flesh. He likewise speaks of salt as an effectual remedy against the bite of this reptile, provided it is applied immediately to the wound in a strong solution. When through neglect the venom has been absorbed, all that can be done is to excite a strong perspiration by means of emetics and powerful sudorifics. This, we are informed by Dr. Barf on*, is effected in a violent degree by the juice of the garden-rue, which the Indians in Jersey give in the dose of two table-spoonsful every two hours. Where this is not to be obtained, or ready at hand, we may ad- vise large doses of Venice treacle, with volatile aromatic spirit and aether, which may be frequently repeated, tbe patient drinking a little warm rum and wafer after each. The use of oil, as a remedy for the bite of serpents, was long ago recommended in the Philosophical Transactions of the Royal Society of London ; but from subsequent experience it seems to have received no sanction. Of late, however, its efficacy has been asserted, in cases ofthe bite of the rattle-snake, by Mr. J. Miller, of Pendleton county, North America. He observes, that in a great number of instances, olive-oil, taken inwardly, in the quantity of a few spoonsful, and applied also to, the bitten part, has proved itself fully adequate to the worst of cases, if timely exhibited. In bites of other venemous serpents the same mode of treatment must be adopted, as has just been advised. The aristolochia, or snake-wood, taken inwardly in the form of infusion, and applied externally in that of poultice, is much used by the negroes against venemous bites ; as is also a species of grass called chichen-foot, which is commonly mixed up by them with a little salt and spirits, so as to make a cataplasm of a proper consistence. Dr. Bancroft mentions, in his History of Guiana, that fhe general remedy for the bites of poisonous animals is a cataplasm of the pulp of lemons mixed up wilh sea-salt, and applied to the wounded part; and this he has frequently found of use when previous scari- fication had been employed. In the sixth volume of the Asiatic Researches, there is a commu- nication on the poison of serpents, by W. Boag, Esq. ; and after having taken an extensive view of the ancient methods of effecting * See Transactions ofthe American Philosophical Society, held at Philadelphia, vol. iii. 808 ANIMAL POISONS. a cure thereof, all shaded with doubt and suspicion, he ultimately recommends, as a specific in this dreaoiiil malady, the argenti nitras : a remedy Ions; ago proposed by Fonlana, who mixed the venom with this caustic, and found that it was thereby rendered entirely innocent. Mr. Boag supposes that the poison of serpents acts upon the blood by subtracting the oxygen, which it receives from the atmosphere in its passage through tbe lungs, and upon which its vitality depends. In the second volume of the same work, page 323, we are fa- voured with an account, by J. Williams, Esq. of the surprising efficacy of a remedy against (he deleterious effects of the bite of several snakes, and especially of the cobra di capello. It consists in the external application to the bitten part, and likewise internal exhibition of liquor ammonia;. We are told that the remedy has been found to put a sudden stop to the baneful effects ofthe poison of this reptile, and possibly that it may have a similar power in the bites of the rattlesnake, viper, &c. In the bite of a rabid animal, when the patient will not consent to have the wounded part ex- cised, or even after it is cut out, this remedy might be tried. Poisonous serpents are best distinguished from those that are innoxious by an accurate inspection of their teeth ; the poisonous ones, or fangs, being usually of a tabular structure, and furnished with a small hole or slit near the tip : they are rooted into a particular bone, so jointed to the rest of the jaw on each side as to permit the fangs to be raised or depressed at the pleasure of the animal. Above the root of each is a glandular reservior of poisonous matter, which, in the act of biting, is pressed into the tube, and discharged into the wound through the hole near the fip. In general the fangs are single on each side, but sometimes they are double and even triple. There are usually small or young fangs situated at the base of the larger ones ready to grow up, and supply the place of any which may be lost by accident or violence. It may be said that innocent serpents have four rows of teeth in the upper jaw, two on the palate, and the rest on each side, but that poison- ous serpents have no outward or side teeth but the fangs. Dr. Russel tells us*, that in serpents not venemous there are three rows of common teelh in the upper jaw ; in the poisonous kinds the external row is wanting. The symptoms which attend on a bite of the viper are, acute pain iu the wounded part, together with a considerable degree of swelling, that is at first red, but which afterwards becomes livid, and diffuses itself over fhe neighbouring parts. After a short time the constitutional symptoms make their appearance ; the person becomes faint, the pulse is small and intermitting, nausea and vom- iting ensue, the skin has a yellow tinge, and death not unfrequently is the con.eqiionce. * See his Account of Indian Serpents. ANIMAL POISONS. ^809 The treatment to be adopted in a case of this nature must be pretty similar to that which has been advised for the bite of the rattlesnake, viz. preventing tiie absorption of the matter into the system by means of a ligature above the part, and destroying the virulence of that which has been introduced into the wound, by scariications, cup- ping, excision, caustic, or the application of soap-lees, volatile alkali, or the spiritus ainmoniae succinatus: employing strong dia- phoretics internally at the same time in order to determine to the surface. As an external application, a poultice of quick-lime with oil and honey has been recommended, as has likewise a cataplasm of garlic. This last has also been given internally with advantage. The bite of the snake or adder of this country is attended with symptoms of a similar nature, but they are not so violent, neither does it often prove fatal. Much the same treatment is to be adopted as in the former cases. Europeans on their first going out to the West Indies and other tro- pical situations, usually suffer very much from the bite of moschetoes. They are a species of gnat, and on whatsoever part these pitch they immediately produce small tumors, which are attended with so high a degree of itching and inflammation that the person cannot refrain from scratching, by a frequent repetition of which he not uncom- monly occasions them to ulcerate, particularly if he is of a robust and full habit. To allay the itching and inflammation the parts may be bathed frequently with a solution of opium in water, or with the liquor plumbi subacetatis sufficiently diluted. The liquor ammonia? sub- carbonatis is likewise a good application. It will at the same time be necessary to make use of some cooling laxative and a spare diet. Where pustules arise on the parts that have been bitten, opening them with a lancet about tbe third day and letting out the watery matter, will be proper. Those who suffer much from the bite of these insects should wear gloves and long linen trowsers by day in order to defend the extrem- ities from their attacks; and by night they should sleep under the eover of a net, which being usually made of thin lawn or gauze, is perfectly cool, and effectually shuts them out. The topical applications for the bites of scorpions, centipedes, spiders, and wasps, are the same as advised for those of moschetoes. Olive-oil is, however, much made use of also as an external appli- cation. In this country some kinds of fish, such as eels, salmon, herrings, and, in peculiar constitutions, muscles, lampreys, and even lobsters, independently of their putrescency, give a singular irritation to the system, and during their digestion in the stomach nccasion a con- siderable efflorescence on the skin, sometimes partial, and at other times over the whole body; sometimes with a considerable febrile 102 $1© ANIMAL POISONS. disorder, and at other times with very little. In warm climates we however meet very frequently with fish possessed of the most dele- terious quality. The barracuda (perca major), king-fish (xiphias), cavallee (scamber), rock-fish (perca marina), smooth bottle-fish (os- tracion glabellum), and yellow-bill sprat, are the fish most to be dreaded. The latter possesses a poisonous virus to an extent almost incredible, and has in several instances been known to destroy life in the space of half an hour by exciting dreadful convulsions. The conger eel, as likewise the large white land-crabs, that feed on the leaves ofthe manchineel-tree, are also frequently poisonous, and pro- ductive of violent cholera. Tbe cause of this deleterious quality in fish has given rise to va- rious conjectures. Some are inclined to think there are two dis- tinct varieties of the same fish ; others impute it to copperas-banks on or near which tbe fish feed; and others again think tbat it pro- ceeds from their particular food, which, although not hurtful to them, tinctures them nevertheless with a poison deadly to many other creatures. Of all these conclusions the last seems to be the best grounded, as it is an indisputable fact, attested in innumerable instan- ces, that when the fish is removed off the book, if the precaution is ta- ken to gut it immediately and salt it, k seldom or never creates any disorder, or at most only in a very slight degree, even if of ever so poisonous a nature. Except in the sprat and cavallee, no two distinct varieties of tbe same fish are to be observed ; and with respect to copperas-banks in the West Indies, their existence is a mere supposition, never having been satisfactorily ascertained. Even if tbe fact was fully established, still it is well known that this substance, or a solution, of it, is inevitably fatal to all fish. The circumstance of the alimentary tube being more poi- sonous than any other part of fish, is certainly a strong confirmation that its deleterious quality is owing to the food ; the muscular parte being only slightly tinctured by the chyle and blood conveyed to them, while the greater part of the poison remains in. the guts. I think we may rest well assured that the poison lies in the intestinal tube, is assimilated with tbe food of the fish, and circulates without any detriment to it; and, moreover, that the longer the fish remains out of water, the more violent the poison becomes ; but what really forms the basis ofthe poison has never been yet accurately ascertain- ed. It is indeed a curious circumstance, that tbe same fish which is perfectly innocuous at one period, often is highly pernicious at another. Certain and rapid death is almost sure to ensue from eating the. yellow-bill sprat; but from a use of most other kinds of poisonous fish the person is seized, after a few hours, with languor, heavi- ness, and faintness, succeeded by great restlessness, flushings in the face, giddiness in tbe head, cardialgia, nausea, griping pains in tbe bowels, and a severe vomiting, and purging. The ANIMAL POISONS. 811 burning which was felt at first only in the face and eyes, is at length extended over the whole body, but more particularly the palms of the hands and soles of the feet, and is often succeeded by an eruption or efflorescence, rising up in large bumps similar to bug-bites, or the nettle-rash. The pulse is usually hard and frequent at first, but it soon becomes low and feeble. With the ardor of the skin there is invariably a prickly sensation in the hands when immersed in cold water, which particular symptom may always enable us to decide with confidence on the real nature of the disease. In some cases the neck of the bladder, urethra, and sphincter ani, are likewise affected with ardor, and the patient experiences a diffi- culty of making water, together with a considerable degree of tenesmus. Some navigators, whose crews were much affected by eating fish of a poisonous nature, have informed us, that a swelling of the salivary glands, accompanied by a profuse spitting, was a symptom which very frequently attended. In the few cases which fell under my care during my residence in the West Indies, no such symptom ever was apparent. In the advanced stage of the disease, I observed that tbe whole sur- face of tbe body acquired a deep yellow hue, as in jaundice, and that the urine was likewise highly tinged of the same colour. Even the perspiration gave a deep yellow tinge to the patient's linen. These appearances took place in a very high degree in one or two cases, but more particularly so in my own, as I was so unfortunate as once to experience the deleterious effects of a poisonous rock-fish. Where a large quantity of the poison has been taken. er it has been of so deadly a nature as to prove fatal, the patient generally goes off in strong convulsions; but where the quantity and nature of the poison have not been so powerful as to occasion death, and the violence of the disorder suffers some abatement, the body becomes emaciated, the cuticle peels off in various parts, but more particularly in tbe palms of the hands and soles of the feet; the hah* drops, and acute shooting pains in tbe articulations of the wrists, knees, and ankles, and sometimes in tbe cylindrical bones, are felt for a considerable length of time. From the great debility which is induced, it not unfrequently happens that cedematous swellings of the lower extremities ensue. The poison of fish is always attended with much immediate danger; and even when the person does not escape its deadly conse- quence, his constitution uncommonly receives so severe a shock, that, in order to restore its wonted vigour, he will find it necessary to visit a cold climate. The necessity of this step I wofully experienced, and years elapsed before the desired end was ob- tained. The intentions of cure in affections of this nature, are, first, #12 ANIMAL POISONS. to procure a discharge of the poison as quickly as possible; and, secondly, to counteract or alleviate tbe effects that arise from it. The first of these intentions is to be answered by giving a smart emetic of tartarized antimony or the sulphate of zinc, together with copious draughts of diluent liquors, as advised under the head of Mineral Poisons. Where the person is of a full plethoric habit, and capable of bearing evacuation, it may also be advisable, after the ope- ration of the vomit, to give some proper purgative, as the oleum ricini, which, as oil is found highly useful of itself in many kinds of poison, may be attended with a double effect. Where there is great irritation Of the stomach without much purging, we may substitute the submu- riate of mercury*, which, being made into pills, may, from the small- ness of bulk, be more likely to be retained. To answer the second intention, we must employ such remedies as have been found to possess a power of counteracting the poison in some degree. Spirituous liquors and other strong cordial", have long been supposed to have a considerable power of obviating tbe deleterious effects of poisonous fish. The conclusion is, I think, well grounded, as it has been observed in most cases, that those who have taken a small quantity of ium or brandy afler eating fish of this nature, have suffered considerably less than those who neglected that precaution. Dr. Clarke, of Dominica, in a letter to Dr. Simmons, of Londonf, observes, that capsicum (Cayenne pepper) has long ago been known to possess the power of counteracting the poisonous effects of fish. If this was really a fact, we should seldom or never bear of any accident of this nature, as the negroes use a considerable quantity of the fresh capsicum with every article whatever of their food. It is probable, however, that it may be employed with rectified spirit and other sti- mulants with some advantage. An infusion of the sensitive plant has been mentioned as a re- medy from which some benefit may be derived in cases of fish poison. I have made trial of it, but cannot report any thing in its favour. Besides employing stimulants internally, to counteract the effects of the poison, we should attend to the symptoms which are most urgent. If the vomiting and purging continue, although proper evacuations have been premised (which frequently happens), we must then have recourse to opiates, administered by the mouth, t See vol. vii. of Medical Facts and Observations, p. 289. 1. R, Hydrargyri Submuriat.gr. vj.—xij Extract. Colocynth. C. gr. x. 1. Take Submuriate of Mercury, six to twelve grains. Compound Extract of Colocynth, ten grains. 9P"» Sr- J- Opium, one grain. Syrup. Simp. q. s. AJ. I Syrup, a sufficiency- Mix them. Fiant pilulae v. pro do«. J Let five pills be formed out of the mass for a dose. ANIMAL POISONS. 813 as advised under the head of Cholera Morbus, and exhibited in clysters, along with mutton broth, or a solution of starch. Con- siderable doses of opium will be necessary likewise where the patient becomes convulsed, and they will require to be frequently repeated. To allay the heat and dryness of the skin, and determine to the surface ofthe body, it will bp proper, after the irritation ofthe stomach has ceased, to give small doses of the pulvis ipecac, compos, pulvis antimonials, or pulvis Jacobi, as recommended under the head of Simple Fever, together with a free use of diluent liquors. Where any degree of strangury is present, these last will more immediately be necessary. Under the supposition that the poisonous quality of the fish before noticed is occasioned by tbeir feeding on the moss which grows on copperas-banks, a late writer on the subject* tells us, that in the treat- ment of such cases during his residence in the West Indies, his object was to decompose the poison; to effect which, he almost en- tirely depended on alkalies in simple solution with water. He never tried, however, the volatile alkali, although he thinks there can be little doubt of its efficacy in counteracting the poison of fish, whatever the basis of it may be. The pains in the joints are sometimes very obstinate, and yield only to a considerable lapse of time. Covering the parts with flannel, together with the frequent use of a tepid bath, and drinking mustard- whey, or a decoction of guaiacum or mezereon, will be the most likely means to afford relief. To obviate the debility which arises in consequence ofthe disease, and restore vigour to the system, the patient must enter on a course of tonies, as recommended under the head of Dyspepsia; and where these do not prove sufficiently efficacious, he should remove, without further loss of time, to a cold climate. As fish forms a great part of the diet of the inhabitants of the West Indies, and is daily served up at most tables, it may be of some im- portance to be able to distinguish those of a poisonous nature from such as are wholesome. The surest criterion to judge by is to give the entrails to a dog, cat, or duck, and if after an hour or two no disor- der arises, the fish may be eaten with safety. Another method much practised, however, i»s to put a silver spoon for some time into the water in which the fish is boiling, and if upon taking out the spoon it appears unsullied, the fish is supposed to be safe ; but if the colour be at all changed, it is then judged unwholesome. This test should never be depended upon. From the observations of fishermen, it appears that fish which have ao scales are most apt to prove poisonous. Those of uncommon magnitude are regarded by them as highly suspicious. To obviate the poisonous effects of muscles, lobsters, oysters, eels, he. a smart emetic should be administered as quickly as * See Dr. Chisholm's Communication, No. 16 of the Edinburgh Medical Journal 814 SUSPENDED ANIMATION. possible, and then the patient may take the acetous acid, and likewise milk. Of SUSPENDED ANIMATION and RESUSCITATION. In consequence of drowning, and also of suffocation and strangula- tion, a considerable check is often given to tbe principle of life, with- out wholly extinguishing it. When it happens from the first of these causes, tbe circulation becomes gradually more feeble and slow, and much anxiety is felt about the praecordia ; to relieve which the person attempts to rise to the surface of the water; he then discbarges a quantity of air from the lungs, and receives into them a very small portion of water, when he again sinks. After struggling in this man- ner for some short time, convulsive spasms arise, the organs of respi- ration cease to act, and he at last expires ; soon after which the skin becomes of a purple or blue cast, particularly about the face and neck, and the body sinks. It has been supposed, and the opinion is indeed still very general among the common people, that in the act of drowning the water enters the lungs, and completely fills them. Experience, however, has shown, that unless the body lies so long in tbe water as to have its living principle entirely destroyed, the quantity of fluid present in the lungs is inconsiderable; for upon drowning kittens, puppies, &ic. in ink, or other coloured liquors, and afterwards examin- ing these viscera, it has been observed that very little of the coloured liquor has gained admittance to them. The circumstance may readily be accounted for by recollecting that the muscles which form the opening into tbe trachea are exquisitely sensible, and con- tract violently upon the least irritation, as we frequently experience when any part of the food or drink happens to come in contact with them. When a person dies from suffocation, the symptoms are nearly the same as in apoplexy.—See Aerial Poisons. The phenomena which attend on strangulation are, convulsive paroxysms, superadded to the apoplectic symptoms. Livid and dark-brown spots on the face, with great rigidity and coldness of the body, a glassy appearance of the eyes, and a flaccid slate of the skin, denote a perfect extinction pf life : but the only certain sign is actual putrefaction; and therefore in every case where this symptom is not present, and where we are unacquainted with the length of time the body may have been under water, every possible mean should be employed immediately upon its being found for restoring it to life, as the noble machine may be stopped, and the spring nevertheless still retain, in some degree, its elastic vigour. Dissections of those who have died by drowning, show that an accumulation of blood in the venous system forms the great morbid change which takes place in accidents of this nature. Tbe lungs SUSPENDED ANIMATION. 81&' are in a state of collapse, and the accumulation of blood is confined fo the vena cava, the heart, and the parts of the venous system. In some cases, the stomach is found to contain a small quantity of water ; in others, none is to be perceived. From the muscles of the trachea having lost the principle of life, upon which the power of muscular contraction depends, they become relaxed, the water enters the wind-pipe. In all instances, the external surface of the brain appears of a highly florid colour, without any great distention of vessels, or marks of effusion. It has been supposed, however, by many, that persons who die by drowning, suffer from the intervention of apoplexy. After a recovery from apoplexy, the person is generally paralytic, whereas no such event follows the recovery from a suspension of life by drowning. In both hanging and drowning, the proximate cause appears to be the stoppage of air to the lungs, which the following experiment, made some years ago by an eminent medical professor at Edinburgh, clearly confirms. A dog was suspended by the neck with a cord, an opening having been previously made in the wind-pipe below the place where the cord was applied, so as to admit air into the lungs. In this state he was allowed to hang three quarters of an hour, during which time the circulation and breathing went on. He was then cut down, without appearing to have suffered much from the experiment. The cord was now shifted below the open- ing into the wind-pipe, so as to prevent the ingress of air fo the lungs ; and the animal being again suspended, he was completely dead in a few minutes. The appearances exhibited on dissection, in cases of strangu- lation and suffocation, are pretty similar to those in drowning, except the absence of wafer in the lungs and stomach : and that in these instances there is always a greater turgescence in the vessels of the pia mater. The following are the means to be employed for the recovery of persons recently drowned. As soon as the body is taken out of the water, it is to be speedily 6onveyed in men's arms, or placed upon a door, or in a cart upon straw, if the distance is considerable, to the nearest house, where it is quickly to be stripped of the wet clothes ; to be wiped per- fectly dry ; and then to be laid between warm blankets, spread upon a mattress or a low table, and on the right side in preference to the left, in order that the passage of the blood from the heart may be favoured by the position. The head is at the same time to be covered with a woollen cap, being properly elevated with pillows, and bags filled with warm sand, or bricks heated and wrapped in flannel, are to be applied to the feet. The doors jind windows of the apartment are to be thrown open, in order that the cool air may be freely admitted, and no persons but such as are necessary to give due assistance, should be allowed fo enter it. Having taken these steps, we should next endeavour to expand the lungs, and make them, if possible, reassume their office, 816 SUSPENDED ANIMATION. When not furnished with a flexible tube nude of elastic gum, and of a sufficient length, or with the bellows invented by Mr. Hunter for this express purpose (which is of such a construction, that, by one action, fresh air is thrown into the lungs, and by another it is thrown out again, so as to imitate or produce artificial breathing), we must be content with blowing in air by means of a common pair ; or by inserting a pipe info one nostril, compressing the other, shutting the person's mouth at the same time, and then blowing through the pipe with a considerable degree of force. By any of these means we may be able to inflate the lungs. At the same time that the lungs are inflated, we should rub every part of the body with warm flannel cloths. On all occasions it will be the best way to divide the assistants into two sets ; the one being employed in endeavouring to restore the heat of the body j the other, in instituting an artificial breathing in the manner just pointed out. Should the frictions not be attended with any effect, we ought to apply flannel cloths, wrung out in very hot water, over the heart and thorax, or we may put the person into a warm bath. A high degree of heat will not be necessary ; a moderate degree will be suificient. If the weather be under the freezing point, and the body, when stripped, feel cold, and nearly in the same con- dition with one that is frozen, it will be necessary at first to rub it well with snow, or wash it with cold water; the sudden application of heat in such cases having been found very pernicious. In a short time, however, warmth must be gradually applied. To assist in rousing the vital principle, it has been customary to apply various stimulating matters, such as common salt, and recti- fied and also volatile spirits, to different parts ofthe body ; but as the skin loses its sensibility in proportion as it is deprived of heat, and does not recover it again until the natural degree of warmth be restored, it is obvious that previous to the restoration of heat, all such applications are useless. Rectified spirits evaporate first, and thereby, instead of increasing warmth, as they are expected to do, carry off a part of the heat from the body. Volatile spirits are liable to the same objections, and are besides distressing to the eyes of the assistants. Common salt quickly frets the skin, and has, in some cases, produced sores which were difficult to heal after recovery. When there is reason to think the skin has, in some degree, recovered its sensibility, the wrists, ancles, temples, and parts over the stomach and heart, may be rubbed with a little of the linimentum ammoniae subcarbonatis, which will evaporate but slowly, and produce no cold in being rubbed in. In cases of suspended animation, it has likewise been usual to stimulate the stomach and intestines ; the former by means of some moderately warm liquor, such as negus highly spiced, introduced into the organ through a flexible tube, and the latter by means of in- jections. Some time ago it was the practice to employ the smoke of fpbacco ; but this, instead of answering our wishes, would prove SUSPENDED ANIMATION. 817 injurious, by further depressing the vital principle. Instead of it, we may recommend a clyster, consisting of a pint or more of water, mo- derately warmed, to which may be added a little volatile spirit, essence of peppermint, or rectified spirit. Electricity is sometimes had recourse to, in order to promote a restoration of life : unless employed by insulation alone, it will however be more likely to do harm than good. Tbe body may be completely insulated, by placing it on a door, supported by a num- ber of quart bottles, whose sides are previously wiped with a dry towel, to remove any moi>»ture they may have contracted. Moderate shocks are found to answer best, and these may, at intervals, be passed through the chest in different directions. They may likewise be sent through the limbs, and along the spine; but it is doubtful how far it is sale to pass them through the brain, as many have re- commended. From some late experiments made by Professor Aldini, of the University of Bologna, on the body of a malefactor who was executed for murder in London, it would appear that galvanism, as an auxiliary, promises great advantages to the interests of human- ity, incases of apparent death by drowning, and others of asphyxia. Before dissection, the corpse «as made to exhibit very powerful muscular contractions, and these continued for upwards of seven hours. On the first application of galvanism to the face, the jaw of the deceased criminal began to quiver, and the adjoining muscles were horribly contorted, and one eye was actually opened. In the subsequent part ofthe piocess, the right hand was raised and clench- ed, and the legs and thighs were set in motion. We are fur- ther told, that it appeared to the uninformed part of the by- standers, as if the wretched man was about to be restored to life. The mode recommended by M. Aldini for tbe employment of gal- vanism, as a mean of restoring suspended animation, is as follows. He immerses tbe hand in a solution of muriate of soda, and establish- esanarc, one of the extremities of which is made to pass round the fore-arm, while the other is brought in contact with the bottom of the pile. He adapts to the extremity of another arc an elastic probe, which is applied to one ofthe ears, moistened by means of a syringe with the same solution, and connects the other extremity of the arc with the summit of the pile. Bleeding is a remedy which is sometimes employed in cases of a suspension of tbe vital powers from drowning. Where stupor, head- ach, he. remain after the person has come to himself, it certainly will be advisable to draw off some blood, and possibly the best way of doing it viill be by the application of leeches to the temples; but where these symptoms do not prevail, or before the natural heat is restored to the body, bleeding in any manner will be more likely to do harm than good, by hazarding the entire destruction of those feeble powers which yet remain, to increase and support which our best endeavours should be directed. 103 318 SUSPENDED ANIMATION. Hanging the patient by the heels, as is sometimes adopted by the ignorant in cases of suspended animation from drowning, under the mistaken principle that this is induced by the water taken into the stomach and lungs, or both, is a most dangerous practice, calculated only to extinguish the spark of life, if any remained, and consequently to exclude every hope of recovery. The means which have been advised are diligently to be perse- vered in for a considerable time, and the case by no means to be given up as irretrievably lost until at least after the expiration of four or five hours' trial, as recoveries have been effected to this extent. When the patient is so far recovered as to be able to swallow, he should be put into a warm bed, with his head and shoulders properly elevated with pillows. Warm wine whey, or any other light and nourishing drink, should now be given in moderate quantities at a time, and a gentle diaphoresis promoted by wrapping the feet and legs in flannels well wrung out of hot water. If the stomach and bowels feel distended and uneasy, a clyster composed of a pint of warm water, with about an ounce of purgative salt dissolved in it, and a little oil, may be administered. The general practice in this case is, to give an emetic; but from the powers of the machine being still very weak, the agitation of vomiting would appear somewhat hazar- dous. The patient should on no account be left alone, until the sen- ses are perfectly restored, and he is able to assist himself, some per- sons having relapsed and been lost, from the want of proper attention to them, after the vital functions were, to all appearance, tolerably established. In cases where life is suspended by hanging, the same means re- commended for drowned persons are to be pursued, with the addition of opening the jugular veins, or applying cupping-glasses to the neck, which will tend considerably to facilitate the restoration of life, by lessening the quantity of blood contained in the vessels of the head, and thereby taking off the pressure from the brain. Except in persons of a full plethoric habit, the quantity drawn off need seldom exceed an ordinary tea-cupful, which will in general be sufficient to unload the vessels of the head, without weakening the powers of life. With regard to the method of treatment to be adopted in cases of general torpor from cold, the same caution and reserve in the application of heat do not appear to be so necessary as in those of benumbed or frost-bitten limbs. In the former, the principal in- dications to be kept in view are to communicate heat, and to excite the respiration and circulation. The patient may be safely brought into a warm room, provided it be, at tbe same time, well ven- tilated. He should be immediately chafed with warm flannels over the whole body, but more particularly the trunk; his nostrils, temples, and epigastric region should be rubbed from time to time with liquor ammoniae subcarbonatis, and his lungs be inflated. As soon as he ha> so far recovered as to be able to swallow, it will DISEASES OF PREGNANCY. 819 doubtless be proper to give him some warm and gently stimulating drink, by spoonsful at a time. While the,, body is cold, and the circulation and respiration are languid, I think blood-letting would be improper. If, however, after these functions and the natural temperature are restored, the patient should remain any time in a comotose state, with a strong full pulse, the propriety and necessity of venesection can hardly be doubted. Before I close this subject, I think it proper fo observe, that in all cases of drowning, as well as in every other instance where death appears to be the consequence of apoplexy, syncope, lethargy, hysteria, or asphyxia, &c. we should be cautious in not allowing the body to be interred until evident signs of decomposition or putrefaction are apparent; as the suspension of respiration, rigidity of the limbs, abolition of sensation and motion, the want of pulsa- tion in the heart and arteries, coldness of the body, and the col- lapse, opacity, and wani of lustre in the eyes, are but equivocal symptoms of death, and ought not therefore to be relied on alone. FROST-BITTEN. If a person has exposed his hands and feet to a very severe coldj the excitability of these parts will be so much accumulated, that if they are brought suddenly near a fire, a violent inflammation and even a mortification may take place, which has indeed often happened ; or at any rate that inflammation called chilblain will be produced, from the violent action of the heat upon those parts; but if a person so circumstanced were to put his hands and feet into cold water, very little warmer than the atmosphere to which he had been exposed, or rub tbem with snow, which is not often colder than 33 degrees, the morbid , excitability will gradually be exhausted, and no bad consequences will ensue. When the hands, feet, nose, or any other part of the body have therefore been exposed to violent cold, so as to be frost-bitten, they ought at first either to be well rubbed with snow, or be put into cold water, and afterwards be subjected to warmth in the most gentle and gradual manner. THE DISEASES OF PREGNANCY. Three different stages evidently exist during a state of preg- nancy, each of which has a distinct set of symptoms ; and when we reflect on the alteration which the constitution suffers in con- sequence of impregnation, and the vast distention and dislodg- ment of the uterus which prevail at a more advanced period, we cannot be surprised at the many complaints and irregularities which then arise. The first stage of pregnancy is usually accompanied with a 826 DISEASES OF PREGNANCY. suppression of the menses, together with frequent nausea ani vomiting, heart-burn, indigestion, peculiar longings, headach, gid- diness, toothach, and sometimes a slight cough ; the breasts become enlarged, shooting pains extend through them, and the circle round the nipple alters'to a dark brown colour. There often occurs likewise a feverish disposition, with uebility, emaciation, irritability and peevishness of temper, and a total alteration of the countenance, every feature of which becomes much sharpened. Some women breed so easily as fo experience hardly any kind of inconvenience whatever : whilst others again are perfectly incapable of retaining the least thing on their stomach, and are thereby reduced to a state of extreme weakness. With some women the vomiting will continue during fhe whole or greater part of the second stage of pregnancy, as well as tbe first ; but this does not usually happen. Partial suppressions of urine, with a frequent inclination to void it ; itch- ing about the external parts of generation, costiveness, tenesmus, and the piles, are what they are chiefly incommoded by during this period. Most women quicken about the sixteenth week after conception, at which time the mother becomes sensible of the slight efforts of the child ; and besides fhe complaints just enumerated, she will then be liable to sudden faintings, and slight hysteric affections. According to the common received opinion, quickening, so termed, has been generally understood fo commence at the time when particular sensations are perceived by the mother, supposed to be occasioned by the first motion of the child. The most usual time of feeling any such symptoms is about the latter end of the fourth or beginning of the fifth month of pregnancy : at this period the uterus filling up, the pelvis slips out and rises above the rim ; and from that sudden transition, women of a delicate constitution, and irritable fibre, are apt to faint, more particularly so if in an erect position*. During the last three months, or third stage of pregnancy, general uneasiness, restlessness (particularly by night), costiveness, oedematous swellings of the feet, ankles, and private parts, cramps in fhe legs and thighs, difficulty of retaining the urine for any length of time, varicose swellings of the veins of the belly and lower extremities, and the piles, are the affections which usually prove most troublesome. In weak delicate women, of an irritable habit, convulsive fits sometimes arise, which are ever to be regarded in a dangerous light. Nausea and vomiting.—It has been observed, that frequent nau- sea and vomiting are apt to prove somewhat troublesome to preg- nant women, and in many cases to reduce them fo a state of very great debility. As these most frequently arise immediately upon * See Obstetric Studies, by Mr. James Hogben. DISEASES OP PREGNANCY. 821 first getting out of bed in the morning, the patient should be recom- mended, under such circumstances, never to rise until she has taken either a dish of tea, coffee, or whatever else she has usually accus- tomed herself to for breakfast. If the vomiting should become at any time so severe as to threaten the bringing on a miscarriage from the violence of straining, it may then be advisable to direct two or three table-spoonsful of the saline medicine to be taken every now and then in such a manner as that the effervescence shall ensue after it is swallowed ; besides which, the patients body should be kept open with some gentle laxalive. If these means do not succeed, we may order about six ounces of blood to be drawn from the arm, and which, if necessary, may be repeated in a week's time. The sickness in such cases depends on irritation, and is only to be removed with certainty by bleeding. Local applications have been recommended to abate excessive vomiting. As such, a piece of folded linen cloth, moistened with tinctura opii, may be kept constantly applied to the region of the stomach. Probably a small addition of aether might increase its good effect. It sometimes happens that vomiting is in- cessant for many days together, accompanied with great pros- tration of strength and constant thirst, and at the same time an utter impossibility of retaining any thing on the stomach. In this state the application of leeches to the pit of it, and a constant attention to suffer nothing to be swallowed that can irritate, allow- ing the patient only asses' milk, and that by single spoonsful, have been found to afford relief. If a considerable degree of nausea prevails, without the ability of throwing up, fourteen or fifteen grains of pulv. ipecac, may then be given, experience having proved that gentle emetics may be administered with perfect salety to pregnant women. Headach, with plethora.—When either headach, drowsiness, or a sense of fulness in the vessels, proves troublesome, drawing off a few ounces of blood from the arm in robust women will most likely be attended with advantage. In those of a weak, irritable habit, the application of a leech or two to each temple will be more advisable than bleeding from the system where the headach proves obstinate and resists the other means we have employed. 1 he bow- els are at the same time to be kept in a proper state by some ^Toltha^L-For the alleviation of the toothach the external as well as internal application of a few drops of the oil of cloves, cajeput, juniper, or any other essential oil, will often prove C ^eZiburn.—U the patient is incommoded by heartburn (which usually proceeds from an acidity in the stomach), half a drachm of magnesia may be taken morning and evening to obviate it : and it this fail we may then have recourse to the absorbent mixture ad- o22 DISEASES OF PREGNANCY. vised below*, which Dr. Sims informs usf he has found the most efficacious of all remedies for the removal of this distressing symp- tom in pregnant women. Longings.—When peculiar longings arise in a state of pregnancy, they should always be gratified, if possible, as women are apt to miscarry from the anxiety these occasion when not indulged in them : but that the child in utero can be marked by any depraved appetite of the mother, or be mutilated by any disagreeable object being presented to her, cannot be admitted. All aberrations from the usual form ought to be ascribed to the irregular operation ofthe powers concerned in generation, and are not produced by the ima- gination of the mother. Hysteria.—Should any hysterical affection or sudden fainting arise, little more will be necessary than to expose the patient to a free open air, to place her in a horizontal position ; and to give her a glass of cold water wilh a few drops of the liquor volat. cornu cervi- ni, or a little wine sufficiently diluted. Costiveness, Piles, he.—Costiveness, partial suppressions of urine, and the piles, which attend on the second stage of pregnan- cy, are occasioned by the great pressure of the uterus on the rectum and bladder. The first and last of these symptoms are to be obviated by a daily use of some gentle laxative, such as a solution of manna, or the electuary advised belowj. Pills composed principally of aloes (such as Anderson's), are too generally used by pregnant women for this purpose : but they are highly improper, as being of too stimulating a nature, and very apt to occasion hemorrhages and the piles. In troublesome piles, which are externally seated, the best application is leeches, and the irritation may afterwards be lessened by preparations of the plumbi superace- tas. Ten grains of this, dissolved in four ounces of rose water, form a good lotion, with which the parts may be washed frequently. If necessary, a little of the vinous tincture of opium may be added. tf See the Medical and PhysicalJournal,No. Viii. p. 206. " 1. R Masncsite, 3j- Aq. Purae, f. jvss. Spirit. Cinnam. f. 3'ij- Liquor. Ammon. f. 3,i- ft. Mistura, cujus sumat cochl. larg. ij. vel iij. pro re nata. X 2. ft Elect. Senna*, ^ij. Potassa? Supertart. 3'j- Pulv. Jalapae, 3ss- Syrup. Roso;, q- s. M. ff. Electuarium,cujus sumat a;gra molem nu- cis moschalaj hora somui, vel pro re nata. * 1. Take Magnesia, one drachm. Pure Water, five ounces and a half. Spirit of Cinnamon, three drachms. Solution of Ammonia, one drachm. Mix them, and take two or three table- spoonsful for a dose, as the occasion may require. f 2. Take Electuary of Senna, two ounces. Supertartrate of Potass, two drachms. Powder of Jalap, half a drachm. Syrup of Roses, a sufficiency. Mix them, and of this electuary the patient may take the bulk of a nutmeg at bed time, or occasionally. .DISEASES OF PREGNANCY. 823 Diarrhcea.—If diarrhoea arises in pregnant women it should be treated just as at any other time (see this disease); and after the stom- ach and intestines are cleared, astringents may be used, if there is no great degree of fever. If fever is present, that must be attended to chiefly, and be first removed. Suppression of Urine.—When a suppression of urine takes place, which is apt to happen in the advanced stage of pregnancy, besides making use of emollient fomentations, clysters, and gentle purgative medicines, such as the oleum ricini, the patient drinking plentifully at the same time of diluent liquors, it will be necessary to have recourse to chirurgical assistance by drawing it off by means of a catheter morning and evening. Retroverted Uterus.— It sometimes happens that a retroversion of the uterus ensues, in which case it becomes misplaced downwards and backwards, because the os uteri is tied forwards to the meatus, urinarius, and there is no communication behind by which it is held to the rectum ; but anteriorly it is connected with the neck of the bladder by close cellular substance; therefore whatever raises the bladder will raise the cervix uteri, and what raises this must at the same time depress the fundus: so that in a retroversion of the uterus, the urethra is drawn up close behind the symphysis pubis; and in the case now under consideration, the bladder rises and draws up the o§ uteri with it. Tbe only period of pregnancy at which a retroversion of the uterus is apt to arise is between the end of the third and fourth months; for in the early months of pregnancy the uterus in length from the fundus to the cervix is not so great as to fill the space between the sacrum and the neck of the bladder, and cannot for that reason produce suppression. This applies to all situations of the uterus in unimpregnated women, and women who are with child, till the close of the fourth month of pregnancy ; after which the uterus cannot be made to go down into the pelvis. When the uterus has once fairly ascended into the abdomen, it is impossible for it to return into the pelvis until its volume has been diminished by delivery or abortion. In most of these cases the suppression of urine is the only material object to be attended to; for the uterus being retroverted tbe woman cannot make water; therefore it must be drawn off by the catheter. If necessary, this operation is to be repeated twice a day till the uterus, by a gradual enlargement, recovers its natural situation, which will be preferable to any interference of the attend- ant to reduce it. Where it is impossible for him to attend twice a day for the purpose of draining off the water, the reductiou may,, possibly be effected by the patient placing herself on her bands and knees, and then passing two fingers of one hand into the vagina, and a finger of the other into the rectum, by which means it is possible sometimes to succeed. Where the event is left to time, 824 DISEASES OP PREGNANCY. the uterus is sure to recover its proper situation ; for which reason it is preferable to leave it. In passing the catheter in cases of retroverted uterus, it will be necessary to attend to its curve, which curve is given by holding the instrument in one hand, and pressing the thumb on the other band on one s de, while it is gently drawn through the hand. The point of the catheter must be dexterously introduced close behind the pubes; for if some dexterity is not used it frequently will not pass into the bladder. Troublesome Itchings.—Where a severe itching about the parts of generation attends on pregnancy, it will be proper lo keep the woman's body perfectly open with some cooling laxative, and to wash the parts three or four times a day with a solution of lead, such as the liquor plumbi subacetatis dilutus: if much inflamma- tion accompanies the itching, topical bleeding may be re- quisite. CEdematous Swellings.—Tbe swellings of the feet, ankles, and private parts, which arise in the last stage of pregnancy, are occa- sioned by the pressure made by the womb, which now prevents the free return of the blood from the lower extremities. Gravid women are usually free from these complaints in the morning, but towards night they frequently suffer much from them. Slight scarifications with the edge of a lancet, to discharge the stagnated fluid, with the after application of flannels wrung out in a warm infusion of emollient herbs, have been employed in cases of great distention. In general, however, it will only be necessary that the pa- tient does not keep her feet in a pendant position for any length of time. Cramp.—Cramps of the legs and thighs are to be relieved by rubbing the parts with cold vinegar, with camphor dissolved in oil, or the liniments here* advised, the person wearing stockings in bed. At an advanced period of pregnancy they are only to be relieved by labour removing the cause. Where tbe stomach is affect- ed with spasms, proper doses of aether and tincture of opium, with the other means advised under the head of Hysteria, in cramps of that organ, will afford the greatest benefit. In such cases the patient must carefully avoid every kind of food that is apt to prove flatulent or hard of digestion, and she must keep her body perfectly open. Inability of Sleeping, and Restlessness.—Inquietude and inability to sleep prove troublesome complaints towards the latter period of pregnancy, the patient being obliged to rise frequently throughout • 3. ft Spirit. Camphora?, f. ^i. ------iElher. Sulph. Tinct. Opii, aa f. ^ss. M ft. linimentum. * 3. Take Camphorated Spirit, one ounce Spirit of Sulphuric Either, Tincture of Opium, of each half an ounce. Mix them for a liniment. DISEASES OF PREGNANCY. 825 the course of the night, in order to expose herself to the influence of cool air. Nothing affords so great relief in cases of this nature as bleeding in small quantities, with the occasional use of some cooling laxative medicine. Opiates are never attended with advantage in such'conditions. Varicose Ferns.—The veins ofthe legs, thighs, and belly often become varicose in fhe last stage of pregnancy^ and sometimes put on an alarming appearance from their great enlargement and distention. No bad consequences have, however, been observed to attend such a condition ; and the only thing necessary to be done is, to empty the vascular system by moderate bleeding, gentle purging, and a spare diet. Should the vein of any particular part become so distended as to prove troublesome, it may be advisable to apply a bandage of a moderate tightness, so as to give the necessary support to it. Jaundice.—In some instances the woman is affected with a pain in her side, and excessive sickness at the stomach and retchings, tbe skin assuming a deep yellow colour. If is only under these circumstances that the complaint proves distressing, and it is usually occasioned by the formation of one or more gall-stones, and the obstruction which they oppose to the usual and regular passage of the bile. The means most conducive to relieve the woman from this degree of the complaint are blood-letting, warm fomentations to the painful part, and large doses of opium, with such laxatives as shall counteract the effects of the opiates. Jaundice or any other bilious affection prevailing during a state of pregnancy from the pressure of the uterus on the gall- bladder or ducts, is to be obviated by keeping the body open with some gentle laxative, such as pills composed of rhubarb and soap. Incontinency of Urine.—This is a very disagreeable complaint, as it keeps the woman constantly in an uncomfortable state. It is to be removed only by delivery, but may be moderated by a fre- quent horizontal posture. Its bad effects may be prevented by a scrupulous attention to cleanliness, and the use of a thick compress of linen, or a sponge of considerable size properly fastened. Over-dislention of the Abdominal Skin.—In the latter months of pregnancy the integuments of the abdomen will sometimes become cracked and sore, the skin seeming to suffer from over-distention. In this case nothing is so effectual as a frequent use of warm oil by friction, and to give it somewhat of a medicated appearance a little camphor may be added. False Pains.—Pains somewhat resembling those of labour, and known by the name of false pains, are apt to come on at an advan- ced stage of pregnancy, and often to occasion an unnecessary alarm. In such cases confinement in an horizontal position, bleed- ing if plethoric, laxative medicines if costive, and administering small and frequent doses of some opiate until the patient finds ease, will be necessary. 104 826 CONVULSIONS. CONVULSIONS. Convulsions may occur either during pregnancy or labour, and are of different kinds, requiring opposite treatment. One species is the consequence of great exhaustion from a tedious labour, excessive fatigue, or profuse hemorrhage. This makes its attack without much warning, and generally alternates with deliquium, or great feeling of depression of strength and debi- lity ; the muscles about the face and chest are chiefly affected, and the pulse is small, frequent, and compressible, the face pale, the eyes sunk, the extremities cold. The fits succeed each other pretty quickly, and very soon terminate in a fatal syncope. Appa- rently it was this species of convulsion that destroyed her Royal Highness the Princess Charlotte of Wales. In all cases of this nature it should be our object to check the further operation of the exciting cause, by restraining hemorrhage if present, or preventing every kind of exertion, and thus husband the strength which remains, or recruit it by cordials. Opiates will be of infinite service in conjunction with aether and camphor. Deli- very is usually necessary. Hysterical convulsions are more common during gestation than during labour. Here it may therefore only be necessary to add to what has already been said under the head of Hysteria, that if they do not speedily yield to antispasmodics, venesection had better be resorted to ; and if that fails, we should, if possible, deliver the woman. The species of puerperal convulsions most generally met with bears some likeness to epileptic fits ; and it is only by being aware of the different degree of violence attending each, that at first sight we can distinguish them. A fit of puerperal convulsion is much more severe than one of epilepsy, and a paroxysm of the former is usually so violent, that a woman, who when in health was by no means strong, has been so convulsed as to shake the whole room, and to resist the coercive powers of many attendants. No force indeed can restrain a woman when in these convulsions. The distortion of her countenance is beyond conception : in regard to deformity of countenance, nothing bears any resemblance to the progress of this disease ; the rapidity wilh which the eyes open and shut, and the sudden twirlings of the mouth, are inconceivable and frightful. Puerperal convulsions seldom happen before the sixth month, but may occur at any time between this period and the completion of labour. They may arise as the first symptom of labour, or after the labour is finished. This species of convulsion depends on the state of the uterus, and has been observed to arise oftener during the first pregnancy than in any after one, particularly where the woman is unmarried. The characteristics of puerperal convulsion are as follow:—The CONVULSIONS. 827 paroxysms occur periodically like labour pains, so that there is a considerable space between them at first, but afterwards they be- come more frequent. They not only occur with the labour pains but in the intervals between ; and whether there have been labour pains or not before they come on, we shall usually find the os uteri somewhat dilated, and it is sure to become still more so from the continuance of these convulsions. At length, if the woman is not relieved, and the convulsions continue without destroying life, the child is actually expelled by the contraction of the uterus, which power is capable of expelling it even after death. The immediate symptoms are somewhat similar to those of the epileptic paroxysm. The woman suddenly loses all sensation, and stretches herself out; the muscles then become extremely rigid, and are speedily afterwards thrown into violent convulsions, the face is distorted, the eyes are protruded, she gnashes her teeth, and foams at the mouth. After the paroxysm is over, she remains in a comatose state, and has stertorous breathing, similar to what takes place in apoplexy. At length, except in very aggravated cases, she slowly comes to herself, but without being conscious that she has been in a fit. After a longer or shorter interval a fresh attack takes place in the manner just described, for it rarely happens that there is not a repetition of the paroxysm in all cases of true puerperal convul- sion. During the fit the skin becomes dark and purple, proving that the circulation through the lungs is not free, which purple colour leaves the woman after the fit is over. By tbe introduction ofthe hand into the uterus when these convulsions have come on, it has been ascertained that this organ is contracted, bnt with a tremulous undetermined sort of force, perfectly different from what takes place at any other time. There are two cases of puerperal convulsion which are very dis- tinct : one is a convulsion dependant on an irritable or excitable state ofthe nervous system ; the other on a fulness ofthe vessels of the brain, or perhaps a slight extravasation from the vessels thereof. When puerperal convulsion arises from the latter cause, it is always preceded by some symptoms, which, if watched, will enable us to relieve, if the patient applies in time, but which is rarely done ; and if these symptoms are neglected, at some period or another convulsions will follow. In a woman strongly disposed to this complaint from such a cause there will be a sense of great fullness in the head, giddiness in the advanced periods of pregnancy, drowsiness, and a sensation of weight when she stoops forward, imperfect vision, and atoms floating before the eyes. These symp- toms strongly denote fulness of the vessels of the head, and if allowed to continue, may lead to extravasation or puerperal con- vulsion ; but if early attended to may be removed, and premature labour prevented. Under such circumstances the first step to be adopted is, to draw ten or twelve ounces of blood from the arm, repeating the operation the next day or so if no alleviation takes place. After the first bleeding the bowels should be opened by 828 CONVULSIONS. some mild purgative, such as a soluf ion of any of the neutral salts and manna, which may be repeated every third or fourth morning until the plethora is removed. With these means the patient ought to abstain from all solid food, wine, &c. When these precautionary means have not been adopted, and puerperal convulsions have ensued, we are, on being called in, to open a vein immediately, particularly the jugular, or even the temporal artery, and to draw off blood in a considerable quantify, being regulated therein by the appearance of the person and her habit of body. From twelve to twenty ounces may be fhe extent of the first bleeding. If the disease goes on, and the os uteri does not admit of delivery from its not be\nz dilated, the convulsions not abated or gone off, and the pulse in such a state as to admit of it, we should bleed again and again. Sixty ounces of blood have been drawn off in the course of the twenty-four hours under these circumstances, and with a happy effect. Women in such a state admit of divided bleedings very largely. On examining the bodies of women who have died of puerperal convulsions, the vessels of the brain are always found enormously turgid ; in some cases blood is extravasated, and the heart is offen perceived com- pletely empty*. After the first bleeding a blister of considerable size should be applied to the neck, or between the shoulders ; the head be shaved and cooled with evaporating lotion ; and, if judged necessary, blood be drawn from the temples by several leeches. The next point to be attended to is fo get fhe bowels lo act as quickly as possible, and this will be effected by throwing up a smart or active clyster, and then giving a strong solution of some neutral salt, as magnesiae sulphas, potassae tartras, or soda fartarizata, in an infusion of senna, as soon as the patient becomes capable of swallowing. The bladder is also to be emptied by a catheter if necessary. If it is a case of convulsion depending upon irritation, we may likewise bleed, but we must proportion the quantity accord- ingly. Eight or ten ounces of blood will be sufficient, and where more may appear necessary, it will be best to draw the remainder by applying leeches to the temples. In cases dependant on irritation opium will be very proper, and it ought to be given to the highest possible extent, the form of a clyster being that to which we ought to give a preference. We are at the same time not to neglect the bowels, which should be kept perfectly open. Dr. Denman proposes that a clyster containing six grains of opium sliould be administered, under supposition, that by putting a stop to the contractions of the uterus, the convulsive contractions in olher parts of the body may also cease. From the tendency of opium to affect the brain, some practitioners have strongly objected to its use in puerperal * See cases reported by Mr. Chevalier, in the Mcdico-Chirurgical Transaction!. CONVULSIONS. 829 convulsions. By throwing it into the intestines, it will not, however, be so likely to affect the sensoriuin as when received into the stomach. Some physicians recommend the use of a warm bath, while others again disapprove of it. The pediluvium, or the application to the soles of the feet of bottles filled with warm water, may at any rate be proper. The warm bath is strongly recommended by Dr. Denman among the means for preventing convulsions in women previous to, or during their confinement.* He states, that from its occasional use worncm will often find much benefit, and tbat it is one of the principal means which professional assistance is capable of affording for preventing puerperal convulsions, and for ensuring an undisturbed labour. He also recommends a warm bath in labours rendered complex by con- vulsions, and this, upon a long and extensive experience. He says, that when convulsions have continued or increased, notwithstanding copious bleeding and the use of all other rational means, the patient may be put into the warm bath, in which she may remain a consider- able time if the convulsions are suspended while she is in it. In in- stances where a warm bath could not be procured, or while it was preparing, he has directed flannels wrung out of hot water to be ap- plied over the whole of the abdomen. Dr. Denman* mentions, that he has seen the patient relieved from that state of irritation immediately preceding the convulsion by dip- ping feathers in cold water, and dashing it with force over the woman's face, as this roused her, and interrupted the progress of the fit. Where the further application of cold may be deemed necessary, and appear advisable, we may throw water over the patient's head, bringing this over the side of the bed, and holding an empty pail underneath to receive it. It should be done on tbe approach of the fit, which may be ascertained by attending to the vibrations of the intercostal muscles. In all cases of puerperal convulsions, after having paid due atten- tion to the lessening of the cause which has given rise to it. we should uniformly exert our best endeavours to deliver the woman as expeditiously as possible where it is practicable with- out violence. When we find that the os uteri begins to relax and open, and which may take place although there be no labour pains, we must introduce the hand slowly, dilate it, and deliver the child. If convulsions take place after the delivery of the child for the first time, then the placenta, if it have not come away, ought immediately to be extracted ; and if the pulse does not ex- pressly forbid it, a vein is to be opened, and afterwards the bowels purged. . . Where convulsions continue after the uterus is emptied of i» See his Introduction to the Practice of Midwifery. 830 ABORTIONS. its contents, all that we can do is to keep the brain unloaded, tbe bowels open, and the irritability of the system counteracted by opium, joined with other antispasmodics, such as musk, camphor, and aether. Where the disorder continues many hours, we may ap- ply a large blister to the head, and if benefit is not obtained by the next day, one may also be applied to the inside of each leg. These, by exciting an irritation upon a part distant from the seat of tbe dis- ease, may tend to diminish the diseased action, and thereby afford some relief. To prevent puerperal convulsions from supervening, as they are in every instance to be considered as highly dangerous, particularly at an advanced stage of pregnancy, it will be prudent, in robust and plethoric habits, to pay an early attention to a use of the lancet during the progress of pregnancy, by drawing off a sufficient quantity of blood at different periods, taking care at the same time, and particu- larly near the termination of pregnancy, to keep the body open by cooling purgatives. In women of an irritable constitution, all exciting causes should be carefully avoided, and the habit be strengthened as much as possible, and thereby be rendered less susceptible of disa- greeable or ready impressions. ABORTIONS. Br abortion is to be understood the expulsion of the contents of the gravid uterus at a period of gestation so early as to render it impossible for the foetus to live. It is an accident or disease of fre- quent occurrence, which is always attended with disagreeable cir- cumstances; and which, although it seldom proves immediately fatal, may still be productive of much mischief at a future period. Abortions may happen at any period of pregnancy, but they take place most frequently about the third or fourth month. From the end of the third month to the period of quick- ening there is a greater susceptibility in the uterus to have its ac- tion interrupted than either before or afterwards, which is tbe reason of more miscarriages happening at that time than at any other, and points out the necessity of redoubling our vigilance in watching and guarding against the operation of any of the causes from the tenth to the sixteenth week that may be likely to excite abortion. When a woman happens to part with her burden before the seventh month, she is said to have miscarried or aborted; but when delivered of it after this time, the term labour is usually applied. Children born at the end of the seventh month are seldom reared; and when they are, they usually prove small and weakly; but those of eight months are frequently preserved by bestowing proper care on them. ABORTIONS. 831 In consequence of an imperfect conception it sometimes happens that moles or substances of a fleshy nature (which upon beingcut open contain not the smallest vestige of a child) are formed in the uterus; and these at length becoming detached, give rise to a considerable degree of hemorrhage. As some women menstruate during the first months of preg- nancy, it will be necessary to distinguish between an approaching miscarriage and a visitation of the menses, which may readily be done by inquiring whether or not the hemorrhage has proceeded from any evident cause, and whether it flows gently or is accom- panied with unusual pains. The former generally arises from some fright, surprise, or accident, and does not flow gently and regularly, but bursts out of a sudden, and again stops all at once, and is also attended with severe pains in the back and bottom of the belly; whereas the latter is marked with no such occurrences. Voluptuous women who are of a plethoric habit, as well as those who are of a weak and irritable frame, are most apt to miscarry; but accidents of this nature sometimes occur from a general de- fective constitution, or from a malconformation of the sexual organs. The causes which give rise to floodings during a state of pregnancy are, violent exertions of strength, lifting some heavy weight, severe exercise, as dancing or much walking, the fatiguing dissipations of fashionable life, sudden surprises and frights, violent fits of passion, great uneasiness of mind, uncommon longings, over-fulness of blood, partial spasmodic action about the os uteri, aloetic purges, profuse evacuations, excessive venery, former miscarriages, weakness in the parts immediately concerned, a diseased state of the uterus, general debility of the system, external injuries, as blows and bruises, strong acrid medicines, such as savin and hellebore, which are often taken for the express purpose of exciting abortion and the death of the child. A pregnant woman may be attacked with a flow of blood from the womb in consequence of any cause which is capable of separa- ting apart ofthe ovum from the corresponding part of the uterus. The vessels which before passed straight from its internal surface into the membranes or placenta, and connected them together, now open, so as to allow the blood to escape between them, and to flow exter- nally. This separation and consequent rupture may arise from any ofthe various causes just recited, but in a few instances it is occasioned by an implantation of a part of the placenta immediately over the os uteri, which cause is by far the most important, because it is the most dangerous, and the least likely to find a spontaneous remedy. Abortions are sometimes induced by what is termed a retrover- sion of the uterus, in which the fundus uteri is retroverted and pressed down between the rectum and the vagina. This rarely oc- curs, however, beyond the first or second month of gestation, and is 832 ABORTIONS. generally preceded by a difficulty in making water, and a consequent tumor ofthe bladder; a violent pain about the perinaeum is thus caused, and a miscarriage is liable to follow. Abortions are often preceded by a general sense of coldness, flac- cidity of the breasts, slight pains in the loins and lower region of the belly, and sometimes with a slight febrile state of the system. In plethoric habits, and where abortion proceeds from over-action or hemorrhagic action of the uterine vessels, the fever is idiopa- thic, and precedes the hemorrhage. After a short continuance of these symptoms, a slight discharge of blood ensues, coming away sometimes in clots, and at others gushing out in a florid stream, then stopping perhaps for a short time, and again returning violently. Sometimes nothing but coagulum can be perceived, that is so firm, and the globules and lymph so disposed as to make it ass-ume, more especially if it has been retained for any time about the uterus or vagina, a streaked or fibrous appearance, which often gives rise to a supposition that it is an organized substance. When the contents of the uterus are expelled, a bloody discharge continues for a few hours, and is then succeeded by a serous fluid. When the pregnancy is advanced beyond the third month and abortion is likely to ensue, we have much bearing down, together with a derangement of the stomach, causing sickness and faintness, and we have likewise a most rapid discharge owing to the increased size of the vessels. In this stage the membranes often give way, and the foetus escapes with the liquor amnii, whilst the rest of the ovum is retained for some hours, or even days, when it is at length expelled with coagulated blood. In some instances the whole ovum comes away entire. After the expulsion the hemonhage ceases, and is succeeded by a discharge somewhat resembling the lochia. With regard to the symptoms and duration of abortion there is a great diversity in different instances. In some cases the pains are very severe and long continued ; in others, short and trifling. Some- times the hemorrhage is profuse and alarming; at other times, although circumstances may not be apparently very different, it is moderate or inconsiderable. Often the sympathetic effects of the stomach and bowels are scarcely productive of inconvenience ; whilst in the great- er number of instances they are very prominent symptoms. As there is a diversity in the symptoms, so there is also in the duration of abortion ; for, whilst a few hours in many, and not above three days in the majoritylof cases, is suflicient to complete the process, we meet with other instances in which it threatened for a long time, and possibly some weeks elapse before the expulsion takes place. Floodings are more or less dangerous according to tbe stage of pregnancy in which they happen. The farther a woman is advanced therein, the greater will be the risk, especially if unaccompanied by labour pains, as the mouths of the vessels which pour out the ABORTIONS. &33 blood are much enlarged during the last stage of pregnancy, and of course a vast quantity will be discharged in a short space of time. Although miscarriages before the fifth month are seldom attended with immediate danger, the loss of blood being usually small, they never- theless frequently lay the foundation of many grievous ailments by happening repeatedly. Some women are visited by habitual miscar- riages, and observe a stated period for several successive pregnancies, which is more usually about the third month than at any other time. The danger of abortion is to be estimated by considering tbe pre- vious state of health and habit ofthe patient, and by attending to the violence of the discharge, the duration of the complaint, the difficulty of checking it, the disposition to expulsion which accompanies it, the period of gestation at which it is threatened, the frequency of its occurrence, and its combination with spasmodic affections or convulsions. Previous to my pointing out tbe best means for checking an abor- tion, and the method of conducting the woman through it when it cannot be avoided, it appears proper to notice those steps which should be taken for preventing miscarriages in tho*e to whom they are rather habitual. In all such cases it will be highly necessary to attend to the history of such former accidents, to the usual habitudes and con- stitution of the woman, and to her condition when she becomes pregnant. A woman that is subject to habitual abortions, and who is of a full plethoric habit, ought to be bled just before the usual time of her miscarrying. She should likewise keep her body perfectly open wilh gentle aperient medicines; use a spare diet, consisting principally of vegetables, and avoid all agitations ofthe mind, severe exercise, vio- lent efforts, and such objects as may be likely to make a disagreeable impression on her. The sleep should be abridged in quantity, and not betaken on a bed of down, but on a firm mattress, prevent- ing at the same time the accumulation of too much heat about the body. Every day she ought to take regular and modeiate exercise, being cautious at the same time not to carry it to the length of exciting fatigue. To bridle the circulation in women of a full plethoric habit that are subject to habitual abortions, in addition to .drawing off a little blood from the arm when the pulse is full or inclined to throb, it would appear advisable to give half a grain of digitalis twice or thrice a day, continuing this medicine until after the usual period ff the woman's miscarrying. In women of a weak lax habit, bleeding would be highly im- proper as a mean of preventing habitual abortion. For such, a nutritive and generous diet, moderate exercise in a carriage, cold bathing, and a course of chalybeates, with other tonics, will be ne- cessary, the patient at the same time avoiding all exciting causes. Until gestation be far advanced, it would even be advisable to live absque marito. Indeed, in every instance of habitual abw- 105 834 ABORTIONS. tion, whatever the condition may be that gives rise to it, it will be essential that the greatest attention be paid to the avoiding the exci- ting causes. In some cases it may even be necessary to confine the patient to her room until the period at which she usually aborts is past. In those cases of habitual abortions accompanied with spasmodic pains in tbe uterus, or a disposition to convulsions, opium given in small doses twice a day might prove eminently serviceable. Where nausea or vomiting prevails in a high degree, in addition to the means before pointed out, we may apply either an opium plaster or a blister to the region of the stomach. An abortion being threatened in consequence of some slight separa- tion of the placenta from the uterus, may frequently be stopped by im- mediately adopting proper steps, and the woman be enabled to go out her full time. On the first appearance of a flooding, the woman should be confi- ned to her bed, and be placed with her hips somewhat more elevated than her head, keeping her at the same time perfectly cool and extremely quiet, debarring her of all food of a heating stimulant nature, giving her cold liquors to drink sharpened with some agreea- ble acid, and applying linen cloths wetted in vinegar and water to tbe loins and private parts. Ice (if to be procured) contained in bladders and laid on the thighs and pubes, may occasionally be sub- stituted. With tbe view of moderating the symptoms attending the progress of a threatened abortion, and preventing it if possible from actually taking place, it may be proper, in robust and plethoric habits, and where the pulse is in any degree full and frequent, to take away a little blood from the arm; after which, if the bowels are confined, we may administer a laxative clyster. If the discharge is copious, and is accompanied with irregular spasmodic contraction of the uterus, or with severe pain, it will be advisable to prescribe opiates in small and frequently repeated doses, so as to keep up a constant effect, and they may be com- bined either with refrigerants* or with astringentsf, or with both. Equal parts of tincture of opium and sulphuric acid make a good medicine in uterine hemorrhage; but it is only in such cases as are attended with irregular spasmodic contractions, or with severe * l. 8; Infus- Rosae> f- Iiss- Potassae N^atis, 3ss. Tinct. Opii, fll ix. M. ft. Haustus 3tia vel 4ta quaque hora sumen dtis t 2. ft Confect. Opii, 3.j. Aq. Menth. Virid. f. gjss. Tinct Catechu, ----Kino, aa f. 3ss. M. ft. Haustus. * L Take Infusion of Roses, one ouuce and a half. Nitrate of Potass, half a drachm. Tincture of Opium, fifteen drops. Mix them. This draught is to be taken every three or four hours. t 2. Take Confection of Opium,one scruple. Mint Water, one ounce and a half. Tincture of Catechu, ----------Kino, of each half a drachm. Mix them, and give this draught every four or six hours. ABORTIONS. 836 pain, that opium is given by the most judicious practitioners. To assist the effect of the medicines, anodyne clysters may be injected from time to time. Astringent injections composed of a saturated solution of alum, sulphate of zinc, or the plumbi superacetas, or of a decoction of oak- bark, are often employed in floodings; and where the hemorrhage is slight or remits for any length of time, they undoubtedly will prove beneficial, and ought therefore to be used as mentioned under the head of Menorrhagia; but in floodings unaccompanied by any re- mission, they are by no means likely to afford much relief. In such cases it will be best to trust to the formation of a coagu- lum. Rest will be absolutely necessary if we wish the woman to go out her full time, and therefore it is sometimes necessary to con- fine her for a few weeks perhaps to her bed, at tne same time that we put her upon an effective course of digitalis*,* giving Jier an anodyne at bed-time, but taking care to keep the bowels in a proper state by some gentle aperient medicine. * Where we cannot prevent the abortion, our study* must be to con- duct the patient safely through the process; and the foint which first claims our attention is the hemorrhage. Bleeding is an opera- tion employed by some practitioners to check this ; but unless the vessels are above their natural force and strength of action^ it isniot likely to do any good. Indeed, the fulness and strength of thejmlse are lost much sooner in an abortion than can be explained Dy the mere loss of blood. Instead of bleeding, we had better therefore give the digitalis, if there is no irritation at the stomach. In pro- tracted cases, where the discharge has continued long, this mediSfce will be highly proper. When the means above mentioned have been pursued without Vel, 3. ft Aluminis, gr- xv. Gum Kino, gr. v. Opii, gr ss. Confect. Ros. q. s. M. ft. Bolus 6tis horis sumendus cum cochl. Infusi Rosae aciduli. "J * 4. ft Pulv. Digital. Purp. Opii, aa gr. ss. Confect. Ros. q. s. M. ft. Pilula 4tis horis sumenda. Vel, 5. ft Tinct Digital. Purp. fll xiij. 4ta quaq. hor. ex quovis vehiculo.. VeU 6. ft Infus Digital. Purp. f. |ss. Tinct. Cardam. f. 3'j- Aq. Purae, f.3vj- M. ft. Haustus quartis horis adhibendus. Or, 3. Take Alum, fifteen grains. Gum Kino, five grains. Opium, half a grain. Confection of Roses, a sufficiency. Mix them, and let this bolus be taken every six hours, with three table-spoonsful of the Infusion of Roses acidulated. 4. Take powder of Purple Foxglove, Opium, of each half a grain. Confection of Roses, a sufficiency to form a pill, which is to be taken every four hours. 5. Take Tincture'W Foxglove, twenty drops every four hours, in a little water, or any like vehicle. Or, 6. Take Infusion of Foxglove, half an ounce. Tincture of Cardamom, two drachms. Pure Water, six drachms. Mix them, and let this draught be given every four houre. 836 ABORTIONS. the desired effect, and the woman becomes exposed to imminent danger from great loss of strength, it will then he necessary to have recourse to powerful astringents*, such as zinci sulphas and plumbi superacetas. Of this last we may give one, two, or even three grains, rep. ;iting the dost every three or four hours, according to the urgen- cy of tbe ca?e. As soon, however, as the hemorrhage has ceased, a gemle purge of the oleum ricini should be adminis'ered, in order to prevent any bud effect from the action of these remedies on the coats of the stomach and intestirxs. Astringents used internally have, however, been thought by some to posses-^ little effect unless they excite sickness, which is a different operation from what is expected from them. The application of linen cloths dipped in cold water to the back and external prfrts, will have a much better effect than internal astrin- gents, and ought therefore never to be neglected. The introduction of a small piece of smooth ice into the vagina has often a very speedy effect in residing the hemorrhage. A snow-ball wrapped in a bit of gpft'lineg will have the same effect; but neither of these should be continued so lung as to produce pain, or much and pro- longed shivering. The heal of the surface may also be moderated by covering the bed Ijghtly with clothes, and admitting a free circu- latfy of air. ' The most effectual local method, however, of stopping tbe he- morrhage is by 'plugging up the vaginaf; and this is best done by taking a4pretty large piece of soft cloth, dipping it in oil, and then wringing it gently. This is to be introduced with the finger, por- tigjuafierfnrtion, until the lower parts of the vagina be well filled. The*remainder is then to be firmly pressed on the orifice, and fixed *by a T bandage, so as to prevent the plug from being displaced. T&is acts by giving time to the efysed blood to coagulate at the mouth of the bleeding vessels, i hereby preventing any further dis- charge. In ob>tinate cases, previous to the introduction of the plug, we may insert a little pounded ice tied up in a rag or small bladder, if to be procured. To recapitulate the means which we are to employ for restrain- ing the hemorrhage : if the pulse be full, hard, and frequent, bleed- ing is to be resorted to ; but if not, we are to trust to digitalis : the t See Mr. Burn's Treatise on Abortions. * 7. Take Sulphate of Zinc, two grains to five grains. Confection of Roses, half ascruple. Opium, half a grain. Mix them. This bolus is to be taken every four hours. Or, 8. Take Superacetate of Lead, two grains. Extract of Catechu, three grains. Opium, half a grain. Syrup, a sufficiency to form a pill, which may be taken every four hours, with a draught of the Infusion of Roses. * 7. ft Zinc. Sulpha^gr. ij.—v. Confect. Ros.^Ps- Of)ii, gr. ss. M. ft. Bolus 4tis horis sumendus. Vel, 8. ft Plumbi Superacet. gr. ij. Extract. Catechu, gr. iij. Opii,gr ss. Syrup, q. s. M. ft Pilula, 4tis horis capienda cum haustu Iniusi Rosae. ABORTIONS. 837 application of cold to the thighs and pubes, admitting cool air freely into the bedchamber, kepping the heat of the body at alow temper- ature, absolute rest in an horizontal position, and which must be con- tinued during the whole piocess, however long it may be, cold acidu- lated liquors for ordinary drink, light food taken in small portions at a lime, carefully abstaining from every thing stimulant, and plugging up the vagina. Where any sickness or great feebleness attends on an abortion, the body is to be kept at rest with the head low ; and we may at ihe same time give small quantities of some stomachic cordial, such as a few drops of aether in a little cinnamon-water, 6r a little peppermint- water with fifteen or twenty drops of the tincture of opium. In very urgent cases, Madeira or diluted brandy may be given, but these are not to be frequently repeated. Where spasmodic contractions attack, the stomach, producing sudden and violent pain, a full dose of the tincture of opium conjoined wilh aether must be ordered immediately. Spasms about the intestines are also to be relieved by opium in some form or other. 4 Where abortion is accompanied by strong hysteric paroxysms, besides attending to the state of the discharge, the best practice is to keep the woman very cool, and to give her thirty or forty drops of tinctura opii, with about two drachms of tinctura Valerianae' am- moniata in a little peppermint-water every four or six hours. A clyster composed of cold water, with tbe addition of two drachms of the tincture of asafoetida, is also sometimes of service. In all cases where a considerable hemorrhage has begun, but partic- ularly at an advanced stage of pregnancy, the first thing of importance to be inquired into and ascertained is its cause, and this can hardly be done too early ; for as long as the accoucheur allows himself to act without this piece of essential information, his practice must necessarily be uncertain, and the life of his patient be exposed to danger. In such cases it will therefore be of the utmost importance to subject the woman to an examination, and in effecting this it will be necessary to introduce the hand into the vagina, passing one finger without the os uteri. This will be preferable to the common mode ; for in presentations of th* placenta this part does not always adhere close to the orifice of the womb, but is sometimes attached inward to the collum uteri; and if we trust to the common mode of examination we shall be liable to fail in feeling the placenta, even when its presentation is the cause of the flooding. If the placenta is in the right place, it is probable^t any rate it is possible, that the hemorrhage may subside permanerWy by the aid of an horizontal posture, a low diet, the application of cold, and a use of the other means before noticed ; but if on the contrary the placenta be placed over the mouth of the womb, however these re- medies may afford a temporary relief, we may be assured that the discharge will return ; for the next lime that a dilatation of the os uteri fakes place, and which must recur sooner or later, a fresh por- 338 ABORTIONS. tion of the placenta will become detached, and other bleeding ves- sels unavoidably be opened. Our practice ought therefore to be de- termined by the result of the examination. If it appears that the placenta is in the right place, the means and remedies before pointed out may be trusted in, unless the symptoms be so alarming as to com- pel us to deliver the woman : but, on the contrary, if the placenta is discovered over the mouth of the womb, or very near thereto, even should there have been only one considerable discharge, we should watch the patient with the greatest vigilance, and proceed to deliver her as soon as^ihe parts are sufficiently dilatable to allow the introduction of the hand without improper force. In all cases during the last stage of pregnancy where our endeavours* to stop or repress the hemorrhage pr>ve abortive, and the life of the -woman becomes endangered by its severity, it will be advisable to deliver her as soon as possible, although we may encounter some difficulty, unless somewhat assisted by the coming on of the natural labour pains. If the ovum be still entire, and the pregnancy consid- erably advanced, the expulsive action is to be excited by rupturing tbe membranes. It sometimes happens in abortions, that the whole ovum does not come away at once, but only the foetus, and that either a part or the whole of the serundines remain behind. These by long retention give rise to an offensive discharge from the vagina, and a febrile state accompanied with hysterical affections. In such instances, instead of endeavouring to extract the remains of the ovum either with the forceps or fingers, which would be productive of irritation, it irflll be advisable to keep the parts clean, by injecting an infu- sion of chamomile-flowers with a small quantity of oxygenated muriatic acid; to keep the bowels open with gentle laxatives or clysters; to support the strength*by light nourishment, with small portions of wine frequently repeated, and plenty of subacid fruit; whilst at the same time we procure rest or allay irritation by opiates, if necessary. After every abortion the woman should be confined to bed for a few days, as getting up too soon is apt to produce a debilitating discharge. Should any morbid symptoms present themselves, they are to be obvi- ated by a suitable treatment. If the patient continues weakly for any time, the use of a cold bath, with bark and other tonics, a generous diet, and pure air, will be" necessary. It has been before observed, that miscarriages are sometimes induced duringfcie first or second month of gestation by the fundus uteri being retroverted and pressed down between the rectum and the vagina; in wiiich case they are preceded by a difficulty of making water, and a consequent tumor of the bladder, together with a violent pain about the perinaeum or rectum. On such occasions draw off the urine with a catheter, and inject an enema with sixty drops of the tincture of opium, if it can be done. Should these symptoms recur after the miscarriage, a wax candle, or a DISEASES OF THE PUERPERAL STATE. 839 pessary, made by rolling some emplastrurn plumbi spread on linen, may he introduced into the rectum, and worn as a compress to prevent the return for a few days, till the parts recover their strength.—See Dr. Hunter's Tables of the gravid Uterus, and. London Medical Observations, vol. iv. p. 388. DISEASES of the PUERPERAL STATE. Parturition, it is well known, is a natural process, and cannot therefore be considered as a disease ; but still it often lays the foundation of many distressing complaints, and is now and then attended suddenly even with fatal consequences. On the separation of the placenta, and on the sudden removal of pressure on the expulsion of the uterine contents, every parturient woman encounters some degree of risk : the latter is indeed not unfrequently a source of danger, which has not been sufficiently insisted upon and practically attended to. A woman sometimes appears safely put to bed after an easy and natural labour ; she has suffered no unusual loss of blood on the separation and removal of the placenta ; the uterus, on the appli- cation of the hand, is found well contracted, and the patient thus far at least appears in a fair way to do well : but notwithstanding these favourable appearances, and perhaps even during the con- gratulations of her friends upon the termination of her sufferings, she complains of a degree of faintness, attended with an inexpres- sible sensation of sinking : this is followed by restlessness, with an anxious depressed countenance, and occasionally by pain and a sense of constriction at the pit of the stomach ; and expressions of alarm for approaching dissolution are not unfrequently repeated. Shortly afterwards the restlessness increases, the countenance becomes more dejected and ghastly, the pulse gradually sinks and fails in its stroke, the oppressive constriction on the epigastrium becomes intolerable, so as considerably to affect respiration ; and if relief to these symptoms be not speedy, she becomes shortly a corpse. That a woman may die suddenly from the rupture of a vessel in the brain, or in the thoracic or abdominal cavities, during the violent efforts of labour, is a conclusion sufficiently natural ; but in accidents of this nature there would be symptoms of pressure on the sensorium in the one instance, and of infernal hemorrhage in the other; and the cause of death on inspedjon would be apparent. To theorize, or reason on a parturient woman suddenly falling into deliquium animi, and almost immediately expiring, is incon- sistent with the nature of this work ; but it has been attributed to the removal of pressure from the parietes of the abdomen, and the contents of its cavity. At the commencement of faintness without loss of blood, we 840 DISEASES OF THE PUERPERAL STATE. should have recouise to the exhibition of brandy, or other spirits, undiluted or diluted, according to the urgency of the symptoms and the rapidity of their progress, and in such quantity as may seem adequate to answer the intended purpose. That being at- tained, and the patient relieved, tiie medicated stimuli, as camphor, aether, volatile spirit, cordial tinctures, &c. may be substituted. Moderate pressure upon the abdomen with the hand, or a bandage applied iound the body, will assist the general intention ; and the patient ought, on no consideration, to be allowed to raise herself from the recumbent posture till she be so far recovered as to warrant security from the recurrence of the symptoms of alarm and danger. The most usual complaints however which occur after delivery, and which demand the attention and assistance of the medical practitioner, are as follow ; viz. AFTER-PAINS. Shortly after delivery fhese usually come on, and wilh some women prove remarkably severe. The quicker the labour has been, the slighter will they prove in general. Women with their first child are seldom much troubled with after pains ; but as the uterus is thought to contract less readily after each future labour, so they are more liable to suffer from them in any succeeding de- livery than in the first. When after-pains prove so troublesome as to deprive the patient of her rest, it will be necessary to have recourse to opiates joined with other antispasmodics*. Heated cloths or bladders filled wilh warm water may be applied as an external fomentation. These means are to be assisted by keeping up a sufficient pressure on the belly at the same time, by means of a broad bandage. COSTIVENESS. This is apt to prevail after delivery, and should always be re- moved by a laxative clyster, or some gentle purgative, such as a solution of some neutral salt and manna, or about an ounce of the oleum ricini. * 1. IJ; Aq. Cinnam. f. ^j. Tinct. Opii, tTl, \x—xxx. ----Castonrf. 3ss. Syrup. Viol*, f. 3ij. M. ft. Haustus hora somni sumendus. Vel, 2. R Castoroi, gr. v. Camphorae, gr. iij. Opii, gr. jss Confect Rosae, q. s. M. ft. Bolus, capiat hora somni. * 1. Take Cinnamon Water, one ounce. Tincture of Opium, thirty to forty- five drops. --------Castor, half a drachm Syrup of Violets, two drachms. Mix them. This draught it is to be taken about bed-time. Or, 2. Take Castor, five grains Camphor, three grains. Opium, one grain and a half. Confection of Roses, a sufficiency to form a bolus, which may be taken at bed-time. DISEASES OF THE PUERPERAL STATE. 841 FLOW OF THE LOCHIA. In all women a certain degree of hemorrhage usually takes place after delivery, produced by the removal ofthe placenta, which thereby lays bare tbe mouths of the blood-vessels in the inside ofthe uterus; and this commonly continues until the womb contracts to such a size as to close them up again. The discharge for the four or five first days consists usually of florid blood, after which time it assumes a mucous"appearance, and so ceases gradually. In weak and relaxed habits it sometimes happens, that instead of saturating a cloth now and then, as is natural to all women, the blood gushes out with such rapidity and violence as to run quickly through ail tbe bed-clothes, and even to soak through the bed itself; in which case the patient will be reduced to a state of great debility if the hemorrhage is not soon restrained. To effect this, the means recom- mended under the heads of Menorrhagia and Abortions must be adopted. ,, Where a suppression of the lochia ensues before the accustomed period, the discharge ought again to be promoted, if possible, by plentiful dilution, and the application of warm fomentations to the parts. Should these means prove ineffectual, gentle evacuations must be made. THE MILK FEVER. About the third or fourth day after delivery, the breasts generally become turgid and painful, from tbe secretion of milk which then takes place in them. When this is moderate and free, no inconve- nience will be experienced; but when copious, and accompanied by any obstruction in the lactiferous tubes in consequence of the use of some repellent application or of an exposure to cold, the breasts will then become hard, swelled, and painful, and a small fever will arise, accompanied by nausea, restlessness, pains in the head and back, and a considerable degree of thirst. To prevent any consequences of this kind, it will always be advisa- ble to apply the child to the breasts at a very early pefriod after delivery. By delaying to do so immediately on the secretion of milk commencing, the breasts are not only apt to become much enlarged and distended, but the nipples are often so much retracted, that the child cannot lay hold of them without the greatest difficulty. Where the mother's health will not admit of her suckling the child, or any other thing happens to prevent it, she should be careful to have her breasts drawn three or four times a day by some other person; and with the view of preventing a copious secretion of milk, she should use a very spare diet, keep her body perfectly open with laxative medicines, and abjstain as much as possible from all liquids. This mode of proceeding will be far preferable to the use of repellent applications to dry up, or put a stop to the secretion. If any degree of fever arises, besides confining the patient to a 842 DISEASES OF THE PUERPERAL STATE. spare diet, keeping her very quiet, and obviating costiveness by means of cooling laxatives, we may give her small and frequently repeated doses of antimonials, together with refrigerants, such as the nitrate of potass, as advised under the head of Simple Fever. INFLAMMATION AND TUMORS IN THE BREASTS. From exposure to cold, and neglecting to put the child at an early period to the breasts, or to get them drawn by some otbeir person, accidents of this nature happen very frequently to lying-in women. With respect to the mode of treating these kind of tumors, practi- tioners differ very much; some asserting that discussion should always be attempted, and others, that they ought to be allowed to suppurate ; as, when the discussion does not succeed, there may be some danger of inducing a scirrhous affection of an obstinate nature. I think tbe same practice should be adopted in this case of inflammation as in every other, and that the discussion of the tumor ought by all means to be attempted on its first appearance ; the distress and pain which always attend on a suppuration of the mamma being very great. When tbe inflammation and swelling have been of such longstanding as to show an evident tendency to suppurate, any attempt to discuss the lumor will not be advisable. Where discussion is proper, recourse should be had at a very early period to a strict pursuance of the antiphlogistic plan. The strength is to be supported by a cool spare diet; the body is to be kept perfectly open with mild laxatives; febrile heat is to be abated by refrigerants, such as the nitrate of potass, with the aid of frequent small doses of some antimonial, such as the pulvis Jacobi, pulvis antimonialis, or solution of tartarized antimony; pain and irritation are to be allayed by sufficient doses of opium; and the inflammation, when considerable, is to be abated by means of leeches applied to the part, as likewise by the constant applica- tion of linen cloths dipped in some sedative lotion*. To assist the effect of these means, the breasts are to be evacuated fre- quently throughout the course of the day, hut more particularly the one diseased, either by the infant or some other person ac- customed to the business. When they are so much, swelled as not * l.R Liquor. Ammon. Acetatis, Spirit. Rectif. Aq. DLstillat. aa f. |ij. M. ft Lotio. Vel, 2. R Ammon. Muriat. 3»j- Acidi Acetic dilut. f. ^ij. Spirit. Camphorae, f. |ss Liquor. Plumbi Subacet. fll xv. JV1 * 1. Take Solution of Acetate of Ammonia, Rectified Spirit, Distilled Water, of each tw* ounces. Mix them and use them as a wash. Or, 2. Take Muriate of Ammonia, two drachms Distilled Vinegar diluted, two ounces. Camphorated Spirit, half an ounce. Solution of Subacetate of Lead twenty-five drops Mix them. DISEASES OF THE PUERPERAL STATE. 843 to allow of laying hold ofthe nipple, the proper glasses made for that purpose should be employed. If the tumor proceeds to suppuration, notwithstanding we may have used every endeavour to prevent it, we should then assist the operations of nature byvthe application of emollient poultices and fo- mentations. As soon as the suppuration is completed, the tumor should be opened, after which it may be dressed with dry lint, and a pledget spread with some kind of digestive ointment be laid over all. Should any fresh suppuration ensue, which not unfrequently happens, the same mode of treatment must be adopted; and tbat proper pus may be formed, the bark of cinchona, with a moderate quantity of wine, will be necessary. EXCORIATIONS OF THE NIPPLES. From the constant state of moisture in which these parts are kept with those who give suck, such occurrences are very apt to happen. When excoriations do arise, the parts should be washed two or three times a day with a diluted solution of alum, the superacetate of lead, or a few drops of the liquor plumbi subacetatis, in rose-water, and then be sprinkled with a little powder of calamine or tutty, or they may be dressed with a little of what is lecommended below*, thinly spread on lint, and so applied to the parts. To prevent the sore from being aggravated by sticking to the woman's clothes, a little cup made of wax may be laid over the nipple, which is the part most apt to suffer. If only one nipple is affected, the child may be con- fined to the other; but if both are affected, and the pain occasioned by its sucking is too great to be borne, the woman must then desist from the duties of a mother until the excoriations are somewhat healed, taking care however to have her breasts drawn regularly twice or thrice a day. As long as we are under the necessity of applying any of the preparations of lead to the nipples of the mother, it will be prudent not to suffer the child to suck her, as there is reason to fear that it might be materially injured by so doing. Where this cannot however be dispensed with, the part should be well washed with a little warm water each time previous to giving the child the breast. When great soreness of the nipples has taken place, it has been proposed, with the view of protecting them, to use an artificial teat, by which the child will be able to suck tolerably well, and the nipple itself, being undisturbed, to heal soon. The way in which one of these substitutes is prepared, is to procure a fresh teat from a heifer, and scooping out the inside, to well steep it in cold water, then put it into spirits till an hour or two be- fore using it, when it must be again laid in water to take away the spirituous taste. The teat is then to be wiped dry, ' 3. R Soda; Sub-boratis, 3ss. Mellis, f. ^ss. Faiinae Tritic. q.s. ad consisten- tiam idoneam. M. * 3. Take Sub-borate of Soda, half a drachm. Honey, half an ounce. Wheaten Flour, a sufficiency lo give the whole a proper consistence. 844 DISEASES OF THE PUERPERAL STATE. and sewn closely and firmly at the edges to the row of holes made in the shield. Such shields are usually made of silver, and may be pro- cured from Mr. Savigny, the instrument maker; but ivory ones turned on the same model will answer equally well. The teat ought to pro- ject somewhat longer than tbe shield, that it may the more readily yield to the infant's mouth. Great attention should be paid to washing the whole thoroughly after suckling, and to keep it constantly in cold water. A woman is often capable of giving milk with a flat or even concave surface, by drawing out the nipple with a glass tube that has a small ball to it, by which a vacuum is produced immediately the glass is removed: the child being put to the breast will keep it out by suck- ing until satisfied. MILIARY ERUPTIONS. In consequence of keeping women very warm, and of using a heating diet, it not unfrequently happens that miliary erup- tions, attended with some degree of fevpr, arise during a puerperal state. Sometimes they are dispersed over the whole body, but they are more usually observed about the neck and chest. To conduct tbe patient with safety through the disease, the practitioner must have recourse to the means advised under the head of Miliary Fever. Should the eruptions strike in suddenly, and the pulse sink, blisters, with cordial sudorific medicines and wine, will be proper. Affections of this nature may however be avoided in general by an attention to diet, by keeping the patient's body perfectly open, and her bed lightly covered with rlothes, and by admitting a proper and free ventilation through her chamber. PHLEGMATIA DOLENS PUERPERARUM, OR THE PAINFUL INTUMESCENCE OF THE LOWER EXTREMITY __ INCIDENT TO LYING-IN WOMEN. Although this disease must have existed as long as most of the others to which lying-in women are subject, still it seems to have been only slightly noticed by any of the ancient writers. Mr. White's Inquiry into its Nature and Causes, which made its appearance in the year 1784, was the first regular treatise on it in this country, and it excited tbe attention of other practitioners to the complaint. In tbe year 1792, Mr. Tyre, of Gloucester, publish- ed a small essay on tbe subject; and at different periods since that time, Dr. Ferriar, and Dr. Hull, of Manchester, have written on it. Phlegmatia dolens appears, however, to be a disease of no frequent occurrence; for Mr. White mentions, that out of 1897 women delivered at the Westminster Ceneral Dispensary, five only were attacked with it; and of 8000 women deli- vered at the Manchester Lying-in Hospital, and their own DISEASES OF THE PUERPERAL STATE. 845 houses, no more than four were seized with it. During a practice of forty-five years only three cases have fallen under my care. When we find practitioners giving in a report of numerous cases which came under their observation, we may therefore naturally presume that they have mistaken other diseases for if, such as anasarca, phlegmon, erysipelas, abscess, rheumatism, peri- tonitis, and puerperal fever. The disease, however, to which, in my opinion, it bears the strongest resemblance, is the glandular affection of the thigh and leg, so frequently met within the island of Barbadoes, and noticed under the head of Elephantiasis. Tne characteristic of phlegmatia dolens is a firm, glossy, warm, tense, elastic, painful, sudden swelling, of a pale white colour, which attacks the hypogastric region, the loins, nates, groin, labium pudendi, thigh, leg, and foot of a lying-in woman some days after delivery, or miscarriage at an advanced period of pregnancy. Mr. White looks on the swelling of the labium pudendi as an invariable symptom of the disorder ; and he asserts, tbat when one limb only is affected the intumes- cence is confined so exactly to the labium pudendi of that side, that if a line were drawn from the navel to the anus it would be found never to go beyond that line in the smallest degree. We are told, however, by Dr. Hull, that the swelling of the labium pudendi is to be considered rather as marking the extent, than serving to characterize the complaint ; and he positively denies that this particular symptom is always to be met with ; for some cases had fallen under his care in which it did not exist. On this point, as well as on most others relating to the nature and causes of phlegmatia dolens, these gentlemen do not agree in opinion. Mr. White attributes the proximate cause of the disease in question to an obstruction, detention, and accumulation of lymph in the limb, and imagines the lymphatics to be ob- structed as high up at least as where they enter the pelvis under Poupart's ligament, in consequence of some accident happening during labour, or some state peculiar to childbed. He conceives it might probably arise from the continued pres- sure of the lymphatic vessels by the head of the foetus on the pelvis, which, he says, is often rough and sharp on its ridge, and might be followed by a rupture of these vessels in some part of their course. The disease has been attributed by Mr. Trye to an obstruc- tion of the lymphatics : but he apprehends that this originates in the inflammation of the trunk or trunks of these vessels, which inflammation may be excited by pressure or the absorption of some acrimonious matter. Dr. Denman entertains sentiments pretty similar to those of Mr. Trye ; for he believes the disease to arise first in the in- guinal glands by the absorption of some irritating principle in the 34t> DISEASES OF TIIE PUERPERAL STAKE. discharge, the consequence of an unhealthy secretion from the uterus. Dr. Ferriar is of opinion*, that phlegmatia dolens may exist independently of every circumstance regarding parturitionf, and he does not think it impossible for it to take place before delivery. The violent pressure on the internal iliacs and the accompanying veins and nerves, which takes place during la- bour, must undoubtedly be considered as a powerful occasional cause of lymphatic inflammation, quite sufficient to account for the phenomena without the supposition of a rupture of the vessels. He adds, that the constitution is much more irritable, more liable to febrile and inflammatory complaints after than before delivery. The balance of the circulating fluids is suddenly and violently changed ; there are new determinations, new sympa- thies produced in a state of debility, agitation, a;id anxiety. It cannot, therefore, surprise us, that under circumstances so pe- culiar, a set of vessels, commonly exempted from inflammatory affections, should take on an unusual disposition. These theories are rejected by Dr. Hull, as being inadequate to explain the various phenomena of the disease ; and he offers the following, which he conceives to be more consonant to its real naturej. As predisposing and exciting causes to it, he enumerates—1st, the increased irritability and disposition to inflammation which prevail during pregnancy, and in a still higher degree for some time after parturition. 2dly, The over- distended or relaxed state of the blood-vessels of the inferior part of the trunk, and of the lower extremities. 3dly, Contu- sions, or violent exertions of the muscles about the pelvis and thighs. 4thly, Plethora, occasioned by a suppression or dim- inution of the lochia, or of the secretion of milk. 5thly, Food taken loo freely ; and, 6thly, Standing or walking too much or too early. The proximate cause he supposes to consist in an inflam- matory affection, producing suddenly a considerable effusion of serum and coagulable lymph from the exhalents into the cel- lular membrane of the limb ; and he thinks that there exists a close connexion between phlegmatia dolens, puerperal fever, peritonitis, and some other disorders. Such a conclusion, in my humble opinion, is not well founded ; for phlegmatia dolens is a disease as distinct from either puerperal fever or peritonitis as it is possible to be. Little or no inflamma- tory tendency prevails in the system in this complaint, neither are any of the abdominal viscera nor their peiifoneal covering occupied by inflammation. The disease appears to be of a local nature, and *" See his Medical Histories and Reflections, vol. iii. V It certainly may; for I had a case lately under my care in an aged woman, and ef course unconnected with parturition. J See hli Essay on Phlegmatia Dolens. DISEASES OF THE PUERPERAL STATE. 847 confined to the lymphatics of the limb on the side affected. Tbe slight temporary derangement which takes place in the system appears to be induced wholly by the local affection, pain, and dis- tention. Phlegmatia dolens generally takes place on one side only at first, and commonly begins in the hypogastric or inguinal region, or in the hip, or top ofthe thigh, and corresponding labium pudendi, preceded by rigors, and followed by pyrexia. In this case the patient perceives a sense of pain, weight and stiffness in some of these parts, which are increased by every attempt to move the pelvis, or lower limb. If the part be carefully examined, it generally is found rather fuller or hotter than natural, and tender to the touch, but not discoloured. After a little lime, the pain increases, always becomes severe, and in some cases is highly excruciating: it extends along the thigh, and at length the top of tbe labium pudendi becomes greatly swelled and distended ; but on this happening, the pain is usually somewhat alle- viated in these parts. It however extends down to the knee, and is generally most severe on the inside and back ofthe thigh. When it has continued for some time, the whole thigh becomes in its turn swelled, and tbe pain extending down to the leg and foot, these parts also swell; but on the swelling taking place, there is a considerable abatement of pain, and the woman does not experience much except she moves the limb. The extremity being now swelled throughout its whole extent, appears perfectly or nearly uniform, and is not perceptibly lessened by an horizontal position like an cedematous limb. It is whiter than the natural colour, is hotter than usual, excessively tense, and exqui- sitely tender when touched. When pressed by the finger in different parts, it is perceived to be elastic, little, if any, impression remaining, and that only for a short time. If a puncture is made into the limb, in some instances no fluid is discharged ; in others, a small quantity of fluid escapes, which does not coagulate, but the whole ofthe effused matter cannot be drawn off in this way. The swelling ofthe limb varies both in degree and in tbe space of time requisite for its full formation. In most instances, it arrives at double the natural size, and, in some cases, at a much greater. In lax habits, and in patients whose legs have been very much affected with anasarca during preg- nancy, the swelling takes place more rapidly than in those who are differently circumstanced : it sometimes in the former class of patient* arrives at its greatest extent in twenty-four hours, or less, from the first attack. After some days, generally from two to eight, the febrile symp- toms diminish, and the swelling, heat, tension, weight, and ten- derness of the lower extremity begin to abate, first about the upper part of the thigh or knee, and afterwards in the leg and foot. Some inequalities are found in the limb, which at first feel like indurated glands; but upon being more strictly examined, their edges are not so well defined as those of conglobate gland?,. 848 DISEASES OF THE PUERPERAL STATE. and they appear to be occasioned by the effused matter being in different degrees of consistence in different points. The con- globate glands of the thigh and leg are sometimes felt distinctly, and are tender to the touch, but are seldom much enlarged; and as the swelling subsides, it has happened that an enlargement of the lymphatic vessels in some part of the limb has been supposed to be felt. Tiie febrile symptoms having gradually disappeared, the pain and tenderness of the limb being much telieved, and the swelling and tension considerably diminished, the patient is much debilitated, and the extremity feels stiff, heavy, benumbed, and weak. It seldom, if ever, returns to its former size, but usually is considerably enlarged for the remainder of life, being always more easily affected by cold than the other, and after exercise it will be more stiff and weak than the sound extremity. It sometimes happens, that after the disease abates in one limb, the other is attacked in a similar way, goes through the same stages, and continues much about tbe same time as the first. Phlegmatia dolens is often slow in its progress, and tedious in its cure ; but it is rarely followed either by suppuration or gangrene; and still more rarely does it terminate fatally ; the extravasated fluid being at length taken up, and returned into the circulation, although from the great distention ofthe limb there is usually much tenderness, pain, and a febrile disposition. We are told by Mr. White, that when not complicated with any other disease, he has never known it to have a fatal termination ; neither has he ever observed the skin to be so discoloured as to point out the presence of local in- flammation: on the contrary, it is of a paler white than ordinary, which circumstance has induced him to name the disease phlegmatia alba dolens puerperarum. By Dr. Hull we are, however, informed, that he has seen cases which have terminated in suppuration, as also in death. With respect to the treatment of phlegmatia dolens, much must be left to the discretion ofthe practitioner, who ought to prescribe accor- ding to circumstances. Should the disease be complicated with any other, such as phlegmon, erysipelas, anasarca, thoincic inflammation, puerperal fever, or peritonitis, then the means which are advised under these heads must be resorted to, in addition to paying a proper atten- tion to the complaint itself. When a woman who is of a robust plethoric habit, is allocked shortly after delivery with a painful tense swelling of one of the lower extremities, accompanied by much heat, thirst, restlessness, and other symptoms of pyrexia, the antiplogistic plan ought certainly to be pursued. Bleeding from the system in a mode- rate quantity, keeping the body open with saline purgatives, so as to procure one or two motions daily ; administering small and frequently repeated doses of some antimonial preparations, to promote a regular and gentle determination lo the surface ; DISEASES OF THE PUERPERAL STATE. 849 giving plentifully of diluent liquors; confining the patient to bed • covering ber lightly with bed-clothes, and keeping her chamber of a proper coolness, will undoubtedly be highly proper in ail such cases. Where nausea exists at the commencement of th||rettack, an emelic may likewise be advisable, but otherwise it appears un- necessary. If the irritability or excitability (adopt which term you may) of the system is much increased, and from tbe severity ofthe pain in the limb tbe patient is deprived of rest for a succession of nights, we may with safety and much advantage, having premised proper evacuations, em- ploy opium. The best mode of administering it will be, to combine it with some diaphoretic*, and probably the pulvis ipecac, compos. may be as good a medicine as we can use. Along with the remedies before enumerated, warm bathing, or the semicupium, may possibly be of service. Such is the general treatment to be adopted in phlegmatia dolens, when arising in a robust or plethoric habit, and where the febrile symptoms run very high; but the antiphlogistic plan would certainly be improper for a woman of lax fibres, and who has already been much debilitated by floodings, or other evacua- tions. In all those cases which are marked with general debility, an impoverished state of the blood, and a diminution of the tone and action of the heart and arteries, we should pursue the following course:— v To remove the affection of the system, and at the same time expedite the cure of the local complaint, we should endeavour to restore proper energy to the constitution, as well as improve the state of the blood; and this is to be effected by bitters, chalybeates, and other tonic medicines, a nutritious diet, wilh a Moderate allow- ance of wine, daily exercise on horseback or in a carriage, but more particularly the latter, and by cold bathing. To assist in carrying off the effused fluid, it may likewise be advisable to employ diuretics, such as the supertartrate of potass, squill, digitalis, &c. combined with cinchona, cascarilla, and other tonics.—See Anasarca. .( Mercury has been recommended both by Mr. Tyre and Dr. Hull in phlegmatia dolens ; but I think it is a remedy from which no benefit is likely to be derived, and particularly in debilitated habits. * 1. ft Liquor. Ammon. Acet. f. 3i«j- Misturae Campbora;, f. |j. Syrup. Papav. f. 3>j- M. ft. Haustus hora somni sumendus. Vel, 2. R Tinct. Opii, fll "V. Liquor. Antimon. Tartarizat. fll * Aq. Purae, f. |j. Syrup. Simpl-f-3«J. M. ft. Haustus. * 1. Take Solution of Acetate of Ammonia, three drachms. Camphor Mixture, one ounce. Syrup of Poppies, two drachms. Mix them, and let this draught be taken ajt bed-time. Or, 2. Take Tincture of Opium, forty drops. Solution of Tartarized Antimony,- fifteen drops. Pure Water, one ounce. Common Syrup, two drachms Mix them for a draught. 850 DISEASES OF THE PUERPERAL STATE. Our attention is next to be directed to the local treatment. When the limb and labium pudendi are occupied by much pain, and any degre*pf inflammation, the application of two or three leeches will be propfcr; after which the parts may be well fomented with flannel cloths vvwing out in hot vinegar, renewing these as often as they be- come cold. This simple mean, unassisted by any other than merely keeping the bowels regular with gentle aperients, such as the neutral salts, has, I understand, been adopted in all cases of phlegmatia do- lens with invariable success, in one of the best regulated lying-in hospitals in London. Should it fail, however, in other hands, some more powerful sedative or discutient may be substituted, such as a solution of muriated ammonia in vinegar, or a diluted solution ofthe liquor plumbi subacetatis. A liniment composed of a drachm of camphor, dissolved in an ounce of olive oil, with about ten grains of powdered opium, and used night and morning, will be a good appli- cation. Much relief has been received by surrounding the limb with a soft poultice, composed of bran, olive oil, with the addition of half an ounce of tinctura opii, and a sufficient quantity of warm water to give it a proper consistence, renewing it morning and night. To drain off some ofthe fluid effused in the limb, it will be advisable, in an early stage of the disease, to apply a blister to the calf of the leg, renewing the application from time to time in the neighbourhood of the former, when it ceases to produce the desired effect. In soma instances, coagulation quickly succeeds the effusion, and there- fore neither scarifications nor punctures would be likely to prove be- neficial. Notwithstandiff^ every attention, the complaint often leaves con- siderable weakness in the leg, requiring a laced stocking or roller applied round it from the bottom to the top, avoiding at tbe same time much standing or walking. To increase the action of the absor- bents in the limb, frequent frictions with rubefacient liniments, or simply with the hand, flannel, or a flesh-brush, may be employed, the effects of which may be assisted by topical cold bathing, or by cold water, fresh or salt, dashed upon the parts, and by electri- city. Immersing the limb in a bath or tepid sea water has sometimes been found beneficial. Probably the application of heat in the man- ner advised for anasarcous limbs, might prove serviceable.—See Anasarca. HYSTER1TIS, OR AN INFLAMMATION OF THE UTERUS*. In natural labours, as well as in those of a difficult sort, many causes of injury to the uterus and the peritonceum which covers it will be applied. The long-continued action of the uterus on the body of the child, and the great pressure made by its head on the * This disease, as well as tbe two which succeed, belong properly to the class of Py- rexiae ; but as the two first do not often occur in the unimpregnated state, and the last is a disease confined to that of the puerperal, I have judged it most proper to insert them all here. ' DISEASES OF THE PUERPERAL STAfE. 851 soft parts, will farther add to the chance of injury. Besides these, an improper application of instruments, or on officiousness of the midwife in hurrying the labour, or extracting the placenta, may have contributed to the violence. To these causes may be added exposure to cold, by taking the woman too early out of bed after delivery, and thereby throwing the circulating fluids upon the in- ternal parts, putting a stop to the secretion of milk, or occasioning a suppression of the lochia. An inflammation of the womb is sometimes perfectly distinct, but it is more frequently communicated to the peritonaeum, Fallopian tubes, and ovaria: and having once begun, the natural functions of the organ become much disturbed, which event greatly adds to the disease. It is oftener met with in women of a robust and plethoric habit than in those of lax fibres and a delicate constitution, particularly where they have indulged freely in food of a heating nature, and in a use of spirituous liquors. It never prevails as an epidemic, like puerperal fever, for which it has probably often been mistaken ; and to this we may, with some reason, ascribe the difference in the mode of treating tbe disease which has taken place among physicians. An inflammation of the uterus shows itself usually about the second or third day after delivery, with a painful sensation at the bottom of the belly, which gradually increases in violence without any kind of intermission. On examining externally, the uterus appears much increased in size, is hard to tbe feel, and on making a pressure upon it, the patient experiences great soreness and pain. Soon afterwards there ensues an increase of heat over the whole of the body, with pains in the head and back, extending into the groins, rigors, considerable thirst, nausea, and vomiting. The tongue is white and dry, the secretion of milk is usually much interrupted, the lochial discharge is greatly diminished, the urine is high coloured and scanty, and if the inflammation has extended to the bladder, it becomes totally obstructed; the body is costive, and the pulse is full, hard, and frequent. These are the symptoms which usually present themselves when the inflammation does not run very high, and is perfectly distinct; but when it is so extensive as to effect the peritonaeum, those of irrita- tion generally succeed, and soon destroy the patient. Where the uterus has been ruptured, a vomiting comes on, and the matter thrown up is of a black colour, resembling coffee grounds, the pulse sinks and becomes irregular, cold clammy sweats break out, and frequent syncope ensues. Uterine inflammation is always attended with much danger, par- ticularly where the symptoms are violent, and the proper means for removing them have not been timely adopted. In such cases it may terminate either in suppuration, scirrhus, #or gangrene and mortification. Frequent rigors, succeeded by flushings of the face, quickness 852 DISEASES OF THE PUERPERAL STATE. and weakness of the pulse, great depression of strength, delirium, and the sudden cessation of pain and soreness in the region of the abdomen, denote a fatal termination : on the contrary, the ensuing of a gentle diarrhoea, the lochial discharge returning in due quantity and qualitv, the secretion of milk recommencing, and the uterus becoming gradually softer and less tender to the touch, with an abatement of heat and thirst, prognosticate a favourable issue. When shiverings attack the patient after several days' continuance of the syoiooms, but little relief can be afforded by medicine, tbe event being generally fatal. In this case the woman emaciates and loses her strength, becomes hectic, and sinks under colliquative sweat- ing or purging. Upon opining the bodies of women who have died of this disease, and where it existed in a simple state, little or no extravasated fluid is usually to be met with in the cavity of the abdomen. In some instances the peritonaeal -surfaces have been discovered free from the disease ; while in others, that portion which covers the uterus and posterior pari of ihe bladder has been found parti illy inflamed. The inflammation has been observed in some cases to extend to the ovaria and Fallopian tubes, which, when cut open, are often loaded with blood. The uterus itsplf usually appears of a firm substance, but is larger than in its natural state, and vhen cut into, a quantity of pus is often found. Gangrene and mortification are seldom, if ever, to be met with. By an early attention to the disease on its first approach, we may often subdue it, and prevent the inflammation from proceeding to any great height. Our immediate and speedy care ought therefore to be directed towards diminishing the quantity of the circulating fluids, and weakening the action of the heart and arteries ; and this is to be done by drawing blood from the system, regulating the quantity which we take away by the violence of tbe symptoms, the state of the pulse, and the age and habit of the patient. In repeating the operation, we are to be governed by the same circumstances, and by the effect produced by the former evacuation. In plethoric habits, a second or a third repetition may be necessary ; but in those who are less robust, if the inflammatory symptoms are not entirely carried off by the first bleed- ing, it may be more advisable to draw off blood by the application of six or eight leeches to the belly, than to make use of the lancet again. To remove the tension and alleviate the pain and soreness, flannel cloths wrung out in a warm decoction of bruised poppyheads and cbamomile-flowers, with an addition of about an eighth of spirituous camphorae, may be kept pretty constantly applied throughout the course of the day to the abdominal region, and at night it may be anointed with a little of the linimentum camphorae. In using fomen- tations, due care must however be taken that they are not applied so wet as to run about the bed, and thereby occasion inconvenience to the patient.* Evacuation by purging would be improper in this inflammation; DISEASES OF THE PUERPERAL STATE. 858 but it would be right to preserve the regular motion of the bowels, by giving from time to time, as may be found necessary, some gentle laxative, or by administering emollient aperient clysters, which perhaps may be the preferable way of procuring stools, as they not only unload the intestines, but likewise act as fomentations. In most interna) inflammations blisters prove a useful remedy; but in that of the uterus, their application is attended with the risk of increasing the irritation in the system, and of adding to the inflamma- tion, by affecting the bladder and kidneys. Whenever they are made use of in this disease with the hope of affording relief, they ought to be sprinkled with camphor, and the patient should drink plentifully of diluting mucilaginous liquors, to guard against such consequences. Diluents will indeed be proper, whether we have recourse to blis- tering or not. •' To determine to the surface of the body, and excite a gentle perspiration, which often proves highly serviceable in this inflam- mation, it will be advisable to give diaphoretic medicines. As such, we may employ the pulvis ipecac, compositus, in the quantity of eight or ten grains, repealed every four hours ; or the pulvis antimo- nialis, in the quantity of about two grains, and half a grain of opium, made into a bolus, with a little of the confectio rosae rubrae. These may be washed down with two or three spoonsful of a saline mixture. In order to alleviate the pain (which alone would greatly aggra- vate tbe disease), procure rest, and prevent symptoms of irritation from arising, the use of opium is indispensably necessary, and its dose ought to be increased until the desired effect is procured. Opium is, however, not to be prescribed in bysteritis until the inflammation has been subdued by venesection and aperient medicines. Should a diarrhoea arise spontaneously in the course of this disease, it ought by no means to be checked, unless it proceeds with such violence as to exhaust the woman's strength. Under such circum- stances, the mistura cretae, with an addition of a small quantity of tinctura opii, may be given with advantage. Should the remedy not be found sufficiently powerful in lessening the number of evacua- tions, three drachms of the tinctura kino, or catechu, may be added to about six ounces ofthe mixture. Where tbe inflammation has extended to the bladder, and occa- sioned a suppression of urine, we must employ the catheter. Throughout the whole course of the disease, the patient is to be supported by food of a light nutritive nature, and such as is easy of digestion, carefully avoiding all kinds of fermented liquors. In chronic inflammation of the uterus or state of scirrhosity, the repeated application of several leeches above the pubes or to the perinamm, the use of gentle laxatives, emollient clysters, and fomentations and blisters to the lower part of the abdomen, fre- quent immersion of the lower parts of the body in a warm slipper &j4 DISEASES OF THE PUERPERAL STATE. bath, with an antiphlogistic regimen, and detaining the patient as much as possible in an horizontal posture, appear to be the most probable means of affording relief at an early period. Hyoscyamus and conium, joined with cinchona and opium, both by the mouth and in the form of clyster, more particularly the latter, to assuage pain, together with injections of tepid water and milk, or of some gently astringent liquor, together with warm bathing, may be the most advisable remedies in the advanced or carcinomatous stage ofthe dis- ease. In order to prevent excoriation from tbe acrimony of the dis- charge, some simple ointment should be applied to the parts over which it passes.—See page 723. Too much caution cannot be observed by women in guarding against any exposure to cold after delivery, as they are thereby apt to bring on diseases, which, if they do not prove quickly fatal, not unfrequently leave effects behind them of which they will be sensible the whole future period of their life. PERITONITIS, OR INFLAMMATION OF THE PERITONAEUM. The peritonitis of the puerperal state appears to be only tbe com- mon inflammation of the peritonaeum attacking a woman already labouring under debility, and being somewhat conjoined thereby with puerperal fever. Perilonaeal inflammation frequently occurs in women after delivery, and is produced by the same causes which give rise to an inflamma- tion of the uterus, viz. tedious and difficult labours, officiousness in tbe midwife, the use of instruments, the application of cold, and administering heating liquors to excess. The disease has by some authors been called puerperal fever ; but this seems improper, as it neither is attended with contagion nor ever prevails epidemically; and therefore tbe term is more properly applicable to the disorder treated of under that particular head. In some cases of peritonitis the inflammation attacks only a small portion of the membrane at first, and is afterwards communicated to the whole of it; and in others it occupies the whole at once. The patient usually is seized with rigors and shiverings, thirst, fever, and an accelerated pulse, and soon feels considerable pain, with soreness, either in a particular part ofthe abdomen, or over the whole of it. The uneasiness and pain increasing rapidly, the abdomen be- comes puffed up and swelled to a size nearly equal to what it was be- fore delivery. From the inflamed state ofthe parts, and the exquisite pain which prevails, the very weight ofthe bed-clothes becomes irk- some and insufferable ; and in order to support it, the patient is obli- ged to lie on her back with her knees bent in towards her belly. She is, moreover, incapable of bearing the least motion. The stomach in most cases is much affected, and a constant sick- ness, with a vomiting of bilious matter, ensues. The state of the intestines is variable ; sometimes costiveness prevails, at others a purging, and sometimes the body is perfectly regular. The bladder DISEASES OF THE PUERPERAL STATE. 855> likewise becomes affected, and there arises a constant inclination to make water, but which comes away, however, in a very small quantity at a time. As the disease advances and the tumefaction augments, great difficulty of breathing ensues ; and in consequence of the general determination to the bowels, the secretion of milk becomes much diminished, and is at last entirely stopped ; the breasts are flaccid and empty, and the lochial discharge is perhaps wholly suppressed. The system is usually affected with a mixture of general inflam- mation and symptoms of irritation; the pulse is frequent, small, and contracted, beating about 120 or 130 in a minute ; the skin is dry and hot, with flushing of the face and redness of the eyes ; the tongue is white and dry, with the prevalence of great thirst; the appetite is diminished, but not wholly lost ; and the patient is restless, uneasy, and gets little or no sleep. The disease continuing to proceed in its course, all the symp- toms become highly aggravated, and at last a total cessation of pain ensues ; the pulse becomes still smaller, but is at the same time more frequent ; cold clammy sweats break out, the urine and faeces come away involuntarily, the extremities are cold, and, the patient is carried off in the course of the sixth, seventh, or eighth day. We may regard the following appearances in a favourable light:; —The pulse becoming fuller and less frequent, the skin moister and cooler, the respiration less laborious, the urine being voided in a proper quantity and less frequently, the return of the milk in the breasts, the reappearance of the lochial discharge, a gradual diminution of the pain and tension in the abdomen, w'ith the ability of remaining in a sitting posture, and the coming on of a gentle diarrhoea towards the close of the disease. On the contrary, we are to consider the sudden cessation of pain, with a sinking pulse, effusion, and tumefaction, as fatal symptoms. Peritonaeal inflammation is fo be distinguished from enteritis by the pain being permanent; by its being increased by pressure, even before any tension has taken place on the abdomen ; by its pror during no inclination to go to stool; and by its not being dimin- ished if this evacuation should take place spontaneously. The appearances on dissection have been those of inflammation in the peritonaeum covering the different viscera, as the slomacb, liver, spleen, omentum, intestines, &c.; bnt that which covers the uterus and bladder is usually found in a higher state of inflamma- tion than any other part. Moreover, there is generally perceived in the cavity of the abdomen a large quantity of a fluid reseroblmg serum, mingled with pus, and intermixed with shreds of coagulable lymph, or portions of solid matter, similar to what is mentioned under the head of Puerperal Fever. It seldom happens that gan- grene or mortification of any of the viscera is to be observed ; but the intestines are usually greatly distended with air. In the cure of this disease, nearly the same mode of treatment 856 DISEASES OF THE PUERPERAL STATfc. which has been advised for an inflammation of the uterus must be adopted. Bleeding from the system to about sixteen or twenty ounces should therefore be had recourse to at a very early period, particularly where the patient is of a robust plethoric habit, and with such it may be necessary to repeal the operation within twelve hours. In those cases where there is no mixture of phlegmonous inflammation with the symptoms of irritation, drawing blood a second time, by the application of a dozen leeches applied to the abdomen, may be preferable to taking it away from the arm. In the pure peritonitis, local blood-letting should never be solely trusted to, and indeed ought not to be advised until there appears some diminution of pain from general bleeding, or till the constitu- tional effects occasioned by the local inflammation are partly removed, and the disorder thereby reduced to a state more nearly approach- ing to a simple topical affection. Then the repeated application of several leeches to the abdomen, so as to keep up a perpetual flow of blood, will be useful. An occasional irregularity in the Complaint often occurs, which is liable to mislead the practitioner: and that is, at the very first attack there is sometimes so great a degree of prostration of strength or seeming debility, accompanied likewise by a pulse scarcely perceptible at the wrist, as might induce us to consider the patient nearly at the point of death, and unequal to undergo the treatment here recommended. These appearances, however, may be supposed to arise from the inflammation extending to the peritonaeal coat of the stomach and intestines. Here the violence of pain and tenderness on pressure must be the chief criterion to determine our practice, but not the state of the pulse ; and if they should be found exquisite, no accidental symptom should lead us from trusting chiefly to the lancet. Such a decision will soon be justified by a freedom in the action of the arterial system, by an abatement of the languor, and by a diminution of the pain and tenderness. Emollient and antispasmodic fomentations, by means of flannel cloths wrung out in a warm decoction of equal parts of chamomile flowers, bryony, and bruised poppy-heads, with a small addition of rectified spirit or spiritus camphoras, will be proper remedies in all cases of peritonitis, and ought therefore not to be neglected. Some cases are recorded in a late publication*, attesting the good effects of cold applications by linen cloths dipped in camphor mixture and water in this disease. Under an apprehension that the application of a blister to the abdomen might prove injurious by its irritating effect, some physicians have objected to advise it in peritonitis, while others again have recommended it fo be employed, under the idea that its determining the inflammation to the external parts, and thereby lessening it on the internal ones, will greatly counterbalance any * See Observations on Peritonitis, by T. Sutton, M. D. ©ISEASES OF THE PUERPERAL STATE. 857 excitement it may occasion. When the constitutional effects occa- sioned by the local inflammation are partly removed by general bleed- ings, and the disorder is reduced to a state more nearly approaching to a simple topical affection, there can be no doubt, 1 think, of the propriety of blistering the abdomen. To empty the bowels freely, it will be necessary to employ active purgatives from time to time. A pill composed of three or four grains of the submuriate of mercury, followed by a full dose of an infusion of senna with sulphate of magnesia, or of castor oil, will not fail to afford relief by promoting several evacuations of fetid and dark stools. Emollient clysters may be administered during the intervals of om? employing purgatives, as they will not only assist in keeping the bowels •pen, but will act likewise as internal fomentations. Should there prevail great irritation at the stomach, wilh frequent vomiting, the patient should be directed to drink freely of diluted mucilaginous liquors, taking every two or three hours a saline draught in the act of effervescence, with an addition of about twelve or fifteen drops of the tinctura opii. In order to determine the circulating fluids to the surface of the body, and excite a slight degree of perspiration, we should administer small and repeated doses of some diaphoretic* ; and to procure sleep and alleviate pain, having previously bled sufficiently, we may make an addition of opium, increasing the quantity according to its effects. These may be washed down with two or three table-spoonsful of the mistura camphorae, which will be likely to prove a serviceable medicine. Where the urine becomes suppressed by the inflammation having extended in a high degree to the bladder, a warm bath, with an occa- sional use of the catheter, may be necessary. In tbe early stage of the disease, where phlegmonous inflammation simply prevails, it might be of service to make use of tbe nitrate of potass and other refrigerants; but at a more advanced period, and where symptoms of irritation arise, they would be improper. When these ensue, the cinchona bark, with a moderate quantity of wine, ought to be given. Should the stomach not be capable of retaining the powder, a decoction or infusion may be tried, with a small addition of tbe tinctura calumba:. * l.ft Pulv. Antimonialis, gr. ij. Confect. Rosae, gr. x. M. ft. Bolus quarlis horis capiendus. Vel, 2. IiPulv.Jacob.gr. v. Opii; gr. ss. Confect. Cort. Aurant. q. s. Vel, .3. R Pulv. Ipecac Comp. gr. x. pro dos. M. * 1. Take Antimonial Powder, two grains. Confection of Roses, ten grains. Mix them, and take this bolus every fotfr. hours. Or, 2. Take James's Powder, five grains. Opium, half a grain. Confection of Orange Peel, a sufficiency to form a bolus. Or, 3. Take Compound Powder of Ipecacu anlia. ten grains for a dose. 858 DISEASES OF THE PUERPERAL STATE. If a gentle diarrhoea should come on in the course of tbe disease, it is by no means to be checked, unless when violent, as it may prove critical. The spirit of turpentine is a remedy which has been strongly recommended in puerperal peritonitis by Dr. Brenan, of Dublin, and is said to have been employed by him with very favourable effects in several instances of the disease. In extreme or very urgent cases, after the failure of the other means which have been pointed out, it may be worthy of a trial. Throughout the whole period of the disorder the patient is to be supported by food of a light nutritive nature, administered in small quantities at a time, and repeated frequently, so as never to overload the stomach. Where effusion in the cavity of the abdomen with tumefaction takes place, no relief can be obtained by medicine: death is the infallible consequence. Chronic peritonitis, the occasional sequela of acute, especially when the depleting plan has not been sufficiently acted upon, must be treated with leeches, blisters, and small doses of the submuriate of mercury, together with some active cathartic twice a week. FEBRIS PUERPERARUM, OR PUERPERAL FEVER. Great soreness, pain, and tension of the abdomen, short anxious breathing, uncommon quickness of the pulse, increased temperature of the body, tensive pain over the forehead, peculiar wildness of the eyes, prostration of the vital powers, suppression or diminution of the milk and lochia, a flaccid state of the mammae, and an unnatural condition of the excrements, accompanied by diarrhoea, may be regarded as the pathognomic symptoms of puerperal fever. Its epidemial prevalence at times, is a suflicient characteristic of its nature, because this circumstance never takes place with respect to simple inflammation of the uterus and peri- tonaeum. It is a disease peculiar to women after delivery, particularly in hospitals, and is supposed to occasion the death of nearly one-half of those who die in childbed. Until of late it had not been much noticed by medical writers, and even now various opinions are entertained with regard both to its nature and the causes producing it. Some have doubted if it deserves the title of specific, or ought to be regarded as of a particular genus; and these have been accustomed to look on it as only a simple modification of the known species of fever, taking its origin from the leaven of the prevailing epidemic constitution, whether inflammatory or putrid, modified by the habit of body, the mode of living, the age and temperament of the patient, the preceding causes, the season of the year, and temperature of the air, he. Others again have considered the disease as uterine and peritoneal inflammation, accompanied in its progress by fever of a low malignant nature, DISEASES OF THE PUERPERAL STATE. 859 or typhoid type*. Indeed the diagnosis between puerperal fever and the more common forms of peritoneal and uterine inflammation which occur in the puerperal state, is still obscure and undetermined : the limits bounding some of these cases are so indistinctly marked, that the one case seems to pass imperceptibly into the other. A stoppage of the lochia has been assigned as one of the causes of puerperal fever; but the circumstance of their being sometimes absent and sometimes present at the attack, and during the progress of the disease, shows their perfect independence of each other. Others again have thought that puerperal fever is produced by the absorption of a putrid sanies arising from dead parts ofthe omentum or mesen- tery, or some other putrid material in tbe abdomen or uterus. By a few physicians it has been represented as owing its existence to an undue secretion of milk; while others have supposed that it derived its origin either from a redundancy, or too great acrimony ofthe bile, the secretion of which appears to be much interrupted during the time of gestation. The late Dr. Young, professor of midwifery at Edinburgh, was of opinion, that the puerperal fever, strictly so called, is, in every instance, the consequence of contagion : but he contends, that the contagious matter of this disease is capable only of producing its effects in conse- quence of a peculiar predisposition given by delivery and its conse- quences. In support of this doctrine he remarks, in a paper read in the Philosophical Society of that city, that for many years the disease was altogether unknown in the lying-in ward ofthe Royal Infirmary at Edinburgh ; but that after it was once introduced into the hospital, almost every woman was, in a short time after delivery, attacked with it; although, prior to delivery, she may have lain even for weeks toge- ther, not only in the same ward with the infected, but even in the very next bed. He further remarks, that it was only eradicated from the hospital in consequence of the wards being entirely emptied, thoroughly ventilated, and new painted. After these processes, puer- peral females in the hospital remained as free from the disease as for- merly. With respect to the infectious nature of this fever, a great contrariety of sentiment has indeed existed : the probability is in favour of its be- ing so, but it is nearly impossible to'form a decided opinion on the sub- ject. Doubtless it will be the safest practice to consider it as infec- tious, and to cut off all intercourse of pregnant and parturient women with those who labour under it. The real cause of puerperal fever is obscure and not yet satis- factorily ascertained. It is however certain, that it has a strong tendency to the typhoid type in an advanced stage, although at its commencement, or during the first twenty-four or thirty-six • See Facts and Observations relative to the Fever commonly called Puerperal, by J. Armstrong, M. D. 860 DISEASES OF THE PUERPERAL STATE. hours, it is usually attended with inflammatory symptoms, and even with topical inflammation in the abdominal viscera, but more particularly the peritonaeum, or membrane which envelops them. Under different circumstances, the disease assumes different appear- ances, and accordingly different distinctions have been laid down by writers between its various forms ; but such distinctions are of no use in practice, and may perhaps be productive of embarrassment to the practitioner. We may conclude, I think, that the only essential difference in the cases that ought to be considered puerperal fever, consists in their degree of violence, and their being epi- demic, or simply sporadic ; for it seems to be admitted that when- ever the disease exists epidemically, it is more urgent in all its symptoms. The period at which women are attacked with this disease is uncer- tain, as in a few instances it has arisen at the distance of a week after delivery: but the most usual time of its attack is on the third or fourth day after that event. The patient is seized at fir-t with a slight cold- ness and shivering, succeeded by pains in the head, ringing in the ears, flushings in the face, great anxiety and restlessness. As the disease advances, the whole abdomen becomes affected, is highly painful to the touch, and much tumefied. She likewise feels great pain in the back, hips, and sometimes in the legs, and she performs respiration with difficulty, the breathing being short and laborious, from the pressure against the diaphragm, as well as from an organic affection of the chest itself. If the milk has been previously determined to the breasts, it suddenly disappears on the approach of the disease; but if the attack of fever commences sooner, the milk does not appear. The lochia are altered both in quantity and appearance ; the urine is turbid, small in quantity, and voided with pain, and a te- nesmus often arises. The skin is hot and dry, the pulse weak and frequent, the number of pulsations being often from 110 to 130 in a minute; thirst prevails, and there is vast prostration of strength, with anxiety, depression of spirits, a disinclination to suckle, carelessness about her child, and watchfulness. To these symptoms are added a tensive pain over the forehead, and a peculiar wildness of the eyes. A vomiting not unfrequently attacks at the same time, and in so high a degree as to prevent the smallest quantity of food or medicine from being retained on the stomach. The matter thrown up is of a dark porraceous colour, and often of a disagreeable smell. The functions 6f the primae vise are likewise much disturbed. At the commencement, they usually go on well; but in tbe progress of the disease, a severe purging often ensues, particularly in (hose cases where the abdomen has been much distended, and the dejections are, abundant, serous, and putrid. It seldom happens that any violent delirium arises, but the patient is apt to fall into a low comatose state, wishing by no means to be disturbed. DISEASES OP THE PUERPERAL STATE. 861 After one or two days' continuance of these appearances, the fever often acquires a malignant and typhoid tendency, particularly in hospitals and confined situations, or when the state ofthe atmos- phere predisposes to diseases of that nature ; the lips, teeth, and tongue are covered with a dark brown fur; aphthae beset the whole internal surface of the mouth, tongue, uvula, tonsils, and pharynx ; the breath is highly offensive ; the stools are fetid, of a dark brown colour, and pass off in\oluntarily ; and in a few cases purple spots appear on different parts of the body. Such in general is the course of the puerperal fever ; the symp- toms of which, however, may be often varied, according to the constitution of the patient, the degree of the disease, and its earli- er or later invasion. Puerperal fever is readily to be distinguished from that affection known by the name of after-pains, by the intervals of ease which attend these last, and by the absence of fever and abdominal ten- sion ; whereas in the former there is fever with its concomitant symptoms ; great soreness and swelling of the abdomen, and an almost uninterrupted continuance of pain throughout the course of the disease. Many circumstances evince a dissimilarity between the puerperal and miliary fevers, notwithstanding the symptoms of anxiety and oppression are common to both. In the puerperal fever the rigor is more violent, of longer duration, and not interrupted, as in the other. The pulse at first is fuller and stronger ; the skin is more hot; and the tongue, whether moist or dry, though generally the latter, is not of a white but brownish appearance. Peritonaeal inflammation is the disease whieh bears the strongest resemblance to puerperal fever, but it never arises from contagion, or prevails epidemically. By paying proper attention, we may in general be able to distin- guish simple peritonitis from puerperal fever. In the last, the abdominal pain is not the most prominent symptom. There is more despondency, debility and headach, less heat of the skin, less thirst, and less flushing of the face. In the former, the pain in the abdomen usually increases rapidly after its commencement, and the swelling increases along .with it : pressure excites con- siderable pain, and the fever is inflammatory throughout. Hysteritis has its proper symptoms by which it may readily be distinguished from puerperal fexer. The progress of puerperal fever is sometimes so very rapid, particularly in warm climates and hot seasons, as to destroy the patient in forty-eight hours. Even in cases seemingly the most favourable, we should look on fhe event as doublful, as the com- plaint is apt to be accompanied with delusive remissions, and indi- cations arise in its progress which are by no means equal to the danger. The risk seems however to be greater in proportion as the ac- cession is sooner after labour. When the disease comes on at a 862 DISEASES OF THE PUERPERAL STATE. late period after delivery, the depression of strength is usually less considerable, the tumefaction of the abdomen is less extensive, and the other symptoms are not so violent, and consequently there will be a greater chance for the woman's recovery. The reappearance of the lochia and a gradual subsidence of the abdominal tension and soreness after copious stools, the pulse at the same time becoming slower, with a moist skin, may be re- garded in a very favourable light. On the contrary, an extensive swelling of the belly, so as to sound on striking it with the finders, sudden cessation of pain, irregularity in the pulse, coldness in the extremities, clammy moisture diffused over the whole body, fre- quent dark-coloured and fetid evacuations by stool, and an indiffer- ence to all external objects, denote certain and speedy death. On a fair computation, three-fourths of the women who have been attacked with this disease have fallen sacrifices to it. The morbid appearances observed on dissection are usually con- fined to the abdomen. The first thing that often presents itself is a collection cf whey-like fluid in the .cavity of Qie abdomen, which is sometimes so considerable in quantity as to amount to several quarts ; and it has a peculiarity of smell different from any olher fluid to be met with in the human body, either in health or disease. Where it is large in quantity, the surfaces of the different viscera and ofthe peritonaeum will usually be found covered with a crust formed of a solid part of this matter, resembling coagulated lymph. If there be any interstices between the intestines or the other viscera, they are frequently filled wilh large masses of the same, adapted exactly to the shape and size of such interstices. In a few cases, a deposite of a caseous and serous nature has been discovered likewise in tbe head, breast, and external cellular membrane, as has before been observed. In most instances there is found a slight degree of inflammation iu some part of the cavity ; but it is not confined invariably to any particular place ; as the uterus, ovaria, peritonaeum, omentum, intestines, and bladder, have all in their turn been observed in a state of inflammation. In many cases of dissection, a considerable quantity of purulent matter has been found in the cavity of the abdomen. Upon analyzing the fluid effused into (he peritoneal cavity of a woman dying from this fever, it has been found to possess a per- fect chemical identity with that furnished by the inflamed pleura. The peritoneal fluid, after depositing a copious whitish precipitate, which afforded albumen fo the different reagents, was of a clear yellowish white colour, and had the property of turning green the gyrup of violets. But the nature and proportion of the alkali en- dowing it with this property, have not been ascertained. The flocculi which float in the abdominal serum of puerperal subjects have been regarded as a cheesy substance, formed of the coagulum of the milk ; but this seems erroneous. Ammonia mixed with the substance in question scarcely acts upon it as a solvent, and evapo- ration developes in it all the characters of albumen. DISEASES OF THE PUERPERAL STATE. 86.mall quantity of rhubarb or jalap, followed up by two or three large spoonsful of a solution of some neutral salt every hour or two, until copious evacuations are procured, will be most ad- visable. Where the disease is in an advanced s;age, and the patient reduced in strength, dislodging the contents of the intestines by means of gentle laxatives, assisted by aperient clysters, appears to be the best mode of procuring evacuations, which at this period ofthe disease are usually of a dark brown colour, resembling coffee grounds, very copious, ofthe consistence of thick gruel, and with a fetid smell. In my opinion the most rational method of treating puerperal fever, but more particularly when attended by abdominal pain and soreness, is to abstract blood from a large orifice to a sufficient ex- tent at the first onset of the disease, and then direct the attention to a free evacuation of the alimentary tube throughout the continu- ance of the disease. A very interesting account of a puerperal fever which was epidemic, at Aberdeen, and published by Dr. Alexander Gordon, gives us to un- derstand, that not only purgatives are useful in this disease, but like- wise bleeding. He tells us, that the disease was infectious; that it seemed to arise from the contagion that was carried by the accou- cheur, or nurse, from one lying-in woman to ajiotber; and that it began with violent unremitting pain of the abdomen on the day of delivery or the next, with shuddering, and a very quick pulse, often 140 in a minute. If he saw the patient within twelve or twenty-four hours of her seizure, he took away from sixteen to twenty-four ounces of blood, which was always sizy. He then immediately gave a cathartic consisting of the submuriate of mercury and jalap. After this had operated, he prescribed an opiate at night, and so continued the purge and the opiate for several days. He asserts, that almost all those whom he was permitted to treat in this manner early in the disease, recovered, to the number of fifty, and that almost all the rest died; but that when two or three days were elapsed, the patients became too weak for this method, and the matter was already formed which destroyed them. Dr. Armstrong is of opinion* that puerperal fever bears a close analogy to typhus complicated with inflammation of the abdomen, and thinks it ought to be arranged under three varieties, namely. the sporadic, the epidemic, and the chronic. He also is perfectly convinced that bleeding at the first onset of the disease, assisted by purgatives, are the main remedies to be depended upon under every fowo. 3lr. Hey, of Leedsf, is also an advocate for the same plan of treating this fever. * See his Illustrations of Typhus and other Febrile Diseases -.--------Treatise on Puerperal Fever. t See Treatise on the Fame, by Mr. Uey DISEASES OF THE PUERPERAL STATE. 863 It often happens that nausea and a vomiting of bilious matter attend an attack of this fever. In such cases we may recommend a gentle emetic of ipecacuanha to be taken, with a view of cleansing the stomach : but I cannot agree with those who advise a repetition of it, as the operation of vomiting never fails to aggravate the pain, and likewise to exhaust the woman, besides endangering a great degree of irritation in the stomach, to which there is naturally too great a tendency. Although I object to a repetition of ipecacuanha or antimonials, given so as to produce an emetic effect, still I think they may be ad- ministered with some advantage at the commencement of puerperal fever, in such small doses as to determine to the surface of the body. As a diaphoretic, I know of none preferable in the present in- stance to ipecacuanha, which may be prescribed in doses of about two grains, to be repeated every three or four hours ; or perhaps it may be still more efficacious to give it combined with opium, as in the pulvis ipecacuanha? compositus. Of this, about six grains made into a bolus, with a small quantity of confection of roses, may be taken as before mentioned, washing it down with a saline draught; and to make the diaphoretic effect more certain, the patient should drink frequently of diluting liquors, such as whey, barley- water, &c. To alleviate the soreness and distention ofthe abdomen, we may re- commend the application of fomentations both inwardly and exter- nally ; inwardly, by injecting emollient clysters from time to time ; and externally, by applying flannel cloths wrung out in a warm decoction of equal parts of chamomile flowers and bruised poppy-heads, wit1, an addition of about one-third of rectified spirit over the whole region of the abdomen ; and these ought to be renewed as often as they become cold, taking due care that they are not so wet as to run about the bed and incommode the patient. The warm bath has been recommended by some practitioners, and it offen produces a calm and disposes to sleep; but this being the effect of exhaustion, it appears to be a doubtful remedy. Where the abdominal cavity is highly painful to the touch, and is occupied by extensive inflammation, the application of cold to the parts by cloths dipped in camphor mixture and cold water, has been attended with a good effect*. If the soreness and pain are not relieved by the means which have been suggested, then the application of a blister to the upper part of each thigh may be proper. Blistering tbe abdomen would not be advisable for the reasons assigned under the head of Peritonaeal Inflammation. Having employed gentle cathartics at an early period for the purpose of obviating costiveness and dislodging the putrescent matter from the bowels, we may then with safety have recourse to * See Cases of Puerperal Fever, by T. Sotton, M. D 109 m DISEASES OF THE PUERPERAL STATE. anodynes administered so as to keep up a constant effect*. The dose of opium must depend on the severity of the pain, and the age and constitution of the patient, and it may be repeated every four or six hours. Opium, when administered in puerperal fever, diminishes the irritability of the system, as well as that of the stomach and intestines. It eases pain, produces sleep, and seems to excite a moderate diaphoresis. In a few instances, I think, 1 have observed it to obviate or relieve delirium in the same manner as in typhus. Should there be any great irritation of the stomach, the saline draught with a proper quantity of tinctura opii may be given, so as that the effervescence shall take place after it is swallowed, as advised under tbe bead of Simple Fever. Should this medicine also be re- jected, the vomiting may perhaps be restrained by opium in the form of pills, and by rubbing the region of the stomach frequently with some strong anodyne liniment. The application of a blister might excite injurious irritation. The strength must be supported by ad- ministering clysters composed of animal broths and other such nutri- tive liquids, until the stomach becomes tranquil and will bear the in- troduction of proper nourishment. If a gentle purging arises in the first stage or commencement of the complaint, it ought not to be too hastily stopped, as the fever has in some instances been carried off by such a spontaneous evacuation ; but if the disease is of some days' standing, tbe stools very frequent, tbe patient much reduced, and no evident relief has been afforded by the diarrhoea, we must then give astringentsf joined with opium to restrain it; and for ordinary drink she may * 1. R Aq. Cinnam. f. |j. Tinct. Opii, fll. x. Syr. Althaea, f. 3ij. Tinct. Lav. C. f. 3ss. M. ft. Haustus. t 2. ft Confect. Opii, 3ss.—3j. Aq. Cinnam. f. f jss. Tinct. Kino, f. 3y. ----Lav.C.f. 3ss. M. Haustus terin die sumendus. Vel, 3. ft Mistur. Cretae, f. §iij. Aq. Pimenta?, — Cinnam. aa f. |jij. Tinct. Catechu, f. 3»j- ------Opii, fll mx. M. ft. Mistura, cujus sumat cochl. larg. ij. tis horis. quar- * 1°. Take Cinnamon Water, one ounce. Tincture of Opium, fifteen drops. Syrup of Marshmallow, two drachms. Compound Tincture of Lavender, half a drachm. Mix them for a draught. t 2. Take Confection of Opium, ten grains to one scruple. Cinnamon Water, one ounce and a half. Tincture of Kino, two drachms. Compound Tincture of Lavender, half a drachm. Mix them. This draught is to be taken three times a day. Or, 3. Take Chalk Mixture, three ounces. Pimenta Water, Cinnamon Water, of each two ounces. Tincture of Catechu,two drachms. ------of Opium, forty-five drops. Mix them, and take two table-spoonsful every four hours. DISEASES OF THE PUERPERAL STATE. 867 take the mistura cornu usti. To support the strength, wine may be necessary ; and this should be given in a moderate quantity, properly diluted with water, as likewise mixed with the food con- sisting of preparations of barley, sago, panado, Indian arrow-root, tapioca, and the like, varied now and then for broths, beef-tea, and milk. It has been observed, that this fever, after continuing a day or two, very often acquires a malignant and putrid tendency. Under such circumstances it will be right to have immediate re- course to the bark of cinchona joined with the mineral acids, but more particularly the muriatic, as noticed under the head of Typhus Gravior, and to exhibit it freely in as large doses as the stomach will bear. If the powder is readily retained, it ought to be pre- ferred to any other preparation ; but if not, a decoction or infusion may be substituted*. Should it be rejected in all these ways, it may then be given in clysters, with an addition of about five-and- twenty drops of tinctura opii to each. If it occasions any purging when taken by the mouth, a few drops ofthe tincture of opium may be added to each dose. When there is no disposition to a putrid tendency, it will be best to wait till a remission of the symptoms, or a partial subsidence of febrile action has taken place, before we prescribe a use of the cinchona. A late physician of eminencef in treating on this disease ob- serves, that the cinchona, although given by him in the different stages of the complaint with remissions tolerably distinct,by no means answered the intention as a febrifuge ; but that in a few cases where the intermissions were complete it had succeeded. He likewise observes, that as a supporter of the general strength, it has been found of less service than might have been expected, on account of the disturbed and very irritable state of the bowels, which it has a tendency to increase. Instead of cinchona, he ad- vises the calumba-rootj in powder or infusion||, in doses to be repeated every four hours. t Dr. Denman. * 4. Take Decoction or Infusion of Peru- vian Bark, ten drachms. Tincture of Cascarilla, two drachms. Muriatic Acid, eighteen drops. Mix them. This draught is to be given every four hours. X 5. Take Powder of Calumba, half a drachm Opium, half a grain. Confection of Roses, a sufficiency to form a bolus. || 6. Take Infusion of Calumba, ten drachms* Tincture of Orange peel, one drachm and a half. Muriatic Acid, fifteen drops. Mix them for a draught. * 4. R Decoct, vel Infusi Cinchona?, f. 3*- Tinct. Cascaril. f. 3« • Acid. Muriatic, fll xii. M. ft. Haustus quartis horis adhibendus. { 5. ft Pulv. Calumb. 3ss. Opii, gr ss. Confect. Rosae, q. s. M. ft. Bolus. || 6. & Infus. Calamb. f. 3*- Tinct. Cort. Aurant. f. 3>ss. Acid. Muriatic, fll "• M. ft Haustus. 868 DISEASES OF THE PUERPERAL STATE. If hiccups and subsultus tendinuin arise in tbe progress ef the disease, recourse must be had to antispasmodics, such as musk, aether, and the like; although it is probable they will avail but little. When any unusual coldness of the extremities is felt, tha application of stimulating cataplasms will be proper. The carbonate of potass is a medicine which is strongly recom- mended by Monsieur Guinot* in puerperal fever, as well as in all diseases connected with the secretion of milk in the female breast. He advises it to be given in doses of from ten to twelve grains three times a day, in any proper vehicle, and to employ at the same time alkalies externally, such as a solution of soap in a decoction of poppy-heads, taking care at the same time not to neglect other remedies indicated by the circumstances and symptoms of the case. This alkaline treatment he recommends under the idea that the disease is occasioned by the predominance of an acid. Whether it acts by counteracting the acid, dissolving the clotted milk, by neutralizing the acid which may actually exist there, by its action on the organs of perspiration, or by inducing other useful crises, cannot be ascertained ; but it appears to have proved very success- ful and advantageous with ofher practitioners besides Monsieur Guinot, and may therefore be tried at an early period of the dis- ease. A combination ofthe carbonate of potass with the cinchona bark might probably be useful in cases of puerperal fever compli- cated with malignancy. It would appear that the effluvia of a patient under puerperal fever is an animal poison sui generis, capable of acting on preg- nant females, their situation giving the predisposition necessary for the operation of its influence. The usual mode of communicating the infection in private practice is by being delivered by some ac- coucheur who has lately been attending a woman labouring under puerperal fever, or her being visited by female friends who have been where it prevailed. It therefore behoves every practitioner when he meets with the disease to observe every possible precau- tion in changing his clothes, and by careful ablution of his hands to guard against conveying infection to other parturient women : moreover, all pregnant women should be excluded from the house ; nor should tbe nurse or other persons about the sick be permitted fo go abroad and visit women in a stage of pregnancy. To prevent the disease from occurring, it will be proper to keep the patient's mind both before, during the time of labour, and afterwards, as free from every kind of uneasiness as possible, as anxiety might greatly predispose to an attack of it. She should likewise carefully avoid any exposure to the infection of fever before delivery, as well as to the occasional causes of it afterwards. Every woman lately delivered ought cautiously to guard against cold ; but in doing this, her room should at the same time be kept of a proper temperature by allowing a sufficient ventilation. * See Extracts from his Memoir inserted in the third volume of the Medical and Physical Journal, pages 80,165,264, and 363. DISEASES OF THE PUERPERAL STATE. 869 It being a well-known fact that puerperal fever has been chiefly confined to close apartments and small hospitals, and that since tbe lying in chambers have been made more airy and commodious, and the hospitals larger, the disease seldom prevails epidemically or becomes general, due attention should be paid to a free ventilation; for it is by no means improbable that a cool air in a lying-in chamber will frequently prevent, and its opposite be likely to induce the phe- nomena of puerperal fever. The patient should observe the strictest cleanliness both as to her- self and the bedding. On the coming of the milk, her breasts ought to be drawn repeatedly throughout tbe course of the day by some person accustomed to the business, or by applying the child; her body should be kept perfectly open, and she should abstain from all food of a heating or irritating nature. An upright posture will be most proper, in order to discharge more readily any putrescent matter that may be in the uterus. When the disease prevails as an epidemic among puerperal women, or occurs in a lying-in hospital, all communication ought immediately to be cut off between those who are affected and such as have lately lain in, or expect shortly to do so ; and in order to root out the disease and stifle contagion, we should have recourse to fumigations, as advised under the heads of Malignant Fever and Dysentery, and afterwards to painting, white-washing, and a free ventilation. In situations where puerperal fever has been prevalent, some advan- tage may be obtained by giving a decoction of the bark of cinchona with tincture of opium and cordials immediately after delivery. These will in some measure enable lying-in women to resist the powers of contagion. INVERSIO UTERI. This complaint consists in the inversion of the cavity ofthe uterus, so that the fundus comes through the os uteri, consequently that part which was formerly the inside of the cavity becomes now the outside of a tumor, either in or projecting from the vagina. It most commonly is the consequence of mismanagement of the pla- centa, by the midwife or accoucheur being in too great a hurry to extract it. Its immediate effects are hemorrhage, faintness, and a sense of fulness in the vagina. When early discovered, the uterus may easily be reduced to its natural situation. If the placenta be adhering to the womb, the latter should be reduced before any separation of the former be attempted, to prevent hemorrhage. PROCIDENTIA UTERI. This complaint consists (as the name implies) in a change of the situation of the womb, by which this organ falls much lower than it ought to do. In some cases it absolutely protrudes entirely 870 DISEASES OF TIIE PUERPERAL STATE. without the vagina. The slighter cases are therefore named a bearing down, and the more violent ones a descent or falling down of the uterus. The complaint is met with in women of every rank and age ; but more frequently in those who have had several children than in such as have not had any. Eve'ry disease which induces general debility, or local weakness in the passage leading to the womb in particular, may lay the foun- dation of this complaint; hence immoderate venery, frequent mis- carriages, improper treatment during labour, and too early or a long continued erect posture of the body soon after delivery, and in some cases after abortion, are in married women the most common causes of procidentia uteri. At this time the womb weighs eight or ten times more than when unimpregnated, and descends by its gravity. In the unmarried it is apt to take place in consequence of violent exercise, such as jumping, dancing, riding, lifting heavy weights, &sc. while out of order. The proximate or immediate cause of prolapsus uteri is relaxa- tion of the broad and round ligaments above, and want of tone in tbe vagina below. The disease comes on generally with an uneasy sensation in the loins whilst standing or walking, accompanied now and then with a kind of pressure and bearing down, as also pains in the groins extending to the labia. There is a sense of fulness in the parts, and probably an increased discharge of transparent mucus from the vagina. All tbe symptoms are relieved by a recumbent position. In procidentia uteri the symptoms arising from the uterogastric sym- pathy are in many cases very distressing; the appetite fails, the stomach and bowels lose their tone, flatulence and borborigrai are troublesome, considerable debility ensues, the spirits are depressed, employment and exercise become irksome, and life at last is scarcely desirable. The discharge varies much at times, the menstrual flow usually is increased, and menorrhagia not unfrequently attends. Before the external protrusion of the tumor, the discharge is greater than afterwards, because the surface of the vagina ceases to secrete when permanently exposed to the air. After a time, patches of healthy looking ulceration attack the exposed vaginal surface, but seldom go deep; and the os uteri is not unfrequently assailed by one of these. By neglecting to pay proper attention to the early symptoms and threatenings of tbe disease, tbe woman becomes at length in- capable of making water without first lying down or pushing up the swelling which seems to impede the discharge of urine; and if the complaint continues to increase, the womb is actually forced out of tbe parts, and takes on the form of a bulky substance hanging down between the thighs. This severe degree of the disorder seldom occurs, however, among women in northern climates, except in those who have had many children, and are at the same time of a relaxed and feeble frame ; but in warm climates it is very frequently to be met with, and particularly in DISEASES OF THE PUERPERAL STATE. 871 negroes and mulattoes, among whom I often observed the protruded parts considerably ulcerated, and occasioned, no doubt, by external irritation and a neglect of cleanliness. Although procidentia uteri is a local disease, it is frequently pro- ductive of several distressing symptoms which undermine the consti- tution. These principally arise from disturbed functions of the sto- mach and bowels, and an impaired condition of the nervous system. In its early stages, if conception should take place, a confinement for some weeks in a recumbent position on a sofa or bed will often enable the parts to regain their tone, so as to render subsequent ar- tificial assistance unnecessary. Where pregnancy does not exist we must have recourse to art. If the disease is of long standing it may be difficult to effect a cure. In the treatment of procidentia uteri, the curative intentions arc to increase the tone of the relaxed parts, both topically and through tbe constitution, and to support the tumor: topically by cold and by astringents. Cold water ought to be applied to the parts of generation, as also to the belly and back, by means of a large sponge, three or four times a day, the water being as cool as pos- sible. Cold water may also be thrown into the vagina as frequently by means of a syringe. In very slight cases, these means, assisted by an horizontal position, may be sufficient; but in cases of some standing, astringent washes should be substituted for simple water. Alum combined with zinci sulphas dissolved in a decoction or in- fusion of some vegetable astringent, such as thea viridis, petala rosae rubrae, cortex quercus, cortex granati, gallae, he. will make an appro- priate injection, various formulae of which are given under the head of Leucorrhoea and Gonorrhoea Simplex, as also below*. In aid of topical applications tonics must be administered inter- nally, especially the bitter tonics, as gentian, cajumba, &c. with cinchona and sulphuric acid: for various formula? of these see Dyspepsia. A due attention must be paid at the same time to the state of the bowels, and this be nicely regulated ; the extreme of constipa- tion and diarrhoea being equally injurious. Aperients of the mildest nature, when requisite, are therefore only to be employed. The bladder should never be suffered to contain a large quantity of urine. When the stomach is not previously much weakened, the "l.&Cort.Querc.f. ?»j- Aq. Purae, Oij. Coque ad dimidium, et colaturae adde Aluminis, 3'ss. Zinci Sulphat. 3ss. M. ft. Injectio. Vel, 2. R Aluminis, 3iv. Plumbi Superacet. 0ss. Aq. Rosae, f. %x. M ft. Injectio. * 1. Take Oak Bark, two ounces. Pure Water, two pints. Boil it down to one pint, and to tbe strained liquor add Alum, one drachm and a half. Sulphate of Zinc, half a drachm. Mix them for an injection. Or, 2. Take Alum, four scruples. Superacetate of Lead, half \ scruple. Rose Water, ten ounces. Mix them for an injection. 872 DISEASES OF THE PUERPERAL STATE. use of a cold bath may prove a valuable auxiliary to the other means; and a salt water bath will be preferable to one of fresh water. In every case of procidentia uteri, the recumbent poslure on a sofa or bard matrass as much as possible ought to be enjoined, keeping the room at the same time as cool as may be consistent with the patient's feelings. The diet should be generous and nutritive, and a moderate quantity of wine be allowed. As exercises, swinging in a cot or hammock, and riding in an easy carriage, will be most appropriate. If the disease resists these remedies, or it shall appear from the first unnecessary to employ them from any idea of their inefficacy, the only relief that can then be afforded, unless the woman becomes pregnant, is to be obtained by wearing a pessary. This is usually made either of wood or ivory, and if properly adapted to the pas- sage and of a fit construction, may be worn without much incon- venience or any pain. Whenever such an instrument is used, cer- tain attentions will however be necessary. Thus, the pessary should never be allowed to remain in the passage above a few days at a time, otherwise it may become the source of some irritation. It ought therefore to be withdrawn occasionally on going to bed, be well cleaned, lest the secreted matter attached to it become acrimonious, and be reintroduced in the morning before the patient quits her bed. Pessaries are always either circular or oval; the former can only be used where the disease has not made much progress, and when the tone of the vagina is not much impaired. It will seldom be safe to introduce a circular pessary, the diameter of which exceeds two inches and a half; it should be large enough however to keep the sit- uation in which it is placed, else it will slip away ; but it should not be of such a size as to incommode the woman or to injure the parts by its pressure. Occasionally the pessary should be changed for one of a smaller size, as the vagina recovers its proper tone. The oval pessary rests with its longest diameter across the vagina, neither interfering with the rectum nor urinary passages. K seems best adapted for those cases in which the tone of the vagina is so much diminished as to require a large support. Its longest diame- ter ought not to exceed three inches and three quarters*. All pessaries ought to be introduced with great care, and be placed as high up in the vagina as possible. Before any attempt is made in the reduction of prolapsus uteri, it will first be necessary to empty the bladder and rectum : this being done, let the patient be so placed as that the pelvis shall be much higher than the shoulders. The practitioner is then to apply his Augers and thumb to the lower part of the tumor where the os uteri is situated, and by a gentle and gradual pressure this is to be carried up into the centre of the tumor itself. The pressure is * See Observation? on the D'seases of Females, by Charles M- Clarke. DISEASES OF INFANTS- %V6 afterwards to be continued until the parts are returned into their proper place. A pessary is then to be introduced, and the patient to be enjoined to remain in a recumbent posture for several hours. Where a woman who is liable to prolapsus uteri becomes preg- nant, there will be no occasion for the pessary after the third month) and by proper treatment after delivery, a return of the complaint may probably be prevented. In married women whilst there remains a possibility of preg- nancy, the hope of a radical cure remains, because the processes to which the vagina and parts connected with it are subjected after parturition, often produce a permanent reduction of the tumor. In these cases the principal remedies therefore are pessaries. But the complaint frequently remains after the period of menstruation is over, and when all likelihood of a radical cure is done away. In cases of this nature, Dr. Hamilton, of Edinburgh, has attempted by exciting artificial inflammation of the vagina, to procure an adhesion of its sides, and thus to form what he terms a fleshy pessary. Unhappily Dr. Hamilton failed iu the experiment which; he made for this puspose. A powerful stimulant is certainly required to produce in the vagina and other canals lined with a mucous membrane, that kind of inflammation which forms coagulable lymph ; for in these parts a slight degree of inflammation occasions pus to be poured forth, but a greater is demanded for the formation of lymph, exactly the contrary to what occurs in most, other parts of the animal body. Mr. John Hunter says*, that he produced adhesive inflammation in the vagina of an ass, by injecting a strong solution of the oxymu- riate of mercury. The remedy would by no means, however, be advisable in a woman. DISEASES of INFANTS. Much attention and experience are required to treat the diseases of infants judiciously ; close and repeated observation being the principal means of supplying Ihe want of that kind of assistance which the personal information of adult patients generally affords. The disorders of early infancy are, however, more obvious than has been generally supposed ; their number is comparatively small, (heir causes are uniform, and the treatment of most of them is simple and pretty certain. Improper food, confined and unwholesome air, the want of due exercise and cleanliness, difficult dentition, and unhealthiness of the parents, are the most general causes of the diseases of infants. Others have indeed been enumerated both by ancient and modern writers, such as their general laxity, the greater irritability of their nervous system, and the delicacy of their muscular fibres, which may indeed be considered as so many predisposing causes. * See his Treatise on the Blood,, p. 240. 874 DISEASES OF INFANTS. The symptoms of the first diseases of infants (by which we alsu judge of their nature) are chiefly retention and excretion, sour belchings, sickness, vomiting, purgings, inquietude, crying, wake- fulness, heaviness, loathing of the food, contractions and sharp- ness of the features, blueness about the mouth, turning up of the eyes, sudden slartings from sleep, thirst, heat, the manner of breathing and of crying, retraction of the lower extremities, hard- ness and distention of the belly, and pustules or eruptions, exter- nal or internal. To these may be added the openness or firmness of the fontanelles and of the sutures, the strength and figure of the bones, and the relaxation or contraction of the skin in general, and of the scrotum in particular. The pulse and urine are less certain marks, in the greater number of their complaints, than they are in older children and adults. Having thus briefly noticed the causes and symptoms of infantile diseases in general, I shall proceed to consider each separately. Small-pox, chicken-pox, measles, scarlatina, and such other erup- tive diseases, together with croup, hydrocephalus, ophthalmia, hooping-cough, scrofula, rickets, tinea capitis, worms, and a great many other diseases, being equally liable to attack children of a maturer age, have already been noticed in the preceding pages of this work, in the class and order to which each belongs.—See the Index and Systematic Arrangement. As it is always more desirable, as far as we are able, to prevent diseases rather than to cure them, and to obviate the causes rather than to remove their effects, I beg leave, previous to my entering on the treatment of infantile diseases, to offer a few observations on the diet and proper management of young children. During the first months of a child's life, the milk of its mother is unquestionably preferable to every other kind of nourishment, and even to the milk of another woman, provided the parent is in good health, and labours under no malformation of the nipples, or con- stitutional imperfection of importance. As, however, it is usually more convenient, and at times absolutely necessary, to bring up the child partly by the hand, as it is called, at the same time that it sucks, we should be careful to regulate the diet both with regard to quality and quantity, that its stomach may neither be disordered with what is improper nor be oppressed with excess. The food which is prepared by art should be thin and liquid, and be made fresh every day. It is to be offered to the infant frequently by little at a time, and at proper intervals, and not to be crammed down its throat as often as it awakes from sleep, or cries, as is the custom with many nurses. Instead of a spoon, a horn or glass botde covered with parchment, and perforated so as to imitate a nipple, may be used. This gives occasion to some little exertion in sucking, imitative of what we see in nature, and is moreover attended with the advantage, that the infant will not be gorged or induced to take more than it really wants. At first it will be suflicient lo give infants occasionally, along DISEASES OF INFANTS. 875 with the breast, a little milk and water warmed to the temperature of the mother's milk, with a very small proportion of sugar; or we may substitute thin gruel made from pearl barley, grits, rice, or arrow-root, mixed with about a third of cow's milk, which may occasionally be changed for thin pap made with bread or biscuit, with a due proportion of fresh milk; but all these should first be passed through a lawn sieve, to insure their being thin and smooth. At the end ol five or six months the diet may be made a little stronger, consisting of plain mutton or chicken-broth, clear and free from fat, or beef-tea, and occasionally some light pudding may be allowed. About the eighth or ninth month a small portion of animal food may be given, particularly if nature has pointed out its propriety by early dentition. The animal food given to young children should be plainly roasted or boiled, hot or cold : fried and boiled meat, and what is heated a second time by hashing or mincing, being less diges- tible, ought to be avoided. If teething commences soon and goes on well, the infant may be weaned at about nine months old ; but if dentition is late or accom- panied with much irritation, it may continue at the breast for a whole year, provided the health of the mother will admit of it, or that she is not again pregnant. When the child is weaned, any kind of light plain animal food may be allowed it once a day, with a due proportion of vegetables, consisting principally of the farinacea. as flour, rice, sago, &c. From a mistaken expectation of strengthening weakly children, some people give them animal food twice or thrice a day, but this is injudicious. The most proper drink for children will be plain water. The practice of swathing infants with bandages is now judi- ciously laid aside ; and deformity, as a consequence of dressing or clothing children improperly, is rarely to be met with. The rule to be observed with respect to the article of dress, ought to be, that a child have no more clothes than are necessary to keep it warm; that they sit easy and loose on its body : and that they be changed frequently, especially when they happen to be wetted. Dirty clothes not only gall and fret the tender skin of infants, but likewise give them an unpleasant smell, and are apt to produce cutaneous disorders, if not vermin; whereas cleanliness, assisted by gentle friction with the hand over every part of the body morning and night, together with proper ablutions with tepid or even cold water, tends greatly to preserve the health of children, and promotes perspiration. In dressing the infant, if the nurse observes the skin any where chafed, after washing the parts and drying them well, let her apply a little common hair powder to it by means of a puff; but if much galled, which will sometimes happen at the time of teething, par- ticularly in very fat children, from the heal and sharpness of the urine let ber bathe them with a wash composed of two parts of common water and one of rectified spirit, and afterwards sprinkle 876 DISEASES OP INFANfSi them with a little calamine or Fuller's earth, powdered very fine. When cutaneous eruptions appear during dentition, no repellent application should be employed. A young child should be amused through the day, and not suffered to sleep much during that time, that it may get the more rest by night. The curtains of its bed should not be drawn closely round, that it may breathe free and easily. It should be early accustomed to be much in the open air, for vigour of the body conduces to that of the mind ; and as it is incapable of any exercise of itself, it should be the business of its nurse or other attendant to toss it well about in her arras from time to time. If the season of the year will admit of it, bathing the child frequently in cold water will very much tend to strengthen and invigorate it. The chamber which is appropriated for the nursery should be roomy, and it ought to be kept remarkably clean, sweet, and properly ventilated. ASPHYXIA. The apparent cessation of life in new-born infants may be owing to various causes, such as universal weakness of tbe vital powers, col- lections of glairy matter in the vesicles of the lungs, the introduction of a quantity of the liquor amnii into the trachea, and a congestion of blood in the lungs, arising either from the neck of the child being tightly encircled by the os uteri or navel-string, or from the head being long detained in the passage. When universal weakness ofthe vital powers seems to be the cause, we must be cautious not to suffer any effusion of blood from the um- bilical cord. The communication between tbe child and the mother should be kept up as long as possible; for which reason we should avoid any violent pullings at-the cord, that the placenta may not be too soon detached ; and we should likewise not be in a hurry to apply a ligature. It not unfrequently happens, after a tedious labour, that tbe child is so weak and faint as to show little or no signs of life. In such cases, after cleansing it and wrapping it in flannel, we should stimulate its temples and nostrils witb spirits of hartshorn, and rub its chest with brandy. If these means fail to excite the languid circulation, we should then introduce a pipe or catheter into its mouth,and thereby endeavour to inflate the lungs ; which plan ought to be pursued for a considera- ble length of time, as there is great reason to suppose tbat many chil- dren might be saved were we to adopt the means which have been pointed out, and continue them long enough. Stimulating the in- testinal muscles to contraction, by pouring cold water on the child's thorax, so that air may rush in by the glottis, may likewise be tried. Besides inflating the lungs and pursuing the other steps which have bepn mentioned, care should be taken tbat the child does not lose its heat; for which reason it will be advisable to put it into a bath of warm water, and while this is preparing, it may be enveloped in warm flannel. From what has been observed on galvanism under the head of DISEASES OF INFANTS. 877 Suspended Animation in consequence of Drowning, it is probable tbat this remedy might prove a valuable auxiliary in many cases of asphyxia. Where a portion of the liquor amnii gets into the tiachea and produces asphyxia, or the mouth ofthe infant is discovered to be filled with a glairy matter, rendering the respiration difficult, sonorous, and rattling, we must not only rinse the throat of the child, but like- wise place it in an attitude which will facilitate the discharge of the liquor. Having done this, we should endeavour to reanimate the infant, by inflating the lungs, and then pressing out the air, imitating in this way, for a considerable length of time, natural respiration. If a congestion of blood in the lungs, from the causes before men- tioned, has occasioned the suspension of life, the most proper step to be pursued will be, to suffer a small quantity of blood to be lost from the end of the divided cord. The same will be advisable after a tedious labour, where there is much stupor present, in order to lessen the determination of blood to the head. Professional men being often called upon to give evidence before a court of judicature in cases of supposed infanticide, it seems right to mention, that much careful obseivation is required to discri- minate between a child that is still-born, and one that has lived only a short space of time after its birth. Various appearances also, both internal and external, may be mistaken for marks of violent death. Even the swimming of the lungs in water, a test on which much reliance has been placed, is on many occasions found to be fallacious; for they will float in consequence of a putrefactive process having commenced, as well as when filled with air by respiration. It may likewise happen, that an unmarried woman, on coming to her full time, and having concealed her condition, may be taken ill when by herself, and be delivered of a live child: but that either from syncope ensuing speedily, or her being suddenly deprived of reason from a distracted state of mind, owing to a sense of the shame which will attach to her foible, she may be so overcome as to be rendered incapable of assisting the infant, whereby it may suffer suffocation under the bed-clothes, or be otherwise so injured as only to make a few inspirations. In other instances it may happen, that although the child is born alive, still, from its uni- versal weakness, the want of due assistance, the circulation of 6lood between the mother and child being so interrupted either from undue pressure in its passage, or the umbilical cord being twisted round its neck in various convolutions, so as to produce congestion in some organ important to life, or from some other pbscure cause, it may soon cease to breathe, without receiving any intentional injury from its mother. No doubt occurrences of this nature do sometimes take place, and they clearly point out the im- 878 DISEASES OF INFANTS. propriety of placing any reliance on the floating of the lungs in water, as a test of infanticide. The floating ofthe lungs of a new born infant, where no putridity exists, incontestibly proves that it has breathed ; but although this is the case, the presumption that the mother has intentionally destroyed it, is by no means satisfactory or clear. Justice undoubtedly requires from every medical practitioner, that his evidence before a coroner or jury should be regulated by truth ; but humanity and mercy dictate to him, that he ought to have the fullest assurances of guilt, before he gives an opinion that rriay deprive a fellow-creature of life. On all such occasions he should recal to mind the holy text which tells us, it were better that many guilty es- cape punishment, than that one innocent suffer. Those who wish to make themselves well acquainted with medical jurisprudence, will derive full information from Dr. Hunter's Remarks, inserted in tbe 6th volume of Medical Observations and Inquiries, p. 271; and from Dr. Farr's Translation of Joh. Fred. Faseli's Treatise on such Tokens in the Human Body as are requisite to determine the Judgment of a Coroner and Courts of Law, in Cases of Divorce, Rape, Murder, &c. London, Becket, 1788. A pleasing writer* informs us, that at Copenhagen there is an hos- pital for the reception of pregnant women who have reasons for seek- ing concealment. They are received into it upon paying a small stipend; they enter at night in masks, and are never seen but by those who are necessary to their comfort, and even their names are not required. Since the establishment of this noble and humane institu- tion, he gives us to understand that there has been a very visible di- minution in the crime of infanticide. Much indeed it is to be regretted, that no asylum on a similar plan is to be found by unfortunate females in our united kingdom; and that so many of them annually suffer an ignominious death, for laying vio- lent bands on their offspring in the moments of shame, anguish, and despair. THE BLACK OR LIVID COLOUR OF INFANTS. It sometimes happens, that immediately after birth tbe face and neck of the infant put on a livid or black appearance, the lips become purple, and the breathing short; which symptoms either go off soon again, or terminate in death. They are to be attributed either to an imperfect closure of the for- amen ovale, or some mal-formation ofthe heart or lungs; or to tbe vessels having imperfectly undergone those changes which are neces- sary for all animals who breathe the common air. I know of no remedy likely to obviate these appearances. In an Appendixf to the fourth edition of the Modern Practice of Physic, published at New-York, Dr. David Hosack, an eminent professor of the University of that State, and to whom I have now Sec Carr's Summer Northern Tour. t See Page t>10. DISEASES OF INFANTS, 879 dedicated this work, as a testimony of the high opinion I entertain of his abilities both as a practical physician and teacher of medi- cine, has recorded two cases of this disease which were successfully treated by him. In the first, he had in vain tried evacuations, and afterwards anodyne medicines, upon the principle of the disease being of a spasmodic nature. He then had recourse to a stimulant mode of treatment, the remedies not having been attended with any relief or advantage. A blister was applied upon the breast, two others behind the ears, cataplasms of mustard, ryemeal, and vinegar, were put to the soles of the feet, the whole body was bathed with warm brandy, and afterwards with diluted spirits of sal ammoniac ; and from time to time an attempt was made to give the child a spoonful of wine whey ; but all these means produced no beneficial effects. After six hours had elapsed it became more feeble, respiration was suspended for a greater length of time than in the commencement of the disease, and the circulation became less vigorous : these, with greater coldness of the extremities, excited great alarm. It appears that Dr. Hosac had frequently employed, in the latter stages of malignant fevers and diseases of great debility, a stimulating bath, prepared with the bark of cinchona and spirits ; and as a last resource he determined to give it a trial in the present case. He therefore directed four ounces of this bark in powder to be boiled for a few minutes, in about two gallons of water ; to this, when fit for use, a pint of Jamaica spirit was added. When it was cooled to a temperature rather above that of the body, the child was immersed in it up to its neck ; and to render the bath more stimulating, a small quantity of the spirits of sal ammoniac was added from time to time. A very apparent and favourable change took place in a short time ; respiration was perfectly restored while the child remained in the bath ; the circulation became vigorous and active, the countenance resumed its lively hue, the power of swallowing (which had been lost) was restored, and in every respect the child manifested symptoms of relief. It was now removed from the bath, wrapped up in warm dry flannels, and put to the breast. This it took with eagerness, and it remained composed and free from complaints for about half an hour, at which time a fresh paroxysm came on. The bath was employed a second time, and repeated during one or two other paroxysms with the same relief as before. These, however, were of shorter duration, and returned after long intervals. The child at length recovered, and was restored to perfect health. u In the second case, when Dr. Hosac visited the child its respiration was completely suspended, the face of a dark bluish colour, the circulation weak, and very irregular, and the extremities were almost cold : he instantly directed a bath to be prepared in the same manner as noticed in the first case, and when ready the child was immersed in it for about fifteen minutes ; its respiration 880 DISEASES OF INFANTS soon became regular. In about half an hour's time the fit re- turned, but was of short continuance and less violent: the bath was employed a second time, which completely removed all complaint. A RETENTION OF THE MECONIUM. A dark-coloured visrid matter, known by the name of meconium, is contained in the bowels of all infants at their birth, and is usually discharged during the two or three first days, in consequence of the milk of the mother, which is first secreted, being somewhat of an aperient nature. In general this will be sufficient to bring off the meconium ; but where it fails to do so in the course of a day or so, the aid of medicine may be necessary, and tbe best we can employ is about two drachms ofthe oleum ricini. Some give a solution of manna in water, or equal parts of oil of almonds and syrup. If these do not act readily, a clyster of thin gruel, with a little olive-oil and common salt, may be thrown up into the intestines. The custom of drenching children with some drug or other tbe moment they are born, whether requisite or not, with the view of carrying off the meconium, is highly reprehensible, for, in most cases, the milk of the mother will of itself be amply sufficient. THE YELLOW GUM, OR ICTERUS INFANTUM. This is a species of jaundice, which affects many children at of soon after their birth, and which usually continues for some days. It has generally been supposed to arise from an obstruction of the biliary ducts forcing the bile back upon the liver, from the meconium impacted in the intestines, or from mucus or viscid matter clogging the ductus communis. The effects produced by it are, languor, indolence, a yellow tinge of the skin, bilious urine, and a tendency to sleep, which is sometimes fatal, where the child is prevented from sucking. For the most part the disease is easily removed by clearing the intestines by some mild laxative, such as the oleum ricini, where the mother's milk does not of itself prove sufficiently aperient. The disease, in some instances, has been supposed to proceed from a viscid matter obstructing the gall-ducts. In these it may be necessary to give a gentle emetic consisting of a few drops of the tartarized solution of antimony, and on the succeeding day we may administer four or five grains of rhubarb. Should the yellow- ness continue after these means have been adopted, the emetic as well as the opening medicine may be repeated in the course of a few days. Dr. Underwood mentions that in those cases where an emetic has been objected to, and the attention devoted wholly to keeping the belly open, the yellowness not unfrequently will con- tinue to the end of the monih, accompanied with langour and other symptoms of debility. We now and then meet wilh instances where infants are affected DISEASES OF INFANTS. 881 with'the true jaundice, distinguished by the skin being every where discoloured, as well as the whites of the eyes. Sometimes this appear- ance is of little importance, scarcely requiring any particular medical aid, and disappearing spontaneously ; but in other cases, the infant appears to suffer much. In these, besides employing daily frictions to the stomach and belly as well as a warm bath, we should administer saponaceous and other medicines as advised under the head of Jaun- dice. (See this Disease). EXCORIATIONS AND ULCERATIONS. Fkom a neglect of proper cleanliness, children are very apt to be- come chafed in the wrinkles of the neck, behind the ears, and in the groins. To remedy occurrences of this nature it will be proper to bathe the excoriated parts twice or thrice a day with a little warm milk and water, and afterwards to sprinkle them with some absorbent powder, such as tutty or calamine, laying over all a bit of scorched linen rag. Where the excoriation is very considerable, a wash composed of two parts of rectified spirit and one of common water, may be used. A little of the ceratum plumbi superacetatis spread upon fine lint may be employed as a dressing. In obviating exco- riations, we are however to be cautious in drying up discharges behind the ears in infants, as very bad consequences have been observed to ensue from making use of repellent applications in such cases. In some children of a gross habit of body, and particularly about the time of teething, a species of excoriation extending low down in the neck is apt to take place, which at length degenerates into large deep sores, and not Unfrequently has terminated in gangrene. Here fomentations of cinchona will be necessary, and we should at the same time administer its powder internally. Cases of this nature do not eccur, however, very frequently. Where ulcerations ensue, and they are large and painful, fomen- tations of poppy-heads boiled in milk will be likely to prove beneficial. Should they show no disposition to heal after such treatment, some mercurial application* may be made use of, and this may be hid on morning and evening spread on a bit of soft linen or fine lint. Where alteratives are thought necessary, small doses of the submuriate of mercury with ihe testacea may be given internally. * 1. Take Submuriate pf Mercury, one drachm. Elder Flower Ointment,one ounce. Mix them for use as an ointment. Or, 2. Take White Precipitated Mercury, half a dracutu. Spermaceti Oigtmfint, half :]rn ounce. Mix them it i l. ]£, Wydrargyn suumunat. ^j. Unguent. Sambuci, ^j. M. Vel, '_K ft Hydrargyr. Pneeip. Alb. 3ss. Unguent. Cetacei, §ss. M. 882 DISEASES OF INFANTS. HICCUPS. Some infants are much incommoded by hiccups, and they arise probably either from acidity in the stomach, or from some nervous irritation. In the former case, a powder composed of a little prepared chalk and rhubarb (about eight grains of the former with two or three of the latter) may prove beneficial. In the latter, it may be proper to give a few drops of the spiritus ammoniae aromaticus, or tbe tinctura camphorae comp. In some instances, a little plain vinegar has proved an effectual remedy. Where the complaint is severe, or returns frequently, it may be advisable to rub the stomach with soap liniment, to which a little tincture of opium has been added. INFANTILE ERYSIPELAS. This is a very dangerous species ofthe spurious or erysipelatous in- flammation, which is not often met with, however, but in lying-in hos- pitals. The ordinary time of its attack being a few days after birth, it was, at the first of its being observed, thought never to appear later than the month; but this has since been found not to be the case. It seizes tbe most robust as well as delicate children, and in a very sudden manner; tbe progress is rapid; the skin turns of a purplish hue, and soon becomes much hardened. The milder species appears often on the fingers and hands, or the feet and ankles, and sometimes upon or near the joints; forming matter in a very short time. The more violent kind is generally seated about tbe pubes, and extends upwards on the belly, and down the thighs and legs; though sometimes it begins in the neck, and is equally fatal. It seems indeed to be always less dangerous when confine/l to the extre- mities, than where it seizes on, or spreads to any other part of the body. The swelling is but moderate: but after becoming hard, the parts turn purple or livid, and very often sphacelate, especially in boys, when it falls on the scrotum; the penis swells, and tbe prepuce puts on that kind of emphysematous appearance, which it has been observed to do, when a stone sticks in the passage, or in the anasarca of the scrotum. The disease often proves fatal in, a few days. Dissections of such children as have been destroyed by this disease have frequently discovered the contents of the abdomen glued together, and their surface covered with an inflammatory exudation, exactly similar to that found in women who have died of puerperal fever and peritoneal inflammation. In males, tbe tunica: vaginales have been sometimes filled with matter, which has evidently made its way from the cavity of the abdomen, and accounts for the appearances of the organs of generation just now described. In females, the labia pudendi are affected in like manner; the pus having forced a passage through the abdominal rings. DISEASES OF INFANTS. 883 As in all cases the appearances to be observed on examination ofthe bodies of children who have sunk under the disease clearly demonstrate that it is truly inflammatory in its first stage, it appears rational to adopt the depleting plan within the first twenty hours. The bowels ought therefore to be freely acted upon by purgatives, after which leeches may be applied to the abdomen, if the skin thereof is not affected with inflammatory redness. We are informed by Dr. Underwood*, who since the days of Hallerf seems to.be the only physician that has distinctly noticed this complaint, that various means were made use of at the British Lying-in Hospital without success ; though tbe progress of the inflammation seemed to be checked for a while by saturnine lotions and poultices, applied on the first appearance ofthe inflammation ; but it soon spread, and a gangrene presently came on ; or where mat- ter had been formed, the tender infant sunk under the discharge. On a further acquaintance with the disease, linen compresses wrung out of camphorated spirit, were applied in the place of the liquor plumbi subacetatis, which we are given to understand have proved more successful in checking the inflammation in several instances. After the cinchona mixed with a little aromatic confec- tion was made trial of internally, it appears that several children recovered. The cinchona ought therefore to be given as soon as possible either by the mouth or thrown up in a clyster, and we may add a little confectio aromatica to it. Dr. Underwood observes, tbat in a few instances the disease has been attended with some varieties ; for infants have not only come into the world with several hard and sublivid inflammatory patches and ichorous vesications about the belly and thighs, but with other spots already actually in a state of mortification. A large eschar has soon spread upon the spine ofthe tibia, with smaller ones about other parts of the legs, and on several of the toes and fingers. In such cases particularly, he says, the bark of cinchona and., cordials must be exhibited liberally, and the inflamed and mortified parts be well fomented, and dressed with warm applications. CUTANEOUS ERUPTIONS. Children at the breast are very subject to slight eruptions, particularly during the first month : and these serve, no doubt, to relieve the body of some acrimonious humour. Of this kind is the red-gum, which consists in an efflorescence or small red spots, most usually confined to tbe face and neck, but in some cases extending to the hands and legs, and even over the whole body, appearing in large patches, and sometimes raised considerably above its surface. Now and then it shows itself in the form of small pustules, which are filled with a limpid, or sometimes a purulent or yellow fluid. * See his Treatise on the Diseases of Children, page 33, vol. i. t See his Chapter de Febre Erysipelacea. 884 DISEASES OF INFANTS. Every species of this eruption has generally been attributed to a predominant acid, but ought rather to be regarded as an exertion of nature to throw off something hurtful. All that is generally necessary in this complaint, is to give a little magnesia, or testaceous powder, according to the state of (he bowels, and to keep the child moderately warm ; otherwise by the rash striking in, the acrimonious humour will fall on the first passages, and be succeeded by sickness and purging, till perhaps the eruption appears again on the skin. In cases of nausea at the stomach, or any disposition to fits upon this eruption being repelled, some light cordial, such as a few drops of the spiritus ammonias aromaticus, may be given twice or thrice a day, and the child's feet, or perhaps the whole body, be put into warm water. The state of the skin and bowels has a peculiar consent ; and on this account infants whose first passages have been frequently dis- ordered, are always benefited by eruptions on the skin. In such, peculiar care is therefore necessary to guard against their being repelled, as well as to invite their return. Another species of eruption which is frequently to be met with in young children is that to which medical writers have given the name of crusta lactea, or lactumen. This often puts on a very unpleasant appearance, but is nevertheless of an innocenl nature, and it has been observed that those children who have been much loaded with it, have usually been healthy, and have cut their teeth easily. A remarkable circumstance attending this eruption is, that, however thick and long-continued the scabs may be, the crusta lactea never excoriates, nor leaves any scar on the parts. The crusta lactea appears first on the forehead, and sometimes on the scalp ; and then often extends half way over the face in the form of large loose scabs, which, as the disorder increases, appear not very unlike the small-pox pustules after they have become dry. It begins with white vesicles larger than the itch, which soon become of a dark colour and then scab, with an efflux of ichor and great itching of tbe parts affected. The rash generally disappears of itself when the child has cut three or four teeth, though it may sometimes continue for several months, and in a few instances even for years. In such cases, tes- taceous powders, fhe submuriate of mercury, and other alteratives, have usually been administered, but in general without success. The Harrowgate or other sulphureous waters might probably have a good effect. In very bad cases, a blister might prove serviceable, During early dentition a rash very much resembling the measles is apt to make its appearance and this usually continues very florid for three or four days, but it does not dry off in the manner of that disease. It is often preceded by nausea and vomiting, but is attended with little or no fever. During the continuance of the eruption, a few doses of the testaceous powders, with the addition of a little ofthe nitrate of potass, will be the most proper medicines: and when it disappears, some gentle laxative may be advisable. DISEASES OF INFANTS. 885 Other rashes in which the spots are larger and often attended with some degree of fever (occasioned probably by the irritation of teething) are frequently to be observed during a more advanced stage of dentition, particularly while the double and eye teeth are cutting. These require only a proper attention to be paid to the state of the bowels, unless the fever is considerable; in which case we should pursue the steps recommended under the head of Den- tition. A slight species of essera, or nettle-rash is another eruptive disease to which infants are liable ; but this requires in general little atten- tion, and often disappears in a few hours. When the body is much covered with eruptions, and they remain long out, attention should be paid to their not being repelled suddenly by any exposure to cold, or by an}' other improper treatment; but should they happen to strike in, we may then have recourse to the tepid bath and light cordials, in order to solicit their return to the surface of the body, which will be of the greatest consequence should the child suffer much from the repulsion. An eruption very much resembling the itch is sometimes to be met with in infants at the breast; as likewise in children who have cut all their first teeth. It usually begins about the arms and thighs, but always spreads soon afterwards to the other parts, and not unfrequently extends from the head to the feet. In some places it appears in very small eruptions like the points of pins, with watery beads; and in others, in as large ones as peas; and sometimes in foul blotches, which, after breaking, form sores and broad ugly scabs. These die away, and similar ones show themselves succes- sively in other parts, sometimes for two or three months, leaving tbe skin of a dirty hue. The external application of an ointment consisting of the unguen- tum sulphuris with a small proportion of the unguentum hydrargyri nitratis, will seldom fail to remove the complaint, if assisted at the same time with the internal exhibition of the hydrargyrum cum creta or hydrargyri sulphuretum nigrum. Washing the parts affected with about two drachms of the liquor potassae mixed with a pint of water will often afford much temporary relief. In all the eruptive complaints of infants, their taking cold ought carefully to be guarded against, and ihe belly should be kept open. if the child is sick at the stomach, a little magnesia or testaceous powder with a small addition of the pulvis contrajervae compositus may be given now and then. Should the eruptions strike in suddenly, every means should be used to reproduce them again on the surface of the body. Repellent applications should never be employed when eruptions appear during dentition. In consequence of some bad quality in the milk ofthe person who nurses the child, it sometimes happens that an eruption comes out on different parts of its body. In all such cases the nurse should be changed. Constipation should likewise be obviated, and some gentle absorbent medicine be given once or twice a day. 886 DISEASES OF INFANTS. ACIDITIES, GRIPES, AND FLATULENCY Costiveness, improper or too much food, bad milk, weak diges- tion, and that natural tendency there is in the stomach of all children to generate acidity, are the causes which give rise to these affections. When the food becomes acid on tbe stomach, instead of being properly concocted and converted into chyle and blood, it is likely to give rise to continual crying, restlessness, drawing up of the legs for- cibly to the body, hiccups, vomiting, diarrhoea, flatulency, sour eructa- tions, griping pains, green stools, and a depression of strength; and where the irritation is very considerable, convulsions are apt to ensue. If acidity prevails in a high degree, and the infant is troubled with sour belcbings and much irritability at the stomach, it may be advisa- ble to evacuate its contents by a weak solution of tartarized antimony, given in the quantity of one or two tea-spoonsful every quarter of an hour, until a sufficient effect has been procured ; after which, a few grains of rhubarb and magnesia may be ordered, to carry off the remaining offending matter. To prevent any fresh accumulation of the same nature, it will be proper to give, as circumstances may seem to require, a little of the mistura cretae, but more particularly where any severe degree of pur- ging attends. Together with these or other remedies, exercise, and frictions of the body, but of the abdomen in particular, should not be forgotten. Acidities and flatulency sometimes prevail in so high a degree as to occasion severe griping pains, perfectly obvious by the infant's screaming, crying, and drawing its knees up to the belly, with the presence of abdominal tension. In such cases it will be necessary to dislodge the contents of tbe intestines, should costiveness prevail, by some gentle laxative; after which we may administer absorb- ents* and carminatives, tbe last of which we may give in a clysterf * 1. R Cret. Praeparat. gr. xij. Aq. Menth. Pip. f. ?ij. Tinct. Lav. C. f. 3s£ Spirit. Carui, f. ^ss. M. ft. Mistura, cujus sumat cochl. minim. ij. pro re nata. Adde, si sit neces &itas, Tinct. Opii, fll iv. singul. dos. Vel, 2. R Mistur. Cretae, f. §ij. Tinct. Calumb.f.3ij. Liquor. Potassae Subcarbonat. TTl x.—xv. M. Capiat cochl. minimum ter quaterve in die t 3. R Decoct. Hordei, f. ?iv. Ol. Olivae, f. 3ij. — Anis. fll iv. M. ft. Enema. Adde, pro re nata, Tinct. Opii, fll v.—vii. " 1. Take Prepared Chalk, twelve grains, Peppermint Water, two ounces. Compound Tincture of Lavender, half a drachm. Spirit of Carraway, half an ounce. Of this mixture the child may take two tea- spoonsful occasionally, adding, if neces- sary, to every dose, Tincture of Opium, six drops. Or, 2. Take Chalk Mixture, two ounces. Tincture ofCaluraba,twodrachm.« Solution of Subcarbonate of Potass, fifteen to twenty-two drops. Mix them, and let a tea-spoonful be taken three or four times a day. t 3. Take Barley Water, four ounces. Olive Oil, two drachms. Oil of Aniseed, six drops. Mix them for a Clyster. Add occasionally) when the child is much griped, Tincture of Opium, eight to ten drops. DISEASES OF INFANTS. 887 as well as by the mouth ; and where the pains seem very acute, and by no means relieved, we may make a small addition of opium. As opiates do not however agree well with children, they should not be resorted to on trivial occasions. Besides adopting these steps, it will be proper to apply warmth externally to the stomach and bowels by means of heated bran or chamomile flowers put into a soft flannel bag, which probably will greatly assist in abating the pain. Children that are partly brought up with the spoon, and who are very subject to flatulency, should always have a few carraway seeds boiled up with their food. As acidities, gripes, and flatulency, seem frequently to originate in some error of the diet, the proper regulation of this ought to form a principal part of their cure. Sometimes it may be necessary to change it almost wholly, or at least to withdraw something from what- ever farinaceous substances are used. A costive habit of body is very apt to occasion flatulency and gri- ping pains in infants. This ought therefore to be obviated by giving twice or thrice a week, as the occasion may require, a small quantity of the oleum ricini, or we may substitute a few grains of magnesia in a spoonful of the aqua anethi sweetened with a little syrup of roses or manna, to which may be added a few drops of tinctura sennae m order to render it warmer, and quicken its opera- tion. Either of these will be preferable to rhubarb, as this possesses too restringent a power, which is not to be counteracted even by joining it with magnesia. To promote the peristaltic motion in costive habits, it will be advisable to rub the region of the stomach and belly several times a day with a piece of flannel or the hand somewhat warmed, in addition to using medicine. Where flatulency is an attendant upon a lax state of the bowels and indigestion, its remedy will consist in a removal of these complaints, as advised under the heads of Diarrhoea and Dyspepsia. Dr. J. Clarke, of Dublin, observes*, it is the general opinion of writers on the diseases of infants, that by far tiie greater number of these originate from acidity or coagulation of the milk, and that therefore absorbent and saponaceous medicines ought to be used, to counteract these morbid eauses. From various considerations, he is induced to suppose that this opinion is founded on a fallacious analogy and superficial observation of the matters evacuated by in- fants. He finds, that healthy human milk suffers no coagulation from acids, ardent spirits, runnet, infusion of the stomach of a foetus, nor from any of the known coagulating substances; and that it contains little or nothing of that matter which constitutes curd, so that there can be no power in the stomach of an infant to separate curd from it : that though it is supposed prone to run into an acescent or acid state, it is far less so than that on which the young of ruminant animals are * See his Treatise on the Properties attributed to human Milk., inserted in the Trans,- actions of the Royal Irish Academy. 888 DISEAM.S OF INFANTS. fed ; a cow's milk acquiring greater acidity in thirty-six hours'thaif the human milk does in many days; and that cow's milk in moder- ate warm becomes offensively putrid in four or five days, a change which human milk does not undergo in many weeks and sometimes months. He finds also that green faeces, commonly ascribed to acid- ity, because bile is turned green by acids, cannot arise from acid milk, because it is only the mineral acids which produce that change of colour; nor has the daily use of sour milk or vegetable acids any such effect on adults, and faeces of this colour are observed in cases where no acidity has been suspected. Dr. Underwood, in speaking on the properties of human milk*, enters into a controversy with Dr. Clarke for alleging that this con- tained no sensible quantity of curdy matter. From the experiments made by the former of these gentlemen, it appears that the human milk does really contain no inconsiderable portion of curdy or case- ous matter, though its separation is attended with peculiar circum- stances. He allows tbat neither runnets, acids, nor spirils separate any very sensible quantity of this curd in the space of eight-and-forty hours, as they constantly do in cow's milk; but that in a longer time it is afforded in evident quantity. It appears also that human milk has less tendency than other kinds to run into acescency or putridity. The length of time necessary for the separation of the curd set-ins to have Ueen the cause, in Dr. Underwood's opinion, of Dr. Clarke's denying its existence. In a practical view this difference of sentiment on the subject does not seem very important. Although the coagulation of milk in the stomachs of infants labouring under the disease be granted, it does not follow, that the chief attention of the practitioner should be directed to the destruction of the acidity, as the means of preventing such coagulation. For the acidity itself is only an effect, arising from a diseased action of the stomach, which of course would engage his attention. OF VOMITING. When what has been taken is returned crude and unaltered, it may be suspected to arise from over-feeding, and to require nothing more than temperance for its cure. Vomiting, however, is often an attendant on other complaints, and sometimes of itself constitutes an original disease. Where there is a vomiting of digested food, it will be right to change the mode of diet, or to open the body by some gentle ape- rient. If these means do not answer, and the vomiting continues, it will be proper to clear the stomach by a gentle emetic, afterwards giving the saline medicine in an effervescing state, with a drop or two ofthe tincture of opium. We may at the same time apply a blister over the region of the stomach, or rub it well with an anodyne liniment. * See his Treatise on the Diseases of Children-. DISEASES OF INFANTS,. §8& OF A LOOSENESS OF THE BOWELS. Various causes may and do occasion a diarrhoea in infants, and perhaps in the greater number of instances it is brought on either by too much or unsuitable food, in which cases a diligent attention must be paid both to the choice and regulation of the diet. In some instances, however, it may be symptomatic of other diseases, or may arise from an exposure to cold, or an increased secretion of bile. In the latter case, it may be advisable first of all to cleanse the stomach b) a gentle emetic ; but in all it will be proper to clear the intestines by a few grains of rhubarb and mag- nesia, the operation of which being over, we may give a little of the prepared chalk*, joined with some aromatic twice or thrice a day. When the stools continue to be more frequent than they ought to be, and are either slimy or tinged with blood, it will be necessary to repeat the rhubarb at proper intervals, and in the mean time the infant may take something to control the complaintf, as well as proper nutriment to recruit its strength. Flour, sago, or ricev boiled in milk, together with the jelly of a calf's foot or isinglass, with a small addition pf wine, will be good articles of diet under such circumstances. In addition to these means it will be advisable to envelop the infant's Body in flannel, so as to keep it of a proper temperature. That form of diarrhoea which is attended by green stools and * 1. ft Cret. Praeparat. 3ss. Aq. Anethi, — Cinnam. aa f. |jss. Tinct. Card. C. f. 3'j- Syrup. Cort. Aurant. f. 3j- M. Capiat cochl. j. iufantis bis terve in die. Vel, 2. ft Pulv. Cinnam. Comp. gr. y. Cret. Praeparat. gr. vj. M. ft. Pulvis 6tis horis sumendus. t 3. ft Confect. Aromat. ©j. Aq. Purae, — Cinnam. aa f. ^jss. Tinct. Catechu, f. 3j- ------Opii, fll viij. M. Cochl. unum infantis mane, hora meridiana, et nocte sumendum. Vel, 4. ft Misturae Cretae, f. f ij. Aq. Cinnam. f. ?j. Tinct. Kino, f 3»- ------Opii, fll vij —x. M. •ft- Mistura, cujus capiat cochleare infantr? bis ferve fn die". 1 10 • 1. Take Prepared Chalk, half a drachm. Dill Water, Cinnamon Water, of each ong ounce and a half Compound Tincture of Carda- moms, two drachms. Syrup of Orange Peel,one drachm. Of this mixture, a pap-spoonful is to be ta- .ken twice or thrice a day. 0r> 2. Take Compound Powder of Cinna=- mon, two grains. Prepared Chalk, six grains. Mix^lbem, and let this powder be taken every six hours. 13. Take Aromatic Confection,one scruple, Pure Water, Cinnamon Water, of each one ounce and a half. Tincture of Catechu, one drachnj. --------Opium, twelve drops. Of this mixture one pap-spoonful is to hs taken morning, noon, and night. Or, 4. Take Chalk Mixture, two ounces. Cinnamon Water, one ounce. Tincture of Kino, one drachm. ----------Opium, from ten to fifteen drops. Of this mixture let a pap-spoonful be giv^p, to the child twice or thrice a day. 39U DISEASES OF INFANTS. griping, may in general be removed readily by a brisk laxative, consist- ing of the submuriate of mercury and rhubarb, followed by small doses of magnesia and chalk. When obstinate, we may give half a grain of hydrargyri submurias each or every other night. The application of a small blister about tbe size of a crown piece to the pit of the stomach, will sometimes produce a very good effect where internal remedies have failed. When the irritability of the intestines seems to be great, the fluid stools being thrown out with quickness and force, and the strength ap- pears to be rapidly sinking, we may advise a clyster composed of starch, with a few drops of tinctura opii to be injected twice or thrice a day. The external application of opium by friction or plaster, is likewise useful. In such cases the application of a blister proves frequently of great use. TRISMUS NASCENTIUM* OR THE LOCKED JAW OF INFANTS This is a disease of very frequent occurrence in the West Indies, where many infants are carried off by it soon after birth, and especi- ally negroes and those of colour, as they are usually called. It is well known, however, to prevail in otherparts ofthe world, and is frequent- ly met with in Min,orcaf, in Switzerland, some ofthe northern districts of Scotland, especially in the island of St. Kilda, and among the chil- dren of the Westmann islands! near Iceland. It has also been met with in Ireland||. In most cases the disease is wholly confined to the jaw; but in a few a considerable contraction and rigidity of other muscles of the face, with strabismus and lolling ofthe eyes, together with subsultus tendi- num, have been observed. It has been attributed to visceral irritation, costiveness, and not purging off the meconium in the bowels; to dividing the navel-string with a blunt lacerating instrument; to not paying attention to its fall- ing off, and consequent irritation from a neglect of the remaining sore, which assumes a sloughy appearance ; and to exposures to cold, and currents of air, negro women in the West Indies being usually permit- ted to lie in at their own houses, which are often in but very indifferent repair. Dr. James Clarke, in his«Treatise on the Yellow Fever and other West India Diseases, informs us, that from having observed the children born in large negro huts generally were exempt from any attack of the disease, and that white children, or those of free people, who had their kitchens apart from their dwelling-houses, escaped the jaw-fall, (the term by which the disorder is known in places where it is prevalent), he suspected that the smoke from burning wood, which is the usual fuel in the West Indies, was * Trismus Nascentium being a spasmodic disease, ought, in adhering to classification, to have been included among those of this nature ; but as being peculiar to uafants. is inserted here. t See Cleghorn on the Diseases of Minorca. f See M'Kenzie's Travels in Iceland, p. 413. I( Dublin Hospital Reports, vol. i. BISEASES OF INFANTS. 891 the cause of it. In consequence of this, he gave orders that no fires should be allowed in the negro houses where the lying-in women were, which effectually answered the purpose of preventing the dis- ease. He adds, that he recommended a lying-in hospital to be built on every estate near the negro houses with a planked floor, so that no fire could be kept in it; since which no children, who were born in these hospitals, and remained in them with their mothers for nine days, have ever been attacked with this disease. I perfectly agree with Dr. Clarke that it is highly necessary every plantation should be furnished with a lying-in house, and it is what I strongly enforced to West India proprietors in a work* I pub- lished some years ago ; but I must dissent from him in ascribing the smoke arising from a wood fire, as the sole cause of the trismus nascentium. Certain it is that infants are never attacked with it after the ninth day of their age, if even exposed to the influence of this cause; and it is therefore probable that it is not the real, and far less the sole one. I am much inclined to suppose that the dis- ease often arises in negro children from the want of attention to the falling off of the navel-string, and the consequent irritation from a neglect of the remaining sore, which becomes sloughy. The period at which the disease occurs seems to correspond exactly with the falling of the funis, and tbe ulceration left behind. What makes strongly against Dr. Clarke's supposition is, that tetanus (of which trismus nascentium is a species) is most usually cured very readily when it arises from an exposure to cold, or any other cause than the irritation occasioned by a wound. When produced by this, it gen- erally proves fatal. The disease in question terminating always in this manner, may with great propriety, therefore, be ascribed to a cause which is of a similar nature. Another argument, which shows the fallacy of Dr. Clarke's sup- position with respect to smoke from burning wood being the chief cause of trismus, is, that during my practice in tbe West Indies I met with some instances of the disease in white children, in whom it was impossible to have arisen from this cause, as no fire-places are to be found in the dwelling-houses of the white inhabitants, and the kitchends always a detached building, into which such infants never enter. Although the exciting cause of trismus nascentium probably is irritation in the wound, from a division of the funis and the process of sloughing connected therewith, still the disease appears to be connected with a more or less vitiated state of the atmosphere, as it occurs mare frequently in hospitals than in private dwell- iDSst- Trismus nascentium proves fatal in most instances. * See Medical Advice to the Inhabitant* of Warm Ql'imeAes, p. 10 of the Intro- duction. f See Dublin Hospital Reports, vol. i- 892 DISEASES OF INFANTS. No effectual means having yet been discovered for the cure of this disease, all that can be done is to avoid as much as possible the several causes which have been mentioned as being likely to give rise to it. Every lying-in woman ought therefore to be accommo- dated in a comfortable house, which is annoyed neither by smoke, rain, nor any partial current of air. On the birth of the infant, the navel-string should be divided with a pair of sharp scissors, after which the portion that remains should be wrapped up in a little scorched linen. No force whatever must afterwards be used to brinsi, on its separation ; it should come away spontaneously; and if any little ulceration is left behind, it ought to be attended to, and daily be dressed with some mild healing ointment, such as the ungu- ent, cetacei or ceratum calaminae, avoiding at the same time any great pressure upon it by bandages. As I have supposed the disease to arise most commonly from the irritable state ofthe divided funis, might it not be advisable, bv way of prevention, to wet the part frequently with a watery solution of opium? To remove costiveness or visceral irritation, and carry off the me- conium, which has been assigned by some practitioners as a probable cause, one or two tea-spoonsful ofthe oleum ricini may be given to the child the day after its birth, which may again be repeated in two or three days, should the mother's milk not procure a sufficient number of stools. On an attack of tbe disease, we ought cprtainly to have recourse to the means advised under the head of Tetanus, however unsuccessful they may be likely to prove. A few recoveries, it is said, have been effected by the warm bath. FEBRIS INFANTUM REMITTENS, OR THE INFANTILE RExMITTENT FEVER. From the age of one year to five or six, children are liable to be attacked with a fever, that makes its advances very gradually, ma- nifesting itself by irregularity in the bowels, which are sometimes too costive, and at others too much relaxed. On its coming on, the child becomes fretful, his lips are dry, bis hands hot, his breath short, the head painful, and his pulse quick, being often 120 in a minute : he is unwilling to stir or speak, the sleep is disturbed by startings, and the food rejected : sometimes very little is discharged from the intestines; and at others too much, the stools being often mucous or slimy ; some children are delirious, or lost and stupid ; many for a time are speechless. In the course of the day there are several slight accessions of fever, during which the child is usually drowsy ; in the intervals of these paroxysms he appears tolerably well, though at times more peevish than usual. These symptoms probably manifest themselves, more or less, for eight or ten days, when all at once a more violent paroxysm DISEASES OF INFANTS. 893 of fever will arise, preceded by a shivering fit and by vomiting. The pulse rises to 140 in a minute ; the cheeks are flushed, the drowsiness is much increased, and the child keeps picking almost incessantly at the skin of the lips and nose, and of the angles of the eyes. This species of fever is mild at its commencement, slow in its progress, and very uncertain in its event. In some respects it resembles hydrocephalus acutus, and I apprehend is sometimes mistaken for it ; but in the latter there are occasional screamings, with much tossing ofthe hands above the head, intolerance of light, with more or less of squinting ; whereas in the remittent fever of infants, none of these appearances are to be met with. In this fever the desire for food is destroyed, and the little patient will take neither aliment nor medicine. In hydrocephalus, on the con- trary, he will usually take whatever is offered to him without re- luctance. The faeces are remarkably changed from their natural appearances in the remittent fever, being sometimes black, and smelling like putrid mud ; and at others they are curdled, with shreds of coagulable lymph floating in a dark greenish coloured fluid. In acute hydrocephalus we meet with nothing very similar in the motions. The infantile remittent fever appearing to depend partly upon an irritation of the intestines, and perhaps partly upon an absorption of their putrid contents, the proper intentions of cure are to clear the stomach by a gentle emetic, and bowels by purgatives, to moderate or remove the febrile symptoms, and then, if necessary, to restore the lost energy by tonics. The first thing therefore to be done is to cleanse the stomach by a few grains of ipecacuanha, which will be preferable to any anti- monial preparation, and soon afterwards to administer some active purgative : I mention active, because the intestines are usually so torpid, that what would on another occasion be considered a full dose, will have no effect in this complaint. For restoring the healthy actions ana* secretions of the chylopoetic viscera, nothing seems so efficacious as small and often repeated doses of the sub- muriate of mercury, followed up after some hours by a solution of the sulphate of magnesia in an infusion of senna, or by a dose of castor oil. When the bowels are very irritable, small quantities of mistura cretae with a few drops of tinctura opii must be given alternately with the purgatives above specified. If the head is much affected, its temperature greater than the rest of the body, and there are other marks of sanguineous deter- mination to the brain, the case must be treated as one of hydroce- phalus acutus. Blood should be freely drawn by leeches, by cupping, or by opening either the external jugular vein or a branch of the temporal artery. ✓ A lepid bath may be useful in this fever after the stomach and bowels are properly cleansed. 894 DISEASES OF INFANTS. To obviate debility when the fever goes off, we may recommend a daily use of some tonic medicine*, if judged necessary. APHTHA, OR THRUSH. The thrush in children has generally been supposed to arise from acidities, or some other acrimonious humour lodged in fhe stomach and bowels. Various causes of derangement in the ali- mentary canal are certainly to be regarded as those which occasion aphthae. One of the chief of these is worms, and it appears in this way that these two complaints are so frequently conjoined. Another occasional cause is bad milk, which may be vitiated by whatever is injurious to the nurse's health, such as great anxiety, violent pas- sions, poor diet, &c. In some instances the thrush may possibly depend upon the natural habits of the infant as well as upon the mode of bringing it up, particularly in regard to food, air, and the state of the bowels. This seems a warrantable conclusion, inasmuch as the thrush is some- limes found to seize every infant in certain families, in whatever way the children may be managed, as well as to occur occasionally in others upon a want of proper attention to the state ofthe alimen- tary canal, where a great number of other children properly watched have uniformly escaped it. The disorder generally appears first in the angles of the lipsj and then on the tongue and cheeks, in the form of little white specks. These increasing in number and size, run together more or less according to the degree of malignity, composing a thin white crust, which at length lines the whole inside of the mouth from the lips even to the oesophagus, and is sometimes found to extend into the stomach and throughout the whole length of the intestines ; producing also a redness about the anus. When the crust falls off, it is frequently succeeded by another of a darker colour, or livid hue ; but this happens only in the worst kind of thrush, for there is a milder sort that is spread thinly over the lips and tongue, which returns a great many times, and always lasts for several weeks. When the thrush is an original disease, it is never attended with * 1. g; Decoct. Cinchon. f. |iij- Tinct. Calumb. f. 3'j- Acid. Sulph. Dilut. fn. is. M. Capiat cochl. unum infantis bis terve in die. Vel, 2. R Pulv. Cascarilla?, 3j. ----Rhei, gr. xij. Ferri Subcarbonat. 3ss. M. Et in charlulas xij. divide, quarum unam sumat mane et vespere. * 1. Take Decoction of Peruvian Bark, three ounces. Tincture of Calumba,two drachms. Diluted Sulphuric Acid, fifteen drops. Mix them The dose may be a pap-spoonful twice or thrice a day. Or, 2.Take powderofCascarilla, one drachm. ■--------Rhubarb, twelve grains. Subcarbonate of Iron, half a scruple. Mix them arid divide them into twelve papers, of which take a dose morning and cvenipg. DISEASES OF INFANTS. 895 any fever at its commencement, although the mouth is frequently so much heated as to excoriate the nipples of the nurse, and becomes so tender that the child is often observed to suck with reluctance and caution; but when it has arisen in consequence of severe bowel complaints, or other infantile disorders, it is then sometimes accom- panied with fever and a severe diarrhoea. Even in very bad kinds of thrush there does not appear, however, any evident fever at the commencement of the complaint; but towards the close it may be apparent, and is sure to be of the low kind. Violent hiccups, vomiting, sense of suffocation, great prostration of strength, severe diarrhoea, coma, the apthae being of a brown colour, and any of the symptoms of cynanche maligna attending, are to be considered as very unfavourable. The disease, when recent and confined to the mouth, may in general be easily removed; but when of long standing, and extending down to the stomach and intestines, it very frequently proves fatal. Among the French, and especially in their public hospitals, the thrush seems to be a much severer disease than in England. To evacuate the stomach of acidities or other acrimonious humors, it will be proper on the first appearance of aphthae to give a gentle emetic. This may be done even in slight cases; but where the specks are of a dark colour, and the inside of the cheeks are beset with them, the remedy, by emptying the sto- mach of the crude juices and acrid matter, will be likely to prove highly useful. After the operation of the emetic we may recommend a course of the testaceous powders, giving a preference to the purest and softest. If the child is of a costive habit, a little magnesia may be advised; on the contrary, if its bowels are rather loose, and its frame delicate, we may then substitute two or three grains of the compound powder of contrajerva. The testaceous powders are to be administered for three or four days successively, and then we may prescribe something more laxative, to carry down tbe scales as they fall off from the ulcerated parts. In mild cases, rhubarb is regarded as the best medicine; but where the child is of a robust habit, and the disease is violent and has extended rapidly, it may be necessary to make an addition of a few grains of the submuriate of mercury. When a child of a weak habit is attacked with thrush which appears of a malignant nature, and which from its dark appearance threatens to terminate in gangrene, we should give a decoction of the bark of cinchona joined with a little aromatic confection. To render its efficacy the more certain, it may likewise be used in the form of clyster, with the addition of a few drops of tinctura opii to prevent its passing off by stool. In order to keep the infant's mouth clean and comfortable, and to prevent as much as possible any injury to the nurse, as well as to dispose the sloughs to fall off, and incline the parts underneath 89G DISEASES OF INFANT'S. to heal, it is customary to make use of detergent applications in tbe* form of gargles and lotions. Ia the gangrenous thrush it will be best to wash the parts frequently by means of a syringe, or a piece of soft linen rag rolled round the finger, with a strong decoction of cinchona bark, rendered somewhat sharp with the diluted sulphuric acid ; but in common cases of thrush, unamended by any disposition to gangrene, we may employ either of the gargles recommended below*. If the aphthae extend to the intestines, it may be advisable to sheathe the parts by emollient clystersf, repeating them twice or thrice a day. When an excess of purging attends, the medicines advised under" the head of Diarrhoea will be necessary. The other means and remedies directed for the cure of cachexia aphthosa, in the former part of this publication, will likewise be proper in this species of thrush, to which head I must beg leave to refer the reader. PROLAPSUS ANI, OR FALLING OF THE FUNDAMENT. We often meet with this disease in children of a weak habit, or who have been much afflicted with severe purgings. In prolapsus ani, considerable advantages have been experienced from a frequent use of astringent injections}, particularly of an infusion of galls or oak-bark; and when a small proportion of opium is added to the liquor, it tends greatly to lessen the irritation in the extremity of the rectum. The same may be used as a wash to the protruded parts, after which they may be sprinkled with a little Armenian bole, powdered very fine, and then be reduced. Should great soreness be experienced by the reduction, the fingers * 1. R Decoct. Hordei, f ^iv. Sodae Sub-borat. 3ss—3>- Mellis Rosae, f. *ss. M. ft, Gargarisma. Vel, 2. R Confect. Rosse, ?ss. Aluminis, 3ss. Aq Pur«,f ^iv. Acid Sulph. Dilut. fll x. Tinct. Myrrh, f. |ss. M. t 3 R Decoct. Avense, f. ^iij. Gum. Acac. Pulv. 3'- Ol. Olivje, f. 2*s. M. ft. Enema octava quaque hora adliibcn dum. \ 4. R Decoct. Quercus, f. ?iv. Tinct Opii, V!\ x ft* LncnT- * 1. Take Decoction of Barley,four ounces. Sub-borate of Soda, halfa drachm to one drachm. Honey of Roses, half an ounce. Mix them for a gargle. Or, 2. Take Confection of Roses, half an: ounce. Alum, halfa drachm. Pure Water, four ounces. Diluted Sulphuric Acid, fifteen, drops. Tincture of Myrrh, half an ounce. Mix them for a gargle. 1 3. Take Oatmeal Gruel, three ounces. Powdered Gum Acacia, one drachm. Olive Oil, half an ounce. Let this clyster be administered every eight hours X 4. Take Decoction of Oak Bark, four ounces. Tincture of Opium, twelve to fiH. > teen drops. ! ^fixthem foraclvjtT. DISEASES OF INFANTS. 897 employed on the occasion may be smeared with some of the oint- ment here directed*. With the view of strengthening the parts, the debility of which is in general to be considered as the sole cause of this disease, we should advise not only the cold-bath in a general way, but likewise the throw- ing cold water more directly on the buttocks and back of the child ; and besides these tonics, it should be put under a course of steel, myrrh, and the bark of cinchona.—See these under the head of Dyspepsia. ATROPHIA ABLACTATORUM, OR WEANING BRASH. This disease occurs in children that are weaned too early, or such as are attempted to be reared without the breast, and also where im- proper food is given with or without sucking. It appears most fre- quently in children of a lax fibre, and whose constitutions at a more advanced stage of life might be supposed liable to the attack of strumous disorders. It commences with frequent griping and purging, in which the stools are usually of a green colour, and is often accompanied with bilious vomiting. In the progress of the disease the stools are some- times ash-coloured and shining, and sometimes lienteric—Atrophy succeeds to these symptoms, and convulsions often come on, and carrv off the child. J A modern writerf supposes the exciting cause of this disease to be too sudden an alteration of the diet of a child at an unfit season. The weaning brash, if attended to in time, may in general be re- moved ; but if neglected, it frequently proves fatal before tbe sixth or seventh week. On dissection the mesenteric glands usually appear either in- flamed or enlarged. In some instances tubercles have been found in the lungs. In others the liver is firm, and larger than natural, and the gall-bladder is filled with dark green bile. Remarkable contrac- tions of tbe diameter of the gut in several parts of the intestinal canal, have been perceived in some instances. A proper attention to diet constitutes the first point to be attended to for the removal of the disease; and, above all, a return to the natural food, the mother's milk, where circumstances will admit of it. Where they do not, animal food, in the form of broth or jelly, should principally be employed. Vegetable food must be prohibited, as well as fruits, acids, and compositions of which butter and sugar form a part. Pure air, exercise, gentle frictions, and frequent washings of the body with tepid or cold } See Essay on the Diseases of Children, by J. Cheyne, M. D. vol. i. p. 31. v*. RPulv. Gallar. 3ij Adipis Prepaiat. |j. Opii Puriftcat. 3ss. M ff. Unguentum. 113 * 5. Take Oak Gall in Powder, two drachms, Prepared Lard, one ounc«. Opium, half a drachm. Mix them well for an ointment. 898 DISEASES OF INFANTS. water will be good prophylactics. Flannel worn next to the" skin- worsted stockings, and every precaution against cold irregularly appli- ed, should be attended to. The employment of a warm-bath, of a temperature from 90 to 100, twice or thrice a week, might prove advantageous. For the cure of the disease, occasional gentle laxatives, such as rhubarb, with absorbents and aromatic medicines interposed, together with minute doses of ipecacuanha joined with the submuriate of mercury, as prescribed below*, seem most advisable. Where the disease arises in children of three or four years of age, we must have recourse to the means recommended under the head of Atrophia, p. 493. OPHTHALMIA PURULENTA, OR PURULENT OPHTHALMIA. This disease is noticed under the head of an Inflammation of the Eyes, pp. 106 and 111. TEETHING. Of all the occurrences to which children are liable, not one is attende d with such grievous and distressing symptoms as difficult dentition. With regard to the time of their cutting teeth, no fixed or exact period can be laid down, as some cut their first tooth at three or four months old, while others again have not the smallest appearance of a tooth before the eighth or ninth month. Dentition generally commences, however, in the majority of children, between the fifth and eighth month, and tbe process ofthe first teething commonly continues to the sixteenth at the least, but often much longer. The two fore-teeth, or dentes incisores ofthe under jaw, are those which usually appear first, and shortly after these are observed two more come out in the upper one, exactly opposite lo the two former. These are succeeded by the four molares, then the canini, and the last of all, of an infant's first teeth, their anta- gonists, or the eye-teeth, making in all sixteen. This, it is well- known, is the ordinary number of a child's first teeth, as they are called ; but some infants cut four double teeth in each jaw instead of only two, making the whole number twenty. In children who are healthy and strong, the process of dentition goes on asjiasjust been described, and the teeth are cut soon and_ easily ; but in unhealthy and weak infants, the process is both slow and uncertain. Accordingly, children sometimes cut their teeth irregularly, both by the teeth appearing first in tbe upper jaw, and also at some distance, instead of being contiguous to each other, which has been accounted, and with some reason, an indication of * l.R Pulv. Ipecac, gr. j. ad g. ----Zingib, gr. iij. Hydrargyr. Submuriat. gr. ss.-ij. M. Et in chartulas iv. divide, quarum unam sumat infans singulis aut alternis noctibns. * 1. Take Powder of Ipecacuanha, one grain to two grains. --------Ginger, three grains. Submuriate of Mercury, half a grain to two grains. Mix them, and divide them into four ^ doses, of which let the child take one each. nieht, or everv other. DISEASES OF INFANT^. 899 difficult or painful dentition. It may also be remarked, that the ease or difficulty of dentition may be guessed at by the circumstances under which the two first teeth shall happen to be cut, the succeeding ones generally making their way in a correspondent manner. At six or seven years of age, all children shed their teeth in a gradual manner, and get a fresh set, and about the age of one-and- twenty, four more come out, one in the corner of each jaw, which, from their appearing at that period of life, have been named dentes sapientiae. Dentition is usually preceded by, or accompanied with, various symptoms : the child drivels ; the gums swell, spread, and become hot; there is often a circumscribed redness in the cheeks, with eruptions on the skin, especially on the face and scalp ; a looseness ensues, with gripings, stools of a green, pale, or leaden blue colour, sometimes mucous, and often thick ; and the child is watch- ful and peevish, starts during sleep, and seems convulsed in partic- ular parts of its body. In almost all cases the child shrieks often, and thrusts its fingers into its mouth. These symptoms are some- times followed by a cough, difficulty of breathing, scrofula, maras- mus, and hydrocephalus, and very frequently by much febrile heat, thirst, and convulsions. When the child's body continues open, and none of the violent symptoms attendant on much irritation ensue, we need seldom apprehend any bad consequences from teething. It has often been observed, that those children in whom there is a copious flow of saliva, suffer the fewest inconveniences during the process of dentition ; that such infants cut their teeth more readily in winter than in summer ; that such as are inclined to be lean cut them more easily than those that are fat ; and those whose bowels are regularly open, the most safely of all. The system during dentition being disposed to inflammation, strong lusty children are much oftener attacked with fever than the tender and delicate ; like athletic adults, who are more disposed to inflammatory complaints than those who are of a colder, but less healthy temperament : and it is by acute fever or convulsions that infants are carried off, who are well known to survive various lin- gering and distressing complaints if their viscera are sound. The extremes of high health and of debility are both attended with some degree of danger ; the one being exposed to acute fever or convul- sions, the other to slow hectic or marasmus. The evils arising in dentition are often prevented or greatly alleviated by spontaneous diarrhcea, in consequence of its lessening the quantity of blood in the system, and diminishing the strong action ofthe heart and arteries. In children whose constitutions are disposed to plethora, (which may be known by their florid com- plexion and fulness), it will therefore be proper to encourage any spontaneous diarrhcea that may arise unless it runs to excess ; but where hone arises naturally, we ought then to give gentle 900 DISEASES OF INFANTS. purgatives, stich as the sulphate or supersulphate of potass, in such doses as to procure two or three loose evacuations in the twenty-four hours. Where a considerable degree of fever attends on dentition, draw- in? blood from the immediate neighbourhood ofthe parts affected with irritation and pain, by slightly scarifying the gums, and apply- ing leeches behind fhe ears, is often practised, and not unfrequently with advantage. In some instances we might possibly substitute blisters instead of the leeches with a good effect. If the symp- toms should not yield to these means, the use of a tepid-bath once or twice in the twenty-four hours, and the exhibition of small doses of ipecacuanha, with a saline draught afterwards, or a solution of tartarized antimony in such moderate doses as to produce a gentle diaphoresis, will be proper. Opium is sometimes resorted to for the purpose of allaying pain and irrigation during difficult dentition, but the practice should be adopted with due caution. About a tea-spoonful of the syrupus papaveris will be the safest opiate we can administer in cases of urgent necessity. In others, fomenting the side of the face with a solution of the extract of poppies in a decoction of chamomile (in the proportion of half an ounce of the extract to a quart of the de- coction), by means of a piece of sponge, may be attended with beneficial effects, avoiding thereby the evil consequences attendant on opiates given internally. Nurses are indeed too apt to adminis- ter some preparation or other of opium in the watchings and com- plaints of children, that their own rest mayT not be disturbed throughout the night. This practice merits the highest censure. When the gums have become tumid and swelled so as to excite a high degree of pain and febrile heat, instead of simple scarifica- tions, an incision should be carried down to the tooth, so as also to divide the membrane which covers it. When the gums over the molares require to be divided, it will not be sufficient to make the incision merely in the direction of the jaw, but tran>verse ones must also be made, to set the toolh quite at liberty, so that in its further advance it may not irritate the gum again. The practice of giving children coral and other hard substances to put into their mouths during the period of teething, is improper, as they have a tendency to harden the gums. A piece of small wax candle that will yield in some measure to whatever pressure is made upon it by the gums of the child, may be serviceable. If acidity prevails during dentition, it is lo be obviated by proportionate doses of magnesia or the mistura cretse ; and if accompanied by flatulency and griping pains, carminatives, such as carraway seeds, or a drop or two of the oleum anisi, may be mixed with its food. During dentition, children are sometimes troubled with ulce- rated gums ; but these may be easily cured by keeping the body open, and touching the parts affected with some astringent applica- DISEASES OF INFANTS. 901 tion. As much alum as will give a moderate roughness to a little honey, or a little sodas sub-boras and honey, may be used. Pure air, proper exercise, wholesome food, an open belly, and everv thing that has a tendency to promote general health, and to guard against fever, will greatly contribute to the safety of dentition, as well as to the child's passing quickly through this hazardous period. CONVULSIONS. Violent spasmodic affections sometimes attack infants without any apparent cause; but in general they are produced either by a lodg- ment of some acrid matter in the intestines, or wind pent up, or they arise from teething, worms, the sudden striking in of a rash, or the ac- cession of some constitutional disease, as, for example, the small-pox, scarlatina, &c. Any trifling matter, capable of irritating the nervous system, will induce symptomatic convulsions in some infants; while others again will withstand a great deal. The younger and more irri- table tbe infant is, the more liable will it be to symptomatic convulsion, especially from any considerable disturbance in the first passages. We are informed by Dr. Clarke, of Dublin, that, owing to mis- management and bad air, an epidemic convulsive disease prevailed in tbe lying-in hospital of that city among the infants within the first nine days, which swept off great numbers of them annually; but this was at length obviated by discovering the cause. When convulsions proceed from any other canse than an eruption ofthe small-pox (in which they are usually regarded as prognosticating a favourable species of it), they are always dangerous, as well as alarming. A surer indication of danger is to be drawn from the dis- tance of the paroxysms than from the forcible contractions of the muscles during the fit. Where the intervals are short, although tbe fit itself be not long nor violent, the disease is to be considered as more dangerous than where severe paroxysms are attended with long intervals. In the treatment of convulsions in children, the chief object to be attended to is the removal, if possible, of the cause which has given rise to them. If they seem to be occasioned by improper food and indigestion, a gentle emetic may be given, and for this purpose we may employ a weak solution of tartarized antimony, of which a tea-spoonful may be administered every ten or fifteen minutes until the desired effect is procured. When supposed to proceed from a lodgment of acrid matter in the bowels, this ought to be removed by a laxative clyster, assisted by some gentle aperient, given by the mouth, such as calomel, followed by an infusion of senna with a little tincture of jalap ; if from flatulency, then carminatives ought to be used, as advised under that particular head; and if from teething, whenever the tooth can be discovered working a passage through the gum, scarifications may be made with the edge of a lancet immediately over it; and this operation we mav repeat for several successive days, till either the tooth H02 DISEASES OF INFANTS. makes its way, or the convulsions cease. If scarifications are not found to answer the purpose, we may cut boldly down to the tooth, and liberate it in every part; and this plan we may likewise adopt with all such as are manifestly making their way. Worms having been looked upon as a frequent cause of recurring convulsions, we should always have recourse to the remedies which have been advised under that particular head, when from the pre- vailing symptoms we suspect them to have been excited by this cause. Should convulsions have arisen from the sudden disappearance of a rash, or the drying up of a discharge from behind tbe ears, the re- appearance of these ought to be promoted. Where the fits are of some duration or frequent recurrence, a warm- bath at the temperature of 92 or 94 degrees of Fahrenheit's scale should be employed, and, if necessary, be often repeated: this, by diffusing the circulation more generally, and determining it to the surface of the body, may be highly useful. . As in the greater number of cases of convulsions there are strong reasons for believing that tbe head is overloaded with blood, it will be advisable to take away some, either by leeches, cupping, or open- ing the external jugular vein. When convulsions are not relieved by the means which have been suggested, blisters should be applied to the lower extremities. The application of cold fluids or ice to the scalp, having previously shaved the head*, has been attended with happy effects in cases of convulsions, as well as in inflammation of the brain, both in children and adults. With the view of shortening the duration of an individual parox- ysm, there is scarcely any stimulus so powerful as the plentiful affu- sion of cold water over the face, the body being placed in an horizon- tal position with the face upwards. The effluvia arising from volatile alkali or ammonia plentifully inhaled, will also prove a useful stimulus. As antispasmodics, the preparations of ammonia and aether will be most serviceable, although assafcetida, valerian, castor, musk, amber, and other fetid substances, are often given. It is only in cases of the most urgent necessity that we should venture on giving a small quantity of the syrup of poppies, or a few drops of the tincture of opium. In those convulsive attacks which frequently precede an eruption of the small-pox, nothing will be required but the free exposure of the child to cool air. The liquor potassae subcarbonatis given in doses of from five to fifteen drops, according to the age of the child, and repeated every ten minutes, has been known effectually to remove convulsive affections in young children, which had for a length of time resisted the power? of the oxyd of zinc, musk, extractum hyoscyarai, clysters of assafcetida, anodyne injections, with opium and blisters. It is * See Commentaries on the most important Diseases of Children, by John Clarke, M. D. DISEASES OF INFANTS. 903 probable, however, that in these cases the fits arose from severe griping pains in consequence of acidity. Where a high degree of organic debility prevails, volatile alkali, viz. the spirit, ammonias succinatus in doses of a few drops, in some proper vehicle, may be substituted for the former. In clysters, the liquor vol. cornu cervi is likewise of avail in these c^ses in a greater or less dose, according to circumstances. When convulsions are not preceded by any ofthe usual symp- toms, they may be regarded as idiopathic. In difficult labours, for example, the brain is often much compressed, and soon after delivery the child is attacked with fits. In such cases it will be advisable to let the navel-string bleed one or two tea-spoonsful before it be tied. Thus the oppression of the brain will be relieved, and the disagreeable consequences will be prevented. But if this has been neglected, and fits have actually come on, we must then endeavour to make a revulsion, and empty the vessels of the head by opening the jugular vein, or by applying leeches to the temples; by procuring an immediate discharge of the meconium ; by putting blisters behind the ears, or to the back ; by bathing the feet in warm water ; and by rubbing the soles with liquor ammonia; carbonatis. Inward fits are much talked of by nurses, and some authors have indeed made mention of them ; but more particularly Dr. Arm- strong. Infants, during the first month, are said to be more or less liable to them. The symptoms are these : the child appears as if it was asleep, but the eyelids are not quite closed ; and if you observe them narrowly, you will see the eyes frequently twinkle, with the white of them turned up. There is a kind of tremulous motion in the muscles of the face and lips, which pro- duces something like a simper oi* smile, and sometimes the appear- ance of a laugh. As the complaint increases, the infant's breath seems now and then to stop for'a time ; the nose becomes pinched ; there is a pale circle about the eyes and mouth, which sometimes changes to livid, and comes and goes by turns ; the child starts, especially if you stir it ever so gently, or if you make the least noise near it. Thus disturbed, it sighs or breaks wind, which gives relief for a while ; but presently it relapses into dozing. Ppmetiines it struggles hard before it can break wind, and seems as if falling into convulsions; but a violent burst of wind from the stomach, or vomiting, or a loud fit of crying, sets all to rights again. For the removal of these, Dr. Armstrong recommends us to give antimonial wine in a few drops, according to the age of the infant ; but all that appears to be necessary is, to take up the child when it sleeps too long, and the smile often returns, with any of the other symptoms just described, and to tap it gently on the back, rubbing its stomach and belly well before the fire. This gentle exercise will bring a little wind from its stomach (which is supposed to be the cause of the complaint), and the 904 DISEASES OF IMANTS. child will then go quietly to sleep again. Should these simple means not prove sufficient, some carminative may be given to h, such as adrop or two of the oleum anisi or oleum caiui on a bit of white sugar. SYPHILIS INFANTUM, OR THE VENEREAL DISEASE IN INFANTS. Although a child sometimes shows some appearances of syphilis at the time of its birth, still it more frequently happens that none are to be observed until after an expiration of at least ten or twelve days. When the disease exists at the time of its birth, or shows itself soon afterwards, it makes its appearance in the form of an erysipela- tous efflorescence dispersed over the whole body, tbe cuticle is in part or altogether destroyed, and a serous matter oozes from the skin. When it makes its appearance some days after tbe birth, irregular blotches of a light red colour, and somewhat elevated, arise about the anus, nates, and pudenda. Crusty eruptions appear in other parts of the body, and these in some places continue dry and scale off, but in others an acrid thin matter exudes from them. Although we may not be able to trace any marks of ihe existence ofthe disease in either the father or mother ofthe child, still it may possibly be derived from them. When children are born with the appearances just described, or several dead births have followed, we may, for the most part, at- tribute them to the parents labouring under some constitutional af- fection of syphilis, without their being probably aware of it. In all such cases it will be necessary to put both of them under a mercu- rial course. To effect a cure in a child at the breast, it will in general be sufficient to give the necessary medicines to tbe woman who nurses it; which office should always be undertaken by tbe mother, as, by getting any other to suckle it, she would in all probability soon be infected likewise, as happened in a case which lately fell under my care. In the progress of the cure, the same rules and cautions are io be observed as have already been pointed out in the syphilis of adults. In instances of this nature, an alterative course long persisted in ought to be preferred to that of exciting any degree of salivation. If it is found necessary to wean the child before the cure is com- pleted, or to introduce mercury into the habit of the child from the very beginning, instead of giving it to the woman who suckles it, we may then diroct that it shall take about a quarter of a grain of the hydrargyri submuiias, every night and morning, mixed up in a little honey or thick syrup; which course ought to be continued for at least a week or ten days after the disappearance of all tbe symptoms. By a due attention to the following circumstances we shall be enabled to ascertain whether tbe nurse infects the child, or the DISEASES OF INFANTS. 905 latter the nurse. Where the breasts of the nurse and the mouth of the child only are diseased at one time, we cannot give a decisive opinion until we have other evidf.nces. If, however, the breasts of the nurse be the only parts diseased, while other marks of syphilis, besides those of the mouth, are apparent on the infant, it is very probable that the complaint has been communicated bv the child; on the contrary, if the infant has no disease except of the mouth, and other marks of it appear on different parts of the nurse besides the breasts, it is then highly probable that the infant has imbibed the disease with the breast milk. Further, if the nurse has secondary symptoms, and the child only primary ones, we may reasonably sup- pose that the complaint has been communicated by the nurse or some other person by whom the infant may have been kept. Where the child has secondary symptoms of syphilis the disease probably has been entailed by its parents. U4 A VIEW OP THE FORMER AND PRESENT LONDON PHARMACOPCELE, TOGETHER WITH THE SYNONYMS OF THE DIFFERENT COLLEGES. Names in the Former London Phar- macopoeia*. Acetum Distillatum Aeidum Acetogum -----Nitrosum -----Nitrosum Dilutum -----Vitriolicum Acetum Colchici. Aeidum Aceticum Aeidum Citrieum Aeidum Nitricum £}rugo & ther Vitriolicus Aloes Barbadensis ----Soccotorina Alumen Ustum Ammonia Praeparata Antimonii Sulphur Praecipitatum Antimonium Calcinatum ----------Tartarizatum Aqua Aluminis Composita ----Ammoniae ------------Acetatae ■ - . .. ■.——Pur« Names in the New Pharmacopoeia. ■Dilut. Sulphuricum jErugo iEther Sulphuricus Rectificatus Acid. Acetosum Distillatum Aeidum Nitrosum Sulphuricum Aloes Vulgaris Extractum ----Spicatae Extractum Alumen Exsiccatum Ammonias Subcarbonas Antimon. Sulph. Praecipit. Osydum Antimonii Tartarizatum Liquor Aluminis Compositus ---Ammoniae Subcarbonatis ------------Acetatis Ammoniae Edinburgh Pharmacopoeia. Acetum Distillatum. [turn Aeidum Citrieum Crystallis Concre Aeidum Nitrosum. Sulphuricum. Subacetas Cupri iEther Sulphuricus. Aloes Hepatica Gummi Resina Aloes Soccotrinae Sulphas Aluminae Exsiccatus Ammoniae Carbonas Antimonii Sulph. Praecipitatum Tartris Antimonii (et Potassae) Liquor Ammoniae Carbonatis Aqua Acetatis Ammoniae Ammoniae Dublin Pharmacopoeia. ^Erugo. yEther Sulphuricus. Aloes Hepatica. Gummi Resina Aloes Soccetrinae Alumen Ustum. Ammoniae Carbonas. Sulphur Antimoniatum Fuscum. Oxidum Antimonii Nitro-Muriaticum. Tartarum Antimoniatum. Liquor Ammoniae Carbonatis. Acetatis. Aqua Ammoniae Causticte. " N, B. Names of the New Articles are printed in Italics, as Acetum Colchici, Aeidum Citrieum, £c- o B o H S H *J O s w > O Names in the Former London Phar- macopoeia. Edinburgh Pharmacopoeia. Aqua Calcis ----Cinnamomi ----Cupri Ammoniati ----Kali Preparati --------Puri ----Lythargyri Acetati Arabicum Gummi Argentum Nitratum Arsenicum Balsamum Canadense ■ Copaiva Composita Barilla Benzoe Borax Calamus Aromaticus Calornelas Calx Antimonii Calx cum Kali pure Canella Alba Cantharis Cassia Fistularis Ceratum Cantharidis ——— Lapidis Calaminaris -------Lythargyri Acetati Compos ———— Resinae Flavae Liquor Calcis Aqua Cinnamomi Liquor Cupri Ammoniata Potassae Subcarbonatis Potassae Plumbi Subacetatis -----Dilutus Acaciae Gummi Argenti Nitras Arsenici Oxydum Subliraatum Terebinthina Canadensis. Copaiba Soda Impura Bensoinum Sodae Sub-boras Cajdputi Oleum Calami Radix Hydrargyri Submurias Antimonii Oxydum Potassa cum Cake Canellae Cortex Lytta Carbo Ligni Cassiae Pulpa Cataplasma Fermenli. Ceratum Lyttae. Calaminae Plumbi Compositum. Aqua Calcis ----Lauri Cinnamomi Aqua Potassae Gummi Mimosa? Niloticae Argenti Nitras Arsenici Oxydum Copaiferae Officinalis Resina Liquida Carbonas Sodae Impurus Styracis Bensoina Balsamum Boras Sodae Melaleucas Leucadendri 01. Vol. Acorus Calamus Radix Hydrargyri Submurias Potassa cum Calce Canella Alba, Cortex Meloe Vesicatorius Carbo Ligni Cassias Fistulae Fruct. —!---Resinae. \Ceratum Sabmce Aqua Calcfc. — Cinnamomi. — Cupri Ammoniati. — Subcarbonatis Kali. — Kali Caustici. Liquor Subacetatis Lithargyri. —--------Lithargyri Compositus. Gummi Arabicum. Argenti Nitras. Arsenicum. Balsamum Copaibae. Barilla. Benzoe. Sub-boras Sodae. Oleum Cajeput. Acari Radix. Submurias Hydrargyri Sublimatum. Oxidum Antimonii Nitro-Muriaticum Kali Causticum cum Calce. Canella Alba, Cortex. Cantharis. Carbo Ligni. Cassia Fistularis. Unguentum Calaminaris Unguentum Safejua?. i Names in the Former London Phar- macopoeia. Ceratum Spermatis Ccti Cerussa ------- Acetata Ccrvus Cornu ChiuiKCi.ie'iim Ciciita Ciiteres Clavellati Coc'.:ineIla Colnmba, Radix Cuufeclio Opiata \ Conscrva Cort. Aunitilii --------Oy:io5ljuli --------Rosa; Cortex Angustura; ------ Cinchona; Flava? ------Cinchona; ----------------Rubra? Chrystalli Tartari Crocus Antimonii Cucuniis A^rcstis Gupruni Vitriolatum Cynosbatus Decoctum Cornu Cervi ---------pro Enemate ------------Fomento Names in the New Pharmacopoeia. Ceratum Cetacei CeruvisitE Fcnnentum. Plumbi Subcarbonas Superacetas Cornua Anthemidis Flores Conii Folia Potassa Impura Coccus Calumbae Radix Confectio Opii Iiuia:. Aurantiorum Rosa? Ca;iina" Gallic a? Cuspariae Cortex. Cinchona? Cordifnlia? Cortex Lancifolia? Cortex Oblons;ifolite Cortex. Hellebori Albi Potassa? Supertartras Antimonii Oxydum Elaterii Poma Cuprum Ammoniatum Cupri Sulphas Rosa? Caiiina; Pulpa. Dauci Radix Mistura Cornu Usti Decoctum Malvae Compositum. — Papaveris. ■ Veratri. Edinburgh Pharmacopoeia. Ceratum Simplex. Oxydum Plumbi Album Act-tis Plumbi Cervi Klaphi Cornu Ant Nobilis Flores Cfonii Maculati Folium Carbonas Potassa? Impurus Coccus Cacti Colnmba; Radix F.lcctiiarium Opiatum. Conserva Aurantii --------Rosa? Canina?. -------------Gallica: Angustura Cinchona? Officinalis Cortex Supertartris Potassa? Impurus Momordica Elaterium, Fructus Re cens Submaturus Ammoniaretum Cupri Cupri Sulphas Dauci Carota? Semines Dublin Pharmacopoeia. Cerussa. Acetas Plumbi. Cornu Cervinum. Chamaemeli Flores. Cicuta. Cineres Clavellati. Coccinella. Columbo. Conserva Aurantii. Rosa?. Angustura. Cinchona. Tartarum Crystalli. Oxidum Antimonii Nitro-Muriaticum Elaterium Fructus. Cuprum Ammoniatum. Cupri Sulphas. Dauci Sylvestris Semines, Decoctum Cornu Cervi. Names in the Former London Phar- ,, . ,, ,.T „, _„„_„„:_ Names in the New Pharmacopoeia. macopoeia. Dolichos F.LATEK1UM Electuarium Cassia5 ---------—■ Senna; Emplastrum Cantharidis ---------—• Cera? Compositum -----------Lithargyri ---;------------Compositum --------------_ cum Hydrargyro .----------cum Resina ----------- PicisBurgundica? Com- positum. Decoctum Quercus. Dolichi Pubes Elaterii Extractum Confectio Cassia; ------Senna? Emplastrum Lytta; -----------Cera1 Ferrum Ammoniacale Ferri Rubigo Ferrum Vitriolatum Flores Benzoe? ■ Sulphuris Loti Gambogia Venista Cammed Extractum Aeon Hi. ---------Belladonna. ---------flu milt. ---------][i/osci/ami. ---------Rhei. ' ---------Taraxaci. Plumbi Galbani Compositum. Hydrargyri ■ Resina? Opii. Picis Compositum. Edinburgh Pharmacopoeia, Ferrum Ammoniatum Ferri Subcarbonas ----Sulphas Aeidum Benzoicum Sulphur Lotum Gambogia. Spartii Cacumirtn Dolichos Pruriens. Leguminis Pubes Rigida Succus Spiss. Mamordicae Elaterii Fleet. Cassia? Fistula? -----------Senna? Dublin Pharmacopoeia. Emplast. Meloes Vesicalorii -------Simplex. -------Oxidi Plumbi Semivitrei Hydrargyri. Resinosum Succus Spissatus Atropa? Belladonna? Murias Ammonia? et Ferri Carbonas Ferri Praecipitatus Sulphas Ferri Aeidum Benzoicum Sulphur Sublimatum Lotum Spartium. Scoparium, Sunjmitas Doliches, Seta? Leguminum. Elaterium. Elect. Cassia?. — Senna?. Emplast, Cantharidis. -----Lithargyri. Lithargyri cum Resina. Murias Ammonia? et Ferri. Ferri Carbonas. Sulphas Ferri. Aeidum Benzoicum. Sulphur Sublimatum Lotum. Genista. Names in the Former London Phar- macopoeia. Names in the New Pharmacopoeia. Dublin Pharmacopoeia. Helleboraster Folium Helleborus Albus Hydrargyri Calx Alba Hydrargyrus Calcinatus -----------JVIuriatus -----------Nitratus Ruber — Sulphuratus Ruber — cum Sulphure Jalapium Kali Acetatum ----Preparatum —— Purum ----Sulphuratum -»— Tartarizatum —— Vitriolatum Lac Ammoniaci ---Assafcetida? ---Amygdala? ---Guaiaci Lapis Calaminaris Linimentum Ammonia: Hellebori fcetidi Folia Veratri Radix Hydrargyrum Praecipitatum Album Hydrargyri Oxydum Cinereum Hydrargyri Oxydum Rubrum Oxymurias Nitrico Oxydum Submurias Sulphuretum Rubrum - Nigrum. Infusum Digitalis. -----Tabaci. Jalapae Radix Potassae Acetas ------- Subcarbonas Potassa Fusa Potassa? Sulphuretum ---'----Supertartras -------Tartras -------Sulphas Mistura Ammoniaci -----Assafcetida? -----Amygdalae -----Guaiaci. Calamina Linimentum Ammoniae Subcarbonatis ----------Camphorae ----------Hydrargyri. ----------Terebinthimc. Veratrum Album. Oxidum Hydrargyri Cinereum. Murias Hydrargyri Hydrargyri Submuriaa Convolvulus Jalapa, Radix Acetis Potassae Carbonas Potassae Potassa Potassae Sulphuretum Supertartris Potassae Impurus Tartris Potassae Potassae Sulphas Emulsio Amygdala? Communis Carbonis Zinci Impurus Oleum Camphoratum Helleboraster. Helleborus Albus. Submurias Hydrargyri Ammoniatus. Pulvis Hydrargyri Cinereus. Oxydum Hydrargyri. Murias Hydrargyri Corrosivum. Oxydum Hydrargyri Nitricum. Submurias Hydrargyri Sublimatum. Hydrargyri Sulphuretum Rubrum. Jalapae Radix. Acetas Kali. Subcarbonas Kali. Kali Causticum. Sulphuretum Kali. Tartarum Crystalli Tartaras Kali. Sulphas Kali. Lac Ammoniaci. —— Assafoetidae. — Amygdalae. Calaminaris. Oleum Camphoratum. Names in the Farmer London Phar- macopoeia. Lythargyrus Lujula Magnesia Alba ---------Usta ---------Vitriolata Mel Acetatum Mentha Piperitis —----Sativa Mistura Camphorata ■ Cretacea • •■ ■ Moschatp Mucilago Gummi Arabici --------Sominis Cydonii Mali Natron Praeparatum ■ Tartarizatum ■-------Vitriolatum Nicotiana Nitrum Oleum Sticcinse Rectificatum ------Vini Names in the New Pharmacopoeia. ________%_________ figgali CalCTrMuriatis. Ferri Alkalini. Hydrargyri Oxymuriatis. Plumbi Oxydum Semivitreum Acetosella. Magnesiae Carbonas Magnesia Magnesia? Sulphas Oxymel Mel Boracis. Mentha Piperita Viridis Mistura Camphora? Cretae Mistura Ferri Composita: Mosch i. Oxymel ^Erujinft Mucilago Acaciae Decoctum Cydoniae. Soda? Subcarbonas Soda Tartarizata Sodae Sulphas Tabaci Folia Potassae Nitras Oleum Pimento. Oleum Succini iEthereum. Linimentum ./Eruginjs Edinburgh Pharmacopoeia, Plumbi Oxydum Semivitreum Magnesiae (sub) Carbonas Magnesia Magnesias Sulphas Mentha Piperita, Herba Emulsio Camphorata Potio Carbonatis Calcis Mucilag. Mimosa? Nilotica? Carbonas Sodae Tartris Potassae et Soda? Sodae Sulphas Nicotiana Tabacum Potassa? Nitras 01. Myrti Pimentae Oleum Succini Furiftimum Dublin Pharmacopoeia. Lithargyruro. Magnesia. Magnesia Usta. Magnesiae Sulphas. Oxymel. Mentha Piperitis, Herba. Sativa. Mistura Camphorata. ------Creta?. Mucil. Gummi Arabici. Carbonas Sodae. Tartaras Sodae et Kali. Soda? Sulphas. Nicotiana. Nitrum. Oleum Baccarum Pimento. 01. Succini Rectificatum, Oxymel .ffirugini* Names in the Former London Phar- macopoeia. Ovis, Sevum Papaver Alvum Papaverum Erraticum Filulae Opii —----Scillae «8Piper lndicum Pix Burgundica Pulvis Aloes cum Guaiaco -----Aromaticus Opiatus Raphanus Rusticanus Rhabarbarum Rosa Damascena; Petakim ----Rubra W Sal Ammoniacus ----Cornu Cervi ----Muriaticus Santalum Rubrum Scammonium Seneka Serpentaria: Virginians; Radix Names in the New Pharmacopoeia. Edinburgh Pharmacopoeia Sevum. Papaveris Somniferi Capsula? Rhceados Petala Ptlulte Cambogia Composita:. Ferri Composite, [pos Hydrargyri Submuriatis Com Saponis cum Opio. Scillae Composita? Capsici Bacca? Pix Arida Potassa Carbonas. ------ Supersulphas. Pulvis Aloes Compositus Cinnamomi Compositus Pulvis Kino Compositus. -----Cornu Usti cum Opio Armoraciae Radix Rhei Radix Rosa? Centifolias- Petala ----Gallica?; Petala Ammoniae Murias Subcarbonas Soda? Muria Pterocarpi JM|num. Scammonia? Gummi Resina Senaga? Radix Serpentariae Radix Soda Subcarbonas Papaveris Capsula? Pilulae Scillitica? Capsici Annui Fructu Pix Burgundica Pulvis Aromaticus — Opiatus. Dublin Pharmacopoeia. Rhabarbarum Rosa? Centifolia? Petala -----Gallica?; Petala Murias Ammonia? Ammoniae Carbonas Sodae Murias Convolvulus Scammonia, Gummi Re- sina Polygala Senega, Radix Aristolochia Serpentaria, Radix Carbonas Sodee Papaver Album. Papaver Erraticum. Pilula? Scilla? cum Zingibere. Capsici Bacca?. Pix Burgundica. Pulvis Aloes cum Guaiaco. Pulvis Aromaticus. Raphani Rusticani Radix. Rheum Undulatum, Rhadix. Rosa Damascena. ----, Rubra; Petala. Sal Ammoniacum. Ammonia? Carbonas. Sal Commune. Scammonium ; Gummi Resina. Seneka. Serpentaria Virginiana. Radix. Carbonas Sodae. Names in the Former London Ph macopceia. Spermaceti Spiritus iEtheris Nitrosi --------------Vitriol ici ------Ammonia? Compositus ■ Anisi Compositus ------Camphoratus ------Vinos Rectificatus ----—-------Tenuior Spina Cervina Stanni Pulvis Succus Cicutae Spissatus Sulphur Antimonii Praecipitatum Sulphuris Flores --------Coti Flores ^ Syrupus Papaveris Erratici en Tartari Chrystalli Thus Tinctura Cantharidis --------Columbae —----'— Ferri Muriati --------Opii Camphorata -------Rhabarbari Trifolium Paludosum, Herba Valeplana Sylvestris Vitriolum Album Names in the New Pharmacopoeia. Cetaceum ,. Spiritus iEtheris Nitrici ---------------Sulphurici ------Ammoniae Aromaticus ------Anisi ------Camphorae ------Rectificatus. ------Tenuior. Rhamni Bacca? Stanni Limatura Extractum Conii Antimonii Sulphuretum Pra?cipit Sulphur Sublimatum -------Lotum. Syrupus Rhceados. Potassae Supertartras Abietis Resina. Tinctura Lytta? -------Capsici. -------Calumba? -------Digitalis -------Ferri Muriatis -------Humuli. -------Hyoscyami -------Camphorae Composita ---—— Kino. -------Rhei Menyanthes Valeriana? Radix Zinci Sulphas Edinburgh Pharmacopoeia. | Dublin Pharmacopoeia. Spermaceti Spiritus iEtheris Nitrosi /Ether Sulphuricus cum Alcohole Alcohol Ammoniatum Aromaticum Tinctura Camphora?. Spina Cervina. Succus Spissatus Conii Maculati Antimonii Sulphuretum Praecipitatum Sulphur Sublimatum Supertartris Potassa? Impurus Tinctura Meloes Vesicatoru --------Columbae --------Digitalis ------— Ferri Muriatis --------Hyoscyami Nigri Tinctura Rhei Palmati Menyanthes Trifoliata, Folium Valerianae Officinalis, Radix Zinci Sulphas Spermaceti. Spiritus iEthereus Nitrosus. Liquor iEthereus Sulphuricus. Spiritus Ammonia? Aromaticus. ------• Anisi Compositus. Snccus Spissatus Cicutae. Sulphur Antimoniatum Fuscum. Sulphur Sublimatum. Tartarum Crystalll. Tinctura Cantharidis. i ;—-----Columbo. --------Digitalis Purpurea". *— ' Ferri Muriatis. --------Hyoscyami. ------■— Opii Camphorata, Tinctura Rhei Trifolium Paludosum Valerianae Radix. Zinei Sulphas. Names in the Former London Phar macopceia. Vitriolum Ceruleum Vinum Antimonii Tartarizati Unguentum Adipis Suillae ----------Calc. Hydrargyr. Albi ----------Cantharidis ■ Cerussa? Acetata? ----1-----— Hydrargyri Nitratis ----------Hellebori Albi ----------Picis ---------— Resina? Flava? — Resina? Nigra?. — Spermatis Ceti Zincum Calcinatum ------Vitriolatum Names in the New Pharmacopoeia. Cupri Sulphas Liquor Antimonii Tartarizati Vinum Opii. Adeps Preparata Unguentum Hydrargyr. Praecip. Albi. Ceratum Lyttap Ceratum Plumbi Superacetatis Ungueat. Hydrargyr. Nitriuo Oxydi Veratri Picis Liquida? Ceratum Resina? Flava?. Unguentum Cetacei ----------Sulphuris Compositum. Edinburgh Pharmacopoeia. Cupri Sulphas Vinum Tartritis Antimonii. Adeps Preparata Unguentum Acetatis Plumbi -----Oxidi Hydrargyri Rubri Zinci Zinci Oxydum — Sulphas Unguent. Oxidi Zinci Zinci Oxydum - Sulphas Dublin Pharmacopoeia. Cupri Sulphas. Adeps Preparata. Unguentum Acetatis Plumbi. --------Subnitratis Hydrargyri. --------Hellebori Albi. --------Picis Liquida? ■ Spermatis Ceti, - Oxidi Zinci. Zinci Oxydum. — Sulphas. f INDEX TO THE DISEASES. PAGE Abscess, Common 101 -------of the Liver 179, 184 . of the Lungs 159 -------------Psoas Muscle 102 Abortions 830 Acidities in the Stomach of Adults 350 -------------'-----— Children 886 Acne, or Blotched Face 782 Acute Rheumatism 213 Adder, bite of the 806, 809 Adynamia?, Order 349 Aerial Poisons 804 Affection, painful, ef the Nerves ofthe Face 749 .-------Hypochondriac 360 After Pains of Lying-in Women 840 Agues 3 Ague Cakes 15, 188 Amaurosis 681 Amenorrhoea 710 Anaphrodisia 693 Anasarca 536, 537 Anchylosis 197, 215 Angina Maligna 139 -----Parotidaea 137 -----Pectoris 403 -----Tonsillaris • 133 -----Trachealis • 147 Animal Poisons 806 Animation, Suspended 814 Anorexia 693 Aphtha Chronica 527 Apthae Infantum 894 Apocenoses, Order 694 Apoplexy 332 689 693 600 194 789 j36, 549 536 876 410 418 B PAGS Barbadoes, Glandular Disease of 647 Barbiers 348 Bile, Obstruction of 670 ----, Preternatural Secretion of 446 ----, Vomiting of 446 Biliary Calculi 670 Bite of the Adder 809 ---------Copra de Capello Snake 808 -----a Mad Dog 42i -----Moschetoes S»9 -----the Rattle Snake '06 -------Viper and other Snakes, 806 808 -------Wasps, Scorpions, and Cer- tipides 809 Bladder, Acute Inflammation of th- . 193 ---«—, Chronic Do. Induratiou,i'hick- ening, and Ulceration of the 193, 709 -----, Stone in the 755 Bleeding from the Nose 291 6 Penis 301,607,616 Blindness, Night fi80 Blood, Involuntary Discharges of 290 299 320 301 670 629, 637 114 720 Appetite, Canine .. . , Loss of Ardor Urina? Arthritis Ascarides Ascites ---,— Ovarii Asphyxia Asthma Arthriticum -, Spitting of , Vomiting of Bloody Stools -----Urine Blotches, Scorbutf1 -------, Vene?«al Brain, Inflammation ofthe Breast, Cance' ofthe ----, Inflapmation and Tumor of the 842: Bronchitis 169 Bronchoc--le 574, 738 Bubo, Pestilential 273 ----, Phagedenic 626 ----, Venereal 597, 625> Bula-n Fever 91 BuVmia 689 Barns and Scalds 769 C Cachexia Africana -------Aphthosa Sypholoidea Atoms floating before the Eyqs 360, 364 Atonic Gout 198, 206 Atrophia f?3 Cancet -----Ablactatorum 897 ----- -----Lactantiura 4^6 ---*"~ Aura Epileptic? 375 Cachexia?, Class of Calculi, Biliary ., Urinary 524 527 631 493 670 755 720 of the Female Breast 72to£«a> 726 ,-----Chimney S\veeperT720, 724 730, 735 916 INDEX- Cancer, Cutaneous .-----ofthe Eye ----------Lip ----------Nose ----------Penis ---------Prostate Gland ---------Pylorus ----------Testicle ----------Tongue ----------Uterus Canine Appetite ------Madness Carbuncle Ca cinomatous Ulceration Cardialgia Carditis Caruncles in the Urethra Catalepsy Catarrhus --------Senilis PAGE 725, 735 725 725 725 725 724 172 724 725, 734 723,854 689 4-21 276, 280 726 352, 372, 753 169 617 382 312 317 745 719 597, 620 PAGE Cornea, Rupture ot the 131 Corpulence 531 Costiveness, Obstinate 701 ------------in Infants 886 ------------pregnant Women 822, 840 Cough, Common 164,314 Cephalalgia Gelation of the Menses Cliai'L'r^s *5halky Concretions in Gouty Habits 197, 199, 205 Chi\ken-pox 254 Chig* 788 Chilbhjns 788 Chincot^h. 395 ChlorosR 711 Cholera JV«,rbUs 446 Chordee 600, 605 Chorea Sanoj viti 383 Chronic Inflatmation of Ihe Bladder 193 ----------------------- Liver 176 185 -, Whooping Coup de Solei) CoW-pox Cramp, different species of the -------in Histerical Women -----:---pregnant Women Cretinism Croup Crustea Lactea in Infants Cynanche Laryngaea ---------Maligna --------Parolidaea --------Pharyngaea --------Tonsillaris --------Traehealis Cystitis 395 340 247 386 373 824 573 147 884 154 139 137 156 133 147 193 D — Rheuniatkm — 1 brush — Weakness Spleen 15,188 213,222 527 350 597, 599 368, 745 806 Clap Clavis Hystericus Cobra de Capella Snakebite ofthe Colic. Bilious 436 ----. Devonshire or PoictOt 440 ----, Flatulent 436 ----, Hysteric 436 Colour, Black and Livid, of Infant 878 Comata Order 332 Conception yiy ----------, Imperfect \ 831 Concretions. Gouty 197, 199, 205 ---------. Uriiu.ry V55 Confluent Small-pox . 234 Constipation, Obstinate 70i Consumption, Pulmonary 497 -----------, Nervous or Atrophy 493 Contagion, Means for avoiding and de- stroying of 68,232,272, 320, 868 Continued Fevers 26 ---------Simple Fever 26 Convulsions in Children 901 ----------, Hysterical 368 -----**"^,n Pre6nani Women 826 Cornea, fj^cities of the 127 Dance of St. Vitus 383 Deafness 685 Death, Sudden, after Delivery 839 Debility. Chronic 350 Defective Appetites, Order 693 DHiquium Animi after Delivery 839 Dentition 898 Diabetes 456 Dyalysis, Order 766 Diaphragmatis 169 Diarrhcea in Adults 450,823 ----------Infants 889 Difficult Menstruation Difficulty of Breathing, or Dyspncea ----------discharging Urine Digestion, impaired Dirt-eating * Diseased Mesenlefic Glands ------Prostate Gland 607,704,705, Spine Diseases of Infants --------Pregnancy —.------the Puerperal State Distinct Small-pox Dog. Bite of a Mad Dolor Faciei Crucians Dolorosi, Order Double Quartan ------Tertian Dracuncuius Dropsy ------of Ihe Belly ------------■ Brain ------------Cellular Membrane 719 410 703 360 524 693 709, 724 341 873 819 839 231 421 749 745 4 4 743 536 536, 549 536, 555 537 — Chest 536, 563 — Ovaria 536, 553 — Tunica Vaginalis Testis 536 554 ---Uterus 636, 653 INDEX. 917 Drowned Persons, Means for Reani- mating Dry Belly-ache Dysesthesia?, Order Dycinesia? Order PAGE Dysentery Djsmenorrhaea Dysorexiae, Order Dyspepsia Dyspnoea Dysuria 814 440 680 694 320 719 689 350 410 605, 703 Fever, Nervous ------, Puerperal ------, Putrid or Malignant ------, Remittent ----------------, of Infants -------, S carlet -------, Secondary, of Small-pox -------, Simple Continued -------, Yellow Walcheren E Ear, Pain in the -—, Inflammation ofthe Egyptian Ophthalmia Elephantiasis Emissions, Nocturnal Emphysema Emprosthonos Empyema Encysted Dropsy Eneuresis Enteritis Emphemera Simplex Ephidrosis Epilepsia ■ Dolorifica Epischcses, Order Epistaxis Eructations Eruptions, Cutaneous, in Children --------, Herpetic , Miliary , Scorbutic --------, Venereal --------, Vesicular Erysipelas Erythema Infantile Phlegmonodes Mercuriale Exanthemata, Order Excessive Perspiration Excoriations in Infants --------ofthe Nipples of Nurses Eyes, Inflammation ofthe 132 132 119, 128 646 696 533 386 159, 167 636, 553, 554 695 172 3 694 374 383 701 291 350 883 744 284, 844 670 629 287 97, 108 882 109, 111 97, 108 622 231 694 881 843 118 Uterus False Appetite ---- Pains in pregnant Women Faintings Febrile Diseases Fever, Bulam -----, Gibraltar -----, Hectic ----r~, Inflammatory ------, Intermittent -----, Miliary —-, Milk —, different Species of -, Eruptive Fish, Poisonous Fistula in Ano, Incipient -------Perineo Flatulency in Adults -----,------, Infants Floodings in Pregnant Women Fluor Albus Flux or Dysentery Fluxes with Pyrexia, Order Framboesia Frost-bitten Fundament, falling ofthe ______________________in Children Fungus Ha?matodes Furious Madness Furor Uterinus pagi; *44 858 68 20 892 262 241 26 71 19 2 231 809 312 605 ^50, 754 886 830 697 320 312 642 819 310 896 736 468 691 G Gall Stones Gans -, Hospital Gastritis Gastrodynia Gibraltar Fever Giddiness, or Vertigo Glands, Mesenteric, Diseased Glandular Disease of Barbadoes Gleet Globus Hystericus Goitre Gonorrhoea Dormientium ----------Virulenta in Men _______________----Women Gout Face, Cancer of the 725, 735 ---- Pimpled and Blotched 782 Faciei Dolor Crucians 749 Falliug of the Fundament in Children 896 -, Atonic -, Misplaced -, Regular -, Retrocedent, or Repelled 198, 2 670 98, 103, 105 106 169 352, 753 91 350 593 647 601, 618 368 673, 738 696 597, 599 602 194 198, 206 198 196 869 689 825 349 1 91 91 301 40 3 284 Gouty Concretions Gravel and Stone Green Sickness Gripes in Infants Guinea Worm Gum, Red, in Infants ----, Yellow, do. Gulta, Rosea or Acne ----, Serena H Haematuria Haematemesis Haemoptysis 841 Hemorrhagic, Ordei 197, 199 755 712 886 743 883 880 782 681 301 299 29." 290 M& LVTiEX. ^ PAGE «iPmorrhois 308 Hair, Plaited, or Plica Polonica 654 Headach 745 with Plethora in Pregnant Women Head, Giddiness in the Hearing, Difficulty of Heartburn ---------iu pregnant Women Hectic Fever Hemiphlegia Hemorrhage from the Anus -------------------- Lungs Nose Stomach Uterus Hepatitis Hernia, Strangulated Herpes Hiccups in Adults ---------Infants Hip Joint, Disease ofthe Hospital Gangrene Hydatids Hydrocele Hydrocephalus Hydrometra Hydrophobia -----------, Spontaneous Hydrops Hydro thorax Hypochondrias]:; Hysteria -------in pregnant Woiui n llysteritis 299 830 176 176 744 394 882 224, 229 106 179, 553 536, 554 536, 555 536, 553 421 4iM 536 386, 563 360 368 822 194, 850 Icterus ■ Infantum 670 880 436, 439 578 781 6!M 497 696 695, 823 352, 491 350 iliac Passion Impetigines, Order Impetigo Impotency Incipient Phthisis Incoutineucy of Semen -----------,— Urine incubus, or Night Mare Indigestion, or Dv.-pepsia infanticide, Cautions to be observed in giving Evidence on 877 Infants, Diseases of 873 ------, Livid and Black Colour of, on Birth 878 Infantile Erysipelas 882 ------Remittent Fever 892 i rifection, how to avoid and destroy 68, 232, 272, 320, 868 iuflammalion, different Species of 96 -----------, Erysipelatous 97 ,.__________, Phlegmonous 96, 98 __________terminating in Effusion *r.d Adhesion ^8 pagk Inflniumation tcrminatingin Gangrene 98, 103 --------------------Resolution 98, 99 .- Scirrhus 99 821 350 685 352, 372 821 501 340 308 295 291 Suppuration, 98,101 of the Bladder ------Brain ------Female Breasts -----Br inchia Diaphragm Penis 301, 600,607. 616 — Ear - Eyes — Heart _ Intestines — Kidneys - Larynx - Liver - Lungs _ Pericardium — in Perineo — ofthe Peritoneum Pharynx ----Pleura ____Prostate Gland Spleen , Spongoid ofthe Stomach ------Testicle ------Throat -----Womb Inflammatory Fever -----A----Sore Throat Influenza Inoculation for the Cow-pox ______________- Measles ______________Plague _______-------Small-pox 193 114 842 169 169 132 118 169 172 189 763 154 176 159 169 605 194, 854 156 156 607 188 736 169 607, 611 133,154 194, 850 40 138 313, 318 253 261 283 243 468 3 172 Insanity Intermittent Fevers Intestines, Inflammation ofthe Intumescence ofthe lower Extremities in lying-in Women 844 Intumescentia?, Order 531 Intussusceptio 172,436 Inversion of the Womb 869 Involuntary Discharges of Blood, Order 290 ______________________Urine 695 __________Emissions of Semen 696 Irregular Gout 198, 20Q Ischuria 703 Ischias, or Disease ofthe Hip Joint 224,229 Ftch 778 ltchkigs in pregnant Women 824 Jaundice in Adults ----------Infants ----------pregnant Women Jaw, Locked , in Infants K Kidneys, Inflammation of *k< 670 880 825 386 S90 INDEX. 9l# PAGE Sidneys, Stone in the 189, 757 King's Evil 678 L Lactumen 884 Larynx, Inflammation of the 154 Laugh, Sardonic 386 Lepra Mercurialis 622 Leprosy 650 Leihargy 339 Leucorrhcea, how distinguished from Gonorrhoea 697 Lip, Cancer of the 725 Lithiasis 755 Liver, Acute Inflammation of the 176 ----, Chronic ditto 176 ----, Suppuration in the 179,184 Livid Colour of Infants 878 Local Diseases, Class of 680 Lochia, Immoderate Discharge of the 841 ----Suppression of the 841 Locked Jaw 386 -----------in Infants 890 Longings in pregnant Women 822 Looseness of the Bowels, or Diarrhcea 450 in Infants Loss of Appetite -----Strength Low Spirits Lues Venerea Lumbago Lungs, Abscess in the -----, Inflammation ofthe ———, Hemorrhage from the -----, Ulceration of the 889 693 350 368 596, 629, 904 224, 229 166 159 295 497 Madness M -, Canine Mai d'Estomach, or Dirt-eating Malignant Fever Sore Throat 468 121 524 58 139 Mamma?, Inflammation ofthe Female 842 Mania ' 468 Marcores, Order 493 Means for obviating Infection and de- stroying Contagion 68, 232, 272,320,868 —'-------preserving the Health of Europeans in Warm Climates 92 —--------preserving the Health of Seamen on board of Ship 660 Resuscitation in cases of suspended Animation Measles ------, Inoculation for the Meconium, Retention of the Melancholia Menorrhagia Menses, Immoderate Flow of the ------, Interruption of the ■------, Retention of the -------r S'ippression of the Menstruation Cessation of ______.______, Difficult ifnd Painful 814 256 261 880 468 302 302 710 711 716 719 719 page: Menstruation, Nuture of 710 Mercurial Course, Rules to be observ- ed during a 632 ---------Erythema 622 Mesenteric Glands,diseased State ofthe 593 Miliary Fever 284 ------Eruptions in lying-in Women 844 Milk Fever 841 Mineral Poisons 794 --------------, Tests for discovering 798 Miscarriages 830 Misplaced Gout 198 Monsters 822 Moil de Chien 448 Mortification, Inflammation termina- ting in 98, 103 -----------of the Feet and Toes 105 ----------------Buttocks and Nates 475 Mucus, how distinguished from Pus 102,502 Mumps 137 Musca? Volitanes, or Atoms floating before the Eyes 360, 364 Moschetoes, Bites of 809 N Nausea and Vomiting in pregnant Wo- men 820 Negro Cachexy 524 Nephritis 189, 763 Nervous Consumption 493 -------Fever, or Typhus 44 -------Headach ' 360, 368 Nellie Rash 289 ----------, or Essera in Children 885 Neuralgia Fascialis 749 Neuroses, Class 332 Night Blindness 680 Night Mare, or Incubus 362,491 Nipples, Excoriation and Ulceration of the 843 Nocturnal Emissions 696 Nodes, Venereal 63ft, 637 Nodosities, Gouty 197,199,205 Nose, Cancer of the 725 ----, Hemorrhage from the 291 Nostalgia 526 Nyctalopia 680 Nymphomania 591 O Obesitas, or Corpulence 531 Obstipatio, or obstinate Costiveness 701 Obstructed Perspiration 312 Obstruction in-the Bowels 436, 440 --------ofthe Menses 711, 716 --------in the Urinary Canal 601, 613,703 Odontalgia 747 tEdematousSweHin5sintheExtremities536 ________________in pregnant Women 824 Opacities ofthe Cornea 127 Ophthalmia, Common H8 __________Egyptian 119,128 __________Purulenta of Infants 120,126 __________, Scrofulous 127, 592 920 INDEX. PAGE Ophthalmia Syphylitiea 127, 630, 638 ---------Tarsi 118 Opisthotonos 386 Otitis 132 Ovaria, Dropsy of the 536, 553 Pain in the Bowels 172,436,440 .________Ear 132 ---------Head 745 ---------Stomach 352, 573 Painful Affection of the Nerves of the Face 749 Pains, After, in lying-in Women 840 ----, Gouty 194 —r—, Rheumatic 213 ——, Venereal 637 Palpitations 409 Palsy 340 Paracusis 685 Paralysis 340 Paraphymosis 600,604 Paraplegia 340 Passion, Iliac 436, 439 Pemphigus 287 Penis, Caner of the 721 ----, Hemorrhage from the 600, 607, 616 Pericarditis 169 Peristaltic Motion, Inversion ofthe 436,439 Peripneumonia Notha 168 -----------Vera 158 Perineum, Tumor in the 605 Peritoneum, Inflammation ofthe 194, 854 Pernio- 788 Pertussis 395 Pes! is 273 Phagedenic Ulcerations 621, 628,639 156 96 844 98 114 497 600,604 440 308 822 782 273 283 281 654 156 159 167 194 794 804 806 794 800 531 776 254 PAGE Pox, Co iv 247 ---, Small 231 ---, Swine 255 ---, Venereal 696, 629 Pregnancy, Diseases attendant on 819 Procidentia Uteri 869 Profluvia, Order, or Fluxes with Pyrexia 312 Prolapsus Ani 311 -----------, in Children 896 --------Uteri 869 Prostate Gland, Diseased State ofthe 607 704, 706,709, 724 Pseudo-Syphilis 626,631 Psora 778 Puerperal Convulsions 826 --------, Fever 858 --------, Mania 490 ________, Slate, Diseases of the 839 Pulmonary Consumption 497 Purging 450 ------, and Vomiting 446 Purulent Ophthalmia of Infants 120,126 Pus, how distinguished from Mucus 102,602 Putrid Fever 58 __________, Sore Throat 139 Pylorus, Scirrhosity of the 172, 351 Pyrexiae, Class 1 Pyrosis 352,401 Quartan Ague Quotidian, ditto Pharynx, Inflammation of the Phlegmasia?, Order Phlegmatia Dolens Puerperarum Phlegmon Phrenitis Phthisis Pulmonalis Phymosis Pictonum Colica Piles -.---. in Pregnant Women Pimpled Face plague -----, Inoculation for the ----, Mode of Preventing the Plica Polonica Pleuritis Pneumonia --------, Typhodes Pod.)t;ra Poisons in General -, Aerial Q R Rabies Rachitis Rash, Nettle Rashes in Infants Rattle Snake, Bite ofthe Regular Gout Repelled ditto Remittent Fever -, of Infants —, Animal ______, Mineral ______, Vegetable Polysaivhia Porrigo Pox- C'-'ikcn 421 571 269 884 606 196 196 20 892 Resolution, Inflammation terminating in 98, 99 Restlessness in Pregnant Women 824 Resuscitation, Means for 814 Retention ofthe Meconium in Infants 880 .------------, Menses 711 Retrocedent Gout 198,210 Retroverted Uterus 823, 809 Rheumatism 213 Rickets 571 Ring Worms 781 Risus Sardonicus 386 Rose, or St. Anthony s Fire 97, 108 Rubeola 256 Rules for avoiding infection aud destroy- ing Contagion 68, 232, 27:2, 320, 86S RuIps to be observed by Europeans in Warm Climates for the Prevention of Diseases 92 Rules to be observed during a Mercu- rial Course €32 INDEX'. 921 Rules for keeping Seamen Healthy on Board of Ships, aud for preventing the Scurvy and other Diseases 660 St. Anthony's Fire 97, 108 St. Vitus's Dance 383 Sanguineous Apoplexy 333 Salivation, how to avoid 621 ----------------promote 632 --------, Rules to be observed during a 632 Sarcoma, Medullary 736 Sardonic Laugh 386 Scalled Head 775 Scalds and Burns 769 Scarlet Fever 262 ----------, Means for preventing the Contagion of the 272 Sciatica 224, 229 Scirrhus 99, 720 -------of the Bladder 193 ------------Female Breast 720, 726 ------------ Liver 179 ------------Prostate Gland 607,704,724 ------------Pylorus 172, 351 ------------Spleen 15, 188 ------------Testicle 724 ------------Womb 723, 853 Scorbutic Eruptions 670 Scorpions, Bite of 809 Scrofula 578 Scrotum, Cancer of the 720, 724, 730, 735 Scurvy 657 -----, Mode of preventing the 660 Semen, Nocturnal Emissions ofthe 696 Serous Apoplexy 333 Serpents, Bites of Venomous 806 Shingles 110 Sibbens 640 Sight, Dimness of 681 Simple Continued Fever 26 Singultus 394 Small-pox 231 --------, Inoculation for the 243 Snake, Bite of the Rjattle 806 Snakes, Bite of other 806 Sphacelus 98, 103, 105 ^pongoid Inflammation 736 Spine, Diseased 341, 346, 592 Spasmi, Order 368 Spasmodic Colic 440 Spitting of Blood 295 Spleen, Scirrhosity ofthe 15, 188 Splenitis 188 Sprains 754 Sore Throat, Inflammatory 133, 154 ----------, Putrid 139 Spurious Peripneumony 158 Squinting *®4 Stomach, Inflammation of the 169 --------, Pain in the 352,753 --------, Cramp or Spasms in the 373 --------, Gout in the 198 101 ------------in the Liver 179, 184 ------------------Spleen 189 Suppression of the Lochia 841 -------------— Menses 716 ---------------- Urine by Gravel 703,755 ----------------------Inflammation 703 ----------------------Spasm 617, 703 •Stricture 601,613 Stones, Urinary Strabismus Strangulated Hernia Strangury Strictures in the Urethra Styes on the Eye-lida in pregnant Women 823 Suspended Animation Sweating, Immoderate Swelling of the Lower Extremities in Lying-in Women ------------— Lower Extremities in pregnant women ----— in Perineo Swine-pox Syncope --------Anginosa Synocha Synochus --------Biliosa 814 694 844 Syphilis of Infants Pseudo 824 605 255 349 495 40 26 3 596, 629 904 625 Tabes 493,593 Taenia, or Tape Worm 790 Teething 898 Tenesmn 320 Teres 789 Tertian Ague 4 Testicle, Inflammation and Swelling of the ' 600, 607,611 ------, Scirrhus of the 724 Tests for Discovering the Presence of Arsenic in supposed Cases of Poison 798 386 744 133, 154 139, 630> 627 894 749 775 725, 734 747 821 654 386 749 890 720 533 58 Tetanus Tetters Throat, Inflammation ofthe ------, Ulceration ofthe Thrush, Chronic ------in Infants Tic Douloureux Tinea Capitis Tongue, Cancer ofthe Toothach --------in pregnant Women Trichoma Trismus ------Dolorificus .------Nascentium Tumores, Order Tympanites Typhus Gravior 922 INDEX. Typhus Icterodes -----Mitior page 71 44 U Vertigo Vesaniae, Order Vesicular Eruption Viper, Bite ofthe Vision, Defective Vitus's, St., Dance of Vomiting of Blood -------in pregnant Women -------and Purging -------in Infants Ulcerated Sore Throat 139 -------■ Prostate Gland 607, 704,710 Ulcerations in Tnfants 881 ————, Venereal, of the Tonsils and Uvula 630 --------, Carcinomatous 720 --------, Phagedenic 621,628, 639 Voracious Appetite Ulcers, Obstinate 765 Urethra, Strictures in the 601,613 Urinary Calculi 755 Urine, Bloody 301 ----, Difficulty in Voiding 703 .---, Involuntary Flow of 695,825 ----, Muco-Purulent 192, 193, 302, 600, 606 ----, Scalding in Making 600 ----, Suppression of, by Gravel 703, 755 — ■ ■-------------- Inflammation 703 ------Spasm 617, 703,708 289 VA6T. 350 468 287 806, 808 680 383 299 820 446 888 689 W Urticaria Uterinus Furor 691 Uterus, Cancer of the 723 -----, Dropsy of the 636, 555 ----, Falling of the 869 ----, Hemorrhage from the 830 ----, Inflammation of the 194, 850 ——, Retroversion ofthe 869 ——, Rupture of the 851 ----, Scirrhosity of the 723 Walcheren Fever 19 Warts, Venereal 613,638 Wasps, Bites of 809 Wasting ofthe Body, or Atrophy 493 Water Brash 352, 401 ----in the Belly 536, 549 ---------Cellular Membrane 637 --------- Chest 536, 563 ---------Head 536, 555 ---------Ovaria 536, 553 ---------Serotum 636, 554 ---------Womb 536, 553 Weakness, Chronic 350 Weaning-Brash 897 Whites " 697 -, how distinguished from Gonor Varicella 254 Varicose Veins in pregnant Women 825 Variola 231 -----, Variola? Vaccina? 247 Worms Vegetable Poisons 800 Venereal Disease 596 --------------in Infants 904 Venery, Uncommon Desire for, in Wo- men 691 Vermes 789 Verruca? Syphilitica? 613, 638 Vertebra?, Diseased 341, 346,692 rhcea Whooping Cough Womb, Cancer ofthe -----, Dropsy ofthe ----->■, Falling ofthe -----, Inflammation ofthe -----, Inversion of the ---, Rupture of the Scirrhosity of the , Guinea , Ring 602 395 723 536, 553 869 194, 850 869 851 723, 853 789 743 781 Yaws 642 Yellow Fever 71 ----------, Means for preventing the 92 -----Gum in Infants 880 APPENDIX: BY DAVID HOSACK, M. D. «=»•#©#•»- Observations on Fever* From the earliest period to the present day, the subject of fever, more than any other disease to which the human frame is liable, has received the attention of physicians. Yet, looking in our obituaries, we find that fever and febrile diseases still constitute the great outlets to human life, and are at this day almost as fatal as they were in the time of Sy- denham, who calculated that fevers, properly so called, make up nearly two-thirds of the diseases which prove fatal (o mankind, and that eight out of nine of all who die are cut off by febrile complaints. However minutely, therefore, we may be acquainted with the symptoms of fever iu its various forms and stages ; however extensive may be our knowledge of its predisposing and exciting causes, wfe certainly are very deficient in our acquaintance with the proximate cause of fever, or its treatment would be mere distinctly defined in its various stages, than it appears to be in any of the great practical works that have fallen under our notice. Whence, then, has arisen the discordant, and, we may almost say, the em- pirical practice, that fills the pages of the best writers on fevers, and that is even to be found in the truly valuable works of Boerhaave, Cullen, Fordyce, Wilson, and others ? We answer; it is in a great degree ascri- babletothe local views of the animal economy to which some of those writers have been limited by their own hypotheses, and which practition- ers, relying upon tbe authority of great names, have hastily adopted. i Boerhaave's exclusive attention to the humoral pathology gave him ne- cessarily but a limited and partial view of the nature of fever, and its operations upon the various parts of the animal economy; he, conse- quently, neglected all those indications in the treatment, that a more extensive view of the nervous system, as taken by Hoffman and Cullen, would have pointed out. But bis successor Cullen, on the other hand, by avoiding Scylla ran on Charybdis. The nervous system, according to his view, had been too much neglected; but in restoring it to its merited notice, he again, in a great degree, lost sight of all the olher parts ofthe human frame, pronouncing the humoral pathology in particular a creation ofthe imagination, and, in xU application to practice, altogether hypo- thetical.* The still more recent writings of Brown, Beddoes, Darwin, Girtanner, Clutterbuck, Rush, and others, have been too successful in spreading these partial views of the human siructure, and, consequently, limited pathology of the diseases to which it is liable. Even the learned and elaborate work of Wilson is calculated to diffuse the tsame erroneous d<5^ ^ee preface to his First Lines 924 APPENDIX. trines ; nor is the more independent and philosophical Fordyce altogether exempt from this chaige, although he professes to be totally guided by facts, regardless of hypotheses. Fever, in the opinion of the writer of these remarks, is a disease of the whole system ; it appears no less in all the faculties of the mind than in all the functions of the body ; it shows itself in every organ of our frame, and affects every nerve and fibre of the system; the absorbing, the circulating, and excreting systems of ves- sels, are all affected by it ; it shows itself in all the various fluids ofthe body as well as in the solids; in a word, it is omnipresent; it has no one pathognomonic symptom, but is constituted by a concourse of symptoms,, and these variously combined hi the various forms that fever assumes, de- pending upon the causes whence it proceeds, and the condition of body in which it occurs. If this view of the subject be correct, it will necessarily lead the physician to more extensive principles of practice ; it will lead him, at the bed-side of the patient, to pay due regard to the ner- vous system, the phenomena it exhibits, and the indications thence arising : but at the same time it will lead him to notice the changes which may be induced in the secretions and excretions, and the circulating mass from whence they proceed. We offer these remarks for the purpose of calling the attention of the reader to the too long neglected pathology of the fluids ;* at the same time that we invite the attention of the practitioner to some points of practice, not in our opinion sufficiently attended to in the treatment of fevers. The recent experiments of Sir Everard Home, relative to the operation of medicines upon the body, through the medium of the fluids—the com- munication of diseases from one animal to another, by the transfusion of the fluids, as lately performed by Mr. Coleman, at the veterinary school of London ; the transmission of diseases from the mother to the foetus inutero ; the analyses of the fluids, both circulating and secreted; the chemical examination of the products of the body as occurring in various diseases, have recently, both in Europe and America, directed the attention of phy- sicians to this neglected part of the human pathology. It is proper here to remark, that, when speaking of fevers, we have in view the continued type of fevers properly so called, not referring to the phlegmasia? or other pyrexious diseases ; yet, in many instances, the prin- ciples we wish to inculcate, and the practical deductions thence arising, will be no less applicable in the typhoid state of many of the phlegmasia; and other febrile diseases, than they are to the advanced stage of typhus fever itself. It will be acknowledged, that fever caunot long continue without in- ducing debility in the heart and arteries, in common with all the other parts of the system, and that the sensibility to impressions must be pro- portionally increased. They are, consequently, predisposed to be more readily acted upon even by the natural stimuli of the system ; the heart and vessels are accordingly excited to preternatural frequency, even ope- rated upon by the blood and other fluids of the system in their natural and healthy condition, as we see daily illustrated in the progress of all fevers, and in convalescence from fever: We contend that fever, long * See Dyckman, mi Ihe Pathology of the Guids, and the Review ofthe same Disser- tation in the Amer. Med. and Phil. Reg. vol. 4. Sec also Professor Cooper's Introduc- tory Lecture, delivered in the University of Pennsylvania, in 1818. APPENDIX. 925 continued, not only wastes the power of the solids, rendering them more irritable, but by the derangement in the functions and excretions, per- haps by the action of the blood-vessels themselves upon their contents, and especially by the retention of those materials which should have been thrown out of the system as noxious, which in health are constantly ejected, the circulating fluids become changed and vitiated, and thereby become additional sources of irritation to the heart and arteries, whose susceptibility of impression, as we have just observed, is also morbidly increased. From this view of the more irritable state of the circulating system, and the vitiated condition of the fluids, we infer, that unless by some salutary power inherent in the system itself, or by some means sug- gested by art, the greater irritability of the whole system, and of the heart and arteries in particular, be diminished, or the morbid changes induced in the fluids they circulate, be counteracted, these causes of fever, mutu- ally operating upon each other, must increase, and fever be continued un- til the vital principle itself be totally expended. How far, then, we ask, is the attention of physicians directed to these two cardinal objects, in the treatment ofthe advanced stage of fevers ? how far is their practice cal- culated either to impart vigour to the system, and thereby to lessen the morbid sensibility of the nervous and moving fibre, or to counteract the septic tendency of the circulating fluids which obtains in most fevers of the continued type ? Are we not hereby led to condemn that indiscriminate and loug continued use of the debilitating evacuants, usually prescribed at this advanced period of fevers and febrile diseases, in as far as they are calculated to add to that waste of excitement, and that very vitiation, to which we have referred ? Is not the abstinence, too, usually enjoined by physicians in the typhoid stage of fever, for the same reasons, no less to be reprobated ? Are we not led, upon the same principle, to condemn the prescription of camphor, musk, opium, digitalis, and other powerful sedatives, so frequently directed in this stage of fever ? We refer to the ordinary mode and quantity in which these narcotics are administered in fevers, by the greater part of practitioners ; and who, forsooth, by a strange misnomer, denominate them stimulants I* The indiscriminate practice of purging, as advised in typhus fevers by Dr. Hamilton,! of Edinburgh, is, in our opinion, no less dangerous by the debility it Induces, and is not prescribed with sufficient caution by that distinguished practitioner, for whose opinions and practice, on most occasions, we entertain, and beg leave to express, our highest respect. E\en the long continued exhibition of the various preparations of mer- cury and antimony, is, in the opinion of the writer, a no less dangerous and fatal practice in this advanced stage of fever. On the contrary, if the views we have taken be correct, after the indications which arise iu the first stage of continued fevers have been fulfilled, in the means of ac- complishing which most physicians are agreed ; after the necessary evacua- tions by the lancet and other depleting means have been made, which arc- frequently called for, both in the invasion and in the progress of fever ; after the stomach and bowels have been cleansed, and due attention has * For the evidence ofthe sedative effects of opium, see Dr. Bard's Inaugural Disserta- tion Edinburgh, 1765 ; Monroe's Experiments on opium : see also tin- late important ob- servations of Orfilaon Poisons. t See his valuable work on the use of Purgatives 936 APPENDIX- been paid to the no less important function performed by the skin, our atten- tion should next be given to the two fol lowing objects, and which the prac- titioner should never lose sight of when the typhoid state of fever has ac- tually arrived : 1st- To preserve the natural powers of the system, and carefully to guard against every further waste of excitement; 2dly. By suitable antiseptic nourishment, and other means, including external ap- plications as well as internal remedies, to preserve the circulating fluids from those morbid changes to which they constantly and rapidly tend in all fevers of the continued type, especially in those arising from contagion, which, in a peculiar manner, depresses and exhausts the vital powers. I'i this advanced or typhoid state of fever, characterized by a disturbed state of the brain and nervous system, showing itself in delirium, watchful- ness, or irregular and interrupted sleep, frequent sighing and subsultus tendinum ; attended with an increased but feeble circulation, hurried and irregular respiration, with its usual consequences and increased heat of the body and dryness of the surface ; characterized also, by a deranged state ofthe secretions and excretions, exhibiting themselves in an offen- sive breath, turbid urine, frothy and offensive discharges from the bowels, a foul sordes about the teeth and gums, discoloured lips, and a brown or a black state ofthe tongue ; and, perhaps, added to these, a cadaverous and offensive smell of the whole body; in this condition of the system, fhe means of fulfilling the indications before mentioned, are, 1st, To supply the patient with the most powerful stimuli both diffusible and permanent; viz. the volatile alkali, aether, wine,* wine whey, porter, vest, bark, Vir- ginia snake-root, bitters, and the mineral acids, preferring each or either of these according to the peculiar circumstances of the case. We are aware that this practice is reprobated by many physicians as improper in this state of excitement, whatever may be the stage of the disease, or the circumstances that may have induced it. This leads us to observe that many physicians are not sufficiently attentive to discriminate between the simple excitement of the early stages of fever, which is characterized by the symptoms of inflammatory action and is kept up by considerable vigour ofthe system ; and the complicated excitement, which appears when the powers of life are greatly exhausted, and the disease has been long protracted. A corresponding want of discrimination appears in their practice; they, therefore, condemn in the last stage those means of ex- citement which are injurious in the first ; and they approve in the last the continuance of the same depleting and debilitating means that have been found useful in the first : what! say they, administer ivine, bitters, or bark in this quickened circulation attended with a hot and dry skin ? We an- swer, that in such'typhoid state of body, in this exhausted state ofthe vi- tal powers, the remedies that have been enumerated are among the most effectual means of reducing that very heat of skin, and of diminishing that increased excitement of the whole system, which, as we have before remarked, are frequently ascribable to the morbid sensibility of the heart and vessels to their vitiated contents ; and that this sensi- bility being counteracted, the circulation is necessarily reduced in fre- quency, the respiration becomes less hurried^ and that the heat of the * The reader will find some pertinent practical remarks on the quantity of wine which may be safely and advantageously administered in this stage and character of fever, \p Moore's Med. Sketches, p. 13, 509, 517, &.c APPENDIX. 92? system, which is ever in proportion to the circulation and rapidity of res- piration, is, consequently diminished. But, 2dly, We should be no less attentive to the state of the fluids than we are to counteract the morbid excitement of the solids: with this view, attention should be daily given to the bowels for the purpose of evacuating their offensive contents, especially of the lower tract of the intestinal canal; for these malcontents being retained, not only in some instances become the sources of irritation to the intestines themselves, pro- ducing diarrhcea, but by their return into the mass of circulating fluids, which are thus rendered still more malignant, they necessarily consti- tute fresh sources of febrile excitement. Evacuations from the bowels, however, are not to be obtained at that expense of the powers of the whole system, which the means recommended by Dr. Hamilton are cal- culated to produce ; on the contrary, at this advanced period of fever, we should just as readily think of putting a lancet into the patient's arm as emptying his bowels by the active purges he has directed : these, too, with other means of depletion as far as they may have been indicated, it is presumed have been already attended to in the first stage of the disease. Enemata, or at most, the occasional use of small doses of rhu- barb and magnesia, or some other mild aperient, are only, in our opinion, admissable at this period of the disease. For the united purposes of pre- serving the surface in a perspirable state, of diminishing its temperature when excessive, and of removing the offensive materials which are ex- creted by the skin and constantly accumulated upon it, the body should be regularly cleansed once or twice in the day, by ablutions of vinegar and water,"which should be applied either tepid or cold, according to the temperature of the body ;* and should the skin remain dry, after such ablutions have been made, fomentations of vinegar and water applied to the extremities, and steadily persisted in, are among the most effectual means of relaxing the surface, at the same time that they are calculated to allay much of that distressing restlessness which attends this stage of the disease. Upon the same principle of correcting the state of the fluids, the nourishments directed should be exclusively of the vegetable kind, as best calculated to resist that putrescent tendency which manifests itself in this state of body ; for this purpose, arrow-root, sago, tapioca, Indian or oat-meal gruel, rendered palatable by the plentiful addition of wine, and some of the most grateful aromatics, should be hourly adminis- tered in this exhausted state of the system. The bedding and the dress of the patient, especially if he wears flannel next the skin, which is the preferable clothing in this form of fever, should also be frequently re- newed. For the purpose of controlling that restlessness which usually appears in the evening exacerbation, and of procuring sleep, an occasional anodyne may, in many instances, be administered with the most benefi- cial effects : but the indiscriminate use of opium or laudanum, through- out the day, and through the whole progress of the fever, with the view to their supposed stimulant effects, cannot be too severely reprobated ; nor have we ever witnessed the stimulant and salutary effects ascribed to the fashionable catnphorated julep, and other preparations of camphor so often had recourse to; but we can indeed say, that, we have in very man> instances, witnessed its debilitating, and, as we bel.eve, its fatal effects, in » See Currie and Jackson on cold bathing in fevers. 'SM APPENDIX. the typhoid state of fever. Such is the practice the author of these re- marks has pursued, for many years past, in the typhus fever of this city, the typhoid stage of dysentery scarlatina, peripneumonia typhodes, and in other febrile diseases ; and he can bear the most unequivocal testimony in favour of its safety and success. The following extract from a report made to the governors of the New- York Hospital, Sept. 1st, 1819; giving a statement of the diseases of that institution, and of the treatment adopted, affords additional evidence of the validity of these opinions. " During the period of my attendance, an ample opportunity has been afforded to the students, resorting to the hospital for instruction, of ob- serving the typhus form of fever, which has been unusually prevalent in this city during the last three months, and of noticing the characteristic symptoms of that type of fever as totally distinct from the yellow fever with which it has been indemnified by many physicians under the general and fashionable appellation of malignant fever. The students have also wit- nessed the successful use of bloodletting and other evacuations in the first stage, and of yest, porter, snakeroot, the vegetable acids, vegetable nour- ishments, and frequent ablution with tepid vinegar and water in the more advanced stage of that disease, instead of the mercurial treatment so generally practised in many parts of the world, and especially in the United States. Indeed, 1 believe, that the typhus fever of our country owes much of its malignity to the indiscriminate use of mercury. I say its indiscriminate use, for in some cases of fever, and in many other diseases it is the physician's only resource. Even in typhus fever under some peculiar circumstances it has been prescribed with infinite benefit. " Ofthe seventy-six cases of fever (of which forty were cases of typhus attended in many instances with symptoms of the highest malignancy seventy-four have been cured by the means before enumerated, without the prescription of a particle of mercury. Dysentery in like manner was treated by bloodletting, blisters, emetics, and saline cathartics, and a vegetable diet, instead of the customary treatment by calomel. Of twen- ty-one patients ill of this disease all recovered or were convalescent at the time I ceased to prescribe. Another observation I have frequently made, and which has been verified in the cases, that have recently occurred in the hospital is, that those who are cured without mercury, recover in a much shorter time, than those who are treated by the usual mercurial course. This is not all,—they not only have a shorter convalescence, but they recover without that injury to the constitution, and that liability to rheu- matism and other inflammatory diseases that we frequently observe in those who have undergone the operation of mercury." Peripneumonia Typhodes. .Notwithstanding what has been thus advanced relative to the treatment of fevers of the typhoid character in general, I am induced to offer a few additional remarks on that peculiar mixed type of disease, which has appeared in various districts of the United States, but more particularly m the eastern and middle sections of the Union : and, which under the ."fferent names of malignant pleurisy, petechial or spotted fever, bilious APPENDIX* 929, tpidemic fevtr, bilious pneumonia, Src. has given origin to such discor- dancy of opinions as to its nature, and which disorder, wherever it has prevailed, has been accompanied by a most alarming mortality. The name peripneumonia typhodes, seems to me to convey a more accurate idea of its character than any other appellation by which it has been de- signated, and I shall accordingly notice it under that denomination. This disease is not a " new calamity" an " unknown epidemic" as it has been represented by some writers : On the contrary, it has been well described by Sauvages,* Huxham,and others : by the former, under the very appropriate appellation of peripneumonia typhodes. Nor is this a new disease in the United States: In the first volume of the American Medical and Philosophical Register, tbe late Dr. John Bard, of this city, has given an account of a disorder which prevailed on Long- Island, in the winter of 1749, and which in its essential symptoms, corresponds with the epidemic lately prevalent in this state^. Dr. Bard has termed the complaint the " malignant pleurisy." In the second volume of the Medical Repository (first series) the same disease is noticed by Dr. Hugh Williamson, as it prevailed in North Carolina, in the year 1792. In the southern states, it is commonly called "pleurisy in the head," in conse- quence of the violent pain in the head, which frequently attends the dis- ease in that climate. Malignant Pleurisy, or rather typhus peripneumo- nia, well expresses the mixed character of this disease; for at the same time that it is attended with inflammation of the lungs, and in some in- stances with inflammation of the brain, the general affection of the whole system is certainly that of typhusfever. That inflammation of the lungs frequently constitutes a part of the disease is manifest, not only from the presence of those symptoms usually attendant upon pneumonic inflammation, viz. cough, pain in the chest, especially upon taking a full inspiration, expectoration tinged with blood in the early stage of tbe complaint ; but it is also evident from the phe- nomena presented upon an examination of the body after death : the overloaded state of the vessels of the lungs, the large effusion of serum, and sometimes purulent matter, the adhesions found between the mem- branes covering the lungs, and those lining the chest, all clearly show that the patient has been destroyed by such inflammation.t In like man- ner, in some cases, the whole force of the disease is vented upon the brain, producing similar phenomena in that organ ; on the other hand, the usual symptoms of a putrescent state of body, the petechia?, blotches, hemorrhagies in the latter stage ofthe disease, the offensive state of the excretions in general, and great prostration of the powers of life, which rapidly ensues, no less declare the enfeebled and vitiated state of the whole habit. There are therefore two opposite conditions of body to contend with ; local inflammation on the one hand, and a typhoid state ofthe whole system on the other. The causes of the disease are no less- compounded than the disease itself. The local inflammatory affections are probably occasioned by the sensible changes of the atmosphere, while the typhoid character of the disease is derived from an epidemic consti- tu of the air, the same which has given rise to the typhus petechialis, or * See Nosologia Methodica, vol. I. t See Report of the Mass. Med. Society, and Dr. Hudson's letter on the prevailing epi demic ; see also Dr. Low's account of this disease, as it lately prevailed in Albany- American Medical and Philosophical Register, vol. 4. 930 APPENDIX'. spotted fever, wuich has prevailed for some time past in our northern and eastern states, and which is doubtless a similar disease, with the ex- ception, that the peripneumonic epidemic is complicated with the symptoms of local inflammation of the chest, brain, throat, &c. the effect ot cold at the season of the year when it prevails With this view ©f the mixed nature of the disease, and of the combined causes which have produced it, we are prepared to expect, the various and opposite opinions and modes of practice, which have been adopted by different physicians. We ac- cordingly find some prescribing the strict antiphlogistic treatment by large and repeated blood letting, active cathartics, and other depleting remedies, treating the disease as purely inflammatory. On the other hand, we find another class of practitioners, pursuing the opposite course of exciting the system by the most powerful and diffusible stimuli, to counteract the putrescent state of body; alledging, that it is exclusively a putrid disease, and only to be controlled by antiseptics, and the avoid- ance of all those means which are calculated to debilitate the system. As far as I have seen tbe disease, they are both wrong; the indiscrimi- nate use of the lancet recommended by some, is, in my opinion, an ad- ditional source of the mortality of the disease. On the other hand, the practice of administering brandy and other ardent spirits, in the quantity they have been lately prescribed, is truly ad- ding fuel to the flame that is already consuming the patient, and cannot be justified, either by principle or practice. But the prudent physician will avoid both these extremes. In the young and athletic, he will prevent the brain from being inundated with blood, by tbe early and judicious use of the lancet, blisters, and other means usually prescribed for diminishing inflammation ; keeping in view, the age, strength, constitution of his pa- tient, and the general symptoms indicating a putrescent state of the sys- tem. On the contrary, in feeble old age, in the habit d/bilitated by dis- ease, or intemperance, in which those inflammatory symptoms are less violent, and the tendency to putrefaction is most predominant, he will depend chiefly on those means usually resorted to, for the purpose of pro- moting the perspiration, and other excretions at the same time, that, by suitable antiseptic drinks and nourishment, he will guard against that de- bility, which so rapidly ensues in this condition of the system. He will in such cases, of course, carefully abstain from'or cautiously make use of blood-letting and otlier depleting remedies. But he will certainly not effect the first purpose, by the excessive use of brandy and ardent spirits. So far from promoting the excretions of the system, they actually restrain those very evacuations which it should be our object to promote, and by which alone, we are enabled to counteract the typhoid state of body, in this, or any other febrile disease. As a substitute, therefore, for this stimulant mode of treatment in those cases where this typhoid tendency prevails, and we are forbidden the use ofthe lancet and other depleting remedies, or where the symptoms of lo- cal inflammation are so mild that they are not indicated, let me recom- mend after emptying the bowels by an enema, or mild purgative, to make free use of the warm bath, fomentations of vinegar and waler to the ex- tremists, the liberal use of the infusion of snake-root, the eupatorium, and wine whey in very debilitated habits, or where the powers of life are much reduced, in order thereby to procure a plentiful perspiration. By •Jns evacuation we not only counteract the general typhoid state of the APPENDIX. SSI system, but we at the same time diminish, and in some cases, totally re- move the local irritation, which affects the lungs or other organs involved in the disease. 1 For further information on the subject of the pneumonia typhodes, see the luminous Report of the Massachusetts Medical Society, an abstract of which may be found in the American Medical and Philosophical Re- gister, vol 1. Dr. Low's account of the Epidemic in vol. 4. of the same work, and the Report of the Saratoga County Medical Society. Observations on Contagion. Communicated in a Letter to Dr. Colin Chisholm, of [Clifton) England i dated New-York, July 16, 1808. Dear Sir, Agreeably to my promise in a former communication, I shall now state to you the result of my observations on contagion, a subject which has created so much dispute in the medical world, and which divides our profession in the western as well as in the eastern hemisphere. As far as I have examined this subject, it appears to tne to be more a dispute about words than facts. The abuse ofthe terms contagion and infection, an i the neglect of writers in not annexing to them a precise definition of the manner in which they severally employ them, have, I believe, been the source of our medical warfare, relative to the contagiousness of yel- low fever, and some other diseases : e. g. the greater number of medical writers enumerate, in the list of contagious diseases, all those which are in any way commuHicable from one person to another, whether by con- tact, fomites, atmosphere, 8fc. without designating the circumstances attend- ing these several modes of communication. Lind, in his papers on contagion and infection, (which he considers as synonymous terms,) is guilty of this error, in which he has been followed by most writers upon the subject of fever, &c. The late Dr. R. Bayley, in his account ofthe yellow fever which prevailed in New-York in 1795, pro- posed a distinction between contagious and infectious diseases. He made use of the first term to denote such as are communicated under any cir- cumstances of atmosphere, whether pure or impure, as small pox, measles, &c. Infectious diseases he denominafed those which ate com- municated in consequence of an impure or vitiated state of the atmos- phere; i. e. that the impurities of the atmosphere communicate the disease, not that the air contains any specific material derived from the patient, except such as may be occasioned by the want of cleanliness. This distinction, proposed by Dr. Bayley, is, in my opinion, an approach nearer the truth than any of his predecessors have advanced, but it does not pre- sent us with a view of the wlwle truth, upon the subject. The visitor or attendant contracts disease from one of two sources, either from the filth of the sick room, or from a specific something issuing from the body of the sick, the consequence of the peculiar disease under which he labours. If a person visiting another ill of the yellow fever or plague, derives his disease from the impure atmosphere of the apartment, I ask how it hap- pens that in all instances he contracts the same disease with that of the person whom he visits ? Why is his disorder not an intermittent, a remit- 032 APPENDIX. tent, jail fever, or dysentery, which are considered the usual produce of filth ? If he derives any thing specific from the sick, his disease is then assuredly not to be considered as occasioned by the atmosphere, but de- pending on the peculiar condition of the fluids, or state of the system, induced by the action of a specific poison ; in other words, it is to be considered a contagious disease. The distinction proposed by Dr. Bay- ley, inasmuch as it docs not account for the communication of the pecu- liar firm of fewer or disease which is thus propagated, 1, therefore, con- sider to be insufficient to account for the circumstances attending the communication of those diseases to which it is applied. That I may not be misunderstood, I will suppose A to be ill of dysentery, a disease well known to be attended with a peculiar train of symptoms ; he is in a small, confined apartment, his person is neglected, the atmosphere around him is rendered impure and offensive ; under these circumstances B visits him, and a few days after is also taken sick with the same disease, attend- ed in all respects with the same dangerous symptoms which characterize the disorder of A. Dr. Bayley, and those who adopt the doctrine of in- fection as opposed to contagion, consider the disease of B to proceed from the impurities of the chamber, and not from any thing peculiar ema- nating or secreted from the body of A. But as we may, without hazard, visit an equally filthy chamber where C lies ill of cholera morbus, or D with a broken limb, I therefore ascribe the disease of B to something more than the impure air of the chamber of A. I ascribe it to a. peculiar virus generated in his system by the disease under which he labours, and communicated by his excretions to the surrounding atmosphere, render- ing it thus capable of producing the same disease in those who may be exposed to its influence. The communication of this virus from the sick to the well, in whatever form it may be conveyed, as uniformly produces the same disease as ino- culation excites the small pox, or vaccination conveys the vaccine virus. So far, then, there is something in common in the communication of con- tagious or infectious diseases, which should be accordingly expressed in the language we employ—some of those diseases are conveyed in one form, others in a different; we should then be equally careful to mark those circumstances in which they differ, as well as those which they possess in common. Such an arrangement appears to me not only practicable, but, at the same time, calculated, in some degree, to harmonize the differences of opinion which now separate the contaaiionists and non contagionists. Under these impressions, I propose to arrange those diseases which are communicable from one to another under three heads. First, those which are communicated exclusively by contact. In this class I enumerate The iich, Syphilis, The Sibbens of Scotland, The Laanda of Africa, Framboesia, or Yaws, Elephantiasis, or Leprosy, Hydrophobia, and The Vaccine virus. Neither of those diseases can be communicated in any other way than by zontact; they are, therefore, contagious diseases, in the strict etymological APPENDIX. 93$ sense of the term. It is also to be remarked, that these diseases are never conveyed through the medium of the atmosphere ; actual contact alone can communicate them from one person to another. These diseases, acknowledged by all to be contagious, and so denomi- nated by all writers, have a law of communication peculiar to themselves. But there is a second class of diseases also considered as contagious, which are communicated under different circumstances, governed, in this respect, by different laws of communication. Those to which I now allude are such as are communicated both by contact and by the atmosphere. In this class I arrange Small pox, Measles, Chicken pox, Hooping cough, Scarlet fever, and Cynanche maligna. Contact, or the close approach to the sick, labouring under these dis- eases, will communicate them to those who are susceptible of their in- fluence—but they are no less communicable through the medium of ihe atmosphere. A second law, which governs the communication of this class of contagious diseases, is, that they are communicable in every season, in the heat of summer, as well as in the cold of winter—in a pure as well as in an impure air, though more readily by the latter than fhe former. A third law of communication in this class of diseases, is, that the persons afflicted with them are not generally susceptible of a second attack. I say gnerally, because exceptions are related upon very res- pectable authority. This second class of contagious diseases is, therefore, abundantly dis- tinguished from the first; but they are still associated by most medical writers under the same head of contagious diseases, without assigning to each class its discriminating characters. The same want of discrimination has, in my opinion, occasioned the numerous disputes among physicians relative to the contagiousness and non-contagiousness of those fevers which I enumerate as the third class of diseases that are communicable from one person to another. Under this head I arrange Plague, Yellow.fever, Typhus, jail, ship, hospital, or lalce fever, and Dysentery. These diseases are only, in general, communicable through the medium of an impure atmosphere: in a pure air, in large and well ventilated apartments, when the dress of the patient is frequently changed, all ex- cretpentitious discharges immediately removed, and attention paid to cleanliness in general, these diseases are not communicated, or very rarely so from one to another. But in an impure air, rendered so by the de- composition of animal and vegetable substances, as takes place in low marshy countries, or by concentrated human effluvia, as in camps, jails, hospitals, or on-shipboard, they are rendered not only extremely malig- nant and mortal in themselves, but become communicable to others who approach the sick, or breathe the same atmosphere, which has become assimilated to the poison introduced, insomuch that the same specific dis- 034 APPENDIX. za»c is communicated, whether it be the plague, yellow fever, typhus, oV dysentery. Hence we account for the fact stated by Sydenham and other writers on epidenjics, that the prevailing disease swallows up all other disorders, 2. e. that during the prevalence of an epidemic plague, typhus, dysentery, or other diseases of this class, every indisposition of a febrile sort readily assumes the character of the prevailing disorder. We know this to be ex- perienced in the diseases of other countries, and we see it daily exem- plified in our own : both in our cities and in the country towns, when, after Heavy showers of rain, and the action of a hot sun, a decomposi- tion of vegetable and animal substances takes place, and dysentery or typhus fever is produced, it assimilates the air to itself, whatever may be the acting poison. But under other circumstances of weather and sea- son the disease thus originating from some local circumstances, or from a peculiar habit of body in the person so affected, does uot extend beyond the family in which it first occurred, or, perhaps, the individual in whom it originated. This class of diseases, therefore, like the former, has a law peculiar to itself* i. e. the diseases composing it are communicable, or otherwise, de- pending upon the condition of atmosphere in which they occur or are in- troduced—whereas those of the second class are conveyed from person to person, through a pure as well as an impure medium : but they also are rendered more virulent and malignant in an atmosphere charged with miasmata, than in that which is free from such ingredients. It is also, I believe, generally true of the diseases of the third class, not perhaps excepting the plague and yellow fever, that they may be taken a second time. This has been advanced by the advocates for the domestic origin of yellow fever, as an argument against the contagiousness of this disease. But, upon the same principle, they must deny the contagiousness of all those disorders which I have enumerated in thefirst class, as itch, sy- philis, &c. for most of them are also to be taken a second time; yet they are acknowledged by all to be contagious diseases. In the same manner, many persons make the small pox a standard, and conclude that yellow fever is not contagious, because it is not communicated under the same circumstances of atmosphere and season, and governed by the same laws with that disease. They might with the same propriety conclude, that the scarlet fever is not contagious, because it is not attended with the pustules of small pox. This teaclies us the importance of correct language to convey the seve- ral degrees Of contagion which have been noticed; and that, while we may make use of the terms now in use, we should annex to them such explanations as will convey those different laws of communication which have been enumerated. With those precautions in the use of the lan- "•uape we employ, I believe, the contagionists and non-contagionists will find themselves very much in the situation of those theologians of whom Pascal speaks, and ready to adopt the expression of one of them, when he obswves, c< La difference qui est entre nous est si subtile, qu'a peine pouvons nous la marquev nous nieuies." Wc would then be ready to admit, that the yellow fever is a conta- gious or communicable disease, in an impure atmosphere 5 but not gene- APPENDIX. 935 jrafly so where the air is preserved pure and free from noxious materials. This doctrine, too, I believe, will better account for the apparently con- tradictory facts, which have been urged by the advocates of the two op- posing opinions, than any system that has been adopted. It will also lead to a system of police regulations, which will best in- sure us against the ravages of yellow fever when introduced, at the same time it will teach us carefully to guard against the introduction of it from abroad. I shall treat this subject more at length upon another occasion, in con- nexion with the evidences of the importation of the yellow fever jinto the United States. I am, with sentiments of high respect, yours, DAVID HOSACK. Dr. Chisholm. In 1809, Dr. Chisholm did me the honour to reply to the foregoing ob- servations, expressing his entire approbation of the two first classes, but objecting to the third. After enumerating his several objections, he re- quests me to re-consider my third division, which appears to him to be the only objectionable one. This I have done, and now submit the result of a further examination of this subject, and a detail of the facts by which I have been led to my conclusion relating to the laws of communication, which I have more particularly assigned to the febrile diseases enume- rated in the third class. W aving for the present all inquiry relative to the nature or properties of the contagious principle secreted by the diseased body, or the chemi- cal qualities of the atmosphere deemed necessary for its propagation, or the manner in which the contagion diffuses itself, I proceed to observe that the history of each disease enumerated in the third class, viz. plague, dysentery, typhus, in all its forms, and yellow fever, furnishes evidence of the correctness of the remark, that they are governed by a law peculiar to themselves, that they are contagious or communicable inn foul atmos- phere, but that they are never or very rarely so in a pure air, where the sick enjoy the benefits of cleanliness and ventilation. The same evidence, I trust, will demonstrate another truth, that these diseases are, in no instances, epidemic, as they have been improperly de- nominated by most practical writers, butsthat their sphere of operation is, with very few exceptions, confined within tiie limits to which the vitiated atmosphere extends, in which they may be engendered, or into which they may be introduced : and that, in this respect, they differ from ordi- nary epidemics, " which appear in different and distant parts of the same place, and at the same time." That the plague, when once generated, whatever may be the sources whence it derives its origin, is communicated by a peculiar virus secreted by the diseased body, will not, I trust, be questioned at this day. Inde- pendently of the facts contained in the writings of Thucydides, Lucretius,, Mead, Dr. Patrick Russell, and others, showing the contagious nature of the plague, the communication of this disease by inoculation, as perform- ed by Malhias Deggio,* Dr. Whytc,t and the Russian surgeon, noticed by • See Med Com. vol. 8. p. 349. t See Wilson's Expedition to Egypt, and M'Gregor <= M^! vhr< 936 APPENDIX. Sonnini,* have recently established the fact of its propagation by a specific secretion, beyond all possible controversy. It has been observed by Assalini, that Dr. Desgenettes, while in Syria, had in vain endeavoured to inoculate himself with the virus of the plague yf and by th33 APPENDIX. Dionysius of Halicarnassus mentions* that the disease seized studs of mares, herds of oxen, and flocks of goats and sheep, doubtless denoting that this disease was remarkably fatal to those animals when collected in numerous bodies. Orosius in his account of the same pestilence, ob- serves, " Many of the patricians were victims, but it was most fatal to the poor."t Livy al?o has a similar observation, that many illustrious persons died, but that among those of inferior note the virulence of the disorder spread its ravages wide. The history of the pestilence of modern times, the accounts of which are more minutely and satisfactorily detailed, no less proves that this dis- ease, when once introduced, spreads its devastation by means of a vitiat- ed atmosphere, more especially where such vitiation proceeds from con- fined human effluvia. Accordingly, in the plague of London, in 1665, at which time nearly one hundred thousand persons perished^ we an: told by Hodges, that while the better sort of people had various re- sources to avoid the dreadful consequences of this fatal distemper, it was entirely confined to the poor, insomuch that some gave it the namr of the poor's plague. The rich, says Mr. Howard, are less liable to the plague than thfc poor. both because they are more careful to avoid infection and have larger and more airy apartments, and because they are more cleanly and live on better food, with plenty of vegetables ; and this I suppose is the rea- son why protectants are less liable to this distemper than catholics during their time of fasting ; and likewise, why the generality of Europeans are less liable to it than Greeks and particularly Jews. He adds, I have heard of instances of servants in European.families who, through impru- dence and carelessness, have been attacked with the plague, while the rest of the family escaped it.| We are told by Diemerbroeke, that it was a common practice in Italy and France, when the plague appeared in any large town, to drive out the poor immediately : so fully were the magistrates convinced that the dis- ease was preserved and propagated by them. Upon the same principle, at the commencement ofthe plague at Marseilles, all beggars were ordered to quit the town.§ " Indeed" says Dr. Blane, " it is a general remark in the history of all plagues, both in Asia and Europe, that they break out and prevail only among the lowest and poorest ranks of people, never becoming epidemic among the better sort."|| When the plague was last in England, upon its first entrance into Poole, in Dorsetshire, the ma- gistrates immediately suppressed it by removing the sick into pest houses without the town.IT Lord Clarendon, in the history of his own life, relates, that when hr and other people of condition, who had fled from the plague, returned to London, they hardly missed one of their friends or acquaintances, the mortality having been confined almost entirely to the lowest orders of the people. " At that time too, the streets of London," says Thornton. " were narrow, crooked, and incommodious, the buildings chiefly 01 wood, dark, close, and ill contrived, and by the several stories projecting beyond each other as they rose over the narrow streets, the circulation of- the air was almost entirely obstructed. To these inconveniences, he " Lib. 10. t Lib. 2. t Account of Lazarettos, p. 25. § Ferriar's Med. Hist. &. Reflect, vol. I. 287 ■) Diseases of Seamen, 3d ed.p, 622. if Roberton': Med. Police, vol. 2. p. 149 APPENDIX. H3^ adds, may in some measure be attributed the destruction which had beei; repeatedly made in the city by the visitation ofthe plague ; for as the air was confined, so the noisome vapours and pestilential atoms were har- boured and nourished. Though the destruction of London by the great fire in the succeeding year (1666) occasioned great temporary distress, yet, in the end, it proved of the utmost utility ; for, by the rebuilding of the city, and the enlargement of the streets, the free circulation of ait- was admitted, the offensive vapours expelled, and the city freed from all pestilential disorders."* It is also stated by Dr. Hodges,+ that at the breaking out of this plague, the city was unusually full of people : he supposes that there must have been upwards of one hundred thousand persons more than usual in the city ; and, according to Dr. Baynard, during the progress of this merciless pestilence, there was such a general calm and serenity ofvoeather, as if both wind and rain had been expelled the kingdom, and that for many weeks together not the least breath of wind could be discovered. It is also worthy of remark, that the city of Oxford, to which the pai:- Iiament was removed during the prevalence of the disease, remained un- infected ; which exemption is ascribed by Dr. Plott, to the draining and greater cleanliness of that city.J The great plague with which Marseilles was visited in 1720, and which destroyed upwards of sixty thousand of its inhabitants, presents us with a detail of facts which leads to the same conclusion. This disease, it is well ascertained, was introduced from the Levant by a ship which arrived at Marseilles from the coast of Syria. It appeared first among the sailons of the suspected ship ; it was next taken by the porters engaged in open- ing and airing the merchandise in the Lazaretto ; it was then introduced into the city, and spread among the poor, and first of all in a street which was only occupied by the lower class of people.^ In the commencement of the disease, Bertrand remarks, none but children and poor persons were attacked by it.|| In a short time it ex- tended to the neighbouring streets ; it was also conveyed into the Hotel Dieu, by a person received as a patient from the street where the distem- per first broke out; two of the nurses and the matron of that institution first died of the disease, when the infection spread with great mortality, destroying the physicians, surgeons, apothecaries, confessors, and all the other officers and servants of the house, with the whole of the poor in the hospital, including above three hundred foundJings.fi Soon after, all intercourse was prohibited between the town and neigh- bouring country : the scarcity of provisions which ensued, independently of the crowded state of the city, greatly added to the mortality of the disease: the number of the sick increasing, an hospital was opened for the reception of the infected, where the disease proved fatal to all the at- tendants. But the disease was not only propagated in those public insti- tutions, where great numbers were crowded together, and in the confined dwellings of the poor ; other circumstances occurred which served greatly to diffuse the poison still more generally throughout the city. Accord- ing to Bertrand, the streets were crowded with " the sick, the dying, and the dead ;" and the vapours which arose from the putrid dead bodies, in * Thornton's History of London. t DePeste ' History of Oxfordshire. § Bertrand's Relation Hi,storique, p. 414. !l Bertrand, p.-50. 'I Ibid. p. 1^. 9$0 APPLNDIX- every part of the city, served to infect the air and spread the contagion , indeed, it soon extended to places that before this had r^een inaccessible to it; monasteries, and houses shut up in the most exact manner, were no longer places of security j the whole city became more or less one infirmary* The infection too, was very much increased from another source not less dangerous. An opinion prevailed that the dogs received the conta- gion from contact with infected clothes, and thereby became the means of spreading it still more extensively; the consequence was an order to destroy them ; in a few days the streets were strewed with their carcasses ; a prodigious quantity were thrown into tbe water; these also were soon cast upon the shore, where, by the action of a hot sun, the air was filled with the most noxious vapours. Infected clothing and furniture were also continually thrown into the streets from the windows ofthe houses in which the disease prevailed, and, if possible, still further to give wings to the poison, fires were injudiciously had recourse to, for the purpose of des- troying the infection: " at hours appointed," says Bertrand, "the whole city appeared on fire, and the air became loaded with a thick black smoke, better calculated to retain than to dissipate the contagious vapour."t In fact, these fires, he adds, appeared to relume that ofthe contagion ;il they heated the air, already rendered suffocating by the heat of the season and climate ; the pestilential poison became mote active, and the disease ac- quired new force."| The plague of Aleppo, in 1760, 1761, and, 1762, might also be cited upon this occasion, as well as many others, both anterior and subsequent to that period, to show that the epidemic influence of this disease is chiefly dependent upon the atmosphere into which it may be introduced. I cannot, however, pass over, without comment, the plague which the British and French troops suffered during the celebrated expedition to Egypt in 1800 and 1801, inasmuch as it will show that this disease, even in its native climate, is governed by the same laws of communication which have been observed when it has been introduced into other coun- tries. We are accordingly told, by the learned Dr. Wittman,^ " that the dis- ease is more prevalent at Rosetta than in- any other town, or part of Egypt;" he adds, " the streets of Rosetta are extremely narrow and very dirty. The crowded manner in which the inhabitants live together would appear sufficient, in a stagnant state of the atmosphere, in most of their towns, to generate pestilential or malignant diseases. The very few com- forts and conveniences which fall to the lot of the poorer class of the natives in Egypt, by far the most numerous, would lead one naturally to expect great mortality when the plague prevails among them. Dreadful examples are seen annually to happen." In another part of the same work, he is still more explicit on Ibis point, showing that the plague " does not always possess the same activity and force;" and the neces- sity, as he expresses it, of some "powerful agent to put the contagion into action, and to give it its full force." He then asks, " May this agent reside in the atmosphere ? Does this peculiar constitution of the air consist in a superabundance, or diminution, of the ordinary proportion of oxygen in the atmosphere ? or in the combination of some peculiar gas, * Ibid. p. 145. i Ibid. p. 74. J Ibid, p To . 1 ?■'-? V §£e American Med. and Phil. Register, vol. 2 94 i APPL.NDlJC. vers, he observes, " I soon discovered that their infectious atmosphere was limited to much narrower extent than even the small pox. So mani- festly I observed this to be the case, that in a clean, well aired room,-of a moderate size, the contagious poison is so much diluted with fresh air, that it very rarely produces the distemper, even in nurses exposed to all the putrid miasms of the breath, perspiration, faeces, &c. whereas, in the close, dirty, and small rooms of the poor, the whole family, generally, caught the fever. Hence we may conclude, that iu well-aired and clean apartments, the air is seldom so fully impregnated with the poison as to acquire an infectious quality,"* The observations of the late Dr. Willan are also in point on this sub- ject. " Formerly," says that accurate observer, " the typhus, with petechia?, &c. often occurred in our prisons, and proved fatal to those who were under confinement in close cells, or who lodged in crowded apartments. Mr. Box, surgeon of Newgate, informs me that the fever has been rendered less frequent there, and less virulent, by removing the persons first affected, into airy rooms, or wards, and by a general atten- tion to ventilation, cleanliness, &c. so that, at present, petechia? do not appear in more than one case in thirty."! And of three hundred and seventy-nine patients committed into the London House of Recovery, says Dr. T. Bafemati, nine only, or about one in forty-two, were affected with petechia1.^ The facts which have been ascertained relative to the communication of yellow fever, fdrnish no less conclusive evidence that this disease, like those already noticed, is, or is not, generally contagious, depending on the qualities of the air to which it may be communicated. The history of every visitation of this disease, in the United States, establishes this truth. It has not only regularly made its first appearance in our sea-port towns, and in those places where the air is most impure; at that season of the year, and in those seasons when such impurities acquire the great- est virulence; in those houses which are most crowded with inhabitants, and where there is the least attention paid to cleanliness; but, wherever the same disease has been thence conveyed to other parts of the same city, or town, or into the country, it either was propagated or extin- guished, according to the local circumstances ofthe place to which it was so conveyed. Dr. Lining, in his description ofthe yellow fever which was introduced into the city of Charleston in 1732, 1739, 1745, and in 1748, observes, that, although the infection was spread with great celerity through the town, yet, if any from the country received it in town, and sickened on their return home, the infection spread no further, not even so much as to one in the same house. He remarks, that the disease was generally more fatal to those who lay in small chambers not conveniently situated for the admissiou of fresh air.§ The yellow fever with which the city of New-York was visited in 1791, and which was introduced by a vessel from the West Indies, and rendered memorable by the death of one of our most respected citizens, General Malcolm, who was the first victim to the epidemic of that season, is thus recorded by Dr. Jonas Addoms in his excellent dissertation on that disease : * Proceedings ofthe Board of Health in Manchester.—Letter from Dr. Havjarth u Dr. Ppirival, p"8. 1 Willan on Cutaneous Disca -is, p. 469. \ Ibid. § L'din. Phys. and Lit. Essay, vol. 2. p. 408. 427 APPENDIX. 94£ " About the middle of August, 1791, a contagious fever appeared in the city of New-York, which first discovered itself near Peck-slip, a part ofthe city thickly inhabited, its houses generally small, and badly venti- lated ; many of the inhabitants were in indigent circumstances, which is a frequent cause of the want of cleanliness. Here it raged a considera- ble time; it then began to spread, as some attendants on the sick became infected who lived in other neighbourhoods. By this means it was car- ried to other families, and most generally could be traced to this source. It likewise proved more particularly fatal near the place where it first ap- peared, than in any other part. Thus at length, it spread through the .city, until about the middle of October, when the weather growing a little cooler, the disease greatly abated, and in a short time disappeared."* Dr. Addoms, the author of that dissertation, since that time resided many years in St. Croix, and being associated with a celebrated physician of that island, the late Dr. Gordon, had ample opportunities of seeing the yellow fever in all its forms. During his last visit to this city, not long before his death, he informed me that the disease which he had seen in New-York in 1791, was precisely the same which he afterwards saw in St. Croix, and which frequently prevailed during his residence there, more especially among Europeans newly arrived within the tropics. He also remarked, at the same time, that this disease always acquired new virulence, and was rendered highly contagious, when introduced among Soldiers crowded in barracks, or on shipboard. In the yellow fever of 1793, which was introduced into the city of Philadelphia from the West Indies, it is conceded, on all sides", that the disease made its first appearance in Water-street, and that all the cases of this fever were, for two or three weeks, evidently traced to that par- ticular spot. It is also a fact well ascertained, that in the vicinity of the place where the infection was first received, the air was, at the same time, xin a very offensive condition from a quantity of damaged coffee which. was exposed upon the dock, and under circumstances favourable to its pu- trefaction and exhalation. From that place the disease gradually infected a considerable part of the city, the Northern Liberties, and district of Southwark, and did not subside until terminated by frost, after having been fatal to nearly five thousand persons. It is also to be remarked, that its ravages were chiefly confined to the poor, and to those parts of the city where the houses were small, and the least attention given to cleanliness and ventilation. In the language of Mr. Cary, " it was dreadfully destructive among the poor. It is \ery probable that at least seven eights of the number of the dead were of that class; the inhabitants of dirty houses have severely expiated their neglect of cleanliness and decency by the number of them that have fallen sacrifices. Whole families, in such houses, have sunk into one silent, undistinguishing grave. The mortality, in confined streets, small alleys, and clos£ houses, debarred the free circulation of air, has exceeded, in a great proportion, that in the large streets, and well-airedjjiooses. In some of the alleys a third or fourth of the whole of the inhabitants are no more. The streets in the suburbs that had the benefit of the country air have suffered little. It is to be particularly remarked that, in general, the more remote the streets were from Water-street, the less of the calamity they experienced, "t * Inaugural Dissertation on Yellow Fever, p. 7 ♦ Carey's Account, 4th edit, p- 61, 62. 119 #46 APPENDIX " Though the disease," says Dr. William Currie, "was highly conta- gious, the influence of the contagion was circumscribed to a narrow sphere."* As a further evidence that it did not depend on a general condition of atmosphere, the same author remarks, " that while this formidable disease was making such ravages in the city, the country, for some miles around, was never more healthy."t In another work Dr. Currie has very explicitly admitted the qualified contagiousness of yellow fever, observ- ing,' *' that it is only contagious in situations where the air is confined, and the exhalations of the sick are permitted to accumulate, through ne- glect of frequently changing the bed and body linen of the patient."| Similar facts are recorded of the visitation which New York experi- enced ofthe same disease in 1795. Upon another occasion I shall make public the evidence which is in my possession, indisputably proving the importation of the yellow fever of that season from Port-au-Prince. In that year the disease appeared upon the east side of the city, first affect- ing some seamen who had received the infection from a brig directly from Port-au-Prince; from thence it spread in the vicinity from Dover- street to Peck-slip; but throughout that season it was confined in a great degree, to that part of the town where the local condition of the atmos- phere was peculiarly favourable to its diffusion; for not only an unusual quantity of filth was accumulated in Peck-slip, but at that very time a great number of emigrant poor had arrived from England, Ireland, and Scotland, so that the numerous lodging houses, especially in that neigh- bourhood, were unusually crowded ; add to this, that the weather was" uncommonly moist, and thereby particularly calculated to spread the in- fection. According to the statement made by Dr. Bayley, it was parti- cularly fatal to the emigrants of that very summer ; for " out of nearly eight hundred persons who died," he observes, " not more than one hun- dred and fifty were citizens of New-York."§ In another part of the same statement he remarks ; " so limited was the operation of the contagion that the number of those taken sick in low situations, compared with those residing in more elevated parts of the city, may be computed as twenty to one."|| In 1798 New-York was again visited with this scourge of our seaport towns: during the months of August, September, and October, about two thousand persons fell victims to this disease, at the end of which time a keen frost put an almost instantaneous termination to its progress. The disease of that season first appeared at the shipyards, in the neigh- bourhood of New-slip, and, as in former years, was introduced from the West Indies.fl After cutting off several persons in the neighbour- hood in which it commenced, the same vessel was removed to another slip, also on the east side ofthe city ; from thence the diseate was com- municated by those who worked on board to a thickly-settled part of the city, where the houses are small, the streets narrow, and chiefly occupi- ed by the poor; viz. Cliff-street, John-street, Ann-street, Fair-street, Eden's-alley, and Rider-street j at the same time, however, it still conti- * Treatise on the Synochus Icterodes, p. 8. T Ibid p. 11. % See Observ. on the Yellow Fever, in the Pbilad. Med. and Phys. Jour, vol 2 part 1 § See Bayley on the Epidemic of 1795, p. 90. * 'V • || Ibid. p. 80.—See also Letters to Dr Buel by E. H. Smith. . IT See statement of facts on this subject by the Rev. Dr. M'Knight, in the Amer. Med and Phil, Rag. vel. 9. APPENDIX. 947 nued to extend its ravages in the vicinity of the place to which the poison had been first communicated ; and to some other thickly.settled parts of the town, to which it was subsequently conveyed. In a short time after- wards it was introduced into Pearl-street, and in that part of it between Burling and Peck slips, where it spread very extensively. In that season a number of circumstances concurred to diffuse the contagion in that part of the city: a great quantity of rain had fallen, so as to overflow the cel- lars in Pearl-street, which were, at the same time, stored with salted pro- visions ; these were soon afterwards spoiled, and loaded the atmosphere with a highly offensive vapour; the disease raging at that time in that neighbourhood, acquired new virulence, and, for the most part, followed the course of the vitiated atmosphere ; " beyond the limits of which," says Mr Webster, " the disease exhibited little infection :" indeed, the exten- sion of this disease, as has already been frequently observed, was so cir- cumscribed within the limits of this impure air that it became very gene- rally believed that, in that season, whatever may have been the case in for- mer years, the disease exclusively arose from those domestic sources, more especially from the putrid provisions. But that the yellow fever of that season did not derive its origin from the spoiled beef is evident, not only/ from the fact that the disease had already previously appeared in other parts of the town, and even in that very neighbourhood, before those heavy rains had fallen, and their pernicious effects were perceived ; but also, that those tainted provisions, unaccompanied with the specific poison of the disease, did not of themselves communicate infection to those who were constantly exposed to their effluvia. Mr. Edmund Prior, the inspector-general of beef at that time, inform- ed me, that of forty persons whom he had employed in examining the beef, andin removing and emptying such barrels as were found in a putrid State, not one was taken ill of the yellow fever.* But Dr. Chisholm and Dr. Stewart have abundantly shown, that deoomposed animal or vegeta- ble matters will not, of themselves, produce the pestilence ;t and that this disease is generated in the human system, and communicated from one person to another, by a peculiar secretion from the morbid body. My object is to show that when such virus is introduced into a certain state of atmosphere, the disease is readily contracted, but that beyond that at- mosphere it is rarely infectious. Although the diseases which have been noticed are rarely communica- ble in pure air, and are not generally contagious in the country, it is not less true, that in some few instances, it appears, either that the virus, as se- creted from the diseased body, is alone, in sufficient quantity, or possesses a sufficient degree of virulence, to reproduce such diseases; or, that by means of the impurities collected about the diseased individual, occasioned by inattention to cleanliness and change of clothing, the retention of his excretions, or the confined air of his apartment, the virus itself becomes multiplied, and thereby the means of communicating the disease from one to another are in the same degree increased: for it is a fact not to be questioned, that instances of yellow fever, as well as of the plague, dy- sentery and typhus fever, have been occasionally infectious, even in the more pure air of the country, though it must be acknowledged that such rases are of rare occurrence. .... r It is observed by Dr. Rush, whose records of the several visitations of the yellow fever in the city of Philadelphia will be lasting moauments of * See Note B ) See note C 948 APPE.NUIX. the facts which they contain, as well as of the impressive and eloquen; manner in which they are related, " that out of upwards of one thousand persons who have carried this disease into the country from our cities, there are not more than three or four instances to be met with of its hav- ing been propagated by contagion."* Such instances, however, have oc- curred in New-Hampshire, as related by Dr. Spalding:t in Connecticut, as stated by Pr- William Moore of this city ;J on Staten-Island, in 1798, as recorded by Dr. R C Moore ;§ at Huntingdon, on Long-.sland,in 1795 and 1798;|| and at Germantown, in the vicinity of Philadelphia, as rela- ted by Dr. Wistar.fl But these very exceptions, if they can with propri- ety be denominated exceptions, manifestly prove the specific character of those diseases, and that they are propagated by a specific secretion pecu- liar to each disease, whether it be plague, dysentery, typhus, or yellow fever. Indeed, to use the emphatic expression of the Edinburgh Review- ers on this subject, " In the present state of medical knowledge, it would not be at all more absurd to deny the existence of fever altogether than to maintain that it is not propagated by contagion."** But, in the language which Dr Mead has applied to the plague, we may say of all the diseases of this class, " that a corrupted state of the air is, without doubt, neces- sary to give these contagious atoms their full force."ft If it were necessary, I might go on to cite every return ofthe yellow fever with which the United States have been visited, to show that the progress of the pestilential poison has ever been commensurate with the impurities of the atmosphere, and that when sufficiently diluted with pure air, it ceases to propagate itself. It is probably owing to tin's impure condition of the atmosphere that the various fevers, and the greater mortality of diseases in general, are to be ascribed, which physicians have frequently observed to precede the appearance of pestilential disorders, and to announce their approach, and which have led many to conclude that the pestilence itself was thus en- gendered by local circumstances, and not imported. Facts of this na- ture have served to mislead the editors of the Medical Repository, and many other late writers, who thus confound the exciting and predisposing causes of disease; who do not discriminate b» tween the inflammable materials, and the spark which lights the flame ; but have identified the domestic circumstances which have served to diffuse the poison of yellow fever, with the peculiar virus itself, by which that disease has been in- troduced into the various cities ofthe United States. The same local circumstances, I believe, will go far in accounting for the" pestilential state of the air," the " secret constitution of atmosphere," so often recorded by writers on epidemics; at the same time that they teach us that the diseases now under consideration are only epidemic in as far as the vitiated state ofthe air is itself epidemic. I, however, wish it to be understood, that I oo not exclude the influence of bodily predisposition, the passions ofthe mind, and many other cir- cumstances, in aiding the propagation of pestilential diseases. Having, as I trust, shown, by the facts that have been adduced, that the " Observations on the Origin ofthe Yellow Fever of 1799, n 12 t Med Repos. vol. 3 p 8. X Addoms' Disser. p. 7. American Med and Phil. Reg vol 3 n 177 j Ibid vol 2 p. 22. || Ibid, vol 3, p. 191. ' I Additional Facts and Observations by tbe. Col lege of Physicians of Philadelphia, p -30 Ldiuburgh Review, vol. 1. p. 246. 11 Mead » Medical Works P APPENDIX. 949 plague, dysentery typhus, and yellow fever, constituting the third class of contagious diseases, require an impure state of the air to diffuse and multiply them, the question next presents itself, in what manner does such impure air operate in spreading those diseases ? Upon this part of the subject I have the misfortune to differ from Dr. Chisholm no less than I do as to the necessity of such an atmosphere to propagate the peculiar poison of each of those diseases. Dr. Chisholm observes, that if the pro- position had been advanced, " that those diseases, particularly the pesti- lential yellow fever, are rendered more violent in their action under the circumstances stated, of an impure atmosphere, that no possible objection could be made to it, inasmuch as it is supported and proved by all expe- rience;" and he proceeds to express the opinion that such an atmosphere" may have an effect" by rendering the system of the healthy person, who receives the poison from the sick, more susceptible at the moment of its introduction) of its peculiar action ;" but that this multiplying power does not proceed from any action of the air upon the peculiar virus of those diseases; that " it does not proceed from the impure atmosphere becoming- assimilated to the poison introduced." That air, deprived of its due proportion of oxygen, and loaded with raephitic materials, especially the confined excretions of the human body, will vitiate the mass of circulating fluids, and impair the functions of the nervous system, cannot be denied ; that the febrile diseases with which the system may be affected while in this state, will acquire an extraordinary degree of malignancy, will also be readily conceded ; but that such condition, either of the atmosphere, or of the human system, increases its susceptibility to be acted upon by the virus of those con- tagious diseases, composing the third«class, does not correspond either with the facts which have fallen under my own observation, or with those 1 have been enabled to obtain from the writings and observations of others. The well known facts relative to the communication of jail fever to thejudges presiding at the Black Assizes, in 1577,* and a similar infec- tion beino1 communicated to the judges on the bench, and other persons present, at the sessions held at the Old Bailey, in 1750, while the prison- ers themselves remained in health, insensible to infection, furnish incon- testible evidence ofthe effects of habit in diminishing the sensibility to the poison of fever : and with regard to the yellow fever, it assuredly has not been the case in the United States, that those who are most accus- tomed to the impure air ofthe place in which the disease prevailed, were more susceptible of the disorder than those who had recently arrived from the pure air of the country, or from the more elevated parts of the town. On the contraiy, those who were least accustomed to the im- pure air of the city, or of the infected spot, were uniformly observed to be most susceptible of the contagion. Those, too, who enjoyed the most vigorous health, and the most robust constitutions, the reverse of that condition of body « hich would be the effect of a residence in impure air were more readily infected upon coming into the atmosphere im- pregnated with the contagion, than those who had remained constantly exposed to its influence. Whatever differences of opinion have existed among the physicians ofthe United States, as to the origin of the disease, they are all perfectly agreed relative to the facts which 1 havejust stated. " Bacon's Works, vol. 2. Stowe's Chronicle—See note D. $50 APPENDIX. Indeed, Dr. Chisholm himself inadvertently admits the same to be true; for he observes, that, in the West Indies, sailors, soldiers, and young men, especially those who had recently arrived from Europe, and are least accustomed to the climate, were more obnoxious to it than others. Dr. Gorden, and indeed, all the most distinguished practical writers on this subject, concur in the same observation. " New coiners," says Dr. Gorden, in ihe appendix to Dr. Chisholm's late valuable letter to Dr. Haygarth, " were infected with the pestilential fever, while the old seasoned soldiers had only the common tropical remittents ; and this was universally the case whenever both diseases were at the same time epi- demic."t A similar, and siill more general, observation on the predis- position ofthose who are unaccustomed to impure air, is made by Dr. Blane. " Infection," says he, " like some other poisons, does not so readily affect those who are accustomed to it, and therefore thosf who are in the habit of being exposed to it, frequently escape its bad effects." For the like reason, he adds, " physicians and nurses are less susceptible than others ; and strangers, who are accustomed to a pure air, are the most susceptible of any."J With these facts and observations before us, we are compelled to conclude, that the impure air necessary to propagate the contagion does not operate in the manner Dr. Chisholm supposes, by "increasing tbe susceptibility ofthe system to the action of the poi- son introduced." On the contrary, I believe that it produces its effects by some chemical combination with the peculiar virus secreted from the diseased body, and that thereby the contagion becomes more or less ex- tensively multiplied, according to the extent and virulence of such vitiated atmosphere. I shall not attempt to define the^jrecise nature of the chemical union which takes place under such circumstances. But I wish it to be dis- tinctly understood, that in such combination, I flo not believe with those writers who contend that a tertium quid is produced ; or, as Dr. Adams of London, in his late publication on Epidemics, has reiterated the same idea," that a new kind of air is generated."§ On the contrary, as far as I am enabled to view the subject in connection with the facts usually obser- ved during the prevalence of the diseases which have been noticed, I am inclined to believe, that in this combination the peculiar virus of those dis- eases is in no way changed, but multiplied ; and that this multiplying power is a process very analogous to that which we observe to take place in the assimilation of the fluids of the human body to the peculiar taint which may be introduced into the system, as, for instance, in small pox and syphilis ; or, perhaps, that it more nearly resembles the process of fermentation, as it occurs in inanimate matter. By both these processes such an assimilation takes place in the fluids acted upon, whether of the living body or in dead matter, that they partake of the same properties with the virus or ferment introduced, and are thereby rendered capable of renewing the same process in other bodies under similar circumstances. This process has very properly been denominated by Dr. Walker, the as- similating fermentation,^ and has been no less successfully employed both by him and by Mr. Cruikshank,!} as well as by Dr. Cullen, to explain the changes which take place in the living system, acted upon by small pox, Chisholm's Letter to Haygarth, p. 182,.&c. + Ibid. 220. X Diseases of Seamen, p. 223. § Adams on Epidemics, p. 11. < 1 Walker's Inquiry into the Small-pox. V, Anatomy ofthe Absorbing Vessels- APPENDIX. 951 and the virus of other contagious diseases, than it has been by Sjr J. Prin- gle,* Macbride,t and Alexander,J to the phenomena of fermentation, as it occurs out of the body4 The history of plague, dysentery, and typhus fever, as well as the recent observations in animal chemistry, furnish a variety of facts which may be adduced in illustration of such fermentative process taking place in the atmosphere, and in watery fluids loaded with the excretions of the human body, or the vapours of vegetable and ani- mal substances in a state of putrefaction. Similar facts, illustrative of the foraentative process contended for, have been observed whenever the yellow fever has prevailed in any ofthe pities or towns of the United States. I have already stated that this dis- ease has always prevailed in proportion to the presence of such fermenta- ble materials. It is no less true, that whenever the disease has been in- troduced it has spread in the greatest degree in those seasons when the air was unusually moist : this was remarkably the case in New-York, in 1795|| and 2798,ff and in Philadelphia, in 1793 and 17»98 :** and that the yellow fever has prevailed in the United States in those seasons when the heat, combined with moisture, was most favourable to such assimilating or fer- mentative process is also proverbially true. It is also to be observed, as universally admitted, that the same disease has uniformly been extin- guished by the approach of frost, which destroys such fermentative pro- cess. Another argument in favour of this explanation is derived from the facfi that this disease has, in several instances, been introduced into our cities, without extending beyond the individuals who have introduced it; mani- festly owing to the active exertions of a vigilant police, at the same time that every attention was paid in preserving cleanliness about the persons of tbe sick. This was remarkably the case in the year 1804, when the yellow fever was introduced at the Wallabout, on Long-Island, and in 1809, when the same disease prevailed at Brooklyn. In each of those years the fever was introduced into this city by persons who had received the infection on Long-Island, but, owing to the circumstances just men- tioned, it was not communicated to others: while the same disorder, owing to local circumstances, spread in the vicinity of those places on Long Island where it had first appeared."!"!" During the year 1811, the yellow fever was also introduced into the city of Amboy, New-Jersey, from the Havana, but did not spread beyond those persons who were first attacked in consequence of their immediate exposure to the air of the infected vessel. The local circumstances of Amboy, its elevated situation, its dry and sandy soil, its wide streets and spacious houses, their distance from each other, and the remarkable eleanliness of the town, most satisfactorily account for the sudden ex- tinction of the disease, while the evidence of its importation must be ad- mitted to be conclusive.^ But there is another circumstance which particularly merits attention in every epidemic visitation of the yellow fever, several days, viz. from eight to twdpre, or fourteen, have generally elapsed between the first cases * Diseases of the Army, Appendix. f Experimental Essays. } Experimental Essays and Experimental Enquiry. § See Note E. 0 See Bayley on the Yellow Fever of 1795. fl Hardie on the Yellow Fever of 179S ** See Rush and Currie. li American Med. :md Phil. Reg. vol 2. p. 95, &c. tl See American Med. and Phil. Reg. vol. 3, also Edinburgh Med. and Surg. Journal, and the Med. and Pays, Journal of London.—See Not", r 9$2 APPENDIX. that appeared, and the communication of it to other persons, even in the same neighbourhood ; insomuch that not only our citizens, but our phy. sicians themselves, have been led to doubt the existence of the disease, and to stigmatise as alarmists those who first announced the deadly visitor.* I can never forget the occasion, in 1795, when that venerable and experi- enced physician, the late Dr. John Bard, assembled the physicians of this city to announce to them the first cases of this disease which he had obser- ved in the family of his friend, Mr. Jenkins. The physicians met, but de- clared they had seen no other fevers than what they had been accustomed to observe every year, and even doubted, on that occasion, the correctness of Dr. Bard's observations, relative to the nature and character of the disease to which he called their attention: but that accurate observer had been too familiarly conversant with the yellow fever as it appeared in New- York in 1743 and 1762, and too well knew the pathognomonic symptoms of that disease to confound it with the fevers of our own climate: he, ac- cordingly, in the most emphatic language, replied to their doubts, " Gen- tlemen, within a fortnight you will all see and acknowledge the West-India yellow fever to exist in our city." The event is well known.t The same interval between the first cases of the disease and its subsequent diffusion in the neighbourhood where it first made its appearance is noticed by al- most every writer who has recorded the yellow fever in the United States. A similar interval has been frequently noticed in the history of the plague. Dr. Russell, in his account of the plague of Marseilles, in 1720, observes, " that from the 12th of July to the 23d there was a deceitful pause, during which the popular apprehensions began to subside. The physicians w-ere reproached with ignorance in having mistaken ordi- nary fevers for the plague. The disease, however, in this interval, had continued to spread in the Rue de 1'Escale, where it made its first- appearance."| It has also been remarked of the plague, as well as of the yellow fever, that the infection spread most rapidly when the atmosphere was not only heated and loaded with moisture, but when it was least agitated by wind or thunder storms. During those calms, when the air may be said to be relatively at rest, it has been uniformly remarked, that the contagion of the yellow fever has multiplied itself most extensively, as was always very apparent by the greater number that were seized within five or six days after such close weather had been observed, all which circumstances certainly conspire to promote the fermentative process that has been contended for. This is not all: whenever the yellow fever has been introduced into the cities of the United States, its first extension has always been slow and gradual. Upon several occasions its boundaries have been accurately defined by our board of health This, as I have stated on a former occa- sion, was remarkably the case in this city in 1805. The disease, in that year, was confined, for some weeks, to a small portion of the eastern side ofthe city, and, as stated by the board of health, " not a case occurred, in any part of the town, that was not referable to that as te source."! This fact being ascertained, the board accordingly forbade intercourse * See Note G. t See Bayley and Hardie on the Epidemic of 1795— See also Currie on the Fever of 1799. t History of the Plague. § Hardies Account ofthe Malignant Fever of 1800 APPENDIX. 9o'.i wjlh the infected portion of our city, and ordered an abandonment of that part of the town, threatening violent measures if their orders were not immediately complied with. In a short time after, the infection extended a few streets further ; the board of health again defined its limits, and again declared that still not a case had occurred that could not be traced to this part of the city as its source.* Will hot the same assimilating or fermentative process furnish the most satisfactory solution yf the fact noticed by Boerhaave, Cullen, Lind, Russel, and many others, that fomites are more to be dreaded than the excretions alone proceeding from the diseased body ? Not, however, in the manner those authors suppose, that such fomites acquire greater viru- lence ; but, that by the same process the specific poison has been more extensively multiplied by means of the atmosphere and foul excretions which are involved in the clothing worn by the sick ; and that by the same means the danger of the infection has been increased in the same degree that the poison has been multiplied. As a further evidence, too, that the contagion is multiplied, but not more concentrated, as those writers have imagined, it is a fact established \fy every Writer on those conta- gious diseases, that the first cases of every epidemic are uniformly the most fatal ; but that, as the season advances, the danger of taking the disease is increased, While the disease itself has, perhaps, become even milder tlian it was in the commencement. Let me further ask, do not the processes lately introduced for disin- fecting the air by means of the fumes of the acetic acid, the oxygenated muriatic acid gas, the nitric, and sulphuric acid vapours, operate by making new combinations with some of the ingredients constituting the tainted atmosphere, and thereby decomposing the morbid compound 1 According to Dr. Crawford, " the-fluids which destroy the foetid odours most speedily are those which are acknowledged to contain the greater portion of oxygen, and it is, therefore, extremely probable that this change depends on the onion of the oxygen with animal hepatic gas, or some one of its constituent parts." But the explanation which has been offer- ed by the late Dr. Garnett, of, the manner in which the oxygen thus em- ployed combines with the hydrogen gas which holds the morbid secretions in solution, appears to me the most satisfactory explanation that has been given of those phenomena.f From these facts, I have been led to conclude, 1st. That an impure atmosphere is indispensably necessary to multiply and extend the specific poison, constituting plague, dysentery, typhus, and yellow fever. 2dly. That tire impurities ofthe atmosphere do not produce their effects, in ihe manner suggested by Dr. Chisholm, by increasing the suscepti- bility of the system to be acted upon by the peculiar virus of those diseases. \ 3dly. That, instead of predisposing the body to be thus acted upon, the reverse is the fact; that the predisposition of those who are most exposed to such impure air is less, whije those who reside in the pure air Of the country are most liable to be infected when exposed to the com tagion. ■ * Chisholm's Letter to Haygartii.—See Note 11. „„„„„,, , „, ♦• t Proceedings ofthe Bostrd of Health of Manchester, p. 40—42 Robertson s Ireatise on Medical Police, vol. 2. p. 127. Robertsons Natural History ofthe Atmosphere, v J 2 n. 352. Sc- Note 1 1?0 954 APPENDIX- 4thly. That the impurities of the atmosphere arc fermentable material^, to be called into action by the specific ferment of those diseases, aided by heat, moisture, and a calm state of the atmosphere; and that as far as such atmosphere extends, and the circumstances favourable to such fer- mentative or assimilating process continue, so far those diseases become epidemic, but no further. The same idea of an assimilating process appears to be expressed by Lucretius, when, speaking of the contagiousness qf, the plague, he ob> serves, " Proinde, ubi se ecelum, quod nobis forte venenuro, Conmovet, atque aer inimicus serpere coepit; Ut nebula ac nubes paullatim repit. et omne, Qua graditur, conturbat, et immutare coactat. Fit quoque, ut in nostrum quoui venit denique caelum Conrumpat, reddatque sui simile, atque alienum " Lucretius, de Nat. Rerum, lib. VI. Or, as it has been rendered by that learned surgeon and accomplished scholar, John Mason Good, Esq. " But when the heaven, of poisonous power to us. First moves romote, Its hostile effluence creeps Slow, like a mist or vapour ; all around Transforming as it passes, till at length, Reachd our own region, it the total scene Taints, and assimilates, and loads with death." If the view which has been taken of this subject be correct, a stili more important truth is the result; that, while by a rigid and well exe- cuted system of quarantine laws we have it in our power to guard against the introduction of the spark that kindles the flame, we are also enabled, by means of domestic cleanliness and ventilation, to ex- tinguish it when introduced. For this purpose our magistrates and guardians of the public health cannot be too attentive in their police regulations to have all noxious materials removed from our streets and our dwellings; and, at the same time that they are ornamenting our cities by the erection of magnificent buildings, and the introduction of other important improvements, they should also avail themselves of every opportunity which may present of widening our streets, and of reserving squares and other pieces of ground to be ever kept vacant, as among the most effectual means of preserving the health of our citizens, and guar ding against the propagation of contagious diseases. *"—to lleXttcrytx«j itgyitv «ji« after general engagements, other «auses can be pointed out as more likely to have produced it. But many instances can be produced.in which thousands of dead bodies have been ,'eft to putrefy on the field of battle, without causing pestilential distem- pers. This was not unnoticed by the attentive Diemerbroek '• Cada- vera, sive hominum," says he, " sive aliorum animalium putrescentia pestem non generare, docent multee magna? strages, in quibus talis cada- ;erum inhumatorum putrefactio nullas pestes induxit. Anno 1642 in agro Tuliacensi, maxima strages facta est, et ad minimum 8000 militum, occisa uerunt praeter majorem adhuc fainulorum, rusticorum, aurigarum, puero- rum & mulierum ntimerum, atque equorum copiam innumerabilem ; corpora inhumata sub diu computruerunt, nulla tamen pestis insecuta est. Hie in Germania, durantibus his nostri aevi crudelissimis bellis, etiam ijlurima? maxima? strages factaj sunt, post multas tamen illarum nulla peste subsequente." (P. 31.) These facts are strengthened by a well- ♦ known circumstance, that in no case could the origin of a putrid fever bt ever traced to the effluvia of dead bodies in a dissecting room. Nor have fevers been observed to originate, or to rage more severely in houses surrounding church-yards, in the middle of large towns, though the stench of the putrid bodies, over-heaped in such receptacles, is often in- sufferably offensive." It has also been stated, that decomposed vegetable matter is not, as con- tended for by many physicians, the cause of yellow fever. The follow- ing fact, stated by Dr. John Stewart, df Grenada, abundantly proves.that cegetable filth has no more agency in the production of that peculiar type of fever than putrid animal substances. " That vegetable and animal matters in a state of putrefaction do produce disease is not to be denied ; but thai vegetable matter in a state of corruption is, on many occasions, harmless, is evident, from the very offensive heaps of cotton-seed, and the pulpy covering of the coffee-berry, which are daily to be met with in Demerara, without being considered as a cause of fever; nor should this circumstance be omitted, that when fever does prevail, it is at a season when tliose causes do not act powerfully." See observations on the Natura and Treatment of the Malignant or Yellow Fever which prevailed in the island of Grenada, ( W. I.) in ihe years 1703, 179d, and 1795, in a Lvtter to David Hosack,from John Stewart, M. D., 8fc. $c. Amer. Med. and Fhil. Register, vol. 3. p. 163. It may also be remarked as an additional testimony to that stated by ' Dr. Stewart, to prove that the yellow fever does not derive its origin from decomposed vegetable matter, that whenever that disease has prevailed in the United States, it has not appeared in the country where such vegeta- ble matter is most abundant; but has been chiefly confined to our largest ' cities, and those towns which are situated on our seaboard; a fact totally inexplicable upon the principle that the yellow fever Is the product of vegetable putrefaction. I am fully aware the opinion has been entertained that this form of fever prevails in the interior of our country, and espe- cially iu the vicinity of the lakes; but whoever will consult the statements APPENDIX. 961 furnished by physicians residing there, and who have had the best means of obtaining correct information, will find ample refutation of that opinion. See Frisbre's Sketch ofthe Medical Topography of the Military Tract of the State ofNew-York; and Brown's Sketch ofthe. Country wa- tered by the Mohawk River, 8fc. Amer. Med. and Phil. Register vol. 4. ; Needham's Sketch of the Medical Topography of Onondug i, state of New-York. See Barton^ Med. and Phys. Journ. 1st supplement. But we need not confine ourselves to European writers for informa- » tion on this subject. Similar facts have been observed in our own coun- try, and in this city in particular, and equally show thd absurdity of re- sorting to vegetable or animal putrefaction as the source ofthe malignant fever with which the United States have been recently visited. Adverting to the condition of the city of New-York .interior to the Ame- rican revolution, and before a regular system of police regulations was adopted ; to the offensive state ofthe town during the revolutionary war, when inhabited by the British troops; to ihe immense collection of foul materials of every sort in the cellars of the numerous buildings de- stroyed by the great fire of 1776, during the whole of which period this . city enjoyed a total exemption from the pestilential fever, we must be convinced of the limited and incorrect views of those who look no fur- ther for the origin of this evil. In like manner, the offensive state of our slips, our wharves, and our market-places, until within a very few years 3 fhe putrefactive processes attendant upon our tauneries, morocco, starch, and glue manufactories, slaughter-houses, tallow chandleries, sugar-houses, &c. &c. the filthy and neglected condition of our streets, and, we may add, of many of our burial grounds, furnish incontestible evidence that these are innocent when considered as the primary causes of the mortal epidemics which have desolated our cities. The influence of such an impure state of the atmosphere, resulting from these various causes, as a secondary agent in multiplying and diffusing the poison of fever when in- troduced, has already, I trust, been made sufficiently manifest. Mr. Howard, in his remarks on the plague, (see History of Lazarettos, p. A3.) adverting to the opinions of those who questioned the contagious- ness of that disease, asks," Have not some of our professors sullied their names with such dangerous doctrines ? From no other cause," he con- tinues, " than the errors of physicians, who continually maintained that the disease, then epidemic, was not contagious, happened that terrible vi- sitation which, in 1743, ravaged the city of Messina and its vicinity, with the loss of above forty-three thousand individuals, in the short space of only three months." May it not with equal propriety be asked, can the physicians of the United States, who shall carefully have reflected upon the facts which have just been stated, and others of a similar nature which might easily be adduced, persist in the belief they have expressed, that the pestilential fe- ver that has appeared in our cities and seaport towns is the product of de composed animal and vegetable matter? NOTE D. (See page 857-) The following statement fully illustrates the principle, that those who are accustomed to breathe an impure air frequently escape disease, while those who from their better condition in life enjoy the more pure atmt»s- 1?1 "16ii APPENDIX phere, are readily attacked with contagious fever when exposed to its ex- citing cause. "The most pernicious infection," says Lord Bacon, "next the plague, is the smell of the jail, when the prisoners have been long, and close, and nastily kept; whereof we have had in our time experience twice or thrice, when both the judges that sat upon the jail, and numbers of those who attended the business, or were present, sickened upon it and died. Therefore, it were good wisdom that in such cases the jail were aired be* fore they be brought forth." Nat Hist. exp. dccccxiv. In Stowe's Chronicle a more particular account is given of the same circumstances, as occurring at the fatal assizes held in the year 1577, in, the following words: "On the 4th, 5th, and 6th days of July were the assizes held at Oxon, where was arraigned and condemned Rowland /en- kins for a seditious tongue ; at which time there arose amidst the people such a'"damp, that almost all were smothered'. Very f• w escaped that were not taken. Here died in Oxon three hundred persons; and sickened there, but died in other places, two hundred and odd" " Of the same kind of infection," says Sir John Pringle, "we have an unhappy instance so fresh in our memory, that I needed not to have mentioned here, had it not been fur such as live at a distance, or those who are to come after us. In the year 1750, on tl>e 1 lth of May, the sessions began at the Old Bailey, and continued for some days; in which time there were more criminals tried, and a greater multitude was present in the court, than usual. The hall in the Old Bailey was a room of only about thirty feet square." " The bench consisted of six persons, viz. the lord mayor, three of the judges, one of the aldermen, and the recorder, whereof four -died, together with two or three of the counsel, one of the under-sheriffs, several ofthe Middlesex jury, and others present, to the amount of above forty ; without making allowance for those of a lower rank, whose death may not have been heard of; and without including any that did not sicken within a fortnight after the sessions.'' Similar instances of infection are related lo have taken place at the Black assizes, at Taunton, and at those of Exeter, in 158G. See Ree's Cyclopaedia art. Contagion. Facts of a like nature have fallen under the notice of that accurate ob- server, Sir Gilbert Blane. An extract from his letter on this subject is here inserted. Extract of a Letter from Sir Gilbert Blanc, M. D. Sfc. to the Hon. Rufus King, Esq. Minister at the Court of St. James from the United States of America, dated London, 26th November, 1798. Sir, I sit down to perform the promise I made you this morning, of putting on paper some remarks on the nature of the yellow fever, and the mean. of preventing it. In doing this I shall chiefly confine myself to those views of it in which the magistrate is concerned. The adopting of measures for the prevention of disease is one of the most important duties of a wise and patriotic government; and the discovery of these means, as well as the efficiency ofthe steps to be taken, must depend on a thorough knowledge of fie ciuses by which it is excited and influenced. My opportunities >ipon actual service in the West Indies in the late war, when physician te. APPENDIX. 96'3 the fleet under the command of Lord Rodney and Admiral Pigot, and my present official duty as a member ofthe Medical Board of the Navy, have necessarily brought to my knowledge a number of facts relating to this subject, and I shall be extremely happy if the communication of some of the most important of them can throw any light, which may prove useful to the American government in checking an evil so afflicting and calamitous. The first question that occurs with a view to preventive measures is, whether this disease be infectious, and under what circumstances it is so ? In those situations in which I observed it in the West Indies it was evidently so. There was the most iocontestible evidence of this, both on boarcrot ships and at Hospitals, and the doubts which haye been start- ed on this point, seem to have arisen from the operation of infection being blended with that of other causes, which must concur with it iu order to give it effect. But whatever doubts there may be on this subject in the West Indies, there can be none in the climate of North America. This will be best proved and illustrated by an example. On the 16th of May, 1795, the Thetis and Hussar frigates captured two French armed ships from Gaudaloupe on the coast of America. One of these had the yellow fever on board, and out of fourteen men sent from the Hussar to take care of her, nine died of this fever before she reached Halifax on the 28th of the same month, and the five others were sent to the hospital sick of the same distemper. Part of the prisoners were re- moved on board ofthe Hussar, and though care was taken to select those seemingly in perfect health, the disease spread rapidly in that ship, so that nearly one third ofthe whole crew was more or less affected by it. This fact carries a conviction ofthe reality of infection, as irresistible as volumes ©f argument; and it further affords matter of important and instructive information, by proving that the infection may be conveyed by the persons or clothes of men in health,. Blane's Diseases of Seamen, p. 605—607. 3d edit. The principle which we have endeavoured to illustrate relative to the operation of febrile infection upon individuals unaccustomed to its influ- ence has, in several instances, been strikingly exemplified by circumstan- ces which have occurred in the Debtor's Prison, and in the Bridewell of New-York. The following memorandum, made at my request by Dr, J. W. Francis, is in point on this subject. " In the month of September, 1811, a febrile disorder of the typhoid character made its appearance in the Debtor's Prison of this city : its origin was owing to causes similar to those which usually produce a vi- tiated state ofthe atmosnhere m confined apartments, the want of pure air, and the crowding of' a large number of persons together, &c. &c. The contagion th-is engendered was observed to operate with peculiar severity upon those individuals who were suddenly introduced into this Vitiated air About the l6th of July, 1814, several cases of the typhus carcerum occurred in the Bridewell of New-York. The disease was first observed to exist in an apartment of the institution commonly called the eastern win-, a room about fifty feet long and twenty-five broad. Within a very few days after, the complaint became more general; and out or eighty-five individuals at that time confined in this part of the building, near- 964 APPENDIX. ly forty were taken ill with symptoms characteristic of typhoid fever. The disease, in this instance, as in the former, was produced from the local circumstances of the place ; the crowded condition of the ward, the want of cleanliness about the persons and in the clothing of the pri- soners, and the neglect of free ventilation. The increased impurities of the atmosphere ofthe apartment seemed to give additional activity to the virulence of the disease: of the persons thus affected, a b.rge majo- rity were those who had come from a pure air, and were but recently subjected to the noxious air ofthe place, several not more than thirty or forty hours, and many not more than thr^e or four da}Ts. The infection was more readily communicated to those, too, who were naturally pos- sessed of vigorous and robust constitutions, and its effects we^e^in most cases, more violent upon persons of this description than upon others. That the sphere of the infection Was confined within certain limits, as affirmed by Dr. Lind of the malignant fever at the naval hospital at Haslar, and lately most satisfactorily shown by induction from well- attested facts concerning typhoid infection in general, (See Letter of Dr. Haygarth to Dr.. Percival,) was abundantly manifest from the healthy condition of the .prisoners in other apartments ofthe Bridewell. The progress of the disease, which I have thus briefly noticed, was arrested by the removal ofthe sick, and the materials impregnated with the mor- bific poison ; by the introduction of pure air, by ablution, and by other means now most generally had recourse to for the purification of fever- wurds and houses of recovery, as recommended by Dr. Ferriar. " It has again and again been observed, by the keepers of our prisons, that those criminals who have long been accustomed to breathe the vitia- ted air of the crowded apartments of these institutions very frequently escape febrile contagion : the poison itself might, at first view, appear to have lost a portion of its virulence ; but it has with more propriety been maintained that the individuals thus inured to its influence are, from habit, exposed to it with impunity ; while, on the other hand, the reverse is the case with the unassimilated, when subjected to the operation %f an impure air, deriving its noxious properties from concentrated human effluvia. It is a remark of most writers, that the infection of typhus, whether oc- curring in jails, ships, or elsewhere, becomes concentrated, and conse- quently, more active by the cold of winter. This opinion is strength* ened by the well known fact, that a greater number of deaths takes place from fevers of this natnre, in our prisons, during the winter than in the summer season." NOTE E. (Seepage 859.) 1 have expressed the belief that the changes which the atmosphere undergoes during the prevalence of certain pestilential disorders are as- cribable to a fermentative or assimilating process. I am strengthened in this opinion, which I have for many years maintained, by the recent and elaborate investigations of M M. Gay-Lussac, De Saussure, and other distinguished chemists, which have thrown much light upon the subject of fermentation, and also by some interesting observations lately publish- ed in the Edinburgh Review. See Edinburgh Review for April, 1814. For a perspicuous elucidation of the manner in which the poison of diseases of specific contagion operates upon the human constitution, iu APPENDIX. 965 assimilating the mass of fluids to its own peculiar nature, the reader may- consult an Essay published by Dr. J. W. Francis, late Professor of Mate- ria Medica in the University of the State of New-York, and inserted in the American Medical and Philosophical Register, (vol. 4. p. 476—519.} also a valuable Dissertation on the Pathology of the Human Fluids, by Dr. Dyckman, of New-York. NOTE F. (Set page 860.) There is scarcely to be found on record a series of facts which so conclu- sively prove the specific character of the pestilential or yellow fever, or points out the circumstances under which it is propagated or extinguished. as those referred to in the text: e.g. we have seen this disease introduced at the Wallabout on Long Island in the summer of 1804, and the poison diffusing itself in that neighbourhood as far as the impurity of the'air ex- tended ; while the same disease conveyed from the Wallabout into the city of New-York, was instantly extinguished by means of the relative purity of the atmosphere, the effect of the rigid system of police then observed. See American Med. and Phil. Register, vol. 2. In like manner, in the summer of 1809, (See Statement by Dr. Giles- pie, Amer. Med. and Phil. Register, vol. I.) the yellow fever was introduced and spread in the village of Brooklyn, Long Island ; at the same time that the city of New-York, within eight hundred yards' distance, enjoyed the most perfect exemption from it; a fact which at once disproves the depen- dence of yellow fever upon a general constitution of atmosphere which many physicians believe to be necessary both for the origin and propagation of this form of fever. We are led to the same conclusion by a perusal ofthe report relative to the introduction ofthe yellow fever into the city of Am- boy, New Jersey, in the summer of 1811. See Amer. Med. and Phil. Re- gister, vol. 3. NOTE G. (Seepage 86lJ The following extract of a letter from the Rev. Dr. Samuel S. Smith, the late president of Princeton College, shows that the fact I have stated of an interval having taken place between the first and subsequent cases of fever* is of so frequent occurrence, that it even attracts the notice of those who are unconnected with the medical profession. Princeton, July 24th, 1808. Dear Sir, I have not any doubt but that yellow fever contains a specific contagion, essentially variant from that of small pox, with which it basso often been compared in order to deny contagion being incident to it. It requires a certain putrid state ofthe atmosphere as a conductor, in order to impart it: and it mayinnoculate and assimilate any confined portion of atmosphere which has been exposed to the requisite causes of contamination, so that every part of it shall have power to communicate the poison. In the pure atmosphere ofthe country the poison is commonly so diluted, that it is too weak to excite the fever, except under peculiar circumstances. In every instance in which yellow fever has been introduced into Phila- delphia one circumstance has invariably taken place : after the persons who have first taken the disease have either died or recovered, there has been an interval of health for several days, usually from ten to thirteen or four- teen before the alarm has been renewed. From this circumstance, I have 366 APPENDIX. concluded, that during that space of time the infection secretly works in the blood before it appears in fever. Often there is a second interval of ap- parent health, but not of so long a continuance 1 hope that your view of the subject will carry more conviction with it than we have hitherto per- ceived; and I hope it will even contribute, among the more sensible part of the profession, who do not think merely by authority, to unite jarring opinions and to settle common principles. SAMUEL S. SMITH. By physicians who have recorded our epidemics such interval has Seen repeatedly.observed. In Dr. Caldwell's Essay on the Yellow Fe- ver of Philadelphia of 1805, it is very circumstantially noticed by that ingenious and able writer. NOTE H. (Seepage 86l.) In the official document of the Board of Health of New-York, published on the 14th of September, 1805, they thus addressed the inhabitants of this city : " The Board have formed a decided opinion, that the principal seat ofthe prevailing disease [the malignant epidemic fever] is that part ofthe city included between Bui ling-slip and Old-slip as far west as Pearl-street. Almost all the cases of disease which have occurred,can be distinctly traced to a communication with that part of the city. It is a matter of extreme regret, that the repeated admonitions ofthe board, to remove from this quar- ter, have been disregarded by a number of individuals who have remained the self-devoted victims of disease and death. They conceive it their duty again to enjoin it upon their fellow citizens, who have continued there, to re- move immediately." Again, and in the same address : " All persons who do not comply forthwith with this advice of the board, to remove from the above described part of the city, which is deemed the principal seat of the disease, and which does not contain more than thirty-three acres, will be con- sidered guilty of a wanton exposure of their lives, and will justify the board in resorting to compulsory measures." The epidemic fever which prevailed in Philadelphia in 1793, spread in a similar manner, according lo Dr. Rush and others. " For awhile," says Dr Rush, " this fever was confined to the above-mentioned part ofthe city, but the disorder is spreading, and now ap- pears in other places, so that several are affected in other parts of Water- street ; some in Second-street; some in Vine-street; some in Carter's-alley ; some in other streets ; but, in most cases, the contagion can be traced to Water-street." Proofs of the same kind might be taken from the rnostau- thentic accounts of the yellow fever as it has prevailed at other seasons, and in other cities and seaports of the United States : proofs wholly irreconcila- ble with the assertions of those who have declared that tbe malignant yellow fever arises at " distant and unconnected points :" that "no relation is ob- served between the source of the supposed contagion and the spreading of the disease to individuals or families;" and who have maintained that there " never was an> successful attempt to trace, in regular series, tbe propaga- tion of it to any number of persons from the first case, or from any single point of infection " See Rush's Account of the Bilious Remitting Yellow Fe- ver as it appeared in Philadelphia in 1793; Account ofthe Yellow Fever of New-London in 1793 .- Hardie on 'hi Mxiignant Fever of New York in 1805 ,• Chisholm's Litter to Hay gar'h; Offcbil Documents published by the Vther local causes, in adding virulence to febrile contagion, may be con- sidered almost an axiom in physic ; and the necessity of a strict adherence to your improved system of quarantine laws and all municipal regulations for the purposes of domestic cleanliness, cannot be too strongly enforced. On this subject the Royal College and the Army Medical Board are united in opinion. (COPY.) Extract from the Report upon. Dr. Pym's publication by the Army Medical Board. " Army Medical Board Office, 6th May, 1816. " It is due to Dr. Pym to state, that we consider him to have been the first English medical man who promulgated the opinion, that the disease in ques- tion, the Bulam fever,) is capable of attacking the human frame but once 5 and if that opinion be correct, which we believe it to be, it is certainly an important fact, and led Dr. Pym to employ those persons as attendants on the sick, who had undergone the disease, and therefore were not likely to be affected by the contagion of it, and thus probably saved many lives. Under these impressions, we beg leave to recommend the industry and re- search displayed by Dr. Pym in his book, to Lord Palmerstone's favour- able consideration. ». " Signed, " J. M'GRE^OR, " W. FRANKLIN, "W. SOMERVILLE.^ The advocates for the unity of disease will. 1 believe, find it insuperably difficult to reconcile with their theory, the facts which I have thus hastily communicated to you ; while the fundamental principle, that there is a ra- dical difference between remitting fever and yellow fever, between fevers depending upon marsh miasms as their source, and those that take their rise from human contagion ; in short, that yellow fever is a distinct idiopa- thic disease acquires additional support It may not therefore be of dis- service to made known the purport 01 this letter. The doctrine maintain- ing that different fevers are of one common origin is in reality so unfound- ed in fact and so pernicious in its consequences that the sooner it is dis- carded, the better will it be for the interests of humanity. Before I conclude, permit me to add a few lines on a subject not wholly foreign to the nature of this letter, the plague. The account of the origin and progress of the plague in the island of Malta, in the year 1813, drawn up by Dr. Calvert, physician to the forces, and printed in the 6th volume ot the Transactions of the Medical and Chirurgical Society of London is a document of great value. The reasoning ofthe author, deduced from the evidence which a faithful narrative affords, seems to be very satisfactory. Contact, he maintains, is the most certain mode of communicating the dis- ease, but he is inclined to deny that it is essential lothe propagation ofthe contagion. " It appears to me, says Dr. Calvert, that this contagion or principle of plague is diffusible in the atmosphere to a distance greater or less from an £76 APPENDIX. infected body, according to the climate and season ofthe year, and possi- bly to other peculiar states of the atmosphere, with which we are unac- quainted ; that in the spring or summer season a single infected person is sufficient to contaminate the air of a whole city ; and that those who happen to be then exposed to febrile causes or otherwise predisposed are the first to become its victims. That these newly infected persons generate a fresh supply of poison, increasing the strength and influence, till at length it be- comes so powerful, that nothing but the winter season will entirely puta stop to it." The various reports that have been so industriously circulated concerning the contagiousness and non-contagiousness ofthe plague, especially as it pre- vailed in the army ofthe East, and the contradictory statements that have been made relative to Baron Desgenettes, induced me, while in Paris in the spring of 1816, to seek an interview with that gentlemen, in order to ascer- tain the truth on this interesting subject. The Baron distinctly declared that it had ever been his settled opinion that the plague was a contagious disor- der ; that his extensive experience as an officer of the medical staff, had only served to confirm him in that opinion ; and further expressed much sur- prise, that any account should have been made public representing his views in a diflerent light. The Baron innoculated himself with the matter of plague, though he felt persuaded that the disease was of a specific charac- ter, and had almost hourly evidence of its contagious effects : but more for- tunate than^he incredulous Whyte, he did not fall a victim to the experi- ment. lam awyehow confidently the case of Dr. Whyte has been denied. So far however from any doubt being entertained by the medical philosophers here, as to tho^iccuracy of the statement of his inoculating himself with the matter of plague, it is well known that his preconceived notions ot the nature of that pestilence, were the cause of his rashness and premature death. Of this I have been assured by personal communication with Sir Gilbert Blane and Sir James M'Gregpr When 1 took pen in hand, I did not expect to produce so long and tedious a letter. My apology must be the nature of the subject, interesting, be- ,yond all others, to an American physician With due respect 1 remain dear Sir, Your Friend JOHN W. FRANCIS. David Hosack. Since the receipt ofthe foregoing letter from Dr. Francis, stating the deci- sions ofthe Royal College and the Army Medical Board, I have made the enquiry among those physicians who have been most conversant with the yellow fever, as it has appeared in the cities of New-York and Philadelphia, more especially since the year 1^91, and in no satisfactory instance, have i found a practitioner who has met with the disease a second time 'in the same individual. During a visit made to Philadelphia in October 1816, I had an opportunity of conversing on this subject with Dr. Kuhn, the Presi- dent ofthe College of Physicians of Philadelphia; that venerable physi- cian informed me, that he ha in a few days, terminated in the death of the patient. The appearances, progress, and termination of this case, led me to the resolution to employ a very different treatment in those cases which might afterwards fall under my notice. Since that period, it has been my practice to support the Strength of my patient by a nutritious and stimulant diet, and the free use of bark and wine ; at the same time preserving the tone and action of the part itself, by frequently washing the tumour with spirits or brandy, and by the constant application of a poultice composed of bark and yest. Find- ing these remedies successful in many instances which have fallen under my care, I enclose to you the follo.wing case, in which this practice was pursued, under the most unpromising circumstances, and therefore is bet- ter calculated to establish the principles upon which the cure of this dis- ease it to be conducted ; especially when it occurs in advanced lite, and is preceded by, or accompanied with, a scorbutic or vitiated habit of body, as, I believe, is most usually the case. I am, with great regard and respect, your's, DAVID HOSACK. On the 5th of March, 1808, I was- called to Elizabeth-town, in New Jersey, to see Mr. John Hartshorne, aged 84, then on a visit to the family of Mr. Thomas Eddy. He was extremely debilitated, and suffering much distress, from a tu^ mour on the small of his back, which had been of several days continuance.- Upon inquiring into the history of the case, 1 was informed that the tu- mour, in the first instance, appeared like a common boil; but having beeu preceded by several smaller ones, and an eruption on the skin, it excited very little attention on the part of his friends. It, however, very soon was attended with an acute burning pain, and began to spread, the adja- cent part assuming a deep red or^ purple colour. The family physician was called, who, at that time, was not acquainted with the peculiar cha- racter of this disease, having never met with it before in his practice, and therefore, very naturally treated it as a common phlegmon ; applying the common cataplasm of bread and milk, for the purpose of inducing suppu- ration, together with the internal use of those remedies that are dually prescribed for the removal of simple inflammatory tumours. The inflammation continued to extend, attended with severe pain in the part, fever, restlessness, loss of sleep, and occasional delirium. In this state I found him The tumour appeared about six inches in diameter; oi a dark purple, livid colour; extremely painful and sensible to the touch; in the centre of the swelling the colour was still darker, and was attended with a discharge of a thin acrid humour, as is usual in erysipelatous in- flammation, altogether exhibiting the symptoms of approaching sphacelus : his pulse was small and frequent ; his skin preter-naturally heated, anci APPENDIX. 9?S attended with a sense of itching over the whole surface of the body; his tongue was moist, but foul; his bowels were costive, except when relieved by injections, which were occasionally administered; his urine were spa- ring in quantity, and high-coloured. • Under these circumstances, of a typhoid state of fever, attended with a gangrenous appearance of the tumour, we advised the part affected to be washed with a strong solution of soap and water, rendered more stimulant by the addition of a small quantity of rum or brandy, and afterwards a cataplasm of bark and yest to be applied over the whole surface of the tu- mour ; the same to be renewed every four hours, making use of fresh yest at each application : a wine-glassful of a decoction of bark and Virginia snake root, was also directed to be taken every two hours, together with the free use of porter, panado made strong with wine, and soup, as his nourishments As be suffered a great deal of pain, he was also directed to take occa- sionally, throughout the day, about twenty five drops of laudanum, and at night an anodyne di aught, if otherwise he was unable to sleep. These directions were faithfully complied with. Upon visiting him on the 7th, his symptoms were much changed for the better. The appearance of the tumour was more healthy, and assumed a brighter colour, but was somewhat increased in sine, and in the extent of the inflammation ; his pulse was more full, and less frequent; his strength was also improved; he suffered less pain, and discovered a greater incli- nation for nourishment than he had before done. As he was fond of eggs and oysters, they were also allowed him. All the other remedies were di- rected to be continued. I did not see him again until the 12th ; in the mean time the bark and yest poultice had been steadily continued, with the decoction of snake-root, a generous diet, the liberal use of wine, and anodynes whenever he suffered much pain, or was deprived of his rest. At this time the tumour began to discharge, at different parts of its surface, a very healthy* pus; the aper- tures were small, but numerous, resembling the cells of a sponge, or honey- comb. It continued thus to discharge for several days. We did not think it necessary to enlarge the openings, through which the matter was evacuated, as directed by Mr. Kirkland, David,f Mr. Coop- er,! and tne Editors ofthe Edinburgh Practice of Physic and Surgery. In cases where the ulceration may be of greater extent than in the present in- stance, and the quantity of matter very great, this practice may be advisa- ble and necessary. About the 22d, we directed the poultice to be omitted, and the wound to be dressed with simple cerate. Within twenty-four hours after this change in the application, the quality ofthe discharge was sensi- bly altered. Instead of a healthy pus, a thin sanies, as in the beginning of the disease, was again poured out. T he complexion of the tumour also assumed a darker appearance; and his friends again became alarmed for his safety. . ,, Finding these changes, we again advised the tumour and neighbouring not a little surprised at the observation of John Pearson (see Principles of f See a very de Chir. torn. iv. ♦ • Sor First J ines ofthe Prwrti™ of f'.ir««rj- 080 APPENDIX. parts to be bathed with brandy, and the poultice of hark and yest to be renewed. From this time the wound recovered its healthy aspect, and continued tp heal, without an unpleasant symptom. When the discharge totally ceased, and the wound had become cicatrized, a light compress of linen wet with rum or brandy, was directed to be applied to the yet tender sur- face of the part affected. As he still continued to complain of an itching over the whole surface of the body, we put him oh the use of the decoction of sarsaparilla and guaiac. On the 7th of April the cure was completed, when he returned to his family, in Monmouth. If it were necessary, I could here add the history of another very for- midable instance of this disease, as it occurred in the family of the late Bri- tish Consul, Col. Barclay ; in which precisely the same treatment was pur- sued, and with the same happy result. D. H. Trachitis or Croup. Croup, according to the definition given of it by Dr. Cullen consists " in an inflammation of the glottis, larynx, or the upper part of the trachea, whether it affects the membranes of these parts or the muscles adjoining." In one particular, this definition is defective, asthe disease is not confined to the upper portion of the trachea, but afso most usually extends itself throughout the whole of the windpipe, even into the bronchia?, and to a degree over the whole surface ofthe lungs. The effusion of the lymph, or * other materials, constituting the membrane, which is the effect of this dis- ease, also very frequently extends into the bronchia?, though of a less firm texture than that part of it which is found in the upper portion of the tra- chea. Some preparations in the anatomical museum of Columbia Col- lege shew this fact. My late distinguished colleague, Dr. John Augustine Smith, the former professor of Anatomy and Surgery in the University of New-York, also informs me, that in a case of croup, met with by him, in which he wascalled upon to examine the parts after death, he observed the membrane to extend as far as the bronchia? could be traced by the knife. Conversing also on this subject with Dr. Bard, the President ofthe col- lege of Physicians and Surgeons of this City, and who has probably been more conversant with this disease than most practitioners, he informs me, that he has commonlv observed in those cases which he has examined after death, that the membrane extended into the bronchia? as well as into the trachea. Dr. Bard also remarks, that the disease is not even limited to the trachea and bronchia?, but that the lungs, throughout their whole substance, to a cer- tain degree, participate in the affection ; insomuch that he has seen those or- gans rendered so dense and solid, that they exhibited in their appearance a great resemblance to the firm and dense structure of the liver, instead of the spongy, loose texture which the lungs naturally present. The appearances upon dissection, related by Dr. Cheyne, in the last edition of his valuable work on this subject, correspond wilh the observations made by Dr. Bard. Dr. Cullen very properly obs.-rves, that croup may arise, " first in these parts, and continue to subsist in them alone, or it may come to affect these parts from the cynanche tonsillaris or maligna spreading into them." This APPENDIX. 981 observation was long since made by Dr. Cullen, and has been abundantly established by the cases and dissections published by Dr. Bard, whose trea- tise is referred to in the Nosology of Dr. Cullen, under the head of cynanche maligna. Other writers however do not appear to have paid sufficient at- tention to this distinction. Dr. Bard informs me. that since the publication of his Essay in 1771 he has frequently observed this disease as the sequela of cynanche maligna. Two cases of croup supervening as an accessory disease in ulcurated sore throat are also related by Dr Ferriar in his valuable paper on that subject. " Though there were large ulcerations in the tonsils," he observes, "there was nothing uncommon in the symptoms till the inflammation extended lo the trachea, when faint, shrill coughing, hissing respiration, and restless- ness came on, which were soon followed by death." Croup also, in some instances, is the attendant upon scarlatina. In Dr. Cheyne's treatise before referred to, a case of scarlet fever is re- corded which proved fatal, in which the membrane was actually formed as in croup, and was removed after death by Dr. Rollo, Surgeon of the Wool- wich Hospital. In some instances, especially where ulcerations take place in the larynx, croup also succeeds to measles. In a case related by Dr. Cheyne, it also succeeded to the secondary fever of small pox ; and by Dr. Underwood it has been known as the attendant upon the putrid thrush. Croup also, says Dr. Cheyne, very often supersedes a common catarrhal affectiou. In a singular instance, Dr. Ferriar also observes, that he has seen pneumonic inflammation converted into a croup on the tenth day of the disease. Dr. Rush remarks, " I have seen it accompany as well as suc- ceed the small pox, measles, scarlet fever, and apthous sore-throat. In the late Dr. Foulke it succeeded acute rheumatism. The late Dr. Sayre in- formed me he had seen it occur in a case of yellow fever in the year 1798." With these facts before us, therefore, there appears to be just ground for dividing this disease into two species, viz. idiopathic and symptomatic croup: idiopathic where the disease is primarily and exclusively seated in the trachea, bronchia? and surface of the lungs ; symptomatic, where it is the consequence of other previous diseases. It is asserted by some writers, but denied by others, that cynanche tra- ■chealis is an infectious disease. As the cynanche maligna and scarlatina are communicated by contagion or infection, doubtless they may also be so in their consequences ; and in this way croup may be transferred by those diseases as the vehicle of communication. The cases related by Von Ro- senstein, in evidence ofthe infectious nature of croup, were probably cases of cynanche maligna, similar to those described by Dr. Bard. We hence see the propriety of Dr. Cheyne's observation, that " when a physician has to visit more than one, with a croupy affection, in a family or neighbourhood,, he ought carefully to examine the state of the fauces." But that idiophatic cynanche trachealis is infectious, I believe there can be no ground for sup- posing. I should as readily beiieve that an inflammation of the brain or of the pleura should be thus communicated, as an inflammation ofthe mem- brane lining the trachea ; and 1 believe it may be safely asserted that the fact is otherwise. In the numerous families in which I have prescribed for this disease I have never known it to be thus communicated, either to the attendants upon the sick or to the other children, even though sleeping in the same room, and frequently in the same bed : but I have more than once been called in the same night, to two children in the same family, both having been exposed to the same cause, and especiaJly where there is a great pre- 382 APPENDIX. disposition to attacks of this disorder, as is the case in particular families. In these instances, as'Dr. Thomas remarks, the attacks are generally less se- vere. I have never visited a child upward of twelve years of age in this complaint, except where it had suffered previous attacks of it; yet in some instances, adults are the subject of this disease. An instance of this which can never be forgotten, is that which deprived our country and world of one of their most illustrious citizens, George Washington. Of the treatment to be adopted for the cure of croup : writers upon this subject differ as widely as they do about the nature or character ofthe disease ; but none in my opinion, appear to have sufficiently dis- criminated between the diflerent stages, in which the remedies they seve- rally recommend ought to be employed : even Dr. Cheype's late,valuable work, which contains the best pathology of this disease, is in some degree de- fective in this respect. I have been led at the bedside to distinguish three distinct stages in croup : the first may be denominate the forming stage of the disease ; in this the affection is local; the irritation has not yet extend- ed to the whole system ; the child even sits laughing and playing upon the lap of its mother, manifesting a very unusual but morbid degree of exhilara- tion ; its skin is cool and moist, its pulse not perceptibly accelerated ; but its hoarse, hollow sounding, and frequently returning cough, its wheezing itv- spiration, its restlessness, and especially its cries after a fit of coughing, all denote to the physician and parent acquainted with the disease, the conse- quences that will ensue, if active means be not employed to prevent the second, or febrile stage. In this stage the whole system partakesof the irri- tation ; the pulse is frequent, the skin hot and dry, the respiration hurried, the tongue covered with the usual white fur indicative of inflammation, the lips and cheeks remarkably florid, the cough frequent, but attended with a more acute sound than that ofthe first stage; every inspiration too is attend* ed with more uniform wheezing than that which appears in the first, when occasionally an interval occurs in which the child breathes as if in health. But in this second stage no such interval is perceived ; the trachea, bronchia? and lungs become so surcharged by the circulating fluid, that the child has not even a momentary relief from its oppression; and in a short time, if left to itself, especially if the patient be plethoric, the countenance exhibits a pur- ple, livid colour, not unlike that of apoplexy, and is even attended with a degree of stupor, or propensity to sleep. If the patient be now neglected, or the evacuations be sparing and insufficient, &c. effusion from the exhal- ent vessels opening into the windpipe, bronchi«, and surface of the lungs, inevitably takes place. In the two former, the effused matter assumes a membraneous appearance, probably owing to the forcible passing and re- passing of the-air through those preternaturally constricted tubes ; but in the lungs themselves it appears in tbe form of a viscid fluid, partly resembling both phlegm and pus. When this effusion has actually taken place, the feb- rile symptoms sensibly abate, and sometimes disappear altogether, the child is also apparently free from pain, but it suffers violent paroxysms of cough and difficult breathing, attended with an irregular and spasmodic respira- tion, as in asthma, or dropsy §f the chest, and with similar intervals of ease. These paroxysms, in young children, continue but a few hours before dis- solution. But in children arrived at eight or ten years of age, they frequently continue several days. In some cases the impediment to inspiration, and the distress attending the paroxysms are so great, that the only position in which the patient can re- hire, is with the head thrown Lack. In this situation the trachea is extend- APPENDIX. 988 e3, and thereby its capacity increased, and adapted to the membrane which it encloses. In some instances before death, general convulsions ensue* which speedily terminate the sufferings ofthe patient. This stage, in which the membranous effusion takes place, I denominate the membranous, or pu- rulent stage: from this advanced state of the disease recovery is so rare. that it is not to be expected ; it might almost be denominated thefatal stage of croup. These distinctions, it is, in my opinion, important for the practi- tioner to keep in view, as they lead to important conclusions in practice. They feacb us, during the first or forming stage of this disease, to adopt the most active means of restoring the suppressed secretions ofthe trachea and surface of the lungs, and by open bowels and perspiration to guard against the general excitement ofthe system. For this purpose, when called to a patient labouring under the first symptoms, in which the disease ap- pears to be confined to the parts primarily affected, it is my practice to ad- minister an emetic composed of tartarized antimony and ipecacuanha. To a child under two years of age I direct from one to two grains of the emetic tartar, with from five to ten grains of ipecacuanha every fifteen min- utes, until it operates to such a degree as to induce a plentiful secretion from the trachea and lungs. VVhen the emetic has no other effect than to produce vomiting, I immediately direct the bowels to be emptied by the common in- jection, and a dose of calomel from five to ten grains to be given, unless the child may be completely relieved : for it frequently happens that an emetic alone, by restoring the excretions from the windpipe and lungs, and the other evacuations by perspiration and stool which it creates, affords immediate re- lief, especially if the physician be called early in the disease. But it too frequently happens, that many of the common family prescript tions are in the first instance employed, and much valuable time lost before the physician is called upon ; in that case, if the febrile symptoms have al- ready manifested themselves, other remedies are indicated. In this second stage of croup, such is the determination ofthe circulating fluids to the part affected, and such the general febrile excitement ofthe system, that the most efficient means of diminishing the plethora ofthe bloodvessels, and of divert- ing the irritation from the part affected, become necessary. With this view, tbe patient should be bled freely, in proportion to its age and powers of con- stitution ; say for a child under two years, from two to four ounces; from two to six years, from four to six or eight ounces, and to be repeated as the urgency of the symptoms may require. Most writers recommend the blood to be taken from the jugular veins : as I have never, even in the youngest children, experienced any difficulty in opening a vein upon the back of the hand, and of drawing a sufficient quantity of blood from that part, especially after immersing the hand a short time in warm water, I have never had occa- sion to open a vein in the neck ; and as the child is generally very restless in this disease, and there is on this account more hazard in opening one of the jugular veins than those on the back of the hand, I have uniformly pre- ferred the latter. It is also preferable on other accounts : it is difficult to ascertain the quantity of blood drawn from the jugular ; the vein cannot be so readily closed, and the orifice is apt to open afresh by a violent fit of cough- ing. After blood-letting generally some partial relief is immediately obtain- ed ; respiration is less frequent; the peculiar noise of inspiration is also di- minished ; the cough becomes more loose and yielding; the skin is rendered moist and the pulse less tense and frequent. But these favourable symp- toms are oftentimes deceptive, and of short duration : the cough, laboured respiration, and heat of skin, are perhaps all renewed in the course of an hour 984 APPENDIX. In that case the antimonial emetic must be immediately employed. Al- though the force of the disease may have been greatly subdued by blood- letting, the alarming symptoms so frequently return, that I am now in the constant practice of prescribing the emetic immediately after blood-letting has been performed, without waiting to ascertain pean:rl in the British Om paign of Egypt, in 1801. 992 APPENDIX. produce immediate relief, by diminishing the excessive evacuation which takes place from the liver and serous vessels of the intestinal canal in these diseases. Cases of this sort have frequently fallen under my observation, in which I have been compelled to employ the lancet, where the remedies ordinarily prescribed, viz. rhubarb, magnesia, emetics, &c. have been ad- ministered without success. In those case* attended with great pain in the stomach and bowels, or with spasmodic affections of this organ, the warm bath and blisters have also been applied, in conjunction with the lancet, with manifest advantage, and probably have afforded relief upon the same principle, by diverting the irritation from the internal organs to the exter- nal surface of the body. Diabetes. As far as experience enables me to decide, Diabetes depends primarily upon a diseased action of the digestive organs or a want of tone in the as- similating powers of the system : the kidneys are secondarily affected. The stomach may become impaired from various causes: in four cases out of five of diabetes which have come under my notice, this condition of the sto- mach was produced by the intemperate use of ardent spirits: and in three other patients, by the immoderate use of fruits and confinement to a vege- table diet. Sydenham was the first who considered it a disease of debility, in which the system was unable to assimilate the nourishment to itself, a fault in the assimilating process ; but he did not consider it an idiopathic affection. Dr. Ferriar adopted the same belief, that it is a disease of pure debility, but supposed at the same time some local disorder in the kidneys: —in the last communication I received from him he retracts this opinion. That the kidneys, because they are the channel or outlet of the disease, are the seat of its proximate cause, is far from conclusive reasoning. We do not infer that the kidneys are diseased, because in jaundice they pour out more or less of bile. The most successful treatment of diabetes is that originally proposed by Sydenham: the use of animal food, and abstinence from all vegetables and fruits. In his letter to Dr. Brady he even particularizes the meats; viz. such as are of easy digestion, " veal, mutton, and the like" Upon the principle of correcting the acetous or fermentative process in the sto- mach, Dr. Rollo has recommended the hepatized ammonia. But this me- dicine is so nauseating and debilitating to the already debilitated stomach, that it cannot but fail of doing more harm than good. Ferriar judiciously prescribes, beside animal food, various tonics, as bark, bitters, chalybeates. &c. and in the 4th vol. of his Med. Histories and Reflections, he has pub- lished details of thirteen cases of which he kept minutes; ten of these re- covered and two were relieved. In the case of a child recently under my care, the disease was removed by animal food alone. In the third volume ofthe Medico-Chirurgical Transactions, Dr. Bostock of Liverpool, has offered some interesting observations on Diabetes Insipi- dus. This disorder, though but seldom noticed, Dr. Bostock is inclined lo believe is of more frequent occurrence than is generally imagined. In the case, the particulars of which are noticed in the work just mentioned, Dr. Bostock effected a cure by the use of preparations of iron and the warm bath. APPENDIX. 3S& Phthisis Pulmonalis* The chapter of our author on pulmonary consumption is upon the whole extremely satisfactory; though it is to be wished he had more forcibly in- sisted upon the division of the disease into two stages, a principle all-im- portant for the practitioner to keep in view. The older as well as the more modern writers have attempted to describe various species of the disorder unnecessary here to enumerate. In my opinion the best distinction that can be made in pulmonary consumption will be to divide it into two stages, the acute and the chronic, analagous to the arrangement of Morton into the jncipiens and confirmata. Acute and chronic are preferable terms as they convey a correct idea of the nature ofthe inflammation attending upon the first stage of phthisis, and of the termination of such inflammation in the last stage, in which, either ulceration or an excessive excretion of pus takes. place. For this reason too I have thought proper to give it a place among the phlegmasia?, instead of considering it as one of the hemorrhagies, in which order it is arranged by Dr. Cullen. The causes of phthisis pulmonalis are pretty amply noticed by Dr. Thom- as ; and, from all that can be adduced, I think the disorder on the increase in our own country as well as in Great-Britain. These causes, how- ever, are not exactly in both countries the same ; with the increase of manu- facturing establishments in England, we find an increase ofthe evils which induce pulmonary disorders ; and of these evils, scrofula may properly be considered among the principal. In the United States scrofula is compara- tively little known; but while we admit the influence of particular employ- ments and modes of living in inducing consumption, this disease in most instances in this country, may be ascribed to the sudden vicissitudes we ex- perience in this climate, particularly on the seaboard ; to imprudence in dress, and improprieties in the use of ardent drink, and other species of dis- sipation. A common catarrh, especially if frequently renewed, may be placed at the head of the causes ofthe disorder in this country ; it is one of those causes too, which, while it attracts the least attention commonly does the greatest mischief. The inflammatory character ofthe forming stage of pulmonary consump- tion, cannot be too constantly kept in view, and the treatment indicated for the removal of other inflammatory affections ofthe chest will be found to be most successful in this more insidious disease. In the quarterly reports on the diseases of this city, I have already noticed this point of practice. " We have in many instances employed blood-letting with the most happy effects in many cases of incipient phthisis, even where strong hereditary pre- disposition existed. Indeed, we are induced, from some late observations on this subject, to express the opinion, that in the commencement of phthisis, as in peripneumony, blood-letting is not sufficuuitly employed, but is too fre- quently neglected until the inflammation has^> far extended that suppura- tion becomes inevitable. Nor do physicians in general appear to have been sufficiently attentive in describing the symptoms characteristic ofthe first or inflammatory stage of phthisis, and consequently, have been regardless of that active antiphlogistic treatment which alone can prevent the tuberculous or suppurative stage. In as much as suppuration, or a purulent secretion from the lungs necessarily implies preceding inflammation, we conceive too early attention cannot be given to the premonitory symptoms which an- nounce the inflammatory stage, but which are frequently so inconsiderable, being seated in tbe less sensible, the cellular portion of the lungsr that both 994 APPENDIX physician and patient are alike regardless of the present symptoms, and ofthe consequences, to which they lead. Instead, therefore, of trusting to sy> ups, anodynes, pectorals, ptisans, the Iceland moss, or the divine alcor- noque, to allay the hacking cough and pains in the chest which indicate the first approach of the-disease, we earnestly recommend the same active treatment by blood letting, blisters, and other means of diminishing excite- ment, as are employed in the treatment of a pleurisy, or any other acute inflammation ; and we could add, in confirmation of this view ofthe sub- ject, many recent cases in which the practice here recommended has been attended with the most beneficial results."—Vide Amer. Med ty Phil. Reg. Much might here be said ofthe utility of mild emetics in the forming stage of phthisis, given occasionally after blood-letting, and other evacuants have been employed. But recommended as they are by Dr. Reid, indis- criminately in all stages of the disease, they cannot fail to do serious mis- chief. The reader will advert with practical advantage to " Thoughts on Pul- monary Consumption" by Dr. Rush, in the Medical Inquiries and Obser- vations. Dropsies. Ofthe disorders arising from a general plethora ofthe system, the various species of dropsy may be mentioned. Experience has long since taught me that morbid accumulations of watery or serous fluids arise as often, nay, more frequently, from increased exhalation, the effect of an overloaded state ofthe blood vessels, than from diminished absorption occasioned from a loss of tone in the absorbent vessels, and consequently that dropsy may and frequently does proceed from the want of blood letting as well as from the excessive use of that evacuation. 1 have seldom if ever attended a case of hydrothorax that did notarise from increased exhalation; the same may be said of hydrocephalus, which is almost always, I consider, prece- ded by, or accompanied witli, inflammation of the brain. Did the limits to which these notes are restricted permit, it were easy to relate many instances of hydrothorax, ascites, and anasarca, produced by such fullness of the vessels, relieved by blood-letiing, calomel and squills, and other depleting remedies ; and the powers of the system again restor-' ed by chalybeates and other tonics. Digitalis, so generally and so freely administered in dropsies, can only be serviceable when the disorder is in its forming state. In the secondary stage ofthe disease, when symptoms of fullness or preternatural excitement do not exist, this active narcotic can- not fail to do harm. Hydrocephalus, in its acute form, is an affection of frequent occurrence in this city: in three cases for which I not long since prescribed, a cuie was effected by blood-lettingAtive cathartics, and blisters, all which were made use of during the inflammatory stage of the disease, before the symp- toms of effusion had taken place, in their greatest extent. In those cases mercury was not administered except as a cathartic in combination with large doses of jalap This fact reminds us of the remark of Dr. Rush, that in consequence of his unsuccessful use of mercury in dropsy of the brain, he has declined the use of that medicine altogether in this disease, ex- cept when combined with some purging medicine,and that he administers it in this form, chiefly with a view of dislodging worms. Query. Does not mer- cury, by the excitement it produces, add to the inflammation which charac- APPENDIX. 995 terizes the first stage of hydrocephalus ?—Mercury, in my opinion, has of- tentimes been the exclusive cause of this disease. Certain it is that dropsy ofthe brain has become of much more frequent occurrence since the general, and i had almost said the indiscriminate use of this metal in febrile and inflammatory diseases. In the fourth volume of the Medical Histories and Reflections, the author, Dr. Ferriar, appears to have been solicitous to find a more certain hydra- gogue than any of those now in use ; and from the successful results of his Own ample experience he recommends an extract of the elaterium as sur- passing every other medicine in the power of removing serous accumula- tions, and as affording astonishing relief in the dyspnoea arising from hydro- thorax and ascites. Pliny, as stated by Dr. Ferriar, though he was not acquainted with the power of the elaterium in dropsical complaints consi- dered it highly valuable, " ad magnos mortalium usus." Dr. Ferriar has briefly related the particulars in twenty cases in which the elaterium was prescribed with various success. Upon its first exhibition to a patient it is nearly as active and as dangerous, if incautiously given, as arsenic. "The sensible effects of the elaterium are severe and constarft nausea, frequent watery stools, and, in considerable doses, vomiting, it does not uniformly increase the urine, and for this reason it is generally proper to combine it with more certain diuretics. After continuing the use of the medicine for some days, the patient will sometimes bear a considerable in- crease ofthe dose I have gone to the extent of five or six grains a day in this manner, without producing any inconvenience. But it is always pro- per to begin with the lowest dose, which is the sixteenth part of a grain of the extract." Since the last edition of this appendix, I have frequently had recourse to the elaterium both in hospital and private practice. My experience coincides with that of Dr. Ferriar : the elaterium is a powerful and in every instance in which I have used it, a certain hydragogue. 1 have begun with the eighth of a grain four times a day, and given it to the extent of two grains three times a day. It produces copious liquid evacuations from the bowels', under circumstances of great torpidity of the intestinal canal, when other powerful means have failed, and at times causes an additional increase in the urinary discharge. This latter effect, however, as remarked by Dr. Ferriar, i» very uncertain. I have deemed it most expedient, notwith- standing its vigorous action, to unite the pulv. exlr. elat. with small doses of cream of tarter, in preference to either calomel or squills. It does not ap- pear to add to the debility of the system, as some other remedies employ- ed to fulfil the indications answered by the elaterium. Doctor Yeats of London, in his letter to Dr. Wall, has lately published some highly interesting observations on dropsy of the brain. In his Dis- sertation on the Pathology of the Fluids Dr. Dyckman has also treated aT .some length of dropsies arising from plethora ofthe vessels. Venereal Disease. Notwithstanding all our author has so ingeniously said to the contrary it is deemed unnecessary here to attempt lo show that gonorrhoea, or ure- thritis as I have denominated it, and lues venerea, are diseases of a differ- ent nature ; that each originates from different causes and that the mode* *f treatment each requires is different. S96 APPENDIX. In the treatment of gonorrhoea regard must ever be had to the stage of thfe disorder The usual prescription, especially among young practitioners, is lead water : many years since I became acquainted with the pernicious consequences of that injection. Indeed in every case of gleet following go- norrhoea, for which 1 have ever been consulted, the disease has been, with- out a single exception, traced to .the debilitating sedative effects of that metal. Most cases too ofthe inflamed testis, which I have seen attendant upon gonorrhoea, have been produced by the same cause, viz. the too ear- ly and sudden check of the secretions ofthe urethra by the use of lead in- jections. In gonorrhoea as in inflammation of the eyes, the treatment of the first stage consists chiefly in abstinence from stimulant drinks and ani- mal food ; the free use of barley water, lemonade, and other diluents, mild cathartics, and other evacuants where tliey are indicated, bathing the part affected with warm water, or the use of the warm bath ; and after the pain, ardor urina?, and other symptoms of inflammation have somewhat subsided, tbe use of an injection of a solution of the sulphate of zinc, from two to four grains, in proportion to the sensibility ofthe parts affected, to an ounce of rain water, employed six or eight times a day until the purulent discharge has totally disappeared. In like manner in the treatment of an inflamed testis, which I may remark I have never seen produced by the vitriolic in- jection, as stated by Dr. Thomas, instead of cold Saturine applications, I have for many years past prescribed in addition to the usual antiphlogistic means, tepid fomentations of vinegar and water with the most beneficial consequences. Were not the remarks in some degree misplaced, I might here consider the treatment frequently adopted with regard to inflamma- tion when affecting other parts, as inflammation of the eyes, &c. In the inflammation of the capsular ligaments, the effect of strains, the practice just stated may be safely recommended, until the pain, tumour, and inflam- mation are removed. When debility alone remains and the parts are free from irritation, cold applications of vinegar, water, or spiritous liniments may then be advantageously prescribed ; but with many practitioners a different practice prevails. Instead of warm, cold applications are direct- ed from the very commencement of the injury, and which rarely fail to stiffen the joint, to increase the pain, and ultimately to add to, instead ot diminishing the inflammation. Mercury is wholly unnecessary in the treats ment of gonorrhoea. In the constitutional disease called syphilis, as a general rule I have found the internal preferable to the external use of mercury, and the mercurial salt which from experience I recommend as combining most advantages, and as agreeing best with the greatest number of cases, is the corrosive sub- limate or oxymuriate of mercury. This salt either in the form of pill or solution I have uniformly employed with success for the cure of syphilis. not only when the disease may have been recently contracted, but in the most malignant form which it assumes when it has been neglected or inju- diciously managed. A valuable auxiliary will also be found in the decoction of tbe lignum guiaci and the radix sarsaparilla?, as powerful alteratives. Here I cannot but protest against the salivating system by friction with mercurial ointment, and the use of calomel so commonly had recourse to. It is true that those forms of exhibiting mercury very soon affect the gums, but it is no less true, that when mercury exerts its influence upon the salivary glands, in proportion as this influence is manifested, it ceases to operate up- on the other excretions ofthe system,and consequently is less active iu elim- inating from the body the poison of the disease. Salivation, it is now wel! APPENDIX. 9$"/ ascertained, is wholly unnecessary in the treatment of syphilis, and the knowledge of this truth, cannot be too extensively circulated in a country, where, notwithstanding the present respectable state of its medical science, many ofthe most pernicious errors of some of the older practitioners are still sedulously inculcated. As the introduction of the corrosive sublimate is calculated to remove many absurdities in the present practice of treating syphilitic disorders in this country, I am induced to make a quotation of some extent from an Essay on this subject inserted in the Amer. Med. and Phil. Register. lam aware that in certain of the public hospitals of Great Britain as well as of the United States, the corrosive sublimate is rigidly proscribed as inefficient for the cure both of the primary and secondary stages of lues venerea ; but it deserves to be recollected, that this form of mercury still retains throughout the European continent, the high celebrity it acquired long since as an anti-venereal In the Venereal Hospital at Paris, the largest and one ofthe best conducted establishments of Europe, the corrosive sub- limate is the only form of mercury employed, and Professor Cullelier, after the most ample experience at this charity, knows not an instance of failure with this remedy, or one in which it has produced injurious effects. In the essay just alluded to, after having considered the modus operandi of mercury upon the human constitution, and the abuse of this medicine as an article of the Materia Medica, Dr. Francis observes : " Among the principal advantages which the corrosive sublimate (the oxymuriate of mercury,) possesses over that of every other preparation of mercury are, that, judiciously administered, it is particularly mild and safe in its operation, will admit of a more extensive use iu all the various forms of lues venerea,and subject the patient to fewer inconveniences : that it readily enters into the general circulation, becomes miscible with the several fluids of tbe body, the soonest arrests the progress ofthe complaint, and eliminates the morbid matter through those emunctories best calculated for that pur- pose : that it supersedes the necessity of salivation, by its action on all the secretions, and by promoting especially the cuticular discharges, and the evacuations from the kidneys : that it is the only preparation to be depended en in those peculiar habits of body so susceptible to become salivated by every other form of mercury now in use ; that in its ultimate effects upon the constitution, it is attended with, comparatively no injury. These fact? are indeed truly important, and many of them are granted by those who altogether reject the use of this preparation. " It is not a little unfortunate for the advocates of other combinations of mercury, that the objections which have been brought against the corrosive: sublimate are so dissimilar. Jt has been assigned as a reason against the preparation itself, that it has failed of its salutary effects by being given in too small doses. By some its anti-venereal properties are said to be lost on account of its too readily exciting the cuticular discharge; by others it is owing to its defective action on the secretions ofthe skin and mouth. By some it is admitted to be beneficial in the primary stage ofthe disease, and by others it is contended that it is calculated to remove only secondary symp- toms. It is also declared that it is violent and uncertain in its operation, and that it does not render the cure permanent.* Some of these objections are indeed, weighty, and, were they well founded, would fully justify the abandonment of this peculiar combination of mercury; but if the lear. " Hunter, Howard,Pearson, Mathias. and others. 998 APPENDIX. reliance is to be placed upon the experience and observation of those who have employed the corrosive sublimate with the most disinterested and honourable views, and solely to determine upon its anti-venereal powers, evidence sufficient to prove the fallacy of these objections, and derived from indubitable sources, might be adduced. The testimony of Dr. Locher, of the Vienna hospital, is so full and explicit, that it were an omission not to insert it. Having witnessed the ' horrid calamities' arising from salivation and other abuses which existed in that institution in the management of venereal patients, upon the recommendation of Van Swieten, he made trial of the corrosive sublimate. From the year 17^4 to 1762, he cured by it no less than four thousand eight hundred and eighty persons, without in- ducing salivation; and testifies, that 'no persons died, or experienced the least painful and dangerous symptoms, in consequence of this remedy.'* In the cases in which the same preparation was recommended by Prirtgre,t the cures that were affected were permanent, and from the repeated expe- rience of many other distinguished practitioners, the Same result ensued. Multa nobis exempla visa sint luis venerea?, mercurio sublimato eorrosivo perfecte sanata?.J " To enter into a consideration of the treatment of the various symp- toms which characterize lues venerea in its simple and in its more confirm- ed state, is not deemed.necessary, nor will it here be attempted. Fully convinced, as the writer is, of the decided advantage which the corrosive sublimate, as an anti-venereal remedy, possesses, in most cases, over other mercurial preparations, he cannot forbear adding a few further observa- tions for the purpose of recommending to more general use this combi- nation of mercury. " A very forcible reason why a preference ought to be given to the cor- rosive sublimate as an anti-venereal remedy, is the mildness of its opera- tion when compared with most other mercurial preparations. In the mind of the judicious practitioner, there need exist no apprehensions ofthe seve- rity of its action ; few articles of the materia medica can be more readily accommodated to the peculiar condition of the patient and the nature and stage of the disease. The evidence of its mildness may be adduced from the salutary effects which it produces in the constitutions of delicate chil- dren, and even of infants. In not a sjngle instance, within the recollection of Dr. Hosack, has it ever been followed by pernicious consequences, though long employed by him in many cases in which the patient laboured under some hereditary taint, obstinate cutaneous eruption, or other symp- toms indicating an alterative course of remedies. The destructive effects which have been mentioned as attending its administration, such as exces- sive pain and irritation of the stomach and bowels, headach, fever, &c. may, in certain cases, arise from some peculiarity of constitution obnoxious to mercurial remedies, but are doubtless, in general, to be attributed either to the improper preparation of the corrosive sublimate, or to its having been given in undue quantity. It has been asserted that this mercurial salt is particularly injurious to those labouring under pulmonary affections. That this objection is ideal, or rather that, of all mercurial preparations, it applies with least force against the corrosive sublimate, must be evident upon considering the general operation of this form of mercury. Every * Lochers Obscrvat. Pract. as quoted by Van Swieten, Commentaries, vol. 17. p. 294 I Gorden, Lond. Med. OLis. and Inq. vol. 1. p. 365. vol. 2. p. 73. t Ratio Medendi, pars sccunda, p. 229. Seealso ftjei'ica Clinira, by Christen Gott- lieb Selle. Berlin, 1S02 APPENDIX* 999 combination of this mineral may prove more or loss injurious in the form- ing stage of consumption, on account ofthe active inflammation which is then present, and the additional irritation attendant upon mercurial ac- tion. For it may be laid down as a general principle, that mercury is in itself injurious when administered to any considerable extent during the existence of inflammation and febrile excitement, and before the employ- ment of blood-letting or other evacuants. " From the mild operation of the corrosive sublimate, properly prepared, may be inferred the utility of its employment in persons of delicate habit,and in those cases especially where the constitution is materially impaired. In cases of this kind its exhibition is followed with the best effects. That the tonic powers of the system may, however, in certain instances, be so far weakened as to render the employment of every form of mercury not only inefficacious in the removal of syphilitic complaints, but productive of the most distressing symptoms, and consequently, that the use of the oxyge- nated muriate will at times be the cause of much inconvenience and real suffering, there is left no room to doubt. In irregular cases of this nature, the remedy necessarily fails of producing its ordinary beneficial effects; and as it becomes an additional source of irritation, it greatly increases the debility which already prevails. These effects, as has just been re- marked, do not result from the exclusive employment of any particular form of mercury; they seem to arise less frequently from the corrosive sublimate, but are common to all mercurial preparations. For if the con- stitution has not the power to support the action of mercury, vain is the at- tempt to eliminate from the system the virus of lues venerea. Hence, in the treatment of certain diseases of hot climates, especially in unhealthy situations, it is not an uncommon practice to administer the bark daily du- ring the whole course, for the purpose of enabling the constitution to bear a suflicient quantity of mercury to subdue the complaint.* Upon the same principle that learned physician and distinguished writer, Dr. Chisholm, maintains, that in the management of disease a reduction of plethora at the commencement, and the augmentation ofthe vis vita? in the advancement, are to be particularly attended to, in order to ensure the successful adminis- tration of mercury.t Dr Ferriar has observed instances in which the vene- real disease itself assumed a peculiar character owing to debility, where the debility so far prevailed that the constitution had not power to form a genu- ine syphilis. When this happens, mercury will not effect a cure. < Under these circumstances,' adds Dr. Ferriar, < l*have advised with success a course of tonics without mercury, to raise up the constitution t the sto- tinued for a long time without P^^^^Seneficial effects than mach and bowels, and W,th greater cer a m^^ the same quantity of this saltin the ^»J»P^0 orthree weeka after JE1^ toacc9mp,ish a radical cure. 19g 1002 APPENDIX. " It has already been observed, that the oxygenated muriate of mercury operates more readily on the constitution than any other form of this mine- ral, and that even in very small quantity it soonest arrests the progress of veneral symptoms, and, by its general action, eliminates the poison of the disease- It deserves to be stated, that during the use of this preparation, all those precautionary measures with regard to diet and regimen, which are generally recommended by writers, need not be regarded with the same scrupulous attention, while in the use of the corrosive sublimate, as during the employment of other mercurial medicines. For as the corrosive subli- mate rarely affects, to any considerable degree, the salivary glands, those subjected to its use are not rendered so susceptible ofthe influence of cold, and the physician is seldom under the necessity of devising means for the purpose of obviating the pernicious consequences of salivation. Instances of peculiarity of constitution may occur which require much management and discretion in the use of this remedy. Mr. Bell has observed, that opi- ates have not the same influence in preventing an undue action of the oxy- muriate of mercury upon the stomach and intestinal canal which they com- raonly have with other mercurial preparations.* The limited experience of tbe writer has not in any case corroborated this opinion : on the contrary, hie has found an occasional recourse to small quantities of opium highly serviceable. " As someone or more articles ofthe vegetable kingdom are, in general, employed in those cases in which the corrosive sublimate is administered, it perhaps would not be irrelevant to examine how far they are entitled to par- ticular confidence. It may be proper to remark, that of the many sub- stances which have been employed as auxiliary remedies, or are now iu use, the lignum guaiaci and the radix sarsaparillae unquestionably claim the first notice. They are acknowledged to be useful during the adminis- tration ofthe oxymuriate of mercury, iu cases of recent affection ; and in the secondary symptoms of the disease, for the removal of the evils which have taken place from the injudicious employment of mercury, &c. their salutary operation has been uniformly evinced. " The compound decoction of guaiacum and sarsaparilla may readily be prepared in the following manner : R. Rasur. ligni guaiac. Rad. sarsapar. fissa?. ail. 31. Coq. in aq. font. ftViij. ad ft>. ij. " Of this decoction the above quantity, taken warm, ought to be drunk within the twenty-four hours. Of its effects as a powerful alterative for the removal of some ofthe most painful symptoms of lues venerea and ob- stinate cutaneous affections, indubitable evidence exists in the pages of the old and in those of the most eminent modern authors.t During a period of more than forty five years its virtues for these purposes have been tested iathe practice of that learnedand distinguished physician, Dr. Samuel Bard, and for more than twenty-five years in the practice of Dr. David Hosack. Its salutary properties appear to be owing chiefly to the general excite- ment which it produces, and to its action as a diaphoretic. When had le- course to, while in the use of mercury, particularly in the treatment of those cases where the disease is of long continuance, it proves eminently useful * Treatise on Gonor, and Lues. Ven. vol. 2. p. 248. i Vide, Aphrodisiacus, Ed. Boerihaavii. Aho, Hunter, Bell, &o - APPENDIX. 1003 by promoting the natural tendency which the corrosive sublimate possesses to increase the cuticular discharge. " The compound decoction of the guaiacum may be taken with success for the removal of many ofthe morbid effects produced by the improper em- ployment of the different preparations of mercury, and for restoring the constitution to its wonted vigour. The advantages arising from the use ofthe Rob Anti-syphilitique* for which so enormous a consideration is demanded, may with confidence be attributed principally to tne sarsaparilla which enters into its composition." For further information the reader is referred to the improved edition of Bell on the Venereal Disease, edited by Drs. Low and Beck of Albany; and to the papers on Mercury, published in the American Medical and Philosophical Register, vols. 3d. and 4th. Anaphrodisia, or Impotency. Dr. Thomas has, in general terms, stated the means best calculated to fulfil the indications of cure in those cases in which from general weakness a debility of the genital system is induced, and a consequent loss of the venereal appetite and powers is the result. Many are the causes which may be assigned for disorders of this nature: the abuse of mercury in the treatment of syphilis and of some other diseases, the unsuccessful manage- ment of gonorrhoea, the still popular and pernicious practice of using lead injections, neglected gleet, excessive venery, and particularly onanism may be enumerated as the principal. In this condition of the physical system the intellectual powers of the patient often largely participate, and few ca- ses, indeed have stronger claims on the attention of the practitioner than those in which these circumstances, arising from these causes, are united. Too frequently the representations and sufferings of the patient are re- garded merely as the phantoms of the mind, and from an indifference both as to the real disease and a want of confidence in the means that may be successfully employed, the most deplorable consequences ensue. To enumerate, in detail, the various methods had recourse to in order to renovate the constitution thus imprudently broken down, would swell this note lo an inconvenient extent, and be, moreover, unnecessary, as most physicians are fully apprised of the means employed for this purpose. " The tincture of lytta, says Dr. Thomas, might likewise be of service if given in small doses." The truth is there is not an article of the materia medica used in any individual disease the value of which ought to be esti- mated more highly than the lytta in cases of semjnal weakness and impo- tency when arising from the sources just stated. Though until within a few years its internal administration was pronounced to be almost uniform- ly productive of dangerous effects, yet it is now fully established, by nu- merous facts, that the instances in which it disagrees with the constitution are extremelv rare, and that when, from unforseen circumstances or pecu- liarity of habit, the mischief isproduced,it can generally be removed by the readiest and mildest means. Occasionally, indeed, an active antiphlogis- tic treatment, such as blood letting, saline cathartics or senna and manna; the free use of diluents as soda water, barley water, &c. and the warm bath may be demanded. The claims of camphor in counteracting the ac- • Vide M'Neven's Account, of the Rob of JUffactcur, in the New-York Med. m& Phil. Journal, Vol. 3. p.,23. 1-004 APPENDIX. tio.i <>f the lytta do not appear to be clearly established. My own expert- ence does not enable me to recommend it : if camphor relieves the morbid symptoms, so seldom excited by the lytta, it must, 1 think, do it by its anodyne or sedative properties, and not by any peculiar virtues attributed to it; and, if such be the case, I would much rather depend on the use of opium in small doses* Most generally any uneasy or distressing symp- toms from the internal use ofthe lytta disappear of themselves by ceasing for a while to taKe the medicine, aiid that too*v#thin twenty-four or thirty- six hours afterwards. The lytta is not, as is generally supposed, local in its action, but pro- duces a general excitement: it increases the sanguineous circulation, the flow of urine and the discharges by perspiration : from its diffused action the whole system becomes invigorated, and this altered state is manifest- ed by an enlivened condition both of the mind and body. The morbid discharge from the urethra becomes altered and assumes a thick and opaque aspect and ultimately the wonted functions of the body are restored. The lytta has been recommended to be given in powder, in the form of pills, and in tincture. The only pharmaceutical preparation which I have employed, for internal use, is the last. The tincture seems to be the most agreeable and, in general, the.most manageable form. The extent ofthe dose depends materially on the peculiarity of the case. Roberton observes, " It seems an invariable rule that the greater the existing de- bility either of the general habit or ofthe generative organs, the greater quantity ofthe lytta is requisite to effect and keep up the irritation in the urinary passages ; and in such cases the cure is always more tedious. In those apparently stout, small doses, comparatively speaking can be taken, while in those whose general health, or whose generative organs only are most morbidly affected, can take the most; and, as they approach to health the doses requisite to keep up the irritation must be diminished, the system and also the generative organs being more susceptible of its action." Experience strengthens the preceding remarks of Mr. Roberton, to whom we are so much indebted for his valuable work on the Generative System. The dose of the preparation with which I have generally com- menced is twenty or five and twenty drops three times a day, in a little wine, tinctura amara, or water. After the use of the article a few days the dose is to be increased to thirty or forty drops and as often repeated within the twenty-four hours. It has happened, at times, that on the third or fourth day, and now and then even earlier that the patient complains of some little uneasiness in passing water : this if it does not increase may be, for a while, disregarded : if the pain becomes severe the remedy must be laid aside, until the distress abates, after which it may again be pre- scribed to the same extent, if not greater, until similar effects are again in- duced : In this manner the use of the lytta is to be continued. A practi- cal precept must be here enforced, perseverance in the use of the remedy. The extent to which it may be carried would, unaided by experience seem increditable. Cures have been effected within a few days; at other times from peculiarity of condition, as many months or years have been required to accomplish the object in view. But such disconsolate cases as call for this prescription demand all the presenber's skill; yet the great success which has followed this practice justifies the firmest perseverance equally on the part of the physician and the patient, * See also Orfila on Poison. APPENDIX. iooi In a case (a Mr. R-----a?t. 27 years,) which came under the care of Dr. Francis and myself, in the month of November, 1816 the lamentable condition to which the sufferer had been previously reduced, by the bad management of a neglected syphilis, and afterwards still further by an in- judicious use of lead injections of an unwarrantable strength for nearly two years, led him in a state of extreme mental anguish to disregard the advice given him and to seek the termination of his anxiety by self de- struction. With this view he took nearly six ounces of the tincture of cantharides during the night. Yet no dangerous symptoms occurred : he admitted he felt a degree of warmth throughout his body to which he had been a long time a stranger and that his mind was less depressed, than before the commission of this act of folly. He nevertheless went out as usual the next morning: lit- after this became persuaded that his situ- ation was not altogether hopeless, and that his constitution as he said had still some stamina left, to justify h )pes of a recovery. He was now indu- ced to take the tincture of lytta in the manner and quantity prescribed : two drachms and a half three times a day united with a dessert spoonful of the tinctura ainara, a generous diet was also recommended. Within about three weeks from this period he was renovated : and considered himself an altered man. His virile powers resumed their wonted energy ; nor has he to the slightest degree relapsed into his former state of weakness. This is unquestionably a rare instance in which the lytta rashly taken and to an inordinate amount was not followed by any serious injury. It never- theless proves that the accounts in general given of this article exciting in moderate doses deleterious effects are not to be received but with the great- est caution. The lytta like the common spirit of turpentine the effect of which was once supposed to prove fatal even in small quantity, experience has now shown may be taken to an extent our predecessors could no! have imagined. In obstinate gleets, after the ordinary vegetable and mineral tonics, the iron and gentian pills, the balsams and terebinthinates have failed, 1 have also given the tincture of lytta in the proportion of a drachm with a tea-spoonful or two of bitters three times a day with per- manent advantage. An error of Mr J. Hunter ought here perhaps to be guarded against. "I think, says he, I have been able to ascertain the fact that when bal- sams, turpentine or cantharides are of service, they are almost immediate- ly so; therefore, if upon trial tbey are not found to lessen or totally re- move the gleet in five or six days, I have never continued them longer." The beneficial effects of the use of the cantharides will occasionally spee- dily follow its administration; but this is an effect which in a majority o.' ca«es is the result of a continuance ofthe remedy for a considerable time. The introduction of this practice in the treatment of cases of this nature, in the United States is due I believe to Dr. Francis the Professor of the Institutes and of Legal medicine in this University. Obstipatio. 1 have no experience ofthe effect of carbon or charcoal for the removal of costiveness. When the ordinary means have failed, I have always had recourse to calomel, given in small and frequent doses, until the gums have become affected. In the Annals of Medicine for 179*5, published at Edin- burff I inserted a case of obstinate constipation ofthe bowels, which con- tinued twenty-two days, and was finally removed by calomel. The patient 1006 APPE>D1X. took, besides other medicine, this preparation of mercury to the extent «i four hundred and eighty grains. Scirrhus ctnd Cancer. One ofthe most frequent errors in the operation for scirrhus and cancerous affections, is the non-removal ofthe entire gland, the seat ofthe disease; and our author does well when he so forcibly recommends the complete ex- tirpation ofthe whole glandular substance ofthe breast, in ordeV to secure against a relapse. With the exception of a single instance, I have uniformly taken out the whole mamma, however small may have been the portion af- fected with cancer, and I have hitherto had reason to be satisfied with this practice, first recommended, as I believe, by the learned Professor Rich- ter, of Goettingen. "Arsenic most lamentably is too frequently and too freely employed for the removal of tumours of a supposed cancerous nature. It is not long since, that a very respectable citizen of New-York fell a victim to this empirical method of treatment. An encisted tumour existed on the side of the neck, and arsenic, in the form of an unguent, was applied for the purpose of re- moving it. The removal ofthe tumour was indeed effected, but the patient. by the long continuance ofthe application, lost the use of his right arm, ana the muscles of the back of his neck, and also those on that side of it from which the tumour was taken In consequence of this paralysis, his head to a considerable degree was thrown upon his breast, from an inability in the mus- cles necessary to elevate it. This distressing affection constantly increas- ed, and finally terminated in the sudden death of the sufferer. Similar facts have frequently come within my knowledge, of the injurious effects arising from the application of this mineral, as employed for the purpose of removing supposed cancerous tumours. The process by mechanical pressure, lately adopted by Samuel Young, of the Middlesex Hospital, for the cure of scirrhus and cancer, and which Dr. Thomas notices at sufficient length, has not been, as I am creditably inform- ed, attended with the success its author anticipated: an inference, indeed ve- ry obvious to one in any wise acquainted with the pathology of the disorder. Tic Douloureux, or Neuralgia. This disease seems to be nearly allied to rheumatism, but is considered oy most physicians as idiopathic. Professor Chaussier has very correct- ly denominated it Neuralgia. As a distinct disease affecting the nervous system, it attracted the attention of physicians at a period much earlier than is generally supposed. It was noticed as such by Dr. Daniel Ludwig >n 1673,* by John Hartmann Degener, a practitioner at Nimeguen, in 3724 ;t by Andree, a French surgeon, in 175G,J and by Dr. John Fother- ';ill of London, in 1776 ;•§ by the latter it is described under the appellation of a painful affection of t lie face. By most physicians who have written upon this disease, and even by » Miscel. Nat. C.ir. Dec. 1, Ann. 111. Observ.252,« dedolore superciliari acerbissimo t Acta Natur. Curios. " de dolore quodinn perraro acerboque maxillae sinistra; partes occapantcct per paroxysmos recurrente," vol. 1. p. 347. t Observations Practiqnes stir les Maladies de Lurethre et sur les plusieurs faits con fulsifs, a Paris, 1756, p. 318, Sic. l § Med. Obs. k Inq. vol. gtk. APPENDIX. 1007 systematic writers, it has been generally considered as seated in the second branch ofthe fifth pair of nerves, or in the portio dura of the seventh. Mr. Abernethy, however,* has related a case which was seated in the: nerves of the ring finger of the left hand Mr. Home, in his Croonian lec- ture^ has also related, some instances of this disease, the effect of an in- jury to the thumb. In the Edinburgh Medical and Surgical Journal, a case is recorded by Dr. Verpinet as occurring in one of the nerves of the fore arm, the consequence of a wound from a knife. Tbe first case of this disease which fell under my notice was that ofthe late Mr. Charles Apthorpe, of New-York, in 1794. The disease was seated in the lower as well as the upper jaw, and occasionally, as in the caSe vl Mr. Rosworth, related by Mr. Leigh Thomas^ embraced all the three branches of the fifth pair of nerves. Previously to this affection of the face and head, Mr. Apthorpe had suffered many years from regular gout. In this case the neuralgic affection was probably induced by the same cause, as the gout was totally suspended upon the appearance ofthe latter disease. Mr. Apthorpe had then passed the 60th year of his age. In three other cases the disease occurred in females between thirty and forty years of age; in all three the nervous temperament was strongly marked, and predisposed them to the complaint; in one the ophthalmic branch ofthe fifth pair of nerves was exclusively the seat of the disease, each paroxysm being attended with violent action of the muscles of the eye, a compression of that organ and a copious discharge of tears: this lady for several years previous tp this affec- tion, had suffered repeated attacks of acute rheumatism, which never recur- red after the appearance of her new complaint- In the second, the nerves extending over the side ofthe head, as in hemicrania, were the seat of the disease. In the third it commenced in the fifth pair, but soon involved the whole nervous system, producing convulsions, to subdue which, required the most liberal use of opium and aether. In all of these cases the patients suffered repeated returns ofthe disease, especially in the fall, winter, and spring; but by the use of tonic medicines, exercise, the cold bath, and at- tention to diet and mode of life, at the same time avoiding exposure to the changes of the weather, they have for some years past escaped the usual visitations of this distressing malady. Another lady, far advanced iu life, in consequence of an injury ofthe extremity ofthe fore-fiuger ofthe right hand, has endured for several years the most severe paroxysms of this complaint, not only affecting the branch of the injured nerve, but those distributed upon fhe fore arm and occasionally extending to those of the neck. Iq August, 1813 I was called upon to visit Mrs. S. aged about 52 ; she was confined to her room by an attack of neuralgia seated in the fourth toe ofthe left foot. She was first affected with this disease about three years before; but knows no cause to which she can ascribe it. She has made use of blood-letting, opium, warm bathing, and fomentations without effect; and upon one occa- sion the pain was so acute that she plunged the part affected in boiling water but without relief—I directed the toe to be involved ui a blister, which'was continued to the part twenty-four hours, but this, like the other means that iad been resorted to, was of no avail. As there is a manifest * Surg. Observ.vol. l.p.244. ! Si'JeTvbilerestingcaseofMr.Bosworthtlie reader will find recorded by D;- Darwin in which all the three branches ofthe fifth p*irandthe several branches ofthe fudiToS neJve were successively divided before the patient obtained relief. See £»o nonria, 3d. edit. Lond. vol. 3. p. 218. 1008 APPENDIX' resemblance between the severe pain frequently suffered in acute rheuma- tism, and that of neuralgia, it occurred that benefit might be obtain- ed by the use of the volatile tincture of guaiac; a tea spoonful of this medicine was accordingly directed to be taken every two hours in half a glass of wine. After taking a few doses, the patient experienced more relief than from any other medicine she had taken.—Since that time, when- ever she has the least irritation in the affected part, she has immediate re- course to the tincture, and uniformly with relief. From these facts it also appears that neuralgia is not confined to the nerves of the face, as most physicians have supposed; but that it is fre- quently connected with the general condition of the nervous system, and that we are not in all instances to rely upon the division ofthe nerve affect- ed for the cure, but to direct our remedies according to the temperament of the patient, the peculiar condition of body and vice of the habit from whence the disease may have originated. Dr. J. Fothergill in some in- stances traced it to a cancerous or vitiated habit of body, and in three cases has removed the disease by the use of hemlock : some French physicians have cured it by mercury,* believing that in some cases it may have arisen from a syphilitic taint; others, treating it as rheumatism, have employed calomel and opium with success.! As the complaint for the most part oc- curs late in life, and in females most generally after the natural cessation of tbe menses, or, if in early life, from the suppression ofthe evacuation, may it not also derive its origin from the state ofthe blood-vessels, an arthritic habit, or that condition of body which induces rheumatism,! especially in persons of the nervous temperament, who are generally the subjects of neuralgia ? In cases of this nature, the lancet, warm bathing, alterative drinks, and the vol. tinct. guaiac, with other means calculated to operate upon the whole system, may, according to the peculiar circumstances of the case, take the place of the knife, now resorted to for the division ofthe nerve affected, and which, in some instances, disappoints both the patient and practitioner.—Dr. Jackson, of Boston, has published an excellent paper on neuralgia in the New-England Journal of Medicine and Surgery, vol. ~\ p. 1/b. The Black or Livid Colour of Infants. The disease to which Dr. Thomas alludes under this name, is doubtless that complaint of infancy which Underwood has given a sketch of, as pro- ceeding from " an imperfect closure of the foramen ovaleP As Dr. Thomas states, that he knows of no remedy for this disorder, 1 am induced to offer the following account of two of several cases which I have had under my "Vare, with the mode of treatment that proved successful; more especially, as Dr. Underwood also, even in the last edition of his work on the Diseases of Infants, has not given us a satisfactory history of this formidable dis- order Case I.—On the morning ofthe 30th of October, 1797,1 was sent for to visit a child of N. P. of this city : it was seven days old, of Apparently good constitution, and had been in perfect health from its birth. * Recueil periodique de Medicine, Paris, 1702, torn. iv. See also Edin. Med. and 'rurg. Journal, vol. 0 p. 273. t Edin, Med and Surg Journ. vol. 4. p. 306. ; See two cases thus induced related by Dr. Pearson- do. vol. 3. p. 272. APPENDIX. 1009 I was informed it had been suddenly taken ill in the night, and that it awoke with an unnatural screaming, which was tbe first symptom of its in- disposition. Mrs. P considering it- complaint to proceed from some disor- der in the bowels, gave it a dose ot castor oil, which operated freely, but without any abatement of its symptoms : a drop of laudanum was then ad- ministered, but without the smallest benefit: the child still continued screaming every few minutes, but after each fit it was perfectly quiet, and apparently free from pain ; but would not take the breast. Finding no relief from the oil or opiate, Mrs. P. became alarmed, and early in the morning I was called to visit it. In a few minutes after I had entered the room, it suddenly screamed out two or three times. 1 at once perceived that this was not the natural cry of the child, and took a seat with the view to examine its symptoms more particularly. The fits of screaming returned about every ten or fifteen minutes; immediately after each fit, the counte- nance appeared natural, both as to thecomplexion and composure of its fea- tures, and the pulse beat with its usual frequency; but in the course of about five or six minutes, respiration became entirely suspended ; the eyes now assumed a vacant stare ; the countenance changed its colour ; instead ofthe natural florid hue, it became of a dark livid bluish colour: this change was first perceived about the upper lip and chin, and was apparent to every by-stander; the pulse became less frequent, and very irregular; in about eight or ten minutes the blueness wasexunded over the whole face; the extremities underwent a similar change of colour, attended with some cold- ness : at this time the pulse was scarcely to be perceived ; in a word, the child, at this moment, manifested every symptom of approaching death. In this critical state of thing- it again suddenly screamed, throwing out its arms and legs as in convulsions, and took two or three violent inspirations : after theselHbrts, respiration was again entirely suspended; but, notwithstanding, its circulation was again for a short time restored, the leaden colour of its countenance disappeared, and its natural complexion, tor the moment, per- fectly returned. These last favourable symptoms did not continoe: as be- fore, in a few minutes, respiration being entirely suspended, the counte- nance became livid and blue; the circulation became slower and very irre- gular, and the extremities lost their heat. Such was the condition of the child, until another fit of screaming restored the respiration for a moment, which gave new energy to the circulation. 1 was now satisfied that the bowels had no connection with its present complaints. Having seen the disease in three other children, 1 readily recognized it; but as, in all those, it proved fatal, I had not the smallest hope of its recovery. In those cases evacuations were first employed, and afterwards anodyne medicines were administered, upon the principle that the disease was of a spasmodic na- ture ; but as these remedies were not attended with any relief or advantage, I resolved to try the effect of a stimulant mode of treatment. Accordingly, I applied a small blister upon the breast, and two others behind the ears; cataplasms, composed of rye meal, vinegar and mustard, to the soles of the feet; bathed its whole body with warm brandy—afterwards, with diluted spirits of sal- ammoniac ; and, from time to time, we attempted to give it a spoonful of wine whey, but to no purpose, as it was incapable of swallow- ing. This treatment was pursued for two or three hours ; in the beginning it appeared to promise relief; the fits of screaming did not return so fre- quently; respiration continued a longer time, and the circulation became more vigorous. In about four hours the blisters produced their effect; upon •heir operation we had great reliance; but they produced no sensible ak 127 1010 APPENDIX. teration in the state ot the disease : the fits still continued to return as in the beginning, and wilh the same succession of symptoms as above des- cribed. Six hours had now elapsed ; the cries of ihe child became more feeble; respiration was suspended for a greater length of time than in the com- mencement ofthe disease, and the circulation became less vigorous : these, wiili the greater coldness of the extremities, confirmed us in our fears of the event Having frequently employed a stimulating bath, prepared with bark and spirits,in the latter stages of malignant fevers, and diseases of great debili- ty, I determined, as a las! resource, to give it a trial in the present case. I therefore directed four ounces of powdered Peruvian bark to be boiled for a few minutes, in about two gallons of water ; to this, when fit for use, a pint of Jamaica spirits was added : when it was cooled to a temperature rather above that of the body, the child was immersed in it up to its neck ; and to render the bath more stimulating, I added, from time to time, a small quantity ofthe spirits of sal. ammoniac. In a very short time a favourable and very apparent change took place ; •respiration, while the child remained in the bath, was perfectly restored; the circulation became vigorous and active; the countenance resumed its lively hue; the eyes recovered their natural expression; the power of swallowing returned, and, in every respect, the child manifested symptoms of relief. In this state of things we removed it from the bath, wrapped it in warm dry flannels, and put it to the breast. To the great joy of its mother, it returned to it with eagerness ; it remained composed, and free from complaints a considerable time, perhaps for the space of halfon hour. At the end of that time, respiration became irregular, and was again, inter- rupted, followed with the same change in the circulation and in the^olour of the skin as has already been described The bath was employed a second time, and with the same relief as before. It now fell into a sleep remained so for an hour, breathing freely ; its circulation regular, and the child, to all appearance, freed from its complaints. At the end of this time we were again alarmed wilh the same distressing symptoms of screaming, and interrupted respiration, with which it was first attacked ; but the bath as readily relieved a third time. As far as I can recollect, it had two or three more paroxysms, but they were of shorter duration, returned after long intervals, and were uniformly relieved by the use ofthe bath. Since that time the child has had no return of the disease, and is at present in perfect health. Case II—In the month of December, a child of my brother, Doctor Alexander Hosack, was suddenly seized with the same disease, and at- tended with precisely similar symptoms : it was six weeks old, of good con- stitution, and had been remarkably healthy I was immediately called to visit it, and upon entering the room, was told that I had come too late, and that the child was dying. At this time respiration was completely suspend- ed, the face of a dark bluish colour, the circulation weak, and very irregu- lar, and the extremities were almost cold, i instant^ directed a bath to be prepared in the same manner as I 'had done for Mr. P's child : in the mean- time the disease underwent nearly the same change and succession of symptoms as were described in the preceding case. When the bath was prepared, the child was immersed in it: in a short time, the respiration became regular: the child was continued in the bath about fifteen minutes but was by no means relaxed, as by the operation of the bath of warm wa- APPENDIX, 1011 ter alone. When it was removed, it appeared to be perfectly relieved, and remained so for the space of twenty minutes, or half an hour; when the fit returned, but was of shorter continuance, and less violent: the bath was employed a second time, which completely removed all complaint. The child is now living, and in good health. Phlegmatia Dolens. The inflammatory nature of this disease after the view taken of it by Dr, Hull, and the late Dr Ferriar, of Manchester, seems to me hardly ques- tionable It may, and frequently does arise from causes similar to those which produce inflammation, and of these causes co/cZmay be considered as the most frequent—This omplaint sometimes occurs independently of parturition ; and where it attends the puerperal state, I have known it to. take place many days after the lochial evacuation had totally ceased :—this discharge therefore in those instances, could have had no agency in the production of the disorder as supposed by Dr. Trye and Dr. Denman ; but the fact that phlegmatia dolens never arises from the offensive dis- charges of the womb that take place in the numerous diseases with which that organ is affected, affords an abundant refutation of that doctrine The comparatively rare occurrence of this disease even after parturition, is opposed to that view of the subject. In the treatment of phlegmatia dolens, regard must be had to the stage ofthe disease ; during the inflammatory or first stage those means should be employed which are calculated for the removal of general and local ex- citement, viz blood letting, saline cathartics, nauseating doses of antimony or ipecacuanha—and the use of tepid vinegar and water as a fomentation to the limb: in some cases blisters to the parts most affected have been found serviceable. In the second stage of the disease, when the febrile and inflammatory symptoms have subsided, great advantage has been obtained from small doses of calomel and squills while stimulating liniments, friction and the flannel roller are among the most beneficial applications to be made to the part. In the first stage of the disease, the diet should be strictly antiphlogistic— in the last tbe moderate use of wine, and the more stimulating nourishments may be administered, proportioned to the degree of debility induced. I have never known phlegmatia dolens to terminate fatally, nor in my opinion is it likely to do so, or even to leave any permanent disease of the limb, where active depletion is employed in the commencement of the complaint before an effusion has taken place in the cellular membrane. Cholera Infantum. Cholera Infantum is a disorder of a very fatal nature in this cli mate, espe- cially in the summer and fall months It may properly be considered as similar tothe. autumnal remittent of adults. Dr. Mann of Wrentham,(Mass.) in his valuable prize dissertation on the autumnal diseases of children, has taken a similar view of the disease; accordingly, instead of prescribing ano- dyne and astringent mixtures to lessen the discharges by the bowels, which are probably the effect of the severe excitement of the system occasioned by the heat ofthe season, and frequently the additional irritation of teeth- lf>12 APPENDIX. ing. we more rationally d;rect those remedies calculated toallay the general febrile excitement, and thereby to remove the irritation- of the intestinal canal. Accordingly, it has been found, that the most successful mode of treatment is in the fiist instance to empty the stomach and bowels with small doses of ipecacuanha and rhubarb Calomel and antimonial medicines are also frequently prescribed with good effect in this stage of thedisease. When the stomach and bowels are freely evacuated by these means, if the fever continues, small doses of ipecacuanha may still be continued with advantage for the purpose of preserving a perspirable state of the surface of the body. "Warm bathing is also at this time made use of with advantage. When the febrile symptoms are removed, weak brandy and water, or port wine and water, beef tea, the liquor l>f clams or oysters, are most grateful, and al- so most useful in restoring the tone ofthe stomach and bovveh^. But if the irritations of the intestinal canal continue after tbe febrile symptoms are re- moved, the chalk julepofthe dispensatory, with the addition oflaudanum or paragoric elixir is very advantageously prescribed. In some instances where the diarrhcea is attended with tenesmus, severe gripings, and the dischar- ges are tinged with blood, small injections,composed of starch and laudanum, are more effectual in relieving the sufferings of the patient than anodynes administered by the stomach, while they are less apt to disturb the func- tions Of that organ : in other instances astringent remedies are indicated to restrain the profuse liquid evacuations from the bowels. For this purpose, nothing will be found more effectual than an infusion ofthe root ofthe marsh rosemary, the statice limonium of Linnaeus. But of all the remedies pre- scribed either for the purpose of preventing or of curing this disease, I know of none so effectual as removal to the cool air of the country, particu- larly near the sea shore, where the atmosphere is not only cooler, but in a peculiar manner restores the appetite and strength ofthe patient. " ft is extremely agreeable, says Dr. Rush, to see the little sufferers revive as soon as they escape from the city air and inspire the pure air of the country."* But among the means of prevention may be recommended the use of flan- nel worn next the skin ; this preserves the action of the vessels on the sur- face, at the same time that, as a non-conductor, it guards the tender infant from the extreme heat and vicissitudes frequently experienced in the hot season of the year. Warm bathing at this season, by lessening the effects of heat upon the system, is no less useful to children than to adults. Syphilis Infantum. Many authenticated cases have been published by Mead, Jennes and others of small pox communicated to the foetus in utero; and in Dr Pear- son's paper in the Medical Commentaries of Edinburgh, the reader will find abundant evidence of this truth. Two cases of this sort occurred to me iu 1791 while I practised physic in Alexandria, Virginia. The fetus in utero, may, and occasionally does become affected with the venereal disease, derived from the mother labouring under the disorder of a constitutional form. The ulcers which at times occur in the mouths of children, the offspring of such infected mothers, have produced the same disease upon the nipples of nurses, by whom they have been suckled. These women have imparted the affection to other children, and these children again to other nurses. Facts of this nature most satisfactorily established * Med. Inquir. it Obscrv. vol. 3, p. 370 APPENDIX. 1013 the principle that not only the blood itself may be vitiated by the matter of certain diseases, but that the secretions themselves are capable of communicating the virus of certain specific affections to the healthy consti- tution. It were easy to relate the particulars of several cases for which I have prescribed, the pathology of which is capable of being explained up- on no other principle. Two instances have fallen under my notice, and se- veral are recorded upon respectable authority. It ought, therefore, no longer to be a disputed point with wTiterfcon medical jurisprudence. The mode of treating these affections of infants is satisfactorily stated by Dr Thomas. The corrosive sublimate in solution made in the manner already mentioned, (see p. 905.) is the form I constantly use. It may be given to the mother or nurse, and produce all the salutary effects desired on the constitution o*f the child ; it may likewise be administered to the child itself with perfect security. Mineral Waters of Battston. I have considered it not wholly foreign to the object of these Notes to add a few remarks on the Medicinal properties of the Ballston and Sara- toga Springs. No mineral waters in the United States enjoy an equal ce- lebrity, and as none are more generally resorted to by invalids, perhaps none are more indiscriminately used. Correctly to ascertain their proper- ties becomes, therefore, an object of importance to every physician.* Several analyses of the Ballston waters have been communicated to the public; according to the analyses made by Mons Caizalet, a teacher of chemistry at Bordeaux, a bottle of the Ballston water containing 25 ounces afforded 1. Carbonic acid, three times its volume. 2. Muriate of soda, 31 grains. 3 Super saturated carbonate of lime, 22 grains. 4. Muriate of magnesia, 12i grains. 5. Muriate of lime, 5 grains. 6. Carbonate of iron, 4 grains. This subject has also recently received the attention of Dr. William Meade of Philadelphia, a gentleman well skilled in practive chemistry and who has made frequent visits to the springs both of Ballston and Sarato- ga, for the express purpose of making'an accurate analysis of those cele- brated waters. The reader desirous of further information on this subject is referred to the work published by Dr Meade,entitled" an Experimental Enquiry into tb iemical pro-erties, and medicinal qualities of the principal mineral wa'ers o\ Ballston and Saratoga*." . ...- Ballston waters have been long known to yield a great quantity of fixed aii, and to hold in solution a large portion of iron. By the analysis now given, it appears that they yield a much larger proportion of fixed air, and that th»y contain a greater quantity of iron, than any other mineral water that has hitherto been discovered, not excepting that of Vichy, Li * The Yellow Springs of Virginia and the waters of Stafford spring in the state of Connecticut might be noticed among the mineral waters of the United States. The Schooley's Mountain Waters in the state of New-Jersey have lalely attracted a consi- derable degree of attention, and been resorted to by many A niinntp and interesting analysis of these waters has been published by Dr. M'^eveii, Profrssor of Chein^try, in the Transactions ofthe Literary and Philosophical Society of New-York, vol, 1 —This ..r„for locms to be chiefly valuable in calculous complaints, ioh APPENDIX. France, one of the strongest chalybeate waters in Europe. But it ap- pears, that they also contain another substance, viz. the muriate of lime, which, with the other ingredients with which it is associated, promises to be of great and extensive utility. We are accordingly from the above analysis induced to ascribe more virtues to the Ballston waters than physicians have generally believed them to possess. Although much is due to exercise, change of air, and an agreeable occupation of the minjj, which the amusements of watering pla- ces usually afford, I have no doubt, from the sensible effects produced up- on the system by the waters themselves, that they are also productive of great good in a variety of diseases, some of which 1 shall now briefly enu- merate. Jst. From the effects ofthe Ballston waters, as a sttong chalybeate, they may be employed with advantage iu most diseases of debility, whether di- rectly or indirectly such. But in those complaints which are attended with an increased excitement of tbe whole system, or with local inflammation, they are manifestly prejudicial. These principles are deducible from the qualities of the waters alone : but they are also confirmed by the experi- ence and observation of physicians who have attended to their operation. Accordingly in intermittent fever, dropsy, dyspepsia, hypochondriasis, and hysteria, connected with, or proceeding from debility of the digestive or- gans ; in paralysis, chronic rheumatism, gout, in its chronic state, chlorosis, filuor albus ; in suppression of the menses when arising from weakness, io worms, and in other diseases of debility, whether ofthe intestinal canal, or ofthe whole system, the Ballston waters have been long and justly celebra- ted. On the other hand, in a plethoric state ofthe system, as in pregnancy, in consumption of the lungs, inflammation ofthe liver, acute rheumatism, dy- sentery, and other diseases of an inflammatory nature, in which they are oftentimes resorted to, they invariably do injury. We may, perhaps, ex- cept from this remark a species of consumption which arises in females about the time of puberty, in which, from want of energy in the system, menstru- ation does not take place at the period in which it usually appears ; dyspep- sia ensues, followed with general irritation of the nervous system, pain in the breast, cough, sometimes haemorrhage from the lungs, and ultimately terminating in confirmed consumption. These consequences have fre- quently been prevented by a course of iron, and vegetable tonics, aided by generous diet, and exercise, especially riding on horseback. Under simi- lar circumstances I have doubt that the Ballston waters may be service- able in this species of phthisis in its incipient state ; but they should ne- ver be employed in diseases of this nature, without the advice of a physi- cian. 2d. From the saline impregnation of these waters, and their operation upon the urinary organs, as well as by perspiration, they are indicated in diseases ofthe kidneys and bladder, in gout, chronic rheumatism, andem/?- tions upon the skin, all which diseases are most frequently produced by, or connected with a morbid condition ofthe fluids, and an impaired state of the secretions. In these complaints, I have repeatedly prescribed these waters with the best effects. Dr. Thacher the author of " The American modern Practice" a work containing much original and valuable information, concurs in the opin- ion of the general efficacy ofthe Balston waters in diseases of debility, and that they are peculiarly beneficial in calculus and gravel, some case- of which have come within his own particular knowledge—and upon the iu- APPENDIX. 1015 formation of Dr. Powell, whose residence at the springs gave him a free opportunity of ascertaining the fact, he adds, that rarely a case of gravel occurred in which relief was not obtained.* But according to the foregoing analysis, they contain an ingredient of great value besides those already enumerated; I mean the muriate of time. It appears upon the authority of Dr. Beddoes, Dr. R. Pearson, Dr. Wood, and Dr. Schraud of Vienna, that this substance has lately been discovered to be a remedy for scrofula, which hitherto has been the opprobrium of our profession. It is true, cases have been recorded by Russell and others of the cure of this disorder by the use of sea water. But as it has been ascer- tained by chemists, that the muriate of lime enters into the composition of sea water, it is very possible that much ofthe efficacy of the latter, in that disease, may be derived from the muriate of lime which it has been found to contain. But as scrofula is usually attended with a general debility of the system, as well as a morbid condition ofthe fluids, the Ballston waters will probably be found peculiarly serviceable, inasmuch as they possess the means of in- vigorating tbe system, at the same time that they contain the antidote to the peculiar virus of that disease. But to obtain the benefits of the Ballston waters in any of the diseases which have been noticed, it is necessary that in the use of them, as it regards the time of taking them, the quantity taken, the stage ofthe disease, and other circumstances which must govern their exhibition, the directions of the physician be particularly attended to. As well might the patient make use of any other article of the materia medica without medical advice, as drink these waters in thve manner in which they are usually taken. It is but a short time since that a very valuable life was destroyed by the im- [ prudent use of them during a state of pregnancy. I was lately consulted by two gentlemen who had left the springs much worse than they had gone to them. The one laboured under dyspepsia, attended with habitual cos- tiveness. Neglecting to relieve his bowels, he commenced the use of the waters; the consequences were, an aggravation of his disease, followed with fever, acute pain in the head, and other symptoms of general excitement. The other person referred to, had come from Virginia, on account of an ob- stinate chronic diarrhcea, attended with great debility, and general emacia- tion. Without advice, he immediately began to drink the waters to the quantity of several quarts daily. The consequences may readily be im- agined ; an increase of his disease, and a degree of debility from which he with difficulty recovered.—See Amer. Med. and Philos. Reg. vol. 1. The administration of these remedies therefore requires some attention. Upon this subject, the following judicious remarks by Dr. Dyckman, contained in his excellent American edition of Dr Duncan's New Dispen- satory, merit the observance of those who visit Ballston and Saratoga, to obtain the benefit of those waters. " The doses must be regulated by the constitution of the patient, the state ofthe stomach, the nature and stage of the disease, and the effects produced. In large quantities, as from a pint to a quart, they usually ope- rate gently as a cathartic, but in small doses their action is determined more particularly to the kidneys and skin. In general, they should be drank till they produce a slight evacuation from the bowels. Care, how- ever should be taken never to distend the stomach so as to occasion incor.- * See Thacher's American modern Practice. 101t> APPENDIX. venience. If from one to two or three pints daily produce no sensible ef- fect, the quantity of fluid v.-ill be apt to prove more injurious as a load, than useful as a medicine. In most instances, perhaps, it will be advise- able to begin with sieall quantities, and repeat them often. When taken to an improper extent, particularly if they do not produce some effect as a purgative or diuretic, they not unfrequently occasion much distress and disturbance ofthe whole system, being followed by anxiety, headach or ver- tigo, perturbation, pains in the stomach and bowels, or spasms. They should not be employed when the stomach and bowels are overloaded, or just before or after meals. When intended to act as an aperient, the pro- per time for administering them is in the morning before breakfast. Their operation will be facilitated by the exercise of walking or riding. Taken after a meal, they are less apt to affect the bowels, than they are the kid- neys aiid skin." FINIS. J. & J. Harper, Printer* RECOMMENDATIONS OF Dr. THOMAS'S WORK. ON THE MODERN PRACTICE OF PHYSIC. From British Journals. " A treatise nearly universal in its object, has been particularly desira- ble, and Dr. Thomas having had opportunities of actually observing the diseases and practice of different countries, but especially those of hot cli- mates, and being conversant with the writings of our best modern authors and teachers, may be considered as well qualified to undertake so import- ant a task. We think that Dr. Thomas has acquitted himself of his under- taking in a manner highly creditable to him as a man of research, and as a Practical Physician, and that his Work deserves to stand high in the ca- talogue of this kind of compilation."—London Medical Review. In compilations of this sort, it is sufficient that, in addition to a clear and methodical arrangement, due diligence be employed in collecting from the proper sources, and judgment in discriminating between real and pretend- ed discoveries. In these respects, we think the author ofthe present work has not been deficient. It is a Compendium ofthe existing Doctrines and Practice of Medicine."—Medical and Chirurgical Review. " This is a judicious compilation of facts, from the best writers, which may be perused with great advantage by students, because the different subjects are treated with brevity and perspicuity. The Author has chiefly followed^r. Cullen, both in the classification of diseases, and in his text; but it is necessary to add, that Dr. Thomas does not prove a servile copy- ist. He has abridged with judgment, has added modern opinions and dis- coveries, has frequently introduced the result of his own experience, and his performance thus becomes an useful Compendium of the present State of Medical Practice."—Monthly Review. " We have read this Work with great satisfaction, and think it a con- cise but judicious abstract of the Practice of Medicine. The Author's des- cription of diseases is clear and characteristic ; his remedies appropriate and well chosen. His discription of the Yellow Fever is peculiarly accu- rate."—Critical Review. " Books of this kind, when properly executed, containing the opinions of the best writers on the several diseases, abridged and placed together be- fore the reader, may serve for occasional reference to refresh the memory, and save the trouble of turning over numerous volumes; they may be useful also to students, prior to their entering on a more severe course of study ; or to persons whose avocations do not permit them to consult more elabor- ate treatises. The style of Dr. Thomas is clear and unaffected, and the arrangement of his Work sensible and convenient."—British Critic. From American Authorities. u The preceding work is executed with a degree of ability and judg- ment which reflects much honour on the talents of the author. In Great Britain, it stands so high in public estimation as to have passed through many editions within a short period ; and is considered by competent judges as the most comprehensive and judicious compend of medical practice now extant, and as condensing, in a small compass, more practical informa- tion than any work which has preceded it. The propriety, therefore, of presenting an American Edition of a work of such character, calculated to diffuse so great a mass of knowledge in so condensed a form, can scarcely be questioned."—Dr. Edward Miller. Dr. Thomas, in this work, has condensed more facts and more precepts for the management of diseases than any modern medical writer we have met with.—New-York Medical Repository, Fol. 3, third series. a»1»WMWieic- CATALOGUE OF BOOKS. The AMERICAN MEDICAL AND PHILOSOPHI- CAL REGISTER, OR ANNALS OF MEDICINE, N\TUR4L HISTORY, AGRICULTURE, AND THE ARTS. Conducted bv DAVID HOSACK, MD.F.R.S.L. & E. Professor of the Theory and Practice of Physic, and of Obstetrics, and the Diseases of Women and Children, in the University of the State of New-York, and JOHN W. FRANCIS, M.D. Professor of the Institutes and Legal Medicine in the University ofthe State of New-York. The CHEMICAL CATECHISM, with Notes, Illustra- tions and experiments, by Samuel Parkes, F.L.S. member ofthe Geologi- cal Society, author of the Rudiments of Chemistry, and Proprietor of the Aqua Fortis Works and Chemical Manufactory in Goswell-Street, London from the Sixth English Edition, with Emendations and considerable addi- tions. The ELEMENTS OF EXPERIMENTAL CHEM- ISTRY. By William Henry, M.D.F.R.S. Member of the Royal Medi- cal and Wernerian Societies of Edinburgh, &c. The third American from the sixth English edition; greatly enlarged by the author, and illus- trated with nine plates : to which are added, notes on AKirious subjects by B. Silliraan, Professor of Chemistry in Yale College. ELEMENTS OF CHEMISTRY, by M. J. A. Chap- tal. The fourth American edition, wilh great additions and improve- ments, by James Woodhouse, M.D. professor of Chemistry in the University of Pensvlvaaia, &c. ^ wz. I? 510