J ****> "ryjfc- r Beck Infant Therapeutics ft t ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C A^-«. . rfcr ESSAYS ON INFANT THERAPEUTICS: ; TO WHICH ARE ADDED OBSERVATIONS ON ERGOT, AND AN ACCOUNT OF THE ORIGIN OF THE USE OF MERCURY IN INFLAMMATORY COMPLAINTS. By JOHN B. BECK, M. D., Professor of Materia Medica and Medical Jurisprudence in the College of Physi- cians and Surgeons of the University of the State of New York ; Cor- responding Member of the Royal Academy of Medicine of Paris; Corresponding Member of the Medical Society of Lon- don; One of the Vice Presidents of the Academy of Medicine of New York, ete., etc. NEW YOUK : W. E. DEAN, PRINTER & PUBLISHER, 2 ANN-ST. 18 49. loo . mi Entered according to Act of Congress, in the year 1848, BY W. E. DEAN, In the Clerk's Office of the District Court for the Southern District of the State of New-York. To the Gentlemen, WHO DURING THE LAST TWENTY-TWO YEARS HAVE ATTENDED THE LECTURES ON MATERIA MEDICA, IN THE COLIEGE OF PHYSICIANS AND SURGEONS OF NEW YORK, THE FOLLOWING ESSAYS ARE AFFECTIONATELY DEDICATED BY THE AUTHOR. The following papers have already appeared in several Medical Journals throughout the country. From the favorable manner in which they have been received by the profession, the author is in- duced to believe that their publication in the pre- sent form may not prove unacceptable. 14 Le Roy Place, Dec. 1, 184S. CONTENTS. I. On the effects of Opium on the Young Subject, - 9 II. On the effects of Emetics on the Young Subject, - 24 III. On the effects of Mercury on the Young Subject, - 39 IV. On the effects of Blisters on the Young Subject, - 54 V. On the effects of Bloodletting on the Young Subject, - 70 VI. Observations on Ergot,......88 VII. An account of the Origin of the use of Mercury in In- flammatory Complaints, - - - • 110 ESSAY I. ON THE EFFECTS OP OPIUM ON THE YOUNG SUBJECT* As a remedial agent, opium has always and just- ly been looked upon as one of the most valuable in our possession. It has been styled the "donum Dei," the gift of God to man, and Sydenham says of it, that it is " so necessary an instrument in the hands of a skilful physician, that the art of physic would be defective and imperfect without it; and whoever is thoroughly acquainted with its virtues and the manner of using it, will perform greater things than might reasonably be expected from the use of any single medicine."* . High as this pane- gyric is, it is unquestionably just. Admirable, however, as this agent is, if properly used, it is equally true, that, in unskilful hands, there is scarce- ly an article, in the whole range of the materia medica, capable of producing a greater amount of mischief. That this must be the case, is evident, if we reflect for a moment upon the nature of the * The works of Thomas Sydenham, M. D., with Notes by Ben- jamin Rush, M. D., p. 115. 10 ON THE EFFECTS OF OPIUM effects which it is capable of producing, and, at the same time, recollect that these effects are not uni- formly the same, but are modified by various cir- cumstances. Thus, at one time, we find it operat- ing exclusively as a stimulant, while at another it displays nothing but its sedative power. Given under certain conditions of the system, it quiets ir- ritation, calms the pulse, softens the skin, and pro- motes balmy sleep. Under other conditions of the system, it quickens the pulse, suppresses the secre- tions, increases animal heat and disturbs the brain. In the one case, the state of the patient is material- ly improved; while, in the other, it is rendered worse. It depends, then, entirely upon the cir- cumstances under which it is given, whether it will prove salutary or injrrious, and it is this which renders the proper use of it a matter which requires so much tact and experience. Now, the circumstances which modify the ac- tion of this agent are numerous. Age, sex, tem- perament, climate, nature of the disease, stage of the disease, in short, every thing which can affect the condition of the system, modifies, in a greater or less degree, its effects. To understand, there- fore, completely the manner in which it operates on the system in its different phases, it is necessary to analyze all these modifying circumstances. On the present occasion, I propose to make a few re- marks upon only one of them, viz., age, with the view of showing more particularly the peculiari- ties of its operation on the young subject. With regard to the effects of opium on young ON THE YOUNG SUBJECT. 11 subjects, there are two facts which seem to be well established. The first is, that it acts with much greater energy on the infant than it does on the adult; -the second is, that it is more uncertain in its action on the infant than the adult. It is in conse- quence of these peculiarities attending its operation on the infant, that even the smallest quantities have not unfrequently produced the most unexpected and even fatal results. Of this, almost every phy- sician must have seen some melancholy instances. Dr. John Clarke states, that " half a drachm of genuine syrup of white poppy, and, in some in- stances, a few drops of Dalby's Carminative, have proved fatal, in the course of a few hours, to very young infants."* In one case, he says, forty drops of Dalby's Carminative destroyed an infant. Mr. Marley says, " I have known three or four instan- ces where the most dangerous symptoms were pro- duced by Godfrey's Cordial and Dalby's Carmina- tive ; two nostrums which have no doubt added considerably to the mortality of infants." In a case that fell under his observation, the most rapid and alarming symptoms followed the exhibition of an ordinary dose of syrup of poppies. In another case, he knew half a small tea-spoonful of the syrup of poppies prove nearly fatal to a child eight or ten days? old. Thirty-five drops of Dalby's Carmina- tive, he has known to prove fatal to a young child, while, in other cases, larger doses have been given without any unpleasant effects. The same writer * Commentaries on the Diseases of Children, p. 33. 12 ON THE EFFECTS OF OPIUM relates the case of an infant, nearly poisoned, by considerably less than half an ordinary-sized tea- spoonful of paregoric* Dr. Bard says, he once knew an infant of several months old killed by ten drops of laudanum, and another brought into very great danger by less than two drops, f Dr. Mont- gomery states, that he has known more than one instance in which a tea-spoonful of the syrup of poppies has proved fatal to a healthy child.J Pro- fessor Hamilton relates two cases, in which four drops of laudanum proved fatal to children some months old.§ Dr. Merriman reports two cases, in which a dose of Godfrey's Cordial proved fatal.U He also states, that he once saw a child in the month thrown into a state of excessive stupor, by taking one dose only of a mixture in which there were four drops of laudanum ; the actual quantity swallowed could scarcely have amounted to one drop.TI Dr. Cristison states, that " the administra- tion of three drops of laudanum in a chalk mixture for diarrhoea, to a stout child, fourteen months old, was followed by coma, convulsions and death in six hours." In another infant, a few weeks old, death resulted from taking four drops of laudanum.** * On the Diseases of Children, pp. 29, 30, 31. ; + Bard's Midwifery, p. 328. J Pereira's Mat. Med., vol. ii., p. 711. i A Treatise on the Management of Female Complaints and of Children in Early Infancy, p. 341. tl Treatise on the Diseases of Children. By M. Underwood, with Notes by Merriman, Hall, and Bell, p. 106. IT Ibid p. 143. ** Treatise on Poisons. Second Edition, p. 625. On the young subject. 13 Dr. Ryan states, that he has known one drop of the " sedative liquor of opium" narcotize an infant.* Of laudanum, two drops have been known to kill an infant, nay, in one case, a single drop destroyed a new-born infant.f I have myself seen a young child narcotized by about twenty drops of pare- goric. The foregoing facts are sufficient to show that opium acts with peculiar energy and uncer- tainty upon the infant subject. The causes of this would seem to be the following: In the first place, the great difference in the phy- sical organization of the infant and the adult. In the young subject the brain and nervous system are much more impressible, and the slightest causes, as we know, will sometimes derange them. Be- sides, in the infant, the circulation is more rapid— there is a greater proportionate quantity of blood circulating in the brain, and hence a much greater tendency to cerebral determinations. From these peculiarities in the organization of the infant, it happens that convulsions are so much more com- mon in the early periods of life. Thus, for exam- ple, the irritation of teething—of worms or crude matters in the intestines, is frequently followed by convulsions. Intermittent fever, which in the adult commences with a chill,.in the child is frequently ushered in by a convulsion. Scarlet fever, too, in the child, not unfrequently commences with a con- vulsion, while in the adult I have never witnessed * Midwifery, p. 477. • t London Medical Gazette for 1839, p. 294. ► 2* 14 ON THE effects of OPIUM such an occurrence. Now, with such peculiar pre- dispositions characterizing the system in infancy, it may readily be conceived how it is that^ such an article as opium should act with more power at that period than in after life. In the second place, the difference in the tempera- ment or constitution of infants. In the adult, we know as a matter of fact, that opium diffep greatly in its effects in different constitutions, "fhus, as a general rule, the sanguine temperament 5 does not appear to bear the use of this drug as well as the melancholic or the nervous. In the former, it is much more apt to produce cerebral disturbance, and in large doses is more likely to prove injurious. Now, infants differ from one another, as much, if not more, than adults, in these peculiarities of con- stitution, and, as a matter of course, thO difference in the effects of this article must be greater. Be- sides, as these peculiarities and differences can only be detected by actual experience, and as we can- not of necessity have the same benefijf of experi- ence in the case of infants, it is obvious that the difficulty of justly appreciating the action of this drug on the infant must be greatly increased. A greater or less degree of uncertainty, therefore, must necessarily from this cause attend its use in the early periods of life. In the third place, the actual state of the system as to disease. There is no circumstance which modifies the effect of opium in so great a degree as this. In the adult, we see this continually. In some conditions of the system, even small doses ON THE YOUNG SUBJECT. 13 produce the most unpleasant effects, while in other conditions, immense quantities may be given with little or no effect; thus, for example, when severe pain or spasm is present, quantities of this article can be borne, which under other circumstances would prove exceedingly injurious. As illustrative of this, I quote an interesting case related by Dr. Percival, He states that a young man was admit- ted into the Manchester Hospital, on account of a violent spasmodic disease which recurred periodi- cally in the evening, and after trials of various remedies, doses of opium sufficiently large to miti- gate the violence of the paroxysm were ordered, and he took twenty-two grains every night during a week, without producing any soporific effect. On the eighth night he had no return of the spasm. He nevertheless took the opium and in the morn- ing was found dead.* In this case, a great and sudden change had unquestionably taken place in the nervous system of the patient, and to this must be ascribed the difference of effect. If in the adult, the state of the system makes such a wide differ- ence in the effects of this article, how much more so must all this be the case in the sensitive infant; and it is by not duly regarding this, that such un- expected results sometimes follow from the use of opium. Thus, for example, a child laboring under the acute pain of colic will tolerate doses, which, in the ordinary condition of the system, might prove destructive. * Percival's works, vol. i., p. 422. 16 ON THE EFFECTS OF OPlOM There is one condition of the young subject par- ticularly in which this remedy is frequently resort- ed to, in which this is strikingly illustrated. I mean that state of exhaustion which arises from diarrhoea and other bowel complaints. In this state the head is very apt to become affected, and if opium be given with a view of checking the in- testinal discharges, not unfrequently insensibility gradually creeps over the little sufferer, and in a short time death is the result; and this, too, even when the quantity used has been apparently adap- ted with great nicety to the wants of the case. Every observing practitioner must have witnessed such instances. Now in many cases of this kind, there can be no question that the child sinks under the sedative influence of the opium; and the rea- son is that, in the exhausted state brought on by the disease, the system succumbs much more readi- ly to the narcotic effects of this article, than it does in other conditions of the system. The foregoing considerations appear to me suf- ficient to account for the greater power, as well as uncertainty in the action of opium on the infant, than on the adult. If it be a fact, then, that opium acts in this way upon the infant, it appears to me to involve infer- ences of great practical moment, which cannot be too deeply impressed on the mind of the young practitioner. 1. That its use should be avoided as much as pos- sible in the young subject. I will not say that it ought to Be interdicted altogether, because if given ON THE YOUNG SUBJECT. 17 with discretion, it is a remedy of great value in many of the diseases of infants, but it should never be used unless there exists a strong and manifest necessity for it. 2. Great caution should be exercised in the form in which it is administered. No preparation should ever be used, which is not of a known and deter- mined strength. In England, the Syrup of Poppies is the preparation most used for children. In this country it is also used, but not to the same extent. This is a pleasant and mild opiate, and is well adapted to children. It is liable, how- ever, to great objections. Besides being apt to ferment and spoil, it is very variable in its strength.* On this account it is really a very dangerous arti- cle ; and many cases are recorded (some of which I have already related) in which fa,tal results have followed the use of it, even in moderate doses. Another objection is, that it is liable to sophisti- cation. Thus a mixture of laudanum and sim-. pie syrup, has sometimes been sold for it. In the London Medical Gazette, (May, 1831, p. 253), a case is related, where a child died in consequence of a small dose of this latter compound having been given by the mother, who had previously given the same quantity of the pure Syrup of Poppies, with advantage. * When properly prepared, one ounce of the Syrup of Poppies Is generally estimated to contain about one grain of opium; a drachm therefore, contains one-eighth of a grain. From the vari- able proportions, however, of active principle contained in the cap- sules of opium, it is impossible to calculate with any degree of precision, the strength of the syrup prepared from them. 18 ON THE EFFECTS OF OPIUM The best preparations for children are lauda- num* and elixir paregoric. These are of known strength, and susceptible of division into the mi- nutest doses. Dover's powder is another prepara- tion, which may be given to children. It may readily be divided into the smallest doses, and it seems to act much more mildly than equivalent doses of simple opium. It need hardly be stated, that all such articles as Godfrey's cordial, Dalby's carminative, &c, should be totally discarded from regular practice. Besides being uncertain in their strength, and on that account exceedingly objec- tionable, the sanction thus given to them encour- ages their use by persons out of the profession, who cannot be supposed to be acquainted, with the dangerous effects of opium on the infant system. 3. In very young subjects, we should never be- gin the use of this article, except in very smalldoses. Although most practical writers lay down cautions about the use of opium in these cases, yet it does not appear to me that these cautions are sufficient- ly precise. Most of the writers to whom I allude, specify doses as suitable to certain ages, without stating, that even these doses, may, in certain con- ditions of the system, prove just as injurious as * Even this preparation should not be given without circum- spection. "When long kept, with occasional exposure to the air, laudanum becomes thick in consequence of the evaporation of a portion of the alcohol, and the deposition of opium. If given in this state, it often acts with unexpected energy, and cases of death have resulted in infants from its use in doses, which would have been entirely safe if the tincture had been clear."— Wood <%• BacMs. Dispensatory, p. 1032, 2d ed. ON THE YODNG SUBJECT. 19 much larger doses. To illustrate, I will quote the directions given by one of our standard authorities. Dr. Dewees says, " the proper dose of laudanum for infants and children, may be reckoned at the following rates. Half a drop for a child under ten days old ; a drop, for one from that period to the end of the month ; a drop and a half, or two drops for one from that period to three months; three drops from this to nine months, &c, &c." " When laudanum is to be used as an injection, we may safely increase the quantity three or four fold." He adds. " These doses are prescribed for children who are altogether unused to the use of this drug; the power of bearing more, may be rapidly increased by habit."* Now, it appears to me that a more dangerous set of directions could not well have been given. Although many children may bear • the quantities here specified without injury, yet every now and then a case will occur, in which the most serious results will follow; and it is against these that the necessary precautions should always be taken. In the case of a new-born infant, we are entirely ignorant of the manner in which such an article as this will affect it, and it therefore will not do to begin with average doses. To practice safely, we must feel our way with doses much smaller; and then we shall have some guide, and the only guide which the nature of the case admits of, to make the necessary increase in the quantity to be given. Under no circumstances, as a first dose, ought half a drop to be given to a child un- * On the Diseases of Children, p. 363. 20 ON THE EFFECTS OF OPIUM der ten days—or a drop to a child during the first month. One-eighth of a drop is sufficient to begin with. The quantity, too, directed for an injection is too large. Instead of three or four times the quantity given by the mouth, as far as my experi- ence goes, double the quantity is quite sufficient. 4. The doses of opium should not be repeated at too short intervals. This, too, is a point which is not sufficiently guarded by some practical writers. One writer, for example, after specifying the quan- tity suitable for a child of two and three months, adds, that " this is not to be repeated in less than an hour." If this means any thing, it means, of course, that after the lapse of an hour, the dose may be repeated with safety. This, however, will not be sustained by experience. Even if a first dose does not narcotize, it frequently produces a degree of listlessness and indifference to food on the part of the child, which, if it be kept up by repetitions of the opiate, may eventually prove just as destruc- tive. This is strikingly illustrated in those states of exhaustion from diarrhoea, where the due supply of nourishment is so essential to recovery. Where repeated opiates are necessary, the intervals be- tween the doses should be long enough to enable the child to recover somewhat from the sedative influence. Before concluding these observations, I cannot refrain from making a remark or two in relation to the use of this article by persons out of the pro- fession. The mischief that is done in this way is incalculable. If, in the hands of those acquainted ON THE YOUNG SUBJECT. 21 with its virtues, opium is an article so dangerous and uncertain in its action, what must it be in the hands of the ignorant; and yet we see it given to infants, day after day, and night after night, by nurses and mothers, not merely without the consent of the physician, but sometimes contrary to his express injunctions. There are two ways in which it is used by per- sons out of the profession, in both of which it proves injurious to the child. The first, is by giving it in occasional doses; the second, by giving it con- stantly. The first is bad enough, but the second is still worse. The first, now and then, unexpectedly destroys a child ; the second is followed by a train of the most disgusting consequences, worse, if pos- sible, than those of habitual drunkenness in the adult. Fortunately, these latter cases are not of such frequent occurrence ; occasionally, however, they are met with where the parent, for the pur- pose of quieting it, has been induced to keep a child for months under the daily influence of pare- goric, Godfrey's Cordial, or some other opiate nos- trum. In these cases, the effect is to stunt the growth of the child ; it is emaciated and puny ; the skin is flabby and shrivelled ; the lips are bloa te and the countenance sallow and wrinkled. There is an absence of all intelligence, and the whole ap- pearance is haggard and aged, presenting a sort of " miniature of old age." Not long since I witnessed a case of this kind, in which a child of fourteen months old did not appear larger than one of two or three months. With the exception of one month, 3 22 ON THE EFFECTS OF OPIUM it had been kept upon paregoric almost every day since its birth. The mother was a poor woman, and on inquiring of her the reason, she stated that she had resorted to this method of keeping the child quiet while she attended to her work. Of the extent of the mischief annually perpetra- ted by the unprofessional use of opium, some idea may be formed from a report made to the House of Commons, containing returns from the coroners of England and Wales, of the inquisitions held by them during the years 1837 and 1838, in cases of death by poison. The total number of deaths by poison in these years was 543, of which 52 were very young children, most of them at the breast, in consequence of opium, or some of its preparations having been given by mothers and nurses, in igno- rance of its effects. In addition to this, 20 more were destroyed by opium or laudanum administered in mistake for other medicines.* These facts are certainly appalling; and if any subject connected with medical police is worthy the attention of the public authorities, it is certainly this. How the evil is to be corrected, it is not easy to say. Much, however, might be done by the proper dissemination of information on the subject. In most cases where opium is administered to chil- dren by persons out of the profession, it is disguised in the shape of some nostrum, so that they are not aware of what they are giving, and even when they are aware of it, they are not acquainted with the * See Dunglison's Intelligencer, vol. iii., p. 299. ON THE YOUNG SUBJECT. 23 dangerous effects of it on the infant system. If parents and nurses were made better acquainted with the fact that such articles as Godfrey's Cordial, Dalby's Carminative, and most of our medicated lozenges and candies, owe all their composing pro- perties to the opium which they contain, and that opium even in small doses is frequently a deadly poison to the infant, one would suppose that it could not but exert a salutary influence in correcting, to a certain extent, at least, the evil of which we are speaking, and the dissemination of this kind of knowledge, by the proper authorities, would confer a lasting benefit upon the community. ESSAY II. ON THE EFFECTS OF EMETICS ON THE YOUNG SUBJECT. With the exception of cathartics, there is no class of remedies more generally resorted to in the management of the diseases of children, than eme- tics ; and in a large number of cases, there is cer- tainly none more useful. They are active agents, however, and like all agents of this description are capable of doing good or evil, according to the manner in which they are given. In the use of them, therefore, it is all important to ascertain whether there is any thing in the young subject which modifies their operation. Unless this is done, it is impossible, of course, to prescribe them with any degree of precision, or even safety. The subject is one of interest as well as of practical im- portance, although it does not appear to have at- tracted the attention to which it is so justly enti- tled. In a previous paper, I endeavored to point out how the effects of opium were modified in the infant subject. On the present occasion, I propose to pursue a similar investigation in relation to Emetics. ON THE EFFECTS OF EMETICS. 25 As it regards the mere mechanical act of vomiting, young children perform it more easily than adults. This' is a fact which has long been observed by practical men, and about which there can be no question. It is no doubt a wise provision of the Creator to enable the child to relieve itself from the effects of an overloaded stomach, to which it is so constantly liable in the early period of its exis- tence. Although the fact has thus been long known, and the intention of it is obvious, yet the, reasons' have not been so well understood. They appear to be the two following. In the first place, from the experiments of Ma- jendie, in relation to the manner in which vomit- ing is performed, it would seem that in that pro- cess, the stomach is in a great measure passive, and that a certain degree of pressure upon it from the surrounding organs is absolutely necessary, before vomiting can be accomplished. This pressure is made by the contraction of the diaphragm from above, and of the abdominal muscles from below, upon the viscera surrounding the stomach. As a matter of course, the pressure thus exerted will be greater or less according to the volume of the vis- cera. Now, it is well known that in the early pe- riods of life, the abdominal viscera have a much larger proportional size than they have in the adult. This is particularly the case with the liver.* In * According to Meckel the proportion between the weight of the liver and that of the whole body, is as 1: 18 or as 1: 20, in the full grown foetus; while in the adult it is as 1: 35 or as 1 : 36. Meckel's Anatomy by Doane, vol. iii., p. 309. _., . 3* 26 ON THE EFFECTS OF EMETICS early life, therefore, during the act of vomiting, the pressure made upon the stomach by the sur- rounding organs must necessarily be greater than it is in the adult, and in consequence of this, the greater the ease with which the organ is evacuated. In the second place, the shape of the stomach in the infant is more favorable to the easy evacuation of its contents. That the stomach undergoes suc- cessive changes in its shape, from birth onwards, is a fact, which although but recently investigated, is, I believe, well established, and for its elucida- tion we are indebted to the labors of Prof. Shultz of Germany. His attention seems to have been called to it from the peculiarities which he noticed in the shape of the stomach of those animals which vomit easily, and those which cannot be made to vomit at all. Thus for example, the horse, rabbit, hare, and guinea pig, cannot be made to vomit even by the most powerful emetics, while the dog and the cat throw up very readily—and he found that the shape of the stomach in the two sets of animals was entirely different, and that the same difference exists between the stomach of the child and the stomach of the adult. The former is more of a conical form, drawn out lengthwise, and gra- dually narrowing towards the- two extremities. The oesophagus is inserted into the fundus at the left extremity, and at a distance from the pylorus, leaving the two curvatures of the stomach running almost parallel to each other. In short the stom- ach of the child resembles that of the carnivorous animals generally. The latter, i. e. the stomach of ON THE YOUNG SUBJECT. 27 the adult, is very different; it is more circular in its form, and the oesophagus, instead of being in- serted into the left extremity, is in the middle, be- tween the left extremity and the pylorus. The pylorus, too, is drawn back towards the cardia, so that the small curvature is very short, while the large curvature is greatly extended. The conse- quence of all this is, that the stomach of the adult has a rounder shape, resembling that of herbivo- rous animals generally. Now, according to Prof. Shultz, the stomach which approaches nearest to the cylindrical shape, must have its contents evacu- ated with the greatest ease ;* and this would ap- pear to be the case, as a matter of course, what- ever theory of vomiting may be adopted; whether performed, as some suppose, by the simple antipe- ristaltic action of the stomach itself; or according to Majendie, by the contractions of the diaphragm and abdominal muscles alone; or according to others, by the combined action of all these organs. The foregoing considerations would seem to ac- count very satisfactorily, both physiologically and anatomically, for the fact with which we started, that the mechanical act of vomiting is performed with greater ease in the child than in the adult. If vomiting, then, be induced in a child by mild agents, the whole process is performed with greater facil- ity than by the adult. This, then, is the first pe- culiarity in the effects of Emetics in children. If, on the other hand, Emetics of an active amd * British and Foreign Medical Review, vol. ii, p. 537. 28 ON THE EFFECTS OF EMETICS debilitating character, and which produce much nau- sea, be used, the effects are more uncertain and ener- getic than in the adult. The articles to which I al- lude, are the antimonial emetics, and these accord- ingly are frequently hazardous to young children, and that, too, when used in doses not peculiarly large. The immortal Sydenham seems to have been fully aware of this fact. In speaking of the continued fever of 1661, 2, 3, and 4, he says, "it has often been a difficulty with me, when called to infants and children in a fever, and observing an emetic indicated, whereby they might have been preserved from danger, that I durst not give them this infusion {crocus metallorum), for fear of a bad consequence."* It will be recollected, that at this time Ipecacuanha had not yet been discovered. Dr. Clarke, of London, states that " a quarter of a grain of Tartrate of Antimony in solution, has been known to excite a vomiting which has ended in the death of a young child, which before was in no danger."f Dr. Armstrong observes that he " has seen again and again, delirium produced by anti- monial preparations, given so as to excite the mu- cous membrane of the stomach and intestinal canal in very young children.";}; Dr. Hamilton advises, that " Tartar Emetic should never be given to in- fants, for alarming convulsions have followed its * The works of Thomas Sydenham, M. D., with notes by Benj. Rush, M. D. p. 18. t Commentaries on some of the most important Diseases of Children. By John Clarke, M. D., &c., p. 33. t Lectures by the late John Armstrong, M. D., p. 248. ON THE YOUNG SUBJECT. 29 use."* By Mr. Noble, of Manchester, a case is related, in which the death of a child, eleven months old, was owing to the effect of antimonial wine given as an emetic, f Mr. Wilton (surgeon to the Gloucester Infirmary) has also reported two cases of children, one a year old and the other four years old, which were manifestly destroyed by the use of antimonial wine given for ordinary colds. Slight convulsions—vomiting—diarrhoea—-sudden prostration and death took place, notwithstanding the use of cordials and stimulants. J I have known a case occurring in this city in which the one-thir- tieth part of a grain of Tartar Emetic given to a child a year old, laboring under croup, produced such severe and protracted vomiting, together with general prostration, as to require stimulants to save life. Some years since I was called to see a child, about three years old, who had been attacked with scarlet fever. The symptoms at first were mild, and no danger was apprehended in the case, when it was suddenly taken with such alarming symp- toms of prostration as to call for a consultation. On inquiry, I found that the attending physician had been prescribing small doses of Tartar Emetic. Notwithstanding the use of stimulants, the child died in an hour or two after I saw it. I then sus- pected, and have since been confirmed in the cor- * A Treatise on the management of Female Complaints/and of Children in early infancy. By Alex. Hamilton, M. D., p. 353. t Provincial Medical and Surgical Journal. By Robert J. N. Streeten, M. D. 1844, p. 47. t Ibid, p. 204. SO ON THE EFFECTS OF EMETICS rectness of the suspicion, that the medicine had no little agency in bringing about the fatal result. The child was naturally delicate, and there certainly was nothing in the symptoms of the case to account for such a termination. The foregoing facts would seem sufficient to show the uncertainty as well as energy with which Tartar Emetic operates on the young subject, and the causes are obvious. In the first place, Tartar Emetic is a powerful sedative, and it is well known, that in early life, the system cannot bear so well the operation of this class of agents, as it can in the adult. A strik- ing illustration of this we have in blood-letting, when carried to the extent of producing syncope. Adults, as a general rule, recover very readily from this state ; children, on the contrary, recover very slowly, and there is always more or less danger to life either from corfvulsions or general prostration, and the same thing holds good in relation to Tar- tar Emetic. Besides this, Tartar Emetic frequent- ly acts as a local irritant. From the delicacy of the mucous tissue in early life, it is of course more apt to act as such at that period, than it is in ad- vanced years. In both these ways, it is evident that Tartar Emetic must necessarily prove more energetic in its action on the young subject. In the second place, there is scarcely any medi- cine, whose action is more decidedly modified by the existing condition of the system than Tartar Emetic. In the ordinary state of the system, it acts as a sedative to the circulation, but at the same time causes, even in very moderate doses, nausea, ON THE YOUNG SUBJECT. 31 vomiting, sometimes free purging and diaphoresis. On the other hand, in certain states of the system characterized by high inflammatory action, very large doses and frequently repeated too, may be given without any other effect than that of lessen- ing excitement, and curing the disease. Again, as soon as this state of excitement is subdued under the use of the remedy, all the ordinary physiologi- cal effects of it are reproduced. Under these cir- cumstances the article can no longer be tolerated, and the use of it must be relinquished. All these interesting peculiarities are abundantly illustrated in the treatment of pneumonia, as first practised by Rasori in Italy, then by Laennec in France, and afterwards by numerous English and Ameri- can physicians. Now, if Tartar Emetic is thus modified in the adult by the existing state of the system, how much more readily must all this take place in the young subject. In the successive changes taking place in the child in the different states of disease, from irritation to inflammation, it is hardly possible to estimate the degree of un- certainty attending the operation of this article. Again, vomiting, we know, depends very much upon the existing'condition of the nervous system. In certain conditions of the brain and nerves, it takes place very readily, while in others it is al- most impossible to excite it, even by the most pow- erful means. For example, when the system is under the influence of some narcotic, such as opium, everybody is aware how difficult it is to bring on vomiting; and the same thing occurs in 92 ON THE. EFFECTS OF EMETICS other morbid states of the nervous system, such as apoplexy, &c. Notwithstanding this, it has been observed, that if under these circumstances, large quantities of Tartar Emetic be given, or if the use of it be too often repeated, although vomiting may not be induced, yet there may remain sensi- bility enough in the system to enable it to operate as a poison. An interesting case illustrative of this is related by Cloquet, of a person laboring un- der apoplexy, who received into his stomach up- wards of forty grains of Tartar Emetic, without producing either nausea or vomiting. On dissec- tion, besides the morbid state of the brain, exten- sive lesjons were found in the alimentary canal, which were attributed to the action of the Tartar Emetic retained in the stomach.* Dr. Christison quotes a case from the Edinburgh Medical and Surgical Journal (vol. vii., p. 305), in which a scru- ple of Tartar Emetic was given to a person poison- ed by opium, without producing any effect as an emetic ; sulphate of zinc was afterwards given, and with success. As he recovered from the effects of the opium, he was seized* with pains in the stomach and bowels, and with tenesmus, which lasted seve- ral days.f Now, it must be evident that in the young subject, all these results are much more like- ly to occur, than in the adult. While Tartar Emetic operates in this way on the young subject, Ipecacuanha is never known to » Paris and Fonblanque, Medical Jurisprudence, vol. ii., p. 280. t Elements of Medical Jurisprudence. By T. R. Beck, M. D. and J. B. Beck, M. D. vol, ii., p. 586. ON THE YOUNG SUBJECT. 33 be followed by any injurious consequences. To the youngest infant it may be given not only with impunity, but frequently with the greatest benefit. Why this is so, must be manifest, if we reflect for a moment upon the peculiar properties of the two articles. Although both are emetics, yet they dif- fer widely from each other in many important re- spects. The one is a mild article and limited in its operation to the stomach, upon which it never produces any thing like local irritation, even when given in large doses. The other, besides acting as a powerful emetic, is a direct sedative, capable of producing general prostration, and in some cases acting as a local irritant to the stomach and bowels, showing itself in excessive vomiting and diarrhoea. With regard to the manner in which Tartar Emetic proves so dangerous to infants, it is proba- bly more by its action as a sedative, than as a local irritant. This may be inferred from the symp- toms attending those cases, as well as from the ap- pearances on dissection. In the two cases record- ed by Mr. Wilt check its progress." A Compendium of Medical Practice. By James Bedingfield. Am. ed., 1823, p. 170. ON THE YOUNG SUBJECT. 49 not doing any harm. Any improvement too, which occurs during the use of the article, is sure to be attributed to the silent operation of it on the sys- tem. Now although this is not unfrequently the case, yet it is not invariably so; and every observ- ing physician must have been aware of cases, in which, in this way, the article has been unneces- sarily and injuriously continued. In bowel com- plaints, under the idea of altering the secretions, it has frequently, no doubt, helped to keep up the very intestinal irritation which it was given to cor- rect. In other cases it has developed the latent tendency to other diseases, such as Scrofula, Phthi- sis Pulmonalis, etc. In adults we know this to be very often the case. How much more likely is all this to happen in the young infant. 4. In the use of mercury in young children, great care should be exercised in ascertaining, as far as possible, their constitutional peculiarities. This, of course, is not in all cases easily to be done. A good deal, however, may be learned from an ac- quaintance with the tendencies of the parents. Wherever the parents show indications of scrofula, or where there is an hereditary predisposition to consumption, great caution ought to be exercised in the use of mercury in their offspring. 5. Mercury should be administered with great caution, in cases where a child has been sick for a considerable length of time, and when the strength of the child has been very much reduced. In this, state of constitutional depression, a single cathartic 5* 50 ON THE EFFECTS OF MERCURY dose of calomel sometimes proves fatal. We think we have seen more than one case, in which a child has been irretrievably prostrated under these cir- cumstances, under the false impression that calo- mel is an innocent purgative to a child. 6. The too common practice of giving calomel as an ordinary purge,on all occasions, is certainly unjustifiable. From the facility with which it may be given, it is unquestionably resorted to in a great number of cases, where it is unnecessary, and in a great number where it positively does harm. The misfortune is, that its use is not limit- ed to an occasional dose, but it is too often given in every slight indisposition of the child. Now, in this way, there can be no question that the use of it has laid the foundation for the ruin of the con- stitutions of thousands. It ought to be a rule laid down and rigidly followed, that in very young chil- dren, mercury ought never to be used as a cathar- tic, unless there is a special reason for resorting to it. In a great majority of cases, milder cathartics are decidedly to be preferred. In concluding these observations, I trust it may not be supposed, that my intention has been to un- dervalue the importance of mercury as a remedy in the diseases of children. On the contrary no* one appreciates it more highly than myself. In many cases, nothing can supply its place, and its judicious use has been, and is, the instrument of saving multitudes of lives. • Notwithstanding, how- ever, the many cautions to the contrary, it is to be ON THE YOUNG SUBJECT. 51 feared that the use of it is still too general and in- discriminate. Indeed, the amount of it which is taken by the human race in one way or other, is incalculable. What is given by regular physicians, is perhaps the smallest quantity. If the public really knew how much of this article is swallowed unknown to themselves, in the shape of bilious pills, worm lozenges, and the white powders* of the Homoeopaths,, they would be amazed at their credulity in deserting their old medical advisers, because they have the boldness to give them an occasional dose, and the honesty to tell them so. • In addition to the peculiarities already mention- ed in the preceding remarks, in relation to the ac- tion of mercury on the young subject, its effects when applied to the skin are not unworthy of no- tice. It is well known that one of the best modes of introducing mercury into the system, is by fric- tion. On the infant subject, however, when ap- plied in this way, it appears to operate even more kindly and efficiently than it does on the adult. This, therefore, is the best method of using it, where the constitutional effect of the article is needed in the young subject. On this point, the suggestions of Sir Benjamin Brodie are so impor- tant, that I cannot refrain from quoting them in full. " Children," says he, " when born, sometimes labor under syphilis, the father or mother having been affected with it—perhaps the father and not * Several cases have occurred in which these white powders have caused salivation. 52 ON THE EFFECTS OF MERCURY the mother. The child, at birth, looks thin, and is of small size; instead of thriving, it becomes still thinner. At the end of three weeks it is covered by a nasty, scaly eruption; there is a sort of ap- thae in the mouth, and chaps about the limbs and anus. I have tried different ways of treating such cases. I have given the child grey powder inter- nally, and given mercury to the wet nurse. But mercury, exhibited to a child by the mouth, gene- rally gripes and purges, seldom doing any good; and given to the wet nurse, it does not answer very well, and certainly is a very cruel practice. The mode in which I have treated such cases for some years past, has been this : I have provided a flannel roller, on one end of which I spread some mercurial ointment—say a dram or more ; and I have applied the roller thus prepared, not very tight, round the knee; repeating the application daily. The motions of the child produce the ne- cessary friction, and the cuticle being thin, the mercury easily enters the system. This causes neither griping nor purging; in a child, it does not even, in general, cause soreness of the gums, but it cures the disease. Very few of those chil- dren ultimately recover in whom the mercury has been given internally; but I have never seen a single case in which this other method of treatment has failed."* A reviewer in the British and For- eign Review states, that the same mode has been resorted to by him in two cases of Hydrocephalus, * Braithwaite's Retrospect, vol. 9, p. 113, vol. 14, p. 134. ON THE YOUNG SUBJECT. 53 with decided success. In these cases, strong mer- curial ointment was spread on each leg, every twelve hours, and covered with a stocking made to tie lightly above the knees.* * Braithwaite, vol. 14, p. 134. ESSAY IV. ON THE EFFECTS OF BLISTERS ON THE YOUNG SUBJECT. It has frequently struck me that a treatise, de- scribing with the necessary precision, the peculiar- ities of the effects of medicinal agents on the young subject, as distinguished from their effects on the adult, has long been needed in our profession. As yet I know of no such work. The systems of Materia Medica, valuable and elaborate as they are, and in which we should naturally look for the requisite information, are confessedly deficient on this subject. The consequence is, that the young practitioner who depends upon them, finds himself continually embarrassed in the treatment of the diseases of children, and he is obliged after all, to rely upon the incidental observations gathered from works on general practice, or upon the slow accumulations of his own experience. Even works professedly on the diseases of children, do not sup- ply the want. They indeed specify doses suitable to the age, and now and then give cautions in re- ON THE EFFECTS OF BLISTERS. 55 lation to the use of certain medicines, but they do not enter into the philosophy of the subject as it ought to be engaged upon. It is treated by them more as a matter of enlightened empiricism, than as one founded on sound and rational physiologi- cal and pathological principles. In some previous papers, I have endeavored to offer some contribu- tions on this subject, and should they be the means of inducing some experienced hand properly to elaborate it, it appears to me that a greater practi- cal benefit could not be conferred on the profes- sion. On the present occasion, I propose to make Blisters the subject of a few remarks. The first peculiarity attending the operation of blisters on the young subject is, that they produce their effects in a shorter time than they do in the adult. This is a fact well known to every practi- tioner. While in the adult, they do not produce their effects until from eight to twelve or even more hours have elapsed, in the child the same takes place in from two to six hours. In this re- spect there is a striking difference between blisters and most other remedies. Emetics and cathartics, for example, do not appear to act with any more rapidity on the child than they do on the adult. Now this fact, of the more prompt action of this class of agents, upon the child, although a simple one, is nevertheless one of great importance, and one which should be continually borne in mind. It has a practical bearing, not merely upon the mode of conducting the process of blistering in young 56 ON THE EFFECTS OF BLISTERS subjects, but also upon the use of it in their various diseases. The second peculiarity is, that the local inflam- mation produced by a blister is greater in the young subject than in the adult. The reason of this is obvious. In infancy, the skin is more delicate in structure, has greater vascularity, and a higher de- gree of sensibility; all circumstances favoring the development of greater inflammation. The local impression, accordingly, made by a blister, is not merely more rapidly developed in the young sub- ject, but it is also more intense. The third peculiarity is, that in young subjects blisters are more apt to be followed by the injurious consequences of inflammation, such as ulceration, gangrene, and even death. Numerous and melan- choly instances of this are to be found on record. Dr. Ryan, speaking of the use of blisters in chil- dren, says, " I have seen a blister on the chest fol- lowed by sloughing, and an aperture form over the epigastrium, which exposed the subjacent visce- ra."* Dr. Thompson states, that he " has seen gangrene and death follow the application of a blister on an infant."f Dr. North states that he has " twice known infants destroyed in conse- quence of the sloughing of blisters, the progress of which could not be arrested."J Professor Chap- * Manual of Midwifery, &c. By Michael Ryan, M. D., p. 476. t Materia Medica. By Anthony Todd Thompson, M. D. vol. ii, p. 535. X Practical Observations on the Convulsions of Infants. By John North, p. 202. ON THE YOUNG SUBJECT. 57 man remarks, that in children a blister " sometimes induces gangrene, as I have witnessed in two or three instances."* My friend Dr. W. C. Roberts informs me, that he has met with two cases in which children sank under the effects of blisters. Numerous other facts of a similar character might be adduced, to show the disastrous effects which sometimes result from the application of blisters to children; and to the minds of many physicians, it constitutes a serious objection to their use in their diseases. Dr. Armstrong says, " I have a great dread of the application of blisters to infants, on account of what is called the local and constitution- al irritation."-)- Now these occurrences may and do take place also in the adult, but they are com- paratively rare, and only under very peculiar con- ditions of the system. In infants, on the contrary, they are by no means uncommon. In any child, however healthy, they may occur from the simple cause of their being left on too long. They are more likely to take place, however, in certain con- ditions of the system or of the skin itself. Thus, for example, in cases where a child is greatly ema- ciated, or the constitution broken down from va- rious causes, the inflammation of a blister is very apt to become unhealthy in its character, and to be followed by injurious consequences. Then again, where the skin itself is in a diseased state, * Elements of Therapeutics, &c. vol. ii, p. 28. t Lectures, p. 362. 6 58 ON THE EFFECTS OF BLISTERS it is much more likely to happen than in the healthy conditions of that surface. The fourth peculiarity is, that the constitutional excitement produced by blisters is generally greater in young subjects than in the adult. That this must necessarily be so. is obvious. In all cases, the general excitement must be in proportion to the degree of local irritation and the sensibility of the patient's system. If so, the general vascular and nervous excitement produced in the child by a blister, must, as a matter of course, be greater than in the adult. So powerful indeed is the impres- sion thus made sometimes, that convulsions have been produced from this cause. Dr. North says: " I have frequently seen very severe parox- ysms (of convulsions) brought on in consequence of their injudicious and unnecessary application."* From the whole of the foregoing, it is evident tliat blisters are much more powerful in their agency upon the young subject than upon the adult. They operate with more rapidity—cause a greater degree of local irritation and constitutional excite- ment—and their operation is frequently followed by consequences which rarely occur in the adult. In the use of these agents, the practical bearing of these facts should be continually borne in mind. 1. If blisters are more powerful in their action upon children than adults, then it would seem to follow that they may be rendered more efficient • Observations on the Convulsions of Infants. By John North, p. 209. ON THE YOUNG SUBJECT. 59 as a means of cure in their diseases. And such appears to me to be really the fact. In all cases, where their revulsive agency is required, and where they are properly applied, it has struck me, that more decided benefit has resulted from their use in children than in adults, and that too, under cir- cumstances as nearly similar as they well could be. Besides acting more powerfully, the rapidity of their operation in children, gives them a great advantage in many cases. We all know that one of the great objections to a blister in the adult, sometimes at least, is the length of time which it takes to produce its effects. In a child this is in a great measure obviated, and we have in a blister not merely a powerful but a comparatively speedy counter-irritant. As remedial agents therefore, in the diseases of children, it seems to me they ought to hold a high rank. I am aware, that by some an opinion, entirely the reverse of this is entertained. Mr. North, in his valuable work on the Convulsions of Infants, states that he thinks, that except as stimulants, in depressed states of the system, blis- ters are altogether objectionable in the diseases of children. As revulsives in cases of local inflamma- tion, he regards them as having gained a character which they do not merit, and that in fact they do more harm than good. On this subject he says, " the period at which we apply blisters in local inflammatory affections is not to be forgotten. We first subdue the severity of the disease by other and appropriate remedies, and when it is upon its decline, when in all probability the unas- 60 ON THE EFFECTS OF BLISTERS sisted powers of nature would successfully perform the remainder of the task, a blister is applied. The patient gets well, notwithstanding the additional pain thus inflicted ; and the fortunate result of the case, which is really to be attributed to the measures previously employed, is said to be owing to the good effects of counter-irritation, &c, and the blister gains a character, to which in point of fact it has no claim."* Now all this may no doubt be true in some cases, but that it is so generally, can hardly be admitted. It should be recollected, that in the treatment of local inflammations, blis- ters are only auxilliary remedies. Of themselves, and alone, capable of doing but little, and yet when co-operating with other agents, such as blood-letting, &c, exceedingly powerful and valua- ble. Every one knows that there are periods and conditions in the career of inflammatory com- plaints, when bleeding and other reducing reme- dies have been carried to the fullest extent deemed advisable, and yet sufficient disease may remain, if not to destroy life, yet to render convalescence tedious, or to lay the foundation of subsequent chronic disease. This of course it is all important to obviate. Now it is just under this condition of things that blisters come in with great effect, and frequently break up completely the remaining ves- tiges of disease, and in this way I look upon them as remedies, acting with more power and efficiency in children even than in adults. * Observations on the Convulsions of Infants. By John North, p. 205—6. ION THE YOUNG SUBJECT. 61 2. From the fact of blisters being such power- ful agents, and especially from the fact of their being so liable to be followed by dangerous conse- quences, more caution is required in their use in children than in adults. Important and valuable as they are and may be made, if properly used, their indiscriminate application cannot be too much reprobated. Just in proportion to the good they are capable of accomplishing, under proper circumstances, is the evil which results from them, if heedlessly or injudiciously resorted to. It is to be feared that this is not always borne in mind as it should be. As a general rule, they should never be resorted to, especially in ve^a- young children, unless some decided benefit is anticipated from them. 3. The mode of conducting the process of blis- tering in a young subject is a matter of greater nicety, and should call for the utmost care on the part of the practitioner. As one of the principal causes of gangrene, is the leaving the blister on too long, this is a point which should be specially attended to. To many this may appear a small matter, but it is really one of great moment, and in relation to which I am sorry to say that the directions given in many of our practical works are so discordant, as to be very poor, if any, guides to the young practitioner. By way of illustration, I will quote a few of them. Dr. Armstrong says, " from twelve to sixteen hours is generally sufficient for the application of the blister in adults, and half 6* 62 ON THE EFFECTS OF BLISTERS that period in children."* Dr. Williams says, that "to avoid grangrene in children, it is advisable never to allow the blister to remain on more than six hours."f Dr. Dewees states that " in children, the blister is frequently found to have performed its duty in eight hours, and very often in six. It should therefore, always be examined at these periods, and dressed, if sufficiently drawn ; if not, it should be suffered to remain until this takes place."J Evanson and Maunsell say, " in no in- stance is the blister to be left on more than a few hours (from two to four)—not longer, in fact, than until the skin is reddened, when vesication will follow; but this-result should not be waited for, as attendants always will do, unless the most ex- press directions to the contrary be given."§ Neli- gan directs that " as a general rule, in infants and young children, blisters should only be left on until redness of the surface is produced, when the ap- plication of a warm poultice to the part will cause vesication."|i Ballard and Garrod remark, that in children a blister should not be allowed to remain on longer than to produce redness of the surface ; and they add, " in very young infants, it * Lectures, &c. By John Armstrong, M. D., p. 362. t Cyclopcedia of Practical Medicine. American Edition. Vol. I., p. 529. Art. Counter-irritation. X A Practice of Physic. By Wm. P. Dewees, M. D., p. 28. § A Practical Treatise on the Management and Diseases of Children. By R. T. Evanson, M. D., and H. Maunsell, M. D., p. 107. II Medicines, their uses and mode of administration. By J. "W. Neligan, M. D., p. 202. ON THE YOUNG SUBJECT. 63 has appeared to us doubtful whether even redness Bhould be permitted to occur before its removal."* The foregoing is a sample of the discrepancy of opinion in relation to a most important point of practice, and one confessedly, too, not unfrequent- ly involving the life of the young subject, as advanced by authors of the highest respectability, and who may be supposed to exert a wide influ- ence in guiding the practice of young beginners in our profession. The fact is, and this perhaps may account somewhat for the difference of opinion just noticed, that no positive rule can be laid down in relation to the precise time that a blister should be left on a young child. From the original differences in the sensibility of the skin in children, the period must necessarily vary, and the only safe general rule, is to be governed by the actual effect pro- duced. For this purpose the Mistering plaster should be raised at suitable intervals and the state of the skin observed. And the safe plan is, ac- cording to the directions of some of the authors quoted above, to remove the blister as soon as the surface appears uniformly red, and then to apply a soft poultice. In most cases this will be followed by suitable vesication, while any injurious conse- quences will be averted. It is not my intention in this paper to go into the minutiae of conducting the process of blistering, but there is one other point which I cannot help no- ticing, and that is, the practice which is so com- * Elements of Materia Medica and Theraputics. By Ed. Bal- lard, M. D„ and A. B Garrod, M. D„ p. 457. 64 ON THE EFFECTS OF BLISTERS mon with some of covering the blistering plaster with dry fly-powder. Although intended to make the blister more potent, it frequently has a directly contrary effect, from the fact that the blister does not adhere so closely to the skin ; over and over again have I seen blisters prepared in this way fail in producing the desired effect, although left on even longer than the usual period. Then again, the dry powder is apt to adhere to the skin after the blister is removed, and in this way strangury is more likely to be produced. In one case, accord- ing to Ure, sphacelus has occurred from this cause.* As apothecaries are very apt to prepare blisters in this way, it is important that practi- tioners should be on their guard to prevent it. With regard to the dressing of a blister, always a matter of importance to the young subject, and frequently so to the adult, I would call the atten- tion of the reader to a mode very recently recom- mended by Dr. D. Maclagan, of Scotland, which holds out many advantages over the ordinary method. After leaving the blister on for a suita- ble time, he applies a poultice of bread and milk for two hours. After discharging the serum, a thick layer of soft cotton wadding is applied over the part, with the undressed or wooly surface next to the skin. If in the course of a few hours this should become soaked with the serums discharge from the blister, so much of the cotton may be removed as can be done without disturbing the • A Practical Compendium of the Materia Medica, &c. By Alexander Ure, M. D., p. 31. ON THE YOUNG SUBJECT. 65 loose epidermis beneath, and the whole again cov- ered with a dry layer of cotton. This is all the dressing which in general is requisite. The cot- ton is allowed to stick to the skin of the blistered part, and when a fresh layer of epidermis is formed, which takes place very readily, the old epidermis and cotton come off together, leaving a smooth whole surface below. The advantages of the above mode, according to Dr. M., are first, " that it renders the blister much less painful and annoying to the patient than when unguents are used. The tenderness in fact, is comparatively so trifling, and the protection by the cotton so good," he says, " that I have been enabled without annoyance to the patient to percuss freely, and apply the stethoscope firmly over blistered parts, which had been dressed for the first time only an hour or two pre- viously ; secondly, the blisters heal faster under it than under dressings with cerate : for although the cotton may remain adhering for some days, I have generally found, that within twelve hours the patient ceases -to feel the blister a source of annoyance. Lastly, it dispenses with the greasy applications so disagreeable to patients of cleanly habits."* 4. To obtain the good and avoid the evils of blisters, it is evident that a nicer discrimination of the conditions of the system is necessary in the use of this class of agents in children than in adults. Long experience has established the fact that it is * Edinburgh Monthly Journal of Medical Science, May, 1847, p. 834. : ... 66 ON THE EFFECTS OF BLISTERS only under certain states of the system, that blis- ters can be used with any prospect of advantage. If this be true in the adult, it is doubly so in the young subject, and any mistake in this respect is much more likely to be followed by injurious con- sequences in the latter than in the former. Now the conditions which influence the effects of these agents, are the state of the skin, and the state of the nervous and vascular systems. With regard to the skin, it may be laid down as a general rule, that when blisters are used as revulsives, the part to which they are applied should be as nearly as possible in a state of perfect health. In this state, the irritation of blistering may be established even in a child with comparative safety. On the con- trary, when the skin is in a morbid state, ulcera- tion and gangrene are by no means unusual occur- rences. All this is occasionally illustrated in scarla- tina and measles. Mr. Pereira mentions that he has seen "two instances of death from the gangrene caused by applying a blister after measles."* My friend, Prof. Dunglison, in his valuable work on Ma- teria Medica, states that he has seen " several cases of death manifestly caused by the use of blisters in scarlatina and measles."f Other facts of a simi- lar character might be adduced, but the preceding are sufficient to show the tendency which there exists in this state of the skin to take on unhealthy inflammation. And the reason is to be sought for in * Materia Medica, Vol. II., p. 775. American Edition. t Vol. II., p. 219. ON THE YOUNG SUBJECT. 67 the changed condition of the skin. During the febrile stage of these diseases the skin is preter- naturally injected and excited. As soon as the fever subsides and the eruption recedes, the skin is left in a state of debility—a state in which, as we all know, inflammation is very likely to terminate unfavorably. I hope it may not be inferred from the preceding, that I mean to express the opinion that blisters ought never to be used in such cases as measles and scarlatina—but the possible occur- rence of such consequences ought to make us ex- ceedingly cautious about the manner of using them, and indeed ought to deter us from using them at all, unless under a manifest necessity. In every case, therefore, before applying blisters to young children, the condition of the skin ought to be attended to. With regard to the state of the system, this is even still more necessary to be inquired into. In- deed this is all important, if we hope to realize any of the expected benefits from these agents. Now there are two states of the system almost equally unpropitious to their use—and these just the reverse of each other. The first is that in which high inflammatory excitement is present. That this is unfavorable to the legitimate operation of a blister as a revulsive, is obvious, if we reflect for a moment upon the effects of this agent. These are, local irritation and general excitement. Now in all cases where an internal inflammation exists, the difficulty of resolving it by any means will be proportioned to the degree of general excitement 68 ON THE EFFECTS OF BLISTERS accompanying it. If a blister be applied where this general excitement is already very great, one of the necessary consequences will be to augment this so greatly as to counteract, in a greater or less degree, according to circumstances, the beneficial effects of the blister as a revulsive. Under this condition of things, the internal inflammation will be aggravated instead of abated, in consequence of the increase of general excitement. Hence the fact has been generally observed, that if blisters are applied in the early periods of inflammatory complaints, or before suitable evacuations have been resorted to, they frequently do more harm than good. They merely add fuel to the fire. On the other hand, a state of great constitutional exhaustion and emaciation is also unfavorable to their operation. The reason here, however, is en- tirely different from that in the preceding case. The danger here is that from the impaired state of the vital energies, the local inflammation of the blister may be followed by ulceration, gangrene and death. In the use of blisters, therefore, both these extremes should be carefully avoided. With regard to the condition most propitious to their use, it is that in which the general excitement is rather below than above the natural standard. When this is the case, there is less danger from any increase of excitement, while the system is in the state most favorable to the transfer of irritations from one part to another. Now all this is applica- ble to the adult, and we can easily see how much ON THE YOUNG SUBJECT. 69 more so it must be in the case of the irritable and sensitive infant. 5. In the use of blisters in children, especial reference should be had to the peculiarities of their temperament and constitution. This is more im- portant perhaps than it may at first sight appear. Every practitioner must have observed the extreme suffering which adults sometimes Undergo from the irritation of blisters. In nervous and irritable habits I have myself seen a state of things thus induced, little short of phrenzy. In children of nervous temperaments all this is much more likely to happen, and accordingly greater caution should be exercised. If the foregoing conclusions be founded in truth, they would seem at once to expose the impropriety of the practice of resorting to the use of blisters on every trifling occasion, in the management of the diseases of children. There is an opinion prevalent—how it has originated I know not, that blisters are innocent remedies—if they do no good, they can^o no harm. Now this is unquestionably a great error, and has been productive of vast mischief. Independently of the unnecessary suf- fering which they may occasion, they sometimes produce death by the manifest causes of ulceration and gangrene, while in others they insiduously aggravate the disease they were intended to relieve. 7 ESSAY V. EFFECTS OF BLOODLETTING ON THE YOUNG SUBJECT. There is no subject, perhaps, so deeply interest- ing to the practical Physician, as the effects of Bloodletting on the human system, and the various uses to which it may be applied in the manage- ment of disease. In promptness and power, it ex- ceeds all other agents, and its capacity for doing good or harm is proportionally great. It is re- sorted to, also, at every period of life, and by some It is even prescribed with equal, if not vapre free- dom in children than in adults. It becomes then, a question of the greatest moment to determine, if possible, whether the age of the patient has any' influence in modifying its effects. And this is the subject upon which I propose to make a few remarks. That the youngest child can sustain the loss of blood within certain limits, as well as the adult, is manifest from a variety of facts. Thus children are sometimes born in a state of asphyxia from apoplexy. On dividing the cord and letting a ON THE EFFECTS OF BLOODLETTING. 71 moderate quantity of blood flow, respiration is established, and eyery thing does well. Again, not unfrequently, from not applying the ligature suffi- ciently tight around the cord, or from the cord contracting and thus loosening the ligature, haemor- rhage takes place, and yet no injurious consequen- ces result. Besides this, we know that in cases of disease, the youngest child may be bled, not mere- ly without injury, but with advantage. When, however, the loss of blood is carried beyond these limits, important peculiarities are observed, show-; ing a difference- in the effects produced in the young subject, from those in the adult. The first peculiarity is, that the young subject does not bear the loss of considerable quantities of blood, so well as the adult. I am not aware that children fall into a state of syncope from the loss of blood more readily than adults ; but when syncope does come on, it is very certain that they do not recover from it so readily, and they are always in more or less danger. In the adult, syncope from the loss of blood, unless the quantity be very large, is a state which, as a general rule, is attended with little or no danger, and from which the patient speedily recovers. Hence it is that physicians are contin- ually in the habit of inducing it in the manage- ment of certain forms# of disease, and not merely with impunity, but evident advantage. In the young subject it is not so, and it is a state always attended with hazard. If the child recover from it, it does so very slowly, and every now and then it sinks irretrievably under its influence. That 72 ON THE EFFECTS OF BLOODLETTING this is a fact, is confirmed by abundant testimony, on the part of those who have taken the trouble to make the necessary observations. Dr. Marshall Hall, in speaking on this subject, says, "In infancy, the state of syncope (from the loss of blood) is a state of danger."* Evanson and Maunsell remark, "As a general rule, it is well to stop the flow of blood when decided pallor takes place, without waiting for actual fainting, from which children do not quickly recover."! Armstrong says, " Do not bleed to actual syncope in children, as they are apt to fall into convulsions, of which they may die. Children do not recruit from very large bleedings like adults."J Dr. Ryan observes, " The abstrac- tion of blood in cases of infants and children until fainting occurs, is the worst practice that can be im- agined, as convulsions or death may be produced."§ Indeed, the general fact admits of no question ; and the reason is obvious enough, if we reflect for a moment upon the nature of the agent, and at the same time compare it with the susceptibility of the subject. Carried to the point of syncope, blood- letting is one of the most direct, speedy, and pro- found sedatives that we have in our possession. In a few moments, it reduces the subject from a state of perfect health or the high excitement of disease, to the state of temporary death. Now it * Researches on the Morbid and Curative Effects of the Loss of Blood. By M. Hall, M. D., p. 87. t On the Management of Diseases of Children, p. 107. X Lectures, &c, by John Armstrong, M. D., p. 387. § Manual of Midwifery. By M Ryan, M. D., p. 475. • ON THE YOUNG SUBJECT. 73 is very evident that the capability of recovering from such a state, must be just in proportion to the powers of the constitution. From the very nature of its organization, therefore, it is obvious that the system of the child cannot sustain so well as the adult a shock so sudden and powerful as this. The second peculiarity attending the loss of blood in the young subject, is, that the nervous system is more powerfully affected than in the adult. The evidence of this is, that convulsions and coma more frequently occur after the loss of blood in children, than in adults. In the adult, both these occurrences sometimes take place, more especially convulsions. Thus, for example, puerperal haemor- rhage is not unfrequently followed by them. I have witnessed the same thing in a gentleman of irritable habit, who had been bleed too largely from the arm. He had lost about a quart of blood, when incipient syncope came on, followed immediately by a violent convulsion. In children, however, these occurrences are much more common; and the reason, no doubt, is the greater predominence, as well as impressibility of the nervous system. A great variety of causes, we know, will induce convulsions in a child, and among these, exhaus- tion is a very common one. With regard to coma, too, this may be brought on in children by any de- bilitating cause. A striking illustration of this we see now and then in diarrhoea, which has been continued too long. In these cases, the brain becomes suddenly affected, and a state of stupor or coma is induced, which is not unfrequently mis- 74 ON THE EFFECTS OF BLOODLETTING taken for Hydrocephalus. The same thing occurs from the loss of too much blood. The third peculiarity is, that the repetition of bloodletting is not so well borne by the child as the adult. A child of good constitution and ordinary strength, may bear a first bleeding, perhaps quite as well as an adult. Under peculiar circumstances, too, of disease, a second may be borne very well. Beyond this, as a general rule, it will be found, I think, that the child cannot well sustain the loss of blood. On this point, I believe, there is little or no difference of opinion among men of judgment and observation. Dr. John Clarke observes that " Very young children bear very well the loss of blood even to fainting, once or twice, but they ill bear a more frequent repetition of bleeding. Their powers sink under it, and by no art can it be replaced."* Marshall Hall says, " In infancy a second or a third bloodletting is borne with difficulty."-)- Evanson and Maunsell say, " Repetitions of bloodletting are not well borne by the child.""]; The fourth peculiarity is, that the effects of local bloodletting, especially leeching, are different upon the child, from what they are upon the adult. In the adult, the effect of leeching is in a great measure local, and it is not usually resorted to until after general bloodletting is considered inadmissible. In a child, on the contrary, it produces very much * Commentaries on the Diseases of Children, p. 103. t Researches on the Loss of Blood, p. 87. x On the Diseases of Children, p. 108. ON THE YOUNG SUBJECT. 75 the same effect as a general bleeding. From the greater vascularity of the skin, too, the amount of blood lost by a leech, applied to a young subject, is much greater than in the adult, and it is fre- quently much more difficult to arrest the haemor- rhage from it. The general effect, then, of leeching, on the young subject, is much greater than upon the adult. Hence it is that cases are so frequently occurring, in which children die from leeching. Of this we have numerous cases on record. Dr. Christison says, " I have twice known children bleed to death in Hospital practice, the nurse hav- ing labored under a common prejudice among their craft, that leech-bites cannot bleed too much."* Pereira states, that " in two cases of infants, I have seen exhaustion with insufficient reaction, conse- quent on haemorrhage after a leech-bite, terminate fatally."-]- Ryan says, " The loss of blood from a single leech-bite has caused the death of a child.""}; From the foregoing, then, it would seem, that although a child may sustain the loss of certain quantities of blood, perhaps quite as well as the adult, when carried beyond this, they do not bear it so well, nor do they bear the repeated and con- tinued loss of blood so well; and under these cir- cumstances, dangerous and even fatal consequen- ces are apt to ensue. In other words, bloodlet- ting is an agent which operates with more power, • Dispensatory, p. 492. t Materia Medica, Vol. II., p. 769; X Manual of Midwifery, p. 475. 76 ON THE EFFECTS OF BLOODLETTING and is attended with more danger in the child than in the adult. If all this be so, the following deductions neces- sarily follow. 1. Great caution should be exercised in bleed- ing children to the point of syncope. If the state of syncope be attended with the danger already alluded to, it is very certain that nothing can justify us in producing it, unless it be deter- mined that it is essential to the management and cure of the case. Now, that in most cases, even of decided inflammation, it is not necessary to carry bloodletting to this extent, is very certain. We know that it is not so in the adult, and it evidently cannot be so in the child. As a general rule, therefore, it cannot be required. By some high authorities, however, it is supposed that under cer- tain conditions of diseased action, the safety of the patient depends upon the production of syncope. Thus, for example, incroup, bleeding ad deliquium has been insisted upon by the late Dr. Bayley of New York,* Dr. Dick of Alexandria,! and Dr. Ferriar of Manchester. The latter especially speaks of it, as " the essential point of the cure, without which no relief can be effected.";}; If in any disease the practice be justifiable, it certainly is in this, and it cannot be denied, that in a great number of instances, it has been resorted to with * New York Medical Repository, Vol. XII., p. 331. t Barton's Med. and Phys. Jour., Vol. II. X Medical Histories and Reflections, by John Ferriar, M. D., p. 371. American Edition. ON THE YOUNG SUBJECT. 77 safety. Notwithstanding this, general experience has abundantly established the fact, that even here it is not necessary, and that all the beneficially sedative effects of the remedy may be obtained, without going to this extent. On this point, there appears to be, at the present time, a pretty general concurrence of opinion among enlightened prac- titioners, and the rule of practice ought to be, never in any case to bleed to syncope, but to stop as soon as paleness of the lips and cheeks comes on. In this way, all the good of bloodletting is secured, while the risks of syncope are avoided. 2. To determine the precise amount of blood proper to be drawn, is a matter of much greater nicety, and involves more serious consequences in the child, than in the adult. In the adult, the loss of a little more blood than is necessary, as a gen- eral rule, is a matter of no very great consequence. In the child, on the contrary, it may prove fatal. In the adult, too, we have means of judging how V far it ought to be carried, which we have not in the child. Thus, for example, the pulse, which in the adult is so valuable a guide in these cases, can- not be depended upon at all in the child. It is always, therefore, a very nice and difficult prob- lem in practical medicine, how to adjust properly in a child the amount of blood necessary to be drawn, to the exact wants of the case. Now there are only two ways in which this can be done. The first is, by fixing upon a certain amount as suitable to different ages. The second is, to judge by the actual effects produced at the time of taking 78 ON THE EFFECTS OF BLOODLETTING the blood. With regard to the first of these modes, it is evident that it must be a very unsatisfactory guide, if we recollect that no two constitutions are precisely alike, and that there is every difference in the capacity of different systems, even in the same disease, to bear the loss of blood. Then, again, the same disease exists in different degrees of violence, and of course requires a modification in the amount of depletion. Besides all this, dif- ferent diseases do not require and cannot tolerate the same loss of blood. A general standard, then, founded upon the age of the patient, is really good for nothing, except as a mere approximation. In individual cases, it must be inapplicable. Hence it is, that all those standards laid down by authors, differ so much from one another, and must neces- sarily do so. If blood be taken by leeches, the difficulty is still further increased, from the circum- stance that the desired quantity can hardly ever be obtained with any degree of precision: if it is so, it is purely by accident. That this must be so is evident, if we recollect the variable quantities of blood drawn by the leeches themselves, and more especially the greater differences in the after- bleedings. It is not yet settled, I believe, exactly how much blood a leech will draw. Christison says, " Twice as much blood may be usually drawn by fomentations, as by the suction of the leech. A single leech, when applied successfully, may thus be held to draw, from first to last, about half an ounce of blood on an average."* According to * Dispensatory, p. 492. ON THE YOUNG SUBJECT. 79 Evanson and Maunsell, " the quantity of blood ob- tained by a good leech, allowed to bleed for half an hour, may be estimated at one ounce."* Pereira says, " I believe four drachms to be the maxi- mum. On an average, I do not think we ought to estimate it at more than a drachm and a half;"-\ i. e., the quantity taken by the leech itself, without reference to the after-bleeding. Now the fact is, it is impossible to specify the amount of blood drawn, either by the leech itself or in consequence of the subsequent bleedings. Leeches differ in their size very greatly, and there must," of course, be a great difference in the quantity of blood they are capable of taking. Then, again, there is every difference in the after-bleedings, depending on the vascularity of the skin, the part of the body to which they are applied, and various other circum- stances. From all this, it is evident how unsafe it must be to draw blood from a child, according to any average standard. With regard to the second mode, that of judging of the extent to which it should be carried by the effects produced at the time : in many cases this answers exceedingly well. In inflammatory com- plaints, where the full effect of the loss of blood may be necessary, the rule can be satisfactorily applied, and the best plan is to bleed in the erect posture, until pallor of the face comes on, without producing actual syncope. In the adult, according * Practical Treatise on Children, &c., p> 106 t Materia Medica, Vol. II., p. 769. f 80 ON THE EFFECTS OF BLOODLETTING to Marshall Hall, the production of actual syncope constitutes the criterion as to the exact amount which the case requires, as well as of the capacity of the system to bear the loss of blood, and there- fore he recommends this as the rule for the due ad- ministration of the remedy. Now, that this will not answer, must be obvious to every one. Every practitioner knows that cases are continually oc- curring, in which actual syncope comes on after the loss of a few ounces of blood, when large quantities are afterwards required to be drawn. In children, of course, the rule cannot be applica- ble. In them, the loss of so much blood as to bring on only approaching syncope might not only be unnecessary, but be attended with danger. From all this, then, it would appear that we are not in possession of any precise mode of determining how much blood ought in all cases to be taken in children; and this shows the necessity of great caution and the exercise of sound judgment, in the use of the remedy. 3. From the uncertainty in estimating the quan- tity of blood lost by leeches, and the dangers at- tending the loss of too much from them in children, too great caution cannot be exercised in their use. From the manner in which leeches are ordered by some physicians, in the diseases of children, one would be led to suppose that no harm could ever result from them. From the ease, too, with which they may be prescribed, and the appearance of energy which it gives to the practitioner, it is to be feared that not unfrequently they are used with- ON THE YOUNG SUBJECT. 81 out being actually necessary, and even when ne- cessary, they are suffered to draw blood without sufficient regard to the quantity which may be lost. Now it should always be recollected, as al- ready stated, that leeches operate differently on the child from what they do on the adult. In the lat- ter, they are in a great measure local in their ac- tion, and may be, and generally are used, when general bleeding is contra-indicated. In the child, on the contrary, they act in the same way as gen- eral bleeding. Their sedative effects, therefore, upon the constitution of the child, are much great- er ; and if suffered to bleed beyond a certain limit, they endanger life. On these accounts, it is more necessary to be cautious in the use of them in children, than in adults. It is not my intention to go into any particulars, in relation to the mode of conducting the process of leeching. There are a few points, however, of a practical character, con- nected with this subject, which may not be unwor- thy of notice. 1. When leeches are applied to a child, the patient should always be placed in the erect posture. The same rule indeed should be observed, in whatever way blood is drawn. If it be a fact that leeches act like general bloodletting upon the child, the propriety of this rule must be obvious ; and it is the more necessary to insist upon it, because it is hardly ever observed. As soon as any paleness of the lips or face appears, the child should be placed in the recumbent posture, and the bleeding arrested. 2. When leeches are ap- plied to a child, the patient should never be left 8 82 ON THE EFFECTS OF BLOODLETTING ur^til after the flow of blood is completely stopped. 3. Leeches should never be applied at bed-time, and suffered to bleed during the night. In this way, the patient has, in more cases than one, bled to death. If applied late at night, they should be watched just as in the day time. 4. As a general rule, leeches should not be applied to soft parts destitute of support from underneath, in conse- quence of the difficulty of making pressure sufficient to arrest the haemorrhage. The importance of this was first noticed by Dr. Cheyne, who advises them to be applied in croup, not to the neck itself, but over the clavicle, sternum, or ribs.* 5. Leeches sometimes open into arteries, and dangerous haemorrhage has ensued from this cause. A case of this kind happened, in which the temporal arte- ry was thus opened, and Sir Astley Cooper was obliged to divide the artery before the haemorrhage could be arrested.f In all cases, therefore, the progress of the bleeding should be carefully watched. 4. If bloodletting be so profound a sedative to children, it is evident that it is capable of doing a vast deal of harm in cases unsuited to its use, and that it requires a very nice discrimination of the character of the case, before it can be used with safety. This may appear very commonplace ; but, commonplace as it is, it is to be feared that it is not sufficiently borne in mind in actual practice. The presence * Pathology of the Larynx and Bronchia, by John Cheyne, M. D., p. 57. t Johnson's Med. Chir. Rev., Vol. IX., p. 71. ON THE YOUNG SUBJECT. 83 of inflammation or congestion is generally consid- ered a condition justifying and requiring a resort to bloodletting, and so indeed, as a general rule, it is ; but it is not so universally. Thus,for example, the inflammation attending scarlatina does not usu- ally require or bear well the loss of blood; and there can be no question that, in this complaint, many a child has been sacrificed by a resort to this remedy. Then, again, symptoms analogous to those produced by inflammation or congestion result from a cause directly the opposite, viz : irri- tation or mere exhaustion. Illustrations of this we see frequently in affections of the head in children, convulsions, &c. In these cases, if the cause of the difficulty be mistaken and depletion be restored to, the result may be fatal. All this shows that, before bloodletting is used in children, the nature of the case should be investigated more nicely even than in the adult. 5. In the use of bloodletting in the young sub- / ject, especial regard should be had to their consti- tutions, as well as their mode of living. No prin- ciple is better understood, or ought to be so, even in adults, than that in the use of debilitating rem- edies, due regard should be had to the powers of the system. No practice is safe which does not take into consideration the relative capacity of the system to bear them; otherwise the remedies may be more fatal than the disease for which they are prescribed. Now we know that in the adult there is every difference in this respect. In the man- agement of the same disease accordingly in differ- 84 ON THE EFFECTS OF BLOODLETTING ent individuals, a very different course of treat- ment is necessary, if not in the remedies themselves, at least in the extent to which they are carried. In the young subject this is still more necessary. Children whose constitutions are naturally feeble and vicious, or who have been enfeebled by debil- itating causes, such as poor diet, confined air, &c, sink very readily under the influence of depressing remedies. In these bloodletting is badly borne, and should never be resorted to unless absolutely necessary, and then in moderate quantities. 6. Great caution should be exercised in the • repetition of bloodletting. After what has been already said in relation to the effects of repeated bloodletting on the young subject, I should not again allude to it, were it not to notice the opinions of an eminent authority. Dr. Rush, in his " Defence of Bloodletting," makes the following statement: " I could mention many more instan- ces in which bloodletting has snatched from the grave children under three or four months old, by being used three to five times in the ordinary course of their acute diseases."* That the children alluded to by Dr. Rush survived this treatment I do not doubt; but that these repeated bleedings were necessary, I can hardly believe. At any rate, a practice like this, if generally adopted, would, in my humble opinion, end in the most disastrous re- sults. In concluding this paper, I trust it may not be thought that I am opposed to the use of blood- * Med. Obs. and Inqs. Vol. IV., p. 300. ON THE YOUNG SUBJECT. 85 letting in the diseases of children. The physician who discards this agent, understands but poorly his profession or the duty which he owes his patients. The proper use of a remedy, however, is one thing, the abuse of it is another ; and I must express the opinion, founded on no small observation, that it is frequently resorted to in children when it is un- necessary—when necessary, it is often carried too far—and that in its general use, there is frequently an absence of precision and care, which in many cases renders it a most dangerous remedy. With regard to the use of bloodletting generally in this country, there can be no doubt that the authority of Dr. Rush has exerted an influence the most deleterious. That it should have done so is not surprising. Living at a time when medicine was yet in its infancy among us—at the head of the oldest and most influential of our medical schoools and attracting by his enthusiasm and his eloquence a large proportion of the students of the country, his sway for a series of years was unlimited, and his sanguinary precepts and his still more sanguinary practice* were speedily diffused from one end of * To justify the language used above, and which may be con- sidered too strong by some, let me make a quotation or two from Dr. Rush's celebrated " Defence of Bloodletting." " Bleeding should be continued while the symptoms which first indicated it continue, should it be until four-fifths of the blood contained in the body are drawn away." Med. Obs. & Inq. Vol. 4, p. 353. The amount of blood in an adult is estimated at about 32 lbs. Four- fifths is over 24 lbs! Again, in enumerating the advantages of bloodletting, he says: " In case's where bleeding does not cure, it may be used with ad- 8* 86 ON THE EFFECTS OF^BLOODLETTING the country to the other. Although sad expe- rience has long since exposed the fallacy, as well as danger of his doctrines, yet many of the evil consequences of them are still to be met with ; and not the least of these, it appears to me, is the opportunity which they have, indirectly at least, afforded for the prevalence of quackery. It is a vantage as a palliative remedy. Many diseases induce death in a full and highly excited state of the system. Here opium does karm, while bleeding affords certain relief. It belongs to this rem- edy, in such cases, to save pain, to relieve convulsions, to compose the mind, to protract the use of reason, to induce sleep, and thus to smooth the passage out of life." Med. Obs. and Inqs. vol. 4, p. 357. In other words, if I understand him, one of the advantages of bleeding is, that it makes persons die easily! This reminds me of a melancholy case which I once witnessed. A young gentle- man, about eighteen years of age, had been suffering about three months under organic disease of the brain. During this period he had been subjected to every kind of treatment. Bloodletting, emetics, cathartics, mercurials, tonics, &c., had all been used in succession, but without arresting at all the progress of the disease, and he had now become stone blind, was paralytic, and reduced to the extremest state of emaciation and debility. In short, he was barely kept alive by the use of stimulants. In~ this state of things a friendly doctor happened to drop in, and expressed the opinion that the disease was inflammation of the brain, and that a good bleeding would relieve him. Notwithstanding the urgent remon- strances of the attending physician, that the result would be almost immediate death, the idea took with his friends, and he was bled by the doctor who suggested the practice. As might have been expected, in about six hours he was a corpse, and the great conso- lation to his friends seemed to be that he died so easily ! Verily, on becoming acquainted with such practice, one would be tempted to believe that the Emperor Nero must have been a very tender- hearted man in condemning Seneca to so pleasant a mode of ter- minating his existence as bleeding to death. Fot the particulars, see the Annals of Tacitus, Book 15, Sec. 60. ON THE YOUNG SUBJECT. 87 part of our nature to fly from one extreme to an- other. When an error is once exposed, we are apt to go immediately to its opposite, inferring that what is the reverse of wrong must necessarily be right; and so it has been in regard to bloodletting. The public having been made acquainted with the evils of the practice of Dr. Rush, a prejudice, if not general, at least very extensive, has been created against the remedy itself, and empirics, always ready to play upon the weaknesses and prejudices of the community, have seized upon it for the mere purposes of traffic. Accordingly, the land is now filled with a set of men who pretend to practice medicine, without resorting not merely to blood- letting, but many of the other remedies sanctioned by long and tried experience. And what is melan- choly, but true, they find a ready sympathy in a large portion of the community. Whether I am too severe in attributing the popular empiricism of the day to the influence of Dr. Rush, must be left to the judgment of the profession. One thing, however, is very certain, and which we see illus- trated every day. Whenever a person has been overtaxed with active medicine, he is apt to discard all belief in medicine generally, and he is then ready to fall into any absurdity. It is with medi- cine as it is with religion. Superstition once thrown off, infidelity follows, and the result in both cases is the same. Calm reflection and rational inquiry are out of the question, and boasted inde- pendence speedily becomes the easy prey of the knave and the empiric. i ESSAY VI. OBSERVATIONS ON ERGOT. In the whole range of the materia medica there is no article more interesting in its effects on the human system than ergot. Given during labor, it possesses the curious property (possessed by no other substance that we know of,) of exciting uterine action, and facilitating in a most extraor- dinary manner, the whole process of delivery. Upwards of forty years have now elapsed since its introduction into general practice in this country ;* * Although used previously by the common people, ergot was first introduced into regular practice in 1807, by the late venerable Dr. John Stearns, of this city, at that time residing in Saratoga county, State of New York. As every thing connected with the use of this article is interesting, I shall give the brief letter of Dr. Stearns, in relation to it, addressed to Dr. S. Akerly of New York, dated, Jan. 25, 1807. " In compliance with your request I herewith transmit you a sample of the pulvis parturiens, which I have been in the habit of using for several years with the most complete success. It expe- dites lingering parturition, and saves to the accoucheur a consid- erable portion of time, without producing any bad effects on the patient. The cases in which I have generally found this powder to be useful, are when the pains are lingering, have wholly sub- OBSERVATIONS ON ERGOT. 89 and during portions of the same period, it has been extensively used in Great Britain and on the con- tinent of Europe. After such ample experience, sided, or are in any way incompetent to exclude the foetus. Pre- vious to its exhibition it is of the utmost consequence to ascertain the presentation, and whether any preternatural obstruction pre- vents the delivery: as the violent and almost incessant action which it induces in the uterus precludes the possibility of turning. The pains induced by it are peculiarly forcing; though not ac- companied with that distress and agony of which the patients fre- quently complain when the action is much less. My method of administering it is either in decoction or powder. Boil half a drachm of the powder in half a pint of water, and give one-third every twenty minutes till the pains commence. In powder I give from five to ten grains; some patients require large doses, though I have generally found these sufficient. " If the dose is large it will produce nausea and vomiting. In most cases you will be surprised with the suddenness of its oper- ation ; it is therefore necessary to be completely ready before you give the medicine, as the urgency of the pains will allow you but a short time afterwards. Since I have adopted the use of this powder I have seldom found a case that detained me more than three hours. Other physicians who have administered it concur with me in the success of its operation. " The modus operandi I feel incompetent to explain. At the same time that it augments me action of the uterus, it appears to relax the rigidity of the contracted muscular fibres. May it not produce the beneficial effects of bleeding without inducing that extreme debility which is always consequent upon copious deple- tion 1 This appears to be corroborated by its nauseating effects on the stomach, and the known sympathy between this viscus and the uterus. " It is a vegetable and appears to be a spurious growth of rye. On examining a granary where rye is stored, you will be able to procure a sufficient quantity from among that grain. Rye which grows in low, wet ground, yields it in greatest abundance. I have no objections to your giving this any publicity you may think pro- per."— New York Medical Repository. Edited by Samuel L- Mitchell, M. D-, and Edward Miller, M- D., Vol. II, p. 308. 90 OBSERVATIONS ON ERGOT. we should naturally suppose that every thing in re- lation to its action would be completely established. Such, however, is not the case. Several impor- tant points are still under dispute, and it is upon these that it is proposed to make a few observa- tions in the following paper. 1. By some it is denied that ergot possesses any such property as is generally ascribed to it. On this point it would seem hardly necessary to say any thing. Whether ergot does or does not possess such property, is a question which must be decided by the observations and testimony of those who have used it, and the mass of recorded as well as unrecorded evidence which we possess on this sub- ject, is so abundant, as one would suppose, would be sufficient to preclude all doubt.* Notwith- standing all this, it is maintained by some high authorities that ergot does not act upon the uterus, and in support of this opinion it is alleged that it has been frequently given without any such effect having followed; and when it has taken place, it is explained upon the ground of its being a mere * Bayle has collected the reports of sixty-two authorities on the subject of ergot, and out of 1176 cases of lingering labor in which it was used, 1051 were more or less promptly terminated by it. In 111 cases, it failed to produce any effect, and in 14 the success was moderate.— Bibliotheque Therapeutique, fyc., par A. L. I. Bayle, tome Hi., p. 534. In addition to the foregoing mass or authority, I will only ad- duce the estimony of Dr. Ward, of New Jersey, who states that during six years, he gave it to between sixty and seventy patients, and in every case, except one, it produced powerful uterine con- tractions in fifteen or twenty minutes after its administration. —New York Med. and Phys. Jour, for 1825, Vol. IV, 212. _. OBSERVATIONS ON ERGOT. 91 accidental coincidence, and that the uterine efforts would have been renewed just as certainly without its agency. Now that ergot has frequently been given without producing any effect on the uterus is readily admitted, and yet this by no means proves that it is destitute of the power ascribed to it. Some constitutions are doubtless not suscepti- ble to its action. This we know to be the case with may agents, whose action on the human sys- tem is universally acknowledged. Besides, much of the alleged inefficacy of ergot may very readily be explained by the fact, now well known, that this article is not always precisely the same. From a variety of causes influencing the growth of this curious substance, independently of designed so- phistications, it has been established that its pro- perties differ very materially, and if these be not duly regarded, it is by no means wonderful that its use is frequently not followed by any effect. With regard to the supposition that the uterine action which follows its exhibition is a mere coin- cidence, it seems to me to be entirely done away with by the fact that the pains'which are produced are entirely different in their character from those of ordinary labor. The latter are distinguished by perfect intermissions; while the former, are not only more severe, but they are continuous until the labor is completed. Females themselves are perfectly conscious of this difference in the two kinds of pain, and by them this difference has been fre- quently described. Besides this, the uniformity and rapidity with which the pains come on af- 92 OBSERVATIONS ON ERGOT. ter the exhibition of ergot, is altogether irrecon- cilable with the supposition of its being a mere coincidence. If the pains came on at remote and variable periods, then indeed might there be some ground for denying the agency of the ergot in pro- ducing them. This, however, is not the case. As a general rule in from five to twenty minutes, se- vere and forcing pains come on,* and after contin- uing for an hour or more, if the delivery be not completed, the same effects may be reproduced by a repetition of the dose. Now, if all this does not prove that the ergot is the cause of the uterine ac- tion, 1 am at a loss to conceive what kind of evi- dence will establish the action of any medicinal agent on the human system. If we still doubt in relation to ergot, we may with equal propriety doubt concerning the operation of ipecacuanha on the stomach, or of calomel on the liver. Although * By Dr. Prescott the time was precisely marked in twenty cases, '•In'two of these, the increased strength of the pains and the con- tinued action commenced in seven minutes from the time the de- coction was taken; in one case, it was eight minutes ; in seven, it was ten; in three, eleven; and in three others, it was fifteen minutes ; in the four remaining cases, there was no apparent op- eration until twenty minutes had expired."—A Dissertation on Ergot, by Oliver Prescott, A. M., p. 11, Boston, 1813. .Dr. Ward, as already quoted, states that he used it in sixty or seventy cases, and jn all excepting one case, it produced " powerful uterine contraction in fifteen or twenty minutes after its adminis- tration."—New York Med. and Phys. Journal, Vol. II. p. 212. Mr. John Paterson, of Aberdeen, states that he used it in eight cases, and it acted strongly in all, in less than five minutes after it was administered.—Edin. Med. and Surg. Journal for Jan., 1840, p. 142. OBSERVATIONS ON ERGOT. 93 there can therefore be no reasqnable question about the operation of ergot, yet it is certain that it sometimes fails. This is a fact which has been frequently noticed by those who have prescribed it. Professor Dewees states that he has " in several instances failed to produce the slightest effect with the ergot procured at one shop, whilst that from another, in the same patient, has been as prompt as it was efficacious."* The same thing has been observed by others. In a large majority of cases this can easily be accounted for. The character of this article is modified by a number of circum- stances, all of which should be attended to if we wish to have it genuine. As these are important in a practical point of view, they are deserving of attention. In the first place, the character of the season, as to dryness or moisture, appears to influence very materially the quality of the ergot. According to Burnett, it has been ascertained that the principle of the ergot resides in the diffluent peridium or ex- ternal covering. Now if heavy rains fall at the time when the peridium is soft and moist.it will be washed away and the hardened nucleus, if wholly denuded, will be utterly inert. If the weather be fineduringthe maturation of the fungus, the diffluent peridium will be dried upon the spur, and the ergot be in its most active state. Hence it is, that although moisture favors the early growth of the • American Journal of Medical Sciences, Vol. I., p. 255. 9 94 OBSERVATIONS ON ERGOT. ergot in the spring and summer, it requires a dry autumn to ensure its activity.* In the second place, the period when it is gath- ered has an influence on the character of the ergot. According to the experiments of Dr. Kluge of Mendelurtz, it would seem that it only displays its active properties, when collected before the cut- ting of the parent crop. At the Maternite of Men- delurtz, trials were made upon fifteen females, and the result was, that what was gathered before har- vest was verv energetic, while that collected after harvest was altogether powerless.! Whether this be true in its full extent or not, certain it is that there is a great difference in the strength of the article according to the time when it is gathered. In the third place, the time it has been kept mod- ifies the quality of the ergot. Although some experiments of Lorinser would seem to show tha1 so far as its action on the stomach is concerned, it retains its active properties for two years,J yet the result of general observation has shown that its influence over the uterus is impaired if it e kept over the year in which it is collected. Like all other vegetables too, it is easily acted on by heat and moisture. To have it good, therefore, it should * Outlines of Botany, by Gilbert Burnett, Prof, of Botany in King's College, London, p. 207. Upon the same principle he explains the fact, that the grain in which the spur prevails in equal proportions, will in some years produce the" dry gangrene, while in others it will not. t American Journal of Medical Sciences, Vol. XIL, p. 515. X Edinburgh Med. and Surg. Journal for 1826, p. 453. OBSERVATIONS ON ERGOT. 95 be fresh ; and it ought to be kept in bottles tightly stopped, and it should not be pulverized until required for use.* In the fourth place, a fictitious ergot has Some- times been sold for the real article. In this coun- try and on the continent of Europe, where rye is extensively cultivated, and where of course there is an abundance of ergot, this is a fraud which is not likely to be met with. In England, however, where much less rye is grown, the ergot is occa- sionally very scarce, and this has led to a variety of impositions. Dr. O'Shaughnessy of London states, that a specimen of suspected ergot was once given him for analysis, and he found it to be com- posed of the sulphate of lime, which had been cast in a mould and colored, so as to imitate very closely the natural ergot.f Mr. Wright says he has sev- * In a recent number of the Journal de Chimie Medicale, the following method for preserving ergot in a good condition for sev- eral years, is recommended by M. Victor Legrip. 1. Reduce the recent ergot well dried into powder. 2. Expose the powder to a temperature of 45 or 50 degrees cen- tigrade, (i. e. 104 or 122 Far.) in order to dry it thoroughly and quickly. 3. Put it into glass bottles and seal hermetically. 4. Withdraw it from the action of light by shutting it up either in a dark place or by covering the bottles with black paper.—Se* London and Edinburgh Monthly Journal of Medical Science. No. 52, April, 1845. According to Mr. Wright, the best ergot is dry, and easily broken, purplish-black on the surface, pale-grayish in its substance, lighter than water, free of insects, inflammable and burning with a clear flame, and incapable of forming a dark-blue pulp when its powder is triturated with iodine and water. t Lancet for 1830-31, Vol. I., p. 638. 96 OBSERVATIONS ON ERGOT. eral times observed the ergot to be adulterated with common paste ; " a fraud," he suspects, " of very frequent occurrence, though not of very easy detection; for the process of baking generally modifies the starch, so that it can scarcely be indi- cated by iodine."* The foregoing causes appear to me abundantly sufficient to account for the discrepancies in the statements which have appeared in relation to the action of this singular substance, as well as for the occasional failure which attends its use. 2. Acting thus powerfully on the uterus, does ergot produce any effect upon the child ? This is a question of great interest, and one which involves conse- quences of great importance, not merely in a pro- fessional, but in a moral point of view. On this subject, the opinion of the profession is divided. While some maintain that it produces no effect, at least no injurious effect upon the child, others con- tend that it frequently proves destructive of life, and that the general use of it is one of the causes of the great increase in the number of still-born children. An attentive examination of the subject, in all its bearings, will, I fear, but too certainly lead to a conclusion in favor of the latter opinion. From the peculiar effect of the ergot upon the uterus, it is evident that the child must sustain a degree of pressure entirely different from what it does in ordinary labor. In the first place, it is much greater. In the second place, it is unremit- * Edinburgh Med. and Surg. Journal, Oct. 1839, p. 297. OBSERVATIONS ON ERGOT. 07 ting and continued, and that too for a considerable length of time. Now, it is by no means unreasonable to suppose that this pressure may frequently prove injurious and even fatal to the child. This would be more especially likely to happen in cases where the waters are discharged early, and where the uterus is contracting directly upon the child. In natural labor, the child has time to recover from the effects of pressure during the intervals between the pains, while here no such chance is afforded. And it is not irrational to suppose that the design in making the pains of labor intermitting, was not merely to allow the mother time to recover her strength, but also to enable the child to recover from the effects of pressure. That continued pressure may and does prove injurious to the child even in cases of ordinary labor, where this process is protracted, either from the disproportionate size of the child, or from the resistance of the parts through which it is to pass, is a fact well known. How much more likely is this to happen where an unnatural and unremitting pressure is kept up, as is the case under the influence of ergot ? From these general considerations it would seem not merely perfectly natural, but unavoidable, that in many cases, the child must suffer from the use of ergot. After all, however, this is a question which must be decided by faets, and these will tend still further to countenance this opinion. So early as the year 1812, it was suggested by the editors of the New England Journal of Medicine and Sur- gery, that while fully convinced of the parturient 98 OBSERVATIONS ON ERGOT. powers of the ergot, they were apprehensive that an evil of great magnitude not ^unfrequently re- sulted from its use ; and that was the death of the child. They stated that they had been led to this apprehension from " observing that in a large pro- portion of cases where the ergot was employed, the children did not respire for an unusual length of time after the birth, and in several cases the chil- dren were irrecoverably dead."* Since then a large amount of testimony has been furnished con- firmatory of the truth of this suggestion. In the same Journal,! a case 1S recorded of a female in her third labor, who was delivered of twins. After the first child was born, which was living, an hour elapsed without the recurrence of a single pain, in consequence of which it was determined to administer the ergot. Fifteen grains in powder were accordingly given in a little water. In fifteen or twenty minutes the pains came on and con- tinued without remission until the child was born, which was in about twenty minutes from the time the pains commenced, the head being born first as in natural labor. The child, however, was still- born, and every effort to resuscitate it failed. It was in every respect as fine a child as the first, perfectly fresh and firm. The writer remarks that "every one who is acquainted with the facility with which in a case of twins, the second child makes its way into the world, will consider the • Vol. I., p. 70. t Vol. II., p. 353. OBSERVATIONS ON ERGOT. 99 death of the child in this instance as an unusual occurrence." Dr. Ward of New Jersey, whose experience with this article appears to have been extensive, and who speaks of it as a valuable agent in many cases, nevertheless admits the danger which attends the child from its use. " In all the cases," he says, " in which I have given it, unless the child was expelled very soon after the powerful contractions came on, it suffered very much, and would lie for sometime without breathing." Again he says, " from my own observation, with regard to the ergot, as well as from other correct sources of information, I am led to conclude that in most cases, after giving it, unless the child is expelled in forty minutes after the powerful contractions come on, it will be born dead."* The late Dr. William Moore, a veteran practi- tioner of obstetrics in this city, after detailing some cases, gives his opinion in_ relation to ergot in the following terms : " It appears to be injurious to the child at all times ; for in every case in which I have seen it exhibited, the child has been still- born, and Jn the greater part of them it was not possible to restore it to life.f Dr. Hosack states that he gave the ergot in three cases, and " although no evidence existed previous to the use of the medicine, that the foetus was not * New York Med. and Phys. Journal, Vol. IV., p. 212. t Compendium of Midwifery, by Samuel Bard, M. D., p. 214, 4th edition. 100 OBSERVATIONS ON ERGOT. living, in eveiy case in which it was administered, the child was still-born."* Dr. Chatard, of Baltimore, made two reports in relation to the effects of ergot. In the first, out of twelve cases in which it was given, six of the chil- dren were still-born.f In a second report, out of twenty-five cases, eight were still-born, two of whom were, however, resuscitated.J Dr. Holcombe, of New Jersey, says, " more chil- dren, I am satisfied from what I have seen and heard, have already perished by the injudicious use of ergot, during the few years which have fol- lowed its introduction into the practice of this country, than have been sacrificed by the unwar- rantable use of the crotchet for a century past."§ Dr. Church, in seven cases, which he details, in which the ergot was used, had five children still- born. Although he thinks that in these cases the ergot had nothing to do with this result, yet he con- fesses that he " has no doubt if given in cases where there is great rigidity of muscular fibre, before the labor is advanced, when the os uteri is undilated, the external parts unrelaxed, and when blood-letting has not been premised, that the pow- erful and continued efforts of the uterus, caused by the ergot, will prevent the retreat of the child's head after it has advanced within the bones, and * New York Med. and Phys. Journal, Vol. I., p 205. t New York Medical Repository, Vol. XX., p. 17. ; Ibid, Vol. XXI., p. 160. I Philadelphia Journal of the Med. and Phys. Science*, Vat XL, p. 318. OBSERVATIONS ON ERGOT. 101 that the unceasing pressure may in some instances occasion death."* Dr. Davies, of London, reports ten cases in which the ergot was used. In four, the child was still- born. In a fifth, the child was apparently still-born, but soon recovered. In all the still-born cases, it appears that the child was not delivered until upwards of an hour had elapsed after the^dminis- tration of the ergot; In the first, two hours elapsed ; in the second, a little more than an hour; in the third, six hours; in the fourth, a little over an hour.f Mr. T. Chavasse, of Birmingham, states that in eighteen cases in which the ergot was used, the children were still-born."J Mr. Jukes, of Birmingham, says that out of six cases in which he used it, five of the children were still-born."§ Mr. P. H. Chavasse, reports nine cases in which its use was followed by the birth of still-born chil- dren, and in all before he administered the ergot, " there was every indication of the children being alive."|| Mr. Elkington says that " several of his patients who took it, had still-born children."! * Philadelphia Journal of Med. and Phys. Sciences, Vol. VIII., p. 139. t New England Journal of Med. and Surgery, Vol. XV., p. 18. t Transactions of the Provincial Med. and Surg. Association, Vol. IV., copied into the Transactions of the New York State Med. Society, Vol. III., p. 353. § Trans, of the State Med. Society, Vol. III., p. 354. II Ibid., Vol. III., p. 355. 11 Ibid, Vol. III., p. 354. 102 OBSERVATIONS ON ERGOT. Mr. John Paterson, of Aberdeen, used the ergot in eight cases, and in three the children were still- born—" than which," he says, " no stronger evi- dence need be adduced of its extreme danger." In the three cases alluded to, he states, that he sat- isfied himself before its administration that the children were not only alive, but apparently strong and hea]4hy ; but as soon as the action of the medi- cine commenced, these impressions became grad- ually less sensible to himself as well as to the mother. And he adds his doubts whether by the use of this article more deaths are not occasioned than by the use of instruments.* In addition to the foregoing, I adduce the follow- ing communication from one of my professional friends in this city, whose long experience entitles his opinions in relation to practical matters, to the highest consideration. New York, January 14th, 1841. My dear sir: After what I considered a fair and full trial, I formed an opinion on the use of ergot, twenty- five years ago, and one which has governed me in practice ever since. I consider it a valuable article of the Materia Medica, to be used with great caution and only in cases of clear necessity. I have reasons satisfactory to my own mind for believing that it has frequently destroyed foetuses and produced sterility in mothers. Entertaining this opinion I am surprised to see by some late * Edinburgh.Med. and Surg. Journal, for Jan. 1840, p. 142. OBSERVATIONS ON ERGOT. 103 "publications that this article continues to be resorted to by, some practitioners under very trivial pretexts. I mean on occasions, where, to say the least, it is totally unnecessary. It hastens labor, it is true, but I entertain so high a respect for the intelligence of nature, that I consider this hazard- ous method of bringing a child into the world before its time, as little better than sending it out before its time. Yours truly, CYRUS PERKINS. Prof. J. B. Beck. The facts which have thus been detailed, would seem to be abundant to show that the use of this article has in many cases proved injurious to the child. That it does not prove so in all cases, and that in the hands of those who have used it pru- dently and judiciously, it has never produced such an effect, is certainly no argument against the cor- rectness of this conclusion. Even by those who have most frequently observed its fatal effects upon the child, it is admitted that this does not uniform- ly take place. The circumstances under which this difference of effect occurs, are easily explicable. As the danger of the child appears to be owing to the degree and duration of the pressure to which it is subjected, it would seem evident that just in pro- portion as the uterine organs are in a condition to admit oP a speedy delivery after the ergot begins to operate, will the danger to the child be lessened ; and on the other hand, in proportion as the deliv- 104 OBSERVATIONS ON ERGOT. ery is protracted, will the danger be increased. This corresponds with the observation of Dr. Ward, already quoted, that whenever the child is not delivered in forty minutes after the action of the ergot commenced, it is generally still-born. For the same reason too it has been found more injurious when used in first labors, than in sub- sequent ones. 3. Is ergot capable of producing any effect on the uterus anterior to the full term of gestation ? On this point there is also a great difference of opinion. Some contending that it acts only at the full period and when the process of labor has already com- menced ; while others assert that it exerts its influ- ence at any period of pregnancy. To settle this question a great number of experiments have been made upon animals, the result of which is, that while in the majority it produced no effect, yet in a number it succeeded. By Dr. Erskine, several experiments were made upon cats, at various periods of pregnancy, and in every instance it is stated that he succeeded in pro- ducing abortion.* By Dr. Oslere, experiments were also made upon animals, and with similar results. The first was on a sow, that was supposed to, be in her seventh week of pregnancy. One drachm of the ergot was given and repeated again in the course of three hours. In the course of the night she had aborted nine small pigs, about the size of common * Philadelphia Journal of Med. and Phys. Science, Vol. XI., p. 112. OBSERVATIONS ON ERGOT. 105 mice. His second experiment was upon a cow, which was supposed to be with calf, though not suf- ficiently advanced to be certain of the fact. Two ounces of ergot in powder were given about ten o'clock in the.morning, and after suffering severe pain she aborted at six o'clock in the evening of the same day. The abortion was about the size of a common full grown rat, but very imperfectly form- ed. His third experiment was on a cat that appear- ed to be near her time of delivery. Sixteen grains of ergot in powder, mixed with butter, were given al eight o'clock in the evening, and the animal con- fined in a room. On visiting her the next morning, she was found to have been delivered of four kittens all of which died during the day.* Dr. Oslere states as the result of his experi- ments, that he has not the least hesitation in believing that the ergot is capable of producing abortion at any period of utero-gestation. Dr. Chatard, of Baltimore, tried its effects upon six cats, all more or less advanced in pregnancy. On the first, it acted as an emetic; the second was slightly purged ; the third, fourth, and fifth, were no^atall affected by it, although the last took a double dose of it at once, i. e., two drachms in powder ; the sixth, half advanced in pregnancy, to which he gave but one drachm, had her legs par- alyzed for a short time, in less than one hour, and abortion took place in twenty-four hours, pre- ceded by considerable haemorrhage.f ♦ Philadelphia Jour. Med. and Phys. Sciences, Vol XL, p. 113. t New York Medical Repository, Vol. XXI.. p. 163. 10 105 OBSERVATIONS ON ERGOT. More recently several experiments were made upon different animals, by Mr. Wright, without producing any effect.* The only inference to be drawn from the fore- going facts, is that although ergot is capable of causing abortion in animals, it does not do so with any degree of certainty or uniformity. That ergot has the power of inducing prema- ture labor in the human subject, is now established by such a number of well-attested cases, as to leave no reasonable doubt on the subject. Dr. Oslere, in a paper published in 1825, states that this had been successfully practiced by Prof. James, in the case of a woman whose pelvis was too small to permit the passage of a full grown child. She had several times been pregnant, and in every case the operation of embryulcia had been resorted to for her delivery. In a subsequent pregnancy, Dr. James suggested the propriety of bringing on premature labor by the use of ergot, and this was accomplished with success, not only in this but in several subsequent pregnancies.*]* Dr. Dewees relates the following case : a female, whose husband had been absent a Jpng time, became pregnant by illicit connection. Wishing to conceal her guilt she applied to a physician, who gave her some powders which he said would pro- duce abortion. After taking several of them, severe pains came on, with haemorrhage. In this state she was found by Dr. Dewees, and shortly after, she was delivered of twins at about the * Edinburgh Med. and Surg. Journal, for Jan. 1840, p. 31. t Philadelphia Jour, of Med. and Phys. Sciences, Vol. XL, p.] !<• OBSERVATIONS ON ERGOT. 10"? fifth month. On examining a powder which was left, and which was similar to those she had taken, Dr. Dewees found it to be a drachm of ergot.* The most satisfactory testimony, however, on this subject, is that which has been furnished with- in a few years by several British physicians. In 1834, Dr. F. H. Ramsbotham, of London, detailed six cases, in which it was necessary to induce pre- mature labor, and in all it was successfully brought about by the use of the ergot. In the first case, the pregnancy had advanced to eight months ; in the second, to seven and a half; in the third, to seven and a half; in the fourth, to seven and a half; in the fifth, to eight; and in the sixth, to seven and a half months.f ' In a subsequent paper, Dr. Ramsbotham has given an account of his practice in those cases, in which, from the narrowness of the pelvis, he was obliged to resort to the induction of premature labor. Of these he states that in all he had had sixty-two cases. In thirty-six cases the membranes were punctured, and in twenty-one of these the children were born alive, and sixteen were still-born. In twenty-six the labor was indu- ced by ergot, without any other means being used ; of these twelve were born alive, and fourteen still- born. Besides establishing, beyond all doubt, the fact that ergot is capable of exciting the uterus into action anterior to the full term, this report is important in another respect, and this is particu- • American Journal of Medical Sciences, Vol. III., p. 408. t London Medical Gazette, June, 1834, p. 436. 108 OBSERVATIONS ON ERGOT. larly noticed by the author. It is that the number of still-births in these cases was much greater in proportion in those in which the ergot was used, than in those in which the practice of puncturing the membranes was resorted to. Dr. Ramsbotham adds the remark, that he has seen the stimulating effects of ergot on the uterus in numerous cases of dangerous haemorrhage in the early months, when it was desirable to procure a complete evacuation of that organ, and where no manual or instrumen- tal means could be put in practice.* Dr. Paterson, of Glasgow, has reported the case of a woman in whom he succeeded in bringing on premature labor in two successive pregnancies by the use of ergot. In both cases it was about the seventh month.*]* A similar case is reported by Mr. Heane, in which the ergot effected a premature delivery at the seventh month. J Another case occurred under the care of M. Dubois, of Paris, in the person of a dwarf, who in her first pregnancy was obliged to be delivered by perforating the head, and thus bringing away the child. On becoming pregnant a second time, he determined upon bringing on premature labor at the eighth month, by dilating the os uteri and the use of ergot. This was accordingly done with success, and a living child delivered.^ The foregoing evidence is conclusive as to the • * London Medical Gazette for June, 1839, p. 422. t Ibid, for June, 1839, p. 333. X Ibid for January, 1839, p. 639- § Dunglison's American Med. Intelligencer, vol. iv. p. 126. OBSERVATIONS ON ERGOT. 109 fact that ergot does exert its action on the uterus anterior to the full term of pregnancy. What the earliest period is, at which it is capable of produ- cing this effect, it is impossible at present to deter- mine. 4. To what extent are we justified in using ergot ? If there be any truth or force in what has been said in relation to the effects of this article on the child, the answer to this question is obvious. In a professional as well as moral point of view, we have no more right to trifle with the life of the child than we have with the life of the mother. When, however, from the nature of the case, it becomes manifest that the life of the mother is in danger, we are not merely justified in using, but it is a positive duty to do so, every means to save her, disregarding every consequence that may result to the child. Now it is for such contingen- cies, that I conceive that ergot ought to be reserved. It should accordingly, I think, never be used except in cases where nature is incompetent to a safe delivery. By too many, it is to be feared, it has been and is still used merely as a time-saving agent. Than this, I cannot conceive of any practice more unjustifiable and reprehensible. As a general rule, nature is competent to a safe delivery, and we may rest assured that the best plan is to leave her alone to accomplish the work. Artificial and violent interference, whether it be applied in the shape of instruments or by the use of ergot, cannot but be improper. 10* ESSAY VII. AN ACCOUNT OF THE ORIGIN OF THE USE OF MERCURY IN INFLAMMATORY COMPLAINTS. Mercury, although known to the ancients, was not used by them as a medicine. By Dioscorides it is noticed, but as an article exceedingly delete- rious in its operation on the system. Pliny also mentions it, but ascribes to it poisonous properties. Galen seems to have been equally ignorant of its true character and properties. It is to the Arabi- ans that we are indebted for first establishing the fact, that when taken internally, this metal is not poisonous. Avicenna states distinctly, that large quantities of it may be swallowed without injury, the metal forcing a passage through the body sim- ply by its specific gravity.* In the shape of ex- ternal applications, it was used by the Arabians in the treatment of various cutaneous affections.f * Argentum quidem vivum plurimi qui bibunt, non lceduntur eo. Egreditur enim cum dispositione sua per inferiorem regionem. —Avicen. lib. 4. t See Lectures on the Materia Medica, &c. By Charles Alston, M. D., Professor of Botany and the Materia Medica in the Uni- versity of Edinburgh, 1770. Vol. I., p. 83. Also the Medical Works of Richard Mead, M. D. 1762, p. 100. MERCURY IN INFLAMMATORY COMPLAINTS. Ill According to Dr. Friend, the power which mercu- ry, when applied externally, has of causing saliva- tion, appears to have been first established in the 13th century, by Theodorick, a friar, who after- wards became Bishop of Cervia. According to Alston, Paracelsus was probably the first who gave mercurial preparations internally. He died in the year 1541. In the year 1608, calomel was first described by Crollius in his Basilica Chemica.* Except in the venereal disease.it was not until during the last century that any extensive use was made of the preparations of mercury ; and it was then, that it was introduced into the treatment of inflam- matory complaints. This practice took its rise in this country, and to the enterprize of American physicians is mainly due the credit of the general introduction of this powerful agent into practical medicine. The circumstances under which it originated, are the following.—Upwards of a cen- tury ago, the American Colonies were the scene of one of the most dreadful epidemics that ever deso- lated a country. It was generally denominated the putrid sore throat, and it commenced its career in May, 1735, at Kingston, an inland town of New Hampshire. From thence it spread itself gradually to the neighboring towns and villages. In the month of September of the same year, it reached Boston. Its progress westward was slow but un- interrupted. Nearly two years elapsed before it reached the Hudson river, from whence it contin- ued to spread to the south and west, until it had * Paris' Pharmacologia, p. 52 112 ON THE ORIGIN OF THE USE OF involved the whole of the colonies in one common calamity.* The numbers who fell victims to the disease were immense. Upon the population of New England, more especially, it committed the most dreadful ravages. According to the account furnished by Dr. Douglass, a physician of Boston, it appears that one-fourth of the inhabitants of that place were seized with it, and of these, one in thirty-five died of it. In other places, he states, that one-sixth, one-fourth, and even one-third of the sick fell victims to it.f By Dr. Kearsley, an eminent practitioner of Philadelphia, an affecting account has been left of its devastations. " Like most new diseases," says he,"till their constitution and nature are known, it swept away all before it; it baffled every attempt to stop its progress, and seemed by its dire effects to be more like the drawn sword of vengeance to stop the growth of the colonies, than the natural progress of disease. In the New England governments, the stroke was felt with the greatest severity; villages were almost depopulated, and parents were left to bewail the loss of their tender offspring, till heaven, at last, the only unerring physician, was pleased to check its baneful influence.""]: * A Letter from Cadwallader Colden, Esq. to Dr. Fothergill, concerning the Throat Distemper, in the Med. Observations and Inquiries of Lond. Vol. I. p. 215. t The Practical History of a new Eruptive Miliary Fever, with an angina ulcusculosa, which prevailed in New England in 1735 and 1736. By W. Douglass, M. D. New England Jour., Vol. XIV. X Observations on the Angina Maligna, or the Putrid and Ul- cerous Sore Throat, with a method of treating it. By John Kears- ley, Jr. Gentleman's Magazine, Vol. 39, p. 521. MERCURY IN INFLAMMATORY COMPLAINTS. 113 Belknap, in his history of New Hampshire, states, that in that province not less than one thousand persons died of the disease, of whom nine hundred were under twenty years of age.* It was in attempting to arrest the ravages of this dreadful epidemic, that mercury appears to have been first introduced into the treatment of inflam- matory complaints, and it is generally conceded that the credit of originality is due to Dr. William Douglass, an eccentric but eminent physician, of Boston. The preparation of mercury which he used was calomel. The following is his language in relation to it. " Where nature required any assistance, the principal intentions were with regard to the cuticular eruption and the ulcusculosa in the throat. Any affection in the throat does frequently produce a natural ptyalism ; mercurials used with discretion, are a kind of specific in such like ulcers and ulcuscula, and in fact, here they moistened the throat and mouth, stopt the spreading of the ul- cusculosa, and promoted the casting off of the sloughs; and as an accessory advantage, (the pa- tients being mostly children,) destroyed worms. Amongst all the preparations, calomel answered best, the gentle vomiting, or few stools that it occasioned in some, did not confound the natural course of the distemper. Turbeth proves generally too strong a revulsion, and the eruption is thereby too much diverted. This distemper did not well bear any other evacuations but mercurials."] This was published in the year 1736, and is the * History of New Hampshire. By Jeremy Belknap, Vol. 2, p. 95. t New England Journal, Vol. 14, p. 4. 114 ON THE ORIGIN OF THE USE OF first notice we have of the practice. Although Dr. Douglass was thus the first to introduce the prac- tice, yet the person who carried it to the greatest extent, and who seems to have regularly systema- tized it, was Dr. Jacob Ogden, a respectable phy- sician of Long Island. In some letters" which he published on this subject, containing the results of twenty years' experience, he commences by observ- ing, that alexipharmic and sudorific medicines had long been esteemed as the basis of a radical cure in this disease, and had accordingly been universal- ly recommended by writers on this subject. An ample experience, however, of these, as well as other remedies, represented as specifics, convinced him of their complete inadequacy in subduing the disease, and prompted him to resort to a new method of treatment. He accordingly, about 1749, tried the effects of mercury, joined with alexipharmics and astringents, which succeeded, as he states, " even beyond his expectations." Calomel was the form in which it was given, and the usual quanti- ties were, to a child of a year old, two or three grains; to one of six or eight years, from four to five grains; and to a grown person, six or eight grains, repeated every twelve, sixteen, twen- ty, or twenty-four hours, as the urgency of the symptoms indicated. Generally speaking, he states, that this treatment arrested the disease in two or three days, provided it was commenced early. In alarming cases, or where the disease had been * See New York Medical Repository, Vol. 5, p. 97, where these letters .are reprinted. MERCURY IN INFLAMMATORY COMPLAINTS. Ha neglected, the remedy was given more freely. In one case, sixty-two grains were given in the course of twelve or fourteen days, to a patient nine years of age, and with perfect success. In consequence of the reputation which calomel thus acquired in the treatment of this disease, it came very naturally to be resorted to in other in- flammatory diseases, and accordingly, about the middle of the last century, it was in common use in pleurisy, pneumonia, inflammatory rheumatism, and other of the phlegmasia?. The common prac- tice was to give it in large doses, when used as a cathartic ; and when given as an alterant, or to affect the system, in doses of one or two grains ; and this was combined with camphor, antimony,or opium, according to circumstances—a practice pre- cisely similar to that of the present day. On this subject we have the positive testimony of the venerable Dr. Holyoke, of Salem, who says, " I profess myself to have been in the habit of pre- scribing this mineral (mercury) ever since the year 1751 or 1752. About that time, pleurisies and peripneumonias were remarkably prevalent, and might be called epidemical; the practitioners of this place made free use of it at that time, and as we found its effects beneficial, have continued to employ it in similar cases ever since."* Concerning the use of mercury in Philadelphia, between 1760 and 1766, Dr. Rush has left us the following account. M Mercury was in general use in the years that have * See a Letter on the Introduction of the Mercurial Practice in the vicinity of Boston. By Edward A. Holyoke, M. D., in the New York Medical Repository, Vol. 1, p. 490. 116 ON THE ORIGIN OF THE USE OF been mentioned. It was given to prepare the body for the small pox. It was administered by my first preceptor in medicine, Dr. Redman, in the same disease when it appeared in the natural way, with malignant or inflammatory symptoms, in order to keep the salivary glands open and flowing, during the turn of the pock. But to Dr. Thomas Bond is the city of Philadelphia indebted, for the intro- duction of mercury into general use in the practice of medicine. He called it emphatically, ' a revolu- tionary remedy,' and prescribed it in all diseases which resisted the common modes of practice. He gave it liberally in the cynanche trachealis. He sometimes cured madness, by giving it in such quantities as to excite salivation. He attempted to cure pulmonary consumption by it, but without success; for at that time the influence of the rela- tive actions of different diseases and remedies upon the human body was not known, or if known, no advantage was derived from it in the practice of medicine."* The foregoing is a sketch of the origin of the mercurial practice in this country, and it is very certain from this, that it prevailed here long before it was known or practiced in any other country. I have been the more minute in the preceding account, because I was desirous of correcting an error, into which one of the most popular writers of the present day has fallen, on this subject. I mean Dr. John Armstrong, the accomplished author of the work on typhus, who gives the sole credit * Observations and Inquiries, Vol. 4, p. 398. MERCURY IN INFLAMMATORY COMPLAINTS. 117 of the practice to Dr. Robert Hamilton, of Lynn Regis.* From the account furnished by Dr. Hamilton himself,f it appears that he was entirely ignorant of the powers of mercury in inflamma- tion, until his attention was called to it, in the year 1764, by a British Navy Surgeon, who had become acquainted with its use in the treatment of hepati- tis in the East Indies. Having tried it in that disease, and found it successful, Dr. Hamilton entered into some generalizations on the subject, and drew the conclusion that it might be rendered available in the other forms of inflammatory disease. The whole paper is that of an able and thinking man, and has elicited a high, though just tribute of praise, from the writer already alluded to.J It may fairly be inferred, from the account given by Dr. Hamilton, that he was unacquainted with the fact of the extensive use of mercury in this coun- try, and therefore it detracts but little from his merit, that the very same practice which he re- commended, and in the very same diseases, had been in common use here many years before his paper made its appearance. * Armstrong on Typhus, p. 327. t See a Letter from Dr. Robert Hamilton to Dr. Duncan, riving an account of a successful method of treating inflammatory diseases by mercury and opium. Med. Commentaries for 1/83, A. & *. Vol 5 P 120., Amer. Ed. "The paper originally published by Dr. Robert Hamilton, notwithstanding some of its defects, deserves to be engraved in "eCro gold, on account of its great practical apphcaUon and um J "-Armstrong on Typhus, Ac., P- 385: Amer. 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