■Sir! ■\&.\f' A COMPENDIUM MEDICAL SCIENCE, *"<' FIFTY YEARS' EXPERIENCE IN THE ART OF HEAL1NU: PLAIN AND PRACTICAL TREATISE PREVENTION AND CURE OF DISEASE, DESIGNED TO ENLIGHTEN THE POPULAR MIND IN THE TRUE ELEMENTARY PRINCIPLES OF MEDICINE, AND PROTECT THE READING PUBLIC FROM THE MISCHIEFS OF QUACKERY. By SAMUEL K. JENNINGS, M. D. Late Professor of Obstetricks, &c., in the Washington University of Baltimore, 1 SUR^ONGEN£nAl!S OFFICE TUSKALOOSA, AlA: fiUGfl \>." 1 '--''>'l^ ; J. SLADE, PRINTER, 1847. j \J MARMADUKE J. SLADE, PRINTER, q J # ) 1947 Entered according to the act of Congress, in the year 1847, By SAMUEL K. JENNINGS, M. D. In the Clerk's Office of the District Court for the Middle District of Alabama. DEDICATION. Authors ask permission, or assume the liberty, to dedicate their publications to illustrious patrons, with the hope of de- riving additional personal dignity, or of procuring for their works a greater number of readers. We frankly acknowledge the influence of both these emulations; and in the spirit of becoming courtesy, dedicate the Compend of Medical Sci- ence to the Intelligent, the Humane, and the Benevolent, of all classes, in our vast community. To the Intelligent first, because they will perceive the in- tention of the writer is, to introduce his readers to such an acquaintance with medical science, as will enable accurate observers, and close thinkers, to a very useful extent, to be- come, what great physicians, great statesmen, great jurists, great agriculturalists, or great merchants, always were, and must continue to be, self-taught. They will perceive, that our work is intended to show to all candid readers, that the art of healing is not necessarily beclouded with inexplicable mystery. That the medical phi- losopher is not the enemy of his fellow citizens; nor the in- telligent practicer of his profession, a curse to the human fam- lly' If therefore, we shall succeed in attracting the attention ol a goodly number of readers of this highly respectable class, our emulation to gain worthy personal distinction, will bo fully gratified. Our dedication is made in like manner to the Humane. It must have been a source of grief to all who feel a becom- 4 DEDICATION. ing regard for the welfare of mankind, to contemplate the melancholy fact, that men of every grade of intellectual at- tainment, are better acquainted with every other concern than that of their own health. The sciences of government, law, religion, morals, &c., are studied as subjects of common in- terest ; as necessary to a safe, peaceable and respectable pas- sage through life, but the knowledge necessary for the preser- vation of health, is confided to those whose professional busi- ness it is, to visit and prescribe for the sick. This is a de- fect in the condition of humanity, that ought to be corrected. If we shall have succeeded in making it manifest, that eve- ry man may know when he is in danger of being sick, and may ward off a threatened attack, or if actually under the influence of any ordinary disease, may arrest it in its onset, by his own exertion, it must follow, that the cause of human- ity will be promoted by our instruction; and that many of our mo§t humane fellow citizens will be numbered with our patrons. If our sanguine hopes, in respect to these two distinguish- ed specifications of our expected patrons shall be realized, we are safe in regard of the Benevolent. Those excellent ones, whose disposition is to be useful to others; whose happiness requires them to cultivate fraternal love to mankind, and who rejoice when occasion offers tc ao them good, will appreciate our confident expectation of un- limited patronage from them. Let the Intelligent give us their sanction, the Humane their approbation, and our success will be secured by the voluntary exertions of the Benevolent. And they will col- lectively, individually, and most deservedly be entitled to the most profound respect of their very obedient, THE AUTHOR. ADVERTISEMENT. In virw of the probability, that our book may be exten- sively read and fall into the hands of many young physicians, we conceived the after-thought, of adding the several items which constitute the appendix. The trealfise on prolapsus, &c. may possibly call the atten- tion of some of the older members of the medical fraternity, and provoke them to renew their acquaintance with a sub- ject which so much interests humanity, and which, they know, has been too much neglected by the profession. Mr. Charles W. Stockton, the gentleman in Philadelphia, who has been so long known as the manufacturer of superior por- celain teeth, holds a patent for the making and vending the pessary described in the treatise, which of course he will supply, as there shall be a demand for it. L oe Synoptical Table of Materia Medica, will be found convenient for reference, to the student of that subject, at the same time, that it presents a very simple and compre- hensive view of the therapeutic principles which should re- gulate the selection of medicinal substances. The abridged treatise on the subject of Toxicology, is ad- ded for the same reasons which led the French Institute, in their report, to recommend it to the notice of government, ad- vising that a copy should be kept for immediate reference, in all the public offices, as well as in every private house in the kingdom. CONTENTS. • Preface,....................................... 17 PART I. Elementary Principles developed and supported by Physio- logical and Pathological facts and observations, prepara- tory to a proper understanding of the following work. CHAPTER I. Treats of vitality, as7 it is apparently inherent in the ani- mal fibre;—as it is modified for special purposes, and man- ifest in the organs of sensation;—and as it is related to a more general and transient sensorial influence, and made dependent on the circulation of the blood. Of sensorial influence as associated with vitality in preserv- ing the vital motions and functions of the system ; its ac- cumulation under circumstances calculated to produce vio- lent disease, and of its deficiency in diseases with prostra- tion. Of the same influence as it is associated with excitement and promptly obedient to stimulants and irritants; of course as being especially concerned in the production of irrita- tion and inflammation. Of excitants as manifest in the actions and functions of the system, in the condition of health and disease. Of stimulants and their agency in the production of excite- 8 contents. ment, whether natural and healthful or excessive and morbid. Of vital heat as an agent requiring special medical attention; and of artificial heat as affording a means for exerting a vast amount of control over incipient disease.............41 CHAPTER II. Details and explains the circumstances developed by an ex- periment which may be conveniently and satisfactorily made by any one, and shows how important it is, to have a due regard to temperature.......................52 CHAPTER III. Description and explanation of disease, when consequent on exposure to cold or inclement weather; demonstrates what disease is, when it is thus suddenly induced in persons previously in good health and in healthful climates.....55 CHAPTER IV. Explains idiopathic fever, or fever properly so called. The most important elements, for the establishment of which this work is intended, are brought into view as they exist and are exhibited in a case of acute inflammation of the lungs; and the same are proved to be, equally the elements which are concerned in the production of a case of inter- mitent fever...................................5g chapter v. Theories of fever—Cullen, Brown, Stokes, Baine, Clanny, Clutterbuck, Broussais and Smith, are briefly noticed; concluding with what the author considers to be an ap- proximation to the true one.......................71 chapter VI. Demonstrates the philosophical propriety and necessity of blood-letting, as the most efficient means of arresting fever in its forming state, and the most effectual and trust- worthy remedy, if timely and judiciously employed, for the cure, when by oversight or neglect it shall have been established....................................gj CONTENTS.. 9 CHAPTER VII. Additional remarks on blood-letting. The use of the lancet superior to leeching, or scarification and cupping; to vomit- ing, purging, or sweating......^.................86 chapter vm. Prejudices against blood-letting met and corrected.......93 CHAPTER IX. Reasons given more extensively wherefore blood-letting is preferable to all other depleting remedies............101 CHAPTER X. Continues the subject of blood-letting, describes some of the states of the pulse which indicate the propriety of its use, presenting important therapeutic instructions, in aid of young physicians, to prevent error or abuse in its employ- ment.........................................105 CHAPTER XL Additional remarks on the pulse..................... 114 CHAPTER XII. Directions for feeling the pulse.....................123 CHAPTER XIII. Considerations forbidding the use of the lancet, or requiring a cautious or sparing use of that remedy..............128 CHAPTER XIV. The use of blood-letting in cases of pregnancy and parturi- tion, .........................................133 CHAPTER XV. Miscellaneous on blood-letting......................137 CHAPTER XVI. The various appearances of the blood when set to cool after blood-letting..................................140 CHAPTER XVII. An inquiry respecting the quantity of blood that can be safe- ly drawn in any instance of blood-letting, and how often it can be safely repeated.........................150 10 CONTENTS. PART II. THERAPEUTICS. CHAPTER I. Defines the legitimate objects and powers of therapeutics, ad- mits the universal concurrence of the recuperative power of nature, in effecting the retirement of disease ; whilst it exposes the absurdity and danger of committing to nature, unaided by art, the disorganizing tendencies of acute dis- ease, or of expecting from her the correction of any organic mischief, the common result of disease when permitted to run its own course.............................159 CHAPTER II. Explains what is meant by a therapeutic indication; shews that a philosophic physician makes up his prescription, con- templating some definite effect, either in regard to the general system, or some particular organ—disparages noso- logical systems of nomenclature, by insisting on the abso- lute necessity of being guided by physiology and patholo- gy in forming an intention to cure, and refusing to be em- barrassed by the name of the disease...............171 CHAPTER IV. In forming therapeutic intentions, scientific reference must be had to the anatomy and physiology of the organ affected by disease, and to the diagnostic symptoms, as settled and confirmed by pathology.........................177 CAAPTER v. Considerations in respect to age, temperaments, &c.....185 CHAPTER VI. Treats of strength and debility, trades, professions, habits, &c. &c........................... ...........200 contents. 11 chapter vii. Treats of additional discretions in respect to the causes of dis- eases, their seats and degrees of intensity...........212 PART III. CHAPTER I. Introductory to Materia Medica.....................227 CHAPTER II. The therapeutic power and value of medicaments.....236 CHAPTER III. Of the surfaces to which medicaments may be applied, and through which impressions may be made by medical agents........................................241 CHAPTER IV. On Emetics.....................................254 CHAPTER V. Emetics continued...............................268 CHAPTER VI. Cathartics.......................................282 CHAPTER VII. Cathartics, continued.............................295 CHAPTER VIII. Diaphoretics.....................................308 CHAPTER IX. Diaphoretics, continued...........................322 CHAPTER X. Diaphoretics further continued with rules respecting their employment and method of application.............334 12 CONTENTS. CHAPTER XI. The Alcoholic Vapor Bath as a diaphoretic, and as the most extensively useful of ail general agents.............341 CHAPTER XII. Epispastics......................................^6/2 PART IV. \ CHAPTER I. An anatomical sketch with physiological remarks, introduc- tory to the practical treatment of disease............373 CHAPTER II. Fever in its general aspect.........................381 CHAPTER III. Intermittent fever...................".............385 CHAPTER IV. Congestive fever,................................388 CHAPTER V. Inflammatory fever...............................391 CHAPTER VI. Catarrh.........................................395 CHAPTER VII. Bronchitis.......................................398 CHAPTER VIII. Chronic Bronchitis................................404 CHAPTER IX. Inflammation of the larynx.........................407 CHAPTER X. Croup..........................................408 f CONTENTS. 13 CHAPTER XI. Hooping Cough.,................................412 CHAPTER XII. Pneumonia or Inflammation of the Lungs............ 416 CHAPTER XIII. Pleurisy,..........................----..........420 CHAPTER XIV. Roseola—Nettle rash........................------422 CHAPTER XV. Erysipelas, or St. Antony's Fire,.................... 424 CHAPTER XVI. Scarlet Fever....................................426 CHAPTER XVII. Measles.........................................430 CHAPTER XVIII. Small Pox,.....................................434 CHAPTER XIX. Mumps.........................................436 CHAPTER XX. Gastritis or Inflammation of the stomach,.............437 CHAPTER XXI. Enteritis and peritonitis inflammation of the mucous mem- brane of the bowels.............................439 CHAPTER XXII. Diarrhoea.......................................442 CHAPTER XXIII. Dysentery......................................444 CHAPTER XXIV. Cholera morbus..................................447 CHAPTER XXV. Colic,..........................................449 CHAPTER XXVI. Dyspepsia.......................................451 14 CONTENTS. CHAPTER XXVII. Jaundice........................................453 CHAPTER XXVIII. Heac-ache......................................454 CHAPTER XXIX. Piles, orHoemorrhoids,............................456 CHAPTER XXX. Rheumatism....................................458 CHAPTER XXXI. Chronic Rheumatism and Gout,....................461 CHAPTER XXXII. Haemopthisis,...................................462 CHAPTER XXXIII. Inflammation of the eye...........................465 CHAPTER XXXIV. Hydrocephalus, or dropsy of the brain...............467 CHAPTER XXXV. Dysmenorrhoea, or painful and difficult menstruation,... 470 CHAPTER XXXVI. Menorrhagia, or immoderate flow of the menses,......471 CHAPTER XXXVII. Cessation of the menses...........................473 CHAPTER XXXVIII. Chronic Hydrocephalus...........................474 CHAPTER XXXIX. Amenorrhoea....................................475 CHAPTER XL. Puerperal, or child-bed fever.......................477 CHAPTER XLI. Phlegmasia alba dolens, or milk leg..................482 CHAPTER XLII. Suppression, retention and incontinence of urine,......484 CONTENTS. 15 CHAPTER XLIII. Colic of infants...................................486 CHAPTER XLIV. Cholera infantum, or summer sickness of children...... 489 CHAPTER XLV. Tabes Mesenterica,...............................495 CHAPTER XLVI. Gangrene of the mouth,...........................497 CHAPTER XLVII. Concluding remarks,.............................500 APPENDIX. Hydropathy, or Water Cure........................503 A Synoptical Table of Materia Medica,..............509 Descent, Procidentia, Retroversion, and Prolapsus Uteri,. 520 Toxicology—Remedies in cases of poisoning, &c.......533 Accidents—Apparent death, suspendeded animation, &c. 563 Medical prescriptions,.............................578 A patient receiving the bath,.......................582 Glossary,......................................583 Index,.........................................587 PREFACE. The author having completed a medical work, the funda- mental principles of which have been under review for the space of forty years, regards it as a duty which he owes to his friends and the public, to submit it to their consideration. He believes it to be the policy as well as the dut}*" of the pro- fession to popularize the science of medicine. The public mind needs to be fortified against the flood of domestic and foreign impositions, under the name of remedies, which are the result of mercenary ignorance, and pernicious to human health and life. With this conviction, it is his earnest desire, before he closes his labors and his life, to leave to posterity his testimony concerning health and disease, prevention and cure;—subjects to which his reflections have been devoted for more than half a century. He flatters himself, that his junior brethren in the profes- sion, will find interest and profit, in perusing the lessons which he has learned in the school of experience ;—lessons not taught by text books, nor often made intelligible, except at the bed side of the sick; and he hopes, that so far as he shall gain access to the community, his work will have a tendency to correct many erroneous opinions, and prevent much injurious practice; whilst it .will serve to elevate in the public estimation, a profession, which, though it often 18 PREFACE. fails to be appreciated and rewarded, by the ignorant and thoughtless, is, nevertheless, justly entitled to the homage and respect, the affection and confidence, of the intelligent and candid, to an extent beyond the claims of any other merely human vocation. Feeling the high responsibilities of men of our profession, more than forty years ago, he entered upon a course of vigi- lant observation, determined, if possible, to detect any exist- ing error which might obtain in the science of medicine, and to make some improvemeut, however small it might prove to be. Two whole years were spent, without having acquired any thing worthy of public notice. Not long afterwards, however, he was called to attend a number of cases of fever, of unusual type, difficult to manage, attended with symptoms of atony of the superficial capillaries, such as called for spe- cial attention to the external surface of the patient. During this service, he found it necessary, in addition to the use of ordinary rubefacients, to employ the external application of artificial heat. In marking the effect of this practice, he formed a number of conjectural opinions, which afterwards were tested by additional experience, and corrected or estab- lished, as facts directed. In the years 1806-7, a similar fever prevailed, to an extent never before known in that district of country. Great num- bers of the sick were intrusted to his management, affording ample opportunity for repeating his observations: In the course of this labor, his inquiries assumed a more systematic form; and from that period, to a considerable extent, he has been guided in his practice, by principles which he then be- gan to understand, and which he now holds to be true. For the space of forty years, he thinks he has paid more PREFACE. 19 attention to the surfaces of his patients, than has been the custom of any other physician of whose practice he has had any knowledge; and has been in habits of making more than ordinary use of artificial heat. The steam of boiling water at first, often served him a valuable purpose; when the sick could sit erect to receive it. When his patient was much enfeebled, he found this to be impracticable. Besides, he had learned by repeated experiments made on his own person, and by similar experiments and observations made on a great number of patients, that dry heat could be employ- ed advantageously, at a degree of temperature which, if made by the steams of water, would inevitably scald the patient to death; and that in cases where a lower degree of heat might suffice, if steam were used, it universally produced so much moisture of the bed clothes and linen, as in a great degree to counteract his intention. So far as he is informed on the subject, he first ascertained that dry heat, made to impinge upon the naked skin, by placing the patient, uncovered, near a brisk fire, or by hold- ing a shovel of burning coals as near to the place affected as it could be borne, if sufficiently repeated, is the most speedy and effectual agent for correcting erysipelatous or phlegmo- nous inflammation ; the mostim portant auxiliary in the treat- ment of an anthrax or an inflamed wound; and a remedy most decisive in treating inflammatory fever.s From time to time he had tried various devices for the production and ap- plication of heat of high temperature, so as. neither to scald the patient nor leave him wrapped in wet clothes. The va- rious devices were more or less beneficial, according to the facility and extent of his approximation to the desired object. At length a perfect method of applying dry heat, became to him a very great desideratum. Afterwards he had the hap- 20 PREFACE. piness to hit upon the use of burning alcohol, and finally he invented an apparatus for conducting, heat so generated, to the naked body of his patient. During the whole course of this pursuit, he had no other design than that of improving his own practice. But the fa- cility with which he has since been able to manage every grade of fever with which he has met, in at least four differ- ent States of the Union, has been such, that he cannot recon- cile it to his obligations to humanity, to withhold from the public the result of his observations. He has therefore pre- pared the following treatise, in which the prinpiples and doc- trines, the origin of which he has thus briefly stated, will b^ /ound so associated and incorporated with some of the most important elements of the profession, and so elucidated by their practical application to a sufficient number of diseases, as to make his design intelligible. By the employment of the apparatus, contrived as above stated, he soon learned that heat so generated and applied, with very little, and sometimes with no other aid, is effectu- al for correcting predisposition to disease ; that by the same method, recent disease, when actually formed, is cured in the same decisive way; that the treatment thus far requires no considerable part of skill, but the necessary decision; no caution, but such as common sense will dictate; and that in the hands of physicians it places within the reach of the heal- ing art, many cases of disease which for ages have been a re- proach to the profession. To extend the knowledge of these facts, he made application to the patent office of the United States, and obtained a patent. As the first and most promising step for bringing it before the public, he determined to introduce it into the army of the United States, then at war with Great Britain. PREFACE. 21 Having the advantage of a personal acquaintance with the Hon. Thomas Gholson, a member of Congress, he for- warded to him a letter, signifying the beneficial effect it would have, in the treatment of disease as incident to the army. Doctor James Tilton, physician and surgeon general of the armies of the United States, happened to lodge in the same house with ^Mr. Gholson, and was made acquainted with the author's views. In a few days the physician general obtain- ed permission from the honorable secretary of war, and he was invited to the seat of government. On his arrival, he had the satisfaction vto find that preparatory measures were already in train for the accomplishment of his wishes. The final arrangement and result of the proceeding, will be seen in the sequel. Washington City, April 7, 1814. Dear Sir—-Conformably to the orders of the secretary of war, you will be pleased to accompany doctor Adam Hays, an hospital surgeon, to Norfolk, in Virginia, and communi- cate to him and the surgeons generally of that post, not only the principles of your newly invented bath, but the method of application; taking care not only to show the cases in which it may be applied with advantage, with the manner, duration, &c, but especially to guard them against the mis- application, so as not to bring an useful remedy into dis- credit. , Agreeably to the secretary's order, your account for ex- penses, &c, may be presented at any time. I am, dear sir, very respectfully, Your most obedient servant.- James Tilton, P. S. G. Norfolk, May 5, 1814. This may certify, that in obedience to an order of the honorable secretary of war, and in conformity to the instruc- 22 PREFACE. tions of the physician and surgeon general of the United States, Dr. Sam'l K. Jennings has accompanied me at the post of Norfolk, Virginia, and satisfactorily demonstrated to me the principles and mode of making the application of his newly inyented method of curing disease in a summary way, by mean's of his hot bath. A. Hays, Hospital Surgeon. Wilmington, (Delaware,) July 16, 1814. Dear Sir—Agreeably to your request, I have no hesitation in giving you my sense of the utility of your newly invent- ed hot bath, in the cure of diseases. I can only speak in general terms on a subject so novel; and, perhaps, the best method I can take for communicating my thoughts and re- flections on the subject, is, by recounting the measures taken by the hospital department for the investigation of its use- fulness. By a special order from the secretary of war, I was directed to make the necessary arrangements for your admis- sion to the hospital at Norfolk. By the same order, I was directed to send Dr. Hays, an hospital surgeon of great res^- pectability, to assist and be witness at the experiments. The doctor reported favorably, and in that correct manner which gratified the secretary of war, as well as myself. He par- ticularly recommends it in regimental practice, "from the op- portunity it affords of meeting disease in its early stages.'' He recommends it in fevers, languid excitement of the surface and diseases produced by suppressed perspiration. The doc- tor made experiments on about thirty cases, very much to his satisfaction, but has not exhausted the subject. I have seen the bath applied in a few instances, and have had it applied to my own person. The ease and facility of the application, and the delightful sensations it affords, are greatly in favor of its general use. And when we consider ilie nervous and sensitive quality of the skin, and the impor- tance of this emunctory, a flood of argument must arise for the application of remedies to the surface of the body. In the promised edition of your explanations, &c. besides PREFACE. 23 the theory and direction for correct application, permit me to request, that you will, by every possible precaution, guard us against the wrong application of so important a remedy. With great respect, I am, dear sir, Your friend and humble servant, James Tilton, P. S. G. Doctor S. K. Jennings. Having performed this service, the author determined on a visit to Philadelphia and New York. With this intention he addressed a note to the President of the United States, and obtained the following letter in duplicate—the one copy addressed to Dr. Physic, the other to Dr. Samuel L. Mitchell: Washington City, August, 1814. Dear Sir—Dr. Jennings has a medical invention, in the value of which he feels so much confidence, that he is anxious to present it to the consideration of the most enlightened of the profession. Although a departure in some measure from an established rule, I cannot refuse a line whichmay promote an opportunity for the explanations by which he wishes his invention to be tested. His benevolent character is a further apology for the liberty I take. Accept assurances of my great esteem and friendly respect. James Madison. Dr. Physic. Doctor Physic was in ill health, and unable to attend to the practice. He favored the author with an interview, how- ever, and spoke very favorably of his invention. Dr. Mitchell, without having received his letter, and with- out solicitation, enclosed under cover to the physician gene- ral the following: New York, March 27, 1815. To Dr. Jennings : I this day, excellent sir, wrote to the physician general of the United States, my opinion of your mode of applying heat 24 PREFACE. to the external surface of the human body; and on Portio's method of directing its action upon the stomach and internal parts. I have caused several experiments to be made with the al- coholic vapor, on the patients of the New York hospital. I am inclined to believe it is an efficacious and valuable reme- dy. It is remarkably neat. Nothing can be more handy. And really it in some sort enables you to place your patient beyond the climates, where snow and frost exercise their chilling influence, to the regions where solar warmth is more uniform and elevated. It is a most important part of your heated air, that it is free from all smoke, soot and ashes. I have considered the spirituous decomposition chemically. I have examined the metallic apparatus mechanically. And I have witnessed the action of the rarified vapors remedially. Considering a torpor of the skin to be a cause or accompa- niment of many diseases, and that heat is the best of all ex- citants, I am well satisfied that your method of applying calo- ric to stimulate the cuticular surface, is happily calculated to give relief in such cases; and produce extensive advantages to the sick and disabled, in many other maladies. Samuel L. Mitchell.* About six months after the receipt of the above highly satisfactory letter, Dr. Mitchell again honored him with the following most definite testimony : New York, 29th October, IS 15. Dr. Samuel K. Jennings : Dear Sir—Since I wrote to you and General Tilton about the vapor bath, I have had many opportunities of trying its practical efficacy. I am more and more satisfied with the value of the remedy. It is so neat, so cheap, so handy, and so within the reach of every body, that it surpasses every thing with which I am acquainted, for applying caloric to the external surface of the human body. It is so capable of * Dr. Mitchell was the very learned Senator of the City of New York, PREFACE. 25 conveying heat, so susceptible of a higher or lower tempera- ture, and withall so well adapted to a longer or shorter con- tinuance, that its power to be beneficial is considerably en- larged. But above all, the caloric may be directed to a part of the body, or to the whole body, to a robust person or to one in the lowest debility, to an adult, or to an infant, with so much ease and benefit, that I reaMy consider it one of the most hap- py expedients that a practitioner can employ. For chills, torpors, and that apathy and langour of the cu- ticular.surface, so often the forerunner or companion of fevers, it is preferrable to any other mode of applying heat. The warm bath, warm fomentations, and the vapors of hot water are very inferior to it. The patients in our hospital are exceedingly pleased with it, and for myself, I explain it, I order it, and I recommend it. Accept the assurances of my high esteem and regard, Samuel L. Mitchell. Woodstock, ( Vt.) February 20, 1816. Dear Sir—I have not the pleasuse of a personal acquain- tance with you, which might be agfeeable ; but I have be- come acquainted with your writings and improvements in the medical department, by the politeness of Mr. Strong, the former representative from this district. He sent me your apparatus for conveying the heat of burning alcohol to the bodies of the diseased, for which I feel very thankful to him and yourself. The very first reflection on the subject car- ried conviction to my mind of its utility, and I could but be astonished, that the use of it had never occurred to me be- fore, considering I have been so intent on the subject of ap- plying heat to the surface, for a series of years. I have made various trials of it, in different diseases, and find it a very valuable improvement. At the time it was presented tome, I was engaged in writ- ing on the epidemic diseases of this State, viz : in the sum- mer and autumn of 1814. I have made favorable mention of your improvement in several places in the work, as a duty 26 PREFACE. I owed to society, and my acknowledgements of gratitude I now tender you. The work I have alluded to, was printed last summer, at Boston, containing four hundred and twenty octavo pages, It is entitled, " Sketches of Epidemic Diseases in the State of Vermont, from its first settlement to the year 1815; with a consideration of their causes, phenomena, and treatment; to which are added, remarks on pulmonary consumptions," $*C. I was astonished to discover from your writings, the simi- larity of object and result, from different trains of reflection and investigation, and in remote parts of the union. Per- haps I am going too far in saying very different modes of in- vestigation, they seemed in many respects similar. It would indeed, be very desirable to me, if your apparatus could be circulated in this quarter. Deaf sir, with wishes for your prosperity and happiness, I am with due respect, Your ob't and very humble servant, Joseph A. Gallup, M. D. The following is from Dr. Thacher, a very eminent physi- cian of Plymouth, Massachusetts, who is the author of a work, entitled the " American New Dispensatory," as also of another, " Observations on Hydrophobia," both of which have done him honor. He was then engaged in the publi- cation of a work entitled " American Domestic Medicine " which had much excited public expectation, and proved to be a very respectable production. Plymouth, (Mass.) March, 17, 1816. Sir—Having been apprized that you have invented a meth- od of communicating heat by means of a spirituous vapor bath, I take the liberty of addressing you on the subject and the enclosed prospectus will explain my views. I am solici- tous to make my intended publication a medium of every improvement and discovery relative to practical medicine- and if consistent with your arrangements, to favor me with PREFACE. ;27 a short sketch of the principles and utility of your method, within a few weeks, to be inserted in the appendix of my work; *it will be very gratefully received, as it may premote the views of us both, and at the same time prove highly ad- vantageous to the public. From report, I am of opinion that your invention is ex- tremely well calculated for the purpose intended, and that it ought to be more generally known in this part of the coun- try. I have not been fortunate enough to meet with either your publication or apparatus, and if any arrangement could be made for the purpose, it might be in my power to extend the employment of it in this vicinity. I am, respectfully, Your obedient servant, James Thacher. Dr. 13. Jennings. A sketch of the author's views was forwarded and publish- ed in the appendix of the American Domestic Medicine. Three of his fellow citizens, very respectable physicians, unsolicited, favored him with the following letters: Lynchburg, March 1, 1814. Dear Sir—I take a pleasure in informing you, that for'the last five or six weeks, I have applied your hot bath with evi- dent good effect, on a great number of my patients—indeed I think it a most valuable acquisition to the catalogue of medical agents. The principles upon which it is used, only want to be known, to bring it into esteem and general use. Out of the many cases to which I applied^ it, for brevity's sake, I will select the following: 1. A case of hepatic state of fever.*—This was a lady, who, before I was called on, had been treated in the usual way, by her attending physicians—bleeding, cathartics, a blister on the part affected, antimonial mixtures, &c. had been tried. I found her with cold extremities and surface ; fixed pain about the region of the liver, attended with cough, * Dr. Cabell was a pupil of Dr. Rush. 28 PREFACE. general debility, and a feeble pulse. By the use of your bath, and a few small doses of calomel, with pectoral febrifuges, she was soon restored to perfect -health. 2. A case of inflammation of the stomach and bowels.—It was a desperate one. This too was a female case, whom I found on visiting her, with cold extremities and surface, vio- lent pain about the region of the stomach and upper bowels, with langour, faintness, and scarcely a perceiveable pulse in the radial artery. In this situation she continued nearly two days, notwithstanding cordials, opiates and cathartics, were administered, and a large blister was drawn upon the region of the stomach, and two upon the extremities. No passage could be procured, or general excitement raised on the sur- face. I applied your bath, and continued its application till a general diaphoresis was produced, and kept up for some hours, soon after which a passage was effected by ordinary means. I then used it periodically, so as to keep up the ex- citement on the surface till the patient was relieved. I con- fidently believe this woman would have died, had it not been for the aid of your bath. Yours, respectfully, John I. Cabell, M. D. Lynchburg, April 3, 1814. Dear Sir—Having used your bath with decisive advantage to several patients, I cannot but regret that any one should so far mistake your object as to suppose that you consider it a specific. Having for four years past received frequent com- munications from you, explanatory of your experiments and observations upon the surface, and of the probable benefits to be derived from a more perfect method of applying heat I am in duty bound to offer you my little influence in oppo- sition to such illiberal insinuation. I know that your inven- tion is the result of much philosophical inquiry, and promises great good to the community, as one powerful auxiliary in the cure of disease. And I know, moreover, that it may be so used, as, in many instances, pleasantly to supersede the use of other agents, which are loathsome in their administration, PREFACE. 29 and, more or less, deleterious in their effects upon the system- Permit me to narrate the circumstances which attended a single case, which I treated upon your principles. It was an instance of a most painful dismenorrhagia, protracted to the length of five days, with frequent faintings, and continued watchfulness. On the fith day she became perfectly deliri- ous, with a pulse beating one hundred and twenty in the minute, and her extremities cold. At this stage I was called in. I immediately exhibited an anodyne, which was reject- ed. An attempt was then made to compose her stomach with cordials,, intended to be preparatory to the trial of an- other opiate. The attempt proved abortive. By this time three hours had passed away in painful anxiety, every mo- ment hoping to see the stomach prepared to receive such agents as appeared to be necessary. Under these circum- stances, I most willingly availed myself of the genial heat of your bath; first applying it to her lower extremities; and so soon as her feet were well warmed, removing it to her stomach, where its powers were concentrated, until a general but moderate diaphoresis was induced. Before the operation was ended, the delirium went off, and the patient dropped into a pleasant sleep, and rested composedly for the space of two hours. An opiate was then exhibited, which was retained by the stomach. Medicines, such as are ordinarily used in these cases, were afterwards advised, and the bath was repeated the following evening. In ten minutes after the repetition of the bath, the patient broke out uncommonly thick with the measles. I was informed that she had been exposed to the cold for twelve hours, about the time she expected to be in delicate health, and the immediate effect was such as I have describ- ed. Till convinced by the fact, her friends were fully of opinion that she had had the measles years ago. It is worthy of notice, that so completely was the surface abandoned by the excitement, so extensively was it locked up in the system, that she had none of the ordinary appearances which usher in the measles. Neither high fever, cough, nor sore throat 30 PREFACE. attended her case. There was indeed, an alarming deficien- cy of animal heat—and I am confident, without the influ- ence of artificial heat, to that extent, and with that decision which your bath only could have furnished, this patient would have died, and no one would have suspected the true nature of the disease by which her dissolution would have been ef- fected. I am yours, respectfully, Gustavus A. Rose, M. D. P. S.—It is a certain fact, that the sleep was induced ex- clusively by the bath. The first anodyne dose was given in form of a pill, which was seen when it was thrown up. G. A. Rose. Doctor S. K. Jennings. Lynchburg, July 17th, 1815. Dear Sir—Every day gives fresh proofs of the value of your bath. In two violent cases of spasmodic croup, I effect- ed a cure with it in twenty minutes. Calomel was exhibit- ed after the spasm was overcome. • Mr. S. Barnard, after working steadily during a warm day, was seized at night with severe spasm; his face was quite distorted when I got to him. and he had lost the use of his superior and inferior extremities ; the muscles concerned in respiration, were,so far deprived of power, that he breathed with difficulty, and those of the tongue so severely paralyzed, that he could scarcely make himself understood. The bath was applied, and it relieved him in a few minutes. He took a cathartic that evening, and was quite well the next day, except the soreness which was consequent upon the violent contraction of the muscles. I have applied the bath in the late epidemic, (Pe?'ipnett- monia Typhoides;) in most cases respiration was immediate- ly relieved by it. Where suffocation was threatened from a swelling of the throat, the bath was of great benefit. It was associated, however, with bleeding, blistering and cathartics. By warming the surface, the determination was changed and in all slighter affections, the engorgement of the lungs PREFACE. 31 readily overcome ; but in the more violent cases, it was ne- cessary to keep the bath in operation until quite a tense ac- tion was induced, after which the lancet could be used with safety, and the lungs more effectually relieved. Where the excitement had been equalized by the use of the bath, the balance was maintained by blistering with a peculiar facility and in many cases blisters were not necessary. In all these cases the bath was used as an auxiliary, together with other medicines. Among others, I also was seized with this dis- ease last fall, and in the course of an hour respiration be- came so difficult, that I began to apprehend very serious con- sequences ; my pulse was small, feeble and frequent, and my veins sunk. I went to bed, but could lie only on my back ; the bath with two cups was put in operation at my feet, and kept there for nearly an hour. By this time my pulse be- came full and bold, I breathed with comparative ease, and could lie on either side. The bath was now changed, and the heat directed to the affected side, for thirty minutes, when my pulse became tense: I then drew ten or twelve ounces of blood, and after remaining an hour longer in bed, arose, put on dry linen, and went about my ordinary business, suffering not the least inconvenience, except from a slight stitch in my side. The bath has been used by me in some cases of puerperal fever. I find that stimulants may be administered with great- er safety when it is applied ; and in some other forms of dis- ease, there appears to be less hazard in the exhibition of opi- ates, as they are rendered more diffusible by the bath, and consequently less disposed to seek an improper determina- tion. Wishing that the powers of this useful invention may be more generally known, I remain your ob't William Owens, M. D. Doctor S. K. Jennings. The following letters were sent to the author, by Doctor 32 PREFACE. Sargent, a respectable physician, and a minister of the Metho- dist Episcopal Church of Philadelphia: Philadelphiar August 10, 1814. Dear Sir—On Sunday evening last, I was called to visit a lady at the corner of Market and Eleventh streets, who on Friday evening previous had been violently attacked with asthma, and when I saw her, was still laboring under much difficulty of breathing, with her face flushed, and great pain in the head, and right side. I immediately applied your patent bath, and in about twenty minutes produced a very free perspiration, with an immediate mitigation of the dis- tressing symptoms. After this application, I gave a teaspoon- ful ofelix'r paragoric, and no other medicine ; expecting how- ever, that she might possibly require some bleeding in the morning. Indeed I would then have bled, but wished to give the bath the fullest trial, to see what its effects would be, without other aid. I saw this lady at 6 o'clock the next morning, and was much pleased to find her entirely relieved. insomuch, that I thought any thing further unnecessary, ex- cept a little of the brown mixture as an expectorant. The lady remarked with surprise that the pain in the side had also left her, which, in every previous attack, had uniformly re- mained some days after all the other symptoms had com- pletely subsided. Yours with esteem, &c. Thomas Sargent, M. D. Dr. S. K. Jennings. ♦ Philadelphia, August 3, IS 15. Dear Sir—A very respectable lady, of the Society of Friends pronounced by her physician in Jersey, to be in the last stage of pulmonary consumption, came here to place herself under the care of Dr. Wistar. But hearing of me, and of your bath, placed herself under my care. I fully expected she would not survive one month ; such were her symptoms and appearance, especially, when she informed me, that she had lost three sisters and two brothers in that disease. Not- PREFACE. 33 withstanding all these discouraging circumstances, I com- menced, and by day gave her the muriatic acid, as you advis- ed, and by night Jennings' Vapor Bath; and by the blessing of God, in six weeks sent her home, not barely recovering, but quite well. The lady to whom I gave the bath in August, 10th, while you were here, in an attack of asthma, has had no return of it since. This I think very singular, as she had been sub- ject to returns of the complaint every three and four weeks, for six or seven years past; she has also recovered her flesh and general health, to all appearance. I lately made the ap- plication to a Mr. Davies in Market street, who for more than a year past, has had violent spasmodic affections of the kid- neys. In a few hours after the application, he discharged a small stone, about the size of a pea, whieh, I would judge must have been formed in the pelvis of one of the kidnies. Yours in love, ^rc. , Thomas Sargent, M. D. Doctor S. K. Jennings. The following letter is introduced in this place, on ac- count of the variety of the cases, and the efficiency of the remedy in the hands of a very respectable citizen of Virginia, who had no pretensions to medical science. Fauquier Court House, August 2d, 1815. Dear Sir—If you could have furnished me with the bath and explanatory pamphlets, in my opinion I could have dis- posed of from fifty to one hundred since last fall. I have made use of it constantly in my family for ten months, in the commencement of all colds, and in almost every instance have found it very beneficial indeed. Most diseases seem to be produced by cold, and on immediate application it checks the disorder in an agreeable and pleasant manner. I am myself very subject to taking cold, and have applied it constantly, and derived great benefit. I am the more pleas- ed with it on account of the pleasant sensation it produces, 3 34 PREFACE. contrary to the expectation of a person never having experi- enced it. I have found it to produce wonders in my own family in the rheumatism, and in the bilious fever; and in the cholic, among some of my neighbors—where they could get relief no other way. Some seemed to be in such an agony, as if they must die, and when the bath was applied, and a pro- fuse perspiration was produced, they were immediately re- lieved. I attended a neighbor not long since, who was suddenly taken with a violent pain across his breast and shoulders, so that he could not turn in his bed. I applied the bath locally, extending and continuing the heat until he was very warm and wet. He was relieved. In fact, in a few hours was out of bed and in health. Really such is my opinion of this in- vention, that I would not take five hundred dollars for the bath, could I not get another. Some weeks past I had a vio- lent cold, was so hoarse and had such a cough that I could scarely talk. I dreaded the application of the heat on ac- count of the very warm weather; not having tried it in the summer till then. But to my surprise it was agreeable, and the hoarseness was removed immediately. The cold broke, I discharged the gathering mucus and was shortly relieved. It certainly would be a great benefit to the world, was its value known, and it was brought into general use. I am, with great respect, Your obedient servant, Thad's Norris. James Mann, M. D. Hospital Surgeon of the army of the United States, in a work published by him in 1816, (page 182,.) says: "Experience has demonstrated, that the vapor bath of Doctor Jennings is superior to any mode of removing rheu- matism. " Without detailing that train of reasoning by which he PREFACE. 35 supports a theory, somewhat peculiar to himself, of the caus- es of diseases, and their most appropriate mode of treatment, especially when supervening with most morbid symptoms, we shall merely say; that diseases attended with general coldness of the body, local or more universal pain through the system, torpor and mental derangement, in which the patient, if not immediately relieved, expires within two or three days, often within the first twenty-four hours, have raged in these regions. The insuperable coldness and tor- por which exists in such cases, have led scientific physicians to restore heat to the body by artificial means. For this purpose, the warm water bath, billets of wood heated, hot ashes, bladders filled with hot water, &c, according to the fancy of the prescribing physician, have been applied, in va- rious ways, to the body. In some instances, these warm and hot applications have been followed with success ; while in others, they have failed; not because the intention of the application was incorrect, but because it was not completely fulfilled. The moisture which is attached to the body and the surrounding clothes, frequently counteracts all the bene- fit derived from the heat communicated, by favoring its speedy evaporation from the body; consequently, the patient, in a short period, is found as cold and as torpid as he was previous to the employment of those heated applications. In these cases internal stimulants, such as ardent spirits, have been resorted to, with effects more frequently danger- ous than salutary. They induced higher degrees of excite- ment in the larger internal vessels, and in some important viscus already in a gorged state, without being capable of extending their influence to the extreme vessels of the skin. " Dr. Jennings' vapor bath remedies the evils which are necessarily connected with the usual application of heat; as its effects are more general, and are diffused throughout the system, establishing a more equable excitement, without the hazard of exhaustion which follows the employment of a water bath heat in consequence of its sudden evaporation. "A full knowledge of his treatment cannot be obtained, 36 PREFACE. except by reading the whole work, which is scientific and incomparable." At the close of 1820, the author having exerted all his in- fluence, and devoted five years to the accomplishment of his purpose—that of making known to the community the value of his discovery, he discontinued further effort, in the hope, that it would make its way without additional pains. Having been disappointed in this hope, in the year 1843, he made application to the Congress of the United States, and the following act was passed in his favor : An Act for the relief of Samuel K. Jennings. Sec. 1. Be it enacted, by the Senate and House of Repre- sentatives of the United States of America in Congress as- sembled, That the Commissioner of Patents be, and he is hereby directed to renew, for the period of fourteen years, the letters patent granted to Samuel K. Jennings, of the city of Baltimore, in the year one thousand eight hundred and fourteen, for an apparatus for the speedy generation and con- venient, prompt and agreeable application of heat to the hu- man system ; and that he embrace in said renewal of letters patent, the improvement subsequently made by said Jennings in its mode of application; subject however, to the rules and usages of the patent office, and all its provisions, except as aforesaid, of the act entitled "an act to promote the progress of the useful arts," and all acts in addition and emandations thereto. Approved, March 3d, 1S43. In conformity, therefore, with Hie directions in the said act contained, I, Edmund Burke, Commissioner of Patents, do hereby certify, that the patent therein described, is by the said act, renewed to Samuel K. Jennings, for the term of fourteen years, from and after the third day of March, one thousand eight hundred and forty-three. In testimony whereof, I have caused the seal of the Patent Office to be hereunto affixed, this fourth day of April, 1S44. f Edmund Burke, Commissioner of Patents. PREFACE. 37 His motives and purposes remain the same. He has ob- tained a renewal of the patent, to secure to himself a reason- able compensation for the labor, time and expense, to which the work has subjected him ; and relies upon the justice and liberality of his fellow citizens, for himself; and upon their humanity and benevolence, for the general relief and bene- fit of the sick. THE AUTHOR. A COMPENDIUM MEDICAL SCIENCE. PART I. Elementary Principles, developed and snpported by Physiological and Pathological facts and observations, preparatory to a proper understanding of the following work. CHAPTER I. VITALITY, SENSORIAL INFLUENCE, STIMULI, EXCITEMENT, &c. &c. M. Richerand defines life to be, "organism in action."* Action, as exhibited in organic Hfe, is an effect. To pro- duce the effect, the organs must be endowed with an apti- tude to be excited by appropriate agencies or influences, and these agencies or influences must be present, and make the requisite impression. This aptitude to be excited, for the sake of intended dis- tinctions, we will denominate vitality. By vitality, the sev- eral organs are made capable of performing the continuous and combined actions, required in organization. It must therefore receive incessant support; this support is furnished through the great nervous centres; and these are sustained by the circulating blood. Hence, vitality, though apparent- ly inherent in the fibre, soon becomes extinct, if it be depriv- ed of the circulation. The circulation of the blood, so indispensable for the pre- * Leibig's idea of vital force, vis vita^ or vitality, is, that it is a " force in a state of rest." 42 vitality, sensorial influence, etc servation of vitality, is effected and sustained, by concurring influences, which proceed from the sympathetic nerves and ganglia, and from the sensorium commune; those from the sympathetic sources, presiding over the organism and func- tions of the viscera; those from the sensorium commune, presiding over the entire organization. These influences, being incessantly produced, are manifest under various aspects. They are manifest in maintaining vitality; in their effects on the functions; in excitement. Vitality is modified by appropriate adaptations to the differ- ent structures, and their respective functions; so that the or- gans are prepared to correspond with the influences issuing from their nervous centres respectively. Hence, each of the organs is dependent for the preserva- tion of its vitality and of its organic motions and func- tions, on its connection with its own nervous centre—and the whole of them are adjusted in harmonious combina- tion, and placed under a general influence, constituting them one organization. This general influence may be denominated sensorial or nervous power. For the purpose of elucidation, we invite attention to the conspicuous organs of sensation. The eye is endowed with vitality, in a manner peculiar to its structure or organism, making it susceptible of impres- sions, which we refer to the rays of light. When such an impression is made on the retina, and is sustained and reg- ulated by the requisite sensorial influence, there is furnished an occasion for the exercise of the function of sight. The ear, by its peculiar organism, consonant vitality, and accompanying sensorial influence, is made susceptible of those vibratory impressions, which furnish occasions for the exer- cise of the function of hearing. The schneiderian membrane, in like manner, is made sus- ceptible of the impressions which furnish occasions for the exercise of the function of smelling. vitality, sensorial influence, etc. 43 The tongue and palate, of those, which furnish occasions for the exercise of taste, in all the various distinctions of that function. And the skin, of the diversified impressions, denominated heat and cold, soft and solid, rough and smooth, wet and dry; in a manner peculiar to itself, furnishing occasion for the ex- ercise of the function of feeling, in its various capacities. Similar organic structure and sensorial correspondence, no doubt obtain, in respect of every important organ throughout the whole system; the sensorium commune,* &c, the sym- pathetic nerve and ganglia; the heart, the lungs; the stomach and smaller intentines; the liver, spleen, pancreas, kidneys, &c. &c. But these references to the organs of sensation, &c. do not furnish notices of the sensorial influence in its co-operation with vitality, and producing the results which more particu- larly claim the attention of the physician. A sketch of it, as it is manifest in the organs and functions of sensation, &c. is submitted, with intention to exhibit one view^ of this diffi- cult subject, in a light so clear, that it cannot readily be mis- apprehended. The main object to be accomplished, is, to prepare the reader to form a correct estimate of the sufficiency or insuffi- ciency of the current supplies of it, for the preservation of the vital motions and functions of the whole system, in view of that harmonious regularity, which is health; to perceive how great its power in instances of violent or morbidly di- rected action, when any organ is threatened with irritation or lesion,f—as also, what the degree of diminution, when the system may languish because of a deficient generation of it, in an instance of exhaustion. J * Sensorium commune, the anatomical name given to the nervous struc- tures which have their centre in the brain and spinal cord. f Lesion—Disturbed action, accompanied with injury done to the struc- ture of parts. J By exhaustion here, is meant the state of the system when worn down • by disease. 44 vitality, sensorial influence, etc. The intended explanations, make it necessary to present the sensorial influence in association with excitement, and to consider the relation which obtains between them. The heart, arteries, veins, lymphatics, glands, secretory vessels, &c. by their respective structures and inherent vi- tality, are prepared to corresp6nd, each with its own appro- priate sensorial influence, so as to perform its own peculiar organic action and function. By this provision, blood and lymph are elaborated and circulated; the various secretions and absorptions are performed, and the different excrements are eliminated. All these organic actions and functions, maintained for purposes essential to animal existence, are embraced in the comprehensive term, excitement.f This view of excitement implies an incessant revenue of influences, inasmuch as every instance of action or motion, reports the arrival of the exciting influence and its evanes- cence or departure. Hence it is obvious, that the volume of influence in any instance under medical consideration, is estimated by the degree or force of the excitement It is commonly admitted, that the influences to which we refer, are generated and sustained by the brain and nerves. It is not necessary to the intended explanations, to deter- mine, whether the great nervous centres are to be consider- ed as so many glands of superior importance, whose func- tions are to secrete and through the nerves to diffuse this in- fluence to its various destinations; or whether they may not be organs, whose effects resemble electric, or galvanic appa- ratus, and in a manner, sui generis, collect and diffuse it;— or whether it be the result of some other provision. By what- soever means it is accomplished, the volume furnished in any given time, by any particular system, must depend on the existing state of health, and be liable to vary with the changes \ All of these functional actions are instituted and maintained in a similar way, consequently, each action is an instance of excitement. VITALITY, sensorial influence, etc. 45 which health may undergo; and like the other phenomena of animal life, be sustained by the blood-making organs. •- In perfect health, the supply will be adequate to the sup- port of the organs and functions essential to the preservation of the system;, and also to any temperate expenditure, in thinking, laboring, &e* If,# however, such expenditure should much exceed habitual boundaries, sleep becomes ne- cessary to repair the effect of this excess. In sleep, vision, attentive hearing, muscular exertion and exhausting thought, are suspended, and by this suspension a proportionate saving of sensorial power is obtained. Sleep is therefore truly said to be "tired nature's sweet restorer." Inasmuch as the organic motions, essential to the preserva- tion of the system, are necessarily incessant, and to be health- ful, must be equably maintained, a considerable diminution in the production of sensorial influence, must not only abridge the ability to labor, study, &c. but the resources on which depend the preservation of the vitality of the organs, may be very seriously affected. We then have two correlative positions— 1. The excitement .will be exalted above the natural de- gree of strength, if at any time, the sensorial influence be generated in greater than ordinary volume. 2. The excitement must necessarily be depressed below the natural degree of strength, if by any means, the influence on which it is dependent, be too sparingly furnished. In order more perfectly to understand these positions, it is necessary to view them in connection with the doctrines per- taining to stimuli.f The natural stimuli consist of a variety pf agents: the different aliments, atmospheric air, caloric, light, sounds, odors, muscular exercise, thought, the various passions and emotions of the mind—all these are liable to * This association is based on the fact, that hard thinking exhausts senso- sorial power as certainly as hard labor. f The word stimuli here, has reference to such agents as setup or incraese the vital motions. 46 vitality, sensorial influence, etc. modification. To these we add caloric, as it exists in animal he^t; the touch and motion of the blood in its circulation through the heart, arteries and veins ; as also the touch together innoxious. Cases explanatory of this affinity be- tween a pulmonitis and an intermittent fever, are continual- ly occurring in the marshy country near the sea coast; one 70 EXPLANATORY OF IDIOPATHIC FEVER, ETC or the other of these two forms, is generally prevalent, fol- lowing the seasons, in an order corresponding to the princi- ples which have been submitted. The periodicity of inter- mittents, presents no serious difficulty in respect of these ex- planatory views. If there exist in the case, sufficient energy for effecting an adequate accumulation of sensorial influence, every night to ensure a daily reaction, after the cold night air shall have ex- erted its sedative influence on the state of excitement, it will be an instance of the quotidian form. If it require two nights to charge the system sufficiently to bring on a reac- tion, it will be an instance of a tertian form. And if three nights be necessary to place the system in a similar condi- tion, the case will assume the form of a quartan. But we have respectable authority in support of the doc- trine' of lunar influence in the production of an intermittent. Doctor Jackson, by a record kept on his almanac, satisfied himself, that a considerable proportion of the cases which occurred through a season, commenced within seven or eight days of the full or change of the moon. Be it so, and in fact, it could not be otherwise, since there is no day, which is not within seven or eight days of the full or change of that sa- tellite. It is a fact of common notoriety, that in as great a proportion of instances, as are equal to Doctor Jackson's ca- ses, the weather is colder, and not unfrequently wet, within seven or eight days of the full of change of the moon. To the vicissitudes of temperature which attend on the phases of the moon, and to no other influences, are to be referred all the imaginary lunar agencies concerned in the production of fe- ver. The numberless variations and modifications of inter- mittents, so far as they actually exist, are the result of various temperaments and their accompanying liabilities to such spe- cial irritations, as may be present at the commencement of the attack, or as may be superinduced by subsequent occur- rences, mal-practice, &c. &c. THEORIES OF FEVER, ETC. 71 CHAPTER V. THEORIES OF fEVER, CONCLUDING WITH WHAT THE AUTHOR THINKS APPROXIMATES TO THE TRUE ONE. Dr. Cullen taught, that the first change induced in the animal system by the operation of the exciting cause of fever, is a diminution of the energies of the brain; that all the powers of the body and all the faculties of the mind ;— that the functions of sensation and motion ;—the processes of respiration, circulation and secretion, all fail or are dimin- ished in the general debility;—that after a certain time, a morbid increase of some of the functions, especially of the circulation, takes place, with an augmentation of heat;—that these three states,—of debility,—of cold,—and of heat, bear A to each other, the relation of cause and effect;—that the first state is.the result of the sedative or debilitating influence of contagion, marsh miasmata, cold or any other exciting cause ; and the subsequent states, the result of the first;—that the debility produces all the phenomena of the cold stage, and especially a spasmodic constriction of the extreme arterial vessels. " Upon the whole," says Dr. Cullen, " our doctrine of fever, is explicitly this;—the remote causes are certain sedative powers applied to the nervous system, which dimin- ishing the energy of the brain, and thereby produce a debility in the whole of the functions, and particularly in the action of the extieme vessels." Here is a description of the events which occur in fever; but the attempt to account fop* and explain them, is altogether a work of imagination. Dr. Brown, like his predecessor and preceptor, attributes all fevers to debility, and affirms, "that the distinctions which physicians have made about the difference of fevers, 72 THEORIES OF FEVER, ETC are without foundation; that they are all the same ; differ- ing only in degree, &c; the cause of all these diseases from the simplest and mildest intermittent, to the jail fever and plague, is the same with that of diseases not febrile ; to wit, debility; differing only in this, that it is the greatest debility compatible with life, and not long compatible with it." This theory is very brief and apparently simple. • It is, however, equally fanciful and unsatisfactory, as that of Dr. Cullen. So late, as the year 1829, from Dublin, from the largest hospital for the reception of fever cases in the British empire, a different doctrine was put forth by Dr. Stokes. " Common epidemic fever,'.' says he, "especially when contagious, has not appeared to me, at any time, to be essentially inflamma- tory;—adynamic fever, a denomination of typhus fever, which I shall employ, as I have hitherto done, to express— the putrid or malignant fever of Sydenham ;—the slow ner- vous fever of Huxham;—the nervous fever of common lan- guage ;—the synochus, typhus mitior and gravior, of Cul- len ;—the jail and hospital fever ;—the essential fever of the » French ;—the epidemic of the Irish writers ;—the contagious of Bateman ;—the typhus of Dr. Armstrong ;—and the pro- per idiopathic of Dr. Clutterbuck; whether it exists sepa- rately or independently, or is combined with any other forms of febrile disease, sporadic or symptomatic, typhoid or ady- namic fever, I consider to be generally symptomatic of mor- bid changes in the physical character of the blood." In in- flammatory fever on the one hand there is increased action; on the other, debility is almost the immediate consequence. On account of this debility being an essential characteristic of typhoid fevers, I denominate them adynamic." B^this extract it appears, that morbid changes in the physi- cal condition of the blood, in the opinion of Dr. Stokes, are produced by the causes which induce fever; in course, the morbid condition of the blood, in his opinion, must act as a secondary cause in maintaining the disease. This fault in the THEORIES OF FEVER, ETC. 73 stat*of the blood, is one of the morbid circumstances, which occur in the course of the formation and establishment of fever. The cause of it is specified, and its proper place in the train of events as they occur in fever, is assigned to it, in chapter IV. The same doctrine was published by Dr. Baine of London. Dr. Clanny, however, taught somewhat differently. Instead of regarding a vitiated state of the blood as the essence of fever, he believes the proximate cause of it, to be a want of power in the system to form blood—"a cessation of chylifi- cation and consequently of sanguification. Chylification like secretion, is a function of the brain, which under peculiar states of the atmosphere is impaired, and in severe cases is suspended altogether. Hence, typhus fever." But in opposition to all such views of fever, it is zealously and ably maintained, that fever is strictly a local disease, that it has its primary and essential seat in one organ, and that it consists of inflammation of that organ. Dr. Clutterbuck, who may be regarded as one of the most distinguished advocates of this opinion, in one of the best works on the subject, contends that fever of every denomi- nation and of every degree, is the result of inflammation ;— that the appearances which have led to the conclusion that it is a general disease, primarily affecting every function of the body, are fallacious;—and that when strictly examined, it will be found, that all general or extensive derangements of the system, are referable to local disease in one organ. " Fever, in regard to its effects on the system," says he, " is the most general of all diseases, and gives rise during its pro- gress, to the greatest variety of symptoms; but its first ap- pearance accurately noticed, will be found to be strictly a topical affection; the general disorder of the system being merely secondary or symptomatic of this." In another work he says " that all the varieties of idiopathic fever, which differ but in degree, as well as those which arise from specific « 74 THEORIES OF FEVER, ETC. contagion, as malignant sore throat, scarlet fever, small 4>ox, and so on, arise from one and the same affection, of one and the same organ, and that affection consists essentially in in- flammation." Broussais taught a similar doctrine. According to him, all " fevers are of the same nature; those termed malignant, differing from other fevers, only, by the violence and danger of their congestions ; all the causes of fever act locally." " Considered in a general and abstract manner, fever is invariably the result of a primitive or sympathetic irritation of the heart, through the effect of which, its contractions are quickened; and every irritation, sufficiently intense to pro- duce fever, is an inflammation." Respecting the nature of fever, there is a perfect accord- ance between the doctrines of Clutterbuck and Broussais. Both are agreed, that it is an affection of the solids of the body; and that its essence consists in inflammation. Both are agreed, that the inflammation is strictly local, being seated in one organ. But in determining what that organ is, there is an entire discrepancy in their opinions. According to Dr. Clutterbuck, " the organ invariably affected, in every variety of idiopathic fever, is the brain. He considers it to be a species of phrenitis, and that it might be arranged in the order phlegmasia, with pleurisy, enteritis and other sympto- matic fevers; but that, since the term phrenitis has been ge- nerally applied to a particular form of inflammation of the brain, and implies delirium, which does not always occur in fever, although it is a frequent symptom4'; encephalitis, would form a proper denomination for this entire class of diseases and might be substituted for the term, fever." Broussais contends, that the primary and essential seat of inflammation in fever, is the mucous membrane of the stom- ach or of the intestines, or both ; but essentially the former and that, therefore, "the proper designation of fever, is gas- troenteritis." THEORIES OF FEVER, ETC 75 These different and opposite theories of fever, are found to have a most important influence on the practice recommended by their respective authors, in the treatment of the disease. The advocates of debility, deprecate all active interference ; the grand evil to be contended with, is debility. "The physician can easily weaken, but he cannot easily strengthen. Of course every kind and every degree of depletion that can add to the primary cause of the malady, must be abstained from, with the utmost caution." The advocates of inflammation state explicitly, that the remedy of the disease is one, and in point of importance one only; which is admitted by all to be the only efficacious one in the treatment of inflammation. " Fever, to be treated successfully," says Dr. Clutterbuck, "must be treated upon the general principles of inflammation ; but at the same time with the modifications arising out of the peculiar nature of the organ affected, and in some degree also, the nature of the exciting cause : Blood-letting is proved by ample testimony to be„not only the most powerful, but the safest of reme- dies." And according to Broussais, in every variety of fever, and in all its stages, leeches are to be applied to the stomach. and scarcely any thing else is to be done, except enjoining rigid starvation. Of all the theorists which we have noticed, we consider Clutterbuck entitled to precedence. His views will be more extensively considered in the sequel; when with all due de- ference, we will show some points in which he is deficient. In so doing, he will excuse us, for he says, " it becomes a duty, incumbent on those particularly, who have been placed in situations favorable for observing the disease, to give the result of their experience to the public; should it tend in any degree, either to prevention or cure. The inquiry is by no means exhausted, considered either in a theoretical or a practical point of view. There is still a want of uniformity of opinion among physicians, regarding the nature of fever 76 THEORIES OF FEVER, ETC in general, and the modifications of treatment necessary in different circumstances. To ascertain these modifications, is the great desideratum, which nothing but the most cautious observation, aided bymuch time, and the joint efforts of nu- merous individuals, can supply." We bring with us,'the proceeds of a considerable practice, extended through a term of half a century, and offer them as our contribution to the common stock. Dr. Southwood Smith, has contributed a highly respecta- ble treatise, which is an approximation to truth, and it is believed that we will cheerfully be indulged in making some extracts from his work. " On careful examination," says he, " it will be found, that the first symptom which denotes the commencement of the ordinary fever of this country, in its mildest form, is a loss of mental energy. This is, however, by no means the first symptom which attracts attention: it is commonly overlooked for some time and excites but little notice, until it has become distressing." " This affection of the mind consists, particularly, in indistinctness and conse- quent confusion in the train of ideas; in an inability to attend to their relations, and therefore in the loss of power to think clearly. The patient is conscious of inability to form a sound judgment on any subject." This is the condi-. tion of the sensorium, when fever is in its incipient state. Cullen considered this symptom, which he says is a diminu- tion of the energy of the brain, to be produced by the excit- ing cause of fever. What then is the exciting cause? Our elementary principles will furnish us with the answer. The external capillaries have been brought into the condition of atony; the skin is more or less constricted, and the arterial structures are injected. The portion of the aorta from the heart to the innominata, and the continuation of the inuom- inata to the carotids, constitute a very direct passage for the blood to the head. Consequently when the arterial struc- tures generally are in a tense state, those of the head will be THEORIES OF FEVER, ETC 7T more particularly incommoded; the course of the blood, from the heart to the head is so direct, and the distance is so short. We answer then, too great pressure made upon the brain by an injected state of the arteries, is the exciting cause, which affects the mind, after the manner above described. General attention ought to be invited to this symptom. It ought to be a warning voice to every person, when first felt; for a sufficient blood-letting employed at this stage, will al- most invariably prevent a fever. The statement here made, is strictly true in regard to the stress imposed on the brain, and in a majority of instances in healthful climates, the effi- cacy of blood-letting would be as decisive and effectual, as it is here declared to be. The doctrine, however, needs qualifi- cation. In sickly districts, very often, and sometimes in re- gions known to be healthful, concurring circumstances, so completely cripple the capillary vessels of the surface ; insti- tute such a degree of atony in those structures, that the addi- tional direct debility set up by blood-letting deprives the sys- tem of abdity to react; which in many cases would be fatal. It follows, that the physician should keep this qualified ex- ception in view. More will be found on this subject, in an- other place. " Closely connected with this mental weakness, is the loss of energy in the muscles of voluntary motion; great lassi- tude ; a distressing sense of weariness, even in a sitting pos- ture." These sensations are additional evidences of contin- ued pressure on the brain, and indicate the increasing neces- sity of depletion. The next symptom in the order of succession, and which is still more characteristic of tension, tending to a state of ir- ritation of the meninges, consists in an uneasy sensation, commonly called restlessness, which is even more distressing than pain. Dr. Smith calls it "febrile uneasiness." These symptoms are soon followed by pain, first in the back and loins, and then in the limbs. The patient looks 78 THEORIES OF FEVER, ETC dejected, as if worn down by fatigue; his face is pallid and his features somewhat shrunk. These appearances indicate a tense condition of the capillaries of the spinal chord, cor- responding to that of the meninges, and calling loudly for blood-letting from the arm, or cupping over the spine, or both. The skin becomes exceedingly sensitive-; ordinary degrees of temperature produces a sensation of cold, which is sometimes intolerable. Chilliness is felt even in a heated room or a warm bed, increasing to shivering. But this feel- ing of chilliness, does not depend on external temperature; it is increased by cold, but it exists in spite of external heat. Doctor Smith says, "while the patient experiences the sen- sation of cold, there is no diminution of the quantity of calo- ric in the system. The thermometer applied to any part of the body, commonly rises as high as in a state of-health, and the skin touched by the hand of another person, communi- cates, not the feeling of cold, but often on the contrary, that of preternatural heat. There is no positive abstraction of caloric from the body, nor any failure of the process, what- ever it be, by which animal heat is generated; there is only altered sensation in consequence of derangement in the functions of the skin.* In this form of fever, the chil- liness, in many cases, never amounts to shivering; in others there is an attack of well marked rigor ; and in others again, there is no feeling of cold, or it is so slight, it escapes observation." The excitement of the capillaries of the skin is so dimin- ished, that for an indefinite length of time, its vitality is in- creased, accompanied by an increased sensibility to cold • and a warm room, or a warm bed, will not correct its morbid sensation, until the returning circulation of the blood restores its natural state. * The superficial heat, which acts on the thermometer, and * In this the Doctor errs. See our elementary remarks on vital heat. THEORIES OF FEVER, ETC 79 nay be felt by the hand of another person, is the consequence )f deficient perspiration. Excitement is below the natural state, and caloric is therefore imperfectly developed. But in he absence of the necessary moisture, it cannot escape, and .herefore accumulates on the surface. If at this stage, the mtient be bled sufficiently, and the depletion be immediate- y followed by an application of external heat, a pleasant per- spiration will be readily established, and all the morbid ap- pearances will retire. The symptoms thus far enumerated, are all referrable to derangement of the functions of the brain and spinal chord, and this derangement is consequent on excessive tension in the arterial structures, pertaining to those two important organs. About this stage, however, the circulating system is be- ginning to exhibit a participation in the morbid action. The pulse expresses langour, and commonly becomes more fre- quent, sometimes it is slower, but invariably weaker, than it is in health. The respiration is shorter and quicker than natural. The chest fails to expand freely, and seeks com- pensation in an additional number of respirations. There is great uncertainty, as to the time which may in- tervene, between the symptoms indicating the impression made on the sensorium, and those which evince a disturbed condition of the thoracic viscera; commonly, the more • acute the shorter the period, but not always. Cases occur, which are slow in forming, and for a while, do not excite alarm ; but ultimately, become formidable, or even fa- tal. All such variations as to time, depend on the ability of the distended vessels to defer a state of irritation. At length • however, the retarded blood, by detention becomes deterio- rated, till it is sufficiently stimnlant to excite and establish a state of irritation. Then the pulse, which was feebler than natural, becomes more full and strong, and generally more frequent than in the healthy state; and the skin, which was 80 THEORIES OF FEVER, ETC. cold, becomes preternaturally hot, rising from 98% the natu- ral standard, to 105° Farenheit. " When the circulation becomes thus excited, the func- tions of secretion and excretion become deranged.' The mouth is dry and parched; the tongue begins to be covered with fur; thirst increases, and the secretions of the liver, pancreas, and mucous membrane lining the alimentary ca- nal, are all vitiated; the urine is altered in its appearance; and the skin becomes hot, dry and harsh to the touch. Meanwhile, the pain in the back and limbs, and the febrile uneasiness are increased. It may be said, the fever is now fully formed. Take a summary review of the subject. The- external ca- pillaries, in consequence of debility, are impaired ; their func- tions partially suspended: the circulation impeded at the ex- tremities of the arterial structures; the whole arterial sys- tem becomes injected to a state of distention; the stress im- posed on the blood-vessels of the head has impaired the func- tions of the sensorium, and of the nerves ; the blood making organs have lost their activity; although the arteries are in- jected to excessive fulness, the veins are emptied into the yielding vessels of the viscera. The viscera decrepid and overburthened, cannot perform the function of assimilation. A deterioration of the blood becomes inevitable, which of course must continue to increase, until the entire train of ir- ritations which constitute fever is established. Ail this might be prevented by one well-timed and sufficient blood-letting. But when fever is established, the irritations which consti- tute it, are inflammatory in their nature and tendencies, and require a treatment according to the views of Clutterbuck and Broussais; giving preference to the doctrines of the for- mer, in treating a case of sensorial or thoracic irritation ; and to those of the latter, when the irritation shall be gastro- interetic. BLOOD-LETTING, ETC 81 CHAPTER VI. BLOOD-LETTING, A MOST IMPORTANT REMEDY IN THE TREATMENT OF FEVER. According to the view's which have been submitted, it will appear that blood-letting is a remedy of the first impor- tance, in the treatment of fever; the superiority of " which, in comparison with other means of cure," says Dr. Clutter- buck, " is shewn in various respects. It is a remedy most frequently called for in general practice, and often, of itself, without the aid of other means, accomplishes all we wish. In point of efficiency, none will bear a comparison with it, while it is one, for which, on numerous occasions, no ade- quate substitute can be found. It is prompt in its effect, so as to be adapted to many cases of great and sudden emer- gency. It is the least equivocal of remedies. Its good ef- fects, when properly administered, are in most cases so im- mediate and striking, as not to be mistaken. This can with truth be said of few others of our curative means; which, except with regard to those of the simplest operation, seldom accomplish what they are supposed to do. In short, blood- letting is a remedy, which when judiciously employed, it is hardly possible to estimate too highly. There are indeed few diseases in which, at some period, and under some cir- cumstances, it may not be used with advantage, either as a palliative or curative means. A great number of diseases are speedily brought to a termination by the early use of this re- medy, which without it, are apt to run a protracted course ; thereby, inflicting much and unnecessary suffering on the patient. On various occasions, life is brought into immediate hazard by the neglect of this essential means; and stikl 6 82 BLOOD-LETTING, ETC. oftener does it happen, that by such neglect, a foundation is laid for chronic maladies of difficult descriptions, which are not less fatal in their result; such as pulmonary consump- tion, dropsy, and confirmed asthma. But blood-letting more than any remedy, requires to be well-timed." In all this report of the value and importance of blood- letting, Dr. Clutterbuck has the confirmation of our observa- tion and experience, carefully conducted for the term of fifty years. " From the earliest times, this remedy has been extensively employed; and at no period has it been held in higher estimation, or more frequently resorted to, than in the present day; one might naturally expect, therefore, that a pretty general agreement in opinion would be formed among practitioners, with regard to it. This, however, is far from being the case. Opinions are still vague and unsettled upon the subject; and in some respects contradictory; while the merits of the practice are by no means justly or sufficiently appreciated. I know of no greater service that could be ren- dered to the healing art, and consequently to society at large, than the assigning with tolerable certainty and precis- ion, the various circumstances that ought to influence us, in the use of this herculean remedy. The task of doing this, however, is of no ordinary kind, and as I believe, not to be perfectly accomplished by any individual. ' Every contribu- tion will therefore be willingly received." The following facts, which we have many times observed, are all sustained by the observations of Dr. Clutterbuck: When blood is drawn from any large vessel, either vein or artery, to a certain amount, and with a certain degree of ve- locity, the loss is followed by a number of changes in the system, which vary according to the quantity lost, the ra- pidity with which it is taken and the particular state of the individual at the time, in regard to strength, age and other circumstances. These changes may be divided into the primary or immediate, and the secondary or more remote. BLOOD-LETTING, ETC. 83 This distinction is necessary in a practical point of view, as we are sometimes desirous of obtaining the primary, some-' times the secondary or remote effects of the evacuation. " In adults of ordinary bulk, and at the middle period of life, the abstraction of six or eight ounces of blood, from a vein, slowly and quietly, as in ordinary venesection, produces commonly no striking or obvious effect, nor generally speak- ing, any that is perceptible afterwards; neither the feelings, nor any of [the functions are sensibly disturbed or impaired by it. But if the' evacuation be carried to twelve, sixteen or twenty or thirty-six ounces, or if a smaller quantity be taken away rapidly, then greater and important changes generally ensue, and which take place in a somewhat regular order, as perceptible in the state of the different functions of the body and mind." " There is commonly first experienced, a slight feeling of langor; and if the pulse at the wrist be examined, it will be found to beat more freely, and often more slowly than before; though sometimes the reverse of this takes place. Breathing also becomes slower, in conformity with the pulse, and it is often irregular, with deep sighs. If the flow of blood goes on, the languor increases, the pulse becomes still more feeble, and sometimes fluttering. To these suc- ceed paleness and coldness of the skin and shrinking of the features; cold drops of sweat hang on the forehead, and sometimes perspiration breaks out over the whole surface ; the eyes look glassy and the pupils are dilated. Occasionally alsoj there is vomiting with other involuntary discharges, and in a few instances epileptic, or convulsive movements more or less general, take place. The pulse at last is not to be felt, the respiration ceases, and consciousness is wholly lost. This is the state termed syncope or fainting ; during which, if complete, there is in appearance, an entire suspen- sion of all the vital movements, morbid as well as healthy; it is in fact, a state of apparent death. These effects seldom continue longer than a few minutes, rarely for half an hour; 84 BLOOD-LETTING, ETC when the pulse again begins to be felt at the wrist, respiration is renewed, often accompanied with yawning; and con- sciousnesi returns." " Sometimes a copious bleeding is followed by a throbbing head-ache, and a sleepless night." Dr. Clutterbuck considers that these last two circumstances go to show, that, "not only the vascular action of the brain, but its functions also have been disturbed by the evacuation. Such throbbing head-ache, however, is not likely to befall any, but such as are of a nervous temperament, and direct debility is the cause of it and of the sleepless night which follows depletion in such cases. Robust patients only, can safely be bled so de- cisively. " When the primary and temporary effects above described have gone off, if the quantity shall have been considerable, as a pound or two or more, there will sometimes follow not only a feeling of languor, but actual weakness. The pulse will be small and feeble and there will be inability to make voluntary exertions. If the loss shall have been very large, as in a violent hemorrhage, or if the blood shall have been largely and frequently drawn, which violent inflammation sometimes requires, the weakness which follows, will be in proportion to the quantity of blood lost, and is often very durable. The skin remains pale and bloodless in appearance, for many months ; there is a great languor or feeling of weak- ness, and an imperfect performance of the functions." This last may commonly be remedied by proper management, as will be seen in the sequel. The effects of blood-letting. however, are by no means, in a strict and uniform accord- ance with the quantity drawn, or the rapidity with which it is discharged from the vessels. The bulk of the patient, his strength and age, have a share in modifying the result. Temperament, climate, manner of life, &e, are all to be considered. Blood-letting makes the most immediate impression on BLOOD-LETTING, ETC. 85 the heart and blood-vessels, the condition and action of which, it can control more effectually and permanently, per- haps, than most, other medicinal agents. This is an impor- tant fact, since the most violent and fatal diseases, and those too, of the most frequent occurrence, are seated essentially in this class of organs. Such are fevers and inflammation of all kinds, in which the action of the heart and arteries, and in consequence the circulation of the blood, are always more or less disturbed. But the effect will be different, according to the degree of irritability of those structures. Blood-letting has no doubt been sometimes resorted to, where it was not absolutely necessary, and in cases which might have done well without it; but much more frequently it has been withheld, when its use would have been fol- lowed, by great and decisive benefits. And it is often em- ployed without being well timed, and without correct judg- ment, in respect to quantity, repetition, and manner of draw- ing. We approve the doctrines of Clutterbuck and Brous- sais, so far as to admit, that all fevers are more or less inflam- matory in their essential characters and effects; and of course that abstraction of blood is often very necessary in the treatment of fever. 86 CONTINUATION OF REMARKS ON BLOOD-LETTING. CHAPTER VII. CONTINUATION OF REMARKS ON BLOOD-LETTING. Agreeably to Dr. Clutterbuck the various opinions of phy- sicians, as to the manner how blood-letting acts in the re- moval of disease, may be reduced to the following heads: That it acts upon the principle of depletion; in other words by diminishing the general mass of the blood. Or simply and altogether by weakening the system. Or as a sedative diminishing vascular action; this in a great number of diseases being in excess. The first of these opinions is formed on the supposition, that there is often a superabundance of blood in the system, constituting what is called a plethora ; and that such a state of fullness is the cause of inconvenience and danger. That it impedes the circulation by its too great volume, and may produce mischief by distension. But Dr. Clutterbuck con- siders the existence of plethora questionable, and that the signs usually pointed out as proof of its existence, are at best» equivocal. That the relief afforded by blood-letting ought to be ascribed to depletion merely, as being effectual to di- minish arterial action, and that the effects which have been ascribed to depletion, ought to be set down to the account of reaction, as if the consequence of over-stimulation. The( second opinion, " that blood-letting acts by weaken- ing the system only," is based on the doctrine of the sthenic and asthenic diathesis. But the same author says " diseases neither consist essentially in, nor are derived from, excess of vigor in the system at large. We do not deny that weak- ening the general system, whether it be effected by blood- letting or any other means, conduces at times and under cer- * In this Dr. Clutterbuck errs. CONTINUATION OF REMARKS ON BLOOD-LETTING. 87 tain circumstances, to the removal of disease and especially where the habit is strong; but the same remedy is often equally effectual for its purpose, when the body is already weak. In both cases, the remedy is uncertain in its effect, and frequently fails to cure. This would seem to show, that it is not simply by inducing weakness that the object is at- tained ; but in some less direct way, probably lessening the disposition to disease." As to the last opinion, that blood-letting acts by a sedative operation, that is, by diminishing vascular action without regard to the general strength, "a great number of diseases in which this remedy is found useful, are accompanied by much vascular excitement; such is the case in febrile diseases in general. But sueh diseases do not consist simply in in- creased vascular action, nor do they yield with any thing like certainty, to this or any other sedative remedy. Blood-let- ting is not required in all cases in which vascular action is in excess, on the contrary equally good effects are often found to result from remedies of a totally different nature." He infers from the whole, " that it is not as an evacuant merely; nor by lessening tension ; nor merely by weakening the sys- tem nor by a sedative operation on the vascular system that blood-letting effects our purpose in the removal of disease. The most intelligible explanation of the matter appears to be this ; that by any considerable loss of blood, however occa- sioned, a kind of shock is given to the system, in conse- quence of which, all vital movements, morbid as well as healthy, are more or less disturbed. In this respect therefore, blood-letting resembles in its effects, other sudden and pow- erful impressions on the system, whether made on the mind or body, and whatever be the cause producing them. In short, blood-letting, in checking or suppressing violent disease of any kind, appears to act upon a principle very analagous to, or identical with, what is called counter-irritation, but which in this case is perhaps better termed counter-impression." 88 CONTINUATION OF REMARKS ON BLOOD-LETTING. " Upon the principle now stated, namely, that of counter- impression, there is no difficulty in comprehending the supe- riority of venesection, in most instances, over the slower modes of drawing blood by leeches or scarificatisn and cup- ping ; and we at the same time, readily understand, why the same remedy should prove effectual for the removal of so many various forms of disease, as is found to be the case." But blood-letting is not always advisable for the purpose of producing counter-irritation. Weakness of the patient may forbid it; whilst in cases, under circumstances to which the remedy is well adapted, it is far more efficacious than the other modes of producing counter-irritation usually resorted to, such as blistering, the use of mercury, and the like, and it is free from any serious inconvenience to which these are liable and which are often such as to render them wholly inexpedient. Let it be repeated, that in the forming state of fever, the external capillary structures are in a state of debility, failing to perform their functions; the skin is constricted more or less tightly around the whole body; the circulation is im- peded at the extremities of the arterial structures; the returning circulation by the veins and lymphatics is acceler- ated by the constriction, which simultaneously resists that of the arteries; and whilst the arteries are injected to a state of tension and likely to be fretted to irritation^ the viscera are burthened with an introversion of the fluids, by which those organs are so much oppressed as to be disabled to perform their functions; the visceral secretions are diminished, of course much excrementitious material is detained; the effete matter which ought to pass off by perspiration is also retained, possi-^ bly to the amount of two or more pounds in a day. Hence it inevitably follows, that in the commencement of fever, the sys- tem is in a plethoric state ; Dr. Clutterbuck's opinion to the contrary notwithstanding. Blood-letting is therefore almost invariably useful, and in a large proportion of instances abso- CONTINUATION OF REMARKS ON BLOOD-LETTING. 89 lutely indispensable. By a copious depletion the advantage of the Doctor's shock is gained—the injected condition of the arteries is retired; the oppression of the sensorium is re- moved ; the volume of the circulating fluids is brought within the compass of functional agency, so that they may be re- fitted for use; and preparation is made for a general restora- tion of order. But in many instances plethora exists until the blood it- self is vitiated. To extract a portion of it, therefore, in a man- ner the most direct possible, must lessen the cause of morbid action. Under these circumstances, Dr. Rush was of opinion, that the effect of blood-letting was as immediate and natural in removing fever, as the abstraction of a particle of sand is to cure the inflammation of the eye when produced by it. Of course, in all cases, especially when there is much pain and the condition of the patient will admit of speedy evacu- ation, it will be better to commence with blood-letting.* It may be performed in a manner so decisively effectual, as to strangle fever in its forming state. And this can always be done, if used with the necessary decision, before general irritation or local congestion, shall have been established. By reducing the quantity of blood to a volume, which the system can command with ease, the circulation becomes free and pleasant, the organs concerned in its elaboration, are regularly employed, and a speedy return to order is establish- ed throughout the whole system. In this way, it often hap- pens, that a very alarming sense of debility is removed at once by bleeding, with or without auxiliary evacuations. In the same manner, when the pulse is uncommonly frequent because of a fullness of the arterial system; by blood-letting, the thraldom of the heart is removed and the pulse assumes a regular motion. So also, when the pulse is p'reternaturally * However, care must be taken, to place the superficial vessels in a condi- tion to secure reaction. The ways and means for accomplishing this will be submitted in their proper places. 90 CONTINUATION OF REMARKS ON BLOOD-LETTING. slow, whether it be the effect of too great fullness of the ves- sels of the head, or of the vena porta and liver, by the loss of blood, the motion of the heart—that is, the circulation of the blood is accelerated. Having mentioned the fullness of the liver and portal cir- culation, we must observe, that when there is a great nausea and vomiting from that cause, very often, blood-letting af- fords immediate relief; and in all cases when the state of the pulse will warrant it, the same remedy will correct or pre- vent, that kind of diarrhoea which attends on eruptive dis- ease, or other inflammatory affections. When the secretions are imperfectly performed or locked up, blood-letting very often in a short time sets them at lib- erty. In obstinate constipation of the bowels, with or with- out known inflammatory appearances, cathartics seldom prove effectual, until preceded by copious blood-letting. If the blood vessels of the intestines are much distended by ar- terial stress, the irritation of gamboge united with calomel, will not be sufficient to excite catharsis. So also in the ad- ministration of mercury, ptyalism will not be produced, until the arterial system is first sufficiently relaxed. The same remark will apply to an attempt to produce diaphoresis, when there is too much inflammatory action. The effort will be ineffectual, whether the attempt be made by the administra- tion of nauseating medicines, diluting diaphoretics, or by the application of external heat, until the blood vessels are first reduced to a suitable condition. A deficiency in the secre- tion of the juices of the mouth and fauces, when consequent on too much fullness or tension of the arterial system, will not be corrected by any kind of drink or wash, till the con- dition of the vascular system shall have been rectified, by blood-letting of other equivalent evacuations. A hot skin, when consequent on that kind of violent ex- citement which is common in cases of pleurisy or pulmonitis when it occurs in persons of vigorous constitutions; as also in CONTINUATION OF REMARKS ON BLOOD-LETTING. 91 many instances at the commencement of malignant fever, is immediately cooled by sufficient loss of blood; as also, a sen- sation of burning which is felt in the stomach in some alarm- ing cases of bilious fever. In this last symptom, however, some special precautions are to be regarded in the employ- ment of blood-letting, which will be noticed in their proper places. There sometimes occurs in bilious fever, a peculiar kind of protracted chilliness, continuing for several days, and which refuses to yield to any ordinary management, not even to the employment of internal or external heat, but which re- tires immediately on sufficient blood-letting. A case of this sort requires diligent investigation, as it universally implies congestion in some important viscus ; and of course, an undue attempt to insure warmth by the use of cordial or stimulating draughts, must have a tendency to produce incorrigible mis- chief. Sometimes, by an unaccountable aberration of sensorial in- fluence, the arterial capillary action of the skin becomes mor- bid, effecting such excessive secretions of sweat, as to threat- en fatal prostration, and at the same time the perspiration, however profuse, affords no relief to the painful symptoms. Blood-letting subdues the arterial action, and the absorbents resume their natural functions. LTnder a similar state of things, although less general, we sometimes meet a profuse sweat of the head and chest. This in like manner is correct- ed by timely blood-letting. In a case of this kind, however, caution is necessary, inasmuch as it is more likely to occur at a later stage of the fever, when there may be too great debil- ity to admit of blood-letting. In any instance, when diar- rhoea or tenesmus occurs in the course of bilious fever, unless there be too much debility, they are most certainly corrected by blood-letting, or leeching, or cupping. And in any case in which it might be supposed, that these were consequent on debility, if they should resist the use of opium and astrin- gents, and especially if the patient have been sufficiently blis- % 92 CONTINUATION OE REMARKS ON BLOOD-LETTING. tered, there will be a tense state of the pulse, which ought to have been regarded at the first, as indicative of the neces- sity of blood-letting. Coma, seldom, if ever, occurs in any instance of fever which has been timely treated with suffi- cient depletion by the lancet; and blood-letting, cupping or leeching, when necessary, is the best—the only anodyne, in cases of febrile restlessness. Dr. Rush was of opinion, that the frequent instances of ef- fusion of serum and of blood, which have occurred towards the conclusion of fevers, when treated with diaphoretics and imperfect evacuations, might have been prevented in almost every case, by sufficient blood-letting; and many instances of the most troublesome coughs, consumptions, asthmas, jaun- dice, abscess of the liver, and all the different forms of drop- sy, which so often follow autumnal fevers, are consequent on deficient blood-letting in their early stages. Fifty years ago we often heard much about putrid or gan- grenous fever. But having been an early advocate for a lib- eral use of the lancet, we have rarely seen an instance of that sort, during the half century of our practice. Dr. Morton, in 1678, described a putrid fever which was epidemic and fatal. Dr. Sydenham, who practised in London at the same time, appears to have taken no notice of it. Dr. Sydenham used his lancet freely. Dr. Morton pursued another course. The result was, the one had to witness great and fatal congestion, the other saw nothing of that distressing condition. Hav- ing mentioned a variety of instances and circumstances in which it is useful and necessary to have recourse to blood- letting, we wish it to be understood, that in all of these, the remedy has been considered in reference to general principles only, and that there are many precautions., which in their places will be submitted. PREJUDICES AGAINST BLOOD-LETTING, ETC 93 CHAPTER VIII. PREJUDICES AGAINST BLOOD-LETTING MET AND COR- RECTED. There are some erroneous opinions and prejudices, enter- tained in opposition to the use of the lancet, which need to be removed out of the way, and which claim our attention. We were once sent for by a German, to visit his daughter, who had been eight or ten days ill with an inflammatory af- fection of the lungs. On our arrival, he let us know, that he would have sent more than a week earlier, only, that he was persuaded that his daughter's disease was a pleurisy, and that it would be considered necessary to let blood. He had therefore waited to see if she would live through the dog days, which she had done, and if we thought fit, she might now be bled. It was too late, she died on the following day. There are many who think it hazardous to bleed in very hot weather. We are informed that Galen bled in a plague, and Arceteus, in a bilious fever, in a warm climate. According to Dr. Sydenham and Dr. Hillary, the most inflammatory fe- vers occur, and succeed to hot weather. It was the practice of Dr. Cleghorn in the warm months, in the Island of Mi- norca. Dr. Mosely, treated yellow fever successfully by blood-letting in the Island of Jamaica. The same practice has been followed in that Island by other physicians, particu- larly by Dr. Broadbelt and Dr. Weston. It has been found to be successful in St. Domingo, and there is high authority in proof, that it is the practice of the native physicians of Upper Egypt. We have used the remedy as fearlessly, and with as decided effect, in summer as in winter or spring. It f)4 PREJUDICES AGAINST BLOOD-LETTING, ETC, is true, it is not so generally necessary, nor do cases common- ly require as many repetitions, in the summer season as in cold weather; and more attention is necessary to insure re- action after the operation. i Another prevailing prejudice with some, is, that the natives of the West Indies, or other warm climates, cannot safely use the remedy. If the natives of such climates inherit ir- ritable constitutions, the remedy will be the more necessary for thern. in any and all cases of inflammatory disease, which may befall them. If not, then of course they have no more to fear than other people. We often find a difficulty in gaining the consent of patients to be bled, when they feel themselves weak. It is almost "impossible to make uninformed persons understand the na- ture of indirect debility. We commonly state in few words, your system is too full to perform its motions and functions with the necessary ease ; you therefore feel weak. By evacua* tion, the vessels will be set at liberty, and you will feel stron- ger upon loss of blood. Ordinary confidence on the part of the patient, supported by some such attempt at explanation, generally insures consent. It would be well to be able to add to this reasoning, when necessary, that if there be a great sense of weakness, in consequence of too great fulness, other remedies, whose effects are dependent on the functions of the viscera, will prove ineffectual, and time will be lost. In a case of this sort, all the time we are waiting, there is an increase of mischief and danger attendant on the disease. The greatest objections are ordinarily made, however, when it is found necessary to bleed persons of very delicate constitutions; and especially if for a long time, they have been in a state of debility. Persons of such temperament and habits, are subject to the same kind of morbid action of the vascular system, which destroys the organs of more robust patients. Although there may be less arterial force, there is a corresponding irritability of the blood vessels. In fact, per- PREJUDICES AGAINST BLOOD-LETTING, ETC. 95 sons having very delicate vital organs, commonly require lar- ger bleedings in proportion to apparent strength, than those more robust. Such patients and their friends, too often in- sist on the use of emetics, purges, sweats, 4*e in preference to blood-letting. The physician, therefore will find it ne- cessary, in many instances, to condescend to the use of an ar- gument, and persevere in it, until he shall have succeeded in removing their prejudices. And if he act discreetly, it will commonly follow, that the speedy diminution of the alarm- ing symptoms, and the unexpected comfort, which follow the use of the lancet, when skilfully employed, will ever after- wards make his way sufficiently easy. Our patients of this description, are, without a single exception, the greatest friends to the blood-letting practice. We have often to encounter other prejudices against the use of blood-letting in instances of infants and young chil- dren. We shall have occasion to state in another chapter, that the remedy when required in children's cases, may be commonly considered to be imperiously necessary. The great irritability of their blood vessels, the difficulty of using other remedies to equal advantage, and especially the danger which awaits them in inflammatory affections of the lungs and head, to which they are particularly liable, make it ne- cessary that the use of the lancet in such cases should be em- phatically insisted on. Mothers and nurses often raise objec- tions ; we commonly succeed with them, by letting them feel, that we shall hold them responsible for the issue, if they take upon them the attitude of opposition, in a case where the practice is necessary. It is another mistake equally great, that old people cannot be bled. The relaxation of their blood vessels makes them liable to plethora, especially when they have pretty good health; for such ordinarily experience an increase of appe- tite, as their age advances. We knew an old man of eighty, who let blood largely at certain stated periods. He was usu- 96 PREJUDICES AGAINST BLOOD-LETTING, ETC ally bled twenty-four ounces at a time. Another, a Scotch labourer, a ditcher, who could earn vages at the age of eighty- four years, was also accustomed to the same practice. There was a lady in our city, about eighty-five years old, whom we bled largely, on frequent occasions of her illness. In 1826, we bled every patient, old or young, who was affect- ed with an inflammatory influenza, which was then epidemic, except one old lady of ninety. We wished to bleed her al- so, but she and her friends declined it, on account of her age. She was relieved in the course of five or six weeks, by fre- quent and gentle cathartics. She might have been cured in six days. Botallus, physician to Henry III of France, who wrote a treatise, De Cur. per Sang. Mission, 1660, says, " majus esse adjuvandos senes missione sanguinis, dum mor- bus postulat, aut corporum eorum habitus malus est, quam ubi hasc juvenibus contingent,"* of course we see, that the practice is not new, and to judge by what has very often come under our own observation, a sufficient experience in the practice of blood-letting will lead any judicious practi- tioner to use the remedy as fearlessly in cases of old patients as of those that are young. It is one of the most common prejudices, that blood-letting is inadmissible in time of menstruation. But the uterus is always during the continuance of that state of things,, in an irritable condition, the system is plethoric, and any incon- siderable exciting cause, frequently produces violent degrees of irritation. There can be no quesiijn therefore, that in ca- ses of fever in such circumstances, blood-letting is more ne- cessary, than at any other time. It has been the practice in olden times, to rely on the natural evacuation, for the remo- val of any disease that might occur about that period. It was not then known, that the four to six ounces of discharge, *That old men are more benefitted by loss of blood, when disease re- quires it, or the condition of their bodies is morbid, than young men in simi- lar circumstances. PREJUDICES AGAINST BLOOD-LETTING, ETC 97 was not really blood, but an elaborate secretion. And even if it were blood, what is the inconsiderable discharge of two or three ounces in twenty-four hours, when the nature of the case might require the loss of fifty, perhaps an hundred oun- ces. We proceed in cases of female patients, throughout the whole time requiring special attention, as if the catamenial discharge had never been thought of; as if we had no con- cern whether it ever would return. And in ordinary instan- ces, it needs no care. It will return with the other functions of the system. As its irregularities are consequent on a dis- eased state of the system, so its regularity will be restored with returning health. Similar prejudices have prevailed respecting a state of preg- nancy. Happily, however, this is less prevalent now, than formerly. The young physician ought to be careful and in- sist on the necessity of blood-letting in all cases, when there may be proper evidence of an inflammatory diathesis, at whatever stage of gestation. For want of this precaution, many valuable lives have been lost. The irritable state of the viscera, the mechanical pressure, and the constant dispo- sition to plethora, all concur to make it often necessary to bleed patients in a state of pregnancy, when, that considera- tion aside, the practice might safely be omitted. An opinion is entertained in some families, that females when pregnant, ought to be bled about the third month, and that the same ought to be repeated about the seventh. All such calculations raised upon periodical necessity, are erro- neous. They ought to loose blood whenever it is necessary, without regard to months or days; and when necessary, it is dangerous to omit it, or even to rely on a substitute evac- uation. Spontaneous sweating in feverr is supposed to forbid or supercede the necessity of blood-letting. In cases of pulmo- nitis, when suffered to progress a day or two, or more, with- out blood-letting, as also, in many instances of violent bilious; 7 98 PREJUDICES AGAINST BLOOD-LETTING, ETC. fever, a profuse sweating often takes place, and appears to attend throughout every paroxysm, without affording the least relief; indeed in such instances the sweating would continue until death. This statement has the support of Drs. Rush and Sydenham. " While this constitution (this particular condition of the atmosphere) prevailed," says Dr. Sydenham, " I was called to Dr. Morris, who then practised in London. He had this fever attended with profuse sweats, and numerous petechias. By the consent of some other phy- sicians, our joint friends, he was blooded and rose from his bed, his body being first wiped dry. He found immediate relief from cooling diet and medicines ; the dangerous symp- toms soon going off, and by continuing this method, he re- covered in a few days." Writing of the same fever in an- other place, the Doctor says, " For though one might expect great advantages in pursuing an indication, taken from what generally proved serviceable, (sweating,) yet I have found by constant experience, that the patient not only finds no relief, but contrariwise is more heated thereby; so that fre- quently a delirium, petechias and other very dangerous symp- toms, immediately succeed such sweats." Morgagni gives an account of a malignant fever, which prevailed in Italy, in which the patients died in profuse sweats; their physicians all the while looking for a crisis. It is quite probable, that blood-letting might have saved ma- ny of them. These instances, and all such, serve to prove the correctness of our opinion respecting the state of the ar- teries, in all cases of inflammatory fever ; in which these ves- sels are injected, while the veins are slightly filled. And whilst this particular subject is before us, we will remark, that the petechias just mentioned in the above quotation from Dr. Sydenham, proves the same doctrine. We cannot con- ceive, how they can occur in any case of direct debility. In all cases of prostration by loss of blood, or other evacu- ations ; as by catharsis or by cholera; in the degree of the debili- PREJUDICES AGAINST BLOOD-LETTING, ETC 99 ty, so is the paleness, or the absence of the blood from the skin. When the system is sinking at the close of aTever which has been treated with sufficient evacuations, as the debility increases, so also the paleness of the skin. But in petechiae, the capillary arteries must not only be filled, but they must be filled with a force sufficient to drive the blood beyond its ordinary extension, and the spots are produced by its effusion under the cuticle. It is true there must be a deficiency of absorption in the capillary veins of the skin, and the want of adjustment in this particular, may be one of the errors which needs to be rectified. But it is equally pro- bable that this want of activity in the absorbent system, is owing to the morbid expenditure of the sensorial influence on the arterial structures. Blood-letting therefore, in such cases, serves to interrupt the morbid action, to break the ca- tenation of motions on which it is dependent, and while the shock is felt, the nerves accompanying the arteries, and which are kept in an irritable state by the accompanying blood, fall into a state of ordinary quietude, whilst the nerves destined to rule over the absorption, resume their power and a balance of the circulation is established. It is true, that petechiae have generally been considered indicative of a gan- greous state of the capillary structures ; and if not speedily corrected will be followed soon by dissolution. But Drs. Sydenham and De Haen, both bled in these appearances with advantage when they were accompanied with an ac- tive pulse. Dr. Rush bled a Mr. John Carrol, who was sick with petechial small pox. He abstracted fifty ounces of blood, when every pock on his arms and legs had assumed a purple appearance, and saved his life. It is said that Louis XIV of France, when he was thirteen years old, was bled five times, to the great honor and emolument of Dr. Forne- lius, who urged it against the advice of all the other physi- cians of the court. Dr. Cleghorn mentions one case only of successful blood-letting in petechial small pox. Dr. Rush, 100 PREJUDICES AGAINST BLOOD-LETTING, ETC, however, thougt it probable that his want of greater success was occasioned by his bleeding too sparingly ; for he repeat- ed it but three or four times. These instances and authori- ties show, that in most, if not all instances, fever with pete- chias needs blood-letting; and that the remedy, if well-timed and sufficiently repeated, will not disappoint. But such a state of things is necessarily urgent, and if permttted to stand any length of time, must present the skin in a state of gan- grene. And it is highly probable that a want of proper re- gard to this fact, has often led to the conclusion, that pete- chias necessarily implied a gangreous state of fever. This symptom alone then, ought not to lead to too hasty decision, but the whole train of occurrences, and all the existing ap- pearances in the case, must be duly considered, without de- lay; and if, upon the whole, blood-letting be indicated, the single appearance of petechiae need not deter us from using the lancet. SUPERIORITY OF BLOOD-LETTING. 101 CHAPTER IX. BLOOD-LETTING PREFERABLE TO ALL OTHER DEPLETING REMEDIES. In a former chapter we gave Dr. Clutterbuck's account of the superior merit of blood-letting. We here present our own, with the explanatory reasons for our preference of the remedy. Blood-letting has great advantages over every other me- thod of depleting the system. It at once reduces the action of the heart and arteries, while the nerves in a good degree retain their integrity of power, and if it be carried to any point approximating to deliquium, very commonly, so effec- tual will be the shock, that the absorbent system comes at once into a state of healthy action, and the disease is smoth- ered in its onset. Other evacuant remedies are indirect and circuitous in their effects, in respect of the action of the blood-vessels. Vomits, for instance, are sometimes effectual in arresting mild fevers in their commencement, and by repetition have served to cure such fevers when fairly formed. They dis- charge any offensive matter remaining in the stomach, they slightly diminish the fullness of the blood-vessels by increas- ing perspiration, and they serve to reduce sensorial power and lessen the morbid action, by making a counter impres- sion on the stomach. But in cases of fever, the stomach is often in such a state of torpor, that the operation of an emetic is too uncertain. And in cases of pregnancy and in such persons as are liable to apoplexy or hoemopthysis, it would often be unmfe. In addition to these exceptions, they some- times induce cramps and inflammation of the stomach. 102 SUPERIORITY OF BLOOD-LETTING. The effect of an emetic is not always under the control of the physician;—is often greater or less than is intended. Be- sides, even in fever of the mildest form, particularly in chil- dren's cases, we have been obliged to recur to the use of the lancet, after having used every effort to substitute emetic articles. Similar objections forbid a reliance on cathartics, in any case where blood-letting is clearly indicated. Purges dis- charge acrid foeces, and bilious secretions from the bowels, and when the system is in readiness, are of importance on other accounts, which in their place are as indispensable as blood-letting in its proper time and place, which will be ex- plained when we come to treat of cathartics. But in com- parison of blood-letting, when speedy depletion of the blood- vessels is desirable, they are uncertain in their effects. In many instances of constipation in fever, and particularly, when there is an inflammatory condition of the abdominal viscera, ounces of salts and castor oil, and drachms of calo- mel and jalap, have been administered without effect. A physician of good experience, cannot be induced to rely on cathartics in any such case. He will know, that a suffi- ciently copious blood-letting, and several repetitions of large bleedings are often necessary, before cathartic medicines can be made effectual. In cases which require accurate calcula- tion, they cannot be trusted, as to the time when depletion is desirable, nor as to the quantity; sometimes as to the kind of discharge which it would be desirable to accomplish. That is, they are not sufficiently under our control. More- over in many instances of advanced stages of fever, they are very unsafe. Scarcely a physician of experience can be found, who has not seen instances of death, which have suc- ceeded upon copious discharges by stool in debilitated habits, and under circumstances too, when there was good reason to have expected recovery, had not such evacuations occurred. Blood-letting is always preferable to sweating, as a deplet- SUPERIORITY OF BLOOD-LETTING. 103 ing remedy. The popular prejudice in favor of sweating, gained its hold on the public mind, when morbific matter was supposed to be the proximate cause of fever; and when a remedy once becomes popular, it is wonderful how long it will retain its reputation with a great portion of the commu- nity. The true philosophy of diaphoresis shall be submitted in its proper place ; when it will appear, that the evacuation of fluid, in reality constitutes but a secondary part of the intention, for which it is judiciously instituted: and of course, it is by no means worthy to be compared with blood- letting as an evacuant remedy. Besides, when there is a great need of diaphoretic treatment, blood-letting or possibly a decided repetition of it may be necessary, before diaphoresis can be properly established. Evacuation by salivation can never be in time to meet the demands of an acutely inflammatory case. And in any in- stance, to be useful in that respect, it must amount to one or two pounds a day. In cases of chronic affections of the head, we have seen it eminently serviceable, but in any or- dinary case, it is objectionable. It is not always to be pro- duced at pleasure, in all cases painful and extremely disagree- able, seldom or never popular; if unsuccessful, always cen- sured, except only, in cases reported by the physician to be hopeless, if treated in the ordinary way. And if there be any want of confidence, no apology will be received as satis- factory. The evacuation produced by blisters, is sometimes suffi- ciently great to be worthy of notice. But in any case of inflammatory action of recent date, especially in any instance occurring in a person of ordinary health and vigor, it never can be a proper substitute for blood-letting. Besides, when we come to examine the subject of epispastics, we shall see, that their good effects more frequently depend on increasing the ability of the skin to maintain its functional action, than in any wise on the evacuation which they produce ;— 104 SUPERIORITY OF BLOOD-LETTING. that the establishment of a blister or issue is instituted, not for the sake of evacuation, but for another very distinct and important purpose. In many cases, abstemious diet or total abstinence may ef- fectually resist a threatened attack of fever. But a decisive blood-letting would be a more certain and comfortable re- medy, and always is more economical, because it saves so much more time. None of the foregoing difficulties or ob- jections lie against blood-letting. It is speedy in its opera- tion and may be accommodated to the demands of the case, however hurried or imperious. It is completely within the control of the physician and may be employed when and where he pleases;—on a journey, if need be ; and moreover he can adapt the quantity, with the greatest precision, to the condition of the patient;—its performance gives the least possible trouble, and of course, requires the least possible attention from nurses and servants;—a circumstance which enables the physician often to aid the poor, who must perish, if their cases require much of the nurse's aid. It can be per- formed with the greatest safety in many cases, in which the agitation, effort and fatigue of either of the other modes of depletion, would be more than could be sustained. It is by far the most delicate and agreeable mode of evac- uating the system;—produces less prostration than an equiv- alent amount of depletion produced by the other methods • —and the convalescence which follows, is more certain speedy and perfect, after bleeding, than after the most suc- cessful use of the other evacuating medicines. Besides the employment of blood-letting does not preclude the use of any of the other agents that may be found necessary; and very often, it is absolutely requisite to use them all in quick suc- cession. THE PULSE AS A GUIDE IN BLOOD-LETTING. 105 CHAPTER X. ON THE PULSE, AS A GUIDE IN THE EMPLOYMENT OF BLOOD-LETTING. With the foregoing preliminary remarks in view, we pro- ceed to consider the circumstances which should regulate the use of the lancet. In the first place we have regard to the state of the pulse. 1st. A full and vigorous pulse, without tension; such as occurs in the yellow fever, gout and apoplexy. It was called by Dr. Rush, the synochus fortis pulse. To understand this specification, it is necessary first to consider the peculiarity of pulse which is intended, when it is said to be tense ; which as it is felt, makes an impulse on the finger, like a stretched cord, drawn tightly lengthwise, from the elbow toward the wrist. This synochus fortis pulse is highly important, and is often made out with difficulty. The state of pulse which most commonly and certainly indicates the necessity of blood- letting, is that which we have denominated tense. But this synochus fortis pulse, is not tense. It is full, making an im- pression on the sense of touch, which reports the arterial tube to be displayed to the full extent of its calibre, and which of course, implies a general fullness of the system, of which the skin in such a case will receive its proportionate participation. The arteries and veins are all full. It is also frequent, say from one hundred to one hundred and fifty, or even one hun- dred and eighty. A kind of motion, of which it is difficult for a young physician to form an adequate conception, until a few cases shall have occurred under his own observation, and thus have afforded opportunity to know it from experi- ence. Neither a fullness nor frequency, constitutes the most 1 106 THE PULSE AS A GUIDE IN BLOOD-LETTING. characteristic mark which defines this kind of pulse. It is full, frequent and vigorous, not much different from the pulse of a healthful man, who has lately taken a free potation of ardent spirits. The power of the sensorium is vigorous; the blood-vessels and nerves are in possession of nearly a full portion of vitality. But the whole system seems to be in a state of perturbation or alarm. There is manifest plethora, insomuch, that the system would seem to be overwhelmed in its own fluids, and is laboring with mighty effort, to keep up a degree of motion commensurate with the alarming oc- casion. And in fact, the danger consists of a great proba- bility of a speedy injection of the meninges, or a suffocation of some^one or more of the important viscera. Blood-letting, therefore, in such a case, serves to make immediate room in the blood-vessels; to give better scope to the circulation, and prevent the mischief which would soon follow. A case of this sort needs special care. For if blood-letting be in time, the cause of the stormy excitement still acting on the system, it must follow, that the state of the pulse, which was at the first full, frequent and vigorous, without tension will change its character on depletion, and when the reaction shall have occurred, there will be a degree of tension, presenting the case under a new aspect. So soon as this tension is suffi- ciently expressed, it will be the signal for further depletion; and as often as the tension recurs, especially if attended with pain, or soreness in any of the viscera, so often should the blood-letting be repeated. This last remark, however, is predicated on the supposition, that the first blood-letting shall have been effectual in changing the state of the excitement; and that the sensorial centres, nerves and blood-vessels, all retain a goodly portion of vitality, so that when the thraldom of plethora is removed, all the powers and organs of the sys- tem, at once come into free and vigorous action. And this is invariably the fact, whenever a second, a third or fourth blood-letting is found to be necessary. We have seen in- THE PULSE AS A GUIDE IN BLOOD-LETTING. 107 stances, however, which probably in the commencement were marked by this kind of synochus fortis pulse, but in the course of twelve hours, sometimes in less ; in twenty-four, or thirty hours, have become so languid, that a single blood- letting would have produced a fatal collapse. We have seen others in which blood-letting appeared to be the only hopeful remedy, but it was employed too late. And others again, have come under our observation, as to all appearances, equally unpromising, which were relieved by a well-con- ducted use of the lancet. In those neglected cases, which progressed most satisfactorily, the blood was drawn slowly, from a small orifice, and as the system was gradually light- ened, the blood flowed with a gradually increasing impetus. The distinction of appearances and circumstances, which might enable the physician to decide with certainty in such cases, when the system has been in thraldom too long, so as to render the blood-letting unsuccessful, and when we might venture with confidence to promise relief, have not yet been fully made out. And in a large majority of the cases, there must be uncertainty, as to the issue, till science shall have had more time and opportunity, to make the subject plain and easy. We repeat an epitome of this state of the pulse. It is full, frequent and vigorous, obviously expressive of great perturba- tion ; but not tense. In accompaniment with hot skin, wild- ness of expression in the eye, heaviness of respiration and other evidences of oppression. Such is the state of things in the onset of malignant fever. The system is in the condi- tion which is plethora; the remote cause is greatly stimulant, urging the heart to violent effort. The injection of the arte- rial system, is exceedingly great; the labor of the heart very oppressive, the sensorial influence being very rapidly ex- pended. The sensorium is soon prostrated partly by the exhausting demands of such excessive excitement, possibly more by the pressure made on the sensorial structures by the 108 THE PULSE AS A GUIDE IN BLOOD-LETTING. carotid arteries. The capillaries are hastily overbalanced by the flood of the circulation, or left decrepid by the tiring heart. The great viscera meanwhile in corresponding state. If sufficiently bled in time, the victim lives—if the intended relief comes too late, he dies. One fact more, however, ought to be noticed. Although we might sometimes use the lancet without success in such a case, other remedies, perhaps I may say all other remedies yet tried, have been found to be as often used without success, as blood-letting: so that on the whole, it may be safely inferred, that appearances are so nearly alike, when the system is approximating to the neplus ultra, and any short time afterwards, it is no just cause of disparagement, not to be able to know with certainty, the precise point or moment of time, at which, the case becomes incurable. ^To conclude this article, the best inference to be taken from the whole, is, that in all such cases, the sooner the physieian is sent for the better. Another state of the pulse indicative of blood-letting is "a full, frequent and tense pulse, such as occurs in the pulmo- nary, rheumatic, gouty, phrenitic and maniacal states of fe- ver." This distinction of the pulse is more readily made out than any other, and in the northern and middle states, most frequently claims attention. Contemplate the artery as being nearly or quite well distended at every systole, with a calibre of full size, and well charged with blood ; at every stroke making an impression, as if it contracted lengthwise, from the elbow to the wrist, and performing its impulse, as if with very considerable force, and you have the view of it, as it presents itself to observation on the first paroxysm of fever, of this description; in which state it will remain often several hours. But all the time it is permitted to remain in this state, there is continually increasing danger of great and fatal congestion. The danger of the full, frequent and vig- orous pulse, not tense, is, that of morbid distension and ge- neral decrepitude of the blood-vessels of the abdominal vis- THE PULSE AS A GUIDE IN BLOOD-LETTING. 109* cera, such as constitutes congestive fever of sickly districts. On letting blood on this state of pulse, as soon as it is well understood, the practice may be regulated with the utmost degree of exactness. The quantity of blood to be drawnr may always be adjusted to the demands of the case. And as accurately, if permitted to flow into a pit, as if measured in a graduated cup. The quantity necessary to be taken in any such case is, just so much as may serve to change the state of the pulse; that is completely to retire its tension. And however effectually it may be done, so long as any con- gestion or inflammatory disposition of the blood-vessels re- mains, there will be a recurrence of the tension ; sometimes at longer, sometimes at shorter intervals. In pleurisy, rheu- matism, and mania, sometimes in six hours, sometimes in twelve, and sometimes in twenty-four hours. If the blood- letting be effectually performed, so as to reduce the tension well, the interval of time, between the instances of recurrence of the tension, will be longer, till the fever will become pe- riodically diurnal, and at length it will disappear. If the tense pulse be neglected too long, it will not fail to ehange its condition. The injection of the arterial system may be- come so general, and the lohg struggle of the heart may so wear down sensorial energy, that the tension may with diffi- culty be made out. We have found the pulse in neglected pulmonitis, so very similar to a typhoid pulse, that we should not have been able to detect the indications of blood-letting, had we not been informed of the history of the case. But when such a state of things occurs in pneumonic affections, it is an interesting fact, that blood-letting changes the state of the pulse ; and after it has been repeated once, twice or thrice, the artery is expanded and filled, so that a pulse of apparently very doubtful character, a pulse which we shall denominate a chord-like pulse, becomes full, free and tense ; and not uncommonly, after the loss of blood enough to set the system free, the case becomes a plain and easy one, and 110 THE PULSE AS A GUIDE IN BLOOD-LETTING. probably will afterwards require more frequent repetitions of the practice than would have been necessary, if it had been instituted at the proper time. The notices which we have taken of this second distinc- tion of pulse, have thus far, all been presented in view of a supposed pulmonary fever, or other simply inflammatory af- fection of recent origin. There are other variations, and dis- tinctions, which occur in chronic affections of the lungs ; and when this organ is the seat of disease, the tension of the pulse is generally a conspicuous symptom, and a degree of obstinacy in its continuance, is the most certain evidence of a tendency to a fatal termination. Indeed so peculiarly, is the pulse disposed to be tense in pulmonary disease, that in phthisis pulmonalis it commonly continues till a very short time before dissolution. The proximity of the lungs to the heart, and the strong sympathy which obtains between them, may afford some explanatory thoughts, respecting this fact; but no consideration, perhaps, is so satisfactory as one which we will call a mechanical one. In the degree in which the pulmonary vessels become impervious, so of course will the struggle of the heart be increased and continued; in the de- gree in which the circulation is impeded in its passage through the lungs, so it will become deficient in its general distribution, and if this condition of the circulation be of long standing, there must of course, be a gradually increas- ing contraction of the arterial tubes, carrying with it the gradually increasing debility and universal emaciation,which attend on such a state of things. And at the same time that the calibre and extension of the arterial system are thus con- tracted and compressed, by reason of the want of the natural stock of vitality, which a better state of circulation would afford, the effort of the heart, as expressed through the mo- tion of the artery, will constantly be indictave of labor and resistance. And under all circumstances, a tense pulse im- plies this kind of mechanical or hydraulic resistance as~ it THE PULSE AS A GUIDE IN BLOOD-LETTING. Ill respects the motion of the heart; this view implies a diffi- culty in pressing the blood through the arteries to the capil- laries which gives origin to the veins, after the manner of a forcing pump, employed to charge a great number of tubes, ramifying, entwining and receiving lateral compression at their extremities. We have associated the appearances of things, particular- ly the expressions of the pulse, which occur in pulmonary, rheumatic, gouty, phrenitic and maniacal states of fever. This association will be found to be a very proper one, for there are times, in each of these modes of disease, in which the state of the pulse in any one of them, is very similar to what it is, in any other of the five diseases. In the commence- ment they are all very similar, and under similar appearan- ces will each require blood-letting, to an equal amount. In each of these affections, when once established, there is near- ly an equal certainty of reaction in the system, after copious bleeding. There is no hazard in proceeding very nearly, if not quite to deliquium. In each of these diseases, this kind of bold practice is useful, often necessary, and may be repeat- ed ; so also in each, we cannot do our patients justice, if the blood-letting be not carried far enough, every time of repe- tition, to put down the tension. In these affections more par- ticularly our doctrines will be found to admit of application, with an exactness, which approximates to scientific certain- ty, and in these we believe them to be most emphatically true. To these doctrines, in respect of the above named affections, we are compelled, after much careful observation, to adhere. As we held them forty years ago, with little improvement, except as regards some of their details, so we hold them now ; every year has furnished additional confirmation of their truth. The accuracy with which our experience has ena- bled us to apply the blood-letting 'practice to these cases, not only justifies us in the belief, that the same kind of practice might be employed in bilious malignant fevers; but, that suf- 112 THE PULSE AS A GUIDE IN BLOOD-LETTING. ficient skill in the tact of pulse feeling and adjusting deple- tion to the existing state of things, would enable the physi- cian to succeed in many cases, in which, with other views, he would fail, even in using the same remedies. Before we dismiss this point, we will say, that any man who hesitates to adopt this practice, in regard of those four diseases, must have erred in his manner of making observation, or has not seen a sufficiency of the practice, to be a judge of its supe- rior worth. The wonderful extent to which blood-letting may be carried in them, safely; the reiterated necessity of repeating the operation; and the certainty with which many cases are cured, and all more or less relieved; all concur to sustain the opinion, that these diseases, having suitable res- pect to each in view of its particular modification, are all in- trinsically resident in the blood-vessels. When a ease of this sort is permitted to progress, that state of things which we denominate congestion, almost invariably occurs. When this shall have happened, it is important that it should be understood. In the onset of pulmonitis, we let blood freely with intention to reduce the impetus of the heart, and to prevent any further extension of the lesion. For the same reason the blood-letting is repeated, as often as the reaction is sufficiently potent to endanger the injured vessels;—still looking for the co-operation of the absorbents, for the remo- val of any misplaced fluids which may have been extravasa- ted, or accumulated in the distended capillaries. And whilst the case is recent, the diminution of arterial pressure, aided by the elasticity of the vessels, and the improving state of the organs intended to give transition to the fluids over from the arteries to the veins, will be found speedily adequate to the recovery of health. Indeed in some cases, when it was scarcely probable, we have seen the most speedy and perfect relief. But when the system has not been aided by timely blood- letting, and extensive congestions have been permitted to THE PULSE AS A GUIDE IN BLOOD-LETTING. 113 take place, all the precautions given in a former chapter will be necessary. The blood-lettings will be more cautiously performed and in less quantities; and more reliance will be placed on the recuperative powers of the absorbents. The de- cision which would be proper in the former cas», would be dangerous in a case of this sort. In the commencement of a pulmonitis, it is particularly desirable to avoid every sort of irritation. We endeavor therefore at the commencement of every paroxysm, to reduce the action and retire the pain. In neglected cases, it is important that the congested tissues should feel the inconvenience of each exacerbation to a suf- ficient extent, to maintain their vitality, and excite the ab- sorbents to the necessary action. We deplete therefore, with the intention to keep the arterial action sufficiently subdued, but duly take care to let the fever rise sufficiently to irritate the congested vessels and excite the absorbents. By this method we retire the misplaced or extrayasated fluids, and the injured vessels gradually return to their natural state and recover a due degree of tone. In a case where we can meet the first exacerbation, we would let blood nearly to deli- quium, and repeat the blood-letting on the rise of each sub- sequent paroxysm;—that is, forestall its rise. In a neglected case, we would permit the return of the paroxysm to be well displayed, before we would repeat the bleeding; that is, we would let the fever fairly show itself before we would again deplete. For many years, we have employed blood-letting as a most valuable means for the removal of chronic affections of the viscera; whether thoracic or abdominaL Sub-acute in- flammation as well as that which is most acute, needs to be treated by blood-letting, either by means of the lancet or by cupping or leeching. When the action of the heart and ar- teries is kept sufficiently subjugated, the absorbents gain the; ascendency, and long standing congestions are removed. 8 114 ADDITIONAL REMARKS ON THE PULSE. CHAPTER XI. ADDITIONAL REMARKS ON THE PULSE, &c. Another distinction of pulse, indicating the necessity of blood-letting, is " a full, frequent and jerking pulse, without tension, such as often occurs in the vertiginous, paralytic, and hydropic states of fever." This description of the pulse, like the first which we have noticed, is described with diffi- culty, so as to make it intelligible to an inexperienced physi- cian. The association of diseases, is given in reference, for the purpose of explanation. A peculiar fullness of the vessels of the head, produces the embarrassment of the circulation, which that state of things would imply; nearly the same might be looked for in a case of dropsy, in which the whole system is oppressed. In affections of this sort, blood-letting can hardly fail to afford some relief, and the subsequent rep- etitions of the practice, must depend on the effect, as to the state of the pulse at the first and the subsequent bleedings. If the practice be proper, the frequency of the pulse will not be materially increased by it; nor will it be followed by any signs of increasing prostration. If it promise much benefit, the frequency will be diminished and the peculiar jerking will cease, inasmuch as the pressure which produces it, re- tires as improvement is made, from time to time, by the blood-letting. The peculiar quickness and struggle, which is intended by calling it a jerking pulse, is particularly re- markable, and yet it is so, only in a comparative sense, and will be pretty readily discovered by one in habits of feeling the pulse, so as to be able to apprehend the comparative dif- ference. The first description, is supposed to exist in apo- plexy, which we have described, full, frequent and vigo- ADDITIONAL REMARKS ON THE PULSE. 115 rous; the vertiginous, paralytic and hydropic pulse, is de- scribed as being full, frequent and jerking. The former is an account of it, in those alarming and overwhelming affec- tions, which soon find a termination, like apoplexy; the lat- ter as it is exhibited in those instances which are similar, but always give more time; so that the degree of vigor which marks the impetus of the systole, in the former case, is di- minished, and the vigorous motion is exchanged for the jerk- ing motion, which describes the latter. Another distinction of the pulse which requires blood-let- ting, is " a small, frequent, but tense pulse, such as occurs in the chronic pulmonary and rheumatic states of fever, and in neglected enteritis." We have given a pretty full account of the tense pulse, in our second definition. In this place we will add, that a tense pulse may be considered as the most infallible, of all the known symptoms, which indicate the propriety of blood-letting ; yet the smaller and more frequent the tense pulse is, the greater the circumspection necessary as to time and the quantity of blood to be drawn ;—especially, upon the first bleeding. It is important that no more should be taken at the first, than is barely sufficient to change the expression of the pulse ; inasmuch as there may be very ex- tensive congestions, and if the circulation be too much re- duced at once, the vitality of some portion of the congested vessels, might be endangered ; in which case, the frequency would be increased by the bleeding; and symptoms indica- tive of dissolution would soon follow. This precaution is more particularly important in cases of pulmonary affections. If the blood-letting promise to be useful, in the course of a few hours the system will react with a return of the tension ; —and as often, as the reaction is considerable, with distinct tension, so often, the blood-letting is to be repeated. In such pulmonary affections, there is also more or less pain or soreness, which affords additional aid in determining the pro- priety and necessity of depletion. The recurrence of the 116 AEDITIONAL REMARKS ON THE PULSE. pain, will pretty uniformly be periodical, growing worse,. regularly, every day, about eleven or twelve o'clock; and about the same hours at night. It should therefore be the business of the physician, to be present about those hours, in order to timethe remedy in accordance with the periodical movements of the disease.. It will be found moreover, that whenever the pulse is thus frequent and tense in pulmonary affections, the skin will be imperfectly supplied with circu- lation ; and that we might carry the blood-letting further than necessary, if we neglect the use of measures calculated to maintain the skin in a proper condition. Early and exten- sive blistering, repeated so as to make the irritation continu- ous, is necessary in all cases of this sort. As to rheumatism, when it takes-on the condition of pulse here described, and when it will be proper to consider, it as subacutely inflammatory, very nearly the same kind of prac- tice will be found necessary in every instance. We have said when it should be considered to be subacutely inflam- matory. Rheumatism has been divided by nosofogists into two distinctions, inflammatory and chronic. In the first, directions are given to let blood and administer antiphlogis- tic medicines. In the other, an opposite plan of practice, of course, is deemed necessary. No modern physician of good information and experience, will subscribe to such distinc- tions or practice. They all know, that rheumatism, after it has continued for months, may be inflammatory, attended with " a small, frequent and tense pulse," and require topical bleedings, sometimes frequent repetitions of them : and that such cases will not yield with readiness,, if at all, without this kind of practice. Another and highly important distinction of pulse,, we shall designate as cord-like. We give it this appellation as being most expressive of the impression made by it, on the sense of touch. It feels like a loose cord, which can with great ease be made to slide from, side to side of the space com- ADDITIONAL REMARKS ON THE PULSE. 117 monly occupied by the pulse, and is more or less incurvated, as if longer than the arm. In this last particular, it is the reverse of a tense pulse. When full, frequent and tense, it always implies danger of a speedy congestion. The action of the heart and arteries is vigorous, and while struggling al- most to weariness, the tension irritates and excites them to frequency of effort; and if this state of things be suffered to continue, pernicious congestions or an established irritation, must soon follow. When either of these circumstances shall have occurred, the full, frequent and tense pulse, will become small, frequent and tense. If however the amount of injury be such as that it can be sustained a sufficient length of time, the violence of the heart's action will abate, and the tension of the pulse will gradually be exchanged for the cord-like state; leading an inexperienced observer to suppose the change to be, the commencement of convalescence. A large proportion of chronic diseases, almost all of the affections of the viscera, which are subacutely inflammatory, present the pulse in the cord-like state. It will be found to obtain in a large majority of fevers and other diseases, which may have required more depletion than the- attending physician would allow, and in which nature has been left to make her own adjustments, whilst the tissues of vessels were remaining in a state of congestion. Thus an inflamed eye, left to recover without the aid of sufficient depletion, may at last be relieved of pain and of the common appearances of inflammation, but the coats of the organ are thickened, the cornea is more or less opaque, and a very slight cause readily excites renewed inflammation. In a similar manner, if congestion or irritation be not entirely removed by means of sufficient depletion, the symptoms of an inflammation readily recur. And if the cord- like pulse be felt, in any case thought to be convalescent, let the attending physician be admonished of his mistake. There will certainly be consecutive mischief;—either a re- lapse or permanent invalidity will follow. A subacutely in- 118 ADDITIONAL REMARKS ON THE PULSE. flammatory condition of the sensorial structures, under such circumstances, will be followed by permanent head-ache;— a similar condition of the thoracic viscera, will be followed by a condition of things tending to phthysis;—or of the liver, by a condition tending to chronic hepatitis;—or of the stom- ach and lower intestines, by the symptoms constituting the various aspects of dyspepsia, &c. &c. All these evils, have been consequent on a timid or too sparing use of the lancet. Most of the instances of hypertrophy are produced by the same cause. The blood too long detained in any portion of the capillary structures, serves to institute a morbid applica- tion of the function of nutrition. The morbid process when once established, progresses indefinitely, till arrested by al- terative means; which ought to be employed in association, with suitable attention to the condition of the external capil- laries, till health shall be recovered. In pursuing this plan of treatment, it commonly happens, that the material taken up by the absorbents, through the influence of the alterative agents, renders the fluids sufficiently stimulant, or the blood- vessels, by the practice, become sufficiently irritable, or the two circumstances combined, serve,.to institute a new action ; blood-letting then becomes admissible and the character of the pulse is changed ; the cord-like condition begins to retire, a tendency to the tense state returns, and by a judicious con- tinuance of alterative means and an occasional blood-letting, the chronic affection is eventually corrected, and the pulse assumes its natural state. There are instances forming ex- ceptions to these remarks, respecting the cord-like pulse. Some are found, who having been invalids for years, enjoy their usual share of health, whilst the pulse is habitually and uniformly cord-like. So also men and women, who have been accustomed to hard labor for many years, and particu- larly such as have regularly used alcoholic drinks, or have for a long time smoked or chewed tobacco, in like manner have the same kind of pulse, and seem to have a pretty good! ADDITIONAL REMARKS ON THE PULSE. 119 portion of health. In the last eventually, as years increase in number, many furnish instances of induration of the arte- rial structures, possibly of ossification;—when the pulse felt at the wrist presents a knotty condition as of a line of beads strung at unequal distances. Perhaps most of these cases, may have been affected with fever—an irritated state of the blood-vessels may have been permitted to run through a long continued course, and at length an imperfect kind of recov- ery, made habitual by continuance is established, leaving the arterial tubes in this peculiar condition. The subject merits further attention. Another description of pulse requiring blood-letting is a " tense and quick pulse, without much preternatural frequen- cy." " This state of pulse is common in the yellow fever." We have met with a few cases only, corresponding to this definition. The pulsation is performed at intervals of time equally divided, and at the rate of seventy or eighty strokes in a minute. But the manner of it has a peculiarity, which is, perhaps, as fully described by the definition as it can well be. It is tense, with a peculiar suddenness of action, of which a very inadequate conception can be formed by any one who never felt it. Another description of pulse requiring depletion is a slow and tense pulse, such as occurs in the apoplectic, hydroce- phalic and malignant states of fever; in which, its strokes' are from sixty to ninety in a minute." A moderate degree of acquaintance with the nature and indication of an ordi- nary tense pulse, would prepare any physician of tolerable information, to meet a case of this sort with his lancet, and repeat the use of it, with becoming decision. The seats of the disease, the unequivocal signs of fullness, together with the force which tension always indicates, would be consid- ered sufficient proof of the necessity of this potent remedy. We occasionally meet an uncommonly " frequent pulse without much tension, beating from one hundred and twenty 120 ADDITIONAL REMARKS ON THE PULSE. to one hundred and seventy or eighty strokes in a minute." " This state of the pulse likewise occurs in the malignant forms of fever. It is not peculiar to malignant fevers, how- ever. It always implies great plethora, and a perturbation of excitement, which calls for a speedy evacuation; and if relief be afforded in this way before a fatal disorganization takes place, the frequency is often lessened by the first cautious bleeding, and commonly, upon the retirement of this great frequency, the character of the pulse will change, so as to place it entirely under another head of description. The bleedings for a day or two should be moderate in quantity and timed with great circumspection. These last remarks in reference to frequency of the pulse as an indication requi- ring blood-letting, are intended to apply to incipient cases only. When the system has been broken down by disease ; when great prostration is consequent on a fever or other affection about to terminate in death, we scarcely need to add, that no man in his senses would think of letting blood. In some instances the pulse is " soft, without much fre- quency or fullness." This state will be met in affections of the brain, in bronchitis, and sometimes, in a sub-acute inflam- mation of the abdominal viseera. In cases of this kind, the pulse often becomes tense after bleeding, and then may be treated as any other instance of similar expression. This state of things, as well as the foregoing, requires very great circumspection. The first bleeding in most instances of either of the two, should be performed with a sparing hand, and the physician ought not to leave the bed-side of the pa- tient, until he is sufficiently informed, respecting the effect of the operation. For, in all such cases, if the reaction be slow and imperfect, the practice should be of the mixed kind;__ suitable, mild excitants, as hot drinks, external application of heat, sinapisms and epispastics, should be associated to insure ihe reaction;; and then the depletion should go on according ADDITIONAL REMARKS ON THE PULSE. 121 to the demands of the case. Let the patient sit erect whilst the blood is flowing. Again, there is an " intermittent pulse." It ought to be remembered, however, before we lay too much stress on this circumstance, that with some particular constitutions, this ap- pears to be habitual, and with most old people it is so. In many cases of old persons, whose pulses habitually intermit, so soon as there is feverish action to a degree requiring blood- letting, the intermission disappears, but returns again after depletion, and its reappearance is the best indication of recovery. Much remains to be learned on the subject of the pulse, and particularly in view of diseases of the head. Mr. Hun- ter, in his treatise on inflammation, chapter III, section 9, observes, that " in inflammation of the brain, the pulse varies more than in inflammation of any other part; and perhaps we are led to judge of inflammation there, more from other symptoms, than the pulse." The slow, uncommonly fre- quent, intermitting and imperceptible states of the pulse, which require blood-letting, may be distinguished from sim- ilar states, when they accompany an exhausted state of the system, and of course forbid blood-letting by the following marks: They occur in the beginning of a fever and under circum- stances which would have led to the expectation of a very different state of things. They occur in the paroxysms of fevers which have remis- sions and exacerbations;—of course, if we should hesitate at the first, the next paroxysm will enable us to decide with fearless confidence. They sometimes occur after bipod-letting, in consequence of the additional power with which the arterial system pro- pels the circulation for a time, after having been released from thraldom by blood-letting. They sometimes occur and continue throughout the whole 122 ADDITIONAL REMARKS ON THE PULSE. course of an inflammation of the stomach and bowels. A small, frequent and tense pulse, seems to be pretty commonly one of the characteristics of inflammation of those organs. And finally they occur in cases of relapse, after the crisis of fever. If the disease in the first onset needed blood-let- ting, and more particularly, if it called for a repetition of the practice, the same will commonly be necessary in case of a relapse. Sometimes it happens, that fever appears to terminate kindly, when the depletion may have been too sparing, but so soon as the patient is permitted to take nourishment, symptoms take place like a relapse, and in a very imperious manner again call for blood-letting. Such circumstances often occur to females, about the second or third week, some- times at a later period, after parturition. DIRECTIONS FOR FEELING THE PULSE. 123 CHAPTER XII. DIRECTIONS FOR FEELING THE PULSE. It will be observed by the reader, that the great variety of considerations which have been submitted in respect of the pulse, would necessarily imply, that an occasion would be ta- ken to give some instruction as to the manner of feel- ing it. Let the arm be placed in such a position, as shall serve to relax the muscles and prevent any pressure upon the artery in the axilla. This is most effectually done, by directing the patient to lie on his back, or nearly so, during the time of the examination. Take the necessary time, and feel both arms, especially in all difficult cases. Lay hold of the patient's wrist, in such a manner as to be able to apply all the fingers of one hand to the pulse. This we have often found of great use in very difficult cases. In order to obtain the advantage to which we refer, it will be best to feel the left hand of the patient with our right, and the right with our left. But we should remember the possibility of an error loci of the artery. It is often ramified near the wrist, one branch only retaining the ordinary location. We ought not to decide upon blood-letting in difficult ca- ses, till we have felt the pulse for some time. We should feel it at intervals of five or more minutes, whenever we have cause to suspect that its condition may have been varied by any contingency not properly connected with the disease ; such as emotions of the mind, which may be produced by our arrival, or by the conversation or deportment of friends, or by-standers. If any recent exercise have been taken, or if 124 DIRECTIONS FOR FEELING THE PULSE. the patient have lately been eating or drinking, all these cir- cumstances ought to be taken duly into consideration. If the pulse cannot be felt at the wrist, we may try the carotid, temporal, or femoral arteries. In difficult cases, we request silence in the sick room, and close our eyes whilst we feel the pulse. In this way we concentrate the power of all our sen- ses in our fingers, and our sense of feeling will be more acute. These general rules were observed by Dr. Rush, and we have regarded them with Tittle or no variation for forty years. In exercising our judgment according to the various states which have been enumerated, and with a reference to the rules which have been laid down, it will be proper to notice the difference in the frequency and force of the pulse, morning and evening ; between sleeping and waking; between a full stomach and inanition. But after all that has been advanced, perhaps the greatest difficulty is, to determine on the necessity of blood-letting, in cases where the pulse reports no sign of disease. One general observation may be of use here. If the disease be of recent date; the part affected be one of the organs impor- tant to life, and one which cannot sustain violent morbid ac- tion, without danger of lesion; if the pain be great and respi- ration difficult; if there be redness of the face; watery, live- ly, or suffused eyes; in such cases the pulse may be disre- garded in determining to use the lancet. Dr. Sydenham added to these a flushing of the cheeks, the escapement of a drop of blood from the nose, and an obsti- nate continuance of a hot skin. But all these marks of Dr. Sydenham are uncertain, and must not be taken for guides without the support of the foregoing rules and indications. It is always important to have regard to the generally pre- vailing temperament of the season, as it may be discovera- ble in our every day practice. There is some difficulty in making ourself understood in this particular. Dr. Rush taught, that regard should be had to the character of the DIRECTIONS FOR FEELING THE PULSE. 125 reigning epidemic, in deciding upon blood-letting. In at- tending to this important admonition, we have acquired the habit of applying the rule to current appearances, as they occur in the round of the season, and are now satisfied, that it is a most useful kind of observation. Dr. Sydenham was convinced that the " atmosphere took on various constitu- tions;" that the variations were produced by extensive evo- lutions, or exhalations of some kind of gas, which proceeded from the bowels of the earth; and that these exhalations produce and govern epidemic diseases. The seasons do vary. The condition of the atmosphere no doubt undergoes such changes as may make important difference in the condition of animal and vegetable life. The physical circumstances which tend to the production of cold or warm temperature, of seasons favorable or unfavorable to luxuriant vegetation; of modifications in respect of electri- city and caloric, and the course of wet and dry weather;. these circumstances affect the ethereal influences, and the proximate or constituent principles which enter in the ali- ments of men, in such a way, that the same persons, the members of the same family, the inhabitants of the same city or district of country, will need blood-letting some seasons under appearances which, in other seasons, would not call for loss of blood. But all these agencies or influences are out of sight, and the only notice we can take of them is> that such variations of general temperament do Occur.. For ourself, we make daily observations in reference to the probable changes which are thus brought about. In letting blood, in a number of instances, apparently under similar circumstan- ces, regarding the same rules and principles of judging, we learn very often, that blood-letting is less important in one month than in another; in one season than in another ; all appearances being the same. But our judgment becomes modified by continued comparative observation^ so that we are seldom taken by surprise by changes in the general, type 126 DIRECTIONS FOR FEELING THE PULSE. of fever. If then, by general observation, we may have as- certained that a disposition to inflammatory action obtains generally, bleeding may be used with more safety and ad- vantage in cases where the indications of it from the pulse, are more or less doubtful. The pestilential fever which fol- lowed the plague in London, in 1665, Dr. Sydenham says, yielded only to blood-letting. Dr. Rush was of opinion, that it is equally necessary in all the febrile diseases which suc- ceed malignant fevers, for many months. We have moreover to regard the seasons of the year, and the state of the weather. It is more frequently and copious- ly indicated in the winter and spring, than in summer and autumn ; and in dry than in wet weather. This last is very worthy of notice, and it accords with our views of reaction, which will always be found to be materially affected by wet, or even cloudy weather." This was noticed by Dr. Huxham, who remarks, that it is a fact observable in diseases of the chest. The constitution and habits of the patient ought also to be regarded. A person known to be plethoric, and in habits of blood-letting, will need the remedy in instances and circum- stances in which others might safely do without it. And persons of a lymphatic temperament, and especially such as are corpulent, must be bled more cautiously and sparingly, than those of sanguineous temperament and habits of body. Of persons of similar temperament, those who are of larger structure can lose more blood than those of less. And in persons between fifty and sixty years of age, more blood may be drawn at once, than from similar persons in middle life, in similar diseases. In persons over seventy, we must use very great discretion, as the pulse is generally full, and the blood, when drawn from such persons in health,'will imi- tate the appearances which we would expect in inflammato- ry action. Regard must be had to the country or place in which a person affected with fevers resides, or where he may have re- DIRECTIONS FOR FEELING THE PULSE. 127 cently resided. Fevers in America are more inflammatory in persons of similar rank, than in Great Britain. And in those from the interior, than in those who reside near the sea- board, in the western states. Ship-captains from this coun- try, have had the misfortune, when sick of pulmonitis in London, to be so treated, that their diseases have terminated in abscesses of the lungs, though attended by the ablest phy- sicians of that city. One or two bleedings, have been trusted, when six or eight have been necessary. And it is a fact, that recent emigrants from England or Ireland, commonly require decisive blood-letting, when they sicken in Balti- more, and the southern States, &c* We must also have regard to the structure and relative sit- uation of the parts or organs, which are the seats of diseased action. The brain, because of its paramount importance to all the functions of life, the rectum when highly inflamed with hemorhoidal tumors, or other inflammatory affection, the bladder, the trachea, and the intestines when affected with inflammation, either from strangulation or other causes ; hernia humoralis; all require more copious bleedings than diseases of the same degree of intensity in the lungs, or oth- er parts of the body, because they are so much out of the in- fluence of the general circulation. In these remote parts, it would seem, that injections bordering on conjestion, or that a conjestion when really established, will, remain and con- tinue their tendency to destruction, until the depletion shall have been so complete as to take off almost the whole pres- sure of arterial action. Sudden relief cannot be produced ; and therefore, we must rely on the absorption which will eventually be excited by the irritation of the parts; the arte- rial action first having been properly subdued. * We mean, having arrived in health, and remained in healthful condition long enough to have come under the influence of our climate. 128 WHEN THE LANCET SHOULD BE CAUTIOUSLY USED. CHAPTER XIII. CONSIDERATIONS FORBIDDING THE USE OF THE LANCET, OR REQUIRING A CAUTIOUS AND SPARING EMPLOYMENT OF THAT REMEDY. Pains having been taken to show how extensive the ne- cessity and benefits of blood-letting, and to designate the points and distinctions, which are to regulate its use ; it will be equally necessary, that we should mention some of the circumstances and states of fever, in which it is forbidden, or in which it should be cautiously or sparingly used. There are instances in which the brain or viscera are in such a state of congestion, that the whole system is prostrated, be- low the point of reaction. Something like this probably oc- curs in those cases, when the pulse becomes imperceptible in the early stages of fever ; and when there is a stagnation of the circulating fluids. The skin and superficial veins being nearly or altogether emptied of their blood, a cold and clam- my state of the surface, with the appearance of a livid hue about the mouth and eyes, make it obvious that the abstrac- tion of blood not only would be improper, but if it were at- tempted, could not be accomplished. This is the state of things, in what is called congestive fever, in the south and west. In such instances suitable measures must first be taken to rouse the capillaries of the skin; extensive sina- pisms, sometimes covering the thorax, abdomen and extrem- ities ;—flannels wetted with whisky or vinegar aided by heat and capsicum, &c. &c.;—or spirits of turpentine or Gran- ville's lotion ;—hot drinks slightly stimulant;—injections of turpentine or capsicumi;—or spirit and water may be used as there may be occasion. In almost any such) instance so soon as we shall have succeeded in exciting the capillary WHEN THE LANCET SHOULD BE CAUTIOUSLY USED. 129 action, blood may be drawn; but always, in such cases, in small quantities at a time ; sometimes we should rely on cups and leeches only; making the application according to the seat of the disease, if it can be satisfactorily located. The practice conducted in this way, will favor a little the circu- lation of the blood in the viscera, and the blood will become more equally diffused. With the return of the blood, trie nerves will be revived, and blood-letting may be performed in the ordinary way and repeated as there may be occasion ; and all subsequent appearances will be such as usually occur, and such as they would have been, if the suffocation which had given the alarm, never had taken place. Blood-letting is seldom proper in a case of malignant fever, after the third day: the congestion, by that time, will be found to have nearly extinguished the vitality of the dis- tended vessels, or to have brought them so nearly to such a condition, that they cannot sustain blood-letting. In such cases, the blood-vessels will not afford proper indications for the use of the lancet, and if there be any possibility of relief, it is to be had in the use of external heat, sinapisms, blisters, gentle cathartics, and management. Blood-letting is to be performed with great circumspection in intermittent fevers. It ought always to be carefully timed. When the patient shall have gone through, the chilly, hot, and sweating stages, very often, a degree of de- bility prevails, so great, that a moderate blood-letting might endanger life. Further instructions will be given in another place. Bleeding is forbidden in most instances, when the pulse is weak and frequent, such as we often meet in typhus gravior; in the plague; malignant sore throat, &c. In such cases, we rely on sinapisms, gentle emetics and purges, and after- wards on cordials. In the subsequent use of cordials an op- portunity is afforded to ascertain, whether the viscera are all in readiness for action. If not, the cordial treatment wil'< 9 130 WHEN THE LANCET SHOULD BE CAUTIOUSLY USED. produce symptoms, which will report the necessity of blood- letting, which when commenced, will be followed by appear- ances, such as attend on depletion properly employed in any other circumstances. We must be very circumspect in prescribing blood-letting m any disease of habitual drunkards. Such are often affected with apparently violent attacks ; but they commonly recover with surprising facility. It may be said, that they are accus- tomed to morbid action. Their animal powers are trained to battle ; insomuch, that morbid action is the ordinary state of their blood-vessels, and unnatural distension their ordinary condition. And hence, probably, the danger of bleeding them under common circumstances. Habitual distension has deprived the arteries of their elasticity, and probably of their natural sensibility; consequently, they require unnatural dis- tension in order to keep the capillary vessels supplied. There is danger of an immediate sinking into a state of irrecovera- ble prostration, or of mania a potu. After an inflammatory affection shall have determined in suppuration, it is ordinarily improper to repeat blood-letting. I;i an instance of angina tonsillaris, for example, blood-letting after the commencement of suppuration, serves only to retard its progress. As the arteries are the agents in the secretion of pus, the reduction of their action tends to retard the pro- cess. In applying this as a general rule, regard must be had to the state of the system; for it is also possible, that the arterial action may be too strong for a kindly suppurative process; and then blood-letting would be particularly useful. In pneumony, after a copious expectoration shall have taken place, further blood-letting is unnecessary. But if coughing be again attended with pain, and there be a recur- rence of a tense pulse, or of difficult and sparing expectora- tion, blood-letting must be resumed. Blood-letting may be dispensed with, in cases of disease, whose progress is such as to afford the necessary time to WHEN THE LANCET SHOULD BE CAUTIOUSLY USED. 131 wait for the indirect or circuitous effects of purging and ab- stemious diet. It requires circumspection, however, to guard against mistake. If we give intimation on the first visit to a patient, that recovery may be expected from the use of very mild remedies, and it shall turn out, that we have erred in our judgment, possibly when too late, we shall be driven to the use of the lancet and other potent remedies, it might prove highly injurious to the profession. When we discover a great and constitutional dread of the operation, and there is no good evidence of danger to life from the omission of blood-letting, in most instances, it would be prudent to avoid'it. Sometimes the effect of the operation on the nerves of the patient may be serious. We once saw a child alarmed into instantaneous convulsions, from being bled with a spring lan- cet when asleep. We say, in course, let the patierit be awake. . It is commonly thought that the appearance of sizy blood invariably warrants a repetition of blood-letting. But this is certainly an erroneous opinion. We have so often seen the contrary, and have so constantly found it necessary to regu- late our practice by other and better guides, that we seldom ask the attendants- to preserve the blood for our subsequent inspection. In fact, after the fourth or fifth and ordinarily the last necessary bleeding, in case of pulmonitis or rheuma- tism, the buffy appearance is very commonly more conspicu- ous than before. In autumnal fevers it will be found, com- monly, that one bleeding is sufficient, and yet in most in- stances, the blood will be buffy. The same thing occurred under the observation of Sir John Pringle, in the hospital fever; and in some instances the blood will put on that ap- pearance when drawn from a patient in consumption a few hours before death. A tense pulse does not always call for the use of the lancet. Perhaps every case of incurable tuberculous consumption 132 WHEN THE LANCET SHOULD BE CAUTIOUSLY USED. will be attended by an incorrigibly tense pulse. In cases of this sort, we may repeat the blood-letting however often, and no improvement will be gained as to the state of the pulse. There are also instances of affections of the head and of the liver, in which the tension of the pulse is equally unconquer- able by blood-letting. In either of these cases, the repetition of the remedy, must be regulated by other indications beside a tension of the pulse. And when the physician keeps the watch with the necessary care, he v/ill be able to judge of the presence or absence of plethora or of the arterial force which will justify blood-letting. In deciding this matter in any such case, regard may be had to the quantity of food taken daily, the efficiency of the blood-making organs in the process of digestion, &c. but particularly the success with which the loss of blood is repaired. Without this kind of circumspection, the life of the patient may be improperly shortened. There are instances in which the sensorial influence is morbidly directed upon the arterial system, apparently at the expense of the absorbents;—the pulse is tense from the be- ginning of such cases, to their termination in death. Such is the fact, sometimes, when great and alarming hemorrhages occur. If the patient be of the lymphatic temperament, and having much flesh, this will be the case, probably, in any in- stance of hemorrhage to which such persons may be liable. BLOOD-LETTING IN PREGNANCY, ETC. 133 CHAPTER XIV. ON THE USES OF BLOOD-LETTING IN CASES OF PREGNAN- CY AND PARTURITION. Having at length brought to a close the general therapeu- tic principles and precautions, in respect of blood-letting, we we shall now briefly invite attention to some remarks on the application of the remedy to some diseases, which are con- sidered to belong to the class of fevers and which we may not have an opportunity to notice, sufficiently, in any other place. In pregnancy it is often necessary, and is top commonly omitted. All the considerations which concur to prove the necessity of bloodletting in diseases of the viscera, apply to pregnant women, and much more; because of the incessant and continually increasing mechanical pressure, made by the growing foetus. When we have been introduced into an in- timate acquaintance with the affections and sufferings of the fair mothers of mankind, we hear of the many precautions against taking cold in child bed. Puerpal fever is almost without exception, consequent upon a diseased state of the viscera, produced by pressure and constipation. An inflam- mation of the uterus alone, is a very rare affection. We have not seen it more than ten times in thirty years. Even when fever has occurred to lying-in women six weeks after partu- rition, we have been able to retrace its predisposing cause, to the mechanical pressure and constipation ; to effects of pres- sure made by the fcetus. Perhaps he ought to add, that the kind of pressure of which we now speak, very commonly. 134 BLOOD-LETTING IN PREGNANCY, ETC like certain chronic affections of the liver, or diseases of the mesentery, is accompanied with a sensation like hunger, on account of which, the patient is lead to eat inordinately. Af- ter continuing this practice for a season, she complains of feel- ing empty if she do not eat very frequently; and this contin- ued inclination to eat, serves to beguile the unsuspecting vic- tim, till the injury sustained by fullness and pressure, be- comes incorrigible. It is attended, however, by daily head- ache, cholic, lassitude, and frequently by pains in the lower extremities; and as the danger increases, by thirst, restless nights, alarming dreams, and great fears as to the issue of parturition. In every such case, frequent bleeding, aided by appropriate cathartics, are indispensable, and if well conduct- ed, are almost infallibly sure of success. These remarks go to show, that almost any disease which is commonly treated with blood-letting, will therefore re- quire it more abundantly when it occurs to a pregnant wo- man. The well known practice in eclampsia is one instance in proof of the correctness of this remark. After having so strongly encouraged blood-letting in cases of gestation, perhaps, we ought to add by way of precaution that there are instances of an opposite or reverse character, which would be injured by blood-letting, and which require the regular use of cordials; taking an occasional dose of castor oil, or magnesia, or sulphate of magnesia, as it may be found by experience, best to suit the patient. Parturition, when it is marked with convulsive or clonic action in the uterus, and is accompanied with chills, heat, thirst, a quick, full, tense, or a frequent and depressed pulse, and great pain, is a disease of serious importance, and requires blood-letting and evacuation of the bowels. The labor will not progress kindly, until the system shall have been thus aided by the necessary evacuations. But we do not consider parturition, in its perfectly natural state, to be a disease. We have seen BLOOD-LETTING IN PREGNANCY, ETC. 135 it occur under circumstances, very moderately inconvenient; and the woman has been able to rise the next day. It is known, that in the Brazils, Calabria, and some parts of Afri- ca, it is scarcely regarded. The Turkish women too, by a very free use of sweet oil, reduce thteir systems to a degree of convenient relaxation, so as to make it a small matter to bring forth their children. We have been credibly inform- ed, that women who having removed from the North to the States of Missouri and Mississippi, have found a very great difference in their favor. The rigidity therefore, which makes parturition difficult, and which seems to be the result of cli- mate and manner of living, together with the consideration in respect of the inevitable mechanical pressure which has been already noticed, are the causes which produce the ap- pearances of disease in parturition. If the system be already predisposed to fever, and is compelled to struggle long and hard, with a rigid os tincce and os externum, the reiterated struggle will produce fever; and the degree qf fever will be in proportion to the extent of these two particulars. When it is considered, that parturition is always attended with un- common facility if the patient has been previously ill with some disease which has required copious blood-letting, espe- cially if a short time only before lying in, and that those ap- pearances which call for blood-letting in other circumstances, would report it doubly necessary in any case of parturition, it is presumed, that we shall feel the necessity of meeting ap- pearances of disease in any such instance with the. necessa- ry decision. That is to say, we would take sixteen to twenty or thirty, or even eighty ounces of blood, keeping in recollection the precautions which are proper in other diseases. Inanition, langour, and feeble morbid action, require cor- dials, opium, on the case, the lesion produced by the violence of the disease, may be fatal to the patient. There is another con- sideration of very great moment. If we rely on other means for reducing the power of the feverish action, and especially if it should require much time, there must necessarily be produced a proportionate degree of prostration, such as would involve the power of the sensorium and the condition of the blood. Blood-letting will enable us to secure an equal de- gree of safety, as it respects the desired debility, avoiding the danger before noticed, and at the same time maintaining the sensorial power, to be employed in effecting the restoration of healthy action. APPEARANCES OF THE BLOOD, ETC. 147 We have often been asked if blood-letting, did not carry with it the great evil, of bringing about the necessity of its habitual use ? That it would be a bad practice to eat and drink to excess, so as to induce plethora, and then have recourse to the use of the lancet for its correction, there can be no question. A repetition of such a practice, would bring about the habit which seems to be dreaded, and it would be a habit which would soon produce very serious consequences. But it must be seen at first view, that the objection is worth nothing, when opposed to the im- perious demands of a case of inflammatory fever. Besides, the time required for the correction of the disease, and for the whole course of convalescence, is always sufficient for an equable invigoration of the whole system, as well the blood- vessels, as the muscles. Bleeding in autumnal fevers has been condemned, because it is frequently followed by fever in the intermittent form. The bare mention of the objection is sufficient to refute it. To exchange a violent and dangerous fever, for one that is safe and manageable, must certainly be an advantageous commutation. Besides there are instances of intermittents which defy all known agents, until the inflammatory diathe- sis, which constitutes the difficulty, is removed by blood- letting. The enemies of the blood-letting practice, have said that it predisposes to effusion of serum in the lungs, chest, abdomen, head, and cellular substance. Our practice and observation do not at all accord with this objection. Indeed they have convinced us, that the mischiefs referred to, have occurred from the want of timely and sufficient depletion ; and instead of charging them to the account of blood-letting, they would much more justly be ascribed to timidity or want of judg- ment, on the part of the practiser; for no man can know the full value of blood-letting, who does not heartily engage in its use. Besides, in the application of this remedy, it is im- 148 APPEARANCES OF THE BLOOD, ETC portant that a proper regard be paid to the condition of the external capillaries ; which done in due time and in an effec- tual manner, there is nothing to fear from effusion. Indeed we cannot readily conceive, how debility alone can dispose to effusion. We have frequently cured dropsies by blood- letting and cooling cathartics; which practice would be strangely absurd, if the objection under consideration had any real merit. If ever bleeding kills, " says Botallus, either directly or indirectly through the instrumentality of some other disease," it is not from its excess, but because it is not drawn in sufficient quantity, or at a proper time. And again in another place, he says " one hundred thousand men perish from the want of blood-letting or from its being used out of time, to one who perishes from too much bleeding, prescribed by a physician." Associations have been formed in cities and country pla- ces, predicated on the practice of the aborigines, proposing to cure all fevers without blood-letting; relying on puking by means of lobelia inflata, sweating by the external application of hot steam, and the internal use of capsicum, ginger, bar- berry bark, &c. That this sort of practice may often relieve slight diseases, and sometimes fail to kill patients seriously ill, we have no doubt. But we have seen some instances of irreparable damage done by it, and no man, at all acquainted with anatomy and physiology, could for a moment believe the tales that are told about the success of a practice, which in every instance of seriously inflammatory character, must endanger the life of the patient. As to the Indian sweat, we shall take occasion to be understood to entire satisfaction, when we come to treat at large the subject of diaphoresis. The most potent and popular argument which they pretend to offer, is, that the blood is the life, and suppose they have defied all contradiction, when they can quote a clause from the scripture of truth, in their support. To strengthen the prohibition given to the children of Israel by Moses, against APPEARANCES OF THE BLOOD, ETC 149 the practice of the Gentiles, of eating the blood of animals; he informed them, that " the blood is the life." But there is not the shade of an insinuation, that blood-letting is for- bidden by the Bible. The position of the veins, and the facility with which they are sufficiently strangulated for the purpose of conveniently performing the operation, seem to invite to the practice. And a proper acquaintance with the physiology of the blood-making organs, collated with the fact every day exhibited, that the blood is a fluid which is per- petually being made, in great abundance, furnishing the ma- terial for all the secretions, would of itself be sufficient to silence such ignorant pretensions. 150 QUANTITY OF BLOOD, ETC. CHAPTER XVII. AN INQUIRY RESPECTING THE QUANTITY OF BLOOD THAT CAN BE SAFELY DRAWN IN ANY INSTANCE OF BLOOD-LETTING, AND HOW OFTEN IT CAN BE SAFELY REPEATED. Our next inquiry will have respect to the quantity of blood that may probably be required to be drawn, in any individ- ual instance. A person of ordinary size, is supposed to contain from twenty-five to twenty-eight pounds, and by casualties of dif- ferent kinds, one-third of that quantity has been lost at once, without hazard. But a greater quantity can be taken with safety, when the blood-vessels are in a state of irritation, than when in health. If the blood is a stimulant when in its healthful condition, and the vessels in a natural state, then it is obvious, that a less than natural quantity will stimulate sufficiently, when, not only the blood is more irritating, but the blood-vessels more irritable, than natural. We know that the eyes and ears, are painfully sensitive to a very little light and sound, when the system is thus affected. And we know, with equal certainty, that under similar circumstances, a very small portion of wine will serve to irritate, to an alarming degree, even those, who in health are well accustomed to its use. We have it recorded in the books, that one man in St. Thomas's Hospital, by the advice of Mr. Kline, drew three hundred and twenty ounces in twenty days, for a contusion of the head. Dr. Haller reports one person, who, lost nine pounds; another twelve, a third eighteen, a fourth twenty- two pounds, by epistaxis, at one time. Dr. Rush speaks of a gentleman at Angola, who lost three and four poimds, per QUANTITY OF BLOOD, ETC. 151 day, in the same manner; and who was cured by being bled ninety-seven times, in one year: of a young woman, who was bled one thousand and twenty times, in nineteen years, to cure her of a plethora, which disposed her to hys- teria ; and of another who lost one hundred and twenty-five ounces of blood, by an hemorrhage, every month. To cure this she was bled every day, and every second day, for four- teen months; and they all recovered. We bled a lady one hundred times in four months; sometimes four ounces— sometimes more at each time for an inflammatory disease of the head; she recovered. We bled a maniac one hundred times in six months, three times two pounds; often a pound and seldom less than half a pound at any one time. He became anasarcous to a moderate degree, when the blood- letting was laid aside. He ultimately recovered. Dr. Sydenham, vol. 1, page 131, says "among the other calamities of the civil war which affected this nation, the plague also raged in several places, and was brought by acci- dent from another place to Dunstan Castle, in Somersetshire ; where some of the soldiers dying suddenly with an eruption of spots, it likewise seized several others. It happened, that a surgeon who had traveled in foreign parts, was in the ser- vice there, and applied to the governor for leave to assist his fellow soldiers, who were afflicted with this dreadful disease, in the best manner he was able ; which being granted, he took so large a quantity of blood from every one, in the be- ginning of the disease and before any swelling was perceived, that they were ready to faint and drop down ;—for he bled them all standing, and in the open air, and had no vessel to measure the blood; which falling on the ground, the quan- tity which each person lost of course, could not be known. After the operation he ordered them to lie in their tents, and although he gave them no kind of remedy after the bleeding, yet of the numbers that were thus treated, not a single per- son died. I had this relation " says the Doctor, from CoL 152 QUANTITY OF BLOOD, ETC. Francis Windham, a gentleman of great honor and veracity, and at this time governor of the castle." It may be remembered too, that blood is rapidly regenera- ted. "A person," says Haller, "lost five pounds a day from the hemorrhordal vessels, for sixty-two days; another sev- enty-five pounds in ten days. We have recited these nume- rous facts, supported by the best authorities, and added our own testimony, to prepare the reader to use the necessary decision in the employment of this important remedy; and to show, that a timid or even a moderate practice in its use, ought not to be relied on. From our own experience we are sure, that half-way measures will generally disappoint. It is better not to bleed at all, than to stop short of the quantity which shall be proportionate to the violence of the case. We must be prepared to judge by the pulse and other appear- ances, and then remember that in blood-letting, as in any other enterprize or undertaking, the value of it is known only, when it is consummated. Whoever desists in administering cathartics in a colic attended with constipation, until he has succeeded in opening the bowels? For similar reasons the bleeding should be repeated, so long as, the indications requi- ring it, continue to return. And we will add, that the con- valescence is always more complete and speedy, when the practice has been sufficiently decisive. But it is also proper to graduate the quantity drawn at any one time, in any case, according to the state of the system. When the pulse acts with force and freedom, from ten to twenty ounces may be taken at once, in any ordinary case: if the pulse be depressed, it is commonly better to take a few ounces at a time, repeating the operation three or four times a day. By this method the blood-vessels are gradually re- leased, and the inconvenience of a shock is avoided. This method or something like it, would commonly be safest in fevers when the pulse is tense, but when the character of the QUANTITY OF BLOOD, ETC. 153 fever is not sufficiently known, the quantity may be regula- ted according to circumstances. In fevers and other diseases whose type and character are known, and which run their courses in a few days, or hours, threatening speedy destruction, there can be no limits previ- ously fixed, as to the quantity of blood which may be drawn at once, or in one day. In such cases, Botallus drew four or five pints in a day. Every physician of good experience, does that or something like it in every case of eclampsia which comes under his direction and management. Dr. Jackson drew fifty-six ounces at one time, from a patient in one of the British hospitals, in a fever of great danger. This patient was instantly relieved ;—in three or four hours, was out of danger ;—and in three or four days returned to duty. It is stated in Philadelphia, that Dr. Physick drew from Dr. Dewees, ninety ounces at once, in an attack of apoplexy. It was so effectual, that he was able to return to business in a few days afterwards. In any instance of violent disease of recent origin, and threatening danger to some one vital organ, we have so often found it important to bleed to deliquium, that we deem it necessary to inculcate the practice. The rationale of its good effects has been given in a previous chapter : but this decisive method should never be employed in the advanced or the last stages of fevers. The system under any circumstances requires all its resources of sensorial energy, to rouse it from a fainting fit; and such requisite stock of energy, does not always exist, except at the onset of disease. In chronic fevers of an inflammatory type, however, small bleedings may frequently be repeated with great ad- vantage. The benefit of this practice, is perhaps too little known. And it will require a degree of vigilant attention and patient observation, which too few are disposed to make, to gain the necessary judgment in its use, so as not to be liable to mistake. All medical men who have any preten- sions, use mercury and antimony, and dietetic management, 154 QUANTITY OF BLOOD, ETC. with alterative intentions. Before this kind of practice can be successfully employed, there must be acquired a maturity of judgment in respect to those particulars, similar to what is here recommended, in regard of blood-letting, as an altera- tive practice. A proper consideration of its physical effects on the circulation, and the ultimate result in regard of the laws of absorption, we have thought, ought to be satisfac- tory. We use the cold bath in some chronic affections, but never expect that two or three immersions will effect a cure. We persist in its use for months and years. So also we must do, if we have recourse to blood-letting as an alterative agent. It should be repeated, while the symptoms which first indicated it, continue, however often, or to whatever amount of loss of blood, it may be found necessary to carry the practice. And even in those cases, which do not admit of cure, and of course, where the bleeding is to serve only as a palliative remedy, it is equally comfortable to the patient, and ought to be employed with the same diligence, as if it were expected to be perfectly effectual. Formerly, great importance was given to the place from whence the blood was drawn. It was taken from the foot in order to excite revulsion from the head or breast. But this is inconvenient on account of the position of the patient. It is more dangerous on account of the greater liability to wound a tendon. And if it be important to review the work by inspecting the blood, it will not be practicable. The pulse is to be considered as the chief indication, " the dial plate of the system." It ought therefore to be studi- ously observed in health and sickness, in the old and young, and in all throughout all the seasons of the year, still contin- uing the observations with untiring attention, until a sound judgment shall have been formed. For it must be admitted, after all that can be said or written on this important topic, that every physician must be eventually prepared to judge of the pulse in his own way; he must adopt his own method of QUANTITY OF BLOOD, ETC. 155 associating his auxiliary considerations, and mark out his own points of discrimination to guard him against mistake. And let us here reiterate the admonition respecting the great importance of forming, what we take the liberty to call, a current judgment, respecting the effect of the seasons, in producing or maintaining a state of things, which calls for blood-letting, when the pulse does not report it, as at other times. We dwell on this, because not only our success in many cases, depends on it, but what is more imperious, the preservation or loss of many lives will be involved in our ability or disability to make the discrimination. This will be found difficult for a time, but perseverance will overcome all difficulty, and the complacency of feeling, which will be our constant companion, when the desired point shall have been gained, will more than compensate, for all the most painful attention which may have been necessary for it? accomplishment. PART IL THERAPEUTICS. PART II. CHAPTER I. INTRODUCTORY TO THERAPEUTICS. Therapeutics has now become a science. For ages it remained an embryo, germinating in the crude accounts of diseases which fancied medicaments were supposed to cure, and was cherished by numerous tales of the wonderful effects which those medicaments were said to produce. Incipient principles and doctrines were collected from the faragos of empyricism, which were recorded in numberless recipes of heterogenous compounds. Ignorance had planted it in the wilderness and endeavored to promote its growth, by collecting around it a chaotic accumulation of substan- ces, which were considered important on account of such specific virtues, as imagination or experience had associated with their names. To the last and present century we are indebted for the systemmatic arrangement of the principles and reasonings, and the classical disposition of the materials, which now sustain its claims to scientific dignity. In presenting this branch of medical knowledge as a sci- ence, we are far from considering it independent of the other equally important branches of the profession. Physiology, 160 INTRODUCTORY TO THERAPEUTICS. pathology, and therapeutics, have so near a relation, so in- separable an affinity to each other, that their nomenclature ought to be formed with a careful reference to the same ana- tomical roots, and their doctrines should so accord as to show their identity of purpose. But the insulated character of too many treatises, which even now occupy places in our libra- ries, intended to give instruction in these several branches, has been such, that they might be read with ordinary atten- tion, and the reader fail to obtain a clear perception of the important truth, that between the organs and functions of the human body, the diseases to which they are liable, and the modus operandi of medicines calculated to heal these diseases, there exits an analogy, the knowledge of which con- stitutes the only sure guide of the physician. This embar- rassing defect will be corrected; and the fundamental princi- ples of medicine will assume an harmonious and settled form. Anatomy has been laboring to establish the identity of the structures, as they exist in the human body; physiology, that of its various functions ; and pathology, that of the laws by which its diseases are governed. All these branches ac- knowledge the near affinity of their several departments, and in their mutual dependence are approximating to the desired maturity. Their well known reciprocity of interest, has already served to procure for each a perfection, which nei- ther of them, had it been cultivated separately, would ever have received. And all these, thus mutually engaged, are contributing largely, with intention to give an equal eleva- tion to therapeutics, in the attainment of a corresponding cer- tainty in the cure of diseases. In contemplating each branch of our profession as a dis- tinct science, we understand, that a suitable acquaintance with any one of them, implies a comprehensive view of the whole, and that each may be considered as one chapter of a great work, of which the principles, the plan and the execu- tion are every where unique. Of course, a division of the INTRODUCTORY TO THERAPEUTICS. 161 great whole is necessary only in the study of the healing art. By this method, we are enabled to submit to the attention of the student, in a suitable succession, the different elements of which medical knowledge is composed. And although each elementary branch, in its place, may alternately seem to as- sume a superior degree of importance, this illusion will van- ish away, as his mind shall be prepared to comprehend the entire system, in the conformation of which, each department is employed. He will then be pleased to see, that whilst anatomy investigates the structure and relative situation of all the organs or parts of the human body; physiology makes observation on those organs or parts, in their healthy state : and detects the laws under the direction of which, their regular functions are performed; pathology examines the causes which disturb the order of those functions, setting up a mor- bid action in the organs or altering their structure, and de- scribes the phenomena which attend upon those disturbances and changes ; and, therapeutics, after having availed itself of all these preliminary investigations, proceeds to ascertain and establish the indications, by which, the physician is to be guided in his attempts to restore regularity to the system when disordered, and health and order to any function or organ which may be the seat of disease. Therapeutics therefore, requires a consideration distinct from materia medica, as well as from the other branches, both in regard of the object of its research, and the end which it proposes. Whilst materia medica is employed in collecting and describing such substances as are useful to the physician. and with the aid of chemistry and pharmacy is making him acquainted with the physical character, chemical combination, or pharmaceutical composition necessary to arm them with the greatest degree of activity, therapeutics is making obser- vation on the diseases, and ascertaining the phenomena and concomitant principles, by which the physician is to be gui- ded in the use of the medicines which, the particular. cas& 11 162 INTRODUCTORY TO THERAPEUTICS. may indicate ; and the utility of which, in similar instances, has been established by experience. Therapeutics may be said to unite medical science, proper, to those branches of physical or natural science, which are auxiliaries to our profession. A scientific acquain- tance with the immediate or secondary effect of medicinal sub- stances, when taken into the system, after a just comprehen- sion of the principles which ought to regulate their employ- ment as medicinal agents, implies a competent acquaintance with anatomy, physiology and pathology. And the truly scientific physician will have added to all these, the know- ledge which is supplied by the naturalist, the chemist and the pharmaceutist. For without these, he cannot properly un- derstand the physical qualities, or select the most useful preparations of those substances, of which the therapeutist advises the use. Therapeutics prepares the physician to be a judge of the value of any medical intention, or distinctly to perceive the occasion which indicates any particular article of medicine, or of the comparative merit of any two or more medicinal substances. When all the important circumstances which pertain to the investigation of any particular case shall have been duly examined, and the curative indication shall have been discreetly adopted, ultimate success will then depend on the therapeutic application of the practice which is to fol- low. It remains after all that has been so far done, to select ihe agent; to judge of the circumstances which are to regu- late its employment; to ascertain its appropriate dose; to modify the formula most favorable for rendering it useful; the time of repletion; the effect or evidences by which to judge whether it is likely to produce the contemplated inten- tion ; and if not, the true cause of the failure ; the variation of its dose and repetition, as the case progresses. To perfect he student of medicine in those attainments which shall en- able him in a workmanlike manner, thus to execute his own INTRODUCTORY TO THERAPEUTICS. 163 curative intention, is the particular object and end of thera- peutics. Disease is a relative state of the human body and is the re- verse of health. Therapeutics labors to effect the cure of disease, by the restoration of health. To understand what pertains to the accomplishment of this object, is to understand the circumstances in detail, which are involved in the forma- tion of disease, the retirement of which, implies the restora- tion proposed ; and a clear discernment of them both, is ne- cessary to the therapeutist. In health, the organs essential to life, perform their functions with a suitable degree of activ- ity and permanence of strength. Their sympathies harmo- niously accord; their demands for sensorial influence, are acknowledged in common; the elaborated fluids which it is their office respectively to furnish are duly accomplished; and the most perfect order is maintained, whilst each is en- gaged in the performance of its own particular function. But when an impression is made by a morbific agent suffi- ciently powerful to produce disease, this harmony is discon- certed, and a series of actions is produced, which tends to very different results. The physician is called, therefore, not to make his observations on a body whose motions and functions are all properly performed, with a view to take measures for their regular continuance ; but to investigate the degree of change and irregularity which may have taken place, and by the morbid phenomena and the degree of vio- lence and rapidity of the disease, to judge of its tendency to destruction. But it is not our design in this place to inquire what it is, that constitutes disease and its consequent injuries. We in- quire how far, the economy of the animal system maybe considered as competent to the task of restoring itself. If this can be done, we shall be better prepared to judge of the extent of artificial interference, which it may be necessary to furnish for its aid, in any particular case. 164 INTRODUCTORY TO THERAPEUTICS. We read much about the healing power of nature,* and of her efforts in sickness to re-establish health. Hippocrates taught and all his disciples received it as truth, that the ani- mal organic system is endowed with b.phusis, corresponding to the Latin, vis medicatrix natural, by which is meant, an inherent power to repel or eliminate morbific agents, and ac- cording to modern doctrines to restore regularity to her dis- ordered functions. In a properly qualified and restricted sense we subscribe to this doctrine of the father of medicine. Our experience compels us to pay him this homage. But at the same time, experience has likewise taught us, that many diseases have a constant tendency, so much to derange the organs or tissues of vessels on which they act, that without the timely inter- ference of art, a ruinous change in the structure of the organs; —in many instances, gangrene and death, are the inevitable consequences: and diseases less dangerous, if neglected, may and too frequently do lead to a state of things, in which new and additional injuries are superinduced, more pernicious than the original morbid affection. All of which are irresis- tible evidences against the vis medicatrix naturas, as it was understood in former times. Instances have occurred, in which, a slight gastritis, or a pulmonary catarrh have been relieved or cured, by a sponta- neous bleeding at the nose, or a copious spontaneous sweat. The evacuations in such cases have been called critical and nature has had the credit of effecting the cures. Such occur- rences do not prove the doctrines, in support of which they have been advanced. The evidence would be in point, if it could be proved, that the vis medicatrix actually presided in the instances mentioned and had an intended recourse to those methods of depletion ; and that in consequence of this design, she was afterwards enabled to bring about a restora- * Sometimes by modern writers called the recuperative power. INTRODUCTORY TO THERAPEUTICS. 165 tion of a healthy condition of the lungs or abdominal viscera. The truth is, that the beneficial result is more properly as- cribable to some contingency in regard of the schneiderian membrane in the one case, subjecting it to an easy rupture of its blood-vessels; and some casualty in relation to the condition of the skin, favorable to a ready production of dia- phoresis, in the other. In each of the two cases, in a way altogether incidental, the necessary depletion had been effec- ted, after which, recovery readily followed under the opera- tions of the restorative powers of nature. It would be a ri- diculous and superstitious credulity, to admit of any othej: view; unless in a majority of the cases which require deple- tion, nature is prepared to avail herself of some sufficient out- let for her own relief. We admit the existence of a medicatrix naturas neverthe- less, but conceive of its operations in a way, very different from the foregoing account. Indeed this healing power is most distinctly and satisfactorily displayed, in the good effects which follow, when the judicious therapeutist shall have made appropriate arrangements for accomplishing his intention. And a proper intention is always formed and ex- ecuted, with a constant reference to this power. In all such cases, as the two referred to above, a plethora prevails, which impedes the regular and healthful performance of the organic motions and functions. The disturbance is expressed by pain in the stomach and vomiting, in the one case, and by a difficult or painful respiration in the other. By a sufficient loss of blood from the nose in the one and by a copious flow of perspiration in the other, the system is considered to have been effectually depleted and set at liberty. The vis medi- catrix, then resumed her regular train of motions, and health was restored. Without the depletion, a very different state of things might have followed. The energies of the system, when once concentrated in a train of morbid motions, instead of effecting relief by an accidental depletion, in a majority of 166 INTRODUCTORY TO THERAPEUTICS. cases continue an unabated struggle, till they produce a fatal cerebral, pulmonary or other congestion. And therefore the facts which can be adduced to prove, that in some instances, the animal economy, without artificial aid, has seemed to re- cover a healthful state of the functions, when they had been thrown into disorder, if collated with the many opposite facts which prove the indispensable necessity of artificial assis- tance ; allowing them all that can be properly claimed, can prove no more than that disease in a mild form may chance to retire spontaneously with or without a crisis. But every physician acquainted with the diseases of our climate, knows, that by far the greater number of cases would persevere, and speedily terminate in death, or become chronic and by the laws of sympathy set up complications in respect of organs which were not involved in the commence- ment, and eventually terminate in suppuration, effusion of serum or lymph, or in some other serious or fatal disorder. Much skill is required, to prepare the physician to judge with certainty, in the commencement of a case, as to the necessity of his interference, as well as to the degree and extent of it, which may be required. And the great point is, to be able with the necessary precision, to adjust the management to the circumstances of the case. To subdue the violence of inflammatory action ; to release organic motion from the oppressive effects of threatened con- gestion when plethora abounds; to remove any known cause of irritation, when it can be done ; to arouse to a proper degree of action any of the secretory organs, when inclined to fall into a torpid state; to protect and preserve the vitality of the surface and extremities of the system when great de- bility prevails and afford the necessary support;—these are some of the instances of artificial interference to which we refer. We mean therefore, that when any or all of these things shall have been performed, the physician is still de- pendent on an agency, which, when it is performed accord- INTRODUCTORY TO THERAPEUTICS. 167 ing to certain laws petaining to the animal economy, present an exhibition of the process and produce the final result. which we call recovery; and this power, is the vis medicatrix naturae; for the existence and agency of which, we are ready to contend. If we contemplate this power with regard to the changes produced in the system in any particular instance, say, the retirement of plethora, as it is associated with inflammatory action, the process of nature will be identically the same as to plethora alone, whether she shall have been released from the thraldom by blood-letting, catharsis, diaphoresis, or inan- ition. So soon as the plethora shall have been removed, the inconvenience or threatened injuries, which it had produced. will be made to retire, by the agency of the vis medicatrix naturas ; that is, by the laws which govern the motions and functions of animal life,—now called the recuperative power. We have been careful in explaining our views of this im- portant power, because every curative intention, if it be phi- losophically instituted, will have a proper and constant refer- ence to its indispensable agency, and because a suitable ac- quaintance with its laws, is one of the surest guides to the- rapeutics. We are desirious also to be explicitly understood, that in maintaining the existence of the vis medicatrix, we are very far from assigning to it that absurd importance. which once led medical men to pursue the dangerous and in- human practice of leaving their patients to languish in pain and anxiety, day after day, waiting for a crisis, the infallible indication of the course which the vis medicatrix intended to take for the removal of the disease. Take an explanatory example or two. For one, let us turn to a case of pulmonitis. Admitting the presence and agency of the vis medicatrix, what is the part she acts, in the commencement of the attack. It is an obvious fact, that the impetus of the circulation, is dangerously violent, and experience has proved, that it must be restrained by blood- 168 INTRODUCTORY TO THERAPEUTICS. letting. The inference then is clear, that in circumstances such as those which mark the commencement of this dis- ease, nature is not to be trusted without the help of art; and the practice of all modern physicians proves, that the treat- ment necessary in such cases, is in direct opposition to the tendencies of nature. A still more unequivocal opposition to nature's movements, is necessary in treating a case of cholera. She loudly reports the necessity of evacuating the stomach and bowels. And here, by the way, whilst in one important respect she reports the truth, her efforts are so ex- travagant, and tend to an issue so adverse, that experience has taught us, that the vomiting and purging must be imme- diately arrested, or in a few hours the life of the patient will be lost. Now if nature's indications are to be our guide, without restriction, the violent and destructive action which obtains in pulmonitis, should be assisted by a copious draught of hot toddy; and the worst instance of cholera should be aided with a good dose of tartarized antimony, and followed with a sufficient portion of some brisk cathartic ; either of which would be absurd. It is after the proper reduction of the mor- bid action of nature, by blood-letting, &c, in the one, and the suppression of her morbid evacuations by the exhibition of the necessary quantity of opium, etc. in the other, that we look for the recuperative process which is the work of the vis medicatrix naturas. It, is true nevertheless, that na- ture's pointing is not unfrequently well enough in accordance with the most judicious curative indications. In cholera, as was noticed above, the evacuations with which the disease commences, to a certain extent, are always useful. Being morbid, however, they continue and progress with such ra- pidity and copiousness, that the balance of excitement is lost. In proof of the correctness of this remark, it is a fact, that in almost every instance of this alarming affection, after quiet- ing the storm by the administration of opium, &c. additional INTRODUCTORY TO THERAPEUTICS. 169 evacuation by the aid of calomel and other appropriate me- dicines, not unfrequently by the lancet, is necessary for the restoration of good health. Also, in bilious fever, and other diseases, which chiefly affect the abdominal viscera, a dis- tressing nausea and inclination to vomit are most certainly relieved by the operation of an appropriate emetic. And al- most all ordinary instances of diarrhoea, and perhaps every case of dysentery is best treated with frequently repeated doses of some suitable cathartic, say caster oil, modified by the addition of laudanum. We have already admitted, that bleeding at the nose may chance to occur in cases which loudly call for blood-letting, and yet it does not follow, that this practice is admissible whenever the nose bleeds. In typhus fever, bleeding at the nose may be critical. It often is, and much blood may thus be spontaneously lost, with ob- vious benefit, in such cases ; and yet at the same time, copi- ous blood-letting from the arm, in most, if not all instances of this kind, would be fatal to the patient. It is not at all wonderful, therefore, that medical philosophers should have arrived at that point of elevation from which they look down and refuse to be guided, blindfold, by the uncertain direc- tions of nature, when she is in the thraldom of diseased ac- tion. As properly we might consult an infuriated maniac, respecting the propriety of securing him in a straight jacket. Aided by a suitable knowledge of anatomy, physiology and pathology; observation and experience have raised the- rapeutics above the uncertainties which marked the practice of the servants of nature. And now, instead of a blind sub- jection to the dictates of nosology, which, with anxious ex- pectations and doubtful calculations, looked for crises which seldom occurred, our therapeutics gives a much more cer- tain direction to our practice, and enables us to discover the errors, and correct the theory and practice of men, whose opinions in their day, were repeated as precious and infallible 170 INTRODUCTORY TO THERAPEUTICS. aphorisms, and carefully recorded and preserved as being worthy of universal and perpetual regard. The object of the literary labors of physicians of every age; the intention of all has been, to acquire an approxima- tion to a perfect, or trustworthy method of treating diseases. All their labored theories, have been subjected to the test of experience, the faithful pioneer which has been engaged for ages in preparing the way for the introduction and establish- ment of legitimate therapeutics. She continues cheerfully and promptly to perform her part, determined to continue her assistance until the healing art shall have been perfected. Under her direction and patronage, the profession has laid aside as lumber, many of the works which once held con- spicuous places in the libraries of physicians, and many others are still retained and preserved, rather as monuments of an- tiquity, than as valuable practical guides. Every judicious practitioner of medicine now knows, that men of great learn- ing and little experience, can form opinions, frame them into theories, and write specious treatises in their defence. But experienced therapeutics comes to the sick bed, and proves the worth of doctrines ; it weighs them in the balance of clinical exactness, and however specious the arguments of their inventors, if deficient in practical truth, it rejects them. For after all, any system of theory and practice of physic, to be reputable and lasting, must be successful; just as certain- ly, as that the greatest physician is he, who makes the most, and most distinguished cures. INTENTION. 171 CHAPTER II. AN INQUIRY AS TO WHAT IS TO BE UNDERSTOOD BY THE TERM, INTENTION, IN THERAPEUTICS. No medical prescription can be judiciously offered, without a suitable reference to a well instituted curative indication. No curative indication can be philosophically instituted, with- out an appropriate reference to the pathology of the case under consideration. No truly philosophical view can be taken, without a competent knowledge of the physiology of the organ, or system of vessels supposed to be the seat of disease ; and no medicine can be administered with becom- ing confidence, until it shall have been proved by sufficient experience, to produce the intended effect. It is the busi- ness of the therapeutist, to lay his foundation sure in a judi- cious intention, and to carry it into effect in a workmanlike manner. Curative indications have varied at different times, and in different countries, as often as the medical theories on which they have been based. The principal intention of the Humorists, was to correct the condition of acrid humors, which they considered to be the causes of diseases. This they attempted to accomplish by administering remedies which were supposed to concoct, or to bring about such a change in those humors, as might fit them to be eliminated through one or more of the emuncto- ries, which served as sewers for their complete discharge. The Mechanicians formed their principal intention with a view to the removal of obstructions, and to the restoration of a suitable freedom of the vital functions, so as to recover 172 INTENTION. the permeability of the vessels supposed to be obstructed. The technical phraseology relating to obstructions, origina- ted with this class of physicians. With them, steel was an important remedy. It gave additional impetus to the circu- lation of the blood, by increasing its momentum; and the angular figure of the particles, or atoms of steel, were supposed to arm the blood with spiculas, which served to break up and fit for removal, the obstructing materials which caused diseases. The leading intention of the excellent Cullen, who reviv- ed and taught the fundamental doctrines of Hoffman, was to remove the spasm of the capillary vessels, and give general freedom to the circulation; and then regulate the reaction with suitable reference to other subsequent intentions, which may be considered to have been as numerous as the different kinds of diseases which he describes, and the different reme- dies which he recommends for their cure. Homeopathy, which first prevailed in Germany, is the most extraordinary doctrine that has perhaps ever been ad- vanced in any age. Its founder is Dr. Hahnemann. It con- sists in administering remedies, calculated to produce a series of symptoms, precisely similar to those constituting the dis- ease. These artificial symptoms, take place of the natural ones, which will thereby be driven away; and as these new symptoms are the effect of remedies, they will subside as soon as the remedies are discontinued. The principles of therapeutics in this doctrine, are to be sought for in the rela- tion existing between the known effects of remedies on the constitution, and the symptoms of the disease, of course there can be but three indications—First, opposition. Second, heterogeneity. Third, similitude. This last, which is cal- led Homeopathic, is the only and most efficacious one. It is explained as follows: "When the specific effects of a remedy are perfectly similar to the natural disease, they reach INTENTION. 173 the organs that it has affected. But as two similar diseases, cannot exist at the same time, in the same point, and as the artificial are more intense than the natural affections, the lat- ter give way, and the former are substituted, which also soon disappear. Reaction is here salutary, because the Homeo- pathic remedy, acting on the organizm exactly like the ex- isting disease, this last will react in an opposite direction, that is, in favor of health.*" The Brunonian system, is distinguished by having chiefly insisted on one invariable intention, which was, to overcome an asthenic condition of the system ; that is a condition of debility, by the employment of stimulants and cordials; to reduce the excitability of the system, by elevating the ex- citement, until it is adjusted to an imaginary graduated scale of health. There are very strong proofs of acute discernment and fer- tile genius in this theory; and whatever deficiencies, imper- fections, or inexplicable mysteries may be thought to adhere to it, Dr. Brown has contributed greatly to the improvement of medical science. Dr. Rush profitted much by the speculations of Dr. Brown and approximated nearer to the truth. He perceived the mutual dependence of excitability and excitement; the re- ciprocal elevation and depression of vitality and sensorial in- fluence, and he carefully and properly turned the attention of the physician, particularly to the protection of the vital or- gans ; availing himself of the leading principles of Dr. Brown, in view of the general system, and when there was occasion, having recourse to such particular agents, as the experience of the profession had proved to be necessary for the correc- tion of particular organic affections. His leading intention. on general principles, therefore, was, to equalize the excite- ment, in view of an imaginary scale, adjusted to the tone of * Quebec Medical Journal^. No. 7, 1827. 174 INTENTION. the vessels of the organ or structure affected by the disease. And then his subsequent intentions, were instituted and car- ried into effect, as daily occurrences might direct. A method of treatment corresponding to this, will be laid down more distinctly in the sequel of this work. The distinguished successor of Dr. Rush, has adopted a theory which wears an aspect very different from that of his predecessor. "Conveniently situated for the purpose, the stomach," says Dr. Chapman, "is probably the throne of the vital principle, from which, would seem to emanate an influ- ence, that, diffused over the system, preserves the order of the parts, and sustains the vigor, tone and well being of the animal economy." "Languido ventriculo, omnia lauguent."* "Assailed however by impressions which it cannot resist, this organ, as the centre of association, becomes the seat of the first link in the chain of most diseases, and is always the chief medium of the operation of remedies in the correction of morbid derangement." (Chapman's Therapeutics, p. 95, 4th ed.) Whatever superior importance may be hypothetically or truly assigned to the stomach, as the centre of associations, and however much the elevation of that viscus, may serve to divert attention from the fundamental principles of Drs. Brown and Rush, we are inclined to think, that the best parts of all modern theories, directly or indirectly are derivative from Dr. Rush, however unwilling the authors may be to make the acknowledgment. If we are correctly informed, the professor of the Insti- tutes and Practice in the University of Pennsylvania, is much more entitled to commendation for his attempts to arrange, classify and explain diseases, with a proper reference to the organs and structures which are known to be the seats of * With a languid stomach, every thing languishes. INTENTION. 175 them, than for his attempts to declare independence of Dr. Rush. And although pains may have been taken to conceal the fact, modern teachers of medicine, avowedly nosologists, either knowingly or unknowingly, have so completely inter- woven into their systems, the great truths taught by our illus- trious countryman, that the discerning student cannot fail to see, they all wear his livery. It is true, nosology fitted up in dress so respectable, in comparison of what it formerly was, may now be considered quite philosophical. In this way, the nosologists of Europe and of the United States, appear to have extricated the science from mechani- cal, chemical and humoral errors which had so long prevail- ed. But it is not our purpose to present a system of Thera- peutics based on any nosological view of the profession. In- dications predicated on such premises, must inevitably mis- guide, unless it can be clearly made out, that the groups of symptoms which are taken collectively for the description of each particular disease, are always the same in similar cases, and always succeed each other in the same order. But we all know that this is not the case. They vary with the con- stitution, temperament, age, &c, of the patient; and each of the variations are again liable to other additional modifica- tions and changes, in consequence of the remedies which may have been used, and of the effects of climates, seasons, and modes of living. And there is yet another difficulty, which is calculated to add materially to the embarrassment of an inexperienced nosological practitioner; which is, at the same time, that there are distinguishing phenomena by which particular diseases may be known, there are appeararices, more or less common to all, more or less conspicuous, ac- cording to various circumstances. With all these difficul- ties in view, it would seem that " a perfect synoptical ar- rangement of diseases is impracticable." And it may be safely predicted, that no perfect system of nosology will ever be devised. Something useful may be accomplished by those 176 INTENTION. treatises, whose divisions and distinctions have been predi- cated upon the natural and obvious divisions of the human body; having their various departments to accord with the known differences of organism. But even this device, spe- cious as it appears to be, has its accompanying difficulties. For at the same time that there are symptoms which are con- sidered definitely to point to a particular diseased organ, we constantly see additional phenomena supervening; sympa- thetic, incidental and variable, to an infinite degree ; and therefore, on the whole, we conclude, that a truly philo- sophical system of therapeutics cannot be framed, if it be made to conform with any known system of nosology, however classical or scientific its doctrines may seem to be. THERAPEUTIC INSTRUCTIONS. 177 CHAPTER IV. AN ANNOUNCEMENT OF THE COURSE WHICH WILL BE PURSUED IN THE FOLLOWING THERAPEUTIC INSTRUCTIONS. We propose, first to make ourselves well acquainted with general principles and their modifications, and then endeavor to show how this general information will be applicable and useful in the investigation and management of particular dis- eases. In our observations we shall be guided also, as much as possible, by the well known divisions of the human body. admitting disease to be specific and particular, whenever it is known to demand particular and specific treatment, in conse- quence of any definite and well known peculiarities which invariably pertain to it when it, fastens on any particular or- gan. By this method, it is hoped, we shall be enabled to se- cure the necessary discrimination, so as to direct our practice against the symptoms which are the real indices of disease and avoid the danger of being misled by those which are merely incidental. We deem it important to be fairly under- stood in regard of the discriminations just now referred tor and therefore we will add a practical explication or two. Without a scientific reference to the anatomy and physi- ology of the organs affected in a case of enteritis, in its com- mencement, the time most important for a successful defence against its dangers, the patient and even an unwary physi- cian, may be led to consider it a mere windy cholic. Heat- ing draughts of course may be administered, probably perse- veringly repeated, even alcohol in dangerous doses may be prescribed, when the only proper indication is very copious blood-letting and other suitable evacuations. So also vari- 12 178 THERAPEUTIC INSTRUCTIONS. ous other inflammatory affections, at the onset, might be con- sidered, as nothing more than peculiar expressions of debility, and be subjected to treatment equally erroneous. By the same kind of misapprehension, hemorrhages produced and kept up by an inflammatory action of the blood-vessels in- volved in the disease, have been treated with tonics, to the destruction of the patients ; when appropriate evacuation and judicious management might have insured recovery. We are aware that the friends of nosology, insist on the practica- bility of such general and specific description, as may serve with all necessary exactness, to guard against mistake. It is nevertheless our settled conviction, that the physician who is not prepared to support his nosology, by a mature judg- ment in respect to the condition of the affected organ, works blindfolded. Admit he may have in full recollection the whole series of symptoms which are put down as pathog- nomonic, in any given case, still even this will not be suffi- cient. The worst diseases do not develope the whole chain of symptoms which characterize them, until, in many cases, they have progressed too far for the safety of the patient; and in all, the disease must at the least have been established and its progress have advanced so far, as to render its man- agement more difficult and its cure less certain on that ac- count. Besides, if we even permit the physician to com- mence his operations before the entire character of the dis- ease is displayed, this will serve only to increase his embar- rassment. It is presumed that the agents to be employed will produce important effects. His attention must then be turned to appearances perpetually variable and evanescent, and he is therefore continually liable to be led astray by the agency of his own remedies. He must frequently meet with anomalies, bringing him endless embarrassment. Nosolog- ical practisers under such circumstances, would be prepared to imagine they had found new diseases. Those who have made themselves more conspicuous in this way, have gone THERAPEUTIC INSTRUCTIONS. 179 on accumulating their anomalies, until the stock of nosology has become an insupportable incumbrance. Unwilling to wander through the dark mazes of this region, in support of medical information, scientific men have at length deter- mined to urge the necessity of a more perfect acquaintance with the remote causes of diseases, the circumstances which specify their determination on particular organs, and the ef- fects of such determinations; and instead of the apparently classical parade of nosology, to recommend that kind of stu- dious attention to anatomy and physiology, which prepares the well instructed physician, to trace out the pathology of any case which may occur to his observation, whenever there is occasion ; and by so doing insure correct diagnosis. The unwieldy materials which nosology had imposed upon teachers of medicine, as well as the embarrassment which it brought to the learner, was felt more particularly towards the close of the last century, when men of genius and enterprise, began to think of some device which would admit of more system and greater simplicity. The ingenu- ous work of Dr. Brown of Edinburgh, was an attempt of this kind, and served to give an impulse to improvement in our profession, which waked up Europe and these United States. About the same time, Paul Joseph Barthes de Marmorions. who was born at Montpelier in France in the year 1734, and died in 1806, made an attempt to simplify the profession. He labored to analyse diseases into distinguishing groups of symptoms, which he called elements. And since his death Charles Louis Dumas, who died about eight years later than Barthes, improving on the elementary method of his prede- cessor, laid the foundation of what is called in France, the doctrines of the school of Montpelier. According to this doctrine, a pathological element is a simple disorder, an im- aginary assemblage of particular symptoms, which are gene- rated simultaneously, almost never separating, produced by known causes, having definite crises and periods, requiring a 180 THERAPEUTIC INSTRUCTIONS. special method of cure, having well known post mortem ap- pearances, attacking one or another person indiscriminately,. or any one organ or tissue of vessels indifferently; possessing the power, nevertheless, to affect some one of these in a par- ticular manner; and sometimes some one among them exclu- sively : An element was not a pathognomonic symptom ; it was a disease. But instead of a catalogue of an almost end- less number of diseases; they attempted to conceive of a more limited number of the elements of disease. They were looking toward the same object, which was the great desideratum of Dr. Rush, when he was striving to prove that disease is a unit. They seem to have thought, that there are elementary morbid affections, which under various combinations, take a leading part in the formation of all the diseases which can possibly attack the human body. And we must admit, that such a system, if fairly made out, would have served to simplify the theory and practice of physic. The theory of Montpelier however, although it had an estimation in France, corresponding to that of Brown in Scotland, wTas more the production of a fertile imagination. than of astute clinical observation. A few additional re- marks will make this sufficiently clear. According to this doctrine, we will suppose plethora to be an element. Plethora however, is more properly a predispo- sition to disease, than any thing else. There is however an approximation to philosophy in the specification of this par- ticular, as an element in the formation of disease. So also pain is an element, and pyrexia, and debility, and spasm, &c. Now our object is to show the effect, which such an elemen- tary scheme was intended to have on their therapeutics. The occurrence of plethora being ascertained, the proper intention is obvious at once. Too great fullness must indicate the necessity of evacuation. Pain, would indicate the necessity of administering an anodyne; spasm of some appropriate antispasmodic; pyrexia of antiphlogistics, and debility of THERAPEUTIC INSTRUCTIONS. 181 tonics. All this, at first view, looks very specious ;—patho- logical elements directly indicating the most appropriate rem- edies. But the judicious physician feels it necessary to know, what circumstances may have concurred in producing the plethora; what the cause of pain ; in what organ it is seated ; in what manner the anodyne is intended to act. Is disorganization threatened which might make the anodyne pernicious ? In a case of spasm, an antispasmodic is to be administered. The phylosophical physician inquires, what cause has produced, what irritation maintains the spasm ? By what kind of agency is the antispasmodic remedy expected to produce relief? The elementary system appears to have been deficient in these essential points, quite unprepared to furnish satisfactory answers to these important inquiries. And yet there appears to have been so glaring a demand for such answers, it is rather surprising that something more sat- isfactory in relation to this deficiency, was not added. Again, spasm indicated the use of antispasmodics ; if spasm be con- sidered as an element, alas! we find it in tetamus, epilepsy, hydrophobia, hypochondriasis, cholic, and many other dis- eases. Then, valerian camphor, musk, ammonia, hoffman anodyne, hyosciamus and opium, would be common reme- dies for all these diseases. Debility, if considered an ele- ment, in like manner attends epidemic catarrh, influenza, bilious fever, typhus and typhoid fever, pneumonia ty- phoides, scarlatina, bronchitis, &c. Of course all these in common, would require stimulants, tonics and cordials: since, if the elements are to be our guides, whenever any of them appear, our indications must of course be, to employ their proper antidotes. The absurdity of which is sufficiently obvious. Dr. Brown's system partook too much of this de- fect. We presume, however, that the school of Montpelier intended their elements to be partial guides only; and under the correction of experience, they no doubt had their use. Even Darwin's theory of irritation, sensation, volition and 182 THERAPEUTIC INSTRUCTIONS. association, is better than none. After this preparatory di- gression, we return more directly to our subject. Curative indications can have no more solid foundation, than an extensive and well digested knowledge of the cau- ses, seats and nature of diseases ; which implies a knowledge of the structures and functions of the organs or tissues which are diseased; and the nature and extent of the injury which they may have sustained. When we shall have made the necessary investigations in view of these particulars, we make up our judgment as to the character of the disease and have recourse to such medicines, as we may have learned from our own experience or that of others, to be effectual in similar cases. If the intention shall have been correctly appointed, and executed with skill and decision, the disease will retire; or its continuance will justify the conclusion, that it is incu- rable by the means so appointed. In some instances, how- ever, when every thing pertaining to the curative operations shall have been properly planned and executed, and when a satisfactory yielding of the morbid appearances shall have proved the correctness of the whole, still the effect is not complete. In such instances, the obstinacy of the symptoms may be considered to be consequent on the existence of an irritation, which has become in some sort independent of the original affection, and which requires a modification in the subsequent prescriptions, and a longer continuance than usual, of the management which has been found appropriate and more speedily effectual in ordinary similar cases. If more than one organ appear to be affected at the same time, or if the disease extend its influence to parts remote from the organ which was primarily affected, the intention of cure is sometimes first directed towards one organ, some- times towards another, in succession ; sometimes it has a pro- per reference to all at once, including within its scope the principal injury as well as any complication, whether they be sympathetic or secondary associations or consequences THERAPEUTIC INSTRUCTIONS. 183 which may accompany or follow it. Still, in each and all cases, a regard to the seat and nature of the disease is to regulate our therapeutic indications. And this is equally true, whe- ther the patient be old or young, male or ^female, robust or delicate. In all cases the fundamental principles are the same ; but different circumstances may require considerable modification in the details of the practice. Different remote causes, referrable to different climate, constitutional tempera- ment, modes of living, intemperance, and sometimes sudden changes of residence, or of articles of clothing, or diet, each may require some modification of treatment; but any such variety will be a secondary consideration. It may make it necessary to introduce one article in place of another; or some one preparation of an important agent, rather than an- other ; or it may require the application of the remedy or its introduction into the system, by a peculiarity of manner, suited to the case; still the leading intention will be the same. An inflammatory affection, for instance, must be treated with evacuation and other corresponding remedies. This will be the general plan, whether the case under deliberation be violent or mild, recent or chronic ; whether the patient be vigorous or feeble in constitution; old or young; male or female ; an adult or an infant. The kind of depletion, or the extent of it, as well as the concomitant management, will be different in each. So far as general principles are concerned, the intention is the same, the practical details only are subject to variation. A physician practising in conformity to these views, has incessant occasion to refer to physiology and pathology, and his discriminations will be clear, positive, and disengaged from the conjectures which are raised under the arbitrary empirical dictates of nosology. He will be prepared to judge of the modus operandi, as well as the value of the agents he may employ ; moreover he will be in possession of the 184 THERAPEUTIC INSTRUCTIONS. only proper means of correcting his own theory and practice. It is true, nosology may assume the appearance of great pre- cision, and with the display of its modern classification may be imposed on beginners as the only classical and sys- temmatic view of the profession. Yet, after all this parade, the art of healing, in that dress, is miserably imperfect, and therapeutic indications made under its auspices, must be con- jectural. The physician who refuses to follow such a blind guide, and is directed by his own knowledge of physiology and pathology, is certain in his views, as to the seats of dis- eases. Well acquainted with the phenomena which attend on the healthy functions of the organs, he is at no loss to judge of the pathology of the case. It follows of course, that when he administers his remedies, he is prepared to es- timate their effects, and judge whether they satisfactorily cor- respond with the therapeutic indication for which they were prescribed, or whether they approximate towards its accom- plishment ; and how far they fall short of it. In a word, he can decide with accuracy as to the propriety of pushing his intention, or retiring it; without unnecessary hazard or loss of time. AGE, TEMPERAMENT, ETC. 185 CHAPTER V. THERAPEUTICS CONTINUED—CONSIDERATIONS IN RE- SPECT OF AGE, TEMPERAMENT, &c. Having presented a sketch of some of the principal theo- ries which in their day were in repute, in order to show what is meant by a therapeutic intention, let us attend to some particular circumstances, which will claim consideration, when there may be occasion to perform a work of so much importance. These have respect to age, temperament, sex, professional pursuit, habits of living, strength and debility; to the causes of diseases, their seats, the degree of their inten- sity, and the periods of their duration. In youth, the nervous system is more acutely susceptible of irritation, and more readily takes on sympathetic action. Irritation, of course in less time by continuity, becomes com- plex and difficult of investigation ; morbid action more speed- ily destroys the organ first affected, and extends its influ- ence to the sensorium and to the arachnoid membrane. The stomach and lesser intestines of young people too, be- ing more active in performing the functions of assimilation for purposes of growth, &c, are subjected to a more frequent and laborious service; those organs are, therefore, more fre- quently affected with congestion and inflammation. On these accounts, in all cases of sick children, the blood making or- gans ought to claim special attention. Irritations of the ab- dominal viscera are frequently very alarming; and if neglect- ed, rapidly become dangerous. The secretions thrown off by the mucous surfaces, when in a state of irritation, have a tendency speedily to become inspissated, the exhalents are 186 AGE, TEMPERAMENT, ETC. embarrassed, the secretions diminished, till it would seem that the effect contributes as largely as the disease itself, to the work of destruction. Croup, furnishes very prominent, and most frequently fa- tal examples of this peculiarity of affection. In children the villous coat of the intestines is more liable to be disorganized, passing into a gelatinous state ; hence the speedy occurrence of a cadaverous foetor in cholera infantum. From the whole we infer, and practical observation justi- fies the inference, that infants, children, and youthful pa- tients, require a decisive practice, corresponding to the fore- going remarks. According to physiological and medical cal- culation, the energies of infants not only equal, but exceed those of adults. Vitality is greater in early life, than at la- ter periods; all the vascular actions, whether healthy or morbid, are performed with greater activity. Inflammation, for example, is more frequent than in adults ; and it runs its course more rapidly, through its different stages, to disorgan- ization and death. Greater promptitude and activity of treatment are necessary, and very decisive blood-letting when called for by the circumstances of the case. When blood- letting is required, it may commonly be considered to be im- periously necessary, and ought to be performed without at- tempting to substitute other evacuations. A speedy and de- cisive discharge of the faeculent matter from the bowels is also required in such cases ;* and in almost all others which call for medical aid. And when this kind of prompt and effec- tual treatment is withholden, overwhelming irritations or fa- tal congestions very often destroy the patient. It should be particularly remembered, that when such decisive practice is necessary, ri^id abstinence from nutritious diet ought to be in- sisted on. In children, it will be found on careful examina- * When infants and young children sicken, especially in warm weather, all drastic medicines are to be avoided or cautiously used. The mucous lining of their intestines can be ruined by one dose. AGE, TEMPERAMENT, ETC. 187 tion, in many cases, when they are seriously indisposed, that the abdomen is enlarged, proving, either that the intestines are too much distended, or that the viscera are swollen, or in the condition called hypertrophy. If the enlargement be consequent on fulness of the vessels, or a flatus, it will be known by making pressure with the hand; and in such a case, with or without blood-letting, sufficient catharsis will not fail to reduce the abdomen to its proper size and condi- tion, and remove at the same time, all the morbid phenome- na which were produced by the existing fulness of the portal vessels. If the enlargement of the abdomen resist the pres- sure of the hand, and especially if the liver, or any other vis- cus be discoverable by reason of its unnatural solidity, then, although cathartic medicines are imperiously necessary, still caution and time will be required in conducting the treat- ment ; moderate repetition, rather than hasty decision, is to be pursued in such cases, paying a proper attention to the strength of the patient, until the indication shall have been accomplished. Alterative agents, together with a suitable repetition of cathartics; light and sparing diet; supporting the action of the stomach, liver, &c, with pleasant and suit- able diluents. This is a summary view of the practice ne- cessary in all such neglected cases. We will add only, that gelatinous syrups, and saccharine mucilages, which in adults are ordinarily consistent with dietetic views, are to be in- terdicted in the treatment of children, as such asticles are too nutritious, to be consistent with a true therapeutic in. dication. The ordinary doctrines in Great Britain, France, indeed of most countries of the world, have been, that children, be- cause of the delicacy and susceptibility of their organs, ought to be treated with the mildest remedies, or if we find it ne- cessary to use active articles, to administer the smallest do- ses. The experience of the most judicious physicians in our country, has proved that our practice here, must be very dif- 188 AGE, TEMPERAMENT, ETC ferent, in all cases of a similar character. It is true, never- theless, that after a proper decision in acute cases, and also after the necessary impression shall have been made in those that are mild, much may be accomplished by management, and the continued use of appropriate and mild remedies. The tendencies of organic life to repair any injuries which may have been inflicted ; the recuperative powers are so great in infancy and youth, that recovery is sometimes possible, when appearances at first are very unpromising; and there are chronic affections, in which decision would be impro- per ; such are best treated with the gentler articles, and suitable management. Some of these are scrofula, rachi- tites, &c. In the decline of life, all the vital functions are performed with less vigor, of course our therapeutics must be modified by considerations in view of that fact. Old men, as well as young, are liable to exposure and accident, and therefore likewise to injury, inflammation and fever in various forms. In all such cases, after duly considering that nature, tired with years, is slow in recovering strength; sparing in her elaborate productions, requiring time at every step ; our treat- ment is conducted by the same general principles, in age, in middle life and in youth. Old age is, however liable to dis- eases peculiar to itself; diseases which seem to be, in a great measure, consequent on the wear and tear of life. These affections require the introduction of other considerations. It would seem that organism and organization long continu- ed, and especially if subjected to any considerable extra ex- ertion by intemperance, must sooner or later assume the con- dition of irritation. Irritation coming under the laws of as- sociation, will continue to spread itself, till the tissues in near affinity with the fretted organ, are brought into the train of morbid action. So the genito-urinary system, very often is made to exemplify this statement; when men advanced in years, are subjected to diseases which embitter all the recol- AGE, TEMPERAMENT, ETC. 189 lections of early life, in which they too much delighted. Dysuria, with its painful and fruitless efforts ; dysuria muco- sa, and other affections of the neck of the bladder; schirrus enlargement of the prostate gland and of the testicles; vari- cose enlargement of the blood-vessels of the testes, especial- ly the veins; schirrus affections of the stomach and duo de- num ; schirrus and other affections of the liver ; diarrhoea ; catarrhal affections and tussis senilis; hypertrophy and en- largement of the heart ; dypepsia; asthma; angina pectoris. In addition to these, the serous and mucous tissues become fibrous and cartilaginous, and the sensorium itself gives signs of fatigue by paralysis, &c. It will be obvious to the most ordinary judgment, that a palliative plan of treatment is all that can be instituted prudently in such cases, which, from the very nature of things are incurable. During the continu- ance of youthful vigor, organs and functions though often excited to excessive action, may continue in a condition ap- proximating to their natural and healthful state. But as age advances, preternatural enlargements, irritations and indura- tions of parts often begin to prevail, and when such a state of things is consequent on excess in eating, drinking, &c, it is likely to continue on with increasing rapidity, un- til eventually, the organism becomes entirely disordered, and the proper functions cease to be performed. It fol- lows, that moderation in the pleasures and toils of life, serve moit effectually to prevent the distressing diseases of old age.*________________________________________________ *A note by my much esteemed, now deceased, friend, Dr. Peter Snyder, late of the city of Baltimore. It is incalculable what good would result to mankind, if they could be im- pressed with a sense of the true effects of excessive organic action, habitu- ally repeated. Reflecting people, if their observation on their own experi- ence, were intelligibly directed by their skillful friend, would generally be led into conviction of the inevitable debility and suqsequent disorder, that any organ long overtasked would fall into, If physicians were more tho- roughly instructed in these physiological and pathological truths, they would address themselves to the people with a force of authority, by which the ig- norant, yet honest mind, would feel, and by which it would be quieted. 190 AGE, TEMPERAMENT, ETC. We defer any additional remarks on the subject of age, and proceed to some considerations which have respect to temper- ament. Here we propose three general classifications ; each of which we suppose to depend on a peculiarity in the struc- ture of its respective tissues of vessels. The first, on that of the blood vessels ; the second, on that of the nerves; and the third on that of the lymphatic system. In making these three general divisions, we have in view some of those evi- dences which appear satisfactorily to prove, that certain laws peculiar to each of them, do maintain a predominance over the remaining two, and indeed over the whole system. We also have in view, the fact, that the peculiarities which con- stitute organic temperaments, are not less evident, than those on which we rest these general divisions. After we shall have disposed of these, we may find it convenient to pay a suitable attention to the subject of organic temperaments. There are many persons of both sexes, whose blood-vessels are very conspicuous, in all their sensible appearances. Their arteries, to the touch of the finger, express a firm and effec- tual consent with the systole and dyastole of the heart. The condition of the circulation affords proof of a firm structure, and ample calibre, in every arterial tube; and when in or- dinary health, the veins of such individuals stand out in bold relief. Of such we are ready to say, they have excellent systems of blood-vessels. And this is true in view of two important considerations—First, if a person of this description should need blood-letting, it may be performed, commonly, with fearless decision; and if required, it may be repeated again and again; and under ordinary circumstances, it will be followed by a speedy reaction, that is, the return of a free and active circulation, which follows the weakness consequent upon blood-letting. We use the same word in those cases, where conspicuous signs of debility give place to an improv- ed circulation. Again, should blood-letting have been omit- ted in such a case, at any time when it would have been AGE, TEMPERAMENT, ETC. l9i particularly useful in the commencement of an attack, the firmness of the vessels will be found capable of sustain- ing the stress, a longer time without running into a state of fatal congestion; which often occurs to persons of a different temperament. Besides, persons of the san- guineus temperament, according to this view of it, may often be relieved, though late, by blood-letting cautious- ly and frequently repeated, apparently in circumstances, in which the same practice, however carefully perform- ed on a patient of a different temperament, would be improper and produce a state of things the most occult and dangerous, terminating after metastasis or other em- barrassing phenomena, in a way to make it very suspi- cious, whether the prescribing physician were not ignorant of the true nature of the case. Moreover, it is an important fact, that persons of this temperament, when attacked with an inflammatory affection, ordinarily present symptoms which happily lead to a suitable defence, without delay. The ex- citement in such cases is usually intense and vascular, the pulse full and incompressible; the respiration indicative of the degree of stress imposed on the pulmonary vessels ; ap- pearances proclaiming the necessity of blood-letting and other evacuations. We will add only, that among those classes of mankind, who are engaged in active and laborious employ- ments from their youth up, we find the most distinct and the greatest number of instances of this kind of temperament. And of course, as the best heritage is such a stability of con- stitution and firmness of texture of the blood-vessels, as those persons are heirs to, they must be ranked among the most fortunate, who are blessed with an education and lot of this sort. In treating of the sanguineous temperament we were able to invite attention to plain facts, visible and tangible to ordi- nary observation. We regret that it is not in our power, to be equally clear and intelligible on the subject of nervous 192 AGE, TEMPERAMENT, ETC temperament. This important tissue of vessels, which bears an imperious sway over all the motions and functions of the human body, is subject to medical observation, only through the phenomena by which their influence is expressed. Per- sons of this kind of temperament, are commonly as remarka- ble for the delicate appearance of their skins and almost en- tire concealment of their blood-vessels, as those of the san- guineous are for the conspicuous enlargement and display of theirs. They are generally such, as have been too tenderly brought up; frequently, they have a full and fleshy appear- ance, but are ill able to sustain fatigue; and the greatest number of them, are found to be of the softer sex. Persons of this description, when seriously attacked with fever, ex- hibit phenomena so various and perplexing, as to make it ex- tremely difficult for a young and inexperienced physician, to avoid mistake. Whilst the ordinary symptoms attendant on fever are scarcely discernible, the sympathetic appearances are intense and alarming, to a degree far transcending a just report of the existing irritation. And very often, at the same time that violent pain, spasms or even convulsions, occur in quick succession, there is no obvious evidence of inflamma- tory action, or of considerable organic injury. In such cases, the morbid influence by which the disease is kept up, is con- fined to the nervous system, whilst the blood-vessels escape irritation. The degree and manner of disturbance of the blood-vessels are expressed by frequency and irregularity of the pulse, whilst the circulation of the blood is not percepti- bly accelerated. The appearances, generally, are such as indicate debility. And this makes the principal difficulty. The debility is indirect, and the use of wine or alcohol will serve only to increase the disease. It is true, excitement of the blood-vessels languishes, as if partially forsaken by the vital powers of the system, whilst there is a morbid determi- nation of those powers on the nervous tissues. On this ac- count,, although wine and alcohol are pernicious, stimulants AGE, TEMPERAMENT, ETC. 193; of a certain kind are found by experience to be necessary; such as first the application, externally, of rubific agents. sinapisms, fyc.—internally, of an infusion of cloves or capsi- cum ; Hoffman's anodyne; Russian castor; assafoetida; lo- belia inflata; oil of turpentine, &c. These articles, judi- ciously administered, have a tendency to correct the morbid aberration of the sensorial influence, and of course, to relieve the nerves by rousing the blood-vessels and bringing forward. a fair expression of the state of the system. When this shall have been accomplished, it is usually found, that small or topical blood-lettings, frequently repeated, gentle aperients, with or without the addition of a suitable portion of calomel, rubific frictions, blisters, &c. constitute the kind of practice which is proper in such cases. And to guard the state of convalescence, the patient should be advised to repose, sub- stituting frequent friction for exercise, till strength is recovered; afterwards, cold bathing, agreeable and mu- cilaginous drinks, a tranquil state of mind; entertaining company and conversation; passive exercise, as riding in a carriage ; and at length moderate labor. By the lymphatic temperament, we mean that peculiar texture of the system, which renders it more liable than oth- ers, to such morbid affections as are particularly referable to the lymphatic system. Persons of this description are more nearly assimilated to those of the nervous temperament. In each of these, the blood-vessels are less conspicuous, than in those of the sanguineous. Those of the lymphatic system, display their blood-vessels least of all. Both are inclined to be fleshy, but the latter most readily become fat. If affected with fever, neither of the two will exhibit a bold arterial ac- tion like the sanguineous system, but the lymphatic patients exhibit a more distinct expression of strong arterial action, and admit of more decisive blood-letting than the nervous. Spasm and other appearances indicative of a prevailing de- termination of the sensorial influence upon the muscles, do 13 194 AGE, TEMPERAMENT, ETC. not attend; and this constitutes the most conspicuous differ- ence in respect to these two temperaments. There is, how- ever, another kind of discrimination, which may be made with great certainty. At the same time that persons of a sanguineous temperament, present a conspicuous display of their blood-vessels, their skin is freely expanded over the whole body, and can be lifted with the thumb and finger, with considerable ease, not being bound down to the cellular substance. But it is not so with persons of a lymphatic tem- perament. If an attempt be made to raise the skin in these, after the manner just described, it will be found to cleave fast to the cellular substance, and to be fitted to such a degree of tightness, as to make it difficult and even painful to grasp or raise it up at all. In persons of this temperament, it would seem, that local irritations do not so constantly make that kind of impression on the general system, which makes up general sensation, and any morbid affection without exci- ting much attention passes into a chronic state; the condi- tion of the organs is changed, morbid secretions are elabora- ted ; new and morbid growth of parts is produced; which imperceptibly go on involving the lymphatics in their vicin- ity; and in many instances the unhealthy condition is exten- ded too far for recovery, before the patient is apprised of any danger ; as is the case, for instance, in suppurative erysipelas. So much for these prominent characters of general tempera- ments. There are temperaments also, which we distinguish with a reference to some particular viscus, each of which, from some peculiar constitutional or accidental condition of its texture, or from some sort of peculiar irritability, is first or most seriously affected by any attack of disease which befals persons of this description. Under this view of the subject, we have persons of a phrenitic tempera- ment, others of a pulmonic temperament, others of a gas- tritic, and still others of a gastro-enteritic temperament; an AGE, TEMPERAMENT, ETC 195 hepatic and so on in reference to any of the organs, which, when diseased can so enlist the sympathies of the system, as to produce general pyrexia. We intend to be understood, that at the same time when one of the three general temperaments prevails, there may also exist a particular or organic temperament, and that the particular affection will be more or less modified by the gene- ral temperament. By way of illustration, a patient of a san- guineous temperament, may be constitutionally or acciden- tally liable to attacks of pulmonitis, as also may be persons of either of the remaining two. Of the three general tempera- ments, a patient of the sanguineous, will be most easily man- ageable, and the disease will be less likely to be followed by an ill condition of the lungs. The lymphatic patient will be managed with greater difficulty, and there will be greater cause to fear that the disease may produce that state of the lung which ends in phthisis pulmonalis. Persons of this temperament, when affected by inflammation of the lungs are liable to effusions, and in the absence of inflamma- tory symptoms, to that particular form of pectoral disease, which is called pleurodynia. Persons of either of the three temperaments, may be liable to gastritis; the case is most manageable and the prospect of recovery best, in the sanguineous. Persons of either of the three, may be intem- perate in eating and drinking, and thus subject themselves to a predisposition to hepatitis. The prospect of the lymphatic patient, in such a case, will be the worst; that of the san- guineous, best. If the liver or any other important viscus be seriously affected in a person of a lymphatic temperament, an extensive catenation of the lymphatic tissues, including the whole glandular system, will be implicated in a manner corresponding to the lymphatic association of those parts of the system. And very often, the parts which are thus sym- pathetically involved, are in the end as seriously affected by the morbid action, are as much distressed with pain and dis- 196 AGE, TEMPERAMENT, ETC organized by disease, as the viscus, which was the original seat of the complaint. The general influence of the nervous temperament is like- wise conspicuous. Persons under its dominion, will often exhibit such entire submission, that at the same time that an alarming organic disease is committing its ravages on some important structure, or viscus, the nervous symptoms are so strong and predominant, that the true cause and seat of the disease which is threatening the destruction of the patient, are with difficulty detected; too often they have remained undiscovered, till recovery was impossible. We have known bilious fever consequent on great congestion of the liver and portal vessels, to commence its attack in the garb of hysteria. Globus hystericus being the chief inconvenience felt by the patient for the first entire paroxysm; and belching, borbo- rygmi, dysuria, &e were the only prominent symptoms, till moderate blood-lettings and frequently repeated cathartics, served to disclose the true character of the disease. Persons of the nervous temperament are very often the subjects of the most serious chronic affections of the liver, spleen, and mes- entery, which are secretly undermining life. The true con- dition of things is not suspected, because the patient com- plains of low spirits, head-ache, habitual cholic and constipa- tion. And so also of many other similar affections, such as dyspepsia and subacute gastro-enteritis. It is important that we should diligently acquaint ourselves with these diversities of temperaments, and, ever intent on the detection of the diseased organs, take care that none of these fallacious ap- pearances, none of these sympathies shall lead us astray. I.ideed, this should be a constant practice in every case of fever. And in all cases attended with pain in the head, tho- rax, or abdomen, we ought to make diligent inquiry into the state of the important viscera; taking great pains not to con- found appearances that are merely sympathetic, with the pa- thognomonic symptoms of the disease. In the mean time, AGE, TEMPERAMENT, ETC. 197 we may profit by our acquaintance with the sympathetic relations, which obtain in various morbid affections, as they serve to prove, that there may be excess of action threatening destruction to one organ, whilst there is deficiency of action in another; making it important that we should find ways and means, to divide, divert, or extinguish the irritation ex- isting in any case. That there may be general debility, at the same time that a morbid excitement is threatening de- struction to some particular organ; of course calling for the employment of some measure, which may divert the excess of action from the suffering organ and diffuse it throughout the general system. With intention to'produce such changes, we associate with the use of internal general agents, the ex- ternal application of issues, antimonial plasters and epispas- tics; all of which are repeated or perpetuated, according to circumstances. The persons of women are more susceptible of injury, their nerves more readily take on irritation, than those of the males. They are liable to diseases peculiar to the sex, as well as those common to both. Moreover, their ordinary diseases are subject to modification through the influence of their peculiarities. The uterus subjects them through a great part of life, to a periodical inconvenience in the secre- tion and discharge of the catamenias. This is liable to be checked or suspended; and when either of these occurrences takes place, it requires the most careful attention. Indeed, so great is the influence which this secretion has on the fe- male system, that it may be considered to participate, more or less, in producing all the extraordinary modifications of the diseases of women. With a majority of the sex, the uterus may be considered the central point to which may be referred, nearly all the sympathetic affections which obtain from the time of puberty, till the menstrjaal secretion disap- pears. So long as this function is preserved in natural con- dition; animation, activity and health abound; ill health 198 AGE, TEMPERAMENT, ETC and a long train of inconveniences soon follow its suspension. If a woman, when in this condition of suspended catamenia, should have an attack of fever, or be subjected to an inflam- mation of any important organ, her disease in either case,will become more difficult to manage, on that account. Inflam- mation or congestion will make more extensive and speedy progress; and if there should be appearances like catamenia, at any time whilst the disease is raging, the discharge, on examination, will commonly prove to be a mere hemorrhage, showing that the uterus, in such cases, is liable to be greatly excited. We have offered these few remarks, with a view to incul- cate the necessity of a strict attention to this important and interesting peculiarity of the fair sex; for when any other irritation may have been instituted for this discharge, it is highly necessary that we should be aware of it in time. Intelligent females universally expect a due degree of atten- tion to a point, in which they all know their sex is so deeply concerned ; and therefore an oversight in regard of it, would inevitably leave an impression unfavorable to the reputation of the profession. If a woman, after some imprudent exposure, by which the catamenia shall have been suspended, should be seized with a violent affection of the head, lungs, or stomach, calling for a copious depletion, it sometimes happens, that a large blood- letting, not only relieves her of her painful affection, of whatever kind it may be, but it will serve also to bring about a complete restoration of the suspended secretion. If, how- ever, this should not follow, it is necessary to add a sufficient repetition of appropriate cathartic doses, aiding them with suitable management, until the ultimate intention shall have been accomplished. If the suspension be the discoverable cause of complaint, then regard must be had to the general condition of the system, particularly to the great blood- making organs. If the suspension be the effect of general AGE, TEMPERAMENT, ETC. 199 debility, it is vain to look for its restoration, until a better state of general health shall be established. If it be conse- quent on some organic disease, the affected organ must be rectified, and then the inconvenience, which is the effect of it, will retire of course. There are also peculiarities incident to women, because of the vastly important circumstances which attend parturition. One of these has respect to the condition of the abdominal viscera, when they shall have been made weak by compres- sion, and injected in consequence of the retirement of that compression. When this occurs, it requires to be treated after the manner of enteritis. Another has regard to the violence of the throes of the uterus, and the consequent rude distension or contusion of the vagina and os externum. In- jury in this way, followed by inflammatory symptoms, will require a treatment like any other inflammatory affection. There is a third which has respect to lactation. If lacta- tion only be implicated, the milk fever is the concern only of a day, and any accidental interruption of the function of the mamma, will often produce great disturbance for a day, but it usually retires on a very moderate degree of evacuation and suitable attention. This inconvenience is vulgarly called the weed. 200 STRENGTH AND DEBILITY, ETC. CHAPTER VI. THERAPEUTICS—STRENGTH AND DEBILITY, TRADES, PRO- FESSIONS, HABITS, &c. When we speak of strength, in relation to the practice of physic, we do not intend merely a healthy and vigorous con- dition of the animal functions, in which we perform with ease and comfort all ordinary exertions; we have respect more particularly to the physiological and pathological cal- culations of strength ; to the expression given of it in the or- ganic action itself, in the motion of the arterial system, and in the support it affords to the vital functions. And when we speak of weakness, we do not intend merely an inability to run or labor, but also that feebleness in the motion and action of the organs essential to life, which is sometimes experienced in the commencement of fever, as also, that spe- cies of debility, which always occurs towards the close of a very violent or long protracted disease. The two states of the system, strength and weakness, are correlative; the esti- mate which we make of them, is always comparative ; and our estimate will be more or less certain or useful, according to the correctness of our standard of judgment, and the accu- racy with which we learn to apply it. To acquire a sound judgment in this particular, is one of the great points of skill in our profession; and an approximation to perfection in it, is within the reach of a well directed experience. There is a difficulty, nevertheless, in making the attain- ment ; inasmuch as the estimate must be accommodated to all the variations of circumstances consequent on difference STRENGTH AND DEBILITY, ETC 201 of climate, education, manner of living, and temperament. The physician should therefore begin to pay attention to this subject, at the commencement of his studies ; and it is proper, that he should be informed at the threshold of his profession, that books, even when aided by the best instruc- tion, will not afford the kind of information, which is par- ticularly necessary in respect to this subject. It must be the result of his own observation. He must pay attention to a sufficient number of instances of the several distinctions above specified, and make himself acquainted with the pulse and general appearances, which mark the healthy and vigo- rous state of each of them. And as opportunity may serve, he must in like manner make himself acquainted with the pulse and other circumstances, which attend on each, when in a state of debility. Having drawn the two lines of dis- tinction, his experience will soon enable him to conceive of all the intermediate grades that can be usefully distinguished, from the highest point of inflammatory action, down to the degree of debility which ushers in death ; a standard of judg- ment, which once regularly formed, will admit of a satisfac- tory application in all cases. Therefore, as early as possible, the student should cary out the investigation in reference to some one particular classification of persons, as often as it may be convenient, until his judgment in regard of that one, shall have been matured. Then, one classification of esti- mates so matured, will afford much facility in the subsequent prosecution of similar investigations. At length, having ac- quired a general view of the subject, he will be prepared promptly to perceive the due degree of strength, or debility, which may obtain in any given case, and to prescribe with judgment. Having attained thus much, he will be qualified to commence the kind of observation necessary to prepare his mind to estimate the marks of debility, as it exists in differ- ent diseases, and in different patients. After these general remarks, we are prepared to notice 202 STRENGTH AND DEBILITY, ETC. some particular kinds of debility, as explanatory of our views. There is one which is expressed by a sense of langour and lassitude, which comes on abruptly, and the cause of which is scarcely known by the subject of it. This is the kind of de- bility, which is felt often at the commencement of fever, and is almost universally the effect of a general fulness of blood, or of a morbid determination of the circulation on the brain, or of an introversion of it upon the abdominal viscera. A condition of things analagous to this, is found to obtain whenever any important viscus is in a state of congestion. It is the more necessary, therefore, to be able to distinguish it with certainty; because the kind of cordial treatment, which would be correct and beneficial in a case of debility, properly so call- ed, would be highly pernicious in this. Physicians have very correctly given to this kind of weakness, the appella- tion of indirect debility, and so long as it is kept up by ple- thora or congestion, the general plan of treatment must be evacuant. And in fact, this kind of practice must ordinarily be continued until the system shall be reduced to the state which is distinguished by the appellation of direct debility. Direct debility, as we propose to distinguish it, is debility in consequence of depletion, inanition, or exhaustion. The organization of the system is to be considered as being entire; or if any organic injury may have had, or still has a place in any instance which may included in the definition, it is to be viewed as already cured, or fairly taking on the condition which we call convalesence; or at the worst, a disease ac- knowledged on all hands to be a disease of debility. It may be produced by loss of blood, either suddenly and copiously abstracted, or by being frequently repeated in more mode- rate quantities. It may be produced by catharsis, diaphorsis, emesis diabetes, inanition, or by protracted disease, as dysen- tary, &c. In each and every case of direct debility, cor- dials, suitable diet, and management, constitute the proper remedies, STRENGTH AND DEBILITY, ETC. 203 There are however a great variety of intermediate shades or modifications of debility, the result of circumstances which take place under the observation of the physician; in which there is an obvious participation of both direct and indirect debility ; sometimes the one and sometimes the other, being most conspicuous. These apparently contradictory circum- stances, take place in many instances of organic disease, and in almost all which become chronic. We have preferred the use of the term intermediate, because the cases in which they occur, require a treatment which necessarily contemplates a qualified and variable course ; such as accommodates itself to the peculiarity of the case. That is to say, we alternate the use of tonics and cordials with that of suitable evacuations ; or we employ such a combination of agents, as is thought to produce a mediate effect. Such is the calculation in the use of alteratives. There is yet another distinction to be noticed, a species of debility, which is produced by too long a continuance in cold and damp places, or in places not sufficiently ventillated, or from which the solar light is excluded. In all these the atmosphere is more or less insalubrious, and vital heat is im- perfectly sustained. Something very nearly resembling the same condition of things, may be produced, by living on in- nutritious diet, or by too rigid abstinence, long continued. It may befall persons engaged in sedentary employments, and more particularly such of this description, as habitually use tobacco, snuff, or opium. In all the cases there is a sim- ilarity of appearance. The subject of it is pale, wan and in- dolent ; the arterial action feeble and inefficient; the arteri- al tube small, and apparently elongated; that is, the pulse is cord like. The very imperfect manner in which the blood is propelled to the extremities is obvious, the red particles are not visible in the skin. After these appearances have continued a sufficient length of time, the absorbent system begins to fail, which is evinced by oedematous swellings of 204 STRENGTH AND DEBILITY, ETC the lower extremities. The tongue becomes tremulous, which with the gums become pale. In all such cases, in whatever way the debility may have been induced, there will be a constant tendency to a concentration of the blood in the vessels of the viscera, and sooner or later, the continu- ed distention of the intestinal vessels, must superinduce some sort of organic injury. The different viscera are not all equally liable to be thus affected, nor the same organs in dif- ferent persons. The pallor affords visible evidence that the skin fails to perform its proper functions, consequently the lungs are compelled to sustain preternatural elaborations, by which they frequently become irritated, and take on latent and chronic phlegmasia, terminating in phthisis. In those who are brought into this state of debility by living on in- nutritious articles of diet, appearances present themselves in form of dyspepsia, cholic, flatulence and eructations, which appearances give notice of the failure of the abdominal vis- cera. The spleen or liver or all the blood making organs become disordered; very often the lymphatic ganglions of the mesentery are involved in the common ruin, which is made manifest by an enlargement of the abdomen attended with marasmus. Here it may be proper to remark, that the reverse of all this is sometimes exhibited, when some one or more of the important viscera are diseased, and all the appearances of de- bility which we have described under this head, are exhibi- ted as the effects of the diseased organs. In almost all cases of this sort, and in many of the former, after the debility has long prevaled, there is produced in the system a predisposi- tion to turgesence of the cellular substance, and of those ves- sels, generally, whose office it is to elaborate and circulate the transparent fluids. It is believed, that this is most com- monly the case, when the subject of it is marked with the peculiarity of structure which we have described under the distinction of the lymphatic temperament. Ordinarily the STRENGTH AND DEBILITY, ETC 205 first visible indication of this state of things, appears in an oedematous swelling of the feet and ankles. We have considered the instances of debility, last describ- ed, as they appear, when produced by remote causes acting on the system according to general laws, and treated the dis- eased condition of particular organs, as being consecutive on the long continuance of the debility which is followed by morbid determinations of excitement, and subsequent disor- ganization of those viscera, or structures, which become af- fected. Although these views will often correctly apply, yet a majority of all such invalids, wherever found, will have had the commencement of their indisposition in some organic disarray ; in some nucleus of congested vessels, which subsequently spreads itself, by an inoculation of the adjoining and corresponding parts, but often spreading itself so insidi- ously, as scarcely to produce painful sensation, even in the organ in which it is seated. And this state of things ought to be suspected, in any or all of those cases, of whatever rank, age, sex, or condition in life, where the invalids com- plain of weak lungs, dyspeptic stomachs, weak and irritable nerves, &c. &c. For want of this precaution, it has often happened, that tonics, stomachic bitters, assafoetida, castor, ether and opium, have been administered, when they served only to amuse and destroy; and in fact, it was necessary to have had recourse to remedies, which are effectual to remove organic disease. In many instances of debility consequent on a chronic affection of some organ, the susceptibility of injury from the improper use of stimulants, is greatly in- creased. Not merely a predisposition to morbid action ex- ists in the affected organ, but an inflammatory condition of the subacute distinction, has become habitual, and the inevi- table result must be, an increase of disease and of general de- bility. A recent irritation, set up in any part or organ, of a person in possession of ordinary vitality, will speedily pro- duce a general disturbance, more or less violent, which will 206 STRENGTH AND DEBILITY, ETC be expressed by the ordinary appearances of pyrexia. But a chronic local affection, to the irritation of which the system has become accustomed, often progresses without exciting a general sympathy, and stimulants might in many instances be administered to an indefinate extent, without rousing the system sufficiently to exhibit a general fever. With these remarks on the subject of debility properly so called, we return to our former position, that indirect debility requires to be treated with evacuation: and we here repeat, that it is necessary to reduce the powers of the system, down to the condition which is direct debility. The lassitude and prostration of strength which attends the onset of fever, is the effect of a plethora. This fullness, under the pressure kept up by the impulse of the heart, supplied with the whole volume of sensorial power, subjects the pulmonary artery and indeed the whole arterial system, to an overwhelming injection; so that the heart itself is enthralled by the un- yielding fullness of the two great arterial trunks, which is inevitably followed by a sense of indirect debility, of fullness in the chest, whilst the thorax seems begirt with an unyield- ing bandage, or pressed down with an insupportable weight, producing a sense of stifling for want of breath. Such a state of things, if not relieved by copious blood-letting and other suitable evacuation, would soon terminate in death. The evacuations must be continued until the quantity of circulating fluids is completely under the control of the pro- pelling power, and of the returning circulation of the system. If no lesion be produced by the injection before the circula- tion is relieved by such a sufficient depletion, the case will not be followed by pyrexia. But if the vessels shall have been injured by the distension, it then becomes necessary to evacuate not only to the degree just named, but to extend it so far, as to induce the state of things which is direct debil- ity, and by appropriate repetition, to secure a continuance of that state, until the system shall have had the necessary time STRENGTH AND DEBILITY, ETC. 207 to repair the injury. The irritation which follows in such cases, and which provokes and maintains pyrexia, is conse- quent on a certain extent of capillary congestion, the removal of which, depends on the process of absorption; which pro- cess will not be performed advantageously, until the system is placed in a condition of direct debility. The same doctrines ought to be admitted in our therapeu- tics in regard of chronic affections, in which we almost uni- versally have to encounter more or less general debility. In these cases, the diseased organ or structure is considered as being in a state of congestion, or at least in a state of irrita- tion ; and although the strength of the patient in the aggre- gate may be below par in view of any given standard, yet very often some depletion is necessary, in order to place the absorbents in a favorable condition. Take a few instances by way of elucidation. The debility which ushers in and attends on a case of pulmonitis, is al- ways the effect of embarrassed circulation. In gastritis, &c. the great prostration which attends, is partly the effect of fullness, but probably more the result of the inconvenience which the nerves of the stomach and intestines suffer, when those organs are brought into a state of inflammation. Inva- lids are rarely if ever attacked, after the manner of those who are overwhelmed with plethora. Such persons if predisposed to organic affections, resist them longer; and in a manner peculiar to their condition retain their usual strength to a later period, than those who are more robust. This last is an important fact. For if we should conclude that weakly persons must be treated with cordials, when they require de- pletion, the mistake will as certainly be fatal to them, as to those who are more robust. It is equally absurd to fortify such invalids against a sickly season, by giving them tonics, bitters, &c. or to brace up those who have narrow chests, or peculiar susceptibility of inconvenience from change of tem- perature, by similar means. The same may be said of those, 208 STRENGTH AND DEBILITY, ETC. who advise stomachics and bitters, because the stomach is affected with symptoms of dyspepsia. Such prescriptions can do no good. On the contrary, they may establish the organic mischief which is already beginning, insidiously, to undermine the lives of the patients. From the whole it will appear, that much care is required to ascertain, in every case of debility, whether it must be placed to the account of the direct or indirect distinction. Also that experience alone can prepare us to adjust the practice, to the one or the other, and still more to perceive the occasions calling for the requisite modifications in treating the cases which need an alternation of cordial and evacuant remedies. A knowledge of the trades or professions of our patients, is often highly useful in conducting our pathological inquiries. And when it can be ascertained, that the disease under con- sideration has been produced by the profession, and especial- ly when known to be peculiar to it, it is often necessary to advise a change of business. If called to a man affected with a violent and unyielding cholic, with great and obstinate costiveness and hardness of the abdomen, it would be impor- tant to ascertain, whether he is a workman exposed to the effluvia of lead, or one who habitually handles substances of which lead is a component part. This kind of inquiry how- ever more properly appertains to a treatise on the causes of diseases and perhaps we may find occasion to notice it again under that head. The influence of habit is no less extensive than it is pow- erful in modifying the condition of the animal economy. It is therefore always important, that the physician should be acquainted with if. If any particular habit shall become in- veterate, health cannot be supported if it be laid aside too abruptly. Those habits to which we here refer, are such as relate to clothing, drink and diet. A man accustomed to eat largely as his daily habit, cannot always suddenly become ab- stemious, without inconvenience and danger. Those who STRENGTH AND DEBILITY, ETC 209' are accustomed to take ardent spirits, must dot be deprived too suddenly of all stimulating drinks. We must gradually diminish the quantity and strength of the customary article, or we must devise a substitute. Facts have demonstrated, that inflammatory diseases are less frequently mortal among drunkards, if we allow them a small quantity of weak wine, and as the lives of such men are very frequently injured by long continued excesses, a strict attention should be paid to this circumstance in order to afford them every possible ad- vantage. Habits of dress require a similar attention. Some people accustom themselves to wear much clothing ; others little v some as to the whole body; others as to certain parts of the body, as the head, breast, feet, &c. These peculiarities, ap- parently of little importance, should not escape our notice. Ordinarily, some real or imaginary cause leads to the habit, which ought to be investigated. By habit, the skin, or stomach, or schneiderian membrane, becomes less sensible of the stimulant, or irritating effect of any agent which may be be applied daily to them. If we wish therefore, to keep up the effect, the application must be gradually made more ac- tive. Tobacco chewers, and snuffers, and dram-drinkers, all learn this instinctively, and sometimes, when any particular article loses its effect, it is found useful to discontinue it for a season, until the nerves which have beceme benumbed shall have had time to recover their ordinary sensibility. It is known that the most poisonous substances become apparent- ly inoffensive if used habitually, with gradual augmentation of the quantity taken. Yet this fact does not justify an in- cessant use of very active medicines. For, although their effects may be imperceptible, they may be deleterious, and eventually end in destruction. The skillful physician guards against the evil in both respects. He gradually increases or diminishes, so as to produce the intended effect, or withholds; 11 •210 STRENGTH AND DEBILITY, ETO. it altogether, if it be found to produce irritation. This rule is one of the greatest importance. The particular fancies or antipathies of our patients, often furnish us useful instruction. Some persons cannot take a particular article of food or drink. We ought to be inform- ed, so as not to advise either. There are some, who are sub- jected to a very inconvenient degree of sickness on taking an emetic, and yet cannot be made to vomit. If an emetic is deemed particularly necessary, in such a case, we ought not to use any article known to the patient as an emetic. An infusion of ipecacuanha, or warm water alone, should be administered in large quantities, until the effect is produced. It would be tedious to enumerate all the circumstances of this kind, requiring attention. There are but few persons who have not some antipathy or partiality for some particu- lar alimentary or medical substance; and it is always im- portant that the physician should acquaint himself with it We have often known serious inconvenience to occur from inattention to this rule. Particular appetites produced by sickness too, claim the attention of the therapeutist. These appetites frequently call for very dangerous substances, and we must guard against their indulgence. Instinct often leads a suffering man to as- sume a convenient position of his body, or to make use of a a suitable beverage. There is some difficulty in deciding when it is proper to obey these calls of nature, and when to refuse them. They may be the result of morbid sensation, and of course are symptoms of the existing disease. If it be known that a healthful condition has not been restored to the viscera, that is, if the disease is still raging, appetites for food or stim- ulating drinks, ought always to be considered as being mor- bid, and they cannot be satisfied without danger. The pru- dent physician will not hastily oppose every such expression of nature's demands. Patients sick with fever, and possibly too long deprived of suitable drink, not unfrequently feel a STRENGTH AND DEBILITY, ETC 211 longing desire to be refreshed with some kind of acidulated beverage. With suitable precaution, they ought always to be indulged. In too many instances, patients in small pox have been smothered under an unreasonable weight of cov- ering, shut up in a close room, and drenched with saffron tea, at the same time that nature clamored loudly for light bedclothes, fresh air, and demulcent drinks.- Thousands of the fair sex, in circumstances the most interesting to human- ity, have been subjected to similar treatment. When in- stinct, as a faithful monitor in each of these cases, would cer- tainly have directed a proper treatment, had it not been op- posed by ignorant officiousness. It is the imperious duty of the therapeutist, to consider the state of his patient, and the known effect of the article or substance which is asked for, by him or his friends. If it promise to be useful, the patient ought by all means to be indulged. If, however, the article proposed be unsafe, then with firmness it must be withhold- en, but it must be done with tenderness. In a condescend- ing and persuasive manner, the physician must endeavor to convince him that it would be pernicious to indulge. And with a view of appeasing the feelings of the patient, he ought to be prepared to furnish some substitute, that may be safely used. Instances occur however, where it turns out that the most skillful may err, and the forbidden article is taken, not only without injury, but obviously with the most decid- ed benefit. In such an instance, address is required to es- cape censure. Ordinarily, the better and safer plan is at once to acknowledge the error. Then as opportunity serves, take occasion to satisfy those concerned, that the mistake grew out of too much solicitude for the safety of the pa- tient. 212 CAUSES OF DISEASE. CHAPTER VII. THE CAUSES OF DISEASE. One of the most important inquiries of the physician has re- spect to the cause of disease. In obscure cases, the want of a distinct expression of the symptoms, or the wide extension, or multifarious diversity of the phenomena which present them- selves, makes it very difficult to ascertain the seat, and, of course, the true character of many affections. To discover its true pathology in cases of this sort, requires a great deal of saga- city. To interrogate the patient, or those about him in an ef- fectual and workmanlike manner, so as to make the investi- gation assume an aspect sufficiently dignified, and to inspire a proper degree of confidence, patiently to hear the details with their appendages, however unmeaning; to collect such auxiliary information as may be obtained from such materi- als ; and then, by the more certain employment and exercise of sight and touch, to secure an intelligible and satisfactory view of the case—this is a task indeed. Experience alone can teach how difficult it is to obtain the truth from patients, either as it relates to the causes of their sicknesses, or the symp- toms by which they were ushered in. In making these re- marks, we do not mean to confine them to those complicated or hidden circumstances which require scrutinous investiga- tion. We include the most simple^facts and appearances, such as it would seem, could not escape the notice of the pa- tient. To judge from the treatises which have been written and published for the use of medical students, they might be led CAUSES OF DISEASE. 213 to suppose, that there is nothing easier than to retrace the circumstances which mark the formation of disease. It is a fact nevertheless; that no investigation can be surrounded with more obscurity, or be more likely to lead to erroneous conclusions. Men are strongly inclined to disguise the true origin of their complaints, and present circumstances and symptoms which have no relation to the case in hand. After having ascertained the seat of the disease, we have to inquire for the cause which produced it. For instance, disease produced by working in lead, by using tobacco, or manufacturing it, or by following sedentary avocations, &e. If well acquainted with anatomy and physiology, we shall always be prepared to form opinions, satisfactorily correct. Guided by these, we are prepared to overlook those occult and hypothetical causes, which took the attention of physi- cians in former times, and investigate the state of any viscus which is the seat of disease. Irritation, produced by what- ever cause, must be corrected. In any case of enteritis pro- duced by worms, it ma3^ sometimes be necessary to reduce the inflammatory condition of the intestines, before we have recourse to anthelmintics. So also in most cases of com- pound fracture, it will be necessary to leave the reduction incomplete, until the inflammation subsides, which may re- quire several days, because the unavoidable disturbance of the fractured parts in operating on the limb, would produce a greater mischief. In treating a case of opthalmia, the con- dition of the general system is first to be regarded; local applications are after considerations. The kind of acute attention which we recommend, will be well exemplified by a case which has been reported by a dis- tinguished French physician. A female was supposed to be indisposed with a disease of the chest. She had a torment- ing cough; a very distressing sense of suffocation frequently recurred ; to these were added a continual head-ache ; dizzi- ness ; a full, hard, and slightly accelerated pulse. In conse- 214 CAUSES OF DISEASE. quence of a sudden surprise, catamenial evacuations had ceas- ed for ten months. A copious blood-letting produced a ces- sation of the painful affection of the head. With a little at- tention the menstrual discharge was re-established; but the cough and distressing symptoms of the chest continued. Further means were used for ten or fifteen days, but with- out success. At length she was observed by her physician, to perform that very remarkable motion which accompanies painful deglutition, and to perform it frequently. Her fau- ces were then for the first time examined. There was a slight irritation discoverable in the pharynx and tonsils, the palate was elongated and filiform, and descended along the root of the tongue, very near to the epiglottis. This was the true cause of the cough. The exuberant appendage of the pallate was taken off, and all the symptoms disappeared. Circumstances similar to these are not uncommon; and the superiority of modern anatomy will enable us, generally to detect them in a shorter time than even the acute French- man required to make this discovery. On visiting the sick room, after decent but short saluta- tion, the first duty of the physician is to examine the condi- tion of the patient, and ascertain which of the organs is in- jured, in a way calculated to exhibit the phenomena under his observation. His researches into the circumstances per- taining to any disease, his discoveries in regard of any de- rangement in the principal functions, all his investigations intended to ascertain the diagnostics of different morbid af- fections, have for their object and their end, a proper know- ledge of the parts primarily affected by the disease. Having obtained a suitable acquaintance with the hurtful agent, which is the cause, and the manner in which it acts in the production of disease ; then with a knowledge of the organ or organs which arc affected, the physician is prepared to conceive justly of the train of injuries which may have been sustained, and understand the phenomena which are from CAUSES OF DISEASE. 215 time to time developed, to institute an appropriate curative intention, and employ the medicament which will be most effectual. Without ascertaining the true seat of the disease, and the condition of the organs which are concerned, there are many diseases which cannot be understood in a manner calculated to insure a safe practice. There are affections of the viscera. which involve the nerves in such a degree as to produce convulsions. Sometimes worms produce the same appear- ances. Severe convulsions frequently occur on the com- mencement of a paroxysm of intermittent fever. A proper knowledge of the causes and seats of diseases, is without question the true basis of correct pathology and successful therapeutics. It is necessary to know the organ which is the seat of dis- ease, in order to select the most suitable remedy. In cases of inflammation of the lungs, we depend chiefly on blood- letting. In hepatitis, after the necessary blood-letting, we rely more emphatically on cathartic agents. In enteritis more bleeding is necessary, according to the apparent strength of the pulse, than in most other diseases, and absolute absti- nence should be considered more rigorously indispensable in inflammatory affections of the alimentary canal, than in almost any other instance of inflammatory condition. except in a case of phrenitis. Digitalis, which is so useful in regulating the action of the blood-vessels in some instances of capillary congestions of the vessels of the thorax, is of no value, in fact it does injury in an ordinary inflammation of the lungs. Cantharides are hurtful to those whose bladder is in an irritated state, but greatly useful in cases of debility of that organ. We should be careful in the study of pathology, to keep our knowledge of symptoms constantly associated with the organs to which they are allied. As articulated sounds are altogether unmeaning, except they are the known expressions 216 CAUSES OF DISEASE. of certain ideas, so symptoms are of no value except they in- dicate pain, or some other affection of a known organ. No solid objection can be raised against an effort to arrive at this kind of knowledge, on account of the fact that post mortem appearances give information only as to the state of things which occurred at the last hour. This difficulty might have more weight, if death never could take place until after the organs had run through all the changes which are implied in their total disorganization. But this is not the case. In- flammation can destroy life, sometimes in a few hours, often in a few days ; and yet, sometimes chronic affections ending in death, may run on for months, and even years. Observa- tion has ;in fact taught us, how long time, under given cir- cumstances, is necessary for the formation of pus, for the thickening of membranes, and other disorganizations. With practice and attention, probable estimates can be made, judg- ing by the violence of the symptoms and the time and cir- cumstances of the case, what the actual state of the diseased parts may have been. We cannot fail to perceive how pa- thological anatomy in aid of scientific physiology, may contribute to the improvement of medical science, and of course, how important it is, that we should carefully im- prove every opportunity offered us for extending our re- searches in this way. Independently of all other considerations, whether they may have respect to the disease in question, or to the patient, the intensity of a pathological affection frequently requires very remarkable modifications in the curative measures which are to be adopted. In a violently inflammatory disease, we must have recourse to blood-letting, and this must be repeat- ed, sometimes frequently and in quick succession. The most rigid abstinence from food and from stimulating drinks, must be prescribed, and in a word the practice must be as decisive as the disease is violent. Any temporizing or half- way measures might be fatal. The time when the cure CAUSES OF DISEASE. 217 ought to have been accomplished will have gone by, and nev- er can be recalled. But when the disease is mild, we use means of less power, take more time, and confide more cer- tainly to the recuperative powers of nature. Moderate evacu- ations, rest, and plentiful dilutions, in such cases may be safe- ly trusted. To judge with certainty and propriety of the true grade of the disease, the power of the agent which shall be found to accord with the strength of the patient, and of course to do all that ought to be done, and no more; this is the consummation of medical skill. It was once deemed essential to good practice to regard the critical days—third, seventh, ninth, eleventh, fourteenth, sev- enteenth, twentieth. On each of these days, it was thought necessary to make especial effort to assist the powers of na- ture to bring about a crisis. All this is now nearly laid aside. Regard is had to the duration of the disease, but this only with a view to keep a proper estimate of the patient's strength, and to judge of the obstinacy of the disease, with which we are contending. - In the commencement of enter- itis, we use a kind of practice which would be altogether de- structive after the patient shall have been prostrated by a long continuance of the disease. When an abscess is threatened we use one kind of treatment in the commencement, (I mean whilst inflammation prevails ;) another after suppuration shall have been completed. And there are times and occasions in all cases of phlegmasias, which we ought to recognize and improve, in order to insure success in their treatment. In the commencement of inflammatory affections, it is alway's important to deplete with the degree of decision, necessary to guard against congestion ; and very often in performing this, a disease, which, if left to nature's powers unaided, would probably continue twenty days, and perhaps destroy life, re- tires completely in consequence of the first day's treatment. We would be understood to teach a doctrine the reverse of what was contemplated, when the critical days were estab- 218 CAUSES OF DISEASE. lished. Physicians, then, looked for a day, which would Invite particular attention to nature's movements, that they might be in readiness to help her to fetch her lingering step over the summit ridge of the disease, that she might have the opportunity of a comfortable walk down the slope of a linger- ing and uncertain convalescence. We insist on a bold and successful attempt to arrest the disease at once, and then leave to nature her well known work of taking care of herself in her ordinary way. The first day's treatment is all-impor- tant, and in many instances it will insure the life or death of the patient. It is the practice of some, to try to perform something like this in the commencement of pulmonary catarrh, and in pain- ful affections of the stomach and abdominal viscera, by quaff- ing down large doses of alcohol, ginger tea, and the like; and then covering themselves heavily in bed, expecting to correct the existing error by provoking an abundant sweat. Physicians may be considered in some degree to imitate this pernicious practice, when, without previous blood-letting, they administer tartarized antimony in the commencement of such affections. It is true, the shock produced by an emetic, when it chances to be followed by a general and equable excitement, may answer a very useful purpose. A copious perspiration or a free secretion from the kidneys, may correct the irritation and produce an artificial crisis. But any attempt in this way, will prove abortive, whenever there is consider- able plethora or very strong arterial action. Indeed, it will make the case more morbid and more difficult to cure, when through failure in the first attempt, recourse shall be had to more appropriate measures. The patient will be subjected to dangers he needed not to have encountered. It may be proper to admit, that we may sometimes adopt a rational plan of treatment and go on to execute it with suitable decision, and after all, fail to effect the changes which we intend. Having been sufficiently circumspect in adopting our plan, there is CAUSES OF DISEASE. 219 no alternative but to reiterate the effort again and again, ta- king care, however, to accommodate the means to the inces- santly decreasing strength of the patient. If we commence with blood-letting, after a certain number of repetitions, blood-letting can no longer be employed, and reliance must be placed on milder remedies, such as under existing circum- stances may have a known tendency to remove the remaining irritation. It is proper to remember, also, that a disease which is inflammatory in its character, does not change its nature nor cease to require the employment of therapeutic means, proper for correcting irritation, although it may be protracted into a chronic form. In the meantime, however, the necessary modifications must be made in view of the tis- sue or organ which is the seat of it, and of the length of time, through which it may have been extended. We reject as absurd, any routine or system of set practice, such as would make it necessary to administer an emetic in the commencement of all bilious or catarrhal affections ; and also such as would make it equally imperious in all cases of debility, to administer tonics and stimulants. Such treatment must be conducted without regard to the nature, seat, and consequence of disease. In either case, much injury is to be feared, and the good which is sometimes apparently done by it, is too uncertain to justify the practice. By improper at- tempts to cure fever of serious character, without blood-letting and other suitable depletion, the cases so ill treated, become protracted, exhibiting foetid excretions, foul and black tongue, accompanied by a general disposition to that form of fever which in former days was called putrid. In the hands of a workman we seldom meet with such rases. Furious deliri- um, hydrophobia, spasm, and convulsions, which so fre- quently occur under bad management, are commonly avoided by a treatment which is really skillful; and true skill, we hope to show in the proper place, will not fail to employ what has been called the antiphlogistic treatment, to a greats 220 CAUSES OF DISEASE. or less extent, in almost every case. By this rational method, a greater number of cases will be cured, and even when cures cannot be effected, while life lasts, the symptoms will be moderate ; even death is stripped of those formidable appear- ances which never fail to attend, when important viscera are still gorged with blood, or their blood-vessels are ruined by fatal congestions. In addition to all the foregoing considerations, we must also have respect to the influence of climate. Every man shows some sign, which is the effect of the climate which gave him birth. His physical organization, his habits of eating or drinking, even his moral character and degree of sensibility, are all more or less modified by the country in which he has long resided. The philosopher, moralist and physician, all read Hippocrates with equal interest, where he describes the characters of the different nations of people known at the time when he wrote. Such is the excellence of his account of them, that the illustrious author of the spirit of laws (Montesquieu) could scarcely make any useful addition to it. Time has not materially changed the pow- erful effect of the laws of climate. In Holland, which is a cold and damp plain, the skin often chilled, performs its func- tions imperfectly; the lungs from that cause are subjected to an unnatural exertion in the performance of their functions. In our low countries and in flat marshy regions generally, persons who can survive, acquire the physical power to live with less blood in their skins. The consequence is, chronic irritation and ultimate disorganization of the lungs, the pre- lude to phthisis pulmonalis. Through the torpor of the skin. the cellular substance and ultimately the whole system of lymphatics, becomes affected, paleness, bloating, dyspepsia and dropsy, are likely to follow in their train, to sweep away those who may escape pulmonic affections. How great the contrast between these people and those who inhabit the equatorial zones. Here the tissues present CAUSES OF DISEASE. 221 a texture corresponding to our ideas of most perfect symme- try, the nervous system susceptible of every impression, even to excess. The muscular system is less vigorous and a pre- vailing inclination to voluptuousness distinguish the inhab- itants of Asia. The abundant fertility of the soil renders it easy to procure the means of living, and the heat of the cli- mate invites to indolence, so that he is almost constrained to prefer a careless and sedentary life, and suffer his bodily vigor to sink into effeminate weakness. The habitual stimulus of the sun's rays, maintains an equable excitement, and in a very peculiar manner promotes a healthful condition of the digestive organs. A short life of pleasure, is of course, the lot of this people. Contemplate such a people in the posses'- sion of riches and repose, surrounded with pleasures, and you will readily perceive how the inhabitants of a northern cli- mate, poor, rough and inured to hardships, were always able to make them an easy prey. And you will understand how the conquerors in turn, became as effeminate and voluptuous as those whom they had vanquished. Hardihood, with little nervous irritability, their sympathies of course not easily en- listed, their organs firm and well balanced performing with facility all their proper functions, an ability to endure fatigue and all the vicissitudes of the weather, wet or dry, hot or cold, such are the distinguishing traits of the inhabitants of northern climates. The face of a country and the means which it affords for the support of its inhabitants, have a. weighty influence over their physical and moral condition and character. In mountainous countries, of whatever lati- tude, where the people are chiefly dependent on the chase and hard labor for their support, we find a strong, vigorous and unconquerable race, always jealous of their liberties and ready to contend for or defend them. Whilst the inhabitants of fertile regions, where every necessary of life is furnished in abundance, almost without care, are tame, indolent and easily conquered. Daily labor performed from inevitable 222 CAUSES OF DISEASE. necessity, can do more than any other thing for the attain- ment of a sound organic structure of the system and the es- tablishment of a vigorous constitution. Indolence and ease, of course, as certainly produce effeminacy. In view of these considerations, the physician has two im- portant points to guard. The first is, to treat the natives of any country, according to their various temperaments and contingencies. The other is, to be vigilant to ascertain the effect the climate has on strangers, and its various effects on such as come from different regions. A deficiency in this kind of observation, dias often led to the destruction of con- quering armies, in different ages of the world. The inhabitants of warm climates, when they pass into damp and cold regions, ought to increase the warmth and quantity of their ordinary clothing, and to be careful to in- sure a suitable degree of warmth to the system every night by using warm and gently stimulating drinks, &e. Their diet should be light in quantity, but consist of substantial materials, indulging moderately in the use of wine or very dilute alcoholic beverages. When the inhabitants of higher latitudes pass into the hot climates of southern regions, it is necessary for them to use vegetable diet chiefly, and flesh very sparingly. And what may seem strange, at first view, their night dresses ought to be warmer than they are accustomed to wear at home. They too, should use a suitable hot beverage on retiring to bed, and regard the utmost temperance in every thing. Persons necessarily going into marshy countries, where bilious and intermittent fevers abound, or where yellow fever, cholera, and dysentery, commit their ravages on the inhabitants, should be careful, in all the above named partic- ulars, and at the same time, avoid those districts where the miasm is known to abound. Every kind of excess or intem- perance ought to be avoided, as if they were infallibly sure to destroy their unfortunate victims. CAUSES OF DISEASE. 223 There are other circumstances in relation to climate, which must be regarded in prescribing medicines. To the vigorous inhabitants of northern latitudes, who have a fast hold on life, we may administer our maximum doses, of whatever article it may be proper to employ; such as copious and decisive blood-letting, and bold cathartics. Those of such as have been accustomed to the use of ardent spirits, or very hearty meals, must not be subjected to too much abste- miousness, and if stimulant means are required, they must be dispensed with a liberal hand. Among the natives of equatorial regions, strict diet, de- mulcent drinks and pleasant palliatives, in aid of minimum doses of appropriate medicines, will be all-sufficient. It is desirable that a more extended investigation should be made, and more careful observation encouraged, in order to ascer- tain what particular organs are most liable to suffer injury from the known different climates, and what the kind of modification which such particular organs assume, under the influence of particular climates. The result of such a course of inquiries, if happily and successfully executed, might be properly enough denominated medical geography. We will conclude with some miscellaneous remarks, such ;)s we could not conveniently introduce under any of the foregoing distinctions. Attention must be paid to the state of the patient's mind. Sometimes there will be occasion for the greatest skill in reli- gious and moral concerns, in order to restore the necessary tranquility of the patient, tormented with unnecessary fears. Sometimes, on the contrary, we meet with such unconquer- able antipathy to the use of medicine, that it becomes indis- pensably necessary to make the patient understand, that the dangers of the case are such, that not only a few doses, but perseverance in the use of medicine will be necessary to prevent threatened dissolution. Much good sense is necessary for the proper performance of either of these . duties. 22*4 CAUSES OF DISEASE. We must also have regard to the effect and the demands of the passing seasons. A physician of acute observation is al- ways prepared to meet the variations produced in the types of the different forms of fever, which occur as the seasons roll round ; so that he may be sufficiently on the alert, not to be taken by surprise. Besides, the kinds of drinks, and the various attentions which are requisite, are also modified by the seasons. During the heat of summer, acidulated and cold drinks, affusion, sponging, wiping, &c. are particularly comfortable and useful to the patient. In most instances, cleanliness and ventilation in the sick room, the speedy re- tirement of the excrements, in a word, the physician ought to afford evidence, that he suffers nothing to pass unno- ticed, which can at all affect the comfort or the safety of his patient. It is greatly consoling to the sick, to see all be- coming solicitude for their safety constantly evinced by their physician. It increases confidence and contributes not a lit- tle to recovery. The young physician will take care to read the various treatises on the practice of medicine as common place ; re- membering that not one, nor all of them together, can give an adequate description of the true state of any patient, or direct the therapeutics by which its management should be conducted. It is his province and his duty, to investigate his own cases like a workman, taking into view the sex. age, degree of strength, the manner of life, and the occupation of each. He must ascertain the seat of the disease ; the degree of violence which marks its progress; the time it has existed, and circumstances by which the patient is surrounded ; that is, the character and ability of the nurse, and the supplies which can be furnished for the sick room. After all these things shall have been duly examined and considered, the therapeutic indication and the details of the practice which are to follow, may be adopted in a workmanlike manner. PART III. MATEEIA MEDICA. PART III. CHAPTER I. INTRODUCTORY TO MATERIA MEDICA. Any substance which possesses the power of producing a remarkable change in the general action of the system of or- gans which constitute the human body, or in any one of those organs, which in certain cases tends to correct a disordered state of the functions, and restore their regular condition, may be considered a medical agent. We give the appellation of medicaments, more emphatically to those well known and tried articles, which having received an established character, have been modified or reduced to a fixed and settled form, and are now presented in a uniform shape, so as to render them most conveniently and extensively useful. The idea of a remedy necessarily implies some disease which the rem- edy is supposed to cure. All remedies are not properly me- dicaments, as many remedial articles are useful only as they may appertain to some Hygiene prescription, as others to cer- tain surgical operations. But all medicaments are to be con- sidered remedies, since we employ them exclusively with in- tention to cure disease. Aliments, medicaments and poison?, are not separated by any insuperable bounds. The state or condition of a patient may be such, that the most innocent and salutary aliments may become fatal poisons; we all 228 INTRODUCTORY TO MATERIA MEDICA. know that the most violent poisons can be employed as the most valuable medicaments. And the old adage is true, that what is an aliment to one man, to another is a poison. Nearly all the substances in nature's wide field, may be made useful to the therapeutist. It is the business of the physi- cian to select those whose efficiency has been established by the experience of the profession, regardless of its natural clas- sification, whether in common acceptation it be an aliment, a medicament or a poison ; to a proper extent following the example of the wise ancients, who confined themselves to the use of substances which were well known, and to the most simple preparations then in use ; when abstinence from food, vegetable decoctions, blood-letting, &c. were the items which composed their materia medica. But they became tired of this commendable simplicity, and combinations of substances the most active or fantastic, or even disgusting, in endless faragos, were made to encumber the pharmacopoeia, until quackery, credulity, ignorance, and that universal mania, a taste for the marvellous, all concurred to hatch, multiply and scatter over the world, numbers of remedies, recipes, and se- crets. Such was the wretched state of things for centuries, and the materia medica continued to wear this appalling as- pect till about a century ago, when all at once the profession laudably set about a reform. The most conspicuous exam- ple perhaps, was set by the great Sydenham of England, who commanded admiration by his successful manner of treating diseases with blood-letting, antimony and opium, almost without other medicines. From that time to the present, this department has been gradually cleared more and more of the useless trash with which it was disgraced, until it may be said in truth that the reformation has been immense. Yet after all,, articles are re- tained which ought likewise to be discharged. By retain- ing in our materia medica, substances, whose effects are equivocal, we inevitably make our therapeutics uncertain. INTRODUCTORY TO MATERIA MEDICA. 229 But if we conform ourselves to the use of real medicaments, and use them judiciously, we shall continue to improve our own judgment and contribute effectually to the advancement of our science. If in this regular and commendable course of procedure, we can make accessions to the catalogue of real medicaments, it will be a source of true complacency to him who may discover a valuable improvement, and of gratitude to the profession and to the world. In administering our medicines, our attention should be di- rected, first, to the effect produced on the stomach, or on any other part of the body, to which its application is made. Secondly, to its effect on the whole vascular system, and on any particular organ. In the third place, to the condition in which it leaves the system, after its agency shall have ceas- ed. And lastly, to the ultimate effect which it may have produced in regard of the course and termination of the disease, for the cure of which it may have been prescribed. We shall not attempt to settle the question, whether me- dicaments produce their final effects, by the peculiar impres- sion made first on the nerves of the stomach, and by the laws of association on the whole nervous system, or by coming in- to contact with a greater number of ramifications of the nervous system by means of absorption. We believe both to be true. But the action of the medicaments cannot be ex- plained by any hypothesis predicated on chemical combina- tion. The laws of life and animal assimilation, are incom- patible with any such opinion. Their action cannot depend on any mechanical power, or impulse, made by them on liv- ing organs, nor by a tendency of the particles which enter into their composition, to penetrate the tissues, or the paren- chymatous substances which pertain to the viscera, and by combining, or uniting, with the animal substance, effect the changes which they produce. All we can know on this sub- ject is, that certain phenomena are produced by the use of certain agents. That these phenomena depend on the pecu- 230 INTRODUCTORY TO MATERIA MEDICA. iiarity of the impression on the part of the agent, and on the manner of feeling and the consequent motion produced by the impression on the part of the body which is the subject of the application. And although any particular agency may invariably produce a similar effect, however often it may be repeated, still the phenomena will vary according to the de- gree of susceptibility or irritability of the system, or of the particular organ which more immediately comes under its influence. This is a fact which should never be forgotten. By way of example; two drachms of the sulphate of mag- nesia, being administered to a healthy adult, would, ordina- rily, produce a very inconsiderable effect, yet this small por- tion, given to a person with an irritable state of the intes- tines, might produce a most alarming state of hypercatharsis. The impression in either case is of the same nature, but in the degree and extent of the cathartic effect, there is a very great difference ; and this is owing to a difference in the state of the system, in the two cases. An epispastic or rubefacient application of limited extent, applied to the surface, or an appropriate lotion applied to the eye, or to the urethra, ordinarily produces effects which are limited to the surface to which the application is made; but this is true only when the system is in a healthy state, or when the disease is such as readily admits of retirement. A weak solution of sulphate of zinc applied to the conjunctiva in a healthy state, will not produce an action implying any permanent inconvenience. But stimulate the eye when it is already irritated, and the local irritation will be increased, producing a general state of pyrexia. The same may be said in regard to the urethra. So also, agents given internal- ly. A moderate dose of quinine administered to a man in health, will only slightly raise the pulse, and when the stimu- lant effect retires, little or no inconvenience is found to re- main. The same dose reiterated a few times, in a case of inflammatory fever, unless the patient shall have been first INTRODUCTORY TO MATERIA MEDICA. 231 prepared by depletion, will be followed by speedy inconve- nience and very often by an increase of fever, which is af- terwards corrected with difficulty. Different remedies are applied in practice to the integu- ments, the conjunctiva, the schneiderian membrane, the ears, mouth, stomach, the rectum, and urethra. It should be re- membered that an agent which may be safely and usefully applied to one of these particular portions of the external or internal surfaces, may be extremely offensive to another. Vinegar, for instance, is perfectly pleasant in the mouth, and may be received into the stomach almost without perception; yet if thrown into the eye, urethra, or rectum, it gives great inconvenience and in many instances would be followed by inflammation. Cantharides may be extensively and usefully applied to the cuticular surface, and the irritation and exco- riation which they produce, accord with sound philosophical therapeutics. If applied internally, so as to produce a simi- lar irritation, the consequence might be fatal. This is a discrimination, therefore, particularly worthy to be kept in recollection. There-can be no doubt of thefact, that medical substances are absorbed. Of course that they aet primarily on the or- gan or part with which they first come into contact, princi- pally the stomach ; that the impression made on the nerves of the stomach, is sympathetically conveyed to the nervous system generally, or to some particular tissue specially, or perhaps to both. And after sufficient time is allowed, cer- tain parts, at least of some agents, are taken into the circula- tion by absorption, and thus coming into immediate contact with a greater portion of the nervous system, serve either to increase the effect, or extend it through a longer period of time. According to these facts, those agents which are known by experience to act on particular organs, or to increase cer- tain functional operations, may be effectual, either directly 232 INTRODUCTORY TO MATERIA MEDICA. or sympathetically; but we are inclined to the opinion, that we are chiefly indebted to the sympathetic relations which obtain among all the organs and functions of the body unit- ing and constituting them one great whole, for the most in- teresting phenomena which claim our attention, in regard of the modus operandi of the best medicaments known to the materia medica. The nerves of the stomach receive the im- pression of the agent employed, through them it is conveyed to the sensorium, when the whole system becomes generally interested, and such organs specially so, whose structures and functions are more particularly calculated to be most excited by the impression. Hence the sympathetic effects, that is, the supposed specific effect of medicaments are ordi- narily proportioned to the intensity of the first impression. Hence also the sympathetic affection in most instances, commences, increases and terminates, with the correspond- ing phenomena, which give notice of the general impres- sion. We introduce into the stomach, wine, opium, camphor, oxymel of squill, kermes mineral, digitatis, &c, the ultimate consequence is, that one excites general action only, another induces sleep, another excites diaphoresis, another increases the secretion of urine, and another diminishes the power of the heart. The first impression is made on the stomach by each. The ultimate result differs in each, and experience alone can make us acquainted with the specific differences which mark their modus operandi. The same, diversity of appearances attends when any of these agents are properly introduced into a vein. We make our applications chiefly, however, to the stomach, to the lower intestines, and to the *kin. But these surfaces may vary in respect of their sus- ceptibility of the impressions which may be intended to be made, either on account of the state of the nerves generally, or of those of the stomach, &c. particularly. The whole system may be so prostrated, that the medicaments will pro- INTRODUCTORY TO MATERIA MEDICA. 233 duce no sensible effect; or the tone and sensibility of the stomach may be so reduced, that an ordinary portion of the most powerful agent seems to be quite inert. Let the ener- gies of any person be exhausted by great fatigue, and he may take an unusual quantity of any appropriate stimulant, not only without injury, but with manifest advantage. If the pneumogastric nerve of a horse be divided, you may give him as much of the nux vomica as would serve to kill him, had not the nervous communication been first cut off. If the stomach be in an irritable state, those agents which ordinarily soothe and tranquilize, serve only to increase irri- tation. When medicines are absorbed, it is not important to know whether the lymphatics or the veins are most concerned. The coloring matter of madder, the odoriferous principle of turpentine, camphor, alcohol, essence of lemons, &c. are found to pass into the blood, and are eliminated by the secre- tions. Then of course medicaments administered at any time will be more or less effectual, as the absorbent system is more or less ready to bear its part. But as to the various modes and degree of fitness or unfitness of the whole system of nerves, or of those of the stomach or of the absorbents, it remains yet unsettled. It is hoped that the zeal and indus- try of the profession, will not cease, until all that is necessary to be known, will have been ascertained and settled. In tetanus, either the assimilating power of the stomach is so much increased as to change the nature of very large por- tions of opium and prevent its usual effect, or else the stom- ach and prima vice axe too insensible to feel, and the absor- bents of those organs too inert to convey it into the circula- tion. Enormous quantities are administered without any discoverable effect. In the same disease, this article intro- duced into the veins, acts in the usual manner. It has been long known that if injected into the rectum, opium is more effectual for the correction of nervous irritation, than when 234 INTRODUCTORY TO MATERIA MEDICA. taken into the stomach. And in this view of the subject it is particularly worthy of remark, that any of the important medicaments which produce special effects as if by an elec- tive action on some particular organ, produce the same effect if introduced into a vein, which they always do when taken into the stomach, or if applied by friction on the skin. So emetics, cathartics, narcotics and diuretics, will severally direct their effects upon the stomach, the intestines, the brain, and the kidneys. Dr. Hale made an experiment on his own person, with ol ricini. It was followed by an oily and nau- seous taste in the mouth, pain in the intestines and with de- cided catharsis. Now if it could be ascertained, what articles most certainly admit of absorption, by what phenomena the physician is to judge of the effect, how to regulate, restrain or render more active, articles which may be safely used in this manner, it might become very important to the therapeu- tist. It would not only give a more extensive control over the maladies of the human family, but it would eventually contribute much towards a definite understanding of the mo- dus operandi of medicines. Perhaps much additional infor- mation might be collected, if practitioners would make more frequent, extensive and careful application of remedies to the skin. It is admitted that the stomach and intestines promise a more ready and complete absorption of medicinal substan- ces. But it is a fact that they possess elective and Tepellent powers also, and are protected by an exquisite sensibility. Besides, they are endowed with the power of assimilation which can modify, and to a considerable degree diminish, the power of any agent applied to them, so that the manner in which the system is primarily affected by them, must re- main very uncertain. In making experiments on the skin there can be but little difficulty and almost no hazard to the patient. Experiments by venous injeetion must necessarily be difficult and always dangerous. But we shall have occa- INTRODUCTORY TO'MATERIA MEDICA. 235 sion to say more on the subject of the skin in our subsequent chapters. There are some important considerations which ought to be kept in recollection, which regard the condition of the body after having undergone the operation of certain impor- tant medicinal agents. An emetic, for instance, when it may have been most distinctly indicated, and carefully and properly administered, often leaves the stomach in a state of irritation, which acid or fermenting drinks do not fail to in- crease, and sometimes they produce very serious effects. Narcotic substances, administered in portions, but a little too large, frequently leave the system in a dull, stupid condition, which may readily become dangerous. These inconvenien- ces should be foreseen and avoided. Blood-letting, at the same time that it reduces the arterial action temporarily, to a certain extent produces a converse effect on the nervous sys- tem, and if at all ill-timed will require an opposite treatment. If a person of nervous temperament be the subject of such treatment, and the error be not timely corrected, spasms and even convulsions may be induced. The application of the most emollient poultice, too long continued, might be fol- lowed by such a state of relaxation, as to require for its cor- rection, the use of roboratives and tonics. It is important that we be prepared to anticipate the immediate and secon- dary effects of the various agents which we employ. A de- ficiency in this kind of information, might not only endanger the life of our patients, but must inevitably endanger the reputation of the profession. 236 MEDICAMENTS. CHAPTER II. THERAPEUTIC POWER AND VALUE OF MEDICAMENTS. After the foregoing prefatory remarks, we come now to the consideration of the therapeutic power and value of medicaments. It is presumed that we are already suffi- ciently prepared upon this subject to perceive, that no medic- ament possesses that kind of mysterious and indefinable property, which imagination assigns to a certain antidote or specific remedy. No well informed physician will believe that any chemical, vegetable, mineral, or animal substance, possesses a power, by which it can directly put to silence the morbid motions which constitute disease ; restore to natural condition the morbid enlargement and indurations, which are consequent on many chronic affections; or change and re- store to a healthful state, the great volume of sickly fluids, rendered morbid by a long continuance of a disease of some one or more of the important secretory organs. None but empyrics, or the dupes of quackery, believe there is any such medicine. The most enlightened and skillful physicians are most ready to admit the uncertainty of the therapeutic eflect of remedies. And it will be found that the most judicious are in the habit of employing the fewest number of articles, and those few in their simplest forms. When a practitioner of medicine shall have administered any one of the boasted medicaments aud looked in vain for promised effect, until sick with disappointment; when a discreet judge of the seat and power of any disease, and of all the complications which it MEDICAMENTS. 237 may involve ; and one who knows in how many instances, cases are presented which are altogether unmanageable; when any such capable physician, has for a long time, in reiterated instances, proved the inefficacy of supposed medic- aments, his good opinion of such uncertain articles must di- minish, and he will daily be engaged in lessening the cata- logue of his materia medica, and in simplifying his practice. It is now sufficiently understood, that any medicine makes its sensible impression on some important organ, generally exciting it to a more active performance of its particular function. And that the impression, although a proper one, may be nearly or altogether useless, by being too slight; or it may be satisfactorily effectual, by being sufficiently decisive. In the administration of remedial agents, the medical philos- opher calculates on physiological effects to be produced, either locally or generally. There is nothing dark or mys- terious in his calculations. He knows the structure of the human body, he is satisfied as to the diseased organ, he knows the nature and power of the disease ; he knows more- over, what medicaments to employ. He foresees the neces- sity of certain changes in the condition of the diseased or- gan, and what agent is known by the profession, from expe- rience, to accomplish the intended effect. His calculation is therefore always simple, and readily tested. And if at any time, he may meet with difficulty, it is because he is not in- formed of the seat or nature of the disease, or he is not ac- quainted with the kind of impression which is necessary for its removal, or with the medicament which is suited to make that impression ; or else the disease is such as must fairly be considered incurable by any known remedy. If we admit the existence of a specific remedy; of a med- icament which possesses the power directly to destroy the disease for which it is the infallible antidote, we must admit, that it possesses sui generis a hidden principle, which lays hold on the organic structure of the part diseased, and 238 MEDICAMENTS. compels it to return to its natural state—an absurdity, a folly, which has no place in science. If each medicament had claim to a specific power, then none would be effectual, ex- cept only in the particular affection for which it is specifically appropriate. But it is now known, that in many instances, the same kind of disease, and in similar circumstances, is cured by agents of opposite powers. Fevers produced by marsh effluvia, are cured by depletion; they are also cured by the liberal use of the potent tonic agent, quinine. More- over if medicaments act by means of specific virtues, then of course, they ought always to be in some degree appropriate, in the respective cases in which they are the reputed anti- dotes ; that is, they ought infallibly to cure, or at least to diminish the violence of the disease. But how is the fact. Quinine which at one time corrects an intermittent fever, at other times increases the power of the disease, and instead of postponing, brings about a hurried anticipation of the parox- ysm and renders every symptom more alarming. A tonic, which always ought to produce an increase of strength and comfort, if at all ill-timed, will greatly increase debility, and if persisted in, destroy the patient. A pectoral preparation, well-timed and appropriate, facilitates the discharge of the mucus, by improving the condition of the exhalents, and like a charm soothes and relieves the patient. Administer the same remedy in a cough accompanying considerable pyrexia, and it will not only fail to give relief, but will greatly aggra- vate every inconvenient symptom. Hence it appears, that anti- spasmodics, tonics, diaphoretics, diuretics, and even emetics and cathartics, are able to produce each their proper effect, then only, when they are made appropriate, by the judgment and skill of the experienced workman in the profession. A classification of medicines, therefore, under these and similar heads, without much precaution, is calculated very seriously to mislead the young physician; and indeed the same may be said of the whole volume of nosology. Tonics, febrifu- MEDICAMENTS. 239 ges, aperients, and the like, are deceitful appellations, and have often led the inattentive far astray. The same has been done by the association of a specific remedy, with the name of a disease. An intermittent or remittent bilious fever is announced, and the principal remedy is quinine. A syph- ilis is announced, and the remedy is mercury. But the dis- cretions which we have had under our consideration, have taught us that, easy as this association of the name of the disease and its supposed appropriate remedy seems to be, it will require much skill and attention, to make a proper use of either of the articles, specified in the cases referred to. The organs essential to life exhibit impressions of motion or action corresponding to the expressions made on them by the medicaments employed in view of affecting their condi- tion, respectively. The motion or action thus artificially ex- cited, will be either in concert with, or in opposition to the motions and actions produced or maintained by the injury or morbid condition of the organ concerned, which the artificial action of course is intended to diminish and remove. The excess of natural ac tion is to be put down by extinguishing a portion of vitality, or removing some irritating agent, or wearing down the mobility by exciting and maintaining an action stronger than the natural action, till the irritated ves- sels shall have become sufficiently tired to take rest and re- turn to order. A sick stomach is often cured by vomiting, a diarrhoea by a cathartic; an intermittent fever by maintaining uniform excitement through the tonic power of quinine, and an erysipe- las by the proper application of external heat. A sick stomach under other circumstances is relieved by the use of opium and carminative drinks, as clove tea, &c. A diarrhoea, under similar circumstances, is likewise arrested by appropriate do- ses of opium ; by astringent and cordial drinks, and by in- jections. An intermittent fever by keeping the patient in bed, and excluding light, and sometimes by the exhibition 240 MEDICAMENTS. of a portion of spider's web. And erysipelas, in the form of shingles, will retire on the eighth day, under the application of dry meal or black cat's blood; that is, it will retire spon- taneously. Apparently the same disease is removed by the use of stimulants of sufficient power, or by a copious blood- letting, the most opposite practice that could possibly be adopted. Note by Dr. Snyder.—" Medicinal substances are those bodies which by due administration, are capable of producing certain changes in the condition of the living system, where- by its morbid actions may be entirely removed, or advanta- geously controlled." This definition excludes aliments. Medicines are relative agents: Sir GilbertBlane, states, that " The virtues of medicines cannot be fairly assayed, nor ben- eficially ascertained by'trying their effects on sound subjects; because that particular morbid condition does not exist which they may be exclusively calculated to remove. An instance occurs in tonics, which are felt in debility, but whose effects are not noticeable, or wholly inappreciable in a robust condi- tion of the body. The effect of a remedy may depend upon mechanical, chemical, or vital agencies. They may be absolute or rela- tive ; primary or secondary; local or general; direct or sym- pathetic ; permanent or transient. Some purges are nearly absolute, as elaterium. Diuretics depend on a certain con- dition of the body, therefore are considered relative, &e OF THE SURFACES, ETC. 241 CHAPTER III. OF THE SURFACES TO WHICH MEDICAMENTS MAY BE APPLIED, AND THROUGH WHICH, IMPRESSIONS MAY BE MADE BY MEDICAL AGENTS. Some intimations have been given respecting the surfaces to which the therapeutist may make the application of his medicaments. There are, however, no more than two upon which we can generally rely. The one is the skin, that is the whole cuticular surface of the body. The other is the mucous membrane, that is the inner surface of the stomach and lower intestines, the schneiderian membrane, the tongue, fauces, urethra, &c. In making our selection of the surface on which we shall attempt to operate, it is necessary that we consider the effect we wish to produce, the state of the several organs or surfaces which are to be the subjects of our choice, and the probable duration of the treatment, which the case will require. If the intention be to use an irritating agent, and which is to be continued a long time ; as is frequently the case in the employment of mercurial remedies; when much stress is laid on the absorption of the article, and especially if the stomach and lower intestines are easily disturbed by its agency, we should prefer an application to the cuticular surface, or to those parts of the mucous membrane, which are less disposed to involve a serious effect on the peristaltic action of the bowels. This method is often employed in the cure of syph- ilis. So the muriate of gold is applied by friction to the tongue. In this way, the effect of the remedy is secured at the same time that the alimentary canal is protected. But 16 242 OF THE SURFACES, ETC. the stomach and intestines, by reason of their peculiar sus- ceptibility of any intended impression, and of the great power of absorption with which they are endowed, present the surest channel for conveying into the system, any ordinary medicine; and therefore physicians generally, have their chief reliance on these, in their therapeutic operations. The great point is, to be prepared to make our application in a manner, which shall accord with the degree of vitality pres- ent, in every case. To be sufficiently decisive without ex- tinguishing the powers on which our therapeutic intention is dependent for success—remembering, that if rightly and de- cisively administered, potent agents are truly medicaments: if with timidity, and in too small portions, they are no better than inert substances; and if in portions too strong, they are poisons. When the stomach is too irritable to admit the use of some important article, the rectum presents a surface, which is capable of a very active absorption. It can be excited, too. in a manner to produce powerful revulsive motion, even tar- tarized antimony will in some instances produce its emetic effect, more agreeably when employed as an enema, than when taken into the stomach; especially so in cases of young children. In some of the hospitals of France and Great Britain, fumigations of mercury and other agents have been applied to the lungs, it is said not without benefit. It would seem probable, that this practice might be improved, and that the time will come, when vapors of suitable powers will be inhaled with certain benefit to the patient. The mucous membrane of the vagina, or of the urethra, the eustachian tube, the inner surface of the ear, the con- junctiva of the eye, are scarcely ever subjected to the appli- cation of medical agents, except only in the instances when any one of them is treated for some disease of which it is itself the seat, and nearly all such cases ibelong to the de- partment of surgery. OF THE SURFACES, ETC 243 ?-------------------------- In speaking of medical applications to be made to the skin, we must call attention to the fact, that some are more effec- tual when applied to the reticular surface, when it has been stripped of the epidermis. The cellular and vascular expo- sure of wounds, present surfaces which perform very active absorption, and any action excited in them, is very speedily propagated and extended over the whole organic structure.* Vaccination acts in conformity with this law. Mercurial applications made in this way, in a short time produce sali- vation and cure syphilis. The same agent applied to chan- cres and buboes afford strong evidence in support of the fact. Arsenic applied to ulcers having been absorbed has produced death. Cantharides applied for the purpose of blistering, have irritated the neck of the bladder to serious inflamma- tion. Messrs. Chiarenti, Alibert, Pinel, Dumeril, Brera and others, have multiplied experiments in this way, and through cutaneous friction, have produced the proper effect of cathar- tics and diuretics ; also the tonic and febrifuge effect of quinine and other therapeutic agents. Messrs. Lambert and Leseiur, have in like manner introduced almost all the articles of im- portance which are known to be taken up by absorption. Substances employed in this way, have been denominated by the French physicians as emplastro-dermique. Such arti- cles ought to admit of great concentration of power in a small compass. When known to be very irritating, they are in- corporated with cerate or gelatin. If they have a tendency * Dr. A. J. Wedderburn has reported in the New Orleans Medical and Surgical Journal, (January No. 1846,) several cases in which the sulphate of quinine applied freely in substance, to the surfaces of ill-conditioned and indolent ulcers produced the most speedy and salutary changes. We have applied the sulphate of morphia to the abraded surface which had been previously blistered, for the correction of the most alarming and pain- ful condition of the abdominal viscera, with the most decisive and beneficial effects. From one to three grains was sprinkled over a surface of from four to six inches square. The effect is the same whether we use the sulphate or acetate of morphia. The article in such eases should be ground up with a little loaf sugar and gum arabic. 244 OF THE SURFACES, ETC. to cicatrize or heal easily, they are united with epispastic pomatum. With the acetate of morphine, they have cor- rected the distressing watchfulness which often afflicts the sick, particularly nervous patients; eased the racking pains of patients in chronic rheumatism, and relieved or cured ob- stinate pulmonary catarrh. By the application of sulphate of quinine, intermittent fevers, tertians and quartans, have been cured, after having been long treated in vain with cinchona and quinine in the usual way. A very distressing neuralgia, accompanied with symptoms of hysteria, was cured with the greatest ease and expedition, by the external application of acetate of morphine mingled with assafoetida. A case of tetanus produced by the application of nux vomica to an ex- coriated blister, was instantly relieved by the acetate of mor- phine. This fact would justify a hope of our being able by this method, to cure tetanic affections. Musk, digitalis, chrystals of acetate of lead, applied to vesicated surfaces, have relieved diseases of the heart, pulmonary congestions, and affections partaking of the nature of asthma. In quoting these instances noticed by modern French au- thors, it should be remembered, that in making the remedial application, an issue, or what is equivalent to an issue, is es- tablished at the outset, and as the treatment is to be contin- ued a sufficient length of time for effecting recovery, it is not improbable that the sympathetic irritation may be entitled to a goodly share of the credit which is given to the quinine, acetate of morphia, musk, digitalis, &c. We have no intention, however, to detract from the merits of this kind of practice. We hope it will be continued, and reiterated under the necessary observation, until it shall be satisfactorily understood, how far credit is to be given to absorption, and how far to irritation merely. The introduc- tion of medicaments into the veins is out of the question, except for incorrigible mania, tetanus, &c. Therapeutic agents probably make an impression winch OF THE SURFACES, ETC 245 has a tendency to change the condition of the tissues, as well as to modify the action of the organs. It is desirable to as- certain the changes which take place in both the solids and fluids of the system, when affected with disease. As yet, however, much remains to be done. When and in what manner medicaments produce changes in the constituent ma- terials, which form lymph, or blood, is an inquiry of great difficulty. It is equally difficult to ascertain, how far the therapeutic effect may depend on such changes. The old doctrines, which proposed to render the blood thick or thin, or sweet or more acid, or alkalescent, are now all exploded, and modern science has not left us a substitute. The re- ceived opinion is, that medicines act on the living organs, after the manner of ordinary or natural stimuli. t Under their influence vital actions return to their natural state, the con- stituent principles of the fluids are duly elaborated, the solids are refitted, so that the several tissues develop themselves and perform their functions with suitable activity; and the most we know with certainty is, that these changes are con- sequent on the impression made by therapeutic agents upon the living organs. And although particles of the medicinal substances which may have been employed, have been de- tected in the blood, bile, lymph, urine, or other recrementi- tious and excretory fluids; it affords no satisfactory evidence, that the good effect produced by the remedy, depended ma- terially, if at all, upon this apparent combination of the med- icine with those fluids. Such appearances are worthy of no- tice, however, and sufficient acumen and observation may one day turn them to account. There can be but little doubt entertained, that the agency of medicaments is felt by the tissues, whose condition can be usefully affected by any appropriate agent. The skin under the influence of proper remedies, can be made to take on its white, smooth and even surface, after it has been covered with pustules or scabs, w 246 OF THE SURFACES, ETC thickened to an unnatural degree. The muscles after hav- ing been lank, languid and devoid of strength, become full, firm and strong, under the use of suitable medicines. Mem- branes which have been relaxed or rigid, are restored to their proper condition and to the performance of their regular functions ; even bone, which has been softened by a disposi- tion to scrofula and rachitis, has been made to recover its proper degree of firmness and solidity. Inflammation, con- gestion, or sanguineous engorgement, unnatural growth or enlargement of parts, all, are made to retire or at least to abate their progress, under the influence of well conducted medical treatment. The therapeutist can effect an increase or abatement or a regulation of. the functions. Digestion, absorption, secretion, circulation, respiration, sensorial energy, even nutrition, are all, more or less subject to his discretion. An increase of the functions may be produced directly in cases of debility, by the employment of appropriate cordials and stimulant means. But when they become languid by reason of too much fullness, which is the case in most instances of fever, the same object is to be accomplished by opposite means, in an indirect way—say, by depletion, and perhaps it may be- come necessary to call to our aid, the means which promote an increase of secretion. Functions when performed in a morbid way to excess, are made to abate also by similar ap- plications of direct or indirect means, and their regulation in general, is accomplished by the employment of either stimu- lant or evacuant medicines, as the case may require. These remarks are intended to be considered in view of disease of recent date and of short standing ; in almost all of which, it will be found on experience, that they are perfectly appropri- ate and include all that will claim attention in respect of the general treatment. But the functions are often put out of condition, by organic diseases of long standing, and in all OF THE SURFACES, ETC. 24 such cases, the employment of the means, just now men- tioned, will be altogether unavailing, except so far only, as every one of them may at any time become a constituent part of a plan, instituted for the purpose of removing such organic injury. -<, Organic disease, if not removed on its first attack, and of course if permitted to assume a chronic form, has a constant tendency not only to alter the particular organ which is the immediate seat of it, but eventually to throw the whole sys- tem of organs into disarray. In such cases the physician will find it necessary to proceed with great circumspection and judgment; without which there can be no hope of suc- cess. He must be prepared to investigate, nay, as if to pen- etrate the condition of the organic structure, in order to as- certain where the original seat of the disease is, to know the progress with which it has entangled other organs, and deter- mine upon which of those to commence his operations. Irritations must be diminished or diverted away from the points on which they have been habitually fixed; associa-N tions of motions or irritations must be dissolved, morbid de- terminations must be called back to the channels from which they may have wandered, the nutritive functions must be guarded and modified, and such general arrangements made, as may bid fairest to promote the accomplishment of the lead- ing intention, which is kept in view. This part of our prac- tice always requires time. The disease may have been months or years in establishing itself; it cannot be recover- ed in a day. Such cases will call into use all the medical science we can collect, and will give employment for our utmost ingenuity. We must devise suitable aliments, such as will support the patient without aggravating the disease, and we must preserve animation whilst in the use of articles inevitably more or less deleterious. The ancients, on observing that diseases were in many ca- 248 OF THE SURFACES, ETC ses complicated, with intention to meet them under all cir- cumstances, introduced the use of compound medicines, so that, let the disease be howsoever occult, some one of the ingredients might, by chance, be its antidote. In avoiding this ridiculous error, we must be careful not to run into the opposite extreme. We may find it necessary to turn atten- tion to more than one organ at 'once. A person laboring un- der the distress of a chronic hepatitis, may by some casualty be subjected to an inflammation of the lungs, to an attack of enteritis, or an inflammatory rheumatism. In any such in- stance of complication of disease, we attend first to the symp- toms which are most painful or dangerous. Inflammation of the lungs, enteritis and inflammatory rheumatism, require blood-letting. But as the liver is diseased, it will be neces- sary to modify the practice with a suitable reference to the condition of that viscus. That is, more catharsis will be re- quired, more time, and more careful attention to the conva- lescence, and after all other symptoms shall have retired, it will be particularly important to review the state of the viscus which was previously affected. Something like this should be the management in all cases of complicated affec- tions. It is now asserted by many physicians, that all medica- ments are either stimulants or sedatives ; acting generally, on particular organs, according to the principles above stated. Our experience has led us to believe, that all medicines, from whichever of the natural kingdoms selected, do act primari- ly as excitants, making their impression first on the part with which they come into contact, and extending an influence, which, according to the phenomena that follow, has served to distinguish their therapeutic characters and merits. And that most, if not all, might be used in such a way, as indirectly to act as sedatives. Of course we can come to no other conclusion but this, that there is no medicine which OF THE SURFACES, ETC. 249 :s directly sedative, although opium judiciously administer- ed when necessary, admits of being used with that intention, with speedy success. At the same time that all medicines are really excitants, the experience of every day proves, that on the use of some particular articles, certain particular organs and tissues give evidence of their particular excitement, and that under suita- ble circumstances, the same results pretty uniformly follow their use ; as if an impression were made analagous to that which attends upon the insertion of the vacine pus, or that of the variola, or that which follows the touch of the syphilitic matter, or the influence of the effluvia which is disengaged from the bodies of persons afflicted with variola or rubeola. So it appears that sulphur affects the skin of all who use it ; antimonial pomatum, or cerate, produces an eruption which is similar in all cases in which it is applied. Digitalis is thought in all cases to reduce the action of the heart; nar- cotics produce nearly the same effects in all similar instances on the nervous system; nitrate of potash on the kidneys; iodine upon the lymphatics; and mercury upon the liver and its appendages, and upon the salivary glands. That these articles, as well as all others, first act on the general system, before they affect the organs which are lia- ble to be permanently excited, is an important consideration. It is often the case, that the general action of the system is such, that the first impression made by any one of them, has a tendency to defeat the object which is contemplated as the ultimate intention. Digitalis, for example, if administered in a case of pulmonary inflammation, will be found altogeth- er inappropriate. Yet the same article in a chronic affection of the lungs, consequent on having relied on insufficient blood-letting, sometimes acts most effectually. Digitalis, then, excites too much on general principles, to be appropri- ate in cases of great recent inflammation. But when there 250 OF THE SURFACES, ETC. remains some effects of congestion in the capillary vessels, which keep up irritation, the excitement given to the system generally by the digitalis, seems to convey additional energy to the capillary absorbent vessels, and make an impression on the heart, which, for a considerable length of time, in a very peculiar manner, renders it less irritable to the touch of the blood, which it is compelled to admit at every diastole. Our conjecture here may possibly be incorrect, but we have sev- eral times used digitalis without effect, and judging that the excitement in each instance was too strong, we have let blood, and immediately found our expectations realized. Every man of experience in the practice has found cases in which the general action of the system was too great, or its suscep- tibility of being excited too acute, to acknowledge the power of mercury, even as a cathartic, and very often as a sialagogue or general alterative. This is so common that it is now a settled rule, that in almost all cases, the use of the article ought to be preceded by sufficient blood-letting. The same may be said of antimony as a diaphoretic : of nitrate of po- tassa as a diuretic, and even of jalap and calomel as cathar- tics. That there is some peculiarity of impression made by each particular agent, which is inseparable from its touch when introduced into the system, is a truth as certain as that the effect is a general one. For this is proved by the uni- formity of the particular phenomena which follow the use of each. And in fact, we are inclined to believe, that the gene- ral impression would appear to observation, to be identi- cal throughout the system, if every organ were prepared to make report. Hence it is, that in frequent instances, when emesis is expected, we are met with catharsis, and vice versa with both, when one only is desired. And it is from this cause, that we sometimes find it impracticable to procure the particular effect at all. Nothing is better known to the prac- tice, than that very often a desire to procure a salivation is OF THE SURFACES, ETC 251 defeated by an incorrigible tendency of hydrargyrus to act on the bowels. This fact calls to mind another considera- tion, the reverse of that just now disposed of; which is, that as all medicines first make an impression which enforces a general action sui generis, before the particular action can be exhibited, which is only consequent on the general action, therefore, it is as indispensable that the powers of the system should be able to sustain.the general action in this last men- tioned instance, as that they should be reduced down to an appropriate standard, when too high to consent with the peculiarity of impression which it is intended to make. These remarks in some sort explain the obscure and mys- terious subject of specific action. Whatever kind of an im- pression is made by any article of the materia medica, it is felt by the whole system, but by some one organ more par- ticularly and for a longer time. This is the whole account of specific action. In further confirmation of the correctness of this viw, we add, that syphilis can be cured without mercury, cinchona can be substituted by a great variety of stimulating articles, in the cure of intermittents ; tetters, ringworm and itch are cured without sulphur, and except vaccination for preventing variola, there is almost no remedy which cannot be substituted by some other, in almost any case ; which proves unequivo- cally, that there can be no absolutely specific action, according to the general acceptation of that word. Again, as our medi- cal agents are all excitants, with greater or less power, and have a tendency to determine the sympathies of the system, one to this organ, another to that, it is within the ability of the therapeutist to divert those sympathies when determined by disease upon any particular organ, to some other, so as to produce what is called a revulsion. In this way, in the com- mencement of an attack of sickness, a decisive emetic or ca- thartic is followed by a complete restoration to health; but 252 OF THE SURFACES, ETC. if the operation of either be too light to accord with this view of revulsion, it will generally be ineffectual. A sore ptyalism will serve to cure some species of head-ache, by the same law, or a reiterated irritation of the primas vise with light doses of calomel and ipecacuanha, will cure a dysentery in some of its forms. It appears very clearly, that the therapeutist must know the character and power of the articles he is to use in his profession, the general action, and the effect of that action on the general system; the particular action and the state of the general system, required to be present, in order that the particular action may be properly and usefully de- veloped. It was remarked above, that more than one organ is some- times diseased at the same time, and of course that our prac- tice must be modified in reference to each of the affected or- gans ; and our remarks in part went to show, that different agents might be employed at the same time, having in view, in the use of each, the particular affection to which it is known to be applicable. Experience justifies this ; for we are in the habit of administering in the form of pill, bolus and tincture, two or more articles, with the intention to meet complicated cases. Such compound medicines, however, are chargeable with empiricism, in all cases in which the therapeutist is not prepared with satisfactory certainty, to know that the combination is not incompatible with the laws of chemical affinity ; and in the next place, that the effect of either on the general system, will not render it unfit to re- ceive the impression intended to be made by the other: that there is no contrariety in the action produced by one, to the action intended to be produced by the other; that the con- dition of the patient is such, that the agency of each may be safely accomplished at the same time, and that either expe- rience, or a very rational and satisfactory analogy affords OF THE SURFACES, ETC. 253 proof, or properly justifies the expectation, that such a com- position may be used in such cases, with safety at least, not to say certain advantage. But after these remarks, it is pro- per to add, that a sufficient acquaintance with chemistry, with anatomy, physiology, pathology and therapeutics, will always justify a discreet use of such combinations of agents; and in cases of great difficulty, when known remedies judi- ciously administered fail, to make trial of other agents ; such as analogy would suggest; and have recourse to other combi- nations, predicated on the accomplishment of other revulsions or irritations. 254 EMETICS. CHAPTER IV EMETICS. " An emetic is a substance which excites vomiting by a specific impression on the stomach, independent of mere dis- tension from quantity, or of nauseous taste or smell." This definition admits of no difference of opinion. But as to the modus operandi, or the mechanism of vomiting, physiologists are not so well agreed. Experiments have been made, ap- parently with great and equal fairness, which have led to very different conclusions. Some have served to prove, that in the act of vomiting, the stomach is quiescent, and that its contents are ejected by being forcibly compressed between the diaphragm and abdominal muscles. Others, that vomit- ing is effected entirely by the contraction of the muscular coat of the stomach—and many now entertain this opinion concerning it. But if we have made correct observation, there is a co-operation of the abdominal muscles and dia- phragm, together with an inversion of the peristaltic action of the stomach, in producing emesis. If we inquire how emetics excite these actions of the stomach and muscles, so as to perform the effort of vomiting, we are compelled to ad- mit that we do not know. Forty years ago, on reading Dr. Darwin's speculations on the subject, we considered them very specious. He supposed, that when nausea is produced, not the stomach only, but the whole system is in a state of temporary debility ; as the nausea increases, the natural pow- ers of the stomach are more and more diminished, until they entirely cease, and then give rise to an inverted motion of EMETICS. 255 its muscular fibres. This view, he thought, was confirmed by the fact, that debility produced by blood-letting to syncope or by concussion of the brain, is almost uniformly followed by vomiting. All this is fanciful, being a statement of the appearances as they occur, with his supposition respecting the causes of those phenomena, and nothing more. When we introduce an agent intended to produce a certain effect, a train of events is exhibited, by the observation of which we arrive at an approximation to the knowledge of the general character, and the order of those events; and this is nearly the amount of our knowledge of the modus operandi of our remedy. Dr. Eberle, in making a statement of his views, says, " The emetic, in the first place, makes an impression on the sentient extremities of the nerves of the stomach. This impression is immediately referred to the sensorium commune, in consequence of which, its natural energies are diminished, as is evinced by the langour of both the intel- lectual and corporeal powers. But as the sensation of an ir- ritated organ, depends in reality, on a peculiar excitement in the sensorium commune, so we may infer, that the sensation of nausea, is the immediate and necessary result of the di- minished and peculiar cerebral excitement referred to the stomach. That is, in fact, the case is demonstrated by the vomiting and nausea, which are sometimes excited by the sight, smell, taste, or even thought, of a disgusting object." Here, however, the Doctor admits our progress is arrested, and this is, in fact, Darwin's definition, with no more than a mere change of phraseology. The simplest statement imagi- nable would explain the invisible agency, full as well as Darwin, Cullen, Chapman, Eberle, or the entire host of phy- siologists. For when it is said, that certain substances are peculiarly offensive to the stomach, that by a law of the ani- mal economy, when any such substance is introduced into that organ, an effort is made to eject it by the act of vomit- ing—that like all other animal functions, the process is re- 256 EMETICS. ferrible to the sensorium under whose influence, in away in- explicable, it is performed—all is said that is known on the subject. However, we cannot regret our having inquired, how far the subject admits of explanation ; especially as we have learned something useful by the excursion. We have learned, that an emetic produces temporary debility, that the state of the system in emesis, is analagous to that whtch im- mediately follows a decisive blood-letting; and that in pro- ducing this effect/ it checks immediately upon the sensorium commune. For these facts, we may find an important use in the sequel. When an emetic is taken, its first effect is, an uneasy sen- sation at the stomach, which gradually increases up to a sense of nausea. In the mean time the pulse becomes fee- ble frequent and irregular; the face turns pale, a general coldness pervades the surface, and the skin displays the cutis anserina. Presently the vomiting commences, when the face suddenly becomes flushed, the capillaries being well fill- ed with blood ; and at last a temporary diaphoresis is produc- ed. So soon as the vomiting ceases, the sickness retires, giving the patient an agreeable respite, during which the sys- tem recovers from the langour consequent on the effort of vomiting. This great effort, and the consequent langour, constitute the principal importance of an emetic. In the first instance, the effort evacuates the stomach. But the pressure made by the abdominal muscles very often causes the contents of the duodenum to regurgitate into the stomach, so that bile is copiously discharged. Hence we infer, that the liver and gall bladder, must likewise be con- siderably compressed between the abdominal muscles and the diaphragm, which produces a more copious discharge of bile into the duodenum. The previous nausea induces a de- gree of relaxation in the ductus communis, which circum- stance is favorable to that process. The appearances of the matter which is discharged by vomiting, Gonfirm this ac- EMETICS. 257 count. During the first efforts, very little bile is thrown up; but by the abdominal pressure and agitation, the biliary ducts and gall bladder are emulged, their contents thrown into the duodenum, and the subsequent and more intense strainings pass them into the stomach, when by vomiting they are at length discharged. In cholera we observe the same thing, since no bilels discharged, until vomiting has continued some time. We may then infer, that vomiting acts powerfully on the nervous system—evacuates the stomach—emulges the vessels of the liver, and by the great agitation and pressure made by the effort, upon the whole of the abdominal viscera. has a tendency to produce important changes in the condition of all the vessels, pertaining to the portal circle. Their ef- fect upon the sensorium is powerfully and happily displayed by administering them after blood-letting in the commence- ment of pleurisies and other highly inflammatory affections. The venerable Mr. Finley of Pennsylvania, so long known as a distinguished member of Congress, informed us, that he ordinarily prescribed for some of his poor sick neighbors, and that it was his practice, first to bleed freely, and immediately afterwards to administer a decisive emetic.# His success was great, and the practice is worthy of imitation. In our elementary observations we stated that after blood- letting, for a certain length of time, there follows an accumu- lation of sensorial influence. This influence when accumu- lated, will invariably direct itself upon the structure which may be in a condition of irritation. Hence it is, that when a very acute pain, such as occurs in pleurisies, may be appa- rently relieved by a.decisive use of the lancet, unless measures be taken to prevent the accumulation referred to, when the system shall react, the pain will return with a degree of vio- lence, in some instances as distressing as it was at the first. A decisive emetic lessens or prevents this inconvenience ; if: # By this practice hemorrhagic reaction was properly regulated., 17 258 EMETICS. administered immediately after the depletion. A counter im- pression is made on the stomach by this practice, by which the accumulating sensorial influence is used up as it rises. If it can be ascertained that a stitch in the side is really at- tributable to an inflammation of the pleura, Avithout any com- plication of the parenchyma of the lungs, the employment of a large dose of opium and calomel, will more effectually se- cure the same result. So also in a case of peritonitis with- out complication, if we bleed to fainting, and follow the use of the lancet with a similar dose of opium and calomel, the effect will be most comfortable. An emetic may follow the blood-letting without hazard; and generally with great benefit. Very frequently a large sinapism or epispastic is greatly beneficial, for the same pur- pose. To meet the intention properly, the mustard ought to be applied fifteen or twenty minutes in anticipation of the intended depletion. By this last precaution, employment is given to the accumulating sensorial influence, and the action of the capillaries of the skin is simultaneously secured. Hemorrhagic reaction, which is the effect of an accumula- tion of sensorial influence, ought generally to be prevented by similar means, whether the depletion which is the cause of it shall have been intentional or accidental. It is a common practice in treating a case of pulmonitis, to let blood freely, and during the interval between the exacer- bations, to make a liberal use of antimonials. This method in some degree accomplishes the same intention. But the subject rightly understood, will eventually lead every man of skill, to the employment of measures which will effectual- ly regulate the sensorial influence, and maintain a continu- ous action of the capillaries of the skin. Until something less offensive shall be discovered, an emetic will merit special attention, as one of the most valuable agents for the accom- plishment of this important end. Permit us to insert in this EMETICS. 259 place a few memoranda, which may be found useful to the practitioner of medicine. . Emetics lose nothing of their power by repetition ; on the contrary, the stomach becomes more susceptible to their im- pression by their frequent use. Vomiting may be made sub- ject to volition, by habitual attempts to excite it. Dr. Cullen mentions an instance in which, by frequent practice, one- twentieth part of a grain of tartarized antimony was an ef- fectual dose. In some instances of protracted fever, an ordinary portion of tartar emetic or ipecacuanha will fail to produce emesis ; and if the dose be enlarged, it will produce hypercatharsis. This is an important fact, inasmuch as the intention impru- dently pressed, might produce fatal effects in one day. Again the system may be in a state the reverse of this, and an eme- tic be ineffectual, till the sensorium is released by blood-let- ting. By violent and repeated retchings, jaundice is sometimes induced. The liver and gall bladder are, in that case, too much pressed, and the bile regurgitating, is carried into the vena cava. According to Haller's experiments, an injection thrown into the hepatic duct, will escape by the hepatic veins ; this is also confirmed by the experiments of Saund- ers, who found that water injected in the same direction, will return by the veins in a full stream, though very little force be used. This kind of jaundice needs no interference, as the bile will be eliminated by the kidneys in a very few days. Severe vomiting should commonly be avoided in the ad- vanced states of pregnancy, in hernia, and in prolapsus uteri. Emetics are advantageously employed in such diseases as are attendant on persons whose abdominal organs are in a sluggish state. In all such instances, however, blood-letting, and other appropriate evacuations, must precede the use of the emetic, especially, when there is a tense pulse and acute pain. 260 EMETICS. Effused fluids are sometimes rapidly absorbed under the influence of an emetic. This has,led to the supposition, that emetics increase absorption. But the same result would fol- low, if they produce a diminution of the power of the exha- lents. And as blood-letting well timed and repeated, will produce the same effect; as the use of nitrate of potash, &c. sometimes affords relief in a similar manner; therefore we may infer, that emetics are useful in dropsies because they make a favorable impression on the nervous system. Experience has established the value of emetics in diseases of the brain. They are useful in asthenic mania, blood-let- ting having been premised. They restore calmness to the action of the vessels of the head, which in such cases is par- ticularly desirable. They are also especially beneficial in melancholic mania, in which it is supposed the brain is lan- guid, in consequence of imperfect sanguification. In hypo- chondriasis physicians generally believe, that some chronic visceral, affection must lie at the root of the evil, and it is very probable that the good eflect of emetics in such cases, are consequent on the impression made by them on the sto- mach and liver, by which the condition of the portal circula- tion is improved. Emetics are used extensively and with great advantage, in almost every form of fever. If administered in the forming stage, they often arrest its progress. " Antimonial emetics," Dr. Armstrong says, " have been very generally recommend- ed in typhus fever, and according to our observation, are ser- viceable when the fever takes on a complicated form, com- monly producing an improvement in the condition of the skin, respiration and pulse ; and perhaps, it is on the power which they possess of determining the blood to the surface, and of changing the morbid states of the circulation, that their efficacy depends." In pneumonia typhoides, emetics will be found almost in- variably of great service. Taking care however, in this as EMETICS. 261 well as in any other affection, to prepare the system, if ne- cessary, by previous blood-letting. In this disease the re- medy may be administered under circumstances and appear- ances, which would forbid it in other affections. In cases in which there are much distress and pain in the chest, and even when the ordinary signs of congestion are present, emet- ics may be fearlessly administered, and they will be found to promote expectoration. Fifty years ago, in treating bilious fevers, the first prescrip- tion was an emetic ; this was followed by a cathartic, the practice to be repeated once or oftener; then the effervescing draught was to be administered, till the type of the fever could be sufficiently developed. If remittent or intermittent in its form, it was encountered with a sufficient quantity of bark, &c. All this was regular empyricism ; and yet it was often successful. Dr. Sydenham taught the necessity of setting out with one moderate blood-letting, and the practice after- wards partook of a similar cast. As bilious or intermittent fever occurs in this country, almost every case will receive benefit from an emetic, once or twice repeated ; but many will need previous blood-letting. Perhaps it ought to be ad- mitted, since it is the opinion of many good physicians, that emetics prepare the stomach to be more susceptible of the im- pression^ of other articles ; and consequently give them a full opportunity to display all their powers. In eruptive fevers, (exanthemata) emetics are often indis- pensible. This is the fact in scarlatina anginosa, but most of all, in its malignant form. In these affections, Dr. Arm- strong says, " When emetics are aided by the warm bath, they tend to free the system from the pressure of the pletho- ra of the internal blood vessels, so frequently observed in the commencement of this disease, and by thus equalizing the whole circulation, to render the future case, most commonly, mild and manageable." Dr. Smith, in his record of cases admitted into the fever 262 EMETICS. hospital of London, lets us know, that he let blood decisively in treating scarlatina; we refer particularly to cases XXVIII and LVI. The first was bled sixteen ounces on the third day, the Jast sixteen ounces twice on the fifth day; they both terminated fatally. If perchance this work should meet his eye, we would call his attention to a few facts, for the establishment of which he has himself done much. He holds, that scarlet fever in every other circumstance but that pertaining to the eruption peculiar to it, commences and pro- gresses like idiopathic fever; the train of events and the or- der of the train being the same. The sensorial structures, the thoracic viscera and the viscera of the abdomen, are all liable to the injuries common to fever. It differs from other fevers, by no specific mark, but that of the eruption. If therefore, we can have opportunity to bleed in anticipation of the establishment of the fever, it may be done with decis- ion, and invariably with good effect. If this advantage be lost, and the fever be permitted to establish itself, more mis- chief may be apprehended from ill-timed depletion in a case of scarlatina, than in fever with the same apparent degree of severity in the ordinary form. Eruptive fevers, in the de- gree of their intensity, invariably present with other symp- toms, great frequency of the pulse. According to our expe- riment made by external heat, as stated in chapter third of| our elements, great excitement of the skin checks heavily on the existing stock of sensorial influence. If therefore the fever in its general character be very severe, serious, possibly fatal congestions, may have been already established, before the violent action of the. capillaries of the skin which is ex- hibited in the eruption shall hav^s begun to appear. If the heat and redness of the skin be very great, it will be found in almost every case, that blood-letting is improper, and if pain in the head and back, &c. shall have been sufficient to justify the belief, that fearful injections may have taken place, the lancet ought by ifio means to be used. Circumstances EMETICS. 263 might occur, to justify the use of leeches for the relief of the head and throat, but even this practice should be employed with great circumspection. A gentle emetic, daily adminis- tered, if it be practicable, would be preferable. In many instances, when the skin shall have been very red for a day or two, the color changes with an inclination to a livid hue. This change indicates great prostration, and it may be inferred from it, that the sensorium is impaired. besides which, there will be symptoms proving the existence of thoracic and abdominal complication. The skin itself is in danger of losing its vitality—to blister the surface would be to institute the condition of gangrene. The stock of vi- tality is so low, that the whole surface needs to be cherished by wrapping the patient in a soft blanket, wrung out of hot water -and alcohol, or vinegar, which should be warmed afresh, every hour. Emetics have been strongly recommended in some varie- ties of erysipelas. Desault considered this affection, in its common and genuine form, to be a bilious disease, and he treated it exclusively with antimonial remedies. We too have great confidence in the value of antimonial emetics in this disease, especially if they be properly aided by a daily ■ use of the alcoholic bath, which is according to the views of Dr. Armstrong. In the early stages of measles and small pox, when the chest seems oppressed, threatening the lungs with conges- tion, Dr. Armstrong thinks that vomits are strongly indica- ted. He says, "when the lungs have been exceedingly oppressed, and particularly, when vomiting has been absent. I have often seen the most striking relief follow an antimo- nial emetic, which may fairly be ranked among the most efficacious remedies in pulmonic congestions. In this cli- mate, however, a majority of cases in measles and small pox, will require previous blood-letting. We have seen a case of small pox, which required four blood-lettings, in the course ' 264 EMETICS. of the day preceding the appearace of the eruption. We proceeded according to the indications, and did not even sus- pect small pox, until it was beautifully displayed on the fol- lowing morning. In measles, whenever the lungs are dis- tressed and the pulse requires it, we let blood before we ad- minister the emetic or the bath. The use of emetics in croup is universally admitted, inso- much, that we believe they are now every where in this country thought to be indispensable. In ordinary cases, after using the vapor bath and suitable rubefacients to the sternum and throat, a decisive emetic serves to remove the disease. But in violent cases, when the breathing is very difficult, and the arterial system much disturbed, blood-letting is necessary. And it may be considered a good rule of prac- tice, if the hot bath, rubefacients and emetics fail to afford speedy relief, that blood-le*tting should be immediately added and carried sufficiently far, at once to make an effectual im- pression. Dr. Ferriar recommends blood-letting to deliquium, and in this we concur. If the case be violent it should al- ways be considered as a struggle between the Doctor and Death. The effect of the disease upon the state of the blood, is such, that the sensorium must soon lose its energies, and the whole system sink into fatal prostration. The blood- letting has a tendency to relax the spasm of the glottis, to resist the inflammation of the trachea, and prepare the system for the full effect of the emetic. The great insensibility of the stomach, and indeed all the violent symptoms, may pos- sibly be consequent on some peculiar cerebral congestion. Blood-letting, therefore, releases the sensorium, and the nerves of the stomach are prepared to acknowledge the power of emetic substances. In the latter stages of croup, emetics are still useful, with a view to promote a more complete and effectual exhalation and expectoration of the viscid mucus, which is so often troublesome towards the close of the disease. EMETICS. 265 In cynanche tonsillaris, bleed decisively and give an emetic. In cases of pneumonia typhoides, emetics are much relied on. Having taken measures to prepare the system by the al- holic bath, and having let blood or not as the case shall re- quire, then suitable emetics operate with the best effects. The embarrassment of the lungs, and of course of the circu- lation, generally in such cases, is attributable to a strong ten- dency to venous congestion, and mild emetics frequently re- peated, will have the happiest effect on the returning circu- lation. When this practice shall have been sufficiently re- peated, the system will be found in readiness to profit by the remedies which are ordinarily recommended ; as small doses of opium and camphor, aided by bran tea, acidulated barley water, &c. remembering throughout, that blisters are of very great importance with a view of relieving the pulmonary af- fection, pain, &c. There is another affection which is vulgarly called bilious pleurisy, [pneumonia biliosa,) in which emetics are likewise greatly serviceable. Richter speaks in high terms of the ef- fect of this practice, in removing excruciating pain in the thorax. Stahl also strongly recommends the use of emetics in this kind of pleurisy. As this disease frequently attacks persons of intemperate habits, and those particularly, whose livers are more or less torpid, it often takes on symptoms not much different from pneumonia typhoides. Hence it may present considerable variety of appearance ; from a high de- gree of inflammatory action requiring decisive blood-letting, down to a degree of prostration in which blood-letting is altogether inadmissible. After depletion when necessary, and the employment of measures for regulating and fixing the capillary excitement by the vapor bath, epispastics, &c. when blood-letting is forbidden, the emetic may be admin- istered, pro re nata. U is thought by many, that emetics will be found greatly 266 EMETICS. useful in acute ophtalmia in all its various forms; and why not equally so in chronic cases? After the necessary blood- letting and a bold cathartic or two, we would not hesitate to have recourse to this practice. Many very respectable writers recommend emetics in the cure of acute rheumatism. Horn, in the Medical Recorder, recommends them very highly, and considers them more useful than any other class of remedies. His method is, to repeat them every day, up to the number of fifteen or twenty. But the disagreeableness of vomiting, will always make it difficult to carry such a practice into full effect. Richter speaks of a form of rheumatism, which occurs in low and marshy situations ; he calls it rheumatismus acutus gastri- cus; depending, according to Stahl, on an irritation from vitiated or redundant bile in the prima via; in which, emetics are greatly serviceable. In all cases of this sort, the charges commonly raised against bile, ought to be attributed to venous congestion of the abdominal viscera. By being locked up in these viscera, the blood is not sufficiently circu- lated through the lungs, of course the sensorimm is imper- fectly supported and the blood is not sufficiently warmed. The system when thus poorly supplied with energy and warmth, if exposed to the vicissitudes of the weather, will be very seriously aftected in a short time ; and if it partake of that species of temperament, which is well inclined to take on rheumatic action, the disease as described by Richter, readily follows. It has frequently occurred under our obser- vation, and it will be readily relieved by an alternation of emetics and cathartics. The most effectual practice is, to take the first steps as we would do in any other fever with congestion of the abdominal viscera—bleed, cup, or leech, according to circumstances; apply external heat, and after using hot cloths wrung out of hot water and vinegar, admin- ister an emetic. Afterwards proceed according to circum- stances, having recourse to blood-letting as the circulation EMETICS. 267 may require it, always following the use of the lancet with an emetic ; but still having regard to the condition of the portal circulation, introducing suitable doses of jalap and cal- omel, &c. as there may be occasion. A physician having experience in the treatment of bilious fever, would not long be at a loss to know, that this kind of rheumatism partakes greatly of the peculiarities of that form of fever, and of course, that it must be accompanied by a similar condition of the abdominal viscera. He will be led by analogy to employ emetics. If he have correct views of general principles, he will add blood-letting when necessary, and cathartics, and sinapisms, and epiapastics, and external heat and quinine! Perhaps no particular disease, affords stronger proof of the unity of general principles, or of the great importance of a right understanding of the manner in which sound medical philosophy can avail itself of the occasion, in any instance of disease—only let it be sufficiently removed from under the blind dictates of nosology. 268 EMETICS. CHAPTER V. EMETICS—CONTINUED. If emetics are beneficial in the treatment of rheumatism when complicated with an irregular condition of the abdom- inal viscera ; by analogy, they ought likewise to be beneficial in gout; and there are authorities which justify the practice. Our own experience in this painful disease, is more limited than in most other affections which are common to this coun- try. But we have seen it often enough, in its different stages, to know, that to a very considerable extent, general principles ought to be regarded in this, as well as in other diseases. A majority of patients in gout, will require blood- letting, in their youthful paroxysms. As they advance in life, they may require the various modes of treatment, which will be found detailed in the books; and when there are in- dications to justify the use of an emetic, it ought to be admin- istered ; but not in those cases in advanced life, in which the disease has a tendency to fasten on the stomach. Mr. Alex- ander Small, a surgeon at Minorca in the Mediterranean, speaks in very high terms of the efficacy of tartarized anti- mony, in his own case of gout. He sometimes combined it with bark, and found a combination of the two articles, to act as a mild aperient. Mr. Saunders, in a treatise on certain diseases of the eye, found that the use of tartarized antimony, so as to excite nausea or full vomiting, was attended with great success. " In that variety of inflammation of the eyes called Egyptian opthalmy, Sir W. Adams speaks of the use of emetics in the strongest terms of praise. Emetics have been long since EMETICS. 269 employed in the treatment of gutta serena. Richter consid- ered the disease to depend on some erroneous condition of the abdominal viscera, and employed them in conjunction with his- deobstruent pill. Emetics have been recommended in hemopthysis. Dr. Eberle raises serious objections to their'use, for reasons, how- ever, in which we are not prepared to concur. He thinks the full inspiration by which the lungs are expanded in vom- iting, would afford a more ready escape to the blood through the bleeding orifice, and that the effort must necessarily give an additional impulse to the circulation, both of which con- siderations ought to be weighed. Moreover, he thinks the pressure of the abdominal muscles and diaphragm, must im- pede the circulation in the abdominal aorta, which would therefore give a greater impetus to the blood through the superior arteries." An emetic ought not to be administered in any case of hemopthysis, when the arterial action is tense, without previous blood-letting. If the loss of blood have been sufficiently great through the ruptured blood-vessel, of course, that would be sufficient. But this never occurs, un- less the rupture be very considerable. In all such cases, therefore, Dr. Eberle's objection is worthy of regard. The greatest degree of stillness ought to be recommended. But in most ordinary cases, it will be found useful if not neces- sary, to let blood once. On the supposition that this opera- tion has been recently performed, the vena cava supplies the pulmonary arteries, and the pulmonary vein supplies the aorta ;—administer an emetic, it first produces nausea, which reduces the power of the general circulation; then, when the act of vomiting comes on, the excitement of the surface is immediately increased. The vomiting is no sooner ended, than it is obvious, that the general circulation is equalized in a very harmless and moderate way. We infer, therefore, that the effect of the emetic on the general circulation is such, that the vena cava is not prepared to overstrain the 270 EMETICS. pulmonary artery, within the short time occupied by one or more contractions of the abdominal muscles and diaphragm in vomiting, and that the hindrance given to the abdominal artery is not sufficient, within the same length of time, mate- rially to hinder the discharge of the pulmonary vein. More- over, the general diffusion of excitement which takes place in the whole cuticular surface, more than compensates any mechanical inconvenience, which the act of vomiting can possibly bring to the circulation. We are aware that Dr. Cullen found one case, in which an emetic increased the he- morrhage to an alarming degree. This we could expect under two circumstances. If the open vessel be large and the rupture extensive, no means ought to be used, which would compel the patient to move, and if the case require blood-letting, that is, if all the vessels are in the condition of injection, it is equally obvious that an emetic ought not to be employed, till after the necessary depletion. It is impor- tant to attend carefully to the fact, that hoemopthysis is pre- ceded by plethora and fever. We once saw a case in which, from the state of the pulse, we predicted a speedy occurrence of an attack of this disease, and before we could get ready with the utmost expedition to let blood, an alarming hemor- rhage took place, and it terminated fatally. Again, there will be found a constriction of the superficial vessels, concen- trating the blood into the viscera and producing a general stress upon the central arteries. In every such case, after a moderate blood-letting, an emetic will be useful. We con- stantly use remedies of this sort, so far as to produce nausea, in almost every case for which we prescribe in this disease. Dr. Eberle is disposed to think that the same mechanical reasons for objecting against the use of emetics, in hoemop- thysis, may be adduced in their favor in uterine hemorrhages. If he had merely insisted, that the same objections do not lie in the latter case, which have been adduced in the former, we should have had no objection to the reasoning, or its ap- EMETICS. 271 - plication. But it is important that we should not be mis- guided in our opinions of the modus operandi of medicines. The pressure made on the aorta must be unimportant, be- cause it is of so short duration. Besides, if it be considera- ble, it must imply an increase of its injecting power, during the time of the compression ; unless, indeed, we can be made to believe, that the pressure is made on a single point, after the manner of a ligature. The proper conclusion is, that emetics are useful in hemorrhages, because they have great power over the whole system, and do much towards the es- tablishment of a healthy general action, and thereby correct any morbid determination of the sensorial influence. In the treatment of dysentery, emetics have been long known and used, as being almost indispensable ; and when it is no more than a modification of marsh fever, which is often the case, emetics produce the same happy effects which follow their use in bilious fever. Sir John Pringle made use of this practice, and Clark, in his treatise on the diseases of the East and West Indies, informs us, that he derived the greatest advantages from the employment of emetics in this disease. Cleghorn says, "when dysenteries begin in the form of diarrhoea, without fever or fixed pain in the belly, the first thing to be done is, to empty the intestines of their acrimonious contents, as soon as possible." For this purpose he used ipecacuanha with cerated glass of antimony, in doses sufficient to operate freely, both by emesis and catharsis. In accordance with this practice, thirty or forty years ago, the planters in Virginia were accustomed to administer an ounce of sulphate of soda, together with a dose of tartarized anti- mony. The operation was considerable, but very commonly produced an excellent effect. It would be necessary, how- ever, to keep in view all the precautions which are to be re- garded in any other disease, and if there be a tense arterial action, and particularly if it be accompanied by pain in the abdomen, blood-letting ought to precede every other remedy; 272 EMETICS. except in such cases of a secondary sort as occur after the system has been previously prostrated. In the treatment of diarrhoea, also, emetics are often found to be very beneficial • but in this as well as in dysentery, or any other affection in which the remedy is useful, its value is chiefly referable to its tendency to equalize the circulation, agreeably to the view already taken. In mania apotu, which arises from the intemperate use of ardent spirits, emetics have an excellent effect. This is the practice at present in Philadelphia, where it was introduced by Dr. Klapp. The same practice is pursued in other places, and will probably become general. It must be remembered, that the stomach is often extremely insensible to the opera- tion of an emetic, and therefore that large doses are neces- sary. So soon as the vomiting can be made complete, the mental hallucinations are immediately much corrected, and if the case be of a mild form, a single dose serves, sometimes^ to effect a cure. The practice, however, ought to be re- peated, from two to six or eight times, at such intervals as the judgment of the physician may deem it proper. We have been in the habit, chiefly, of relying on opium for the cure of this affection, and since we adopted the practice, have not failed once to recover our patient. But the practice of Dr. Klapp is, to rely almost entirely on emetics, voiding the bowels if necessary with suitable aperients. As it re- spects opium, he doubts the propriety of using it, except the emetic medicine should induce hypercatharsis. Dr. Eberle confirms this practice, assuring us, that emetics induce sleep more readily than opium, under any mode of management. In the cases which we have attended, the patients were much prostrated, and there was an unequivocal demand for opium and wine, and these remedies have had the happiest eflect. We have intimated, that emetics would be found useful in other varieties of mania, and in hypochondriasis. In the commencement, of a paroxysm of rage, if a sufficient dose of EMETICS. 273 tartarized antimony could be introduced, so as to excite co- pious emesis, it would scarcely fail to quiet the patient, and at the same time, it would promise advantage in view of ul- timate recovery. We knew a man in Virginia, who was in the practice of drinking to excess, at three or four periods in the year; when he commenced, seldom ceasing, until he had brought on mania. So soon as it had arrived at a cer- tain state of violence, the family would send for medical aid. By this time he had ceased to be able to serve himself with his drink, and a servant maid was compelled to hand it to him. We then could pour into his tumbler a portion of a solution of tartarized antimony, instead of water, and it was interesting to see how soon vomiting would restore his intel- lect. An emetic will rouse the hypochondriac patient from men- tal and physical torpor; so that other remedies can be made to act. The modern practice in this case, is predicated upon the opinion, that the disease is consequent on chronic visce- ral congestion. Hence the employment of blue pill and oc- casional saline purgatives—the same sort of practice which is recommended in chronic affections of the liver and spleen. Frequent emetics, in association with this practice, will al- i ways be found to be useful. In puerperal mania this practice has been found to be par- ticularly beneficial. When the mechanical pressure made by the fcetus, has subjected the viscera to the condition of debility peculiar to gestation and parturition with its accom- panying depletion, should a sudden collapse of the system occur, one of the consequent evils is, puerperal mania. Emet- ics seem to improve the state of the nerves, to agitate and resuscitate the torpid viscera; secretion and absorption are again established, and the patient is restored. But in this, as in any other affection, we must not be discouraged at an apparent failure upon the exhibition of a dose or two; it must be repeated as often as the case may require. If the 18 274 EMETICS. abdominal viscera be relieved, the sensorium will regain its functions. In hysteria, so long an almost universally unmanageable disease, emetics are now found to be greatly useful. They are administered with advantage in almost every form of this protean disease, but more particularly in that form which is attended with complete suspension of the animal functions, bringing on a state resembling syncope. Dr. Dean, in a paper published in the Medical Recorder, vol. 4, page 259, says " it is in the chronic variety of this complaint, in which the common routine of what are improperly termed antispas- modic medicines produce no other than transient relief to the patient, that I have experienced the most permanent good effects from the administration of emetics. In cases of this description, when the patients had labored under the disease for ten years, and during that time by the advice' and direc- tion of respectable physicians, exhausted, with at most, bat temporary benefit, the whole class of remedies which are usually prescribed, I have by the continued exhibition of vomits either entirely removed the complaint, or so far inter- rupted the habits of the diseased action in the stomach, that antispasmodic and tonic medicines, would in general com- plete the cure." Dr. Joseph Smith of New York, has re- commended emetics in equally strong terms in hysteria and epilepsy; and he considers them "more efficacious than any remedy ordinarily employed." In asthma, emetics are of unquestionable advantage, and particularly when lobelia inflata is employed as the emetic agent. We have used it in frequent instances, with decided benefit. Dr. Porter of Pennsylvania, informed us, that it had not failed in his hands to afford relief in any case in which he had tried it. Dr. Eberle is inclined to the opinion, that the result was due to the mechanical effect of vomiting upon the diaphragm, in enlarging the thorax and thereby making more abundant room for the passage of the circulation through EMETICS. 275 the lungs. It is probable that the expansion of the thorax does some good; but we are confident that the shock given to the nervous system, does much more ; and the superiority of lobelia inflata, which is an antispasmodic, and almost a specific in the disease, goes far to confirm us in our opinion. Every physician is accustomed to the use of emetics in whooping cough, and will admit with us, that they afford more benefit ihan any other remedy in our profession. Whooping cough is, however, often marked with strong signs of plethora and inflammatory action. In such cases, emetics alone will not be effectual. Copious and timely blood-letting will always be found necessary, and when such is the case, if not employed within a reasonable time, the patient will perish. In many instances where blood-letting is not used, the patient is subjected to an affection like croup, which is superinduced, and then, nothing but copious bleeding can possibly prevent a fatal termination. Emetics have been recommended in apoplexy; but there are good reasons for doubting the safety of the remedy. It must certainly be very proper if an emetic be tried in this disease, always to precede it with a sufficient blood-letting. Although it really seems to be a doubtful remedy, yet if the patient be attacked immediately after eating, or if there pre- viously existed known causes of gastric irritation, the use of an emetic is certainly indicated, and after the necessary blood-letting, it ought to be administered. But where there is no good reason to suspect a fullness of the stomach, nor any gastric irritation, the disease of course must be consid- ered as essentially connected with an engorgement of the cerebral vessels. Under such circumstances, the violent struggle which occurs in the act of vomiting, must do more harm than good. ^ As to the use of emetics in epilepsy, the books give us very contradictory accounts; some recommending, whilst others condemn them. Now, as each party is entitled to 276 EMETICS. equal confidence, there remains but one way of reconciling them. We are willing to give due credit to both, and must therefore conclude, that each have used the remedy in differ- ent states of the system—the one probably without depletion, or before the system had, by time, become sufficiently passive to profit by the remedy—the other had reduced their patients artificially, or had the good fortune to find them reduced to their hand. To judge by what has occurred* under our own observation, we are inclined to believe, that those who have found benefit from the practice, may have met with cases in which a morbid condition of the abdominal viscera had par- ticipation in the disease. We have frequently known the first paroxysm of bilious or intermittent fever in children, to commence with a violent convulsion. Possibly, then, some of the accounts may have been raised on occasions of this sort, and the commencement of an autumnal fever was considered the commencement of epilepsy. An emetic repeated as often as such convulsion should recur, would hardly fail to afford relief; and a nosologist might readily enough make such a mistake. But there is another view of the subject which deserves to be noticed. Dr. Thomas says " when an attack of idiopathic epilepsy can be foreseen, there is perhaps no remedy which will be more likely to prevent the paroxysm, than an emetic administered about an hour before its acces- sion. This is a very judicious view of the subject. Dr. J. Clark used the sulphate of zinc in a state of solution, pre- pared with an aqueous infusion of ipecacuanha. Dr. Eberle succeeded in the case of a child, by repeating a dose of ipe- cacuanha alone once every third day. There is of late a great prevalence of dyspepsia, and there can be no doubt of the value of emetics in this afflicting dis- ease. • We put it down as a general cause of this affection, that every subject of it, has by some means, acquired the habit of over-eating—we mean too much for the digestine powers of his own system. No two persons can have their EMETICS. blood-making organs precisely similar. The demands of na- ture in each of ten thousand, if they could be accurately measured, would present a different account. But it is the constant practice of mothers and nurses, and too commonly of fathers and other relations and acquaintances, to press and tempt children and their young friends to eat, and almost to eat incessantly. The consequence is, that in almost every instance, when there is not an iron conformation of the vis- cera, premature death or dyspepsia, or some definite disease of an important viscus is induced. In dyspepsia there is generally a great propensity still to eat on; and whenever the stomach can be compelled to receive food, they continue to throw it in. By this imprudence, the system gradually runs into a worse condition, till eventually, a cure is imprac- ticable. According to this view, nothing would promise so much, as a frequent use of emetics, in the commencement of this disease. They will not only evacuate and improve the state of the stomach and other viscera; but they also check the insatiate demand for food, which perhaps is the most fre- quent cause of failure in our attempts to cure indigestion. In the advanced stages of the disease, we cannot perceive how they can do much good. There are occasions, how- ever, when we are obliged to employ them. Prof. Revere in a very good paper published in the Medical Recorder, says that persons of this description, whose digestive organs have become much debilitated, sometimes on taking food, which in the healthy state of the stomach is perfectly innocent and nutritious, will be subjected to great general distress, numb- ness of the scalp, violent cholic, acute pain in the side and bladder, vertigo, apoplexy and convulsions. He relates sev- eral instances of this kind, in which the efficacy of emetics was very promptly and satisfactorily manifest. Pr. Wilson Phillip, however, very properly cautions us against too fre- quent repetition of the practice, in the further and more ad- 278 EMETICS. vanced stages of the disease. He considers their use to be more or less important, according to the prevalence or recur- rence of irritating,matter in the prima vim, and under other circumstances to be injurious, especially if too frequently re- peated. As it is supposed, that the good effect of emetics depends in a considerable degree, on their tendency to increase the activity of the absorbents, they have been much employed in every variety of dropsy. They have, however, been found to be more particularly beneficial in cases of anasarca and ascites. It is not greatly important to us to ascertain, whether emetics produce their good effect by increasing the action of the absorbents, or by diminishing the action of the exhalents; and by the by, we think they do both. They certainly improve the condition of the skin, and an improved circulation must carry over to the absorbents a better supply of the means of their support. By the nausea they lessen the force of the exhalents, giving the absorbents less to do; and by improving the circulation of the skin they convey the blood to the absorbents in an improved condition; and the consequence is, that the absorbent system is ultimately re- stored to health. It is not improbable, however, that the best effect of emetics is produced by the improved condition, which they in many instances secure to the great abdominal viscera; the blood is more perfectly elaborated, and conse- quently all the organs and functions of the system are re- paired by that means. Emetics have also been recommended in diabetes. Rich- ter more particularly mentions several cases that were effec- tually cured by them. In many cases this disease depends on some visceral irregularity, and it is to be presumed, that such was the fact in many of the instances related by Rich- ter. When the liver becomes inactive in its functional ope- rations, we find the kidneys frequently performing secretions EMETICS. 279 in imitation of bile ; in proof of a disposition to act a vicari- ous part for the liver. Even the skin evinces a similar ten- dency. There is a great difficulty in making a thorough in- vestigation into the causes of diabetes. It never terminates in a short time, and of course post mortem examinations, however carefully conducted, would present very uncertain appearances. If, however, it should turn out, that emetics do commonly produce appearances, such as those noticed by Richter and bring up great quantities of bilious matter; and it seems in one case, that after such an evacuation the dia- betes disappeared in one night; if the German physicians, who use these remedies very commonly in this disease, have detected its true pathology; the cure of diabetes by the repe- tition of emetics, will go far to prove, that this malady is one of the dread consequences of leaving the mesentery, when in a state of venous congestion, to be disencumbered by the unaided functions of the viscera. The importance of frequent emesis in jaundice has been long known, and whether the disease be consequent on tor- por, inspissated or viscid bile detained in the ducts or cist, or by a gall stone, the remedy is equally rational and proper. The relaxing or generalizing effect of an emetic, will be use- ful in preparing the system to come very advantageously under the agitation of vomiting, and the tendency of the me- chanical pressure to emulge the biliary duct,, must be useful . where there is detention or sluggishness in the passage of N the bile through the ductus communis. After blood-letting and fumigation, if there should be de- lay in an attempt to reduce the swelling in a case of hernia humoralis, an emetic or two will be found useful; more par- ticularly, if the tumor be very painful. ' But blood-letting and hot steam sufficiently repeated, are the most comfortable and effectual remedies that we have ever seen used in affec- tions of this sort. 280 EMETICS. Dr. Hossack of New York, in a paper which was published in the Medical and Physical Journal of that city, details seven cases of obstinate constipation of the bowels, in which emet- ics were of great service to the patients. He says " that in the commencement of constipation, or in its more advanced stages, when the symptoms of inflammation have been sub- dued by the lancet, emetics may be very advantageously ex- hibited; both for the purpose of removing the hepatic ob- struction and of counteracting the spasmodic constriction and pain, ordinarily attendant upon the disease." Our own ob- servation confirms the propriety of this practice. Not unfre- quently, the true cause of such constipation, is the painful distension of the blood-vessels of the mesentery and intes- tines, as well as a torpid or congested state of the liver. Such is the inconvenience of that state of things, that the stomach and bowels are insensible to the impressions made by a ca- thartic in the common way. After blood-letting, however, a sufficient portion of tartarized antimony renovates the con- dition of the stomach; the agitation of emesis wakes up the portal circulation ; the liver and all its appendages are roused; and the detained and distending fluids are passed off; leav- ing the viscera ready to perform their functions. This ex- position shall be made more satisfactorily, when we come to speak of catharsis. And here, whilst in view of the modus operandi of emet- ics, permit us to suggest a thought respecting the unity of disease. We have seen in how many apparently different affections emetics as well as blood-letting, have been found by experience to be greatly useful, and we are prepared like- wise to perceive, that the benefit attributable to the agency of emetics, is in no shape specific, further than the evacua- tion of the stomach is concerned. All their good effects as medicaments, are the results of a general agency, performed under the control of general laws, the operation of which is EMETICS. 281 improved by the shock imposed on the nervous system, by agitation, by evacuation and inanition. A considerable error in the liver, or any other organ, disturbs the general harmo- ny; an ill condition of the blood in consequence of a torpid liver imposes unnatural labor on some other viscus, whose function is therefore embarrassed. One error involves a se- cond, a second a third, and so on, until the contamination may be extended beyond the reach of recovery. And after all there is an unity of principle in the progress of disease, and an unity of agency in the mqdus operandi of the medi cines, by which disease is to be removed. 282 CATHARTICS CHAPTER VI. CATHARTICS. The intestines receive thft chyme from the stomach, and aid in perfecting its assimilation for the support of the sys- tem. In performing this function, they are furnished with the secretions which are continuously supplied by the liver and pancreas, which, together with the secretions issuing from the pellicles of their internal surface, when commingled with the chyme, serve to change its condition, converting it into chyle. When the lactuals have taken up that portion of the chyle which is fitted for the purpose of nutrition, there is left a large amount of foecal matter, which, if detained, would be obnoxious to health. The intestinal tube, therefore, is prepared to perform an additional service. It becomes a co- laborator with the skin, lungs, liver, and kidneys, in exhaling and conveying away excrementitious matter. Suitable pro- vision is made to lessen the inconvenience which would oth- erwise attend it, by causing the discharge to be made peri- odical. The length and folds of the small intentines, serve in some degree to detain the aliment in its descent, but the saccated arrangement and peculiar location and flexure of the colon, constitute it a reservoir for the foeces, so as to secure this important object. Infants and young children, have frequnt and comparatively copious alvine evacuations, with a pecu- liar odor. They take a greater portion of nourishment in proportion to their bulk, than adults, and render greater and more frequent discharges necessary. Adults are commonly CATHARTICS. 283 moved once in twenty-four hours, and the color and odor of their evacuations undergo a very great change from what they were in their infant and youthful state. There are great va- rieties, however, as to time, condition, &e, depending on the state of the viscera, and on habit. Some are always in- clined to looseness; others are always costive; some] have a call once in twenty-four hours; some once in three or four days; others once a week. We knew one man and one wo- man, both of whom, often went several weeks without any evacuation from the bowels. We made an artificial anus for a child, when three months old, which previously had a small aperture only, which, with some difficulty, admitted the introduction of a common probe, through which a fluid es- caped, so as to stain its clothes. In every other respect the child had perfect health. We commonly use cathartic agents, with two intentions ; the one, to evacuate the bowels when in the condition of constipation; the other, to increase the secretion of fluids into the intestines; and this, in fact, is what we mean, when we speak of purging. It is in reference to these two intentions, that we distinguish between laxative and purga- tive medicines. The latter act by their stimulating power, which will commonly be in proportion to the quantity or dose administered. But as in many parts of the intestinal tube, its contents are carried in a direction which has to oppose the laws of gravi- ty, it is evident that a considerable force must be exerted from the stomach'downward, or onward, in order to propel the alvine discharges in a regular manner. The force which performs this propelling effect, is called the peristaltic action, and this action is a regular series of contractions of the mus- cular fibres of this organ, from above downwards. An inad- equate force of this action will produce constipation. The same may be the effect of mechanical resistance, or a defi- 284 CATHARTICS. cient secretion of the fluids intended for dilution, §x.; or more than one of these causes may combine to produce con- stipation. If any article of medicine therefore, increases the alvine discharges, it must produce the effect, either by increasing the peristaltic action of the bowels, or by increasing secre- tions, or by removing the impedfments which hinder its reg- ular powers, or by producing these effects simultaneously. Cathartics increase the peristaltic action, provoke an in- creased secretion, and so'diminish the resistance made to the passage of the substances propelled, by lubricating the internal surface, and rendering the substances more fluid. In the catalogue of agents of this class, we have articles which possess different degrees of cathartic power, which enables us to adjust them to all the variety of cases which can require their use. We have them too, with peculiar dif- ferences of agency, in relation to the parts of the intestinal tube, upon which they more immediately exert their action, and also in relation to the nature and appearances of the dis- charges which they procure. As examples, calomel, gamboge, jalap, act more particu- larly upon the primas vias, and upper portions of the intes- tines ; castor oil, colocynth, and some others, act with a more extensive range upon the intestinal tube; whilst aloes acts almost entirely upon the lower portion of the bowels. We have it in our power too, to make a selection of our article, in view of the kind of discharge we may wish to produce. Jalap, and the different saline purges, produce copious watery discharges. Castor oil and rhubarb, merely evacuate the contents of the bowels; whilst calomel and gambouge in- crease the secretion of bile, and carry it off in very copious quantities. Dr. Paris seems to think, " that a medicine may act more immediately and especially upon the stomach, or the small or CATHARTICS. 285 large intestines, according to th"e relative facility with which its principles of activity, enter into solution; that those which are dissolved before they pass the pylorus, are quick and vi- olent in their effects, and liable to affect the stomach; as is exemplified-in the action of gamboge, &e, whilst some re- sinous purgatives, on the other hand, as they contain princi- ples less soluble, seldom act until they have reached the co- lon. Colocynth, has a wider range of operation, because its principles of activity reside both in soluble and insoluble ele- ments. Aloes again, being still further insoluble, passes through the whole alimentary canal, before it is sufficiently dissolved, and acts, therefore, more particularly upon the rectum." These circumstances are particularly worthy of notice, both in a therapeutical and pharmaceutical point of view, since it will enable us to modify the peculiar action of these remedies, by having a due regard to their degree of solubility, and to select such articles as may most effectually correspond to the intention, in view of the circumstances of the diseases for which we may prescribe them. If we would treat an ascites, we would naturally be induc- ed to exhibit such articles as have the greatest tendency to evacuate much serum from the intestines. We of course select the saline substances. So likewise, in cases attended with a redundancy of vitiated bile, we would have recourse to those articles which act upon the upper portion of the in- testines, and at the same time rouse the functions of the bili- ary system. We therefore exhibit calomel, gamboge, ipeca- cuanha, &c If, again, we wish to evacuate the bowels, and at the same lime produce some effect upon the pelvic viscera,. as on the uterus in amenorrhae, we then select aloes, because of its known effect on the rectum. In addition to these im- mediate effects of the different cathartic agents, they admit of application on general principles, which we have yet to consider. 286 CATHARTICS. 1st. They diminish the action of the heart and arteries, ahd thererore are used with more or less advantage in most diseases of an inflammatory character. They produce this effect not merely by evacuating the bowels of their vitiated and accumulated contents, thus removing such causes of irri- tation, but they indirectly evacuate the blood-vessels, by in- creasing the secretions of serous fluid from the alimentary canal. Dr. Eberle thinks their operation in this respect, re- sembles in some degree the effect of blisters, which, though acting primarily as stimulants upon the sanquiferous system, reduce its action, as a secondary effect, by the effusion of the serum which they occasion. We are ready to admit the sim- ilarity as far as it obtains, but we object to the comparison made in this place. Blisters act chiefly by stimulation, ca- thartics by evacuation. 2d. Cathartic medicines promote the absorption of fluids,* from the internal cavities. As they provoke a discharge of serum from the' blood-vessels, they thus indirectly prepare the absorbents to take up a supply from those cavities, in which it may exist in a state of morbid accumulation. It appears to have been established by the experiments and pa- thological observations of Magcndie and others, that absorp- tion is accelerated, in proportion as the quantity of fluid cir- culating in the blood-vessels is diminished. It is thought moreover, that there is a constant effort in the system to preserve the regular portions of serum in the blood, and that any loss by one outlet is compensated either by an absorp- tion from some of the internal cavities, or by the diminished action of one or more of the serous emunctories. For exam- ple, when the exhalents of the peritoneum effuse a preter- natural quantity of serum into the abdomen, producing asci- tis, the morbid diminution of this fluid in the blood-vessels, is in some degree compensated by the diminished action of the cutaneous exhalents and of the kidneys. But if we suc- ceed in exciting the kidneys into a more perfect performance CATHARTICS. 287 of their functions, some new supplying power will be requi- site to keep up the necessary proportion of serous fluid in the blood-vessels. The absorbents are therefore called into action, and the dropsical fluid is reabsorbed into the circulation, and then eliminated by the regular emuncto- ries. Cathartics irritate the exhalents of the internal surface of the intestines, by which a very great secretion of the serum is suddenly produced. The consequence is, a diminution of the effusion of the dropsical fluid; because the action of the exhalents, that is, of the arteries, is diminished, accompa- nied by an increased action of the absorbents, which go to work to supply the deficiency thus produced by the increas- ed action of the exhalents, which is performed in obedience to the mandate of the cathartic. Dr. Paris and others state, that cathartics often increase the effect of diuretics. For instance, if we give a diu- retic remedy to a dropsical patient, it may be, it will pro- duce a very insufficient increase of urinary secretion. The absorption remains proportionally small. Under these cir- cumstances let a cathartic be administered. This will dis- charge a considerable portion of serum from the bowels, which will create a demand for the restitution of this con- stituent portion of the blood ; consequently a new impulse is given to the supplying, that is, the absorbing vessels, which continuing after the operation of the cathartic ceases, will have the effect of supplying the kidneys with a larger por- tion of the elements, which employ their functions, and of course, it will appear that the diuretic is made satisfactorily effectual. 3d. Cathartics have a tendency to remove the torpor which so often prevails in the portal circulation ; and in that way promotes the biliary secretions. They do this, in the opin- ion of Dr. Johnson, by exciting a brisk, peristaltic motion of the intestines, whereby the blood which is accumulated and 288 CATHARTICS. almost stagnated in the portal circles is propelled forwards. This is one of the most important facts in view of the good effects of cathartics in the treatment of fever, particularly in children, and in the fevers which prevail in the summer and autumn. 4th. They provoke a determination of the circulating flu- ids, to the abdominal viscera, affording relief when necessa- ry, to the vessels of the head and. thoracic viscera. But to secure this intention, it is generally necessary to premise blood-letting. Dr. Paris says, "I have often noticed this fact, in contending with a plethoric diathesis, whenever bleed- ing preceded the purgative, the effect of the latter has been uniformly more speedy and considerable. In obstinate con- stipation, the same fact has been observed, and mild reme- dies have been known to act more powerfully when preced- ed by blood-letting, than potent ones have done, when ex- hibited antecedent to it. After these four general statements respecting the proba- ble modus operandi of this class of remedies, we will offer some therapeutic details, for regulating their use in particu- lar diseases. • In almost every variety of febrile disease, cathartics are commonly considered indispensable, and as holding rank amongst the most important curative means we possess. The alimentary canal has been called " the storehouse of disease." Here our views differ materially from all we have seen written on the subject. One of the most respectable paragraphs that we have met is the following: "Whatever may be'the original febrile cause, whether seated in the bow- els or elsewhere, it is certain, that the secretions which are poured into the alimentary canal, are perhaps in almost eve- ry instance of fever, changed from their natural or healthful condition, to a state which renders them additional causes of irritation to the already preternaturally excited system." It certainly is important to remove such causes of irritation, CATHARTICS. 281' throughout the whole course of nearly all acute diseases. But their good effects are not confined to the mere evacua- tion of the vitiated and irritating contents of the bowels. They are useful on account of the indirect depletion of the blood-vessels and consequent subjugation of the vascular ac- tion which accompanies irritation. Commonly, in the first stages of all fevers, we should select such cathartics as are calculated at once to evacuate the contents of the bowels, completely, and procure an abundant effusion of serous fluid from the intestinal exhalents. With this intention, the sa- ' line cathartics are generally preferred in the ordinary syno- chus fevers. But if the disease be attended with functional derangement of the biliary system, which is generally the case in intermittent and remittent fevers, we add such arti- cles as are known to correct disordered hepatic secretions : and with that intention, we add calomel to other appropriate cathartics. Typhus fever was considered for ages as being essentially characterized by debility, and cathartics were almost univer- sally considered improper in its treatment, until Dr. Hamil- ton, of Edinburg, established their utility; and the truth of his observation and experience is generally admitted. Dr. Rush long since called attention to the fact, that purging re- moves the apparent debility which frequently exists in the latter stages of acute diseases. In yellow fever, he often saw the prostrated strength of a patient suddenly renovated, by the operation of a cathartic. Irritating matters acting on the intestinal nerves, can produce very alarming debility. A meal of indigestible food, in persons of weak digestive pow- ers, has often brought on the most alarming prostration of strength. We restrict our patients from taking articles which in health would be too light for their ordinary support, be- cause we fear that their blood-making organs might be weak- ened, convalesence interrupted, or that a tumult would hn- 19 290 CATHARTICS. raised, dangerous to life. And if this precaution be reasona- ble, is it not obvious, that the retention and irritation of viti- ated matters in the intestines of debilitated typhous patients, must certainly have a tendency to produce very pernicious consequences. That the secretions of the abdominal viscera are vitiated in typhus fever, and indeed, in all protracted fevers, there can be no doubt. The appearance of the discharges, the suspended digestion and morbid state of the foeces, sufficiently confirm it. If there were no other object in view than the removal of the morbid and irritating materials, we cannot fail to perceive the utility of employing mild purges, during the latter state of typhus fever. By re- moving such cause of irritation, we renovate the vital power# and prepare and provoke the intestinal emunctories to resume their natural functions. " I have directed," says Dr. Hamilton, " a strict attention to this practice for a long time, and am now thoroughly per- suaded, that the full and free evacuation of the bowels, re- lieves the oppression of the stomach, cleanses the loaded and parched tongue, and mitigates thirst, restlessness, and heat of surface; and that thus the latter and more formidable im- pression on the nervous system is prevented, recovery more certainly and speedily promoted, and the danger of relapsing into fever much diminished." He furthermore informs us, that " he is disposed to refer the superior utility of purga- tive medicines in typhus fever, to the circumstance of their operating throughout the whole extent of the intestinal ca- nal ; to their acting upon an organ, the healthy functions of which are essential to recovery, in a manner that is conso- nant to the course of nature, by propelling its contents from above downwards." " Enemata, whose effects are confined to the rectum, must be altogether inadequate to procure the full evacuation which the circumstances of the case require. It will be noticed, that the practice is intended to be consid- ed only as applicable to the latter stages of typhus fever. In CATHARTICS. 291 its commencement, when vascular action is considerable, free purging with brisk agents is necessary, not only for the purpose of unloading the bowels of their irritating contents, but also for the more important purpose of their depleting ef- fects on the blood-vessels. Dr. Armstrong confirms this view. " Purgatives," says he, "seems beneficial by unloading the intestines of foeces and excrementitious matter, which when retained, excite and keep up much general irritation. But is it not exceedingly probable, that they have another and far more salutary effect in restoring healthy secretion, and in diverting irregular de- terminations of blood from the head, liver, and other parts ? The full operation of aperients sometimes corrects an un- natural heat of the skin, or a morbid state of the pulse, al- most as effectually as the affusion of cold water or venesec- tion ; consequences which surely indicate that the action ex- tends further than the mere removal of foecal matter from the intestinal canal." The doctor does not seem to have con- sider%d, that the inconveniences named, might all have been produced by intestinal irritation, and its removal of course would procure the retirement of its effects. He adds, "I believe that purgatives are also beneficial, by preventing through their operation, the absorption of the morbid secre- tions and excrementitious matters of the intestines ; for when these have been allowed to be retained in typhus, I have generally observed a considerable increase of irritation, with an offensive odor from the lungs and from the skin ; and on the contrary, when the morbid secretions and excrementi- tious matters have been regularly evacuated, there has been mostly a diminution of irritation, with an absence of the pe- culiar odour." Much judgment is necessary in making our selection of the proper article for purging usefully in typhus fever. In the commencement, calomel—or calomel and jalap—or calomel with jalap and aloes—neutral salts, or infusion of senna—or 292 CATHARTICS. senna and salts combined, may be employed. These should be used with decision in the beginning ; afterwards half a grain of calomel, with one grain or-less of ipecacuanha every morning and evening, with a continued use" of rheum and serpentaria. In exanthematous fevers, cathartics are very useful reme- dies ; so long as it is proper to keep in subjection the excite- ment of the skin ; and it is unquestionably a morbid excite- ment of the skin which constitutes these diseases. As cold air, tepid bathing, and ablutions act kindly in such affections, so also do cathartics, with this difference—ablutions mode- rate and improve the excitement of the skin ; cathartics only procure a reduction of the action. The one therefore can- not be a proper substitute for the other. Cathartics deter- mine the circulation upon the intestines, and effect a simul- taneous diminution of the action of the skin—the converse of which is produced by sudorifics, and therefore by the pro- per use and alteration of these two modes of treatment, we may manage exanthematous diseases, not always ho#ever without blood-letting. In scarlatina simplex and scarlatina anginosa, purges are useful. Drs. Hamilton and Armstrong, have added their tes- timony in favor of this practice, which is now pretty gene- rally adopted. In these affections, it is necessary in the be- ginning to produce brisk and copious evacuation. Dr. Arm- strong recommends sulphate of magnesia with tart, antimo- ny, so as to produce rapid purging and vomiting. The sys- tem may be in plethoric condition, with tendency to irrita- tion, and escape observation. Such is the state of things of- ten in the commencement of catarrh. On letting blood free- ly, the morbid condition may seem to be corrected. If how- ever, the intestines shall need evacuation ; if an appropriate cathartic should be required, and be overlooked, and the pa- tient expose himself to the weather—in consequence of the debility of the capillaries of the skin, produced by the bleed- CATHARTICS. 293 ing, a constriction, will follow—the circulation will be brought again into a state of stress, and an irritation will as certainly be the result, as if the blood-letting had not been performed; indeed the secondary irritation may be more serious than the first. This will always be found a very proper, and sometimes necessary practice. After the disease shall "have had any standing, so as materially to affect the vitality of the skin, blood-letting is inadmissible, and strong and brisk purging are in like manner to be avoided. We have used reiterated small doses of calomelvand ipecacuanha, in all cases of scar- latina anginosa, after the disease has progressed till the throat is considerably sore*, and the tongue and fauces are much coated with sordes; paying attention to the skin, according to the views submitted in the chapter on emetics. In erysipilas, ordinarily, purges are useful, but it is emphat- ically important in this affection, to have regard to the state of the stomach and intestines, and take special care to guard against a collapse of the skin, and an introversion of the ex- citement. To use a vulgar explanation, we must take care that the disease does not turn in upon the bowels, which it often has a very great tendency to do. We explain this by considering the patient to have been in a state of debility before the at- tack—produced by the agency of cold, upon a temperament favorable for the production of erysipelas. The eruption is consequent on an imperfect attempt at a recovery of the ex- citement of the skin. To deplete therefore, under some cir- cumstances, would produce a dangerous collapse. After it shall have produced general irritation, and a consequent re- action determined to the head, then blood-letting is an ap- propriate remedy. In dysentery, most decidedly cathartics are beneficial. If the disease be consequent on the detention of foeculent mat- ter, it is obvious that this must be removed. If it be the re- sult of venous congestion, evacuation from the bowels is 294 CATHARTICS. equally necessary. The disease implies an irritated condi- tion of the bowels—all irritating agents therefore must be speedily removed. It is important also, that we should be careful to make a judicious selection of the article with which we propose to accomplish our intention. In the commence- ment something which shall act decisively and freely; af- terwards, castor oil, or sulphate of magnesia, and if necessa- ry, these alternated with calomel, or calomel and ipecacuanha combined, according to circumstances. But in a majority of cases, after decisive depletion by blood-letting, when admis- sible, and a suitable cathartic once or twice administered, a good dose of castor oil, with ten, or fifteen, or twenty drops of laudanum may be employed as often as the tormina and tenesmus recur. And with a proper attention to the skir, this treatment may be relied on,for a cure. CATHARTICS. 295 CHAPTER VII. CATHARTICS—CONTINUED.. Cathartics are valuable in the treatment of puerperal fever and peritonitis. In affections of this sort, brisk purging in the onset, very often, will be found effectually to arrest their their further progress. If the attack be acute, the most deci- sive blood-letting will always be indispensable; afterwards, cathartics suitably adjusted to the demands of the case, with cupping and leeching, will constitute the principal remediate measures, and upon which we most rely. Our observations have led us to believe, that in the fever most commonly met in childbed, the peritoneal coat nf the intestines, is more fre- quently concerned than the uterus. As in other instances of inflammatory affectines of the intestines, there is a general soreness of the abdomen, and in very bad cases, the abdo- men becomes tumid and hard. Constipation also often ob- tains to a very alarming degree. Therefore, after blood-let- ting, when necessary, brisk cathartics ought to be adminis- tered, and they will be more or less beneficial, according to their activity. Sometimes there is difficulty in effecting ca- tharsis, so great as to require strong doses of calomel and ja- lap, which ought to be fearlessly administered, whenever necessary. There have existed very great errors in the opin- ions of physicians upon this subject. Drs. Abercrombie and Broussais, must have been in error when they wrote against the use of cathartics in peritoneal inflammations. Broussais says, they are hurtful, because the vermicular contractions which they excite in the intestines, must increase the mor- 296 CATHARTICS. bid sensibility of the peritoneum. In abdominal inflamma- tion, provided the mucus tissues are not inflamed, cathartics excite the secreting vessels, and that not only of the whole external surface of the intestines themselves, but also of the glandular organs, whose excretory ducts open into the primas viae ; and by the most direct channel within the reach of art, deplete the vascular portion of the abdominal viscera. When the intestines are inflamed, the peritoneal covering which is reflected over them, will of course be more or less implicat- ed. However much this may be the case, if the villous coat of the intestines remain unaffected, the alimentary canal will commonly be found in a condition, which uniformly de- mands the aid of cathartic remedies, and the most direct pos- sible way to relieve the peritoneum, is to evacuate the con- gested vessels of the abdominal viscera. To excite the mu- cous membrane therefore, will as certainly relieve the peri- toneal inflammation, as a free expectoration from the mucous membrane of the lungs, will relieve the vascular turgescence and inflammation of the parenchymatous structure or pleural covering of that organ. It may be proper, however, before we dismiss this subject, to observe, that in some instances of great prostration in childbed, the intestines may be in a con- dition which will require much care and management, espe- cially when worn down by long continued diarrhoea. It may be necessary to use small doses of calomel and opium, to be aided by occasional doses of castor oil; infusions of sen- na, with or without the addition of a little sulphate of mag- nesia; epispastics, external warmth, semicupium with vine- gar ; sinapisms, the vapor bath, &c. Cathartics properly belong to the class of antiphlogistic medicines, and therefore there are very numerous instances of inflammatory disease, in which they are useful. In pleurisies they are of less importance, and sometimes become injurious. In these affections we rely chiefly on blood-let- ting. But in rheumatism they are generally useful. Dr. CATHARTICS. 297 Scudamore, in his treatise on the nature and cure of gout and rheumatism, says, that the advantage of making a de- traction from the general circulation, by the channel of the alimentary canal, is no less remarkable in rheumatism, than in every other inflammatory disease. In proportion as we pursue this practice from day to day, we obtain its effect in acute rheumatism ; the circulation becomes moderated ; the inflammatory diathesis subdued; and the absorbent system is excited to increased action." This statement accords with our own experience. The true reason why the use of ca thartics ever became doubtful has been, that they have been used too sparingly. By pressing the system hard with rei- terated purging, " we promote the removal of excessive se- cretions of the synovial membranes, which causes the dis- tention and impedes the motion of the parts affected. Sa- line purgatives administered in small doses, and repeated at intervals, are the most advantageous." This last is a cor- rect view of the practice in cases of long standing, in which the system is worn down to a state of debility. In the ear- ly stages one or two blood-lettings may be employed, and when by the reiterated use of gentle cathartics, we keep down the inflammatory action ; and we excite the absorbent system, when sufficiently reduced, to obey a treatment less powerful in its effect. It may be remembered however, that it is important in the cure of rheumatism, to have special re- gard to the state of the skin. All the different unguents, lin- iments and opodeldocs, have obtained their reputation chiefly because, either the friction necessary to make the application, or the irrijating qualities of them, or both conjoined, or the necessity of making the application before a hot fire, or un- der the influence of a hot shovel, have served to keep up the excitement of the skin. Sinapisms and epispastics are per- manently useful, then only, when they make an impression/ on the skin, which ensures a permanent excitement of its vessels, so as to maintain its functions. In view of this im- 298 CATHARTICS. portant consideration, we conduct the use of cathartics in rheumatism. After depletion shall have been carried to a certain extent, the skin will be in danger of losing its excite- ment. When we arrive at this stage, we must be careful as to the quantity of blood to be drawn, and also as to the pow- er of the cathartics to be used. It is equally important not to repeat either, until the system reports itself in readiness for permanant reaction. Aided by a proper use of heat, sina- pisms, frictions and blisters, so as to compel the skin to keep time with our depletions, we can bleed as often and give as many cathartics in six days, as can safely be done in nine without the necessary attention to the skin. Very nearly the same practice, and all its discretions are equally appropriate in the treatment of gout. Whatever be the real nature of this painful disease, we are of the opinion, that there is always some organic disease, some functional derangement of the liver and portal system of vessels. This is also the opinion of Dr. Scudamore. Admitting this, there can be no doubt respecting the beneficial effects of purging in gout. This practice is also recommended by Dr. Sutton. The experience of the faculty in relation to gout, has led to the adoption of a practice in full accordance with the discre- tions which we have submitted in relation to rheumatism. Dr. Scudamore informs us that "he invariably employed, with the greatest advantage, purgative and diuretic medicines conjointly; so that the exhalent vessels of the alimentary canal, and the secreting function of the kidneys, are stimula- ted to increased action at the same time." Such a union of purgatives and diuretics, is particularly serviceable in those cases that are attended with dropsical effusions in the ex- tremities. In any such case, and indeed in all cases of gout, regard ought to be had in a very particular manner, to the general temperament of the patient, and also to any organic temperament which may obtain in the case, especially to the habitual state of the patient's skin. And if he have been ac- CARHARTICS. 299 customed to a constant moisture of the surface, every suitable measure must be adopted to insure the concurrence of the skin, in the train of arrangements which enter into the plan of treatment. It will of course be seen, that sometimes it may be necessary to unite diuretics, cathartics, and diapho- retic medicines, in order to do ample justice to a gouty patient. In hydrocephalus internus, cathartic medicines are indis- pensable. Physicians of late years seem to have to a pretty general consent of opinion, that the symptoms ordinarily at- tendant upon hydrocephalus are often consequent on gastric irritation. The disease in such cases, first evinces its ap- proach by great disturbance of the stomach and bowels, and the " alvine discharges afford unequivocal proof of great functional disorder of the liver. They commonly consist of large quantities of black or green or glary bile, and are sel- dom if ever found to exhibit the appearance of natural and healthy evacuations. Dr. Cheyne, in his post mortem exam- inations, found in the liver, the remains of great inflammatory action, with appearances proving that undue irritation had existed in the alimentary canal. Mr. Abernethy also found the brain of a child, that had died of what were considered unequivocal symptoms of hydrocephalus, to be perfectly healthy; the only disease being in the bowels. Dr. Cheyne mentions a very remarkable case of a girl, who complaining in the evening of a headache, was put to bed by her mother and soon fell asleep; next day at noon she was still sleeping, respiring fully and slowly, with now and then a heavy sigh : the eyes were fixed, the pupils large and immoveable. She had been very costive for some days previous, and was lan- guid : she was ordered an enema and this roused her, so as to swallow a bolus of jalap and calomel, which operated pow- erfully and brought away two chamber pots full of the most extraordinary collection of foeces the Doctor ever saw. This patient recovered immediately. In accordance with the 300 CATHARTICS. opinion which this case is intended to inculcate, cholera in- fantum very often terminates in unequivocal symptoms of hydrocephalus acutus. We have often seen very alarming appearances, such as indicate danger to the head, corrected immediately by a plentiful catharsis ; and sometimes by the administration of a simple enema. According to our obser- vation, a great proportion of children are over-fed. Their brains are greatly irritable, and a fever which in reality has its origin in a morbid condition of the viscera, will be found seriously to affect the head. There would be no hazard, therefore, in believing that nearly all the instances of this disease, which are not produced by falls or some other known injury done to the head, are primarily diseases of the viscera; and that the injury sustained by the sensorium, is superin- duced by the violence and continuance of the fever. But whether the disease be idiopathic or secondary, purging is equally necessary in both. The propriety of cathartics is most obvious when the disease is dependent on an irritation of the intestines, as in such cases, they tend at once to re- move the cause of irritation, and by producing a determina- tion of the fluids to the intestines, diminish the quantity which would otherwise have been determined on the brain. The bowels, therefore, ought to be actively moved, in every case where the symptoms indicative of hydrocephalus are found to supervene. Dr. Cheyne, in his essay on the dis- eases of children, says : " Should we ascertain, that the ali- mentary canal is torpid and imperfectly performing its func- tions, admitting an accumulation of frrculent matter, or that the secretions flowing into it, are vitiated or diminished in quantity, which we discover by the peculiarity in the appear- ance, or by the pungent foetor of the. stools, we must, by steadily pursuing the purgative plan, endeavor to effect a change in the hepatic system, the alimentary canal, and all the parts, including every organ essential to life, which is connected with them." This is in perfect accordance with CATHARTICS. 301 the experience of every judicious physician in this country. If the facts and arguments adduced, in proof of the propriety of purging decisively in hydrocephalus, be admitted ; if ca- thartics determine the circulation from the head and remove the causes of intestinal irritation, it must be obvious, that they will likewise be useful in apoplexy; and for the same rea- sons ;—with a view to diminish the afflux of blood to the head and direct it upon the intestines and other abdominal viscera; and the more decisive the purges, the more bene- ficial will be their operation. Hypochondriasis is produced by a diseased state of ftie chylopoietic viscera. It is the ordinary course of it, first to take on the symptoms of dyspepsia; the appetite is either morbidly increased or diminished ; a distressing sense of full- ness is experienced in the stomach, with foetid belchings; white tongue ; obstinate constipation ; and headache. These are unequivocal evidences of visceral disease ; yet in this af- fection, brisk purging does not produce a good effect. Ordi- narily, the viscera are in a state of too great debility, to en- dure drastic purges. We have thought that most cases of this sort, are consequent on a state of things, approximating to schirrus. If the evacuations be too considerable, there- fore, they will serve only to increase debility; inasmuch as the vessels are not prepared to keep time with the depletion. The kind of practice which the experience of the profession has led them to adopt, is the frequent and almost daily use of laxatives. By gently exciting the bowels in this way, we in some sort, substitute the natural intestinal and hepatic se- cretions, and counteract the torpor which in this disease pre- vails in the portal circulation. To accomplish this, we unite purgative articles with mild bitter tonics, and give them, so as to procure one or two good evacuations in the course of twenty-four hours. When the disease is of long standing, there is often the most remarkable constipation; of course an amazing quantity of fceculent matter is accumulated and 302 CATHARTICS. impacted in the lower bowels. This must have a tendency to keep up and increase irritation, and what is particularly remarkable, purgatives do not remove it. When it is de- tected, in such cases, it is the practice to use mild but copious injections. The whole of this practice is merely palliative. Every such patient needs remedies which have a tendency to cure the visceral disease which lies at the root of the evil. He should be treated with the utmost respect, and be made fully to understand that he is laboring under a disease which re- quires steady and long continued attention. We use a pill of calomel and ipecacuanha, in association, or in alternation with laxative bitters, and repeat it as often, and continue to use it as long as possible so as not to induce salivation. Whenever ptyalism is threatened, we withdraw the pill and trust the bitters without it for a week or two, and then again resume the pill. If it too readily induce a salivation, we sub- stitute for it the blue pill, and follow the same plan. If a cure be practicable, it will be accomplished. Hysteria is also, more or less, the effect of diseased viscera. Its most prominent symptoms are, wandering pain in the ab- domen, flatulence and foetid evacuations, with constipation— the certain indications of disorder in the functions of the viscera. This is also the opinion of Dr. Hamilton, who says " these symptoms afford conclusive evidence, that the gastric affection is primary, and that the other multifarious symp- toms of hysteria, depend on it. We have therefore thought it reasonable, to attend particularly to the state of the stom- ach and intestines, and to employ in the first place, purgative medicines, to remove the constipation which most commonly prevails in hysteria." In this disease, however, much more decisive purging is necessary than is proper in hypochondri- asis ; and it is found beneficial to unite purging medicines with the foetid gums. Assafoetida is commonly preferred. There is a striking fact which has been noticed by Dr. Ham- CATHARTICS. 303 llton and others ; that the first purgatives seem on some oc- casions to aggravate the symptoms. In a case of that sort, it will require address to insure the necessary repetition, and the practice must not be deserted on that account. The dis- tress which the first dose gives, is owing to the inconven- ience of relaxation, and corresponds to the uncomfortable sensations which those females feel, who are accustomed to tight lacing, when on any account they lay off their corsets. By perseverance in the use of cathartics, the intestinal vessels will be evacuated, and their natural sensation will be restored. After a brisk purge or two, we use small doses of calomel and ipecacuanha for a few days. If the pulse rise under the agency of this preparation, we let blood, repeat the cathartic and then recur to the pill of calomel and ipecacuanha, made in the proportion of about one-fifth of a grain each. So soon as the patient becomes too susceptible of the mercurial influ- ence to bear this combination, we have recourse to the blue pill, in small portions, and continue one, two, or three per day. Dr. Hamilton is the first physician who directed the atten- tion of the profession to the use of purgative medicines in treating chorea sancti viti. This disease is thought to be often dependent on gastric irritation or great foecal accumula- tion in the lower intestines ; and of course, whenever such a state of things exists, purges in decisive doses, must unques- tionably be of very great utility. This practice is sustained by very considerable authority, as Sydenham, De Haen and Stahl. Dr. Hamilton divides the disease into two stages— the first includes all the time, so long as the intestines retain their sensibility, and before the accumulation of foeces is great. During this stage, he thinks that gentle purges, re- peated as occasion may require, will effect a cure, or more properly prevent a full formation of the disease. In the se- cond, which is, when the disease has become confirmed, a more careful attention will be required. Powerful doses 304 CATHARTICS. ought to be given in pretty quick succession, at intervals so short, that the latter dose may support the effect of the for- mer, until the expulsion of the accumulated matter shall have been effected. But in order to gain permanent advan- tage by the practice, it must be pursued in a suitably decis- ive manner. "Half measures," says Dr. Hamilton, "in in- stances of this kind, will surely prove unsuccessful." But chorea does not always depend upon causes seated in the viscera of the abdomen; and therefore we find it will not yield to the most complete and efficient course of purgative treatment. Indeed, there are frequent instances in which evacuation serves obviously to aggravate the disease. All such, will be relieved most effectually by the use of the min- eral solution of Fowler, cuprum ammoniacum, iodine or moxa applied to the spine. There can be no considerable hazard in testing first the effect of Dr. Hamilton's plan, which probably in a majority of instances is the most rational me- thod of treating the disease. In marasmus, purging is the only useful remedy. This disease is unquestionably connected with derangement of the digestive organs. We are informed by Dr. Hamilton, that during the first stage, which extends from its commence- ment to the accession of the hectic state, it may be cured by mild purgatives. During this first stage, the bowels are not altogether torpid, nor are they overloaded with accumulated foeces. But after the disease has advanced into the second, which is the febrile stage, more active medicines are required, which must be regularly and perseveringly employed. Dr. Hamilton recommends the exhibition of small, but frequently repeated doses of cathartic medicine, so administered, that the latter dose may support the effect of the former or preceding ones. When the bowels are once opened, then stronger doses, given at longer intervals, will accomplish the cure. He also recommends the use of purgatives in the treatment of chlorosis. " The slightest attention to the history of the CATHARTICS. 305 disease," he says, "evinces, that costiveness precedes and accompanies the other symptoms. Costiveness induces the foeculenjt odor of the breath, the disordered stomach, depraved appetite, and impaired digestion. These preclude a sufficient supply of nourishment, at a period bf growth when it is most wanted ; hence paleness, laxity, flaccidity, the nervous symp- toms, the wasting of the muscles, languor, debility, the reten- tion of the menses, the suspension of the other secretions. serous effusions, dropsy and death." Inasmuch as all these phenomena are the effects of costiveness—suppose we inquire what state of things produces the constipation? No doubt. a diseased state of the skin and portal circle. The ordinary method of treating patients of this description, has been to administer tonics, such as iron, wine, bitters, &c. There must be good constitutions, when cases of this nature are cured by such treatment. Our experience goes to sustain the opinion and practice of Dr. Hamilton, as to the use of ca^ thartic remedies. His practice is correct, though he does not look sufficiently deep into the cause of the disease. In cases of this affection, we associate the pill of calomel and ipecacuanha with the use of tonics, if there be any need for their use. The pill should be continued so long as any vis- ceral disease remains. Some females are liable to a vomiting of blood, an affection which occurs from the age of eighteen to thirty. The attack is preceded by languor, and oppression about the chest, and a sense of fullness of the precordia;. hiccough, dyspnoea, and sometimes pain in the chest, loss of appetite, headache, ver- tigo, disturbed sleep;- the eye is dull, countenance expressive of distress, pulse feeble, bowels constipated—these are the precursors of the hemorrhage, and these indicate a-fullness of the liver from which the blood in such cases, is discharged. The treatment of course is the same as the preceding. No class of medicinal agents admits of more extensive use than that of cathartics, in. almost every, disease and in.every 2U 306 CATHARTICS. part of the known world. Hence it is, that so large a traffic in pills, under such an endless variety of names, is carried on in Europe and America. Like all other useful things, it is often abused. Yet so many find temporary relief and com- fort, that the injury done by an injudicious or an ill-timed employment of a remedy so universally popular, is seldom ascribed to its true cause. It would be a valuable service, if the dangers which follow its abuse, could be made sufficiently obvious to secure the necessary caution. This, however, will be a hard task, and the more so in this country, when there is such an abundant supply of food, and such prevail- ing inclination to indulgence. Those who take great delight in the luxuries of the table, so often need the aid of pills, and are so frequently prepared by their use, to return to their "chief joy," that next to the pleasures of eating, are the supposed means of sustaining their ability to eat. It is a customary thing for epicures, when their'health and ability to eat and drink with their usual relish begin to fail, to visit the springs. The waters are sufficiently medicated, when taken in liberal quantities, to act freely on the bowels, without restraining the appetite for food. The invalid finds that he can eat with great satisfaction, and by means of a speedy evacuation be ready to repeat his meals more fre- quently and indulge more freely than when in health; and if the evacuations are frequent and free enough to convey away a sufficient portion of the chyle, before the lacteals can have time to absorb too much, the waters will probably prove really beneficial; for on this point alone the issue turns, whether for benefit or injury. In managing the cases of in- valids of this description, we have the greatest difficulty in respect to diet. They cannot govern their appetites. Hence the best concerted plans are so frequently defeated. In treating a case of this kind, therefore, we should never ex- pect a rigid regard to prescribed abstemiousness, but adopt CATHARTICS. 307 measures which will insure the intention without much self- denial. We should associate with the intended medicament, the daily use of Bedford or Saratoga water, or some artificial substitute, to an extent sufficient to imitate the effect of a residence at the springs. We often administer to our pa- tients, whose livers and other'important viscera have been a long time sore and languid, one, two or three doses, a day, of calomel and ipecacuanha, of each, one-fifth of a grain, and associate with this minima pill, frequent repetitions of drachm doses of Epsom or Rochelle salt, sufficiently diluted, so as to secure at least two evacuations every afternoon. The pill will produce the alterative effect, if the system be sufficiently deprived of its nourishment, and the salts, diluted with ale and water or ginger tea, or water only, may be used to sub- stitute the water frdm the springs. Although the patient may be thus indulged, the evacuation of the food so as to rob him of his chyle, will serve to put the absorbents in a state of requisition, and any existing enlargement or induration of the diseased viscus, will be retired. 308 DIAPHORETICS. CHAPTER VIII. DIAPHORETICS. Medicines which increase the natural transpiration by the exhalents of the cuticular surface, we denominate diaphoret- ics. When they act so extensively and effectually, as to produce sweating, we call them sudorifics; the term diapho- retics is usually associated with such articles as serve more • particularly to increase the sensible perspiration. Much has been written on the subject of obstructed perspi- ration ; and the latest and best works, have advanced so far only, as to make the distinction which regards "opposite states of the system." They have learned that obstructed perspiration " may depend on, or be connected with a high febrile action," and also, on a " slow and languid circulation." This is a considerable step towards the true philosophy of diaphoretics, but it falls short of affording all the instruction necessary to guide the young physician, in his remedial treat- ment in respect to the skin. It is useful to know, that rem- edies which are calculated to restore this function when its defect or loss is associated with high vascular action, must be very different from those, which are calculated to excite it when in an opposite state." That, in the former case, our diaphoretics must be such as have a direct tendency to lessen the action of the heart and arteries, and at the same time pro- mote the action of the transpiratory vessels. That cold ab- lutions, refrigerants, antimonials and blood-letting, are very often directly and manifestly diaphoretic; and when a de- ficiency of this function is accompanied by a languid cir- DIAPHORETICS. 309 culation, and a pale, shrivelled, or cold skin, that recourse must be had to diaphoretics of a stimulating character. These general principles have served as imperfect guides in the employment of diaphoretics, and are nearly in consent with the physiology and pathology which we have adopted in view of the skin. After all that has been done thus far, we still have to in- quire, what is meant by an obstructed perspiration? and what is expected to be accomplished by its restoration? If the excitement of the skin be partially suspended, for a short time only, the system being in ordinary good healthf reac- tion will be speedy and agreeable, accompanied by a pleas- ant moisture of the skin. This position is exemplified and confirmed by what occurs on using the shower bath; or on stepping about a few minutes, without any clothing, in the open air. In either case, after being dressed, reaction and slight perspiration immediately follow. So also in winter, after exposure for a considerable length of time, by the aid of fire in the usual way, a similar state of things readily oc- curs. For this alternation of suspension and reaction of ex- citement, the skin seems to have been particularly and em- phatically destined. A suspension of the circulation, such as is produced by exposure to cold, when it befalls a person in good health, at first induces a stricture of the capillaries of the skin. This stricture is consequent on an accumulation of vitality. When the capillaries of the skin are filled with blood, the excitement which includes the circulation and concomitance of all its functions, gives full employment for all the vital influences pertaining to that structure. Where a sedative power abates the excitement of the capillaries, the unemployed sensorial influence fastens on the fibre of the ves- sels emptied of their fluids, producing the spastic condition observed by Cullen, which we take the liberty to designate by the term stricture, to distinguish it from the condition 310 DIAPHORETICS. consequent on the evanescence of the sensorial influence, when the capillaries fall into a state of collapse. If the exposure be too long continued, the stricture will retire, and the skin will become collapsed by reason of such evanescence of its vi-, tality. We stated in our elements, that the suspension of excitement is accompanied, through a limited period, by a corresponding accumulation of sensorial influence, and that when there is an ordinary degree of vigor, this accumulation will eventually induce a spontaneous reaction. If circum- stances be favorable in regard to time, temperature, &c, the reaction will be limited mainly to an increased excitement of the skin. If circumstances thus favorable to an adjustment, through the medium of the skin, do not concur in time, and a stricture takes place on the surface, the reaction may be di- rected to other determinations; it may produce a more gen- eral effort, and excite the heart and arteries. If then the pul- monary vessels be overstrained by this effort, it may produce an instance of pulmonitis. If the abdominal vessels give way, we will have enteritis. If the blood-vessels of all the viscera maintain their integrity, after a struggle sufficient to expend the accumulated sensorial influence, eventually the excitement of the skin will be restored, and a free per- spiration follows in the train. But all these statements are made in view of a healthful condition of the viscera. When the circulation of the cuticular surface is suspend- ed, the blood must find place in a distention of the vessels of the abdominal and other viscera. A diurnal influx and re- flux from the cuticular surface of the viscera, if not strictly natural, is universally habitual, and justifies the conclusion, that the blood-vessels of the abdominal viscera, are prepared by a suitable organism, to admit of the influx, and suffer it for a certain length of time without injury. This occurs un- der ordinary circumstances during the night, and if not too much exposed to cold when we sleep, or if not too long exr DIAPHORETICS. 311 posed to cold or wet weather at any one time, or if not too frequently repeated. Each instance of influx or introversion, will be spontaneously corrected by the reflux or reaction, which, on the return of morning, upon taking exercise or re- freshment, or on returning to the fire after exposure, is con- tinually experienced by persons in ordinary good health. If this spontaneous reaction should not take place in the usual manner, and the blood be thus accumulated, and too long delayed in the vessels of the abdominal viscera, a stricture of the cutaneous blood-vessels will be an inevitable consequence, which will be accompanied with head-ache, chilliness, list- lessness, stiffness of the limbs, and sometimes with nausea, thirst and wandering pains. In every such instance, it is ne- cessary to have a proper regard to the state of the viscera, in making an estimate as to the probability of a spontaneous reaction of the cutaneous vessels. If the general circulation be not materially impeded by plethora, and no one viscus is in a state of congestion, bathing the patient's feet in hot wa- ter, giving him a cup or two of hot tea, and covering him warmly in bed, will be effectual in correcting the stricture, and in re-establishing the cutaneous circulation, that is, "re- storing the circulation." In any instance, however, in which there is considerable plethora, or the blood-vessels of the viscera have been in a state of distention until their tone is too much impaired to consent with the arrangement intended to favor centrifugal action, or when any one of the viscera is in a state of congestion, neither pediluvium, nor hot drinks, nor retir- ing to bed. nor the agency of any stimulating or diapho- retic medicine, will be efficacious in correcting the stricture. In consequence of the plethora, the blood is not in a state of complete assimilation; it is deficient in respect to all the in- fluences derived from a free circulation through the lungs and skim A considerable portion of effete matter is retained in 312 DIAPHORETICS. consequence of its languid circulation through the secreting organs, causing these also to languish. Moreover, because of the imperfect state of the blood, the condition of the sen- sorium, the nerves, and all the viscera is continually growing worse. In every such case the system must be released from its thraldom by the necessary depletion, before any diapho- retic agent can be made to take effect. But after the neces- sary blood-letting and purging, in a majority of instances, any agreeable stimulant drink, if taken in sufficient quantity, will be followed by a pleasant diaphoresis. Under such cir- cumstances, the heart and arteries readily command the re- maining volume of fluids ; the viscera, lightened of their ex- cessive load, perform their functions well; the blood again becomes charged with its vivifying principles, and is propel- led freely to the surface; and if the correction be made in time, the skin by its sui generis action will admit, and circu- late its portion, which will be evinced by a return of perspi- ration. If the case have been attended with some delay, in addition to the requisite depletion, it may be necessary to make appropriate application of external heat, and adminis- ter internally some diaphoretic agent, calculated to favor a determination of the circulation to the capillary vessels of the skin, without materially augmenting the action of the heart and arteries. In instances of this sort, we pro- cure the most perfect exhibitions of diaphoresis. When the cutaneous vessels have been long in a state nearly destitute of circulation, such -as subjects the nerves to a condition approximating to torpor, which is always accom- panied by a collapsed state of the skin, there will be much additional difficulty. Some congestion of the viscera will be found to have previously existed, so long, that the blood will be more or less deteriorated. There will be found to exist a corresponding degree of general debility, such as for the time will forbid blood-letting, or much depletion in any DIAPHORETICS. 313 way. In such a case, a potent stimulant would probably en- danger the congested viscus, and a mild diaphoretic would not be sufficient to recover the circulation of the cutaneous vessels. There will be occasion therefore, to employ a train of preparatory measures. The bowels must be evacuated according to the strength of the patient, external heat must be used in a manner having respect to the time of continuance, which will probably be required to accomplish the intention; then some appropriate diaphoretic drink must be adminis- tered, as an infusion of Serpentaria Virginiana, &c. adding when necessary, spiritus mendreri, wine whey, &c. &c* By this treatment, it is probable, that a part of the excess of blood detained in the veins of the viscera, will be trans- ferred into the arteries, and may possibly produce a degree of tone in the arterial action, which should be corrected by blood-letting; and this is always a favorable occurrence whenever it takes place, inasmuch as it reports an improve- ment in the condition of the veins, and of the nerves de- pendent on the circulation through the capillary vessels of the surface. If this occurrence should take place whilst the patient is under the influence of diaphoretic remedies, or at any time after the intention may be considered to have been accom- plished, it is as necessary to correct the tension of the arteri- al action by depletion, as if no appearance of debility had oc- curred in the first instance. A condition of things corres- ponding to that which is presented in an instance of this kind sometimes occurs spontaneously. An elderly lady, say fifty years of age, who had for a long time been subject to cough, without appetite for food, having head-ache, some unnatural thirst, confined bowels, and a good deal of the time being unable to sit up long at once, having * "* The foregoing paragraph describes the condition of the^ system when predisposed for an attack of typhoid fever. 314 DIAPHORETICS. occasionally made use of gentle laxatives, at considerable in- tervals ; at length, rather unexpectedly, felt so much better that in the evening of the same day, after having sent for us in the morning, she declined any medical attention, believ- ing she was so much improved as to need no prescription. She was sitting up, but there was a livid paleness of complec- tion, and a peculiar feebleness of the arterial action, without frequency or discoverable tension, which led us to apprehend that she would be disappointed. We were the more appre- hensive, because her respiration was somewhat restricted, al- though an attempt at a full respiration gave no sensible in- convenience. We did not think her convalescent, but were informed that if things should not progress agreeably to her expectation, she would let us hear from her. The follow- ing day, she still considered herself to be doing well, having had, on the whole, an agreeable night. The second day she was disposed to take nourishment, but whilst in the act of eating dinner, was suddenly taken with a violent chill, like the onset of pneumonitis, followed very quickly by an excru- ciating pain in the breast, great difficulty in breathing, insa- tiate thirst, cy*c. Being sent for in haste, we reached her in the evening and found her very ill. Her case was now obvious- ly inflammatory, requiring blood-letting, which was repeated daily for two days, in each instance affording great comfort. When the violence of the inflammatory action was subdued, the case was marked with considerable debility, on account of which, after each blood-letting, heated bricks wrapped in napkins and moistened with vinegar, were applied to her feet and knees; and several times exchanged, so as to main- tain the temperature ten or twelve hours. After the first bleeding, a large epispastic, ten by twelve inches, was appli- ed over the epigastric and hypochondriac regions—spiritus mendereri and oxymell of squill were administered through the day, to which were added a little camphorated tincture DIAPHORETICS. 315 of opium, and nitrous ether, through the night. The case progressed very comfortably, but the disposition to phthisis, pulmonalis still prevailed without improvement. Had there been less sensorial activity in this case, the in- flammatory attack could not have occurred. Similar appear- ances in autumn, and with sound lungs, probably would have eventuated in fever. It was winter; and although the circulation of the cutaneous blood-vessels was languid, the sensorial influence was gradually accumulated, until the system was charged for a spontaneous reaction.— In the mean time, the stricture of the cutaneous vessels. which were bordering on the state of collapse, prevented a free and general distribution of the circulation, in consequence of which, the pulmonary arterie's were subjected to a very alarming morbid action. In collating this case with those in which apparent debility under the influence of a stimulant diaphoretic treatment, is. abruptly followed by inflammatory appearances, it is neces- sary to invite attention to the following particulars. The accumulated and apparent latent vitality in the case referred to above, is roused by means of artificial excitants, made the more stimulant by the concomitant employment of heat. In this case a similar accumulation existed, and was permitted to progress, till the natural'or ordinary stimuli were sufficient to rouse the system to a spontaneous reaction, so strong ak to produce violent symptoms like pulmonitis. It is not a com- mon occurrence, that the system, when fallen into the state of a collapsed surface, will be so roused by a course of dia- phoretic management, as to require blood-letting. Cases like that just now described, are also rare ; whenever either of the circumstances does occur, it will be found useful to treat the patient according to the plan of practice above stated. When cases become chronic, and especially when some or- ganic disorder has taken place, and when it has become ne- 316 DIAPHORETICS. cessary to introduce an alterative plan of treatment, a healthy condition of the cuticular surface cannot be hastily establish- ed—in fact too great an effort to establish it hastily, at any one time might prove injurious. " Diaphoretics," says Dr. Eberle, " may act by relaxing the mouths of the perspiratory vessels, or by increasing their ac- tivity, or by establishing their increased activity, or* by ef- fecting an increased flow of blood into them, or by producing these two last mentioned effects simultaneously." When the blood has been for some time turned too heavily upon the viscera, and has become deteriorated, not only by reason of the imperfect performance of the functions of the organs which have been thus overcharged, but also by the detention of the morbific particles, which ought to have been thrown out by perspiration, it is very obvious, that in addition to the restoration of the excitement of the skin, it is necessary that a state of perspiration should be kept up for some time. In cases of established fever, such as require much depletion, it has been customary for the physician to be satisfied with the diaphoretic effects of antimony; on the supposition that much advantage is gained from the evaporation of the morbid heat, which is a considerable source of irritation. Sudorifics have been among the earliest and most com- mon remedies in every nation. But valuable as they are, and extensively as they have been used, there is perhaps no other class of medicines, which has been so often abused in the treatment of sickness. Van Helmont and his followers who believed that the most acute diseases were cured by ex- pelling some morbific matter, after " its proper concoction," employed the most stimulating sudorifics, together with high temperature in every grade of febrile exacerbation. This practice appears to have prevailed during the seventeenth, and the early part of the eighteenth century ; and it is easy to perceive, that its effects must very frequently have been DIAPHORETICS. 317 pernicious. More than one hundred years ago, a certain German physician made use of an apparatus for applying heated air by means of ignited alcohol. He used it exclu- sively, however, for the cure of syphilis. For several [days he poured in enormous quantities of guiacum, •376 ANATOMICAL SKETCH, ETC. them, in two principal trunks. They are found in all the organs except the brain, spinal marrow, the eye. the external ear and the placenta. Magendie says, they do not absorb, but receive the white particles of blood immediately from the arteries. And why not armed with the power of absorption ? As the capillaries giving origin to the veins, take up the col- ored particles of the blood with its serum, &e, so those of the lymphatics take up the transparent particles, which con- stitute lymph. In their course, there are numerous glands. A gland seems to be an interlacing of lymphatics with in- osculating veins and nerves. These glands are more fully developed and better nourished in infancy- and youth; therefore children and young people, are more liable to be affected with acute and chronic irritation of those ttructures. The glands are endowed with great irritability, hence scro- fula and tubercles, especially of the lungs. Tubercles are consequent on chronic irritation of the lymphatics. The capillary system is every where connected, and con- tains within it, the great mass of the fluids. A disturbance in one part, is felt to a greater or less extent in other parts, and sometimes an irritation in one part, will involve all the functions, so as to bring on disturbance throughout the whole. Probably this structure may be the portion of the system, which receives the impression and gives the direction and extension, to what is called in modern pathology, the irrita- tion of continuity. The blood may be accumulated excessively in one part and be derived from other parts. The capillaries of the in- ternal mucous surface antagonize those of the skin, and the condition of these two sets may be in reverse states. Inter- nal inflammations and congestions, are accompanied with torpor, atony or want of action, and with icelike coldness of the surface. Inflammation of the meninges of the brain, is attended with cold extremities. i ANATOMICAL SKETCH, ETC. 377 Lymphatics are an annexation to the veins. They con- duct a transparent fluid, which in its course through them, is nearly converted into blood, probably by an action assimilat- ed to that of the capillaries. They have their origin in ca- pillary radicles, in the intimate structures of the organs, and in the surface of the intestines. Monroe and Henderson con- sidered them to commence with open or patulous mouths or orifices. Fohman, a German anatomist, was confident that in fishes they originate in a cul de sac. This is a matter 01 no importance, since it is a settled point, that all the animal membranes absorb fluids. Cellular tissue is a white, spongy and soft texture. It is diffused throughout the whole body, uniting its various or- gans, between which it is interposed, surrounding and pene- trating into their interior, and of course forming a part of their structure. If it could be presented alone, all other parts of the system feeing removed, it would exhibit the entire configuration of the body. The structure is lamellar and filamentous ; is disposed into permanent irregular and varia- ble areoloe, having a free communication with one another. In a healthy state it is thought not to possess sensibility. This we know to be an error. It is endowed with irritabil- ity, and is susceptible of vital contraction. It is the seat of anthrax and phlegmon, than which, few morbid affections give more pain, however limited in their extent; and when erysipelas phlegmonoides occurs in any case, we have irrita- tion and anguish in perfection. It is the seat of serous exhalation, and its moisture facili- tates the movement of the organs and of such parts as are contiguous, and constitutes an'essential membrane for each organ, enveloping its minutest particles, and determining its form and size. It isolates each organ to a certain extent from all others, and by this provision, perhaps, each one is in some measure defended from diseased action, which may 378 ANATOMICAL SKETCH, ETC. be prevailing in contiguous parts. Its serosity may accumu- late, producing CEdema, when the affection is local, or it may be general, as in anasarca. It may be penetrated and infil- trated wither or gasses, constituting emphysema. An acute inflammation of this tissue, may produce lymph or gelatine. The tumefaction in that case, does not pit on the application of pressure. A tumid,condition of this sort, is in a peculiar fanner elastic, if subjected to pressure by the application of finger. With this sketch in view, we will take a brief notice of the general circulation of the blood. The heart is the great central propelling organ, which is supplied with four cavities; two of these receive the blood, and two propel it. We will commence at the lungs. The blood collected by the capillaries throughout all parts of the lungs, flows onwards towards the heart, through the pulmo- nary veins, which are continually uniting and becoming lar- ger, until they finally form four large vessels. These pour their contents into the cavity of the heart, which is called the left auricle. As soon as this auricle is filled, it contracts and presses the blood into the second cavity, which is called the left ventricle. This left ventricle, wheal it contracts, propels the blood into the great artery called the aorta. The aorta passes over from the top of the heart to the spine forming a large curve, and gives off branches in its course, for the support of the arms, neck and head. Then descend- ing down op the left side of the spine, behind the bowels, it gives off branches for the support of the thoracic and abdom- inal vicera; and in descending, near the hips, it divides into two great branches ; one of which supplies each of the lower extremities. All these branches go on dividing and ramifying, until they become capillary, and are extended to every part of the body, internal and external. And by the action of the capil- ANATOMICAL SKETCH, ETC. 379 laries, the blood is changed in its colour, from a lively red, to that which distinguishes the blood when drawn from the veins. The blood collected by the capillaries is returned by veins, from all parts of the body towards the heart; and as they approach this organ, all those descending from the head and upper extremities, become united in one common venous trunk; and all those ascending from the lower extremitkfi and the pelvis, are united in another. These two trunks aWL called the venal canal; which meet at the heart at an angle, and are united end to end, where, by a large opening, they pour their contents into the upper cavity on the right side of the heart. This cavity is the right auricle. When this auri- cle is full, it contracts and forces the blood into the lower cavity on the right side of the heart, or right ventricle. When the right ventricle contracts it propels the blood through the pulmonary artery and its branches, into every part of the lungs. In the capillaries of the lungs, the blood is subjected to the action of that organ and fitted for another round of the circulation. This done it returns by the pulmonary veins, to the left side of the heart, and proceeds on again; thus per- petuating the circle. It will be useful to add in this place, a sketch of the anato- my of the portal vessels. The blood that is distributed by the branches of the aorta to the abdominai viscera, does not return from the capillaries into corresponding veins, like that sent to other parts of the body. It is collected into an independent set of vessels, hav- ing a structure similar to that of the veins, except -that they have no valves. These vessels unite and form a large trunk, which is called the portal vein, which passes into the liver, and its branches are distributed like arteries throughout all parts of this large organ. From the dark blood of this ves- sel the liver secretes bile. When this function has been 380 ANATOMICAL SKETCH, ETC. performed by the capillaries of the liver, the blood thus freed of its bilious material, is conveyed into the vena cava and is there mingled with the general mass of the circulating fluids. The vena porta is very distensible, and can bear much full- ness, if it can be timely relieved. If it has no outlet howev- er, but that which is provided through the function of the ^^er. If therefore the liver by any means should become ^By inactive, the yielding structure of the vena porta, may Subject it to a degree of fulness, such as occurs in conges- tive fever. And a very inconvenient degree of distension occurs in almost all oases of intermittent and remittent bilious fever. The morbid fulness of the portal vessels is the cause of the soreness and distress felt in the abdomen in instances of fevers of this sort. FEVERS CONSIDERED. 381 CHAPTER n. FEVERS CONSIDERED. Forty years ago, having then been engaged in the practice! of physic about ten years, an honest nosolgist, we learned our first trustworthy lesson on the subject of fever. A gentleman living in Campbell county, Va. had built his house on an elevated spot, in the midst of a very healthful neighborhood. To save the expense of erecting a kitchen, he dug away the earth on the south side of the house, form- ing a basement, three sides of which were considrably below the surface of the earth. - The floor of the basement was laid on logs of post oak, with the bark left on them, except that their upper sides were hewed, that the boards might be neat- ly nailed upon them. On the side of this cellar kitchen, which was next to the fire place, three of the log sleepers had their largest ends turned to the upper side of the room. As these sleepers had no connection with the frame of the building, they were let down, each in a trench suited to its size. If therefore the earth were nearly level, when water should be permitted to fall into these trenches, it would flow towards the large end of the sleepers. The kitchen table, upon which the washing of dishes and the like were perform- ed, and the tubs of the washerwoman were placed, had its station immediately over the deep ends of these trenches. The slop-water therefore was sufficiently copious to keep the large ends continually wetted. The house had been stand- ing in this condition twelve years, when, m the month of February, the ground being covered with snow, a most :382 FEVERS CONSIDERED. alarming fever commenced among the blacks, who labored and slept in that part of the kitchen. The cook, a woman over thirty years old, had her bed placed within the distance of six or eight feet from the shop table. A girl of fifteen years, who assisted the cook, spent much of her time, and often slept at the fire, near the same corner. The washer- woman was engaged more or less of her time every day, also, in the same part of the kitchen. ^ The cook was the first victim. She complained of head- ache and not much additional inconvenience. Their mas- ter, as had been his custom when his people complained of indisposition, administered a dose of jalap and calomel. The medicine seemed to operate kindly, and the patient consider- ed herself much relieved. The following night the girl was taken violently ill. Having been sent for before day, we arrived early in the morning, and found the case truly alarm- ing. Excessive pain of the head, accompanied with a degree of heat of the scalp, and of the whole surface, such as we had never before met; excruciating pain of the back ; distressing sickness of the stomach and vomiting; with a pulse about one hundred and fifty or more per minute. She was bled, and then affusions of cold water were applied to her head for several hours. Doses of calomel and ipecac, were repeated every seeond hour. In despite of these remedies, the pain of the head and back, and the heat of the surface continued incorrigible. After an interval of six hours, the blood-letting was repeated, the calomel and ipecac, and the affusions of ■cold watereontinued some hours longer. When, finding no improvement whatever in the case, we informed the gentle- man -that the prospect was hopeless. Before leaving for the evening, we were requested to see the cook. We found her seated on a bench, holding on her knees a plate well filled with bacon and cabbage, with an ample supply of bread, of which she appeared to eat with an agreeable appetite. Her pulse appeared to indicate a hope- FEVERS CONSIDERED. 383 ful convalesence. There was no febrile heat of surface, and very little thirst. We made a favorable report and set out for home. The next morning we were aroused before day- light, with tidings that the cook-woman was dead ; the girl whom we visited the day before was much worse, and the washer-woman was also taken very ill. On our arrival, having examined the patients, we inform- ed the gentleman that the sickness was malignant and must have been produced by some ill conditioned material, which we probably would detect under the floor of the kitchen. On an examination we found the whole of the sleepers en- tirely decomposed, having left a black earthy deposite in the • trenches, except only the large ends of the three before men- tioned, as being near to the fire place. About three feet of these were in the condition of rotten wood, so soft, that when compressed in the hand, it would escape like dough, through the fingers. Its color was whitei, and its ordor was that of rotten wood only. We were standing and looking over the men at work, when the offensive material was first opened, and were seized abruptly with an exceedingly severe head- ache, which continued for half an hour, but gradually retired through the course of the day. The whole mass of the rotten wood and water in which it had been so long steeped, were removed at once, in one large wash tub, not exceeding four or five bushels in capacity. The cook-woman, who slept nearly over the pernicious material, died within forty-eight hours after her attack. The girl who assisted her, died on the third day, and the washer- woman on the fifth. The cause of this fatal malady having been removed, the greater part of the family sickened, amounting perhaps to twenty cases ; every case was marked with considerable vas- cular action ; the degree of violence varying according to the occasions they had to visit the kitchen ; the distances of their bed-chambers from the source of the poison, and the differ- 384 FEVER CONSIDERED.S ent temperament of each. All required depletion. Some were bled once only, others twice, and some five times. All recovered without difficulty or delay. Every grade of febrile action was exhibited, and the great and important truth demonstrated, that fever, in its essential characteristics, is a unit, and that its varieties are the effects of contingencies, of temperaments, &c. corresponding to the general views already submitted. It is a source of gatification to us, that Dr. Mcintosh, the distinguished Scottish leeturer on pathology and the practice of medicine, in Edinburg, entertains the same opinion on this subject. " After having watched the progress and termina- tion of fevers in various climates, I have been led to con- clude, that the nature and seat of fever are pretty much the same in all constitutions, in all climates, and under all cir- cumstances. The leading difference being in intensity, and the rapidity with which some run through their course ; be- ing sometimes connected with inflammation, sometimes not; it other times depending on functional disorder of the body, md also upon the lost balance of the circulation. INTERMITTENT FEVER. , 385 CHAPTER III. INTERMITTENT FEVER. In the first part of this work we have given our views res- pecting the origin and nature of fever, where we had occa- sion to describe it in its intermittent form. To this the read- er will please refer. It is there stated that debility first dis- ables the capillaries of the skin, which become morbidly af- fected by the low temperature of cool nights, especially such as occur at the full and change of the moon, as also in times of cold and wet weather. The cold air serves to produce, a stricture in the capillaries. When this error shall have ex- isted a certain length of time,(an exacerbation is the conse- quence. The chilly state of the system, thus set up, is ac- companied by an introversion of the blood upon the abdomi- nal viscera. If this occurrence should be frequently repeat- ed, or if the chill should be at any one time greatly protract- ed, the portal vessels become impaired by the distention. and the blood by the delay of its circulation in the vena porta is deteriorated. TREATMENT. Ill treating a case of fever in this form, the management and medication must be accommodated to the existing con- dition of the patient. During the cold stage, the circulatioit through the lungs is in thraldom, This inconvenience may- be lessened by administering a teaspoonfull of paregoric in a tumbler of hot lemonade, an hour in anticipation of the pa.- 25 386 INTERMITTENT FEVER. roxysm, or at the earliest notice of its approach, then let the patient be surrounded with bottles or small jngs filled with hot water, and be covered with a sufficiency of bed clothes. If he should be robust, and the anodyne seem to affect his head, as the chill is commencing, he should be bled from the arm, one pound or more. If the chill do not pass off in twenty or thirty minutes, repeat another dose of the para- goric and hot lemonade. If lemonade cannot be had, sage tea may be substituted. If the stomach be very sick, five grains of ipecac, may be administered and repeated every fifteen or twenty minutes, until it produce vomiting. Bleeding in the cold stage, in a majority of instance, will cut short the disease. It will not only put a stop to the pa- roxysm, but in many instances it will effect a cure ; and par- ticularly in those instances in which quinine seems to fail. If the patient be languid after bleeding, apply the vapor ba/h, and continue the application until the reaction shall be complete. Whilst the bath is in operation, and during the continu- ance of the hot stage, let the patient be indulged in drinking cold water, to the full extent of his inclination, and as often as he desires it; but he must serve himself with a tea-spoon. If there be much heat in the head, make an application of cloths well wetted with cold water, changing them often enough to keep them cold. If he suffer from general heat, wet his skin with a sponge filled .with cold water and alco- hol, laying off a part of his bed clothes. When the sweating stage commences, be careful to prevent his being chilled by the sweat. Let him have a napkin in hand, and, if neces- sary, let an assistant aid him in wiping away the sweat as it accumulates on his skin. Let the wiping be performed with energy, so as to cause considerable friction. When this ap- plication shall have been pretty well accomplished, let the pa- tient rise out of bed, be seated at the fire, and his linen be changed. The wet sheets or blankets ought all to be re- INTERMITTENT FEVER. 387 moved. Then place him in a dry bed, covered with the usu- al amount of bed clothes. Having made all these prepara- tions, let him take one or two grains of quinine every second hour during the succeeding intermission; at the same time. using one of the compound blue pills, every third hour, until his bowels shall be suitably affected. About six hours in anticipation of the next paroxysm, ap- ply the vapor bath in the usual manner. If there be a re- turn of the paroxysm, meet it a second time as above direct- ed, regarding all the instructions as before, except only that the blood-letting may be omitted, if a stricture across the breast, or a pain in the head do not recur. After the chills shall have retired, and the patient appears to be convalescent, four or six doses of the quinine should be continued daily for several days, to prevent a relapse. As a feeble state of the skin is the condition which sub- jects persons to attacks of intermittent fever, the inhabitants of those regions where intermittents prevail, should be care- ful to keep up good fires every morning and evening through- out the sickly season, and all the day long in wet and cold weather. Laborers and others, in circumstances requiring unavoidable exposure to cold and night air, would do well to protect themselves by taking a cup of hot coffee, or some other hot beverage, on going out, and should not fail to avail themselves of a good fire on coming in, before retiring to bed. 388 CONGESTIVE FEVER. CHAPTER IV. CONGESTIVE FEVER. This is a fever, in the most severe form of which, the pulse and the heat of the skin are generally below the natural standard. In slighter cases, the extremities are cold, or have a tendency to be cold, while the heat of the trunk of the body is increased. The most perfect examples of congestive disease are exhibited in those individuals, who die in the cold stage of intermittents and yellow fevers. This form of the disease, like all instances of indospathic fevers, advances in- sidiously. The patient is threatened with indisposition for ten days or a fortnight, perhaps three weeks, previously to the time of his confinement to his bed. His appetite is gra- dually impaired, his bowels irregular; he complains in the mean time of alternate chills and flushes of heat; till at length the alarming chill fastens on him. In mild cases, the heat of the skin is diminished, the pulse weak and oppressed, beating perhaps fifty or sixty to the minute; great prostra- tion of strength; tongue moist but loaded with lymph; the patient dull and sleepy, but can be roused ; his sensibility ev- idently diminished; he complains of giddiness, confusion of intellect, heaviness, pain, or a sense of weight, at the crown of his head or his forehead. According to our view of the course of events which oc- cur in fever, the head is first affected.. There may be com- plications. After the fever is fully established, in the early exacerbations, the violence of the action may fix conges- tions on the lungs, or V\e universal langour of the circula- CONGESTIVE FEVER. 389 tion may, by the remora, fix venous congestion on the liver and portal vessels. When a fever of this sort is about to terminate fatally, it is marked by a peculiar expression of countenance ; it looks be- sotted ; in the manner of the patient there is an appearance of carelessness; his speech slow ; his eyes look dim, and seem partly insensible to light. If he attempt to walk, he staggers like a drunken man. In very severe cases, the pa- tients are unable to stand on their feet, or even to lift their hands to their heads. A sensation like a great load is felt at the pit of the stomach. The respiration short, quick, and weak. The patient becomes more and more insensible; picks the bed clothes; lies on his back, constantly sliding down towards the foot of the bed; his breathing becomes more difficult; his complection takes on a leaden hue; sometimes convulsions occur about this time, and some- times vomiting; soon involuntary stools follow, and he dies. TREATMENT. In this, and in every form of fever, it would be greatly important that the disease should be arrested in its forming state. When this shall not have been done, the case must be treated according to circumstances. If the patient be in the state of chill, make large applications of mustard. Cov- er his breast, abdomen, and his upper and lower extremities with mustard plaisters, or wrap him in a blanket wet with alcohol and spirits of turpentine, then lay bottles or jugs, fil- led with hot water around him on both sides. As there shall be appearances of reaction, tie up his arm carefully, open a vein, then administer large doses of quinine every hour. If the blood-letting be in time the reaction will be secured, and the patient rescued from death. 390 CONGESTIVE FEVER. After this shall have been accomplished, the case will as- sume a simple form, and may be treated subsequently as if it were an ordinary intermittent. The reader may have noticed the fact, that the vapor bath, which is a most potent agent in exciting and giving estab- lishment to the action of the capillaries, is not advised for correcting the chilly state of fever, either in its intermittent or congestive form. It is not recommended because it is too powerful a remedy in such cases. When the capillaries are inactive, and the vitality of the skin is too much reduced. whilst at the same time the viscera are in a state of conges- tion, the general circulation of the blood cannot be made to reach the blood-vessels of the skin, within the necessary time to protect them against the great stimulant power of heat. Under such circumstances, the intended remedy would still more diminish the vitality of the surface, and instead of be- ing beneficial, in most instances would be greatly injurious. This is an important fact, which ought to be kept in view in every instance, when the alcoholic vapor bath is employ- ed in treating disease. And it may be put down as a gene- ral rule, that the bath, if appropriate, will be more or less agreeable to the patient. So also, if it be oppressive, some auxiliary measure is required in order to insure success. INFLAMMATORY FEVER, 391 OH CHAPTER V. INFLAMMATORY FEVER. The symptoms common to fever, are present in a case of this sort. There will be heat, much greater than what is natural. The pulse will be strong, tense, and frequent, and ordinarily, there will be pain. It commonly commences with some degree of rigor. The patient feels drowsy, but cannot sleep. He is languid and weak. His appetite fails. His tongue is moist and loaded with fur, but soon becomes dry: and he suffers from-great thirst. He complains of general soreness, headache and pain in the back, which are often accompanied by nausea and vomiting. These appearances progress with various modifications; becoming more and more intense; the patient meantime is more restless, till eventually, he is delirious at night. The symptoms vary, however, according to the organ prin- cipally affected. If the brain be the seat of inflammation, there will be a difference in the symptoms, when the membranes including the brain are the structures affected, and when the substance of the brain itself is the seat of morbid action. If the dis- ease be seated in the membranes, there will be delirium at- tended with unnatural increase of strength ; insomuch, that it will be difficult to keep the patient in bed. His counten- ance will be fierce; his eyes red, with contracted or dilated pupils; he will complain of headache, or there will be some sign by which it may be seen, that he feels pain in his head. If the case be permitted to progress without correction, his 392 INFLAMMATORY FEVER. face may become pale; his pulse irregular; his tongue dry and continually in motion ; his tendons may twitch ; perhaps he may pick the bedclothes. If he be young, he may have convulsions. He seems sleepy, but his sleep is comatose; his pulse, which was weak, becomes slower; then varies; is irregular and intermits. His sleep becomes more profound, and he dies. If the substance of the brain be inflamed, the heat of the skin will not be increased. The pulse will be lower than natural; it may not exceed sixty or fifty in a minute, and even slower than fifty. The extremities may be in motion or not; they may be rigidly contracted, particularly the fore- arms ; or they will become contracted the moment the arm is touched, even if it be to feel his pulse. The pupils of the eyes are dilated, and the eyelids half or feebly open ; some- times one is shut and the other open ; the tongue is moist till , towards the last stage of the disease. In both varieties, the breathing is very nearly in the same state. The bowels generally are confined ; and when it is otherwise, the stools are involuntary; which, as well as his urine, are passed in bed. Sometimes, however, the bladder is insensible and becomes greatly distended. If the lungs be affected with inflammation, breathing be- comes laborious; sometimes there,will be cough with more or less expectoration ; sometimes a feeling like rawness under the breast-bone and in the wind-pipe incommodes the pa- tient ; sometimes a stitch in the side is felt, especially on ta- king in a very full breath. If there be inflammation in any of the viscera of the abdo- men, or of the lining of that cavity, there will be pain in that region, which will be increased on making pressure with the hand; it must be remembered, however, that when the mucus membrane is the seat of the inflammation, often, little or no pain is felt, even on pressure. The patient inclines to Lie in a position, so as to relax the muscles of the abdomen; INFLAMMATORY FEVER. 393 there will be more or less tympanites, with considerable heat in that part of the body; there will be nausea and vomiting; insatiate thirst; the tongue is often furred, with an elevation of the papillae ; or it is covered with small ulcers or numerous fissures ; or it may be red and glazed ; or it may appear as if skinned, with or without patches of white fur ; when any of these appearances occur, we safely conclude, that the lining membrane of the alimentary canal is in a diseased condition. TREATMENT. In this form of fever, and indeed in all others, it is vastly important to have recourse to proper treatment as early as possible. The congestions which set up or accompany the irritation, are continually growing worse, extending and in- volving greater surfaces or larger portions of structure, every moment. If taken in time, decisive blood-letting once or twice re- peated, aided by the equal izing^pwer of the vapor bath, will generally put an end to the disease. All medicines calcula- ted to irritate the stomach or bowels are pernicious. The effervescing draught, or a solution of the citrate of potash, if acceptable to the patient, will commonly be useful. Two drachms of this article may be dissolved in six ounces of water, a little sweetened with sugar; and half a table spoon- full, or twice that quantity, may be taken every two hours. Cloths wetted with cold or hot Water, may be used as there may be occasion ;—cold cloths to the head, hot cloths to the chest or abdomen or both. The hands and feet may be fre- quently bathed in hot water; and if the patient be not much relieved by a second bleeding, apply a large blister, eight by ten, or ten by twelve inches square, over the region of the stomach, which ought to be renewed as soon as,.a tendency to heal is exhibited, thus making it continuous, till the patient shall be recovered. If the case seem to linger, let a moderate 394 INFLAMMATORY FEVER. use of the bath be repeated, every morning and evening, comforting the patient with some suitable beverage, accord- ing to the instructions given respecting the use of that agent. If symptoms indicative of a protracted irritation of the membranes of the head, or of the brain continue in defiance of the general treatment above recommended, let his head be shaved and a large blister applied over the whole scalp, and if necessary, repeat it, till those symptoms disappear. The diet should be light and fluid. Barley water; rice gruel; two milks whey; afterwards, chicken water; thin broth with rice and such like preparations; gradually in- creasing the quality and quantity of his nourishment, in a manner corresponding to his progress in convalescence. Du- ring the whole course of the management, his bowels may be kept in comfortable condition, by repeating two or more mild injections, every twenty-four hours. The injections may be made of very thin broth a little salted, or of thin gruel seasoned in like manner, adding a table spoonful of lard or sweet oil. I CATARRH. 305 CHAPTER VI. CATARRH. When a patient is seized with chilliness, followed by sneez- ing, slight fever, impaired appetite, hoarseness, occasional loss of voice, and a cough ; he is said to have catarrh, or a common cold. His bowels are out of order, and he has an exacerbation of fever and difficulty of breathing at night. The cough is sometimes slight; at others severe. A slight degree of wheezing is heard, and the disease has a salutary termination in a day or two, by expectoration of mucus, which is discharged by occasional fits of coughing. Sometimes the disease is confined to the mucous mem- brane of the nose, and frontal sinuses, and is then known by the common name of "cold in the head." When catarrh is a general complaint, attended by conside- rable prostration and constitutional symptoms, the disease has been denominated Influenza. In this modification of catarrh, there is a greater fullness of blood, and a greater thraldom of the circulation, in respect of the capillary ves- sels of the lungs. Catarrh is a slight, sub-acute, inflammation of the nrucous membrane of the nose, frontal sinuses, the larynx and trachea. If the membrane which lines the bronchial tubes be affected with a similar inflammation, it may be called bronchitis, an affection which has often passed by the name of ca- tarrh. 306 CATARRH. Causes.—Exposure to cold, particularly alternations from heat to cold, with insufficient clothing. It would appear to be of no consequence how cold the air we breathe, provided the surface of the body be properly protected. It occurs most frequently, and prevails most ex- tensively in autumn. A great proportion of the people about that season of the year, indulge in hearty eating. They do not feel themselves compelled by the weather to put on win- ter clothing ; the temperature of the atmosphere, although not painfully cold, so as to compel them to use fires, is, nev- ertheless sufficiently sedative to diminish the action of the superficial capillaries; in course to suspend perspiration and the other functions of the skin. The vitality of the mucous surfaces is elevated to the degree preparatory for producing irritation. The reaction which follows is accompanied with the symptoms of catarrh ; and the case will be more or less severe, according to the existing irritability.* treatment. In slight cases, one or two applications of the alcoholic vapor bath, followed by a moderate cathartic, will be found all sufficient for the cure. In cases more severe, especially if there be pain in the head, or a sense of soreness or tight- ness of the chest, the patient should be bled decisively. After blood-letting, he should be treated with an applica- tion of the bath, which should be followed by a purge of calomel, say five or ten grains, and twenty grains of jalap, or instead of the jalap, after an interval of three hours from the * To prevent catarrhal affections, begin early in the autumn to have a brisk fire, morning and evening; and in wet weather delicate persons and invalids should keep up their fires throughout the day. CATARRH. 397 time of taking the calomel, he might take two tablespoons- full of castor oil. The succeeding day, if the symptoms con- tinue to be distressing, let the bath be repeated. If the sweat afford pleasant relief, nothing more may be necessary. If, whilst under the influence of the bath, the head ache, or the tightness across the chest should return, or be increased, im- mediately after the use of the bath, have a second recourse to the lancet, and give another gentle cathartic, and in a large majority of cases this treatment will be all that will be necessary. The practice may be similar, whether the case be simply a catarrh, or be in some degree complicated with sympsoms of bronchitis. When delicate persons, particularly those of the fair sex, subject themselves to such exposure as is commonly follow- ed by catarrh, they should never postpone the necessary means of correction. Thousands by such neglect of them- selves, have permitted irritations to be established, which have ended in that fatal disease, consumption. 398 BRONCHITIS. CHAPTER VII. BRONCHITIS. There are two modifications of this disease; acute and chronic. The acute form of bronchitis "commences with some degree of chilliness, succeeded by signs of fever, hoarse- ness, difficulty of breathing, with a dry cough, tightness, or a sense of stricture in the chest, and oppression in the region between the heart and stomach ; prostration of strength, the tongue coated with lymph, and the bowels costive. An ex- acerbation is almost always observed at night. In a day or two, expectoration takes place, which relieves the patient for the time; the respiration becomes more difficult, but the cough bears no proportion to the difficulty of breathing; the tightness about the chest is increased with a sense of suffo- cation, and the pulse becomes very frequent. The deadly paleness or lividness of the lips and cheeks, becomes more and more anxious; and the patient frequently requests to be raised and to have more air. A loud wheezing may now be heard, even at a great distance from the bed side. The vo- luntary muscles of respiration are brought into play. The patient becomes insensible ; a rattling is heard in the throat, the extremities and face becomes cold and livid, a cold per- spiration bedews the skin, and death soon closes the scene. Sometimes the head is seriously affected. When this is the case, there will be much complaint of head-ache. It is an insidious disease, and in the cases the most dangerous, although the oppression in the chest is more or less conside- rable, there is neither heat of the skin, pain, nor much febrile BRONCHITIS. 399 movement in the pulse. There is such an apparent absence of fever, that too often no alarm is taken, till the patient is threatened with suffocation, or some organictoischief is done ; and then it is too late. The disease is very fatal in infancy and childhood. It commences in such subjects in the same manner as in adults; like a common cold. The breathing becomes oppressed; is performed with great effort, the shoulders are in constant motion, as well as the nostrils, and the abdomen becomes more prominent, by the increased action of the diaphram dur- ing inspiration. A sore throat frequently accompanies the disease, and the child suffers so much pain during the act of coughing, that an attempt is made to suppress it; a wheez- ing soon takes place, which is more decided than the difficul- ty of breathing ; expectoration is generally followed by mit- igation of suffering, which continues for a longer or shorter time, till more phlegm is formed. The mucous secreted in the air passages, is frequently discharged by spontaneous vomiting, exactly as it occurs in whooping cough. Children under four or five years of age, cannot be made to spit up the plegm ; they swallow it, af- ter it has been discharged from the air passages. Children refuse food, but drink greedily, until the disease is far ad- vanced, when they cannot take a long draught for want of breath. An infant at the breast sucks pretty well during the first stage of this affection ; but subsequently, although it seizes the nipple with avidity, it cannot suck for any length of time, perhaps for not more than ten or fifteen seconds, when it will be observed to bite the nipple very forcibly, and discontinue sucking; it will cry, throw its head back quick- ly, and continue in this position for some time, even after the cough has produced the expulsion of the mucus. If the dis- ease remain unsubdued, the difficulty of breathing increases; the face has a livid appearance, the skin becomes cold, the 400 BRONCHITIS. extremities sometimes swell, and the child dies from suffo- cation. In all affections of the lungs, particularly in the acute, the bowels become constipated, and the evacuations foetid. The expectoration in bronchitis, is at first scanty and vis- cid, particularly so in the most acute cases; by degrees it becomes more copious and less viscid, and therefore more easily expectorated; till at last it is discharged in considera- ble quantities, having the appearance of starch mixed with small bubbles of air, and occasionally streaked with a little blood, or is discharged in the form of pellets or small lumps. If the case go on well, the expectoration gradually diminishes and becomes slightly yellow in color; the patient is troubled with the cough and expectoration, in the morning only; at length they cease entirely. Sometimes, however, the acute disease runs into the chronic form. TREATEENT OF ACUTE BRONCHITIS, " This depends exactly upon the period of the disease, the extent of the morbid action, the state of the cough, the ex- pectoration and the previous health of the patient. Bleeding is certainly not necessary in every case of bronchitis which comes before us; particularly in one that is slight and con- fined to a small part of the lungs ; but if the whole lung be affected, and more especially when both organs are implica- ted, bleeding is to be had recourse to, early and decidedly." If the case be slight, very often one decisive application of the alcoholic vapor bath will effect a cure, or at the least so change its character, as to remove the bronchitic symptoms, and place the system in the condition of simple catarrh; or if the case be more severe, and there shall exist any doubt respecting the necessity of blood-letting, the use of the bath v/ill make the case plain and easy. Dr. Mcintosh says "bleeding is a very doubtful remedy. when the second stage is far advanced ; and highly injurious BRONCHITIS. 401 in the last." This is true according to the experience of the profession; and the cause of the uncertainty and danger, is at hand. As the function of the lung becomes impaired, the capillaries of the external surface become more feeble, and their functional action is lessened, so that there is a very early tendency to dissolution. If under such circumstances, the vitality of the capillaries should be still farther reduced by blood-letting, they may fail to react and the patient will be lost. If, however, in such doubtful condition, the alcoholic vapor bath be used, the ca- pillaries are reanimated, the arterial action greatly improved, and any existing necessity for the use of the lancet will be readily detected. And for producing this powerful and ben- eficial effect, the bath is of the utmost importance. The Doctor says, " I know of no disease more under manage- ment by any remedy than bronchitis is, by bleeding, if per- formed in the first stage, br during the first part of the se- cond." - The use of the bath places the capillaries in the con- dition, which insures the happy effect of blood-letting. " Many assert that bronchial inflammation will run through a certain course in spite of every remedy; and it will, if the inflammatory stage should be nearly over, before discovered, or if bleeding be not used in a decided manner," or if the vapor bath be not used in its proper place. " Although late bleed- ings are to be especially condemned in this disease, yet cases do occur, where the lungs become suddenly congested with blood, in which a well-timed venesection is of signal service." "In the first stage of bronchitis, when both lungs are ex- tensively affected, one bleeding will in general suffice." And the more certainly, if it be preceded or followed by the use of the bath. "And we need not be afraid to carry it nearly to fainting, as long as the air passages are freed from mucous ; but after it has collected in considerable quantities, (and I mean my remarks to refer more particularly to double bron- chitis,) sudden death may be the consequence, by robbing; 26 402 BRONCHITIS. the patient of that strength, which is required in coughing, to produce expulsion." In such circumstances, the bath ought to precede any attempt to. use the lancet. And if the action of the heat, by expanding the external capillaries be attended with much inconvenience, the opera- tion should be suspended, five or ten minutes, and then be resumed and continued in a moderate way;—gradually in- creasing the heat, as the patient can bear it, till it produce its full effect; after which he may be bled with much benefit, in cases in which the practice would be fatal without the bath. In bronchitis we can scarcely ever determine the necessity or propriety of bleeding, by' the ordinary signs; because in some cases, the disease may be very extensive without violent symptoms; in others it may be very slight, and the symp- toms very severe, owing perhaps to a disordered state of the stomach and bowels, or to some other, perhaps slight cause; and it is of great consequence to know when to desist from further depletion. After becoming acquainted with the pow- erful effect of the bath in treating such cases, all these diffi- culties are greatly diminished, and the management of such affections is made easy, even in the hands of young physi- cians. In some instances, in cases of infants and young children, it is difficult to bleed from the arm. When this inconvenience occurs, it may be necessary to use cups or leeches; and we will add, cups in peference to the leeches. "Next in point of importance to blood-letting, in pulmo- nary inflammation, stands antimony as a contra-stimulant." So says our excellent author, Dr. Mcintosh. So said Cullen, Fordyce, &c. It is in like manner the opinion of the most enlightened of the faculty. And antimony is so generally beneficial, because it serves to prevent the accumulation of sensorial influence, which is consequent on blood-letting, and which would produce a reaction, marked with more power, than is consistent with the safety of the structures, when in a condition which may require depletion. If blood-letting be followed by an appropriate application of the alcoholic vapor BRONCHITIS. 403 bath, the effect of this powerful agent on the capillary struc- tures, will prepare the way for the antimony; and the arrange- ment of medications, made according to this order, will be found more efficient. Moreover blood-letting will be found to be admissible, and the agency of antimony useful, if the bath be used also, in many instances in which their effect without the bath, would be deleterious. Colchicum has been highly recommended in this disease, and the effect of it is sometimes very serviceable. " Emetics are very useful in the first stage, and are abso- lutely necessary in the last, in order to clear the air passages, when the cough fails to do so ; and are more particularly serviceable, in childhood and infancy. The patient's bowels should be moderately free, but deci- sive purging may produce injurious prostration. " Expectorants and [the common] diaphoretics are more in- jurious than beneficial, except perhaps in chronic affections."* " Opiates are sometimes useful in the first stage, after the violence of the disease has been reduced by the lancet. In the last stage also, when there is considerable irritation and violent cough, which, if not mitigated, keeps the patient from sleep and wears him out." Blisters, when, in consequence of the depletions which may have been found necessary, the skin is too much disabled to maintain the action of its eapillaries, without the aid of contra-irritation. Special attention should be paid to the condition of the skin, particularly to the temperature of the extremities, du- ring the whole period of the disease ; and the bath should be repeated, as occasion may require. The circulation of the blood shbuld be continuously kept conspicuous in the vessels of the surface. The diet of the patient should be very light, avoiding every thing stimulating, until all inflammatory symptoms shall disappear. The patient should be kept quiet in bed ; every exertion should be avoided; even the exercise of the voice is injurious. 404 CHRONIC BRONCHITIS. CHAPTER VIII. CHRONIC BRONCHITIS. " Like other chronic inflammations, this affection some- times succeeds to an acute attack; sometimes, however, it takes place as a slow and insidious inflammation of the bron- chial membrane. This form of the disease may affect indi- viduals of all ages ; but it is most frequently met with in old people, and those who, by occupation, are exposed to the in- halation of dust. It sometimes succeeds also, to the eruptive fevers ; and frequently coexists with diseases of the heart. "It is occasionally mistaken for phthisis pulmonalis, ana is one of the morbid conditions of the organs within the chest, which give rise to the symptoms denominated asth- ma ; and is likewise, a frequent cause of dropsical affections. " When the disease succeeds to acute bronchitis, the fever declines, but the pulse for some time continues frequent; the cough and difficulty of breathing continue, but they are al- ways relieved for a considerable time after a free expectora- tion. The patient still has night exacerbations, and disturbed sleep ; which, however, gradually decline with the disease. The expectoration still copious, becomes opake, yellow, sometimes puriform, and has occasionally a greenish hue ; at last it diminishes in quantity. The appetite returns; and although weakened by night perspirations, which take place during the day also upon making the least exertion, the pa- tient is sensible of gaining some strength. Gradually all these symptoms cease, and some individuals seem to recover perfect health; but in <.reneral throughout, subsequent life, CHRONIC BRONCHITIS. 405 exposure to night air, an easterly wind, or a hurried atmos- phere, occasions a renewed attack; and with many, the same effect is produced by eating indigestible food, or by neglect- ing the bowels. Now and then, therefore, they become in- disposed ; the voice becomes hoarse; the cough short and croupy; with more or less oppression in breathing, attended sometimes with febrile symptoms. In the chronic form of the disease, the expectoration takes place in a much shorter time from the commencement of the indisposition, than in the acute ; sometimes in a few hours ; it is viscid at first, but soon becomes copious; and the patient is relieved by the discharge. One attack leads to another, until at last, the individual is always affected with some de- gree of difficult breathing ; he is almost constantly coughing and spitting; and is unable to he in the horizontal posture ; he feels great difficulty in mounting a stair, and is said to have an habitual asthma. "In acute and chronic forms of bronchitis, cases now and then present themselves, in which the expectoration is very small in quantity. In this form, it has been denominated dry catarrh, and dry "asthma." TREATMENT OF CHRONIC BRONCHITIS. Patients affected with this disease are liable to sudden at- tacks of acute inflammation, sometimes too, of congestion of the lungs, and sometimes, individuals become dropsical. In any such cases, general bleeding is commonly neces- sary. After blood-letting, apply the bath, so conducting the process as to make the application gradual. This will restore the vitality of the external capillary structures ; which done, will give the lungs the benefit of the restored functions of the skin, and do much in aid of the recuperative tendency which blood-letting will have set up, in the bronchial vessels. 406 CHRONIC BRONCHITIS. The same should be repeated once or twice every twenty- four hours, for two or three days. If the symptoms should be at all obstinate, administer an emetic, say finely powdered lobelia inflata twenty grains; ipecacuanha twenty grains; hot water four ounces. Of this give two table spoonsfull, and repeat one half the same quan- tity every fifteen, twenty, or thirty minutes, until it operates. This treatment might be repeated with advantage as often as the paroxysm shall recur, especially every night. It will, greatly relieve respiration, and procure for the patient rest and sleep. If the difficulty of breathing return in the morn- ing, repeat the emetic, for the better effect of which the pa- tient may be prepared by a moderate repetition of the bath. In some cases the syrup of squills is useful; in doses of a tea spoonfull repeated every two or three hours. As often as there shall be apprehension of a return of an attack, let the patient retire to bed, take a bath, and follow it by a dose of lobelia and ipecacuanha as advised above, and in most in- stances the paroxysm will be prevented. Perseverance in this mode of treatment will often effect a permanent cure. INFLAMMATION OF THE LARYNX. 407 CHAPTER IX. INFLAMMATITION OF THE LARYNX. " This disease has a very close analogy to croup." It is a very common cause of death, in small pox and scarlet fever ; and sometimes it follows measles. " When this disease oc- curs in the acute form, it is known by a painful sense of constriction in the throat, which is increased by pressing the larynx. Speaking aggravates the pain, as does swallowing. The voice is hoarse ; the breathing soon becomes laborious and shrill, during the act of inspiration; there is considera- ble heat of skin ; thirst; frequency and tension of the pulse, and great anxiety. On looking into the throat, the fauces frequently appear to be swollen and turgid, and of a dark red color, or coated with lymph ; but this affection of the throat is not peculiar to laryngitis, or an inflammation entirely con- fined to the larynx. In some cases the epiglottis is involved, which renders the motion of the tongue painful. The pa- tient is constantly hawking, in order to clear the air passages, and occasionally spits up a small quantity of thick tenaceous mucous. As the disease advances, the face becomes swol- len and turgid; it frequently has a livid appearance, and life is quickly destroyed by suffocation. Convulsions occasion- ally precede death. This disease sometimes runs its course, in from thirty-six to forty-eight hours." The treatment proper in this affection, is so nearly similar to that which is proper in a case of spasmodic croup, which will be our next chapter; that it is not necessary to say more than that the same course may be pursued till the patient shall be relieved* 108 CROUP. CHAPTER X. CROUP. This disease is of frequent occurrence among children re- siding in damp, bleak situations, on the sea coast, and in ma- ny places in the United States, which are considered health- ful. It consists of an inflammation of the lining membrane of the trachea, and is often complicated with bronchitis and laryngitis, the one running into the other, so much so, that frequently they cannot be distinguished. It is a disease almost peculiar to infancy and childhood. Inflammation of the larynx and bronchial tubes, occurs at all ages; croup seldom occurs to any after twelve years of age. One attack predisposes to another, but as age advances, this susceptibility goes off. Croup has been divided into three species : acute, chronic and spasmodic. It usually commences like catarrh, the symptoms being more or less severe, with some degree of fe- ver preceded by chilliness ; the voice soon becomes hoarse ; febrile symptoms increase ; and in a day or two the breathing becomes more and more impeded, particularly during inspi- ration ; at least the inspiration becomes stridulotls, and the voice shrill; a harsh dry cough exists from the beginning, and when there is any expectoration, it has more or less of a muco-purulent appearance ; sometimes small masses of lymph are discharged, which occasionally resemble portions of false membrance. As the disease advances, the expression of croup. 409 countenance becomes more anxious; the lips and cheeks have a livid and swollen appearance, alternating with a dead- ly paleness. The pulse is frequent and small, and some- times intermits. There is a prostration of strength with great restlessness ; although the surface of the body be gene- rally speaking hot, the extremities are frequently cold; at last, the body is covered with a cold clammy sweat, and the child dies of suffocation. The cause of the disease is various; sometimes children are cut off early, as if merely by want of breath, but in gen- eral, it lasts from two to three or four days. In chronic af- fections of the trachea, the symptoms are less violent and urgent, it is longer in progress, but the symptoms are the same; the breathing difficult and stridulous, and the voice shrill. It is in the chronic form of this disease, that the false membrdne is sometimes formed in the trachea. This form comes on insidiously.' The patient is considered to have ta- ken cold in the common acceptation of the term ; there is a slight difficulty of breathing, from the increased vascularity or congestion of the mucous membrane, producing a thick- ening of the membrane, and consequently a lessening of the calibre of the wind-pipe ; gradually the same surface, in its extensions throughout the bronchi and air cells, becomes more and more congested, secreting a very viscid mucus, which becomes more and more dense, till the bronchi are choked and the child dies. TREATMENT. " This disease, of all others, requires promptness and de- cision, and activity in practice ; fdr if the false membrane be allowed to form, not above one case in the hundred will be saved. The worst instances are those in which a sore throat 410 CROUP. has been neglected, and the inflammation has spread into the wind-pipe; or those in which patients have labored under bronchitic symptoms for a week, or perhaps longer, before the disease has affected the trachea and larynx." Such cases are almost always fatal, and to these M. Bretonneau gave the name, diphthrite. When a child is attacked by this disease, it should be bled without delay, and to such an extent as to make a decisive impression. The blood-letting should be immediately followed by an effectual use of the bath. If the bathing be not completely satisfactory, it should be fol- lowed by a dose of the tartrate of antimony ; two grains of which may be dissolved in two ounces of water. Of this preparation, a teaspoonful may be given every five or ten minutes, till its emetic effect shall be complete. Sometimes it is difficult to produce vomiting. In such an instance, the t antimony should be used nevertheless. As a counter stimu- lant it is greatly beneficial, though it should uot produce its emetic effect. After a free use of the antimony, and the stomach shall have become quiet, two, three, or four grains of calomel should be given every second hour, so as to intro- duce from thirty to sixty grains in the space of twenty-four hours. When five or six doses of calomel shall have been administered, if the child should not be greatly relieved, repeat the bath, apply a large blister over the region of the stomach ; and whilst it chall be making its impression, repeat the emetic, which may be again followed with five or six doses of calomel. This kind of decisive treatment will commonly be successful, if commenced and carried out before the false membrane is formed—after its forma- tion, it is useless to torture the child with any severe re- medy. When the patient is less than eighteen months old, and it shall be found impracticable to bleed it from the arm, re- course should be had to the employment of leeches, a suffU CROUP. 411 cient number of which should be applied to the child's throat and neck, up and down the course of the trachea; six, eight, ten, or more, so as to make a complete impression. The lancet however is greatly preferable, inasmuch as it pro- duces the necessary effect more promptly; and the sudden- ness of the shock not only makes the effect more visible, but on that account it is more useful. In that form of the disease which has been called spas- modic croup, it will be found that the use of the bath alone will often afford relief, and that the addition of blood-letting and an emetic will be completely effectual in almost every instance. It should be remembered, however, that no de- lay is admissible in a case of this sort, as death may en- sue within a very short time after the attack. In a word, no case of cold, threatening bronchitic or croupy symptoms, should be avoidably neglected; not even for one hour. I 412 HOOPING-COUGH, CHAPTER XI. HOOPING-COUGH. This disease, in its commencement, is almost always con- founded with a common slight cold. The time how long this mistake continues, varies very much ; in general it ex- tends through ten or twelve days. The cough, meanwhile is dry; there is occasionally a sense of constriction in the chest, and a feeling of weight in the'head. "The eyes are sometimes a little swollen and red, with frequent sneezing and involuntary tears; in many cases there is little or no fever, exeept in the night; the bowels generally are out of order. We sometimes suspect the disease to be hooping cough because it is epidemic at the time, or because we no- tice the convulsive appearance in the paroxysm of coughing. At last the cough assumes a peculiar character; when this takes place, the disease is said to be in its second stage. It is characterized by a long and sonorous inspiration, producing a peculiar shrill noise, which is termed in common language, the whoop; to which succeeds an expiration which is bro- ken by frequent fits of coughing. No one that has seen the disease when fully formed," can mistake it. When the cough commences in slight cases, the features become a little swol- len, the face red, the eyes suffused with tears; the cough, which is often interrupted by a long inspiration, is hoarse, the paroxysm ceasing with an expectoration more or less co- pious, frequently assisted, by the act of vomiting, which dis- charges the contents of the stomach. As soon as this is ac- complished, children are commonly able to return to their usual amusements, and appear to suffer little or nothing un- HOOPING-COUGH. 413 til towards the period of the next paroxysm. The appetite is in general good. The expectoration is at first slight, scanty and viscid; but if the disease go on in a favorable manner, the discharge becomes more copious and less tena- ceous. Young children scarcely ever spit out the expecto- ration, unless during the act of vomiting; it generally is swallowed as soon as discharged from the air passages. The patient generally is warned of the approach of the paroxysm by a greater or less degree of chilliness on the surface, and a tickling in the throat, immediately succeeded by a sense of tightness both in the larynx and chest, and a dread of suffo- cation, which induces him to fly Ho his nurse, or to lay hold on any thing within reach for support during the fit. Others seem to derive relief from lying all-fours on the floor, and when the discharge has taken place, they jump up and run about. In more severe cases, the sense of suffocation is dreadful; the respiration is much more impeded, the cough more intense and protracted, the features more swollen and of a livid color; the eyes seem ready to start out of their sockets, the eye-lids much swollen, and their cheeks perhaps bathed in tears, till at last expectoration takes p^ace, when the child will pant for breath, and be unable to return to play for a considerable time. The skin is above the natural tem- perature, particularly at night; complaint is made of head- ache ; the appetite is bad, the bowels are more disordered, and flatulent distension aggravates the patient's suffering. The straining which takes place during the paroxysm, is sometimes so severe as to produce involuntary discharges of foeces and urine. It is no uncommon thing for a small blood- vessel to give way in the coat that covers the eye, producing ecchymosis ; sometimes, though rarely, a bleeding from the lungs, but very often a bleeding from the nose, which when it takes place in children of a full habit, is considered a use- ful occurrence. In the worst forms of the disease, fever is certainly pre- 414 HOOPING-COUGH. sent, and the breathing is always more or less impeded, which shows that some mischief is going on internally. Fits of temporary loss of breath are frequent, which are very often mistaken for convulsions, and by them children are sometimes suddenly cut off. Sometimes convulsions do oc- cur and carry off the patient. THE NATURE AND SEAT OF THIS DISEASE. " The essence of hooping cough consists in irritation and inflammation of the mucus membranes of the body, but more particularly that of the air passages." The inflammation at the first is slightly sub-acute ; and there is therefore no heat of the skin, no discernible disturbance of the pulse, no thirst; when the inflammation runs higher, then these constitution- al symptoms make their appearance. It begins like catarrh, and at the first cannot be distinguished from it; the disease, when formed, comes in paroxysms. The paroxysm com- mences with a sense of coldness on the surface, making an irregular determination of blood upon the lungs. These or- gans become gorged, and the air is prevented from obtaining a free passage through the ramifications of the bronchi and air cells. Hence the difficulty of breathing, with tightness in the chest, and a sense of suffocation. The air passages become congested and inflamed ; the larynx and parts in the neighborhood principally suffer, and the injection of the ves- sels being suddenly increased at every paroxysm, become swollen; the rima glottidis, or opening in the windpipe, is diminished, producing the hoop, and the appearances which seem to threaten suffocation. TREATMENT. As in its first appearance it cannot be distinguished from catarrh, let it be treated as it it were the same affection. If HOOPING-COUGH. 415 the symptoms be very slight, give a gentle emetic; if threat- ening severity, let blood, give him an application of the bath and follow it with an emetic. If he shall not be relieved, and the symptoms become severe/ repeat the same practice. If this kind of decisive treatment be performed as often as it shall be necessary, during the first stage, which is consider- ed to continue three weeks, the case will presently assume a mild aspect, and the patient will be safe. It should be re- membered, that his bowels should be kept gently free through- out the whole course of the disease. For this purpose, some- times, a moderate dose of castor oil may suffice. And com- monly the following preparation will be found particularly useful. Take bicarbonate of potas, one drachm, powdered ipecacuanha, fifteen grains, water, four ounces. Of this a teaspoonful may be given to a child two years old, every second hour, till it shall produce the necessary effect. After the disease shall have assumed a mild and settled form, if by taking fresh cold, or from whatever other cause, the symptoms should again become severe, let him again be bled, bathed and vomited as before, with one variation only. In the commencement, the vomiting had better be produced by an appropriate dose of tartrate of antimony, in the later stages by a little ipecacuanha. 416 PNEUMONIA. CHAPTER XII. PNEUMONIA, OR INFLAMMATION OF THE LUNGS. ' This disease has been denominated peripneumonia and pneumonitis; and when attended with a complication of in- flammation of the pleura, it has been designated by the term pleura peripneumonia. "Like all other acute diseases, pneumonia commences with shivering, followed by a hot stage, which is generally pretty violent, unless the inflammation be congestive, when coldness predominates. There is more or less difficulty of breathing, and the number of respirations considerably ex-' ceeds twenty in a minute ; and twenty may be considered as the natural standard. The breathing in some cases is very laborious; but we must be very careful not to suffer our- selves to be led astray by the account which the patient may give respecting this point. Often, when the respiration is short and hurried, he will assure us that he does not feel the least impediment. Pain is not a well marked symptom in inflammation of the substance of the lungs; the patient com- plains rather of a tightness in the thorax; and when pain exists, it is in general dull instead of sharp. The cough is short and perpetual, and does not come on by fits ; it is dry at the commencement, and continues to be very distressing and obstinate. The expectoration is scanty, viscid and dis- colored, from an admixture of blood ; sometimes it is bright, like red currant jelly; but in general it is rusty looking, re- sembling brickdust intimately mixed with viscid mucus; it is very tenaceous. and adheres firmly to the sides of the ves- PNEUMONIA. 417 sel into which the patient spits; the expectoration, though rarely, is sometimes foetid. A gangrenous odor is perceived when the case terminates in gangrene. In this disease the pulse is variable, and therefore to an in- experienced physician, an uncertain guide. The effect of depletion is different according to the condition of the patient. If his pulse be full because he is in a plethoric state, and conges- tion of the lungs have already occurred, well conducted blood- letting will diminish the frequency of the pulse and lessen the difficulty felt in respiration. If the pulse be small, tense and frequent, it will become fuller, stronger, less tense and fre- quent, after the depletion. The skin in some instances is hot and dry; and in others below the natural standard. The tongue soon becomes parched and dusk colored. A dry and glossy tongue always indicates danger, as does delirium also if it occur in the early stages. In acuteanflammation of the lungs, the part affected is red, and the parenchyma, or structure of the affected portion is more dense than natural, being overcharged with blood. In the second stage the structure becomes solidified, or in the language of Lasnnec,. it is hepatized. TREATMENT. In treating pneumonia, the lancet is to be used freely, and may be repeated and employed later in the disease than in bronchitis. If the pulse be compressible and not tense, the blood on the first bleeding should be permitted to flow till the pain abates, or till the vascular action is rendered mode- rate. The patient should then be carefully watched until the pain and difficulty of respiration begin to return, when, on careful examination the pulse will be found to be tense. Whenever this state of things occurs, the bleeding should be repeated, and the blood made to flow until the tension for th;r glove,------------ .. Igr. i. to iii.. APPENDIX. 5i: A SYNOPTICAL TABLE OF MATERIA MEDICA—CONTINUED. ORDER 1--NARCOTICS, (CONTINUED.) POSOLOGICAL. Nicotiana tabacum, tobacco,................ I Strychnos, Nux vomica, (rasped,)...........gr. i. to iii. Acidum Hydrocyanicum, prussic acid, (diluted,) m. i. to iv. Laurus nobilis, bay tree. I Morphia,...............................Igr. J, J, to |. Narcotin. I ORDER 2—ANTISPASMODICS. I * Assafaeetida,............................Igr, Castoreum, castor,........................gr, Galbanum,..............................gr Gum ammoniacum, gum ammoniac,..........gr Moschos moschiferus, musk,............ Valeriana officinalis, valerian,.......... Draconitum, skunk cabbage,................gr. x. to xx. x. to xv. x. to xx. v. to xv. x. to xx. gr. ii. to xx. gr. xx. to dr. i. iEther sulphuric us, sulphuric ether,..........'dr. Oleum succini, oil of amber,................m. Belladona, deadly night shade,...............gr. Camphora, camphor,......................gr. gr- gr- gr. gr- err. Hyoscyamus, henbane, Sagapenum............................. Opium,................................ Datura Stramonium, thorn apple,........... Conium maculatum, hemlock,.............. Ipecacuanha radix, ipecacuanha root,....... Cuprum ammoniatum, ammoniated copper, ... Nitras argenti, nitrate of silver,............ Zinci oxydum, oxyde of zinc,.............. Zinci sulphas........................... ORDER 5—NERVOUS STIMULANTS. Ammonia,............................. Allium porrum, leek (juice,)............... Allium sativum, garlic,................... Strychnia Nux Vomica, (rasped,)......*---- Opopanax, ............................. Secale cornutum, spurred rye, ergot,........ Anethum graveolens, dill,................ Assafcetida,............................ Galbanum, ............................ Valeriana officinalis, valerian,............. Rhus toxicodendron, poison oak,........... iEther sulphuricus, sulphuric ether,......... Sagapenum,...........................• ss. to ii. v. to xv. ss. to v. ii. to xx. iii. to x. x. to xx. ss. to iii. ii to iii. ii. to x. ss. to iii. ss. to iv. to vi. i. to v. i. to iii. x. to dr. ss. ss. to i. ss. to ii. i. to v. x. to xxx. xv. to xx, xv. to dr. i. x. to xx. v. to xv. xx. to dr. i. ii. to iv. ss. to ii. t x. to xx. CLASS V. Medicines which act on the muscular fibres. Order 1st__Astringents. Medicines which, by inducing contraction oi the muscular fibre, restrain inordinate evacuations and haemorrhage. 518 APPENDIX. A SYNOPTICAL TABLE OF MATERIA MEDICA—CONTINUED. ORDER 4—ASTRINGENTS. Querius et Gallae, oak bark and galls, .. :..... Geranium malculatum, crane's bill,.......... Hffimatoxylon Campeachianum, logwoood, (deco. Kino,................................. Catechu,............................... Krameria triandra, rhatany, (decoc.).......... Rosa Gallica,Verf roses,.................... Salix alba, white willow,................... Tormentilla erecta, tormentU,............... Uva ursi,............................... Alumen, alum,........................... Acidum sulphuricum, sulphuric acid, (diluted,). Acctas plumbi, acetate of lead,.............. Sulphas zinci, sulphate of zinc,.............. POSOLOGICAL. gr. x. to xx. dr. i. to iss. oz. ii. to iii. gr. x. to dr. i. gr. x. to xx. oz. i. to ii. gr. x. to xx. gr. xx to dr. ss. gr. x. to dr. ss. gr. v. to xx. m. x. to xl. gr. ss. to iii. gr. i. to iii. CLASS VI. Medicines which act upon the skin and external parts, by application to the surface of the body. Order 1st—Epispastics. Medicines which excite external irritation. " 2d—Emollients. Medicines which allay external irritations by softening the skin., Note.—All medicines externally applied (except those which belong to Class vi.) may be considered as stimulant, tonic, sedative, &c. and are there- fore arranged in their respective orders. ORDER 1—EPISPASTICS. Nitras argenti, nitrate of silver. Catharis vesicatoria, Spanish flies. Ammonia. Granville's lotion. Allium sativum, garlic, Euphorbia ipecacuanha, American ipecacuanha, Elemi. Potassa fusa. Acida, acids. Pix Burgundica, burgundy pitch. Sabina, savine. Sinapis, mustard. Antimonium, antimony, with lard, dr. i. to oz. i. Iodina, iodine. Potassa cum calce, potassa with lime. ORDER 2—EMOLLIENTS. Cetaceum, spermaceti, Oleum oliva?, olive oil, Sevum, suet. Aqua calida. Adeps, lard. APPENDIX. 519 A SYNOPTICAL TABLE OF MATERIA MEDICA—CONTINUED. TINCTURES. Tinctura aloes, ..................................... " alois composites,........................ " assafoetidae, ............................., u aurantii, orange peel,........ ....... " camphorss composites,................ " cantharidis, Spanish flies,........... " capsici, red pepper, ................... " castorei,................................. " digitalis, fox glove,.................... " ferri ammoniati,....................... " ferri muriatis,.......................... " guaiaci ammoniatae,.................. " hamuli, hops, .......................... " iodini, ................................... " kino,...................................... " rhei compositse, .............................. " Valerianae,..................................... " lobelias, Indian tobacco,................... " camphor8s, ..............:.................... " seminum colchici, seeds of mead, saffron " stramonii, thorn apple, ..................... " sanguinariaB, bloodroot,..................... SYRUPS. Syrupusscillae, squill,.................................... " phytolaccae decandrss, poke root,........ '• aurantiorum, orange peel,.................. " papaveris, poppies,........................... " rosearum, roses,............................... '• rosearum gallicarum, red roses,............ " lnnonis, lemon, .....'.......................... POSOLOGICAL. dr. i. to ii. dr. i. to ii. dr. i. to ii. dr. i. to ii. dr. i. toii. m. x. to dr.i. in. x. to dr. i. dr. i. to ii. m. x. to dr. ss. dr. ss. to ii. m. v. to dr. ss. dr. ss. to ii. dr. ss. to ii. m. x. m. xl. dr. i. to ii. dr. i. to oz. ss. dr. i. to ii. dr. i. to ii. to dr. i. m. x. tolx. x. to xx. m. xxx. to lx. dr. i. to iss. dr. i. to ii. dr. ss. to oz. 1. dr. ii. to oz. ii. dr. i. to ii. DESCENT, PROCIDENTIA, RETROVERSION, AND PROLAPSUS UTERI. The vagina, or canal that leads to the uterus, is so con- structed, that its posterior portion, which lies in contact with the rectum, and which may be considered its lower surface, if measured from the commissure upwards and around for- ward to the upper side of the neck, is about three inches lon- ger than its anterior portion, or upper surface, which lies in contact with the bladder. Its upper surface is attached to the bladder, by peritonaeal, and to the urethra by cellular con- nections ; and its lower surface is attached to the rectum, al- so by cellular connection, till it reaches to the reflection of the peritonaeum. The uterus is so situated as to have the bladder before, and the rectum behind it, with both of which it is connected by a reflection of the peritonaeum. Its shape resembles that .of a pear, but flattened, more particularly so on its anterior side. Its small extremity, or neck, is not a continuation of the same line with the vagina. It is projected into the anterior side of that canal, in the greater number of subjects, about an inch nearer to the os externum, than the angle or upper ex- tremity of the sac which terminates the canal. Hence the APPENDIX. 521 reflection of the posterior portion of the vagina, as it turns from the rectum upwards and forwards to meet the anterior portion, and form a junction round the neck, produces a cul- de-sac at the upper extremity, above and behind the os uturi. Writers have divided the uterus into three parts: the fun- dus, the body, and the neck. The fundus includes all that part of the organ, which is above a line passing across the origin of the fallopian tubes. The body includes the portion below that line, down to the commencement of the neck. The neck is the portion which dips into the vegina, and terminates in the os tineas. The peritonaeum passing downwards from the inner side of the abdomen, covers the fundus of the bladder and de- scending till it meets the body of the uterus, turns upwards and covers its anterior side, making a pocket between the bladder and uterus; then passing over and making a cover- ing for the fundus, it descends, covering the body till it reach- es the rectum, &c. making another and a deeper pocket be- hind the uterus, between it and the rectum. In forming these pockets, the peritonaeum makes two folds on each side of the uterus, which being extended laterally, counects them to the sides of the pelvis, constituting the broad ligaments, each of which has an anterior and a posterior portion. The anterior portion includes the fallopian tubes, the posterior, the ovaria. The round ligaments originate, one on each of the sides of the uterus, and passing along in the doublings of the broad ligaments, rise to the brim of the pelvis, and turn over it, through the abdominal rings. The broad and round ligaments aid in supporting the uterus in its proper position, but the vagina, sustained as it is, by its connections with the rectum and bladder, is its main support. The fundus with the broad and round ligaments, together with the two pockets above described, constitute the floor on 522 APPENDIX. which the lower intestines rest; and in course are liable to be pressed downwards by lifting heavy weights or by the pressure made by the muscles of the abdomen when the bow- els are in a state of constipation. If the uterus should sink,from its natural position in the brim, into the cavity of the pelvis, which change is termed a descent, it must put its ligaments on the stretch, and drag the rectum and bladder, more or less inconveniently, according to the degree of descent. If the descent take a direction, so that the uterus shall slide down into the vagina, we have the second stage of displace- ment, a tendency towards a prolapsus, which is called a pro- cidentia. In this condition of things, we have a greater dis- tension of the ligaments, as well as an increased tendency of the vagina, rectum and bladder, to descend with the uterus, until at length it may protrude beyond the vulva, which con- stitutes the third stage, and which is strictly a prolapsus uteri. Those of the sex who have large pelves; those who are of relaxed habit; those Who have borne many children; and those advanced in years, are more liable than others to the inconvenience under consideration. But it is not confined to these alone, it may befal the aged matron or the youthful virgin. Doctor William Campbell of Edinburg, encounter- ed complete protrusion in a female of twenty-one, who had labored under it for more than two years previously; and Capuron relates an instance of prolapsus in a girl of fourteen. Doctor Dewees met with a number of instances of the same kind, which befel unmarried females; and the writer of this essay has been consulted by fifteen, or perhaps twenty, in the course of his practice. In the first stage, the stretching of the ligaments, and drag- ging of the connections which fasten the uterus to the rec- tum and bladder, produce pain in the loins, which in conse- quence of the sympathies of the connecting structures, often APPENDIX. 523 extend along the sacrum and coccyx, sometimes accompani- ed by a knawing or dragging sensation in the groins, and an inability to continue for any length of time in the erect pos- ture. All these inconveniences are often considered by the patient to be the effect of debility or rheumatism. Some ca- ses however, are less liable to such misapprehension, being attended by an increase of menstrual secretion, or by a leu- chorrhoeal discharge, more or less profuse. Any additional inconveniences which may occur as the case progresses into the condition which is termed the second stage—such as difficulty in discharging faeces and urine, or even entire disability until the uterus is elevated by the fin- ger—tenesmus; disuria; an increase of leuchorrhoeal dis- charge ; are all referrible to the altered situation of the womb —the dragging which it exerts on the organs to which it is connected, and the lateral pressure which its descent must inevitably make on the circumambient structures. A sum- mary of the symptoms may be acceptable. An unusual weight in the pelvis, and a dragging sensation in the iliac regions, which are aggravated by the erect pos- ture ; a bearing down resembling tenesmus ; pain in the back, accompanied by a peculiar appearance in the patient's walk, as if her lower extremities were exceedingly weak; a be- numbing sensation shooting down the thighs, especially when she first rises on her feet, or when she attempts to re- cline—sometimes she will support herself in a leaning pos- ture, resting her hands on her knees ; a discharge of a mate- rial of a muco-purulent appearance from the vegina, which is sometimes tinged with blood, and in some instances gives out an offensive odor—the menstrual discharge is in some instancess too abundant, and recurs too frequently ; in others durin°- the interval of the menses, there is a constant leu- chorrhcea. When these symptoms shall become established, on ex- amination, the uterus will be felt nearer the external part 524 APPENDIX. than usual, or its neck will be projected slightly from the vagina. From this time, every function which requires much action of the diaphragm or other abdominal muscles, will serve progressively to advance the uterus towards the os externum, until a considerable portion or the whole of it be at last pushed extra vulvam, which constitutes the third stage. Clear and satisfactory as this description of the disease may seem to be, an examination per vaginam and per rectum ought always to be insisted on before giving a prescription. This done, and the true state of things having been ascer- tained, the condition of the system in regard of general health, is to be considered and treated according to existing circumstances. As far as practicable, the true pathology of the case should be known. Inflammatory action should be subdued by means of depletion, general or topical, or both, as there may be occasion, and by the use of the bath. Irri- tation should be soothed and retired, and any visceral disease should be treated with a proper regard to the organ affected. But as the management shall have respect to the prolapsed uterus, the principal intention should be to replace, and then by means of a suitable instrument, to sustain it, in situ, until the relaxations shall be corrected and the natural tone of the ligaments, vagina, rectum, bladder and their peritonaeal con- nections, shall be recovered. In treating a case of procidentia, much may be done by posture. Sir Charles Mansfield Clark says, the patient should he as much as possible upon a bed, or upon a sofa; but con- siders a mattress better than either. Strong action of the abdominal muscles must be guarded against, and the diet of the patient should be sufficiently nutritious, but the stomach and bowels should never be loaded. The bladder should not be suffered to contain a large quantity of urine, and all articles of food or drink Imown to produce flatulency ought to be avoided. A pessary of proper shape and dimensions affords the most APPENDIX. 525 effectual support for the uterus, when that sort of aid is re- quired. The flat concave circular instrument, recommended by Dr. Dewees, has afforded comfort in many instances, and sometimes permanent relief. If, however, it is large enough to prevent its escape, it must produce too much lateral or cir- cumferential distension. It makes a bed on which the ute- rus may recline, but it is too much below its natural position to relieve the ligaments,, and afford them good opportunity to recover their natural tone and retract to their proper length: besides the lateral or circumferential expansion which the instrument will produce, must hinder the vagina from recovering its longitudinal distension, without which complete recovery must be impracticable. The spherical or globular pessary is better, inasmuch as it must produce more longitudinal distension of the vagina, of course, more elevation of the uterus ; relieving the tension of the ligaments and lessening the dragging of the rectum and bladder. The utility of a pessary of this description was known to Hippocrates, who employed a pomegranate of suitable dimension, first steeping it in wine. Dr. Charles M. Clark says, " a good pessary should com- bine firmness, lightness and closeness of texture: firmness, that it may not yield to pressure ; lightness, that it. may not incommode by weight; and closeness of texture, that it may not imbibe the secretions of the vagina." " Pessaries are made of various shapes as well as of differ- ent materials, adapted to different cases and circumstances. For a majority of cases a circular or oval pessary answers sufficiently well; but the circular pessary can be used in those cases only, where the disease has not made great pro- gress, and where the tone of the vagina is not much im- paired • if the vagina has been much dilated, no pessary of small size can be sustained in it; and one of a larger size, of a circular form, might do mischief by compressing the 526 APPENDIX. urethra and rectum, and so preventing the discharge of the faeces and urine." The inconveniences and injuries which have been pro- duced by the various kinds of pessaries have been such, that their usefulness is held to be doubtful by some physicians of great pretensions; indeed, the remedy has been considered as altogether injurious. An instrument of proper construc- tion, it is hoped, will rectify all these evils. If we duly consider the anatomy of the organ to be sup- ported by a pessary, we cannot fail to perceive, that the in- strument, if it shall have good pretension to a philosophical adaptation, ought to fill the cavity of the vagina without in- convenient distension, either lateral or longitudinal. It should reach about four inches above the os externum, and should have a neck, by which the entire weight of the organ and instrument, may be made to rest upon a bandage or cushion fitted for that purpose. Its upper extremity should occupy the cul-de-sac, lifting it above the neck, and present a suitable cavity on its anterior side, into which it shall re- ceive the neck of the womb. This last named adjustment, will secure to the uterus the necessary elevation, and to the fundus of the organ an inclination in conformity to its natu- ral angle with the vagina; and the neck when received into the cavity will subserve to keep the instrument in its proper position. On the anterior side of the instrument there should be a sulcus or groove of sufficient capacity to protect the urethra. This groove will also enable the patient at any time, very conveniently, with the end of the fore finger, to ascertain whether the instrument retains its intended position ; and it will make a channel for the exit of the secretions. To the small end, there should be attached a neck or stem, about an inch and a half in length, having at its lower ex- tremity, two circular buttons, seven-eighths of an inch in diameter, and one-fourth of an inch apart, for the purpose of APPENDIX. 527 receiving and holding the bandage which is intended to sus- tain its weight. Preparatory to the successful employment of this pessary, it should be ascertained, that the vagina is in a condition for admitting the longitudinal distension necessary for its recep- tion ; which will not be the case, if the uterus and its liga- ments are bound down too low, by unnatural adhesions, or contractions. When the womb is in its natural position, its fundus in- clines a little forwards and its neck a little backwards. But when it begins to sink down towards the perinaeum, its in- clination is often retroverted, so that it is made to bear hard on the rectum, and the irritation produced by the misplace- ment, sooner or later sets up a sub-acute inflammatory con- dition of the parts involved, which is followed by adhesions more or less extensive or obstinate, corresponding to the de- gree of previous irritation and the time of its continuance. When such adhesions of the peritonaeal coverings of the uterus and ligaments, with those of the rectum and circum- jacent parts have become established, the contractions present to the finger when examined per rectum, the resemblances of tumors of various figure and dimensions. In cases of this kind the entire attachments must be broken up, and the ute- rus with its ligaments made to swing freely forwards to their natural position. Sometimes the contractions are found to be greater in the posterior surface and its connections with the rectum. In some instances the broad ligaments are dragged down and adhere to the posterior and lateral peri- tonaeal surfaces upon which they ought merely to slide. And in others the anterior surface between the os externum and the neck is greatly contracted. All these points should be considered, and if either or all of them be found to exist, suitable manipulation must be applied and repeated as there may be occasion, till the correction shall be complete. Without this important preparation of the parts, all attempts 528 APPENDIX. to maintain the uterus in situ, will be unavailing; and in such instances, it requires a good deal of tact, to separate the adhesions and elevate the organ properly. One of the lead- ing objects in preparing this essay is, to embolden the profes- sion in performing an operation which may prove to be of vast importance to thousands. Many cases will be found, in which, although the state of things may seem forbidding, yet by firm and patient perseverance, the morbid condition may be overcome, and perfect and permanent relief be af- forded. ' About twenty-five years ago, we visited a patient in great distress. Her symptoms were such as commonly attend pro- lapsus uteri, but her greatest inconvenience, was an almost total inability to discharge her faeces or urine. On examina- tion per vagi nam and per rectum, we found the uterus lying with its fundus nearly at one extremity of the long diameter of the pelvis, and the neck at the other ; a lateral displace- ment ; the uterus enlarged to a triple size, and so rigidly bound down to the circumambient structures, as not to admit * of the least elevation without great force. Our first impres- sion was, that the case was incorrigible, and we were about to abandon it. Considering, however; that the enlargement of the organ and its adhesions might be the eflect of dis- placement, merely;—an inflammatory tumefaction ; which was confirmed by the fact, that it was very sore to the touch, we concluded that an attempt to elevate it might be safely conducted, if not done too hastily, and if any new irritation which might be produced by the attempt, should be met with decision and careful treatment. With this conclusion, we proceeded at once to use our customary manipulations, per rectum, being very careful always to apply the finger late- rally, and not point foremost. Beginning with a moderate degree of pressure, and gradually increasing the force, on the right, on the left, and on the middle of the tumid uterus, as we could effect more room or. find access for the finger; all APPENDIX. 529 the while attending carefully to the complaints of our pa- tient. This first attempt satisfied us that the adhesions might be made to yield, and also, that too much must not be attempted at one sitting. So soon, therefore, as the patient earnestly desired respite, the operation was discontinued for that time. A gentle aperient of castor oil was administered, and repeated the following morning. In the course of thir- ty-six hours there was an occurrence of fever with tense pulse. She was bled sixteen ounces from the arm, which was succeeded that night by a dose of calomel, ten grains, with opium, two grains. The following day she was kept quiet in bed, and mild aperient and cooling remedies were used. On the fourth day, another and somewhat bolder attempt at elevation was made. This in like manner excited some irritation, making further depletion necessary. One moderate blood-letting and a gentle cathartic once or twice repeated, again tranquilized the system; after which. we continued to operate about twice a week. After ten or twelve sittings we succeeded in releasing the uterus from its unnatural attachments, and replaced it, in situ. By contin- ued attention; a few times leeching the os tincae; frequent blood-letting from the arm ; frequent small doses of calomel and ipecac, and when necessary, hyosciamus, or opium, or both, in order to allay existing irritation, and secure rest at night; after eighteen months or two years, this patient was cured. In this case and in all others that we have treated, the pessary was not introduced, until a liberation and elevation of the uterus, and a retirement of existing irritation, had been accomplished. We have given this, the most difficult and forbidding in its appearance, of all the cases that have fallen under our ob- servation which admitted of cure, and feel great solicitude that it may meet a kind and candid reception ; because a 34 530 APPENDIX. majority of the cases which we have treated for uterine af- fections, have been such as labored under a descent and retro- version of the organ. Prolapsus uteri appears to have been sufficiently well understood and defined by our writers on that subject. But the obstinate case here submitted, was not a prolapsus. The neck of the uterus had not slid down into the vagina. The uterus had descended, and its ligaments and connections vwith the vagina, rectum, and bladder, hav- ing become relaxed, it continued its descent, dragging after it the circumambient structures, till it had assumed a lateral displacement. After having met this case, we became more circumspect in our investigations, and have learned, that there are many instances, such as a physician on an ordinary and hasty ex- amination per vaginam might consider to be well enough, and which on a more careful investigation made per vaginam and per rectum, he will find to be retroversion and adhesion, requiring the most careful and skillful attention and manage- ment. This state of things may be present and an examina- tion per vaginam give very little inconvenience to the patient; when at the same time, a slight degree of pressure made upon the uterus with the finger per rectum, will give great pain. It is a fact, however, that in such instances, when the opera- tion necessary for correction shall have been repeated, at each subsequent repetition, the patient will make less complaint, and at length, as the morbid attachments are broken up, she will experience but little inconvenience when the womb is elevated. The many trials which we have made of the flat circular pessary, of the oval and of the spherical pessaries, and the repeated disappointments which we met in the use of them, impelled us to try a three and a half inch tubular one, made of gum elastic, which answered better. But it would be- come too soft by the warmth and moisture of the vagina. Afterwards we had them made of wood, which answered APPENDIX. OHl better, as it respected the necessary firmness; but there was a good deal of difficulty in retaining any of them in then- proper position. This last mentioned inconvenience led to the conclusion, that the instrument should make considerable longitudinal distension, and to produce its full effect, must occupy the cul-de-sac, and by means of a suitable cavity on the anterior side, receive the neck, which with little trouble and attention would not fail to answer the intended purpose. In this shape we have so far proved its efficacy, that we are obliged to believe it will correct any condition of prolapsus, if it be properly used—we mean, if the medical treatment required in the case be judicious, and the instrument be rightly fitted, as to its length and size, including its cavity. Indeed, we entertain a hope, that it will supercede the neces- sity of a recourse to the surgical operation of Messrs. Marshall Hall, Heming and Ireland,—meritorious as it is said to be, in the hands of those distinguished gentlemen. The introduction of a pessary requires care. Having smeared the body and stem of the pessary with some unc- tuous substance, it should be passed in upon its side, and its upper end slid against the rectum with its stem inclined to- wards the pubis, until it shall be resisted by the cul-de-sac. Then turning it on its back, it cannot fail to receive the neck of the womb into its cavity. The patient should previously be furnished with a broad laced bandage to fit her lips with greater or less tightness, to suit her feelings. A convenient strap with a button-hole or two in the middle, suited to the stem of the pessary, is then to be buttoned on it, and the end of the strap attached by a button or buckle to the bandage behind drawing the stem backwards, so as to make pressure on the perinseum. This last measure makes the neck and back part of the instrument act on the perinaeum and rectum, which serve as a fulcrum; and the upper end as a lever} causes the uterus to swing forward to its place. The ante- rior end of the strap should be drawn up by another buckle 532 APPENDIX. fastened to the waistband, above the pubis, with sufficient tightness to sustain the weight of the uterus. The attention of the patient should be called to all these particulars, and she should be instructed in them all, and have privilege to regulate them at discretion ; save only that she should be very careful that the instrument be introduced to its full length, every time it is applied, and always made to bear more or less against the perinaeum. She should also be made to understand, particularly, that if the instrument be not admitted to its full length, it had better be laid aside till the arrival of her physician ; since the impracticability of its admission affords evidence, that the uterus is retroverted and needs the introduction of the finger per rectum, to throw it forward to its place ; or that some adhesion is remaining or has recurred, which needs to be broken up. Sometimes the uterus is in such a condition, that when the pessary is apparently in place, there is an escapement of the os tincae out of the cavity prepared to hold it, consequent on enlargement of that portion of the organ. When this cir- cumstance occurs, it produces much inconvenience, which requires correction. If the patient complain of pain or soreness after the intro- duction of the pessary, the inconvenience here referred to should be suspected, and an examination should be made to ascertain the true position of the instrument, and if the os tincae be dislodged it should be replaced. In withdrawing the instrument, a rotary motion should be given it, so as to dislodge the neck of the uterus from the cavity, which, without this precaution, might produce pain and subsequent soreness. TOXYCOLOGT, REMEDIES IN CASES OF POISONING AND OP ACCIDENTS, By Professor Orfila, of Paris, recommended by the French Institute in their Report, to be ordered by government, that a copy should be kept for immediate reference in all the public offices, as well as in every private house in the kingdom; with numerous additions to the original, of the newest discoveries, and importont correc- tions from Andral, Apjohn, Beck, Sir C. Bell, Chris- tison, Cooper, Dumas, Edwards, Fodere, S. K. J. and others. GENERAL SYMPTOMS OF POISONING. A person is supposed to be poisoned, if being in perfect health he be attacked, after having taken some food or drink, with violent pain, cramp in the stomach, nausea, vomiting, convulsive actions, and a sense of suffocation; or if he be seized, under the same circumstances, with giddiness, deli- rium, or unusual drowsiness. Beck. The effects of poisoning may, in most cases, be known and distinguished from natural diseases or sudden illness, by the following symptoms: 1. The person, when in a state of perfect health, becomes all at once very ill, sick, with violent pain in the stomach, burning in the throat, and retching. In sudden apoplexy, the stomach and throat are not affect- 534 APPENDIX. ed. In cholera and internaL^nfiammations, there is no burn- ing in the throat before vomiting begins.—Apjohn. There is also a feverishness not observed at first, in poisoning.— Fodere. 2. The effects of a strong dose of poison usually show themselves in a few minutes, though others not for some hours. After a meal or eating, when a person is taken very ill, poisoning may be suspected.—Christison. Apoplexy, cholera, and inflammation, which also appear suddenly after eating, may be distinguished as above. 3. The effects of poisoning not only appear suddenly, but increase rapidly and alarmingly, after or within an hour, and sometimes prove fatal in a few minutes. Internal inflammation, diseases of the heart, cholera, plague, apoplexy and some other diseases, that often end fatally with- in a few hours, may be distinguished from poisoning, by what is said above, as well as from individual circumstances. 4. The effects of poisoning most usually increase without intermission of their severity, and are also, for the most part, uniform in kind. Internal inflammations, and some of the diseases already mentioned, have often the same character, and can only be distinguished by circumstances.—Christison. WHAT TO DO IN GENERAL. When it is strongly suspected from the above symptoms, that poison has got into the stomach, though it be not known what sort of poison, not a moment is to be lost in removing it, by means of the stomach pump, if one be at hand, and if not, by promoting full and copious vomiting. For this purpose, the most speedy means are, the tickling of the back part of the mouth with a feather, and repeatedly thrusting the finger as far back into the throat as possible. When the gullet is much inflamed, however, APPENDIX. 535 none of these means can be employed. Other means to be used, are given below. Irritant, Caustic, or Corrosive Poisons. This division comprehends strong or concentrated acids and alkalies, metallic preparations of antimony, arsenic, bis- muth, copper, lead, mercury, tin and zinc, phosphorus, can- tharides or blistering fly, and acrid plants. General Effects.—All the poisons of this division, pro- duce inflammation of the parts which they touch, in differ- ent degrees ; sometimes, as in the case of acquafortis, harts- horn or bluestone, they burn as violently as a red hot iron would do, causing death in the same way as burning by fire : sometimes, as in the case of arsenic and corrosive sublimate. without burning the parts so intensely, they get into the blood, and prove rapidly fatal, by destroying the vitality of the heart, of the lungs, and of the brain. POISONING BY STRONG CONCENTRATED ACIDS. COMMON NAME. CHEMICAL NAMES. Spirit of Salt—Muriatic Acid. Hydrochloric Acid. Aquafortis. , Nitric Acid. Oil of Vitriol—Spirits of Vitriol. Sulphuric Acid. Acid of Phosphorus. Phosphoric Acid. General Effects.— Instantly after swallowing a strong acid. a very disagreeable, sour, burning taste is felt in the mouth ; belching acrid gas; an acrid heat in the gullet and stomach ; a very sharp pain, and feeling of tightness in the throat; great difficulty or impossibility of swallowing ; the breath becomes insupportably foetid ; retching and copious vomiting ensue of bitter stuff, sometimes mixed with blood ; there are hiccough and sometimes costiveness, but oftener copious stools, more or less bloody; colic and tenderness of the belly, so as to render even a shirt too heavy to be borne ; oppressed breath- ing ; burning thirst, increased by drinking, all drink being soon vomited ; cold, clammy sweats; repeated and vain ef- forts to make water; distressidg restlessness; convulsive 536 APPENDIX movements of the lips, face and limbs; the countenance is pale, ar lead colored; while the mind for the most part re- mains unaffected till death, which occurs in two hours to half-a-day, and sometimes from three to seven, or even fif- teen days.—Christison. Mistakes of cholera for irritant poisoning may be prevent- ed by knowing, that in cholora there is no blood vomited, and no heat and pain of the throat until after vomiting has begun. In violent colic there are no vomiting and purging. In inflammation of the intestines, there is always fever, which does not at first occur in poisoning.—Fodere. WHAT TO DO IN POISONING BY STRONG ACIDS. Antidotes, or Counter Poisons.—The best counter poison is magnesia, (but not calcined magnesia—Aikin,) which should be given without losing a moment, or the patient will be lost, by mixing an ounce in a pint of water, and giving a glassfull of this every two minutes. When magnesia is not •at hand, dissolve half an ounce of soap in a pint of water. When neither magnesia or soap are to be had, beat down the plaster of a room, and make it into a thin paste with water, (Christison,) and let it be instantly swallowed, in order to neutralize the poison. Enemas or clysters of the same should also be given. Other Treatment.—The stomach pump cannot always be used, from the inflamed state of the gullet; and hence it is much better to promote vomiting than waste time with it. This must not be done by tickling the throat with a feather, or the finger, but by giving water, milk and water, whey, barley water, gum arabic water, or linseed tea. The inflam- mation of the gullet and stomach must be also immediately relieved by putting from twelve to thirty leeches on the parts where there is most pain, fomenting the stomach with water in which chamomile and poppy heads have been boiled. A warm bath will also be advisable. (Use the vapor bath— *S*. K. J.) No food, not even the weakest broth or tea, must APPENDIX. 537 be taken, till the inflammation is subdued; but when the cramps or convulsions disappear, a little gruel, or veal, or chicken broth may be given; and no solid food for some time- POISONING BY OXALIC ACID, OR ACID OF SUGAR. This acid, used chiefly for cleaning brass, or boot tops, and removing ink spots, was not known to be poisonous till 1814, since when numerous fatal cases have occurred by mis- taking it for Epsom salts, which it resembles so closely in appearance, that the salts ought always to be tried before taking them, by putting a crystal in a penful of ink, which will not be changed by the salts, but will become reddish brown with oxalic acid. Effects when swallowed.—If abut half an ounce, or even less, of oxalic acid be taken into the stomach, it very rapidly produces effects like burning or scalding in the mouth or gul- let, the tongue and gums swelling, and smart violent burning pains arising in the throat and stomach. This is usually (not always) followed by excessive vomiting of a dark colored, or sometimes bloody matter, which continues till near death ; sometimes (not always) there is violent purging. The skin becomes cold and clammy, the pulse at the wrist can scarce- ly be felt, and torpidity and drowsiness—great sinking and weakness, with change of the countenance, announce death to be near. Where the acid is taken in smaller quantity, or diluted with about twenty times its weight of water, it does not produce the violent burning pains, but attacks the heart, the brain, and the nerves, stopping the motions of the heart, producing apparent death, or suspended animation, by paralyzing the organs of breathing, while symptoms ensue resembling lock- jaw, followed by death. In still smaller doses, it causes great weakness of the limbs, pains in the back and numbness, without proving fatal.—Christison. 538 APPENDIX. WHAT TO DO. Antidotes, or Counter Poisons.—Oxalic acid acts with such dreadful rapidity, that remedies must be given on the instant. The best are chalk, magnesia, (not calcined,) or the mortar or plaster taken from a wall, mixed thick in cold water, and swallowed copiously.—Christison. Any one of these combines with the acid, and forms an insoluble salt. Solution of soap, or soda, or potass, must not be given. Other Treatment.—Carefully avoid giving water or drink to promote vomiting, for by diluting the acid, it is rendered easier to be carried into the blood.—Christison. After giv- ing any of the counter poisons, the stomach pump may be used, or a smart emetic taken. When the immediate dan- ger is over, if there be no pain in the gullet, the stomach, or the bowels, the patient may have some wine, or spirits and water, to rouse him, and have hot fomentations, or a mustard poultice, applied to the stomach.—Beck. Use our bath.—$. K.J. POISONING BY STRONG or CONCENTRATED FIXED ALKALIS. COMMON NAMES. CHEMICAL NAMES. Caustic Potash. Hydrate of Potass—Potassa Fusa. Salt of Tartar, Oil of Tartar. Carbonate of Potass—Subcarbonate of Potass. Caustic Soda. Oxide of Sodium. Washing Soda—Kelp, or Barilla. Carbonate of Soda—Subcarb. Soda. Lime—Quicklime. Oxide of Calcium. Slaked Lime. Hydrate of Lime. Lime Water. Solution of Lime. Effects when swallowed.—The most remarkable difference from the effects of strong acid is, in the case of alkalies, a peculiar styptic, acrid, burning, and urinous taste in the mouth, produced by potass or soda, destroying the skin lin- ing the mouth and gullet, and causing a burning pain, with tightness like strangling, and great difficulty or incapability of swallowing, with violent retching and vomiting, often mixed with blood, tasting urinous, and changing vegetable blue colors green. These first effects are followed by sharp APPENDIX. 539 pains at the pit of the stomach, and great tenderness of the whole-belly, from internal inflammation, and often actually burning through the stomach. In the third stage, there are excessive weakness, cold clammy sweats, hiccough, convul- sive twitching of the limbs, and trembling, followed by tor- turing colic, and purging of dark or bloody matter. These symptoms precede death, which may take place in less than twenty-four hours.—Christison. The mind is usually more or less deranged.—Beck. Sometimes the first symptoms remit, and the patient continues to live for some weeks, or months, but is at length exhausted by purging and incapa- bility of swallowing food.—Dewar and Sir C. Bell. WHAT TO DO. Counter Poison, or Antidoes.—Let no time be lost in giv- ing vinegar, or lemon juice, in the quantity of two table- spoonfuls in a glass of water; and, if this be not at hand, a few drops of elixer of vitriol, [sulphuric acid,] or spirit of salt, [hydrochloric acid,] (Apjohn,) may be added to the wa- ter, so as to render it about as sour as weak vinegar. Oil, such as olive oil, or oil of almonds, given freely, is also good, by converting the potass, or soda, into soap, and promoting vomiting.—Chereau. Other Treatment.—Besides these counter poisons, bland drinks, such as barley Avater, gruel, linseed tea, milk, whey, and jellies, may be given, to sheath the virulence of the poi- son. The internal inflammation must be subdued by twelve or more leeches applied to the pit of the stomach and to the throat, or by cupping or the lancet. The tender state of the gullet will often render it impossible to introduce the stom- ach pump, or to tickle the throat with a feather or the finger. Milk, warm water, or weak chamomile tea, are best for pro- moting vomiting ; all strong emetics being improper. (After all the bath.—S. K. J.) 540 APPENDIX. POISONING BY AMMONIA AND ITS SALTS. COMMON NAMES. CHEMICAL NAMES. Volatile Alkali. Solution of Ammonia—Liquor Am- moniae. Smelling Salts-Volatile Salts-Harts- Sesqui-Carbonate of Ammonia. horn. Sal Ammoniac—Baker's Salt—Mu- Hydrochlorate of Ammonia. riate of Ammonia. Effects when swallowed.—These are nearly the same as in the case of potass and soda, with the addition of a pungent, suffocating, burning sensation, caused by the vapor or gas of the ammonia. This poison also, much more rapidly, brings on dreadful convulsions and cramps, resembling those of lock-jaw.—Apjohn. When taken in smaller quantity, it causes bleeding from the mouth, the nose, and the bowels; makes the teeth drop out, and brings on a fatal hectic.__ Huxham. Effects when the Vapor is breathed.—When smelling salts are incautiously held long to the nostrils of persons who have fainted, the vapor inflames the throat and lungs, and produ- ces burning pain in the mouth and throat, great difficulty of swallowing, oppressed breathing, and distressing cough.__■ Nysten. The bottle of smelling salts should only be appli- ed from time to time; three parts of water may be added to weaken its virulence.—Apjohn. WHAT TO DO. Counter Poison, or Antidotes.—As in the case of potass and soda, vinegar is the best counter poison of ammonia— (Beck)—and when that is not at hand, lemon juice, or any vegetable acid ; but unless very speedily taken, the vinegar will be of no use; for death has occurred in four minutes from this poison. When the vapor has been breathed in in- jurious quantity, the vapor of hot vinegar may be inhaled by the mouth and nostrils. POISONING BY IODINE AND ITS SALTS. Effects when swallowed.—In the quantity of from ten to twenty grains, it produces metallic taste in the mouth; a APPENDIX. 541 sense of tightness and strangling in the throat, nausea, severe pain at the pit of the stomach, increasing on being pressed; retching, vomiting, colic, palpitation, trembling, blood-shot and throbbing eyes, with sinking of the pulse.—John. WHAT TO DO. Counter Poisons, or Antidotes.—Dissolve a quantity of white (not blue) starch, arrow root, or wheat flour, in water, and give it immediately, as a probable antidote.—Apjohn. Other treatment.—When the pain of the stomach is dis- tressing, apply leeches and fomentations; and give for drink, barley water; or what is better, rice water, if it can be had ; alternating the bath.—S. K. J. POISONING BY MERCURY. COMMON NAMES. CHEMICAL NAMES. Corrosive Sublimate—Muriate of Mer- Bichloride of Mercury cury—Oxy-muriate of Mercury Calomel Chloride of Mercury Red Precipitate Nitric Oxide of Mercury Vermillion, or Cinnabar Bisulphuret of Mercury Turbeth Mineral Sub-Sulphate of Mercury Prussiate of Mercury Percyanide of Mercury Effects of swallowing Mercury.—When one grain, or more, of corrosive sublimate, or over doses of the other mer- curial preparations have been swallowed, the effects are more rapid and powerful than even those of arsenic, causing a most disgusting metallic taste, somewhat like that of rue, in the mouth; an acrid dryness in the throat, with a sense of tightness and strangling ; pain in the back part of the mouth, the stomach, and the bowels, which soon becomes insupport- ably severe ; nausea, belching of foetid air; inclination to vomit, retching, and at length vomiting, and purging of bloody matter ; hiccough, oppressed breathing, difficulty of swallowing, unquenchable thirst; difficulty of making water, cramp, clammy skin, icy coldness of the hands and feet; alarming weakness and sinking ; change of the countenance, which is usually swelled or flushed; dreadful convulsions and delirium precede death, which takes place in from twen- 542 APPENDIX. ty-four to thirty-six hours; or sometimes in three days or more, according to the quantity taken, and to the constitu- tion of the patient. Effects when applied externally.—When corrosive subli- mate, or other strong mercurials, are applied to wounds or sores, or even to the unbroken skin, in the form of dangerous cosmetics, or to destroy vermin in the hair, similar effects, more or less violent, are produced as those just mentioned; particularly cramp, and inflammation of the stomach and bowels, intense head-ache, cold sweats, convulsions, and death in from ten to thirty hours. WHAT TO DO. Counter Poisons, or Antidotes.—As quickly as possible, mix up the whites of a dozen eggs or more, with two pints of cold water, and give a glassful of the liquid every two minutes, till the stomach can contain no more, in order to promote vomiting. When fewer eggs only are at hand, use all there are, and supply the deficiency with milk. The dried gluten of wheat, or even wheat flour itself, mixed with water, is also a good counter poison to corrosive sublimate.— Taddei. Other treatment.—When no eggs, milk, wheat gluten, nor wheat flour are at hand, linseed tea, sugared water, barley water, or other bland drinks, should be copiously given ; and vomiting should be provoked, if the gullet be not inflamed, by tickling the throat with a feather, or with the finger. If the stomach pump is at hand, it ought to be employed with- out delay. When inflammation of the stomach and bowels comes on, leeches, and fomentations of poppy water, must be applied. Also, the bath.—S. K. J. POISONING BY ARSENIC. COMMON NAMES. CHEMICAL NAMES. White Arsenic—Oxide of Arsenic— Arsenious Acid —Fly Powder Macquer's Salt of Arsenic—Arseniate Arsenite of Potass of Potash Orpiment—King's Yellow—Rusma Sesqui-Sulphuret of Arsenic Realgar Red Sulphuret of Arsenic APPENDIX. 543 Fowler's Solution—Tasteless Ague Solution of Arsenite of Potass— ■Drop Liquor Arsenicalis Arsenical Paste—Plunket's Remedy Contain Arsenious Acid for Cancer Effects when swallowed, or introduced internally.—As these effects vary in different individuals, from difference of constititution, they are classed under three varieties. 1st Variety.—In about half an hour, or more, after the arsenic is introduced into the body, nausea and faintness come on, soon succeeded by burning pain in the stomach, and obstinate vomiting of yellowish green matter, much in- creased by any sort of drink ; and after a time, more or less blood is generally brought up. Along with the vomiting, there are heat, dryness, and a tight strangling sensation in the throat, with unquenchable thirst; the voice becomes hoarse, and speaking painful; gripes, and purging of green, watery, viscid matter, usually (not always) sets in with much irritation, and vain straining at stool; the belly is tense and painful; the pulse quick, and the heart flutters; the skin is cold and clammy; palsy of the extremities, convulsions, and in some cases delirium, precede death, which occurs in from twenty-four hours to three days.—Apjohn. 2d Variety.—When solid lumps, or a very large dose of arsenic, has been introduced, death ensues with great rapidity in about six hours or less, with little or no irritation, but ex- cessive faintness, stupor, and slight convulsions; sometimes there are trivial vomiting and pains of the stomach.—Chris- tison. 3d Variety.—The patient sometimes lives six days, and in rare cases partially recovers; the effects being at first the same as in the first variety, the vomiting, &c. being, perhaps, more violent, followed about the second or fourth day by palsy, epilepsy, hysteric lock-jaw, and sometimes outrageous madness.—Christison. Effects when externally applied.—When arsenic is applied to cancerous sores, as in the form of arsenical paste, or of 544 APPENDIX. Plunket's or Aldis's remedies, or to destroy vermin, itch, and the like, it does not affect the stomach so muchas the nerves, producing giddiness, fainting, trembling of the limbs, heart- burn, excessive thirst, scalding on making water, slight vom- iting, delirium, and death in from twenty-four to forty-eight hours. WHAT TO DO. Counter Poisons, or Antidotes.—No specific counter poi- son is yet discovered ; though lime water may be tried, pre- pared by heating for five or six minutes, a quarter of an ounce of slaked quick-lime in two pints of water, straining the liquor through a linen cloth, and giving several succes- sive glasses of this, mixed with equal parts of sugared water. Dr. Christison, however, says this is absolutely useless. Other treatment.—The stomach pump, if one can be im- mediately had, is here most valuable (Apjohn;) and if not, exciting vomiting by tickling the throat with a feather or the finger. Vomiting must also be promoted by drinking copi- ously so as to fill the stomach with warm or cold milk, water, sugared water, linseed tea, or barley water. When vomiting cannot easily be excited, an emetic of 24 grains of the sul- phate of zinc should be given.—Christison. Enemas of cas- tor oil, and suppositories prepared with opium, are highly valuable.—Ryan. Useless Remedies.—'Treacle, oil, gall nuts, Peruvian bark, the bark of pine and pomegranates, liver of sulphur, or sul- phuret of potassium and vinegar, formerly recommended, are not only useless, but often, as in the case of the liver of sul- phur, even dangerous. The more recently vaunted remedies of magnesia and charcoal are, at best, of extremely doubtful utility.—Christison. After Treatment.—Bleeding from the arm seems to be de- cidedly advantages, [followed by the bath.—S. K. J.] Blis- ters to the belly, with opiates, anodynes, mild laxatives, and bland (not stimulating) food, are most advisable.—Christison. APPENDIX. 544 The hydrated sesqui-oxide of iron has been discovered to act as an antidote to arsenious acid. The best process to ob- tain it, consists in oxidizing, with the assistance of heat, a solution of protosulphate of iron, by adding to it nitric acid in small portions at a time. Precipitate the solution thus ob- tained by caustic ammonia, and wash the sesqui-oxide by agitating it with water several times ; decant the supernatent liquid, and preserve the hydrate under water in close stop- pered vessels.—Bunsen and Burthold. The above substance is not recognized as an absolute an- tidote to arsenic. See Schultz in Hufeland's Journal, Janu- ary, 1838. POISONING BY COPPER. COMMON NAMES. CHEMICAL NAMES. Verdigrise,—Oxide of Copper. Diacetate of Copper. Verdigrise Chrystals. Pure Diacetate of Copper. Blue Stone— Blue Vitriol—Blue Copperas. Sulphate of Copper. Verditer—Copper Nitre. Nitrate of Copper. By using untinned copper vessels for cooking, or by pre- serving in these vessels articles of food, such as pickles, pre- serves, or milk, as well as copper stop-cocks, when any acid or grease is present, as is almost always the case, a poisonous salt is produced, which may cause deleterious consequences. __Apjohn. Cooking in very clean copper vessels at a high heat, and removing the material before cooling, is safe.— Proust. Effects when swallowed.—When any of the above salts of copper are taken by accident or design, there are produced an acrid, styptic, disgusting, coppery taste in the mouth ; with a dry parched tongue, a sense of strangling, tightness in the throat, coppery belchings, continual spitting ; nausea, copi- ous vomiting, or distressing and vain efforts to vomit; shoot- ing and often severe, pains in the stomach ; dreadful griping ; frequent purging, sometimes of black or bloody matter, with much vain straining at stool; the belly is painful to the touch, and swells up; there are great heat of the skin, and burning, 35 546 APPENDIX. unquenchable thirst; succeeded by jaundice (never occurring from arsenic or mercury,) and by great weakness and faint- ness, difficulty of breathing, violent head-ache, giddiness, cold sweats, scanty urine, cramps of the legs, convulsions, and death. Counter Poisons, or Antidotes.—The best antidote for neutralizing poisonous salts of copper in the stomach is, white of eggs, of which one dozen, if so many can be had, should be mixed with a pint or two of water, and taken in glassfuls every two minutes. The next best is Prussian blue, or per- cyanide of iron; or an ounce of fine, clean, iron filings may be taken in milk, or other bland fluid.—Edwards and Du- mas. Useless and Dangerous Antidotes.—Liver of sulphur, or sulphuret of potassium, alkalies, gall-nuts, bark, charcoal, particularly vinegar, formerly recommended, must not be given. Other Treatment.—Sugar, though not as at first supposed, an antidote, will be of advantage, given in coffee, or water, to promote vomiting; and this may also be provoked, if it do not come on of itself, by tickling the throat with a feather or the finger. The stomach pump will only be available when employed early. When there is great pain of the belly, or at the pit of the stomach, leeches will be advisable. [Say bleeding, following it with the vapor bath.—$. K. J.] POISONING BY ANTIMONY. COMMON NAMES. CHEMICAL NAMES. ; Tartar Emetic—Tartarized Antimo- Totassio-Tartrate of Antimony. ny—Antimoniated Tartar. Butyr, or Butter, of Antimony—Mu- Chloride of Antimony. riate of Antimony. Kermes Mineral. Hydro-Sulphate of Antimony. Glass of Antimony. Oxide of Antimony. James' Powder. Serious consequences often ensue by putting tartar emetic into tea, liquors and the like, for the purpose of detecting do- ~>^stic pilferers, by making them ill, (Christison;) and by the ignorant use of James' Fever Powders. APPENDIX. 547 Effects when swallowed.—The common effects produced are, a rough, metallic taste in the mouth, nausea, copious vomitings, frequent hiccough, severe heart-burn, burning heat, and pain at the pit of the stomach, griping colic, purg- ing, fainting ; the skin, in some cases, cold; in others, burn- ing hot; difficult breathing, giddiness, like intoxication, loss of sense, convulsive motions, distressing cramps in the legs, and death. Sometimea there is great difficulty, or impossi- bility of swallowing, from the tightness and strangling sen- sation in the throat; sometimes, when there is no vomiting or purging, the other effects are more severe.—Beck. Effects when externally applied.—In the form of ointment, as used by the late empiric, St. John Long, and scientifical- ly recommended by the late Dr. Jenner, tartar emetic may cause not only painful tumors and bad ulcers, but nausea, vomiting, and even death.—Francis in Beck. Counter Poison, or Antidotes.—The decoction or tincture of galls, when at hand, should be given to neutralize the poison. The yellow Peruvian bark, from containing gallic and tannic acid is, by some, recommended as the best anti- dote, and may be given in powder, in tincture, or in decoc- tion, repeating the doses.—Apjohn. As Antidotes—Ipecacuanha, blue vitriol, or sulphate of copper, white vitriol, or sulphate of zinc, should not be giv- en to promote vomiting. Other Treatment.—The vomiting, when it begins, must be promoted by several glasses of plain water, or sugared water; but when vomiting has continued some time, with increasing pains, one grain of extract of opium, or an ounce of syrup of poppies, dissolved in a glass of sweetened water, should be given thrice, at intervals of a quarter of an hour. If the symptoms continue to increase, a dozen leeches or more, should be applied over the pit of the stomach; aud if there be much sensation of strangling in the throat, the name num- ber of leeches may be applied there. [Bleed and apply the bath.~£. K. J.} 548 APPENDIX. POISONING BY TIN. COMMON NAME. CHEMICAL NAMES. Butter of Tin—Salt of Tin—Muriate of Tin. Bichloride of Tin. Putty Powder—Flowers of Tin—Worm Powder. Oxide of Tin. These preparations are used in dying, and the arts; and in one case the salt of tin was mistaken and used by a cook for common salt. Metalic tin is not poisonous. Effects when swallowed.—There are produced, by small doses, colic and purging ; and by larger doses, when given to brute animals, palsy, convulsions, and death. Counter Poisons, or Antidotes.—The best counter poison for tin, is milk, but till this is procured, warm or cold water should be given to promote vomiting. Other treatment.—The colic may be relieved by leeches and fomentations, the convulsions, by opium, or syrup of poppies, as recommended for antimony. [According to the severity of the symptoms, bleed and use the bath.-AS1. It. J.] POISONING BY ZINC. COMMON NAMES. CHEMICAL NAMES. White Vitriol—White Copperas—Vitriol of Zinc. Sulphate of Zinc. Flowers of Zinc—Nihil Album. Oxide of Zinc. Vessels made of zinc should not be used for milk, nor in the kitchen, it is also dangerous to use zinc for water pipes, as it readily oxidizes.—Proust. Effects when swallowed.—When taken in larger doses than a drachm, the salts of zinc are apt to produce dangerous vom- itng. The usual effects are, an astringent, metallic taste in the mouth, a sense of strangling, tightness in the throat, nau- sea, copious vomiting and purging, pains at the pit of the stomach, extending over the belly, difficulty of breathing, paleness of the face, cold and clammy skin ; but seldom death. —Beck. WHAT TO DO. Give copious draughts of milk, or milk-warm water, to render the vomiting easy. The pain in the stomach, and tightness in the throat, may be relieved by leeches and fo- mentations—[better by bleeding and bathing.—S. K. J.] APPENDIX. 549 POISONING BY SILVER. COMMON NAMES. CHEMICAL NAMES. Lunar Caustic—Lapis Infernalis. Nitrate of Silver. Fulminating Silver. Ammoniuret of Silver. Effects when swallowed.—In doses of more than three grains, nitrate of silver will burn the internal parts it touches, and produce an ulcer and mortification, with excruciating pain.—Boerhave. Six grains have been taken with benefit. S. K. J. WHAT TO DO. Counter Poisons, or Antidotes.—A table spoonful of com- mon salt, or chloride of sodium, dissolved in two pints of wa- ter, or sea water, if at hand, drank copiously, will decompose the poison, and produce the harmless chloride of silver, or horn silver. For fulminating silver, charcoal powder diffused in water, and drank, is said to be the best antidote.—Pagot Laforet. Other Treatment.—If the vomiting and pain continue dis- tressing, recourse must be had to leeches, fomentation and bland drinks—[and bleeding and bathing.—S. K. J.] POISONING BY BROMINE. Chlorine, Bismuth, Gold, Chrome, Platinum, Cobalt, Manganese, Nickel, and other metals. Effects when swallowed.—These are little known as poi- sons ; but produce, more or less, similar effects to iodine, ar- senic, mercury, or copper. WHAT TO DO. The best treatment, in the absence of a knowledge of ef- fectual counter poisons, is, to give copius draughts of milk, whey, or barley water, to promote vomiting. White of egg is an antidote to chlorine. POISONING BY NITRE. COMMON NAMES. CHEMICAL NAMES. Saltpetre—Salt of Nitre. Nitrate of Potass. Sal Prunelle. Hydrated Nitre of Potass. Saltpetre is sometimes taken in mistake for Glauber's salts, with dangerous consequences. 550 APPENDIX Effects when swallowed.—When an ounce or less of salt- petre has been taken in the stomach, it gives rise to obsti- nate vomiting of bloody matter, inflammation, burning pains in the stomach, purging of bloody matter, sinking of the pulse, and cold clammy sweats; followed by a sort of intoxication, palsy of the limbs, convulsions, fainting, great debility, and death in from three to ten, or sometimes sixty hours.— Beck. WHAT TO DO. The poison must be removed as speedily as possible, by an emetic of three or four grains of sulphate of copper, or by the stomach pump; and copious draughts of warm water, or of any bland liquid, may be given to promote vomiting. POISONING BY LIVER OF SULPHUR. The liver of sulphur, termed by chemists the sulphuret of potassium, as well as the sulphuret of sodium, is used in pre- paring medicated baths; such as Whitlaw's, which are there- fore dangerous. Effects when sioallowed.—When three drachms, or more, of liver of sulphur are taken, there are produced burning pain, and sense of strangling in the throat, acrid taste in the mouth, frequent vomiting of sulphurous matter; mortal faint- ness, and death in fifteen minutes; the air of the chamber remaining tainted with sulphurous vapor. WHAT TO DO. Counter Poison, or Antidotes.—Common salt, or chloride of sodium and bleaching powder, or chlorinated lime, given, dissolved in water, will decompose and render harmless the deletereous fumes of sulphuretted hydrogen.—Christison. Other Treatment.—Put two tablespoonfuls of vinegar, or lemon juice, in a tumbler of water, give immediately, and re- peat it to promote vomiting. Then apply a dozen leeches. or more, to the throat, stomach and belly, to subdue the in- flammation—[or bleed and bathe.— S. K. J.] APPENDIX. 551 POISONING BY BARYTA AND ITS SALTS. COMMON NAMES. CHEMICAL NAMES. Heavy Spar—Ponderous Earth—Barytes Baryta, or Protoxide of Barium. Muriate of Barytes-Hydrochlorate of Barytes. Chloride of Barium. Cauk—Heavy Stone. Carbonate of Baryta. Effects when swallowed.—The immediate effect of taking half an ounce, or even much less, of these poisons, are, violent vomiting, convulsions, palsy in the limits, headache, deaf- ness, pains in the belly, hiccough, rending colic, change of the countenance, insensibility, convulsions, and death in from six minutes to one hour. Counter Poisons, or Antidotes.—Half an ounce of Glau- ber's or Epsom salts, dissolved in a pint of water, should be given immediately ; and if neither of these be at hand, the hardest pump water, or water rendered sour by vitriol, should be drank, in order to form thereby the harmless sulphate of baryta. Other Treatment.—Vomiting should be promoted by giv- ing sugared water, or any bland drink. POISONING BY PHOSPHORUS. Effects when swallowed.—If phosphorus, in substance, or dissolved in oil, or in water, be taken into the stomach, it catches fire and burns, producing inflammation, vomiting, ex- haling the smell of garlic, violent convulsions, distressing priapism, and death in forty hours or more. WHAT TO DO. It is advisable to give an emetic of three or four grains of sulphate of copper, to use the stomach pump, and to drink copious draughts of water mixed with magnesia.—Beck. POISONING BY CANTHARIDES, OR BLISTERING FLIES, AND CANTHARIDIN. Effects when swallowed.—When taken either in powder, or dissolved in a liquid, this poison causes an acrid and very nauseous taste in the mouth, a burning heat in the throat, stomach and belly, retching, vomiting, and purging of bloody 552 APPENDIX. matter; excruciating pain in the stomach, distressing pria- pism, and heat in the bladder, with pain and great difficulty of making water, and then often mixed with blood ; great difficulty of swallowing, and sometimes even hydrophobia, or dread of water; the jaws at length become fixed, with gene- ral stiffness, frightful convulsions, delirium, and death in four days, or less. WHAT TO DO. Oil, which was formerly recommended as a counter poison to cantharides, is now found to be dangerous. The best treat- ment is, to use the stomach pump, if it can be instantly had ; and if not, to give an emetic of three ot four grains of sul- phate of copper, promoting vomiting by warm water, or cha- momile tea. Oil or oil fluids, may be injected into the blad- der, or given as enemas or clysters, and the warm bath may be used with advantage; leeches may also be safely applied to the stomach. [Bleed and Bathe.—S. K. J.] POISONING BY GLASS AND ENAMEL. The common opinion that pounded glass is poisonous, is not true; though when glass, in fragments, is swallowed, it may occasion serious injury by wounding the internal parts. WHAT TO DO. The best treatment is, to cause the patient to eat large quantities of vegetables; such as beans, potatoes, cabbage, bread or the like, in order to fill the stomach, and protect it from the sharp angles of the glass. POISONING BY LEAD. Lead is frequently contained, by accident, in water kept in leaden cisterns, or running through leaden pipes; in milk, spirits, wine, beer, cyder, pickles, preserves, orange-flower water, &c; when these are kept, or prepared in leaden ves- sels. Or it may be introduced intentionally to sweeten sour beer, cyder, and wine, or to color cheese, sweetmeats, &c. Effects when swallowed.—When sugar of lead, or any of APPENDIX. 553 the soluble salts of lead, are taken in the quantity of two drachms, or more, it produces a sugary, astringent, metallic and very disgusting taste in the mouth, tightness, and a sense of strangling in the throat; pains, more or less severe in the stomach ; retching, and obstinate, distressing vomiting, often of bloody matter ; but, in general, the effects are much less violent, though they usually end in the well known severe colic, termed the painter's colic. WHAT TO DO. Counter Poisons, or Antidotes.—It is the best practice to give immediately a large dose of Epsom or Glauber's salts, or of plaster of Paris, mixed with the hardest pump water that can be procured, any of which will decompose the poi- son, and form sulphate of lead, which is harmless. Phos- phate of soda is also an excellent antidote. It is dangerous to give liver of sulphur. Other treatment.—If the patient do not vomit, it will be proper to use the stomach pump; to give an emetic of 24 grains of sulphate of zinc, (Christison;) and to subdue in- flammation by leeches or blood-letting.—S. K. J. Effects of the Fumes of Lead.—When persons sleep in fresh painted rooms, and painters, miners, white lead manu- facturers, or others, are much exposed to the fumes of lead, it frequently brings on distressing colic, termed the lead or painter's colic ; with dryness of the mouth, vomiting, cos- tiveness, numbness, or .palsy in the limbs. WHAT TO DO. The best treatment is to give a smart dose of Epsom salts, followed in an hour by a grain of opium, or sixty to a hun- dred drops of laudanum ; and repeating these two medicines, if necessary. " I have never seen the second dose fail to re- move the colic." Christison. When palsy occurs, the bowels must be kept open, spirits applied to the palsied limbs, (Apjohn;) and the patient ought, if possible, to change his employment. 554 APPENDIX. POISONING BY ACRID PLANTS. Effects of acrid Vegetable Poisons when swallowed.—Soon after swallowing any of these poisons, there is felt an acrid, biting, more or less bitter taste in the mouth, with great dry- ness and burning heat; the throat becomes painfully tight, with a sense of strangling, distressing retching, vomiting and purging, and pains more or less severe in the stomach and bowels ensue; and these are succeeded by a quick and throbbing pulse, oppressed breathing and panting, a tottering gait, as if the patient were intoxicated, alarming weakness, sinking, and death. Sometimes there are convulsions more or less severe, acute pain, and causing plaintive cries, with stiffness of the limbs. The several poisons of this class, vary much in the violence of their effects. WHAT TO DO. The first thing is, to remove the poison from the stomach by means of the stomach pump, if one be at hand, or by tickling the throat with a feather or the finger, or by an emetic of 24 grains of sulphate of zinc, (but not tartar emetic nor any acid,) promoting the vomiting by copious draughts of warm water, sugared water, barley water, milk, or other bland liquid, (but by no means vinegar.) When stupor, or intoxication, comes on, give several cups of strong coffee, made by pouring a pint of boiling water on eight ounces, and straining it through linen or blotting paper : it must not be boiled. If the coffee do not remain on the stomach, some may be given in the form of enema or clyster, and three or four grains of camphor may be taken in the yolk of an egg. Laudanum or decoction of poppies will be useful to subdue convulsions; and leeches to lessen the pain of the belly. Effects when applied to the skin, or to wounds and sores. When acrid vegetable poisons are rubbed upon the skin, or applied to sores or wounds, they not only produce great irri- tation of the parts, but often a spreading inflammation, some- APPENDIX. 555 times affecting the stomach and bowels, as in the case of cro- ton oil, in the same way as when swallowed. WHAT TO DO. With the exception of exciting vomiting, the treatment must be similar to what has been directed, when the poison has been swallowed. II. Stupefying, or Narcotic Poisons. This division comprehends certain plants, such as poppy, henbane, bitter sweet, poison lettuce, yew leaves, bay, cher- ry laurel, and vegetable productions, such as opium and prus- sic acid. General Effects.—-These poisons in general act with great rapidity; producing stupor, drowsiness, palsy, apoplexy, con- vulsions, and death. Mistakes of poisoning, for natural diseases they may resem- ble, may be avoided, by considering, that a fit of apoplexy or ' epilepsy, usually gives warning, for some days, by headache, giddiness, &c, and comes on abruptly; while narcotic poison comes on gradually. There is, in inflammation of the brain, usually fever; in narcotic poisoning, none.—Christison. POISONING BY PRUSSIC ACID. The prussic acid, termed by chemists hydrocyanic acid, is contained in cherry-laurel, cherry-laurel water and oil, in the peach, in the bird cherry, or hagberry, in the sloe, in the bul- lace, in the common cherry, in the bitter almond, in the moun- tain ash or rown tree, and in the kernels of most stone fruit. It is the prussic acid which gives to these, and to sherry wine, the agreeable bitter nutty flavor. The strong acid is rarely made. Effects when swallowed, or applied externally.—-This is the most powerful and rapid poison known, as one or two drops put into the eye, or on the tongue of the strongest dogs, will kill them in one or two minutes. When a person swal- lows a quantity not sufficient to prove instantly fatal, it pro- 556 APPENDIX. duces weight and pain in the head, particularly in the back part of the head, rapid pulse, nausea, and sometimes saliva- tion. In a large dose, death is preceded by convulsions, re- sembling lockjaw. In cases instantly fatal, the patient dies almost as if shot.—Apjohn. , WHAT TO DO. Counter Poison, or Antidoes.—Solution of chlorine or of ammonia smelling salts, or hartshorn, should be applied, by a feather, to the nostrils, or by holding the head over a ves- sel containing the chlorine, diluted with about twelve wa- ters, to prevent inflammation from the vapor. Other Treatment.—Cold water should be dashed over the patient to rouse him, and repeated every fifteen minutes. Herbert. Brandy and water may be also given to support the sinking powers.—A. B. Granville. POISONING BY OPIUM AND LAUDANUM. The disguised preparations of opium, often given to in- fants, such as American Soothing Syrup, Daffy's Elixir, Dalby's Carminative, Godbold's Balsam, Hive Water, Bate- man's Drops, &c, poison many fine babies—a practice well exposed by Boz, in his Oliver Twist, and by the Dispatch newspaper. Effects when swallowed.—The first effects of a poisonous dose of opium or laudanum are, in from a few minutes to several hours, stupor without previous excitement, giddiness, numbness, heaviness of the head, inclination to sleep at first slight, and afterwards irresistible, followed by intoxication, a stupid lf>ok, and furious or merry delirium. Sometimes pain and convulsions more or less severe, palsy of the legs, and death. In cases of recovery, the patient may sleep for twenty-four or thirty-six hours, and awaken with nausea and vomiting. WHAT TO DO. The stomach pump, if at hand, must be instantly had re- course to do; and, if not, tickling the throat with a feather. APPENDIX. 557 or the finger may be tried. Emetics dissolved in a small quantity of water, may also be tried; such as twenty-four grains of sulphate of zinc, or three or four grains of sulphate of copper, or one grain of tartar emetic, repeated, if necessa- ry; but the stomach is so often torpid, that vomiting cannot be produced; in such cases, dashing cold water over the head, sometimes rouses the patient and brings on vomiting. Grater. The patient should also be dragged up and down, between two men, or shaken and driven with speed over rough roads, in a cart. Apjohn. Pulling the hair, so as to give pain, and ejecting water into the ears, are also recom- mended.—Christison. No vinegar, lemonade, cream of tartar, coffee, nor other liquids, should be given, till the poison is removed from the stomach, when they maybe of advantage. POISONING BY HENBANE, OR HYOSCYAMUS. Effects when swallowed.—This poison produces giddiness, loss of speech, trembling, intoxication, violent delirium, leth- argic sleep, and death. WHAT TO DO. The treatment must be similar to that just recommended in poisoning by opium. HI. Narcotico-Acrid Poisons. Under this division are arranged poisons possessing a com- bination of the properties of the first two divisions ; among which are certain plants, such as deadly nightshade, hemlock, tobacco, and virulent mushrooms ; and certain vegetable pro- ductions, such as camphor, ardent spirits, strychnia, and spurred rye or ergot. POISONING BY DELETERIOUS MUSHROOMS. Mushrooms may be suspected, when they grow in moist shady places, have many or gaudy colors, are moist, dirty, or bitten on the surface, and have soft stems. 558 APPENDIX. Effects when swallowed.—When poisoned ketchup, or stewed deleterious mushrooms, have been taken, in from five to twelve hours or more, nausea, heat, and severe pain of the stomach, and often vomiting and purging, are produced, with insatiable thirst, convulsions, fainting, delirium, stupor, cold sweats, and death. WHAT TO DO. Use the stomach pump, and give emetics, the same as di- rected under poisoning by opium. When inflammation of the stomach and bowels comes on, leeches should be applied, and the bowels cleared by brisk purgatives, such as an ounce of Glauber's salts, given in three doses, at twenty minutes interval. POISONING BY NUX VOMICA. Effects when swallowed, or applied to wounds.—The usual effect of these poisons is upon the brain and spinal marrow, causing convulsive stiffness, with the head drawn back upon the shoulders, and the breathing very irregular, often almost stopped, when death, without inflammation, speedily ensues. Intervals of intermission sometimes take place, but the symp- toms soon return with increased violence. Strychnia, next to prussic acid, is the most frightful poison known; the sixth part of a grain killed a dog in two minutes ; and one-third of a grain killed a wild boar in ten minutes.—Christison. Brucia is twenty-four times less powerful.—Andral. WHAT TO DO. It is of the greatest moment to remove the poison from the stomach by the stomach pump, or by tickling the throat with a feather or the finger; or an emetic, of 24 grains of sulphate of zinc, should be given. Iodine or chlorine, are newly-reported counter poisons, but a delay of ten minutes in giving them, renders them of no avail.—Donne. When breathing stops, air must be blown into the lungs, as recom- mended below, in cases of drowning; and a spoonful should be given every ten minutes, of a mixture composed of a APPENDIX. 559 drachm of ether, two drachms of spirits of turpentine, half an ounce of sugar, and two ounces of water. POISONING BY NIGHTSHADE, HEMLOCK, &c. Tobacco, Thorn Apple or Jamestown Weed, Foxglove, Digitaline, &c. Effects when swallowed, or applied to a wound.—The usual effects are great agitation, pain, piercing cries, convul- sive movements of the face and limbs ; delirium, more or less merry; retchings, obstinate vomiting and purging, pains in the belly, more or less severe; a sort of intoxication, with trembling, great depression, sinking of the pulse, and death. WHAT TO DO. Similar treatment will be advisable with that directed un- der opium, particularly an emetic will be indispensable, fol- lowed by a brisk purgative of Glauber's salts. Should there be much stupor, blood should be taken from the arm, or from the jugular vein; and a dozen leeches should be applied to the belly, with fomentations and draughts of linseed tea, or other bland fluids. [After blood-letting, the vapor bath.— S. K. /.] DANGEROUS INTOXICATION, OR POISONING BY INTOXICA- TING LIQUORS. The alcohol, or spirit of wine, contained in wine, ale, beer, cider, or other fermented liquors, when taken in too great quantity, is a true poison. Effects.—The chief symptoms produced by this sort of poisons, are violent excitement, flushing of the face, giddi- ness and delirium, soon followed by dozing and dangerous sleep, from which the patient only awakens to die. In more severe cases, the face becomes livid, or ghastly pale, with stertorous breathing, and speedy death.—Christison. When the pupil of the eye is dilated and motionless, recovery is rare.__Bedingfield. Cold extremities and clammy sweat, often accompany the lethargic sleep. 560 APPENDIX. WHAT TO DO. The stomach pump is, in dangerous cases of intoxication, invaluable, if soon enough procured; and if not, tickling the throat; or a smart emetic should be given, and vomiting promoted by warm water, mixed with vinegar or lemon juice. The whole body should be rubbed with cloths dipped in warm vinegar; and the torpor should be subdued by leeches to the neck. IV. Putrefying, or Septic Poisons. The poisons, in this division, are those derived from ani- mals, living or dead, such as poisonous serpents and insects, mad dogs, diseased fish, rancid bacon or beef, and the like. POISONING BY MUSSELS AND OTHER FISH. The fish that have produced the effects of poisoning, the causes of which are quite unknown, are the mussel, the oys- ter, the crab, the herring, the trout, the mackerel, the salmon, and the eel. Similar effects have occurred from eating dis- eased beef, rancid, or rusty bacon, &c. Effects.—In a few hours, and sometimes not for nearly a day, after eating the fish or meat, the patient is seized with irregular chills, acute pain in the stomach and head; rest- lessness, great thirst, redness and swelling of the face and eyelids, distressing itching, and red or puffy blotches all over the body, like severe nettle-rash, convulsions, and sometimes death, in from three hours to three days.—Apjohn. WHAT TO DO. If the symptoms appear within an hour or so, an emetic should be given ; if longer time has elapsed, a brisk purga- tive of Glauber's salts, and strong lemonade should be drank. POISONOUS BITES OF SERPENTS AND INSECTS. The only venomous serpents in this country are the adder or viper, moccoson and rattlesnake—the snake, slow worm, APPENDIX. 561 and toad being harmless ; our chief venomous insects are the bee, wasp, and hornet. Effects.—In the part wounded, a sharp tingling pain, is felt, which soon extends all around, with swelling, at first reddish and afterwards livid. In slight cases, this produces little constitutional derangement; in delicate children and females, and in severe cases, there are fever, sickness, nau- sea, vomiting, convulsions, and, sometimes, jaundice, diffi- cult breathing, loss of sight, cold sweats, mortification of the wounded part, and death, sometimes lingering for several months, or even for years, with symptoms resembling con- sumption of the lungs. WHAT TO DO. If a cupping glass be at hand, it should be instantly ap- plied over the part, or it may be safely sucked by the mouth. and as much blood drawn as possible, to wash out the poi- son. If this be not done within a few minutes, the part should be burned with aquafortis, caustic potass, or a red hot iron, and afterwards covered with surgeon's lint, dipped in equal parts of sweet oil and hartshorn. A moderately tight bandage above (not over) the wound will tend to prevent the poison getting into the blood. It is important to encourage perspiration, by giving six or eight drops of ammonia, or hartshorn, in a glass of chamomile water, and by covering up the patient in a warm bed, and applying the bath. In slight stings of insects, salt water, or hartshorn and oil, may be applied, after the sting has been extracted by a needle. [For snake or spider bite, bleed and bathe, and if the pain continue, repeat the bath.—S. K. J.] HYDROPHOBIA FROM BITES OF MAD ANIMALS. Dogs are the most common causes of this frightful disease ; but it also may be caused by cats, pigs, or any other infected animal, chiefly in very hot or in very cold weather. Effects—From the twentieth to the thirtieth, or fortieth 36 562 APPENDIX. day, sometimes even three or four months after the bite, the patient is seized with pain in the part, even if the wound be healed, with uneasy anxiety, languor, cramps, horror, dis- turbed sleep, and oppressed breathing. These symptoms rapidly increase with violent convulsions, hideous distortions of the face, swelling of the tongue, with clammy, virulent saliva, horror of fluids, (but not always,) with impossibility of drinking ; bilious vomiting and death. WHAT TO DO. As hydrophobia, when it once forms, is altogether incura- ble, every means of prevention should be tried. The bitten part should be immediately and fearlessly cut out to some extent, and cupping glasses instantly applied over the parts, to extract all the poison, if possible ; making still more sure, by bathing, with warm water, as long as blood will flow into the glasses. After this, a red hot iron, or any caustic, should be applied to the wound, and the whole covered with a car- rot poultice, and suffered to heal. Perspiration should be promoted by hot drink, and a warm bed. [Use the vapor bath—aS*. K. J.] Dogs, cattle, and other animals, when bitten, should have the bitten part treated in the same way. t ACCIDENTS. APPARENT DEATH, SUSPENDED ANIMATION, OR ASPHYXIA. This class of accidents, from frequent occurrence, is ren- dered of little less importance than poisoning. APPARENT DEATH FROM CHARCOAL VAPOR AND CAR- BONIC ACID GAS. This may occur in close rooms where charcoal or coke is burning ; near lime kilns, from the reek ; in coal pits, wells, and morasses, but most commonly in breweries and similar places, where much carbonic acid is produced by fermenting liquors; and in very crowded rooms, from the breath of the people. It gives no warning, from being devoid of smell, and the air can only be tested by a candle, which will not burn in carbonic acid gas. Effects when breathed.—The first observed effects, are slight giddiness, and inclination to sleep; but in severer cases, there is a sense of weight in the head, and soon, ster- torous breathing and death-like sleep.—Sir H. Davy. The person becomes, at length, motionless, with the limbs some- times stiff and distorted; at other times, easily bent. The heat of the body remains natural. What to do.—The first thing to be done, is to remove the person to the open air, and however cold the weather may be, to take off the clothes, laying him on his back, with 564 APPENDIX. his head propped high. It is dangerous to fumigate with tobacco, or to place him in a warm bed. Cold water, or what is better, vinegar and water, dashed over the body, and towels, dipped in this, should be rubbed upon the face and chest, wiping dry the wetted parts in three or four minutes with hot towels; and repeating these processes more than once. If the patient can swallow, cold lemonade, or vinegar and water, should be given; hartshorn, or smelling salts, or sulphur matches, should be lighted and passed under the nostrils, which might also be irritated with a feather. Rub- bing the back, the soles of the feet, and palms of the hands, roughly with a brush, is also good. Blood, if it will flow, should be taken from the arm, from the jugular vein, or by cupping from the neck.—Apjohn. But by far the most im- portant remedy, is to keep up artificial breathing, by blowing into the lungs with a pair of common bellows; with the mouth; or, what is better, with the double bellows, contin- uing this for five or six hours, even where there are no signs of life. When the patient is once roused, he should be placed in a warm bed with the windows open; and may have a glass of good wine, or brandy, and he must be care- fully watched, lest he relapse. APPARENT DEATH FROM HYDROGEN GAS. Sulphuretted hydrogen gas is generated in common sew- ers, water closets, necessaries, foul pools and some mineral springs; and it is the cause of a disgusting smell. Carbu- retted hydrogen gas, or coal gas, is the well known gas used for lighting our streets, but is not so deleterious as the former. Effects when breathed.—In slight cases, there are uneasi- ness, inclination to vomit, convulsive motions in the muscles of the joints and chest, cool skin, and irregular, but free breathing. In more serious cases, there is a loss of sense and consciousness: the body is cold; the lips and face, livid; a bloody froth comes from the mouth; the breathing is APPENDIX. 565 short, oppressed, and convulsive ; and the limbs are relaxed. In still more dangerous cases, the body is bent backwards, and the patient bellows somewhat like a bull; the heart pal- pitating irregularly and tumultuously. What to do.—In the first instance, expose the patient to the open air, dash cold vinegar and water over him, and rub the body as directed in cases, of charcoal vapor. Then if chlorine can be had, it is important to pass the bottle con- taining it, cautiously under the nose. Bleed from the arm, or the jugular vein ; and this repeated, if necessary, will tend to allay the palpitation of the heart; and the cold bath will be useful for cramps or convulsions, rubbing dry after it, and putting the patient in a warm bed. If there be no signs of life, mustard poultices, or boiling water, in bladders, may be applied to the soles of the feet, in order to produce immediate blisters. APPARENT DEATH FROM DROWNING. Effects.—When a person has been under water for about twenty minutes, more or less, there is little chance of recov- ery, though means should always be tried. The warmth of the body, and the clearness and motion of the pupils of the eyes, are the surest signs of life not being extinct, of which the stiffness of the body is chiefly to be relied on, as a sign of death. • What should not be done.—As it is not the water get- ting into the lungs, according to vulgar opinion, that causes death, but the want of air and stoppage of breathing, a drowned person ought not to be hung up by the feet to let out the water, little or none being swallowed. ' Violent sha- king, or rolling on casks, to rouse the patient, will also be dangerous; as it also is to give tobacco, or the smoke of to- bacco, in form of enema or injection. The body must not be rubbed with salt nor spirits. What to do.—With the least possible delay, even when the patient is received into a boat (Portal)—he should, with- 566 APPENDIX. out jolting, be laid on his right side, on a plank or mattrass, with his head uncovered and a little raised; the wet clothes must be quickly removed by cutting them open, the water let out from the mouth by opening the jaws; the body rub- bed dry; and then covered immediately with the spare clothes of the bystanders, till warm blankets be got ready, in which the patient is to be wrapped. It is important that the body be warmed very gradually, and the best thing for this purpose is a warm bath, about as hot as the hands can easily bear ; but in default of this, fill bladders with warm water, or heat bricks, and apply to the pit of the stomach, to the arm-pits, between the thighs, and to the soles of the feet, and the palms of the hands. Then pass backwards and forwards upon the skin, particularly along the back, a covered warming pan, a heated smoothing iron, or a bag filled with hot ashes. The skin ought also to be briskly rubbed all over, with the hand, or with a dry brush, or hot flannel, continuing the other means, just re- commended, at the same time. [Use our bath.—&. K. J.] It will tend to rouse the patient, to apply cautiously under the nostrils, lighted brimstone matches, smelling salts, or hartshorn, or to tickle the nose with a feather. In order to restore breathing, introduce the pipe of a common bellows (when a special apparatus is not at hand) into one nostril, carefully closing the other and the mouth. At the same time, draw downwards, and push gently backwards, the up- per part of the windpipe, popularly termed Adam's apple, to allow a more free admission of air : blow the bellows gently so as to inflate the lungs, till the breast be perceptibly raised a little. The stopping of the other nostril and the mouth, should then be discontinued, and the breast be pressed with the hand, repeating this so as to imitate the process of brea- thing, till life appears.—Humane Society's Directions. If the patient still remain insensible, small bits of cork, or paper, or of German tinder, should be burned on the pit of APPENDIX. 567 the stomach, on the thighs, and on the arms. If the limbs be warm and easily bent, but the face livid or black, blood may be taken from the jugular vein, or from the foot; but this need not be done when the skin is cold, and the limbs stiff. When there are signs of recovery, inject into the stomach, by means of an elastic tube and syringe, half a pint of warm wine and water, or good spirits and water; and when the patient can swallow, a spoonful of wine or cologne water, diluted with two waters, or a teaspoonful of camphorated spirit, may be given every five or ten minutes, and he must be forced to drink so long as there remains difficulty of swal- lowing. It is important to continue the means for four, five, or more hours; even eight or ten hours are very often not suffi- cient to establish recovery. APPARENT DEATH FROM STRANGLING OR HANGING. Effects.—From the return of the venous blood being stop- ped by the rope, &c. round the neck, the face is rendered black, the eyeballs stand out from their sockets, and the nos- trils are wider than in natural death. What to do.—After the rope, &c. has been removed, the taking of blood from the jugular vein is advisable, as well as all the other means directed under Drowning, except artifi- cially warming the body, which will, in most cases, be unne- cessary. The bellows may be considered the most important agent. CHOKING FROM ANY SUBSTANCE IN THE WINDPIPE. Every morsel that is swallowed, slides slowly over the top of the windpipe; but is prevented from getting into it, by a sort of moveable lid, or valve, called the epiglottis, which the passing morsel shuts down. But if a breath be drawn dur- ing the act of swallowing, this lid is raised, and part of the morsel, or of the drink, may thus get under the lid. 568 APPENDIX. CHOKING FROM ANY SUBSTANCE IN THE GULLET. If a splinter of bone, a pin, or the like, be accidentally swallowed, and stick in the gullet, it will produce great un- easiness to the sufferer, though it may not be dangerous. What to do.—A plentiful draught of water, or twirling round a large goose or swan quill, will sometimes dislodge the substance, and make it fall down into the stomach, whence it may be brought up by vomiting. Even after its removal, a roughness or soreness remains, which makes the sufferer think it is still there. When the substance is large and not far down, it may be extracted with a pair of forceps; if it be too far down for that, it may be pushed into the sto- mach with a thin piece of whalebone, with a piece of sponge attached to the end of it, called a probang.—Mac Fayden. APPARENT DEATH FROM A STROKE OF LIGHTNING. The effects of lightning on the body are, general paleness of the surface, the limbs remaining warm and easily bent, long after life is extinct. What to do.—The only probable means of restoration, are galvanism or electricity, with the use of the bellows, and wine, as directed under Drowning. APPARENT DEATH FROM TOO GREAT HEAT. When a person becomes insensible, from being in* too hot a place, he ought, without loss of time, to be removed into the fresh air, to be undressed, or, if very cold, his clothes loosened; to have an enema, or injection of salt and water, with six to twelve leeches on the temples, and if he can swallow, a little vinegar and water, or lemonade, should be given. In other things, proceed as directed for Charcoal Vapor. APPARENT DEATH FROM TOO GREAT COLD. Effects.—Exposure to intense cold produces a general numbness, a sort of intoxication, irresistible and rather pleas- ing inclination to sleep, which soon comes on, with loss of APPENDIX. 569 consciousness and insensibility, and from which the patient rarely awakens. What to do.—The body should, on finding it, be wrapped in a blanket, leaving the head uncovered, till conveyed to a house, when the clothes must be taken off, and the skin rub- bed with snow, pounded ice, or cold water, rubbing from the body towards the extremities ; to be succeeded by rubbing with cloths dipped in milk-warm water, it being important to restore warmth, not suddenly, but very gradually. When no snow nor ice is at hand, a cold bath ; very gradually heated, may be advisable. When the skin begins to feel warm, the sufferer may be put into a cold bed, and the bellows and other means used as under Drowning. FROST BITE, AND FROZEN LIMBS. Effects.—When the extremities, or any part of the body, is exposed to intense cold, the circulation of the blood, and the feelings of the nerves are destroyed, by the parts freezing. What to do.—If the frozen part is suddenly thawed by heat, speedy mortification comes on; therefore, the best thing to do, is to restore warmth very slowly, by rubbing the part with snow, or ice water; and at first, to give no heating or stimulant liquors internally; lying on a cold bed is good. APPARENT DEATH IN NEW-BORN INFANTS. In the absence of medical attendance, if the skin be pale and bloodless, the navel string must, on no account, be cut, nor twisted, nor dragged ; but the head should be raised, and the face exposed to the air, while the body is to be wrapped in flannel, and the back and the soles of the feet rubbed with a soft hand. Artificial breathing through a quill, or any small tube, should be tried, as directed under Drowning. On the other hand, if the face be livid,.or black and swelled, the skin discolored, and the chest as if filled with blood, cut the navel string instantly, and encourage it to 570 APPENDIX. bleed, by holding up the head and rubbing the chest and belly with warm cloths. Should little or no blood flow, ap- ply one or two leeches behind the ears, and put the sufferer in a warm bath, with which some wine, brandy, or vinegar, may be mixed; and use the quill for artificial breathing as just directed. INSECTS, SAND, AND OTHER SUBSTANCES IN THE EYES. If a grain of sand, an insect, or any small substance, get into the eye, it will produce irritation and inflammation, and may either cause dimness, or entire loss of sight. A\ hat to do.—When the substance lies loosely on the surface of the eye, it may be easily removed by means of a camel hair pencil dipt in oil; or, what is, for the most part, more easily procured, a bit of paper rolled into the size of a quill, and softened in the mouth. When the substance is fixed in the coats of the eye, an accident frequent among blacksmiths, and termed by them, fire in the eye, it may be removed by the thumb-nail, by the tongue, or by a blunt pointed piece of wood. If none of these are successful, application must be made to a surgeon. INSECTS, AND OTHER SUBSTANCES IN THE EAR. The opening into the outer ear, as far as the drum, is on- ly about half an inch, and is defended by a sort of down, as well as by a kind of soft wax. Among boys at school, bits of slate pencil, peas, and other things, sometimes get into the ear, and occasion much uneasiness. Bed bugs and other in- sects, also creep occasionally into the ear. What to do.—Peas, and such small substances, must be extracted by means of a pair of forceps. Insects may be kill- ed, by dropping in any sort of oil, such as oil of almonds, or sweet oil. ACCIDENTAL BURNING OR SCALDING. Bums or scalds may either be trifling or serious, and even dangerous, according to their extent, or to the constitution of the patient. Young children, or infants, seldom recover APPENDIX. 571 from such accidents, when of much extent, for their skin is so tender, that a common medical blister heals with difficul- ty, if at all. Burns or Scalds of small extent.—The danger lies chiefly in the extent of the portion of the skin injured ; for a deep burn of small extent, may not be dangerous; while a super- ficial scald, of considerable extent, may prove fatal.—S. Cooper. What to do.—The part injured should be plunged, or bathed in pounded ice, or very cold water, mixed with some quick-lime, or sugar of lead, renewing it as soon as it be- comes warm, and continuing the application till the pain is subdued, when it may be wrapped up in bandages, dipt in lime water, or sugar of lead water.—Sir J. Earle. The blisters, if any, should not be broken for two or three days, lest the pain should be increased, nor delayed longer, lest ul- cers might form; at that time, they may be opened with a needle, to let out their serous fluid or water, and dressed with cerate, spread on linen, keeping down inflammation by bath- ing with sugar of lead water, and if that be not effectual, apply a linseed or other poultice. When the pain is distress- ing, so that the weight of the dressing is insupportable, the part should be annointed by a camel-hair pencil, with Carron oil, made with equal parts of linseed, or sweet oil, and of lime water, shaken together. The patient should be kept on low diet, and have a brisk dose of salts and senna. When ulcers form, they should be dressed with creasote ointment, to pre- vent scars. DEEP BURNS. When the burn is deep, the surface will appear to be scorched, as if charred, with more or less inflammation a- round it. What to do.—The best application, in this case, will be a linseed, or other poultice, smeared with camphorated oil, if it can be borne; and if not, it should be dressed with ce- 572 APPENDIX rate, till the charred portion comes off, when it must be dress- ed, twice a day, with surgeon's lint, on which is spread some crease ointment. This will tend to prevent a scar. Oily salves are improper. EXTENSIVE BURNS, OR SCALDS. If a burn or scald, though not deep, be spread over a con- siderable surface of the body, the accident is dangerous, and may become fatal. The accompanying pains are excruciat- ing, and the consequent fever and inflammation usually run high. What to do.—The application of cold, which answers in non-extensive cases, is apt to cause shivering, to hasten fe- verishness ; and though it ease the pain for a time, this soon returns with increased severity. Instead of cold applications therefore, repeatedly bathe the injured parts with linen cloths, dipt in warm spirit of turpentine, or spirit of wine, whether the skin be blistered or not, and afterwards dress with a cerate, made with one part of oil of turpentine, and two parts of basilicon ointment, spread on linen. The smarting pain caused by this, at first goes off in an hour or two, and much ease is felt. This dressing must be renewed in twen- ty-four hours, by small portions at a time, to prevent expos- ing the sore to the air, while all blisters may be opened with a needle. The parts should be bathed with common spirits, with vinegar, or with laudanum slightly warmed, and dress- ed with Turner's cerate, or sugar of lead ointment.-Ke?itish. If there be much inflammation, a warm linseed poultice will be advisable, to remain on for six or eight hours, and if the surface be raw, it may be entirely covered with finely pow- dered chalk, in order to absorb all moisture, and the poultice may be applied over this.—Cleg horn. RUFFLED SKIN, OR ABRASION. When the thin, insensible scarf skin is accidentally des- troyed, the inner and thicker skin, which is very sensible, APPENDIX. 573 on exposure to air, is irritated, and rendered painful by the oxygen in the air acting on the fine tips of the nerves. What to do.—All sand and dirt should first be removed from the injured part, by means of warm water, and linen dipt in spirits and water, should be applied, till the pain is somewhat subdued. The parts ought then to be defended # from the air, by a piece of dry surgeon's lint, or caddice, and a poultice should be laid over it, if there be much inflamma- tion, or swelling. If a sore of any size should form, it may be dressed with creasote ointment, to prevent a scar. CHAFED SKIN, OR EXCORIATION. If the skin be galled by riding, or, in infancy, by inatten- tion to cleanliness, it ought to be bathed with warm milk and water, to clean it; and afterwards with cold water, to wash off the milk and remove inflammation. Fine Fuller's earth, moistened with water, or spermaceti ointment, is good for an- ointing the parts. If there be much pain, a bread and water poultice may be advantageous.—Hamilton. Dust the part with lapis calaminaris.—*S*. K. J. CUTS AND WOUNDS. The danger of cuts or wounds may be partly inferred from the parts injured; wounds in the belly, for example, being more dangerous than in the limbs ; and an inference may al- be drawn from the bleeding. When a large vein has been cut, the blood will come away of a dark color, and a contin- ued stream ; when a large artery is cut, the blood will come in pulse-like jets, and of a bright crimson color. What to do.—In slight cases, let the bleeding continue for an hour, if it do not stop sooner, taking care to remove all dirt, or other matter, that may have got into the wound. When the bleeding ceases, bring the edges of the wound neatly together, and keep them so with slips of heated stick- ing plaster, and do not remove this for two or three days, when it will usually be found healed. If it inflame, it must be poulticed. In slight cases, salves are now disused by all 574 APPENDIX. good surgeons, as worse than useless. In severe and alarm- ing cases, little can be done without a surgeon; but when dark venous blood flows, strong pressure a little below the part will tend to stop it; and when bright arterial blood jets out, similar strong pressure a little above may do good; cov- ering the part with cloths will only conceal the danger. Cold water, or turpentine, or Friar's balsam, may tend to stop the bleeding, perhaps; but not when large vessels have been cut. A strong silk handkerchief, twisted tight on the limb, below or above the injured part, according as the blood is dark or bright, may often be advisable.—MacFayden. When the bleeding has been stopt, the edges of the wound are to be brought together, and treated just as directed for slight cases, using bandages when the sticking plaster is not strong enough. If it becomes inflamed use dry heat—a shovel of coals. BRUISES. In all bruises, the nerves are affected, causing a sort of stunning pain. Swelling and discoloration are caused by blood vessels, small or great, being burst, and the blood be- ing effused around, particularly when the bones are near the surface, as on the shins and the head. Inflammation of the injured parts generally follows in an hour or more. What to do.—In slight cases, bathe the parts with vine- gar and water, or spirits and water. In severe cases, particu- larly near the joints, it is important to prevent inflammation, which might lead to white swelling, &c. For this purpose a dozen or more leeches should be applied. Then use dry heat—bleed and use heat intensely.—S. K. J. SPRAINS. When the ligaments of the ancle, of the wrist, or of other parts, are twisted, or over-stretched, there are produced weak- ness, and more or less pain, which increases with the conse- quent inflammation. The parts swell and become tense, red, and warmer than natural. If neglected, or if the sufferer is APPENDIX. 575 of a particular constitution, sprains may end in white swel- ling, or incurable lameness. What to do.—The sooner the better, bathe the part with three parts of cold water, mixed with one part of laudanum, and one part of any common spirits; and bind up the limb with a moderately tight bandage, and laying it horizontally, in a state of absolute rest. If inflammation do come on, bleed and apply dry heat with a shovel of burning coals.—S. K. J. Those who know how difficult it is to get rid of even trifling sprains, will not think this too severe treatment. BONES BROKEN OR FRACTURED. When a limb has been broken, there is not only a loss of motion, as when out of joint, but more or less distortion and swelling, while the broken ends of the bones may, by hand- ling, be made to produce a grating sound. The best advice, in this case, is to get a surgeon as soon as possible, or remove the sufferer, on a board, to an hospital. If neither can be done, the injured limb must not, on moving, be allowed to hang down. The limb is set by bringing the broken ends of the bones together, and keeping them in their place with splints and bandages. If they be displaced, the limb will heal in a distorted form. The bones generally unite in from thirty to forty days, and sooner in the young than in the old. When inflammation occurs, it must be treat- ed as directed under Sprains. LIMBS OUT OF JOINT, OR DISLOCATED. When the head of a bone is dislodged from its socket, the form of the joint is changed, the limb cannot be moved, and it is rendered sometimes longer, and sometimes shorter. What to do.—Delay here is productive of the worst con- sequences ; for, at first, it is comparatively easy, though after a while, sometimes impossible, to replace the bone. Great force is often necessary to draw the limb out far enough to 576 APPENDIX. get the head of the bone over the edge of the socket, but it can rarely be done without surgical aid. A FAINTING FIT, OR SYNCOPE. In consequence of exhaustion from fatigue, long fasting, violent passion, severe pain, wind in the stomach, and the like, the patient grows deadly pale, and is deprived of sen- sibility, the eyes become dim, the hearing is gone, the pulse stops, breathing is imperfect, and the voice is lost. The fit seldom lasts beyond a few minutes, but leaves the patient languid or sick. What to do.—The coming on of a fainting fit may be sometimes prevented by drinking a glass of cold water, or wine. When it takes place, throw open the windows, sprin- kle cold water on the face, and cautiously hold smelling salts, or a lighted brimstone match, under the nostrils. On reviv- ing, a glass of water or wine will be advantageous. CONVULSIVE FITS. Infants and children are very subject to convulsive fits, from teething or disordered bowels, and sometimes from wa- ter in the head, hooping cough, &c. When dangerous, the body is often bent back, the features distorted, and the eye fixed or rolling. A fit may continue from a few minutes to several hours. What to do.—As the fit may end in death, the child should, without delay, be put into a warm or cold bath, till it go off, and cold water should be sprinkled on the face. When the fit continues long, apply two or three leeches to the temples, and give a laxative enema, or injection. [We say let it be bled.—£. K. J.] HYSTERIC FITS. Before the fit oomes on, there is a feeling as if a ball were rising in the throat, threatening suffocation, and the sufferer soon falls down, the body being twisted, the hands clenched, while the person rolls about, screaming, crying, or laughing APPENDIX. 577 involuntarily. As the fit goes off, the patient remains for a time stupid, and half insensible. What to do.—The fit may sometimes be prevented by taking twenty or thirty drops of laudanum, and as many of ether, in a glass of water. Open the windows, and loosen the tight parts of the dress ; sprinkle cold water on the face. If the patient be of a full habit, let blood. A FIT OF APOPLEXY. Apoplexy is caused by too much blood pressing on the brain. Sometimes the person falls down suddenly; at other times, there is previously violent head-acke, high fever, and delirium. What to do.—In this case it will be dangerous to apply lighted brimstone matches, or smelling salts to the nostrils ; or to introduce wine or other strong liquor into the stomach. as directed for Fainting or Hysterics. The patient should be placed in an upright posture, supporting his head to pre- vent any bend in the neck, while the neckcloth must be re- moved, and the shirt collar unbuttoned. Bleeding is often important, but must depend on medical advice. FITS OF FALLING SICKNESS, OR EPILEPSY. This more resembles a fit of hysterics, and is often brought on by drinking, by violent passions, &c. An attempt to feign epileptic fits, may readily be detected by feeling the pulse, which is suspended or very irregular in genuine epi- lepsy; in which also there is frothing at the mouth, imitated, however, by means of soap. What to do.—Raise his head, and put a piece of soft wood or cork of suitable size, if possible, between the teeth, to prevent his biting his tongue. Then proceed as for Hys- terics. 37 MEDICAL PRESCRIPTIONS. CATHARTIC, OR ANTI-BILIOUS PILLS. Take aloes, (socotrine,) dr. i. powdered jalap. dr. i. calomel, dr. i. castile soap, dr. i. gambouge, gr. xv. Scrape or powder the soap very finely; add half a small tea- spoonfull of water, mix the mass well. The whole will make sixty pills. As each pill will contain one grain of calomel, the dose may vary from one to six, as the occasion may require. ANOTHER FORM OF ANTI-BILIOUS PILLS. Gambouge, gr. xx. Calomel, dr. i. Compound extract of Colocynth, dr. i. Powdered jalap, dr. i. Castile soap, dr. i. Prepared as the Cathartic Pill. Dose the same. THE MINIMA PILL. Take Calomel, gr. v. | Ipecacuanha, gr. v. Crumb of corn or wheat bread, size of a large pea. Work them well together, and the mass will make 25 pills. One is the dose, to be repeated once, twice, or three times a day. If continued too long, may produce a sore mouth. COMPOUND BLUE PILL. castile soap, dr. i. Take blue mass, dr. i. rheubarb, powdered, dr. i. aloes, powdered, dr. i. ipecacuanha, gr. xv. water, about forty drops, or q. s. Work the materials well together; the mass will make sixty pills ; the dose, one, two, three, or four. They will be gent- ly aperient. ANODINE ALTERATIVE PILL. Tale calomel, gr. vi.; ipecacuanha, gr. vi.; Opium, gr. iv.—make 25 pills. ANTI-BILIOUS PILLS Made of calomel and ipecacuanha, one grain of each to a pill, APPENDIX. 579 and repeated every third hour, will operate very gently. If made of three or five grains each, and repeated in the same manner, they operate with sufficient effect for the first day or two in a case of fever, on its first attack. This for an adult patient. Similar pills of half grains of calomel and ipecacu- anha, will be suitable for children of two, three, or four years old. The same articles in doses of a fourth of a grain each, will suit children six months old, and in doses of one-third of a grain each, will suit for children one to two years old. PILLS FOR EPILEPTIC FITS. Take of the powdered leaves of stramonium, which is the thorn-apple of the North, and the Jamestown weed of the South. It ought to be gathered in the last week of August, and dried in the shade. Of the powdered leaves of this herb, take one dram, work it up with molasses and make it into thirty pills, of which give three or four per day. When his pulse is tense near the time of an expected return of the fit, let him be bled, about mid-day; and as often as his pulse is tense about that time, repeat the blood-letting. Let his bow- els be regulated by using the cathartic pills. PILLS TO BE USED IN A CASE OF ABORTION. Take calomel, gr. x. Opium, gr. vi. Make three pills. If there be much fever, with or without a pain in the head, let the patient be bled one pint, or one pint and a half, according to her strength; then give one pill every sixth hour, till she is easy, or drops the foetus or ovum. In the meantime, use the bath. FOR A SOUR STOMACH IN GESTATION. Take supercarbouate of soda, dr. i.; Rhubarb, gr. xxx.; Oil Cloves, drops iii. Give one-sixth of the preparation, every second hour, in two table spoonsful of sweetened water, until it affords relief. SYRUP OF PHYTOLACCA DECANDRA. Take of the fresh root of phytolaccadecandra, (poke root) dug in August or September, ten pounds, chopped into small pieces, boil it in ten pounds of water, till quite soft, then 580 APPENDIX strain and squeeze the root, so as to obtain the whole of its virtues. Let it stand till the sediment shall be fairly precip- itated. Carefully decant and measure the decoction. Then put it on the fire and evaporate, till it is reduced to five quarts. At this stage, add ten pounds of brown sugar, and keep it on a slow fire, till reduced again to five quarts, when it will be fit for use. Of this syrup, a large teaspoonful is the dose, to be repeated three or four times a day. It will be important, in treating scrofulous ulcers, scrofu- lous tumors, secondary syphilis, mercurial diseases, heredi- tary syphilitic taint as it exists when it befalls scrofulous sub- jects, especially as this condition of things is exhibited, in that formidable affection, known in some parts of Virginia, by the appellation of the yaws. We often associate with this syrup, the hydriodate of potash. With or without this addi- tion, it is very useful also in cases of chronic rheumatism. N. B. When the root is dug, let it be immediately washed and chopped to pieces. Let it remain one day, and then weigh it. If it remain a day or two before it is boiled, it matters not. But the weight as found the second day, is to guide the preparation. COMPOUND CHALK MIXTURE FOR DIARRHCEA. Loaf Sugar, oz. i. I Pulverized Gum Opium, gr. vi. Prepared Chalk, dr. ii. I Oil of Cloves, drops vi. Pulverized Gum Arabic, dr. ii. | Oil of Pepper, drops xii. Grind the above together; then add tincture of kino, oz. i. ss., and water, oz. vi. ss. Dose, a teaspoonful every hour till the intended effect is produced. Remedy for Thrush.—Take equal parts of sweet oil and lime water, well shaken together. DETERSIVE SOLUTION FOR FISTULOUS ULCERS, WITH OR WITHOUT CARIES. Alcohol, lb. ss. Vinegar, oz. iv. Salt, oz. iv. Corrosive Sublimate, gr. xx. to xxx. Honey, oz. iv. Water, lb. i. This to be used as an injection or wash. APPENDIX. 581 A VERY NEAT BLISTERING OINTMENT. Take tallow, oz. vii. I bees-wax, * oz. iii. hogs lard, oz. ii. | resin, oz. ii. Melt them together, stirring them effectually. Take the pre- paration off the fire, to reduce the temperature a little, then add two ounces and a half of Spanish flies, very finely pow- dered, and stir till the ointment is cold. PLUMBEAN OINTMENT. Take red lead, oz. xx. 1 Linseed oil, two quarts. These are to be put in to an earthen vessel, (which must be a new one every time the ointment is made,) and placed on a slow fire, out of doors, and boiled until it becomes brown, stirring all the time. Useful as a plaster for scattering the swelling of an inflam- ed breast, after child-birth; first letting blood, or giving a gentle cathartic. It may be spread on a thin cotton cloth, of a suitable shape, &c, and removed every six hours for the purpose of using a shovel of hot coals, as advised in any case of pain and swelling. A camphor plaster would answer when this is not at hand. It is also useful for burns and old sores. Let it remain in the crock, and keep it covered with water. ERUGINOUS OINTMENT. Take fresh butter or lard, lb. i. I Bees-wax, oz. ii. Burgundy pitch, oz. iv. | Verdigris chrystalized, oz. ss. Melt these well together, and when beginning to cool, add red precipitate, oz. i. ss. (ground to the greatest possible fine- ness,) and oil of juniper, oz. ss. Let the composition be faith- fully stirred till it is cold. Useful for scald head, tetters, &c. Wash and soak off the crusts and scabs, and apply the ointment with the finger, rub- bing it in well. Repeating once or twice every day. 582 APPENDIX. A PATIENT RECEIVING AN APPLICATION OF JENNINGS' PATENT VAPOR BATH, Fig. 1. The tubular stove, for directing the heated air into the hollow space made by placing the frame, covered with three or four blankets, over the patient. Fig. 2. The cups, one of which is rilled with alcohol, or spirit of good proof, placed in the stove, and set on fire with a blaze. Fig. 3. The frame uncovered for inspection. Note.—If the patient be sponged all over with diluted sulphuric acid,(oil of vitriol,) say two or three drams to a pint of warm water, immediately be- fore applying the heated air, it will be equal to a sulphuric bath, and will cure the itch, and some other affections of the skin. It may be necessary sometimes to repeat the application. GLOSSARY. As it is probable that this book may be purchased for family reference, the author has added a Glossary of the technical terras used in the work. ABDOMEN, the belly, or paunch. Abdominal, pertaining to the abdomen. Adipose, fat. Anasarcous, dropsical. Anastomose, the communication of ves- sels with each other. Anginose affections, inflammatory af- ■g fections of the throat. Anormal, irregular, unnatural. Anthelmintic, having the power of des- troying worms. Antiphlogistics, medicines that reduce fever and inflammation. Antispasmodics, medicines that allay spasms, or cramps. Aperients, medicines that gently open the bowels. Aphorism, a precept, a detached sen- tence containing an important truth. Aphtha, small superficial ulcers in the mouth. [a^ues. Apyrexia, the period of intermission in Arachnoid, the middle membrane cov- ering the brain. Ardor urince, a scalding of urine. Arthritis, rheumatic pains of the joints. Asphyxia, apparent death, suspended animation. Asthenia, diminished vital energy. Asthenic, the same. Axilla, the arm pit. Axungia, hog's lard. B Belladonna, deadly night shade. Blennorhaa, a morbid secretion of mucus Borborygmus, rumbling produced by wind in the bowels. Bronchia, the air tubes in the lungs. Bronchotomy, an incision into the wind pipe- Bulimia, insatiable craving for food. Cachexia, a generally weak, relaxed and disordered state, without fever. Canthus, angle of thev eye. Capillary vessels—Capillaries, the very minute vessels, between the arteries and veins. Cardia, the upper orifice of the stomach. Cardiac region, the pit of the stomach Caries, an ulcerated bone. Carotids, the arteries that convey the blood to the head- [males. Catamenia, the monthly discharge of fe- Cataplasm, a poultice. Catenation, a chain of morbid actions. Catheter, a hollow tube for drawing off the urine. Cellular membrane, or tissue, the filmy meshes which connect the minute component parts of most of the struc- tures of the body. Cephalalgia, head-ache. Cephalic, relating to the head. Cerebral, relating to the brain. Cerebrum, the brain. [in the neck. Cervical vertibra, the joints of the spine Cerxsix uteri, neck of the uterus. Chyle, the milky fluid produced by di- gestion. Chyme, the food after it has undergone theprocessof digestion in the stomach, and has passed into the bowels. Colliquative stools, profuse, watery dis- charges from the bowels. Collyrium, an eye wash. Coma, profound lethargic stupor or sleep. Comatose, morbidly sleepy, [in a part. Congestion, the accumulation of blood Conjunctiva, the mueous membrane which lines the posterior surface of the eye-lids, and is continued over the forepart of the globe of the eye. 584 GLOSSARY. Constipation, costiveness. , Crassamentum, the red globules of the blood, collected in a mass with the coagulable lymph. D Dejections, alvine, evacuations by the Deliquium, fainting. [bowels. Demulcents, soothing, mucillaginous fluids, as flax-seed tea. Dentition, teething. Derivatives, remediate applications, that draw the blood from an affected part. Desquamation, scaling off, or separation of the skin in small scales. Diagnosis, the distinguishing marks of particular diseases. Diaphoresis, gentle perspiration. Diaphragm, the muscular partition be tween the chest and abdomen. Diathesis, any particular diposition, or habitude of the body. [the diet Dietetic, relating to the regulation of Diluents, bland drinks. Diuretics, medicines that increase the flow of urine. Duodenum, the first twelve inches of the small intestines. Dyspnoea, oppressed breathing, [urine Dysuria, difficulty and pain in passing E Ecchymosis, blood seen under the skin. Eclampsia, convulsions in child-bed. Effluvia, exhalations, vapors, &c. Ejections, discharges from the stomach by vomiting. Electuary, a compound medicine, made into the consistence of honey. Emesis, vomiting. Emetic, a medicine that causes vomiting Emulsion, a milk-like fluid, formed by mixing oily or resinous substances, by means of mucilage, with water Encephalic, relating to the cavity of the skull. Encephalon, the brain with its mem- branes. Endemic, a disease peculiar, or especial- ly prevalent, in certain localities or districts. Endermic, a term signifying an applica- tion of medicine to the skin, Enema, a clyster, an injection. Enemata, injections. Engorgement, an accumulation and stagnation of fluids in a part. Epidermis, the outer skin. Epilepsy, fits, or falling sickness. Epispastics, [substances that blister the skin, as Spanish flies. Epistaxis, bleeding from the nose. Errhines, substances used to produce sneezing. Error toci, an error of place, the pulse is sometimes found out of place. Erysipelas, St. Anthony's fire. Erythema, a slight inflammation of the skin. [applying caustic, &c. Eschar, the dead substance produced by Etiology, relating to the causes and ori- gin of diseases. [a fever. Exacerbation, the period of increase of Exanthemata, acute eruptive diseases, Ecitability, the capacity of being excit- ed by stimuli. Excitement, the action caused by stimuli. Exfoliate, to cast, or scale off, as the skin, or a piece of dead bone. Expectorants, medicines that promote spitting. F Farinaceous, made of meal. Fascia, a tendinous expansion. Fauces, the posterior part of the mouth, or top of the throat. Febrifie, that which causes fever. Febrifuge, a medicine that has the pow- er of arresting the progress of an in- termitting fever; as bark. Febrile, feverish. Femoral artery,the artery felt in the groin Filamentous, thread-like. Fistula, a deep, tube-like ulcer. Foramen, an opening, or hole. Function, the action, or office performed by an organ. Ganglion, a small knot, or roundish en- largement of a nerve or tendon. Gangrene, mortification. Gastralgia, pains in the stomach, with- out fever. Gastric, relating to the stomach. Gastritis, inflammation of the stomach. Gastro enteritis, inflammation of the stomach and bowels. Gestation, the act of bearing the young in the womb. Globus hystericus,*a feeling like a ball rising from the stomach to the throat. Hematemesis, vomiting of blood. Hematuria, voiding bloody urine. Hemopthysis, bleeding from the lungs. Hemorrhage, bleeding from any part of Hemorrhoids, piles. [the body. Hectic, a slow habitual fever, with sweats and emaciation; accompanies con- sumption. GLOSSARY. 585 Hemicrania, pain on one side]of the head. Hemiplegia, palsy on ono side. Hepatization, change of structure, so as to resemble the substance of the liver. Hernia, a rupture. " Humoralis, swelled testicles. Herpetic, having the character of a tetter Humoral, relating to the fluids, particu larly the blood. Hydragogue, a purge that produces wa- tery stools. Hydrocephalus, dropsy in the head. Hydropic, dropsical. Hydrophobia, dread of water, difficulty of drinking. Hygiene, the preservation of health, that part of medicine which regards the preservation of health. Hypercartharsis, excessive purgation. Hyper-trophy, an unnatural enlargement ofan organ. Hypocondriasis, hyp, low spirits. Hypothesis, a system or doctrine found- ed on a theory. I Icterode, yellow, jaundice-like. Zc