iV*'/-VVi****' V.AV.V.T.'ASX 1 MODERN ^ PRACTICE OF PHYSIC, EXHIBITING THE CHARACTER, CAUSES, SYMPTOMS, PROGNOSTICS, MORBID APPEARANCES, AND IMPROVED METHOD OF TREATING THE DISEASES OF ALLCMMATES. BY ROBERT THOMAS, M. D. . > AND AX HONORARY MEMBER OF THE HISTORICAL AND PHILfiSWHICAL SOCIETIES OF NEW-YORK. •% SIXTH AMERICAN FROM THE SEVENTH SfWDON EDITION, REVISED, AND CONSIDERABLY ENLARGED BY AN ADDITION OF MUCH IMPOE- TANT MATTER, AS WELL AS BY AN ENGtfJSsH TRANSLATION OF THE FORMULAE OR PIMj|WJUPTIONS. —»@«— . ,";-. .WITH ^APPENDIX BY DAVID HOSACK, M. D. LL.D. PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE IN ', THE UNIVERSITY OF NEW-YORK; AND ONE OF THE PHY- *j>, v ^r' SICIANS OF THE NEW-YORK HOSPITAL. I / « \)\ '.'■ %'t ■ H BUSHED BY COLLINS & CO. 189 PEARL-STREET 3. h J. HARPER. PRINTERS. 1822. **P**ipp,-^,!^F^ T 4-61 w Southern District of New-York, us. L S "RE IT REMEMBERED, That on the n.neteenth day of January, ,1 ,ne tortr- JJ sixth year of the Independence of the United States of America, Collii . & Ca. of the said District, have deposited in this office the title of a book, the right whereoi they claim as proprietors, in the words following, to wit: " The Modern Practice of Physic, exhibiting the Character, Causes, Symptoms, Proenoi- hcs, Morbid Appearances, and Improved Method of Treating the DiseasesTof alf Climates By Robert Thomas, M. D. and an Honorary Member of the Historical and Philosophical Societies of New,York. Sixth American from the seventh London edition, revised, and considerably enlarged by an addition of much important matter, as well as by an English " translation of the Formulae or Prescriptions. With aV Appendix by David Hosack Rl D " LL. D. Professor of the Institutes and Practice of Medicine in the University of New-York : " and one of the Physicians of the New-York Hospital." ' In conformity to the Act of Congress of the United States, entitled " An Act for the en . couragement of Learning, by securing the copies of Maps, Charts, and Books, to the author and proprietors of such copies, during the time therein mentioned." And also to an Act ' lentitled " an Act, supplementary to an actrentitled an Act for the encouragement of Learning-' '•by securing the copies of Maps, Charts, and Books, to the authors and proprietors of such copies, during the times therein mentioned, and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." Clerk of Ike. Southern. District of Nwr-Yo-ri TO DAVI D H O SAC K, M. D. F. R. S. PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE, IN THE IS MOST RESPECTFULLY DEDICATED, IN TESTIMONY OF THE VERY GREAT ESTEEM AND REGARD OF S* .* /;* PREFACE, The reception which this work has met with from every branch of the medical Profession, and indeed from the public at large, merits my most grateful ac- knowledgments ; and as the best way of expressing them, I have endeavoured to render it still more useful by collecting from every valuable source whatever was likely to prove serviceable, and thereby enable it to maintain its claim to a continuance of that approbation with which the six former editions have been so emi- nently distinguished. The seventh is now laid before them, and it will be found to contain such an addition of important matter, as I trust will keep the spirit of the work on a level with the improvements which are an- nually taking place in the science of medicine. The doctrines and observations contained in it are grounded on a practice of forty-eight years in different climates, after a study of several years at the Edinburgh University during the zenith of its reputation, and when it numbered the elder Dr. Munro, Dr. Cullen, Dr. Black, and Dr. Gregory among its professors: assisted by an attentive perusal of the works of all the modern wri- ters of eminence, and notes carefully taken of any par- ticular cases which have fallen under my care. Under these circumstances, I trust I shall not be deemed pre- sumptuous in having undertaken so important a task as the compilation of such a work as this is, nor be thought defective in judgment by not having properly discrimi- nated between matters of fact, and those which have no other support than vague hypothesis. As in the former editions the diseases are divided into the following classes, viz. Pyrexiae, or Febrile Diseases: Neuroses, or Nervous Diseases; Cachexia?, or Diseases connected with a general bad habit of Body; Locales, or Diseases only affecting Parts; those not referrible to any particular class: the Diseases of the Pregnant and VI J*REFAti& Parturient States, and those of Infancy; and although this arrangement is by no means perfect or unobjection- able (indeed all the systems of nosology yet published have important defects, and are imperfect,) still it may be sufficient to answer every useful purpose. The necessity of studying nosology and teaching me- dicine upon a nosological plan, has indeed been objected to by some Professional men; but this can only have arisen from an imperfect acquaintance with its nature and tendency, and a consequent inadequate estimate of its utility. It is necessary, in my opinion, that every Practitioner should be enabled to distinguish diseases by their symptoms or signs, if he would hope to cure them by appropriate remedies. He must therefore pos- sess in his mind an arrangement of the characteristic symptoms of every disease, and especially of those by which one disease may be distinguished from other diseases which resemble it, or with which it has several symptoms in common. The new nomenclature has been adopted throughout the different prescriptions, and a table of the synonyms of the different colleges of London, Edinburgh, and Dublin, has been annexed, which cannot but be consi- dered as a valuable addition to the work. To oe able to arrest the progress of contagious disea- ses must be a very desirable object, and therefore those means which have been found most effectual not only for this purpose, but for totally annihilating every kind of contagion, have been pointed out under the several heads of the different species of Typhus, Scarlatina, Cynanche Maligna, Variola, Pestis, and Dysenteria. The best means for preserving the health of Europeans in warm climates, and of sailors on shipboard, have also been noticed; and as both cold and warm bathing, as well as many mineral waters, may be regarded as useful auxiliaries in the cure of some disorders, their different qualities and virtues have been specified. Such is the nature of this work; and 1 trust it will be found an accurate compendium of the present state of medical practice, from which the young Practitioner may derive both information and instruction, while it may rIso prove a serviceable reference occasionally to those of PREFACE. VH longer standing in the Profession. In cases of emer- gency, it may likewise serve as a guide to other persons, who on any sudden or violent attack of illness, either in their own families, or those of the neighbouring poor, might find it necessary to administer some appropriate remedy in the interval of their obtaining professional assistance. It is my intention, however, to submit to the public towards the termination of the present year another work on Domestic Medicine, wholly divested of all pro- fessional terms; and chiefly intended for the use of fami- lies, managers of plantations, and factories in our colo- nies abroad, and masters of ships not having any medical Practitioner on board, which I trust will prove of as high utility to those for whom it is designed, as the present work has done to those engaged in the practice of medicine. Besides giving the treatment of the diseases incidental in both cold and warm climates to men, women, and children, it will point out the steps to be adopted for preventing the further extension of such as are of a con- tagious nature, as also the means for preserving health, and prolonging human life. I think it necessary to state, that the doses advised in the various prescriptions of the present work are in- tended for adults, except where particularly specified for infants or children; and that, in general, women require a smaller quantity of medicine to produce a desired effect than men, and those of a sanguine tem- perament, less than those of the melancholic. In regu- lating the doses, due consideration ought therefore to be paid to the sex, temperament, habit, idiosyncrasy, and disease of the patient, as no correct general rule can be laid down. It would be ungenerous in me not to express my warmest acknowledgments to Dr. Hosack of New-York. for his exertions to extend the usefulness of the Modern Practice of Physict not only by recommending it to his pupils as professor of the Institutes and Practice of Medicine in the University of that state; but by the many valuable observations in the appendix which he has added to the different editions, six in number inclu- vii'i PREFACE. ding the present, that have been published in New-York under his sanction, and which have rendered the work more complete and better adapted to the climate and constitution of the Americans. I very much regret, that Dr. Hosack's discourse on the medical police of the city of New-York, and which has been published at the particular request of the Cor- poration thereof, did not fall under my inspection in sufficient time to notice, in the present edition, under the head of Yellow Fever, some of the valuable observations and regulations recommended therein, for the suppres- sion and extinction of the contagion of this disease. Here I can only say, that the body of evidence brought forward and detailed in this discourse ought, in my opinion, for ever to set at rest the question which relates to the origin of this fatal malady: it clearly proves that the Yellow Fever arose from imported contagion, and had not a domestic origin, or was the product of decom- posed animal and vegetable matter. It is incumbent on me also to return my best thanks to Dr. Goven, late of the Lunatic Asylum of Charenton in France, for the honour done me by his translation of this work into the French language, the knowledge of which I obtained through the medium of letters from the Continent during a tour through France in 1818, published in the Gentleman's Magazine for July 1820. ROBERT THOMAS, Salisbury, August 20, 1#21. ADVERTISEMENT TO W33& &MWM®£^ 1SMK81M * JlHE very extensive circulation which the work of Dr. Thomas has met with, and the high estimation in which it is held by the profession as a compendium of the present state of medical practice, render any commendation on the part of the American Editor altogether superfluous. While the Preface by the Author announces the numerous and important additions which have been made to the present seventh edition, it is due to the American reader to observe, that the Appendix has been also revised with great care, and such additions have been made to it as the Editor believed would be best calculated to enhance the value of the work. In the present impression, and in the former editions, the integrity of the London copy has been faithfully preserved. JVew-York, January, 1822. A SYSTEMATIC ARRANGEMENT OF THE DISEASES INTO CLASSES AND ORDERS; TOGETHER WITH AN EXPLANATION AND DERIVATION OF THEIR NAMES. —-»00O~— CLASS I. PYREXLE (Febrile Diseases) from itv%, fire, and ff a frenzy or distraction. Ophthalmia (Ditto of the Eye,) from 6jf, the stomach. Enteritis (---------------Intestines,) from evregov, an intestine. Hepatitis (----------------Liver,) from esraf, the liver. Splenitis (----------------Spleen,) from o-b-Ajjv, the spleen. Nephritis (——------------Kidney,) from n**>, bile, and pea, to flow. Diarrhoea (Purging,) from hxppea, to flow through. Diabetes (Excessive Discharge of Urine,) from hot., through, and Zxiyay to pass. ORDER IV. Vesanije (Mental Disease,) from vesania, madness. Mania (Madness,) from ft.xtvoft.xi, to rage. Incubus (Night-mare.) CLASS III. CACHEXIjE (Cachectic Diseases,) from xxzos, bad, and e|«s, a habit* ORDER I. Marcores (Universal Emaciation,) from marceo, to become thin. Atrophia (Atrophy,) from x, priv. and r^o

i, nutrition. Phthisis.(Pulmonary Consumption,) from the windpipe, and tcnto, a tumour. Dracunculus (Guinea Worm.) ORDER VIL Dolorosi (Painful Affections, unaccompanied by Pyrexia.) Cephalalgia (Headach,) from xea£x, the itch. Impetigo (Ring-worm,) from impelo, to infest Acne (Blotched and pimpled Face,) from x^yv chaff. Chigre (an Insect resembling a Flea.) Pernio (Chilblain.) DISEASES NOT REFERRIBLE TO ANY PARTICULAR CLASS. Vermes (Worms.) Venena (Poisons.) Animatio Suspensa (Suspended Animation.) Gelatus (Frost-bitten.) DISEASES OF THE PREGNANT STATE. Convulsiones (Convulsions,) from convello, to rend. Abortio (Abortions and Floodings,) from aborior, to be steril. DISEASES OF THE PUERPERAL STATE. Lochia (Discharge after Labour,) from Xo%eva, to bring forth. Febris Lactea (Milk Fever.) Inflammatio Mammae (Tumour and Inflammation of the Breast.) Papilla? Excoriatae (Excoriated Nipples.) Eruptiones Miliarias (Miliary Eruptions.) SYSTEMATIC ARRANGEMENT OF DISEASES. XV Phlegmatia Dolens (Painful Intumescence of the lower Extremity,) front | < Three Scruples. ---Scruple.............3 i o i Twenty Grains. ---Grain ..............gr.J^ \ These, and the Signs by which they are denoted, are the same in all the British Pharmacopoeias. Measure of Fluids. The Gallon, Cong. ---Pint (Octarius) —- Fluid Ounce .. --- Fluid Drachm ---Minim......... The value of these Measures is the same in all the Pharmacopoeias, but the signs by which they are denoted are peculiar to the London. The Edinburgh and Dublin retain the old signs, which are, for the gallon, cong.; the pint, lb. ; the ounce, § ; the drachm, 3 ; and the drop, gt. The London College of Physicians, when they directed the dropping of fluids from bottles to be discontinued on account of the uncertainty of the dose (much depending on the size of the phial and the quantity of the fluid contained in it,) and the minim to be substituted for the drop, ought to have cautioned practitioners against considering these terms as sy- nonymous ; for there is a considerable difference between them, the former exceeding the latter by at least half as much again : thus ten minims of any fluid, if measured by the graduated minim measure, will amount to about fifteen drops. In the administration of very active medicines, such for instance as the liquor arsenicalis and tinctura opii, this may be of great importance. The signs of the London Pharmacopoeias have been adopted in the different Latin formulas throughout this work ; but in the translated copies, for the convenience of those who are not of the profession, and who may not possess the graduated measure, the drop has been substi- tuted for the minim, attention having been paid at the same time to their relative proportion*. S Eight Pints. Sixteen fluid Ounces. Eight fluid Drachms. Sixty Minims. PRACTICE OF PHYSIC. CLASS I. PYREXLE, or FEBRILE DISEASES. > r j • he character assigned to this class of diseases is, increased heat t-;id frequency of the pulse, after a shivering, accompanied withta disturbance in many of the functions, and diminution of strength, especially in the limbs. >^ >?; ORDER I. FEBRES, or FEVERS,. It is impossible to give a concise and oroper definition of the disease known by the name of fever, as it has r.o symptom invaria- bly attendant on it, which can point out its real nature or essence. The pulse is exceedingly various in such cases : it may be small, weak, slow, contracted, and unequal; or it may be strong, quick, full, and regular; hard or soft, according as the fever is at the com- mencement, increase, height, or in the remission and termination- or as the genus and nature of the fever may chance to differ. So also, the heat may be equally diffused, or confined to particular parts : sometimes the external parts are cold, with a sense of inter- nal heat; at others, there is general heat or cold over the body ; and sometimes the heat is not greater than what is natural. Some- times the face is pale, and at others it is red or swelled ; now it has the natural look, and now the reverse of this. The eyes are heavy, languid, and sad; or red, and impatient of light; they are promi- nent, distorted, or wild ; shining, dull, or ghastly; sometimes be- dewed with tears, and deprived of their usual lustre. The tongue is generally dry, chapped, scabrous, red, white, or variegated; often covered with mucus ; but not unfrequently moist and natural, without any thirst. The breathing is frequent, hot, unequal, or impeded; the breath is often offensive. The appetite is usually extinct; but, in few instances, some desire for food remains. Some- times the urine is crude and watery; at others, red and thin ; or often thick, soon becoming turbid, and depositing a sediment: sometimes it is of a natural appearance. To these symptoms are added, pains in different parts of the body; depression of strength, and watchfulness j or, on the other hand, heaviness, stupor, or O PVREXIA, OR FEBRILE DISEASED. [Class I. imbecility of mind, delirium, diarrhoea, or constipation, vomiting, tension of the hypochondria, subsultus tendinum, emaciation, and other affections arising with the fever itself, or gradually super- vening to it. Besides the ordinary febrile symptoms of hot skin, irritated cir- culation, foulness of the tongue, thirst, and deficient or irregular se- cretions, preceded by lassitude, heaviness, listlessness, and rigours, there are pains in the head, generally of the throbbing kind, and ex- tending along the continuation of that portion of the brain which is lodged in the channel of the spine ; increased heat of the head (easily perceived on compressing it with the hands,) even though the body and extremities be cold ; unusual throbbing of the arteries in the temples and neck ; suffusion of the eyes, and an altered expression of features, easily observed, but difficult to be described, together with disturbance of all the functions immediately belonging to the brain. If to these be added irregularity in regard to sleep, and watching, which, though common to many diseases, belongs, in a peculiar manner, to the one under our investigation, we shall have characters always sufficient to enable us'to detect the presence of fever in the system, and affording at the same time the clearest indications of its nature. It is only from a diligent examination of these appearances con- joined together, that we are enabled to judge of the presence or absence of fever ; not from any of them taken singly. By making a general assemblage of the symptoms, we may venture to call it a disease which affects the whole system, the head, trunk of the body, and extremities; the skin, muscular fibres, and membranes, the circulation, absorption, and nervous system, the body, and likewise the mind. It does not, however, affect the various parts of the sys- tem uniformly and equally ; but, on the contrary, one part is much more affected than another.* Fevers are usually divided into intermittents, remittents, and con- tinued, on account of their taking up different times in their natural duration; some being compounded of a number of paroxysms, fol- lowing each other in a regular succession, at some distance of time as happens in intermittents ; in others, a fresh paroxysm comes on, immediately on the crisis of the former, so as hardly to leave the patient entirely free of fever, as happens in remittents ; and in others, there is such a quick succession of paroxysms, that the one comes on before there is any visible abatement of the febrile symp- toms, as in continued fevers. In some instances of the last-mentioned fever, the remissions and exacerbations are so inconsiderable, as not easily to be perceived which has induced a few practitioners to conclude, that there is a species of fever which subsists for several days together, and which is composed only of a single paroxysm : but we may safely presume that no such fever ever existed ; on the contrary, we may be well * See Dissertation on Feve-r, by Dr. George Fordyce. Order /.] intermittent fevers. 3 assured, that every continued fever consists of a repetition of paroxysms, in the manner just mentioned. Now and then we meet with a fever consisting of only a single paroxysm, and which goes through its course in a few hours, as in the ephemera simplex ; but this does not very frequently occur. Continued fevers usually last nearly of the same violence for several days, there being commonly an exacerbation in the evening, and a remission towards morning. The fevers of this species have been noticed to be of great diversity, by ancient nosologists 5 but modern ones have limited them, very properly, either as they show an inflammatory irritation, or as they point out an affection of the nervous system, and in which the powers of sense and motion are particularly impaired. The distinctions of inflammatory and nervous fevers are, therefore, those now generally made use of; the former being known by the title of synocha, and the latter by that of typhus. A combination of these two genera seems, however, to be that form of continued fever which is most prevalent in this climate ; and this I shall treat of under the appellation of simple continued fever, or synochus. A variety of continued fever has been noticed by some physicians under the title of synochus biliosa, where, in addition to the other febrile symptoms, we meet with a redundant secretion and vitiated state of the bile, giving rise to a vomiting of dark green matter, or diarrhoea, and excited by an exposure to extreme heat of weather. In some cases, however, the bowels are very torpid, and the motions procured even by purgatives are of a hard consistence, and dark as pitch; but as this variety of fever seldom appears under a continued type, and rather assumes a remittent form, it ought, undoubtedly, to be considered as a remittent. Several species are comprehended under the head of typhus: they do not, however, imply any specific difference, but seem to arise either from a different degree of power in the cause ; from different circumstances of the climate or season in which they happen; from some peculiarity in the constitution of the person affected; or from a peculiar state of the fluids predisposing to putrescency. As hectic fever cannot be considered as an idiopathic disease, but merely as a symptom of some other, and of phthisis in particular, it is not noticed under a distinct head, but under that of pulmonary consumption. FEBRES INTERMITTENTES, or INTERMITTENT FEVERS. The title of intermittent is applied to that kind of fever which consists of a succession of paroxysms, between each of which there is a distinct and perfect intermission from febrile symptoms, or an apyrexial period. Different names have been applied to this fever, according to the distance of time observed between the periods of its return. When 4 pyrexiae, or febrile diseases. [Class I. it comes on within the space of every twenty-four hours, it is called a quotidian; when it returns every other day, or there is a space of forty-eight hours between its attacks, it is called a tertian; and when it attends on the first and fourth day, with an interval of seventy-two hours, it is named a quartan. That under the tertian type is most apt to prevail in the spring, and is, indeed, the most frequent form of the disease. The quartan is the most obstinate and dangerous, being chiefly prevalent in autumn. The quotidian is more likely than the others to assume the continued type. Of the quotidian, tertian, and quartan intermittents, there are several varieties andforms: as the double tertian, having a paroxysm every day with the alternate paroxysms similar to one another. The double tertian, with two paroxysms on one day, and another on the next. The double quartan, with two paroxysms on the first day, none on the second and third, and two again on the fourth day. The double quartan, with a paroxysm on the first day, another on the second, but none on the third. The triple quartan, with three paroxysms every fourth day. The triple quartan, with a paroxysm every day, every fourth paroxysm being similar. When these fevers arise in the spring of the year, they are called vernal; and when in autumn, they are known by the name of au- tumnal. Intermittents often prove obstinate, and are of long dura- tion, in warm climates; and they not unfrequently resist every mode of cure, so as to become very distressing to the patient, and often give rise to other chronic complaints, but more particularly anasar- cous swellings, and an enlargement of the liver, or spleen. It seems to be pretty generally acknowledged, that marsh mias- mata, or the effluvia arising from stagnant water, or marshy ground, when acted upon by heat, are the most frequent exciting causes of this fever. In marshes the putrefaction of both vegetable and animal matter is always going forward, it is to be presumed; and hence it has been generally conjectured, that vegetable or animal putrefaction imparted a peculiar quality to the watery particles of the effluvia arising from thence. We are not yet acquainted with all the circumstances which are requisite to render marsh miasmata productive of intermittents. According to the observations made in the fenny districts of this kingdom, it has been ascertained, that marsh miasma, when much diluted with aqueous exhalation, as in summers where an unusual quantity of rain has fallen, are nearly inert; but when arising from stagnant waters of a concentrated foulness, in consequence of great drought and heat in the latter end of summer and the early part of autumn, they act with great violence and malignancy. In admitting the powers of marsh effluvia to produce intermit- tents, we ought not, at the same time, to look on them as their universal cause, since it is found that persons residing constantly in the most healthy part of cities, and far remote from marshes are sometimes attacked by them. The testimony of unquestionable writers, proves that febrific Or3,er I.\ intermittent fevers. i> miasmata may arise, under certain conditions, from almost any soil; and what is still more extraordinary, that these febrific miasmata may be wafted by currents of air* to a distance far exceeding what has been supposed or admitted upon this subject. By some physicians, the heavenly bodies have been supposed to have a considerable influence on intermittent fevers, particularly in warm climates. Dr. Lind mentions, that eight seamen were seized with a return of their fevers exactly at the moment of the beginning of an eclipse ; and others have cited cases where people have been seized with intermittents at the full and change of the moon. Many of these observations have, however, on a more par- ticular scrutiny, been referred to the tides, which, in warm climates, sometimes rise to a prodigious height at the new and full moon, and leave a great extent of marshy ground, the exhalations from which produce the disease; and it has been found, that by removing to a proper distance from these, the disorder was prevented, al- though the influence of the moon remained the same. People in warm climates usually take their exercise very early in the morning, but frequently in the evening, being prevented in the day by the excessive heat: the cool and damp air, to which they are thereby exposed, often produces fevers, which have absurdly been attributed to the influence of the moon. A similar explana- tion may be given of the influence which the winds are said to have on fevers. In some marshy countries they produce intermittents when they blow over the marshes, and cease to spread when the wind changes its direction. A watery, poor diet, great fatigue, long watching, intemperance, grief, much anxiety, debility, exposure to cold, lying in damp rooms or beds, wearing damp linen, a warm, moist, or cold damp atmosphere, the suppression of some long-accustomed evacuation, the recession of eruptions and preceding disease, have been ranked among the exciting causes of intermittents ; but it is more reason- able to suppose that these circumstances act only by inducing that state of the body which predisposes to these complaints. By some it has been imagined, that an intermittent fever may be communi- cated by contagion ; but this supposition is by no means consistent with general observation. One peculiarity in this fever is, its great susceptibility of a re- newal from very slight causes, as from the prevalence of an east- erly wind, or from the repetition of the original exciting cause. It would appear likewise, that a predisposition is left in the habit, which favours the recurrence of the complaint. In this circum- stance, intermittents differ from most other fevers, as it is well known, that after a continued fever has once occurred, and been completely removed, the person so affected is by no means so liable to a fresh attack of the disorder, as one in whom it had never taken place. * See Report of the Epidemic Fever, in the years 1809—10—11, by the Com- jmittee of Physicians appointed by the Madras Government (J pyrexia, or febrile diseases. [Class I. We have not yet attained a certain knowledge of the proximate cause of an intermittent fever ; but a deranged state of the stomach and primas vias is that which is most generally ascribed. Each paroxysm of an intermittent fever is divided into three different stages, which are called the cold, the hot, and the sweat- ing stages, or fits. The cold stage commences with languor, a sense of debility, and sluggishness in motion, frequent yawning, and stretching, and an aversion to food. The face and extremities become pale, the features shrink, the bulk of every external part is diminished, and the skin over the whole body appears constricted, as if cold had been applied to it. At length the patient feels very cold, and uni- versal rigours come on; the respiration is small, frequent, and anxious; the urine is almost colourless; sensibility is greatly im- paired ; and the pulse is small, frequent, and often irregular. In a few instances, drowsiness and stupor have prevailed in so high a degree, as to resemble coma, or apoplexy ; but this is by no means usual. These symptoms abating after a short time, the second stage commences with an increase of heat over the whole body, redness of the face, dryness of the skin, thirst, pain in the head, throbbing in the temples, anxiety and restlessness; the respiration is fuller and more free, but still frequent; the tongue is furred, and the pulse has become regular, hard, and full. If the attack has been very severe, then, perhaps, delirium will arise. When these symptoms have continued for some time, a moisture breaks out on the forehead, and by degrees becomes a sweat, and this at length extends over the whole body. As this sweat con- tinues to flow, the heat of the body abates, the thirst ceases, the urine deposits a sediment, respiration is free and full, and most of the functions are restored to their ordinary state ; the patient is however, left in a weak and wearied condition. This constitutes the third stage. • Having pointed out the phenomena usually attendant on a paroxysm of intermittent fever, and likewise their mode of suc- cession, it may not be unworthy of observation to notice, that in different cases they may prevail in different degrees; that the scries of them may be more or less complete ; and that the several stages, in the time they occupy, may be in different proportions to one another. After a specific interval, according to the species of ague, a fresh paroxysm commences in the manner above described. Such a depression of strength has been known to take place on the attack of an intermittent fever, as to cut off the patient at once • but an occurrence of this kind is very uncommon. Patients are seldom destroyed in intermittents, from general inflammation, or from a fulness of the vessels, either of the brain or of the thoracic viscera, as happens sometimes in a continued fever; but when their duration is of any length, they are apt to induce other complaints Order /.] intermittent fevers. 7 such as loss of appetite, flatulency, scirrhus of the liver and spleen, dropsical swellings, and general debility, which, in the end, now and then prove fatal. In warm climates particularly, intermittents are very apt to terminate in this manner, if not speedily removed; and in some cases they degenerate into continued fevers. When the paroxysms are of short duration, regular in their recur- rence, and leave the intervals quite free, we may expect a speedy recovery ; but when they are long, violent, and attended with much anxiety and delirium, the event may be doubtful. Other unfavour- able symptoms are, great prostration of strength, vertigo, foetid excretions, the presence of dysentery, cholera morbus, enlarge- ments of the liver and spleen," inducing dropsy or jaundice, and convulsions occurring during the paroxysm preceded by coma. Relapses are very common to this fever, at the distance even of five or six months, or even a year ; and autumnal intermittents are more difficult to remove than vernal ones. Dissections of those who have died of an intermittent, show a morbid state of many of the viscera of the thorax and abdomen; but the liver, and organs concerned in the formation of bile, as likewise the spleen and mesentery, are those which are usually most affected. The indications of cure in the treatment of intermittents, are, first, to put as speedy a stop as possible to the fit, when it has taken place, and, secondly, during the intermission to prevent its return, at the usual, or any after period, both by exciting a new action in the system, by administering certain remedies at the commencement or immediately before the accession of the cold fit, thereby destroy- ing the morbid concatenation induced by the cause of the disease, and by invigorating the body. To effect the first of these intentions, it is proper to have recourse to warm .diluent liquids, artificial warmth, the pediluvium, or fomentations to the feet, arid cordial diaphoretics.* These often failing, however, to put a stop to the fit, has induced modern M. R; Misturae Camphors, f. J^xij. Ammoniae Subcarbon. gr. v. Vini Antimon. tf[. xij. Syrup. Simpl. f. 3j. M. ft. Haustus, tertiis vel quartis horis su- mendus. Vel, 2. R Potassae Subcarbon. ^j. SucciLimon.q.s. ad saturationem. Aq. Cinnam. f. 3y. —Puree, f. ^j. Antimon. Tartarizat. sr. 1. Syrup Cort. Aurant. f. gj. M, ft. Haustus. * 1. Take Camphorated Mixture, twelve drachms. Subcarbonate of Ammonia, five grains. Antimonial Wine, about twenty drops. Common Syrup, one drachm. Mix them. One of these draughts is to be taken every three or four hours. Or, 2. Take Subcarbonate of Potass, one scruple. Lemon Juice, sufficient to satu- rate it. Cinnamon Water, two drachms. Pure Water, one ounce. Tartarized Antimony, sixth of a grain. Syrup of 0,-an^e Peel,one drachm. Mix them for a draught. & pyrexia, or febrile diseases. [Class I. practitioners to search after more powerful and certain remedies. Doctor Trotter mentions, in his Medicina Nautica, that finding intermittents became very frequent on board the Vengeance, one of the Channel fleet, under Earl Howe, he was resolved to try the full effects of opium in preventing the fit. He reports, the moment the sick felt the first approach of an attack, they were sure to run to the cockpit for relief. A dose of tinctura opii was then adminis- tered: if the first dose did not bring on some warmth in the space of ten or fifteen minutes, from twelve to twenty drops more were given. He never gave less than thirty drops the first time, and never had occasion to go beyond sixty in the space of an hour, for in no case did the remedy fail, we are informed, to give relief in this time. He further reports, that in a few minutes, from the exhibition of the opiate, an exhilaration of spirits was perceived, which was quickly followed by a relaxation of the surface, the countenance looked cheerful, and a flush was spread on the cheek. The pulse, from being weak, quick, and sometimes irregular, became less frequent, full, and equal; an agreeable warmth was diffused over the whole frame, and every unpleasant feeling vanished sometimes in a quarter of an hour. Sleep now and then followed a large dose; but this did not in general happen. As soon as any symptoms indicated another paroxysm, whether on the following day or not, till the tertian interval, the tinctura opii was repeated in the same manner as in the former fit, and always with equal success ; so that the patient seldom experienced much trembling or shaking. He adds, the second paroxysm was commonly an hour or two later in the day than the preceding one, and but few instances occurred where any indisposition indicated a third attack at the expected period of accession. The very patients themselves, he observes, were not a little surprised at the sudden change in their sensations by so small a quantity of medicine, and that they were certainly the completest cures which ever came under his observation. A late writer tells us,* that he gave five grains of the subcarbonate of ammonia with an equal quantity of camphor, and a scruple of aromatic confection, in cases of Walcheren intermittents, with great- er success than any other medicines. The confectio opii no doubt would have been preferable to the other confection. Indeed, he acknowledges that he found it superior,to opium, or its tincture. In the Medical Commentaries for the years 1794 and 1797, pub- lished by Dr. Duncan, we are informed by Mr. George Kellie, an ingenious navy surgeon, of the good effects of compression by the tourniquet, in stopping the cold fit of intermittents, and several instances are related of this curious fact. The plan pursued by him was to apply the instrument on one thigh and on one arm, of oppo- site sides, at the same time. In two minutes after the application of the tourniquets, the shaking and other symptoms of the cold * See Observations on the Diseases of Walcheren, by G. Dawson. Order I.] intermittent fevers. 9 stage entirely ceased, a mild hot stage was immediately induced, and the patient found himself quite relieved. After suffering the instruments to remain on for about fifteen minutes, they were removed, and the cold symptoms did not return. From various trials which Mr. Kellie made, he concludes, first, that if at any time during the cold fit of an intermittent, tourniquets be so applied as to obstruct the circulation in two of the extremities (for example, one on the subclavian, and the other on the iliac of opposite sides,) the hot fit will be induced in about three minutes afterwards; secondly, that if the tourniquets be applied previous to the accession of the paroxysm, the cold stage will be entirely prevented; and thirdly, that where the cold stage of an ague is either thus shortened, or altogether prevented, the following hot stage will be rendered both milder and of shorter duration. Sulphuric aether administered in the quantity of a drachm for a dose, on the approach of the cold fit of an intermittent, has been found in some instances to prevent the accession of the hot one. In the fifth volume of Medical Facts and Observations, two cases are recorded by Mr. Davidson of the efficacy of this remedy, where the bark and other medicines which were previously used had failed. The first dose is not to be expected to remove the disease at once, and therefore on the approach of the next fit it ought to be repeated. During the intervals, the bark and other tonics are to be taken. By administering an emetic immediately before the accession of the cold stage, we may sometimes be enabled to destroy the morbid concatenation induced by the cause of the disease, and thereby pre- vent a return of the paroxysm. Might not the affusion of cold water be employed with some prospect of success, two or three hours before the expected acces- sion of the paroxysm, or immediately after the hot fit is completely formed ? Indeed I have tried it, and with some advantage, in the former instance. The morbid catenation in these fevers has been broken by putting the patients under a copious shower-bath in the hot stage of the paroxysm. On the authorities I have mentioned, we are induced to presume that we have a knowledge of powerful remedies for cutting short the cold fit of an intermittent; or, should the hot fit succeed, that it will certainly be rendered both milder and of shorter duration each time of its return. Should we, however, be disappointed in our expectations, and the febrile symptoms run high, we may then advise the use of gentle diaphoretics, in small and frequently re- peated doses, as prescribed under the head of Simple Continued Fever, or below ;* and to increase their effect, the patient must be directed to drink frequently of tepid diluting liquors. If there is any inflammatory diathesis, nitre may be added to these medicines. * 3. Take Juice of Lemon, half an ounce. Subcarbonate of Potass, one scruple. Mint Water, one ounce. 3 3. R Succ. Limon. f. fss. Potassae Subcarbon. 9». Vq. Menth. f. |j. 10 pyrexia, or febrile diseases. [Class Where there is much nausea with vomiting, the stomach may be washed out with one or two basins full of chamomile tea. If incommoded by a cough, attended with a pain in the side affecting the breathing, we may recommend the application of a blister ; and should these affections not be relieved by the remedy,^ it may not be improper to take away a small quantity of blood. It the head becomes much affected, either during the paroxysms or the intermissions, the application of a blister to the back, and of leeches to the temples, will be advisable, laying opiates aside. Should there be great coldness of the legs, with a sinking of the pulse, cataplasms of mustard may be applied to the soles of the feet. In Dr. Lind we find an advocate for the exhibition of opium likewise in the hot fit. He tells us he has observed, that, if taken during the intermissions, it had not the least effect, either in pre- venting or mitigating the succeeding paroxysm ; when given in the cold fit, it once or twice seemed to remove it; but that when administered half an hour after the commencement of the hot fit, it generally afforded immediate relief. When given in the hot fit, he observed the following effects to ensue :— 1st, It shortened and abated the fit; and this with more certainty than an ounce of the bark was found to affect the disease. 2d, It generally gave a sen- sible relief to the head, took off the burning heat of the fever, and occasioned a profuse sweat. This sweat was attended with an agreeable softness of the skin, instead of the burning sensation which affects patients sweating in the hot fit, and was always more copious than in those who had not taken opium. 3d, It often pro- duced a soft and refreshing sleep to a patient tortured in the agonies of the fever, from which he awaked bathed in sweat, and in a great measure free from all complaints. The Doctor has always observed, that the effects of opium are more uniform and constant in intermitting fevers, than in any other disease, and are there more quick and sensible than those of any Antimon. Tartar, gr. A. Syrup. 3ij. f. M. ft. Haustus, tertiis horis repetendus. Vel, 4. R- Liquor. Ammon. Acetat. f. 3HJ. Aq. Cinnam. f 3ij- — Purae, f. 3v. Vin. Antimon. U\. x. Syrup. Cort. Aurant. f. 3J. M. ft. Haustus. Vel, 5. ft. Pulv. Antimonial. gr. ij. ----Contrajerv. gr. x. M. ft. Pulv. 4tis horis sumendus. Vel, 6. B; Pulv. Ipecac. C. gr. x. Capiat tertia quaque hora. Tartarized Antimony, the sixth of a grain. Common Syrup, two drachms. Mix them for a draught, which is to be repeated every three hours. Or, 4. Take Solution of Acetate of Ammo- nia, three drachms. Cinnamon Water, two drachms. Pure Water, five drachms. Antimonial Wine, sixteen drops. Syrup of Orange Peel, one drachm. Mix them for a draught. Or, 5. lake Antimonial powder, two grains. Powder Contrajerva Root, ten grains. Mix them, and let this powder be taken every four hours. Or, 6. Take Compound Powder of Ipecacu- anha, ten grains, repeating the dose every three hours. Order /.] intermittent fevers. 11 other medicine. An opiate thus given soon after the commence- ment of the hot fit, by abating the violence, and lessening the duration of the fever, preserves the constitution so entirely unin- jured, that, since he used opium in agues, a dropsy or jaundice has seldom attacked any of his patients in those diseases. When opium did not immediately abate the symptoms of the fever, it never increased their violence ; on the contrary, most patients reaped some benefit from an opiate given in the hot fit, and many of them bore a larger dose at the time than they could at any other. Dr. Lind offers it as his opinion, that opium in this disease is the best preparative for the bark, as it not only produces a complete intermission, in which case alone that remedy can be safely admi- nistered, but occasions such a salutary and copious evacuation by sweat, as generally to render a much less quantity of bark requisite. When we obtain an intermission, the cinchona bark is to be given, during the intervals, in large doses. One or two drachms of the powder may be taken every hour, if the stomach will bear so much, as the benefits to be expected from this medicine greatly depend on a large quantity being administered in a short space of time; for five or six ounces of bark taken in a few days, will be attended with a much better effect than perhaps as many pounds taken in the course of some weeks. If it will not sit easy on the stomach in substance, we must be content to substitute a decoction or infusion of it, or we may give the extract,* joining a few drops of sulphuric acid. Where the intermissions between the paroxysms are long, as in the tertian and quartan types, we should delay giving the bark until within eight hours or so of the accession of the cold fit. If all the forms which have been mentioned are nauseated and rejected by the stomach, we may advise the bark to be given in clysters, in which form it likewise proves very efficacious. For this purpose,about a drachm of its extract, dissolved in a sufficient quantity of water, with the addition of a few drops of tinctura opii, in order to its being longer retained, will be most proper. With children who cannot be prevailed on to take the bark, we may ad- minister it with much efficacy in this way, repeating the clyster every four hours. For the cure of intermittents in children, the bark has sometimes proved effectual when applied externally, by putting the powder of it into a quilted waistcoat. In most intermittents it would perhaps be the best practice to unite opium with the cinchona bark, as it would enable the stomach to bear much larger doses of the latter, and likewise add very con- siderably to its good effects. • 7. R Extract. Cinchon. gr. xv. * 7. Take Extract of Peruvian Bark, fif- teen grains. Decoct, ejusdem, f. §jss. Decoction of the same, one ounce and a half. Tinct. Cort. Aurant. f. 3j. M. Tincture of Orange Peel, one drachm. it. Haustus, alternis horis sumendus. (Mix them, and let this draught be taken I every other hour. 1:2 PYREXIA, OR FEBRILE DISEASES. [ClttSS I. It is conjectured by some physicians, that cinchona stops the paroxysms of an ague, not through the medium of the circulation, but by its tonic effect on the nerves of the stomach ; and indeed it is only in this way that the salutary operation of several other re- medies in intermittent fever can be accounted for. Various substances of either an astringent, stimulant, or aromatic nature, such as alum, the various preparations of iron, &c. nutmeg, and snake-root, have been joined to the cinchona bark, with a view of increasing its powers; but as these lessen its dose by their bulk, it will be best to give it by itself, unless it occasions a purging, and then about eight or ten drops of tinct. opii, or about a drachm of the tinct. kino, may be added to each dose. On the contrary, should it produce costiveness, some gentle laxative may be taken occasionally, such as a few grains of rhubarb. In intermittents of long continuance, where the person is advan- ced in years, and weak, the habit phlegmatic, the season rainy, and the situation damp, it will be proper to make an addition of snake- root and some warm aromatic* to the cinchona bark ; and when the symptoms have more of an inflammatory tendency, it may be given with a small portion of the potassae subcarbonas.t In cold climates, it will in general be advisable to wait for a perfect and regular intermission before we give the bark : but in warm ones, where intermittents are apt to degenerate into conti- nued fevers or remittents, and in which the habit is more irritable and weak, it will be right to administer it, even on the most im- perfect intermission, or slightest remission. In all cases of intermittents, it will not be sufficient that the re- currence of paroxysms be stopped for once or twice by a use of the bark ; a relapse is commonly to be expected, and it should there- fore be prevented by a continued exhibition of the medici ne at proper intervals ; even for some weeks after the disease appears to be re- moved, it may be advisable to take a little of it occasionally, partic- ularly in damp weather, or during the prevalence of an easterly wind. Various species of the bark are now to be met with among the venders of this medicine, and we have been favoured with the report 8. RPulv. Cort. Cinchon. |j. Coq. in Aq. Font. Oj. ad Oss. Colat. adde Tinct. Serpent. Rad -----Card. C. aa. f. JJvj. M. 8. Take Powdered Peruvian Bark, one ounce Pure Water, one pint; boil it over a slow fire until reduced to half a pint, strain it, and when cool, add Tincture of Snake-Root. Compound Tincture of Carda- moms, six drachms of each. Capiat Cochl. iy. magna pro dos. saepe Mix them, and take three large spoonsful per diem. for a dose, several time^ a day \ y. ft Decoct. Cort. Cinchona?, f. |jss. t 9. Take Decoction of Peruvian Bark, an ounce and a half. Subcarbonate of Potass, from ten to fifteen grains. Potassae Subcarbon. gr. x. ad xv. Syrup. Althaea?, f. jij. M. Syrup of Marshmallows, two drachms ft. Haustus, quartis horis adhibendus. ^lix them. This draught may be taken i every four hours. Order I.] intermittent fevers, 13 of several gentlemen* of eminence in their profession giving a decided preference to the yellow (cinchonae cordifoliae cortex,) as possessing virtues far superior to the red, or any other species yet introduced into use. From various trials made with it, these physicians report, that it is bitterer to the taste, and more astringent, than the other sorts; that a decoction and infusion of it are less liable to undergo fer- mentation ; and that in every instance in which it was used by them, it invariably proved successful. Half a drachm of the yellow bark in powder, given every two hours, has in general been found sufficient for the cure of an intermittent; hence they have presumed that it possesses nearly a double febrifuge power to that of common bark. Of its good effects I can myself bear testimony, having used it with the most decisive success. During my residence in the West Indies, I met with many cases that resisted the powers of cinchona, and that gave way to a use of quassia. Indeed, so sovereign a remedy was this found in inter- mittents, and so easy was it to be obtained, that it was pretty gene- rally substituted by all practitioners, for the cinchona, in common cases, on the plantations. The best way of administering it is in the form of infusion, as below.t The A ngustura bark (cortex cuspariae) is another remedy which I have often used with success. Other substitutes for cinchona have been mentioned and advised. In the sixth volume of Medical Facts and Observations, published in the year 1795, we are favoured by Dr. Roxburgh with an account of a new species of the swietenia (mahogany,) which from repeated trials, and experience of its effects, he proposes as a substitute for the cinchona. He calls it the swietenia febrifuga, and says, its astringent and bitter qualities are more intense than those of the Peruvian bark, and that its active parts are much more soluble than those of the other, particularly in watery menstruums. He adds, that it contains a much larger share of active (bitter and astringent) powers than cinchona oblongifolia or red bark; that watery pre- parations of it remain good much longer than similar ones of the latter; that spirituous and watery preparations of it bear being mixed in any proportion without decomposition ; and that its an- tiseptic powers are stronger. A great variety of other barks, such as the cinchona Jamaicensia discovered by Dr. Wright; the cinchona Charibbaea, or St. Lucia bark, the Tellicheri bark, &c. have been substituted for the Peruvian, * Dr. Relph, Dr. Saunders, and Dr. Babington, physicians to Guy's Hospital; Dr. Lind, of Haslar Hospital; and the late Dr. Woodville t 10. R- Quassia?, 3>j 1110. Take Quassia Bark bruised, 2drachms, Aq Bullient. f jviij. Postho- ram unam Col. et adde Tinct. Cascaril. ----- Cardam.C.aaf. §ss. M. Cochlearia iij. magna tertiishoris sumen- da Boiling Water, eight ounces ; infuse for an hour, then strain off the liquor, and add Tincture of Cascarilla, Compound Tincture of Carda- moms, each half an ounce. Mix them. Three large spoonsful are *•** be taken everv three hourc. 14 PYREXIA, OR FEBRILE DISEASES. [Class I. with a very good effect when this could not be obtained. As a tonic and febrifuge, the willow bark has of late years been much employed with considerable success both in England and on the Continent. The varieties of the willow which have been noticed by botanical writers, are very numerous; but the salix latifolia or caprea (broad-leafed willow bark) seems to possess virtues greatly superior to the others. A late writer* has endeavoured indeed to convince us, that it has a superior efficacy above the cinchona in various diseases, more particularly that branch of the healing art termed medical surgery. The decoction is the form to which this practitioner gives the preference : one ounce and a half of the dried and pounded bark boiled for a quarter of an hour in two pints of soft water. Of this, the ordinary dose is two or three spoonsful, given three or four times a day. A cheap substitute for the bark of cinchona, and which has proved very successful, consists of equal parts of bistort and cala- mus aromaticue, with the addition of a little ginger. This remedy may be given in the same doses as the former. The radix rhataniae is another substitute, which has lately been proposed for the cinchona; but from a few trials I have made of it in intermittents, I am convinced that it is by no means deserving of the encomiums which have been lavished on it by Dr. Rees. Twenty grains of the powder may be considered as a moderate dose ; and it may also be employed either in the form of extract, decoction, or tincture. All these barks, probably, owe their efficacy to one common principle ; but what this is, it may be difficult to ascertain. Their febrifuge .power has been attributed by some principally to the tannin, which they all contain in a greater Or less quantity; but this opinion must be erroneous, as it appears, from Mr. Davy's ex- periments, that very little tannin is contained in the cinchona, or in the other barks supposed to be possessed of febrifuge properties. Charcoal is a remedy much employed by physicians in Sicily in the cure of intermittent fevers, and apparently with much success.! It is administered in doses of one scruple, or half a drachm, three or four times a day. In intermittents, where from flatulency, distention of the abdomen, or a retention of faeces, it becomes necessary to have recourse to laxatives, we may employ something of a warm aromatic nature,! * See Wilkinson's Experiments on the Broad-leafed Willow Bark. t Edinburgh Medical Journal for October 1814. J 11. R Pulv. Rhei, gr. xv. ----Cinnam. Compos, gr. v. ft. Pulvis. Vel, 12. ft Infus. Sennae, f. ^jss. Tinct. Rhei, f. 3jj. -----Lav. C.f. 3J.M. ft. Haustu*. Jll. Take Powdered Rhubarb, 15 grains. Compound Powder of Cinna- mon, five grains. Mix them. Or, 12. Take Infusion of Senna, one ounce and a half. Tincture of Rhubarb, 2 drachms. Compound Tincture of Laven- der, one drachm. Make them into a draught. Order I.} intermittent fever*. lj which should be taken during the intermission, so that its operation shall have ceased before the accession of the next paroxysm. It often happens, when intermittents have continued a long time, that scirrhosities of the liver or spleen take place, which are vulgarly denominated ague cakes. These complaints have been attributed to an improper use of the cinchona bark ; but they evidently arise from the great quantity of blood which is thrown on these parts during the cold fit, which distends them, and so produces a scir- rhosity in them, and which we often find it difficult to remove, although a stop is put to the fever. In such cases it may be proper to join deobstruents with cinchona, as below.* If these do not answer, we must have recourse to mercury.! A small dose should be given every night, so as just to affect the mouth, but the tonic medicines are to be continued. If the patient cannot take this remedy internally, he must substitute its external use in the form of unction, rubbing into the groins about a scruple, if an adult, of the unguentum hydrargyri fortius every night at bed time. Mercury is, however, employed unsuccessfully in many instances of these enlargements, and which have afterwards given way to other remedies. Two cases of enlarged spleen, which resisted the effects of mercury, although the salivary glands had been suffi- ciently excited, and were afterwards removed by the succus in- spissatus conii, are recorded in the work of a late writer.J In warm climates particularly, these swellings are often to be met with as the consequence of long continued intermittents ; but of these, more particular mention is made under the head of Chronic Inflammation of the Liver, as also of the Spleen. These tumours, by pressing on the ramifications of the vena portarum, which passes into the liver, and branches in the manner of an artery, prevent the blood from returning from the abdominal viscera with the same facility that it commonly does. The passage t See Essay on Herpatitis and other Bilious Complaints in India, as well as Eu- rope, by Charles Griffith, M. D. * 13. Take Peruvian Bark in powder, one ounce. Powdered Rhubarb, one drachm and a half Subcarbonate of Soda, two drachms. Syrup of Ginger, as much as 13. R Pulv. Cinchon.gj. ----Rhei, 3jss. Sodae Subcarbon. gij. Syrup. Zingib q. s. M. ft Elect. umat Cochl. min. ter quater i 14. R- Hydrargyr. Submuriat. gr. j. Cujus sumat Cochl. min. ter quaterve in may be sufficient to form the whole into an die. , electuary, of which take about a tea- spoonful three or fourtimes a day. t 14. TakeSubmuriateof Mercury (Calo- mel,) one grain. Opium Confection, 3 grains. Form them into a pill, to be taken eveiy night. Or, 15. Take Mercurial Pill, three grains. Opiate Pill, two grains. Form them into a pill, to be taken as the former. Confect. Opii,gr. iij. M. Fiat pilula, omni nocte sumenda. Vel, 15. R- Pilul. Hydrargyri, gr. iij. ----Opiat. gr. ij. M. ft. Pilula. 16 PYREXIAE, OR FEBRILE DISEASES. [ClaSS I. of the blood being thus retarded, occasions a greater extravasation of lymph in the cavity of the abdomen, so that the ordinary exertion of the absorbents is not sufficient to take up the whole lymph. Thus an ascites takes place, and in this case wc must have recourse to the means advised under that head. Dropsy likewise arises sometimes from mere weakness, without any tumour of the abdominal viscera, and occasioned by the long continuance of the disease. In these instances it may be removed by exhibiting the bark of the cinchona together with stomachic bitters, diuretics, and chalybeates. As the strength returns, and the patient recovers his health, the dropsical appearances will diminish by degrees. When tumours are formed in any of the abdominal viscera, it not uncommonly happens that they press on the ductus communis choledochus, the duct of the gall-bladder, the hepatic duct, or the pori biliarii; by which means the bile is prevented in part, or wholly, from getting into the duodenum ; it is therefore absorbed, and produces jaundice of itself, without any concomitant dropsical symptom, or along with it, ascites. When this happens, the dis- ease is generally fatal. The blood, by being determined from the blood vessels upon the abdominal viscera, when the patient becomes weak after an inter- mittent has continued for some months, sometimes occasions an increased secretion from the glands of the intestines, and thus gives rise to a diarrhoea. This affection usually proves more severe during the remissions and intermissions ; and less severe, or ceases altogether, at the time of the accession and during the time of the paroxysm. Such diarrhoea tends to increase the weakness consi- derably, and not unfrequently occasions dropsical appearances. At first, oedematous swellings appear in the lower extremities; these increase, rising up to the thighs, and then to the integuments of the abdomen. Ascites also takes place. If astringent remedies be em- ployed, so as to put a stop to the diarrhoea, the dropsical appear- ances usually increase, and the intermittent continues to recur although often very obscurely and very irregularly. If the diarrhoea be permitted to go on, or if it has been stopped, and is allowed to return by leaving off the astringents, the weakness increases in such a degree as to destroy the patient. If the bark of cinchona be exhibited,,it often increases the diarrhoea without having the effect of preventing irregular returns of the attacks or exacerbations. In this case, Dr. Fordyce* says it will be best to clear the primae via? by employing about twenty-five grains of rhubarb ; after its opera- tion is over, to exhibit cinchona in pretty considerable quantity such as a drachm every three hours, and to give at the same time a grain of ipecacuanha with fifteen drops of tinctura opii, together with a moderate quantity of any warm spice, every four hours. In some cases of intermittents, which have continued a great * See his Fourth Dissertation on Fever. Order /.] intermittent fevers. 17 length of time, owing to their having been entirely neglected in their beginning, or where the cinchona has failed to procure the desired effect, preparations of iron and copper have been adminis- tered with success. The oxydum zinci, given in the dose of two grains thrice a day, has removed obstinate intermittents when the usual remedies have failed. The sulphas zinci has likewise been administered with much success. The sulphate of copper, given in doses of a quarter or half a grain every four or six hours, is also said to have proved very efficacious in some cases of obstinate intermittents. As a tonic, the cuprum ammoniatum* has been given with advantage. All these may be employed along with a decoction of the cinchona, or any of the other tonic bitters which have been mentioned. Arsenic has been strongly recommended as a remedy in intermit- tents, and it is undoubtedly a very powerful medicine, for I have found it to remove obstinate intermittents which had long resisted all other means. The inhabitants of a considerable portion of the country which surrounds Salisbury (the place of my residence,) are very subject to these fevers, but I have never yet been disappointed in removing even those of an obstinate nature, by a proper use of the arsenical solution : it is, however, my constant practice to con- join four or five drops of tinctura opii with each dose of it. The late Dr. Fowler seems to have been the first physician to advise this medicine in agues, and on his recommendation many practitioners have used it, agreeably to his directions, with the most pointed success. The preparation he advised is now introduced into the London Pharmacopoeia, under the name of liquor arsenicalis. The dose is from two to twelve drops, once, twice, or oftener in the day, according to the age, strength, &c. of the patient. Eight days' administration of the medicine, in the manner just mentioned, will generally be found sufficient for the radical cure of an intermittent. Vomitings, gripings, swellings, and the loathing of food, are the troublesome symptoms now and then produced by an improper use of the arsenical solution. They however disappear generally on a discontinuation of the drops, or only require the exhibition of gentle opiates, or some warm cathartic, such as the tincture of rhubarb. From the observations which have been made on the use of arsenic in agues, there seem just grounds for believing it to be the most powerful of ail the medicines which have been recommended in these complaints. In Lincolnshire, which is a fenny country, where agues are very prevalent, it is universally used, and with the * 16. ft Cupr. Ammoniat.3j. Mic. Panis, gij. Syrup. Cort. Aurant. q. s. M. fiant pilul. xxiv. capiat j. vel ij.—iij. (sensim augendo dosem) hora decubitus quotidie. * 16.*Take Ammoniated Copper, 1 scruple. Crumb of Bread, two drachms. Syrup of Orange Peel, as much aa will be sufficient to form the mass, which divide into twenty-four pills. Take one, two, or three, every night at bed-time, gradually increasing the dose, IS FVKEX1.E, OR FEBRILE. DISEASES. [Class I. most uniform success. Military and naval surgeons will find the arsenical solution a valuable substitute for the bark of cinchona, when their store of this is small or exhausted. Arsenic has long been administered by empirics with the greatest success in inter- mittents, under the appellation of the ague-drop. The manner in which arsenic acts in curing intermittent fevers, Dr. Darwin thinks, cannot be by its general stimulus, because no intoxication or heat follows the use of it; nor by its peculiar stimulus on any part of the secreting system, since it is not in small doses succeeded by any increased evacuation or heat, and must therefore exert its power on the absorbent system. He sus- pects its success in the cure of intermittents to depend on its stimu- lating the stomach into stronger action, and thus by the association of this viscus with the heart and arteries, prevents the torpor of any part of the sanguiferous system. A combination of the arsenical solution with cinchona* in sub- stance, decoction or infusion, is likely, I think, to prove a valuable remedy in cases of obstinate intermittents, and where either of these medicines administered singly might fail. During the fits of an intemittent, the patient's strength is to be supported by food of a light nutritive nature, such as preparations of barley, sago, panado, and the like; but when the fit is off, he may be allowed animal food, and a moderate use of wine. A change of air and situation has sometimes a happy effect in removin an intermittent, particularly if from a low marshy country to an ele- vated one. In autumnal intermittents it has been found, that the air of a city or large town is more favourable than that of the country, owing most likely to the great number of fires that are always burning. When none of the viscera are affected, cold bathing may be used with advantage. As intermittents are very apt to return, the patient should care- fully avoid all such causes as might produce a fresh attack. Should he be incommoded by a giddiness of the head, which is not un- * 17. ft Liquoris Arsenical, flliij.—vi. Decoct. Cinchon. f. "Sx. Tinct. Cort. Aurant. f. 3ij. ----Opii, Til v. M. ft. Haustus, ter in die sumendus. Vel, IS.ft Infus. Rad. Calumb. f. gxj. Liquor. Arsenical. 1T|. v. Tinct. Opii, fll iv. ----Cinchonse C. f. 3j. M. ft. Haustns, 4tavel 6ta quaque hora capi- endo. * 17. Take Arsenical Solution, from five to ten drops. Decoction of Peruvian Bark, ten drachms. Tincture of Orange Peel, two drachms. ----- of Opium, eight drops. Mix these, and let the draught be taken thrice daily. Or, 18. Take Infusion of Calumbo Root, eleven drachms. Arsenical Solution, eight drops. Tincture of Opium, six drops. Compound Tincture of Peruvian Bark, one drachm. Mix them, and let the draught be taken every fourth or sixth hour, Order I.] intermittent fevers. 19 commonly the case even after a slight attack of this fever, it may generally be relieved by volatiles* and the bark in wine. The chief malady which prevailed among the British troops on the island of Walcheren, and which swept off so many of them in a short space of time, was evidently the endemic fever of marshy countries. It made its appearance towards the close of summer, and became very prevalent during autumn, particularly in the months of August and September, showing itself at first under the quotidian, tertian, double tertain, quartan, and even remitting type, (but of all these the double tertian was the most common,) after- wards degenerating, in many instances, into a continued fever of the typhoid nature, accompanied with considerable malignancy. The disease apparently was not contagious in itself, but assumed this new form and character of fever wherever ventilation was de- fective, the patients much crowded together, or where other local causes of impurity prevailed. This was particularly noticed at Flushing, where the accommodations for the sick were very con- fined and crowded, and where the ditches were foul and obstructed, from the consequences of the siege, and the streets filthy from an imperfect police. Among those whose constitutions had not been habituated to the climate, who had been much exposed to wet and damp, who had undergone great military fatigues, and who were accommodated in close confined quai tens, the disease assumed a character of much malignity, corresponding with the degrees of combinations of all the predisposing causes. On the approach of winter the disease subsided, but was only put a stop to by removing the convalescents as speedily as possible to England, previous to the entire evacuation of Walcheren. The treatment was varied as the fever assumed an intermittent, remittent, or continued type, and the appropriate remedies noticed under each of these heads were resorted to accordingly. Most of the cases which did not terminate fatally, were tedious, and subdued with difficulty, and when overcome, left behind them great debility, as well as a strong disposition to relapse : perfect recoveries were rare, convalescence never secure, and where the recurrences of fever did not destroy life, they laid quickly the foundation for visceral obstructions, thereby rendering a large portion of the suf- ferers unfit for after military purposes. Chronic diarrhoea, dysen- tery, and dropsy, were frequent consequences. The deaths were numerous, and often sudden. Had several large hospital ships been moored in convenient situ- ations at a little distance from the land, and the convalescents been * 19. R Aq. Menth. f. giijss. * 19. Take Mint Water, three ounces and a half. Spirit. Amnion. Aromat. Til xxx. Aromatic Ammoniated Alco- hol, forty-five drops. Syrup. Cort. Aurant. f.gss. M. Syrup of Orange Peel, half an ounce. Capiat Cochl. larg. j. ter quaterveIn die. Mix them. The dose may be one large spoonful three or four times a day. -Q PYREXIAE, OR FEBRILE DISEASES. [Class I. quickly removed to them on their recovering from the first attack of the fever, several of the fatal relapses which took place among those who continued to be exposed to the local exhalations, might have been prevented, and many valuable lives have been saved. REMITTENT FEVER. By a remittent is to be understood where the fever abates, but does not go off entirely before a fresh attack ensues ; or, in other words, where one paroxysm succeeds the other so quickly, that the patient is never without some degree of fever. It is to be observ- ed, moreover, that the remissions happen at very irregular periods, and are of uncertain duration, being sometimes longer and some- times shorter. This fever is principally induced, as well as the intermittent, by marsh miasma, or the exhalations arising from stagnant water im- pregnated with the decaying remains of animal and vegetable substances, and is most apt to arise when calm, close, and sultry weather quickly succeed heavy rains or great inundations. In warm climates, particularly as we approach the tropics, where great heat and moisture rapidly succeed each other, the remittent is a very prevalent type of fever, and often appears under a highly ag- gravated and violent form, prevailing epidemically. It is likewise often met with in low marshy situations abounding with wood and water, from which miasma are consequently evolved, and is most apt to attack those of a relaxed habit, those who undergo great fa- tigue, and those who breathe an impure air, and make use of a poor and unwholesome diet. Although this fever is produced originally by marsh miasma, and in its simple state is consequently not of an infectious nature, still, under bad management, such as crowding too many sick together, and neglecting proper cleanliness and a free ventilation, there cannot be a doubt that it may, in its course, engender a matter capable of occasioning a highly contagious fever. Remittent fever cannot be communicated at any great distance from the source of its exciting cause, however severely and epide- mically it may prevail in certain situations and districts ; and al- though the matter producing it be essentially the same, still we may conclude, I think, that a more aggravated form of disease is occasioned by a more concentrated state of the poison : hence the different degrees of severity of remittent fever at different periods of the year, and in different climates. It has long been' observed, that the natives of any place are much less liable to be affected with the diseases peculiar to the situation than strangers, or those newly arrived; and it may like- wise be added, that when they are attacked with any endemic affection, it is rarely so severe as it is found to prevail among strangers, and those not accustomed to the climate. This I had great opportunities of seeing confirmed1 in the West Indies, in the Order I.} remittent fever. xJl case of remittent fever, which seldom affects the natives so severely as it does Europeans not sufficiently naturalized, although in every respect using the same diet, and adopting the same mode of life. Preceding an attack of a remittent fever, the patient is usually heavy and languid, and is troubled with anxiety, listlessness, sigh- ing, yawning, and alternate fits of heat and cold. On its accession he experiences severe pains in the head and back, intense heat over the whole body, with thirst, difficulty of breathing, and great dejection of spirits ; the tongue is white ; the eyes and skin ap- pear yellow ; there is a pain and sense of swelling about the region of the stomach; nausea, and a vomiting of bilious matter, ensue; and the pulse is frequent and small. After a continuance of these symptoms for a time, the fever abates considerably, or goes off imperfectly by a gentle moisture diffused partially over the body ; but in a few hours it returns with the same appearances as before. In this manner, with exacerba- tions and remissions, it proceeds at last to a crisis, or is changed into a fever of a different type. In warm climates, the remission often occurs so early as the second day ^ but in cold ones, it fre- quently does not take place until from the fourth to the sixth or eighth day. The accession of fever which has just been described is, how- ever, the mildest form under which it ever makes its appearance; for sometimes a severe delirium arises, and carries off the patient during the first paroxysm ; or the remission, perhaps, is scarcely perceptible, and is immediately followed by another paroxysm, wherein there is a considerable aggravation of all the symptoms. The heat of the body is greatly increased, the face is highly flushed, the thirst is excessive, the tongue is covered with a dark brown fur, respiration is laborious, the pulse is quick, throbbing, and tremulous, and a delirium arises. At the distance of some time, perhaps another short or imperfect remission again takes place ; but the symptoms return once more with redoubled violence, and at length destroy the patient. The symptoms which attend a remittent fever are apt to vary according to the situation and constitution of the patient, and like- wise the season of the year, and therefore it is impossible to give a certain detail of them; for sometimes those pointing out a re- dundancy of the bile predominate, sometimes the nervous are most prevalent, and at other times the putrid. A remittent fever is always attended with some hazard, particu- larly in warm climates, in which it usually goes through its course in the space of five or six days; but in cold ones, its crisis is not usually affected until the twelfth or fourteenth. The shorter and more obscure the remissions are, the greater will be the danger, and each succeeding paroxysm is attended with more risk than the former. On the contrary, the milder the attack, and the nearer the fever approaches to an intermittent, the fairer will be the prospect for a recoverv. PYREXIA, OR FEBRILE DISEASES. [ClaSS I. The usual appearances on dissection are, congestions of blood in the liver and spleen, inflammations in the alimentary tube, a dis- tended state of the venous vessels of the brain, and serous effusion into the cavities of that organ. ~ From the determinations to particular organs which take place in a remittent fever, and the marks of inflammation which are oc- casionally observed on dissection in the brain, stomach, and biliary organs, it would seem that bleeding is a necessary operation. In both cold and warm climates, and at an early stage of the disease, it will be proper to have recourse to it, where the patient is young and of a full plethoric habit, the pulse full and hard, the heat in- tense, the breathing difficult, or the head much affected with stupor or delirium : and in some cases it may be necessary to repeat the operation in a few hours, if the force of the circulating fluids is not sufficiently diminished thereby: but in warm climates, when none of these symptoms are present, it will be better to omit it, espe- cially if the person has been an inhabitant therein for any length of time, and not lately arrived from Europe. In all protracted cases of this fever, under every climate, where the pulse is weak, but still the head much,affected, the application of cupping glasses to the occiput, or of leeches to the temples, and blisters, will be more advisable than venesection. To assist in allaying the violence of the fever, it will be prudent carefully to remove and avoid every thing that might in the least contribute to increase it, such as too strong a light falling on the eyes, all noise and motion, and likewise any excess of heat. The patient is therefore to be kept perfectly quiet; the covering of his bed is to be light, and his chamber of a moderate temperature, by allowing a free admission of cool air into it. To assist these means, he should be presented from time to time with some cooling acidu- lated liquor, such as lemonade, tamarind beverage, or a solution of the crystals of tartar, or even cold water. Throughout the whole course of the disease, it will be advisable to change his body-linen, as well as that of the bed, frequently; to sprinkle his chamber often with vinegar, and to remove immediately whatever he avoids by stool. As in most cases there is a determination to the brain, the patient's head should be kept rather elevated, and being shaved, numerous folds of linen, moistened with vinegar and water (artifi- cially cooled,) may be kept constantly applied to it: his feet may be immersed occasionally in warm water. As nausea usually prevails at the commencement of the disease, it will, in all cases,be right to ch .mse the stomachby giving a gentle emetic of ipecacuanha, or a solution of tartarized antimony, which perhaps may be preferable : the operation of this being over, the bowels may then be emptied by some gentle laxative, which will seldom fail in bringing off a considerable quantity of dark bilious matter. Drastic purges, by determining inwardly and increasing the irritability of the stomach, would be prejudicial; and therefore, if it is necessary to obviate costiveness in the course of the disease, Order /.] remittent fever. 23 it will be most advisable to do it by the laxative medicines here prescribed,* assisted now and then with aperient clysters. The necessity of carefully inspecting the alvine discharges in remittent fever cannot be too strongly inculcated, as it affords the best or principal index as to the regulation of our employing pur- gative medicines. In this fever, as well as typhus icterodes, the submuriate of mer- cury, combined with rhubarb or jalap, may be regarded as a valua- ble remedy, where we wish to carry off putrid feculent matter from the bowels, and there is at the same time any degree of nausea or vomiting present; as from the smallness of its bulk, it may pos- sibly be retained on the stomach when every other purgative might be rejected. After these evacuations, and where there is no delirium present, an opiate will be found of great service in quieting the commotions induced either by the spontaneous or artificial discharges, and in enabling the patient to retain on his stomach both nourishment and medicines. In the remittent fevers of warm climates, as well as of temperate countries in the hotter seasons of the year, the best effects are to be derived from cold affusion, or throwing cold water over the patient; but it is to be understood that the height of the paroxysm is the proper time for the application of the remedy. The sensations of heat are then strong; the headach is violent, and delirium fre- quently runs high. By employing the remedy at an early period, we may be able either to arrest the disease precipitately, or bring about an early solution of the paroxysm ; but at the least we may for the most part so ameliorate its aspect, as that from an obscure remittent it will soon become an intermittent of a distinct and re- gular type. Where signs of congestion, or irregular action, pre- sent themselves in the abdominal or biliary system, and the disease is recent, it will be advisable, previous to having recourse to affu- sion, to premise proper evacuations. In the progress of the disease, where much debility has arisen, * 1. ft Potassae Tartrat. 3ij. Infus. Sennas, f. §jss. Tinct Jalapae, 3i. M. ft, Haustus. Vel, 2. R Pulv. Rhei, gr. x.—xv. Hydrargyr. Submuriat gr. v. Syrup, q. s. M. Fiant Pilul. iv. pro dos. Vel, 3. R Hydrargyr. Submur. gr. v. Pulv. Jalap, gr. xv. M. ft.Pulvis. * 1. Take Tartrate of Potass, 2 drachms. Infusion of Senna, one ounce and a half. Tincture of Jalap, one drachm. Mix them for a draught. Or, 2. Take powdered Rhubarb, from ten to fifteen grains. Submuriate of Mercury, five grains. Common Syrup, as much as wilt form the mass, which divide into four pills, to be taken at once. Or, 3. Take Submuriate of Mercury, five grains. Powdered Jalap, fifteen grain?. Mix them, and take them for a dose, ~4 PYREXIA, OR FEBRILE DISEASES. [Class L aspersion, or sponging the body over with cold water and vinegar, together with an internal use of wine, may be substituted for affu- sion or immersion. The general effects to be observed from affusion, when it can be practised with propriety, are a diminution of heat and anxiety, greater cheerfulness of countenance, improved recollection, ten- dency to sleep, the pulse becoming fuller and more uniform, and the skin moist, with now and then a distinct remission. To alter the type of the fever, and bring the remissions into per- fect intermissions, if possible, by promoting a gentle diaphoresis, it will be proper to give antimonials in small and frequently re- peated doses. They may be prescribed as mentioned under the head of Simple Continued Fever, or as below ;* and to assist their effect, the patient should take frequent small draughts of some tepid diluting liquor. Where frequent vomitings prevail, antimonials will not be proper. In their stead, we may direct the saline medicine to be adminis- tered, so as that the effervescence shall take place in the stomach, with the addition of about ten drops of tinct. opii to each dose. Moreover, we may direct flannel cloths, wrung out in a warm decoction of chamomile flowers and bruised poppy-heads, with an addition of rectified spirits, to be kept constantly applied over the region of this organ. Should these means fail in procuring the desired effect, a large blister may be put immediately over the part, which will be found, in general, a very effectual remedy. The early application of a blister, even in cases where no great irritability of the stomach prevails, might in most instances be proper, as it will tend to pre- vent the determination to that organ. Blisters likewise prove highly serviceable in the latter stages of a remittent fever, when the spirits flag, and the pulse is low and fluttering, with insensibility or a disposition to coma. In such cases they may be applied be- tween the shoulders, or to the legs. Sinapisms of mustard may also be put to the soles of the feet. When a severe vomiting has arisen, the patient ought to swallow as little drink as possible, and should only now and then just moisten his mouth and throat; for whatever reaches the stomach is sure to be rejected shortly with considerable violence ; and each time it is thrown into these convulsive motions, the disease is strengthened, and the person exhausted. Under such circum- stances, it will be better to support the strength by administering clysters, composed of broths and other nutritious liquids, than to attempt it by giving any thing by the mouth. When the stomach is not in an irritable state, and every thing is * 4. R Pulv. Jacob. Ver. gr. iv. Camphor, gr. iij. Confect. Rosae, q. s. M. ft. Bolus, 3tia vel 4ta hora sumendus. * 4. Take James's Powder, four grains. Camphor, three grains. Confection of Roses, a suffi- ciency to form them into a bolus or 2 pills, to be taken every third or fourth hour Order /.] REMITTENT FEVER. 2o retained readily, the patient is to be supported by food of a light generous nature. During the remissions, a little wine may be mixed with it. As soon as the fever shows a disposition to yield, and a perfec remission takes place, we ought to give the bark of cinchona in substance, and in such doses as the stomach will easily bear : and if about twenty drops of the acidum sulphuricum dilutum are added to each dose, the effect will be increased. Should the cinchona in powder prove either disagreeable to the patient, or excite nausea, then a decoctio'n or infusion of it must be substituted. If any of its preparations should occasion a purging, about ten drops of the tinctura opii, or a drachm of the tinct. catechu, may be added to each dose. In cold climates we may wait for a perfect and complete remis- sion before we give the cinchona: but in warm climates we ought to administer it even on the most imperfect and short remission : and although it may not prove sufficiently efficacious to prevent a fresh attack at first, yet it will seldom fail to mitigate the subsequent returns of the fever, and will at last bring about a regular and per- fect intermission. By neglecting to give the cinchona in the West Indies and other warm climates upon the first remission, the fever is apt to assume a continued form. Where danger is to be apprehended with every return of the paroxysm, and where the interval is likely to be short, we should give at least half an ounce of this bark at once, immedi- ately on the commencement of the intermission. During the rest of the intermission or remission, we may administer it in doses of about two drachms, repeated at such distances as that the patient shall take an ounce, or an ounce and a half, if possible, previous to the next accession. When the interval is pretty long, the remedy may be divided into smaller doses. To guard against a relapse, the cinchona should be continued for some days after a cessation of the attacks, and not to be too hastily left off, as is sometimes the case. The late Dr. Fowler found the most beneficial effects from the use of arsenic in the form of solution in this fever, as well as in in- termittents. From his report, published in the ninth volume of the Medical Commentaries, it appears that he experienced its-virtues from repeated trials made of it on himself, having been visited by several attacks of a remittent between the years 1786 and 1791. He took the solution as directed to be prepared under the title of liquor arsenicalis, in doses of from eight to ten drops twice a day, and always experienced the curative effects of the medicine, during each period of its administration, to be very pointed and successful. We are also informed by Dr. Ferriar,* that he has employed it in some very dangerous and tedious remittents, and always found it a safe and certain remedy. He observed that it generally lessened, Spe the new edition of his Medical Histories and Reflection? 5 -'t> PYREXIA, OR FEBRILE DISEASES. [ClttSS I. if it did not suspend, the second paroxysm after its being exhibited, and it effected the purpose without producing the slightest dis- turbance in the habit. To an adult, he usually gave five drops of the saturated solution every four hours, and seldom found it necessary to exceed this dose. The only sensible effects produ- ced by it, Dr. Ferriar tells us, are the removal of the crust on the tongue, the appearance of a sediment in the urine, and increased firmness of the pulse. Probably it might be best to administer this solution combined with the cinchona, either in substance, decoction, or infusion.— See Intermittents. Every thing that may have a tendency to bring on a fresh attack of fever is carefully to be avoided during the state of convalescence. A change of air and situation (particularly if it has been low and damp) may have a good effect in expediting the patient's recovery ; and if the appetite does not return readily, he may take stomachic bitters with advantage.-—See Dyspepsia for these. Gestation in the open air in wheel carriages is a remedy which has been strongly recommended by Dr. Jackson,* towards the close of the bilious remittent fever of warm climates, as well as of all others which have arisen from infection ; and he cites many instan- ces which fell under his treatment and immediate observation, whilst he officiated as physician to the army, both on foreign stations and at home, in which it was employed not only with safety, hut with the highest efficacy, particularly so in those where the diseased action had ceased, but where the healthy movement was slow. He observes, that although the good effects of gestation be in them^ selves conspicuous, they are at the same time much increased by ablutions, by an entire change of clothes, and by frictions, both before the journey is undertaken, and after it is finished. In seasons and places where this fever is prevalent, it will be advisable, by way of preventive, to take a proper dose of the tinct. cinchonae composita, about twice a day, but more particularly on an empty stomach in the morning. CONTINUED FEVERS. Fevers of this nature continue for several days with nearly the same violence, having evident exacerbations and remissions dailv, SYNOCHUS, or SIMPLE CONTINUED FEVER. Synocha and typhus, blended together in a slight degree, seem to constitute this species of fever, as has before been observed ; the former being apt to preponderate at its commencement, and the latter towards its termination. It is contagious, and is of more frequent occurrence in this country than any other kind of fever. ' See his Exposition on applying Cold Water in Fever, p. 398 Order /.] simple continued fever. ->'i Every thing which has a tendency to enervate the body, may be looked upon as a remote cause of fever; and accordingly, we find it often arising from great bodily fatigue, too great an indulgence in sensual pleasures, violent exertions, intemperance in drinking, and errors in diet; and now and then, likewise, from the suppression of some long-accustomed discharge. Certain passions of the mind (such as grief, fear, anxiety, and joy) have been enumerated among the causes of fever, and in a few instances it is probable they may have given rise to it; but the concurrence of some other power seems generally necessary to produce this effect. The most usual and universal cause of this fever is the application of cold to the body, giving a check to perspiration; and its morbid effects seem to depend partly upon certain circumstances of the cold itself, andpart- ly upon certain circumstances of the person to whom it is applied. The circumstances which seem to give the application of cold a due effect, are its degree of intensity ; the length of time which it is applied; its being applied generally, or only in a current of air; its having a degree of moisture accompanying it, and its being a considerable or sudden change from heat to cold. The circumstances of persons rendering them more liable to be affected by cold, seem to be debility, induced either by great fatigue or violent exertions ; by long fasting ; by the want of natural rest; by severe evacuations ; by preceding disease ; by errors in diet; by intemperance in drinking; by great sensuality; by too close an ap- plication to study, or giving way to grief, fear, or great anxiety ; by depriving the body of a part of its accustomed clothing; by expos- ing any one particular part of it while the rest is kept of its usual warmth; or by exposing it generally or suddenly to cold when heated much beyond its usual temperature : these we may therefore look upon as so many causes giving an effect to cold, which it other" wise might not have produced. Another frequent cause of fever seems to be, the breathing air contaminated by the vapour arising either directly or originally from the body of a person labouring under the disease. A peculiar matter is supposed to be generated in the body of a person affected with fever; and this floating in the atmosphere, and being applied to one in health, will, no doubt, often cause fever to take place in him, which has induced many to suppose that this infectious matter is produced in all fevers whatever, and that they are all more or les9 contagious. The effluvia arising from the human body, if long confined to one place without being diffused in the atmosphere, and proper cleanli- ness and a free ventilation are not sufficiently attended to, will, it is well known, acquire a singular virulence, and will, if inhaled or applied to the bodies of men, become a cause of fever. This happens frequently in typhus. Exhalations, arising from animal or vegetable substances in a state of putrefaction, have been looked upon as another general cause of fever; marshy or moist grounds, acted upon by heat for 28 PVREXI./E, OR FEBRILE DISEASES. [Class I. any length of time, usually send forth exhalations which prove a never failing source of fever. Marsh miasma, as these exhalations are usually termed, have, undoubtedly, the peculiar effect of inducing fever on human bodies, exposed under certain conditions to their influence. From their denomination it is too commonly understood that marshes are the only sources whence these exhalations arise; but they also proceed from moist earth, slime, mire or mud, in a great variety of situations and climates of inhabited, as well as unfrequented and uncultivated tracts of country, in almost every quarter of the globe. They are more powerful, concentrated, and virulent in hot climates and in warm seasons, than in temperate ones. It further appears, that the types, or periodical evolutions of the fever which they excite, are chiefly governed by the degrees of concentration which these exha- lations possess; the type being more continued and less intermit- tent or remittent, in proportion to the power of the exhalation. Numerous are the writers, who, for upwards of a century, have successively exerted their talents in pointing out what each con- ceived to be the proximate cause, or essential nature of fever; some supposing it to consist in a noxious matter, introduced into, or generated in the body, the increased action of the heart and arteries being an effort of nature to expel this morbific matter; others offer- ing it as their opinion, that it consisted in an increased secretion of bile; and others, again, that it is to be attributed to a spasmodic con- striction of the extreme vessels on the surface of the body, which, indeed, was the doctrine taught by the late Dr. Cullen. A modern writer,* however, tells us, that the local and primary seat of idiopa- thic fever is in the brain, and that it is nothing more or less than a species of phreriitis, or topical inflammation of the brain. Dr. Currie supposes debility ofapeculi'ar kind to be the first opera- tion of the remote cause producing fever; the necessary conse- quence, or concomitant effect, is, he thinks, a spasm or'contraction of the arteries, but more especially of the extreme vessels and capil- laries of the surface : hence follows an accumulation of blood on the heart and lungs, the reaction of these organs, the separation of mor- bid heat, and morbid association. The ground of this theory is indeed, nearly the same with that of Dr. Cullen, resting, however^ more fully on morbid heat, and admitting into the chain of opera- tion an appendage of morbid association. To investigate these different hypotheses, would lead me into a train of theoretical and vague reasoning, inconsistent with the plan of this publication; I shall, therefore, proceed to point out the manner in which fevers usually come on, barely observing, that the proximate cause of fever is by no means, as yet, satisfactorily ascertained, and that it is a disease, the whole of the appearances of which have not been accounted for.t * See Inquiry into the Seat and Nature of Fever, by H. Clutterbuck M T> 4 See Dissertation on Fever, by Dr. George Fordvce Order I.) simple continued fever. 2(J An attack of synochus is generally marked by the patient's being seized with a considerable degree of languor or sense of debility, together with sluggishness in motion, and frequent yawning and stretching; the face and extremities at the same time become pale, and the skin over the whole surface of the body appears constricted : he then perceives a sensation of cold in his back, passing from thence over his whole frame ; and this sense of cold continuing to increase, tremoursin the limbs and rigours of the body succeed. With these, there is a loss of appetite, want of taste in the mouth, slight pains in the head, back, and loins, and a small and frequent respiration. The sense of cold and its effects, after a little time, become less violent, and are alternated with flushings, and at last, going off altogether, they are succeeded by great heat diffused generally over the whole body ; the face looks flushed ; the skin is dry, as likewise the tongue ; universal restlessness prevails, with a violent pain in the head, oppression at the chest, sickness at the stomach, and an inclination to vomit. There is likewise greatthirst and costiveness; and the pulse is full and frequent, beating, perhaps, 90, 100, or 120 strokes in a minute. When the symptoms run very high, and there is a considerable determination of blood to the head, delirium will arise. In this fever, as well as most others of the continued kind, there is generally an increase of the symptoms towards evening. If the disease is likely to prove fatal, either by its long dura- tion, or by the severity of its symptoms, then a starting of the tendons, picking at the bed-clothes, involuntary discharges by urine and stool, coldness of the extremities, and hiccups, will be observed: where no such appearances take place, the disease will go through its course, and at length cease. As a fever once produced will go on, although its cause be entirely removed, there can be no certainty as to its duration ^and it is only by attending to certainappearances or changes, which usually take place on the approach of a crisis, that we can form any opinion or decision on this head. It has, moreover, been asserted by some of our eminent teachers of medicine, but more particularly by Dr. Cullen and Dr. George Fordyce,* that the continued or fresh cause of fever neither will increase that which is already produced, nor occasion a new one : but the soundness of this doctrine I am much inclined to doubt; for although a fever will run its course notwith- standing the cause which gave rise to it has ceased to exist, still the reiterated application of the cause, or continuance within the range of its influence, may, I think, signally exasperate the fever in its progress. The symptoms pointing out the approach of a crisis, are, the pulse becoming soft, moderate, and near its natural speed ; the tongue losing its fur and becoming clean, with an abatement of thirst; the skin being covered with a gentle moisture, and feeling soft to the touch ; the secretory organs performing their several offices, and the " See his Treatise^on Simple Fever, • jO pyrexia, or febrile diseases. [Class J. urine depositing flaky crystals of a dirty red colour, and becoming turbid on being allowed to stand any time. Many physicians have been of opinion that there is something in the nature of all acute diseases, except those of a putrid kind, which usually determines them to be of a certain duration ; and, therefore, that these terminations, when salutary, happen at certain periods of the disease rather than at others, unless disturbed in their progress by an improper mode of treatment, or the arising of some accidental circumstances. These periods are known by the appellation of critical days, and from the time of Hippocrates down to the present, have been pretty generally admitted. The truth of them, I think, can hardly be disputed, however they may be interrupted by various causes. A great number of phenomena show us, that both in the sound state and the diseased, nature has a tendency to observe certain periods; for instance, the vicissitudes of sleeping and watching, occurring with such regularity to every one ; the accurate periods that the menstrual flux observes, and the exact time of pregnancy in all viviparous animals, and many other such instances that might be adduced, all prove this law. With respect to diseases, every one must have observed the defi- nite periods which take place in regular intermittents, as well those universal as topical, in the course of true inflammation, which at the fourth, or at the farthest the seventh day, is resolved, or after this period changes either into abscess, gangrene, or scirrhus ; in exan- thematous eruptions, which, if they are favourable and regular, show themselves on a certain and definite day ; for example, the small-pox about the fourth day. All these appear to be founded on immutable laws, according to which the motions of the body in health and in disease are governed. The days on which it is supposed the termination of continued fevers principally happens, are the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth, and twentieth. A simple continued fever terminates always by a regular crisis in the manner before mentioned; or from the febrile matter falling on some particular parts, it excites inflammation, abscess, eruption, or destroys the patient. Great anxiety, loss of strength, intense heat, stupor, delirium, irregularity in the pulse, twitchings in the fingers and hands, picking at the bed-clothes, startings of the tendons, hiccups, invo- luntary evacuations by urine and stool, and such-like symptoms, point out the certain approach of death. On the contrary, when the senses remain clear and distinct, the febrile heat abates, the skin is soft and moist, the pulse becomes moderate and is regular, and the urine deposits flaky crystals, we may then expect a speedy and happy termination of the disease. It sometimes happens that the^ fever does not affect every part of the system equally; the symptoms being less severe in one part of it than in another. This, which the young and inexperienced Order I.] simple continued fever. 31 practitioner, and the by-standers in a much greater degree, are apt to think fortunate for the patient, is in fact the very reverse, as has been very judiciously observed by Dr. Fordyce ;* there being nothing more dangerous in fever than its not affecting every part of the system in an equal degree. The usual appearances which are to be observed on dissection of those who die of this fever, are congestion, or an effusion within the cranium, and topical affections, perhaps, of some of the viscera. In fever all motion of the body should be avoided, especially that which requires the exercise of the muscles ; the patient ought there- fore to be confined to his bed. The exercise of the mind proving a stimulus to the body, all impressions which lead to thought, es- pecially those which may excite emotion or passion, are to be carefully shunned. A person labouring under a fever ought there- fore to be kept as composed and quiet as possible ; and his chamber should not be close and warm, as is too usually the case, but, on the contrary, perfectly cool and sufficiently ventilated, taking care, however, that the air does not come in a direct stream or current upon him. He is likewise to be lightly covered with bed- clothes. The strict pursuance of an antiphlogistic regimen will be highly necessary to be observed in this fever, as well as in some others of the continued kind. That sort of aliment which gives the least stimulus will be the most proper : the food should belight, nourish- ing, and easy of digestion, consisting of preparations of barley, oatmeal, sago, vermicelli, tapioca, and the meal of Indian arrow- root, varying them now and then for panado, roasted apples, &c. Animal broths produce an increase of heat in the body, and are there- fore improper, unless the patient is in a state of convalescence. For drink he may take barley water, linseed tea, toast and water, milk whey, thin gruel, and lemonade, which may be varied now and then for an infusion of balm, and such other herbs, carefully shunning the use of any kind of spirituous or fermented liquor. In fever it is no uncommon occurrence for peculiar longings to arise, and when they do, should always be gratified in moderation, although they may seem not altogether proper. The stomach, and the rest of the alimentary canal, are manifestly affected in many cases of fever in a higher degree than other parts of the body, and therefore emetics and purgatives are usually the first means which present themselves to the notice of the physician. In fever it will, therefore, be necessary to pay an early attention to the state of the stomach; and if there are any crudities or corrupted humours, producing nausea or vomiting, to dislodge them by ad- ministering a gentle emetic.t To assist its operation, the patient * See his fifth Dissertation on Fever. * 1. ft Pulv- Ipecac, gr. xv. j t 1. Take Powdered Ipecacuanha, fifteen grains. Vntimon. Tartarizat. gr. j. 1 Tartarized Antimony, one grain. 32 pyrexiae, or febrile diseases. [Class should drink freely of lukewarm water, or an infusion of chamo- mile flowers. To remove the feculent contents of the bowels some gentle laxa- tive* may be taken; and throughout the remainder of the disease the body should be kept open, if necessary, by a repetition of some such medicine, administered as the occasion may require, or by means of aperient clysters.t Where the disorder seems to have arisen from, or to be kept up by a redundant secretion of bile, mild purgatives will still be more highly necessary, and, perhaps, the submuriate of mercury, joined with a few grains of jalap or cathartic extract, may best answer our purpose. Purgative medi- cines are sometimes combined with antimonials.J In the simple continued fever it will seldom be necessary to have recourse to the lancet, particularly in warm climates ; but should the disease have arisen in a young person of a plethoric habit, and the attack of fever have been severe, with considerable flushing of the face, redness of the eyes, intense pain in the head, or delirium, and a full, hard, and obstructed pulse, or should there be symptoms of congestion in some important organ, we may then advise the taking away eight or ten ounces of blood from the arm. This quantity should be drawn off at once from a large orifice, and not by repeated bleedings, as by the former mode there will be greater temporary, but less permanent weakness induced by the evacuation. Under no other circumstances will it be advisable to resort to this operation. For the purpose of removing any pain of the head, the application of a few leeches to the forehead and temples will, in many cases, be quite sufficient; and where these are not to be pro- cured, a blister on the nape of the neck may be found a valuable substitute. By bleeding unnecessarily at the commencement of this fever, such a degree of weakness may be induced as, added to the depres- sion of strength, which arises in its progress, might produce symp- Aq. Menth. Virid. f. ^jss. M. ft. Haustus emeticus. * 2. ft Potassae Tartrat. Jss. Manna? Optim. |j. Aquae Fervent, f! |iij. ----Cinnam. f: ^ss. M. ft. Solutio, cujus sumat dimidium, et re- petatur dos. post horas duas, nisi alvus prius respondeat. t 3. g: Sodae Sulph. gss. Decoct.Malvae Composit. f. ^xij. 01ei01ivae,f. |-s.M. ft. Enema. t 4:^ Hydrargyri Submuriat. gr. v. Pulv. Antimonial. gr.j.—>j. M. ft. Pulvi? Mint Water, one ounce and a half. Mix these for an emetic draught. * 2. Take Tartrate of Potass, half an ounce. Manna, one ounce. Warm Water, three ounces. Cinnamon Water, half an ounce. Mix them, and of the solution take the half for a dose, which repeat after two hours, unless the bowels are sufficient- ly acted upon by the former. 13. Take Sulphate of Soda, half an ounce. Compound Decoction of Mal- low, twelve ounces. Olive Oil, half an ounce. Mix them for an aperient clyster. \4. Take Submuriate of Mercury, five grains. Antimonial Powder, from one to two grains. Mix them. Order I.\ SIMPLE CONTINUED FEVER. 33 toms of putrefaction in the second or third week of the disease so as to prove fatal. By neglecting to bleed, however, when-'the pulse is full, hard, and quick, the respiration hurried, breath hot, skin dry, and the head highly painful, we shall commit a dangerous error, and endanger the life of the patient. It has been considered by some physicians of eminence,* that the best time of drawing blood is in the evening, during the febrile paroxysm, as the patients then bear it better, and the relief the next day is always observed to be more effectual and permanent. Bleeding in fevers is strongly .recommended by a late writer,! and he seems to value it far more highly than any of his cotempo- raries. In malignant fevers it has generally been considered as near- ly inadmissible ; but even in these, as well as the fevers of tropical climates, he deems it, on many occasions, to be an essential part of the preparation for his curative means. It is necessary, however, to observe, that he by no means considers bleeding as a debilitating process. Its effects, he says, are stimulative, relatively according to the circumstances of the subject, and they are extensive, for they are felt in all parts of the circulating system, and conse- quently through the whole extent of the animated machine. The abstraction of blood, by its express effect, diminishes the quantity of a body to be moved; and, therefore, increases the power of the mover: it thus facilitates motion; but this, we are told, is not all. The diminution of the quantity of blood, and change of movement in consequence of such diminution, is in some manner productive of a change of condition at the sources of life : motion is effected, changed, even suspended; diseased motions are arrested ; an opportunity is thereby furnished for the more effective action of those powers, which are provided and exprefsly calculated for the stimulation of the due action of health. Bleeding, as it is the most manageable power, so it possesses the most absolute in- fluence over animal movement, either as directly effective of a final purpose, or as preparatory to the action of other means necessary to insure the final purpose. Such is Dr. Jackson's mode of reasoning; and although plausible, still I conceive there will be found few among our modern physi- cians who will be ready to adopt his practice, but particularly those whose patients compose the higher classes in life, and whose ener- vated frames are ill calculated to bear copious depletion by vene- section. The stout, robust, and hardy British soldier and seaman (who, indeed, bear phlebotomy better than any class of people in private life) may undergo such a discipline with less injurious ef- fects, and in cases of severe attacks, may undoubtedly require a free use of the lancet; but surely the remedy in question cannot be so uni- versally necessary as Dr. Jackson supposes. He moreover tells us J * See the Works of Drs. Armstrong, Percival, and Cheyne. t See Dr. Jackson's Appendix to his Remarks on the Constitution of the Medical Department of the British Army. i See his Exposition on the Practice of applying Cold in Fevers. 6 3i pvrexije, or febrile diseases. [Class I. that a certain condition of susceptibilitj' is necessary to insure the action of whatever means we may employ in fever, and that where this does not exist naturally, it must be excited artificially, which is to be accomplished in some degree by applying fomentations to the legs and feet; or by immersing the lower parts, and even the whole of the body, in a warm bath, but principally by sub- tracting blood from a vein, the quantity of which is to be mea- sured according to the circumstances of the case, and the effect which arises in the course of the progress, and not by any precon- ceived opinion of what may be sufficient; for few, he observes, can be supposed to possess such a knowledge of the nature of things, as to be capable of measuring it with exactness in the prescription- book. The effect to be looked for, and which is to decide the mea- sure of the quantity, he notices, implies a remission of pains of all denominations, relaxation of the skin, freedom in all the secretory functions, and a change in the condition of the pulse, which, instead of being hard, tense, and tumultuously agitated, becomes free, open, and regular. Dr. Jackson is at the same time ready to admit, however, that many instances occur where the action of the fever is not principally manifested in the circulating system, either by increase or defect of action ; consequently, where bleeding is not the remedy of chief dependence. If great heat with much thirst prevails, refrigerant medicines may be taken with advantage, and the most useful of this class is the nitrate of potass, which may either be joined with others,* or be added to whatever the patient uses for common drink.t Acids of all kinds, when sufficiently diluted, are refrigerant reme- dies, well adapted to continued fevers. Those most in use are the sulphuric, mtftiatic, and vegetable, but more particularly the latter, such as the acfd of tamarinds, oranges, lemons, mulberries, &c. As a refrigerant, cold water may likewise be drank. For the purpose of arresting the febrile course, and moderating or abstracting the morbid excess of heat, and restoring a healthy action,cold bathing has of late years been much employed in fevers. The practice of bathing in fevers appears, indeed, to be of great antiquity, for its use andmanagement were well known to Galen, and are well defined by him. It farther appears, by the relation of travel- lers, to have been long used by several of the eastern nations. We have likewise indisputable proof that cold affusion had long ago * 5. ft SucciLimon. f. jjss. Potassae Subcarbon. 3j. vel. q. s. Ad ejus saturationem, -----Nitrat. gr. x. Aq. Fontan. f. 5j. Syrup. Violae, f. 3j. M. ft. Haustus, 3tia quaq. hora sumendus. t 6. g; Decoct. Hordei, Oij. Potassae Nitrat. sij. ft. Potus. * 5. Take Lemon Juice, half an ounce. Subcarbonate of Potass, one scruple, or a sufficiency. After being saturated, add Nitrate of Potass, ten grains. Pure Water, one ounce. Syrup of Violets, one drachm. Mix them, and let the draught be taken every three hours. t 6. Take Decoction of Barley, two pints Nitrate of Potass, two drachms. Mix them for ordinary drink. Order L] simple continued fever. 35 been employed by Dr. Wright of Jamaica, and some other physi- cians in the West Indies, particularly by Dr. Jackson. The notice which this remedy has attracted in England, has certainly, however, been owing to the popular manner in which the subject has been treated by the late Dr. Currie of Liverpool. For the safest time, and most advantageous mode of employing cold affusion in fevers, I beg leave to refer the reader to the admonitions given under the heads of Typhus Mitior and Typhus Gravior. Under the present, I will only observe, that affusion with cold water, either by means of a large watering pot, so as to allow the streams to pour on the head and shoulders with some force, or by dashing it out of a pail, may be boldly and fearlessly resorted to at the commencement of the greater number of fevers of every climate, where no catarrhal symptoms or inflammatory affection of the lungs are present; but in the advanced stages, or latter periods of most, and where there is much debility, this remedy should be adopted with due caution, and a careful consideration of the attendant circumstances. With a view to determine the circulation to the surface of the body, it will be right to resort to an early use of such medicines as possess this peculiar power. To excite a perspiration, it will in many cases be sufficient only to make the patient lie abed, and drink plentifully of diluting liquors; but should these simple means not prove efficacious, it will then be necessary to resort to more powerful agents. Neutral salts, when taken into the stomach, soon produce a sense of heat on the surface of the body ; and if it be covered close, and kept moderately warm, a gentle sweat is often readily brought on. These, therefore, being possessed of the power of determin- ing to the surface, are highly useful in fever, and may be prescri- bed as in the under-mentioned forms.* - 7. Pi Ammon. Subcarbonat. gr. x. Succi Limon. f. ^ss. Aq. Menth. Virid. f. gj. Tinct. Lav.Com. fit rj. Syr. Althaeae.f. 3ij. M. ft Haustus. Vel, 8. ft Succi Limon. f. gjss. Potassae Subcarbon.3j- vel q. s.ad. Ejus saturat. dein adde Aq. Menth. f. ^j. ---Fontan. f. ^iij. Antim. Tartarizat. gr. jss. ad ij. Syrup, f. gij. M. ft. Mistura, cujus capiat Cochl. ij. magna tertiis horis. Vel, 9. 5k Liquor. Ammon. Acetatis. * 7. Take Subcarbonate of Ammonia, ten grains. Lemon Juice, half an ounce. Mint Water, one ounce. Compound Tincture of Laven- der, ten drops. Syrup of Marshmallow, two drachms. Mix them for a draught Or, 8. Take Lemon Juice, one ounce and a half. Subcarbonate of Potass, about a drachm. After the effervescence has ceased, add— Mint Water, one ounce. Pure Water, three ounces. Tartarized Antimony, from one and a half grains to two grains. Common Syrup, two drachms. Mix them, and let the patient take two large spoonsful every three hours. Or, 9. Take a solution of Acetate of Ammonia, 36 PYREXIAE, OR FEBRILE DISEASES. [ClaSS I. Emetic medicines, and particularly antimonials, given inf small nauseating doses, have likewise a similar power of determining the circulation to the surface of the body, and of producing symptoms similar to those which take place in the crisis of fever: these are therefore advisable. They may either be combined with those of the before-mentioned class, or be given by themselves.* From the uncertainty with which Dr. James's Powder and the pulvis antimonialis act, the tartarized antimony may be considered as preferable in many cases. To increase the diaphoretic effect of these medicines the patient should take frequent small draughts of some tepid liquor. Warm bathing, or fomenting the lower extremities, are reme- dies sometimes employed in fever to produce moderate sweating. Where these relieve delirium, induce sleep, and are easily borne by the patient, we may be assured of their propriety. Sweating, however, when excited in fevers by stimulant, heating, and inflam- matory medicines, is almost sure to prove hurtful. It likewise proves injurious, when excited by much external heat: as also where, instead of relieving, it rather increases the frequency and hardness oft he pulse, the anxiety and difficulty of breathing, the headach, and delirium. When sweating is partial, and confined to the superior parts of the body, it will be more likely to prove hurt- ful that salutary. If a cough accompanies the fever, and a rawness and soreness in the fauces, together with a tightness at the chest, are present, then, Aquae Cinnam. aa f. ?ss. ----Fontan. f. gvi. Vini Antimon. 1T[ x. Spirit. Athens Nitrici, f. 3ss. M. ft. Haustus, 3tia quaq. hora sumendus. * 10. ft Pulv. Antim. gr.j.ad iij. Confect. Rosae, gr. vj. M. ft. Bolus, 4tis horis sumendus. Vel, 11. ft Pulv. Jacob. Ver. gr. v. pro dos. Vel, 12. ft Pulv. Ipecacuanhae, gr. iij. Confect. Cort. Aurant. gr. vj. M. ft. Bolus. Vel, 13. ft Antim. Tartarizat. gr. jss. Aq. Fontan. f. !|vj. Syrup. Croci, 3j. M. ft. Mistura, cujus sumat Cochl. ij. magna 2da vel 3tia hora. Cinnamon Water, of each half an ounce. Pure Water, six drachms. Antimonial Wine, fifteen drops. Spirit of Nitric jEther, half a drachm. Mix them, and give this draught every three hours. * 10. Take Antimonial Powder, from one to three grains. Confection of Roses, six grains. Make them into a bolus, to be taken every four hours. Or, 11. Take James's Powder, five grains for a dose. Or, 12. Take Powdered Ipecacuanha, three grains. Confection of Orange Peel, six grains. Form them into a bolus, to be taken every four hours, as the former. Or, 13. Take Tartarized Antimony, one grain and a half. Pure Water, six ounces. Syrup of Saffron, one drachm. Of this mixture, give two table spoonsful Order /.] simple continued fever. 37 besides pursuing the antiphlogistic plan before advised, we may give demulcents* in frequent repeated doses. Should a vomiting arise in the course of this fever, and the irrita- tion prove considerable, a saline draught may be taken in the act of effervescence, or it may be administered so as that this shall take place in the stomach. The manner of doing it is by giving the patient about half an ounce of lemon juice mixt up with a little mint water and syrup, and immediately afterwards, about a scruple ofthepotassas subcarbonas, dissolved in an ounce of common water. If the irritation at the stomach is not abated by this mean, we may add a few drops of tinctura opii with a little aqua cinnamomi. In this fever partial evacuations, such as purging and sweating, which have no tendency to prove critical, often arise. When these happen, we should, by all means, put a stop to them. The former may be checked by astringents, as below,! or as advised under the head of diarrhoea';' and the latter, by keeping the patient cool, by washing his body frequently with a sponge dipped in cold water, and giving him refrigerants. We may distinguish critical evacuations from those which are not so, by attending to the appearances which take place in other parts of the system. For instance, if a purging should arise, and the tongue continue foul, and the skin dry, without any abatement of heat and thirst, then we may regard it as by no means critical; but if, on its taking place, the tongue becomes clean and moist, the pulse moderates, the febrile symptoms abate, and the skin has a gentle breathing sweat universally diffused over it, then a crisis may be expected. In the progress of this fever it sometimes happens that particu- 14. ft Cetacei, gij. Vitel. Ovi, q. s. ad solut. Dein adde Aquae Pulegii, f- §iv. Aceti Scil. f. 3ij- Syrup. Tolutan. f. Jjiij. M. ft.Mistura,cujussumatpaululumsubinde. Vel, 15 ft. Mucil. G. Acaciae, Aq. Fontan. aa ^iij. Potassae Nitrat. 3j. Vin. Antimon. fll xxx. Syrup. Limon. f. |ss. M. ft. Mistura. Cochl. ij. pro dos. tusse ur- genti sumenda. t 16. ft Confect. Aromat. gij. Aq. Cinnam. f. !|j. ----Fontan. f ^iij. Tinct. Catechu, f. 3ij- M. ft. Mistura cujus surnat Cochl. ij. magna post singulas sedes liquidas. * 14. Take Spermaceti, two drachms. Yolk of an Egg, sufficiency to dissolve the former. Then add Penny Royal Water, four ounces. Vinegarof Squill, 2 drachms. Syrup of Tolu, three drachms. Mix them well together, and let^the pa- tient take a mouthful'from timeto time. Or, 15. Take Mucilage of Acacia, Pure Water, each three ounces. Nitrate of Potass, one drachm. Antimonial Wine, fifty drops. Syrup of Lemons,half an ounce. Mix them, and give about two large spoonsful occasionally, as the cough is troublesome. 116. Take Aromatic Confection, two drachms. Cinnamon':Water,*one ounce. Pure Water, three ounces. Tincture of Catechu, two drachms. Mix them, and let two table spoonsful be taken after every liquid stool. 38 pyrexia, or febrile diseases. [Class I. lar parts of the body are much affected, and that there prevails either great oppression of breathing, or that violent pains in the head, stupor, or delirium ensue. In all such cases, the application of a blister near the part affected will be proper, and relief will often be quickly procured by it. Where there is any unusual cold- ness of the extremities, with a sinking pulse, blisters to the inside of the legs will likewise prove highly serviceable. Their efficacy in such cases may be increased by the application of stimulating cataplasms* to the soles of the feet and palms of the hands. Cam- phor, ammonia, musk, and aether, are remedies which may be used at the same time, either separately or combined together; and the patient should be allowed a liberal use of wine, both in a diluted and undiluted state. When we administer camphor in this or any other disease in a liquid form, in order to render it properly diffusive in water, and obtain its full effect, we should (instead of trusting to the mistura camphorae of the London Dispensatory, which contains but a small proportion of the resin) dissolve it in a little rectified spirit, or ex- pressed oil, and then triturate it well with mucilage of gum acacia previous to adding the water. By triturating camphor with milk, it is nearly as readily dissolved as with rectified spirit. The emulsio camphorata may be prepared agreeable to the annexed prescrip- tion,! and none of the camphor will be lost by precipitation. Severe pains in the head, accompanied with a throbbing of the arteries, or any degree of delirium, and which have not been sub- dued by leeches to the temples, or a blister to the nape of the neck, may sometimes be relieved by the application of linen rags, mois- tened in cold evaporating fluids (such as water, with an addition of aether) to the forehead or shaven scalp. Under this cooling pro- cess I have known tranquillity and sleep succeed to restlessness in the course of a few hours. In synochus there is often a great interruption to sleep; and the more violent the fever, the greater in general is the interruption. It is unfortunate, however, that it cannot be procured with safety to the patient, as opium proves generally prejudicial in all fevers, except those of the typhus kind. To procure rest, therefore, in that which I am treating of, we must be contented in directing him to be kept as still and quiet as possible. If necessity obliges us to a use of sedatives, the spiritus aetheris nitrici, and Hoffman's liquor, will be the least exceptionable. 17. ft Seminum Sinapeos Crass. Medullae Panis, aa foss. Aceti quantam satis sit. M. et fiat Cataplasma. t 18. ft Camphorae, 3ss. solv. in Lactis Vaccinae, §ij. dein adde Aq. Purae, % vi. f. M. ft. Emulsio. * 17. Take Bruised Mustard Seed, Crumb of Bread, each half a pound. Vinegar, a sufficiency to form the whole into a Cataplasm. 118. Dissolve Camphor, half a drachm, in Fresh Milk, two ounces, then add Pure Water, six ounces. Mix them so as to make the whole into an Emulsion. Order /.] simple continued fever. 39 Where this fever is kept up merely by weakness and irritability, opium, given in small doses, may be proper. If it is found to pro- cure refreshing sleep, the dose may be repeated the ensuing night; but if the rest has been much disturbed, its use ought to be dis- continued. By introducing opium into the system by means of friction, as advised under the head Cholera Morbus, it possibly might not be attended with any injurious effect. In this fever, as well as in all others, where we wish to procure sleep, and cannot have recourse to opium, on account of delirium being present, we may employ some of the preparations of the hop, or humulus lupulus, such as its extract or tincture. Hyoscyamus is now and then given under similar circumstances with benefit. This fever is, in some instances, continued and kept up solely by debility, as has been just mentioned. In such cases, if the symp- toms are mild, we may venture to prescribe a use of the cinchona bark ; and as it will be more likely to sit easy on the stomach in the form of decoction* or infusion,! these preparations of it will here be preferable to giving it in substance. If, on a trial, the patient sleeps well, breathes easily, and does not find any increased heat, we may then venture to go on with it; but if, on the contrary, it produces restlessness, difficulty of breathing, &c. its use should be omitted. In the continued fevers of warm climates we should by no means wait foracomplete crisis, inorder to administer the bark of cinchona. In these it will be prudent to embrace even the least remission, let it be ever so imperfect, or of short duration, as likewise to give it in as large doses as the stomach will bear, and to repeat these fre- quently. The same attention must, however, be paid to the effects it produces, as have been mentioned, or may hereafter be noticed. In cold climates it is usual to wait for a regular intermission be- fore the cinchona is given. As a tonic, this medicine has acquired the greatest celebrity in all febrile cases, and is, therefore, usually preferred to all others ; its effects are evidently more obvious when given in substance, than in any other form. About a drachm of the * 19. ft Pulv Cinchonae, |i. Aq. Fontan. Ojss. Coque ad Oj. Col. dein adde Tinct. Calumbae, f. ^j. M^ ft. Decoctum, de quo sumat Cochl. iij. magna quartis horis. f 20. ft Cort. Cinchonae in pulv. trit.^ss. Aq. Bullient. f. |vj. post horam. Colat adde Tinct. Cort. Aurant. f.'3ij. M. ft. Infusum, cujus sumat Cochl. iij. tertiis horis. * 19. Take Powder of Peruvian Bark, one- ounce. Pure Water, one pint and a half. Boil these slowly till reduced to one pint, then strain off the liquor, and add Tincture of Calumbo, one ounce, Mix them, and of the decoction let three table spoonsful be taken every four hours. t 20. Take Peruvian Bark, reduced to a coarse Powder, half an ounce. Boiling Water, six ounces. Infuse them for an hour, strain off the liquor, and add Tincture of Orange Peel, two drachms. Mix them, and let three table spoonsful be taken every three hours of this infusion. 40 PYREXIA, OR FEBRIXE DISEASES. [ClaSS I. powder is a common dose, and this may be repeated every two or three hours, according to the exigency of the case. Ten or twelve drops of the acidum sulphuricum dilutum may be added to each dose. The bark of cinchona is apt, at first taking it, to affect the bowels, and pass off by stool with many people. When this hap- pens, five or six drops of the tinctura opii, or about half a drachm of the tinctura catechu, may be added to each dose. With some persons the cinchona bark will not sit easy on the stomach almost in any shape. In such cases we may substitute the use of quassia,* or any of the other astringent bitters noticed under the head of Intermittents. On a recovery from fever the patient should cautiously avoid any fatigue, exposure to cold, or improper food. As restoratives, a ge- nerous diet, with a moderate use of wine, will be serviceable ; and if the season of the year will admit of cold bathing, it will likewise be advisable. A change of air, with moderate daily exercise, either in a carriage or on horseback, will prove powerful auxiliaries in en- abling the convalescent to regain his strength. Where the appetite is defective, we may prescribe stomachic bitters.—See Dyspepsia. SYNOCHA, or INFLAMMATORY FEVER. Synocha is a fever with much increased heat; a frequent, strong, and hard pulse ; the urine red : the animal functions but little dis- turbed, although at an advanced stage the sensorium is apt to be- come much affected. We may readily distinguish synocha from either typhus mitior or typhus gravior by its being attended with symptoms of an inflammatory nature. It makes its attack at all seasons of the year, but is most prevalent in the spring; and it seizes persons of all ages and habits, but more particularly those in the vigour of life, with strong elastic fibres, and of a plethoric con- stitution. It is a species of fever almost peculiar to cold and tem- perate climates, being rarely met with in very warm ones, except among Europeans lately arrived; and even then the inflammatory stage is of short duration, as it soon assumes the typhoid type. The exciting causes are, sudden transitions from heat to cold, the application of cold to the body when warm, swallowing cold liquors when much heated by exercise, too free a use of vinous and spiri- tuous liquors,greatintemperance,violentpassionsof the mind, expo- sure to the rays of the sun, topical inflammation, the suppression of habitual evacuations, the drying up of old ulcers, and the sudden * 21. ft Quassiae, gij. Aq. Bullient. f. |vj. post horam Colat. adde Tinct. Calumb. ----Card. Com. aa f. §ss. M. ft. Mistura, cujus capiat Cochl. ij. tertiis horis cum Acidi Sulphur. Diluti fll x. * 21. Take Quassia, two drachms. Boiling Water, six ounces. Strain off the liquor after one hour's infusion, and add Tincture of Calumbo, Compound Tincture of Carda- moms, each half an ounce. Mix them, and take two table spoonsful every three hours, with fifteen drops of Diluted Sulphuric Acid. Order /.] inflammatory fever. 41 repulsion of eruptions. It may be doubted if this fever ever origi- nates from personal infection ; but it is possible for it to appear pretty generally among such as are of a robust habit, from a pecu- liar state of the atmosphere. It comes on with a sense of lassitude and inactivity, succeeded by vertigo, rigours, and pains over the whole body, but more par- ticularly in the head and back ; which symptoms are shortly follow- ed by redness of the face, throbbing of the temples, great restless- ness, intense heat, and unquenchable thirst, oppression of breath- ing, and nausea. The skin is dry and parched; the eyes appear inflamed, and are incapable of bearing the light ; trie tongue is of a scarlet colour at the sides, and furred withHvhite in the centre : the urine is red and scanty, the body is costive, and there is a quickness, with a fulness and hardness in the pulse, not much af- fected by any pressure made on the artery. Its pulsations are from 90 to 130 in a minute; and when blood is drawn, it exhibits a yellowish or buffy crust on its surface, which is the coagulable lymph or fibrin. If the febrile symptoms run very high, and proper means are not used at an early period, stupor and delirium come on at a more advanced stage ; the imagination becomes much dis- turbed and hurried, and the patient raves violently. The disease usually goes through its course in about fourteen days, and terminates critically, either by a diaphoresis, diarrhoea, haemorrhage from the nose, or the deposit of a copious sediment in the urine ; which crisis is usually preceded by some variation in the pulse. In some instances, it, however, terminates fatally. Our judgment, as to the termination of the disease, must be form- ed from the violence of the attack, and the nature of the symptoms. If the fever runs high, or continues many days, with great action of the heart and arteries, flushed, turgid face, red eyes, intolerance of light, with vertigo, or early stupor and delirium, the event may be doubtful; but if to these are added, picking at the bed-clothes, starl- ings of the tendons, involuntary discharges by stool and urine, and hiccups, it will then certainly be fatal. On the contrary, if the febrile heat abates, and the other symptoms moderate, and there is a tendency to a crisis, which is marked by an universal and natural perspiration on the body; by the urine depositing a lateritious sedi- ment, and by the pulse becoming more slow or soft; or by a haemor- rhage from the nose ; diarrhoea supervening ; or the formation of abscesses ; we may then expect a recovery. In a few cases, this fever has been succeeded by mania. On opening those who die of an inflammatory fever an effusion is often perceived within the cranium ; and now and then topical affections of some of the viscera are to be observed. From the symptoms which attend this disease, it is evident our endeavours should be early exerted to avoid the mischief that may ensue from general inflammation; and as evacuation by bleeding is the chief mean we can confide in, it should be resorted to on the first of its attack; and one large bleeding at this period will have a much better effect than repeated small ones afterwards. If the 7 42 FYREXIJE, OR FEBRILE DISEASES. [ClaSS I. symptoms run high, therefore, and the person is young and pletho- ric, twelve or sixteen ounces may be drawn off at once from the arm through a large orifice. In repeating the operation, we are to be governed by the effect it produces on the pulse, and by the ap- pearance the blood puts on after standing some time. If the for- mer continues full, strong, and tense, and the latter exhibits a buffy, sizy coat on its surface, the bleeding should be repeated by all means, but in smaller quantity than before. Blood-letting relaxes the vascular system, diminishes its action, and takes off plethora. The pulse, in this fever, is apt, however, to become fuller and stronger afterWeeding, which may easily be explained ; for the ple- thora may be so great as to distend the vessels beyond their proper tone : in such cases the vessels cannot act fully, and the pulse is contracted ; but when the plethora is taken off by copious bleeding, and the vessels are allowed to contract properly, the pulse becomes fuller, which shows that the remedy has been proper, and should induce us to repeat the operation if the case requires it. It may be difficult to determine whether drawing blood from the temporal artery ought not to be preferred in severe attacks to vene- section at the arm. Both, indeed, will relieve the headach, gid- diness, and stupor ; but I conceive that a more permanent benefit will be derived from the former. When the fever has been of several days' standing, and the head is much affected either with severe pain or delirium, topical bleed- ing, by the application of three or four leeches to each temple, may be preferable to any other mode of drawing blood. Applying linen cloths, wetted in cold water with aether, to the forehead and temples, or over the shaven scalp, may be attended with some advantage in such cases. With the view of diminishing inflammation and general excitement, digitalishasbeen proposedasa remedy in this disease, afterhavingem- ployed proper venesection ; and probably it may prove serviceable. If any nausea prevails at the commencement of the disease the stomach may be relieved by making the patient drink one or two cupsful of an infusion of the flores anthemidis ; but should these simple means not be attended with the desired effect, he may then take a table spoonful of an emetic solution,* every quarter of an hour, until sufficiently eased. To obviate costiveness, one or two motions should be procured daily, by means either of some aperient medicine,! or by laxative * l.TakeTartarized Antimony,twograins. Pure water, three ounces. „„. , sy™P °f Saffron, one drachm. Mix them. 12. Take Pulp of Tamarinds, half an ounce Supertartrate of Potass, two drachms. Boiling Water, five ounces- strain off the liquor, and add Cinnamon Water, one ounce * 1. R Antimon. Tartarizat. gr. ij. Aq. Fontanae, f. ^iij. Syr. Croci, f. 3j. M. t 2. g. Pulp. Tamarind. §ss. Potassae Supertartrat. 3.1 j. Aq. Bullientis, zv. Colat. adde Aq. Cinnam. f. ?j. Order /.] inflammatory fever. 43 clysters.* In synocha, cathartics, particularly the saline ones, will prove singularly useful. If the stomach is in an irritable state, we can substitute a few grains of the hydrargyri submurias, made up into pills, with a small quantity of cathartic extract, instead of the other laxative medicines. To abate thirst the patient should be directed to drink frequently of diluting liquors, acidulated with lemon juice or potassae super- tartras. He may likewise take small and frequently repeated doses of the nitrate of potass;! or as a refrigerant, he may be allowed to drink freely of cold water. For the purpose of moderating or abstracting the morbid excess of heat, various parts of the body should be sponged frequently with cold water. Cool air may be freely admitted also, as it has been found that a person in fever may be kept much cooler than one in health without uneasiness or harm. The acid fruits, such as oranges, &c. will be very proper. Sudorifics do not appear to be advisable in this fever, as they might bring on profuse sweating; and it is not possible to keep the body warm without producing a considerable increase of heat. The neutral salts may be given in any of the forms advised under the head of Simple Fever, every two or three hours, joined with small nauseating doses of tartarized antimony, or the like. A pediluvium at night may assist their effect. Should the breathing be oppressed, or should stupor or delirium arise, it will then be right to apply a blister in the neighbourhood of the part so affected. If the pulse sinks, and the extremities become cold, the application of sinapisms to the soles of the feet will be proper. Camphor, aether, ammonia, and cordials, will be proper remedies on such occasions. In this fever, as in most others, sleep is much interrupted, and from a want of this, delirium often arises: opium here would be an Antimon. Tartarizat. gr.j. M Sumat Cochl. iv. et repetatur dos. post horas tres, nisi alvus prius respondeat. Vel, 3. R Infus Sennae, f. Zjss. Magnes. Sulphat. giij. Mannae Optim. 3ij- ft. Haustus aperiens. * 4. R Infusi Sennae, f. ?xss M. Sodae Sulphat. 5j 01. Olivae, f. |ss. M. ft. Enema. t 5. ft Potassae Nitrat. 3ij- -------Supertart giij. Antimon. Tartarizat. gr. jss. M. ft Pulvis, dividend, in Chart, vj. Sumat j. dosem tertia hora. Tartarized Antimony, one grain. Take four table spoonsful, and repeat the dose in three hours, should no mo- tions be procured in that time. Or, 3. Take Infusion of Senna, one ounce and a half. Sulphate of Magnesia, three drachms. Manna, two drachms. Mix them for an aperient draught. * 4. Take Infusion of Senna, ten ounces and a half. Sulphate of Soda, one ounce. Olive Oil, half an ounce. Mix them for a clyster. t 5. Take Nitrate of Potass, two drachms. Supertartrate of Potass, three drachms. Tartarized Antimony, one grain and a half. Mix them, and divide the powder into six doses, of which one is to be taken every three hours. 44 pyrexia:, or febrile diseases. [Class I. uncertain medicine, for, should it fail to procure rest, the delirium would be greatly increased by it. It should therefore be given only in cases of imminent danger, and even then, only in small doses frequently repeated, paying a strict attention to the effect it pro- duces. In other instances, we should be contented with giving directions for the patient to be kept as quiet as possible. Probably we might employ some of the preparations of the hu- mulus lupulus (hop,) or hyoscyamus, in this fever with benefit, in lieu of opium. In cases of severe delirium, threatening phrenitis, might not a use of the circular swing, noticed under the head of Mania, produce a good effect 1 Throughout the whole course of the disease, the patient is to ab- stain from solid food and animal broths, supporting nature with gruel, and preparations of barley, sago, tapioca, &c. His chamber is by no means to be kept warm, either by fires or by being closely shut up, as is too generally the case ; on the con- trary, it should be of a proper temperature, by allowing the admis- sion of cool air into it from time to time. His bed ought to be lightly covered with clothes. On his recovery a strict attention should be paid to regimen, scrupulously avoiding to overload the stomach, and partaking only of such things as are light, nutritive, and easy of digestion: all other causes likely to induce a relapse, are also to be carefully shunned. Fresh air, gentle exercise on horseback or in a carriage, agreeable company, and a moderate use of wine, will greatly contribute to the recovery of convalescents. Should the appetite not readily return, or the digestion prove weak, stomachic bitters,* conjoined with the cinchona bark, may be advised.—See Dyspepsia. TYPHUS MITIOR, or NERVOUS FEVER. Typhus is derived from rvQes, stupor, a degree of sensorial affec- tion which generally supervenes, sooner or later, in most continued fevers, and which is universally allowed to be a prominent symptom of that to which this name has been especially applied. Typhus mitior may be distinguished from typhus gravior at its commence- ment, by the attack being more gradual, and the symptoms much milder: in the progress of the disease, by the absence of those symptoms of putrescence enumerated in typhus gravior; and by its * 6. R Infus. Gentian. C. f. ^v. Tinct. Cort. Cinchona?, C. f. ^ss. -----Calumbae,f. 3iij. M. Capiat Cochl. ij. ter in die. Adde pro re nata Acid. Sulph.DilufuT. x. adxv. * 6. Take Compound Infusion of Gentian, five ounces. Tincture of Bark, half an ounce. -------■— Calumbo, three drachms. Mix them, and give two table spoonsful thrice a day, adding occasionally from htteen to twenty drops of the Diluted Sulphuric Acid. Order /.] NERVOUS FEVER. Ab being accompanied with less heat and thirst, less frequency of the pulse, and no bilious vomitings. It principally attacks those of weak lax fibres ; those who lead a sedentary life, and neglect proper exercise ; those who study much; and those who indulge freely in enervating liquors. It likewise is apt to attack those who are weakened from not using a quantity of nutritive food, proportionable to the exercise and fatigue they daily undergo ; hence it is very prevalent among the poor. It is often generated in jails, hospitals, transport and prison ships, ill-con- structed and crowded barracks, workhouses, and the ill-ventilated apartments of the indigent. It is also to be met with very fre- quently in the damp and dirty cellars of the poorer class of manu- facturers in large towns. In warm climates typhus sometimes occurs, and continued fevers. of most kind, are apt to degenerate into fever of a typhoid type! It is, however, most prevalent in temperate and cold climates. In Great Britain typhus is favoured by a low temperature, being most prevalent in the cold months of winter, generally abating or disap- pearing as the heat of summer advances, and often prevailing in a considerable degree in cool wet autumns. The most general cause of typhus mitior is contagion, communi- cated through the medium of an impure or vitiated atmosphere, by concentrated effluvia arising from the body of a person labouring under the specific disease; but whatever debilitates the system or depresses the mind, may induce a state of predisposition more readily to be influenced by the operation thereof. Thus, perhaps, we may explain the fact of the ready spreading of an epidemic fever among an army which has for some time suffered great fatigue and exhaustion, as happened with that under the command of Sir John Moore on his retreat to Corunna, or among a people who are ill supplied with nutritive food ; whence war, famine, and pesti- lence, have been observed to succeed each other, or to occur to- gether, from the earliest periods of history. A season of continu- ed heat, combined with moisture, appears also to predispose the human constitution to receive the impression of contagion: for contagious diseases more generally become epidemicin the autum- nal period of the year. In the origin and progress of typhus and such-like fevers, it is undeniable that contagion is the most powerful agent in propagating the disease ; but still many of these fevers, though not contagious at their origin, become so in their progress and decline, and in some instances generate others of a much worse description than the original ; and this is the way, probably, in which epidemics ap- pear and spread. In a number of persons exposed to the contagion of typhus, some (although rarely) are attacked on the third or fourth day, and others again on the thirteenth; but the most common periods of sickening, after exposure, are from the end of the first week to the middle of the third. '16 pyrexia, or febrile diseases. [Class I. Dr. Haygarth* has employed much attention for many years to ascertain, by numerous facts which had occurred to himself and to other practitioners with whom he had professional intercourse, in what manner the contagion of typhus is propagated, in order to discover how it. may be prevented. The conclusions which he has deduced from these facts are of very great importance, for the prevention of misery and preservation of life. They may be briefly comprised, he thinks, in the following natural laws of typhous contagion. 1. Miasms (or contagious vapours,) issuing from patients ill of typhus, or from the poison contained in their dirty clothes, utensils, &c. are diffused or dissolved in air, and thus infect persons who are exposed to them. II. These miasms render the air infectious but to a little distance from the patient, or the poison. They never extend so far as to infect persons in an adjoining street, nor an adjoining house, nor in an adjoining room of the same house, nor even in the patient's own chamber, if large, airy, and kept clean.! III. Not more than one person in twenty-three is naturally ex- empted from typhus; for when one hundred and eighty-eight men, women, and children, were exposed fully to the typhous contagion, for days and nights together, in small, close, and dirty rooms, all of them except eight were infected with this fever.f IV. The miasms of variolous, scarlet, typhous, and other conta- gions, do not render clothes, &c. exposed to them contagious.§ V. Hence, it follows, that the only way by which typhus can be conveyed from the patient's room, so as to infect others out of it, is in the form of contagious dirt, as dirty clothes, utensils, &c. and consequently that the contagion may be completely destroyed by washing them clean. VI. The typhous poison remains in the body in ^.latent state from about the tenth to the seventy-second day,(] reckoning between the time of exposure to the contagion and the commencement of the fever. This law of nature was discovered by Dr. Haygarth in 1781, from observations on seventy-two cases. It was fully confirmed by Dr. Bancroft!! in 1809, from observations on ninety-nine cases, who as orderlies and nurses attended the army which had arrived at Ply- mouth from Corunna, infected with typhus: they had not been pre- viously exposed to contagion. He observed that the latent period of typhus varied from the thirteenth to the sixty-eighth day. From these laws of contagion observed by nature, Dr. Haygarth concludes that typhus may be easily and certainly prevented by ventilation (in large, airy, and clean rooms ;) or by separation (into * See his Letter to Dr Percival on the Prevention «>f Infectious Fevers. t See his Letter to Dr. Percival, p. 76. f See Letter, p. 31. § See Letter, p 54; and his Inquiry, pp. 67, 86; and his Sketch, pp. 217, 369, 384,386, 404, 542 ; and the cases related under Scarlet Fever, where 65 young la- dies were notinfected, though approached by clothes exposed to contagious miasms. || See Letter, pp. 64, 69. II See his Essay on Yellow and Typhus Fevers, p. 5ia[ Order I.J nervous fever. 47 an hospital, or into an adjoining room of the same house where prac- ticable ;) or, especially by cleanliness,* which entirely destroys the poison, wherever it can be completely accomplished. On these principles, the fever wards of the Chester Infirmary were established in 1783, the House of Recovery at Manchester in 1796, and since that time fever hospitals at Liverpool, London, Edinburgh, Dublin, and most of the large towns in Great Britain and Ireland. It is highly probable, that typhus always proceeds from a specific poison, like the small-pox, measles, &c. The opinion that typhus is generated by putrefaction, filth, bad diet, or accumu- lated human exhalations from many persons crowded together in a close room, has been completely refuted by Dr. Bancroft,! as Dr. Haygarth alleges, from numerous well authenticated facts. On the whole, it is manifest that typhus might be exterminated from any town or district by easy and practicable regulations. This conclusion Dr. Haygarth thinks is not conjectural. It is established on far stronger and more positive evidence than most other kinds of medical knowledge. Ever since 1783, being thirty-two years, the physicians of Chester have preserved their fellow-citizens from typhus, byrequiring the lodgings of the patients, generally strangers, to be completely cleansed on their removal into the fever wards of the Infirmary.| Other towns have established fever hospitals, but to very little purpose, because they have neglected, what is incom- parably of most importance, to cleanse thoroughly from all conta- gious dirt the houses whence infectious patients had been removed. It may not be irrelevant to add a few words on the manner in which the matter of contagion may be admitted into the body. It may be conveyed into the st mach by the saliva, or it may be absorbed by the skin ; but daily observation may satisfy us, that by far the most ordinary way is inhalation by the lungs. It is in this way applied to the delicate membranous expansion which covers all the minute vessels distributed with such an infinitude of branches around the air-cells of the lungs. The most general opinion which has been entertained of typhus fever is, that in all its stages it is a disease of real debility ; but a modern writer§ of some eminence tells us, that extensive observa- tion has convinced him, that genuine typhus, so far from being of an asthenic nature, is most certainly an affection of excitement, or of congestion in its first stages, demanding at such times the decidedly evacuant plan. By him typhus has been arranged under three varieties, viz. the simple, the inflammatory, and the congestive. I will not pretend to say, whether or not these divisions are either necessary or judicious ; but it must at the same time be admitted, that from a variety of circumstances, typhus may, however simple * See Dr. Haygarth's Letter to Dr. Percival, pp. 72. 89. t See his Essay on the Yellow Fever, &c. pp. 37—156. t See Dr. Haygarth's Letter to the Physicians of the Fever Hospital in Dublin, printed by the Society for bettering the Condition of the poor in Ireland. § See Practical Illustrations of Typhus, &c. by J. Armstrong, M. D. 48 pyrexia:, or febrile diseases. [Class I. in its outset, become connected with local inflammation and de- terminations of blood to the head, the chest, or abdominal viscera ; hence, occasionally there is considerable intellectual de- rangement, or there is uncommon irritabil ty of the stomach, in- testines, and liver, or there is a troublesome cough and pneumonic affection. Typhus mitior generally comes on with a remarkable mildness in all its symptoms; and although the patient experiences some tri- fling indisposition for several days, still he has no reason to suspect the approach of any severe disease. At first no rigours are per- ceived, there being only a slight chilliness, which is not succeeded by any increase of heat or redness of the face ; on the contrary, it is unusually pale and sunk. He perceives, however, some de- gree of lassitude, and apparently of debility, with anxiety, dejection of spirits, sighing, and a loathing of food; and towards evening these affections are somewhat increased. In the course of a few days, and as the disease advances, there arise a difficulty of breathing, oppression at the chest, pains in the head, accompanied with a confusion of ideas : there is great depres- sion of strength apparently, even occasionally to fainting, whenever the patient attempts to sit up ; the tongue becomes dry, and is covered with a dark brown fur; the teeth are thickly incrusted with the same ; the pulse is small, low, and frequent, and now and then intermits ; cold clammy sweats break out on the forehead and backs of the hands, while the palms glow with heat; the urine is pale and watery, like whey; the whole nervous system is much affected with tremors and twitchings ; involuntary motions of the muscles and tendons arise ; the patient picks at the bed-clothes, and either mutters to himself or talks incoherently. There is seldom, how- ever, any high degree of delirium, nor is this fever ever attended with violent ravings, but there is usually a dilatation in the pupils of the eyes. In simple typhus, there is usually some remission of the fever towards the morning, and the patient in general is less oppressed at that period than at any other throughout the twenty-four hours ; but as the excitement gains ground, the debility increases, and may be observed to be greatest, when the exacerbation is at its highest point in the evening. In the progress of the disease, the system is unequally affected ; for sometimes headach, restlessness, and uneasiness, prevail in a high degree, while at the same time the tongue is clean and moist: and at other times, while there is no headach or restlessness, the tongue will be dry, foul, and incrusted with dark fur, and profuse sweats will break out. This fever, moreover, is not only thus irregular in affecting various parts of the body differently, but it is also irregular in its exacerbations : and these, instead of taking place in the evening, will arise often in the morning. Again, some- times the fever is very violent for the first three or four days ; it then diminishes for a time, and then perhaps increases again. Order I.J NERVOUS FEVER. 49 Evacuations, such as sweating and purging, are very apt to ensue in the course of the disease, which never fail to exhaust the patient. In typhus fever, a great discharge of saliva sometimes occurs ; but as it now and then continues for a considerable time without affording any relief to the patient, it may be concluded to arise from some accidental circumstance, perhaps not unlike to the ptyalism that sometimes takes place in hysteria. In many in- stances, the spitting is so viscid and ropy as to inconvenience the patient very much, and by clogging up the fauces, greatly to im- pede both deglutition and respiration. In such cases, moreover, the tongue and whole of the mouth are frequently beset with aphthous ulcerations. Typhus mitior frequently runs on for some weeks, and produces such a state of debility as to destroy the person from that cause alone, or it degenerates into typhus gravior; but when it terminates favourably, it usually goes off about the fourteenth or twentieth day, perhaps, either by diarrhoea, or by a gentle moisture diffused equally over the whole body : but often it exceeds a month in du- ration, and terminates at last without any evident crisis. Profuse evacuations by sweating or purging, much watchfulness, sinking of the pulse, greatincoherency of ideas, mutterings, picking at the bedclothes, considerable dilatation of the pupils of the eyes, involuntary discharges by urine and stool, starting of the tendons, and hiccups, point out the near approach of death ; whereas on the contrary, the pulse becoming fuller and more slow, the tongue moist, respiration free, a gentle moisture coming on about the fourteenth day, deafness ensuing, tumors appearing behind the ears, or miliary eruptions, unattended by profuse sweats, being perceived on the body, promise a favourable termination. From the great disposition to relapse in the severer modifications of this fever, and the patient not being always safe until he is per- fectly recovered, it will be advisable to be cautious in the progno- sis or opinion we may give to the relatives of the sick, as to the final result. The usual appearances on dissection are, a softness and flaccidity in the solids ; a dissolved state of the fluids, particularly of the blood ; collections of sanious matter in the different cavities; tur- gescence and inflammation of the thoracic and abdominal viscera ; and in the interior parts of the brain, increased vascularity and collections of a serous fluid. In some cases, however, accompa- nied by great intellectual derangement from the beginning, the minutest dissection after death has not been able to detect the least vestige of cerebral disease. From the very gradual manner in which this fever comes on, the great mildness of the symptoms at its commencement, and the time that usually elapses previous to absolute confinement, it is seldom that practitioners have it in their power to cut short its progress by a timely exhibition of proper remedies. Typhus is a disease, which, 8 50 PYREXIA, OR FEBRILE DISEASES. [Class I. once formed, it is impossible to stop: it will run its course, and our treatment of it must consist in attending to its progress, and mitigating the violence of its symptoms when necessary. If there is any nausea or vomiting at the time 'of applying for advice, it will be right to recommend a gentle emetic of about four- teen or sixteen grains of ipecacuanha, to be immediately taken ; or should any costiveness prevail, we may prescribe some laxative medicine to carry off the feculent matter ; and to ensure and keep up a regular alvine evacuation in the further course of the disease, it will be proper to repeat this from time to time, or to have re- course to emollient laxative clysters. In many instances, however, the stimulus of the latter, being limited merely to the rectum, may not be adequate to procure so complete an evacuation as may be necessary; and therefore, in these cases, we ought to employ ape- rient medicines that will dislodge and bring off whatever feculent matter may be contained in the bowels, which by retention might be likely to prove highly offensive, as well as irritating. In admi- nistering purgatives, we ought, at the same time, to guard against employing them in such doses as to excite unusual secretion into the intestines, or Watery stools. Small doses of hydrargyri submu- rias or jalap,* or a solution of some mild neutral salt, will be the most proper medicines of this class. With these we may evacuate the contents of the bowels with safety and advantage in typhus, from the commencement to the termination of the fever. In many cases of typhus mitior, venesection will neither be neces- sary nor proper; and it should be borne in mind by every prac- titioner, that the system sooner sinks under depletion by the lancet in typhus, than in merely symptomatic fevers ; which peculiarity in the disease should never be lost sight of by the medical attendant, particularly when arising in persons of a delicate frame. Cases do occur, however, where typhus is somewhat complicated with visce- ral congestions, or with a considerable determination of blood to the head, giving rise to a high degree of stupor, and occasionally to much intellectual derangement. Under these circumstances, an abstraction of blood appears necessary ; but it is only at the onset of the fever, that blood-letting will be advisable, for when blood is drawn on the second or third day after the attack, it will often be found to have already suffered a change : it will be black, dissol- ved, and will not coagulate; under which state, depletion will of course be hurtful. To relieve the cerebral disease at the commencement, where the symptoms run high, topical bleeding from the temples, by means of several leeches, will be most advisable in persons of a delicate con- * 1. R Hydrargyr. Submur- gr. iij. * 1. Take Submuriate of Mercury, three grains. Pulv. Jalapae, gr. x. Powdered Jalap, ten grains. Syrup. Rhamni, q. s. M, Syrup of Buckthorn, a sufficien- Fiant pilulse iij cy to form the mass, which divide into three pill?, Order /.J .nervous fever. 51 stitution ; but in full plethoric habits, it maybe more proper to draw off six or eight ounces of blood from the jugular vein or arm on the first day of the attack. With regard to venesection in typhus, I would observe, that it is a remedy applicable only to particular cases, but by no means proper in all. A large portion of cases of this fever would be hurt by venesection, and in many, to say the least, it is uncalled for; but, on the other hand, there are some, and those the most formidable that fall under our observation, which as imperiously require it. The legitimate object of blood-letting in this disease, is the checking those dispositions to the inflamma- tory action which are often met with in severe cases. A judicious abstraction of blood, in the early stage of fever, not only diminishes the headach, the great sensibility to light and sound, as also the delirium, but it apparently shortens the course of the disease. That genuine acute inflammation does not always, or perhaps even in the majority of cases, attend typhus, may, I think, be ad- mitted ; yet in most of the worst cases, and by consequence in most of those which come under posthumous examination, there are unequivocal evidences of genuine inflammation, accompanied with those appearances of venous congestion, which frequently distin- guish these diseases from the proper phlegmasiae. In cold latitudes, and in the winter season of the year, it is by no means an uncommon occurrence to meet with typhus complicated with more or less of topical inflammation of the thoracic viscera, constituting pneumonia typhodes. In such cases, I have known venesection to have been employed ; but even in these, unless re- sorted to on the onset of the disease, it has appeared to me to be detrimental; and in two instances which occurred under my obser- vation, seemed indeed to have destroyed the patients. Instead, therefore, of having recourse to the lancet, where topical inflamma- tion of the viscera of the thorax attends on typhus, and has been of some days' continuance, I would recommend drawing blood from the chest, either by means of a few leeches, or by the application of a scarificator and cupping-glass.—See Pneumonia Typhodes. Affusing the body with cold water, is one of the most powerful and efficacious means which we can make use of in typhus fever; but its effects will be more salutary in proportion as it is adopted early, or during the first stage of the disease. Such being an indis- putable fact, established upon the firmest basis, we ought always to employ it during the first, second, or third day of excitement. The affusion may be repeated four or five times in the twenty-four hours, using spring water impregnated with common salt, when sea water is not to be procured, the feet of the patient being at the same time placed in warm water. The operation being over, they are to be dried, the patient put to bed, and some tepid bland fluid given to him, with the view of promoting a gentle perspiration. In a more advanced stage of the fever, it will be advisable to sub- stitute tepid affusion ; and when we do so, a small portion of ardent spirit may be added to the water, with the view of increasing the 5- pyrexia, or febrile disease*. [Class I. evaporative process, on which its efficacy depends in a great mea- sure. Vinegar is usually substituted on such occasions, but the former is preferable. We are informed by Dr. Currie,* that the safest and most advan- tageous time for using cold water, either in aspersion or affusion, (but he gives a preference to the latter,) is when the exacerbation is at its height, which is marked by increased flushing, thirst, and restlessness; or immediately after its declination has begun, which induced him to direct its being employed from six to nine o'clock in the evening; but he thinks that it may be used at any time of the day, when there is no sense of chilliness present, when the heat is steadily above what is natural, and when there is no general or profuse perspiration. During the cold stage of the paroxysm of fever, while there is any considerable sense of chilliness present, or where the body is under profuse sensible perspiration, this reme- dy ought never to be employed, as we might extinguish life by it. When cold affusion is used in the more advanced stage of ty- phus, where the heat is reduced, and the debility great, some cor- dial, such as wine warmed with an addition of spice, or even bran- dy, should be given immediately after it. In the early stage of the disease, cold affusion appears to cut short the progress of the dis- ease. At more advanced periods, when the strength of the pa- tient, and other circumstances, will admit of its application, it will seldom fail to moderate the symptoms, and materially contribute to a favourable termination. Whilst cold water dashed forcibly from a pail, or falling from a height in considerable quantity from a garden watering-pot, is deci- sively impressive, and ordinarily safe, when employed in an early- stage of this and other typhoid fevers ; so aspersion, or ablution of the body by means of a sponge, will be more eligible and safe in the advanced periods. The effects produced by both modes are grateful and refreshing to the patient, and they usually bring about an abatement of fever, followed by more or less of a diaphoresis, and this again by a refreshing sleep. As to the modus operandi of cold and tepid affusions, whatever may be their immediate influence on the temperature and nervous system, the permanently good effects are to be attributed to the changes which they induce in the circulation.! We .have been gratified with an ingenious publication from the pen of Dr. Jackson, on the subject of cold affusion ;J and although he agrees with Dr. Currie as to its utility and propriety in the milder forms of fever (whether infectious, and such as is usually called typhus, or endemic, such as arise from the action of common causes in a diffused form,) in the early stages of fever, still he dif- fers from this gentleman on other important points. Dr. Currie had employed the affusion of cold water in the mild * See his Medical Reports on the Effects of Water in Fevers he. t See Illustrations of Typhus, &c. by J. Armstrong, M. D. % See Exposition on the Practice of applying Cold in Fevers, by Dr. Jackson, Order I.J NERVOUS FEVER. 53 and open forms of fever, without any previous preparation, and likewise in those which are violent, concentrated, and complicated, provided the temperature of the body, on being measured by a thermometer, was higher than the natural standard; but when lower than this, he advises us to abstain from its application. Dr. Jackson, in resorting to it, is guided by what he terms the evidences of a susceptible condition of the system, connected with the simple condition of the disease, being obvious; of the presence of which, he judges by the sensation communicated to his hand in touching the patient's body. Where he finds this deficient in any degree, or where it is unusually distributed on the surface, and unaccompanied by any primary mark of local inflammation, or congestion of any one of the internal organs being discernible, he endeavours to restore the susceptibility of impression, by conducting the patient into an apartment where the air is of a high temperature ; by applying warm fomentations to the extremities ; by purifying the skin by warm water, soap, and brushes, and then by immersing the whole body in a warm bath, or by affusing warm water generally over its surface. Where there is either a violent or rapid action, or a slug- gish circulation, he does not consider these as proper conditions for the cold affusion; but to make them so, he recommends a prepara- tory process of general bleeding, and other evacuations : whereas, Dr. Currie considered venesection unnecessary to a previous use of cold affusion, except in cases of idiopathic inflammation. The affusion of cold water on the surface of the body, is con- sidered by Dr. Jackson as a power which makes a strong and general impression on the system, and which arrests the disease, or changes its condition in virtue of that impression ; but not by subtracting increased heat, as supposed by Dr. Currie. Indeed, the good ef- fects of the remedy in question cannot, I think, be wholly owing to the mere subtraction of heat; for it has been used with great advantage in many cases of fever, where there has been ho per- ceptible increase of temperature ; and where, by affusion, ablution, or aspersion with cold water, the disease has been cut short abrupt- ly, as well as in those where it had risen to a high point. I think we may safely infer that cold affusion, or the suddenly pouring cold water over the whole surface of the body, operates, as a pow- erful stimulant, although its effects, probably, are of short duration, unless frequently repeated; they are produced by the suddenness of the application affecting the nervous energy, and by the shock rousing the dormant susceptibility, so as to induce a new action, as it were, of the nervous system, removing spasmodic contraction of the extreme vessels on the surface, carrying off a large portion of morbid heat by general evaporation, and the remainder by insen- sible perspiration: thence restoring the healthy action of the ex- halants and capillaries. Although medicines which might excite much sweating would be highly improper in this fever, still we may venture to give those PYREXIA, OR FEBRILE DISEASES. [Class I. ful, indeed, are the effects produced by wine in typhus fever, when given in the proper stage, as we often see persons recover by a free use of it under unpromising circumstances. \A late physician* of greafcelebrity, recommends wine and opium in small quantities, repeated every three hours alternately, and this with a view of rousing the system from a state of torporand debility. In advising a free use of wine, I must caution the practitioner not to run into excess, and over-stimulate the patient, as this might destroy him. Wine, although a very grateful and convenient sti- mulus, is very liable to be abused by being given in too great a quan- tity, and at too early a period of the disease. In ordinary cases, a very good effect may be obtained by half a bottle in a day, and this may be regarded as a moderate quantity for an adult; but in some cases a whole bottle may be necessary, and in some a little more; but it should always be given with an equal part of water. The best rule is to proportion the quantity to the degree of debility pre- sent, the age of the patient, and the effect produced on him by it. Spirits have sometimes been recommended as a substitute for wine, in cases where the latter cannot be afforded or procured; but they do not answer so well. When given, they should be ad- ministered much diluted, as in the form of punch. Cider has been considered by some physicians, particularly Dr. Gregory, of Edin- burgh, as the best substitute for wine. Where wine disagrees with the patient, these may be employed, together with aromatics. Throughout the whole course of the disease, he should be kept perfectly quiet, and none but those whose business it is to attend on him ought to go near him, except in those cases where the symptoms are very mild, and where there is little or no affection of the head. In such cases the presence of a friend may sooth the mind, and help to dispel gloomy ideas. A plentiful supply of cool and fresh air throughout the whole course of the disease, is a point of the highest importance, and therefore the patient's chamber should be kept freely ventilated, and his bed be lightly covered with clothes: he should be solaced and comforted with the hope of a speedy recovery, and his thoughts be diverted from that anxiety and dread of danger which invariably attend the complaint. Many practitioners are in the habit of giving the cinchona bark in this fever, without waiting for even the most imperfect crisis ; some having in view its supposed febrifuge qualities, and others, its tonic powers. In mild cases, where there prevails hardly any stupor, or other affection of the head, and where the remissions are regular, it may perhaps be of service ; but in a state of convales- cence it will prove highly beneficial, and may therefore be given either in substance, decoction, or infusion, as may be found to sit best on the stomach, combined with a few drops of sulphuric or muriatic acid, or with subcarbonate of potass and lemon juice. Where the skin and the tongue are dry, where the remissions are * Dr. Darwin. Order I.J \ervous fever. 57 irregular, and where the fever abates for a day or two, and then returns with violence, I have always found it prove prejudicial. In all such cases, an infusion of cascarilla will be a better vehicle to administer the acids in, and I am of opinion that the muriatic is entitled to the preference. Miliary eruptions sometimes appear as the crisis to this fever ; they ought, therefore, by no means to be checked by any kind of evacuation, nor should the patient, on the contrary, be kept too warm in order to force them out. Where there prevails any unusual coldness in the lower extremi- ties, the application of a couple of small blisters to the inside of the legs, or of stimulating cataplasms to the soles of the feet, will be proper. In the last stage of typhus, when neither cinchona, wine, nor brandy, cold bathing, nor even occasional doses of Cayenne pepper, had the effect of rousing the powers of life, or of lessening the thick crust which covered the tongue, it appears, by Dr. Ferriar's report, that the most singular advantages were obtained by giving the arsenical solution. He found that it did not operate as a general stimulant, but merely as an active tonic, and therefore, that neither the concomitancy of cough, or dyspnoea, prohibits its use in typhus. As soon as the febrile paroxysms are stopped, he thinks it will be best to suspend the use of the arsenical solution, and to support the patient with bark and different cordials. A very severe case of typhus lately fell under my care, the patient having suffered two relapses of the fever, and her life despaired of, when I was induced to make trial of the mineral solution. Its effects exceeded my expectations, for the woman's life was apparently preserved by it. It was administered in an infusion of cascarilla, with an equal quantity of camphorated mixture. In bad cases, where startings of the tendons and hickups arise, besides making use of the means advised, it may be necessary to have recourse to antispasmodics,* such as musk, ammonia, aether, camphor, and opium. * 7. Take Musk, ten grains. Cinnamon Water, one ounce and a half. Spirit of Sulphuric iEther, twenty-five drops. Tincture of Opium,sixteen drops. Mix them for a draught, to be taken three times a day. Or, 8. Take Subcarbonate of Ammonia, five grains. Camphor, four grains. Opium, half a grain. Aromatic Confection, a suffi- ciency to form the whole into a bolus, to be taken every six hours. Or, 9. Take Musk Mixture, Camphor Mixture, each three ounces. 9 * 7. ft Mosch. gr. x. Aq. Cinnam. f. 5jjss. Spt. JEthev. Sulphuric, fit xv. Tinct. Opii, fll x. M. ft. Haustus, ter in die sumendus. Vel, S. ft Ammoniae Subc. gr. v. Camphor, gr. iv. Opii, gr. ss. Confect. Aromat. q. s. M. ft. Bolus, 6ta quaq. hora sumendus. Vel, !'■ R Misturae Moschi, -----Camphorae, aa f. ^iij. 58 PYREXIiE, OR FEBRILE DISEASES. [Class I. If this fever is likely, or threatens in its progress, to degenerate into typhus gravior, we should administer the mineral acids, but more particularly the muriatic, in such doses as the patient is capable of bearing. To prevent its affecting the stomach and bowels, a few drops of tinctura opii may be added to each dose. An infusion of cascarilla, calumbo, or orange peel, may be em- ployed as the vehicle, or we may give the acid in a little wine and water.—See Typhus Gravoir. In an advanced stage of this disease, it sometimes happens that, in addition to a profuse secretion of viscid saliva, little white ulcers, or aphtha?, appear in the inside of the mouth and fauces. In such cases, a gargle composed of borax, honey, and an infusion of roses, should be used three or four times a day.' When the fever goes off, and the patient has somewhat regained his strength, he may take daily exercise on horseback, or in a carriage; and in order to remove the irritability and weakness which are left behind, he should enter on a course of the cinchona bark, and other tonics. After a little time, the cold bath will be a proper remedy, if the season of the year is such as to admit of it. If the appetite does not readily return on the cessation of the fever, stomachic bitters* will be proper.—See Dyspepsia. A degree of mania, or temporary alienation of the mind, some- times arises at the close of typhus. All that can be done in such a case is to support the patient with a generous nutritive diet; to keep him as quiet and tranquil as possible ; and to put him under a course of tonics, carefully avoiding all evacuations. A specific poison, capable of causing a similar disease in others, is generated in the system of a person under this fever. The poison, as soon as the disease is fairly begun, continues unremittingly to exhale from every pore, until convalescence is nearly completed. Not only the surface of the skin, but also the inner surface of the Spirit. .Ether. Sulphuric, f. 3ij. M. ft. Mistura, de qua capiat Cochl ij. mag- na tertia vel quarta quaqtie hora. * 10. R Infus. Gentian. Comp. f. %iv. Tinct. Card. C. ----Calumb. aa f. 5jss. M. Capiat Cochl. ij. ampla mane, hora meri- diana, et vespere. Adde pro re nata Acid. Sulphur. Dilut. ft], xx. Vel, 11. R Infus. Cort. Cascaril. f. gx. Tinct. Gentian. C. ----Cinnam. C. aaf. 3j> Acid. Sulph. Dilut. fllxiij. ft. Haustus, ter in die sumendus. Spirit of Sulphuric .Ether, two drachms. Mix them. The dose may be two table spoonsful every three or four hours. * 10. Take Compound Infusion of Gen- tian, four ounces. -----■----Tincture of Carda- mums, Tincture of Calumbo, each half an ounce. Mix them, and give two table spoonsful morning, noon, and evening, adding occasionally thirty drops of the Diluted Sulphuric Acid. Or, 11. Take Infusion of Cascarilla, ten drachms. Compound Tincture of Gentian, ~" Cinnamon, each one drachm. Diluted Sulphuric Acid, twenty drops. Make them into a draught, which is to be taken three times a day. Order I.J nervous fever. ,)y lungs, mouth, intestines, and bladder, continue to pour out the con- tagious vapour; consequently the very secretions and excretions are highly impregnated with it. In truth, the patient is surround- ed by an atmosphere of his own, very deleterious to all persons susceptible of the disease, who may happen to be exposed to it. As a matter of precaution, therefore, strict non-intercourse with the sick should be enforced ; and those whose duty or kindness leads them to visit the patient should be very careful not to inhale his breath, or expose themselves to that steam of perspirable matter which emanates from his body when the bedclothes are turned down, for the purpose of rendering him any offices of assistance. While engaged in such duties, they should retain their breath for a time ; and if under the unavoidable necessity of inhaling the tainted atmosphere, they should, as soon afterwards as possible, blow from the nose, spit, or wash the mouth, with a view of detaching any infectious particles that may have adhered to these passages. All the discharges of the patientshould be thrown away at some distance as soon as they are rendered, and the vessel washed with boiling water. But the most important precaution of all is to maintain a perpetual circulation of air in the patient's chamber, throughout the whole course of the disease; and for this purpose, a part of the window should be left open both at top and bottom, and the oppo- site window where there is one, or else the door of the rofcm, should also be a little opened. For the better success of ventilation, the bed curtains should never be drawn close round the patient, but merely one of them let down to screen him from the irritation of light. When open windows cannot be had recourse to on account of high winds, or other inclemency of the weather,a small fire must be kindled in the grate, so as to cause a current and frequent re- newal of the air in the chamber, without considerably raising the temperature. Another essential precaution consists in frequently changing the body and bed-linen of the patient, which, as soon as removed and carried a'way. may be put into a tub and covered over with water, into which a handful of lime or potash maybe thrown, for the purpose of detaching the animal matters with which they may be impregnated. In few words, unremitting regard to venti- lation, and the strictest attention to cleanliness in all its parts, constitute the whole secret of evading contagion. Fumigations with nitric, or muriatic acid, in a state of vapour, as recommended under the succeeding head of Typhus Gravior, may, however, be employed as auxiliaries. As circumstances may occur for rendering it necessary to remove patients labouring under typhus fever to some distance, it is im- portant to know that this may be effected without subjecting them to any risk. Indeed, considerable benefit has been derived on such occasions by conveying the sick in open carriages, or spring wagons,* for several miles, freely exposed to the air. * See Outlines of the History and Cure of Fever, by J. Jackson, M. D.—Re- marks on the Constitution of the Medical Department of the Army, by the same. £0 pyrexia;, or febrile disease:-. [Class I. TYPHUS GRAVIOR, or MALIGNANT and PUTRID FEVER. This fever takes its name from the malignancy of its nature, and the symptoms of putrefaction which are to be observed towards its close. It is to be readily distinguished from the inflammatory by the smallness of the pulse, the sudden and great debility which ensues on its first attack, the brown or black tongue, the dark and fetid sordes about the teeth, the livid flush of the countenance, and the acrid and more intense heat of the skin : and in its more advanced stage, by the petichiae, or purple spots, which come out on various parts of the body, and the fetid stools which are dis- charged ; and it may be distinguished from typhus mitior by the great violence of all the symptoms on its first coming on. The most general cause which gives rise to this disease is conta- gion, applied either immediately from the body of a person labour- ing under it, or conveyed in clothes or merchandise, &c.; but possi- bly it may be occasioned by the effluvia arising either from animal or vegetable substances in a decayed or putrid state. A want of pro- per cleanliness, accumulated human exhalations, and contamina- ted air, may also, I think, prove causes of this fever; hence it pre- vails in the houses of the poor, in hospitals, jails, camps, and on board of ships, especially when such places are much crowded, and the strictest attention is not paid to a free ventilation and due cleanliness. Those of lax fibres, and who have been weakened by any previ- ous debilitating cause, such as poor diet, long fasting, hard labour, continued want of sleep, &c. are most liable to attacks of it. We are, therefore, to look on these as so many causes which induce that state of predisposition readily to be influenced by the opera- tion of contagious miasms. It has been denied by some physicians of the present time, that either the plague, yellow fever, or typhus, are contagious diseases; and it is true, indeed, that we cannot, in every case, ascertain that the complaint originated from a communication with diseased per- sons ; nor will the actual communication always produce fever: many predisposing causes are requisite ; and, moreover, the human constitution is evidently less susceptible of diseases at one time than at another. Whoever has paid proper attention to the symp- toms of typhus, may, however, be induced readily to conclude, that the surrounding atmosphere, to an extent more or less great, particularly in small, close, unventilated rooms, may become suffi- ciently impregnated with the effluvia continually exhaling from the diseased -body, to infect other persons with a similar disease. In a pure air, in large and well ventilated apartments, where the dress of the patient is frequently changed, all excrementitious discharges constantly removed, and an attention paid to cleanliness in general, neither typhus, under any form, plague, or dysentery, are usually Order I.J malignant and putrid fever. 61 contagious, or under such circumstances are rarely communicated from one person to another. Some writers have supposed infants to be as liable to fevers as adults, and from the same causes ; but I cannot agree with them; for I have observed that infants do not readily take fevers, although exposed for a long time to that contagion which has appeared to affect adults round them : and every physician who attends lying-in hospitals, must not only have known many infants suckled without injury, through the whole stage of bad fevers from which their mothers have recovered; but also, in other instances, sucking gree- dily within an hour or two of their mother's death. On the first coming on of typhus gravior, the person is seized with languor ; dejection of spirits; amazing depression of mus- cular strength; and apparently great debility; universal weariness and soreness ; pains in the head, back, and extremities, and rigours ; the eyes appear full, heavy, yellowish, and often a little inflamed; the temporal arteries throb violently ; the tongue is dry and parch- ed ; respiration is commonly laborious, and interrupted with deep sighing; the breath is hot and offensive ; the urine is crude and pale ; the body is costive; and the pulse is usually quick, small, and hard, and now and then fluttering and unequal. Sometimes a great heat, load, and pain, are felt at the pit of the stomach, and a vomiting of bilious matter ensues. As the disease advances, the pulse increases in frequency (beat- ing often from 100 to 130 in a minute :) there is apparently a vast debility; great heat and dryness of the skin; oppression at the breast, with anxiety, sighing, and moaning; the thirst is greatly increased; the tongue, mouth, lips, and teeth, are covered over with a brown or black tenacious fur ; the speech is inarticulate, and scarcely intelligible ; the patient mutters much, and delirium arises. The fever continuing to increase still more in violence, symp- toms of putrefaction show themselves; the breath becomes highly offensive; the urine deposits a black and fetid sediment; the stools are dark, disagreeable, and pass off insensibly ; haemorrhages issue from the gums, nostrils, mouth, and other parts of the body ; livid spots or petechias appear on its surface ; the pulse intermits and sinks; the extremities grow cold ; hickups ensue ; and death at last closes the tragic scene. When this fever does not terminate fatally, it generally begins, in cold climates, to diminish about the commencement of the third week, and goes off gradually towards the end of the fourth, without any very evident crisis ; but in warm climates it seldom continues above a week or ten days, if so long. Our opinion, as to the event, is to be formed by the degree of violence in the symptoms, particu- larly after the appearance of petechiae,although, in some instances, recoveries have been effected under the most unpromising appear- ances. An abatement of febrile heat and thirst, the tongue be- coming moist and clean, a gentle moisture diffused equally over the whole surface of the body, loose stools, turbid urine, the puis*; ti~ inKEXIit, OR FEBRILE DISEASES. [ClttSS I. being stronger, but less frequent, a free secretion of saliva, tumor and suppuration of the parotid, axillary, or inguinal glands, a scabby eruption about the mouth, and the delirium and stupor abating, or going off, may be regarded in a favourable light. On the contrary, great muscular debility, very laborious respiration, difficulty of deglutition, stupidity, and listlessness of the eyes, perpetual writh- ing of the body, petechias of a livid colour, with dark, offensive, and involuntary discharges by urine and stool, fetid and cadaverous sweats, haemorrhages, subsultus tendinum, and hickups, denote the almost certain dissolution of the patient. The appearances usually perceived on dissection are, inflamma- tions of the brain and viscera, but more particularly of the stomach and intestines, which are now and then found in a gangrenous state. In the muscular fibres there seems likewise a strong tendency to gangrene. On the very first taking place of any of the symptoms of thisfever, we should immediately attend to them, and endeavour to prevent any bad consequences from ensuing, as they will never go off of themselves, but will continue to increase, until a disease of a most dangerous nature takes place. This being the case, we should re- sort to proper remedies at the first onset, and not wait until the body is enervated. The most proper remedy at first, will be an emetic of about fifteen grains of ipecacuanha, with one grain of tartarized antimony, which may be worked off with an infusion of the flores anthemidis. An emetic at the commencement of the dis- ease, is a very important article, and the clearing of the stomach is not the only good effect to be expected from this remedy. After its operation is over, the bowels may be opened with some gentle purgative.* Possibly a few grains of hydrargyri submurias com- bined with jalap, or the extract of colocynth, may be preferable to any other. Should the desired effect not be produced by these medicines, an aperient clyster may be administered.! Throughout the course of the disease, the patient, in no case, should be more than two days without a stool, for a great deal of fasces are pro- duced in fever although little food is taken, and costiveness is * l.R Mann. Optim. 3\j. Potassae Tartrat. 3iij. Infus. Sennae, f. Jiss. M. ft. Solutio pro dos. Vel, •2. R Hydrargyr. Submur gr. v. Extract. Colocynth. C. gr. x. Fiant pilulae iij. pro dos. f 3. Decoct. Malvae Compos, f. Sjxij. Sodae Sulphat. zss. 01. Olivae, ft. gj: M. f. enema. *l.Take Manna, two drachms. Tartrate of Potass, three drachms. Infusion of Senna, one ounce and a half. Mix them for a dose. Or, 2 Take Submuriate of Mercury, five grains. Compound Extract of Colocynth, ten grains. Make the mass into three pills, to be taken at once. t3. Take Compound Decoction of Marsh- mallows, twelve ounces. Sulphate of Soda, half an ounce Olive Oil, one ounce. Mix them for a clyster. Order I.J malignant and putrid fever. Qj apt to induce an increase of heat, and affections of the head, as delirium, &c. These steps being pursued, and the nature of the disease clearly ascertained, 1 would advise the ablution of the patient with cold water, or rather a general affusion, provided the heat of the body is steadily above the temperature of health. The good effects of this mode of practice 1 have often experienced. The late Dr. Currie, of Liverpool, reports, that this fever having made its appearance in a regiment quartered in that town, he had the men drawn up and examined, seventeen of whom were found with symptoms of it upon them : these he subjected to the cold affusion once, or sometimes twice a day. In fifteen of this number the contagion was extinguished, and in the remaining two the fever went through its course. The healthy part of the regiment bathed in the sea daily, and by these means he effectually destroyed the contagion. He further relates, that of thirty-two who went through the disease, by its being too confirmed to be removed at the time of his first seeing them, only two died; and with these the cold affusion was not had recourse to. This gentleman's report, with the authorities of other practition- ers of eminence, clearly prove the application of cold water by affu- sion on the first attack of the complaint to be, under certain re- strictions, an efficacious remedy for stopping its progress, as like- wise that of other low contagious fevers. Dr. Currie found that the most advantageous time for using the cold affusion is when the exacerbation is at its height, or imme- diately after it is begun, which is generally from six to nine in the evening; but he observes it may be used with safety at any time of the day, when there is no great sense of chilliness present: when the heat of the surface is steadily above what is natural ; and when there is no general or profuse perspiration. The same remedy has likewise been successfully employed by him, myself, and many others, in the more advanced stage of the fever, so as seldom to fail of procuring a safe termination. He relates the case of a soldier who was in the ninth day of the disease when he first saw him : his pulse was 100, and feeble; his heat was 104 ; his thirst very great; his tongue foul and black ; his mind much confused, and at times he was delirious ; and petechias were dispersed over his whole body. The mode of treatment was as follows : his strength was directed to be supported by administering a bottle of wine a day, with an equal quantity of gruel; every night .he took an opiate draught, and his body was kept open by laxative clysters, and when these failed, by few grains of calomel. A bucket-full of salt water was directed to be thrown over him imme- diately, which was to be repeated according to circumstances. The effect was, that in a few minutes after the affusion, the heat lessened to 98 ; the pulse moderated to 96; and hi? mind became more calm and collected. Two hours afterwards he had relapsed 64 PYREXIA, OR FEBRILE DISEASES. [ClaSS I. nearly into his former state, but the night was passed with greater tranquillity. The whole of this practice was continued with nearly the same result, until the twelfth day of the disease, the affusion having been performed in the evening, and occasionally at noon. The fever continued its usual period; but on the twelfth day, the heat having sunk to its natural standard, the cold affusion was thenceforth omitted, and instead of it, the body was sponged all over one or twice a day with vinegar. In those cases where the fever had been of eleven, twelve, or thirteen days' standing, and the heat of the body was'inconsiderable, he thought it prudent to make the degree of cold very moderate, and in some instances he substituted tepid ablution, or sponged the body over with vinegar by itself or diluted with water. Some communications to Dr. Currie from Mr. Marshall, surgeon of the Cheshire regiment, bear further testimony of the good effects of this remedy in typhus fever. In sixty cases out of sixty-four, in which it was employed at an early period, the disease was arrested by having recourse to it three or four times: and in the other four which were advanced in their progress, although the disease was not stopped from going through its natural course, still all the patients recovered. Mr. Marshall mentions, that from the time he began the cold affusion, he used little or no wine, no opium, nor indeed scarcely any other remedy in any one case in which the cold affusion was employed ; which report is of itself sufficient to esta- blish its decided superiority over every other mode of treatment. It is, however, in the early stages of low contagious fevers that we can employ it with most advantage. It has, indeed, been used by many practitioners, in some instances, so late as the twelfth, or even the fourteenth day, with safety and success ; but it can only be employed at this advanced period, in the instances in which the heat keeps up steadily above the natural standard, and the respira- tion continues free. In such cases it has been observed to appease agitation and restlessness, dissipate delirium, and, as it were, snatch the patient from impending dissolution. When the remedy is to be had recourse to, every arrangement should be made for the affusion before the patient is moved at all, and fatigue as well as disquiet should be avoided as much as possible. In those cases where the delicacy of the system, or the apprehensions of the patient, or of the by-standers, may prevent cold affusion from being employed, we may substitute tepid affusion, for the [more powerful remedy! or we may recommend either ablution or aspersion. A memorable instance of the good effects of cold affusion came under my immediate knowledge some years ago, whilst I practised in the West Indies. A professional gentleman of my acquaintance, residing in the island of Nevis, was attacked with this fever, and it proceeded with such violence, that in a few days petechias appeared on different parts of his body, and a hasmorrhage of blood issued from his nostrils, mouth, and other places. Under these unfavour- Order I.J malignant and putrid fever. 65 able circumstances he was freely exposed to the open air, and one or two buckets of cold water were thrown over him ; he was then wiped perfectly dry, and replaced in his bed ; which plan of pro- ceeding was repeated twice and sometimes thrice a day. By means of this application, the administration of an opiate at night, and a liberal allowance of wine, his life was preserved, to the great but pleasing astonishment of all his friends. Of late years I have been much in the habit of recommending cold affusion, or ablution, in most cases of typhus fever, and with very beneficial effects. The same practice has been adopted in the London House of Recovery, and apparently with the most decided success. Obvious, however, as are the advantages to be derived from the remedy in question, still there are many practitioners who look on it as an innovation, and are therefore averse to it. This prejudice, I hope, will soon subside. In the early stage of typhus, the superior efficacy of affusion over ablution, is unquestionable ; its operation extends beyond the mere abstraction of heat from the surface: it acts powerfully on the nervous system. Besides its effectually removing the uneasy sensation of heat in the beginning of febrile diseases, and thus in- directly recruiting the animal powers, it induces sleep. We well know that when any disagreeable sensation is removed, sleep soon follows, and it happens so in this instance. After the fourth or fifth day of fever, the influence of both affusion and ablution is greatly diminished, and not sufficient to interrupt the morbid actions ; at a still more advanced stage the heat is removed nearly in the same degree by washing the surface of the body with a wetted sponge, or cloths dipped in water, as by pouring cold water on the naked body; and the patient is relieved nearly the same by one mode of treat- ment as by the other. Thus much for the comparative merits of affusion and ablution. In the advanced stages of typhus gravior, as well as of typhus mitior, where either the affusion of water, of a low temperature, the immersion of the patient, or even the sprinkling his body with cold water, might in the least endanger our arresting the movements of life, we should always take the precaution of giving a glass of warm wine, or some other powerful cordial, immediately after em- ploying the remedy. It is no uncommon occurrence for the symptoms to run very high at the commencement of this fever, so as to give it rather an in- flammatory appearance ; which has induced practitioners, at times, to draw off blood, by opening a vein : but experience has not sanc- tioned the propriety of so doing, except in those cases where there is great intellectual derangement, considerable determination of blood to the head, or symptoms of venous congestion therein. In all such cases, no doubt, the drawing off blood (proportioning the quantity to existing circumstances,) at an early stage of the disease, will be proper and serviceable ; and should the cerebral congestion 10 fc>fc> MREXI2L, OR FELRILE DISEASE^. [ClttSS I. not be relieved, or the fever be of some days' duration,'we may then apply six or eight leeches to the temples. The prostration of strength, which ensues in the early stage of typhus, has by some physicians been considered as chiefly occa- sioned by an undue quantity of blood being determined to the ves- sels of the brain ; and under this idea, when called to a person la- bouring under this fever, however great the depression of strength may appear, if the pain in the head be violent, they either order the temporal artery to be opened, where it can be done conve- niently, or direct eight or ten leeches to be applied to the forehead and temples, and be afterwards allowed to bleed freely. Whatever is given to the patient for drink ought to be cold, and gently acidulated with the juice of oranges or lemons. The mine- ral acids likewise are, beyond all doubt, better remedies in this and other malignant diseases, than we have been accustomed to regard them ; and from having employed them, but more particularly the muriatic, for several years Avith very great success in typhus gra- vior, I can vouch for their efficacy. My usual plan of proceeding is as follows : having relieved the stomach by a gentle emetic where nausea prevails, cleared the bowels of their feculent contents by a proper dose of hydrargyri submurias joined with a few grains of the extract colocynth. c, and subjected the patient to cold affusion when the circumstances already noticed have admitted of it, 1 pre- scribe for adults ten or twelve drops of the muriatic acid, guarded with five drops of tinctura opii, and as a vehicle I employ about an ounce and a half of an infusion of cascarilla, calumbo, or orange peel. This draught I direct to be repeated every four hours, gradu- ally increasing the quantity of the acid in each to eighteen or twenty drops or more. When the fever begins to decline, or to show remissions, I substitute a decoction of cinchona instead of the infusion of calumbo, cascarilla, or orange peel. The effects of the muriatic acid in all febrile diseases of a malig- nant nature are truly great; and from using it in all such cases, my practice has been attended with the most decided success. As a confirmation of its utility, it is proper to mention, that a consider- able pension has been granted by the King of Prussia to Dr. Reich, professor of medicine at the university of Erling, in Franconia for making known a remedy, by the use of which all danger was' re- moved in acute diseases of a malignant nature, and that on a dis- closure of the secret, it proved to be the acids containing oxygen, but particularly the muriatic. In cases of extreme danger, we are told by him,* that one or two drachms of the acid may be given at once. The discovery, however, cannot be claimed by the Prussian professor, as it is well known that the late Sir William Fordyce highly recommended the muriatic acid to be given internally in diseases of a putrid or malignant nature, and likewise to be applied * See a translation of his German work, by Dr. Parry, of Bath. Order I.J malignant and putrid fever. 67 in the form of gargle to the sloughs of the throat which often ac- company such fevers. In typhus gravior, as well as in scarlatina, the internal use of the oxygenated muriatic acid is a powerful and highly efficacious me- dicine. A material circumstance to be attended to, not only at the com- mencement of this fever, but through its whole course, is to cover the patient lightly with bed-clothes, and to keep his apartment cool and properly ventilated, by allowing a regular and free admission of fresh air into it; and in order to render it pleasant both to him- self and his attendants, it ought to be sprinkled several times a day with warm vinegar and camphorated spirit. Fumigations in the manner hereinafter noticed will also be advisable. Cleanliness, in the strictest sense of the word, is to be most carefully attended to • and, therefore, not only the bed and body linen should be changed frequently, but whenever a motion takes place it ought immediately to be removed. The viscid phlegm, which collects about the tongue and teeth should be coagulated by some austere acid, and then it maybe scraped off by a knife; or be wiped away with a bit of flannel dipped in vinegar, or salt and water. Although there is not usually any regular crisis to this fever, still nature sometimes endeavours to throw it off by a gentle moisture diffused equally over the whole surface of the body: to promote this, we may advise some gentle diaphoretic ;* but we are carefully to guard against exciting profuse sweats, which would certainly prove highly prejudicial. A physician! of some eminence, speaks highly of the effects of the spiritus astheris sulphurici in this fever when given with antimonials, as having an advantage over most cordials in not increasing the heat of the body or quickening the pulse ; but on the contrary, rendering the action of the heart more regular and slow, and, moreover, proving serviceable in promoting a diaphoresis, and lessening anxiety and tremors. In the first stage of the disease, where there arises any violent affection of the head, or any great difficulty of breathing, it has been usual to apply a blister to the neighbourhood of the part affected ; but blistering seems a doubtful remedy in typhus gravior, as well as in the mild species of the disorder. Where stupor prevails, with little or no delirium, we need not employ it: but where the delirium, in the first stage of the disease, is violent, and accompanied with great wildness of the eyes, so as to threaten aphrenitis, we may re- commend it. In an advanced stage, or after symptoms of putres- t Dr. Carmichael Smyth. * 4. R Camphorae, gr. iv. * 4. Take Camphor, four grains.' Pulv. Ipecac, gr. iij. Powder of Ipecacuanha, three grains. Confect. Aromat. gr. x. M. Aromatic Confection, ten grains. ft. Bolus, 6tis horis sumendus. Make them into a bolus, which may be taken every six hours. 68 rvREXL/E, or febrile diseases. [Class I. cency have become obvious, the application of a blister would be highly improper. In typhus gravior, as well as in the milder form of the disease, the application of cold to the head might probably be substituted for a blister with advantage in those cases where there prevails either coma, or delirium, or there is great pain in the head, with much restlessness. Having had the head properly shaved, a large towel, dipped in the coldest water, may be applied all over it, re- newing the process frequently until the patient is easier, the heat less, and a disposition to tranquil sleep has taken place. At first it will be necessary to repeat the operation at short intervals, and it will be desirable to do it with such quickness and perseverance as to produce some degree of shivering. In severe cases, we may substitute the application of powdered ice, enclosed in a blad- der, to the shaven scalp. When haemorrhages ensue, and petechias have appeared on the body, we should have recourse to the most powerful antiseptics, such as vegetable and mineral acids, carbonic acid in every form, liquors in a state of fermentation, oxygen gas, oxygenated muriate of potass,* aerated waters, wine, cold affusion, and cinchona.! * 5. R Muriat. Potassae Oxygenat. 3i— 3ss. Tinct. Cort. Aurant. f. gj. Aq. Cinnam. f. ^jss. Syrup. Simpl. f. 3j- M. ft. Haustus, 3tia hora capiendus. 16. R Decoct. Cinchonae, f. §vij. Tinct. Serpent, f. ----Cinnam. f. aa |ss. M. ft. Mistura, cujus sumat uncias duas ter- tiis horis cum Acid. Nitrici Dilut. fll vj.—xvi. Vel, 7. RPulv. Cinchon. ^ss.—3j- Tinct. ejusdem, f. 31J. Aq. Cinnam. f. ^jss. Acid. Muriat. Til viij.—xij. M. Pro haustu, secunda vel tertia quaque hora sumendo. Vel, 8. R Decoct. Cinchon. f. gjss. Tinct. ejusdem, f 3'ij- Acid. Muriat. Oxygenat. til *• M. ft. Haustus. 3tis hori» capiendus. * 5. Take Oxygenated Muriate of Potass, from one scruple to half a drachm. Tincture of Orange Peel, one drachm. Cinnamon Water, one ounce and a half. Common Syrup, one drachm. Mix them. This draught may be taken every three hours. t 6. Take Decoction of Bark, seven ounces. Tincture of Snake Root, -------Cinnamon, each half an ounce. Shake them together, and of the mixture let the patient take about four table spoons- ful every three hours, with from ten to twenty-four drops of Diluted Nitric Acid, Or, 7. Take Powder of Peruvian Bark, from half a drachm to one drachm.. Tincture of the same, two drachms. Cinnamon Water, one ounce and a half. Muriatic Acid, from twelve to twenty drops. Mix them for a draught, to be taken every second or third hour. Or, 8. Take Decoction of Peruvian Bark, one ounce and a half. Tincture of the same, two drachms. Oxygenated Muriatic Acid, fifteen drops. Mix them, and give this draught every throe hours. Order I.J malignant and f_utrid fever. 69 We may also administer clysters of diluted vinegar,* or crystalli- zed acid of lemons in moderate quantities, that they may remain in the rectum, and thereby be likely to be absorbed. The exhibition of fixed air has been recommended in this fever. The Rev. Edward Cartwright having read of the power of fixed air in preserving meat from putrefying, was induced to make trial of it on a boy of fourteen years of age, who had been ill several days of a putrid fever, for which bark and wine had been exhibited without any apparent advantage, and where there was but little hope of a recovery. He directed two table-spoonsful of yeast to be taken every three hours ; which having been complied with, the body found almost immediate relief, and recovered very quickly. Mr. Cartwright reports, that he gave the same remedy to above fifty patients in this fever without losing one. With respect to the use of yeast internally in this fever, some practitioners have looked upon it rather as a doubtful remedy, although they readily subscribe to its good effects as an external application in fetid putrid ulcers. I have made trial of it very frequently, and, as I conceive, with some advantage ; nor did it, in a single instance, excite any commotion or disorder, either in the stomach or bowels of my patients, as some have reported to have happened with them on making use of it. As the good effects of yeast seem to depend on the fixed air which it contains, it is probable that we might substitute water, im- pregnated with the gas, to great advantage, as we should thereby avoid the disagreeable consequences attributed to it. The mode in which I administered yeast was by adding one or two table-spoonsful of it to a quart of an infusion of malt or mild porter, of which the patient took a wine-glassful very frequently. Whatever may be the mode of action of yeast in typhus, the fact appears to be indisputable, that fixed air takes off that extreme debility of the stomach so conspicuously marked in disorders of this nature ; and in proportion as that subsides, the pulse rises, becomes slower and fuller, the burning heat on the skin disappears, and a truce is gained for the reception of nutritive supplies. In the first stage of typhus, when there is a high degree of ex- citement, wine would be improper, but after some days' continuance, and when there is no cerebral or other visceral congestion, a mode- rate use of it will be advisable. It may then be mixed in panado, gruel, or whatever else of the like kind the patient takes for food, or it may be given to him properly diluted with water to drink. For the healing of ulcers in the mouth, we may employ a solutibn * 9. R Decoct. Malvae Compos, f. |vj. * 9. Take Compound Decoction of Marsh- mallows, six ounces. Aceti Communis, L §ijss. M. Common Vinegar, two ounces , and a half. ft. Enema. Mix them for a clyster 70 pyrexia:, or febrile diseases. [Class I. of alum in water (an ounce of the former to a pint of the latter,) as a gargle, which will quickly take away the stench that arises from them, or we may substitute that which has been recommended in typhus mitior. In typhus gravior it is of the utmost consequence to procure rest, and therefore, where there is no great delirium, we may give an opiate towards bedtime. Combining it with some diaphoretic* will prevent any deleterious effects from it, and therefore it will be best to give it in this way. A slight purging, attended with a gentle moisture on the skin, not unfrequently arises towards the close of this fever, and now and then assists in carrying it off; but where it does not seem to pro- duce a critical effect, it ought to be stopped as quickly as possible by astringents.! When we succeed in removing the symptoms entirely by the means which have been pointed out, or in procuring a cessation of the fever, we are to endeavour to prevent its return by a free use of cinchona bark, the cortex cuspariae, infusions of gentian and orange-peel, and other stomachic tonics; and in order to recruit the strength, (he patient should be directed to use a nourishing diet, with wine in moderation ; and he should take such gentle exercise as his state of convalescence will admit. Having pointed out the mode of treatment to be adopted when the disease actually takes place, it seems proper likewise to mention the precautions it may be necessary to pursue, in order to prevent its contagion from being communicated to others. When the disease arises, the sick ought to be removed to a clean and well-aired room in the most remote part of the house, and as much separated from the rest of the family as possible; his bed- linen should be changed frequently ; his body be kept clean ; what- ever comes from him, be immediately removed and emptied; and his chamber be well ventilated by allowing a free admission of fresh air into it; it may likewise be sprinkled frequently with warm vinegar, in which some of the aromatic herbs have been infused. No fire should be kept in the room. In summer the patient should be covered only with a sheet, and in winter with a single blanket above the sheet. The good effects which arise from removing pa- " 10. R Liquor. Ammon. Acet. f. 3»»j- Aquae Cinnam. f. j|j. Tinct. Opii, Til xxv. Syrup Simpl. f. 3ij. M. ft. Haustus. t 11. R Confect. Aromat. 3ss. Aq. Cinnam f. ----Pimentos, aa f. !|jss. ----Fontan. f :§ij. Tinct. Kino, f. 3U- ----Opii, ffl xxx. M. ft. Mistura, cujus sumat Cochl. ij. magna 4tis horis. * 10. Take Solution of Acetate of Ammo- nia, three drachms. Cinnamon Water, one ounce. Tincture of opium, forty drpps. Syrup, two drachms. Mix them for a draught. til. Take Aromatic Confection, half a drachm. Cinnamon and Pimento Water, of each one ounce and a half. Pure Water, two ounces. Tincture of Kino, two drachms. —------Opium fifty drops. Of this mixture, take two large spoonsful every four hours. Order I.J malignant and putrid fever. 71 tients in this fever from contaminated air, are particularly remark- able among the poor; for a great many of them will recover when brought to an hospital or ward of recovery, although they take little or nothing; whilst those who remain at their own houses, and have the best medicines and attendance, will sink rapidly. None but the necessary attendants should have any communication with the sick; and these, to guard against contagion, should avoid sitting down on the patient's bed ; and they must likewise carefully avoid inhaling the vapour arising immediately from his body. When near him, they may keep a sponge or handkerchief, moistened in camphorated spirit or vinegar, to the nose and mouth. In every species of typhus, direct and immediate exhalations from the sick, provided there is a sufficient approximation or actual contact of another, are indisputably equal, in some cases, to the infecting such person, even when the most minute attention shall have been paid to cleanliness and ventilation. In hospitals, camps, and on board of ships, where a number are unavoidably crowded together, so as to render it impossible to cut off the communication between the healthy and the diseased, these simple means will not prove sufficiently powerful for destroying the contagion, and therefore others must be adopted. In all such instances, besides well fumigating the apartments, clothes, beds, bedding, and hammocks of the sick, as hereafter advised, changing them frequently for fresh ones, paying the strictest attention to cleanliness in every respect, well ventilating every place where they are lodged by a constant and free admission of fresh air, we should oblige those in health, as well as those tainted by the conta- gion, to undergo daily ablution with cold water. Nitric acid has been used by Dr. Carmichael Smyth, as a fumi- gation, with the greatest success in this fever. In the year 1780, the disease broke out among the Spanish prisoners confined in Winchester castle; he embraced the opportunity of giving the remedy a fair trial, and obtaining the most decisive evidence of its happy power in preventing the spreading or farther communi- cation of the infection. He found he could use it without risk or inconvenience to respiration, and therefore thought it the most proper antidote to be applied, where persons are unavoidably obliged to be present. The doctor's mode of obtaining nitric acid, is by decomposing nitre by means of heated sulphuric acid, which may be done as follows : put half an ounce of this acid into a crucible, glass, china cup or saucer, and warm this over a lamp, or in heated sand, adding to it, from time to time, some nitre: these vessels he directs to be placed at 20 or 30 feet distance from each other, according to the height of the ceiling and the virulence of the contagion. In hospitals and prisons, he advises the lamps or vessels containing heated sand to be placed on the floor ; but on board of ships, he recommends to hang them to the beams by waxed silk cords. From the well-known efficacy of the sulphuric acid in destroying pvrexia;, or febrile diseases.. [Class contagion, he advises it to be employed as a fumigation for clothes and furniture, &c.; but for purifying empty prisons, hospital wards, and ships, he gives the preference to the nitric, its vapour being more volatile and penetrating, and not leaving the disagreeable smell which the sulphuric does, and thinking it at the same time equally efficacious. Monsieur Guyton Morveau,in his Treatise on the means of pu- rifying Infected Air, claims the merit of being the discoverer of the power of the mineral acids to destroy contagion, and endeavours to establish the superiority of the muriatic acid over all others. Upon a full investigation of the matter, it appears, however, thatthe power of the mineral acids to destroy contagion was known to Sir John Pringle as early as the year 1750, and their utility for that purpose was mentioned by Dr. Johnson in his pamphlet published in 1758, in which we are told that the vapour of muriatic acid was success- fully employed by him in correcting the contagion of a very malig- nant fever, which had raged at Kidderminster two years before that period. Dr. Smyth has also claimed the having been the first who used the mineral acid gases in the apartments of the sick, and has alleged that they never had been employed by Dr. Johnson but in places where no one was present, or whence the sick were removed. This opinion has been refuted by Dr. Johnson's son, and the invention of his father most incontestably established.* What Dr. Smyth seems therefore entitled to is, the merit of having brought the dis- covery into public notice, and of having applied and extended it to general use. It seems of little consequence whether we employ the nitric acid or the muriatic in the form of gas, for the purpose of destroying contagion and purifying infected air, as the powers of both are ex- tensive and certain. The muriatic is, however, 'hought to be more diffusible than the other. When we give it the preference, it may be used in the following manner:—put one pound of common salt into an earthen vessel, and pour over it, from time to time, a small quantity of sulphuric acid, till the whole salt is moistened. If the air is foul and peculiarly offensive, apply a gentle heat under the vessel, to extricate a larger quantity of vapour; but, in general, the simple addition of the acid to the salt will be found sufficient, un- less the apartment is very large. The most effectual, however, of all fumigations, is perhaps the following, but it requires some nicety. Take of manganese in powder two parts, the same of common salt, of sulphuric acid three parts, and of water one part. Put an ounce of the mixed manga- nese and salt into a basin, add of water a large tea-spoonful, then drop in half a tea-spoonful of sulphuric acid, and repeat this till you have used a tea-spoonful and a half of the acid. In this manner keep up a sensible extrication of the fumes. * See Dr. John Johnson's Reply to Dr. Smyth. Order I.J VELLOW fever. On the appearance of typhus or any infectious disorder in a jail, hospital, workhouse, garrison, transport-ship, or any other place where many persons are crowded together, we should not fail to advise one of these gaseous fumigations in every room, in addition to a free ventilation and the greatest cleanliness. The same steps should be adopted in academies, boarding-schools, and even our dwelling-houses. Of the YELLOW FEVER, or TYPHUS ICTERODES. This disease takes its name (improperly however) from one par- ticular symptom; but which, although pretty general, is by no means universal, nor even essential to its existence. By Sauvages, it has been denominated typhus icterodes; by Cullen, typhus cum flavi- dine cutis ; by the French, la maladie de Siam, andfievre des ma- telots; and by the Spaniards, vomito prieto. Of late years this fever has prevailed throughout the several colonies in the West Indies, and over a great portion of the American Continent, from which places it extended in a short period to the southern parts of Europe, and has nearly equalled the plague in its devastation. With respect to the origin of the yellow fever in America, there has prevailed a great difference of opinion; some supposing it to have been introduced from the West Indies; and others, that it took its rise from the exposure of putrid animal and vegetable sub- stances on the public wharfs of the city of Philadelphia; which opi- nion is strongly supported by Dr. Rush, as he found that the streets adjoining to these wharfs were the first in which the disease made its appearance, and that in several instances it could clearly be traced from thence to other parts of the city. Let this be as it may, it is evident, from the report of Dr. Chisholme, and others who have written on the disease, that the fever which prevailed in Philadel- phia was exactly the same with that which raged in the West In- dia colonies. Dr. Clarke informs us, that there appears to have been such an extensive and very peculiar deranged state of the atmosphere in the towns of the West Indies and in North America, that it is more probable the disease was produced by this general cause, breaking out nearly at the same time in these different places, than- that it was carried from the one to the other, either by persons or in any kind of goods or merchandise. We are informed by Dr. Miller, of New York, that the yellow fever in America always begins in the lowest part of a populous mercantile town near the water, and continues here without much affecting the higher parts. It rages most where large quantities of new ground have been made by banking out the rivers, for the pur- pose of constructing wharfs. The appearance and prevalence of the yellow fever in low situations, have led to the belief, he tells us, that the disease was imported by ships from the West Indies. But 11 74 PYREXIiE, OR FEBRILE DISEASES. [Class J. a person seized with this fever in an affected part of the town, and conveyed to one that is healthy, or carried into the country, does not communicate it, he asserts, to the neighbourhood, nor to those immediately around him. He therefore is of opinion, that the yellow fever is generated by the impure air or vapour which issues from the new-made earth or ground raised on the muddy and filthy bottom of rivers, and which deteriorate the air above it, in like manner as air becomes offensive and injurious when it approaches or passes over a body of vegetable or animal matter in a state of putrefaction. It appears that the shores of the rivers of New-York and Phila- delphia have undergone great and rapid alterations from their natural state within a few years, on account of the vast increase of commerce, and for the sake of making wharfs ; and Dr. Miller mentions, it is only in such parts where these alterations have taken filace, that the yellow fever has been produced. The parts where ittle or no alteration has taken place on the east and north river, and which continue nearly in their natural state, do not produce the yellow fever. He adds, eighty new wharfs have been made since the war; the consequence of which has been, that great quantities of filth and corruptible matter, deposited in the muddy bottom of the river contiguous to the shore, and which produced no ill effect while exposed to the air and washed twice every four-and-twenty hours, have been covered over several feet deep with new earth, and closely pent up so as to exclude the tide. It is in these places. and these only, that the yellow fever is produced, we are told. On the other hand, we are informed by Dr. Hosack, who is professor of the Institutes and practice of medicine in the uni- versity, New York, as well as by many other physicians of emi- nence in America, that the yellow fever did not originate there from domestic causes, but was exclusively of foreign origin,* and contagious in a confined deteriorated atmosphere and unventilated situations. Dr. Bancroftf is of opinion, that the only existing cause of yellow fever is the application of marsh miasmata to the human body, and that the disease is really a marsh remittent fever. He thinks him- self justified, from repeated observations, in concluding that the joint influence of marsh miasmata, and of an atmosphere unusually and sufficiently heated, upon persons habituated to a cold or tem- perate climate, is, of itself, fully capable of causing an epidemic yellow fever, resembling that which has committed such ravages in the West Indies, the United States of America, and the South of Europe. We are told by him, that the common bilious remittent of hot climates, which is universally admitted to be the effect of miasmata, differs from the yellow fever only by being less violent; that at the utmost their symptoms only vary in degree, and conse- * See American Medical and Philosophical Register. t See his Essay on the Disease called Yellow Fever. Order I.J YELLOW FEVER. 75 quently the danger being greater in the latter than the former, for the yellow colour appears in both. Some have imagined, that the fever, which has occasioned such devastation, is totally of a different nature from the yellow fever formerly met with in the West Indies and other tropical climates ; but in my opinion, it seems to be the same, and that its only dif- ference consists in its having prevailed as an epidemic, from the subsisting vitiated state of the atmosphere, and from its having, from other concurring circumstances, acquired a degree of malig- nancy and virulence unknown before. During a residence of nine years in the West Indies, from 1776 to 1785, I had frequent opportunities of meeting with the yellow fever among seamen, and such new-comers as were imprudent on their first arrival; and although the disease never prevailed during that period epidemically, still I looked upon it as capable, under certain circumstances, of being communicated from one person to another. We ought to be aware that a fever, not contagious at its commencement, may acquire that character from confined air, filth, and accumulation ; then why deny that the same may take place during the prevalence of typhus icterodes 1 I think it ought to be admitted, that the fever which has prevailed of late years, both in America, the West Indies, and Spain, is a contagious or communi- cable disease in an impure atmosphere ; but where great cleanliness is observed, and the air preserved pure and free from noxious par- ticles and materials, its contagion may be counteracted. The ad- mission of this doctrine will readily account for the apparently contradictory facts which have been brought forward by the advo- cates of the two opposing opinions. It is probable that marsh exhalations, and the effluvia arising from putrid vegetable and animal substances, under a concurring vitiated state of the atmosphere, were the causes which gave rise to this fever, and that it was afterwards kept up by contagion, heightened, by various accidental circumstances, to a pestilential degree of violence. Very hot and suitry weather, with a long drought, will greatly predispose to the prevalence of this fever as an epidemic, in all tropical climates; and it may have a similar effect in America, where the summer months are intensely warm. It has been ascertained, from tables and records for the last twenty years, that in Philadelphia the yellow fever does not pre- vail when the months of June and July do not exceeed 70° Fahr.; but that in every summer since 1793, whenever the average heat of those months has exceeded 79°, then the fever has raged, and that it has been most mortal in those years in which the, thermo- meter has indicated the greatest altitude. Dr. Rush, and a few others, are of opinion that the yellow fever is not contagious in its simple state, and that it spreads exclusively by means of exhalations from putrid matters, which are diffused in the air: and Dr. Bancroft tells us, that of the many thousands who 76 PYREXIA, OR FEBRILE DISEASES. [Class L in the West Indies, as well as at Charleston, Norfolk, Baltimore, Philadelphia, New-York, &c. were removed beyond the reach of marsh miasmata, whilst labouring under the disease or after having imbibed the poison, though in many of these the disorder appear- ed under its worst forms, and proved fatal, still it has never been communicated to others. This point, however, has by no means been satisfactorily established ; and some facts which have been brought forward by Sir James M'Gregor*, and others, which are inserted in the American Medical and Philosophical Register,! very clearly show that this fever may be communicated by conta- gion. Moreover, the reports of Sir James Fellowes, lately pub- lished, tend completely to refute the very mischievous doctrine, that the pestilential fever of America and Spain, &c. is not conta- gious. No doubt ought now, in my opinion, to be entertained upon this point, so interesting to mankind. Contagion, perhaps, may not be necessary to originate the yellow fever, or it may not propagate the disease unless aided by exterior circumstances favourable to its agency; but we want facts of a more positive kind, in order to prove that no virus is formed in the body of an individual labouring under this fever, capable of im- pregnating another with a certain quantum at least, if not kind of disease. By diffusion in the open air, the disease may rarely be commu- nicated from one person to another in country situations, where there is a constant circulation of fresh air; but in confined and un- ventilated situations, where cleanliness is neglected, 1 am decidedly of opinion that its contagion may as readily be propagated as that of typhus gravior, the jail or hospital fever. Several of the distinguished writers on yellow fever have asserted that the constitution is invulnerable to the operation of its con- tagion a second time; but this point has not been satisfactorily ascertained. If a fact, (which I greatly doubt,) the exemption may possibly be the result of the reduction of the plethoric constitution of the new-comer, which at first so much predisposed him to an at- tack of the disorder. The persons most liable to be attacked by this fever in the West India Islands, were the Europeans who had lately arrived ; and hence it was, that the troops sent out to recruit our arinies, and the seamen to strengthen our fleet, fell its earliest victims. Women were observed to be less liable to its attacks than men, and children still less so than these ; and the people of colour were by no means so apt to be seized with it as the whites. When the disease did appear among them, it was always much milder, owing most likely to their necessary temperance. Those of a full plethoric habit, and that were intemperate in their mode of living, were much greater sufferers by it than those of a lax fibre, and who were See his Medical Sketches. f Volume II. page 22. Order I.J YELLOW FEVER. 77 guilty of no irregularity. Young people born in the West Indies and educated in Great Britain, and persons having resided some years in England, after they had passed a great part of their lives between the tropics, were observed to be liable to an attack of this fever on their return to the West Indies. There is evidently something peculiar to the constitution of people from a cold country, which renders them more obnoxious to fever in a warm climate than either the natives or those who have been assimilated to it by a long residence. Accordingly we find that the same exposure to the causes, predisponent and occasional, will produce fever in a stranger, while the native or old inhabitant remains in good health; and the symptoms will be tenfold more urgent in the one than the other, supposing both are attacked. flence it happens, that long residents, and natives in general, are not very liable to the yellow fever in its continued and malignant form; but when they are attacked with the remittent of the country, the symptoms partake more or less of the nature of the prevailing epidemic. In persons of the former class, the body, from long exposure to the influence of the climate, has become creolized, approaching to the conformation of the natives, by having their original firmness of fibre reduced to the appropriate standard for continuing the healthy action underexposure to preternatural heat. The heat of the body of new-comers in the West Indies has been noticed, by Dr. M'Kitrick, to be between three and four degrees above that of the temperature of the natives ; and to this he ascribes, in part, the predisposition of new-comers to the yellow fever. A disposition to take on an inflammatory action has been assigned, therefore, as the reason why Europeans, within the first few months after their arrival in the West Indies, are so obnoxious to this fever. Not only does the yellow fever invade Europeans newly arrived in the West Indies in preference to Creoles, negroes, and those who by a long continued residence have become acclimated, but even among those Europeans who happen to be susceptible, the most healthy and robust, and in general those who are earliest subjected to great exertions, and a high degree of temperature, are sooner seized, and more rapidly destroyed, than those of laxer fibres, or those who have had an opportunity of becoming more gradually inured to the climate. In North America it also happens, that the inhabitants who con- stafitty reside in the most southern States are seldom attacked with this fever in its violent form, while those of the north-east Stales are destroyed by it in great numbers: but even in these districts it has been remarked, that it more readily seizes strangers from Europe, or peasants from the interior provinces, than the natives of the towns in which the disease prevails. The inhabitants of the southern States, from being subjected to constant heat, approach in constitution nearly to the Creoles or natives of the West Indies ; but those residing in the more northern States, although exposed to a high degree of heat during the summer, can never become 78 pyrexia:, or febrile diseases. [Class I. creolized, (if the expression may be allowed,) on account of the intervening winter, which annually renews the predisposition, and creates a susceptibility to the disease ; still, from living during a part of the year in excessive heat, the inhabitants of the place where the disease prevails are in some degree less susceptible of the most malignant form of the fever than strangers from Europe, or peasants from the inland districts, whose more dense and rigid fibre renders them peculiarly predisposed. It is therefore obvious, that the strongest men, those of the most dense and rigid fibre, are particularly subject, both in America and the West Indies, to the high degree of the yellow fever; and are most frequently and rapidly destroyed by it. Women, children, convalescents from former malady, and those who have been re- duced by the use of mercurial remedies, are less frequently the* objects of its attack ; and when it happens to seize them, it is usu- ally milder, and less rapid in its progress. In these classes, the state of the animal fibre, either from original conformation, or from eventual circumstances, more nearly approaches to that of the Creoles and natives.* Dr. Pinckard, who was a physician to the army in the West Indies, from having observed this fever exhibited such instability, and varied so incessantly in its character, that he could not dis- cover any one symptom to be decidedly diagnostic, has been in- duced to offer it as his opinion, that the yellow fever so called is not a distinct or specific disease, butmerely an aggravated degree of the common remittent or bilious fever of hot climates, rendered irregular in form, and augmented in malignity, frOm appearing in subjects unaccustomed to the climate. Dr. Jackson also views this disease as only a modification, or very high degree of the common fever of the country. This species of fever is excited into action by a variety of causes; the chief of which are, intemperance, excessive fatigue in the sun, checked perspiration by being exposed to a current of air, or sleep- ing exposed to the dews, costiveness, &c. In fact, whatever proves an exciting cause of fever in any country, is ejually so in the West Indies, but it is not the same species of fever that is induced. The yellow fever usually attacks with lassitude and weariness, chilly fits, listlessness of every thing around, faintness, giddiness, flushing of the face, redness of the eyes, pains in the eye balls and lower part of the forehead, as likewise in the back, debility fnd sighing, thirst, and a tendency to coma; the urine is high-coloured, small in quantity, and turbid ; the perspiration is irregular, inter- rupted, and greatly diminished ; the saliva is viscid ; the tongue is covered over with a dark fur; the bile is secreted in unusual quan- tities, and thrown into the stomach, from which it is again speedily ejected ; and the skin is hot, dry, and hard. The disease continuing to advance, the eyes become of a deep See Notes on the West Indies, by George Pinckard, M. D. Letter LIV, Order l.J yellow fever. 7g yellow, the face and breast are tinged with the same hue ; an in- cessant retching and vomiting of frothy bile ensues ; great costive- ness prevails, and a peculiar delirium arises, which is attended with a permanent dilatation of the pupils of the eyes. There is hardly ever an evident remission until the fever has en- tirely gone through its first stage, which is generally in thirty-six or forty-eight hours ; when there is often such an abatement of the symptoms as to induce the patient to think himself tolerably well; but an early recurrence of the symptoms in an aggravated form, ac- companied with extreme debility, soon convinces him of the contrary. In the last stage of the disease, the greatest debility prevails, and symptoms of universal putrefaction arise ; large patches of livid spots are to be observed on different parts ; the tongue becomes dry and black, the teeth are incrusted with a dark fur, the breath is highly offensive, the whole body exhibits a livid yellow in many cases, but not in all; haemorrhages break forth from the mouth, ears, and nostrils, dark and fetid stools are discharged, hickups ensue, the pulse sinks, ami death follows very quickly. These are the usual appearances to be met with; but great irre- gularities have been observed by different practitioners. Dr. Chis- holme mentions, that he often found patients, without any previous complaint, suddenly become giddy, lose their sight, fall down almost insensible, and remain in that state for half an hour and upwards; the body then became overspread with a cold sweat, and this was succeeded by intense heat, a quick, small, hard pulse, violent pain of the head, particularly in the forehead, great anxiety about the praecordia; the eyes were much inflamed, watery, protruded, and wildly rolling; the face was much flushed ; there was great heat at the pit of the stomach, with nausea, frequent retching and vomiting, as also severe pains in the small of the back and calves of the legs. During 12, 18, 24, or 36 hours, he found all these symptoms con- tinue to increase, except the quickness and hardness of the pulse, which were not materially changed, and that they were then suc- ceeded by general coldness, clammy sweats, and a greater or less- degree of coma or delirium. Life, in this case, was lengthened out to sixty or ninety hours from the attack. A short interval of reason perhaps took place, the patient considered himself better, and flattered himself for the moment with the hope of recovery; but a fit, as sudden and as unexpected as the first, came on, during which he rolled his eyes dreadfully, foamed at the mouth, and threw out and pulled back his extremities in violent and quick alternate suc- cession. Dr. Chisholme observed, that in general the patient ex- pired in this fit; but in a few instances he recovered from it, and continued rational for a short time, when another has ensued and carried him off. He noticed, that in a few instances the patient complained of violent pains in the testicles, and on examination, he perceived them much lessened in size and retracted, with an excoriation of the scrotum: now and then he found a remarkable change in the voice, 80 lJVREXI4i, OR FEBRILE DISEASES. [Class I. and that it became weak and shrill; in a few instances he could discover little or no yellowness of the skin. Dr. Rush says, the disease appeared with different symptoms in different people ; he observed the premonitory signs of it were, costiveness, a dull pain in the right side, defect of appetite, flatu- lency, perverted taste, heat in the stomach, giddiness or pain in the head, a dull, watery, brilliant yellow, or red eye, dim and im- perfect vision, a hoarseness, or slight sore throat, low spirits, a dis- position to sweat at nights, or after moderate exercise, or a sudden suppression of night sweats. More or less of these symptoms fre- quently continued for two or three days before the patients were confined ; and in some they continued during the whole time of the prevalence of the fever in the city of Philadelphia, without pro- ducing the disease. Many went to bed in good health, and awoke in the night with a chilly fit; many rose in the morning after natural and regular sleep, and were seized at their work, or after a walk, with a sudden and unexpected attack. He observes, that it frequently came on with "St weak pulse, and often without any preternatural frequency or quickness ; and that, in some instances, it was so low as not to be perceived without pressing hard on the artery; in some cases, the pulse intermitted^ and these intermissions occurred in several persons who were in- fected, but who were not confined by fever; in others, there was a more than ordinary slowness of the pulse, which was now and then accompanied with a dilated pupil of the eye. Haemorrhages hap- pened at the commencement of the disorder, chiefly at the nose and uterus : and as it advanced, the discharge of blood became more universal, and then issued from the gums, ears, stomach, bowels, and urinary passage. Many complained of a dull pain in the region of the liver, but few felt any soreness to the touch, or pain at the pit of the stomach; in some, a determination of blood took place to the lungs, but the brain was chiefly affected with morbid congestion, which was indi- cated by the suffusion of blood in the face, redness of the eyes, dilatation of the pupils, pain in the head, haemorrhages from the nose and ears, by sickness or vomiting, and by an almost universal costive state of the bowels. With respect to the secretions and excretions, there appeared to be a preternatural secretion of bile, which was discharged from the stomach and bowels in large quantities, and of very different quali- ties and colours, being in some cases yellow, and in others black. The urine was sometimes plentiful and of a high colour; sometimes it was pale, and in others it was small in quantity and turbid: more- over sweats of a yellow colour, and highly offensive to the smell, often broke out. On the first and second day the tongue was in- variably moist and white ; but as the disease advanced, it became red, and put on a smooth shining appearance : towards the close, a dry black streak appeared in its middle, which gradually extended to every part of it. Order I.J YELLOW FEVER. 81 The effects produced on the nervous system were different, according as the fever affected the brain, the muscles, the nerves or the mind. In a few instances, apoplexy was induced, which usually proved fatal; tremors of the limbs, and twitching of the tendons, were common ; delirium was a frequent symptom, but many passed through the disease without the least derangement of ideas: in some cases, the pain in the head was acute and distressing; and the stomach, towards the close, was affected with burning or spasmodic pain of the most severe nature. The senses and appetites exhibited several marks of the ravages of this fever upon the body. Deafness and dimness of sight some- times took place. Thirst, and want of appetite, were present, as in most other fevers. The convalescence was marked by a sudden renewal of the propensity to venery.* Swellings in the inguinal and parotid glands took place in a few instances, which did not proceed to suppuration. In some cases, the skin was preter- naturally warm ; in others it was cooler than injaealth. The yel- low colour was by no means universal; wheh it took place, it was seldom to be observed before the third day, but more fre- quently about the fifth or seventh from the first attack. The eyes seldom escaped a yellow tinge. There were eruptions of various kinds on the skin, and, in the latter stage, petechiae were common ; carbuncles also took place in a few cases. The disease ended in death in various ways. In some, it was sudden ; in others, it came on gradually. The last hours of some were marked with great pain and strong convulsions; but, in many, death seemed to insinuate itself into the system with all the gentleness of natural sleep. In every case that came under Dr. Rush's care, there tfere evident remissions or intermissions of the fever, ^ 'of such symptoms as were substituted for it. The disea*= continued for 15, 20, or 30 days in some people. He ohs^wved, that ajl were affected by it; but persons in the prime p* hie were most liable to it. Men were more subject to i*3 attacks than women. He likewise observed, that the ref"gees fr°m the West Indies univer- sally escaped it; whereas **e natives of France, who were settled in the city of Philadelphia, were much annoyed by it; and he found that the people <**" colour took the disease in common with the white people, but in them it was usually much milder. Critical days were hardly ever distinguishable in this fever, nor was the crisis often very evident. Sometimes a copious perspira- tion put an end to it; and at others, the return of sleep, an haemor- rhage from the nose, or sudden diarrhoea, carried it off. Dr. Fordyce is of opinion! that typhus icterodes ought to be regarded rather as an irregular semi-tertian than as a continued * The same is frequently noticed on recovering from the plague- f See his Fourth Dissertation on Fever. 12 82 pyrexia, or febrile diseases. [Class I. fever; for it often happens that a patient becomes greatly relieved, and appears to be recovering, when all at once a fresh attack takes place, and carries him off. He thinks that the dark brown colour of the skin in this fever arises rather from a greater secretion of the matter secreted by the sebaceous glands of the skin, than owing to a quantity of bile getting into the blood-vessels. In support of this opinion, he observes, that the colour is very different from that which takes place in jaundice. The evacuations from the intestines have not that clay-like appearance which is common in jaundice. The secretion from the kidneys has not that dark yellowish brown, nor that thick sediment, which have almost always been noticed in those persons in whom bile has got into the blood-vessels. The dark brown matter which the patient throws up by vomiting, he thinks, has the appearance of the matter observed upon the tongue in very violent fevers, and that probably it is formed on the surface of the stomach, and perhaps of the duodenum, or even on the beginning of ^he jejunum. The force of the exertions in vomit- ing often occasions a greater quantity of bile to be secreted, and so to be thrown back into the stomach, and be brought up with the dark brown matter. When this happens, it gives to the matter thrown up, he observes, the taste and appearance of bile. At other times, however, there is no appearance of bile at all, but only of this dark brown matter. Dr. Bancroft is of opinion,* that the black matter thrown up in this fever is merely blood which has been effused from some of the small arteries, ruptured in consequence of the suppuration of certain portions of the villous coat, and has coagulated within the cavity of the stomach, or on the surface over which it was effused, and having been afterwards detached and triturated by the violent and frequent contractions of that organ in the efforts to vomit, has had its appearance as a coagulum of blood altered, and its colour darkened by#thegas^ic juice, or by some chymical decomposition, either spontaneous or p.^uced by the action of the air, or other matters contained in the ston»cn# Dr. Jacksont thinks that the bla^v co]our of the matters ejected from the stomach, or discharged by the ^nus m the latter stages of this form of fever in the West Indies, owes m origin to an admix- ture with diseased secretions from the mucous in°mbranes of the whole gastric system, more particularly of the liver. He observes the secretion is ropy and clear during the early periods of the disease, becomes brown or black in the latter; sometimes black as soot, more particularly in persons where the head and stomach are simultaneously affected, and where no strong vascular action takes place during the course of the disease. Concerning the nature of the black vomit, various opinions have * See hi3 Dissertation on the Yellow Fever. t See his Sketch on the History of Febrile Diseases, as they appear in the West Indies among the Soldiers of the British Army. Order I.J yellow fever. 83 indeed been entertained. Some have considered it as consisting of putrid bile ; some as composed of a mixture of blood and bile ; some of the villous coat of the stomach dissolved in the progress of inflammation, terminating in sphacelus ; and others, of bile mixed with the septicacidcontainedinthealimentary canal. Dr. Cathrall, of Philadelphia.* considers all these opinions as erroneous, and offers it as his, that the black vomit is an altered secretion from the liver. We are informed by him, that the black vomit, or matter so called, appears to be of two kinds ; one consisting of a number of flaky particles, resembling the grounds of coffee ; the other, of a dark-coloured inspissated mucus. From various and repeated experiments, he concludes, that the black vomit, besides a considerable proportion of water tinctured with resinous and mucilaginous substances, contains a predominant acid, which is neither the carbonic, phosphoric, or sulphuric, but hints it may be the muriatic. It appears from Dr. Cathrall's experiments, that the black vomit, when applied to the most sensible parts of the body, produced little or no effect. It likewise appears that large quantities of this fluid may pass through the stomach and bowels of quadrupeds and other animals, without apparently disturbing digestion, or affecting the health. This fact incontestably proves the inactivity of this fluid, and renders it probable that the speedy death which ensues after this discharge in yellow fever, is not from any destructive effect of this matter on the stomach and bowels, but most likely from the degree of direct and indirect debility which had been previously induced. Another fact which has been proved by this gentleman's experiments is, that an atmosphere highly impreg- nated with the odour of the black vomit recently obtained, would not produce fever, apparently under the most favourable circumstances. The yellow fever differs from typhus in the following circumstan- ces, viz. it usually prevails only during, or immediately after very hot seasons, in which typhus is soon extinguished ; and it is in its turn completely annihilated upon the accession of cold weather, in which typhus is commonly most prevalent, particularly if accom- panied with humidity of the atmosphere. It attacks most readily and violently the young and robust, over whom typhus is allowed to have the least power; it begins with much greater exertions of the living power than typhus, is attended with many symptoms of a different nature, and it frequently changes into a regular remittent, and sometimes even to an intermittent fever, which true typhus is never observed to do. It differs from the plague, in that it prevails only in those coun- tries, and in those seasons, in which the heat is, or has recently * See the New-York Repository of 1800, for his Memoir on the Analysis of the Black Vomit, ejected in the last stage of this fever. 84 pvrexije, or febrile diseases. [Class I. been, so great as to destroy or stop the progress of the plague; in the inter-tropical climates, therefore, so favourable to the existence of the yellow fever, the plague is unknown. The glandular and cutaneous affections called buboes and carbuncles, so constantly accompanying the plague, are seldom met with in the yellow fever. A violent febrile paroxysm is essential to the character of yellow fever ; whilst, according to the best authorities, persons have been attacked by the plague without having the least febrile affection. In forming an opinion as to the event of the yellow fever, we must have in view the nature of the symptoms, the mode of attack, and the age and habit of the patient. Youth, and a plethoric state, are invariably circumstances of danger. A sudden oppression of all the functions at once ; great debility ; weak, irregular pulse ; sighing; severe vomiting of dark matter ; tremors of the body when moved, with a tendency to faint on the slightest exertion; pensive sadness in the countenance ; and a dilatation of the pupils of the eyes, with coma ; are signs of great danger. Very few recover from that stage in which a black vomiting is the prominent symptom. Black and fetid discharges by urine and stool, the breath being highly offensive, and the appearance of petechias, portend almost certain death. The symptoms that we may regard as favourable are, a settled state of the stomach, lessened headach, eyes lively, appearance of an eruption on the skin, (known in tropical climates by the name of prickly heat,) free perspiration, copious and high-coloured urine, bilious flux, and sound sleep. No disease, however, exhibits a greater variety of symptoms, and often less to be depended upon, than this; for sometimes it goes on with favourable appearances, then suddenly changes to the worst, and sometimes patients apparently almost in a state of con- valescence, expire in a few hours. Dissections of the bodies of those who have died of the yellow fever have shown the coats of the oesophagus corroded; the stomach and intestines loaded with a black fetid matter, or both to be often much inflated, inflamed, and sphacelated; the liver, in many cases, to be shrunk to less than half its natural size, very flaccid, and of a colour approaching to buff; and the gall-bladder to be flaccid and grayish, having but little bile contained in it. In some instances the lungs have been found inflamed ; and the bladder has been observed to be much thickened, and to contain a considerable quantity of urine. In those cases where there has been a dis- charge by vomiting of a black coagulated matter resembling the grounds of coffee, the gall-bladder and biliary ducts have been found distended with the like substance. Where an affection of the head has formed a prominent feature of the disorder the integuments of the brain have been observed more or less inflamed the vessels of the dura and pia mater to be very turgid with blood and occasionally there has been extravasation. Sometimes the Order I.J YELLOW fever. 85 volume of the brain has been found increased, and the substance of it more firm than usual. The same difference of opinion which arose among the profes- sional gentlemen of Philadelphia with regard to the origin of the disease, seems likewise to have subsisted between them as to the mode of treatment to be pursued; some recommending and adopt- ing the antiphlogistic plan, by bleeding, purging, and a low diet; some, the stimulant plan, with a liberal use of the bark,' wine, opium, and the cold affusion; and others, again, either purged moderately with calomel, or bled on the first or second day of the fever, and then resorted to a free use of bark, wine, laudanum, and aromatic tonics : and this practice they adopted on the supposition that the disease was inflammatory in its first stage, and putrid in its last. According to the report of Dr. Rush, this last mode of treatment was scarcely more successful than the tonic and stimulant one ; and that which he found to succeed best was the antiphlogistic, pursued even to a degree of extreme rigour; for we are given to understand, that although in some instances he allows of one or two moderate bleedings being sufficient, still, in most cases, he was in the habit of repeating the operation much oftener, and of drawing off a con- siderable quantity each time, even from the poor who resorted to his house for advice. Whether or not bleeding may be practised with advantage to the patient in America, or to what length it may be carried, I am not capable of determining, never having been on that continent; but being well acquainted with the climate of the West Indies, from a long residence there, and having often met with the disease, (although not under its very malignant form,) I must concur with the objectors, who contend that, in tropical climates, venesection resorted to among the natives, and such others whose bodies and constitutions have been perfectly assimilated to the climate by a long residence, cannot produce* a good effect: the reduction of tone, which a certain period of residence occasions in the consti- tution of Europeans, as well as of the natives, renders it unneces- sary ; but when this fever has attacked new comers of a vigorous constitution and in rude health, but more particularly soldiers and seamen, (who bear phlebotomy better than any class of people in private life,) then I am ready to admit, that the abstraction of blood soon after the seizure, or during the early stage, may be beneficial, if the quantity drawn off is in due proportion to the age, habit, and other circumstances of the patient. When the fever is completely formed, or is of a longer standing than 36 or 48 hours, it will bid defiance to depletion by the lancet, and then, instead of proving serviceable to the patient, will be highly injurious. Dr. Clarke, in his treatise on this disease, mentions, that no na- tive recovered when the lancet had been used; and Dr. Chisholme observes, that although the blood drawn, in the cases where this remedy was employed, appeared remarkably florid, and always 8b' PYREXIA;, OR FEBRILE DISEAaEo. [ClaSS I. threw up an inflammatory crust of greater or less thickness, and although the pains seemed to undergo a temporary mitigation, yet the consequence, at the expiration of a few hours, was always fatal, notwithstanding the patient- were remarkably robust, florid, and generally in the vigour of life. Dr. Hector M'Lean, who has likewise published on this/ever, is one of the few West India practitioners who approves of bleeding. —He observes, that the determinations to particular organs, which take place in the disease, and which constitute its greatest danger; the marks of inflammation, which dissections have shown in the stomach and biliary organs, evidently point out the propriety of this evacuation. He adds, that experience confirmed its utility ; for his practice was much more successful after he had adopted blood- letting, than before. By way of caution, he mentions, however, that it is only in the very early stages he thinks it advisable to have recourse to the operation, and that if it is not performed as early as the second, or at farthest the third day, he apprehends it will not be successful. Dr. Jackson, in his Exposition of affusing cold Water in the cure of Fever, tells us, that he holds a substraction of blood in large quantity to be a most decisive process in the more intense and concentrated forms of the endemic fever of the West Indies, and that the remedy produces a condition susceptible of being more readily acted upon afterwards by cold affusion, and the other means we may employ. He adds, that whatever may be the pre- cise quantity necessary to produce the effect, it must always be supposed to stand high, and seldom lower than thirty ounces; in strong athletic European soldiers, recently transported to a tropi- cal climate, sometimes far above it. In a work* of a later date he mentions, that he is fully warrant- ed by long experience and attentive observation to say, that vene- section, prescribed with consideration and conducted with manage- ment in execution, is both a safe»and powerful remedy, either de- cisive of curing from its own effect, or preparatory of the curative effect of others. If there be no prohibitory circumstances in the case, one bleeding, he says, is to be preferred to repeated small ones : for although the latter diminish violence, and thereby avert the destruction of organic structures, they do not prevent the dis- eased action from proceeding the regular process of what he terms coction, to a constituted period of formal crisis. He however readily admits, that bleeding in a large, or even in any quantity, is not invariably or uniformly either proper or safe. A late writer! on the yellow fever says, that it is only by a copious abstraction of blood employed while the fever is forming, * See Dr. Jackson's Sketch of the History of Fehrile Diseases among the Soldiers of the British Army in the West Indies. t See Treatise on the Causes of the Tropical Endemic or Yellow Fever, bv J.H OiclvsonM. D. ' Order I.J yellow fever. g7 or within a short time after it is formed, aided by purgatives, and by the cold affusion if indicated, that we can entertain any plausible expectation of arresting a disease where the morbid motions are of such rapidity and power. He very properly observes at the same time, that the ability with which men bear the loss of blood will much depend upon the habit and locality, and its efficacy on the early stage of the disease. Dr. Bancroft is of opinion that bleeding may be resorted to in certain cases of the yellow fever, not only with safety but advan- tage, and he quotes himself as an example ; but, he says, that the propriety of the operation, and the quantity of blood to be taken away, must be determined by the circumstances of the patient. On a more intimate acquaintance with this specie's of fever than physicians possessed at first, many of those who have had most ex- perience in attending patients labouring under the disease, now approve of venesection at the onset, or soon after its seizure. To obviate the inflammatory diathesis which prevails during the - first stage of the disease, and to take off the determination from the head, as well as to cleanse the primae viae of acrid and offending humours, we may employ gentle purging, so as to procure one or two evacuations daily during the continuance of the fever ; but as the stomach is seldom in such a state as to be capable of retaining those purgatives which are in common use, besides a triple dose being generally necessary, it has been found best to administer the hydrargyri submurias, either by itself, or combined with jalap or extract, colocynth. c. as below.* If the first dose does not operate in due time, it is to be repeated. At the end of six hours or so, if the purgative has not yet been attended with the desired effect, it ought to be assisted by an enema, giving at the same time by the mouth about an ounce of magnesiae sulphas dissolved in a little mint water. In no stage of typhus icterodes can emetics be administered with safety, owing to the disposition to vomit which usually prevails, and which it is often difficult to allay. Instead of prescribing emetics, we are to endeavour by every possible means to calm and allay the irritation of the stomach. As there appears to be a morbid determination of febrile or in- flammatory action in this disease upon the intestines, we may * 1- ft Hydrargyri Submur. gr. iv. Pulv. Jalap, gr. viij.—xvj. Syrup. Zingib. q. s. M. ft. Pulvis pro dos. Vel, 2. R Hydrargyr. Submur. gr. vi. Extract. Colocynth. C. gr. x. M. Fiant pilul. iij. * 1. Take Submuriate of Mercury, four grains. Powder of Jalap, from eight to sixteen grains. Mix these for a dose. Or, 2. Take Submuriate of Mercury, six grains. Compound Extract of Colo- cynth, ten grains. Mix them together, and form the mass into three pills. 38 PVREXI.E, OR FEBRILE DISEASE.^. [ClttSS I. endeavour to counteract this disposition and produce an opposite determination by suitable diaphoretics, combined with opium in small doses, assisted in urgent cases by the warm bath, warm fomen- tations and a blister on.the belly, taking care, at the same time, to promote sufficient evacuations by stool, in order to relieve the intes- tines as much as possible from all irritation and uneasiness which they might suffer by a retention of hardened feces and other matters. Mercury being known to be a kind of specific in local inflamma- tions of the liver, and there being evidently a great determi- nation of blood to this viscus in the yellow fever, practitioners have been induced to employ it likewise with the view of exciting a degree of salivation ; and where an incessant vomiting has pre- vented their us'ing the submuriate of mercury in sufficient doses to effect this, they have substituted mercurial frictions. In some of the cases, where the hydrargyri submurias was administered with this view, its quantity was obliged to be increased to an almost in- credible extent. Dr. Chisholme mentions a case, where 400 grains were given before the salivary glands were affected ; and in the Medical Commentaries for the year 1795, Dr. Duncan, of Edinburgh, takes notice that a correspondent in Jamaica had re- ported an instance where, within the space of a few days, the pa- tient had taken 270 grains of it, and had rubbed in twenty drachms of the strongest mercurial ointment, from which the happiest ef- fects were at last produced. On such authorities, and from the well-known efficacy of mer- cury in inflammations of the liver, it may, probably, be a proper and valuable remedy in typhus icterodes. To ensure its success, it should, however, be employed at the very commencement of the disease, and be so conducted as to affect the mouth before the dangerous symptoms of the second stage of the fever make their appearance. Dr. Currie, of Philadelphia, informs us,* that in every case in which he has seen mercury employed after the dis- tressing and dangerous symptoms of the second stage had come on, it aggravated them and increased the danger ; and that when re- sorted to after signs of what is called putrescency have made their appearance, it has invariably accelerated the fatal event, notwith- standing the declaration of Dr. Chisholme to the contrary. In having recourse to mercury externally, we may direct half a drachm, or even a drachm of the strongest ointment to be rubbed into the thighs, hams, legs, and arms, every four hours; and we may give hydrargyri submurias internally, either by itself, or combined with opium,! according to the state of the bowels. * See vol. ix. page 102, of the Med. and Phys. Journal. f 3. Pi Hydrargyri Submuriat. gr. ij — Opii, gr. ss. Confect. Rosas, q. s. M. ft. Pilula, 4tis horis repetenda. t 3 Take Submuriate of Mercury, from two to four grains. Opium, half a grain. Confection of Roses, a sufficien- cy to form a Pill, which is to be repeated every four hours Order I.J YELLOW FEVER. 89 When a gentle ptyalism takes place, its use ought immediately to be omitted, and only nourishment and wine be given. That many patients have recovered by a mercurial treatment, if early adopted, appears from Dr. Chisholme's excellent work, as well as from the practice of the naval and military hospitals in the different West India islands, and the reports given in by various private practitioners. In typhus icterodes, possibly, there may be congestions in the liver, both from an accumulated and imperfect secretion of bile ; and mercury certainly possesses very stimulating and deobstruent qualities. We are told by Dr. Bancroft, however, that mercury admi- nistered so as to produce a salivation, appeared to him to be extremely equivocal in its operation. He is of opinion that the good effects of the mercurial treatment have been greatly exag- gerated ; that many persons have died of this fever, although mer- cury administered externally or internally had produced a copious salivary discharge, and that in many others who have recovered, the discharge did not begin until after a solution or great mitiga- tion of the fever, and therefore could not have been the effect of the salivation. He, however, deems the use of mercury as a pur- gative highly beneficial, and into this quality he is strongly disposed to believe its reported efficacy in all fevers is to be resolved. At the first commencement of typhus icterodes, it is not unusual for a frequent vomiting to prevail. In such cases it may be ad- visable to wash out the stomach with an infusion of the flores an- themidis; but should it continue, stupes, wrung in a decoction of bruised poppy-heads, with an addition of one-third part of cam- phorated spirit, may be kept constantly applied to the region of the stomach, and the saline medicine may be administered (so as that the effervescence shall take place in the stomach) with an addition of about ten or twelve drops of tinctura opii to each dose. Sulphuric aether has been given, and even ardent spirits are some- times administered with partial relief, as the heat and vascular action subside. Warm clysters made of mucilaginous and aromatic vegetables infused in boiling water, with an addition of sixty or eighty drops of the tincture of opium, have been attended with the most imme- diate and sensible benefit in cases where vomiting, oppression about the praecordia, and great irritability appeared to be owing to exhaustion from too copious depletion. In cases of great irritability of the stomach, where excessive vomiting prevails, the early application of a blister immediately over the part may be attended with the best effect; but this re- medy is in general applied too late, and a determination to that important organ is suffered to take place before any attempt is made to counteract it, which at last proves too powerful to be re- moved. In some instances the vomiting has been known to cease upon 18 90 PYREXIA, OR FEBIIILE* DISEASES. [Class I. the application of a large poultice of mustard-flour to the stomach and feet which occasioned a very extensive and painful inflamma- tion of the skin. By employing cold affusion on the first onset of typhus icterodes, we may probably, in some instances, arrest its progress, and in- terrupt the morbid actions; and even in cases of some days' con- tinuance we shall be able, by means of it, to abstract heat, induce sleep, and recruit the animal powers. In an advanced stage, it will be best to substitute aspersion, or ablution with a wet sponge. In all cases where there may be the smallest danger of arresting the movements of life by either affusion or aspersion, a glass of wine, or some other more powerful cordial, should be taken immediately after using the remedy. Cold water is certainly a very efficacious remedy in this fever, and when applied externally, affords very great relief to the feelings of the patient, who is frequently distressed with a sensation of burning heat, the temperature of the skin, at the same time, being actually raised some degrees of Fahrenheit's thermometer above the natural standard. It is however only when the heat of the body is above the natural standard that cold water should be applied externally; and the period of its application and the fre- quency of its repetition must be determined by the feelings of the patient ; for should he become chilled by it, much mischief might ensue. To avoid any fatigue to the sick, which the usual mode of applying this remedy is apt to induce, a late writer* on this fever recommends as an useful substitute, that the patient should be covered as he lies in bed with a single sheet wetted with cold water, which by evaporation will gradually reduce the temperature of his body to a proper standard. Dr. M'Lean has seen the best effects to arise from cold affusion in this fever, and tells us, in order to heighten its power, that he often premised the warm bath, and while the patient was sitting in it, he dashed two or three buckets of cold water suddenly on him. In those cases where the remedy was happily applied, the general effects observed from it were, an improved recollection, greater cheerfulness of aspect, a diminution of heat and anxiety, the pulse becoming more full and equable, a tendency to sleep, and some- times a distinct remission. tJT^ZTffr °f ?*% °'Leai7's> th™gh the medium of the London Medical Journal,! further establish the good effects of the affusion of cold water in typhus icterodes. We are told bv him, that he was ordered, soon after his arrival at Barbadoes from Europe, to attend the sick of the 70th regiment at Antigua wher^ on his arrival, he found they amounted to about an hundred Thev werednefly affected with the yellow fever, and the mortality had * See Dr. Bancroft's Essay on the Yellow Fever t See vol. xvi. page 490. Order /.] YELLOW FEVER. 91 been very great; but on his employing cold affusion judiciously, agreeably to the rules advised by Dr. Currie (see Typhus Mitior and Gravior,) very few died afterwards. He mentions, that so sensible were the men of its efficacy being superior to any other remedy, and of the relief obtained from it, that in his absence they frequently entreated the officers, when duty led them to visit the hospital, to have it repeated on them. In a short history of the yellow fever which prevailed at Norfolk in America, and communicated by Drs. Selden and Whitehead to Dr. Miller of New-York,* further testimony in favour of an early use of the cold affusion is produced. From the great benefit which these physicians experienced in their two or three first trials of it, they proceeded to recommend it afterwards with confidence. They have reported, that of all those patients to whom they had an op- portunity of exhibiting this remedy on or before the second day of the attack, they had the good fortune not to lose one; but after this period, when the fever had begun to subside, without symp- toms of amendment, the affusion of cold water seemed to hasten the fatal catastrophe. In no instance did they employ the remedy in question without the exhibition of calomel at the same time. No disagreeable effect was produced by combining the use of calomel with the affusion of cold water; nor did the mercury occasion a salivation in a single instance, although the discharge from the bowels was scarcely as great as when it was used alone in the cure of the disease. In temperate and cold climates where we employ affusion, it will be sufficient to take the water fresh from the spring, pump, or the sea ; but in warm climates, in order to command the full and expected effect, it will be necessary that its temperature be redu- ced to a low degree (as about 40 of Fahrenheit's thermometer) by exposing it to the night air previously, or by adding some salt to it. Much benefit will probably be derived from cold water taken internally as drink, small quantities of which, frequently repeated, have been observed to moderate the excessive heat of the body, as well as the violence of general febrile action and thirst: it is like- wise efficacious in disposing the skin to perspire gently, and in pre- venting inflammation and irritation of the stomach. For reducing the temperature of the body to its natural and healthy standard, and for producing a refrigerant effect in this and other fevers of the typhoid type, we have been informed by Dr. Cumming,t that he has derived the highest benefits from either sprinkling or sponging the bodies of the sick with ardent or rectified spirits, and that he considers these to be in every respect superior to cold water. The effect, no doubt, will be quicker from using spirit, as the evaporation will be more rapid ; but it has been a See vol. x. page 266, Med. and Phys. Journal. t See Med. and Phys. Journal, vol. xviii. p. 197. f*2 FYREXIiE, OR FEBRILE DISEASES. [Class I. questioned, and very properly, whether or not the great advantages which are derived from the cold affusion or washings, are to be at- tributed solely to the abstraction of heat in fever. Should proper means not have been adopted sufficiently early, or should they have failed in procuring the desired effect, and symp- toms of putrefaction have made their appearance, our endeavours must be directed towards stopping the putrid disposition of the fluids by the most powerful antiseptics. West India practitioners have of late administered the capsicum, in the form of pills, as a stimulant, and with very good effect. Spirituous baths have like- wise been employed. The cinchona bark must be given in as large doses as the stomach will bear; and if it will not retain any quan- tity, either in substance, decoction, or infusion, it may then be given in the form of clyster. A pint of decoction, made by boiling an ounce of the powder in a quart of water, until one half is evapo- rated, may be injected every three or four hours. Acid fruits may likewise be given liberally ; and the ordinary drink should be wine sufficiently diluted with water, and acidulated with lemon or orange }uice. The mineral acids might likewise be serviceable in this fever, as well as in typhus gravior and scarlatina anginosa, and I much wish that a fair trial may be made of them, but more particularly the muriatic, in an early stage of the disease. The sooner it is ad- ministered, the more likely will it be to prove efficacious. Its wonderful effects in other malignant disorders I have often wit- nessed ; and typhus icterodes being evidently of this nature, is it not reasonable to suppose that its use might prove highly service- able in this also ? Throughout the whole course of the disease, but more particu- larly under the above circumstances, the strictest attention ought to be paid to cleanliness, by not only changing the patient's linen frequently, and immediately removing and emptying' whatever comes from him, but likewise by sprinkling his chamber every now and then with warm vinegar, and allowing a perfect and free ven- tilation of air through it. To destro) contagi n, and assist in cor- recting the fetor, the gaseous fumigations recommended under the head of Typhus Gravior ought to be employed. The patient's strength is to be supported throughout the disease with preparations of barley, sago, tapioca, Indian arrow root, &c. mixed with wine, and his thirst allayed by a liberal use of barley water, common water, or any other grateful beverage. Dr. M'Lean observes, that he always found opium to be injurious in the beginning of this fever, although restless nights and anxiety often tempted him to prescribe it in large doses. It procured no settled rest: for a time, the delirium was increased, to which stupor rather than sleep succeeded: and the next day, languor, irrita- bility, and weakness prevailed. When remissions had commenced, and where a return was apprehended, he gave opium freely, and apparently with a good effect. It was likewise useful when con- Order I.J YELLOW FEVER. 93 vulsions took place, and to procure sleep towards the decline of the disease. When a severe headach, with great depression of spirits, is com- plained of, camphor and aether may probably be administered with some advantage. In cases where violent delirium prevails, the ap- plication of a blister to the neck or shoulders may be advisable ; but where there is only coma, this remedy will not be necessary. When remissions are obtained, and the disease shows a disposi- tion to yield, the cinchona bark, joined with sulphuric acid, may be taken with advantage, and its use should be continued during the whole stage of convalescence, which is often tedious and long, owing to the great debility that is always left behind, and from which the patient cannot readily recover, unless by a change of climate. Quassia in a cold infusion is a valuable medicine during conva- lescence, and here the cold bath may also be serviceable. The cortex cuspariae has likewise been found^an useful medicine towards the close of this fever, when debility is the chief symptom. An infusion of it* sits easy on the stomach, and is attended with the most beneficial effects in restoring the strength and appetite. Other tonics may be used at the same time: for these, see Dyspepsia. In recommending a use of the cortex cuspariae, it appears worthy of observation to guard practitioners against a spurious species of it met with in the trade, and which proves of a deleterious and poisonous nature. That of a safe nature, and commonly used, is a thin smooth bark, of a yellowish colour in the fracture, and of a bitter aromatic taste. The poisonous kind is less thick, a white, or yellowish white bark ; in the fracture gray, on the inner edge yellowish, partly approaching to brown, of an unpleasant bitter taste, and hardly possessing any aroma. The effects of the spuri- ous and bitter cusparia, both on mankind and animals, are pretty much the same with those produced by the nux vomica. Not long ago a fever of a highly malignant nature made its appearance at Gibraltar, as well as at Cadiz and Malaga, and destroyed some thousands of the inhabitants. By some practi- tioners it was supposed highly contagious,! by others again not so. Thus it appears that the same diversity of opinion prevailed on this head with respect to this disease, as with regard to the yellow fever, which indeed it very nearly resembles, and probably f- See Reports of the Pestilential Disorder of Andalusia, Cadiz, and Gibraltar, by Sir James Fellowes. * 4. U Infus. Cort. Cuspariae, f. %v. Tinct. Cinchon. f. ------Calumb. f. aa !§ss. M. Capiat Cochl. magna ij. ter quaterve in die, cum Acid. Sulph. Dilut. fl\ xvi. * 4. Take Infusion of Aagustura Bark, five ounces. Tincture of Peruvian ditto, --------of Calumbo, each half an ounce. Mix them The dose maybe two table-spoonsful three or four times a day, adding about twenty- four drops of Diluted Sulphuric Acid. ft'i PYREXIA, OR FEBRILE DISEASES. [ClaSS I. is the same. That which has been denominated the Bulam fever, is also nearly allied.* This seems to be merely the bilious continu- ed, or bilious remittent, of warm climates.! It appears by the practice and writings of the most eminent physicians who have witnessed the Gibraltar and other parts of the Mediterranean fever, that the leading remedies were blood-letting, and purging by the submuriate of mercury and antimony; for upon opening many bodies after death, the brain as well as the abdomi- nal viscera presented appearances demonstrative of a turgescence of the vessels of the former, and an inflamed state of some of the latter. In many, the stomach contained a dark or black slimy fluid, closely adhering to the internal coat. Where the disease breaks out in a garrison, the healthy should immediately be separated from the sick, and, if possible, be en- camped at a considerable distance. Subjecting the former to cold ablution daily might possibly enable them to resist the powers of contagion the better ; for that it is of a highly contagious nature, I am perfectly convinced. In the apartments of the sick, fumigation (as advised under the head of Typhus Gravior) should be adopted. An attention to these, and other precautionary means, may be at- tended with the most happy effects : a neglect of them, with ruinous calamity and devastation, as was unfortunately experienced at Gibraltar on the first appearance of the disease. Mr. Jackson, in his account of the empire of Morocco, states it as his opinion, that the epidemic fever which made its appearance at Cadiz, and afterwards spread all along the southern shores of Spain, was really the plague, imported from the Barbary States, and suffering, after its passage to a Christian country, some varia- tion, originating from the different modes of living, and other cir- cumstances. Having pointed out the most approved method of treating the yellow fever, it seems advisable to offer a few hints, by an attention to which Europeans may often be enabled to withstand its attack, or, if seized, to go through it with the least danger. The plethoric and robust being the subjects most liable to this malignant disease, all such, on their approach to the warm latitudes, ought to be bled in proportion to their strength ; but should this have been neglected during the voyage, it may be done immediately on their arrival on shore. It will easily be understood here, that bleeding, as a pre- parative, will have a very different effect from what it would have in a curative intention; for in the former, it prevents morbid action, and gives time for assimilation; whereas, in the latter, it may induce debility, and morbid associations, very dangerous to life. After bleeding, if the patient is of a full and plethoric habit, the bowels are to be opened by some cooling purgative; and if he is * See Observations upon the Bulam Fever, by Dr. Pym. t See Dr. Bancroft's Sequel to his Essay on Yellow Fever Order I.J YELLOW PEVER. yd naturally of a bilious habit, it may be advisable to premise a gentle emetic. Having adopted these steps, he may then begin a slight course of mercury, taking from two to four grains of hydrargyri submurias, according to his age and other circumstances, every other night, either in the form of a pill, or that of a powder, mixed in some thick vehicle, until the gums become somewhat affected. Should the medicine run through the bowels, a grain of opium, or a few drops of tinctura opii, may be added to each dose. When the mouth shows the mercurial action, a dose of cooling physic ought to be administered after one or two days' intermission of the medicine. In some constitutions, not easily affected by mercury, it will be necessary to persevere with steadiness, until the system be thoroughly impregnated; for thereon depends the safety of the patient. On his voyage being completed, and his landing, he must ob- serve the greatest lemperance in his diet, and carefully guard against any exposure to the sun in the middle of the day, and to the cool air of the night, until he becomes somewhat habituated to the climate. The effects of temperance, as a prophylactic, are strikingly demonstrated by Dr. Chisholme, who observes, that while the yellow fever raged at the island of Grenada, the utility of this was remarkably illustrated by the almost total exemption of the French inhabitants from the disease, whose mode of living, compared with that of the English, is temperate and regular in an uncommon degree. Dr.. Clarke tells us, that new settlers who could be prevailed upon to undergo a gentle course of mercury, taking a few laxative medicines, afterwards coiifining themselves to a moderate use of wine, and living chiefly on vegetables and fruits for the first two or three months, may rely almost to a certainty on escaping this fever. The remark is, 1 think, well founded, excepting that, not- withstanding all these precautions, it may arise from contagion, and in this case its virulence, in all probability, will be greatly diminished. Europeans appear to suffer in point of priority and severity of attack by the yellow fever, precisely in the degree that they possess bodily vigour, rigidity of fibre, and are of a sanguineous tempera- ment ; and when relaxed by a long residence, or other causes, they become, like the Creoles and people of colour (as they are termed,) in a great degree exempt from the influence of this fever. It is the reduction of tone, which a certain period of residence occa- sions in the constitution of Europeans, that secures them in a great measure from the seizure of the yellow fever. It is a corresponding (atonic) state of constitution which affords immunity to the native inhabitant. Having pointed out the means for enabling Europeans to with- stand an attack of this fever, I proceed to offer, from personal experience, a few admonitions or rules, by an assiduous attention to which they probably may be enabled to enjoy a long and unin- terrupted state of good health in warm climates, unassailed by any *G PYREXIA, OR FEBRILE DISEASES. [ClaSS I. other disease whatever. Men who exchange their native for a distant climate, may be considered in a light somewhat analogous to that of plants removed into a foreign soil, where the utmost care and attention are required to inure them to their new situation, and keep them healthy. Every European, in changing his own climate for a warm one, should, if possible, avoid arriving in his new situation during the rainy season of the year. This, with some small variation, com- mences in the month of August, and terminates in October. If he has it in his power to choose the place of his residence, he ought to prefer that situation which is somewhat elevated, dry, open to the air and sun, and remote from woods, stagnant waters, or marshy grounds. Most of the towns in the West Indies, as likewise the factories on the coast of Africa, with some of our settlements in the East Indies, are, for the convenience of trade, situated on low grounds, either contiguous to the sea, or on the banks of some large river. Swamps and marshes, therefore, exist in their neigh- bourhood, and when acted upon by a powerful sun, particularly after heavy rains, they send forth noxious vapours and exhalations, which prove a never-failing source of intermittent and remittent fever, fluxes, &c. to all descriptions of inhabitants, but more parti- cularly to Europeans lately arrived. Persons of this description, ought, therefore, to pass as little of their time as possible in such a situation; and, where obliged by- business to resort there by day, they should retire early in the evening to one that is elevated, and that has the advantages before described. If no such situation is to be procured without great inconvenience, sleeping on board a vessel in an open road or healthy harbour, will then be preferable to passing the night on shore. Where unfavourable circumstances do not admit of either of these advantages, and new comers are obliged to remain con- stantly in an unhealthy spot, they will act prudently in adopting such means as will tend in some measure to lessen the danger to which they are exposed. The highest apartment in the house should be chosen to sleep, in; if furnished with a stove, a small fire should be kept in it; and the windows that front the swampy ground, if the house is to the leeward of this, are to be kept shut, admitting the light and air by the others. About half an ounce of the compound tincture of bark may betaken every morning on an empty stomach, repeating the dose again in the evening. Smoking tobacco might also be serviceable in such a situation. A propensity to smoking is, however, too general among Europeans and natives, in tropical climates ; but it ought to be considered not only as a degrading but an injurious habit, as, during the process, the grog glass is in constant circulation. In particular places, where marshy or other deleterious exhalations abound, or during very moist damp weather, at certain seasons of the year it may be useful and allowable. The diet of Europeans, newly arrived in a warm climate, should Order I.J yellow fever. 97 consist of a greater proportion of vegetable food than of animal, avoiding such articles of the latter as are either salted or very highly seasoned. To all such, a free use of ripe subacid fruits will be highly proper, as they will not only assuage thirst, but serve to correct any tendency in the fluids to putrefaction. In the West Indies it is usual to take weak punch in the forenoon daily: sher- bet, or an infusion of preserved tamarinds, in water, will be found, however, a grateful and more salutary beverage to allay thirst. The danger of drinking cold fluids of any kind when the body is much heated by exercise, and the perspiration profuse, cannot but be obvious to every person. The unbounded hospitality of the islanders in the West Indies frequently proves a source of much evil and danger to new comers ; for they are no sooner arrived, than they are engaged by invitation in a daily round of visiting and feasting, committing therein exces- ses, which, together with an unavoidable exposure to the dews of the evening, are not unfrequently productive of a severe attack of illness. To all new settlers I beg leave, therefore, to recommend a very moderate indulgence in the delicacies of the table ; a spare and temperate use of all kinds of vinous and spirituous liquors, giving wine the preference to spirits; a proper self-command in sensual gratifications ; the carefully avoiding any exposure to a cur- rent of air, or moisture, particularly when the body is heated by exercise ; their avoiding this in the heat of the day, taking it early in the morning and cool of the evening; their return early to their respective homes so as to avoid the night dews ; their refraining from dancing and such other active amusements; and their cau- tiously obviating a costive habit, by taking from time totime some gentle cooling laxative, until they are able to establish a proper re- gularity in this point, by visiting the temple of Cloacina at certain hours every day, and soliciting natural evacuations. The custom of going early to bed, and rising betimes in the morning, is conducive to health every where, but more especially so in hot countries. If gentle exercise, either on foot or horseback, be added in the morning, it will prove highly salutary ; and should cold bathing be first used, the body would thereby be much invi- gorated, and rendered less susceptible of external impressions. Where the convenience of a proper bath is not to be procured, water properly cooled, by having been exposed all night to the air in pots, or a tub, may be thrown over the body. Minor ablutions, at other periods in the day, may also have a good effect. Cold bathing is one of the most powerful means we possess for counter- acting the injurious influence of a hot climate, and it connects the most grateful sensations with the most salutary effects, but it should be used in the mornings. The practice would, however, be inju- rious to those who labour under any visceral derangement; for such, a slight tepid bath may be substituted with advantage. The dress of new-comers should consist of coats made of thin woollen cloth, with waistcoats and breeches of dimity or nankeen; 14 98 PYREXIAE, OR FEBRILE DISEASES. [ClaSS I. and they should clothe in proportion to the exposure. What is worn next to the sk*in should be made of cotton in preference to linen, as this last when moistened with perspiration, in consequence of any severe exercise, is very apt to convey a sense of chilliness when the body becomes inactive again. Calico shirts will, there- fore, be preferable to linen ones. Those who are afflicted with rheumatic pains may substitute a waistcoat of thin flannel next to the skin. New settlers should observe the greatest precaution in changing their clothes, of every kind, as soon as possible after getting wet; a circumstance too frequently made light of and ne- glected, and which often, therefore, proves the cause of an attack of some severe disease. In a few words, the preservation of the health of Europeans in tropical climates will very much depend on avoiding the various predisposing and exciting causes of disease, until the physical sen- sibility of the system is reduced by habit to the climate. The rules to be observed for preserving the health of seamen in warm climates, as well as in cold ones, are inserted under the head of Scurvy. ORDE11 II. PHLEGMASIA, or INFLAMMATIONS. The character of this order of diseases is synocha fever, with inflammation or topical pain ; the function of an internal part being at the same time injured ; the blood upon venesection exhibiting a huffy surface. Before I proceed to speak of the different inflammatory diseases to which the human frame is liable, it seems proper to make a few observations on inflammation in general, and likewise to point out the different species of it which are to be met with in practice. In every inflammation there is an increased action of the blood- vessels, propelling forward a greater quantity of blood than usual into the part affected, by which means its sensibility and irritability are increased, its vessels distended beyond their natural tone, and the circulation of blood through them rendered more rapid. A variety of opinions have, however, been entertained with respect to the nature of inflammation. Hoffman, and Dr. Cullen, supposed the proximate cause to consist in an increased action of the blood-vessels, with a spasmodic stricture of their extremities; but as the beginning veins are in a state of over-distention in an inflamed part, as well as the arteries, it is evident that no such spasmodic stricture can exist. Dr. M'Bride's hypothesis on the nature of inflammation is, that, besides the action of the blood- vessels being increased, the resistance to the course of the blood is Order II. J INFLAMMATIONS. 99 diminished ; and a third doctrine has lately been advanced, which teaches, that instead of an increase of action in the vessels of the part, as is commonly supposed, the direct contrary takes place, and that there is a deficiency of action and paralysis of the vessels affected, instead of spasm. The principal argument in favour of this hypothesis is drawn by its founder, Mr. Latta,* from the swelling of the inflamed part, which he attributes to a partial stag- nation of blood ; but the great heat of the part, the throbbing pain, and in many cases, the accelerated action of the whole sanguiferous system, clearly point out an increase of action m the vessels. When the inflammation is confined to one particular part, with- out producing any general affection in the system, it is called local or topical; but when it produces effects on the whole system, it is known by the name of general inflammation. Inflammation is properly of two kinds ; viz. the phlegmonous and erysipelatous. By the phlegmonous is to be understood an inflammatory circumscribed affection of the skin and cellularmem- brane, with a swelling rather prominent in the centre, and of a bright red colour, attended with pain and distention, and in which any effusion that happens to take place is usually converted into pus. By the erysipelatous is implied an inflammatory affection confined principally to the skin when seated outwardly, and to the mucous membrane when internally, with hardly any evident swell- ing, being of a mixed red colour, readily disappearing upon pres- sure, but quickly returning again, the redness being of no regular circumscription, but spreading unequally, with a pain like to that of burning, which gives rise to a number of small blisters, and terminating usually in a desquamation of the scarf-skin, and now and then in gangrene, but never in a suppuration, unless combined with phlegmon. Such a combination does frequently occur in practice, constituting what has been denominated erysipelas phleg- monodes. Besides the differences in the circumstances of these two kinds of inflammation, there is another very evident one, which is, that a phlegmon, when considerable, is generally accompanied with more or less of the symptoms of general inflammation; whereas, erysipelas is usually attended with symptoms of irritation when perfectly pure ; from which circumstance, it will be necessary to adopt a different mode of treatment in each of them. Of the erysipelas there are two cases : one, when it is merely an affection of the skin alone, with very litth-of the whole system, which is called erythema ; the other, when it is an affection of the system, and is named erysipelas. Persons in the prime of life, and in full health and vigour, and of a plethoric habit of body, are most liable to the attacks of phlegmonous inflammation: whereas those advanced in years, and See bis System of Surgery 100 PYREXIA. OR FEBRILE DISEASES. [Class J. those of a weak, irritable, and spare habit, are most apt to be at- tacked with erysipelatous or erythematic inflammation. The more moderate the different symptoms are, the better is the chance of the inflammation terminating by resolution. When it does not readily yield to proper remedies, and is unusually obsti- nate, or deep-seated, there is reason to believe that it will terminate by suppuration. When the symptoms are very violent, especially if the inflammation is of the erythematic kind, there will be reason to fear gangrene. Resolution is always a favourable termination: suppuration is also favourable if the inflammation be external and the habit good ; but in internal inflammations we shall find it is generally to be dreaded. Internal gangrene is always fatal. It is only when the gangrene is external that medicine can avail, and then it often fails. PHLEGMON. This species of inflammation is occasioned by the application ©f stimulants, such as fire or burning ; by external injuries, either bruising, wounding, over-stretching, or compressing the parts; by extraneous substances which have lodged, and either by their form, bulk, or quality, produce irritation ; by the application of cold ; and by any thing that determines an increased impetus of blood to the part. The chief seat of phlegmonous inflammation is the inner surface of the true skin and the cellular substance contiguous to it, from which it extends to the adjoining parts of the cellular membrane and skin; so that the surface soon assumes a florid colour, the tumour, at the same time, extending both in depth and circum- ference. It comes on with an itching, dryness, redness, and increased heat and circulation in the affected part; which symptoms are shortly succeeded by a circumscribed tumour, through which shooting and throbbing pains extend. If the inflammation runs high, and is of considerable extent, then an increased action of the heart and arteries takes place; the pulse becomes full, hard, and quick; the skin dry and hot; great thirst arises, and a feverish disposition ensues. Phlegmonous inflammation usually terminates either by resolu- tion, suppuration, effusion, and adhesion, or gangrene. By reso- lution we are to und^-stand the natural cure or going off of the inflammation by a gradual cessation of all the symptoms, the state and texture of the part remaining entire. By suppuration is implied, the conversion into matter, or pus, of the serum, or coagulable lymph and blood which have been effused in the adjoining cellular substance, in consequence of which a cavity, termed an abscess, is formed. When effusion takes place without terminating in suppuration, the matter exuded is frequently viscid, a-nd unites the neighbouring parts together often in twenty-four or Order II.] PHLEGHO&. ID1 thirty hours. In some cases this takes place from a slow degree of inflammation, such as is not noticed at the time : hence, on opening bodies, adhesions between the pleura and lungs, or among the abdominal viscera, are often found. By gangrene is meant a mortification not yet actually formed, but approaching, being the intermediate state between the height of inflammation and spha- celus. Sphacelation implies the total loss of life in the part, an absolute derangement of its structure, the abolition of all its func- tions, and an utter incapacity of its being restored to any service in the animal economy. Many of the phenomena of gangrene seem to depend on a great violence in the action of the vessels, follow- ed by a relaxation, or loss of tone in them ; this, in many cases be- ing so complete, that the action cannot be restored, which occa- sions the part to become perfectly dead, or sphacelated. Such are the most common terminations of this species of inflammation ; but in the schools a fourth has been noticed, which is in a scirrhus, implying an indolent, knotty hardness of the part, unattended by any discolouration, but accompanied with lancina- ting pains, the tumour after a time ulcerating and becoming cancer- ous. This termination of inflammation is, however, confined to glandular parts. When the patient is seized with reiterated shiverings ; when the fever and inflammatory appearance cease quickly without any per- ceptible reason; when a heavy, cold, and dull uneasiness is expe*- rienced in the part affected, instead of acute pain ; when the most elevated portion of the tumour appears soft and white, while the rest has its redness increased ; and when, at the same time, the sur- geon can feel the fluctuation of a fluid, we may be assured that a termination in suppuration has ensued. The latter symptom, how- ever, occurs only where the matter lies superficially: but a man endued with great nicety of touch may be able, in many cases, to perceive the undulations of matter, even when deeply lodged. In most instances, indeed, of this nature, the quick subsidence of all the inflammatory symptoms, the repeated rigours, and the sense of weight and coldness in the part, are the only obvious appearances ; but the patient being afterwards attacked with emaciation, noctur- nal sweats, and other hectic signs, very clearly point out that there is a hidden collection of matter. The symptoms which denote the termination of inflammation in incipient mortification are ; first, a sudden diminution of the pain and sympathetic fever: secondly, a livid discolouration of the part, and which, from being yellowish, becomes of a green hue : thirdly, a detachment of the cuticle, under which a turbid fluid is effused : and fourthly, the swelling, tension, and hardness subsiding, while, at the same time, a crepitus is perceived on touching the part, owing to a generation of air in the cellular membrane. . The term gangrene has been applied to the disease in this stage ; but when the part has become black and fibrous, and destitute of natural heat, sensation, and motion, it is denominated sphacelus. lOi1 PYREXIAE, OR FEBRILE DISEASES. [ClaSS I. In phlegmon, our prognostic should be drawn from the symp- toms which are present, as well as from the seat of the inflamma- tion. If the inflammatory appearances cease suddenly, and blisters discharging a thin ichorous matter arise, together with the part affected losing its sensibility and becoming of a livid colour, then a gangrene will certainly ensue. On the contrary, a gradual abatement of the inflammatory symptoms by a termination, either in resolution, or a suppuration where proper pus is formed, may be regarded as prognosticating a favourable event. This re- mark holds good, however, only with respect to external suppura- tions, as internal ones are always dangerous, and not unfrequently fatal. In the incipient state of a phlegmon, it will always be proper to attempt the cure by procuring a resolution of the tumour, if possi- ble ; and, therefore, an early attention should be paid to the re- moval of the cause which has excited it, as likewise to obviate the phlogistic diathesis, either of the whole system, or of the particular part which is affected. If the inflammation has proceeded from a lodgement of some extraneous body, such as a bullet discharged from any kind of fire- arms, or has been occasioned by a thorn or splinter of wood, &c. it ought immediately to be removed, and, if necessary, the wound must be dilated to such a size as to admit of its being readily got at. In cases of local inflammation, the phlogistic diathesis may be obviated by drawing a proper quantity of blood immediately from the neighbourhood of the part affected, either by scarifications with the aid of cupping-glasses, or by the application of several leeches, which will be the preferable way if they can be procured ; promo- ting the flow of blood by linen cloths dipped in warm water, and renewing them as soon as they cool : butin internal inflammations, it will be advisable to draw blood from the system by opening a vein or artery, taking care to proportion the quantity drawn off to the age and strength of the patient, as well as to the severity of the symptoms. With a view of obviating the phlogistic diathesis, we may like- wise have recourse to purgative medicines. In inflammations of any of the external parts of the body, as likewise in those of the head and chest, a frequent use of purgatives will be attended with a good effect; but in a similar affection of the bowels, active pur- gatives should be administered with due caution. Those of a mild nature, together with emollient laxative clysters, deserve a prefer- ence.—See Enteritis. To assist these means, and terminate the inflammation by reso- lution, if possible, it will be right to make use of some discutient application, as remedies of this nature are, in some mild cases, of themselves sufficient to disperse an incipient phlegmon. In cases of violent contusion or fracture, where a considerable degree of tension prevails, a poultice of rye-meal, or crumbs of bread* Order II.J phlegmon, 303 moistened with the liquor plumbi acetatis, properly diluted with water (viz. about eighty drops of the former to about a pint of the latter,) will be a very proper application; and this may be renewed twice or thrice a day, until the swelling and inflammation subside : but in a common phlegmon, or where the part is so tender and painful as not to be able to bear the weight of a poultice, we must be content to apply pieces of soft linen moi; tened in some sedative application.* It is to be understood, however, that these remedies are to be applied cold, whether we use poultices or wet pledgets, and that they are to be renewed as ofteu as they become stiff, hard, or warm. The application of cold is indeed one of the most powerful means which we possess for abstracting heat and subduing inflammation ; and it has been carried so far in some instances, that pounded ice and snow have been employed for the purpose. When these are not to be obtained, we may substitute, as a refrigerant, pieces of soft linen moistened in a solution of the nitrate of potass and muriated ammonia in water, or even in simple cold water; but they are to be renewed frequently. In some cases of phlegmonous inflammation, particularly that which attends compound fractures, swelled testicle, &c. the pain is often so violent as to deprive the patient of his natural rest. When this happens, we may give opiates both with advantage and safety, provided sufficient evacuations have been premised, and that we afterwards obviate the costiveness produced by them by gentle aperients. The dose, however, should be considerable ; otherwise opium, instead of proving serviceable, will have a contrary effect. About fifty or sixty drops of tinctura opii may be given to an adult an hour or two before bedtime, and in a like proportion to those of a younger age. Children at the breast may take a small quantity of the syrup, papaveris, instead of the tinct. opii. When the inflammatory symptoms run so high as to affect the system, is it not unusual for a febrile disposition to prevail. In such cases we may order some febrifuge medicine to be taken every three or four hours, combined with the nitrate of potass.t * l.g; Liquor. Ammon. Acetatis, Aquae Distillat. Spirit. Rectific. aaf. ^ij. M. Vel, 2. U Ammon. Muriat. 3j. Acid. Acetic. Dilut. f. ^ij. Spirit. Camphorae, f. §j Liquor. Plumbi Acetat.Til xvj. M. ft. Lotio. t 3. ft Potassae Nitrat. ^ss.—3J. Aq. Fervent. ,^viij. Antimon. Tartarizat. gr. ij. ^yr. Viola?, ^ij. M. * 1 Take Solution of Acetate of Ammonia, Distilled Water, Alcohol, each two ounces Mix them, and use them as a wash. Or, 2. lake Muriate of Ammonia, one drachm- Distilled Vinegar, two ounces. Camphorated Spirit, one ounce. Solution of Acetate of Lead, twenty-four drops. Mix them for a wash. t 3. Take Nitrate of Potass, from half a drachm to one drachm. Hot Water, eight ounces. Tartarized Antimony,two grain? Syrup of Violets, two drachms 104 pyrexia;, or febrile diseases. [Class I. If, notwithstanding these means, the tumour should show an evident tendency to suppurate, we are then to accelerate its pro- gress by the application of warm emollient cataplasms, which ought to be renewed three or four times a day. If linseed can be procured, a poultice made of this, slightly bruised and boiled up with milk and water, will be preferable, on account of its emollient quality; but when it is not to be obtained, the white bread poultice, with a small addition of oil, may be used : previous, however, to the application of the poultice, the part affected should be well fomented with flan- nels wrung out of a warm decoction or infusion of emollient herbs.* In inflammatory tumours, which are slow in suppurating, stimu- lating poultices, composed of onion, garlic, galbanum, or ceratum resinae, mixed with the white of an egg, and the common poultice, may possibly forward the suppuration. Warm plasters of galba- num, or pix arida, applied to slow suppurating tumours, sometimes prove useful; and they have this advantage over poultices, that they do not prevent people from doing their ordinary business. When the suppuration is completed, and the tumour is become very soft to the touch, and is near the surface, it is to be opened, either with a lancet or a trocar, in the part which is most dependent, taking care to press the matter perfectly out; after which the wound is to be dressed with dry lint, and a pledget spread with the ceratum resinae to be laid over all. If the wound does not heal readily, the cinchona, with other tonics, should be used till the pa- tient is restored to health. To support the vis vitae, a full diet, with a moderate allowance of wine, will be requisite. In very large abscesses, particularly in that of the psoas muscle, it has been found a judicious practice to evacuate the matter by means of a seton, or by a flat trocar in a canula, which is to be in- sinuated between the skin and cellular membrane for some space, and then to be plunged in a slanting direction down into the ab- scess, leaving the canula, and withdrawing the trocar. The orifice in the skin, and deep-seated parts, by this means will not be in a ft. Mistura, cujus sumat cochl. magna ij. pro dos. Vel, 4. & Haust. Salin. fjss. vini Antimon. tit »•]■ Syrup. Simpl. 3j- M. ft. Haustus, 3tiaquaque hora sumendus. * 5: R Flor. Anthemidis, Fol. Althaea?, aa |ij. Papav. Somnif. Exsiccat. gj. Aq. Ferventis, Oiv. M. Mix them, and take two table-spoonsful for a dose. Or, 4. Take Saline draught, one ounce and a half. Potassae Nitrat. gr. x.—xv. Nitrate of Potass, ten or fifteen j grains. Vini Antimon. f?t x\^. Antimonial Wine, eighteen drops. Common Syrup, one drachm. Mix them as a draught, to be taken every three hours. " 5. Take Camomile Flowers, Marshmallow Leaves, each two ounces. Poppy Heads, bruised, an ounce. Boiling Water, two quarts. Infusethemfora proper time,thenpour ofV ft Fomentun? the liquor, and use it for fomentation Order ll.J phlegmon. 105 direct line, and the severe constitutional symptoms which are apt to arise from the exposure of an extensive cavity to the air, are thereby avoided. In the like cases it will also be proper to direct the patient to take at least an ounce of cinchona bark a day, in or- der to promote the production of proper pus ; and to support his strength under the discharge, a nutritive diet, with a moderate use of wine, should be allowed. Good pus is of the consistence of Cream, and of much the same colour; it has no smell, scarcely any taste, and six parts in seven appear to be water, but it is in general rather heavier than water. In the common heat of the atmosphere it does not unite with this liquid, but does so when exposed to heat. It contains in it some volatile matter, the peculiar properties of which have not been fully explayied \ when examined by the microscope, it commonly appears to be flaky. Pus, when examined chymically, has the same general properties as the blood. The matter of an abscess is either absorbed or discharged, but more generally the latter; and in either case, if it is well condi* tioned, the cavity is gradually filled up by an operation of nature, which is termed granulation, from the new parts appearing in the form of small red grains. When this process goes on favourably, the granulations are of a florid red colour, and proceed in a regular manner till the cavity is accurately filled, its edges (if the matter of the abscess has been discharged externally) being even, or nearly so, with the sound skin. When the granulation is too languid, it may be forwarded by the same means which promote a favourable secretion of pus. It is, however, sometimes too luxuriant, forming irregular masses, which project beyond the lips of the wound. In such cases, it will be necessary to check the granulating process, and destroy the pro- jecting parts by escharotics ; but for more particular information on this head, I must refer to the works on surgery. It has been customary to treat inflammation, terminating in sup- puration, in the manner just detailed ; but in the treatment of such abscesses, it has lately been recommended* to approximate the lips of the wound, immediately after the contents of the sac are dis- charged, by strips of adhesive plaster, then applying a compress, and securing the whole by a roller of sufficient length, applied somewhat tight. The dressings are, at the same time, to be kept constantly moistened with a cold saturnine lotion. By proceeding thus, instead of in the usual way, the external air (if it really be productive of the evil commonly attributed to it) is effectually ex- cluded ; adhesion, and obliteration of the sac, will certainly be ob- tained ; the health of the patient will in nowise be injured, either by the quantity or quality of the subsequent discharge, as the cutis vera approximates closely; when the cure is effected, there is no * See Mr. Cunningham's communication in vol. v. p. 272 of the Medico-CHirur- gical Journal, 15 1W" PVREXiA:, OR FEBRILE D1SEA.^E>. [ClttSS I. waste of cuuneous substance, which frequently renders the parts weaker afterw aids than they were before; there will be no unseemly or puckered cicatrices, so often observed on the site of large ab scesscs; and, finally, instead of the curative process occupying weeks, nay, months sometimes, by this plan of treatment the cure is nearly effected in a few days: for when the cavity of the abscess is once obliterated by the adhesion of the investing integuments to the surface below, the cure may be considered as next to being completed, as the lesion then constitutes merely a simple wound. Should phlegmonous inflammation threaten to terminate in gan- grene, or already have shown symptoms denoting such a termina- tion, we are then to stop the progress of the mischief, and promote the speedy separation of the dead parts from the living. To effect this, it was formerly customary to make slight sqflrificjitions, and afterwards to apply warm antiseptic fomentations, and poultices: but modern practitioners, particularly Mr. Bell and the late Mr. John Hunter, have highly disapproved of this mode of proceeding, and recommend a reliance to be placed on a liberal use of the bark of cinchona, together with a nutritive diet, and such a quantity of wine as will be sufficient to keep up the pulse, and induce the ne- cessary slight degree of inflammation. To give energy to the sys- tem, to restore vitality to the affected parts, and to lessen the mor- bid irritability in them, are the objects which we should keep in view in all cases of gangrene. In cases of gangrene, arising from external injury, and exposing the life of the patient to danger, Monsr. Larry* strongly advises that amputation should be performed, without waiting the appear- ance of the line of separation between the living and dead parts. Where gangrene arises from debility, opium frequently proves useful : and as it by no means counteracts the effects of the cinchona bark, it may be given along with it: indeed opium will prove gene- rally beneficial, and particularly in that variety of the complaint in which no previous inflammation existed, but which is accompanied by violent pain. The efficacy of the bark of cinchona is in every instance indeed much increased by its junction with opium in these affections, and therefore they cannot be too early employed in the curative plan of treatment conjoined together. In cases of gangrene, accompanied with convulsive spasms, or arising from any local injury, such as a fracture, &c. producing irritation, a combination of musk with ammonia has been found by Mr. White, of Manchester, and other practitioners, on his recom- mendations, to have been attended with a happy effect in abating subsultus tendinum, stopping the progress of mortification, and oc- casioning the dead parts to separate from the living. A bolus, con- sisting of ten grains of musk, and the same quantity of ammonia, re- peated every three hours, is what is advised on such occasions. Sef his Mcmoire* de < 'hirurgie Mililaire Ordir U.j J'Hi.egmov. |(:)7 Musk combined with the volatile salt of amber might probably prove a still more powerful remedy for checking the progress of gangrene arising from any local injury producing irritation. By modern practitioners we are instructed to keep the parts cool, and that all applications to them ought to be cold instead of warm, as was formerly practised. As an application to parts in a gangre- nous state, there can be none better than a poultice made by stirring into an infusion of malt (such as may be readily obtained from the ale or porter brewers) as much oatmeal as is required to make it of a proper thickness, and afterwards adding about a spoonful of yeast.* In applying it, due care must be taken not to bind it on too closely, as the fermentation, a short time after its application, will be considerable, and its bulk of course so in- creased, as to put the.cloths and bandages which confine it very much on the stretch. The cataplasma carbonis (which is prepared by mixing two ounces of wood charcoal, reduced to a very fine powder, with ' half a pound of the common farinaceous poultice) is another ap- plication which has lately been much used in gangrenous cases, as well as in sweetening fetid ulcers, and disposing them to granulate favourably. By some communications through the medium of the Medical and Physical Journal,! we are given to understand that the pro- ' gress of mortification has been checked, and the offensive stench issuing from the wound entirely removed in a very short space of time, by sprinkling the diseased parts thickly over with the nitrate of potass pulverized very fine. In the instances alluded to, the dressing was renewed twice or thrice a day. When the diseased parts separate and slough off, dry lint is to be laid on the wound with a pledget, spread with some digestive ointment, applied over all. In the second volume of the Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, is inserted a paper from Dr. Harness, at that time a physician to the fleet, on the good effects of the application of the gastric fluid of gramini- vorous animals to parts in a gangrenous state. By this gentleman we are informed, that he found its application to succeed in more than a hundred cases of sphacelus in entirely removing the sloughs, and occasioning healthy granulations. As a gentle stimulus to parts in a stale of gangrene, where any is thought proper, and in preference to warm gums, balsams, or rectified spirit, Mr. B. Bell advisesf the use of a weak solution of ammonia muriata in vinegar and water. We are informed by him that a drachm of the salt, to two ounces of vinegar and six of water, fdrrn a mixture of a proper strength for every purpose of this kind ; ■■ This is the Cataplasma Effervesconn; of the Pharmacopeia Cliirurgira. ' See vol. xi. p. 206. ; s strong and full, whereas in the former it is small, hard, and more H8 PYREXIA, OR FEBRILE DISEASES. [ClaSS I. rapid. In phrenitis, the delirium is the primary affection ; but in synocha, it is consequent upon the general fever. Phrenitis, whether idiopathic or symptomatic, may always be regarded as a dangerous and alarming complaint: it often proves fatal between the third and seventh day; and if long protracted, is apt to terminate in mania, or great prostration of strength : it often terminates in stupor and insensibility. In children, an effusion of water between the membranes of the brain, or in the cavities of its ventricles, is a frequent consequence. Grinding of the teeth, white or ash-coloured faeces, suppression of urine, startings of the ten- dons, with convulsions, cold sweats, a fluttering pulse, and coma supervening on delirium, denote a fatal termination : on the con- trary, when there is a copious haemorrhage from the nose, mouth, or lungs, or even from the urinary passages or hemorrhoidal vessels, or when diarrhoea ensues, when the delirium is relieved by sleep, and the patient remembers his dreams, when the perspiration is free and general, the deafness diminished or removed, the pulse less frequent, but fuller and soft, and the febrile symptoms become milder, there are hopes of a recovery. Dissections of persons who have died of phrenitis have shown the brain and membranes red and inflamed, the membranes consi- derably thickened and hardened, and in a few instances the pia mater has been found as thick as the dura mater. In some cases, abscesses in the ventricles and adhesion of the dura mater to the skull have been perceived. On the first coming on of idiopathic phrensy, immediate recourse should be had to bleeding, proportioning the quantity that is drawn off to the age and constitution of the patient, and the severity of the symptoms. The orifice which is made with the lancet should be large, and the patient, if possible, ought to be placed in an erect posture. The blood drawn off is usually buffy and cupped upon cooling. Opening the jugular vein, or temporal artery, may be preferable to drawing blood from the arm; and taking away a con- siderable quantity at once, will certainly be better than drawing off only a little at a time, and repeating the operation frequently. Thirty or forty ounces of blood taken at one operation, will more decidedly stop the progress of the disease, than sixty or eighty drawn off by driblets of twelve or fourteen ounces at a time. A man who in a state of health would faint from the abstraction of a pound of blood, will, when an inflammatory diathesis is present, suffer the loss of two or three pounds, without any, or but trifling inconvenience. If the patient is perceived to be much reduced by the largeness of the evacuation, and the disease should nevertheless still continue with violence, the application of several leeches to each temple will be more advisable than any repetition of bleeding from the system. When leeches are not to be procured, blood may be abstracted by means of a cupping-glass and scarificator. The next proper step to be taken, will be to direct the head to Order II.J PHRENITIS. 119 be shaved, and to apply a large blister over it. Linen cloths wetted with vinegar and water, cold spirituous lotions, diluted aether, or iced water, may likewise be kept constantly to the temples and forehead; and they should be re-wetted as often as they acquire the temperature of the scalp by continuance. Topical cold over the region of the brain by a wet towel, or other like medium, will indeed, in many cases prove more efficacious than the application of a blister, as this has been observed occasionally not only to ac- celerate the pulse, but likewise to render the patient more unman- ageable. With a view of obviating the inflammatory diathesis, and of di- verting the humours from the head, a strong purge* may be ordered ; and this ought to be repeated every second or third day during the continuance of the complaint. Purgatives of the saline kind are good antiphlogistics, and may be prescribed instead of others. When we cannot employ purgatives, laxative clysters may be used. In all inflammatory affections of the head, a copious discharge from the intestines will be found highly beneficial, and experience has indeed ascertained that venesection itself is often less powerful. To assist in diminishing the determination of blood to the head, the patient should be kept as near the erect posture as can easily be borne. Warm bathing of the lower extremities, and the application of rubefacients to them, for the purpose of revulsion, have been very generally employed in idiopathic phrenitis. By some physicians, and particularly by Dr. Cullen, they have, however, been regard- ed as ambiguous remedies; and it is probable that they will be likely to do harm, if employed before the excitement has been suf- ficiently reduced. From the well known power of digitalis in lessening the action of the heart and arteries, it is probable that small doses of it admi- nistered from time to time might prove beneficial. Opiates have not been thought advisable remedies in this disease: hyoscyamus might however be serviceable, if we at the same time employed copious evacuations and a low diet. In symptomatic phrenitis, particular attention should be paid to the primary disease which has given rise to it, and the treatment ought to be varied according to the nature and progress of the dis- order which has occasioned it. If it is in its first stage, and inflam- matory, copious bleeding from the system will be necessary; but * 1. R Hydrargyri Submur. gr. viij.—x. Extract. Colocynth. gr. vj. M. fiant Pilulae iij. pro dos. Vel, 2. B Pulv. Jalapre, gr. xv.—3i. Hydrargyr. Submur. gr. vj. M. ft. Pulvis Catharticus, * 1. Take Submuriate of Mercury, from eight to ten grains. Extract of Colocynth, six grains. Form the mass into three pills for a dose. Or, 2. Take Powdered Jalap, from fifteen grains to one scruple. Submuriate of Mercury, six grains Mix them, and let the cathartic powder be taken at once. iiiO PYREXIA!, OB FEBRILE DISEASES. [Cla&S I. if it has been of some continuance, drawing blood from the tem- ples, by means of leeches or cupping with scarifications, will be preferable. Symptomatic phrenitis will not require our using active purga- tives ; on the contrary, we should keep the body open only with gentle aperients, or laxative clysters, administered from time to time, as the occasion may require. In most cases, the application of a blister to the neck, or between the shoulders, will be proper. As a medicine, the patient may take in both species of phrenitis a diaphoretic bolus* every three hours, washing it down with two or three table-spoonsful of some febrifuge mixture.t If phrenitis arises in consequence of some suppressed evacuation. ot eruption, we must endeavour to restore it by the proper means*, which will be understood from the nature of the former discharge,. During the whole course of the disease the patient ought to be kept cool, and as quiet and undisturbed as possible, excluding light from him ; and his food should be mild and nourishing, consisting of preparations of barley, sago, gruel, &c. Cold acidulated liquors should be allowed with freedom. In idiopathic phrenitis, every part of the antiphlogistic regimen will be necessary. OPHTHALMIA, or INFLAMMATION of the EYE. Ophthalmia is of two kinds, viz. the idiopathic and symptoma- tic ; the latter proceeding either from diseases of the eye, or parts in its neighbourhood, or from diseases of the system ; and the for- mer from the causes hereafter assigned. In ophthalmia, the inflammation is seated either in the mem- branes of the eye, its deep-seated parts, muscles, and the lachrymal gland, or in the sebaceous glands placed in the edges of the eyelids: but sometimes all these parts are affected in consequence of sympa- thy ; and indeed it rarely happens that any of these suffer in a con- siderable degree without the inflammation extending further. It readily spreads along the conjunctiva, from the tarsi to the eye, or in the contrary direction. When the conjunctiva is much inflamed, the adnata soon partakes of the inflammation ; and if the com- plaint increases, it gradually spreads to the deep-seated parts. * 3. R Camphorae, gr. iv. Pulv. Antimon. gr. ijss. Confect. Rosae. q. s. M. ft. Bolus. 14. & Succ. Limon. f. |jss. Ammoniae Subcarbonat. 3ss. vel. q. s. ad ejus saturationem ; dein adde Aq. Menth Virid. f. §j. — Fontan. f. %iv. Potassae Nitrat. 3j- Syrup. Rosae, f. gij. M. i*. Mistura. * 3. Take Camphor, four grains. Antimonial Powder, two grains and a half. Confection of Roses,a sufficiency to form the whole into a small bolus. t 4. Take Lemon Juice, one ounce and a half. Subcarbonate of Ammonia, half a drachm,ora sufficiency to sa- turate the acid; then add Mint Water, one ounce. Pure Water, fourounces. Nitrate of Potass, one drachm Syrup of Roses, two drachms Mix them. Order II.J ophthalmia. 121 With some people there is a great tendency to a recurrence of the disease ; and in many cases it has been observed to renew its attacks, or to have regular exacerbations at a particular time of the day. The causes producing ophthalmia are, external injuries, such as blows, contusions, and wounds on the eyes; extraneous bodies, of an irritating nature, introduced under the eyelids; exposure to bleak winds and cold; little inflammatory tumours called styes, which rise on the eyelids ; various acrid fumes acting as chymical stimuli, such as the smoke of pit coal, that of wood, turf, &c.; too free a use of vinous and spirituous liquors, the suppression of ac- customed discharges, the long application of a strong light, or fixed attention to minute objects, and an acrimony prevailing in the mass of blood. To these causes we may, perhaps, add with some propriety the bare inspection of the eyes of a person when in a highly inflamed state ; for although practical writers have not enumerated this among the causes of ophthalmia, yet 1 have occa- sionally met with cases which appeared to arise from this, as pre- vious to inspecting the diseased eyes the person made not the least complaint, but very soon afterwards complained of uneasiness in his own. The occurrence once happened indeed to myself, and! the inflammation that ensued was very violent. Ophthalmia is sometimes symptomatic of other diseases, such as measles, small- pox, scurvy, scrofula and syphilis. A very obstinate and dangerous species of ophthalmia of the purulent nature is now and then produced by the accidental appli- cation of gonorrhoeal matter to the eye, or eyes, A distressing case of this nature, wherein the patient, a very stout man, was for ever totally deprived of sight by imprudently washing his eyes with his urine, whilst labouring under gonorrhoea, lately came under my observation. Mons. Sonnini, in his Travels through Egypt, mentions, that ophthalmia is a complaint which is endemical in that country, and that eyes perfectly sound, or which are not swelled, are rarely to be seen. This he attributes to the excessive heat, the air being- impregnated with noxious particles, and the acrid and burning dust which the winds scatter in the atmosphere. Another cause of the cecity so general at Cairo, he says, is the frequent watering of the streets and houses. Water, thrown abundantly and frequently upon a burning soil, containing a great many saline particles, pro- duces, he observes, acrid vapours, which may be considered as one of the principal causes of blindness in Egypt. Sir Robert Wilson mentions* that the Egyptian ophthalmia h supposed to originate in the nitrous particles emitted from the ground by the force of the sun, which are of a quality so pungent and penetrating as to injure the fine vessels of the eye. The acrid and burning dust flying continually in the atmosphere, irritates still more the already affected part; while the reflection of the ' Sf>e his Hhtory of the Expediting, to Egypt. 17 il'2 PYREXIA, OR FEBRILE DISEASES. [ClttSS /, soil, the heat of the air, and vivid light of the sky, tend to weaken the sight, at last occasioning excessive inflammation. According to the best information which we have received, this species of ophthalmia arises in the first instance soon after the over- flowing of the Nile, or rather on its recession, when a vast quantity of slimy mud is deposited on its banks and other places which were overflowed, and which being acted upon by a powerful sun, send forth miasma, or effluvia that excite inflammation in the eyes of this peculiar nature. The custom in Egypt of sleeping in the open air, possibly may increase the power of the cause. Ophthalmia has not been considered in Great Britain as a con- tagious disease, although it has often been known to appear as a prevailing epidemic at different times ; but it is an undoubted fact, that the Egyptian species is highly contagious. During the cam- paign in Egypt our troops were dreadfully afflicted with it, and many returned with a total loss of sight; whilst others, still labour- ing under the disease, propagated it at Malta and Gibraltar, where they first landed; and from which places it was at length brought into this country. It seems to be established, I think, on the most indisputable evi- dence, that the Egyptian ophthalmia maybe propagated by conta- gion, and thr.t in this way it has been introduced into our united kingdom, and has spread in the same manner as in its native soil* The influence of climate, and other local circumstances, on the general character and progress of the disease, cannot, however, be denied. In most of the instances in which this species of ophthal- mia has prevailed in this country, it has appeared with mitigated symptoms, in comparison with the disorder as it occurs in Egypt; but it has nevertheless been observed, that where the patients were exposed to the influence of a marshy soil, it equalled in the severity of its symptoms the Egyptian ophthalmia. A modern Writer* assures u3, that its spreading is not owing to contagion in the ordinary sense of the word (that is, to any infectious matter thrown off from the system of those, labouring under the disease, and operating at a greater or less distance from its source,) but to the actual conveyance of the purulent matter from the inflamed organ to the eye of a person in health. Dr. Edmonston has also pointed out.t that the sphere of action of this contagion is very limited, and that most of the cases which came under his obser- vation arose from the direct application of virus from diseased to sound eyes. It has been indeed ascertained as a fact, that many soldiers, with the hope and view of obtaining a discharge from their regiments, absolutely inoculated their eyes with the contagious matter, there- by inducing a loss of sight in one or both. .* See an Account of the Ophthalmia which has appeared in Engknd since the return of the British Army, by J. Veitch, M. D. t See Edmonston's Account of an Ophthalmia which appeared in the 2d Regi ment of Anrv-'eshire Fencibles in 1802. with Observations on Egyptian Ophthalmia Order IJ.J OPHTHALMIA. 123 Mr. Ware is of opinion,* that the disease which has appeared as a prevailing epidemic among soldiers since the return of our troops from Egypt, ought to be denominated the purulent ophthalmia in- stead of the Egyptian; since one of its chief symptoms, and that which distinguishes it from any other, is the profuse discharge of a purulent coloured fluid, closely resembling the pus or matter that issues from an ulcerated surface. He also thinks that it greatly resembles, in many respects, a disorder, which he has described with minuteness in his Observations relative to the Eye (see vol. i. pp. 129 and 309,) under the title of the Purulent Eye of new-born Children, and in which, no less than in that under consideration, the discharge of matter is always profuse. The common ophthalmia usually comes on with a sensation as if some gritty particles had insinuated themselves under the eye-lids, accompanied with great heat, redness, and pricking, darting pains. As it increases, the parts swell, and the vessels of the eye become not only increased in size, and turgid, but appear more numerous than in the natural state. Great pain is excited upon the least motion of the ball of the eye ; the patient cannot bear the light, and an affusion of tears from the lachrymal gland ensues, which is of so acrid a nature as to excoriate every part on which it happens to fall. When the inflammation runs high, a slight febrile disposi- tion often attends. These appearances, after some days' continue- ance, gradually abate, and at length entirely cease ; but in some cases, a discharge of thick glutinous matter ensues, which collects in considerable quantities about the angles of the eye, particu- larly during sleep. Where only one eye has been affected, it is often succeeded by an inflammation of the other, particularly in a scrofulous habit. In the Egyptian ophthalmia, the symptoms which present them- selves are somewhat different from those of common ophthalmia. In the early stage of the former, the conjunctiva is red, swelled, and turgid ; the secretion of tears is copious ; the patient complains of excessive pain, and roughness of the ball of his eye, and he can- not bear even a feeble light. The eyelids are red at their edges, and swelled, and there is often a sense of weight and scalding of the eye. Sometimes there is a soreness of the integuments of the forehead and temples, with rigours, a quick hard pulse, headach, and other febrile symptoms. In a very short time, oedematous swelling and tension of the eyelids, and prodigious tumefaction and turgescence of the conjunctiva, with a feeling as if the eye was to burst out of the head, succeed to the other symptoms. The least ray of light falling on the retina gives acute pain, and excites in the patient the feeling as if some sharp instrument was thrust into his eye. In some cases the under eyelids are turned somewhat outwards ; in others both eyelids are closed and swollen, and the skin of these * See his Remarks on Purulent Ophthalmy *~4» PYREXIA, 6B FEBRILE DISEASES7. [Class 1. parts has an efflorescent shining appearance. It is not unusual to see the eyelids open, and the conjunctiva so swelled and turgid as to protrude from the eye in the form of two or three folds. When the tumefaction of the conjunctiva is not very great, and the eye can be brought fully into view, the cornea sometimes appears pel- lucid, the pupil is contracted, and the iris discoloured, or as it were full of spots. As the inflammation proceeds, a secretion of purulent-like mat- ter takes place from the surface of the conjunctiva and glands of the tarsi. This matter is pent up for some time within the eyelids in those cases in which the tarsi come in contact; but in others. where they remain separated, it flows from the eye mixed with tears. It is so acrid as to irritate the eye exceedingly, and to ex- coriate the palpebral and cheeks in passing over them. In this stage of the disease the sufferings of the patient are excessive. He is hot and feverish, cannot remain long in one posture or situation, gets no sleep either by night or day, and describes his feelings, as if boiling water was poured into his eyes. If a sight of the hall of the eye can now be obtained, it is found bathed with the purulent matter ; the cornea is muddy in a part or the whole of its extent, or its surface is studded with small white spots. These appearances denote the commencement of a suppu- ration of the cornea. Sometimes the whole of the cornea is in- cluded in the suppuration, and destroyed, the iris is laid bare, the lens and vitreous humour are forced on the iris or entirely evacu- ated, and even the form of the eye does not remain. At other times only a portion of the cornea suppurates, and the sight is more or less affected afterwards, according to the point at which the sup- puration has taken place, and the extent to which it has gone. If the abscess be situated before the pupil, and if it penetrate the whole depth of the cornea, the aqueous humour, in escaping, will carry with it a portion of the iris through the aperture in the cornea ; and the pupil will be in general totally obliterated by the protrusion of the iris, and its subsequent adhesion to the sides of the ruptured cornea. During some violent paroxysm of pain, from the excessive in- creased volume of the whole compages of the eye, locked within the orbit, the coats of the eye at length give way. By this circum- stance, the tension in the parts is considerably diminished, the in- flammation gradually subsides, and the state of the eye begins to improve, unless in the melancholy instances in which the iris con- tinues to protrude. Such is the most violent form of the disease ; but even in slighter cases, where no rupture of the cornea takes place, on the discharge of pus ceasing, a number of granulations are sometimes perceived to arise, on an inspection of the eye, from the interior of the eye- lids, and to present a shocking spectacle. * With some, the Egyptian ophthalmia lasts only nine or ten days; in others, the patients have suffered for months : and unfortunatelv .Order H.J OPHTHALMIA. 1'35 there is no security, we are informed, against a new attack even after a perfect recovery. The common ophthalmia, when slight, and not symptomatic of any other disease, will readily give way to proper means ; but if it is very violent, or has continued for any length of time, it is apt to occasion specks, or to terminate in a dimness of sight or opacity of the crystalline lens. In some cases the inflammation terminates in suppuration of the cornea and deep-seated parts. When it arises in a scrofulous habit, or is symptomatic of syphilis, the cure is often tedious. In the treatment of ophthalmia, its varieties of idiopathic and symptomatic, and of acute and chronic, ought duly to be consider- ed, and to form the basis of our practice. Our object therefore should be, to determine with precision, how far each particular case is to be referred to one or other of these kinds, and to adopt our plan accordingly. Those who are engaged in an extensive practice, now and then meet with cases of idiopathic and acute ophthalmia, accompanied not only with a high degree of organic inflammation, but likewise with much systematic derangement, such as thirst, great heat of the body, fulness and frequency of the pulse, severe pains in the head, and violent throbbings of the temporal arteries. Such in- stances are, however, rare; but when they do occur, general bleeding or venesection ought not to be neglected ; and we should .take care to proportion the quantity we draw off to the existing circumstances, and quickly to repeat it, if necessary. In patients afflicted with violent ophthalmia, it will always be best to bleed from a large orifice as they stand erect upon their feet, as it sooner makes an obvious and great impression upon the circulation than in any other way, and thereby enables us to attain our object by a moderate abstraction of blood : the tunica adnata, which before venesection in this way had been intensely red, will often be found comparatively whitened after it, with a most sensible relief in al- most every other respect. In the worst cases the blood may be: drawn from the jugular vein or temporal artery, in preference to taking it from the arms. In general, however, ophthalmia is only a local affection, accom- panied with little or no fever, except what is excited by the irrita- tion or pain in the organ, and this but trifling; and therefore it will not often be necessary to resort to general bleeding: the pre- ferable way will be to draw blood from the neighbourhood of the affected part, by applying several leeches round the eye; which process we may repeat again and again, as long as the inflammation continues. They ought not, however, to be applied on the upper, but on the under lid. Where leeches cannot be procured, blood must be drawn from the temples by scarifying and cupping. If the inflammation runs high, so as to endanger vision, by pro- ducing an opacity, it will be advisable to make scarifications daily, with the edge of a lancet, on the turgid vessels of the adnata itself; which, if done by a steady hand, will be attended with no kind of 126 PYREXIAE, OR FEBRILE DISEASES. [ClttSS I. danger, but, on the contrary, with infinite advantage. Its effects in diminishing inflammation are very great, even though no more than a few drops of blood be obtained ; and the relief is frequently so considerable as to induce patients after once undergoing the operation, to request its repetition. It is almost unnecessary to observe, that when ophthalmia has arisen from any extraneous body getting into the eye, as particles of sand, dust, lime, or metal, small flies, the hairs of the eyelids, &c, the irritating cause ought immediately to be removed, and the part be defended from the light by the patient's wearing a deep shade of green silk, and sitting in a darkened room. Having adopted topical bleeding, we may then order some active purgative to be taken ; and this should be repeated every third or fourth day, as long as may be found necessary. A few grains of hydrargyri submurias, with a sufficient quantity of jalap, or a solution of any of the neutral salts, will best answer the intention. Where the complaint has arisen from exposure to cold, or other causes suppressing the perspiration, it is probable that the patient may receive benefit from small doses of some antimonial prepara- tion given so as to excite a proper diaphoresis.—(See Synochus.) The pediluvium may also be employed with the same intention. It was a common practice of the late Mr. Saunders, who was esteemed a very eminent oculist, to employ emetics, particularly a solution of tartarized antimony, in the early stage of every variety of acute ophthalmia, so as to produce nausea or full vomiting ; and the same practice has been adopted by Sir William Adams with the greatest success, especially in that species of it which has been denominated the Egyptian. To abate the inflammation and irritation, it it customary to have recourse to the frequent application of some cooling and astringent wash. Such remedies, applied to the eye by means of an eye-cup, or by wet pledgets, prove, beyond a doubt, highly serviceable. Any of the undermentioned* may be used. Where the pain is * 1. B Zinc. Sulphat. Plumbi Superacet aa gr. viij. Aq. Distillat. f. §vj. M. ft Collyrium. Vel, 2. IJ; Liquor Ammon- Acetatis, Aquas Rosae, singul. f. |ij. Mistura? Camph. f. %j. M. Vel, 3. R Aluminis Purif. 3ss, Aq. Rosa:, f. §vj. Vel, 4. ft Aq. Rosae, f. Ziij. Liquor. Plumbi Acetat. fll- xij, M * Take Sulphate of Zinc, Superacetate of Lead, of each eight grains. Distilled Water, six ounces. Mix them for a Wash for the eyes. Or, 2. Take Solution of Acetate of Ammonia, Rose Water, of each two ounces. Camphor Mixture, one ounce. Mix them. Or, 3. Take Alum, half a drachm. Rose Water, six ounces. Mix them. Or, 4. Take Rose Water, three ounces. Solution of Acetate of Lead", eighteen drops. Mix them. Order II.J OPHTHALMIA. 127 very acute, forty or fifty drops of the vinous tincture of opium may be added to any of the foregoing applications, or the eyes may be bathed frequently with a decoction of bruised poppy-heads. In such cases, an internal use of opium will also be advisable ; and it may therefore be taken in doses of a quarter of a grain, repeated every four or six hours. For the purpose of appeasing heat and inflammation in the eyes, some practitioners prefer warm collyriums to cold ones; and among this number, I think is Mr. Ware. The fact is, that inflammation of the eyes sometimes yields to cold applications, and at others it resists them. In instances of the latter nature, the application of warm fomentations may be used. The alternate use of cold and hot applications has sometimes succeeded when neither of them singly appeared capable of putting an end to the diseased action. In inveterate cases of ophthalmia, where inflammation prevails in a high degree, it probably might be advantageous to drop into the eye a strong infusion of digitalis, or the extract of belladonna dissolved in water. The former, I understand, is much employed by an eminent veterinary surgeon for the purpose of subduing violent inflammation in the eyes of horses, and with a very good effect. When ophthalmia is found not to yield to bleeding, both general and topical, duly repeated, purgatives, emetics, fomentations, and the other means which have been pointed out, it will be proper to put a blister at the back of the neck, or behind the ear on the side with the eye which is affected, supposing only one to be diseased ; and to promote a proper discharge, it ought to be dressed with some stimulating ointment.* In those cases where the disorder appears to be constitutional, or to be kept up by any acrimonious humour in the habit, issues between the scapulae, or the insertion of a seton in the neck, will be advisable. Errhines have been recommended in instances of habitual oph- thalmia, and probably may sometimes prove good auxiliary reme- dies. The pulvis asari compositus may be used on the occasion. The pulvis digitalis will likewise excite a copious excretion from the membrane which lines the nostrils, although not generally known to possess such a power. In chronic and strumous ophthalmia, the vinous tincture of Vel, 5. JJ Zinc. Sulph. gr. x. Aq. Rosae, Mistur. Camphor, aa f. giij. M. •'" 6. R Cerat. Resinae, jj;i. ----Lyttae, 3iij. M. ft. Unguentum. Vel, 7- R Cerati Sabina>, gi. Or, 5. Take Sulphate of Zinc, ten grains. Rose Water, Camphorated Mixture, of each three ounces. Mix them. * 6. Take Resin Cerate, one ounce. Cerate of Spanish Fly, three drachms. Mix them into the form of an ointment. Or, 7. Take Savine Cerate, one ounce 128 PYREXIA, OR FEBRILE DISEASES. [ClttSS I. opium is one of the best applications we can employ, and was much used by Mr. Ware in such cases. It has been mentioned, that in ophthalmia the eyelids are apt to be glued together, (particularly during sleep) by a thick glu- tinous matter which is secreted. To prevent this inconvenience, their edges should be anointed with a little soft ointment* every night, or every night and morning. In the ophthalmia tarsi, arising from a scrofulous habit, the unguentum hydrargyri nitrico- oxydi, mixed with an equal quantity of adeps praeparata to render it milder, is one of the most powerful remedies we can employ. Red precipitate mixed with lard is sometimes used, and it seems to be serviceable by destroying the small ulcers that now and then appear on the edge3 of the eyelids. About fifteen grains of it to an ounce of adeps praeparata seems to be the strongest proportion that can be used with safety. It will seldom be necessary to use poultices for an inflammation of the eye, except it is of the purulent kind, in which case we may apply with advantage one made by stirring a lump of alum in the whites of two eggs, until they form a coagulum, and this is to be laid to the eye between two pieces of thin linen or muslin. Cold poultices of rasped potatoes and turnips are often used on such occasions. Mr. Ware is of opinion that the purulent is very similar to the gonorrhoea! ophthalmia. He found the purulent eye, we are told,t most commonly to occur in the children of those women who have had an acrimonious discharge from the vagina at the time of delivery; and the purulent ophthalmia of adults, he thinks, is very generally found connected with some gonor- rhoeal affection. In public schools he noticed the disease to spread obviously, in consequence of the indiscriminate use of basins and towels among the children. Hence, he believes that the purulent ophthalmia arises from the direct application of some poisonous matter to the eyes. Two or three cases of purulent ophthalmia in infants, and evi- dently arising from their mothers being afflicted with leucorrhoea at the time of delivery, have lately been under my care ; and 1 am apt to think that the reason why more children are not affected in the like manner, is owing to the careful ablution they usually undergo immediately after birth, and before they are dressed. The disease is found to prevail mostly among the lower classes of society, who, t See his Remarks on the Purulent Ophthalmia. * 8. ft Tutiaa Praeparat. 3j- Unguent. Cetacei, gj. M. Vel, 9. R Unguent. Adipis Praeparat. §j. Zinc. Sulphat. 3ss. M. Vel, 10. R Ceratum Plumbi Superacetatis. * 8. Take Prepared Tutty, one drachm. SpermacetiOintment, one ounce. Mix them. Or, 9. Take Prepared Lard, one ounce. „„. . Sulphate of Zinc, half a drachm. Mix them. Or, 10. Take Cerete of Superacp.te.te of I <^.<* Order II.J OPHTHALMIA. J.-29 we may naturally suppose, are not so attentive to cleanliness a a those in a higher sphere of life. Mr. Gibson, of Manchester, seems to have been the first to attri- bute this disease in new-born infants to the cause just assigned ; and he thinks it highly probable, from the frequent coincidence of fluor albus in the mother, and the puriform ophthalmia in the child, that these disorders stand in the relation of cause and effect to each other : but, at the same time, he by no means wishes it to be under- stood, as supposing leucorrhcea to be the only cause of a puriform discharge from the eyes of an infant. In some cases, it possibly may arise from exposure to cold, or from a peculiar constitution ef the atmosphere. Mr. Ware appears to have described and treated one of the symp- toms of purulent ophthalmia as if constituting it, and seems to have overlooked the relation between the inflammation and the dis- charge, of cause and effect. He states the first stage of the disease to be an increased discharge from the minute pores of the conjunc- tiva ; and attributes the subsequent affection of the cornea to the eroding quality of the retained matter, joined to the pressure oi the swollen eyelids. In conformity to this hypothesis, he thinks the indication of cure consists in immediately constringing the re- laxed vessels by strong styptic injections. The late Mr. Saunders'' has stated the disease to consist in an inflammation of the conjunc tiva, which is affected much in the same way as the membrane of the urethra in gonorrhoea : he therefore advises that a strict antiphlogistic plan should precede the use of injections, and that when the activity of the inflammation has subsided, the injections should be of a mild nature. If ophthalmia is dependent on a venereal taint, mercury is the remedy we must rely on to remove it. When it arises in a scrofu- lous habit, affecting chiefly the tarsi, and is attended with ulcera- tions, as is often the case, cinchona bark, with alteratives, mineral waters, and sea bathing, will be the most proper remedies. In these cases, hemlock, combined with cinchona bark, has sometimes proved serviceable. Cinchona, with the carbonate of soda, may als« have a good effect. At the same time that we are employing these remedies, we ought not to neglect topical applications. The eunes of the eyelids may be smeared every morning and night with a lit- tle, ointmentt composed of mercury or the sulphate of zinc. When a speck has ensued in consequence of previous inflamma- Sce his Treatise on some Practical Points relating to the Diseases of the Eye.' I 11. ft Unguent. Hydrarg. Nitr'atis, Adipis Praeparatae, aa. ^ss. M. ft. Unguentum. Vel. 12. ft Zinci Sulphat. 3j. AdipisPra?parat. |j. M. til. Take Ointment of the Nitrate of Mer- cury, Prepared Lard, of each half an ounce. Mix them. Or, 12. Take Sulphate of Zinc, one scvujti Prepared T.ard, one ounce M?\ tbfm- loO pyrexia, or febkile disj".am>. [Class f. tion, which has destroyed some part of the transparency of the cornea, it may be touched with some gentle escharotic on the point of a fine camel's hair pencil twice a day. In employing escharotics for the removal of opacities of the cornea, much care and atten- tion will, however, be requisite, otherwise they may prove more injurious than serviceable. That species of opacity which is seated on the external surface of the cornea, and accompanied with some growth, may sometimes he removed by the knife in a steady hand, or by dividing the blood vessels going to it, but not always, as it is sometimes so much dif- fused as to render the operation impracticable. A case of opacity, which arose from a local injury, and which extended nearly over the whole lucid cornea, lately fell under my observation, and was entirely removed by having a few drops of the liquor cupri ammo- niati admitted into the eye every day. In opacities of the cornea, the application of animal gall to the part has been found to be efficacious, when other remedies have failed. Being a stimulant, it ought never to be applied while the inflammatory action is increasing, but should not be delayed one minute after the inflammation is at a stand, as an indolent un- healthy state is apt to take place, which too often terminates in opacities, that no applications can afterwards remove. It may either be used pure, or diluted ; perhaps the latter may be most advisable at first, as it is apt to occasion a painful sensation; but this, however, soon goes off. Its effects seem to be similar to those of a weak solution of the argenti nitras. We are informed by Mr. Ware,* that he has had occasion to at- tend a considerable number of cases, in which an opacity of the crystalline humour was produced by some violence done to the eye; and in most of these, the opacity was dissipated, and the sight res- tored, during the external application of aether. He says, " In using this remedy, I have sometimes diluted it with a third or a fourth of a weak solution of hydrargyri oxymurias; hut in general I have used the aether alone, which has been applied hy means of a camel's hair pencil to the eye itself. The applica- tion of the remedy occasions a very pungent pain in the eye, with considerable redness in the tunica conjunctiva ; but these go off in a few minutes, and leave the eye as easy, and the conjunctiva as pale, as they were before the aether was used." In all cases of ophthalmia it will be requisite to avoid every thing which might occasion irritation ; for which reason the patient ought to be confined to a dark chamber, or, at least, he should wear a blind of green silk over the eye, to prevent a great glare of light; and he ought likewise to abstain from reading, writing, and from all food of a heating or stimulating nature, and a use of vinous or spirituous liquors. In severe eases the diet should be very spare and light, and the * See his second edition of Observations on the Cataract. Order II.J ophthalmia. i3£ drink consist chiefly of some mild farinaceous decoction, which, while it allays thirst and supplies sufficient nourishment, tends both to moderate excitement and promote perspiration. After the removal of ophthalmia, it may sometimes be necessary to employ means to prevent its return, by continuing the use of blisters behind the ears, or the insertion of an issue. In some instances, however, it may be connected with a debilitated habit, and then the best means of preventing its return are those which tend to strengthen the vessels of the eye, or the system in general; and these will sometimes remove habitual ophthalmia when all others have failed. One of the most powerful of these means is the cold bath, which may be employed either by immersing the whole body, or by washing the head in cold water once or twice a day. The ap- plication of cold water to the eyes themselves, or of any astringent collyrium, by means of an eye-cup, twice or thrice a day, may likewise be serviceable in preventing the return of ophthalmia, or removing it after it has become habitual. Cinchona, and other tonics, have also been resorted to with a good effect. In that species of the disease which has been denominated the Egyptian ophthalmia, a favourable termination will uniformly de- pend on our being able to moderate the inflammatory affection during its earliest stage, and therefore the first and great object of the surgeon should be directed to this end : for, if this is not affect- ed, the structure of the visual organ will be destroyed, or be s© altered as to impede or annihilate its functions. By a prompt ap- plication of proper means at the commencement, every bad symp- tom most likely will be arrested. Bleeding to the amount of sixteen or twenty ounces, or more,. according to the urgency of the case, and the strength of the pa- tient, is the first step to be adopted, and perhaps it may be prefer- able to draw off this quantity of blood from one or both of the temporal arteries, as one or both eyes may be affected, in prefer- ence to taking it from the arm ; and to prevent secondary ha»- morrhage it may be advisable to secure the divided artery by the tenaculum, as the pressure of a tight bandage round the temples will, in severe cases, add to the tumefaction of the palpebrae, and increase the pain and inflammation. Should the inflammation of the organ not be greatly moderated in six or eight hours after this bleeding, it will then be necessary to take away more blood in the same manner as before, again regulating the quantity according to the severity of the complaint. If our attempts to subdue the in- flammation still prove ineffectual at the expiration of eight hours more, and the symptoms seem to require it, the operation ought to be repeated a third time in sufficient quantity. We are told by Dr. Veitch,* that the principal remedy which " See his Treatise on the Egyptian Ophthalmia. 13i psrexia;, or plbrile diseases. [Class I. has been productive of any good effect in the ophthalmia that has prevailed among the British soldiers since their return from Egypt, and to which the name of Egyptian ophthalmia has been applied, is bleeding; but in order to ensure its full power, that it has been found necessary to carry this evacuation to a great extent, and with a freedom far beyond what we have been accustomed to re- commend. In short, he informs us that he found it absolutely necessary to draw off upwards of twenty ounces at a time, or ra- ther to bleed the patient ad deliquium animi, and to repeat the operation pretty frequently to this extent. Immediately after the first bleeding in the Egyptian ophthalmia, an active dose of purgative salts is to be administered, and this should be repeated every second or third morning. A large blis- ter is to be applied at the same time either over the whole of the head, or behind the ears and to the nape of the neck. The pa- tient is to be lodged in a dark but well-ventilated room, and to be confined to a spare and antiphlogistic diet. A tardiness in the use of evacuants, particularly a sparing use of the lancet, or its not being early resorted to, may be considered, in most instances, as the chief cause of subsequent disorganization and destruction of the eye, in the various shapes of suppuration, ulceration, sloughing, and rupture of the cornea, adhesions of the iris, opacities, &c. which are met with in cases of Egyptian oph- thalmia ; and even if these bad results do not occur, such omissions will tend to form and protract an obstinate chronic stage, from the debility induced in the vessels of the membranes, owing to previ- ous excessive action and distention. In this species of ophthalmia, as well as in severe cases of the common kind, it may be advisable to make frequent scarifications on the ball of the eye ; but perhaps it may be the better way to carry the lancet along the inside of the lower lid, parallel to its edge, and not far distant from it. Scarifications made in this way will be far preferable to pricking the eyelid repeatedly in quick succession, as is sometimes practised. The issue of blood from the scarifications may be assisted by gently everting the lid with the end of the finger; and it will be more useful to take off the finger occasionally, and then to apply it again, and thus renew the ever- sion, than to continue the finger steadily on the lid. Whilst, by large and sudden evacuations of blood from the sys- tem, as well as from the affected eye, we lessen the violence of the disease, and prevent either an opacity of the crystalline lens, or a rupture of the cornea from ensuing ; we are, at the same time, to moderate the external symptoms, and lessen the secretion by lo- cal applications—linen cloths, dipped in some cooling lotion, (see those before prescribed) should therefore be kept constantly to the eye, or eyes, if both are affected, and such applications as experi- ence seems to have accommodated to the different stages of the disease, ought to be carefully dropt into the eye. The best appear Order II.J ophthalmia. 133 to be the liquor plumbi acetatis, properly diluted ; solutions of alum or sulphate of zinc, or the camphorated collyrium, prescribed below,* or before mentioned. When we consider, however, that the morbid mucus is confined between the swelled conjunctiva that lines the eyelids, and that part of it which covers the globe of the eye, it must be evident that in order to bring the matter effectually away, the lotion must be pro- pelled over the eye with some degree of force; and this cannot be better effected than by the use of a small blunt pointed syringe, by means of which the medicated liquor may be conveyed over the whole surface of the eye, and the retained matter be each time entirely cleared away. The injection ought to be repeated at least once an hour during the height of the disease; but when the vio- lence of the inflammation has abated, and the quantity of the discharge is decreased, a longer period maybe allowed to intervene between the times of applying it. In those cases where the pain of the eye and tumefaction of the conjunctiva are very considerable, it may be advisable not only to make the lotion of a weak standard, and to leave longer intervals between the times of employing it, but occasionally to interpose v the injection of merely tepid water. Under the like circumstances, the frequent application of hot water also, or of a warm decoction of poppy heads, by means either of a flannel or of a large sponge, - may likewise prove serviceable. During the inflammatory stage of the disease, and when the irritation is great, a warm poultice of bread and milk may be applied to the eye, renewing it frequently throughout the day. Possibly it might be of service to shave the head and keep cloths wetted with vinegar to it, the forehead, and temples. The introduction of the vinous tincture of opium by a few drops at a time into the eye, will have a very good effect when employed in the early stage of the disease. In the intermittent form of this and the other species of oph- thalmia, where the pain observes periodical paroxysms, probably the administration of cinchona during the intervals, may be at- tended with a very good effect. Such are the means to be adopted in the treatment of this variety of ophthalmia. It sometimes happens, however, that in spite of our utmost endeavours to subdue the inflammation, we cannot succeed, and that there is great danger of a rupture of the cornea taking place, and discoverable by the cornea losingits transparency, and a white ring forming round its circumference. In such cases it will be highly advisable to evacuate the aqueous humour, by :: 13. ft Cupri Sulphat. Bol. Armen. aa gr. viij. Camphorae, gr. ij. Misce et af- funde Aq. Bullientis, f. %vi\j. Cum lot io sit frigida, effundatur liquor lim - pidus,et saepissime injiciaturpaululum !»ter oculum et palpebras omni hora. 10. XciKe ouiputue ui supper, Armenian Bole, of each eight grains. Camphor,two grains; mix them and add Boiling Water, eight ounces. When the liquor is cool, pour it off clear,, and let a little of it be injected between the eye and eyelids everv hour. lo4 PVREXI.h, OR FEBRILE DISEASES. [ClUxS I, making a puncture with a common lancet into the anterior cham- ber of the eye. This operation, it appears, has been performed in several in- stances with perfect safety, and the highest advantage, by Mr. Wardrop,* of Edinburgh, under the like circumstances; and he thinks it probable that the great and immediate relief afforded by it arises chiefly from the sudden removal of tension. Mr. Ware! coincides with Mr. Wardrop on the propriety of puncturing the cornea to evacuate the aqueous humour when a rupture of it is threatened ; and he very properly observes, that by suffering this to happen spontaneously, it may take place in such a part of it as afterwards to impede the passage of light, but that, when the opening is made by a surgeon, it may be done in such a place as to obviate any impediment of the kind. We are informed by Mons. Larry,} that in order to be secure from ophthalmia in Egypt, it will be necessary to wash the eyes, and, indeed, the whole of the head, frequently with warm water and vinegar; to avoid the direct impressions of light and dust during the day; at night to be covered from head to foot; to put a bandage over the eyes ; to avoid, as much as possible, damp and marshy places; and to keep up the perspiration, and encourage moderate sweating by a use of the Egyptian baths and exercise during the fine season. It will also be necessary to avoid strong liquors, and heating and indigestible aliments, fortifying the stomach by tonics, such as the bitter infusions. OTITIS, or INFLAMMATION of the EAR. Inflammations of the ear are for the most part unaccompanied by pyrexia, although the sufferings of the patient are sometimes very great; but in some instances they are attended with fever, as- sume a formidable appearance, coma, delirium, and convulsions supervene, and even a fatal termination has been the consequence. O ;tis is produced by the same causes with other inflammations/ but by none more readily than a partial exposure to cold. In the treatment of this complaint we should proceed on the same principles as in that of ophthalmia. While it is merely a local affection, local remedies alone are necessary, if we except cathartics, for the purpose of dislodging the contents of the primae viae. Local blood-letting, the application of a blister behind the ear, and of warmth, are the means chiefly to be relied on. If the pain does not abate, but, on the contrary, should continue to increase, we may expect a suppuration to ensue. This we may then encourage by the application of emollient poultices and warm vapour ; and when the abscess bursts, or is opened, we may syringe the ear from time to time with some mucilaginous and gently astringent decoction. * See vol. iii. of the Edinburgh Journal, p. 56. t See his Remarks on Purulent Ophthalmia. ". Fee his Memoirs of Military Surgery. Order Il.J inflammatory sore throat. 135 When otitis is accompanied with universal pain diffused over the whole head, fever, delirium, or coma, the most powerful gene- ral means are to be combined with the local ones, as recommended in phrenitis. Suppuration is generally the consequence of these violent forms of the disease, and then the structure of the whole internal ear is often destroyed, the bones being discharged through the meatus auditorius with much purulent and fetid matter. In such cases the sense of hearing in the ear affected is wholly lost of course. Fistulous ulcers of the internal ear are now and then the conse- quence of suppuration, and prove very troublesome. Ear-ach sometimes continues many days without any apparent inflammation, and is then frequently removed by tilling the ear with cotton or wool, wetted with tincture of opium or aether, or even with warm oil, or warm water. Sometimes a pain in the ear is the consequence of association with a diseased tooth, in which case the aether should be applied to the cheek over the suspected tooth, or a grain of opium, with a little camphor, be applied to the tooth itself. CYNANCHE TONSILLARIS, or INFLAMMATORY SORE THROAT. In this complaint the inflammation principally occupies the glands, such as the tonsils ; but it often extends through the whole mucous membrane of the fauces, so as essentially to interrupt the speech, respiration, and deglutition of the patient. It is readily to be distinguished from cynanche maligna by the strength of the pulse, the greater difficulty of deglutition, the absence of ulcers in the throat, and the accompanying fever being synocha. The causes which usually give rise to it are, exposure to cold, either from sudden vicissitudes of weather, from being placed in a partial current of air, wearing damp linen, sitting in wet rooms, or getting wet in the feet, or coming out of a heated and crowded room suddenly into the open and cool air; all of which may give a sudden check to perspiration. It may also be occasioned by violent exertions of the voice, blowing wind instruments, acrid substances irritating the fauces, and by the suppression of accus- tomed evacuations. It principally attacks the youthful, and those of a full and plethoric habit, and is chiefly confined to cold cli- mates, occurring usually in the spring and autumn ; whereas the cynanche maligna chiefly attacks those of a weak irritable habit, and is most prevalent in warm climates. The former differs from the latter likewise in not being contagious. In many people there seems to be a particular tendency to this disease, as from every considerable application of cold it is readily- induced. An inflammatory sore throat discovers itself by a difficulty of ^wallowing and breathing, accompanied by a redness and tumour lot , PVREXIiE, OR FEBRILE DISEASES. [ClaSS L in one or both tonsils, dryness of the throat, foulness of the tongue, lancinating pains in the parts affected, hoarseness of the voice, m frequent but difficult excretion of mucus, and some small degree of fever. As the disease advances, the difficulty of swallowing and breathing becomes greater, the speech is very indistinct, the dryness of the throat and the thirst increase, the tongue swells and is encrusted with a dark fur, and the pulse is full, hard, and frequent, beating from 100 to 140 in a minute. In a few cases, small white sloughy spots are to be observed on the tonsils, and in very violent ones there is complete deafness. When the symptoms of cynanche are considerable, the whole face partakes of it, the eyes are in- flamed, and the cheeks florid and swelled, respiration is performed with difficulty, and the patient is obliged to be supported in nearly an erect posture to prevent suffocation. Even delirium and coma sometimes supervene. If the inflammation proceeds to such a height as to put a total stop to respiration, the face will become livid, the pulse will sink, and the patient will quickly be destroyed. The chief danger arising from this species of quinsey is, the in- flammation occupying both tonsils, and proceeding to such a degree as to prevent a sufficient quantity of nourishment for the support of nature from being taken, or its wholly impeding respira- tion : but this seldom happens, and its usual termination is either in resolution or suppuration. When proper steps are adopted early, it will in general readily go off by the former. Cynanche tonsillaris rarely terminates either in gangrene or scirrhus. Little fever, free respiration, deglutition not much impeded, the inflammation being of a vivid red colour, universal but gentle diaphoresis, and a copious ptyalism or moderate diarrhoea coming on about the fifth day, are to be regarded as symptoms which de- note a termination of the disease in resolution. When suppuration is likely to ensue, the parts affected become more pale and less painful, a sense of pulsation is felt in them, and there are slight rigours. The suppuration sometimes takes place at the lower part of the tonsils, and then the matter is discharged into the oesophagus, and passes into the stomach, and it is only known to have happened by the immediate relief which the patient experiences. Sometimes, however, it is brought up, and discharg- ed by the mouth, being of a very clotted appearance, often mixed with blood, of a nauseating bitter taste, and fetid smell. The relief experienced by the discharge is often very remarkable from its suddenness ; for the person who a few minutes before was not able to swallow the smallest quantity of any thing, and who breathed with great difficulty, now feels perfect ease, and is able to eat and drink heartily. Sometimes, however, the disease does not terminate by a proper suppuration, but in several small abscesses, which produce trifling superficial ulcers, being of a white or gray colour, similar to aphthae ; whereas those in cynanche maligna are of a dark brown, or black colour. If gangrene is to take place, the Darts aff^ctfd lose their red nnd shining colour, and from being Order I I.J inflammatory sore throat. 131 tense and tumid, they become flaccid, brown, and livid; the pulse, from being strong, becomes small, weak, and irregular ; the face assumes a cadaverous appearance ; cold clammy sweats break out; the extremities are cold; coma, and symptoms of debility, make their appearance, and destroy the patient. Where cynanche tonsillaris has proved fatal by suffocation, little more than a highly inflamed state of the parts affected, with some morbid phenomena in the head, have been observed on dissection. In the treatment of this complaint, our first and chief endeavour should be to carry off the inflammation; for which reason an anti- phlogistic plan must be pursued. If the inflammatory symptoms run high, the pulse be quick and hard, and the breathing some- what difficult, twelve or fourteen ounces of blood (supposing the patient to be an adult) ought to be drawn from the jugular vein, in preference to the arm; but if they do not, it will be sufficient to draw blood by the application of several leeches under the ears, particularly on the side most affected. Drawing blood from the tonsils by internal scarifications, is likewise a powerful remedy in this species of quinsey, and when employed with freedom on its first appearance, will greatly tend to abate the inflammation, and prevent a suppuration from ensuing. At the commencement of cynanche tonsillaris, and before the febrile symptoms are any way violent, the timely exhibition of an emetic often proves extremely useful, and now and then checks its complete formation. To assist in removing the inflammatory diathesis, gentle evacua- tion from the intestines, by means of laxative medicines, should be advised occasionally. Saline cathartics, such as the potassae tar- tras, sodas sulphas, or hydrargyri submurias with jalap, may be most proper. In those cases where the inflammation is considerable, the early application of a blister or cataplasm of mustard round the throat, or to the back of the neck, will most probably be attended with a good effect; but in slight cases it will be sufficient to have these parts rubbed twice or thrice a day with some stimulating embro- cation, such as the linimentum camphorae vel ammoniae, putting a piece of flannel round them afterwards. In this complaint it is found of service to wash the mouth and fauces frequently with mild astringent gargles* somewhat acidu- ■* 1. ft Confect. Ros. Gallic. |j. Aq. Bullient, Oss. Acid. Sulphuric. Dilut. f. gj. M ft. Gargarisma. Vel, % ft Decoct. Hordei, f. ^vj. * Take Confection of the Red Rose, one ounce. Boiling Water, half a pint. Diluted Sulphuric Acid, one drachm. Mix them for a gargle. Or, 2. Take Barley Water, six ounces Mel. RosaB, f. |j. j Honey of Roses, one'ounce Acid. Sulphuric Dilut Til xxx. M. Diluted Sulphuric Acid, forty-five I drop? Mix them. '9 134J FVRKXIAJ, OR FEBRILL DISEASES. [ClaSS I. lated, and likewise to scrape and cleanse the tongue from the fur which is apt to collect on it. Gargles composed of a few grains of the plumbi superacetas have sometimes proved highly service- able in abating the inflammation, when other remedies have failed; but from the general prejudice against the use of this preparation in the form of gargle, lest any of it should happen to be swallow- ed, it is seldom prescribed. When white sloughy specks are observed on the tonsils, we may substitute the gargles advised in cynanche maligna for those men- tioned here. If a tendency to gangrene should appear, we should immediately have recourse to those of an antiseptic nature, the best of which are composed of cinchona bark, myrrh, and Port wine, or of capsicum and vinegar—See Cynanche Maligna. Gargling is the best mode of washing the internal fauces ; but its motion is sometimes so painful or irksome, as to prevent the patient from having recourse to it. In such cases, the medicine may be thrown into the fauces by means of a syringe. Frequently inhaling the vapour arising from wrarm water mixed with a little vinegar throughout the course of the day, will greatly assist the effects of gargles ; and where Mudge's inhaler cannot be procured for the purpose, we must be content to substitute a basin with an inverted funnel over it. When a febrile disposition prevails, it will be proper to employ diaphoretic medicines with the view of determining to the surface of the body. Any of those advised under the head of Simple Continued Fever may be used; and to increase their effect, the patient should take frequent small draughts of whey, barley-water, or any other diluting liquor. Neutral salts, as recommended under the same head, will likewise be proper medicines, and therefore the saline mixture combined with tartarized antimony will answer the purpose. Where the symptoms run high, the patient ought to be confined to bed. Probably a pediluvium in the evening might have a good effect. If our endeavours to resolve the inflammation have proved fruit- less, and it seems likely to terminate in a suppuration, we ought then to hasten it by the frequent application of warm fomentations and emollient poultices to the throat, and by directing the patient to receive the vapour arising from warm milk and water into the fauces several times a day, in the manner before recommended. Vel, Or, 3. ft Aluminis Puri, 3j. 3. Take Alum, one drachm. Decoct. Hordei, Oss. Decoction of Barley, half a pint. Mellis Rosae, f. §j. M. Honey of Roses, one ounce. Mix them. Vel, Or, 4. ft Infus. Rosae, f. 5jvj. 4. Take Acidulated Infusion of Roses, six ounces. Tinct. Myrrh, f. |ss. Tincture of Myrrh, half an ounce. Mellis Sodae Borac. gij. M. Honey of Borax, two drachms. Mix them. Order II.J mumps. 139 Warm gargles composed of a decoction of figs and barley-water may also be employed, and the best way of using them will be to permit as large a quantity as can conveniently be retained to lie on the part till it cools to the temperature of the mouth. When the matter is formed, if the tumour does not break readily, a lancet may be applied to it. During this stage of the disease, the passages to the stomach and lungs are sometimes so closed by the size and pressure of the tumour, as to endanger the life of the patient, either by suffocation, or the want of nourishment. In the first case, recourse should be had in proper time to the operation of bronehotomy, in order to keep up respiration ; and in the last, the strength must be support- ed by nutritive and mucilaginous clysters, consisting of animal broths, thick gruel, arrow-root, barley-water, or a solution of starch, which should be thrown up the intestines in a small quantity each time, as they will thereby be absorbed the more readily, and will not be so apt to pass off again, without affording any benefit. Before we resort, however, to bronehotomy, it may be worthy of a trial to endeavour to break the tumour, either by exciting vomiting, or by making the patient receive through an inhaler the steams arising from warm water, to which a sufficient quantity of aether has been added. The stimulus will prove so great as to succeed in many cases, particularly where the suppuration is nearly completed. In cynanche tonsillaris every part of the antiphlogistic regimen is necessary, and should be mora or less strictly enjoined according to the degree of general excitement. Even where this is not very considerable, all kinds of animal food and fermented liquors must be avoided, and the diet should be light and diluent, consisting of mild vegetable matters, such as roasted apples, boiled turnips, and subacid fruits. Any fresh exposure to cold, even in the slightest cases, ought carefully to be avoided, otherwise the disease may be lengthened out to a great degree, and perhaps terminate in pneu- monia. The tonsils sometimes become affected with permanent swelling and induration in consequence of an attack of cynanche, giving a good deal of uneasiness to the patient. In some cases the com- plaint will yield to astringents ; but when it does not, and impedes his respiration or deglutition, there can be no impropriety in re- moving the diseased parts by a piece of wire with a noose at the end of it, or even by a pair of scissors. CYNANCHE PAROTIDE, or THE MUMPS. This disease chiefly affects children, but particularly among the lower class of people; is often epidemic, and manifestly contagious. It is distinguished by an external moveable swelling that arises most commonly on both sides of the neck, but in some instances 140 PYREXIA, OR FEBRILE DISEASES. [ClttSS 1. it is confined to one. These tumours occupy the maxillary and parotid glands ; are large, hard, and somewhat painful; and some- times they attain to such a considerable size, as greatly to impede the powers of respiration and deglutition, giving rise thereby to pyrexia. The swelling usually continues to increase till the fourth day ; but from that period it declines, and in a few days more goes off entirely, and then the febrile disposition likewise ceases. As the swelling of the fauces subsides, it not unfrequently happens that tumours affect the testicles in the male sex, or the breasts in the female ; but these generally go away in a few days. Some- times the tumour in the fauces becomes suddenly suppressed, and is not accompanied with the last-mentioned symptom ; or if so, this is quickly repressed; in which case the fever becomes very consi- derable, is attended with delirium, and at length proves fatal. In a few instances where the swelling has been very great, suppura- tion has taken place in the cellular membrane, and occasioned pro- digious deformity ; or by bursting inwardly, and discharging its contents into the larynx, has suffocated the patient. There is, however, seldom much danger from this disease, except when symptoms of congestion in the brain or its membranes arise. The mumps do not often require the assistance of medicine; and all that is in general requisite, is to keep the head and face warm, to avoid taking cold, and to open the bowels by the mildest cooling laxatives ; but should the tumour in the neck suddenly disappear, and the febrile symptoms increase, so as to induce an apprehension that the brain will be affected, it will be advisable to promote and reproduce the swelling by warm fomentations and stimulating lini- ments ;* and to obviate the fatal consequences that might ensue from its suddenly receding, by means of venesection, nauseating doses of emetic medicines,! cathartics, and blisters, according to the violence of the disease. *. 1. ft Liniment. Ammonia? Fort. f. £j. Vel, 2. ft Spirit. Camphorae, f. ^j. Liquor. Ammoniac Subcarbonat. f-3'j- Tinct. Lyttaj, f. gss. M. ft. Linimentum. t 3. ft Potassae Nitrat. 3j. Antim. Tartarizat. gr. iss. M. Et in chartulas vj- divid. quarum, unam dosem sumat 4tis horis. Vel, 4. R Haust. Salin. f. |jss. Liquor. Antimon Tart. TTt x.—xv. Syrup. Cort. Aurant. 3j ft. Haustus 3tia quaque hora capiendus. * 1. Take Strong Liniment of Ammonia, one ounce. Or, 2. Take Camphorated Spirit, one ounce. Solution of Subcarbonate of Ammonia, two drachms. Tincture of Spanish Fly, half a drachm. Mix them for a Liniment. t 3. Take Nitrate of Potass, one drachm. Tartarized Antimony, one grain and a half. fMix them together, and divide them into six papers, of which one dose is to be taken every four hours. Or, 4. Take Saline Draught, one ounce and a half. Solution of Tartarized Antimony, from fifteen to twenty-two drops. Syrupof Orange Peel ,*one drachm. Make them into a draught, which i« to be- taken every three hours Order II.J putrid sore throat. i 41 When the testicles become affected and are much swelled, every endeavour should be exerted to prevent suppuration from ensuing, and we are therefore to have recourse to bleeding, both general and topical, cathartics, cooling and discutient applications, and a suspensory bag. Much the same means are to be adopted when, on a retrocession of the tumour in the neck, the female breast be- comes indurated and swelled. CYNANCHE MALIGNA, or PUTRID SORE THROAT. The putrid sore throat is readily to be distinguished from the inflammatory quinsey by the soreness and white specks or aphthae covering ulcers which appear in the fauces, together with the great debility of the system, a small fluttering pulse, and an eruption on the skin of the same nature with that of scarlatina, which are to be observed in the former; whereas in the latter there is always great difficulty of breathing, a considerable degree of tumour, with a tendency in the parts affected to suppurate, and a hard full pulse. Moreover, in the former disease the inflammation is seated prin- cipally in the mucous membrane of the mouth and throat, and the accompanying fever is of the typhoid type ; whereas in the latter, it chiefly occupies the glandular parts, and the fever is of the in- flammatory kind. The putrid sore throat often arises from a peculiar or humid state of the atmosphere, and so becomes epidemical, making its attacks chiefly on children, and those of a weak lax habit, principally about autumn and the beginning of winter. It is produced likewise by contagion, as it is found to run through a family, when it has once seized any person in it: and it proves often fatal, particularly to those in an infantile state. In some instances the symptoms of scarlatina and cynanche maligna are so blended together, that it is difficult to say of which disease they partake most: iii a practical view this is however of no importance, as both disorders require a similar treatment. By some physicians scarlatina anginosa'and cynanche maligna have however been considered as distinct in their nature ; but from the observations which I have made, I am induced to look on them merely as modifications of the same disease ; for I have noticed it under all its different forms in the same epidemic, and even in the same family from the same contagion. The putrid sore throat sometimes attends on measles which are of a malignant nature. Cynanche maligna usually makes its attack with cold shiverings, anxiety, nausea and vomiting, succeeded by heat, restlessness, thirst, debility, and oppression at the chest; the face looks flushed, the eyes are red, and a stiffness is perceived in the neck, with a hurried respiration, hoarseness of voice, and soreness in the throat; and upon viewing the internal fauces, there appears a fiery redness 142 I'YREXliE, OR FEBRILE DISEASES. [Class I. in every part, with some slight degree of swelling in the tonsils, which, however, is by no means so great as to impede either res- piration or deglutition. The inflammation, after a short time, takes a peculiar termina- tion; for, upon a further inspection into the throat, a number of sloughs of a shade between a light ash colour and a dark brown are to be observed on the tonsils, velum pendulum palati, and uvula ; the breath is highly offensive ; the tongue is covered with a thick brown fur ; and the inside of the lips is beset with vesicles, containing an acrid matter, which falling on the corners of the mouth and other parts, occasions excoriations. With these symp- toms there is likewise a coryza, which pours out a thin acrid mat- ter, excoriating the nostrils. A purging often attends also, par- ticularly in infants, and a thin acrid matter flows from the anus, excoriating this and the neighbouring parts. From the first attack of the complaint there is a considerable degree of fever, with a small, frequent, and irregular pulse ; and every evening there occurs a manifest exacerbation, and in the morning some slight remission, together with debility and general loss of strength. In some cases the brain is affected with delirium of the low muttering kind, or coma. About the second or third day, large patches of a dark red co- lour make their appearance about the face and neck, which by degrees become dispersed over every part of the body, even to the extremities of the fingers, which feel swelled and stiff. These eruptions, after continuing for about four days, depart without producing any remission of the symptoms. The inflammation, as in the cynanche tonsillaris, sometimes spreads along the Eustachian tube to the internal ear, occasioning ulceration, and sometimes wholly destroying its structure. In other cases it extends to the parotid, maxillary, and other glands of the fauces, which become swelled and painful. The whole neck, indeed, sometimes swells, and assumes a dark red colour. As the sloughs spread, they generally become of a darker co- lour, the interstices at the same time assuming a purple hue; new specks arise, and the whole internal fauces are at length covered with thick sloughs, which, when they fall off, discover ulcers some- times very deeply seated. In the worst cases, the fauces appear quite black, the sloughs corrode deeper and deeper, and spread throughout the whole of the alimentary tube, so as to terminate at last in gangrene; and the symptoms of irritation continuing to increase, together with a severe purging coming on, the patient is cut off; which event happens usually before the seventh day, and, in some cases, so early as on the third. Where there is a great increase of the evening paroxysm of fever, with vast debility, depression or irregularity in the pulse, early delirium, coma, much vomiting, diarrhoea or subsultus tendi- num, and these are accompanied with considerable swelling of the Order II.J putrid sore throat. i4g throat, and dark coloured spreading ulcers, with great fetor of breath, petechias, or haemorrhage, the disease will certainly termi- nate fatally: but where the pulse becomes more moderate and stronger, the respiration freer, the skin soft and moist, the efflo- rescence copious on the surface of the body, the florid colour begins to return to the fauces, and a better matter to be discharged from the ulcers, with less acrimony in that which flows from the nares, we may expect a favourable termination. In slight cases, where the fever is of a less putrid nature, and the symptoms are moderate, and where the appearance of the efflojreScence is succeeded by a remission, and this remission of the fever increases daily in the progress of the disease, we ir^od not apprehend danger. Cynanche maligna generally arrives at its height about the fifth or sixth day, and in cases which terminate favourably declines in five or six days. It has, however, been observed to run through its course more slowly in adults than in children. Twenty or thirty of the latter for one of the former are destroyed by this dis- ease, owing most likely to their not being able to wash off the acrid ichorous matter from the'throat and fauces by gargling as adults do, and which, by passing down the oesophagus, produces affections of the stomach and bowels, as likewise excoriations about the anus. It sometimes happens that cynanche maligna appears without any affection or efflorescence of the skin in the same manner as we meet with scarlatina without any .ulceration in the throat: in general, however, the affections of the throat and skin are com- bined, and seem wonderfully influenced by the state of each other. But while the absence of the sore throat in scarlatina always de- notes a favourable prognosis, that of the eruption in cynanche ma- ligna generally affords an unfavourable one. The eruption in cynanche maligna is seldom uniformly diffused, but comes out in blotches or small points scattered over the trunk and extremities, which are rarely of a florid red, but of a dark purplish or livid hue, and which terminate in but a very scanty desquamation. As in other eruptive fevers, the eruption in this sometimes suddenly recedes, and an alarming train of symptoms arise. The patient becomes dropsical, the countenance assumes a cadaverous appearance, and convulsions supervene which ter- minate in death. The same consequence has ensued on the eruption suddenly assuming a very pale or livid appearance. A florid colour of the eruption, with a uniform diffusion of it over the body, and a copious desquamation, afford a favourable prognosis. From dissections it appears, that in this disease the fauces are inflamed, suppurated, and gangrenous ; and that the trachea and larynx are likewise in a state of inflammation, and lined with a viscid fetid matter. In many instances the inflammatory affection extends to the lungs themselves. Large swellings of the lymphatic 1 '14 PYREXIA, OR FEBRILE DISEASES). [Class 1. glands about the neck, occasioned by an absorption of the acrid matter poured out in the fauces, are now and then to be found. The same morbid appearances which are to be met with in typhus gravior present themselves in other parts of the body. Cynanche maligna, as it differs very much in its nature and appearance from cynanche tonsillaris, differs also very much in its treatment, and this difference depends upon the former being attended with a fever of the typhoid nature, and a strong dispo- sition to gangrene in the ulcerated parts, which prohibit the employment of those antiphlogistic remedies which we find proper and necessary in the latter, and call for others of a very opposite nature. In the treatment of cynanche maligna, we should abstain from all kinds of bleeding, either topical or general, as it would infallibly prove injurious by increasing the irritability, and likewise the debility, which naturally are very great. The same precaution is necessary with respect to the employment of active purgatives ; and we are sufficiently deterred indeed from the use of them, by observing that a diarrhoea, arising even spontaneously, always does harm, and often proves fatal. The regular expulsion of the faeces is therefore to be solicited by gentle aperients and clysters, and even these are only to be had recourse to when nature is defective. It has often happened in this complaint, that from a want of due attention to this precaution, a cathartic has been followed by a retrocession of the eruption, and a train of the most alarming symptoms. If active cathartics are ever admissible in cynanche maligna, they can only be so at its very commencement or at the termination of those cases, where, although there is a healthy appearance in the throat, with an abatement of all the febrile symptoms, still the abdomen becomes swelled from a collection of putrid colluvies ; or glandular obstructions are formed. In such instances a few grains of hydrargyri submurias with rhu- barb may be administered with caution. It has been proposed by Dr. Currie to extinguish the disease in the beginning (as in the first twelve or sixteen hours of its attack) by the copious affusion of cold water; and in some cases this plan may be adopted with success, equally as in scarlatina. After the affusion, it was Dr. Currie's practice to put the patient into bed, and to give him about eight ounces of wine, if an adult, and so in proportion to children; which plan, it appears, was very successful, for in fifty out of fifty-two cases, where he had adopted it very early in the disease, he succeeded. At the commencement of cynanche maligna it has been found of service to give a gentle emetic : wherefore a few grains of ipecacu- anha may be taken. It will not fail to bring off a considerable quantity of acrid matter, which, by getting into the bowels, might induce a diarrhoea; an affection to be avoided by every possible means, as always adding to debility, and endangering the life of the patient. During the first four and twenty hours, an emetic (Jrder 1I.J PUTRID sore throat. ]4ti will in some eases cut short the progress of the disease, and in all it will be likely to break the force of it. At an advanced stage of the disorder, if we still wish or think it proper to evacuate the con- tents of the stomach, it may be done by an infusion of chamomile flowers in preference to ipecacuanha. The grand objects to be kept in view in this malignant disease, should be, to check or counteract the septic tendency which pre- vails ; to wash off from time to time the acrid matter from the fauces, and so obviate debility. Should any particular symptoms arise during its progress which may tend to aggravate it, such as diarrhoea, haemorrhage, &c, they ought to be immediately at- tended to. In the year 1785, at which period I was in the West Indies, this disease prevailed in the island of Saint Christopher's, as an universal epidemic among children, and a vast number of them fell martyrs to it, in spite of the utmost endeavours of the profession to save them ; when at last the most happy effects were derived from the use.of a remedy, the basis of which was Cayenne pepper. The medicine was prepared by infusing two table-spoonsful of this pep- per and a tea-spoonful of salt, in half a pint of boiling water. adding thereto the same quantity of warm vinegar. After standing for about an hour, the liquor was strained through a fine cloth, and two table-spoonsful were given every half hour. The speedy and good effect produced by the use of this medicine in every case in which it was tried, evidently points out theutilitv of giving warm aromatics, which will bring on a timely separation of the sloughs, as well as other antiseptics, to correct the tendency in the parts to gangrene. Since the period above mentioned, many practitioners in the United Kingdom have become vouchers for the very beneficial effects which were derived in various instances of cynanche ma- ligna from this medicine. My own experience induces me to speak well of it also. To assist the effect of the pepper remedy, it will be highly ad- visable to give the bark of cinchona at the same time in doses of from two scruples to a drachm, every two hours ; and if the in- flammatory symptoms do not run high, it may be mixed in a little Port wine. Should the stomach not be able to retain the powder, we may then substitute the extract or strong decoction or infusion of it, adding to each dose about two drachms of the tincture. If the least degree of diarrhoea is produced by the use of the bark, a few drops of the tincture of opium may be added to each dose. With many children it may be impossible to prevail on-them to take the cinchona bark in any form. In such cases it ought to be. administered in a clyster. Two drachms of the fine powder may be given in four or five ounces of barley-water, every three or four hours, to young children ; and about half an ounce, in a propor- tionate quantity of the liquid, to those of eight or ten years of age. Should the first clvster come away too soon, from five to 20 MC JYREXIJE, OR FEBRILE DISEASED. [ClaSS I. ten or fifteen drops of the tincture of opium may be added to the subsequent ones. The extract of cinchona may be employed in the same way. In cynanche maligna, a junction of the muriatic acid with the bark of cinchona, as advised under the head of Typhus Gravior, or of the oxygenated muriatic acid, as noticed under that of Scarlatina, will be very proper. Where we give these acids in considerable doses, it may be necessary to add a few drops of tinctura opii to each, in order to prevent any disagreeable effect on the stomach and bowels from ensuing. To check the septic tendency in the parts, as well as to remove the acrid matter which is secreted, it will be necessary to wash out the fauces with some proper gargle,* making frequent use of the pepper remedy in the same manner; but as young children cannot be prevailed on to gargle, it ought to be injected into the mouth and throat with a syringe. After washing the parts in this manner, the steams arising from warm vinegar and water may be received into the fauces by means of an inhaler. Oxygen gas may also be inhaled by adults. Where there is any difficulty in inducing the patient to sit up in bed to inhale this gas, or we are not furnished with the necessary apparatus, we may substitute the following method, which perhaps may answer equally well. Cause the windows and doors of the person's apartment to be closed, and then taking a chafing-dish with some live coals, throw into it half an ounce of purified nitre - 5. Yx. Mel. Rosae, f. gj. Decoct. Iiordei, f. ^x. Tinct. Myrrh, f. |ss. Acet. Optim. f. |j. M. ft. Gargarisma. Vel, 6. g; Decoct. Cinchonae, f. §vj. Acid. Muriat. f. ^j. Tinct. Cinnam. Compos, f. 3|ss. ---"Myrrh, f. gj. M. Vel, 7. g. Decoct. Hordei Compos, f. ^xij. cui inter coquendum adde Rad. Contrajerv. Contus. gss. Liquori colato admisce Acid. Acetic, f. t^ij. Tinct. Myrrh, f. § j. Mel. Rosa?, f. ^ss. M. Vel, 3. & Extract. Cinchon. 3j- Vini Ruhr. Generos. f. !§yj. Acid. Sulphur. Dilut. 3j. M. * 5. Take Honey of Roses, one ounce. Decoction of Barley, ten ounces. Tincture of Myrrh, half an ounce. Vinegar, one ounce. Mix these for a gargle. Or, 6. Take Decoction of Peruvian Bark, six ounces. Muriatic Acid, one drachm. Compound Tincture of Cinna- mon, half an ounce. Tincture of Myrrh, one ounee. Mix them. Or, 7. Take Compound Decoction of Barley, twelve ounces. Add during its boiling Bruised Contrajerva Root, half an ounce. To the strained liquor, add Acetic Acid, two ounces. Tincture of Myrrh, one ounce. Honey of Roses, half an ounce. Mix them. Or, 8. Take Extract of Peruvian Bark, one drachm. Port Wine, six ounces. Diluted Sulphuric Acid, one drachm. kirder Ij.) putrid sore throat, 14? in powder, which will fill the room with a thick white cloud, that will continue for a considerable time. This process ought fre- quently to be repeated in the course of the day. Many judicious practitioners have thought that the greater fa- tality among children than adults, in such as have laboured under cynanche maligna, is in a great measure to be attributed to their swallowing the morbid secretion from the throat. This, beyond all doubt, induces vomiting, griping pains, and a purging of the worst kind, by causing the complaint to spread along the aliment- ary tube ; and it is very frequently by these affections that children are destroyed. Possibly they might be prevented by removing the acrid matter from time to time by a small sponge fastened to the end of a quill or piece of wood; and by means of another sponge at the other end, the ulcerated fauces may be touched with the remedies best calculated to promote their healing. This mode of proceeding will be the more necessary when gargling is not freely employed. No force whatever is to be used for occasioning a separation of the sloughs ; and if, after a continuation of the gargles for some time, the sloughs should not begin to separate, all that can be done with safety is to touch them with a little alum, or the muriatic acid mixed with honey, &c. applied with a small piece of soft rag, or hair pencil. When any considerable degree of fever attends, and the skin is very dry, it may be advisable to give small and frequently repeated doses of some diaphoretic medicine ; but as antimonials are apt to act downwards, and produce a purging, some caution will be necessary in administering them. To prevent this tendency, they may be combined with a small quantity of the aromatic confec- tion.* Small doses of the pulv. ipecac, comp. will however be preferable to any antimonial. They may be given with the mis- tura camphorae. Where cynanche maligna is conjoined with scarlatina, we may probably employ a solution of ammoniae subcarbonas in the pro- * 9. R Pulv. Antimonial. gr. j.—ij. Confect. Aromat. Qss. M. ft. Bolus, tertia hora sumendus. Vel, 10. R Pulv. Ipecac. Comp. gr. iij.—vi. Vel, 11. g. Mistur. Camphorae, f. |ij. Confect. Aromat. jss. Liquor. Antimon. Tart. AT, xxv. Aq. Cinnam. §iij. M. Capiat cochl. magnum 3tia quaque hora. * 9. Take Antimonial Powder, one grain to two grains. Aromatic Confection,half a scruple. Make them into a Bolus, to be taken every three hours. Or, 10. Take of Compound Powder of Ipe- cacuanha, from three to six grains for a dose. Or, 11. Take Camphorated Mixture, two ounces. Aromatic Confection, half a drachm. Solution of Tartarized Antimo- ny, forty drops. Cinnamon Water, three ounces". Of this mixture take alarge spoonful every third hour. 148 PVREXIjE, or febrile diseases. [Class I. portion of two drachms to five ounces of water with some advan- tage, giving two tea-spoonsful every three or four hours, according to the urgency of the symptoms. For the purpose of promoting perspiration, the pediluvium has frequently been used in this disease ; but at an advanced stage its effects would be too debilitating; and at all periods, if the symp- toms run high, the trouble attending its use would not be compen- sated by any good effect it might have. The pediluvium seems therefore advisable only in those cases where the efflorescence becomes very pale, or suddenly recedes. Should a diarrhoea arise in the progress of the disease, immediate recourse must be had to some powerful astringent,* to which may be added a use of wine or brandy mulled up with spice. Every possible endeavour should be exerted to put an immediate stop to it, as in every period of the disease diarrhoea is a very dangerous symptom. Violent vomiting arising in the course of cynanche maligna is to be appeased by the saline medicine in the effervescing state; by opiates joined with camphor, and by applying linen cloths wetted with tinctura opii to the region of the stomach. It has been usual to apply blisters to the throat in this complaint, particularly when there is any considerable degree of tumour; but they are attended with some danger, as in a few instances where blisters were applied I have observed white specks shortly to arise ©n the part, which, from the prevailing disposition to putrefaction, have soon degenerated into ulcerations, that have become gangre- nous, and at length have destroyed the patient. It may, however, be attended with a good effect to excite a slight degree of inflammation externally, by applying a cata- plasm of mustard moistened with a small quantity of camphorated spirit, or by rubbing the parts with rubefacients, as in cynanche tonsillaris. A suppression of urine sometimes arises in cynanche maligna, and then it is frequently a symptom of debility. In such cases the necessity of pushing as far as possible the invigorating plan is strongly indicated. Emollient fomentations, or cold applications over the region of the bladder, are the most advisable means for removing this affection; and where the patient has been long cos- tive, some mild clyster may be expedient. When the suppression continues obstinate, the assistance of a surgeon will be necessary to draw off the water with a catheter. 12. U Confect. Aromat. gj. Mistur. Cretae, f. ^ij. Aq. Cinnam. f. ^ijss. Tinct. Opii, flX xx.—xxx. -----Catechu, f. 3j. M. ft Mistura cujus sumat cochl. magna.ij. quaTtis horis-. *12.TakeAromatic confection,one drachm Chalk Mixture, two ounces. Cinnamon Water, two ounces and a half. Tincture of Opium, from thirty to fifty drops. ——----— Catechu, one drachm. Shake them, and of the mixture give two large spoonsful every four hours. Order II.} putrid sore throat. -J49 In the last or putrid stage of this complaint, it is not uncommon for a haemorrhage to break forth from the nose, mouth, or ears. which never proving critical, but, on the contrary, threatening the greatest danger, ought always to be immediately stopped, if pos- sible, by administering strong antiseptics internally, as advised under the head of Malignant Fever, and by the external appli- cation of tents dipped in some powerful styptic, such as a solution of cupri sulphas.* Through the whole course of the disease the patient is to be supported with a sufficient quantity of liquid vegetable nutriment, such as gruel, barley-water, and preparations of tapioca, Indian arrow-root, rice, sago, and panado ; and his ordinary drink may consist of wine-whey, or Port wine negus acidulated with Orange- juice, or some other acid, either vegetable or mineral. The quantity of wine allowed must be in proportion to the age of the sick, the violence of the febrile symptoms, the degree of de- bility that exists, or the tendency that there is to putrescency. The chamber should be kept sufficiently ventilated, and of a proper temperature, so as not to be too hot, nor at the same time to be so cool as to give any check to the perspiration, or efflores- cence ; and it may be sprinkled several times a day with warm vinegar, in which rosemary or some other aromatic herb has been infused. The greatest cleanliness is moreover to be observed in removing, as soon as possible, whatever is voided by stool; the patient's linen, as also that of his bed, ought frequently to be changed, and the mouth and throat be repeatedly washed and kept clean. The putrid sore throat being highly contagious, especially among children, it will be prudent, on the first appearance of the disease, to separate the sick from the rest of the family: and in order to destroy the contagion, and render the attendants less susceptible of being infected, it may be advisable to fumigate with the nitric or muriatic acid, as advised under the head of Malignant Fever. The capsicum medicine before mentioned has not only been used in the cure of cynanche maligna, but it has likewise been advised for the prevention of it. By giving the attendants of the sick, and others who may unavoidably be exposed to infection, a tea-spoon- ful or two every three hours, using it at the same time as a gargle, the preventive effect of the remedy is said to have proved certain. It seems to act by producing and keeping up a regular excitement in the tonsils, uvula, and fauces, and thereby enabling them to re- sist the sedative effects of the poison which is inhaled. * 13. R Cupri Sulphat. 3jss. Aluminis, £ss. Aq. Purae, f. ^vij. Spirit. Rtctificat. f. ft. Solutio. M 13. Take Sulphate of Copper, one drachm and a half. Alum, half a drachm. Pure water, seven ounces, Alcohol, one ounce. Mix them for a wash. loO PVREXl/E, OR FEBRILE DISEASE.-. [ClaSS 'I. CYNANCHE TRACHEALIS, or CROUP. The croup is an inflammatory affection of the mucous membrane of the trachea and larynx, excited so high as to stimulate the ves- sels to throw out coagulated lymph, instead of inducing only an increased and altered secretion, according to the customary action of those membranes. In many instances it extends even to the bronchial ramifications and surface of the lungs, producing an exu- dation that appears partly in a membranous coating, and partly in a fluid resembling pus, and is attended with a peculiar wheezing * sonorous inspiration, compared by some to the crowing of a cock, a similar or stridulous sound in coughing and speaking, great diffi- culty of breathing, thirst, and other febrile symptoms, as likewise by some degree of spasmodic affection. Children are most liable to attacks of this disease. Some physicians have judged it proper to divide croup into two species, viz. idiopathic where the disease is primarily and exten- sively seated in the trachea, bronchiae, and surface of the lungs; and symptomatic, where it appears as the consequence of some previous disorder, such as the measles, scarlatina, or cynanche ma- ligna, for it has at times been found as the attendant of these com- plaints. The distinctions into spasmodic and inflammatory must be objected to, as the disease is always to be considered as arising from inflammation. The croup may be distinguished from acute asthma by the fol- lowing diagnostics :—in the former, the cough is frequently ringing in our ears, whereas in the latter there is little or no cough. In croup there is caldom or ever any remission, whereas in the acute asthma it is one of the most striking phenomena of the disease, and it is attended with some evacuation, such as belching, vomiting, or purging. In croup, the pulse is strong, with much febrile heat, the urine high coloured, and the voice shrill and small: in acute asthma, the pulse, although perhaps equally quick, is less full, the urine is limpid, and the voice is croaking and deep. The inflammation in the croup appears of a very peculiar and singular nature. If it was like that met with in common, we might expect to find the same kind of concretion on the surface of the trachea every day, as its mucous membrane is so frequently the seat of inflammation, attended with an increased secretion. The matter, however, of which this substance is formed, possesses dif- ferent properties from those of the mucus which is thrown out upon the membrane of the nose, or of the trachea, in common catarrhal affections. Most practitioners from thence have been induced to suppose, that the film which we find in the croup is not formed by a secretion from the mucous glands, but is an exudation from the exhalant arteries, and that it is analogous to the inflammatory exu- dation from the inflammation of other internal membranes, first described by the late Dr. Hunter. Upon this principle we can indeed more easily account for such a film not being found in com- Order 11.} CROUP. 151 raon catarrhal affections, in which the mucous glands are, perhaps, more the seat of the disease. The opinion now universally enter- tained is, that the new membrane formed in croup is nothing but coagulated lymph. The croup does not appear to be contagious, but it sometimes prevails epidemically. It seems, however, peculiar to some fami- lies ; and a child having been once attacked, is very liable to its returns, at uncertain periods, from any slight exposure to cold, but then its attacks are usually less severe. It is likewise peculiar to children from the age of a year to eight or ten, particularly the ruddy and robust, and has rarely been known to attack a person arrived at the age of puberty. The application of cold seems to be the general cause which pro- duces this disorder, and therefore it occurs more frequently in the winter and spring, when the weather is stormy and blowing, than in the other seasons. It has been observed to be most prevalent near the seacoast, where the air is loaded with moisture, and the changes of the weather are sensibly experienced; but it is fre- quently met with in inland situations, and particularly those which are marshy. It is less known in the temperate than in the northern regions of Europe. A day or two previous to an attack of the disease, the child ap- pears drowsy, inactive, and fretful; the eyes are somewhat suffused and heavy, and there is a cough, which from the first has a peculiar shrill sound : this, in the course of two days, becomes more violent and troublesome, and likewise more shrill. Every fit of coughing agitates the patient very much ; the face is flushed and swelled, the eyes are protuberant, a general tremour takes place^ and there is a kind of convulsive endeavour to renew respiration at the close of each fit. As the disease advances, great difficulty of breathing prevails, accompanied with a swelling and inflammation in the ton- sils, uvula, and velum pendulum palati, and the head is thrown back in the agony of attempting to escape suffocation. There is not only an unusual sound produced by the cough, but respiration is performed with a hissing noise, as if the trachea was closed up by some light spongy substance, and thought by some to resemble the sound of a piston forced up a dry pump, or the crowing of a cock. The cough is generally dry ; but if any thing is spit up, it has either a purulent appearance, or seems to consist of films resembling portions of a membrane. Where great nausea and frequent retch- ings prevail, coagulated matter of the same nature is brought up. With these symptoms there is much thirst, an uneasy sense of heat over the whole body, a continual inclination to change from place to place, great restlessness, and frequency of the pulse. Very often the symptoms suffer considerable and sudden remissions and exacerbations. In an advanced stage of the disease, respiration becomes more stridulous, and is performed with still greater difficulty and some lo2 PVREXIJE, OR FEBRILE DISEASES. [Class f. degree of spasmodic affection, being repeated at longer periods. and with greater exertions, until at last it ceases entirely. The croup is to be considered as a very dangerous disease, and which sometimes will destroy the child quickly by suffocation, induced either by spasm affecting the glottis, or by a quantity of matter blocking up the bronchiae : but when it terminates in health, it is by a resolution of the inflammation, by a cessation of the spasms, by relief to the dyspnoea, and the voice becoming natural, with a copious and free expectoration of the matter exuding from the trachea, or of the membrane formed there. The unfavourable symptoms are, considerable difficulty of breathing, great anxiety, violent fever, frequent fits of coughing, no expectoration, the voice becoming more shrill, and the pulse irregular and intermitting. The disease has, in a few instances, terminated fatally within twenty-four or thirty hours after its attack ; but it more usually happens, that where it proves fatal, it runs on to the fourth or fifth day. Where portions of the membranous film, formed on the surface of the trachea, are thrown up, life is sometimes protracted for a day or two longer than would otherwise have happened. More than one half of the cases of croup terminate fatally. The younger the patient, the greater will be the danger. On opening the bodies of children who have died of the croup, it is not unusual to find the lungs in a healthy state ; but in some instances the lungs are inflamed on particular points of their sur- face, and in others, adhesions to the pleura are discovered ; occa- sionally they are found full of dark-coloured blood and serum, and sometimes a quantity of pus is met with. In tracing the bronchias throughout their minute ramifications, they are usually found filled with mucus, but which is of a firmer consistence in the trachea, and as it were pasted on the surface of the tube, forming a mem- branous-like concretion of variable colour and texture. The upper part of the trachea is the most usual seat of deviation from the natural structure ; but this is sometimes observed also in the lungs, and extending to the smallest ramifications of the bronchiae. It has been, and I believe still is, in a great measure the common opinion, that the inflammatory affection in croup is chiefly confined to the trachea and bronchiae; but Dr. Baillie,* as well as Dr. Cheyne,t have asserted the contrary, and have given a minute account of several dissections of this disease, wherein the lungs were affected with deep-seated inflammation, and obvious from the firmness of these organs, from their not collapsing when the chest was exposed, and from a kind of purulent matter found within their cells. From the appearances on dissection, and the symptoms which attend the disease, there can be no doubt but that it is an inflam- s See his Morbid Anatomy, p. 91. 1 See pathology of the Membrane of the Lavynx, by J. Cheyne. M. 1*> Order Il.J CROUP. 153 matory affection of the mucous membrane of the trachea, larynx, and other parts immediately connected therewith, attended by a spasmodic contraction of the muscles in consequence thereof; the treatment ought therefore to be managed accordingly. * In the first or incipient stage of croup, our best and most strenuous endea- vours should be exerted to lessen the increased action which pre- vails all over the mucous membrane of the trachea, larynx, and bronchiae ; and therefore bleeding, emetics, purgatives, and blister- ing, are to be resorted to. The first thing to be done should be, to take away blood, either from the jugular vein or arm, but a pre- ference is due to the former, proportioning the quantity to the age and habit of the child, and continuing it so as nearly to produce fainting, where the difficulty of breathing is great. Should the symptoms not mitigate from the bleeding, or should they return after a little time, more blood ought to be drawn from the arm. and afterwards if necessary, by applying several leeches immediately over the trachea ; but previous general bleeding should never be omitted in any case. In those which are urgent, active depletion will be necessary. The use of the lancet has indeed been deprecated by a few practitioners; and the tinctura opii, in doses proportionate to the violence of the symptoms, recommended as being likely to give relief as speedily as venesection, or any other remedy. I think bleeding, both general and topical, with other antiphlogistic remedies, ought never to be neglected in the first stage of the disease. The prompt abstraction of blood at the commencement of croup, in such a quantity as effectually to lower vascular action upon the tracheal surface, before it has continued long enough to produce any exudation, or effusion of coagulated lymph, or whatever it may be that constitutes the adventitious membrane, is in my opinion the principal remedy from which any relief is to be derived ; and it is only at this period, most probably, that bleeding can be useful- Immediately after bleeding it will be proper to apply a large blister all across the throat from ear to ear, keeping up a discharg- ing surface after it is removed, by dressing it with a little of the ceratum sabinae. Having adopted these steps, we ought to give a gentle emetic of ipecacuanha, or tartarized antimony, in a dose proportioned to the age of the child, so as to produce sufficient vomiting. Great relief will be afforded by the remedy, in consequence of a considerable quantity of ropy mucus being brought off. In all cases of the croup the child should be kept nearly upright in bed, to guard against suffocation. Throughout the whole course of the disease an antiphlogistic regimen will be necessary; and the body should be kept open by the frequent administration of some purgative. Brisk purgatives ?.l 15'k pyrexia:, or eeuruve di»lase3. [Class I. (in which the submuriate of mercury* may be an ingredient,) when the bowels are inactive, are obviously proper. Their operation may be solicited by occasionally administering clysters. To assist the expectoration, and promote a determination to the surface of the body, we may employ diaphoretics, such as a few drops of vinum ipecac, or the solution of tartarized antimony. I usually give a preference to the latter, administered every, two or three hours in such doses as to excite nausea. To increase the effect of this medicine, a warm bath of between 90 and 100 of Fahrenheit may be used. Possibly moderate doses of the pulvis antimonialis, combined with a small quantity of the submuriate of mercury, might prove very serviceable. By promptly resorting to the means which have been pointed out, the progress of croup may be frequently averted ; but by neglecting these during the first day or two of the disease, and trusting to trifling remedies, thereby suffering the inflammatory ac- tion to proceed, the practitioner will be constrained to witness that distress and loss of his patient which promptitude and energy might have prevented; for I think the croup in its early stage is, generally speaking, as much under the control of early and copious bleeding, emetics, purgatives, and the other remedies pre- scribed, as most other inflammatory disorders. In the course of the disease there is always a lodgment of lymph or mucus in the trachea, and therefore it will be advisable to excite vomitingt once or twice a day, in order that the effused fluid, or adventitious membrane formed thereby, may be dislodged if possi- ble, and brought off. Inhaling the vapour arising from warm water with a small addi- tion of aether, may possibly prove a good auxiliary, both in lessen- ing the violence of the spasms, and assisting expectoration. Some cases of this disorder have been successfully treated with the digitalis. J In these, the tincture was employed in the dose of five drops, repeated every four hours. Its good effects would appear to depend partly upon its operating quickly and powerfully on the arterial system, and thereby stopping the rapidity of the inflammatory symptoms, and partly on its allaying the spasmodic $ See Med. and Phys. Journ. vol. iv. p. 20. * 1. R Hydrargyri Submur. gr. iij. Pulv. Jalapse, gr. iv.—viij. M. ft. Pulvis catharticus. Vel, 2. R Pulv. Rhei, gr. vj. Hydrargyri Submur. gr. ij. M. ft. Pulvis. \ 1 3. ]J Antimon. TwEtarizat. gr. ij. Aq. Pura?, f.^13- Oxymel. Scillce, f. §ss. M. Capiat cochl. duo minima subinde ad vomiturn promovendum * 1. Take Submuriate of Mercury,3 grains Powdered Jalap, from four to eight grains. Mix these together for a purge. Or, 2. Take Powdered Rhubarb, six grains. Submuriate of Mercury,two grains Mix them. \ 3.TakeTartarized Antimony, two grains. Pure Water, two ounces. Oxymel of Squill, half an ounce. Mix them together, and give two tea- spoonsful from time to time until vonv*. ing is exciter! Order II.] croup. 155 irritation. I have myself employed it in two or three cases of croup, and with much seeming advantage, but I always premised general as well as local bleedings. After copious depletion, by bleeding both general and topical, vomiting, purging, and blisters, when the inflammatory symptoms have subsided, and the disease seems almost entirely spasmodic, we may venture to give a few drops of the tincture of opium every two or three hours, combined with the wine of ipecacuanha, or solution of tartarized antimony, for the purpose of procuring rest and a remission of the spasms. Musk and assafoetida have been recommended as antispasmodics in this disease, but here they are not entitled to our confidence. From the report of some authors we should be induced to sup-; piose, that the croup was a disease of long duration and easy ma- nagement ; as by one we are informed that mercury, employed so as to produce a salivation, effectually cures it: another is confident of the success of a lotion made with spiritus aetheris sulphurici compositus; and a third places his reliance on a decoction of seneka : but such is the celerity of the dangerous symptoms, that few practitioners have, I think, witnessed a recovery from the croup, where an extravasation of coagulable lymph within the trachea and bronchial tubes had taken place in a high degree. In one or two mild cases of the disease, hydrargyri submurias has been indeed employed, on the recommendation of Dr. Rush, with some seeming advantage; but as the relief we obtain is always in proportion to the quantity of mucus brought up, it would appear that we should never neglect exciting frequent vomiting, by means - of tinctura scillse, vin. ipecacuanhas, or a solution of tartarized antimony, in order to have recourse to mercury. y It comes on with an acute pain in the side, which is much aggravated on making a full inspiration, and is accompanied by flushing in the face, increased heat over the whole body, rigours, difficulty of lying on the side affected, together with a cough and nausea; aud the pulse is hard, strong, and frequent, and vibrates under the finger when pressed upon, not unlike the tense string of a musical instrument. If blood is drawn, and allowed to stand for a short time, it will exhibit a thick sizy or buffy coat on its surface, consisting of the coagulable lymph or fibrin. If the disease is neglected at its onset, and the inflammation proceeds with great violence and rapidity, the lungs them- selves become affected, the passage of the blood through them is stopped, and the patient is suffocated ; or from a sornbination of the two affections, the inflammation proceeds on to suppuration, and an abscess is formed. The prognostic in pleurisy must be drawn from the severity of the symptoms. If the fever and inflammation have ran high, and the pain should cease suddenly, with a change of countenance and a sinking of the pulse, great danger may be apprehended ; but if the heat and other febrile symptoms abate gradually, if respiration is performed with greater ease and less pain, and a free and copious expectoration ensues, a speedy recovery may be expected. Empyema, or a collection of pus in the cavity of the thorax, is occasionally one of the terminations of pleuritis. The appearances on dissection are much the same as those mentioned under the head Peripneumony ; viz. an inflamed state of the pleura, connected with the lungs, having its surface crowded with red vessels, and a layer of coagulated lymph lying upon it; adhesions also of the substance of the lungs to the pleura. Besides these, the lungs themselves are often found in an inflamed state, with an extravasation either of blood or coagulated lymph in their substance. Tubercles and abscesses are likewise frequently met with. In the treatment of pleurisy our chief attention must be directed to the removal of the inflammation, by copious bleedings from the system at an early period of the complaint, taking the pulse for a guide, and giving the age and constitution of the patient proper consideration. While the pulse remains full, hard, and obstructed, the pain in the side acute, the breathing difficult, and the blood continues to exhibit a sizy crust on its surface when cool, so long ought we to repeat the operation, with this exception, that after a free expectoration has commenced, it will be injurious. Here it is proper to mention, that physicians have been struck at all times with the effect produced, by taking the blood from a large orifice* in inflammatory diseases; and it is certainly a step which cannot be too strongly urged, but more particularly in pleuritis and pneumonia. It is true, that from a small orifice an equal quantity * Sec Dr. Fordy<:abated, we may venture'to give some cathartic medicinet by the mouth. In enteritis, attended with constipation, the submuriate of mercury, given in the d*se of ten or fifteen grains, with a small quantity of cathartic extract, and made into little pills, may perhaps be the best purgative we can employ. To relax the spasm, and thereby remove one of the principal impediments to the cure, an emollient laxative clyster may at the same time be administered from time to time. To- bacco clysters are sometimes used, but they are very apt to pro- duce nausea and vomiting, if not cautiously employed, may wholly extinguish life. In all cases of enteritis, purgative medicines are certainly essential to the plan of treatment; but bleeding, although con- sidered as of the greatest importance, is not always employed so as to produce a powerful impression upon the system at large. Our attention should always be directed principally at first to the subduing of the inflammation by repeated large venesections on the very onset of the disease; and afterwards by local bleeding, succeeded by the application of a blister to the abdomen: and when we have effected this object, we may then resort to purga- tives to remove the constipation. This latter being the effect, and not the cause of the disease, should not be the symptom first attended to. It is indeed too much the custom to -have recourse to active purgatives at the very commencement of enteritis, and this too in very considerable doses—a practice which cannot fail to ^ 1, R Infus. Sennae, f. ^xj. Soda? Sulphatis, ?j. 01. Ricini, f. ^ss. M. ft. Enema. f 2. R 01. Ricini, f. gj. Aq. Menth. f. f ss. Tinct. Jalap. f73ss. M. ft. Haustus. Vel, 3. ,$; Infus. Senna?, f. §jss. Tinct. ejusdem, f. 3j Magnes. Sulphat. 3«j. it. Hau^i;* <24 * 1. Take Infusion of Senna, eleven ounces. Sulphate of Soda, one ounce. Castor Oil, half an ounce. Mix them for a clyster. t 2. Take Castor Oil, one ounce. Mint Water, half an ounce. Tincture of Jalap, half a drachm. Mix them for a draught. Or, 3. Take Infusion of Senna, one ounce and a half. Tincture of the same, one drachm. Sulphate of Magnesia, three drachms. Mix them for a draught. Itti pyrexia;, or febrile diseases. [Class L prove highly prejudicial. The intention is, to evacuate the bowels; • % but it should be considered that purgatives empty the intestinal canal by means of their specific stimulus, which increases the secretions, and quickens its peristaltic motion : let it also be recol- lected, that the bowels are already excited to the utmost; that they are in, or at least tending to a state of high inflammation, and that no pathological fact is better ascertained, than that excessive excitement destroys secretion; that by applying stimu- lants to an inflamed membrane, every secretion which it was wont to pour out, is loeked up. In enteritis, as well as peritonitis, the warm bath is often made use of; but by some practitioners its effects have been considered as somewhat doubtful, if not hurtful, until the in- flammatory action is checked by general and local bleedings, together with purgatives. Cloths wetted in cold vinegar and water, applied over the whole surface of the abdomen at short intervals, have been attended, in some cases of peritoneal inflam- mation, with the best effects, after fomentations with warm water and warm bathing have failed. Opiates are used by many practitioners in the early stage of this complaint, where the stomach is in a very irritable state, and much vomiting prevails; but it is obvious that they must prove injurious, and ought therefore not to be employed, at least not before sufficient evacuations by bleeding, as well as by laxatives or emollient clysters, have been premised. Until the obstruction is removed by evacuations, the stimulus of opium might be likely to increase the action of the vessels. When it is given by the mouth it should always be joined with some cathartic* Whatever is given to the patient as aliment should be of the most mild diluent nature, such as barley-water, beef-tea, and chicken-broth; and these ought to be taken sparingly, and only in small quantities at a time, until some evacuation has been procured; as much food forced against the obstruction must necessarily increase the irritation, and of course aggravate all the symptoms. The strictest adherence to the antiphlogistic regimen must be enjoined. When the disease is combined with spasmodic colic, the means recommended under that head must be pursued. In severe obstructions of the intestinal tube, accompanied by obstinate constipation, and where purgatives fail in procuring motions, it has been a common practice to have recourse to quick- silver in considerable quantity, and no doubt it will find its way "' 4. g, Hydrargyri Submur. gr. v. n 4. Take Submuriate of Mercury,, five grains. Extract. Colocynth. C. gr. viij. Compound Extract of Colo- cynth, eight grains. Opii, gr. ss.—j. Opium, from half a grain to one | grain. Fiantpilute iij. pro do- I Make these into three pills for a dosp Order II.J inflammation of the liver. 17H through the intestinal tube in most instances merely by its gravity; but in cases of enteritis, where there is intus-susceptio, or it is combined with hernia of any species, this remedy cannot fail to prove highly injurious. As enteritis is very apt to recur from slight causes, the greatest circumspection will be requisite after recovery. Improper food and exposure to cold are therefore cautiously to be avoided, and cos- tiveness to be immediately removed. If there be any appearance of suppuration and ulceration, particular attention becomes still more necessary, as it will give the ulcers a better chance of healing. In the cure of strangulated hernia, the judicious surgeon will never place his patient on his head, and toss him about in the manner sometimes adopted, as such a practice might increase instead of abate tumefaction; nor will he attempt to push the protruded parts by force through an aperture which bears no proportion to their dimensions. No; he will enjoin composure, and strictly keep in view, that until the obstruction in the intestine. which is the effect of inflammation, is removed by copious and repeated venesections, its being replaced in its original situation ought not to be attempted. In a word, bleeding to a great extent, and avoiding manual efforts, will be the most likely means to ensure success in all cases of strangulated hernia. Where our endeavours fail, recourse should be had in due time to the proper operation for removing the stricture on the protruded parts, to guard against gangrene. HEPATITIS, or INFLAMMATION of the LIVER. Pyrexia, tension, and pain of the right hypochohdrium, often pungent, as in pleuritis, but sometimes dull, pain in the clavicle and top of the right shoulder, uneasy lying on the left side, difficult respiration, dry cough and vomiting, are the characteristics of hepatitis : very frequently there is some degree of jaundice. Hepatitis has generally been considered of two kinds ; the one acute, the other chronic ; the former showing the essential character of gew^ne inflammation ; the latter exhibiting symptoms of less violence as to their inflammatory tendency, but an enlargement and hardness of the liver, with an obtuse pain. Besides the causes producing other inflammations, such as the application of cold, external injuries from contusions, blows, &c. this disease may be occasioned by violent exercise, by intense summer heats, by long-continued intermittent and remittent fevers, by high living, and an intemperate use of vinous and spirituous liquors, but more particularly the latter, and by various solid Con- cretions in the substance of the liver. In five cases out of six, the exciting cause of acute hepatitis will be found to be the partial application of cold or wet when the body is heated or over fatigued by violent exercise. Derangement of the digestive organs, sup- pressed secretions, inflammations, compression, fevers, and mental 130 pyrexia, or febrile diseases. [Clam I. solicitude, are very general causes of obstructions and diseases of the liver. In warm climates this viscus is more apt to be affected with inflammation than any other part of the body, probably from the increased secretion of bile which takes place when the blood is thrown on the internal parts by an exposure to cold; or from the bile becoming acrid, and thereby exciting an irritation in the part. An inflammation of the liver, and the diseases consequent thereon, are indeed affections more frequently to be met with in warm climates than in cold ones, particularly in the East and West Indies, where few Europeans can reside for any length of time without being attacked by them. The liver in warm climates seems to be the seat of disease, nearly in the same proportion that the lungs are in Great Britain. Both acute and chronic hepatitis are frequently met with in persons who come, to Europe from the East and West Indies, and in those who have been affected when in those climates they are very apt to recur by the application of causes which would be likely to have a different effect upon any body else. Between the hepatitis of India and that of Europe there is no small dissimilarity in the symptoms. The flux, which may be termed the pathognomic of the former, is always wanting in the latter. That of India partakes more of inflammatory congestion and ob- struction ; the other of active inflammation, and if not early checked, frequently runs on to suppuration. Such an occurrence in India or the West Indies is principally met with among those lately arrived from Europe, and may in most cases be traced to intem- perance, violent exercise in the sun, or sudden exposure to cold when the body has been in a state of considerable perspiration. The hepatitis of India is generally allowed to be, in all similar stages, a milder disease than the sporadic hepatitis of this country. the phlogistic symptoms being less violent.* The acute species of hepatitis comes on with a sense of chilliness preceding pain in the right hypochondrium, sometimes dull, some- times sharp, extending up to the clavicle and shoulder of that side most usually, which is much increased by pressing uf on the part, and is accompanied with a cough, oppression of breathing, and difficulty of lying, except on the side affected ; together with nausea and sickness, and often with a vomiting of bilious matter; the intestines are generally inactive, and the stools show a defi- ciency of biliary secretion, or at least of any intermixture of it with them ; the urine is of a deep saffron colour, and small in quantity ; there is loss of appetite, great thirst, and costiveness, with a strong, hard, and frequent pulse, of from 90 to 100 in a minute, and some- times intermitting; the skin is hot and dry at the same time, and the tongue covered with a white, and sometimes a yellowish fur; * See Dr. Saunders's Treatise on the Liver. See Essay on the Influence of Tropical Climates on Europeans, bv J. Johnson. Order 1I.J inflammation of the liver. 181 and when the disease has continued for some days, the skin and eyes become tinged of a deep ye^ow, particularly when the inflam- mation \r produced by calculi in the parenchyma of the liver. The appearance of the blood is somewhat remarkable just before it eovulates, when, the red part falling to the bottom, and the huffy coat not yet being formed, it appears of a dull green colour. This is owing to the mixture of the yellow coloured bile with the purple coloured venous blood, as yellow and purple form green; the coagulable lymph contains none of the purple colour, therefore the bufly coat is not green, but yellow. The same appearances are observed in the blood of a person labouring under jaundice. In hepatitis, as well as in other diseases, we do not always find the symptoms of the same degree of violence as they are described in the definition : thus in some cases the fever is severe, in others it is scarcely perceptible: in some instances the pain is very acute and violent; in others, collections of pus have been found after death, when no pain has been felt. When the pain is seated deep in the substance of the liver, as that possesses little sensibility, the pain is usually obtuse ; but when the surface is affected, it is acute, and apt to spread to the diaphragm and lungs, producing cough. Both ancient and modern nosologists have made a distinction between the symptoms that occur when the inflammation occupies the Convex surface of the liver, and those that are present when the disease affects the concave. It is said, when great difficulty of breathing, and cough, accompany the pain in the region of the liver, that these symptoms indicate the inflammation to be seated in the superior or convex part; but where the inflammation occu- pies the concave or inferior surface, which lies contiguous to the stomach and duodenum, there is more sickness and vomiting; and, moreover, the pain is not so violent in the region of the organ as in the other instance. My own observations, during a practice of many years in the West Indies, (where hepatitis is a disease of frequent occurrence,) as well as in England, do not permit me to say that the symptoms which have just been pointed out are so unequivocal as had been represented by nosologists. It seems probable, says Dr. Cullen, that acute hepatitis is always an affection of the external membrane of the liver, and-that the parenchymatic is of the chronic kind. The chronic species is usually accompanied with a morbid com- plexion, loss of appetite and flesh, lowness of spirits and despond- ency of mind, headach or giddiness, general weakness, a morbid sensibility of the nervous system, costiveness, indigestion, flatu- lency, acidity, and pains in the stomach, a yellow tinge of the skin and eyes, clay-coloured stools, high-coloured urine, depositing a red sediment, and ropy mucus ; an obtuse pain in the region of the liver, extending to the shoulder, together with a sense of weight, unusual fulness, and some enlargement and hardness of the organ, and not unfrequently with a slight difficulty of breathing, or dys- 182 PVREXIiE, OR FEBRILE DISEASES. [Class L pnoea. In some cases of chronic inflammation of the liver the pulse has been observed to intermit, and probably induced either by the blood through the hepatic artery being obstructed by the scirrhosity, by an accumulation of it in the branches of the vena portarum, or by bile in the hepatic ducts. These symptoms are, however, often so mild and insignificant as to pass almost unnoticed, as large abscesses have been found in the liver upon dissection, which in the person's lifetime had created little or no inconvenience, and which we may presume to have been occasioned by some previous inflammation. We may readily distinguish hepatitis from pneumonia by the pain in the former extending into the shoulder ; by the sallowness of the countenance; by the cough being unaccompanied by expec- toration ; and by the less degree of dyspnoea. The heat and pain not being increased upon taking any thing into the stomach, its being able to retain whatever liquids or medicines are received into it, without the immediate rejection of them, and the less prostra- tion of strength, will distinguish it from gastritis. Hepatitis may be discerned from spasm on the gall-ducts, by there being no nau- sea, by the pain being permanent, by the pulse being 100 and up- wards iii a minute, and by the patient always preferring to keep the body in a straight quiescent posture; whereas the greatest ease, when there is spasm on the gall-ducts, is obtained by bending the body forward on the knees. Hepatitis, like other inflammations, may end in resolution, sup- puration, gangrene, or scirrhus, in which the liver becomes swelled and hard; but its termination in gangrene is a rare occurrence." It is frequently accompanied with chronic obstruction. Its tendency to run into suppuration is not so great in this country as in warm climates. Indeed it is a rare occurrence here. The period of sup- puration is influenced by the degree of inflammation, the season of the year, climate, and the remedies that have been employed. Scirrhus may exist in the liver without previous active inflamma- tion, as in those who have long resided in the East or West Indies. Indeed, a scirrhosity of the liver most generally arises from this cause, and by an abuse of ardent spirits. The disease is seldom attended with fatal consequences of an immediate nature, and is sometimes carried off by an haemorrhage from the nose or hemorrhoidal vessels; and likewise by sweating, by a diarrhoea, or by an evacuation of urine depositing a copious sediment. In a few instances it has been observed to cease on the appearance of erysipelas in some external part. Serous effusion in the cavity of the abdomen is sometimes a consequence of hepatitis showing itself under the form of ascites. Hydatids now and then form in or on the liver, and sometimes acquire so considerable a size and hardness, as to be distinguished with great difficulty from chronic hepatitis terminating in suppura- tion. A case of this nature, which had been of long standing, in a lady of about forty-eight years of age, and the mother of a large Order II.J inflammation of the liver. 18o family, lately came under my observation. She had some time back consulted some of the most eminent surgeons in London, as also one of this city, by whose advice she was put under a course of mercurial frictions, with the internal use of the pilula hydrargyri and nitric acid, under the supposition that her disease was indura- tion and enlargement of the liver which might ultimately terminate in a suppuration. There was wanting, however, that yellow tinge of countenance and derangement in the biliary system, to satify me perfectly that a just idea had been formed of the nature of her complaint. Laterally it was obvious that a fluid was contained in the tumour, which had now acquired so considerable a size as to render an operation indispensably necessary. On performing this it became evident that the disease was really a very large hydatid, as sixteen pints of water were drawn off through the canula, to- wards the close of the flowing of which a small quantity of lymph came away. The most favourable signs in hepatitis are, a gradual abatement of the pyrexia! symptoms, an improvement in the complexion, the strength not much reduced by the remedies, return of the appetite, and an increase in the bulk of the body. Intensity of pain in the region of the liver, a full and frequent pulse, considerable heat, thirst, dry skin, costiveness, and frequent rigours, denote approach- ing suppuration. When the inflammation terminates in the formation of matter, the inflammatory symptoms gradually subside, and give way to those of suppuration. The fever becomes somewhat intermittent, fre- quent rigours or shiverings are felt, the sense of weight in the part increases, the pains are less acute but throbbing, the tongue is white, with flushings of the countenance : and when the abscess is formed near the edge of the liver, or towards the concave surface, it not unfrequently projects under the false ribs, so that the fluc- tuation may be felt externally. If the abscess forms on its convex surface, it points towards the cavity of the thorax, corrodes through the diaphragm, and distends the pleura, which it sometimes pushes through the interstices of the ribs. At last the matter finds its way through the intercostal muscles, and may be distinguished through the integuments. If the abscess is apparent, there will be found a fluctuation in the centre, while the circumference remains hard. A change of colour in the skin only occurs where a great quantity of matter is accumulated ; or where, by its bad quality, it changes the colour of the integuments. If much pressure on the tumour with the fingers is employed, a pulsation may often be felt, particularly in irritable habits. Sometimes the inferior lobe of the lungs con- tracts adhesions with those points of the diaphragm connected with the abscess, by which means the matter will be discharged by the bronchiae : this is, however, a rare occurrence; but it often happens that the matter is effused into the cavity of the thorax, and forms a purulent empyema. It likewise happens now and then, that the. sides of the abscess, forming adhesions with the stomach, or much 184 !■ YREXI.4;, OR FEBRILE DISEASES* [Class / oftener with the colon, the matter is discharged into their cavity, and evacuated either by vomiting or stool. On dissection of those who die of hepatitis, the liver is often found much enlarged and hard to the touch, its colour is more of a deep purple than what is natural, and its membranes are more or less affected by inflammation. Dissections likewise show that ad- hesions to the neighbouring parts often take place ; that tubercles, as well as vesicular cysts, denominated hydatids, are sometimes found in it; and that large abscesses, containing a considerable quantity of pus, are often formed in its substance. Biliary calculi are now and then met with. In a few instances, the livers of those who have died of this disease have been found in a putrid state, resembling a honeycomb ; but the most common appearance to be observed in those who die of diseased liver is the formation of tubercles* in its substance, with an exception to adhesions. The liver has not unfrequently been found after death to be indurated, or otherwise injured, without any marked indication of disease during the life of the patient, excepting dyspepsia or simple indigestion. What constitutes great difficulty in managing hepatitis is, that in many cases the symptoms which are primary and indicative of inflammatory affection, are but very slightly marked, even when it is in such a degree as to run with readiness into suppuration, and particularly in the East and West Indies. The pain in the side is not constant or acute, the patient himself takes little notice of it, seldom mentions it unless he is asked about it, and when ques- tioned concerning it, he only tells you perhaps, that he has felt at times slight pains about the pit of the stomach, or in the right side. It is only by observing the secondary symptoms, such as a diarrhoea, or a short dry cough, and pain felt at the top of the shoulder, or that there is a degree of fulness or tenderness on pressing on the organ a little hard, with some yellowness of the eyes and countenance, that the true state and nature of the dis- order is to be ascertained in such cases. During the inflammatory stage of acute hepatitis it will be proper to adopt general bleeding, proportioning the quantity which is taken away to the severity of the pain, and the degree of fever that is present; and repeating the operation very soon again if the symp- toms do not greatly abate, and the inflammatory action appear to be subdued. By neglecting to bleed in due quantity, and promptly to repeat the operation at the commencement of acute hepatitis. there will be danger of suppuration ensuing. In warm climates, general bleeding may be used with greater moderation than in cold ones. After venesection we should give a proper dose of hydrar- gyri submurias with jalap, or some other cathartic, repeating it every other day until the inflammatory symptoms subside. These steps being taken, we may recommend the application of several *' See Morbid Anatomy, by Dr. Bailie Order II.j inflammation of the liver. 186 «, leeches over the region of the liver, or we may draw off a suffi- cient quantity of blood by applying the scarificator and cupping- glasses. Some practitioners disapprove of bleeding from the system in this disorder, and recommend in its stead to draw blood from the neighbourhood of the part, by means either of leeches, or scarifi- cations and cupping, which may be the preferable way in those cases which are unattended with much pain or pyrexia, or where the disease has followed a bad intermittent or remittent fever, and consequently the patient is in a cachectic state ; but in those where the pain is acute, the pulse Hull and strong, and the febrile heat and thirst are considerable, copious and repeated venesection at an early period of the disease will be necessary. It will, however, be hetter to take away at once a quantity proportioned to the age and temperament of the patient, and the degree and extent of the disease, than by repeated small bleedings. It will be proper also in Weeding to make a large orifice, as physicians have been struck at all times with the effect produced by taking the blood from a large orifice* in inflammatory diseases. If the symptoms do not abate in consequence of these means, a large blister applied over the region of the liver will be. likely to prove serviceable. Should it be inclined to heal up too rapidly, or before the desired intention is obtained, a fresh one must be laid on. A succession of blisters will be far preferable to keeping open the first one with any kind of stimulating ointment. In every case of acute hepatitis, the whole of the antiphlogistic plan is to be rigorously pursued, particularly where the febrile symptoms run high and endanger a termination in suppuration: and therefdre it will be understood, that a farinaceous or gruel diet is to be strictly enjoined at the commencement, carefully shunning animal food in broths or otherwise ; that thirst is to be assuaged by a free use of cooling drinks impregnated with vegetable acids; that cool air is to be freely admitted into the apartment of the sick, and that the intestines are to be kept perfectly open with gentle purga- tives, such as solutions of the neutral salts,! or jalap with the sub- muriate of mercury administered from time to time. As in other inflammatory complaints, we may excite a diaphoresis by means of nauseating doses of tartarized antimony, to which we * See Dr. George Fordyce's Fourth Dissection, p. 50. —-------"■------------Fifth ditto, p. 15. 11. R Infus. Sennae, f. ^jss. Magnes. Sulphat. 3iij ■ Tinct. Jalapse, Syrup. Rhamni, a» f. 3J. M. H. Haustus. f 1. Take Infusion of Senna, one ounce and a half. Sulphate of Magnesia, three drachms. Tincture of Jalap, Syrup of Buckthorn, of each one drachm. Mix them for a draught, 186 PYREXIA, OR FEBRILE DISEASES. [Class L may join the nitrate of potass.* The pediluvium, with a plentiful use of mild diluent and cooling liquids, will also be proper. Putting the patient into a warm bath may be advisable in those cases where the skin is dry, and the pain in the region of the liver very severe. In acute hepatitis, When after having strictly pursued the anti- phlogistic course which has been pointed out for four or five days, the disease is found not to give way, we should call in the aid of mercury. Some practitioners, particularly in the East and West Indies, have recourse to it on the first attack ; but the mostjudicious do not in general use it to effect a mercurial operation until the urgent inflammatory symptoms have been somewhat subdued by an antiphlogistic treatment. In every inflammatory affection of the liver, and where febrile excitement is present, but more particu- larly in northern climates, although it may be advisable to employ mercury as a purgative at the commencement of acute hepatitis, still I am of opinion that we should not then use it with the view of promoting salivation. The remedy in question, when properly used, is certainly attended with wonderful efficacy, but it appears improper on the first attack of acute hepatitis, which, like other visceral inflammations, readily yields in Great Britain to the ordi- nary plan of depletion.! We may begin the mercurial course at the expiration of the fourth or fifth day of the disease. The most proper way of intro- ducing mercury into the system will be, by rubbing in a small quantity of the ointment (perhaps about one drachm) in the neigh- bourhood of the part affected, every night, until a slight degree of salivation is excited, or rather until some very obvious effect is produced on the constitution ; by which means we shall in general be able to disperse the swelling and hardness. It will be advisa- ble to rub the ointment on the right side, in preference to any other part, because some advantage may possibly be derived from the mere friction. If rubbing in the mercury in the neighbourhood of the part is at- tended with any pain or inconvenience to the patient, the unction may then be applied to the groins, taking care however not to carry it much beyond the point bordering on salivation. With the view of assisting the discussion of the inflammation, and obviating any severe effects from the use of mercury, some gentle purgative, t See Dr. Saunders's Treatise on Diseases of the Liver. * 2. R Haust. Salin. f. ?jss. * 2. Take Saline Draught, one ounce and a half. Potassae Nitratis, gr. x.—xv. Nitrate of Potass, from ten to fifteen grains. Antimon. Tartarizat. gr. f. Tartarized Antimony, the sixth of a grain. Syrup. Altheeae, f. 3y- M- J Syrup of Marshmallow, two drachms. « Haustus. i .Mix them for a febrifuge draught. Order II.J inflammation of the liver. 187 such as a solution of any neutral salt in an infusion of senna, may be taken every third or fourth morning. A modern writer mentions,* that it is by no means sufficient to render the mouth sore by mercury; it must be carried to the ex- tent of producing a copious salivation, as the disease never yields till the saliva flows freely. In this opinion I believe he is singu- lar; but indeed the generality of the East India practitioners seem to carry the point too far. Should we wish the mercurial action to be soon effected, we may employ mercury internally as well as externally; and to make its effect the more certain, we may join small doses of opium or anti- mony with it, administering them in the form of a pill.t If we find the submuriate of mercury not to answer our wishes, we should substitute the pilula hydrargyri, the patient taking one or two every night at bedtime, as may be judged necessary. In hepatic derange- ments this remedy has of late years been very extensively and usefully employed in the United Kingdom. If the disease yields readily, a short course of mercury will be sufficient; but if not, its use ought to be continued for, perhaps, five or six weeks. I wish here to recapitulate the treatment of acute hepatitis just pointed out, and to say, that he who will most successfully combat the disease, will endeavour first to arrest and subdue the inflammatory action, as much as possible, by copious bleeding from the arm, and afterwards by leeches or scarifications over the region of the liver, succeeded by blisters, while mercurial purga- tives are at the same time employed to clear the whole line of the alimentary canal. When by these means the vascular excitement is reduced to a certain level, then a restoration of the secretion in the liver will be the surest safeguard against future lesion, both of structure and function, in this important viscus, and this is to be done by a judicious exhibition of mercurials joined with anti^ monials, or even with opium. Throughout the whole of this course, there will be a strict necessity to avoid the remote and exciting causes which brought on the disease. * See Medical Sketches, by Sir James M'Gregor, M. D. i 3. R Hydrargyr. Submur. 3i- Opii, Camphorae, aa gss. Syrup. Simpl. q. s. M. ft. massa, in pilulas sequales xxx. distri- buenda, capiat j. vel ij pro dos. Vel, 4. U Hydrargyr. Submuriat. 3j. Opii Purif. ^j. Antimon. Tartarizat. gr.v. Syrup. Simpl. q. s. M. ft. massa, in pilul. xxx. divid. j. mane et nocte quotidiesumenda. f 3. Take Submuriate of Mercury, one-. drachm. Opium, Camphor,of each half a drachm. Common Syrup, a sufficiency to form the mass, which divide into thirty pills, and take from one to two for adose. Or, 4. Take Submuriate of Mercury, one drachm. Opium, one scruple. Tartarized Antimony,five grains. Syrup, a sufficiency to form the mass; divide this into thirty pills, and let one be taken night and morning. 188 PYREXIAE, OR FEBRILE DISEASES. [ClttSS 1, When assistance has not been procured in due time, or the means which have been employed to carry off the inflammation in the liver have not been attended with the desired effect, and sup- puration has ensued, we must endeavour to promote the formation of proper pus, and the discharge of the abscess externally. To effect the first of these intentions, the patient should be directed to take a drachm of the powdered bark of cinchona every two or three hours, using at the same time a generous nutritive diet, with a moderate quantity of wine, which course ought to be continued until the suppuration is completed; and to promote the second intention, a large emollient poultice should be kept con- stantly over the part, well fomenting it twice a day, previous to the application thereof. When the tumour points outwardly, and has become somewhat soft, with evident fluctuation, we should immediately open it in the most dependent part, taking care not to touch its adhesion with the corresponding portion of the peri- toneum. The opening may be made through the external integu- ments with a scalpel, and on reaching the abscess it may either be touched with a lancet, or be pierced with a trocar, which may be the preferable way, as we shall thereby have it in our power to evacuate the matter slowly and gradually, which in large collect tions is a point of importance, and therefore deserving of attention. The fluid discharge is most commonly of a grayish colour, but not invariably so. To facilitate the discharge of the matter, the patient ought to be placed in the most favourable position, and the belly be gradually compressed by means of a proper bandage. The dressings ought to be simple, and frequently renewed. Should the lips of the wound after some days seem disposed to close before the healing of the interior parts, a tent of soft lint, dipped in some digestive ointment, may be inserted into them. To the end of the cure, cinchona, with stomachic bitters, wine, and a generous diet, will be proper. Suppuration of the liver is a disease of such frequent occurrence in the East Indies and other warm climates, that the practitioners there are become very expert at this operation, and frequently perform it with safety when the tumour does not point at all, judging merely by the preceding progress of the case, and the degree of fulness in the hypo^ chondrium. Abscesses in the liver sooner heal when opened than similar affections in other parts of the body, and perhaps with less incon- venience ; and, therefore, whenever we have good grounds for suspecting that matter has formed in this viscus, we may advise an opening to be made into the abscess, whether situated on the convex part of it or not, in preference to suffering it to break internally, by which its contents must be evacuated into the ab- domen, to the almost certain destruction of the patient. Should the abscess discharge itself into the cavity of the chest, and so form purulent empyema, the proper operation ought to be performed without any loss of time.—See Empyema. Order II.J inflammation of the liver. 189 The common plan of cure in chronic hepatitis is by mercury, and it is certainly the most effectual practice. It should be given in small doses and slowly, so as to keep up a brassy taste in the mouth for a considerahle time, as it promotes the secretion of bile, and excites the extreme vessels on the surface. To increase the latter effect, it has, however, been found useful to combine it with a small proportion of antimonial powder, as likewise of opium, to protect the bowels from irritation. The next most salutary process is to keep up the regular peri- staltic motion of the intestines, and excite the mouths of the ex- cretory ducts of the liver. With this view one or two of the pills prescribed below* may be taken occasionally at bedtime, succeed- ed the ensuing morning by a draught composed of some neutral salt, as prescribed in the treatment of acute hepatitis. Our attention is at the same time to be directed to the cuticular discharge, which ought to be promoted by the most gentle means, such as moderate exercise and flannel next to the skin. When hepatic obstructions exist, with too great a determination to the bowels, keeping them in an irritable state, the utility of flannel is apparent. The assiduous and frequent application of the flesh brush, or friction with the hand over the hypochondriac region, will be found to excite the healthy action of the biliary organ in no slight degree. A tepid bath will be useful, but some caution will be requisite in avoiding subsequent chilliness. Warm mineral waters may also be taken internally. When there is much local uneasiness, repeated.blisters may be had recourse to with some advantage. General bleeding is never necessary in chronic hepatitis: in a few instances, topical may be serviceable. Among the local means, I beg leave to observe, that in those instances where the liver has been exceedingly enlarged, decided benefit has sometimes been derived from the application of a plaster of ammoniacum spread largely over the diseased surface, so as to act medically, as well as on the principle of a bandage in giving some support. In that species of diseased liver which arises from an immoderate use of vinous or spirituous liquors, a mercurial course has been ob- jected to by Dr. Trotter. In the tubercular or scirrhous liver, he tells us,t it had seldom appeared to him to be of any service, be- yond its action in keeping the bowels open, when costiveness was t See his Essay on Drunkenness, and its Effects on the Human Body. 5. & Extract Colocynth. C- gj. Hydrargyr. Submur. 3j. Antimon. Tartarizat. gr. iv. 01. Carui, m v. Syrup. Simpl. q. s. M. ft. Pilulse xxx. *5. Take Compound Extract of Colocynth, one drachm. Submuriate of Mercury, one scruple. Tartarized Antimony, four grains. Oil of Caraway, seven drops. Common Syrup, a sufficiency to form the mass, which is to be made into thirty pills. ^90 FYREXLSE, OR FEBRILE DISEASES. [Class I. to be guarded against. My own experience, however, does not lead me implicitly to adopt this conclusion; on the contrary, in more than one instance of incipient scirrhous liver, slightly com- plicated with dropsy, I have seen mercury employed with advan- tage. Mercury, however, will not fail to prove injurious in those eases where the structure of this viscus is considerably destroyed. We have been informed, that of late the nitric acid, largely diluted with water and mucilage of syrup,* has been used in the East Indies in chronical affections of the liver, and it is said with much benefit. As an auxiliary remedy, it certainly may be employed with safety and advantage. Where the disease arises in a person of a scorbutic habit, there is no doubt that the use of mercury would be highly improper, as it would infallibly increase the symptoms, and hasten the fatal termination thereof; and in such cases, the nitric acid may be given with much advantage, as it will not only relieve the hepatic affection, but may likewise, in some degree, amend the scorbutic tendency. In the treatment of chronic inflammation of the liver, great commendation has been bestowed upon the taraxacum (dandelion) by a modern writer,! who tells us that he has seen the most de- cided advantage, both in incipient scirrhus of the liver, and also in several chronic derangements of the stomach, in the dose of half a drachm of the extract twice a day. Either a strong decoc- tion, or the fresh expressed juice, in doses of from two ounces to four, two or three times within the twenty-four hours, will how- ever be found more active preparations. Enlargements of the liver and spleen are sometimes the conse- quence of long continued intermittents, and they not unfrequently resist the effects of mercury, although the salivary glands have been sufficiently excited. In cases of this nature we may make trial of the succus inspissatus conii, probably with better success. —See Intermittents. The diet best adapted for persons labouring under chronic hepatitis, is such as is attenuant, nutritive, and easy of digestion; avoiding salted meats and greasy substances. By degrees it may be improved by the addition of broths, light animal food, &c. until health is perfectly restored. He who labours under ob- structed liver, and hopes to prolong his existence, must abandon what are called the pleasures of the table, and observe a rigid temperance with respect to diet. If wine is drank, it ought to be diluted with water; but in most cases this last alone will be the i Dr. Robert Pemberton's Treatise on Diseases of the Abdominal Viscera, p. 42. "* 6. g. Acid. Nitric, m vi.—x. * 6. Take Nitric Acid, from nine to fifteen drops. Aq. Purae, f. ^xij. M. Pure Water, twelve drachms. Syrup Cort. Aurant. f. jij. M. Syrup of Orange Peel, two drachms, ft. Haustus ter quaterve die sumendus. Make them into a draught, which is to be; taken three or four times a day Order IL] inflammation of the spleen. 191 best beverage. Malt liquors will seldom agree, and spirituous ones ought to be shunned as poison. Late hours and night air ought to be cautiously avoided. Such as labour under chronic affections of the liver in India, or the West Indies, should never return to Europe in the winter. Those of the former who cannot undertake the long and expensive voyage to Europe, ought to change a continental for an insular situation. The most proper places will be Prince of Wales's Island, which enjoys a milder air and a lower range of tempera- ture than any of the Presidencies; or St. Helena, which approxi- mates more to the climate of Europe than that of any other inter- tropical situation. Those of the West Indies may go to America, and they will be likely to experience considerable benefit from the voyage and sea air. The complicated diseases which are often brought on by a long residence in warm climates, affecting the secretion of bile, the functions of the stomach and alimentary canal, and which ge- nerally produce organic derangement in some parts of the hepatic system, often receive much benefit from the Bath waters, if used at a time when suppurative inflammation is not actually present; and they will certainly prove a good auxiliary to other proper means. Cheltenham water may also be taken with singular advantage by those who labour under any chronic affection of the liver; and this spring is indeed the resort of most of those who have had their biliary organs injured by a long residence in a warm climate. This water, besides containing salts of a purgative nature, is like- wise a chalybeate, and the iron is suspended by carbonic acid, of which gas the water contains about an eighth. Its great efficacy, however, in chronic hepatitis, is owing to the gentle continued purging which it excites. Persons of a bilious habit, and who are at the same time cos- tive, will find much benefit by taking two or three of the aperient pills here* recommended, at night, or in the morning, as necessity may require. SPLENITIS, or INFLAMMATION of the SPLEEN. This disease comes on with rigours succeeded by heat, thirst, and other febrile symptoms; there is an anxiety and straitness in the prascordium, with difficult respiration, often conjoined with a cough without expectoration. The patient complains also of ex- ternal heat, tension, pains in the left side, which sometimes extend * 7. ft Extract. Colocynth. C. gi. Jalapae, 3ss. Antimon. Tartarizat. gr. iv. Sapon. Venet. £j. 01. Essent. Carui, TTj, viij. Syrup. Rhamni, q. s. M. Syrup of Buckthorn, a sufficfenc massa, in pilulas xl. distribuenda. 'to form the mass into forty pill?, 7. Take Compound Extract of Colycyntb, one drachm. Extract of Jalap, half a drachm. Tartarized Antimony, four grains. Soap, one drachm. Oil of Caraway, twelve drops. 192 PYREXLSE, OR FEBRILE DISEASES. [Class /. through the whole region of the abdomen, or shoot through the diaphragm, and into the left shoulder. The pains are increased on pressure, and are pulsatory, pungent, and burning in various de- grees. The pulse on the left side is sometimes partially suppress- ed, often intermittent, weak, and not quick. There is lassitude and loss of strength, watchfulness, and sometimes delirium. Dys- pepsia, anorexia, vomiting of green bilious matter, and sometimes difficulty of urine from an affection of the kidney or bladder. Swelling in the region affected, representing the form of the spleen, faintings, and bleeding from the nostrils at the height of the dis- ease ; but the most remarkable symptom which attends, is the bloody vomiting, which most authors have considered as peculiar, and have designated by various names. By the ancients it was termed atra bilii. At the commencement, the intestines are ra- ther confined, but they soon become relaxed, and emit substances somewhat coloured by black blood. Like the liver, the spleen is often attacked with chronic inflam- mation, and in time becomes enlarged and indurated. 'Sometimes suppuration ensues, and forms an abscess. The causes of the disease are most generally the same with those of other inflammatory diseases; but enlargements of the spleen are frequently the consequence of long-continued intermittents ; and these, as well as indurations of the liver, are called ague-cakes. They arise, no doubt, from too great a determination of blood to these viscera during the several attacks of the cold fits. With respect to the prognosis in splenitis, it need only be ob- served, that, like other inflammations, it may terminate either in resolution, suppuration, or scirrhus. Sometimes it is carried off by a vomiting of dark-coloured matter, resembling coffee-grounds; sometimes by a diarrhoea, and sometimes by a haemorrhage from the hemorrhoidal vessels. The vomiting of grumous matter is under common circumstances to be considered a favourable and critical evacuation, yet it sometimes proceeds to a fatal excess. Where splenitis terminates in suppuration, and the contents of the abscess are evacuated in the cavity of the abdomen, the event may prove fatal sooner or later; but a simple enlargement of the spleen is often supported for many years without any very great incon- venience or hazard to the patient. Dissections of dead bodies show that the spleen is inflamed and sometimes gangrenous, and that the surrounding viscera partake of the inflammation : occasionally an abscess is formed. The conclusions which have been drawn from a multitude of pathological as well as anatomical facts are, that the spleen is an organ peculiar to red-blooded animals ; that it is of great importance in preparing and mixing the blood ; and that its action is of great consequence to the liver. During the acute stage of splenitis we must adopt the antiphlo- gistic plan, by general and topical bleedings, by purging frequently with the submuriate of mercury combined with jalap, and by the OrderII.J inflammation of thk kioneys. 193 repeated application of a blister over or near the part affected* If the inflammation should terminate in suppuration, the abscess is to be encouraged to discharge its contents externally, by fomentations and poultices. Where its termination is in enlargement and in- duration, or scirrhus, we must employ mercury at an early period, both as a purgative and deobstruent, in the manner advised for the removal of inflammation of the liver. The nitric acid may also be tried. If these remedies are not attended with success in removing the enlargements, although the salivary glands have been sufficiently excited, we may make trial of the succus inspissatus conii, which has been found to answer when mercury has failed.*— See Intermittents. NEPHRITIS, or INFLAMMATION of the KIDNEYS. Nephritis, properly considered, appears to be of two kinds ; the one arising from the general causes of inflammation, and being seated principally in the external membrane of the kidney ; the other occasioned by the stimulus of gravel or a stone in the pelvis of it, and the inflammation occupying the interior parts. It is, however, only the first of these that I mean here to investigate ; fhe other will be noticed under the head of Calculus. This species of inflammation may be distinguished frOm the colic, by the pain being seated very far back, and by the urine being of a deep red colour, voided frequently, and in small quantity at a time ; and it may be known from rheumatism, as in nephritis the pain is not much increased by motion Of the body. It is to be distinguished from a calculus in the kidney or ureter, by the symptoms of fever accompanying of immediately following the attack of pain, and these continuing without any remarkable intermission; whereas in a calculus of the kidney or ureter, they do not occur until a considerable time after a violent pain has been felt. In the latter case, too, a numbness of the thigh, and a re- traction of the testicle, on the affected side, Usually take place, together with a constant nausea and vomiting. Nephritis is to be distinguished from lumbago by the seat of the complaint, discovered upon pressure, by the dysuria and'mic- turition, and it being frequently attended with vomiting, and by the pain extending along the course of the ureter, and not being much increased on motion, or by an erect posture. The causes which give rise to this species of nephritis are, ex- ternal contusions, strains of the back, acrids conveyed to the kid- neys in the course of the circulation, violent and severe exercise either in riding or walking, exposure to cold, and sand or stone in the kidney. In some habits there is an evident predisposition to this complaint, particularly the gouty; and in these there are often translations of the disease to the kidneys, which very much " See Essay on Hepatitis and other Bilious Complaints in India, as well as Eu- rope, by Charley Griffith. M. D, , Q6 1(J4 pyrexiae, or febrile diseases. [Class J. imitate nephritis. In plethoric and inflammatory habits, an im- moderate use of spirituous liquors may give rise to nephritis. An inflammation of the kidney is attended with a sharp pain on the affected side, extending along the course of the ureter; and there is a frequent desire to make urine, with much difficulty in passing it; the body is costive, the skin is dry and hot, the patient feels great uneasiness when he endeavours to walk or sit upright, he lies with most ease on the affected side, and is incommoded with nausea and vomiting, and there are often costiveness and colic pains. In forming an opinion as to the event, we are to draw our con- clusion from the severity of the symptoms, and from the quantity and appearance of the urine which is voided. When the disease is protracted beyond the seventh or eighth day, and the patient feels an obtuse pain in the part, has frequent returns of chilliness and shiverings, there is reason to apprehend that matter is forming in the kidney, and that suppuration will ensue. Remission of pain, fever, and tension, followed by a copious secretion of high-coloured mucous urine, universal diaphoresis, or a flow of blood from the hemorrhoidal veins, are favourable symptoms. The terminations of nephritis are of the same nature as other inflammations. In slight and favourable cases, resolution may be obtained; but where the disease has continued with considerable violence for upwards of a week, suppuration may be apprehended. It may happen, however, that when the disease has been kept down by proper remedies, resolution may take place as late as the four- teenth day. It is marked by the disappearance of the fever and all the symptoms. Suppuration is marked by a remission of the pain, with rigours, throbbings, and hectic fever: in some cases, pus is discharged with the urine. Nephritis has been known to terminate in gangrene; but this is very rare. The occurrence is characterized by a sudden cessation of the pain after it had long resisted every remedy; with sinking of the pulse, cold sweats, &c. as in other cases of gangrene. Another termination of the disease is scirrhus, or enlargement and hardening of the kidney. Sometimes nephritis gives rise to gravellish complaints, probably from extravasated blood, or lumps forming a nucleus. Dissections of nephritis show the usual effects of inflammation on the kidney, and they likewise often discover the formation of abscesses which have destroyed, its whole substance. In a few- instances the kidney has been found in a scirrhous state, and pro- digiously enlarged; in others nearly wasted away. In the cure of nephritis our chief reliance is to be placed on blood-letting, both general and local, assisted by fomentations, the use of a warm bath, and emollient clysters, &c. On the first coming on of this complaint, a quantity of blood pro- portionable to the severity of the pain, and the age and habit of the patient, ought immediately to be taken away; and if the first bleed- Order H.J inflammation of the kioney.s. 19o ing does not afford considerable relief, the operation should be re- peated on the same day, or on the next at farthest. Topical bleeding, with several leeches over the kidney affected, may after- wards be necessary. After bleeding, we may advise flannel cloths wrung out of a warm decoction of emollient herbs, or a bladder filled with warm water, to be kept constantly applied over the part which is painful; and by way of internal fomentation, an emollient clyster may fre- quently be injected. The patient is at the same time to be directed to drink plentifully of mild diluents, such as barley-water, thin gruel, whey, linseed or marshmallow tea, &c. The nitrate of potass is a good antiphlogistic medicine in most internal inflammations : but in nephritis, its use has been supposed to be very doubtful, on account of its passing quickly by the kid- neys, and irritating them. The intestines arc to be emptied by gentle aperients,* employ- ed as frequently as the occasion may require, in addition to emol- lient clysters, as constipation ought carefully to be guarded against. Should these means have been adopted without affording relief to the patient, he ought then to be put frequently into a warm bath, continuing him in it for about ten minutes each time. The remedy will produce a powerful determination to the surface of the body, and greatly increase the action of the cutaneous exhalants. Mild diaphoretics, such as the saline medicine combined with nauseating doses of tartarized antimony, will at the same time be proper. When the febrile symptoms do not run high, and the inflamma- tion has been subdued by a vigorous adoption of antiphlogistic re- medies, opiates may be used occasionally to sooth pain, and may be added to the clysters. In nephralgia they are very important remedies, but not in pure nephritis. In nephritis the application of blisters would be improper. They are apt to affect the urinary organs and vessels, and to occasion much irritation, and would consequently increase the inflammation. Sprinkling the surface of blisters with camphor is said to prevent any irritation of the kidneys ; but never having observed such an effect, I will not pretend to attest its efficacy. Rubefacient lini- * 1. R Mannae Oplim. ^ss. Potassae Tartrat.'giij. Aq. Fervent, f. giss. Tinct. Sennae, f. sjj. M. ft. Haustus. Vel, 2. R 01. Ricini, f. |j. Mucil. Gum. Acacia?, Aquae Fcenicul. aa f. ^ss. Tinct. Jalap. TT1 kxxv, M. ft. Hau«tu = . * 1. Take Manna, half an ounce. Tartrate of Potass, three drachms. Warm Water, one ounce and a half. Tincture of Senna, one drachm. Mix them for a draught. Or, 2. Take Castor Oil, one ounce. Mucilage of Gum Acacia, Fennel Water, of each half an ounce. Tincture of Jalap, fifty drops. Mix them as a draught. lyti PYREXIjE, or febkile diseases. [Class 1. ments over the region of the kidney may perhaps be of some service. It has been mentioned that a difficulty of making water is one of the symptoms attendant on this disease: to obViate it, some prac- titioners give heating diuretics, such as turpentine, balsams, &c. The practice seems very improper, and ought not to be followed, as it will be more advisable to apply warm fomentations over the region of the bladder and kidney, to inject emollient clysters with an addition of opium, and to make the patient drink frequently of warm diluents. A decoction of the dried leaves of the peach-tree (Amygdala Persica Linn.,) prepared as mentioned under the head of Haema- turia, and drank in the quantity of a pint a day, has been found a very useful remedy in many cases of nephritis. When the urine deposits a quantity of muco-purulent matter, showing that the inflammation has terminated in a suppuration, or that an ulcer has already formed in the kidney, balsamics and de- tergent medicines, with a long-continued course of chalybeate wa- ters, but more particularly those of the Bristol Wells, will be very proper. The cinchona bark may also prove serviceable. One of the best medicines, however, with which I am acquaint- ed in such cases, is the uva ursi, which may be given in doses of half a drachm, or a drachm, three times a day. I have tried it in several instances, and in general with a happy effect. Where an inflammation of the kidney has arisen from the stimu- lus of a stone or large piece of gravel lodged there, we should have recourse to the exhibition of anodynes and opiates in considerable doses, both by the mouth and by clyster, together with the other means advised under these particular heads. In renal haemorrhage, as well as in most other internal haemor- rhages, alum as an astringent, and the superacetate of lead and digitalis as sedatives, are the remedies chiefly to be depended upon. In nephritis every kind of food which is of a stimulating nature ought carefully to be avoided, and such only as is lenient and nu- tritive should be used, as every thing which is heating or acrid proves a stimulus to the kidneys. Emollient and thin liquors should be drank plentifully, and the patient should take frequent small draughts of them notwithstanding the vomiting, as nothings© safely abates the inflammation, after proper evacuation by bleed- ing, as copious dilution. Those who are liable to frequent returns of the disease, or to obstructions in the kidneys, ought carefully to avoid getting wet in the feet, as likewise all exposures to cold : they ought to lie on a mattress in preference to a feather-bed ; their exercise should be moderate, and they should use no kind of wine which abounds with tartar. Order II.\ inflammation of the bladder. 107 CYSTITIS, or INFLAMMATION of the BLADDER. Tension and pain over the pubes, with a frequent desire of making water, difficulty in voiding it, or a total suppression, to- gether with tenesmus and pyrexia, mark this disease. It is seldom a primary affection, but arises in consequence of in- flammation in the neighbouring parts. It is sometimes, however, occasioned by a suppression of urine and consequent over-disten- tion of the bladder, or by a stone of considerable size lodged in it. The treatment advised in nephritis, or in ischuria and dysuria, to which I beg leave to refer the reader, will be proper here, ex- cept that we should not give liquids in great quantities, lest we distend the bladder beyond what it is capable of bearing. In consequence of previous inflammation from some exciting cause, the mucous membrane of the bladder now and then becomes thickened, indurated, or ulcerated ; and a considerable quantity of mucus mixed with pus passes off with the urine, giving to it the appearance of whey, and now and then blood is discharged. In the treatment of such cases, we are to prevent any collection of faeces in the rectum by means of some cooling laxative taken from time to time ; to abate pain by small doses of opium, and to inject the bladder two or three times a day with warm water, or some emollient decoction, by means of an elastic gum catheter with a bottle of the same material fitted to it, or that modern apparatus termed the vesicae lotura, from which mode of treat- ment very great relief and benefit* have been obtained in cases of ulcerated bladder, or where there has been a purulent sediment in the urine with a frequent desire to void it. Some of the detergent balsams, such as the copaiba, terebinthina Canadensis, &c. may be advisable. Where we have reason to suspect scirrhosity, the ex- tractum conii, or hyoscyami, will be more proper medicines in addition to the former. PERITONITIS and HYSTERITIS. Inflammation of the peritoneum, and also that of the uterus, as belonging to the class of pyrexiae, ought properly to have succeed- ed cystitis; but as they occur most frequently to women after deli- very, they have been placed among the diseases of the puerperal state. Peritonitis is, however, by no means an uncommon disease, inde- pendent of parturition, and of course is not unfrequently met with in males as well as females. In these instances the disease is pro- duced by an exposure to cold when the body has been heated by severe exercise, and the inflammation now and then seizes the sto- mach, intestines, or liver, and then is translated to, and principally occupies the peritoneum, as happened in a case which lately came * See Account of the Vesicae Lotura, by Mr. Jesse Foot ^oo Tn«e« of Dkwed Bladder, by Mr. Wadd. p. 16 198 pyrexijE, or febrile disease*. [Class I. under my observation, and which proved fatal by a high degree of effusion taking place in the cavity of the abdomen, notwithstanding that active depletory means, both by general and topical bleedings, were early resorted to. PODAGRA, or GOUT. Hereditary, arising without an apparent external cause, but preceded generally by an unusual affection of the stomach, pyrexia, pain at a joint, particularly of the great toe, infesting the articula- tions of the feet and hands, returning at intervals, and often alter- nating with affections of the stomach, or other internal parts, are assigned by Dr. Cullen as the characteristics of gout. A morbid action of a peculiar or specific nature seems to take place in the disease. Of the gout there are four species or varieties : the regular, ato- nic, misplaced, and retrocedent. The only disorder for which gout can possibly be mistaken is the rheumdtism; and cases may occur wherein there may be some difficulty in making a just discrimination; but the most certain way of distinguishing them will be to give due consideration to the predisposition in the habit, the symptoms which have preceded, the parts affected, the recurrences of the disease, and its connexion with the other parts of the system; which circumstances are usually different in the two diseases. In the gout the pains generally attack the small joints, and are at the same time less inclined to shift; but when they do, they usually seize the corresponding limb, or some of the viscera; the parts are more red and swollen than in rheumatism, and the dyspep- tic symptoms, which rarely precede rheumatism, are present in a considerable degree for some days preceding the taking place of a fit of the gout. Rheumatism and gout are, however, sometimes combined; in which cases, a diagnosis is neither necessary nor possible. The attacks of gout are chiefly in the spring of the year, and the beginning of winter, and the disease seldom appears at an earlier period of life than from five-and-thirty to forty. When it does, it may be presumed to arise in general from an hereditary predispo- sition, susceptibility, or constitutional bias. Gout chiefly attacks men, and particularly those who live well and lead a sedentary life ; those who are addicted to literary pur- suits ; those who keep late hours, or who are in the decline of life : but we meet with it now and then in females of a full and robust habit of body. Men who are employed in constant bodily labour, or who live much upon vegetable food, as well as those who make use of wine and other fermented liquors very sparingly, are not often afflicted with the gout. Eunuchs are seldom attacked by it. The exciting causes of the gout may be divided into those which induce a plethoric state, of the body, and, those which occasion Order U.J gout. 199 weakness of the body in general, or of the stomach in particular. Among the latter may be enumerated intemperance of every kind, late hours, intense application to study, long want of rest, much grief or anxiety of mind, great sensuality, long continued fatigue, exposure to cold, particularly by getting wet in the feet, too free a use of acidulated liquors, a sudden change from a full to a spare diet, excessive evacuations, accumulated acidity in the primae viae, violent passions of the mind, &c. A full diet of animal food, ragouts, and rich sauces, with a free use of spirituous and fermented liquors, particularly of wines abounding with tartar, together with indo- lence and inactivity, are the causes which give rise to corpulency and a full habit of body; hence the frequency of gout among the rich. Dr. Darwin mentions, it is a common opinion that this disease is as frequently owing to gluttony in eating, as to intemperance in drinking fermented or spirituous liquors ; but that he has never seen any person afflicted with the gout who has not drank freely of fermented liquors, as beer or wine ; though as the disposition to all the diseases which have originated from intoxication is in some degree hereditary, a less quantity of spirituous potation will induce the gout in those who inherit the disposition or constitutional bias from their parents. A fit of the gout is sometimes brought on by severe exercise or walking far, and sometimes by a sprain ; and that the disease occa- sionally takes place from an hereditary predisposition or suscepti- bility is beyond doubt, as youths of a tender age, and females who have been remarked for their abstemiousness, have been attacked with it. A predisposition to become affected with this and some other diseases, particularly scrofula and mania, on the application of ex- citing causes, does certainly exist in the human race. In some in- stances it is more strongly marked than in others, but predisposi- tion of itself may be inert and insufficient to produce disease : it re- quires for this purpose the application of an exciting cause. Such is the light in which we should view what are termed hereditary predisposition and hereditary disease. A peculiar saline acrimony existing in the blood, in such a pro- portion as to irritate and excite to morbid action the minute termina- tions of the arteries in certain parts of the body, has been assigned by some physicians as the proximate cause of gout. Dr. Cullen supposed it to be a loss of tone in the extremities of the system, while it is in a vigorous and plethoric state, and the energy of the brain still retains its vigour. Dr. Darw.in thought that it arises from the inirritability or defective irritation of some part of the sys- tem, the consequence of which is torpor and inflammation. The opinion most generally entertained by modern physicians is, that the gout proceeds from an accumulation of humours in the relaxed vessels of the ligaments and tendons of the joints; but concerning the nature of those humours, different opinions are 20V PYREXIA, OR FEBRILE DlbEASES. [ClttSS 1. entertained, one looking on them as a morbid secretion, and others considering them to be mere blood. The gout has appeared in some instances to be under the influ- ence of the imagination; for terror suddenly excited, such as by the house of the patient taking fire, has been known in a few minutes to restore the use of his limbs, and admit of his escape with great ease. A paroxysm of regular gout sometimes comes on suddenly, with- out any warning; at other times it is preceded by an unusual cold- ness of the feet and legs, a suppression of perspiration in them, and numbness; or by a sense of pricking along the whole of the lower extremities; and with these symptoms the appetite is diminished, the stomach is troubled with flatulency and indigestion, a degree of torpor or languor is felt over the whole body, great lassitude and fatigue are experienced after the least exercise, the body is costive, and the urine pallid. Some previous affection of the stomach or dyspepsia is almost constantly met with. On the night of the attack the patient perhaps goes to bed in tolerable health, and after a few hours is awakened by the severity of the pain, which has affected either the joint of the great toe, the heel, calf of the leg, or perhaps the whole of the foot; and this becoming at length still more violent, is succeeded by rigours, and other febrile symptoms, together with a severe throbbing and in- flammation in the part. Sometimes both feet become swelled and inflamed, so that neither of them can be put to the ground, nor can the patient endure the least motion without suffering excruciating pain. Towards morning he falls asleep, and a gentle sweat breaks out, and terminates the paroxysm, a number of which constitutes what is called a fit of the gout, the duration of which will be longer or shorter, according to the disposition of the body to the disease, the season of the year, and the age and strength of the patient. When the paroxysm has thus taken place, although there is an alleviation of pain at the expiration of some hours, still the patient is not entirely relieved from it, and for some evenings successively he has a return both of pain and fever, which continue with more or less violence until morning. In time the paroxysms however prove more mild every day, till at length the disease goes off either by perspiration, increased flow of urine, or some other evacuation; the parts which have been af- fected becoming itchy, the cuticle falling off in scales from them, and some slight degree of lameness remaining. At first an attack of gout occurs perhaps only once in two or three years ; it then probably comes on every year, and at length it becomes more frequent, and is more severe and of longer dura- tion each succeeding fit. It may be stated that gout, with little'exception, requires strength with each returning fit, both as to the number of parts which it attacks, and as to the duration and degree of suffering; and it does not. like some chronic diseases, wear itself out by repetition, and Order IL] GOLT. 201 yield to the power of time. A premature old age comes on, and together with painful and crippled limbs, the nervous system is so enfeebled, that both mind and body become less equal to sustain the conflict. In the progress of the disease various parts of the body are affected, and translations take place from one joint or limb to another; and after frequent attacks, the joints lose their strength and flexibility, and become so stiff as to be deprived of all motion. In some instances little swellings, of a very hard nature, arise in the joints of the fingers, to which a late writer* has applied the title of nodosities. Nephritic affections of the kidneys arise also, calculi are produced, and concretions, of a chalky nature, are formed upon some of the joints, particularly on those of the fingers, owing to a deposit of the same kind of matter in them. The fluid which is so effused, is at first white ; by degrees the watery and serous parti- cles are absorbed, leaving a substance which is soft and clayey, and that afterwards becomes hard and friable, and when put into acids is perfectly soluble. This effusion occurs not only during fits of gout, but likewise in the intervals; and as the extremities, particularly the hands and feet, are the principal seat of gout, it is there that the greatest accumulations of chalk take place. Though this process is usually preceded by, and accompanied with inflammation, the chalk is never enclosed in a cyst like pus in an abscess. It lies usually in the cellular membrane, in the bursae mucosae, or in the cavities of the joints. The chalky liquid, when first secreted, gives to the finger, upon pressure with it, the feeling of a fluctuation, and cannot be distin- guished from the ordinary serous effusion of gout; but unfortunately the absorbents do not take up the chalky particles. The consist- ence of the liquid therefore becomes thicker and thicker, till at last nothing remains but a hard mass. It requires, however, repeated effusions to form any gouty mass of chalk, and the consistence will depend upon its age and the activity of the absorbents. By re- peated paroxysms, the quantity at last accumulated becomes con- siderable, and seriously augments the sufferings of the patient; by its bulk, greatly distends the surrounding parts, and obstructs the motion of the tendons and joints, often occasioning a complete anchylosis. The cutis, when distended to the utmost by frequent deposits of chalk, sometimes gives way, and an opening is formed, through which a quantity of it is evacuated. It sometimes happens, that although a gouty diathesis prevails in the system, yet from certain causes no inflammatory affection on the joints is produced; in which case the stomach becomes parti- cularly affected, and the patient is troubled with flatulency, indiges- tion, violent pain, loss of appetite, eructations, nausea, vomiting, and a peculiar sense of cold in the epigastric region; and these af- ^ee Dr. Haygarth's Clinical History of Diseases 27 202 PYREXIA, OR FEBRILE DISEASES. [Class L fections are often accompanied with much dejection of spirits, and other hypochondriacal symptoms. In some cases the head is affected with pains and giddiness, and now and then with a tendency to apoplexy; and in other cases the viscera of the thorax suffer from the disease, and palpitations, faintings, cramps, and asthma, arise. This is what is called atonic gout. It likewise happens sometimes, that after the inflammation has occupied a joint, instead of its continuing the usual time, and so going off gradually, it ceases suddenly, and is translated to some internal part. The term of retrocedent gout is applied to occur- rences of this nature. When it falls on the stomach it occasions nausea, vomiting, anxiety, or great pain, with a sensation of cold- ness in the epigastric region; when on the heart, it brings on syncope ; when on the lungs, it produces an affection resembling asthma ; and when it occupies the head, it is apt to give rise to apoplexy or palsy. In retrocedent or repelled gout, we generally find the disease on the stomach producing violent pain, sickness, vomiting, &c. and patients have died in a few minutes after such an attack; indeed the symptoms are so violent, that they generally think themselves dying. It seems closely connected with a spasmodic affection of the stomach. A third species of irregular gout is the misplaced, which implies where the gouty diathesis, instead of producing the inflammatory affections of the joints, occasions an inflammatory affection of some internal part, and which appears with the same symptoms that attend inflammations of those parts from other causes. All occurrences of this nature, as well as of the two former, are to be regarded as attacks of irregular gout, and are to be guarded against as much as possible. Cases of misplaced gout are not verv frequent. The prognosis in gout may be considered as favourable when the visceral organs are sound in structure, and not materially disturbed in their functions ; when the tongue becomes moist and clean ; where there is a return of the natural appetite; the faeces recovering a healthy appearance, the urine ceasing to deposit sediment, and at the same time losing its high specific gravity; when the nervous system becomes tranquil, and when the local sensations readily yeild in their severity to remedies, the local inflammation soon abating, and not showing a disposition to quick transference from one part to another, or if it be fugitive, not fixing severely on new parts. In a regular fit of the gout there is seldom any great danger; it is only where the disease appears under an irregular or repelled form that danger arises, and in which either the stomach, heart, lungs, or head become affected. A quick transference of severe inflamma- tion from one part to another, joined with painful sympathy of the stomach, or the head, or with exquisite sensibility of the whole nervous system, are to be considered among the unfavourable signs in gout. In some cases the whole system becomes weak and Order II.J goux. 203 languid, dyspepsia and syncope supervene, and the disease at last terminates in palsy, asthma, or dropsy, appearing most commonly in the form of hydrothorax. In youth the disease admits more readily of alleviation than in an advanced period of life ; and its attacks may be rendered milder when acquired, than when it proceeds from an hereditary disposi- tion : moreover, the fit is generally shorter in proportion to the violence of the febrile symptoms and the length of intermission. When the constitution has suffered great ravages from frequent . and severe attacks of the gout, various morbid affections of the viscera are to be observed on dissection; calculi of different sizes and colour are to be found in the kidneys ; and on examining the joints which have been rendered stiff and immoveable, it appears as if their motion had been destroyed by the formation of chalky concretions of a similar nature with those lodged in the kidneys. These calculous concretions, or chalk-stones, as they are called, are supposed to be the consequence of local diseased action, and not of systematic origin; or, in other words, that they are only the effects and not causes of gouty action. In a paper read before the Royal Society, June 22d, 1797, Dr. Wollaston demonstrated, that the concretions which form on the joints of gouty persons are composed of the lithic acid and soda, forming a compound salt, the lithiate or urate of soda. Dr. G. Pearson likewise, in a paper read before the same society in December, 1797, in which he relates the results of the analysis of upwards of three hundred urinary calculi, particularly mentions the existence of this acid in arthritic concretions. The word lithic, borrowed from the term lithiasis, he reccommends to be changed to that of uric. Fourcroy also about the same time discovered the uric acid in these concretions. Notwithstanding the many remedies which have been highly extolled at different times for the cure of gout, it is a fact well established, that not one which has yet been offered possesses any- such power; and all that can be done with safety to the patient is to conduct him through the paroxysm when it has once commenced. afterwards by abstaining from the remote causes, such as full living, acescent food, strong liquors, &c, and making use of gentle daily exercise, to render recurrences of the disease less frequent and more mild than they otherwise might be. In short, tempe- rance and regular moderate exercise are the most likely means to prevent severe and frequent attacks. During a paroxysm of the gout, if the attack is severe, it may be necessary to confine the patient in bed, keeping the inflamed parts of a moderate temperature. The confinement of morbid heat by covering of a very warm nature might only serve to increase pain and prolong the disease. He is at the same time to be kept as quiet and free from all irritation as possible ; and as gouty people are generally captious from the severity of the pain which they suffer, they should be solaced, and not be thwarted. If the patient is young --04 PYREXIA, OR FEBRILE DISEASES. [Class J. and plethoric, he should abstain from all sorts of animal food, aromatics, and fermented liquors, living on water-gruel, panado, sago, arrow-root, and other farinaceous substances. His drink- should be some mild diluting beverage, such as barley-water, toast and water, or tea. In elderly people, where the tone of the stomach is weak, or where the patient has been in the constant habit of using strong liquors, and of living principally on animal food, a more generous diet, with a moderate use of wine, may be allowed : and as Madeira and Sherry wines are the least apt to become acid on the stomach, they ought therefore to be used in preference to any other kind. The fostering of athritic inflammation by the topical use of increased temperature, or covering the parts with flannel, &c, together with the internal employment of stimulant medicines, with a view to obviate its retrocession, and ensure its final extinction on the part affected, is supposed, by Dr. Kinglake,* to be a very erroneous practice, and as repugnant to the in- dication of relief furnished by every constitutional feature of the disease. He tells us, that observation and reflection have forced on his conviction the fact, that however loose the analogy may be between the respective proximate causes of ordinary phlegmonous and arthritic inflammations, the resemblance is sufficiently close in the degree of concomitant temperature. In both, the vascular actions of the system, and of the part affected, generate a morbid excess of heat, alike referrible to distempered conditions of motive- power. Impressed with the persuasion, that with regard both to inordinate temperature, and to its general as well as topical mani- festations, a radical similitude subsists between these nominally different inflammations, it has appeared to him strictly warrantable to institute a perfectly similar plan of cure, viz. that of reducing heat by keeping cloths wetted with cold water constantly to the parts affected. In support of the efficacy of this plan, he recites several cases which were successfully treated by topically abstract- ing the stimulus of heat from the parts by water, and such other cold media. We are further told by him, that he thinks himself justifiable in drawing the following inferences: viz. that a high temperature, whether the cause or effect of the morbid conditions of vital power, which proximately constitute gout, is safely and speedily control- lable by the simple application of cold water ; that the prevailing opinion relative to the critical nature of that disease on the extre- mities is liable to much distrust; that the local deposit is not, as commonly supposed, a particular preponderance and detention of the constitutional disorder, but that it originates in the parts them- selves, and is thence distributed by associated influence over the system ; and lastly, that the longer the local affection endures, the See his Treatise on the Gout Order 1I.J gout. oq;, greater probability there will be of morbid sympathies being gene- rated and established on the vital organs, which may terminate in rapid and painful death. Such is Dr. Kinglake's theory; and being somewhat vague, is not, I think, likely to make many proselytes. Popular prejudice is, moreover, very strong against the remedy recommended by him ; and therefore the young practitioner in particular should be cautious in advising it. It is indeed well known that various diseases of the head such as headach, vertigo, mania, epilepsy, apoplexy, and great depression of spirits, in many instances, immediately, or soon succeed the recession of inflammatory gout from the extremities ; and a late writer of eminence has recorded* two cases where immersion of a gouty foot in water produced instant relief from the pain, and a proportionate abatement of the inflammation, but which was followed in a few hours by hemiplegia, showing clearly the danger of adopting Dr. Kinglake's plan. The application of cold water in gouty paroxysms has not however originated with Dr. Kinglake, for it is a mode of treatment noticed hy Hippocrates and Celsus, and even by some modern writers.! It is therefore only the revival of a practice which has frequently been brought forward, and again abandoned, from its being somewhat hazardous. If the cooling, or refrigerant treatment is ever adopted, I think it should not be ventured upon until the stomach and other viscera have shown indubitable si. + See his Tract on Gout. Order II.] GOUT. 209- during the intervals ; by avoiding the exciting causes of the disease ; by moderate regular exercise every day; by avoiding cold ; and by strengthening the body. In young persons, a cold bath, with moderate exercise afterwards, might probably be used with ad- vantage during the intervals ; but in elderly people, or where there is any inflammation of the joints, this remedy should never be recommended. Drinking half a pint daily of the double acidulated soda water possibly may have a good effect during the intervals of the paroxysms. When any swelling and stiffness remain in the joints after the paroxysms have ceased, the stimulus of galvanism, or electricity, conjointly with the frequent use of the flesh-brush, may be attended with some benefit. Jn consequence of frequent attacks of the gout, assisted^ pro- bably, by some peculiarity of the patient's constitution or habit of body, little swellings or nodosities arise on or near the joints of the fingers; for the removal of which we are told by a late writer* that the following indications should be observed: viz. first, to diminish the increased action of the vessels in the part by which the secre- tion of the morbid matter is performed ; secondly, to promote a free perspiration of the part affected; and, thirdly, to correct the pre- vailing disposition to acidity in the primae viae, and in the system in general. To accomplish the first of these indications, leeches are to be applied to the tumefied part, their number being deter- mined by the extent of the tumour and degree of the disease. To obtain the object of the second indication, the part is to be sur- rounded by a plaster of equal parts of simple diachylon and white soap, the adhesion of which to the skin becomes in a few days so slight as to admit the free exit of the perspirable matter through the skin, and which being hindered from escaping farther, con- denses on the surface of the plaster. To fulfil the third indication, a due attention is to be paid to the mode of living, by avoiding acid and acescent matters, and particularly such fermented liquors as have begun to manifest marks of acescency. To neutralize that acidity which being present in the stomach would secure its increase by acting as a ferment, it may be advisable to give the carbonate of soda in doses from five grains to ten or fifteen in the day. From the combined influence of these measures it appears, by Mr. Parkinson's account, that the utmost success that hope could look for has been obtained. The gradual diminution, and finally, the complete removal of nodosities which had existed for several months, have been thus procured; while those which had existed for some years have been so much reduced as to allow of consider- able motion in joints which had become nearly immoveable. Dr. Bardsley, physician to the Manchester Infirmary, mentions, in his Medical Reports, that he looks on nodosities, of the joints to be more nearly allied to chronic rheumatism than to gout. He has v See Observations on the Nature and Cure of Gout, &c. by Mr. James Parkinson, 2B 210 PYREXIJE, OR FEBRIBE DISEASES. [Class I. therein given the history of three cases of this nature, in the last of which, after a fair but unsuccessful trial of arsenic, cod-liver oil (a remedy much used in Lancashire,) cinchona, guaiacum, and warm bathing, he had recourse to mercurial frictions, and by establishing and keeping up for some time a gentle salivation, with^the assistance of tepid bathing, and topical bleedings by leeches, he effected a cure. From this instance he appears to think that mercury is capable of destroying the disease when in its incipient state. When gout attacks a part in which there is an accumulation of chalk, and that is highly inflamed, the best application will be an emollient poultice, having previously well fomented with flan- nels wrung out in the decoctum papaveris made warm. If the cutis opens, yet leaves the chalky effusion confined by the cuticle only, a small puncture may be made. This will permit some por- tion of the fluid to escape, and more will run out into the poultice, by which means the tension will be removed. When the inflam- mation has subsided, greater freedom may be used. Some portion of the cuticle may then be removed to facilitate the discharge, and gentle pressure be employed. During violent paroxysms, if the inflamed partis threatened with gangrene, the cataplasma effervescens (see Gangrene) may be sub- stituted instead of the common emollient poultice, after well fomenting with a decoction of cinchona bark and bruised poppy- heads. The cinchona with aromatics, ammonia, wine, and opium, must be exhibited at the same time in doses proportioned to the danger and the powers of the stomach. Where ulceration remains behind with chalk at the bottom, after the violence of the fit has subsided in severe attacks, mild dress- ings only ought to be used; for as gouty habits are always irritable, stimulants, such as the hydrargyri nitrico oxydum, or any caustic application, might do mischief. Masses of chalk are sometimes formed, however, on parts so inconvenient, or occasioning such deformity, that the patient is anxious to get rid of them even at some risk. On favourable occasions of this nature, where the constitution is sound, and the means recommended by Dr. Bardsley and Mr. Parkinson have failed to produce the intended effect, this may be obtained by destroying the skin with the potassa fusa. After the opening is formed, the sore is to be treated in the common manner. In irregular, or atonic gout, where no inflammation of the joints is produced, although the gouty diathesis prevails in the system, but the stomach is affected with indigestion, flatulency, acid eruc- tations, and pain, the patient ought not only to avoid all debi- litating causes, but should employ proper means for strengthening the system in general, and the stomach in particular. To support the tone of the system, a proper quantity of animal food ought to be taken, and that which is most nutritive and plain should be preferred. Gout, when in the system, and not regularly Order II.J gout. 211 formed, requires an excess of animal food to drive it to the ex- tremities, though in some measure it may aggravate the disease should a paroxysm ensue. With the same view a moderate allowance of wine will be proper ; but all kinds of acescent wines, such as hock, claret, &c. ought to be avoided. Madeira and Sherry are those which will be most suitable. If the acidity in the stomach is perceived to be increased by a use even of these wines, weak brandy and water, without any addition of either sugar or lemon, may then be substituted. To strengthen the stomach, aromatics, the cinchona bark,* and chalybeates, such as the ferri subcarbonas, ferri sulphas, &c. may be given.—(See Dyspepsia.) Cinchona is not apt, when long con- tinued, to produce atony in the stomach like bitters, and therefore a preference should be given to it over all others by persons of a gouty habit. Bitters and aromatics certainly give a transient relief; but if long persisted in, they usually produce a bad effect. Some years ago the Portland powder, (a compound of bitter ingredients, viz. equal parts of the roots of round birthwort and gentian, of the leaves of germander and ground pine, and of the tops of the lesser centaury, all dried,) was much used by gouty people, but from having proved pernicious in many instances is now laid aside. Dr. Cullen mentions, in his Practice of Physic, that in every instance which he knew of the exhibition of the Portland powder being persevered in for any length of time, the persons who had taken it were indeed afterwards free from any inflammation of the joints, but they were soon affected with many symptoms of atonic gout, and all quickly after finishing their course of the medicine were attacked by apoplexy, asthma, or dropsy, which proved fatal. Dr. Murray, professor at Gottingen,, reports in his Apparatus Medicaminum, that he found the Portland powder produce in many instances apoplexy, palsy, and acute disorders, together with difficulty of breathing, a dry cough, &c. which proved suddenly mortal. Dr. Darwin likewise tells us, in his Zoonomia, that two cases of a fatal termination, from a long- -■> 4. ft Infus. Rad. Calumb. f. giv. Tinct. Cort. Cinchonae C. -----Cardam. C. aa f. gss. M. ft. Mistura, cnjus sumat aeger cochl. ij. magna bis terve in die. Vel, 5. ]$ Subcarbonatis Ferri, 31J. Pulv. Cort. Cinchonae, |j. ----Cinnam. Compos, giss. Syrttp. Cort. Aurant. q. s. M. ft. Electuarium, de quo capiat quantita tfm juglandisbis in die. * 4. Take Infusion of Calumbo Root, four ounces. Compound Tincture of Peruvian Bark, -----------------Cardamoms, of each, half an ounce. Of this mixture let the patient take two large spoonsful twice or thrice a day. Or, 6.TakeSubcarbonate of Tron,two drachms. Powder of Peruvian Bark, one ounce. Compound Powder of Cinna- mon, one drachm and a half. Syrup of Orange Peel, a suffi- ciency to form these ingredients into an electuary, of which the bulk of a walnut i« to hft taken twice a day. ;»12 i-vrexijE, or elbrile diseases. [Class 1. continued use of bitter medicines, fell under his observation. The daily use of hop in our malt liquors must, he thinks, add to the noxious quality of the spirit in them, and contribute to the pro- duction of apoplexy, or inflammation of the liver. It has indeed been observed by many other physicians of eminence, that a long- continued and excessive use of bitter remedies seldom fails to weaken the digestive power of the stomach, so as to produce a loss of appetite and impaired digestion, which has accelerated the death of those who had used them. The Eau Me"decinale d'Husson is a remedy much in vogue at present in gouty attacks, and in some cases it appears to have considerably alleviated the paroxysm ; but in a few others it has produced alarming effects, such as syncope, cold sweats, extreme prostration of strength, excessive evacuations from the stomach and bowels, accompanied with a pulse scarcely perceptible, and a degree of insensibility that indicated approaching dissolution. Such consequences have, however, only ensued when an improper dose of the nostrum has been taken. Besides possessing the pro- perties of an emetic and a cathartic, it appears also to be endowed with the virtues of a narcotic, as in some instances it seems to act as an anodyne previous to any sensible evacuation taking place. The remedy consists of some vegetable of a bitter nauseous taste (supposed by some to be white hellebore, by others gratiola, or hedge-hyssop, and again by others to be colchicum,* or the common meadow saffron) infused in Spanish white wine, with an addition of tinctura opii. The vinum colchici prepared from the roots of the meadow saffron, and given in the quantity of a fluid drachm twice "a day, in any vehicle, has certainly been found a valuable remedy in both gout and rheumatism ; but to render the success of the medicine more certain, the state of the bowels should be particularly attended to, the patient abstaining from all food likely to prove flatulent. The roots of the colchicum have been generally employed to make the vinum colchici, as in the Eau Medecinale, but it has sometimes appeared inert; at others, productive of sudden long- continued and excessive action of the stomach and bowels, and occasionally it has proved fatal. In a communication from Dr. Williams, through the medium of the London Medical Repo- sitory, (see No. 85,) we are informed that the seeds of the col- chicum, when employed instead of the root, seldom fail of the desired effect, and invariably operate without the occurrence of any of those distressing and alarming symptoms so prevalent from the exhibition of the root. It is also mentioned that the colchicum seeds, so far from being limited in their use to gout and rheu- matism, may be safely and beneficially extended nearly to the * Two ounces of the root of colchicum autumnale cut into slices, and macerated in four ounces of proof spirit, until the latter is fully imbued with the properties of the jfcrmer, is said, by Mr. Want, to be the exact composition of the Eau Medecinalev Order II.] gout. 213 whole range of painful diseases of the asthenic kind.—Where acidity or flatulency prevails, the spiritus seminum colchici ammo- niatus (prepared by macerating for ten days two ounces of the seeds in a fluid pint of the spiritus ammoniae aromaticus) will be found, by the report of Dr. Williams, a medicine of greater value than the vinum seminum colchici. In the stomachs of gouty people, a morbid acidity, accompanied by heartburn and flatulence, is usually to be met with, and even this has been thought to have the power of bringing on the disease. Antacids have therefore been found a useful and salutary class of medicines for gouty persons. Alkalies have been considered as of too acrid a nature, and therefore absorbents are preferred ; that most commonly used is magnesia, which proves both absorbent and laxative. To quicken its operation, if found necessary, we may combine* it with a small proportion of rhubarb. Alkalies in various forms, such as the fixed alkali both mild and caustic, lime water, and soap, have however been employed in gouty habits, and of late the alkaline aerated water has been much used. Since it became common to exhibit those medicines in nephritic calculous cases, it has often happened that they were given to those who were at the same time subject to the gout; and it has been observed, that under a use of these medicines, gouty persons have received relief, and been longer free from attacks of the disease than before. As a gentle aperient, rhubarb may be employed when costiveness is to be removed. If it disagrees, aloes may be given in the quan- tity of five or six grains combined with any aromatic,! the intent being not to purge, but to keep the bowels regular. In those cases were gout produces anomalous affections of the * 6. ft Magnesias, 3j. Pulv. Rhei, gr. viij. ----Cinnam. C. gr. v. M. ft. Pulvis, pro re nata sumendus. Vel, 1. ft Magnesiae, 3ss. Pulv. Rhei, gr. x. Aq. Menth. Pip. f. ^iss. M. ft. Haustus. Vel, 8. ft Aq. Menth. Pip. §vij. Tinct. Gentian, ^ss. Liquor. Potassae, ttl xx. M. Magnesiae, 3»- ft. Mistura. Sumantur cochlearia duo media bis terve in die. 19. ft Pulv. Aloes Spicat. gr. vi. ----Zingib. gr. iij. M. Syrtip. Rhamni, q. s. ft. Massa, in pilulas duas dividenda. * 6. Take Magnesia, one drachm. Powdered Rhubarb, eight grains* Compound Powder of Cinnamon, five grains Mix them. This powder is to be taken oc- casionally, as the case may require. Or, 7. Take Magnesia, half a drachm. Powdered Rhubarb, ten grains. Peppermint Water, one ounce and a half. This draught may be taken whenever there is occasion. Or, 8. Take Peppermint Water, seven ounces. Tincture of Gentian, half an ounce. Solution of Potass, thirty drops. Magnesia, one drachm. Of this mixture two dessert spoonsful may be taken twice or thrice a day. t 9. Take Powder of Socotrine Aloes, six grains. -----------Ginger, three grains. Syrup of Buckthorn, a sufficiency to form the mass, which divide into two pills. 214 PYREXLE, OR FEBRILE DISEASED. [GlttSS I. head, stomach, and bowels, the greatest benefit may be derived from the Bath water ; and it is here a principal advantage to be able to bring by warmth that active local inflammation in any limb which relieves all the other troublesome and dangerous symptoms. Hence it is, that this water is commonly said to produce the gout; by which is meant only, that where persons have a gouty affection, shifting from place to place, and thereby much disordering the system, the internal and external use of the Bath water will soon bring on a general increase of action, indicated by a flushing in the face, fulness in the circulating vessels, and relief of the dyspeptic symptoms ; and the disorder will at length terminate in a fit of the gout, which is the crisis to be wished for. In various cases of gout, especially where the high inflam- mation of particular limbs has gone off, and where it has left either a number of dyspeptic symptoms, or a rigidity or impaired action in the seat of the disease, an internal use of Buxton water has been recommended. As an external application in gout, it has also been found serviceable in restoring the functions to parts so diseased. In the sciatica or gout affecting the hip, we may recommend frequent blistering along the course of the sciatic nerve, together with electricity. In severe attacks of atonic gout, some practitioners have ad- vised the application of blisters to the lower extremities : but they ought to be avoided in those cases which are attended with much pain in the parts. Sinapisms, pediluvium, together with wine and other stimulants, have also been recommended in atonic gout for bringing the disease to the extremities. The greatest attention should be paid to promote perspiration and avoid cold; and this is most effectually done by warm clothing, joined to moderate exercise. A flannel shirt, with a pair of stout shoes, and thick woollen or fleecy hosiery stockings, will be neces- sary articles of attire for those who cannot remove in the winter to a warmer climate. When the stomach or intestines becomes affected in consequence of retrocedent gout, immediate relief ought to be attempted by making the patient drink freely of wine, or even brandy, joined with aromatics. In affections of this nature, strong spirits impreg- nated with assafcetida or garlic may also be given with much advantage. Opiates* joined with aromatics, or with camphor, musk, ' 10.R Opii, gr. j. Camphorae, gr. v. Ammoniae Subcarbon gr. vj. Confect. Aromat. gr. v. M. ft. Bolus, pro re nata adhibendus. Vel II. p.Mkmr:^ rraraphora?.f. 3js«. * 10. Take Opium, one grain. Camphor, five grains. Subcarbonate of Ammonia, six grains. Aromatic Confection, five grains. Make them into a bolus, to be taken when requisite. Or, 11. Take Camphor Mixture, one ounce and a half Order II.J Gout. 215 or ammonia, may be of service. From one to four teaspoonsful of equal parts of camphorated tincture of opium, and ammoniated tincture of guaiacum, in any suitable vehicle, will be a proper medicine. ./Ether will likewise be a useful remedy. At the same ' time that we administer these medicines internally, warmth should be applied externally to the region of the stomach by hot cloths, fomentations, or a bladder filled with warm water, and hot bricks wrapped in flannel must be put to the feet. Frictions with brandy, or the linimentum ammoniae fortius, over the stomach, will also be proper. If nausea and vomiting come on, the stomach is to be relieved by taking a few draughts of wine, somewhat diluted with warm water, having recourse afterwards to opiates combined with camphor. In retrocedent gout, where the heart becomes affected, the above means may be adopted. If there is a translation of the disease from the extremities to the head, so as to threaten apoplexy or palsy, a large blister ought to be applied to the back, as likewise small ones to the inside of the legs, with cataplasms to the soles of the feet; and the patient must take from twenty-five to forty drops of the spiritus ammonias aromaticus every three or four hours, or a combination of volatile alkali, aether, and aromatics, as specified in the formulae at the bottom of the preceding page, omitting the opium. About six drachms or an ounce of the tinctura aloes may also be taken as a gentle purgative. When the gout attacks the lungs, and produces asthma, blisters should be applied to the breast or back, and stimulating cataplasms to the soles of the feet, and opiates and antispasmodics should be administered internally. From twenty to fifty drops of aether may be taken every two or three hours in a glass of wine, and an opiate* may be repeated as the necessity of the occasion requires. In this particular retrocession of gout, where the attack is so Ammoniae Subcarbon. gr. x. Tinct. Opii, tH, viij. Spt. jEther. Sulph. fll xx. M. ft. Haustus, tertia quaque hora sumendus. Vel, 12. R Moschi, gr. v. solve in Misturae Camphor, gx. Dein adde Spirit. Ammon. Aromat. 3ss. Tinct. Opii, til viij. M ft. Haustus. * 13. R Confect. Aromat. gss. Subcarbonate of Ammonia, ten grains. Tincture of Opium,twelve drops Spirit of Sulphuric jEther, thir- ty drops. Mix them. Take this draught every three hours. Or, 12. Take Musk, five grains : dissolve it in Camphorated Mixture, ten drachms. Then add Aromatic Spirit of Ammonia, half a drachm. Tincture of Opium,twelve drops Mix them for a draught. * 13. Take Aromatic Confection, half a drachm. Aq. Cinnam. f. Jjsjs. j Cinnamon Water, one ounce I and a half. Tinct. Opii, 111 xx. M. | Tincture of Opium, thirty dropgs ft. Haustus | Mix them for a composing draught. 216 pyrexiae, or febrile diseases. [Class I. severe as to threaten suffocation, as well as where there is a translation to the head, venesection might be resorted to with ad- vantage. In severe cases of a sudden translation or metastasis of gout from the extremities to any vital part, such as the head, heart, lungs, or stomach, it may be justifiable to excite a counter-irritation by the external application of nitric acid, as has lately been prac- tised in the cholera morbus of Hindostan, (see Cholera,) in pre- ference to a blister of the lytta, which acts slowly, and requires a lapse of some hours to produce vesication. Where the disease attacks the kidneys, and imitates a fit of the gravel, the patient ought to keep warm fomentations, or bladders filled with warm water, constantly applied over the parts affected ; he should drink freely of tepid diluting liquors; and an emollient clyster, with an addition of a small quantity of tinctura opii, ought frequently to be injected. In order to alleviate the pain, thirty or forty drops of the same tincture may likewise be taken by the mouth in any kind of vehicle. During paroxysms of the gout, the treatment must be active and appropriate : after they have subsided, the remaining duty to be performed, is the restoration of the healthy state of the digestive functions, and of due strength in the weakened limbs. In such cases and circumstances as do not forbid the use of steel, from too much vascular fulness and action, the tincture of ammoniated iron may be taken advantageously in a little warm water, in doses of twenty drops, gradually increased to about sixty. The gout imitates many diseases, as has already been observed 5 and by being mistaken for them and treated improperly, is often diverted from its regular course, to the great danger of the per- son's life ; for which reason, those who have had the gout ought to pay particular attention to any complaint that may happen to take place about the time they may have reason to expect another attack of it. Those likewise who never had the gout, but who, from constitution or manner of living, have reason to expect it, ought also to be very circumspect with regard to its first approach, as by any wrong conduct, or improper treatment, it might be diverted from its right course, and be thrown upon some vital part. To render the recurrences of gouty paroxysms less frequent, and their attacks less severe, we may rest assured that more is to be done by temperance in diet, cheerfulness and serenity of mind, a moderate exertion only of the intellectual faculties, an early hour of retiring to rest, obviating costiveness as the occasion may require, and by regular moderate exercise, than by any other means whatever, being at the same time attended with greater safety. The exercise must be suited to the condition of the patient. Walking will certainly be the best; but if he be unable to use it, he must employ some other kind, as riding on horseback, or in a carriage. Although walking may probably be irksome at first, Order U.J coirl. ,217 and the feet feel tender, yet by perseverance it will become more agreeable, and great advantage will be derived. Where no exercise can be taken, some benefit may possibly arise from frictions. In those who have an hereditary disposition to gout, it is certain that it may often be prevented from taking place by paying an early and strict attention to regimen, temperance, and exercise ; and even after it has shown itself by a regular attack, its returns may possibly be prevented for the remainder of life : but it is only those who have sufficient resolution to observe a steady per- severance in such a course, that can have any reason to expect a cure. Exercise in persons disposed to the gout, not only strengthens the system, but tends likewise to prevent a plethora. To prove advantageous, it must, however, be constant, regular, and con- tinued through life, and should only be moderate. In the begin- ning of the disease, when the disposition or tendency to it is not strong, exercise will often prevent an attack which might otherwise have taken place, and in the intervals it will always be proper as long as the patient retains the use of his limbs. In a more advanced stage of the disease, where there is an evident disposition to a paroxysm, much walking ought to be avoided, as it might tend to hasten its approach, by increasing the inflam- matory disposition in the lower extremities. While the vigour of the system still remains unimpaired, either by intemperance or frequent attacks of the gout, an abstinence from animal food may be entered upon with safety, in order to prevent a recurrence of the disease ; but if this abstinence shall not have been adopted until the constitution has been hurt by intemperance, frequent fits, or the decline of life, it certainly will prove injurious, and might tend to bring on an irregular attack. A sudden change from a full to a spare and low diet, will in all cases whatever be highly improper; and whenever an alteration is made in the mode of living, it ought to be done in a gradual manner. Where an abstinence from animal food is to be observed, a diet consisting of milk and the farinaceous seeds will be the most proper, and all kind of spirituous and fermented liquors are to be avoided; but where custom or a declining state of the system has rendered them absolutely necessary along with a use of animal food, they are then to be used with moderation. Besides regimen and exercise, it will be necessary for the patient to observe universal temperance; he is to shun night studies, and any excess in sensual gratifications; he should go to bed betimes, and rise early; and he should avoid all exposure to cold, but more particularly getting wet in the feet. In the gout as well as in regard to all other diseases, the cardinal rules in preserving the health are founded on temperance and exercise, on the choice of all those means which are found by the individual to invigorate tin svstem, and the shunning whatever injures and enfeebles itf 29, 218 FKREX1.&, OR- FE-BRIBE DISEASES. [CIum 1. Some persons much disposed to gout, who have been reduced to poverty and obliged to work hard and use a low diet, have been cured by it, which clearly demonstrates the efficacy of exercise, temperance, and a spare regimen. RHEUMATISMUS, or RHEUMATISM. The characteristics of rheumatism, as assigned by Dr. Cullen, are pyrexia, pain about the parts following the tract of the muscles, attacking the knees and larger articulations, in preference to those of the feet or hands, increased by external heat. The disease is distinguished into the chronic and the acute; being known by the former appellation when there is no great degree either of inflammation or fever present, but merely pains ; and by the latter, when both fever and inflammation exist in a high degree. It may arise at all times of the year, when there are frequent vicissitudes of the weather from heat to cold; but the spring and autumn are the seasons in which it is most prevalent: and it attacks persons of all ages; but very young people are more exempt frOm it than adults. Those whose employments subject them to alternations of heat and cold, are particularly* liable to rheumatism. Although acute rheumatism somewhat resembles the gout, still in some respects it differs from it. It does not usually come on so suddenly as a fit of the gout, but for the most part gives the patient warning by a slow and gradual increase of pain. Neither is it fixed to one spot like the gout, but is distinguished by its frequent wanderings from place to place, accompanied by a sense of numbness. It seldom attacks the small joints, but is confined chiefly to the larger, as the hip, knee, and shoulders. Acute rheumatism is generally attended with a continued fever; whereas the gout has periodical remissions. Like most of the pyrexiae, it is preceded by rigours, and a sense of cold. A febrile, quick, and hard pulse supervenes ; the veins near the part affected swell; and a throbbing pain is felt in the arteries. By degrees the pain in- creases, and the patient suffers cruel torture, which is increased on the least motion. The sense of pain resembles that of a slow dilaceration of the parts, and commonly goes off by a swelling of the joint or joints. The rheumatism, moreover, is n6t preceded by dyspeptic symptoms, as is usually the case with the gout; neither do chalky concretions form about the small joints and fingers, as in the latter. Obstructed perspiration, occasioned either by wearing wet clothes, lying in damp linen, sleeping on the ground or in damp rooms, or by being exposed to cool air when the body has been much heated by exercise, or by coming from a crowded room or public place into the cool air, is the cause which usually produces rheumatism. Those who are much afflicted with thi« complain? Order U.J RHEUMATISM. 219 are very apt to be sensible of the approach of wet weather bv finding wandering pains about them at that period; in fact, some are living barometers. The proximate cause of the acute species of the disease at least is supposed to be an inflammation of the membranes and tendinous aponeuroses of the muscles. Acute rheumatism usually comes on with lassitude and rigours, succeeded by heat, thirst, anxiety, restlessness, and a hard, full and quick pulse ; the blood, when drawn from a vein, exhibits an inflammatory surface upon cooling, and the tongue preserves a steady whiteness; after a short time excruciating pains are felt in different parts of the body, but more particularly in the joints of the shoulders, wrists, knees, and ancles, or perhaps in the hip; and these keep shifting from one joint to another, leaving a redness and swelling in every part they have occupied, as likewise a great tenderness to the touch. Towards evening there is usually an exacerbation or increase of fever, and during the night the pains become more severe, and shift from one joint to another. Sometimes the pain is confined to a few joints ; in other cases it affects many at the same time. In no disease do we meet with such remarkable instances of metastasis, and no muscular part is exempted from the pain. The internal muscles, as the diaphragm and heart, have been said to be sometimes affected with metastasis. In these translations of rheumatic inflammation, the stomach is- also sometimes attacked. The pain is met with in every degree of violence, and is highly aggravated by pressure or motion. The face in general is not flushed, there is seldom much headach, and in most cases there seems to be little tendency to delirium. The stomach generally is not affected, but the bowels are usually costive. Early in the course of the disease some degree of sweating usually occurs; but it seldom removes the pains, or proves either salutary or critical; and it is somewhat singular that the pained limbs remain dry, when a sweat is on the rest of the body. In the beginning the urine is without any sediment; but as the disease advances in its progress, and the fever admits of considerable remissions, a lateritious sediment is deposited ; but neither does this prove critical. Chronic rheumatism is attended with pains in the head, shoul- ders, knees, and other large joints, which at times are confined to one particular part, and^ at others shift from one joint to another without occasioning any "inflammation or fever; and in this manner the^ complaint continues often for a considerable time, and at length goes off, leaving the parts which have been affected in a state of debility, and very liable to fresh impressions on the approach of moist damp weather. Little danger is attendant on chronic rheumatism: but a person having once been attacked with it, is ever afterwards more or less liable to returns of it, and an incurable anchylosis is sometimes formed in consequence of vei\v frequent relapse?. Neither i« the 220 P-YKEXIJE, OR- Ef.h.Kil.E DlSEASKfa. | ClaSS f. acute rheumatism often accompanied with much danger, as it usually goes off spontaneously, or is removed by the timely employ- ment of proper remedies ; but in some instances the patient has been destroyed by general inflammation, and now and then by a metastasis to some vital part, such as the head, lungs, heart, and stomach. Many cases of cardiac inflammation are indeed either combined or alternated with acute rheumatism. It has been observed, that persons subject to rheumatism are attacked more frequently than others with symptoms of an organic disease in the heart; and that in some instances the lungs have been much affected with severe dyspnoea, no doubt from the disease being translated to these parts, occasioning real inflammation of these organs.* When retrocession actually occurs, there is no safety until the disease is removed, and the prognosis ought therefore to be very guarded indeed. Acute rheumatism, although accom- panied with a considerable degree of inflammation in particular parts, has seldom been known to terminate in suppuration ; but a serous or gelatinous effusion sometimes takes place. A general, but not unnaturally profuse perspiration, the deposit of a lateritious or furfuraceous sediment in the urine, eruptions on the skin, or moderate haemorrhage of blood from the nose or other parts, may be regarded as favourable symptoms ; whereas the in- flammation becoming erysipelatous, and assuming a dark red or rose colour, and this followed by vesications, metastasis of the in- flammation to the head, chest, or abdominal viscera, producing the symptoms of the idiopathic diseases of these organs, are to be looked upon as unfavourable. Rheumatism seldom proving fatal, very few opportunities have offered for dissections of the disease. In the few which have oc- curred, the same appearances have been observed as those men- tioned under the head Inflammatory Fever. In the joints, thicken- ing of the membranes, adhesions, and gelatinous effusions, are the only phenomena to be met with. The principal thing to be attended to in the treatment of acute rheumatism, is to obviate the general inflammation which prevails, and this is to be effected by strictly pursuing an antiphlogistic regi- men, and by blood-letting in all cases where the vascular action is strong, the constitution robust, and the heat considerable, propor- tioning the quantity we take away to the*violence of the symptoms, and the age, strength, and habit of the patient. If the pains con- tinue very severe, and the pulse full, hard, and quick, after bleeding, and the blood appears very sizy on becoming cool, we may with great propriety repeat the operation either on the same day or the next; but this mode of proceeding should be adopted only at an early period of the disease. The reduction of vascular action is, however, more particularly to regulate the repetition, than the bufiy appearance of the blood, which in many cases continues to increase, ■: Sep MeHico-Chirurgical Tran«nrtions. vul. i Order II.J rheumatism. 221 notwithstanding the abstraction of blood, and is not diminished by bleeding. This circumstance should be attended to. To repeat bleeding until the pulse be reduced to 100 or a little below, maybe a good rule- In weak irritable habits, where no great degree of general inflam- mation prevails, and little or no fever attends, and where the in- flammation is chiefly local, or the pain not violent, topical bleeding, by means of several leeches applied to the part affected, may be substituted instead of using the lancet, and will often be found to afford essential relief. Moreover, they are not attended with the risk of causing translations of the disease. They may likewise be used with benefit where much inflammation prevails in the system, as well as in particular parts, provided that some general bleeding has been premised or adopted. When leeches cannot be procured, scarifying and cupping may be employed in their stead. It has been usual in acute rheumatism to rely principally on large and repeated bleedings at an early period, joined with an antiphlogistic regimen ; and no doubt this evacuant plan of treat- ment has in some cases been carried to excess, and produced an alarming degree of debility. Having reflected much on this cir- cumstance, and well considered the wonderful power which the digitalis possesses of diminishing the action of the heart and arte- ries, I have employed it in some severe cases of acute rheumatism after one or two bleedings from the system, and with much appa- rent advantage ; for I found that its use rendered any further re- petition of venesection unnecessary. In the instances to which I allude, from ten to twenty drops of its tincture were given every four or six hours. In cases of costiveness prevailing, one or two evacuations should be procured daily by making use of some gentle cooling purgative, such as the neutral salts, or by giving laxative clysters, which may be the preferable way when the disease is general and violent, as the motion occasioned by frequently getting up to stool would prove irksome and painful to the patient. Where the pain is chiefly confined to one part, and is unaccom- panied by much inflammation, the application of a blister will be likely to prove serviceable, or we may rub it with some kind of rubefacient liniment ;* but where the pains are wandering, and * 1. $; Spirit. Camphoraj, f. !§ij. Liquor. Ammon. f. ^ss. Essent. 01. Rosmarin. fU_ x. M. ft. Linimentum. Vel, 2. fl 01. Olivae f. 3iij. —Terebinth, f. %). Acid. Sulph. Ill x. M. Vel, 3. R 01. 01iva«, f. gij. Camphors. 3u- Sol v. et ailoV * 1. Take Camphorated Spirit, two ounces. Solution of Ammonia, half an ounce. Oil of Rosemary, fifteen drops. Mix them for a Liniment. Or, 2. Take Olive Oil, three ounces. Oil of Turpentine, one ounce. Sulphuric Acid, fifteen drops. Mix them. Or, 3. Dissolve. Camphor, two drachms, in Olive Oil.twoouncps: «ndsidd .222 PYREXIA, qr febrile diseases. [Class I. there are frequent translations from one joint to another, neither of these remedies will be of much use. In acute rheumatism, warm fomentations ought never to be employed, as they arc found to aggravate the pains instead of alleviating them. Where, on the sudden subsidence of the external pain and inflam- mation, the head, heart, lungs, or stomach are attacked, so as to endanger the life of the patient, blisters should always be applied near those parts where the disease had originally existed, their power of counter-irritation being useful on such an occasion. Their action being however very slow, it might be justifiable in such cases, as well as in gouty metastases, to substitute the external application of nitric acid, in the manner mentioned to have been practised of late in the cholera morbus, which prevailed in Hindostan.—See this disease. When any of the joints of the extremities swell very much, and are highly painful, we may, besides drawing blood from the part by means of leeches, make use of attenuating cataplasms, such as the cataplasma farinae compositum* of the Pharmacopoeia Chirur- gica, the ingredients of which, being wrought into a paste with hot water, are to be wrapped round the part affected, and to be renewed morning and evening. The reduction of heat by keeping linen cloths wetted in cold water, or in a solution of muriated ammonia, with the nitrate of potass, constantly to the inflamed parts, may, I think, be adopted with safety and much advantage in acute rheumatism, although in gout the remedy ought certainly to be looked on as hazardous. During the summer of 1807 I visited Russia for a few months, and understood that the physicians there are in the habit of recom- mending the application of snow or pounded ice in cases of this nature, and often with a very good effect. When rheumatic inflammation is local and stationary, the aid of cold applications, or of the evaporating treatment with camphor mixture, conjoined either with alcohol or aether, made tepid, as no- ticed under the head of Gout, will be likely to prove very benefi- cial ; but when the inflammation quickly wanders from one part to another, almost eluding our pursuit, we must rely more confidently on constitutional means, and make our local treatment accordingly both more subservient and considerate. After the necessary evacuations have been made, diaphoretics may then be used ; and either those of the antimonial kind, as ad- Tinct. Lyttae. f. 3j. Liquor. Ammon. f. §ss. M. 4. R Farina? Secalis, rbj- Fermenti Veteris Acris, f. §iv. Natri Muriati. %\). M ffc Cafaolac-m-£ Tincture of Spanish Fly, one drachm. Solution of Ammonia, half an ounce. Mix them for a Liniment. * 4. Take Rye Flour, one pound. Stale Vinegar or Beer, four ounces. Muriated Natron, two oimc" Mix fhem for a cataplw^m- Brder II.] RHEUMATISM. .22$ vised under the head of Simple Fever, may be prescribed in small and frequently-repeated doses, or from ten to fifteen grains of the pulvis ipecacuanhae compositus* may be given every three or four hours. This indeed appears to be the best sudorific we can exhibit in acute rheumatism. Volatiles are employed by some practitioners in the cure of rheumatism, for the purpose of exciting a diapho- resis. With the same view camphor has been likewise adminis- tered. They may be given separately, or be combined together, agreeable to the formulae advised below,t should the remedies before recommended not prove sufficiently powerful. To increase the effect of all these medicines, the patient should at the same time be enveloped in flannel, every article of linen being removed; and as soon as he begins to sweat, and not before, lest vomiting be induced, he ought to drink freely of diluents, such as herb tea, barley-water, and wine whey. As an auxiliary remedy, warmth applied to the extremities, espe- cially to the affected parts, is of some consequence. It may be employed either in the form of fomentations, or in a dry one, by warm bottles, or bricks wrapped in flannel. Sweating is an evacuation which is resorted to very generally both * 5. ft Pulv. Ipecac. C. gr. x. Confect. Rosae, gr. xij. Syrup, q. s. M. ft Bolus, 3tia vel 4tahora sumendus, su- perbib. cochl.iij. Misturae sequentis :— 6. g; Succ. Limon. f. §jss. Ammoniae Subcarbonat. gj. Aq. Fontan. f. ^ivss. Potassae Nitrat. 3ss. Syrup. Simpl. f. §ss. M. ft. Mistura. t 7. ft Ammoniae Subcarbon. gr. x. Pulv. Antimon, gr. ij. Confect. Rosae, q. s. M. ft Bolus, 4tis horis sumendus. Vel, 8. ft. Seri Lactis Vinos, f. §x- Liq. Vol.CornuCerv.1ll xx. M. Bibat aeger hora decubitus. Vel, 9. U Mistur. Camphorae, f. §j. Liquor. Ammon. Acetat. f. giij. Liquor. Antimon. Tart, m xv. M ft. Haustus, 4ta vel 6ta quaquehorarepe- rendu s * 5. Take Compound Powder of Ipecacu- anha, ten grains. Confection of Roses, twelve grains. Syrup,asufficiencytoformaBoIus, which may be taken every three or four hours, washing it down with three large spoonsful of the following Mixture :— 6. Take Lemon Juice, one ounce and a half. Subcarbonate of Ammonia, one drachm. Pure Water, four ounces and a half. Nitrate of Potass, half a drachm. Syrup, half an ounce. Mix them. t 7. Take Subcarbonate of Ammonia, ten grains. Antimonial Powder, two grains. Confection of Roses, a sufficiency to form a Bolus, which may betaken every four hours. Or, 8. Take Wine Whey, ten ounces. Volatile Liquor of Hartshorn, thirty drops. Mix them, and let the patient drink the whole on going to bed. Or, 9. Take Camphor Mixture, one ounce. Solution of the Acetate of Ammo- nia, three drachms. Solution of Tartarized Antimony, twenty-two drops. Mix them for a draught, to be repeated every four or six hours. --24 PYREXIA, OR FEBRILE DISEASE. [CiaSS 1. in the acute and chronic rheumatism, and in many instances with very essential benefit; but it has its inconveniences, for sometimes it comes out freely without producing any good effect, and when long continued it relaxes the skin, and makes the patient very sus- ceptible of cold afterwards : to guard against which, it will be ne- cessary for him to be confined to his chamber, and to wear a flannel shirt for some time. In the early stage of the disease it is desirable to procure per- spiration by diaphoretics of the antimonial kind, or the compound powder of ipecacuanha joined to saline medicines, and in some cases material relief has been obtained thereby. If, however, obvious benefit does hot ensue within forty-eight hours, we ought then to discontinue the use of diaphoretics, as being more likely to do injury than good. Every local means to increase perspiration ought also after this period to be avoided, whether by a use of flan- nels, hot applications to the painful parts, or the warm bath. In- stead of them, linen cloths dipped in camphor mixture and cold water may be applied. Opiates combined with camphor are given by many practitioners in acute rheumatism ; but such a compound is not likely to prove efficacious; and the best way of administering opium in this disease when the pain is considerable, is by using the pulvis ipecacuanhae compositus, as has just been mentioned, or by giving it combined with antimony.* Other narcotics, such as conium, hyoscyamus, acoriitum, and digitalis, are sometimes employed with seeming ad- vantage after the bowels have been freely evacuated. A new mode of treating every case of acute rheumatism by a liberal and early use of the bark of cinchona had been adopted, as well as recommended, by alate celebrated reader of Lectures on the Practice of Physic.t He informs us, in his Third Dissertation on Fever, that for the last fifteen years he had entirely left off bleeding in this disease, and that he had not lost above two or three patients although he treated several hundreds who laboured under it in this way; and he adds, that when he practised bleeding largely in acute t Dr. George Fordyce. * 10. ft Fulv. Antimonial. gr. ij—iij. Opii, gr. ss. Confectionis Rosa?, q. s. M. ft. Pilula, 6ta quaq. hora sumenda cum haustu salino communi. Vel, 11. ft Liquor. Ammon. Acetat. f. 3nj- Aquae Menth. Virid. f. |y. Liquor. Antimon. Tart, fit xv. Tinct. Opii, rn. xx.—xxx. Syrup. Simpl. f. 3ij. M * 10. Take Antimonial Powder, from two to three grains. Opium, half a grain. Confection of Roses, a sufficiency to form these into a pill, which is to be ta- ken every six hours, washing it down with the common saline draught. Or, 11. Take Solution of the Acetate of Am- monia, three drachms. Mint Water, one ounce. Solution of Tartarized Antimony, twenty drops. Tincture of Opium, thirty to forty-five drops. Common Syrup, two drachms. it. Haustus, hora somui adhibendus. uMix tuem,and give the draught at bedtime Order U.J rheumatism. .225 rheumatism, metastases were very apt to take place, and to destroy the patient, which accident had rarely happened since he discon- tinued its use. With due deference to so high an opinion, I am however induced to think, that where the inflammation of the system is great, the pulse quick and full, and the person young and of a robust consti- tution, early venesection (the quantity of blood to be abstracted beingduly proportioned to the circumstances of the case) is not only necessary in attacks of acute rheumatism, but that those who fall victims to it die frequently from its not having been adopted. Another advocate for a very early use of the bark of cinchona in this disease is Dr. Haygarth, who tells us,* that for several years his usual method of treating acute rheumatism has been to give either the antimonial powder or tartarized antimony, generally the former, till the stomach and bowels are sufficiently cleansed: with- out waiting for any other evacuation, or abatement either of the inflammation or the fever ; he then orders the cinchona bark at first in small doses, and if they succeed, gradually in larger; but if it disagrees in any respect, or does not produce manifest relief of the symptoms, the bark is suspended, and the antimony again repeated till it shall have produced sufficient evacuations. After cleansing the stomach and bowels a second time, he administers the bark again, at first sparingly, and then more freely. He never continues it longer nor in larger quantity than what perfectly agrees with the stomach, the fever, and the rheumatic inflammation. Dr. Haygarth cautiously adds, however, that if doubts occur on any of these points, it will be advisable to have recourse to bleeding by the lancet or leeches, or both, and to more evacuations by antimony. In such cases the cinchona is not to be again employed till the inflammatory symptoms are abated. Our author assures us, that with the exception of a very few cases, this bark has uniformly produced the most salutary effects. The pains, swellings, sweats, and other symptoms of inflammatory fever, manifestly and speedily abated, and gradually ceased, till health was perfectly restored. The evidence adduced by him is much in favour of the cinchona, as a remedy in acute rheumatism. It appears that Dr. Haygarth began to administer cinchona in the acute rheumatism in 1772, at first cautiously, and, as it mani- festly produced salutary effects, more freely, upon the recommenda- tion and high authority of that very eminent physician Dr. John Fothergill.t In the last edition of his Clinical History of Acute Rheumatism, Dr. Haygarth has adduced the most respectable testi- mony:): in favour of this practice. The late Sir George Baker (who learned this method of treating the disease from Sir Edward Wilmot,) Dr. Heberden (who quotes the recommendation of his * See Dr. Haygarth's Clinical History of Acute Rheumatism. t Ibid. pp. 59—72. : Ibid. pn. 141—155. 30 226 pyrexia, or febrile diseases. [Class 1. father,) Dr. Saunders, Dr. Willan, Sir Lucas Pepys, Dr. Lettsom, Sir Walter Farquhar, and Dr. Aikin, have all of them administered cinchona at an early period of acute rheumatism with very salutary effects. A late author* also confirms the utility of this practice from his own observations. But this mode of treatment, Dr. Hay- garth observes, being directly contrary to medical theories, even successful experience by the most learned and sagacious physicians has not yet prevailed against established doctrines, and the practice is but partially adopted. By most physicians the use of cinchona bark, during the inflam- matory state of acute rheumatism, has been disapproved of; and it is only after the inflammatory diathesis has been subdued by anti- phlogistic remedies, and where at the same time the exacerbations of the disease are periodical, with considerable remissions inter- posed, that its use has been thought proper. Since the first edition of this work appeared before the public, I have been much in the habit of administering the cinchona, joined with nitre,! in acute rheumatism, and generally with a very happy effect. I would therefore recommend this combination of medicine at an early stage of the disease, in preference to giving the bark separately ; but I do not advise the use of it even in this way until the inflammatory symptoms have been somewhat counteracted by the antiphlogistic remedies which have been pointed out. Where there are intermissions of pain, a clean and moist tongue, a per- spiring skin, and a lateritious sediment in the urine, the use of this remedy is clearly indicated, and should no longer be delayed. In some cases I have of late employed it with much^benefit, combined with the oleum terebinthinae.j Dr. Hamilton, of Lynn Regis, informs us,|| that in those cases of acute rheumatism where blood-letting and sudorifics have been pushed as far as may be thought prudent, without being productive * See Granger's Medical and Surgical Remarks, pp. 240- || See vol. ix. of the Edinburgh Medical Commentaries. -267. t 12. ft Pulv. Cinchonae, 3ss.—gj. Potassae Nitratis, gr. x. M. ft. Pulvis, 4tis horis repetendus. Vel, 13. ft Decoct. Cinchon. f. ^iss. Potassae Nitratis, gr. xij. M. ft. Haustus. i 14. ft Decoct. Cinchona?, f. ^iss. Tulv. ejusdem, 9j. 01. Terebinth m, xv.—xxv. M. ft. Haustus. sextis horis adhibendus. 112. Take Powder of Peruvian Bark, half a drachm to one drachm. Nitrate of Potass, ten grains. Mix them, and repeat this powder every four hours. Or, 13. Take Decoction of Peruvian Bark, one ounce and a half. Nitrate of Potass, twelve grains. Mix them for a draught, to be taken as the former. $ 14. Take Decoction of Peruvian Bark, one ounce and a half. Powder of the same, one scru- ple. Oil of Turpentine, twenty-two to eight and thirty drops. Mix them, and give the draught every six hour? Order II.] rheumatism. 007 of the desired effect, and where a sufficient remission cannot be obtained so as to give the cinchona bark, very great benefit is often to be derived from the use of the submuriate of mercury, combined with opium, which combination he has frequently employed in the proportion of from five grains to one of the former, and from one to one-fourth of the latter, according to the age and strength of the patient, and administered every six, eight, or twelve hours, as the degree of inflammation, or the threatening aspect of the disorder, seemed to require. Along with this remedy he enjoins a plentiful dilution with barley-water, or any other weak tepid beverage. Early and moderate venesection, succeeded by gentle purgatives, calomel, opium, and antimony, is perhaps the best plan that can be pursued in acute rheumatism. In acute rheumatism the patient must be kept on a cool spare diet, as milk, whey, buttermilk, light vegetable matters, panado, ripe fruits, &c.: animal food and fermented liquors should be avoided. A different mode of treatment from what has been advised in acute rheumatism must be adopted in the chronic species. Here bleeding from the system will neither be necessary nor proper. Where the ligaments and membranes of the joints are the peculiar seat of the disease, or an enlargement of the extremities of the bones has taken place, the first attempt at relief, especially in young and vigorous subjects, should be directed to local bleeding, either by leeches, or what is to be preferred, the operation of scarifying and cupping. When the pain and irritation are abated by repeated bleeding, no time should be lost in securing a drain from the part by the aid of issues, making them with caustic in preference to the knife. In hip cases of long standing, as well as in obstinate ones of sciatica, the same practice will be found highly beneficial. In most cases it will be advisable to rub the parts which are the seat of the disease several times a day with some rubefacient lini- ment, as prescribed in acute rheumatism, after which they are to be enveloped in flannel. The regular use of a flesh-brush, with electri- city or galvanism, may be requisite in cases of long standing, and where there is any rigidity in the parts. Exercise either of the whole body or of particular limbs will be highly important. As an exercise for the arm, the dumb-bells answer very well. For the lower extremities none will answer better than walking; and although it may prove a little irksome at first in some cases, still by perseverance much benefit will soon be experienced. The want of exercise is apt to induce stiffness in the limb. Frictions with acetic aether on the painful parts have been employed in France with much benefit, particularly in cases of sciatica and lumbago. The remedy is reported* to possess the ''■ See Reciieil Peiiodique de la Societe de Medecine de Paris, No. xlviii. 228 i'yrexia;, or febrile disease*. [Class 1. advantage of producing an agreeable heat on the skin, and a very useful perspiration, without augmenting the irritation or erethism in the parts. Camphor dissolved in aether, and applied externally in painful affection of the joints, has likewise afforded singular relief in a great variety of instances. The ointment and embrocation of tartarized antimony have the property of producing a crop of pustules wherever they are rubbed, and when this effect is procured, they ought of course to be dis- continued. Immersing the whole body in a warm bath, or applying it topi- cally, by pouring warm water upon the limb from a kettle several times a day, has, in many instances, proved very useful, together with proper exercise, either of the part itself, or of the whole body, if the patient is capable of taking it. A quarter of an hour, or twenty minutes, will be sufficient time to remain in the bath, the temperature of which may at pleasure be varied from 90 degrees to 114. This scale appears sufficiently extensive in all cases to ensure the beneficial effects to be expected from the use of a tepid or hot bath. If the pains are of a recent date, and chiefly attack the muscles and thin membranous coverings, occasionally shifting from one part to another, and the strength is at the same time but little reduced, there can be no doubt that a moderate use of the warm bath may be serviceable ; but where it proves unsuccessful after two or three trials, it ought to be discontinued. In soothing pain, relaxing the stiffened joints and rigid fibres, particularly in elderly patients whose strength has been much reduced by the length and violence of the disorder, a tepid bath of from 84 to 90 will often prove a useful auxiliary to the other means we employ. Both remedies however may, I think, be considered of inferior value in the cure of rheumatism, when compared with the topical, and sometimes general use of hot water in the form of vapour. Whenever the joints are very rigid, and the pain upon motion ex- quisitely severe, or where the muscles have become contracted and almost paralytic; and indeed in all protracted cases of the disease of the hip joint, lumbago, or sciatica, the vapour of hot water, locally and properly applied, will seldom fail, in conjunction with other proper topical applications, to prove a safe and successful remedy. The mode of applying it must be regulated according to circumstances. A large boiler with a pipe affixed to it forms a simple apparatus. With this the parts affected may be steamed for about half an hour at a time, repeating the process two or three times a day. A vapour bath, constructed agreeably to the plan advised by the Honourable Basil Cochrane,* or in the Russian manner, would be a great acquisition in all infirmaries and hospitals. The latter is very See his pamphlet on Vapour Baths. Order II.] rheumatism. 229 simple. The building usually consists of a wooden house, situated, whenever it is possible, by the side of a running stream. In the bath-room is a large vaulted oven, which, when heated, makes the paving stones lying upon the top of it red hot; and adjoining to the room is a kettle fixed in masonry for the purpose of holding boiling water. Round about the sides of the room are a few rows of benches one above the other, like the seats of an amphitheatre. Little light is admitted, but here and there are apertures for permit- ting the vapour to escape, the cold water which is wanted being let in by small channels. The heat of the bath-room is usually from 32 to 40 degrees of Reaumur's thermometer, that is, from about 114 to 132 of Fahren- heit's. Warm water is thrown every five minutes or so upon the hot stones, by which means the heat is somewhat increased, espe- cially in the upper parts of the building. The bathers recline on the benches in a state of nature, and they perspire more or less in proportion to the heat of the humid atmosphere in which they are enveloped. To promote perspiration the better, and completely to open the pores, they are at first well rubbed with the hands, and then gently flagellated with leafy bunches of birch. After remain- ing awhile, they quit the sweating bench, and wash the body with warm or cold water. During my stay at Petersburgh, I observed that many of the Russians threw themselves immediately from the bath-room into the adjoining river. In the winter they roll them- selves in snow, in a frost often or more degrees of Reaumur's ther- mometer, nor is sudden change succeeded by illness, or pro- ductive of the least inconvenience. In cases of chronic rheumatism, were great debility prevails, with deep-seated pain, the warm bath frequently renders the patient hot and restless, and seldom or never relieves, unless it induces sweat. Now the advantage of the vapour bath is, that perspiration takes place at a much lower temperature in it than the other: the vapour bath need not to be heated above 96 degrees to produce a salutary perspiration, whereas a warm bath seldom produces this discharge at a lower temperature than 100 degrees, and from that it is used up to 112 in some of the hot springs at Bath. Besides this increased heat applied to the skin when the exhalants are ready to yield their contents, the surrounding medium presses upon the cuticle, and in some measure prevents the flow of perspiration which it had brought on the surface : on the contrary, in the vapour bath the heat being applied to the body in an aeriform state, unites with the insensible perspiration as it arises by the exhalants, condenses upon the surface, and drops from the body by its own weight, meet- ing with no resistance from the elastic vapour.* After exposing the diseased parts for a due length of time to the action of vapour, and diligently rubbing in some rubefacient lini- ment during the operation, we may immediately after employ elec- See Treatise on Warm and Vapour Baths, by Dr. Kentish. 230 PYREXLE, OR FEBRILE DISEASES. [Class I. tricity, either in slight shocks, or by drawing sparks. Perhaps the latter may be the preferable way. The process being completed, parts are then to be enveloped in flannel. Dr. Bardsley, in his Medical Reports, mentions, that he has seen at the Manchester Infirmary several hip cases of long standing yield to the persevering use of topical bleeding by means of cupping and scarifying, with the aid of issues; but in order to re- move the rigidity and want of tone which remained in the parts after the subsidence of the more violent symptoms, he was obliged to have recourse to the aid of vapour and electricity. In some very obstinate cases of sciatica, which resisted all other means of relief, he has also witnessed the happiest effects from issues ; but, he ob- serves, that he often found it necessary to surround the joints with several of these drains, moderating the degree of irritation and dis- charge according to the obstinacy of the disease and the strength of the patient. The chronic rheumatism in all its forms succeeding to the acute, and where the inflammation has been chiefly seated in moving parts, is often wonderfully relieved by bathing in the Buxton waters, and the healthy action is soon so far restored as to enable the patient to use the more powerful remedy of sea-bathing, or the common cold bath. On account of the slightness of the shock of immersion, very delicate and irritable habits, and especially parts weakened by dis- ease, can generally bear this degree of cold, and overcome it by a very small reaction; to produce which appears to be often a most salutary effort of the constitution. Hence the Buxton bath is be- come almost a technical term for any bath heated to the highest degree that is compatible with giving some sensation of cold when the body is first plunged into it. The power of the Bath water is chiefly confined to that species of rheumatism which is unattended by inflammation, or in which the patient's pains are not increased by the warmth of his bed. Cold bathing has been advised by some physicians, while others again have disapproved of it. In some instances it has certainly proved very beneficial. The cold bath is a stimulant, and pro- motes perspiration, and by strengthening the body, prevents a relapse. While there are any febrile symptoms it should not be used. The shower bath, with subsequent frictions and warm clothing, will be found not only a successful mean of cure in many cases of chronic rheumatism, but also a very effectual preventive. Blisters are sometimes employed in this complaint; but they seem to be most serviceable in those cases where the disease par- takes of the nature of acute rheumatism, or where the pain is fixed in any particular joint. With respect to the mode of their applica- tion, it seems proper to observe, that a repetition of fresh blisters will be far preferable to keeping up a constant sore by stimulating the vesiraied parts with the unguentum lyttae : and in the former Order 1I.J rheumatism. 231 way we shall likewise produce greater effect upon the disease. In some instances it will be found more beneficial to app.y ;hc .<. ,nedy at a little distance from the seat of the disease, than to jay h im- mediately on the affected part. Indeed, whenever the complaint seizes upon any of the larger an^ de-1 o-seated nuaues at their origin near the joints, applying outers to the inferior extremities of such muscles, and near to the points of their insertion, will be found highly beneficial. Thus in recent and slight cases of scia- tica, the application of a blister to the inferior extremity of the thigh-bone often proves speedily useful. Compressing the large arteries by means of a tourniquet, as men- tioned under the head of Intermittents, is another remedy which has been employed with advantage* in some instances of severe rheumatic pains. Several cases of chronic rheumatism of great severity and long standing, and which had resisted all previous means, but which were promptly and effectually removed by bandages of flannel round the diseased limb, carried from below upwards, are recorded by Dr. Balfour in the Edinburgh Medical and Surgical Journal,! as well as in a work published by him.J In applying them, he found it necessary in some instances, especially at the beginning, to roll them tighter than they could well be borne for any length of time, and in such cases the frequent removal of the bandages, with the aid of manual application of friction, and more especially of percussion in the intervals, he says, are indispensable. The practice of applying pressure by bandages, in his opinion, may prove an useful adjuvant or auxiliary to the other means, particu- larly warm bathing, for the removal of this painful disease. Where the knee or any other joint becomes enlarged from effusion, it ought to be diligently rubbed twice or thrice a day with about an ounce of the muriate of ammonia dissolved in twelve ounces of common vinegar. The internal remedies which have been most generally recom- mended in chronic rheumatism are sudorifics and medicines of a stimulating nature, which abound in essential oils and resins ; and therefore volatile alkaline salts, guaiacum, turpentineCombinedwith cinchona and the like, may be administered as in the undermen- tioned formulae.|| In the most aggravated instances of this species * See Dr. Duncan's Annals of Medicine for 1801. t See No. xlii. i See New Method of Treating Rheumatism, by Wm. Balfour, M. D. || 15. ft 01. Terebinth, f. 3Jss. Vitell. Ovi, q. s. Dein adde . Spirit. Junip. Comp. f. 5J. Decoct. Cinchon. f. 5V. M. ft. Mistura, cujus sumat. cochl. larg. ij. quarta quaq. hora. || 15. Take Oil of Turpentine, one drachm and a half. Yolk of Egg, a sufficiency to mix them. Then add Compound Juniper Spirit, one ounce. Decoction of Bark, five ounces. Of this mixture, two table spoonsful may be taken every fourth hour. 232 pyrexia, or febrile diseases. [Class I* of rheumatism, where great torpor and debility prevail, guaiacum, in as large doses as the stomach will bear, often proves a powerful remedy, when aided by topical applications. The ammoniated tincture of this medicine, joined to a strong decoction of cinchona, often proves serviceable in very obstinate cases. Internal medi- cines, however, without the aid of the external means before noticed, will seldom or never effect a cure in severe and obstinate cases. Hydrargyri submurias and other preparations of mercury have been given in this disease along with the decoctum sarsaparilla* compositum ; but they seem best adapted for those cases where we suspect it to be connected with a syphilitic taint. In palliating symptoms, and allaying pain and irritation, small doses of the antimonial powder and opium combined with the submuriate of mercury, sometimes prove useful. Some medicines of the narcotic class, as conium and aconitum, have also been administered in chronic rheumatism. In chronic rheumatism it will be absolutely necessary to per- severe for a considerable length of time in the use of whatever medicines we employ, otherwise but very little benefit can be de- rived from them. If in the course of the disease the patient's rest should be Vel, 16. ft Tinct. Guaiac. Ammoniat. f. 3ij- Spirit. Cinnam. f. ^ss. Decoct. Cinchon. f. 2;j. Liquor. Antimon. Tart. IU xvj. M. ft. Haustus, bis terve die sumendus. Vel, 17. ri Tinct. Guaiac. Ammoniat. f. 3'j pro dos. in quovisvehiculo. Vel, 18. & Gum. Guaiac. 3j. Ammoniae Subcarbonat. gr. x. Confect. Rosae, q. s. M. ft. Bolus, mane et vespere adhibendus. Vel, 19. R Gum. Guaiac. gr. xv. Pulv. Antimonial. gr. ij. Confect. Opii, gr. x. Syrup, q. s. M. ft. Bolus. Vel, 20. R Gum. Guaiac. Pulv. 3j. Pulv. Ipecac. Comp. 3ss. t'i. Pulvis. nmii'f nocte capiendus. Or, 16. Take Ammoniated Tincture of Guaiac, two drachms. Spirit of Cinnamon, half an ounce. Decoction of Bark, one ounce. Solution of Tartarized Antimony, twenty-four drops. Mix them for a draught, to be taken twice or thrice a day. Or, 17. Take Ammoniated Tincture of Guaiac, two drachms for a dose. In any vehicle. Or, 18. Take Gum Guaiac, one scruple. Subcarbonate of Ammonia, ten grains. Confection of Roses, a sufficiency to form a bolus, which may be given morning and evening. Or, 19. Take Gum Guaiac, fifteen grains. Antimonial Powder, two grains. Opiate Confection, ten grains. Syrup, a sufficiency to make them into a bolus. Or, 20. Take Powdered Gum Guaiac, one scruple. Compound Powder of Ipeca- cuanha, half a scruple. Mix them for a dose, to'be taken ever> night, at. bed-time. Order II.J RHEUMATISM. ■233 much disturbed throughout the night by the severity of the pains, an anodyne draught may be ordered for him, to be taken at bedtime.* Colchicum combined with opium is a good combination of medicine, and well calculated to afford relief, particularly in the chronic form of the disease.—See Gout, p. 212. Where the different combinations of guaiacum, opium, antimony, and mercury, have proved ineffectual, very speedy and good effects have been derived from a cautious exhibition of the arsenical solu- tion, as noticed under the head of Intermittents. It may be given with an equal proportion of tinctura opii in doses of ten drops, repeated twice or thrice a day in any convenient vehicle, and pro- bably a decoction of the cinchona bark may be as good as any we can employ. It seems, however, to be pretty generally ad- mitted, that it is chiefly in the protracted chronic rheumatism, where the vital powers are much diminished, and the ends ^f the bones, periosteum, capsules, or ligaments of the joints, are likewise partially affected, that the use of arsenic is likely to prove essentially serviceable or successful.t In such cases we can begin with the quantity before mentioned, and so increase the dose gradually according to the effect produced on the stomach and bowels. In some instances, a degree of erythema arises on different parts of the body in consequence of administering this remedy; and in others, a soreness of the mouth and ptyalism are excited. Costiveness generally ensues, and this we must obviate by some proper laxative taken from time to time. It may be some- times necessary to intermit its use for a day or two, and then return to it again. Arsenic will do little good in recent cases of rheumatism, and especially in young subjects : indeed it can rarely be persevered in where the patient is not much reduced in strength, owing to the greatness of its stimulating power; for which reason it succeeds best in old persons. As a mean of relief in chronic rheumatism, particularly in pro- tracted cases, the cinchona bark may be employed. No change whatever will be necessary in the patient's ordinary mode of living in chronic rheumatism, unless it happens to be in- termixed with the acute, and then the diet should be cooling, light, and nutritive. In chronic rheumatism, mustard and horse- radish may be taken freely in their natural state. Weak wine- t See Dr. Bardsley's Medical Reports. * 21. r£ Liquor.^Ammon. Acet. f. 3>ij- Aq. Cinnam ,5J. Tinct. Opii.fri xxvi. Liquor. Antimon. Tart. in_ xvj. Syrup. Papav. Somniferi,£. M. 21. Take Solution of the Acetate of Am- monia, three drachms. Cinnamon Water, one ounce. Tincture of Opium, forty drops. Solution of Tartarized Anti- mony, twenty-four drops. Syrup of Poppies, two dra'chms uu«nk i Mix them for a draught 2->4 PYREXIA, OR FEBRILE DISEASES. [ClaSS 1. whey, or barley-water, with a small quantity of the supertartrate of potass dissolved in it, may be used for common drink. Those who are subject to either kind of rheumatism should wear flannel next to the skin. Where there are any suspicions of the disease being connected with a syphilitic taint, a long-continued course of mercurial altera- tives (see Syphilis) must be entered upon. Chronic rheumatism sometimes affects the lumbar region, with an acute pain shooting down into the os sacrum, so that the patient cannot stand upright without suffering great pain ; neither can he enjoy ease when in bed. This affection is known by the name of lumbago. The disease sometimes fixes likewise in the hip-joint, aud is then called sciatica. Both of these affections are to be treated nearly in the same manner as chronic rheumatism. In sciatica and local pains of the hip and loins turpentine is often given with relief, as is likewise guaiacum combined with the essen- tial oil of sassafras. From a paper inserted in the sixth volume of the Memoirs of the Medical Society of London, by Dr. Wm. Falconer, it appears that the external application of the Bath waters has proved a most valuable and efficacious remedy in innumerable instances of ischias, or the diseases of the hip-joint. The following is the mode of proceeding which has been pursued. When the patient is tolerably strong, and the symptoms mode- rate, he is directed to bathe in a hot bath of about 105 degrees of heat. The usual time of continuing in the bath is from fifteen to twenty-five minutes, and it is generally repeated twice or thrice a week. After a few times bathing, the dry pump, as it is quaintly called, or pumping on the affected part without bathing, is advised; and this is tried on the affected part on those days when the patient does not bathe. From fifty to two hundred strokes of the pump are usually given. The first good effects of the application are to abate the stiffness and pain of the joint, and to afford a greater latitude and extent of motion, which are often perceived after using it three or four times. As the effects of the remedy proceed, the soreness and swelling diminish; the nocturnal pain, which is often very distressing, abates; the power of supporting the body on the lower limbs on the affected side increases ; the legs, whether shorter or longer, approach towards their proper dimensions ; and the muscles, that were let down and wasted, regain their natural shape, firmness, and plumpness. Where a use of the waters seems to succeed thus favourably, there is no other remedy employed. It sometimes happens, however, that the waters will show their beneficial effects to a considerable extent for a time, and then the amendment seems to be at a stand, but still without any accession of new morbid symptoms, or without any aggravation of the old. In such cases it is found requisite to suspend the use of the waters for a short period, and to apply a bitter upon the -eat of the pain : Order 11.] RHEUMATISM. •235 after the healing of which, the application of the waters may be repeated with advantage. Where it happens that the irritability of the nerves is much excited by a use of the bath, or that it causes profuse perspiration, much caution is required. In instances of the latter kind, unac- companied by fever, a light infusion of cinchona with aromatics is generally serviceable ; but the tendency to fever is most to be apprehended. If the spot where the uneasiness is felt be extremely sore, and tender to the touch, and the swelling and pain are con- siderable, then it will be necessary to be on our guard. Cupping- glasses, with scarifications, are applied in such cases with advan- tage* ; or if the skin be too sore or tender to endure without much pain the suction of a cupping-glass, a large number of leeches have been substituted in the place of the other, and by being repeatedly applied, have proved of great service. In aid of these applications, saline cooling purgatives, and the common febrifuge draught, with antimonials, are administered with advantage. For the relief of the pain, which often subsists without fever, it is found necessary to employ opiates ; and a preference is given by Dr. Falconer to the pulvis ipecac, compos, in the quantity of from five grains to twenty, once or twice in the course of the day and night. If these means prove effectual in procuring an abatement of the symptoms, the bath is cautiously tried, and especially the cross- bath, which is cooler than the other, and this for a short time only. If it can be borne without aggravating the symptoms, but rather with a soothing effect, it is directed to be repeated after an interval of three or four days, interposing the purgative before mentioned occasionally. When the bath can be borne with ease, the use of the pump in the bath is recommended, as the impetus of the water thrown on the part affected is less than in the dry pump, by the stream being conducted to the part beneath the surface of the water of the bath. By these means, together with the assistance of a blister on the part, the application of the waters is rendered safe, and often effectual, in cases, we are told, that seemed at first view not to allow their use. To reduce the swelling, and promote a reabsorp- tion of the effused fluid, when that can be safely done, Dr. Falconer directs a trial to be made of the lime poultice, composed of one part of quick-lime, fallen to powder in the air, and two parts of oatmeal, which being made into a poultice with hog's-lard, and spread thick on a cloth, is to be applied temperately warm to the part. This poultice is to be repeated every night, but to be removed in the morning. It generally produces some degree of moisture or exudation under it, thodgh without raising a blister : and this gradual local discharge is often an effectual though gradual method of reducing tumours both of the hip and of the knee. Those who are subject to rheumatic complaints ought carefully to avoid all exposures to cold and wet, and they should go warmly clothed, and wear flannel next the skin. .236 f'Y'REXia:, OR 1EBRILE DISEASES. [Class I. ORDER III. Op EXANTHEMATA, or ERUPTIVE FEVERS. Most of the diseases of this order are contagious, and attack a person only once in his life : they begin with fever, and at a definite time numerous and small eruptions are perceived scattered over the skin. In the nosology of Dr. Cullen, erysipelas is placed among this order, and although considered by some as contagious, still as it often affects the same person repeatedly, and in some becomes constitutional, it cannot be so arranged with propriety. In this volume it is placed with erythema among the preceding order of phlegmasia?. VARIOLA, or SMALL-POX. ^mall-pox is a disease of a very contagious nature, marked by a fever which is usually inflammatory, but now and then is of a typhoid nature, attended with vomiting, and upon pressure of the epigastrium, with pain ; succeeded after a few days by an eruption of red pimples on different parts of the body, which in the course of time suppurate, and at length fall off, leaving frequently behind them little pits in the skin, and, in severe cases, scars. With regard to the history* of the small-pox, it appears from the researches of eminent writers, that this disease, as also the measles, had prevailed in China and Hindostan from remote antiquity, yet had not extended to the more western nations until the middle of the sixth century. About this period these maladies reached the southern coasts of Arabia, by vessels trading with India, and broke out near Mecca, during the war of the elephant, (as it has been termed) in the year 569, immediately before the birth of Mahomet. During the latter parts of the sixth, and whole of the seventh century, they were spread by the Arabians over the remaining countries of Asia, and all that part of Africa which is washed by the Mediterranean Sea. In the eighth century Europe was con- taminated in consequence of the Saracens invading Spain, Sicily, Italy, and France, and the above diseases gradually extended to the north. They had reached Saxony, Switzerland, and England, in the ninth or tenth century. And lastly, in the beginning of the sixteenth century, twelve years after the death of Columbus, the infections were transported by the Spaniards to Hispaniola, and soon afterwards to Mexico, and diffused speedily over that hemi- sphere also. The small-pox attacks people of all ages, but the young of both sexes are more liable to it than those who are much advanced in life ; and it may prevail at all the seasons of the year, but in gene- ral is most prevalent in the spring and summer. * See Mr. Moore's History of the Small-Pox, p. 110. Order 1II.J small-pox. 037 It rarely happens that any person is attacked a second time with the disease, however he may be afterwards exposed to its infection or even be repeatedly inoculated with variolous matter. A few in- stances to the contrary have now and then occurred however, and with a high degree of severity. Affirmations of this from the highest authorities are on record. Dr. Jenner is of opinion, I be- lieve, that the susceptibility to receive variolous contagion always lemains through life, but under various modifications or gradations from that point where it passes silently through the constitution, up to that where it appears in a confluent state, and with such violence as to destroy life. The small-pox is distinguished into the distinct and confluent implying, that in the former the eruptions are perfectly separate from each other, and that in the latter they run much into one another. The distinct may often be distinguished from the con- fluent before the eruption appears, by the mildness of its attack, by the synochal type of the fever, the late appearance of the eruption, and the absence of typhoid symptoms. Some anomalous varieties of small-pox occasionally occur in practice : viz. the crystalline, in which the fluid never becomes opaque or purulent; the vesicular, in which small vesicles appear in the interstices of the pustules; and some others; but which are merely different modifications of the same disease. Both the distinct and confluent small-pox are produced either by breathing air impregnated with the effluvia arising from the bodies of those who labour under the disease, or by the introduction of a small quantity of variolous matter into the habit by inoculation ; and it is probable that the variety of the small-pox is not owing to any difference in the contagion, but depends on the state of the person to whom it is applied, or on certain circumstances concur- ring with the application of it. Many physicians of eminence are of opinion, that the variolous contagion is limited to a narrow sphere, and that it seldom, if ever, is conveyed by the wind to a distance, as some have imagined it capable of being. Dr. Haygarth, in his Sketch of a Plan to exter- minate the casual Small-pox from Great Britain, informs us, that certain facts appear to exhibit negative proofs that the open air is not contaminated to a great distance from the patient; not to one thousand five hundred feet, nor probably to one hundredth part of the space. He mentions, that very few cases have been adduced by those who have corresponded with him on the subject, in which clothes exposed to variolous miasma have been even suspected of conveying infection, and that several have given a negative testi- mony against this mode of communication. He further notices, that innumerable instances are to be produced where medical men' after exposing themselves to the miasms of an infectious chamber^ in a very short time nearly approach persons liable to the distem- per, who are yet not infected by the interview; and that inoculators are daily in this situation without communicating the casual small- 238 PYREXIAE, OR FEBRILE DISEASED [CtUiS 1. pox. The period during which infection remains latent in the body, he observes, is determined by the testimony of many to be, in the inoculated small-pox, from the fifth day to the sixteenth, seventeenth, and even the twenty-third : in the casual or natural small-pox, a little but not much longer than the common period in inoculation. A variety of opinions have been entertained respecting the effect of the variolous infection on the foetus in utero ; a sufficient number of instances, however, have been recorded, to ascertain that the disease may be communicated from the mother to the child. In some cases the body of the child at its birth has been covered with pustules, and the nature of the disease has been most satisfactorily ascertained by inoculating with matter taken from the pustules. In other cases there has been no appearance of the disease at the time of the birth, but an eruption and other symptoms of the ma- lady have appeared so early, as to ascertain that the infection must have been received previously to the removal of the child from the uterus. Moreover, some cases reported in the first volume of the Medico-Chirurgical Transactions of London,* by Dr. Jenner, point out the obvious infection of the foetus before birth, and communi- cated through the mother, she being already secure from any visi- ble occurrence of the disorder, which is indeed a very extraordi- nary occurrence. Four different states or stages are to be observed in the small- pox :—first, the febrile ; second, the eruptive ; third, the matura- tive ; and fourth, that of declination or scabbing, which is usually known by the name of secondary fever. When the disease has arisen naturally, and is of the distinct kind, the eruption is commonly preceded by a redness in the eyes, sore- ness in the throat, pains in the head, back, and loins, weariness and faintness, alternate fits of chilliness and heat, thirst, nausea, inclination to vomit, and a quick pulse. In some instances these symptoms prevail in a high degree, and in others they are very moderate and trifling. In young children, startings and convulsions are apt to take place a short time previous to the appearance of the eruption, always giving great alarm to those not conversant with the frequency of the occurrence. About the third or fourth day from the first seizure, the eruption shows itself in little red spots (similar to flea-bites) on the face, neck, and breast; and these continue to increase in number and size for three or four days longer; at the end of which time they are to be observed dispersed over several parts of the body. If the pustules are not very numerous, the febrile symptoms will enerallv go off on the appearance of the eruption, or they will be- come very moderate. It sometimes happens, that a number of little spots of an erysipelatous nature are interspersed among the pustules; but these generally go in again as soon as the suppura- * See page 271 Order III.J SMAtt-YOX". 239 tion commences, which is usually about the fifth or sixth day ; at which period a small vesicle, containing an almost colourless fluid, may be observed upon the top of each pimple. Should the pustules be perfectly distinct and separate from each other, the suppuration will probably be completed about the eighth or ninth day, and they will then be filled with a thick yellow matter ; but should they run much into each other, it will not be completed till some days later. When the pustules are very thick and numerous on the face, it is apt about this time to become much swelled, and the eyelids to be closed up ; previous to which, there usually arises a hoarseness and difficulty of swallowing, accompanied with a considerable discharge of viscid saliva. About the eleventh day the swelling of the face usually subsides, together with the affection of the fauces, and is succeeded by the same in the hands and feet; after which the pustules break, and discharge their contents, and then becoming dry, they fall off in crusts, leaving the skin which they covered of a brown red colour, which appearance continues for many days. In those cases where the pustules are large, and are late in becoming dry and falling off, they are very apt to leave pits behind them ; but where they are small, suppurate quickly, and are few in number, they neither leave any marks behind them, nor do they occasion much affection of the system. In the confluent small-pox the fever which precedes the eruption is much more violent than in the distinct, being attended usually with great anxiety, heat, thirst, nausea, vomiting, and a frequent and contracted pulse, and often with coma or delirium. In in- fants, convulsive fits are apt to occur, which either prove fatal before any eruption appears, or they usher in a malignant species of the disease. The eruption usually makes its appearance about the third day, being frequently preceded or attended with a rosy efflorescence, similar to what takes place in the measles : but the fever, although it suffers some slight remission on the coming out of the eruption, does not go off as in the distinct kind ; on the contrary, it becomes increased after the fifth or sixth day, and continues considerable throughout the remainder of the disease. As the eruption advances, the face being thickly beset with pus- tules, becomes very much swelled, the eyelids are closed up, so as to deprive the patient of sight, and a gentle salivation ensues, which towards the eleventh day is so viscid, as to be spit up with very- great difficulty. In children, a diarrhoea usually attends this stage of the disease instead of a salivation, which is to be met with only in adults. The vesicles on the top of the pimples are to be perceived sooner in the confluent small pox than in the distinct; but they never rise to an eminence, being usually flattH in : neither do they arrive io 240 FVREXLffi, OR FEBRILE DISEASES. [ClaSS I. a proper suppuration, as the fluid contained in them, instead o*" becoming yellow, turns to a brown colour. About the tenth or eleventh day the swelling of the face usually subsides, the hands and feet beginning then to puff up and swell, and about the same time the vesicles break, and pour out a liquor that forms into brown or black crusts, which upon falling off leave deep pits behind them that continue for life ; and where the pus- tules have run much into each other, they disfigure and scar the face very considerably. Sometimes it happens that a putrescency of the fluids takes place at an early period of the disease, and shows itself in livid spots interspersed among the pustules, and by a discharge of blood by urine, stool, and from various parts of the body. In the confluent small-pox, the fever, which perhaps had suf- fered some slight remission from the time the eruption made its appearance to that of maturation, is often renewed with consi- derable violence at this last-mentioned period, which is what is called the secondary fever; and this is the most dangerous stage of the disease. It has been observed, even among the vulgar, that the small-pox is apt to appear immediately before or after the prevalence of the measles. Another curious observation has been made relating to the symptoms of these complaints, namely, that if, while a patient labours under the small pox, he is siezed with the measles, the course of the former is generally retarded till the eruption of the measles is finished.* The measles appear, for instance, on the second day of the eruption of small-pox; the progress of this ceases till the measles terminate by desquamation, and then it goes on in the usual way. Several cases are however recorded in the Medical and Physical Journal, as likewise in the third volume of the Medical Commentaries, in which a concurrence of the small- pox and measles took place without the progress of the former being retarded. The only diagnosis that is necessary is between small-pox and chicken-pox. In the latter the pustules commonly go back without coming to proper suppuration. Their number, size, appearance, and course, differ very essentially. There is great reason to sup- pose, however, that the one disease is sometimes mistaken for the other, which may account for many of the supposed failures of the vaccine inoculation. The distinction is sufficiently apparent between chicken-pox and the small-pox when each of these diseases appears in its proper colours ;* but when the latter is peculiarly mild, and the former ex- traordinarily violent, which is sometimes the case, then all the dis- criminating marks are obscured. The distinct small-pox is not attended with danger, except when ■ See P> Duncan'* Medical Commentaries, vol. i Order III.] SMALL-POX. 2.U the eruptive fever is very violent, or when it attacks pregnant women, or approaches nearly in its nature to that of the confluent; but this last is always accompanied with considerable risk, the de- gree of which is ever in proportion to the violence and permanence of the fever, the number of pustules on the face, and the disposition to putrescency which prevails. When there is a great tendency this way, the disease usually proves fatal between the eighth and eleventh day; but in some cases death is protracted till the fourteenth or sixteenth. The con- fluent small-pox, although it may not prove immediately mortal, is very apt to induce various morbid affections. Both kinds of small-pox leave behind them a predisposition to- inflammatory complaints, particularly to ophthalmia and pneu- monia ; and they not unfrequently excite scrofula into action^ which might otherwise have lain dormant in the system. The regular swelling of the hands and feet upon that of the face subsiding, and its continuance for the due time, may be regarded in a favourable light. Violent eruptive fever, delirium, stupor, severe vomiting, dyspnoea, sudden disappearance of the eruption, subsi- dence of the swelling of the face or extremities, suppression of saliva, or depression of the pustules, followed by much prostration of strength, pallor of the skin, great anxiety, syncope, or convul- sions, are appearances which denote the greatest danger. The dis- ease in its progress assuming a malignant character and typhoid type, and the pustules becoming livid, or being interspersed with petechias, portend a fatal termination. The dissections which have been made of confluent small-pox, have never discovered any pustules internally on the viscera. From them it also appears, that variolous pustules never attack the cavi- ties of the body, except those to which the air has free access ; as the nose, mouth, trachea, the larger branches of the bronchiae, and the outermost part of the meatus auditorius. In cases of prolapsus ani, they likewise frequently attack that part of the gut which is exposed to the air. They have usually shown the same morbid appearances inwardly as are met with in typhus gravior, where the disease has been of a very malignant nature. Where the febrile symptoms have run high, and the head has been much affected with coma or delirium, the vessels of the brain appear, on removing the cranium and dura mater, more turgid, and filled with a darker coloured blood than usual, and a greater quantity of serous fluid is found, particularly towards the base of the brain. Under similar circumstances the lungs have often a darker appearance, and their moisture is more copious than usual. When a person who has never had the small-pox, is attacked with febrile symptoms after having been exposed to infection, or in consequence of the diseaseprevailingepidemically, weought imme- diately to advise a strict pursuance of the antiphlogistic plan, de- barring him from animal food, impregnating his drink with cooling acids, keeping his body open with gentle laxatives, and above all, 32 242 PYREXIA, OR FEBRILE DISEASES. [CletSS 1. exposing him freely to cool air, as, beyond all doubt, there is not a more effectual remedy for moderating the febrile heat produced by this disease than the application of cool air ; and the more urgent the symptoms, the more will the patient stand in need of it; for where the ventilation is free, it is inconceivable how refreshing it proves, and how suddenly it is capable of reducing the pulse, and of moderating all the symptoms. The proper treatment of the patient from the very first attack of the disease will have great in- fluence on the form which it assumes : if he be kept in a warm room, be loaded with bedclothes, and get warm drink, the fever will be severe and the eruption copious ; while by an opposite treat- ment the disease may be broken at the beginning. In the early stage of small-pox, and during the eruptive fever, when the symptoms run high, we may, in addition to exposing the patient freely to cool air, recommend washing the body partially or generally with cold water. As the quantity, as well perhaps as the quality of the pustules depends greatly on the violence and duration of the eruptive fever, and, as by mitigating the one, we render the other more favourable, it would seem really advisable, as soon as a person is seized with variolous fever, wherein the febrile symptoms are any way high, to have cold water thrown over the body every four or six hours ; which plan may be continued until the eruption is completed. The safety and utility of the remedy are recorded in the thirteenth number of the Edinburgh Medical Journal, and are confirmed by my own experience. When had recourse to on the attack of variolous fever, it usually mitigates the headach, pain in the back, and other febrile symptoms ; a slow and gentle perspiration succeeds, and a mild eruption takes place. Where it is resorted to after the small-pox have made their appearance, and by their quantity and the duration of the fever a confluent pock is expected, the cold bath seems not only to moderate the febrile symptoms, but likewise to diminish the number of the pustules, and in doing so, greatly to lessen the danger of the disease. The temperature of the patient's chamber should always be such that he may experience no disagreeable degree of heat, but rather a sensation of cold; and except he complains of being chilly, we need not be afraid of carrying the cool regimen too far. He should lie on a mattress covered only with a few bedclothes, a feather-bed being apt to occasion too great an accumulation of heat. If convenient, he should have an apartment to himself, as the heat of a crowded room would be sure to prove injurious ; and his body-linen, as well as that of the bed, should be shifted frequently. In many instances, little more will be requisite than to pursue the steps which have been advised ; but sometimes the fever and general inflammation run so high (particularly in adults of a ple- thoric and robust habit) as to be accompanied with great heat and dryness of the skin, redness of the face and eyes, considerable dif- ficulty of breathing, acute pain in the head, stupor, or delirium ; in Order III.] SMALL-POX. 243 which case it may be necessary to take away a little blood; but in resorting to this operation, great prudence is necessary ; for should a fever of a malignant nature, or putrid tendency, accompany the disease, bleeding might prove highly injurious. Indeed it might perhaps be the best practice to recommend it only in those cases where the effects expected from it cannot be procured by other re- medies ; and even in these local blood-letting by scarification of the temples, or the application of leeches, ought to be preferred. Where the eyes look red and fiery, or coma prevails, topical bleed- ing may prove a valuable remedy. The same caution should be observed with respect to a use of purgatives. For the purpose of diminishing excitement in the dis- tinct small-pox, they may prove serviceable if administered in mo- deration ; but if the accompanying fever is of the typhoid kind instead of synocha, then these and other antiphlogistic remedies are by no means warrantable. To dislodge the contents of the intestinal tube in such cases where costiveness prevails, we should only em- ploy the most gentle laxatives, such as the neutral salts, with the occasional use of emollient clysters. On the coming on of the fever, the stomach in some cases is much disordered, and a constant nausea, or frequent vomiting, is apt to arise; to obviate which, it will be proper to give a gentle emetic, working it off with a few draughts of chamomile-tea. It is no uncommon occurrence for convulsive fits to attack children some short time previous to the appearance of the erup- tion, which are apt to alarm those who are not conversant with the disease. In this instance little more will be requisite, in general, than to admit cool air freely to the child; but should they occur at a very early period of the disorder, and be repeated frequently with any violence, they then are attended with considerable danger, and ought to be removed, if possible, by giving opium in doses propor- tioned to the age of the child. About five drops of the tinctura opii will be sufficient for a child of a,year old, about eight drops for one of two years old, and so on in a regular gradation. Blisters are sometimes used in cases of this nature ; but from the great length of time which elapses previous to their producing any effect, they seldom prove serviceable. In those instances where the eruption does not come out kindly, it has been advised to immerse the whole body for a short time in a warm bath; but perhaps it maybe more proper only to put the feet and legs into warm water at first, using at the same time a more generous diet; and should these means fail, the other mode of proceeding may then be adopted. If there be great irritability and restlessness, opium in small quantities, either with the saline mixture, or a grain or two of anti- monial powder, will be serviceable. Where the febrile symptoms run high after the appearance of the eruption, we should give small and frequently repeated doses 244 PYREXIJE, OR FEBRILE DISEASE*. [ClasS I. of antimonials, as advised under the head of Simple Continued Fever. With the same view of lessening febrile heat and excitement, we may employ refrigerant medicines, such as nitre and saline draughts, administering the latter in the act of effervescence. Cold diluents, such as lemonade, imperial, &c, may be taken freely to allay thirst. It will likewise be proper to avoid heat, and to expose the body .to cool air. The cool regimen, in its fullest extent, is however by bo means so necessary after the completion of the eruption, or where the fever has almost or wholly disappeared, as before. At the same time we must be careful to avoid the opposite and more dangerous extreme of relaxing too suddenly in the employment of the cool regimen. The use of laxative medicines, or clysters, as far as is necessary to prevent costiveness, is to be continued ; and with regard to the application of cold, it should at this period be regu- lated by the patient's feelings. If, on the other hand the febrile symptoms continue consider- able, notwithstanding the appearance of the eruption, the plan of treatment must not be relaxed. The continued use of gentle cathartics and the cool regimen is then necessary; at an early period they are the best means of moderating the eruptive fever; they are now the most effectual for preventing the appearance of the secondary, which is always to be feared where the remission on the completion of the eruption is inconsiderable. When a degree of cynanche is present, gargles and the inhalation of warm steam may be used. In those cases where the pustules contain a thin watery fluid, and are accompanied with great soreness, uneasiness, loss of strength, and lowness of the pulse, the cinchona bark should be given in large doses, and be frequently repeated, and although it may perhaps increase the difficulty of breathing, and render the expectoration a little more difficult, still its good effects in ob- viating the symptoms of irritation, and the tendency to putres- cency, will greatly overbalance the former. To assist the effects of this bark, a free use of wine-whey ought to be allowed. In the confluent small-pox, particularly where there is a putrid tendency, where the pustules are filled with a bloody water, or where petechiae are interspersed among them, we must also have recourse to the bark of cinchona joined with wine, together with acids, all kinds of which have been much employed in this form of the disease, but more particularly the muriatic and sulphuric, as noticed under the head of Typhus Gravior. Where haemorrhages arise, we may give alum in addition to these remedies. If the eruptions, after having made their appearance, strike in suddenly, or if the disease has arisen in a person of lax fibres, and is attended with a weak low pulse, and a sinking in of the pustules, then, besides allowing a liberal use of wine-whey, we Order 111.] SMALL-POX. 24a should apply cataplasms to the soles of the feet, and blisters suc- cessively to different parts of the body, paying no regard to their being covered with pustules. Camphor, ammonia, musk, and aromatics, may likewise be advisable medicines. The warm bath will also be proper. Where the suppuration in the pustules does not go on kindly, owing to the want of rest, it will be necessary to give opiates. About forty drops of the tinctura opii may be administered to an adult every night at bedtime, and one or two teaspoonsful of the syrupus papaveris somniferi to young children. If opiates are given when the excitement is considerable, or if they are found to induce coma, their use will certainly be improper ; but in all other cases, more particularly during the maturating stage, in the confluent small-pox, a quantity of opium, sufficient to allay restlessness, provided care be taken, by administering gentle laxatives, to prevent its constipating effects, will be sure to prove beneficial. The secretion from the glands of the mouth and throat in the confluent small-pox, usually goes on without the help of medicines Until near the time of the completion of the suppuration, so that it is only necessary to defend the parts from the matter secreted by giving mucilaginous drinks, such as barley-water, linseed-tea, or a solution of gum. acaciae ; but towards the time of its being com- pleted, the secretion is apt to become so thick and viscid, as to be expectorated with the greatest difficulty, and often even to endanger suffocation. In this case we should give an emetic,* after which the mouth and throat must be washed out frequently with some proper gargle, as below,t or as advised under the head of Inflammatory Quinsy. If the emetic does not afford a perma- nent relief, we may then apply a blister to the external fauces with some prospect of advantage. When the swelling of the face begins to subside, if we should find that the extremities do not become puffy and swelled, as they ought to do, cataplasms and blisters may be applied to them, to excite inflammation. Determination to the head or chest, or other viseera, requires blisters, pediluvium, and sinapisms to the feet. If a strangury or suppression of urine should ensue in the course of the disease, as sometimes happens, it possibly may be relieved by making the patient walk barefooted several times across the floor, and by giving him small doses of nitre at the same time. Dashing cold water on the legs, as is sometimes practised to solicit the * 1. IJ; Antimon. Tartarizat. gr. jss. Aq. Fontan. f. ^j. Oxymel. Scillae, f. 3-ss. M. it. Haustus. t 2. R Infus. Rosae Gallic, f. gvij. Mel. Optim.f. Zss, ft. Gargarisma. M. * 1. Take Tartarized Antimony, one grain and a half. Pure Water, one ounce. Oxymel of Squill, half an ounce. Mix them for a draught. t 2. Take Infusion of Roses, seven ounces. Honey, half an ounce. Mix them for a gargle. 2461 PYREXIA, OR FEBRILE DISEASES. [Class 1. alyine discharge, may also be tried. Should these means fail in affording relief, we ought then to resort to the other remedies recommended under these particular heads. Obstinate vomiting, which in this disease often proves a very troublesome as well as dangerous symptom, is most effectually allayed by saline medicines, taken in the act of effervescence, and joined with opium.* Profuse diarrhoea is a troublesome occurrence in the confluent small-pox, particularly in children : but unless this symptom pro- duces a dangerous degree of debility, we should be cautious in checking it; and even when it does occasion considerable debility, the safest plan will be to endeavour to moderate it by very gentle astringents and tonics. There is perhaps* no instance, except to- wards the termination of the disorder, in which the diarrhoea can be safely stopped by astringents, and then it is to be done cau- tiously ; and when these medicines, either conjoined with opium, or of themselves, produce too sudden an effect, it must be coun- teracted by gentle laxatives. In all cases where there is a propensity to sweating, after the eruptive fever has passed, a cool regimen will be particularly necessary. In the distinct small-pox there ensues little or no secondary fever; but it regularly attends on the confluent, and is always in proportion to the number of pustules, proceeding probably from an absorption of the matter. This being the case, it may be advisable to open every pustule, as soon as the suppuration in it is completed; and in order to moderate the fever, as well as to prevent hectic symptoms, and after-suppurations from arising, we ought to employ mild cathartics, so as to keep the bowels regularly open. If, at the approach of the secondary fever, the pulse is quick, hard, and strong, the heat very great, the head much affected, and the breathing laborious, a quantity of blood, proportioned to the urgency of the symptoms, may probably be taken with safety, by means of scarifications or leeches applied to the part most affected; but a use of gentle cathartics, and other antiphlogistic means, seems much more advisable. If, on the contrary, the patient is faint, the pustules look pale and much indented, and the extremities feel cold, with other symptoms of irritation, the fever is then to be considered as of the typhoid kind ; and the proper remedies to be employed are cinchona bark, in whatever form it is found to sit easiest on the stomach, conjoined with wine and aromatics, * 3. g; Potassae Aerati, T)i. Aq. Cinnam. f. 3*. Tinct. Opii, (fl, viij. Syrup. Cort. Aurant. 3j. M. ft. Haustus, quarta quaque hora adhiben- dus in actu effervescentiae cum coch- leare magno succi limonis. * 3. Take Aerated Potass, one scruple. Cinnamon Water, ten drachms. Tincture of Opium,twelve drops. Syrup of Orange Peel, one drachm. Mix them, and let this draught be given every fourth hour with a table-spoonful of lemon juice during the effervescence. Order III.J inoculation of the small-pox. 247 together with mineral acids, opium, and artificially prepared pure air, or oxygen gas. To prevent the face from being marked after the confluent small- pox, it has been recommended to bathe it three or four times a day with warm milk and water, and on the seventh or eighth day to apply over its whole surface a mask made of fine cambrick, thinly spread with a soft liniment, composed of olive oil, white wax, and prepared lard, or with the unguentum cetacei, so as to exclude the external air; which application is to be renewed twice or thrice a day. When the pustules are numerous on the face, it sometimes happens that the eyes become much affected, and that a loss of sight is the consequence. In thosecases, therefore, where the face is much beset with pustules, the use of mild and gently astringent collyria, as advised under the head of Ophthalmia, should never be neglected. To prevent the eyelids from adhering together in such cases, it may be necessary to bathe them from time to time with warm milk, and to besmear them frequently with a little emollient ointment of any kind. The small-pox, particularly when it proves severe, is apt, in habits disposed to scrofula, to excite that disorder into action, when it otherwise might not have shown itself. Frequent instances of this nature occur in practice, and prove obstinate to the practi- tioner, as well as distressing to the patient. In all such cases we must resort to the means advised under that particular head. In the confluent small-pox, as well as the distinct, the patient's strength must be supported by food of a light nutritive nature, such as panado, bread-pudding, preparations of sago, arrow-root, roasted apples, &C.; and for common drink he may take thin gruel or barley-water gently acidulated, together with a little wine-whey now and then, when the febrile symptoms do not run high. If the accompanying fever is of a typhiod nature, a liberal use of wine will be proper. Of INOCULATION. Experience has taught us that by applying variolous matter to a scratch or wound, so as to occasion an absorption, we shall in general procure fewer pustules and a much milder disease than when the small-pox is taken in the natural way. Notwithstanding these evident advantages, objections have been raised against inoculation, on the score that it exposes the person to some risk, when it is possible he might have passed through life without being attacked by the disease in question; but in reply it may be urged, that he will be exposed to much greater danger from the intercourse which he must have with his fellow-creatures, by taking the disorder in the natural way. In objection to inoculation, instances have been adduced to sUp* 248 PYREXIA, OR FEBRILE DISEASES. [Class I. port the probability of a person's being liable a second time to the small-pox, when produced at first by artificial means, but such instances are very rare indeed, and we may safely conclude, that in most of those cases the matter used was not variolous, but that of some other eruptive disorder, such as the chicken-pox; which, when severe, may be mistaken for the small-pox by those who are not very conversant with the difference between them. It has been computed that a third of the adults die who take this disease in a natural way, and about one-seventh of the children; whereas of those who receive it by inoculation, and who are properly treated afterwards, the proportion probably is not greater than one in five or six hundred. Although inoculation for the small-pox may have been beneficial to individuals by greatly lessening the chance of death, yet it may safely be asserted that it has proved of no benefit to the community at large, but the reverse ; which is evident by the bills of mortality, as they clearly prove that the disease of small-pox has increased in England since the introduction of inoculation, in the proportion of 19 in every 100. This has arisen in a great measure from the want of some laws of exclusion, analogous to those of quarantine, by which those who produce the disease by inoculation should be prohibited from exposing the inoculated persons in the way of such as are liable to the infection. A recent decision in the Court of King's Bench, however, has shown, that such an exposure, where it produces the disease in others, is a misdemeanour by common law, and that those who thus trespass on the community, and are guilty of the act, are liable to imprisonment. The practice of inoculating is generally supposed to have been introduced into Britain from Turkey, by Lady Mary Wortley Monta- gue, about the year 1721, whose son had been inoculated at Con- stantinople during her residence there, and whose infant daughter was the first that underwent the operation in this country. Some letters, however, of Dr. Williams, Mr. Owen, and Mr. Wright, which may be seen in the Philosophical Transactions for the year 1722, assert, that inoculation was well known in the south of Wales at that time, and had been of long standing. It seems likewise to have been practised in the Highlands of Scotland, before its introduction into England. Mr. Mungo Park, in his travels into the interior of Africa, found that inoculation had long been practised by the negroes on the Guinea Coast, and nearly in the same manner, and at the same time of life, as in Europe. Where inoculation really originated is a matter of doubt, although it has been ascribed to the Circassians, who employed it as a mean for preserving the beauty of their women. It is more than probable that accident suggested the expedient among the different nations to whom the small-pox had long been known, independently of any intercourse they had with Order IU.J inoculation of the smai.l-pox. 249 each other: and what greatly adds to the probability of this conjecture is, that in most places where inoculation can be traced back for a considerable length of time, it seems to have been practised chiefly by old women before it was adopted by regular practitioners. Many physicians held the practice of inoculation in the greatest contempt at first, from its supposed origin ; others again discredited the fact; while others, on the testimonies of its suc- cess in distant countries, believed in the advantages it afforded, but still did not think themselves warranted to recommend it to the families they attended ; and it was not until after the experi- ment of it had been made on six criminals, (all of whom recovered from the disease and regained their liberty,) that it was practised in the year 1726 on the royal family, and afterwards adopted as a general thing. To ensure success from inoculation, the following cautions should strictly be attended to :— 1st, That the person should be of a good habit of body, and free from any disease, apparent or latent, in order that he may not have the distemper and a bad constitution, or perhaps another disorder, to struggle with at the same time. 2dly, To enjoin a temperate diet and proper regimen; and where the body is plethoric, or gross, to make use of gentle purges, together with mercurial and antimonial medicines, as hereafter mentioned. 3dly, That the age of the person be as little advanced as possi- ble ; but not younger, if it can be avoided, than four months. 4thly. To choose a cool season of the year, and to avoid external heat, either by exposures to the sun, sitting by fires, or in warm chambers, or by going too warmly clothed, or being much in bed. 5thly, To take the matter from a young subject who has the small-pox in a favourable way, and who is otherwise healthy, and free from disease; and when fresh matter can be procured, to give it the preference. Where matter of a benign kind cannot be procured, and the patient is evidently in danger of the casual small-pox, we should not however hesitate a moment in recommending inocu- lation from any kind of matter that can be procured, as what has been taken in malignant kinds of small-pox has been found to produce a very mild disease. The mildness or malignity of the small-pox appears therefore to depend little, if at all, on the inoculating matter. Variolous matter, as well as the vacine, by being kept for any length of time, particularly in a warm place, is apt, however, to undergo a decomposition by pu- trefaction, and then another kind of contagious material has been produced. In inoculating, the operator is to make the slightest puncture or scratch imaginable in the arm of the person, rubbing that part of 2jO PYREXIA, OR FEBRILE DISEASE*. [ClttSS 1. the lancet which is besmeared with the matter repeatedly over it, by way of ensuring the absorption ; and in order to prevent its being wiped off, the shirtsleeve ought not to be pulled doWn until the part is perfectly dry. In preference to either puncturing the arm, or scratching it in a direct line, it has been recommended to introduce the lancet armed with the matter obliquely beneath the cuticle, so as to wound very slightly, and occasion little or no flow of blood. This mode may probably be preferable ; but in withdrawing the point of the lancet, it will be right to press the wound with the finger, that the parts in contact with the matter may wipe it off the lancet, and thereby secure the success of the operation. When inoculation is performed in any of these ways, the application of a plaster or bandage will be unnecessary. The matter of small-pox must be applied to a wound in order to induce the complaint. Dr. Rush informs us, he could not induce the small-pox by rubbing the matter on the entire skin; and Ke likewise mentions, that a negro girl took some variolous matter mixed with a dose of physic, which produced no sensible effect. A singular circumstance attending inoculation is, that when this fails in producing the effect, the inoculated part nevertheless sometimes inflames and suppurates, as in cases where the complaint is about to follow ; and the matter produced in^such cases is as fit for inoculation as that taken from a person actually labouring under the disease. The same happens very frequently in inoculation for the cow-pox. If on the fourth or fifth day after the operation, no redness or inflammation is apparent on the edges of the wound, we ought then to inoculate in the other arm in the same manner as before ; or, for greater certainty, we may do it in both. Some constitutions are incapable of having the disease in any form. Others do not receive the disease at one time, however freely exposed to its contagion, even though repeatedly inoculated, and yet receive it afterwards by merely approaching those labouring under it. Dr. Huxham* makes mention of cases of this nature. His words are : " 1 know an old nurse, and one apothecary, who for many years attended persons, and a great number too, in the small-pox, and yet never had them ; nay, many that have indus- triously endeavoured to catch the infection, by frequenting the chambers of the sick, have done it without effect, and yet some of these persons, some months or years after, have been seized with the small-pox." On the coming on of the febrile symptoms, which is generally on the seventh day in the inoculated small-pox, the patient is by no means to be suffered to take to his bed: but, on the contrary, must be constrained to keep up, and to be as mnch in the cool air •' Ser tijfi Treatise oa Fes er^ Small-Pos. Sn- 5# Order III.] inoculation of the small-pox. 251 as possible : and if thirsty, he may partake freely of some cooling antiseptic drink. As the number of pustules would probably be much increased by lying with another person, the patient should always have a bed to himself. From the time that the matter is introduced into the system to the appearance of the eruptions, it will be necessary to observe a total abstinence from all animal food, and to give some gentle purgative every second or third day, if the person is of a gross habit; and on the intervening ones, he may take a dose of the fol- lowing preparative powder:—Mix a drachm of prepared chalk with twelve grains of hydrargyri submurias, and one grain of tartarized antimony, which for an adult may be divided into three doses, and for a child of a year old, into twelve. Some late experiments might induce us to believe that prepara- tion has little or no effect on the future eruption, and that the cause of its mildness, in the inoculated small-pox, is to be ascribed to the operation itself, independent of any thing else. Mons. Des- serts, in the sitting of the French National Institute, is said, how- ever, to have adduced a number, of facts to prove that the natural small-pox is rendered much milder by the useof mercurial remedies, and probably the inoculated disease may likewise be influenced by them. Indeed it appears from the experiments of Van Woensel, that the submuriate of mercury, given as an alterative for some days before inoculation, and til! the eruptive fever commences, does with certainty render the disease mild. A singular circum- stance, mentioned by the same author, is, that this preparation of mercury, triturated with variolous matter, incapacitates it from conveying the disease by inoculation. The mode of treating the small-pox being the same, whether it arises naturally or from inoculation, a reference must be had to the plan which is laid down in the preceding pages ; and as purging is not less necessary after the small-pox by inoculation than by the natural way, it ought by no means to be neglected. Various plans have been proposed with a view wholly to banish the casual small-pox. Dr. Haygarth* has bestowed much attention on this subject; and were the regulations pointed out by him to be rigidly enforced, there is reason to believe they would be found sufficient for the purpose. A surer and more effectual way, how- ever, to eradicate the disease, is by inoculating with vaccine matter every adult who never has had the small-pox ; as likewise every child soon after its birth. It has frequently been attempted to communicate the small-pox and measles to quadrupeds by inoculation, but in vain. * See his Sketch of a Plan to Exterminate the Casual Small-Pox from Great Britain. 2ii PYREXIA, or febrile diseases. i Class 1. VARIOLA VACCINAE, or COW-POX. In many of the dairy counties it has been long known that the cows are liable to an eruption on their paps or udders, which was occasionally communicated to the hands or arms of"those who milked them, producing an ulcer, and some degree of fever; and it had been observed by the people of those counties, that those who had gone through this disease, known by the name of cow-pox, were not liable to the small-pox. The disease had not, however, undergone any medical investigar tion, until Dr. Jenner, then of Berkley, in Gloucestershire, paid particular attention to it. He very satisfactorily ascertained that it was a much milder disease than the small-pox, and that the fact was true, that in general it secured those who had been infected with it from afterwards being liable to variolous infection. He also obr- served that the vaccine-pox is not infectious but by inoculation ; and that on this account it might be inoculated in a family without endangering others : a circumstance of the greatest importance. On the suggestions of Dr. Jenner,many practitioners were induced to adopt the practice of substituting the one disease for the other, and its efficacy is in most cases now fully established. With respect to the origin of the disease in the cow, we are in- formed by Dr. Jenner, that he traced it to the diseased heels of horses which had been affected with the grease : and by the person appointed to apply the dressings to them not paying a due atten- tion to cleanliness, and incautiously bearing his part in milking the cows, with some particles of the infectious matter adhering to his fingers, he has communicated the disease to them. From numerous experiments made, however, at an early period, by the late Dr. Woodville, and by Mr. Coleman, Professor at the Veterinary College, with the matter of grease, taken in the various stages of that complaint, no such effect has been produced upon cows. Neither were inoculations with this matter, nor with several other morbid secretions in the horse, productive of any effects upon the human subject, which by no means accord with the facts adduced by Dr. Jenner on this point. Some communications through the medium of the Medical and Physical Journal (see vol. iv. pages 381 and 466,) in conse- quence of still later experiments, seem however to give support to Dr. Jenner's opinion as to the origin of the disease. On its first investigation, some circumstances led to the suppo- sition that the cow-pox and smali-pox were originally one and the same disease; the latter being derived from the animal at some remote period, and having undergone, in the lapse of years, and by the influence of various constitutions, the changes we now experience. Subsequent facts have, however, invalidated this opinion. From various experiments it appears that the vaccine disease and the small-pox are not susceptible of intermixture, but that each Order III.] i.OW-POX 233 preserves its distinct character under all circumstances. At the Small-Pox Hospital it has been noticed, that when the vaccine and variolous fluids are mixed together, and thus inserted, sometimes the vaccine pustule, at others the variolous, has been produced, each of them retaining its characteristic marks throughout. Again, it has been found that when the two fluids are inserted separately, and so near together that the two pustules which follow spread into one, by inoculating with the fluid taken from one side of it, the vaccine pustule alone will be produced, while the fluid taken from the other excites the genuine variolous pustule, with the general eruption of small-pox on the body. Another point of dissimilarity between the variolous and vaccine disease is this : the inoculation of the former we well know supersedes the natural disease many days after exposure to infection. The effect produced by submitting persons to the influence of variolous and vaccine matter at the same time, is, that they both prove effective : for the vaccine vesicle proceeds to its#cme in the usual number of days, and the maturation of the variolous pus- tules is attended with a pustular eruption on different parts of the body; but when variolous matter is not inserted until the ninth day after the inoculation with vaccine matter, the action of the variolous seems to be wholly precluded. The variolous and vaccine fluids, inoculated about the same time, restrain the action of each other. The vaccine vesicle, in this case, is smaller, and proceeds more slowly to its maturity, and the variolous pustules are small, hard, and shining, producing only a small particle of matter at their apices. The nipples of the cow being once affected, the disorder is com- municated to the dairy maids, and other assistants employed in milking, and by them it is spread through the farm, until at last most of the cattle experience its consequences. The disease appears on the nipples of the cows in the form of irregular pustules, which on their first appearance are commonly of a colour somewhat approaching to livid, and are surrounded by an erysipelatous inflammation, according to the report of Dr. Jenner; but Dr. Woodville seems to think that it is rather an indurated tumefaction of the skin which surrounds the pustules, than an inflammation of an erysipelatous nature. Unless proper remedies are applied in time, these pustules soon degenerate into phagedenic ulcers, which prove extremly troublesome ; the animals then become much indisposed, and the secretion of milk suffers a considerable diminution. Inflamed spots now begin to appear on different parts of the hands and wrists of the domestics employed in milking, which run on quickly to suppuration, assuming at first the appearance of small vesications produced by a burn. Most commonly they come out about the joints of the fingers, and at their extremities ; but whatever parts are affected, if the situation will admit, these superficial suppurations put on a circular form, with their edges 254 PYREXIAE, OR FEBRILE DISEASES. [ClaSS 1. more elevated than their centre, and of a colourdistinctly approach- ing to blue. In consequence of absorption, tumours appear in each axilla, the system becomes affected, the pulse is quickened, and rigours, with general lassitude and pains about the limbs and loins, with a vomiting, come on. In some instances the head is much affected, and a delirium arises. The symptoms, varying in their degrees of violence, usually continue for three or four days, leaving ulcerated sores about the hands, which from the sensibility of the parts are very troublesome, and commonly heal slowly, becoming not unfrequently phagedenic, like those from which they sprung. The lips, nostrils, eyelids, and other parts of the body, are like- wise affected sometimes with sores, in consequence of being heed- lessly rubbed or scratched with the patient's infected fingers. Dr. Jenner informs us, that he had never met with any case of the cow-pox, either taken naturally, or produced artificially, which proved fat^; but by Dr. Woodville we are told, that out of five hundred cases of inoculated cow-pox under his care, one proved fatal, which was a child at the breast, on the eleventh day after the matter had been inserted in the arm. From that occurrence, and a few cases in which the febrile symptoms ran high, this gentleman was at first very adverse to the vaccine inoculation; but from further trials he latterly gave it, with almost every other practitioner, a decided preference. The few instances of death which have occurred from vaccine inoculation, since it has been more generally practised, may probably be referred with much justice to some unknown pecu- liarities of the constitution; to intervening disorders independent of the vaccine ; and to inflammation excited by accidental causes in young children, especially when they have been ill fed and badly nursed—circumstances not uncommon among very poor people. When the pustules are numerous, as sometimes happens where the disease has been received immediately from the cow, a con- siderable degree of fever attends : but when it has arisen from inoculation, few or no pustules are to be observed, except im- mediately round the wound in the arm ; and little or no incon- venience is experienced. A more general knowledge of the disease than what we had at first, has ascertained it to be an undoubted fact, that the vaccine virus is greatly modified, and rendered much milder, by passing through different habits ; and that although the cow-pox has proved in many instances a severe disorder in those who received the infection immediately from the animal, still in a few instances only have the symptoms run high, or has the least inconvenience been experienced, where proper matter taken from the human subject was used for inoculation. In the few cases which have been brought forward, where a numerous eruption, preceded by a fiery redness, took place, wr Order 11I.J COW-POX. 255 should attribute it to something wrong in the habit of body; to the intervening of some other eruptive disease ; or possibly to the having inoculated with matter which had undergone a decom- position, in consequence of putrefaction, or some other cause not obvious. A use of medicine seems wholly unnecessary in the cow-pox, except in those cases of the natural disease where much febrile heat attends; and then the antiphlogistic plan ought to be pursued. The vaccine virus is certainly of a very singular nature, inasmuch as that a person who has been infected by it, is generally found to be for ever after secure from the infection of the small-pox ; neither exposure to variolous effluyia, nor the insertion of the matter into the skin, being capable of producing the disease. Many direct experiments, made by innumerable practitioners, prove that the sus- ceptibility of the small-pox is in general totally destroyed by inocu- lating with the vaccine matter. The permanency of the effect was indeed a matter of some doubt, but that is now fully established. It appears from the Report of the Small-Pox Hospital in London, that up to December, 1802, eleven thousand eight hundred patients and upwards had been vaccinated, of which number twenty-five hundred were afterwards proved to be secured from the natural small-pox, by receiving a further inoculation with small-pox matter while they were at the same time exposed in a hospital full of its infection, without effect. It was said at first, that although the cow-pox destroyed the susceptibility of the small-pox, still it possessed not the same power with regard to itself, as a person might have the disease more than once. Instances certainly have been adduced of the cow-pox taking place a second time; but they are of very rare occurrence, and should be looked on as irregular. The same has happened with the small-pox. In Dr. Jenner's first treatise he mentions that the small-pox is not always a security against the cow-pox, and that although the susceptibility of the virus of the cow-pox is for the most part lost in those who have had the small-pox, yet in some constitutions it is only partially destroyed, and in others it does not appear to be in the least diminished. A more intimate knowledge of the disease has convinced us of the fallacy of this opinion. Soon after Dr. Jenner's first publication on the vaccine disease, a few instances were adduced, tending to invalidate his sup- position of the preventive power of the cow-pox with regard to variolous infection; but these he considers to have been cases of a spurious disease, and therefore not affecting his general conclusion. In using this term, he does not mean, however, to imply that there is a true and false cow-pox, but merely to express an irregularity or difference from that common form and progress of the vaccine pustule from which its efficacy is inferred. Those who perform vaccination ought therefore to be well instructed, a.nd should have watched., with the great est care, the regula;; 2i>6 PYREXIA, OR FEBRILE DISEASE.-^. [Ciitsu I. process of the pustule, and learnt the most proper time for taking the matter. A few cases of still later occurrence have also been brought forward by Mr. Goldson* of Portsmouth, and others, with the view of proving that the inoculated cow-pox is not a permanent security against the infection of the small-pox ; but a failure in one or two cases out of more than thirty thousand, although ever so well substantiated, should be considered in no other light than as a casual irregularity, upon which no solid determination, can, or ought to be grounded. Instances of the like nature have been known to occur likewise among persons inoculated with variolous matter, and when they are met with, ought to be looked on as anomalous. There can be little doubt, however, that some of the failures- are to be imputed to the inexperience of the early vaccinators; and it is by no means unreasonable to expect, that further observa- tion will yet suggest many improvements that will reduce the number of anomalous cases, and furnish the means of determining with greater precision when the vaccine disease has been effectu- ally received. Persons who have been vaccinated and passed through the cow-pox with all the usual accompanying symptoms, and who have afterwards taken the small-pox, of which a very few instances may have happened, have generally imperfect pustules, which die away in a few days, without exciting any constitutional complaint; but the matter taken from these pustules will communicate the small-pox. This circumstance has been brought forward by the anti-vaccinists as a proof that persons who have had the cow-pox may afterwards take the small-pox by inoculation, and otherwise, not making the proper distinction between local and constitutional infection; or perhaps not understanding how any one can com- municate a disease to others, with which he is not himself in- fected. We are informed by Dr. Jenner that the sources of a spurious cow-pox are as follow :— 1st, That arising from pustules on the nipples or udder of the cow, which pustules contain no specific virus. 2dly, From the matter (although originally possessing the specific virus) which has suffered a decomposition either from putrefaction or from any other cause less obvious to the senses. 3dly, When the matter is taken from an ulcer in an advanced stage, which ulcer arose from a true cow-pox : and, 4thly, He supposes a spurious disease to arise from matter pro- duced on the human skin, from contact with some peculiar morbid matter generated by ahorse. The characteristics of the true cow-pox areas follow : viz. a cir- cumscribed, circular, elevated eruption, surrounded by a red halo * See his Cases of Sinyll-Pox subsequent to Vaccination. Order 1U.J COW-POX. -2q7 or efflorescence; smooth surface ; brown, black, or mahogany and tamarind-stone coloured long adhering scab. From a chymical analysis of vaccine matter by some French physicians, it was found to consist of water and albumen. The succeeding arguments have been urged in favour of inocu- lation for the cow-pox over that for the small-pox. 1st, Of several thousand persons who have had the inoculated cow-pox, only one or two have died. 2dly, Very few well-attested instances have been produced out of many thousands of the above persons, known to have had the inoculated vaccine-pox, and who were subsequently inoculated for the small-pox, of this disease being afterwards taken; although many of these were also exposed to the infectious effluvia of the natural small-pox. And traditionally, this fact has been established time immemorial with regard to the casual cow-pox. 3dly, It may safely be affirmed, that the inoculated cow-pox is generally a much slighter disease than the inoculated small-pox i and that the proportion of severe cases in the latter is to the former as at least ten to one. 4thly, It does not appear that the genuine vaccine-pox catr be propagated, like the small-pox, by effluvia from persons labour- ing under it. Hence, if the vaccine inoculation should be uni- versally instituted in place of the small-pox, it is reasonable to conclude, that this most loathsome and fatal malady will be extinguished. 5thly, It does not appear that the vaccine poison, like that of the small-pox, can be conveyed so as to produce the diseases indirectly from diseased persons, by adhering to clothes, furniture, bedding, letters, &c. Hence no danger of its propagation in these channels is to be apprehended from the universal practice of the inoculation of the cow-pox. 6thly, It has been found, that a person whose constitution has distinctly undergone the vaccine disease, is in future unsusceptible of the same disorder. Hence no objection can be made to the new inoculation, as was once urged, on account of its being believed, that by the commutation of the small-pox for the vaccine-pox, an eruptive disease would be introduced, to which the same person would be repeatedly liable. 7thly, It does not appear that those who have already gone through the small-pox are susceptible of the vaccine disease, as. was at first believed. Hence no objection can be urged on the score of persons who have already gone through the small-pox being liable to a new infectious disease, by the introduction of the vaccine inoculation. 8thly, Experience shows, that there is no reason to apprehend the smallest chance of deformities of the skin from the vaccine inoculation. 9thly, The extensive practice of the vaccine inoculation, and the accounts of the disease in the casual way, do not show that 34 258 PYREXIAE,'OR FEBRILE DISEASES. [Class I. any other disease will be excited subsequently, which is peculiarly imputable to the new practice. On a review of these arguments, founded on facts, there can remain no doubt but that the vaccine inoculation will soon wholly supersede and do away the variolous. Could all parents be per- suaded to inoculate their children with vaccine matter soon after birth, the small-pox might be entirely eradicated in time. The introduction of this species of inoculation generally throughout both the army and navy, and its extension to France, Spain, Ger- many, and every part of the continent, as well as to both the Indies, fully stamp its value and efficacy, and give us reason to hope that it will shortly be adopted by every nation of the earth with whom we have the least communication. Vaccination has indeed penetrated to the remotest corners of the globe ; and wherever it has been introduced, the increasing experience of every year has only served to confirm pretty generally a con- fidence in its efficacy. It has been recommended and adopted by far the greatest and most respectable part of the profession, every where, but by a few individuals it has been obstinately op- posed through interested motives. In inoculating for the vaccine disease, we should carefully attend to the following circumstances :— 1st, That the matter should not be taken later than the ninth day of the disease. 2dly, That the fluid should be perfectly transparent, as it is not to be depended upon if it has become in any degree opaque. 3dly, That the matter, if not used immediately, should be allowed to dry gradually and thoroughly before it is laid by for future use. 4thly, That the punctures can scarcely be made too superficial, and on no account should more than one be made in each arm. 5thly, That attention should be paid to repress, as soon as may be, any excess of inflammation that may happen to arise; and this is best done by cola and restringent applications. With respect to the operation of vaccination, it will be impor- tant to ascertain that the vesicle has not acted locally, but effected the desired change on the constitution : hence has origina- ted the practice of testing by re-vaccinating during every period of the progress of the vaccine vesicle. From the report of the physicians of the Vaccine-Pox Institu- tion, it appears that the matter of a single pustule, being mixed with one quarter of an ounce measure of warm water, such diluted mat- ter excited as distinct a vaccine-pox by inoculation, as an equal quantity of undiluted matter. A pox so excited was not attended with less inflammation, or constitutional affection, than that exci- ted by a larger quantity of undiluted matter; which points out an e^sy method of inoculating several persons from a single vaccine- pock—a great conveniency indeed, when the poor to be inoculated at one time are very numerous. Order II1.J measles. 259 VARICELLA, or CHICKEN-POX. This disease, like the small-pox, seems to depend upon a specific contagion, and affects a person but once during life. The eruption is sometimes preceded by chilliness, succeeded by flushings and heat, pains in the head and back, thirst, restlessness, and a quick pulse ; but at other times no such symptoms are per- ceptible. About the second or third day the pustules become filled with a watery fluid, which is never converted into yellow matter, as in the small-pox (to the milder species of which it seems, however, to bear some affinity;) and about the fifth day they usually dry away, and are formed into crusts or scabs. No danger ever attends the chicken-pox. The small-pox and chicken-pox differ, in the eruption of the former being preceded by a fever of a certain duration, while that of the latter is either preceded by none, or one of uncertain con- tinuance ; in the vesicles appearing much earlier in the chicken- pox than in the small-pox, and about the second or third day being filled with serum ; in the matter of the former never acquiring the purulent appearance, which it always does in the distinct small- pox, and in the crusts which cover the pustules being formed about the fifth day, at which time those of the small-pox are not at the height of their suppuration. These distinguishing marks it will be necessary to attend to, as there is great reason to suppose the chicken-pox has not only been sometimes mistaken for small-pox, but that its matter has been used for that of small-pox in inoculation, to which may be ascribed many of the supposed cases of small-pox having appeared a second time in the same person. In general it is only necessary to make use of a spare regimen on the first appearance of the eruption, and to give one or two cooling purgatives afterwards,; but should the febrile symptoms run high, it may then be advisable to make the patient take frequent small doses of some antimonial, with saline draughts and nitre, as advised under the head of Simple Fever, or the distinct Small-Pox, drink- ing plentifully at the same time of cold diluting liquors, and keep- ing the body open with gentle laxatives or emollient clysters. The like treatment will also be proper in the swine pox, which is indeed only a species of the varicella. RUBEOLA, or MEASLES. This disease is an inflammatory infectious fever, attended by cough, sneezing, a defluxion of thin humours from the eyes and nose, and a determination of acrid matter to the surface of the body, showing itself in red spots over every part of it, but which never come to any suppuration, as in the former disorders, but go away in a small mealy desquamation of the cuticle after a few days' continuance. 2"69 pyrexia, or febrile diseases. [Class I. In systems of nosology several varieties of the measles are men- tioned, but they may all be comprehended under two heads; the benign and malignant: the former attended with more or less of the symptoms of general inflammation, the latter accompanied by a putrid diathesis and typhoid fever. The scientific Willan* divides rubeola into three species, viz., rubeola vulgaris, rubeola sine catarrho, and rubeola nigra : in the latter of which the papulae suddenly assume a black or dark purple colour. Scarlatina sometimes resembles the measles so exactly as not to oe easily distinguishable : though this is a matter of great import- ance, because the method of cure in the two diseases is extremely different. The redness of the scarlet fever is more equally diffused than in the measles, and is not in distinct spots with the natural colour of the skin interposed; yet in a few cases it has been ob- served so. In the measles the eruption rises more above the skin, and occasions a manifest roughness to the touch, which is hardly observable in the scarlet fever, except a very little roughness some- times in the arms. In the scarlet fever there is seldom a severe cough; the eyes do not water much, and the eyelids are not red and swoln ; all which rarely fail to attend the measles. The time of the eruption is likewise different, for it appears in the scarlet fever both in the face and arms on the second day; but in the measles it begins only about the third day to be visible on the chin and breast, and does not come to the arms and hands till the fourth or fifth day. The measles may prevail at all seasons of the year as an epidemic, but the middle of winter is the time they are usually most preva- lent ; and they attack persons of all ages, but children are most liable to them. They prove rather unfavourable to such as are of a plethoric or scrofulous habit. Like the small-pox, when genuine, they rarely affect persons but once, their contagion appearing to be of a specific nature. A recurrence of the measles has been dis- puted by some, but a number of examples are recorded by different writers where the measles took place twice.! From a number of cases lately observed at New-York, when the measles were very prevalent there, it appears that spurious forms of the disease, insufficient to protect the system from subsequent attacks, occur in a manner very analogous to the spurious appear- ances of the small-pox and of the variolae vaccinae.| For many persons, who on former occasions of the measles prevailing, and after exposure to their contagion, had exhibited certain irregular appearances of febrile, catarrhal, and eruptive symptoms, mistaken for the true disease, were afterwards attacked with measles in an exquisitely genuine form. The fact is likewise noticed by Dr. * See his Description and Treatment of Cutaneous Diseases. t See Transactions of a Society for the Improvement of Medical and Chirurgt- cal Knowledge, vol. iii. { See th? New-York Medical Repository, vol. v. No. 3 Order III.J measles. 2G.1 Willan,* and he mentions that the rubeola sine catarrho appears to be an unusually mild form of the disorder, which does not destroy the susceptibility to an attack in future. Two instances of its re- currence happened among his own children, at an interval of two years. In a later publication! he informs us, that he has since seen other cases of the same kind, wherein the efflorescence without fever or catarrhal symptoms having declined, there appeared, on the fourth day from its commencement, a new efflorescence, and violent disorder of the constitution. The eruption of benign measles is usually preceded by a chilli- ness and shivering, succeeded by heat, thirst, anxiety, pains in the head, back, and loins, heaviness, and redness of the face and eyes, with an effusion of tears, swelling of the eyelids, nausea, and pro- bably a vomiting of bilious matter; and with these symptoms there are a dry cough, hoarseness, hurried respiration, difficulty of breath- ing, frequent sneezing, and a discharge of acrid water from the nostrils. The pulse is at the same time frequent and strong. In alarming cases, spasms of the limbs, subsultus tendinum, deli- rium, or coma, supervene. This last symptom, however, so fre- quently attends the eruptive fever of measles, that by some prac- titioners it is regarded as one of its diagnostics. In measles, as in other febrile diseases, the symptoms generally suffer some remission towards the morning, returning however in the evening with increased severity. About the third or fourth day small red spots, somewhat similar to flea-bites, appear in clusters about the face, neck, and breast, and in a day or two more the whole body is covered with them. They do not rise into visible pimples, but by the touch are per- ceived to be a little prominent. The febrile symptoms do not however abate on the appearance of the eruption, as happens in the small-pox, but, on the contrary, are usually much increased, and they do not cease till after the desquamation takes place. The cough, hoarseness, difficulty of breathing, and defluxion from the eyes and nostrils, seem likewise greatly aggravated. On the fifth or sixth day the spots from a vivid red are changed to a brownish hue, and they begin to dry away about the face, never having proceeded to any kind of suppuration ; about the eighth or ninth day they disappear on the breast, and other parts of the body, with a meanly desquamation of the cuticle. About this period it is no uncommon occurrence for a diarrhoea to ensue. The malignant form of the disease is accompanied with typhus fever, and with petechias and other signs of putrescency, as enume- rated under that head. Moreover, the eruption appears more early, and all the concomitant symptoms are in an aggravated form. The fauces not unfrequently assume the same appearance as in cynanche * See his Reports on the Diseases of London, 1799, p. 207. t See his Description and Treatment of Cutaneous Diseases, Order iii. Part I. 262 PYREXIJE, OR FEBRil,:. DISEASES. [Class 1. maligna, probably from a combination of the two diseases. Some cases of this nature have lately fallen under my care, two of which proved fatal. The febrile and other symptoms being mild, a gentle diarrhoea, a free and copious expectoration, a moisture on the skin at the appearance of the eruption, and an early and free desquamation, denote a favourable termination of the disease ; hut a high degree of fever, hot and parched skin, hurried and difficult breathing, flushed countenance, unusually hard pulse, the energy of the system not proving sufficient to throw out the eruption to the surface of the body, and the mucous membrane of the larynx, trachea, and bronchial ramifications being invaded therewith, as happens sometimes in scarlatina, ulcerated fauces, severe diarrhoea, the vomiting continuing after the eruption, great pain in the head and eyes after it, considerable degree of coma or delirium, the eruption becoming of a livid hue, with great prostration of strength, small intermittent pulse, petechiae, and other marks of putrescency, point out the highest degree of danger. The existence of typhoid symptomsalong with a severe pneumonic affection, always increases the danger. The consequences attendant on the measles are frequently more to be dreaded than the immediate disease ; for although a person may get through it, and appear for a time to be recovered, still pul- monary consumption and hectic fever shall afterwards arise and destroy him, or an obstinate ophthalmia will ensue. Measles, as well as the small-pox, not unfrequently call into action a disposition to scrofula, where such happens to exist in the habil. Another bad consequence of the measles is, that the bowels are often left by them in a very weak state : a chronic diarrhoea re- maining, which has sometimes proved fatal. Dropsy has also been known as a consequence of measles. A singular circumstance attending the contagion of the measles is, that if it be taken a sufficient time before inoculation for the small-pox, so that the eruption may commence before the variolous fever comes on, it stops the progress of the small-pox in the inocu- lated wound, and delays it till the fever of the measles has finished its career. The morbid appearances to be observed on dissections of those who die of the measles, are pretty much confined to the lungs and intestines : the former of which always show strong marks of in- flammation, with sometimes a tendency to sphacelus. Where the patient dies under the eruption, the trachea and larger branches of the bronchiae, as in the small-pox, are often found covered with it, which may account for the increase of the cough after the appearance of the eruption. In some instances the measles make their attack in a mild man- ner, and go through their natural course without medical aid ; but in others the febrile symptoms run high, particularly after the ap- Order III.] MEASLES. 263 pearance of the eruption, and are accompanied with a strong pulse, much coughing, great difficulty of breathing, and other symptoms of pneumonic inflammation; in which cases it will be proper to draw off a quantity of blood proportioned to the age and habit of the patient. We should, however, be careful never to draw blood unnecessarily, nor to take a greater quantity away than what may really be requisite. Topical bleeding by means of leeches to the chest or head, when symptoms of local inflammation in either of these are apparent, may be more advisable than venesection. So long as a considerable difficulty of breathing, a troublesome cough, or any other symptom indicative of inflammatory action in the lungs exists, the topical abstraction of blood from the chest by means of leeches, or the scarificator with cupping-glasses, may be repeated from time to time. In those instances where the pulse is weak, and from the nature of the epidemic we may have strong reasons to ap- prehend an accompanying fever of the typhoid kind, or a disposi- tion to putrescency, venesection ought not to be adopted. During the whole course of the disease it will be highly proper to keep the body open ; and therefore, if costiveness prevails, it should be obviated by giving cooling laxatives, such as the neutral salts and emollient clysters. Should the difficulty of breathing and oppression at the chest not be relieved by the bleeding, and other antiphlogistic means, a blister may then be applied in the neigh- bourhood of the part or between the shoulders. In removing local inflammation, the application of a blister often proves a valuable remedy. Where inflammation attacks the chest, a warm bath strongly im- pregnated with salt has been found a powerful subsidiary remedy in addition to blood-letting.* The cough being usually very troublesome, it will be necessary to make frequent use of^ome demulcent pectoral, either of an oily or mucilaginous nature, as advised under the heads of Catarrh, Pleurisy, and Peripneumony, which will sheath the throat, and ob- viate that rawness and soreness of it, which are generally much felt. Besides using pectoral medicines, the patient may drink freely of barley-water, linseed-tea, or the decoctum hordei compositum, gently acidulated with lemon-juice. If the patient is oppressed with a tenacious phlegm threatening suffocation, the best way of dislodging it is to give an emetic. Where the cough proves very troublesome, and is attended with great difficulty of breathing or soreness at the chest, inhaling the steam arising from warm water and vinegar may prove serviceable. A pediluvium might be a good auxiliary. If the febrile symptoms run high, and great heat, thirst, and restlessness prevail, small nauseating doses of antimonials may be given every two or three hours, as advised under the head of 3ee Dr. Armstrong on Scarlet Fever, he. 264 PYREXIJE, OR FEBRILE DISEASES. [Class I. Simple Continued Fever, in order to determine to the surface of the body. In this, as well as in other cases of excitement, it will be advisa- ble to have recourse to nitre and saline draughts, along with anti- monials, whenever the inflammatory symptoms run high. When the cough harasses the patient much by night, so as to deprive him of rest, it may be necessary to give him an opiate about bed-time. The tinctura opii may be used for adults, combined with some diaphoretic ;* but for children it will be better to sub- stitute the syrupus papaveris somniferi. Opiates are, however, to be administered with great caution in this disease, as well as in all other inflammatory ones, and ought never to be employed where there is much fever present, with great difficulty of breathing. When these symptoms have been removed by timely bleeding, ape- rient medicines, &c. and the cough and watchfulness are those only which are urgent, opiates will prove both safe and efficacious. In formidable cases of measles, when the urgency of the cough, the quick, difficult, anxious, or laborious respiration, with a high fever, denote a dangerous disease, but in which blood-letting, or the exhibition of opium, may be thought equivocal, we may recom- mend full doses of the tinctura digitalis.! In such cases the fever is allayed, respiration relieved, and the bowels relaxed by its means ; whereas the very reverse is frequently the consequence of opium. Hence its superiority in many instances. If a severe purging should arise, we may moderate it by giving astringents joined with opium (see Diarrhoea;) but as an open state of the bowels proves serviceable, it ought not to be sup- pressed, unless it is violent. When the eruption of measles disappears before the proper period, and great anxiety, and delirium, or convulsions, take place, the indication will be to restore the eruption to the skin. To effect this, immediate recourse must be had to the warm bath, blisters to the chest and legs, and the administration of wine properly diluted * 1. g; Liquor. Ammon. Acetat. f. ^ss. Aquas Purae, f. §j. Spirit. iEther. Nitrici, TO. xxv. Liq. Antimon. Tart. HI xv. Tinct. Opii, fll xxv. Syrup. Tolutan. 3»j- M- ft. Haustus. t 2. R Misturae Camphorae, f. .2[x. Spirit. .Ether. Nitrici, f. 3j. Tinct. Digitalis, VC[ xiv. Syrup. Papav. Somnifer. f. 3'j- M U Haustus. * 1. Take Solution of Acetate of Ammonia, half an ounce. Pure Water, one ounce. Spirit of Nitric .Ether, forty drops. Solution of TartarizedAntimony, twenty drops. Tincture of Opium, forty drops. Syrup of Tolu, two drachms. Mix them for a draught. t 2. Take Camphor Mixture, ten drachms. Spirit of Nitric iEther, one drachm. Tincture of Foxglove, twenty drops. Syrup of Poppies, two drachm0. Mix them for a draught Order If I.J jieasle,-;. 2Q-5 with warm water : ammonia, camphor, aether, and antimonials^ will be the best medicines.* Should the symptoms manifest a malignant kind of the disease, and a putrid tendency prevail, we must then adopt a very different mode of treatment from what has been advised for the inflamma- tory. The cure must be conducted on the general antiseptic plan by cinchona, wine, acids, (particularly the mineral) and pure air, &c.—See Typhus Gravior. Throughout the whole course of the measles the patient ought to be confined to his bed, and to avoid any exposure to cold air, which might repel the eruption ; but in observing this precaution, he is not to run into the opposite extreme, and excite increased heat either by loading himself with bed-clothes, or by not allowing a sufficient ventilation through his chamber. The degree of tempe- rature should be regulated by the patient's feelings. Rubeola does not either require or bear the free application of cold, which is so potent a remedy for the most distressing symptoms of scarlatina ; but nevertheless the propriety of coolness in the apartment and bed, as also in the drink of the patient, must be obvious. A diluent and antiphlogistic diet being one of the best means of obviating inflammatory complaints, we ought to recommend it in the early stages of measles : but in managing it properly, we should recollect its tendency to produce debility, and in weak habits be careful not to push it too far. Where the disease shows a malig- nant and putrid tendency, a diet, of this nature would be highly im- proper. In such cases a quantity of wine, proportioned to the age of the patient, the urgency of the symptoms, and the effect it pro- duces, ought to be allowed, in addition to the bark of cinchona, mineral acids, and opiates. After the disappearance of the eruption, it will be proper to give one or two doses of some Cooling purgative. This practice, although disregarded by many, seems nevertheless worthy of atten- tion, as ophthalmia and other troublesome complaints may proba- bly be prevented by conforming to it. If a difficulty in breathing, pain in the side, and cough, should " 3. ft Pulv. Antimon. gr. ij. . *3. Take Antimonial Powder, twograins. Camphorae, gr. iij. Camphor, three grains. Ammoniae Subcarbonat. gr. iv. ] Subcarbonate of Ammonia, four grains. Confection of Orange Peel, a suf- ficiency to form a bolus, which is to be given every four or six hours. Or, Confect. Cort. Aurant, q. s. M. ft. Bolus, quartis vel sextis horis adhi- bendus. Vel, 4. ft Liquor. Ammoniae Acet. f. ?i. Misturae Camphorae, f. !|v. Spirit..Ether. Sulph. C. f. 3ij. Liquor. Antimon. Tartarizat. fl| xx. M. l\. Mistura cujus sumantur cochlearia duo magna secunda vel tertia quaque hora 4. Take solution of Acetate of Ammonia, one ounce. Camphor Mixture, five ounces. Compound Spirit of Sulphuric ./Ether, two drachms. Solution of Tartarized Antimony, thirty drops : shake them. Of this mixture take two table-spoonsful every second or third hour. 3'5 266 PYREXIJE, OR FEBRILE DISEASES. [ClttSS I. ensue in consequence of the measles, it will be advisable to take away a proper quantity of blood, in order to remove the inflamma- tory state of the system which has been induced by the disease; besides which, the patient must pursue the other steps advised under the head of Incipient Phthisis Pulmonalis, making use of a milk and vegetable diet, breathing as pure an air as possible, and taking daily horse exercise : but he should carefully avoid cold. As a weeping from the eyes and slight ophthalmia are apt to ensue after the measles, it may be right to wash them occasionally with a little rose water, in which a few grains of the sulphate of zinc have been dissolved, and to avoid exposure to any glaring light. Having gone through the treatment of measles, it only remains to be observed, that the disease may be propagated by inoculation, as well as the small-pox. Dr. Home, of Edinburgh, appears to have been the first who actually made the experiment, and from not being able to collect either matter, or a sufficient quantity of broken cuticle at the time of desquamation to produce the disease, he drew blood from the most superficial cutaneous vein, where the eruption was thickest. This received on cotton, he applied to a wound made on each arm of the person to be inoculated. We are informed by him, that he inoculated twelve persons in this way, in all of whom the operation succeeded equal to his hopes. The eruptive fever generally commenced six days after inoculation, and the symptoms of the complaint were milder than they generally are in the casual measles. The fever was less severe, the cough either milder or wholly absent ; the inflammation of the eyes was trifling ; they watered, however, as much ; and the sneezing was as frequent as in the casual measles ; nor did bad consequences follow any case of inoculated measles. No affection of the breast remained after it. The chief difference between the casual and inoculated measles seemed to be the absence of any pulmonic affection at all periods of the latter. It appears that Dr. Home tried another experiment. He put a piece of cotton, which had remained in the nose of a patient under the measles, into that of a healthy child, making him breathe through the infected cotton; but the experiment, although repeated did not succeed in inducing the disease. Notwithstanding Dr. Home's success, still inoculation for the measles is seldom or never practised. The few who have been in- duced to attempt it, have not, I believe, made quite so favourable a report of it ; on the contrary, it has been said to have produced an aggravated disease. When the measles prevail epidemically, it may be advisable to confine such children as have never had them to a vegetable diet, giving a gentle aperient once or twice a week. Children thus pre- pared may be likely to have a mild disease. Order III.] SCARLET FEVER. 267 SCARLATINA, or SCARLET FEVER. The characteristics of scarlatina are as follow.—The fever is the contagious synocha. About the fourth day of the disease the face is a little swelled : a florid redness in large spots, afterwards coalescing, spreads partially over the skin, and in three days more or so goes off in furfuraceous scales, often succeeded by anasarca. The disease takes its name from the colour of the patient's skin. It is divided into three kinds: when unaccompanied with an ulceration of the throat, it is named scarlatina mitis, or simplex ; when attended with such an affection, it is called scarlatina angi- nosa: and when accompanied by symptoms of malignancy and putrescency, the term scarlatina maligna is applied to it. The two latter are, however, very frequently blended together. It has been disputed, whether the scarlet fever and malignant sore throat ought to be esteemed different diseases, or only varieties of the same disease. In my opinion they are the same in specie, which is confirmed by our finding that they are both epidemical at the same time : even in the same family, where a number of children have been ill either together, or immediately after one another, some have had the dis- tinguishing symptoms of scarlet fever, and others of the malignant sore throat. Indeed it is now pretty generally admitted, that scar- latina, in all its forms, as well as the cynanche maligna, is produced by the same specific contagion.* There prevails much doubt amongst practitioners respecting the recurrence of scarlatina, some affirming that they have seen the dis- ease recur in so manifest and unequivocal a form, as to leave no doubt on their minds as to its possibility, whilst others deny its ever affecting the same person a second time. Amongst the great number of persons who have been infected, a few may be admitted, I think, to have gone through it a second time : but persons who have once been attacked with it, are less susceptible than those who never have had it. Scarlatina attacks persons of all ages, but children and young people are most subject to it, and it appears at all seasons of the year; but it is more frequently met with towards the end of autumn, or beginning of winter, than at other periods, at which time it often becomes a very prevalent epidemic. Sudden changes from heat to cold, rainy weather, and indigestion, may predispose the body to be acted upon more readily by the infection. As an epidemic, scarlatina does not always assume precisely the same appearance. This diversity depends probably, in part, upon the varying nature and constitution of scarlatina itself, inde- pendently of all extrinsic circumstances ; in part, upon certain contingencies, which are common to all the inhabitants of a whole " See Dr. Willan on Cutaneous Disease?. Order iii, 2,ti& pi'rexls:* or febrile diseases. [Class K district of country : such as the season of the year, the temperature of the air, the mildness or inclemency of the weather, together with other unknown qualities of the atmosphere ; and partly upon circumstances which apply to individuals subjected to the disease, their general habit of body and constitution, their particular state of health at the time of the attack, and their situation with respect to lodging, ventilation, and cleanliness. Beyond all doubt scarlatina is of a very contagious nature. Simple contact, inoculation, and inhalation, are the different ways by which the infection, not only of scarlet fever, but of other con- tagious disorders, may be introduced into the human body. It is the opinion, however, of Dr. Blackburne,* that the chief and only avenues to infection, in common, are the mouth and nostrils ; and, consequently, that to guard against its communication through these channels, is the principal, or only necessary precaution. He thinks that the introduction of infectious particles into the human body by simple contact is impossible ; and to support this, he brings forward the testimony of the late philanthropic Mr. Howard, who made no scruple of going into the open air to the windward of a person ill of the plague, and feeling his pulse; as likewise that of Djy Russell, who personally attended the sick in the plague, and felt the pulses of a great number. That infection by the simple contact of poisonous matter on the skin is far less ready to excite disease than when applied, in the subtile state of vapour, to the more irritable surface of the nostrils and bronchiae, is indisputable; but that it proves universally innocuous under every state and condition of the body, may be doubted. The disorders to which scarlatina bears the greatest resemblance are the measles and cynanche maligna; but from the former it may be distinguished by attending to the following characteristic marks, in addition to those noticed under the head of Rubeola. The efflorescence in scarlatina generally appears on the second day of the fever ; in the measles, it is seldom very evident until the fourth. It is much more full and spreading in the former disease than in the latter, and consists of innumerable points and specks under the cuticle, intermixed with minute papulae, in some cases forming continuous, irregular patches; in others, coalescing into an uniform flush over a considerable extent of surface. In the measles the rash is composed of circular dots, partly distinct, partly set in small clusters or patches, and a little elevated, so as to give the sen- sation of roughness when a finger is passed over them. These patches are seldom confluent, but form a number of crescents, with large intervening portions of cuticle, which retain their usual ap- pearance. The colour of the rash is also different in the two diseases, being a vivid red in the scarlatina like that of a boiled Jobster's-shell; but in the measles a dark red, with nearly the hue of a raspberry. See his Observation's on the Prevention and Cure of Scarlet Fever Order III.J scarlet fever. 2fi9 During their febrile stage, the measles are distinguished by an obstinate harsh cough, forcing up, in repeated paroxysms, a tough acrimonious phlegm ; by an inflammation of the eyes and eyelids, with great sensibility to light; by an increased discharge from the lachrymal glands, sneezing, &c. Scarlatina is frequently attended with a cough, as also with redness of the eyes ; but on minute ob- servation, it will generally be found that the cough in scarlatina is short and irritating, without expectoration ; that the redness of the eyes is not attended with intolerance of light; that the ciliary glands are not affected ; and that, although the eyes appear shining and watery, they never overflow. In scarlatina there is usually a peculiar sensation of anxiety, depression, and faintness in all cases which are attended with fever ; whereas in the measles symptoms of general inflammation are to be met with, except where the disease appears under a malignant form. The following are the chief distinctions between scarlatina mitis and cynanche maligna. The fever in the former is somewhat of an inflammatory nature, and is unattended with sloughy ulcerations in the throat: in the latter these are always to be observed, the breath is very fetid, and the accompanying fever is of the typhoid kind. In scarlatina the skin is of a brighter scarlet, smooth, and always dry and hot; in cynanche maligna it is red and pimply, the pimples being redder than the interstices. Scarlatina mitis, like all other fevers, begins with languor, lassi- tude, confusion of ideas, chills, and shiverings, alternated by fits of heat. The thirst after a little time becomes considerable, the skin dry, and the patient is often incommoded with anxiety, nausea, and vomiting. The alvine evacuations are most commonly of the usual quantity; the urine is high-coloured and turbid ; and the pulse is weak, and varying from fOOto 120 strokes in a minute. In a few cases some slight affection of the fauces is perceived. About the second or third day the scarlet efflorescence appears on the skin, which seldom produces, however, any remission of the fever. On the departure of the efflorescence, which usually con- tinues out only for three or four days, a gentle sweat comes on, the fever subsides, the cuticle or scarf-skin falls off in small scales, and the patient gradually regains his former strength and health. Such is the disease in its mildest aspect. In scarlatina anginosa the patient is seized not only with a cold- ness and shivering, but likewise with great languor, debility, and sickness, succeeded by heat, nausea, vomiting of bilious matter, soreness of the throat, inflammation and ulceration of the tonsils, uvula, and velum pendulum palati, a frequent and laborious breathing, and a quick, small, and depressed pulse. When the efflorescence appears, it brings no relief; on the contrary, the symptoms are much aggravated, and fresh ones arise. In the progress of the disease, one universal redness, unattended however by any pustular eruption, pervadec the face, bodv. and 270 PYREXIJE, OR FEBRILE DISEASES. [Class I. limbs, which parts appear somewhat swollen. The eyes and nostrils partake likewise more or less of the redness ; and in proportion as the former have an inflamed appearance, so does the tendency to delirium prevail. There is moreover an acrid discharge from the nostrils, which excoriates whatever part it falls upon. On the first attack of scarlatina anginosa, the tonsils and uvula are much inflamed, but the inflammation is soon succeeded by dark-coloured sloughs from three to five lines in diameter, or under the surrounding surface, and which conceal beneath them spreading gangrenous ulcers. These occasion the breath to be highly fetid. The patient is often cut off in a few days. Even if he recovers, it will be by slow degrees, and probably anasarcous swellings will ensue. In some instances, swellings of the submaxillary, parotid, or other small glands arise, and prove troublesome and tedious in suppurating. The malignant form of the disease is characterized by the fol- lowing appearances : its symptoms, on the first day, are nearly the same as in the scarlatina anginosa; but some of the following peculiarities are afterwards observable. The pulse is small, in- distinct, and irregular; and the tongue, teeth, and lips, are covered with a brown or black incrustation. There is a dull redness of the eyes, with a dark red flushing of the cheeks, deafness, delirium, or coma. The breath is extremely fetid ; the respiration rattling and laborious, occasioned partly by a viscid phlegm clogging the fauces; the deglutition is constricted and painful; and there is a fulness and livid colour of the neck, with a retraction of the head. Ulcerations are to be observed on the tonsils and adjoining parts, covered with dark sloughs, and surrounded by a livid base; and the tongue is often so tender as to be excoriated by the slightest touch. An acrid discharge flows from the nostrils, causing sore- ness, or chops, nay even blisters, about the nose and lips ; the fluid discharged being at first thin, but afterwards thick and yellowish. The rash is usually faint, excepting in a few irregular patches ; and all of it presently changes to a dark, or livid red colour. It appears late, is very uncertain in its duration, and often intermixed with petechiae. In some instances the rash disappears suddenly a few hours after it is formed, and comes out again at the expiration of two or three days. In an advanced stage of the disease, where petechiae and other symptoms charac- teristic of putrescency are present, haemorrhages frequently break forth from the mouth and nose. When scarlatina is to terminate in health, the fiery redness abates gradually, and is succeeded by a brown colour; and the skin becoming rough, peels off in small scales: the tumefaction subsides, and health is gradually restored. On the contrary, when it is to terminate fatally, the febrile symptoms run very high from the first of its attack, the skin is intensely hot and dry, the pulse is very frequent hut small, great, thirst prevails, the breath is very Brder UI.J SCARLET FEVER. 271 fetid, the efflorescence makes its appearance on the second day, or sooner, and about the third or fourth is probably interspersed with large livid spots; and a high degree of delirium ensuing, or haemorrhages breaking out, the patient is cut off about the sixth or eighth day. In some cases a severe purging arises, which seldom fails to prove fatal. Some again, where the symptoms do not run so high, instead of recovering, as is usual, about the time the skin begins to regain its natural colour, become anasar- cous, or fall into an atrophy, and are carried off in the course of a few weeks. Scarlatina in its mild state is not usually attended with danger; but when it partakes much of the nature of cynanche maligna, or discovers a putrid tendency, it often proves fatal. The discharge of a highly acrid matter from the nose, diarrhoea, the fauces of a dark red or purple colour, without swelling, ash coloured or brown specks, soon becoming ulcerated, great prostration of strength, delirium, coma, anxious difficulty of breathing, petechiae, and haemorrhages, are very unfavourable symptoms. When scarlet fever is very mild and wholly unattended by any inflammation or ulceration in the throat, little more will be requisite than to keep the apartment clean and open; to enforce a light diet without animal food; to direct cooling acidulated liquors for common drink, and to administer gentle medicines suitable to the symptoms that present themselves. In more severe cases, where the skin is very hot and dry, the pulse much accelerated, the head very painful, and advice is called lor at the onset of the disease, the best step we can adopt, is to have recourse to affusion, or immersion in cold water, for the speediest and most effectual relief will be obtained by it. In pri- vate practice, where there often arises much difficulty in sub- duing prejudices, and we are prevented from making use of cold affusion, or immersion, we must be content to substitute simple ablution pretty generally over the whole body with a sponge dipped in equal quantities of cold water and vinegar. Dr. Currie mentions in his Medical Reports, that he found the affusion of cold water to extinguish incipient scarlatina in repeated instances, so as to prevent either efflorescence or any affection of the throat from taking place. He says, the plan that I follow, if called in at this early period, where the patient feels steadily hot and the shivering having gone off, is to strip him quite naked, and dash four or five gallons of the coldest water over his naked body ; the heat returning, it is sometimes necessary to use it ten or twelve times in twenty-four hours. During this time, he says, cold water and lemonade should be used as drinks, and the bowels opened, if necessary, by the submuriate of mercury. In a few cases he has thought it advisable to assist the affusion by the diaphoretic power of a solution of tartarized antimony. He adds, that in upwards of 150 cases he uniformly followed the practice here detailed, and with a degree of success so nearly invariable. £72 PVREXI.E, OR FEBRILE DISEASES. [ClttSS /. that he could not contemplate it without emotions of surprise, as well as of satisfaction. We are also informed by Dr. Mosman,* that during the hot stage of scarlatina he has seen the most happy effects derived from sponging the body over with cold vinegar and water, and by allowing a free current of air through the patient's chamber. He very properly cautions us, however, against such a practice, when the least chilliness prevails, or where there is a tendency to perspiration. In such cases, tepid water and vinegar may be substituted. Some communications from Dr. Reid,l physician to the Finsbury Dispensary, bear also ample testimony of the unequivocal efficacy and success which attended the use of cold and tepid ablution in many cases of scarlatina. He mentions, it ought to be kept in mind, that in an early stage of the disease, when the strength is not much reduced, when the skin is hot and dry, and where the febrile anxiety is considerable, cold washing is decidedly indicated. But when extreme debility has come on, after the fever has con- tinued for several days ; when the pulse is small and irregular and the skin more relaxed, then the reaction produced by cold washing might prove too violent, and of course, in such cases, tepid spong- ing is preferable. The experience which I have had not only of the perfect safety, but likewise of the utility of both affusion and ablution with cold water at the onset of scarlatina, where there is great heat and dry- ness of the skin, with considerable febrile anxiety, and a rapid pulse, induces me to regard these remedies as means very likely to afford decided relief, and under such circumstances to recom- mend their being more generally adopted than what they are. In an advanced stage of the disease, tepid ablution will certainly be preferable. On the first coming on of both scarlatina mitis and scarlatina anginosa, it would seem proper to administer an emetic of ipeca- cuanha, for the purpose of dislodging any mucus that may have ac- cumulated in the throat. In the last more particularly, I am fully convinced it ought never to be omitted ; and probably a slight re- petition of it might be the means of preventing any disposition to diarrhoea, which is so apt to arise, from a considerable quantity of acrid matter passing from the fauces into the stomach, and from thence to the intestines. After vomiting, it will be proper to dislodge all feculent matter from the bowels by means of some gentle aperient ;| and during * See Dr. Duncan's Annals of Medicine for 1799, Article xii. t See Medical and Physical Journal, vol. xi. page 27. ~ 1. ft Hydrargyri Submuriat.gr. iij. t 1- Take Submuriate of Mercury, three grains. Pulv- Rhei; vel Jalapae, gi\vj.—xij. Powdered Rhubarb, or Jalap, M. from six to twelve grains. ft, Puh is aperiens ex raelle sumendus. { Mix them in a little honey. Order ///.] Scarlep fever. .113 the remainder of the disease, if costiveness arises, it must be obviated by laxative clysters administered from time to time, as the occasion may require. These, as inducing no debility, will be far preferable to purgatives, when the disease has made some progress. Purgatives ought indeed carefully to be avoided, except oh the first onset of scarlatina; and even then, vVhatever we employ, should be of the mildest nature, lest we should induce diarrhoea, which is apt to occur of itself. This precaution, with respect to administering purgatives in scarlet fever, but more particularly in that species of it which has been denominated scarlatina anginosa, although sanctioned by the opinion of most of our eminent physicians, and ratified by my own experience, by no means accords with the directions of a modern writer ;* for he tells us, that in treating scarlatina he has con- fided much in the use of purgative medicines, and that no variety of the disease has prevented him from pursuing out this practice to the extent he judged necessary. He indeed somewhat qualifies this mode of treatment, by afterwards acknowledging, that he wishes to limit their effects to the express purpose of unloading the bowels, and securing the complete expulsion of their contents, without inducing what he calls full purging. Bleeding from the system will not be necessary in scarlatina mitis, even although a slight inflammatory diathesis may seem to prevail on its attack. In those cases of scarlatina anginosa where the tonsils are so much inflamed and swelled as to impede deglu- tition, or considerably interfere with respiration, it will be much safer to apply a few leeches under each ear, ^rfid draw blood in this way from the neighbourhood of the parts immediately affected, than from the system by venesection. Where the eyes look red and fiery, and a high degree of delirium prevails in scarlatina, the application of two or three leeches to each temple may be resorted to with safety, and possibly with some relief. The physicians on the Continent have indeed recommended drawing blood from the arm, or when the head is much affected, from the jugular veins; and it appears that Morton adopted the same practice in many of the cases he attended in London: but I think there will be found very few among our modern physicians who would advise it, particularly in scarlatina maligna, even at an early stage of the disease. Dr. Armstrong! is, however, among the few who approve of venesection; and we are told by him that experience in scarlatina has induced him to abandon the stimulant plan of treatment, even in the most malignant forms of the com- plaint, from having ascertained its inefficacy: and that since he has had recourse to depletory measures of an active and decided kind, he has practised in the disease with much more satisfaction of mind, arising from far greater evidence of success. * See Observations on the Utility of Purgative Medicines, by Dr. Hamilton. * See his Practical Illustrations of the Scarlet Fever, he 10 > 2.-; 4 PiKEXE*;, OR FEBRILE DISEASES. [Class 1. Even in scarlatina maligna let the practitioner, he says, give a fair trial to the cold affusion as soon as the stage of excitement is developed, and if they should not effectually reduce the fever, let him not pause an instant longer, but open a vein in the arm or neck, or even a branch of the temporal artery, and allow the blood to flow until it is stopped by approaching faintness. If this should not give, he adds, a marked relief to the most prominent symptoms, a second but more moderate venesection should be tried in an hour or two afterwards. The putrid symptoms only occurs, he says, in the stage of collapse, and are the products of the preceding stage of excitement. The head must be always raised very high, and after having been shaved, it should be repeatedly covered with folds of linen soaked in cold water. Im- mediately after the bleeding, the bowels are to be opened by a large dose of submuriate of mercury and jalap, aided by the sulphate of magnesia, or some other neutral salt, and the purgative plan must be persisted in vigorously until there is a visible change for the better in every respect. It must however be recollected, he observes, that these powerful proceedings must be solely confined to the stage of excitement, and that unless they are carried into effect within the first thirty hours of that stage, nothing decidedly beneficial is for the most part to be expected from them. To determine gently to the surface of the body, it may be ad- visable to give the saline medicine from time to time with small doses of some antimonial.* Throughout the whole course of the disease, if there is either inflammation or ulceration in the throat, it will be proper to make frequent use of some detergent gargle, as recommended under the heads of Cynanche Tonsillaris and Maligna, which in young children may be thrown into the fauces with a syringe, as they seldom can be prevailed on to gargle. A little of the linimentum ammoniae subcarbonatis may at the same time be rubbed twice or thrice a day externally, covering the parts afterwards with flannel. Where the throat is much affected, a mustard poultice may be applied, and kept on as long as it can be borne without producing too great a degree of irritation. When the fauces are in a sloughing or gangrenous state, a warm fomenta- tion of nitric acid largely diluted, together with the stimulating gargle of Cayenne pepper, as mentioned under the head of Cy- nanche Maligna, will be likely to prove highly serviceable. " ft Haust. Sal in. Mistur. Camphorae, aa f. 3yj. Antimon. Tartarizat. gr. l-6th. Syrup. Cort. Aurant. f. 3j-£_M. ft. H?>u«tus 4th horis sumendus. * 4. Take Saline Draught. Camphor Mixture, of each six drachms. Tartarized Antimony, sixth of a grain. Syrup of OrangePeel,onedrachm. Mix them as a draught, to be taken every four hour's Order III.J SCARLET FEVER. 275 Blisters have been employed by some practitioners in those cases where the deglutition is difficult, the head much affected, or a high degree of delirium has arisen; but they have too frequently been observed to prove detrimental, by rather increasing the irritation of the patient. Immersing the feet and legs in warm water might probably be attended with a good effect. When blisters are applied under a tendency to putrefaction, they are apt to become gangrenous. In scarlatina maligna they never therefore should be used. To obviate inquietude and restlessness, opiates are sometimes resorted to ; but where the head is much affected, or there is delirium, they would prove injurious. JEther, and the spiritus astheris compositus, or Hoffman's liquor, would be more suitable remedies on such occasions. In those cases of scarlatina which show a disposition to malig- nancy or putrescency, it will be advisable to give the bark of cin- chona in substance, decoction, or infusion, (as shall be found to sit easiest on the patient's stomach,) along with the mineral acids, (particularly the muriatic,) wine, and other antiseptics, from the first commencement of the disorder.—See Typhus Gravior. As an antiseptic, carbonic acid gas has sometimes been used in this species of the disease with advantage. The best way of giving it is, by administering the neutralized medicine in such a manner as that the evolution of the gas may wholly take place in the stomach, which is to be done by the patient's taking the potassae subcarbonas and lemon-juice in separate draughts immediately after each other. The oxygenated muriatic acid is a remedy which has been much employed of late in scarlatina anginosa, and in many instances with a very beneficial effect, even at an advanced stage of the disease. The proper quantity for persons from fourteen to twenty years of age, will be about one drachm of it in the course of twelve hours, divided into small doses, and given atproper intervals. For younger patients a less quantity will be sufficient. As a vehicle to admi- nister the oxygenant remedy in, we may use common water or a weak infusion of calumbo; and to prevent the disoxygenating influence of the light, the medicine should be placed in a dark situation, wrapped in paper. In administering it to the patient, it will be necessary to caution the nurse or other attendant not to employ a spoon, lest a poisonous fluid be thereby [conveyed into the stomach, by the oxygen rapidly oxydating the metal of which it is composed. We may also employ the oxygenated muriatic acid in the form of gargle* in scarlatina anginosa. 3. ft Aq. Hordei, f. gvij. Mellis Rosae, i.gi. Acidi Muriat. Oxygenat. f. gi. Tinct. Myrrh, f. gss. M. ft. Gargarisma. * 3. Take Barley Water, seven ounces. Honey of Roses, one ounce. Oxygenated Muriatic Acid, one drachm. Tincture of Myrrh,half an ounce Mix them, and use them as a earele 27b" I'VREXXjE, OR FEBRILE DISEASES. [Class I. It may not be improper to mention, that camphor is a medicine much employed in scarlatina, and often with a seeming good effect; but more particularly in those cases where the pulse it very low, or the efflorescence disappears suddenly. In these instances ammonia, the aromatic confection, warm bathing, and wine, will likewise be advisable. A solution of the subcarbonate of ammonia, in the proportion of two drachms to five ounces of water, of which two tea-spoonsful are to be taken every two, three, or four hours, according to the urgency of the symptoms, is another remedy which has been found highly beneficial in this disease.* My usual plan of proceeding in both scarlatina anginosa and scarlatina maligna is, to give a decoction of the bark of cinchona, with an equal quantity of wine and a few drops of oxygenated muriatic acid, and in two or three hours afterwards the draught! of camphor and ammonia, and so on alternately; which mode of proceeding I have found very successful. If a purging arises in scarlatina anginosa, it ought to be sup- pressed as soon as possible, by astringents joined with aromatics, opium, and wine.—See Diarrhoea. The ©edematous disposition which ensues after some cases of scarlatina is to be removed by diuretics, joined with tonics and a generous diet, as advised under the head of Anasarca, giving at the same time some gentle laxative occasionally. By the generality of practitioners this oedema has been considered as a disease of atony, but we are told by the author of a small tract,! that his experience has proved it a true arterial dropsy, (as he terms it;) and he says that bleeding will often cure it without any assistance from medicine, but that purging is the safest and readiest means of * See Dr. Peart's Treatise on the Malignant Scarlet Fever and Sore Throat. | See Dr. G. Gregory's Lecture on Dropsy. Vel, 4. ft Piperis Indici, ^ij. Aq. Ferventis, f. §v. Macera et colaturae adde Decoct. Cinchon. f. §iij. Acid. Muriat. Oxygenat. f- gi. M. ft. Gargarisma. * 5. ft Camphorae, gr. v. Solve in Spirit. Rectif, f. 3ss- pt a(lde Aq. Pura?, — Cinnam, aa f. 3V> Ammonia? Subcarbonat. gr. x. Syrup. Cort. Aurant. f. gj. fi HaH^tus, 4ti"- bori? capiendus. Or, 4. Take Cayenne Pepper, two scruples. Hot Water, five ounces. Let them infuse, and to the strained liquor add Decoction of Peruvian Bark, three ounces. Oxygenated Muriatic Acid, one drachm. Mix them for a gargle. 15. Take Camphor, five grains. Dissolve it in Alcohol,half adrachm; then add Pure Water, Cinnamon Water, of each five drachms. Subcarbonate of Ammonia, ten grains. Syrup of Orange Peel, 1 drachm. Mix them, and let this draught be taken everv four hours. Order III.] SCARLET FEVER. 277 relief, and not bark and aromatics, hitherto generally prescribed in such cases. In most cases of scarlatina, when the fever has subsided, the cinchona, stomachic bitters, chalybeates, the mineral acids, wine, a nourishing diet, pure air, and gentle exercise, will greatly accele- rate the recovery of the patient. Scarlatina being of a very contagious nature, and never failing to excite the greatest consternation and anxiety when it breaks out in schools and families, it seems right to notice the means which have been recommended,* under such circumstances, for checking its progress, and attempting its total extinction. So long ago as 1779, Dr. Haygarth! preserved 37 boys from the scarlet fever in a boarding-school at Chester, by confining a patient ill of it to a violent degree, in a separate room of the same house, and by attention to perfect cleanliness. In a boarding-school at Bath, in 1805, two young ladies had a scarlet fever and a malig- nant ulcerated sore-throat, one of them dangerously. The go- verness visited the patients, and assisted to syringe their throats frequently in the day. After washing her hands, and with other strict attention to perfect cleanliness, so as carefully to avoid con- veying any contagious dirt out of the sick chamber, but without changing her garments, she went among 65 of her scholars in the adjoining rooms of the house to hear their lessons and examine their work : not one of these young ladies was infected with the fever, as Dr. Haygarth was informed by the physician who attended these patients. The testimony of such numerous facts proves, beyond all controversy, that contagious miasms, in his opinion, do not adhere to clothes so as to infect others closely exposed to them. Hence typhus, scarlatina, &c. are always caught either by miasms issuing from the patient, or by miasms issuing from the contagious poison in a solid or liquid form discharged from the patient; but not by miasms adhering to clothes, &c. It completely confirms the fourth law of contagion mentioned under the head of Typhus, which is of very great importance, being highly conducive to the simpli- city, facility, and certainty of the rules of prevention. If, in future, a patient ill of either typhus or the scarlet fever, be permitted to infect the family, where there is a room in the house for the separa- tion of the sick, it will be justly imputed to the want of knowledge or the want of care in the attendants. All masters and mistresses of boarding-schools ought for their own sakes, as well as for the interest of the children committed to their care, to be provided with one or more separate apartments, in proportion to the size of the establishment, for the reception of invalids. These should be so contrived that the communication between the rooms appropriated for the sick and the rest of the house may be speedily and completely cut off at any time. If the establishment be too small to admit of such appendages under the * See Dr. Blackbnrne's Observations on Scarlet Fever. i See Dr. Haygarth's Sketch of a Plan to exterminate the Small Pox, p. 247- -78 PYREXIA, OR FEBRILE DISEASES. [CYflRS /. same roof, a proper lodging should be reserved in the neighbour- hood, to be always in readiness, whenever the occasion might re- quire to resort to it. As soon as the fever manifests itself in one subject, the person so affected should be separated without delay from all the rest. The next essential step to be taken is to subdue unnecessary alarm and consternation; in the performance of which duty the parent or guardian must co-operate fully with the instructer. Where the scholars are numerous, and the extent and disposition of the pre- mises admit of it, the best plan is not to disperse the school; for by dismissing the children, those in whom the infection is latent, and to be afterwards produced, thereby convey it to their respective families, and so promote the further propagation of the disease, to the great injury of the junior branches in particular, who are more susceptible of the contagion than adults. Having ascertained and cut off the source of infection ; having separated the originally tainted as soon as they begin to sicken, and while they yet remain incapable of imparting disease; having disposed of them in proper apartments, and strictly enforced the rules of prevention ; the evil may be crushed in its infancy. The extent and magnitude of the mischief will thus be accurately measured and totally obviated. But if the accommodations of the establishment be too limited for the complete execution of this scheme, or parents be unwilling to commit their offspring to any other than their own inspection in the time of illness, it is a sacred duty imposed on them not to admit even a suspected child, much less a diseased one, into family intercourse with themselves, their other children, or their servants. A separate apartment, where circumstances allow of such a con- venience, ought to be in readiness, or in a state to be made ready, for accidental sickness. Here a strict quarantine should be per- formed, whether the subject be suspected or convalescent, the period of which may be regulated, partly by what is already known on the subject, and finally determined by future observation and the result of aggregated facts. If the child be really infected, im- mediate separation, with a suitable regimen, should be adopted. To annihilate the powers of contagion, we may employ fumiga- tions with manganese, salt, and sulphuric acid, as advised under the head of Dysentery ; or we may have recourse to those of the mu- riatic or nitric acid, as noticed under that of Typhus Gravior. In regard to prevention, it is obvious that an improvement of the diet in such as live low, moderate exercise in the open air, cold bathing, and in short every mode of strengthening the constitution, with great attention to cleanliness and ventilation, must have a tendency to ward off the disease. Those who are in attendance ought as much as possible to avoid inhaling the breath of the sick, as it is clear that scarlatina, as well as some other diseases, may be so received. By using a gargle of capsicum frequently, as noticed under the head of Cynanche Maligna, they probably may be enabled to resist contagion the better. Order 111.] the flauue. 279 PESTIS, or the PLAGUE. The plague is a fever of a putrid and very contagious nature, in the progress of which, extreme debility, buboes, carbuncles, pete- chiae, haemorrhages, colliquative diarrhoea, and such other symp- toms arise. The contagion of the plague is of a specific nature, giving rise to febrile symptoms, and particularly affecting the ner- vous and glandular system. Sir James M'Gregor, in his Medical Sketches of the Expedition from India to Egypt, notices, that the plague is subject to consi- derable varieties in different seasons and circumstances. In the Indian army, he observed, that when the disease first broke out, the cases sent from the crowded hospitals of the 61st and 88th re- giments were, from the commencement, attended with typhoid or low symptoms. Those which were sent from the Bengal volunteer battalion and from the other corps, when the army was encamped near the marshy ground at El-Hammed, were all of the intermittent and remittent type. The cases which occurred in"the cold rainy months of December and January, had much of the inflammatory diathesis ; and in the end of the season, at Cairo, Ghiza, Boulac, and on crossing the isthmus of Suez, the disease wore the form of a mild continued fever. The appearances of the plague have been arranged by different authors in different ways. The French writers on the subject have specified five varieties ; Dr. Russel has extended them to six; but the arrangement of Sir Brooke Faulkner,* drawn from exten- sive observation during the late appearance of that complaint in the island of Malta, which admits only of three species, appears to be the most judicious ; and this I shall therefore adopt. The pro- priety of distinguishing the plague into three species is also sanc- tioned by a small tract from the pen of Dr. Pearson.! The plague is by most writers considered as the consequence of pestilential contagion, which is propagated from one person to another by association, or by coming near infected materials. Some, however, have doubted whether the disease is really con- tagious or not, whilst a few! have asserted positively that it is not so, an absurd doctrine truly, which if acted upon by the Legislature would be likely to be attended with the most injurious consequences. The fact that it is evidently contagious is fully established in Sir James M'Gregor's opinion; but the laws of its transmission are not more accurately known than the specific nature of the contagion. Dead bodies, we are told, did not seem to convey it; the heated animal body, and still more with a febrile moisture on the skin, appeared to transmit it most readily. Among the most obvious causes which contribute to induce the plague besides * See his Essay on the Plague, inserted in the Edinburgh Medical and Physical Journal, vol. x. t See his Brief Description of the Plague. ! ^'ee Dr. M'Lean'? Researches in the Levant concerning the Plague, 280 PYREXIA!, OR FEBRILE insEASEiS. [ClaSS L contagion, may be enumerated the following, viz. corrupt or damaged grain, putrid fish or other animal substances, noxious exhalations arising from stagnant waters or slimy mud, a residence in confined situations where the current of air is obstructed, and the want of due cleanliness. The disease attacks persons of all ages and both sexes indis- criminately; but women, young people, and infants at the breast, have been observed in general to resist infection more than robust men. Those who were exposed to vicissitudes of heat and cold, such as bakers, cooks, and smiths, were noticed, during the cam- paign in Egypt, to be more particularly attacked with it. In some Eastern countries the plague is wholy unknown, but more particularly in Persia and Japan. The Egyptians denominate the winter and early part of the spring their season of the plague, which they acknowledge never passes without this disease appearing in some degree. It has also been remarked that the rise, progress, and abatement of this disease in different years, bears a striking resemblance to each other. At its first appearance, which is usually in November, it assumes its most deadly form, and those affected by it sink into the grave almost without complaint. During the winter and beginning of spring, it scarcely manifests any diminution of its virulence, but towards the end of the latter, when the weather increases in warmth as the summer approaches, its attacks become less frequent, and its malignant symptoms subside into the appearances of ordinary disease, still however retaining the characteristic one of glandular affection. Towards the end of June, it is said to disappear.* The plague is known to be most prevalent in Egypt soon after the inundation of the Nile, or rather its recession; for a quantity of slimy mud being deposited on the banks of the river and other places it has overflowed, occasions humid mephitic exhalations to arise, and which are supposed to produce the disease. From Sir Robert Wilson's account of the diseases of Egypt,! there is great reason to suppose that a humid state of the atmosphere is favour- able to the production of the plague ; for the English and Turkish armies which marched to Cairo escaped contagion, notwithstand- ing almost every village was infected; while the troops that re- mained stationary on the moist shore of Aboukir were severely affected, and lost many men. A dry atmosphere appeared to him not only to be a preventive of the plague in some degree, but like- wise to act as a remedy; for we are told that several men confined with this disorder in the hospital at Jaffa, escaped into the desert, and endeavoured to reach the army ; but finding the attempt im- practicable, they returned in three days perfectly recovered. Baron LarreyJ observes that the plague puts on a more formidable . * See Mr. Webbe's Narrative of Facts relative to the Plague in vol. vi. p. 118, of the Transactions of the London College of Physicians. t See his History of the Expedition to Egypt. ■t See his Memoirs of Military Surgery. Order HI.] the plague. 281 appearance during the continuance of the south winds than during the winds from the north or north-east. When the latter prevailed, its effects were diminished ; and if it continued for any time, the disease disappeared altogether. On the return of the south winds, (or khamsyn) it appeared again with as much violence as ever. A curious observation made by this gentleman was, that the plague rarely attacks wounded men whose wounds were in a state of plen- tiful suppuration; but as soon as the wounds were skinned over, a great many were seized, and few escaped death. He observed the same thing among the inhabitants of the country who had issues open. Galen, and many other celebrated writers, have also noticed, that in countries which they have seen ravaged by the plague, it had spared all those who had issues plentifully discharging. It has been observed that the plague generally appears as early as the fourth or fifth day after infection ; but it has not yet been ascertained how long a person who has laboured under the disease is capable of infecting others; nor how long the contagion may lurk in an unfavourable habit without producing the disease, and may yet be communicated, and the disease excited, in habits more sus- ceptible of the infection. It has generally been supposed, however, that a quarantine of forty days is longer than is necessary for persons, and probably for goods also. Experience has not yet de- termined how much of this term may be abated. If I mistake not, the Board of Trade has, however, under the sanction of the College of Physicians, somewhat abridged it. To repeal or abrogate the quarantine laws wholly because a few misguided men have asserted that the plague is not contagious, would be likely to bring down devastation on this nation by exposing it to the visitation of a malady the most destructive of any to human life. In the first species of the plague, according to the arrangement of Sir Brooke Faulkner, the energy of the brain and nervous system is greatly impaired, indicated by coma, slow, drawling, or interrupted utterance; the tongue is white, but little loaded with sordes, and usually clean, more or less, towards the centre and extremity, the anxiety is great, countenance pale, stomach extreme- ly irritable, and the strength much impaired. Rigours and pain in the lower part of the back are among the early precursors of the other symptoms. This was observed by Sir Brooke Faulkner and the other physicians at Malta to be the most fatal species of the plague, and prevailed chiefly at the commencement of the late disaster. Those who were affected sometimes died in the course of a few hours, and with petechiae. In the second species, the state of the brain is the reverse of what takes place in the former, the symptoms generally denoting a high degree of excitement; the pain in the head is intense, thirst frequently considerable, though sometimes wanting, countenance flushed, and utterance hurried. The attack is ushered in by pain n the hack, and rigours, as in the first species. Epistaxis notun- 37 282 pyrexia, or febrile diseases. [Class I. frequently occurs in this. Glandular swellings come out tardily, and after appearing, recede again without any remission of the general symptoms. Carbuncles arise over different parts of the body or extremities, which are rapidly disposed to become gangre- nous. The delirium continues extremely high and uninterrupted, and the patient perishes in the course of two or three days. Some- times he lingers on to the seventh, yet rarely beyond this period, without some signs of amendment. Sir Brooke Faulkner found the instances of this second species very numerous, and they were nearly as fatal as the preceding. In the countenances of some of the sick, just previous to the accession of the more violent symp- toms, there is an appearance of despair and horror which baffles all description, and can never well be mistaken by those who have once seen it. The third species is somewhat akin to the last, only the symp- toms are much milder, and the brain comparatively is little affected. The buboes and other tumours which make their appearance go on more rapidly and kindly to suppuration ; and by a prompt and early employment of remedies to assist the salutary operations of nature, the patient has a tolerable chance of surviving. Cases of this kind are often so mild, that persons have been known to walk about in seeming good health, and without any evident inconvenience from the buboes. Such are the characteristic symptoms of this malignant disease, the varieties of which seem to depend in a great measure on the constitution or state of the air at the period of the epidemic prevail- ing, and on the habit of body of the patient at the time of the attack. In no disease do patients bear motion worse than in this. The least motion has been known to induce syncope, and even death, particularly in the last stage of the complaint. The plague is always to be considered as attended with imminent danger, and when it prevailed in this country about two hundred years ago, proved fatal to most of those who were attacked with it. It is probable, however, that many of them died from want of care and proper nourishment, the infected being forsaken by their nearest friends; because in Turkey and other countries where attention is paid to the sick, a great many recover. Of the French army that invaded Egypt, little more, however, than one third of all that were attacked with the plague recovered, as appears by the report made by Dr. Desgenettes,* who was the chief physician to that army. The duration of the disease is various. In some instances the effect of the pestilential contagion is the immediate extinction of life ; and cases have occurred wherein the patient has survived but a few hours the first sensation of illness. In other instances again, he has lived till the thirteenth, and even the seventeenth day of the disease. Where the plague is ushered in by fever and delirium, it is ' See his Histoire Mtdioale de 1'Armee de POrient. Order III] THE FLAGUE. 283 seldom that the patient recovers ; in spite of every endeavour, he is generally deprived of life within forty-eight hours, or on the third day at furthest. If the fever does not occur until the second day from the attack of the disease, there is less danger, as time is thereby given to obviate the consequent symptoms. When the plague is unattended by buboes, it runs its course more rapidly, and is more generally fatal, than when accompanied by such inflammations. The earlier they appear, the milder usually is the disease. When they proceed kindly to suppuration, they usually prove critical, and ensure the patient's recovery. Sudden death has, however, been known to happen even when the violence of the constitutional disturbance appeared to have been subdued, when buboes have made their appearance, were suppurating, and the patient considered convalescent. It is generally a favourable sign when the bubo does not adhere, but shakes on its base. A gentle diaphoresis, arising spontaneously, has been known in many instances to prove critical. When carbuncles show a disposition to become gangrenous, the event will be fatal. Furuncles, pete- chiae, haemorrhages, severe vomiting, and a colliquative diarrhoea, denote the same termination. The worst forms of the disease are always accompanied with the usual symptoms of putridity and malignity; and such rarely ter- minate favourably. It has been remarked, that if a patient, after an access of delirium, was suddenly restored to his senses, he seldom recovered. Most cases terminate fatally wherein the pa- tient is comatose from the beginning. The typho-mania may be regarded as a more fatal form of delirium than the inflammatory. Dissections of the bodies of those who have died of the plague have discovered the omentum, stomach, and intestines grangrenous in some places ; the liver in a state of congestion and considerably enlarged, the gall bladder filled with black fetid bile, and the pericardium with a bloody fluid.* Proofs of inflammation and gangrene have also been found in the brain and its investing mem- branes, in the lungs, and kidneys. In many instances the glan- dular system has been found in a very diseased state, and the blood black and loose in its texture, similar to what occurs in putrid fever. Under the supposition that a person has been exposed to the contagion of the plague, and in consequence of this becomes much indisposed, the first step to be adopted is to give him an emetic, particularly where nausea or vomiting ensues. If a severe retching should prevail after the operation of the emetic, this may possibly be relieved by administering the saline medicines in the act of effer- vescence ; but if it should not, we may make an addition of a few drops of tinctura opii to each dose. To obviate costiveness and draw off any putrescent matter which * See Memoirs of Military Surgery, by Baron Larrey, abridged froni the French by J. Waller. * "284: fvrexi^:, OR FEBRILE LiSEASES. [Class L may be lodged in the bowels, it will be necessary to make use of some gentle laxative ; but large evacuations, by the aid of strong purgatives, would be very improper. In an advanced stage of the disorder, emollient clysters would be most advisable, as being less apt to excite diarrhoea, which, when it arises towards the close, generally destroys the patient. So careful are the Eastern nations in avoiding this occurrence, that they most commonly make use of suppositories only. When a diarrhoea does occur, either spontaneously or from an improper use of cathartics, it should be suppressed as quickly as possible by astringents, opiates, and every other means we can employ. We are informed by Dr. Russell, that many, particularly the Asiatics, make it a rule to let blood in all cases of the plague, if they see the patient at an early period; and some recommend it as late as the fourth, fifth, sixth, or seventh day ; and even some European practitioners have gone nearly as far. To him it ap- peared that very plentiful bleeding at the first appearance of the disease was of great service. Dr. Buchan was in the habit of occasionally resorting to bleeding, we are are told by Sir James M'Gregor, and that during the first season he had met with several cases where the operation proved of the greatest service. The Turks, we are informed, employ local instead of general blood-letting, most commonly, and in the latter they draw off only a very small quantity. Sydenham considered the plague as an inflammatory affection, and speaks of the efficacy of bleeding in the warmest terms ; and Dr. Mead* not only advises venesection, but declares that we must draw blood with a more liberal hand than in other cases, if we are to expect success from it in this complaint. In opposition to the opinion entertained by most modern physicians, who have con- sidered the plague as an affection of direct and excessive debility, a late writer! asserts, on the contrary, that it is one of excitement and congestion, and of course he advocates the necessity of em- ploying the lancet in its treatment. The advantages of blood-letting in this disease appear to be of a very dubious nature; for we are given to understand that Dr. Whyte, one of the physicians to the forces in Egypt, used the lancet very freely, but that every one of his patients died. In the first stage of the disease, where there exists congestion or turgescence in any part of the body, the application of cupping-glasses, with previous scarification, may probably be a safer remedy than venesection. It has been observed that a gentle diaphoresis sometimes proves critical, and carries off the disease, but more particularly when it arises spontaneously. To assist nature in throwing off the morbid matter by the pores, if possible, it will be right to employ diapho- * See his ^orks. f See Illustrations of Typhus and other Febrile Diseases, by J. Armstrong, M. D. Order III.J THE PLAQUE. 285 retics, such as the neutral salts, small doses of antimonials, or the pulv. ipecac, compos, as advised under the head of Simple Fever; the effects of which may be increased, by directing the patient to drink plentifully of diluent acidulated liquors ; and where the heat of the body is not very considerable, his strength may be supported under this operation by means of a little wine. Profuse sweating is, however, by all means to be avoided, as by inducing debility it would prove injurious. Dr. Falconer of Bath, in his Essay on the Plague, seems to in- sinuate, that no small share of the mortality formerly observed in this disease may be attributed to the sweating regimen, then com- monly employed for its cure. Instead of adopting this plan, he advises the avoidance of a warm bed, and indeed of a bed alto- gether, if possible, in the day time ; a circulation of free and cool air, light clothing, cool drinks, and particularly cold water ; and he mentions, that if any benefit is to be expected from the use of this regimen, it must be tried largely and steadily ; not as if cold liquor were an indulgence permitted or allowed, but as a remedy enjoin- ed, on which the principal dependence was to be placed. In addi- tion to these means Dr. Falconer recommends the external use of cold water in the manner pointed out by the late Dr. Currie of Li- verpool, and noticed under the head of Typhus Gravior. Savary, in his Letters on Egypt, mentions an anecdote which is considered by Dr. Falconer as much to his purpose. The captain of a ship, whose sailors had contracted the plague at Constantino- ple, caught it himself by attending on them : he felt, as he express- ed himself, excessive heat, which made his blood boil; the disease seized his head, and he perceived (as he thought) that he had only a few moments to live. The little remaining reason he had, taught him to attempt an experiment: he laid himself down quite naked on the deck : the heavy dews that fell, penetrated, according to his sensations, to his very bones. In a few hours he could breathe better; his agitated blood became calm, and bathing the morning after in the sea, he was perfectly cured. This case brings to my recollection another of a French soldier, and reported by Dr. Desgenettes, who being afflicted with the plague, threw himself into the Nile, under a high degree of delirium, and on being taken out of the water after a "short lapse of time, soon recovered from the disease, seemingly in consequence of his im- mersion. A similar case is brought forward of the good effects derivable from the sudden application of cold water by Sir Brooke Faulkner, in his Observations on the Plague.* Spunging the body with vinegar or citric acid has been found a useful remedy. Camphor is a medicine which has been much recommended in the plague. For the purpose of allaying irritation and procuring sleep, opiates See Edinburgh Med. and Surg. Journal for April 1814, p. 151, 286 PYREXIA, OR FEBRILE DISEASES. [Class I. are advisable, and, when used, have by no means been found to produce coma. They seem equally proper as in typhus. If we are so fortunate as to procure a crisis by the remedies which have been advised, the bark of cinchona should be given in as large doses as the stomach will bear, and be repeated every two hours; but if there is no chance of obtaining this desirable end, then, besides this bark, we should adopt the other means recom- mended under the head of Malignant Fever, with the view of ob- viating extreme debility and the disposition to putrescency. A free use of both vegetable and mineral acids seems advisable in the plague as well as in typhus gravior. Acidulated drinks will be highly proper. Sir James M'Gregor, in his tract before men- tioned, indeed hints that he found the nitric acid, and other irregu- lar remedies to be serviceable. He likewise employed mercury, as he thought, with some advantage; and when the mouth was speedily made sore by it, recoveries oftener took place in the same manner as in yellow fever, than when the system proved unsus- ceptible of the mercurial action. It appears from this gentleman's report, that some patients were kept under the influence of wine and opium for a time, according to the Brunonian theory, but that the practice never proved suc- cessful. Where the patient survives the disease, the treatment of the carbuncles or buboes becomes the province of surgery. Their de- velopement at an early period ought to be assisted by stimulants and rubefacients. OF THE MODE OF PREVENTION. It is well known that the pestilential virus which emanates from the human body may adhere for a long time to other substances, and preserve its power of producing and propagating future infec- tion ; and that in this manner it may be conveyed from the Eastern countries into any other; the persons first attacked by being ex- posed to the contagion, then becoming the source of infection to others. This fact being well established, it has been judged proper by the legislature of this kingdom and of some others, to oblige ships, persons, and all kinds of merchandise coming from places apt to be infected with the plague, to procure bills of health, or to undergo a certain quarantine, during which period the goods are, or ought to be, properly ventilated. An adherence to these re- gulations has of late years prevented the importation of the disease; but should it unfortunately ever be introduced, the following steps must be pursued for destroying the infection, and preventing its fur- ther propagation. 1st, The infected should be confined in lazarettos, surrounded by strict guards, and no kind of communication be held with them, ex- cept by such attendants as may be absolutely necessary. 2dly, The nurses or others employed in attending the sick, must Order III.] THE PLAGUE. 287 take care to come in actual contact with them as seldom as pos- sible, or place themselves in such a situation as that a stream of air may carry the effluvia towards them.* They should likewise pay an unrelaxing attention to personal cleanliness. Dresses of oiled silk have been strongly recommended by Sir Brooke Faulkner, as an invaluable armour to such persons as are constantly obliged to be about the sick.! One of these he wore himself, as did also the attendants in the military plague hospital at Malta, during the extensive prevalence of the disease, in the year 1813, in that Island. Medical attendants will act prudently in changing their linen and clothes, and in well washing their whole body, but more particularly their hands, with warm water and vinegar, as soon as they quit the lazaretto. 3dly, All substances capable of being impregnated with the effluvia, or of vitiating the atmosphere, ought to be removed from the apartments of the sick to situations where the healthy cannot suffer by them, and where they may undergo a proper purification by exposing them to a heat of about 120 of Fahrenheit, and then freely ventilating them. The linen and other clothes of the patient should be burnt. The dead should be immediately interred : pro- bably combustion would be preferable to inhumation. 4thly, The atmosphere surrounding the infected ought to be kept as pure as possible, so that neither the patient nor his attendants may suffer from the exhalations : with which view, the strictest attention should be paid to cleanliness, a free ventilation, and fumigating with the nitric or muriatic acid, as advised under the head of Malignant Fever. A long stay in pestilential apartments that are but little aired, ought carefully to be avoided, as also the exhalations from the dead bodies, or from patients in the last stage of the disease. 5thly, To avoid whatever weakens the body, by giving way to intemperance or sensuality, or by making use of a poor diet, great fatigue, or considerable evacuation. * It is a fact well known, that the pestilential poison, unlike other ordinary epide- mics, is confined to the vicinity of the affected body, and becomes so dilute at the distance of a very few paces, as to be incapable of further action. Mons. Samoi- lowitz, a celebrated Russian physician, and author of a very good Memoir on the Plague, insists that this disease exists neither in the air, nor is communicated by the air,butby contact alone: andMons. Sonnini tells us, thatit is sufficient for Europeans settled in Turkey to shut themselves up in their houses in order to be preserved from the contagion, even when it makes the greatest ravages in towns which they inhabit, and although they draw from without their provisions and daily food. The report made by Sir James M'Gregor likewise shows how very limited in extent is the action of contagion in the plague. Thirteen of the medical gentlemen of the army of Egypt were directly in the way of contagion, for it was their duty to come into contact with the infected; of these, seven caught the infection, and four died. To the atmosphere of the disease, all the medical men of the army were exposed, as they saw and examined the cases in the first instance ; but, except from actual contact, there never appeared to be any danger of contagion. Although the disease is communicated chiefly by contact, yet it appears to me that authors go too far when they infer that it is not communicable by an atmos phere strongly tainted with pestilential miasmata. t See Edinburgh Journal for April 1*14, 288 PYREXIAE, OR FEBRILE DISEASES. [Class I. 6thly, To keep the mind cheerful, and as free from care, anxiety. fever, and lowness of spirits, as possible. 7thly, As it is supposed that by strengthening the bodies of men we can thereby enable them to resist contagion the better, some advantages may probably be derived from using cold bathing, with wine, bark, and other tonic medicines, with a generous diet. Where access to the sea cannot be had, and water is scarce, the substi- tute proposed by a late writer* is, that a shirt be dipped every morning in a saturated solution of common salt in cold water, and after being well rung out to be put on wet and cold, keep- ing the body in motion for some time afterwards by moderate exercise. Those who cannot keep themselves isolated from the contagion, will act prudently, in conformity to the observations of Baron Larrey and other writers, in opening a large issue, or perpetual blister. In Dr. Duncan's Annals of Medicine for 1797, is inserted an ar- ticle relating to the cure and prevention of the plague by frictions of the whole surface of the body with olive-oil, and communicated, as we are given to understand, by George Baldwin, Esq. at that period his Britannic Majesty's agent, and consul-general in Egypt. It is mentioned, that there is no instance of a person rubbing a patient having taken the infection ; but, by way of precaution, it is advised to anoint himself all over with oil, and to avoid receiving the breath of the infected person into his mouth and nostrils. The prevention to be used in all circumstances, is that of carefully anointing the body, and living upon light and easily digestible food. A striking observation made by Mr. Baldwin is, that among upwards of a million of inhabitants carried off by the plague in Upper and Lower Egypt, during the space of four years, he could not learn that a single oilman, or dealer in oil, had suffered-! Mr. Jackson, in his Reflections on the Commerce of the Mediterranean, likewise informs us, that in the kingdom of Tunis, where the plague frequently rages in the most frightful manner, destroying some thousands of the inhabitants, there never was known any instance of any of the coolies, or porters, who work in the oil-stores, being in the least affected by this disorder, their bodies being always well smeared with the oil, as well as their clothes being imbued with it. It has been considered as pretty certain that in the generality of instances the contagion of the plague enters the body through the medium of the cutaneous lymphatics, and thence produces the dis- order of the lymphatic glands. This idea is illustrated by the pro- bability that the external use of oily frictions lessens the sus- * See Description of the Plague, Sic. by Richard Pearson, M. D. t It has been said,that when the plague raged in London, about two hundred years ago, the dealers in pitch, tar, and tobacco, were particularly observed to eicapc the contagion. Order 1IL] the pi.au u*,. 283 ceptibihty of infection ; and Sir James M'Gregor* mentions a fact which much favours the opinion, by observing, that the men who were employed in applying oily friction to the camels for some cpidemy affecting them, escaped the plague. The" evidence produced in behalf of the plan communicated by Mr. Baldwin, seems more satisfactory as to the preventive powers of the application, than as to its sanative properties after the disease has once taken place. It seems, however, right to notice, that Dr. Assalini, who was a medical officer in the French army which invaded Egypt, makes a favourable mention of oily frictions in his Observations on the Plague, as being generally followed by copious sweating; and to this, he thinks, their beneficial operation is to be attributed. We are also told by Mr. Jackson,! that he recom- mended the remedy to several Jews and Mussulmen during the time that the plague was depopulating West Barbary,'in 1799 and 1800, and no instance of its failure, when duly persevered in, even after infection had manifested itself, had c,ome to his knowledge. Inoculation for the plague has been tried by some physicians, in order to discover if this malady could not be checked or rendered less virulent thereby; and it appears from Sir Robert Wilson's History of the Expedition to Egypt, that Dr. Whyte, resolving to become the patient of his own speculation during the time this disease raged at Rosetta, inoculated himself with matter taken from the buboes of an infected person. The attempt failed twice ; the .third proved fatal in three days after the symptoms showed themselves. It likewise appears, that Dr. Desgenettes, in order to lessen the general alarm, and to inspire confidence among the French troops, inoculated himself both in the groin and arm-pit, with a lancet dipped in the pus of a bubo in a convalescent patient. The inocu- lation, however, failed; and the only consequence was a slight inflammation on the inoculated parts, which continued for more than three weeks. As the future susceptibility to the disease is by no means, how- ever, destroyed, for the same person may be afflicted with it repeatedly, and even may be attacked twice in the same season with it, as Dr. Desgenettes experienced, (many of the convalescents from the plague, who were appointed to take care of the sick, having been, he observes, seized a second time,) this experiment would not be advisable, unless it could be ascertained that the disorder is render- ed milder by the inoculation. This is a point not yet, however, es- tablished : indeed the information afforded us by Mons. Sonnini! seems to lead to a contrary conclusion; for he mentions, that a Russian surgeon, who was a prisoner at Constantinople, with a number of his countrymen, took it into his head to inoculate these * See his Medical Sketches. f See his Account of the Empire of Morocco" ". Travels iajo Greece and Turkey, p. 497, 290 PYREXIA?, OR FEBRILE DISEASES. [Class I. unfortunate men with the plague, under the supposition of render- ing the contagion less destructive; but by doing so, he killed two hundred of these prisoners : and fortunately for the rest, the inocu- lator, after having performed the operation on himself, soon died of his own treatment. By a paper read before the Royal Society of London, on the 27th of June, 1816, it appears, from comparative experiments on the disinfecting powers of vinegar, chlorine, and the fumes of sulphur, that the best and most efficacious method of disinfecting letters coming from places supposed to be visited by the plague, is to expose them to the fumes of burning sulphur, mixed with nitrate of potass. M1LIARIS, or MILIARY FEVER. This fever takes its name from the small pustules or bladders which appear on the skin, resembling in shape and size the seeds of millet, being in general numerous on the breast, back, and other parts where there is most moisture on the skin. It may be distin- guished from the other exanthemata by its pathognomic symptoms, the peculiar sour and rank odour of the sweat, attended with de- jection of spirits, oppression, and sense of constriction about the precordia, anxiety, and frequent sighing. Many of our modern physicians seem to think that the disease is never a primary one, but arises in consequence of some other ; particularly where much sweating has been excited, either by keeping the patient too warm, or by giving heating medicines. All debilitating powers, such as a lax habit of body, weakness, however induced, excessive evacuations, the presence of irritating matter in the primae viae, the period of child-birth, long-continued menstruation, &c. may be regarded, most probably, as predisposing causes, while the hot regimen is to be looked upon as the principal exciting cause of the eruption. This conclusion seems justifiable, as it is found, that whatever the state of the patient may be, miliary eruption is very generally avoided by exposure to cool air, and administering cold liquors. It has been observed to affect both sexes, and persons of all ages and constitutions, but that females of a delicate habit are most liable to it, particularly in child-bed. It is, however, by no means a contagious disease, and has rarely, if ever, been known to prevail epidemically. Moist variable weather predisposes most to this eruption, and its occurrences are more usual in the spring and autumn than in the other seasons. Winter is the least favourable to its appearance. Miliary fever makes its attack with a slight shivering, succeeded by heat, restlessness, loss of strength, depression of spirits, anxiety, sighing, difficulty of breathing, oppression at the chest, and a low quick pulse. The tongue appears white, the mouth is dry, the body costive, and when the disease is violent, coma or delirium Order III.} miliary fever. 291 is apt to arise. Great dejection of spirits and anxiety, with fetid sweats, are, however, the most common forerunners of the miliary eruption. The patient after a short time feels an itching or pricking pain under the skin, soon after which innumerable small pustules, of a red colour, and of the size of millet seeds, come out first upon the neck and breast, thence gradually extending to the trunk and ex- tremities ; their prominence is imperceptible to the sight, yet evident to the touch ; they often lose their redness, and appear of the ordinary colour of the skin. They are usually distinct, but now and then we may perceive them clustered together. About the second day after the appearance of the eruptions a small vesicle may be observed on the top of each pimple, and in two or three days more, they break, and are succeeded by small crusts, which fall off in scales. Sometimes it happens, that when one crop of eruptions has disappeared, another will succeed it. On the eruption being visible, most of the foregoing symptoms are usually relieved. The sweating is apt, however, to continue, unless proper means are used to check it, and to be attended for many days with a fresh crop of eruptions. The eruption being steady, and not disappearing after having come out; the fever inclining more to the nature of synocha than typhus; and there being a considerable remission of the symptoms upon the appearance of the eruption, denote a favourable issue; whereas great anxiety,* dejection of mind, vast prostration of strength, difficulty of breathing, flaccidity of the parts covered by the eruption, its sudden disappearance, a rapid, weak, and inter- mitting pulse, violent vomiting, profound coma, delirium, convul- sions, petechiae and other symptoms of putrescency, are to be con- sidered as prognosticating a fatal termination to the disease. The appearances to be observed on dissection will depend on the nature of the fever which accompanies the eruption, and which most usually is of the typhoid kind. As the disease is evidently brought on by the application of too much heat, an early attention ought to be paid to the means of pre- venting it from appearing, in those affections which it is apt to accompany. With this intent, the patient should not be covered with too many bedclothes; neither should the chamber be kept hot by means of too much fire, or by being closely shut up: on the contrary, a sufficient ventilation ought to be allowed, so as to keep it of a proper temperature. In doing this, we are, however, to take care not to run into the opposite extreme, and allow too free an admission of cold air. Sweats which are not followed by an abatement of the febrile symptoms, cannot of course prove critical, and may therefore be safely,.and advantageously checked, by keeping the patient's apart- ment cool, by covering him lightly and loosely with bedclothes, by making him lie with his arms exposed, and by giving him whatever he drinks perfectly cold * hut in sweats which are likelv to be 292 PYREXIAE, OR FEBRILE DISEASES. [ClttSsl. critical, the practitioner must take care to regulate the admission of air, so as that it shall not prove prejudicial. By adopting these precautions at an early period, we may often prevent miliary eruptions, which might otherwise have appeared : and after they have made their appearance, we probably may be able to moderate them, by using the same means. Miliary eruptions sometimes accompany inflammatory affections; in which case it will be necessary to have recourse to gentle aperients, or laxative clysters ; but bleeding ought never to be used. They are found to attend more usually on diseases where much debility prevails, or where there is a disposition to putres- cency ; in which instances the patient's strength must be supported with wine, and a nutritive diet; making use at the same time of tonics, the cinchona bark, mineral acids, and other antiseptics, as advised under the head of Typhus Gravior. Whatever debilitates, is, in most cases of miliary fever, pernicious; whatever supports the vigour of the system, beneficial. Great sickness at the stomach is apt to precede any fresh erup- tions that come out in the course of the disease, and to prove very distressing. To allay it, we may order small and frequently repeated doses of the mistura camphorae. Where delirium or coma comes on, blisters will be proper. When a retrocession of the eruption happens, our principal view should be to bring out and support a sweat by powerful diapho- retics, camphor, ammonia, frictions to the skin, external warmth, pediluvium, &c. Where any considerable evacuation ensues on a retrocession, we must be careful not to check it hastily. Should convulsions supervene thereon, musk and opium are particularly recommended. To prevent the disease from arising in pregnant women, costive- ness ought carefully to be guarded against; and when in child-bed, they should strictly observe a cool regimen, and keep their chamber of a proper temperature, being at the same time lightly covered with clothes,, PEMPHIGUS, or VESICULAR ERUPTION. This disease consists in eruptions dispersed over different parts of the body, internal as well as external, which gradually rise up into vesicles of about the size of a large nut, containing a yellow, serous fluid, that is in some instances of an inchorous nature, and which again disappear in the course of three or four days. By some authors it is described as being attended both by fever and contagion; and by others as being accompanied by neither. It is therefore supposed that there are two species of it, the chronic and the acute. The disease is, however, of very rare occurrence. Dr. Willan* describes three varieties of it, viz. pemphigus vulgaris, pemphigus contagiosus, and pemphigus infantilis ; but he has f—......——- •-•■■*■-.-------------------- .....—■------- * See hi» Treatise on Cutaneous Diseases. Qrder /7/.] PEMPHIGUS. 293 never seen any instance of the two first. The last, he says, oc- curs sometimes in weak, emaciated children, who are destroyed by the pain and irritation of the successive vesications and ulcerations. By the generality of the physicians who have favoured us with their opinions, the principal of whom is Dr. Dickson,* it has not been considered as contagious. This gentleman saw six cases of the complaint, in none of which it wasTeceived by contagion, nor communicated to those who attended the sick. Dr. Cullen informs us, that the blisters are filled with*a thin ichor, which is discharged, not absorbed, as mentioned by Dr. Dickson ; but during his whole practice it appears that he met only with a single case of pemphigus. Some slight degree of lassitude, sickness, and headach having prevailed for a day or two, small vesicles of about the size of a pea make their appearance over different parts of the body, and not unfrequently in the mouth, and other portions of the alimentarv canal ; and these gradually increase till they become as large as a nut or almond. Now and then they are to be met with of the size of a walnut. They are surrounded by an inflamed margin, or areola, and distended with a faintly yellow serum. They often are accompanied with difficulty of deglutition, nausea, vomiting, a sense of soreness in the abdomen, and intense heat of the skin. Sometimes they are so numerous as to run into each other. The pulse during this time is small and frequent, and the patient is sensible of a considerable degree of debility. An intense burning heat of the skin appears to be a prominent feature of the disease; and in no other exanthematous fever is there usually felt so strong a sensation of heat ; the vesicular eruption appearing to be the consequence of extreme action of the capillarv vessels, thereby generating an increased evolution of heat, and augmenting the virulence of the discharge. The sensation it conveys to the patient is somewhat similar to a common scald, with a train of concomitant febrile symptoms. After the vesicles have remained for some days, they either break and discharge thei* contents, or they begin to shrink, and so disappear. This seems to be the most favourable termination, as they have been known to leave troublesome, ulcers behind them when they broke. Pemphigus resembles the small-pox, infrequently leaving pits in the skin, and in the parts which the vesicles occupied remaining of a dark colour for a considerable time afterwards. In the third volume of Medical Facts and Observations, Dr. Winterbottom takes particular notice of this occurrence. We are to be influenced in our prognosis by the seat and appearance of the vesicles. When they appear only on external parts, and are not numerous, they demand little attention ; when r See hi? Paper on Ppmphigus, in the Transactions of the Royal Iri«h Acadc ■ ii 17H7 294 PYREXIA, OR FEBRILE DISEASES. [Class I. they are numerous, when they attack the alimentary canal, and are attended with a small hard pulse, and great prostration of strength. the danger is considerable- The danger is likewise very great when the ulcers left by the vesicles show a tendency to gangrene, by becoming livid ; which seldom happens, however, unless a fever of the true typhoid kind has accompanied the eruption. On taking a comprehensive survey of what has been recorded by eminent writers on the subject, (and in addition to those already referred to, 1 beg leave to add Dr. Hall,)* we must, I think, conclude, that pemphigus is an affection merely sporadic, and not of a contagious nature ; that it is connected with a state of debility ; and that the symptoms accompanying one or other intances of this affection are those which attend febrile diseases, whether inflam- matory or putrid. The most important distinctions necessary to be ascertained appear therefore to be, 1st, Whether the fever is of an inflammatory nature, and accompanied with a strong and increased action of the vascular system : or, 2dly, Whether the fever has a tendency to the typhoid type, and is marked by great debility, and other symptoms which denote a tendency of the fluids to putrefaction. It will be obvious, that in the first case evacuation and other antiphlogistic remedies will be proper; and that in the second it will, on the contrary, be necessary to shun all evacuations, and to employ those remedies alone which support the strength, and give tone and vigour to the system. In some cases the disease seems to be connected with a certain state of debility, and a tendency of the fluids to putrefaction, and therefore the indications of cure are obvious. Having cleansed the stomach by a gentle emetic, where nausea prevails, and dislodged the contents of the intestines by some mild laxative, such as the saline purgatives, or small doses of the sub- muriate of mercury with jalap, we may then give the cinchona bark either in infusion, decoction, or powder, along with wine. The mineral acids, in a state of proper dilution, if administered early, will likewise be of service in obviating the effects of debility, and an}7 tendency to putrefaction. On the first accession of the disorder, if the skin is hot and dry, it may be of service to give the saline medicine, with small doses of some mild antimonial, in order to excite a gentle diaphoresis ; but these should not be continued long. To diminish the effects of irritation, opiates combined with sulphuric aether will be proper. Where vesicles arise in the mouth, and break, so as to become ulcers, we should then employ detergent gargles, as advised under the head of Cynanche Maligna. * See Essay on Pemphigus, by Dr. Hall, in volumes 3d Rnd 4th of the Edinburgh Annals nf Medicine Order III.} nettle-rash. ,293 If there is reason to apprehend that the eruption has extended to the alimentary canal, it will be necessary to order copious draughts of some mucilaginous decoction, as mentioned under the head of v Aphtha Chronica. When obstinate ulcers are formed on any exterior part of the body, in consequence of the vesicles breaking, the assistance of a surgeon will be requisite. Some practitioners are in the habit of opening the larger vesicles, hut the propriety of this step is not yet fully established. On recovery, the patient's strength is to be recruited by tonics and other auxiliaries, as noticed under the head of Dyspepsia. URTICARIA, or NETTLE-RASH. This disease takes its name from its being attended by an erup- tion on the skin, similar to what is produced by the stinging of nettles, and terminates in^a desquamation of the cuticle. Dr. Willan, in his Treatise on Cutaneous Diseases, notices six varieties of it.— See Order III. In some instances, a slight degree of fever either precedes or attends the eruption : this is not confined to any particular parts of the body, but is somewhat dispersed, being always accompanied with a considerable degree of heat and itching. In some persons it lasts only a few days, in others many months, appearing and disappearing at intervals. It usually disappears in the day-time, and in the evening breaks forth again, accompanied sometimes with slight febrile symptoms. In some cases urticaria is charac- terized by large wheals or bumps, which, on pressure, appear of a solid nature, without any cavity or head; nor do they contain any kind of fluid. The causes of urticaria are by no means obvious, but it has been supposed to arise from suppressed perspiration, or some irritating matter in the stomach. A disease very similar to febrile urticaria is produced in particular constitutions by substances received into the stomach which prove offensive, such as almonds, mushrooms, crab-fish, muscles, lobsters, herrings, &c. When a person is poisoned by fish of a deleterious nature, it frequently shows itself as a consequence thereof. (See Animal Poisons.) The effect is rapid, and the symptoms are violent for some hours. In consequence of such circumstances, physicians have been indu- ced to conclude that urticaria, attended with fever, originates generally from indigestion, or from some substance of a noxious quality taken into the stomach. The nettle-rash readily gives way in general to a cool regimen, and keeping the body open with mild laxatives, such as the potassae supertartras, or any of the neutral salts. When it has arisen from any thing noxious being eaten, an emetic should be administered at the commencement of the attack. If it proves obstinate, we may resort to small doses of the suhmuriate of mercury and nitric i\r\d. £96 PYREXIAE, OR FEBRILE DlSEAfaES. [VlaSS i. An infusion of serpentaria, made in the proportion of two drachms to a pint of water, is spoken very favourably of by a late writer* on chronic urticaria.! ^ ORDER IV. HEMORRHAGIC, or INVOLUNTARY DISCHARGES of BLOOD. Under this title are comprehended active haemorrhages only ; that is, those attended with some degree of symptomatic fever, and which depend upon an increased impetus of the blood in the vessels from which it flows, chiefly arising from an internal cause. On venesection the blood appears as in the cases of phlegmasiae ; that is, the glutten separated, or a crust formed. The general remote causes of haemorrhages of this nature are, external heat, a sanguine and plethoric habit, whatever increases« the force of the circulation, as violent exercise, strong exertions, anger, and other active passions, particular postures of the body, ligatures producing local congestion, a determination to certain ves- sels, rendered habitual from the frequent repetition of haemorrhage, the suppression of accustomed evacuations, external violence, and exposure to cold. Haemorrhages may be occasioned either by too copious a pro- duction of the vital fluid, by some partial accumulation of it, or by the laxity or tenuity of the vessels which contain it. Haemor- rhage seldom, however, comparatively speaking, arises from a more than ordinary mass, or impetus of blood, but in general from a want of that contractile power in the artery which is necessary to resist its tendency to effusion. The general treatment of haemorrhages must consist in putting a stop to the discharge of the blood; in preventing its recurrence, by removing the causes by which they were excited, and by de- stroying the inflammatory diathesis when any exists. These means remain to be pointed out under each distinct haemorrhage, as in the subsequent pages. EPISTAXIS, or HAEMORRHAGE from the NOSE. In the nose there is a considerable net-work of blood-vessels expanded on the internal surface of the nostrils, and covered only with a thin tegument: hence upon any determination of a greater * See Mr. Cook's Practical Treatise, he. p. 209. t According to the nosological arrangement of Dr. Cullen, Aphtha should have fol- lowed next as one of the Exanthemata; but being more frequently met with among infants than persons of a mature age, it has been inserted among the diseases of the infantile state. Cachexia aphthosa, or chronic thrush, not being an idiopathic disease, but sympto- matic of some other, such as general debility, is placed in the class Cachexia Order IF.} hemorrhage from the nose. 297 quantity of blood than ordinary to the vessels of the head, those of the nose are easily ruptured. In general the blood flows only from one nostril; but in some cases it is discharged from both, then showing a more considerable disease. Persons of a sanguine and plethoric habit, and not yet ad- vanced to manhood, are very liable to be attacked with this complaint; females being much less subject to it than males, particularly after menstruation has commenced. Peculiar weak- ness in the vessels of the part, and the decline of life, may also be considered as predisposing causes. Great heat, violent exertion, external violence, particular postures of the body, and every thing that determines the blood to the head, are to be looked upon as its exciting causes. Epistaxis comes on at times without any previous warnings; but at others, it is preceded by a pain and heaviness in the head, vertigo, tinnitus aurium, flushing in the face, heat and itching in the nostrils, a throbbing of the temporal arteries, and a quickness of the pulse. In some instances, a coldness of the feet, and shivering of the whole body, together with a costive belly, are observed to precede an attack of this haemorrhage. The complaint is to be considered as of little consequence when occurring in young persons, being seldom attended with danger; but when it arises in those who are more advanced in life, flows profusely, and returns frequently, it indicates too great a fulness of the vessels in the head, and not unfrequently precedes apoplexy, palsy, &c. and therefore in such cases is to be regarded as a dan- gerous disease. When this haemorrhage arises in any putrid disorder, it is to be considered as a fatal symptom. As a bleeding from the nose proves salutary in some disorders, such as vertigo and headach, and is critical in others, such as phrensy, apoplexy, and inflammatory fever, where there is a deter- mination of too great a quantity of blood to the head ; we ought properly to consider the time it happens, whether it really is a disease, or intended by nature to remove some other. When it arises in the course of some inflammatory disorder, or in any other where we have reason to suspect too great a deter- mination of blood to the head, we may suppose that it will prove critical, and therefore we should suffer it to go on, at least as long as the patient is not weakened by it. Neither should it be suddenly stopped, when it happens to per- sons in good health, who are of a full and plethoric habit. In short, where a bleeding at the nose relieves any disagreeable symptom, and does not proceed so far as to induce debility, it ought not to be hastily checked. When it arises in elderly people, or returns too frequently, or continues till the patient becomes faint, it ought to be put a stop to as quickly as possible : to effect this, the person is to be ex- posed freely to cool air, and to be placed nearlv in an erect posi- 39 298 fyrexijEj or febrile diseases. [Ctas-- L tion, with his head somewhat inclined backwards ; to drink freely of cold liquors, and to make use of an antiphlogistic regimen. Besides these means, he may immerse his head in water impreg- nated with ammonia muriata, or common salt, and snuff vinegar diluted with cold water frequently up the nose; or he may throw some astringent wash* repeatedly up the nostril from which the haemorrhage proceeds, by means of a syringe. Should the bleeding nevertheless continue, a dossil dipped either in a solution of the sulphate of copper in water, the sulphate of iron in brandy, or in Ruspini's styptic, may be introduced up the nostril. A tent wetted with the compound tincture of benzoin, and afterwards rolled in equal parts of alum and sulphate of zinc, may be tried upon a failure of the former. One of the most powerful styptics, however, which we can use, is powder of charcoal. In epistaxis, it may be applied by means of tents, first moistened with water, and then dipped in this powder ; but in slight cases, it will answer by being taken like snuff. To assist the affect of all such applications, a little cold water may be sprinkled with the fingers on the patient's face, and the genitals of a male be immersed now and then in the same fluid. Dr. Darwin mentions in his Zoonomia the case of a lady who had a continued haemorrhage from her nose for several days ; the ruptured vessel was not to be reached by plugs up the nostrils, and the sensibility of her fauces was such, that nothing could be borne behind the uvula. After venesection, and other common applications, she was directed to immerse her whole head in a pail of water, which was made colder by the addition of several handsful of salt; in consequence of which, the haemorrhage im- mediately ceased, and returned no more ; but her pulse continuing hard, she was necessitated to lose blood from the arm, on the suc- ceeding day. In epistaxis, the application of pressure to the mouth of the * 1. R Zinc. Sulphat 3j- Plumbi Superacet gr. x. Aquae Distillat. ( %x. M. ft. Injectio. Vel, 2. g- Aluminis in pulv. trit. 3y- Aq. Rosa?, f. %vy Acidi Acetici, f. ^j. M. Vel, 3. J£ Tinct. Ferri Muriatis, f. giss Aq. Distillat. f. f vj. M. Vtl, 4. R Acid. Sulph Dilut. f. 3»ss—f. 31J. * 1. Take Sulphate of Zinc, one dr achm. Superacetateof Lead,ten grain?. Distilled Water, ten ounces. Mix them for an injection. Or, 2. Take Powdered Alum, two drachm?. Rose Water, six ounces. Distilled Vinegar, one ounce. Mix them, and use the liquor as a wash or injection. Or, 3. Take Tincture of the Muriate of Iron, one drachm and a half. Distilled Water, six ounces. Mix them. Or, 4.Take Diluted Sulphuric Acid,a drachm \ and a half, or two drachms. \q. Pin-a3.f. Sijss. M i Pure Water, two ounces and ;> j half. Mix thoni Order IV.J hemorrhage from the nose. 299 hleeding vessel is often attended with a good effect, when other means prove unsuccessful: to effect which, a piece of hog's gut that has been previously dried, and moistened again, may be used. One end of it being firmly tied with a bit of small packthread, is, by means of a probe, to be pushed along the course of the nostril from which the blood is discharged to the upper part. The gut is then to be filled with cold vinegar and water by means of a syringe inserted at the end hanging out of the nostril, and as much being injected as the gut will admit, the whole is to be pressed up as far as possible, and to be then secured in this situation by a proper bandage. While we are pursuing these steps, we are at the same time to open the body, if necessary, with cooling purgatives, in order to make some derivation from the vessels of the head; and the patient is carefully to avoid all those circumstances which might either determine the blood to the head, or prevent its free return from it. Refrigerants, such as the saline medicine, with nitre, may be advised every hour or so, the patient drinking cold acidulated liquors, and exposing himself freely to cool air. Astringents, such as the sulphate of zinc, alum and plumbi su- peracetas, with opium, are sometimes given internally; but their effect seems doubtful, as they seldom have time to act. When the complaint is of long duration, they may be used as below.* Alum, 5.1$; Infus. Rosas Acid. f. j|vj. Potassae Nitrat.3j. M. ft. Mistura, cujus sumat. cochl. larg. iij tertia quaq. hora. Vel 6.f£ Acid. Sulph. Dilut. H\ xvi. Aq. Font. f. ^jss. Syrup. Rosce, f. :jij. Tinct. Opii, nT. x. M. Prohaustu, terquaterve diesumendo. Vel 7. R Zinc. Sulphat'gr. 1-4—1-2. Aluminis, gr. x. Infus. Roses, f. |jss. Syrup, ejusdem, f. jj. M. ft. Haustus, 6tis horis adhibendus. Vel, 8. R Aq. Distillat. f. gjss. Plumbi Superacet. gr. j.—ij. Tinct. Opii, fllx.—xij. Syrup. Rosae, f. gj. M. ft. Haustus.sexta quaque hora capiendus. * 5 Take Infusion of Roses, six ounces. Nitrate of Potass, one drachm. Shake them together, and of this mix- ture take three large spoonsful every third hour. Or, 6. Take diluted Sulphuric acid, twenty- four drops. Pure water,one ounce and a half. Syrup of Roses, two drachms. Tincture of Opium, fifteen drops. Mix them for a draught, to be taken three or four times a day. Or, 7. Take Sulphate of Zinc, one quarter or half a grain. Alum, ten grains. Infusion of Roses, one ounce and a half. Syrup of the same, one drachm. Mix them for a draught, to be adminis- tered every six hours. Or, 8. Take Distilled Water, one ounce and a half. Superacetate of Lead, from one to two grains. Tincture of Opium, fifteen to twenty drops. Syrup of Roses, one drachm. This draught may be taken every sh hours. jOO rniEXLs;, or febrile disease^. [Class I. catechu, and gum kino, are astringents more applicable for haemor- rhages from the lungs, stomach, and intestines, than for epistaxis. In this haemorrhage, as well as in all other active ones, the tincture of digitalis, given in doses of thirty drops from a two- ounce phial (the size will make some difference in the drops) every six hours for four or five doses, may prove an efficacious remedy, particularly in full robust habits, or where there is a quickened circulation. In obstinate cases, the application of a blister to the neck has occasionally produced a good effect. After the bleeding has ceased, the patient must be careful not to remove the tents or clotted blood, but should allow them to come away of themselves : and in order to avoid any return of the haemorrhage, he must be kept as still and quiet as possible, taking care not to apply any thing of a stimulating nature to the nose. It sometimes happens, that when the bleeding is stopped out- wardly, it nevertheless continues inwardly, and prevails in so high a degree as to threaten suffocation, particularly when the person falls asleep. In such cases the passage may be stopped by intro- ducing a pliable probe up the nostril, through the eye of which some strong threads have been passed, and so bringing it out at the mouth, then fastening pieces of sponge to their extremities, afterwards drawing them back, and tying them on the outside with a sufficient degree of tightness. Where epistaxis arises in adults of a full plethoric habit, a fre- quent use of cooling purgatives, and an antiphlogistic regimen, may probably prevent any return of the complaint When occa- sioned by too great a determination of blood, to the head, topical bleeding, by means of leeches to the temples, will be advisable. When it is occasioned by the suppression of some accustomed evacuation, such as the menstrual or hemorrhoidal flux, this is to he restored if possible ; but if we do not succeed, some other dis- charge, by means either of an issue or seton, must be substituted. HAEMOPTYSIS, or SPITTING of BLOOD. In haemoptysis there is a discharge of blood of a florid colour, and often frothy, from the mouth, brought up with more or less of coughing or hawking, and preceded usually by a saltish taste in the saliva, a sense of weight about the precordia, difficult respi- ration, and a pain in some part of the thorax. It is readily to be distinguished from haematemesis, as in this last the blood is usually thrown up in considerable quantities, is moreover of a darker colour, more grumous, and mixed with the other contents of the stomach, and is unattended by any cough; whereas blood proceeding from the lungs is usually in small quantity, is of a florid colour, fluid, mixed with a little frothy mucus, and brought up by coughing. A spitting of blood arises most usually between the ages of &\\- Order IV.J spitting of blood. 301 teen and twenty-five, and may be occasioned by any violent exer- tion, either in running, jumping, wrestling, singing, speaking loud, or blowing wind-instruments ; as likewise by wounds, plethora, pneumonia, weak vessels, hectic fever, coughs, irregular living, excessive drinking, or the suppression of some accustomed dis- charge, such as the menstrual or haemorrhoidal. It may likewise be occasioned by breathing air which is too much rarefied to be able properly to expand the lungs. Persons in whom there is a faulty proportion either in the vessels of the lungs, or in the capacity of the chest, being distinguished by a narrow thorax and prominent shoulders, or who are of a delicate make and sanguine temperament, or who have had pre- vious affections of the same disease, seem much predisposed to this haemorrhage; but in these the complaint is often brought on by the concurrence of the various occasional and exciting causes before mentioned. A spitting of blood is not however always to be considered as a primary disease. It is often only a symptom ; and in some dis- orders, such as pleurisies, peripneumonies, and many fevers, often arises, and is the presage of a favourable termination, if only very slight. Sometimes it is preceded (as has already been observed) by a sense of weight and oppression at the chest, a dry tickling cough. some slight difficulty of breathing, and a hard jerking pulse. At other times it is ushered in with shiverings, coldness of the extre- mities, pains in the back and loins, flatulency, costiveness, and lassitude. The blood which is spit up is sometimes thin, and of a florid red colour; and at other times it is thick, and of a dark or blackish cast: nothing, however, can be inferred from this circum- stance, but that the blood has lain a longer or shorter time in the chest before it was discharged. An haemoptoe is not usually attended with danger, where no symptoms of phthisis pulmonalis have preceded or accompanied the haemorrhage; where it leaves behind no cough, dyspnoea, or other affection of the lungs ; or where there is no malconformation of the pulmonary system : nor is it dangerous in a strong healthy person of a sound constitution, unless the haemorrhage is very great; but when it attacks persons of a weak lax fibre and delicate habit, it may be difficult to remove it. It seldom takes place to such a degree as to prove fatal at once : but when it does, the effusion is from some large vessel. The danger, therefore, will be in proportion as the discharge of blood comes from a large vessel or a small one, and as the quantity is profuse or trifling. When the disease proves fatal in consequence of the rupture of some large vessel, there is found, on dissection, a considerable quantity of clotted blood between the lungs and pleura, and there is usually more or less of an inflammatory appearance at the rup- tured part. Where the disease terminates in pulmonary consump- o02 PYREXIAE, OR FEBRILE DISEASES. [Class 1. tion, the same morbid appearances are to be met with as described under that particular head. In an haemoptoe the effusion is to be moderated by a strict observance of the antiphlogistic plan; by carefully avoiding heat, and every kind of bodily exertion, and where the haemorrhage is severe, even speaking; by employing occasionally cooling pur- gatives,* such as mana, tamarinds, phosphorated soda, sulphate of potass, &c. and by making use of a light vegetable diet, with ice and other refrigerants.t Cold acidulated liquors should be taken for ordinary drink. Dr. Darwin is of opinion, that one immersion in cold water, or a sudden sprinkling all over with it, might probably stop a pulmonary haemorrhage. Indeed the appli- cation of cold to the genitals, or immersing the feet, and even the lower part of the body, ought in no case of haemoptysis to be neglected. If the patient is hot and feverish, youthful, or of a plethoric habit, and has a hard jerking pulse, bleeding from the arm may he used with advantage, and the operation be repeated according to circumstances ; but on the contrary, where there are marks of debility and laxity, and the blood is of a dark colour, depletion will be improper. In all cases where the haemorrhage is considerable, besides re- sorting to cooling purgatives and refrigerant medicines in the manner before mentioned, we ought to give astringents,! in order ' I. JJ Infus. Rosae, f. §iss. Magnes. Sulphat. 3"j- M. ft. Haustus, bis in die adhibendus. 12. g; Infus. Rosa;, f. ^iss. Potassae Nitrat. gr. xv. Tinct. Opii, rjlx. M. i't. Haustus, 4tis horis sumendus. Vel, 3. g: Potassae Supertart. 3"j- Potassae Nitrat. 3ij- M. ft. Pulv. capiat aeger 3ss- pro dosi ex cy- atho parvo decocti hordei, vel aquae frigidae. Vel, 4. R Acid Sulph. Dilut. fll xvj. Aq. Fontan. f. ^jss. Tinct. Opii, fllxiij. Syrup. Rosae, 3j- M. ft. Haustus. J5. Pi Aluminis, gr. viij. Extract. Catechu, gr. x. Confect. Rosae, q. s. M. ft. Bolus, 4ta. quaq. hora sumendus super- bib, cochl. iij. magna Infusi Rosa5. * 1. Take Infusion of Roses, one ounce and a half. Sulphate of Magnesia, three drachms. Mix them, and take this draught twice in the day t 2. Take Infusion of Roses, one ounce and a half. Nitrate of Potass, fifteen grains. Tincture of Opium,fifteen drops. Mix them for a draught, to be taken every four hours. Or, 3. Take Supertartrate of Potass, three drachms. Nitrate of Potass, two drachms- Mix them, and let the patient take half a drachm of the powder dissolved in a teacupful of barley-water, or cold water. Or, 4. Take Diluted Sulphuric Acid, twenty- four drops. PureWater,oneounce and a half. Tincture of Opium,twenty drops. Syrup of Roses, one drachm. Mix them for a draught. J 5. Take Powdered Alum, eight grains. Catechu, ten grains. ConfectionofRoses,a sufficiency toform a bolus,which may be taken every four hours, washing it down with three tablespoonsful of the Infusion of Rrw - Order IV.] ^pitting of blood. 303 to stop it as quick as possible; and if we find mild ones to fail, we must then employ others of a more powerful nature,* taking care to exhibit some laxative, such as the oleum ricini, now and then, to prevent there having any deleterious effect. The superacetate of lead has been used freely, and with great advantage, in haemoptysis. One grain every four or six hours may be employed with perfect safety. In cases attended with imminent danger, we may venture on two or even three grains. It may be given in an infusion of roses, with a few drops of tinctura opii, or in the form of a pill, if more agreeable. The remarkable operation of digitalis in retarding the pulse has suggested its use in cases of active haemorrhage, and particularly in haemoptoe, in which disease it has been used by many practi- tioners, and repeatedl) by myself, with a very happy effect. It may be given in small doses, repeated twice or thrice a day, as prescribed here.f Vel, - 6. g; Tinct. Kino, ----Catechu, aa f. 3jss ---- Opii, 3ij. M. Capiat fR xx.—xxx. pro dos. ter quaterve in die. 7. g; Zinci Sulphat. gr. ss.—ij. Gum. Kino, gr. viij. Opii, gr. ss. Confect. Rosae, gr. x. M. ft. Bolus, ter de die adhibendus. Vel, S. fj; Sulphat. Cupri, gr. v. solve in Aq. Rosae, f. Jviij. et adde Tinct. Opii, fTlxl. M. ft. Mistura, cujus sumat aeger cochlear, j 4tis horis. Vel, 9. B Infus. Rosae, f. f jss. Aluminis, gr. x. Zinci Sulphat. gr. 1-2. Tinct. Opii, T1X x. Syrup. Simpl. f ^j.M. i't. Haustus, 4tis horis capiendus. Vel, 10. rj; Plumbi Superacet. gr. jss.—iij. Opii. gr. ss. Confect. Rosae, q. s. M. It. Pilula, quarta vel sexta quaque hora sumenda. f 11. ri Pulv. Digitalis Purp. gr. j. Confect. Rosae, gr. x. M. ' I. Bolus, mane, hora raeridiana,etve>pere sumendw. Or 6. Take Tincture of Kino, ----■.----Catechu, of each half an ounce. Opium, two drachms. Mix them well, and take from thirty to forty five drops for a dose, three or four times a day. * 7. Take Sulphate of Zinc, from half a grain to two grains. Gum Kino, eight grains. Opium, half a grain. Confection of Roses, ten grains. Make them into a bolus, to be given three times a day Or, 8. Take Sulphate of Copper, five grains* Dissolve it in Rose Water, eight ounces, and add Tincture of Opium, sixty drops. Of this mixture let the patient take a large spoonful every four hours. Or, 9. Take Infusion of Roses, one ounce and a half. Alum, ten grains. Sulphate of Zinc, half a grain. Tincture of Opium, fifteen drops. Syrup, one drachm. Mix them for a draught, to be taken every four hours. Or, 10. Take Superacetate of Lead, one gram • and a half to three grains. Opium, half a grain. Confectionof Roses,a sufficiency to make them into a pill, which may be taken every fourth or sixth hour. t 11. Take Powdered Purple Foxglove? one grain. Confection of Roses, ten grains. Form a bolus, to be taken morning, noon, find evening- 304 pyrexia, or febrile disease. [Class /, As a powerful sedative the Prussic acid will be likely to prove highly advantageous in haemoptoe, particularly if accompanied by a dry convulsive cough. For the mode of administering it see Phthisis. Should these remedies prove ineffectual in putting a stop to the haemorrhage, we may make trial of Ruspini's styptic : but as it appears to possess very active powers, the full dose advised in the printed directions should not be continued after the bleeding stops. If its use is persevered in to prevent a return of the disease, the dose should be reduced to one half, and be repeated at longer intervals. If the haemorrhage resists all the means which have been advised, and there is reason to fear that the patient may sink under the loss of blood, it will be proper to apply a blister to the chest: which remedy has often been attended with much advantage in cases of this nature. Dr. Rush tells us that a table-spoonful or two of common salt is often successful when other means will fail. When much coughing attends on haemoptoe, it will be necessary to have recourse to opium, exhibited in small and frequently repeat- ed doses along with the other remedies. Different preparations of the hyoscyamus have been successfully employed in haemoptoe by the German physicians ;* but being in the posession of so active a remedy as the digitalis for suppressing pulmonic haemorrhage, by diminishing the action of the heart and arteries it seems unnecessary to resort to this, except in those cases where we give it the preference to opium, with the view of tranquillizing the cough. After the effusion is stopped, we are to use every possible means for preventing its return. If the complaint has arisen from predis- position, and where an inflammatory diathesis prevails, it may be necessary to obviate this by small bleedings, repeated according to the urgency of the symptoms ; besides which, we may employ re- frigerants and cooling purgatives occasionally, the patient at the same time adhering strictly to an antiphlogistic regimen, and avoid- • See Extracts from Hufeland's Journal, in vol. iii. p. 576, of the Medical and Physical Journal. Vel, 12. g. Infus. Digitalis, f. svi. Plumbi Superacet. gr ij. Tinct. Opii, ftl viij. M. ft. Haustus, 6ta quaque hora adhibendus Vel, 13. g. Infus. Bosae, f. ^jss. Tinct. Digitalis, "Q\ x. ----Opii, T1X xii. M. ft. Haustus, fitis horis capiendus. Or, 12. Take Infusion of Foxghrv e, six drachms Superacetate of Lead, two grains. Tincture of Opium, twelve drops. Mix them for a draught to be taken every six hours. Or, 13. Take Infusion of Roses, one ounce and a half Tincture of Foxglove, fifteen drops. ------Opium, eighteen drops. Mix them for a draught, to be taken every six hour.*. Order IV.J vomiting of blood. 305 ing all vigorous exertions of the body, agitations of the mind, and other occasional causes. Sailing, travelling in an easy carriage, swinging and riding gently on horseback, will be the most proper exercises. Where the disease arises in persons of a lax fibre and delicate habit, it has been customary to exhibit the bark of cinchona and chalybeates. These seem, but more particularly the latter, to be unsafe medicines in all cases of active haemorrhage, and have been experienced frequently to prove prejudicial in haemoptoe, by in- creasing the phlogistic diathesis. Whenever there is a fixed pain in the chest, a blister may be applied over the part with considerable advantage. H.EMATEMESIS, or VOMITING of BLOOD. A hemorrhage of blood from the stomach is readily to be dis" tinguished from one which proceeds from the lungs, by its being usually preceded by a sense of weight, pain, or anxiety in the region of the stomach ; by its being unaccompanied by any cough ; by its being discharged in a very considerable quantity; by its being of a dark colour, and somewhat grumous ; and by its being mixed with the other contents of the stomach. The disease may be occasioned by any thing received into the stomach which stimulates it violently or wounds it ; or may pro- ceed from blows, bruises, or any other cause capable of exciting inflammation in this organ, or of determining too great a flow of blood to it : but it arises more usually as a symptom of some other disease (such as a suppression of the menstrual or haemorrhoidal flux, or obstructions in the liver, spleen, and other viscera,) than as a primary affection. Towards the close of scarlatina maligna, typhus gravior, and other disorders of a like nature; where symptoms of putrescency prevail in a high degree, a haemorrhage from the stomach is very apt to arise. Haematemesis is seldom so profuse as to destroy the patient sud- denly ; and the principal danger seems to arise either from the great debility which repeated attacks of the complaint induce, or from the lodgment of blood in the intestines, which, by becoming putrid, might occasion some other disagreeable disorder. The appearances to be observed on dissection, where it proves fatal, will depend on the disease of which it has been symptomatic. Where this complaint has arisen in a plethoric habit, and is attended with febrile symptoms, or such as indicate an inflamma- tory diathesis, it may be necessary to take away a small quantity of blood from the arm; but the great debility which the disease produces of itself will not admit of this operation under any other circumstances. In moderate attacks of the disorder it may be sufficient to make use of refrigerants, as advised under the head of Haemoptysis, toge- 40 306 pyrexia, or febrile diseases. [Class 1. ther with small doses of opium repeated twice or thrice a day, con- fining the patient at the same time to food of a light nutritive na- ture, and directing him to take some kind of cool acidulated beve- rage for his ordinary drink: but if these means do not quickly allay the haemorrhage, we ought then to employ powerful astringents and sedatives, as advised under the last-mentioned disease. Duringthe use of these medicines, it will be necessary, however, to give some gentle laxative (such as the oleum ricini) now and then, in order to obviate costiveness and prevent any deleterious effects. In haematemesis I have the strongest reasons for presuming that there is not a more effectual astringent than the tinctura ferri mu- riatis ; for by being applied here immediately to the mouth of the bleeding vessel, it acts as a styptic. It may be given in doses of twenty or thirty drops in a little cold water, and be repeated every hour or two, till the haemorrhage ceases. Should it resist this medicine, we may make use of Ruspini's styptic. It is said that large doses of spermaceti have been given in this disorder with success ; but its use seems more likely to prove bene- ficial after the haemorrhage has ceased than during its continuance, particularly where the effusion is considerable. If the practitioner is disposed to make a trial of it in mild cases, he can give it as below.* The application of a blister to the abdomen in severe attacks is sometimes attended with a good effect. When the haemorrhage has stopped, it will be advisable to dis- cover, if possible, the cause from which it proceeded, and by re- moving that or the primary disease, to prevent any return of the complaint. Where haematemesis arises in putrid diseases, we must have re- course to the most powerful antiseptics.—See Typhus Gravior.— Where scirrhous tumours of the liver or spleen exist, and seem to have given rise to the haemorrhage, we must resort to hydrargyrus, conium, and the other means advised in chronic hepatitis and splenitis. A modern writer! informs us, that he has met with a variety of this disease in females from eighteen to thirty years of age, and by no means originating in organic affection of the stomach or viscera connected with it, that resisted the usual routine of treatment with t See Observations on theutilityof PurgativeMedicines,byDr.Hamilton,page 109. u 1. IJCetacei, §ss. Vitel.Ovi, q. s. Terantur in mortar. marmoreo,etadde Aq. Pulegii, f. gj- — Fontan. f. §v. Potassae Nitrat. 3j- Tinct. Opii, m xl. M. ft. Mistura, cujus sumat cochl. larg. iij 3tia vel 4ta quaq. hora. * 1. Take Spermaceti, half an ounce. Yolk of Egg, a sufficiency. Let them be mixed in a marble mortar, and then add Penny Royal Water, one ounce. Pure Water, five ounces. Nitrate of Potass, one drachm. Tincture of Opium, sixty drops. Of this mixture, let three large spoonsful be taken every three or fourhour=. Order IV.J voiding of blood by urine. 307 cold acidulated liquors and different emmenagogues, but which readily gave way, by procuring copious and free alvine evacuation. by the exhibition of purgatives. HEMATURIA, or VOIDING of BLOOD by URINE. This disease is sometimes occasioned either by falls, blows, bruises, or some violent exertion, such as hard riding and jumping ; but it often arises from a small stone lodged either in the kidney or ureter, which by its size or irregularity wounds the inner surface of the part it comes in contact with ; in which case the blood dis- charged is most usually somewhat coagulated, and deposits a sedi- ment of a dark brown colour, resembling the grounds of coffee. It is rarely, if ever, an idiopathic disease. A discharge of blood by urine, when proceeding from the kidney or ureter, is commonly attended with an acute pain and sense of weight in the back, and some difficulty of making water, the urine which comes away first being muddy and high-coloured, but to- wards the close of its flowing becomes transparent, and of a natural appearance. When the blood proceeds immediately from the bladder, it is usually accompanied with a sense of heat and pain at the bottom of the belly. It is distinguished from the high-coloured urine attendant on many diseases, by the deposit of a coagulum to the bottom of the vessel, and by its staining linen of a red colour. The voiding of bloody urine is always attended with some danger, particularly when mixed with purulent matter. When it arises in the course of any malignant disease, it shows a highly putrid state of the blood, and always indicates a fatal termination. The appearances to be observed on dissection will accord with those usually met with in the disease which has given rise to the complaint. In the treatment of haematuria we must be guided by the cause which has occasioned it. If it has arisen in consequence of some external injury, such as a blow or fall, or the patient is of a full plethoric habit, it may then be proper to make use of evacuation by bleeding, giving him a couple of table-spoonsful of an acidulated infusion of roses, with a small quantity of nitre dissolved in it, every two or three hours, and employing some gentle purgative, such as the oleum ricini, magnesiae sulphas, or sodae sulphas, every second or third day, to keep the body open. If the haemorrhage should continue after these steps have been taken, we must resort to astringents, as noticed under the former heads, beginning with those of the milder kind. To allay irritation, we may also give opium in small doses every four or six hours. Where there is any deposite of a muco-purulent matter in the urine, about half a drachm of uva ursi in powder, three times a day, may 308 pyrexije, or febrile diseases. [Class I. be of service, the patient taking the double acidulated soda water for common drink. When haematuria proceeds from a stone either in the kidney, ureter, or bladder, it is only to be cured by removing the cause : but as this may not be always practicable, we must then be con- tented to moderate the symptoms by making the patient drink plentifully of mucilaginous liquors, such as thick barley-water, solu- tions of gum. acaciae, or a decoction of marsh-mallows, sweetened with honey; by giving him repeated small doses of opium joined with refrigerants, as advised under the head of Haemoptysis, and by throwing emollient clysters frequently up the intestines. A case of haematuria is recorded in the eighth volume of Medi- cal Facts and Observations, which had resisted repeated bleedings and warm bathing, saline purgatives, emetics of different kinds, camphor and opium in large doses, uva ursi, mephitic alkaline wa- ter, &C. and which was quickly and effectually removed by giving the patient a pint a day of a decoction of peach-leaves. This was prepared by boiling an ounce of dried leaves of the peach-tree (Amygdala Persica, Linn.) in a quart of water, till it was reduced to a pint and a half. When haematuria is symptomatic of some malignant disease, as putrid fever, &c. powerful antiseptics must be administered. MENORRHAGIA, or IMMODERATE FLOW of the MENSES. A flow of the menses is to be considered as immoderate when it either returns more frequently than what is natural, continues longer than ordinary, or is more abundant than is usual with the same person at other times. With the extraordinary flux of this secretion there are usually pains in the back and belly somewhat like those of child-birth. The usual period of its visitations is from twenty-seven to thirty days. As to the time of its continuance, this is various in different women; but it seldom continues longer than six days, or less than three, and does not cease suddenly, but in a gradual manner. The quantity generally discharged in a healthy and regular woman is from four to six ounces at each visitation. Those of a lax and de- licate constitution have, however, a more copious and longer con- tinued discharge than persons of a robust habit: thus the full blooming country girl does not discharge half the quantity that the pale-faced lady of quality does. The quantity of the menstruous fluid is greater in warm than in cold climates; so if a woman lives in an atmosphere artificially warmed, much the same effect is produced. For practical purposes, it is of consequence to observe, that menstruation is a secretion, and not an effusion of pure blood either from the arteries or veins. Order IV.J immoderate flow of the menses. 303 All blood from the sanguiferous vessels (with very few morbid exceptions) coagulates, whilst the fluid of the catamenia does not whether it comes away in a dropping manner, or is retained in any considerable quantity, as in the case of imperforate vagina. For other observations on menstruation, see Amenorrhoea. The causes of menorrhagia may be referred to, 1st, A plethoric state, or general fulness of habit. 2dly, Accidental circumstances determining the blood more copiously and forcibly into the uterine vessels, as violent exercise in dancing, strokes or contusions on the belly, strains and violent passions of the mind. 3dly, Irritations acting particularly on the uterus, as great cos- tiveness obliging the person to much straining at stool ; excess in venery, particularly during menstruation, or the application of wet and cold to the feet, which may determine a greater flow of blood than natural to the uterus. 4thly, Laxity and debility of the organ, arising from frequent child- bearing, difficult and tedious labours or repeated miscarriages. 5thly, Those which induce debility of the whole system, as a sedentary and inactive life, indulging much in grief and despon- dency, living upon a poor low diet, drinking freely of warm ener- vating hquors (such as tea and coffee,) and living in warm cham- bers ; and, 6thly, Organic affections, such as scirrhus, polypus, ulceration, &c. An immoderate flow of the menses arising from plethora is often preceded by headach, giddiness, or dyspnoea, and is afterwards attended with pains in the back and loins, some degree of thirst universal heat, and a frequent, strong, hard pulse; but where it arises in consequence of a laxity of the organ, or of general debility and such attacks are frequently repeated, the symptoms which attend are, paleness of visage, chilliness, laxity and flabbiness in the muscular fibres, unusual fatigue in exercise, a hurried respi- ration on the slightest effort, pains in the back on remaining any length of time in an erect posture, and coldness of the extremities, together with loss of appetite, indigestion, and a long train of nervous complaints. If the disease has induced much debility by frequent and severe attacks, it is no uncommon occurrence for the feet to be affected with oedematous swellings, particularly towards the evening, and for a leuco-phlegmatic habit to take place. In forming our prognostic in this disease, we must be directed by the nature of the cause which has given rise to it. If occasioned by plethora, or a general fulness of the system, we need apprehend no danger, as a temporary debility will be the only inconvenience the woman will experience ; but where it is produced by a laxity of the vessels of the organ, and is profuse, long continued, and of frequent occurrence, there will always be a risk of its inducing much general debility, and a leuco-phlegmatic habit. Leucorrhcea is a common consequence of it. Where it arises from an organic 310 PYREXIiE, OR FEBRILE DISEASES. [Class I. affection of the part, which is sometimes the case after the age of forty-five, it is usually deemed incurable. When menorrhagia proves fatal in consequence of a scirrhus of the uterus, this organ is observed on dissection to be much in- creased in size, and its substance to be thick and hard, and when cut into, shows a firm structure intersected with membranous septa. The internal surface is at the same time usually ulcerated, and beset with ragged processes, and from these ulcerated parts the haemorrhage proceeds. If polypi are the organic affection, these on dissection are gene- rally to be found adhering to some part near the neck of the womb, and they are surrounded with varicose vessels, which throw out the blood in considerable quantity when a rupture of any of them happens to take place. Where a profuse flow of the menses is attended with pains in the back, and the patient is of a full and robust habit, with pyrexial symptoms, it may be proper to draw off a few ounces of blood ; but in other instances, venesection may safely be omitted. In general it will be sufficient to employ the other antiphlo- gistic means, such as keeping the body gently open with laxa- tive medicines that give but little stimulus ;* administering refrigerants,t such as nitre ; making use of a spare regimen; drinking freely of cool acidulated liquors, such as lemonade or tamarind beverage, and keeping the chamber of a moderate tem- perature, and the bed, or mattress (which will be more proper) * 1. gs Potassae Tartrat. :§ss. Mannae Optim. 3iij- Aq. Fervent, §iij. Tinct Lav. C. 3ss. M. ft. Mistura, cujus sumat dimidium pro dos. Vel, 2. R Magnes. Sulphat. gij. Aq. Fervent, ^vj Tinct. Sennae C. ^ss. Syr. Rosae, 3ij. M. Cochl. larg. iv. pro dos. sumenda. t 3. R Potassae Subcarbonat. 3j. Succ. Limon. f. §ss. Potassae Nitrat. gr. xv. Aq. Font.f. ?j. Syr. Simpl. f 3»j- M. ft. Haustus, 3tia hora capiendus. Vel, 4. R Infus. Rosae, f. ^iss. Potassae Nitrat. gr. x. Adde, pro re nata, Tinct. Opii, in, x. M. ft. Haustis, 4tis horis repetendus. "1. Take Tartrate of Potass, half an ounce. Manna, three drachms. Warm Water, three ounces. Compound Tincture of Lavender, half a drachm. Shake them, and of this mixture take the half for a dose. Or, 2.TakeSulphate of Magnesia,two ounces. Warm Water, six ounces. Compound Tincture of Senna, half an ounce. Syrup of Roses, two drachms. Of this mixture let four table-spoonsful be taken for a dose. \ 3. Take Subcarbonate of Potass, one scruple. Lemon Juice, half an ounce. Nitrate of Potass, fifteen grains. Pure Water, one ounce. Common Syrup, two drachms. Mix them, and take the draught every three hours. Or, 4. Take Infusion of Roses, one ounce and a half. Nitrate of Potass, ten grains. Adding, if necessary, Tincture of Opium, fifteen drops. Mix them, and repeat this draught every four hours. Order I V.J immoderate flow of the menses. 311 lightly covered with clothes. Besides adopting these means, the patient is to avoid an erect posture, and all such things as might prove exciting causes. By avoiding these, and moderating the first beginnings of the disease, it is probable that women might in most cases prevent that debility which repeated and severe attacks are apt to occasion. When no symptoms denoting an increased action in the vessels of the uterus are present, and we suppose that the augmented secretion has arisen in consequence of a laxity of the vessels, besides keeping the woman in a recumbent posture, shunning much external heat, making use of refrigerants internally, and avoiding venery, costiveness, and the other remote causes, we should have recourse to sedatives and astringents, both of which may be used externally as well as internally. After these we should prescribe tonics and stimulants. Linen cloths dipped in vinegar and cold water,and kept constantly applied to the back and private parts, have a powerful effect in many cases of uterine haemorrhage. These means ought therefore always to be employed in those instances where menstruation is profuse. Opium has been much used internally in menorrhagia; and where the patient experiences spasmodic pains in the uterus, it undoubt- edly will prove a very valuable and useful medicine. On such occasions it may be given in small and frequently-repeated doses, combined either with refrigerants or astringents ; but as opium possesses the power of greatly relaxing the system when used libe- rally, it ought not to be administered in cases of general debility, unless under the circumstance just mentioned. Producing nausea by frequently-repeated doses of ipecacuanha, combined with opium, every two or three hours, (say three grains of the former with the fourth of a grain of the latter,) has in some cases of menorrhagia proved highly useful, the flooding having ceased the moment that nausea was induced. The astringents most employed in this disease are, alum, catechu, gum kino, and Armenian bole, which may be given as advised below,* or as prescribed under the heads of Haemoptysis and * 5. B: Aluminis, gr. xij. Gum. Kino, gr. viij. Confect. Rosa?, q. s. M. ft. Bolus, 3tia vel 4ta hora sumendus. Adde, pro re nata, Opii, gr. ss. Vel, 6. B Extract Catechu, gr. xij. Aluminis furif. gr x. Confect. Rosa?, q. s. M. ft. Bolus. Vel, 7. fi Decoct. Cinchon. f. |iss. * 5. Take Alum, twelve grains. Gum Kino, eight grains. Confection of Roses, a sufficiency to form a bolus, which is to be taken every third orfourth hour. Occasionally add Opium, half a grain. Or, 6. TakeExtractof Catechu ,twelvegrains. Alum Purified, ten grains. Confection of Roses, a sufficiency to form a bolus. Or, 7. Take Decoction of Peruvian Bark, one ounce and a half. 312 pyrexia, or febrile diseases. [Class 1 Abortions. The sulphate of zinc, and superacetate of lead, may- be substituted in cases of profuse haemorrhage.—(See Haemoptysis.) We may give the latter in doses of one, two, or even three grains, every three or four hours, according to the urgency of the symptoms. In those cases where the haemorrhage is profuse, and resists the means already recommended, it will be proper to throw up astrin- gent injections into the uterus from time to time. Any of those here* prescribed may be used on the occasion. Where symptoms denoting an increased action in the vessels of the uterus are observable, it would probably be right to give the digitalis, as advised under the heads of Abortions and Haemop- tysis. In a few cases of this nature I have employed it with a good effect. Where menorrhagia proceeds from a scirrhous or ulcerated state of the uterus, all that can be done is to afford a temporary relief by administering opium in considerable doses. A combination of it with the extract of hemlock might possibly add somewhat to its palliative effect. Hyoscyamus may likewise be tried. In those cases where menstruation becomes profuse, continues longer than ordinary, or returns more frequently than what is natural, in consequence of general laxity in the system, and not from inflammatory action, it will be proper for the patient, during its intervals, to enter on a course of tonic medicines, such as cin- chona, the cortex cuspariae, myrrh, and preparations of steel, which may be given as advised below,t or under the head of Dyspepsia. Aluminis, gr. xij. Tinct Kino, f. 3J. ----Opii, ITl x. M. ft. Haustus, 4tis horis sumendus. s 8. B Decoct Cort. Querc. f 3[vj. Aluminis, 3JSS. M. ft. Injectio. Vel, 9. B Zinc. Sulphat gr. xv. Plumbi Superacet. 3J. Aq. Distillat. Oj. M. Vel, 10. B; Aluminis, 3'iv. Zinc. Sulphat. gr. x. Aq. RosaB, §viij. M. Vel, 11. R Infus. Gallae Contus. Oj. f 12. ]$, Gum. Myrrh. 3j- solve in Mor tario cum Aq. Distillat. |vj. et adde ----Cinnam. f. 3J. Potassae Subcarbonat. 3?=. Alum, twelve grains. Tincture of Kino, one drachm. -------Opium, fifteen drops. Mix them, and take the draught every four hours. ' 8. Take Decoctionof Oak Bark,six ounces. Alum, one drachm and a half. Mix them for an injection. Or. 9. Take Sulphate of Zinc, fifteen grains. Superacetate of Lead, one drachm. Distilled Water, one pint. Mix them. Or, 10. Take Alum, four scruples. Sulphate of Zinc, ten grains. Rose Water, eight ounces. Mix them. Or, 11. Take Infusion of Oak Galls, one pint. t 12. Take Gum Myrrh, one drachm. Dissolve it in Distilled Water, six ounces; and add Cinnamon Water, one ounce. Subcarbonate of Potass, half a drachm. Order I F.J \ immoderate flow of the menses. 313 To assist the effect of these remedies, she may make use of cold bathing, together with gentle horse exercise and a generous nutri- tive diet with wine. Where chalybeate springs can be resorted to with convenience, a use of these waters will be likely to afford much benefit. When, from great weakness, and relaxation in the uterine parts the patient is troubled with a profuse menorrhagia, or with fluor albus, she will often experience great relief from Tunbridge water or any other such chalybeate springs ; and as this state of local debility is very frequently a cause of abortion or barrenness these waters have often been the means of removing such un- pleasant circumstances. With regard, however, to haemorrhagy from the uterus, it is often accompanied with a degree of general fever, pains in the back and loins, and local irritation, when every internal stimulant medicine would aggravate the disorder ; and therefore the use of chalybeate waters in these cases requires much judgment and a proper discrimination. To repress the too great or permanent menstruation, which occurs in weak constitutions at the time of life when it ought to cease, we should have recourse to chalybeates, alum, bitters, and opium; the last of which may be administered in the dose of a grain every night, with about five grains of rhubarb. H.EMORRHOIS, or PILES. The piles consist of small tumours situated on the verge of the anus, which are sometimes separate, round, and prominent, but sometimes the tumour consists only of one tumid or varicose ring- surrounding it. In some cases there is a discharge of blood from these tumours, particularly when the patient goes to stool, and then the disease is known by the name of bleeding piles ; and in others there is no discharge, when it is called blind piles. These affections may be occasioned by habitual costiveness, plethora, hard riding, excesses of various kinds, the suppression Ferri Sulphat. 3j. Syrup. Simpl. f, 3ij. ft. Mistura, in Haustus iv. distribuenda, quorumj. sumat mane, hora quinta post meridiem, et hora decubitus. Vel, 13. U Decoct. Cort. Cinchonae, f gjss. Tinct. Cort. Cuspariae, ----Card. C. aa f. gj. M. it. Haustus, ter in die capiendus. Adde, pro re nata, Acid. Sulph. Dilut. m xij. 41 Sulphate of Iron, one scruple. Common Syrup, two drachms. Mix them, and divide the whole into four draughts, of which take one every morn- ing, at five in the evening, and at bed-time. Or, 13. Take Decoction of Peruvian Bark, one ounce and a half. Tincture of Augustura Bark, Compound Tincture of Carda- mons, of each one drachm. Mix them for a draught, to be taken thrice a day, adding occasionally Diluted Sulphuric Acid, eighteen drops. •il'l pyrexia, or febrile diseases. [Class I. of some long accustomed evacuation, and by a use of strong aloetic purges ; and are most apt to arise in those of a robust habit, and who lead a sedentary life. Pregnant women are frequently afflicted with the piles, owing to the pressure of the uterus upon the rectum, which interrupts the return of venous blood from that part, and the costive habit to which such women are usually liable. The piles are sometimes accompanied by a sense of weight in the back, loins, and bottom of the belly, together with a pain or giddi- ness in the head, sickness at the stomach, and flatulency in the bowels. On going to stool, a pungent pain is felt in the funda- ment, and small tumours are perceived to project beyond its verge. If these break, a quantity of blood is then voided, and a considerable relief from pain is obtained ; but if they continue unbroken, the patient in that case experiences great torture every time he goes to stool, and feels an inconvenience even in sitting down on any hard seat. The tumours are sometimes considerable, and from pressure upon the bladder, produce much irritation and even pain in voiding urine. Haemorrhoids are by no means dangerous, but they often prove both troublesome and disagreeable. In some instances they are to be regarded as a salutary evacuation. Hemorrhoidal tumours are sometimes attended with a considerable degree of inflammation, which proceeding to a suppuration, terminates in sinuous ulcers, or fistula. Dissections of piles show that the tumours consist partly of the fine skin round the anus on the outside, and partly of the internal membrane of the gut. In general they are entire, but they sometimes have small openings in them through which the blood issues. In the treatment of piles due attention should be paid to the cause from which they have arisen : and as costiveness is one of the most frequent, the bowels ought to be kept open and regular by medicines which will prove gently laxative,* * 1. B; Confect. Sennae, §ij. Pulv. Jalap. 3'j- Potassse Nitrat. sjjss. Syr. Rhamni,q. s. M. ft. Electuarium, de quo sumat magnitudi- nem juglandis pro re nata. Vel, 2. R Sulph. Sublimat ?j. Confect. Sennas, §ij. Potassae Supertart. 31IJ. * 1. Take Confection of Senna, two ounces. Powdered Jalap, two drachms. Nitrate of Potass, one drachm and a half. Syrup of Buckthorn, a sufficiency to form an electuary, of which take the bulk of a walnut occasionally. Or, 2. Take Sublimed Sulphur, one ounce. Confection of Senna, two ounces. Supertartrate of Potass, three drachms. Syrup. Rosa?, q. s. M. Syrup of Roses, a sufficiency to ft. Electuarium. j make the whole into an electuary. Vel, O, ',1. R 01. Ricini, f. 3VJ,—§j. [ 3. Take Castor Oil, six drachm^ to onr 1 ounce. Qrder IV.] PILES. 315 without irritating the rectum ; and as a habit may be acquired it will be right for the patient to observe stated times in the day for endeavouring to obtain motions, but without straining. Should none be procured by the aid of the laxative medicines, the peristaltic motion maybe excited by clysters of tepid water with soap and oil. When the tumours are attended with much pain, and a consider- able degree of inflammation, it may be adviseable to apply a few leeches; after which, pledgets wetted in a solution of the superacetate of lead, or sulphate of zinc, may be laid on, the patient taking care after each stool to anoint the parts with some kind of emollient ointment.* In these cases, fomentations and poultices are likewise employed ; but the former are preferable, except in those cases where a suppuration has commenced. This, however, should be prevented if possible, as a fistula is sometimes the con- sequence thereof. Injections of cold water up the rectum have sometimes afforded great relief when even leeches and opiates have failed. In a plethoric habit small doses of nitre may prove serviceable. particularly if mixed with sulphur. Balsam of copaiba, given to the extent of forty or fifty drops morning and evening, often relieves the pains so frequently produced by piles. Where the tumours are unattended by much inflammation, but are numerous and troublesome, compression is the most effectual remedy ; and however large these bodies may project at stool or at ether times, if the patient lies down on his back and makes a gradual but constant pressure with his fingers, they will almost always be reduced within the sphincter ani, and by a bandage properly secured with a small pad over the anus, may be prevented from prolapsing. If we cannot reduce the tumours, we must support them by a soft compress dipt in anodyne lotion and retained by the bandage. In a most violent case of external and internal haemorrhoidal affection, which had resisted judicious treatment for five weeks, Vel, Or, 4. B; Pulv. Jalapae, £j Potass* Supertartrat. 3ij. M Ft. Pulv, pro dos. * 6. R Unguent. Cetacei, ^ij. Opii, 3j- M. ft. Unguentum. Vel, 6. B; Cerati Plumbi Superacet. §ij. Opii, 3ij- M. Vel, 7. B Cerati Cetacei, —— Plumbi Superacet.aa sjss. Pulv. Opii, 3ss- M. 4. Take Powder Jalap, one scruple. Supertartrate of Potass, two scruples. This powder'to be taken as a dose. * 5.TakeSpermacetiOintment,two ounces. Opium, reduced to powder, one drachm. Mix them, and use the ointment. Or, 6. Take Cerate of Superacetate of Lead, two ounces. Opium, two drachms. Mix them. Or, 7. Take Spermaceti Ointment, Cerate of Superacetate of Lead; of each half an ounce. Opium in Powder, half a drachm iMix them 3 lb PYREXIA, OR FEBRILE DISEASES. [ClttSS 1. Dr. M'Lean mentions,* that almost immediate relief was obtained by giving the patient forty drops of the tinctura digitalis, and that a rapid recovery was effected by repeating thirty-five drops evening and morning. It is observed, that when he fitsl applied for advice, his countenance was pale and sallow, his strength and flesh much exhausted, he walked with extreme pain and difficulty, his pulse was quick and small, and his appetite impaired ; in a week the contrast was very striking. If a prolapsus ani attends the piles, the part is carefully to be replaced each time after going to stool, by laying the patient in a horizontal posture, and pressing gently with the fingers till the reduction is affected. Its return is to be prevented by avoiding the occasional causes as much as possible ; and where it proceeds from a laxity of the rectum, besides applying a proper bandage, we may employ astringents both internally, as advised under the heads of the preceding haemorrhages, and also externally. Pled- gets dipped in a strong decoction of galls, or oak bark, may be kept constantly to the parts as an external astringent, and they may be anointed from time to time with an ointmentt possessing similar virtues. As a general tonic, cold bathing may he employed with advantage. It has been noticed that haemorrhoids are to be regarded in some instances as a salutary evacuation. In all such, therefore, the haemorrhage should not be stopped, but moderated. In those cases where it is so profuse as to occasion great loss of strength, we must have recourse to astringents both internally and externally, as has just been advised, taking care to obviate costive- ness by some gentle laxative. Confinement to an horizontal posture with the most perfect quietude, will be adviseable in such cases. If the patient can lie on his face, so much the better. He should be lodged in an airy chamber, and his bed be lightly covered. When the haemorrhage has been very considerable, good effects have been derived from the early application of pressure, made by introducing up the rectum a piece of sheep's or pig's gut tied at one end, and by filling it at the other extremity with any cold liquid, such as ^vinegar and water, forcing up the liquid * See Medical and Physical Journal, vol. iv. p 134. + 8. Bi Adipis Praeparat §j. Pulv Gallarum, 31J. Opii, 33- M. ft. Unguentum. Vel, 9. B; Cerat. Plumbi Superacet. 3j- Pulv. Gallar. 31 j. M. t 8 Take prepared Lard, one ounce. Oak Gall, in fine Powder, two drachms. Opium, one drachm. Mix them. Or, 9. Take Cerate of Superacetate of Lead, one ounce. Oak Gall, in powder, two drachms Mix them. Order IF. i PILES. 317 po as to increase the degree of pressure, and then securing it with a proper bandage. When the haemorrhage proceeds from tumours seated high up and is so severe as to induce great debility, we may throw up cold water in such a small quantity as just to fill the rectum, or some astringent injection,* if it cannot be moderated by the means just recommended. In those cases where the discharge has become habitual, arising from plethora, this state of fulness must be prevented >> moderate exercise on foot, or in a carriage, by the use of a spare diet, by taking cooling purgatives from time to time, and by carefully- avoiding all strong liquors. An internal use of Harrowgate water is a remedy from which great benefit is derived in the piles. The advantages of sulphur, as a mild unirritating purgative, and one which seems to continue its operation through the whole of the intestinal tube, has long esta- blished its virtue in those haemorrhoidal affections that require this evacuation; and the neutral salts, with which it is united in this mineral water, cannot but contribute to its efficacy. Those who are afflicted with piles should shun all such causes as may either increase the determination of blood into the haemor- rhoidal vessels, or prevent its return back from them, but more particularly riding on horseback. During the continuance of this complaint the diet should be cool and nutritious, consisting principally of vegetables, ripe fruit, jellies, broths, &c. Fermented and spirituous liquors will be hurt- ful, and therefore the patient should only drink cooling acidulated liquors, water, or toast and water. Where piles have been of long standing, the intestinal varicose tumours or haemorrhoidal excrescences sometimes become so trou- blesome as to render their extirpation necessary either by ligature or excision. Under certain and prudent limitations, the latter has been strongly recommended by Mr. Ware :f and by Sir James l^arle+ their removal has been powerfully urged ; but very serious t See his Remarks on Fistula Lachrymalis. with Observations on Hemorrhoids ; bee Observations on the Hemorrhoidal Excrescence.—Pott's Works, bv Sir James Earle, vol. iii. ' } * 10. B; Cort. Querc Contus. Z\. Aq. Fontan. Oij. Coque adOj. Colature adde Aluminis, 3ij. Tinct. Opii, f. 3j. M. ft. Injectio. Vel 11. R Zinc. Sulphat. &J. Aq. Rose, Oj. M. Vel 12. B: Gallae Contus! fss. Aq.Forvf-n?. Oij. Col. >: 10.Take Decoction of OakBark,one pint. Alum, two drachms. Tinctureof Opium,onedrachm. Mix them for an injection. Or, 11. Take Sulphate of Zinc, one drachm. Rose Water, one pint. Mix them. Or, 12. Take BruisedOakGall,half an ounce. Hot Water, two pints. fnfusethem, and strain off the liquor. 31o- PXREXLiE, OR FEBRILE DISEASES, [Cl»SS /* consequences have, however, now and then resulted from both modes. Their removal by the knife appears far preferable to doing it with ligatures, as peritoneal inflammation, convulsions, suppression of urine, and even tetanus, have ensued from the latter mode of treatment. If the disease is recent, it may sometimes be relieved by milder means, such as the introduction of a large-sized bougie up the rectum. Where the radical operation is not thought adviseable, or there may be any other objection to its performance, we ought to make trial of the bougie, as it has been found* very considerably to relieve strictures in the rectum and such like inconveniences produced by haemorrhoidal excrescences. When in consequence of piles, the rectum becomes so much affected as to threaten the patient with a fistula, we may recom- mend a use of Dr. Ward's celebrated paste,t as inserted in the Pharmacopoeia Chirurgica, which is to be prepared in the following manner:—The three first ingredients are to be finely powdered and well mixed : after which, the honey and sugar melted together over the fire, and formed into a clear syrup, are to be added, and the whole beaten together into a mass. ORDER V. PROFLUVIA, or FLUXES, with PYREXIA. Pyrexia, with an increased excretion, not naturally bloody, constitutes this order of diseases. CATARRHUS, or CATARRH. A catarrh consists in an increased excretion of mucus from the membrane of the nose, throat, and bronchiae, accom- panied with a slight degree of fever, and other symptoms usually attendant thereon. It attacks persons of all ages and constitutions, but more particu- larly the young, and those who have had any former affection of the lungs; and it may take place at any time of the year when there are sudden changes of the weather from heat to cold, and vice versa. '* See Observations on the Diseases of the Rectum and Anus, by T. Copeland. + 13.RRad. Enul. Campan. Pulv. Piperis Nigri singul. ifess. Seminum Faenicul. Pulv. ibjss. Mellis Dispumati. Sacchar. Purificat. singul. ft>j- M. Ft. Pasta, de qua capiat quantitatem nucis moshate bis trrvo de die. t 13. Take Elecampane Root, in powder, Black Pepper, of each half a pound. Fennel Seed, powdered, one pound and a half. Clarified Honey, White Sugar, of each one pound. Makethem into a paste,of which let the bulk of a nutmeg be taken twice or thrice daily. Order F.J CATARRH. 319 In the former instance, the application of cold to the body seems evidently to be the remote cause of the disease ; and in the latter it appears to depend on a specific contagion, having, in the years 1732 and 1733, spread in a progressive manner over the whole of Europe, and part of America, and in 1785 and 1803, over the whole of Britain. When the disease has prevailed epidemically in this manner, the term of influenza has been applied to it. The proximate or immediate cause of the catarrh, seems to be an increased afflux of fluids to the mucous membrane of the nose, fauces, and bronchia, in consequence of some degree of inflamma- tion in these parts. Catarrh is to be distinguished from the measles by the great mildness of the febrile symptoms, and by the absence of many of the symptoms accompanying the latter. The disease usually comes on with a dull pain, or sense of weight in the forehead, a redness of the eyes, and a fulness and heat in the nostrils, which symptoms are soon followed by the distillation of a thin acrid fluid from these parts, together with a soreness in the trachea, hoarseness, frequent sneezing, some difficulty of breathing, a dry cough, loss of appetite, general lassitude over the whole body, and chilliness; towards evening the pulse becomes considerably quickened, and a slight degree of fever arises. In the progress of the disorder the cough is attended with an excretion of mucus, which at first is thin, white, and expectorated with some difficulty ; but becoming gradually thicker and of a yellow colour, is at length brought up with greater ease and less coughing. Even where there is not much affection of the system, it often happens that the natural evening paroxysm is considerably increased; and from restlessness, and frequent coughing, the patient is prevented from sleeping till the morning, at which time a crisis takes place for the present, and he then remains tolerably easy until the return of the evening paroxysm. When the secretion of mucus ceases, the inflammation goes off also, so that a natural cure almost always arises in the disease. Catarrh is seldom attended with fatal consequences, except when it either arises in elderly persons, attacks those of a consumptive habit, or has been much aggravated by some fresh application of cold, or by improper treatment; and it usually terminates in the course of a few days, if not neglected, either by an increased expectoration, or a spontaneous sweat. In some instances it how- ever lays the foundation of phthisis pulmonalis, or gives a tendency to asthma and hydrothorax. In others it becomes habitual, and is accompanied by severe dyspnoea, particularly in the winter: such patients often suffer fatally from the accession of a sharp frost; their usual complaint immediately attacks them, and passes on to the peripneumonia notha on the one hand, in which they are suffo- cated by the profuse effusion of viscid phlegm into the air cells .-md tubes; or, on the other, it puts on Hie more active form of 320 P¥REXI.£, OR FEBRILE DlaEAaES. [CIU6S I. common peripneumony. Very old persons are apt to be carried off by comparatively moderate attacks of catarrh, which seemed to wear out their feeble portion of vitality merely by the slight interruption to the function of respiration, which the phlegm secreted in the bronchial passages occasioned, and they quietly sink into the sleep of death, without any urgent symptom or appearance of distress. The inner membrane of the trachea usually appears on dissection, in fatal cases of catarrh, to be much inflamed, and its cavity to be filled with a considerable quantity of mucous fluid. The same morbid state is likewise communicated to the lungs, which seem loaded with matter of a similar nature, producing suffocation. In mild attacks of this disease it may not be necessary to have recourse to the aid of medicine. In general it will be sufficient to confine the patient to bed, and to make him use an abstemious regimen, and drink plentifully of warm diluent mucilaginous liquors, such as barley-water, thin gruel, &c. acidulated with a small quantity of lemon-juice, or crystals of tartar; but in violent attacks, where there is a great difficulty of breathing, much febrile heat, and a full, frequent pulse, it will be necessary, besides adop- ting these means, to guard against the effects of general inflamma- tion, by employing various remedies. In those cases, therefore, where there is much general affection of the system, and the inflammatory diathesis is great, we should have recourse to the lancet, and other antiphlogistic remedies, proportioning the quantity of blood which we draw off to the vio- lence of the symptoms and the age of the patient. If the difficulty of breathing and oppression at the chest are not soon relieved by venesection, local blood-letting will be adviseable, af er which it will be proper to apply a blister over the part affected; which application will seldom fail to afford relief, if employed early in the disease. To encourage a determination to the surface of the body, and promote expectoration, it will be necessary to administer small and frequently-repeated doses of antimonials, as advised under the head of Simple Continued Fever, or other diaphoretics, as prescribed below ;* the effect of which may be assisted by making the patient .1. B Succ. Limon. f ^jss. Ammon. Subcarbonat 3ss. Aq. Fontan. f. §v. Antimon. Tartarizat. gr. jss. Syrup. Tolutan. f. gss. M. ft., Mistura, cujus sumat cochl. larg. ij tertiis horis. Vel, 2. B Liquor. Ammon. Acetat. f. §ss. Mistur. Camphorae, f. f j- * 1. Take Juice of Lemon, one ounce and a half. Subcarbonate of Ammonia, half a drachm. Pure Water, five ounces. Tartarized Antimony, one grain and a half. Syrup of Tolu, half an ounce. Of this mixture two large spoonsful are to be taken every three hours. Or, 2. Take Solution of Acetate of Ammo- nia half an ounce. Camphorated Mixture, one Ounce. Order V.J CATARRH. 321 drink plentifully of mucilaginous diluent liquors acidulated, and confining him to bed. Ammonia is a very powerful diaphoretic, and particularly if administered in wine-whey. Twenty or thirty drops of liquor vol. corn, cervi, in half a pint of wine-whey, if the patient is kept in a moderately warm bed, will soon elicit a profuse sweat. Neutral salts promote insensible perspiration, when the skin is not warmed much externally. When these are sufficiently diluted with water, and given, a copious perspiration is procured. Half an ounce of vinegar saturated with ammonia (as in the liquor ammon. acetatis,) and taken every two or three hours, will answer this purpose very well. Nitre is a medicine which is often given in this disease, as well as in gonorrhoea. In the latter, it will be sure to augment the pain by its stimulus on the excoriated or inflamed urethra; and in the former, where the discharge is too thin or saline, it cannot fail to increase the coughing. The secretion of mucus in the lungs and fauces may likewise be assisted by administering pectorals of the attenuating class, such as squills, gum ammoniac, &c.,* and by applying to them repeat- edly, throughout the course of the day, the steams arising from warm vinegar and water, by means of Dr. Mudge's inhaler. When the cough is troublesome, and there is great soreness and rawness in the fauces, demulcents! may be used with advantage ; Liquor. Antimon. Tartarizat. [II xii Syr. Althaeas, 3ij. M. ft. Haustus, quartis horis adhibendus. Vel, 3. B; Camphorae, gr. iv. Pulv Antimon. gr. ij. Confect. Rose, q. s. M. ft. Bolus. * 4. & Misture Ammon. f. gvss. M. Oxymel. Scillae, f. Jss. ft. Mistura, cujus sumat cochl. media ij. subinde vel tusse urg^nti. t 5. Bs Mucilag. Gum. Acacia?, f. |v. 01. Amygdal. D. f. gj. Syrup. Tolutan. f. |ss. Liquor. Ammon. Subcarbonat. f. 3ss. M. ft. Emulsio, cujus saepe sumat cochl.larg.j Vel, 6. B; Cetacei, 3>ss. Vitellum Ovi unius. Misceantur bene in mortario, et adde 42 Solution of Tartarized Antimony, eighteen drops. Syrup of Marshmallow, two drachms. Mix them as a draught, to be given every four hours. Or, 3. Take camphor, four grains. / Antimonial Powder, two grains. Confection of Roses, a sufficiency to form a bolus, which may be taken as frequently as the former. * 4. Take Mixture of Ammoniac, five oun- ces and a half. Oxymel of Squill, half an ounce. Of this mixture two desert spoonsful may be taken now and then, or when the cough is troublesome. t 5. Take Mucilage of Gum Acacia, five ounces. Oil of Sweet Almonds, one ounce. Syrup of Tolu, half an ounce. Solution of the Subcarbonate of Ammonia, half a drachm. Mix them, and of this emulsion the patient may take a large spoonful frequently. Or, 6. Take Spermaceti, one drachm and a half. The Yolk of an Egg. Mix them well together in a mortar, then add 322 PYREXIAE, OR FEBRILE DISEASES. [ClttSS I. and after the inflammatory symptoms have abated, opiates will afford effectual relief, and may be joined with the former. Where the patient's rest is particularly disturbed in the night, an opiate* at bed-time will be highly necessary, but it should 1>e combined always with some diaphoretic. If costiveness prevails in the course of the disease, it ought to be removed by gentle laxatives. When the mucous membrane of the nose is much affected, it may be smeared from time to time with a little tallow, or sperma- ceti ointment. The diet of the patient should be cooling and spare, as water- gruel, chicken-broth, beef-tea, vegetables, &c. Such is the treatment which should he adopted during the first stage of the disease: but it often happens, that after the inflam- matory symptoms have subsided, a weakness remains, and there is an increased secretion from the lungs, which perhaps continues for many months, without the least appearance of purulence. In such cases, the patient is carefully to avoid all fresh exposures to cold, and he should defend himself by going warmly clothed. Where the disease runs on for any length of time, or has become habitual, the patient should continue long in bed in the morning, so that the natural evening paroxysm of fever may be entirely carried off there, and he should go early to bed at night. He is likewise to abstain from wine, and all food which is hard of diges- tion; to breathe as pure open air as possible; and to use gentle exercise daily on horseback: which will take off the blood from the interior parts, and thereby diminish the internal secretions. Much benefit has been derived in some cases of chronic catarrh by using a warm bath, but particularly the vapour-bath, as by the Syrup. Tolutan. f. gss. Aq. Distillat. ----Pulegii, aa f. giij. M. ft. Mistura, cujus capiat eger cochleare maenum frequenter. 4 Vel, 7. R Mel. Optim. Ol. Amygd. D. aa f. gij. Sue. Limon. f. 5j. Syrup. Tolutan. f. 31J- M. ft. Linctus, de quo saepe lambat eger. '" 8. R Liquor. Ammon. Acetat. f. Jjiij. Mucilag. Gum. Acaciae, f. gj. Syrup. Tolutan, f. 3j- Tinct. Opii, Iff, xxvi. M. ft. Haustus, hora decubitus sumendus. Vel, 9. R Pulv. Ipecac. Comp. gr. xij. Pulvis sudorificus. Syrup of Tolu, half an ounce. Distilled Water, Penny Royal Water, of each three ounces. Shake them together, and let the patient take a large spoonful frequently. Or, 7. Take Clarified Honey, Oil of Sweet Almonds, of each two ounces. Lemon Juice, one ounce. Syrup of Tolu, two drachms. Mix them, and of this linctus let the pa- tient take a little often. * 8. Take Solution of Acetate of Ammo- nia, three drachms. Mucilage of Gum Acacia, one ounce. Syrup of Tolu, one drachm. Tincture of Opium, forty drops. Mix them for a draught, to be taken on going to bed. Or, 9. Take Compound Powder of Ipeca- cuanha, twelve grains. Order V.J CATARRH. 323 latter we have the power of introducing into the chest soothing, or stimulant vapours, which act immediately on the seat of the disease. When the secretion from the chest is greatly lessened, and debility alone remains, we may alternate the vapour-bath with the cold one, using the latter twice a week, and the vapour-bath once. By paying a proper attention to the means which have been advised, by keeping up a constant inflammation on the breast by plasters of Burgundy pitch, or pix arida, and blisters, and by employing opiates to mitigate the cough, and tonics, we shall in general be able to remove all consequences of the disease. If, notwithstanding these means, the cough should be dry, or be unattended with proper expectoration, and, together with a soreness, produce shooting pains through the breast and between the shoulders, accompanied with difficulty of breathing, flushing in the cheeks after meals, a burning sensation in the hands and feet, and other symptoms of hectic fever, no time should be lost, as there is reason to fear that tubercular suppurations will follow. Under such circumstances, the steps advised in the treatment of phthisis pulmonalis ought immediately to be adopted. It is necessary here to notice a species of catarrh, with which persons advanced in life, and who have had frequent attacks of such affections, are apt to be afflicted. They are seized with a cough, which at length becomes habitual and chronic, and con- tinues for many years, proving extremely distressing. Its attacks are most common early in the morning, and the ill-fated patient, otherwise in good health, is thrown into fits of coughing, which last a long time, and are only terminated by a free expectoration taking place, when relief is immediately obtained. Next morning, however, the same distressing symptoms again seize the enfeebled patient, and thus the little strength he may have to support him through the fatigues of the day is nearly exhausted. In northern climates in particular, this species of catarrhal affection is very frequently to be met with among elderly people ; and it seems to arise from an unusual quantity of mucus secreted in the bronchiae, and perhaps in the lungs themselves, which by impeding respira- tion, or mechanically irritating these parts, produces the cough. When the complaint is protracted, or occurs in aged people who are much exhausted, the expectoration possibly ceases, while at the same time the bronchial secretion goes on, the skin is cold, the pulse is small and fluttering, the patient becomes drowsy, the face is tumid and discoloured, the lips livid, and the breathing is more and more difficult, till at last the bronchiae are so replete with mucus that the admission of a sufficient quantity of air to support life becomes impossible, and suffocation ensues, as happened in a late instance which came under my care. A combination* of squill * 10. R Pulv. Gum. Myrrh. gj. i * 10. Take Gum Myrrh in powder, one J drachm. Gum. Ammoniac 3ss. ----Ammoniac,halfadrachm. Scillae Pulv. gr. x. Powdered Squill, ten grains. 324 PYREXIA, OR FEBRILE DISEASES. [Class I. and gum ammoniac will be proper in this species of catarrh. Tonics appear likewise advisable, and therefore we may recom- mend the sulphate of iron, with subcarbonate of potash and myrrh, as noticed under the head of Phthisis. Opium, by checking the expectoration, might prove prejudicial. Digitalis* will be very likely to produce much benefit also in chronic coughs accompanied with dyspnoea, great secretion of viscid phlegm, and any tendency to effusion into the cells of the lungs. The catarrhal fever, known by the name of influenza, which pre- vailed so universally in most parts of this kingdom in 1803, as well as in France, where it was called la-gripe, first showed itself in London towards the latter end of the month of February, when a damp and mild state of the atmosphere had succeeded to severe cold, and when this again had been followed towards the beginning of March by frost and keen easterly winds. Like preceding epidemics of the same kind, this disease ex- hibited various degrees of morbid affection, having been in some instances so slight as not to incapacitate persons from following their ordinary occupations and pursuits, and scarcely to require the aid of medicine; while in others the attack was of so severe a nature as to endanger life, and even to destroy it. To young children and elderly people it proved very fatal indeed, but more particularly so to the latter. Those likewise of a middle age, who either laboured under habitual asthma, or had any predisposition to phthisis, experienced its dire effect. It was generally preceded by chilliness and shiverings, which were succeeded by some degree of heat, pains in the head, a dis- charge from the eyes and nostrils, severe sneezing, hoarseness, and cough. In the course of a few hours the headach became much increased, as well as the heat; the pulse was quickened, but small; the breathing was difficult and oppressed, or transitory stitches Syrup. Tolutan. q. s. M. ft. Massa in pilulas, gr. v dividenda. Ca- piat ij. pro dos omni mane et nocte. Vel, 11. B Gum. Myrrh. 3ss. Solve in. Aq. Purae, ^j- et adde Mistur. Ammoniac. !|v. Oxymel. Scillae, 2;ss. Tinct. Camphorae Compos, gij. M Capiat cochl. amplum pro dos. bis terve in die. * 12. R Misturae Ammoniac, f. ^v. Oxymel. Scillae, f. ^ss. Tinct. Digitalis, 1t[ xxv. M. Sumat cochl. amplum subinde, vel tuss, •"it dyspnoea urgenti. Syrup of Tolu, a sufficiency to form the mass, which is to be divided into pills of five grains each, andtwo to be taken morning and night. Or, 11. Dissolve Myrrh, half a drachm in Purewater,one ounce; then add Mixture of Ammoniac, five ounces. Oxymel ofSquill,half an ounce. Compound Tincture of Cam- phor", two drachms. Mix them and take a large spoonful twice or thrice a day. 12.TakeMixture of Ammoniac, 6 ounces. Oxymelof Squill,half an ounce. Tincture of Foxglove, forty drops. • Mix them, and let a large spoonful be taken from time to time, when either the cough or shortness of breath ic troublesome Order V.J CATARRH. 325 across the chest were felt. Some patients complained of pains in the shoulders and limbs, very much resembling chronic rheumatism and there were instances in which the difficulty of breathing might be, in part, attributed to a similar affection of the intercostal muscles. The tongue was usually while ; the thirst considerable • the bowels were costive ; the urine was high-coloured and clear- and very frequently there was nausea at the stomach, with more' or less of vomiting. Towards the second or third night the cough became greatly aggravated, and was strong and almost incessant, being usually accompanied, even on its first coming on, with an expectoration of thin sharp mucus. The evening paroxysm of fever was likewise more severe, being attended with extreme anxiety and restlessness as well as considerable heat, and often with a great confusion in the head, and rambling. At this stage of the disease the pulse was usually from 100 to 120 strokes in a minute. Towards the morning there was commonly a remission of the febrile symptoms, but the cough continued urgent, and greatly interfered with the patient's getting any sleep after this time. Where gentle perspirations came on early, and the bowels were kept open, the fever usually declined about the fifth or sixth day, and the urine, which was before high-coloured and clear, now became turbid, or deposited a copious sediment; but the cough continued for many days, the sputum being however of a milder quality and thicker consistence, and the expectoration more free. Depression of spirits, languor, and debility, which were universal attendants on this epidemic, together with restless nights, harassed the patients for a considerable length of time after the decline of the fever. Such was the common form of the disease, but its modifications were extremely numerous; for in some instances there was a violent headach with a swelling of the eyes, or inflammation of the conjunctiva, or pains in the limbs, with but little catarrhal affec- tion ; in others, the throat was principally affected; and in others again, a peripneumohic condition existed. In a few instances the fever assumed the typhoid type. In the treatment of the influenza, bleeding was not much em- ployed, and it was only had recourse to in those cases where the symptoms of pneumonia were very urgent, and the patient com- plained of a great difficulty of breathing or an acute pain in the side. Where dyspnoea prevailed, the application of a blister to the chest usually afforded considerable relief. If nausea was complained of at the commencement, a gentle emetic proved serviceable ; and where costiveness existed, as was usually the case, is was necessary to give some gentle laxative. When there was no great degree of heat or fever present, it was by no means requisite to keep patients in bed: in such cases, con- finement to their chamber, with plentiful dilution, and a spare regimen, was sufficient; but when the febrile symptoms ran high, 3^t» PVREXI«, OR FEBRILE DISEASES. [ClttSS I. it was necessary to keep them in bed, and to administer diapho- retics. Small doses of the pulvis antimonialis, assisted by a solu- tion of some neutralized salt, and given every three or four hours, seldom failed to excite a gentle determination to the surface of the body. Further than this was not proper; for immoderate sweat- ing, and particularly at the decline of the disease, was sure to prove injurious, by adding to the languor and debility. Some advantages were derived from a free use of the compound decoction of barley, and solutions of gum. acaciae, with the addi- tion of a little syrup of lemons, in those cases where the fauces and throat were affected by rawness and soreness. Towards the decline of the disease, where the expectoration was both viscid and difficult, squills were employed with benefit. Where the cough proved very troublesome, and the febrile symptoms had subsided, an anodyne at night had a very good effect. To counteract the languor and debility which invariably attended this epidemic, it was necessary, during a state of convalescence, to have recourse to tonics ; such as a decoction of the bark of cin- chona, with the mineral acids; or some preparation of myrrh, with an infusion either of calumbo root or gentian, various formulae of which are inserted under the head of Dyspepsia. At the commencement of the disease, a spare, mild, and vegetable diet was most advisable; but at its decline, a generous one, with a moderate quantity of wine, was proper. Many persons seemed to have relapses, and therefore it was found necessary to guard carefully against any fresh exposure to cold. In many instances the period of convalescence was much protracted; and during the debility which prevailed in consequence of it, patients were liable to the attack of some chronic disorder that proved obstinate and tedious, but more particularly to chronic rheumatism. By some physicians the disease was supposed to be contagious; by others not so : indeed its wide and rapid spread made many suspect some more generally prevailing cause in the atmosphere, as alone capable of accounting for its extensive and speedy diffu- sion. It arose probably at the first from a peculiar state of the atmosphere, like other epidemics, and was afterwards kept up and propagated by contagion. DYSENTERIA, or DYSENTERY. The dysentery is a disease in which there is an inflammation of the mucous membrane of the intestines, accompanied with frequent -tools, severe griping pains, a tenesmus, and some degree of fever; the stools, although frequent, being small in quantity, and without any natural faeces intermixed, but consisting principally of mucus, which is sometimes streaked with blood. When the natural faeces do appear, they are usually under the form of small, compact, hard substances, known hy the name of scybala. Order V.J DYSENTERY. 321 In the medical schools of Europe, it has been taught that dysentery is of a highly contagious nature, and it undoubtedly is so where the sick are over accumulated, and cleanliness and ven- tilation are not properly attended to ; but it seems probable that the disease itself, under all ordinary circumstances of accommo- dation, is not of an infectious nature. Dysentery occurs chiefly in the autumn, and is often occasioned by cold or moisture succeeding quickly to intense heat or great drought, whereby the perspiration is suddenly checked, and a determination made to the intestines. It is likewise occasioned by a use of unwholesome and putrid food, and by noxious exhalations and vapours ; hence 'it appears often in armies encamped in the neighbourhood of low marshy grounds, spreads rapidly, and proves highly destructive, particularly where there is an undue accumu- lation of sick, and a neglect of cleanliness and due ventilation. From the same causes it occurs frequently on board ships of war, and vessels transporting slaves from the coast of Africa, proving equally fatal. The free use of fruits has been assigned as one of the causes productive of the disease in warm climates; but very erroneously, for they have quite the opposite effect, and tend to preserve those from it who partake freely of them when perfectly ripe. A particular disposition in the atmosphere seems often to predispose or give rise to the dysentery, in which case it prevails epidemically. It frequently occurs about the same time with autumnal inter- mittent and remittent fevers, and with these it is often complicated. It is likewise frequently combined with typhus. A late writer* supports the proposition that the simple dysentery is of itself never contagious, nor the intermittent and remittent forms of the disease ; that the combination with typhus is alone possessed of that pro- perty ; and this, he insists, originates not in the virus specific to the dysentery, but in the contagion of fever. Others have, however, given it as their opinion, that the contagion arises from the effluvia of the faeces of dysenteric patients, and not from their febrile per- spiration or breath. The dysentery is much more prevalent in warm climates than in cold ones; and in the months of August, September, and October, which is the rainy season of the year in the West Indies, it is apt to break out, and to become very general among the negroes on the different plantations in the colonies. It likewise prevails much in the unhealthy parts of the East Indies, and in our fac- tories on the coast of Africa, both during the wet season and some time after it. The body having been rendered irritable by the great heat of the summer months, and being exposed suddenly to cold or moisture with open pores, the blood is thereby thrown from the exterior vessels upon the interior, so as to give rise to dysenteries. The dysentery of tropical climates is usually found connected * See Observations on Simple Dysentery and its Combinations, by Wm. Harty, M. D 328 PYREXIA, OR FEBRILE DISEASES. [Class I. in some way or other with derangement of the liver ; but whether the one is a cause or a consequence of the other, observation has not accurately determined; for sometimes hepatitis precedes the rise of Indian dysentery, at other times it follows in success- ion, and in some instances there are evident symptoms of both diseases existing from the commencement to the termination of the case. Dysentery may readily be distinguished from diarrhoea by the absence of fever and tenesmus in the latter: the appearance of the stools, and the other symptoms, will further assist us. An attack of dysentery is sometimes preceded by loss of appetite, costiveness, flatulency, sickness at the stomach, and a slight vomit- ing, and comes on with chills succeeded by heat in the skin, and frequency of the pulse. These symptoms are in general the fore- runners of the griping and increased propensity to stool which afterwards occur; but it sometimes happens that the local affection is perceived first. When the inflammation begins to occupy the lower part of the intestinal tube, the stools become more frequent and less abundant, and in passing through the inflamed parts they occasion great pain, so that every evacuation is preceded by a severe griping, as also a rumbling noise, and there is unusual flatulence in the bowels. The motions vary both in colour and consistence, being some- times composed of frothy mucus streaked with blood, and at other times of an acrid watery humour, like the washings of meat, and of a very fetid smell. Sometimes pure blood is voided ; now and then lumps of coagulated mucus, resembling bits of cheese, are to be observed in the evacuations, and in some instances a quantity of purulent matter is passed. Sometimes what is voided consists merely of mucous matter, without any appearance of blood, exhibiting that disease which is known by the name of dysenteria alba, or morbus mucosus. While the stools consist of these various matters, and are voided frequently, it is seldom that we can perceive any natural faeces among them, and when we do, they appear in small hard balls, called scybala, which being passed, the patient is sure to experience some temporary relief from the griping and tenesmus. It frequently happens, from the violent efforts which are made to discharge the irritating matters, that a portion of the gut is forced beyond the verge of the anus, which in the progress of the disease proves a troublesome and distressing symptom, as does likewise the tenesmus, there being a constant inclination to go to stool, without the ability of voiding any thing, except perhaps a little vitiated mucus, or a small quantity of blood. More or less of pyrexia usually attends with the symptoms which have been described throughout the whole course of the disease, where it is inclined to terminate fatally, and is either of an inflam- matory or putrid tendency. • In the other case the febrile state Ot^der V4 DYSENTERY. 329 wholly disappears after a time, while the proper dysenteric symp- toms probably will be of long continuance. When the symptoms run high, and are accompanied with violent. irritation of the whole intestinal tube, great prostration of strength, strangury, and hickup, or with a putrid tendency, and fetid and involuntary discharges, the disease often terminates fatally in the course of a few days : but when they are more moderate, it is fre- quently protracted to a considerable length of time, and induces great emaciation and debility, but goes off at last by a gentle per- spiration diffused over the whole body ; the fever, thirst, and griping then ceasing, and the stools becoming of a natural colour and con- sistence. When the disease is of long standing, and has become habitual, it seldom admits of an easy cure; and when it attacks a person labouring under an advanced stage of scurvy or pulmonary consumption, or whose constitution has been much impaired by any other disorder, it is sure to prove fatal. It sometimes appears at the same time with autumnal.intermittent and remittent fevers, as has before been observed, and is then more complicated and difficult to remove. A great degree of tenesmus, severe griping pains, frequent incli- nation to go to stool and but little voided, much depression of strength, fetor of the evacuations, a tense abdomen, violent pyrexia, cold clammy sweats, coldness of the extremities, aphthae, hickup, petechiae, and a weak irregular pulse, are to be regarded as very unfavourable symptoms. Whereas a gentle and universal diapho- resis, moderate pyrexia, the evacuations becoming less frequent and more of a natural consistence, and a gradual diminution of the griping and tenesmus, are favourable appearances. The disease is very liable to a relapse from any exposure to cold, wet, or fatigue. Upon opening the bodies of those who die of disentery, the internal coat of the intestines (but more particularly of the colon and rectum) appears to be affected with inflammation and its con- sequences, such as ulceration, erosions, contractions, scirrhosities, and gangrene.- The peritonaeum and other coverings of the abdomen, in many instances, have likewise an inflammatory appearance Two different stages seem evidently to exist in the course of this disease ; wherefore, to treat it properly, due attention should be paid to that which is present at the time when advice is applied for. An important point to be attended to, is not to neglect it at its commencement. In its first stage, if the patient is young and plethoric, and the disease is accompanied by acute inflammation of the villous coat of the intestines, and a considerable congestion of blood, or inflam- mation of the liver, as is sometimes the case in warm climates, early blood-letting may be requisite. It will also be proper where an inflammatory state of the intestines appears to be the cause of dysentery, and besides the tormina and tenesmus, there is a con- siderable discharge of Mood with the stools, which consist of little 13 33I> 1>YREX1J:, OR FEBRILE DISEASES. [Class I. else than that and mucus ; but otherwise venesection will not be necessary, particularly as the fever which accompanies dysentery is very apt in the course of the disease to assume a typhoid type. It has been a matter of doubt with some physicians whether to consider the inflammation that attends on dysentery as the conse- quence or cause of the disease. My own opinion is certainly in favour of the latter; but nevertheless, I do not recommend an indiscriminate use of the lancet, but, on the contrary, a very cau- tious one. In most cases, we may begin the cure by giving a gentle emetic in the evening, and the next morning we may administer castor oil or some saline purgative, which should be repeated every second or third day, in order to procure an evacuation of natural faeces, which seldom pass off in any quantity, unless by artificial means. As a complete cure in dysentery can only be effected by a full and free discharge of purulent matter from the intestines, and this kept up throughout the whole period of the disease, a frequent repetition of such medicines as will effectually promote the end in view must be assiduously attended to. Should those which are prescribed below* not procure copious stools, we must then employ stronger purgatives.! Some practi- tioners are in the habit of combining emetic and purgative medi- cines^ such as some of the mild neutral salts, with tartarized anti- mony, and often with a very good offect. With the view of determining the circulation to the surface of * 1. R Soda? Sulphat 3vi. Mannae Optim. 3jss. Aq. Fervent, f. |jiss Tinct. Sennae C. ^ij. M. ft. Haustus. Vel, 2. R 01. Ricini, f. ^j. pro dos Vel, 3. R Magnes. Sulphat. gi. Mannae Optim. gss. Aq. Fervent. — Menth. Pip. aa f. giis. Tinct. Rhei, f. 3ij. M. ,Cujus sit dosis cochlearia quatuor pro re nata. t 4. Hydrargyr. Submuriat. gr. iij. Pulv. Jalapae, 9j. Syr. Rhamni, q. s. M. ft. Mass. in pilulas v. pro dos. dividenda t 5. R Infus. Sennae, f. gv. Potassa? Tartrat. ?j. Antimon. Tartar, gr. ij. Solv. Hujus mistura? sumantur cochl iv. quo- libet trihorio, donee venter rite so- lutes fnerit. * 1. Take Sulphate of Soda, six drachms. Manna, half an ounce. Warm Water, one ounce and a half. Compound Tincture of Senna, two drachms. Mix them as a purgative draught. Or, 2. Take Castor Oil ,one ounce for a dose. Or, 3. Take Sulphate of Magnesia, one ounce. Manna, half an ounce. Warm Water, Peppermint Water, of each two ounces and a half Tincture of Rhubarb, two drachms. Of this solution four large spoonsful may be taken occasionally. 4. Take Submuriate of Mercury three grains Powdered Jalap, one scruple. Syrup of Buckthorn, a sufficiency. Form the mass into five pills, to be taken for a dose. 5. Take Infusion of Senna, five ounces. Tartrate of Potass, one ounce. Tartarized Antimony, two grains. Dissolve them, and of this mixture four large spoonsful may be taken every three hours, until the bowels are suffi- ciently moved. Order V.J SYSENTERV. §31 the body, small doses of some diaphoretic* may be taken every three or four hours, after proper evacuations, so as to produce and keep up a gentle perspiration without exciting much nausea. A warm bath, assisted by diluents and warm covering, may pfdve good auxiliaries. By these means we may be able sometimes to, cut the disease abruptly short, and arrest its progress. Cerated glass of antimony has been much extolled by Sir John Pringle for its great efficacy in the cure of dysentery, and may therefore be given if the other medicines are not found to answer. The dose for an adult is about eight grains; but it will be most advisable to begin with four or five grains, increasing the quantity according to the effect produced. A novel method of using emetic medicines in dysentery has been recommended by a late writer ;t and we are assured by him, that he has found the practice highly successful. This is in the form of a clyster ; and that which he has experienced to answer best, has been about three drachms of ipecacuanha root, bruised and boiled in a quart of water down to a pint, which he repeats twice or thrice in twenty-four hours. If dysentery is accompanied with violent retchings or a severe vomiting on its attack, so as to threaten the patient with cholera morbus, neither emetics, purgatives, nor diaphoretics, will be ad- visable at first. In such cases the stomach must be evacuated of its contents by the gentle stimulus of large draughts of chamomile- tea. The same, or weak broth, may be thrown up the intestines in the form of clysters until these are cleansed ; after which an opiate should immediately be given. If the opium is rejected, a double quantity of it is then to be administered in a clyster. Should the vomiting continue very obstinate notwithstanding these means, the safety of-the patient will then depend on bathing the region of the stomach well with tincture of opium and cam- phorated spirits ; on repeating the clysters frequently with a proper quantity of opium in each ; and on adopting the other steps advised under the head of Cholera Morbus. A blister applied oyer the stomach may sometimes be useful. In dysentery, when the abdomen is hard, tense, and painful to the touch, and the gripings are frequent and severe, the application of flannels, wrung out in a warm decoction of chamomile-flowers and poppy-heads, with a small addition of camphorated spirits, to the part, may afford considerable relief: but should fomentations not procure the desired effect, a blister ought to be put on. Most cases of dysentery, and particularly during the acute stages of the t See Observations on the Nature and Cure of the Diseases of the East and West Indies, by Thomas Clarke, Surgeon. * 6. R Pulv. Ipecac. Com. gr. iij. * 6. Take Compound Powder of Ipecacu" anha, three grains. Confect. Aromat. gr. x. M. AromaticConfection,tengrains. ft. Bolus, 4tis horis sumendus. Make them into a bolus, to be taken ', f.very four hour? 532) PYREXIiE, OR FEMRILE DISEASES'. [Class 1. disease, may be relieved by immersing the patient in a warm bath of a moderate temperature, and keeping him in it for some time. Perhaps rubbing the abdomen with some warm and stimulating embrocation* on his being taken out of the bath, might increase its effect. To defend the inner coat of the intestines from the acrimony of its contents, and to counteract the vain attempts at evacuation, it will be necessary to give something to be discharged. Here then we should not only administer mucilaginous substances, such as solutions of gum acacia in milk, preparations of barley, rice, arrow- root, &c.t by the mouth; but we should likewise inject a clyster of a similar nature} three or four times in the course of the day. All vain attempts to go to stool, as also all violent strainings in evacuating the contents of the bowels, ought carefully to be avoided by the patient throughout the disease ; for if obedience be paid to every seeming call of nature, the straining which ensues will be highly detrimental, as little or nothing, except mucus and blood, comes away in four out of five efforts. If the fundament becomes inflamed or excoriated, the parts should be anointed with a little soft pomatum or prepared lard, after each evacuation. In the cure of Indian dysentery, mercury is the remedy now much relied on, but it is to be employed in an early stage of the disease. The plan recommended is, to give the hydrargjri sub- murias in a considerable dose night and morning without interrup- tion, accompanied by a mercurial friction of the abdomen until the mouth becomes sore. If diarrhoea ensues, this symptom is not to be interfered with, but rather encouraged by an occasional purga- tive of the sulphate of soda or rhubarb. I am much inclined to doubt, however, whether mercury so employed as to produce sali- vation will be found useful, or even innocent, in the cure of real dysentery. Indeed I should think it could not fail in many in- stances to prove hurtful, and particularly in the doses which are : 7. R Liniment. Saponis, f. §iss. Tinct. Opii, f, ^ss. OleiRosmarin. f. 3i. M. ft. Embrocatio. t 8. R Gum. Acaciae, gij. Solv. in. Decoct. Hordei, Oij. et adde Syrup. Cort. Aurant. f. spj. Bibat ajger pro potu ordinario. Vel, 9. R Misturae Corn. Usti,Oj. in die. t 10. R Decoct. Ainyli,f. ~v. 01. Olivae, f. ^ss. M. ft. Enema; adde pro re nata. Tinct. Opii, f. 3SS—3i. M. ft. Fnema. * 7 Take Soap Liniment, one ounce and a half. Tincture of Opium,half an ounce, Oil of Rosemary, one drachm. Mix them for an embrocation. t 8. Take Gum Acacia, two ounces. Dis- solve it in Barley Water, two pints, and add Syrup of OrangePeel, two ounces. The patient may take this for ordinary drink. , Or, 9. Take Mixture of Burnt Hartshorn, one pint daily. 110.Take Decoction of Starch, five ounces. Olive Oil, half an ounce. Add occasionally Tincture of Opium, half a drachm to one drachm. Mix them for a clyster. Order V.J DYSENTERY. 333 mentioned. When given, it probably might be found best to combine it with ipecacuanha, as, for instance, half a grain of calomel with one of ipecacuanha every two hours, until the gums are affected, or we may administer it combined with antimonial powder and opium. In the inflammatory variety of dysentery, the necessity of previous bleeding and purging to the employment of mercury, with the view of producing ptyalism, must be obvious to every practitioner. Where there exists a disease of the liver, or any diseased action of the biliary system in dysentery, mercury has certainly been found highly useful; and it is from its singular utility in this combination of disease, that the practice has become in warm climates so general of treating it, in all its stages, by this remedy ; a treatment, however, which must in many cases be improper. The connexion between dysentery and the deranged functions of the skin and liver has been illustrated by Dr. Johnson who is a great advocate for scruple doses of hydrargyri submurias, combined with small portions of opium. We are also told by a modern writer* that a proper combination of these two medicines has a surprising effect in restoring the natural balance of the vascular system, and in pro- moting the free secretion of bile. He says, that when it fails in acting forcibly on the skin in dysentery, small doses of the pulvis antimonialis and camphor may perhaps be added with advantage, the warm bath being occasionally used at the same time to equa- lize the circulation. There are some grounds for presuming that the disease which the authors here quoted! have called the dysentery of India, is in its nature, symptoms, and causes, and likewise in its method of treat- ment, very different from that which is described under this name in other countries ; that it differs in nothing from the bilious fluxes so commonly to be met with there, and arises from an affection of the liver ; for they describe the stools as being copious and liquid, frequently bilious, and seldom or never as containing scybala__ symptoms by no means characteristic of true dysentery. The singularity in the appearance of the faeces (as seldom passing by the anus in the form of scybala, but whether by the action of medicine or otherwise, being generally loose and liquid) has not been passed by unobserved by Sir James M'Gregor, Mr. Banfield,J and others, and it has been conjectured that this peculiarity in tro- pical dysentery arises probably from the intestinal secretions being considerably increased in consequence of climate, the secretions in such temperatures being more thin and acrid than in the climates * See Practical Illustrations of Typhus and other Febrile Diseases, by J. Arm- strong, M. D. t See M'Gregor's Medical Sketches; Clarke on the Diseases of Warm Climates : Milne's Account of the Diseases that prevailed during two Voyages to the East Indies; and Essay on the Influence of Tropical Climates on European Constitutions, by J. Johnson, M. D. h ^e his Pratfical Treatise on Tropical Dysentery. 334 PYREXIA, OR FEBRILE DISEASES. [ClaSS I. of Europe, and hence scybala are easily broken down and amalga- mated with the more fluid matter in their passage along the intes- tinal canal to the rectum. In the secondary attacks of Indian dysentery, where the relaxed and weakened state of the bowels seemed to keep up the disease, the nitric acid, in the quantity of about two drachms in the day, in barley-water, has proved an useful adjunct in the cure, and has been found to diffuse an agreeable sensation of warmth through the whole line of the alimentary canal. On leaving off the use of this medicine, an infusion of quassia, calumbo, or cascarilla, may be administered till the stomach and bowels have recovered their vigour and proper tone. At the commencement of dysentery it would be improper to employ either opiates or astringents ; but in the second stage, where the patient's strength is exhausted by frequent returns of the complaint, proceeding rather from a weak relaxed state of the howels than from any remains of malignancy, a use of these remedies will prove both proper and beneficial, taking care to obviate costiveness, and evacuate the contents of the intestines from time to time, by administering a few grains of rhubarb, or some such gentle laxative. In this stage of the disease, should the patient's rest be much disturbed throughout the course of the night from the frequency of the motions, we may direct an opiate* to be taken at bed-time. The hyoscyamus (henbane,) by its anodyne and gentle laxative qualities, seems a medicine well adapted to this disease, and may be tried when we cannot venture on opium. In chronic and habitual fluxes, which are complaints frequent with those who have suffered much sickness in tropical climates, it is seldom, indeed, that relief can be obtained without the aid of opium, and it is often found necessary to add it to all the other medicines we administer. Opiates, especially those of the warmer kind, such as the confectio opii, &c» are as valuable in these cases as the bark of cinchona is in intermittents. When the bowels have been effectually relieved, it often happen^ after the disease has continued for some time, from the tender state of the rectum, that a severe and troublesome tenesmus remains. Under such circumstances, or in the advanced stage of the disease, soothing and anodyne clysters are much used by professional men ; but in some instances the irritation produced by introducing the pipe more than counterbalances the soothing effects * ll.R Aq. Cinnam. f. 3vi- Spirit. Pimentae, f. |ss. Syrup Zingib. f. 31. Tinct Opii, tn_ xxv. M ft. Haustus. Vel, 13.ROpii,gr.j.—-ij. Pulv Antim. gr. j 11. Take Cinnamon Water, six drachms. Spirit of Pimenta, half an ounce. Syrup of Ginger, one drachm. Tincture of Opium, forty drops. Mix them as a draught. Or, 12. Take Opium, one grain to two grains Antimonial Powder, one grain. Confect. Aromat. q. s. M. Aromatic Confection, a suffi ft Pilula. I ciency to form a pill ©rder F.J dysentery. 3-30 of the injections. As a commodious substitute for anodyne clysters, we may therefore direct the patient to insinuate into the anus a pill of about two grains of opium, previously somewhat softened betwixt the fingers. We may also cause warm fomenta- tions to be applied to the parts, and a bladder filled with hot water to the hypogastric region. These will be likely to afford great relief to the patient. We are told that opium, combined with the nitric acid, agreeable to the prescription* here advised, has, on various trials, been found to have been attended with the best effects in the advanced stage of dysentery, when all other remedies have proved ineffectual, and even in cases where death seemed almost inevitable.t The astringents best adapted for the cure of a dysentery, are the different preparations of catechu, gum kino, logwood, &c. which may be given as below,} the patient at the same time taking Porfe wine properly diluted with water for his ordinary drink. Lime- water mixed with an equal proportion of milk has been much t See Observations on the Effects of Nitric Acid and Opium in the Cure of Dy- sentery, in vol. iii. p. 413, of the Medical and Physical Journal. * 13. R Acid. Nitrici, f. 31J- Tinct. Opii, rn_ xxx. Aq. Purae, f. giij. M. Capiat cochleare minimum ter quaterve die in quovis vehiculo t 14. R Extract. Lign. Campech. 3J. Mist Cretae, f %iv Tinct. Catechu, f. 3»j- Spirit. Myristicae, f. %j. M. ft. Mistura, cujus sumat. cochl. larg. ij. quartis horis. Vel, 15. R Confect. Aromat. Jj. - Aq. Cinnam. f. ?v. Spirit. Pimentae, f. 3jj. Tinct. Kino, f. 3ij. M. ft. Mistura. Adde pro re nata singul. dosi Tinct. Opii, fl\ x. Vel, 16. R Confect. Opii, gr. x. Aq. Cinnam. f. ^jss. . Tinct. Catechu, f. 3jss. M. ft. Haustus, quarts horis sumendus. Vel, 17. R Elect. Catechu, gr. xv. Aq. Pimentae, f. |jss. Tinct Kino, f. 3j- ft. Haustu« ■Opii, fl\ x- M * 13. Take Nitric Acid, two drachms. Tincture of Opium, forty-five drops. Pure Water, three ounces. Mix them, and take about a tea-spoonful three or four times a day. 114. TakeExtract of Logwood,one drachm. Chalk Mixture, four ounces Tincture of Catechu, two drachms. Spirit of Nutmeg, one ounce. Of this mixture take two table-spoonsful every four hours. 0r' , • 15. Take Aromatic Confection, one drachm. Cinnamon Water, five ounces. Spirit of Pimenta, one ounce. Tincture of Kino, two drachms. This mixture may be taken as the former, adding occasionally to each dose, Tincture of Opium,fifteen drops. Or, 16. Take Opium Confection, ten grains. Cinnamon Water, one ounce and a half. Tincture of Catechu, one drachm and a half. Mix them, and take this draught every four hours. Or, 17. Take Electuary of Catechu, fifteen grains Pimenta Water, one ounce and a half. Tincture of Kino, one drachm. ■ Opium, fifteen drops Mix them for a draught. 33b PYREXIA, OR FEBRILE DISEASES. [Class 1. recommended as a useful remedy in the latter stage of the disease. During my residence in the West Indies I was in the habit of recommending a strong decoction of logwood with the barks of pomegranate-fruit and the cushew cherry-tree, or anacardium, as an astringent drink, from which my patients seldom failed to ex- perience a good effect. In the advanced and chronic stage of the disease, as acidity at the stomach is apt to prevail, absorbents, such as the mistura cretae, pulvis cretae compositus, liquor calcis, &c. combined with opiates, will be useful.—See Dyspepsia for formulae of these medicines. Where there exists an extreme degree of atony, and a frequent discharge of faeces without pain, small doses of zinci sulphas combined with opium have proved of singular utility in many instances. The impaired tone of the intestines is likewise to be restored by a use of tonics and bitters,* together with a light nutritive diet and moderate exercise. The application of cold water to the abdomen, * 18. R Cort. Simarouba?, contus. ----Cascaril aa §ss. coque ex Aq. Biillient. Oj. ad §viij. colat adde Spirit. Cinnam. f. a;ij. Tinct. Opii, H\ xxx. M. Capiat cochl.larg. iij.quarta quaque hora, Vel, 19. R Infus. Cort. Cuspariae, f. ^vj. Tinct. Calumba3,f. Zj. ----Catechu, f. 3*j- Acid. Nitric, f. 3i. M. ft. Mistura, cujus sit dosis cochleariamag na iij. ter in die. Vel, 20. R Decoct. Cort Cinchonae, f. gjss Tinct. Calumb. ----Cort. Aurant. aa f. 3jss. ----Kino, flj xxv. M. ft. Haustus, ter quaterve die sumendus. Vel, 21. R Extract Gentian. --------Lign. Camp, aa 3j. Ferri Sulphatis, Gum. Myrrh, aa 3ss; Syrup. Zingib.q. s. M. Fiant pilulae xl quarum iij. sumat ter in die cum Decoct Simnroub. aut infusi Cascarilla?. f. ^ij. * 18. Take Simarouba Bark, bruised, Cascarilla Bark, of each half an ounce. Boil them in a pint of wateruntil reduced to eight ounces, strain off the liquor, and add SpiritofCinnamon,twoounces. Tincture of Opium, 45 drops. Mix them, and let the dose be three table- spoonsful every four hours. , 0r> 19. Take Infusion of Augustura Bark, six ounces. TinctureofCalumbo,oneounce. --------Catechu,twodrachms. Nitric Acid, one drachm. Of this mixture the dose may be three table-spoonsful thrice a day. Or, 20. Take Decoction of Peruvian Bark, one ounce and a half. Tincture of Calumbo, --------Orange Peel, of each one drachm and a half. ------------Kino, forty drops. Mix them for a draught, to be taken three or four times a day. Or, 21. Take Extract of Gentian, ----------Logwood, of each one drachm. Sulphate of Iron, Gum Myrrh, of each half a drachm. Syrup of Ginger, a sufficiency to form the mass, which is to be divided into forty pills, and of these three are to be taken morning, noon, and night, wash- ing them down with about two ounces of a decoction of Simarouba Bark, or an in- fusion of Cascarilla. Order F.J DYSENTERY, 337 and particularly to the lower parts of it, by means of cloths or sponges ; or the immersion of the lower part of the trunk in a tub of water, may probably prove a good auxiliary mean. The fever accompanying this disease sometimes appears under an intermittent or remittent form, and is protracted much longer than it otherwise would have been, in consequence of its being so complicated. In such cases its treatment is to be regulated as directed under these heads, by a use of the bark of cinchona, &c. In those instances where a dusky sallow hue of the countenance tenderness upon pressure over the region of the liver, and a clayey appearance in the faeces which happen occasionally to be voided manifest the presence of a diseased or obstructed state of the liver • we should resort to mercury, pushing it to such an extent as to keep up a gentle affection of the mouth until the symptoms are miti- gated. We may give the nitric acid at the same time. In the first stage of dysentery, a use of ripe fruits will be proper; but in a more advanced period, where any morbid acidity seems to prevail in the stomach, they should not be recommended. Every sort of food which readily tends to putrefaction ouoht carefully to be avoided throughout the whole course of the disorder as also all kinds of fermented and spirituous liquors, supporting the patient's strength with preparations of barley, rice, sago, flour panado, Indian arrow-root boiled in milk, occasionally varied for gelatinous broths. During the state of convalescence, Port wine or Madeira, or even a moderate quantity of brandy, properly diluted with water, may be allowed. Persons recovering from a dysentery should observe the greatest caution and regularity in their mode of living, and they should «d warmly clothed by wearing flannel next the skin, as the diseased very liable to relapse from any fresh exposure to cold, wet, damp night air, or sudden atmospherical vicissitudes. The importance of warm clothing, both in the prevention and cure of bowel complaints, is too obvious to require my saying much on the subject; I will therefore only observe, that warmth ought not to be a secondary object; on the contrary, it ought to be the first; for if a patient only wears his ordinary clothing, he will receive comparatively little benefit from any medicine. A waist- coat of flannel or fleecy hosiery next to the skin ought always to be worn, as likewise sliders of the same; and these should be laid aside with caution, and by slow degrees. The writer* of a small tract on dysentery lays much stress on swathing the abdomen with flannel bandages, as being the best mode of confining a certain degree of heat over that part of the body which is the seat of the disease ; and this practice is reported by Sir James M'Gregort to have been found very serviceable in many cases, both as affording * See H. Dewar's Observations on Diarrhoea and Dysentery, as those Disease appeared in the British Array during the Campaign in Egypt in 1801. ■» See Medico-Chirurgical Observations, vol. vi. p. 433. 44 ^^ Pi'KEXIiE, OR 1EKR1LE DisEAaES. [ClaSS L an equal support, and keeping up a due degree of warmth on the surface of the abdomen. Dysentery being by most considered of a very contagious naturer every precaution should be taken, particularly in situations where many people are crowded together (as in camps, and on board of ships,) to prevent the disease from spreading. The sick ought immediately to be separated from those in health, or who labour under any other disorder; they should be lodged, if possible, in distinct rooms or tents, and the strictest attention should be paid to cleanliness, taking care to remove the stools as soon as voided, and to have them quickly buried: to ventilate the chamber suffi- ciently, and sprinkle it now and then with a little warm vinegar; and to change the linen both of the body and beds frequently. In addition to these means, the fumigations advised under the head of Typhus Gravior may be resorted to. For the destruction of contagion of every species, where a number of persons are collected together, Dr. Rollo,* in addition to free ventilation and cleanliness, recommends the following as being an easy, safe, and very effectual method, and which is pursued at the Royal Artillery Hospital. Take of pulverized manganese, two parts ; common salt, four parts; sulphuric acid, three parts ; water, one part. A suitable proportion of this mixture is to be put into an earthen vessel, and suffered to remain until no vapours arise from it, or its peculiar smell is not perceptible. He mentions, that when a patient is admitted with an infectious disease, one or two gallipots are placed in the wards with about three ounces of the manganese and salt, to which is added half an ounce of water, and then is gradually poured on the whole a part of the ounce of sulphuric acid, the remainder occasionally. These quantities are according to the proportions previously stated, and they answer the consumption of a day. A pot or two is placed, we are informed by the Doctor, on the outside of the doors of the same wards in the gallery. The vapour is diffused over the whole ward, penetrates every where, and destroys every other smell than what itself conveys. Even the contagion of the small-pox has been noticed to be destroyed by this vapour, and of course it is likely to prove destructive of other contagions. In the manner here described, it can be used with due effect, and without the least prejudice to the sick. Its application, besides annihilating contagion, may also prevent its formation : and its use is recommended by Dr. Rollo in all situations where a number of persons in health are confined together, as on board of transports, especially in bad weather. Two or three gallipots, with the quantities before mentioned, he says, would be sufficient, and it would not be necessary to use them oftener than twice or thrice a week. Spp bis Account of the Royal Artillery Hospital at Woolwich Order I.J APOPLEXY. 339 It has been recommended to make trial of the remedy in marshy situations, where there maybe an unavoidable exposure : in these places the gallipots with the materials should be placed in the inside of the windows and doors of the habitations next to the marshes. CLASS II. NEUROSES, or NERVOUS DISEASES. The character assigned to this class of diseases is, preternatural affection of sense and motion, without idiopatic or primarv pyrexia, and without local disease. ORDER I. COMATA. Diminution of voluntary motion, with sleep, or a suspension of sense, is the character of this order of diseases. APOPLEXIA, or APOPLEXY. This disease consists in a sudden diminution or abolition of all the senses, external and internal, and of all voluntary motion, while at the same time the heart and lungs continue to perform their action. The state of the pulse, difficult respiration, stertorous breathing, profound sleep, and the affection of all the powers of volition, will distinguish apoplexy from palsy: the stertor, sopor, diminution of the power of volition, and the absence of convulsions, will distinguish it from epilepsy. In general it may readily be distinguished from intoxication by the patient not being roused by shouting in his ear, by applying volatile spirits to his nostrils, nor by shaking or pinching him. His respiration is low, labouring, and irregular, his countenance flushed, the pupils of his eyes often contracted, and his breath not tainted with the smell of wine or spirituous liquors. The extreme of insensibility from intoxication is sometimes, however, with difficulty to be distinguished from apoplexy, but its duration seldom exceeds ten or twelve hours at the utmost. Apoplexy makes its attack chiefly at an advanced period of life, and most usually on those who are of a corpulent habit, with a short neck and large head, and who lead an inactive life, make use of a full diet, or drink to excess. Young subjects are not, however, exempted from apoplexy, but it is Very rare when compared with persons advanced in the vale of years. The immediate cause of apoplexy is most generally a compres 340 neuroses, or nervous diseases. [Class It. sion on the brain, produced either by an accumulation of blood in the vessels of the head, and distending them to such a degree as to compress the medullary portion of the brain ; or by an effusion of blood from the red vessels, or of serum from the exhalants, which fluids are accumulated in such a quantity as to occasion compres- sion ; but it takes place sometimes without congestion, extravasa- tion, exudation, or effusion in the head being the consequence, as in many instances we see patients recovering quickly from a fit of apoplexy without any paralytic affection being left behind, which could not happen if either of these had existed. Such cases have by some physicians been supposed to originate in a peculiar con- dition of the brain and nerves alone, unattended by any discover- able alteration in their anatomical structure. Possibly a particular condition of the stomach and local irritations will produce this state. When the disease arises from an accumulation of blood in the vessels of the head, or by an effusion of blood from the red vessels, it is called sanguineous apoplexy, and when occasioned by serum from the exhalants, it is known by the name of serous apoplexy. The states of over-distension and effusion may be brought on by whatever increases the afflux and impetus of the blood in the arteries of the head ; such as violent fits of passion, mental anxiety, indolence, great exertions of muscular strength, severe exercise, excess in venery, gluttony, drunkenness, intense study, stooping down for any length of time, wearing any thing too tight about the neck, long exposure to intense cold or a vertical sun, the sudden suppression of any long-accustomed evacuation, the appli- cation of the fumes of certain narcotic and metallic substances, such as opium, alcohol, charcoal, mephitic airs, mercury, &c.; and by blows, wounds, and other external injuries. In short, apoplexy may be occasioned by whatever fills, distends, obstructs, ruptures, lacerates, corrodes, or compresses the vessels of the brain and its meninges too much, and thereby urges, retards, or entirely impedes the flow of blood through the same ; or in any manner destroys the intimate fabric and structure of the brain. A loss of vitality in the brain has been assigned as a cause of apoplexy in those cases where neither extravasation, exudation. nor effusion, are to be discovered on dissection. The circumstances disposing to sanguineous apoplexy are a full and luxurious mode of living, with but little exercise, a sanguine temperament, a full habit, middle age, short neck, suppressed eva- cuations, and warm weather. Those which dispose tp serous apoplexy, are a phlegmatic temperament, cachectic habit of body, poor living, depressing passions of the mind, much study, watching, and old age. Sanguineous apoplexy is sometimes preceded by giddiness, dimness of sight, drowsiness, loss of memory, or faltering of the tongue in speaking; but it more usually happens, that without much previous indisposition, the person falls down suddenly, the face is red. and appears puffed up, the veins of the head, partial- Order I.J APOPLEXY. 341 larly of the eyes, temples and neck, seem turgid, the head feels hot, the eyelids are half open and rigid, the eyes are prominent and fixed, the breathing is difficult and stertorous, and for the most part the pulse is strong, regular, and generally less frequent than what is natural. In a few instances, a grinding of the teeth, with slight convulsive motions are observable. When the disease continues for any length of time, the pulse becomes languid, weak, and slow, and the breathing is shortened, until at length it ceases altogether. In serous apoplexy the attack is more gradual in general, the face is pale and tumid, the veins are depressed, the pulse is small, weak, irregular, and intermittent, respiration is impeded and ster- torous, and the extremities are cold and flaccid. Sometimes these appearances are preceded by vertigo, torpor, and an impediment in the speech, together with a failure of memory. Although the whole body is affected with the loss of sense and motion in apoplexy, it takes place nevertheless very often more upon one side than the other, which is called a hemiplegia, and in this case the side least affected with palsy is somewhat con- vulsed. In some few instances of apoplexy the patient lies for several days insensible and motionless, and yet gradually recovers the use of his understanding, and his muscular strength ; but for the most part he is permanently deprived of the command of one side of his body, or he regains it imperfectly after a time; his mind sustains a shock which is never recovered from ; his sensations and percep- tions becoming less accurate, and his memory and powers of com- bining being much weakened, or at least his faculty of expression; for even while his memory and imagination are unimpaired, he is not always able to find appropriate words to express the notion which is excited in his mind. In forming our opinion as to the event, we must be guided by the violence of the symptoms, and according as the vital functions are more or less disordered. If the fit is of long duration, the respiration laborious and stertorous, the deglutition continues to be impeded, the pulse quick and hard, the extremities cold, and the person advanced in years, the disease in all probability will termi- nate fatally. In some cases it goes off entirely, either by diarrhoea, haemorrhage, return of the haemorrhoidal or any other habitual dis- charge, and sometimes by the appearance of fever; but more frequently it leaves a state of mental imbecility behind it, or terminates in a hemiplegia, or in death. Even when a person recovers from an attack of this disorder, it is very apt to return after a short period of time, and in the end to prove fatal. Where there is extravasation, the patient's recovery will be slow and difficult; for the power of absorption cannot be equal to its being immediately taken up. When the person's recovery is immediate, it is a presumptive evidence that there has been neither extravasation, effusion, nop exudation, but that the com- •J4-- -NEUROSES, OB NERVOUS DISEiAS£.S, [ClaSS iU pression arose from a repletion in the vessels of the brain. The sanguineous apoplexy is more dangerous than the serous. Dissections of those who have died of sanguineous apoplexy offer ample proof of the arterial as well as the venous system being in a remarkable state of repletion. When the scalp is divided there is sometimes a considerable flow of blood from the occipital and frontal veins ; indeed during the dissection the venous blood flows from all parts of the head. The dura mater is sometimes thickened and bound to the cranium by strong adhesions ; some- times the tunica arachnoides loses its transparency, is opaque, and much thickened. The pia mater is often remarkably vascular; the Veins are turgid with dark blood, and in particular parts of this membrane there appears high arterial action ; the whole surface sometimes acquires a bright vermilion tint. Between the pia mater and tunica arachnoides there is often to be observed a serous effusion which in some bodies is colourless; in others, turbid, bloody, or even mixed with streaks of coagulable lymph. With respect to the substance of the brain, it is frequently found unusually firm, and when cut into, the numerous points of blood show that the divided vessels are enlarged. A considerable quan- tity of serous fluid is often found in the ventricles, and these are much enlarged. For the most part, extravasated blood is met with in the cranium, sometimes between the membranes, and sometimes in the substance of the brain, and sometimes in the ventricles. Dis- sections have confirmed the observation, that the blood is generally hut not invariably found extravasated in the hemisphere opposite to the side of the body which was paralyzed. In most instances the extravasation of blood is confined to the cerebrum, but it has not unfrequently been found in the cerebellum ;* we do not always dis- cover extravasation of blood, but we never fail to find the remains of greatly increased action, and great congestion in the arterial and venous systems of the brain. Sometimes the longitudinal and lateral sinuses are swelled and distended. In those who die of serous apoplexy, dissections show the cere- bral arterial system nearly empty, their veins contain more blood, but less than in the sanguineous apoplexy; the brain is somewhat flaccid and soft, with perhaps a little watery effusion oh its surface, between the convolutions or in the ventricles; the left cavities of the heart, as well as the arteries, are empty; the right cavities contain some coagula of black blood; the pulmonary organs are full; frequently the digestive passages are impeded, and in a state ©f remarkable plenitude. In some dissections of serous apoplexy, venous turgesence, as well as effusion of serum, has been discovered; and in others, there were satisfactory proofs of increased arterial action having existed shortly before death. In the cure of sanguineous apoplexy no time should be lost in employing powerful remedies, the chief of which is early and extern * See Cases of Apoplexy, by J. Cheyne. M. D. Order l.\ apoplexy. 343 Sive depletion by bleeding; and it will be found that the action of the heart and arteries will require increased freedom and force, as the repeated bleedings have the effect of lessening the stupefactive pressure existing on the brain. On the person's being seized, due care must be taken to remove all compression from about the neck, to support him in as erect a position as possible, and to allow a free admission of cool air. These steps being adopted, sixteen or eighteen ounces of blood should immediately be taken away, and if it can be drawn from the jugular vein instead of the arm, it will be the more likely to be attended with a good effect. When any branch of the temporal artery seems so turgid as to admit of being easily opened, drawing blood from thence may probably prove a still more effectual way of unloading the vessels of the brain. In those cases where one side of the body is perceived to be more affected with the loss of motion than the other, the bleeding should be made, if possible, on the opposite side to that affected, as dissections show that the congestions producing apoplexy are generally on the side which is not affected. If the first bleeding has not been of service, and the disease is unequivocally established, the operation should be repeated a second time ; and if it is ascertained that this also is ineffectual in stopping the progress of the disease, a third bleeding ought to follow, as blood-letting is to be regarded as the most effectual remedy we can employ in sanguineous apoplexy. The quantity of blood to be drawn off must be regulated by the appearance and habits of the patient; by the circumstances of the attack; its violence and duration ; the effects of the previous evacuations; the appearance of the blood, which is often sizy ; and the state of the circulation; particularly the relief of the pulse and breath- ing, and the reduction of the complexion. After general bleeding, leeches may be applied, if necessary, to the temples, or the scarificator and cupping-glass to the occiput; and when sufficient evacuations have been procured by these means, we may then apply a large blister to the nape <>f the neck, and small ones to the extremities, together with cataplasms to the soles of the feet, or warm fomentations. Should apoplexy appear in a gouty constitution, or after symp- toms of the gout, the lancet, I think, may be used with safety and advantage. If the power of swallowing remains, some active purgative* ''* 1. ft Infus Senna;, f. Sjiv. Potassae Tartratis, f gvj. Tinct. Jalapa>, f ^ij. Syrup. Rhamni, f. 3iIf, ■ Capiat dimidium pro dos. v ei, '--. R Gum. Gambog. gn» iij- Tmto bene cum * 1. Take Infusion of Senna, four ounces, Tartrate of Potass, six drachms. Tincture of Jalap, two drachms. Syrup of Buckthorn, three drachms » Mix them, and let the half be taken for a dose, to be repeated after an hour or two, if necessarv Or, 2. Dissolve Gamboge, three grain? ic 344 LEUKOSES, OR NERVOUS DlSLAsEs. [Class. U. should be given by the mouth in divided portions, and at proper intervals, so as not to excite any vomiting; but if not, the contents of the intestines are^to be dislodged by a strong clyster,* or one composed of a solution of soap, which is to be repeated every three or four hours, until a sufficient effect is procured. Emetics are made use of by some practitioners. Where the disease has been brought on by intoxication, or by a large indi- gested meal distending the stomach, pressing upon the aorta descendens, obstructing the free expansion of the lungs, and thus crowding the arteries of the head with more blood than ought to be there, the exhibition of a gentle emetic may be admis- sible and proper, provided it has been preceded by copious vene- section ; or should vomiting arise naturally, the stomach may be relieved by washing it out with a little chamomile-tea; but where the disease arises spontaneously, and is occasioned by an extravasation either of blood or serum on the brain, more particu- larly the former, it cannot be denied, I think, that an emetic would be a very hazardous remedy. A supposed case of apoplexy which fell under the care of Dr. Langslow, of Halesworth, and Mr. Crowfoot, of Beccles, gave rise to much controversy with respect to the propriety of administering emetics in this disease. Those who wish to peruse the arguments which have been brought forward on the occasion by these gentlemen, as well as by many other practitioners, will find the subject amply discussed in the sixth and seventh volumes of the Medical and Physical Journal. When the fit goes off, we may advise some of the cephalic and nervous medicines recommended under the head of Palsy ; and in order to obviate any costiveness that may happen to arise, a little tincture of rhubarb may be taken occasionally. Tinct. Sennae C. f. ^j. et adde -----Jalapae,f. 3j. M. ft. Haustus. Vel, 3. g; Hydrargyr. Submuriat. gr vj. Extract. Colocynth. C. gr. xv. M. Fiant Pilulae iv. pro dos. - 4. ft Fol. S-nnae, 3»j- Aq. Fontan. Oj. Coque leniter ad Oss. Colat. adde Sodae Sulphat. JJj. 01. Ricini, f. gj. M. ft. Enema. Vel, 5. U Extract. Cofocynth. C. Jss—3" Infus. Sennae, f. ^xi. 01. Ricini, f.^j. M. '•.Enema. st?tim iniioiendum- Compound Tincture of Senna^ one ounce, and add Tincture of Jalap, one drachm. Mix them for a draught. Or, 3. Take Submuriate of Mercury, six grains. Compound Extract of Colocynth, fifteen grains. Make them into four pills, to be taken for a dose. 4. Take Senna Leaves, three drachms. Pure Water, one pint. Boil them slowly until redueed to half a pint, strain off the liquor, and add Sulphate of Soda, one ounce. Castor Oil, one ounce. Mix them for a clyster. Or, 5. Take Compound Extract of Colo- cynth, half a drachm to a drachm. Infusion of Senna, eleven ounces. Castor Oil, one ounce. Mix them, and inject this clyster immc diatelv. * Order /.] APOPLEXr. 3A5 In serous apoplexy, blood-letting may be more sparingly used than in the sanguineous. . To promote an absorption of the effused serum, after bleeding proportionate to existing circumstances, it will be proper to have recourse to warm purgatives, sternutatories,* and a free application of blisters to the head, back, and extremities and of sinapisms to the soles of the feet. Electricity is sometimes resorted to, and slight sparks passed through the head, but it is only under a failure of the other remedies that this should be em- ployed. Emetics in this species of apoplexy, as well as the former, seem of doubtful effect. Stimulants of various kinds, such as volatile salts, cephalic elixirs and cordials, have been much employed in serous apoplexy; but as they determine the circulation to the head, their use appears not altogether advisable. When they are employed, sufficient evacuations should always precede their use. Out of a fit of serous apoplexy, the cephalic and nervous medi- cines, advised under the head of Palsy, will be proper, taking some stomachic purgative now and then. When apoplectic symptoms proceed from opium, or any other narcotic poison taken into the stomach, the offending matter ought to be got rid of as soon as possible, by exciting vomiting, with tar- tarized antimony or sulphate of zinc, should none have arisen spontaneously. Having procured its discharge, we are to have recourse to bleeding, and the exhibition of acrid clysters, with the view of relieving the congestion in the brain and lungs, together with the other means recommended under the head of Vegetable Poisons. Although stimulants are improper in apoplexy arising from other causes, still they may be employed with great safety and utility in those cases where it proceeds from any narcotic poison taken into the stomach, or otherwise applied to the body; but here, too, proper evacuations should he premised. The external stimulants in general use, are volatile spirits applied to the nose and temples, rubefacient ointments to the breast and back, blisters, sinapisms with horseradish, and warm fomentations to the extremities, together with frictions with flannels or a flesh-brush, impregnated with flour of mustard, and throwing cold water over several parts of the body, which in general proves one of the most effectual means of rousing apoplectics of this kind, particularly if the person is first carried out into the open air. The internal stimulants to be employed, are the volatile alkaline salts or spirits, white mustard- seed, horseradish, white scurvy-grass, and various aromatics, such as rosemary, lavender, &c. used either in substance, tincture, or in their essential oils. If the disease arises in consequence of the suppression of piles, leeches should be applied to the haemorrhoidal veins, fomentations 6. Pulv. Asari Compos. * 6 Compound Powder of Asarabacca. 15 3-1G NEUROSES, OR NERVOUS DISEASES. [Class II must be employed, and the intestines be stimulated by means of aloetic purges. Those who, from a plethoric state of the blood-vessels of the head, are predisposed to an attack of apoplexy, will act prudently in confining themselves to a very spare diet, carefully abstaining from strong liquors, from all high-seasoned food, and from meat suppers. A limitation of the use of fluids in habits predisposed to plethora and apoplexy will likewise be worthy of attention. Dr. Mossman tells us* he is taught by long observation and experience to expect effects highly beneficial from the adoption of this plan; for he constantly noticed the phenomena of plethora and obesity are referrible, not to the taking in of solid but of liquid nutriment. Persons predisposed to apoplexy should likewise be careful to keep their botry open by some gentle laxative, taken occasionally, and such moderate exercise ought to be used, as will support the per- spiration without hurrying respiration, or exciting heat. Nothing tight should be worn round the neck; and when in bed, the head ought to be supported at a proper height. The feet should be kept warm and dry, and the extremes of heat and cold must be avoided. Nothing has a better effect in preventing apoplexy in those who are predisposed to its attacks, than a perpetual issue between the shoulders, or a seton in the neck; but great care must be taken not to allow them to dry up, without opening some other drain in their stead. When an attack of apoplexy is immediately threatened, blood- letting is the remedy most to be relied on, and the blood should be drawn either from the jugular vein or temporal artery, as before advised. The extent of the bleeding can only be determined by the nature of the case.. Under doubtful circumstances, where the symptoms are not very urgent, the application of several leeches to the temples, or scarifications with cupping at the back of the head or neck, may prove amply sufficient. When a lethargic disposition prevails, we should advise bleed- ing, but particularly topical, from the temples, by means of leeches, or from the nape of the neck by the scarificator and cupping. We should also administer cathartics frequently, and direct a blister* to be applied to,the head or in the immediate neighbourhood of it. Every thing which may tend to stimulate the brain, such as ardent spirits, strong wines and tobacco, ought to be avoided. Where lethargy has been induced by great excitement o£ the mind, a change of scene, travelling by easy stages, cheerful com- pany, the amusements of watering places, and a course of those mineral waters which relax the bowels, (such as those of Chelten- ham) are worthy of a trial. >.. The coup de soleil, or stroke of the sun, which so frequently occurs in warm climates to those who are long exposed under its immediate influenee, seems evidently to be an attack of apoplexy, * ^re Medical and Physical Journal, vol. ix. P- 412. Order I.J PALSV. •J 47 and is to be treated in the same manner as pointed out in tho pre- ceding pages. The application of linen cloths wetted in cold vinegar and water to the temples, may likewise be tried. It may not be improper to remark here, that as the vital princi- ple frequently remains in a latent state for some time, and as we are yet unacquainted with any certain criterion between positive and apparent death, besides that of putrefaction, some appearances of incipient decomposition should therefore^be allowed to take place, in every case of sudden decease, before interment. In warm countries, where it is customary to bury the body within four and twenty hours, I have great reason to fear that premature interment sometimes happens. PARALYSIS, or PALSY. Palsy is a diminution or total loss of the powers of motion and sensibility in certain parts of the body, often attended with drow- siness. In some instances the disease is confined to a particular part or set of muscles ; but it more usually happens that one entire side of the body, from the head downwards, is affected, which is known by the name of hemiplegia. If the power of motion and sense of feeling in the half of the body, taken transversely, be impaired, the complaint is denomi- nated paraplegia. Palsy may arise in consequence of an attack of apoplexy ; and, like it, may be occasioned by any thing that prevents the flow of the nervous power from the brain into the organs of motion; hence tumours, over-distention, and effusion, distortions of the spine, and a thickening of the ligaments that connect the vertebrae together, often give rise to it. It may also be occasioned by translations of morbid matter to the head, by the suppression of usual evacuations, and by pressure made on the.nerves by luxations, fractures, wounds, or other external injuries. The long continued application of sedatives will likewise produce palsy; as we find those whose occupations subject them to the constant handling of white-lead, and those who are much exposed to the poisonous fumes of metals or minerals, are very apt to be attacked with it. Whatever tends to relax and enervate the system, may likewise prove an occasional cause of this disease: hence those who lead a sedentary or luxu- rious life ; those who are guilty of frequent irregularities,* or great debaucheries; those who are engaged in intense studies during the night, or labour under great distress of mind or anxiety, are very subject to this malady. It has very properly been doubted by some writers* whether palsy of the lower extremities alone, or of one single part, has so often its cause in the brain as it is said. The cause may, it is thought, also reside cither in the nervous chord of the spine, or in ' Ser: Ob=ervatiousouDerangedManife«tationsof the Mind: byDr.Spurzheiiu, p.28 348 NEUROSES, OR NERVOUS DISEASES.. [ClttSS. II. the abdominal viscera, or in the affected limbs themselves. The spinal chord is certainly composed of a nervous mass, and has the same membranes as the brain ; hence it may be affected by the same diseases, such as inflammation, suppuration, induration, tumour, congestion, or ossification of the blood-vessels, collection of any fluid, by irritation, weakness, or exhaustion of the nervous mass. The spinal chord may also be injured or compressed by the deviation of any of the vertebrae. It is to inflammation of a more chronic form in that part, that we impute those shaking palsies which are attended with pain. All the varieties of palsy more generally appear in the aged and infirm than in the young and robust. The left side is more fre- quently affected than the right. A decline of energy is often to be regarded as a commencement of palsy. In the premature diminution of the capacity of either bodily or mental exertions, there may be, in many cases, a well- founded fear of ultimate paralysis, unless the tendency to it be in due time counteracted by the relinquishment of pernicious habits, or the administration of appropriate remedies. Palsy usually comes on with a sudden and immediate loss of the motion and sensibility of the parts ; but in a few instances it is preceded by a numbness, coldness, and paleness, and sometimes by slight convulsive twitches. When the head is much affected, the eye and mouth are drawn on one side, the memory and judgment are much impaired, and the speech is indistinct and incoherent. If the disease affects the extremities, and has been of long duration, it not only produces a loss of motion and sensibility, but like- wise a considerable flaccidity and wasting away in the muscles of the parts affected. It has been mentioned, that a curvature of the spine, owing to one or more of the vertebrae being displaced, sometimes induces paralytic affections of the lower extremities, from the pressure that they make upon the nerves of those parts, and that sometimes the disease appears to arise solely from a thickening of the ligaments that connect the vertebrae together, without any particular affection of the bones. When one of the vertebrae only is diseased, it is observed that the patient is more completely deprived of the power of his limbs than when two or more of them are displaced, owing, as Mr. Bell* thinks, to the angle being more acute, and consequently the pressure on the medulla spinalis greater, when one bone only is thrown out of the range. This also accounts for the paralytic symptoms in some being less remarkable in the more advanced stages of the disease than they were at first; for although one bone only is displaced at first, yet one or both of the con- tiguous vertebrae almost constantly yield at last; and the difference arising from this is so great, that patients almost always linger and die in the course of a year or two, often in a less time, when one * See his System of Surgery, vol. vii. p. 213. Order I.J PALSV. 349 bone alone is deranged ; while they live for a great length of time, frequently as long as if no such circumstance had occurred, when the curvature of the spine becomes more extended. Paralytic affections from distortions occur in all ages; but more frequently about puberty than at any other period, and more com- monly in girls than in boys. In general the effects that result from them are observed before the cause is suspected ; for there i* seldom much pain in the part immediately affee^d. WheL distor- tion of the spine occurs du^mr infancy, the patient appears to be suddenly depriveu ot the use of his limbs ; but at more advanced periods, he complains first of feeblenesss and languor, and of numb- ness or want of feeling in the lower extremities* By degrees this want of sensibility is found to increase, and he is often observed to stumble and to drag his legs, instead of lifting them properly ; nor can he stand erect for any length of time, without much difficulty. At last he loses the use of his legs entirely, which become altogether paralytic; and when the spine is distorted much forward, so as to compress the thoracic and abdominal viscera, he becomes distressed with dyspnoea, or with complaints in the stomach and bowels, according to the part of the spine that is diseased. Palsy is to be distinguished from apoplexy by the pulse, which in the former disease is soft and slow, by the loss of sense and motion being only partial, by the absence of stertor, and likewise by the other symptoms. When palsy attacks any vital part, such as the brain, heart, or lungs, it soon terminates fatally. When it arises as a consequence of apoplexy, it generally proves very difficult to cure. Paralytic affections of the lower extremities, ensuing from any injury done to ihe spinal marrow, by blows and other accidents, usually prove incurable. Palsy, although a dangerous disease in every instance, particularly at an advanced period of life, is sometimes removed by the occurrence of a diarrhoea or fever. A feeling of warmth, and a slight pricking pain, as if stung by ants in the parts affected, with returning sensation and motion, are favourable symptoms. The morbid appearances to be observed on dissection in palsy are pretty similar to those which are to be met with in apoplexy: hence collections of blood, and of serous fluids, are often found effused on the brain, but more frequently the latter, and in some instances the substance in this organ seems to have suffered an alteration. In palsy, as well as in apoplexy, the collection of extravasated fluid is generally on the opposite side of the brain to that which is affected. When this disease arises in a young person of a full plethoric habit, comes on suddenly, and the head appears to be much affected, or seems to arise from the causes producing apoplexy, it will be advisable to take away some blood, by opening the jugular vein or temporal artery; after which it will be proper to give an <>5Q AEUROSES, OR NERVOUS DISEASE.^. [ClilSS II. active purgative, as advised under the head of Apoplexy ; but in old age, or where palsy arises in a debilitated constitution, neither bleeding nor purging should be resorted to. Where costiveness prevails, in such habits it may be obviated by some stomachic laxative, such as the tinctura rhei composita. In most cases, but particularly where the disease- has arisen in aged Or decrepit persons, the external application of stimulants will be highly proper; wherefore the parts affected, as well as all along the spine, may be rubbed several times a day with flannels, or a flesh-brush impregnated with flour or essepce of mustard, or else with the palms of the hand, and some kind of rubefacient liniment :* and, in addition to these remedies, we may recommend the application of warm fomentations, blisters, and sinapisms! to the palms of the hands and soles of the feet. As a gentle stimulus to parts affected by paralysis, urtication may sometimes be used. Warm bathing is a remedy which has been much employed in most cases of palsy, as an external stimulant. In those, however, which arise in sanguineous habits, from a congestion of blood in the vessels of the brain, its use would, in all probability, prove injurious both by stimulating the solids and rarefying the fluids, and thereby becoming a stimulus to the sanguiferous system ; but in those cases where palsy has arisen in consequence of the appli- cation of narcotic powers, diminished vital heat, or an enfeebled constitution, the use of warm bathing will be likely to prove highly beneficial. In palsy we ought therefore most cautiously to * 1. R 01 Oliva?, f. f ij. — Terebinth, f- |j. M. ft. Linimentum. Vel, 2. r>; Spirit. Camphorae,f. §j. Tinct. Lyttae, f. gij. Liquor. Ammon. Subcarb; f. 5ss. M. Vel, 3. IJ. Liniment. Ammon. Subcarbonat 01. Terebinth, f. 3»j- M. ft. Linimentum. Vel, 4. ft Liniment. Camph. Comp. f. Jj. > Tinct. Lyttae, f. 3j- M. t 5. r* Semin. Sinap. Pulv. Rad. Armoraciae Contus. aa 3;j. Micae Panis aut Farin. Sem. Lini. Acidi Acetic, q.s. M . ft; Cataplasma, plantif pedum applican dum. * 1. Take Olive Oil, two ounces. Oil of Turpentine, one ounce. Mix them for a liniment. Or, 2. Take Camphorated Spirit, one ounce. Tincture of Spanish Fly, two drachms. Solution of Subcarbonate of Ammonia, half an ounce. Mix them. Or, 3. Take Liniment of the Subcarbonate " of Ammonia, twelve drachms. Oil of Turpentine,three drachms.' Mix them. Or, 4. Take Compound Camphor Lini- ment, one ounce. Tincture of Spanish Fly, one drachm. Mix them. t 5. Take Mustard Seed, in Powder,. Horseradish, bruised, of each an ounce. Crumb of Bread, or Linseed Meal, two ounces. Acetic Acid, a sufficiency to form a cataplasm, which is to be applied to the soles of the feet. Order I.J palsy. 35 j ascertain whether an increased or diminished degree of vital heat or action in the sanguiferous vessels is the cause of the disease. Whether the natural baths, such as those of Bath, in Somerset- shire, &C. possess more efficacious qualities than the ordinary warm ones, seems a matter of doubt with many practitioners, as the substances with which the former are impregnated, are but trifling in point of quantity. The late Dr. Heberden thought these waters are neither in any way detrimental, nor of the least use in palsy. Bath has indeed been, for a great Jength of time, a favourite place of resort for the paralytic, whether made sq,by debauchery, or any other cause of premature decay; hut it is highly probable the fashionable springs of that crowded mart of health are not impregnated with the power of restoring lost energies, or bringing back the tide of ebbing animation.* When a natural warm bath cannot be resorted to, an artificial one may be substituted : and this may be made by dissolving a «proper quantity of the ferri sulphas in the water, and impregna- ting it with fixed air. Electricity, both by sparks and shocks, is another remedy which is universally employed in the cure of the palsy as an external stimulant, and often with the most happy effect ; but, in using it, proper care should be taken to apply it only with a moderate force, as more is to be expected from its repetition than from employing it with violence ; and likewise to confine its application to parts which are somewhat remote from the head, as in those cases which depend upon a compression of the brain, it might do injury, by acting on the vessels of this organ. Galvanism is also a remedy from which advantages might pro- bably be derived. Indeed some practitioners have gone so far as to declare, that they have experienced its effects in palsy to be superior to electricity. Dr. Bardsley tells us,t he has found it to succeed when the latter has failed. When the disease affects several different parts 6f • the body, as in hemiplegia, or paraplegia, we should use stimulants internally as well as externally. Those m most general use are mustard-seed, horseradish, garlic, and volatile alkaline salts, or spirits, and aether, which may be taken agreeably to the prescription advised below.J * See Essay on Nervous Diseases, by John Reid, M. D. t See his Medical Reports and Cases, p. 183. , 6. ft Sem. Sinap. Alb. ^j. > Capiat ssger cochl. min. ij. ex. Aq. Frigid. Cyatho bis terve die. Vel, T. ft Sem. Sinap. Alb. Contus. Rad. Armoraciae, aa ^ij. Cort. Aurant. ?ss. '$ 6. Take white Mustard Seed, two tea- spoonsful twice or thrice a day, wash- ing them down with a little cold water. Or, 7. Take of Bruised Mustard Seed, Horseradish Root, of each two ounces. Orange Peel, bruised, half an ounce. 35* NEUROSES, OR NERVOUS DISEASES. [ClaSS II. The arnica montana (leopard's bane) is a remedy* much recom- mended, and great advantages have been derived from it in Aq. Fontan. Oij. Coque ad Oj. Col. Fiat Decoctum cujus sumat Cyath.j amplum ter in die. Adde pro re nata, Tinct, Valerian. Ammon. TT1 xx. Vel, 8. ft Spirit. Ammon. Aromat. f. ^j. Sumat T1X x.—xx. pro dos. ter in die. Vel, 9. ft Tinct. Lav. Comp. f.3j- Spirit. Ammon. Foetid, ^ss. M Capiat fl], xvj.—xxvj. in quovis vehiculo appropriato. Vel, [ 10. ft Spirit. Armoraciae Compos.f. 3ij ---- Ammon. Foetid, V\ xvj. Tinct. Valerian, f. 3ij- Aq. Anethi, f. ^j. M. ft. Haustus, ter in die sumendus. Vel, 11. U Ammon. Subcarbon. gr. vj. Tinct. Cardam. Comp. f. 3»j - Aq. Menth. Virid. f. ^jss. M. ft. Haustus, 6ta hora capiendus. Vel, 12. ft Spirit. Ammon. Aromat. f. 3ss. Aq. Pimentae, f. 3*. Tinct. Cinnam. C. f. 3ij. M. ft. Haustus, sextis horis adhibendus. * 13. ftFlor. Arnicae Mont. 3U-—3»j- Aq. Bullient, f. ^x. Maceraper horam in vase clauso et cola. • ft Colati Liquoris, f. 3*- v Tinct. Card. C. f. 3ij. Syrup. Zingib. f. 3j- M. ft. Haustus, ter in die sumendus. Pure Water, two pints. Boil them slowly until reduced to one pint, then strain off the liquor, and let the patient take a wine-glassful three times a day, adding occasionally. Ammoniated Tincture of Vale- rian, thirty drops. Or, 8. Take Aromatic Ammoniated Spirit, one ounce. Of this, from fifteen to thirty drops may be given for a dose thrice a day. Or, 9. Take Compound Tincture of La- vender, two drachms. Foetid Spirit of Ammonia, half an ounce. Mix them, and take from twenty-four to fifty drops occasionally, in any suitable vehicle. Or, 10. Take Compound Spirit of Horse- radish, two drachms. Foetid Spirit of Ammonia, twenty-four drops. Tincture of Valerian, two drachms. Dill Seed Water, one ounce. Mix them for a draught, to be taken three times a day. Or, 11. Take Subcarbonate of Ammonia, six grains. Compound Tincture of Carda- mom, two drachms. Mint Water, one ounce and a half. Mix them, and let this draught be taken every six hours. Or, 12. Take Aromatic Ammoniated Spirit, half a drachm. Pimenta Water, ten drachms. Compound Tincture of Cinna- mon, two drachms. '-' Make these into a draught, to be taken as frequently as the former. * 13. Take JTlowers of Leopard's Bane, two or three drachms. Boiling water, ten ounces. Let them infuse for an hour in a covered vessel, then strain off the liquor. Take of the strained liquor, ten drachms. Compound Tincture of Carda- mom, two drachms.' Syrup of Ginger, one drachm. Mix them, and let this draught be taken thrice aday> Order I.J PALai, 353 paralytic and other affections depending upon a want of nervous energy. Resinous substances, such as guaiacum and the turpentines, have sometimes been employed with advantage in palsy; but from being apt to prove too inflammatory, their use is by no means general in this disease. When palsy has arisen in consequence of the system being ener- vated by any debilitating cause, besides applying stimulants exter- nally, and likewise administering them internally, we should make use of tonics joined with aromatics, as advised under the head of Dyspepsia. The arsenical solution is a remedy which promises some relief in this disease, particularly when confined to particular parts. The nux vomica is a medicine which has lately been given with considerable benefit, it is said, in some cases of palsy. It will be best to begin with two grains, night and morning, in powder, com- bined with about ten grains of compound tragacanth, and to increase the dose every other day, by an additional half grain, till it amounts to seven grains. In that palsy of the lower extremities which is occasioned by a deformity of the spine, or which arises from a thickening of the ligaments that connect the vertebrae together, without any parti- cular affection of the bones, the insertion of issues conjoined with a recumbent position (see Scrofula) have proved advantageous in many cases. The late Mr. Pott, to whom we are much indebted for his observations on this subject, speaks highly of the effects of drains placed as near as possible to the tumour. He recommends an issue to be opened with caustic on each side of the swelling, large enough to admit of a kidney bean, and the bottom of the sore to be sprinkled from time to time with powder of cantharides. My advice was sometime ago requested on the case of a young lady about seventeen years of age, who had gradually lost all sense of feeling as well as motion in her lower extremities. The disease had then been of two years' standing; she had consulted two or three practitioners, and had gone through a course of the usual medicines, together with blistering and other stimulating external applications, and she had made trial both of warm and cold bathing; but all without avail. Independent of the paralytic affection in the lower extremities, she seemed to suffer no inconve- nience ; her countenance was healthy, and her appetite good; she slept well, and felt no pain. She rode on horseback every day when the weather permitted, and when it did not she went out in a carriage for the benefit of the aiv. Upon being informed of the history of the case, 1 immediately suspected that the disease was occasioned by some injury done to the spine, or that there was a thickening of the ligaments that connect the vertebrae together; and in this supposition I was confirmed by passing my hand down the lower extremity of the spine. I ordered issues to be inserted in the •nanner just advised, and had the satisfaction to see my patient 4G 3o4 AEUROaES, OR AER\OUs 1)I»LAjE.->. [Class li soon recover the feelings in her feet, so as to be sensible when they touched the ground, and at the end of about three months she was capable of walking alone. I have every reason however to con- clude, that the disease was in the ligaments only, and that the bones of the spine were not affected. When the vertebrae are diseased, a complete cure, I am afraid, can seldom be obtained ; but the symptoms may certainly be greatly mitigated, and the pressure upon the spinal marrow diminished, by exciting a discharge in the neigh- bourhood of the parts, and keeping the patient in a recumbent po- sition.—See Scrofula. Dr. Clutterbuck informs us, in a phamphlet published not very long ago, that he had found mercury to be an excellent antidote to lead, and that he had1 used it with the most happy effects in many instances of paralytic affections which had arisen among those who were employed in manufacturing the several preparations of lead, and in applying them to their respective uses. In confirmation of the success of the remedy, he has recited several cases which seem clearly to prove its utility-; and he has likewise added a letter from the late Dr. Bradley, physician to the Westminster Hospital, bear- ing testimony in favour of the use of mercury in such cases. In the removal of those distressing and terrible symptoms which frequently result from exposure to saturnine emanations (see Colica Pictorum,) the nitrate of silver has been in some cases employed with success.* The remedy was administered in doses of from one to five grains three or four times a day, preceded by a dose of castor oil. From the activity of its operation on the bowels it may be ne- cessary to combine it occasionally with opium. The paralysis, or loss of nervous power in particular limbs, which arises as a consequence of that painful and obstinate colic produced by the poison of lead, is found to be peculiarly relieved by a use of the Bath waters, more especially when applied externally, either generally or upon the part affected. In the treatment of that species of palsy of the hands which is produced by the poison of lead, the use of an ingenious mechanical contrivance adapted to place the muscles in a favourable state, is highly recommended by a late writer,! and it appears also to have been employed by him with much advantage. It is a splint, made somewhat in the form of a battledore, to be fastened under the fore- arm, and continued to the extremities of the fingers. The object of the instrument is to take off the weight appended to the extremities of the muscles, under the idea that this weight is a principal object to the restoration of the muscular power. In the first trial which our author made, the splint was applied to the right arm. only, and the result, we are told, was as follows : In one month from the first application he had the satisfaction to find that the right hand was able to raise an eight ounce weight into * See London Medical Transactions of the College of Physicians, vol. v. art. 4th. t See Dr. Pemberton's Treatise on the Diseases of the Abdominal Viseory. Order 1.1 palsv, 355 a line with the fore-arm by the power of the extensor muscles : whereas at this time the left hand remained as perfectly paralytic as before. In five weeks more the extensor muscles of the right hand had regained their natural strength, but the left hand con- tinued paralytic. For the purpose of ascertaining how far this improvement could he conceived to have arisen from any change of the constitution, and not from the local mean which was used, it appears that he discharged the patient from under his care for one month, at the end of which time he returned to him with the left hand still per- fectly paralytic, but the right hand enjoying its full and natural powers. The splint was then applied to the left hand, and in se- ven weeks the power of the extensor muscles of that hand was also perfectly restored. The result of the experiment certainly places the use of this mechanical contrivance in a favourable light; but it is proper to observe, at the same time, that it failed in producing the desired effect in some cases of palsy which were not occasioned by the poison of lead. In palsy the diet should be light, nutritive, and of a warm aro- matic nature. If the patient is able to walk, he should take such daily exercise as his strength will admit; but if deprived of the use of his legs, he ought then to be carried abroad in a carriage, or on horseback ; and frictions, with strong stimulants, should frequent- ly be applied to the parts affected. Flannels should be worn next to the skin, and all exposure to cold, damp, and moist air, ought carefully to be avoided. If possible, a warmer climate should be resorted to. In those cases where the appetite fails, and the person sinks in- to a state of debility from the long continuance of the disease, it will be proper to employ the bark of cinchona, stomachic bitters, and other tonics to strengthen the system as advised in Dyspepsia. The inhabitants of the East Indies are very subject to a species of palsy which is called barbiers, but known by the natives under that of beriberii, a word signifying a sheep. The disease probably has received this denomination, because those who are seized with it have a tottering of the knees and a peculiar manner of walking exhibiting to the fancy a representation of the gait of that animal. It attacks both natives and strangers, especially during the rainy season, commencing in November and terminating in March or April, but is most violent on the Malabar coast. During this season the land winds issue every morning about sunrise from the neigh- bouring mountains with remarkable coolness; and such as are tempted by the serenity of the atmosphere to sleep exposed to these winds, are often suddenly seized with the disease. Among the chief symptoms by which it is characterized, is a lassi- tude over the whole body. 'The motion and sensation, especially of the hands and feet, are languid and depraved. Sometimes only a part of the extremities are affected, and nt others the whole of 006 NEUROSES, OR MERVOUS DISEASES. [Class II them. The speech is now and then so much obstructed, that the patient can scarcely pronounce a syllable articulately. The disease seldom proves fatal; but the cure is generally tedious, and notwithstanding a use of the most powerful medicines, is said* seldom to be effected till after the shifting of the monsoons, unless the patients are removed to the coast of Coromandel, or to any place to the eastward of the Balagat mountains, where, by a change of air, they quickly recover. The means principally employed by the native practitioners, how- ever, are fomentations and baths made of aromatic herbs, together with strong frictions. The Indians likewise adopt earth bathing by putting the patient into a hole dug in the ground, and covering him with sand up to his neck. This is performed in the middle of the day, and he remains there as long as he can bear the heat of the sand. When the disease is chronical, and of long standing, sudorific medicines are proper; and therefore camphor, volatile salts, and gum guaiacum, are frequently given. To obviate costiveness, aloetic purges must be interposed. Due exercise, either on horse- back or by walking, will be necessary to restore the action and strength of the extremities, together with warmth, and frictions with rubefacients. ORDER II. ADYNAMIC. A diminution of the involuntary motions, whether vital or natural, is the character of this order, SYNCOPE, or FAINTING. This disease consists in a decreased action, and sometimes total cessation of the pulse and respiration. It is sometimes preceded by anxiety about the praecordia, a sense of fulness ascending from the stomach towards the head, vertigo, or confusion of ideas, dim- ness of sight, and coldness of the extremities. Attacks of syncope are frequently attended with, or end in vomiting, and sometimes in convulsions, or in an epileptic fit. The causes of this affection are sudden and violent emotions of the mind, pungent and other kinds of odours, derangement of the primar viae, debility from preceding disorders, defect of the stimulus of distention, as after blood-letting, haemorrhage, or the operation of paracentesis in ascites ; organic affection of the heart, or of the parts immediately connected with it, such as aneurism either of See Dr. Lind on the Diseases of Warm Climates, p. 286. Order II.] INDIGESTION.. 357 The heart itself, or of the arch of the aorta; ossification of the valves of the heart, or its large blood vessels, or polypi. During the paroxysm, the nostrils are to be stimulated with volatile spirits or salts, and the face to be sprinkled with cold water. Where the disease arises as the consequence of an haemorrhage, the patient should be placed in a recumbent posture, and in all cases a free admission of pure cool air should be allowed. If the disease arises as the consequence of debility or defective excitement, the system should be strengthened by the use of cinchona, sulphuric acid, stomachic bitters, and chalybeates, together with cold bath- ing.—(See Dyspepsia.) It need hardly be added, that avoiding the occasional causes, and removing them, if in our power, is a matter we should always keep in view. VERTIGO, or GIDDINESS in the HEAD. Vertigo proceeds most usually either from too great a fulness of blood in the vessels of the head, or is symptomatic of dyspepsia, hypochondriasis, or hysteria. The patient is seized on a sudden with a swimming in the head : every thing appears to him to go round, he staggers, and is in danger of falling down. This complaint is attended with no danger, when it arises as a symptom of hysteria, or any other nervous disease ; but when it takes place in consequence of an overfulness of blood in the vessels of the head, and is not timely relieved by proper evacuation, it may terminate in apoplexy or palsy. Where vertigo prevails as a symptom of some nervous disease, recourse must be had to the medicines and remedies which are most suitable to the removal of the primary affection ; (see Hysteria and Dyspepsia) but where it is occasioned by an over-distention of the vessels of the head, either general or topical bleeding by the ap- plication of several leeches to the temples, or the scarificator and cupping-glass to the nape of the neck, the latter being the most certain ; together with a frequent use of cooling purgatives, and a spare regimen ought to be employed. Should the complaint not be removed by these means, scapulary issues will be advisable. DYSPEPSIA, or INDIGESTION. This disease chiefly arises in persons between thirty and forty years of age, and is principally to be met with in those who devote much time to study, or who lead either a very sedentary or irre- gular life. A great singularity attendant on it is, that it may, and often does continue a great length of time without any aggrava- tion or remission of the symptoms. The. disease is a frequent attendant on chronic weakness. 35S NEURGSEb, OR NERVOUS DISEASES.. [ClaSS 1J- In Dr. Parry's opinion,* idiopathic dyspepsia consists in a morbid fulness of the vessels of the villous coat of the stomach. Great grief and uneasiness of mind, intense study, indolence, profuse evacuations, excess in venery, hard drinking, particularly of spirituous liquors; irregularity of life, too frequent a use ot warm diluent liquors, and of tea, tobacco, opium, and other nar- cotics, immoderate repletion, a.id over-distention of the stomach, very frequent rejection of the saliva, in consequence of smoking or chewing tobacco, or a diminution or interruption of the due se- cretion of it, a deficiency in the secretion of the bile, pancreatic, or gastric juice, diseases of the liver and spleen, hysteria, hypo- chondriasis, and exposure to moist and cold air, when without exercise, are the causes which usually occasion dyspepsia. Unless where dyspepsia arises from slight inflammation and thickening of the coats of the stomach, and then exists as a pri- mary disease, it is almost universally symptomatic of organic affection of the liver or spleen, and not an idiopathic disease, of which the practitioner may be convinced by paying due attention to the colour of the alvine and renal discharges ; to the pasty or doughy feel of the skin, and the dingy pale hepatic hue of the countenance that generally attend dyspepsia. Scirrhus in the pyloric orifice, or outlet of the stomach, is very apt to take place in those who addict themselves to ardent spirits ; and there are numerous glands at this part, which, from such a practice, are liable to be affected, giving rise to a high degree of acidity in the stomach. Many, perhaps most of the diseases of the digestive organs, caused by various circumstances, consist in a weakness or atony of the affected parts, accompanied by a de- ficiency or depravity of the fluids secreted by them, and upon the healthy qualities of which a right performance of the functions depends. The state of the tongue is in genera] a pretty good criterion of a disordered state of the stomach, but it does not point out the kind and degree of that disorder. With a furred tongue, there is perceived a disagreeable taste in the morning, and the breath in most instances, notwithstanding the greatest care that can be taken, acquires an offensive smell. In consequence of continued disease, the cuticle of the tongue sometimes appears to have lost its usual colour, and to become permanently white. In some states of depraved dejection, there is nearly a complete disrelish for food ; but still the appetite is not greatly impaired, as at the stated periods of the patient's meals, he can eat heartily, although without much gratification. With hard drinkers nausea and vomiting frequently occur in the morning; and in ruined con- stitutions, there is an almost constant thirst, with feverishness, loss of appetite and strength, shortness of breath, paleness of the coun- tenance, languor, and towards the close anasarcous swellings. ^e hh FJementsof Patholoay and Therapeutic Order 11.} INDIGES'i'iOA. 359 In stomach complaints, in addition to defective appetite, indi- gestion, flatulency in a high degree, acidity and cardialgia, the patient is often afflicted with costiveness, vertigo, pain in the balls of the eyes, imperfect vision, ringing in the ears, and palpi- tations. The mind in such cases is frequently irritable and de- sponding, and great anxiety is observable in the countenance. The pulse is usually feeble and frequent, and slight exercise produces considerable fatigue and perspiration. Restlessness prevails at night, the sleep is disturbed by frightful dreams and startings, not affording much refreshment, and occasionally there is much moan- ing, with a sense of a heavy weighton the chest, or what has been denominated the nightmare. In some instances, the disease is complicated with gastrodynia, or severe pain in the stomach itself, and now and then with pyrosis. Although dyspeptic complaints, when they exist in consequence of debility of the stomach, maybe alleviated, or be entirely removed by timely desisting from bad habits, and taking proper medicines, still when they have been of long continuance, so as to produce great debility, and pass into some other disease, such as dropsy ; or when they originate from any organic affection, such for instance as a scirrhus of the pylorus, they will be sure to prove fatal. The morbid appearances to be observed on dissections of this disease, are principally confined to the liver, spleen, and that part of the stomach which is called the pylorus, this being often found either in a contracted, scirrhous, or ulcerated state. In every in- stance the stomach is perceived to beconsiderably distended withair. In the case of habitual drunkards and hard drinkers, the coats of this viscus are often found thickened and indurated, and its interior surface beset with small processes of a fungous appearance; the liver in general isjnuch enlarged, and studded with tubercles, the spleen usually somewhat diminished in size, and the gall blad- der pale and nearly empty. In the treatment of the disease, three indications must be at- tended to:—- The first is to avoid or remove the remote causes which have been enumerated. The second is to obviate the symptoms which contribute to con- tinue or aggravate the disease. The third is to restore the tone of the organ, if possible. To effect the first of these intentions, it must be the business of the physician to point out to the patient the indispensable ne- cessity of renouncing such habits or pursuits as may have tended to give rise to the disease, as the continued application or frequent repetition of these causes may defeat the use of whatever remedies are employed. If he leads a fashionable life, it will be necessary for him to for- sake the haunts and habits of dissipation ; to leave the crowded city, and its alluring amusements, conducted in rooms, where the air he breathes is vitiated and contaminated by the great number of persons collected together; to shun luxurious tables, indolence 360 NEUROaES, OR NERVOLS DlaEAM^. [CiaSS 11. and late hours ; to retrace the footsteps by which he had deviated from simple nature, and to court the country, pure air, moderate exercise, early rising, simple diet, the society of a few select friends^ and pleasing occupations. To accomplish the second intention of obviating the symptoms which contribute to continue or to aggravate the disease, it will be necessary to remove the crudities in the stomach by giving a gentle emetic. It will also be necessary to correct the morbid acidity in the organ by alkalies and absorbents,* as the potassae subcarbonas, soap, liquor calcis, magnesia, chalk, ozc.; to assuage the pain and flatulency in th* stomach and intestines by carmi- natives,! antispasmodics,J fcnd opiates; and, lastly, to obviate 1. ft Liquoris Calcis Oj. Capiat aeger, f. §ij—§iv. bis in die. Vel, 2. R Liquor. Potassa?, f. Jj. ----— Calcis, f. §vij. M. Capiat aeger cochleare magnum bis in die ex poculo jusculi bovini. Vel, 3. R Magnesia;, ^iij. Pulv Rhei, £j._ Aq. Fontan. f. ^iv. ----Cinnam. f. ^j. Tinct. Lavend. C.' f. 3ss. M. it. Mistura, cujus suinat cochl. ij. ter in die Vel, 4. R Cretae Praeparat. gr. xv. Spirit. Myristicae, f. £j. Aquae Fontan. f. Zjss. Liquor. Potassae, if\ x. Syr™. Zingib. f. gij. M. ft. Haustus, bis die sumendus. Vel, 5. R Magnesiae, Qij. Pulv. Rhei, gr v. ----Nuc. Mosch. gr. iij. M. ft. Pulvis, mane et verpere sumendus. t 6. R Cret Praeparat. gr. xij. Aq. Month Pip. f. Jss. ----Font.f. %. Spirit Pimentae, f. 3ij- Tinct. Opii, Til viij. M. it. Haustus, ter die sumendus. R Aq. Aneth, f. jfiij. Spirit. Cinnam. f. §j Tinct. Valerian. Amr Ammon. f. 3'j- ----Onii, tit xxv. .iEther. Sulphuric, f. 3j- M. Capiat cochl. larga ij.bisterve in die, ■* '■! dolore votrhuili nnrente * 1. Let the patient take from two to four ounces daily of Lime Water. Or, 2. Take Solution of Potass, one drachm. -------Lime, seven ounces. Mix them, and take a table-spoonful twice a day in a little beef-tea. Or, 3. Take Magnesia, three drachms. Rhubarb in powder, one scruple. Pure Water, four ounces. Cinnamon water, one ounce. Compound Tincture of Lavender, half a drachm. Of this mixture two table-spoonsful may be taken three times a day Or, 4. Take Prepared Chalk, fifteen -grains. Spiritof Nutmeg, one drachm. Pure Water, one ounce and a half. Solution of Potass, fifteen drops. Syrup of Ginger, two drachms. Mix them and let this draught be taken twice a day. Or, 5. Take Magnesia, two scruples. Rhubarb in powder, five grains. Powdered Nutmeg three grains. Mix them. This powder may be taken morning and evening. t 6. Take prepared Chalk, twelve grains. Peppermint Water, half an ounce. Pure Water, one ounce. Spirit of Pimenta, two drachms. Tincture of Opium, twelve drops. Mix them. This draught is to be taken three times a day. 17. Take Dill Water, three ounces. Spirit of Cinnamon, one ounce. Ammoniated Tincture of Vale- rian, two drachms. Tincture of Opium, forty drops. Sulphuric iEther, one drachm. Mix them, and let two table-spoonsful be taken twice or thrice a day, or when- ever the nain in the stomach is severe Order II.J tNniGESTiOiV. 361 costiveness by a use of such gentle laxatives,* joined with aromatics, as will promote a ready discharge of the contents of the intestines, without hurrying their action, or increasing the excretions made into their cavity. An habitual attention to the removal of costiveness by institu- ting a regular custom of periodically soliciting an evacuation by voluntary and persevering efforts, will powerfully aid the beneficial effects of the other means we employ. The morning is the proper time for the attempt; and the trial should be prosecuted during at least fifteen minutes, if the peristaltic be not earlier excited to adequate motion. Perhaps a week liiay be unavailingly employed in this endeavour, but the proposed effect will probably be attain- ed within a month ; one month- has indeed in numerous instances fully established an habitual call to intestinal evacuation, under circumstances that previously required the almost daily use of aperient medicines. Where dyspepsia is occasioned by defective biliary secretion, and is combined with a diseased state of the liver, spleen or biliary ducts, the stools indicating a want of due mixture of bile with them, we should employ the submuriate of mercury. A pill con- taining about two grains of this may be taken every third night, succeeded the next morning by an aperient draught composed of one ounce and a half of infusion of senna, with two or three drachms of sulphate of magnesia. * 8. R Pil. Aloes cum Myrrh, gr. xv. in filulas iij. pro dos. divid. Vel, 9. R Aloes Spicatae ExtracL Pulv. Rhei, aa 3j- «• ---Cinnam. Comp. 3j. Sapon. Venet. 3ss. Syrup, q. s. M. Fiat massain pilulasl. dividenda, quarum ii. sumat pro dos. J Vel, 10. R Confect. Sennae, ^ij. Pulv. Jalapae, 3»j- ----Cinnam. Com. 3j Potassae Supertart. 3j- Syrup. Zingib. q.'s. M. ft. Electuarium, cujus capiat quantitatem juglandis hora somni. Vel, 11. R Tinct. Rhei, f. 3vj- F° dos. *Vel 12. R Pulv. Rhei, S>j. ----Zingib. gr. v. Magnesiae, 3ss. M. ft. Pulvis, pro re nata sumendus. 47 * 8. Take Aloetic Pills with Myrrh, fifteen grains. Divide the mass into three pills for a dose. Or, . 9. Take Soccotrine Aloes, Powdered Rhubarb, of each one drachm. Compound Powder of Cinnamon, one scruple. Hard Soap, half a drachi#. Syrup, a sufficiency to form the mass, which is to be divided into fifty pills, of which two will be a sufficient dose. Or, 10. Take Confection of Senna, two ounces. Jalap in Powder, two drachms. Compound Powder of Cinnamon, one scruple. Supertartrate of Potass, one drachm. Syrup of Ginger, a sufficiency to form an electuary, of which take the bulk of a walnut at bed-time. Or, 11. Take Tincture of Rhubarb, six drachms for a dose. Or, 12. Take Powdered Rhubarb, one scruple. ---------Ginger^ five graii;$. Magnesia, half a drachm. Mix them, and take this powder when neces^arv- 362 NEUROSES, OR NERVOUS DISEASES. [ClaSS II. For the removal of cardialgia and vomiting which attend on dyspepsia, the application of a blister over the stomach often proves serviceable. In such cases,Jblisters invigorate the exertions of the arterial and lymphatic vessels of the skin, produce an in- crease of insensible perspiration and of cutaneous absorption, and augment the action of the stomach, and consequently its power of digestion. To accomplish the third intention of restoring the tone of the stomach, the loss of which is to be considered as the chief and immediate cause of dyspepsia, we are to employ such medicines as operate directly on this organ, and such remedies, and other means, as have a tendency to strengthen the system in general. The medicines best calculated to restore the tone of the stomach are aromatics and astringent bitters,* as likewise the cinchona bark,! ;- 13. R Infus. Gentian. C. f. |jss. Tinct. Card. C. f. 3ij. ----Myrrh, f. 3j. M. ft. Haustus, bis terve de die adhibendus. Vel 14. R Infus. Rad. Calumb. f. 3x. Tinct. Cascaril. ----Cort. Aurant, aa f. 3j- M. ft. Haustus. Vel, 15. R Quassiae, 3>j- Aq. Fervent.f. ^v. Colat. adde Tinct. Cascaril. "*"''•"" ----Card. C. aa f. ?ss. M. Capiat aeger cochl. iij. ter in die. Adde pro re nata Acid. Sulph. Dilut. fll xiij, Vel,. 16. R Infus. Gentian. C. f. |v. Tinct. Cinnam. C. f. ^j. ----Lavend. C. 3i. M. 1L Mistura. Vel, 17. R Rad. Gentian. Contus. ^ss. —^-Calam. Aromat. C. Cardam. Sem. Contus. aas^iij. Cort. Aurant. Sic. C. 3ij- Vin. Alb. Hispan. Oij. Infundantur per dies octo. Hujus Infusi capiat cochl.ij. bis quotidie. t 18. R. Decoct. Cinchona?, f. ?jss. * 13. Take Compound Infusion of Gentian, one ounce and a half. -------Tincture of Cardamom, two drachms. Tincture of Myrrh, one drachm. Mix them. ThisMraught is jto be given three times a day. Or, 14. Take Infusion of Calumbo Root, ten drachms. Tincture of Cascarilla, -----of Orange Peel, of each one drachm. Mix them for a draught. Or,\ 15. Take Infusion of Quassia, five ounces. Tincture of Cascarilla, Compound Tincture of Carda- mom, of each half an ounce. Of this mixture let the patient take three table-spoonsful thrice a day, adding occa- sionally twenty drops of Diluted Sulphu- ric Acid. Or, 16. Take Compound Infusion of Gentian, five ounces. -------Tincture of Cinnamon one ounce. ------------------Lavender one drachm. Mix them. The dose the same as the former. Or, 17. Take Gentian Root bruised, half an ounce. Sweet Flag Root, sliced, Cardamom Seeds, bruised, of each three drachms. Orange Peel, dried,two drachms. White Wine, two pints. Infuse them for eight days, and let the patient take two table-spoonsful twice a day. 118. Take Decoction of Peruvian Bark one ounce and a half. Order II.] indigestion. 3G3 the mineral acids, and chalybeates.* The latter, in particular, are of eminent service in an impaired or capricious appetite, Tinct. Calumb. f 3«j- ----Myrrh. f.3j- M. ft. Haustus, ter in die sumendus. Vel, 19. R Pulv. Cinchonae, 3j- Aq. Cinnam. f. ^jss. Tinct. Gentian. C. 3ij- Acid. Sulph. Dilut. Til xiij. M. ft. Haustus. Vel, 20. R Infus. Cinchonae, f. ^v., Tinct. ejusd. C. ----Card. C. aaf. -fss. M. Sumat cochl. iij. ter in die". Adde pro re nata Acid. Sulp. Dilut. Til xiij. - 21. R Tinct. Ferri Muriat. f. ^ss. ITlx.—xvj. ter die sumendae in quovis vehiculo. Vel, 22. Aq. Chalybeatae. Vel 23.R Vin. Ferri, f. 3y- Infus. Gentian, f. ^jss. Tinct. Cascaril. f. 3j- M. Pro haustu, bis terve in die sumendo. Vel, 24. R Pulv. Myrrh. 3ss. Solve in Spirit. Cinnam. f. 3'j- et adde Aq. Pimentae, f. ?j. Ferri Sulphat. gr. iij,—vj. Potassae Subcarbon. gr. x. M. ft. Haustus, ter die sumendus. Vel, 25. R Extract. Cinchonae, -----Gentian, aa 3j- Ferri Sulphat. 3ss. Pulv. Myrrh. 3j. Syrup. Zingib. q. s. M. Fiant pilulae Ix. quarum iij. sumat bis terve in die cum. Infusi Cascarillae Cort.f. ?ij. Vel, 26. R Pulv. Cinchonae, ^j. Tincture of Calumbo, two drachms. -----Myrrh, one drachm. Mix them,and take this draught thrice a day. Or, 19. Take Powder of Peruvian Bark, one drachm. Cinnamon Water, one ounce and a half. Compound Tincture of Gentian, # two drachms. Diluted Sulphuric Acid, twenty drops. Mix them for a draught. Or, 20. Take Infusion of Peruvian Bark, five ounces. Compound Tincture of the same, ------------------Cardamoms, of each half an ounce. Of this mixture three large spoonsful may be taken thrice a day, adding occasion- ally of Diluted Sulphuric Acid, twenty drops. * 21. Take Muriated Tincture of Iron, fif- teen to twenty-four drops thrice a day in any vehicle. Or, 22. Chalybeate Waters. Or, 23. Take Wine of Iron, two drachms. Infusion of Gentian, one ounce and a half. Tincture of Cascarilla, one drachm. Mix them for a draught, to be taken twice or thrice a day. Or, 24. Take Myrrh, half a drachm. Dissolve it in Spirit of Cinnamon, two drachms ; and add Pimenta Water, one ounce. Sulphate of Iron, from three to six grains. Subcarbonate of Potass, ten grains. Mix them, and let this draught be taken three times a day. Or, 25. Take Extract of Peruvian Bark, -------Gentian, of each one drachm. Sulphate of Iron, half a drachm. Powdered Myrrh, one drachm. Syrup of Ginger, a sufficiency to form the mass, out of which sixty pills are to be made, of which three are to be taken twice or thrice a day, washing them down with about two ounces of an Infusion of Cascarilla Bark. , Or, 26. Take Powder of Peruvian Barkr one ounce. 364 neuroses, or nervous disjeases. [Class II. and weakness of the assimilating organs, irregular digestion, flatulent distention of the abdomen, anxiety about the praecordia, difficult respiration from sympathy with the stomach, and occasion- al vomiting of viscid mucus. Beside the vegetable bitters that we have long been accustomed to, two others have very lately been recommended and brought forward as deserving our notice. The one is the humulu9 lupulus, Or common hop, different preparations of Which, such as the powder, extract, and tincture, are to be procured at the shops of many druggists; the other is the radix rhataniae, or rhatany root. This last, we are told by Dr. Reece,* who seems to have been the first to give it notoriety, has been found to invigorate the diges- tive organs, produce a relish for food, and promote digestion. He further mentions, that it is more grateful to the palate than cinchona bark, and that he has found it to succeed better. This has not, however, been the case in the trials which I have made of it ; neither has it answered the expectations of most others who have administered it. An aromatic tincturet of it seems to be its best preparation. In cardialgia, gastrodynia, pyrosis, and such other complaints of the stomach, the oxyd of bismuth is a remedy which has been employed with considerable advantage in a variety of instances.J The proper dose is from three to ten grains, with about twenty-five grains of gum tragacanth, repeated three times a day. It will be best, however, to begin with a dose of only three grains, increasing it gradually. The remedy is perfectly safe as well as useful. As a diminution of the due quantity of gastric juice is some- times a cause of dyspepsia, it may not be improbable that in such cases the symptom may be relieved by supplying the patient with the gastric liquor of those animals whose food is most similar to * See his Treatise on the Rhadix Rhataniae. t See Memoirs of the London Medical Society, vol. v. — Medical Reports, by Dr. Bardsley. Pulv. Myrrh. 3'ij. ----Cinnam. C. 3ss. Ferri Subcarbonat. 3ij- Syrup. Cort. Aurant. q. s. M. ft. Electuarium, cujus sumat quantitatem juglandis ter indie cum Infus. Quassiae, t 27. R Rad. Rhatan. Contus. ^ij. Cort. Aurant. Sic. C. ?ss. ----Canel. Alb. C. 3jss. Spirit. Rectificat. Ten. Oij. Digere per dies decern et cola. Sit dosis cochl. ij. minima bis in die ex cyatho aqna» pura*. Powder of Myrrh, two drachms. Compound Powder of Cinna- mon, half a drachm. Subcarbonate of Iron, two drachms. Syrup of Orange Peel, a suffi- ciency to form an electuary, of which the bulk of a walnut may be taken three times a day, with two ounces of an Infusion of Quassia. t 27. Take Rhatany Root, bruised, two ounces. Orange Peel, dried, half an ounce. Canella Bark, bruised, one drachm and a half. Proof Spirit, two pints. Infuse them for ten days, then strain off the liquor. The dose may be two tea- spoonsfnl twice a day in a glass of water. Order II.] indigestion NEUROSEt,, OR NERVOUS DISEASE:-.. [ClttSS II. heart-burn, and spasmodic pains in any part of the alimentary canal, and complaints in which a use of Seltzar water affords likewise the greatest relief. Pyrmont water is another remedy which may be advantageously used in all cases of debility, where the constitution requires an ac- tive tonic, and which at the same time does not excite a perma- nent heat. It increases the secretion of urine, and sometimes occasions a temporary eruption on the skin. It is of an agreeable, though strongly acidulated taste, and emits a large portion of gas, which affects those who drink it, with a sensation somewhat re- sembling that produced by intoxication. The dose must vary ac- cording to circumstances, and the nature of the patient's complaint, but in general the quantity to be taken ought not to exceed three pints per day. If a person residing in a warm climate should labour under chronic weakness for any length of time, he will act prudently in removing to a colder one before the disease becomes inveterate, and lays the foundation of some dangerous complaint. If his cir- cumstances or business will not admit of such a change, he ought then to remove to the coolest situation that can be procured ; or, in preference to remaining on shore, he may sleep on board of some vessel; and as often as opportunities offer he should make short voyages, as wonderful recoveries have been effected by sea air in cases of this nature. The diet in dyspepsia ought to be nutritive and generous, con- sisting chiefly of animal food, on account of the disposition to acescency; and it should be taken every three or four hours, and never exceed a few ounces at any one time. Moreover, due care is to be taken to masticate it properly, in order that it may be reduced by comminution and salival commixture to a semi-fluid state. Instead of fermented bread, the patient should eat biscuit with his food. No diluent fluids should be taken at his meals, nor until some time after each repast, lest the solvent property of the mixed saliva should thereby be diminished ; nor should the quantity of fluid taken at once ever exceed half a pint, nor be repeated oftener than at intervals of three hours. About half an hour before swallowing the portion of aliment proposed, brisk friction should be performed with a flesh-brush over the region of the stomach during some minutes, and a similar operation may follow the meal. A moderate use of wine, such as Madeira or Sherry, ought to be allowed : but should these disagree with the patient, and become acid on his stbmach, weak brandy and water may be substituted for ordinary drink. Under no other circumstances should a use of ardent spirits be resorted to ; as by an indulgence in them, a habit imperceptibly steals on, before the person is aware of the conse- quences to which it leads. By too free a use of spirituous liquors, obstructions in the principal organs ensue, the nervous system becomes blunted and depraved to every feeling, the energies of the Order II.] INDIGESTION. 567 mind suffer, loss of memory takes place, a train of nervous dis- orders come on, and an attack of jaundice, dropsy, or consump- tion, at length terminates existence. In this progress, even the passages to the stomach lose their feeling, become indurated and callous ; and the organ itself, taking on the same state, has its digestion impaired, and becomes unfit to prepare nourishment for the body. Pure wine, in a moderate quantity, gently stimulates, increases the action of the heart and arteries, and augments the nervous energy over the whole body, communicates a serenity and ease of mind, a liveliness of imagina- tion, and a powerful exertion of every faculty: but, on the other hand, if taken immoderately, these favourable appearances are changed, the powers of the nervous system are weakened, the mind is deranged, and in the end both motion and sensation are much impaired, if hot lost. In that species of chronic debility which is brought on by drink- ing spirituous or fermented liquors to excess, there is not such reason to expect a return to healthful vigour, where the power of digestion is considerably destroyed; but in other cases, the person may probably recover his health by a prudent and gradual dimi- nution of the quantity of spirits. In such a case, he should atfirst omit one-fourth of the quantity of spirit he has lately been accus- tomed to ; and if in a fortnight his appetite increases, he should be advised to omit another fourth ; but if he perceives that his diges- tion becomes more-impaired, from the want of the usual quantity of spirituous potation, he should then be advised to continue as he is, and rather bear the ills he has, than risk the encounter of great- er. Animal food, with or without spice, is at the same time to be recommended, as likewise the cinchona bark, with myrrh and steel between his meals. At night he may take half a grain or a grain of opium, with five or eight grains of rhubarb. Various dyspeptic affections of the stomach are apt to arise in consequence of a stricture or strictures in the oesophagus, or tube through which the food is conveyed to it. In all such cases, a fair and sufficiently long trial should be made by the intro- duction once or twice a day, of a bougie of a proper size, compo- sed either of wax and oil spread on linen,'or of the elastic gum, with the view of dilating, in a gradual manner, the strictured part of the tube. We should begin with a bougie of a moderate size, and, after a few days, lay it aside for one a little larger. Should the disease not yield to this means, it will be advisable to resort to the caustic bougie, managing it in the same manner as is recommended for the removal of strictures in the urethra. Some cases of stric- ture in the oesophagus are reported in Sir Everard Home's work,* which were successfully treated with caustic, having previously resisted all the other means which were adopted. ^cc h;s Practical Observation* on Stricture?, he, vol. i 368 NEUROSES, OR NERVOUS DISEASES. [ClttSS 11. Nervous persons are apt to complain of atoms floating before the eyes, or what are termed muscae volitantes : but for the treat- ment of these, I beg leave to refer to the succeeding disease. HYPOCHONDRIASIS, or HYPOCHONDRIAC. AFFECTION. This disease, known likewise by the name of low spirits, or the vapours, is a certain state of the mind along with dyspepsia, wherein the greatest evils are apprehended upon the slightest grounds, and the worst consequences imagined from an unusual feeling even of a trifling kind ; and in respect to such apprehensions and feelings there is always the most obstinate belief and persuasion. Hypochondriasis bears a strong resemblance to dyspepsia ; but there is this difference between them, that the former prevails at an advanced period of life, and is more an affection of the mind than of the body ; whereas the latter occurs principally from the age,of puberty to that of 35, and depends chiefly on debility. Hypochon- » driasis may, moreover, be distinguished from dyspepsia by the languor, listlessness, want of resolution and activity, fear of death, ^\ and suspicious disposition being always present, and by the dys- peptic symptoms being often absent, or when present, they are in a much slighter degree. Men of a melancholic temperament, whose minds are capable of great attention, and whose passions are not easily moved, are at an advanced period of life most liable to be attacked with this disease ; and when it has once taken place, it goes on increasing as life advances, being usually most troublesome in the autumnal and winter seasons,. which accounts for more acts of suicide being com- • mitted at these times of the year than any other. * The English have been accused as the nation of all others which is addicted to suicide; and perhaps this proneness ought more reasonably to be attributed to an indulgence in unhappiness and domestication of misery, from trivial circumstances, than to the influence of fogs, or the physical effects of coal fires, as have been assigned by foreigners. Hypochondriasis seems to depend on a loss of energy in the brain, or on a torpid state of the nervous system, induced by various remote causes, such as close and intense study, long and serious attention to abstruse subjects, the constant remembrance of some material loss or disappointment which has occurred, great anxiety of mind, leading an inactive, indolent, or sedentary life, immoderate venery, or a use of crude, flatulent, or unwholesome food, being guilty of great irregularity and intemperance, as likewise,by obstructions in the viscera, and by long-continued evacuations. Hypochondriasis and olheriiervous complaints are, through the Order Il.J hypochondriac affection. 3j6j9 medium of sympathy, scarcely less infectious (it is probable) than febrile diseases; and even persons naturally of a cheerful temper, by being long domesticated with those of a melancholic desponding cast, have been known to become decidedly and often deplorably dejected. The hypochondriac affection is attended with inactivity, a want of resolution with respect to all undertakings, lowness and dejec- tion of spirits, great despondency, and apprehension of evil upon the slightest grounds, and a dread of danger from any unusual feeling even of a trifling kind, together with flatulency in the stomach and bowels, acid eructations, costiveness, a copious dis- charge of pale urine, spasmodic pains in the head and other parts of the body, giddiness, dimness of sight, and palpitations. In short, it is attended with such a long train of symptoms, that it would fill many pages to enumerate them all, as there is no function or part of the body that does not suffer in its turn by its tyranny; the miserable patient indulges wild imaginations, and fancies that he labours under almost every disease ; and with respect to these feelings and apprehensions, he entertains the most obstinate belief, being highly displeased if any attempt is made to reason with him on the absurdity of his persuasions. There are few examples of hypochondriacal people who find themselves worse at night than in the morning : the generality of them, like most of those who are afflicted with any of the com- plaints styled nervous, are seemingly hurt by their sleep, little as it is; and the longer they happen to sleep, the worse they are: they awake out of it with confusion, and do not come immediately to themselves ; and when they do, they can think only of melan- choly subjects, and feel the worst horrors of their disorder. This state continues till dinner, with very little abatement; after dinner they feel themselves a little revived : and at night the tide of their spirits returns, which being desirous to enjoy, and dreading their certain ebb when they lie down, they go late and with reluctance to bed. In hysterical women the operations of the animal powers seem to be the most disturbed and perverted ; but in men the mind is most affected; involuntary exclamations, faintings and convulsions of all sorts, being most common in women, and silent despair in men. Hence, perhaps, suicide occurs more frequently with men than among women. As to the prognostic, the disease, if recent, is rather to be regarded as troublesome than dangerous ; but if long continued, it is apt to produce scirrhi of the viscera, cachexy, dropsy, incurable melancholy, or madness. On dissections of hypochondriacal persons, some of the abdo- minal viscera (particularly the liver and spleen,) are usually found considerably enlarged. In some few instances, effusion, and a turgescence of the vessels, have been observed in the brain. 48 370 neuroses, or nervous diseases. [Class II. The indications of cure in this disease seem to be, 1st, To excite the nervous energy which has been depressed, and that particularly by attending to the state of the mind. 2dly, To remove or alleviate the symptoms which serve to con- tinue and aggravate the disease. 3dly, To strengthen the alimentary canal and promote the se- cretions. • To answer the first of these indications, the patient's attention is to be engaged and diverted to other objects than his own feelings ; he is to be directed to vary the scene frequently by going from one place to another; to associate as much as possible with agreeable cheerful company; to engage in such pursuits as will afford him moderate exercise in the open air, which gardening, riding on horseback, and field sports, as hunting and shooting, are particu- larly calculated to ; and by all means to avoid absolute idleness: but in doing this, all application to former studies, especially pro- fessional ones, is to be forbid : entertaining books, will, however, be serviceable, as assisting to divert the mind from itself. Gardening is a pursuit highly proper for hypochondriacs, as it will keep the mind alert and the body in exercise. Such as live in the country should therefore engage in it. In cities or large towns where this healthy recreation cannot be enjoyed, no better substitute can be employed than that of fitting up an apartment as a work-shop. Working in a cool and free atmosphere would prove a deliverance from that chilliness which for above half of our year so miserably persecutes the tender, and it might act equally as a charm on the ruffled spirits. Hypochondriasis is far from being a metropolitan disease, as the multiplicity of external objects, which in a large capital are con- tinually giving a new direction to the current of thought, is of course unfavourable to the uniformity and self-absorption of the melancholy. A residence therefore even in a large city which affords objects of interest and motives of exertion, ought to be recommended tohypochondriacal or nervous patients, in preference to the most healthy situation in the country, where there is not enough to rouse the sluggishness or fill the vacuity of the mind. Compassion, and,not raillery, is to be bestowed on the hypochon- driac, as the firm persuasion which he entertains, will not allow his feelings to be treated as imaginary, nor his apprehension of danger to be considered as groundless, however the physician may be of opinion that it is the case in both respects. To gain his con- fidence, it will be necessary to attend to his complaints, as if they were all real: and to satisfy him, it will by all means be advisable to givehim some kind of innocent medicine or placebo, changing itfrom time to time whenever he expresses any disappointment of relief. In the absence of every other diversion, even the swallowing of medicine may be a source of amusement. The times for taking the different draughts, or doses, are so many epochs in the chronology Order II.] hypochondriac affection. 371 of an hypochondriac, which by dividing, help to conquer the tedium of his day. However sceptical a physician may be with regard to the inherent or permanent qualities of any medicine, it is his duty, perhaps, to take advantage of the tide of opinion, and he may honestly make use of his patient's credulity, in order to relieve him from the pressure of his disease, and render the par- tial weakness of his mind instrumental to the general restoration of his corporeal strength.* The complaints of hypochondriacs should be treated by the physician as of real existence ; and from whatever cause they may arise, it is his province to employ his art to subdue it; not to ruffle an irritable mind by unseasonable levity, or expose a morbid sen- sibility to insult and reproach. From the slow evacuation of the stomach in melancholic tempe- raments, acidity often prevails in a high degree with hypochon- driacs ; to obviate which, and answer the second indication of cure, it will be necessary for the patient to make use of absorbents and alkalies, as advised under the head of Dyspepsia. Vomiting, though sometimes employed, is by no means suited to this disease. Costiveness, which is another frequent symptom in hypochon- driasis, is to be obviated by instituting a regular custom of periodi- cally soliciting an evacuation by voluntary and persevering efforts once or twice a day at certain hours: and until the desired inten- tion can be established in this way, some gentle laxative may be taken occasionally, as mentioned under the head of Dyspepsia. Harrowgate water may be used with a fair prospect of advantage in correcting the obstinate costive habit of body that accompanies hypochondriasis ; and this habit, when removed by mineral waters, appears to be less liable to return than when only the resinous and drastic cathartics are employed. Flatulency is another constant attendant, and is to be prevented by making use of carminatives, essential oils, and spices, formulas of which will likewise be found under the head of Dyspepsia. Besides these affections, hypochondriacs are apt to be troubled with spasmodic pains in the head and stomach; to relieve which, it may be proper to employ such medicines as aether, musk, and opium, either given separately or combined together.! * See Essay on Nervous Diseases, by John Reid, M. D. t 1. 3. Spirit. iEther. Sulph. fll xx — xxx pro dos. Vel, 2. ft Misturae Moschi, f. ^iss. Spir. jEther. Sulphur, ul xx. M ft. Haustus, ter in die sumendus. f 1. Take Spirit of Sulphuric uEther, from thirty to forty-five drops, for a dose. Or, 2. Take Musk Mixture, one ounce and a half. Spirit of Sulphuric jEther, thirty drops. Make them into a draught,to betaken three times a day. 372 neuroses, or nervous diseases. [Class II. Asafoetida, castor, camphor, valerian, volatile salts, salt and oil of amber, are medicines which are likewise much employed in the cure of the disease: and therefore, when the patient loses a con- fidence in the one, we can readily substitute another, hypochondri- acs being seldom satisfied, unless they are liberally supplied with some drug or other. Various forms of these remedies will be found under the heads of Hysteria and Epilepsy. Nervous people are apt to be troubled with what are termed muscae volitantes (atoms flying before the eyes,) which though harmless and slight, often excite alarm and apprehension on the part of such patients, and may be mistaken for amaurosis, or inci- pient cataract: but whenever the appearance of muscae volitantes is unaccompanied with the sensation of a mist, which more or less obscures the appearance of objects, we may safely conclude that it is not a symptom of cataract; and whenever this appearance is not accompanied with a fixed state of the pupil, it may be safely inferred that it is not a symptom of gutta serena.* The plan of cure for these muscae volitantes is to relieve the mind from intense application, and from objects of anxiety; to clear the bowels by a brisk purgative, and then to give volatile medicines. Local bleeding, or any other debilitating treatment, is commonly injurious. In hypochondriasis, as well as in most other nervous diseases, it is too much the custom with many to addict themselves to a frequent and immoderate use of opium, in some form or other; but this remedy should be carefully shunned, unless on urgent occasions; for although it may afford some little relief for the present, it will nevertheless, by a constant use, greatly add to the disease. The immediate effect produced by opium upon such as addict themselves to its use is, that with an increase of the frequency of the pulse the heat of the body is generally somewhat augmented, so as to produce very often flushings in the face ; and from a * See Medico-Chirurgical Transactions of London, vol. v. Essay 18th. Vel, &. ft Infus. Gentian. C. f. ^jss. Tinct. Card. C. f. 3'j. Spirit. iEther. Sulphur. Til xxij. Tinct. Opii, til xj. M. ft. Haustus. Vel, 4. ft Spir. Carui, f. |ss. Mistura> Camph f ?v. Spir. .Ether. Sulph. f. 3j. Tinct. Opii, til xxv. ----Lavend. C. f. ftl xxx. t Mistura, cujus sumat cochl. larg. ij terquartervo die. v Or, 3. Take Compound Infusion of Gentian, one ounce and a half. -------Tincture of Carda- moms, two drachms. Spirit of Sulphuric .ffither, thirty-five drops. Tincture of Opium,sixteen drops. Mix them for a draught. Or, 4. Take Spirit of Carra way, half an ounce. Camphor Mixture, five ounces. Spirit of Sulphuric iEther, one drachm. Tincture of Opium, fortydrops. Compound Tincture of Laven- der, forty-five drops. Mix them, and let two large spoonsful be taken three or four times a dav. Order II.J hypochondriac affection. 373 depressed state, they become active and alert, with an exhilaration of spirits ; but after the operation of the remedy is over, depression of mind ensues, the body is cold and heavy, and in this dull and indolent condition it remains until the dose is repeated. The peculiar power which the citric acid possesses of counter- acting the noxious effects of opium is deserving of attention by those who accustom themselves to a regular use of this drug ; and it has indeed been recommended by some physicians, that with every dose of opium a proportion of the juice of lemons, or oranges, in the quantity of two ounces to the grain of opium, should be taken : by this means the uneasiness which the medicine often occasions will be prevented, its depressing consequences avoided, and the tendency to constipation obviated. To a very free use of the vegetable acids is ascribed the slight effect which opium pro- duces on the Turks, and not to the influence of coffee, as has been alleged by some. These people, as well as others of the eastern nations, are in the habit of drinking daily large quantities of sherbet, which is a liquor composed of the juice of lemons or oranges, mixed with water and sugar. From the quantity of acid in the composition of the black drop, a preparation of opium now much used, it will often stay upon the stomach when other preparations of this drug will not, and a long continued use of it may perhaps be less injurious to the constitu- tion from the same cause. The original recipe for the black drop (see Dr. Armstrong's Practical Illustrations of Typhus) is 'given below.* Many of those who labour under a lowness of spirits, have re- course to wine, or other fermented liquors, and what is still worse, to spirituous ones, in order to raise them. The momentary relief so obtained is much too dearly bought by the far greater languor which succeeds : and the necessity of increasing the quantity of these liquors, in order to obtain the same effect, irrecoverably ruins the health, and this in the most miserable manner, as has been noticed under the head of Dyspepsia. It is remarked by the judicious writer! before alluded to, that the best way of attempting to conquer the vice of intemperance in another, especially when it has been induced (as very frequently is the case) by some permanent or weighty cause of sorrow, is to picture to the mind of the patient the agreeable change in his situ- ation which would be likely to arise-from an alteration in his mode * Take half a pound of opium sliced, three pints of good verjuice, one ounce and a half of nutmegs, half an ounce of saffron. Boil these to a proper thickness ; then add a quarter of a pound of sugar, and two spoonsful of yeast. Set the whole in a warm place near the fire for six or eight weeks; then place it in the open air until it becomes like a syrup. Lastly, decant, filter, and bottle it, adding a little sugar to each bottle. These ingredients, when properly mixed, should yield about two pints of the strained liquor. One drop of it is supposed to be equal to three drops of the tinoture opii of the London Pharmacopoeia. t See Essay on Nervous Diseases, by John Reid, M. D. p. 10L 374 NEUROSES, OR NERVOUS DISEASES. [ClttSS II. of life, rather than to present to him those deeper shades which must successively ensue from a continuance of his ignominious servitude and habits of fatal indulgence. The latter, though the more common mode of endeavouring to effect the reformation of an unfortunate inebriate, is in general calculated only to confirm and aggravate the evil, by sinking his spirits lower, aid in some instances perhaps, converting the languor of dejection into the mental palsy of despair. It is not easy to determine whether the use of opium or of strong fermented liquors is most detrimental to the human constitu- tion : unluckily the victims who addict themselves to either are insnared by a habit which they find it impossible to relinquish, be- cause the constitution, when habituated to a strong stimulus, be- comes-incapable of carrying on the functions of life without con- tinual excitement, which of itself brings on debility and prema- ture decay. Grievous, however, as is the depression which takes place, as the second effect of all fermented liquors, that which succeeds to the excitement produced by opium, in any shape, is still more in- tolerable. It is of course a task less difficult to refrain from the former than the latter, when the latter has been regularly applied to for temporary comfort or support, on a desertion or prostration of the spirits. To answer the third indication of strengthening the alimentary canal, and promoting the secretions, a plaster of pix arida, or of laudanum, is to be applied to the abdomen ; and chalybeates are to be employed, as advised under the head of Dyspepsia. Mineral waters, particularly those of Bath and Tunbridge, have been used in hypochondriacal cases with infinite advantage to the patient, which perhaps may be attributed as much to the amuse- ments and avocations accompanying the drinking of these waters at the spring, as to the tonic power they possess, from the small quantity of iron with which they are impregnated. Perhaps the elementary water, by favouring the excretions, may have a share in relieving the disease. Bitters and astringents are generally supposed to be improper in hypochondriasis, because there is not a loss of tone, as in dys- pepsia, but only a torpor, or want of activity. Chalybeates, how- ever, may be advisable. As a general stimulant, cold bathing may sometimes seem useful to the hypochondriac, as well as to the dyspeptic; but this does not often happen, as tepid bathing proves in general much more useful, from the rigidity of the solids which prevails. A bath of about 96 or 98 degrees of heat used for half an hour once a day, or every other day, has in many instances proved of great service. Where a natural warm bath can be procured, a preference should be given to it. The use of a warm bath is generally resorted to with decided advantage by hypochondriac patients as a remedy for wakefulness, Order II. hypochondriac affection. 375 or broken and untranquil sleep, even when they had previously tried all the medicinal and dietetic opiates, as well as other methods for producing the same effect, without obtaining the object of their wishes. Frictions of the whole body every morning and evening for ten minutes or longer, with coarse flannel cloths, will be likely to prove beneficial; and so will be also bodily exercise. For the cure as well as prevention of hypochondriasis, and other nervous affections, there is no means better adapted than bodily exercise in the open air; and a man suffering under a fit of the vapours will often find that by walking or riding, particularly in agreeable company, he will be able to remove it. The load upon his mind may be exone- rated and removed by the continued agitation of his body. Walking, no doubt, is best adapted to a state of unimpaired health or vigour ; but for the feeble and hypochondriacal, or those who are affected by any visceral obstruction or disease, riding on horseback is for the most part preferable to any other kind of exercise. Instances not unfrequently occur of persons with broken spirits and apparently ruined constitutions, in whom an unexpected restoration to strength and cheerfulness has been effected by regular and daily horse exercise, when almost every other method of recovery had been tried without any sensible advantage. Nearly to live on horseback will be a good prescription for all nervous as well as bilious patients. A person often indolently bends under the burden of hypochon- driacal indisposition, which a spirited effort would at first have removed ; and on this account I would strongly recommend that those who are labouring under this distressing evil should be sti- mulated to gradual exertion of all their faculties, both bodily and mental. The diet in hypochondriasis should consist of what is light, generous, and nutritive, avoiding what is apt to prove either acescent or flatulent; and, therefore, animal food will be the most proper. The stomach ought never to be overloaded ; neither should it be suffered to remain perfectly empty. If a faintness is perceived at any time between meals, a bit of cake or biscuit may be taken with a glass of wine ; which precaution will be the more necessary with those in high life, from the late hour at which dinner is usually served up. Port wine, Sherry, or good Madeira, properly diluted with water, may be used for ordinary drink, instead of malt liquors; but should these disagree with the stomach, water with a small proportion of brandy may be drank in their stead. Tea and coffee are improper articles of diet for hypochondriacs ; but more parti- cularly when taken very warm. For breakfast, cocoa, chocolate, and infusions of aromatic herbs and roots, such as balm, sage, and ginger, may be substituted instead of these. 376 NEUROSES, OR NERVOUS DISEASES. [Class II. ORDER III. SPASMI, or SPASMODIC DISEASES. Irregular or preternatural motions of the muscles or muscular fibres are characteristic of this order of diseases. HYSTERIA, or the HYSTERIC DISEASE. This complaint appears under such various shapes, imitates so many other diseases, and is attended with such a variety of symp- toms which denote the animal and vital functions to be consider- ably disordered, that it is difficult to give a ;ust character or defi- nition of it; and it is only by taking an assemblage of all its appearances that we can convey a proper idea of it to others. The disease attacks in paroxysms or fits. These are sometimes preceded by dejection of spirits, anxiety of mind, effusion of tears, difficulty of breathing, sickness at the stomach, and palpitations at the heart; but it more usually happens that a pain is felt on the left side, about the flexure of the colon, with a sense of distention advancing upwards, till it gets into the stomach ; and removing from thence into the throat, it occasions by its pressure a sensation, as if a ball was lodged there, which by authors has been called globus hystericus. The disease having arrived at this height, the patient appears to be threatened with suffocation, becomes faint, and is affected with stupor and insensibility ; while at the same time the trunk of the body is turned to and fro, the limbs are variously agitated, wild and irregular actions take place in the alternate fits of laughter, crying, and screaming; incoherent expressions are uttered, a temporary delirium prevails, and a frothy saliva is discharged from the mouth. The spasms at length abating, a quantity of wind is evacuated upwards, with frequent sighing and sobbing, and the woman recovers the exer- cise of sense and motion without any recollection of what has taken place during the fit; feeling, however, a severe pain in her head, and a soreness over her whole body. In some cases there is little or no convulsive movement, and the person lies seemingly in a state of profound sleep, without either sense or motion. Hickup is a symptom which likewise attends in some instances on the hysteric disease ; and now and then it happens that a fit of hysteria consists of this alone. In some cases of this nature it has been known to continue for two or three days ; during which it frequently seems as if it would suffocate the patient, and proceeds gradually weakening her, till it either goes off, or else occasions death by suffocation: but this last is extremely rare. Besides hickup, other slight spasmodic affections sometimes wholly form a fit of hysteria, which perhaps continue for a day or two, and then either go off of themselves, or are removed by the aid of medicine. Order ///.'] hysteric disease. ,*77 In some cases the patient is attacked with violent pains in the back, which extend from the spine to the sternum, and at length become fixed upon the region of the stomach, being evidently of a spasmodic nature, and often prevailing in so high a degree as to cause clammy sweats, a pale cadaverous look, coldness of the extremities, and a pulse hardly perceptible. Hysteric affections occur more frequently in the single state of life than in the married, and most usually between the age of puberty and that of thirty-five years ; and they make their attack oftener about the period of menstruation than at any other. They are readily excited in those who are subject to them by passions of the mind, and by every considerable emotion, espe- cially when brought on by surprise : hence sudden joy, grief, fear, &c. are very apt to occasion them. They have also been known to arise from imitation and sympathy. Women of a delicate habit, and whose nervous system is ex- tremely sensible, are those who are most subject to hysteric affec- tions ; and the habit which predisposes to their attacks is acquired by inactivity and a sedentary life, grief, anxiety of mind, late hours, dissipation, a suppression or obstruction of the menstrual flux, ex- cessive evacuations, and the constant use of a low diet, or of crude unwholesome food. The disease is sometimes met with in the more delicate of the male sex. Hysteria differs from hypochondriasis in the following par- ticulars, and by paying attention to them may always readily be distinguished from it. Hysteria attacks the sanguine and plethoric; comes on soon after the age of puberty ; makes its onset suddenly and violently, so as to deprive the patient of all sense and volun- tary motion ; is accompanied with the sensation of a ball rising upwards in the throat, so as to threaten suffocation ; is attended usually with much spasmodic affection ; is more apt to terminate in epilepsy than in any other disease ; and on dissection its morbid appearances are confined principally to the uterus and ovaria. The reverse happens in hypochondriasis. It attacks the melan- cholic ; seldom occurs till after the age of thirty-five : comes on gradually; is a tedious disease, and difficult to cure; exerts its pernicious effects on the membranous canal of the intestines, as well by spasms as wind; is more apt to terminate in melancholy or a low fever than in any other disease ; and on dissection exhibits its morbid effects principally on the liver, spleen, and pancreas, which are often found in a hard, scirrhous, or other diseased state, Another very material difference might be pointed out between these two diseases, which is, that hysteria is much relieved by advancing in age, whereas hypochondriasis usually becomes aggravated. The two diseases have been often confounded together; but from considering the foregoing circumstances, it appears that a proper line of distinction should be drawn between them. The hysteric passion likewise differs from a syncope, as in tkk 49 378 NEUROSES, OR NERVOUS DISEASES. [Class II. there is an entire cessation of the pulse, a contracted face, and a ghastly countenance : whereas in the uterine disorder there is often something of a colour, and the face is more expanded; there is likewise a pulse, though languid; and this state may continue two or three days, which never happens in a syncope. It also differs from apoplexy, in which the abolition of sense and voluntary motion is attended with a sort of snoring, great diffi- culty of breathing, and a quick pulse ; which do not take place in hysteric cases. It differs from epilepsy, in that this is supposed to arise in con- sequence of a distention of the vessels of the brain ; whereas in hysteria, the spasmodic and convulsive motions arise from a turges- cence of blood in the uterus, or in other parts of the genital system. Hysteria may be distinguished from epilepsy by the globus hyste- ricus, by the great flow of limpid urine, by the sudden transitions from laughing to crying, and by the fear of death preceding and succeeding to the paroxysm. However dreadful and alarming an hysteric fit may appear, still it is seldom accompanied with danger, and the disease never termi- nates fatally,/mless it changes into epilepsy or mania, or the patient is in a very weak reduced state. In the cure of hysteria two indications are to be attended to. The first is to allay the spasmodic symptoms which constitute the fit; and The second, to lessen the excitability of the nervous system, and strengthen the whole frame during the intermission of the paroxysms. The first of these indications is to be answered by bleeding, if the patient is young and plethoric, the pulse full, and the attack quite of a recent nature; but in weak and delicate constitutions, or where the disease has been of long standing, we should never have recourse to this operation. During the fit it will be the safest practice to rouse the patient by applying burnt feathers, asafoetida, or volatile salts or spirits, to the nose ; by rubbing the temples with aether, and by putting the feet into warm water. Dashing cold water over the extremities and face is sometimes attended with a good effect. In case of costiveness, a laxative clyster, with an addition of asa- foetida or castor, may be thrown up into the intestines. Where the fit continues for any length of time, I have seen very speedy and effectual relief afforded by administering clysters composed of turpentine.* We may at the same time apply a small blister to the inside of each leg. During the fit, due care is * 1. R 01. Terebinth, f. 3iij. Mucilag. Gum. Acac. f. ?es. Misceant. bene simul in mortario, et adde Decoct, Avense, f. ?si. ft. Enema. * 1. Take Oil of Turpentine,three drachms. Mucilage of Gum Acacia, half an ounce. Mix them well together in a mortar, and add Thin Gruel, eleven ounces, for ;i clyster. Order 111.] hysteric'disease. <3?i3 to be taken that the patient sustains no injury from the violence o f her struggles. As soon as she is perceived to be capable of swallowing, some antispasmodic, as asafoetida, castor, ammoniated tincture of valerian, camphor, aether, &c. should be given to her frequently. Such medi- cines may either be administered separately, or be combined to- gether, as in the formulas below.* In those cases where the spasms are very violent and the fit of long duration, opium may be employed in addition to other antispasmodics. In common cases it will, how- ever, be best to avoid its use, as it seldom fails to leave the patient remarkably low, particularly if long continued. In cardialgic paroxysms of the hysteric kind, the liquor potassae subcarbonatis in doses of twenty drops, frequently repeated, has been found an excellent palliative remedy, and may therefore be prescribed. The second indication is to be answered by giving medicines, during the intermissions of the paroxysms, to strengthen the system, such as the cinchona bark, and other bitters, with the sulphuric acid, and chalybeates ; proper formulae of which have been inserted under the head of Dyspepsia ; but if more agreeable to the practitioner, those mentioned heret may be substituted. * 2. jg. Misturae Asafcetid. f. ^vj. Tinct. Valerian. Ammon. f. 3U- Spir. JEther. Sulphuric, f. 3j- M. ft. Mistura, cujus sumat asgra cochl. ij. sextis horis. Vel, 3. ]J Tinct. Valerian. Ammon. f. 3j- ----Lavend. C. f. 3ij. Spirit. Cinnam. f. 3i'j. Mistur. Camph.f. ^vj. M. ft. Mistura, capiat, cochl. ij. pro dos. ter quaterve in die. Vel, 4. rx Aq. Cinnam. f. ^jss. Tinct. Castor, f. 3j. Spirit. Ammon. Foetid, fll xiv. Spirit. iEther. Sulphuric, m xx.M ft. Haustus, 4taaut 6taquaq. hora sumen- dus. Vel, 5- R Spirit. Ammon. Foetid, fix xv.—xx pro dos. Vel, 6. fy Spirit. Mther. Sulphuric, Til xx.— xxx. in quovis vehiculo. t 7. U Ferri Subcarbonat. gr. vj. Extract. Cinchona?, 3j. * 2. Take Mixture of Asafoetida, six ounces. Ammoniated Tincture of Valerian, two drachms. Spirit of Sulphuric iEther, one drachm. Of this mixture the patient may take two table-spoonsful every six hours. Or, 3. Take Ammoniated Tincture of Vale- rian, one drachm. Compound Tincture of Lavender, two drachms. Spirit of Cinnamon, three drachms. Camphor Mixture, six ounces. Mix them, and let the dose be two table- spoonsful three or four times a day. Or, 4. Take Cinnamon Water, one ounce and a half. Tincture of Castor, one drachm. Fetid Spirit of Ammonia, twenty drops. Spirit of Sulphuric JEther, thirty drops. Mix them for a draught, to be taken every four or six hours. Or, 5. Take Fetid Spirit of Ammonia, from twenty-two to thirty drops for a dose. Or, 6. Take Spirit of Sulphuric JEther, from thirty to forty-five drops in any vehicle. 17. Take Subcarbonate of Iron, six grains. Extract of Peruvian Bark, one scruple. •S80 NEUROSES, OR NERVOUS DISEASES. [Class IL Mineral waters are found to be very efficacious in hysteric affec* tions, and their powers may greatly be increased by proper exercise, particularly riding on horseback, together with early rising, a gene- rous nutritive diet, cool dry air, and cold bathing. In addition to these, the mind is to be kept constantly easy and cheerful, and, if possible, to be always engaged in some agreeable and interesting pursuit; for which reason watering places are well adapted for those who are subject to hysteric affections, and parti- cularly where they have taken their origin from grief, anxious thoughts, or other distresses of the mind. If the stomach is affected at any time with phlegm, so as to excite nausea, a gentle emetic may be taken to remove it ; or if there is a tendency to costiveness, it may be obviated by some gentle laxative. as advised under the head of Dyspepsia. When hysteric affections arise from a suppression or obstruction of the menses, these evacuations must again be promoted by adopting the means recommended under those particular heads. Hysterical women are often afflicted with slight spasmodic affec- tions in various parts of the body, and particularly with cramps, which are most apt to seize them in bed, and when asleep. In mild cases of this nature, immersing the feet and legs in warm water will often be sufficient to remove them ; but where the spasms are violent, and of some duration, we must attempt the cure by opiates, musk, aether, camphor, &c. internally, and by the warm bath, and frictions with anodyne liniments externally.—See Tetanus. In those cases where the stomach becomes affected with cramp, we must have recourse to considerable doses of aether combined with opium.* Its external region may likewise be anointed with a liniment of the same nature.! If the feet are cold, bottles filled Syrupi, q. s. M. ft Bolus, bis in die sumendus,cum Infus. Quassias, f. ^ij. Vel, 8. I£ Extract. Cinchonae, Pulv. Myrrh, aa 3j- Ferri Sulphat. 3ss. 01. Carui, HI v. Syrup. Zingib q. s. M. Fiant pilulae xxxvj., quarum ij. capiat eegra ter quaterve in die; superbibendo Infus Gentian. C. f. |ij. "* 9- R Aq. Cinnam. f. 3j. Spir. JEther. Sulphuric, f. 3j. Spirit. Carui, f. ^ss. Tinct Opii, in, viij. ----Castor, f. 3ss. ft. Haustus, ter quaterve die capiendus. 110. R Spirit. Camphorae, f. ?ij. Tinct. Opii, f. z<*. Common Syrup, a sufficiency to form a bolus, which may be taken twice a day, washing it down with about two ounces of an infusion of Quassia, Or, 8. Take Extract of Peruvian Bark,| Powdered Myrrh, of each one drachm. Sulphate of Iron, half a drachm. Oil of Carraway, eight drops. Syrup of Ginger, a sufficiency to form the mass into thirty-sixpills, of which the patient may take two, three or four timesa day, washingthem down with two ounces of the Compound Infusion of Gentian. * 9. Take Cinnamon Water, one ounce. Spirit of Sulphuric ^Ether, one drachm. ------Carraway, half an ounce. Tincture of Opium, twelve drops. i"—— Castor, half a drachm. Mix them, and let the draught be taken three or four times a day. 110. Take Camphorated Spirit, two ounces. Tincture of Opium, half an Order III.] EPILEPSY. 361 with warm water should be applied to them. Throwing up an emollient clyster into the intestines may also be proper, particu- larly where costiveness accompanies the spasmodic affection of the stomach. To lessen the irritability or excitability of the system, and pro- duce permanent effects, some physicians have recommended a use of antispasmodics along with tonics. The undermentioned formulae* may be advised on the occasion, the patient washing them down with a little valerian tea. , From the great disposition of the stomach to acescency in this disease, as well as in hypochondriasis, a diet of animal food will be most proper. Wine diluted with a sufficient quantity of water should be preferred to all other liquors for common drink. EPILEPSIA, or EPILEPSY. This disease consists in a sudden deprivation of the senses, ac- companied with a violent convulsive motion of the whole body. It attacks by fits, and after a certain duration goes off, leaving the person most commonly in his usual state; but sometimes a considerable degree of stupor and weakness remains behind, parti- cularly where the disease has frequent recurrences. It is oftener met with among children than grown persons, and boys seem more subject to its attacks than girls. Its returns are periodical, and its paroxysms commence more frequently in the night than in the day, being somewhat connected with sleep. It is a disease some- times counterfeited, in order to extort charity or excite commisera- tion. Occasionally we meet with epilepsy in combination with mania. Epilepsy is properly distinguished into sympathic and idiopathic ; being considered as sympathic, when produced by an affection in Spirit. JEther. Sulphuric, f.giij. M.I Spiritof Sulphuric ^Ether, three V drachms. Mix them for an embrocation. 11 Take Musk, six grains. Camphor, three grains. Extract of Peruvian Bark, ten grains. Syrup, a sufficiency to form a bolus, which is to be taken twice or thrice a day. Or, 12. Take Powdered Myrrh, Castor, of each one drachm. Sulphate of Iron, one scruple. Extract of Chamomile, half a drachm. Oil of Amber, eight drops. Common Syrup a' sufficiency to form the mass. Divide this into thirty-six pills, and let the patient take three night and morning, with two table-spoons- ful of an Infusion of Calumba Root. ft. Embrocatio. * 11. rj; Moschi, gr. vi. Camphorae, gr. iij. Extract. Cinchon. 3ss. Syrup, q. s. M. /t. Bolus, bis terve die sumendus. Vel 12. ft Pulv. Myrrh.' Castor, aa 3j- Ferri Sulphat. 3j. Extract Anthemidis, 3ss. 01. Succin. fll v. Syrup-Simpl. q s. M. Fiant. pilul. xxxvj., quarum iij. capiat aegra mane et hora decubitus, cum cochl. ij. magnis Infusi Rad. Calumbae 382 NEUROSES, OR NERVOUS DISEASES. [CktSS II. some other part of the body, such as acidities in the stomach, worms, teething &c. ; and idiopathic, when it is a primary disease, neither dependent on, nor proceeding from any other. The causes which give rise to epilepsy are blows, wounds, frac- tures, and other injuries done to the head by external violence, to- gether with plethora of the vessels of the head, lodgments of water in the brain, tumours, concretions, polypi, and a deformity in the shape of the bones in any part of the skull. Epilepsy has also been known to arise from an affection of the spinal marrow ; and it is to inflammation in that part of a more chronic form, that those shaking palsies, which are attended with pain, have been imputed. Violent affections of the nervous system, sudden frights, fits of passion, great emotions of the mind, frequent intoxications, acute pains in any part, worms in the stomach or intestines, teething, the suppression of some long-accustomed evacuation, too great emptiness or repletion, and poisons received into the body, are causes which likewise produce epilepsy. Sometimes it is here- ditary, and at others it depends on a predisposition arising from a mobility of the sensorium, which is occasioned either by plethora or a state of debility. We are told by Dr. Parry,* that whatever may be the primary -■*- cause of epilepsy, it usually depends immediately on excessive im- petus of blood in the vessels of the brain. An attack of epilepsy is now and then preceded by a heavy pain in the head, dimness of sight, noise in the ears, palpitations, flatu- lency in the stomach and intestines, weariness, and a small degree ' of stupor, and in a few cases there prevails a sense of something like a cold vapour or aura rising up to the head ; but it more gene- rally happens, that the patient falls down suddenly without much previous notice; his eyes are distorted or inverted, so as that only the whites of them can be seen; his fingers are closely clenched; his limbs and the trunk of his body, particularly on one side, are much agitated ; he foams at the mouth, and thrusts out the tongue, which often suffers great injury from the muscles of the lower jaw being also affected ; he loses all*sense of feeling, and not unfre- quently voids both urine and faeces involuntarily. After a continuance of the convulsions for some time they abate gradually, and the patient continues for a short period in a state of insensibility, but on coming to himself, feels very languid and exhausted, and retains not the smallest recollection of what has passed during the fit. When the disease proceeds either from tumours, polypi, concre- ' tions, or a deformity in the bones of the skull, the case is hopeless. When it arises from an hereditary disposition, or comes on after the age of puberty, or where the fits recur frequently, and have become habitual, or are of long duration, it will be very difficult to effect a cure ; but when it attacks at an early age, and is occa- * See his Elements of Pathology and Therapeutics. Order 1II.J ETILEPSV. 383 sioned by worms, or any accidental cause, it may in general be removed. In some cases it has been entirely carried off by the recurrence of a fever, or by the appearance of the menses, or of a cutaneous eruption. It has been known to terminate in apoplexy and in some instances to produce mental derangement, or a loss of the powers of the mind, and so to end in idiotism. Epilepsy has been perceived to disappear suddenly about the age of puberty where it has attacked children of five or six years old and where no treatment has had any effect. The number of fits are always increased by parturition, and by every other thing which has a tendency to debilitate the system. The appearances usually to be observed on dissection, are serous and sanguineous effusion, a turgid tense state of the vessels of the brain without any effusion, a dilatation of some particular part of the brain, excrescences, polypi, and hydatids adhering to it, obstructing its functions, and likewise ulcerations. In some in- stances the pituitary gland is found in a diseased state, even when every other part of the brain has appeared natural. In numerous dissections the spinal cord has been found more or less dis- eased. In epilepsy the intentions of cure should vary according to the cause which occasions the disease. When it is sympathic, and arises from worms, medicines pos- sessed of the power of destroying or dislodging these vermin ought to be employed. As an anthelmintic, the oil of turpentine in doses of from half an ounce to one ounce has been found a very Useful medicine in some cases of epileptic fits. When they proceed from teething, that part of the gum which appears to be inflamed should be deeply scarified, the body should be kept open by laxative medi- cines or emollient clysters, and the feet be bathed in warm water. When cases occur without any symptoms of direct pressure on the brain, and there is occasional sickness, attended with flatulency, disturbed sleep, and other marks of disordered digestion, either preceding or following epileptic paroxysms, it will be right, espe- cially in the former case, to evacuate the contents of the stomach by an emetic, consisting of a solution of the sulphate of zinc in an aqueous infusion of ipecacuanha, and to repeat it in six, eight, or ten days, according to circumstances.* The dose must vary according to the age of the patient, and the different degrees of irritability of the stomach, as no general rule can apply to every case. Afterwards, if the stomach should exhibit marks of weakness, light bitter infusions may be given, assisted by some active stimu- lant, as ammonia or oleum cajeputi. When there is a great prevalence of acid, from the imperfect digestion of vegetable food, soda, liquor potassajor liquor potassa; subcarbonatis, may be combined with the bitter. * See Dr. J. Clarke on the Diseases of Children, 384 NEUROSES, OR NERVOUS DISEASES. [Class II. If the bowels are confined at the same time, magnesia may be employed advantageously. On the contrary, if too much relaxed, which is seldom the case, cretaceous preparations may be resort- ed to. If epilepsy appears to proceed from any suppressed discharge, in particular the bleeding piles, leeches should be applied to the haemorrhoidal vessels, together with fomentations, and we should at the same time administer aloetic cathartics. Where it attacks children of a costive habit, and seems to take its rise merely from a foulness of the bowels, active purgatives should be employed. A combination of the submuriate of mercury and jalap will be very proper. If it arises from any stimulus, which by exciting pain occasions the complaint, this ought to be removed as quickly as possible. If it is a case of sympathic epilepsy, and is accompanied with the aura epileptica, we should then endeavour to destroy the part, either by cutting it out, or by applying caustic to it ; and when these means cannot be adopted, we ought then to endeavour to correct the morbid affection in it, either by blisters or by inserting an issue ^ the part. Should the disease seem to proceed from the partial division of a nerve, and it can be got at readily, we ought to cut through it in the'same manner as in tetanus. Cutting off the communi- cation with the brain has likewise been attempted by the appli- cation of ligatures upon the limb, above the part from which the aura arises. A case which was successfully treated in this way, is recorded by Mr. Adolphus T. Leoffler, Professor of Altona, in his Obser- vations on Medicine and Surgery. An epileptic patient felt, on every attack, a sense of coldness at the sole of the foot, and which gradually ascended till it reached the head. It occurred to the Professor to make a strong ligature above the knee of the affected limb, before the cold sensation had proceeded so high. The method succeeded; and as often as he took this precaution sufficiently early, he prevented the attack from taking place. In the idiopathic epilepsy, the cure consists in avoiding the occasional causes, and in removing or correcting those which pre- dispose to it. The occasional causes which are to be avoided, are over dis- tention, turgescence, intoxication, fits of passion, and all other emotions of the mind ; and as the disease is confirmed by repe- tition and habit, so the avoiding frequent recurrences of it is of the utmost importance. It is a fact well supported, that in some instances the disease has been found to continue from custom alone, after the original cause had long ceased to act. In such cases, our endeavour* should be exerted to make nature discontinue this custom if pos- sible. When an attack can be foreseen, no medicine, perhaps, undersuch circumstances, will be more likely to prevent an epileptic Order III.J EPILepsv. 385 fit, than an emetic given about an hour before its approach. Re- moving to another country, and changing former habits and the manner of living, may likewise be serviceable in such cases. If the predisposition to the disease has arisen from a plethoric state of the system, or from a turgescence in the vessels of the head, this is to be obviated by bleeding, both generally and to- pically, but more particularly the latter; by an abstemious diet and proper exercise, and by issues between the scapulas, or a seton in the neck. These last may not only be supposed to be good remedies for obviating the plethoric state of the system, but may likewise be the means of determining occasional turgescences to such places, and therefore of diverting them in some measure, from their action upon the brain. In those cases where, from frequent paroxysms, a morbid condition of the encephalon has prevailed, the insertion of a seton in the neck has been attended with a very happy effect. In some dissections of those who have been destroyed by epilepsy, the spinal cord towards the upper part having been found now and then diseased, the insertion of issues on each side of the spinous processes of the cervical vertebras (one of them, near the occiput, the other about the commencement of the dor- sal vertebras,) has been attended with success after a failure of all other remedies. Some of the French surgeons have applied moxa to the spine, and this with considerable success, it is as- serted. In some cases of epilepsy, the patient lies in a comatose state after the paroxysm of convulsion has ceased, owing to a violent determination of blood to the head, his breathing is stertorous with foaming at the mouth, and the pulse is full, hard, and beating one hundred in a minute. In such cases, bleed to the extent of twenty ounces or more, order cold applications to the forehead, temples, and head, and evacuate the bowels freely by a powerful dose of some active purgative, assisted by an enema of the same nature. If these means do not restore the patient to a state of sensibility, repeat the bleeding again, apply leeches to the temples, and a large blister to the neck, or between the shoulders. Epilepsy is one of the diseases in which the digitalis has been found serviceable, but most so in those cases where a plethoric state or turgescence in the vessels of the head prevails. To pro- duce however, a permanent effect, the constitution must be kept under its influence for some weeks, by giving from half a grain to one grain of the powder, or from fifteen to thirty drops of the tincture, three or four times a day. Under the head of Mania, I have mentioned a severe case of epilepsy in a middle-aged married • woman, accompanied with mental derangement, wherein, by ad* ministering the digitalis in the manner just noticed, and carefully guarding against the exciting cause (frequent intoxication,) a com- plete cure was effected. When the predisposition i< owing to y state of debility, which i' 5Q/ 38G NEUROSES, OR \ER\OU> DISEASES. [Class IL sometimes the case, we are to obviate and prevent its effects by recommending the patient to breathe a cool air, to make use of a generous nutritive diet, to take daily exercise adapted to his strength, particularly on horseback, and to go frequently into a cold bath ; and besides adopting these steps, he may enter on a regular course of antispasmodic, astringent, and tonic medicines. The antispasmodics in most general use are, valerian, castor, musk, aether, oil of amber, oleum cajeputae, arnica montana, belladonna, hyoscyamus, digitalis, and opium, all of which may be given, as advised under the heads of Hysteria, Hypochon- driasis, and Palsy, or as prescribed below.* A combinationt of opium and valerian, or of opium and musk, will be likely to prove valuable remedies. In particular, they should be given a short time before the expected return of the paroxysm, and be repeated at proper intervals, increasing the dose in a gradual manner, in proportion to the violence or frequent recurrence of the fits. Where the disease depends upon a plethoric state, it would be highly improper to give opium ; but where no plethora exists, and it seems to depend upon irritation, or upon increased excitement, opium will prove a safe and powerful remedy. When given in a large dose, such as two grains in substance, or sixty or seventy drops in tincture, on the approach of a fit, it has been known to prevent it altogether ; but should it even fail in this, it will infalli- bly be found to lessen its violence. If the stomach rejects the internal use of opium, its external ap- plication may possibly be resorted to with much advantage, and it may likewise be employed in this way during the convulsions. The whole spine of the back may be moistened with tinctura opii, or a * 1. rx Aq. Anethi, f. ^jss. Tinct. Valer. Ammon. m.xx ---- Castor, f. 3j- Spirit. iEther. Sulphuric.fflxx. M. ft. Haustus, bis terve die sumendus Vel, 2. ft Infus. Cort. Cascaril. f. ^jss. Tinct. Valerian. Ammon. fllxx. ---- Calumb. f. 3ij. ---- Hyoscyami, TTJxv. M, ft. Haustus. t 3. ft Moschi. Castorei, aagr. x. Opii, gr. ss. \ Confect. Rosa?, q. s. M. ft. Bolus, 6ta quaq. hora capiendus. Vel 4. ft 01. Succiu. f. |ss. Tinct. Opii, f. 3ij. M Guttaj viginti, bis terve in die sumendae ex cyatho aquae pura?. * 1. Take Dill-Wafer, one ounce and ahalf. Ammoniated Tincture of Valerian, thirty drops. Tincture of Castor, one drachm. Spirit of Sulphuric iEther, thirty drops. Mix them for a draught, to be taken twice or thrice a day. Or, 2. Take Infusion of Cascarilla Bark, one ounce and a half. Ammoniated Tincture of Valerian, thirty drops. Tincture of Calumba, two drachms. ■ Henbane, twenty drops. Mix them for a draught. f 3. Take Musk, Castor, of each ten grains. Opium, half a grain. Confection of Roses, a sufficiency to form a bolus, which may be taken every six hours. Or, 4. Take Oil of Amber, half an ounce. Tincture of Opium, two drachms Mis them, and take twenty drops twice or thrice a davin a little water. Order 111.} EPILEPSY. 387 liniment consisting of six grains of pure opium, well triturated with a little prepared lard, may be rubbed in. The astringent medicine most celebrated formerly in the cure of epilepsy, was the misletoe, or viscus quercinus. It was given in doses of from half a drachm to a drachm of the powder, or about an ounce of the infusion repeated twice a day. It was indeed looked upon by many more as an object of superstition than of real utility, and for many years past has experienced almost total neglect. A modern writer on epilepsy* speaks, however, highly in its favour, and has recited several cases which were radically cured by it. As a tonic, the cinchona baik has been much employed in the cure of this disease. Its use seems, however, best adapted to those epilepsies which recur at certain periods, and which are without plethora : in which cases, if it is given in a considerable quantity, some little time before the expected recurrence, it will be very likely to prove serviceable. When taken for a constancy, it may be combined with valerian, &c. as below.t Metallic tonics having been found more powerful than the ve- getable ones, have therefore been more generally employed. The preparations of iron most used are, the ferri sulphas, the ferrum ammoniatutn,! and the ferri carbonas. Those of copper are the cuprum ammoniatum of the Edinburgh Dispensatory, and the cupri sulphas, which§ maybe given in small doses at first, repeated * See Dr. Henry Frazers Treatise on this Disease. f 5. ft Decoct. Cinchon. f. 3&. Tinct. ejusdem C. f. 3ij. ----Valerian. Ammon. f. 3ss. M. Pro haustu, ter in die sumersdo. t 6. ft Ferri Ammoniat. gr. x.—xv. Extract. Gentian, gr. x. Syrup, q. s. M. ft. Bolus, ter in die sumendus. Vel, 7. ft Tinct. Ferri Ammoniat. fT|xv. bis terve die in aquae frigid, cyatho ^ 8. R Cupri Ammoniat. gr. j.—iv. Confect. Aurant. gr. x. M- ft. Bolus, bis in die adhibondus. Vel, 9. ft Cupri Sulphat. gr. iij. Extract. Cinchonae, gr. xij. Opii, gr. ij. Syrup, q. s. Misceantur bene in ruassam et in pilulas vj.'divd. quarum apiat aeger unam vel duas ter in die. t 5. Take Decoction of Peruvian Bark, ten tVachms. Compound Tincture of the same, two drachms. Ammoniated Tincture of Valerian, thirty drops. Mix them for a draught, to be taken thrice a day. X 6. Take Ammoniated Iron, ten to fifteen grains. Extract of Gentian, ten grains. Syrup, a sufficiency to form a bolus, which may be taken thrice a day. Or, 7. Take Ammoniated Tincture of Iron, twenty-two drops twice or thrice a day in a glassful of water. § 8. Take Ammoniated Copper, one grain, gradually increasing it to four grains. Confection of Orange Peel, ten grains. Make them into a bolus, to be taken twice n d;iv. Or, 9. Take Sulphate of Copper, three grains. Extract of Bark, twelve grains. Opium, two grains. Syrup, a sufficiency. Divide the mass into six pills, of which one or two mav be taken thrice a dav 388 NEUROSES, OR XEKYQIS DISEASES. [Classlf, twice a day, increasing them gradually to as much as the stomach will bear. The pulvis stanni, and other preparations of tin, have likewise been used in the cure of epilepsy ; but their effects seem doubtful. The oxyd of zinc has been much extolled for its virtues in this disease. The dose is from one grain* to three, four, or five. It will always be the best way to begin with a single grain, repeated three or four times a day, and so to increase the dose gradually according to the effect it produces on the stomach. The sulphate of zinc is another metallic tonic much recommended in this disease. We may give half a grain of it thrice a day, and increase the dose gradually. Arsenic has likewise been employed in the cure of epilepsy with some success. It will be best administered in the form of solution, as recommended under the head of Intermittent Fever. Some instances of the cure of epilepsy having occurred from an accidental use of mercury, this also has been proposed as a remedy. The nitrate of silver] has been found to be a valuable medicine in the cure of epilepsy, even where the disease has been of many years standing, and had resisted the powers of other medicines. Two cases of this nature are recorded in the Medical and Physical Journal.]: It will be best to begin with a quarter of a grain thrice a day, which dose will be sufficient for an adult at first, but it may afterwards be gradually increased to one grain, or one grain and a half, and be taken in the form of a pill. A singular occurrence attendant on a long course of this medi- cine is, that the skin of the patient has been known to contract a blue colour over the whole of the bodv$ without there beinff the t See vol. i. p. 184, and vol. ii. p. 70. § See Medico-Chirurgical Transactions, vol. vii. part i. p. 279. * 10. ft Zinc. Oxydi, gr. xij. , * 10. Take Oxyd of Zinc, twelve grains. Pulv. Cinnam. Comp. gr. xv. Compound Powder of Cinnamon, fifteen grains. ----Cinchonae, 3j- Powder of Peruvian Bark, one drachm. M'et in chartul. xij. divide, quarum unam Mix them, and divide the powder into dot sumat ter in die. j twelve papers, of which take one dose I three times a day. Vel, j Or, 11. ft Zinc. Oxydi, gr. xxiv. j H.TakeOxydofZinc,twenty-fourgrains. Extract. Gentian. 3ss. 1 Extract of Gentian, half a ! drachm. Syrup, q. s. M. ft. Massa inpilulasxij.dividenda, quarum mass, which divide into twelve pills, j. sumat mane etve.?perecum Decocti Cinchona', ?iss. t 12. ft Argent. Nitratis, gr. iij. Solve terendo in Aqua? Distillatae. in. aliquot, et adde Mica; Panis. q. s, ft. Massa in pilulas viginti distribuenda. '"ura vel duas *;umat bis terve in die. Syrup, a sufficiency to form the whereof two may be taken morning and evening, with one ounce and a half of a Decoction of Peruvian Bark. t 12. Take Nitrate of Silver, three grains. Dissolve it in a lew drops of Distilled Water, then add Crumb of Bread, a sufficiency to form a mass, which is to be made into twenty pills. The dose may be from one to two twice or thrice a day. Order HI.] epileI'sV. 3#9 least disease'of the heart, and where neither the circulation nor respiration were in the least affected. As the blood in these patients is always of the natural hue, it cannot be doubted, I think, with others, that the blue colour must be looked for in the reticula Malpighiana, in which it is produced by the nitrate of silver. Certain stimulants, such as the tinctura? lyttae and oleum tere- hinthinas have lately been employed with considerable benefit in epilepsy. They produce irritation in certain other organs and parts of the body,, particularly the urinary apparatus and alimen- tary canal, and it is during the continuance of this irritation, or determination to a distant part, that the brain obtains an immunity from the disease. The oleum terebinthinae, as just observed, has certainly been used in some cases of epilepsy with success,* as well as in a few other spasmodic diseases: the dose should be considerable to produce any effect, viz. one ounce for a delicate female, an ounce and a half for a robust female or small man, and about two ounces for a robust man. The best vehicle for it appears to be milk. The most proper time for administering it will be early in the morning, on an empty stomach. It must be obvious, however, that this remedy can only be em- ployed efficaciously in cases depending upon a cause unconnected with diseased organization, and which is producing too great an ex- citement in the nervous system. In cases connected with diseased organization of the brain, the administration of turpentine would in all probability only aggravate the malady by exciting activity in the vessels of the morbid organ, which it should be the endeavour of the physician rather to arrest and tranquillize. In some of the worst cases of epilepsy, in which the fits were long and violent, as well as frequent throughout the course of the day, and where the disease had been of some standing, electricity has beeti found to render them weaker, and to reduce their number very materially in a short space of time. When other means fail to procure the desired effect, we ought therefore to have recourse to this remedy, or galvanism. The diet in epilepsy should consist of such things as are light, nutritive, and easy of digestion, taking care to avoid whatever is apt to prove flatulent. During the intervals, the patient is to keep himself as cheerful and tranquil as possible, carefully guarding against all violent passions or other emotions ; and he should take care never to put himself in a hazardous situation, lest a fit should happen to attack him at that period. When it is present, due care ehould be taken to prevent him from bruising himself in his struggles; and especially that he does not get his tongue between his teeth. Rubbing the nose, temples, ,and pit of the stomach with aether, may possibly help to abbrevi- ate the fit by its action on the olfactory organ. * See Edinburgh Medical and Surgical Journal, No, 3">, 390 NEUROSES, OR NERVOUS DISEASES. [Class II. A smaller degree of epilepsy is where the sensibility and irri- tability remain, but there are spasmodic contractions of the muscles ; hence we see many persons affected with twitchings of the face. There are also certain spasmodic pains that come on by paroxysms, which seem likewise of the epileptic kind. When any of these arise as sympathic affections, they are only to be cured by removing the primary disorder upon which they de- pend ; but where they take place independent of any other disease, they are to be treated in the manner just recommended to be pur- sued in the cure of epilepsy. CATALEPSIS, or CATALEPSY. Catalepsy is that state of the muscular system in which the patients, without fever, lose voluntary motion, and commonly the functions of the five senses, but preserve the nobility of the mus- cles, and keep the exact position wherein they are attacked, or arbitrarily placed by other persons. The causes of catalepsy seldom appear to be local, but mostly general. There have been examples where plethora has produced this singular disorder, and where it has been removed by a spon- taneous haemorrhage. Suppressed catamenia, worms, and painful emptions of the mind, as terror, grief, disappointment, profound meditation, anger, &c. have all occasioned attacks of catalepsy. Women are more frequently attacked by it than men. It some- times changes into epilepsy, apoplexy, or melancholia, and has been known occasionally to terminate fatally in a few days. We should, in treating the disease judiciously, endeavour to find out the occasional cause, and adapt our remedies accordingly. If supposed to proceed from plethora, we should unload the vessels by cupping at the back of the neck, cathartics, blisters, a seton, or an issue. When arising from causes of a debilitating nature, tonics joined with antispasmodics will be proper. During the paroxysms, stimulating cataplasms may be applied to the palms of the hands and soles of the feet. Internally we may administer musk joined with volatiles,* &C. CHOREA SANCTI V1TI, or DANCE of ST. VITUS. This disease is marked by convulsive actions, most generally confined to one side, and affecting principally the arm and leg. When any motion is attempted to be made, various fibres of other ' l.ft Mistur. Moschi, 2'iij. Aq. Pulegii, 2ij. Spirit. Ammon. Foetid. 3'j- Tinct. Valerian. ?ss. M. ft. Mistura, cujus sumat cochl. ij.secundis vel tertiis horis. * l.Take Musk Mixture, three ounces. Penny Royal Water, two ounces. Fetid Spirit of Ammonia, two drachms. Tincture of Valerian, half an ounce. Mix them, and let two table-spoonsful be taken everv two or three hours. Order HI.] dance of st. virus. 391 muscles act which ought not, and thus a contrary effect is pro- duced from what the patient intended. It is chiefly incident to young persons of both 6exes, but particularly those of a weak constitution, or whose health and vigour have been impaired by confinement, or by the use of scanty and improper nourishment, and makes its attacks between the age of ten and fifteen, occur- ring but seldom after that of puberty. By some physicians it has been considered rather as a paralytic affection than as a convulsive disorder, and has been thought to arise from a relaxation of the muscles, which being unable to per- form their functions in moving the limbs, shake them irregularly by jerks. Chorea sancti viti is occasioned by various irritations, as teeth- ing, worms, acrid matter in the bowels, offensive smells, poisons, &c. It arises likewise in consequence of violent affections of the mind, as horror, fright, and anger. Occasionally it depends upon excessive impulse of blood in the brain, and in such cases it is greatly aggravated by whatever increases the action of the heart, and of course relieved by means that lessen this. In many cases it is produced by general weakness and irritability of the nervous system, and in a few it takes place from sympathy at seeing the disease in others, or by imitating them ; hence it not unfrequently spreads in public seminaries, particularly among girls, if its pro- gress is not checked by separation. The fits are sometimes preceded by a coldness of the feet and limbs, or a kind of tingling sensation that ascends like cold air up the spine, and there is a flatulent pain in the left hypochondrium, with obstinate costiveness. At other times the accession begins with yawning, stretching, anxiety about the heart, palpitations, nausea, difficulty of swallowing, noise in the ears, giddiness, and pains in the head and teeth, and then come on the convulsive motions. These discover themselves at first by a kind of lameness or insta- bility of one of the legs, which the person draws after him in an odd and ridiculous manner, as if it was paralytic ; nor can he hold the arm of the same side still for a moment; for if he lays it on his breast, or any other part of his body, it is forced quickly from thence by an involuntary convulsive motion. If he is desirous of drinking, he uses many singular gesticulations before he can carry the cup to his head, and it is forced in various directions, till at length he gets it to his mouth, when he pours the liquor down his throat with great haste, as if he meant to afford amusement to the by-standers. Sometimes various attempts at running and leaping take place, and at others the head and trunk of the body are affected with convulsive motions. The eye loses its lustre and in- telligence, and the countenance is pale and expressive of vacancy ; deglutition is occasionally performed with difficulty, and articula- tion is often impeded, and sometimes completely suspended. In the advanced periods of the disease, flaccidity and wasting of the 392 neuroses, or nervous- diseases. [Class II muscular flesh take place, the consequence of constant irritation, of abated appetite, and impaired digestion. In many instances the mind is afflicted with some degree of fatuity, and often shows the same causeless emotions, such a? / weeping and laughing, which occur in hysteria. When the disease arises in children, it usually ceases again be- fore the age of puberty, and in adults is often carried off by a change from the former mode of life. Unless it passes into some other disease, such as epilepsy, or its attacks are very violent, it is not attended with danger. Where chorea arises in those of a weak irritable habit, and is wholly unconnected with any species of irritation, either of teeth- ing, worms, or acrid matter in the first passages, we should not employ evacuants, but have recourse to strengthening remedies, with the view of increasing the tone of the muscular system. Cinchona bark in large doses, with the assistance of cold bathing, has often effected a cure ; but the metallic tonics which have been advised under the head of Epilepsy, will be more likely to prove efficacious than those of the vegetable class. We have just grounds for believing that the liquor arsenicalis is a valuable and powerful medicine in the treatment of chorea, particularly if conjoined with a few drops of tinctura opii; and indeed several cases of this disease which were cured by this medicine, are recorded in vol. x. part i, of the Medico-Chirurgical Transac- tions of London ; a few have also occurred in my own practice. To tonics we may join antispasmodics, such as opium, musk, and camphor, as prescribed under the same head. Hyoscyamus and belladonna are medicines sometimes employed in chorea with success, when all others have proved ineffectual, particularly the latter. When given to children, we may begin with about a grain daily, in divided doses, and gradually increase the quantity to one grain and a half. During a use of these medicines, if costiveness prevails, it should be removed by some gentle laxative. Should the disease resist these means, it probably may be carried off by strong electrical shocks directed through the whole body. Terror suddenly excited has been known to effect a cure. The application of a perpetual blister to the os sacrum has in addition to electricity been found a valuable remedy. Dry cupping has in some instances been thought to have proved useful. In some cases of chorea, where from the frequency of the paroxysms a morbid condition of the brain has arisen, the insertion ofasetonin. the neck, and kept open for a considerable time, has been attended with a happy effect. Chorea has pretty generally been considered by systematic wri- ters as a disease of debility) and this opinion has been almost univer- sally adopted by practical physicians, inducing them to employ tonics, stimulants, and antispasmodics for its; cure ; but in main cases this has proved very difficult; and when not removed by the s "Order HI.J dance of st. vitus. 39.J change which the system undergoes at the age of puberty, the dis- ease has continued to harass the wretched sufferer ever afterwards. This fact being well established, we should undoubtedly regard the symptoms of chorea as sometimes depending on local irritation and not on debility; and in such cases they are to be obviated by removing the "causes of irritation, by scarifying the gums, by ex- pelling worms, or by a use of brisk purgatives. From some cases reported in the first number of the Edinburgh Medical and Surgical Journal, and which were received into the Royal Infirmary of that city, it appears that very complete cures were effected by the frequent exhibition of drastic purges, consisting of mercury and jalap. Irritation in the first passages no doubt had occasioned the chorea in these instances. A modern writer tells us,* that having met with many cases of chorea which he treated in the usual way, but without success, he was induced to desert the practice, and to consider the disease in a different light from that in which it had been commonly viewed. He conceived that the debility and spasmodic motions hitherto so much considered, might not be the leading symptoms of the dis- ease, but might depend upon previous and increasing derangement of health, as indicated by irregular appetite and constipation of the bowels. Under this impression he resolved to alter the mode of treating the disease, and began trying the effects of purgative medicines, given regularly in moderate doses. The success of the new practice established, he mentions, the justness of his opinion, and encouraged him to persevere with stea- diness and activity. To procure a discharge of the indurated and fetid faeces, he found it necessary to employ active and strong pur- gatives in the confirmed stage of the disease, given in successive doses in such a manner that the latter doses might support the effect of the former ; but in the first stage of chorea, while the in- testines yet retain their sensibility, and before the accumulation of faeces is great, gentle purgatives, repeated as the occasion may require, he experienced readily to effect a cure, or rather prevent the full formation of the disease. He mentions, that an occasional stimulus from purgatives will be requisite to support their due action, and to restore their healthy tone, even after a regular appe- tite for food, a more intelligent eye and lightened countenance, cheerfulness, increasing aptitude for firmer motions, the restoration of articulation, and the power of deglutition, and a renovation of flesh and strength succeed each other. The oleum terebinthinae in considerable doses has been adminis- tered with decided advantage in some cases of chorea ; and probably this may be owing to its acting as a powerful cathartic. —See Taenia. That a disordered state of the bowels is the only source of irri- tation capable of exciting chorea, cannot, I think, be admitted. ': ^ee Observations on the Utility of Purgative Medicine*, by Dr. Hamilton 394 neuroses, or nervous ]m«l:a»es. [Class U. although it may be aWowed a frequent one. Any other source of irritation in any organ of the system may be equally capable of exciting these convulsive motions. In the treatment of the disease, our object should therefore be to ascertain what is the cause of the present disturbance, and to prescribe accordingly. Some people, particularly women in a state of pregnancy, are very subject to spasmodic contractions of the joints, coming on periodically, and attended with very violent pain : for the removal of these, anodyne frictions appear to be the best remedy. RISUS SARDON1CUS, or SARDONIC LAUGH. In this disease there prevails a fit of laughing, arising from no evident cause, which continues often in a violent degree for three or four nights, so as to prevent the patient from sleeping. By its duration in this way, great debility is produced ; and frequency of the pulse and other febrile symptoms arise. It then either proves fatal by its violence, or goes off spontaneously. Antispasmodics, such as musk, castor, asafoetida, camphor, and aether, have usually been employed to remove the disease, but with- out effect, so that we are unacquainted with any remedy that will prove effectual, and the spontaneous cessation of the fit is more to be trusted to than any aid from medicine. Large doses of opium might probably afford some relief. TETANUS, or CRAMP. Tetanus is an involuntary and almost constant contraction of all or several of the muscles, while the senses remain perfect and entire. It may be considered as of two kinds, viz. symptomatic, the consequence of wounds, and idiopathic, occasioned by exposure to cold. In Europe, the traumatic species is almost the only form in which tetanus occurs, whereas between the tropics the idiopa- thic tetanus is by no means unfrequent. By practical writers, tetanic complaints have been distinguished into opisthotonos, emprosthotonos, and trismus, in allusion to the situation of the parts affected; but they are all evidently only different degrees of one and the same disease. These affections arise more frequently in warm climates than in cold ones. They attack persons of both sexes, of all ages, tem- peraments, and complexions, but the male sex more frequently than the female, and those of a robust and vigorous constitution oftener than those of a weak habit. An idea is entertained by many, that negroes are more predisposed to attacks of tetanus than white people ; they certainly are more frequently afflicted with it; but this circumstance does not arise from any constitutional pre- disposition, but from their being more exposed to punctures and wounds in the feet, by nails, splinters of wood, pieces of broken »lass, &c. from going usually barefooted. Order HI.] i-;ramp. 395 Tetanic affections are occasioned either by exposures to cold when under profuse perspiration, sleeping in the open air on damp ground, or by the presence of irritating substances in the stomach and bowels, such as worms; or by some irritation of the nerves, in consequence of local injury by puncture, incision, or laceration. Lacerated wounds of tendinous parts prove, in warm climates, a never-failing source of these complaints. In cold climates, as well as in warm ones, the locked-jaw, or trismus, frequently arises in consequence of various surgical operations, particularly the ampu- tation of a limb, or of gunshot wounds. Some cases have been recorded where trismus was supposed to be owing to affections of the mind. When the disease has arisen in consequence of a pucture. wound, or any other external injury, the symptoms show them- selves generally about the eighth day ; but when it proceeds from an exposure to cold, they generally make their appearance much sooner. In some instances tetanus comes on suddenly, and with great violence ; but it more usually makes its attack in a gradual manner ; in which case a slight stiffness is at first perceived in the back part of the neck, which after a short time becomes considerably increased, and at length renders the motion of the head both difficult and painful. With the rigidity of the head there is likewise an uneasy sensa- tion at the root of the tongue, together with some difficulty of swal- lowing ; and great tightness is perceived about the chest, with a pain at the extremity of the sternum shooting into the back. A stiffness also takes place in the jaws, which soon increases to such a height that the teeth become so closely set together as not to admit of the smallest opening. When the tetanic affection is confined to the jaws, the disease is called trismus. In some cases the spasmodic affection extends no further ; in others, the spasms at this stage of the disease, returning with great frequency, become likewise more general, and now affect not only the muscles of the neck and jaws, but likewise those of the whole of the spine, so as to bend the trunk of the body very forcibly back- wards, and this is what is named opisthotonos. Where the body is bent forwards, the disease is called emprosthotonos. During the whole course of the disorder the abdominal muscles are violently affected with spasm, so that the belly is strongly retracted, and feels very hard, most obstinate costiveness prevails, and both the flexor and extensor muscles of the lower extremities are commonly affected at the same time, so as to keep the limbs rigidly extended. The flexors of the head and trunk become at length so strongly affected as to balance the action of the extensors, and to keep the head and trunk so rigidly extended and straight as to render it incapable of being moved in any direction. The arms, which were little affected before, are now likewise rigidly extended, the tongue 396 neuroses or nervous diseases. [Class If. also becomes affected with spasm, and being convulsively darted out, is often much injured by the teeth, the jaws at that moment snapping together. It is to this state of the disease that the term of tetanus has been strictly applied. The spasms which recur at first every ten or fifteen minutes, besides being brought on by slight movements of the body and pressure on the abdomen, are, in the advanced stages, excited by the presentation of any substance, solid or fluid, to the lips, so as at first view nearly to resemble those in a person affected with rabies. Tetanus is seldom attended with either nausea or vomiting, or with any fever, but always with most violent pain. The disorder continuing to advance, every organ of voluntary motion becomes affected, the eyes are rigid andV immoveable in their sockets, the countenance is hideously distorted, and expresses great distress, the strength is exhausted, the pulse becomes irre- gular, and one universal spasm puts a period to a most miserable state of existence. With regard to the duration of tetanus, when it proves fatal it generally carries off the patient before the tenth day, but some- times before the fifth ; and the younger the subject, the more rapid the disease. When tetanic affections arise in consequence ©f a wound, punc- ture, or laceration, they are almost sure to prove fatal, as I never but once met with a recovery under such circumstances, during a very extensive practice and long residence in the West Indies. The lock-jaw arising in consequence of an amputation, or gun- shot wounds, likewise proves usually fatal. When these affections are produced by an exposure to cold, they may in most cases be removed by a timely use of proper remedies, notwithstanding a considerable space will probably elapse before the patient will be able to regain his former strength. Although there is sometimes a great abatement of the spasms in tetanus, still they are apt to return with renovated force. Dr. Parry* has remarked, that if, in an adult, the pulse by the fourth or fifth day does not reach 100 or 110 beats in a minute, he believes the patient almost always recovers: if, on the other hand, the pulse on the first day is 120 or more in a minute, few instances, he apprehends, will be found in which he will not die. This obser- vation respecting the acceleration of the pulse, has not, however, been confirmed by other practitioners. On dissections of this disease, slight effusions within the cranium have been observed in a few instances; but in by far the greater number nothing particular has been discovered either in the brain or any other organ. In some instances, however, the blood is not found in coagula, but fluid like molasses, as in animals killed by lightning, appearing to indicate that the whole muscular fibres of the arterial system had partaken of the general spasmodic action. ' See his Case^ of Tetanus and Rabies Contagiosa, p. 18 Order III.] CRAMP. 39; The bodies of tetanic patients run rapidly into putrefaction after death. It is stated by Baron Larrey, that in his examination of bodies of persons who have died of tetanus, he found the pharynx and oesophagus much contracted, and their internal membranes red, inflamed, and covered with a viscid reddish mucus. Others have discovered the intestines much inflamed, and in a few instances a yellow waxy fluid of a peculiar offensive smell covering their internal surface ;* but whether the inflammation was primary, or only a consequence of the pressure of the abdominal musles, which contract so violently in this disease, has not been decided. The inflammation in tetanus is however different from that observed in enteritis : in the latter, the intestines often adhere to one another by layers of coagulable lymph, recently thrown out; flakes of a curdled matter are frequently found, and pus is sometimes formed. In the inflammation attending tetanus, there are no adhesions ; nor is there any formation of pus. The nerves of tetanic patients have been examined after death, from the place of injury to their central termination, but no inflam- mation has been observable in any part of their course : the suppo- sition, therefore, of an inflamed nerve being the cause of tetanus^ ought to be rejected. Although our endeavours may not be crowned with success, where tetanus or trismus arises from a lacerated wound, or puncture in some tendinous part, still we should by no means suffer the patient to remain in so miserable a state of existence without making some efforts to afford even a temporary relief or allevia- tion of his sufferings. On being applied to for advice, the practitioner should endeavour in the first place to find out the cause which has given rise to the disease. If supposed to proceed from a wound or puncture, he ought carefully to examine the injured part, and to extract, as quickly as possible, any extraneous body that may have lodged therein, taking care at the same time to dilate or freely lay open the wound. These steps being taken, it may possibly be attended with some advantage to pour a small quantity of a strong solution of opium into the wound, dressing it afterwards with a little lint dipped in the same, and laying a pledget spread with some digestive ointment over the whole. Every time the dressings are renewed, the wound is again to be wetted with the solution. The partial division of a nerve being sometimes supposed to occasion tetanic affections, the practitioner ought, when this is suspected to be the case, to make a deep incision into the part which has been injured, so as to divide the tendinous and nervous fibres entirely, after which he should adopt the mode of treatment that has just been recommended. * See Medico-Chirursical Transactions, vol. vii. part ii. p. 4kP 398 .NEUROSES, OR NERVOUS DISEASES. [CldSS II. Pencilling the wound freely with lunar caustic, and afterwards covering it with a poultice of bread and milk, with the view to obtain suppuration as soon as possible, is another mode of proceed- ing which has been pursued in tetanus arising from external injury. Baron Larrey has recommended the application of a hot iron in these cases, promoting suppuration afterwards as speedily as possible by stimulant dressings.* Dr. Darwin recommendst the wound to be dilated, and then to fill it with lint moistened with spirits of turpentine, which brings on an inflammation in it, and thereby cures or prevents the convulsions. A case of trismus, which was successfully treated by Dr. Steven- son, of Baltimore, \merica, in this manner, is recorded in the 3d No. of the New Medical and Physical Journal, p. 220.—S. P. a stout plethoric black woman, aged about thirty-five years, in walking barefoot, chanced to tread upon a piece of glass, which wounded her foot near the first joint of the little toe. It bled copiously, and no attention was paid to it. It healed, as usual, in a few days after the accident. At the expiration of three weeks she was suddenly seized with a spasm in the muscles of the lower jaw, accompanied with intolerable pain, particularly near the coronoid and condyloid processes. This, in spite of large quan- tities of opium, increased, and a rigidity of the jaw superseded to such an extent, that she could not masticate her food. Two grains of opium were given every two hours without any alleviation of the symptoms. In this dreadful state the Doctor made an incision about half an inch deep, and an inch and an half in length, imme- diately above the cicatrix, in a transverse direction, and then poured strong spirits of turpentine into the wound. In a few minutes violent pain was created in the part; in half an hour the spasms left the jaw; and in a few hours more the rigidity entirely vanished. The pain in the wound became excessive, and continued so for four or five hours ; but the trismus was completely removed, nor did it ever recur. Little or no suppuration ensued, the wound healing by the first intention, or adhesive inflammation. Opium is the medicine which has been employed with the best effect in cases of tetanus ; but it should always be given in moderate doses at first, and so be increased gradually. In administering opium in this disease, the attention must, however, be directed to the effect that it produces on the patient, and not to the quantity which is taken, as many cases are on record, where an ounce of it in substance has been given in the course of twenty-four hours, the spasms having been very frequent and violent. By many it has been supposed that ,oining it with musk, cam- phor and aether, has greatly added to its effects. A combination of these medicines (as in the formulae belowj) had therefore best be * See his Military Surgery. t See Zoonomia, vol. iv. page 47. i 1. ft Moschi, gr. x. Spirit. Cinnam. f. 3U- Mistur. Camphorae, f. "j. t 1. Take Musk, ten grains. Spirit of Cinnamon, two drachma Camphor Mixture, one ounce. Order HI] CRAMP. 399 used, taking care to increase the quantity of opium in each suc- ceeding dose. The good effects of opium combined with James's powder, as also with ipecacuanha in some cases of tetanus arising from wounds, are attested by Dr. Latham, in the 4th volume of the Medical Transactions of the London College of Physicians. Giving the mild alkali internally, and administering opium at the same time in alternate doses, together with the use of a hot bath impregnated with potass, and a few ounces of quick-lime, is a mode of treatment much recommended by Dr. Stutz, of Suabia, in tetanus and trismus traumaticus.* An alternate internal use of opium and carbonate of potass is said to have been employed in the hospitals of Germany among the wounded soldiers in the late war with a most happy effect. The remedy is, therefore, worthy of our attention in tetanic affec- tions. In those cases where the jaws are so firmly locked together as to prevent a spoon from being introduced between them, and where the teeth are quite perfect in front, it will be necessary to extract some of them, for the purpose of giving the patient his medicines and food. When he loses the power of deglutition, opium is then to be administered in clysters. Besides giving opium internally, it may likewise be employed externally, by rubbing the parts frequently which are most affected by spasm with equal parts of the linimentum saponis and tinctura opii, or with the ointments prescribed below.t This mode of introducing opium into the system will more par- ticularly be necessary where the patient loses the power of swal- lowing ; and by being applied to the parts immediately affected, promises fair for affording essential relief. Dr. Mosely asserts,! that opiates applied externally are not of * See Medical and Physical Journal, vol. iii. p. 572, and vol. v. p. 472. X See his Treatise on Tropical Diseases, p 494. Tinct Opii, Til xxvj. M. ft. Haustus, 3tia vel 4ta hora sumendus. Vel, 2. B Misturae Camphorae, f. ^vjss. Spirit. jEther. C. f. gss. Tinct. Opii, f. 3ij. M. ft. Mistura, cujus sit dosis cochlearia duo magna tertiis horis. t 3. ft Opii Pulv. Subtilis, jj. Camphora?, gr. xv. Adipis Praeparat. Jss. M. ft. Unguentum. Vel, ■ 4. ft Adipis Praeparat. ^j, Olei Succin. f. £ss. Opii Pulverisat. 3ij. M. Mix them tincture of Opium, forty drops. Mix them for a draught, to be taken every third or fourth hour. Or, 2. Take Camphor Mixture, six ounces and a half. Compound Spirit of ^Ether, half an ounce. Tincture of Opium, two drachms. Of this mixture, the dose may be two table-spoonsful every three hours. t 3. Take Opium, reduced to a powder, one drachm. Camphor, fifteen grains. Prepared Lard, half an ounce. Mix them as an ointment. Or, 4. Take Prepared Lard, one ounce Oil of Amber, half an ounce. Opium, pulverized, twodrachmc 400 NEUROSES, OR NERVOUS DISEASES. [Class 11. the smallest utility either in the prevention or cure of tetanus. In this I must beg leave to differ from him, as, during my practice in the West Indies, I met with many instances where the most evident advantages were derived by using it in this way. To procure a relaxation of the spasms, it has been customary to make use of a wirm bath in conjunction with anodyne frictions, and occasionally a clyster of tobacco* has been administered about twice a day with success: but in all the instances of a recovery from tetanus which have taken place under my care, the cold bath was substituted instead of the warm. These, however, were cases (one excepted) which arose from exposures to cold. The plan generally pursued was, to throw a large pailful of cold water every two hours on the patient, after which he was wiped dry, and again put into bed ; an opiate draught, similar to what has been advised, was then given to him, and the parts most affected were well rubbed with a strong anodyne liniment. When he was so far recovered as to be able to swallow with facility, the cinchona bark was also given to him with a very free allowance of wine ; which course was pursued for a considerable time after the spasmodic affection had ceased. It has been recommended by some physicians to endeavour to excite a salivation by using mercury both internally and externally; hut I must say I never found it answer. My trials of it were, however, few ; for having experienced the method which I have recommended to be so very successful, in almost every instance where the disease arose from an exposure to cold, I should not have thought myself justified in losing time by using any remedy which was attended with uncertainty. Where mercury is employed in the cure of tetanus with the view of exciting a salivation, the patient should be put ndw and then into a warm bath ; and that he may have every chance of recover- ing, I would recommend a joint use of opium at the same time. In the Transactions of the College of Physicians of Philadelphia, vol. i. part i. is inserted a case of tetanus, from the extraction of two teeth, which was successfully treated by Dr. Rush, by a use of mercury and wine ; and others are elsewhere recorded on indispu- table authorities. In the New-York Medical Repository for 1797, is mentioned another case of tetanus arising from the puncture of a pin in the wrist, which was successfully treated by Dr. Hosack with wine (Madeira) alone; the woman having taken three gallons in a few days, in doses of a wine-glassful (containing about two ounces) every hour. It seems necessary to observe, however, that in this case the wound was freely pencilled with lunar caustic, after which it was covered with an emollient poultice. In those affections where inflammation of the system might be of service, Dr.Darwin thinks wine might be preferable to opium. He * See the Edinburgh Med. and Surgical Journal, No. 42, p. 1*98. 1 Order 1H.J cramp. iOl mentions, that he has observed a mixture of rectified spirit and warm water, given alternately with the doses of opium, has soonest and most certainly produced that degree of intoxication which was necessary to relieve the patient in the epilepsia dolorifica.* In most cases of tetanus arising from wounds in the limbs, it probably would be the best practice to amputate as soon as the symptoms appear. This plan is strongly recommended by Baron Larrey, who acted as surgeon-in-chief to the French army in Egypt and Syria ;t for he found that it succeeded in some instances after opium, camphor, and other remedies had been used in vain. Even where the case terminated fatally he found that the operation relieved the symptoms very considerably. When tetanus has proceeded from an exposure to cold, it is apt to be attended with some slight inflammatory symptoms; to remove which, bleeding is sometimes had recourse to, but it usually prove- injurious instead of beneficial. As costiveness is a constant attendant on tetanus, it should be obviated by the frequent exhibition of some active aoerientj whde the power of swallowing remains; and after it has ceased, by the regular exhibition of clysters. Of the utility of purgatives in cases of tetanus, whether idiopathic or occurring after wounds, there can be no doubt, and their efficacy is strongly enforced by Dr. Hamilton.|| The torpor of the intestines which precedes and accompanies this disease, is highly deserving of attention. In many instances the evacuations have not the appearance of faeces, but are nevertheless of a highly offensive nature. Among the remedies for tetanus, it may be proper to mention the oleum petrolei, or Barbadoes tar, which, by being taken internally. has been said in some instances to have effected a cure. Electricity is reported to have lately been employed in some cases of the locked-jaw with a happy effect. The remedy seems -herefore deserving of further trials. Throughout the whole course of all tetanic affections, the patient's strength is to be supported by wine, mixed with such things as he can easily swallow; and where this power ceases, nutritive clysters must be substituted. The trismus nascentium is a species of tetanus ; but this is inserted among the diseases peculiar to infants. Dr. James Clark, in his Treatise on West-India Diseases. •' See Zoonomia, vol. ii. p. 431. t See Relation Historique et Chirurgicale de I'Expedition de l'Armee d'Orient en Egypte et en Syrie, par D J. Larrey. || See bis Treatise on Purgatives. j 5. ft Infus. Sennce. f. ^jss. Sodae Sulph. f. |ss. Tinct. Jalapte, f. 3ij. Syrup. Bhamni, f. '"]. M. ft. Haustus i 5. Take Infusion of Senna, one ounce and a half. Sulphate of Soda, half an ounce. Tincture of Jalap, two drachms. Syrup of Buckthorn, one drachm Mix them for a draught 102 NEUROSES. OR NERVOUS DISEASES. [Class II. informs us, that, being unable to cure the symptomatic tetanus. he endeavoured to prevent it; and for this purpose, after wounds and punctures, he gave two or three grains of calomel twice a day ti!l a gentle salivation came on, and he pursued the same plan after operations. Out of fifteen patients after amputation, that were heated in this way, only one died, and he was in so irritable a state before, that bad consequences were dreaded. In those who had been wounded or punctured, that success was greater; two only having been lost out of a great number since this mode of practice was begun. To prevent tetanic affections from arising after wounds and chirurgical operations, I understand it is almost an universal practice on board of ships of war to mix tincture of opium with the dressings, and that since this practice has been adopted these complaints seldom occur. As a prophylactic, I should be much inclined to adopt this mode of treatment in preference to that proposed by Dr. Clark. SINGULTUS, or HICKUP. Hickups are a spasmodic affection of the stomach and diaphragm? arising from some peculiar irritation. They are in general symp- tomatic, but in some instances they appear as a primary disease. When they are idiopathic, they usually arise from an error in diet or from an acidity in the stomach. When symptomatic, they either come on towards the termination of some acute disease, attend on injuries done to the stomach and other viscera, or prevail as an affection attendant on hysteria. Hickups prevailing as a primary affection, are never attended with danger, and are in general easily removed ; but when the} arise in any acute disorder, or after a mortification has taken place. they may always be looked upon as the forerunners of death. The appearances on dissection will depend entirely on the dis- ease of which they have appeared as a symptom. A common hickup is often removed by taking a few small draughts of cold water, in quick succession, or by a sudden excite- ment of some degree of fear or surprise. When these simple means do not answer, recourse must be had to antispasmodics, the most useful of which for this disease seem to be aether, musk, and opium. These may either be combined together, or be given separately. In the accidental hickup of youth or of very old people, a pretty certain remedy is a small quantity of any powerful acid, such as a tea-spoonful of vinegar or lemon-juice, or a little peppermint-water acidulated with a few drops of sulphuric acid. Where hickups prove violent as well as obstinate, the application of a large plaster of Venice treacle to the patient's stomach some- times affords relief: but should it fail, a blister may then bo sub- stituted. Order Ul.J HOOPING-COUGH. 10.' Hickups sometimes proceed from an acidity in the stomach, and iience it is that infants are very apt to be affected with them. When they arise from this cause, a little prepared chalk or mag- nesia joined with some carminative, such as the oleum anisi, will he the most proper medicine. When hickups arise at the close of any acute or malignant disease, or in consequence of a mortification, no advantage can be obtained from medicine, or any other means whatever. PERTUSSIS, or HOOPING-COUGH. Pertussis is a convulsive cough, interrupted by a full and sono- rous inspiration, and returning in fits that are usually terminated by a vomiting or expectoration. In its first stage, it may be con- sidered as a febrile disease. Children are most commonly the subjects of pertussis, and it seems to depend on a specific contagion, which affects them but once in their life. The disease being produced, the fits of cough- ing are often repeated without any evident cause ; but in many cases the contagion may be considered as only giving the predis- position, and the frequency of the fits may depend upon various exciting causes, such as violent exercise after a full meal, the having taken food of difficult digestion, and irritation of the lungs by dust, smoke, or disagreeable odours. Emotions of the mind may like- wise prove an exciting cause. Pertussis often prevails epidemically, but does not, in this re- spect, appear to be influenced by any particular season of the year. It has however been observed to be niuch milder in warm climates than in cold ones ; and it would seem, in conformity to this law, that the disease is found to be more severe in this country during autumn and winter, than during spring and summer. It arises generally from contagion, it is true ; still it must be allowed that there is a principle independent of contagion capable of producing the complaint, and that this principle undoubtedly exists in the at- mosphere, which it pervades to a certain extent; but what it is, and how formed, remains a curious subject for physical research. The proximate or immediate cause of pertussis seems to be a viscid matter or phlegm lodged upon the bronchiae, trachea, and fauces which sticks so close as to be expectorated with the greatest difficulty. Some have supposed it to be a morbid irritability of the stomach, with increased action of its mucous glands ; but the affec- tion of the stomach which takes place in the disease, is clearly only of a secondary nature, so that this opinion must be erroneous. The hooping-cough usually comes on with an oppression of breathing, some degree of thirst, a quick pulse, and other slight febrile symptoms, which are succeeded by a hoarseness, cough, and difficulty of expectoration. These symptoms continue perhaps for a fortnight or more, at the end of which time the disease puts on • prescribed for this purpose, when judged necessary. Possibly a tepid bath, by eliciting the blood to the surface of the body, might prove useful in relieving the central organ of circulation from the load with which it is oppressed. Perfect quietude, a free access of pure air, the supine posture and frictions of the extremities, will assist the heart in recovering its accustomed rate of action. Should the paroxysm at any time assume the appearance of actual deliquum ; it may be expedient to apply the spirit of ammonia to the nose, or to sprinkle the face, neck, and breast, with vinegar and water, or with sulphuric aether. If the cessation of the vital principle continues long, or appears very complete, the application of a large blister to the chest will be advisable. In very desperate cases we may venture to pass slight electric shocks through it, rubbing the limbs at the same time with stimulating embrocations. Our exertions are to be con- tinued on such occasions until unequivocal signs of real death are obvious, or the patient is reanimated. With the view of rousing the patient during a state of fainting, or whilst he is just recovering from this condition, wine and other cordials have been administered by some practitioners, but there is reason to doubt if they have proved beneficial.* In the case of the late Mr. John Hunter, and reported by Sir Everard Home, it was evident that stimuli were not attended with a good effect. Both at the commencement of the spasm, and while it was on him, it appears that recourse was had to the camphor julep, but no relief was obtained. He tried Hoffman's anodyne liquor in the dose of a tea-spoonful, but not finding it to answer alone, joined it to the camphor julep. The spasms, however, seemed to be more violent. One night he took twenty drops of the tincture of opium, which occasioned his head to be greatly confused the next day, but did not at all abate the spasms. Not having drank wine for four or five years, he was advised to try it, which he complied with, but found the spasms more readily brought on after using it, than on those days in which he drank none. After eating a hearty meal they were more readily produced. * See Observations on Diseases of the Heart, by Mr. Allen Burns. ----./Ether. Sulph. nT. xx. Tinct. Lav. C. fiT. x. M. ft. Haustus. Vel, 2. ft Aq. Pimentae, f. 3yj. Tinct. Card. C. f. 3y. Cinnam. C. f 3'. Spirit Ammon. Aromat. Til x. M. d. Haustus. -----Sulphuric iEther, thirty drops. Compound Tincture of Lavender; fifteen drops. Mix them for a draught. Or, 2. Take Pimenta Water, six drachms. Compound Tincture of Carda- mom, two drachms. ----------------Cinnamon, one drachm. Aromatic Spirit of Ammonia, fif- teen drops. Mix them to be taken as a draught. 416 neuroses, or nervous diseases. [Ciass If. Where the sleep is interrupted considerably, the extract of hyoscyamus, or some of the preparations of the humulus lupulus, (see Mania) may be tried instead of opium, should this drug produce an injurious effect. It has been observed, that angina pectoris is a disease always attended with considerable danger, and in many instances has proved fatal under every mode of treatment. We are given, however, to understand, by Dr. Macbride,* that several cases of it have been treated with great success, and the disease radically removed by inserting a large issue in each thigh. These, therefore, or instituting a sufficient and permanent drain from the region of the heart, should never be neglected. In one case, with the view of correcting or draining off the irritating fluid, he ordered instead of issues a mixture of lime water, with a little of the spiritus juniperi comp. and an alterative proportion of Huxam's antimonial wine, together with a plain, light, perspirable diet* From this course the patient was soon apparently mended; but it was not until after the insertion of a large issue in each thigh that he was restored to perfect health. Dr. Darwin likewise makes mention,! that four patients who laboured under the angina pectoris in a severe degree, were all recovered, and continued well three or four years, by the use (as he believes) of issues on the inside of each thigh, being large enough at first to contain two peas each, but afterwards only one. They took besides some slight antimonial medicine for a short time. Two remarkable cases of this disease are recorded in the sixth volume of the Medical and Physical Journal, which were cured by applying pieces of calico to the sternum, wetted with a solution of tartarized antimony in the proportions mentioned below,J several times a day. The stimulus from this application produced an uncommon and violent eruption on the skin in a short time, having the peculiar malignant appearance of carbuncles, itching and smarting excessively, many of which suppurated, while hundreds were continually rising up, some as large as peas, others as small as pins' heads. As soon as the eruption appeared, considerable relief from the spasmodic affections was obtained in both instances, and the patients went on gradually recovering, after continuing the remedy two or three times a day for about a month. Having pointed out the best means for moderating and removing the paroxysms of angina pectoris, it is proper to notice those from a rigid and steady adherence to which, such as are subject to its attacks will experience much benefit, and these be prevented from proceeding to any alarming extent. c- See Medical Observations and Inquiries, vol. vi. t See Zoonomia, vol. iv. p. 43. i 3. ft Antimon. Tartar. 3j. |3.TakeTartarized Antimony,onedrachm. Aq. Fervent Oj. ' Warm Water, one pint. ?nirit. Camphora?,f. ?ss. M. Camphorated Spirit, half an ounce.. Mix them. 417 Order 111] palpitation/ The patient should sedulously shun every source of mental inquietude and irritation, and the circulation be vigilantly guarded from the influence of sudden gusts of passion. Moderate exercise in the open air, particularly on horseback, which will be preferable to walking and not likely to bring on a fit, if the rider will be content with a moderate pace, should daily and regularly be taken. but no violent or long continued corporeal exertion should be attempted ; nor should rising ground ever be ascended on foot without the utmost deliberation and care. Plain food, easily digestible, and not prone to fermentation in the stomach, should be made use of in small quantities at a time, being carefully masti- cated, and deliberately swallowed. All fermented liquors will be improper. Gastric distention is indeed a very frequent concomitant upon organic diseases of the heart, and a source of great uneasi- ness and distress to those who labour under them. The occur- rence of this symptom may, however, be obviated by abstinence from fermentable aliment; and when existing may be palliated, or removed by the judicious exhibition of the mineral acids, by the carbonate of soda or potass, and by the aromatic spirit of ammonia m combination with bitters. Whenever the patient perceives any tendency to plenitude in the vascular system, he should -rigidly adhere to a low and abstemious regimen, and occasionally take some purgative, such as the submuriate of mercury and jalap conjoined with a little ginger or any other aromatic. At all times the bowels should be kept regular, and one or two daily evacua- tions be procured. Some relief possibly may be obtained by keeping up a permanent counter-irritation and discharge on the surface, as near as possible to the seat of the disease, by means of a perpetual blister, or by a seton passed through the integuments over the region of the heart. Warm bathing and friction of the extremities might also prove useful, by promoting circulation in ™e Am,b.s' and determining to the surface of the body, thereby diminishing the fulness of the heart and large vessels. As a medicine, pills composed of carbonate of soda, sulphat of iron and extract of gentian, may be taken twice a day with an infusion of ginger. PALPITATIO, or PALPITATION. This disease consists in a vehement and irregular motion of the heart, and is induced by organic affections, a morbid enlargement of the heart itself, or of the large vessels, a diminution of the cavi- ties of its ventricles from inflammation or other causes, polypi ossification of the aorta or other vessels, plethora, debility or mobility of the system, malconformation of the thorax, and many of the causes inducing syncope. During the attacks the motion of the heart is performed with greater rapidity, and generally with more force than usual, which •s not only to he felt with the hand, butmav often be perceived bv M 418 -\EUROSES, OR PEJBRILi. VlsEA^Es. [Class IL the eye, and in a few instances even be heard ; there is frequently dyspnoea, a purplish hue of the lips and cheeks, and a great variety of anxious and painful sensations. In some instances the complaint has terminated in death, but in many others it is merely symptomatic of hysteria and other nervous disorders. In the treatment of this disease, it should be our study, if pos- sible, to find out the exciting cause, and to remove this. If it arises from plethora, bleeding with purgatives and the rest of the antiphlogistic course should be adopted ; if from debility, bitters with chalybeates and cold bathing, &c. will be proper; when symtomatic of any nervous disorder, aether, castor, musk, and other antispasmodics, conjoined with tonics, will be advisable. As the disease, however, arises from an organic affection of the heart itself in many instances, or of the aorta, or other large vessels connected with it, all that may be in our power in such cases will be to caution the patient against exposing herself or himself to such circumstances as may increase the action of the sanguiferous system, particularly fits of passion, sudden surprises, violent exer- cise, or great exertions of the body. ASTHMA. This disease is a spasmodic affection of the lungs, which comes on by paroxysms most generally at night, and is attended by a frequent, difficult, and short respiration, together with a wheezing noise, tightness across the chest, and a cough; all of which symptoms are much increased when the patient is in an horizontal position. Asthma rarely appears before the age of puberty, and seems to attack men more frequently than women, particularly those of a full habit, in whom it never fails, by frequent repetition, to occa- sion some degree of emaciation. Dyspepsia always prevails, and appears to be a very prominent feature in the predisposition. Its attacks are most frequent during the heats of summer, and in winter when heavy fogs or sharp cold winds prevail. When the disease is attended with an accumulation and discharge - of humours from the lungs, it is called the humid asthma; but when it is unaccompanied by any expectoration, it is known by the name of the dry or spasmodic asthma. On the evening preceding an attack of asthma, the spirits are often much affected, and the person experiences a sense of fulness about the stomach, with lassitude, drowsiness, and a pain in the head. On the approach of the succeeding evening he perceives a sense of tightness and stricture across the breast, and a sense of Ktraightness in the lungs impeding respiration. The difficulty of breathing continuing to increase for some length of time, both inspiration and'expiration are performed slowly, and with a wheez- Order HI.] ASTHMA. 419 ing noise ; the speech becomes difficult and uneasy, a propensity to coughing succeeds, and the patient can no longer remain in an horizontal position, being as it were threatened with immediate suffocation. These symptoms usually continue till towards the approach of morning, and then a remission commonly takes place ; the breath- ing becomes less laborious and more full, and the person speaks and coughs with greater ease. If the cough is attended with an expectoration of mucus, he experiences much relief, and soon falls asleep. When he awakes in the morning he still feels some degree of tightness across his breast, although his breathing is probably more free and easy, and he cannot bear the least motion without rendering this more difficult and uneasy; neither can he continue in bed, unless his head and shoulders are raised to a considerable height. Towards evening he again becomes drowsy, is much troubled with flatulency in the stomach, and perceives a return of the diffi- culty of breathing, which continues to increase gradually till it becomes as violent as on the night before. After some nights passed in this way, the fits at length moderate, and suffer more considerable remissions, particularly when they are attended by a copious expectoration in the mornings, and that this continues from time to time throughout the day ; and the disease going off at last, the patient enjoys his usual rest by night without further disturbance. During the fits the pulse is not usually much affected, hut in a few cases there is a frequency of it, with some degree of thirst, and other febrile symptoms. In some persons the face becomes turgid and flushed during the continuance of the fit, but more commonly it is pale and shrunk. Urine voided at the beginning of a fit is generally in considerable quantity, and with little colour or odour; but after the fit is over, what is voided is in the ordinary quantity, of a high colour, and sometimes deposits a sediment. Asthma, but more particularly the spasmodic, is brought on by almost every thing which increases the action of the heart; and which stimulates and fills the vessels of the mucous membrane. Thus it is produced by intense heat, by lightness of air, by severe exercise, by strong mental emotions, by full meals, by stimulating drinks, by exposure to cold and atmospherical influence, and by certain effluvia, as those of hay, whether new or old, of sealing wax, and other burning substances. Congestions of blood, or of serous and pituitous humours in the lungs, noxious vapours arising from a decomposition of lead or arsenic, impure and smoky air, cold and foggy atmosphere, sudden changes of temperature, scrofulous, rheumatic, gouty, psoric and scorbutic acrimony; dyspepsia or irritation in some of the abdominal viscera, but particularly in the stomach; irritation r>f the bronchial svstem bv aerial acrimonv or other canoes, sup- 420 NE«R0SES, OR VERVOtLS WISEASEji. [0aSS H. pression of long accustomed evacuations, frequent catarrhal at- tacks, erratic gout, general debility, water in the chest, aneurisms, polypi, or concretions of grumous blood in the large vessels, and the like, are the causes from which this formidable disease may arise in different individuals. In some instances it proceeds from an hereditary predisposition, and in others from malconformation of the chest. Asthma having once taken place, its fits are apt to return peri- odically, and more especially when excited by certain causes, such as by a sudden change from cold to warm weather, or from a heavier to a lighter atmosphere ; by severe exercise of any kind, which quickens the circulation of the blood; by an increased bulk of the stomach, either from too full a meal or from a collection of air in it; by exposures to cold, obstructing the perspiration, and thereby favouring an accumulation of blood in the lungs; by violent passions of the mind; by disagreeable odours ; and by irritations of smoke, dust, and other subtile particles floating in the air. A consequence of convulsive motions is the^abit of repetition, the muscles have contracted by laws peculiar to the animal economy; so asthma is believed to depend frequently upon this cause. The proximate or immediate cause of the disease has, by Dr. Cullen, and most other writers, been supposed to be a preter- natural or spasmodic constriction of the muscular fibres of the bronchia?, which not only prevents their being so dilated as to admit of a free and full inspiration, but also gives them a rigidity, which interferes with a free and full expiration. This doctrine has, however, been disputed by Dr. Bree, who, in a very ingenious treatise on this disease, offers it as his opinion, that irritation seated within the air-cavities, and arising either from an effusion of serum, or from a«rial acrimony, is the true proximate cause of convulsive asthma. The mucus which is excreted in the course of the disease, and which has been looked upon by Dr. Cullen and others as only an effect, Dr. Bree views as a prominent cause of the paroxysm ; or, when it is absent, only yielding to a different cause equally irritating to the organ, and exciting spas- modic contractions of the respiratory muscles. Dr. Darwin says, that whatever may be the remote cause of the paroxysms of asthma, the immediate cause of the convulsive respi- ration, whether in the common asthma, or in what is termed the convulsive, which are perhaps only different degrees of the same disease, must be owing to violent voluntary exertions to relieve pain, as in other convulsions ; and the increase of irritability to internal stimuli, or of sensibility during sleep, must occasion them to commence at this time. Asthma usually diminishes as soon as a mucous secretion begins to take place, and is more speedily and effectually relieved by a spitting of blood. These frets are convincing proofs of a prefer- Ord Enema- l.Mij tliem forach -ifjr. 424 NEURONES, OK NERVOUS l>l!iEASE.->. [Class 11* Of this class, aether and opium have been found most useful, and particularly the latter ; but its value is frequently much enhanced by combining it with the former, as below.* These medicines seem however to have no certain efficacy in shortening the paroxyms, except in those cases where the disease arises from a preternatural mobility or irritability of the lungs, or is continued from habit. In these instances they may prove highly serviceable, but in no others. The fetid gums, particularly asafoe- tida,! have also been much employed in those cases of asthma where spasmodic difficulty of breathing is obvious. Dr. Bree mentions, " that having been afflicted with asthma, he took during a paroxysm of the first species four grains of solid opium, which produced nearly an apoplectic stupor for two days. After a few hours, the most debilitating sickness came on, with incessant efforts to puke. The labour of the respiratory muscles was abated, but the wheezing evidently increased ; a countenance more turgid than usual, and intense headach attended. The pulse was increased in strength and quickness for a few hours, but then sunk into great weakness." He further observes, " that the paroxysm showed itself four hours earlier than usual the next day, and two grains more were taken when it was perceived to commence ; respiratory labour seemed again to abate, but the anxiety increased to an alarming degree as the stupor became less. The pulse was now weaker, and fre- quently irregular. Loose motions succeeded, and a general sweat. The energy of the paroxysm then revived with exquisite distress. A medical friend, who attended with great care to the progress of these trials, became alarmed, and endeavoured to promote puking without effect. Blisters were applied, and draughts of vinegar and pepper were given, interposed with strong coffee and mustard. The patient was at last brought back to a state more usual in former paroxysms: but with every care, the exacerbations were no fewer than nine, before expectoration, becoming gradually more copious, concluded the fit. Notwithstanding the bad success of this experi- ment, opium was used in another paroxysm after an active vomit, and bad consequences still ensued, though not so extensively." As the free passage of air to and from the lungs is obstructed in * 2. ft Mistura Camphor, f. 3x. Spirit. iEther. Sulphuric. HI xxv. —xl. Tinct. Opii, III x. M. ft. Haustus, 4tavel6ta quaq. hora sumen dus t 3- JJ Misturae Asafoetida?, ------Camphorae, aa 3yj. Spirit. iEther. Sulph. Ill xx. Tinct. Opti, flivj. M. ft. Haustus. quartis vel sextis horis capien- do. * 2. Take Camphor mixture, ten drachms.1 Spirit of Sulphuric Mther, forty to sixty drops. Tincture of Opium, fifteen drops. Make them into a draught, to be taken every four or six hours. t 3. Take Asafoetida Mixture, Camphor Mixture, of each six drachms. Spirit of Sulphuric iEther, thirty drops. Tincture of Opium, nine drops, Mix them, and let this draught be taken every four or six hours Order HI. asthma. 425 the first species ol asthma by a lodgment of mucous matter, the expulsion of this should be promoted by pectorals, such as gum ammoniac, squills, &c. combined as below,* or as prescribed under the head of Peripneumony ; but oily demulcents ought to be avoided as being injurious. A decoction of madder-root has in some cases been used as an aftenuant and expectorant with a good effect. In most cases of asthma, dyspepsia is a prominent symptom, and the patient is much'troubled with flatulency of the stomach, acidi- ties, and other symptoms of indigestion. To remove these, it will be necessary to make use.of absorbents with stomachics and bitter infusions, as recommended under the head of Dyspepsia. Dr. Bree observes, that chalk and opium will astonish the asthma- tic, by the excellence of their effects, when the irritation proceeds from dyspepsia of the first passages only. Vinegar separately exhibited was likewise found by him to counteract the flatulence and distention of the stomach. Diaphoretics, such as tartarized antimony, &c. are a class of medicines which may prove useful in that species of asthma which is dependant upon pulmonic irritation of aerial acrimony, by pro- moting exhalation from the vessels of the lungs. Small doses of opium may be conjoined with a good effect, as in the pulv. ipecac c. and the patient should not be subjected to the influence of irri- tating causes, such as are known to exist in towns and manufac- tories. Warm pediluvia may likewise be ordered. The digitalis is a medicine which has lately been administered in asthma. In the fourth volume of the Medical and Physical Jour- nal, page 329, mention is made of a case by Dr. Sugrue, of Cork, in which its salutary effects were speedily and decisively produ- ced. The tincture (as advised to be prepared by Dr. Darwin) was the preparation had recourse to, and this was administered in doses of fifteen drops, repeated twice a day. We are informed that when * 4. Take mixture of Ammoniac, four ounces. Oxymel of Squill, three drachms. Solution of Tartarized Antimony, forty-drops. Distilled Vinegar, half an otince. Of this mixture let two table-spoonsful be taken occasionally, or when either the cough or shortness of breath is trouble- some. Or, 5. Take mixture of Ammoniac, one ounce. Solution of Acetate of Ammonia, two drachms. -------- Tartarized Antimony, fifteen drops. Syrup of Tolu, one drachm. Mix them, and take the draught every six ihoursw Or, 6. Take Compound Squill Pills, two,con- pnune uuae, stxms jkjhs capienuce. sisting of five grain* each, every six hours an * 4. p£ Misturae Ammon. f. ?iv. Oxymel. Scillae, f. 3iij- Liquor. Antimon. Tartariz. tlX-xxyj. Acidi Acetic, f. ?ss. M. ft. Mistura, cujus sumat cochl. ij. suhjnde, vel urgenti tusse aut dyspnoea. Vel, 5. I£ Misturae Ammoniac, f. ?i. Liquor. Ammon Acetat. f. 3 he is incapable of enduring light, or the motion of air; his respira- tion is laborious and uneasy, but his judgment is unaffected, and as long as he retains the power of speech his answers are distinct. In some few instances a severe delirium arises, and closes the tragic scene; but it more frequently happens that the pulse becomes tremulous and irregular, that convulsions arise, and that nature, being at length exhausted, sinks under the pressure of misery. Our prognostic in this disease must always be unfavourable, as in most instances all means whatever have proved ineffectual. Death commonly takes place about the third or fourth day from the first appearance of the symptoms. The appearances to be observed in the human species on dissec- tion in hydrophobia are unusual aridity of the viscera and other parts; marks of inflammation in the lower portion of the oeso- phagus and cardiac extremity of the stomach, and even in the stomach itself. Some marks of inflammation are likewise to be observed in the brain, consisting of a serous effusion on its surface, or in a redness of the pia mater; which appearances have also presented themselves in the dog. Now and then we meet with an accumulation or effusion of blood in the lungs. In some cases of dissection, not the least morbid appearance has been observed either in the fauces, diaphragm, stomach, or intestines. The poison has therefore been conceived by some physicians to act upon the nervous system, and to be so wholly confined to it, as to make it a matter of doubt whether the qualities of the blood are altered by it or not, or whether the poison at ail enters the system by the absorbents. As far as my knowledge extends, the lymphatic glands in the course of absorption have never been found diseased. On the developement of the symptoms of hydrophobia, the pain beginning in the bitten part appears indeed to follow rather the course of the nerves than that of the absorbents. On opening rabid animals, slight marks of inflammation about the epiglottis and pylorus, with occasionally some livid marks in the villous coat of the stomach, are now and then to be observed, but sometimes* no appearances of inflammation either in the sto- mach or elsewhere are to be observed, on inspecting the bodies of these animals. As in rabies, when once manifested in the system, the power of medicine and all human skill have failed in most instances, our views should be early directed to prevent the accession of the disease : and for this purpose the most effectual is excision of the wounded part, with free ablution and scarifications. Immediately, therefore, on the infliction of the bite, or as soon afterwards as possible, ablution with water and soap should be had recourse to, and be continued until professional aid is procured. On the arrival of the surgeon, a free and complete excision of the bitten part is to be made, taking care to carry the knife to a sufficient depth, so as to ensure iis complete removal. The excised part bcincf removed. 436 \EUR0S*ES. OR NERVOUS DISEASES. [Class If. ought carefully to be examined to see if there is any place in the piece through which the dog's teeth appear to have passed; and in case there is, -the excision ought to be carried still deeper than before. Should the-knife, on a close examination, appear to have entered the wound made by the dog's teeth, it may be advisable to recommence the operation with a clean knife, lest the other should be contaminated by its having entered the wounded parts, and by which the sound ones might become inoculated with the canine virus. The sooner that the wounded part is extirpated after the accident the better; but it will be right to do it even at the distance of seyeral days, rather than that the person should be debarred of the chance which excision affords, as there is great reason to presume that the canine poison does not enter the system so quickly as a variety of others are perceived to do.* This conclusion we are somewhat authorized to draw, as in several well-attested cases, many weeks, nay months, have intervened between the accident of w being bitten, "and the appearance of the disease. If the bite be of , long standing, and the wound consequently cicatrized, and there be a certainty that the animal by which it was inflicted was really rabid, it should immediately be laid open, cauterized, and caused to suppurate. Dr. Darwin observes,t that if the patient is bitten in a part which could be totally cut away, as a finger, even after the hydro- phobia appears, it is probable it might cure it, as he suspects the cause still remains in the wounded tendon, and not in a diffused infection tainting the blood. Hence there are generally uneasy?^ sensations in the old cicatrix before the hydrophobic symptoms commence. Even in cases where assistance has not been requested until the consequent disease had already appeared, I am of opinion that the wounded parts should be excised: for if the excision of the part, in which the virus of small-pox, syphilis, or any similar disease is deposited, after the local action has evidently com- menced, prevents absorption, and consequently the complete formation of the general disease; what reason is there for sup- posing that the same effect would not result from this operation, at the same period, in the case of the bite of a rabid animal, if the poison enters the system by the absorbents. After excision, ablution is again to be performed with a solution of volatile alkali in water, and when the flow of blood begins to cease, suction with the cupping-glass may be resorted to. The alternate employment of ablution and the exhaustedjreceiver may be continued for some hours. Having proceeded thus far. caustic, such as the argenti nitras, or potassa fusa, may be applied to the wound, so as to produce a slough in the first instance, and after- * See Mr. Gillman's Prize Dissertation on the Bite of a Rabid Animal, + See Zoonomla, vol. iv. p. 50. Order III.] canine madness. 437 wards a purulent discharge for some weeks. By this mode of treatment many persons have been known to escape the disease : while others who have been bitten by the same animal, and who neglected these means, have become affected. It sometimes happens that the wounded or bitten part is so situated as not to admit of excision, or from the timidity of the patient he cannot be persuaded to submit to the operation. Under this dilemma we must be content to have recourse to a careful and persevering ablution, and afterwards to scarification and cupping, bathing the parts with warm water to promote a free flow of blood, and to assist in washing away any remaining particle of the poison. With respect to the fluid to be employed at first in the ablution, a weak solution of volatile alkali, in the proportion of one part of the alkali to four of water, may be as proper as any we can use. With this solution, which is fully capable of dissolving the saliva, the wounded part should be freely washed, and injections with a syringe forcibly be made into the wound. After this, water may- be substituted to assist in washing away any remaining particles of the canine poison. Having washed the wound for a considerable time, it may be touched with caustic, the argenti nitras, or the potassa fusa. Ligatures above and below the wounded part have been recommended during the ablutions by Dr. Percival, when they can be put on. The bitten part must be destroyed to the bottom, by repeated applications of the caustic. To assuage the inflammation caused thereby, the wound is to be dressed for some time with poultices; and afterwards with acrid dressings and hot digestives, to remove the eschar, create a discharge, and drain the injured parts. Where there has been any delay after the accident, the wound should thus be kept open for two or three weeks, or even longer. From some experiments made by Dr. Linke, of Jena, with the saliva taken from a mad dog after it was dead, and that had bitten other animals with a fatal effect, the external application of a strong solution of white arsenic in water to wounds besmeared with the poison, appears to have been attended with the happy effect of destroying the virus, and of preventing the disease from taking place. The remedy seems therefore worthy of further trials in wounds made by rabid animals. Under the head of Animal Poisons it is mentioned that the external application, as well as the internal exhibition of the liquor ammonias, was found on many trials entirely to do away the inju- rious consequences arising from the bite of the cobra de capello. a snake of the most venomous kind, and productive of symptoms pretty similar to those arising from a rabid animal. The same remedy would, therefore seem worthy of atrial incases of hydro- phobia ; but as there would be great difficulty in administering caustic volatile alkali in a state necessarily diluted with some mild bland liquor, where the increased sensibility of the fauces and the dread of liquids are so strongly felt, we might convey it into the i3b NEUROSES, OR NERVOUS DISEASES, [CldSS II. stomach in the manner practised by Mr. John Hunter, and herein- after mentioned, or we might mix the volatile alkali with crumbs of bread, and form the mass into pills, or a bolus. In addition to these modes of prevention, it has strongly been recommended to commence, very speedily, a course of mercurial unction, which is to be continued regularly, and to be applied in a considerable quantity at once, so as to occasion some degree of salivation ; to expedite which, the submuriate of mercury may be given internally night and morning, and warm bathing be used occasionally. Mercurial fumigations may also assist. With the design of exciting a rapid salivation in hydrophobia, Dr. Darwin has suggested that one grain and a half of the hydrar- gyri oxymurias dissolved in half an ounce of rectified spirit may be given frequently to the patient with a prospect of advantage. From a paper by Mr. Addington, of West Bromwich, inserted in the Contributions of Medical Knowledge published by Dr. Beddoes, it appears that a similar mode is adopted by him for the cure of gonorrhoea virulenta, and that he has cured hundreds in a very short time in this manner, without the least disagreeable conse- quence. He directs us to proceed as follows: three grains of hydrargyri oxymurias are to be dissolved in one ounce of rectified spirit. Half of this mixture is to be taken undiluted at going to bed ; it produces a copious salivation for an hour and a half, or longer, during which the patient spits about a quart. Some ape- rient salts are to be taken on the second day after this operation. and on the evening of that day he is to repeat the draught, and the salts on the day but one following. Dr. Thomas Reid, in a pamphlet which bears the title of Obser- vations on the Application of warm and cold Sea-bathing, recites a case which strongly attests the preventive effect of mercury. He makes mention, that a man, a woman, and several dogs, were bitten by a supposed mad dog, who was soon after destroyed. A fortnight after the accident, he saw them ; the woman was slightly wounded in the little finger, a black scab remained on the punc- ture : she had great pain in the arm, shooting up to her head, particularly in the night, with disturbed and frightful dreams, and great depression of spirits. The man had been bitten in the hand also, but had not so much pain. He directed mercury for them in the manner published by Dr. James. In a few days the symp- toms abated; and as the woman's mouth was sore, she desisted from using it. The pain, however, returned very soon, greatly- augmented, and affected her head ; she resumed" the medicine, and every symptom vanished ; they both remained perfectly well. Had any return of the disease taken place, he is certain he would have been informed of it. Dr. Reid further mentions, that the same medicine was given to dogs; but by some accident one of them was forgotten, and took none; he became raving mad the. thirtieth day, and in that state he had him shot; all the other dogs remained well, except a Order 1II.J canine mabneso. 439 small lap-dog, which died of the salivation. Neither the man nor woman supposed the dog to have been mad, until they began to take the medicine ; the mind had therefore no influence in pro- ducing the symptoms that ensued. These facts seem well authenticated, and strongly attest the good effects of mercury, when used at an early period. During the actual presence of the disease, its inutility has been proved in numberless instances. Dr. Mosley* has, indeed, recorded a case of recent hydrophobia, and timely discovered, which was successfully treated by exciting a rapid and plentiful salivation by means of an ounce of strong mercurial ointment rubbed into different parts of the body at four frictions within forty-eight hours. Dr. Richard Pearson, of Birmingham, in his Treatise on Hydro- phobia, offers it as his opinion, that'if the disease has ever been cured by mercury, it has been in consequence of a counter-impres- sion communicated to the whole system, and not in consequence of the salivation ; for a salivation is a constant symptom of the disease, so that if it were curable by a flow of spittle, it would cure itself. This seems, however, a vague mode of reasoning. Although medicine has hitherto proved ineffectual in most of the cases where the disease had fully established itself, still it is neces- sary to mention the plan which has usually been pursued on such occasions. From certain symptoms which attend on hydrophobia, such as heat, thirst, restlessness, fever, difficulty of breathing, priapism, watchfulness, and furor; from the inflammatory appearances usually .j*'observed on dissection, and from the successful employment of venesection in some supposed cases of rabies, this remedy has been much used by many practitioners. Where the true characteristics of the disorder were really pre- sent, it had not heretofore afforded relief; but two successful cases have lately been reported in the 167th No. of Phillips's Medical Journal, by Dr. Shoolbred, of Calcutta, in which bleeding ad deli- quium animi, and repeating the operation at intervals as long as firmness of arterial action or the symptoms of hydrophobia remained, completely removed the disease. In these instances, venesection was resorted to immediately on the disorder becoming apparent. The cure in these cases, although attributed by Dr. Shoolbred to blood-letting alone, has by some been supposed to be owing to the combined use of mercury at the same time. The trials which have as yet been made of the depletory practice in Europe are too limited and defective to admit of their being received as decisive of the question as to the utility of copious bleeding at the onset of rabies. The operation should be performed as soon as the wound reassumes an inflamed appearance, or an aversion from drinking is manifested: the orifice ought to be a large one, and the bleeding be continued till actual fainting ee his Dissertation on Canine Madne«s. 440 NEUROSES, OK NERVOUS DISEASES. [Class 11. is induced, for it is not the quantity of blood lost, but the suddeness with which it is abstracted, and the fainting, that determine its efficacy. f The inflammatory diathesis, which has been supposed to exist in this disease, has of late been disputed, and particularly by Dr. Pearson. He observes, that some of the symptoms are merely accidental, others scarcely perceptible, and some, even if present, would not denote the disease to be of a nature requiring venesec- tion. Dr. Parry says, that with respect to the proximate constitu- tional character of rabies, there cannot be a greater mistake than to suppose either that the fever consequent on the disease is of the inflammatory kind, or that its peculiar symptom arises from local inflammation of the fauces, the cardia, or any other part. Under the idea that rabies is an inflammatory disease, warm bathing, and the rest of the antiphlogistic plan, have been much used in its treatment; but these means proving ineffectual, and from a fancied analogy between tetanus and rabies, some prac- titioners have been induced to recommend cold bathing, with a free use of wine. Dr. Russell makes mention that wine in large quantities has been administered with success against the bites of venomous serpents ; between which disorder and rabies we can readily allow some de- gree of affinity. With respect to cold bathing, this has been found to aggravate the disease when it has once absolutely taken place, by exciting convulsions: but before it has shown unequivocal symptoms, and is apparent, this remedy may probably be used with advantage. That cold bathing possesses a degree of preven- > tive power against the effects of canine poison, is an opinion handed down by ancient writers, and is still entertained by many of the moderns. From considering that the poison of a rabid animal produces an excessive increase, or morbid alteration of the natural sensibility, and that those who are bitten by a mad dog, or other animal so diseased, are in a perpetual state of restlessness, from the beginning of the attack to the end, that they can ill bear the impression of objects upon the senses, that the least noise is offensive, and that all feeling is painful, opium has been much employed ; and consi- dering that the poison produces these effects, we might be induced to suppose that it would have proved a valuable and powerful re- medy. Many cases are however on record, where, although it was given to the quantity of 180 grains in the space of fourteen or fifteen hours, it failed to produce any good effect.* Whenever opium is administered the dose ought to be pretty considerable, and its repetition should be regulated by the effect it occasions, without much attention to the quantity. Might not the external application of it, as advised under the head of Tetanus, be worthy of a trial ? Where the patient loses the power of degluti- *"See Medical Record and Researches, art. viii. p. 117 Order III.] canine madness. 441 tion, introducing opium into the system by means of friction? appears to be a very eligible plan. Mr, Ward, of Manchester, was, I believe, the first who suggested its being employed in hydropho- bia in this manner. Indeed, as the throat appears in this disease always to be affected with spasmodic contractions, it would seem that no remedy we can employ promises better effects than the rubbing in (and particularly about the throat and chest,) opium in the form either of liniment or ointment.* Dr. Stutz, of Suabia, very much recommends a trial of the vegetable alkali in this disease, alternately administered with opium, together with its external application in a warm bath. Besides opium, other antispasmodics, such as musk, have been employed in the treatment of hydrophobia, but without much advantage. The best plan will be to unite their powers, by giving them combined as below.t As ipecacuanha in small doses proves serviceable in some spas- modic diseases, it perhaps might be useful to give it in this. It should not, however, be administered so as to provoke vomiting, but only in such doses as will be sufficient to promote a copious perspiration, by exciting a slight degree of nausea. It is probable that the pulvis ipegacuanhae compositus (in which there is a portion of opium) ought to be preferred to the simple powder, as being usually attended with a more certain diaphoretic effect. It has been recommended to make a trial of the spirit of tur- pentine in the form of clyster, during the convulsive stage of the disease, from its efficacy in some other spasmodic affections, but more particularly hysteria. The hint seems worthy of attention. It is asserted that some cures have been performed by a liberal use of vinegar. We have likewise been assured, that anointing the body freely with sweet oil, and pouring repeated draughts of it forcibly down the throat, has lately been discovered to be a successful remedy in hydrophobia. The dread of fluids is said to diminish in proportion to the quantity of oil which is swallowed. A method of preventing the plague, somewhat similar to this, has been noticed under the head of that disease. Among the medicines celebrated for their virtues in hydrophobia 1. ft Tinct. Opii, f. £j. Spirit. Camphorae, f. ^ss. Liquor. Ammonia?, f. 3>j- M. ft. Linimentum. Vel, 2. ft Adipis Praeparat. ^i. Opii in Pulv. subtilis. trit. 31ij. M ft. Unguentum, t 3. ftMoschi, gr. xij. Camphorae, gr. v. Opii, gr. iij.—x. Bals. Peruv. q. s. M. vt Bolus, 4tis horis sumendus. * !• Take Tincture of Opium, one ounce. Camphorated Spirit, half an ounce. Solution of Ammonia, two drachms. Mix them,and use them as an embrocation. Or, 2. Take Prepared Lard, one ounce. Opium, in fine powder, three drachms. Mix them into an ointment. t 3. Take Musk, twelve grains. Camphor, five grains. Opium, three grains to ten. Balsam of Peru, a sufficiency to forma bolus, which may be taken every four hours. 442 NEUROSES, OR AKRVOUS DISEASES. [ClaSS {1. are to be enumerated the Ormskirk powder, the Tonquin remedy, and the Carnatic pill. The former of these seems perfectly inert, and on a careful analysis was found to consist of about half an ounce of prepared chalk, ten grains of alum, three drachms of Ar- menian bole, one drachm of powdered elecampane root, and a few drops of the oil of aniseeds. The principal ingredient in the latter is arsenic. This mineral is much employed by the Hindoo physicians as an antidote to hydrophobia. It enters into the composition of the East India snake-pill, a medicine communi- cated to the presidency of Madras by a native of Tanjore, and which, we are told by Dr. Simmons, (one of the company's surgeons) he has administered with apparent success to persons bitten by mad dogs. In Dr. Hamilton's Treatise on Hydrophobia, it is indeed much recommended to try the effects of arsenic in this disease. As strong epileptic paroxysms have been stopped by administer- ing the arsenical solution, possibly it might have a good effect in rabies. A combination of arsenic and opium has been proposed by Dr. Blane,* as a prophylactic for the bite of a mad dog. The oxyde of zinc, and the cuprum ammoniatum, are other mineral preparations which have been named, as well adapted to the disease. The Tonquin medicine consists of twenty-four grains of native cinnabar, with the same quantity of factitious, made into a powder, with sixteen grains of musk. It is directed to be taken in a tea-cupful of arrack or brandy, and is said to secure the pa- tient for thirty days, at the expiration of which it is to be repeated ; but if he has any symptoms of the disease, it must be repeated in three hours. The first dose is to be taken as soon after the bite as possible. * The alisma plantago, reduced to powder, and given to the person bitten, is reported to be much used among the Russians with a happy effect in hydrophobia. It may be given in doses from twenty to twenty-four grains of the powdered root, at intervals of two hours, but it ought never to be relied on to the exclusion of the local treatment, nor indeed should any other medicine. Notwithstanding the various nostrums that have in all ages and different countries been extolled as antidotes to the poison of rabid animals, we may rest assured that the only remedy on which we can place a confidence is excision or cauterization, but particular- ly the former. Even in wounds completely healed, perhaps it would be advisable' to adopt one or other of these, and thereby expose the part within reach of the animal's teeth. If the remedy is resorted to before lancinating pains and uneasiness begin to show themselves about the cicatrix, we may be more likely to succeed by our preventive means, as such symptoms indicate the passage of the virus through the absorbents, or along the course of the nerves. Dr. Pearson is of opinion, that the exciting some degree of fever * See Transactions of. a Society for the improvement of Medical andChirurgi- <;ai Knowledge Order III.] canine madness. 443 and inflammation may have a salutary effect in canine madness. He observes, that there is no instance of a person having recovered from an animal poison introduced into the system without more or less inflammatory action. The poison which produces the plague is often most fatal when it is accompanied with the least degree of fever; and swelling and inflammation of the bitten part, together with increased heat over the whole body, are the usual forerun- ners of recovery in cases of viper bites. On these grounds he is induced to presume that wine, ardent spirits, and aromatics, may have a beneficial effect in rabies, pro- vided the aversion to liquids is not so strong as to render the exhibi- tion of wine impracticable. He says, that perhaps the nitric or other mineral acids or vinegar (as mentioned by Dr. Ferriar,) might be advantageously mixed with the wine. Besides giving wine and vinegar by the mouth, he tells us they should likewise be injected up the rectum. These things are to be administered on the first appearance of the symptoms characteristic of rabies ; for as the disease advances, neither wine nor any other liquid can be swal- lowed in quantities sufficient to produce a powerful effect ; and there is sometimes an equal impediment to the administration of clysters. Even in this state of things, he mentions, we are not without resource. Some of the concrete acids, such as the essential salt of tartar, the essential salt of lemons, or even theacidum benzoicum, may be given joined with about half as much powdered capsicum, or other strong aromatic, and divided into small portions, to be enveloped in wafer-paper, and formed into boluses. Not less than 20 or 30 grains of the concrete acids, nor less than 8 or 10 grains of the capsicum, should be given for a dose. Dr. Pearson further observes, that while these things are administered internally, topical applications are not to be neglected. Where the bite is in a part that will admit of it, a ligature, as proposed by Dr. Percival, should be applied above the cicatrized wound. This will prevent farther absorption. At the same time the bitten part may be opened or destroyed by the application of lunar caustic, or concentrated mineral acids. After the corrosion of the cicatrized wound by the means just mentioned, the ligature which had been passed round the limb should be removed. Such is the plan proposed by Dr. Pearson, which being novel, it seemed right to'notice. Whether stimulants are really useful and powerful remedies in the treatment of hydrophobia or not, can only be determined on trial, and not on any previous view of the nature of the disease which theory may suggest. It now remains only to observe, that during the furious stage of the disease the greatest care must be taken that the patient is so confined by means of a strait waistcoat, as to be rendered inca- pable of doing any injury either to his attendants or himself. As long as he can swallow, his strength is to be supported by things that are light and nutritive, and when deprived of this power. 444 NECROSES, OR NERVOUS DISEASES. [ClasS II. clysters of animal broths must be injected. To assuage his thirst, wine and water may be poured down his throat from the spout of a tea-pot; but if his dread at liquids and act of deglutition are insur- mountable, a sponge dipped in hot vinegar may be kept constantly to his mouth and nostrils. - If great costiveness prevails at any time in the course of the disease, it should be removed by a laxative clyster. If this fails in procuring the desired effect, the purgative pills advised below* may be given. Dr. Rush has suggested that it might be proper, in cases of hy- drophobia, to make an artificial opening into the windpipe, obvia- ting by this means the most fatal symptom, and giving time for the employment of otherremedies, according to the state of the system ; or fluids might be conveyed into the stomach in the manner prac- tised by the late Mr. John Hunter in a patient who was afflicted with a paralysis of the oesophagus, and consequently unable to swallow any nutriment.! The instrument made use of was a fresh eel-skin, of rather a small size, drawn over a probang, and tied up at the end where it covered the sponge, and tied again close to the sponge where fastened to the whalebone, a small longitudinal slit being made into it just above this upper ligature. To the other end of the eel-skin was fixed a bladder, and a wooden pipe, similar to what is used in giving a clyster, only the pipe being large enough to let the end of the probang pass into the bladder without filling up the passage. The probang thus covered, was introduced into the stomach, and both food and medicines being put into the bladder were squeezed down through the eel-skin. As cases however of this kind may occur where eel-skins cannot be procured, a portion of the gut of any small animal will make a go6d substitute. By this mode, whatever fluids are administered would not come in contact with the irritable parts of the gullet* COLICA, or COLIC. Colic is a painful distention of the whole of the lower region of the belly, with a twisting round the navel in particular, often ac- companied with vomiting, costiveness, and a spasmodic contrac- tion of the muscles of the abdomen. The disease is produced by various causes, such as crude and acescent food, flatus, a redundance of acrid bile, long-continued costiveness, hardened faeces, certain metallic poisons, derangement t See Transactions of a Society for the Improvement of Medical Knowledge, vol. i. * 3. ft Extract. Colocynth. C. 3j. Hydrargyri Submuriat. gr. v. 01. Carni, flliij. M. ft*. Massa, in pilulasvj.dividenda. * 3. Take Compound Extract of Colo- cynth, one scruple. Submuriate of Mercury, five grains. Oil of Carraway, four drops. Mix them, and divide the mass into six pills. Order III.J COLIC. 445 ©f the prima? viae, metastasis of gout or rheumatism, hysteria, the application of cold and moisture, worms in the intestinal tube, and the having swallowed poisonous substances. It has commonly been considered as being of different species, and has been variously de- nominated, according to the cause which has given rise to it, as the bilious, the flatulent, and the hysteric : but in all of them the proximate cause seems to be the same, viz. a spasmodic constric- tion of some part of the intestines. In the bilious colic there is loss of appetite, bitter taste in the mouth, thirst, febrile heat, costiveness, and a vomiting of bilious matter, attended with an acute pain all round the region of the navel; and as the disease advances, the former becomes more fre- quent, and the latter more severe and lasting. In the flatulent colic there is great costiveness, attended with pain, soreness, and griping of the bowels, a rumbling noise, disten- tion of the stomach, an inclination to throw up, and coldness of the extremities. In the hysteric colic there is nausea and sickness at the sto- mach, accompanied with severe spasms, costiveness, and dejection of spirits. The disease, when rising to a violent height, and attended with a stercoraceous vomiting, obstinate costiveness, and an evacuation ef faeces by the mouth, constitutes what is called the iliac passion. In this, as well as in intus-susceptio, the peristaltic motion is in- verted, and a high degree of inflammation is the consequence. The colic is to be distinguished from enteritis by the spasmodic contraction of the abdominal muscles, by the absence or trifling degree of fever, by the state of the pulse, and by the diminution ©f the pain upon pressure of the abdomen. When the pain remits, or shifts its situation, not being obstinate- ly confined to one place, and when the patient experiences consi- derable ease after a discharge either of wind or faeces, and stools are obtained, we may have reason to expect a favourable termination to the disease ; but the sudden cessation of pain, with the costive- ness remaining obstinate, cold sweats breaking out, a weak tremu- lous pulse, frequent syncope, and ensuing of hickups, denote super- vening inflammation terminating in gangrene. When the disease proves mortal, the usual appearances to be ob- served on dissection are, inflammation on the surface of the intes- tines, distention and irregular contraction of some particular part of the tube, or a passing of one portion of it within another to a considerable extent, the part received within the other being in a contracted state, or probably gangrenous. In all cases of colic, where the patient is young and vigorous, and the symptoms proceed with such violence as to endanger the ensuing of an inflammation of the intestines, it will be advisable to take away some blood, being regulated as to the quantity by the state of the pulse and the appearance of what is drawn off. In re- 44fc NEUROSES, OR NERVOUS DISEASES. [ClttSS II. peating the operation we are to be guided by the severity of the attack, the continuance of the constriction on the intestines, the habit of the patient, and the state of the pulse. In the bilious colic, if there is great irritation at the- stomach with frequent vomiting, we may direct a saline draught to be taken every two or three hours in the act of effervescence, with an addi- tion of about five and twenty drops of tinctura opii; but if only a nausea prevails, the patient may be made to drink plentifully of ehamomile-tea. Externally we may apply flannel cloths wrung out in a warm decoction of emollient herbs, or a bladder filled with hot water, interposing between the paroxysms frictions with anodyne liniment. When the nausea and vomiting have ceased, he should take some active purgative* to carry off the offending matter, the operation of which may be assisted by a free use of diluent liquors,'such as thin gruel and animal broths. Should the purge be rejected by the mouth, or not operate quickly, we must then attempt to dislodge the contents of the intestines by clysters, making use of mild laxative ones at first, and afterwards resorting to those which are more powerful, if necessary ; and these are to be repeated un-.,-, til a sufficient effect is produced. In the flatulent colic we may begin the cure by giving a wine- glass of some aromatic cordial combined with an opiate.t II relief is not soon obtained, a carminative clysterj may be injected <* 1. ft Pulv. Jalapae, 3ss. Hydrargyr. submur. gr. v. Syr. Rhamni, q. s. M. Piant pilula? v. pro dos. ■V 2. ft Aq. Menth. Pip. f. |j. Spirit. Carui, f. ?ss. Tinct. Lav. C. f. 3j. ft. Haustus. Opii, ITlxx. M. Vel, 3. ft Tinct. Cardam.C.f. 3iij. ---- Opii, fllxxv. Aq. Menth. Pip. f. ^iss. M. ft. Haustug. • % 4. ft Sem. Anis Contus. Flor. Anthemidis, aa ?ss. Ceque ex Aq. Fontan. Ojss. ad ^xj. et colaturae adde Sodae Sulphat. 3yj. ©1. Ricini, f. ^j. M 1>. Enema. s 1. Take Powder of Jalap, half a drachm. Submuriate of Mercury, five grains. Syrup of Buckthorn, a suffi- ciency. Form the mass into five pills, to be taken for a dose. f 2, Take Peppermint Water, one ounce. Spirit of Carraway,half an ounce. Compound Tincture of Lavender, one drachm. Tincture of Opium, thirty drops. Make them into a draught. Or, 3. Take Compound Tincture of Carda- mom, three drachms. Tincture of Opium, forty drops. Peppermint Water, one ounce and a half. Mix them for a draught. X 4. Take Aniseed, bruised, Chamomile Flowers, of each half an ounce. Pure Water, one pint and a half. Boil them slowly until the water is redu- ced to eleven ounces, and to the strained liquor add Sulphate of Soda, six drachms. Castor Oil, one ounce. Mix them fop a 'elvstpr. Order 111. J COLIC. 447 every three or four hours, and warm fomentations with an addition of rectified spirit, be applied over the whole region of the belly. Should clysters not procure a copious evacuation of faeces and wind, some stomachic purgative* may be administered by the mouth. Ammonia, joined with carminatives, will be very proper in the flatulent colic. If the disease continues to increase with violence notwith- standing these means, so as to threaten the approach of an inflammation in the bowels, we must then resort immediately to bleeding, the warm bath, and blistering over the part more par- ticularly affected. On apprehending a similar consequence in the bilious colic, we may adopt the same means.—See Enteritis. In the hysteric colic it will seldom be necessary to make use of evacuation ; but should obstinate costiveness prevail, it will be proper to give some gentle laxative,t administering at the same time every four or six hours the clyster of turpentine recom- mended in the flatulent colic, as I have known it in many instances to have been attended with much benefit, and this almost immedi- ately. If a vomiting attends, the stomach may be cleansed by drinking one or two cupsful of chamomile-tea, after which the pa- tient may be ordered some antispasmodic medicine.}: Vel 5. ft 01 Terebinth.' f. 3iij. Vitel. Ovi, q. s. Misceantur in mortario raarmoreo, dein adde gradatim Decoct. Avenae, f, ?xij\ ft. Enema. * 6. ft Tinct, Senna? C. f. ^j. ----Jalapae,f. 3j- M. ft. Haustus. Vel, 7. ft Infus. Sennae, f. §v. Tinct. ejusd. C. f, 3yj. Magnes. Sulphat. ?j. Syrup, Zingib. f. |ss. M. it. Mistura, cujus capiat aeger cochlearia tria magna omni bihoria donee alvus purgetur. t8. ft Pulv. Rhei, 3j. Spirit. Anisi, f. ^ss. Aq. Cinuam. f. ?j. Tinct. Jalapae, f. 3j. M. it. Haustus, statim sumendus. t 9. ft Aq. Anethi, f. ^ivss. Spirit. jEther. Sulphur, f. 3j. ,.----- Ammon. Foetid, f. 3ss. Tinc%. Opii, fllxxxiij. ---- Castor, f. |ss. M. ft. Mistura, cujus sumat cochl. magna ij 'ri-i-vsvel 'inartis horis-. Or, 5. Take Oil of Turpentine, three drachms. Yolk of Egg, a sufficiency. Mix them well together in a marble mor- tar, then slowly add Thin Water Gruel, twelve ounces. Mix them for a clyster. * 6. Take Compound Tincture of Senna, one ounce. Tincture of Jalap, one drachm. Mix them for a dose. Or, 7. Take Infusion of Senna, five ounces. Compound Tincture of the same, six drachms. Sulphate of Magnesia, one ounce. Syrup of Ginger, half an ounce. Of this stomachic purgative let the patient take three table-spoonsful every two hours until the bowels are well moved. 18. Take Powdered Rhubarb, one scruple. Spirit of Aniseed, half an ounce. Cinnamon Water, one ounce. Tincture of Jalap, one drachm. Make them into a draught, which is to be taken immediately. X 9. Take Dill Water, four ounces and a half. Spirit of Sulphuric .ffither, one drachm. Fetid Spirit of Ammonia, half a drachm. Tincture of Opium, fifty drops. --------Castor, half an ounce. I Of this mixture two large spoonsful may i He taken r-vpvv thre« orfotir horn's. 448 NEUROSES, OR NERVOUS DISEASE.^. [ClaSS II. When a colic of any kind proceeds with great violence, and ter- minates in an inversion of the peristaltic motion, or iliac passion (as it is usually called,) notwithstanding the means which have been recommended have all been employed, it then becomes ad- visable to have recourse to the injection of tobacco clysters, which herb maybe used either in the form of infusion* or that of smoke. Where even these fail, it has been customary to attempt a mechani- cal dilatation of the intestines, by giving a large quantity of quicksilver by the mouth. The practice seems, however, attend- ed with a considerable degree of danger; for should the inversion of the peristaltic motion have arisen in consequence of intus-sus- eeptio, the complaint, instead of being relieved by the remedy, would certainly be increased by it. A surer and much safer method of employing mechanical dila- tation is by injecting a large quantity of tepid water by a proper syringe, which will throw it into the rectum in a continued stream, and with some force, the patient drinking copiously at the same time. Some persons have borne two gallons to be injected in this way, and the cases were attended with the desired success. In those instances where there is an accumulation of hardened faeces in the colon, these large injections seem to be a powerful remedy, as they serve the two intentions of dilating the passage, and of softening the faeces. Obstinate constipations, arising from an accumulation of indu- rated faeces in the rectum, and attended with severe colic pains which resisted the usual means of relief, have been removed by J introducing the finger, or scoop used in lithotomy, in ano, and then breaking and loosening the scybala. Two cases of this nature are recorded in the Edinburgh Medical Commentaries for the year 1795, which undoubtedly suggest an important caution ; to advert to the cause above pointed out, in cases of obstinate costiveness and colic, where the usual means of aperient medicines and clysters have had a reasonable trial, without the desired effect. Throwing cold water on the extremities, or applying pounded ice, snow, or towels wetted with a solution of ammonia muriata and nitre in cold water to the region of the belly, have been found, in some cases of obstinate constipation, to have been attended with a good effect, where all other remedies have failed. It is well known, that many people have a skin of so irritable a texture that if exposed to cold it will bring on a purging. In all constitutions cold increases the peristaltic motion of the intes- tines, and again, if cold is applied to the external surface of the body, even although the bladder is not full, there will be a strong inclination to empty it. ' 10. ft Fol. Tabaci, 3ss.—3ij. j* 10. Take Tobacco, half a drachm to twif Soe his Treatise on the Diseases on the Abdominal Viscera, p. 155 Order HI.J cholera morbus. 4do on it a little sulphuric acid, and pass the gas produced into a flask of water by a bent tube. This water poured on wine mixed with litharge, renders it black and'flaky, and produces an abundant precipitate, which soon falls to the bottom of the vessel. CHOLERA MORBUS, or VOMITING ane> PURGING. Frequent and violent discharges of bilious matter, both up- wards and downwards, with painful gripings constitute cholera morbus. In warm climates it is met with at all seasons of the year, and its occurrences are very frequent; but in England, and other cold climates, it is apt to be most prevalent in the autumn, when there is excessive heat or there are sudden transitions from heat to cold ; and the violence of the disease has usually been observed to be greater in proportion to the intenseness of heat. These circum- stances naturally induce us to presume that cholera morbus is the effect of a warm atmosphere producing some change in the state of the bile ; which change may consist either in the matter of the bile being rendered more acrid, or its being secreted in a preternatural quantity. In some instances the disease has been observed to pro- ceed from an obstructed perspiration, and likewise from food which has passed readily into the acetous fermentation, from unripe fruit and acrid ingesta; but these causes probably would not give rise to it without the predisposition acquired by preceding great heat, succeeded by sudden transitions to cold, particularly in the evenings. It usually comes on with nausea, soreness, pain, distention, and flatulency in the stomach, and acute griping pains in the bowels. succeeded quickly by a severe and frequent vomiting and purging of bilious matter, heat, thirst, a hurried respiration, and a frequent but weak and fluttering pulse. When the disease is not violent, these symptoms, after continu- ing for a day or two, cease gradually, leaving the patient in a debi- litated and exhausted state ; but where the disease proceeds with much violence, there arises great depression of strength, with cold clammy sweats, considerable anxiety, a hurried and short respira- tion, cramps in the legs, coldness of the extremities, and hickups, with a sinking and irregularity of the pulse, which quickly termi- nate in death; an event that not unfrequently happens within the space of twenty-four hours. Cholera morbus is to be distinguished from diarrhoea and dysen- tery by the matter which is discharged by stool being pure bile, unmixed with blood or mucus, and with scarcely any admixture of faeces. It may be distinguished from colica pictonum by the eva- cuations : for in the latter, although there is sometimes a consider- able quantity of bilious matter1,'thrown off by vomiting, yet the bowels remain obstinately costive. 35ti NEUROSES, or nervous diseases, [Class 11. Our opinion must ever be unfavourable when the evacuations Upwards and downwards are accompanied by great prostration of strength, much distention of the abdomen, intermitting puke, cold clammy sweats, a short hurried respiration, constant hickup, spasm of the extremities, or convulsions : but a gradual diminution of the symptoms, especially the vomiting, succeeded by sleep, or a gentle moisture on the skin, may be regarded in a favourable light. The appearances generally to be observed on dissection, where cholera terminates fatally, are an accumulation of bile in the sto- mach and intestines, particularly in the duodenum ; relaxation and distention of the biliary ducts and choledochus, and a removal of many of the viscera from their proper places, occasioned probably by the violence of straining in vomiting. From the very irritable state of the stomach on the first attack of the disease, it is almost impossible for any kind of medicine to be retained on it, and every thing is thrown up again almost as soon as swallowed. To abate this irritation, and evacuate the redundant or acrid bile, it will be necessary, during this stage of the disorder, to make the patient drink plentifully of diluent liquors, such as barley-water, linseed-tea, rice-gruel, animal broths, or toast and water; and to assist the effect of their operation, tepid mucilagi- nous clysters of the same nature may likewise be injected. In addition to these means, flannel cloths wrung out in a warm ' decoction of poppy-heads slightly bruised, with an addition of about one-fourth of spiritus camphorae, may be applied to the region of the stomach, taking care to renew them as often as they become cold. Warmth should likewise be applied to the extremities by means of bottles filled with hot water. As soon as the stomach is sufliciently cleansed by the diluents , just recommended, we should endeavour to allay or put a stop to me irritation, by administering opium in sufficiently large doses. ^ but, at the same time, in as small a bulk as possible. It may be given in the quantity of a grain or a grain and a half with four or five grains of the submuriate of mercury in the form of a pill, and >•"*' be repeated every two hours, as long as the urgency of the case may require : if the pill is rejected, about forty drops of tinctura opii may be added to a small saline draught, swallowed in the act 1 of effervescence ; and this may be repeated as frequently as the former. In some instances, where the spasms have been so vio- <3h| lent as quickly to induce an alarming state of debility, I have known the quantity of opium to have been increased to eight or ten grains in each dose. --i After the administration of opium in the manner advised, it will '--A he proper to immerse the patient as soon as possible in the warm bath, as this will be a likely means of checking the inordinate secretion of bile by restoring the circulation to the surface of T^m the body, and of course relieving the orgasm of the chylo-poetic * viscera. In the advanced stage of the disease, where the pulse is weak. Order HI.J cholera morbus. •>+• 451 and the extremities are cold, opiates joined with aromatics, as in the c%nfectio opii, and musk in large doses, may be employed with; radvantage. Opium, when given by the mouth, even in the smallest possible bulk, is frequently rejected by vomiting in cholera morbus'; but if given in an enema, will often in a very short space,of time com- pletely remove all the urgent symptoms, and transfer the patient from a state of torture to one of ease. Clyster^ of this rtature, containing about two drachms of tinctura opii in each, ought there- fore to be injected frbm time to time as long as the irritation at the stomach continues. , Two writers on the diseases of India* mention, that a^very severe and fatal spasmodic cholera, proceeding fron£ acrid bile in the primae viae, is a very prevalent disease on the, coafct of Malabar, where it is know^by the name of mort de chien, from its fatality. In this species of the disease, opium in the form of injection has succeeded when all medicines1 by the mouth have been ineffectual in allaying the orgasm of the stomach'and intestines. A cataplasm of opium and camphor applied to the region of the stomach will sometimes revert its retrograde motions. In several cases wb^ere there prevailed great pain and irritation at the sto- mach, and where the patient could retain nothing on it, I have ex- perienced the best effects from the external application of opiam to the epigastric region in the form of an embrocation.! Indeed no substantial reason can be assigned why it may not be introduced into the system by friction, as. mentioned under the head of Colica j. Pictonum, as well as pjercury, camphor, rectified spirit,^fec. The application of a blister to the stomach will sometimes put a * stop to the vomiting, by stimulating the skin and by sympathy * affecting the stomach. In very severe cases of cholera in this climate it might probably be advisable to;resort to the external application of nitric acid as a counter-irritaut^for a.considerable feme "must elapse before the Spanish fly commences its irritation, which practice has been adopted in that Aggravated form of the disease which has lately been developed in Hindostan.—See the succeeding pages. I have been informed by a medical friend who practised many years in the West Indies, where cholera is of frequent occurrence, ' as has before been observed, that he found large doses of acidum pLmlphuricum dilutum to abate the irritation of the stomach more readily than even opium. -» Some-cases of*this disease which had resisted the powe* of * See Mr. Curtis's Treatise on Indian Diseases. Essay on the Influence of Tropical Climates, by J. Johnson, M. D. ' --------- ■----------------1 ---------* t 1. fx Spirit. Camphont, f. ijss. \' |t 1. Take Camphorated Spirit,halfanbunce Tinct. Opii/f. ii. M. >> | Tincture of Opium, once'.ounce. ft. Enibrocaiio, supra vnlriculiregionem] Mix them, and rob a little of the Embro- a-pe iufricanda. . canon fiA«iently over the region of thf 4 I stomach.'^ f ■ ■ *? #* .50 J&L 45S NEUROSES;,Oft NERVOUS DISEASES. [Class II. opium, have indeed been Successfully treated with diluted nitric acid in small doses, combined with an infusioqj. of calumba or cascarilla. Its valuable effect in allaying the irritation at the stomach I have myself witnessed of late in two or three instances. As soon as a sedative effect is produced on the. stomach and intestines, and .the violence of the attack has somewhat subsided, a mild laxative will assist the calomel in carrying off any diseased secretions. .iThe aperient draught prescribed bejpw* may be taken for this purpose. ■* : *&- Although we may have been so fortunate as to procure a remis- sion of the symptoms, still as the spasms have a great tendency in this disease to recur'*after the operation of the opium is over, it will bv all means be advisable to "continue its use for several days in such a manner as to keep up a constant effect. In ordinary cases, where the evacuations are moderate, astrin- gents would be improper, as they might aggravate the complaint by jcetaining the vitiated bile in the intestines, which ought to be discharged as long as the morbid secretion from the liver continues** As the debility induced by the disease greatly favours the dispo- sition.to spasmodic affections, it may be proper, at the same time that we use opiates to employ tonics, as wine, cinchona, and chaly- beates (see Dyspepsia,) in order to restore the tone of the stomach, taking care at the same time to obviate costiveness by some gentle laxative, such as rhubarb. As strengthened of the stomach and intestines, calumba root and cascarilla bark will be found useful medicines, and may there- • fore be given.! On recovery, the patient should pay particular attention to his' diet, carefully abstaining from all things which might promote a return of the disease, and using only such as are light and nutritive, and which do not readily become acescent. He is likewise to pay _____________________________________________________j£&---— 2. R Magnes. Sulphat. 3'j-X Infus. Rosae, f. 3x. , >yr.up. Croci, EJJj. M. flis, quartis horis repetendus, ft.;Haus(us, quartis erit necessitaa. t 3. R hifus. Cascarillae, f. gjss. Tinct,'Calumb. f. 3iij. ----Card.C.f.3j- M. ft. Hgmstus,terdie sumendus. Vel, 4. % Pulv, Calumb. gr. k. ----Zingib. * Ferri Subcarbonat. aa gr. v. ■ *■ Syrup Rosae, q-:?. M. ft. Bolus, bi> ouotidie cspiendu^. * 1. Take Sulphate of Magnesia, two. drachms. Infusion of Roses, ten drachms. Syrup of Saffron, one drachm. Mix them, and let the draught be repeated every four hours, as long as may be ne- cessary. 13. Take Infusion of Cascarilla, one ■ ounce and a half. Tincture of Calumba, thrte drachms. Compound Tincture of Carda- mom, one draohm. Mix them, and let this drat%nt be taken three times a day. Or, ' 4. Take Powder of Calumba, ten grains. --------Ginger, Subcarbonate of Iron, of each five grains. Syrup of Roses, a sufficiency to form a bolus, which is to be tyken twice pverydav.'' Order III.] Cholera morbid. > 45$ a minute attention at the same time to the functions of the skin by flannel or othe^warm clothing, while the night air and sudden alternations of temperature are to be cautiously guarded against. There are some people who are subject to periodical attacks of cholera, returning by intervals of a few weeks, producing for two or three days, sickness and vomiting, increased heat of the skin, and quickness of the pulse, white tongue, and thirst. Sometimes, however the bowels are torpid. Heaviness of the eyes, and great dispositjoflt>;to drowsiness, are commonly the precursors to the attack ;"*and if a dose of hydrargyri submurias joined with some gentle purgative *be then given, it will either considerably lessen its violence, or altogether7 pre Vent it. Exercise, particularly on horseback, tonics, and the Bath or Cheltenham waters, are well calculated to afford relief, and pre- vent recurrences of the complaint in all such cases. It has already been mentioned, that a very severe cholera morbus is a prevalent disease on the coast of Malabar, but towards the close of the year 1817 and the year 181.8, this disorder prevailed epidemically throughout Hindostan and the peninsula of India, and several thousands of the natives, both Mussulman and Hindoo, as also Europeans, fell a sacrifice to it. Almost every corps in the army was attacked with it. It raged with dreadful fatality in Calcutta, and from January 1818, to the succeeding May, the deaths in that city seldom fell short of two hundred each week. The practitioners in India admit, that no marked peculiarity in . the weather was observed previous to the appearance of this disease in Bengal, and it does not seem to have been at all affected in its severity or progress by the circumstances of season, temperature, or moisture. It was observed to prevail with equal violence when ^ the thermometer was at 40° or 50°, as when it stood at 90° or 100°, during the prevalence of incessant rains for months, and when the face ofathe earth was scorched up by long-continued heat and drought. It appears from the report given in by the practitioners who were commissioned, on the occasion, to scrutinize into the nature of the disease and its treatment, that the principal curative means resorted to, were bleeding, calomel, opium, and other antispas- modics. By most, bleeding at the onset was considered as indis- pensable. It was found, that whilst the blood was flowing from the arm, the most distressing symptoms were frequently relieved; the vomiting gene rally teased ; the burning sensation attbe stomach abated, and the'pains and spasms in the abdomen relaxed in severity, and it was always perceived, that the pulse invariably rose while ,the blood flowed from the arm. Bleeding was however found more necessary in Europeans than in the natives. Calomel was given in doles of fifteen-grains, or a, scruple com- - bined with two grains of solid opium, or followed by- sixty or one hundred, and twenty drops of tinctura op\\.—The»effect in general 460 v NEUROSES, OR NERVOUS rtlSEASE.-. [Class II. was speedy, and its sedative power in this large dose was admit- ted by all. If the first dose was immediately rejected, it was again repeated and continued without any regard to quantity, according to the urgency of the symptoms. In conjunction with these remedies, Cordials and antispasmodics, such as peppermint, aether, the spiritus ammonias aromaticus, and other diffusible stimuli were found the most useful adjuncts ; but the whole hopes of success rested on bleeding at the onset of the disease, calomeh/and opium. When these remedies were employed early and .conjointly, it is reported that the success was almost in every instance nearly certain. The patient generally fell asleep, and awoke free from the most painful symptoms, or was greatly relieved c and when bile appeared in the alvine evacuations instead of the watery or clayey matter which was the usual attendant, it was a sure sign that the-a remedies were effective, and amendment taking place. After these effects were obtained, it was necessary to give a mild laxative, » and the carbonate of magnesia was generally found to answer the purpose. It has been mentioned in a preceding page, that the external application of nitric acid had been employed by one of our surgeons in the East Indies, as a counter-irritant in that aggravated form of cholera morbus which has lately been developed in Hindostan. The rapidity with which it rushes to a fatal termination, and the necessity which exists to administer remedies without the least delay, for the purpose of arresting its progress, led to this practice, because he well knew that much time might elapse before the Spanish fly commences its irritation, thereby permitting the dis- - ease to acquire invincible strength. A good way of employing the acid in severe cases of cholera, (and perhaps it might be beneficial also in cases of a translation of gout or rheumatism from the extremities to the head, heart, or stomach, endangering life,) is to brush the acid slightly diluted in water with a feather over the space of two palms of the epigastric region, neutralizing in some measure the severe effects of the acid, by applying quickly afterwards some alkaline preparations, or by rubbing the .parts with a soft rag soaked in cold water, so as to f dilute whatever portion of acid that might remain, after it has effected its immediate irritation. ^ ■*; The remedy in question should "be-employed only in cases of great urgency, for the great irritation which it produces and pro- tracts through''the healing process,.and the longer period which this process, ^requires, will prevent the employment ofitas an external application in common cases. From the report given in, it appears that the disease was not considered by the majority of practitioners in India as con- tagious', although judged by some to have such an influence. The proximate or exciting cause of the epidemic was obscure. Rapid atmospherical vicissitudes, in regard to temperature or moisture ; exposure of tr>e body concurrents of cold air, particularly the chill Order 111.] * diarrhoea. 46] of the evening, after being heated by violent exercise of any kind, inducing exhaustion or debility ; low marshy situations; insufficient clothing; flatulent and indigestible food, especially crude and watery vegetables, which compose a large proportion of the diet of the natives^ and particularly that gradual undermining of the constitution which arises in a condensed, dirty, and ill-fed mass of population, are all unquestionably powerful predisposing causes, and althoagh not absolutely necessary to the production of the disease, might, when present, offer a more unlimited range to the operation of the original cause, whatever that may have been. .. DIARRHCEA, or LOOSENESS. Diarrhosa consists in frequent and copious discharges of fecu- lent matter by stool, accompanied by griping, and often at first with a slight degree of vomiting, but unattended either by inflam- mation, fever, or contagion. The presence of these, with tenesmus and an evacuation of blood and purulent mucus with hardened v halls or scybala, instead of natural faeces, which prevail in dysentery, will always enable the practitioner readily to discern the two diseases from each other. It is to be distinguished from cholera morbus by the discharge not being very bilious, and also by there being no vomiting of bile. In diarrhoea there is evidently a morbid increase of the peristaltic motion; which morbid increase is the effect of a variety of causes applied either to the body in general, or acting solely on the parts affected. Of the former may be noticed the application of cold to the surface of the body, so as to give a check to perspiration, and thereby determine the flow of blood more to the interior parts; as likewise passions of the mind, and certain diseases, as dentition, retrocedent gout and rheumatism, fever, &c. Of the latter may be-enumerated, first, matters taken into the stomach, and acting either from their quantity, as in the case of overcharging the organ, or from their nature, on the state of the stomach1 itself, producing fermentation, as acid fruits, as also oily and putrid substances, and purgative medicines : secondly, matters generated in the body and thrown into the intestines, acrid bile, pan- creatic juice, purulent matter, water in dropsy, worms, &ic.: thirdly, mucous matter poured from the mucous follicles of the intestines themselves,! n consequence of an increased excretion, and producing what is known by the name of diarrhoea mucosa. In diarrhoea, each discharge is usually preceded by a murmuring noise and flatulence in the intestines, together with a sense of weight and uneasiness in the lower part of the belly, which cease on the discharge taking place, but are again renewed before the one which is to succeed" ensues. The appearance of the stools is various. Sometimes they are thinner than natural, from the ad- mixture of a larger quantity of fluid poured out by the exhalents of the intestines than common. ^Sometimes they are slimv, and * J-' *' ' 't62 NEUROSES, OR NERVOUS DISEASES. [ClttSS 11. sometimes they are green, when first discharged; sometimes they are evacuated of a yellow colour, but become green on exposure to the air, and now and then they are of a dark brown coldur, and very fetid. As the disease advances, the stomach becomes affected, and sickness, nausea, and vomiting, occasionally prevail, the coun- tenance turns pale, and the skin is dry and rigid. If it continues for any length of time, universal emaciation, dropsy of the lower extremities, and relaxation of every part ensue, together with a great loss of strength. In forming our prognostic in this disease, we are to be deter- mined by the particular cause from which it arises ; whether symp- tomatic of another disorder, and whether of a critical nature ; as likewise by the degree of debility present in the system, and the- length of time it has continued. Where it attacks pregnant women,' it is generally to be considered as attended with danger. Dissections of diarrhoea, which have terminated fatally, have shown, that where it prevailed as a primary disease, ulceration of some portion of the intestines is the morbid change most usually met; with ; in which cases the inner membrane is often abraded for a considerable extent, and its muscular coat laid bare. They have likewise shown that the follicular glands are the most frequent seat of such ulcerations, and that they now and then become cancerous, and. assume the same appearance as schirrus and cancer in other parts. When it has been symptomatic, the morbid changes of the organ belong to the primary diseases, of which the diarrhoea is merely a symptom. , ' In the treatment of diarrhoea it will be necessary to attend to the following indications :— First, To obviate or remove the morbid cause. Secondly, To suspend the increased action which constitutes the disease: and, Thirdly, To restore the impaired tone of the parts. Vomits not only cleanse the stomach but promote all the secre- tions ; and therefore when diarrhoea has arisen from excess, or repletion, or from crude and acrid matter in the stomach, the first indication may be answered by giving a gentle emetic in the even- ing, and some aperient* the succeeding morning. * 1. R. Pulv. Rhei, 3j. Aq. Cinnam. f. |jss. Tinct. Lav. C. f. "3ss. M. ft. Haustus.' Vel, , 2. £. Aq. Anethi, f. 3vi. Tinct. Rhei, f. ^ss. Cretae Preparat. 3j. Syrup. Zingib. f. 3j. M. ft. Haustus. .&■> VJ ' "1.Take Powder of Rhubarb, one scruple. Cinnamon Water, one ounce and ... a half. Compound Tincture of Lavender, half a drachm. Mix them for a draught. Or, 2. Take Dill Water, six Jrachms. Tincture of Rhubarb, half an ounce. Prepared Chalk, one scruple. Syrup of Ginger, one drachm- This is to be taken as a draught. Order III.] diarrhoea. 4t>3 If it has proceeded from obstructed perspiration, in consequence of exposure to cold, we must then endeavour to restore this by nauseating doses of ipecacuanha,* or of some antimonial prepara- tion, as the pulvis antimonialis, pulvis Jacobi verus, or a solution of theantimonium tartarizatum, which maybe repeated every two or three hours in the manner which has been advised under the head of Simple Fever. At night the patient may immerse his feet in warm water. An irritable state of the bowels,'with long-continued diarrhoea, and which had resisted the ordinary means, of cure, has been ulti- mately overcome by the assistance of a warm or vapour bath. This, by exciting the action of the cutaneous arteries of the whole system, and determining'a greater flow of blood to the surface of the body, ending in secretion, has relieved the irritable state of the intestines and removed the disease. ^ Along with these remedies we may recommend a free use of diluents and demulcents, such as a decoction of barley, rice, marsh- mallows, quince, or calcined hartshorn, mutton suet dissolved in milk, the emulsion of gum. acaciae, linseed-tea, or toast and water; which will serve both to wash out the offending matter, and to guard the intestines against its further action. Where a septic fermentation is conspicuous (as in the case of scurvy and other putrid diseases) we must employ acids, such as ripe fruits, or the acidum sulphuricum, in a diluted state. When diarrhoea seems to arise or be kept up by(a septic acid generated in the intestinal canal, and known by frequent eructations of air, diffusing a hot and disagreeable sensation upon the fauces and mouth, griping pains in the bowels, with dejections of a white chalky appearance, which in passing off occasion a hot smarting sensation at the end of the rectum, it will be necessary to have recourse to absorbents! joined with opiates. Alkalies will also be Vel, 3. ft Pulv. Rhei, 3j. ----Cinnam. Comp. gr. v. Syrup. Zingib. q. s. M. ft. Bolus. Vel, 4. ft Magnesiae, 3ss. Pulv. Rhei, 3j. ----Zingib. gr. x. M. ft. Pulvis. " 5. ft Pulv. Ipecac. Comp. gr- iij. "' f.. *- M ----Cinnam. Comp. gr. v. Confect. Rosae, q. s. M. ft. Bolus, quartis hpris sumendus. .f I 6. ft Mistur. Cretae, f. jiv. * Spirit. Cinnam. f. ^j. Liquor. Amnion. Subcarbonat, f. 3j Or, 3. Take Powder of Rhubarb, one scruple. Compound Powder of Cinna- mon, five grains. Syrup of Ginger, a sufficiency to form a bolus. Or, 4. Take Magnesia, half a drathm. *• Powdered Rhubarb, one scruple. -------Ginger, ten grains. Mix them. * 5. Take Compound Powder of Ipecacu- anha, three grains. ---„--------------Cinnamon, five grains. . * Confection of Roses, a sufficiency to form a bolus; which is to *be taken every four hours. t 6. Take Chalk Mixture, four ounces. Spirit of Cinnamon, one ounce. Solution of Subcarbonate of Am- monia, one drachm. & 4t>4 NEUROSES, OR NERVOUS DISEASES. [Class II. an useful class of medicines, and therefore we may advise frequent doses of the subcarbonate of potass dissolved in a little veal broth throughout the course of the day, and at night an anodyne. In mosl; cases of diarrhoea strong purgatives are found to prove injurious; but where it arises from an acrimony, which is extremely tenacious, and that adheres closely to the internal surface of the intestines, or is retained in their folds, those of a mild nature are the only remedies that can remove the disease, and ought therefore in such a case to be employed. The neutral salts will be proper purgatives on this occassion, particularly the magnesiae sulphas, sodae sulphas, and soda phosphorata. , Should diarrhoea proceed from acrid or poisonous substances taken into the stomach, the patient must drink plentifully of diluting liquors, with fat broths, to promote a vomiting ; and to carry the remainder downwards a purgeof the oleum ricini may immediately afterwards be administered. To remove the irritation, small doses of tinctura opii may be taken after the purge operates. When gout, repelled from the extremities, falls on the intestines and occasions a diarrhoea, it must again be solicited towards the extremities by warm fomentations, cataplasms, or blisters. The perspiration is at the same time to be promoted by drinking plen- tifully of wine whey. If these means fail, a gentle dose of some stomachic purgative, such as the tinctura rhei compos, may be given; after which the absorbent mixture just recommended may be used in frequently-repeated doses, with an addition of ten or twelve drops of tinctura opii to each. > Tinct. Opii, fit xxiv. ft; Mistura, cujus sumat aeger cochl. am- ' pia ij. pro re nata. Vel, 7. ft Misturae Corn. Usti. Oj. in die pro . potu ordinario. Vel, 8. ft Ammoniae Subcarbonat. gr. x. >t Aq. Menth. Pip. f. ^jss. Tinct. Opii, tTl x. Syr." Rosae, f. 3j. M. ft. Haustus, bis in die adhibendus. . Vel, 9. ft Magnesiae, &\y Pulv. Rhei, gr. viij. ----Cinnam. Comp. gr.'x. M. ft. Pulvis, inane vespereque sumendus. Vel, _ 10. ft Pulv. Cretae C. cum Opto, gr. xv. Confect. Rosae, q. s. ft. Bolus, bis in (lie capiendo*. Tincture of Opium, forty drops. Of this mixture let the patient take two large spoonsful occasionally. Or, 7. Take Mixture of Burnt Hartshorn, one, pint in the course of th*e day, as ordinary drink. Or, 8. Take Subcarbonate of Ammonia, ten 4 grains. Peppermint Water, one ounce and a half. Tincture of Opium, fifteen drops. * Syrup of Roses, one drachm. Mix them, and let this draught be taken twice a day. > *~ Or, 9. Take Magnesia, two scruples. PowderofRhubarb,eight grains. Compound Powder of Cinna- mon, ten grains. Mix them, and take this powder night aud morning. 0r>J* 10. Take Compound Powder of Chalk with Opium, fifteen grains. Confection of Roses, a sufficien- cy to form abolus, which mav bt- taken Order H/.J diakkhce.a. 1G.J Should diarrhoea be occasioned by worms, which may be known from the sliminess of the stools, mixed with pieces of the decayed worms, medicines must be given to destroy and carry off these vermin, as advised under that particular head. When it proceeds from an use of unwholesome water, and the situation of the person will not admit of its being changed, the addition of a small quantity of quick-lime, chalk, or the like, possibly may correct this effect. The diarrhoea which attends on dentition should never be check- ed, unless it prevails in so high a degree as to prove hurtful to the child ; in which case four or five grains of toasted rhubarb, with about eight or ten of prepared chalk or magnesia, may be given. This, if repeated three or four times, will generally correct the acidity, and put a stop to the griping stools. If it fails, we may- make a trial of the mixture advised below.* Should purgings return frequently in the time of teething, or upon the striking in of some eruption on the skin, it will be very useful to procure a small discharge behind the ears, or to apply a plaster of pix arida to the back. For the former purpose, some finely-powdered Spanish flies may be rubbed on the part till a proper excoriation is produced, or we may draw a bit of narrow tape through a piece of the emplastrum lyttae, and lay it close; behind the ears. A diarrhoea that is likely to prove critical or salutary, is by no means to be rashly stopped ; but when it attacks pregnant women, the most powerful remedies ought immediately to be employed. To answer the second indication in the cure of diarrhoea, viz;. that of suspending the increased action which constitutes the dis- ease, it will be proper to have recourse to opiates, which may either be given separately, in small and repeated doses, so as to keep up a constant effect, or be combined with whatever other medicines! we administer. * 11. Take Powdered RhubarV fifteen grains. Carbonate of Magnesia, half a drachm. Dill Water, two ounces. Aromatic Spirit of Ammonia, twenty-four drops. Tincture of Opium, twenty drops. Of this mixture, two or three tea-spoonsful are to be taken twice or thrice daily, as * may be judged necessary. t 12. Take Confection of Opium, fifteen grains. Cinnamon Water, Pimenta Water, of* each six drachms. m Tincture of Kino, one drachm. Compound Tincture of La- vender, half a drachm. Haustus,4tavel 6ta quaq. bora sumen-j Thin draught may be taken every fourth dus. I or sixth hour. •_60 "* _ * '%, "11. ft Pulv. Rhei, gr. xv Magnes. Carbonat. 3ss- Aq. Anethi, f. ^ij. Spirit. Ammon. Aromat. fit xvj. Tinct. Opii, fll xiij. M. u. Mistura, cujussumantur cochl.ij.\ el iij minima bis terve in die, vel ut opus sit t 12. ft Confect. Opii, gr. xv. Aq. Cinnam. — Pimentae, aa f. "vj. Tinct. Kino, f. 31- ----Lav. C. f. 3ss. M. 4bti NEljROoE.-., OR NERVOUS DISEAaK^. [Class 11. The third indication is to be effected by an use of astringents, joined with aromatics and tonics. These remedies are especially adapted to those cases where the irritability of the intestines depends upon a loss of tone, and which may occur, either from debility of the whole system, or from causes acting on the intes- tines alone. The astringents in most general use are, alum, logwood, catechu, and gum kino, which may be administered in any of the forms advised below.* In habitual and long-protracted diarrhoea, some patients have derived much benefit from drinking about a pint of lime-water a day, mixed with an equal quantity of milk, in which an ounce of gum. acaciae has been dissolved. The tonics which are most likely to prove useful are, the cin- chona, cusparia, simarouba, quassia, and cascarilla barks, calumba- root, preparations of iron, and chalybeate waters, together with a proper quantity of Port wiae taken daily. Where this becomes acid on the stomach, Madeira, sherry, or weak brandy and water, may be substituted. The above medicines may be administered as here recommended,! or as prescribed under the head of Dyspepsia. ? 13. ft Aluminis Pulv. Catechu Extract, aa gr. x. Opii, gr. ss. Confect. Ros. q. s. M. ft. Bolusj tei quaterve die capiendus. Vel, 14. ft Misturae Creta;, f. ^v. Extract. Ha matoxyli. 3ss. Aq. Pimentae, f. ^ij. Tinct. Kino, f. 3j- Syr. Zingib. f. 3ij. M. if. Mistura, cochl. ij. magna ter quaterve in die adhibenda. Vel, 15- ft Confect. Aromat. 3j- Aq. Cinnam. f. ?ij. — Fontan. f. ^iv. Tinct. Catechu, f. 3M- ----Opii, fll xxxiv. M. K. Mistura. t 16. ft Cort. Cascaril. Contus. t. ----Simaroub. C.aa 3'j- Coq. ex Aq. Fontan. Oj. ad f. ? viij. Colat. adde Spirit. Cinnam. f. ?j. Tinct. Kino, f. 3ij- M. ft. Mistura, cujus sumat cochl. magna iij ter quaterve in die. » Vel, 17. ft Infus. Cort. Cusparia?, f. ^vj. Tinct. Calumb. f. zj. * 13. Take Powdered Alum, Catechu, of each ten grains. Opium, half a grain. Confection of Roses, a sufficiency to form a bolus, whicli is to be taken three or four times a day. Or, 14. Take Chalk Mixture five ounces. Extract of Logwood, half a- drachm. Pimenta Water, two ounces. Tincture of Kino, one drachm. Syrup of Ginger, two drachms. Of this mixture, the dose may be two large spoonsful three or four times a day. Or, 15. Take aromatic confection, one drachm. Cinnamon Water, two ounces Pure Water, four ounces. Tincture ofCatechu,two drachms. -----Opium, fifty drops. The dose of this mixture to be the same as the former. t 16. Take Cascarilla Bark, bruised, Simarouba Bark, bruised, of each two drachms. Pure Water, one pint. Boil them slowly until reduced to eight ounces, strain off the liquor, and add Spirit of Cinnamon, one ounce. Tincture of Kino, two drachms. Of this mixture,let three large spoonsful be,., taken three or four times every day. Or, 17. Take Infusion of Cusparia Bark, six ounces. Tincture of Calumba, one ounce Order III.] diabetes. 467 From whatever cause a diarrhoea proceeds, whenever it is found necessary to check it, the diet ought to consist of rice boiled with milk, and flavoured with cinnamon, together with preparations of sago or Indian arrow-root, and the lighter sorts of meats roasted, as veal, lamb, or chickens. Weak brandy and water, or diluted wine, may be substituted for malt liquor as common drink, Those who are liable to frequent returns of this disease, either from a peculiar weakness, or too great an irritability of the bowels, should live temperately, avoiding crude summer fruits, most kinds of vegetables, all unwholesome food, and meats of hard digestion. They ought likewise to beware of cold, moisture, or whatever may obstruct the perspiration, and they should wear flannel next to the skin. DIABETES. Weariness and disinclination to" motion or exertion, with the feelings of weakness, dryness and harshness of the skin, costive- ness, great thirst, a voracious appetite, accompanied by an apparent defect in the process of chylificatioh, gradual emacia- tion of the whole body, and a frequent discharge of urine, con- taining a large proportion of saccharine and other matter, which is generally voided in a quantity far exceeding that of the aliment or fluid introduced, are the characteristics of this disease. It has been usual to apply different names, to it, as the diabetes mellitus, wherein the urine is of a fragrant smell, and of the colour and taste of honey, and the diabetes insipidus, with limpid urine, not sweet; but some have considered this division as more fanciful than real, and more systematic than useful. Tinct, Catechu, f. 3'j- Spirit. Pimenta?, f. 3ss. M, ft. Mistura. Vel. 18. ft Cort. Granat. Contus. 3ij. Rad.Simaroub. C. ^ss. Aq. Ferventis. f. ?xvj. macera'per boras duas, et colaturae adde Coafect. Aromat. 3j- Tinct. Card. Comp. f. ^j. M. 'ft. Mistura, cujussumantur cochlearia larg tria ter quaterve in die. Vel, 19. ft Decoct. Cinchonee, f. gjss. Tinct. Ejusd. C. f. 3»j. ----Kino. f. 3j- ----Opii, in vij. M. ft. Hnustus. 4ti« attt 6ti« horis sumendus. Tincture of Cathechu,two drachms. Spirit of Pimenta, half an ounce. Mix them. Or, 18. Take Pomegranate Bark, bruised, two drachms. Simarouba Bark, bruised, half an ounce. Boiling Water, sixteen ounces. Let them infuse for two hours, strain off the iquor, and add to it Aromatic Confection, one drachm. CompoundTincture of Cardamoms. one ounce. Of this mixture, three large spoonfuls are to be taken three or four times a day. Or, 19. Take Decoction of Peruvian B.ark, one ounce and a half. Compound Tincture ofthe same, two drachms. Tincture of Kino, one drachm. --------Opium,.ten drops. Mix them for a draught, to be taken cvrr four or six boi'r=. Lbl; XEL'R0.^E>, OR NERVOUS DISEASE.-.. [ClaSS If. Those of a shattered constitution, and those who'are in the decline of life, are most subject to its attacks. The few cases which have occurred to me in practice, all arose in persons who had addicted themselves to spiritous liquors, and who at the same time fared hard, and were much exposed to cold. It not unfre- quently attends on hysteria, hypochondriasis, dyspepsia, and asthma ; but it is always much milder when symptomatic, than when it appears as a primary affection. Diabetes may be occasioned by a use of strong diuretic medi- cines, intemperance of life, and hard drinking, excess in venery, ^ severe evacuations, immoderate use of acid drinks, excessive labour joined to a poor vapid diet, and the depressing passions, or ,vi hy any thing that tends to produce an impoverished state of the blood, or general debility. Some individuals have an hereditary jiH disposition to the disease, as has been noticed in a communication from Dr. Storer to Dr. Rollo. In some cases it has arisen from an exposure to cold and suppressed perspiration. It has, however, taken place, in many instances, without any obvious cause. That which immediately gives rise to the disease, has ever been considered as obscure, and various theories have been advanced on the occasion. It has been usual to consider diabetes as the effect of relaxation of the kidneys, or as depending on a general colliqua- tion of the fluids. Dr. Richter, professor of medicine in the university of Gottingen, supposes the disease to be generally of a , < spasmodic nature, occasioned by a stimulus acting on the kidneys; hence a secretio aucta urinae, and sometimes perversa, is the conse- &k quence. Dr. Darwin thinks, that in diabetes there is another' ^ passage from the intestines to the bladder,; besides that of the sanguiferous system, through the kidneys, and supposes it is effected by the retrogade motions of the urinary branch of the lymphatic system; which doctrine, although it did not escape the censure of the best anatomists and experimental physiologists, met nevertheless with a very favourable reception on its being first announced. The late Dr. Cullen offered it as his opinion, that the proximate cause of this disease might be some fault in the assimi- latory powers, or in those employed in converting alimentary matters into the proper animal fluids; which theory has since been adopted by Dr. Dobson, and still later by Dr. Rollo, surgeon- general to the royal artillery. The liver has been thought by some to be the chief source of the disease ; but diabetes is seldom attended with any affection of this organ, as has been proved by frequent dissections, and when observed, it is to be considered as accidental. My own opinion as to the cause of diabetes mellitus is, that it consists in a perverted or diseased acton of the kidneys, and that*gn it is by virtue of this action that the saccharine matter in the urine jB is produced, ^ The primary seat of the disease is far from being absolutely &% determined in favour of any hypothesis yet advanced : but from ■■'.' .4 ) Order III.] diabetes. 4ti9 an attentive consideration of all the circumstances, the weight of evidence appears to induce the majority of practitioners to con- sider diabetes as depending on a primary affection of the kidneys. The morbid state in which these organs are usually found on dis- section, certainly strengthens the opinion that they are the primary seat of the disease. From the peculiar matter which is elaborated by the kidneys being secreted in twice its usual quantity, we are at least induced to conclude that their action is very considerably increased. It must, however, be acknowledged, that the excessive increase of appetite, accompanied with an apparent defect in the process of chylification, which are the usual attendants on diabetes, seem to demonstrate that some derangement exists also in the digestive organs. Possibly this ma) be secondarily. Dr. Rollo informs us in his ingenious publication, that from having duly investigated the most remarkable circumstances and changes which took place during the cure in several cases of this disease, he thinks himself authorized to draw the following in- ferences :— 1st, That the diabetes mellitus is a disease of the stomach, &c. proceeding from some morbid change in the natural powers of ■digestion and assimilation. 2d, That the kidneys, and other parts of the system, as the hea.4t and skin, are affected secondarily, and generally by sympathy, as well as by a peculiar stimulus. 3d, That the stomach affection consists in an increased action and secretion, with a vitiation of the gastric fluid, and probably in too active a state of the lacteal absorbents. 4th, That the cure of the disease is accomplished by regimen and medicines preventing the formation of sugar, and diminishing the increased action of the stomach. 5th, That confinement, an entire abstinence from every species of vegetable matter, or a diet solely of animal food with emetics, hepatized ammonia, and narcotics, comprehend the principal means to be employed. 6th, That the success of the treatment in a variety of cases, in a great measure establishes the five preceding inferences. 7th, That the saccharine matter of the disease is formed in the stomach, and chiefly from vegetable matter, as has been shown by the immediate effects produced by the abstinence from vegetable matter and the use of animal food solely. 8th, That acescency is predominant in diabetic stomachs, which continues even some time afterthe entire abstinence from vegetable matter, and after the formation of sugar ; and that while such acescency remains, the disposition to the disease maybe supposed to continue. 9th, That the saccharine matter may be removed in three days, and, by avoiding vegetable matter, will not again be re-produced ; but when the disease and the disposition to it will be finally removed, • annotbe stated with accuracv. Such knowledge may, however, < 470 -veuroseo, or nervous diseases. [Class II. be acquired in those cases where the patients adhere correctly to rules. 10th, That there are two circumstances to be considered in thi> disease, which we may separate in the progress of the treatment: as it has been shown, that though the formation of sugar was pre- vented, yet the increased action of the stomach remained, and maintained the defect of assimilation, which prevented nutrition. Hence two objects occur in the cure ; for it is not yet determined whether the preventing the formation of sugar by an entire absti- nence from vegetable matter, and the use of animal food with fats, if properly persevered in, might not ultimately comprehend the other, namely, the removal of the morbid action of the stomach. 11th, That the lungs and skin have no connexion with the pro- duction of the disease. 12th, That the quantity of urine is probably in proportion to the quantity of liquids taken in, and has but little dependance on an absorption of fluids from the surface of either skin or lun^s. 13th, That though the disease has been shown to consist in an increased morbid action of the stomach, and probably too great a secretion, with vitiation of the gastric fluid ; yet the peculiar or specific condition of either, as forming the disease, is acknowledged to lie in obscurity, and must remain so, until the physiology of healthful digestion is properly explained and established. The following are the objections which have been made to Dr. Rollo's theory of diabetes. 1st, That saccharine matter has not been detected in the blood, or in the stomach. 2dly, That the disease often shows symptoms of dyspepsia or weakness of digestion. 3dly, That the stomach affection may be sympathetic of diseased kidney, from the intimate consent between both : and, 4thly, That the kidneys may be capable of forming or secreting matter under a peculiar action, similar to the breasts of women. In answer to the first of these objections, Dr. Rollo has replied, that it is difficult to ascertain the exact period in the process of digestion, when this change may be lcoked for, and therefore an emetic might fail in affording the necessary contents. With respect to the blood, Dr. Dobson affirmed the existence of saccharine matter in diabetic blood. In several instances, the serum was turbid and wheyish, and it did not, on standing, undergo the usual changes of animal matter. To the second objection which has been made to Dr. Rollo's doctrine, he answers, that the increased action of the stomach is of a morbid, kind, and connected with debility: being, therefore, irregular and imperfect, it does not accomplish digestion. To the third objection, Dr. Rollo has replied, that the stomach affections which exist in diabetes, are entirely different from those which take place in consequence of primary morbid conditions of the. Iridnev. He observes, besides, that mo^t cases of the di«ea«e Order UI.J JJJAUKTEs". L/l have been preceded by stomach derangement, or have been pro- duced by causes immediately operating on the stomach. To the fourth objection he observes, that the kidneys are not secreting organs, but separating only, and that a much greater change in their structure than has ever been found must take place before they could become capable of secretin saccharine matter. He further notices, that in some instances of diabetes the structure of the kidneys has not been visibly changed. In support of the doctrine which Dr. Rollo advances, he has used the following arguments :— 1st, The fact, that a stomach affection generally precedes the urinary characteristic symptoms of the disease. 2dly, The fact, that a stomach affection always attends the disease, which materially differs from that sympathetic of primary kidney affection. 3dly, The fact, that a diet of animal food, with an entire abstir nence from vegetable or other matter capable of forming sugar in the stomach, removes speedily the general symptoms, the saccha- rine matter, the quantity of urine, and its unnatural state. 4thiy, The fact, that dissection has shown no morbid condition of the kidneys, but what may be referrible to a continuance of increased action from the application of a simple stimulus^ and probably sympathy, augmenting merely the capacity of their vessels. Such are the arguments brought forward by Dr. Rollo in favour of his theory; but a still stronger than any of these is the success which has attended his mode of treatment, and which, on his recom- mendation, has been pursued by other practitioners witha happy effect in some cases of this disease. Diabetes sometimes comes on slowly and imperceptibly without any previous disorder, and it now and then arises to a considerable degree, and subsists long without being accompanied with evident disorder in any particular part of the system, the great thirst which always, and the voracious appetite which frequently occur in it, being often the only remarkable symptoms; but it now and then happens, that a considerable affection of the stomach precedes the coming on of the disease, and that in its progress, besides the symptoms already mentioned, there is great dryness of the skin, with a sen>e of weight in the kidneys, and a pain in the ureters, and the other urinary passages. The temperature of the body is usually below the standard of health. The spirits are depressed, the dispo- sition is equally indifferent to study or amusement, and there is evidently a decline of mental energy, with a loss of the power of virility. Ulceration of the tongue and gums are of frequent occurrence in diabetes, owing probably to the derangement of the digestive functions. Some morbid change in the alvine excretion always accompanies the diabetic habit, and costiveness is perhaps the most common of these : for in some instances the bowels have been so remarkably torpid, that even the most powerful medicines. •4"'- ' ;\i.liRObi>, OK WKliVOtfS l/l^EAaEr*. [Glass. ^ 11^ in large doses, produced but a trifling effect. \rery frequently some degree of inflammation and swelling about the external orifice of the urethra is to be observed.* It has been remarked, that diabetes is often preceded or accompa- nied with a pulmonic affection ; and we are told by Dr. Bardsley,t that he does not recollect an instance of the disease which was not attended with some affection of the chest. Under a long continuance of the disease, the patient becomes much emaciated, the feet oedematous ; great debility arises, and an obscure fever, with all the appearances of hectic, prevail. In point of number the pulse is very much diversified : in most cases it is quicker than natural, but sometimes it is below the common stand- A, ard ; but whether it be quick or slow, it is generally such as to9 denote great debility in the system. In some cases vision becomes very indistinct, and the patient is troubled with vertigo. The urine, in diabetes, from being at first insipid, clear, and eolourle'ss, soon acquires a sweetish or saccharine taste, its leading characteristic in many instances. From some experiments which were made on diabetic urine, the following conclusions have resulted:—1st, That it contains neither urea, nor the earthy phosphates. 2dly, That it does contain a gfe considerable quantity of a brown extract, united with a proportion of sugar: and, 3dly, That when the sugar is absent, its place is sometimes supplied by a bitter principle. ,. In some instances the quantity of urine is much greater than can f be accounted for from all the sources united. Cases are recorded ' % in which from twenty-five to thirty pints were discharged in the s^ace of a natural day for many successive weeks and even months; and in which the whole ingesta, as was said, did not amount to half the weight of the urine. To account for this overplus it has been alleged that water is absorbed from the air by the surface of the <] body, as also that an extraordinary quantity of water is com- pounded in the luugs themselves. Dr. Rutherford, professor of botany in the university of Edin- burgh, has found, on examining diabetic blood, that it appears to be deficient in the usual quantity of hydrogen gas. He supposes that this deficiency of hydrogen gas has been consumed by uniting, in the lungs, with the oxygen of the atmosphere, and thus forming water. The water thus generated is taken up by i idic lymphatics, carried to the bronchial glands, and through them 'poured into the general mass of blood, whence it is eli- minated by the kidneys. Dr. Darwin Is of opinion, that in the aqueous diabetes the cuta- neous absorbents frequently imbibe an amazing quantity of atmo- spherical moisture : and although it has been mentioned by Dr. Rollo, that one patient whom he weighed, after being ten minutes jn a warm bath, did not weigh heavier on his leaving it, still he ^eCa-vs of Diabetes- byR. Watt, p. 139. * See his Medical Reporjts. 0 fde r III. J o i v b e i E& \ < 3 suspects that if the bath be made very* hot, perhaps much above animal heat, the bather may perspire more than he absorbs, and become in reality lighter. In a bath of moderate heat, provided the patient has been previously exhausted by abstinence or fatigue, he iriay be likely, Dr. Darwin thinks, to absorb much ; but if his system be already'full of fluids, from the food and liquids which^ he has previously eaten and drank, he may not then absorb any thing. : That the cutaneous absorbents can imbibe such a quantity of atmospheric moisture as to account for the surplus of urine over the aliment and fluids which are taken, I am by no means inclined to admit. It has been usual to regard this disease as always attended with great difficulty of cure, and no inconsiderahle degree of danger, particularly where it attacks persons advanced in years, or whose Constitutions have suffered much by any debilitating cau.se what- ever, especially hard drinking ; but if we are to credit Dr. Rollo's report, which seems both candid and ingenuous, and has indeed been confirmed by the testimony of other practitioners who have adopted the mode of treatment he recommends, wre may presume that it need not in future be regarded in so unfavourable a light, and that cures may be effected under unpromising circumstances, provided a rigid compliance with his plan is observed. Great abatement of the thirst, and extraordinary desire for food, the skin becoming soft to the touch and perspirable, the bowels more lajt or regular, the urine being voided less frequently, and in smaller quantity each succeeding day, being at the same time of a more natural colour, taste, and smell, the dyspeptic affection being much diminished, and the bodily strength somewhat recruited, together with a return of mental energy, are to be regarded as very favourable symptoms ; whereas the contrary denote a fatal termi- nation sooner or later. Dissections of diabetes have usually shown the kidneys to be much affected. In some instances they have been found in a loose flabby state, much enlarged in size, and of a pale ash colour; in others they have been discovered much more vascular than in a healthy state, approaching a good deal to what takes place in inflammation, and containing in their infundibula a quantity of whitish fluid, somewhat resembling pus, but without any sign of ulceration whatever. At the same time that these appearances have been observed in their interior, the superficial veins on their surface were found to be much fuller of blood than usual, forming a most beautiful net-work of vessel^ the larger branches of which exhibited an absorbent appearance. In many cases of dissection, the whole of the mesentery has been discovered to be much dis- eased, and its glands remarkably enlarged ; some of them being very hard, and of an irregular texture ; others softer, and of an uni- form spherical shape. Many of the lacteals have, likewise been seen cTansiderablv enlarged. The liver, pancreas» spleen, and stomach. 474 NEUROSES, OR NERVOUS DISEASED. [Class If. are in general perceived to be in a natural'state; when they are not so, the occurrence is to be considered as accidental. The bladder is now and then found to contain a quantity of muddy urine ; in some cases its coats are much thickened, and its size less than natural. The fat within the thorax, abdomen, and pelvis, in some instances, has seemed entirely converted into a gelatinous-like matter, some- what of an amber colour, and, when slightly pressed between the fingers, did not appear unctuous. The subcutaneous fat is found in general much diminished. The treatment of diabetes has hitherto been conducted on the principles of diverting the increased discharge elsewhere, and af- terwards of restoring the tone of the parts. The first indication has been attempted by a use of remedies which open the pores, such as emetics exhibited occasionally, dia- phoretics, the warm bath of about 96 or 98 degrees of heat, addU tional clothing, or the removal to a warm climate. As diaphore- tics, the pulvis ipecac, compos, and antimonials combined with opium, have principally been employed. For the purpose of diverting the increased discharge, blisters are sometimes applied over the region of each kidney in succession, and the ulcerated parts kept open afterwards by the unguentum lyttae, or ceratum sabinae. The second indication has been aimed at by astringents and tonics. The astringents which have been most used are, alum, zinci sulphas, gum kino, catechu, and the sulphuric and nitric acids, but the first and second seem to be the most efficacious, and may be combined together as below,* or be given separately. The tonics generally employed are the different preparations of cinchona, myrrh, and chalybeates, as advised under the head of Dyspepsia, together with cold bathing. The Bristol Hot-well waters, when drank at the fountain head, have long been celebrated for their good effects in this disease, and have by many been looked on as a kind of specific ; they may there- fore be resorted to, if the situation and circumstances of the patient will admit of it; but if not, he must be content to substitute lime- water, which may betaken in the quantity of a pint or quart a day, mixed with an equal proportion of milk. By dissolving about half an ounce of gum. acaciae in each pint of milk,, some further advan- tages may possibly be derived. The mephitic alkaline water has been much recommended in this disorder, and it is probable thatSchweppe's soda-water may be of * 1. r>s Aluminis, gr. xij. Zinc, Sulphur, gr. ij. jOpii, gr. ss. 'Confect. Rose, q. s. , ft. Bolus, ter quaterve die sumendus super bibendo Liquor. Calcis, f. ^iv. * 1. Take Alum, twelve grains. Sulphate of Zinc, two grains. Opium, half a grain. Confection of Roses, a suffi- ciency to form a bolus, to be taken three or four times a day, washing it down with about four'omir.r* of Lime Water. ijrdcr III.J '• DIABETES- 475 service, as it is well calculated to relieve acidity in the stomach. The soda will be preferable to the vegetable alkali, as being less likely to act on the kidneys. Administering large doses of opium has occasionally been found highly useful in this disease. Some cases recorded in the 4th volume of the Medical Transactions of the London College of Physicians, by Dr. Warren, clearly show the very great influence which opium is capable of exerting over the Morbid secretion of the kidneys in this disorder, and point it out as a remedy worthy of attention in addition to animal regimen.* The tinctura lyttae is a medicine which has sometimes been employed in diabetes. Rubbing the skin with oil, or any adhesive liniment, so as to put a stop to the supposed absorption of fluids thereby, has been much recommended in diabetic cases. From experiments made by Dr. Gerrard, of the Liverpool Infirmary, as well as by Dr. Rollo, it does not appear however that there is any absorption of fluids by the skin in this disease, for the body gained nothing by im- mersion in a warm bath : this remedy seems therefore of a doubtful nature. To assist the effects of the means which have been advised, gentle exercise on horseback, along with frequent friction over the kidneys by means of a flesh-brush or flannel, when not in a blistered state, together with warm clothing next to the skin, ought to be used. The patient is at the same time to abstain from all strong drink, to make use of animal food as much as possible instead of vegetable, and by all means to avoid external cold, as any thing that checks the perspiration cannot fail to determine a large quantity of fluid to the kidneys. While we pursue these steps, we are to obviate costiveness, and keep the body perfectly open, either with rhubarb or an infusion of senna. When diabetes is symptomatic of hysteria, hypochondriasis, or asthma, the proper remedies for the primary disease should be administered. The mode of treatment which has just been laid down is, with some small improvemnt, that which has been pursued by most practitioners, but it must be acknowledged to have proved in many instances very ineffectual. This being the case, it is proper to make mention of the plan recommended by Dr. Rollo, which is said to have often performed a cure under the most unpromising circumstances. The indications to be attended to, he supposes to be, to destroy the saccharine process going on in the stomach; to promote a healthy assimilation; to prevent a supposed increased absorption by the surface ; to diminish the increased action, and to change the imagined derangement of the kidneys. To answer these indications Dr. Rollo enjoins a diet consisting - See al?o Clinical and Pathological Reports, by Dr. S. Black, Case i. \>, 203- + 76 NEUftGSEo, . 487 ing the heads of maniacal subjects are, an opacity of the arachnoid membrane, and occasionally a thickening thereof; a preternatural determination of blood to the membranes as well as the substance of the brain itself; together with an effusion of water into the ven- tricles, and between its membranes and convolutions. Exclusively of these, ossification of some of the arteries, or a preternatural hardness of the substance of the brain, is occasionally observed. Sometimes the pineal gland has been discovered charged with sabulous matter. Mania ever has been found on dissection to be connected with a morbid state of the brain and its membranes; but whether this peculiar state ought to be regarded as the cause or effect of the disease, is a point not yet satisfactorily ascertained. From the anatomical observations of Dr. G reding, it appears that the greater number of insane people fall into a state of atrophy or decay towards the close of their life, as it was observed that of one hundred maniacs sixty-eight died in this way. Of all diseases, hydrothorax appeared to be that to which maniacs are most subject, for out of one hundred of them, seventy-six laboured under it. We are informed by the same gentleman, that consump- tion from an ulcerated state of the lungs appears to be another disease which frequentlj terminates the existence of insane people, as it was found that of one hundred maniacs there were forty who laboured under phthisis pulmonalis. Mr. Haslam has observed, thatmaniacs are more liable to attacks of apoplexy and palsy than other diseases. Insane people are very subject to mortification of the toes, feet, and nates, when closely confined, which shows their susceptibility to the effect of cold. The helpless, insane, and bed-ridden patients are very liable to be attacked with a mortification^of the buttocks. It therefore appears a most advisable point that all asylums for the insane should be warmed by means of flues and heated air. In the internal economy of all such buildings this would be an important and humane improvement. The treatment of mania consists in the management of the patient, in humouring the subject of the mental disease, and the aid which medicine may afford ; but although the first is of great consequence, still where the mental faculties are only partially affected, the assistance of medicine is of high importance. That maniacs require medical aid in the first stage of the disease, cannot, I think, admit of a doubt; and very likely the recovery of such persons will depend in a great degree upon early medical attention and assistance; without it the chance of a cure will be much lessened. When the disease arises in women, (which it is apt to do between the ages of sixteen and forty,) moral treatment alone, let the management be ever so proper, will not be likely to recover them without the aid of medicine. In the management of the insane, the great objects to be aimed at are, in the first place, that the invalids be separately and properlv classed, both in respect to their ages, sexes, condition in life, and 483 \EtRO.SES, OR NEfiVOl? OlSEAsEa. [Class II. kind or degree of their disorder. Secondly, free ventilation, so insured as to guard against undue exposure to the inclemencies of the weather. Thirdly, a rigid system of cleanliness. Fourthly, such a judicious regulation both of mental and bodily exercise as shall excite without fatigue, and exhilarate without exhaustion : and, lastly, a combination of tenderness, lenity, and conciliation, with proper firmness, at the same time, on the part of the keepers. It should always be the object of the superintendant and keeper to gain the confidence of the patient, and to awake in him proper respect and obedience, which is to be effected by discipline of temper and dignity of manners. Tyrannical severity may excite fear in the lunatic, but it will be mingled probably with contempt. In the management of insane persons, the superintendant must endeavour to obtain a complete ascendancy over them. When this is once effected, he will be enabled on all future occasions to direct and regulate their conduct according as his judgment may suggest. He should possess firmness, and, when occasion may require, should exercise his authority in a peremptory manner. He should never threaten but execute, and when the patient has misbehaved, should confine him immediately ; and as example operates more forcibly than precept, it will be best to order the delinquent to be confined in the presence of the other patients, be the institution a public or private one. Such a conduct will display authority; and the person who has misbehaved becomes awed by the spectators, and more readily submits. When the patient is a powerful and strong man, two or more keepers should assist in securing him; for when the maniac finds his strength or skill in the contest pre- vail, he is sure to make the most of such an advantage, and the con- sequence of this victory has sometimes proved fatal to the keeper.* When coercion is absolutely necessary, such an overpowering force ought to be employed as to preclude all possibility of success- ful resistance, by which means every idea of making any at all will most commonly be extinguished. The keeper should convince the maniac that all impropriety of conduct will be restrained. A prudent and vigorous coercion will generally restrain the fury, and sometimes restore rationality very speedily. He must then be treated with lenity and kindness, and with the manners due to his station in life, which will insure the respect of the pupil to his master, upon which every indulgence consistent with safety and propriety may be allowed. It is obvious, therefore, that a system of intimidation without cruelty, of restraint without indignity, of rigid order and discipline, combined with lenity and conciliation, is the only rational and successful method of combating the extravagances of lunatics. To obtain a salutary influence over the wanderings of a maniac, we ought first to secure his confidence. This cannot be done without behaving towards him with a delicacy due to his unfortu- * See Observations ou Madness, by Mr. Haslam. Order IF.J MADNESS. 4«y nate state, which for the most part ought to be regarded, not as an abolition, but as a suppression merely of the rational faculties. There is indeed ground to apprehend that fugitive folly is too often converted into a fixed and settled frenzy; a transient guest into an irremovable tenant of the mind ; an occasional aberration of intel- lect into a confirmed and inveterate habit of dereliction, by a premature and too precipitate adoption of measures and methods of management, which sometimes indeed are necessary, but which are only so in cases of extreme and ultimate desperation. At some asylums for the reception of insane persons, but more particularly those of a public nature, we have just reasons for apprehending that severe and harsh treatment is not unfrequently resorted to, and the strong principle of fear sternly applied by blows, the strait waistcoat, or chains,* to be the most usual means adopted for correcting the wanderings of reason, or the diseased ebullitions of passion; as it is less trouble to fetter by these re- straints than by the assiduities of sympathy or affection. Nothing, however, has a more favourable and controlling influence over one who is disposed to, or actually affected with melancholia or mania, than an exhibition of friendship or philanthropy, excepting indeed, in such cases, and in that state of the disease in which the mind has been hardened and almost brutalized by having already been the subject of harsh and humiliating treatment.! r3y an experiment made in an asylum near York, named the Retreat,J it has been ascertained that the best effects have re- sulted from a system, the prevailing feature of which is kindness, and even certain degrees of indulgence ; and that the proportion of old or hopeless cases which have been discharged from thence cured, very far exceeds that from St. Luke's or Bethlem. At the Retreat, the convalescents of every class are frequently introduced into the society of the rational parts of the family. They are also permitted to sit up till the usual time for the family to retire to rest, and are allowed as much liberty as their state of mind will admit. Although the effect of fear is not excluded from this institution, when indispensably necessary, yet the love of esteem is considered as a still more powerful principle. There are two asylums for lunatics in the immediate vicinity of Salisbury, the place of my residence ; the one at Laverstock, under the direction of Dr. Finch ; the other in Fisherton, under that of Mr. Charles Finch. The former is on a large and very extensive scale, and of course the patients are numerous ; the latter being on a more limited plan, receives fewer patients, which no doubt will be considered by many as a matter of high importance. In both of these asylums the patients are treated with the greatest atten- tion, kindness, and lenity ; they are allowed every indulgence and recreation consistent with their safety and welfare. Bodily restraint * See Report of the Evidence before a Committee of the House of Common^ f See Essays on Nervous Affections, by John Reid, M. D. f: See Description of the Retreat near York, bv Samuel Take. 63 490 neuroses, or nervous diseases. [Class II. is employed only on the most urgent occasions, or during violent furious paroxysms, and then the mildest is necessarily resorted to. Both asylums are pleasantly situated, they command extensive prospects over a fine country, and have considerable pleasure grounds attached to them, where the patients take daily regular exercise and breathe pure air, without being exposed to the view of persons passing by. In both asylums the paupers are kept dis- tinct from those in e. superior station of life, and the male and fe- male patients are accommodated considerably apart from each other. From the most scrutinous observations, I am induced to enter- tain a very favourable opinion of the conductors of both of these asylums, and therefore can recommend them to the attention of those who may have relatives or friends afflicted with mental de- rangement under any form whatever. Under slight attacks of mania, where the degree of irritation is trifling, as well as during a state of convalescence, it will not be necessary to confine the patient within doors in fine weather ; taking care, however, at the same time, to put it out of his pow- er to escape, or do any injury either to himself or others. His mind is to be soothed, and his attention diverted as much as pos- sible, by getting him to engage in some exercise or amusement, that will employ both body and mind at the same time, and that will divert the latter from pursuing any train of thought. He should be recommended to avoid as much as possible thinking up- on questions of a perplexing and intricate nature. In melancholia, this plan will be doubly necessary, and we may likewise allow en- tertaining books, cheering company, amusing scenes, music of the exhilarating kind, playing at billiards, or even cards. If the patient is fond of gardening, the employment of some portion of his time in this way will prove both healthy and agreeable. It has been observed, that in all institutions for the insane, the male patients, who assist in digging, planting, weeding, wheeling, wood-cutting and making fires, &c. and the females who are employed in washing, ironing, and scrubbing floors, often recover; while persons whose rank exempts them from performing such services, languish away their life within the walls. In the management of insane persons, the value of exercise and employment is to be highly estimated. Female patients may be employed in sewing, knitting, or domestic affairs, and many of the convalescents may assist the attendants. Of all the modes by which patients may be induced to restrain themselves, regular employment is perhaps the most efficacious, and those kinds of it ought doubtless to be preferred, both on a moral and physical account, which are accompanied by considerable bodily action ; that arc most agreeable to the patient, and which are most opposite to the illusions of his disease, or the hallucination possessing the mind. At the Lunatic Hospital, at Charenton,* in France, the * The author of the Modern Practice of Physic here begs leave to return hi« best thanks to M. Goven attached to this Asylum, for the honour done him by trans- lating this work into the French language Order IF.] MADNESS. 491' experiment has been made to induce the patients to act plays for their amusement. To these exhibitions their friends were invited, and a beneficial effect was produced thereby.* It has been asserted, that some maniacs have been cured by- being compelled to constant, and even harddabour; and as a forced attention to the conduct of any bodily exercise is a certain mean of diverting the mind from pursuing any train of thought, it is probable that such exercise may be useful in many cases of mania. Monsieur Pinel, in his Treatise on Insanity, tells us, that at the principal hospitals in Spain, but more particularly the one established at Saragossa, the maniacs capable of working are distributed every morning into separate parties. An overlooker is appointed for each class, who apportions to them all, individually, their respective employments, directs their exertions, and watches over their conduct. The whole day is thus occupied in salutary and refreshing exercises, which are interrupted only by short intervals of rest and relaxation. The fatigues of the day prepare the labourers for sleep and repose during the night. Hence it happens, that those whose condition does not place them above the necessity of submission to toil and labour, are almost always cured; whilst the grandee, who would think himself degraded by exercises of this description, is generally incurable ; by retaining his privileges, he retains his lunacy. In violent states of mania, the patient should be confined alone in a dark and quiet room, so that he may not be affected by the stimuli of light, and sound, such abstraction more readily disposing to sleep. To prevent him from committing any violence, his hands ought to be properly secured with manacles, and he may likewise be confined by one leg, or he may be strapped by the hands and legs in a large chair fastened to the floor. As an horizontal posture tends to increase the fullness of the vessels in the brain, this should be avoided in the day-time. The strait waistcoat is another mode of confinement well calculated to prevent maniacs from doing any injury either to themselves or others: but in the furious state, and particularly in warm weather, it is apt to irritate and increase that restlessness which patients of this description usually labour under. Where malevolence forms a prominent feature, and the person is very furious, close confinement in the manner just detailed is doubly necessary; but chains are not to be used on any occasion. In some asylums, but more particularly in the ward at Guy's Hospital appropriated to insane persons, when bodily restraint is deemed absolutely necessary, instead of the strait waistcoat, in hot weather, a strong leathern belt is substituted, which is girded round the body, with a small strap round each arm; and this allows the patient the use of his hands without occasioning heat, as ' See Paris, par Monsr. San;zur. 492 NEVROSES, OR NERVOUS DISEASES. [ClOSS H. the strait waistcoat does. This mode of restraining violent patients appears therefore decidedly preferable to the other. The straw on which such persons lie as are insensible of the calls of nature, ought to be changed very frequently, and the strictest attention paid to their bodily cleanliness, and that of their apart- ments, by frequent washings, and proper ventilation throughout the day. The wet patients at Guy's are lodged on bedsteads lined with lead and sloping to one corner, which occasions the urine to run off without any offensive smell remaining, as is the ease in other houses. In slight cases, where the patient is in a condition to be sensible of restraint, he may be punished for any improper behaviour by confining him to his room; by degrading him, and not allowing him to associate with the convalescents, and by withholding those indulgences he has been accustomed to enjoy ; the infliction of corporeal chastisementought never to be resorted to. All violence and harsh treatment on the part of domestics should strictly be proscribed, being a law of fundamental importance, and highly jessential to the prudent and successful management of all institu- tions for insane persons. Moreover, any confinement of the patient beyond what is absolutely necessary will inevitably tend to create such an irritation of mind as might greatly interfere with the cure. In most of the public asylums there is an insufficiency of the number of keepers in proportion to the number of persons intrusted to their care, which unavoidably leads to a proportionably greater degree of restraint than the patients would otherwise be under, and this unnecessary restraint must greatly tend to retard recovery. Another evil by which the recovery of patients is not unfrequently retarded, is, that many of such asylums receive a greater number of insane persons than can comfortably be accommodated, in con- sequence of which several are lodged in the same room, and not unfrequently two or more are put into the same bed.* Moreover, in some of the asylums they do not pay proper attention in sepa- rating those patients who are violent and outrageous from those who are quiet and inoffensive ; nor those who are insensible to the calls of nature, from those who are cleanly and orderly. The placing a patient afflicted with deep religious melancholy in the same apartment with one who makes a sport of religion, or to associate a person of a timid disposition with an individual of a violent character, is to commit an act of cruelty towards one of the parties, and highly prejudicial to both. The congregating insane persons together in this promiscuous way, is certainly an evil of pernicious tendency; and therefore I repeat, that the separating and properly classing such invalids, both in respect to their sexes, ages, condition in life, and kind ordegree of theirdisorder, is a point of high importance in their management within all lunatic asylums. * See Report from the Committee of the House of Commons on) Madhouses inEngland Order 1F.J MADNESS. 493 Persons in a state of, convalescence ought always to be kept apart from those who are labouring under a paroxysm of the disease ; for by having constantly before their view those who are suffering under the disgusting or affecting symptoms of the malady, their cure would probably not only be retarded, but be ultimately prevented. Insane persons should be made to rise early, to take such exer- cise as their condition will admit of, and have their food served up to them at stated times. Independently of such regularity contri- buting to health, it also renders them more manageable. In all cases of madness it will be proper to remove the patient from those objects with which he was formerly acquainted, as (hese might call up ideas and the various associations; and on this account, a change of situation, and removal from his friends, will be advisable; for it is a fact well known to those who superintend lunatics, that patients are seldom or never recovered at home. It not unfre- quently happens, indeed, that maniacs, who have been brought immediately from their families, and who are said to be in a violent and ferocious state at home, become suddenly calm and tractable when placed in a lunatic asylum. On the other hand, it is equally a fact, that there are many patients whose disorder speedily recurs after having been suffered to return to their families, although they have for a length of time conducted themselves, under confinement, in a very orderly manner. The restraint, cunning, and dissimulation, which many insane persons are capable of, are well known to those who are conversant with them; but the ignorant are apt to cry out against secluding them from society, because they probably happen to conduct themselves with propriety before strangers, and in short conversations appear coherent and rational. To attempt the complete seclusion of a maniac in a furious state at his own house, in the bosom of his family, is by no means desirable; and indeed it is seldom practicable ; for a patient con- fined at home naturally feels a degree of resentment when those whom he has been accustomed to command, refuse to obey his orders, or attempt to restrain him. If, however, a patient be rich, quiet and manageable without coercion, the attendance of an affectionate wife, or husband, brother, sister, or friend, may, with proper instruction, be able to do much more than can be expected where a great number are to be attended to. Various objections have indeed been raised against sending maniacs to a place of confinement, both among the highest and lowest classes of society. A principal one is, the fear of severe and cruel treatment, and the hazard of rendering the disorder per- manent ; but these apprehensions appear groundless; for there must be some grievous defect in the mode of amending the dis- ordered mind, if correct sentiments and rational and orderly beha- viour are not inculcated by the habit of self-denial and strong 494 NEUROSES, OR NERVOUS DISEASES. [ClaSS 11. efforts of the will. Let the appeal be fairly made by visiting a maniac at his own house, or at an establishment appropriated for the reception of such persons. To endeavour to refute the notions of lunatics will be labour in vain ; it will be best to coincide with their extravagancies, and apparently to humour the prevailing hallucination. The skilful physician will always endeavour to investigate the maniacal idea or hallucination, as it may not only acquaint him with the probable designs of the patient, from whence may be deduced the necessity of confinement, but also may sometimes lead to the most effectual plan of cure. A late writer* on mania, who has long kept an establishment for the reception of lunatics, of both sexes, has recorded a number of striking examples, where, by humouring the subject of the mental disease, the most happy effects ensued, and the patients were perfectly restored to reason and health. To assist the young practitioner in applying a judi- cious moral treatment under similar circumstances, I transcribe one of the cases, which is as follows : Case 2d. Mr.----, aged 40, of a spare and melancholic tempe- rament, remarkable for general and almost universal acquired knowledge, and always possessing singular equanimity, had injured his health by too close an attention to extensive mercantile con- cerns. At length he was observed to be very attentive to every feeling, of which he made minute descriptions to his family: this increasing, he became a prey to empiricism, read several ridiculous popular pamphlets, and was soon worked up to a belief that his body was the common receptacle of disease: pills, potions, powders, unctions, lotions, and mercurial girdles, were employed and dismissed in succession. The metallic tractors for a time amused him, till it was proved to the patient and to his friends who witnessed the experiments, that these expensive baubles possessed no more properties than a rusty nail. All the fears of the patient became at length concentred into one ; from the contemplation of, and conversation on which, no argument could divert him: he believed all his sufferings arose from repelled itch. A formal con- sultation of medical men was therefore determined on, who having previously agreed on the propriety of humouring the subject of the mental disease, were unanimously of opinion the conjecture of the patient was just. A medical plan was laid down ; some rube- facient applications to different parts of the body occasioned crops of eruptions from time to time, which were washed with some simple preparation. This farce continued a few weeks, and the patient at length was perfectly restored to health and reason. A number of cases tending to show the great utility of investi- gating the maniacal idea or hallucination are likewise reported by Dr. Darwin in the 4th volume of his Zoonomia, page 66. With regard to the diet of maniacs, it is only necessary to * See Practical Observations on Insanity, by J. M. Cox. M. P. Order IF.] VIADNEftS. 195 observe, that it should be conformable to the general curative plan. If the whole treatment is antiphlogistic or lowering, the diet must be similar : if the curative plan be tonic, the diet must correspond ; and if at the same time tonics combined with aperients are indi- cated, the diet ought not to be in opposition. Although temperance is strictly to be enjoined, still wine may be allowed in moderation during a state of^convalescence in melancholia. The criterion of the proper quantity should be that which does not affect the temper of the patient, nor exasperate his aversions. Maniacs who are paralytic, require to be kept warm, and to be allowed a more nutri- tious diet, and cheering beverage, than insane patients of any other description. In the winter months they suffer extremely. Lunatics sometimes refuse all food for many days, so as to endanger their lives. In private receptacles it isusual, Mr. Haslam says, to have recourse to the operation of what is called spouting, whereby the front teeth are commonly broken and destroyed. To prevent this, he recommends an instrument,* by which food may be conveyed into the stomach with great facility, and without any injurious consequences to the teeth. Bleeding has been much employed in mania. In paroxysms of madness, which are preceded by a heightened complexion, wild- ness and prominence of the eyes, and exuberant loquacity, or where there is obvious plethora, or evident determination and congestion about the head, a use of the lancet, no doubt, is often attended with a happy effect; but bleeding, practised as it fre- quently is, without rule or bounds, among maniacs, often exaspe- rates the complaint, and reduces the patient to a state of extreme debility, occasioning periodical and curable mania to degenerate into idiotism. Where absolutely necessary, drawing blood from the jugular veins will be preferable to taking it from the arm, or we may draw it from the head, by applying six or eight cupping- glasses to the scalp, after having it shaved. From eight to sixteen ounces may be drawn off in this way, and the operation be repeated as circumstances may require. Blood when drawn in mania does not display the inflammatory crust or buff, and therefore copious and indiscriminate blood- letting in cases of insanity is neither proper nor necessary. It should be borne in mind that there is a wide difference between insanity and phrenitis, and that venesection is only advisable in the first of these diseases, where there is considerable turgescence in the vessels of the head, or in very plethoric habits. Against mere insanity, unaccompanied by bodily derangement, medicine appears to be almost powerless; but where an insane person happens to be diseased in body as well as mind, medicine, or more strictly medicinal treatment, is not only of as great impor- tance to him as to any other person, but much greater, as diseases of the body are commonly found to aggravate those of the mind. '' 'Sec his Observations on Madness, 496 NEUROSES, OR NERVOUS DISEASES. [ClaSS II. In acute cases of mania, patients require speedy as well as regular assistance to prevent that disorganization which might lead to protracted or incurable insanity. For the purpose of obviating the fullness and tension of the vessels of the brain, purging is generally adopted, and medicines of the drastic kind, such as hellebore, are often made use of; but more advantage will be derived from a frequent exhibition of the potassae tartras and other saline cooling purgatives, which are the principal medicines to be depended upon in mania. It is an assiduous, a continued, an alternating and alterative use of cathartic and opening medicines, the operation of which is gentle, that promises, and in reality has proved, to be beneficial in cases of madness and melancholy. When the nervous system is so much deranged as the cases in question suppose, there is almost invariably a tendency to faulty action in the first passages, and their immediately connected viscera. This state of the stomach and bowels comes in the course of time to react as it were upon the nervous system, and to prove an occasion for the continuance of that derangement of which it was at first a mere consequence. Cathartics* are of the utmost importance therefore in the treat- ment of insanity, but more particularly when the excitement is great; and as constipation is a common occurrence with maniacs, those who have their superintendance should regularly inquire into the state of their bowels. In obstinate cases the submuriate of mercury joined with a few grains of the extract, colocynth. c. may be used. In periodical mania, the paroxysms are usually preceded by obstinate costiveness ; and a dose or two of some purgative medicine, at an early period, will frequently put a stop to the progress of the attack; which fact ought to have due weight. Moreover, it has frequently happened, that a speedy convalescence has ensued in mania after the coming on of a diarrhoea, and in a few instances it has proved a cure. At the commencement of the paroxysms of furious madness, where the eyes look wild and rambling, and there is high excite- ment, both purging, venesection, and the topical abstraction of blood from the head, by means of several leeches, or the appli- cation of cupping-glasses preceded by scarification, will un- doubtedly be proper, in addition to having the head shaved, and linen cloths, wetted in some evaporating lotion, kept constantly applied to it: but in melancholia, where there is extreme depression both of strength and spirits, neither active purging nor bleeding should be adopted. In such cases, all debilitating means ought to be avoided, as tending to aggravate the symptoms of the disease, and to increase the probability of supervening idiotism. ' 1. R Infus. Sennae.f. qjss. \* 1. Take Infusion of Senna, one ounce and a half Potassa? Tartrat 3'ij. Tartrate of Potass, two drachms Tinct. Jalapae, f. 3ij. Tincture of Jalap, two drachms. Syrup Rhamni. f. 3j. M. 1 Syrupof Buckthorn, one drachm ft Haustus catharticus. : Mix them, for a cathartic draught OrderlF.J madness. 497 Emetics have been recommended by some physicians* in mania, but by the generality of them they have been disapproved of, as being likely to increase the determination to the head, and occa- sion apoplectic or paralytic attacks. We are told by Mr. Haslamj thatfrom many years' observation and administration of many thou- sand emetics to insane persons at Bethlem Hospital, he has notjbeen enabled to place any confidence in this class of medicines, asa cure for insanity; admitting, at the same time, that the lunatic, whose stomach was in a disordered state, has been equally benefited with a person in his senses by the operation of a vomit. In my opinion, emetics ought not to be administered, except with the view of removing symptoms that may be concomitant with mania. Small and frequent doses of the antimonium tartarizatum, so as to excite a slight degree of nausea, and thereby determine to the surface of the body, may however be serviceable in those cases where there is a high degree pf excitement. Cold bathing, by diminishing irritation, is a remedy by which maniacs have been relieved, and sometimes entirely cured, espe- cially when applied in a certain manner. This consists in throwing the person into cold water by surprise, by detaining him in it for some length of time, and pouring water frequently on his head, while the whole of the body except the head is immersed ; and thus managing the process, so as that, with the assistance of some fear, a refrigerant effect may be produced. That the external application of cold may be of service, we have full experience from the bene- fits which have been received in some maniacal cases from the ap- plication of ice and snow to the naked head. Mr. Haslam, however, mentions, that he has known in many in- stances paralytic affections to have ensued in a few hours after cold bathing, especially where the patient has been in a furious state, and of a plethoric habit. In other cases, he has known vertigo, or a considerable degree of fever, to ensue after a cold immersion. In all cases of furious madness connected with plethora, there can exist no doubt that a cold bath will prove prejudicial. Warm bathing has been recommended by some physicians, and others again have disapproved of it. Probably it may be most use- ful to those of a rigid melancholic temperament. The late Dr. Willis was of opinion! that warm bathing might be useful to luna- tics, but that cold bathing could seldom be required. Indeed warm bathing, and the judicious administration of cathartics, appear to be the best physical agents we can employ upon mental disorder : the effects of the former in calming nervous irritation are often abundantly conspicuous. At the Retreat, or asylum at York for the reception of insane persons, warm bathing has been used for several years, and is still considered of greater importance and efficacy, in most cases of •" See Observations on Insanity, by J. Cox, M. D. — Essay on the Cure of Insanity, byG.'jN. Hill. »-See Repertofthe Select Committee appointed to inquire into the.Smteof;f.i!T$N(T« 498 neuroses, or nervous diseases. [Class 11. melancholia, than all the other medical means which have been employed.* In the lunatic hospital in Paris, denominated la Salpetriere, and which is under the superintendence of Dr. Pinel, great stress is laid upon the tepid bath as a remedy for mania; to which is added, when the patient is riotous, a douche, or pumping of cold water, falling several feet on the head. A novel method of treating insanity is practised by Messrs. Lucett and Delahoyde, at their reception for insane persons, at Sion Vale. The process employed by these gentlemen is however kept concealed from the public ; but it appears from the statement of a Mr. Tardy, that he was engaged in the management and em- ployment of this process with Mr. Lucett prior to the latter's con- nexion with Mr. Delahoyde, and that during this they treated some cases of mental derangement with variable effects, but striking enough to countenance and encourage further inquiry. The great influence which the process was proved to effect upon the circulation and pulse, was, as far as we can trust to the correctness of our infor- mation, caused by the immersion of the patient's body in warm water, and at the same moment pouring a stream of cold water on the naked head. The bath was at first 90 degrees, and subsequently increased to 108. The patient was kept in the bath about four minutes on the firsttrial, and afterwards from 30 to 40 minutes. The effects produced were a decrease of the velocity, but an in- crease of fulness of the pulse ; a quieting of disturbed and erratic mental action, followed by calm sleep of several hours' continuance. Opium, when administered to madmen during a violent paroxysm, has hardly ever been found to procure sleep ; but, on the contrary, has rendered those who have taken it much more furious ; and where it has for a short time procured rest, the patient has, after its operation, awoke in a state of increased violence. Opium, to prove serviceable in maniacal cases, ought to be administered in very large doses, such as about two hundred drops of its tincture. It seems however, at best, to be but a doubtful remedy. An extensive friction, with a liniment consisting of six or ten grains of opium well triturated, with a small quantity of prepared lard, has been recommended for the purpose of inducing sleep in maniacs where its internal administration might be prejudicial. Where frictions fail we might possibly employ opium in the form of fumigation with some advantage. Where the patient appears much reduced from the want of sleep, but Still we dare not give opium from having found it prejudicial, we may make trial of the extractum papav. albi, or the extractum hyoscyami in the dose of four or five grains.! * Description of the Retreat, by Samuel Tukc, r 1. 1^ Camphora?, gr. x. I t 1. Take Camphor, ten grains. Extract. Hyoscyami, gr. v. Extract of Henbane, five grains Syrup, q. s. JV1. Syrup, a sufficiency. Fiant pilulas iij. pro dos. sexHs horis su- Let the mass be formed into three pill? 't)?nilo?. which may be taken every six hours Order IV.J madness. 499 With regard to the medical properties of the hop, or lupulus com- munis, the experiments made on it show that it is evidently narco- tic, inducing sleep like opium ; but it seems rather to dispose to laxity of the bowels than costiveness. In this disease, as well as in some painful cases where an opiate is greatly wanted, but where it cannot be exhibited in any of the usual forms without pro- ducing untoward symptoms, a strong infusion of the hop used both internally and externally, has frequently, it is said, been found to sooth pain, and finally to procure a calm, tranquil sleep. The best preparation however of the hop appears to be the tincture, made by digesting four drachms of the lupulus communis in ten ounces of rectified spirit. The dose may be from forty drops to one hundred. The sedative effects of the digitalis point it out, we have reason to presume, as an useful and powerful remedy after frequent pur- gingand phlebotomy in cases where great excitement and increased tone prevail in the nervous and arterial systems. It has therefore been used in mania, and not unfrequently with success.* When the derangement is accompanied, and in some degree regulated by an accelerated circulation, a use of foxglove will be highly proper. A few drops of the tincture, or half a grain of the powder, are to be given at first, and the dose to be gradually increased till the desired effect is produced. To make this permanent it will however be necessary to keep the constitution for some length of time un- der the influence of the medicine. A case of mania, preceded by strong epileptic fits of frequent recurrence, and induced by a long and intemperate use of spirituous liquors, some time ago come under my care, wherein, by adopting this plan, the mental affection, as well as the spasmodic, entirely ceased. On discontinuing a use of the digitalis, the patient com- menced a course of the oxyd of zinc, joined with stomachics, which completed the cure. Camphor is a medicine which has been much recommended by some physicians in mania, while by others it is said to be use- less. I understand that Dr. Willis gave the camphorated mixture at the same time with the extracts of conium, hyoscyamus, and other narcotics. Might not a combination of it with digitalis prove ad- vantageous ? Blisters and other drains, such as issues or a seton, have likewise been employed in this disease; and when recent, may probably have a good effect. In cases of long standing they have been found ineffectual. Dr. Monro, in his Observations on Mania, mentions, that a blis- ter, when applied to the head itself, seldom proves useful: and the same circumstance has been noticed by other physicians. When we have recourse to blisters, it will be most advisable therefore to apply * See Observations on the Digitalis Purpurea, by Dr. Currie, vol.iv. article second, nf Memoirs of the Medical Society of London.—See Essay on Insanity, by G, N Hill. 500 NEUROSES, OR NERVOUS DISEASES. [ClttSS 11. them to the neck or back. To keep up a sufficient discharge from them, I have found the ceratum sabinae far preferable to the unguentum lyttae. In the cure of insanity, quietness, and the abstraction of all stimuli, are in general to be enjoined ; yet there appears to be exceptions, Dr. Cox* very judiciously observes, both with regard to light and other stimuli; for in some cases total darkness aggravates all the symptoms, excites fear, dread, and apprehension ; though in others it may be had recourse to with an intention of producing these effects. It appears a curious circumstance that the conver- sion of religious melancholy into furious madness is an occurrence that sometimes happens, and when it does, is generally followed by recovery, which has suggested the propriety, in some cases that have resisted more common means, of producing a degree of excitement by means of stimuli; in fact, keeping the patient for some successive days in a state of intoxication. This plan, we are told, has often occasioned an alleviation of symptoms, and some- times restored the sufferers to reason. Incases of mental derangement, originating from the passions of grief, sorrow, or religious fear, and in which the system has sunk into apathy and dulness, the stimulus of galvanism, or of gentle electricity, affords some prospect of relief, more especially if the patient be not very far advanced in life. When we have recourse to the first of these remedies, it will be best to employ a pile con- sisting only of a few plates at first, that the brain may not be sub- jected to too violent an action. The same must be carefully guarded against when we resort to electricity. Dr. Cox speaks highly of swinging as a remedy in mania, and he recites many cases where the happiest effects were derived from making use of it. We are told by him, that it may be employed in the common oscillatory way, or in a circular manner of whirl; the patient at the same time sitting erect, or lying horizontally. On persons in health he observed these swings to produce only the common effects ; but in proportion to the motion communicated, and sooner by the circular than by the oscillatory, and in the hori- zontal than in the perpendicular position. In some maniacal cases, independent of these more obvious effects, he noticed that swinging, often repeated, had the singular property of rendering the system sensible to the action of agents whose powers it before resisted. One of its most valuable properties was, its proving a mechanical anodyne. This effect I have myself observed. After a very few circumvolutions, Dr. Cox has witnessed its soothing, lulling effects : the mind has become tranquil, and the body quiescent: a degree of vertigo has often followed, and this has been succeeded hy the most refreshing slumbers ; an object the most desirable in every case of madness, and procured with the utmost difficulty in general. Maniacs, he has noticed, are not usually ? cee bis Observations on Insanity. Order IF.} aiadnes.s. oOl sensible to the action of the common oscillatory swing, although it affords an excellent mode of secure confinement, and of harmless punishment. By the protracted action of the circular swing or whirl, he has sometimes seen the patient almost deprived of his locomotive powers; and although it required the combined strength and address of several experienced attendants to place him in it, still he has been taken out of it by a single person : the most pro- found sleep has followed, and this has been succeeded by convales- cence, and a perfect recovery, without the assistance of any other means. One of the most constant effects of swinging is a greater or less degree of vertigo, attended by pallor, nausea, and vomiting, and frequently by an evacuation of the contents of the bladder. Where insanity attacks patients of a delicate habit, with previous consumptive or pulmonic symptoms, swinging in the common way has in many instances proved highly beneficial. It has been mentioned in the preceding pages, that insane people, when closely confined, are very subject, in winter, to a mortification of the toes, feet, and nates, and that the helpless and bed-ridden patients are very apt to be attacked with a mortifi- cation of the buttocks. In all cases of this nature, we are told by Mr. Crowther,* who was, until lately, surgeon to Bethlem Hospital, that the treatment usually adopted (consisting of hot fomentations, lint dipped in stimulating liniments applied warm, and over the whole a poultice of the grounds of stale beer and oatmeal) invariably failed; whereas by substituting an embrocation of rectified spirit, lowered with water according to the degree of sensibility of the parts, and afterwards covering them with soft lint spread with the ointment heret prescribed, not a single death arising from a mortified state of the nates afterwards happened. When madness has taken place in consequence of great deblility and weakness, as sometimes happens at the close of typhus mitior, all evacuations whatever ought to be avoided, a nutritive and resto- rative diet should be allowed, and a regular course of the cinchona bark and other bitters, together with chalybeates, be entered upon, the patient taking at the same time such daily exercise in the open air, either in a carriage or on horseback, as his strength will admit. The mind is apt to be much affected, both after abortion and delivery, and in some instances the woman becomes either melan- cholic or mad, the latter being more frequent. This mania is in general sudden in its attack, and is often preceded by great palpi- tation and some other nervous affection. * See his Practical Remarks on Insanity. * 2. R Unguent. Resinos. Empl. Resinae, aa ^ij. Bals. Terebinth. ?i. M. t 2. Take Resinous Ointment, Resin Plaster, of each two ounces. Terebintbinate Balsam, one ounce Mix them 302 neuroses, or nervous disease,-,. [Class 11. The most common time for it to begin is a few days, or a week or two, before delivery. Sometimes it occurs after some months, during nursing, or soon after weaning. It has occasionally been noticed to have arisen even at the commencement of labour. The approach of the disease is announced by symptoms which excite little apprehension, because they so often occur without any such termination. The pulse is weak without any manifest cause ; the nights are restless, and the temper is easily ruffled : soon how- ever there is an indescribable hurry and peculiarity of manner ; the woman's conduct and language become wild and incoherent, and at length she becomes decidedly maniacal. It will be fortunate if the malady is discovered ere she attempts to do herself some injury. The disease, although frequently tedious, is oftener got the better of than any other species of mania. In the treatment of puerperal mania our attention should be directed to the following circumstances :—1st, To protect the patient from injuring herself, and should there be any difficulty in confining her to bed, if necessary, we may have recourse to the strong leather belt before mentioned or a strait waistcoat, by which she will be restrained. Whenever possible, she ought to be committed to the charge of a nurse accustomed to the task, as she will not be equally safe under the care of any other, how- ever discreet and intelligent. 2dly, To evacuate by occasional purgatives any impurities in the alimentary canal which might keep up or aggravate the original disorder. 3dly, To watch the state of the circulation, and if congestion or inflammation in the brain should supervene, to remove it by applying leeches to the temples, and other antiphlogistic remedies, with an exception to venesection. 4thly, To procure sleep by night, by administering the extractum hyoscyami in sufficient doses during the early stage of the disease, as opium appears to be a doubtful remedy at an early period, although it probably may be productive of benefit at the wane. To allay irritation throughout the day, the camphor mixture combined with aether may be given. 5thly, To manage the mind of the patient according to circumstances, soothing it during irritation, encouraging it during depression, and when the violence of the disease has subsided, to facilitate the recovery of the native feelings and faculties by presenting their natural objects. In a state of convalescence the mind and the attention are to be occupied by cheerful conversation, music, light reading, and after- wards by a change of scene, and regular exercise daily in a carriage or on foot. Melancholy madness comes on later than furious delirium. The disease differs nothing in appearance or symptoms from melancholy occuring at other times. It is however frequently obstinate, but in common goes off after the child is wearied, and the strength has returned. Sending the patient into thfe countrv. if resident in Order IF.] nightmare. 60£ town, will therefore be advisable, as soon as possible removing the child also from sucking her. Insanity has sometimes been pretended for the purpose of eva- ding justice after the perpetration of murder. The principal means for the detection of such pretenders to madness are, a considera- tion of their probable motives for counterfeiting this state ; a strict examination of their conduct when they suppose themselves to be alone and not overlooked, contrasted with their behaviour when they are conscious of being observed ; the existence of that pecu- liar fetor in the exhalations which so generally accompanies the true maniacal state ; aud the manner in which the subject is affect- ed by the administration of drastic drhgs. INCUBUS, or NIGHTMARE. In this disease there is such a weight and oppression felt as to impress the patient with the idea of some living being having taken its position on the chest, inspiring terror, impeding respiration, and paralyzing all the voluntary muscles. Incubus will sometimes occur in the healthiest person when any indigestible food happens to be in the stomach or the upper por- tions of the alimentary tube during sleep ; but a peculiar habit of body is necessary to render a person liable to it. Those of a con- templative disposition, and of (hat particular temperament which disposes to hypochondriasis and other nervous diseases, are very subject to its attacks. Sedentary employments, confinement within doors, literary studies, anxiety of mind, &c. all predisposes to visita- tions of incubus. Sailors have been observed to be very liable to this disease.* Hypochondriacs and pregnant women are also its victims, but the male sex more frequently than the female. In advanced life it is not often met with, except where corpulency, asthma, or a tendency to lethargy exists. The disease always attacks during sleep : if this be profound, the first approach of the fiend is usually in the shape of a disagree- able dream. The patient imagines himself exposed to some danger, or pursued by an enemy whom he finds it impossible to avoid. He frequently feels as if his limbs were tied, or deprived of motion: at other times he fancies himself confined at the bottom of a cavern or vault, and in danger of suffocation. This is often the whole of the sensation which the disease produces, when it goes off either by an oblivious sleep or dream. Here incubus is not fully formed, the predisposition is only evinced. When the paroxysm actually takes place, the uneasiness of the patient in his dream rapidly increases, till it ends in a kind of consciousness that he is in bed and asleep, but he feels oppressed with some weight which confines him on his back and prevents his breathing, which is now become extremely laborious, so that the lungs cannot be fully inflated by any effort he can make. The - ^ee Mr. Waller's Tre^ti-e on Incubus V04 NEUROSES, OR NERVOUS DISEASES. [ClaSS 11. sensation is now the most painful that can be conceived: the person becomes every instant more awake and conscious of his situation ; he makes violent efforts to move his limbs, especially his arms, with the view of throwing off the incumbent weight, but not a muscle will obey the impulse of the will; he groans aloud, if he has power to do it, while every effort he makes seems to exhaust the little remaining vigour. The difficulty of breathing goes on increasing, so that every breath he draws seems to be almost the last that he is likely to draw; the heart generally moves with increased velocity, sometimes is affected with-palpitation, the countenance appears ghastly, and the eyes half open. The patient, jf left to himself, lies in this state gene- rally about a minute or two, when he recovers all at once the power of volition, upon which he either jumps out of bed, or in- stantly changes his position, so as to awake himself thoroughly. If this be not done the paroxysm is very apt to recur again imme- diately, as the propensity to sleep is almost irresistible; and if yielded to, another paroxysm of nightmare is, for the most part, inevitable. Where the disease is established, some confusion of the head, singing in the ears, and spectra before the eyes, will often remain for a time after being roused. There is often also a sense of weight at the stomach, an unpleasant taste in the mouth, acceleration of pulse, and palpitation of the heart. When the paroxysm goes off, as frequently happens, without the patient awaking, strange hallucinations are occasionally produced, which give origin to reputed visions and supernatural visitations even among people of great intellectual cultivation. The degree of consciousness, during a paroxysm of nightmare, is so much greater than ever happens in a dream, that the person who has had a vision of this kind, cannot easily bring himself to acknowledge the deceit unless he awakens out of his paroxysm, and finds some incongruity in respect to time or place, which proves the transaction to be an illusion.* Spasmodic constriction of the diaphragm and muscles of the chest has been assigned by some as the proximate cause of incu- bus. The disease is not attended with danger. The complaint seems to be altogether dependent on a state of dyspepsia, and is usually accompanied with a distention of the stomach and bowels ; by flatus, constipation, and acid eructations. Whenever the dyspeptic symptoms are urgent, we may administer one of the draughts prescribed below,t repeating it as the occasion x See Mr. Waller's Treatise on Incubus for various deceptions of this kind. + 1. I^Potassa; Subcarbon. gr. xij. i \ 1. Take Subcarbonate of Potass, twelve I grains. Aq. Menth. Pip. f. |i. J Peppermint Water, one ounce. iinct. Card. Comp. f. 3"j. j Compound Tincture of Carda- ' moms, three drachms. Syrup. Zingib. f. ~i. Syrup of Ginger, one drachm. •t. H;i";tu= Mix them lor a drought. Order I.J atrophy. 505 may require. Costiveness is to be guarded against by some gentle aperient, such as a few grains of rhubarb with magnesia. Where there is much languor and debility, with loss of appetite, we may recommend the pilula ferri cum myrrha, together with either the decoctum cinchonae, infusum gentian, comp. vel quassiae, or any other agreeable bitter, various formulae of which may be found under the head of Dyspepsia. The carbonate of soda, mixed with ale or porter, will form a pleasant beverage for those who are liable to dyspeptic symptoms and incubus. Persons subject to incubus ought carefully to shun all (kinds of food likely to prove flatulent or of difficult digestion, particularly for supper; they should be guilty of no intemperance whatever, and should avoid gloomy contemplations, a sedentary life, and particu- larly intense study, with late hours. Moreover, they should always have some person to sleep near them, so as to be immediately awoke by'their groans and struggles ; for the sooner a person is roused from a paroxysm of the nightmare the better, as when, in a very high degree, it differs little from a fit of epilepsy. Where medicine is not at hand, a glass of any cordial will frequently dispel flatulence, and prevent the paroxysm of incubus. class in. CACHEXIA, or CACHECTIC DISEASES. A depraved state of the whole, or greater part of the body, without any primary febrile or nervous affection, constitutes this class.________________ ORDER I. MARCORES. Emaciation of the whole body is the character of this order. ATROPHIA, or ATROPHY. This disease is marked by a gradual wasting of the body unac- companied either by a difficulty of breathing, cough, or any evident fever at first, but usually attended with a loss of appetite and im- paired digestion, depression of spirits, and general languor. Vel, 2. R Ammonia;, gr. x. Aq. Cinnam. f. 3X- Tinct. Capsic. f. 31- ■ Syrup. Croci.f. 3'^?- M. ft. Haustus 65 Or, 2. Take Ammonia, ten grains. Cinnamon water, ten drachms. Tincture of Capsicum, one drachm. Syrup of Saffron, one drachm and a half. Mix them as a draught. 1)06 caciiexi—, or cachectic diseases. [Class III. The causes which commonly give rise to it are, a poor diet, un- wholesome air, excess in venery, scrofulous disposition, fluor albus. severe evacuations, continuing to give suck too long, a free use of spirituous liquors, mental uneasiness, and worms ; but it frequently comes on without any evident cause. Young persons of both sexes, who are of a delicate make, and at the same time grow very fast, are apt to be attacked with this complaint before they arrive at the age of puberty. It is par- ticularly prevalent in large and populous cities, where children are deprived of ready access to exercise in pure air, or where they are confined in crowded schoolrooms. Children also who are em- ployed in manufactories, where their occupation and confinement are such as to weaken and enervate them, are very likely to be attacked with it. Emaciation of the body very frequently arises from a morbid state of the mesenteric glands, induced by scrofulous inflammation, to which they appear peculiarly liable. Whatever may be the effect of diseased mesenteric glands upon the chyle, we are war- ranted in assigning this as the most frequent cause of bodily ema- ciation in children, seeing that the two states are almost invariably associated. Sluggishness, lassitude on the slightest exertion, depravity, and loss of appetite, wasting of the muscular flesh, paleness of the countenance, with bloating, swelling, and prominence of the belly, (edema of the lower extremities, an irregular and generally costive state of the bowels, a change in the colour and odour of the faeces, and fetid breath, mark the beginning of the disease, When these symptoms have continued for a little time, they are followed by alternate paleness and flushing of the countenance, heat, and dry- ness of the skin, a feeble and quick pulse, thirst, fretfulness, great debility, and disturbed sleep. Atrophy, arise from whatever cause it may, is usually very diffi- cult to cure, and not unfrequently terminates in dropsy. In attempting however to effect this, we should endeavour to find out the cause from which it has originated, and to remove it, if possible. If occasioned by worms, these must be destroyed by the vermifuge medicines advised under that particular head ; if by sensual excesses, or the continuing to give suck too long, these must wholly be discontinued; if from severe evacuations, these must be suppressed ; if from an impoverished diet and unwholesome air, these must be quickly changed ; if from a scrofulous disposition, deobstruents, purges, and tonics must be had recourse to in due turn; (see Scrofula) and if from a venereal taint, which is sometimes the case, we must then resort to a use of mercury, with the decoc- tum sarsae, and other auxiliaries, as recommended under the head of Syphilis, together with a milk diet. In all cases of atrophy the patient should, make use of food that is nutritive and easy of digestion, and it should be taken frequently, ^ut in a small quantity at a time. He should likewise breathe a pure. Order /.] ATROPHY. 507 dry, and wholesome air; taking such moderate exercise every day as his strength will admit, particularly on horseback. To assist the digestive powers it will be proper to put him under a course of stomachic bitters, cinchona, and chalybeates. Due evacuations by stool ought to be strictly attended to. Mild Jaxa- tives, repeated at certain intervals, will therefore be necessary. They will preserve the bowels in proper action, carry off faeces which had begun to be offensive and hurtful, and prevent accumu- lation. Gentle vomitings, with the cupri sulphas, as mentioned under the head of Phthisis Pulmonalis, might possibly, by their stimulus, prove of infinite service. The myrrh mixture, recom- mended in the cure of the same disease, would be likely to produce a good effect. In this complaint cold bathing will be proper; but the patient should begin with a tepid bath, reducing it gradually to a cool, and at length to a cold temperature. When there is a disposition to oedematous swellings of the legs and feet, we should combine diuretics with whatever tonics we administer, as advised in Anasarca. In children of a scrofulous habit atrophy is often accompanied with an enlargement of the mesenteric glands ; and then indiges- tion, costiveness, or purging, irregular appetite, flushed cheeks, or a total loss of colour, impaired strength and spirits, remit- ting fever, and a hard and tumid belly, with emaciated limbs, prevail. In a general way, the principal indications in such cases are to remove the obstructions in the lymphatic system, and effect a reso- lution of the indurated glands of the mesentery; to carry off the viscid matter; and lastly, to strengthen the system and esta- blish a good digestion, as well by means of proper diet as by medicines. Among the first, and as general deobstruents, are mercurial and antimonial remedies, neutral salts, soap, steel, and hemlock, to which perhaps may be added with propriety, frictions to the abdo- men, and the employment of a tepid salt water bath. The hydrar- gyri submurias is the best mercurial we can employ, and may be joined with some purgative medicine, such as rhubarb : this com- bination may be continued in small doses daily, or every other day, till there shall be some favourable change in the feel and size of the belly. When we do not like to have recourse to mercury, we may administer rhubarb, joined with potassae tartras, as a purge. Occa- sional gentle emetics may be good auxiliaries. The emaciated state, to which the patient is generally reduced, even although we should be fortunate enough to remove the ob- struction, will require the aid of tonic remedies. To strengthen the stomach and alimentary canal, and promote a good digestion, the only means by which a nutritious chyle can be obtained, and the body kept in a healthy state, we should have recourse to bitter j08 CACHEXIJS, OR 'CACHECTIC DISEASES. [ClttSS 111. infusions,* joined with aromatics, cinchona, and steel.1 To these may be joined daily frictions of the belly, limbs, and spine. Where the obstructions are removed, the cold bath will be a proper remedy. Where atrophy arises as a consequence of suckling, the curative indications are to restore the wasted strength, to relieve the affec- tion of the lungs, and to quiet or remove the fever. The first point then is, for the woman to avoid the exciting cause, and there- fore the child must be weaned immediately : she must live on milk, broths, jellies, sago, blanc-mange, salep, Indian arrow-root, and tapioca, with eggs, and a moderate quantity of animal food for dinner. Wine in moderation will likewise be proper. To add to the effects of a restorative diet, a course of the cinchona or other bitters, with the sulphuric acid, myrrh, and chalybeates, as advised for dyspepsia, may be entered upon. * 1. R Infus. Gentian, f. ^iijss. Tinct. Cardam. f. ^ss. Potassae Subcarbonat. 3ss. M. Capiat cochl. j. infantisbis terve in die. Vel, ■ -'. R Infus. Cinchonas, f. ^ijss. Tinct. Calumb. f. 3i»j- Potassae Subcarbonat. 3j M. Cochl. j. bis in die sumendum. Vel, 3. rj; Rad. Calumb. Contus. 3iij. Aq. Bullientis, f. §iv. Post horas tres cola, et adde Tinct. Cinnam. C. f. ?ss. •Sodae Subcarbonat. 3SS. M. 14. r>; Ferri Subcarbonatis, gr. ij ad. v. Pulv. Calumb. gr. viij. M. ft. Pulvis mane et vespere capiendus Vel, 5. R. Pulv. Cinchon. gr. x. ad 3ss. Ferri. Sulphat. gr. j. ad iij. ft. Pulv. pro des. bis in die repetendus. * l.Take Infusion of Gentian, three ounces and a half. Tincture of Cardamoms, half an ounce. Subcarbonate of Potass, half a drachm. Mix them, and let a child's spoonful be taken twice or thrice a day. Or, 2. Take Infusion of Poruvian Bark, two ounces and a half. Tincture of Calumba, three drachms. Subcarbonate of Potass, one scruple. Of this mixture, a child's spoonful maybe taken twice daily. Or, 3. Take Calumba Root, bruised, three drachms. Boiling Water, four ounces. Let them infuse for three hours, strain off the liquor, and add Compound Tincture of Cinna- mon, half an ounce. Subcarbonate of Soda, half a drachm. Mix them. The dose maybe the same as of the former. \ 4. Take Subcarbonate of Iron, two to five grains. PowderofCalumba,eightgrains. Mix them, and let this powder be taken morning and evening. Or, o. Take Powder of Peruvian Bark, ten grains to half a drachm, ac- cording to the age. Sulphate of Iron, one grain to three. Mix them. This powder may be repeated twice a dnv. Order 1.] pulmonary consumption. oG9 If the affection of the lungs appears to be of an inflammatory nature, and marked by hardness of the pulse, oppressed breathing, or a fixed pain in some part of the thorax, bleeding to the amount of three or four ounces may be necessary, which ought to be drawn from as near the painful part as possible by means of leeches ; but if none of these symptoms are present, we should be content with applying a succession of blisters about the thorax. Where there is any inflammatory action, the diet must be confined to vegetables and milk, omitting the cinchona and other medicines, and substi- tuting laxatives, and the saline mixture with nitre, combined with small nauseating doses of tartarized antimony. The fever is to be removed by shortening the paroxyms when they come on, and during the intervals by preventing their recur- rences by the means pointed out under the heads of Intermittent and Remittent Fevers. The atrophia ablactatorum belongs to the order of Marcores, but is inserted among the infantile diseases. PHTHISIS, or PULMONARY CONSUMPTION. Pulmonary consumption is accompanied with general emacia- tion, debility, pain in the side or chest, some degree of dyspnoea after walking or speaking, and a cough, which usually proves most troublesome towards morning. In an advanced stage, purulent expectoration ensues, with hectic fever and diarrhoea. Pulmonary consumption does not often occur till after the age of puberty, but in some cases it is evidently formed before that period by tubercles arising. Women are more subject to it than men, as well from their going more slightly clad as from the greater delicacy of their organization. The causes which predispose to this disease are very numerous; the following are, however, the most general: hereditary disposi- tion ; particular formation of the body, obvious by a long neck, prominent shoulders, and narrow chest; scrofulous diathesis, indi- cated by a fine clear skin, fair hair, delicate rosy complexion, large veins, thick upper lip, a weak voice, and great sensibility : certain diseases, such as catarrh: pneumonic inflammation, haemoptoe, syphilis, scrofula, small-pox, and measles ; particular employments exposing artificers to dust, such as needle pointers,* stonecutters, millers, &c. or to the fumes of metals or minerals under a confined * In the fifth volume of Memoirs of the Medical Society, we are informed by Dr. Johnson, that persons employed in the pointing of needles, by dry-grinding them, are quickly atfected by pulmonary complaints, such as cough, and purulent and bloody expectoration ; and that they scarcely ever attain the age of forty years. We are also told by Dr. Willan, in his Reports, that hair-dressers, bakers, masons, bricklayers, labourers, laboratory men, coal-heavers, and chimney-sweepers, are very liable to obstinate pulmonic diseases, as are likewise in an equal degree, the dressers of flax &nd feathers, and workmen in the warehouses of leather sellers, Many persons thus engaged struggle witn a hard tormenting cough until it terminates in consumption, whereas, by a timely removal into pure air, and having recourse to a suitable regimen, they might soon have been restored to health. -&10 CACHEXIA, OR CACHECTIC DISEASES. [ClttSslll. and unwholesome air ;* violent passions, exertions, or affections of the mind, as grief, disappointment, anxiety, or close application to study, without using proper exercise ; playing much on wind in- struments ; frequent and excessive debaucheries, late watching, and drinking freely of strong liquors : great evacuations, as diar- rhoea, diabetes, excessive venery, fluor albus, immoderate discharge of the menstrual flux, and the continuing to suckle too long under a debilitated state ; and lastly, the application of cold, either by too quick a change of apparel, keeping on wet clothes, lying in damp beds, or exposing the body too suddenly to cool air, when heated by exercise ; in short, by any thing that gives a consider- able check to the perspiration. In enumerating the causes of phthisis a late writer mentions,! that moist air is a very frequent one ; he supposes it to operate by occasioning general relaxation and debility, and observes, that the frequency of the disease in Holland has been attributed to this cause. It has not, however, been satisfactorily proved that phthisis is really frequent among the Dutch. The reverse indeed has been stated ; for Dr. Beddoes, in his Essay on Pulmonary Con- sumption, quotes Dr. Cogan, a physician who practised many years in Holland, as remarking on the infrequency of coughs and colds in that country, in comparison with England ; and consump- tion has been said to be much more rare in the fenny parts of Lincolnshire, than in the high lands in the same county. The more immediate or occasional causes of phthisis are haemop- tysis, pneumonic inflammation proceeding on to suppuration, catarrh, measles, asthma, and tubercles, (which in nineteen cases out of twenty depend on a scrofulous habit,) the last of which is by far the most general. The connexion between scrofula and pulmonic consumption is obvious, and generally acknowledged ; the latter being often no more than constitutional symptoms in- grafted upon the scrofulous diathesis. At the time when scrofula disappears from the surface of the body, it frequently falls upon the lungs. Various causes have indeed been assigned for the increasing prevalence at the present time of this distressing disease in the United Kingdom : and among others, the disuse of wood fires, and the general adoption of mineral coal for fuel, has of itself been thought sufficient by some persons to account for it. But the great and sudden changes of temperature or variableness to which our climate is subject, ought properly to be considered as the real cause of the frequency and prevalence of this disease ; and there is great reason to suspect tbat the warmth and closeness of our apartments, together with the present scanty, light, and flimsy * Mr. Polwhele, in his History of Cornwall, mentions, that the miners there are very subject to consumption, aud that more than one half of their population fall a sacrifice to it, owing, as he supposes, to their working in what are termed damps. in which the air is mephitic, or unfit for respiration. t See Dr. Wilson's Treatise on Febrile Diseases, vol. iv. Order I.] pulmonary consumption, off attire of our modish females, very much increase the liability to this complaint. In an economical point of view, as savin** an expenditure of fuel, the ingenious contrivances of Count Rumford and others undoubtedly are very efficacious for the purpose • but in the winter, when we leave such apartments to go into the open air, the sudden change of temperature which we experience, often amounts to 25 or 30 degrees ; the entrance to the lungs and glottis consequently falls into torpor, from the stream of cold air which is constantly passing between them for the purpose of respiration; and when we re-enter our apartments, the blood rushes with vio- 'lence into these vessels previously rendered torpid by the cold; and like the pain our hands experience on coming near a fire after being exposed to cold, we feel a sensation of heat about the glands of the throat; this local inflammation spreads, and we experience all the u'sual symptoms attendant on a recent catarrh. In noticing the causes of the vast prevalence of phthisis pulmo- nalis, I think 1 may put down the increase of scrofula among us, and we therefore meet with more cases of tubercular consumption than of any other kind. The predisposition to scrofula is inherited by children from their parents, and at some period or other of their life the disease shows itself either in inflammation of some gland that suppurates and breaks externally : or in tubercles in the lungs that proceed to suppuration and ulceration, and terminate in con- sumption. That consumptive mortality has very considerably increased in Great Britain within the last century, cannot be denied; and ac- cording to the calculations of a modern writer,* the annual vic- tims to consumption in this island are not less than fifty-five thou- sand persons out of a population of eleven millions. By attending to the thick purulent expectoration connected with hectic fever, the disease may readily be distinguished from all others. All oyer the Levant, not only the natives, but also the physicians entertain an opinion that phthisis is a disease of a contagious nature ; and in the Venetian states there is a law, I understand, which directs the clothes and even furniture of those who have died of consumptions to be burnt. Under the same idea, it is cus- tomary among the Sicilians to desert the consumptive patient, and when he dies, they burn his bed and bed-clothes, and well ventilate and fumigate the apartments in which he lay. It does not seem probable, however, that phthisis pulmonalis is infectious, at least it is not regarded so among us at present, although Morgagni, Van Swieten, and of a still later date, Mortonf were of that opinion ; but it often occurs in a family from an exposure to the same occa- sional causes, or from a similiarity of consitution and hereditary- predisposition. The only way in which I conceive the disease can * See Remarks on the Progressive Increase of Consumption. &c.bv W WnnT '•ombe, M. D. J ' ' 1 SeePhlhisolog.lib. ii cap. 1 ^•12 CACHEXIAS OR CACHECTIC DISEASED [ClttSS 111. be conveyed from one person to another, if at all possible, is by sleeping constantly in the same bed with one who labours under it, in its ulcerative stage, accompanied with fetid expectoration and cadaverous-smelling night-sweats, and so inhaling his breath. > Two or three seemingly well-marked cases of this nature have fallen under my own observation. Respecting the question of contagion in this disease, the late Dr. Heberden observes,* that he has not seen proof enough to say that the breath of a consumptive person is infectious ; and yet he has seen too much appearance of it to be sure that it is not; for he has observed several die of con- sumptions, in whom infections seemed to be the most probable origin of their illness, from their having been the constant com- panions, or bed-fellows, of consumptive persons. Viewing the subject in this light, it would therefore be advisable to avoid being too closely inmated with patients, in the last stage of pulmonary consumption. The proximate cause of phthisis is supposed to be an ulcer in the ' lungs. Climate, occupation, and temperament, will diversify the form of phthisis ; but for practical purposes, it may be sufficient to distin- guish carefully between pulmonary consumption which occurs in persons of the strumous temperament, and that whicK attacks con- stitutions of a different description from accidental causes, such as an exposure to cold, or as the consequence of other diseases. The most common and most destructive form of the disease is, the .$$$. strumous or tubercular phthisis. lp* The incipient symptoms of phthisis will vary with the cause of the disease ; but when it arises in persons of a strumous tempera- ment, or from tubercles, it is mostly thus marked : it begins with a short dry cough, that at length becomes habitual, but from which nothing is spit up for some time, except a frothy mucus that seems to 'proceed from the fauces. The breathing is at the same time somewhat impeded, and upon the least bodily motion is much hurried; a sense of straitness, with oppression at the chest, is experienced ; the body becomes gradually leaner, and great languor, with indolence, dejection of spirits, and loss of appetite, prevail. In this state the patient frequently continues a considerable length * of time, during which he is however more readily affected than usual by slight colds; and upon one or other of these ocassions the cough becomes more troublesome and severe, particularly by night, and is at length attended with an expectoration, which to- wards morning is more free and copious. By degrees the matter which is expectorated becomes more viscid and opaque, and now assumes a greenish colour and purulent appearance, being on many occasions streaked with blood. In some cases a more severe * See his Commentaries on the History and Cure of Di*eH«e« Order 1.j pulmonary consumption, 613 degree of haemoptysis attends, and the patient spits up a consider- able quantity of florid frothy blood. The breathing at length becomes more difficult, and the emacia- tion and weakness go on increasing. With these the person begins to be sensible of a pain in some part of the thorax, which, however, is usually felt at first under the sternum, particularly on coughing. At a more advanced period of the disease a pain is sometimes perceived on one side, and at times prevails in so high a degree as to prevent the person from lying easily on that side ; but it more frequently happens, that it is felt only upon making a full inspira- tion, or coughing. Even where no pain is felt, it often happens; that those who labour under phthisis cannot lie easily on one or other of their sides, without a fit of coughing being excited, or the difficulty of breathing being much increased. At the first commencement of the disease the pulse is often na- tural, or perhaps is soft, small, and a little quicker than usual: but when the symptoms which have been enumerated have subsisted for any length of time, it then becomes full, bard, and frequent. At the same time the face flushes, particularly after eating; the palms of the hands and soles of the feet are affected with burning heat; the respiration is difficult and laborious, evening exacerba- tions become obvious, and by degrees the fever assumes the hectic form. , This species of fever is evidently of the remittent kind, and has in many cases exacerbations twice every day. The first occurs usually about noon, and a slight remission ensues about five in the afternoon. This last is, however, soon succeeded by another exa- cerbation, which increases gradually until after midnight; but about two o'clock in the morning a remission takes place, becoming more apparent as the morning advances, and in the advanced stage of the disease terminating in a profuse sweat, which however is usually partial. During the exacerbations the patient is very sensible to any coldness of the air, and often complains of a sense of cold, when his skin is, at the same time, preternaturally Warm. Of these exacerbations, that of the evening is by far the most considerable. From the first appearance of the hectic symptoms, the urine is high-coloured, and deposits a copious branny red sediment. The appetite, however, is not greatly impaired, the tongue appears clean, the mouth is usually moist, and the thirst is inconsiderable. As the disease advances, the fauces put on rather an inflamed ap- pearance, and towards the termination are often beset with aphthae, and the red vessels of the tunica adnata become of a pearly white. During the exacerbations a florid circumscribed redness appears on each cheek; but at other times the face is pale, and the countenance somewhat dejected. At the commencement of hectic fever the belly is usually^costive; ■n\t in the more advanced stages of it a diarrhoea often comes on. 514 CAiHEXIjE, OR CACHECTIC DISEASES. [Class III. and this continues to recur frequently during the remainder of the disease : colliquative sweats likewise break out, and these alternate with each other, and induce vast debility. The degree of heat in which the patient is kept has often a great effect on the diarrhoea; for by exposing him to cool air in the morning, the sweat may be much diminished, but the diarrhoea will be increased; and on the other hand, if the diarrhoea be relieved by opiates and astringents, the sweating will be aggravated : thus they frequently alternate for a long time, but in a few instances they are both severe at once. In the last stage of phthisis the emaciation is so great that the patient has the appearance of a walking skeleton; his countenance is altered, his cheek bones are prominent, his eyes look hollow and languid, his hair falls off, his nails are of a livid colour, and much incurvated, and his feet and ankles are affected with oedematous swellings. To the end of the disease the senses remain entire, and the mind is confident and full of hope. It is indeed a happy cir- cumstance attendant on phthisis, that those who labour under it are seldom apprehensive or aware of any danger; and it is no un- common occurrence to meet with persons labouring under its most advanced stage, flattering themselves with a speedy recovery, and forming distant projects under that vain hope. Shortly before death the extremities become cold. In some cases a delirium precedes that event, and continues until life is extinguished. The cause of hectic fever is generally supposed to be the absorp- tion of vitiated purulency, but possibly it may proceed from other Kg lb •* \:a( Hi:\tit, or c.uhecik uiSv.a.ses. [Class Hi. tilage. Although indolent at first,',they at length become inflamed, and are at last changed into little abscesses, or vomicae, which breaking, and pouring their contents into the bronchiae, give rise to purulent expectoration and thus lay the foundation of phthisis. Such tubercles, or vomicae, are most usually situated at the upper and back part of the lungs; but in some instances they occupy the outer part, and then adhesions to the pleura are often formed. When the disease is partial, only about a fourth of the upper and posterior part of the lungs is usually found diseased ; but in some cases life has been protracted till not one twentieth part of them appeared, on dissection, fit for performing their function. A singu- lar observation, confirmed by the morbid collections of anatomists, is, that the left lobe is much oftener affected than the right. Experience having taught that it is only in the early stage of phthisis that remedies are likely to be employed with success, we ought by all means to pay the greatest attention to the first appear- ance of the symptoms. Where a spitting of blood occurs in a person of a phthisical habit, or in one born of phthisical parents, we are to endeavour by every possible means to prevent ulceration from taking place, which is to be done by employing the means for moderating the haemorrhage, and likewise preventing any future return of it, as advised under the head of Haemoptysis ; and these means and precautions ought to be continued, and extended beyond the period at which phthisis proves chiefly fatal, which is usually between the twentieth and thirtieth year of his age. The pbthisis which ensues from pulmonic inflammation proceed- ing on to suppuration, is only to be prevented by pursuing the means that will procure a resolution of such inflammation. Of these particular mention has been made in the cure of peripneu- mony, to which head I beg leave to refer the reader. When a person of a phthisical habit, or born of parents who have had the same disposition, is about the age of twenty, or sooner, attacked in the spring of the year, or summer, with the symptoms which have been enumerated in the first stage of the disease, and this even in the very slightest degree, we have just grounds to ap- prehend that tubercles have either formed, or are about to form, in the lungs : in such a case we are to exert our utmost endeavours, to prevent their formation, and consequent inflammation and sup- puration ; for by so doing the disease may be kept under for many years, if not entirely subdued. To effect these purposes, wc must have recourse to a strict puiv suance of the antiphlogistic plan, such as bleeding from the arm, as well as topically from the chest, by means either of leeches or cupping, keeping the body open with gentle laxatives, and the use of a spare regimen. The propriety of the first of these remedies, viz. blood-letting, fcas, hpwever; of late years been much disputed, and it has indeed Order I.J pulmonary consumption. 51" fallen a good deal into discredit. Blood-letting, and the rest of the antiphlogistic plan, may formerly have been carried much too far in many cases, I readily admit; but certain it is, that for some years past the opposite system has been carried to an equally hurt- ful excess. In the inflammatory and first stage of phthisis, where the patient complains of a difficulty of breathing with pain in his breast or side, has hot restless nights, with a hard contracted pulse, and a cough, there can be no doubt but that bleeding may be of infinite service, provided the quantity taken away bears a just proportion to his strength and habit, and to the severity of the symptoms ; but having recourse to it under the stage of ulceration, where the expectora- tion has become purulent, and where great debility prevails, with night-sweats, and repeating the operation frequently, even in small quantities^at a time, as was formerly practised, must evidently prove highly injurious. At an early period, we have in view to procure a resolution of the inflamed tubercles ; but in confirmed phthisis this hope no longer exists. During the first and inflammatory stage of the disease it will be advisable, in compliance with the antiphlogistic plan, to employ gentle laxatives, should the bowels be costive. When there is any febrile heat, with a cough or pain in the chest, we may give diaphoretics, such as small doses of tartarized anti- mony or the pulvis antimonialis, repeated three or four times a day, together with the saline mixture and nitre. It will be necessary to pay a proper attention to regimen. The diet should consistof such things as are nutritive and easy of diges- tion ; as preparations of the different farinacea with milk, most kinds of vegetables and fruits, poached eggs, light puddings, cus- tards, jellies, and animal broths. The different kinds of shell-fish (but more particularly oysters, lobsters, crabs, prawns, and cray- fish) may also be proper. Where the symptoms are but trifling, and the patient cannot well refrain from animal food, he may then he allowed such as is of (he lightest nature, and most easily digested. All fermented liquors, but more particularly spirituous ones, are to he avoided. Milk of itself is a valuable remedy in phthisis. That of the ass is usually preferred to any other ; but it cannot always be obtained : •besides, it is .generally taken in a very small quantity ; whereas, to produce any effect, it ought to make a considerable part of the patient's diet. Instead of taking half an English pint night and morning only, as is usually practised by phthisical patients, they ought to take it at least four times a day, eating a little bread with it, so as make it a kind of meal. If the milk should happen to purge, it may be mixed with a little ,of the powder of prepared chalk, or with a small quantity of the .confectio rosae Gallicae. The best effects have been known to proceed from a long-con- . inued use of women's milk, which is indeed the best of all others for ■515! CACHEXIA, OR CACHECTIC DISEASES. [Class III. consumptive persons : but as it is not to be obtained in a sufficient quantity, we are generally obliged to substitute either asses' milk, or that of cows. The milk of cows, although not so easily digested as that of asses or mares, may be rendered much lighter by allowing it to stand for some time, and then taking off the cream. In cases of incipient phthisis, a free use of butter-milk has fre- quently been attended with much advantage. In order to make it sit easy on the stomach, it should at first be taken sparingly, and the quantity gradually be increased. To assist in preventing an inflammation of the tubercles in the lungs, it will be necessary that the patient avoids any particular irritation of the part affected, which may arise from the violent exercise of respiration, as in singing, playing on wind instruments, or making long and loud declamations: he is likewise to avoid going into crowded rooms, the air of which, from being inhaled by many different people, becomes at length very unfit for respiration, particularly in those whose lungs are already in a weak and irrita- ble state; he is to refrain horn placing his body in such a position, either in reading, writing, or following his ordinary occupation in life, as that the capacity of the thorax shall be the least straitened in consequence of pressure against it: he is to shun all kinds of bodily exercise which require much exertion, and in particular, he is carefully to guard against any exposure to cold, which never fails to determine a greater quantity of blood to the lungs and other internal parts than what is natural. With the view of guarding against any diminution of cutaneous perspiration, in consequence of the application to cold, he should wear a flannel waistcoat next to his skin, together with sliders of the same, and stockings of cotton or worsted. Such a dress may be found a little irksome at first; but time soon reconciles it, and in the end renders it truly desirable and comfortable. Where the patient cannot bear flannel next the skin, he may make trial of calico, which will keep up a more equable temperature on the surface of the body than linen, and guard against the action of external cold., He is by all organs to avoid exposing himself to the piercing northeast winds of this country. In our climate, tubercles are evidently induced and accelerated in winter, and retarded in summer. A person gets a dry cough in winter or spring, which goes'off as the summer advances, and was regarded as a catarrh, but tubercles were forming: if therefore such a person could be removed to a warm climate before the winter comes on, he might escape an attack at this period, and by conti- nuing there for a few years, may be perfectly recovered. Going to a warm climate is not merely avoiding what might be hurt- ful : it is applying a remedy which has the best chance to prove beneficial. It may justly be admitted, that the cold and variable temperature of the winters in England is the great source of phthisis in this Order I.J pulmonary consumption. 519 country, and when the disorder is once formed, greatly contributes to its fatal termination ; and that a warm and equable temperature in some measure prevents the formation of the disease, and when it has taken place in only a slight degree, possesses some power in retarding its progress. In the early stage of consumption, that is to say, when suppura- tion and ulceration have not )et taken place, it appears from the report of Sir James Macgregor, that the disease was checked by the climate of the Peninsula* among those of the army affected with phthisis ; but that when suppuration and ulceration had taken place, it run even a more rapid progress than in England, and the same remark has been made in regard to the East and West Indies. It is indeed a well-established fact, that a warm climate is only advantageous in cases of incipient phthisis. Persons who have passed the first stage of pulmonary consumption, will derive no benefit from a journey to the South of Europe, or elsewhere. Those who labour under confirmed phthisis should never quit their own country. By leaving it, they will lose many comforts; they most probably will be deprived of the attendance of their nearest and dearest friends, as well as that of the medical men in whom they can place confidence, as the English are apt to be pre- judiced against foreign physicians : they will, moreover, expose themselves to much anxiety and fatigue, and all this for a vague hope of recovery or prolonging life, an expectation very seldom if ever realized. If they remain at home, which they had best do, in all cases of confirmed phthisis, they may live throughout the winter in a regulated temperature. If the patient's case is one of incipient phthisis only, and his circumstances will admit of removing in due time, that is (o say, on the first threatenings of the disorder, from this climate to one in which the temperature is warm during winter, he may comply therewith. The islands of Madeira, and Malta, Lisbon, Italy, or the south of France, have been recommended as proper places. To persons liable to catarrhal or consumptive complaints, the most important properties of the climates of other countries are warmth and equability of temperature, especially in the winter months. The islands of Madeira and Malta present, numerically, a mean temperature for the winter months, but Pisa, Nice, Villa Franca, (very near the latter,) and Hieres, are certainly the most desirable places for an invalid. A female writer! of some celebrity informs us, she is convinced by experience, that the lives of many consumptive patients might be saved were they sent by sea to Leghorn, advised to winter at Pisa, cautioned against travelling much by land, and above all things, interdicted from crossing the Apennine and Alps, which people very frequently do, in order to spend the summer months ' See his Sketch of the Medical History of the British Armies in the Peninsula of Spain aud Portugal, in vol. vi. of theMedico-Chiiur^ical Transaction* + See Stark's Letters vol. ii. p. 261. b20 CACHEXIJE, OR CACHECTIC DISEASES. [ClttSS HI. in Swisserland, one of the most unequal climates in Europe. She thinks, that in pulmonary complaints, Pisa is entitled to a decided preference over Nice, Massa, Florence, Rome, or Naples, or in- deed to any other place in Europe, from the beginning of October till the end of April. She was advised to travel over-land to Italy, and, therefore, she passed over to France. Nice was recommended to her as the best winter climate, and she therefore spent many months in that city : but experience soon convinced her that she might have adopted a more eligible plan ; for long journeys over- land on the continent are to consumptive persons dangerous expe- riments, owing to the accommodations being so very indifferent that it is scarcely possible for an invalid to sleep at an inn out of a great town without suffering. To consumptive persons and in- valids in general, she therefore recommends the going to Italy by sea in a vessel bound to Leghorn, and so wintering at Pisa. When the patient's circumstances or business will not admit of his removing to a more temperate climate, he must endeavour to pass his winter in some place which is dry and well sheltered from cold bleak winds, where the air is free and pure, and the soil of a gravelly nature. The mild and sheltered vales of Devonshire, but more particularly Sidmouth, Torquay, and Penzance in Cornwall, offer desirable situations of this nature ; but the latter may be con- sidered as entitled to a decided preference. It has indeed been thought by some as equal to any situation abroad, and, therefore, the victim to consumption will not find it necessary to fly an exile from his home and friends to seek a doubt- ful advantage in a foreign clime. From a register of the weather at Penzance, by Dr. Forbes,* the mildness and equability of the temperature of that country are evident. He observed the maximum temperature of July was only 78° of Fahrenheit, the minimum of December, only 33°, and the mean range of the barometer, 1.48 inches. With the enjoyment of a free and pure air, the patient should take daily moderate exercise either in a carriage or on horseback, but more particularly the latter. By taking it in progressive journeys, through different parts of the country, in fair and settled weather, the efficacy of the remedy, great as it may be at other times, would be much increased ; for in such a tour the mind would find an ample store of amusement, and be diverted from any train of unpleasant thought. The pursuit of some object at the same time might probably add to the effect. All violent exertions, such as dancing, &c, liberties in diet, and going to crowded public places, are most cautiously to be avoided. If the disease has made considerable progress, and the patient is thereby prevented from exposing himself out of doors during the winter and spring, he must be contented to live in chambers subject to very little change from the atmosphere, and heated See VimsiUof Philosophy for :\l.arq^819. Order I.] pulmonary consumption. -ril from 62 to 65 degrees, which temperature will be most suitable. A stove may be employed for the purpose, and a preference should be given to one of porcelain (like the German and Russian stove ) over one of iron, as a very unpleasant smell is occasioned by the latter. Dr. Buxton* is of opinion that in the common shop stove or ironing stove used in laundries, we possess all that is necessary for the purpose of the proposed remedy. Under the principle of amusing the mind, and at the same time of having a desirable end to be obtained, many phthisical patients are yearly sent to the Hot-wells at Bristol. The waters of these wells have long been extolled for their supposed good effect in consumptive cases ; but in my humble opinion they are by no means deserving of the credit ascribed to them, as during a resi- dence of some time at and near these wells, I cannot charge my memory with a single instance where any person labouring under a confirmed phthisis experienced much relief from their use alone. That many persons who have been of a phthisical habit have derived benefit from resorting to the Bristol Hot-wells, I am ready- to admit; but this should not be attributed wholly to the waters. The horse exercise, which is taken daily by such patients, on afine airy down, where most beautiful views and rich landscapes are presented to the eye on every side ; the salubrity of the air ; the healthfulness of the situation, and the frequent attendance on the different amusements which are furnished at these wells, and those at Clifton, prove beyond all doubt most powerful auxiliaries. Places of public resort are food to the mind of convalescents, and serve to keep it in the same active state that exercise does the body, preventing thereby that indulgence in gloomy reflection, to which the want of cheerful scenes and agreeable company is apt to give rise in those who are in an indifferent state of health. The opinion which I have here offered on the efficacy of the Bristol Hot-wells waters, seems however by no means to accord with that entertained of them by a gentleman who some time ago published a dissertation on their chemical and medical properties.? On the subject of pulmonary consumption, he observes, that the utility of a journey to Bristol, undertaken while a cure is yet prac- ticable, is demonstrated by hundreds of examples annually, where the disease is prevented in many, and suspended or mitigated in others. I agree, however, with Dr. Beddoes,} that the fine things which medical men put into their pamphlets about the water of the places where they constantly or occasionally reside, are to be received with a large share or weight of allowance. Nay, I am decidedly of opinion, that at least three-fourths of the cures attri- buted to all mineral waters, ought rather to be placed to the account of a difference in air, exercise, diet, amusement of the * See his Essay on the Use of a regulated temperature in Winter Cough and Con- "Tsee "Dr. Carrick's Dissertation on the ChemicaJ and Medical Properties of the Bristol Hot-wells Water. 1 See his Manual of Health, p. 337 a: o22 cachexia, or cachectic diseases. [Class III. mind, and the regulations productive of greater temperance, than to any salutary or efficacious properties in the waters themselves. Respecting the composition of the Bristol water, it appears, from Dr. Carrick's experiments, to consist of the following principles : a wine gallon of 231 inches is impregnated with "Muriated magnesia.....7± grains. Muriated soda ----- 4 Vitriolated soda .....11? Vitriolated lime .....llf Carbonated lime .....13| Making together of solid matter 47| grains. Carbonic acid gas .....30 cubic inches- Respirable air .....3 Making together of gaseous fluids 33 cubic inches. On the supposed virtues of this water in phthisis, there has indeed prevailed much diversity of opinion, and many have denied that it possesses any peculiar power superior to simple water. Dr. Saunders* thinks, that although it is by no means a cure for con- sumption, still it will be found to alleviate some of the most harassing symptoms in this formidable disease. He observes, it is particularly efficacious in moderating the thirst, the dry burning heat of the hands and feet, the partial night-sweats, and the symptoms that are peculiarly hectical; and thus in the early stages of phthisis it may probably contribute to a re-establishment of health; and even in the latter periods it may considerably relieve, when the prospect of a cure has long been doubtful, if not hopeless. Short voyages on sea have been much recommended to con- sumptive persons, under the idea that sailing is of all modes of exercise or conveyance the smoothest and most constant. The good effects produced by sea voyages seem to depend, however, chiefly on the purity of the air, assisted somewhat probably by the occasional vomiting, which persons unaccustomed to be on board of a ship usually experience. Swinging is another species of exercise much recommended to phthisical patients. The use of what are called dumb bells might perhaps likewise prove serviceable. To remove inflammation from the lungs, and prevent the tuber- cles from proceeding to suppuration, the application of a blister will be highly proper; and that it may be rendered perpetual, it should be shifted from the chest to the side, and from the side to the chest, whenever the discharge ceases to be plentiful. Issues or a seton are frequently inserted in the side, or between the See his Treatise on Mineral Waters., p. 125 Order 1.] pulmonary consumption. 523 scapulae ; and in cases of incipient phthisis sometimes produce a good effect. Topical bleedings, by means of leeches and cupping, might likewise be resorted to with advantage in this stage of the disease. Both blisters and topical bleedings will afford considerable relief where there is a fixed pain in the breast or sides, which is increased upon coughing. Previously to the tubercles becoming much inflamed, perhaps they may be relieved, or be entirely removed by a solution of the muriate of lime, beginning with a drachm a day, and gradually increasing the dose. On the recommendation of Dr. Beddoes, factitious airs some years back were employed in the early stage of phthisis, and as auxiliaries, they undoubtedly proved serviceable ; but from their v virtues having been overrated, and an almost sole dependance placed upon them in many cases, they fell into disrepute, and other remedies have been substituted in a very rapid succession. Oxygen reduced by an addition of hydrogen, and other aerial fluids, with carbonic acid gas, are those which were chiefly used. With these the air of a room may easily be impregnated by means of the apparatus invented by Mr. Watt, of Birmingham. Where there is any difficulty in procuring the proper apparatus and materials, so as to prevent the possibility of adopting the most expeditious, or, upon the whole, the most advantageous methods of procuring the aerial fluids, the practitioner will do well in con- sulting Tiberius Cavallo's Essay* on the Medical Properties of Factitious Airs, in which a substitute is recommended. The following are his observations on the gases, and they are highly judicious. " In the use of oxygen," he says, " we have a singular stimulus, which admits of its being rendered more or less active by dilution with various proportions of common air. In its pure or nearly- pure state, it is a powerful exciter of suspended animation, and when diluted with a considerable quantity of common air, it is a gentle stimulus, which, by invigorating the various parts of the ani- mal body, by communicating firmness to the solids and energy to the fluids, does frequently obliterate the causes of morbid habits. " The use of azotic gas, and of the various species of hydrogen gas, produce a diminution of the irritability of the animal fibre to any degree, and hence it becomes useful in a variety of those dis- orders which depend on an increased irritability, such as inflam- mations, coughs, spasms, &c. In the use of carbonic acid gas we have a powerful antiseptic, and, in certain cases, a solvent of con- siderable efficacy. " The use of pure oxygen air is confined to the purpose of exciting the dormant powers of suspended animation, and it is therefore to be administered to children born apparently dead or overlaid ; to persons suffocated by drowning, by fumes of charcoal. See.chapter the first 524 cachexia, or cachectic diseases. [Class III by foul air, &c. whenever the circumstances of the case may indi- cate a possibility of recovery. " Those cases excepted, the respiration of pure or nearly pure oxygen air is almost always attended with unfavourable symptoms, such as a preternatural heat, especially about the region of the lungs; a quickened and feverish pulsation, inflammation, &c. And these symptoms come on after a longer or shorter use of the oxygen air, according to the particular constitution of the experimenter, and the purity of the gas. " But when the oxygen is diluted with much common air, viz. in the proportion of one to eight, and even as far as one to twenty, it then is a safe and useful remedy, whose principal action consists in giving tone, elasticity, and consistence to the fluid as well as to the solid parts of the body, and of course it promotes all the natural consequences of those effects, viz. it quickens languid circulation, it strengthens the organ of digestion, promotes secretion, invigorates debilitated habits, and assists nature in throwing off bad humours, and other lurking causes of diseases." Our author concludes with the following observations :— " After a careful consideration of the preceding general and comprehensive prospect of the medicinal use and efficacy of the aerial fluids, we may easily regulate the measure of our hopes by the standard of reason and experience. The idea of finding in them a remedy capable of curing consumption in their various stages must be laid aside, and the hope of healing all sorts of internal ulcers will naturally vanish. A use of reduced atmosphere does undoubtedly diminish the irritability of the fibre, and a diminution of irritability favours the healing of certain ulcers, but by no means of them all ; nay, in some cases it will even produce the contrary effect. The use of oxygen air has been found ad- vantageous in many of those disorders that are called nervous, and it has undoubtedly strengthened and invigorated debilitated or emaciated habits ; but it would be absurd to expect that it should prove beneficial in all cases of emaciation and debility, since those visible effects are often produced by causes that may be rather fomented than checked by the use of oxygen air." The only remark I have to add to these judicious observations, now fully established by the repeated trials of others, is, that the confidence placed by certain practitioners in the efficacy of artificial atmospheres seems entirely to be done away. The vapour of spiritus aetheris sulphurici dropped into warm water, has, in some cases of phthisis pulmonalis, been inhaled with considerable advantage to the patient. Earth-bathing, and stabling with cows, have been recommended by Dr. Beddoes in cases of incipient phthisis. Having had no experience of these remedies, I must beg leave to pass them over, it being sufficient that I have mentioned them. The former of these, we are given to understand by Van Swicfen. in his Com- Order I.J pulmonary consumption'. ^2b mentaries of Boerhaave, is much adopted in Granada, Andalusia. and other parts of Spain, in the cure of phthisis pulmonalis, and was first used in this country by the late well-known empiric Dr. Graham. One of the latest remedies which has been introduced into prac- tice for the cure of phthisis, is the digitalis purpurea. To speak properly, it is however rather the revival of an old remedy long laid aside than a new one. Concerning the virtues and mode of operation of this medicine, a variety of opinions have been enter- tained ; some attributing to it the power of diminishing secretion, and of exciting the action of the absorbents; and others again looking upon it as only useful from the power it possesses of les- sening the action of the heart and arteries. Foxglove has indeed been generally considered as a direct sedative ; and by this power producing a rapid diminution in the frequency of arterial pulsation. A modern writer* contends, however, that it is a powerful stimu- lant ; that it increases the strength and frequency of the pulse. and if continued sufficiently long, produces a flushed face, headach, hot skin, restlessness, and other symptoms of febrile action. These are effects which indeed we have never before heard attributed to this drug, being diametrically opposite to what they are by all others believed to be. The chief advocates for foxglovet are men of considerable emi- nence in their profession, and their report is certainly highly in its favour. They seem however to be too confident of having dis- covered a specific (if I may be allowed the term) for this dreadful disease ; and until it is determined that the digitalis alone, and riot conjointly with other medicines, has uniformly cured pulmonary consumption, and that it produces effects on the human system different from all others of the same class, we are by no means authorized to consider it in so very favourable a light. Dr. Beddoes, in his Essay on Consumptions, after having in- formed us that his own experience has fully verified the observa- tions of the two first gentlemen mentioned in the note below, uses the following forcible words :— " I daily see many patients in pulmonary consumption advancing towards recovery with so firm a pace, that I hope consumption will henceforward as regularly be cured by the foxglove, as ague by the Peruvian bark. Could we obtain a single auxiliary for foxglove, such as wt have in many instances for the bark, 1 should expect that not one case in five would terminate as ninety-nine in an hundred have hitherto terminated. But I believe a majority of cases will yield to simple foxglove. It is evident that no new cases need be suffered to advance beyond the first stage, without the application of this medicine, and few into it." Dr. Drake speaks of it thus :J " It has for several years been * See Dr. James Saunders on Pulmonary Consumption. t Dr. Fowler, of Stafford, Dr. Drake, Dr. Beddoes, Dr. Mossman + See Medical and PhyMeal Journal, vpl. ii. p. 418. 52G OACHEXLffi, OR CACHECTIC DISEASE-). [CluSS HI, given in pulmonary haemorrhage with effect, and certainly will con- tinue to be, with the intelligent, whatever may be the result of its trial in phthisis. I am happy however to say, that the [success which has hitherto attended the exhibition of the digitalis in phthisis has been very considerable ; several patients, in its con- firmed state, hare been cured by this remedy ; almost all have been relieved ; life has even been protracted by it; and when death has taken place, whilst the system was under its influence, it has been free from pain or struggle ; my expectations have been answered, and Dr. Fowler, I understand, from further trials, is fixed in hi< former favourable opinion." Dr. Mossman says,* " I have prescribed the digitalis very extensively for upwards of twelve months, and during the last six of that period I have had very ample experience of its powers. I am now fully persuaded, that by a judicious management of the plant, variously combined, I can obviate pneumonic inflammation with as much certainty as I can arrest the progress of an intermit- tent fever by means of the bark of cinchona. Again, I am per- suaded, that if pulmonary consumption be divided into four stages. the digitalis will very certainly cure the first three, and as certainly alleviate the distressing symptoms of the last." In the primary stages of the complaint, Dr. Mossman is of opi- nion that this remedy approximates to a specific. He thinks that it possesses in itselff a power directly sedative, and that the appli- cation of this power, by lessening the irritability of the muscular fibre, will explain its salutary operation in the cure of pulmonary consumption. From the observations of all these gentlemen, as well as from those of other physicians,} the digitalis must certainly be admitted to be a very powerful remedy in phthisis ; and although it is by no means to be regarded as a specific, still it must be allowed to have, in many instances, procured the most beneficial effects. In its early stage, wheii the powers of the system are not broken down, it promises to be productive of very essential service, by moderating the pulse, and by diminishing the hectic fever, the most distressing of all the symptoms, and that which seems to hurry on the patient to a fatal termination. After the purulent stage is com- pletely formed, it has appeared to me however not to produce any considerable or permanent good effects ; but even in this stage of phthisis it has been thought by some physicians to alleviate the sufferings of the patient. It does not seem that any evil of magnitude can arise from its use in tubercular consumption, if properly exhibited; that is to say, if given in moderate doses about thrice a day, and increased in a gradual manner until it produces a sensible effect on the system. The most unpleasant symptoms consequent on a liberal and long- " See his Essay on Glandular Consumption. f Ibid. vol. iv. p. 309. X See Dr. Kinglake's Remarks on the Effects of Digitalis, vol. iii. p. 120, of the Medical and Physical Journal. Order l.J Pulmonary consumption. 327 continued use of this medicine, are vertigo, nausea and sickness. In one case where the stomach and head were soon disordered by even a small dose, we are informed by Dr. Drake,* that a little lemon-juice produced an immediate good effect, removing both the sickness and vertigo, and enabling him to throw in a larger quan- tity of the tincture with ease and safety. A few drops of tinct. opii with each dose of the tincture of digitalis, he mentions, will some- times prevent the rejection of the latter from the stomach ; but he has not found it very effectual in removing the sensation of languor, or the affection of the head. The preparation of the digitalis used by the late Dr. Fowler, of Stafford, is a decoction,t of which he directed his patients to take half an ounce, twice, thrice, and, in a few instances, four times in the twenty-four hours. That used by Dr. Drake was the saturated tincture, in the proportion of five ouncesof proof spirit to one ounce of the leaves coarsely powdered, without any dilution of the colour or diminution of strength or taste. Of this saturated tincture he at first gave his patients from fifteen to twenty drops twice a day, which in some cases he gradually increased to ninety or an hundred drops with safety, even in patients greatly debilitated, before either sick- ness or irregularity of the circulation took place. Dr. M'Lean, of Sudbury, in Suffolk, is another gentleman who has favoured us with his sentiments on the foxglove ; and although he does not speak of it in such high terms as those of whom I have made mention in the preceding pages, and allows its powers to be limited even in the very early stages, still he is ready to acknow- ledge that he found it a valuable remedy in consumption.! He says, " It will sometimes cure when the most approved remedies fail. When of itself it is insufficient to subdue the disease, it will prove a valuable auxiliary to other means. It has always with me quieted and soothed the sufferings of the patient more or less ; and where it ultimately failed, it lengthened the duration of life, and smoothed the avenues to death." He goes on with observing, " This is all I apprehend it will be found capable of performing ; but this is doing * See Medical and Physical Journal, vol. ii. p. 419. X Ibid. vol. ii. p. 117. i. ft Fol. Digital. Purpur. Recent, ^ij. Coque ex Aq. Pura, Oj. ad Colat. ^vijss. et adde Tinct. Cardamom, f. ^ss. M. Vel, 2. rj^Fol. Digitalis Purp. Siccat. 3j- Infunde in Aq. Pur. Bullient. f "5viij. etposthoram cola. i't. Iufusum. Dos.f. -ss.ad. f. .^yj. t 1. Take Fresh Leaves ot Turple Fox- glove, two ounces. Pure Water, one pint. Boil it down to seven ounces and a. half. Strain of the liquor, and add Tincture of Cardamoms, half an ounce. , Mix them. Or, 2. Take Dry Foxglove Leaves, one drachm. Boiling Water, eight ounces. Infuse them for an hour, then strain off the liquor. The dose of this may be from half an ounce to six drachms. 528 CACHEXI2E, OR CACHECTIC: DISEASES. [ClaSS III. a great deal. Those who expect wonders from it, or that it will in general cure consumption, will be disappointed." The preparation of the digitalis, recommended and used by Dr. M'Lean, is that of the tincture made according to the formulae* here advised ; but he gives the preference to the last, as having the plant in its perfect state. He begins with from ten to fifteen drops three times a day, increasing two drops every second day, until the habit feels its influence. He then desists, and afterwards dimi- nishes in the same gradual manner, or augments the dose according to the effect. By these means, he observes, the body may, with the greatest safety, be kept under its influence for weeks, and even months. From Dr. McLean's report it appears, however, that he never was able to exceed a greater dose than thirty drops, repeated three times a day. With respect to the supposed mode of action of the digitalis^ instead of allowing, with Doctors Darwin, Fowler and Drake, that •its good effects depend always upon its power of diminishing secre- tion, and promoting pulmonary absorption, he observes, that it is equally, and indeed more efficacious in cases where there is no increase of muscus or pus. He attributes the good effects of the remedy in question to its power of correcting the diseased condition of the whole frame, and the train of morbid phenomena resulting from it. His words are : " It is to these I have been disposed to attribute, in a great degree, its salutary effects in this deplorable malady. If it frequently possesses such a control over the heart as to reduce its contractions from 120, and even 140, to fifty in a minute ; if it allays as it does in a most extraordinary manner, the cough and irritation of the lungs, and indeed of every part, the advantages thence resulting will be incalculable. The vessels of the diseased lungs will be placed in a condition of secreting bland healthy fluids ; every organ in a state of performing its healthy functions ; and thus the unison and harmony which constitute the healthy standard will be established throughout the body." In opposition to the theories of Doctors Drake and Fowler, and to that of Dj"« M'Lean, with respect to the mode of action of the digitalis, there are some practitioners who allow of its having no other powers than those of a sedative nature. The opinion seems by no means to be well founded. The modus operandi of this plant does not seem however to be clearly understood as yet. Let its powers depend upon what they may, certain it is that its ' 3. ii Folior. Digital. Purp. exsic. |j. Spirit. Ten. f ^viij. M. Digere leni calore per dies septem, dein cola, Vel, 4. g, Folior. Digital. Purpur.recent. §iv. Spir. Rectif. f. %v. M. Bigere per dies septem leni calore, dein *3- Take dry Leaves of Purple Foxglove, once ounce. Proof Spirit, eight ounces. Let them stand in a warm place for seven days, then strain off the liquor. Or, 4. Take fresh Leaves of Purple Fox- glove, four ounces. Rectified Spirit, five ounces. Let them stand for seven days in a gentle warmth, then ftrnin offthe liquor Order I.J pulmonary consumption. 529 success is proportioned to its early exhibition; and that therefore in every case where the disease arises in a phthisical habit, or is clearly marked, it ought to be had recourse to without any further loss of time. As the saturated tincture, recommended by Dr. .M'Lean, appears to be its best preparation, we should give it the preference. In administering foxglove it will be necessary to attend to the state of the pulse under different positions of the body; for it appears by the report of some physicians, that there is a consider- able difference of its velocity in the erect and recumbent postures. A case is recorded in the third volume of the Edinburgh Medical Journal, page 271, in which, after taking this medicine, the pulse was not lessened in frequency when the patient stood erect, being upwards of an hundred. When he sat down it fell considerably ; and when lying on his back, it fell much more. When sitting it was reduced to seventy-five, and when lying to forty. The experi- ment was repeated many times, and always with the same effect. The like singularity is noticed by Dr. Hamilton in his Treatise on Digitalis. Hemlock is a remedy which has been much recommended in glandular affections. As a narcotic it may be useful in some cases of tubercular consumption, but opium most likely will answer this purpose better. It may be given conjoined with myrrh, in the form of pills,* when we wish to make trial of it. Muriate of barytes is another remedy which has been much recommended by some physicians in incipient phthisis, as well as scrofula. It is best given in the form of the solutio muriatis barytas, at first in doses of five or six drops, which may afterwards be increased to twenty, twenty-five, or thirty, twice or thrice a day. In that variety of the disease which appears to be occasioned by an enlarged and indurated state of the abdominal viscera, or the lymphatic glands of the mesentery, we are told by Dr. Wilsont that he found mercury a valuable remedy, and that he has seen the patient saved by it even at an advanced stage. Mercury is, indeed, a remedy which has been much recommended, and sometimes employed in the early stages of phthisis pulmonalis by a few physi- cians in America, but more particularly by Dr. Rush. I think, how- ever, it promises no relief except in the cases Dr. Wilson used it. In all others it may be more likely to aggravate the disease than amend it. t See his Treatise on Febrile Diseases, vol. iv. * 3. pj. Extract. Conii, Gum. Myrrh, pulv. aa 3ss, Mucilag. Gum. Acac. q. s. M. ft. Massa, in pilulas viginti distribuenda, qu&rum duas sumat bis terve in die. OB * 5. Take Extract of Hemlock, Gum Myrrh, in powder, of each half C drachm. Mucilage of Gum Acacia, a suffi- ciency to form the mass, to be divided into twenty pills, of which take two twice or thrice a day. 530 cachexia:, or cachectic ni&EASEa. [Class HI. lntthe early stage of phthisis, the exhibition of an emetic every second or third day is usually attended with a very happy effect, and seems indeed to be one of the most powerful remedies we know of. As such, it should never be neglected, with an exception to pregnant women. From the cupri sulphas having been found to ex- cite vomiting readily and easily, without relaxing the stomach, irri- tating the intestines, or greatly fatiguing the patient, it has been more generally used in phthisical cases than any other medicine of the same class. The dose is from three grains to ten or fifteen, in proportion to the age of the patient, dissolved in two or three ounces of water. A vomiting is excited soon after it is received into the stomach, on which the patient may drink a pint of water. Dr. Maryatt* seems to have been one of the first who recom- mended the employment of the cupri sulphas as an emetic in phthi- sical cases. He advised it to be combined with tartarized anti- mony in the proportion of seven grains of each, which he directs to be divided into three powders, one of which is to be given twice or thrice a week. When any diarrhoea attends, he gives one grain of the cupri sulphas with five grains of ipecacuanha. During the operation of the medicine he advises nothing to be drank, for which reason he calls it the dry vomit. Dr. Senter, in his remarkst on Phthisis Pulmonalis, assures us, that he has restored more persons labouring under hectic fever from glandular suppuration by vomiting every second or third day with the cupri sulphas, and giving in the intervals as much as the stomach would bear of Dr. Griffith's myrrh mixture (hereafter to be mentioned,) than by all other methods he has ever read of or tried. He looks upon the sulphate of copper to be one of the most safe and efficacious emetics, joined with ipecacuanha, that the ma- teria medica furnishes us with, and advises from seven to ten grains of each, made up into pills, to be taken in the morning fasting, without drinking any thing afterwards. To the good effects of the mode of treatment pursued by Dr. Senter, I can bear ample testimony, having adopted it in many cases of incipient phthisis with infinite advantage. As the cough often proves troublesome in the first stage of the disease, as well as in the last, it may be found necessary to make use of some pectoral.J In such cases, the patient, besides using * See bis Therapeutics. t See Transactions of the College of Physicians of Philadelphia, vol. i. part i. 6. JJ. Misturae Ammon. f. ?viss. Acet. Scillaj, f. 3ij. Syrup. Tolutan. f. 3Uj. M. Tinct. Opii Camphor, f. 3ij. X 6. Take Mixture of Ammoniac, six ounces and a half. Vinegar of Squill, two drachms. Syrup of Tolu, three drachms. Compound Tincture of Camphor, two drachms. it. Mistura, cujus sumat cochl. j. larg. Of this mixture, let the patient take a large tusse urgenti. c.m,^('„i ...i_______.£_____, . . ■ P tusse urgenti. spoonful whenever the cough i? trouble- I some Order I.J pulmonary consumption. 531 these medicines as necessity may render needful, should take for ordinary drink what is here* recommended. In this stage of the disease opiates would he likely to prove prejudicial, and we should resort to them only in those cases where the rest at night is much disturbed. The extractum papaveris in doses of five grains or more should be preferred to opium. The digitalis, by allaying the irritation of the lungs, in consequence of its retarding the circula- tion through them, may be of much advantage in appeasing the cough. Hyoscyamus and the humulus lupulus have been employed with advantage where opium cannot be administered: but we are told by Dr. Duncan, senior,! that of all the substitutes for opium which he had ever used in practice, he had found none of so much benefit, in phthisis particularly, as the preparations formed from the inspis- sated white juice of the common garden lettuce, or lactuca sativa of Linnaeus. Dr. Duncan thinks favourably of the effect of inhaling the vapour of sulphuric aether in which the dried leaves of conium maculatum have been macerated; and he recommends it as par- ticularly relieving the cough and dyspnoea, and promoting ex- pectoration. The hydro-cyanic (Prussic) acid has lately been given in phthi- sis. The medicine was first introduced into practice by the Italians, under the form of distilled laurel water, and has been given by them and the physicians of other nations in various affections, known to depend on inflammatory excitement of some organ, as well as on some species of more evident chronic inflammation. It has been considered by Dr. Granville,! to be a valuable and t See his Observations on Pulmonary Consumption. X See his Observations on the Internal Use of Prussic Acid in Pulmonary and some other Diseases. Vel, 7. IJ; Misturae Amygdal. §vj. Oxymel Scillae, 3i»J- Tinct. Opii Camph. 3ij. ----Digitalis, Ttlxx. M- Sumat paululum subinde. Vel, 8. J£ Cetacei, 3ij- Vitel. Ovi, q. s. ad Solut. et adde Aq. Pulegii, f. ^v. Potassae Nitrat. 3j. Tinct. Digitalis, ff\xxvij. Syrup. Tolutan. f. §ss. M. * 9. R Decoct. Hordei, Oij. Gum. Acaciae, 3"j- Syrup. Limon. f. %}>"■ Pro potu ordinario M Or, 7. Take Almond Mixrure, six ounces. Oxymel of Squill, three drachms. Compound Tincture of Cam- phor, two drachms. Tincture of Foxglove, thirty drops. Mix them, and take a mouthful from time to time. Or, 8. Take Spermaceti, two drachms. Yolk of Egg, a sufficiency for solution, Then add Pennyroyal Water, five ounces. Nitrate of Potass, one scruple. Tincture of foxglove,fortydrops. Syrup of Tolu, half an ounce. Mix them. * 9. Take Decoction of Barley, two pints. Gum Acacia, three drachms. Syrup of Lemons, one ounce and a half. Mk them for ordinary drink. 532 CACHEXIAS, OR CACHE<; TIC^DISEASE-. [ClaSS III. powerful remedy in checking the progress of pulmonary consump- tion, when in its incipient state. We are told by him that it is eminently sedative, that it appears to exert its influence on the nervous system, that it gradually diminishes all irritability, checks too rapid circulation, and calms many of the symptoms of fever. If a dry cough be present, it is said to promote expectoration in the first instance, and subsequently to stop the cough itself. In hectic fevers, he tells us, it affords ease, lowers the pulse, dimi- nishes the force and number of the paroxysms, works a favourable change in the action of the lungs and their circulation, while the morbid heat of the skin and the circular flush of the cheeks gradually disappear. ' The night sweats are also said to be soon suspended. In consequence of the powers attributed to it by Dr. Granville, I was induced to make trial of it in several cases, but with no other advantage than that of reducing the pulse very considerably indeed. It has been recommended, to begin with the dose of two drops, repeating this about four times a day, and so gradually increasing it to three or four, and may be administered agreeable to the formulas below.* In all prescriptions having this acid as one of the ingredients, it is indispensably necessary to use no other than distilled water, as decomposition of the salts contained in common water, or of the acid itself, will, otherwise, take place; Prussic acid, although contained in small quantity in bitter almonds, the kernels of apricots, and several plumbs, the leaves of the peach, nectarines, and lauro-cerasus, is obtained by a chemical process recommended by Vauquelin. The lichen Islandicus is a favourite remedy with the continental physicians, and is daily employed by them in the routine of phthisical cases. The most usual form of exhibiting it is in that of a decoction with milk ; or, when this disagrees with the stomach, in water. It is not used, however, indiscriminately in every species of phthisis, nor in every stage of that disorder. It is chiefly recommended in those instances where the cough is attended with purulent expectoration; in cases preceded by, or accompanied with haemoptysis; in incipient phthisis, where from relaxation there is an increased discharge of mucus from the bronchia; in the sequeke of measels attended with a quick small pulse, pain of the breast, emaciation, violent cough, and purulent expectoration. Of late, the lichen Islandicus has become a fashionable remedy likewise 10. g; Mistura? Amygdal. 3ix. j* 10. Take Almond Mixture, nine drachms. Acid. Prussic. gutt. ij.^ ^ Prussic Acid, two drops. Syrup of Tolu, one drachm. Mix them for a draught. Or, 11. Take Distilled Water, or Infusion of Roses, ten drachms. Prussic Acid, two drops. Syrup of Poppies, one dr»ch.m Mix them. Syrup. Tolutan. 3"i. M ft. Haustus. Vel, 11. H Aq.Distillatse aut Infus. Rosae 3* Acid, rrussic. gutt. ij. Syrup. Papav. 3i. M Order!.] pulmonary- dosstfirTTiQ'i,. 5& among our own physicians, and I have myself prescribed it in several cases of phthisis, but without any evident beneficial effect. It seems indeed better calculated for an article of diet than a medicine. Such are the means which should be had recourse to during the first stage of phthisis. In the second and latter stages we are to counteract, if possible, the effects of the absorbed matter ; to miti- gate the most distressing symptoms, such as the cough, diarrhoea, and colliquative sweats ; and, lastly, to put the body into as good general health as possible, by air, moderate exercise, and a proper course of mild nutritive food. No antidote against the poison which especially operates here having been found out, and it appearing that too great a degree of inflammation may have a share in preventing the ulcer from heal- ing, and in urging on its fatal consequences; it has been proposed . to employ means for moderating the inflammation in this stage of the disease, as well as in the first. With this view, small bleedings. frequently repeated,have been advised by some physicians. Draw- ing off blood, when this disease has arrived at the stage of ulcera- tion, is, in my opinion, exhausting the vital stream very unneces- sarily ; it is adding to debility, and must therefore be very improper. The same reasoning will hold good against a use of purgatives. When we want to lessen the action of the heart and arteries, from the pulse being very frequent, and the patient much troubled with flushing heats, in consequence of hectic fever, we should employ the digitalis, instead of having recourse to such debilitating means ; this having been found capable, as has already been observed, of reducing the pulse from 120, and even 140 strokes in a minute, to something below the natural standard. Dr. Bourne, of Oxford, has published some cases of pulmonary consumption, in which he made trial of the uva ursi: and the dose in which he mostly exhibited it to his patients, was from eight to fifteen grains of the powder three times a day. He is of opinion that it has a very sensible effect in diminishing the hectic fever, and in abating the increased frequency of the pulse dependant thereon. It appears that he was first induced to make use of it in phthisis from having remarked its good effects in a disease of the urinary organs, attended with a discharge of muco-purulenf; matter along with the urine, and accompanied with all the usual characteristics of hectic fever. The uva ursi is possessed of con- siderable astringency, and to the taste is slightly bitter ; but neither its sensible properties nor its immediate effects on the system point it out as a medicine of great activity, particularly in phthisis pulmonalis. In the second stage of the disease, the employment of emetics must be duly persisted in, every second or third morning, in the manner advised during the first stage. As detergents, different balsamics have been much used in the ulcerated stage of the disease. Balsam of copaiba, in the dose of S>34 CACHEXIA, OR CACHECTIC DISEASE^. [Ctos W. from twenty to thirty drops twice or thrice a day, may be tried. Myrrh is, however, the medicine which is employed with the greatest success in those cases of hectic fever which are unat- tended by any great degree of heat or thirst, and v/hich do not show manifest signs of inflammation. The preparation* used by the late Dr. Moses Griffiths seems to be preferable to all others. If at any time it should be thought too heating, the spirituous water may be omitted, as the solution may be made without it: but it is a doubt if it will agree so well with the stomach of patients in general. The myrrh may gradually be increased to seventeen or eighteen grains for a dose, the potassae subcarbonas to ten, and the ferri sulphas to four. But it is always best to begin with small doses, and as the symptoms abate, to give two draughts a day, containing eighteen or twenty grains of myrrh, twelve of the potassae, and five or six of the ferri sulphas, which is the largest dose that should be taken. This medicine, although a little nauseous at first, is nevertheless seldom rejected by the stomach, or excites any kind of disturbance in the habit afterwards. Where hectic heats and flushings prevail in a high degree, and the pulse is very frequent, it probably might be most advisable to omit the last article entirely. Dr. Beddoes has expressed a wish that we could obtain a single auxiliary to foxglove, as that then he should expect that not one case in five would terminate as ninety-nine in an hundred have hitherto done. I would propose this myrrh mixture of Dr. Griffith's, and vomiting twice a week, with the cupri sulphas, as mentioned in the preceding pages. A proper dose of the tincture of digitalis may be added to each of the myrrh draughts, and so be given toge- ther. This plan of proceeding I have adopted in several cases. and with much seeming advantage. Should the mixture not sit easy on the stomach, or be objected to on account of its nauseous taste, we may then form the myrrh and other ingredients into pills,t and give the digitalis in about an ounce of the infusion of quassia or cascarilla. " 12. ]J Myrrhae, 3j Solve terendo in mortario cum Spirit. Pimentae, f. 3yj. Aquae Distillat. f. §yjss. Dein adde Potassae Subcarbon. 3ss. Ferri Sulphatis, gr. xij. Syrup, f. 3ij. M. ft. Mistura, in haustus quatuor distribuen da, quorum unum capiat mane, hora quinta post meridiem,et hora decubitus t 13. R Myrrh. Pulv. 3ij. Ferri Sulphat. 3j. Pota«ae Subcarbon. 3,j' * 12. Dissolve of Myrrh, one drachm, in a mortar, with Spirit of Pimenta, six drachms. Distilled Water, six ounces and a half. Then add Subcarbonate of Potass, half a drachm. Sulphate of Iron, twelve grains. Syrup, two drachms. Mix them, and divide the whole intofour draughts, of which one is to be taken every morning, another at five in the evening, and one at bedtime. 113. Take Myrrh in Powder,two drachms. Sulphate of Iron, one scruple. Subcarbonate of Potass, • one drachm. Order l.J pulmonary consumption o3o The cinchona bark has been employed in the ulcerated stage of phthisis ; but if ever it proves serviceable, it can only be when the morning remissions of the fever are considerable, and the noon exacerbations well marked. In all other cases it will be likely to prove prejudicial. The reason why pulmonary ulcers are prevented from healing, is their being constantly exposed to the air. It is remarkable that matter produced by suppuration may be concealed in the body many weeks, or even months, without producing hectic fever; but as soon as the wound is opened, so as to admit air to the surface of the ulcer, a hectic fever very quickly supervenes. The suckling of children longer than is consistent with the mother's ability, is sometimes a cause of pulmonary consumption; but more particularly among the lower class of females who are of. a tender and delicate constitution. In such cases the cinchona bark given early in moderate doses, and merely as a tonic, is often attended with the best effect. Where a disposition to consumption arises in consequence of any enfeebling evacuation, such as a considerable abscess, fluor albus, or the like, without any inflammation of the lungs having yet taken place, cinchona will likewise prove serviceable, and may be given as advised below.* After inflammation has come on, or ulceration has commenced, it would not fail to prove injurious, by increasing the cough and the tightness and oppression of breathing. To counteract the effects of absorption, vegetable acids, such as oranges, and other fruits yielding an acid but not acrid juice, have been much recommended. When they do not affect the bowels they may be given freely with the powder of sarsaparilla. Fresh subacid fruits, although supposed to be usually laxative, are often useful in the diarrhoea of hectics, by their antiseptic quality. When the diarrhoea of hectic is accompanied with pain, and resists the action of astringents and anodynes, small doses of the submuriate of mercury have been found useful. In this stage of the disease, as well as in the incipient, we are to Extraet. Gentian. 3jss. Syrup. Simpl. q. s. M. ft. Massa in pilulas lxx. distribuenda, quarum sumat iij.—iv. ter in die. • 14. f* Potassae Subcarbon. 3ij. Succ. Limon. f. ?j. Decoct. Cinchon. f. ?v. M. Mistura, cujus capiat cochl. ij. bis terve indie. Vel, 15. $ Decoct. Cinchon. f. ~v. Liquor. Ammon. Acetat. f. |j. M fj. Mistura Extract of Gentian, one drachm and a half. Syrup, a sufficiency to form the mass, which is to be divided into seventy pills, whereof three or four are to be taken thrice a day * 14. Take Subcarbonate of Potass, two scruples. Juice of Lemons, one ounce. Decoction of Peruvian Bark, five ounces. Of this mixture, let the patient take two table-spoonsful twice or thrice a day. Or, 15. Take Decoction of Bark, five ounces. Solution of Acetate of Ammonia, one ounce. Mix them .53b' cachexijb, or cachectic disease's. [Class III. obviate inflammation, and divert the matter, if possible, by means of blisters, issues, or a seton. To palliate the cough, which is very apt to prove troublesome, and to assist the expectoration, we may have recourse to demul- cents, as before advised. If the patient's rest is much disturbed by night, we may employ opiates ; and although they are supposed to increase the phlogistic diathesis, and in some degree to check the expectoration, still they amply compensate for these by the ease and sleep they procure. In the tubercular or true scrofulous phthisis, Dr. Crichton, of Petersburgh, has seen very great benefit derived from a use of tar fumigation. He found that it heals the ulcers and subdues the; inflammation of the tubercles; but where there are large abscesses, or vomicae, in sanguineous habits, and in cases of suppuration succeeding active hemorrhages, accompanied with fever, in young persons, little or no advantage was derived from the remedy. It is also of importance to know that the use of the fumigations should not be continued after the cough, expectoration, and hectic symp- toms are greatly subdued, and the patients should not again expose themselves hastily to a cold air. The simplest and best manner of filling a room with the vapour from tar, is to place the vessel containing it over a spirit lamp, taking care that it boils slowly and does not burn. The vessel should be well cleansed every day, and the fumigation be repeated every three hours. Some of the subcarbonate of potass (in the proportion of one ounce to the pound of tar) is to be added, in order that the pyroligneous acid, as Dr. C. terms it, (perhaps more properly the empyreumatic acetic acid,) may be destroyed. With respect to the treatment of phthisis by bituminous vapour, the subject is not altogether new, as similar good effects have resulted from the vapour of melted rosin ; a case of which nature, that occurred in the year 1771, is reported in the 53d No. of the London Medical Repository, page 400. In slow hectic fever, attended with frequent flushings and profuse night-sweats, and with much coughing and fetid purulent expecto- ration, Seltzer water will often in a high degree check the violence of perspiration, diminish the discharge from the lungs, and corrrect its fetor; and under the operation of this medicine the patient will for a time be able to gain quieter nights, and a better appetite. Seltzer water mixes well with milk, and will not soon coagulate it; which mixture has been strongly recommended in cases of hectic fever with expectoration. In very irritable habits it may be highly necessary to dilute the water in this way, as in its simple state it might prove too powerful. When the sweats are profuse, the infusum rosae, with a sufficient quantity of diluted sulphuric acid, will be a good medicine to check them, and may answer instead of Seltzer water. The nitrate of silver, in doses of an eighth or fourth of a grain twice or thrice a day, has been administered with a happy effect in some cases of Order I.J pulmonary consumption. o37 profuse sweating, accompanied by purulent expectoration. The superacetate of lead, when joined with opium, also restrains, in a very powerful manner, the morning perspiration, which wastes and harasses the patient. When a diarrhoea arises, it is to be stopped by astringents com- bined with opium, as recommended under that head. For common drink, the patient may take the mistura cornu usti, and arrow-root. By the- consent between the intestines and skin, twenty grains of Armenian bole given on going to bed to hectic patients, will fre- quently check their tendency to sweat as well as to purge, and the more certainly if joined with one grain of opium. Where a spitting of blood arises in persons labouring under phthisis, the internal use of the superacetate of lead conjoined with opium, together with the other means advised under the head of Haemoptysis, must be resorted to. The aphthous sores in the mouth which frequently arise in the latter stage of phthisis, are to be cleansed by washing or rincing the fauces often with an infusion of cinchona, having a little borax dissolved in it.—See Cachexia Aphthosa. The strength is to be supported by food of a light nature, but which is at the same time highly nutritive; and the different exer- cises, such as sailing and riding in a carriage or on horseback, but more particularly the latter, should be taken daily in fine weather, When the inflammatory diathesis is subdued, chalybeates, com- bined with myrrh and the subcarbonate of potass, may be given with much advantage. The liquor calcis will be a good menstruum for dissolving the myrrh. Should we be so fortunate as to subdue the disease by the means which have been pointed out, it will be indispensably necessary for the patient to persevere in employing the regimen recommended in the treatment of this complaint, for a considerable length of time after every symptom has disappeared; and he should return to his former manner of living with the utmost caution. Some practitioners, from considering pulmonary consumption as entirely of a scrofulous nature, disapprove highly of the antiphlo- gistic plan, by bleeding and a spare diet even in the first stage of the disease. Instead of these, they recommend a nutritious diet, consisting of shell-fish and animal food; the use of conium and sarsa in powder as medicines ; warmth in the dress, by wearing flannel next to the.skin, and at the same time heating the patient's room to the West India point, when he cannot remove to a warmer climate ; the application of blisters, and frequent smart riding on horseback by way of exercise. With regard to the remedies usually employed in the treatment of phthisis, Dr. Ferriar has observed that the digitalis, with the ferri sulphas, myrrh, cinchona, and other tonics, may be most proper in those cases of consumption which arise from scrofula; while the digitalis with opium, mucilaginous medicines, and diuretics, may he opposed to the florid consumption- 53o CACHEXIA, OK CACHECTIC DIsEASE^. [ClttSS 111. CACHEXIA AFRICANA, or NEGRO CACHEXY. This disease, known by the name of mal d'estomac among the French, and by that of dirt-eating in our West India colonies, is frequently to be met with among negroes, but more particularly those imported from Africa. Mons. Sonnini makes mention, in his Travels through Egypt, that a propensity for eating earth is a dis- ease frequently to be met with likewise among the Egyptians. Between it and chlorosis there is, in many respects, a great simi- larity; but they differ in this circumstance, that the latter only affects females, and that principally about the age at which men- struation ought to commence ; whereas the former affects males as well as females, and is often to be met with in children of six or seven years old, as I have seen happen in various instances. Cachexia Africana evidently arises from a want of due energy or vigour in the system, induced by various debilitating causes, as grief and despondency, occasioned by their being separated from their families and friends, and reduced to a state of bondage; by poor diet, hard labour, and harsh treatment. With some the dis- ease is however constitutional, and proceeds from general relaxa- tion, a vitiated state of the stomach, and bad digestion. Negroes imported from the coast of Africa, who are of an inactive indolent habit, and children of lax fibres, and who have been badly nursed and afterwards neglected, are most liable to its attacks. Nostalgia, in which there prevails an unaccountable desire of re- turning to one's own country, is a disease somewhat similar to the negro cachexy. It is derived from the Greek words vac-res, return, and «Ay«s, grief, because it is only cured by returning to the paternal roof. The French,* among whom the disease is denominated mal du pays, as also the Swiss, are said to be particularly liable to it, and the latter, when taken into foreign service, very frequently desert from this cause. Its effects on the Africans are more violent, and not unfrequently impel them to dreadful acts of suicide. Sometimes it plunges them into deep and incurable melancholy, which induces the unhappy sufferers to end a miserable existence by a more tedious, though equally certain method, that of dirt-eating. Cachexia Africana shows itself by a fondness for solitude, and an indulgence in grief and despondency, together with a loss of appe- tite, constant pain in the stomach, difficulty of breathing upon the least bodily exertion, paleness of the face and palms of the hands, whiteness of the tongue, with an appearance like stains of ink upon it, whiteness of the lips, drowsiness, inactivity, unwillingness tc attempt and inability to perform motion, and general debility. The tunica adnata is of a glassy whiteness, the skin of an olive complexion and cold to the touch ; the eyelids, face, and extremi- ties, show evident signs of an extravasation of water in their cellular See Recollections and Essays, by F. A. De Chateaubriand, vol. ii. p. 138 Order I.] NEGRO CACHEXY. 33y membrane ; and the unhappy sufferer can only breathe in an erect posture, from water being likewise collected in the chest and cavity of the abdomen. The stools are at the same time of a white or clay colour, the urine is scanty* and the pulse is always small, and generally becomes quicker as the night approaches. In consequence of the vitiated state of the gastric juice and impaired digestion, a morbid acidity prevails; and a symptom arises from this cause, which with some has given name to the disease, viz. a habit of eating dirt, chalk, or whatever will obtund acrimony. This vitiated action is propagated throughout the whole aliment- ary canal; the lacteals are abraded by acrimonious fluids, and no longer possess the power of absorbing healthy chyle ; hence the lymphatic glands become indurated and inflamed; the liver also is enlarged and of a scirrhous hardness; the blood poor, vapid, and colourless, no longer stimulates the heart and arteries to action ; hence asphyxia and sudden death. Fatal consequences usually attend this disease. On dissection the stomach is often found much enlarged and thickened in its coats ; the liver is of an increased size, scirrhous, and always pre- ternaturally white; biliary concretions are sometimes met within the gall bladder; the bile is never of a healthy appearance, but usually of a thin watery consistence, and of a slightly yellow or fresh colour ; the mesenteric glands are indurated and scirrhous. and polypous concretions are occasionally found in the heart. The proper indications of cure seem to be, first, to strengthen the general system, and give due energy to the constitution ; and, secondly, to correct the morbid acidity which prevails. To answer the first of these purposes, the patient must be allowed a generous and nutritive diet, consisting principally of animal food and wine, or weak fermented liquors. Cane juice boiled to the consistence of a thin syrup (as in the first process of sugar-making) is also of a very restorative nature, and ought during crop-time to be allowed liberally. With a generous diet, the patient should be made to take moderate exercise daily, as a want of this will not fail to increase the general debility, and add to the disease. Warm clothing, with occasional frictions by means of flannels, will like- wise be proper. To assist the effect of Jhese means, we must put the patient under a course of stomachic bitters, joined with aromatics, dif- ferent preparations of the cinchona bark, with myrrh and chaly- beates, as advised under the head of Dyspepsia. The antihectic mixture of Dr. Griffiths (see Phthisis) will he likely to prove a most valuable remedy in this disease. The second indication is to be answered by alkalies and absorb- ents, as likewise recommended under the head of Dyspepsia. The exhibition of an emetic of the cupri sulphas once or twice a week, as advised in phthisis, seems likewise proper. When costiveness prevails, it ought to be removed by an use of •34f> CACHEXIA, OR CACHECTIC DISEASES. [ClttSS lit. some warm stomachic laxative, such as the tinctura rhei composita, or tinctura aloes composita. If the disease has been of such standing as to be attended with anasarcous swellings, besides using the means already re- commended, we must have recourse to diuretics, as advised in dropsy. Where it is accompanied with a retention of the menses, we must endeavour to promote these by calling in the assistance of emmena- gougues.—See Chlorosis. In order that the depravity of appetite may not be indulged, the patient should be lodged in a room which has a boarded floor, and where he cannot possibly get any dirt; and when he goes out for exercise, he should be accompanied by an attendant, who will not permit him to eat it. Dr. Chisholme, in his ingenious Essay on this disease,* says, it is remarkable that negroes who are subject to it have been much benefited by living in a low situation, near marshes, which quickly prove fatal to whites ; and he had long observed this before he formed any theory on the subject. He adds, perhaps the hydro- carbonic air may act as a cordial; it is perhaps the nervous asther itself. It has been remarked by medical writers, that the attack of remittent marsh fevers is frequently preceded by an unusual flow of spirits. From my own observations, during a long residence in the West Indies, I am ready to admit with Dr. Chisholme, that mountainous situations do not agree with cachectic negroes so well as low ones ; but I cannot with him attribute the effect to the influence of marsh effluvia. Noxious vapours arising from stagnated waters and marshy grounds, acted upon by a powerful sun, prove, in warm climates, a never-failing source of disease under all circumstances, and under every condition of the body. The cachectic negro can- not endure the cold, chilling, and damp air of a mountainous situa- tion ; but in a low one (the more remote from marshy grounds or stagnant waters the better,) he feels warm and comfortable, and breathes a pure dry air, moderated in its temperature by the refreshing and reviving breezes which come off the sea. CACHEXIA APHTHOSA, or CHRONIC THRUSH.1 Chronic thrush is a disease xery frequently to be met with among the inhabitants of our West India colonies, many cases of it having occurred during my practice there, but which is likewise apt to prevail in those northern countries where the cold is combined with aconsiderable degree of moisture, or where the soil is of a very marshy nature. It may in some cases be considered as an idiopa- thic affection, but it is more usually symptomatic. It is dependant * See the New-York Medical Repository. t The common species of Aphtha, as principally affecting infants, is included among the diseases peculiar to them ; but in Dr. Cullen's nosological arrangement it stands among the Exanfhempfa. Order I.] CHRONIC THRUSH* ■Ml. on a cachectic state of the whole system, characterized by ulcera- tion of the mouth, tongue, fauces, and intestinal canal. It shows itself at first by an uneasy sensation or burning heat in the stomach, which comes on by slow degrees, and increases gra- dually in violence. After some time, small pimples, of about the size of a pin's head, appear on the tip and edges of the tongue, and these at length spread over the whole inside of the mouth, and occasion such a tenderness and rawness of the parts, that the patient cannot take any food of a solid nature ; neither can he receive any vinous or spirituous liquor into his mouth, without great pungency and pain being excited : little febrile heat attends, although there is some thirst, but the skin is always remarkably dry, rough, and without the least moisture on it; the countenance is of a pale olive colour, the pulse is smaller and more languid than in health, gene- ral coldness is felt over the whole body, but more particularly in the extremities, and the urine is small in quantity, and sometimes exhibits a milky or wheyish turbidness. These symptoms will continue probably for some weeks, the general health being sometimes better and sometimes worse, and then the patient will be attacked with acid eructations, and a vomiting of acrid phlegm, as likewise with a severe purging, which greatly exhausts his strength, and produces considerable emaciation of the whole body. The stools indicate a defective biliary secre- tion, strongly resembling thick oatmeal gruel in an incipient state of fermentation ; but there is no pain or enlargement of the liver, nor jaundice, although the complexion is somewhat of the olive colour. After a little time, the symptoms cease, and he again enjoys better health ; but sooner or later the acrid matter shows itself once more in the mouth, with greater virulence than before, and makes frequent translations to the stomach and intestines, and so from these to the mouth again, until at last the patient is reduced to a perfect skeleton. Death in its approach still lingers, and seems as it were unwilling to overtake its languid victim, until worn down with fatigue and inquietude, he sinks into a state of exhausted apathy, and life at length is extinguished. General relaxation, exposure to cold combined with great moisture, obstructed perspiration, and an acrimony of the hu- mours, are supposed to be the causes which give rise to the chronic thrush. Elderly people and persons with a shattered constitution are most liable to its attacks. It often admits of palliation from the resources of medicine, but it is seldom cured, even at an early stage of the disease. When en- gendered beneath the influence of a tropical sun, or it has been neglected, is of long standing, or has made its attack in an advanced period of life, it will terminate fatally. The principal appearances to be observed on dissection are the aphthae, which extend through the whole of the alimentary canal. The muscles throughout the body are relaxed and flaccid, and then ronnecting cellular membrane is divested of any fat. 342 CACHEXIA, OR CACHECTIC DISEASES. [CldSS HI. It will in all cases be advisable to begin the cure with giving a gentle emetic, to dislodge the acrid phlegm with which the sto- mach is usually loaded ; and if any acidity prevails afterwards (which may be known by sour belchings attended with a degree of heat and pain,) a little magnesia, or a small quantity of the absorbent mixture* here recommended, may then be taken oc- casionally. Wherever we suspect the disease to have arisen, or to be kept up from the ingesta, then, besides an emetic, it may be right to cleanse the prima? viae by some gentle cathartic ; as the irritating matter, when permitted to accumulate in the alimentary canal, in- creases the morbid affection of the intestines. A combination of rhubarb with magnesia, or the submuriate of mercury, will be a proper laxative. Medicines of this nature are however to be ad- ministered only in the first stage of the disease, as the risk of in- ducing excessive purging more than counterbalances the chance of advantage from them. In an advanced stage of the disease, where it is found necessary to evacuate the intestines, emollient clysters may be employed. When a purging arises, we should have recourse to astringents joined with opiates agreeable to the prescriptions below,! or as advised under the head of Diarrhoea ; besides which, the patient should drink about a pint a day of the mistura cornu usti, or the same quantity of lime-water with an equal proportion of milk. Where there is no tendency to excessive purging, opiates perhaps may be omitted, unless they be necessary to procure sleep or allay irritation. In mitigating the pain, exhaustion, and despondency which sig- nalize the ravages of the disease towards its fatal termination, opium is indeed the remedy principally to be relied on. With the view of determining the humours to the surface of the ' 1. ft Magnesiae, 3j Aq. Purse, f §vss- Spirit. Cinnam. f. 3"j- Liquor. Ammon. f. 3j- M. Capiat, cochl. ij. larg. pro re nata. * 2. ft Confect. Catechu, 31J. Aq. Cinnam^f. §ij. — Purae, f. §iij. Tinct. Kino, f. 3ij. ----Opii, fflxxv. M. ft. Mistura, cujus sumat cochl. ij. vel iij in die. Vel, 3. ft Mistur. Cretae, f. ?iv. Spirit Cinnam. f. 3jj. Tinct. Catechu, f. 3u> ----Opii.fllxxyj. M. ter * 1. Take Magnesia, one drachm. Pure Water, five ounces and a half. Spirit of Cinnamon, 3 drachms. Solution of Ammonia, 1 drachm. Of this mixture take two table-spoonsful occasionally. t 2. Take Confection of Catechu, two drachms. Cinnamon Water, two ounces. Pure Water, three ounces. Tincture of Kino, two drachms. --------Opium, forty drops. Of this mixture let two or three table- spoonsful be taken thrice a day. Or, 3. Take Chalk Mixture, four ounq.es. Spirit of Cinnamon, one ounce. TinctureofCatechu,twodrachms. --------Opium, forty drops. Mix them. The dose may be the «amp as the former. Order 1.J chromc thrush. body, it will be right to give frequent small doses of some diapho- retic, such as the pulv. ipecac, compos. ; and to assist their opera- tion, flannel should be worn next to the skin. Should these fail in exciting a proper perspiration, and the patient continue to waste in flesh, a tepid bath may prove serviceable, and where a natural one can be procured, it ought to have the preference. To remedy the inconvenience arising from the soreness of the mouth and tongue, these should be washed frequently with some. kind of healing astringent gargle.* When the rectum is affected, mild injections are proper, and produce effects similar to those of gargles in the fauces; they should consist of mild mucilaginous and gently stimulating de- coctions, such as veal broth, boiled with rice and bruised turnips, or turnip radishes, which will likewise prove an excellent article of diet. In mild cases of the disease, a decoction of the cinchona bark combined with the subcarbonate of soda, is often used internally, and with much advantage. In those cases where it puts on an alarming appearance, the preparation should be employed as a gargle, and the powder be administered in as large doses as the stomach will bear. If it excites a purging, a few drops of tinct. opii may be added to each dose. In its first or simply dyspeptic state, the disease may often be removed in northern climates by a few doses of calomel, and some bitter infusion combined with magnesia or rhubarb. Occasionally mercury has been used both externally and internally in this dis- ease with advantage : externally, in the form of ointment or plaster to the hepatic region ; internally in that of the hydrargyri submu- rias combined with opium. The diet in cachexia aphthosa should consist only of such things ' 4. ft Infus. Rosae, f. |vj. Aluminis, 3jss- Mel. Optim. f. ^j. Liquor. Plumbi. Acet. 1T]x. ft. Gargarisma. Vel, 5. R Zinc. Sulphat.4ti CACHEXIA, OR CACHECTIC DISEASES. [Class III. cumstances of the greatest corpulence, and diseases consequent thereon, by a rigid adherence to the plan just recommended. As medicines, diaphoretics, with an occasional use of moderate purging, have been employed. Soap is recommended to melt' down and facilitate the absorption of the fat in corpulent people; but probably the potassae subcarbonas would be more powerful. Diuretics might possibly be used with advantage. The aerated alkaline water, which is supposed to render the fat more fluid at the same time that it determines to the kidneys, may be taken.by the patient for his ordinary drink. Vinegar and lemon-juice are too frequently used by young women to reduce corpulence ; but an excessive use of acids is apt to destroy the digestive powers, and in the end to bring on a train of dyspeptic complaints. 11—INTUMESCENTI^ FLATUOS^, or FLATULENT SWELLINGS. EMPHYSEMA. This disease consists in a collection of air in the cellular mem- brane. In general it is confined to one place; but in a few cases it spreads universally over the whole body, and occasions a con- siderable degree of swelling. It sometimes arises spontaneously, which is, however, a rare occurrence, or comes on immediately after delivery, without any evident cause ; but it is most generally induced by some wound or injury done to the thorax, and that affects the lungs; in which case, the air passes from these through the wound into the sur- rounding cellular membrane, and from thence spreads sometimes over the whole body. Emphysema is attended with an evident crackling noise and elasticity upon pressure ; and sometimes with much difficulty of breathing, oppression, and anxiety. J We are to consider it as a disease by no means unattended bv danger; but more probably from the causes which give rise to it than any hazard from the complaint itself. ' The intentions of cure which we should have in view must be first to remove the cause of the disease; secondly, to relieve the urgent symptoms; and, thirdly, to evacuate the collected air To answer the first of these, the assistance of surgery will be necessary, as arising most commonly from a wound or other iniurv done to the thorax, which at the same time affects the Junes as in the case of a fractured rib, the ragged edges of which penetrate the pleura and substance of the lungs, and thereby admit of an extravasation of air into the cellular membrane. In such cases the air is to be evacuated by scarifications into the cellular membrane in different parts of the body, as circumstances may require, assisted by proper pressure with the hand. Violent dyspno-a and anxiety are to be relieved by bleeding and laxatives; and the pain aud uneasiness arising from the distention Order U.) TYMPANY. o47 by relaxing applications to the skin, such *j the ungyentum cetacei, &c. TYMPANITES, or TYMPANY. Tympany consists in a violent distention either of the intestines. or cavity of the abdomen, by wind. In the former instance it has been supposed to arise from the sudden suppression of diarrhoea or dysentery, or as a consequence of febrile diseases, or the sudden drying up of long-continued discharges ; from cutaneous eruptions, or a use of crude vegetable aliment; and in the latter from an erosion of the intestines, the effect also of preceding complaints. Tympanites intestinalis sometimes comes on suddenly, at others it is more slow in its progress, and preceded (be the cause what it may) by great flatulency, borborygmi, and a frequent expulsion of the air upwards and downwards, attended with colic pains. As it advances, the abdomen becomes considerably distended, and retains the same figure under every variation of position. The swelling does not yield much to pressure, and in what it does, it soon recovers its former state ; it feels very elastic, but no fluctua- tion can be perceived. The urine at first is not altered either in quantity or quality ; but in the advanced state of the disease a change takes place in both respects, and dysuria and even ischuria sometimes come on. The body is usually very costive, the appetite is impaired, thirst, heat, and pyrexia attend, and general emaciation ensues. In time the respiration becomes difficult, with much anxiety and cough ; the strength is exhausted, the belly is enormously swelled, and the patient is not unfrequently destroyed in consequence of supervening gangrene. In tympanites abdominaJis the swelling is more equal than in the former species, the tension greater ; it is more elastic, and, upon percussion, sounds like a drum or bladder filled with air. Moreover, there are no discharges of flatus. Tympanites is easily to be distinguished from ascites by the absence of fluctuation, by the tense feel of the abdomen, by the quick reaction of the parts after removing the pressure of the finger, by the frequent desire to belch, and by the state of the bowels and urine at the commencement of the disease. It is, almost in every instance, an obstinate and dangerous dis- ease, slow in its symptoms, marking a total relaxation of the sys- tem ; and therefore it frequently terminates in dropsy, showing the same emaciation of countenance, dry cough, and hectic state, in the end. An unimpaired constitution with frequent explosions of flatus, showing that the air is contained within the intestines, may be regarded in a favourable light. When the wind is confined within the intestines, its evacuation is to be attempted by introducing an unarmed clyster-pipe up the rectum, and keeping it there for some time, so as to take off the ••>4.B eACHi-.xrn;, uk ia< hi:< th diseases. [Class Iff. resistance of the sphincter : and by giving carminatives, essential oils, spice, and stomachics, which may be joined as in the fol- lowing forms,* -or as advised under the head of Dyspepsia ; and when costiveness prevails, by an occasional use of laxative medi- cines, joined with aromatics and essential oils, or clysters! fre- quently repeated. Should these gentle means fail in procuring sufficient evacua- tions, we must then employ active purgatives ;} and where there * 1. rj; Pulv. Cinnam. Comp. Extract. Gentian, aa gr. x. 01. Anisi. fltfij. Syrup. Zingib. q. s. M. ft. Bolus, 4tis horis sumendus cum cochl magnis duobus misturae sequentis. 2. R Aq. Menth. Pip. Mistura; Camphorae, aa f. rijs«. Spirit. iEtheris Sulph. f. 3lss. Tinct. Card. C. f. Jss. M. ft. Mistura, capiat cochl. ij. pro dos. Vel, 3. JJ, Infus. Cort. Cinchon. f. "j. Tinct. Cardam. C. Spirit. Pimenta?, aa f. "ij. ----Lav. Comp. f. 3ss. M it. Haustus, ter quaterve in die sumendus, Vel, 4. fy Infus. Cort. Cascaril. f. ?j. Tinct. Calumb. f. Si- Spirit. Carui, ---- Anisi, aa f. 3'ss. M ft. Haustus. t 4.1^ Sem. Anis. Contus. 3iij. Flor. Anthemidis, sjss. Coque ex. Aq. Fontan. Ojss. ad f.sjxij. Colut.adde Soda* Sulphat. ^ss. Ol. Terebinth, f. 3'j—"ss. M. ft Enema. t 5 p>; Tinct. Senna; Comp. 1. 3 j. • './■ —— Jalapae, f. "ij- M ft. Haustus catharticus. Vel, 6. ]\ Extract. Colocynth. V. gr. \\. Hydrargyri Submur. gr. v. Ol. Carui,q. s. M. 4f Massa, in pihrias i\-. dirid. pro dos. 1. Take Compound Powderof Cinnamon, Extract of Gentian, of each ten grains. Oil of Aniseed, five drops. Syrup of Ginger a sufficiency to form a bolus, which may be taken every four hours with two table-spoonsful of the following mixture :— 2. Take Peppermint Water, Camphor Mixture, of each two ounces and a half. | Spirit of Sulphuric .flCther one ! drachm and a half. Compound Tincture of Carda- i mom, half an ounce. s Mix them. The dose may be two table 1 spoonsful. i r Or, j 3. Take Infusion of Peruvian Bark, one ounce. Compound Tincture of Cardamoms. j Spirit of Pimenta, of each two drachms. • Compound Spirit of Lavender, half a drachm. Mix them, and take this draught three or four times dailv. Or, 4. Take Infusion of Cascarilla, one ounce. Tincture of Calumba, one drachm. Spirit of Carraway, -----— Aniseed, of each one \ drachm and a half. j Mix them for a draught. | 14.Take Aniseed, bruised, three drachms. Chamomile Flowers, half an ounce. Pure Water, one pint and a half. |Boil them until reduced to twelve ounces. ; and to the strained liquor add j Sulphate of Soda, half an ounce. Oil of Turpentine, two drachms or l half an ounce. i\ii\ (hem for a clyster. * 5. Take Compound Tincture of Senna. one ounce. Tincture of Jalap, two drachms. Mix them as a purgative draught. j Or, , 6. Take Compound Extract of Colo- cynth, fifteen grains. Submuriate of Mercury, five grains. j Oil of Carraway, a sufficiency to form the mass, which divide into font pills to be taken at onee Order II.] I'YMPAXV. 549 is great irritability of' the stomach, with nausea and frequent vomit- ing, it will be advisable to give them in the form of a pill, as being most likely to be retained. If the disease resists all our endea- vours, and the bowels continue obstinately costive, with increasing distention, thirst, heat, and other symptoms of pyrexia, we should then have recourse to the lancet, in order to guard against super- vening inflammation and its consequences. It is only in acute attacks however, that we need dread such a termination. Antispasmodics of the strongest kinds, such as asafoetida, aether, &c, with infusions of horseradish and ginger, together with chaly- beates, are remedies which have sometimes proved useful in tympa- nites, and therefore should not be neglected. To excite the action of the distended intestines, it has been recommended, along with these remedies, to apply cold substances, such as iced water or snow, to the belly, after which it is to be bandaged tight with flannel. A case of severe tympanites, some time ago, came under my care, wherein very great benefit was derived from the frequent application of pounded ice to the abdo- men. It is probable that frictions with turpentine, oils, the lini- mentum ammonias fortius, or the linimentum camphoras, and the hand, might afford some relief, and excite the intestines, when assisted by pressure and other proper means, to discharge the accumulated air. The application of a warm stimulating plaster, or even a blister, may be tried if these means fail. Mercurial frictions upon the surface of the abdomen, with active purgatives, sometimes prove useful in tympanites. It has been proposed as a query,* Whether the cold bath con- tinued long enough to become antispasmodic and relaxant, might not produce good effects in this disease as well as in trismus ? To afford relief in desperate cases, where the air is diffused in the cavity of the abdomen, it may be necessary to have recourse to the operation of paracentesis, or tapping with a small trocar. In this case, tonics will likewise be advisable. During the continuance of the disease, that aliment which is least apt to prove flatulent should be taken, and such things be given as will check the fermentation of the food. The mineral acids and small quantities of ardent spirits will have this effect. Should we be so fortunate as to remove the disorder, the patient must pay particular attention to his diet, avoiding all food of a flatulent nature, and using only such as is light and easy of diges- tion. He is at the same time to guard against costiveness, by an occasional use of some stomachic aperient, and to invigorate his body by gentle exercise, and the other tonic means advised under the head of Dyspepsia. See Br. Temple's Practice of Physic, p. 234 5^0 cachexia, or cachkc'im; disease.-. [Class III III.—INTUMESCENTIiE AQUOSA:, or WATERY SWELLINGS HYDROPS, or DROPSY. Dropsy is a preternatural or morbid accumulation of a serous or watery fluid in some part of the body, impeding or preventing the functions of life, and receives different appellations, according to the particular situation in which it is lodged. When it is diffused through the cellular membrane, either generally or partially, it is called anasarca. When it is deposited in the cavity of the cranium, it is called hydrocephalus. When in the chest, hydro-thorax, or hydro-pericardium. When in the cavity of the abdomen, ascites. In the uterus, hydrometra ; and within the scrotum, hydrocele. Water is likewise encysted in the ovarium now and then, and is named ascites ovarii. Abdominal dropsy is infinitely more common than thoracic: the average may be about one thoracic to six or seven abdominal cases. Infants, youth, and adults, are equally liable to these effusions in the various cavities of the body. A modern writer* having remarked, that in many cases of dropsy the urine possesses the property of being coagulated by heat, instead of classing dropsical affections according to their situation, has divided them into those with coagulable, and those with uncoagulable urine. The causes of these diseases are, a family predisposition thereto, frequent salivations, excessive and long-continued evacuations, a free use of fermented or spirituous liquors, (which never fail to destroy the digestive powers,) scirrhosities of the liver, spleen, pancreas, mesentery, and other abdominal viscera ; preceding dis- eases, as the jaundice, diarrhoea, dysentery, phthisis, asthma, gout, intermittents of long duration, scarlet fever, and some others of the exanthemata ; a suppression of accustomed evacuations, the sudden striking in of eruptive humours, ossification of the valves of the heart, polypi in the right ventricle, aneurism in the arteries, tumours making a considerable pressure on the neighbouring parts, permanent obstruction in the lungs, rupture of the thoracic duct,^ exposure for a length of time to a moist atmosphere, laxity of the exhalants, defect in the absorbents, topical weakness, general debility, and whatever powerfully disposes the body to a state of relaxation. Diminished absorption and increased effusion, or both united, may be considered as the proximate causes of the different species of watery swellings. * See Observations on the Nature and Cure of Dropsy, by J. Blackall, M. P. Ordxr I.J drof&»v in the cellular membrane. 551 ANASARCA, or DROPSY in the CELLULAR MEMBRANE. This species of dropsy shows itself at first with a swelling of the feet and ankles towards evening, which for a time disappears again in the morning. The tumefaction is soft and inelastic ; and when pressed upon with the finger retains its mark for some time, the skin becoming much paler than usual. By degrees the swelling ascends upwards, and occupies the thighs and trunk of the body, and, at last, even the face and eyelids appear full and bloated. When it has become pretty general, the viscera are affected in a similar way; the cellular membrane of the lungs partakes the affection, the breathing then becomes difficult, and is accompanied by cough, and the expecto- ration of a watery fluid ; the urine is small in quantity, high- coloured, and deposits a reddish sediment; sometimes, however, it is of a pale whey colour, and more copious ; the belly is costive, the perspiration much obstructed, the countenance yellow, and a considerable degree of thirst, with emaciation of the whole body, prevails. To these symptoms succeed torpor, heaviness, and a slow fever. In some cases the water oozes out through the pores of the cuticle; in others, being too gross to pass by these, it raises the cuticle in small blisters ; and sometimes the skin, not allowing the water to escape through it, is compressed and hardened, and is at the same time so much distended as to give the tumour a consider- able degree of firmness. The disease is always to be regarded as admitting more readily of a cure when it arises from topical weakness or general debility, than when it has been occasioned by visceral obstruction ; as like- wise when recent, than where it has been of long continuance. The skin becoming somewhat moist, with a diminution of thirst, and an increase in the flow of urine, are to be regarded as very favourable symptoms. In some few cases nature makes powerful efforts of her own accord, and the disease goes off by a sponta- neous crisis, either by a vomiting, purging, or an unusual discharge of urine ; but this does not often happen. Concomitant organic disease, great emaciation, erysipelatous inflammation, much drow- siness, petechiaB and ecchymosis, haemorrhage, febrile heat, great thirst, and a quick small pulse, are very unfavourable symptoms. On opening the bodies of anasarcous persons after death, the whole of the cellular membrane is found distended with an aqueous and serous fluid. In the interior of the abdomen, the stomach is not unfrequently found scirrhous, the spleen enlarged and hard, the mesenteric glands much increased in size, and the liver enlarged, indurated, and beset with tubercles. In the thorax, we frequently find, besides water in the cavities of the pleura and pericardium, enlargement of the heart, adhesions of this to the pericardium, flakes of Ivmph floating in the water of the pericardium, in the 552 cachexi.*., ok cachectic disease.-.. [Class HI. cavity of the chest, or loosely attached to the pleura. Sometimes we meet with white spots or depositions of lymph upon the surface of the heart, ossification of the valves of the aorta, the internal coat of the aorta inflamed, aneurism of the aorta, and, lastly, tuber- cles, or vomicae in the lungs. When dropsy occurs connected with this state of local disease, it generally assumes the form of ana- sarca and hydro-thorax, or that of hydro-pericardium. In the cure of anasarca we are to keep in view the three follow- ing indications :— 1st, To remove the remote causes of the disease : 2dly, To evacuate the serous fluid already collected: and, 3dly, To restore the tone of the system, and strengthen the general habit. In dropsical cases we should always carefully investigate whether the disease is an original one, or prevails as a symptom of some other; for by removing the cause we shall often be,enabled to perform a cure. For instance, if it has arisen as the consequence of intemperance, a free use of spirituous liquors, Gxposure to a moist atmosphere, or the having had recourse to large evacuations, particularly by bleeding, these ought carefully to be avoided in future; or if it has proceeded from long-continued intermittents, obstructions in the abdominal or thoracic viscera, and the like, these should be obviated. In the treatment of anasarcous swellings arising from the pres- sure of a tumour on some large lymphatic, the only thing that can be done is to remove it. When weakness of a limb, in consequence of a sprain or some contusion, has given rise to these swellings, the best method of cure will be to support the weakened parts, either with a laced stocking or a flannel roller, to prevent their yielding to distention, till in the course of time, and by the effects of cold bathing and moderate frictions, they recover their natural tone. When cedematous swellings come on in consequence of any of the lymphatic vessels of a limb being cut, as sometimes happens in extirpating indurated glands from the axilla, small punctures made in the under part of the limb will afford immediate relief. The treatment of the diseases on which dropsy may depend, has already been pointed out in various parts of this treatise, each under its distinct head ; but unfortunately it may, and does some- times depend on diseases which are incurable, such as polypi of the heart, ossification of its valves and great vessels, erosions of the thoracic duct, and scirrhosity of the liver, spleen, &c. In such cases, medicine will avail T)ut little. To answer the second indication, of evacuating the serous fluid already collected, we must either have recourse to openings made immediately into the cellular membrane, or we must endeavour to excite certain serous excretions. The openings most frequently used in anasarca are either slight -fcarifieations <»rsmall punctures, mi having recourse lo thes'-. w Order II.J dropsy in the cellilar membrane. 553 should, however, take care to avoid them in parts that are depend- ent, and they should be made so superficial as to extend to rro greater depth than the cellular membrane, as deep incisions in dropsical parts are very apt to become gangrenous. To promote a discharge of the water by the several orifices, the parts may be bathed three or four times a day with some kind of emollient fo- mentation.* At an early stage of dropsy, issues made with caustic below one or both knees have sometimes been employed to evacuate the water from the upper parts ; but they are by no means so safe as small punctures or slight scarifications, and if inserted in parts that have lost their tone, might terminate in gangrene. With the like intention of drawing off the water from anasarcous limbs, blisters have sometimes been applied; but the objection which has been urged against the use of issues applies equally to these, and therefore they should be resorted to with great circum- spection and caution. The application of colewort-leaves to the legs and feet of anasar- cous persons, is another way which has been proposed for drawing off the water; but although they become imbued with moisture, still their effect is too trifling to be depended upon. An excitement of the different excretions is the other mode which has been proposed for carrying off the fluid diffused through- out the cellular membrane. This is to be done by emetics, purga- tives, diaphoretics, and diuretics, all of which, by their evacuating effects, tend to increase the power of the absorbents. Emeticst have been much administered in dropsical cases, under the supposition that they greatly promote absorption, and in many instances they have certainly been attended with a very good effect. To employ them, however, with advantage, we ought to repeat them frequently. If they are found to weaken the patient, without procuring any mitigation of the disorder, we should then desist from using them. An emetic of the cupri sulphas, as advised under the head of ' LRFol. Malvae, Flor. Anthemidis, aa ?jss. Aq. Fontan. Oiv. Paulisper coque, et cola pro fotu. * 2. r>; Oxymel. Scillae, f. 3VJ. Vin. Ipecac, f. ?ss. M. ft. Haustus emeticus. Vel, 3. ft Oxymel. Scillae, f. £j. Aq Menth. f. ^ss. Antimon. Tartarizat.gr.j.—ij. M. ft. Haustus, 1. Take Marshmallow Leaves, Chamomile Flowers, of each one ounce and a half. Pure Water, two quarts. Boil them slowly for some time, then strain off the liquor and use it for fomentation. \ 2. Take Oxymel of Squill, six drachms. Wine of Ipecacuanha, half an ounce. Mix them for an emetic draught, Or, 3. Take Oxymel of Squill, one ounce. Mint Water, half an ounce. Tartarized Antimony, one to two grain?. Mix them. 71 554 UACHEXIiE, OR CACniJ'TlC diseases. [Class 111. Phthisis, or below,* appears to be the most proper, as having less tendency to exhaust than any other used in common. Purgatives are likewise much employed in dropsical cases, with the view of carrying off a portion of the water by stool, and of exciting absorption; and as the stimulus of those which are of a drastic nature! is most readily communicated to the system, so thesjp are more generally used than those of a mild kind. The potassae supertartras is, however, a purgative of this nature, which has been given with considerable success, but it is more usual to combine it with some of the drastics, such as jalap, elaterium, scammony, and gamboge,! than to give it alone. Evacuants, particularly of the drastic kind, are, however, only admissible and * 4. fx Cupri Sulphat. gr. v. ad x. Pulv. Ipecac, gr. v. M. ft. Pulv. secundo vel tertio quoq. mane sumendus. t 5. f* Scammon. gr. xij. Hydrargyr. Submur. gr. v. Pulv. Zingib. gr. vi. M. ft. Pulvis pro dos. Vel, 6. ]^ Pulv. Jalapae, ----Scammon. aa gr. xij. Cinnamon. Comp. gr. x. M, ft. Pulvis. Vel, 7. ft Gum. Gambog. gr. iij. Terito bene cum Tinct. Sennae Comp. f. ^ss. et adde ----Jalapae, f. 3'j- Syrup. Zingib. f. 3iij. M. ft. Haustus. .; Vel, S. JJ, Pulv. Elaterii, gr. j. ad ij. ----Zingib. gr. x. 01. Junip. ftliij. •Syrup. Simp. q. s. M. ft. Bolus, aut in pilulas iv. divid. pro dos X 9. rx Potassa? Supertart. ?iij. 4. Take Sulphate of Copper, from five to ten grains. Powder of Ipecacuanha, five grains. Mix tfrem, and let this powder be taken eVery second or third morning. t 5. Take Scammony, twelve grains. Submuriate of Mercury, five grains. . Powdered Ginger, six grains. Mix them for a dose. Or, 6. Take Powdered Jalap, ---------Scammony, of each, twelve grains. Compound Powder of Cinnamon, ten grains. Glambog. gr. ij. Pulv. Nuc. Moch. gr. x. M. * ft. Pulvis. Vel, 10. g; Pulv. Elaterii. gr. i.—ij. Potassae Supertart. 3j. Pulv. Cinnam. C. gr. v. M. it. Pulvis. pro dos. sumendus. Mix them. Or, 7. Take Gamboge, three grains. Di<- solve it in Compound Tincture of Senna, half an ounce ; and add Tincture of Jalap, two drachms. Syrup of Ginger, three drachms. Mix them for a draught. Or, 8. Take Powder of Wild Cucumber, one grain to two. Ginger in powder, ten grains. Oil of Juniper, five drops. Syrup, a sufficiency to form a bo- lus, or divide the mass into four pills for a dose. X 9. Take Supertartrate of Potass, three drachms. Gamboge, two grains. Powdered Nutmee, ten grains. Mix them. Or, 10. Take Powder of Wild Cucumber, one to two grains. Supertartrate of Potass, one drachm. Compound Powder of Cinna- mon, five grains. Mix them for a do>=e Order H.J dropsy in the cellular membrane. 555 useful where the habit is indolent, and the dropsy extensive, with- out much local determination. To administer purgatives with the greatest advantage, they ought to be repeated at as short intervals as the patient can bear; for, when purging is not carried to the degree of quickly exciting ab- sorption, the evacuation weakens the system, and thereby increa- ses the afflux of fluids to the hydropic parts. Diaphoretics are another class of medicines which have been em- ployed in dropsy. In a few instances sweating may, perhaps, have produced a good effect; but in general it proves inefficacious, and only tends to add to general debility. On this account diaphoretics are not much employed in dropsical cases, particularly where there. is great weakness and general relaxation of the systen. Should the practitioner wish to make a trial of them under the failure of other remedies, he can administer them as here* advised, directing the patient at the same time to be laid between blankets, with a shirt and trowsers of flannel next to his skin, and to drink plenti- fully of tepid liquors, of which none probably may be more proper than mustard-whey. Another method of promoting a diaphoresis, and of thereby in- creasing absorption from the cellular membrane, is by warm air, or by warm steam. If the swelled legs of a dropsical patient are enclosed in a box, the air of which is made warm by a lamp or two, a copious sweat is soon produced by the increased action of the capillary glands, which is seen to stand on the skin, as it cannot readily exhale in so small a quantity of air, which is only changed so fast as may be necessary to permit the lamps to burn. At the same time the lymphatics of the cellular membrane are stimulated by the heat into greater action, as appears by the speedy reduction of the tumid legs. Possibly it might be well worth trying an experiment upon a person labouring under a general anasarca, by putting him into a room filled with air heated to about 120 degrees, which would pro- bably excite a copious general diaphoresis, and an universal cellular absorption, both from the lungs and every other part. That air of so great heat may be borne for many minutes without much incon- • 11. R Camphorae, gr. v. Pulv. Antimonial. gr. ij. Confect. Aromat. gr. x. M. ft. Bolus, hora decubitus sumendus. Vel, 12. I£ Liquor. Ammon. Acetat.f. ^ss. Aquae Purae, f. §j. Vin. Antimon. fllxvj. Spirit. Ammon. Aromat. fl\ x. Syrup, Zingib. 3'j- M * 11. Take Camphor, five grains. Antimonial Powder, two grains. Aromatic Confection,ten grains. Make them into a bolus, to be taken at bedtime. Or, 12. Take solution of Acetate of Ammo- nia, half an ounce. Pure Water, one ounce. Antimonial Wine, twenty-four drops. Aromatic Spirit of Ammonia, fifteen drops. Syrup of Ginger, two drachms Haustus. 'Mix them as a draught 55b' CACHEXIA, OR CACUl.CTIO DISEASES. [ClttSS III venience, has been demonstrated by the experiments made in heated rooms by Dr. Fordyce. Another experiment of using warmth in anasarca and other dis- eases, might be by immersing the patient in warm air, or in warm steam, received into an oil-skin bag, or bathing-tub of tin, so managed that the current of warm air or steam should pass round and over the whole of the body, except the head, which might not be exposed to it: and thus the absorbents of the lungs might be induced to act more powerfully by sympathy with the skin, ana not by the stimulus of heat.* By employing stimulants, we sometimes are able to increase the action of the absorbent vessels, and thereby occasion watery fluids to be absorbed from their cavities. As such, mercury has some- times been made use of; but it is apt to leave a great degree of weakness behind it, and to prove thereby highly prejudicial. If mercury will cure the disease on which dropsy depends, then it will be a proper remedy, but not otherwise. The parts affected with dropsy have been stimulated by rubbing them very well every morning with warm dry flannels ; and the practice is certainly productive of a very good effect. Ammonia- ted liniment, and such other stimulating applications, can only prove useful in partial dropsies. To remove swellings of the legs proceeding from a deficient action of the absorbents of the lower extremities, a warm saline pediluvium has often been used with success. The quantity of sea-salt should be about one-thirtieth part of the water, which with about one-eightieth part of the sulphate of magnesia, or bitter cathartic salt, constitutes the medium strength of the sea-water round this island. In such a pediluvium, the legs should be im- mersed for half an hour every night for a fortnight, at the heat of about 96 or 98 degrees. Dr. Reid, in his Treatise on Sea-bathing, recommends an uni- versal warm bath of sea-water in oedematous swellings, and appa- rently has employed it with success. He advises friction at the same time to be diligently used in the bath on the tumid limbs, taking care always to rub them from their extremities towards the trunk of the body, and not in the contrary direction, as in this way the progress of the fluids in the absorbent system must be most facilitated, though these vessels are furnished with valves to prevent its return. In a warm bath of sea-water the stimulus of the salt is added to that of the heat. The evacuation which will be attended with the least danger of inducing debility, and at the same time with the best effect, is the excretion by the kidneys ; and it is on this account that diuretics are more generally employed in all,cases of dropsy, than any other class of medicines. Even these often fail, however; but not un- * This and the former experiment have been proposed by the late Dr. Darwin- Sec vol. ii. of his Zoonomi'»: article iv. Sorbentia. Order 1I.J dropsy itf the cellular membrane. oo'\' frequently, we may presume, from their use being discontinued too soon. Of the class of diuretics, none seems to be more active than the digitalis. Its power of increasing the discharge from the kidneys, and of succeeding in effecting a cure of dropsical affections, in consequence of the increased evacuation produced by it, has of late been clearly ascertained in a great variety of instances. On account of its acting powerfully on the nervous system, destroying its mo- bility, and weakening the vital powers by repressing arterial action, it has, however, by some practitioners, been thought an improper remedy in dropsy ; but even large doses of it have been given in this disease without any of those uncontrollable and dangerous effects, which are said to deter many from its use, being observed to ensue. It is a circumstance of curious and interesting moment, not perhaps very generally known, that a relaxed, weakened, and de- pressed state of the system, is the most favourable for displaying the full effects of digitalis. Dr. Withering* had early pointed out the fact, that in persons of tense fibres and great natural strength, labouring under ascites or anasarca, the digitalis seldom succeeded; and that, on the contrary, where the pulse was found feeble, or intermitting, the anasarcous limbs and body soft and yielding, the countenance pale, and the skin cold, the diuretic powers of the plant were more conspicuous. We are informed by Dr. Macleant that these observations fully accord with those which he made; and, he adds, that it seldom succeeds in those of a fat corpulent habit with a dull sluggish fibre, while it speedily relieves those of a weak, delicate, irritable constitution, with a thin, soft, smooth skin, which in the anasarcous limb is transparent. When the urine is not serous, I have perceived that digitalis usually fails of success ; on the contrary, I have found it to succeed where the habit was not entirely depraved, or the substance of the viscera not affected. When the organs of digestion fail, and there is frequent sickness or diarrhoea, and the bad habit of body is more remarkable than the extent or seat of the dropsy, its use has appeared to be injurious. It may not here be unworthy of notice, that where the foxglove is given in such doses as to excite nausea, or to produce an evi- dent narcotic effect, it does not then operate as a diuretic. In a long use of it, its narcotic effect seems to preclude its action as a diuretic. A diarrhoea supervening on the use of this remedy, i^ likewise found to stop its diuretic effect. If the digitalis does not answer within the first fortnight, the best way will be to change it for some other diuretic; as it not unfrequently happens, that where we have failed with one remedy * See his Essay on Digitalis, p. 189. ' See his Inquiry into the Nature, &c. of Hydrothorax, p. 251 558 CACHfc.MiE, OR CACHECTIC DISEASES. [Class HI. of this class, we shall be successful with a second or a third. No class of medicines is so uncertain in their effect as this, and it will often occur that a diuretic of very inferior expectation will procure the effect we wish, after a failure of those which rank highest in power. In employing the foxglove in dropsy, we may give it either in infusion* or saturated tincture, as mentioned under the head of Phthisis; or we may give it in substance, washing it down with a teacupful of any diuretic infusion. The digitalis lutea has been found by Dr. Careno, of Vienna, to possess stronger diuretic powers than the digitalis purpurea, and without producing any of the usual noxious effects. He tells ust that he has succeeded in curing many dropsies with the digitalis lutea after the other species had failed. The potassae supertartras is another diuretic which is often em- ployed in dropsical affections with a very happy effect. As pos- sessing no deleterious qualities, and being easily managed by practitioners of the smallest judgment, a preference over the digitalis has been given to it by some. Whether it possesses as great an anti-hydropic power, has not been satisfactorily ascer- tained. The experiments of Dr. HomeJ and Dr. Ferriar|| seem to assure us that it does; but from my own experience I am induced to conclude that it does not In some cases, however, the potassas supertartras diminishes the swellings very speedily. It produces an increase of urine with watery stools; and for the most part lessens the patient's size more quickly than the increase of urine would lead us to expect. When it is likely to prove successful, it usually operates very early, pro- ducing, in general, an increased flow of urine within twenty-four hours; but its salutary effects have been known to have been delayed to the end of the third or fourth week. It is given in doses of from two drachms to one or two ounces a-day, as by habit it loses a great deal of its effect. When the quantity is con- siderable, it will be best to divide it. into three or four doses, instead of taking it all at once, which few stomachs will bear. In conjunction with gamboge orelaterium, as before advised, it forms a powerful medicine, and, according to circumstances, may be made either to assist or to take the lead of the digitalis. From a junction of the potassae supertartras with digitalis or t See Memoirs of the Royal Academy of Berlin for 1794-5. \ Clinical Observations, Experiments, &c. p. 349. || Medical Histories and Reflections. 13. $ Infus. Digital. Purp. 3vj. • 13. Take Infusion of Purple Foxglove, six drachms. Tinct. Card. Comp. 3y. Compound Tincture of Carda- moms, two drachms. Spirit, either. Nitr. 3i. M. Spirit of Nitric jEther, one drachm. ft. Haustus, bis in die sumendn? Mix them, and take this draught twice a dav. Order 11.J dropsy in the cellular membrainl. 559 squills* or both, (see Hydrothorax) interposing purgatives occa- sionally, the greatest advantages have been derived in some cases which occurred in my practice. A total abstinence from drink has long been considered as highly necessary in all cases of dropsy : but in many instances the practice has been carried to aconsiderable length without any advantage. It seems, however, to have fallen a good deal into discredit, as large quantities of watery liquors are often now allow- ed, where diuretics, but more particularly the potassse supertartras, are given. This mode of treatment seems indeed by far more proper than the former, as these medicines can hardly be carried in any quantity to the kidneys, without being accompanied with a large portion of water. When, upon a fair trial, the quantity of urine is not found to be increased by drinking water or other watery liquors,! their use may in that case be discontinued. Beer boiled with juniper berries is much used as a diuretic drink by the German physicians. The different preparations of squillf have been used very much "* 14. ft Potassae Supertartrat. 3y. Pulv. Cinnam. Comp. gr. v. ----Digitalis, gr. j. M. ft. Pulvis, bis terve in die sumendus. Vel, 15. rjL Pulv. Digitalis, gr. ss—j. ----Scilla?,gr. j. Potassae Supertart. 3'j- M. ft. Pulvis, ter in die adhibendus. t 16. ft Rad. Armoraciae Incis. Sem. Sinap. C. aa ?ss. Aq. Bullient. Oj. Infund.per horas xij. et adde Liquori colat Potassae Acetat. 3iij. Spirit. Junip. Comp. ^ij. M. Bibat aeger cyathum ter quaterve in die. Vel, 17. ft Decocti Genbtae Recent, ^xij. Potassae Acetat. 3ij. Spirit. Armoraciae Compos, f. ?i M. 5 Sumat cochl. larg. iij. ter quaterve in die. 18. ft Potassae Acetat. &l Aq. Fceuicul.f. ^j. Acet. Scillae, f. 3j. Spirit Armoraciae C. f. 3».f• 14. Take Supertartrate of Potass, two drachms. Compound Powder of Cinnamon, five grains. Powder of Foxglove, one grain. Mix them. It may be taken twice or thrice a day. Or, 15. Take Powder of Foxglove, half a grain to one grain. ------— Squill, one grain. Supertartrate of Potass two drachms. Mix them, and let this, powder be given thrice a day. t t 16. Take Horseradish Root, sliced, Mustard Seed, bruised, of each half an ounce. Boiling Water, one pint. Infuse them for twelve hours, and to the strain- ed liquor add Acetate of Potass, three drachms. Compound Spirit bf Juniper, two ounces. Mix them, and let the patient drink a wine- glassful three or four times a day. Or, 17. Take Decoction of Fresh Broom, twelve ounces. Acetate of Potass, two drachms. Compound Spirit of Horseradish, one ounce. Mix them, and take three table-spoonsful three or four times a day. X 18. Take Acetate of Potass, one scruple. Fennel Water, one ounce. Vinegar of Squill, one drachm. Compound Horseradish Spirit. two drachms. 660 CACHEXIA, OR CACHECTIC DISEASES. [Class III. in dropsical cases ; but although this medicine has sometimes been attended with a good effect, still the advantages to be derived from it are by no means so certain as those we usually obtain from the digitalis or potass* supertartras. A combination of squill and the submuriate of mercury* has been tried, but it has not been found to diminish the swellings in proportion to its diuretic effect. The spiritus aetheris nitricit is anomer diuretic, and may be combined with other medicines of this class. A decoction of green broom, drank in large quantities, is also a diuretic of considerable powers, particularly in anasarcous cases. It may therefore be used with the other remedies which have al- ready been advised. Bacher's pillsj (which consist principally of hellebore) are among fhe diuretics often employed in dropsy. Whenever they produce Tinct. Digitalis, rTUyj. M. ft. Hau*64 cachexia:, or cachectic diseases. [Class III. viscera of the abdomen, scirrhosities of the liver, spleen, or pan- creas, enlargement of the mesenteric glands, local injury, &c, do sometimes occasion ascites. Ascites is often preceded by loss of appetite, sluggishness, inactivity, dryness of the skin, oppression at the chest, cough, diminution of the natural discharges of urine, and costiveness. Shortly after the appearance of these symptoms, a protuberance is perceived in the hypogastrium, which extends gradually, and keeps on increasing, until the whole abdomen becomes at length uniformly swelled and tense. The distention and sense of weight, although considerable, vary somewhat according to the posture of the body, the weight being felt the most in that side on which the patient lies, while at the same time the distention becomes somewhat less on the opposite one. In general the practitioner may be sensible of the fluctuation of the water, by applying his left hand on one side of the abdomen, and then striking on the other with his right. In some cases it will be obvious to the ear. As the collection of water becomes more considerable, the diffi- culty of breathing is much increased, the countenance exhibits a pale or'bloated appearance, an immoderate thirst arises, the skin is dry and parched, and the urine is very scanty, thick, high-coloured, and deposits a lateritious sediment. In the general dropsy, the urine coagulates like the diluted serum of the blood, whilst in that which proceeds from unsound viscera, it is usually high-coloured, scanty, and, on cooling, deposits a pink-coloured sediment. With respect to the pulse, it is variable, being sometimes considerably quickened, and at the other times slower than natural. Although ascites is sometimes accompanied by fever, still it is frequently absent. It has, however, been observed, that during ascites the derangement in the general system is greater than in other species of dropsy. The principal difficulty which prevails in ascites, is the being able to distinguish with certainty when the water is in the cavity of the abdomen, or when it is in the different states of encysted dropsy. To form a just judgment, we should attend to the fol- lowing circumstances :— When the preceding symptoms give suspicion of a general hydropic diathesis ; when at the same time some degree of dropsy appears in other parts of the body; and when, from its first appear- ance, the swelling has been equally diffused over the whole belly, we may generally presume that the water is in the cavity of the abdomen. But when an ascites has not been preceded by any remarkable cachectic state of the system, and when, at its begin- ning, the tumour and tension had appeared in one part of the belly more than another, there is reason to suspect an encysted dropsy. Even when the tension and tumour of the belly have become general, yet, if the system or body in general appear to be little affected ; if the patient's strength be not much impaired; if the Order II.] dropsy of the bellv. oijb appetite continue pretty entire, and the natural sleep be little interrupted; if the menses in females continue to flow as usual; if there be yet no anasarca, or, though it may have already taken place, if it be still confined to the lower extremities, and there be no leucophlegmatic paleness or sallow colour in the countenance; if there be no fever, nor so much thirst or scarcity of urine, as occur in a more general affection ; then, according as more of these differentcircumstances take place, there will be the stronger grounds for supposing the disease to be of the encysted kind.* By carefully attending to the symptoms of pregnancy, and which are enumerated under that head, we cannot fail to distinguish it readily from every species of dropsy. Ascites is always to be considered as of very difficult cure, let the cause have been what it may. The urine being little diminished, or becoming more copious ; the swelling of the abdomen subsiding, the skin ceasing to be dry, the strength originally little impaired, and the respiration becoming free, may be regarded in a favourable light; on the contrary, intense local pain, great emaciation, sym- pathetic fever, the disorder having been induced by a diseased state of the liver, or other abdominal viscera, are to be looked upon as very unfavourable circumstances. Dropsy of the encysted kind generally terminates, sooner or later, in the destruction of the patient. The usual appearances to be observed in dissections of those who have died of ascites, are as follow :—We observe a large quantity of fluid effused in the cavity of the abdomen, which for the most part is serous, but it now and then presents material differences both in colour and consistence, and we frequently notice flakes of coagulable lymph floating in it. In some cases, the water, instead of being collected in the general cavity of the abdomen in one large body, is lodged in distinct small cysts forming what are called hydatids. Besides the accumulation of water in the abdomen, we often find the liver swelled, hard, tuberculated or gorged with blood, the spleen, pancreas, and mesenteric glands considerably enlarged, the stomach occasionally scirrhous, and the peritonaeum, either generally or in patches, inflamed, thickened, studded with white elevated points, and sometimes in a state approaching very nearly to gangrene. Polypi are not unfrequently observed in the large blood-vessels, as also ossifications in various parts of these organs. In the treatment of ascites we are to attend to the two following indications :— 1st, To evacuate the accumulated fluid ; and, 2dly, To prevent any fresh collection. To answer the first of these intentions, it has been customary to have recourse to purgatives of a drastic nature, or to diuretics, with * These remarks are taken from Dr. Cullen's First Lines of the Practice of Physic, as convey i ng a clear idea of the distinguishing signs between ascites and encysted cfropsy. 566 CACHEXIiE, OR CACHECTIC DISEASES. [ClttSS HI. the occasional use of emetics, in the same manner as has been fully noticed under the head of Anasarca, and to which 1 must beg leave to refer the reader, in order to save the trouble of recapitulation. A singular method which has been recommended for procuring a discharge by urine in ascites, is by long-continued gentle friction of the abdomen with the fingers dipped in oil, which operation is to be repeated daily. The only effect to be derived from the oil appears to be that of preventing an excoriation of the skin. We should give a fair trial to these remedies with the view of increasing the natural secretions, and particularly to diuretics ; and where any particular one of this class does not promote an increased flow of urine, we ought to make trial of another. If all means fail, and the pressure and tension of the abdomen become insupportable, or if we have reason to suspect the pressure of the water upon the kidneys prevents the diuretics from having a due effect on them, we must then resort to tapping. This mode of evacuating the water is undoubtedly the most ready, but it has no disposition to eradicate the disease. The operation is considered by some as not being likely to be attended with injurious conse- quences, and is by a few practitioners advised as the first step to be pursued; but as erysipelatous inflammation, terminating in gangrene, has not unfrequently arisen in the wound, it would seem best to make trial of other means before we have recourse to it. In drawing off the water, a proper degree of pressure should be made on the abdomen by means of a broad bandage, and this ought to be kept up for some time. By giving a smart purgative of elaterium combined with the supertartrate of potass, (see Anasarca) the day after the performance of the operation when there is no great debility present, and re- peating it two or three times, with an interval of a few days between each dose, 1 have, in a few instances, prevented any fresh accumulation of water, and in a great many, very much retarded it. The re-accumulation is sometimes obviated by removing the causes which induced the disease, and by strengthening the tone of the parts in particular, and of the system in general. For instance, if the disease proceeds from chronic visceral obstruction, by mercurial friction over the abdomen, and an occasional drastic purgative: a scruple, or half a drachm of the unguentum hydrar- gyri fort, may be rubbed in over the helly, until the mouth becomes slightly affected, while about two grains of elaterium may be given once or twice a week. Where the disease arises in weak delicate habits from debility, tonics, aromatics, and stimulants, combined with diuretics, as directed for anasarca, together with a nutritive diet, exercise, and pure air, will be most appropriate. It has been mentioned that partial or encysted dropsy often takes place, and in a few instances the womb itself has been imagined to form the seat of collections of a watery fluid like other cavities of the body. Probably this never happens, however. Order II.J dropsy of the belly. 567 except where the fluid is contained within white small bladders of various sizes, known by the name of hydatids. The appendages to the womb, or ovaria, are indeed very frequently the seat of dropsy, and the disease is met with at every period of life, but more frequently after puberty than before. A dropsy of the ovarium is at first inconsiderable, and is attended with no very disagreeable symptoms. It increases gradually in bulk, and is originally confined to one side only, and more gene- rally the left one. Until the tumour has acquired a considerable size, the patient's health suffers no very visible diminution ; it then induces pain and numbness in the thigh corresponding with the side in which the swelling is situated, and by degrees the body becomes wasted, the appetite bad, and the strength greatly impaired. The progress of the disease varies in different cases. In some, dangerous symptoms have ensued soon after the disorder becomes apparent, whilst Others have laboured under it for a year or two previous to its destroying the patient. Nothing can be more uncertain than the progress and termination of the complaint; for experience has proved, that under the most apparently desperate circumstances the health has been in some measure restored, or life protracted for a considerable time, while on the other hand, where no urgent symptoms have been manifest, a sudden aggrava- tion of the disease has occurred, and a rapid advance to a fatal termination has taken place. Nothing satisfactory can be offered respecting the causes of a dropsy of the ovaria, as women of every condition and age are found to be afflicted with it. Dropsy of the ovarium is to be distinguished from ascites by attending to the symptoms which have been already enumerated under the head of the latter. Great caution will be requisite in not mistaking pregnancy for this complaint, as fatal consequences might ensue therefrom. Fortunately, the two are readily dis- tinguished from each other. Sometimes hydatids also form in the cavity of the abdomen, and not unfrequently on the surface of the liver; for an extra- ordinary case of which see Hepatitis. These to appearance consist of membranous bags, the coats of which are so thin as to be semi- transparent, and to have no visible muscular structure. From the effects produced by the different parts of these bags, while the animal is alive, being exactly similar to the contractions and relax- ations of the muscular fibres in the human body, we have great reason to conclude, however, that these membranes are possessed of similar power. The hydatid, from its apparent want of muscles, and other parts which generally constitute an animal, was for a long time denied its place in the animal world, and considered as merely the produc- tion of disease : we are, however, at present in posession of a suffi- cient number of facts to ascertain, not only that it is an animal, but that it belongs to a genus of which there are different species. 508 CACHEXIA, OR CACHECTIC DISEASES. [Class III. Encysted dropsy of every kind is to be treated in the same manner as ascites. In that of the ovaria, every means which can promote general health, and an increased action of the kidneys, ought to be employed, as noticed under the head of Anasarca. In addition to tonics and diuretics, the bowels may be kept open by laxative salts, where costiveness prevails. While this plan is pur- sued, the belly should be firmly compressed by a flannel roller, or some proper bandage. If these means fail in unloading the patient of the accumulated fluid, (which is the case in most instances,) and dyspnoea and the other symptoms become urgent, the water must be drawn off by tapping, still persevering in the use of the diuretic and tonic medicines. Most likely the water will accumulate again after a time ; if so, the operation must be repeated ; but in a few in- stances, it has not accumulated afresh. The fluid in dropsical ovaria, however, is more frequently contained within hydatids than in a single sac, which may be known by the inequality of the tumour; but even in these cases tapping may be beneficial, and at any rate will afford a temporary relief. In hydrocele, the point we wish to obtain is the obliteration of the cavity of the tunica vaginalis. To effect this, various methods have 1 een proposed, such as excision, incision, seton, tent, caustic, and the injecting of vinous or other liquors, having previously dischargeJ the water by a trocar. This last method of treating the diseass has been particularly recommended by Sir James Earle. It is however by no means a modern invention, as we find it advised by Monsieur Lambert in his CEuvres Chirurgicales, published near a century ago at Mar- seilles. He used a strong solution of muriated mercury in lime- water, and enumerates many cases in which it proved successful. We are informed by Mr. Bell,* that in Scotland rectified spirit some time after this was employed for the same purpose, but that the violent pain and inflammation which it excited soon occosioned its being laid aside. The injection employed by Sir James Earle is red wine, diluted with a fourth or fifth part of water. Notwithstanding what he has asserted on the subject, Mr. Bell affirms that it is not near so cer- tain a remedy as either of the other ways, and that the pain which is saved in the operation is not worth consideration, when put in competition with the certainty of a cure. Besides the uncertainty of this, he enumerates the following objections. The inflammation may sometimes rise to such a height as to produce suppuration within the cavity: when this happens, besides the pain and risk attending the inflammation, an incision equally extensive, for dis- charging the matter, will be necessary, as if the mode of cure by incision had been adopted at first. It does not admit of an exami- nation, of the testis with accuracy. The strength of the injection s See hh Treatiseon Hydrocele, and other Diseases of the Testk Order 11.] waiek i.\ the head. 5t>9 necessary for producing inflammation of the tunica vaginalis may be more than the testis can bear. Under such a diversity of opinion experience alone can deter- mine at last in favour of one or other of the methods proposed, simple incision being that recommended by Mr. Bell. HYDROCEPHALUS, or WATER in the HEAD. Pyrexia, violent and continued pain in the head, particularly across the brow, stupor, dilatation of the pupils, suffused redness of the eyes, great sensibility and aversion to light, suddenly interrupt- ed sleep, with screaming, nausea, vomiting, and obstinate costive- ness, with the dejections glossy, and of a dark green colour when procured by medicines, the pulse at first preternaturally quick, afterwards becoming inordinately slow, and convulsions, are the pathognomic symptoms of this disease. One of the earliest crite- rions is the patient being uneasy on raising his head from the pil- low, and wishing to lie down again immediately. Hydrocephalus is almost peculiar to young children, being rarely known to extend beyond the age of twelve or fourteen, and it seems more frequently to arise in those of a scrofulous and rickety habit than in others ; or at least among those who have the pecu- liarities of skin, complexion, and features, which indicate scrofula. It is an affection which has been observed to pervade families, affecting all or the greater part of the children at a certain period of their life ; which seems to show, that in some cases it depends more on the general habit than on any local affection or accidental cause. It is to be distinguished from apoplexy by its being attended with fever, and from simple typhus by the paroxysms being very irregular, with perfect intermissions, many times in a day. Whatever difficulties there may be in the early stage, particularly in infants, there is no disease more easily distinguished in the ad- vanced stages than hydrocephalus ; indeed, how can we mistake, when we see a child rolling its head on the pillow, or perhaps saw- ing the air with one hand, while the opposite side is palsied ; with a hectic on the cheek, his eyelids half concealing the pupil, and the eyes deprived of their vivacity by the filmy covering of the cor- nea; the complete dilatation of one or both pupils,and the suffusion of the adnata ; drawing a long sigh ; frequently grinding his teeth; quite incoherent, or in a state of complete insensibility : with a burning fever on the skin, or sweat forced from every pore, and all these symptoms alternating with, and at last finished by a palpi- tating breathing, and violent convulsions ?* The disease has generally been supposed tq arise in consequence either of an immediate affection of the sensorium, from some gene- ral disease, as fever, or of injuries doneto the brain itself, by blows, * ^ee E«ay on Hydrocephalus Acut.u«. by J. Cheyne, M D 570 cachexia;, or cachectic diseases. [Class III. falls, &c; from scirrhous tumours or excrescences within the skull from original laxity or weakness in the brain, or from the brain morbidly sympathizing with a distant part. There is, however, reason to believe, that the disease, in by far the greater number of cases, owes its origin to a degree of inflammation in the membranes of the brain, which produces a morbid accumulation of blood, and generally an extravasation of watery fluid before death. Nosolo- gists have been accustomed to place hydrocephalus among dropsies, and I have followed their example, although it ought to stand, I think, among the diseases connected with inflammation. Its first stage is phrenitis, or inflammation of the brain ; and the effusion of water which afterwards takes place between its mem- branes, or in the cavities of the ventricles, is the consequence. In many cases of hydrocephalus, the affection of the brain has been considered by»a few writers* as only secondary, and depend- ing on a primary diseased state of the digestive organs. No doubt the first disorders often take place in the abdomen, and the greater determination of blood to the brain is the result; yet numerous anatomical dissections have convinced me, that in the greater number of cases the morbid appearances of the abdo- men are secondary symptoms of.the affection of the head. With respect to its proximate cause, very opposite opinions are still entertained by medical writers ; which, in conjunction with the equivocal nature of its symptoms, prove a source of considerable embarrassment to the young practitioner. Dr. Beddoes says, he believes it to belong to inflammations, and that at an early period he should be inclined to bleed as largely as in pneumonia. Dr. Withering observes, that in.a great many cases, if not in all, congestion and slight inflammation are the precursors to the aqueous accumulation. Dr. Rush thinks, that instead of its being considered an idiopa- thic dropsy, it should be regarded only as an effect of a primary inflammation, or congestion of blood in the brain. It appears (he says) that the disease in its first stage is the effect of causes which produce a less degree of that inflammation which constitutes phre- nitis ; and that its second stage is a less degree of that effusion which produces serous apoplexy in adults. The former partakes of the nature of the chronic inflammation of Dr. Cullen, and the asthenic inflammation of Dr. Brown. There are others again who view the subject in a very different light. Dr. Darwin supposes inactivity or torpor of the absorbent vessels of the brain to be the cause of hydrocephalus internus; but he confesses, in another part of his work, that the torpor of the absorbent vessels may often exist as a secondary effect. Dr. Whytt, who has published an ingenious treatise on the dis ■* See Essay on Hydrocephalus Acutus, by J. Cheyne, M. D. ---Dr. Teat's Letter to Dr. Wall on the Disease termed "Water in the Brain Order Il.J watkr in. the heao. 571 ease, observes, the immediate cause of every kind of dropsy is the same ; viz. such a state of the parts as makes the exhalent arteries throw out a greater quantity of fluids than the absorbents can take up. From what he afterwards mentions, he evidently considers this state as consisting in debility. As many cases are accompanied with an increased or inflamma- tory action of the vessels of the brain, and others again are obser- ved to prevail along with general anasarca, it seems rational to allow that hydrocephalus is in most instances the consequence of con- gestion or slight inflammation in the brain or its membranes, and that in a few it arises either from general debility or topical laxity. In children labouring under extreme debility, the vessels of the brain, in common with those of the body in general, become greatly relaxed, and in this state effusion into the ventricles may, and no doubt does sometimes take place. In admitting these as incontro- vertible facts, I am at the same time induced to suppose that the cases of its occuring from mere debility are very rare. The great analogy subsisting between the symptoms which are characteristic of inflammation, and those which form the first stage of the acute species of hydrocephalus (for the disease has been divided into the chronic and acute by some writers,) together with the good effects often consequent on blood-letting, and the inflam- matory appearance which the blood frequently exhibits, seem to point out strong proofs of the disease being, in most instances, an active inflammation, and that it rarely occurs from mere debility as a primary cause. The progress of the disorder has by some been divided into three stages. When it is accompanied by an increased or inflammatory action of the brain, its first stage is marked with many of the symptoms of pyrexia, such as languor, inactivity, loss of appetite, nausea, vomiting, parched tongue, hot dry skin, flushing of the face, headach, throbbing of the temporal arteries, quickened pulse, aver- sion to light and sounds, and watching : which symptoms always suffer an exacerbation in the evening, but towards morning become milder. Many of these appearances are not observable when no inflam- matory action of the brain is discernible. In these cases the coun- enance of the child is strongly expressive of distress and suffering, ts temper is irritable and fractious, it has a great propensity to bed ind a recumbent position, has pains over the eyes, with an aver- ion to being moved, and as the disease advances, it rolls its head rom side to side, or throws its arms over it. It often sighs, and ts breathing is extremely irregular, particularly when asleep. It s averse to take any thing, either liquid or solid, especially the atter; and apparently it suffers from constant nausea, but what is brown up consists merely of the food and drink which have been iken. The urine has nothing remarkable in its appearance; but is retained longer than usual; great costiveness prevails, and no • >"<- CACHEM/K, OR CACHECTIC DI*KASl>. [CldSSlll. stool is voided without the aid of purgatives, either given by the mouth, or thrown up as clysters ; and in general the most powerful medicines of this class are requisite to produce the desired effect. Motions, when obtained, are commonly of a dark green colour, with an oiliness or glossy bile, rather than the slime which accompanies worms; and their smell is more of a cadaverous nature than that arising from feculent matter. The disease at length makes a re- markable transition, denoting the commencement of the second stage. The child screams frequently, and without being able to assign any cause ; its sleep is much disturbed ; there is a consider- able dilatation of the pupils of the eyes, which do not contract on being exposed to light; the pulse becomes slow and unequal, and perhaps lethargic torpor, or double vision, ensues. In the third stage the pulse returns again to the febrile state, becoming uncommonly quick and variable, and coma, with squint- ing and convulsions, succeed. When the accumulation of water is very great, and the child young, the sutures recede a considerable way from each other, and the head, towards the end, becomes much enlarged. We are not however to expect that these stages will follow each other in all cases, in a regular and increased progress ; for a child has sometimes appeared in health on the very night on which it was seized with convulsions by which it was destroyed a few days afterwards. The disease commonly terminates in three weeks from the date of the first symptom; but in some instances its termination is extended to four, five, or six weeks. Like every disease of the brain, its duration is, however, uncertain; for in some cases it has run its course in a few days. When recoveries have actually been effected in hydrocephalus, after effusion has taken place, we ought probably to attribute more to the efforts of nature than to the interference of art; but by an early recourse to antiphlogistic means, during the inflammatory stage, we may sometimes succeed in removing the disorder. It is indeed only in this stage that remedies are likely to prove successful. In most instances it is to be regarded as a difficult cure ; but the chance of this is nearly in proportion to the dura- tion of the symptoms. When the patient cannot bear to be raised up in bed, without great uneasiness, it is a bad symptom. So is deafness, which there is reason to believe is now and then mistaken for stupor. When the dilatation of the pupil of either eye or squinting is very appa rent, or the pupils of both eyes are much dilated, a fatal termina- tion is denoted. Apoplectic stertor, coma, with loss of sight, great enlargement of the head, difficult respiration, a weak intermitting pulse, and involuntary evacuations, are also very unfavourable symptoms. Hydrocephalus is a disease which is most frequent in families where the strumous constitution may be recognized, and many Order II.] water in the head. 573 children of the same family in some instances fall under it, each about the same age, but nothing like scrofulous condition in the diseased parts is ever to be perceived on dissection. An accumulation of water in the ventricles of the brain is one of the most common appearances to be observed on those occasions. In different cases this is accumulated in greater or less quantities. It sometimes amounts only to a few ounces, and' occasionally to some pints. When the quantity of water is considerable, the fornix is raised at its anterior extremity in consequence of its accumula- tion, and an immediate opening or communication is thereby formed between the lateral ventricles. The water is of a purer colour and more limpid than what is found in the dropsy of the thorax or abdomen. It appears however, to be generally of the same nature with the water that is accumulated in these cavities. In some instances the water in hydrocephalus contains a very small pro- portion of coagulable matter, and in others it is entirely free from it. When the water is accumulated to a very large quantity in the ventricles, the substance of the brain appears to be a sort of pulpy hag, containing a fluid. The skull upon such occasions is very much enlarged in size, and altered in its shape, and it appears exceedingly large in proportion to the face. On removing the scalp the bones are found to be very thin, and there are frequently broad spots of membrane in them. These appearances are however only to be observed where the disease has been of long continuance. In some cases where the quantity of water collected is not great, the substance of the brain has appeared to be indurated, and in others softened. We frequently find within the cranium the veins, particularly those of the membranes on the surface of the brain and lining of the ventricles, gorged with dark blood ; sometimes considerable adhesions between thickening of the membranes and minute and florid vessels upon the pia tnater: collections also of a viscid tenacious matter have been discovered in cysts upon its external surface, and tumours have been found attached to its substance. Dr. Rowley is of opinion, that there exists a species of hydroce- phalus where the water is collected between the tunica arachnoides and the pia mater, without any effusion in the ventricles of the brain ;* but no such morbid appearances have ever, I believe, been discovered on dissection. The treatment to be adopted in the first stage of this disease should vary according to the symptoms which are present. If it is marked by an increased or inflammatory action in the vessels of the brain, which is usually the case, we should by all means recom- mend bleeding, and this at the first onset of the disease ; for when our fears, as to the real nature of the complaint, are awakened, not a minute should be lost in prescribing the remedies from which * See his Treatise on the Membranous Dropsy of the Brain 574 cachexia, or cachectic diseases. [Class III, benefit is to be expected. The necessity of blood-letting in such cases seems very obvious, and it ought to be carried to such an extent as to answer a determinate end, viz. that of lessening topical congestion, and diminishing arterial action. Opening the jugular vein will be the most advisable way of drawing off blood in these cases ; and on the succeeding day we ought to have recourse to the application of three, four, or more leeches to each temple, or to cupping, with previous scarifications, which may, probably, be preferable to the application of leeches, both on account of the promptness with which the blood can be drawn, and the greater certainty of obtaining the quantity desired. It may be performed on the scalp, or behind the ears, or the nape of the neck, or between the shoulders. To trust wholly to leeches without general bleeding, is only tampering with a most formidable disorder. In abstracting blood from infants a due consideration must be paid to their age. The repetition of both general and topical bleeding should depend on the appearance the disease exhibits; and as long as it is marked by an inflammatory action in the vessels of the brain, or shows symptoms of local congestion, these opera- tions ought to be repeated from time to time, but more particularly the local detraction of blooo!, from the consideration that the acti- vity in the extreme vessels, giving rise to the effusion, is somewhat independent of the action of the heart. When the disease seems to have arisen from topical weakness or general debility (which, as before observed, does not often hap- pen,) and is of course unaccompanied by any febrile symptoms ; or when it has arisen from a family constitution, or as a consequence of scarlatina, which sometimes occurs, or is advanced into its third tage, bleeding would be improper. Purgatives, by lessening the determination to the head, will be .ecessary where the symptoms point out an increased or inflamma- 3ry action in the vessels of the brain. They will likewise be proper >here there is foulness of the bowels, indicated by the stools being ither of a cadaverous smell or dark and slimy. After bleeding liey ought to be resorted to immediately. Jalap combined with he submuriate of mercury, or the supertartrate of potass with jamboge or scammony, as advised under the head of Anasarca, may be taken in doses proportionate to the age of the child, and be repeated occasionally so as freely to empty the bowels. In every stage of the disease, and let the cause have been what it may, blisters appear to be highly advisable from the great dis- harge which they occasion from the vessels of the head ; and with his view we may apply a cap blister over the whole head, keeping p a copious discharge from it as long as we can. When it heals resh ones may be put on the forehead, occiput, and sides of the lead in succession. Of late it has been recommended to apply hem in the course of the sutures, and to keep up a discharge by leans of an is-ne ; but as the ceratum lvtta? is capable of exciting Order U.J water in the head, 575 a proper discharging surface, it appears preferable, its application being much less troublesome than that of an issue. The ceratum sabinae is now and then employed for the purpose of keeping up a proper irritation. Some recommend the blistered parts to be dressed with mercurial ointment. The application of caustic to the bregma is preferred by a late writer* on hydrocephalus to blisters ; and as it is a more powerful stimulus, and more permanent in its effects, it may probably be more useful. The caustic usually employed by him was the lunar, reduced to a powder, put on the surface of any adhesive plaster, spread on strong leather, of the size and shape of an elongated half crown, and renewed every twelve hours, until it produces a suffi- cient eschar, destroying the skin of the part; after which a suppu- ration and separation of the eschar is promoted by the usual sur- gical dressings. Cold applications to the head, after it has been shaved, such as iced water, or linen cloths wetted in aether and water, or vinegar and water, and renewed as often as they become warm and dry, have been recommended by some practitioners at the onset of the disease. That they may not interfere with blistering, we ought, in having recourse to them, to apply the blister to the nape of the neck, or between the shoulders. Where much thirst with universal heat prevails, we may give small doses of antimonials, as advised under the head of Simple Fever, together with refrigerants, such as the nitrate of potass and the saline medicine. Such is the plan of treatment to be adopted when the disease has not run on to the second stage, so as to produce an effusion of water, the natural consequence of inflammation in the cavities of the body. In the second 6tage, when effusion has taken place in the cavities of the skull, it will be requisite to produce such an excitement of the vessels of the brain as may be likely to occasion a reabsorption of the fluid. With this view mercury both internally exhibited and externally applied, is usually employed ; but it is very doubtful that mercurial frictions are attended with any benefit. The inter- nal use of mercury has been regarded by some physicians as a spe- cific in hydrocephalus; and some cases which occurred in the practice of Dr. Percival and Dr. Dobson are said to have been cured by it; but experience has convinced me and many others, that when administered alone, or uncombined with other medi- cines, it more frequently fails than succeeds. A combination of the submuriate of mercury combined with a few grains of jalap, in doses proportionable to the age of the child, and administered so as to procure daily a copious discharge of green mucous stools, seem in my opinion to promise fairer for suc- cess than giving it alone so as to excite what is called a mercurial action in the system. * See Treatise on Hydrocephalus, by J. Carmichael Smyth, M D. 576 cachexia:, or cachectic diseases. [Class 111 The submuriate of mercury combined with the pulvis antimoni- alis, is a medicine which is reported* to have been given with much advantage in several cases of this disease. A combinationof mercury with freshsquill havingbeen employed by Dr. Carmichael Smyth in hydrothorax with a happy effect, he has been induced to recommend it in hydrocephalus.! The foxglove has been suggested as a remedy in hydrocephalus ; but it has not yet received the sanction of experience. To what particular state of the disease it may be adapted, whether it might relieve by diminishing arterial action, or by its power as a diuretic, on the same principle that it succeeds in the cure of dropsy, is uncertain, and only to be ascertained by further trials and observa- tion. Its exhibition in any of the forms advised under the heads of Phthisis and Anasarca, with the external application of about half a drachm of the unguentum hydrargyr. fort, might probably be attended with good effects, when either remedy given separately might fail. The best way of administering it will be, to begin with a mode- rate dose (eight or ten drops of the saturated tincture,) and to every succeeding dose which may be given at an interval of six hours, an addition of two or three drops may be made, so that in a day or two the system will be affected. We should proceed with caution, ascertaining, while augmenting it, the effect of the medicine after each increased dose. A discharge from the nose ought at the same time to be promo- ted, by causing the patient to snuff up the powder of asarabacca, white hellebore, or the like.J The erect posture is requisite throughout the disease as much as possible ; but when the little patient is in bed, his head should be raised considerably by pillows stuffed with horsehair or chaff, to avoid warmth. Slight electric shocks passed through the head twice a day have been found useful in some cases which were thought to depend on debility. It has been proposed as a query, whether frequent vomiting might not be likely in hydrocephalus, as well as in anasarca and * See Dublin Med. and Physical Essays, Article, 1st Number. t See his Treatise on Dropsy of the Brain. * 1. 3; Folior. Exsiccat. Asari, If 1. Take Dry Leaves of Asarabacca, Majoranae, --------------Mari Syriaci, Florum Exsiccat, Lavend. aa ?ss Simul in pulverem tere. Fiat pulv. ster nutatorius. Vel, 2. g. Pulv. Sacchar. Alb. gr. x. ----Veratri Rad. CR«FULA. 599 matters. When not at the sea-side, a solution of any of the neutral salts, such as the potassae tartras, potassae sulphas, &c. may be sub- stituted. The submuriate of mercury is, however, by far the most cele- brated of all the purgative medicines which have been employed in the treatmentof scrofula, and itis undoubtedly a serviceable remedy in many stages of the disease. To enjoy its beneficial effects, how- ever, with safety, we must be careful to avoid giving it in so large a quantity as to produce the specific effects of mercury to any extent; for it is well known that any deep mercurial impression on the system aggravates every symptom of scrofula. The hydrar- gyri submurias, however, when given cautiously in moderate doses, so as to act merely as an alterative, or gentle purgative, agrees well with scrofulous complaints, and greatly contributes to discuss tumours and resolve indurations of such a nature. But to produce the desired effect, this alterative course must be continued for a sufficient length of time, carefully watching its effect, lest it should exceed the prescribed bounds, and produce any ptyalism or severe purging. The dose must be regulated by the age of the patient and other circumstances. A few weeks' trial will be sufficient to determine the probability of its removing or relieving the complaint. In recent cases of obstruction, the submuriate of mercury joined with tartarized antimony,* has been used with benefit; and during the progress of the disease, where there is much irritation, or where there are deep-seated affections of the joints, opium has been added. Other alteratives, such as the hydrargyrus cum sulphure,f Plummer's pill,J as likewise antimonials, with decoctions of guaia- cum, sarsaparilla, sassafras, dulcamara, and mezereon, together with the Lisbon diet-drink (which is a combination of these,) have * 1. R Pulv. Cretae Praeparat. 3j. Hydrargyri Submuriat. g. iij.—vj. Antimon. Tartarizat. gr. ij. M. ft.Pulvis in chartulas xij.dividend, quarum j. sumat. bis in die. \ 2. Jjk Sulphuret. Hydrargyri Nigr. gr. xv. Pulv. Antimon. gr. j. M. ft. Pulv. nocte et mane sumendus. % 3. fy Hydrargyr. Submuriat. Antimon.Sulphuret. Praecip. aa 3ss. Gum. Guaiac. pulv. gj. Syrup, q. s. M. it. Massa in pilulas xxx. distribueda, quarum j. capiat, omni nocte et mane. * 1. Take Prepared Chalk, pulverized, one drachm. Submuriate of Mercury, from three to six grains. Tartarized antimony, two grains, Mix them, and divide the whole into twelve papers of which let a dose be taken twice a day. t 2. Take Black Sulphuret of Mercury, fifteen grains. Antimonial Powder, one grain. Mix them. Take this Powder night and morning. X 3. Take Submuriate of Mercury, Precipitated Sulphur of Anti- mony, of each half a drachm. Gum Guaiac, in powder, one drachm. Syrup, a sufficiency to form the , mass, which is to be divided into thirty pills, one of which is to be taken night and morning. 000 «- AOHEXIJE, OR CACHECTIC DISEASES. [ClaSS 111. likewise been much employed, but usually without any seeming advantage. Muriated barytes is said to have been given in some cases of scrofula with success. The proper dose is from three to ten or twelve drops twice a day, according to the age of the person. Beyond a certain dose it is apt to occasion sickness, tremors, and a loss of power. The muriate of lime, we are given to understand by Dr. Wood,* has been much employed at the Newcastle Infirmary in lieu of the muriate of barytes, and with two great additional advantages ; viz. its action was more immediate, and no bad consequences attended an over-dose, while at the same time its efficacy was decisive. He used it at first in the form of crystals, by dissolving three grains in an ounce of water; but he found the process of crystallizing the salt to be too tedious and difficult for general use, and that it did not possess any advantage over a fluid solution of the carbonate of lime in muriatic acid. Of the solution prepared agreeably to the Edinburgh Pharmacopoeia, about a drachm for adults, and thirty drops for children, given in water twice or thrice a day, will be a sufficient dose. A late writer on scrofula! tells us, however, that the muriate of lime had been employed by his colleague, Professor Thomson, of Edinburgh, in various cases of this disorder, without having derived benefit from it in a single instance. I can say little in its praise, as in the cases I have employed it no evident amendment or advan- tage was derived from it. Medicines of the narcotic tribe, but more particularly hemlock, have also been used for the cure of scrofula, both in the stage of swelling, and that of ulceration. From my own experience of hem- lock, as well as the report made of it by others, it appears, when administered internally,! to prove often serviceable in discussing swellings of this nature ; and it likewise appears in some cases of ulceration to have afforded relief by being employed externally, either in the form of poultice, or fomentation, or both. As an internal remedy in the ulcerated stage of scrofulous tumours, it seems to be inefficacious. It has, however, been considered by a modern writer§ as an useful auxiliary in cases of great irritation, particularly if it be combined with calomel or preparations of iron, when either of these remedies is indicated. To enjoy the full benefit of the curative powers of hemlock, it " See Edinburgh Medical Journal, vol. i. p. 147. t — Treatise on Scrofula, by Mr. J. Russel, p. 85. § — Essay on the diseases of the Vessels and Glands of the Absorbent System, by W. Goodlad. * 4. f£ Extract. Cinchon. 3>j - t 4. Take Extract of Peruvian Bark, two drachms. ■ -----Conii, 3j- M. -------Hemlock, one drachm. Fiant pilul. xl. quarum ij.—iij. sumat bis {Mix them, and make forty-pills out of the vel ter de die. " mass, of which from two to three may be taken twice or thrice a_day. Order III.J sckoflla. U'Oi will be necessary to give it to the full extent that the constitution can bear with impunity. The limit of the dose, therefore, is to be measured by its effect in producing incipient symptoms of giddiness or nausea, which disturb the functions of the head and stomach. The course requires to be continued many weeks, before the good effects of its operation are perceptible. The juice of the fresh leaves of the tussilago, or coltsfoot, is said to have been given with some advantage. When it cannot be pro- cured in the fresh state, a strong decoction of the dried leaves may be substituted. Lime-water and alkalies, as the sodae carbonas, subcarbonate of ammonia, &c, are enumerated among the remedies often used in this disease, and administered, no doubt, under the supposition of an acid acrimony prevailing in the fluids. In some instances a junction of soda with cinchona has been attended with a very good effect. In a small work* lately published, the successful treatment of several severe cases of scrofula, by means of the internal use of caustic alkali in doses proportioned to the age of the patient, with the external application of small quantities of mercurial ointment at the same time, and which are mentioned to have resisted all other remedies, is laid before the public. The annexed formulaf is what was employed. The water is directed to be boiled in a tin kettle, adding the lime by little at a time; the whole being properly slacked, the pearl ashes are to be put in, the mixture to be well stirred together, and then to be put into an earthen jar or pot well glazed on the inside, with a wooden spicket and faucet fixed in it to draw it off when wanted. The dose is a small tea-spoonful, or a drachm by measure, for children from four to six years old ; one tea-spoonful and a half for those from six to eight; two tea-spoons- ful for those from eight to fifteen; and in the like proportion to those of more advanced age. The medicine is to be taken twice a day in a little malt-tea, barley-water, or thin gruel. Burnt sponge is another remedy which has been much adminis- tered in scrofula, and frequently with advantage. It may be given either in the form of a bolus or draught.! A rn°re active medicine, *V * See Observations on Scrofula, by Mr. J. Brandish. t 5. $ Calc. Viv. Recent. ft>ij. Ciner. Clavellat. American. fbyj. ----Ligni Combust. ftVj- Aquae Bullient. cong. vj. M. t& R Spong. Ust. 3j.—3ss. Pulv. Rhei. gr. iij. * Mel. Optim. q. s. M. (t. Bolus, bis in'die sumendus. Vel, 7. f> Spong. Ust. 3j. Confect. Aromat. gr. x. 15. Take Quick Lime, two pounds. American Potass, six pounds. Wood-asb, two pounds. Boiling Water, six gallons. Mix them. X 6. Take Burnt Sponge, from a scruple to half a drachm. Powder of Rhubarb, three grains. Honey, a sufficiency to form a bolus. Let this be taken twice a day. Or, 7. Take Burnt Sponge, one scruple. '■ ATomatic-Gonf^ction, ten grainX 602 cAfiiEXUE, or Cachectic diseases. [Class III4 however, is the sodae carbonas, which is now employed in lieu of the former, of which, indeed, it is the basis. The dose, in these cases, is from ten to twenty grains to a drachm, twice or thrice a day.* To invigorate the constitution, it will be necessary in the cure of scrofula to employ such medicines as are supposed to impart strength to the body. Of the vegetable class the cinchona is the most esteemed; but previous to its use, and to insure the full benefit from it, the bowels must be previously cleared of any mor- bid accumulation of faeces, either by the submuriate of mercury or neutral salts, in the manner before mentioned. The cinchona seems, however, best suited to those cases where there are extenr sive ulcers or large abcesses, with copious exhausting discharges of purulent matter ; and in general to communicate that degree of energy to the actions of the system which tends to support and confirm the patient's strength. If the stomach will bear the powder, it will be the best mode of exhibiting it; but should it disagree, then either a decoction or infusion of it may be substituted, or we may try the extract properly dissolved. If none of these preparations agree with the patient, or we wish after a time to change the medicine, some of the other vegetable tonics, such as calumba, cascarilla, gentian, myrrh, Sic. (for various formulae of these see Dyspepsia,) may be given ; and to add to their efficacy, we may conjoin some agreeable aromatic, such as the tinc- tura cardamomi, or tinctura cinnamomi composita. Aq. Menth. f. ^j.—|jss. M. ft. Haustus. Capiat bis in die. * ■ - *8. ft Sodse Carbonat. 3iij. Pulv. Cinchonae, ^jss. Mucilag. Gum. Acaciae, q. s. M. ft. Electuarium, cujus sumat quantitatem nuc. moschatae ter in die. Vel, 9. ft Decoct. Cinchon. f. 3*. Tinct. Card. C. f. 3iss. Sodaj Carbon, gr. xv. M. ft. Haustus, bis terve de die sumendus. Vel, 10. R Soda? Carbonat 3»j- Infus. Cinchon. f. 3V. Tinct. Cinnam. C. f. gss. Syrup. Cort. Aurant. f. 3ij. M. Capiat cochl. larg. ij. ter quaterve in die. Mint Water, one ounce to one ounce and a half. Mix them as a draught, and let this be ta- ken twice a day. * S.Take Carbonate of Soda,three drachms, Powder of Peruvian Bark, one ounce and a half. Mucilage of Gum Acacia, a suffi- ciency to form an electuary, of which let the bulk of a nutmegbe taken thricea day. Or, 9. Take Decoction of Peruvian Bark, ten drachms. Compound Tincture of Carda- moms, one drachm and a half. Carbonate of Soda, fifteen grains. x Mix them, and let this draught be taken twice or thrice a day. Or, 10. Take Carbonate of Soda, two drachms. Infusion of Peruvian Bark, five ounces. Compound Tincture of Cinna- mon, half an ounce. Syrup of Orange Peel, two drachms. Of this mixture two large spoonsful are to be taken three or four times a day. Order 111.} S«ROFLLA. 60j Of the mineral tonics, iron and the sulphuric and nitric acids are most valued for their virtue in the cure of scrofula. The latter are palatable, grateful to the stomach, and agree with all forms and stages of the disease, being peculiarly adapted to that state of fever which is connected with the putrid sloughs that are often formed on the inside of large tumours when first exposed to the air, and to that state of weakness which disposes to copious perspiration upon any moderate degree of exercise. Dr. Mosman informs us,* that he found muriated barytes and the nitric acid to increase the appe- tite, and impart vigour to the system; but he never saw them ex- hibit any beneficial effect on the morbid glands. A few drops of either of the acids may be given with each dose of the cinchona, or other vegetable tonics. Of the preparations of iron, the subcar- bonate, ferrum ammoniatum, and muriated solution,have been found most efficacious. We may give doses of these proportioned to the age of the patient, twice or thrice a day. To derive the full benefit from tonic medicines in scrofula, it will be advisable occasionally to administer the vegetable and mineral at the same time in com- bination.—(See formulae thereof under the head of Dyspepsia.) About ten grains of the ferrum ammoniatum, in the space of twen- ty-four hours, will be sufficient for an adult, and so in proportion for children. Iron is less liable than cinchona to oppress the stomach with indi- gestion, or to produce accumulation in the bowels, and on these accounts is a more unexceptionable medicine in scrofula than the latter. During the use of tonics, a few grains of rhubarb, with one or two of the submuriate of mercury, may be given now and then. Mineral waters of the sulphureous and chalybeate class may likewise prove serviceable in the treatment of the disease under investigation. Arsenic is another mineral production which has been employed in scrofula with some advantage, and is said to contribute greatly to the cure of scrofulous ulcers. From one to five drops of a solu- tion of this (see Intermittents) may be given to children twice or thrice a day, according to their age; and from five to ten, or more, to grown persons, diminishing the quantity if it affects the bowels. Besides employing medicines internally to correct the cachectic state of the fluids and strengthen the system, we are often obliged likewise to make use of external applications. Upon the first appearance of any tumour or the enlargement of any joint by tumefaction of the parts surrounding it, it will always be advisable to disperse it, if possible, as we shall thereby relieve the patient from the risk of some very troublesome consequential symptoms. The discutients commonly employed are, different saturnine applications, the liquor ammoniae acetatis, solutions of the muriate of ammonia, camphorated and ammoniated oils, a * See his Essay on the Nature, Origin, and Connexion of Scrofula and Glandulal? Consumption. B04> CACHEXIA, OR CACHETIC DISEASES. [Class HI. mixture of fresh bile with saponaceous liniment, plasters of soap, ammoniacum and mercury, sea-water poultices, hemlock, mercurial ointment, electricity, and likewise blisters. The quercus marinus or sea-tang, bruised, and made into a poultice, is an application much recommended. These may be tried in rotation, and where one fails, another may probably succeed. Where sea-bathing can fee obtained, it will prove the most efficacious of all remedies. It is only, however, in the incipient stages of the attack, and before effusion has attained a stationary state, that any benefit is to be expected from discutient applications; for after the parts have lost their activity, and have become indolent, these remedies will have little or no power over them. The topical detraction of blood, by means of leeches, will prove a powerful mean in those cases of large glands which lie superficially, or adhere to the surface, and which are attacked with inflammation that threatens to terminate in suppuration, or where this occupies any joint or its immediate vicinity, but it is only under such circumstances that local detractions of blood are necessary and advisable. During the incipient or inflammatory stage of scrofulous glandu- lar swellings, an occasional gentle purgative to keep the bowels soluble, and consisting of a few grains of rhubarb joined with calomel, may prove serviceable. In a case of some years' standing, in which the glands of the neck had become enormously enlarged, and the tumour was attend- ed with excruciating pains, much relief was obtained by anointing the parts morning and night with an ointment composed of one drachm of tartarized antimony rubbed with an ounce of lard, even after considerable doses of opium administered internally had failed to alleviate the pain. After using the ointment a few days, several pustules of considerable size appeared on. the tumour, being the usual consequence of its application. Galvanism and smart electrical shocks passed through scrofulous tumours of an indolentnature, particularly when occupying glands in the neck, have in some instances had a good effect in dispersing them. Repeated frictions simply with the hand without any substance interposed, except perhaps a little flour to prevent the abrasion of the skin, and continued for a considerable length of time each day, have been much recommended in indolent enlarged glands, and in some instances apparently with a very good effect. A case of this nature in a young lady, whose knee became much enlarged after an attack of scarlatina, and which had resisted the repeated applications of leeches, and tepid water poured over it, while the submuriate of mercury, hemlock, lime, &C. were given internally without the least advantage, and which was at last effec- tually cured under the care of Mr. Grovenor, of Oxford, by assi- duous frictions with the bare hand, exercise on foot, and an occa- sional use of calomel, is recorded in the 29th No. of the Edinburgh Medical and Surgical Journal. Order III.] S6R0fula. 60^> The application of blisters to glandular swellings of this nature has sometimes proved effectual in occasioning them to suppurate quicker than they otherwise would have done. Where the activity of'the inflammation is on the decline, and the swelling of a gland has become indolent and stationary, the stimulus of a blister imparts fresh vigour of action, which possibly may dispose the swelling to suppurate. In some instances both blistering and elec- tricity have, however, been attended with a direct contrary effect, and have occasioned them to disperse. When we fail in our attempts to disperse scrofulous swellings, and a suppuration has commenced, we are to promote and expedite this as much as we can. Poultices and other warm applications have little effect,however,inbringingforward these kind of tumours. and when long used, they tend to weaken and relax the part so much, that the sores which ensue are rendered difficult of cure. Washing the parts with strong brine has sometimes been employed with success, and has expedited the formation of matter in scro- fulous swellings. It is well known that scrofulous tumours suppu- rate very slowly, in spiteof emollient poultices and otherlike appli- cations, but it has been found* that by taking off the atmospheri- cal pressure from the most depending part of the tumour by means of a cupping-glass applied over it, for about an hour twice or thrice a day for four or five days successively, applying immediately after- wards a warm poultice, so considerable an excitement is produced in the parts as to effect a speedy suppuration, and early discharge of the contents of the abscess. Where the process of suppuration is sufficiently advanced, the contents of the abscess are to be evacuated by a lancet at once, if the collection be not large ; if otherwise, by repeated puncture at proper intervals, and the access of external airprevented by careful closure of the orifice, similar to what has been long practised by the most skilful surgeons in the treatment of lumbar abscess. To correct the discharge, repress or destroy any luxuriant fungous growth, promote a proper suppuration, and dispose the ulcers to heal, it is usual to employ gentle escharotics, such as the hydrarg. nitrico oxydum, verdegris, and burnt alum, which may either be sprinkled over them, or be applied mixed up with some mild ointment, as the unguentum cerae. Where there is a languid action in any sore, which suspends its progress towards amendment and renders it stationary, the use of gentle stimulants will be pro- per. A solution of the neutral or metallic salts, as the muriate o* ammonia, oxymuriate of mercury, nitrate of silver, or the sulphate of zinc, will stimulate the ulcer to shoot forth granulations. A solution of the latter, in the proportion of from half a drachm to one drachm to about eight ounces of water, is considered by Mr. Goodladt to be the best application that can be made to scrofulous sores that have suppurated and opened. * See Medical and Physicial Journal. No.250. p.454, + See hi« Tract on Scrofula, tiQt> CACHEXIA, OR CACHEsClI© DISEASES. [Class HI. Scrofulous abscesses have been punctured, and the cavity after- wards injected with a solution of the sulphate of zinc in the pro- portion oT about eight grains of the latter to an ounce of the former, with the best effects,* as healthy inflammation has supervened, which terminated in adhesion, without any return of the complaint. The application of linen cloths dipped in cold water, sea-water, or lirne-water, and renewed as frequently as they become dry throughout the course of the day, with that of some mild plaster or ointment, such as the ceratum plumbi superacetatis, spread upon fine lint by night, is a mode of treatment much recommended in scrofulous ulcers. If these fail in healing the ulcers, the linen rags may be moist- ened with a solution of two drachms of the plumbi superacetas in a pint of water, from which application I have seen very good effects derived. Dr. Darwin used powdered oak-bark mixed with white lead. Scrofulous ulcers which had resisted many other remedies, have healed under a weak solution of nitric acid in water. In sores which are spreading and irritable, the application of an aqueous solution of opium or of hemlock, and afterwards of a solu- tion of zinc, may be beneficial. Where the granulations rise above the surface, and are broad and flabby, and where pressure cannot be applied, the sorrel poul- tice has proved useful. The topical employment of bruised sorrel leaves (rumex acetosa,) has been strongly recommended as con- tributing very much to the cicatrization of indolent scrofulous ulcers. In sores of an ugly, gleeting, and ill-conditioned appearance, much benefit has been obtained by the application of a poultice made with crumbs of bread moistened with a solution of about an ounce of the crystals of soda in a quart of water. The sub-borate of soda in the proportion of half a drachm, or one drachm mixed in an ounce offceratum cetacei or ceratum cala- minae, has been found a useful and efficacious application to scro- fulous ulcers ; and by such dressings they have frequently been healed ia a short space of time, after having resisted other modes of treatment. Painful and deep-seated ulcerations, the consequence of a scro- fulous habit, and which are attended with much local irritation, have been relieved by a use of the Malvern water. Applied to the sore, it moderates the profuseness of the discharge, corrects the foetor which so peculiarly marks a caries of the bone, promotes the granulating process and a salutary exfoliation of the carious part, | and by a long perseverance in this course, very dangerous and obstinate cases have at last been entirely cured. Inflammation of the eyes, especially the ophthalmia, which is so troublesome in scrofulous habits, often yields to this simple application.! * See Practical Observations in Surgery, 8ic. by Mr. J. Howship, t See Dr. Saunders's Treatise on Mineral Waters. Order IU.J diseased mesenteric glands. WQ7 It has already been observed, that diseases of the vertebras, which inconsequence of the softness of their bodies occasions a protrusion of their spinal processes, and a compression of the medulla, are frequently connected with scrofula. In such cases Mr. Pott de- pended principally on a drain by issues applied on each side of the projecting spinal process, and in some of them successfully treated in this manner, confinement to an horizontal position was unavoid- able. Sir James Earle, fully aware that issues were ineffectual unless the superincumbent weight was removed from the morbid part, and objecting to the horizontal position from its being irksome to the patient, " weakening and relaxing, and consequently retard- ing the cure," as he expresses it, endeavoured to substitute a mean betwixt the confinement to bed and the pressure from an erect position. He therefore recommended and employed a form of machinery, which should take off the incumbent weight from the diseased vertebrae and transfer it to the pelvis. Mr. Baynton,* (who is the latest writer on diseases of the spine,) having compared the opinions and practice of Mr. Pott and Sir James Earle, and from facts collected from the writings of other surgeons of emi- nence, has been induced to conclude, that a system of resting in an horizontal position, regulated by scientific principles, will accom- plish the cure of diseases of the spine, after the failure of drains and machinery steadily continued a numberof years under the direction of skilful surgeons ; and to substantiate the efficacy of the mode of treatment which he advises, he has recited the history of some cases which fell under his care. He is induced to suppose that the success which attended the cases treated by Mr. Pott, by issues made with caustic, conjoined with an horizontal position during the greatest part of the cures, as the patients could not bear to remain upright, was more owing to the uninterrupted rest they enjoyed than to the effects of the drains from the neighbourhood of the diseased portion of the spine. Great doubts have indeed been entertained by other practition- ers respecting the efficacy of caustics in caries of the spine, and they have recommended in their stead occasional cupping, repeat- ed blisters, aperients, the muriate of lime, a milk diet, and long- continued repose in an horizontal position, and particularly at the commencement of the disease. DISEASED MESENTERIC GLANDS. Children of a scrofulous habit are very often affected with a diseased state of the mesenteric glands, the little patient usually complaining of a deep-seated lancinating pain within the abdomen, which gradually enlarges, while the other parts of the body are emaciated.—(-See Atrophia.)—The countenance becomes altered. the eyes seem glassy and sunk in their sockets, the nose is sharp- ' See hi? Account of a successful Method of treating Diseases of the Spine. t>tiH CACHEXIA, OR CACHECTIC DISEASES. [Class 111. ened, the cheeks are of a marble whiteness, unless when they are flushed with hectic fever, and the whole body is indeed of the same hue. Sometimes the lips are swelled and of a deep red colour, and sometimes the angles of the mouth are beset with small ulcers. The state of the bowels is variable, though more commonly relaxed than otherwise. When they are relaxed, the stools consist chiefly of frothy muscus tinged with bile, by which discharge an excoria- tion of the verge of the anus is now and then produced. Although the appetite is tolerably good, nay often voracious, in children whose mesenteric glands are thickened and diseased, neither health nor strength result from it; the more food that is taken the worse the child is generally, as it oppresses without nourishing the system. Until the obstructions are removed, no healthy appearance can therefore take place. In the advanced stage of the disease the child is fretful, peevish, and inactive. There is usually an accession of fever towards the evening, the pulse being at that time generally about 120, while at other times of the day it is seldom less than 100 in a minute. There is but little thirst, and the tongue suffers no change, except perhaps being now and then streaked with white at the sides. The skin is dry to the touch and rough, and the cuticle is not unfre- quently thrown off in scales. It has been supposed that a connexion frequently exists between chronic peritonitis and a diseased state of the mesenteric glands. This diseased state of the mesenteric glands is to be distin- guished from enteritis by there being no vomiting or difficulty in procuring evacuations with the ordinary quantity of medicines, and but little pain being perceived on pressure ; and it may be known from the febris infantum remittens, by the accession of fever being attended with restlessness rather than an inclination to sleep ; bv the excretions not being particularly changed from their natural appearance ; by the accession of fever occurring only in the even- ing ; and by the duration of the complaint: whereas in the remit- ting fever the paroxysms are attended with drowsiness ; the evacu- ations are unnatural both in smell and colour; the accessions of fever are very irregular, as well in their recurrence as in their duration; and the disease has more the character of an acute than of a chronic one. The disorder attacks children from the age of a few months to ten or twelve years ; and the earlier it appears the greater will be the danger. In all ages the prognostic should be guarded, and for the most part be unfavourable; for the disease is generally-far advanced before it becomes an object of medical attention, owing to its gradual progress, and being attended with scarcely any pain at first. An improvement of the colour and look of the counte- nance, the evening accession of fever being less severe, and its duration shortened, increase of the flesh and appetite, and a dimi- nution of the size of the abddmen, are to be regarded as favour- able pigns. The most unfavourable symptoms are, a rapid increase Order III.] diseased mesenteric glands. b09 of the emaciation, the evening accession of fever being severe and continuing through most of the night, the abdomen being much enlarged and tense, and the cuticle pealing off. In the treatment of this diseased state of the mesenteric glands, gentle action upon the intestines by aperients will be highly proper, and, therefore, it will be necessary to give one of the submuriate of mercury* in a dose proportioned to the age of the child twice every week. On the intermediate days, some slight tonic may be administered twice or thrice a day.—(For these, see Atrophia.) If the bowels are confined between the doses of aperients, they ought to be opened with a solution of some of the neutral salts ; but we are at the same time to be cautious not to exhaust the strength of the patient by the exhibition of active purgatives. The less severe the evening accession of fever appears, the more free we may be in the exhihition of tonics, and the less necessity will there be for the use of purgatives : on the other hand, the more severe the evening paroxysm, the greater caution will be necessary in the exhibition of tonics, and the less restraint be required in the use of purgatives. It is of the utmost importance in cases of diseased mesenteric glands to ensure the healthy state of the chylopoetic viscera, and the proper digestion of the food. By such treatment we remove a concurring cause to the prejudicial effects of this state of the glands upon the constitution of the patient. We thereby afford an oppor- tunity for as much nutritious matter to be carried into the system as is compatible with the existing disease. Exciting the surface of the body to healthy action by warm bath- ing every second or third night, and employing frictions! night and morning with the hand over the whole of the abdomen, will greatly assist and expedite the cure. The diet should be milk, gruel, sago, and other kinds of farina- ceous food, with an admixture of dressed vegetables. Provided the patient exceeds the age of two or three years, a small quantity of animal food may be allowed. Animal broths, jellies, &c, may be given to all that are weaned. Exercise in the open air should be especially recommended, and as that of the sea usually proves beneficial to such patients, where * 1. ft Hydrargyr. Submuriat.gr. ij.—iv. * 1. Take Submuriate of Mercury, two to four grains. Pulv. Rhei, gr. iv.—x. M. Powder of Rhubarb, four to ten grains. ft. Pulvis catharticus. \ Mix them as a cathartic. Vel, Or, ■J., ft Hydrargyri Submur. gr. ij.—iv J 2. Take Submuriate of Mercury, two to four grains. Tartrate of Potass, eight grains to one scruple. Mix them. f 3. Take Compound Soap Liniment for an embrocation. Or, 4. Take Compound Camphor Liniment. Potassae Tartrat.gr. viij.—3j. M. 3. ft Liniment. Saponis Comp. pro em- brocatione. Vel, 4. ft Liniment. Camphor. Comp. 78 olO CACHEXIAS, OR CACHECTIC DISEASES. [ClttSS 111. a residence near the coast is practicable it should be adopted. Where the disease gives way, and a decided diminution of the fever, pain, and enlargement of the abdomen, has taken place, we may recommend sea-bathing at first with a bath heated to about 80 degrees, and so reduce the heat gradually, until at last the patient can safely bear the sea-water at its usual temperature. If it should be winter, the water may be heated to about 65 or 70 degrees. SYPHILIS, or the VENEREAL DISEASE. The part of the world where this disease first originated has been much disputed, some looking upon it as of French extraction, and others supposing it to have been brought from America by the soldiers of Christopher Columbus. Be this as it may, it is certain that it was first observed at the seige of Naples in the year 1493, and that from thence it spread very rapidly throughout France, Spain, Germany, and other kingdoms. The syphilitic poison is peculiar to the human species, and pro- duces no effect whatever on any of the brute creation, as has incontestably been proved by repeated experiments, from whence we might infer that it was intended not only as a check against any deviation from the rules of connubial chastity, but likewise as an incentive (if I may be allowed the expression) to the gay and young, to form, at an early period of life, a satisfactory and honourable alliance, by which they may be enabled to gratify the passions implanted in them by nature, and propagate the species, without the risk of disease. Some practitioners of the present day go so far as to doubt the existence of this virus, and even deny the specific power of mercury. Syphilitic poison cannot, as happens in other eruptive com- plaints, such as the small-pox, measles, &c, be conveyed in the form of vapour, or, in other words, by breathing air which is contaminated by a person labouring under it. To give rise to syphilis, it is necessary that the matter or poison should be applied to some part which is soft or covered with a mucous membrane, or else to some place where there exists either an excoriation, ulcer, or wound. It has been doubted whether it is possible for the disease to be communicated from the mother to the infant in utero. However rare such an occurrence may be, still it is very possible, and many well authenticated cases are on record to substantiate this fact. Venereal matter is always sure to occasion a conversion of the mucus of the part, or of the fluids of the wound or ulcer to which it has been applied, into matter similar to itself; and when a sufficient quantity has been produced, it excites an inflammation in the mucous membrane or glands, or in the wound or ulcer, and is then absorbed into the system, and but very seldom before. Instances have indeed occurred in practice where absorption has Order III.] venereal disease. 611 taken place without any apparent effect of this kind being pro- duced ; they are, however, very rare. The infection is almost always sure to show itself first in that part to which the matter is applied ; and as syphilis most gene- rally arises in consequence of an intercourse between the sexes, so the symptoms usually show themselves first in or about the organs of generation. Where a child at the breast communicates the contagion to its nurse, her nipples and breast will be the parts first affected; and on the contrary, where it is the nurse that infects the infant, then its lips and other parts of its mouth will show the first symptoms of the disease. In like manner if the infection is conveyed to an accoucheur, in consequence of having a slight scratch on any of the fingers of the hand with which he officiates, the wounded part will show the first appearances of the disease by becoming inflamed, soon after which the glands in the axilla of the same side will swell, be painful, and indurated. Syphilitic matter, by being applied to the body, produces in the course of time either a local or a constitutional disease. By the former is meant, an affection confined solely to those parts to which the poison was first applied; and by the latter is to be understood, a general taint of the whole system and mass of fluids. Syphilis is therefore generally sure to show itself in both sexes, either as a local affection under the form of a gonorrhoea or chancre, or else as a constitutional one, under that of a confirmed lues venerea. Between a local and a constitutional affection there are, however, certain appearances which are apt to take place in the absorbent vessels and glands nearest in situation to the parts affected with ulceration, and produced, no doubt, by the passage of the vene- real matter through them. When the former become affected, a hard, red, inflamed line, somewhat similar to a cord, may be felt running all along the back of the penis; and when the latter are affected, which more usually happens, an induration, swelling, and inflammation of the glands themselves will take place, and a bubo will be the consequence. As in most instances the matter is applied first to the parts of generation, in consequence of an intercourse between the sexes ; so, of course, the glands of the groins are most usually the seat of this symptom. Bjr a gonorrhoea virulenta, or clap, is to be understood a secre- tion and discharge of matter from the mucous membrane and glands of the urethra, in consequence of the application of syphilitic matter to them. By a chancre is meant a venereal ulcer, the na- ture of which is to be much inflamed, to be very sore and painful, to be unequal at the bottom, to have prominent edges of an ash colour, and to show no kind of disposition whatever to heal when left to itself, but, on the contrary, to spread very much ; and by a lues venerea is implied an affection of the whole habit and mass of fluids, in consequence of an absorption of the poison into the con- l>12 CACHEXIA, OR cachectic diseases. [Class III. stitution, which produces certain effects on various parts of the body while diffused in the circulation. Although a gonorrhoea and a chancre are both of them local affections on their first appearance, still there is this material dif- ference between them, that, as in the first there is a formation of matter without any breach in the solids, and in the latter there is always a breach, so the first may go on for some time without de- generating into an affection of the whole system, and may at last effect its own cure ; whereas the latter is never attended with this happy effect; but, on the contrary, affords great reason to fear, that in those cases where the virus is not corrected by a timely use of proper antidotes, an absorption of the matter will take place, and in due time give rise to a confirmed lues. In mentioning this distinction between a clap and a chancre, I wish not, however, to be understood to mean, that the former never terminates in, or occasions a taint of the whole system. In some cases, where a gonorrhoea has been of long standing, it has been attended with this effect, owing most probably to the forma- tion of some little ulcer in the urethra; not but that I conceive it possible for absorption to take place without ulceration. The application of venereal matter for any considerable length of time to a part that is of a soft and spungy nature like the glans penis, may in some instances, I apprehend, be productive of a constitu- tional taint without the existence of any previous ulceration. It has been disputed whether or not the matter secreted in a clap is of a similar nature with that secreted from a chancre, and whether or not it is possible for a person labouring under the one or the other to communicate to a healthy subject a different species of the disorder from that with which he is infected. That a gonorrhoea, chancre, and confirmed lues, all arose fronvthe same original infection, may, 1 think, readily be admitted ; and that the matter produced both in gonorrhoea and chancre is of the same nature, ought not to be doubted, as daily observation must con- vince those who are frequently consulted in venereal cases, and who have given themselves the trouble \.o investigate the nature of the complaint which the person laboured under who propagated the infection, that the matter from a gonorrhoea may, and often does, give rise either to a clap, chancre, or confirmed lues, and that the matter secreted from a chancre will do the same. The event depends, most assuredly, on the state of the parts and the constitution of the patient, together with other accidental circum- stances at the time the poison is applied, and not on any difference in the nature of the matter secreted in the one or the other affection. I am aware that the doctrine I have here supported by no means accords with that which has been advanced by Mr. Ben- jamin Bell, and a few other modern practitioners of eminence ; for these gentlemen consider gonorrhoea and lues as arising from Order III.] venereal disease. 613 different specific contagions. By the greater number of the pro- fession, however, they are still considered as the same ; and it appears by Mr. Cross's Report* that the French surgeons are still of opinion that the lues may arise from gonorrhoea, and therefore that the poisons of both are identically the same. When facts, supported by accurate experiments and observation, are brought forward to convince me that they are separate poisons, I shall be ready to adopt the new opinion, but not until then. When a person labouring under the venereal disease forms a connexion with another who is free from it, and who happens to have any little excoriation, ulcer, or wound; about the parts of generation, it is probable, that if the poison is conveyed to the healthy subject, it will be most likely to show itself under the form of a constitutional affection ; as in this case the matter is applied so as readily to be absorbed into the system, in a manner similar to what happens in the small-pox ; whereas if it is applied to a part that it spungy, or to a surface covered with a mucous membrane, and where neither excoriation, ulcer, nor any wound exists, then the most probable consequence will be either a go- norrhoea or a chancre. In offering this as my opinion, I wish not to be understood that I mean to assert this will invariably be the case. Much (as has already been observed) will depend on the state and irritability of the parts at the time the poison is applied, as also on the habit of the person, and other accidental circumstances. Another remark which may be added on the nature of the venereal poison is, that there seems to prevail in some constitu- tions a greater liability to be infected by it than in others, as two men having been connected with a diseased woman within a very short space of time, one of them shall contract infection from her, and the other shall escape with impunity. GONORRHOEA VIRULENTA.t No certain rule can be laid down with regard to the time that a clap will take before it makes its appearance after infection has been conveyed. With some persons it will show itself in the course of three or four days; while with others there will not be the least appearance of it before the expiration of some weeks. It most usually is perceptible, however, in the space of from six to fourteen days, and in a male begins with an uneasiness about the parts of generation, such as an itching in the glans penis, and a soreness and tingling sensation along the whole course of the urethra ; soon after which, the person perceives an appear- ance of whitish matter at its orifice, and also some degree of pun- gency on making water. * See bis Sketches of the Medical Schools of Paris. t This disease belongs to Class IV. Locales, Order IV. Apocenoses, in the systematic arrangement of Dr. Cullep ; but I have judged it preferable not; to separate the varie- ties of the venereal disease from each other. G14 cachexia, or cachectic diseases. [Class IIL Here it may be proper to mention, that it is necessary to dis- tinguish accurately true gonorrhoea from that discharge that sometimes takes place from the internal surface of the prepuce, and produced by any thing causing irritation there, or behind the corona glandis, as a want of due cleanliness, warts, &zc. In the course of a few days the discharge of matter in gonor- rhoea will increase considerably, will assume most probably a greenish or yellowish hue, and will become thinner, and lose its adhesiveness ; the parts will also be occupied with some degree of redness and inflammation ; in consequence of which, theglans penis, will put on the appearance of a ripe cherry, the stream of urine will be smaller than usual, owing to the canal being made narrower hy the inflamed state of its internal membrane, and a considerable degree of pain and scalding heat will be experienced on every attempt to make water. Where the inflammation prevails in a very high degree it prevents the extension of the urethra on the taking place of any erection, so that the penis is at that time curved downwards with great pain, which is much increased if attempted to be raised towards the belly, and the stimulus occasions it often to be erected, particularly when the patient is warm in bed, and so deprives him of sleep, pro- ducing in some cases, an involuntary emission of semen. The above symptoms denote the presence of a chordee. In consequence of the inflammation it sometimes happens that at the time of making water, owing to the rupture of some small blood-vessel, a slight haemorrhage ensues, and a small quantity of blood is voided. In consequence of inflammation, the prepuce likewise becomes often so swelled at the end that it cannot be drawn back ; which symptom is called a phymosis : or that, being drawn behind the glans, it cannot be returned ; which is known by the name of paraphymosis. Now and then, from the same cause, little hard swellings arise on the lower surface of the penis, along the course of the urethra ; and these perhaps suppurate and form into fistulous sores. The adjacent parts sympathizing with those already affected, the bladder becomes irritable, and incapable of retaining the urine for any length of time, which gives the patient a frequent inclination to make water, and he feels an uneasiness about the scrotum, perinaeum, and fundament. Moreover, the glands of the groin grow indurated and enlarged, or perhaps one of the testicles becomes swelled and inflamed ; in consequence of which he experiences ex- cruciating pains, extending from the seat of the complaint up into the small of the back, he gets hot and restless, and a small symp- tomatic fever arises. Where the parts are not occupied by much inflammation, few or none of the last-mentioned symptoms will appear, and only a discharge, with a slight heat or scalding in making water, will prevail. Tn consequence of the inflammation of gonorrhoea extending Order III.} venereal disease, 616, along the urethra, it sometimes happens that the mucous membrane of the bladder becomes thickened, indurated, and ulcer- ated, and pours out a considerable quantity of muco-purulent matter, which added to the urine, gives to it the appearance of whey. If a gonorrhoea is neither irritated by an irregularity of the patient, nor prolonged by the want of timely and proper assistance, then in the course of about a fortnight or three weeks the discharge, from having been thin and discoloured at first, will become thick, white, and of a ropy consistence, and from having gradually begun to diminish in quantity, will at last cease entirely, together with every inflammatory symptom whatever : whereas, on the contrary, if the patient has led a life of intemperance and sensuality, has partaken freely of the bottle, and high-seasoned meats, and has at the same time neglected to pursue the necessary means, it may then continue for many weeks or months, and on going off may leave a weakness or gleet behind it, besides being accompanied with the risk of giving rise, at some distant period, to a constitutional affection, especially if there has been a neglect of proper cleanliness ; for where venereal matter has been suffered to lodge between the prepuce and glans penis for any time, so as to have occasioned either excoriation or ulceration, there will always be danger of its having been absorbed. Another risk arising from the long continuance of a gonorrhoea, especially if it has been attended with inflammatory symptoms, or has been of frequent recurrence, is the taking place of one or more strictures in the urethra. These are sure to occasion a considerable degree of difficulty as well as pain in making water, and, instead of its being discharged in a free and uninterrupted stream, it splits into two, or perhaps is voided drop by drop. Such affections become, from neglect, of a most serious and dan- gerous nature, as they not unfrequently block up the urethra, so as to induce a total suppression of urine. We may rest assured that inflammation in the urethra is the usual source of all strictures, and for most part this is excited by gonorrhoea ; occasionally it has, however, arisen from some other cause producing continued irritation in the parts, as for instance, from some previous disease in the bladder or prostate gland. Most commonly the course of the complaint is this. The gonorrhoea has arisen and gone on unchecked until the inflammation being at its height, there is a puruleut secretion, and probably chordee : the disease which was at first seated neaT the orifice of the canal has spread backwards ; but by the use of appropriate remedies, the pain and other inconvenient symptoms which the patient had experienced are ameliorated; still, however, the irritation does not entirely subside. Some pain and heat in voiding urine are still perceived, and from time to time there flows a gleety discharge ; but this gleet is not the effect of mere* re- laxation of the vessels allowing a profuse discharge, as is too often supposed; it is the vestige of inflammation in a milder and G16 CACHEXIA, OR CACHECTIC DISEASES. [Class III. more chronic form. When this state of the parts is allowed to continue, a pretty firm stricture will at length be formed. The degree and firmness of the contraction will hold a strict relation to the length of time, and the frequency of the occasional increase of the irritation, pain, and discharge. Where a gonorrhoea has been of long standing, warty excres- cences are likewise apt to arise about the parts of generation, owing to the matter falling and lodging thereon; and they not unfre- quently prove both numerous and troublesome. Having noticed every symptom which usually attends on go- norrhoea in the male sex, it will only be necessary to observe, that the same heat and soreness in making water, and the same discharge of discoloured mucous matter, together with a slight, pain in walking, and uneasiness in sitting, take place in females as in the former ; but as the parts in women which are most apt to be af- fected by the venereal poison are less complex in their nature, and fewer in number, than in men, so of course the former are not liable to many of the symptoms which the latter are ; and from the urinary canal being much shorter, and of a more simple form in them than in men, they are seldom, if ever, incommoded by stric- tures. With women it indeed often happens that all the symptoms of a gonorrhoea are so very slight that they experience no other incon- venience than the discharge, except perhaps immediately after menstruation, at which period it is no uncommon occurrence for them to perceive some degree of aggravation in the symptoms. Women of a relaxed habit, and such as have had frequent miscarriages, are apt to be afflicted with a disease known by the name of fluor albus, which it is often difficult to distinguish from gonorrhoea virulenta, as the matter discharged in both is, in many cases, of the same colour and consistence. The surest way of forming a just conclusion in instances of this nature, will be to draw it from an accurate investigation both of the symptoms which are present, and those which have preceded the discharge; as likewise from the concurring circumstances, such as the character and mode of life of the person, and the probability there may be of her having had venereal infection conveyed to her by any connexion in which she may be engaged. Not long ago it was generally supposed that gonorrhoea depended always upon ulcers in the urethra producing a discharge of purulent matter ; and such ulcers do indeed occur in con- sequence of a high degree of inflammation and suppuration ; but many dissections of persons who have died while labouring under a gonorrhoea have clearly shown that the disease may, and often does exist, without any ulceration in the urethra, so that the discharge which appears is usually that of vitiated mucus thrown out from the mucous follicles of the urethra. On opening this canal, in recent cases, it usually appears red and inflamed, its mucous glands are somewhat enlarged, and Order III] venereal ju^kase^' ol? its cavity is filled with matter to within a small distance from its extremity. Where the disease has been of long continuance, its surface all along, even to the bladder, is generally found pale and relaxed, without any erosion. In the cure of a gonorrhoea we are to be directed by the symp- toms which are present, and by the state of the disease at the time that advice is applied for. If at the commencement of the com- plaint the patient should experience much pain, heat, and difficulty in making water, together with other inflammatory symptoms, and he is at the same time of a full plethoric habit, it may be advisable to have recourse to antiphlogistic means, as bleeding, keeping the body open with gentle purgatives, allaying irritation by means of sedative injections,* drinking copiously of mucilaginous diluting liquors, such as barley-water, linseed-tea, or solutions of gum. acaciae in milk ; making use of a very spare regimen ; abstaining from all kinds of fermented and spirituous liquors, and avoiding exercise : but if an inflammatory diathesis does not exist, nor any great degree of ardor urinae prevail, it then will be unnecessary to have recourse either to general bleeding from the system or to purging. In avoiding purging, when not necessary, we are however to take care not to run into the opposite extreme by suffering costiveness to prevail, as the lodgment of indurated faeces, as well as the voiding * 1. ft 01. Amygdal. f. |iv. Liquor. Plumbi Acet. Til xiii. M. ft. Injectio. Vel, 2. ft Aq. Fontan. f. ?iv. Tinct. Opii Vinos, fit xxv. M. Vel, 3. ft Liquor. Plumbi Acet. IQ, xiii. Aquae Rosse, f. ^viij. M. Vel, 4. ft Infus. These Virid. Herb. f. §vj. Liquor. Plumb. Acet. fll xiii. M. Vel, 5. ft Mucilag. Gum. Acaciae, f. ?iij. 01. Olives, f. ^j. M. et adde Tinct. Opii Vinos. Til xxx. M. Vel,% 6. ft Liquor. Ammon. Acetat. f. |j. Aquae Fontan. f. ^iv. M. 1. Take Oil of Almonds, four ounces. Solution of Acetate t>f Lead, twenty drops. Mix them. Or, 2. Take Pure Water, four ounces. Vinous Solution of Opium, forty drops. Mix them. Or, 3. Take Solution of the Acetate ©f Lead, twenty drops. Rose Water, eight ounces. Mix them. Or, i. Take Infusion of Green Tea, six ounces. Solution of Acetate of Lead; twenty drops. Mix them. Or, 5. Take Mucilage of Gum Acacia, three ounces. Olive Oil, one ounce Mix them. And add Vinous Solution of Opium, forty- five drops. ' Or, >. Take Solution of Acetate of Ammo- nia, one ounce. Pnre Water.' four ounce? Mix them ' '*■ CI 8 CACHEXIA, OR CACHECTIC DISEASES. [Cluss 111 of them, might prove a stimulus to the urethra. In every stage of gonorrhoea it therefore will be advisable to keep the body perfectly open by a regular use of some mild laxative* that is not of an irri- tating or drastic nature. Nitre is a medicine which is often employed where there is any heat of urine; but this is very erroneous, for it cannot fail to in- crease the pain in making water by its stimulus on the excoriated or inflamed urethra. In the active or inflammatory stage of gonorrhoea, cubebs have of late been greatly lauded as a valuable remedy. Among the symptoms attendant on gonorrhoea, it has been men- tioned that phymosis and paraphymosis are sometimes present. In such cases it will be necessary either to immerse the penis frequent- ly in warm water, or to have recourse to emollient fomentations, with the after application of poultices, composed of linseed-meal, or crumb of bread mixed up with a solution of the plumbi superacetas or a sufficient quantity of the liquor plumbi acetatis diluted with common water, which are to be laid on cold; and the patient is at the same time to keep as much as possible in a recumbent position ; or, if obliged to walk about, he should sapport the penis up to the belly by means of a proper bandage. In those cases, both of phymosis and paraphymosis, accompanied by considerable inflammation, it will be advisable, previous to adopting the foregoing steps, to draw blood freely from the arm, to administer cooling purgatives every other day, and to observe a strict antiphlogistic regimen, with rest. Local blood-letting, so use- ful in other inflammations, would not be advisable here; for if the matter which flows from beneath the prepuce should happen to 3 7, ft Confect. Sennae, |jss. Potassae' Supertart. 3'j- Pulv. Jalapae, 3ss. Syrup. Simpl. q. s. M. ft. Electuarium,cujus sumat cochl. minim j. mane et vespere pro re nata. Vel, 8. ft Mannas Optim. |ss. Potassae Tartrat. 3"j' Aq. Fervent, f. S;iss. Tinct. Jalapae, f. 3i- M. ft. Haustus, pro re nata capiendus. Vel, 9. ft Magnes. Sulphat. ^ij. Aq. Fervent, f. |vij. Tinct. Sennas C. f. jfj M, Capiat cochl. magna iv. pro dos 7. Take Confection of Senna, one ounce and a half. Supertartrate of Potass, two drachms. Powdered Jalap, half a drachm. Common Syrup, a sufficiency to form an electuary, of which let a tea. spoonful be taken morning and evening as the occasion may require. Or, 8. Take Manna, half an ounce. Tartrate of Potass, three drachms. Warm water, one ounce and a half. Tincture of Jalap, one drachm. Mix them for a cathartic draught, to be ta- ken occasionally. Or, 9. Take Sulphate of Magnesia, two ounces. Warm Water, seven ounces. Compound Tincture of Senna, one ounce. Of this mixture let four table-spoonsful be taken for a do^e Order III.J venereal disease. 619 come in contact with the wounds inflicted by the leeches, trouble- some sores might ensue. In phymosis, besides pursuing the plan just recommended, it will be advisable every now and then to inject a little warm milk and water between the prepuce and glans penis for the purpose of washing off any matter that may have lodged there, and which, if suffered to remain for any length of time, might produce ulceration. Where phymosis is accompanied with chancres it will he proper to inject mercurials (such as the oxymuriate, in the proportion of one grain to an ounce of water) inside the prepuce. Indeed in most cases of confirmed phymosis, whether congenital or the result of inflammation, the division of the prepuce with a knife appears to be expedient. The surgeon's attention should be directed to the early stage of the complaint, and it should be a general rule to examine the naked glans before entering on a con- stitutional use of mercury, as not only warts and chancres are apt to be formed, but now and then extensive inflammation, terminating in ulceration and sloughing, occasionally takes place. Where ul- ceration is threatened to prevent extravasation and preserve the urethra during healing, great advantage may be derived from the introduction of a small elastic gum catheter. Where erysipelatous inflammation of the penis supervenes either on phymosis, paraphymosis, gv chancre, no preparation of mercury should be employed either internally or externally until this subsides. If a chordee attends on gonorrhoea, rubbing the parts with a strong solution of opium or the tinctura opii, and keeping linen pledgets, dipped in the same, constantly applied (taking care to renew them however as often as they become warm,) wiJl greatly tend to remove both the pain and the spasmodic contraction. The most certain method of preventing this unpleasant symptom is to give the patient an opiate draught at bed-time, consisting of at least fifty or sixty drops of the tincture of opium in one ounce of camphor mixture. ^ In consequence of the inflammation running high, and extending a considerable way up the urethra, a tumour sometimes forms in the perinaeum. In this case we should endeavour to disperse it by means both of general and topical bleedings, but more particularly the latter; by the application of saturnine poultices, such as before mentioned ; by frequently administering laxative medicines, and by making use of a very spare regimen. Rubbing mercurial ointment on the part has been advised in cases of this nature ; but it is sel- dom attended with a good effect. Where the inflammation shows no disposition to remit from adopting these means, but on the contrary seems to proceed with haste to a suppuration, the evacuation of the matter externally should be promoted, to prevent its making sinuous openings into the urethra, and thereby terminating in fistula in perineo, which can only be removed by the proper surgical operation. Sometimes the bladder becomes affected in consequence of the 620 CACHEXIA, OR CACHECTIC DISEASES. [ClttSS HI. inflammation extending to it; in which case the patient is troubled with a frequent inclination to make water without the ability of voiding it, together with pain in the organ itself, and a consider- able degree of tension over the os pubis. To remove this affection it will be necessary to have recourse to general bleedings, copious dilution, and emollient fomentations and clysters, &c. as advised under the head of Ischuria. In some cases of an obstinate sup- pression of urine, and where the endeavour to drawit off has failed, by placing the patient in a warm bath, and bleeding him ad deli- quium animi, the surgeon has been enabled to pass the catheter with great ease. If these means prove unsuccessful, throwing up an enema of an infusion of tobacco (see Ischuria) will sometimes be attended with a decisive effect. The tinctura tabaci administered in a little linseed-tea in doses of thirty drops, repeated twice or thrice a day, has proved an ex- cellent remedy in dysuria arising in gonorrhoea, either from too early an use of astringent injections, or any other cause. It has already been mentioned, that in consequence of the inflam- mation of gonorrhoea extending along the urethra, the mucous membrane of the bladder sometimes becomes thickened, indurated, and ulcerated, so as to occasion it to pour out a considerable quan- tity of muco-purulent matter, which, added to the urine, gives it the appearance of whey ; and, moreover, that there is often a dis- charge of blood also. An obstinate case of this nature came lately under my care, and arose from an imprudent use of strong astrin- gent injections, and an internal one of the tinctura lyttae. The cure of this chronic species of inflammation is to be effected by injecting the bladder with emollient decoctions and oil ;* by the use of uva ursi taken in the dose of a drachm three times a day ; by balsamics ;t and by a regular course of soda water.—See Cystitis. * 10. ft Infus. Sem. Lini, f. 3jv. Tiuct. opii Vinos, f. 3ss. M. ft. Injectio. * 10. Take Infusion of Linseed, five ounces. Vinous Solution of Opium, half a drachm. Mix them for an injection. Vel, j Or, 11. ft Liquor. Calcis, f. ^iv. 11. Take Lime Water, four ounces. 01. Lini Recent, f. 3ij. Liquor. Plumbi Acetat.fll xij. M. t 12. ft Terebinth. Canadensis, Olive Oil, two drachms. Solution of Acetate of Lead, eighteen drops. Mix them. t 12 Take Canada Turpentine, Bals. Copaib. aa f. 3j- Balsam of Copaiba, of each one drachm. White Sugar, half an ounce. Sacchar. Alb. ^ss. Misceanturin mortario. Dein adde paulathn. Aq. Distillat. f. ?viij. Tinct. Opii, nT. xx. M. ft. Emulsio, de quo sumat aeger cochlearia uj. magna ter in die. Let them be well mixed in a mortar, and then add by degrees Distilled Water, eight ouuces. Tincture of Opium, thirty drops. Of this emulsion let the patient take three large spoonsful thrice a day. Order HI.] venereal disease. 02\ The prostate gland as well as the bladder is sometimes affected also in consequence of gonorrhoea, and an inflammation arises in it, which is known by a pain and heat in the perinaeum extending into the rectum, and a frequent desire to make water, without the ability of voiding more than a few drops at a time. To obviate this we should make use of topical bleedings, by the application of several leeches to the perinaeum, together with a warm hip-bath and emollient fomentations and poultices, and we should keep the patient's body open with laxative medicines and clysters. Where there is great pain and irritation we may employ anodynes, both by the mouth and by adding them to the clysters.—See Dysuria. In most cases of urinary irritation the best mode however of exhibiting opium is that of enema. Sixty or eighty drops of the tincture may be administered in thin gruel with a table-spoonful of olive-oil. Occasionally we may introduce opium into the rectum in substance, and formed into a pill containing two or three grains. The extract of hyoscyamus, as also of aconitum, are sometimes employed as substitutes for opium where its preparations confine the bowels ; but if pain be the symptom to which our attention is directed, nothing but opium can be, relied upon. In those deplorable cases where a total suppression of urine arises, and we are unable to draw it off either by a catheter or hol- low bougie of elastic gum, we should puncture the bladder. The most approved method of doing this appears now to be through the rectum.—See Ischuria. > It seldom happens that a hemorrhage of any consequence takes place in gonorrhoea ; but when there does, it is to be suppressed by- injecting sedatives and astringents into the urethra, such as a solution of plumbi superacetas, alum, or zinci sulphas, in rose- water; by the application of pledgets dipped in the same exter- nally, and by keeping the body at rest. Where these means prove insufficient to stop the hemorrhage, we must apply a sufficient pressure. Practitioners who aim at popularity by endeavouring to make hasty cures of gonorrhoea, are much in the habit of employing astringent injections on its first appearance. A frequent conse- quence however of this mode of practice is, that although the dis- Vel, j Or, 13. ft Terebinth. Chiee, gr. iij. 13.Take Cyprus Turpentine, three grains. Saponis Hispanic, gr. v. i Hard Soap, five grains. Pulv. Gentian, q.s. M. Powder of Gentian, a sufficiency Fiant pilulae iij. ter in die sumendrc. to form the mass, out of which let three pills be made, to betaken thrice a day. Vel, Or, 14. ft Extract. Conii, gr. iij. j 14. Take Extract of Hemlock, three -•'■ ■-/.. j grains. Resin. Flava», gr. vj. I Yellow Resin, six grains. Bals. Copaib. q. s. M. j Balsam of Copaiba, a suffi- I ciency. Fiat pilulae iij. omni mane, hora meridi- Divide the whole into three pills, which ana et vespere capienda? dose may be t.yken morning, noon and evening. 622 cachexia, or cacheoic diseases. [Class III. charge is, perhaps, speedily suppressed, the person is soon after- wards attacked with an inflammation and swelling in one or both of the testicles. Such a consequence being observed too frequently to arise from this treatment, it seems proper to notice, that previous to a use of astringent injections, we should take care to remove every inflam- matory symptom whatever by a strict pursuance of the antiphlo- gistic plan ; and that in employing them after we have effected this, we ought to make them only of a moderate degree of astrin- gency at first. During the inflammatory stage it will be most proper to employ those of a sedative nature, as before advised; but on its going off, any of the astringent ones* here recommended may be substituted. An injection of the sulphate of zinc in the proportion of about a grain or two to each ounce of water, though perhaps one of the most active and successful of any we usually recommend, is apt, in persons of an irritable habit, to produce occasionally great pain, an increase of the discharge, and a peculiar liability to swelling of the testicles. Under such circumstances, we are informed by Mr. Henry,t that he was induced to make trial of an injection composed of eight or ten grains of the acetate of zinc, dissolved in t See Medical and Physical Journal, vol. ix. p. 53. 15. ft Zinc. Sulphat. 3j.—3ij. Aq. Rosae, f. |viij. ft. Injectio. Vel, 16. ft Plumbi Superacetat. gr. xv. Zinc. Sulphat. gr. x. Aq. Distillat f. 3viij. M. Vel, 17. ft Aluminis, 3j- Aq. Rosce, f. ?vj. M. Vel, 18. ft Cupri Sulphat. gr. viij. Aq. Fontan. f. ^viij. M. Vel, 19. ft Calamine Praepar. 3jss. Bals. Copaib. f. 3"ij Mucilag. Gum. Acacia;, f. §ij. Aq. Distillat. f. ?vj. M. Vel, 20. ft Bals. Copaib. f. 31J. Mucilag. Gum. Acaciae, f. |ss. Misceantur, simul, et adde Liquor. Calci = . f. -vj. * 15. Take Sulphate of Zinc, from one to two scruples. Rose Water, eight ounces. Mix them for an injection. Or, 16. Take Superacetate of Lead, fifteen grains. Sulphate of Zinc, ten grains. Distilled Water, eight ounces. Mix them. Or, 17. Take Alum, one drachm. Rose Water, six ounces. Mix them. Or, 18. Take Sulphate of Copper, eight grains. Pure Water, eight ounces. Mix them. Or, 19. Take Prepared Calamine, one scru- ple and a half. Balsam of Copaiba, two scruples. Mucilage of Gum Acacia, two ounces. Distilled Water, six ounces. Mix them. Or, 20.TakeBalsam of Copaiba,twodrachms. Mucilage of Gum Acacia, half an ounce. Mix them well together, and add Lime Water, six ounces Order 111.} ve.nereal disease. 623 four or six ounces of water, or of a thin mucilage of quince-seeds, or a decoction of linseed or of barley, the success of which exceeded his expectations, and far surpassed that of any, the use of which he had ever witnessed. The following is one of the methods advised for preparing the acetate of zinc :—To a solution of zinci sulphas in six or eight times its weight in water, add a solution of the acetate of lead in twice its weight in water as long as any precipitation ensues, or a little longer, in order to ensure the complete decomposition of the sulphate of zinc ; throw the whole upon a linen strainer, and wash off the soluble part by repeated affusions of distilled water, then evaporate and crystallize. Some surgeons are much in the habit of employing injections of a mercurial nature; but in recent cases, and during the inflammatory stage of gonorrhoea, they are equally as improper as those of the astringent kind. When the inflammation has somewhat abated, and the discharge still continues in a virulent form, as likewise in those cases where there is reason to suspect that there are ulcera- tions in the urethra, mercurial injections* will be likely to be attended with a very good effect by easing the ardor urinse, lessening the discharge, and shortly removing the complaint altogether. There are a few who totally deny that gonorrhoea has a venereal origin; and there are others again who contend that it is a peculiar species of the venereal disease ; but at the same time they look on it as a local complaint, in which there is no danger of the system becoming affected by an absorption of the matter. They moreover regard it as a disease which will be sure to wear itself out, and at last effect its own cure, and therefore they neglect giving any medicine with the view of counteracting or destroying the syphilitic virus. The impropriety of proceeding in this manner, and the many injurious consequences which frequently result from it, must be too apparent to require my dwelling on them. Expe- rience must have convinced the prudent surgeon, that in order to guard against any disagreeable consequences, and ensure a perfect * 21. ft Hydrarg. Oxymuriat. gr. ij. Solv. in Spirit. Rectif. f. 3ij. et adde Aq. Distillat. f. ^viij. Ammon. Mnriat. gr. vj. M Vel, 22 ft Mucilag. Gum. Acacia;, f. ?ij. Hydrargyr. Submur. 3j. Terantur simul in raortario, et adde * 21. Take Oxymuriate of Mercury, two grains. Dissolve it in Rectified Spirit, two drachms. adde ! And add Aq. Distillat. f. ^viij. Distilled Water, eight ounces. Muriate ofAmmonia, six grains. Mix them. Or, 22. Take Mucilage of Gum Acacia, two ounces. Submuriate of Mercury, one scruple. Let them be rubbed together in a mortar, and add \q. Calcis, f. ,^vj. Lime Water, six ounce*. t>24 >*• cachexia:, or cacukctic maEASta. [Class III. cure, it will be advisable, in most cases of gonorrhoea, to make use of a proper quantity of mercury, in some shape or other. In making this observation, I by no means wish to infer. however, that a clap can in no instance effectually be removed without mercury. In those cases where the disease is recent and perfectly mild, and where neither excoriation nor ulceration has taken place, it probably may continue a local affection, and at last effect its own cure ; but as we cannot discriminate those eases in which the matter will not be absorbed into the system, from those in which it will, it appears to be the safest and most advisable plan to have recourse to mercury in all severe cases of gonorrhoea, as by so doing wo shall guard against any unpleasant consequences, which, whenever they ensue from neglect, will be sure to hurt the practitioner in the esteem of his patient. As soon, therefore, as we can procure an abatement of the in- flammatory symptoms, we may begin with a use of mercury, as well as of astringent injections, regulating the dose according to the effect it produces. If we give the pilula hydrargyri, in pre- ference to any other preparation of this medicine, we may begin with one, consisting of aboutsfive grains every night, which is to be continued until either a coppery taste is perceived in the mouth, or the gums become slightly affected. On the event of either of these, the pill is to be taken only every second or third night, which will be sufficient to saturate the system, and effectually destroy the syphilitic virus. If the pilula hydrargyri occasions a purging, we may substitute one composed of a combination of the submuriate of mercury and opium,* or of the hydrargyri oxydum rubrum,t as advised here, or directed in the treatment of confirmed lues. If these likewise purge, we must then have recourse to mercurial ointment, half a drachm of the strongest kind of which should be rubbed into the^r hams and groins every night, till the mouth becomes affected in! either of the ways before mentioned. Whatever preparation of / mercury we may employ, it ought by all means to be continued for some short time after the disappearance of every symptom, during the whole of which period the patient is cautiously to avoid any exposure to cold. 23. ft Hydrargyr. Submur. , * 23. Take Submuriate of Mercury, Camphora;, aa3j. Camphor, of each one scruple Opii, gr. xij. ■Syrup, q.s. M. Fiant pilul. xx. quarum j. vel ij. sumat mane et nocte quotidie. 124. ft Hydrargyr. Oxydi rubri, 3ss. Opii, gr. v. Extract. Cascaril. 3j. Syrup, q. s. M. Fiantpilul; xij. capiat j. vel ij. bis in die. Opium, twelve grains. Syrup, a sufficiency. Let twenty pills be made out of the mass, of which one or two may be taken every morning and night \ 24. Take Red Oxyd of Mercury, half a? scruple. Opium, five grains. Extract of Cascarilla,one scruple Syrup, a sufficiency. Mix them, and form them into twelve pilR i Order III.J venereal disease. ti2o In the Contributions of Medical Knowledge, published by Dr. Beddoes, there is a curious paper by Mr. Addington, of West Bromwich, on the cure of gonorrhoea virulenta, by large doses of the oxymuriate of mercury. Three grains of this are dissolved in an ounce of rectified spirit of wine; half of this solution is taken undiluted at going to bed ; it produces a copious salivation for an hour and a half, or longer, during which the patient spits a quart. Some aperient salts are to be taken on the second day after this operation, and on the evening of that day he is to repeat the draught, and the salts on the day but one following. Mr. Addington witnessed that three or four doses frequently removed a venereal gonorrhoea in a few days, without any disagreeable consequence, and was informed that hundreds have been cured by it. It will be difficult to account for the action of this medicine in any other way, than by supposing it to be owing to the consent of parts between the throat and the urethra. Upon the plan of diminishing the irritability of the system, as well as of the parts particularly affected, opium has been much used in gonorrhoea, not only by injecting a watery solution of it frequently up the urethra, throughout the course of the day, but likewise by giving it by the mouth every night towards bed-time. This practice is certainly attended with very good effects, and ought therefore to be adopted more generally than it is. In consequence of a sympathy of the parts affected, or the having imprudently used any severe exercise, or had too early recourse to strong astringent injections, it sometimes happens that inflammation and swelling attack one of the testicles, showing them- selves at first by a similar affection of the spermatic vessels and epididymis. In these cases we must rigidly pursue an antiphlogistic mode of treatment, by bleeding from the system, where an inflam- matory diathesis seems to prevail, and by topical bleeding by means of several leeches where it does not; besides which, we should give the patient a brisk purge* every third or fourth day, and confine him to a very spare regimen, and to a recumbent posture. To abate the swelling and inflammation, the parts may be bathed several times a day with some discutient and refrigerant lotion,! and afterwards be covered with small pledgets dipped in * 25. ft Pulv. Jalaps, 3ss. Hydrargyr. Submuriat. gr. v. M, ft. Pulvis. * 25. Take Powder of Jalap, half a drachm. Submuriate of Mercury, five grains. Mix them for a dose. t 26. ft Ammon. Muriat. 3u- 126. Take Muriate of Ammonia, 2 drachms. Acid. Acetic, f. ?ij. Distilled Vinegar, two ounces. Spirit. Camphorae, f. ^j. Camphorated Spirit, one ounce. Liquor. Plumbi Acet." f. 3ss- M. ( Solution of Acetate of Lead, half a drachm. ft. Lotio. Mix them for a lotion. SO 626 cachexia, or cachectic diseases. [Class III. the same, which are to be renewed as often as they become dry, of warm. By night a poultice of linseed or rye-meal, moistened with a solution of the plumbi superacetas, may be kept to the part; but it is also to be applied cold ; and in order that the testicles may not at any time hang by their own weight, the scrotum should be supported by a suspensory bandage. During the continuance of the inflammation and swelling, it will be advisable to omit the use of mercury, and to employ in its stead cooling medicines, such as the nitrate of potass ;* and in order to allay irritation, we should give an opiate every night at bed-time. Emetics have been much administered in inflammation of the testicle, but they seem to afford most relief in those cases where the swelling is unaccompanied by any hardness. Indeed, so powerful is the effect of emetics in some cases of swelled testicle, that they have been frequently found efficacious, when the re- peated application of leeches, purgatives, and discutient lotions have failed. The cupri sulphas may be employed as advised under the head of Phthisis, when we judge vomiting to be proper, or we may give tartarized antimony twice a day in such doses as to produce some degree of vomiting. Where a hardness remains after the inflammation and swelling have subsided, poultices of hemlock, and its use internally joined with the cinchona bark, together with the application of mercurial unction every night, will be the most likely remedies to remove it. Almost every case of inflamed testicle will terminate favourably, Vel, 27. ft Liquor. Ammon. Acetat. Spirit. Rectif. Aq. Distillat. aaf. |ij. M. Vel, 28. ft Plumbi Superacet. 3ss. Aq. Rosae, f. ^iv. Tinct. Opii, f. 3y. M. * 29. ft Potassae Subcarbonat. 3j. Suce. Limon. f. ^ss. Aq. Fontan. f. |j. Potassae Nitrat. gr. xv. Liquor. Antimon. Tart. HI x. Syrup. Simpl. f. 3ij. M. ft. Haustus, ter de die sumendus. Vel, 30. ft Potassos Supertart. 3"j- Nitrat. 3'j- M. et in dos. x. divid. quarum unam sumat ter quatevve in die. Or, 27. Take Solution of Acetate of Am- monia, Rectified Spirit, Distilled Water, of each two ounces. 28. Or, Take Superacetate of Lead, half a drachm. Rose Water, four ounces. Tincture of Opium, two drachms. * 29. Take Subcarbonate of Potass, one scruple. Lemon Juice, half an ounce. Pure Water, one ounce. Nitrate of Potass, fifteen grains. Solution of Tartarized Antimony, sixteen drops. Syrup, two drachms. Mix them for a draught, to be taken thrice a day. Or, 30. Take Supertartrate of Potass, three drachms. Nitrate of the same, two drachms. Mix them, and divide the whole into ten doses, of which let one be taken three or four times a day. Order III.J venereal disease. 627 by paying proper attention to this plan; but when, either from im- proper treatment, neglect, or any untoward circumstance, a sup- puration has ensued, the matter must be discharged by making an opening into the most dependant part of the abscess, and the re- mainder of the treatment must be the same as in collections of pus in other parts of the body. The matter discharged in gonorrhoea, being in some instances of an acrid and virulent nature, is apt, by lodging between the prepuce and glans penis in men, and on the labia pudendi in women, to occasion an excoriation and ulceration in these parts. To prevent such consequences, it will be right to pay strict atten- tion to cleanliness, by washing them at least twice a day. When they take place, we must employ lotions* of plumbi superacetas, or the liquor plumbi acetatis, sufficiently diluted with water, sus- pending the penis at the same time to the abdomen, by means of a proper bandage. Warty excrescences now and then appear about the external organs of generation in both sexes, as a consequence of gonorrhoea and chancres. They are of various sizes, appearance, and con- sistence, adhering sometimes by a narrow base and sometimes by a broad one. Wherever a ligature cannot be applied round them, from the broadness of their base, or their being very numerous, they may either be touched with caustic, or be destroyed by the frequent application of other stimulants, such as acetic acid— (see Lues,) a solution of the oxymuriate of mercury, ammonia muriata, or savine powder. This last has been found to succeed when all the other usual remedies have failed. It acts by pro- ducing a considerable discharge from the surface, by which the excrescence is gradually wasted without causing an eschar like a caustic application. Moreover, it gives little or no pain, and is never productive of inflammation, which not unfrequently follows the use of either a solution of the oxymuriate of mercury, or pure potass, or any of the potent caustics. In consequence of inflammation, certain parts of the urethra are apt to become contracted, and to occasion strictures, which cause the urine, instead of flowing in a free and direct stream, to split into two, or to be voided drop by drop. So constant is inflammation the forerunner of stricture, that it may be held a point as well es- tablished by evidence, that the origin of all strictures in the urethra is in consequence of inflammation, as, that adhesions of the pleura are produced by it. In what is termed spasmodic stricture, it has well been ascertained that the spasm is not in the stricture itself, but it is a spasmodic action of the muscles surrounding the urethra. The most usual way to remove strictures is, by a regular and long- * 31. ft Spirit. Camphorae, f. 3jj. #31. Take Camphorated Spirit, two Liquor. Plumbi Acet. ft. 3j. drachms, Solution of Acetate of Lead, one drachm. Aquae Distillat. Oj. M. Distilled Water, one pint. ft. Lotio. Mix them for a lotion* 628 cachexia, or cachectic diseases. [Class III, continued use of a bougie; and if made of the elastic gum, bent like a catheter, will be preferable to those in common use. Were all such as are afflicted with these complaints not to neglect this remedy, we should seldom, if ever, meet with those dreadful cases of suppressed urine which occur in practice. In making use of bougies, it will, however, be necessary to attend to the following rules :— 1st, To begin with one of a moderate size, and so to increase it very gradually; but previous to its introduction, if made of wax and oil, as those in common use are, I would recommend it to be held near a fire for a short time, so as to soften it, and then to bend it, in the shape of a catheter, so as to adapt it to the curvature of the urethra, by which means its passage will be greatly facilitated. 2dly, To employ no force in introducing it; but where we meet with great resistance, to be content with merely suffering its point to press against the stricture for a short time each day, with the hope that by a perseverance in this plan a dilatation of the con- tracted part may at last be effected. j* 3dly, To wear it at first only for about half an hour, gradually^ increasing the time as the parts can bear it without irritation. 4thly, Never to pass it into the bladder, except at first to ascer- tain the extent of the disease, but merely to carry its point some small distance beyond the stricture or strictures. 5thly, To guard against its slipping into the bladder, by bending its end, and tying it with a cotton thread fastened to the penis. 6thly, To avoid all exercise during its introduction ; and, 7thly, To continue its use for a considerable length of time after the disappearance of the stricture, and again to have recourse to it on the least return of obstruction. English surgeons almost invariably adopt these prudent and cautious rules in the treatment of strictures, whereas those of France seem to consider stricture as a disease to be cured by main force, the gum elastic bougie or the conical catheter* being the only means employed by them for its removal; when the case admits of either of these instruments being made to reach the bladder. In those cases where a bougie even of the smallest size cannot be passed, as likewise in those which are of such long standing as to preclude the hope of perfect recovery from its use, it has been proposed to make use of caustic. This was first advised by the late Mr. John Hunter, and since his time has been much urged by Sir Everard Home. It appears from the report of this gentleman, that Mr. Hunter, fully sensible of the many inconveniencies which attended the application of caustic to strictures in the urethra, hy means of a canula, as at first practised, had for some years previous to his death adopted a more improved mode of applying it; and that he himself has continued to make use of it ever since, without * See Sketches of the Medical Schools of Paris, p. Ill, by Mr. Cross, Order III.J venereal disease. 629 having ever found it (as we are informed) to be attended with dis- advantage. This improved mode of applying the caustic is thus managed: take a bougie, of a size that can readily be passed down to the stricture, and insert a small piece of lunar caustic into the end of it, letting the caustic be even with the surface. This should be done some little time before it is required to be used ; for the mate- rials of which the bougie is composed become warm and soft by being handled in inserting the caustic ; and therefore the hold the bougie has of the caustic is rendered more secure after it has been allowed to cool and harden. This bougie, so prepared, is to be oiled and made ready for use; but previous to passing it, a common bougie of the same size is to be introduced down to the stricture to clear the canal, and to measure exactly the distance of the stricture, from the external orifice; this distance being marked upon the armed bougie, it is to be passed down the stricture immediately upon withdrawing the other. When it is found in contact with the obstruction, it is to be steadily retained there, with a moderate degree of pressure at first, and less as it is longer continued, since the bougie becomes soft by remaining in the urethra, and readily bends if* the pressure is too great. The time it is to remain must depend a good deal upon the sensations of the patient, and the length of time the parts have been diseased; but on the first trial, it should not be for more than a minute, as it then gives greater pain than on any future application. The pain produced by the caustic is not felt so immediately as it would be natural to expect: the first sensation arises from the pressure of the bougie on the stricture, a little after there is the feeling of heat, and then the parts become painful. As soon as the caustic begins to act, the surgeon who applies it is made sensible of it by the smaller arteries of the parts beating with unusual violence, which is very distinctly felt by the finger and thumb that grasp the penis. After the caustic has been withdrawn, it is desirable that the patient should make water, as in that way any of the remains of the dissolved caustic are washed off: but it sometimes happens that no water will flow at the first effort. When that is the case, it should not be urged, as it is not of any great consequence. It happens not unfrequently, that at the first time of making water some blood passes along with it; this is also of no bad consequence, but is rather favourable ; as when it has occurred, the stricture usually proves to be so far destroyed, that at the next trial the bougie passes on to the bladder. Every other day appears, in general, to be as often as it is prudent to apply the caustic. By this mode of arming the bougie, strictures in the membranous part of the urethra may have caustic applied to them, vvhich cannot 630 cachexia:, or cachectic diseases. [Class III. be done by a silver catheter, unless made flexible, and even in that state it is liable to many objections. It appears that Mr. Hunter made use of caustic only in cases of impervious stricture ; but Sir Everard Home, from a number of facts, thinks it established as a general principle, that the irritable state of a stricture is kept up, and even increased, by a use of the bougie, but lessened and entirely destroyed by the application of lunar caustic : hence he recommends the use of the caustic in many cases likewise of spasmodic stricture, in preference to the bougie. In speaking of the comparative effects of the bougie and caustic, he observes, that from what he has seen, he thinks he may safely infer, that the caustic is a mode of cure more extensively useful, milder, quicker, more effectual, and more permanent than the bougie. So general and indiscriminate a use of caustic as is here recommended by Sir Everard Home, appears to me to be injudi- cious, and likely, in many instances, to be productive of injurious effects. No doubt the caustic bougie may be, and often is, applied to strictures without exciting any particular inconvenience or trouble, but still the application of so active a remedy to so delicate an organ, will sometimes give rise to disagreeable symptoms; and accordingly, during the employment of it, various circumstances will frequently occur to embarrass, or even disappoint our hopes of a cure. Most commonly the pain excited is not very acute, but occasionally it is severe, owing to a degree of inflammation and tenderness of the urethra at the time the caustic is applied. The best means to remove any unpleasant symptoms will be a light diet, rest, opiates, injections, cooling laxatives, and the warm bath. Should a suppression of urine be the consequence of the application of the caustic, the same means ought to be resorted to. Should a swelling of the testicles arise, it will be proper to desist from the remedy, and to employ the usual means for reducing this affection, such as topical bleeding with several leeches, rest, an antiphlogistic regimen, cooling laxatives, and saturnine applica- tions, with a suspension of the parts. But one of the most trouble- some circumstances attending the employment of caustic for the cure of strictures, and which is apt more or less to embarrass the surgeon, and to alarm the patient, is a profuse haemorrhage. The quantity of blood lost is sometimes very considerable, and the haemorrhage may return from time to time, for several days. Nothing, however, is to be apprehended from the quantity lost, except a temporary faintness and debility. To check its profuse- ness, we may employ cold applications, rest, internal astringents, and laxatives. Gentle pressure in the perinaeum will frequently put a stop to the discharge, and in severe cases we can use some slight styptic injection, such as a solution of alum, or the sulphate of zinc. Where a paroxysm of fever attends the application of the caustic bougie, and the patient is seized with rigors, succeeded by heat Order III.J VENEREAL disease. 631 and profuse sweating, as now and then occurs, the only treatment necessary is the administration of a smart purge, followed perhaps by a full dose of opium, and exciting and keeping up a free per- spiration by the use of warm diluent drinks. In very irritable habits, it might probably be a good plan to give a full dose of opium an hour or so previous to die application of caustic to the strictured parts. The practice of applying caustic should, I think, be confined to such strictures of the urethra as are either utterly impervious, or so contracted as to be incapable of dilatation by the common or gum bougie ; for the urethra, even in its healthy state, being tender and irritable, and connected with parts of great importance in the system, all violent remedies ought to be applied to it with the greatest caution. The invariable rule to be followed, should be to endeavour to dilate all strictures by means of an elastic gum or common bougie, before any attempt is made to effect their removal with caustic. The bougie armed with caustic should be kept as a remedy of reserve to be employed in those more difficult and complicated cases in which the former has faileck or to which it is inapplicable. It must, however, be admitted, that the dilatation effected by the unarmed bougie is seldom more than a temporary cure, particular- ly in strictures of long standing; for although the passage may be dilated sufficiently for the urine to pass, yet there remains the original tendency for contraction, which generally returns sooner or later on any exposure to cold or act of intemperance. Two other methods of applying caustic to strictures in the urethra, where such an application seems necessary, have been proposed, the one by Mr. Cartwright, and the other by Mr. Whately, and these were fully noticed in the first edition of this work; but as, after a fair trial, they have been found to possess no superior advan- tages over the method recommended by Sir Everard Home, and are more complicate, I have thought it unnecessary to give a par- ticular detail of them here. In the second tract more lately published by Mr. Whately on strictures in the urethra, he tells us that he has discovered a more efficacious, and at the same time a less hazardous and painful reme- dy for the disease in question than lunar caustic. It is the potassa fusa; and with this he directs a bougie to be properly armed, but much in the same manner as recommended by Sir Everard Home. This innovation has not, however, been looked upon by the best surgeons as an improvement; for whatever tends to weaken the action of the caustic, will at the same time destroy or lessen its effects on the stricture. It has been considered by one or two practitioners as an impor- tant distinction between the use of the potassa fusa and of the argenti nitras, that a certain lubricity is given to the urethra by the solution of the first forming a soap with the secretions, so as readily to admit the bougie into the narrow part of the canal; whereas the 632 cachexia, or cachectic diseases. [Class HL argenti nitra coagulates the secretions, and when it has been applied to a stricture with the intention of burning it, and acting as a caustic, the part touched by it becomes dead, rough, and no lon- ger smooth and lubricated. A new method of treating strictures in all parts, but more parti- cularly those in the urethra, has been recommended by a late writer, which is by distending this during the operation with a liquid injected through the catheter from a bag attached to its outer extremity. The instrument he* has called a dilator, and it consists of oiled silk lined with the thin gut of some animal (that of the cat being thought preferable on account of its thinness and strength,) to make it air tight, and then attached upon the extremity of a small canula, by which it is distended with water or air from a bag or syringe at the outer end with a stop-cock or valve to keep in the air when received. Caruncles and excrescences in the urethra sometimes arise as a consequence of gonorrhoea, but they are usually situated towards its extremity, and never any length within it. They are to be re- moved by the bougie and caustic, as well as strictures. Where—a spasmodic constriction of the urinary passage ensues in gonorrhoea, (which is known by its suddenly taking place without any previous appearance of interruption, and its being as suddenly removed,) we must have recourse to emollient applications, such as fomenting with flannel cloths wrung out in a warm infusion of chamomile flowers and bruised poppy heads, and rubbing the penis with tinctura opii and aether combined. Where these fail, a warm bath, together with the internal use of opium, in considerable doses, by the mouth, as well as in clysters, must be employed. A combi- nation of the submuriate of mercury with opium has been attended with a very happy effect in many cases of a retention of urine in gonorrhoea from spasmodic strictures in the urethra. Two grains of the former, with one of the latter, may be given every second hour for six hours, unless the desired effect is produced sooner. To prevent any return of the complaint, a pill of the same nature may be continued night and morning for a few days. In suppressions of urine arising from spasm, it is observed, under the head of Ischuria, that the profession is indebted to Mr. Cline for the discovery of a very efficacious remedy. This is the tinctura ferri muriatis, which we are instructed to give in doses of ten drops, repeated every ten minutes, until some sensible effect is produced. After six doses the urine usually flows freely, the patient previously becoming a little sick and faint. If we are foiled in overcoming the spasmodic contraction by these means, we may endeavour to introduce an elastic gum ca- theter, but no violence should be used in passing it. In spasmodic stricture, where the irritability of the urethra is so considerable as to forbid the introduction of a common bougie, *See Treatise on Strictures, by Mr. James Arnott, p. 73. Order 111.] venereal disease; 633 this may be readily lessened by touching the point of the instru- ment slightly with liquor potassae, after it has been oiled and is ready for introduction. The effect of potass employed in this manner upon an irritable urethra is often astonishing, and a full- sized bougie may be thus easily got into the bladder, which had been previously regarded as impracticable. The enema nicotianas* has proved eminently useful in many Cases of suppressed urine arising from spasm, where all other means have failed : the effect is often powerful and decided; the patient becomes faint and sick, the pulse sinks, his whole body is bathed in perspiration, and in a few minutes the urine will often flow in a moderate stream. In consequence of the repeated attacks of a gonorrhoea, and the debility of the parts occasioned thereby, it not unfrequently happens that a gleet or small discharge remains behind, after all danger of infection has ceased. In recent cases, the disease may in general easily be removed; but in those of long standing, where the mucous glands have suffered much relaxation, or where there is either a stricture or callosity, it may continue for life in spite of e\ir best endeavours to cure it, having, however, certain intervals* This is, nevertheless, to be attempted by a frequent use of astrin- gent injections, and even by those of a stimulant nature, as acrid solutions of ammonia muriata, mercury, verdigris, balsam of copaiba, &c.t employing the last class more seldom, 'however, than the former; as likewise by forming an issue, or putting a seton in or near the perinaenm, thereby diverting the discharge elsewhere. Besides* using injections, we may employ remedies internally4 To give vigour to the whole system, and restore the * 32. ft Fol. Nicotian. 3ss__3j. Aq. Bollient, f. ^xj. Col. post semihoram. ft. Enema. k 33. ft Hydrargyr. Oxymutfat. gr. ij-. Ammon. Muriat. gr. x. Aq. Distillat. f. |x. M. ft. Infect. I'd, 3.4. ft Bals. Copaib. f. 3ij. Mucilag. Gum. Acacias, f. jj. ■Mis.cfiant.ur in mortario, et adde Liquor. Calcis, f. ?v. Tinct. Lyttae, fit viij. M. ft. Inject. + 35. ft Bals. Copaib. Cochl. min. bis tetve in die paux. sacch. albi. Vel, 3.6. ft Terebinth. Canadensis, f. 3>j. Hy.drargyr. Su^;mmat= 3j. * 32. Take Leaf Tobacco, half a drachjtt to one drachm. Boiling Water, eleven ounces. Infuse them for half an hour, and strain off the liquor for a clyster. ;t 33. Take Oxymuriate of Mercury, two grains. Muriate of Ammonia, ten grains? Distilled Water, te"n ounces. Mix them for an injection. Or, 34. Take Balsam of Copaiba,'two drachm?? Mucilage of Gum Acacia, one ounce. Mix them in a morlar^ And add Lime Water, five ounces. Tincture of Spanish Fly, tweXrfi drops. To be used as an injection. | 35. Take Balsam of Copaiba, a small tea-spoonful twice or thrice a day, upon white sugar. Or, 36. Take Balsam of Canada,twO drachma Submuriate of Mercury, one scrupTe. 81 634 CACHEXIA', OR CACHECHC DISEASES. [G7tf3S ]//„ tone of the parts at the same time, the patient should enter on a course of chalybeates, as advised under the head of Dyspepsia, assisted by cold bathing, country air, and a restorative diet. The tinctura ferri muriatis, when steadily employed, frequently produces very permanent benefit in gleets. From twenty to thirty drops may be given for a dose thrice a day in an ounce of the de- coctum cinchonas. No remedy proves more efficacious, however, than the prudent administration of cantharides.* In every case where the disease is obstinate and stricture sus- pected, the introduction of a bougie will be proper to ascertain it; and when satisfied as to its real existence, we ought to advise a perseverance in the use of bougies. The caustic in the manned < practised by Sir Everard Home may be resorted to as the finsfl • resource, should these not prove effectual. CHANCRES. The second local form under which the syphilitic poison hag been mentioned to phow itself, is that of a chancre: this is distin- guished by a want of disposition to heal, a thickened base and cir- cumscribed inflammation, with other characteristic marks already noticed. The parts most apt to be affected with these ulcerations in men, are the prepuce, the fraenum, at the orifice of the urethra, and in the angle between the glands and body of the penis; and in women, ;,* about the labia, nymphae, and clitoris ; but in some instances they have extended into the vagina, and even so far up as the os uteri- Syphilitic matter, by being applied to other parts of the body covered with a mucous membrane, such as the lips, nostrils, &c. may give rise to chancres there also; but being most usually applied to the organs of generation, in consequence of an intercourse be- tween the sexes, these are generally the seat of such ulcers. A chancre makes it appearance either with a slight inflamma- tion, which afterwards ulcerates ; or there arises a small pimple or *■' pustule filled with a transparent fluid, which soon breaks and forms into a spreading ulcer. The period at which it makes its appear- ance after infection is very various, being most commonly in five or six days, hut in some cases not till after the expiration of as many weeks. Polv. Cinchon. 3j. M." Fiant pilul. xl. Capiat iij. vel iv, mane et vespere. Vel 37. ft Zinc. Sulphat. 3j. Pulv. Rhei, 3j. Terebinth. Chias, q. s. M. Fiant pilulae xx. quarum j. vel ij. sumat mane et nocte. * 38. ft Tinct. Lytta, f. fi. Sil dosls 1TI xvj. ter die ex qiftvls vehi- £ulo. Powder of Peruvian Baric, cine drachm. Mix them, and form the masjs into forty pills, of which three or four may be taken morning and evening. Or, 37. Take Sulphate of Zinc, one drachm. Powder of Rhubarb, one scruple* Cyprus Turpentine, a sufficiency to form the mass. Divide this into twenty pills, whereof let one or two be taken morning and night. * 38. Take Tincture of Spanish Fly, one ounce. The dose may be twenty-four drops fhrice a dav, in anv vehicle. Order Hl.J YEiTJtEAL DISEASE. 635 As there is always a risk that an absorption of matter may take place from a chancre, and possibly very speedily, it will not only be necessary to attend to the ulcer, but likewise to secure the con- stitution by a use of such remedies as are well known to possess (he power of counteracting the syphilitic poison. In cases of a very recent nature, chancres may often be removed hy the application of caustic, or by washing them with a weak so- lution of hydrargyri oxymurias in rectified spirit diluted; but where they are extensive, and have been of some standing, it will he necessary to dress them daily with ointments composed of hy- drargyri nitrico oxydum, or the submuriate of mercury spread upon fine lint. When much pain and irritation prevail, opiates will have a good effect. In some cases of obstinate chancres of an inveterate and corro- ding nature, which have not benefited by the dressings just advised, much advantage has been derived from the application of a poul- tice composed of the inner soft part of a loaf of wheaten bread, moistened with a solution of the sulphate of soda in boiling water, in the proportion of one ounce of the former to four pounds of the latter. To give chancres a disposition to heal kindly, it will be highly necessary to attend strictly to cleanliness. Mr. John Hunter, in his Treatise on the Venereal Disease, seems however to have thought this unnecessary; for he says he is inclined to believe that no matter of whatever kind can produce any effect on the part that formed it; neither can the matter of any sore, let it be what it will, ever do hurt to that sore ; and from thence he draws the con- clusion, that the wiping or washing away matter under the idea of keeping the parts clean is in every case absurd. Where chancres exist along with phymosis, the cure will be both tedious and uncertain, and cannot often be effected by simply throwing up injections of a cleansing nature from time to time be- tween the prepuce and glans. The more certain method will be, to make an incision through the former, or to perform the opera- tion of circumcision. Chancres sometimes appear on the nipples of women who suckle infected children, and excite much pain. To lessen the irritability of the parts that are diseased, it will be proper to bathe the ulcers twice or thrice a day with a strong solution of opium in water, and afterwards to dress them with the unguentum cetacei, to which a proper quantity of hydrargyri submurias has been added. Besides topical applications, it will be necessary to secure the constitution from becoming affected at some after-period, in con- sequence of an absorption of the matter from the ulcers, by having recourse to mercury, which must be used either externally or in- ternally, as shall be found most suitable to the constitution and convenience of the patient. In employing it, we are, however, to avoid exciting any degree of salivation, and therefore we are to introduce it gradually into the system, carefully watching its effects. The length of time it ought to be used will depend on G46 CACHEXI/B, OR CACHECTIC DISEASES.. [ClaSS Jll% the virulence of the disease and other accidental circumstances: but at any rate we should never totally desist from its use until the expiration of several days after the disappearance of the ulcers. Where erysipelatous inflammation of the penis supervenes to chancre, mercury should neither be exhibited internally or be used externally in any form whatever, until it has subsided. In consequence of the irritation of venereal virus in a debilitated constitution, aggravated perhaps by an excessive or injudicious ex- hibition of mercury, more particularly in a crowded hospital, it not unfrequently happens that chancres become phagedenic. They commence with a livid redness of the part, succeeded speedily by vesication and ulceration, which extends laterally, and sometimes penetrates deeply. The ulcer has a corroding appearance, is highly painful, discharges a great quantity of matter, and is often attended with fever. In all such cases stimuli would be injurious, and when used have been known to re-excite the morbid actions of the sore in such a degree as to occasion the death of the patient; mercury must therefore be omitted. The ulcerated parts should be well fomented morning and even- ing with flannel cloths wrung out in a decoction of bruised poppy- heads and the powder bark of cinchona, and afterwards be covered with an emollient poultice mixed with carbon. (See Gangrene.) Internally we may give opium freely, and at stated intervals, as likewise some light preparation of cinchona bark joined with sarsaparilla and a mineral acid. Wine in moderate quantities will also be proper. The patient, if in a hospital, should be re-r ,moved to a purer atmosphere. A peculiar eruptive disease arising from the exhibition of mer- cury, has lately attracted the attention of some practitioners in Ire- land ;* and although of frequent occurrence, no doubt, in the Lon- don hospitals, it docs not appear to have been particularly noticed by any surgeon belonging thereto, except by Mr. Pearson.t Mr. Benjamin Belt, indeed, in his Treatise on the Venereal Disease, very accurately describes it,J although, from the manner in which he speaks of it, the cases he had seen could not have been of a severe nature. The disease is generally supposed to be produced by exposure to -cold while the system is under the influence of mercury ; yet, a$ its occurrence is infinitely too rare to be the necessary conse- quence of so common a cause, probably a peculiar idiosyncrasy or unknown state of the constitution of the person affected, may he necessary for its production. It seems nearly allied to the ge- nus erysipelas, and has by some been named the erythema me.r- curiale. This complaint sometimes shows itself by a heat and itching about the scrotum, and the upper and inner parts of the thighs, * See a Description of the Mercurial Lepra, by Dr. Moriarty ; and an Essay o;u a peculiar Eruptive Disease arising from the use of Mercury, by George Alley. i See Observations on the cure of Lues Venerea. ± See his Treatise on Gonorrtwsa Virulenta and Lues Venerea, vol. 'ii. p. 2Jft.. Order III.} venereal diseasj!, GJ3i7 which on examination appear faintly red, and are somewhat rough. On other occasions, the heat, redness, and roughness, are first to he observed in the groins, and at the bend of the arms. In most cases the anterior parts of the • body are affected before the posterior, and the lower extremities suffer prior to its appearance on the trunk of the body; yet there is not so much of constancy and regularity in the order in which it proceeds, that the upper extremities are not occasionally attacked as early as the thighs. The redness beginning on the extremities makes a slow and gra- dual progress over the whole body, no part being exempted from it. Its increase is attended with great tenderness of the skin, a troublesome itching, and an evident tumefaction of the parts affected. The swelling is not unlike that which attends erysipelas, and it has been as considerable as that which accompanies the small-pox. The temperature of the skin is increased, the tongue is white, and the pulse frequent; but neither the functions of the stomach, nor of the sensorium commune, are evidently disturbed by this complaint. The lepra mercurialis is always a vesicular disease, although the vesicles, which contain a pellucid fluid, are, at their first appear- ance, so small that they cannot easily be distinguished from papulse without the aid of a convex glass: they are then seen to be dis- tinct, each vesicle surrounded by a circle of redness ; and if they are not ruptured at an early period, they acquire the size of a large pin's head, at which time the contents are opaque. The rupture of the vesicle is succeeded by the discharge of a thin acrid. fluid that irritates the surface which it touches, and greatly in- creases the patient's sufferings, and as the disease proceeds, he> is excoriated almost from head to foot. The quantity of the discharge is in proportion to the extent of the excoriated surface; it is always considerable, and renders the linen which absorbs it- stiff and unyielding. As the fluid discharged becomes thicker and more adhesive, it emits an offensive scent similar to that which arises from the secretions of the sebaceous glands when under the influence of the disease. The lepra mercurialis does not invade the whole surface of the body at once, but occupies the different parts of it successively, so the several portions of the skin affected by it exhibit a more or less advanced state of the disease at the same time : hence whilo the part first attacked is discharging the adhesive matter, the thin acrid fluid may be flowing from another portion. From this repre- sentation it must be obvious that the exact period observed by this disease cannot be easily ascertained ; nor indeed does it appear to be limited by any regular term of duration. When it has affected but a small part of the body it often terminates in ten or twelve days; but when it has been universal, the patient seldom recovers completely in less than six, eight, or ten weeks. When the discharge ceases, the loosened cuticle acquires first a pale brown colour, and then becomes nearly black,'separating in large flakes, and leaving a faint redness on the exposed surface- 63§ CACHEXIA, OR CACHECTIC DISEASE?. [CiasS llU The first desquamation is often succeeded by a second, or even a Uurd; but in these latter desquamations the cuticle is more of a white colour, and separates in farinaceous-like scales, so that the surface of the skin appears as if it were covered with a white powder. The effects of the lepra mercurialis are not, however, confined to the destruction of the epidermis. All the hair of the body, the beard, the hair under the axillae, and on the regio pubis, and the greater part of the eyebrows, and hair of the head, have been known to separate, and leave the parts as smooth as in a state- ef infancy. The disease ceases after a time, but it is doubtful whe- ther any remedies have the power of interrupting its regular course, or of abridging its duration. » The mode of treatment however which has been recommended consists in desisting from the further use of mercury, and in em- ploying such remedies as will serve to support the patient without increasing fever, and such topical applications as may lessen the irritation arising from the perpetual loss of skin. Keeping the bowels open with saline purges; exciting a gentle determination to the surface of the body by diaphoretics; allaying irritation by means of an opiate at night; and frequent warm bathing, will be proper in most cases. Where the disease assumes a putrid type, the bark of cinchona, with wine and some of the mineral acids, may be necessary. Starch powder, meal, or flour, will be the best topical applications. The use of saturnine applications to so large an exposed surface might be injurious. A case which is recorded in the 18th Number of the Edinburgh Medical and Surgical Journal, by Dr. flutter, of Liverpool, evi- dently shows, however, that mercury does not appear to be the sole cause of erythema in a high degree, for an eruption exactly of a similar nature took place when his patient had neither taken or used in any manner whatever a single particle of mercury. We have hitherto been accustomed to look upon mercury as the only certain antidote against the venereal poison ; but the nitric- acid has been recommended as possessing a similar power. Dr. Scott, late of Bombay, seems to be the first who employed it in syphilis. He tells us, he has had such extensive experience of its good effects, that he looks upon it to be by no means less effectual than mercury in removing that disease in all its forms, and in every stage of its continuance; and from its not producing many of the inconveniencies that arise from a use of that metala he thinks it may in some respects be preferable. He observes, that mercury introduced into the circulation is attended by many disagreeable effects that render it often necessary to give over its use before it has answered the desired intention; but that the nitric acid may be taken a long time without any material injury to the health, and without producing inflammation and a flow of saliva, as from a use of mercury, but merely a temporary soreness in the gums and teeth. On the recommendation of this gentleman, many practitioner^ have been induced to employ the nitric acid in the primary affec- Order IU.J ,. • tenereal disease. G'39 tions of syphilis, such as chancre, gonorrhoea, &c, and with some success. A few however have not made a favourable report of its effects; but more particularly Mr. Blair, surgeon to the Lock hospital. The nitric acid at any rate may assist the use of mercurials as well as opium in the cure of venereal ulcers, although it should net be solely depended upon. A matter of much importance, and worthy of notice, is, that the nitric acid has not been perceived to excite the action of other dis- eases, more especially scrofula, one of the greatest inconvcniencies attending a mercurial course, and by which many have had theip constitution ruined, and others have lost their lives. The sensible effects generally produced by a use of this acid are an increase of the appetite, costiveness, the mouth and tongue becoming moist and white, with a slight soreness in th? gums, and urine being of a light straw colour, clear, and increased in quantity * and the blood when drawn exhibiting the same appearances as under active inflammation, the coagulum being covered with a tough coat of coagulable lymph. In a few instances a burning sensation in the stomach has been observed; but this has only happened where the dose has been too great. The mode of administering the nitric acid is to give one drachm, of it diluted in a quart of an infusion of lemon-peel in warm water every day; and where this quantity does not seem to produce the desired effect, to increase it gradually to two or more drachms'. A course of this medicine requires no particular regimen nor confinement. Nitric- acid is known to contain about four parts of vital ail? united to one of azote, with a certain proportion of water, and is supposed to remove the symptoms of syphilis by oxygenating the body to a considerable degree, producing thereby a general in- creased action of the whole system. In a work* lately published, Dr. Scott has inserted a paper ex- plaining the reasons of the failure of this remedy in this country, and under the direction of other practitioners. He therein states, that the acid he employed was not pure nitric acid, but an impure acid containing an admixture of muriatic acid. He therefore now recommends the use of a compound acid containing equal parts of nitric acid and of the muriatic, which he administers internally, and also applies externally'either as a wash or bath, largely diluted, (say eight ounces of the acid to forty gallons of water,) until the gums are affected and ptyalism produced. He conceives every trial as quite inconclusive unless these constitutional effects occur. We are informed by Dr. Scott, that he found this acid particularly useful, even in this country, in that description of syphilis which is termed pseudo-syphilis, and which he considers as real syphilis combined w.ith scrofula, called into action by the mercury employed for the« J/ e Journal of Science and the Arts of India, vbl. i, p. 205—11. 6'4'0 CACHEXliE, OK CACHECTIC DISEASES'. (CldSS ill cure of the syphilitic affection, and consequently not curable by mercury although syphilis be still in the habit, but undoubtedly not produced by that remedy. It appears also, that sponging the skin with a solution of chlorine (water saturated with the nitro-muriatic acid) is attended with the same effects exactly as arise from the -Union of the acids, and employed in the same way. Dr. Scott wives no explanation of the modus operandi of the acids in coiv junction, but thinks the power depends on the chlorine, as Sir II. Davy terms it.* A BUBO. It has already been observed, that between a local and consti- tutional affection there often arises a kind of intermediate state, and that in consequence of an absorption of venereal matter from" some surface to which it has been applied, the glands situated nearest to the parts thus affected are apt to become indurated, swelled, and inflamed, and so to give rise to a bubo ; and the parts of generation usually coming first in contact with the matter, so (he glands in the groins are the most general seat of this particular symptom. In most cases the syphilitic virus is absorbed from a chancre or ulcer in the urethra; but instances have occurred where a bubo has arisen without either gonorrhoea or any kind of ■ulceration, and where the matter appears to have been absorbed without any evident erosion of the skin or of the mucous membrane. A bubo comes on with a pain in the groin, accompanied with some degree of hardness and swelling, and is at first about the size of a kidney-bean, but continuing to increase, it at length becomes as large as an egg, occasions the person to experience some diffi- culty in walking, and is attended with a pulsation and throbbing in the tumour, and a great redness of the skin. In some cases the suppuration is quickly completed ; in others it goes on very slow; and in others again, the inflammatory appearances go off without any formation of pus. In a few instances the glands have been known to become scirrhous. As many other swellings in the groin, such as a rupture, aneu- rism, lumbar abscess, and scirrhous affection of the glands, may be mistaken for a bubo, it will always be advisable in doubtful cases to inquire whether or not the patient has lately been afflicted either with a gonorrhoea or chancre ; and whether or not he has lately laboured under any other complaint that might have given rise to the swelling. It may likewise be advisable to attend to the pro- gress which the tumour has made. By a due consideration and investigation of these circumstances we cannot fail to form a just conclusion as to the real nature of the disease. The following are the characteristics of a venereal bubo: the swelling is usually confined to one gland; the colour of the skin where inflammation prevails is of a florid red; the pain is very f* See Sir H. "Davy's Theory of Chlprme. London Med. and' Fbysit.al Jovitji^ vqI. xyxv. p. ill. I "*' Order III.J venereal disease. 641 acute; the progress from inflammation to suppuration and ulcera- tion is generally very rapid; the suppuration is large in proportion to the size of the gland; and there is only one abscess. A bubo is never attended with danger where the inflamed gland proceeds on regularly to suppuration; but in particular cases it acquires an indolence after coming to a certain length, arising from a scrofulous taint; or, being combined with erysipelas, it termi- nates in phagedenic ulceration, and occasions a great loss of substance. This termination is, however, more frequently met with in hospitals than in private practice, and may partly be attributed to the contaminated state of the air of the wards wherein syphilitic patients are lodged. The many inconveniencies that ensue from allowing a venereal bubo to suppurate, should induce the practitioner to exert his utmost endeavours to prevent it from proceeding to such a state, and to occasion its speedy resolution or dispersion, if possible. To effect this, it will be proper, where the skin is occupied by much redness and inflammation, and the tumour by a throbbing, to draw off a sufficient quantity of blood immediately from the neighbour- hood of the inflamed part, during the first days of the disease, by means of four or five leeches; the patient at the same time keeping his body open with some gentle laxative, using a very spare diet, and avoiding exercise. After the leeches have ceased to bleed, the parts may be wetted frequently throughout the course of the day with linen pledgets dipped in any of the sedative lotions advised for a swelling of the testicle, and by night be covered with a poultice of linseed or rye-meal, moistened either with a diluted solution of plumbi superacetas, or the liquor plumbi acetatis. If the tumour is unattended by any inflammatory symptoms, then topical bleeding may not be necessary, as probably the timely ap- plication of mercurial ointment will be sufficient to disperse it. To give this its due and proper effect, it should not however be applied ,^ immediately upon the tumour, but be rubbed in on the inside of i the thigh which is affected. I With regard to the quantity to be used, no express rule can be laid down, as some constitutions are readily affected by mercury, and others again are neither very quickly nor sensibly operated upon by it. In all cases it will be most advisable to begin with a small quantity of about the size of a hazel-nut, and so to increase it daily, until it comes to that of a moderate-sized walnut; which course is to be pursued every night until the tumour and induration have entirely subsided. Indeed, if it is continued for some little time after the disappearance of both, it will be attended with a more certain effect. Should the salivary glands become affected from a use of the unction, and any degree of salivation ensue, the patient ought im- mediately to discontinue it for some days, keeping his body open with gentle laxatives, and washing his mouth and throat frequently 82 'i42 cachexia:, or cachectic diseases. [Class 111. with a gargle composed of borax and honey* dissolved in water. The borax will not only act as an astringent, but will diminish the irritable state of the glands by its sedative power. To assist in lessening the irritation, it will be advisable, during a course of the unction, to give an opiate every night at bedtime. If a bubo is too far advanced to be dispersed at the time that assistance is applied for, or obstinately continues its course to sup- puration, in spite of our best endeavours to prevent it, we are then to assist the formation of proper pus by a full diet, and the appli- cation of emollient poultices. When this is formed, the tumour may be opened by a lancet or caustic, and the ulcer be brought to a proper digestion by suitable dressings and the internal use of mercury; taking care, however, not to carry it to the extent of pro- ducing salivation. In those cases where there prevails a scrofulous disposition, it frequently happens that the sore does not heal kindly, but, on the contrary, spreads from the glands to the cellular substance, inflames the skin and contiguous parts, assumes a foul, spongy appearance, and is accompanied by much pain and a discharge of a highly acrid matter; or should the ulceration heal in one part, it shortly afterwards breaks out in another, and becomes extensive. Cases of this nature have been most successfully treated by fomenting the ulcerated parts twice a day with a strong decoction of the leaves of hemlock or of bruised poppy-heads, and then covering them with some emollient cataplasm, or that advised for chancres of a corroding and phagedenic nature. Where the ulcers have a fungous appearance, and discharge a thin acrid sanies, a little of the hydrargyri nitrico oxydum may now and then be sprinkled over them, which will seldom fail to promote proper pus, and will by no means excite pain. As internal medicines, we may administer the bark of cinchona joined with the nitric acid, together with a decoction of mezereon, which may be taken in the quantity of a quart daily. Opium has been much employed in these untoward cases, partly on the supposition of its being possessed of some specific power in the cure of syphilis; but its utility seems to depend entirely on its narcotic quality, and its allaying the pain and irritation with which such sores are uniformly accompanied when the discharge is thin and acrid. Hemlock has likewise been resorted to in these cases, and some- 1 39. ft Sodae Sub-boratis, 3U- *39. Take Sub-borate of Soda, two drachms. Honey of Roses, one ounce. Hot Water, eight ounces. Mix them for a gargle. Or, 40. Take Alum, two drachms. Decoction of Barley, two pints Mollis Rosae, f. 2ii. M. Honey of Roses, two ounces Mix them. Mel. Rosse, f. *j. Aq. Fervent, f. |viij Gargarisma. Vel, 10.15; Aluminis, 3y- Decoct. Hordei, Oij Order 1II.J venereal disease. 643 times with advantage; it may therefore be taken internally. We may begin with about two grains of its extract in the form of a pill, and so increase the quantity daily, until it shows its effects on the system hy producing a slight degree of giddiness. Buboes in scrofulous habits, or when accompanied with erysipe- $•' latous inflammation, are very apt, particularly in hospitals where the air of the ward is much contaminated by many mercurial breaths, to degenerate into phagedenic ulcerations, which extend in a short time over a considerable space, and not unfrequently lay bare a large portion of the thigh and lower part of the abdomen, and even the testicles themselves. In cases of this nature the ulcerated parts should be well fomented two or three times a day (j with flannel cloths wrung out in a warm decoction of bruised poppy- H heads and the cinchona bark, and afterwards be covered with an jJk emollient poultice, and occasionally with the cataplasma carbonis mentioned under the head of Gangrene. The use of mercury should immediately be desisted from, employing in its stead large and frequently repeated doses of the bark of cinchona, joined with sarsaparilla, together with opium, so as to keep up a constant effect. The patient is at the same time to be supported with a generous diet and wine, and, if possible, to be removed into a purer air. without which our endeavours may not be crowned with success. In all cases of bubo, as well as of canchre and gonorrhoea, where mercury is used either internally or externally, it will be necessary for the patient to abstain from food of a high-seasoned and salted nature, and from all kinds of spirituous and fermented liquors ; and as any exposure to cold, while under a course of this medicine, is very apt to bring on a salivation when it would not otherwise have arisen, he ought most carefully to avoid getting wet, or exposing himself to moist, cold air; taking the precaution, at the same time, to adapt his clothing to the season of the year. THE CONSTITUTIONAL DISEASE. A constitutional taint is the third form under which it has been mentioned that the syphilitic poison is apt to show itself, and which always arises in consequence of the matter being absorbed, and carried into the circulating mass of fluids. The absorption of it may, however, take place in three ways:— 1st, It may be carried into the circulation without producing any evident local effect on the part to which it was at first applied : 2dly, It may take place in consequence of some local affection. such as either gonorrhoea, chancre, or bubo : and, 3dly, It may ensue from an application of the matter to a common sore or wound, similar to what happens in inoculating for the small-pox. The most general way, however, in which a constitutional taint is produced, is by an absorption of the matter, either from a chancre or bubo. 644 cachexia, or cachectic diseases. [Class III. When syphilitic matter gets into the system, some symptoms of it may often be observed in the course of six or eight weeks, or probably sooner; but in some cases it will continue in the circulating mass of fluids for a few months before any visible effects are pro- duced. The system being completely contaminated, it then occa- sions many local effects in different parts of the body, and shows itself under a variety of shapes, many of which put on the appear- ance of a distinct disease. We may presume that this variety de- pends wholly on the difference of constitution, the different kinds of parts affected, and the different state these parts were in at the time the matter or poison was applied. The first symptoms usually show themselves on the skin, and in the mouth and throat. When the matter is secreted principally in the skin, reddish and brownish spots appear here and there on its surface, and eruptions of a copper colour are dispersed over different parts of the body, on the top of which there soon forms a thick scurf or scale. This scurf falls off after a short time, and is suc- ceeded by another; and the same happening several times, and at length casting off deep, an ulcer is formed which discharges an acrid fetid matter. When the poison is secreted in the glands of the throat and mouth, the tongue will often be affected, so as to occasion a thick- ness of speech : and the tonsils, palate, and uvula, will become ulcerated, so as to produce a soreness and difficulty in swallowing, and likewise a hoarseness in the voice. The tonsils are more usually affected with syphilitic ulceration than the uvula or velum palati, though the affection may spread to these from the tonsils. The ulcer of the latter is an excavation, as if a piece was scooped out; the sore has an uneven, jagged, foul appearance, with an erysipelatous redness on a hard, elevated, de- fined border; the ulcer is commonly covered with a whitish or brown slough; it is progressive, and like the rest of the syphilitic symptoms, it is not curable by the powers of the constitution. Generally there is not much pain nor much enlargement attendant on this form of the disease ; in other respects the sensations do not materially differ from those produced by ulceration of the throat proceeding from other causes. If the disease affects the eyes, obstinate inflammation, and some- times ulceration, will also attack these organs. The matter sometimes falls on deep-seated parts, such as the tendons, ligaments, and periosteum, and occasions hard, painful swellings to arise, known by the name of nodes. When the disease is suffered to proceed, and is not counteracted by proper remedies, the patient will in the course of time be afflicted with severe pains, but more particularly in the night-time: his countenance will become sallow ; his hair will fall off; he will lose his appetite, strength, and flesh; his rest will be much dis- turbed by night, and a small fever of the hectic kind will arise. The ulcers in the mouth and throat being likewise suffered to spread, 4 Order III.J venereal disease. 645 and to occasion a caries of the bones of the palate, an opening will be made from the mouth to the nose; and the cartilages and bones of the nose being at length corroded away, this will sink on a level with the face. It now and then occurs that primary symptoms followed by secondary ones present themselves, all closely imitating syphilis in its primary and secondary stages, and yet are not venereal. Symp- toms resembling the secondary appearances of syphilis occur also without any preceding primary symptom, and turn out not to be venereal. In some of the cases the symptoms go off, and the patient gets well without any remedy : in others, common alteratives, such as a decoction of the woods, &c. have subdued the complaint. These complaints resembling the venereal disease have been called by the name of cachexia syphiloidea, or pseudo-syphilis. Mr. Hunter * has remarked, that undescribed diseases resembling the venereal one were numerous; and Mr. Abernethy t has drawn the attention of medical men by his remarks on diseases resembling syphilis. Some constitutions will bear up for a considerable time against the disease, while others again will soon sink under the general weakness and irritation produced by it. If the disorder is recent, and the constitution not impaired by other diseases, a perfect cure may easily be effected ; but where it is of long standing, and accom- panied with the symptoms of irritation which have been mentioned, the cure will prove tedious, and in many cases uncertain, as the constitution and strength of the patient may not admit of his going through a course of medicine sufficient to destroy the poison ; or his health may be in such a state as that only a very small quantity of mercury can be administered, even at considerable intervals. The general appearances to be observed on dissections of those who die of lues, are caries of the bones, but more particularly those of the cranium, often communicating ulceration to the brain itself; together with enlargements and indurations of the lymphatic glands, scirrhus of several of the organs, particularly the liver and lungs, and exostosis of many of the hardest bones. We have always been accustomed to consider mercury as the most certain antidote, which we are acquainted with, to the syphi- litic poison, if judiciously employed or administered ; from whence it is evident, that it will be necessary to have recourse to it in all cases where the system becomes tainted. A class of practitioners has indeed lately started up, but particu- larly among regimental surgeons, to propagate the practice of curing syphilis and pseudo-syphilis, in all their Protean forms, without any mercurial preparation whatever: but I here beg leave to warn my readers against this new doctrine of trusting the cure of syphilis to sarsaparilla and such like remedies, in exclusion of mercury, as by * See his Treatise on the Venereal Disease. + See his Surgical Observations. '•46 CACHEXIA, OR CACHECTIC DISEASES. [ClaSS III. t. such a practice we can never ensure the patient against secondary appearances of the disease. The manner in which mercury removes syphilis is not yet satis- factorily ascertained; but, in the opinion of some physicians, its action has been supposed to be chemical, the remedy combining with and destroying the virus ; for it has been found that venereal matter applied by inoculation readily propagated chancre, but if mixed with a variety of mercurial preparations, no infection follow- , ed. The same effect of mercury over variolous matter has been noticed under the head of Inoculation for the Small-pox. A few who rank as regular practitioners, besides those who act i as quacks, fully sensible of the credulity of mankind, have endea-"*! voured to make the vulgar believe, that by repeated examinations 4 of the various productions of nature, they have each of them been J able to discover a specific of a milder and more innocent nature m than mercury for the venereal disease ; and puffing handbills and.3 advertisements daily announce that they can perform a radical cure i without giving one grain of this mineral. A fair analysis of such of these nostrums as have been found at all serviceable in cases of this nature, has, however, clearly detected the falsity of these men's *t assertions, and proved beyond a possibility of doubt, that their new- discovered specifics are but some active preparation of mercury un- der a disguised shape. Mercury may be introduced into the system in two ways, viz. either by an external application of it in the form of unction, or by- giving some preparation of it internally; and it may be used to such an extent as to excite a salivation, or with such moderation as only to give a tendency that way, without suffering it to proceed so far, which in all cases will be the safest and most advisable plan. A third method, or alterative course, has been adopted by some practitioners ; but although this may answer in primary affections, still it is by no means calculated to cure a confirmed lues. There are some persons who are but little affected by mercury when applied externally to the body in the form of unction, as the . absorbent vessels will not readily receive it ; and there are others ** again whose internal absorbents will not take up a sufficient quan- tity to produce much effect either on the disease or the constitu- tion ; in which case the medicine passes off by the bowels, occa- sioning sickness at the stomach and griping pains. To administer mercury judiciously, it ought therefore to be used j in the way that is most suitable to the constitution of the patient. * If on a trial the external application of it should produce no effect, either on the disease or constitution, then it should be administered inwardly : on the other hand, if its internal use fails, or produces any disagreeable effect on the stomach and intestines, then the external application ought to be substituted. Indeed, the skin not being so essential to life as the stomach, is capable of bearing the application of mercury to it much better than the latter. Although the quantity of mercury to he introduced into the Order IH.J venereal diseases. ' 647 system for the cure of a lues must always be in proportion to the virulence of the disease, still in throwing it in we should neither proceed with haste or violence, nor administer it in large or too frequent doses. In all cases it will be most prudent to begin with a small quantity, whether given internally or applied externally, and to increase it gradually, so as that the system shall be inured imper- - ceptibly to the remedy; and as soon as the patient perceives a copperish taste in his mouth, with a great fcetor of breath, and a more than ordinary secretion of saliva, he ought then to proceed cautiously, and where necessary, wholly to desist from its use for a day or two, returning to it however as soon as the sensations have somewhat abated. To use the medicine so as to give a tendency to salivation, with- out proceeding any length, and to keep it constantly at that point jjgL. during the whole course, is what he is to aim at. "J* Mercury, when introduced hastily and in large doses into the constitution, is apt to produce sensible and disagreeable effects upon i*. particular parts of the body. It often occasions a swelling and inflammation in the mouth, tongue, and salivary glands, and there- by produces a profuse salivation. It likewise affects the stomach and intestines, and excites nausea, griping pains, and diarrhoea; and in some instances it produces profuse sweats and great debility. Introducing mercury into the system, so as to give rise to any of these effects, will therefore be highly improper. Unless the disease is proceeding so fast in its course as that it might be at- tended with some risk to the patient to wait until it was checked by introducing it gradually ; or unless he is so irritable to the ef- fects of mercury, as that even the smallest quantity used in- ternally, or applied externally, affects his mouth, it will be ^ wrong to occasion a salivation, as the cure will in general be r rendered thereby more tedious, as well as uncertain, instead of '.^o,being hastened. To prevent a salivation it will be necessary, besides beginning with small doses of mercury and proceeding gradually, that the v patient should take care not to stimulate the salivary glands, either * by rubbing the skin over them, and keeping it too warm with flannel; or by applying any thing of a stimulating nature to the mouth; and he should likewise avoid as much as possible any exposure to cold; for this being applied while the body is in an irritable state from the use of mercury, is likewise apt to occasion inflammation and tumefaction of these glands, and so to give rise to a salivation. In a warm and well-regulated temperature, a mercu- rial course is more under the command of the practitioner, the' remedy produces its effects with more certainty and safety, the malady yields more pointedly to its operation, and the several dangerous effects of incautious exposure to cold and damp are avoided. The person who is under a course of mercury should abstain from all salted and high-seasoned meats, confining his diet to plain 648 CACHEXIA, OR CACHECTIC DISEASES. [Class 111, animal food that is of a light digestion, to thin broths, preparations of sago, barley, and rice, custards, light pudding, milk, vegetables, ripe fruits, he. He should avoid all spirituous liquors and vegetable acids ; and if he drinks wine, the quantity ought to be very small, and always diluted with a proper proportion of water. The late Mr. John Hunter seems, however, to have thought an attention to diet, under such circumstances, wholly unnecessary; for in his Treatise on the Venereal Disease, he says, that the manner of living under a mercurial course need not be altered from the common, because mercury has no action upon the disease, which is more favoured by one way of life than another ; and he adds, " 1 see no reason why mercury should not cure the venereal disease under any mode whatever of regimen." He asks, What * effect eating a hearty dinner, and drinking a bottle of wine after ; it, can have over the action of mercury upon a venereal sore, either.^ to make it affect any part sensibly, as falling on the glands of the ~# mouth, or prevent its effect on the venereal irritation ? In answer '** thereto, I have only to say, that a use of mercury never fails to render the body irritable; so any thing of a stimulating nature applied to the salivary glands while under a state of increased sus- ceptibility and irritability, will be likely to occasion an inflamma- tion and tumefaction in these parts, and thereby provoke a saliva- tion ; an event which should be ever avoided when it can possibly be dispensed with. When we make use of unction for the cure of syphilis, without intending to excite a salivation, we* may direct the patient to rub thoroughly into the hams and thighs about half a drachm of the unguentum hydrargyri fortius* every night; and this course he is to continue until a coppery taste is perceived in the mouth, with somewhat of an increase of saliva. As soon as these are percepti- "* ble, he must go on gradually, and should they seem to proceed to a greater height than what is intended, instead of using the ointment jJ| every night, he ought then to have recourse to it only every other STf night. On the contrary, should the quantity of ointment here di- "' rected be insufficient to produce any apparent effect on the mouth, '■ • he must then increase it gradually every night, until he can attain the desired point. If we employ mercury internally with the same view of not bringing on a salivation, we may then give one or two of the pilula hydrargyri every night at bed-time ; or instead of these, we may recommend some of the other active preparations of mercury, * By putting six ounces of quicksilver into a proper sized mortar, with about two ounces of strong mercurial ointment, (if rancid the better,) and rubbing them briskly together, the globules of quicksilver disappear in a few minutes; and by continuing to rub it well for five or six minutes longer, an union will be so far accomplished that the lard may be gradually added. By this simple process a pound of strong mercu- rial ointment may be well made in ten or twelve minutes, which according to the usual method requires as many hours. A knowledge of this fact may prove of high utility to apothecaries and druggists—See No. 7 of the Medical, Surgical, and Phar- maceutical Repository, p. 53. VENEREAL DISEASE. 649 Order III.J such as the hydrargyri submurias,* the hydrargyri oxydum rubrum,t or hydrargyri oxymurias,! which may be taken in small doses at first, and so be augmented gradually, as maybe found necessary. Along with these remedies we may recommend the patient to drink about a quart a day of the decoctum sarsaparilla* compositum, which will tend to carry off the mercury by the skin and kidneys. Where any of its preparations affect the bowels, and excite either a purging or griping, a sufficient quantity of opium should be given at the same time to prevent these consequences. When, from the urgent nature of the case, we are obliged to employ mercury so as to excite a salivation, we must introduce it into the system in a gradual manner, by beginning with a small quantity, and augmenting it daily, taking care to observe its effects with great attention. If we use unction, (to which a preference ought always to be given where we mean to excite a salivation,) we may direct the patient to rub in, as has before been advised, about a drachm of it every night previous to his going to bed. If the salivary glands do not become affected after a few days' application of the ointment, he can then increase the quantity each night, until a sufficient flow of saliva is procured. During the continuance of the spitting, the pulse should never , exceed 95 or 100 in a minute; neither should the quantity of the saliva which is discharged be greater than two or three pints in twenty-four hours. Under such a course, the body is to be enve- loped in flannel, and the patient to drink plentifully of diluent * 41. g; Hydrarg. Submur. Camphorae, aa 3|j. Opii, gr. x. Mel. Optim. q. s. M. Fiant pilul. xx. quarum j. vel ij. sumat mane et nocte quotidie. Vel, 42. p, Hydrargyr. Submur. 3j. Antimon. Tartarizat. gr. v. Opii Purificat. gr. x. Mel. Optim. q. s. M. Fiant pilul. xx. capiat ij. bis in die. t 43. ft Hydrargyr. Oxydi Rubr. Camphorae, aa 3j. Opii, 3j. Syr. Simpl. q. s. M. Fiant pilul. 1. quarum sumat asger j. vel ij. omni nocte hora decubitus. t 44- ft Hydrargyri Oxymuriat. gr. viij. Solve in mortario vitreo cum Spiritus Ten. Oj. ft. Solut. cujus capiat semi unciam mane et vespere. * 41. Take Submuriate of Mercury, Camphor, of each, two scruples. Opium, ten grains. Honey, a sufficiency. Mix them, and out of the mass let twenty; pills be formed, of which take from one to two morning and night daily. Or, 42. Take Submuriate of Mercury, one drachm. Tartarized Antimony,five grains. Opium, ten grains. Honey, a sufficiency to form the mass. Out of this let twenty pills be made, of which take two twice a day. t 43. Take Red Oxyd of Mercury, Camphor, of each one drachm. Opium, a scruple. Syrup, a sufficiency. Let the mas3 be divided into fifty pills, of which the patient may take from one to two every night on going to bed. 144. Take Oxymuriate of Mercury, eight grains. Dissolve it in a glass mortar with Proof Spirit, one pint. Of this solution let half an ounce be taken morning and evening. 83 OdO CACHEXIA, OR CACHECTIC DISEASES. [ClttSS III. liquors. To alleviate the soreness of his mouth and gums, he may use some soothing gargle* three or four times a day. From the report of a modern writert it appears that mercurial frictions are hardly ever employed by the French surgeons in hos- pitals, although sometimes in private practice they adopt them, and the most common preparation used internally by them in most cases is the oxymuriate of mercury. This is usually given by them either in a simple solution in water and a little spirit, or under the form of Van Swieten's liquor. The usual quantity daily taken by a patient is half a grain, which is administered at a single dose, that the surgeon may see it given. They begin, however, with as much of the solution as contains a sixteenth, or an eighth of a grain, and so increase it. When the constitution indicates the necessity of di- vided doses, it is given morning and evening, and sometimes in the form of pills. If we give mercury internally, with the intention of exciting a salivation, we must proceed in the same cautious manner as when under a course of mercurial frictions, increasing or diminishing the dose according to the effect produced. WThen a salivation comes on quicker, or proceeds with greater violence than we could wish, notwithstanding all our precautions, we must not only lessen the quantity of mercury, but we must also give one or two gentle purges, and keep the chamber some- what cooler than before. Sulphur has generally been supposed to possess a power of checking the rapid effects of mercury ; and, therefore, where a salivation comes on with great rapidity and violence, we may have recourse to it in doses of from half a drachm to one drachm twice a day, besides taking the steps just mentioned. In mild cases of syphilis it probably will require from four to six weeks' perseverence in the use of mercury to effect a cure : but in cases of long standing, and a more confirmed nature, it may be necessary to continue it for eight or ten weeks, or even longer. Whether we attempt the cure by salivation, or in the milder way, by giving a tendency to it, without preceding that length, we should always recommend the patient to persevere in the plan, even for some short time after the departure of every symptom, in order that he may be ensured a perfect cure; for the venereal action may to appearance be stopped, and the symptoms vanish, and yet all return again; the virus not having been completely subdued. As soon as the use of mercury is left off, the diet may be amended, a purge or two be exhibited, and a return to the free air be gradu- t See Sketches of the Medical Schools of Paris, by Mr. John Cross. *• 45. ft Decoct. Hord. f. ^vj. Sodae Sub-borat. 3j. Mel. Rosae, f. |j. Tinct. Opii, f. 3j. M. ft. Gargarisma. * 45. Take Decoction of Barley, six ounces. Sub-borate of Soda, one drachm. Honey of Roses, one ounce. Tincture of Opium, one drachm Mix them for a gargle. Order III.J venereal disease. 651 ally made ; after which, tonics, with country air and exercise, will greatly tend to recruit the strength. In the progress of the disease, it is often found necessary, besides employing mercury in order to counteract or destroy the virus in the system, to attend to particular symptoms ; for the removal of which, a topical treatment may likewise be requisite. The tonsils, uvula, and other parts of the fauces, as likewise the nose, are fre- quently discovered in a state of ulceration, where the disease has been of long standing. In such cases, the parts should be well cleansed by washing them twice or thrice a day with some proper gargle ;* after which, the fumes arising from myrrh and the hydrargyri sulphuretum rubrum thrown upon a hot iron may be brought into contact with them by means of an inverted funnel. When eruptions ulcerate, washing them with submuriate of mercury and water, or the hydrargyri oxymurias and liquor calcis, and dressing them with mild mercurial ointment, will be mostproper; making use, at the same time, of a decoction of mezereon-root, as advised in those cases where nodes arise. Venereal pains, blotches, and scaly eruptions will be removed most readily by employing sudorifics at the same time with mercury. About a quart of the decoctum sarsaparillae compositum, or of the Lisbon diet-drink,t the qualities of which have been the subject of so much encomium, may therefore be drank daily with this view. In preparing this last, the powdered antimony and pumice-stone are to be tied in separate pieces of rag, and boiled along with the other ingredients. It is probable that the operation of these medi- cines, where the patient is not under a salivation, may be assisted by going into a warm bath now and then; but in having recourse to this remedy, the patient must observe the greatest precaution not to take cold, by wrapping himself up in a very warm clothing on his coming out of the bath. If the pains are so severe as to interrupt his rest by night, he should take an opiate J on going to bed. * 46. ft Hydrarg. Oxymuriat. gr. v. * 46. Take Oxymuriate of Mercury, five grains. Solve in mortario vitreo cum Dissolve it in a glass mortar with Spirit. Rectif. f. ?ss. et adde Rectified Spirit, half an ounce, and add Decoction of Bark, six ounces. Tincture of Myrrh, one ounce. Honey of Roses, half an ounce. Mix them for a gargle. t 47. Take Sarsaparilla, sliced, China Root, of each one ounce. Dry rind of twenty walnuts. Antimony, two ounces. Powder of Pumice Stone, one ounce. Distilled Water, ten pints. Boil it slowly until the liquor is reduced one half, then strain it. % 48. Take Solution of Acetate of Ammo- t nia, half an ounce. Decoct. Cinchon. f. ?vj. Tinct. Myrrh, f. ?j. Mel. Rosae, f. |ss. M. ft. Gargarisma. 147. ft Sarsaparillse Concis. Rad. Chins, aa ^j. Nucum Juglandiscortic. siccata- rum xx. Antimonii, ^ij. Lapid. Pumicis Pulv. |j. Aq. Distillat. Ox. Coque ad dimidium et cola. ± 48. ft Liquor. Ammon. Acetat. f. ^ss. 6o2 CACHEXIA, OR CACHECTIC DISEASES. [Class 111. Nodes on the bones are to be relieved by rubbing them every night with a small quantity of mercurial ointment, or by wearing a plaster of the same nature over them, assisted by a decoction of the woods, or mezereon,* together with opiates, where the pain is great. In inveterate cases, where the surface of the bone becomes carious, it will be found necessary either to make an incision through the integuments and periosteum the whole length of the diseased part, or to apply a caustic to it for the purpose of procu- ring an exfoliation; but this last will require great caution and skill, and in applying it some expertness will be requisite, to prevent it from spreading to a greater extent than what is intended, or may really be necessary. Acetic acid will remove corns in one or two applications with the greatest certainty, and, if not carefully managed, the surround- ing cuticle also which it happens to touch. To large verrucae, or warts with broad bases, the same application will be effectual. Those that are pendulous with narrow necks may be removed with scissors; and after the oozing of blood has ceased, they may be touched with the sulphate of copper, or a solution of lunar caustic. —See Gonorrhoea. Inflammation of the iris, although frequently met with in syphilis where mercury has not been exhibited so as to affect the system, still its occurrence is more frequent as consequent upon the use of it than arising as an idiopathic disease. Under these circum- stances it is not surprising that some surgeons of reputation should be disposed to deny that the inflammation of the iris is a venereal inflammation, and should consider it as belonging to that class of symptoms which resemble, or are grafted upon the syphilitic, and that others should regard it as an inflammation produced by the poison of mercury.1 In the early and active stage of acute inflammation of the eyes, and previous to any mercurial action being induced, it will always be advisable to have recourse to blood-letting, both from the arm, and topically by the application of several leeches to the temples. It will likewise be necessary to give one or two doses of some t See Surgical Essays by Mr. Astley Cooper and Mr. Travers, vol. i. p. 60. Aquae Menth. Virid. f. ^i. Liquor. Tart. Antimon. til xvj. Tinct. Opii, til xx. Syr. Papav. Somnif. f. 3j- M. ft. Haustus. * 49. ft Rad. Mezerei Contus. 3>j- ------Glycyrrhizae, ?j. Aq. Distillat. Oij. * Coque ad dimidium, e't col.bibat Oss. ad Oj. in die. Mint Water, one ounce. Solution of Tartarized Antimony, twenty-four drops. Tincture of Opium, thirty drops. Syrup of Poppies, one drachm. Mix them for a draught. * 49. Take Mezereon Root, bruised, two drachms. Liquorice Root, one ounce. Distilled Water, two pints. Boil them until the liquor is reduced to a half, and then strain it off. From half a pint to a pint may be drank daily. Order III.J venereal disease. 653 cooling purgative. Besides these means, the eyes may be bathed two or three times a day with some cooling collyrium, as advised under the head of Ophthalmia, and the irritation of light be avoided, either by confining the patient to a dark room, or obliging him to wear a large green shade over his eyes. Should the pain and inflammation not abate in due time by this mode of treatment the application of a small blister behind each ear, or of a large one to the nape of the neck, will be proper. When the inflammation is reduced, we may begin with a use of mercury. Where syphilis falls on the bones of the nose, besides making use of mercury with the decoctum sarsaparillae compos, or the Lisbon diet-drink, we should employ detergent lotions,* which may be applied to the parts by means of a syringe. When com- bined with ulcerations of the tonsils, palate, or uvula, we must likewise make use of fumigations and gargles, as before recom- mended. In those cases where ulcers of a phagedenic nature present themselves, we must omit the use of mercury for a time, and have recourse to the cinchona bark, with wine and a nutritive diet, removing the patient at the same time into a pure air, if his situation is any way close or confined. Occurrences of this nature happen more frequently in hospitals than in private practice, and are owing, in a great measure, to the vitiated air which prevails in the wards set apart for venereal patients, as has already been mentioned. In several cases of phagedenic ulceration, which had resisted the usual means employed by surgeons, the application of lint, moistened in the balsam of Peru, has been attended with happy effects, occasioning in a few days the sphacelous parts to slough off, the face of the sore to become clear, and healthy granulations to extend over its surface. In broken constitutions, where oedematous swellings of the legs have begun to manifest themselves, a perseverance in a mercurial course ought not to be pursued. In such distressing cases, a gene- rous diet, country air, and regulated exercise, are the best remedies, entirely omitting the use of mercury till the constitution is reno- vated. Where dropsy has actually taken place, nitric acid, given in as large doses as the stomach and bowels can bear, conjoined with digitalis or squill, may be of great service. Other remedies have been recommended as possessing specific effects in syphilis besides mercury. These are the oxygenated * 50. ft Hydrarg. Oxymuriat. gr. iij Solve in mortario vitreo cum Spir. Rectif. f, |ss. et adde Decoct. Cinchon. f. ^vj. Tinct. Myrrh f. 3ij. Mel. Rosae, f. ?ss. M. ft. lotio. J * 50. Dissolve Oxymuriate of Mercury, three grains in a glass mortar, with Rectified Spirit, half an onnce, and add Decoction of Peruvian Bark, six ounces. Tincture of Myrrh, 2 drachms. Honey of Roses, half an ounce. Mix them for a lotion. 654 cachexia: or cachectic diseases. [Class III. muriate of potass and the different mineral acids, but more particu- larly the nitric, which has been noticed in pointing out the proper treatment of chancres. It remains further to observe, that from the trials I have made of it, it appears to be well calculated to remove many of the primary symptoms of this disease, and may therefore be used in all such cases with safety, and most likely with the assurance of much advantage; but in a confirmed syphilis it ought never to be solely relied on. Its inefficacy in all such cases has been fully substantiated, not only by Mr. Blair,* but by various other practitioners of eminence. Many allow it, however, to possess a palliative power, and almost all admit its salutary effects in remedying the disordered state of the system arising from the excessive use of mercury. The lobelia, or blue cardinal, is another new remedy which of late has been recommended for the cure of syphilis; but its effects are by no means sufficiently established to place any great depend* ance upon it. It is given in the form of decoction,t the patient beginning with half a pint twice a day. After some little time the same quantity is to be taken four times a day, and to be continued so long as its purgative effect is not too considerable. When the case is otherwise, it is to be discontinued for three or four days, and then to be had recourse to again till the cure is completed. The effects of this decoction are evidently purgative, as will be observed from what has just been mentioned. Another new remedy is the decoctum astragali,J which has been very extensively used in Germany, and is said to possess powerful effects as an antisyphilitic. For a more particular account of its virtues, I must beg leave to refer the reader to the London Medical Journal. The decoctum dulcamarae|| is likewise another new remedy which is highly spoken of in anomalous diseases originating in lues venerea. The dose is half a pint in twenty-four hours, mixed with an equal quantity of milk. The treatment of syphilis in infants is noticed among the other diseases to which they are subject. * See his Essay on the Venereal Disease, part iii. t 51. ft Rad. Lobeliae Syphilitic. Siccae, manip. j. Aq. Distillat. Oxij. Coque ad Oviij. J 52. ft Rad. Astragal. Excapi, |j. Aq. Fontan. Oiij. Coq. ad Oij Bibat. in die. || 53. ft Stipitum Dulcam. Recent. §»j Aq. Fontan. Oiv. Coq. ad Oij. et cof. t 51. Take Dry Roots of Blue Cardinal, one handful. Distilled Water, twelve pints. Boil them down to eight pints. X 52. Take Stemless Milk Vetch Roots, one ounce. Pure Water three pints. Boil them to two pints, and let this quantity be drank daily. 53. Take Fresh Bittersweet, two ounces. Pure Water, four pints. Boil it down to two pints, and strain off the liquor. Order III.] SIBBENS. 655 SIBBENS. Sibbens, or sivvens, is a disease which was first noticed by Dr. Gilchrist; and we are told by him that it was then confined to the west of Scotland. He supposes that its spreading is chiefly owing to a neglect of cleanliness; but from the report of others we are informed, that it is commonly got by drinking from the same cup, smoking tobacco from the same pipe, sleeping in the same bed, or handling the sores of such as labour under it. The first appearances of the disease are usually to be observed in superficial ulcerations on the tonsils and uvula, together with an aphthous eruption in the inside of the mouth, cheeks, and lips. Sometimes a hoarseness attends this state of the parts, and excres- cences similar to a raspberry arise from them. From these the name of sibbens is derived. Soon after the affection of the mouth has taken place, small pus- tules are to be discovered on the skin, which break after a time, and leave behind them dry livid crusts, beneath which ulcers form that bear some resemblance to a chancre, as they spread more in depth than in breadth. Instead of ulcerations, collections of matter in the form of boils or critical abscesses, sometimes appear at different parts, which degenerate into sores of a superficial kind, discharging a thin acrid secretion. These are soon filled up with fungous excrescences which shoot up in the form of a raspberry, like those of the mouth and throat. It is seldom that the bones become affected in consequence of the sibbens ; but in those cases the gristly parts of the nose have suffered by erosion. By the natives the disease has been supposed to have some con- nexion with the itch ; by others it has been thought to bear a great affinity to syphilis ; but undoubtedly it has a greater resemblance to the yaws than to any other disease whatever, and possibly might have been introduced into the west of Scotland by some persons from the coast of Africa or the West Indies, where the yaws is a very prevalent disorder, being however chiefly confined to negroes, mulattoes, and others of a mixed race ; but white people are some- times attacked by it. I am indeed firmly of opinion that sibbens is not a distinct disease from the yaws, but merely a variety; and that the trifling dissimilitude which may be observed between them is wholly to he attributed to the difference of climate, mode of living, diet, colour of the skin, &c. A friendly communication from the late Dr. Colling- wood, of Sunderland, has strongly corroborated this opinion. He informs me, that about the year 1769, a West Indian vessel was wrecked on the coast of Wigton, in Cumberland, some of the crew of which were saved, and hospitably received into the houses of those who resided near the spot, and that very soon afterwards the disease in question was communicated to the inhabitants, and be- 656 cachexia, op cachectic diseases. [Class III. came frequent. Dr. Collingwood being then a resident at Wigton, was called upon for advice, and he treated every case as had been recommended in the yaws by men of experience, and with the greatest success. I am further informed by Dr. Collingwood, that a few years ago he made a tour of the south-west of Scotland for near 150 miles, and that he repeatedly inquired for the sibbens among the practitioners, the younger of whom had never seen such a disease, while those of more advanced years assured him that it had wholly disappeared. Dr. Adams, in his Observations on Morbid Poisons, informs us, that the sivvens is to be distinguished from lues by the venereal ulcer being attended with a callous edge and base ; whereas that of sivvens consists only of the clean phagedenic ulcer. Moreover, the former retains much longer its copper appearance, and after- wards becomes elevated, having more the colour of the skin, and the scab, when formed, more scaly. In sivvens the appearance is very rarely pustular, and he never could detect pus under the cuticle; he therefore conceives pus still less in quantity than in syphilis. He adds, it is universally admitted that sivvens never attacks the bones but by spreading from the soft parts, and that it yields earlier to mercury than syphilis. Sibbens is to be cured exactly in the same manner as the yaws, both as to its topical and constitutional treatment. During the first stage of sibbens we ought to employ diaphoretics, with warm bathing to determine the noxious matter to the surface of the body; hut in the second stage, where the eruptions begin to dry off, it will he necessary to put the patient under a gentle course of mercury, with the occasional aid of some mild purgative. FRAMBCESIA, or the YAWS. This is a very common disease among the negroes in our sugar- colonies, and imported, no doubt, originally from Africa. It never spreads by miasma floating in the air, but may be quickly propa- gated by cohabiting or otherwise coming in contact with such as are affected by it: hence, although white people do not seem so susceptible of its influence as those of colour, they nevertheless sometimes become tainted. It may likewise be communicated by the application of matter from a yaw pustule or sore to a wound in a person who has not before had the disease; and it is no uncommon occurrence for negroes to inoculate themselves with the view of obtaining a long exemption from labour. It is one of those complaints which affect the same person but once in his lifetime. The yaws are sometimes preceded by pains in the limbs which somewhat resemble those of rheumatism, and are particularly severe round the joints; these pains are attended with languor and debility, and frequently continue for many days without any further appearance of disease. After a time these precursory Order Hi.'} vaws. Go,7 symptoms are succeeded by a degree of pyrexia, sometimes at- tended with rigors, although in other instances the fever is slight and scarcely noticed. For the most part the patient complains of headach, loss of ap- petite, and pains in the back and loins, which are rather exacerba- ted towards evening. When these symptoms have continued for a few days, they are followed by an eruption of pustules more ox less numerous, which appear in various parts of the body, but especially apon the forehead, face, neck, arm-pits, groins, pudenda, and round the anus. The eruption of these pustules is not com- pleted over the whole body at one time, neither do they show themselves in any regular succession on the different parts; but while one crop is falling off, a fresh one is making its appearance in another place. Every new eruption of pustules is usually pre- ceded by a slight febrile paroxysm. On the first appearance of the pustules or pimples, they are not larger than a pin's head, but gradually increase until they attain the size of a sixpence, or even of a shilling. The pustules are filled with an opaque whitish fluid., and when they burst a thick viscid matter is discharged which forms a foul and dense crust or scab upon the surface. From the larger kind of pustules there frequently arise red fungus excres- cences of various magnitudes, from the size of a pea to that of a large mulberry, which fruit, owing to their rough granulated sur- faces, they somewhat resemble. These fungi, though they rise considerably above the surface of the skin, have but a small degree of sensibility; they never suppurate kindly, but discharge a sordid glutinous fluid which forms an ugly scab round the edges of the- excrescence, and covers the upper part of it, when much elevated, with a white slough. When these eruptions appear upon any part of the body covered with hair, the colour of this is gradually t changed from black to white. In general the number and size of the pustules are proportioned to the degree of eruptive fevef*. When the febrile symptoms are slight, there are few pustules ; but t,, they are mostly of a larger size than when the complaint is more violent and extensive. The duration of the yaws is very uncertain, but is generally sup- posed to depend a good deal on the habit of body at the time of receiving the infection. , In some eases they arrive at their full size and maturity in the space of four or five weeks; hut in otjiers they have taken two or three months. When no more pustules are thrown out, and when those already upon the skin no longer increase in size, the disease is supposed to have reached its height. About this time it happens on some part of the body or other that one of the pustules becomes much larger than the rest, equaling the size of a half-crown piece; it assumes the appearance of an ulcer, and instead of being elevated above the skin, like the others, it is somewhat depressed; the sud- fa.ee is foul and^ sloughy, and pours out an ill-conditione,d iehorr 658 cachexia, or cachectic diseases. [Class III. which spreads very much by corroding the surrounding sound skin j this is what is called the master or mother yaw. If proper atten- tion be not paid to keep the surface of the ulcer clean, the mattei' becomes very acrid, and when near a bone sometimes affects it with caries. When the excrescences appear upon the soles of the feet they are prevented from rising by the resistance of the thick hard epidermis-, and give so much pain that the person affected is unable to walk* The fungi thus situated are called by the negroes in the West Indies, tubba, or crab yaws. They are sometimes so large as to cover a great part of the sole of the foot; at other times they are not larger than a shilling; like corns, they are frequently affected by different states of the atmosphere, but more particularly by rainy weather. Where a judicious mode of treatment has been adopted, the yaws, although a very loathsome complaint, seldom proves either difficult or tedious of cure, and even in the worst of cases is never attended with immediate danger; but where the eruptions have been repelled into the system by external applications, or too early an use of mercury has been resorted to, the cure is often greatly protracted, and in some cases rendered uncertain. Where the dis- ease has been suffered to pursue its course without any assistance-, foul ulcers of a considerable extent are apt to be formed, which induce great debility, and often occasion a caries of the bones. Having clearly ascertained the disorder to be the yaws, the negro" ought to be sent immediately to some very private part of the estate where he can have no possible communication with such as never had it. This precaution is by no means sufficiently attended to, as those who labour under the disease are too fre- quently suffered to associate and mix in friendly intercourse with other negroes, by which means it is propagated from one to another instead of being eradicated. During the eruptive stage of the disease we are to assist the efforts of nature in determining the noxious matter to the surface of the body by giving some mild diaphoretic,* which may be washed down with about half a pint of the decoct, sarsaparillae compositum. With these remedies the patient should make use of a warm bath * 1. ft Pulv. Contrajerv. gr. x. Camphorae, gr. iij. Sulph. Sublimat. gr. xv.—3ss. Syr. Simpl. q. s. M. ft. Bolus, mane et nocte sumendus. Vel, 2. J^j Pulv. Gum. Guaiac. 3ss. ----Antimonial. gr. ij. Sulphur. Sublimat. gr.xx.—3ss. M. ft, Pulvis, mane nocteque capiendus. * 1. Take Powder of Contrajerva,ten grains-. Camphor, three grains. Sublimed Sulphur, fifteen grains to half a drachm. Syrup, a sufficiency. This bolus is to be taken morning and night. Or, 2. Take Gum Guaiacum in powder, ten grains. Antimonial Powder, two grains. Sublimed Sulphur, fifteen grains to half a drachm. Mix them, and let this powder he takes mornibg and night. Order III.J VAW.& 659 about twice a week, confining himself at the same time to a vegetable diet. He ought to be comfortably and warmly lodged, and his system be invigorated by taking daily exercise proportioned to his strength. In the second stage of the disease, where the eruptions begin to dry off, it will be advisable to employ mercury, so as to produce an alterative effect. A weak solution of the hydrargyri oxymu- rias* is the medicine which I have found to answer best on this occa- sion; and in order to disguise its nauseous taste it may be given in a little milk. The decoctum sarsaparillae compos, may be used at the same time. Both are to be continued until the scabs become per- fectly dry and fall off; at which period they are to be omitted, and then a few doses of any aperient salt, or other gentle purgative, should he given. If the mouth becomes much affected by the mercury, its use must either be discontinued for a time, or the dose be lessened. It has already been observed, that there usually remains one large eruption after all the rest have died away ; and this, by degenerar ting into a foul ulcer, discharges an ichorous matter. The best ap- plication for its cure is the unguentum hydrargyri nitrico oxydi. An ointment composed of the subcarbonate of iron with citric acid and prepared lard is much employed in the West India islands, and with great efficacy. From the thickness of the cuticle in the feet, when the yaws appear there, the discharge is apt to be confined. When they break they are difficult to heal, often ulcerating the whole sole and thereby rendering the person incapable of walking. A poultice of the fresh cassava-root, Vvhich is of the narcotic tribe, and well known in every West India island, is the best application in such cases. Hard swellings of a very painful nature which do not suppurate sometimes appear likewise in the soles of the feet as a consequence of the yaws, and occasion lameness. To remove them the patient should bathe his feet in warm water until the swellings become somewhat soft; they then should be seared with a hot iron, which produces an eschar and sore that is readily healed by dressing it with some gentle escharotic. * 3 Hydrargyr. Oxymuriat. gr. iij. Solve in Spirit. Tenuior. f. |vi. M. Sumat semiunciam mane et vespere. Vel, 4. Hydrargyr. Oxymuriat. gr. xxv. Solv. in Spirit. Yin. Gal. f. §j. et adde Liquor. Antimon. Tart. Tinct. Opii, aa «sfe. M. Capiat fqxi'j..—xx. mane et nocte, quoti- die. 3. Dissolve Oxymuriate of Mercury, three grains, in Proof Spirit, six ounces. Take half an ounce morning ajid evening. 4. Take Oxymuriate of Mercury, twenty- five grains. Dissolve it in Brandy, one ounce. And add Solution of Tartarized Antimonv, Tincture of Opium, of each half an ounce. Vfix them, and take twenty to thir.ty dr.ops morning and ni^ht, daily. U60 cachexia, or cachectic diseases, (Class Uli Inoculation has been proposed for this disease, and probably it might be rendered thereby more mild in its symptoms, and quicker in its progress; but as many negroes pass through life without the yaws, and they never prove fatal when judiciously treated, it is not likely that the owners of West India estates will be ready to submit to the unnecessary loss of labour which would be incurred by hav- ing recourse to the operation, the disease requiring in some cases many months to go through its regular course* ELEPHANTIASIS. * Elephantiasis appears to belong to the class of lymphatic dieases : it attacks the skin and adipose membrane of the lower extremities, and gives to the limbs a bulk so monstrous and a form so hideous, that they have been compared to the feet of an elephant, from which appearance the name has been taken. The disease in general is, however, confined to one leg. Elephantiasis has generally been supposed to arise in consequence t of some slight attack of fever, on the cessation of which the morbid matter falls on the leg, and occasions a distention and tumefaction of the limb, which is afterwards overspread with uneven lumps and deep fissures. Some authors, in treating on this disease, confound and blend it with lepra, in which the constitution is generally affected, the whole of the skin becoming thick, rough, and scaly^ and assuming a yellow colour, the hair falling off, small elevations arising in different parts of the body, particularly on the face, which in time degenerate into wide spreading ulcers that discharge a fetid corrosive matter, and have a dusky red margin, occasioning extreme debility and inducing hectic fever; but from having met with many cases during my residence in the West Indies, where elephantiasis was confined entirely to the lower extremities, and unaccompanied hy any of the symptoms just detailed, and being moreover a non- contagious disease, the direct contrary being the case with leprosy, I have given it a distinct consideration. It sometimes comes on gradually without much previous indis- position, but more generally the person is seized with a coldness and shivering, pains in the head, back, and loins, and some degree of nausea. A slight fever then ensues, and a severe pain is felt in one of the inguinal glands, which after a short time becomes hard,, swelled, and inflamed. No suppuration however ensues, but a red streak may be observed running down the thigh from the swelled gland to the leg, and along the course of the lymphatics. As the inflammation increases in the parts the fever generally abates, and perhaps after two or three days' continuance goes off. It however returns again at uncertain periods, leaving the leg at last very hard, difficult of motion, and greatly swelled with varicose turgid veins, the skin rough and rugged, and a thickened membrana cellulosa. Scales appear also on the surface, which do not fall off. but are en- Qrdtr III] ejjsphantiasJs, G£l barged by the increasing thickness of the membranes; uneven Iamp#, with deep fissures, are formed, and the leg and foot become at length of an enormous size and hideous appearance. A person may labour under this disease many years without finding much alteration in the general health, except during thp continuance of the attacks; and perhaps the chief inconvenience he will experience is the enormous bulky leg which he drags about1 with him. The encumbrance has indeed induced many who have laboured under the disease to submit to an amputation ; but tha operation seldom proves a radical cure, as the other leg frequently becomes affected. Dr. Hillary observes,* that he never saw both legs swelled at the same time. Instances where they have alike acquired a frightful and prodigious size, have however frequently fallen under my ob- servation as well aa that of other physicians. From the report of a modern writer,t it appears* that the inha- bitants of Cochin, on the coast of Malabar, are very much afflicted with an enlargement and swelling of one leg, somewhat similar to elephantiasis; and as the disease is not to be met with in other- parts of India, it has the appellation of the Cochin leg. The swel- ling is always confined to one leg, and reaches from the ancle te the knee : the dimensions of the leg in every part being so large as to equal, if not exceed, the thigh of the same person ; but no uV convenience or pain is felt in walking. A particular species of elephantiasis is said by Dr. Hendy| to be endemial in the island of Barbadoes. It has been denominated the glandular disease : he tells us, that it is not incident to the inha- bitants of the other West India islands, and that a person who has- suffered from it in Barbadoes may have fresh attacks of it if he remains there ; but that by removing to any other place, he may he ipertain of preserving himself from any return of the disease. In this assertion Dr. Hendy is certainly mistaken, for I have met with it in both of the islands of St. Christopher and Nevis, and so also have other physicians.|| Moreover, a gentleman from the former of these islands who came to Europe for the recovery of his healthy in consequence of both his legs being affected with this species of glandular disease, not long ago applied to me for advice ; and al- though he had been in England nearly two years, and had con- sulted several of the faculty, still both limbs were very much en,- farged, and but very little diminution of size had taken place. By Dr. Hendy we are informed that the disease is truly charac- terized by the appearances it produces on the lymphatic system. These are almost universally a certain chord, which is hard or red (often both,) extending in the ordinary direction of the lymphatic vessels towards the lymphatic gland. The part affected swells and ,/• See his Treatise on thp Diseases bf Barbadoes. "f See Parson's Travels in Asia and Africa, p. 228. ■ ± See his Treatise on the Glandular Disease of Barbados-. (j See Medjjco.CllirtirgtcalTrails^ctjoite, vol. vi:. p,.73i Gil2 CAfJUEXI-^, OR CACHECTld DISEASES. [GUtSS UL puts on a shining and cedematous appearance; it does not however often pit to the touch, though strongly pressed with the finger, ex- cept only when the disease is recent; the effect of pressure is then the same as in cases of anasarca. The joint nearest to the affection becomes stiff and contracted in consequence of the neighbouring inflammation and swelling. When the concomitant fever abates, after a duration which varies in different patients, it leaves the local swelling and inflammation, frhich continue for a few days afterwards. The swelling indeed eldom entirely subsides, particularly when the lower extremities are affected. There are some instances, however, in which these enlargements have totally disappeared, but they are rare. The lymphatic gland has in several instances been left enlarged and indurated. Sometimes the inflammation in the gland proceeds to suppuration. The inflammation that takes place in the lympha- tic vessels is of the erysipelatous kind, and sometimes terminates in, mortification. At other times, however, it resembles rheumatism, and in several instances abscesses have been formed in the cellular substance. Ulcers which are difficult to care are in some cases the consequence of these abscesses. Dr. Hendy conceives, that the lymphatic vessels being inflamed and obstructed, will be incapable of absorbing and transmitting the lymph deposited in the cellular membrane by the exhalant arteries; that an undue accumulation of this fluid in consequence taking place, the skin will be distended; that the great distention will crack the skin and suffer the lymph to ooze through the fissures, and that this fluid drying, occasions the scaly scabby appearances exhi- bited in those cases. He illustrates his opinion by an appeal to the late Mr. Hewson's experiments, by which we are taught that the lymph deposited in the cavities and vessels of an healthy animal will always jelly on being exposed to the air. The parts most apt to be affected with this disease are the infe* rior extremities, but the penis and scrotum are also very frequently the seat of it, and the latter in some cases becomes of an uncom- mon magnitude. In the sixth volume of* the Medico-Chirurgical Transactions, p. 73, a case is recorded in which the tumour mea- sured longitudinally, from the symphisis pubis to its base, 29 inches, circularly 43. It was removed by an operation, and weighed 70 pounds. The patient recovered and lived many years afterwards. tJpon examining the tumour, the testicles were found to occupy their natural position ; the left one was about the size of a hen's egg; the tunica vaginalis of the right side contained three pints of water, but the testicle was considerably diminished. The right side of the scrotum being opened, the integuments at the upper part were about two inches in thickness; nearer the base they increased to four inches and a half; a fluid oozed from its substance, and the cavity was filled with gelatinous matter and a fluid: on cooling, the lattej became gelatinous also. The occasional cause of (lie disease is referred by Dr. Ilc'ndy Order til.} ELEPHANTIASIS. 6.63 Chiefly to cold; ^and he considers the peculiar dryness ©f the atmos- phere of Barbadoes, arising from its being cleared of woods, with tyhich the other West India islands abound, as the circumstance which renders the people of Barbadoes particularly liable to this complaint. What the real cause may be I will not pretend to de- 'termine, but I think it may be owing more likely to some peculiarity in the waters of that island. The inhabitants of certain district^ abounding with saline and mineral springs, are more frequently afflicted, we well know, with diseases of the glands in the neck, such as the goitre and Derbyshire neck, than persons residing in other situations. Although there is some little difference in the appearance of the two affections here described, the Barbadoes disease strongly re1- s'embling the chronic stage of phlegmasia dolens, (see this affection) Still both require a similar treatment at their onset. Notwithstanding that the fever which precedes the inflammatory affection of the groin sometimes runs high, still it seldom will be necessary, in elephantiasis, to have recourse to the lancet in order to moderate it. Should any great degree of nausea prevail, it may he advisable to give an emetic; and after its operation, if the body should be costive, some gentle purgative may be administered. To promote a moderate perspiration, the diaphoretics advised under the head of Simple Fever may be prescribed; to assist the effect of which, the patient should drink plentifully of warm diluting liquors. The parts affected are to be well fomented with cloths dipped in a warm infusion of emollient herbs, and afterwards be wrapped up in flannel. At the commencement warm bathing might possibly be of use. When the fever goes off, the cinchona may be given with advan- tage ; and it is probable that an issue put into the thigh might he serviceable. If suitable means have been neglected on the first attack of the disease, and the leg has become much enlarged, with a scaly and irregular surface, no cure can be expected. It is probable, howeverj that gentle alteratives,* with warm bathing, might somewhat retard its progress. The decoct, sarsaparillae compos, mezerei, or lobelias syphilitica^ (see Lues and Leprosy), might also be used with advan- tage, changing the one for the other as the circumstances of the qase may seem to require. * 1. R.. Antimon. Sulphureti Praecipit.f* 1. Take Precipitated Sulphur of Antimo* 3ij. ny, two scruples. Hydargyr. Submuriat. 3j. Submuriate of Mercury, o;ne | scruple. Pulv. Gum. Guaiac. 3j. Powdered Gum Guaiacum,one " drachm. Syrup. Simpl. q. s. M. Syrup, a sufficiency to form the F.Jatft pilulae xxx. Capiat j. vel. ij. mane mass, out of which let thirty pills be made. e"t nocte, quotidie cum De£,o.ct> Sarga- One or two of these may be taken niglit paril. Cftmpos. O.S.S-. and morning, with half a pint of the compound Decoction of Sarsapar/lla. SlM CACfiEXLE, OR CACHECTIC DISEASE^. [ClllSS HL A case of elephantiasis, reported by Mr. Ward of Manchester, in ftre 9th vol. of the Medical and Physical Journal, p. 545, induce* me to recommend a trial to be made of the effect of pressure. The "best mode of applying it is that advised by Mr. Baynton, in the cure of ulcers, and which is fully detailed in the treatment of these Complaints ; but previous to the application of the strips of adhesive plaster and bandage, it will be advisable to wash the tumid parts" Very well with tepid water and soap at least two or three times a vfeek. It appears from some late accounts that the Hindoo physician's Use arsenic internally in the treatment of elephantiasis. They make it into pills with pepper in the following manner :— . Take of white arsenic, fine and fresh, one part; of picked black f| pepper, six parts. #' Let both he very well beaten together for a considerable timft in an iron mortar, and then reduced into an impalpable powder in one of stone, with a stone pestle; and thus completely levigated, a little water being mixed with them, make pills of them as large as fares or small pulse, and keep them dry in a shady place. ,* They direct one of these pills to be taken morning and evening with some betel-leaf, or in countries where this is not to be had^ with cold water. If the body be cleansed from foulness and ob- structions by gentle cathartics and bleeding before the medicine is administered, the remedy, we are told, will act more speedily. When an amputation of the diseased limb is submitted to, in conseqence of the great encumbrance, a proper discharge should, fbi? very obvious reasons, be promoted from the other leg by means ©fan issue, or from the end of the stump itself, provided the ampli- 9 Ration has been made below the knee. LEPRA, or LEPROSY. Leprosy consists in an eruption of copper-coloured spot's dis- persed over various parts of the body, with some degree of insen- sibility in them, together with a glossy and scaly appearance of the skin, thickening of the lobes of the ears, falling off of the hair, hoarseness of the voice, offensiveness of the breath, and ulcerations in various parts. Monsieur Sonnini informs us*, that the leprosy, whatever may he its nature, is not in Egypt considered as a contagious disease* and that lepers are not there, as in Turkey, secluded from society. The Egyptains take no precautions to preserve themselves from in- fection, nor do they consider that this indifference is attended with the smallest danger. In so doing, I must say, they lie under a great error, for the disease is very readily propagated from one person to another by contact or cohabitation, as I have often witnessed: during my residence in the West Indies* * See his Travels through Egypt p. 5.5.Q. Order HI.J LEPROSY. 6.6.0 He further mentions, that from a variety of observations, it appears that persons afflicted with the leprosy have ardent dispo- sitions towards the physical instances of love; and he quotes an instance of a leper, who on the very night of his death was several times hurried away by the warmth of his temperament. He tells Us, he has noticed at Canea, in the island of Candia, great numbers of lepers, both men and women, banished without the gates of the city in miserable hovels, where they abandoned themselves to the greatest excesses of voluptuous irritation. They were sometimes to he seen satisfying their disgusting and impetuous lust in open day, by the side of the roads leading to the town near which they lived ; but, he observes, it is only those who are troubled with that species of leprosy which is confined to the joints that have this dis- position to venery. Those afflicted with the other species of leprosy which Hilary has distinguished, in his Treatise on the Diseases of Barbadoes, under the title of Leprosy of the Arabs, have no such propensity. The sufferings these undergo deprive them at once of every kind of desire, as well as of the means of gratification, sup- posing they even possessed the power. Dr. Adams also observes, in his Treatise on Morbid Poisons, that in many cases of this affection the genitals diminish, the testicles waste away and are absorbed, and all sexual appetite is lost. The same circumstances are noticed by Dr. Gourlay in his History of Madeira. The disease arises sometimes from an hereditary taint or pre- disposition, being in that case entailed from one' generation to another; but it more commonly proceeds from infection, commu- nicated either by cohabiting, or otherwise coming in contact with those who labour under it in a high degree. That a predisposition to the leprosy is often derived from the parents, 1 have had the most convincing proofs, having seen it affect many persons of one family, although they have been kept apart from each other. The leprosy shows itself in numerous copper-coloured spots dis- persed over the whole body, which are attended with a degree of insensibility, and these keep increasing gradually, both in size Stnd number, perhaps for some months, without occasioning any great alteration in the general state of health. As the disease advances, however, the skin begins to grow rough and scaly; the features of the face become greatly enlarged^ especially above the eyebrows, the hairs of which, and the beard, fall off; the alae of the nose swell and become scabby ; the nostrils ulcerate ; the voice is hoarse, and the pronunciation nasal; the lobes of the ears are greatly thickened, and affected with tubercles and dry scabs ; and sometimes ulcers are produced upon the fingers and toes, which at Tast separate joint after joint; the breath is highly offensive ; fetid virulent sores arise in various parts of the body, which becomes at length a putrid mass ; it wastes daily* and nature at last sinks under the weight 6f misery. This is the form under which the leprosy is usually met wJth in 85 666 cachexia:, Or cachectic diseases.. [Class ill. warm climates among negroes, a race of people seemingly more liable to its attacks than whites; but in cold climates it always appears under a much milder form, and is never attended with the violent symptoms just enumerated, seeming to be merely a local disease of the cutis, its vessels and glands. Although by paying a proper attention to regimen, and adminis- tering alteratives, we may be able somewhat to retard the progress of the disease, and thereby prolong the life of the patient, still when the habit becomes generally tainted, all means will be likely to prove inefficacious. When it arrives at the stage of ulceration it is highly infectious by contact. In dissections of leprosy, all the organs have been discovered in a state of putrescency except the heart. If any relief is to be afforded in this disease, it is chiefly to be obtained by the regular and rigid observance of a vegetable diet, commenced on the first appearance of its approach. As soon, therefore, as any symptom of it is observed, the patient should he debarred from fish, butter, and all sorts of animal food whatever, substituting fruits and vegetables of various kinds; and this course ought to be persisted in for the remainder of his life. At the same time that he gives up the use of animal food, he ought likewise to avoid all heating liquors, such as wine and spirits. Besides paying much attention to diet, he is likewise to take a due proportion of moderate exercise, and to keep his body regularly open by efficient laxatives. Small doses of mercury joined with antimony have been given at an early period of the disease, but I cannot say I ever saw any good effect derived from their use. A solution of hydrargyri oxymurias and Plummer's pill,* are the preparations most in repute, and with these the patient may drink about a pint a day of the decoctum sarsaparillae compositum. A decoction of elm-bark taken in the same quantity daily, has proved highly serviceable in some cases of incipient leprosy. A beer made from the essence of spruce fer- mented with molasses or syrup, and used for ordinary drink, has likewise proved beneficial in some instances. Strange remedies, such as viper and lizard broths, have been recommended in the cure of leprosy; but on all the trials which I have known made with them during my practice in the West Indies they proved wholly inefficacious. Arsenic has lately been proposed as a remedy, which we are given to understand is much used in Asia in this disorder. The arseniate solution or liquor, as mentioned under the head of Inter- * 1. Hydrargyri Submuriat. Antimon. Sulphuret. Prsecip. aa 3ss. Guaiac, Gumm. Resin. 3>j- Syrup. Simpl. q. s.. M. Fiant pilulae lx. Capiat j.—iv. omni iiQCte hora decubitus.-. * 1. lake Submuriate of Mercury, Precipitated Sulphur of Antimo.ny, of each half a drachm. Gum Guaiacum, two drachms. Syrup, a sufficiency. Form sixty pills out of the mass, and let from one to four be taken every night at Order Ut.\ LEPROsV. 667 mittents in the dose of about six drops three times a day, increased gradually to twelve or fifteen; or the pills as advised under that of Elephantiasis, may be employed; and indeed, as the disease is accompanied by symptoms of general debility, the remedy appears well calculated to prove serviceable. As a putrid disposition evidently prevails in leprosy, might not a long-continued course of the bark of cinchona, joined with muriatic or nitric acid, be likely to produce a good effect ? In in- cipient cases, I think, there can be no doubt but that the cinchona bark, with the mineral acids, might be of service. Possibly the oxygenated muriate of potass may be a good auxiliary. If tried, it ought to be given in the form of solution. To counteract the corrosive effect of the matter discharged from Ihe sores, as well as to lessen the disagreeable sensation in the skin, the surface of the body should be washed frequently with some saponaceous solution, or with lime water in a tepid state. The ulcers ought to be regularly dressed with some absorbent ointment- To prevent the leprosy from spreading, it will be necessary to avoid any kind of close communication with persons who are infected. It is too customary with proprietors and managers of estates in the colonies to turn such negroes adrift on the public, and being thus exonerated frOm labour and servitude, they range about, and infect all those with whom they either cohabit or associate. It is true, indeed, that the legislative body in many of the islands has enacted laws for the prevention of this evil; but, from a neglect in the magistrates and constables to enforce them, they are wholly disregarded, and the disease has become a very frequent one. The mild species of leprosy met with in cold climates is to be removed by small doses of mercury conjoined with antimony, as* in Plummer's pill, given so as to produce an alterative effect, as~ sisted by warm bathing and a decoction of the woods, mezereon, lobelia syphilitica, and the decoct, dulcamara? or decoct, astragali, as mentioned under the head of Syphilis. These will cleanse and soften the skin. The mineral solution may prove a good remedy in many cases of lepra, and we may add the nitric acid as an aux- iliary to it. The conjoint effect of these medicines possibly may accomplish what either separately would not. A gentle aperient of the saline class ought to be repeated at due intervals during the progress of the cure. As- a vehicle for both the mineral solution and nitric acid, we may employ the decoctum ulmi, of which the patient may drink a pint daily. It sometimes happens that the skin of leprous persons in this country is so tender and irritable as to. be disagreeably affected by even the mildest applications. In these instances, a strong infusion of the bruised leaves of fresh digitalis, with a small proportion of the liquor plumbi acetatis dilutus, has proved highly soothing and curative. . Harrowgate water has been found very serviceable, not only m a 6jS8 cachexia, or cachectic diseases. [Class III, great variety of cutaneous complaints of a trifling nature, but like- wise in many of the more obstinate and painful disorders of the' skin, such as the elephantiasis and leprous eruption. These com- plaints receive material advantage by employing the warm bath, which accordingly makes part of the plan of cure ; and during its use, very moderate doses of the water warmed, and repeated at proper intervals, will materially assist in keeping up that full perspi- ration which is promoted by the bathing, and always continued for some hours, by confining the patient in bed after immersion, wrap- ped up in flannel. In this respect, however, the cold sulphureous waters are not so advantageous as those which are naturally hot; for the former, in being artificially warmed, must lose some of the sul- phureous gass, on which part of their efficacy, even when applied externally, must depend; but we have no natural springs of this kind in our country. They are,^iowever, to be met with at Aix-la-Cha- pelle, in Germany, and in our two colonies, the islands of Jamaica and Nevis. Persons resident in these places, who labour under le- prous eruptions, should not fail to avail themselves of the advan- tages to be derived from these waters. We are informed by Dr. Kinglake,* that, in several eases of chronic eruption on the cuticular surface, which had resisted the warm bath, the internal and external use of the oxymuriate of mercury, antimonials, guaiacum, and likewise the nitric acid, he performed complete cures by giving the patient ten drops of the sulphuric acid three times a day in a tea-cupful of pure water, and by washing the eruptions with a solution of the same mixed in / water, in the proportion of half a drachm of the former to one pint of the latter. This was done by dipping a small piece of linen in the liquid, and moistening with it the parts affected. He observed that the external application was'productive of severe pain at first, but this inconvenience daily diminished. The dose of sulphuric acid above mentioned is calculated for a child of three years of age, but adults may take thirty drops thrice a day in half a pint of water, gradually increasing the quantity to a tea-spoonful or two. If attended with any purgative effect, a small addition of tinctura opii may be made. PLICA POLONICA vel TRICHOMA, or PLAITED HAUL Plica Polonica is a disease in which a morbid matter is deposited upon the hair, and binds it together in such a manner, that to unravel it is impossible. In Poland, Lithuania, Hungary, Transylvania, Prussia, Russia, and Tartary, it is endemial; but the scalp is not its only seat, for it sometimes extends to the hairs of the pubes. The exciting causes of the disease are uncertain, as neither the air, water, nor food seem to have any effect in producing it; nor * See Medical and Physical Journal, vdl. iv. p. 482. Order III.] plaited hair. 669 are cleanliness Tind regular combing of the hair, it is said, any defence against it. Certain it is, however, that it prevails only among the lower clas3 of people, and who are neglectful of personal cleanliness; for the opulent are generally exempt from plica, and the disease is pretty generally met with among the poor who live in filth and misery, particularly among the Jews, a race of people so negligent of cleanliness both in their persons and dwellings. Prom s;ome observations made by Mr. Frederick Hoflman, surgeon to the Prussian army, it appears that a predisposition to it may be trans- mitted from parents to their offspring; and, he observes,* that as no other cause can be assigned for the disease, it is probable that it arises, according to the general opinion, from contagion; a contagion which, like that of psora, can be communicated by contact only. I confess that I look on plica polonica as a mere local disorder arising from a great length of hair, and neglect of combing it, and produced evidently by sweat^ dirtiness, and vermin; for the hair, when kept short, and due cleanliness is observed, never contracts plica, as I am informed. The military police enforces this on the Polish militia and recruits every year; and if any of them happen te have the plica, their locks are cut off, and their heads shaved without scruple or danger. We are told by Mons. AJibert, physician to the Hospital of Sh Louis, at Paris,! that as the Poles rarely comb, and scarcely ever wash or clean their hair, which they suffer to grow very long, and as they wear warm for caps, the disease in question is mueh favoured thereby. By the heat, he says, an afflux of humours is determined towards the head, which thus becomes a common sewer to all the organs of the body, whilst by its nastiness the pores are so obstructed, that the exuberant fluids are forced through the canals of the hair. He observes, that plica is sometimes communi- cated by contagion, and sometimes by suckling, but he has noticed •at the same time that strangers are but little liable to be affected by it The nature of this disease was narrowly investigated by Baron Larrey,\ Inspector General of the French Army, when at Warsaw, and he was fully satisfied that it is a local and factitious complaint, produced by dirt and neglect; likewise that it is not contagious, a.nd may be cured with facility, notwithstanding the absurdities which prejudice has set forth to the contrary. According to Monsieur de la Fontaine,|| an eminent physician at Warsaw, the proximate cause of the disease seems to be a pecu- liar morbid matter, which is clammy and acrid, has its seat in th'e lymph, and is deposited critically upon the hair. * See his Observations on Plica Polonica, vol. iv. part ii. ef the Memoirs of the" Literary and Philosophical Society of Manchester. + See his Description des Maladies de la Peau. ^ISee his Memoires de Chirurgie Militaire et Campagnes. || See article the first, vol. the 1st, of the Annals of Medicine for the Ye.ar 17&5, bj' Andrew Dunc.an, M. L>. 670 CACHEXIA, OR CACHECTIC DISEASES. [CUtSS Hi* An opinion universally prevalent with.the Polish peasants is, (hat the disease is a salutary effort of nature to expel a morbid matter from the body, and that to interrupt the course of it would be productive of danger; hence they make no attempt to cure or even palliate the complaint. This opinion is, however, erroneous, as will appear from what I have already mentioned, as well as from the occurrence afterward recited. Both sexes have been observed to be equally liable to the attacks of plica. It more usually comes on during infancy than after the age of puberty. Besides the human species, other animals, such as the horse, and those of the canine species, as dogs, wolves, and foxes, are said to be subject to this complaint. The accession of the disease, we are told, is commonly preceded by general lassitude and heaviness, pains in different parts of the body, particularly in the head and eyes, and some degree of febrile affection, all of which diminish or cease immediately on the appearance of the plica. Most usually the hairs of the head are alone affected, and that only in particular parts. In these the hairs grow considerably longer than in the rest, they often seem greatly enlarged in their diameter, and are much knotted and entangled; being also covered with the viscid matter which issues from their roots, and which assists in gluing them to- gether. In proportion as the quantity of this gluten, and the implication ef the hair increase, it is still more and more difficult to clean and comb it; hence a degree of phthiriasis is produced, and the head contracts an extremely fetid smell, to which, however, the Polish peasants are so much accustomed, that they endure it without complaint or any manifest inconvenience. In consequence of frequent scratching, the nails of the fingers being imbued in the matter, now and then become diseased : they increase in thickness, change their colour, and are unequal on their surface. The disorder frequently continues for life, when neglected ; but is not found to be attended with fatal consequences, except perhaps from an injudicious mode of treatment. In the beginning of the disease, we are recommended by Mons. de la Fontaine to employ resolvent, attefiuant, saponaceous, demul- cent, and emollient remedies, to prepare the morbid matter for a crisis. If these be not sufficient, he adds extract of aconite, or hemloek, the submuriate of mercury, or some antimonial. In general, he says, antimony is a specific in this disease. If it be complicated with lues, muriated mercury in small doses produces the very best effeets, but salivation is highly detrimental in every case. These remedies can only be employed when no fever is present; in this case blood-letting and evacuants must be used very cautiously. Mons. de la Fontaine compares the disease to the small-pox, and observes, that when the fever is too weak to pro- Order III.] TLAITE© HAIR, 671 duce the eruption, it must be increased ; when it is too violent, it must be diminished. Hence the strength of the patient must often be supported with a generous diet. To bring about a crisis, we are advised to make use of sudorifics. If the morbid matter be deposited on the surface of the body, it occasions malignant and obstinate sores, which give a great deal of trouble. Antimony should always be an ingredient in whatever medicine we administer. When our endeavours prove inadequate to produce the crisis, inoculation of the disease will often, it is alleged, effect it. Thus is performed by putting on a cap which has just been worn by one who has a recent plica. After a complete crisis, the plica sepa- rates from the head, and remains attached only by the sound hair. If it has become dry, and all symptoms have ceased, it may be cut off. External remedies are always proper and necessary; such as the application of warmth to the helad in the form of vapour, warm. bath, or fomentation: washing the head with a warm solution of soap will likewise prove serviceable. Hair-powder rubbed with mercury will be a good remedy to destroy the vermin. Where the patient is much incommoded by a headach, the application of a blister to the neck or between the shoulders may possibly relieve it. It has before been stated that the opinion generally entertained in Poland, that there is danger in cutting off the hair in this dis- ease, and promoting the cure by external remedies, is wholly erroneous. The following fact, which occurred at Breslaw, and communicated by Dr. De Carro, of Vienna, in a letter to the Editors of the Bibliotheque Britannique, fully establishes this as- sertion. " Some years ago, one third of the recruits of the regiments of artillery brought from South Prussia, were attacked with plica polonica. An order was received from Berlin to send to that city all those that were infected, and to take care that the disease was not communicated to others. This order, it appears, was not agree- able to the commanders of companies, as it would have occasioned the loss of at least two hundred young soldiers. M. Haenel, surgeon-major to the artillery regiment, became mediator in the cause: he made the recruits be brought on the ramparts, and ordered that a general shaving should be made. In a little time, a pile of a plica was accumulated ; these trophies were then cast into a ditch, and the heads of the men carefully washed with soap and water daily for some weeks; by this simple method those dirty Polanders were speedily transformed into good soldiers, without having in the least suffered by the loss of this precious ornament of their heads." This statement clearly points out the absurdity of the opinion entertained by the generality of the Polanders, and shows that the disease in question may be cured with as much safety as tinea 672- GAeHEXLE, OR CACHECTIC DISEASES.. [CUtSS III, capitis.*' It likewise evinces that many of the external remedied which have been advised in the latter may be employed with ad- vantage in the former: indeed tinea capitis and plica polonica seem, I think, to he very similar diseases. SCORBUTUS, or SCURVY. • The characteristics of this disease, as affixed by Dr. Cullen, arfe debility ; bleeding of the gums ; spots of different colours on the skin, for the most part livid, particularly at the roots of the hairs, occurring in cold countries, after living on putrescent salted animal food, with a deficiency of recent vegetable matter. The scurvy is a disease of a putrid nature, much more prevalent jn cold climates than in warm ones, and which chiefly affects sailors, and such as are shut up in besieged places, owing, as is supposed, to their being deprived of fresh provisions, and a due quantity of acescent food, assisted by the prevalence of cold and moisture, and by such other causes as depress the nervous energy, as indolence, confinement, want of exercise, neglect of cleanliness, much labour and fatigue, sadness, despondency, &c. These several debilitating causes, with.the concurrence of a diet consisting principally or Salted or putrescent food, with foul water, will be sure to produce this disease. It seems, however, to depend more on a defect of nourishment than on a vitiated state; and the reason that salted provisions are so productive of the scurvy, is, most probably, be* cause they are drained of the nutritive juices, which are extracted and run off in the brine. As the disease is apt to become pretty general among the crew of a ship, when it has once made its ap- pearance, it has been supposed by many to be of a contagious na- ture ; but the conjecture seems by no means well founded. The. circumstance arises most probably from the men being alike ex- posed to the exciting causes of it. A preternatural saline state of the blood has been assigned as its proximate cause. It has been contended by some physicians, that the primary jporbid affection in this disease is a debilitated state of the solids, arising principally from the want of aliment. Various theories have indeed been advanced with respect tp scurvy. By Sir John Pringle it has been supposed to be owing t& a putrescency of the blood. By Dr. Lind, Dr. Blane, and Dr. Millman, it has been looked upon as a disease of debility, having its origin in the weakness of the organs of digestion, or in the gradual diminution of the vital power by the remote causes: or that it is owing rather to a defect of nourishment than to a vitiated state of it. Dr. Trotter, reasoning from the experiments of Dr. Goodwin concerning the action of dephlogisticated air on the blood, infers that the black colour of this, in scurvy, is owing to the "* See vol. vi. p. %1, of the Medical Transactions of the London College for a paper to this purport? Order 1I.J SCURVY. 673 abstraction of this principle, (dephlogisticated air) and thatfresh ve- getables cure the disease by restoring to the blood this lost principle. Dr. Beddoes supposes scurvy to be owing to a gradual abstraction of oxygen from the whole system, just as death is produced in drowning, by withholding all at once the same substance from that blood which is to pass the posterior cavities of the heart. Of the two causes of scurvy, want of fresh vegetables, or want of air suffi- ciently furnished with oxygen, Dr. Beddoes thinks the latter is by far the most powerful. Captain Cook's unexampled success in preserving his crews from the scurvy during his two last voyages, seems to have been owing in a great measure to his extreme care in keeping every part of the ship well ventilated. The crew on many occasions were reduced to salt provisions, and much longer out of sight of the land than many other ships which have been dreadfully afflicted with the scurvy. In his last voyage there did not appear among the men any symptom of this disorder; and ia his second, only one man had it in any considerable degree. The scurvy comes on gradually, with heaviness, weariness, and unwillingness to move about, together with dejection of spirits, anxiety, and oppression at the prascordia, considerable loss of strength, and debility. As the disease advances in its progress, the countenance becomes sallow and bloated ; respiration is hurried by the least motion; the teeth become loose ; the gums are spongy, swelled, and bleed upon the slightest touch; the breath is very offensive ; livid spots appear on different parts of the body; old wounds which have been long healed up, break out afresh; severe wandering pains are felt, particularly by night; the skin is dry; the urine small in quantity, turning blue vegetable infusions of a greencolour ; and the pulse is small, frequent, and towards the last, intermitting; but the intellects are for the most part clear and distinct. In some cases of scurvy, and even in its incipient stage, nyctalopia has been observed as one of the attendant symp- toms*. By an aggravation of the symptoms, the disease in its last stage exhibits a most wretched appearance. The joints become swelled and stiff, the tendons of the legs are rigid and contracted, general emaciation ensues, haemorrhages break forth from the nose, ears, anus, and other parts of the body, fetid evacuations are discharged by stool, and a diarrhoea or dysentery arises, which soon terminates the tragic scene. Scurvy, as usually met with on shore, or where the person has not been exposed to the influence of the remote causes before enumerated, is unattended by any violent symptoms; as slight blotches, with scaly eruptions on different parts of the body, and a spunginess of the gums, are the chief appearances to be ob- served. In forming our judgment as to the event of the disease, we are * See Dr. Blane's Work on the Diseases of Seamen. 86 674 cachexia, or cachectic diseases. [Class 111. to be directed by the violence of the symptoms, by the situation of the patient with respect to a vegetable diet, or other proper substi- tutes, by his former state .of health, and by his constitution not hav- ing been impaired by previous disorders. The person being capable of muscular motion with little reduc- tion of strength, the health not injured by previous disease, the skin moist, the pulse slow, a gentle bilious diarrhoea, the absence of ulceration, and the petechiae, if any appear, being of a bright red colour, are to be looked upon as favourable circumstances ; whereas great prostration of strength, flushed countenance, quick weak pulse, extreme oppression at the praecordia, fetid and invo- luntary evacuations, petechiae and maculae of a dark livid colour, and profuse haemorrhages of dissolved blood, denote the highest degree of danger. Dissections of those who die of scurvy have always discovered the blood to be in a very dissolved state. The thorax usually contains more or less of a watery fluid, which in many cases pos- sesses so high a degree of acrimony as to excoriate the hands by- coming in contact with it. The cavity of the abdomen contains the same kind of fluid. The lungs are black and putrid ; and the heart itself has been found in a similar state, with its cavity filled with a corrupted fluid. In many instances, the epiphyses have been found divided from the bones, the cartilages separated from the ribs, and several of the bones themselves dissolved by caries.— The brain seldom shows any marks of disease. From experiments made on the blood and urine of scorbutic patients, it appears that three ounces of blood, on cooling, con- sisted of two ounces of coagulum and one of serum. The coagulum was composed of two parts; that on the top, about the sixteenth of an inch, was of a florid red, and tough; that in the bottom, of a deep red, approaching to black, and easily divided. The serum, with respect to colour, was not uncommon. Vinegar did not alter the colour of the black part of the coagulum. By the addition of lemon-juice it became somewhat lighter; on the admixture of a solution of nitre in vinegar it became of a florid red: the same took place with nitre and lemon-juice. By the subcarbonate of ammo- nia and diluted sulphuric acid, the coagulum was turned black, and was again rendered florid by the addition of nitre in the juice of lemons, and in vinegar. To counteract the principal remote causes of the disease, viz. the effect of salt provisions, and the want of fresh meat and vegetables, every ship bound on a long voyage should be supplied with an ample store of flour, eggs for puddings, pearl barley, groats, peas, oatmeal, rice, sago, vermicelli, portable soup, potatoes, and other vegetables in season, sour krout, (which is cabbage fermented with vinegar) raisins, currants, prunes, and other dried and fresh fruits, various spices, many kinds of medicinal herbs, as balm, mint, penny- royal, sage, &c.; together with tea, coffee, cocoa, sugar, treacle, honey, Seville oranges made into marmalade, essence of spruce, Order III] SCURVY. 675 and fresh wort. High encomiums have indeed been passed on the efficacy of this last by all the navigators who have made trial of it, and they seem by no means to have been unworthily bestowed ; but as its salubrious qualities are greatly impaired by becoming damp and mouldy, every possible care should be taken to prevent this from happening. Besides the articles which have been enumerated, the ship should likewise be supplied with a sufficient store of spirituous and fer- mented liquors, as rum, brandy, beer, and porter, together with wine, cider, vinegar, and other acids, but more particularly the concrete juice of lemons, limes, and oranges, together with these fruits in their natural state. If possible, a milch cow should be embarked, and there ought to be an abundance of live stock. If it can be avoided, salted provisions should by no means be constantly served out to the crew; but fresh animal food, with a due proportion of such farinaceous substances as the ship is sup- plied with, or of such fresh vegetables and fruits as have been procured at whatever ports it may have touched, ought to be de- livered out to the men. The vegetable food with which seamen are principally supplied, consists of flour, biscuit, and peas, and it very frequently happens that a great deal of the former which is served out to crews on board of his Majesty's ships, is in a de- cayed state, and by no means equal to the support of their strength. The biscuit likewise which is furnished them is often too old, is worm-eaten, and has lost much of its nutritive quality. The health of seamen may be supposed to depend considerably on the goodness and purity of the water which they drink, as well as on the nutritive quality of their food; but it too frequently happens, by an inattention in laying in the store of this necessary article, that it very soon becomes both putrid and offensive, and in this state they are obliged to make use of it. Nothing has been found so effectual for preserving water sweet at sea, during long voyages, as well charring the insides of the casks before they are filled; and certainly it would be highly advisable for our Admiralty Board to issue orders for the universal adoption of this process throughout the navy. Care ought at the same time to be taken that the casks should never be filled with sea water, as sometimes happens, in order to save the trouble of shifting the ballast, because this tends to hasten the corruption of the fresh water afterwards put into them. When the water becomes impure and offensive at sea, from being ignorant of the preservative effect produced on it by charring the casks previous to their being filled, it may be rendered perfectly sweet by putting a little fresh char- coal iu powder into each cask before it is tapped, or by filtering it through fresh burnt and coarsely pulverized charcoal. Mr. Williams, of Portsmouth, one of the gentlemen entrusted by the Admiralty Board with making trials as to the best method of preserving water during long sea voyages, has experienced that 676 CACHEXI2E, OR CACHECTIC DISEASES. [ClaSS lilt of all the remedies tried during a course of many years' observation, none has answered better than the practice of charring the water casks on their inside. We are informed by him, that he has seen three casks of water in one of his Majesty's dock yards, of three years's standing, and perfectly sweet. There is, therefore, little doubt that water may be preserved fresh and fit for drink any length of time in charred barrels. It has generally been supposed that the putrefaction to which water is liable, arises from its con- taining organic matter; but this is not so much the case as a real decomposition of the water being effected by the chemical action of the wood, to which it is constantly exposed. To preserve seamen in health, and prevent the prevalence of scurvy, and other diseases, it will be further necessary to keep the ship perfectly clean, and to have the different parts of it daily purified by a free admission of air, when the weather will admit of it, and likewise by frequent fumigations, agreeable to the plan mentioned under the head of Typhus Gravior. This precaution will more particularly be necessary for the purification of such places as are remarkably close and confined. The coldness and moisture of the atmosphere are to be corrected by sufficient fires. Cleanliness on board of a ship is highly necessary for the preservation of the health of seamen ; but the custom of frequent swabbings or washings between the decks, as is too frequently practised, is certainly injurious, and greatly favours the produc- tion of scurvy and other diseases, by a constant dampness being kept up. The removal of all offensive substances by scraping and sweeping, has indeed been more accurately attended to during the late war than was formerly the case in the navy; and the washing of decks, particularly in cold and damp weather, has been much less prac- tised. Dryness, so essential to health and comfort, is now more studied, and rubbing with hot sand, scraping, and portable fires, have been found much more salutary operations than frequent washing. Gravel, sand, and other earthy substances which have hitherto proved prolific sources of foul air, by absorbing the putrescent matters on board of ships, have lately been dispensed with throughout the navy ; and what are called iron tanks are now pretty generally substituted for the lower tier of water casks, and placed over the iron ballast. The men should be made to air their hammocks and bedding every fine day ; they should wash their bodies and apparel often, for which purpose an adequate supply of soap ought to be allowed; and they should change their linen and other clothes frequently. In rainy weather, on being relieved from their duty on the deck by the succeeding watch, they should take off their wet clothes, instead of keeping them on, and lying down in them, as they are too apt to do. Two sets of hammocks ought to be provided for them. In fine pleasant weather, and after their usual duty is over, / Order UI.J SCURVY. 677 they should be indulged in any innocent amusement that will keep their minds, as well as bodies, in a state of pleasant activity, and perhaps none is more proper than dancing ; which makes a fiddle^ or a pipe and tabour, desirable acquisitions on board of every ship bound on a long voyage. No seaman labouring under any disease, especially one of a contagious nature, should be suffered to remain among those that are in health. On the contrary, he ought quickly to be removed to the hospital or sick room, a place which every ship that has a number of men on board should by all means be furnished with; and this should be situated in an airy and dry part of it. While speaking of the means of preserving the health of sea- men, it may not be improper to observe, although not immediately relating to the disease I am here treating of, that in warm climates the crews of ships are healthier at sea, when the air is dry and serene, and the heat moderated by gentle breezes, than when rainy or damp weather prevails; and they usually enjoy better health when the ship is moored at a considerable distance from the shore, and to windward of any marshy ground, or stagnant waters, than when it is anchored to leeward of these, and lies close in with the land. Masters of vessels stationed at, or trading to, any parts between the tropics, will therefore act prudently, when they have arrived at their destined port, to anchor a considerable distance from the shore, and as far to windward of all swamps, pools, and lakes as can conveniently be done, as the noxious vapours which will be wafted to the crew, when the ship is in a station of this nature, will not fail to give rise to diseases among them. When unavoidably obliged to submit to such an inconvenience, some means ought to be adopted to prevent disagreeable conse- quences from ensuing. For this purpose a large sail should be hoisted at the foremast or most windward part of the ship, so as to prevent the noxious vapours from coming abaft; the cabin, steerage, and between the decks should be fumigated now and then, and the seamen be made to smoke tobacco freely. Unless absolutely necessary, it will be improper to permit any of the crew to sleep from on board, when stationed off an unhealthy shore ; but when necessity obliges them to do so, for the purposes of wooding or watering, a tent or marquee should be erected, if a proper house cannot be procured, and this should be pitched on the driest and highest spot that can be found, being so situated a9 that the door shall open towards the sea. Under cover of this, a sufficient number of hammocks are to be suspended for the accom- modation of the men by night, as they should by no means be suf- fered to sleep on the ground. If the tent happens unfortunately to be in the neighbourhood of a morass, or has unavoidably been pitched on flat moist ground, it will be advisable to keep up a constant fire in it by day as 678 cachexia:, or cachectic diseases. [Class III. well as by night; and as a further preventive against those ma- lignant disorders which are apt to arise in such situations, the men should be directed to smoke freely of tobacco, and to take a wine-glassful of the tinctura cort. cinchona?, composita every morning on an empty stomach, and the same quantity again at night. In tropical climates, the healthiness of seamen will much de- pend upon avoiding undue exposure to the sun, rain, night air, long fasting, intemperance, unwholesome shore duties, especially during the sickly season, and upon the attention paid to various regula- tions and preventive measures. The bad effects of remaining too long in port at any one time, and independent of irregularities, of harbour duties, particularly after sun-set, as well as during his me- ridian power, cannot be too strongly adverted to by the commander of every ship ; and therefore a measure of the highest importance in the British navy is the employment of negroes and natives of the country, or at least men accustomed to the torrid zone, in wooding, watering, transporting stores, rigging, clearing, careen- ing ships, &c.; and, in fine, in all such occupations as might sub- ject them to excessive heat or noxious exhalations, which cannot fail to be highly dangerous to the health of the unassimilated European. The practice of heaving down vessels of war in the West Indies, in the ordinary routine of service at least, cannot be too highly deprecated, as well from the excessive fatigue and exertion it demands, as because it is a process which requires for its execution local security, or, in other words, a land that is locked, and there- fore generally an unhealthy harbour. The instances of sickness and mortality from the effects of clearing a foul hold in an un- healthy harbour, are too numerous to be specified; but Dr. Bancroft* makes mention of a particular one, on the authority of Dr. Dickson, in speaking of the production of the yellow fever, accompanied in a great many cases with black vomit and conse- quent death on board the Circe frigate, principally from the duties of clearing the hold, and heaving down, by which so many of the ship's company were soon after attacked with this fever, that one hundred and forty-six men were obliged to be sent to the hospital at Antigua. A very productive source of disease in warm climates among seamen, is an immoderate use of spirituous and fermented liquors, ns they are too apt, whilst under a state of intoxication, to throw themselves on the bare ground, where perhaps they lie exposed for many hours to the influence of the meridian sun, the heavy dews of the evening, or the damp chilling air of the night. The commander of a ship who pays attention to the health of his crew, will therefore take every possible precaution to prevent his men * Pee his Sequel to an Essay on Yellow Fever. Order III.J scurvy. 679 from being guilty of an excess of this nature; and likewise that they do not lie out in the open air, when overcome by fatigue and hard labour. The different voyages of that celebrated navigator, Captain Cook, as well as that of the unfortunate La Perouse, incontestably prove that by due care and a proper regimen, seamen may be preserved from the scurvy and other diseases which have formerly been inseparable from long sea voyages; and that they can support the fatigues of the longest navigations in all climates, in all lati- tudes, in the midst of fogs, and under a burning sun. In all long voyages it ought to be our object not only to find out and employ the most effectual means to cure the scurvy when it shows itself, but likewise to prevent its arising at all, as the taint never fails to give a fatal or malignant tendency to the other disor- ders incident to seamen, such as ulcers, dysentery, &c.; and with this view, our preventive plan ought to commence from the first day on which the sailing stock of fresh vegetables and ship's beer is ex- pended ; since from many experiments it appeals, that much greater success is likely to attend our endeavours in this way than by reserving them for the period in which the marks of a scorbutic diathesis begin to manifest themselves. When, from a want of the proper precautions before pointed out, the scurvy makes its appearance among a number of men, be it on board of a ship or in a close garrison, we are then to counter- act its effects, first by obviating the putrid state of the system, and secondly by restoring it to its former vigour. The first of these is to be accomplished by a diet of fresh animal and vegetable food, but more particularly the latter, consisting of garden and water-cress, mustard, horse-radish, common radish, scurvy-grass, celery, endive, and lettuces, all of which may be eaten in their crude state, together with spinach, beet, carrots, turnips, cabbages, cauliflowers, brocoli, asparagus, the young shoots of hops, &c.j which may be prepared by any common process of cookery. To these may be added, a free use of ripe fruits, especially those of a subacid kind, such as oranges, shadocks, and others of this class. For ordinary drink, the patient may use milk, or its productions, as whey, butter-milk &c, or else an infusion of malt or spruce. Such things are however only to be procured on shore, and therefore cannot be obtained for a sliip's crew, unless they remain in port. When at sea, other substitutes must be resorted to. One of the most effectual of this kind has been found to be lemon-juice, with which most ships belonging to government, and bound on a long voyage, are, I understand, now supplied; and I am informed that the daily regulated allowance is now one fluid ounce* mixed with one ounce and a half of sugar. Where fresh vegetables are not to be obtained, we ought to have recourse to this. To render its effects more certain, and prevent it from irritating the bowels, we should mix it with a sufficient quantity t»80 cachexia, or cachectic diseases. [Class-UL of water and sugar, which will make a pleasant drink usually known under the name of sherbet. If a due proportion of wine is added, it will render it still more antiseptic. The quantity of juice used during the first three or four days, ought not to exceed two ounces daily, but it may afterwards be increased to three or four per diem. In Dr. Trotter's Medicina Nautica is inserted a letter from Mr. A. Baird, surgeon to the Hector, ship of war, communicating to him the wonderful benefit derived from the use of lemon-juice in a voyage to and from the East Indies, during which, although the scurvy became very prevalent, he did not lose a single man. His words are, " When I consider the alarming progress which the scurvy was making among the Hector ship's company previous to the administration of lemon-juice as a preventative, the sudden check that disease met with afterwards, and the powerful effect of the acid in very bad cases, I think I shall not be accused of presumption when I pronounce it, if properly administered, a most infallible remedy both in the cure and prevention of scurvy." Where the fresh juice cannot be procured we may substitute with the greatest advantage the citric acid in a concrete form, at first prepared by Mr. Coxwell. We are informed by Dr. Trotter* that he has experienced its powers against scurvy to be equal to any effect he has ever observed from the recent fruit in its most perfect state. Other practitioners have reported alike favourably of it. It takes from sixteen to eighteen parts of water to bring the concrete acid to the standard of lemon-juice. It is obtained after the manner of Scheele,t by combining the fresh vegetable acid with lime, and then precipitating by means of the sulphuric acid. Dr. Trotter observes, that government mistake in making their contract for lemon-juice for the use of the navy, as what is fur- nished is often adulterated with the acetous acid, and sometimes contains the pulp, which render it liable to ferment. Lemon and lime-juice, he says, should be procured in Portugal and the West Indies, and in each place be combined with calcareous earth. It may be imported in barrels, and in that state be sent to sea, when the separation of the liquid acid is so easy a process as to require no trouble, and the medicine will be always in the best state. Combined with calcareous earth, the acid will remain unchanged for a great length of time. It has been common to employ the fossil acids in this disease ; but there is some reason to doubt if they are of any service, and it is certain they are not effectual remedies. Moreover, they can hardly be thrown in in such a quantity as to be useful an- tiseptics. • See Medical and Physical Journal, vol. iv. p. 154. t See Crcll's Journal for 1784. Order I1I.J SCURVY. 681 In a treatise on Scurvy, by Mr. D. Patterson, surgeon in the navy, we are informed, that from certain reasons, he was induced to try a solution of the nitrate of potass in common vinegar in several cases of this disease, which, with inexpressible pleasure, he saw to succeed in every one of them ; and from frequent trials of it he is convinced that the scurvy may be cured at sea without the assistance of recent vegetable matter. If this turns out as stated, the discovery will indeed prove of great national advantage. Mr. Patterson supposes that the good effects of the nitrate of potass in mitigating or removing the disease, are to be accounted for solely from the dephlogisticated or vital air it contains, and that it may be rendered more active by being combined with an acid. He allows common vinegar to be of little or no utility when given by itself; yet supposes, that if it was charged with dephlo- gisticated or oxygen air it might prove highly beneficial; and this he presumes to be effected by the addition of nitre. The following is his method of preparing this new remedy, and making use of it. At first he dissolved two ounces of nitre in one quart of the ship's vinegar, and gave half an ounce of the solution (which he named acidum nitrosum, or nitric vinegar) to some twice, to others thrice in the day, and as frequently bathed their blotched and ulcerated limbs with the same. From the good effect it had, and from its not producing the smallest degree of nausea, colic, or diarrhoea, he was induced to augment the dose to an ounce, and to repeat it as often as before. Finding by far the greater number of scorbutics who were under his charge bore the increased dose of the medicine without expressing the least uneasiness, he now, instead of two, dissolved four ounces of nitre in one quart of vinegar, and gave from half an ounce to two ounces of this strong solution twice, thrice, or four times in the day, if they were either blotched, stiff, or ulcerated. In this manner, we are informed, he continues to use it. He adds, " Some patients cannot bear the nitric vinegar without the addition of water; while others, without the least inconve- niency, bear it undiluted. The discharge by stool, or the presence of gripes, and nausea, guide me with respect to increasing or dimi- nishing the dose of the nitric vinegar; but at the same time it is not a slight degree either of nausea, colica, or diarrhoea, that ren- ders an alteration in the quantity of the medicine necessary. To a great number of scorbutic patients eight ounces of this strong solu- tion, containing one ounce of nitre, have in the course of the day, as long as such a quantity was necessary, been administered to each with the greatest success. Also, a circumstance no less curious than pleasing, large and frequently-repeated doses of this medicine have been given in cases of dysenteria scorbutica; and instead of increasing I have always found it remove the disease. Sometimes. notwithstanding the free use of the nitric vinegar, I have known constipation take place to a considerable degree : :n which ca=e I >oi~ cachexia, or cachectic disease.-. [Class HL have found intermediate doses of the potassa? supertartras neces^ sary and highly advantageous. This very constipated state gene- rally occurred where the disease was far advanced ; but in a few particular cases in delicate habits, and where the disease, was not far advanced, I perceived even small doses of the nitric vinegar ruffle the stomach and intestines ; to prevent or remove which I have found two, three, or four grains of camphor, with each dose of the medicine, very effectual." The effects of this medicine are as follow: "During a course of the nitric vinegar the belly in general is kept gently lax ; the dis- charge of urine is increased, and changes from the alkaline to a healthy nature; the skin becomes open and more agreeable to the touch; the chilliness is changed to a pleasing warmth; and the pulse acquires steadiness and healthy strength. Sleep comes to be more and more natural. The sallow and the gloomy is gradually changed into a clear and cheerful countenance. By degrees the inflammation of the mouth and nose subsides; the gums heal and get firm. The lower extremities lose faster than could have been supposed their livid hue ; they gradually become softer, less painful, and more flexible, and ulcers put on a healthy appearance and skin over. The great oppression about the breast and stomach gives way, and the cough and the breathing become less laborious. The appetite and the sense of taste are restored; the depression of spirits and the lassitude are not remembered; the strength increases, and at last health returns." Mr. Patterson, in comparing the effect of vegetable acid with that of the nitric vinegar, writes as follows:—"In the month of July, 1794, at sea, a small quantity of limes were purchased by order of Admiral Murray, for the use of the scorbutics at that time on board ; but instead of depending altogether on their power, I gave them only to a certain number, on purpose to compare their effect with that of the nitric vinegar, which was more generally administered; and from what I have seen of both, and after having weighed all circumstances, I am at present inclined to decide in favour of the latter." Such is the report made by Mr. Patterson on the effect of these two acids; and as he seems to attribute the good effect of the remedy which he most approves of to the nitre it contains, and not to the vinegar, I beg leave to propose the following query: Might not a solution of the nitrate of potass in lemon or lime-juice (which of themselves are powerful remedies in scurvy) be preferableto a solution of it in vinegar, or even to these acids given by themselves ? By the means which have been pointed out, together with some other auxiliaries, such as spruce-beer, fresh infusions of malt or wort, sugar, and the succus cochleariae compositus, we are induced to suppose that we shall in most cases, even in those of a desperate nature, be able to obviate the putrid tendency of the system, and effect a cure. Introducing oxygen into the system by any kind of means may likewise prove a good auxiliary. Order III.} sgurw, , 683 It appears that the gases were used by the celebrated navigator La Perouse in his voyage round the world; but he very wisely observes, that bottles-full of them might be swallowed without doing seamen a thousandth part of the good they receive from good slices of roast beef, turtle, fish, fruit, herbs, &C. In the course of the disease particular symptoms may arise which will require a separate treatment. Pains of the belly are to be allayed by emollients and opiates; oppression at the chest and impeded respiration by blisters, for bleeding is never to be used; contractions of the hams and calves of the legs are to be relieved hy fomenting the parts with warm vinegar and water, and by the application of emollient poultices and frictions; sponginess of the gums and looseness of the teeth are to be obviated by washing the mouth frequently with gargles of an astringent and antiseptic nature ;* and foul ulcers are to be cleansed and healed by washing them with lemon-juice, or a tincture consisting of equal parts of that of myrrh and cinchona bark, and then dressing them with some kind of digestive ointment, or a poultice of sorrel (see Ulcers.) Some navy surgeons report that they have known the most obsti- nate ulcers of a scorbutic nature cured by applying a paste of oatmeal and water to them, the surface being sprinkled with the liquor plumbi acetatis. In very bad cases of ulceration it is probable that the application either of the cataplasma effervescens, or cataplasma carbonis, as mentioned under the head of Gangrene, might be attended with a very good effect. Dr. Harness, physician to the British fleet in the Mediterranean some years ago,t informs us, that afterj the failure of other reme- dies in the cure of scorbutic ulcers, and those where there was a tendency to mortification, he found the application of the gastric fluid of graminivorous animals to have been productive of the hap- piest consequences. If in the course of the disease the bowels should not be loosened by the use of fresh vegetables, and costiveness prevail, we may then advise the taking a decoction of tamarinds with a little of the potassae supertartras to obviate it. Where the skin is dry and parched, a gentle diaphoresis may be excited by a decoction of the woods joined with antimony, as advised in lues venerea, or by camphor combined with the pulvis ipecacuanhae compositus. To answer the second indication of restoring the former t See Dr. Duncan's Annals of Medicine for 1797. ■* 1. r>; Infus. Rosae, f. ?yj. {* 1. Take Infusion of Roses, six ounces. Aluminis, 3jss. Alum, one drachm and a half. Mel. Optim. f. 3j. M. Honey, one drachm. ft. Gargarisma. «~ (Mix them for a gargle. Vel, Or, 2. pj; Decoct. Cinchonae, f. |vj. j 2. Take Decoction of Peruvian Bark, six ounces. Tincture of Myrrh, one ounce and a half. Muriatic Acid, from twenty U thirty drops. Tinct. Myrrh, f. 2jss. Acid. Muriatic, til xij.—xx. M. 684 CACHEXIA, OR cachectic diseases. [Class HI. vigour of the system, the patient should be put under a course of cinchona bark, with the mineral acids, chalybeates, and other tonics, as directed under the head of Dyspepsia. He should at the same time breathe a pure, temperate, and dry air; take such daily exercise as his strength will admit of, use a generous nutritive diet of fresh animal and vegetable food, and lead a life of great regu- larity and temperance. It has been generally supposed that scorbutic patients require land air, and land recreations, for their more speedy and effectual recovery. Dr. Trotter, in his Medicina Nautica, endeavours to controvert this opinion. His words are, " There is not at present an officer in the fleet, that, in doing justice to either his people or his country, would prefer the cure out of a ship. Nay, there is often the most urgent necessity for keeping them on board till they acquire a certain degree of strength. In the very weak state a scorbutic patient cannot bear the external air, which has been long observed, and recently confirmed by five men dying in the boat belonging to the Prince of Wales ship of war, between the Downs and Deal hospital." An instance is mentioned in Mons. Charpentier Cossigny's Voyage to Canton, of a German soldier of twenty-eight years of age who expired suddenly when the crew came in sight of the island of Roderigo, and who, although he had some slight symp- toms of the scurvy, was not so ill as to be entered on the sick list. M. Cossigny observes, that he has seen other scorbutic patients on inspiring the land air lose all their strength, and die while they were carrying to the hospital. He conjectures, that the density of the land air stifled the German soldier, his lungs having lost their elas- ticity, &c. Dr. Trotter's sentiments are corroborated by this gen- tleman's remarks. In those painful affections of the skin, of the kind usually termed scorbutic eruptions, that rise often without any very obvious cause, that chiefly depend on the habit of body, and make their appear- ance at stated intervals in painful ulcerations of the skin, producing a discharge of lymph, and an abundant desquamation, a long-con- tinued course of Cheltenham water is often attended with a very good effect. Where the disease is inveterate, it may be necessary to have recourse to alterative medicines, such as a combination of mercury with antimony (see Herpes,) together with the decoctum ulmi, nitric acid, spruce-beer, &c, and a diet consisting chiefly of vegetables and milk. Sea-bathing will also be proper. ICTERUS, or JAUNDICE. Jaundice is characterized by a yellowness of the skin, more especially observable in the tunica conjunctiva of the eyes, a bitter taste in the mouth, a sense of pain or uneasiness in the right hypo- condrium, whitish or clay-coloured faeces, and the urine obscurelv red, tinging things dipped into it of a yellowish colour. Order tll.J JALND1CE. 685 It takes place most usually in consequence of an interrupted ex- cretion of the bile, from an obstruction in the ductus communis choledochus, which occasions its passing again into the blood-ves- sels. In some cases it may, however, be owing to a redundant se- cretion of the bile. The causes producing the first of these are, the presence of biliary calculi in the gall-bladder and its ducts; inspissated bile; spasmodic constriction of the ducts themselves; and, lastly, the pressure made by tumours situated in adjacent parts: hence jaun- dice is often an attendant symptom on an inflammation or scir- rhosity of the liver, pancreas, &c. and frequently likewise on pregnancy. The proximate cause of icterus is absorption or regur- gitation of the bile ino the vascular system. Chronic bilious affections are frequently brought on by drinking freely, but more particularly of spirituous liquors; hence they are often to be observed in the debauchee and the drinker of drams. They are likewise frequently met with in those who lead a seden- tary life, and who indulge much in anxious thoughts. A slight degree of jaundice often proceeds from a redundant se- cretion of the bile, and a bilious habit is therefore constitutional to some people, but more particularly to those who reside long in a warm climate. By attending to the various circumstances and symptoms which present themselves, we shall in general be able to ascertain with much certainty the real nature of the cause which has given rise to the disease. We may be assured by the long continuance of the complaint, and by feeling the liver, and other parts externally, whether or not it arises from any enlargement or tumour in this viscus, the pan- creas, mesentery, or omentum. Where passions of the mind induce the disease without any hard- ness or enlargement of the liver or adjacent parts, and without any appearance of calculi in the faeces, or on dissection after death, we are naturally induced to conclude that the disorder was owing to a spasmodic affection of the biliary ducts. Where gall-stones are lodged in the ducts, acute lancinating pains will be felt in the region of the parts, which will cease for a time, and then return again; great irritation at the stomach, and frequent vomiting will attend, and the patient will experience an aggravation of the pain after eating. A pain at the top of the shoulder or right arm is another diagnostic of concretions in the gall-bladder and ducts. When calculi are passing through the common duct into the duodenum the symptoms are not so obscure and uncertain as when lodged in the gall-bladder. Sometimes the attack is preceded by or accompanied with a sense of coldness in the back and lower extremities. The person is seized with a sudden violent pain exactly where the common duct enters the intestine. The pain is often so circumscribed, that the patient is apt to say he can cover 686 CACHEXIA, OR CACHECTIC DISEASES, [ClaSS III the extent of it with a finger, and sometimes it shoots through the back, and extends up between the shoulders. Persons thus seized cannot endure a recumbent posture, but are obliged to sit up with the body bent forward, which seems to afford a slight mitigation of the pain. In most cases the stomach is so irritable that every thing is immediately rejected. Sometimes bile is brought up, but not always ; neither is vomiting a constant attendant. The intes- tines are invariably constipated; indeed, the whole canal appears to share the spasmodic state induced on the duodenum by the irri- tating cause. If the bile is completely obstructed in its passage into the intes- tine, the faeces will be of a light clay-colour, and the skin and eyes become yellow, from a regurgitation of the bile into the system. Although the pain is more exquisite than in hepatitis, and is some- times accompanied with great disturbance in the general system, such as heat of the skin, quickness of the pulse, thirst, white tongue, high-coloured urine with a dark-coloured lateritous sediment, still inflammation seldom occurs. Sometimes the disorder continues several hours, and then a remission of pain ensues, either in conse- quence of the calculus entering the duodenum, or otherwise falling back into either of the ducts or gall-bladder. After an interval of some days, or perhaps weeks, the paroxysm possibly returns again. indicating that the obstructing cause has not been removed. Biliary calculi are of various sizes, from a pea to that of a walnut, and in some cases are voided in a considerable number, being, like the gall, of a yellow brownish or green colour. They vary also with regard to their figure and hardness. Some are very rough and angular; at other times they are oval or round, and their surface smooth. Although these concretions have been generally found in the gall-bladder and ducts, yet they are sometimes met with in the pori biliarii and parenchyma or spongy and cellular substance of the liver. The experiments made by Dr. Saunders on biliary calculi prove them to consist chiefly of a resinous matter with a little earth (ap- parently calcareous) combined with the mineral and volatile alkali. The jaundice comes on with languor, inactivity, loathing of food, flatulency acidities in the stomach and bowels, and costiveness. As it advances in its progress, the skin and tunica conjunctiva of the eyes become tinged of a deep yellow ; there is a bitter taste in the mouth, with frequent nausea and vomiting ; the urine is very high coloured, and tinges linen yellow; the stools are of a grey or clayey appearance, and a dull obtuse pain is felt in the right hypo- chondrium, which is much aggravated by pressure with the fingers. Where the pain is very acute, the pulse is apt to become hard and full, and other febrile symptoms to attend. The disease when of long continuance and proceeding from a chronic affection of the liver or other neighbouring viscera, is often attended with anasarcous swellings, and sometimes with ascities. Petechiae and maculae sometimes appear in different parts of the Order HI.] jaundice. 687 body; the skin, before yellow, turns brown or livid ; even passive haemorrhages and ulcerations have broken out, and the disease has in some instances assumed the form of scurvy. Where jaundice is recent, and occasioned by concretions ob- structing the biliary ducts, it is probable that by using proper means we may be able to effect a cure ; but where it is brought on by tumours of the neighbouring parts, or has arisen in conse- quence of other diseases, attended with symptoms of obstructed viscera, our endeavour?, most likely, will not be crowned with success. Arising during a state of pregnancy, it is of little con- sequence, as it will cease on parturition. A gradual diminution of the sense of weight and oppression about the prascordia, a return of appetite, and of the digestive powers, the stools becoming copious and easily procured, the urine being secreted in a larger quantity, and ceasing to tinge linen of a yellowish colour, are*to be regarded as favourable circumstances. A violent pain in the hypochondrium or epigastrium, attended with a quick pulse, loss of strength and flesh, with anasarcous swellings of the extremities, chilliness, watchfulness, melancholy, or hiccup, denote great danger. On opening the bodies of those who die of jaundice, the yellow tinge appears to pervade even the most interior part of the body ; it is diffused throughout the whole of the cellular membrane, in the cartilages and bones ; and even the substance of the brain is occa- sionally coloured by it. A diseased state of the liver, gall-bladder, or adjacent viscera, is usually to be met with. Calculi are some- times found in the biliary ducts. As jaundice occurs in almost every morbid condition of the liver. and as its occurrence evidently does not depend upon a specific morbid action of that organ, some physicians have been induced to consider it only as a symptomatic affection. Under the general appearance of jaundice, we ought therefore by a careful investiga- tion to ascertain, as far as we are able, the real condition of the liver; for certainly such a discrimination must appear indispensably necessary, when it is considered that the mode of treatment must be varied according to the cause by which such an appearance is in- duced. The cure of the disease, unpromising as it may at times appear. is nevertheless to be attempted, first, by restoring the interrupted passage of the bile through the duct; secondly, by carrying it off by the intestines; and thirdly, by relieving the particular symptoms. Whether the passage of the bile is obstructed by biliary concretions or by spasmodic constriction of the "ductus communis choledocus, the same plan nearly must be adopted., Concretions, when of a large size, frequently excite, by their great distension of the biliary duct in their passage through it, not only acute pain, but very often a considerable degree of inflammation likewise. When this is the case, much fever is apt to attend. To guard against such consequences, it will therefore be advisable, in full plethoric habits, where the symptoms run high; to take away a, 688 CACHEXIA, OR CACHECTIC DISEASES. [Class lilt quantity of blood, proportionable to the state of the pulse, the seve- rity of the pain, and the age of the patient. Having adopted this step, we should next direct him to be put into a warm bath, in which he may be allowed to continue until some degree of fainting is excited ; he is then to be removed to bed, and to take an opiate, which may be repeated every four or six hours until ease is procured ; and as the stomach is generally so irritable during the attack, that every thing taken into it is imme- diately rejected, especially fluids, it will perhaps be the best way to administer it in a solid form, as that of a pill. Besides these means, we may advise the constant application of a bladder filled with warm water immediately over the region of the part which is most pain- ful. Throwing up emollient clysters may serve as internal fomen- tations. Small nauseating doses of antimonials, or of thepulvisipe- cacuanhae compositus, together with a free use of diluting liquors, might probably afford some relief. With the intention of pushing forward biliary concretions, vomit- ing has been much employed in jaundice. In recent cases, where we have no reason to suspect the concretion to be of any great magnitude, and where the*pain is not acute, this remedy may be attended with a good effect, by compressing, during its operation. the distended gall-bladder and biliary vessels ; but in cases attended with acute pain and a considerable degree of fever, by which we are made acquainted with the presence of inflammation, vomiting would certainly be very likely to prove injurious. An interesting case of inflammation of the gall-bladder proceeding from biliary calculi and terminating in suppuration, which at length pointed externally, came under my observation some years back. The patient was a woman of about forty years of age, who for a considerable time had been severely afflicted with pain in the stomach, febrile heat, faintings, and a purging. After a month or so there arose a swelling near the navel, which upon being opened discharged a quantity of yellow matter for many days. The pain becoming very acute in the tumour, the surgeon was induced to introduce his probe into the orifice of the wound, when to his Lstonishment he found a hard gritty substance at the bottom of it, which upon being discharged a few days afterwards, proved to be a gall-stone of the size of a common nut. This was shortly suc- ceeded by another, and in due time the woman's health was per- fectly restored. In many instances it seems probable that there is not much pain produced whilst a calculus of a moderate size is lodged in a gall- bladder, or even in the biliary ducts, until it arrives at that part where the common duct perforates the intestine ; which opinion seems confirmed from cases reported by writers of the first respec- tability, where biliary calculi have been met with on dissection in the gall-bladder of persons who never were incommoded during their lifetime with any symptoms that indicated the presence of such a conmlaint. Order HI.] JAUNDICE,. 689 Purgatives have been much used in the jaundice, not only with the view of obviating costiveness, but also with that of exciting the action of the biliary ducts by increasing that of the intestines. Some physicians have, however, judged them useful only where there is a slow and bound belly; while others again assure us, that drastic purges, whose action is both brisk and of long continuance, have proved highly serviceable. Regular stools, with a soluble state of the bowels, are certainly necessary to a person afflicted with the jaundice ; and in more than one or two instances I have known it to be completely removed by a diarrhoea supervening of its own accord. Where the disease proceeds either from calculi or from spasmo- dic stricture, it seems rational therefore to presume, that after ha- ving pursued the steps before recommended, we may make use of purgatives* with much advantage ; and in these cases I have cer- tainly experienced their beneficial effects very frequently: but where jaundice arises in consequence of some chronic affection of the liver or other adjacent viscera, active purgatives would be likely to do harm by inducing much debility. In instances of this nature we may substitute aperients, such as any of the neutral salts. With the intention of dislodging biliary concretions, gentle ex- ercise, but more particularly that of riding on horseback, together with frictions, have been much advised, and certainly will be very proper except during the paroxysms. Electrical shocks passed through the liver in the course of the common duct, may * 1. $ Pulv. Rhei, 3j. Sapon. Alb. 3?s. Hydrargyr. Submur. gr. xij. Syrup, q. s. M. Fiant pilul. xxvv. Capiat ij. vfel. iij. ho- rse decubitus. Vd, 2. rj,Hydrargyr. SubmUr. gr. v. Pulv. Jalapae, 3ss. Mel. Optim. q. s. M. ft*. Bolus, pro re nata capiendus. Vel, 3. R Pilul. Aloes cum Myrrh, gr. xv HydVargyr. Submuriat. gr. iv. Syrup. Zingib. q. &. M. Fiant. pil. iv. pro dos. Vel, 4, R Gum. Scammon. Pulv. gi4. v—x, Potassae Supertartrat. Pulv. Zingib. aa gr. xij. ft. Pulvis pro dos. * 1. Take Powdered Rhubarb, one scruple. Hard Soap, half a drachm. Submuriate of Mercury, twelve grains. Syrup, a sufficiency. Divide the mass into twenty-four pills, and take from two to three at bed-time. Or, 2. Take Submuriate of Mercury, five grains. Powder of Jalap, half a drachm. Honey, a sufficiency to form a bolus, which may be taken occasionally. Or, 3. Take Aloetic Pills, with Myrrh, fifteen grains. Submuriate of Mercury, four grains. Syrup of Ginger, a sufficiency. the mass into four pills for a Divide dose. Or, 4. Take Scammony reduced to Powder, five to ten grains. Supertartrate of Potass, Powdered Ginger, of eaph twelve grains. Mix them for a dose. 88 690 CACHEXIA, OR CACHECTIC DISEASES. [ClaSS 111* likewise prove a good auxiliary in promoting the passage of the calculus. The warm bath and anodynes, by their relaxing and antispasmo- dic powers, have proved highly useful in the jaundice when pro- ceeding either from calculi or spasmodic strictures ; and therefore when either of these causes is suspected to have given rise to ii, they should by no means be neglected. When a biliary concretion remains stationary in spite of all our endeavours to dislodge it, and promote its being voided by stool, we may attempt its solution, however unsuccessful or inadequate the means may prove. Dr. Darwin* made experiments on some fragments of a bile- stone with weak spirit of marine salt, a solution of mild alkali, a solution of caustic alkali and oil of turpentine, without being able to dissplve them. After some time these were all put into boiling water, and then the oil of turpentine dissolved the fragments, but no alteration was produced upon those in the other fluids, except some little change of their colour. Upon putting some other fragments of the same bile-stone into sulphuric aether, they were quickly dis- solved without additional heat. Dr. Darwin therefore asks, Whe- ther aether mixed with yolk of egg or honey, might not be given with advantage in bilious concretions ? We are informed! that a mixture of aether and spirit of turpen- tine is a remedy which has been employed by many practitioners •on the continent as a solvent of biliary concretions with the most decided success ; but more particularly by Monsieur Durande, who affirms, that of late he has cured all whom he met with suffer- ing from gall-stones. The plan adopted by him is, after having con- tinued the use of emollient and aperient remedies, to give his pa- tients a mixture of three parts of sulphuric aether and two of spi- rit of turpentine, in the dose of two scruples or a drachm every morning; and upon this he directs them to take some emollient drink, such as milk-whey, veal-broth, &c. &c. We are told in the publication alluded to, that M. Durande has seen biliary concre- tions perfectly dissolved, and discharged by stool in the form of a yellow matter resembling peas by this method. As the remedy, however, is apt sometimes to occasion nausea and other distressing symptoms, it should be administered with due caution, lest the pain should be increased by it; and before having recourse to its aid, the proper steps for obviating inflammation ought assiduously to be adopted. Should we discover that jaundice has arisen in consequence of an inflammatory affection of the liver, we must, at an early period, have recourse to the usual means for carrying it off by resolution ; viz. by venesection, topical bleedings, the exhibition of cooling saline purgatives from time to time, and the application of a blister over the part, which ought to be renewed in a quick succession, if •:ee Zoonomia, vol. ii. p. 4. -f See Soemmering de Cbircretiqne Bills. Order HI.J jaundice.. 691 the disease does not soon abate;—(see Acute Hepatitis) but where these have either failed or been neglected, and it has proceeded on to a chronic state of enlargement and scirrhosity, pressing thereby on the biliary ducts, we must then resort to a use of mercury both externally and internally, as advised under the head of chronic in- flammation of that viscus. In cases of this nature, as well as in those of jaundice arising from biliary concretions, it has been much the practice to employ neutral salts,* together with alkalies,! soap, and other deobstruents."| Soap has indeed been looked upon as a kind of specific in jaundice, and has therefore been employed in considerable quantities. Hem- lock has also been used, but most probably without any good effect. Combining it either with cinchona bark or mercury|| might possi- bly make it more efficacious. __________________ * 5. [I Infus. Gentian. C. f. ^jss. Tinct. Cinchon. f. 3'j. PotaSsa? Tartrat. gr. xv. Pulv. Rhei, gr. v. M. ft. Haustus, mane, hora meridiana et vespere sumendus. *f 6. & Sodse Subcarbonat, 3'j. Pulv. Cinchonae, |j. .----Rhei, 3ss. Mucilag. Gum. Acacias, q. s. M. ft. Electuarium, cujus sumat nucis mos- cllataj quajatitatem ter in die. Vel, 7. f£ Decoct. Cinchon. f. 3x. Tinct. Calumb. f. 3ij. Potassae Subcarbonat. gr. xij. M. ft. Haustus, mane, iterumque hora me- ridiana et vespere sumendus. X & rjj Gum. Ammoniac. Sapon. Dur. aa. 3j« 01. Junip. Til v. Syrup. Zingib. q. s. M. Fiant pilulae xxiv. quarum sumat iv. vel v. bis in die. Vel, 9. R Pulv. Rhei, 3j. —«—Cinnam. C. 3ss- Saponis Dur. 3'j. Ol. Junip. fll v. Syrup. Simpl. q. s. M. ft.. Massa, in pilulas 1. dividenda, quarum sumat iij. vel iv. mane et nocte. J! 10. R Extract. Cinchon. ■• ' - - Cc-nij, aa 3ij> i. 'lake Compound Infusion of Gentian, one ounce and a half. Tincture of Peruvian Bark, two drachms. Tartrate of Potass, fifteen grains. Powdered Rhubarb, five grains. Mix them. This draught is to be taken morning, noon, and evening. 16. Take Subcarbonate of Soda, two drachms. Powder of Peruvian Bark, one ounce. ----Rhubarb, half a drachm. Mucilage of Gam Acacia, a suffi- ciency to form an electuary, of which let the bulk of a nutmeg be taken thrice a da)\ Or, 7. Take Decoction of Peruvian Bark,. ten drachms. Tincture of Calumba, two drachms. Subcarbonate of Soda, twelve grains. Mix them, and let this draught be taken every morning, again at noony and in the evening. \ 8. Take Gum Ammoniac, Hard Soap, of each a drachm. Oil of Juniper, eight drops. Syrup of Ginger a sufficiency lo form the masa, out of which make twen- ty-four pills, and let four or five be taken twice a day. Or, 9. Take Powdered Rhubarb,one drachm. Compound Powder of Cinnamon, half a drachm. Hard Soap, two drachms. Oil of Juniper, eight drops. Common Syrup, a sufficiency. Divide the whole into fifty pills, of which three or four are to be taken morning and night. || 10. Take Extract of Peruvian Bark, ---— Hemlock, of each fsro drachms. 632 CACHEXIA, OR cachectic diseases. [Class ill. The symptoms which usually prove most distressing in this dis- ease are, the pain in the epigastrium, sickness at the stomach, and costiveness. The two former of these will generally be relieved by bleeding, the warm bath, fomentations applied to the part, the exhibition of emollient clysters, and opiates, as before advised. Where they fail, the application of a large blister may possibly be attended with a better effect. Should the nausea and vomiting continue in spite of these means, we may then give the saline medicine in the act of effervescence, or something of a cordial antispasmodic* nature., that may be likely to abate the irritation in the stomach. Costiveness is to be removed by gentle laxatives, such as are here advised, t When the disease is of a chronic nature, and attended with ana- sarcous swellings, it will be proper to employ diuretics, as recom- mended under the head of Dropsy, strengthening the general Syrup. Zingib. q. s. M. Fiant pilul. lx, sumat iij.—xif in die. Vel, 11. R Pilul. Hydrargyri, 3ss. Extract. Conii, 3ij. M. Fiant pilul. 1. quarum iij. sumat mane et nocte. * 12. R Confect. Aromat. 3j- Aq. Fontan. f. fvss. Spirit. Pimentae, f. ^ss. ----Ammon. Aromatic, f. 3ss. Tinct. Opii, fit xxv. M. ft. Mistura, cujus capiat cochl. ij. vel. iij, urgenti nausea. t 13. R'Ol. Ricini, f. Sij. Mucil. Gum. Acaciae, f. ^j. Misceantur simul in mortario, et adde Aq. Anethi, f. ^j. Tinct. Jalapae, f. 3iij. M. Capiat dimidium pro re nata. Vel, 14. R Pulv. Jalapae, 31. Potassae Supertart. 3'j- ft. Pulvis pro dos. Vel, 15. R Aloes Spicat. Sjss. Sapon. Venet. 3j- Potassae Subcarbonat. 3ss. Syrup Rhamni, q. s. M. Fiant pilul. xxxvj. capiat iij. vel. iv hora decubitus. Let sixty pills be formed oul of the mass, and from three to twelve be taken in the course of the day. Or, 11. Take Mercurial Pills, half a drachm. Extract of Hemlock, two drachms. Mix them, and divide them into fifty pills, of which three may be taken morning and night. * 12. Take Aromatic Confection, one^ drachm. Pure Water, five dunces and a half. Spirit of Pimenta, half an ounce. Aromatic Spirit of Ammonia, half a drachm. Tincture of Opium, forty drops. Of this mixture let two or three table- spoonsful be taken when the nausea and sickness are urgent. t 13. Take Castor Oil, two ounces. Mucilage of Gum Acaryaj, one ounce. Mix them in a mortar, and add Dill Water, one ounce. Tincture of Jalap, three drachms. Take the half for a dose as the occasion may require. , Or, 14. Take Powder of Jalap, one scrapie. Supertartrate of Potass, two scruples. Mix them for a dose. Or, 15. Take Soccotrine Aloes, ene, drachm and a half. Hard Soap, one drachm. Subcarbonate of Potass, half a drachm. Syrup of Buckthorn, a sufficiency. Let thirty-six pills be formed out of the mass, and three or four be taken at bed-time.. Order HI.] jaundice. 6*93 System at the same time with astringent bitters, chalybeates, mine- ral waters, a nutritive generous diet, and gentle daily exercise, but more particularly on horseback. Moderate quantities of both soda and Seltzer waters will be proper. In the progress of the disorder, it sometimes happens that a spon- taneous diarrhoea arises and prevents the future absorption of the bile into the mass of fluids. As long as it continues moderate, and induces no debility, it may be allowed to go on ; but where it at- tacks with violence, or takes place in a constitution much injured and enfeebled, it should be checked by having recourse to the means advised under that particular head. When a putrid disposition shows itself, this must be counteracted by proper antiseptics.—(See Scurvy.) In jaundice arising from a scirrhosity of the liver, we must adopt the steps recommended ifl chronic hepatitis. A variety of other different remedies have been mentioned a3 possessing a good effect in jaundice, but many of them have been found on trial to be perfectly inert. Among the rest, raw eggs have been proposed as a solvent. Dr. Darwin mentions the case of a gentleman between forty and fifty years of age, who had laboured under the jaundice about six weeks without pain, sickness, or fever, and had taken emetics, cathartics, mercurials, bitters, chalybeates, aether, &c, without any apparent advantage. On a supposition that the obstruction of the bile might be owing to a paralysis or torpid action of the common bile-duct, and the stimulants taken into the stomach seeming to have no effect, he directed half a score of smart electric shocks from a coated bottle, which held about a quart, to be passed through the liver and along the course of the common gall-duct, as near as could be guessed, and on that very day the stools became yellow; the electric shocks being continued a few days more, the patient's skin became gradually clear. In cases where we have reason to suspect the obstruction of the bile to be owing to a torpid action of the bile-duct, and where other means have failed in promoting the desired intention, we should therefore- m,ake trial of electricity. Jaundice which arises from simple obstruction of the gall-ductg, is often removed by the internal as well as external use of Bath waters. The complicated diseases which are brought on by a long resi- dence in hot climates, affecting the secretion of bile, the functions of the stomach and alimentary canal, and which generally produce organic derangement in some part of the hepatic system, likewise receive much benefit from the Bath water, if used at a time when suppurative inflammation is not actually present. Whenever there is an increased heat of the skin and quickness of the pulse during the paroxysms excited by biliary concretions, these waters should not be taken until the acute symptoms subside. Cheltenham water is another remedy which has been found of 6J34 local diseases. [Class IV. <*ssential service in obstructions of the liver, and the other organs connected with the functions of the alimentary canal. Persons who have had their biliary organs injured by a long residence in warm climates, and who are suffering under the symptoms either of excess or deficiency of bile, and an irregularity in its secretion, receive remarkable benefit from a course of this water judiciously exhibited. Its use may be here continued even during a considerable degree of debility; and from the great determina- tion to the bowels, it may be employed with advantage to check the incipient symptoms of dropsy and 'general anasarca, which so often proceed from an obstruction in the liver. In full sanguine habits, the water of the saline spring only should be drank. Dr. Saunders recommends drinking it warm.* Cheltenham water, besides containing salts of a purgative nature, is likewise a chaly- beate. The iron is suspended entirely by carbonic acid, of which gas the water contains about an eighth of its bulk. A diet consisting chiefly of vegetables appears to be best calcu- lated for persons labouring under jaundice, or in whom bilious con- cretions are apt to form. Together with a use either of the Bath or Cheltenham waters, great advantage may be derived from regular and sufficient exercise daily, particularly on horseback, as nothing will tend more to pre- vent the bile from stagnating and becoming inspissated, which it is apt to do in those persons who lead a studious or sedentary life. CLASS IV. LOCALES, or LOCAL DISEASES. Affection of a part, not of the whole body, characterizes this* Class. ORDER I. THE DYSESTHESIA. Deprivation or loss of some sense, from the fault of the ex- ternal organ. NYCTALOPIA, or NIGHT BLINDNESS. In this disease the sight is perfectly clear and distinct in the day- time, but a total blindness takes place by night, from which occur- rence it derives its name. * See his Treatise oh Mineral Water?.' Order I.J (Jutta serena. 69,5 The disorder is peculiar to the inhabitants of tropical climates, and the southern parts of Europe, being rarely, if ever, met with in cold ones; and has been supposed to proceed from torpor of the retina and optic nerves, which suffer so much from the strong reflected rays of the sun by day, as not to be susceptible of the faint or weak light which the night furnishes. It is a frequent concomitant to scurvy between the tropics. In some cases, it is symptomatic of derangement in the chylopoetic organs, but more particularly in the hepatic system. It becomes apparent towards evening with a dimness of sight, which gradually increases as the night approaches ; and the darker it gets, so much the more indistinct does vision become. It is in general unattended by any other symptom, except that perhaps a more than ordinary sense of fulness is now and then perceived in the forepart of the head and over the eyes. Nyctalopia seldom proves a disease of much importance, or of long duration ; but, on the contrary, generally admits of an easy cure. Evacuation, both by bleeding and purging, has been recom- mended by such writers as have taken notice of this disorder; but as it is supposed to depend upon a relaxed state of the optic nerves or paralyzed condition of the retina, these remedies appear to be improper, and those we employ ought to be such as will strengthen the tone of the parts. With this view, the eyes should be washed several times a day by means of an eye-cup, with cold water, or some gentle astringent collyrium ;* the patient at the same time wearing a green silk bjind over his eyes, and avoiding all exposures to the sun or any great glare of light. Blisters applied to the temples, tolerably close to the external canthus of the eye, and repeated several times, will expedite the cure, unless depending on scurvy, in which case they will have little effect until that complaint be removed. If the internal use of any medicine is necessary in nyctalopia not dependent on scurvy, or on any derangement of the chylopoetic organs, but merely on a peculiar state of the optic nerves or retina, it is probable that the cinchona bark, joined with valerian and chalybeates, might be the most proper. GUTTA SERENA, AMAUROSIS, or DIMNESS of SIGHT. Gutta Serena (a species of blindness, wherein the eyes remain fair and seemingly unaffected) consists in a dimness of sight, whether the object be near or at a distance, together with 1 R Zinc. Sulphat. gr. viij.—xv. Aq. Rosse, f. "iv. M. * 1. Take Sulphate of Zinc, eight to fif- teen grains. Rose Water four ounces. Mix them. 6.96 LOCAL DISEASE'.}, [CltiiS IV* the representation of flies, dust, „c. floating before the eyes ; and the pupil is generally deprived of its power of contraction. It is supposed to depend on some affection of the optic nerves; but its causes are nevertheless said to be various ; some of which are, from their nature, incapable of being removed. Thus in one case the blindness has been found to be occasioned by an encysted tumour which was situated in the substance of the cerebrum, and pressed on the optic nerves near their origin; in a second, by a cyst, containing a considerable quantity of water, and lodging itself on the optic nerves at the part where they unite; in a third, by a caries of the os frontis, occasioning an alteration in the optic foramina; and in a fourth, by malformation of the optic nerves themselves. In some cases the defect of vision has been attempted to be accounted for by supposing a defect in the optic nerves, disquali- fying them for conveying the impression of objects through the eyes to the brain, as upon the minutest inspection by dissection, nothing has been discovered either in the structure of the eyes, or in the state of any of the component parts contributing to the faculty of vision, which could at all obstruct the performance of their proper office. Mr. Ware in his treatise on this disease, mentions, that a dila- tation of the arterial circle surrounding the cella turcica (which is formed by the carotid arteries on each side, by branches passing from them to meet each other before, and by other branches passing backward to meet branches from the basilary artery be. hind) may likewise be a cause of gutta serena. The anterior portion of this circle passes over the optic nerves, which un- doubtedly may therefore become compressed when any enlarge- ment of these vessels takes place. A dilatation of the artery which passes directly through the centre of the optic nerve to the retina, may, it is presumed, like- wise become a cause of defective vision. The proximate cause of amaurosis is generally allowed to be the insensibility of the retina. Violent contusions of the head ; apoplectic fits ; sudden flashes ©f lightning; frequent exposure to the rays of the sun; severe exercise and strong passions, especially terror and anger; drunken- ness ; immoderate venery; and all those causes which predispose to nervous and paralytic affections, may give rise to amaurosis. An over-distention of the blood vessels of the brain, or of the im- mediate organ, has sometimes been a cause of the disorder. Gutta serena, although considerably relieved in some instances, proves generally an incurable disease. Its treatment is usually regulated on the plan of stimulating either the parts themselves, or the system in general. The first is to be done by applying blisters and issues behind the ears or at the back of the neck, and continuing them for a considerable Order!.] gutta serena. 697 it. ?■-....'•. . . ■*•■»« ■<• * ,i length of time ; by promoting a discharge from the nose by means of errhines,* and by stimulant collyriums. t Electricity has been employed in some cases with the happiest effect, when other remedies have failed, by passing very slight shocks through the forehead twice a day, and afterwards drawing sparks from the parts surrounding the eye or eyes ; which plan ought to be persevered in for a proper length of time. Galvanism has likewise been resorted to with advantage. Dr. Darwin records! the case of a lady who laboured under gutta serena, and whose sight was restored by these means. He adopted the experiment of Volta, by employing two rods, one of them of zinc, about the size of a writing pencil, and the other a silver pencil-case, about the same size ; and by putting the end of the zinc rod in contact with the external corner of one eye, and the end of the silver pencil-case in contact, with the external corner of the other eye, and then repeatedly making the other ends touch each other; sparks were. visible in the eyes both at the time of contact and at the time of separating the two rods. He mentions that she took valerian and calumba at the same time, and perfectly regained her sight in about three weeks. Mr. Ware informs us, that in several instances of common gutta serena he observed considerable relief to be obtained by the use of a snuff composed of ten grains of turbith mineral, with about a drachm of the pulvis sternutatorius; or in the place of that, the glycirrhiza, or saccharum commune. Stimulants have been applied immediately to the eyes, in some eases of gutta serena, with a good effect, but more particularly in those which seem to depend upon an inirritability of the optic nerve. vIn such cases, an infusion of dried capiscums in water, in the pro- portion of one grain to the ounce, may be made use of, dropping a few drops into the eyes morning and evening. -The severity of the pain may be great at first from this application, but by perseverance, it will he found to abate. The vapour arising from warm rectified spirit passed through a tube and received into the eyes, has some- times produced a good effect. To stimulate the system, it is customary to have recourse to mercury, which is to be used and to be continued until it produces some sensible effect. In that form of the disease which is accom- panied with a contracted state of the pupil, and which has been produced, probably, by an internal ophthalrny, Mr. Ware is of t See Zoonomia, vol. iii. class 1, 2, 3, 5. '* 1. R Pulvr. Asari Compo3it. Pharma- * 1. Take Compound Powder of Asara« /•■•" cop. Londinensis. • I bacca. Z " Vel, - Or, % R Hydrargyr. Sulphat, gr.j. ..,,. 2. Take Sulphate of Mercury, one graiu ' J Pulv. Glycyrrhiz. gr. vj.' Powdered Liquorice, six grains. L' Pah'. Rad.Veratri. gr. ij. M. Powdered White Hellebore Root, two grains. Mix them, and use the powder as enufF. 89 696 LOCAL DISEASES. [Class IV. opinion, that it may best be relieved by the internal use of the hy- drargyrus oxymuriatus, a quarter of a grain for a dose. Where the disease seems to arise from a dilatation of the anteri- or portion of the circulus arteriosus, as before mentioned, bethinks the cause may often be removed by topical bleeding, purging, blis- tering, &c, but unfortunately we have no criterion to distinguish this from other causes : and this state of the parts can only be in- ferred from a plethoric habit of body in the patient. In those cases which seem to depend upon a relaxation of the optic nerve, the means advised under the head of Nyctalopia may be proper. We are informed by Dr. Richter, professor of medicine in the university of Gottingen, in a publication which bears the title of Medical and Surgical Observations, that he has lately restored to sight several patients who laboured under gutta serena. In all those cases, he thinks the cause of the disease seemed to be seated in the abdominal viscera; for he cured them all, he says, by means of medicines which remove obstruction in the viscera and evacuate. He affirms, that in this way he has not unfrequently performed a complete cure, in cases where he hardly expected it, and in some where the disease had L.tually continued for several years After vomiting he recommends the pills mentioned below ;* and he says, it is often necessary to persevere in the use of these reme- dies six or eight weeks before any amendment is perceived. A gradual increase of the dose is also requisite. A disappearance of the fiery sparks from before the eyes, and of the sensation of.,_ tension in their balls, are the first symptoms he observes of amenjM ment which gives reason to hope for success in the cure of gutta^^ serena. Costiveness should carefully be obviated in all cases of amau- C, rosis. The disease is almost universally admitted to consist in an im- paired or total loss of sensibility of the nerve appropriated to the sense of vision, the tunics and humours of the organ retaining their natural transparency. Whatever causes are capable of deranging the function of the optic nerve, by acting directly on its origin in the brain, or its expanded termination in the retina, or, lastly by its sympathy with some remote viscus as the stomach, may become *3. R Gum. Ammon. ——Assafoetid. Pulv. Rad. Valerian. ----Summitat. Arnic. * 3. Take Gum Ammoniac, ----Assafoetida, Powder of Valerian, Tops of Leopard's Bane, Sapon. Venet. U 3y. I Venetian Soap, of each two drachms. Antimon. Tartarizat. gr. xviij. Tartarized Antimony, eighteen I grains. r t, , SyfuP- <1- 5- M- , Syrup, a sufficiency to form the ft. Pilul. pond. gran. v. quarum sumat ma^s, out of which let pills of five grains iij. ter in die. each be formed, and of these three are to 'be taken thrice a dav. Order I.J deafness. 699 the exciting cause of amaurosis; but as these are various, so must be the modes of treatment. Hence it follows, that to attempt the cure in all instances by stimulants and nervines, on the supposition that the disease arises from a weakness or torpor of the nerve, must be irrational as well as unavailing. When an over-distention of the blood vessels is suspected to be the cause, active general and topical depletion will be the most proper means to obtain a restoration of sight. Some cases successfully treated in this way have lately been transmitted to the Medical Society of London.* PARACUSIS, or DEAFNESS. Deafness is occasioned by any thing that proves injurious to the ear, as loud noises from the firing of a cannon, violent colds, particularly affecting the head, inflammation or ulceration of the membrane, hard wax or other substances interrupting sounds ; too great a dryness, or too much moisture in the parts ; or by atony, debility, or paralysis of the auditory nerves. In some instances it ensues in consequence of preceding diseases, such as fever, syphi- lis, &c. ; and in others it depends upon an original defect in the structure or formation of the ear. In the last instance the person is usually not only deaf, but likewise dumb. It is often difficult to remove deafness, but more especially where it prevails as a consequence of a wound, ulcer, or inflammation of the tympanum. Where it proceeds from malconformation it admits of no cure. When deafness is occasioned by wax sticking in the ear, or by any defective or diseased actions of the glanduke ceruminae, a little of either of the remedies heret advised may be dropped into it; or be applied at the end of a small dossil of cotton every morning sr and night, previously syringing it with a little warm milk and water, or soap and water. If a thin acrid or fetid discharge accompanies the difficulty of hearing it will be adviseable to apply a small blis- ter behind the ear, and to render it perpetual by dressing it with the unguentum lyttae. When the disease proceeds from cold particularly affecting the head, the patient should be careful to keep this warm by night; the effects of which may be increased by putting the feet into warm water previous to his getting into bed, and taking some proper * See Mr. Stevenson's Oration before this Society, inserted in the Medico-Chirur- gical Transactions for May, 1817. t 4. R Fellis Bovis, f. 3iij. It 4 Take Ox-Gall, three drachms. Balsam. Peruv. f. 3j. M. Balsam of Peru, one drachm. Mix them. Vel, ' Or, 5. R Sodae Muriati, 3j- 5. Take Muriate of Soda, (sea salt,) one drachm. Aquae Distillat. q. s. ad solutionem. Distilled Water, a sufficiency to , ' dissolve the former. 700 local diseases. [Class II. diaphoretic. Indeed, from whatever cause the disorder may origi- nate, it will always be proper to keep the head warm. If deafness seems to be owing to a debility of some part of the organ, or arises in consequence of any nervous affection, it is then to be removed by stimulants* dropped into the ear; by drawing sparks with an electrical machine; by galvanism, and by cold bathing. iEther dropped into the ears of some people who are deaf, seems to possess a twofold effect: one, of dissolving the in- durated wax; and the other of stimulating the torpid organ; but it is liable to excite some degree of pain unless it be freed from the sulphuric acid, some of which arises along with it in distillation. To purify it from this it should be rectified from manganese. In that particular species of deafness which depends on a defec- tive energy of the auditory nerve, we are told by Mr. Wilkinson,t that galvanism is capable of effecting a cure. He observes, that this species of deafness is ascertainable by the common practice of placing a sonorous body in contact with the teeth. If the com- munication of sound should not be thus rendered more distinct, we may conclude that the defect originates in the nerve ; seeing that provided the deafness has been owing to any derangement of the other parts of the ear, the sound transmitted by the medium of the teeth through the connecting bony substance to the seat of hearing would have been distinctly perceived. In several cases where the deafness seemed to have arisen from a relaxation of the membrana tympani, attended by a diminished secretion of cerumen, Mr. Wilkinson experienced good effects from the employment of galvanism, which not only induced a grateful warmth in the meatus, but also considerably augmented the secre-^ tion of wax. Where the disease is the effect of fever it usually goes off as the patient regains his strength. To assist the hearing of persons who are deaf in a high de- gree, we may recommend the use of an ear-trumpet, vulgarly so called. Tobacco-smoke is a remedy which has been employed in some cases of severe and long-continued deafness, but more particularlv t See his Elements of Galvanism. * 6. R. 01. Amygdal. Dulc. |ss. — Terebinth. V\ xxvj. Vel, 7. R 01. Olivae, |ss. Liquor. Ammon. flX xx. M. Vel, 8. R Ol. Amygdal. |i. Camphora, 3i. Solve. * 6. Take Oil of Sweet Almonds, half an ounce, ------Turpentine, forty drops. Or, 7. Take Olive Oil, half an ounce. Solution of Ammonia, thirty drops. Or, C. Take Oil of Almonds, one ounce. Camphor, one drachm. Dissolve it. Vel, Or, 9. R Spirit. JEther. Sulph. i 9. Take Spirit of Sulphuric iEther. Order I.} deafness. * 701 by Mr. Grosvenor, of Oxford, surgeon, with great success and efficacy. The mode of using it is to fill the mouth with the smoke of the strongest tobacco, instantly to close the mouth a d nose, and then for the person to make all possible effort as if he meant to force the smoke through the nose, which must be prevented by holding the nostrils very tight; this forces the smoke through the Eustachian tube into the'ear. The efforts are to be repeated till one or both ears give a seeming crack, immediately on which the hearing returns. We are informed by Mr. Grosvenor,* who had been exceeding deaf for a long time, that the first night he made trial of tobacco smoke, after the third effort, the right (which was his best) ear, gave a violent crack or pop, and to his great asto- nishment, he immediately heard. He repeated the process every evening till the right ear regularly cracked, when the hearing always improved. After some evenings the left ear cracked also, and he now hears tolerably well with it: whereas, before it was scarcely possible to make him hear, even with the assistance of a trumpet. He has found that as he continues the practice each evening it is longer before the effect takes place. In addition to deafness, Mr. Grosvenor, it appears, was troubled with an incessant noise in the head and ears, which he found to decrease as his hearing improved. Before using the tobacco smoke he could not hear the clock strike the hours, whereas he now hears every tick it makes. Mons. de Saissy, surgeon at Lyons, has been successful in some cases of deafness by making injections into the hollow of the tym- panum through the Eustachian tube. In that species of deafness which arises from an obstruction of the Eustachian tube, Mr. Astley Cooper recommends the punctu- ring of the membranana tympani.t He was led to this operation by reflecting that as an aperture in this membrane did not appear to injure the power of the ear, and a small opening would be \ sufficient to admit a free passage of air to and from the tympa- »* num, perhaps a substitute might be thus easily found for the Eustachian tube, and the membrane by such an aperture be restored to its natural functions. He observes, that there are ;everal causes by which a closure of the Eustachian tube may be produced. It may arise, first, from a common cold affecting the parts conti- guous to the orifices of the tube, and thereby preventing the free passage of air into the tympanum. The deafness thus produced, however, is often only temporary; but the frequent recurrence of such attacks may produce a permanent enlargement of the tonsils, which by their pressure on the Eustachian tubes will occasion a constant deafness. Secondly, the scarlet fever causes ulcers in the throat, which in * See Supplement to vol. lxxxiv. part i. of the Gentleman's Magazine. f ^ee Philosophical Transactions of the London Royal Society for 1801. 70* local diseases. Class IV. hearing frequently close the Eustachian tube, thereby producing lasting deafness. '' Thirdly, A venereal ulcer in the fauces by the cicatrix it pro- duces, often occasions a closure of the Eustachian tube, causing a deafness which nothing but the operation here spoken of can relieve. Fourthly, He has known the closure of the tube produced by an extravasation of blood'in the cavity of the tympanum. Lastly, Jfe met with one instance of a stricture in the tube, which although it did not entirely obstruct the passage of the air, yet rendered it extremely difficult. In this the gentleman who was the subject of the disease, in order to enable himself to hear, was under the necessity of forcing air from the mouth into the cavity of the tympanum, which pressed the membrana tympani towards the meatus ; then by pressing gently on the ear, he forced out a part of the air which the tympanum contained; thus giving the mem- brane liberty to vibrate, and producing an immediate increase in the power of hearing. > As the operation will not afford relief in any cases of deafness, ; except such as arise from a closed Eustachian tube, Mr. Astleyv Cooper is anxious that it should be performed in those only which ;_j are clearly of that description. The criteria by which he judgesifiJI whether the tube is closed or open are the following : ' * " First, If the person in whom it is suspected to be closed should feel, in blowing the nose violently, a swelling in the ear from the membrane being at that time forced outward, the tube is open ; for' when closed no sensation is produced. " Secondly, The Eustachian tube may be closed, yet the beating of a watch may be heard if it be placed between the teeth or pressed against the side of the head; and if it cannot be heard when it rests upon the teeth, this operation cannot relieve, as the power of the auditory nerves must have been destroyed. Jt " Thirdly, It is right to inquire if the deafness was immediately mk preceded by any complaint in the throat. *™ " Lastly, In a closed Eustachian tube there is no noise in the head like that which is known to accompany nervous deafness. This species of deafness generally approaches in a gradual manner; the person hears better at one time than another; a cloudy day, a warm room, agitated spirits, or the operation of fear, produce a considerable diminution in the powers of the organ. In the open air the hearing is better than in a con- fined situation; in a noisy than in a quiet society; in a coach when it is in motion, than when it is still. A pulsation is often felt in the ear: a noise resembling sometimes the roaring of the sea, and others in ringing of distant bells is heard. This deafness begins generally in a diminished secretion of the wax of the ear, which the patient attributes to some unusual exposure of the head to cold: and this continues as long as the disorder remains/? 4 canine appetite. 703 . *■■ ORDER II. DYSOREXIiE. False or defective appetite. BULIMIA, or CANINE APPETITE. • This disease is the direct opposite of anorexia, as the patien*: is affected with an insatiable and almost perpetual desire of eating, in which if he is not indulged he is apt to fall into fainting fits. With its real causes we seem not to be very well acquainted. In some cases it has been supposed to proceed from an acid in the stomach; and in others from too great a sensibility or peculiar affection of its nervous coat. In most instances it ought, in my opinion, to be considered as depending more frequently on mon- strosity than disease. In the third volume of the Medical and Physical Journal* is reported an extraordinary and well-attested case of this nature in a French prisoner, who in one day consumed of Raw cow's udder 4lbs. Raw beef......10 Candles....... 2 Total____16lbs. Besides five bottles of porter. it appeal's from Dr. Cochrane's report of this case, as inspector and surgeon of the prison in Liverpool, where this cannibal was confined, that the faeces were by no means in proportion to the ingesta, and indeed seldom exceeded those of other men, and that with the ordinary allowance of drink, the quantity of urine was not more than a quart a day: neither was it more offensive than that of other men, but there was a constant propensity to exhala- tion from the surface of his body, and soon after his getting into bed he was usually attacked with such a profuse sweating as to oblige him to throw off his shirt. In this case it is therefore evident that the recrementitious parts of the aliment were evacuated prin- cipally by the skin; and the same may probably happen in most cases of buliir*:i. Another singular case of voracious appetite has*been reported to the National Institute by M. Percy, a surgeon in chief to the French army. A young man from the neighbourhood of Lyons, named Tarare, and who early in life belonged to a troop of strolling jugglers, accustomed himself to swallow flints, enormous quantities Order II.] * See page 209. 704 LOCAL DISEASES. [ClaSS IV. of broken victuals, baskets-ful of fruits, and even living animals. The most alarming symptoms endured in consequence were not sufficient to overcome this dangerous.habit, which became at lasf; an imperious necessity. Enrolled at the commencement of the late war in one of the bat- talions of the army of the Rhine, he sought for the necessary supply of food around the moveable hospital. The refuse of the kitchen, the remains of the messes, the rejected matters, or corrupted meat's, did not suffice him. He often disputed with the vilest animals their filthy and disgusting meal:'he was perpetually in search of cats, dogs, and even serpents, which he devoured alive. He was obliged to be driven by force or threats of punishment from the dead room, and the places where the blood drawn from the sick was deposited. &* It was in vain attempted to cure his ravenous appetite by giving wj| him fat, acids, opium, and even pounded shells. The disappear- W ance of a child of sixteen months' old gave birth to horrible suspi- •* cions of him, and he fled. Five or six years afterwards he was ^ admitted into the Infirmary of Versailles in a consumptive state, \ which succeeded his enormous appetite. He soon after died. *m Mons. Tessier, chief surgeon of the Infirmary, examined the ''% body, notwithstanding an abominable odour exhaled from it. The j3 stomach was of an extraordinary capacity, the intestines were ** ulcerated and remarkably distended, and the gall-bladder was of a very large size. Tarare was small in stature, flabby, and weak ; his countenance had nothing ferocious in it. When he had fasted for a time the *> skin of his belly could be almost wrapped round him; and when m full he appeared as if dropsical. A thick vapour issued in torrents from his mouth; all his body smoked; the sweat flowed abundantly from his head; and like all other voracious animals, he slept during the time of digestion. A case of fever attended with inordinate appetite is recorded in the 5th volume of the Medical Transactions of the London College ,*jv. of Physicians. The patient was a young gentleman sixteen years L' of age, who with all the other symptoms of fever, attended at first with a powerful determination to the head, showed the usual want of appetite and dislike to food (owing to the deprivation of the * powers of digestion attendant on almost all pyrexial diseases) until the fifth day, when the most insatiable craving for food came on, and continued during the whole period of the disease, j which was extended to upwards of thirty days, with all the -J ordinary characteristics of typhus. The desire for food came on regularly with the paroxysm of fever, and continued unabated until that subsided, when he usually fell into a profound sleep. A remarkable circumstance in this case was, that the digestive pow- ers of the stomach were equal to the supply of food, and by the ~J aid of active purgatives six or seven copious^stools were daily pro- * cured, equal in bulk and consistence to those of a strong, healthy adult. Order 1L] nymphomania. 705 When a ravenous appetite is occasioned by an acidity in the stomach, this ought to be corrected by an emetic, with the after- use of alkalies. Where the power of the stomach in quickly dissolving, assi- milating, and disposing of the aliment, is so great as in the cases' just mentioned, We probably may be able to allay its contractile force by oil, fat meats, opiates, and a free use of tobacco, which may both be chewed and smoked. The-liquOr potassas administered in doses of about five-and-twenty or thirty drops in a little veal broth, and repeated twice or thrice a day, might probably have a good effect. A medical friend has communicated a case of bulimia to me, which was cured by confining the patient to a diet consisting wholly of eggs boiled to a very hard consistence; and these he carried constantly about with him in order to satiate his appetite whenever it became craving. ♦ FUROR UTERINUS, or NYMPHOMANIA, This disease comes on with melancholy, lacivious casting about of the eyes, and frequent sighing; and, as it increases, the faee becomes red and flushed, and the woman makes use of libi- dinous gestures and speeches, and shows an immoderate desire for coition. It frequently arises either from inflammation of the pudenda, of from an acrimony in the fluids of the parts. In most instances it ought to be considered as a high degree of hysteria, or as a species of madness. When the disease is the consequence of local inflammation, we must resort to bleeding and cooling laxative medicines, together with refrigerants, such as nitre, and the topical application of seda- tive lotions.* Internally we may likewise employ camphor com- bined with opium,t or the extract of belladonna. If these fail, small doses of the plumbi superacetas. \ 1. R Aq. Distillat. f. f iv. Liquor. Plumbi Acet TTI xvj. Tinct. Opii Vinxis. ffl. xxv. M. Tinet. Opii Vinos. 111 xxx. M. t 3. R Camphorae, gr. Yj—.xlj. Potassae Nitrat gr. x. Opii, gr. ss. Confect. Rosa, q. s. M. ft. Bolus, ter quaterve die sumendus. ,* 1. Take Distilled Water, four ounces. Solution of Acetate of Lead, twenty-four drops. Vinous Tincture of Opiunv forty drops. ■Mix them. Vel, | Or, 2. R Liquor- Ammon. Aceiafis., 2'. Take Solution of Acetate of Ammonia, Aqua? Distillat. Distilled Water, Spirit. Rectif. aa f. |*y. Alcohol, of each two ounces. Vinous Tincture of Opium, forty- five drops. Mix them. f 3. Take Camphor, six to twelve grains. Nitrate of Potass, ten grains. Opium, half a grain* Confection of Roses, a sufficiency to form a bolus, which may be taken three or four times a dav. 90 706 LOCAL DISEASES. [CL&SS IV . If it proceeds from acrid matter, the patient must drink plenti- fully of cooling demulcent liquors. Injections of the same nature may also be thrown up the vagina ; the parts be washed with a sedative lotion as just advised, or be anointed with some soothing liniment ;* and opium be administered in small and frequently re- peated doses. The diet is to be cooling and light, consisting principally of ve- getables and milk; and every thing that might prove an additional stimulus should be avoided. As the clitoris is the seat of pleasure during the act of coitus, nymphomania might possibly be cured by extirpating this organ. The following case, which is recorded by a French writer,t is much to the purpose. A young woman was so addicted to masturbation that she was nearly exhausted by marasmus : sensible of the danger of her situation, yet not possessed of sufficient fortitude, or else irresistibly impelled by the pleasurable sensations to which she yielded, she could not command herself, and excited profuse emis- sions. Her parents took her to Professor Dubois ; 'and, upon the authority of Levret, he thought it advisable to propose amputation of the clitoris, which the patient and her parents agreed to. The organ was removed with one stroke of a bistoury, and the bleeding prevented by an application of the cautery. The operation com- pletely succeeded, and the patient was cured of her fatal habit, quickly recovering her health and strength. —-QSSS5WV--- DEFECTIVE APPETITES. ANOREXIA, or LOSS of APPETITE. A want of appetite and loathing of food is not usually an original affection, but prevails as a symptom of some other disease, t See Noso°:raphic Chirurgicale, par Anthelme Richerand, M. D., &c. Vel, I Or, 4. JJ; Extract. Belladon. gr. i.—iss. 4- Take Extract of Belladonna, one grain to one and a half. Camphor Mixture, ten drachma Mix them, and let this draught be taken thrice a day. * 5. Take Spermaceti Ointment, Cerate,of Superacetate of LeatL of each half an ounce. Mix them. Or, 6. Take Sulphate of Zinc* Superacetate of Lead, of each fifteen grains. Prepared Lard, half an ounce. Opium, reduced to fine powder. half a drachm. Mix them. Misturte Camph. f. 3*. M. ft. Haustus, bis terve in die sumendus. £ 5. R Unguent, Cetacei, Cerati Plumbi Superacet. aa ?ss. 1VI Vel, 6. ft Zinci Sulphat. Plumbi Superacetat aa. gr. xv. Adipis Praeparat. ^ss. Opii Pulv. 3ss. M. Order I1I.J impotencv. 707 such as dyspepsia, and is therefore to be obviated by aromatics, bitters, cinchona joined with sulphuric acid, chalybeates, _c. as. advised under that head. In spontaneous anorexy, where the stomach is loaded with bile or crudities, an emetic in the evening, with some kind of stomachic purgative the next morning, will seldom fail to effect a cure. ANAPHRODISIA, or IMPOTENCY. In some cases this disease is owing to an original defect in the organs of generation ; but it more usually arises either from topical weakness, brought on by excess in venery, or onanism; or from great debility in the system, produced by severe evacuations pre- ceding diseases, or the want of nutritive food. In a few instances it may be occasioned probably by a want of sufficient confidence, or a degree of fear at the time of coition. Where the disease proceeds from an original defect in the organs of generation, it will not be possible to effect a cure. When it de- pends upon some disease of the parts, this must be removed by the means which have been pointed out as most proper. If it arises in consequence of general weakness the system is to be strengthened by a generous nutritive diet; by cold bathing, both general and topical; by the cinchona bark, myrrh, chalybeates, and other tonics, as advised under the head of Dyspepsia. Stimulants, such as the tinctura lyttae,* might likewise be of service if given in small doses. ORDER III. DYSCINESLE. Obstructed or depraved motions, from fault in the organs. *' 1. g. Pulv. Lyttae, gr. xviij. Opii, Camphorae, aa gr. xxxvj. Connect. Rosae Caniiiae, q. s. M. Fiant pilulae xxxvj. Capiat j.—ij. omni tfocte hora decubitus. Vel, g. ft Decoct. Cinchon. f. |j. Tinct. Cinnam. C. f. 3ij. ----Lyttae, HX xiij.—xx. M. ft Haustus, bis in die sumendus. * 1. Take Powder of Spanish Fly, eigh- teen grains. Opium, Camphor,of each thirty-six grains. Confection of Dog Rose, a suffi- ciency to form the mass, out of which let thirty-six pills be made. From one to two may be taken every night on going to bed. Or, 2. Take Decoction of Peruvian Bark, one ounce. Compound Tincture of Cinna- mon, two drachms. Tincture of Spanish Fly, twen- ty to thirty drops. Mix them. This draught is to he taken twice a day. >06 local diseases:. [Class IV* STRABISMUS, or SQUINTING. Squinting is generally owing to one eye being less perfect than the other; on which account the person endeavours to hide the worst eye in the shadow of the nose, that his vision by the other may not be confused. Sometimes the habit is acquired, and can- not afterwards be easily corrected. Where squinting has not been confirmed by long habit, and one eye is not much worse than the other, we are told* the defect may often be obviated by making the child wear, for some hours every day, a piece of gauze stretched on a circle of whalebone over the best eye, in such a manner as to reduce the distinctness of the vision of this eye to a similar degree of imperfection with the other; or the better eye may be totally darkened by a tin cup co- vered with black silk for some hours daily, by which means it will be gradually weakened by the want of use, and the defective eye will be gradually strengthened by using it. In most cases of strabismus we shall be enabled to afford essen- tial relief by the simple process of binding up the sound eye every day for two or three hours, so as to oblige the patient to make use of the debilitated organ, and according as it is more or less indis- posed, to keep the other more or less veiled, continuing the process until the diseased eye can fully and properly perform its functions;. ORDER IV. APOCENOSES. Unusual flux of Tdood or other humours', without pyrexia, or increased impetus of the fluids. EPHIDROSIS, or IMMODERATE SWEATING. Tins is usually a symptomatic affection, but it nevertheless some- times prevails as an idiopathic disease, and then is commonly owing to general weakness and debility, accompanied with a preterna- tural determination to the surface of the body. It is generally to be met with in the last stage of.pulmonary consumption. The cure is to be effected by covering the body lightly with ap- parel and bed-clothes: by keeping the chamber of a moderate temperature; by determining from the surface of the body, by means of diuretics and gentle laxatives; and, lastly, by strenthen- ing the system by chalybeates and other tonic medicines, cold bathing, and the means advised under the head of Dyspepsia^ avoiding at the same time too long an indulgence in bed, and a use of warm slops. * See Darwin's Zbonomia, vel. iii. class 1, °2; 4, 5. Order IV.J incontinence of urine* 7Q9 In the colliquative sweating which attends hectic fever and phtisis pulmonalis, the diluted sulphuric acid is much employed. ENEURESIS, or INCONTINENCY of URINE. This disease usually proceeds either from relaxation or a para* lytic affection of the sphyncter of the bladder, induced by various debilitating causes, such as too free a use of spirituous liquors, masturbation, and excess in venery; or it arises from compression on the bladder, from a diseased state of the organ, or from some irritating substance contained in its cavity. We are informed by a modern writer,* that the reason why children pass their urine in bed is owing to their sleeping on their back, for the occurrence never takes place but when the boy is in this position. The cure, ho asserts, is therefore simple, by turning himself round. He should accustom himself to sleep upon his side or face: by so doing the ill habit will be broken, and the urine net be passed, nor will he be excited to dream of making urine while he keeps this position. It is added, that when a child wets the bed it is in consequence of a dream, excited by irritation of the sensible spot a little behind and below the orifice of the bladder, by the urine resting there, and stretching the bladder. The remedy pro- posed merits the attention of parents, and those who superintend schools for boys. When an incontinency of urine prevails in consequence of re- laxation in the parts, the cure is to be attempted by general and topical cold bathing, but more particularly the latter; by blister^ applied to the perinaeum, and by an internal use of chalybeates and other tonics, as advised under the head of Dyspepsia. The uva ursi taken from a scruple to half a drachm twice or thrice a day, drinking about half a pint of lime-water after each dose, may like? wise be of some service. Should the disease be owing to a paralysis of the bladder, besides applying a blister to the perinaBum and making use of electricity to the parts, we should give the patient medicines of a stimulating nature, sueh as the tinctura lyttae. External pressure applied in perinago on a line parallel with the urethra, has in some cases of eneuresis arising from paralysis of the sphincter, effected a complete cure. A bandage might be so contrived as to .answer this purpose, and would be of easy ap- plication. When it is occasioned by an extraneous substance lodged in thja bladder such as a stone, we cannot effect a cure but by removing this. As arising from pregnancy, it is only to be relieved by delivery 3 * See Treatise on the Diseases of the Urethra, Vesica .Urinaria-, &cv, by Mr, Charles _efl. 4 710 lo£al lusi;\5.ls.. [Class IV, but possibly it may be palliated by confining the woman as much as possible to a horizontal posture. To prevent in men the urine from galling und excoriating the parts, it will be necessary for the patient to wear some vessel adapted to the penis that will receive it as it drops ; or he may employ a ju^um penis, which will obviate its being evacuated invo- luntarily. Women may use a sponge so fastened as to absorb the moisture. GONORRHOEA DORMIENTIUM, or INVOLUNTARY EMISSION of the SEMEN. An involuntary emission of semen during sleep sometimes pro- ceeds from general debility, but is more usually the effect of a weakness of the seminal vessels in consequence either of excessive venery ov onanism. In a few instances it may probably be occa- sioned by a repletion of these vessels. The disease is often difficult to remove, and in many cases proves incurable. Its cure, however, is to be attempted by the patient's abstaining from the remote causes depending upon his will; by a generous and nutritive diet; by cold-bathing, both local and general; by balsams ;* by chalybeates,! the cinchona bark, and other astrin- gent bitters, as advised under the head of Dyspepsia ; and by the application of a blister to the perinasum. * 1. ft, Bals. Copaib. f. 3ij. Vitel. Ovi uni. Misceantur in m'ortario maraior. et adde gradatim, Aq. Fontan. f. ^vss. Tinct. Cinchon. f. |j. Syrup. Althaaae, f. ^sb. M. fjt. Mist, cujus sumat cochl. ij. ter qua- terve in die. t 2. ft Gum. Myrrh. Extract. Cinchon. aa 3j- Ferri Sulphat. £)j. Bals. Copaib. q. s. M. ft. Massa in pilul. xl. distribuenda, qua- rum sumat iv. ter in die. Vel, 3. ft Zinc. Sulphat. gf. xxiv. Extract. Anthemidis, 3ss. —-----Cinchon. 3j- i Syrup, q. s. M. I Fiant pilul. xxiv. capiat j—ij. mane et\ nocte quptidie. 1 * 1. Take Balsam of Copaiba, two drachms. The yolk of an Egg. Let them be well mixed in a marble mor- tar, and add gradually, Pure Water, five ounces and a half. Tincture of Peruvian Bark, one ounce. Syrup of Marshmallow, half aa ounce. Of this mixture let two table-spoonsful be taken three or four times a day. 2. Take Gum Myrrh, Extract of Peruvian Bark, of each one drachm. Sulphate of Iron, one scruple. Balsam of Copaiba, a sufficiency to form the mass, which is to be divided into forty pills, of which four may be taken three times a day. Or, 3. Take Sulphate of Zinc, twenty-four grains. Extract of Chamomile, half a drachm. ■-------Peruvian Bark, one drachm. Syrup, a sufficiency. Mix them, and form them into twenty-four pills Take one to two morning and night dailv. Order IP.] WHITES. *tt\ In preventing an involuntary discharge of semen, and obviating the debility of the parts, a use of Spa water has often proved very serviceable. It is a strongly acidulous chalybeate water, containing mpre iron, and especially more carbonic acid, than any we have in this country. LEUCORRHCEA, FLUOR ALBUS, en WHITES. This disease is marked by the discharge of a thin white or yel- low matter from the uterus and vagina, attended likewise with some degree of foeter, smarting in making water, pains in the back, and loins, anorexia, and atrophy. In some cases the discharge is of so acrid a nature, as to produce effects on those who are connected with the woman, somewhat similar to venereal matter, giving rise to excoriations about the glands penis and preputium, and Occa- sioning a weeping from the urethra. To distinguish leucorrhoea from gonorrhoea, it will be very necessary to attend to the symptoms. In the latter the running is constant, but in a small quantity; there is much ardor urinse, itching of the pudenda, swelling of the labia, increased inclination to venery, and very frequently an enlargement of the glands in the groin; whereas in the former, the discharge is irregular, comes away often in large lumps, and in considerable quantities, and is neither preceded by, nor accompanied with, any inflammatory af- fection of the pudenda. • Immoderate coition, injury done to the parts by difficult and te- dious labours, frequent miscarriages, immoderate Sowings of the menses, profuse evacuations, poor diet, an inactive and sedentary life, and other causes giving rise to general debility, or to a laxity of the parts more immediately concerned, are those which usually produce the whites, vulgarly so called, from the discharge being commonly of that colour. Fluor albus in some cases indicates that there is a disposition to disease in the uterus, or parts connected with it, especially where the quantity of discharge is very copious, and its quality highly acrimonious. By some the disorder has been considered as never arising from debility of the system, but as being always a primary affection of the uterus, or produced by a change in the structure^ position, or actions of the neighbouring parts, such change being the effect of natural or morbid causes.* Delicate women with lax fibres, who remove from a cold climate to a warm one, are, how- ever, to my knowledge, very apt to- be attacked with it, without th'e parts having previously sustained any kind of injury. The disease shows itself by an irregular discharge from the uterus and vagina, of a fluid, which in different women varies much in colour, being of a white, green, yellow, or brown hue* In the beginning it is however most usually white and pellucid, and in the progress of the complaint acquires the various dis- * See Observations on the ,Dis,easjes of Female?., by C. JM. Clarke, $12 local biseases [Class IV, colourations, and different degrees of acrimony ; from whence proceeds a slight smarting in making water. Besides the dis- charge, the patient is frequently afflicted with severe and constant pains in the back and loins, loss of strength, failure of appetite^, pain in the stomach, dejection of spirits, paleness of the counte- nance, chilliness, and languor. The sleep is disturbed by fearful dreams, and affords but little refreshment. The woman becomes pale and emaciated, her eyes are dull, and a flushing of the face is alternated by a ghastly paleness. In process of time the feet and ancles swell, palpitations, and a difficulty of respiration, are experienced ; the mind is deject- ed, apprehensive, and occasionally affected with melancholy. Very » frequently the functions of generation are greatly injured, and ste- rility is often the consequence thereof. Hysteria also, in a greater or less degree, is generally a concomitant of lcucorrhoea, the urine fs turbid, and the menstrual discharge is sometimes scanty, and even Suppressed : at others, it is too copious, irregular, or attended with much pain. The disease is seldom removed but by artificial means ; and where these are long deferred, it proceeds to waste the constitution with accumulating mischief. Every symptom becomes highly aggrava- ted, the eyelids and face swell, are bloated and disfigured, the body is wasted and debilitated; and hectic fever, with its doleful train, and dropsy in every form, supervene, and terminate a miserable existence. In some cases prolapsus uteri, and ulcerations are to be met with. Where leucorrhoea terminates in death, the internal surface of the uterus appears on dissection to be pale, flabby, and relaxed; and where organic affection have arisen, much the same appearances are to be met with as have been noticed under the head of Menor- rhagia. The proper indications of cure to be observed in fluor albus seem to be to increase the action of the absorbents of the uterus and vagina by restoring the tone of the parts ; to correct the acri- mony of the discharge, diminish its quantity, and alleviate other urgent and distressing symptoms; and, thirdly, to strengthen the system when the disease is complicated with general debility and relaxation. The first of these intentions is to be effected by astringents administered by the mouth, and likewise thrown up into the vagina and uterus in the form of injections.* Alum, sulphate of zinc, gum * 1. ft Zinc. Sulphat. f. 3j- *l.Take Sulphate of Zinc, one drachm. Plumbi Superacet, gr> x. Superacetate of Le_f ten grain? Aq. Distillat. Oj. M. Distilled Water one pint. ft. Inject. Mix them for an injection. Vek. Or, 2. ft. Decoc. Cort. Quercus, Oj. 2. Take Decoction of Oak Barkj one pint Aluminis, 3j- M. Alum one drachm. Mix them. Vel., Or, 3. ft Gall. Contus._ r°?. Z- Take Oak Gall, bruised, half an ounce, AqT Ferfeti*. C;; ' I- Hot Wa'e'r, two pint*, Order IV.] whites. ;i3 kino, and catechu, are the astringents which are most em- ployed as internal remedies ; and these may be given either sepa- rately, or combined with some tonic, such as the cinchona, bitters, chalybeates, and the sulphuric acid, as advised below,* or recom- mended under the head of Menorrhagia ; together with partial cold bathing, by sprinkling or sponging the loins and thighs with cold water. Besides astringents, it has been usual to employ in this disease such stimulating medicines as are most commonly deter- mined to the urinary passages, which, from their vicinity to the uterus, have often been found to afford considerable relief. Tur- pentine and other balsams, such as bals. copaibae, terebinthina Ca- nadensis, with many more of a like nature, have been used on the occasion.t The tinctura lyttas has likewise been much administered with the same view; and indeed in several obstinate cases 1 have r '■'■'■ 4. ft Aluminis Pulv. 3'j- Ras. Nuc. Moach. 3ss. Catechu Pulv. 3j- Pulv. Cinchon. ^ss. Syr. Zingib. q. s. M. ft. Electuarium, cujus sumat quantita- tern juglandis ter in die. Vel, 5. ft Alum. Pulv. gr. x. Catechu, gr. v. Zinc. Sulphat. gr. j. Confect. Ross, q. s. M. ft. Bolus ter in die sumendus. Vel, 6. ft Extract. Cinchona?, Gum Kino, aa 3j- Aluminis, 3ss. Ras. Nuc. Mosch. 3j. ■ Syrup. Simp. q. s. M. ft. Massa in pilul. xxxvj. divid. quarum iij. sumat bis terve in die ex cyatho aquae calcis. t 7. ft Terebinth. Vulg. f. 3ij. Pulv. Cinchon. 3vj- -----Gentian. 3'j- Mel. Optim. |j. M. ft. Electuarium, capiat magnitudinem nucis moschatae pro dos. bis terve in die. Vel, 8. ft; Terebinth. Canadens. f. 3ij. Pulv. Rad. Rhei, 3j. ■Cinnam. C. 3ss. M. ' 4. Take Alum, powdered, two drachms. Raspings of Nutmeg, half a drachm. Catechu, powdered, one drachm. Powder of Peruvian Bark, half an ounce. Syrup of Ginger, a sufficiency to form an electuary, of which let the bulk of a walnut to be taken thrice a day. Or, 5. Take Alum, pulverized, ten grains. Catechu, five grains. Sulphate of Zinc, one grain. Confection of Roses, a sufficiency to form a bolus. Thi3toay be taken three times a day. \ Or, 6. Take Extract of Peruvian Bark, Gum Kino, of each a drachm Alum, half a drachm. Raspings of Nutmeg, one scruple. Syrup, a sufficiency to form the mass. Divide this into thirty-six pills, and let three be taken twice or thrice a day, washing them down with a tea-cupful of lime-. water. f 7. Take Common Turpentine, two drachms. Powder of Peruvian Bark, six drachms. ---------Gentian, two drachms. Honey, one ounce. Vtake them into an electuary, and take the bulk of a nutmeg twice or thrice a day. Or, 8. Take Canada Turpentine, two drachms. Powder of Rhubarb, one drachm. Compound Powder of CinnamoD, half a drachm, 91 714 LOCAL DISEASES. [Class IV. given it with much advantage. It may be joined with balsam copaiba,* or some tonic.t The application of a blister to the sacrum has in some cases been attended with advantage. Stimulating the intestines and rectum by giving small doses of rhubarb, or the pilula? aloes cum myrrha, every night on going to bed, for a considerable length of time, has likewise been found serviceable. Gentle emetics have also been supposed to be of singular utility in fluor albus, not only by cleansing the stomach and bowels, and making a revulsion of the humours from the inferior part of the body, but likewise by their exciting all the powers of the constitu- tion to a more vigorous action. To answer the second intention, of correcting the acrimony of the discharge and lessening its quantity, a diligent attention must be paid to cleanliness by washing the parts frequently with cold water, ^ ^ ] or a little milk and water, and then throwing astringent injections up the vagina. These may consist of a strong infusion of green tea, or a solution of alum, or sulphate of zinc, in the proportion of a drachm of the latter to a pint of water, or the decoctum quercus, or infusum corticis granati. When there are excoriations either externally or internally, the liquor plumbi acetatis, diluted suffi- ciently with water, may be employed as a wash. Injecting frequently with the same in those cases when any of Fiant pilul. 1. quarum ij. ad iij. sumat aesrra bis in die. Vel, 9. ft Zinc. Sulphat. 3*s. • Pulv. Catechu, 3'j- Bals. Copaib. q. s. M. ft. Pilul. xl. capiat ij. vel iij. mane et vespere. * 10. ft Bals. Copaib. 3U- Vitell. Ovi uni. Misceantur in mortario marmor. et adde gra- datim, Aq. Fontan. |vij. Mellis Despum. ^ss. Tine. Lyttae, 3j- M. Capiat cochl. med. ij. ter in die. t 11. ft Infus. Gentian. C. f. §j. Tinct. Cinchon. f. 3'j- ----LyU.32, gut. x.—xv. M. ft. Haust. bis terve in die sumendus. Mix them together, and let fifty pills be formed out of the mass, of which the pa- tient may take from two to three, twice a day. Jl Or, 9. Take Sulphate of Zinc, half a drachm Powdered Catechu, two drachms. Balsam of Copaiba, a sufficiency. Form forty pills, and let two or three be taken morning and evening. ..,—^ * 10. Take Balsam of Copaiba, two drachms. The Yolk of an Egg. Let them be well mixed together in a mar- ble mortar, and gradually add Pure Water, seven ounces. Clarified Honey, half an ounce. Tincture of Spanish Fly, one drachm. Mix them, and take two desert spoonsful thrice a day. til. Take Compound Infusion of Gentian, one ounce. Tincture of Peruvian Bark, two drachms. -------- Spanish Fly, fifteen drops to twenty-four. Mix them. This draught may be taken three times a dav. *% Order V.J COSTIVENESS. 715 the symptoms of an inflammatory action are present, or where a cancerous state of the uterus is suspected, will be attended with considerable advantage. The pains in the back and loins are to be relieved by envelop- ing them with the emplastrum picis compos, spread upon coarse linen or leather, and by avoiding a standing posture of long conti- nuance, much walking, dancing, or other violent exertion. Languor, debility, and faintings, are to be obviated by a ge- nerous nutritive diet, consisting of milk, with isinglass boiled up in it, blanc-mange, jellies, eggs, sago, gelatinous broths, and light meats, together with cordial medicines, but more particularly Port wine. To strengthen the general system where the disease is com- plicated with universal debility, besides the restorative means just mentioned, we must have recourse to bitters of an astringent and stomachic nature, the cinchona bark, preparations of steel, the use of mineral waters, cold bathing both topical and general, and other tonics, as advised under the head of Dyspepsia. Women that are afflicted with fluor albus should avoid all the remote causes of the disease, and by no means indulge in the use of tea and other warm slops of a relaxing nature : they should lie on a mattress in preference to a feather-bed; they should avoid too free an indulgence in sensual gratification, and they should rise early, and take such daily exercise as their strength will admit, particularly on horseback. Where there is much languor, with a considerable degree of chilliness, it is probable that frictions with flannels might afford some relief. In winter they ought to wear a flannel shift or sliders. -«=>l®l©|#|®I*les-- ORDER V. EPISCHESES. Suppression of excretions. OBSTIPATIO, or COSTIVENESS. Costiveness is to be considered either as constitutional or symptomatic ; but in general it prevails as the latter. The word implies a retention of the excrement, accompanied with an unusual hardness and dryness, so as to render the evacua- tions difficult, and sometimes painful. Sedentary persons are peculiarly liable to this complaint, espe- cially those of a sanguineous and choleric temperament; or who are subject to hypochondriac affections, the gout, acute fevers, and a diseased state of the liver and spleen. 716 LOCAL DISEASES. [Class IV. H Costiveness is frequently occasioned by neglecting the usual time of going to stool, and checking the natural tendency to those salutary excretions ; by an extraordinary heat of the body, and copious sweats; by receiving into the stomach a larger proportion of solid food than is proper for the quantity of fluids swallowed ; by a free use of opium, and by taking food that is dry, heating, and difficultof digestion. Drinking freely and frequently of Port wine may likewise occasion costiveness. With the defect of stools there sometimes exist nausea, want of appetite, flatulency, pains in the head, and a degree of febrile heat. The disease is to be obviated by an attention to diet; by observ- ing certain regular periods for soliciting motions ; and where these fail, by having recourse to laxatives. The diet of such as are of a costive habit ought to consist a good deal of vegetables and ripe fruits, and their ordinary drink of malt liquors. With respect to the second object to be attended to, a habit of regularity should be endeavoured to be established by the^^ person's going at a certain hour or hours each day, and making proper efforts at each period for promoting an evacuation. If a natural inclination arises at any time, this ought likewise to be en- couraged. The laxatives most proper for obviating costiveness are those which afford the least irritation,* but which will at the same time procure one or two motions daily. V: 1. ft Potassae Tartratis, ^ss. Mann. Optim. 3'j. Aq. Fervent, f. ^iij. Tinct. Jalapae, f. 3ij. M. Capiat dimidium pro dos. Vel, 2. ft Infusi Sennae, f. |v. Magnes. Sulph. ~ss. Syrup. Rhamni, f. 3ij. M. Sumat ^ij. pro dos. et repetatur post horas tres, si sit necessitas. Vel, 3. ft 01. Ricini, f. 3vj. pro dos. Vel, 4. ft Elect. Sennae, ?ij- Potassae Supertart. 3»j• Pulv. Jalaps, 3j- Syrup. Zingib. q. s. M. ft. Electuarium, cujus quantitatem ju glandis hora somni sumat. 1. Take Tartrate of Potass, half an ounce. Manna, two drachms. Hot Water, three ounces. Tincture of Jalap, two drachms. Mix them, and let the half be taken for a dose. Or, 2. Take Infusion of Senna, five ounces. Sulphate of Magnesia, half an ounce. Syrup of Buckthorn, two drachms. Mix them. Three table-spoonsful may be taken for a dose, and the same quantity be repeated in three hours if the bowels are not sufficiently moved. Or, 3. Take Castor Oil, six drachms for a dose. Or, 4. Take Electuary of Senna, two ounces. Supertartrate of Potass, two drachms. Powdered Jalap, one drachm. Syrup of Ginger, a sufficiency to form an electuary, of which let the bulk of a walnut be taken occasionally at bed time. Order V.J COSTIVENESS. 717 Persons of a costive habit of body, and particularly pregnant women, are very apt to make use of Anderson's Pills, which are composed wholly of aloes, with a little oil of aniseed to prevent the griping effect of the former: and indeed these pills have acquired an extensive reputation. In phlegmatic constitutions they may indeed be used occasionally with some advantage possibly ; but in pregnant women, or those of a bilious habit, where the bowels are naturally irritable, they cannot fail to do harm. Their operation is confined in a great measure to the lower part of the rectum, and they are thereby apt to induce piles. The. use of every purgative medicine, moreover, creates a necessity for its repetition, and by this repetition the bowels lose their energy, their delicate nerves become torpid to the stimulus of the food and drink, and the secre- tions formed from them. A natural discharge of the contents of the bowels ought therefore to be solicited by those of a costive habit, in preference to the habitual use of any kind of purgative whatever. \ In cases of obstinate costiveness, as also in enteritis, a caution presents itself respecting active purgatives, which by irritating the intestine above the obstructed part when the obstructing matter is too large to pass the narrowed channel, must inevitably increase the mischief. In those cases where inveterate costiveness has once taken place, and the usual simple remedies have proved abortive, carbon, or charcoal divested of heat, has been administered with some success. It is reported to have p.ocured the desired relief in every instance. Three drachms of it finely levigated may be mixed with three ounces of the electuarium sennae, adding about two drachms of the carbonate of soda. Of this mixture, from half an ounce to one ounce may be taken as circumstances require. In some cases of very obstinate costiveness, where every variety of purgatives, both by the mouth and clyster, fomentations to the abdomen, the warm bath, and pure quicksilver have failed, the spi- ritus turbinthinae has been known to remove the obstruction and act freely on the bowels. Costiveness is frequently occasioned by a stricture or strictures in the rectum, or some higher portion of the intestinal tube ; there are few cases, however, of the former nature which will not yield to a proper use of the rectum bougie. They are made like the wax urethra bougie, or of sponge coated with wax, or they are tubes of elastic gum, or of metal. Another mode of distending the rectum is by the introduction of a gut of six or eight inches in length, which gut is afterwards to be filled slowly with some tepid fluid by means of a syringe. The distended gut answers the purpose of a bougie, and is particularly . Vel, j Or, J5. ft Pilul. RheiComp.gr. xv. in pilul. 5. Take Compound Rhubarb Pills, fifteen iii. pro dos. dividend. grains, divided into three pills 1 for a dose. 718 local l>iseask.>. [Class IV. useful when we are desirous of distending the rectum fully without producing to the same extent a like effect on the anus. To prevent any accumulation of faecal matter in the intestines and melt down into a fluid form what would not pass through the strictured part, gentle purgative medicines regularly taken, assisted occasionally by emollient clysters, will be highly proper. ISCHURIA et DYSURIA, or a SUPPRESSION and DIFFICULTY of URINE. When there is a frequent desire of making water attended with much difficulty in voiding it, the complaint is called dysuria or strangury ; and when there is a total suppression of urine, it is known by the name of ischuria. Both ischuria and dysuria are .> distinguished into acute when arising in consequence of inflamma- tion, and chronic when proceeding from any other cause, such as calculus, &c. The causes which give rise to the diseases, are, an inflammation of the urethra, occasioned either by venereal sores, or by a use of '^ acrid injections, inflammation of the veru-montanum, Cowper's* gland, prostrate gland, bladder, or kidneys, considerable enlarge- ments of the haemorrhoidal veins, a lodgment of indurated faeces in the rectum, spasm at the neck of the bladder, exposure to cold, the absorption of cantharides applied externally or taken inter- nally, excess in drinking either spirituous or vinous liquors, or par- ticles of gravel sticking in the neck of the bladder, or lodging in the urethra and thereby producing irritation. Gout, by being translated to the neck of the bladder, will sometimes occasion these complaints. In many instances the obstruction to the flow of urine, is in a great measure, owing to a diseased action of the muscles; in some of them it is entirely to be attributed to this cause. A very frequent cause, however, of both dysuria and ischuria is an enlargement or other diseased state of the prostate gland, a com- plaint with which men in advanced life are very apt to be afflicted. M It is usually excited by full living of every kind, inebriety, indul- * ging to excess with women, or producing frequent excitement in the seminal vessels by masturbation, severe attacks of gonorrhoea, a confined state of the bowels, and exposure to cold. Indeed what- ever increases the circulation of the blood in these parts beyond the healthy standard may become a cause of inflammation in this gland, the blood-vessels of which lose their tone in an advanced period of life. From various dissections made by Sir Everard Home,* he is of opinion, that when the prostate gland becomes diseased, it is not its body or lateral portions which in general are principally enlarged, a See Philosophical Transactions for 1806, part i. art. 8. — Practical Observations on the Disease* of the Vrostate dand. Order VJ suppression of urine. 719 but its middle lobe, which gradually becoming of an increased size, presses inwards towards the cavity of the bladder in the form of a nipple, pushes the internal membrane of the bladder before it, obstructs the flow of urine, and gives rise to dysuria and tenesmus, with many constitutional symptoms. Dissections, however, by other surgeons have demonstrated, and seemingly very satisfactorily, that the part projecting into the bladder, and forming the valve, is not the third lobe, but a more anterior part of the gland. It has also been ascertained, that when- ever this valvular projection from the prostate takes place, and aptly denominated by Mr. Charles Bell* uvula vesicas, the muscles of the ureters are enlarged, and will be found inserted at the root of the tumour. In dysuria there is a frequent inclination to make water, attended „^ with a smarting pain, heat and difficulty in voiding it, together with a sense of fulness in the region of the bladder. The symptoms often vary, however, according to the cause which has given rise to it. If it proceeds from a calculus in the kidney or ureter, besides the affections mentioned, it will be accompanied with nausea, vomiting, and acute pains in the loins and region of the ureter and kidney of the side affected. When a stone in the bladder or gravel in the urethra is the cause, an acute pain will be felt at the end of the penis, particularly on voiding the last drops of urine, and the stream of water will either be divided into two, or be discharged in a twisted manner, not unlike a cork-screw. If an enlargement or scirrhus of the prostate gland has occasioned the suppression or difficulty of urine, a hard indolent tumour, unattended with any acute pain, may readily be felt in the perinaeum, or by introducing the finger in ano. Dysuria is seldom attended with much danger, unless by neglect it should terminate in a total obstruction. Ischuria may always be regarded as a dangerous complaint when it continues for any length of time, from the great distention of the bladder, and often consequent inflammation which ensue. In those cases where neither a bougie nor a catheter can be introduced, the event in all probability will be fatal, as few patients will submit to the only remaining means of drawing off the urine before a conside- rable degree of inflammation and tendency to gangrene have taken place. When dysuria has arisen in consequence of the application of a blister, as sometimes happens, nothing more will be necessary than to direct the patient to drink plentifully of warm diluent liquors, such as a thin solution of gum. acaciae, linseed-tea, marsh- mallow decoction, or barley-water. When it proceeds from any other'cause, and the symptoms are violent, besides the means just mentioned, flannel cloths wrung out in a warm decoction of emol- lient herbs, or a bladder filled with warm water, should be kept ■ See his Treatise on the Diseases of the Urethra, Vesica Urinaria, kr * 720 local diseases. (Class TV, constantly applied over the region of the pubcs; and emollient clysters should be injected frequently, both with the view of acting as an internal fomentation, and of dislodging any indurated faeces that may be collected, and which by their pressure and stimulus will of themselves often produce a strangury, or difficulty of making urine. In ischuria it will always be advisable to guard against the taking place of any degree of inflammation, by drawing off from the arm a quantity of blood proportionable to the age and habit of the patient, at an early period of the complaint, besides having recourse to emollient fomentations and laxative clysters. Where inflammation is supposed already to exist at the neck of the bladder or prostate gland, it will likewise be proper to make use of topical bleeding by applying several leeches to the perinaeum. In the commencement of diseased prostate, where there is inflam- mation accompanied by an inordinate irritation at the neck of the bladder, nothing is so likely at first to allay the irritation as the injecting of the bladder by means of an elastic catheter with a vegetable bottle affixed thereto. We thereby sooth the irrita- bility of the part, by substituting tepid water for the acrid urine.* In the healthy state of the parts connected with the bladder, the surface is not susceptible of the stimulus from the urine, or in only the due degree ; but when inflammation occupies these parts, the acrid urine becomes a continual source of excitement. Besides, by thus injecting the bladder, the ropy mucus and purulent secretion, when there is any, are washed away, and that sort of tenesmus vesicae caused by their presence, is much relieved. If the suppression of urine does not give way to the means advised, the patient should be put into a warm bath ; and having kept him in it for about ten minutes or a quarter of an hour, he is then to be taken out, and the introduction of a metal catheter, or one of flexible gum, (which is preferable,) to be attempted. Where an oval tub can be procured for the purpose of bathing him, it ought to be preferred, as then the introduction of the catheter may be attempted in the bath, and possibly with a more decisive effect. In some obstinate cases of ischuria, and where every endeavour to draw off the urine has failed, by placing the patient in a warm bath and bleeding him ad deliquium animi, the surgeon has sometimes been. enabled to pass a catheter with the greatest ease imaginable. In all cases it will be necessary to introduce the catheter with gentleness ; even a moderate force improperly directed is capable of injuring the urethra in such a manner as to render the operation almost impracticable ; and it must be obvious to every surgeon, that long-continued and violent attempts have a tendency to in- crease the inflamed state of the urethra ; but besides this, a lace- ration of its membranous parts is apt to arise, so as to endanger the making of an artificial passage by the catheter. * See Mr. Charles Bell's Treatise on Diseases of the Urethra, Vesica, Urinaria, &r. Order V.J suppression of urine. 721 In a retention of urine proceeding from an enlarged or diseased state of the prostate gland, and where there is a fulness in the region of the bladder, with a turgidness of the parts, having pre- mised copious bleeding both general and topical, no time should be lost in introducing the catheter and drawing off the water. In doing this, three things are, however, to be attended to :—1st, To avoid bringing on spasms of the urethra ; 2dly, To conduct the point of the instrument over the prominence at the neck of the bladder; and, 3dly, To employ an instrument that is fitted to be retained in the bladder, should much difficulty have occurred in the introduction, as less disturbance is likely to arise from an instru- ment remaining therein, than will be produced by repeating the operation of introducing it, where any degree of violence is com- mitted upon the parts. The instrument should be soft and smooth, round at the point, and as large as the canal will easily admit, that it may more readily disengage itself at the turn into the bladder: the apertures in its side should be wide, to render them less liable to be clogged with mucus or blood, and it should be pliant, that it may adapt itself to the form of the parts, and give little disturbance while retained; another desirable property for it to possess, we are told by Sir Everard Home,* is a permanent curvature at the point, even to a greater degree than is usually given to the common silver catheter. The only instrument which possesses these requisites is the elastic gum catheter. To acquire the proper curvature, if should be kept upon an iron stilet of a proper shape. In some cases of an enlargement of the lobes of the prostate gland, even a flexible gum catheter with a stilet cannot pass along the urethra on account of spasm, but by having given it a consider- able curvature by its being kept a sufficient time upon a stilet, and then introducing it in a flexible state without the stilet, we shall succeed, and be able to draw off the water. Hard metallic instruments should never be employed in cases of diseased prostate when the others will answer the purpose. Sir Everard Home gives the following directions for passing the catheter in cases of diseased prostate. It should be introduced either towards the left or right side with the handle nearly in an horizontal line; and when it reaches the membranous part of the urethra, the handle should be gently and gradually brought towards the perpendicular line, the point all the time being kept in motion ; and when it is nearly upright, the handle should be depressed. When the flexible catheter has no stilet, a good deal of dexterity is often required. If the catheter without the stilet cannot be made to pass, it ought to be tried with one, and if it is still pre- vented from going on, by introducing a finger into the rectum, and pressing upon the curved point of the catheter, we may give it a right direction, so as to guide it into the bladder. When neces- * See his Observations on the Diseases of the Prostate Gland, 92 ''22 i.uCAL OlstASES. [Class IV. sary to introduce the finger in ano, a recumbent posture must be employed; but in other instances Sir Everard Home prefers the standing position. In every instance of the complaint, whether arising from stric- ture, gravel, inflammation, or spasm, opiates will prove highly serviceable, and ought therefore to be administered not only by the mouth along with diuretics* of a mild or bland nature every four hours, but likewise in clysters repeated frequently.t The liquor potassae in doses of from twenty to thirty drops joined with tinctura opii is a very useful remedy in all cases of irritation at the neck of the bladder. Injecting sweet oil, or even warm milk and water, frequently up the urethra, will often afford relief, especially if the suppression has been occasioned by a small piece of gravel which has stuck in the canal. Injecting tepid water into the bladder itself in similar cases by the apparatus before mentioned will also afford great relief in such cases In both ischuria and dysuria, arising from gravel or a stone in the bladder, besides adopting this step, we should have recourse to the means advised expressly under these heads. Making the patient stand on a cold stone floor, and applying snow or ice to the region of the pubes, have been known to remove a suppression of urine when other remedies have failed. * 1. g; Mucilag. Gum. Acaciae, f. ?j. 01. Olivae, f. 3ij. Terantur simul in mortario, et adde Spirit. Mther. Nitrici, f. 3j. Tinct. Opii, tit xv. Aq. Foenicul. gss. M. ft. Haustus. Vel, 2. ]£ Potassa; Acetat. 3j. Aq. Foenicul. 3xj. Tinct. Opii, fllx. Syrup Althaeae, f. 3'j- / St. Haustus. t 3. % Bals. Copaib. f. 3ij. Vitel. Ovi, q. s. ad solut. et adde Decoct. Malvai Compos, f. ?xj. 01. Ricini, f. ^ss. Tinct. Opii, TT1 xxx.—lv. Pro enemate. Vel, 4. }fe Decoct. Amyli, ? vj. M. Ol. Oliva?, f. |ss. Vini Opii, fllxxxv. Knema. M * 1. Take Mucilage of Gum Acacia, one ounce. Olive Oil two drachms. Let them be well mixed in a marble mortar, ••'*'. and then add Spirit of Nitric iEther one drachm. Tincture of Opium, twenty- three drops. Fennel Water, half an ounce. Mix them for a draught. Or, 2. Take Acetate of Potass, one scruple. Fennel Water, eleven drachms. Tincture of Opium, fifteen drops. Syrup of Marshmallow, two drachms. » Mix them for a draught. t 3. Take Balsam of Copaiba, two drachms. Yolk of an Egg, a sufficiency. Then add +' Compound Decoction of Marsh- mallows, eleven ounces. Castor Oil, half an ounce. Tincture of Opium, from fifty i, eighty drops. Mix them for a clyster Or, 4. Take Thin Decoction of Starch, six ounces. Olive Oil, hall an ounce. ,;y Wine of Opium,„fiftv drops* .."'*' ! Mix them for a clyster Order V.J suppression of urine. 73,S Throwing a little cold water on the thighs has sometimes enabled the person to pass urine in a tolerable stream, although before suppressed. When all these means prove unsuccessful, an enema of an infusion of tobacco* will often be attended with a powerful and decisive effect in cases arising from spasmodic affection, as I have experienced in two or three instances ; the patients became faint and sick, the pulse sunk, a profuse perspiration broke out, and soon afterward the urine flowed in a small stream. From the great depression of the powers of life which tobacco clysters are apt to occasion, (even to an alarming degree sometimes,) due caution must be observed in repeating them. A bougie medicated with tobacco is reported by Dr. Shaw, of Philadelphia, to have been employed by him with great success in several cases of retention of urine arising from stricture. In cases of retention arising from spasm combined with stricture, the injection of warm olive oil into the urethra has sometimes proved beneficial. The tinctura tabaci administered in doses of thirty drops twice or thrice a day in a tea-cupful of linseed-tea has proved an excellent remedy in many cases of dysuria. The tinctura ferri muriatis is a remedy which often proves efficacious in suppressions of urine arising from spasm; and should the tobacco clyster fail in producing the desired effect, it may be given in doses of ten drops, repeated every ten minutes, until some sensible effect is obtained. After six doses the urine usually flows freely. To the good effect of this medicine I can myself bear testimony, having tried it in some cases of spasmodic suppression with success. In ischuria, particularly where it is of a chronic nature, camphor has been found a very valuable medicine, and may be given as advised below,t administering a dose of the oleum ricini now and then. * 5. fy Tabaci, 3ss.—3i. Aq. Fervent, f. ?x. Col. post semi- horam. Pro enemate. ■^'+ 6. rx Camphor, gr. v. f*l -J Hydrargyr. Submuriat. gr. ss.—j. Opii, gr. j. Confect. Aurant, q. s. M. ft. Bolus, bis in die sumendus. Vel, 7. 1^ Camphora?, gr. vj.—x. Solve in Lactis Vaccinae, f. ^iss. et adde Tinct. Opii, TT| x. M. ft. Haustus. rapiat tertia quaque hora. * 5. Take common Tobacco, half a drachm. to one drachm. Warm Water, ten ounces. After half an hour's infusion, strain on" the liquor for a clyster. t. 6. Take Camphor, five grains. Submuriate of Mercury, half a grain to one grain. Opium, one grain. Confection of Orange, a sufficien- cy to form a bolus, which is to be taken twice a day. Or, 7. Take Camphor, six to ten grains. Dissolve it in Fresh Cow's Milk, one ounce and a half, and add Tincture of Opium, fifteen drops. Mix them. This draught may be taken every three hour?. 724 LOCAL diseases. [Class IV. In morbid conditions of the bladder, in which a suppression of urine is apt to arise, and to recur frequently, the extract of hyos- cyamus may prove a good medicine, beginning with doses of four or five grains, and so gradually increasing the quantity according to the state of the distress, and the effect produced. When a diseased condition of the bladder is supposed to be connected with, or dependant on scrofula, possibly hemlock may be of some service; but to derive benefit from it in such cases it should be used in as large doses as possible. Gentle courses of mercury, conjoined with hemlock, have sometimes been beneficial in the like cases: but where, under a morbid condition of the bladder, the inflammation and irritation are great, and verging to a state of scirrhus or ulceration, mercury would certainly be injurious.—See Cystitis. In desperate cases, where all the means which have been advised prove ineffectual, where no catheter can be passed, and where im- minent danger is to be apprehended from the vast distention of the bladder, recourse is to be had, before it is too late, to the opera- tion of puncturing it with a trocar; and the mode of doing this now most generally adopted by surgeons is (I believe) through the rectum. In the manner of thus operating, some little variation from the usual mode has been recommended by Mr. Charles Bell, with the view of avoiding the prostate gland, vesiculae seminales, and vasa deferentia. He directs when the finger is introduced in ano, and a proper distinction made betwixt the membranous part of the urethra, the prostate, and the body of the bladder, then to intro- duce the trocar, not exactly in the centre and behind the prostate, but to one side of the latter. If the bladder be struck behind, and a little to one side of the prostate gland, the vase deferentia will be thus distant from the wound ; the vesiculae seminales will also be avoided, and we have this further motive, he observes, that even if they were touched, the wounding them could be attended with no serious effect, while the division of the vas deferens would be equal to castration. Those who are subject to attacks of dysuria or ischuria ought carefully to guard against all exposures to cold, and particularly getting wet in the feet; they should lead a temperate life, avoid all severe exercise, especially on horseback ; and they should use every precaution against receiving any venereal taint. Those who are liable to a suppression or difficulty of urine, either from strictures or caruncles in the urethra, will act prudently in wearing a bougie for an hour or two every day. In the first stage of an enlargement of the prostate gland, the best means to resort to are frequent bleedings fr6m the perinaeum by means of leeches, or from the loins by cupping, assisted by cooling purgatives from time to time, opiate clysters, and the use of a tepid hip bath of 94 or 95 degrees of temperature once in the twenty-four hours. Quietness, abstinence, and all the other common Order V.J interruption of the menstrual flux. r 725 means for allaying irritation, are to be employed at the same time. On no account should bougies or catheters, particularly of the metallic kind, be,introduced; since when done in the most adroit manner they cannot fail to produce some disturbance which the parts are not in a state to bear; and if an instrument is unskilfully passed, it will increase the swelling, and probably bring on a com- plete retention of urine. In a more advanced stage of the disease the treatment should consist in keeping the urine in a state of dilution by means of watery mucilaginous drinks, the bowels open by gentle aperients, the diseased parts soothed by suppositories* and clysters of warm water, and medicines of the narcotic kind administered internally. Of these, opium, the compound powder of ipecacuanha, hemlock, and hyoscyamus, are most to be depended upon. A temporary re- lief may be experienced by a hip bath of common salt water at a low temperature. The insertion of a seton or issue in perinaso might perhaps retard the progress of the complaint. The patient should abstain from every kind of food and liquor of a stimulant nature ; he should carefully avoid horse exercise, or violent exertion of any kind, and he should sit on a chair with a cushion which is hollowed out in the centre ; moreover, he never should retain his urine for any length of time so as to distend the bladder by an ac- cumulation of it. Where ulceration takes place in the prostate gland, the case is marked by an increased secretion of every viscid mucus mixed with pus, and sometimes with blood ; a frequent desire to make water, and more or less with a stinging pain at the neck of the bladder and glans penis. Ulceration of this gland is usually the consequence either of small irregular pieces of gravel escaping from the bladder, but entangling themselves just behind the veru- montanum, so that the sharp points wound the membrane, and by degrees sink deeper into the substance of the gland, and become fixed in that situation; or of the incautious use of instruments, more especially of the metallic kind, in attempts to pass them into the bladder; or it ensues in consequence of the formation of an abscess in the substance of the gland. Cases of ulceration in the prostate gland are truly deplorable, and all that can be done is to mitigate the sufferings of the patient by narcotics, &e., recommending him, at the same time, strictly to follow the plan already detailed. AMENORRHEA, or INTERRUPTION of the MENSTRUAL FLUX. Amenorrhea is to be considered as of two kinds : the one where the menses do not begin to flow about the period of life at * 8. rj: Opii, gr. iij. j* 8. Take Opium, three grains. Extract. Conii, gr. iv. M. 1 Extract of Hemlock, four grains. ft. Pilula, in ano introducta. Make them into a pill, and insert it up the I anus. 726 local diseases. [Class IV. which they generally appear; and the other where, after having made their appearance, they cease to return at their usual periods from other causes than conception. The term of retention has been applied to the former, and that of suppression to the latter. Menstruation seems evidently to give a disposition to the female organs of generation to be acted upon by the male semen so as to fit them for impregnation, as women seldom, if ever, bear children before they have menstruated, and few or none ever become preg- nant after the total cessation of this discharge. Whether or not the blood which should have passed off by menstruation contributes to the formation and nutriment of the foetus in utero, is looked upon as a matter of doubt: that it does not, is the opinion most generally entertained. An ingenious solution of the problem, Why nature should have doomed the human female to the menstrual discharge ? has been offered by Mr. Abernethy.* It can only be solved, he remarks, by supposing that it relieves uterine irritation, and mitigates the ex- treme of sexual desire, thus enabling a woman to conform to the laws of morality, and the social compacts that are established be- tween us. In warm climates menstruation takes place at a much earlier period of life than in cold ones, as in the former it often makes its appearance at the age of ten or eleven years ; whereas in the latter it is seldom to be observed before fifteen or sixteen. It also ceases much sooner with women who reside in warm climates than it does with those who are inhabitants of cold ones: as in the former, menstruation is not often to be observed after the age of forty; whereas in the latter it seldom stops before that of forty-five, and is in many instances extended to fifty years. Some women begin to menstruate without any previous indispo- sition ; but with most of them the first appearance of the discharge is preceded by a swelling or enlargement of the breasts, together with a sense of fulness at the lower region of the belly, pains in the back and inferior extremities, and some slight hysteric affections, all of which cease as soon as the flow of blood takes place. For the two or three first times of its appearing it is apt to be somewhat irregular, both as to the quantity of blood which is dis- charged and the period of its return ; but after these it usually ob- serves stated times, and nearly the same quantity is lost at each visitation, unless some irregularity ensues. To ascertain the quantum generally discharged with exactness is impossible, as this varies in different women, and greatly depends on the constitution. Those of a delicate habit and lax fibre have a more copious and a longer continued discharge than women of a robust contitution. In general, however, the menses continue to flow from four to six days, and the quantity of blood discharged is about five ounces. *See his Physiological Lectures delivered before the roval College of Surgeons in «h" year 181.7. Order V.J retention of the menses. 727 Pregnant women, and those that suckle children, do not usually menstruate during such processes. m — > i. CHLOROSIS, or RETENTION of the MENSES. The cause of this disease seems to be a want of power in the system arising from weakness to propel the blood into the uterine vessels with a force sufficient to open their extremities, so as to allow of a discharge of blood from them ; but the origin of the weakness which appears at this particular period of life, we are wholly unacquainted with. Some have referred it to a certain state or affection of the ovaria, between which and the uterine vessels there is a seeming connexion. The mere want of the discharge may not produce the diseasef for frequently it does not appear until seventeen or nineteen years of age without producing any morbid affection. This is not to be considered as morbid unless the system is evidently deranged thereby. In many cases, however, morbid symptoms do appear, which are evidently connected with the defect of the menses, and' go off upon its discharge. The supposed connexion of chlorosis with defective menstrua- tion as its cause, and with the restraints imposed by the laws of so- ciety on certain natural appetites and passions, has been combated by a late writer,* and he thinks that the leading symptoms may be readily explained by a reference to the state of the primae vias. Costiveness always precedes and accompanies the other symptoms. This induces, he says, the feculent odour of the breath, disordered stomach, depraved appetite, and impaired digestion, which preclude a sufficient supply of nourishment at a period of growth when it is most wanted. In reporting this gentleman's ideas on the subject of chlorosis, I cannot avoid observing, at the same time, that since the publica- tion of his work on the utility of purgative medicines, it has become too prevalent to attribute a long catalogue of diseases as consequential affections upon a disordered state of the digestive organs, or chylopoietic viscera; many of which, in my humble opinion, arise from other causes. Heaviness, listlessness to motion, fatigue on the least exercise, palpitations at the heart, pgiins in the back, loins, and hips, flatu- lency, and acidities in the stomach and bowels, costiveness, a pre- ternatural appetite for chalk, lime, and various other absorbents, together with many dyspeptic symptoms, usually attend on chlo- rosis. As it advances in its progress the face becomes pale, and after- wards assumes a yellowish hue, even verging upon green, from whence it has been called green sickness; the lips lose their * See Observations on the Utility of Purgative Medicines in several Diseases, by Or James Hamilton, of Edinburgh 728 local diseases [Class IV* colour; the eyes are encircled with a livid areola; the whole body has a leucophlegmatic appearance, with every indication of a want of power and energy in the constitution; the feet are affec- ted with oedematous swellings ; the breathing is much hurried by any vigorous exertion of the body ; the pulse is quick, but small; and the person is apt to be affected with a cough, and with many of the symptoms of hysteria. Sometimes a great quantity of pale urine is discharged in the morning, and not unfrequently hectic fever attends. To procure a flow of the menses proves in some cases a very difficult matter ; and where the disease has been of long standing, various morbid affections of the viscera are often brought on, which at length terminate fatally. By marriage, and a change in the mode of life, the disorder has in several instances been * removed. Dissections of those who have died of chlorosis, have usually shown the ovaria to be in a scirrhous or dropsical state. In some cases, the liver, spleen, and mesenteric glands, have likewise been found in a diseased condition. The cure of the disorder is to be regulated on the plan of in- creasing the tone of the general system, and of exciting the ac- tion of the uterine vessels by stimulants. The first of these is to be effected by a generous nutritive diet, with a moderate use of wine; by gentle and daily exercise, but more particularly on horseback ; by associating with agreeable com- pany, so as to keep the attention engaged, and the mind tranquil and amused; by inhaling dephlogisticated air or oxygen gas ; and by a regular use of/tonic medicines, as the cinchona, infusum gen- tianae compositum, infusum quassias, &c. together with chalybeates,* * 1- ft Myrrh. Pulv. 3ss. 1*1. Take Powdered Myrrh, half a drachm. Ferri Sulphat. 3j. Sulphate of Iron, one scruple. Sodse Subcarbon. gr. xv. j Subcarbonate of Soda, fifteen j grains. Extract. Cinchon. 3j. Syrup. Zyngib. q. s. M. ft. Massa, in pilulas xxiv. dividenda, qua- rum duas sumat bis terve de die cum cochl. magnis duobus mistura? sequen- tis:— 2. ft Infus Gentian. Comp. f. |vj. #»- Tinct. Cinchon. C. ----Cardam. C. aa f. ^ss. M. ft. Mistura. Vel, 3. ft. Tinct. Ferri Muriatis, f. |j. Cujus sumantur 1Y[ decern ter de die ex cyatho aquae frigidas ant Decocti Cin- chona? . Extract of Peruvian Bark, one scruple. Syrup of Ginger, a sufficiency to form the mass, which is to be divided into twenty-four pills, and two to be taken twice or thrice a day,washing them down with two table-spoonsful of the following mixture :— 2. Take Compound Infusion of Gentian, six ounces. -------Tincture of Bark, ----s---■-------Cardamoms, of each half an ounce. Mix them. Or, 3. Take Tincture of Muriate of Iron, one ounce. The dose may be fifteen drops thrice a day in a glassful of cold water, or a Decoction Order V.J retention of the menses, 72'9 various forms of which will also be found under the head of Dys- pepsia. Previous to a use of these medicines, it may, however, be advi- sable to give a gentle emetic, for the purpose of cleansing the stomach, and freeing it from acidities and inactive fluids. Chlorosis (a disease which is at all times much relieved by steel, and will bear it even where there is a considerable degree of feverish irritation,) is often entirely removed by a course of Bath water ; and its use as a warm bath will greatly contribute to remove that languor of circulation, and obstruction of the natural evacua- tions, which constitute the leading features of this troublesome dis- order. Women of an irritable habit should not, however, drink more than a pint a day. Tunbridge-well water is another chalybeate which frequently roves serviceable to chlorotic women. To those of a weak irrita- le stomach the fresh-drawn water is apt to prove too cold, and to occasion a nausea or sickness which always defeats the general intention of the medicine. This inconvenience is to be prevented by giving the water a tepid warmth ; and to do this it is by far the best method to put it into a bottle closely corked, and to immerse the whole in hot water, for by this means but little of the carbonic acid escapes. During a course of this water, as well as of the for- mer, it will be advisable to employ the warm bath occasionally j the propriety of which practice is proved by daily experience. A bath of about eighty degrees will be highly serviceable : a colder one might do injury. Pyrmont and Spa waters may likewise be found useful in this disease. As the former of these is very strong, and contains a large excess of carbonic acid, it will bear dilution with boiling water sufficient to bring the whole to a moderate temperature ; but with the mild weak chalybeates, such as that of Tunbridge, the method of warming it in the manner before mentioned is by far the best.— In using the Spa water, it will be most advisable to begin with a moderate quantity, not more than half a pint for a dose, which may be repeated three or four times in the day, and be gradually increas- ed till some effect is produced on the secretions. Many patients, but more particularly those on the spot, are in the habit of diluting with this water the wine that forms their common drink, which makes a pleasant and salutary beverage. Vel, 4. ft Pulv. Myrrh. 31 Solve in Spirit. Cinnam. L 3ij. et adde Aq. Pimenta*, f. 3*. Ferri Sulphat. gr. v. Potassae Subcarbonat. gr. viij. Syrup. Simpl. f. 3i. M. ft. Haustus, ter in die adhibendus. I Or, 4. Take Myrrh, one scruple. Dissolve it in Spirit of Cinnamon, two drachms. And add Pimenta Water, ten drachms. 1 Sulphate of Irou, five grains. 1 Subcarbonate of Potass, eight grains. Commom Syrup, one drachm. Mix them. This draught is to be taken ' thrice a duv 93 730 LOCAL DISEASES. [Class IV* The second intention of cure (viz. of exciting the action of the uterine vessels) is to be promoted by the exercises of walking, dancing, and jumping, by frequent friction, by putting the feet often into warm water, by heat applied to the organs of generation and lower region of the belly, in the form either of steam or stupes, by compression of the iliac arteries in obstinate cases, and by electric shocks passed through the pubic, hypogastric, and lumbar regions; the last of which, by being used at the same time, is more likely to be attended with a good effect. In all cases venery is however the most certain and natural remedy. Stimulating the rectum by purgatives is a mean which is likewise usually employed in chlorosis to excite the action of the uterine vessels. Those most in use are the drastic resins, such as aloes, „c, which may be given as advised below.* Mercury is some- times employed as a stimulant and deobstruent fn this disease, and the preparation of it most used is the hydrargyri submurias; but it is by no means universally approved of as a safe medicine. When given in cases of this nature it ought to be combined with some drastic! Some practitioners are in the habit of giving these stimulating purgatives twice a week; but the preferable way seems to be that of employing them in a small but sufficient dose every night when the patient retires to rest, so as to keep up a regular and sufficient alvine evacuation. The author of the observation before quoted, tells us, that he has found the purgative plan very successful in chlorosis, but that it requires great assiduity and perseverance frequently to accom- plish the end desired. The formation of this and many other 5 . ft Pilul. Aloes cum Myrrh. 3j. In pilulas xij. divid. quarum sumat iij, vel iv. pro dos. Vel, 6. ft Pilul. Galban. C. Aloes Spicat. aa 3j- Syr. Rhamni, q. s. M. ft. Massa in pilulas xxiv. dislribucnda, quarum iij. vel iv. capiat hora decu- bitus. Vel, 7. JJ; Tinct. Aloes Comp. f. 3\j-—f- pro dos. f 8. ft Pulv. Scammon. cum Hydrargyri Submuriate, 3j. Syrup, q. s. M. ft. Massa in pilul. xij. distribuenda, iij pro dos sumenda?. * 5. Take Aloe tic Pills with Myrrh, one drachm. Divide the mass into twelve pills, of which take from three to four for a dose. Or, G. Take Compound Galbanum Pills, Soccotrine Aloes, of each one drachm. Syrup of Buckthorn, a suffi- ciency. ' The mass is to be divided into twenty-four pills, of which let from three to four be taken occasionally on going to bed. Or, 7. Take Compound Tincture of Aloes, from two drachms to half an ounce for a dose. t 8. Take Powder of Scammony with Sub- muriate of Mercury, one drachm. Syrup, a sufficiency to form the mass, which is to be distributed iulo twelve pills. Of these three may be ta- ! ken for a dose. Order V.J retention of the menses. 731 diseases, he thinks, may be prevented wholly hy promoting at all times, where nature is defective, a regular and sufficient alvine evacuation. Besides purgatives, other stimulants, under the name of emme- nagogues, such as savin, &c, have been employed in the cure of chlorosis : but they seem better calculated for a suppression of the -menses than for a retention of them, as in this disease tonics and chalybeates are the most advisable. Should the practitioner, however, be disposed to make trial of them, he will find various forms of the same under the succeeding head. If the desired effect is not produced by these remedies, we may, after a fair trial of them, recommend a teaspoonful of the medicines advised below,* to be taken morning, noon, and evening, giving now and then an emetic of the cupri sulphas, as prescribed under file head of the Pthisis Pulmonalis. Should the patient in the course of the disease be troubled with acidities in the stomach, she ought then to have recourse to absor- bents, as directed in Dyspepsia. The liquor potassae subcarbonatis, in small doses, frequently re- peated, is a good medicine for palliating cardialgic paroxysms in chlorotic constitutions. Where chlorosis is attended with symptoms similar to pulmonary consumption, it will be of considerable utility to administer a gentle emetic occasionally, keeping the bowels open at the same time. Myrrh combined with the sulphate of iron may also prove of much service. If there is pain in the side, the application of a blister over the part, or some warm plaster, will be proper; and if the cough be troublesome, squills may be used as an expectorant, with «n opiate at bed-time. If the skin be permanently hot, or irregu- larly hot and cold, without any weakening perspiration, a tepid bath may be of some service, or we may substitute small doses of the saline julep from time to time. In such cases emmenagogues would be of no use ; nay, they might be detrimental. A removal into the country, with pure air and moderate exercise on horse- back, will greatly contribute to a re-establishment of the woman's health. The diet ought to be light and nourishing. In many * 9. ft Tinct. Cinchonae, f. ?jss. —— Ferri Muriat. f. 3j. * 9. Take Tincture of Peruvian Bark, one ounce and a half. -------Muriate of Iron, one drachm. Lyttae, f. 3ss. M. -------Spanish Fly, half a | drachm. j.Mix them. Vel, j Or, 10. ft Tinct. Aloes C. f. |jss. j 10. Take Compound Tincture of Aloes, one ounce and a half. -----llelleb. Nigr. Tincture of Black Hellebore, -----Castor, aa f. 3>j- -------Castor, of each two j drachms. —— Lyttae. f. 7«s. M. j —'----- Spanish Fly, half a drachm. IMix them. LOCAL DISEASES. [Class IV. instances milk agrees well with the patient; but it is not necessary to restrict her from animal food of easy digestion. In the winter she should be removed to the southern part of our island, or to a milder climate. A SUPPRESSION of the MENSES. Any interruption occurring after the menstrual flux has once been established in its regular course, except when occasioned by conception, is always to be considered as a case of suppression. A constriction of the extremeties of the vessels of the uterus arising from accidental circumstances, such as cold, anxiety of mind, fear, inactivity of body, the frequent use of acids and other sedatives, &c, is the cause which evidently produces a suppression of the menses. In some few cases it appears as a symptom of other diseases, and particularly of general debility in the system. Herein there is a want of the necessary propelling force or due action of the vessels. When the menstrual flux has been suppressed for any considera- ble length of time, it not unfrequently happens that the blood which should have passed off by the uterus being determined more copiously and forcibly to other parts, gives rise to haemorrhages; hence it is frequently poured out from the nose, stomach, lungs, and other parts, in such cases. At first, however, febrile or in- flammatory symptoms appear, the pulse is hard and frequent, the skin hot, and there is a severe pain in the head, back, and loins. Besides being subject to these occurrences, the patient is likewise much troubled with costiveness, colic pains, and with dyspeptic and hysteric symptoms. Our prognostic in this disease is to be directed by the cause which has given rise to it, the length of time it has continued, and the state of the person's health in other respects. When suddenly suppressed, in consequence of cold, it may easily be restored by pursuing proper means ; but where the suppression has been of long standing, and leucorrhoea attends, we ought always to consider such circumstances as unfavourable. In those cases which have terminated fatally in consequence of the long continuance of the disease, the same morbid changes in the ovaria and uterus are to be observed on dissection, as in those ef a retention of the menses. What we are principally to have in view in the treatment of this complaint is to remove (if possible) the constriction which affects the extremities of the vessels of the uterus; and this is to be attempted by a use of relaxants, antispasmodics, and general stimulants, as advised under the head of ^Retention, with an ex- ception to tonics and cold bathing, which appear to many of an ambiguous effect. In those cases, however, where the suppression is symptomatic of general debility, they may be used. As relaxants, bladders filled with warm water may be applied fo Order V.J suppression of the menses. the region of the pubes and adjacent parts, or warm vapours may be received on them, by making the patient sit on a chamber-pan rilled with hot water; and in order that these applications may have the due effect, they should be employed particularly at the time when nature seems to be making some effort to produce the discharge, which may be known by a sense of fulness in the organs of generation, a weight in the back and loins, and slight spasmodic pains in the uterus. Pediluvium and semicupium will also be proper. To increase the relaxing powers of these topical applications, we may at the same time give an opiate, particularly in the form of clyster, where there is much pain. Such are the means we should pursue when the efforts of the System are concurring ; but at other times, or during the intervals, we ought to have recourse to medicines, which acting either by peculiarly removing spasm, or by increasing the general action of the system, have heen denominated emmenagogues. Those most in use are castor, myrrh, black hellebore, savin, wood-soot, madder, and the submuriate of mercury. In employing emmenagogues, the practitioner must be careful to discriminate those cases of suppression which are the conse- quence of a lax habit, and which, although not very frequent, now and then occur, from those which proceed from a constriction of the extremities of the vessels of the uterus ; as in the former, a liberal use of forcing medicines would be likely to prove injurious, and which can only be relieved by chalybeates and other tonics. Where it is proper to employ emmenagogues, they may be admi- nistered in any of the forms* here recommended. ?' 1. ft Tinct. Sabin. Compos, ^j. ----Helleb. Nigr. jss. ----Castor. 3ij. M. Capiat fit xx.—xxx. ter die ex quovis vehiculo. Vel 2, ft Tinct. Helleb'. Nig. f. ^ss. ----Myrrh, f. ^j. ----Lyttae, 3ij. M. Sumat aegra fit xx. ter quaterve in die. Vel, 3. ft Tinct. Aloes Comp. f. ^ss. ----Castor, f. 3'j- M. Vini Ferri, f. ^ss. Cochl. minim, j. ter die sumendum. Vel, 4. ft Pulv. Myrr. Compos. 3j. Ferri Ammoniati, gr. v. Confect. Cort. Aurant. q. s. M. ft. Bolus, bis terve in die capiendus. * 1. Take Compound Tincture of Savin, one ounce. Tincture of Black Hellebore, half an ounce. -------Castor, two drachms. Mix them. The dose may be from thirty to forty-five drops thrice a day in any vehicle. Or, 2. Take Tincture of Black Hellebore, half an ounce. ----.---------Myrrh, one ounce. -------------Spanish Fly, two drachms. Mix them, and let the patient take thirty drops three or four times a day. Or, 3. Take Compound Tincture of Aloes, half an ounce. Tincture of Castor, two drachms. Wine of Iron, half an ounce. Mix them. Take a teaspoonful thrice a day. Or, 4. Take Compound Powder of Myrrh, one scruple. Ammoniated Iron, five grains. Confection of Orange Peel, a suffi- ciency to form a bolus, which is to be taken twice or thrice a day. 734 local diseases. [Class IV. Women subject to, or labouring under a suppression of the menses, should carefully avoid all exposures to wet and cold, par- ticularly in the feet, which parts ought to be kept not only dry but warm. Practitioners should be aware of the connexion between sup- presson and pregnancy. DYSMENORRHEA, or DIFFICULT MENSTRUATION. Besides the two deviations from the usual course of nature already mentioned, there sometimes occurs a third, viz. where menstruation, although not wholly suppressed, is nevertheless some- what difficult, and accompanied with severe pains in the back, loins, and bottom of the belly. This disease is supposed to be owing to a weak action of the vessels of the uterus, or spasm of its extreme vessels, and is to be obviated by chalybeates, warm bathing, both topical and general, together with the use of opiates, which should be employed as soon as the symptoms that denote its approach are apparent. The extractum stramonii given in half grain doses, will sometimes prove serviceable in cases of painful menstruation when other narcotics and anodynes fail. OF a CESSATION of the MENSES. The period of life at which menstruation ceases is always a very critical one to women, as the constitution then undergoes a very considerable change, and it not unfrequently happens, that chronic complaints then arise which create much disturbance, and after a time terminate fatally, if not counteracted. The menses seldom cease all at once, but for some time before their stoppage become somewhat irregular both as to the periods and the quantity. Or, 5. Take Compound Galbanum Pills, Sulphate of Iron, of each one drachm. Extract of Savin, half a scruple. --------Black Hellebore, one scruple. Syrup of Ginger, a sufficiency. Mix tbem, and form thirty-six pills out of the mass. Let the patient take three morning and evening. Or, 6. Take Subcarbonate of Iron, Myrrh, in powder, of each one drachm. Soccotrine Aloes, two scruples. Venetian Soap, half a scruple. Syrup, a sufficiency. Mix them. Let thirty-six pills be formed out of the mass, and take three twice or thrice a day. Vel 5. ft Pilul. Galban.C. Ferri Sulphat. aa 3j. Extract. Sabin. 3ss. ------Heleb. Nigr. 3j. Syrup. Zingib. q. s. M. ft. Massa. in pilulas xxxvj. distribuenda, quaram iij. sumat segra mane et vespere. Vel, 6. ft Ferri Subcarbonat. Pulv. Myrrh, aa 3j. Aloes Spicatse Extract. 3ij. Sapon. Venet. 3ss. Syrup, q. s. M. Fiant pilul. xxxvj. capiat iij, bis terve in die. Order VI.J scirrhus and cancer. 735 When they happen to disappear suddenly in women of a full plethoric habit, such persons should be careful to confine them- selves to a more spare diet than usual; they should likewise take regular exercise, and keep the body open by a use of some mild laxative, such as the electuarium senna?, the purgative quality of which may be increased, if not found sufficiently powerful, by adding a small quantity of powdered jalap. Where the patient is sensible of a seeming fulness of the vessels, with giddiness and occasional pains in the head, small bleedings, by applying leeches to the temples, may likewise be advisable. If ulcers break out in the legs or any other part of the body on a total cessation of the menses, they ought to be regarded as critical discharges, and should by no means be healed up without substituting some other drain by an issue. Should any scirrhous or cancerous affection of the uterus take place on a stoppage of the menstrual flux, as sometimes happens, all that can be done in such a case is to have recourse to palliatives, such as opium, hyoscyamus, and conium, in the manner pointed out in the succeeding diseases. ——ooo-— ORDER VI. TUiVlOURS. Increased bulk of a part, with little or no inflammation. SCIRRHUS and CANCER. A scirrhus is to be considered as the occult or primary stage of cancer, and is not an unfrequent consequence of inflammation when it has attacked or occupied glands. The part becomes of increased size, is knotty, hard, and irregular to the touch, being however unattended with any discolouration of the skin, and acute lancinating pains are every now and then felt darting through the tumour. At length a tendency to cancerous ulceration becomes obvious. ' A cancer is an ulcer of the very worst kind, with an uneven surface, and ragged and painful edges, which spreads in a very rapid manner, discharges a thin acrimonious matter that excoriates the neighbouring integuments, and has a very fetid smell, and which is usually preceded by a hard or scirrhous swelling of the part,-if glandular. The disease is most commonly confined to glands, and particur larly the testes and mammae ; but is nevertheless now and then to be met with in the uterus, as likewise in the face and other parts that are thinly covered with flesh, and which are at the same time a good deal exposed to external irritation, such as the lower lip, 736 local disea&e*. [Class IV. the angles of the eyes, the organs of vision, the alas nasi, tongue, and penis. From a lodgement of soot in the rugae of the scrotum, chimney-sweepers who have arrived at the age of puberty are very subject to a peculiar cancerous affection in this part, and first » noticed by the late Mr. Pott.* Cancer is most generally met with in persons advanced in life, and particularly in women about the period when the menses cease. The disease being often met with in unmarried females about this time of life, it has been thought by some that celibacy predisposes to the complaint. Women who have had no children, as likewise those who have had them but not suckled them, are frequently affected with cancer. From several persons of one family having been afflicted with cancer, it seems as if there had been an here- ditary predisposition, from some peculiarity or structure, in these instances to the disease. Climate appears to have some degree of influence in predisposing to cancer: in cold northerly regions the disease is not only more frequent than in the southern parts of Europe, but seems likewise to be more intractable in its nature. It has been observed by many surgeons, that cancerous affections are most prevalent in persons of a scrofulous constitution.! The experiments of Mr. North! and others prove the non- existence of specific cancerous matter. Mons. Alibert|| inoculated himself and some of his pupils with cancerous matter; and although in some instances inflammation of the part and of the lymphatics proceeding from it occurred, yet nothing like scirrhus or cancer succeeded. A cancer arises most frequently from some external injury, such as a blow; but is now and then to be met with as the consequence of previous inflammation excited by other causes. Irritation during the scirrhous state of a gland, without any wound or breach of the skin, may be propagated to other glands, and these may take on a similar action with the gland first diseased; but absorption does not take place until the gland becomes ulce- rated. When this is the case, the irritation from one gland to another goes on not only more rapidly, but absorption takes place from every part of the diseased surface. A late writer§ has offered it as his opinion that cancer is pro- duced by hydatids. That these may be formed on a cancerous gland cannot be disputed, but that they are generally to be met with, or are essential to the disease, cannot be admitted. Cancer usually begins with a small swelling in the gland, unac- companied by pain or any discolouration. It gradually increases both in size and hardness, in process of time is attended with lancinating pains, as if a sharp-pointed instrument was entering * See his Chirurgical Works, p. 734. t See Howard on Cancer. X See Observations on the Treatment of Scirrhous Tumours on the Breast. || See Description des Maladies de la Peau. * Hee Dr. Adam's Observations on Morbid Poisons. (JttUrVI.J >.GIRRHU5 AND CANCER*, 737 the tumour, and with varicose swelling of the subcutaneous veins, together with an uneasy and painful sensation in the neighbouring parts. Sometimes it remains in this indolent and occult or scir- rhous state for a length of time, but in other instances it proceeds on to suppuration with great rapidity, and forms an ulcer. Its progress will, however, depend much on the state of the person's constitution, and other like causes. It has been supposed, that in proportion to the rapidity of the progress of any individual case, so is its degree of malignancy. During the occult state of cancer, the pains recur at very irre- gular intervals, and are dependent upon causes concerning which nothing satisfactory is known. If the disease is seated in the breast, and the female of such an age that the catamenia have not altogether disappeared, she will usually suffer a considerable exa- cerbation of pain in the part about the times of their recurrence. The tumour will likewise undergo most likely a proportionally greater augmentation of bulk than during the same space of time at any other period. When the tumour begins to form adhesions to the surrounding parts, and that the disease is in the breast, it is not uncommon to find one or more of the axillary glands on the same side of the body somewhat enlarged. As the disease approaches near the surface, the integuments which had hitherto retained their natural appearance begin to look puckered, or as if they were drawn together in folds. From this cause, the nipple will he sometimes so retracted and sunk as it were in the surrounding parts, that its existence might be overlook- ed by a superficial observer. When the disease has advanced further, the skin becomes inse- parably united to the tumour beneath it, and in a little time more it may be observed to have acquired a slight tinge of redness. The other characters of inflammation are also present, though some of them may be in an inconsiderable degree. After a time the whole surface of the swelling puts on a purple shining appearance, and in this state it continues with but little change till ulceration is about to take place. From the great exacerbation which usually happens at this period, a degree of febrile irritation will often be excited in the system at large. The superincumbent parts at length give way to ulceration, and the patient probably experiences a temporary relief from the dis- charge of a small quantity of sahious or ichorous matter. In general it is not until after some time that the ulceration becomes deep and exeavated; for under mild treatment it has been known to continue superficial for some months. Sooner or later, however, the uleer assumes the true carcinomatous characters. It penetrates deep towards the more central parts, while at its circumference the edges appear hard and elevated. The surrounding skin puts on a livid aspect, and from the surface of the sore there is a con- siderable discharge of an irritating corrosive quality. Matter of a 94 738 LOCAL diseases. [Class IV. true purulent appearance is hardly ever furnished by carcinomatous^ ulcers. The odour of the discharge impresses the organ of smel! with a peculiar but indiscribable sensation. If the ulceration be extensive, it will be observed, that while one part of the sore is undergoing a sloughing process, another will be active in throwing forth luxuriant granulations of a loose and spongy texture. These changes appear sometimes to alternate with each other upon the ulcerated surface, and in their further progression give rise to considerable haemorrhages from the erosion of the vessels. From the derangement which is occasioned in the functions of the lungs by the morbid condition of the parts, there gradually1 comes on dyspnoea, attended by cough and some degree of ema- ciation, which symptoms are usually followed at no great distance by a fatal termination, and this frequently without any remarkable alteration in the external appearance of the diseased part. Cancer of the breast is chiefly a disease of middle and advanced life ; from forty to fifty years is perhaps the most frequent period at which it makes its appearance. The female organ which is most likely to suffer from cancer, next to that of the breast, is the uterus, and, like the former, it is a disease of comparatively rare occurrence before the period of life at which the catamenia usually disappear. The early symp- toms of this complaint somewhat resemble those of polypus and prolapsus uteri: among them may be enumerated a sense of weak- ness, with pain or uneasiness in the loins, leucorrhoeal discharge, and a sense of bearing down. To these may be added weight and fullness in the region of the pelvis, with acute shooting pains across the cavity, and more or less of derangement in the functions of the chylopoietic viscera. There is also a pain in coitu, and on an exa? initiation with the finger, the os uteri is discovered to be partially thickened and indurated, with an increase of size in its aperture. It sometimes happens, however, that the enlargement begins higher up in the cervix uteri, the os uteri remaining closed. In both cases the uterus appears to be situated lower in the vagina than is usual in the healthy unimpregnated state, and when supported upon the finger, a sensible addition to its weight is to be perceived. After ulceration has taken place there will be a constant dis- charge of an offensive sanious matter from the vagina. If an exa- mination be again instituted, the os uteri will be found more open, and with ragged irregular edges. Pressure upon these parts will now occasion some degree of pain, and a little blood will commonly be observed to come away upon the finger. About this time the vagina undergoes a considerable deviation from its natural struc- ture-* it becomes somewhat hard to the feel, and its rugae cease to be distinguishable. At the superior part it will frequently be af- fected with carcinomatous ulceration, communicated from the os Uteri by the continuity of surface. As the different functions of the body become more and more Order Vl.J scirrhus and cancer. 739 disordered, emaciation increases with rapidity. Frequent retching and vomiting, with torpidity or irregularity of the bowels arise, mental dejection and despondency ensue, and a sort of hectic fever is constantly present. Towards the latter period of the disease, if the ulceration of the vagina becomes extensive, there will fre- quently be an enlargement of the absorbent glands in the groin, and this sometimes arrives to such a degree as to occasion oedema of the whole lower extremity. It seldom happens that the haemor- rhage from the ulcerated parts is in so violent a degree as to prove fatal of itself. The progress of scirrhus of the testicle is usually slower than where the disease occurs in other glandular parts, yet it is capable of being more or less accelerated according to the degree in which the different causes of irritation, whether local or constitutional, are permitted to have influence. The tumour goes on gradually to increase in size, and is attended with nearly the same symptoms and appearances that have been described as appertaining to the cancerous breast. The acute darting pain is at first confined to the precise site of the swelling, but afterwards extends in the direction of the spermatic chord to the abdomen, and even up the spine and in the loins. In process of time the shape of the gland becomes totally ob- scured, and nothing remains to be distinguished but the enlarge- ment, which is remarkable on account of its weight, excessive degree of hardness, and its surface being studded more or less with protuberant inequalities. When the disease begins to extend, it proceeds from the testicle to the epididymis, and thence by the lymphatic vessels of the chord, till it arrives at the lumbar glands. In this course there is produced great thickening and induration of the different parts through which it passes. An irregular or knotted feeling of the spermatic chord is another and very striking effect of the extension of the disease. Some time after the lumbar glands have been contaminated, derangement in the functions of the various neigh- bouring viscera is perceptible, and at this time a prominent tumour may be distinguished through the parietes of the abdomen, con- sisting of a cluster of these enlarged lymphatic glands. In process of time, cancerous ulceration of the testicle ensues, and in some instances is extended to the scrotum. Scirrhosity of the prostate gland is a disease with which men far advanced in life are very apt to be afflicted, but particularly those who imprudently produce an excitement of the seminal vessels by long toying with women, or by unnatural means, or onanism. The frequency of the disease may be attributed to the unusual degree of irritation, which, in the present licentious state of society, is kept up in the organs of generation by Cytherean excesses, and their attendants, strictures, and the use of bougies. After a time, sharp lancinating pains arc felt darting through the 74U L'PCAT, DI.bEASEi. [CkiSS IV, gland now and then, the flow of urine bcGom.es considerably obstructed, and dysuria, and occasionally tenesmus, with ischuria, and other distressing symptoms, arise. At length ulceration ensues, and the patient sinks gradually under a state of misery and pain, or he is cut off* by a total suppression of urine. The cancer with which chimney-sweepers are sometimes attack- ed generally begins in the rugae of the scrotum in the form of a wart. This, from the itching and uneasiness it at first occasions, and from the part being frequently rubbed in the act of climbing and de- scending the chimneys, is often scratched and otherwise irritated: thus a constant stimulus is applied in addition to the action of the soot on the part. If the head of the wart is picked or rubbed oh> another is soon formed, and at length there is not only a horny crust, but a thickened base beneath, proceeding inwards, until a large fungus or a spreading ulceration is produced, which at length occasions the testicle also to become affected. Cutaneous cancer is most frequently observed to occupy the lower lip, the angles of the eyes, the alae nasi, and penis. At its commencement it usually appears under the form of a small preter- natural enlargement or elevation of the skin. Sometimes it is so hard to the touch and in consistence as nearly to approach to the nature of horn, while on other occasions it will bear a much nearer resemblance to a common wart. In a few instances it will put on the appearance of a small discoloured pimple. Under whatever form the disease may first appear, a degree of surrounding hardness will invariably be found to take place. Some degree of shooting pain from time to time is likewise experienced in the part. In many cases ulceration seems to be materially accelerated by the accidental irritation of the patient's fingers, which are often, although unconsciously, applied in the vicinity of the disease. Sometimes, however, a sort of scale is generated so as to form a covering to the little tumour, and this will be removed and again be renewed several times in succession before ulceration is perfectly established. When the part has once arrived to a state of ulceration, it quickly puts on those characters of malignity which have occa- sioned it to be classed as a species of cancer. The surface of the sore possesses, indeed, the common appearance of carcinomatous ulceration, and there is a discharge from it of sanious or other ulcerated matter. In cutaneous ulcer it seldom happens that the lymphatic glands begin to enlarge or grow painful till after the diseased part has been in a state of ulceration for a considerable time, which forms a striking point of difference between this disease and that which has its seat in glandular structures. In a very great number of cases of cancer of the penis, it has been remarked, that phymosis had naturally existed ; hence it \\u> been "inferred by some surgeons, firnt phymosis may generate a Order VI.J scirrHus a#d cancer. 741 redisposition to this affection. A review of the cases published y the authors referred to,* and in which amputation of the penis was performed, seems to countenance the opinion that cancer of the penis is an affection purely local, and hence less frequently produced than cancer of other parts. Cancer of the tongue, like cutaneous cancer, seems to admit of a certain degree of variability in its appearance, which is, however, most commonly that of a small hard tumour situated on the upper surface of the tongue, and at no great distance from its anterior extremity. The tumour usually possesses a firm connexion with the subjacent parts, and, before arriving at a state of ulceration, it is not unusual to see it attain a size equal at least to that of a corns- mon hazel nut. Another form under which this disease sometimes shows itself at" an early period, is that of a little discoloured pimple, having a dis- position to bleed very freely from the slightest causes; but there is likewise a third case, where carcinomatous ulceration suddenly breaks out upon the tongue without the part having previously suf- fered any morbid change of structure, or presented any unnatural appearance sufficient to attract notice. The pain attendant on the disease in its different stages, though, varying in degree, is yet always of that peculiar darting kind which belongs to cancer. When first complained of, it is only slight and partial; but gradually increasing in severity as the disorder advan- ces, it will in time extend so as to be felt both about the fauces and base of the skull. The disease may continue a long time even in an ulcerated state without the health appearing to suffer very ma- terially from it. The entire destruction of a great portion of the tongue will sometimes be produced by cancerous ulceration before death takes place, in consequence of the disease. Cancer of the tongue is more frequently met with in those who are pretty far advanced in years than in subjects under the age of puberty. Scirrhous tumours are often removed with perfect safety, and thereby prevented from degenerating into true cancers, when extirpation is not delayed too long; but after a tumour of this description has ulcerated, thereby assuming the carcinomatous -character, and has afforded an opportunity for an absorption of 4;he matter into the system, there is every reason to suppose that a complete cure can seldom, if ever, be effected; for although we remove the diseased part, still the virus will be likely, sooner or later, to show itself in some other glandular place. Under such circumstances, extirpation will therefore, in all probability, be attended with no lasting advantage. Sir Everard Hornet has observed, that with respect to tire internal structure aud appearance of the breast affected with a * See Practical Observations in Surgery, by Mr. Hey. — Parallel of French and English Surgery, by Mon'?. R'omx' 1 ^'ci- his Observations on Cancer. - Mi-. Fennta's Treatise on iH"is Di'Ceis'e''. I 74*3 Local diseases.. [Class IV, scirrhus, if a section is made of such a tumour in an early stage. where the structure is seen to advantage, it puts on the following appearances:—The centre is the most compact, harder to the feel, has a more uniform texture than the rest of the tumour, and is usually of the consistence of cartilage. This middle part does not exceed the size of a silver penny, and from this, in every direction, like rays, are seen ligamentous bands of a white colour, and very narrow, looking in the section like so many irregular lines passing to the circumference of the tumour, which is blended with the substance of the surrounding gland. In the interstices between these bands the substance is different, and becomes less compact towards the outer edge. On a more minute examination, transverse ligamentous bands of a fainter appearance form a kind of net-work, in the masses of which the new-formed substance is enclosed. In a further advanced stage of the tumour, the whole of the diseased parts has a more uniform structure: no central point can be distinguished, the external edge is more defined and distinct from the surrounding gland, and the ligamentous bands in differ rent directions are very apparent, but do not follow any course that can be traced. fto regular distinction of structure can be made in parts affected with carcinomatous ulceration. In the centre, however, is a small irregular cavity filled with a bloody fluid, the edges of which are ulcerated, jagged, and spongy. When any gland has become enlarged, indurated, and shows a« tendency to scirrhus, we should, from the earliest period, use our utmost exertions to discuss it if possible, or at least to prevent its further increase. Applications of a discutient and sedative nature should be had recourse to without delay; pressure of any kind should be guarded against, particularly from the stays, if the breast is the part affected ; the bowels must be kept free and open by gentle purgatives administered from time to time, and a cooling regimen be enjoined, cautioning the patient to abstain from all vinous and spirituous liquors, and from other stimuli of every kind. It will, at the same time be necessary to draw blood from the vicinity of the diseased gland or glands by means of several leeches, which operation we ought to repeat frequently. They should never be applied to the skin immediately covering the tumour, for ulcera- tion has been known to have been greatly accelerated when leeches have been suffered to draw blood from the surface of an inflamed scirrhus or cancer. By being applied in the neighbourhood every good purpose will be secured, and the danger of exciting a compa- ratively dormant disease be avoided. In the incipient stage of scirrhus, and in addition to the means just recited, blisters have sometimes been applied with the view of promoting a considerable serous discharge from the neighbour- hood of the part. In a posthumous work* of the late Mr. John ?'ee Mr. Howard's PracKcal Observation* on Cancer. Order Pl.J sciERffuS and CANCERi 743 Howard's, and published by Dr. Gower, we are informed, that the author was strongly of opinion much may be done in all incipient scirrhous tumours by repeatedly blistering the part, having how- ever premised the frequent application of leeches, the use of dis- cutient and sedative applications, with occasional purgatives and a cooling diet. If blistering is ever thought of, this circumstance ought to be Cautiously kept in view, viz. the skin which covers the tumour should be in an uninflamed state, and not have taken on the shining purplish hue of cancer, the excoriation being likely to heal kindly. If applied when the skin is in an irritable and in- flamed state, it might tend to ulcerate the part, and prematurely bring on cancerous mischief, as happened in a case of scirrhous mamma which lately came under my inspection. The blister was applied by an ignorant pretender to a knowledge of curing such diseases ; ulceration ensued and spread most rapidly, whereby the unfortunate woman was soon destroyed. Immersion of the body in a warm bath, by directing the circu- lation to the surface of the body, and increasing both the sensible and insensible perspiration from the cutaneous glands and pores, might perhaps be employed with some advantage in scirrhous tumours. To allay pain and irritation, and probably thereby retard the progress of the disease, we may employ opium, which we may five internally, and likewise apply externally mixed with the ifferent preparations of lead that we use as sedatives and dis- cutients.* If the means which have been pointed out are not after a fair trial attended with the benefit and relief that were wished for, we may then recommend a slight course of mercurial unction, either * 1. R Liquor. Ammon. Acet. f. ^i. * 1. Take Solution of Acetate of Amrop. nia, one ounce. .' drops. Aq. Purse, f. ?i. Pure Water, one ounce, Tinct. Opii, f. 3iss. M. Tincture of Opium, one drachm and a half. ft. Lotio. Mix them for a lotion. Vel, Or, 2. R: Spirit. Camphorae, f. 53s. 2. Take Camphorated Spirit, half an ounce. Aceti Distillat. f. Zi. Liquor. Plumb. Acet. f. 3i- Distilled Vinegar, one ounce. Solution of Acetate of Lead, one drachm. Tinct. Opii, f. 3ij. M. Tincture of Opium, two drachms. Vel, Or, 3. rx Cerat. Plumb. Superacet. "i. 3. Take Cerate of Superacetate of Lead", one ounce. Opii in Pulv. trit. 3ss. M. Opium, rubbed into a powder, halt a drachm. ft. Unguentum. Mix them into the form of an ointment. Vel, Or, 4. R Empl. Plumbi Oxydj. 4. Take a Plaster of the Oxyd of Lead.) and apply it to the tumour. 74,4 local diseases [Class 1V\ immediately over orvin the neighbourhood of the diseased gland, together with small doses of the hydrargyri submurias internally, joined with antimony. In the early stage of the disease, a slight course of mercury, conformable to the plan just mentioned, and assisted by a decoction of vegetable substances which possess a diaphoretic effect, such as guaiacum, sassafras, sarsaparilla, and mezereon, of which the decoctum sarsaparillae compositum is com- posed, has in some instances been attended with a good effect. With regard to the use of mercury in scirrhous tumours, it is necessary however to mention, that when either given internally or used externally, it can only be of service in the first or early stage of the disease, when simple obstruction, and not altered organiza- tion, has taken place. By its tendency to hasten ulceration (a natural consequence of its action) it will be likely to prove highly prejudicial in all cases which are verging on cancer. Hemlock is a medicine which, since the days of Stork, has been much employed in every stage of cancer, and there is reason to sup> pose sometimes with advantage. To derive this with the greater eertainty, however, we should make use of it during the occult or scirrhous state, and before ulceration has commenced. In admi- nistering hemlock we ought always to begin with a small dose, and so augment it gradually till the patient experiences some little in- convenient effects on the head and stomach, such as nausea and vertigo, when the quantity is to be lessened, or the medicine wholly be desisted from for a short time. The extract is the most active preparation, and this may be given in pills of two grains each, in the number of from one to ten or twelve in the twenty- four hours. Bella-donna and hyoscyamus are medicines of the same class with conium, and the timely use of these has sometimes proved advantageous in glandular tumours and indurations that are likely to become cancerous. Where no advantage seems to be derived from any of the means which have been advised, but on the contrary, the tumour is pro- ceeding hastily on to ulceration, the only effectual remedy then left is the complete removal with the knife, not solely of the indurated part, but of the whole glandular substance of the breast, so as to> secure against a relapse ; and this we should not fail to enforce most strenuously to the patient, provided the tumour is moveable and not attached to bony parts, and its local situation does not render the operation improper. If there be one or more enlarged lymphatic glands in the direction of the axilla, these are also to be cautiously removed. The causes of the failure of operations for the removal of scirrhi proceed either from the constitution having been already involved in those diseased actions which were local in their origin, or from the diseased parts not having been perfectly and entirely removed by the surgeon. All carcinomatous tumours ought therefore to be removed at an early stage when the usual remedies fail in arresting Order VI.J scirrhus and cancer. '< 46 the disease ; and in performing the operation, the surgeon should not be contented merely to dissect away the diseased part from its neighbouring connexions; but a portion even of these should be cut away, so as to secure the patient against a recurrence of the disease. To destroy the living powers of the morbid growth in scirrhous tumours, and to effect its consequent separation from the sound parts which are immediately adjacent, caustic applications, and particularly those composed of arsenic, have been much employed by itinerants and quacks; but when we seriously reflect on the danger and uncertainty which necessarily attend their operation, they must be held cheap in the estimation of the profession, and a decided preference be given to the knife. As the female breasts are liable to enlargements and indurations from external injuries, exposures to cold during a puerperal state. and such other causes as by inattention might possibly be mis- taken for a scirrhus, it will certainly be necessary in all doubtful cases to scrutinize minutely into the rise of the tumour, the symp- toms and appearances with which it is attended, and the progress that it has made, in order that we may ascertain the real existence of the disease in question, previous to our having recourse to an operation. Where this has been neglected, in real scirrhus, and the inflam- mation has proceeded on to suppuration and ulceration, we are then to endeavour to correct the foetor and acrimony of the discharge ; to defend the adjacent parts from its effects; and to quiet the pain and lessen the irritability of the sore. The first of these intentions is to be answered by washing the ulcer with the dephlogisticated muriatic acid diluted with three times its weight, or more, according to the irritability of the sore, and the smarting it occasions, as recommended by Dr. Crawford ; and then applying a carrot poultice, or one composed of an infusion of malt, oatmeal, and yest, as directed under the head of Gan- grene. The cataplasma carbonis (which is composed of about half a pound of the common bread poultice, with two ounces of wood charcoal in very fine powder) is another application which has likewise been found highly useful in sweetening fetid ulcers, and obtunding the acrimony, and may perhaps be preferable to the fermenting cataplasm, as this, by lying on the part some hours, be- comes more offensive than the smell it was intended to correct. The charcoal should be taken fresh from the fire, and powdered very fine as soon as cool; when it is immediately to be put into a bottle and corked, in order that it may not be exposed to the air. The application of carbonic acid gas, or air in its elastic state, has been much used in the ulcerated stage of the disease, and often with a seeming happy effect, as we are informed by Dr. Ewart,* of Bath, who employed it agreeably to the following process :— * See his History of two Cases of ulcerated Cancer of the Mamma, one, of which has if en cured, the other much relieved, by a new method of applying carbonic acid gn- 95 746 local diseases. [Class IV. The neck of a bladder was cut off, so as to make a circular aper- ture in it, of such dimensions as to correspond nearly with the size of the ulcer of the breast. A round hole of the same size was cut in a piece of soft leather, spread with adhesive plaster, and large enough to surround the ulcer: the cut end of the bladder was introduced through the hole in the leather, and its edges folded back, and stuck to the plaster on the opposite side, forming some- what of the shape of a round hat, the plaster resembling the rim, and the bladder, when distended, the crown. In order more effectually to cement the adhesion of the bladder to the plaster. and to make it air-tight, narrow circular strips of plaster were applied round their juncture both inside and without. The large plaster was then fixed on the mamma, the aperture in its centre, with the bladder attached to it, being, placed exactly over the ulcer, no part of which was touched by the plaster. A small orifice was made at the fundus of the bladder, sufficient to admit a tube of about a quarter of an inch diameter, which communicated with the top of an inverted cylinder, suspended upon water, which cylinder was filled with carbonic acid gas. The bladder being closely squeezed, to expel from it the atmospheric air it contained, and the above-mentioned tube being inserted into the orifice formed to receive it, and tied by a ligature passed over the bladder, the inverted cylinder was pressed down in the water, so that the carbonic acid air was made to rush through the tube and distend the bladder; the tube being then withdrawn the orifice of the fundus of the bladder was tied, to prevent the escape of the carbonic acid air, which was thereby kept in contact with the ulcer. As often as the bladder collapsed, so as to show that much of this air had got out, it was filled in the same manner as before; and this operation was repeated sometimes twice, sometimes three times a day, according as it appeared necessary. A proof of this simple apparatus fully answering its purpose, was, that the bladder, when filled at night, was for the most part found to contain a considerable quantity of its air in the following morning. The second indication of defending the adjacent parts from being acted upon by the acrimony of the discharge, is to be effected by the strictest attention to cleanliness, and by dressing or covering them with mild cerates, composed of calamine, or the superacetate of lead: and The third indication, of quieting the pain, and lessening the irritability of the sore, is to be answered by fomenting it with a decoction of poppies, and then applying a cataplasm of hemlock, as likewise by an internal use of opium or hyoscyamus at the same time. If the part affected will admit of it, the tumour should be sus- pended, so as to keep it as easy as possible night and day. It should be kept neither too warm nor too cold, as both extremes would be injurious. Order VI.J scirrhus and cancer. 747 Henbane, nightshade, and others of the narcotic class, have also been employed in external applications as well as hemlock. When used in this way, the leaves may be boiled in milk, so as to form a decoction sufficiently strong, and with this the part must be fre- quently fomented. The gastric liquor of graminivorous animals applied tr putrid and cancerous ulcers, has sometimes been at- tended with benefit. As a topical application in external cancer, such as of the lip, mamma, &c. lint dipped in a solution of the sub-borate of soda,* and applied to the ulcerated surface, renewing it as often as it be- comes dry, has not unfrequently been attended with a good effect, occasioning the discharge to assume a comparatively healthy and purulent appearance, the size of the ulcer to be much reduced in a short time, and the pain to be rendered trifling. Applications of a caustic nature have been much used in the ulcerated stage of cancer, and they have been employed under a variety of forms, but their principal ingredients are well known to be either arsenic or the oxymuriate of mercury. The most noted are the Arundel powder, Guy's powder, and Plunket's powder,! the last of which is a composition of crow's-foot, dog's fennel, and arsenic. It is prepared and applied as follows:—the crow's-foot, and dog's-fennel being fresh gathered and bruised, the other in- gredients are to be added, and the whole beaten into a paste. This is to be formed into balls, and dried in the sun. When used, they are to be powdered, mixed with the yolk of an egg, and applied, on a piece of pig's-bladder, to the surface of the can- cer. In this state the caustic is to remain, till the eschar separates spontaneously. When this remedy is used in cancers of the nose or lips, the greatest circumspection will be necessary, lest a por- tion of the arsenic should be swallowed. A caustic composed of one ounce of powdered antimony and half an ounce of powdered arsenic, fluxed together in a crucible, and afterwards reduced to powder, was very extensively used by the late Mr. Justamond in his treatment of cancers, and often with a most happy effect. By an addition of powdered opium, this re- medy may be reduced to any degree of mildness. Equal parts of white arsenic and sulphur form a caustic application that is very powerful. The paste arsenicale is a favourite application of many of the most eminent French surgeons in cancerous affections.} This X See Sketches of the Medical Schools of Paris, p. 45. by Mr. J. Cross. 5. ft Sodae Sub-boratis, 3"j- Extract. Hyoscyam. 3'ij. Aq. Distillat. tepid. ?viij. M. 6. R; Ranunculi Acris Fol. Flammulae Vulg. Fol. aa |j. Arsenic. Alb. Laevigat. 3j. 'nilphuris Sublimati, 3v. M. *5.Take Sub-borate of Soda, three drachms. Extract of Henbane, two drachms. Distilled Water made warm, eight ounces. t 6. Take Meadow Crowfoot, Dog's Fennel, of each, one ounce. Arsenic, one drachm. Sublimed Sulphur, five scruples. Mix them 748 LOCAL DISEASES [Class IV. is composed of seventy parts of cinnabar, twenty-two of sanguis draconis, and eight of the oxyd of arsenic, which are made into a powder, and formed into a paste with saliva at the time of apply- ing it. A good method of using arsenic is by mixing about two or1 three grains of it with a drachm of pulvis calamince, and strewing a little of the powder on the cancer every day till the whole is destroyed, and sloughs off. Whenever caustic is applied, it will be necessary to give con- siderable doses of opium to allay the irritation and pain it occa- sions ; and we should also use anodyne fomentations, composed of a decoction of bruised poppy heads. Arsenic seems to possess in cancer powers which are peculiar and distinct from those of other caustics. If applied to the skin it will not affect it; but if this is abraded, it will produce an eschar to a certain degree, but it will be superficial. When continued for any length of time, the eschar will not be increased, yet the parts beneath the eschar will be found sloughed to a degree and extent proportionable to the strength in which the mineral has been applied: in short, to accomplish this end by the application of arsenic, it is not necessary that it should be in contact with the whole of the part it is intended to destroy. Arsenic, besides being applied externally in cancers, has likewise been administered internally, and sometimes with a seeming good effect. Where the practitioner is desirous of making a trial of it, he can give it in a solution, as mentioned under the head of Inter- mittent Fever. A poultice made with crumb of bread, and mois- tened with some of this solution, diluted to the proportion of one grain of arsenic to a quart, might probably prove a very good ex- ternal application, as well as the former which have been noticed. A saturated solution of muriated barytes, in doses of from three or four to ten or twelve drops twice a day, in any convenient vehicle, has been recommended by Dr. Crawford in cancerous and scrofulous affections. In the early stage of cancer, it seems to have been frequently used with some advantage, but never in its last stage. Some cases of cancer were published a little time back by Mr. Carmichael,* wherein he had employed different preparations of iron with some success, and which under a failure of other means may therefore be tried. For internal use, he is inclined to prefer the sub-oxyphosphate of iron to the carbonate, which like all the other salts of this mineral, answers best when given in small doses, and frequently repeated ; and he thinks the best manner to exhibit this preparation is to blend it with white of egg, and to add a small portion of pure fixed alkali, which will render the iron more soluble in the stomach, afterwards forming the whole into pills * See his E«r.y en U>e Effect of Carbonate 9n<1 other Preparations of Iron unor Order VI.} scirrhus and cancer, 749 with a little powdered liquorice. When the carbonate of iron is employed, it may be given in doses of five grains, repeated every four or five hours. After trying a variety of cathartics for the pur- pose of obviating the costiveness which a course of ferruginous medicines is apt to occasion, Mr. Carmichael discovered that aloes answered the best; and, moreover, that this cathartic, in com- bination with iron, has a far greater effect than if given in a more considerable quantity alone. He experienced that half a grain of aloes, combined with four grains of the carbonate of iron in the form of a pill, and taken three times a day, was perfectly sufficient to keep the bowels free and open. The preparations of iron which Mr. Carmichael had used exter- nally in ulcerated cancers are the carbonate, the phosphate, oxy- phosphate, acetate, and arseniate. He says, that the best mode of applying these preparations of iron possibly may be to blend them with water to the consistence of a thin paste, with which the surface of the ulcer should be covered, and the application in general be renewed in twenty-four hours. In occult cancers,, he has used a solution of the sulphate of iron as an external applica- tion, and commonly in the proportion of an ounce of the salt to a pint of water; he prefers, however, the acetate of iron diluted with eight or ten times its weight of water. These embrocations are applied by means of folded linen, over which a piece of oiled silk should be placed to prevent the fluid from injuring the clothes. From the use of arseniate of iron Mr. Carmichael has also found considerable advantage. It has indeed been doubted by some practitioners of eminence, if the cases reported by Mr. Carmichael, in which the preparations of iron have been successful, were truly cancerous. We are told, however, by Mr. Denman,* that there is scarcely a class of medicines in the Materia Medica with some of which he has not made repeated trials in all the different stages of cancer. but the benefits derived from the use of any of them have been very little indeed, if compared with those obtained by the use of preparations of iron, and generally that all other medicines have been wholly unavailing. The common effects of iron, when used in cases of ulcerated cancer, are a speedy mitigation of pain, an amendment in the appearance, of the sore, and the correction of the foetor, with a diminution in the quantity of discharge. Even in hopeless cases it renders the progress of the malady less horrible and distressing. we are told, than when it is treated in any other manner. Carcinomatous ulcers of the tongue have been successfully treated by a course of the nitric acid. A case of this nature, where the ulceration was of considerable magnitude, is reported in No. 141 of the London Medical Journal, which, after having ": F^ee his Observations on the C'lre of ''ancer, r, ^" 750 local diseases. [Class IV* resisted various remedies, was completely cured by nitric acid*. An opiate was given at night, and to prevent the acid from corroding the teeth it was directed to be sucked through a tube. In fourteen days after the exhibition of this medicine, healthy granulations were perceived to shoot out at the bottom of the ulcer, which gradually healed from this time, and in the course of three months, although half the tongue had been in a state of ulceration, it was perfectly healed. Nothing was applied to the diseased part but a lotion composed of extractum conii, spt. recti- ficatus et aqua pura, to which little or no efficacy was ascribed. In cancerous ulcers of the face the expressed juice of the carduus tomentosus Linn, (the woody-headed thistle or friar's crown) has been employed with much advantage by the continental physicians, and particularly by Dr. Handel. He ordered his patients to anoint the parts affected with the fresh juice six or eight times every day, and he found that in the course of a fortnight it checked the pro- gress of a most malignant cancer of the face, but it produced no relief whatever where* the female breast was affected with that loathsome disease. In the cancer scroti, to which chimney-sweepers are peculiarly subject, extirpation bids fair for effecting a complete cure, if done before the virus has seized the testicle and the habit is tainted. A case of this nature some time ago came under my care, in which the diseased part was removed by ligatures; the patient having been, some months before his application to me, discharged from the Winchester hospital, for refusing to submit to an extirpation of the part with a knife, to which, undoubtedly, a decided preference was due. The cure, however, proved as complete a one as I ever witnessed, although the case was somewhat deplorable, the patient being far advanced in life, and much emaciated by disease, pain, and poverty. In every species of open cancer, the air should be excluded as much as possible; a covering of double oiled silk may therefore be applied over the dressings. A new process by mechanical pressure has lately been suggested, and indeed practised with some success, for the cure of scirrhus and cancer, by Mr. Samuel Young,t and the means employed by him to effect the pressure have been plaster straps, sheet lead forming shields of various thickness, tin plates, linen compresses, and the use of appropriate rollers. The strength of the application is to be progressive, commencing in most cases with the use of t See Cases of Cancer and Cancerous Tendency successfully treated by Mr. Samuel Young, Surgeon. '* 7. ft Acid. Nitric. Dilut. f. fj. * 7. Take Diluted Nitric Acid, one ounce. Mellis. f. jij. Honey, two ounces. Aq. Purae, Oij. M. Pure Water, two pints. Mix Capiat cochlear iij. s»pe in die. them. Three table-spoonsful are to be taken frequeuflv throughout the day. Order VI.J medullary sarcoma. 751 straps only, in some by single, and in others by double layers ; the force of their application controlled by the existing circumstances, and the sensations of the patient. Scirrhus of the breast may be specifically compressed by the use of the pressure plates, and the adjustment of the linen compress, including at the same time a general pressure of the whole. In cases of open cancer the wound is to be filled with powdered chalk, and the surface well dusted with hair-powder, after which the pressure is to be applied as in the case of scirrhus. Irritable parts should be defended by some goldbeater's skin. The best composition for the straps was found by Mr. Young in equal parts of common strengthening and soap, plasters, mixed and spread somewhat thinly on linen. The plaster should be uniformly smooth; and in the application of the straps, which ought to be long and commanding, it is of the first importance that all wrinkles should be avoided, and that an equal surface of resistance should be given. In the direction of specific pressure on the diseased part all sorts of partial stricture ought to be avoided. The effects produced by Mr. Young's plan of treatment are cer- tified by some other practitioners who have been eye-witnesses to it, that there is a very rapid stop put to the ravages of the disease, whether in a state of scirrhosity or ulceration ; the discharges are gradually lessened, and, from being of a most acrimonious kind, become bland and salutary. Besides, there is evidently a gradual decrease of the tumefaction and induration, and the whole not only assumes an appearance of amendment, but a promise of recovery. These are indeed very great advantages. In a case which lately occurred at the Middlesex hospital, Mr. Young's plan of treatment was adopted, and was found to have exceeded the expectations of the most sanguine. Further expe- rience has not, however, sanctioned it. FUNGUS H^MATODES, or MEDULLARY SARCOMA. A disease has of late attracted the attention of some surgeons, and has been pretty generally classed and treated as a cancerous affection in whatever parts of the body it may have been known to occur; but although in its history it has some analogy to cancer, still its symptoms and appearances on dissection are so different from those of cancer, that it cannot, I think with propriety be considered as a disease arising from the same morbid alteration of structure. By some writers* it has been named the fungus hoema- todes ; by others,t the medullary sarcoma; and others again have given it the appellation of spongoid inflammation. Mr. Burns,| •* See Practical Observations on Surgery, by Mr. Hey, of Leeds, 1803. — General Observations on Fungus Haematodes,by Mr. J. Wardrop, of Edinburgh, t See Surgical Observations, 1K04, by Mr. Abernethy. f See his Dissertation on Inflammation 152? local diseased. [Class IV. who has adopted the latter name, mentions it as appearing only in the superior and inferior extremities ; but this probably from his not having met with any other cases of it; whereas the other writers describe it as occurring likewise in the ball of the eye, testicle, liver, lungs, uterus, female breasts, and other parts. A great difference of opinion seems to exist between the English and French pathologists respecting the precise application of fungus haematodes. Mr. Roux asserts,* that most of the cases pointed out to him, when in London, as specimens of this affection, were merely a variety of carcinoma, the soft fungus cancer; not prece- ded, like the more common form, by a state of scirrhus. He de- nies the existence of what we call fungus hoematodes as a specific or peculiar malady. The progress of fungus hasmatodes, as well as of cancer, is generally slow. When ulceration has taken place, neither of them discharge a purulent matter, but a thin fetid ichor, and occasionally they bleed profusely. They both sometimes assume a fungous appearance, and during their progress contaminate the absorbent glands which are in the course of circulation: they are-also equally destructive, communicating the disease to the neighbouring parts, whatever the nature of these may be, whether cellular membrane, skin, muscle, periosteum, or bone. Fungus haematodes is generally a disease of early life, whereas cancer is usually confined to those who are advanced in years. Cancer, moreover, seems to be confined to a very few organs of the body, and to a few textures, whereas fungus haematodes has been detected in parts where no true scirrhus structure has been ever met with. On dissection, fungus haematodes presents a very different series of phenomena from the scirrhus tumour. When it appears on the external parts of the body, and has not yet acquired a considerable bulk, instead of being hard and unyielding, it is soft and elastic, and has a tolerably equal surface. Its form, when removed from the body, is accurately circumscribed, having generally a distinct covering of condensed cellular membrane. In place of the hard, fibrous looking substance (the principal component part of scir- rhous tumours) the morbid growth in fungus haematodes consists of a soft pulpy matter, which mixes readily with water, and is somewhat hardened by acids, and by being boiled in water. It has been compared to medullary matter in consistence and colour. When the skin or covering of fungus haematodes has been eroded in the progress of the disease, instead of the morbid growth being destroyed by ulceration, a fungus arises from it, and the tumour seems to increase more rapidly in bulk. If the fungus haematodes is not interrupted in its progress, both the original tumour, and the fungus mass growing from it, attain a considerable size, and the fungus, which is of a dark red or purple-coloured mass, of an irre- * Pee his Parallel of French and En?lish Sursrerv. Order VI.J bronchocele. 753 gular shape and of a soft texture, is easily torn, and bleeds, pro- fusely when slightly pressed, or otherwise injured. A want of success has generally attended all efforts in the cure of fungus haematodes in whatever part of the body the disease has existed. One successful case of it came however under my care some years ago, during my residence at Guilford, in Surrey. The patient was a man of about forty years of age. The fungus Had attained the size of a small cauliflower, and at times bled profusely. It had been of some months' standing when I first saw it, was of a deep red or purple colour, discharged a fetid, ichorous matter, and was seated in the left hypochondrium. The tumour and excrescence were removed by one or two applications of arsenic reduced to powder, and combined with sulphur and opium, and the wound healed up kindly in due time by the common and Usual dressings. About a year after the man was carried off, as I have since understood, by some complaint seemingly unconnected with his former disease. Where the fungus has a narrow pedicle, and we are enabled to apply a ligature with tolerable ease, possibly it may be most advi- sable to resort to it in the first instance, taking care to make it only of such a tightness as not to cut the vessels, but merely impede their circulation. When the fungus with the surrounding ligature falls off, should any slight haemorrhage ensue, a saturated tincture of galls or some other styptic may be employed to suppress it. Should the surface show any disposition to renew the fungus, the part may be sprinkled with arsenic combined with opium, as before mentioned, which application may be renewed a second time aftBFthe slough is thrown off, if requisite. Of BRONCHOCELE. This disease is marked by a tumour on the forepart of the neck, and seated between the trachea and skin. In general it has been supposed principally to occupy the thyroid gland. It is a very common disorder in Derbyshire, but its occurrence is by no means frequent in other parts of Great Britain or in Ireland. Among the inhabitants of the Alps, and other mountain- ous countries bordering thereon, the Valois, the Valteline, at Lu- cerne, Berne, Fribourgh, in some parts of Piedmont, in the valleys of Savoy, and at Milan, it is a disease which is very often met with, and is there known by the name of goitre. The cause which gives rise to it is by no means certain, but by some writers it has been attributed to a use of snow water. From its having been observed that the inhabitants of districts abounding with saline and mineral springs are more frequently affected with diseases of this sort than persons living in other situations, it has been supposed that the waters descending from these mountains, with which the dissolved snow mixes itself, may 9.G \0(i' LO.CAL DLSEASE-v [ClajS IV. also be impregnated with some saline or mineral ingredients capa- ble of producing this singular affection in the throat. Dr. Saunders observes,* that snow water has long lain under the imputation of occasioning those strumous swellings in the neck which deform the inhabitants of many of the Alpine valleys ; but that this opinion is not supported by any well-authenticated indisputable facts, and is rendered still more improbable, if not entirely overturned, by the frequency of the disease in Sumatra, where ice and snow are never seen; and its being quite unknown at Chili and in Thibet, though the rivers in these countries are chiefly supplied by the melting of the snow with which the mountains are always covered. • Certain experiments have moreover proved, that the water of dissolved snow is perhaps the purest of any that can be procured. A modern writer,! in his History of Java, mentions, that there, a3 well as in Sumatra, there are certain mountainous districts in which the people are subject to those large wens in the throat termed in Europe goitres, and the cause assigned by the natives is the quality of the water, but that there seems good ground for concluding that it is rather to be attributed to the atmosphere. Inproof of this he tells us, that there is a village near the foot of the Teng'gar moun- tains in the eastern part of the island, where every family is afflicted by this malady, while in another village, situated tat a greater ele- vation, and through which the stream descends which serves for the use of both, there exists no such deformity. He also mentions, that these wens are considered as hereditary in some families, and flius seem independent of situation. The disease in question is evidently of too local a nature to be attributed solely to an habitual use of snow water, nor can it be "brought on by using water impregnated with calcareous earth, as some have imagined ;| for the same effects are not Uniformly pro- duced where such water is used. A predisposition to bronchocele is, I think, often entailed by parents upon their children, as well as that glandular affection known by the name of scrofula ; which fact is corroborated by the strongest evidence, as I know a family con- sisting of seven, all of whom were attacked with it before they arrived at the age of puberty ; the father having been afflicted with it at an early period in life. This family resided at Crondall, in Hampshire, and were the only persons in the place who laboured tinder it. The predisposition to the disease must therefore have been entailed on the children by the parent. Where we meet with the disease in particular districts, may we not therefore with good reason attribute its frequency of occurrence rather to the inhabitants of those regions being somewhat secluded from the rest of mankind, and intermarrying among each other, thereby entailing the predi> * See his Treatise on Mineral Waters. f See History of Java, vpl. i. page 60, by T. S. Raffles, late Governor tjjereof. $ See Coxe's Account of Switzerland. Ureter VI.] bronchocele*. **o~5 position to it on (heir offspring, than to any peculiarity in thfe arti- cles used for diet ?—See Cretinism. In those situations in the vicinity of mountains where the disease is found to be endemial, it has been attributed by some to a pecu- liarity in the air, and it has indeed been found more generally pre- valent among the lower class of people, and those who are most exposed to the unguarded influence of the weather, and various changes that take place in the air of such situations. The swelling in bronchocele is at first without pain or any evi- dent fluctuation, and the skin retains its natural appearance; but as the tumour increases in size it grows hard and irregular, the skin acquires a yellow colour, and the veins of the neck become vari- cose ; the face is subject to flushings, and the patient complains of frequent headachs, and likewise of pains darting through the body of the tumour. When the disease is of long standing, and the swelling conside- rable, we shall find it in general a very difficult matter to effect a cure by medicine or any external application; and it might be unsafe to attempt its removal with the knife on account of the enlarged state of its arteries and its vicinity to the carotids; but in an early stage of the disease we may often be able, by the aid of medicine, to effect a eure, particularly if assisted by frequent fric- tions over the tumour. Bronchocele has by some practitioners been supposed to be a dropsical affection of the thyroid gland ; and it is true that a great number of capsules filled with water have in one or two instances been found in it on dissection, but in general no such appearances are to be observed. In two cases examined by Mr. Benjamin Bell? this gland was evidently much diminished in size from the compres- sion of the tumour, which was chiefly composed of condensed cellular substance, with effusions of a viscid brown matter in dif- ferept parts of it. To me the tumour appears to be of a steato* matous nature. To treat bronchocele judiciously, I am of opinion we ought at the same time that we give appropriate medicines internally, to employ local remedies, but particularly friction with the hand for at least half an hour three times a day, the efficacy of which may probably be assisted by the joint use of such applications* as are calculated to excite the aetion of the absorbent system. Should the size of the tumour not be diminished after a due time by means * 1. JJ. Liniment. Sapon. Comp. Vel, 2. $; Liniment Camphor. Camp. ^i. Lfquw. Potassa, The dose for an adult was ten drops of one of these preparations, in half a glass of the-syrup of capillaire and water, taken early in the morning, fasting; a second dose at 10 o'clock, and a third ifi ihe evening, or at bed-time. At the end of the first week, 15 drops were given in the place of 10, three times a day, and in a few days after, when the effect seemed evident on the tumour, the dose was increased to 20 drops. This quantity was rarely exceeded, and was found in general sufficient to dissipate the largest goitres. DRACUNCULUS, or GUINEA-WORM. This disease consists in a small round worm, very muqh re- sembling the string of a violin, and of a white colour all over, except the head, which is black, that is discovered in different parts of the body, immediately between the muscles and cellular membrane. The arms, legs, and thighs, are, however, the most general seats of it, in which parts it is often found of the length of one or two feet. *■ Sjie Annates de Chimie, Septembre. Journal xle Pharmaqie, Octptire 1C2& Ordiy Vlj GfllSEA-WORJI. -^53 It is a disease chiefly to be met with among negroes that are brought from the coast of Africa, or sailors who are lately returned from thence, and has generally been supposed to arise from drink- ing or bathing in the waters of stagnant ponds or wells, where the animalcules or embryo worms are deposited. It is said also to be a common complaint at Bombay, and all over that part of the coast of India,* particularly during the rainy season. Sir James M'Gregor reports, in his Medical Sketches, that this. malady prevailed very much on the voyage from India to Egypt, both among the troops and seamen ; and it was only by separating the sick from the sound, and by a very strict attention to cleanli- ness, ventilation, and fumigation, that he was able to arrest its progress. He by no means, however, attributes its appearance to the water which was drank, as this came from different quarterss Bombay, Ceylon, and Madras; for the officers of the 88th regiment^ as well as the artillery, drank the same water, he mentions, and yet escaped. It is obvious, therefore, that the embryos of the worm must have punctured through the skin, and lodged in it among the men pre^ vious to their embarkation. The most probable way, indeed, of accounting for the rise and production of these worms, is by supposing, that in a minute or embryo state (similar to what happens with the chigre) they pene- trate the skin of persons who go exposed without any covering than perhaps a hat, skirt, or trowsers; as those who are properly clad, and wear stockings and gaiters, or boots, are never attacked; hence common seamen are liable to them, whilst their officers sel- dom or never suffer from them. This, in my opinion, clearly establishes the origin of this affection. Intestinal worms possibly may be produced by an internal use of certain waters, or mucilaginous vegetables, but that those in question can arise from such a cause cannot readily be admitted ; for after being received into the stomach by drinking the water in which they are contained, they must become mixed with the chyle,, enter the blood in a living state, and finally be deposited in the cellular membrane and insterstices of the muscles, to be afterwards hatched, and produce the living dracunculi. In my opinion, they can only be caused by the embryo worms insinuating themselves into different parts of the body, and having formed a nidus, in due time acquire a considerable size. Several persons being exposed to their influence may become diseased, and induce-us to suppose that the complaint is of an infectious nature, but which certainly is not the case. The patient is usually sensible of an itching in the part or parts at first, and on a narrow inspection a small bladder or blister may often be observed. The Guinea-worm does not produce, however, any-acute pain, until it is near a state of maturity, at which period * Sep No. xiii, o*f (he E.cl'ih'B.ur*h Medical and Surgical Joitrrial, p^. TT>li 7QQ local disease?. [Ci'a'23 IV. the part in which it is lodged become swelled, inflamed, and very painful to the touch, and bears a strong resemblance to a boil which is not much disposed to suppurate. The tumour, after having remained in an indolent state for a considerable length of time, breaks at last, and then the head of the worm may be perceived protruded from the orifice, which continuing to ptish a little forward every day, may at last be laid hold of with ease. No injurious consequences attend on the disease when properly treated, although when the inflammation is very considerable, there is often much fever present; but by breaking the worm, from being in two great a hurry to extract it, large abscesses and ill-con- ditioned ulcers are sometimes formed. In a few instances mortifi- cation has ensued, and Very large sloughs have been cast off; p alarming haemorrhages have also occurred. Frequently after ex- tracting one worm from a patient, a second, or a third, or even a fourth will appear; and after getting one out of the leg, another may be observed in one or both hands, or in the other leg. While the tumour remains in a hard indolent state, it will be necessary to keep an emollient poultice constantly applied to it, in order to bring it to a speedy and proper suppuration. When it breaks, and the head of the worm protrudes so far as that it can be laid hold of with ease, a piece of cotton rolled up like a quill is then to be tied to it, and as it advances it is to be daily twisted gently round, until the whole is extracted, using at the same time the ,; . greatest precaution that it may not be broken. The wound is then to be covered with dry lint, over which is to be laid a pledget of tow, spread with the ceratum resinae. We are informed, by Sir James M'Gregor, that the native prac- titioners are much more successful in getting out the worms than Europeans. After long feeling with their fingers for the body of the worm, they make an incision as nearly as they can judge over its middle, and pulling the worm by a duplicature of it, draw out both ends at one time. In the treatment of the Guinea-worm mercurial ointment'has been rubbed on the parts affected by some surgeons, and electrical shocks have been passed through the tumours, but without any good effect. An internal use of medicine is necessary only where the inflammatory symptoms run high, and then cooling purgatives, with the rest of the antiphlogistic plan, must be resorted to. We are told by Dr. Chisholm,* that an internal use of mercury is highly necessary ; and in order to destroy the insect or its ova, the remedy must be employed so as to pervade the system. In the many cases which came under my care during my practice in the West Indies, perfect cures were, however, effected without the use of mercury. As the malady has been said to spread from a neglect of cleanli- * S'ee the Edinburgh Medical and Physical Journal-, No. xiii-. 1 ' Order VI1.J HEADACH. 761 ness, the greatest attention should be paid to ventilation, and frequent washings and fumigations, in all situations where it makes its appearance. Those who may be unavoidably exposed to its influence should bathe often in the sea or some river. —"OOO"— ORDER VII. DOLOROSI. PAINFUL AFFECTIONS. CEPHALALGIA, or HEADACH. This affection is, in some instances, general over the whole of the head; at other times it is confined to a particular side; and now and then cases occur where the pain occupies so small a part, that it may readily be covered with the end of the finger, which has been called clavis hystericus. The causes which give rise to the headach are most usually indi- gestion, foulness of the stomach, the hinderance of a free circula- tion of blood through the head, long exposures to the sun, transla- tions of gouty and rheumatic matter from other parts of the body, the stoppage of some long-accustomed evacuation, inebriety, and lastly, too great a determination of blood to the head. Headach, is, however, more frequently a symptomatic affection than a primary one, and often arises in consequence of a fever, or of hypochon- driasis, hysteria, or some other nervous disease. The symptoms which attend on a pain in the head usually vary according to the cause which has produced the complaint. Where a headach is symptomatic of some other disease, it will be likely to cease on a removal thereof, as in the case of fever. Where the pain comes on suddenly, is acute, and attended with a noise in the ears, giddiness, and a loss of speech, it denotes an attack of apoplexy or palsy. When it arises in hypochondriacal or hysterical persons, is very acute, and accompanied with much throbbing of the temporal arteries, it is apt to terminate in madness. A headach proceeding from some fixed nervous affection, is diffi- cult to be removed entirely, and the patient is liable to frequent returns of it. Between the head and stomach there is a great sympathy; wherefore it happens, that where there is a foulness in the stomach, the head is frequently affected with pain. Where such a cause is apprehended to exist, it will by all means be advisable to give a gentle emetic; and if any costiveness prevails, this should be removed by some proper laxative. Where the disease proceeds from an over-fulness of the vessels, or from too great a determination of blood to the head, a proper 97 762 LOCAL DISEASES^ [ClttSS IV. quantity may be drawn off by opening the jugular vein on the side most affected, or by the application of leeches to the temples; the patient afterwards taking care to use a spare regimen, to keep his body perfectly open, and to wear nothing tight about his neck. Those who are of a full plethoric habit of body, and who are troubled with severe and frequent attacks of the headach, will act prudently in having recourse to scapulary issues. To alleviate the pain at the time, linen cloths wetted in vinegar and water, or in camphorated spirits, may be applied to the forehead and temples. When a headach arises from a translation of gout or rheumatism from some other part, it will be advisable to excite a slight inflam- mation in the extremities by the application of small blisters, and at the same time to open the body by administering some stoma- chic purgative, as the tinctura rhei composita. If a venereal taint is the cause of the headach, recourse must be had to mercury, as advised in syphilis. In the headach which arises as a consequence of some nervous affection, the most proper medicines will be valerian, castor, assafoetida, and aether, together with cinchona bark, and steel, which may be administered as recommended in hypochondriasis, hysteria, and dyspepsia. Rubbing the temples from time to time with" a little aether mayjalso have a good effect. The habit is to be rendered at the same time more robust by gentle and regular exercise every day in the open air; by a diet consisting chiefly of animal food, with a moderate quantity of wine, and by great regularity as to the hours of rest and rising, and likewise of meals. Where a headach is attended with great pain, long want of rest, and a slight delirium, we may venture to give opiates in a consi- derable dose, provided proper evacuations have been premised. Should we have reason to suppose that the headach has pro- ceeded from a stagnation of serum in the vessels, or on the mem- branes of the head, perpetual blisters, issues, and mercurial purges, will then be necessary; and along with these we may employ errhines, such as the pulvis asari compositus. In periodical headachs, we are informed by the late Dr. Fowler, of Stafford, that he experienced the most happy effects from giving the solution of arsenic, as mentioned in the treatment of inter- mittent fevers. The best way in such cases will be, to begin with about three drops repeated twice a day, and so to increase the number gradually to eight or ten. The extractum bella-donnae has proved singularly successful in a great number of complaints of the head, whether resembling tic douloureux, or partaking of an intermittent form. Small doses of one or two grains, repeated every two hours, during a continuance of the pain, have been sufficient. The patient should always be apprized of the probable consequences to vision, and the other faculties, which may ensue from a use of this medicine,—See Tic Doulonroux.. Order VII.} aoothach. ?«33 ODONTALGIA, or TOOTHACH. The toothach consists in an acute pain in one or more of the teeth; but most generally it originates in one, and from that is diffused to the adjacent parts. A caries of the tooth itself, acted upon by different irritating causes, such as the application of cold, or some acrid matter, is the most usual cause of this complaint; but in some cases it would seem to proceed from a rheumatic affection of the muscles and membranes of the jaw; and here the whole side of the face will be affected. When it takes place in pregnancy, jt is to be considered as arising either from an increased irritability or from sympathy. It may be presumed that the acrid matter which occasions the toothach is produced by some vice that originates in the tooth itself. In some instances the caries appears first upon the external surface or enamel of the tooth, in one or more spots which are superficial; but in others it commences in the internal surface, or bony part: the former is, however, by far the most frequent. The caries, by spreading and corroding deeper, at length pene- trates the substance of the tooth: and the external air, and other matters, getting into the cavity, stimulate the nerve, and thereby excite the toothach. The most effectual cure for this disease is extraction of the carious tooth: but as this in some cases may not be advisable, and in others might be strongly objected to by the patient, it will often be necessary to substitute palliative means. To relieve the urgency of pain in those cases where there is an opening made into the substance of the tooth by the caries, it is usual to introduce either cotton impregnated with substances of a caustic nature, such as the essential oil of cloves, cajeput, nutmeg, &c. together with sulphuric or other mineral acids, or a small pill composed of opium and camphor. In some instances the actual cautery has been employed to destroy the sensibility of the nerve. To prevent a return of the pain when it has ceased, the hole in the tooth should be widened within by a proper instrument, and then be stopped with leaf-gold, or leaf-lead, by which operation it may often be preserved for many years without any further inconve- nience to the person. These are the remedies and means to be made use of when the disease is confined to a single tooth; but when the neighbouring parts become likewise affected, or there is no access for such an application to the nerve, in consequence of the tooth having no cavity in it, other measures are to be adopted. Exciting an irritation in the neighbouring parts, by means of blisters applied behind the ears, or by rubbing the jaws with some kind of rubefacient liniment,* and afterwards keeping them warm * 1. R Liniment. Ammon. Fort. f. ^j. j* 1. Take Strong Liniment of Ammonia. one oTin^e T64 local diseases. [Class IV. with flannel, has often afforded much relief, in cases where the pain is somewhat diffused. Promoting an increased excretion from the salivary glands, by means of pungent masticatories, such as horseradish, scurvy-grass, ginger, and pellitory-root, has likewise been adopted in similar eases with much advantage. In those rheumatic affections of the maxillae;, to which many persons are subject under certain states of the atmosphere, and in which the pain is not confined in any one tooth, but occupies the whole jaw, the pyrethrum has often been peculiarly useful. When the tenderness or tumour of the gums renders the mastication of the root impracticable, a piece of lint, moistened in the tincture, prepared as below,* may then be applied to the most painful part, renewing it as the occasion may require : or one of the pills heref advised may be held in the mouth until dissolved. Washing the teeth every morning with a soft brush or piece of sponge dipped in clear water, frequently removing the tartar from off them, and making use of some absorbent testaceous powderj reduced to a very fine consistence, twice or thrice a week, are the best means for preserving the teeth. Where the patient is of a scorbutic habit, and the gums inclining to softness and sponginess, they may be washed now and then with what is here advised.|| Charcoal reduced to a fine powder is an excellent dentifrice, and by washing the mouth with a little of it diffused in water, it im- mediately takes away the bad smell from decayed teeth. A lump Vel, 3. (J; Spirit. Camphorae, f. 3;j. Liquor. Ammon. f. 3iij- Essent. 01. Bergam. TlX *• M. * 3. ft Pulv- Rad. Pyrethri, 3x. Spirit. Rectif. Oj. Infund. per dies decern et Cola. Postea adde Camphorae, ?j. Ol. Rorismarin. f. 3ss. Tinct. Opii, f. 3ij. M. Fiat tinctura. % 4. R. Pulv. Rad. Pyrethri, 3j. Mucilag. Gum. Acaciae, q. s. M Fiant Pilulae xij. % 5. R. Bol. Armen. Com. Calcinat. aa 3u« ^. |j 6. R Tinct. Cort. Cinchonas, f. |ij. —— Mvrrh. f. ?ss. M. Or, 2. Take Camphorated Spirit, one ounce. Solution of Ammonia, three drachms. Essential Oil of Bergamot, fifteen drops. Mix them. * 3. Take Pellitory of Spain, powdered, ten drachms. Rectified Spirit, one pint. Let them infuse for ten days, then add Camphor, one ounce. Oil of Rosemary, half a drachm. Tincture of Opium, two drachms. Mix them. t 4. Take Powdered Pellitory of Spain, one drachm. Mucilage of Gum Acacia, a suf- ficiency. Mix them, and form twelve pills therefrom. 5. Take Bole Armenic, Burnt Hartshorn, of each two drachms. Mix them for a dentifrice. || 6. Take Tincture of Peruvian Bark,'two ounces. ---------Myrrh, half an ounce. Mix them. Order VI1.J painful affection of the face. 765 of the charcoal should be put a second time into the fire till it is red-hot, and when it becomes cool again, the external ashes are to be blown off, and it is to be immediately reduced to a fine powder in a mortar, and kept close stopped in a phial for use. Tinctures composed of mineral acids diluted, and concealed under various artifices and gritty substances, tinged of divers colours, are vended in the shops under pompous names, as dentifrices ; but although they give a whiteness to the teeth, they nevertheless prove highly pernicious to the enamel, and ought therefore to be used with great caution. •— FACIEI MORBUS NERVORUM CRUCIANS, or PAINFUL AFFECTION of the NERVES of the FACE. This is one of the most painful chronic complaints to which the human frame is subject; and although of rare occurrence, still practitioners have now and then the misfortune to meet with it, and to deplore the severe sufferings of the patient and the inefficacy of any aid from medicine. It is the trismus dolorificus of Sauvage, or tic douloureux, by which name it is vulgarly known; but as the one which has been applied to it by a late writer* is more accurate and expressive of its real nature I have been induced to adopt it. The term neuralgia facialis has been employed by a French nosologist of the preseht day, which indeed indicates with accuracy and precision the leading characters of the disease, and is at the same time consistent with a correct and philosophic no- menclature. The late Dr. Fothergillt seems to have been the first author who noticed the disease ; since which we have been furnished with some remaks on it by Dr. Haighton, in a paper inserted in the Medical Records and Researches, as likewise by Darwin in his Zoonomia. By some it has been supposed to be owing to a can- cerous acrimony, but we may with greater reason attribute it to a diseased state of the nerves of the face or their covering. Its true cause has not however been satisfactorily ascertained, but it is generally supposed that the several ramifications of the second branch of the fifth pair of nerves are the parts chiefly affected by it. Rheumatic and gouty irritation may sometimes be the real source of neuralgic affections. The most frequent seat of the affection is the nerves over the cheek-bone, just below the orbit; the alae of the nose, upper lip, teeth, and gums. When this is the case, it will be found to proceed from the second branch of the fifth pair of nerves, the superior maxillary nerve, which passes through the foramen rotundum, and whose branches are chiefly distributed to those parts. Sometimes the forehead and temple and inner canthus of the eye, and even , * See a Syst matic Account of this Disease by S. Fothergill, M. D. ^ t Medical Observations and Inquiries, vol. v. 766 LOCAL DISEASES. [Class IV. . the globe of the eye itself, are first affected, from the first branch of the fifth pair, the ophthalmic branch being the subject of the disease ; and as there are some cases recorded in which the patient suffered much from an effusion of tears, it might probably arise from that branch of the ophthalmic which goes to the lachrymal gland being the seat of the disorder. When the lower jaw and tongue are affected in addition to the parts already named, the third branch of the fifth pair, or lower maxillary nerve, is diseased. Perhaps as frequently as any of these nerves is the portio dura of the seventh pair diseased; it gives off branches to most parts of ihe face, and they communicate with several of those of the fifth pair. The distinguishing mark of its being affected is, that besides the parts already enumerated, we find pain in the ear, the mastoid process, and the angle of the lower jaw. The disease is then chiefly confined to the fifth pair of nerves, of which most fre- quently the second branch only is affected, and the branches of the portio dura of the seventh pair. From the intimate connexion, however, of most of the branches of these nerves with each other, the disease seldom continues long without extending its ravages; and, in very inveterate cases, all the nerves may possibly be affected. The only disease with which tic douloureux can be confounded are, rheumatism, hemicrania, and toothach. It is to be distinguish- ed from the first of these by a paroxysm being excited by the slightest touch, by the shortness of its duration, and the extreme violence of the pain: neither are the symptoms similar; for in rheumatism, if acute, there is fever with redness and increased heat in the affected part, and generally some degree of swelling; if chronic, the pain is obtuse, long continued, and often increased at night; whereas none of these symptoms usually occur in the morbus crucians faciei. From hemicrania it may clearly be distinguished by the circum- stance of the pain in tic douloureux accurately following the rami- fications of the affected nerve; and It may be known from the toothach by the shortness of the pa- roxysm and the rapidity of its succession, and during the interval an entire freedom from all pain; the seat of the pain, and its dart- ing in several directions, according to the particular nerve affected, with an acuteness and poignancy differing from that of the tooth- ach, which seems to strike deep, while the pain of the morbus cru- cians faciei is always more superficial and infinitely more lancina- ting ; and, lastly, the convulsive twitchings, which, though not) always present, are very frequent, and are never experienced in odontalgia. Neuralgia facialis commonly arises in persons of a delicate irritable habit at that period of their lives when the bodily strength begins to give way; for the most part between the fortieth and fiftieth year, and is excited into action by exposure Order VII.J painful affection op the face. 767 to a cold and humid atmosphere, by great fatigue, by external vio- lence, and by uneasiness of mind. Stimulating and anodyne embrocations, blisters, topical bleeding by means of leeches, frictions with mercurial ointment,* prepara- tions of quicksilver, particularly the submuriate, given in combina- tion with opium in doses sufficient to exhibit a decided constitu- tional influence,! the application of ice or very cold water, and electricity, have been resorted to in the palliative treatment of neu- ralgia fascialis; and the arsenical solution, extracts of hemlock, hyoscyamus, and opium, in considerable doses, frequently repeated, as well as being applied externally in the form of liniment, the ex- tract of cinchona,| in very large doses, and the different medicines usually administered in nervous complaints, have at the same time been given internally with some temporary relief. In some cases of tic douloureux which had resisted the effects of the arsenical solution, the nitrate of silver, the extract of hen- bane in considerable doses, and opium, the ferri carbonas is re- ported! *° fiave been employed with very great success. It was given in doses of two scruples to a drachm, repeated two or three times a day. A severe case of the disease in a gentleman of about sixty years of age lately came under my care, wherein I was induced to make trial of this medicine, owing to a failure of the cinchona, arsenical solution, and every other means that had been adopted prior to my being consulted, and it is an undoubted fact that the malady soon ceased, and has not again returned, although some months have elapsed since its removal. It appears, however, from the report of a late writer,§ that the most certain and powerful remedy which has been employed in this excruciating disease is bella-donna. In many cases recorded by him which were attended by excessive pain, and which had resisted every means before tried, this medicine proved effectual. From two to three grains of the extract, or from twenty to forty minims of the tincture, in any vehicle, were administered every four or five hours during the severity of the paroxysms to adults, but the dose was considerably lessened when ease was procured. It appears that the use of bella-donna, is, however, accompanied by some distressing symptoms, such as giddiness in the head, impaired vi- sion, numbness, tightness in the chest, and a sense of dryness in the throat, and suffocation, when given in such doses as to produce a certain effect; but these soon cease again on diminishing the dose or wholly discontinuing the medicine. * See vol. iii. p. 272, of the Edinburgh Journal, for a case of tic douloureux suc- cessfully treated with mercurial ointment so as to excite a copious ptyalism. t See vol. iv. p. 306, of the same Journal. — vol. vii. p. 381, of the New Med. and Phys. Journal. X See Dr. Kerrison's Inaugural Thesis de Neuralgia Faciali Spasmodic:-. i| See Case3 of Tic Douloureux successfully treated by Mr. B. Hutchinson. 5 See Observations on the Use of Bella-donna in Painful Disorders of the He'iO and Face, by Mr. John Bailev. 76« LOCAL DISEASES. [Class IV. It appears, then, that bella-donna exercises a striking and powerful influence over those chronical sympathetic irritations that particularly belong to the head and face, which harass and distress the sufferer to an almost interminable length, and which hitherto had shown nearly an unyielding obstinacy to the power of every other medicine than bella-donna, but which has proved a most potent auxiliary in the cure of this excruciating disease. Be- sides its internal use, a tincture of it has been employed as an ex- ternal application in some cases with advantage. It has been attempted to exterminate this painful affection in some instances by a division of the nerve, and the operation is fully justified by the extreme acuteness of the disorder, and by the considerable degree of success that has attended this mode of treat- ment. It is well known, however, that the operation, although a radical cure in the part immediately affected, does not always pre- vent a recurrence of the pain in the collateral branches of the nerves ;" and therefore, previous to having recourse to it, we should consider whether the nerve or nerves can be divided between the part where the pain originated, and the parts to which it afterwards extended. When this can be done, there will be a probability of operating with success ; but when several parts are attacked at the same time, or where the pain extends in several directions from the part primarily impressed, there will be but little reason to ex- pect advantage from an operation. When the portio dura of the seventh pair (which is distributed very extensively upon the face under the name of pes anserinus) is the seat of the disease, and which may be ascertained by the pa- tient complaining of a pain that begins in the forepart of the cheek, sometimes as high as the forehead, and extends itself in the direc- tion of the ear, no relief whatever can be obtained by dividing the second branch of the fifth pair, as such a division cannot possibly give any interruption to the communication between the sensorium and the seat of irritation. Paralysing the nerves by the application of cerussa, succeeded in a case* under the care of Mr. Astley Cooper, that had resisted every other remedy, and even the knife. Two scruples of this formed into an ointment were rubbed in the morning on the affect- ed cheek, about an hour before the paroxysm was expected. The application was continued for a month or more, and the patient (who was a man) left the hospital apparently perfectly cured.__ The effect of the lead is reported to have been rapid and striking the person being rendered comparatively comfortable in a short time, from a state of excruciating torment. No particular effect was produced by a cerussa on the stomachor bowels. It has already been observed, that tic douloureux is pretty gene- rally supposed to be primarily seated in the nerves of the face; but a modern writer thinks, however, that it has its origin in the brain, rV= See Mr. Bedingfield'? Compendium of Medical Practice, chapter xii, ~ Qrckr VH.J pain in the stomach. T-6'9 to which the affection of the face merely stands in the relation tff an effect. This opinion, he says,* has been impressed upon his mind by a careful examination of the cases which have fallen under his eyes, in the whole course of which the affection of the face was preceded and attended by clear manifestations of cerebral disease such as pain, giddiness in the head, confusion, or some other uneasiness in the head, more or less disorder in the functions of some of the external senses, with symptoms of congestion, or of increased action in the vessels of the brain, and sometimes the stomach and liver were simultaneously or sympathetically affected, a circumstance not uncommon in many diseases of the sensorium. Forcibly struck with the appearances that indicated the seat of the malady in question to be in the brain, the physician alluded to resolved to try the power of decided bleeding, both general and local, and purging. In many cases of a recent nature this plan, Aye are told, succeeded without any other aid. In one of much longer standing, the plan was followed up by opium and the sub- muriate of mercury combined together. The occasional appli- cation of a blister either to the scalp or nape of the neck, might be likely, he supposes, to assist the use of purgatives, and the depletion by general and topical bleeding. From a consideration of all the circumstances attendant on tic doulourex, Dr. Parryt has likewise been induced to attribute this painful affection to increased vascularity, or determination of blood (amounting perhaps to inflammation) to the neurilema or vascular membranous envelope of the facial nerves, or of the second or superior maxillary branch of the trigeminus. Of course the plan of treatment advised by him is depletion by general and local bleedings. GASTRODYNIA, or PAIN in the STOMACH. This disease often occurs in those who are afflicted with dys- peptic symptoms, such as heart-burn, eructations, flatulency, &c. In addition to what has been mentioned of these complaints under the head of Dyspepsia, it may be proper to notice that cardialgia and gastrodynia originate from an inactivity of the stomach, whence the aliment, instead of being concocted by digestion, and converted into chyle, runs into fermentation, producing acetous acid. Sometimes the gastric juice itself becomes so acid as to give pain to the upper orifice of the stomach; and it is probable that violent cardialgia is more fre- quently owing to an increase of the acidity of the gastric juice than to the acetous acid produced by fermenting aliment. The heartburn, as arising from indigestion, is often an afflicting and pertinacious complaint, being not unfrequently attended with * See Practical Illustrations of Typhus and other Febrile Diseases, p. 212. by Dr. Armstrong. t See his ElejnentSjOf Pathology and Therapeutics. 98 1^0 LOCAL DISEASE'S. [C/tfSS ii • an emaciation of the body from the want of sufficient chyle. Td obtain a temporary relief, we must have recourse to antacids, calcareous earths, alkaline salts, the aerated alkaline water, or Seltzer water. To check the fermentation in severe cases, we may employ the sulphuric acid in a diluted state, together with a due quantity of brandy or other spirit lowered with water; but for the purpose of procuring a permanent relief, we should endeavour to strengthen the digestion by the stimulus of a blister externally, and by the use of aromatics, bitters, and chalybeates internally, as advised under the head of Dyspepsia. The diet should consist of such things as do not easily ferment* such as animal food, shell-fish, and biscuit. It appears by the experiments of Pringle and M'Bride, that the saliva swallowed along with our food greatly prevents its fermentation ; and there- fore dyspeptic persons should be particularly careful in well mas- ticating what they eat. Flatulency is to be obviated by carminatives and a due ob- servance of the means just mentioned. Perhaps a waistcoat made so tight as slightly to compress the stomach and bowels, might prove serviceable in assisting the digestive process. In gastrodynia attended with acute pain in the organ, we must have recourse to antispasmodics, particularly aether and opium in combination with stomachic bitters and chalybeates. The oxyd of bismuth is a remedy which is reported to have been employed with considerable advantage in gastrodynia—(see Dyspepsia.) The proper dose is from three to ten grains, with about twenty-five grains of gum tragacanth, repeated three times a day. We had better however begin with a dose of three grains^ and so increase it gradually. I have myself used it with advantage in some cases. SPRAINS. Accidents of this nature happen most frequently in the wrists, knees, and ankles ; and are usually occasioned by a slip, or some sudden effort or violent exertion. ' Sprains of the tendons and ligaments are usually productive of an immediate painful and inflammatory swelling. In severe sprains there is often not only an increased action of the arteries in the inflamed part, but there is likewise an instantaneous effusion from the rupture of some of the small vessels. In general, we may suppose the effusion to be of the serous kind, as the skin is not altered in colour for some time after the accident; but it some-. times happens that the tumid parts are either of a deep red or leaden colour from the very first, owing to blood being extra- vasated from the ruptured vessels. In the treatment of sprains, two circumstances are principally to be attended to: the first, to prevent, by all possible means, the swelling from arriving at any considerable magnitude; the second, Ovdsr ftK\ SPRAINS.. 771 to employ those remedies which are known to be powerful in re- moving inflammation. To answer the first of these intentions, restringent applications, such as vinegar, ardent spirits, and the lees of red wine, may be made use of. By immersing the injured part in any of these immediately on receiving the injury, the effusion will be rendered much less than it otherwise would be, and may perhaps be alto- gether prevented. Plunging the sprained limb into the coldest water that can be procured as soon after the accident as possible, is often attended with the best effect, and may be advised as the first step, till one or other of the articles just mentioned can be procured. To answer the second intention, of removing inflammation, we may have recourse to local blood-letting by the application of Several leeches to the tumid part; and if the pain and inflamma- tion do not subside readily, they may be applied again the next day. Should any degree of fever attend in consequence of the violence of the sprain, opiates, together with refrigerants, and the remedies which prove useful in other inflammations producing fever, ought to be administered. In cases where the accident is trifling, or after blood has been drawn off from the part affected, we may apply a solution of the plumbi superacetas or liquor plumbi acetatis properly diluted, by keeping linen cloths dipped in either of them constantly to it throughout the course of the day. At night, a poultice consisting of oatmeal and linseed meal mixed up with vinegar, may be laid on. This last, however, will not be essentially necessary, except where much tension and pain are present. With these and such other discutient applications,* proper rest will be necessary for the limb, which never should be kept in a pendent position. . Where a weakness remains in consequence of a sprain, pumping * 1. Take Solution of Acetate of Ammonia^ Soap Liniment, of each one ounce, Mix them. Or, 2. Take Camphor Liniment, Solution of Acetate of Ammonia, of each one ounce. Tincture of Opium, half an ounce. j Mix them. Vel, \ Or, 3. Take Muriate of Ammonia, two drachms. Distilled Vinegar, Rectified Spirit, of each half a pint. Mix tlitm. Or, 4. Take Oil of Amber, Tincture of Opium, of each t,wo ounces. Adipis Praspar. 3j- M\ j Prepared Lard, one drachm. ft. Linimentum. Mix them. To be used as Sfliniraent. 1. ft. Liquor. Ammoniae Acetatis, Liniment. Saponis, au f. Zj. jvi. Vel, 2'. IJs Liniment. Camphorae, Liquor. Ammon. Acetat. aa f. |j Tinefc Opii, f. gss. M. Vel, 3. r£ Ammoniae Muriat. 33- Acidi Acetici, Spirit. Rectif. aa Oss. M. Vel, 4. IX Olei Sucqin. Tinct. Opii, aa f. jij. " -t» -LOCAL DISEASES.. [Class 1V. cold water upon the part every morning, and wearing a calico bandage for a considerable length of time, as a supp6rt to it> will be the best means to pursue. LITHLASIS, or THE GRAVEL and STONE. These diseases depend upon a peculiar disposition of the fluids, and more particularly the secretion of the kidneys, to form a cal- culous matter, and have been supposed to be owing to the presence of an acid principle in them, termed the uric acid, which seems confirmed by the benefit derived from a course of alkaline medi- cines. Uric acid is indeed one of the essential elements of the urine of a person in perfect health, and not an accidental or diseased production of the animal economy : in the healthy 6tate, it is wholly dissolved in the urine ; and in gravel, a portion of it is deposited in the form of sand or calculi in the cavities destined to collect and evacuate the fluid secreted by the kidneys. A lone use of fermented liquors, and of wines abounding with tartar, may possibly in some constitutions prove occasional causes of thegravei and stone. It has also been long supposed that water impregnated "with sulphate and carbonate of lime, constituting what is called hard water, predisposes persons to be afflicted with the gravel and stone; but Dr. Henry, in his excellent thesis, looks upon this opinion as an unfounded prejudice. Instances have been adduced where a stone has arisen from the accidental introduction of some substance in the bladder, thereby forming a nucleus. That a morbidly increased secretion of gravelly matter frequently occurs independent of external causes, we have the most satisfactory proof in the hereditary disposition of many families to this complaint. An excess of uric acid is generally supposed to be the proximate cause of the formation of sand and calculi, and this excess will much depend on the mode of life and kind of diet adopted by the patient All substances containing azote furnish matter for the formation of uric acid,* into which it is readily transformed, and tends to the production of gravel. The use of animal food and other analogous aliments tends to diminish the quantity of urine at the same time that it increases the proportion of uric acid, whereas a vegetable diet has the contrary effect. Those who are in the decline of life, and who have been much engaged in sedentary employments, as likewise those who are much afflicted with the gout, are in general very subject to nephritic complaints; but it is a matter of notoriety that the period of life from infancy to about fifteen years, is most subject to the forma- tion of calculi in the bladder, and that the children of the poor are afflicted in a greater proportion than those of the opulent. From the difference in the structure of the urinary passages in the * Stee Dr. Majerrdte's Physiological and Med. Researches infodie Causes of Grave* Qvder VlhJ gravel and stone, *"?3 sexes, men are much more liable to them than women. In warn} climates we seldom meet with instances of calculous concretions forming of any size either in the kidneys or bladder, as the partis cles of sand deposited from the urine usually pass off before they can adhere together, owing to the relaxed state of the parts; but in those that are cold they are found frequently of considerable magnitude. A very interesting case is reported by Sir James Earle, in the PhilosophicalTransactions of the Royal Society for 1809, in which a calculus was found in the bladder larger than any of which we have an equally well-authenticated account. About ten years after the symptoms of calculus were experienced, lithotomy was per- formed, and the extraction attempted by Mr. Cline, at the par- ticular request of the patient. A considerable quantity of frag- ments was removed, but the great mass of the calculus could not be extracted, and after a few days death ensued. On dissection, the bladder was found entirely filled, and even distended by the stone: it weighed forty-four ounces, and was sixteen inches in length. It seemed to have completely occupied the cavity pf the pelvis, and to have projected beyond, and rested upon the pubes. The pelvis of the kidneys and ureters were much enlarged, and the latter appeared to have been the receptacles of the urine. The stone, on being analyzed, was found to consist of the triple phos- phate of ammonia and magnesia, with phosphate of lime mixed with an unusually large quantity of animal matter. A fit of the gravel is attended with a fixed pain in the loins, numbness of the thigh on the side affected, nausea and vomiting, and not unfrequently with a slight suppression of urine. As the irritating matter removes from the kidney down into the ureter, it sometimes produces such acute pain as to occasion faintings and convulsive fits. The symptoms often resemble those of nephritis, but the deposition of reddish brown sand, or very fine powder of the same colour in the urine, on becoming cold, will demonstrate the difference. One of the principal diagnostic symptoms of calculus in the kidney, however, is the dark appearance of the urine, as if it were mixed with coffee grounds, evidently depending on broken down particles of blood, proceeding from the obscure but continued irritation of the kidney. When this occurs in conjunction with a dull heavy pain in the loins, there can be very little doubt of tiie presence of calculus in the kidney. In mere inflammation of mis organ, when no calculus is present, the urine does not put on the above appearance. When gravel has once formed in the pelvis of the kidney or elsewhere, it continues to increase by receiving on its surface new ■"layers of uric acid successively precipitated, of which we may be convinced by cutting the concretions transversely, which enables us to perceive that they are almost entirely composed of concentric layers-. rv4 local disease^,. (Class IV- Disordered affections of the prostate gland are those whicjl without proper attention are most likely to be confounded with stone in the bladder. One mark of distinction which the young practitioner will do well to attend to* is, that in the prostate affection the pain experienced in making water will be always in the commencement of micturation, while on the contrary, it is most usually during the passage of the urine, or when the bladder is nearly emptied, that pains and obstructions are perceived in cases of calculus. Another important diagnostic of stone is, that the irritation which it induces does not much affect the general health as the same degree of local disturbance from other causes. The symptoms which attend on a stone in the bladder are a fre-> quent inclination to make water, which flows in a small quantity, is often suddenly interrupted, and is voided towards the end with pain in the glans penis. The patient, moreover, cannot bear any kind of rough motion; neither can he make use of any severe exercise without enduring great torture, and perhaps bringing on either a discharge of bloody urine, or some degree of temporary suppression. With these symptoms he experiences pain in the neck of the bladder, tenesmus, itching and uneasiness in the anus, frequent nausea, and sometimes a numbness of one or both thighs, with a retraction of one of the testes. As all attempts to dissolve a calculus in the kidneys or bladder have hitherto proved ineffectual (whatever certain persons actuated hy selfish motives may have alleged to the contrary.) we are to consider the disease as capable of being removed in males only by lithotomy; an operation always attended with much danger; but more particularly so where the patient is advanced in years, the disease complicated with any organic affection of the parts, and the general health considerably impaired. Under such circum- stances it indeed never should be attempted. In females, calculi of a moderate size, as likewise extraneous substances which have accidentally escaped from the urethra into the bladder, have been extracted therefrom! by gradually dis- tending the former by means of a bougie, observing to increase its size every day until the urethra has become sufficiently distended to allow the introduction of a pair of forceps. The knowledge of this fact I have deemed worthy of being recorded, as it may induce many to make trial of a mild mean, instead of resorting hastily to a severe operation. One great advantage of this mode is, that it may be employed as soon as a small 6tone is discovered in the bladder, when it may be extracted with great ease, and at a time that a more dangerous-^ painful, and important operation would be hardly proposed. When the preference is given to a palliative mode of treatment m males, instead of resorting to lithotomy, we must in that cas£ * See Dr. Heberden's Commentaries. t Pee the 138th No. of the London Medical Journal, p.-. 147. ■-- Medi'Co-ChipUrgi'oal Transactions; vol. yiji". p..^. Order V1I.J gravel and stone. ^75' nave recourse to lithontripties. These will prevent the farther accumulation of calculous matter. Of the class of lithontripties, the fixed alkali seems to be the most powerful, and has indeed been most generally employed. It may be used both in its caustic* and mildt state. It has been satisfactorily ascertained, that in the majority ef Cases the nuclei of calculi originate in the kidneys, and that of these nuclei, by far the greater number consist of uric acid: the good effect therefore so frequently observed from the use of alka- lies, arises not from any actual solution of calculous matter, but from the power which they possess of diminishing the secretion of uric acid, and thereby preventing the enlargement of the calculus, so that while of a very small size, it may probably be voided by the urethra. The alkaline aerated water is a preparation of the mild kineT, which has been mueh extolled for its virtues in calculous and ne- phritic complaints, and is indeed pretty generally substituted in- stead of the liquor potassae, and other active lithontripties, the long exhibition of which is commonly attended with injurious conse- quences. The quantity of the aerated alkaline water usually taken is about a gill thrice a day, viz. before breakfast, dinner, and sup- per. When the stomach will bear a greater quantity, an English pint may be taken in a day. If it proves cold to the stomach, or occasions flatulency, a tea-spoonful or two of brandy may be added. Should the irritation of the urinary passages be great, it probably may be of use to take a few drops of the tincture of opium with each dose ; but this ought to be discontinued as soon as there is an abatement of the pain. No particular diet or regimen is ne* cessary to be observed while using this medicine, farther than ab- staining from acids, butter, and fat meats. Alkaline salts, although possessed of acrimonious properties ill their separate state, are nevertheless rendered perfectly mild and inoffensive to the system by combining them with fixed air, as in * i. "tp Liquor. Potass®, 171 xij—xx. in jusculi cyatho ter in die. Senslm augeatur dosls. f % ft Sodae Carhonat. 3j—35s. bis ter- ve in die. Vel, o. IJ. Potassae A'erati, 3y. bis die in Aquae Distillat. Oss. solut. Vet, 4. fi PiluL Sapon. gr. x. pro dos mane et nocte. Vel, 5. H Liquor. Calcis Oj. in die cum Lacte vaccina? permixt. Vel, 6. Tji Aq. Supercarbon. Spite, Oss. bis terve in die. * 1. Take Solution of Potass, from twenty to thirty drops three times a day, in a tea-cupful of broth. The dose may be somewhat increased gradually. t2. TakeCarbonate of Soda,from one scrapie to half a drachm twice or thrice a day; Or, 3. Take Aerated Potass, two draehms^ twice a day, dissolved in half a pint of Distilled Water. Or, 4. Take Soap Pills, ten grains for a dftsg. morning and night. Or, 5. Take Lime Water, one pint in thp day, mixed with milk. Or, Q. Take Soda Water, half a pint, twice or thrice a dgty* 77G local diseases. (Class IV. the aerated water, and they are found by no means to lose their solvent quality. For the introduction of this water into medical practice, the world is indebted to Mr. Colbourne of Bath; since which, its beneficial effects have been noticed, and strongly re-* commended by Dr. Falconer, Dr. Percival, and other writers. When the machine for preparing the aerated alkaline water, invented by Dr. Nooth, is not at hand, a medicine nearly similar tnay be prepared in the following manner: Dissolve grs. 20 of the sub-carbonate of potash in two or three table spoonsful of water, and add to the solution a table-spoonful of the juice of lemons. This mixture should be swallowed immediately, and is the proper doSe which maybe repeated three or four times a day. It may however, be doubted if the effects of this would be as powerful as the other. The method of preparing the aerated alkaline water with the machine invented by Dr. Nooth differs from that just, Mentioned, in adding to each pint of water in the middle of the' glass of the machine, a quarter of an ounce of the fixed vegetable alkali. The potassa aerata is a preparation somewhat of a similar feature which is now used at St. Bartholomew's, and other hospi- tals, as a lithontriptic, and is given in the dose of two drachms dissolved in a pint of distilled water twice a day. It consists of half an ounce of the subcarbonate of potass, five drachms of dis- tilled water, and one drachm of subcarbonate of ammonia. The potass being dissolved in a water bath, the ammonia is to be added, and when the effervescence is at end, the mixture is to be set by to crystallize. Dr. Duncan is of opinion that a solution of the super-carbonate of soda in pure water (in the proportion of four scruples to a pint,) is preferable to the aerated soda water, on account of the carbo- nic acid gas not being disengaged on exposure to the atmosphere. -!'^ On ,the addition of a small quantity of lemon or tartarous acid, a ' veryvp4easant effervescence is produced. The carbonate of soda, by being combined with an excess of carbonic acid gas in this preparation is rendered not only more pleasant to the taste, but less liable to offend the stomach; and Dr. Duncan thinks it is the only form in which the soda can be exhibited in sufficient doses, and for so long a continuance as to derive much benefit from its use in calculous complaints. Where alkalies fail to relieve the increased secretion of uric acid, and to prevent its forming calculi in the kidneys, and where they disagree with the stomach, magnesia has been found * generally effectual, and it may be persevered in for a considerable time without inconvenience, where the tendency to form uric acid remains. Muriatic acid given in doses of twenty or thirty drops three or four times a day, diluted with water^ has been found in several * S^e Ob.sen:ati•■ of mucus or slimy matter. Hence it is a disease most common to children; but they sometimes prevail in adults to a very high degree, particularly in those who live chiefly on a vegetable diet. The tape worm is not often met with in infancy or childhood; in- stances of it do, however, now and then occur. Worms may readily be distinguished by the following symptoms, viz. variable appetite, fetid breath, acid eructations, and pains in the stomach, grinding of the teeth during sleep, picking of the nose, paleness of countenance, hardness and fullness of the belly, slimy stools, with occasional griping pains, more particularly about the navel, heat and itching about the anus, short dry cough, emaciation ^ of the body, slow fever, with evening exacerbations, and irregular Jkj pulse, and sometimes convulsive fits. jdam. It is often a very difficult matter to expel worms from the body, ' but more especially the taenia. When they prove fatal, it is by their erosion of particular parts, and their inducing a tabid state. In" the cure of this disease we must have in view, first, the effect- ing the destruction and discharge of the worms; and, secondly, the preventing, their future generation. The" first of these is to be accomplished by certain remedies known by the name of vermifuges, whichall act in one of the three following ways:— 1st. By simple evacuation or purging, as mercury, rhubarb, ja- lap, and aloes; as also the different strong bitters, as rue, tansy, and wormwood. 2dly. Mechanically, as the pulvis stanni, cowhage, &c, or, 808 WORMS. 3dly. Chemically, as lime-water, which loosens their adhesion to the intestines by dissolving the mucus in which they are in- volved. We may begin with those which act mechanically,* and which have been found the most powerful; and after continuing them for two or three days we may have recourse to those which have a purgative effect,! changing both after a continuance of some time for those which act chemically.^ Along with those which act mechanically it will be proper to employ some kind of bitter infusion.II * 1. ft Stanni Limatur. Confect. Cassiae, aa ?ss. Syr. Simpl. q. s. M. ft. Electuarium, cujus sumat magnitud. nucis moschatae bis in die. Vel, 2. ft Spicul. Stizolobii aut Dolichi Pub. gr. vj.—x. Limatur. Stanni, gr. x. M. ft. Pulvis, mane et nocte capiendus cum syrupo, aut melle permixtus. Vel, 3. ft Spicul. Stizolobii, gr. vj.—x. Mel. Optim. vel Theriac. q. s. M ft. Bolus bis in die adhibendus. Vel, 4. ft Spicul. Stizolobii, 3j- Syrup. Simpl. q. s. M. ft. Electuarium, Capiat cochl. minimum mane primo per dies tres. t 5. ft'Hydrargyr. Submuriat. gr. iij.—\ Pulv. Rhei, gr. x. M. ft. Pulvis. Quarto mane sumendus. Vel, 6. ft Pulv. Jalapae, gr. x. Hydrargyr. Submuriat. gr. iij. M. Vel, 7. ft Olei Ricini, f. |ss.—f. ^j. pro dos. X 8. ft Liquor. Calcis, Oss. in die. || 9. R Rad. Gentian. Contus. Fol. Absinth. 1 ; ---- Rutffi, 4| Cort. Limon. aa 3lj- Aq. Ferventis, Oj. Macera per horam unam, et cola. Hu- jus in fusi sumat cochl. magna iij. bis terve in die. * 1. Take Filings of Tin, Cassia Confection, of each half an ounce. Syrup, a sufficiency. Mix them. Of this electuary the bulk of a nutmeg may be taken twice a day. Or, 2. Take the Down of Cowhage, six grains to ten. Filings of Tin, ten grains. Mix them. This is to be taken night and morning, mixed with a little syrup or honey. Or, 3. Take the Down of Cowhage, six to ten grains. < Honey or Treacle, a sufficiency tot form a bolus, which is to be given twice as day. Or, 4. Take Down of Cowhage, one drachm; Common Syrup, a sufficiency. Form an electuary, of which take a tea- spoonful every morning for three days on an empty stomach. t 5. Take Submuriate of Mercury, three to five grains. Powdered Rhubarb, ten grains. Mix them. This purgative powder is to be taken on,the fourth morning after any of the preceding vermifuge medicines. Or, 6. Take Powder of Jalap, ten grains Submuriate of Mercury, threi grains. Mix them for a cathartic. '•* Or, 7. Take Castor Oil, half an ounce to one ounce for a dose. X 8. Take of Lime Water, half a pint in the day. || 9. Take Gentian Root, bruised, Wormwood Leaves, Rue Leaves, Lemon Peel, of each two drachms. Warm water, one pint. Infuse them for an hour, and then strain off the liquor. Of this infusion three table- spoonsful may be taken twice or thrice a dav. WURMa. aW , If these means prove ineffectual, we may then make use of the Indian pink root, or spigelia, which has on many occasions been found a very powerful medicine. About ten grains of the powder may be given morning and night to a child of eight or ten years old, to which age the doses of the preceding remedies are adapted. The spigelia is without doubt a poisonous and narcotic vegetable, and it is in all probability by virtue of this poisonous quality that it proves so beneficial in cases of worms. By a proper use of stizolobium or cowhage, (the dolichos pro- liens of Linnaeus,) with the submuriate of mercury combined with jalap, or the oleum ricini every third or fourth morning as a pur- gative, we seldom? however, shall have occasion to seek relief from any other medicine, as in several hundred cases where I had used , it, during my practice in the West Indies, I never knew it once to "via.il. It appears to have been but very lately introduced into this " country, which, considering its wonderful vermifuge powers, is somewhat surprising. The stizolobium or dolichos is a plant like the vine, long, slender, and creeping. The leaves are thin, pointed, and covered with a down. The flowers grow in clusters, and are followed by a pod, somewhat similar to the common pea in shape and size, and con- taining several purple beans. The pods are thickly covered by very fine stiff pointed hairs, which, upon being applied to the skin, produce an intolerable itching, and it is only this downy portion of the plant that is employed to destroy worms. A decoction of the Geoffraea inermis, or cabbage bark, is another remedy much used in the West Indies, but more parti- cularly in Jamaica, for destroying worms, and often with a very happy effect. For the destruction of ascarides it is very usual to throw up" ^injections into the rectum that will prove obnoxious, and thereby * dislodge them. Any of those recommended below* may be tried. '*•■ 16. Jft Liquor. Calc. tepid, f. |x. pro enemate. Vel -11. ft Fol. Rutas, ——Absinth, aa ?ss. Coq. ex' Aq. Purse, ©j. ad gx. Colat. adde 01. Ricini, f. =ss.M. . advantage in any agreeable form, followed by as large a quantify of diluted alkali as the stomach can bear. Muriate of soda counteracts the corrosive effects of tb.e nitrate of silver, and it is the best antidote. A person suffering under the deleterious effects of this, should drink several glasses of a solution of the muriate of soda" in the proportion of a table- spoonful of the salt to two pints of water. Vomiting will ensue, and the symptoms will diminish. Should they continue, recourse should be had to emollient drinks and fomentations, as also leeches to the abdomen. ,,^ Milk is the best antidote of ^muriate of tin, by which it is coiri- jpletely coagulated. The coagulum contains muriatic acid and oxyd of tin, which is not deleterious. It has been observed that an over-dose of tartarized antimony sometimes produces severe consequences. In such cases our chief dependance is to be placed on mucilaginous and diluent drinks, speedily to remove the medicine from the stomach, and when this is done, opium, and perhaps blisters, may be of some service. Mr. Orfila conjectures that a decoction of the cinchona bark and strong tea may aid in counteracting the injurious effects of an over-dose of tartarized antimony. In all cases of poison by the sulphuric, nitric, or muriatic acids, calcined magnesia will be the best remedy, as soda and potassa are somewhat irritating. The patient should take as soon as pos- sible a mixture of the carbonate of magnesia and water, in the proportion of an ounce of the former to a pint of the latter. Of ' this a glassful should be swallowed every four or six minutes, in order to favour vomiting, and prevent the acid from acting on the coats of the stomach. Pure magnesia should not be given, as when suddenly added to concentrated sulphuric acid, prodigious heat and vapour are excited. Carbonate of magnesia has not this effect, and is therefore the proper remedy. When the carbonate of magnesia is not at hand, half an ounce of soap dissolved in a pint of water should be given. After promoting vomiting and neutralizing the acid, our next object is to obviate the inflammation likely to ensue, and with this view several leeches and afterwards fomentations should be applied to the abdomen. If prompt relief be not obtained by these means, assisted by a warm bath, blood is to be drawn from the arm in greater or less quantities, according to the urgency of the symptoms. All food is to be prohibited for the time. Diluents, such as milk, linseed tea, and gruel, are to be taken plentifully, and laxative clysters injected frequently. During convalescence, a return to the usual diet ought to be very gradual. Acetic acid, or vinegar diluted with water, is the best antidote against the effects of an over-dose of any alkali. In all cases of poison arising either from arsenic, oxymuriate of mercury, or any other mineral, it will be necessary to procure as speedy and quick an evacuation upwards as possible, by means of MIXERAL POISONS. 815 a -irong emetic;* drinking freely afterwards of diluting liquors, such as a decoction of barley, with gum. acaciae, mutton andjreal broths, linseed-tea and milk, in order to wash out the stomach, as well as to sheathe the parts, and prevent their being acted upon by the particles of the poisonous matter. With the same intention, oil is not only frequently administered J by the mouth, but likewise thrown up into the intestines in the form of clyster, mixed with a decoction of emollient herbs. It appears, however, from numerous trials, that when arsenic is given to animals combined with oil, butter, or other fatty sub- stances, they are destroyed much more quickly than when it is given in an aqueous vehicle. The use of fat bodies ought there- fore to be interdicted during the first moments in cases of such a poison, and mucilaginous and gelatinous substances be employed in their stead. Alkaline salts have been found to diminish the injurious effects of mineral poisons, and therefore in accidents of this nature it will ^ Railways he advisable to make use of them without loss of time. For this purpose,' dissolve about an ounce of the subcarbonate of potass in half a gallon of water, and give the patient a tea-cupful frequently. Where none of these salts are at hand, then a small quantity of wood-ashes, mixed up with boiling water, so as to make it of a sufficient strength, may be substituted, suffering the liquor to stand until it settles, and then filtering it through linen for use. Fresh charcoal powdered fine has (it is affirmed) been found an efficacious medicine in obviating the deleterious effects of arsenic on the stomach and intestines. The carbonate of magnesia has been recommended as a good remedy to counteract the deleterious effects of arsenic ; but from some experiments reported in the London Medical Repository,! it appears that calcined magnesia does not decompose the white oxyd of arsenic, but on the contrary, that it combines with it, and forms a soluble arsenite of magnesia, which has not a feeble action on the human frame, as is too generally supposed. From these experiments, it also appears that chalk, and also lime water, destroy the deleterious effects of an over-dose of a solution of the white oxyd, if taken in time, and are likely even to suspend or tSee No. 44, p. 157. * 1. ft Zinc. Sulphat. gr. xv.—3ss. j* 1. Take Sulphate of Zinc, fifteen grains to I half a drachm. Pluv. Ipecac, gr. x. M. j Powder of Ipecacuanha, ten grains. ft. Pulvis statim sumendu3. Mix them, and let this powder be taken im- mediately. Or, 2. Take Tartarized Antimony, two grains. Sulphate of Zinc, fifteen grains to one scruple. Pure Water, one ounce. Mix them for an emetic draught. Vel, 2. ft Antimon. Tartarizat. gr. ij. Zinc. Sulphat. gr. xv.—3j. Aq. Purac, ?i. M ft. Haustus Emeticus. 316 MINERAL POISON. greatly lessen the action of the poison swallowed in a solid form, if aided by plentiful dilution. Lime water is recommended by Orfila,* who., proved by experiments that the arsenite of lime (formed by pouring lime water into a solution of white oxyd of arsenie) is insoluble, and when swallowed is not poisonous. Of all antidotes to the poison of the oxymuriate of mercury, we are informed by the French writert before referred to, that he found albumen (which is only the white of egg dissolved in water and filtered) to be the most powerful and efficacious. It is to be properly diluted with water previous to use. In defect of this, milk, gum-water, decoction of linseed, mallow, or sugar and water, should be taken in abundance. The fulness«of the stomach will produce vomiting, and consequently an evacuation of the poison, which is more to be relied on than chemical remedies. On the principle of removing inflammation in cases of mineral poisons, it may be advisable to employ copious bleeding, (if not contraindicated by the state of the circulation,) together with the application of a large blister to the epigastric region, keeping the bowels open at the same time with frequent doses of the oleum ricini. A successful case of this nature is recorded in the 2d volume of the London Medico-Chirurgical Transactions. Indeed when • inflammation is only commencing from the ab- sorption of the mineral, and the morbid symptoms have not yet reached to any alarming height, it would appear, that after having administered an emetic to clear the stomach of the poisonous par- ticles, assisted by copious dilution, with mild and mucilaginous fluids, and then an active purgative to evacuate the bowels, blood- letting is a remedy obviously pointed out. In cases where the poison of verdigris has been recently swal- lowed, emetics should first be given, and afterwards eold water, gently alkalized, ought to be drank in abundance. By experiments made on animals by the French writer just quoted, it was ascertained that sugar exercises a chemical action on verdigris, and renders it insoluble in water. It was therefore used by him and others as an antidote to verdigris, and was found in all cases of this poison to allay the pain and other alarming Symptoms, and to produce an immense quantity of liquid stools. Those who have eaten provisions prepared in a copper vessel badly tinned, are occasionally attacked a short time afterwards with symptoms characteristic of the poisonous effects of the metallic substance, in which cases the exhibition of charcoal has proved highly beneficial when other remedies have failed.! The success of the treatment of all cases of mineral poisons will depend in a great measure on the sort of regimen the patient observes during his convalescence, which is frequently long and painful. He ought to be principally nourished by milk, gruel, * See Trait6 des Poisons, par M. P. Orfila, Docteur en Medecine, torn. i. partie i. +t — The same. J See Journal Gen. de Medecine for April, 181$. MINERAL POISONS. 817 farinaceous preparations, and nutritive broths. Great thirst usually accompanies such occurrences, which may be allayed by frequently washing the mouth with cold water, this being preferable to drinking any great quantity of watery liquors, lest vomiting should be excited or kept up thereby. The following are the tests by which arsenic may be discovered in the contents of the stomach, where it has been administered as a poison. First, if a few grains of it are thrown on a redhot iron, a smell like garlic will be perceived. 2dly, If a few grains are placed between two plates of copper, and subjected to a red heat, the copper becomes whitened. 3dly, Where the quantity is suffi- cient, some wheat may be steeped in a solution of it, and which, if given to chickens or small birds, will destroy them. A simple and efficacious mean for detecting the presence of arsenic is that of Bergman. It consists in infusing a portion of the suspected matter in a solution of vegetable alkali: after stand- ing an hour or two, pour upon it a solution of the sulphate of copper. If any arsenic is present, the copper will be immediately converted into a beautiful green, and will soon be precipitated. In this way water, or the contents of a stomach supposed to contain arsenic, may be examined. The precipitation of arsenic from any fluid in which it is dis- solved, may also be made by an alkaline hydro-sulphuret. Another process for discovering the presence of arsenic is by combining it with silver. This test has been strongly recommended by Mr. Hume, of Long Acre, under the title of the ammoniaco- nitrate of silver, and is thus prepared: dissolve a few grains, say ten, of the nitrate of silver, called lunar caustic, in about nine or ten times its weight of distilled water; to this add, by a drop at a time, a solution of ammonia, till a precipitate is formed. Con- tinue to add the ammonia, now and then shaking the bottle, till the precipitate shall be taken up, and the solution again become transparent, or nearly so, as the ammonia need not be in great excess, if in any; for, a solution of ammonia being lighter than water, the superfluous portion would remain on the surface of any fluid to which this test liquor may be applied. This simple liquid, if kept in a phial with a glass stopper, will not easily spoil. Its application is very simple: for nothing more is required than to dip a strip of glass into this liquor, and apply it to the solution containing arsenic. Should the material suspected to contain arsenic be of a dry nature, such as a mixture of sugar, meal, bread, meat, or any other kind of food, let some boiling water be poured on the suspected substance, and filtrate the solu- tion through paper. If a bright yellow colour appear on present- ing the nitrate of silver, we may conclude, without reserve, that there is arsenic in the mixture under examination. It is said by Mr. Hume, that this test, by proper management, will prove the existence of white arsenic, even if dissolved in more than four hundred thousand times its weight of water. 104 318 MINERAL POISONS. It is of great importance to employ boiling water in examining the vomited matters and contents of the stomach, in cases of. poisoning by arsenic. By Klaproth's experiments, it appears that one part of the white oxyd requires four hundred parts of water, at 59 Fah. for its solution ; although one hundred parts, which had been boiled on white oxdy of arsenic and cooled down to 59°, retain three grains of, the oxyd in solution. This is contrary to Bergman's opinion, and adopted by many chemical writers, which states, that one part of white oxyd is soluble in fifteen parts of boiling water, and in eighty of cold. For the discovery of the oxymuriate of mercury, the methods almost exclusively resorted to are its precipitation by. means of one of the fixed alkalies, such as the subcarbonate of potash, or the carbonate of soda, or by lime water, which will detach it under the form of an orange coloured, or orange yellow, sediment. Nitrate of tin is a very delicate test, as one drop only produces an imme- diate and copious dark brown precipitation. The matter vomited, and contents of the stomach, should be collected for the purpose of being examined by these tests. The oxymuriate of mercury is white, and may be known by its metallic and peculiarly styptic disagreeable taste. It is soluble in about twenty times its weight of water, but readily so in a small proportion of alcohol. A solution of the oxymuriate of mercury, even although very weak, instantly tarnishes polished silver immersed in it, and gives it a dull pewter colour, not easily removed. The presence of lead may be detected by adding a little sulphuric acid, which will precipitate the mineral in the form of a white powder. Sulphuret of potass, or lime, may also be employed, which will occasion a blackish deposit. If, on the addition of a solution of the sulphate of soda or potash to the suspected fluids, a precipitate occurs, we may conclude they contain lead ; these tests produce a white precipitate in water containing one hundred thousand of its weight of lead, and are considered by Dr. Thomson as the most unequivocal re-agents of that metal we possess. The test for discovering lead in wines (which are sometimes adulterated by the dealers with this mineral) is as follows. Put into a phial 16 grains of sulphuret of lime, prepared in the dry way, and 20 grains of acidulous tartrite of potash or cream of tartar. The phial is then to be filled with distilled water, and shaken for ten minutes, the clear liquor then decanted, and kept in a well- stopped bottle for use. This, when fresh prepared, gives a dark coloured precipitate, if lead is present in wine. When copper is taken into the stomach, the beautiful blue colour produced in its solutions by pure ammonia, is the most decisive and satisfactory evidence that can be required. Such are the tests by which the practitioner will be enabled to form his opinion with tolerable accuracy, (if called upon to appear before a court of judicature,) in most cases of supposed poison by MINERAL POISONS. 819 any mineral. In those which admit of the smallest doubt, we should never fail to attempt a reproduction of the poison in its metallic state, by evaporating the fluid with which it may be supposed to be mixed or held in solution, this being the surest and most accurate. Most other tests are liable to some distrust in cases of supposed poison by arsenic, in as much as it has been demonstrated, that similar results will be obtained from them where it is obvious none of this mineral could be present.* The following mode of reproducing the white oxyd of arsenic is simple and easy, but it is necessary to have a quantity that is tangible. When white arsenic is mixed with carbonaceous or unctuous matter, and then exposed to a red heat in a glass tube closed at the end, it will be sublimed in the form of shining metallic scales; and then exposed to the air under the heat of ignition, will burn with a blue flame, and revert to the common white oxyd.t Before I quit this subject, it may not, however, be amiss to notice a peculiar appearance which is now and then met with in the stomach on dissection, and which, in a case of judicial investi- gation, might be mistaken by the inexperienced practitioner for the effect of some mineral poison. 1 allude to the dissolved or eroded state in which a portion of this organ is at times found on anatomical inspections, and solely occasioned by the gastric juice. Several well authenticated instances have lately been brought forward, proving satisfactorily a solution of the coats of the stomach, either partly or wholly, by this secretion. Such a solu- tion is most frequently met with in those who have been suddenly deprived of life when in full health, a circumstance first noticed by the late Mr. John Hunter; but still the occurrence is notxon- fined to such cases alone; it has been found in those who have died of lingering and .debilitating diseases. J This, however, is in contradiction to the opinion of some practitioners who have written on the subject; for they hardly conceive it possible that the coats of the stomach can be dissolved, in a person labouring under a state of debility at the time of death, by the gastric juice. The fact appears nevertheless incontrovertible. In the case of the young woman at Liverpool, whose body was opened under the supposition of being poisoned, and for which a trial was instituted, a hole of considerable size was discovered in the stomach ; but as no particles of any metallic poison were found, and one of the physicians who was examined as an evidence sug- gested the possibility of the erosion being occasioned by the gastric * See Edinburgh Medical and Physical Dictionary, under the head Arsenic. ----The Trial which took place atLaunceston in Cornwall, before Justice Abbot. t See Marshall on Arsenic. X See Mr. Burn's Observations on Digestion of the Stomach after Death, in the 22d Number of the Edinburgh Medical and Surgical Journal. 820 VEGETABLE POISONS. juice, the prisoner* was acquitted. The case and result gave nso to much medical controversy at the time. Op VEGETABLE POISONS. The vegetable poisons are very numerous, and consist of two classes; the narcotic or stupifying, and the irritant or stimulant. Opium, hyoscyamus, belladonna, digitalis, hemlock, stramonium, aconitum, laurel, cassava-root in its crude state, and several fungi, particularly the small agaric, (denominated by the French cham- pignon, and somewhat resembling mushrooms,) belong to the first class; whereas, colchicum autumnale, hellebore, savin, and colculus indicus, come under the latter class. Those of the first occasion stupor, sleep, and death, and occasionally vomiting, purging, and convulsions ; those of the latter class produce pain, inflammation, and erosion. Many of the former, and particularly the champignons, are often taken through mistake, and prove poisonous. The same happens frequently in the West Indies from using the cassava-root in its crude or unprepared state. In this state, it proves a deadly poison; but by having its acrimonious juice carefully expressed, and being afterward baked into thin cakes, it becomes a whole- some and nutritive kind of bread, much used in most of the islands, as also in Africa. Such is the wonderful effect produced by fire over this plant. The following are the indications by which the mushroom tribe that are of a suspected nature may be distinguished. All those may be regarded as suspicious and of a dangerous quality which grow in marshy shaded places, as thick forests, where the sun has no access ; their substance is softer, more open, more porous, and moister than edible mushrooms. They have besides a more dis- agreeable appearance, and a more or less hilmid and dirty-looking surface. Those also which are dusky and change colour when cut, or which exhale a strong unpleasant odour, or have a gaudy colour, or many very distinct hues, particularly if they have been originally covered by an envelope, and are found in shady places, ought not to be eaten. Those which have short bulbous stalks, or fragments of skin adhering to their surface, or which grow rapidly and corrupt very quickly, should also be rejected. It has generally been supposed that fungi lose their deleterious * Several experiments made by Dr. Bostock, of Liverpool, in consequence of the acquittal of this person, and recorded in the 17th Number of the Edinburgh Journal ought to have some influence in all judicial proceedings where the question of poi- soning is agitated. He found that an animal may be suddenly killed by receiving a metallic poison into the stomach, and yet that the nicest tests may not be able to de- tect any portion of the poison, after death, in the contents of the stomach. A poison may, I think, produce fatal effects, and yet be so completely evacuated by vomiting and purging as to leave no trace, discoverable by chemical analysis, in the contents of the alimentary canal. A case reported in the 26th Number of the Edinburgh Journal, by Dr. Henry, confirms this opinion. VEGETABLE POISONS. 821 properties by being dried; but this is a rule to which there are many exceptions, and which ought therefore to be very cautiously admitted.* The symptoms occasioned by all poisonous substances of the vegetable class are, giddiness, confusion of sight, wildness of the eyes, palpitations, loss of memory and voice, stupor, nausea, vomitingi, great distention of the stomach, universal twitchings and convulsions. The bodies of those who have been destroyed by vegetable poisons generally swell prodigiously, soon become offensive, and covered with livid gangrenous spots. On opening the body, the viscera are usually found in a sound state, but the veins are full and distended, the blood remarkably fluid, and the arteries empty. When nightshade has occasioned death, the intestines arc gene- rally inflated and inflamed, or corroded and gangrenous. In accidents from vegetable poisons we must attempt the imme- diate evacuation of the offending matter; but it is only quickly after the narcotic has been taken, and before it has excited its peculiar symptoms, that an emetic can be advantageously given, as the efforts to vomit might increase the dangerous determination of blood to the head. The most proper emetic will be a strong solution of the sulphate of zinc with tartarized antimony, as advised under the head of Mineral Poisons. Where the patient is in a state of complete insensibility, and incapable of swallow- ing, the emetic solution may be injected into the stomach by means of an elastic gum catheter introduced into the oesophagus from the right nostril. In some cases of poison by opium, or such other powerful sedatives, occasioning great torpor in the stomach, so as to resist the effects of even strong emetics introduced into that organ, a scruple or half a drachm of tartarized antimony dissolved in a little water, and thrown up the intestines in the form of a clyster, has excited vomiting, and at the same time freely evacu- ated the entire alimentary tube. In very obstinate constipations, eight or ten grains of the medicine administered in this way, will commonly be found sufficient to effect the desired purpose. A very singular case is related in the French Dictionary of Medical Sciences, among the Cas Rares, of a man 60 years of age, who swallowed a piece of meat wliich stuck in the oesophagus, near the lower end of the tube. Alarming symptoms followed quickly, but the surgeon could not displace the foreign body. He opened the median vein in the arm, and injected four grains of tartarized antimony dissolved in an ounce of water.. About a minute afterward the patient vomited up the piece of meat. Query, Might not the same plan be adopted with advantage in cases of poison from opium and other powerful narcotics, where the patient is deprived of sensibility or the power of swallowing, * See Traite dea Poisons, &c, par Mons. Orfila. 822 VEGETABLE POISON?. or where there prevails very great torpidity of the stomach ? For the operation in question, a syringe of peculiar construction will be requisite, in order to avoid throwing air into the blood- vessels. To counteract the effects of the poison, the patient should be made to drink, after vomiting has been excited, but not before, if possible, of liquors strongly acidulated with the juice of* lemons, vinegar, or sulphuric acid, giving the preference however to the former. These fluids should be given in small doses, and be re- peated every ten minutes. Contrary to the generally received opinion that vinegar and the vegetable acids are antidotes to the poison of opium, a French writer* concludes, from the results of a series of experiments upon dogs, these acids aggravate the symptoms of poisoning by opium, by dissolving the greater quantity, and thereby increasing its narcotic power, when the poison has not been rejected by vomit- ing; but he found, if the poison has been vomited, that then vinegar and vegetable acids possess the property of diminishing the symptoms of the poison, and even altogether overcoming them. No experiments, however, have been made upon the human body of the like nature, to prove whether a similar result would ensue. It will, however, be most advisable to excite vomiting by a power- ful emetic previous to a use of acids. In urgent cases of persons of a robust and plethoric habit suffer- ing under the influence of opium, opening the jugular vein in pre- ference to any other, will be advisable, as by this means only can the dangerous accumulation of blood in the brain be relieved. Bleeding unnecessarily might however not only retard, but endan- ger the recovery of the patient. For the purpose of rousing the system from a state of torpor. particularly in cases where an immoderate dose of laudanum or opium has been taken, the patient is to be kept in constant motion on his legs, if capable of standing; but if not, by frequently shaking and moving his body. We may at the same time assiduously rub different parts of it with warm salt and other stimulating appli- cations. If these means fail, water of the temperature of about 106 or 110 degrees may be dashed over the patient every now and then : this will sometimes rouse him (at which time we may be enabled to give him a strong emetic or any other proper medicine) when even violently shaking him could not keep him awake. To assist in producing such a degree of irritation as shall coun- teract the soporific quality of the poison, a large blister may be put between the shoulders, and sinapisms to the palms of the hands and soles of the feet. The nostrils may be irritated from time to time with a feather dipped in the liquor vol. cornu cervi. With the like view of obviating the torpor of the stomach, and stimulating the whole system, it would appear advisable to give * See Trait6 des Poisons, &c. par Mons. Orfila. VEGETABLE POISONS. 823 considerable doses of ammonia. Indeed we are informed by a modern writer,* that he has observed where any of the narcotic poisons, particularly opium or hyoscyamus, has been swallowed, and an alarming stupor has continued for many hours, notwith- standing every effort made by the by-standers, a spoonful of a strong solution of ammonia has awakened the patient, and enabled him by words to express the benefit he has received from it; and by a repetition of the medicine, as the stupor returns, the sensibi- lity and irritability have been gradually restored. There can be no doubt but that strong stimuli will be necessary as soon as the effects of the one constituting the disease are ob- served to be subsiding, and the system discovers marks of sinking. In this state we ought therefore not only to employ frictions ex- ternally with salt, as have been directed, and excite the action of the intestinal tube by irritating clysters, but we should give ammo- nia, with as much brandy as can be got down into the stomach, even by tea-spoonsful at a time. Where the cause of death is the cessation of the functions of the lungs, as in cases of suffocation, inflating these organs is generally recommended. Possibly the same mode of treatment might be employed with advantage as an auxiliary for the recovery of persons labouring under the effects of opium and other vegetable poisons. Cases of poisoning by henbane, and other vegetable narcotics, require much the same kind of treatment as those by opium or its preparations. In cases of poisoning by fungi, Mons. Orfila advises that the stomach and bowels should be first cleared as quickly as possible, by a mixture composed of three or four grains of tartarized anti- mony, twenty-four grains of ipecacuanha, and from six drachms to one ounce of sulphate of soda, with a proportionate quantity of water. Castor oil may afterward be given, and likewise purgative clysters. The poison being freely evacuated, spoonsful of a po- tion containing a large dose of aether should then frequently be swallowed, and recourse be had to mucilages and other demulcents, should the patient complain of any pain in the abdomen. If the poison, however, has been taken long before the assistance of the practitioner is required, and inflammation has already come on, then such evacuants would not be proper: bleeding and other an- tiphlogistic means must be resorted to. Vinegar is useful only when the poisonous fungus has been ex- pelled by vomiting; but as long as it remains in the stomach, the reverse is said, by this able writer, to be the case, as the acid dis- solves the poisonous principles, and thereby facilitates its absorp- tion. Muriate of soda (common salt) acts in the same manner as vinegar, and therefore requires to be employed under the same limitations. Sulphuric aether, as it also takes up the poisonous * See Dr. Stone's Treatise on the Diseases of the Stomach. 824 AERIAL POlSONa. part of the fungi, should not be used previous to the evacuation of the stomach, but afterward it will be of great utility. Volatile alkali is more hurtful than salutary, and oil, butter, and milk, are useless in this kind of poison. Several cases of accidental death have of late occurred from taking oxalic acid in a mistake for common purging salts, to which it indeed bears a strong resemblance. This acid is used in various, domestic purposes, particularly for cleaning boot-tops and other articles of leather, and persons using it are too apt to leave it about in a careless manner. The appearances on dissection of those who are destroyed by this poison, are as follow:—the cuticular coat of the oesophagus peels off with the slightest effort; the blood-vessels of the inner coat of the stomach appear as if injected with a carbonaceous sub- stance ; the stomach itself is in some cases so perforated that its contents escape into the cavity of the abdomen, whilst the other part is so tender that it tears with the slightest force : the spleen and other parts contiguous to the stomach, by the acid falling upon them, also become in part destroyed. * From some experiments made by Dr. Thomson,* it appears, that oxalate of lime does not produce any deleterious effect when swallowed; and that a mixture of chalk and water, if taken, by producing oxalate of lime in the stomach where oxalic acid has been previously swallowed, may be regarded as the antidote of that acid when exhibited very soon after the poison has been swallowed. Of AERIAL POISONS. Aerial Poisons are frequently the cause of death, but more frequently by accident than design. The fumes arising from many of the metals in a state of fusion or aerial solution, are extremely pernicious. Those from arsenic cause dryness of the tongue, a sense of suffocation, headach, vomit- ing, &C. and by long exposure, pulmonary consumption is a fre- quent consequence. The fumes from mercury are highly delete- rious: they occasion salivation, tremors, paralysis, and extreme weakness. Those arising from lead occasion asthma, pains in the chest and body, paralysis, &c. The external appearances of persons suffocated by the delete- rious fumes arising from charcoal, coke, or fermenting liquors, (carbonic acid gas,) as well as in consequence of sleeping in unven- tilated apartments, or respiring the foul air of wells, privies, caverns, and mines, are as follow :—the head, face, and neck are swoln ; the eyes are propelled from their sockets; the tongue is protruded at one side of the mouth; the jaws are firmly closed; the face is of a livid, and the lips are of a deep blue colour; the abdomen is * See No. 17, p. 388, of the London Medical Repository. aerial poisons. 825 inflated; the body is insensible to pain, and the person appears to be in a profound sleep. The first symptoms which the patient experiences on inhaling air vitiated with these deleterious fumes are, giddiness, headach, lethargy, fainting, convulsions, and general torpor. Immediately on discovering a person who has been suffocated by any kind of deleterious fume, the windows and doors ought to be thrown open, and the body undressed and exposed freely to cool air, being supported at the same time, in a leaning posture, on a chair: after a little time it must be covered with flannel or blankets, the face be sprinkled with vinegar, and the pit of the stomach with cold water. Vinegar properly diluted with cold water may be introduced into it through a flexible catheter. The legs may also be put into a cold bath ; and as it is a well-known fact, that the recovery of the dogs which are made the subjects of experiment in the Grotto del Cani, is much favoured by their being plunged into a neighbouring lake, possibly a sudden immersion of the whole body in cold water might be of service. After each application of vinegar and water, the skin ought to be rubbed with flannel or a soft brush, the temples and inside of the nostrils be stimulated by applying volatile spirits, and bottles filled with warm water be laid to the soles of the feet, then leaving the person for a few minutes in an undisturbed state. Farther, clysters, consisting of vinegar and water, will be useful; and, on the return of life, an inclination to vomit should be promoted by a feather dipped in oil, while gentle friction is to be continued at intervals. The first symptoms indicating this happy change will be foaming at the mouth and shivering of the whole body, especially after affusions of cold water. Where the means which have been mentioned fail in reani- mating the patient, it will be advisable to employ the united powers of electricity or galvanism: repeated shocks of either of which, particularly the latter, may be passed through the chest. Blood- letting, and the artificial introduction of air into the lungs by means of a pipe or bellows adapted for the purpose, are also to be tried. If these efforts prove successful, so that the patient seems again to breathe, he may then inhale oxygen gas. When he .is able to swallow, the most proper drink will be vinegar and water, or some other acidulated liquor. The body should not be deserted whilst there is any hope, and hope should not be abandoned speedily, as persons have recovered after lying in an insensible state for some days. Pits, wells, deep vaults, &c. should never be entered imme- diately after they are opened. It will be a good precaution first to let down a lighted torch or candle, for where these will not burn, animal life cannot long be sustained. In Russia the common people are frequently deprived of sensa- tion by vapours arising from the following cause:—Persons of rank in that country have double windows to their houses in winter, but 105 826 ANIMAL I0IS0NS. those of the poorer classes are only single. During frosty weather, an incrustation is formed on the inside of those windows, from a condensation of the breath', perspiration, &c. of a number of persons living together in the same room. This mephitic crust is mixed with the noxious fumes of candles, and of the stove with which the chamber is heated. „ When a thaw succeeds, and this plate of ice is converted into water, a deleterious principle is disengaged, which produces effects similar to those arising from the fumes of charcoal. f The method of recovering persons affected by this effluvium is as follows :—They are immediately to be carried out of doors and placed on the snow, .with no other covering than,a shirt and linen drawers. Their temples and the regions of the stomach are then to be well rubbed with snow, and cold water is to be poured down their throats. The friction is to be continued till the livid hue of the skin disappears, and the surface acquires it natural colour. The carburetted hydrogen gas, or fire damp, which is formed in large quantity at the bottom of coal pits, though not properly con- sidered as a poison, is frequently the cause of the death of many of the miners by unexpected explosion. An apparatus has been contrived by Sir Humphrey Davy,* and also by Dr. Murray, for preventing these dreadful effects, by consuming the gas. Or ANIMAL POISONS. Several of these have already been mentioned, and their mode of operation noticed under the heads of Hydrophobia, Syphilis, Cancer, and Contagion. It only therefore remains to treat of the poison of Prussic acid, venomous snakes, the viper, and some pe- culiar kinds of fish, the last of which, in warm climates, is fre- quently attended with fatal consequences. Prussic acid being artificially obtained by the decomposition of animal substances, is generally deemed an animal acid, but it exists in a natural state in bitter almonds, the kernels of apricots, the leaves of laurel and peach blossoms, from which it may be extracted by distillation. It has a sweet taste, smells like bitter almonds, and is highly poisonous in improper doses ; producing the same effects on the animal system as laurel water, such as convulsions resembling epilepsy, paralysis, and death; but, in the dose of two or three drops, is a valuable medicine in the whooping and other convulsive coughs, and has been supposed serviceable in phthisis.—See this disease for the best mode of administering it. Alkaline salts, and other stimulants, are proper remedies for an over-dose of Prussic acid. The spirit of ammonia largely diluted with water should be forced down the throat to the extent of two or three drachms. * See Philosophical Magazine, for December, 1815. ANIMAL POISONS. 827 In many parts of India, persons working in the fields are often bitten by venomous serpents ; and as no puncture is to be observed, very frequently the poor fellows* are apt to attribute the uneasi- ness at first to the pricks of thorns, thistles, &c. A few minutes, however, never fail to exhibit the real state of the case ; the unfor- tunate victim becoming sick, with cold sweats and stupor, and gra- dually sinking, perhaps occasionally convulsed, into the arms of death. Few, we are told, survive more than half an hour, and some die within a few minutes. The symptoms which attend on the introduction of the poison of the rattle-snake into the blood, are :—nausea ; a full, strong, agi- tated pulse ; swelling of the whole body; eyes much suffused with blood ; sometimes copious bloody sweats; and often haemorrhages from the eyes, nose, and ears; the teeth chatter; and the pains and groans of the sufferer indicate approaching dissolution. The poison of this reptile is generally of a yellowish, somewhat greenish colour, which becomes darker in hot weather. During the coupling season it is observed to be more active or virulent than at any other. So deadly are its effects, that it has been known to kill a dog in a few minutes. When a person has been wounded by a venomous snake, the first step to be adopted is, to pass a tight ligature above the injured part (where capable of such an application) so as to prevent the furtherjabsorption of thevirus into the system, and then to evacuate that which has already been admitted by sucking the wound, as practised by the Creek Indians with impunity, and by afterwards promoting discharges of blood and serum from it by means of scarifications, cupping, excision, or the application of caustic. In bites of the rattle-snake, cobra capello, &c. cutting out the wounded part as quickly as possible, and afterwards immersing the limb in warm water so as to encourage the bleeding, together with the internal use of opium to allay irritation and pain, have in some instances proved a successful mode of treatment. Soap-lees, volatile alkali, and the spiritus ammoniae succinatus, and eau de luce, have all been found excellent applications to wounds inflicted by the rattle and other venomous snakes, provided they have been used immediately after the accident. The last remedy is likewise used internally in the East Indies in the propor- tion of a tea-spoonful to a wine-glassful of water, and by being repeated a few times, is said to be attended with a happy effect. The fresh juice of the rattle-snake plantain, applied to a wound of this nature, is said to be a powerful antidote against the poison of this reptile. - We are are told by Captain Carver, in his Travels through North America, that so convinced are the Indians of the power of this antidote, that, for a trifling bribe of spirituous liquor, they will at any time permit a rattle-snake to drive his fangs into their flesh. * See Oriental Field Sports. 828 ANIMAL POISONS. He likewise speaks of salt as an effectual remedy against the bite of this reptile, provided it is applied immediately to the wound in a strong solution. When through neglect the venom has been absorbed, all that can be done is to excite a strong perspiration by means of emetics and powerful sudorifics. This, we are informed by Dr. Barton,* is effected in a violent degree by the juice of the garden-rue, which the Indians in Jersey give in the dose of two table-spoonsful every two hours. Where this is not to be obtained, or ready at hand, we may advise large doses of Venice treacle, with volatile aromatic spirit and aether, which may be frequently repeated, the patient drinking a little warm rum and water after each. The use of oil as a remedy for the bite of serpents, was long ago recommended in the Philosophical Transactions of the Royal Society of London; but from subsequent experience it seems to have received no sanction. Of late, however, its efficacy has been asserted, in cases of the bite of the rattle-snake, by Mr. J. Miller, of Pendleton county, North America. He observes, that in a great number of instances, olive-oil, taken inwardly, in the quantity of a few spoonsful, and applied also to the bitten part, has proved itself fully adequate to the worst of cases, if timely exhibited. In bites of other venomous serpents the same mode of treatment must be adopted as has just been advised. The aristolochia, or snake-wood, taken inwardly in the form of infusion, and applied externally in that of poultice, is much used by the negroes against venomous bites ; as is also a species of grass called chicken-foot, which is commonly mixed up by them with a little salt and spirits, so as to make a cataplasm of a proper consistence. Dr. Bancroft mentions, in his History of Guiana, that the general remedy for the bites of poisonous animals is a cataplasm of the pulp of lemons mixed up with sea-salt, and applied to the wounded part; and this he has frequently found of use when previous scari- fication had been employed. In the sixth volume of the Asiatic Researches, there is a commu- nication on the poison of serpents, by W. Boag, Esq.; and after having taken an extensive view of the ancient methods of effecting a cure thereof, all shaded with doubt and suspicion, he ultimately recommends, as a specific in this dreadful malady, the argenti nitras : a remedy long ago proposed by Fontana, who mixed the venom with this caustic, and found that it was thereby rendered entirely innocent. Mr. Boag supposes that the poison of serpents acts upon the blood by subtracting the oxygen, which it receives from the atmosphere in its passage through the lungs, and upon which its vitality depends. In the second volume of the same work, page 323, we are * See Transactions of the American Philosophical Society, held at Philadelphia, vol. iii. ANIMAL POISONS. 829 favoured with an account by J. Williams, Esq., of the surprising efficacy of a remedy against the deleterious effects of the bite of several snakes, and especially of the cobra dicapello. It consists in the external application to the bitten part, and likwise internal exhibition of liquor ammoniae. We are told that the remedy has been found to put a sudden stop to the baneful effects of the poison of this reptile, and possibly that it may have a similar power in the bites of the rattle-snake, viper, &c. In the bite of a rabid animal, when the patient will not consent to have the wounded part ex- cised, or even after it is cut out, this remedy might be tried. Poisonous serpents are best distinguished from those that are innoxious by an accurate inspection of their teeth ; the poisonous ones, or fangs, being usually of a tubular structure, and furnished with a small hole or slit near the tip : they are rooted into a parti- cular bone, so jointed to the rest of the jaw on each side as to permit the fangs to be raised or depressed at the pleasure of the animal. Above the root of each is a glandular reservoir of poisonous matter, which, in the act of biting, is pressed into the tube, and discharged into the wound through the hole near the tip. In general the fangs are single on each side, but some- times they are double and even triple. There are usually small or young fangs situated at the base of the larger ones, ready to grow up and supply the place of any which may be lost by accident or violence. It may be said that innocent serpents have four rows of teeth in the upper jaw, two on the palate, and the rest on each side, but that poisonous serpents have no outward or side teeth but the fangs. Dr. Russel tells us,* that in serpents not venomous there are three rows of common teeth in the upper jaw; in the poisonous kinds the external row is wanting. The symptoms which attend on a bite of the viper are, acute pain in the wounded part, together with a considerable degree of swelling, that is at first red, but which afterwards becomes livid, and diffuses itself over the neighbouring parts. After a short time the constitutional symptoms make their appearance ; the person becomes faint, the pulse is small and intermitting, nausea and vomiting ensue, the skin has a yellow tinge, and death not unfre- quently is the consequence. The treatment to be adopted in a case of this nature must be pretty similar to that which has been advised for the bite of the rattle-snake, viz. preventing the absorption of the matter into the system by means of a ligature above the part, and destroying the virulence of that which has been introduced into the wound, by scarifications, cupping, excision, caustic, or the application of soap-lees, volatile alkali, or the spiritus ammoniae succinates: employing strong diaphoretics internally at the same time in order to determine to the surface. * See his Account of Indian Serpents. 830 ANIMAL POISONS. As an external application, a poultfce ol quick-lime with oil and * honey has been recommended, as has likewise a cataplasm of garlic. This last has also been given internally with advantage. The bite of the snake or adder of this country is attended with symptoms of a similar nature, but they are not so violent, neither does it often prove fatal. Much the same treatment is to be adopted as in the former cases. Europeans on their first going out to the West Indies and other tropical situations, usually suffer very much from the bite of mos- chetoes. They are a species of gnat, and on whatsoever part these pitch they immediately produce small tumours, which are attended with so high a degree of itching and inflammation that the person cannot refrain from scratching, by a frequent repetition of which he not uncommonly occasions them to ulcerate, particularly if he is of a robust and full habit. To allay the itching and inflammation the parts may be bathed frequenly with a solution of opium in water, or with the liquor plumbi acetatis sufficiently diluted. The liquor ammoniae sub- carbonatis is likewise a good application. It will at the same time be necessary to make use of some cooling laxative, and a spare diet. Where pustules arise on the parts that have been bitten, open- ing them with a lancet about the third day, and letting, out the watery matter, will be proper. Those who suffer much from the bite of these insects should wear gloves and long linen trowsers by day in order to defend the extremities from their attacks; and by night they should sleep under the cover of a net, which being usually made of thin lawn or gauze, is perfectly cool, and effectually shuts them out. The topical applications for the bites of scorpions, centipedes, spiders, and wasps, are the same as advised for those of mos- chetoes. Olive-oil is, however, much made use of also as an ex- ternal application. The lytta vesicatoria or Spanish fly is sometimes administered as a medicine, but when taken internally, either in tincture, infusion, or substance, except in very small doses, is apt to occasion very violent effects, as furor uterinus, involuntary emissions, strangury, bloody urine, violent pain, inflammation and ulceration of the stomach, bowels, and bladder, tenesmus, delirium, convulsions, and death. The remedies to be resorted to are oil, milk, diluent drinks, as gruel and linseed tea, drank plentifully, and thrown up by clys- ter. The same may also be injected into the bladder. As an in- ternal medicine, opium joined with castor oil may be tried in mo- derate doses, frequently repeated. In this country some kinds of fish, such as eels, salmon, herrings, and in peculiar constitutions, muscles, lampreys, and even lobsters, independently of their putrescency, give a singular irritation to the system, and during their digestion in the stomach ANIMAL POISONS. 831 occasion a considerable efflorescence on the skin, sometimes partial, and at other times over the whole body ; sometimes with a considerable febrile disorder, and at other times with very little. In warm climates we however meet very frequently with fish possessed of the most deleterious quality. The barracuda (perca major), king-fish (xiphias), cavallee (scamber), rock-fish (perca marina), smooth bottle-fish (ostracion glabellum), and yellow-bill sprat, are the fish most to be dreaded. The latter possesses a poisonous virus to an extent almost incredible, and has in several instances been known to destroy life in the space of half an hour, by exciting dreadful convulsions. The conger eel, as likewise the large white land-crabs, that feed on the leaves of the manchineel- tree, are also frequently poisonous, and productive of violent cholera. The cause of this deleterious quality in fish has given rise to various conjectures. Some are inclined to think there are two distinct varieties of the same fish ; others impute it to copperas- banks on or near which the fish feed; and others again think that it proceeds from their particular food, which, although not hurtful to them, tinctures them nevertheless with a poison deadly to many other creatures. Of all these conclusions the last seems to be the best grounded, as it is an indisputable fact, attested in innumerable instances, that when the fish is removed off the hook, if the pre- caution is taken to gut it immediately and salt it, it seldom or never creates any disorder, or at most only in a very slight degree, even if of ever so poisonous a nature. Except in the sprat and cavallee, no two distinct varieties of the same fish are to be observed ; and with respect to copperas-banks in the West Indies, Vfctheir existence is a mere supposition, never having been satis- factorily ascertained. Even if the fact was fully established, still it is well known that this substance, or a solution of it, is inevitably fatal to all fish. The circumstance of the alimentary tube being more poisonous than any other part of fish, is certainly a strong confirmation that its deleterious quality is owing to the food; the muscular parts being only slightly tinctured by the chyle and blood conveyed to them, while the greater part of the poison remains in the guts. 1 think we may rest well assured that the poison lies in the intestinal tube, is assimilated with the food of the fish, and circulates with- out any detriment to it; and, moreover, that the longer the fish remains out of water, the more violent the poison becomes; but what really forms the basis of the poison has never been yet accurately ascertained. It is indeed a curious circumstance, that the same fish which is perfectly innocuous at one period, often is highly pernicious at another. Certain and rapid death is almost sure to ensue from eating the yellow-bill sprat; but from a use of most other kinds of poisonous fish the person is seized, after a few hours, with languor, heaviness, and faintness, succeeded by great restlessness, flushings in the face, giddiness in the head, cardialgia, nausea, griping pains in the 832 ANIMAL POISONS. bowels, and a severe vomiting and purging. The burning which was felt at first only in the face and eyes, is at length extended over the whole body, but more particularly the palms of the hands and soles of the feet, and is often succeeded by an eruption or efflorescence, rising up in large bumps similar to bug-bites, or the nettle-rash. The pulse is usually hard and frequent at first, but it soon becomes low and feeble. With the ardour of the skin there is invariably a prickly sensation in the hands when immersed in cold water, which particular symptom may always enable us to decide with confidence on the real nature of the disease. In some cases the neck of the bladder, urethra, and sphincter ani, are likewise affected with ardour, and the patient experiences a difficulty of making water, together with a considerable degree of tenesmus. Some navigators, whose crews were much affected by eating fish of a poisonous nature, have informed us that a swelling of the salivary glands, accompanied by a profuse spitting, was a symptom which very frequently attended. In the few cases which fell under my care during my residence in the West Indies, no such symptom ever was apparent. In the advanced stage of the disease, I observed that the whole surface of the body acquired a deep yellow hue, as in jaundice, and that the urine was likewise highly tinged of the same colour. Even the perspiration gave a deep yellow tinge to the patient's linen. These appearances took place in a very high degree in one or two cases, but more particu- larly so in my own, as I was so unfortunate as once to experience the deleterious effects of a poisonous rock-fish. Where a large quantity of the poison has been taken, or it has , been of so deadly a nature as to prove fatal, the patient generally c< goes off in strong convulsions ; but where the quantity and nature of the poison have not been so powerful as to occasion death, and the violence of the disorder suffers some abatement, the body becomes emaciated, the cuticle peels off in various parts, but more particularly in the palms of the hands and soles of the feet; the hair drops, and acute shooting pains in the articulations of the wrists, knees, and ankles, and sometimes in the cylindrical bones, are felt for a considerable length of time. From the great debility which is induced, it not unfrequently happens that oedematous swellings of the lower extremities ensue. The poison of fish is always attended with much immediate danger; and even when the person does escape its deadly con- sequence, his constitution not uncommonly receives so severe a shock, that, in order to restore its wonted vigour, he will find it necessary to visit a cold climate. The necessity of this step I wofully experienced, and some years elapsed before the desired end was obtained. The intentions of cure in affections of this nature, are, first, to procure a discharge of the poison as quickly as possible ; and, cccondly, to counteract or alleviate the effects that arise from it. ANIMAL POISONS. 833 The first of these intentions is to be answered by giving a smart emetic of tartarized antimony or the sulphate of zinc, together with copious draughts of diluent liquors, as advised under the head of Mineral Poisons. Where the person is of a full plethoric habit, and capable of bearing evacuation, it may also be advisable, after the operation of the vomit, to give some proper purgative, as the oleum ricini, which, as oil is found highly useful of itself in many kinds of poison, may be attended with a double effect. Where there is great irritation of the stomach without much purging, we may substitute the submuriate of mercury,* which, being made into pills, may, from the smallness of bulk, be more likely to be retained. To answer the second intention, we must employ such remedies as have been found to possess a power of counteracting the poison in some degree. Spirituous liquors, and other strong cordials, have long been supposed to have a considerable power of obviating the deleterious effects of poisonous fish. The conclusion is, I think, well grounded, as it has been observed in most cases, that those who have taken a small quantity of rum or brandy after eating fish of this nature, have suffered considerably less than those who neglected that precaution. Dr. Clarke, of Dominica, in a letter to Dr. Simmons, of London,! observes that capsicum (Cayenne pepper) has long ago been known to possess the power of counteracting the poisonous effects of fish. If this was really a fact, we should seldom or never hear of any accident of this nature, as the negroes use a considerable quantity of the fresh capsicum with every article whatever of their food. It is probable, however, that it may be employed with rectified spirit and other stimulants with some advantage. An infusion of the sensitive plant has been mentioned as a remedy from which some benefit may be derived in cases of fish poison. I have made trial of it, but cannot report any thing in its favour. Besides employing stimulants internally, to counteract the effects of the poison, we should attend to the symptoms which are most urgent. If the vomiting and purging continue, although proper evacuations have been premised (which frequently happens) we must then have recourse to opiates, administered by the mouth, as advised under the head of Cholera Morbus, and exhibited in clysters, along with mutton broth, or a solution of starch. Con- t See vol. vii. of Medical Facts and Observations, p. 289. * l.g-Hydrargyri Submuriat.gr.vj.—xij. * 1. Take Submuriate of Mercury, six twelve grains. Extract. Colocynth. C. gr. x. Compound Extract of Col cynth, ten grains. Opii, gr.j. Opium, one grain. Syrup. Simp. q. s. M. Syrup, a sufficiency. Mixthei Fiant pilulae v. pro dos, Let five pills be formed out of the mass f a dose. 106 834 ANIMAL POISONS. siderable doses of opium will be necessary likewise where the patient becomes convulsed, and they will require to be frequently repeated. To allay the heat and dryness of the skin, and determine to the surface of the body, it will be proper, after the irritation of the stomach has ceased, to give small doses of the pulvis ipecac, com- pos, pulvis antimonialis, or pulvis Jacobi, as recommended under the head of Simple Fever, together with a free use of diluent liquors. Where any degree of strangury is present, these last will more immediately be necessary. Under the supposition that the poisonous quality of the fish be- fore noticed is occasioned by their feeding on the moss which grows on copperas-banks, a late writer on this subject* tells us, that in the treatment of such cases during his residence in the West Indies, his object was to decompose the poison; to effect which, he almost entirely depended on alkalies in simple solution with water. He never tried, however, the volatile alkali, although he thinks there can be little doubt of its efficacy in counteracting the poison of fish, whatever the basis of it may be. The pains in the joints are sometimes very obstinate, and yield only to a considerable lapse of time. Covering the parts with flannel, together with the frequent use of a tepid bath, and drink- ing mustard-whey, or a decoction of guaiacum or mezereon, will be the most likely means to afford relief. To obviate the debility which arises in consequence of the dis- ease, and restore vigour to the system, the patient must enter on a course of tonics, as recommended under the head of Dyspepsia; and where these do not prove sufficiently efficacious, he should remove, without further loss of time, to a cold climate. As fish forms a great part of the diet of the inhabitants of the West Indies, and is daily served up at most tables, it may be of some importance to be able to distinguish those of a poisonous nature from such as are wholesome. The surest criterion to judge by is to give the entrails to a dog, cat, or duck, and if after an hour or two no disorder arises, the fish may be eaten with safety. Another method much practised, however, is to put a silver spoon for some time into the water in which the fish is boiling, and if upon taking out the spoon it appears unsullied, the fish is sup- posed to be safe ; but if the colour be at all changed, it is then judged unwholesome. This test should never be depended upon. From the observations of fishermen, it appears that fish which have no scales are most apt to prove poisonous. Those of uncom- mon magnitude are regarded by them as highly suspicious. To obviate the poisonous effects of muscles, lobsters, oysters, eels, &c, a smart emetic should be administered as quickly as possible, and then the patient may take the acetous acid, and likewise milk. See Dr. Chisholm's Communication, No. 16 of the Edinburgh Medical Journal, SUSPENDED ANIMATION. 835 Of SUSPENDED ANIMATION and RESUSCITATION. In consequence of drowning, or a long exposure to the action of severe cold, and also of suffocation and strangulation, a conside- rable check is often given to the principle of life, without wholly extinguishing it. When it happens from the first of these causes, the circulation becomes gradually more feeble and slow, and much anxiety is felt about the praecordia; to relieve which the person attempts to rise to the surface of the water ; he then discharges a quantity of air from the lungs, and receives into them a very small portion of water, when he again sinks. After struggling in this manner for some short time, cunrularrc spasms arise, the organs of respiration cease to act, and he at last expires ; soon after which the skin becomes of a purple or blue cast, particularly about the face and neck, and the body sinks. It has been supposed, and the opinion is indeed still very general among the common people, that in the act of drowning the water enters the lungs and completely fills them. Experience, however, has shown, that unless the body lies so long in the water as to have its living principle entirely destroyed, the quantity of fluid present in the lungs is inconsiderable ; for upon drowning kittens, puppies, &c. in ink, or other coloured liquors, and afterwards examining these viscera, it has been observed that very little of the coloured liquor has gained admittance to them. The circumstance may readily be accounted for by recollecting that the muscles which form the opening into the trachea are exquisitely sensible, and contract violently upon the least irritation, as we frequently expe- rience when any part of the food or drink happens to come in con- tact with them. In those cases where a person has been long exposed to the ac- tion of cold in a severe degree, and is suffering from great numb- ness, and a sort of intoxication, he is apt to fall quickly asleep, and becomes quite insensible. Occasionally he comes to himself with- out assistance, but more frequently he falls a sacrifice. When a person dies from suffocation, the symptoms are nearly the same as in apoplexy.—See Aerial Poisons. The phenomena which attend on strangulation are, convulsive paroxysms, superadded to the apoplectic symptoms. Livid and dark-brown spots on the face, with great rigidity and coldness of the body, a glassy appearance of the eyes, and a flaccid state of the skin, denote a perfect extinction of life: but the only certain sign is actual putrefaction ; and therefore in every case where this symptom is not present, and where we are unacquainted with the length of time the body may have been under water, every possible means should be employed immediately upon its being found for restoring it to life, as the noble machine may be stopped, and the spring nevertheless still retain, in some degree, its elastic vigour. Dissections of those who have died by drowning, show that an 336 SUSPENDED ANIMATION. accumulation of blood in the venous system forms the great morbid change which takes place in accidents of this nature. The lungs are in a state of collapse, and the accumulation of blood is confined to the vena cava, the heart, and the parts of the venous system. In some cases the stomach is found to contain a small quantity of water; in others, none is to be perceived. From the muscles of the trachea having lost the principle of life, upon which the power of muscular contraction depends, they become relaxed, the water enters the wind-pipe. In all instances, the extepal surface of the brain appears of a highly florid colour, without any great disten- tion of vessels, or marks of effusion. It bas been supposed, how- ever, by many, that persons who die by drowning, suffer from the intervention of apoplexy. After a recovery from apoplexy, the person is generally paralytic, whereas no such event follows the recovery from a suspension of life by drowning. In both hanging and drowning, the proximate cause appears to be the stoppage of air to the lungs, which the following experiment, made some years ago by an eminent medical professor at Edinburgh, clearly con- firms. A dog was suspended by the neck wi4h a cord, an opening having been previously made in the wind-pipe below the place where the cord was applied, so as to admit air into the lungs. In this state he was allowed to hang three quarters of an hour, during which time the circulation and breathing went on.. He was then cut down, without appearing to have suffered much from the ex- periment. The cord was now shifted below the opening into the wind-pipe, so as to prevent the ingress of air to the lungs; and the animal being again suspended, he was completely dead in a few minutes. The appearances exhibited on dissection, in cases of strangula- tion and suffocation, are pretty similar to those in drowning, except the absence of water in the lungs and stomach: and that in these instances there is always a greater turgescence in the vessels of the pia mater. The following are the means to be employed for the recovery of persons recently drowned. As soon as the body is taken out of the water, it is to be speedily conveyed in men's arms, or placed upon a door, or in a cart upon straw, if the distance is considerable, to the nearest house, where it is quickly to be stripped of the wet clothes ; to be wiped per- fectly dry; and then to be laid between warm blankets, spread upon a mattress or a low table, and on the right side in preference to the left, in order that the passage of the blood from the heart may be favoured by the position. The head is at the same time to be co- vered with a woollen cap, being properly elevated with pillows, and bags filled with warm sand, or bricks heated and wrapped in flan- nel, are to be applied to the feet. The doors and windows of the apartment are to be thrown open, in order that the cool air may be freely admitted, and no persons but such as are necessary to give due assistance, should be allowed to enter it. SUSPENDED ANIMATION. 837 Having taken these steps, we should next endeavour to expand the lungs, and make them, if possible, reassume their office. When not furnished with a flexible tube made of elastic gum, and of a sufficient length, or with the bellows invented by Mr. Hunter for this express purpose (which is of such a construction, that, by one ac- tion, fresh air is thrown ifcfc.o the lungs, and by another it is thrown out again, so as to imitate or produce artificial breathing,) we must be content with blowing in air, by means of a common pair : or by inserting a pipe into one nostril, compressing the other, shutting the person's mouth at the same time, and then blowing through the pipe with a considerable degree of force. By any of these means we may be able to inflate the lungs. At the same time that the lungs are inflated, we should rub every part of the body with warm flannel cloths. On all occasions it will be the best way to divide the assistants into two sets ; the one being employed in endeavouring to restore the heat of the body; the other, in instituting an artificial breathing in the manner just pointed out. Should the frictions not be attended with any effect, w6 ought to apply flannel cloths, wrung out in very hot water, over the heart and thorax, or we may put the person into a warm bath. A high degree of heat will not be necessary ; a moderate degree will be sufficient. If the weather be under the freezing point, and the body, when stripped, feel cold, and nearly in the same condition with one that is frozen, it will be necessary at first to rub it well with snow, or wash it with cold water; the sudden application of heat in such cases having been found very per- nicious. In a short time, however, warmth must be gradually applied. To assist in rousing the vital principle, it has been customary to apply various stimulating matters, such as common salt, and recti- fied, and also volatile spirits, to different parts of the body; but as the skin loses its sensibility in proportion as it is deprived of heat, and does not recover it again until the natural degree of warmth be restored, it is obvious that previous to the restoration of heat, all such applications are useless. Rectified spirits evaporate fast, and thereby, instead of increasing warmth, as they are expected to do, carry off a part of the heat from the body. Volatile spirits are liable to the same objections, and are, besides, distressing to the eyes of the assistants. Common salt quickly frets the skin, and has, in some cases, produced sores which were difficult to heal after recovery. When there is reason to think the skin has, in some degree, recovered its sensibility, the wrists, ancles, temples, and parts over the stomach and heart, may be rubbed with a little of the linimentum ammoniae subcarbonatis, which will evaporate but slowly, and produce no cold in being rubbed in. In cases of suspended animation, it has likewise been usual to stimulate the stomach and intestines; the former by means of some moderately warm liquor, such as negus highly spiced, introduced into the 838 SUSPENDED ANIMATION. organ through a flexible tube, and the latter by means of injec- tions. Some time ago it was the practise to employ the smoke of to- bacco ; but this, instead of answering our wishes, would prove injurious, by further depressing the vital principle. Instead of it, we may recommend a clyster, consisting 1. r\. Magnesiae, 3j. Aq. Purae, f. ?vss. Spirit. Cinnam. f. 3"j' Liquor. Ammon. f. 3j- ft. Mistura^ cujus sumat cochl. larg. ij. vel iij. pro re nata. % 2. ft Elect. Senna?, Zij. Potassae Supertart. 3y- Pulv. Jalapae, 3ss. Syrup. Rosae, q. s. M. ft. Electuarium, cujus sumataegramolem nucis moschata hora somni, vel pro re nata. 1. Take Magnesia, one drachm. Ture Water, five ounces and a half. Spirit of Cinnamon, three. drachms. Solution of Ammonia, one drachm. Mix them, and take two or three table- spoonsful for a dose, as the occasion may require. X 2. Take Electuary of Senna, two ounces. Supertartrate of Potass, two drachms. Powder of Jalap, half a drachm. Syrup of Roses, a sufficiency. Mix them, and of this electuary the patient may take the bulk of a nutmeg, at bed- time, or occasionally. 841 DISEASES OF PREGNANCY. principally of aloes (such as Anderson's) are too generally used by pregnant women for this purpose : but they are highly improper, as being of too stimulating a nature, and very apt to occasion haemorrhages and the piles. In troublesome piles, which are externally seated, the best application is leeches, and the' irrita- tion may afterwards be lessened by preparations of the plumbi superacetas. Ten grains of this, dissolved in four ounces of rose water, form a good lotion, with which the parts may be washed frequently. If necessary, a little of the vinous tincture of opium may be added. Diarrhoea,—If diarrhoea arises in pregnant women, it should be treated just as at any other time; (see this disease;) and after the stomach and intestines are cleared, astringents may be used, if there is no great degree of fever. If fever is present, that must be attended to chiefly, and be first removed. Suppression of Urine.—When a suppression of urine takes place, which is apt to happen in the advanced stage of pregnancy, besides making use of emollient fomentations, clysters, and gentle purga- tive medicines, such as the oleum ricini, the patient drinking plen- tifully at the same time of diluent liquors, it will be necessary to have recourse to chirurgical assistance, by drawing it off by means of a catheter, morning and evening. Retroverted Uterus.—It sometimes happens that a retroversion of the uterus ensues, in which case it becomes misplaced down- wards and backwards, because the os uteri is tied forwards to the meatus urinarius, and there is no communication behind by which it is held to the rectum; but anteriorly it is connected with the neck of the bladder by close cellular substance; therefore what- ever raises the bladder will raise the cervex uteri, and what raises this, must at the same time depress the fundus: so that in a retro- version of the uterus, the urethra is drawn up close behind the symphysis pubis; and in the case now under consideration, the bladder rises and draws up the os uteri with it. The only period of pregnancy at which a retroversion of the uterus is apt to arise is between the end of the third and fourth months; for in the early months of pregnancy, the uterus in length, from the fundus to the cervex, is not so great as to fill the space between the sacrum and the neck of the bladder, and cannot, for that reason, produce suppression. This applies to all situations of the uterus in unimpregnated women, and women who are with child, till the close of the fourth month of pregnancy ; after which, the uterus cannot be made to go down into the pelvis. When the uterus has once fairly ascended into the abdomen, it is impossible for it to return into the pelvis until its volume has been diminished by delivery or abortion. In most of these cases the suppression of urine is the only material object to be attended to; for the uterus being retroverted, the woman cannot make water; therefore it must be drawn off by the catheter. If necessary, this operation is to be repeated twice a DISEASES OP PREGNANCY. 845 day till the uterus, by a gradual enlargement, recovers its natural situation, which will be preferable to any interference of the attend- ant to reduce it. Where it is impossible for him to attend twice a day for the purpose of drawing off the water, the reduction may possibly be effected by the patient placing herself on her hands and knees, and then passing two fingers of one hand into the vagina, and a finger of the other into the rectum, by which means it is possible sometimes to succeed. Where the event is left to time, the uterus is sure to recover its proper situation ; for which reason it is preferable to leave it. In passing the catheter in cases of retroverted uterus, it will be necessary to attend to its curve, which curve is given by holding the instrument in one hand, and pressing the thumb on the other hand on one side, while it is gently drawn through the hand. - The point of the catheter must be dexterously introduced close behind * the pubes ; for if some dexterity is not used it frequently will not pass into the bladder. Troublesome Itchings.—Where a severe itching about the parts of generation attends on pregnancy, it will be proper to keep the woman's body perfectly open with some cooling laxative, and to wash the parts three or four times a day with a solution of lead, such as the liquor plumbi acetatis dilutus; if much inflammation accompanies the itching, topical bleeding may be requisite. (Edematous Swellings.—The swellings of the feet, ankles, and private parts, which arise in the last stage of pregnancy, are occa- sioned by the pressure made by the womb, which now prevents the free return of the blood from the lower extremities. Gravid women are usually free from these complaints in the morning, but towards night they frequently suffer much from them. Slight scarifications with the edge of a lancet, to discharge the stagnated fluid, with the after application of flannels wrung out in a warm infusion of emollient herbs, have been employed in cases of great distention. In general, however, it will only be necessary that the patient does not keep her feet in a pendant position for any length of time. Cramp.—Cramps of the legs and thighs are to be relieved by rubbing the parts with cold vinegar, with camphor dissolved in oil, or the liniments here* advised, the person wearing stockings in bed. At an advanced period of pregnancy they are only to be relieved by labour removing the cause. Where the stomach is affected with spasms, proper doses of aether and tincture of opium, with the other means advised under the head of Hysteria, in cramps of that organ, will afford the greatest benefit. In such cases the patient must carefully avoid e\ery kind of food that is apt to prove * 3. fy Spirit. Camphorae, f. ^i. * 3. Take Camphorated Spirit, one ounce. ------VEther. Sulph. Spirit of Sulphuric .Ether. Tinct. Opii, aa f. ^ss. M. Tincture of Opium, of each half an ounce. ft. Linimentunn [Mix them for a liniment. S4B DISEASE* OF fREGAA.VCY. flatulent or hard of digestion, and she must keep her body perfectly" open. Inability of Sleeping, and Restlessness.—Inquietude and inability to sleep prove troublesome complaints towards the latter period of pregnancy, the patient being obliged to rise frequently throughout the course of the night, in order to expose herself to the influence of cool air. Nothing affords so great relief in cases of this hature as bleeding in small quantities, with the occasional use of some cooling laxative medicine. Opiates are never attended with ad- vantage in such conditions. Varicose Veins.—The veins of the legs, thighs, and belly often become varicose in the last stage of pregnancy, and sometimes put on an alarming appearance from their great enlargement and distention. No bad consequences have, however, been observed to attend such a condition; and the only thing necessary to be done, is to empty the vascular system by moderate bleeding, gentle purging, and a spare diet. Should the vein of any particular part become so distended as to prove troublesome, it may be advisable to apply a bandage of a moderate tightness, so as to give the ne- cessary support to it. Jaundice.—In some instances the woman is affected with a pain in her side, and excessive sickness at the stomach and retchings, the skin assuming a deep yellow colour. It is only under these circumstances that the complaint proves distressing, and it is usually occasioned by the formation of one or more gall-stones, and the obstruction which they oppose to the usual and regular passage of the bile. The means most conducive to relieve the woman from this degree of the complaint are blood-letting, warm fomentations to the painful part, and large doses of opium, with such laxatives as shall counteract the effects of the opiates. Jaundice or any other bilious affection prevailing during a state of pregnancy from the pressure of the uterus on the gall- bladder or ducts, is to be obviated by keeping the body open with some gentle laxative, such as pills composed of rhubarb and soap. Incontinency of Urine.—This is a very disagreeable complaint, as it keeps the woman constantly in an uncomfortable state. It is to be removed only by delivery, but may be moderated by a fre- quent horizontal posture. Its bad effects may be prevented by a scrupulous attention to cleanliness, and the use of a thick compress of linen, or a sponge of considerable size, properly fastened. Over-distenton of the Abdominal Skin.—In the latter months of pregnancy the integuments of the abdomen will sometimes become cracked and sore, the skin seeming to suffer from over-distention. In this case nothing is so effectual as a frequent use of warm oil by friction, and to give it somewhat of a medicated appearance a little camphor may be added. False Pains.—Pains somewhat resembling those of labour, and known by the name of false pains, are apt to come on at an ad- CONVULSIONS 847 vanced stage of pregnancy, and often to occasion an unnecessary alarm. In such cases confinement in a horizontal position, bleed- ing if plethoric, laxative medicines if costive, and administering small and frequent doses of some opiate until the patient finds ease, will be necessary. CONVULSIONS. Convulsions may occur either during pregnancy or labour, and are of different kinds, requiring opposite treatment. One species is the consequence of great exhaustion from a tedious labour, ex- cessive fatigue, or profuse haemorrhage. This makes its attack without much warning, and generally alternates with deliquium, or great feeling of depression of strength and debility; the muscles about the face and chest are chiefly affected, and the pulse is small, frequent, and compressible, the face pale, the eyes sunk, the extre- mities cold. The fits succeed each other pretty quickly, and very soon terminate in a fatal syncope. Apparently it was this species . of convulsion that destroyed her Royal Highness the Princess Charlotte of Wales. In all cases of this nature, it should be our object to check the further operation of the exciting cause, by restraining haemorrhage if present, or preventing every kind of exertion, and thus husband the strength which remains, or recruit it by cordials. Opiates will be of infinite service in conjunction with aether and camphor. De- livery is usually necessary. Hysterical convulsions are more common during gestation than during labour. Here it may therefore only be necessary to add to what has already been said under the head of Hysteria, that, if they do not speedily yield to antispasmodics, venesection had better be resorted to; and if that fails, we should, if possible, deliver the woman. The species of puerperal convulsions most generally met with bears some likeness to epileptic fits ; and it is only by being aware of the different degree of violence attending each, that at first sight we can distinguish them. A fit of puerperal convulsion is much more severe than one of epilepsy, and a paroxysm of the former is usually so violent, that a woman, who, when in health was by no means strong, has been so convulsed as to shake the whole room, and to resist the coercive powers of many attendants. No force indeed can restrain a woman when in these convulsions. The distortion of her countenance is beyond conception: in regard to deformity of countenance, nothing bears any resemblance to the progress of this disease ; the rapidity with which the eyes open and shut, and the sudden twirlings of the mouth, are inconceivable and frightful. Puerperal convulsions seldom happen before the sixth month, but may occur at any time between this period and the completion of labour. They may arise as the first symptom of labour, or after 843 CONVULSIONS. the laboui is finished. This species of convulsion depends on Ihf state of the uterus, and has been observed to arise oftener during the first pregnancy than in any after one, particularly where the Woman is unmarried. The characteristics of puerperal convulsion are as follow :—The paroxysms occur periodically like labour pains, so that there is a considerable space between them at first, but afienvards they become more frequent. They not only occur with the labour pains, but in the intervals between ; and whether there have been labour pains or not before they come on, we shall usually find the os uteri somewhat dilated, and it is sure to become still more so from the continuance of these convulsions. At length, if the woman is not relieved, and the convulsions continue without destroying life, the child is actually expelled by the contraction of the uterus, which power is capable of expelling it even after death. The immediate symptoms are somewhat similar to those of the epileptic paroxysm. The woman suddenly loses all sensation, and stretches herself out; the muscles then become extremely rigid, and are speedily afterwards thrown into violent convulsions, the face is distorted, the eyes are protruded, she gnashes her teeth, and foams at the mouth. After the paroxysm is over, she remains in a co- matose state, and has stertorous breathing, similar to what takes place in apoplexy. At length, except in very aggravated cases, she slowly comes to herself, but without being conscious that she has been in a fit. After a longer or shorter interval a fresh attack takes place in the manner just described, for it rarely happens that there is not a repetition of the paroxysm in all cases of true puer- peral convulsion. During the fit the skin becomes dark and purple, proving that the circulation through the lungs is not free, which purple colour leaves the woman after the fit is over. By the intro- duction of-the hand into the uterus when these convulsions have come on, it has been ascertained that this organ is contracted, but with a tremulous undetermined sort of force, perfectly different from what takes place at any other time. There are two cases of puerperal convulsion which are very dis- tinct : one is a convulsion dependant on an irritable or excitable state of the nervous system ; the other on a fulness of the vessels of the brain, or perhaps a slight extravasation from the vessels there- of. When puerperal convulsion arises from the latter cause, it is always preceded by some symptoms, which, if watched, will enable us to relieve, if the patient applies in time, but which is rarely done ; and if these symptoms are neglected, at some period or another convulsions will follow. In a woman strongly disposed to this complaint from such a cause there will be a sense of great fulness in the head, giddiness in the advanced periods of pregnancy, drowsiness, and a sensation of weight when she stoops forward, imperfect vision, and atoms floating before the eyes. These symptoms strongly denote fulness of the vessels of the head, and if allowed to continue, may lead to extravasation or puerperal CUN'VL 840 'Jdnvulsion ; but if early attended to may be removed, and prema- ture labour prevented. Under such circumstances the first step to be adopted is, to draw ten or twelve ounces of blood from the anil) repeating the operation the next day or so if no alleviation takes place. After the first bleeding the bowels should be opened by some mild purgative, such as a solution of any of the neutral salts and manna, which may be repeated every third or fourth morning Until the plethora is removed. With these means the patient ought to abstain from all solid food, wine, Sic. When these precautionary means have not been adopted, and" puerperal convulsions have ensued, we are, on being called in, 16 open a vein immediately, particularly the jugular, or even the tem- poral artery, and to draw off blood in a considerable quantity, being regulated therein by the appearance of the person and her habit of body. From twelve, to twenty ounces may be the extent of the first bleeding. If the disease goes on, and the os uteri does not admit of delivery from its not being dilated, the convulsions not abated or gone off, and the pulse in such a state as to admit of it, we should bleed again and again. Sixty ounces of blood have been drawn off in the course of the twenty-four hours under these circumstances, and with a happy effect. Women in such a state admit of divided bleedings very largely. On examining the bodies of women who have died of puerperal convulsions, the vessels of the brain are always found enormously turgid; in some cases blood is extravasated, and the heart is often perceived com- pletely empty.* After the first bleeding a blister of considerable size should he applied to the neck, or between the shoulders; the head be shaved and cooled with evaporating lotions ; and, if judged necessary, blood be drawn from the temples by several leeches. The next point to be attended to is, to get the bowels to act as quickly as possible, and this will be effected by throwing up a smart or active clyster, and then giving a strong solution of some neutral salt, as magnesias, Sulphas, potassae tartras, or soda tartarizata,in an infusion of senna, as soon as the patient becomes capable of swallowing. The bladder is also to be emptied by a catheter if necessary. If it is a case of convulsion depending upon irritation, we may likewise bleed, but we must proportion the quantity accordingly* Eight or ten ounces of blood will be sufficient, and where more may appear necessary, it will be best to draw the remainder by applymg leeches to the temples. In cases dependant on irritation* opium will be very proper, and it ought to be given to the highest possible extent, the form of a clyster being that to which we ought to give a preference. We are at the same time not to neglect the bowels, which should be kept perfectly open. Dr. Denman pro- poses that a clyster containing six grains of opium should be ad- ministered, under the supposition, that by putting a stop to the con- • Sfie cases reported bv Mr. Chevalier, in the Medico-ChnHirglcal Transactions, 108 8oO I'ONvlJLSlOSa. tractions of the uterus, the convulsive contractions in other parLs of the body may also cease. From the tendency of opium to affect the brain, some practitioners have strongly objected to its use in puerperal convulsions. By throwing it into the intestines it will not, however, be so likely to affect the sensorium as when received into the stomach. Some physicians recommend the use of a warm bath, while others again disapprove of it. The pediluvium, or the application to the soles of the feet of bottles filled with warm water, may at any rate be proper. The warm bath is strongly recommended by Dr. Denman among the means for preventing convulsions in women previous to, or during, their confinement. He states, that from its occasional use women will often find much benefit, and that it is one of the prin- cipal means which professional assistance is capable of affording for preventing puerperal convulsions, and for insuring an undis- turbed labour. He also recommends a warm bath in labours rendered complex by convulsions, and this upon a long and exten- sive experience. He says, that when convulsions have continued or increased, notwithstanding copious bleeding and the use of all other rational means, the patient may be put into the warm bath, in which she may remain a considerable time if the convulsions are suspended while she is in it. In instances where a warm bath could not be procured, or while it was preparing, he has directed flannels wrung out of hot water to be applied over the whole of the abdomen. Dr. Denman* mentions, that he has seen the patient relieved from that state of irritation immediately preceding the convulsion by dipping feathers in cold water, and dashing it with force over the woman's face, as this roused her, and interrupted the progress of the fit. Where the further application of cold may be deemed necessary, and appear advisable, we may throw water over the patient's head, bringing this over the side of the bed, and holding an empty pail underneath to receive it. It should be done on the approach of the fit, which may be ascertained by attending to the vibrations of the intercostal muscles. In all cases of puerperal convulsion, after having paid due atten- tion to the lessening of the cause which has given rise to it, we should uniformly exert our best endeavours to deliver the woman as expeditiously as possible, where it is practicable without violence. When we find that the os uteri begins to relax and open, and which may take place although there be no labour pains, we must introduce the hand slowly, dilate it, and deliver the child. If convulsions take place after the delivery of the child for the first time, then the placenta, if it have not come away, ought im- mediately to be extracted; and if the pulse does not expressly forbid it, a vein is to be opened, and afterwards the bowels purged. * See his Introduction to the Practice of Midwifery. ABORTIONS. O T 1 oj J TV here convulsions continue after the uterus is emptied of its contents, all that we can do is to keep the brain unloaded, the bowels open, and the irritability of the system counteracted by opium, joined with other antispasmodics, such as musk, camphor, and aether. Where the disorder continues many hours, we may apply a large blister to the head, and if benefit is not obtained by the next day, one may also be applied to the inside of each leg. These, by exciting an irritation upon a part distant from the seat of the disease, may tend to diminish the diseased action, and there- by afford some relief. To prevent puerperal convulsions from supervening, as they are in every instance to be considered as highly dangerous, par- ticularly at an advanced stage of pregnancy, it will be prudent, in robust and plethoric habits, to pay an early attention to a use of the lancet during the progress of pregnancy, by drawing off a suffi- cient quantity of blood at different periods; taking care, at the same time, and particularly near the termination of pregnancy, to keep the body open by cooling purgatives. In women of an irritable constitution, all exciting causes should be carefully avoided, and the habit be strengthened as much as possible, and thereby be ren- dered less susceptible of disagreeable or ready impressions. ABORTIONS. By abortion is to be understood the expulsion of the contents of the gravid uterus at a period of gestation so early as to render it impossible for the foetus to live. It is an accident or disease of frequent occurrence, which is always attended with disagreeable circumstances; and which, although it seldom proves immedi- ately fatal, may still be productive of much mischief at a future period. Abortions may happen at any period of pregnancy, but they take place most frequently about the third or fourth month. From the end of the third month to the period of quickening there is a greater susceptibility in the uterus to have its action in- terrupted than either before or afterwards, which is the reason of more miscarriages happening at that time than at any other, and points out the necessity of redoubling our Vigilance in watching and guarding against the operation of any of the causes from the tenth to the sixteenth week that may be likely to excite abortion. When a woman happens to part with her burden before the seventh month, she is said to have miscarried or aborted; but when delivered of it after this time, the term labour is usually applied. Children born at the end of the seventh month are seldom reared ; and when they are, they usually prove small and weakly : but those of eight months are frequently preserved by bestowing proper care on them. 053 AJBjQRT.10.XS; In consequence of an imperfect conception it sometimes happens that moles or substances of a fleshy nature (which upon being cut open contain not the smallest vestige of a child) are formed in the uterus; and these at length becoming detached, give rise to a con- siderable degree of hasmorrhage. As some women menstruate during the first months of pregnancy, it will be necessary to distinguish between an approaching mis- carriage and a visitation of the menses, which may readily be done by inquiring whether or not the haemorrhage has proceeded from any evident cause, and whether it flows gently or is accom- panied with unusual pains. The former generally arises from some fright, surprise, or accident, and does not flow gently and regularly, but bursts out of a sudden, and again stops all at once, and is also attended with severe pains in the back, and bottom of the belly; whereas the latter is marked with no such occurrences. Voluptuous women, who are of a plethoric habit, as well as those who are of a weak and irritable frame, are most apt to miscarry; but accidents of this nature sometimes occur from a general de- fective constitution, or from a malconformation of the sexual organs. The causes which give rise to floodings during a state of preg- nancy are, violent exertions of strength, lifting some heavy weight, severe exercise, as dancing or much walking, the fatiguing dissipa- tions of fashionable life, sudden surprises and frights, violent fits of passion, great uneasiness of mind, uncommon longings, over- fulness of blood, partial spasmodic action about the os uteri, aloetic purges, profuse evacuations, excessive venery, former miscarriages, weakness in the parts immediately concerned, a diseased state of the uterus, general debility of the system, external injuries, as blows and bruises, strong acrid medicines, such as savin and helle- bore, which are often taken for the express purpose of exciting abortion, and the death of the child. A pregnant woman may be attacked with a flow of blood from the womb in consequence of any cause which is capable of sepa- rating a part of the ovum from the corresponding part of the uterus. The vessels which before passed straight from its internal surface into the membranes or placenta, and connected them together, now open, so as to allow the blood to escape between them, and to flow externally. This separation and consequent rupture may arise from any of the various causes just recited, but in a few in- stances it is occasioned by an implantation of a part of the placenta immediately over the os uteri, which cause is by far the most im- portant, because it is the most dangerous, and the least likely to find a spontaneous remedy. Abortions are sometimes induced by what is termed a retrover- sion of the uterus, in which the fundus uteri is retroverted and pressed down between the rectum and the vagina. This rarely occurs, however, beyond the first or second month of gestation, and is generally preceded by a difficulty in making water, and a A&QK,TIQNS# 853 consequent tumour of the bladder; a violent pain about the peri- naeum is thus caused, and a miscarriage is liable to follow. Abortions are often preceded by a general sense of coldness, flaccidity of the breasts, slight pains in the loins and lower region of the belly, and sometimes with a slight febrile state of the system, In plethoric habits, and where abortion proceeds from over-action or haemorrhagic action of the uterine vessels, the fever is idiopa- thic, and precedes the haemorrhage. After a short continuance of these symptoms, a slight discharge of blood ensues, coming away sometimes in clots, and at others gushing out in a florid stream, then stopping perhaps for a short time, and again returning vio-» lently. Sometimes nothing but coagulum can be perceived, that is so firm, and the globules and lymph so disposed, as to make it as- sume, more especially if it has been retained for any time about the uterus or vagina, a streaked or fibrous appearance, which often gives rise to a supposition that it is an organized substance. When the contents of the uterus are expelled, a bloody discharge con- tinues for a few hours, and is then succeeded by a serous fluid. When the pregnancy is advanced beyond the third month, and abortion is likely to ensue, we have much bearing down, together with a derangement of the stomach, causing sickness and faintness, and we have likewise a most rapid discharge, owing to the increa- sed size of the vessels. In this stage the membranes often give way, and the foetus escapes with the liquor amnii, whilst the rest of the ovum is retained for some hours, or even days, when it is at length expelled with coagulated blood. In some instances the whole ovum comes away entire. After the expulsion the haemor- rhage ceases, and is succeeded by a discharge somewhat resembling the lochia. With regard to the symptoms and duration of abortion, there is a great diversity in different instances. In some cases, the pains are very severe and long continued; in others, short and trifling. Sometimes the haemorrhage is profuse and alarming; at other times, although circumstances may not be apparently very different, it is moderate or inconsiderable. Often the sympathetic effects of the stomach and bow els are scarcely productive of inconvenience ; whilst in the greater number of instances they are very prominent symptoms. As there is a diversity in the symptoms, so there is also in the.duration of abortion; for, whilst a few hours in many, and not above three days in the majority of cases, is sufficient to complete the process, we meet with other instances in which it is threatened for a long time, and possibly some weeks elapse before the expulsion takes place. Floodings are more or less dangerous according to the stage of pregnancy in which they happen. The farther a woman is advanced therein, the greater will be the risk, especially if unaccompanied by labour pains, as the mouths of the vessels which pour out the blood arc much enlarged during the last stage of pregnancy, and oj' m ABORTIONS. course a vast quantity will be discharged in a short space of time. Although miscarriages before the fifth month are seldom attended with immediate danger, the loss of blood being usually small, they nevertheless frequently lay the foundation of many grievous ail- ments by happening repeatedly. Some women are visited by habitual miscarriages, and observe a stated period for several suc- cessive pregnancies, which is more usually about the third month than at any other time. The danger of abortion is to be estimated by considering the previous state of health and habit of the patient, and by attending to the violence of the discharge, the duration of the complaint, the difficulty of checking it, the disposition to expulsion which accom- panies it, the period of gestation at which it is threatened, the fre- quency of its occurrence, and its combination with spasmodic affec- tions or convulsions. Previous to my pointing out the best means for checking an abortion, and the method of conducting the woman through it when it cannot be avoided, it appears proper to notice those steps which should be taken for preventing miscarriages in those to whom they are rather habitual. In all such cases it will be highly necessary to attend to the history of such former accidents, to the usual habitudes and constitution of the woman, and to her condi- tion when she becomes pregnant. A woman that is subject to habitual abortions, and who is of a full plethoric habit, ought to be bled just before the usual time of her miscarrying. She should likewise keep her body perfectly open with gentle aperient medicines; use a spare diet, consisting principally of vegetables, and avoid all agitations of the mind, severe exercise, violent efforts, and such objects as may be likely to make a disagreeable impression on her. The sleep should be abridged in quantity, and not be taken on a bed of down, but on a firm mattrass, preventing at the same time the accumulation of too much heat about the body. Every day she ought to take regular and moderate exercise, being cautious at the same time not to carry it to the length of exciting fatigue. To bridle the circulation in women of a full plethoric habit that are subject to habitual abortions, in addition to drawing off a little blood from the arm when the pulse is full or inclined to throb, it would appear advisable to give half a grain of digitalis twice or thrice a day, continuing this medicine until after the usual period of the woman's miscarrying. In women of a weak, lax habit, bleeding would be highly im- proper as a mean of preventing habitual abortion. For such, a nutritive and generous diet, moderate exercise in a carriage, cold bathing, and a course of chalybeates, with other tonics, will be ne- cessary, the patient at the same time avoiding all exciting causes. Until gestation be far advanced, it would even be advisable to live absque marito. Indeed, in every instance of habitual abortion, whatever the condition may be that gives rise to it, it will be ABORTIONS. 855 essential that the greatest attention be paid to the avoiding the ex- citing causes. In some cases it may even be necessary to confine the patient to her room until the period at which she usually aborts is past. In those cases of habitual abortions accompanied with spasmodic pains in the uterus, or a disposition to convulsions, opium given ia small doses twice a day might prove eminently serviceable. Where nausea or vomiting prevails in a high degree, in addition to the means before pointed out, we may apply either an opium plaster or a blister to the region of the stomach. An abortion being threatened in consequence of some slight se- paration of the placenta from the uterus, may frequently be stopped by immediately adopting proper steps, and the woman be enabled to go out her full time. On the first appearance of a flooding, the woman should be confined to her bed, and be placed with her hips somewhat more elevated than her head, keeping her at the same time perfectly cool and extremely quiet, debarring her of all food of a heating, stimulant nature, giving her cold liquors to drink sharpened with some agreeable acid, and applying linen cloths wetted in vinegar and water to the loins and private parts. Ice (if to be procured) contained in bladders and laid on the thighs and pubes, may oc- casionally be substituted. With the view of moderating the symptoms attending the pro- gress of a threatened abortion and preventing it if possible from actually taking place, it may be proper, in robust and plethoric habits, and where the pulse is in any degree full and frequent, to take away a little blood from the arm ; after which, if the bowels are confined, we may administer a laxative clyster. If the discharge is copious, and is accompanied with irregular spasmodic contraction of the uterus, or with severe pain, it will be advisable to prescribe opiates in small and frequently repeated doses, so as to keep up a constant effect, and they may be com- bined either with refrigerants,* or with astringents,! or with both. * 1. R Infus. Rosas, f. |jss. Potassae Nitratis, 3j. Tinct. Opii, til x. M. ft. Haustus, 3tia vel 4ta quaque hora sumendus. t 2. R Confect. Opii, 0j. Aq. Menth. Virid. f. Zjss. Tinct. Catechu, ----Kino, aa f. 3ss. M. ft. Haustus 4tis aut 6tis horis capiendus. ' Vel, 3. R Aluminis, gr. xv. Gum Kino, gr. v. * 1. Take Infusion of Roses, one ounce and a half. Nitrate of Potass, one scruple. Tincture of Opium, fifteen drops. Mix them. This draught is to be takeji every three or four hours. t 2. Take Confection of Opium, one scru- ple. Mint Water, one ounce and a half. Tincture of Catechu, ---------Kino, of each half a drachm. Mix them, and give this draught every four or six hours. Or, 3. Take Alum, fifteen grains. Gum Kino, five grains. oob ABORTlOXi. Equal parts of tincture of opium and sulphuric acid make a gooci medicine in uterine haemorrhage ; but it is only in such cases as are attended with irregular spasmodic contractions, or with severe pains, that opium is given by the most judicious practitioners. To assist the effect of the medicines, anodyne clysters may be injected from time to time. Astringent injections composed of a saturated solution of alum. sulphate of zinc, or the plumbi superacetas, or of a decoction of oak-bark, are often employed in floodings; and where the haemor- rhage is slight or remits for any length of time, they undoubtedly will prove beneficial, and ought therefore to be used as mentioned tinder the head of Menorrhagia; but in floodings unaccompanied by any remission, they are by no means likely to afford much relief. In such cases it will be best to trust to the formation of a coagu- lum. Rest will be absolutely necessary if we wish the woman to go out her full time, and therefore it is sometimes necessary to confine her for a few weeks perhaps to her bed, at the same time that we put her upon an effective course of digitalis,* giving her an anodyne at bed-time, but taking care to keep the bowels in a proper state by some gentle aperient medicine. Where we cannot prevent the abortion, our study must be to conduct the patient safely through the process; and the point which first claims our attention is the haemorrhage. Bleeding is an operation employed by some practitioners to check this ; but unless the vessels are above their natural force and strength of action, if: is not likely to do any good. Indeed, the fulness and strength of the pulse are lost much sooner in an abortion than can be ex- plained by the mere loss of blood. Instead of bleeding, we had better therefore give the digitalis, if there is no irritation at the stomach. In protracted cases, where the discharge has continued long, this medicine will be highly proper. Opii, gr. ss. Confect. Ros. q. s. M. Ft. Bolus 6tis horis sumendus cum cochl "j- Infusi Rosas aciduli. * 4. R Pulv. Digital. Purp. Opii, aa gr. ss. Confect. Ros. q. s. M. ft. Pilula 4tis horis sumenda. Vel, 5. R Tinct. Digital. Purp. 1\[ xiij. 4ta quaq. hor. ex quovis vehiculo. Vel, 6. R Infus. Digital. Purp. f. t-ss. Tinct, Cardam. f. 3ij. Aq. Pure, f. 3vj. M. it. Haustus quartis horis adhibendufc Opium, half a grain. Confection of Roses, a sufficiency. Mix them, and let this bolus be taken every six hours, with three table-spoonsful of the Acidulated Infusion of Roses. 4. Take Powder of Purple Foxglove, Opium, of each half a grain. Confection of Roses, a sufficiency to form a pill, which is to be taken every four hours. Or, 5. Take Tincture of Foxglove, twenty drops every four hours, in a little water, or any like vehicle. Or, 6. Take Infusion of Foxglove, half an ounce. Tincture of Cardamom, tux drachms. Pure Water, six drachm?. Mix them, and let this draught be gty.en every four hours. ABORTIONS. 857 When the means above mentioned have been pursued without the desired effect, and the woman becomes exposed to imminent danger from great loss of strength, it will then be necessary to have recourse to powerful astringents,* suxh as zinci sulphas and plumbi superacetas. Of this last we may give one two, or even three grains, repeating the dose every three or four hours ac- cording to the urgency of the case. As soon, however as the haemorrhage has ceased, a gentle purge of the oleum ricihi should be administered, in order to prevent any bad effect from the action of these remedies on the coats of the stomach and intestines. As- tringents used internally have, however, been thought by some to possess little effect unless they excite sickness, which is a different operation from what is expected from them. The application of linen cloths dipped in cold water to the back and external parts, will have a much better effect than internal astringents, and ought therefore never to be neglected. The in- troduction of a small piece of smooth ice into the vagina has often a very speedy effect in retarding the haemorrhage. A snow-ball wrapped in a bit of soft linen will have the same effect; but neither of these should be continued so long as to produce pain, or much and prolonged shivering. The heat of the surface may also be moderated by covering the bed lightly with clothes, and admitting a free circulation of air. The most effectual local method, however, of stopping the hae- morrhage, is by plugging up the vagina ;t and this is best done by taking a pretty large piece of soft cloth, dipping it in oil, and then wringing it gently. This is to be introduced with the finger, portion after portion, until the lower parts of the vagina be well filled. The remainder is then to be firmly pressed on the orifice, and fixed by a T bandage, so as to prevent the plug from being displaced. This acts by giving time to the effused blood to coagulate at the mouths of the bleeding vessels, thereby preventing any further discharge. In obstinate cases, previous to the introduction of the plug, we may insert a little pounded ice tied up in a rag or small bladder, if to be procured. To recapitulate the means which we are to employ for restraining the haemorrhage : if the pulse be full, hard, and frequent, bleeding t See Mr. Burn's Treatise on Abortions. * 7. R Zinc. Sulphat. gr. ij.—v. Confect. Ros. 3ss. Opii, gr. ss. M. ft. Bolus 4tis horis sumendus. Vel, 8. R Plumbi Superacet. gr. ij. Extract. Catechu, gr. iij. Opii, gr. ss. Syrup, q. s. M. ft. Pilula, 4tis horis capienda cum haustu fnfusi Rosae. 109 * 7. Take Sulphate of Zinc, two grains to five grains. Confect. of Roses, half a scruple. Opium, half a grain. Mix them. This bolus is to be taken every four hours. Or, 8.Take Superacetate of Lead,tw© grains.'. Extract of Catechu, three grains. Opium, half a grain. Syrup, a sufficiency to form a pill, which may be taken every four hours, with a draught of the Infusion of Rosea. 858 ABORTIONS, is to be resorted to: but if not, we are to trust to digitalis: the application of cold to the thighs and pubes, admitting cool air freely into the bedchamber, keeping the heat of the body at a low temperature, absolute rest in a horizontal position, and which must be continued during the whole process, however long it may be, cold acidulated liquors for ordinary drink, light food taken in small portions at a time, carefully abstaining from every thing sti- mulant, and plugging up the vagina. Where any sickness or great feebleness attends on an abortion, the body is to be kept at rest with the head low ; and we may at the same time give small quantities of some stomachic cordial, such as a few drops of aether in a little cinnamon-water, or a little pep- permint-water with fifteen or twenty drops of the tincture of opium. In very urgent cases, Madeira or diluted brandy may be given, but these are not to be frequently repeated. Where spasmodic con- tractions attack the stomach, producing sudden and violent pain, a full dose of the tincture of opium conjoined with aether must be ordered immediately. Spasms about the intestines are also to be relieved by opium in some form or other. Where abortion is accompanied by strong hysteric paroxysms, besides attending to the state of the discharge, the best practice is to keep the woman very cool, and to give her thirty or forty drops of tinctura opii, with about two drachms of tinctura Valerianae am- moniata in a little peppermint-water every four or six hours. A clyster composed of cold water, with the addition of two drachms of the tincture of asafoetida, is also sometimes of service. In all cases where a considerable haemorrhage has begun, but particularly at an advanced stage of pregnancy, the first thing of importance to be inquired into and ascertained is its cause, and this can hardly be done too early; for as long the accoucheur allows himself to act without this piece of essential information, his practice must necessarily be uncertain, and the life of his patient be exposed to danger. In such cases it will therefore be of the utmost importance to subject the woman to an examination, and in effecting this it will be necessary to introduce the hand into the vagina, passing one finger without the os uteri. This will be pre- ferable to the common mode; for in presentations of the placenta this part does not always adhere close to the orifice of the womb, but is sometimes attached inward to the collum uteri; and if we trust to the common mode of examination we shall be liable to fail in feeling the placenta, even when its presentation is the cause of the flooding. If the placenta is in the right place, it is probable, at any rate it is possible, that the haemorrhage may subside permanently by the aid of a horizontal posture, a low diet, the application of cold, and a use of the other means before noticed ; but if, on the contrary, the placenta be placed over the mouth of the womb, however these re- medies may afford a temporary relief, we may be assured that the discharge will return : for the next time that a dilatation of the os ABORTIONS. 859 uteri takes place, and which must recur sooner or later, a fresh portion of the placenta will become detached, and other bleeding vessels unavoidably be opened. Our practice ought, therefore, to be determined by the result of the examination. If it appears that the placenta is in the right place, the means and remedies before pointed out may be trusted in, unless the symptoms be so alarming as to compel us to deliver the woman ; but, on the contrary, if the placenta is discovered over the mouth of the womb, or very near thereto, even should there have been only one considerable dis- charge, we should watch the patient with the greatest vigilance, and proceed to deliver her as soon as the parts are sufficiently dila- table to allow the introduction of the hand without improper force. In all cases during the last stage of pregnancy where our endea- vour to stop or repress the haemorrhage prove abortive, and the life of the woman becomes endangered by its severity, it will be advi- sable to deliver her as soon as possible, although we may encounter some difficulty, unless somewhat assisted by the coming on of the natural labour pains. If the ovum be still entire, and the pregnancy considerably advanced, the expulsive action is to be excited by rupturing the membranes. It sometimes happens in abortions, that the whole ovum does not come away at once, but only the foetus, and that either a part or the whole of the secundines remain behind. These by long retention give rise to an offensive discharge from the vagina, and a febrile state accompanied with hysterical affections. In such instances, instead of endeavouring to extract the remains of the ovum, either with the forceps or fingers, which would be pro- ductive of irritation, it will be advisable to keep the parts clean, by injecting an infusion of camomile-flowers with a small quantity of oxygenated muriatic acid; to keep the bowels open with gentle laxatives or clysters ; to support the strength by light nourishment, with small portions of wine frequently repeated, and plenty of sub- acid fruit; whilst at the same time we procure rest or allay irritation by opiates, if necessary. After every abortion the woman should be confined to bed for a few days, as getting up too soon is apt to produce a debilitating discharge. Should any morbid symptoms present themselves, they are to be obviated by a suitable treatment. If the patient con- tinues weakly for any time, the use of a cold bath, with bark and other tonics, a generous diet, and pure air, will be necessary. It has been before observed, that miscarriages are sometimes induced during the first or second month of gestation by the fundus uteri being retroverted and pressed down between the rectum and the vagina; in whkh case they are preceded by a difficulty of making water, and a consequent tumour of the bladder,, together with a violent pain about the perinaetim or rectum. On such occasions draw off the urine with a catheter, and inject an enema with sixty drops of the tincture of opium, if it can be done. Should these symptoms recur after the miscarriage, a wax candle, or a 860 DISEASES OF THE PUERPERAL STATE. pessary, made by rolling some emplastrum plumbi spread on linen, may be introduced into the rectum, and worn as a compress to prevent the return for a few days, till the parts recover their strength.—See Dr- Hunter's Tables of the gravid Uterus, and London Medical Observations, vol. iv. p. 388. DISEASES op the PUERPERAL STATE. Parturition, it is well known, is a natural process, and cannot therefore be considered as a disease; but still it often lays the foundation of many distressing complaints, and is now and then at- tended suddenly even with fatal consequences. On the separation of the placenta, and on the sudden removal of pressure on the expulsion of the uterine contents, every parturient woman encounters some degree of risk: the latter is indeed not unfrequently a source of danger, which has not been sufficiently insisted upon and practically attended to. A woman sometimes appears safely put to bed after an easy and natural labour; she has suffered no unusual loss of blood on the separation and removal of the placenta; the uterus, on the appli- cation of the hand, is found well contracted, and the patient thus far at least appears in a fair way to do well; but notwithstanding these favourable appearances, and perhaps even during the congra- tulations of her friends upon the termination of her sufferings, she complains of a degree of faintness, attended with an inexpressible sensation of sinking: this is followed by restlessness, with an anxious, depressed countenance, and occasionally by pain and a sense of constriction at the pit of the stomach; and expressions of alarm for approaching dissolution are not unfrequently repeated. Shortly afterwards the restlessness increases, the countenance becomes more dejected and ghastly, the pulse gradually sinks and fails in its stroke, the oppressive constriction on the epigastrium becomes intolerable, so as considerably to affect respiration ; and if relief to these symptoms be not speedy, she becomes shortly a corpse. That a woman may die suddenly from the rupture of a vessel in the brain, or in the thoracic or abdominal cavities, during the violent efforts of labour, is a conclusion sufficiently natural; but in accidents of this nature there would be symptoms of pressure on the sensorium in the one instance, and of internal haemorrhage in the other; and the cause of death, on inspection, would be apparent. To theorize, or reason, on a parturient woman suddenly falling into deliquium animi, and almost immediately expiring, is incon- sistent with the nature of this work ; but it has been attributed to the removal of pressure from the parietes of the abdomen, and the contents of its cavity. At the commencement of faintness without loss of blood, we diseases of the puerperal state. 861 should have recourse to the exhibition of brandy, or other spirits, undiluted or diluted, according to the urgency of the symptoms and the rapidity of their progress, and in such quantity as may seem adequate to answer the intended purpose. That being attained, and the patient relieved, the medicated stimuli, as camphor, aether, volatile spirit, cordial tinctures, &c. may be sub- stituted'. Moderate pressure upon the abdomen with the hand, or a bandage applied round the body, will assist the general intention; and the patient ought, on no consideration, to be allowed to raise herself from the recumbent posture till she be so far recovered as to warrant security from the recurrence of the symptoms of alarm and danger. The most usual complaints, however, which occur after delivery, and which demand the attention and assistance of the medical practitioner, are as follow: viz. AFTER-PAINS. Shortly after delivery these usually come on, and with some women prove remarkably severe. The quicker the labour has been, the slighter will they prove in general. Women with their first child are seldom much troubled with after-pains; but as the uterus is thought to contract less readily after each future labour, so they are more liable to suffer from them in any succeeding de- livery than in the first. When after-pains prove so troublesome as to deprive the patient of her rest, it will be necessary to have recourse to opiates joined with other antispasmodics.* Heated cloths or bladders filled with warm water may be applied as an external fomentation. These means are to be assisted by keeping up a sufficient pressure on the belly at the same time, by means of a broad bandage. COSTIVENESS. This is apt to prevail after delivery, and should always be re- moved by a laxative clyster, or some gentle purgative, such as a solution of some neutral salt and manna, or about an ounce of the oleum ricini. FLOW OF THE LOCHIA. In all women a certain degree of haemorrhage usually takes place after delivery, produced by the removal of the placenta, * 1. g; AqvCinnam. f. ^j. Tinct. Opii, fll xx—xxx. ------Castor, f. 3ss. Syrup. Violee, f. 3ij. M. ft. Haustus hora somni sumendus. Vel, 2. fy Castorei, gr. v. Camphorae, gr. iij. °P"5 Rr. jss- Confect. Rosas, q. s. M. ft. Bolu9 capiat hora somni, * 1. Take Cinnamon Water, one ounce. Tincture of Opium, thirty to forty- five drops. ---------Castor, half a drachm. Syrup of Violets, two drachms. Mix them. This draught is to be taken about bed-time. Or, 2. Take Castor, five grains. Camphor, three grains. Opium, one grain and a half. Confection of Roses, a sufficien- cy to form a bolus, which may be take.n at bed-time. S62 diseases of the puerperal state. which thereby lays bare the mouths of the blood vessels in the inside of the uterus; and this commonly continues until the womb contracts to •such a size as to close them up again. The discharge for the four or five first days consists usually of florid blood, after which time it assumes a mucous appearance, and so ceases gra- dually. In weak and relaxed habits it sometimes happens, that instead of saturating a cloth now and then, as is natural to all women, the blood gushes out with such rapidity and violence as to run quickly through all the bed-clothes, and even to soak through the bed itself; in which case the patient will be reduced to a state of great debility if the haemorrhage is not soon restrained. To effect this, the means recommended under the heads of Menorrhagia and Abortions must be adopted. Where a suppression of the lochia ensues before the accustomed period, the discharge ought again to be promoted, if possible, by plentiful dilution, and the application of warm fomentations to the parts. Should these means prove ineffectual, gentle evacuation from the bowels must be made. THE MILK FEVER. About the third or fourth day after delivery, the breasts gene- rally become turgid and painful, from the secretion of milk which then takes place in them. When this is moderate and free, no in- convenience will be experienced ; but when copious, and accompa- nied by any obstruction in the lactiferous tubes, in consequence of the use of some repellent application, or of an exposure to cold, the breasts will then become hard, swelled, and painful, and a small fever will arise, accompanied by nausea, restlessness, pains in the head and back, and a considerable degree of thirst. To prevent any consequences of this kind, it will always be ad- visable to. apply the child to the breasts at a very early period after delivery. By delaying to do so immediately on the secretion of milk commencing, the breasts are not only apt to become much en- larged and distended, but the nipples are often so much retracted, that the^child cannot lay hold of them without the greatest difficulty. Where the mother's health will not admit of her suckling the child, or any other thing happens to prevent it, she should be careful to have her breasts drawn three or four times a day by some other person; and with the view of preventing a copious secretion of milk, she should use a very spare diet, keepher body perfectly open with laxative medicines, and abstain as much as possible from all liquids. This mode of proceeding will be far preferable to the use of repellent applications to dry up, or put a stop to, the secretion. If any degree of fever arises, besides confining the patient to a spare diet, keeping her very quiet, and obviating costiveness by means of cooling laxatives, we may give her small and frequently repeated doses of antimonials, together with refrigerants, such as the nitrate of potass, as advised under the head of simple Fever. DISEASES OF THE PUERPERAL STATE. 863 INFLAMMATION AND TUMOURS IN THE BREASTS. From exposure to cold, and neglecting to put the child at an early period to the breasts, or to get them drawn by some other person, accidents of this nature happen very frequently to lying-in women. With respect to the mode of treating these kind of tumours, practitioners differ very much; some asserting that discussion should always be attempted, and others, that they ought to be allowed to suppurate; as when the discussion does not succeed, there may be some danger of inducing a scirrhous affection of an obstinate nature. I think the same practice sbould be adopted in this case of inflammation as in every other, and that the discussion of the tumour ought by all means to be attempted on its first ap- pearance ; the distress and pain which always attend on a suppu- ration of the mamma being very great. When the inflammation and swelling have been of such long standing as to show an evident tendency to suppurate, any attempt to discuss the tumour will not be advisable. Where discussion is proper, recourse should be had at a very early period to a strict pursuance of the antiphlogistic plan. The strength is to be supported by a cool, spare diet; the body is to be kept perfectly open with mild laxatives ; febrile heat is to be abated by refrigerants, such as the nitrate of potass, with the aid of frequent small doses of some antimonial, such as the pulvis Jacobi, pulvis antimonialis, or solution of tartarized antimony; pain and irritation are to be allayed by sufficient doses of opium; and the inflammation, when considerable, is to be abated by means of leeches applied to the part, as likewise by the constant applica- tion of linen cloths dipped in some sedative lotion.* To assist the effect of these means, the breasts are to be evacuated fre- quently throughout the course of the day, but more particularly the one diseased, either by the infant or some other person ac- customed to the business. When they are so much swelled as not to allow of laying hold of the nipple, the proper glasses made for that purpose should be employed. If the tumour proceeds to suppuration, notwithstanding we may have used every endeavour to prevent it, we should then assist the * 1. R Liquor. Ammon. Acetatis, f. Spirit. Rectific. f. Aq. Distillat. f. aa ^ij. M. ;t. Lotio. Vel, 3. R Ammon. Muriat. 3>j- Acidi Acetic, dilut. f. ?ij. Spirit. Camphorae, f. ^ss. Liquor. Plumbi Acet. fllxvj. M, * 1. Take Solution of Acetate of Ammonia, Rectified Spirit, Distilled Water, of each, two ounces. Mix them, and use them as a wash. Or, 2.Take Muriate of Ammonia,two drachms. Distilled Vinegar diluted, two ounces. Camphorated Spirit,half an ounce. Solution of Acetate of Lead, twenty-fivA drops. Mix them 8b'4 DISEASES OF THE PUERPERAL STATE- operations of nature by the application of emollient poultices and fomentations. As soon as the suppuration is completed, the tumour should be opened, after which it may be dressed with dry lint, and a pledget spread with some kind of digestive ointment be laid over all. Should any fresh suppuration ensue, which not unfrequently happens, the same mode of treatment must be adopted; and that proper pus may be formed, the bark of cinchona, with a moderate quantity of wine, will be necessary. EXCORIATIONS OF THE NIPPLES. From the constant state of moistnrp in which these parts are kept with those who give su^k, such occurrences are very apt to happen. When excoriations do arise, the parts should be washed two or three times a day with a diluted solution of alum, the super- acetate of lead, or a few drops of the liquor plumbi acetatis, in rose-water, and then be sprinkled with a little powder of calamine or tutty, or they may be dressed with a little of what is recom- mended below,* thinly spread on lint, and so applied to the parts. To prevent the sore from being aggravated by sticking to the woman's clothes, a little cup made of wax may be laid over the nipple, which is the part most apt to suffer. If only one nipple is affected, the child may be confined to the other; but if both are affected, and the pain occasioned by its sucking is too great to be borne, the woman must then desist from the duties of a mother until the excoriations are somewhat healed, taking care however to have her breasts drawn regularly twice or thrice a day. As long as we are under the necessity of applying any of the preparations of lead to the nipples of the mother, it will be prudent not to suffer the child to suck her, as there is reason to fear that it might be materially injured by so doing. Where this cannot however be dispensed with, the part should be well washed with a little warm water each time previous to giving the child the breast. When great soreness of the nipples has taken place, it has been proposed, with the view of protecting them, to use an artificial teat, by which the child will be able to suck tolerably well, and the nipple itself, being undisturbed, to heal soon. The way in which one of these substitutes is prepared, is to procure a fresh teat from a heifer, and scooping out the inside, to well steep it in cold water, then put it into spirits till an hour or two before using it, when it must be again laid in water to take away the spirituous taste. The teat is then to be wiped dry, and sewn closely and firmly at the edges to the row of holes made in the shield. Such shields are usually made of silver, and may be procured from Mr. Savigny, the instrument maker; but ivory ones turned on the same model will answer equally well. The teat ought to project somewhat longer * 3. R Sodae Sub-boratis, 3ss. * 3.Take Sub-borate of Soda, half a drachm. Mellis, f. ?ss. Honey, half an ounce. Farinae Tritic. q. s. ad consisten- Wheaten Flour, a sufficiency to tiam idoneam. M- give the whole a proper consistence. DISEASES OF THE flJERPKUAL STATE. 86 5 than the shield, that it may the more readily yield to the infant's mouth. Great attention should be paid to washing the whole thoroughly after suckling, and to keep it constantly in cold water. A woman is often capable of giving milk with a flat or even con- cave surface, by drawing out the nipple with a glass tube that has a small ball to it, by which a vacuum is produced immediately the glass is removed: the child being put to the breast, will keep it out by sucking until satisfied. MILIARY ERUPTIONS. In consequence of keeping women very warm, and of using a heating diet, it not unfrequently happens that miliary eruptions, attended with some degree of fever, arise during a puerperal state. Sometimes they are dispersed over the whole body, but they are more usually observed about the neck and chest. To conduct the patient with safety through the disease, the practitioner must have recourse to the means advised under the head of Miliary Fever. Should the eruptions strike in suddenly, and the pulse sink, blisters, with cordial sudorific medicines and wine, will be proper. Affections of this nature may, however, be avoided in general by an attention to diet, by keeping the patient's body perfectly open, and her bed lightly covered with clothes, and by admitting a proper and free ventilation through her chamber. PIILEGMATIA DOLENS PUERPERARUM, OR THE PAINFUL INTU- MESCENCE OF THE LOWER EXTREMITY, INCIDENT TO LYING-IN WOMEN. Although this disease must have existed as long as most of the others to which lying-in women are subject, still it seems to have been only slightly noticed by any of the ancient writers. Mr. White's Inquiry into its nature and causes, which made its appearance in the year 1784, was the first regular treatise on it in this country, and it excited the attention of dther practitioners to the complaint. In the year 1792, Mr. Tyre, of Gloucester, pub- lished a small essay on the subject; and at different periods since that time, Dr. Ferriar, and Dr. Hull, of Manchester, have written on it. Phlegmatia dolens appears, however, to be a disease of no frequent occurrence; for Mr. White mentions, that, out of 1897 women delivered at the Westminster General Dispensary, five only were attacked with it; and of 8000 women delivered at the Manchester Lying-in Hospital, and their own houses, no more than four were seized with it. During a practice of forty-five years, only three cases have fallen under my care. When we find practitioners giving in a report of numerous cases which came under their observation, we may therefore naturally presume that they have mistaken other diseases for it, such as anasarca, phleg- mon, erysipelas, abscess, rheumatism, peritonitis, and puerperal fever. The disease, however, to which, in my opinion, it bears 110 866 DISEASES OF THE PUERPERAL STATE. the strongest resemblance, is the glandular affection of the thigh and leg, so frequently met with in the island of Barbadoes, and noticed under the head of Elephantiasis. The characteristic of phlegmatia dolens is a firm, glossy, warm, tense, elastic, painful, sudden swelling, of a pale white colour, which attacks the hypogastric region, the loins, nates, groin, labium pudendi, thigh, leg, and foot of a lying-in woman some days after delivery, or miscarriage at an advanced period of pregnancy. Mr. White looks on the swelling of the labium pudendi as an invariable symptom of the disorder; and he .asserts, that when one limb only is affected, the intumescence is confined so exactly to the labium pudendi of that side, that if a line were drawn from the navel to the anus it would be found never to go beyond that line in the smallest degree. We are told, however, by Dr. Hull, that the swelling of the labium pudendi is to be con- sidered rather as marking the extent, than serving to characterize the complaint; and he positively denies that this particular symp- tom is always to be met with; for some cases had fellen under his care in which it did not exist. On this point, as well as on most others relating to the nature and causes of phlegmatia dolens, these gentlemen do not agree in opinion. Mr. White attributes the proximate cause of the disease in question to an obstruction, detention, and accumulation of lymph in the limb, and imagines the lymphatics to be obstructed as high up at least as where they enter the pelvis under Poupart's ligament, in consequence of some accident happening during labour, or some state peculiar to childbed. He conceives it might probably arise from the continued pressure of the lymphatic vessels by the head of the foetus on the pelvis, which, he says, is often rough and sharp on its ridge, and might be followed by a rupture of these vessels in some part of their course. The disease has been attributed by Mr. Tyre to an obstruction of the lymphatics: but he apprehends that this originates in the inflammation of the trunk or trunks of these vessels, which inflam- mation may be excited by pressure or the absorption of some acri- monious matter. Dr. Denman entertains sentiments pretty similar to those of Mr. Tyre; for he believes the disease to arise first in the inguinal glands by the absorption of some irritating principle in the dis- charge, the consequence of an unhealthy secretion from the uterus. Dr. Ferriar is of opinion,* that phlegmatia dolens may exist independently of every circumstance regarding parturition,t and he does not think it impossible for it to take place before delivery. The violent pressure on the internal iliacs and the accompanying veins and nerves, which takes place during labour, * See his Medical Histories and Reflections, vol. iii. + It certainly may; for I had a case lately under my care in an aged woman, and, of course unconnected with parturition. DISEASES OF THE PUERPERAL STATE. 867 must undoubtedly be considered as a powerful occasional cause of lymphatic inflammation, quite sufficient to account for the pheno- mena without the supposition of a rupture of the vessels. He adds, that the constitution is much more irritable, more liable to febrile and inflammatory complaints after than before delivery. The balance of the circulating fluids is suddenly and violently changed ; there are new determinations, new sympathies, produced in a state of debility, agitation, and anxiety. It cannot, therefore, surprise us, that, under circumstances so peculiar, a set of vessels, commonly exempted from inflammatory affections, should take on an unusual disposition. These theories are rejected by Dr. Hull, as being inadequate to explain the various phenomena of the disease; and he offers the following, which he conceives to be more consonant to its real nature.* As predisposing and exciting causes to it, he enumerates—1st, The increased irritability and disposition to inflammation which.prevail during pregnancy, and in a still higher degree for some time after parturition. 2dly, The over-distended or relaxed state of the blood-vessels of the inferior part of the trunk, and of the lower extremities. 3dly, Contusions, or violent exertions of the muscles about the pelvis and thighs. 4thly, Plethora, occasioned by a suppression or diminution of the lochia, or of the secretion of milk. 5thly, Food taken too freely; and, 6thly, Standing or walking too much or too early. The proximate cause he supposes to consist in an inflammatory affection, producing suddenly a considerable effusion of serum and coagulable lymph from the exhalents into the cellular membrane of the limb ; and he thinks that there exists a close connexion between phlegmatia dolens, puerperal fever, peritonitis, "and some other disorders. Such a conclusion, in my humble opinion, is not well founded ; for phlegmatia dolens is a disease as distinct from either puerperal fever or peritonitis as it is possible to be. Little or no inflamma- tory tendency prevails in the system in this complaint, neither are any of the abdominal viscera, nor their peritoneal covering, occupied by inflammation. The disease appears to be of a local nature, and confined to the lymphatics of the limb on the side affected. The slight temporary derangement which takes place in the system appears to be induced wholly by the local affection, pain, and distention. Phlegmatia dolens generally takes place on one side only at first, and commonly begins in the hypogastric or inguinal region, or in the hip, or top of the thigh, and corresponding labium pudendi, preceded by rigours, and followed by pyrexia. In this case the patient perceives a sense of pain, weight, and stiffness in some of these parts, which are increased by every attempt to move the pelvis, or lower limb. If the part be Carefully examined it ge- --------------------------jt--—* - ———■ ' * See his Essay on Phlegmatia Dolens. 868 DISEASES OF THE PUERPERAL STATE. nerally is found rather fuller or hotter than natural, and tender to the touch, but not discoloured. After a little time the pain increases, always becomes severe, and in some cases is highly excruciating: it extends along the thigh, and at length the top of the labium pudendi becomes greatly swelled and distended; but, on this happening, the pain is usually somewhat alleviated in these parts. It however extends down to the knee, and is generally most severe on the inside and back of the thigh. When it has con- tinued for some time, the whole thigh becomes in its turn swelled, and the pain extending down to the leg and foot, these parts also swell; but, on the swelling taking place, there is a considerable abatement of pain, and the woman does not experience much ex- cept she moves the limb. The extremity being now swelled throughout its whole extent, appears perfectly or nearly uniform, and is not perceptibly lessened by a horizontal position like an oedematous limb. It is whiter than the natural colour, is hotter than usual, excessively tense, and exquisitely tender when touched. When pressed by the finger in different parts, it is perceived to be elastic, little, if any, im- pression remaining, and that only for a short time. If a puncture is made into the limb, in some instances no fluid is discharged; in others, a small quantity of fluid escapes^ which does not coagulate, but the whole of the effused matter cannot be drawn off in this way. The swelling of the limb varies both in degree and in the space of time requisite for its full formation. In most instances, it arrives at double the natural size, and, in some cases, at a much greater. In lax habits, and in patients whose legs have been very much affected with anasarca during pregnancy, the swelling takes place more rapidly than in those who are differently circumstanced: it sometimes, in the former class of patients, arrives at its greatest extent in twenty-four hours, or less, from the first attack. After some days, generally from two to eight, the febrile symp- toms diminish, and the swelling, heat, tension, weight, and ten- derness of the lower extremity begin to abate, first about the upper part of the thigh or knee, and afterwards in the leg and foot. Some inequalities are found in the limb, which at first feel like indurated glands; but, upon being more strictly examined," their edges are not so well defined as those of conglobate glands, and they appear to be occasioned by the effused matter being in different degrees of consistence in different points. The con- globate glands of the thigh and leg are sometimes felt distinctly, and are tender to the touch, but are seldom much enlarged; and, as the swelling subsides, it has happened that an enlargement of the lymphatic vessels in some part of the limb has been supposed to be felt. The febrile symptoms having gradually disappeared, the pain and tenderness of the limb being much relieved, and the swelling and tension considerably diminished, the patieBt is much debili- DISEASES OF THE PUERPERAL STATE. 869 tated, and the extremity feels stiff, heavy, benumbed, and weak. It seldom, if ever, returns to its former size, but usually is con- siderably enlarged for the remainder of life, being always more easily affected by cold than the other, and after exercise it will be more stiff and weak than the sound extremity. It sometimes happens, that-after the disease abates in one limb, the other is attacked in a similar way, goes through the same stages, and con- tinues much about the same time as the first. Phlegmatia dolens is often slow in its progress, and tedious in its cure; but it is rarely followed either by suppuration or gan- grene ; and still more rarely does it terminate fatally ; the extrava- sated fluid being at length taken up, and returned into the circu- lation, although, from the great distension of the limb, there is usually much tenderness, pain, and a febrile disposition. We are told by Mr. White, that when not complicated with any other disease, he has never known it to have a fatal termination ; neither has he ever observed the skin to be so discoloured as to point out the presence of local inflammation : on the contrary, it is of a paler white than ordinary, which circumstance has induced him to name the disease phlegmatia alba dolens puerperarum. By Dr. Hull we are, however, informed, that he has seen cases which have terminated in suppuration, as also in death. With respect to the treatment of phlegmatia dolens, much must be left to the discretion of the practitioner, who ought to prescribe according to circumstances. Should the disease be complicated with any other, such as phlegmon, Erysipelas, anasarca, thoracic inflammation, puerperal fever, peritonitis, then the means which are advised under these heads must be resorted to, in addition to paying a proper attention to the complaint itself. A- When a woman who is of a robust plethoric habit is attacked shortly after delivery with a painful, tense swelling of one of the lower extremities, accompanied by much heat, thirst, restlessness, and other symptoms of pyrexia, the antiphlogistic plan ought certainly.to be pursued. Bleeding from the system in a moderate quantity, keeping the body open with saline purgatives, so as to procure one or two motions daily; administering small and fre- quently repeated doses of some antimonial preparation, to promote a regular and gentle determination to the surface ; giving plenti- fully of diluent liquors; confining the patient to bed; covering her lightly with bed-clothes, and keeping her chamber of a proper coolness, will undoubtedly be highly proper in all such cases. Where nausea exists at the commencement of the attack, an emetic may likewise be advisable, but otherwise it appears un- necessary. If the irritability or excitability (adopt which term you may) of the system is much increased, and from the severity of the pain in the limb the patient is deprived of rest for a succession of nights, we may with safety and much advantage, having premised proper evacuations, employ opium. The best mode of administering it 870 DISEASES OF THE PUERPERAL STATE. will be, to combine it with some diaphoretic,* and probably the pulvis ipecac, compos, may be as good a medicine as we can use. Along with the remedies before enumerated, warm bathing, or the semicupium, ma> possibly be of service. Such is the general treatment to be adopted in phlegmatia dolens, when arising in a'robust or plethoric habit, and where the febrile symptoms run very high ; but the antiphlogistic plan would certainly be improper for a woman of lax fibres, and who has already been much debilitated by floodings, or other evacua- tions. In all those cases which are marked with general debility, an impoverished state of the blood, and a diminution of the tone and action of the heart and arteries, we should pursue the following course :— To remove the affection of the system, and at the same time expedite the cure of the local complaint, we should endeavour to restore proper energy to the constitution, as well as improve the state of the blood; and this is to be effected by bitters, chaly- beates, and other tonic medicines, a nutritious diet, with a mode- rate allowance of wine, daily exercise on horseback or in a car- riage, but more particularly the latter, and by cold bathing. To assist in carrying off the effused fluid, it may likewise be advisable to employ diuretics, such as the supertartrate of potass, squill, digitalis, &c. combined with cinchona, cascarilla, and other tonics. —See Anasarca. Mercury has been recommended both by Mr. Tyre and Dr. Hull in phlegmatia dolens; but I mink it is a remedy from which no be- nefit is likely to be derived, and particularly in debilitated habits. Our attention is next to be directed to the local treatment. When the limb and labium pudendi are occupied by much pain, and any degree of inflammation, the application of two or three leeches will be proper; after which the parts may be well fomented with flannel cloths wrung out in hot vinegar, renewing these as often as they become cold. This simple mean, unassisted by any other than merely keeping the bowels regular with gentle aperients, such as the neutral salts, has, 1 understand, been adopted in all cases of phlegmatia dolens with invariable success, in one of the best re- gulated lying-in hospitals in London. Should it fail, however, in other hands, some more powerful sedative or discutient may be ■* 1. ft Liquor. Ammon. Acet. f. 3i'j- Mistura Camphorae, f. ^j. Tinct. Opii, HI x*. Syrup. Papav. f. 3ij. ' M. ft. Haustus, hora somni sumendus. Vel, 2. ft Tinct. Opii, HI xxv. Liquor. Antimon. Tartarizat .TTlx, Aq. Purae, f. ?j. Syrup. Simpl. f. 3ij. M. *. 1. Take Solution of Acetate of Ammonia, three drachms. Camphor Mixture, one ounce. Tincture of Opium, thirty drops. Syrup of Poppies, two drachms. Mix them, and let this draught be taken at bed-time. Or, 2. Take Tincture of Opium, forty drop*. Solution of Tartarized Antimony, fifteen drops. Pure Water, one ounce. Common Syrup, two drachm?, ft. Haustus. Mb; them for a draught. DISEASES OF THE PUERPERAL STATE. 871 substituted, such as a solution of muriated ammonia in vinegar, or a diluted solution of the liquor plumbi acetatis. A liniment com- posed of a drachm of camphor, dissolved in an ounce of olive oil, with about ten grains of powdered opium, and used night and morning, will be a good application. Much relief has been re- ceived by surrounding the iimb with a soft poultice, composed of bran, olive oil, with the addition of half an ounce of tinctura opii, and a sufficient quantity of warm water to give it a proper con- sistence, renewing it morning and night. To drain off some of the fluid effused in the limb, it will be ad- visable in an early stage of the disease, to apply a blister to the calf of the leg, renewing the application from time to time in the neighbourhood of the former when it ceases to produce the desired effect. In some instances coagulation quickly succeeds the effu- sion, and therefore neither scarifications nor punctures would be likely to prove beneficial. Notwithstanding every attention, the complaint often leaves considerable weakness in the leg, requiring a laced stocking or roller applied round it from the bottom to the top, avoiding at the same time much standing or walking. To increase the action of the absorbents in the limb, frequent frictions with rubefacient liniments, or simply with the hand, flannel, or a flesh-brush, may be employed, the effects of which may be assisted by topical cold bathing, or by cold wafer, fresh or salt, dashed upon the parts, and by electricity. Immersing the limb in a bath of tepid sea water has sometimes been found beneficial. Probably the appli- cation of heat in the manner advised for anasarcous limbs, might prove serviceable.—See Anascarca. HYSTfcRiT,^, OR AN INFLAMMATION OF THE UTERUS.* In natural labours, as well as in those of a difficult sort, many causes of injury to the uterus and the peritonaeum which covers it will be applied. The long-continued action of the uterus on the body of the child, and the great pressure made by its head on the soft parts, will farther add to the chance of injury. Besides these, an improper application of instruments, or an officiousness of the midwife in hurrying the labour, or extracting the placenta, may have contributed to the violence. To these causes may be added exposure to cold, by taking the woman too early out of bed after delivery, and thereby throwing the circulating fluids upon the in- ternal parts, putting a stop to the secretion of milk, or occasioning a suppression of the lochia. An inflammation of the womb is sometimes perfectly distinct, but it is more frequently communicated to the peritonaeum, Fallo- pian tubes, and ovaria : and having once begun, the natural func- * This disease, as well as the two which suoceed, belong properly to the class of Pyrexiae; but as the two first do not often occur in the nnimnregnated state, and the last is a disease confined to that of the puerperal, I have judged it most proper to insert them all here. 872 DISEASES OF THE PUERPERAL MATE. tions of the organ become much disturbed, which event greatly adds to the disease. It is oftener met with in women of a robust and plethoric habit than in those of lax fibres and a delicate constitution, particularly where they have indulged freely in food of a heating nature, and in a use of spirituous liquors. It never prevails as an epidemic, like puerperal fever, for which it has probably often been mis- taken ; and to this we may, with some reason, ascribe the diffe- rence in the mode of treating the disease which has taken place among physicians. An inflammation of the uterus shows itself usually about the second or third day after delivery, with a painful sensation at the bottom of the belly, which gradually increases in violence without any kind of intermission. On examining externally, the uterus appears much increased in size, is hard to the feel, and on making a pressure upon it, the patient experiences great soreness and pain. Soon afterwards there ensues an increase of heat over the whole of the body, with pains in the head and back, extending into the groins, rigors, considerable thirst, nausea, and vomiting. The tongue is white and dry, the secretion of milk is usually much interrupted, the lochial discharge is greatly diminished, the urine is high-coloured and scanty, and if the inflammation has extended to the bladder, it becomes totally obstructed ; the body is costive, and the pulse is full, hard, and frequent. These are the symptoms which usually present themselves when the inflammation does not run very high, and is perfectly distinct; but when it is so extensive as to affect the peritonaeum, those of irritation generally succeed, and soon destroy the patient. Where the uterus has been ruptured, a vomiting comes on, and the matter thrown up is of a black colour, resembling coffee grounds, the pulse sinks and becomes irregular, cold clammy sweats break out, and frequent syncope ensues. Uterine inflammation is always attended with much danger, par- ticularly where the symptoms are violent, and the proper means for removing them have not been timely adopted. In such cases it may terminate either in suppuration, scirrhus, or gangrene, and mortification. Frequent rigors, succeeded by flushings of the face, quickness and weakness of the pulse, great depression of strength, delirium, and the sudden cessation of pain and soreness in the region of the abdomen, denote a fatal termination : on the contrary, the ensuing of a gentle diarrhoea, the lochial discharge returning in due quantity and quality, the secretion of milk recommencing, and the uterus becoming gradually softer and less tender to the touch, with an abatement of heat and thirst, prognosticate a favourable issue. When shiverings attack the patient after several days' continu- ance of the symptoms, but little relief can be afforded by medicine, the event being generally fatal. In this case the woman emaciates DISEASES OF THE PUERPERAL STATE. S73 and loses her strength, becomes hectic, and sinks under colliqua- tive sweating or purging. Upon opening the bodies of women who have died of this dis- ease, and where it existed in a simple state, little or no extravasated fluid is usually to be met with in the cavity of the abdomen. In some instances the peritonaeal surfaces have been discovered free from the disease; while in others', that portion which covers the uterus and posterior part of the bladder, has been found partially inflamed. The inflammation has been observed in some cases to extend to the ovaria and Fallopian tubes, which, when cut open, are often loaded with blood. The uterus itself usually appears of a firm substance, but is larger than in its natural state, and when cut into, a quantity of pus is often found. Gangrene and mortifi- cation are seldom, if ever, to be met with. By an early attention to the disease on its first approach, we may often subdue it, and prevent the inflammation from proceeding to any great height. Our immediate and speedy care ought therefore to be directed towards diminishing the quantity of the circulating fluids, and weakening the action of the heart and arteries; and this is to be done by drawing blood from the system, regulating the quantity which we take away by the violence of the symptoms, the state of the pulse, and the age and habit of the patient. In re- peating the operation, we are to be governed by the same circum- stances, and by the effect produced by the former evacuation. In plethoric habits, a second or a third repetition may be necessary; but in those who are less robust, if the inflammatory symptoms are not entirely carried off by the first bleeding, it may be more advi- sable to draw off blood by the application of six or eight leeches to the belly, than to make use of the lancet again. To remove the tension and alleviate the pain and soreness, flannel cloths wrung out in a warm decoction of bruised poppy- heads and chamomile-flowers, with an addition of about an eighth of spiritus camphorae, may be kept pretty constantly applied throughout the course of the day to the abdominal region, and at night it may be anointed with a little of the linimentum cam- phorae. In using fomentations, due care must however be taken that they are not applied so wet as to run about the bed, and thereby occasion inconvenience to the patient. Some practitioners of late have recommended the application of linen cloths wetted in camphor mixture and cold water to the ab- domen, instead of warm fomentations.—See Peritonitis. Injecting tepid water into the uterus morning and evening, by means of a proper syringe, may be likely, I think, to add to the good effects of fomentations externally applied. Evacuation by purging would be improper in this inflammation; but it would be right to preserve the regular motion of the bowels, by giving, from time to time, as maybe found necessary, some gentle laxative, or by administering emollient aperient clysters, which perhaps mav be the preferable way of procuring stools. Ill ^7'1 DISEASES OF THE rUEJirER.AL STATE, as they not only unload the intestines, but likewise act ats fo» mentations. In most internal inflammations, blisters prove a useful remedy; but in that of the uterus, their application is attended with the risk of increasing the irritation in the system, and of adding to the in- flammation, by affecting the bladder and kidneys. Whenever they are made use of in this disease, with the hope of affording relief, they ought to be sprinkled with camphor, and be applied to the upper part of the thighs, with the view of remote counter excite- ment, and the patient should drink plentifully of diluting mucila- ginous liquors. Diluents will indeed be proper, whether we have recourse to blistering or not. To determine to the surface of the body, and excite a gentle perspiration, which often proves highly serviceable in this inflam- mation, it will be advisable to give diaphoretic medicines. As s.uch, we may employ the pulvis ipecac, compositus, in the quanti- ty of eight or ten grains, repeated every four hours; or the pulvis antimonialis, in the quantity of about two grains, and half a grain of opium, made into a bolus, with a little of the confectio tosbs rubrae. These may be washed down with two or three spoonsful ©fa saline mixture. In order to alleviate the pain, (which alone would greatly aggra- vate the disease,) procure rest, and prevent symptoms of irritation from arising, the use of opium is indispensably necessary, and its dose ought to be increased until the desired effect is procured* Opium is, however, not to be prescribed in hysteritis, until the inflammation has been subdued by venesection and aperient medicines. Should a diarrhoea arise spontaneously in the course of this dis- ease, it ought by no means to be checked, unless it proceeds with such violence as to exhaust the woman's strength. Under such circumstances, the mistura cretae, with an addition of a small quan- tity of tinctura opii, may be given with advantage. Should the Bemedy not be found sufficiently powerful in lessening the number of evacuations, three drachms of the tinctura kino, or catechu, may be added to about six ounces of the mixture. Where the inflammation has extended to the bladder, and occa- sioned a suppression of urine, we must employ the catheter. Throughout the whole course of the disease, the patient is to be supported by food of a light nutritive nature, and such as is easy of" digestion, carefully avoiding all kinds of fermented liquors. In chronic inflammation of the uterus, or state of scirrhosity, the repeated application of several leeches above the pubes, or to th,e perinaeum, the use of gentle laxatives, emollient clysters, and fomentations and blisters to the lower part of the abdomen, fre- quent immersion of the lower parts of the body in a warm slipper bath, with an antiphlogistic regimen, and detaining the patient as much as possible in a horizontal posture, appear to be the most probabje means of affording relief at an early period. Hyo,s,cyamii3 DISEASES OF THE PUERPERAL STATE'. 87j and conium, joined with cinchona and opium, both by the mouth and in the form of clyster, more particularly the latter, to assuage pain, together with injections of tepid water and milk, or of some gently astringent liquor, together with warm bathing, may be the most advisable remedies in the advanced or carcinomatous stage of the disease. In Order to prevent excoriation from the acrimony of* the discharge^ some simple ointment should be applied to the paf.C3 over which it passes. Too much caution cannot be observed by women in guarding against any exposure to cold after delivery, as they are thereby apt to bring on diseases, which, if they do not prove quickly fatal, not unfrequently leave effects behind them of which they will be seii-- sible the Avhole future period of their life. PERITONITIS, OR INFLAMMATION OF THE PERITONAEUM. The peritonitis of the puerperal state appears to be only ths common inflammation of the peritonaeum attacking a woman already labouring under debility, and being somewhat conjoined thereby with puerperal fever. Peritonaeal inflammation frequently occurs in women after deli- very, and is produced by the same causes which give rise to an in- flammation of the uterus, viz. tedious and difficult labours, officious- ness in the midwife, the use of instruments, the application of cold, and administering heating liquors to excess. The disease has, by some authors, been called puerperal fever; but this seems improper, as it neither is attended with contagion nor ever prevails epidemi- cally ; and therefore the term is more properly applicable to the disorder treated of under that particular head. In some cases of peritonitis, the inflammation attacks only a smsflj portion of the membrane at first, and is afterwards communicated to the whole of it; and in others, it occupies the whole at once* The patient usually is seized with rigors and shiverings, thirst, fever, and an accelerated pulse, and soon feels considerable pain, with soreness, either in a particular part of the abdomen, or over the whole of it. The uneasiness and pain increasing rapidly, the abdomen betomes puffed up and swelled to a size nearly equal to what it was before delivery. From the inflamed state of the parts, and the exquisite pain which prevails, the very weight of the bed- clothes becomes irksome and insufferable; and, in order to support it,, the patient is obliged to lie on her back with her knees bent in towards her belly. She is, moreover, incapable of bearing the Ieas£ motion. The stomach, in most cases, is much affected, and a constant sickness, with a vomiting of bilious matter, ensues. The state of the intestines is variable; sometimes costiveness prevails, at others a purging, and sometimes the body is perfectly regular. The blad- der likewise becomes affected, and there arises a constant inclina- tion to make water, but which comes away, however, in a very small quantity at a time. 876 DISEASES OF THE PUERPERAL STATE. As the disease advances, and the tumefaction augments, great difficulty of breathing ensues; and, in consequence of the general determination to the bowels, the secretion of milk becomes much diminished, and is at last entirely stopped; the breasts are flaccid and empty, and the lochial discharge is perhaps wholly suppressed. The system is usually affected with a mixture of general inflam- mation and symptoms of irritation; the pulse is frequent, small, and contracted, beating about 120 or 130 in a minute ; the skin is dry and hot, with flushing of the face and redness of the eyes; the tongue is white and dry, with the prevalence of great thirst; the appetite is diminished, but not wholly lost; and the patient is restless, uneasy, and gets little or no sleep. The disease continuing to proceed in its course, all the symp- toms become highly aggravated, and at last a total cessation of pain ensues; the pulse becomes still smaller, but is at the same time more frequent; cold clammy sweats break out, the urine and faeces come away involuntarily, the extremities are cold, and the patient is carried off in the course of the sixth, seventh, or eighth day. Chronic inflammation of the peritonaeum is not a very unusual sequela of the acute species, when the patient survives that. We may regard the following appearances in a favourable light: —The pulse becoming fuller and less frequent, the skin moister and cooler, the respiration less laborious, the urine being voided in a proper quantity and less frequently, thS return of the milk in the breasts, the re-appearance of the lochial discharge, a gradual diminution of the pain and tension in the abdomen, with the ability of remaining in a sitting posture, and the coming on of a gentle diarrhoea towards the close of the disease. On the contrary, we are to consider the sudden cessation of pain, with a sinking pulse, effusion, and tumefaction, as fatal symptoms. Peritonaeal inflammation is to be distinguished from enteritis by the pain being permanent; by its being increased by pressure, even before any tension has taken place on the abdomen; by its pro- ducing no inclination to go to stool; and by its not being dimi- nished if this evacuation should take place spontaneously. The appearances on dissection have been those of inflammation in the peritonaeum covering the different viscera, as the stomach, liver, spleen, omentum, intestines, &c.; but that which covers the uterus and bladder is usually found in a higher state of inflamma- tion than any other part. Moreover, there is a remarkable change in the omentum, which is frequently as thick as a persons hand,* and there is generally perceived in the cavity of the abdomen a large quantity of a fluid resembling serum, mingled with pus, and intermixed with shreds of coagulable lymph, or portions of solid matter, similar to what is mentioned under the head of Puerperal * See Morbid Anatomy, by Dr. Baillie. DISEASES OF THE PUERPERAL STATE. 877 Fever. It seldom happens that gangrene or mortification of any of the viscera is to be observed; but the intestines are usually greatly distended with air. In the cure of this disease, nearly the same mode of treatment vvhich has been advised for an inflammation of the uterus must be adopted. Bleeding from the system to about sixteen or twenty ounces should therefore be had recourse to at a very early period, particularly where the patient is of a robust, plethoric habit, and with such it may be necessary to repeat the operation within twelve hours. In those cases where there is no mixture of phlegmonous inflammation with the symptoms of irritation, drawing blood a second time by the application of a dozen leeches applied to the abdomen, may be preferable to taking it away from the arm. In the pure peritonitis, local blood-letting should never be solely trusted to, and indeed ought not to be advised until there appears some diminution of pain from general bleeding, or till the consti- tutional effects occasioned by the local inflammation are partly removed, and the disorder thereby reduced to a state more nearly approaching to a simple topical affection. Then the repeated application of several leeches to the abdomen, so as to keep up a copious flow of blood, will be useful. An occasional irregularity in the complaint often occurs, which is liable to mislead the practitioner: and that is, at the very first attack there is sometimes so great a degree of prostration of strength or seeming debility, accompanied likewise by a pulse scarcely perceptible at Jhe wrist, as might induce us to consider the patient nearly at the point of death, and unequal to undergo the treatment here recommended. These appearances, however, may be supposed to arise from the inflammation extending to the peritonaeal coat of the stomach and intestines. Here the violence of pain and tenderness on pressure must be the chief criterion to determine our practice, but not the state of the pulse ; and if they should be found exquisite, no accidental symptom should lead us from trusting chiefly to the lancet. Such a decision will soon be justified by a greater freedom in the action of the arterial system, by an abatement of the languor, and by a diminution of the pain and tenderness. Emollient and antispasmodic fomentations to the abdomen by means of flannel cloths wrung out in a warm decoction of equal parts of chamomile-flowers, and bruised poppy-heads, with a small addition of rectified spirit or spiritus camphorae, will be proper remedies in all cases of peritonitis, and ought therefore not to be neglected. Some cases are recorded in a late publication,* atteting the good effects of cold applications by linen cloths dipped in camphor mixture and water in this disease. Under an apprehension that the application of a blister to the * See Observations on Peritouitis, by T. Sutton, M. D. 8'78 DISEASES OF THE PUERPERAL STATE. abdomen might prove injurious by its irritating effect, some phy- sicians have objected to advise it in peritonitis, while others again have recommended it to be employed, under the idea that its de- termining the inflammation to the external parts, and thereby lessening it on the internal ones, will greatly counterbalance any Cxeitement it may occasion. When the constitutional effects occasioned by the local inflammation are partly removed by general bleedings, and the disorder is reduced to a state more nearly approaching to a simple topical affection, there can be no doubt, I think, of the propriety of blistering the abdomen. Probably, more benefit might result, generally speaking, not only in this and other visceral affections, by remote counter excite- ment, than from the prevailing practice of employing it in the im- mediate vicinity of the diseased organ. Thus it might prove more remedial to blister the upper parts of each thigh in peritoneal in" flammation, and to apply fomentations Or linen cloths dipped in camphor mixture and water, as may be judged most proper, over the region of the abdomen. A similar practice is certainly most salutary in phrenitis, and perhaps it might be safely extended to acute affections of the belly and chest. To empty the bowels freely, it will be necessary to employ active purgatives from time to time. A pill composed of three or four grains of the submuriate of mercury, followed by a full dose of an infusion of senna with sulphate of magnesia, or of castor eil? will not fail to afford relief by promoting several evacuations of fetid and dark stools. Emollient clysters may be administered during the intervals of eur employing purgatives, as they will not only assist in keeping the bowels open, but will act likewise as internal fomentations. Should there prevail great irritation at the stomach, with frequent vomiting, the patient should be directed to drink freely of diluted mucilaginous liquors, taking every two or three hours a saline draught in the act of effervescence, with an addition of about twelve or fifteen drops of the tinctura opii. In order to determine the circulating fluids to the surface of the body, and excite a slight degree of perspiration, we should ad- minister small and repeated doses of some diaphoretic ;* and te procure sleep and alleviate pain, having previously bled Sufficiently, we may make an addition of opium, increasing the quantity ac- * 1. B; Pu*v* Antimonialis, gr. ij. Confeet. Rosaj, gr. x. M. fr. Bolu"s quartis horis capiendus; Vel, % % Pulv. Jacob, gr. V. Opii, gr. ss. Confect. Cort, Aurant. q. s. M, Vel, 3, Ijt Pulv. Ipecac. Comp. gr. x.- pi'o do> * 1, Take Antimonial Powder, two grains. Confection of Roses, ten grains. Mix them, and take this bolus every foyr hours. Or, 2. Take James's Powder, five grams;? Opium, half a grain. Confection of Orange Peel., ^ sufficiency to form a holug. Or, % Take Compound Powder of Tp^catru- anha, ten grains §1* a dos£. DISEASES OF THE PUERPERAL STATE. 8.79 cording to its effects. These may he washed down with two or three table-spoonsful of the mistura camphorae, which will be likely to prove a serviceable medicine. Where the urine becomes suppressed by the inflammation having extended in a high degree to the bladder, a warm bath, with an occasional use of the catheter, may be necessary. In the early stage of the disease, where phlegmonous inflamma- tion simply prevails, it might be of service to make use of the nitrate of potass and other refrigerants ; but at a more advanced period, and where symptoms of irritation arise, they would be improper. When these ensue, the cinchona bark, with a moderate. quantity of wine, ought to be given. Should the stomach not be capable of retaining the powder, a decoction or infusion may be tried, with a small addition of the tinctura calumbae. If a gentle diarrhoea should come on in the course of the dis- ease, it is by no means to be checked, unless when violent, as it may prove critical. The spirit of turpentine is a remedy which has been strongly recommended in puerperal peritonitis by Dr. Brenan, of Dublin, and is said to have been employed by him with very favourable effects in several instances of the disease. In extreme or very urgent cases, after the failure of the other means which have been pointed out, it may be worthy of a trial. Throughout the whole period of the disorder the patient is to be supported by food of a light nutritive nature, administered in small quantities at a time, and repeated frequently, so as never to over- load the stomach. Where effusion in the cavity of the abdomen with tumefaction takes place, no relief can be obtained by medicine: death is the infallible consequence. Chronic peritonitis, the' occasional sequela of acute, especially when the depleting plan has not been sufficiently acted upon, must- be treated with leeches, blisters, and small doses of the submuriate ■af mereury, together with some active cathartic twice a week. FEBRIS PUERPERARUM, OR PUERPERAL FEVER. Oreat Soreness, pain, and tension of the abdomen, short, -anxious breathing, uncommon quickness of the pulse, increased temperature of the body, tensive pain over the forehead, peculiar wildness of the eyes, prostration of the vital powere, suppression or diminution of the milk and lochia, a flaccid state of the mammae, and an unnatural condition of the excrements, accompanied by idiarrhoea, may be regarded as the pathognomic symptoms of puerperal fever. Its epidemical prevalence at times, is a sufficient characteristic of its nature, because this circumstance never takes place with respect to simple inflammation of the uterus and peri- tonaeum. It is a disease peculiar to women after delivery, particularly in hospitals, and is supposed to occasion the death of nearlv one half 880 DISEASES OF THE PUERPERAL STATE. of those who die in child-bed. Until of late it had not been much noticed by medical writers, and even now various opinions are entertained with regard both to its nature and the causes producing it. Some have doubted if it deserves the title of specific, or ought to be regarded as of a particular genus; and these have been accustomed to look on it as only a simple modification of the known species of fever, taking its origin from the leaven of the prevailing epidemic constitution, whether inflammatory or putrid, modified by the habit of body, the mode of living, the age and temperament of the patient, the preceding causes, the season of the year, and temperature of the air, &c. Others again have considered the disease as uterine and peritonaeal inflammation, accompanied in its progress by fever of a low malignant nature, or typhoid type.* Indeed the diagnosis between puerperal fever and the more common forms of peritonaeal and uterine inflamma- tion which occur in the puerperal state, is still obscure and unde- termined: the limits bounding some of these cases are so indis- tinctly marked, that the one case seems to pass imperceptibly into the other. A stoppage of the lochia has been assigned as one of the causes of puerperal fever; but the circumstance of their being sometimes absent and sometiiries present at the attack, and during the progress of the disease, shows their perfect independence of each other. Others again have thought that puerperal fever is produced by the absorption of a putrid sanies arising from dead parts of the omen- tum or mesentery, or some other putrid material in the abdomen or uterus. By a few physicians it has been represented as owing its existence to an undue secretion of milk; while others have sup- posed that it derived its origin either from a redundancy, or too great acrimony of the bile, the secretion of which appears to be much interrupted during the time of gestation. The late Dr. Young, professor of midwifery at Edinburgh, was of opinion, that the puerperal fever, strictly so called, is, in every instance, the consequence of contagion : but he contends, that the contagious matter of this disease is capable only *f producing its effects in consequence of a peculiar predisposition given by deli- very and its consequences. In support of this doctrine he remarks, in a paper read in the Philosophical Society of that city, that for many years the disease was altogether unknown in the lying-in ward of the Royal Infirmary at Edinburgh; but that after it was once introduced into the hospital, almbst every woman was, in a short time after delivery, attacked with it; although prior to deli- very, she may have lain even for weeks together, not only in the same ward with the infected, but even in the very next bed. He further remarks, that it was only eradicated from the hospital in consequence of the wards being entirely emptied, thoroughly * See Facts and Observation? relative to the Fever commonlv called Puerperal-,. hy J. Armstrong, M. D. ,, DISEASES OF THE PUERPERAL STATE. 881 ventilated, and new painted. After these processes, puerperal females in the hospital remained as free from the disease as formerly. With respect to the infectious nature of this fever, a great con- trariety of sentiment has indeed existed; the probability is in favour of its being so, but it is nearly impossible to form a decided opinion on the subject. Doubtless it will be the safest practice to consider it as infectious, and to cut off all intercourse of pregnant and parturient women with those who labour under it. The real cause of puerperal fever is obscure, and not yet satis- factorily ascertained. It is, however, certain, that it has a strong tendency to the typhoid type in an advanced stage, although, at its commencement, or during the first twenty-four or thirty-six hours, it is usually attended with inflammatory symptoms, and even with topical inflammation in the abdominal viscera, but more particu- larly the peritonaeum, or membrane which envelopes them. Under different circumstances, the disease assumes different ap- pearances, and accordingly different distinctions have been laid down by writers between its various forms ; but such distinctions are of no use in practice, and may, perhaps, be productive of em- barrassment to the practitioner. We may conclude, I think, that the only essential difference in the cases that ought to be considered puerperal fever, consists in their degree of violence, and their being epidemic, or simply sporadic ; for it seems to be admitted that whenever the disease exists epidemically, it is more urgent in all its symptoms. The period at which women are attacked with this disease is uncertain, as in a few instances it has arisen at the distance of a week after delivery ; but the most usual time of its attack is on the third or fourth day after that event. The patient is seized at first with a slight coldness and shivering, succeeded by pains in the head, ringing in the ears, flushing in the face, great anxiety and restlessness. As the disease advances, the whole abdomen.be- comes affected, is highly painful to the touch, and much tumefied. She likewise feels great pain in the back, hips, and sometimes in the legs, and she performs respiration with difficulty, the breathing being short and laborious, from the pressure against the diaphragm, as well as from an organic affection of the chest itself. If the milk has been previously determined to the breasts, it suddenly disappears on the approach of the disease; but if the attack of fever commences sooner, the milk does not appear. The lochia are altered both in quantity and appearance ; the urine is turbid, small in quantity, and voided with pain, and a tenesmus often arises. The skin is hot and dry, the pulse weak and frequent, the number of pulsations being often from 110 to 130 in a minute ; thirst prevails, and there is vast prostration of strength, with anxiety, depression of spirits, a disinclination to suckle, care- lessness about her child, and watchfulness. To these symp- 112 882 DISEASES OF THE PUERPERAL STATE. toms are added a tensive pain over the forehead, and a peculiar wildness of the eyes. A vomiting not unfrequently attacks at the same time, and in so high a degree as to prevent the smallest quantity of food or me- dicine from being retained on the stomach. The matter thrown up is of a dark porraceous colour, and often of a disagreeable smell. The functions of the primae viae are likewise much dis- turbed. At the commencement they usually go on well; but in the progress, of the disease, a severe purging often ensues, par- ticularly in those cases where the abdomen has been much distended, and the dejections are abundant, serous, and putrid. It seldom happens that any violent delirium arises, but the patient is apt to fall into a low comatose state, wishing by no means to be disturbed. After one or two days' continuance of these appearances, the fever often acquires a malignant and typhoid tendency, particu- larly in hospitals and confined situations, or when the state of the atmosphere predisposes to diseases of that nature ; the lips, teeth, and tongue are covered with a dark brown fur ; aphthae beset the whole internal surface of the mouth, tongue, uvula, tonsils, and pharynx; the breath is highly offensive ; the stools are fetid, of a dark brown colour, and pass off involuntarily ; and, in a few cases, purple spots appear on different parts of the body. Such, in general, is the course of the puerperal fever ; the symp- toms of which, however, may be often varied, according to the constitution of the patient, the degree of the disease, and its ear- lier or later invasion after delivery. Puerperal fever is readily to be distinguished from that affection known by the name of after-pains, by the intervals of ease which attend these last, and by the absence of fever and abdominal ten- sion ; whereas in the former there is fever with its concomitant symptoms, great soreness and swelling of the abdomen, and an almost uninterrupted continuance of pain throughout the course of the disease. Many circumstances evince a dissimilarity between the puerpe- ral and miliary fevers, notwithstanding the symptoms of anxiety and oppression are common to both. In the puerperal fever, the rigor is more violent, of longer duration, and not interrupted, as in the other. The pulse at first is fuller and stronger ; the skin is more hot; and the tongue, whether moist or dry, though generally the latter, is not of a white, but brownish appearance. Peritonaeal inflammation is the disease which bears the strongest resemblance to puerperal fever, but it never arises from contagion, or prevails epidemically. By paying proper attention, we may in general be able to dis- tinguish simple peritonitis from puerperal fever. In the last, the abdominal pain is not the most prominent symptom. There is more despondency, debility, and headach, less heat of the skin. DISEASES OF THE PUERPERAL STATE. 883 less thirst, and less flushing of the face. In the former, the pain in the abdomen usually increases rapidly after its commencement, and the swelling increases along with it: pressure excites conside- rable pain, and the fever is inflammatory throughout. Hysteritis has its proper symptoms, by which it may readily be distinguished from puerperal fever. The progress of puerperal fever is sometimes so very rapid, particularly in warm climates and hot seasons, as to destroy the patient in forty-eight hours. Even in cases seemingly the most favourable, we should look on the event as doubtful, as the com- plaint is apt to be accompanied with delusive remissions, and indi- cations arise in its progress which are by no means equal to the danger. The risk seems however to be greater in proportion as the ac- cession is sooner after labour. When the disease comes on at a late period after delivery, the depression of strength is usually less con- siderable, the tumefaction of the abdomen is less extensive, and the other symptoms are not so violent, and consequently there will be a greater chance for the woman's recovery. The reappearance of the lochia, and a gradual subsidence of the abdominal tension and soreness after copious stools, the pulse at the same time becoming slower, with a moist skin, may be regarded in a very favourable light. On* the contrary, an agitated countenance, with a hurried, unconnected manner of speaking, constant sigh- ing, attended with a tossing about of the arms, pain and oppres- sion at the chest, visual deceptions, imaginary strange sounds and voices, muttering and stupor, are to be considered as unfavourable symptoms. An extensive swelling of the belly, so as to sound on striking it with the fingers, sudden cessation of pain, irregularity in the pulse, coldness in the extremities, clammy moisture diffused over the whole body, frequent dark-coloured and fetid evacuations by stool, and an indifference to all external objects, denote certain and speedy death. On a fair computation, three-fourths of the women who have been attacked with this disease have fallen sacrifices to it. The morbid appearances observed on dissection are usually con- fined to the abdomen. The first thing that often presents itself is a collection of whey-like fluid in the cavity of the abdomen; which is sometimes so considerable in quantity as to amount to several quarts; and it has a peculiarity of smell, different from any other fluid to be met with in the human * body, either in health or disease. Where it is large in quantity, the surfaces of the different viscera and of the peritonaeum will usually be found covered with a crust formed of a solid part of this matter, resembling coagulated lymph. If there be any interstices between the intestines or the other viscera, they are frequently filled with large masses of the same, adapted exactly to the shape and size of such interstices. In a few cases, a deposit of a caseous and serous nature has been 884 DISEASES OF THE PUERPERAL STATE. discovered likewise in the head, breast, and external cellular mem- brane, as has before been observed. In most instances there is found a slight degree of inflammation in some part of the cavity; but it is not confined invariably to any particular place; as tlie uterus, ovaria, peritonaeum, omentum, intestines, and bladder, have all in their turn been observed in a state of inflammation. In many cases of dissection, a considerable quantity of purulent matter has been found in the cavity of the abdomen. Upon analyzing the fluid effused into the peritonaeal cavity of a woman dying from this fever, it has been found to possess a per- fect chemical identity with that furnished by the inflamed pleura. The peritonaeal fluid, after depositing a copious whitish precipitate, which.afforded albumen to the different re-agents, was of a clear yellowish white colour, and had the property of turning green the syrup of violets. But the nature and proportion of the alkali en- dowing it with this property, have not been ascertained. The flocculi which float in the abdominal serum of puerperal subjects have been regarded as a cheesy substance, formed of the coagulum of the milk : but this seems erroneous. Ammonia mixed with the substance in question scarcely acts upon it as a solvent, and eva- poration developes in it all the characters of albumen. In a disease where the symptoms come on with such violence, where the progress is so very rapid, and the event so generally fatal, every assistance should be afforded as soon as possible. Unfortu- nately, however, there has prevailed a great diversity of opinion among physicians relative to the remedies to be employed during its first stage, some advising copious bleeding, and others highly disapproving of its being ever adopted. Under such a contrariety of opinion, it will be best to pursue that plan which seems most congenial to the nature of the disease. I shall consider puerperal fever as admitting of the same variety of treatment with other affections in which an inflammatory disposition prevails on its first attack; but in which a typhoid and malignant tendency is to be observed after a continuance of one or two days. During the first stage of puerperal fever, (which should not be considered as extending beyond twenty-four or six-and-thirty hours from its attack,) if the patient complains of abdominal pain and soreness, I am of opinion that we may advantageously resort to venesection, proportioning the quantity of blood that is drawn off to the habit of the patient and the violence of the symptoms. In strong plethoric women, it should not be less than twenty ounces, nor ought it to exceed thirty ; and care should be taken that the orifice is made large, so as to produce a decisive effect at once.— (See Pleurisy.) A repetition of the bleeding ought in general to be avoided ; but if judged indispensable, from the abdominal soreness and pain not being removed or materially alleviated within six hours, a smaller quantity, not exceeding twelve ounces, should be taken away after this interval. It is only during the first stage of DISEASES OF THE PUERPERAL STATE. 885 puerperal fever, however, that blood-letting is advisable ; this being usually marked by inflammatory symptoms; whereas characters highly typhoid become manifest during its second stage. In a few instances of this fever, extreme debility (marked by great depression of strength and a small, feeble pulse) and a typhoid tendency, may be apparent from its commencement. In these it would be improper to draw blood from the arm; but where there is much abdominal pain, with great soreness, the application of several leeches to the belly may be advisable. In some countries, the application of leeches to the vagina or haemorrhoidal veins has been considered as the best mode of bleeding in this disease, but its inefficacy must be obvious. The propriety of administering purgatives in puerperal feyer has admitted of as much doubt as that of venesection. Some physicians observing that women who die of this fever are generally molested with a diarrhoea, have been induced to consider this symptom as of the most dangerous and fatal tendency, and which ought to be restrained by every possible means; whilst others again have re- garded it rather as critical than symptomatical, and think it ought therefore to be moderately supported instead of being restrained. To procure stools where costiveness prevails, and remove putrid feculent matter, it appears reasonable that we might employ pur- gative medicines at the commencement of the disease with ad- vantage ; and possibly a few grains of the submuriate of mercury, with a small quantity of rhubarb or jalap, followed up by two or three large spoonsful of a solution of some neutral salt every hour or two, until copious evacuations are procured, will be most advi- sable. Where the disease is in an advanced stage, and the patient reduced in strength, dislodging the contents of the intestines by means of gentle laxatives, assisted by aperient clysters, appears to be the best mode of procuring evacuations, which at this period of the disease are usually of a dark brown colour, resembling coffee grounds, very copious, of the consistence of thick gruel, and with a fetid smell. In my opinion, the most rational method of treating puerperal fever, but more particularly when attended by abdominal pain and soreness, is to abstract blood, from a large orifice, to a sufficient ex- tent at the first onset of the disease, and then direct the attention to a free evacuation of the alimentary tube throughout the continu- ance of the disease, at first by purgatives, and towards the close by aperient medicines and laxative clysters. A very interesting account of a puerperal fever which was epidemic at Aberdeen, and published by Dr. Alexander Gordon, gives us to understand, that not only purgatives are useful in this disease, but likewise bleeding. He tells us that the disease was infectious ; that it seemed to arise from the contagion that was carried by the accoucheur, or nurse, from one lying-in woman to another; and that it began with violent unremitting pain of the abdomen on the day of delivery, or the next, with shuddering, and 886 DISEASES OF THE PUERPERAL STATE. a very quick pulse, often 140 in a minute. If he saw the patient within twelve or twenty-four hours of her seizure, he took away from sixteen to twenty-four ounces of blood, which was always sizy. He then immediately gave a cathartic, consisting of the sub- muriate of mercury and jalap. After this had operated, he pre- scribed an opiate at night, and so continued the purge and the opiate for several days. He asserts, that almost all those whom he was permitted to treat in this manner early in the disease, recovered, to the number of fifty, and that almost all the rest died; but that when two or three days were elapsed, the patients became too weak for this method, and the matter was already formed which destroyed them. Dr. Armstrong is of opinion,* that puerperal fever bears a close analogy to typhus complicated with inflammation of the abdomen, and thinks it ought to be arranged under three varieties, namely, the sporadic, the epidemic, and the chronic. He also is perfectly convinced that bleeding at the first onset of the disease, assisted by purgatives, are the main remedies to be depended upon under every form; and he adds, moreover, that it is not simply bleeding and purging in which he places his confidence, but in copious bleeding, immediately succeeded by copious purging, or rather in the powers of these two means simultaneously exerted on the disease at its onset. Mr. Hey, of Leeds,! is also an advocate for the same plan of treating this fever. It often happens that nausea and a vomiting of bilious matter attend an attack of this fever. In such cases we may recommend a gentle emetic of ipecacuanha to be taken, with a view of cleansing the stomach: but I cannot agree with those who advise a repetition of it, as the operation of vomiting never fails to aggravate the pain, and likewise to exhaust the woman, besides endangering a great degree of irritation in the stomach, to which there is naturally too great a tendency. Although I object to a repetition of ipecacuanha or antimonials, given so as to produce an emetic effect, still I think they may be administered with some advantage at the commencement of puer- peral fever, in such small doses as to determine to the surface of the body. As a diaphoretic, I know of none preferable in the present instance to ipecacuanha, which may be prescribed in doses of about two grains, to be repeated every three or four hours; or perhaps it may be still more efficacious to give it combined with opium, as in the pulvis ipecacuanhae compositus. Of this, about six grains made into a bolus, with a small quantity of confection of. roses, may be taken as before-mentioned, washing it down with a saline draught; and to make the diaphoretic effect more certain, the patient should drink frequently of diluting liquors, such as whey, barley water, &c. * See his Illustrations of Typhus and other Febrile DJFeases, ------Treatise on Puerperal Fever. ' ?ee Treatise on the same, by Mr. Hey. DISEASES OF THE PUERPERAL STATE. 887 To alleviate the soreness and distention of the abdomen, we may recommend the application of fomentations both inwardly and ex- ternally ; inwardly, by injecting tepid water into the uterus every four or six hours, °and administering emollient clysters from time to time ; and externally, by applying flannel cloths wrung out in a warm decoction of equal parts of chamomile flowers and bruised poppy-heads, with an addition of about one-third of rectified spirit, over the whole region of the abdomen; and these ought to be renewed as often as they become cold, taking due care that they are not so wet as to run about the bed and incommode the patient. The warm bath has been recommended by some practitioners, and it often produces a calm and disposes to sleep; but this being the effect of exhaustion, it appears to be a doubtful remedy. Where the abdominal cavity is highly painful to the touch, and is occupied by extensive inflammation, the application of cold to the parts by cloths dipped in camphor mixture and cold water, has been attended with a good effect.* If the soreness and pain are not relieved by the means which have been suggested, then the application of a blister to the upper part of each thigh may be proper. Blistering the abdomen might not be advisable, at least not until the topical abstraction of blood had been adopted by the application of several leeches.—See Peritonitis. Having employed gentle cathartics at an early period, for the purpose of obviating costiveness and dislodging the putrescent matter from the bowels, we may then with safety have recourse to anodynes administered so as to keep up a constant effect.t The dose of opium must depend on the severity of the pain, and the age and constitution of the patient, and it may be repeated every four or six hours. Opium, when administered in puerperal fever, diminishes the irritability of the system, as well as that of the stomach and intestines. It eases pain, produces sleep, and seems to excite a moderate diaphoresis. In a few instances, I think, I have observed it to obviate or relieve delirium in the same manner as in typhus. Should there be any great irritation of the stomach, the saline draught with a proper quantity of tinctura opii may be given, so as that the effervescence shall take place after it is swallowed, as advised under the head of Simple Fever. Should this medicine also be rejected, the vomiting may perhaps be restrained by opium in the form of pills, and by rubbing the region of the stomach fre- quently with some strong anodyne liniment. The application of a * See Cases of Puerperal Fever, by T. Sutton, M. D. t 1. R Aq. Cinnam. f. ^j. Tinct. Opii, H\ x. Syr. Althaea?, f. 3ij- Tinct. Lav. C. f. 3s- it. Haustus. t 1. Take Cinnamon Water, one ounce. Tincture of Opium, fifteen drops. Syrup of Marshmallovv, two drachms. Compound Tincture of Lavender, half a drachm. Mix them for a draught. 888 DISEASES OF THE PUERPERAL STATL-. blister might excite injurious irritation. The strength must be sup- ported by administering clysters, composed of animal broths and other such nutritive liquids, until the stomach becomes tranquil, and will bear the introduction of proper nourishment. If a gentle purging arises in the first stage or commencement of the complaint, it ought not to be top hastily stopped, as the fever has in some instances been carried off by such a spontaneous evacuation; but if the disease is of some days' standing, the stools very frequent, the patient much reduced, and no evident relief has been afforded by the diarrhoea, we must then give astringents,* joined with opium, to restrain it; and for ordinary drink she may take the mistura cornu usti. To support the strength, wine may be necessary; and this should be given in a moderate quantity, properly diluted with water, as likewise mixed with the food con- sisting of preparations of barley, sago, panado, Indian arrow-root, tapioca, and the like, varied now and then by broths, beef-tea, and milk. The oleUm terebinthinae is a medicine, which is highly spoken of by one or two practitioners in this disease, but further experience is re- quisite to satisfy us that it is deserving of the character ascribed to it. It has been observed, that this fever, after continuing a day or two, very often acquires a malignant and putrid tendency. Under such circumstances it will be right to have immediate recourse to the bark of cinchona joined with the mineral acids, but more par- ticularly the muriatic, as noticed under the head of Typhus Gravior, and to exhibit it freely in as large doses as the stomach will bear. If the powder is readily retained, it ought to be pre- ferred to any other preparation ; but if not, a decoction or infusion may be substituted.! Should it be rejected in all these ways, it * 2. R Confect. Opii, Qss.—9j. Aq. Cinnam. f. ^jss. Tinct. Kino, f 3>j- ----Lav. C. f. 3ss. M. ft Haustus ter in die sumendus. Vel, 3. R Mistur. Cretae, f. |iij. Aq. Pimentae, —Cinnam. aa f. ^ij. Tinct. Catechu, f. 3y- ----Opii, fll xxx. M. ft. Mistura, cujus sumat cochl. larg. ij quartis horis. 14. Rj- Acid. Muriatic. 1T1, xii. M. it. Haustus quartis horis adhibendus. * 2. Take Confection of Opium, ten grains to one scruple. Cinnamon Water, one ounce and a half. Tincture of Kino, two drachms. Compound Tincture of Lavender, half a drachm. Mix them. This draught is to be taken three times a day. Or, 3. Take Chalk Mixture, three ounces. Pimento Water, Cinnamon Water, of each two ounces. Tincture of Catechu, two drachms. ------ of Opium, forty-five drops. Mix them, and take two table-spoonsful every four hours. t 4. Take Decoction or Infusion of Peru- vian Bark, ten drachms. Tincture of Cascarilla, two drachms. Muriatic Acid, eighteen drops. Mix them. This draught is to be giver every fom- hours. DISEASES OF THE PUERPERAL STATE. 889 may then be given in clysters, with an addition of about five-and- twenty drops of tinctura opii to each. If it occasions any purging when taken by the mouth, a few drops of the tincture of opium may be added to each dose. When there is no disposition to a putrid tendency, it will be best to wait till a remission of the symptoms, or a partial subsidence of febrile action has taken place, before we prescribe a use of the cinchona. A late physician of eminence* in treating on this disease ob- serves, that the cinchona, although given by him in the different stages of the complaint with remissions tolerably distinct, by no means answered the intention as a febrifuge; but that in a few cases where the intermissions were complete it had succeeded. He likewise observes, that as a supporter of the general strength, it has been found of less service than might have been expected, on account of the disturbed and very irritable state of the bowels, which it has a tendency to increase. Instead of cinchona, he advises the calumba-roott in powder or infusion,f in doses to be repeated every four hours. If hiccups and subsultus tendinum arise in the progress of the disease, recourse must be had to antispasmodics, such as musk, aether, and the like; although it is probable they will avail but little. When any unusual coldness of the extremities is felt, the application of stimulating cataplasms will be propfer. The carbonate of potass is a medicine which is strongly recom- mended by Monsieur Guinot§ in puerperal fever, as well as in all diseases connected with the secretion of milk in the female breast. He advises it to be given in doses of from ten to twelve grains three times a day, in any proper vehicle, and to employ at the same time alkalies externally, such as a solution of soap in a decoction of poppy-heads, taking care at the same time not to neglect other remedies indicated by the circumstances and symptoms of the case. This alkaline treatment he recommends under the idea that the disease is occasioned by the predominance of an acid. Whether it acts by counteracting the acid, dissolving the clotted mijk, by neutralizing the acid which may actually exist there, by its action on the organs of perspiration, or by inducing other useful crises, cannot be ascertained; but it appears to have proved very success- * Dr. Denman. »«• .. i } See Extracts from his Memoir inserted in the third volume of the Medical and Physical Journal, pages 60, 165, 264, aud 363. t 5. R Pulv. Calumb. 3ss. Opii, gr. ss. Confect. Rosae, q. s. M. ft. Bolus. X 6. R Infus. Calumb. f. 3x. Tine. Cort. Aurant. f. 3iss. Acid. Muriatic, fll in. M. ft. Haustus. t S.Take Powder of Calumba,half a drachm. Opium, half a grain. Confection of Roses, a sufficiency to form a bolus. X 6.Take Infusion of Calumba, ten drachms. Tincture of Orange Peel, one drachm and a half. Muriatic Acid, fifteen drops. Mix them for a draught. 113 890 DISEASES OF THE PUERPERAL STATE. ful and advantageous with other practitioners besides Monsieur Guinot, and may therefore be tried at an early period of the dis- ease. A combination of the carbonate of potass with the cinchona bark might probably be useful in cases of puerperal fever compli- cated with malignancy. It would appear that the effluvia of a patient under puerperal fever is an animal poison sui generis, capable of acting on preg- nant females, their situation giving the predisposition necessary for the operation of its influence. The usual mode of communicating the infection in private practice is by being delivered by some ac- coucheur who has lately been attending a woman labouring under puerperal fever, or her being visited by female friends who have been where it prevailed. It therefore behoves every practitioner when he meets with the disease to observe every possible pre- caution in changing his clothes, and by careful ablution of his hands to guard against conveying infection to other parturient women: moreover, all pregnant woman should be excluded from the house; nor should the nurse or other persons about the sick be permitted to go abroad and visit women in a stage of pregnancy. To prevent the disease from occurring, it will be proper to keep the patient's mind both before, during the time of labour, and afterwards, as free from every kind of uneasiness as possible, as anxiety might greatly predispose to an attack of it. She should likewise carefully avoid any exposure to the infection of fever be- fore delivery, as well as to the occasional causes of it afterwards. Every woman lately delivered ought cautiously to guard against cold ; but in doing this, her room should at the same time be kept of a proper temperature by allowing a sufficient ventilation. It being a well-known fact that puerperal fever has been chiefly confined to close apartments and small hospitals, and that since the lying-in chambers have been made more airy and commodious, and the hospitals larger, the disease seldom prevails epidemically or becomes general d ue attention should be paid to a free ventila- tion : for it is by no means improbable that a cool air ina lying-in chamber will frequently prevent, and its opposite be likely to induce the phenomena of puerperal fever. The patient should observe the strictest cleanliness both as to herself and the bedding. On the coming of the milk, her breasts ought to be drawn repeatedly throughout the course of the day by some person accustomed to the business, or by applying the child; her body should be kept perfectly open after she is delivered, as well as before her confinement, by some mild purgative medicine, and she should abstain from all food of a heating or irritating nature. An upright posture will be most proper, in order to discharge more readily any putrescent matter that may be in the uterus. When the disease prevails as an epidemic among puerperal women, or occurs in a lying-in hospital, all communication ought DISEASES OF THE PUERPERAL STATE. 891 immediately be cut off between those who are affected and such as have lately lain in, or expect shortly to do so; and in order to root out the disease and ^tifle contagion, we should have recourse to fumigations, as advised under the heads of Malignant Fever and Dysentery, and afterwards to painting, white-washing, and a free ventilation. In situations where puerperal fever has been prevalent, some ad- vantage may be obtained by giving a decoction of the bark of cin- chona with tincture of opium and cordials immediately after deli- very. These will in some measure enable lying-in women to re- sist the powers of contagion. MANIA PUERPERARUM. The characteristics, symptoms, and treatment of madness arising in women after delivery are fully detailed under the head of Mania, page 501, which see. INVERSIO UTERI. This complaint consists in the inversion of the cavity of the uterus, so that the fundus comes through the os uteri, consequently that part which was formerly the inside of a cavity becomes now the outside of a tumour, either in or projecting from the vagina. It most commonly is the consequence of mismanagement of the placenta, by the midwife or accoucheur being in too great a hurry to extract it. Its immediate effects are haemorrhage, faintness, and a sense of fulness in the vagina. When early discovered, the uterus may easily be reduced to its natural situation. If the placenta be adhering to the womb, the latter should be reduced before any separation of the former be attempted, to prevent haemorrhage. PROCIDENTIA UTERI. This complaint consists (as the name implies) in a change of the situation of the womb, by which this organ falls much lower than it ought to do. In some cases it absolutely protrudes entirely with- out the vagina. The slighter cases are therefore named a bearing down, and the more violent ones a descent or falling down of the uterus. The complaint is met with in women of every rank and age ; but more frequently in those who have had several children than in such as have not had any. Every disease which induces general debility, or local weakness in the passage leading to the womb in particular, may lay the foundation of this complaint; hence immoderate venery, frequent miscarriages, improper treatment during labour, and too early or a long-continued erect posture of the body soon after delivery, and in some cases after abortion, are in married women the most common causes of procidentia uteri. At this time the womb weighs 892 DISEASES OF THE PUERPERAL STATE. eight or ten times more than when unimpregnated, and descends by its gravity. In the unmarried it is apt to take place in conse- quence of violent exercise, such as jumping, dancing, riding, lifting heavy weights, &c. while out of order. The proximate or immediate cause of prolapsus uteri is relaxa- tion of the broad and round ligaments above, and want of tone in the vagina below. The disease comes on generally with an uneasy sensation in the loins whilst standing or walking, accompanied now and then with a kind of pressure and bearing down, as also pains in the groins extending to the labia. There is a sense of fulness in the parts, and probably an increased discharge of transparent mucus from the vagina. All the symptoms are relieved by a recumbent posi- tion. In procidentia uteri the symptoms arising from the utero- gastric sympathy are in many cases very distressing ; the appetite fails, the stomach and bowels lose their tone, flatulence and bor- borigmi are troublesome, considerable debility ensues, the spirits are depressed, employment and exercise become irksome, and life at last is scarcely desirable. The discharge varies much at times, the menstrual flow usually is increased, and menorrhagia not unfre- quently attends. Before the external protrusion of the tumour, the discharge is greater than afterwards, because the surface of the vagina ceases to secrete when permanently exposed to the air. After a time, patches of healthy looking ulceration attack the ex- p osed vaginal surface, but seldom go deep : and the os uteri is not unfrequently assailed by one of these. By neglecting to pay proper attention to the early symptoms and threatenings of the disease, the woman becomes at length in- capable of making water without first lying down or pushing up the swelling which seems to impede the discharge of urine ; and if the complaint continues to increase, the womb is actually forced out of the parts, and takes on the form of a bulky substance hang- ing down between the thighs. This severe degree of the dis- order seldom occurs, however, among women in northern climates, except in those who have had many children, and are at the same time of a relaxed and feeble frame ; but in warm climates it is very frequently to be met with, and particularly in negroes and mulat- toes, among whom I often observed the protruded parts considera- bly ulcerated, and occasioned, no doubt, by external irritation and a neglect of cleanliness. Although procidentia uteri is a local disease, it is frequently productive of several distressing symptoms which undermine the constitution. These principally arise from the disturbed functions of the stomach and bowels, and an impaired condition of the ner- vous system. In its early stages, if conception should take place, a confine- ment for some weeks in a recumbent position on a sofa or bed will often enable the parts to regain their tone, so as to render subBP- DISEASES OF THE PUERPERAL STATE. 893 quent artificial assistance unnecessary. Where pregnancy does not exist we must have recourse to art. If the disease is of long standing it may be difficult to effect a cure. In the treatment of procidentia uteri, the curative intentions are to increase the tone of the relaxed parts, both topically and through the constitution, and to support the tumour : topically by cold and by astringents. Cold water .ought to be applied to the parts of generation, as also to the belly and back, by means of a large sponge, three or four times a day, the water being as cool as possible. Cold water may also be thrown into the vagina as fre- quently by means of a syringe. In very slight cases, these means, assisted by a horizontal position, may be sufficient; but in cases of some standing, astringent washes should be substituted for simple water. Alum combined with zinci sulphas dissolved in a de- coction or infusion of some vegetable astringent, such as thea viridis, 'JSty petala rosae rubrae, cortex quercus, cortex granati, gallae, &c, will make an appropriate injection, various formulae of which are given under the head of Leucorrhoea and Gonorrhoea Simplex, as also below.* In aid of topical applications, tonics must be administered inter- nally, especially the bitter tonics, as gentian, calumba, &c, with cinchona and sulphuric acid : for various formulae of these, see Dyspepsia. A due attention must be paid at the same time to the state of the bowels, and this be nicely regulated : the extreme of constipa- tion and diarrhoea being equally injurious. Aperients of the mildest nature, when requisite, are therefore only to be employed. The bladder should never be suffered to contain a large quantity of tsrine. When the stomach is not previously much weakened, the use of a cold bath may prove a valuable auxiliary to the other means; and a salt water bath will be preferable to one of fresh water. In every case of procidentia uteri, the recumbent posture on a sofa or hard matrass as much as possible ought to be enjoined, keeping the room at the same time as cool as may be consistent with the patient's feelings. The diet should be generous and nu- tritive, and a moderate quantity of wine be allowed. As exercises, * 1. 5: Cort. Querc. f. ?ij. I* 1. Take Oak Bark, two ounces. Aq. Purae, Oij. | Pure Water, two pints. Coque ad dimidium, et colatura? adde Boil it down to one pint, and to the strained. liquor add Alum, one drachm and a half. Sulphale of Zinc, half a drachm. Mix them for an injection. Or, 2. Take Alum, four scruples. Superacetate of Lead, half a scru- ple. Aq. Rosa?, f. ^x. M. ! Rose Water, ten ounces. :t. JtiKctio. 'Mix them for an injection. Aluminis, 3»sb. Zinci Sulphat. 3ss. M. ft. Injectio. Vel, 2. r>: Aluminis, 3iv. Plumbi Superacet. 33s. 891 DISEASES OF THE PUERPERAL STATE. swinging in a cot or hammock, and riding in an easy carriage, will be most appropriate. If the disease resist these remedies, or it shall appear from the first unnecessary to employ them from any idea of their inefficacy, the only relief that can then be afforded, unless the woman becomes pregnant, is to be obtained by wearing a pessary. This is usually made either of wood or ivory, and if properly adapted to the pas- sage and of a fit construction, may be worn without much incon- venience, or any pain. Whenever such an instrument is used, certain attentions will, however, be necessary. Thus, the pessary should never be allowed to remain in the passage above a few days at a time, otherwise it may become the source of some irritation. It ought, therefore, to be withdrawn occasionally on going to bed, be well cleaned, lest the secreted matter attached to it become acri- monious, and be re-introduced in the morning before the patient quits her bed. Pessaries are always either circular or oval; the former can only be used where the disease has not made much progress, and when the tone of the vagina is not much impaired. It will seldom be safe to introduce a circular pessary, the diameter of which exceeds two inches and a half; it should be large enough however to keep the situation in which it is placed, else it will slip away; but it should not be of such a size as to incommode the woman or to injure the parts by its pressure. Occasionally the pessary should be changed for one of a smaller size, as the vagina recovers its proper tone. The oval pessary rests with its longest diameter across the vagina, neither interfering with the rectum nor urinary passages. It seems best adapted for those cases in which the tone of the vagina is so much diminished as to require a large support. Its longest diameter ought not to exceed three inches and three quarters.* All pessaries ought to be introduced with great care, and be placed as high up in the vagina as possible. Before any attempt is made in the reduction of prolapsus uteri, it will first be necessary to empty the bladder and rectum: this being done, let the patient be so placed as that the pelvis shall be much higher than the shoulders. The practitioner is then to apply his fingers and thumb to the lower part of the tumour where the os uteri is situated, and by a gentle and gradual pressure this is to be carried up into the centre of the tumour itself. The pressure is afterwards to be continued until the parts are returned into their proper place. A pessary is then to be introduced, and the patient to be enjoined to remain in a recumbent posture for several hours. Where a woman who is liable to prolapsus uteri becomes preg- nant, there will be no occasion for the pessary aftei the third month, and by proper treatment after delivery, a return of the complaint may probably be prevented. * ?ee Observations on the Diseases of Females, by Charles M. Clarke. -DISEASES OF INFANTS. 895 In married women, whilst there remains a possibility of preg- nancy, the hope of a radical cure continues, because the processes to which the vagina and parts connected with it are subjected after parturition, often produce a permanent reduction of the tumour. In these cases the principal remedies therefore are pessaries. But the complaint frequently remains after the period of menstruation is over, and when all likelihood of a radical cure is done away. In cases of this nature, Dr. Hamilton, of Edinburgh, has attempted by exciting artificial inflammation of the vagina, to procure an adhe- sion of its sides, and thus to form what he terms a fleshy pessary. Unhappily Dr. Hamilton failed in the experiment which he made for this purpose. A powerful stimulant is certainly required to produce in the Vagina and other canals lined with a mucous membrane, that kind of inflammation which forms coagulable tymph; for in these parts a slight degree of inflammation occasions pus to be poured forth, but a greater is demanded for the formation of lymph, exactly the contrary to what occurs in most other parts of the animal body. Mr. John Hunter says,* that he produced adhesive inflammation in the vagina of an ass, by injecting a strong solution of the oxymuriate of mercury. The remedy would by no means how- ever, be adviseable in a woman. DISEASES of INFANTS. Much attention and experience are required to treat the diseases of infants judiciously ; close and repeated observation being the principal means of supplying the want of that kind of assistance which the personal information of adult patients generally affords. The disorders of early infancy are, however, more obvious than has been generally supposed ; their number is comparatively small, their causes are uniform, and the treatment of most of them is simple and pretty certain. Improper food, confined and unwholesome air, the want of due exercise and cleanliness, difficult dentition, and unhealthiness of the parents, are the most general causes of the diseases of infants, Others have indeed been enumerated both by ancient and modern writers, such as their general laxity, the greater irritability of their nervous system, and the delicacy of their muscular fibres, which may indeed be considered as so many predisposing causes. The symptoms of the first diseases of infants (by which we also judge of their nature) are chiefly retention and excretion, sour belchings, sickness, vomiting, purgings, inquietude, crying, wake- fulness, heaviness, loathing of the food, contractions and sharpness of the features, blueness about the mouth, turning up of the eyes, sudden startings from sleep, thirst, heat, the manner of breathing * See his Treatise on the Blood, p. 240. S9G DISEASES OF INFANTS. and of crying, retraction of the lower extremities, hardness and dis- tention of the belly, and pustules or eruptions, external or internal. To these may be added the openness or firmness of the fontanelles and of the sutures, the strength and figure of the bones, and the relaxation or contraction of the skin in general, and of the scrotum in particular. The pulse and urine are less certain marks, in the greater number of their complaints, than they are in older children and adults. Having thus briefly noticed the causes and symptoms of infantile diseases in general, I shall proceed to consider each separately. Small-pox, chicken-pox, measles, scarlatina, and such other eruptive diseases, together with croup, hydrocephalus, ophthal- mia, hooping-cough, scrofula, rickets, tinea, capitis, worms, and a great many other diseases, being equally liable to attack children of a maturer age, have already been noticed in the preceding pages of this work, in the class and order to which each belongs.—See the Index and Systematic Arrangement. As. it is always more desirable, as far as we are able, to prevent diseases rather than to cure them, and to obviate the causes rather than to remove their effects, I beg leave, previous to my entering on the treatment of infantile diseases, to offer a few observations on the diet and proper management of young children. During the first months of a child's life, the milk of its mother is unquestionably preferable to every other kind of nourishment, and even to the milk of another woman, provided the parent is in good health, and labours under no malformation of the nipples, or constitutional imperfection of importance. As, however, it is usually more convenient, and at times absolutely necessary, to bring up the child partly by the hand, as it is called, at the same time that it sucks, we should be careful to regulate the diet both with regard to quality and quantity, that its stomach may neither be disordered with what is improper nor be oppressed with excess. The food which is prepared by art should be thin and liquid, and be made fresh every day. It is to be offered to the infant frequently by little at a time, and at proper intervals, and not to be crammed down its throat as often as it awakes from sleep, or cries, as is the custom with many nurses. Instead of a spoon, a horn or glass bottle covered with parchment, and perforated so as to imitate a nipple, may be used. This gives occasion to some little exertion in sucking, imitative of what we see in nature, and is moreover attended with the advantage, that the infant will not be gorged or induced to take more than it really wants. At first it will be sufficient to give infants occasionally, along with the breast, a little milk and water warmed to the temperature of the mother's milk, with a very small proportion of sugar ; or we may substitute thin gruel made from pearl barley, grits, rice, or arrow-root, mixed with about a third of cow's milk, which may occasionally be changed for thin pap made with bread or biscuit, DISEASES OF INFANTS. 897 with a due proportion of fresh milk; but all these should first be passed through a lawn sieve, to insure their being thin and smooth. At the end of five or six months the diet may be made a little stronger, consisting of plain mutton or chicken-broth, clear and free from fat, or beef-tea, and occasionally some light pudding may be allowed. About the eighth or ninth month a small por- tion of animal food may be given, particularly if nature has pointed out its propriety by early dentition. The animal food given to young children should be plainly roasted or boiled, hot or cold; fried and boiled meat, and what is heated a second time by hash- ing or mincing, being less digestible, ought to be avoided. If teething commences soon and goes on well, the infant may be weaned at about nine months old ; but if dentition is late, or ac- companied with much irritation, it may continue at the breast for a whole year, provided the health of the mother will admit of it, or that she is not again pregnant. When the child is weaned, any kind t)f light plain animal food may be allowed it once a day, with a due proportion of vegetables, consisting principally of the fari- nacea, as flour, rice, sago, &c. From a mistaken expectation of strengthening weakly children, some people give them animal food twice or thrice a day, but this is injudicious. The most proper drink for children will be plain water. The practice of swathing infants with bandages is now judi- ciously laid aside; and deformity, as a consequence of dressing or clothing children improperly^ rarely to be met with. The rule to be observed with respecfrto the article of dress, ought to be, that a child have no more clothes than are necessary to keep it warm: that they sit easy and loose on its body ; and that they be changed frequently, especially when they happen to be wetted. Dirty clothes not only gall and fret the tender skin of infants, but likewise give them an unpleasant smell, and are apt to produce cutaneous disorders, if not vermin: whereas cleanliness, assisted by gentle friction with the hand on every part of the body morning and night, together with proper ablutions with tepid or even cold water, tends greatly to preserve the health of children, and pro- motes perspiration. In dressing the infant, if the nurse observes the skin any where chafed, after washing the parts and drying them well, let her apply a little common hair powder to it by means of a puff; but if much galled, which will sometimes happen at the time of teething, par- ticularly in very fat children, from the heat and sharpness of the urine, let her bathe them with a wash composed of two parts of common water and one of rectified spirit, and afterwards sprinkle them with a little calamine or fullers' earth, powdered very fine. When cutaneous eruptions appear during dentition, no repellant application should be employed. A young child should be amused through the day, and not suf- fered to sleep much during that time, that it may get the more rest 114 898 DISEASES OF INFANTS. by night. The curtains of its bed should not be drawn closely round, that it may breathe free and easily. It should be early ac- customed to be much in the open air, for vigour of the body con- duces to that of the mind ; and as it is incapable of any exercise of itself, it should be the business of its nurse or other attendant to toss it well about in her arms from time to time. If the season of the year will admit of it, bathing the child frequently in cold water will very much tend to strengthen and invigorate it. The chamber which is appropriated for the nursery should be roomy, and it ought to be kept remarkably clean, sweet, and pro- perly ventilated. ASPHYXIA. The apparent cessation of life in new-born infants may be owing to various causes, such as universal weakness of the vital powers, collections of glairy matter in the vesicles of the lungs, the intro-"' duction of a quantity of the liquor amnii into the trachea, and a congestion of blood in the lungs, arising either from the neck of the child being tightly encircled by the os uteri or navel-string, or from the head being long detained in the passage. Asphyxia sometimes takes place also in consequence of a portion of the funis protruding through the os uteri during labour, by which means the circulation through the chord is completely interrupted. When universal weakness of the vital powers seems to be the cause of asphyxia, we must be cautious not to suffer any effusion of blood from the umbilical chord. #The communication between the child and the mother should be K^pt up as long as possible; for which reason we should avoid any violent pullings at the chord ; that the placenta may not be too soon detached; and we should likewise not be in a hurry to apply a ligature. It not unfrequently happens, after a tedious labour, or where a portion of the funis has protruded through the os uteri during labour, so as completely to interrupt the circulation through the chord, that the child is so weak and faint as to show little or no signs of life. In such cases, after cleansing it and wrapping it in flannel, we should stimulate its temples and nostrils with spirits of hartshorn, and rub its chest with brandy. If these means fail to excite the languid circulation, we should then introduce a pipe or catheter into its mouth, and thereby endeavour to inflate the lungs : - pressing the thyroid cartilage at the same time to prevent the air from passing down the oesophagus, which plan ought to be pursued for a considerable length of time, as there is great reason to sup- pose that many children might be saved were we to adopt the means which have been pointed out, and continue them long enough. Stimulating the intestinal muscles *to contraction, by pouring cold water on the child's thorax, so that air may rush in by the glottis, may likewise be tried. Besides inflating the lungs and pursuing the other steps which have been mentioned, care should be taken that the child does not lose its heat; for which DISEASES OF INFANTS. 899 reason it will be advisable to put it into a bath of warm water, and while this is preparing it may be enveloped in warm flannel. From what has been observed on galvanism under the head of Suspended Animation in consequence of Drowning, it is probable that this remedy might prove a valuable auxiliary in many cases of asphyxia. Where a portion of the liquor amnii gets into the trachea and produces asphyxia, or the mouth of the infant is discovered to be filled with a glairy matter, rendering the respiration difficult, sonorous, and rattling, we must not only rinse the throat of the child, but likewise place it in an attitude which will facilitate the discharge of the liquor. Having done this, we should endeavour to reanimate the infant, by inflating the lungs, and then pressing out the air, imitating in this way, for a considerable length of time, natural respiration. If a congestion of blood in the lungs, from the causes before- mentipned, has occasioned the suspension of life, the most proper step to be pursued will be, to suffer a small quantity of blood to be lost from the end of the divided chord. The same will be advisable after a tedious labour, where there is much stupour present, in order to lessen the determination of blood to the head. Professional men being often called upon to give evidence before a court of judicature in cases of supposed infanticide, it seems right to mention, that much careful observation is required to discrimi- nate between a child that is still-born, and one that has lived only a short space of time after its birth. Various appearances also, both internal and external, may be mistaken for marks of vio- lent death. Even the swimming of the lungs in water, a test on which much reliance has been placed, is on many occasions found to be fallacious ; for they will float in consequence of a putrefac- tive process having commenced, as well as when filled with air by respiration. A woman suffering the pains of labour, may have the foetus escape from her and fall to the ground on its head whilst she is resting on her knees and elbows, or standing on her feet so as to destroy the child unintentionally. It should also be understood, that an infant, even at the full time of utro-gestation, may escape from a woman into a privy, or any such like place, during her exer- tions to evacuate the contents of the intestines, and this may happen without her intending to destroy it. Such cases beyond doubt do sometimes occur. It may likewise happen, that an unmarried woman, on coming to her full time, and having concealed her condition, maybe taken ill when by herself, and be delivered of a live child : but that either from syncope ensuing speedily, or her being suddenly deprived of reason from a distracted state of mind, owing to a sense of the shame which will attach to her foible, she may be so overcome as to be rendered incapable of assisting the infant, whereby it may 900 DISEASES OF INFANT*. suffer suffocation under the bed-clothes, or be otherwise so injured as only to make a few inspirations. In other instances it may happen, that although the child is born alive, still, from its uni- versal weakness, the want of due assistance, the circulation of blood between the mother and child being so interrupted either from undue pressure in its passage, or the umbilical chord being twisted round its neck in various convolutions, so as to produce congestion in some organ important to life, or from haemorrhage from the umbilical chord, when no ligature has been applied to it; or from some other cause, it may soon cease to breathe, without receiving any intentional injury from its mother. No doubt occur- rences of this nature do sometimes take place; and they clearly point out the impropriety of placing any reliance on the floating of the lungs in water as a test of infanticide. The floating of the lungs of a new-born infant, where no putridity exists, incontestably proves that it has breathed; but, although this is the case, the presumption that the mother has intentionally destroyed it, is by no means satisfactory. or clear. Justice undoubtedly requires from every medical practitioner, that his evidence before a coroner or jury should be regulated by truth; but humanity and mercy dictate to him, that he ought to have the fullest assurances of guilt, before he gives an opinion that may deprive a fellow-creature of life. On all such occasions he should recall to mind the holy text which tells us, it were better that many guilty escape punishment, than that one innocent suffer. Those who wish to make themselves well acquainted with medical jurisprudence, will derive full information from Dr. Hunter's Remarks, inserted in the 6th volume of Medical Observations and Inquiries, p. 271 ; and from Dr. Farr's Translation of Joh. Fred. Faseli's Treatise on such Tokens in the Human Body as are requisite to determine the Judgment of a Coroner and Courts of Law, in Cases of Divorce, Rape, Murder, &c. London, Becket, 1788.. ' A pleasing writer* informs us, that at Copenhagen there is a hospital for the reception of pregnant women who have reasons for seeking concealment. They are received into it upon paying a small stipend ; they enter at night in masks, and are never seen but by those who are necessary to their comfort, and even their names are not required. Since the establishment of this noble and hu- mane institution, he gives us to understand that there has been a very visible diminution in the crime of infanticide. Much, indeed, it is to be regretted, that no asylum on a similar plan is to be found by unfortunate females in our united king- dom ; and that so many of them annually suffer an ignominious death, for laying violent hands on their offspring in the moments of shame, anguish, and despair. p' See Carr's Summer Northern Tour. DISEASES OF INFANTS. 901 • THE BLACK OR LIVID COLOUR OF INFANTS. It sometimes happens, that immediately after birth the face and neck of the infant put on a livid or black appearance, the lips become purple, and the breathing short; which symptoms either go off soon again, or terminate in death. They are to be attributed either to an imperfect closure of the foraman ovale, or some mal-formation of the heart or lungs ; or to the vessels having imperfectly undergone those changes which are necessary for all artimals who breathe common air. I know of no remedy likely to obviate these appearances. In an Appendix* to the fourth edition of the Modern Practice of Physic, published at New-York, Dr. David Hosack, an eminent professor of the University of that State, and to whom I have now dedicated this work, as a testimony of the high opinion I entertain of his abilities both as a practical physician and teacher of medi- cine, has recorded two cases of this disease which were success- fully treated by him. In the first, he had in vain tried evacuations, and afterward anodyne medicines, upon the principle of the disease being of a spasmodic nature. He then had recourse to a stimulant mode of treatment, the remedies not having been attended with any relief or advantage. A blister was applied upon the breast, two others behind the ears, cataplasms of mustard, ryemeal, and vinegar, were put to the soles of the feet, the whole body was bathed with warm brandy, and afterwards with a diluted solution of ammonia; and from time to time an attempt was made to give the child a spoon- ful of wine whey; but all these means produced no beneficial effects. After six hours had elapsed it became more feeble, respi- ration was suspended for a greater length of time than in the com- mencement of the disease, and the circulation became less vigo- rous : these, with greater coldness of the extremities, excited great alarm. It appears that Dr. Hosack had frequently employed, in the latter stage of malignant fevers and diseases of great debility, a stimulating bath, prepared with the bark of cinchona and spirits; and as a last resource he determined to give it a trial in the present case. He therefore directed four ounces of this bark in powder to be boiled for a few minutes, in about two gallons of water; to this, when fit for use,a pint of Jamaica spirit was added. When it was cooled to a temperature rather above that of the body, the child was immersed in it up to its neck; and to render the bath more stimulating, a small quantity of the diluted solution of ammonia was added from time to time. A very apparent and favourable change took place in a short time; respiration was perfectly restored while the child remained in the bath; the circulation became vigorous and active,' the countenance resumed its lively hue, the power of swallowing * See.j)age 910. 902 DISEASES OF INFANTS. (which had been lost) was restored, and in every respect the child manifested sysmptoms of relief. It was now removed from the bath, wrapped up in warm dry flannels, and put to the breast. This it took with eagerness, and it remained composed and free from complaints for about half an hour, at which time a fresh paroxysm came on. The bath was employed a second time, and repeated during one or two other paroxysms with the same relief as before. These, however, were of shorter duration, and returned after long intervals. The child at length recovered, and was restored to perfect health. In the second case, when Dr. Hosack visited the child, its respiration was completely suspended, the face of a dark bluish colour, the circulation weak, and very irregular, and the extremi- ties were almost cold: he instantly directed a bath to be prepared in the same manner as noticed in the first case, and when ready the child was immersed in it for about fifteen minutes ; its respiration soon became regular. In about half an hour's time the fit re- turned, but was of short continuance and less violent: the bath was employed a second time, which completely removed all com- plaint. A RETENTION OF THE MECONIUM. A dark-coloured viscid matter, known by the name of meconium, is contained in the bowels of all infants at their birth, and is usually discharged during the two or three first days, in consequence of the milk of the mother, which is first secreted, being somewhat of an aperient nature. In general this will be sufficient to bring off the meconium ; but where it fails to do so in the course of a day or so, the aid of medi- cine may be necessary, and the best we can employ is about two drachms of the oleum ricini. Some give a solution of manna in water, or equal parts of oil of almonds and syrup, if these do not act readily, a clyster of thin gruel, with a little olive-oil and com- mon salt, may be thrown up into the intestines. The custom of drenching children with some drug or other the moment they are born, whether requisite or not, with the view of carrying off the meconium, is highly reprehensible, for, in most cases, the milk of the mother will of itself be amply sufficient. THE YELLOW GUM, OR ICTERUS INFANTUM. This is a species of jaundice which affects many children at or soon after their birth, and which usually continues for some days. It has generally been supposed to arise from an obstruction of the biliary ducts forcing the bile back upon the liver, from the meco- nium impacted in the intestines, or from mucus or viscid matter clogging the ductus communis. The effects produced by it are, langour, indolence, a yellow tinge of the skin, bilipus urine, and a tendency to sleep, which is sometimes fatal, where the child is prevented from sucking. DISEASES OF INFANTS. 903 For the. most part the disease is easily removed by clearing the intestines by some mild laxative, such as the oleum ricini, where the mother's milk does not of itself prove sufficiently aperient. The disease, in some instances, has been supposed to proceed from a viscid matter obstructing the gall-ducts. In these it may be necessary to give a gentle emetic, consisting of a few drops of the tartarized solution of antimony, and on the succeeding day we may administer four or five grains of rhubarb. Should the yellow- ness continue after these means have been adopted, the emetic as well as the opening medicine may be repeated in the course of a few days. Dr. Underwood mentions that in those cases where an emetic has been objected to, and the attention devoted wholly to keeping the belly open, the yellowness not unfrequently will con- tinue to the end of the month, accompanied with languor and other symptoms of debility. We now and then meet with instances where infants are affected with the true jaundice, distinguished by the skin being every where discoloured, as well as the whites of the eyes. Sometimes this appearance is of little importance, scarcely requiring any parti- cular medical aid, and disappearing spontaneously; but in other cases, the infant appears to suffer much. In these, besides em- ploying daily frictions to the stomach and belly, as well as a warm bath, we should administer saponaceous and other medicines as advised under the head of Jaundice.—(See this disease.) EXCORIATIONS AND ULCERATIONS. From a neglect of proper cleanliness, children are very apt to become chafed in the wrinkles of the neck, behind the ears, and in the groins. To remedy occurrences of this nature it will be proper to bathe the excoriated parts twice or thrice a day with a little warm milk and water, and afterwards to sprinkle them with some absorbent powder, such as tutty or calamine, laying over all a bit of scorched linen rag. Where the excoriation is very considerable, a wash composed of two parts of rectified spirit and one of common water may be used. A little of the ceratum plumbi superacetatis spread upon fine lint may be employed as a dressing. In obviating exco- riations, we are however to be cautious in drying up discharges behind the ears in infants, as very bad consequences have been observed to ensue from making use of repellent applications in such cases. In some children of a gross habit of body, and particularly about the time of teething, a species of excoriation extending low down in the neck is apt to take place, which at length degenerates into large deep sores, and not unfrequently has terminated in gangrene. Here fomentations of cinchona will be necessary, and we should at the same time administer its powder internally. Cases of this na- ture do not occur, however, very frequently. When ulcerations ensue, and they are large and painful, fomen- I* 904 DISEASES OF INFANTS. tations of poppy-heads boiled in milk will be likely to prove beneficial. Should they show no disposition to heal after such treatment, some mercurial application* may be made use of, and this may be laid on morning and evening spread on a bit of soft linen, or fine lint. Where alteratives are thought necessary, small doses of the submuriate of mercury with the testacea may be given internally. HICCUPS. Some infants are much incommoded by hiccups, and they arise probably either from acidity in the stomach, or from some nervous irritation. In the former case, a powder composed of a little prepared chalk and rhubarb (about eight grains of the former with two or three of the latter) may prove beneficial. In the latter, it may be proper to give a few drops of the spiritus ammoniae aromaticus, or the tinctura camphorae comp. In some instances, a little plain vine- gar has proved an effectual remedy. Where the complaint is severe, or returns frequently, it may be advisable to rub the sto- mach Avith soap liniment, to which a little tincture of opium has been added. INFANTILE ERYSIPELAS; This is a very dangerous species of the spurious or erysipelatous inflammation, which is not often met with, however, but in lying-in hospitals. The ordinary time of its attack being a few days after birth, it was, at the first of its being observed, thought never to appear later than the month; but this has since been found not to be the case. It seizes the most robust as well as delicate children, and in a very sudden manner ; the progress is rapid ; the skin turns of a purplish hue, and soon becomes much hardened. The milder species appears often on the fingers and hands, or the feet and ankles, and sometimes upon or near the joints ; form- ing matter in a very short time. The more violent kind is gene- rally seated about the pubes, and extends upwards on the belly, and down the thighs and legs, though sometimes it begins in the neck, and is equally fatal. It seems indeed to be always less dan- gerous when confined to the extremities, than where it seizes on, or spreads to any other part of the body. The swelling is but moderate ; but after becoming hard, the parts turn purple or livid, * 1. g; Hydrargyri Submuriat. 3j- * 1. Take Submuriate of Mercury, one drachm. Unguent. Sambuci, ^j. M. Elder Flower Ointment, one ounce Mix them for use as an ointment. Vel, Or, 2. fy Hydrargyr. Praecip. Alb. 3ss. 2. Take White Precipitated Mercury half a-drachm. Unguent. Cetacei, ~ss. M. Spermaceti Ointment, half ar ounce. Mix them. DISEASES OF INFANTS. 905 and very often sphacelate, especially in boys, when it falls on the scrotum ; the penis swells, and the prepuce puts on that kind of emphysematous appearance, which it has been observed to do, when a stone sticks in the passage, or in the anasarca of the scrotum. The disease often proves fatal in a few days. Dissections of such children as have been destroyed by this disease have frequently discovered the contents of the abdomen glued together, and their surface covered with an inflammatory exudation, exactly similar to that found in women who have died of puerperal fever and peritonaeal inflammation. In males, the tunicae vaginales have been sometimes filled with matter, which has evidently made its way from the cavity of the abdomen, and accounts for the appearances of the organs of generation just now described. In females, the labia pudendi are affected in like manner; the pus having forced a passage through the abdominal rings. As in all cases the appearances to be observed on examination of the bodies of children who have sunk under the disease clearly de- monstrate that it is truly inflammatory in its first stage, it appears rational to adopt the depleting plan within the first twenty hours. The bowels ought therefore to be freely acted upon by purgatives, after which leeches may be applied to the abdomen, if the skin thereof is not affected with inflammatory redness. We are informed by Dr. Underwood,* who, since the days of Haller,t seems to be the only physician that has distinctly noticed this complaint, that various means were made use of at the British Lying-in Hospital without success ; though the progress of the inflammation seemed to be checked for a while by saturnine lotions and poultices, applied on the first appearance of the inflammation ; but it soon spread, and a gangrene presently came on; or where matter had been formed, the tender infant sunk under the dis- charge. On a further acquaintance with the disease, linen compresses wrung out of camphorated spirit, were applied in the place of the liquor plumbi acetatis, which we are given to understand have proved more successful in checking the inflammation in several instances. After the cinchona mixed with a little aromatic confec- tion was made trial of internally, it appears that several children recovered. The cinchona ought therefore to be given as soon as possible either by the mouth or thrown up in a clyster, and we may add a little confectio aromatica to it. Dr. Underwood observes, that in a few instances the disease has been attended with some varieties ; for infants have not only come into the world with several hard and sublivid inflammatory patches * See his Treatise on the Diseases of Children, page 33, vol. i. f See dis Chapter de Febre Erysipelacea. 115 906 DISEASES OF INFANTS." and ichorous vesications about the belly and thighs, but with other spots already actually in a state of mortification. A large eschar has soon spread upon the spine of the tibia, with smaller ones about other parts of the legs, and on several of the toes and fingers. In such cases particularly, he says, the bark of cinchona and cor- dials must be exhibited liberally, and the inflamed and mortified parts be well fomented, and dressed with warm applications. CUTANEOUS ERUPTIONS. Children at the breast are very subject to slight eruptions, particularly during the first month : and these serve, no doubt, to relieve the body of some acrimonious humour. Of this kind is the red-gum, which consists in an efflorescence, or small red spots, most usually confined to the face and neck, but in some cases extending to the hands and legs, and even over the whole body, appearing in large patches, and sometimes raised considerably above its surface. Now and then it shows itself in the form of small pustules, which are filled with a limpid, or sometimes a purulent or yellow fluid. Every species of this eruption has generally been attributed to a predominant acid, but ought rather to be regarded as an exertion of nature to throw off something hurtful. All that is generally necessary in this complaint, is to give a little magnesia, or testaceous powder, according to the state of the bowels, and to keep the child moderately warm ; otherwise, by the r&sh striking in, the acrimonious humour will fall on the first passages, and be succeeded by sickness and purging, till perhaps the eruption appears again on the skin. In cases of nausea at the stomach, or any disposition to fits upon this eruption being repelled, spme light cordial, such as a few drops of the spiritus ammoniae aromaticus, may be given twice or thrice a day, and the child's feet, or perhaps the whole body, be put into warm water. The state of the skin and bowels has a peculiar consent; and on this account infants whose first passages have been frequently disordered, are always benefited by eruptiong*bn the skin. In such, peculiar care is therefore necessary to guard against their being repelled, as well as to invite their return. Another species of eruption which is frequently to be met with in young children, is that to which medical writers have given the name of crusta lactea, or lactumen. This often puts on a very unpleasant appearance, but is nevertheless of an innocent nature, and it has been observed that those children who have been much loaded with it have usually been healthy, and have cut their teeth easily. A remarkable circumstance attending this eruption is, that, however thick and long-continued the scabs may be, the crusta lactea never excoriates, nor leaves any scar on the parts. The crusta lactea appears first on the forehead, and sometimes on the scalp; and then often extends half way over the face in the DISEASES OF INFANTS. 907 form of large loose scabs, which, as the disorder increases, appear not very unlike the small-pox pustules after they have become dry. It begins with white vesicles larger than the itch, which soon be- come of a dark colour and then sc*ab, with an efflux of ichor and great itching of the parts affected. The rash generally disappears of itself when the child has cut three or four teeth, though it may sometimes continue for several months, and in a few instances even for years. In such cases, tes- taceous powders, the submuriate of mercury, and other alteratives, have usually been administered, but in general without success. The Harrowgate or other sulphureous waters might probably have a good effect. In very bad cases, a blister might prove serviceable. During early dentition a rash very much resembling the measles is apt to make its appearance, and this usually continues very florid for three or four days, but it does not dry off in the manner of that disease. It is often preceded by nausea and vomiting, but is attended with little or no fever. During the continuance of the eruption, a few doses of the testaceous powders, with the addition of a little of the nitrate of potass, will be the most proper medicines; and when it disappears, some gentle laxative may be advisable. Other rashes in which the spots are larger and often attended with some degree of fever (occasioned probably by the irritation of teething) are frequently to be observed during a more advanced stage of dentition, particularly while the double and eye-teeth are cutting. These require only a proper attention to be paid to -the state of the bowels, unless the fever is considerable ; in which case we should pursue the steps recommended under the head of Dem tition. A slight species of essera or nettle-rash is another eruptive dis- ease to which infants are liable; but this requires in general little attention, and often disappears in a few hours. When the body is much covered with eruptions, and they remain long out, attention should be paid to their not being repelled suddenly by any expo- sure to cold, or by any other improper treatment; but should they happen to strike in, we may then have recourse to the tepid bath and light cordials, in order to solicit their return to the surface of the body, which will be of the greatest consequence should the child suffer much from the repulsion. An eruption very much resembling the itch is sometimes to be met with in infants at the breast; as likewise in children who have cut all their first teeth. It usually begins about the arms and thighs, but always spreads soon afterwards to the other parts, and not unfrequently extends from the head to the feet. In some places it appears in very small eruptions like the points of pins, with watery heads ; and in others, in as large ones as peas; and sometimes in foul blotches, which, after breaking, form sores and broad ugly scabs. These die away, and similar ones show them- 908 DISEASES OF INFANTS. selves successively in other parts, sometimes for two or three months, leaving the skin of a dirty hue. The external application of an ointment consisting of the un- guentum sulphuris with a small proportion of the unguentum hydrar- gyri nitratis, will seldom fail to remove the complaint, if assisted at the same time with the internal exhibition of the hydrargyrum cum creta or hydrargyri sulphuretum nigrum. Washing the parts affected with about two drachms of the liquor potassae mixed with a pint of water will often afford much temporary relief. In all the eruptive complaints of infants, their taking cold ought carefully to be guarded against, and the belly should be kept open. If the child is sick at the stomach, a little magnesia or testaceous pbwder with a small addition of the pulvis contrajervae compositus may be given now and then. Should the eruptions strike in sud- denly, every means should be used to reproduce them again on the surface of the body. Repellent applications should never be em- ployed when eruptions appear during dentition. In consequence of some bad quality in the milk of the person who nurses the child, it sometimes happens that an eruption comes out on different parts of its body. In all such cases the nurse should be changed. Constipation should likewise be obviated, and some gentle absorbent medicine be given once or twice a day. ACIDITIES, GRIPES, AND FLATULENCY. C6stiveness, improper or too much food, bad milk, weak digestion, and that natural tendency there is in the stomach of all children to generate acidity, are the causes which give rise to these affections. When the food becomes acid on the stomach, instead of being properly concocted and converted into chyle and blood, it is likely to give rise to continual crying, restlessness, drawing up of the legs forcibly to the body, hiccups, vomiting, diarrhoea, flatulency, soUr eructations, griping pains, green stools, and a depression of strength; and where the irritation is very considerable, convulsions are apt to ensue. If acidity prevails in a high degree, and the infant is troubled with sour belchings and much irritability at the stomach, it may be advisable to evacuate its contents by a weak solution of tartarized antimony, given in the quantity of one or two tea-spoonsful every quarter of an hour, until a sufficient effect has been procured ; after which, a few grains of rhubarb and magnesia may be ordered, to carry off the remaining offending matter. To prevent any fresh accumulation of the same nature, it will be proper to give, as circumstances may seem to require, a little of the mistura cretae, but more particularly where any severe degree of purging attends. Together with these or other remedies, exercise, and frictions of the body, but of the abdomen in particular, should not be forgotten. diseases of infants. 909 Acidities and flatulency sometimes prevail in so high a degree as to occasion severe griping pains, perfectly obvious by the infant's screaming, crying, and drawing its knees up to the belly, with the presence of abdominal tension. In such cases it will be necessary to dislodge the contents of the intestines, should costiveness prevail, by some gentle laxative; after which we may administer absor- bents* and carminatives, the last of which we may give in a clyster! as well as by the mouth ; and where the pains seem very acute, and by no means relieved, we may make a small addition of opium. As opiates do not however agree well with children, they should not be resorted to on trivial occasions. Besides adopting these steps, it will be proper to apply warmth externally to the stomach and bowels by means of heated bran or chamomile flowers put into a soft flannel bag, which probably will greatly assist in abating the pain. Children that are partly brought up with the spoon, and who are very subject to flatulency, should always have a few carraway seeds boiled up with their food. As acidities, gripes, and flatulency, seem frequently to originate in some error of the diet, the proper regulation of this ought to form a principal part of their cure. Sometimes it may be neces- sary to change it almost wholly, or at least to withdraw something from whatever farinaceous substances are used. A costive habit of body is very apt to occasion flatulency and griping pains in infants. This ought therefore to be obviated by giving twice or thrice a week, as the occasion may require, a small quantity of the oleum ricini, or we may substitute a few grains of magnesia in a spoonful of the acjua anethi sweetened with a little syrup of roses or manna, to which may be added a few drops of tinctura sennae in order to render it warmer, and quicken its ope- ration. Either of these will be preferable to rhubarb, as this pos- *1. Take Prepared Chalk, twelve grains. Peppermint Water, two ounces. Compound Tincture of Lavender, half a drachm. Spirit of Carraway, half an ounce. Of this mixture the child may take two tea-spoonsful occasionally ; adding, if ne- cessary, to every dose, Tincture of Opium, six drops. Or, 2. Take Chalk Mixture, two ounces. Tincture of Calumba, two drachms, Solution of Subcarbonate of Potass, fifteen to twenty-two drops. Mix them, and let a tea-spoonful be taken three or four times a day. t 3. Take Barley Water, four ounces. Olive Oil, two drachms. Oil of Aniseed, six drops. Mix them for a Clyster. Add occasionally, when the child is much griped, Tincture 'of Opium, eight to ten drops. * 1- ft Cret. Praeparat. gr. xij. Aq. Menth. Pip. f. ^ij. Tinct. Lav. C. f. 3ss. Spirit. Carui, f. ^ss. M. ft. Mistura, cujus sumat cochl. minim. ij. pro re nata. Adde, si sit uecessitas, Tinct. Opii, fn. iv. singul. dos. Vel, 2. ft Mistur. Cretae, f. ^ij. Tinct. Calumb. f. 3ij. Liquor. Potassae Subcairbonat. til x__xv. M. Capiat cochl. minimum ter quaterve in die. t 3. ft Decort. Hordei, f. ?iv. 01. Olivse, f. 3'j- — Anis. 1TI iv. M. ft.. Enema. Adde, pro re nata, Tinct. Opii, fll v.—vii. 910 diseases of infants. sesses too restringent a power, which is not to be counteracted even by joining it with magnesia. To promote the peristaltic motion in costive habits, it will be advisable to rub the region of the stomach and belly several times a day with a piece of flannel or the hand somewhat warmed, in addition to using medicine. Where flatulency is an attendant upon a lax state of the bowels and indigestion, its remedy will consist in a removal of these complaints, as advised under the heads of Diarrhoea and Dyspepsia. Dr. J. Clarke, of Dublin, observes,* it is the general opinion of writers on the diseases of infants, that by far the greater number of these originate from acidity or coagulation of the milk, and that therefore absorbent and saponaceous medicines ought to be used, to counteract these morbid causes. From various considerations, he is induced to suppose that this opinion is founded on a fallacious analogy and superficial observation of the matters evacuated by infants. He finds, that healthy human milk suffers no coagulation from acids, ardent spirits, runnet, infusion of the stomach of a foetus, nor from any of the known coagulating substances; and that it contains little or nothing of that matter which constitutes curd, so that there can be no power in the stomach of an infant to separate curd from it; that though it is supposed prone to run into an acescent or acid state, it is far less so than that on which the young of ruminant animals are fed ; a cow's milk acquiring greater acidity in thirty-six hours than the human milk does in many days; and that cow's milk in moderate warmth becomes offensively putrid in four or five days, a change which human milk does not undergo in many weeks and sometimes months. He finds also that green fa3ces, commonly ascribed to acidity, because bile is turned green by acids, cannot arise from acid milk, because it is only the mineral acids which produce that change of colour; nor has the daily use of sour milk or vegetable acids any such effect on adults, and faeces of this colour are observed in cases where no acidity has been suspected. Dr. Underwood, in speaking on the properties of human milk,? enters into a controversy with Dr. Clarke for alleging that this con- tained no sensible quantity of curdy matter. From the experiments made by the former of these gentlemen, it appears that the human milk does really contain no inconsiderable portion of curdy or case- ous matter, though its separation is attended with peculiar circum- stances. He allows that neither runnets, acids, nor spirits, separate any very sensible quantity of this curd in the space of eight-and- forty hours, as they constantly do in cow's milk; but that in a longer time it is afforded in evident quantity. It appears also that human milk has less tendency than other kinds to run into acescency or putridity. The length of time necessary for the separation of the * See his Treatise on the Properties attributed to Human Milk, inserted in th« Transactions of the Royal Irish Academy. t See his Treatise on the Diseases of Children. diseases of infants. 913 curd seems to have been the cause, in Dr. Underwood's opinion, of Dr. Clarke's denying its existence. In a practical view this difference of sentiment on the subject does not seem very important. Although the coagulation of milk in the stomachs of infants labouring under disease be granted, it does not follow, that the chief attention of the practitioner should be directed to the destruction of the acidity, as the means of pre- venting such coagulation. For the acidity itself is only an effect, arising from a diseased action of the stomach, which of course would engage his attention. OF VOMITING. When what has been taken is returned crude and unaltered, it may be suspected to arise from over-feeding, and to require nothing more than temperance for its cure. Vomiting, however, is often an attendant on other complaints, and sometimes of itself consti- tutes an original disease. Where there is a vomiting of digested food, it will be right to change the mode of diet, or to open the body by some gentle ape- rient. If these means do not answer, and the vomiting continues, it will be proper to clear the stomach by a gentle emetic, after- wards giving the saline medicine in an effervescing state, with a drop or two of the tincture of opium. We may at the same time apply a blister over the region of the stomach, or rub it well with an anodyne liniment. OF A LOOSENESS OF THE BOWELS.' Various causes may and do occasion a diarrhoea in infants, and perhaps in the greater number of instances it is brought on either by two much or unsuitable food, in which cases a diligent attention must be paid both to the choice and regulation of the diet. In some instances, however, it may be symptomatic of other diseases, or may arise from an exposure to cold, or an increased secretion of bile. In the latter case, it may be advisable first of all to cleanse the stomach by a gentle emetic; but in all it will be proper to clear the intestines by a few grains of rhubarb and mag- nesia, the operation of which being over, we may give a little of the prepared chalk,* joined with some aromatic, twice or thrice a day. * 1. $ Cret. Praeparat. 3ss. Aq. Anethi, — Cinnam. aa f. ?jjss. Tinct. Card. C. f. 3ij. Syrup. Cort. Aurant. f. 3j. M. Capiat cochl. j. infantis bis terve in die. Vd, 2. ft Pulv. Cinnam. Comp. gr. ij. * 1 Take Prepared Chalk, half a drachm. Dill Water. Cinnamon Water, of each one ounce and a half. Compound Tincture of Carda- moms, two drachms. Syrup of Orange Peel,one drachm. Of this mixture, a pap-spoonful is to be taken twice or thrice a day. Or, 2. Take Compound Powder of Cinnamon. two grains. 912 diseases of infants. When the stools continue to be more frequent than they ought to be, and are either slimy or tinged with blood, it will be necessary to repeat the rhubarb at proper intervals, and in the meantime the infant may take something to control the complaint,* as well as proper nutriment to recruit its strength. Flour, sago, or rice boiled in milk, together with the jelly of a caifs foot or isinglass, with a small addition of wine, will be good articles of diet under such circumstances. In addition to these means it will be advisable to envelope the infant's body in flannel, so as to keep it of a proper temperature. That form of diarrhoea which is attended by green stools and griping, may in general be removed readily by a brisk laxa- tive, consisting of the submuriate of mercury and rhubarb, fol- lowed by small doses of magnesia and chalk. When obstinate, we may give half a grain of hydrargyri submurias each or every other night. The application of a small blister about the size Of a crown piece to the pit of the stomach, will sometimes produce a very good effect where internal remedies have failed. When the irritability of the intestines seems to be great, the fluid stools being thrown out with quickness and force, and the strength appears to be rapidly sinking, we may advise a clyster composed of starch, with a few drops of tinctura opii, to be injected twice or thrice a day. The external application of opium by friction or plaster, is likewise useful. In such cases the application of a blister proves frequently of great use. TRISMUS NASCENTIUM, t OR THE LOCKED JAW OF INFANTS. This is a disease of very frequent occurrence in the West Indies? where many infants are carried off by it soon after birth, and espe- cially, negroes and those of colour, as they are usually called. It is well known, however, to prevail in other parts of the world, and is + Trismus Nascentium, being a spasmodic disease, ought, in adhering to classifica- tion, to have been included among those of this nature; but as being peculiar to infants, i? inserted here. Cret. Praeparat. gr. vj. M. ft. Pulvis 6tis horis sumendus. * 3. ft Confect. Aromat. 3j. Aq. Purae, — Cinnam. aa f. ?jss. Tinct. Catechu, f. 3j. ------Opii, til viij. M. Cochl. unum infanti? mane, hora meri- diana et nocte sumendum. Vel, 4. fy Misturae Cretae, f. |ij. Aq. Cinnam. f. ^j. Tinct. Kino, f. 3j. ----Opii, flT, vij.—x. M. ft. Mistura, cujus capiat cochleare infan- tis bis terve in die. Prepared Chalk, six grains. Mix them, and let this powder be taken every six hours. * 3. Take Aromatic Confection, one scruple. Pure Water. Cinnamon Water, of each one ounce and a half. Tincture of Catechu, one drachm. --------Opium, twelve drops. Of this mixture, one pap-spoonful is to be taken morning, noon, and night. Or, 4. Take Chalk mixture, two ounces. Cinnamon Water, one ounce. Tincture of Kino, one drachm. --------Opium, from ten to fifteen drops. Of this mixture, let a pap-spoonful be given to the child twice or thrice a day. DISEASES OF INFANTS. 913 frequently met with in Minorca,* in Switzerland, some of the northern districts of Scotland, especially in the island of St. Kilda, and among the children of the Westmann islands! near Iceland. It has also been met with in Ireland.^ In most cases the disease is wholly confined to the jaw ; but in a few a considerable contraction and rigidity of other muscles of the face, with strabismus and rolling of the eyes, together with sub- sultus tendinum, have been observed. It has been attributed to visceral irritation, costiveness, and not purging off the meconium in the bowels ; to dividing the navel- string with a blunt, lacerating instrument; to not paying attention to its falling off, and consequent irritation from a neglect of the remaining sore, which assumes a sloughy appearance; and to ex- posures to cold, and currents of air, negro women in the West Indies being usually permitted to lie-in at their own houses, which are often in but very indifferent repair. Dr. James Clarke, in his Treatise on the Yellow Fever and other West India Diseases, informs us, that from having observed the children born in large negro huts generally were exempt from any attack of the disease, and that white children, or those of free people, who had their kitchens apart from their dwelling-houses, escaped the jaw-fall, (the term by which the disorder is known in places where it is prevalent,) he suspected that the smoke from burning wood, which is the usual fuel in the West Indies, was the cause of it. In consequence of this, he gave orders that o fires should be allowed in the negro houses where the lying-in women were, which effectually answered the purpose of preventing the disease. He adds, that he recommended a lying-in hospital to be built on every estate near the negro houses with a planked floor, so that no fire could be kept in it; since which no children, who were born in these hospitals, and remained in them with their mothers for nine days, have ever been attacked with this disease. I perfectly agree with Dr. Clarke that it is highly necessary every plantation should be furnished with a lying-in house, and it is what I strongly enforced to West India proprietors in a work|| I pub- lished some years ago ; but I must dissent from him in ascribing the smoke arising from a wood fire, as the sole cause of the trismus nascentium. Certain it is that infants are never attacked with it after the ninth day of their age, if even exposed to the influence of this cause; and it is therefore probable that it is not the real, and far less the sole one. I am much inclined to suppose that the dis- ease often arises in negro children from the want of attention to the falling off of the navel-string, and the consequent irritation from a neglect of the remaining sore, which becomes sloughy. The period * See Cleghorn on the Diseases of Minorca. t See M'Kenzie's Travels in Iceland, p. 413. X Dublin Hospital Reports, vol. i. I! See Medical Advice to the Inhabitants of Warm Climate?, p. 10 of the Introduction. 116 914 DISEASES OF INFANTS. at which the disease occurs, seems to correspond exactly with the falling of the funis, and the ulceration left behind. What makes strongly against Dr. Clarke's supposition is, that tetanus (of which trismus nascentium is a species) is most usually cured very readily when it arises from an exposure to cold, or any other cause than the irritation occasioned by a wound. When produced by this, it generally proves fatal. The disease in question termina- ting always in this manner, may with great propriety, therefore, be ascribed to a cause which is of a similar nature. Another argument, which shows the fallacy of Dr. Clarke's sup- position with respect to smoke from burning wood being the chief cause of trismus, is, that during my practice in the West Indies, I met with some instances of the disease in white children, in whom it was impossible to have arisen from this cause, as no fire-places are to be found in the dwelling-houses of the white inhabitants, and the kitchen is always a detached building, into which such infants never enter. Although the exciting cause of trismus nascentium probably is irritation in the wound, from a division of the funis and the process of sloughing connected therewith, still the disease appears to be connected with a more or less vitiated state of the atmosphere, as it occurs more frequently in hospitals than in private dwellings.* Trismus nascentium proves fatal in most instances. No effectual means having yet been discovered for the cure of this disease, all that can be done is to avoid as much as possible the several causes which have been mentioned as being likely to give rise to it. Every lying-in woman ought therefore to be accommo- dated in a comfortable house, which is annoyed neither by smoke, rain, nor any partial current of air. On the birth of the infant, the navel-string should be divided with a pair of sharp scissors, after which the portion that remains should be wrapped up in a little scorched linen. No force whatever must afterwards be used to bring on its separation ; it should come away spontaneously ; and if any little ulceration is left behind, it ought to be attended to, and daily be dressed with some mild, healing ointment, such as the unguent, cetacei or ceratum calaminae, avoiding at the same time any great pressure upon it by bandages. As I have supposed the disease to arise most commonly from the irritable state of the divided funis, might it not be advisable, by way of prevention, to wet the part frequently with a watery solu- tion of opium ? To remove costiveness or visceral irritation, and carry off the meconium, which has been assigned by some practitioners as a probable cause, one or two tea-spoonsful of the oleum ricini may be given to the child the day after its birth, which may again be repeated in two or three days, should the mother's milk not pro- cure a sufficient number of stools. * See Dublin Hospital Reports, vol. i. DISEASES OF INFANTS. 915 On an attack of the disease, we ought certainly to have recourse to the means advised under the head of Tetanus, however unsuc- cessful they may be likely to prove. A few recoveries, it is said, have been effected by the warm bath. FEBRIS INFANTUM REMITTENS, OR THE INFANTILE REMITTENT FEVER. From the age of one year to five or six, children are liable to be attacked with a fever, that makes its advances very gradually, manifesting itself by irregularity in the bowels, which are some- times too costive, and at others too much relaxed. On its coming on, the child becomes fretful, his lips are dry, his hands hot, his breath short, the head painful, and his pulse quick, being often 120 in a minute ; he is unwilling to stir or speak, the DISEASES OF INFANTS. moderate or remove the febrile symptoms, and then, if necessary, to restore the lost energy by tonics. The first thing therefore to be done is to cleanse the stomach by a few grains of ipecacuanha; which will be preferable to any anti- monial preparation, and soon afterwards to administer some active purgative: I mention active, because the intestines are usually so torpid, that what would on another occasion be considered a full dose, will have no effect in this complaint. For restoring the healthy actions and secretions of the chylopoetic viscera, nothing seems so efficacious as small and often repeated doses of the sub- muriate of mercury, followed up after some hours by a solution of the sulphate of magnesia in an infusion of senna, or by a dose of castor oil. When the bowels are very irritable, small quantities of mistura cretae with a few drops of tinctura opii must be given al- ternately with the purgatives above specified. If the head is much affected, its temperature greater than the rest of the body, and there are other marks of sanguineous deter- mination to the brain, the case must be treated as one of hydro- cephalus acutus. Blood should be freely drawn by leeches, by cupping, or by opening either the external jugular vein or a branch of the temporal artery. A tepid bath may be useful in this fever after the stomach and bowels are properly cleansed. To obviate debility when the fever goes off, we may recommend a daily use of some tonic medicine,* if judged necessary. APHTHiE, OR THRUSH. The thrush in children has generally been supposed to arise from acidities, or some other acrimonious humour lodged in the stomach and bowels. Various causes of derangement in the ali- mentary canal are certainly to be regarded as those which occasion aphthae. One of the chief of these is worms, and it appears in this way that these two complaints are so frequently conjoined. Another occasional cause is bad milk, which may be vitiated by whatever is injurious to the nurse's health, such as great anxiety, violent pas- sions, poor diet, &c. In some instances the thrush may possibly depend upon the 1. ft Decoct. Cinchon. f. ^iij. Tinct. Calumb. f. 3ij. Acid. Sulph. Dilut. Ill x. M. Rhei, gr. xij. Ferri Subcarbonat. 3ss. M. *1. Take Decoction of Peruvian Bark three ounces. Tincture of Calumba, two drachms. Diluted Sulphuric Acid, fifteen drops. Capiat cocM. unum infantis bis terve in j Mix them. The dose may be a pap-spoon- die. j ful twice or thrice a day. Vel, I Or, 2. R Pulv. Cascarillae, 3j. 2. Take Powder of Cascarilla, one drach. ------Rhubarb, twelve grains. Subcarbonate of Iron, half a scruple. Mix them, and divide them into twelve Etinchartulasxij. divide, quarum unam dosem sumat mane et vespere. papers, of which take a dose mornm- and evening DISEASES OF INFANTS. 917 natural habits of the infant as well as upon the mode of bringing it up, particularly in regard to food, air, and the state of the bowels. This seems a warrantable conclusion, inasmuch as the thrush is sometimes found to seize every infant in certain families, in what- ever way the children may be managed, as well as to occur occa- sionally in others upon a want of proper attention to the state of the alimentary canal, where a great number of other children properly watched have uniformly escaped it. The disorder generally appears first in the angles of the lips, and then on the tongue and cheeks, in the form of little white specks. These, increasing in number and size, run together more or less according to the degree of malignity, composing a thin white crust, which at length lines the whole inside of the mouth from the lips even to the oesophagus, and is sometimes found to extend into the stomach and throughout the whole length of the 'vi^intestines; producing also a redness about the anus. When the crust falls off, it is frequently succeeded by another of a darker colour, or livid hue ; but this happens only in the worst kind of thrush, for there is a milder sort that is spread thinly over the lips and tongue, which returns a great many times, and always lasts for several weeks. When the thrush is an original disease, it is never attended with any fever at its commencement, although the mouth is frequently so much heated as to excoriate the nipples of the nurse, and becomes so tender that the child is often observed to suck with reluctance and caution ; but when it has arisen in consequence of severe bowel complaints, or other infantile disorders, it is then sometimes accom- panied with fever and a severe diarrhoea. Even in very bad kinds of thrush there does not appear, however, any evident fever at the commencement of the complaint; but towards the close it may be apparent, and is sure to be of the low kind. Violent hiccups, vomiting, sense of suffocation, great prostration of strength, severe diarrhoea, coma, the aphthae being of a brown colour, and any of the symptoms of cynanche maligna attending, are to be considered as very unfavourable. The disease, when recent and confined to the mouth, may in general be easily removed; but when of long standing, and extending down to the stomach and intestines, it very frequently proves fatal. Among the French, and especially in their public hospitals, the thrush seems to be a much severer disease than in England. To evacuate the stomach of acidities, or other acrimonious humours, it will be proper on the first appearance of aphthae to give a gentle emetic. This may be done even in slight cases; but where the specks are of a dark colour, and the inside of the cheeks are beset with them, the remedy, by emptying the stomach of the crude juices and acrid matter, will be likely to prove highly useful. After the operation of the emetic we may recommend a course of 913 DISEASES OF INFANTS. the testaceous powders, giving a preference to the purest and softest. If the child is of a costive habit, a little magnesia may be advised; on the contrary, if its bowels are rather loose, and its frame delicate, we may then substitute two or three grains of the compound powder of contrajerva. The testaceous powders are to be administered for three or four days successively, and then we may prescribe something more laxative, to carry down the scales as they fall off from the ulcerated parts. In mild cases, rhubarb is regarded as the best medicine ; but where the child is of a robust habit, and the disease is violent and has extended rapidly, it may be necessary to make an addition of a few grains of the submu- riate of mercury. When a child of a weak habit is attacked with thrush which appears of a malignant nature, and which from its dark appearance threatens to terminate in gangrene, we should give a decoction of the bark of cinchona joined with a little aromatic confection. To render its efficacy the more certain, it may likewise be used in the form of clyster, with the addition of a few drops of tinctura opii to prevent its passing off by stool. In order to keep the infant's mouth clean and comfortable, and to prevent as much as possible any injury to the nurse, as well as to dispose the sloughs to fall off, and incline the parts underneath to heal, it is customary to make use of detergent applications in the form of gargles and lotions. In the gangrenous thrush it will be best to wash the parts frequently by means of a syringe, or a piece of soft linen rag rolled round the finger, with a strong de- coction of cinchona bark, rendered somewhat sharp with the diluted sulphuric acid ; but in common cases of thrush, unattended by any disposition to gangrene, we may employ either of the gargles re- commended below.* If the aphthae extend to the intestines, it may be advisable to sheathe the parts by emollient clysters,! repeating them twice or thrice a day. 1. ft Decoct. Hordei, f. ^iv. Sodae Sub-borat. 3ss.—3i. Mellis Rosae, f. |ss. M. ft. Gargarisma. Vel, 2. ft Confect. Rosae, ?ss. Aluminis, 3ss. Aq. Purae, f. §iv. Acid. Sulph. Dilut. 1U x. Tinct. Myrrh, f. |ss. M. ft. Gargarisma. t 3. ft Decoct. Avenae, f. |iij. Gum. Acac. Pulv. 3'« Ol. Olivae, f. §ss. M. ft. Enema octava quaque hora adhiben dum. * 1. Take Decoction of Barley, four ounces. Sub-borate of Soda, half a drachm to one drachm. Honey of Roses, half an ounce. Mix them for a gargle. Or, 2. Take Confection of Roses, half an ounce. Alum, half a drachm. Pure Water, four ounces. Diluted Sulphuric Acid, fifteen drops. Tincture of Myrrh, half an ounce. Mix them for a gargle. t 3. Take Oatmeal Gruel, three ounces. Powdered Gum Acacia, one drachm. Olive Oil, half an ounce. Let this clyster be administered every eight hours. DISEASES OF INFANTS. 919 When an excess of purging attends, the medicines advised un- der the head of Diarrhoea will be necessary. The other means and remedies directed for the cure of cachexia aphthosa, in the former part of this publication, will likewise be proper in this species of thrush, to which head I must beg leave to refer the reader. PROLAPSUS ANI, OR FALLING OF THE FUNDAMENT. We often meet with this disease in children of a weak habit, or who have been much afflicted with severe purgings. It is also a frequent consequence of irritation in the rectum, arising from the nestling of ascarides in the gut. In prolapsus ani, considerable advantages have been experienced from a frequent use of astringent injections,* particularly of an infusion of galls or oak-bark; and when a small proportion of opium is added to the liquor, it tends greatly to lessen the irritation in the extremity of the rectum. The same may be used as a wash to the protruded parts, after which they may be sprinkled with a little Armenian bole, powdered very fine, and then be reduced. To effect this, we should first order the protruded parts to be well fomented with a decoction of poppy-heads, after which we are to make a gradual and general compression of the protruded gut, and thereby reduce it, and place it within the anus. In children it is often difficult to reduce the last folds if the finger is pushed through the orifice, for when it is again withdrawn, the gut slips down. We may, therefore, twist a piece of stiff paper into the form of a cone, soften the point by wetting it, and oil the surface: having done this, place it upon the point of the finger, and so push the last portion of the gut within the anus: the cone will slip out easily without bringing down the gut with it.f Another way of reducing the prolapsus is by using a piece of distended gut to push it up, and this distended gut may be pressed up altogether within the rectum, so as to replace it effectually. On letting out the air from the distended gut, it is readily to be brought out without the prolapsus following it. The child should not be permitted to strain, nor take the usual position at stool. It should be kept in the erect posture, and his t See Mr. Charles Bell's Treatise on Diseases of the Urethra. * 4. ft Decoct. Quercus, f. |iv. Tinct. Opii, fit viij.—xj. ft. Enema. Vel, 5. ft Liquor. Calcis, f. Infus. Gallar. f. aa ^ij. Vini Opii, m, viij. M. ft. Enema. * 4. Take Decoction of Oak Bark, four ounces. Tincture of Opium, twelve to fifteen drops. Mix them for a clyster. Or, 5. Take Lime Water, Infusion of Galls, of each two ounces. VinousTinctureofOpium,twelve drops; for an injection. y20 DISEASES of infants. hips ought to be held together, so as to compress and support the gut. With the view of strengthening the parts, the debility of which is in general to be considered as the chief cause of this disease, we should advise not only the cold bath in a general way, but likewise the throwing cold water more directly on the buttocks and back of the child; and besides these tonics, it should be put under a course of steel, myrrh, and the bark of cinchona.—See these under the head of Dyspepsia. ATROPHIA ABLACTATORUM, OR WEANING BRASH. This disease occurs in children that are weaned too early, or such as are attempted to be reared without the breast, and also where improper food is given with or without sucking. It appears most frequently in children of a lax fibre, and whose constitutions at a more advanced stage of life might be supposed liable to the attack of strumous disorders. It commences with frequent griping and purging, in which the stools are usually of a green colour, and is often accompanied with bilious vomiting. In the progress of the disease the stools are sometimes ash-coloured and shining, and sometimes lienteric.— Atrophy succeeds to these symptoms, and convulsions often come on, and carry off the child. Amodern writer* supposes the exciting cause of this disease to be too sudden an alteration of the diet of a child at an unfit season. The weaning brash, if attended to in time, may in general be removed; but if neglected, it frequently proves fatal before the sixth or seventh week. On dissection the mesenteric glands usually appear either inflamed or enlarged. In some instances tubercles have been found in the lungs. In others the liver is firm, and larger than natural, and the gall-bladder is filled with dark green bile. Remarkable contractions of the diameter of the gut in several parts of the intestinal canal, have been perceived in some in- stances. A proper attention to diet constitutes the first point to be attended to for the removal of the disease; and, above all a return to the natural food, the mother's milk, where circumstances will admit of it. Where they do not, animal food, in the form of broth or jelly, should principally be employed. Vegetable food must be prohibited, as well as fruits, acids, and compositions of which butter and sugar form a part. Pure air, exercise, gentle frictions, and frequent washings of the body with tepid or cold water, will be good prophylactics. Flannel worn next to the skin, worsted stockings, and every precaution against cold irregularly applied, should be attended to. The employment of a warm bath, * See Essay on the Diseases of Children, by J. Cheyne, M. D. vol. i. p. 34. DISEASES OF INFANTS. 921 guard against fever, will greatly contribute to the safety of denti- tion, as well as to the child's passing quickly through this hazard- ous period* CONVULSIONS, Violent spasmodic affections sometimes attack infants without any apparent cause ; but in general they are produced either by a lodgment of some acrid matter in the intestines, or wind pent up, or they arise from teething, worms, the sudden striking in of a rash, ©r the accession of some Constitutional disease, as, for example, the small-pox, scarlatina, &c. Any trifling matter, capable of irri- tating the nervous system, will induce symptomatic Convulsions- in some infants; while others again will withstand a great deal. The younger and more irritable the infant is, the more liable will it be to symptomatic convulsion, especially from any considerable disturbance in the first passages. We are informed by Dr. Clarke, of Dublin, that owing to mis- management and bad air, an epidemic convulsive disease prevailed in the lying-in hospital of that city among the infants within the first nine days, which swept off great numbers of them annually : but this was at length obviated by discovering the cause. When convulsions proceed from any other cause than an erup- tion of the small-pox, (in which they are usually regarded as prog- nosticating a favourable species of it,) they are always dangerous, as well as alarming. A surer indication of danger is to be drawn from the distance of the paroxysms than from the forcible con- tractions of the muscles during the fit. Where the intervals are short, although the fit itself be not long nor violent, the disease is to be considered as more dangerous than where severe paroxysms- are attended with long intervals. In the treatment of convulsions in children the chief object to» be attended to is the removal, if possible, of the cause which has given rise to them. If they seem to be occasioned by improper food and indigestion, a gentle emetic may be given, and for this purpose we may employ a weak solution of tartarized antimony, of which a tea-spoonful may be administered every ten or fifteen minutes until the desired effect is procured. When supposed to proceed from a lodgment of acrid matter in the bowels, this ought to be removed by a.laxative clyster, assisted by some gentle aperient, given by the mouth, such as calomel, followed by an infusion of senna with a little tincture of jalap ; if from flatulency, then carminatives ought to be used, as advised under that parti- cular head; and if from teething, whenever the tooth can be dis- covered working a passage through the gum, scarifications may be made with the edge of a lancet immediately over it; and this operation we may repeat for several successive days, till either the tooth makes its way, or the convulsions cease. If scarificat- ions are not found to answer the purpose, we may cut boldlv down JM&EASES OF INF&NTS, 925 to the tooth, and liberate it in every part; and this plan we may likewise adopt with all such as are manifestly making their way. Worms having been looked upon as a frequent cause of recur- ring convulsions, we should always have recourse to the remedies which have been advised under that particular head, when from the prevailing symptoms we suspect them to have been excited by this cause. Should convulsions have arisen from the sudden disappearance of a rash, or the drying up of a discharge from behind the ears, thp reappearance of these ought to be promoted. Where the fits are of some duration or frequent recurrence, a warm bath, at the temperature of 92 or 94 degrees of Fahrenheit's. scale should be employed, and, if necessary, be often repeated: this, by diffusing the circulation more generally, and determining it to the surface of the body, may be highly useful. As in the greater number of cases of convulsions there are strong reasons for believing that the head is overloaded with blood, it will be advisable to take away some, either by leeches, cupping, or opening the external jugular vein. When convulsions are not relieved by the means which have been suggested, blisters should ^e applied to the lower extremities. The application of cold fluids or ice to the scalp, having pre1 viously shaved the head,* has been attended with happy effects in cases of convulsions, as well as in inflammation of the brain, both in children and adults. With the view of shortening the duration of an individual paroxysm, there is scarcely any stimulus so powerful as the plen- tiful affusion of cold water over the face, the body being placed in a horizontal position with the face upwards. The effluvia arising from volatile alkali or ammonia, plentifully inhaled, will also prove a useful stimulus. As antispasmodics, the preparations of ammo- nia and aether will be most serviceable, although asafoetida, vale* rian, castor, musk, amber, and other fetid substances, are often given. It is only in cases of the most urgent necessity that wet hhould venture on giving a small quantity of the syrup of poppies* or a few drops of the tincture of opium. In those convulsive attacks which frequently precede an eruption of the small-pox, nothing will be required but the free exposure of the child to cool air. The liquor potassae subcarbonatis given in doses of from five to fifteen drops, according to the age of the child, and repeated every ten minutes, has been known effectually to remove convulsive affections in young children, which had for a length of time resisted the powers of the oxyd of zinc, musk, extractum hyoscyami, clys* ters of asafoetida, anodyne injections, with opium and blister*. * .See.QQmm^ntaries on tfre rrro&t important Diseases of Children, by Jotln Clarke; Mi D. '£26 . DISEASES of ixrANi'.-.. I,t is probable, however, that in these cases the fits arose from a*. vere griping pains in consequence of acidity. Where a high degree of organic debility prevails, volatile alkali, viz. the spirit, ammoniae succinatus in doses of a few drops, in some proper vehicle, may be substituted for the former. In clysters, the liquor vol. cornu cervi is likewise of avail in these cases in a greater or less dose, according to circumstances. When convulsions are not preceded by any of the usual symp- toms, they may be regarded as idiophatic. In difficult labours, for example, the brain is often much compressed, and soon after delivery the child is attacked with fits. In such cases, it will be advisable to let the navel-string bleed one or two tea-spoonsful before it be tied. Thus the oppression of the brain will be relieved, and the disagreeable consequences will be prevented. But if this has been neglected, and fits have actually come on, we must then endeavour to make a revulsion, and empty the vessels of the head by opening the jugular vein, or by applying leeches to the temples j fey procuring an immediate discharge of the meconium ; by putting blisters behind the ears, or to the back; by bathing the feet in warm water; and by rubbing the soles with liquor ammoniac carbonatis. Inward fits are much talked of by nurses, and some authors have indeed made mention of them ; but more particularly Dr. Arm- strong. Infants, during the first month, are said to be more or less liable to them. The symptoms are these : the child appears as if it was asleep, but the eyelids are not quite closed: and if you observe them narrowly, you will see the eyes frequently twinkle with the white of them turned up. There is a kind of tremulous motion in the muscles of the face and lips, which pro- duces something like a simper or smile, and sometimes the appear- ance of a laugh. As the complaint increases, the infant's breath &eems now and then to stop for a time ; the nose becomes pinched; there is a pale circle about the eyes and mouth, which sometimes changes to livid, and comes and goes by turns; the child starts, especially if you stir it ever so gently, or if you make the least noise near it. Thus disturbed, it sighs or breaks wind, which gives relief for a while ; but presently it relapses into dozing. Some* times it struggles hard before it can break wind, and seems as if falling into convulsions ; but a violent burst of wind from the stomach, or vomiting, or a loud fit of crying, sets all to rights again. For the removal of these, Dr. Armstrong recommends us to give antimonial wine in a few drops, according to the age of the infant; but all that appears to be necessary is, to take up the child when it sleeps too long, and the smile often returns, with any of the other symptoms just described, and to tap it gently on the back, rubbing its stomach and belly well before the fire. This gentle exercise will bring a little wind from its stomach, (which is supposed to be the cause of the complaint,) and fhe DISEASES OF INFANTS'. 927 tihild will {hen go quietly to sleep again. Should these simple means not prove sufficient, some carminative may be given to it* Such as a drop or two of the oleum anisi or oleum carui on a bit of white sugar. SYPHILIS INFANTUM, OR THE VENEREAL DISEASE IN INFANTS'. Although a child sometimes shows some appearances ©f syphilis at the time of its birth, still it more frequent^/ happens that none are to be observed until after an expiration of at least ten Or twelve days. When the disease exists at the time of its birth, or shows itself * Soon afterwards, it makes its appearance in the form of an erysi- pelatous efflorescence dispersed over the whole body, the cuticle is in part or altogether destroyed, and a serous matter oozes from the skin. WThen it makes its appearance some days after the birth,, irregular blotches of a light red colour, and somewhat elevated, arise about the anus, nates, and pudenda. Crusty eruptions appear *■■* in other parts of the body, and these in some places continue dry and scale off, but in others an acrid thin matter exudes from ;- .v,„ them. *-•''- * Although we may not be able to traee any marks of the existence of the disease in either the father or mother of the child, still it may possibly be derived from them. When children are born with the appearances just described, Of several dead births have followed, we may, for the most part} attribute them to the parents labouring under some constitutional affection of syphilis, without their being probably aware of it. In all such cases it will be necessary to put both of them under a mercurial course. To effect a cure in a child at the breast, it will in general be sufficient to give the necessary medicines to the woman who nurses it; which office should always be undertaken by the mother, as, by getting any other to suckle it, she would in all probability soon be infected likewise, as happened in a case which lately fell under my care. In the progress of the cure, the same rules and cautions are to be observed as have already been pointed out in the syphilis of adults. In instances of this nature, an alterative course long persisted in ought to be preferred to that of exciting any degree of salivation. If it is found necessary to wean the child before the cure is com- pleted, or to introduce mercury into the habit of the child from the very beginning, instead of giving it to the woman who suckles it, we may then direct that it shall take about a quarter of a grain of the hydrargyri submurias, every night and morning, mixed up in a little honey or thick syrup ; which course ought to be continued for at least a week or ten days after the disappearance of all the symptoms. By a due attention to the following circumstances we shall be enabled to ascertain whether the nurse infects the child, or th£ 9*28 UISEASES 0*-INFANTS Fatter the nurse. Where the breasts of the nurse and the mouth ol' the child only are diseased at one time, we cannot give a decisive opinion until we have other evidences. If, however, the breasts of the nurse be the only parts diseased, while other marks of syphilis, besides those of the mouth, are apparent on the infant, it is very probable that the complaint has been communicated by the child; on the contrary, if the infant has no disease except of the naouth, a*d other marks of it appear on different parts of the nurse besides the breasts, it is then highly probable that the infant has imbibed the disease with the breast milk. Further, if the nurse has secondary symptoms and the child only primary ones, we may reasonably suppose that the complaint has been communicated by the nurse, or some other person by whom the infant may have been kept. Where the child has secondary symptoms of the syphilis the disease probably has been entailed by its parents', A VIEW FORMER AND PRESENT LONDON PHARMACOPCELE, TOGETHER WITH THE SYNONYMS OF THE DIFFERENT COLLEGES. Names in the FormerLondonPharmacopoeia.* Acetiim Distillatum Acidum Acetosum .., Nitrosum ............ Nitrosum Dilutum Vitriolicum......... iErugo .............. IEther Vitriolicus Aloes Barbadensis.................... ----Socotorina...................... Alumen Ustum....................... Ammonia Praeparata................ Antimonii Sulphur Praecipitatum Antimonium Calcinatum........... i Tartarizatum......... Aqua Aluminis Composita.......... ----Ammoniae....................... ------------Acetatae............ ------------Purte..... Acetum Colchici. Acidum Aceticum AcidumCitricum .. Acidum Nitricum Names in the New Pharmacopoeia. Dilut. Sulphuricum iErugo iEther Sulphuricus Reclifieatus Aloes Vulgaris Extractum ..... —— Spicatae Extractum ....... Alumen Exsiccatum............. Ammoniae Subcarbonas.......... Antimon. Sulph. Praecipitatum Oxydum Antimonii Tartarizatum........... Liquor Aluminis Compositus ..... ------Ammoniae Subcarbonatis -------, Acetatis ........ Ammoniae Edinburgh Pharmacopoeia. Acid. Acetosum Distillatum. Acidum Nitrosum Sulphuricum Subacetas Cupri iEther Sulphuricus. Aloes Hepatica..................... Gummi Resina Aloes Socotrinae Sulphas AluminaeExsiccatus .... Ammoniae Carbonas .............. Antimonii Sulph. Praecipitatum Tartris Antimonii (et Potassae) Liquor Ammoniae Carbonatis Aqua Acetatis Ammoniae..... ——- Ammoniae ............... Dublin Pharmacopoeia. Acetum Distillatum. Acidum Citricum Crystallis Concre- Acidum Nitrosum. [turn, ----Sulphuricum, iErugo. iEther Sulphuricus. Aloes Hepatica. Gummi Resina Aloes Socotrinae Alumen Ustum. Ammoniae Carbonas. 'i Sulphur Antimoniatuin Fuscum. Oxidum Antimonii Nitro-Muriaticum Tartarum Antimoniatum. Liquor Ammonias Carbonatis. -----------— Acetatis. Aqua Ammonia Causticae. * N. B. Names of the New Articles are printed in Italics, as Acetum Colchici, Acid-urn Citricum, be, Names in the Former London Pharmacopoeia. \qua Calcis ..............,............. ----■ Cinnamomi ....................... ----Cupri Ammoniati................ ----KaliPreparati.................... -------Puri........................... ---Lythargyri Acetati.............. -----------■ ■ ■ • Composita Arabicum Gummi .........,........... Vrgeutum Nitratum .................... Arsenicum................................ Balsamum Canadense................ ---------Copaiva................... Barilla ................................... Benzoe ................................... Borax..................................*.. Calamus Aromaticus..........__ Calomelas ............................... Calx Antimonii.......................... Calx cum Kalipuro................... Canella Alba.......................... Cantharis................................ Cassia Fistularis........................, Ceratum Cantharidis .....,.........., -------Lapidis Calaminaris...... -------Lythargyri Acetati Compos —i-----Resinae Flarse............... Names in the New Pharmacopceia. Liquor Calcis........................... Aqua Cinnamomi ...................... Liquor Cupri Ammoniata ....'......... ------Potassae Subcarbonatis....... Potassae......................... ------Plumbi Subacetatis ........... ----Dilutus Aqua Calcis............... — Lauri Cinnamomi Acaciae Gummi ....... Argenti Nitras ................... Arsenici Oxydum Sublimatum Terebinthina Canadensis. Copaiba............................ Soda Impura..................... Benzoinum........................ Sodae Sub-boras .................. Cajaputi Oleum .,................ Calami Radix...................... Hydrargyri Submurias........... Antimonii Oxydum............. Potassa cum Calce................. Canellae Cortex .,................. Lytta....................,.............. Carbo Ligni........................ Cassiae Pulpa...................... Cataplasma Fermenti. Ceratum Lyttae. • Calaminae.............. --------Plumbi Compositum. Resinae. Ceraficm Sabinte Edinburgh Pharmacopceia. Dublin Pharmacopceia. Aqua Potassae Gummi Mimosae Niloticae Argenti Nitras.............. Arsenici Oxydum.......... Copaiferae Officinalis Resina Liquida Carbonas Sodae Impurus ............ Styracis Bensoina Balsamum....... Boras Sodas ........................... Melaleuca? Leucadendri 01. Vol.. Acorus Calamus Radix Hydrargyri Submurias .. Potassa cum Calce .... Canella Alba, Cortex Meloe Vesicatorius Carbo Ligni........... Cassia Fistulae Fruct. Aqua Calcis. ----Cinnamomi. — Cupri Ammoniati. — Subcarbonatis Kali. — Kali Caustici. Liquor Subacetatis Lithargyri. —--------Lithargyri Compositus Gummi Arabicum, Argenti Nitras. Arsenicum. Balsamum Copaibae, Barilla. Benzoe. Sub-boras Sodae, Oleum Cajeput. Acari Radix. Submurias Hydrargyri Sublimatum Oxidum Antimonii Nitro-Muriaticum Kali Causticum cum Calce, Canella Alba, Cortex, Cantharis. Carbo Ligni. Cassia Fistularis, Unguentum Calaminaris,. Unguentum Sabinse, Names in the Former London Pharmacopceia Names in the New Pharmacopceia. Ceratum Spermatis Ceti Cerussa Acetata Cervus Cornu..... Chamaemelum..... Cicuta .............. Cineres Clavellati Coccinella.......... Columba, Radix .. Confectio Opiata .. Conserva Cort. Aurantii -------Cynosbati ..... --------Rosa?............ Cortex Angusturae........ ------Cinchonae Flavae ------Cinchonae ......... Rubrae Crystalli Tartari . Crocus Antimonii Cucumis Agrestis Cuprum Vitriolatum Cynosbatus ........... Decoctum Cornu Cervi .. ---------pro Enemate .. -------------Fomento .. .,----.—— Hellebori Albi Ceratum Cetacei........ Cerevisiee Fermentum, Plumbi Subcarbonas .... ---Superacetas ...... Cornua .................... Anthemidis Flores....... ConiiFolia................ Potassa Impura........... Coccus ..................... Calumbae Radix......... Confectio Opii............ -----Rutce. -----Aurantiorum . -----Rosae Caninae -----;-----Gallicae Cuspariae Cortex.................. Cinchonae Cordifoliae Cortex.... -------Lancifoliae Cortex. Oblongifoliae Cortex. Potassae Supertartras Antimonii Oxydum Elaterii Poma ....... Cuprum Ammoniatum. Cupri Sulphas .......... Rosas Caninae Pulpa. Dauci Radix ........... Mistura Cornu Usti Decoctum Malvae Compositum. -----— Papaveris. ,—:----Veratri. Edinburgh Pharmacopoeia. Ceratum Simplex. Oxydum Plumbi Album ... Acetis Plumbi................ Cervi Elaphi Cornu........ Ant. Nobilis Flores.......... Conii Maculati Folium..... Carbonas Potassae Impurus Coccus Cacti .............. Columbae Radix.............. Electuarium Opiatum. Conserva Aurantii....... -----Rosae Caninae. ----------Gallicae . Angustura.................... Cinchonae Officinalis Cortex Superlartris Potassae Impurus Momordica Elaterium, Fructus Re- cens Submaturus..................... Ammoniaretum Cupri................. Cupri Sulphas......................... Dauci Carotae Semines Cerussa. Acetas Plumbi, Cornu Cervinum. Chamaemeli Floresc Cicuta. Cineres Clavellati, Coccinella. Columbo. Conserva Aurantii. Dublin Pharmacopceia. Rosae. Angustura. Cinchona. Tartarum Crystalli. Oxidum Antimonii Nitro-Muriaticum Elaterium Fructus. Cuprum Ammoniatum. Cupri Sulphas. Dauci Sylvestris Semines. Decoctum Cornu Cervi Names in the Former London Pharmacopceia Dolichos Elaterium ............................ Electuarium Cassiae ................... ----------Sennae.................... Emplastrum Cantharidis ............. -------—- Cerae Compositum....., ----------Lithargyri ............... ------------------Compositum, ■ cum Hydrargyro positum ' cum Resina Picis Burgundicae Com- Ferrum Ammoniacale Ferri Rubigo............ Ferrum Vitriolatum Flores Benzoes.......... -----Sulphuris Loti.. Gambogia......,....... Genista................... Names in the New Pharmacopceia. Decoctum Quercus. Dolichi Pubes........................ Elaterii Extractum.................. Confectio Cassiae ..................... --------Sennae..................... Emplastrum Lyttae................... ---------Cerae ................... ---------Plumbi.................. ---------Galbani Compositum. ■ Hydrargyri ............ -------!—Resinae.................. ---------Opii. ---------Picis Compositum. Extractum Aconiti. --------Belladonna............. --------Humuli. --------Hyoscyami. --------Rhei. --------Taraxici. Ferrum Ammoniatum .............. Ferri Subcarbonas................... ----Sulphas...................w... Acidum Benzoicum.................. Sulphur Lotum...................... Gambogia. Spartii Cacumina ................... Edinburgh Pharmacopceia. Dolichos Pruriens. Leguminis Pu bes Rigida ........................... Succus Spiss. Mamordicae Elaterii Elect. Cassiae Fistula?.................. ---------— Sennae................... Emplast. Meloes Vesicatorii.......... ------Simplex. -------Oxidi Plumbi Semivitrei .. ------Hydrargyri. -------Resinosum.................... Succus Spissatus Atropaa Belladonnae. Murias Ammoniae et Ferri ..,.. Carbonas Ferri Praecipitatus ... Sulphas Ferri ..................... Acidum Benzoicum .............. Sulphur Sublimatum Lotum.... Spartium Scoparium, Summitas Dublin Pharmacopceia. Doliches, Setae Leguminum. Elaterium. Elect. Cassiae. Sennae. Emplast. Cantharidis. ——— Lithargyri, Lythargyri cum Resina. Murias Ammoniae et Ferri. Ferri Carbonas. Sulphas Ferri. Acidum Benzoicum. Sulphur Sublimatum Lotum, Genista. Names in the Former London Pharmacopceia Helleboraster Folium ....... Helleborus Albus .................. Hydrargyri Calx Alba............ Hydrargyrus Calcinatus.......... ----------Muriatus ..........., ----------Nitratus Ruber .... ----------Sulphuratus Ruber ----------cum Sulphure...... Jalapium........................... Kali Acetatum........'............ —— Preparatum.................. ----Purum......................... ----Sulphuratum................. ----Tartarizatum................. ----Vitriolatum................... Lac Ammoniaci.................... ——• Assafoetidae................... Amygdalae.................... —— Guaiaci ....................... Lapis Calaminaris................. Linimentum Ammoniae............ Names in the New Pharmacopoeia. Hellebori foetidi Folia.................. Veratri Radix ........................... Hydrargyrum Praecipitatum Album . Hydrargyri Oxydum Cinereum........ Hydrargyri Oxydum Rubrum........ Oxymurias................ Nitrico Oxydum.......... Submurias ................ Sulphuretum Rubrum... - Nigrum. Infusum Digitalis. -------Tabaci. Jalapae Radix Potassae Acetas....... ------Subcarbonas Potassa Fusa............ Potassae Sulphuretum ------Supertartras .., ------Tartras ........ ------Sulphas ........ Mistura Ammoniaci -------Assafoetidae -------Amygdalae -------Guaiaci. Calamina................................ Linimentum Ammoniae Subcarbonatis --------Camphora................. ■ Hydrargyri. --------Terebinthince. N Edinburgh Pharmacopoeia. Veratrum Album Oxidum Hydrargyri Cinereum Murias Hydrargyri .............., Hydrargyri Submurias........... Convolvulus Jalapa, Radix Acetis Potassae ................. Carbonas Potassae ............. Potassa .......................... Potassae Sulphuretum........ Supertartris Potassae Impurus Tartris Potassa? ................ Potassae Sulphas................ Emulsio Amygdalae Communis Carbonis Zinci Impurus......... Oleum Camphoratum.......... Dublin Pharmacopoeia. Helleboraster. Helleborus Albus. Submurias Hydrargyri Ammoniatus. Pulvis Hydrargyri Cinereus. Oxydum Hydrargyri. Murias Hydrargyri Corrosivum. Oxydum Hydrargyri Nitricum. Submurias Hydrargyri Sublimatum. Hydrargyri Sulphuretum Rubrum. Jalapae Radix. Acetas Kali. Subcarbonas Kali, Kali Causticum. Sulphuretum Kali. Tartarum Crystalli, Tartaras Kali. Sulphas Kali. Lac Ammoniaci. ---Assafoetidae. — Amygdalae. Calaminaris. Oleum Camphoratum. Sames in the Former London Pharmacopceia. Lythargyrus....................... Luj ul a..........................j.y.. Magnesia Alba ........,......... -------—Usta................... ---------Vitriolata ............ Mel Acetatum..................... Mentha Piperitis.................. ■ ' Sativa..................... Mistura Camphorata.............. ------Cretacea ...-............... ------Moschata................. Mucilago Gummi Arabici ....... • ■ * Seminis Cydonii Mali Natron Praeparatum........., -------Tartarizatum......... ■ ■ ■ Vitriolatum.......... Nicotiana.................... \itrum...................... Oleum Succinae Rectificatum.. ------Vini.................. Qxymel ^Eruginis............. Names in the New Pharmacopceia. Liquor Arsenicalis. ------Calcis Muriatis. ------Ferri Alkalini. ------Hydrargyri Oxymuriatis. Plumbi Oxydum Semivitreum .., Acetosella. Magnesiae Carbonas Magnesia......... Magnesiae Sulphas . Oxymel........... Mel Boracis. Mentha Piperiti ... ----Viridis..... Mistura Camphorae ----Cretae Mistura Ferri Composita. ---- Moschi. Mucilago Acaciae .. Decoctum Cydoniae. Sodae Subcarbonas . Soda Tartarizata... Sodae Sulphas ..... Tabaci Folia ..... Potassae Nitras..... Oleum Pimenta; .... Oleum Succini xEthereum. Linimentum .ffiruginis Edinburgh Pharmacopoeia. Plumbi Oxydum Semivitreum Magnesia (sub) Carbonas Magnesia.............. Magnesiae Sulphas ...... Mentha Piperita, Herba Emulsio Camphorata ... Potio Carbonatis Calcis Mucilag. Mimosa? Niloticae Carbonas Sodae.........., Tartris Potassae et Sodae . Sodae Sulphas ........... Nicotiana Tabacum ....., Potassae Nitras.......... 01. Myrti Pimentae ..'..... Oleum Succini Purissimum. Dublin Pharmacopceia. Lithavgyrum* Magnesia. Magnesia Usta. Magnesiae Sulphas. Oxymel. Mentha Piperitis, Herba. Sativa. Mistura Camphorata. ------Cretae. Mucil. Gummi Arabici, Carbonas Sodae. Tartaras Sodae et Kali. Sodae Sulphas. Nicotiana. Nitrum. Oleum Baccarum Pimento, 01. Succini Rectificatum. Oxymel JEruginis> Names in the Former London Pharmacopeia. Ovis, Sevum Papaver Album Papaverum Erraticum Pilulae Opii..... -----Scillae ... Piper Indicum .. Pix Burgundies Pulvis Aloes cum Guaiaco -----Aromaticus........ Opiatus Raphanus Rusticanus .... Rhabarbarum........... Rosa Damascena; Petalum —— Rubra ............ Sal Ammoniacus — Cornu Cervi ---Muriaticus .. Santalum Rubrum ^c ammonium Seneka ..................... ^erpentarise Virginianee Radix Sevum. Papaveris Somniferi Capsulae...... Rhoeados, Petala................ Pilulae Cambogim Composites. Ferri Composita;. Hydrargyri Submurialis Comp, Saponis cum Opio. Scillae Compositae.......... Names in the New Pharmacopoeia. Capsici Baccae Pix Arida...... Potassa Carbonas. Supersulphas. Pulvis Aloes Compositus .... Cinnamomi Compositus Pulvis Kino Compositus. ----Cornu Usti cum Opio Armoraciae Radix..... Rhei Radix.........., Rosae Centifoliae Petala '<£•— Gallicae Petala ., Ammoniae Murias .... ———• Subcarbonas Sodae Murias............ Pterocarpi Lignum. Scammoniae Gummi Resina Senagac Radix..... Serpentariae Radix Soda Subcarboms. .; Edinburgh Pharmacopoeia. Papaveris Capsulae Pilulae Scilliticae .... Capsici Annui Fructus Pix Burgundica...... Pulvis Aromaticus — Opiatus. Rhabarbarum ......... Rosae Centifoliae Petala ----Gallicae Petala .. Murias Ammoniae .. Ammoniae Carbonas Sodae Murias...... Convolvulus Scammonia, Gummi Resina...................... Polygala Senega, Radix......... Aristolochia Serpentaria, Radix . Carbonas Sodae............... Dublin Pharmacopceia. Papaver Album. Papaver Eraticurn. Pilulae Scillae cum Zingibere, Capsici Baccae. Pix Burgundica. Pulvis Aloes cum Guaiaco. Pulvis Aromaticus. Raphani Rusticani Radix. Rheum Undulatum, Radix. Rosa Damascena. ----, Rubra; Petala. Sal Ammoniacum. Ammoniae Carbonas. Sal Commune. Scammonium; Gummi Resina. Seneka. Serpentaria Virginiana. Radix. Carbonas Sodae. Names in the Former London Pharmacopoeia, Spermaceti................... Spiritus iEtheris Nitrosi ....... i Vitriolici...... ------Ammoniae Compositus ... ------Anisi Compositus....... ------Camphoratus .......... ------Vinos. Rectificatus..... ------------Tenuior......... Spina Cervina................ Stanni Pulvis................. Succus Cicutae Spissatus....... Sulphur Antimonii Praecipitatum Sulphuris Flores............... --------Coti Flores ......... Syrupus Papaveris Erratici..... Tartari Chrystalli........... Thus........................ Tinctura Cantharidis ......... ——— Columbae........... .. Ferri Muriati....... . Opii Camphorata ..... --------Rhabarbari ......... Trifolium Paludosum, Herba ... Valeriana Sylvestris......... Wtriolum Album......,.. •... Names in the New Pharmacopceia. Cetaceum ...,................ Spiritus iEtheris Nitrici....... ------------—- Sulphurici..... ------Ammoniae Aromaticus ... ------Anisi ................. ------Camphorae ............ i Rectificatus. ------Tenuior. Rhamni Baccx............... Stanni Limatura. Extractum Conii ............. Antimonii Sulphuretum Praecipit. Sulphur Sublimatum........... ----Lotum. Syrupus Rhoeados. Potassae Supertartras........., Abietis Resina. Tinctura Lyttae............... -------Capsici. ------- Calumba?............. -------■ Digitalis............. -------Ferri Muriatis ....... -------Humuli. -------Hyoscyami........... ■ Camphorae Composita -------Kino. ------- Rhei ................ Menyanthes.................. Valerianae Radix............. Zinci Sulphas ......•.....•»..• Edinburgh Pharmacopoeia. Spermaceti ................... Spiritus iEtheris Nitrosi ........ iEther Sulphuricus cum Alcohole Alcohol Ammoniatum Aromaticum Spermaceti. Spiritus JSthereus Nitrosus. Liquor JEthereus Sulphuricus. Spiritus Ammoniae Aromaticus. ----Anisi Compositus. Tinctura Camphorae. Spina Cervina. Succus Spissatus Conii Maculati .. Antimonii Sulphuretum Praecipitatum Sulphur Sublimatum............ Supertartris Potassae Impurus Tinctura Meloes Vesicatorii Columbae .... Digitalis Ferri Muriatis Hyoscyami Nigri Dublin Pharmacopoeia. Succus Spissatus Cicutae. Sulphur Antimoniatum Fuscuni ----Sublimatum. Tartarum Crystalli. Tinctura Cantharidis. - Columbo. - Digitalis Purpurea? - Ferri Muriatis. - Hyoscyami. Opii Camphorata. Tinctura Rhei. Trifolium Paludosum Tinctura Rhei Palmati....... Menyanthes Trifoliata, Folium Valerianae Officinalis Radix........Valerianae Radix, Zinci Sulphas....................IZinci Sulpha*. Names in the Former London Pharmacopceia, Names in the New Pharmacopceia. Edinburgh Pharmacopceia. Dublin Pharmacopceia. Vitriolum Ceruleum.............. Vinum Antimonii Tartarizati...... Unguentum Adipis Suillae........ -------------Calc. Hydrargyr. Albi ------------Cantharidis......... ------------Cerussae Acetatae .... ------------Hydrargyri Nitratis .. ------------Hellebori Albi...... —-----------Picis .............. —----------Resinae Flavae....... ------------Resinae Nigrae. ;----------— Spermatis Ceti...... ) ■ Zincum Calcinatum............... -------Vitriolatum.............. Cupri Sulphas ......... Liquor Antimonii Tartarizati Vinum Opii. Cupri Sulphas........... Vinum Tartritis Antimonii. Adeps Preparata................. Unguentum Hydrargyr. Praecip. Albi, Ceratum Lyttae. Ceratum Plumbi Superacetatis..... Unguent. Hydrargyr. Nitrico Oxydi, Veratri................. Picis Liquids.......... Adeps Preparata Cupri Sulphas. Adeps Preparata. Unguentum Aceta,tis Plumbi ....... ----------Oxidi Hydrargyri Rubri. Ceratum Resinae Flavae. Unguentum Acetatis Plumbi. --------Subnitratis Hydrargyri. --------Hellebori Albi. --------Picis Liquidae. Unguentum Cetacei............ ----------Sulphuris Compositum. Spermatis Ceti, Zinci Zinci Oxydum ---- Sulphas ., Unguent. Oxidi Zinci Zinci Oxydum...... — Sulphas....... Oxidi Zinci. Zinci Oxydum. — Sulphas. INDEX TO THE DISEASES. —QRNfe- AbSCESS, Common ................ 104 --------of the Liver......... 183, 188 --------of the Lungs........ 163, 169 ------------ Psoas Muscle...... 104 Abortions................................ 851 Acidities in the Stomach of Adults ... 357 -------------------— Children 908 Acne, or Blotched Face ...............800 Acute Rheumatism .................... 218 Adder, bite of the...................... 830 Adynamiae, Order......................356 Aerial Poisons...........................824 Affection, painful, of the Nerves of the Face ..............................765 ; ----Hypochondriac .............368 After Pains of Lying-in Women......861 Agues .................................... Ague Cakes......................... 15, 192 Amaurosis................................695 Amenorrhoea............................725 Anaphrodisia ............................707 Anasarca ...............:.................551 Anchylosis .........................201, 219 Angina Pectoris.......................411 Animal Poisons..........................826 Animation, Suspended .................835 Anorexia.................................706 Anthrax.................................. 110 Aphtha Chronica .......................540 Aphthae Infantum ....................... 916 Apocenoses, Order......................708 Apoplexy ................................339 Appetite, Canine.................•.......703 -------, Loss of........................706 Ardor Urinae............................. 613 Arthritis................................. 198 Ascarides .................................. 807 Ascites ...................................563 ------Ovarii ...........................567 Asphyxia..................................898 Asthma ...................................418 ------Arthriticum....................427 Atoms floating before the eyes .. 368, 372 Atonic Gout.............................. 202 Atrophia..................................505 --------Ablactatorum...............920 --------Lactantium.................508 Aura Epileptica........................384 B ■Barbadoes, Glandular Disease of... 661 Barbiers ..................................355 Bile, Obstruction of......... 15, 181, 684 ——, Preternatural Secretion of ... 455 PAGE Bile, Vomiting of.......................455 Biliary Calculi ....................685, 687 Bite of the Adder ...................... 830 --------Cobra de Capello Snake . 827 ------aMadDog....................429 ------- Moscheto....................830 -------RattleSnake....;........... 827 -------Viper and other Snakes ... 829 ------- Wasps, Scorpions, and Centipedes............................ 830 Bladder, Acute Inflammation of the . 197 -------, Chronic do. Induration, Thickening, and Ulceration of the ................................197,718 -------, Stone in the .................774 Bleeding from the Nose ...............296 --------------Penis.........614, 621 Blindness, Night .......................694 Blood, Involuntary Discharges of, Or- der ......................................296 -----, Spitting of ......................300 -----, Vomiting of.....................305 Bloody Stooh.............................326 ------Urine............................307 Blotches, Scorbutic....................684 -------, Venereal ......................610 Brain, Inflammation of the............116 Breast, Cancer of the .................736 -----, Inflammation and Tumour of the......................................863 Bronchitis ............................... 171 Bronchocele.......................587, 753 Bubo, Pestilential.........'.............279 Phagedenic ......................643 Venereal ......................... 640 Bulam Fever............................ 94 Bulimia...................................703 Burns and Scalds........................787 C Cachexia Africana .....................538 ---Aphthosa.....................540 —— Sypholoidea................. 644 Cachexiae, Class of.....................505 Calculi, Biliary ...................685, 687 -, Urinary........................ 772 Cancer...................................735 -of the Female Breast...........736 — Chimney Sweepers...........740 — Cutaneous.......................740 -ofthe Eye......................740 -------Lip......................740 -------Nose....................740 -------Penis ...................740 -------Pylorus..........173, 35S 940 INDEX. PAGE Cancer of the Scrotum.................750 ------------Testicle................ 739 ------------Tongue ................ 741 ------------Uterus ..................738 Canine Appetite ........................703 ------Madness ........................429 Carbuncle..............■..................110 Carcinomatous Ulceration............ 735 Cardialgia............................... 357 Carditis .................................. 172 Caruncles in the Urethra.............632 Catalepsy................................ 390 Catarrhus................................ 318 --------Senilis ........................323 Cephalalgia..............................761 Cessation of the Menses ............... 734 Chancres...................................634 Chalky Concretions in Gouty Habits 201, 209 Chicken-pox.............................259 Chigre.................................... 80, Chilblains ................................ 805 Chincough .......:.......................403 Chlorosis.................................727 Cholera Morbus .........................455 Chordee............................614, 619 Chorea Sancti Viti......................390 Chronic Inflammation of the Bladder 197 --------------Liver---15, 181, 189 --------------Peritonaeum ... 876, 879 --------------Spleen ............... 191 -----------Womb .............. 874 ----------■■----Rheumatism ..219, 22 --------------Thrush .............. 540 --------------Weakness ...........357 Clap ......................................613 Clavis Hystericus ....................... 376 Cobra de Capella Snake, bite of the 827 Colic, Bilious...........................445 ----, Devonshire or Poictou ........ 449 ----, Flatulent .........................445 ----, Hysteric ..........................445 Colour, Black and Livid, of Infants . 901 Comata, Order ......................... 339 Conception............................... 841 <----.------, Imperfect................ 852 Concretions, Gouty...............201, 209 ----------, Urinary................... 772 Confluent Small-pox.................... 23 Consumption, Pulmonary..............509 , Nervous or Atrophy ... 505 Contagion, Means for avoiding and destroying of .... 59, 70, 277, 286, 338 Continued Fevers ...................... 26 , Simple Fever .............. 26 Convulsions in Children............... 924 ----------, Hysterical................376 ----------in pregnant Women......847 Cornea, Opacities of the ...............130 ------, Rupture of the................133 Corpulence..............................544 Costiveness, Obstinate...........448,715 ----------,in Infants.................908 Coptiveness, parturient Women......861 , pregnant Women.......843 Cough, Common........................ 318 , Whooping ......................403 Coup de Soleil.......................... 346 Cow-pox ............................r... 252 Cramp, different Species of the......394 , in hysterical Women........ 376 , pregnant Women ............. 845 Cretinism................................ 587 Croup .................................... 150 Crustea Lactea in Infants.............. 906 Cynanche Laryngaea................... 156 Maligna ..................... 141 Parotidaea................... 139 Pharyngaea ................. 158 Tonsillaris ................. 135 Trachealis ................. 150 Cystitis ................................... 197 D Dance of St. Vitus ...................... 390 Deafness ...................y............ 699 Death, Sudden after Delivery........L860 Debility, Chronic ...................... 357 Defective Appetites, Order.........'.. 706 Deliquium Animi after Delivery .... 860 Dentition ................................ 921 Diabetes .................................467 Dialyses, Order........................ 782 Diaphragmatis.......................... 172 Diarrhoea in Adults ...............461, 844 ----------Infants ..................... 911 Difficult Menstruation................. 734 Difficulty of Breathing, or Dyspnoea 418 discharging Urine.......718 Digestion, Impaired ..i.................357 Dirt-eating .............................. 538 Diseased Mesenteric Glands..........607 -------Prostate Gland .. 621, 718, 721 -------Spine...................... 348, 353 Diseases of Infants........................ 895 Pregnancy.................. 841 the Puerperal State.......860 Distinct Small-pox...................... 237 Dog, Bite of a Mad......................429 Dolor Faciei Crucians.................. 765 Dolorosi, Order........................... 761 Double Quartan ........................ 4 Tertian.......;................... 4 Dracunculus........................... 758 Dropsy .................................... 550 ------of the Belly.....................563 ------------Brain .................... 569 ------------Cellular Membrane ... 551 ------------Chest .................... 577 ------------Ovaria.................. 567 ------------Tunica Vaginalis Tes- tis ....................................... 568 Uterus...................550 Drowned Persons, Means for Reani- mating .........;....................... 835 Dry Belly-ache .........................449 INDEX. 941 Dysesthesias, Order....................694 Dyscinesiae, Order......................707 Dysentery................................326 Dysmenorrhea ..........................734 Dysorexiae, Order ........................ 703 Dyspepsia................................ 357 Dyspnoea.................................418 Dysuria....................,........620, 718 E Ear, Pain in the ........................ 134 —, Inflammation of the .............. 134 Egyptian Ophthalmia...................121 Elephantiasis .............................660 Emissions, Nocturnal...................710 Emphysema...............................546 Emphrosthonos ...•.......................394 Empyema ................................169 Encysted Dropsy........................566 Eneuresis..................................709 Enteritis .................................. 17 Ephemera Simplex ..................... 3 Ephidrosis................................ 708 Epilepsia..................................381 --------Dolorifica....................401 Epischeses, Order........................715 Epistaxis..................................296 Eructations............................... 35" Eruptions, Cutaneous, in Children .. 906 --------, Herpetic .................... 791 --------, Miliary..............296, 865 -------—, Scorbutic....................684 -, Venereal...............644, 651 Fever, Puerperal........................ 879 , Putrid or Malignant......t..... 60 , Remittent...................... 20 of Infants ..........915 -----, Scarlet...........................267 -----, Secondary, of Small-pox......238 -----, Simple Continued.............. 26 -----, Yellow........................... 73 -----, Means for preventing the .... 94 -----, Walcheren ...................... 19 -----, different Species of............. 2 -----, Eruptive ........................236 Fish, Poisonous.......................830 Fistula in Ano, Incipient.............. 318 , Perineo........................619 Flatulency in Adults ....................357 ------------Infants...................908 Floodings in Pregnant Women.......852 Fluor Albus .............................711 Flux or Dysentery ..................... 326 Fluxes with Pyrexia, Order........ 318 Framboesia .......................~..j»v:: 656 Frost-bitten ...............................840 Fundament, falling of the ............ 328 in Children 919 --------, Vesicular.................... 292 Erysipelas ........................... 99, 111 ---------, Infantile .............. 112, 904 ---------, Phlegmonodes ........ 99, 111 Eiythema............................99, 111 --------Mercuriale..................636 Exanthemata, Order....................236 Excessive Perspiration ..................708 Excoriations in Infants ................. 903 -----------of the Nipples of Nurses 864 Eyes, Inflammation of the..............120 F Face, Cancer of the ...................740 ----, Pimpled and Blotched ..........800 Faciei Dolor Crucians .................765 Falling of the Fundament in Children 919 -----------Uterus ................... 891 Fungus Haematodes..................... 751 Furious Madness.........................479 Furor Uterinus..........................705 G Gall Stones............................".. 686 Gangrene................................. 100 Hospital..................... 108 False Appetite .....'..................... 703 —'■— Pains in Pregnant Women..... 846 Faintings..................................356 Febrile Diseases ......................... 1 Fever, Bulam ............................ 94 -----, Continued ...................... 26 -----, Gibraltar........................ 93 -----, Hectic ........................ 3,513 -----, Inflammatory ................... 40 -----intermittent ......".............. 3 -----, Miliary ....................290, 865 -----, Milk ............................862 Gastritis ................................. 172 Gastrodynia................. 357, 364, 769 Gibraltar Fever....................... 93 Giddiness, or Vertigo ..................357 Glands, Mesenteric, Diseased........607 Glandular Disease of Barbadoes......661 Gleet............................... 615, 633 Globus Hystericus' ......................376 Goitre...............................587, 753 Gonorrhoea Dormientium .............710 -----Virulenta in Men........613 ----------------Women .... 616 out ...................................... 198 , Atonic ............................. 202 •, Misplaced.........................202 ■, Regular........................... 200 -, Retrocedent, or Repelled......202 Gouty Concretions ..................... 201 Gravel and Stone....................... 772 Green Sickness..........................727 Gripes in Infants........................908 Guinea Worm............................ 758 Gum, red, in Infants ....................907 ----, Yellow, do....................... 902 Gutta Rosea or Acne ................... 800 , Serena ............................ 695 -, Nervous H Haematuria...............................307 Haematemesis ............................305 44'Haemoptysis ................................300 942 INDEX. Haemorrhage, Order...................296 Haemorrhois..............................313 Hair, Plaited, or Plica Polonica......668 Headach ..............................761 , with Plethora in pregnant Women.................................842 Head, Giddiness in the.................357 ----, Pain in the.........................761 Hearing, Difficulty of..................699 Heartburn...............................357 ■--------in pregnant Women.......843 Hectic Fever......................... 3, 513 Hemiphlegia ............................347 Hajrhorrfaagiae, Order..................296 Haemorrhage from the Anus...........313 ■-----------------Lungs ........300 ------------------Nose...........296 ------------------Penis ... 614, 621 ------------------Stomach...... 305 ------------------Uterus... 308, 852 Haemorrhagise, Order.................. 296 Hepatitis ................................ 179 Hernia, Strangulated...................179 Herpes .................................. 791 Hiccups in Adults ....,.................402 ---------Infants ......................904 Hip Joint, Disease of the ,........214, 230 Hospital Gangrene .....................108 Hydatids...................... 182, 563, 567 Hydrocele ...............................568 Hydrocephalus......................... 569 Hydrometra............................ 550 Hydrophobia ............................429 --------■—, Spontaneous ............430 Hydrops ..................................550 Hydro-Pericardium.....................550 Hydro-thorax..............................577 Hypochondriasis..................368 Hysteria.........................376 -------in pregnant Women.......843 Hysteritis.........................871 I Icterus..........................684 ------Infantum..................902 Iliac Passion.................448, 451 Impetigines, Order................592 Impetigo.........................798 Impotency .......................707 Incipient Phthisis.................509 Incontinency of Semen............7 J 0 ------------- Urine........709, 846 Incubus or Night Mare............503 Indigestion, or Dyspepsia..........357 Infanticide, Cautions to be observed in giving Evidence on...........899 Infants, Disease of.................895 ------, Livid and Black Colour of, on Birth.......................901 Infantile Erysipelas............112, 904 -------Remittent Fever.........915 Infection, how to avoid and destroy 59, 70, 277, 286, 338 Inflammation, different Species of ... 98 I'AGC Inflammation, Erysipelatous........99 --------, Phlegmonous---99, 190 --------, terminating in Effusion and Adhesion..................100 Inflammation terminating in Gan- grene .....................100, 106 --------------Resolution .... 100 ---------—---Scirrhus......110 --------------Suppuration 100,104 ------of the Bladder...........197 ■ Brain and Membranes 116 ---------Female Breasts......863 ---------Bronchia ...........171 ----------Diaphragm..........172 ----------Ear................134 ----------Eyes...............120 ----------Heart...............172 ----------Intestines...........175 ----------Kidneys............193 ----------Larynx ............156 ----------Liver..............179 ----------Lungs............,. 162 ----------Pericardium........ 172 ----------in Perineo..........619 ----------Peritoneum--- 197, 8-75 ----------Pharynx............158 ----------Pleura..............158 ----------Prostate Gland 621, 718, 721 ----------Spleen.............191 ----------, Spongoid...........751 ----------Stomach............172 ----------Testicle ... 614, 622,,625 ----------Throat.............135 ----------Womb.........197, 871 Inflammatory Fever.............. 40 -------Sore Throat........135 Influenza........................324 Inoculation for the Cow-pox.......257 ---------------Measles........266 --------------- Plague........289 ---------------Small-pox......247 Insanity..........................479 Intermittent Fevers ............... 3 Intestines, Inflammation of the......175 Intumescence of the lower Extremi- ties in lying-in Women..........865 Intumescentiae, Order............544 Intus-susceptio...............175, 445 Inversion of the Womb............891 Involuntary Discharges of Blood, Or- der ............................296 ---------------------by Urine 307 ---------Emissions of Semen .... 710 Irregular Gout....................202 Ischuria..........................7ig Ischias, or Disease of the Hip Joint... 234 Itch.............................795 Itchings in pregnant Women.......845 J Jaundice in Adults................684 —----Infants................902 -----pregnant Women......846 INDEX. 943 Jaw, Locked.....................395 ----------, in Infants............912 K Kidneys, Inflammation of the......193 -------, Stone in the.............773 King's Evil......................592 L Lactumen........................906 Larynx, Inflammation of the......156 Laugh, Sardonic..................394 Lepra Mercurialis................636 Leprosy.........................664 Lethargy............t...........346 Leucorrhoea, how distinguished from Gonorrhoea....................711 Lip, Cancer of the................740 Lithiasis.........................772 Liver, Inflammation of the........179 ----, Chronic ditto..........15, 181 -----, Suppuration in the.....183, 188 Livid Colour of Infants............ 901 Local Diseases, Class of............694 Lochia, Immoderate Discharge of the 861 ■, Suppression of the.........862 Locked Jaw .'....................395 ----------in Infants ............912 Longings in pregnant Women......843 Looseness of the Bowels, or Diarrhoea 461 --------in Infants...............911 Loss of Appetite..................706 -,-----Strength..................357 Low Spirits......................368 Lues Venerea....................643 Lumbago........................234 Lungs, Abscess in the ........163, 169 , Inflammation of the........158 , Haemorrhage from the......300 ——-, Ulceration of the...........509 M Madness.........................479 -------, Canine .................429 Mal d'Estomac, or Dirt-eating .... 538 Malignant Fever.................. 60 --------Sore Throat ............141 Mammae, Inflammationof the Female 863 Mania ...........................479 Marcores, Order.................505 Means for obviating Infection and de stroying Contagion 59,70, 277,286,338 ———— preserving the Health of Europeans in Warm Climates .. 94, 95 -------- preserving the Health of Seamen on board of Ship........674 ——— Resuscitation in Cases of Menses, Suppression of the.........732 Menstruation, Cessation of........734 , difficult and painful.. 734 Nature of...........726 Mercurial Course, Rules to be obser- ved during a...................646 Erythema...............636 Mesenteric Glands, diseased State of the............................607 Miliary Fever....................290 Eruptions in Lying-in Women 865 Milk Fever...................... 262 Mineral Poisons..................812 •, Tests for discovering 817 Miscarriages.....................851 Misplaced Gout..................212 Monsters........................843 Mort de Chien...................457 Mortification, Inflammation termina- ting in....................100, 101 --------of the Feet and Toes ... 108 ------------Buttocks and Nates 487 Mucus, how distinguished from Pus . 105 Mumps..........................139 Muscae Volitantes, or Atoms floating before the Eyes............368, 372 Moschetoes, Bites of.............. 830 N Nausea and Vomiting in pregnant Women........................842 Negro Cachexy..................538 Nephritis........................193 Nervous Consumption.............505 Fever, or Typhus ........ 44 Headach............368, 376 Nettle Rash...................... 295 ■, or Essera, in Children 907 suspended Animation ..........385 Measles..........................259 -, Inoculation for the........266 Meconium, Retention of the........902 Melancholia......................479 Menorrhagia.....................308 Menses, Immoderate Flow of the .... 308 ------, Interruption of the........725 ------, Retention of the..........7271 Neuralgia Facialis................765 Neuroses, Class.................. 339 Night Blindness..................694 Night Mare, or Incubus............ 503 Nipples, Excoriation and Ulceration of the ........................864 Nocturnal Emissions.............. 710 Nodes, Venereal..................652 Nodosities, Gouty............201, 209 Nose, Cancer of the..............740 ----, Hemorrhage from the........296 Nostalgia........................538 Nyctalopia.......................694 Nymphomania ...................705 d Obesitas, or Corpulence ..........544 Obstipatio, or obstinate Costiveness 448, 715 Obstructed Perspiration..........318 Obstruction in the Bowels.........449 of the Menses.......,. 727 in the Urinary Canal 615,627 Odontalgia........................ 763 Edematous Swellings in the Extre- mities .....................551, 845 -----------in pregnant Women 845 944 IKDEX. Oesophagus, Stricture in the........367 Opacities of the Cornea ..........130 Ophthalmia, Common........120, 123 -------, Egyptian...............121 --------, Purulenta of Infants 123, 128, 921 -------, Scrofulous..............592 -------, Syphilitica.....129, 644, 652 -------, Tarsi.................. 120 Opisthotonos......................394 Otitos............................134 Ovaria, Dropsy of the..............56' P Pain in the Bowels............... 445 ---------Ear..................134 —:-------Head................761 —---:----Stomach.....357, 364, 769 Painful Affection of the Nerves of the Face..........................765 Pains, After, in Lying-in Women ... 861 ----, Gouty.....................198 ----, Rheumatic.................218 ----, Venereal..............644, 651 Palpitations......................417 Palsy............................347 Paracusis........................699 Paralysis.........................347 Paraphymosis.................614, 618 Paraplegia.......................347 Passion, Iliac................448, 451 Pemphigus.......................292 Penis, Cancer of the..............740 ----, Haemorrhage from the........614 Pericarditis......................172 Peristaltic Motion, Inversion of the 448, 451 Peripneumonia Notha ............171 ------------Vera .'.............162 Poisons, Aerial...................824 —■—-, Animal..................826 —, Mineral..................812 , Vegetable................820 Polysarchia......................544 Porrigo...........................793 Pox, Chicken....................259 ----, Cow.......................252 ----, Small......................236 ----, Swine......................259 ----, Venereal...................643 Pregnancy, Diseases attendant on .. 841 Procidentia Uteri.................891 Profluvia, Order, or Fluxes with Py- rexia........................... 318 Prolapsus Ani....................328 ------in Children.........919 Uteri...................891 Prostate Gland, Diseased State of the.........:........621,718,721 Prussic Acid, Poison of the........826 Pseudo-Syphilis ..................645 Psora............................795 Puerperal Convulsions.............847 Fever.................879 Mania.....,............501 State, Diseases of the .... 860 Pulmonary Consumption ..........509 Purging, or Diarrhoea........461, 844 and Vomiting............455 Perineum, Tumour in the.........619 Peritoneum, Inflammation of the 197, 875 Pernio ..........................805 Pertussis.........................403 Pestis............................279 Phagedenic Ulcerations............636 Pharynx, Inflammation of the......158 Phlegmasiae, Order .............. 98 Phlegmatia Dolens Puerperarum ... 865 Phlegmon....................99, 100 Phrenitis..........*...............116 Phthisis Pulmonalis___...........509 Phymosis......-..............614, 618 Pictonum Colica.................449 Piles............................313 ----in pregnant Women ........843 Pimpled Face....................800 Plague......................---279 ■------, Inoculation for the.........289 ------, Mode of preventing the .... 286 Plica Polonica.................... 668 Pleuritis.........................158 Pneumonia.......................162 --------, Typhodes.........162, 170 Podagra...........................198 Poisons in general.................811 Purulent Ophthalmia in Infants 123, 128, 921 Pus, how distinguished from Mucus . 105 Putrid Fever.................... 60 Sore Throat................141 Pylorus, Scirrhosity of the .... 173, 358 Pyrexiae, Class................... l Pyrosis......................364, 409 Q Quartan Ague.................... 3 Quotidian, ditto.................. 3 R Rabies..........................429 Rachitis.........................385 Rash, Nettle.....................295 Rashes in Infants................„. 906 Rattle Snake, Bite of the..........827 Rectum, Stricture in the...........717 Regular Gout....................200 Repelled ditto....................202 Remittent Fever................. 20 of Infants.........915 Resolution, Inflammation terminating in............................10d Restlessness in pregnant Women .... 846 Resuscitation, Means for...........835 Retention of the Meconium in. Infants 902 Menses............727 Retrocedent Gout................202 Retroverted Uterus......844, 852, 859 Rheumatism.....................218 Rickets........,................385 Ring Worms....................798 INftEX. 946 Risu* Sardonicu* . .................. 394 Rose, or St. Anthony's Fire...... 99, 111 Rubeola.................................. 259 Rules for avoiding infection and de- stroying Contagion, 59,70,277,286,338 Rules to be observed by Europeans in warm climates for the preven- tion of diseases................... 94, 95 Rules to be observed during a Mer- curial Course ........................ 646 Rules for keeping seamen healthy on board of ships, and for preventing the Scurvy and other "diseases .... 674 S St. Anthony's Fire................. 99, 111 St. Vitus's Dance...................... 390 Sanguineous Apoplexy................ 329 Salivation, how to avoid.............. 646 ---------------promote .......... 646 -, Rules to be observed during 646 Sprains................................... 770 Sore Throat, Inflammatory........... 135 Putrid.................. 141 Spurious Peripneumony .............. 171 Squinting................................ 7D8 Stomach, Inflammation of the........ 172 —, Pain in the..... 357, 364, 769 , Cramp or Spasms in the .. 380 , Goutinthe................ 202 Stones, Biliary .................... 685, 687 , Urinary ....................... 772 Strabismus.............................. 708 Strangulated Hernia .................. 179 Strangury............................... 718 Stricture in the GUsophagus......... 367 Rectum.............. 717 Urethra....... 615,627 Sarcoma, Medullary................... 751 Sardonic Laugh........................ 394 ScalledHead ........................... 793 Scalds and Burns...................... 787 ScarletFever.......'.................... 267 ■ ----,Meansfor preventingand annihilating the contagion of the . 277 Sciatica............................ 214, 230 Scirrhus..................... 101, 110,735 -------of the Bladder................. 197 -----------Female Breast........ 735 -----------Liver.............. 15,182 -----------Prostrate Gland...... 739 -----------Pylorus........... 173,358 ---------—Spleen................. 15 .-----------Testicle ................ 739 -----------Womb ................. 874 Scorbutic Eruptions................... 684 Scorpions, Bite of...................... 830 Scrofula.................................. 592 Scrotum, Cancer of the............... 750 Scurvy................................... 672 ------, Mode of preventing the..... 674 Semen, Nocturnal emission of the .. 710 Serous Apoplexy........................ 339 serpents, Bites of venomous......... 827 Shingles, or Ceingles.................. 112 Sibbens.................................. 655 Sight, Dimness of...................... 695 Simple Continued Fever............. 26 Singultus ................................ 402 Small-pox ............................. 236 -, Inoculation for the........ 247 Stye3 on the Eye-lids .................. 120 Suppuration, Inflammation termina- tingin........................... 100,104 --------, in the Liver............. 183 Spleen........... 192 Suppression of the Lochia............ 862 ---------------Menses............ 732 ---------------Urine by Gravel 772 ---------------Inflammation,620,718 ---------------Spasm............. 622 ---------------Stricture ... 615,627 -------------in Pregnant Women 844 Suspended Animation................. 835 Sweating, Immoderate................ 708 Swelling qf the Lower Extremities in Lying-in Women ................ 865 -------------Lower Extremities in Pregnant Women................ 845 ------in Perineo...................... 619 Swine-pox.............................. 259 Syncope ................................. 356 Anginosa...................... 411 Snake, Bite 6f the Rattle ............. 827 Snakes, Bite of other.................. 827 Sphacelas................................ 101 Spongoid Inflammation................ 751 Spine, Diseased .................. 348,353 Spasmi, Order Synocha................................. 40 Synochus ................................ 26 -------Biliosa........................ 8 Syphilis.................................. 610 ------of Infants....................... 927 ------Pseudo ...................... 645 T Tabes .................................... 505 Taenia, or Tape Worm............... 807 Teething................................ 921 Tenesmus......................... 328,334 Teres..................................... 807 Tertian Ague........................... 3 Testicle, Inflammation and Swelling of the...................... 614, 622,625 ------, Scirrhus of the............... 739 Tests for discovering the presence of Arsenic in supposed cases of Poison 817 Tetanus ................................. 394 76JTetters .................................. 791 Spasmodic Colic ............^........... 449 Throat, Inflammation of the.......... 135 Spitting of Blood....................... 300------, Ulceration of the............. 141 Spleen, Scirrhosity of the..........15, 192 Snlenitis................ ....... 191 Thrush, Chronic....................... 540 ------in Infants....................-91'j 120 940 ItfDEX. Tic Douloureux................. Tinea Capitis..............i....... Tongue, Cancer of the .......... Tonsils, Diseased................ Toothach.......................... --------in Pregnant Women Trichoma ......................... Trismus......t.................... ------Dolorificus ..'........... ■------Nascentium............ Tumores, Order.................. Tympanites ....................... Typhus Gravior ................. ------Icterodes................. -------Mitior .................... PAGE . 765 . 793 . 741 . 139 . 763 . 843 . 668 . 395 , 765 912 , 735 547 , 60 , 73 . 44 U Ulcerated Sore Throat................ Prostrate Gland............ Ulcerations in Infants ................. ---------, Venereal, of the Tonsils and Uvula......................644, -, Carcinomatous ---------, Phagedenic........ 636, Ulcers, Obstinate ...................... Urethra, Strictures in the...... 615, Urinary Calculi........................ Urine, Bloody........................... , Difficulty in voiding .... 620, -----, Immoderate flow of........... -----, Involuntary flow of............ -----, Muco-Purulent.....196, 615, -----, Scalding in making........... -----, Suppression of, by Gravel... ----------- ii- diseased Prostrate Gland Inflammation, 620. Spasm.............. Urticaria .., Uterinus Furor ........................ Uterus, Cancer of the................. ------, Dropsy of the................. ------, Falling of the................. ------, Haemorrhage from the . 308, ■-----, Inflammation of the.......... ------, Retroversion of the.....844, —---, Scirrhosity of the............ V Varicella................................ 259 Varicose Veins in Pregnant Women 846 Variola................................... 236 Variolae Vaccinae ...................... 252 Vegetable Poisons..................... 820 141 739 903 652 735 653 782 627 772 307 718 467 709 620 613 772 721 718 622 295 705 738 550 891 851 871 891 738 IPAGt! Venereal Disease...................... 610 in Infants........... 927 Venery, uncommon desire for in Wo- men .................................... 705 Vermes.................................. 807 Verrucae Syphilitica; ...... 616, 627, 652 Vertebrae, Diseased.............. 348,353 Vertigo .................................. 357 Vesaniae, Order........................ 470 Vesicular Eruption.................... 292 Viper, Bite of the ...................... 829 Vision, Defective ...................... 695 Vitus's, St. Dance of.................. 390 Vomiting of Blood ..................... 305 -------in Pregnant Women...... 841 and Purging ................ 455 in Infants.................... 911 Voracious Appetite .................... 703 W Walcheren Fever...................... 19 Warts, Venereal............616,627, 652 Wasps, Bites of........................ 830 Wasting of the Body, or Atrophy .... 505 Water Brash............................ 409 -----in the Belly.................... 563 ----------Cellular Membrane ... 551 ----------Chest.................... 577 -------:—-Head.................... 569 ----------Ovaria................... 567 -------Scrotum ................ 568 Womb................... 550 Weakness, Chronic.................... 357 Weaning Brash........................ 920 Whites ................................... 711 ---, how distinguished from Go- norrhoea.............................. 711 Whooping Cough...................... 403 Womb, Cancer of the................. 738 , Dropsy of the................. 550 , Falling of the................. 891 , Inflammation of the .... 871, 874 , Inversion of the ... 844, 852, 891 , Scirrhosity of the............ 874 Worms................................... 807 , Guinea........................ 758 , Ring........................... 798 Y Yaws .................................... 656 Yellow Fever........................... 73 -------, Means for preventing the..................................... 94 —~ Gum in Infants................ 902 APPENDIX: BY DAVID HOSACK, M. D. Observations on Fever. i ROM the Earliest period to the present day, the subject of fever, more than any other disease to which the human frame is liable, has re- ceived the attention of physicians. Yet, looking in our obituaries, we find that fever and febrile diseases still constitute the great outlets to human life/and are at this day almost as fatal as they were in the time of Sydenham, who calculated that fevers, properly so called, make up nearly two-thirds of the diseases which prove fatal to mankind, and that eight out of nine of all who die are cut off by febrile complaints. How- ever minutely, therefore, we may be acquainted with the symptoms of fever in its various forms and stages ; however extensive may be our knowledge of its predisposing and exciting causes, we certainly are very deficient in our acquaintance with the proximate cause of fever, or its treatment would be more distinctly defined in its various stages, than it appears to be in any of the great practical works that have fallen under our notice. Whence, then, has arisen the discordant, and, we may almost say, the empirical practice, that fills the pages of the best writers on fevers, and that is even to be found in the truly valuable works of Boerhaave, Cullen, Fordyce, Wilson, and others ? We answer ; it is in a great degree ascribable to the local views of the animal economy to which some of those writers have been limited by their own hypotheses, and which practitioners, relying upon the authority of great names, have hastily adopted. Boerhaave's exclusive attention to the humoral pathology gave him necessarily but a limited and partial view of the nature of fever, and its operations upon the various parts of the animal economy ; he, conse- quently, neglected all those indications in the treatment, that a more extensive view of the nervous system, as taken by Hoffman and Cullen, would have pointed out. But his successor, Cullen, on the other hand, by avoiding Scylla ran on Charybdis. The nervous system, according to his view, had been too much neglected ; but in restoring it to its me- rited notice, he again, in a great degree, lost sight of all the other parts of the human frame, pronouncing the humoral pathology in particular a creation of the imagination, and, in its application to practice, altogether hypothetical.* The still more recent writings of Brown, Beddoes, Darwin, Girtan- ner, Clutterbuck, Rush, and others, have been too successful in spread- ing these partial views of the human structure, and, consequently, limi- ted pathology of the diseases to which it is liable. Even the learned and elaborate work of Wilson is calculated to diffuse the same errone- * See. preface to his First linr^ 948 APPENDIX. ous doctrines ; nor is the more independent and philosophical Fordyce altogether exempt from this charge, although he professes to be totally guided by facts, regardless of hypotheses. Fever, in the opinion of the writer of these remarks, is a disease of the whole system ; it appears no less in all the faculties of the mind than in all the functions of the body; it shows itself in every organ of our frame, and affects every nerve and fibre of the system; the absorbing, the circulating, and excreting sys- tems of vessels, are all affected by it; it shows itself in all the various fluids of the body, as well as in the solids ; in a word, it is omnipresent; it has no one pathognomonic symptom, but is constituted by a concourse of symptoms, and these variously combined in the various forms that fever assumes, depending upon the causes whence it proceeds, and the condition of body in which it occurs. If this view of the subject be correct, it will necessarily lead the physician to more extensive princi- ples of practice ; it will lead him, at the bed-side of the patient, to pay due regard to the nervous system, the phenomena it exhibits, and the indications thence arising : but at the same time it will lead him to no- tice the changes which may be induced in the secretions and excretions, and the circulating mass from whence they proceed. We offer these remarks for the purpose of calling the attention of the reader to the too long neglected pathology of the fluids ;* at the same t.me that we invite the attention of the practitioner to some points of practice, not in our opinion sufficiently attended to in the treatment of fevers. The recent experiments of Sir Everard Home, relative to the opera- tion of medicines upon the body, through the medium of the fluids__the communication of diseases from one animal to another, by the transfu- sion of the fluids, as lately performed by Mr. Coleman, at the veterinary school of London; the transmission of diseases from the mother to the foetus in utero ; the analyses of the fluids, both circulating and secre- ted ; the chemical examination of the products of the body as occurring in various diseases, have recently, both in Europe and America, directed the attention of physicians to this neglected part of the human pathology. It is proper here to remark, that, when speaking of fevers, we have in view the continued type of fevers properly so called, not referring to the phlegmasia; or other pyrexious diseases ; yet, in many instances. the principles we wish to inculcate, and the practical deductions thence arising, will be no less applicable in the typhoid state of many of the phlegmasia; and other febrile diseases, than they are to the advanced stage of typhus fever itself. It will be acknowledged, that fever cannot long continue without in- ducing debility in the heart and arteries, in common with all the other parts of the system, and that the sensibility to impressions must be pro- portionally increased. They are, consequently, predisposed to be more readily acted upon even by the natural stimuli of the system ; the heart and vessels are accordingly excited to preternatural frequency even operated upon by the blood and other fluids of the system in their na- tural and healthy condition, as we see daily illustrated in the progress of all fevers, and in convalescence from fever : we contend that fever long continued, not only wastes the power of the solids, rendering them « See Dyckman, on the Pathology of the fluids, and the Review of the same Dissertation in the Amer. Med and Phil. Reg. vol. 4. See also Professor Cooper's Introductory SrL delivered in the University of Pennsylvania, in 1818. V tuuouuorory Lecture, APPENDIX. 949 wore irritable, buj; by the derangement in the functions and excretions, perhaps by the action of the blood-vessels themselves upon their con- tents, and especially by the retention of those materials which should have been thrown out of the system as noxious, which in health are constantly ejected, the circulating fluids become changed and vitiated, and thereby become additional sources of irritation to the heart and ar- teries, whose susceptibility of impression, as we have just observed, is also morbidly increased. From this view of the more irritable state of the circulating system, and the vitiated condition of the fluids, we infer, that unless by some salutarj power inherent in the system itself, or by some means suggested by art, the greater irritability of the whole sys- tem, and of the heart and arteries in particular, be diminished, or the morbid changes induced in the fluids they circulate, be counteracted, these causes of fever, mutually operating upon each other, must in- crease, and fever be continued until the vital principle itself be totally expended. How far, then, we ask, is the attention of physicians direc- ted to these two cardinal objects, in the treatment of the advanced stage of fevers ? how far is their practice calculated either to impart vigour to the system, and thereby to lessen the morbid sensibility of the nervous and moving fibre, or to counteract the septic tendency of the circulating fluids which obtains in most fevers of the continued type ? Are we not hereby led to condemn that indiscriminate and long con- tinued use of the debilitating evacuants, usually prescribed at this advan- ced period of fevers and febrile diseases, in as far as they are calculated to add to that waste of excitement, and that very vitiation, to which we have referred ? Is not the abstinence, too, usually enjoined by physi- cians in the typhoid stage of fever, for the same reasons, no less to be reprobated ? Are we not led, upon the same principle, to condemn the prescription of camphor, musk, opium, digitalis, and other powerful se- datives, so frequently directed in this stage of fever ? We refer to the ordinary mode and quantity in which these narcotics are administered in fevers, hy the greater part of practitioners; and who, forsooth, by a strange misnomer, denominate them stimulants !* The indiscriminate practice of purging, as advised in typhus fevers by Dr. Hamilton,! of Edinburgh, is, i»our opinion, no less dangerous by the debility it induces, and is not prescribed with sufficient caution by that distinguished practitioner, for whose opinions and practice, on most occasions, we entertain, and beg leave to express, our highest re- spect. Even the long continued exhibition of the various preparations of mercury and antimony, is, in the opinion of the writer, a no less dan- gerous and fatal practice in this advanced stage of fever. On the con- trary, if the views we have taken be correct, after the indications which arise in the first stage of continued fevers have been fulfilled, in the means of accomplishing which most physicians are agreed ; after the necessary evacuations by the lancet and other depleting means have been made, which are frequently called for, both in the invasion and in the progress of fever ; after the stomach and bowels have been cleansed, and due regard has been paid to the no less important function perform- * For the evidenceof the sedative effects of opium, see Dr. Bard's Inaugural Dissertation, Edinburgh, 1765; Monroe's Experiments on Opium : see also the late important observations of Orfila on poisons. | Sec his valuable work on the use of Purgatives. 950 APPENDIX. ed by the skin, our attention should next be given to the two follow- ing objects, and which the practitioner should never lose sight of wheo the typhoid state of fever has actually arrived ; 1st. To preserve the natural powers of the system, and carefully to guard against every fur- ther waste of excitement; 2dly. By suitable antiseptic nourishment, and other means, including external applications as well as internal re- medies, to preserve the circulating fluids from those morbid changes to which they constantly and rapidly tend in all fevers of the continued type, especially in those arising from contagion, which, in a peculiar manner, depresses and exhausts the vital powers. In this advanced or typhoid state of fever, characterized by a disturbed state of the brain and nervous system, showing itself in delirium, watchfulness, or irregu- lar and interrupted sleep, frequent sighing and subsultus tendinum ; at- tended with an increased but feeble circulation, hurried and irregular respiration, with its usual consequences, an increased heat of the body and dryness of the surface ; characterized also, by a deranged state of the secretions and excretions, exhibiting themselves in an offensive breath, turbid urine, frothy and offensive discharges from the bowels, a foul sordes about the teeth and gums, discoloured lips, and a brown or a black state of the tongue ; and, perhaps, added to these, a cadave- rous and offensive smell of the whole body; in this condition of the system, the means of fulfilling the indications before mentioned, are, 1st. To supply the patient with the most powerful stimuli both diffusible and permanent; viz. the volatile alkali, aether, wine,* wine whey, por- ter, yest, bark, Virginia snake-root, bitters, and the mineral acids, pre- ferring each or either of these according to the peculiar circumstances of the case. We are aware that this practice is reprobated by many physicians as improper in this state of excitement, whatever may be the stage of the disease, or the circumstances that may have induced it. This leads us to observe that many physicians are not sufficiently atten- tive to discriminate between the simple excitement of the early stages of fever, which is characterized by the symptoms of inflammatory action, and is kept up by considerable vigour of the system ; and the complicated excitement, which appears when the powers of life are greatly exhausted, and the disease has been long protracted. A corresponding want of discrimination appears in their practice ; they, therefore, condemn in the last stage those means of excitement which are injurious in the first; and they approve in the last the continuance of the same depleting and debilitating means that have been found useful in the first: what! say they, administer wine, bitters, or bark in this quickened circulation at- tended with a hot and dry skin ? We answer, that in such typhoid state of body, in this exhausted state of the vital powers, the remedies that have been enumerated are among the most effectual means of reducing that very heat of skin, and of diminishing that increased excitement of the whole system, which, as we have before remarked, are frequently ascribable to the morbid sensibility of the heart and vessels to their vitiated contents ; and that this sensibility being counteracted, the cir- culation is necessarily reduced in frequency, the respiration becomes less hurried, and that the heat of the system, which is ever in propor- * The reader will find some pertinent practical remarks on the quantity of wine which may be safely and advantageously administered in this stage and character of fever, in Moore's Med. Sketches, p. 13, 509, 517, &c. APPENDIX. 951 tion to the circulation and rapidity of respiration, is, consequently di- minished. But, 2dly. We should be no less attentive to the state of the fluids than we are to counteract the morbid excitement of the solids : with this view, attention should be daily given to the bowels for the purpose of evacuating their offensive contents, especially of the lower tract of the intestinal canal; for these malcontents being retained, not only in some instances become the sources of irritation to the intestines themselves, producing diarrhoea, but by their return into the mass of circulating fluids, which are thus rendered still more malignant, they necewarily constitute fresh sources of febrile excitement. Evacuations from the bowels, however, are not to be obtained at that expense of the powers of the whole system, which the means recommended by Dr. Hamilton are calculated to produce ; on the contrary, at this advanced period of fever, we should just as readily think of putting a lancet into the pa- tient's arm as emptying his bowels by the active purges he has directed ; these, too, with other means of depletion, as far as they may have been indicated, it is presumed, have been already attended to in the first stage of the disease. Enemata, or at most, the occasional use of small doses of rhubarb and magnesia, or some other mild aperient, are only, in our opinion, admissable at this period of the disease. For the united pur- poses of preserving the surface in a perspirable state, of diminishing its temperature when excessive, and of removing the offensive materials which are excreted by the skin and constantly accumulated upon it, the body should be regularly cleansed once or twice in the day, by ablutions of vinegar and water, which should be applied either tepid or cold, ac- cording to the temperature of the body ;* and should the skin remain dry, after such ablutions have been made, fomentations of vinegar and water applied to the extremities, and steadily persisted in, are among the most effectual means of relaxing the surface, at the same time that they are calculated to allay much of that distressing restlessness which attends this stage of the disease. Upon the same principle of correct- ing the state of the fluids, the nourishments directed should be ex- clusively of the vegetable kind, as best calculated to resist that putrescent tendency which manifests itself in this state of body ; for this purpose, arrow-root, sago, tapioca, Indian or oatmeal gruel, rendered palatable by the plentiful addition of wine, and some of the most grateful aroma- tics, should be hourly administered in this exhausted state of the system. The bedding and the dress of the patient, especially if he wears flannel next the skin, which is the preferable clothing in this form of fever, should also be frequently renewed. For the purpose of controlling that restlessness which usually appears in the evening exacerbation, and of procuring sleep, an occasional anodyne may, in many instances, be ad- ministered, with the most beneficial effects ; but the indiscriminate use of opium or laudanum, throughout the day, and through the whole pro- gress of the fever, with the view to their supposed stimulant effects, cannot be too severely reprobated ; nor have we ever witnessed the stimulant and salutary effects ascribed to the fashionable camphorated julep, and other preparations of camphor so often had recourse to ; but v^e can indeed say, that we have, in very many instances, witnessed its *■ See Currie and .Taction on cold bathing in fevers 952 APPENDIX. debilitating, and, as we believe, its fatal effects, in the typhoid state of fever. Such is the practice the author of these remarks has pursueds for many years past, in the typhus fever of this city, the typhoid stage of dysentery scarlatina, peripneumonia typhodes, and in other febrile diseases ; and he can bear the most unequivocal testimony in favour of its safety and success. The following extract from a report 'made to the governors of the New-York Hospital, Sept. 1st, 1819 ; giving a statement of the diseases of that institution, and of the treatment adopted, affords additional evi- dence of the validity of these opinions. " During the period of my attendance, an ample opportunity has been afforded to the students resorting to the hospital for instruction, of ob- serving the typhus form of fever, which has been unusually prevalent in this city during the last three months, and of noticing the characteristic symptoms of that type of fever as totally distinct from the yellow fever with which it has been identified by many physicians, under the gene- ral and fashionable appellation of malignant fever. The students have also witnessed the successful use of blood-letting and other evacuations, in the first stage, and of yest, porter, snakeroot, the vegetable acids, vegetable nourishments, and frequent ablution with tepid vinegar and water, in the more advanced stage of that disease, instead of the mercu- rial treatment so generally practised in many parts of the world, and especially in the United States. Indeed, I believe, that the typhus fever of our country owes much of its malignity to the indiscriminate use of mercury. I say its indiscriminate use, for in some cases of fever, and in many other diseases, it is the physician's only resource. Even in typhus fever, under some peculiar circumstances, it has been pre- scribed with infinite benefit. " Of the seventy-six cases of fever (of which forty were cases of ty- phus, attended, in many instances, with symptoms of the highest malig- nancy) seventy-four have been cured by the means before enumerated, without the prescription of a particle of mercury. Dysentery, in like manner, was treated by blood-letting, blisters, emetics, and saline ca- thartics, and a vegetable diet, instead of the customary treatment by calomel. Of twenty-one patients ill of this disease, all recovered or were convalescent at the time I ceased to prescribe. Another obser- vation I have frequently made, and which has been verified in the cases that have recently occurred in the hospital is, that those who are cured without mercury, recover in a much shorter time, than those who are treated by the usual mercurial course. This is not all—they not only have a shorter convalescence, but they recover without that injury to the constitution, and that liability to rheumatism and other inflammatory diseases that we frequently observe in those who have undergone the operation of mercury." During the prevalence of the bilious, remitting, and typhus fevers, as well as in the typhoid termination of other febrile diseases, as they ap- peared in the New-York Hospital in the autumn of 1821, the students of the university of New-York have again had an opportunity of wit- nessing similar successful results of the mode of treatment herein re- commended ; i. e. in the first stage, by active depletion, by blood-let- ting, cathartics, and the usual means of relaxing the skin : and in the 5*^nd stage, by the use of tonics, stimulants, andvege'^ble nourish- »x-.pe\dix; 9.5,3 Stents', at, the same time preserving a soluble state of the bowels, and especially a perspirable condition of the surface of the body. The writer cannot conclude these remarks upon fever without exr* nestly calling attention to the valuable work op typhus fever recent- ly published by Doctor Armstrong.* The just views entertained by that author relative to the contagious character of typhus fever, the changes effected in different parts of the system, and the modes oi" treatment, as adapted to the various stages of fever, are' eminently wor- th}' of regard. Peripneumonia Typhodes. Notwithstanding what has been thus advanced relative to the treat- ment of fevers of the typhoid character in general, I am induced to of- fer a few additional remarks on that peculiar mixed type of disease, whieh has appeared in various districts of the United States, but more particularly in the eastern and middle sections of the Union : and which, under the different names of malignant pleurisy, petechial or spotted fever, bilious epidemie fever, bilious pneumonia, fye. hasstven origin to such discordancy of opinions as to its nature, and wlwCnaisor- der, wherever it has prevailed, has been accompanied by a most alarm- ing mortality. The name peripneumonia typhodes, seems to me to con* ■vey a more aceurate idea of its character than any other appellation by which it has been designated, and I shall accordingly notice it under that denomination. This disease is not a " new calamity," an " unknown epidemic," as it lias been represented by some writers. On the contrary, it has been well described by Sauvages,| Huxham, and others: by the former, un- der the very appropriate appellation of peripneumonia typhodes. Nor is this a new disease in the United States. In the first volume of the American Medical and Philosophical Register, the late Dr. John Bard, of this city, has given an account of a disorder which prevailed on Long-- Island, in the winter of 1749, and which, in its essential symptoms, cor- responds with the epidemic lately prevalent in this state. Dr. Bard has termed the complaint the " malignant pleurisy." In the second volume of the Medical Repository (first series) the same disease is noticed by Dr. Hugh Williamson, as it prevailed in North Carolina, in the year 1792. In. the southern state9, it is commonly called "pleurisy in the head," in consequence of the violent pain in the head, which frequent- ly attends the disease in that climate. Malignant Pleurisy, or rather ty- phus peripneumonia, well expresses the mixed character of this disease ; for at the same time that it is attended with inflammation of the lungs, and in some instances with inflammation of the brain, the general affec- tion of the whole system is certainly that of typhus fever. That inflammation of the lungs frequently constitutes a part of the disease is manifest, not only from the presence of those symptoms usual- ly attendant upon pneumonic inflammation, viz. cough, pain in the chesty especially upon taking a full inspiration, expectoration tinged with blood in the early stage of the complaint; but it is also- evident from the * S.ee the last London edition. 1 See Nosologic Methodjca, vol. 1 171 A ^,54. APl'KMJlX. 'l phenomena presented upon an examination of the body alter dealh ; th£ overloaded state of the vessels of the lungs, the large effusion of serum, and sometimes purulent matter, the adhesions found between the mem- branes covering the lungs, and those lining the chest, all clearly show that the patient has been destroyed by such inflammation.* In like manner, in some cases, the whole force of the disease is vented upon the brain, producing similar phenomena in that organ ; on the other hand, the usual symptoms of a putrescent state of body, the petechia?, blotches, hemorrhages in the latter stage of the disease, the offensive state of the excretions in general, and great prostration of the powers of life, which rapidly ensues, no less declare the enfeebled and vitiated state of the whole habit. There are therefore two opposite conditions of body to contend with ; local inflammation on the one hand, and a ty- phoid state of the whole system on the other. The causes of the disease are no less compounded than the disease itself. The local inflammato- ry affections are probably occasioned by the sensible changes of the at- mosphere, while the typhoid character of the disease is derived frtfm an epidemic constitu of the air, the same which has given rise to the ty- phus petechialis, or spotted fever, which has prevailed for some time past in our northern and eastern states, and which is doubtless a similar dis- ease, with the exception, that the peripneumonic epidemic is complica- ted with the symptoms of local inflammation of the chest, brain, throat, &.c. the effect of cold at the season of the year when it prevails. With this view of the mixed nature of the disease, and of the combined causes which have produced it, we are prepared to expect the various and opposite opinions and modes of practice which have been adopted by different physicians. We accordingly find some prescribing the strict antiphlogistic treatment by large and repeated blood-letting, active ca- thartics, and other depleting remedies, treating the disease as purely in- flammatory. On the other hand, we find another class of practition- ers pursuing the opposite course of exciting the system by the most powerful and diffusible stimuli, to counteract the putrescent state of body ; alleging, that it is exclusively a putrid disease, and only to be controlled by antiseptics, and the avoidance of all those means which are calculated to debilitate the system. As far as I have seen the dis- ease, they are both wrong ; the indiscriminate use of the lancet recom- mended by some, is, in my opinion, an additional source of the morta- lity of the disease. . On the other hand, the practice of administering brandy and other ardent spirits, in the quantity they have been lately prescribed, is truly adding fuel to the flame that is already consuming the patient, and can- not be justified either by principle or practice. But the prudent phy- sician will avoid both these extremes. In the young and athletic, he will prevent the brain from being inundated with blood, by the early and judicious use of the lancet, blisters, and other means usually pre- scribed for diminishing inflammation ; keeping in view the age, strength, constitution of his patient, and the general symptoms indicating a pu- trescent state of the system. On the contrary, in feeble old age, in the habit debilitated by disease, or intemperance, in which those inflamma- * See Report of the Mass. Med. Society, and Dr. Hudson's letter on the prevailing epide- mic ; see also Dr. Low's account of this disease, as it lately prevailed in Albany—American Medical and Philosophical Register, vol. 4. AFPE.NM.X', 955 ftiry symptoms are less violent, and the tendency to putrefaction is most predominant, he will depend chiefly on those means usually resorted to, for the purpose of promoting the perspiration, and other excretions, at the same time, that, by suitable antiseptic drinks and nourishment, he will guard against that debility which so rapidly ensues in this condi- tion of the system. He will in such cases, of course, carefully abstain from, or cautiously make use of, blood-letting, and other depleting reme- dies. But.he will certainly not effect the first purpose, by the exces- sive use of brandy and ardent spirits. So far from promoting the ex- cretions of the s}rstem, they actually restrain those very evacuations which it should be our object to promote, and by which alone we are 4. enabled to counteract the typhoid state of body, in this, or any other febrile disease. As a substitute, therefore, for this stimulant mode of treatment iu those cases wligre this typhoid tendency prevails, we are forbidden the use of the lancet and other depleting remedies, or where the symp- toms of local inflammation are so mild that they are not indicated, let me recommend, after emptying the bowels by an enema, or mild purga- tive, to make free use of the warm bath, fomentations of vinegar and water to the extremities, the liberal use of the infusion of snake-root, the cupatorium, and wine whey in very debilitated habits, or where the powers of life are much reduoed, in order thereby to procure a plenti- ful perspiration. By this evacuation we not only counteract the gene- ral typhoid state of the system, but we at the same time diminish, and in some cases, totally remove the local irritation, which affects the lungs or other organs involved in the disease. For further information on the subject of the pneumonia typhodes, see the luminous Report of the Massachusetts Medical Society, an ab- stract of which may be found in the American Medical and Philosophi- cal Register, vol. 1. Dr. Low's Account of the Epidemic in vol. 4. of the same work, and the Report of the Saratoga County Medical Societv. Observations on Contagion, Cammunicalcd in a letter to Dr. Colin Chisholm, of (Clifton) England ; dated New-York, July 16, 1808. Dear Sir, Agreeably to my promise in a former communication, I shall now - state to you the result of my observations on contagion, a subject which has created so much dispute in the medical world, and which divides our profession in the western as well as in the eastern hemisphere. As far as I have examined this subject, it appears to me to be more a dis- pute about words than facts. The abuse of the terms contagion and in- fection, and the neglect of writers in not annexing to them a precise de- finition of the manner in which they severally employ them, have, I believe, been the source of our'medical warfare relative to the conta- giousness of yellow fever, and some other diseases : e. g. the greater number of medical writers enumerate, in the list of contagious diseases, all those which are in any way communicable from one person to ano- ther, whether by contact, fomites, atmosphere, fyc. without designating the rircnmsfances attending these several modes of communication. O.bG appendix; Lind, in his paper's on contagion and infection, (which he consjdci J as synonymous terms,) is guilty of this error, in which he has been follow- ed by most writers upon the subject of fever, &c. The late Dr. R- Bayley, in his account of the yellow fever which prevailed in New-York in 1795, proposed a distinction between contagious and infectious dis- eases. He made use of the first term to denote such as are communi- cated under any circumstances of atmosphere, whether pure or impure, as small pox, measles, &e. Infectious diseases he denominated those which are communicated in consequence of an impure or vitiated state Of the atmosphere ; i. e. that the impurities of. the atmosphere commu- nicate the disease, not that the air contains any specific material derived ji from the patient, except such as may be occasioned by the want of $ Cleanliness. This distinction, proposed by Dr. Bayley, is, in my opi- ^ nion, an approach nearer the truth than any of his predecessors have ad- j^jj vanced, but it does not present us with a view of the whole tnah upon- -__ the subject. The visiter or attendant contracts disease from one of twa ■ vj Sources, either from the filth of the sick room, or from a specific some- thing issuing from the body of the sick, the consequence of the pecu- liar disease under which he labours. If a person visiting another ill of the yellow fever or plague, derives his disease from the impure atmos- phere of the apartment, I ask how it happens, that in all instances he contracts the same disease with that of the person whom he visits ? Why is his disorder not an intermittent, a remittent, jail fever, or dysentery\ which are considered the usual produce of filth ? If he derives any thing specific from the sick, his disease is then assuredly not to be con- sidered as occasioned by the atmosphere, but depending on the peculiar condition of the fluids, or state of the system, induced by the action of a specific poison ; in other words, it is to be considered' a contagioizs dis- ease. The distinction proposed by Dr. Bayley, inasmuch as it does not account for the communication of the peculiar form of fever or disease which is thus propagated, I, therefore, consider to be insufficient to ac- count for the circumstances attending the communication of those dis- eases to which it is applied. That I may not be misunderstood, 1 will suppose A to be ill of dysentery, a disease well known to be attended. with a peculiar train of symptoms ; he is in a small, confined apartment, his person is neglected, the atmosphere around him is rendered impure and offensive ; under these circumstances B visits him, and a few days. after is also taken sick with the same disease, attended in all respects with .the same dangerous symptoms which characterize the disorder of *. A. Dr. Bayley, and those who adopt the doctrine of infection as oppos* ed to contagion, consider the disease of B to proceed from the impuri- ties of the chamber, and not from any thing peculiar emanating or secre- ted from the body of A. But as we may, without hazard, visit an equal- ly filthy chamber where C lies ill of cholera morbus, or D with a broken, limb, I therefore ascribe the disease of B to something more than the impure air of the chamber of A. I ascribe it to a peculiar virus ge- nerated in his system by the disease under which he labours, and com- municated by his excretions to the surrounding atmosphere, rendering it thus capable of producing the same disease in those who may be ex- posed to its influence. The communication of this virus from the sick to the well, in what- ever form it may be conveyed, as uniformly produces the same d&eafe APPENDIX. 9.57 as iiiotntl-atioii excites the small pox, or vaccination conveys- the vaccine* "suras. So far, then, there is something in common in the communica* tion of contagious or infectious diseases, which should be accordingly expressed in the language we employ—some of those diseases are con- veyed in one form, others in a different; we should then'be equally careful to mark those circumstances in which they differ, as well as those which they possess in common. Such an arrangement appears to me not only practicable, but, at the same time, calculated, in some degree, to harmonize the differences o€ •opinion which now separate the contagionists and non-contagionists- Under these impressions, I propose to arrange those diseases which are communicable from one to another under three heads. First, those. which are communicated exclusively by contact. In this class 1 enumerate. The Itch, Syphilis, The Sibbens of Scotland, The Laanda of Africa, Framboesia, or Yaws, Elephantiasis, or Leprosy, Hydrophobia, and The Vaccine virus. Neither of those diseases can be communicated in any other wqiy than by contact; they are, therefore, contagious diseases, in the strict etymological sense of the term. It is also to be remarked, that these diseases are never conveyed through the medium of the atmosphere 3 actual contact alone can communicate them from one person to another. These diseases, acknowledged by all to be contagious, and so denomi- nated by all writers, have a law of communication peculiar to them- selves. But there is a second class of diseases also considered as con- tagious, which are communicated under different circumstances, go-* verned, in this respect, by different laws of communication. Those to which I now allude are such as are communicated both by 'rifntact and by the atmosphere. In this class I arrange Small pox, Measles, Chicken pox, Hooping cough, Scarlet fever, and Cynanche maligna. Contact, or the close approach to the sick, labouring under these dis- eases, will communicate them to those who are susceptible of their in- fluence—but they are no less communicable through the medium of the atmosphere. A second law, which governs the communication of this class of contagious diseases, is, that they are communicable in every sea:- sdn, in the heat of summer, as well as in the cold of winter—in a puret as well as in an impure air, though more readily by the latter than the former. A third jpzv of communication in this class of diseases, is, that the persons afflicted with them are not generally susceptible of a second attack. I say generally, because exceptions are related upon very re- spectable authority. ' This second class of contagious diseases is, therefore, abundantly dis- *:'i!i'uishedfrom the first; but- they are si ill associated by most medical &i*> APPENDIX, Writers under the same head of contagious diseases, without assigiiiujr tp each class its discriminating characters. The same want of discrimination has, in my opinion, occasioned the numerous disputes among physicians relative to the contagiousness and non-contagiousness of those fevers which I enumerate as the third class of diseases that are communicable from one person to another. Under this head I arrange Plague, Yellow fever, Typhus, jail, ship, hospital, of lake feoet, and Dysentery. The«e diseases are only, in general, communicable through the me» dium of an impure atmosphere : in a pure air, in large and well ventila- ted apartments, when the dress of the patient is frequently changed, all e.xcrementitious discharges immediately removed, and attention paid to cleanliness in general, these diseases are not communicated, or very rarely so, from one to another. But in an impure air, rendered so by the decomposition of animal and vegetable substances, as takes place in low marshy countries, or by concentrated human effluvia, as in camps, jails, hospitals, or on shipboard, they are rendered not only extremely malignant and mortal in themselves, but become communicable to others- who approach the sick, or breathe the same atmosphere, which has be» come assimilated to the poison introduced, insomuch that the same spe- cific disease is communicated, whether it be the plague, yellow fever, ty- phus, or dysentery. Hence we account for the fact stated by Sydenham and other writers- on epidemics, that the prevailing disease swallows up all other disor- ders, *. e. that during the prevalence of an epidemic plague, typhus, dysentery, or other diseases of this class, every indisposition of a fe- brile sort readily assumes the character of the prevailing disorder. We know this to be experienced in the diseases of other countries, and we 6ee it daily exemplified in our own : both in our cities and in the coun- try towns, when, after heavy showers of rain, and the action of a hot sun, a decomposition of vegetable and animal substances takes place, nnd dysentery or typhus fever is produced, it assimilates the air to it- self, whatever may be the acting poison. But under other circumstan- ces of weather and season, the disease thus originating from some local circumstances, or from a peculiar habit of body in the person so affect- ed, does not extend beyond the family in which it first occurred, or, per- haps, the individual in whom it originated. This class of diseases, therefore, like the former, has a law peculiar to itself; i. e. the diseases composing it are communicable, or other- wise, depending upon the condition of atmosphere in which they occur or are introduced—whereas those of the second class are conveyed from person to person, through a pure as well as an impure medium : but they also are rendered more virulent and malignant in an atmos- phere charged with miasmata, than in that which is free from such ingre- dients. It is also, I believe, generally true of the diseases of the third class, nob perhaps excepting the plague and yellow fever, that they may be ta- ken a wW tjme. This has been advanced by the advocates for the. APPENDIX. 953 dWesuo origin ef yellow fever, as an argument against the contagious- ness of this disease. But, upon the same principle, they must deny the contagiousness of all those disorders which I have enumerated in the first class, as itch, syphilis, 4*c for most of them are also to be taken a second time ; yet they are acknowledged by all to be contagious diseases. In the same manner, many persons make the small pox a standard, and conclude that yellow fever is not contagious, because it is not communicated unde'P the same circumstances of atmosphere and season, and governed by the same laws with that disease. They might with the same propriety conclude, that the scarlet fever is not contagious, because it is not attended with the pustules of small pox. This teache9 us the importance of correct language to convey the several degrees of contagion which have been noticed: and that, while we may make use of the terms now in use, we should annex to them sueh explanations as will convey those different laws of communi- cation which have been enumerated. With those precautions in the use of the language we employ, I believe, the contagionists and non-conta- gionists will find themselves very much in the situation of those theolo* gjans of whom Pascal speaks, and ready to adopt the expression of one of them, when he observes, *' La difference qui est entre nous est si subtile, qu'a peine pouvons nous Ia niarqirey npjlS menres." We would then be ready to admit, that the yellow fever is a conta- gious or communicable disease, in an impure atmosphere ; but not gene- rally so where the air is preserved pure and free from noxious mate* rials. This doctrine, too, I believe, will better account for the appa- rently contradictory facts, which have been urged by the advocates of the two opposing opinions, than any system that has been adopted. It will also lead to a system of police regulations, which will best in- sure us against the ravages of yellow fever when introduced ; at the same time it will teach us carefully to guard against the introduction of it from abroad. I shall treat this subject more at length upon another occasion, in connexion with the evidences of the importation of the yellow fever into the United States. I am, with sentiments of high respect, yours, DAVID HOSACK. Dr. Cuisholm. In 1809, Dr. Chisholm did me the honour to reply to the foregoing ob- servations, expressing his entire approbation of the two first classes, but objecting to the third. After enumerating his several objections, he requests me to re-consider my third division, which appears to him to be the only objectionable one. This I have done, and now submit the result of a further examination of this subject, and a detail of the facts by which I have been led to my conclusion relating to the laws of communication vvhich I have more particularly assigned to the febrile diseases enumerated in the third class. Waving for the present all inquiry relative to the nature 'or properties of tfie contagious principle secreted by the diseased body, or the chejmi> 9'tiO APPENl)I\. cal qualities of the atmosphere deemed necessary for its propagation, dr. the manner in which the contagion diffuses itself, I proceed to observe, that the history of each disease enumerated in the third class, viz. plague, dysentery, typhus, in all its forms, and yellow fever, furnishes evidence oi the correctness of the remark, that they are governed by a law peculiar to themselves, that they are contagious or communicable in a fout at- mosphere, but that they are never or very rarely so in a pure air, where the sick enjoy the benefits of cleanliness and ventilation. The same evidence, I trust, will demonstrate another truth, that these diseases are, in no instances, epidemic, as they have been improperly denominated by most practical writers, but that their sphere of opera- tion is, with very few exceptions, confined within the limits to which the vitiated atmosphere extends, in which they may be engendered, or into which they may be introduced : and that, in this respect, they dif- fer from ordinary epidemics, " which appear in different and distant parts of the same place, and at the same time." That the plague, when once generated, whatever may be the sources whence it derives its origin, is communicated by a peculiar virus se- creted by the diseased body, will not, 1 trust, be questioned at this day. Independently of the facts contained in the writings of Thueydidesy Lucretius, Mead, Dr. Patrick Russell, and others, showing the conta- gious nature of the plague, the communication of this disease by inocu- lation, as performed by Mathias Deggio,* Dr. Whyte,f and the Russian surgeon, noticed by Sonnini,J have recently established the fact of its propagation by a specific secretion, beyond all possible controversy. It has been observed by Assalini, that Dr. Desgenettes, while in Sy- ria, had in vain endeavoured to inoculate himself with the virus of the plague ; and by the same writer it is incorrectly added, that Dr< Desgenettes made the experiment under the persuasion that the disease was not contagious ; but from the account of the facts as stated by Dr. Desgenettes himself, it appears that the experiment was not made un- der that persuasion. On the contrary, he expressly declares, that its Contagiousness was demonstrated by a thousand examples, and observes, contrary to the opinion of many, that the same person was liable to a se- cond attack of it, as was the case with the convalescents whom he em- ployed to attend upon the sick : furthermore it appears, from his own account, that he inoculated himself with the matter taken from a per- son who had the disease in its mildest form, what he denominates the first degree ; in which the fever was slight, and the patient easily and promptly cured. Dr. Desgenettes adds, that it was an imperfect ex- periment, and that it does not disprove the communication of the disease by contagion, and that he made the experiment for the purpose of quiet- ing the fears of the French troops, and of inspiring them with confi- dence.§ But that the plague, in common with the other diseases I have asso- ciated with it, is only communicable through the medium of an impure or vitiated atmosphere, is an opinion which, although it has never been •attended to by physicians, will be found to be verified by every writer on this disease. The plague of Athens, the first of which we have any • See Med. Com. vol. 8. p. 349. f See Wilson's Expedition to Egypt, and McGregor's Sketches. i; See Travels into Greece and Turkey, p. 497. c See Note A. APPENDIX. 961 authentic or satisfactory account, furnishes evidence of the truth. Whether that disease originated in the city of Athens, or was introduced into it from ^Ethiopia, the fact is established, that the circumstances under which it appeared in that city were peculiarly favourable to its diffusion. It appeared, according to Thucydides, in the beginning of the summer season, and first of all at the Piraeus, the port and harbour of Athens, from whence it spread with increasing mortality into the upper part of the city. It appeared, too, at a time when Athens was so crowded with those who had fled thither from the adjacent country of Attica for safety from the invading armies of the Peloponnesians and their allies, that many of them were forced to lodge themselves within the turrets of the walls, or wherever they could find a vacant corner. " The city," says the historian, " was not able to receive so large a conflux of peo- ple :" " afterwards the long walls, and a great part of the Piraeus, were portioned out to them for little dwellings ; at the same time, too, the Athenians were fitting out, at the Piraeus, a fleet of one hundred ships to infest Peloponnesus." Even the Pelasgic, a hitherto vacant spot of ground below the citadel, which it was thought profaneness to occupy, and the settlement of which the Pythian oracle had specially prohibited, they were constrained, by urgent necessity, to turn into a dwelling- place. By this influx from the neighbourhood of Athens its number of inhabitants, as stated by a late writer, was Suddenly increased from fifty thousand to more than four hundred thousand persons.* In another place, Thucydides observes, " Those who had come in from the coun- try had no houses, but dwelled all the summer season in booths, where there was scarcely room to breathe ;" he adds, " The pestilence destroy- ed with the utmost disorder, so that they lay together in heaps, the dying upon the dead, and the dead upon the dying." Even in the public streets, some were tumbling one over another, or lay expiring round about every fountain, whither they had crept to assuage their immode- rate thirst; the temples, too, in which they had erected tents for their reception, were full of the bodies of those who had expired there. Thucydides proceeds, " In a calamity so outrageously violent, things sacred and holy had quite lost their distinction ; all regulations obser- ved before in matters of sepulture were quite confounded, since every one buried wherever he could find a place." He also observes, "it raged the most, and for the longest time, in Athens, but afterwards spread into the other towns, especially in the most populous, but never extended itself to Peloponnesus." We are told by the, same historian, that" at the siege of Potidaea, which took place during the same season, the plague followed them even thither, and, making grievous havock among the Athenians, destroyed the army ; and that even those soldiers that had been there before, and had, from the beginning of the siege, been in perfect health, caught the infection from the troops brought thither by Agnon. After a stay of forty days, having, in that time, lost one thousand and fifty out of four thousand men, he returned with his ships to Athens."! With these facts before us ; the season of the year in which the plague ma.\3 its first appearance, the part of the city in which it commenced, the multitudes which crowded into it, and those, too, unaccustomed to * Medical Repository, vol. 1. p. 16. ■f- Smith's Translation of Thucydides, vol. 1. p. 153. 122 962 APPENDIX. the air of the town, having been habituated to active employment in the pure air of the country, the impure state of the atmosphere necessarily resulting from this condition of things, combining the evils both of pes- tilence and war ; the disease itself being confined within the walls of the city, while, at the same time, it never extended itself to the neighbour- ing country, not even to the contiguous towns of Peloponnesus and Bceotia, we are led to the conclusion, that an impure atmosphere is the vehicle or medium by which this disease is propagated. The circumstances attendant upon the plague, as it has appeared at different periods in the city of Rome, are no less demonstrative of this truth. I will only notice the more remarkable visitation of this disease which took place in the year of Rome 290, and four hundred and sixty- one years before Christ. " This," says Livy, " was a season of great distress; for during this year a pestilential disorder spread itself not only through the city, but over the country, affecting both men and cat- tle with equal malignity ; the violence of the disorder was increased by admitting into the city the cattle and the inhabitants of the country, who fled thither for shelter from the enemy's ravages : such a confused col- lection of animals of every kind suffocated the citizens by the unusual stench, while the country people, crowded together in narrow apart- ments, suffered no less from the heat, the want of rest, and their at- tendance on each other ; besides, even contact served to propagate the infection."* Baker's Livy. Dionysius of Halicarnassus mentions! that the disease seized studs of mares, herds of oxen, and flocks of goats and sheep, doubtless de- noting that this disease was remarkably fatal to those animals when collected in numerous <**odies. Orosius, in his account of the same pes- tilence, observes, " Many of the patricians were victims, but it was most fatal to the poor."J Livy also has a similar observation, that many illustrious persons died, but that among those of inferior note the virulence of the disorder spread its ravages wide. The history of the pestilence of modern times, the accounts of which are more minutely and satisfactorily detailed, no less proves that this disease, when once introduced, spreads its devastation by means of a vitiated atmosphere, more especially where such vitiation pro- ceeds from confined human effluvia. Accordingly, in the plague of London, in 1665, at which time nearly one hundred thousand persons perished, we are told by Hodges, that while the better sort of people had various resources to avoid the dreadful consequences of this fatal distemper, it was entirely confined to the -poor, insomuch that some gave it the name of the poor's plague. The rich, says Mr. Howard, are less liable to the plague than the poor, both because they are more careful to avoid infection and have larger and more airy apartments, and because they are more cleanly, and live on better food, with plenty of vegetables ; and this I suppose is the reason why protestants are less liable to this distemper than ca- tholics during their time of fasting ; and likewise, why the generality * Grave tempus et forte annus pestilens erat url>i, agrisque, nee hominibus magis, Ibid, p. 74. APPENDIX. 96a The plague of Aleppo, in 1760, 1761, and 1762, misrht also be cited upon this occasion, as well as many others, both anterior and subse- quent to that period, to show that the epidemic influence of this disease is chiefly dependent upon the atmosphere into which it may be intro- duced. I cannot, however, pass over, without comment, the plague which the British and French troops suffered during the celebrated ex- pedition to Egypt in 1800 and 1801, inasmuch as it will show that this disease, even in its native climate, is governed by the same laws of com- munication which have been observed when it has been introduced into other countries. We are accordingly told, by the learned Dr. Wittman,* "that the disease is more prevalent at Rosetta than in any other town, or part of Egypt;" he adds, "the streets of Rosetta are extremely narrow and very dirty. The crowded manner in which the inhabitants live together would appear sufficient, in a stagnant state of the atmosphere, in most of their towns, to generate pestilential or malignant diseases. The very few comforts and conveniencies which fall to the lot of the poorer class of the natives in Egypt, by far the most numerous, would lead one naturally to expect great mortality when the plague prevails among them. Dread- ful examples are seen annually to happen." In another part of the same work, he is still more explicit on this point, showing that the plague " does not always possess the same activity and force ;" and the necessity, as he expresses it, of some " powerful agent to put the conta- gion into action, and give it its full force." He then asks, "May this agent reside in the atmosphere ? Does this peculiar constitution of the air consist in a superabundance, or diminution, of the ordinary propor- tion of oxygen in the atmosphere ? or in the combination of some pe- culiar gas or gasses diffused in it ?" He suggests that a series of eudio- metrical and other observations, continued for several years, might throw some light on this subject: " Time alone," he adds, " may unfold this mystery, "t But when we take into view the facts he has already sta- ted, relative to Rosetta, and are told by the same author, that in Egypt the plague prevails when the Nile is low, and of course the air loaded with the impurities thence arising ; that at Constantinople, the cold weather, in winter, puts a period to its progress, and the still more ge- neral observation, that the extremes both of heat and cold are unfa- vourable to the propagation of plague : these facts, in connection with those already stated of this disease, as it has appeared at different times and in different parts of the world, are certainly calculated to dissipate much of the mystery in which this subject has been enveloped. The remarks'of Dr. M'Gregor, (now Sir James M'Gregor, principal of the medical staff,) that the plague varies its type according to the state of the air, and other circumstances, and that by ventilation, fumigation, and attention to cleanli- ness, the progress of the disease was arrested,\ also serve to confirm the correctness of the view which has been taken of this subject. Even the writings of Assalini, who disbelieves the communication of this disease by contagion, furnish additional support to the principle here contended for ; for he admits, that when persons are shut up and crowded together, in infected places, the disease is readily contracted. • • r- APPENDIX. 979 T7t nebula ac nubes paullatim repit, et omne, t^ua graditur, conturbat, et immutare coactat. i it quoque, ut in nostrum quom venit denique coelum Conrumpat, reddatque sui simile, atque alienum." Lucretius, de Nat. Rerum, lib. VI. Or, as it has been rendered by that learned surgeon and accomplish- ed scholar, John Mason Good, Esq. " But when the heaven of poisonous power to us, First moves remote, its hostile effluence creeps Slow, like a mist or vapour; all around Transforming as it passes, till at length, Reach'd our own region, it the total scene Taints, and assimilates, and loads with death." If the view which has been taken of this subject be correct, a still more important truth is the result; that, while by a rigid and well exe- cuted system of quarantine laws we have it in our power to guard against the introduction of the spark that kindles the flame, we are also enabled, by means of domestic cleanliness and ventilation, to ex- tinguish it when introduced. For this purpose our magistrates and guardians of the public health cannot be too attentive in their police regulations to have all noxious materials removed from our streets and our dwellings ; and, at the same time that they are ornamenting our cities by the erection of magnificent buildings, and the introduction of other important improvements, they should also avail themselves of every opportunity which may present of widening our streets, and of reserving squares and other pieces of ground to be ever kept vacant, as among the most effectual means of preserving the health of our citi- zens, and guarding against the propagation of contagious diseases. -------" Best is Pelasgic empty" was wisely expressed by the Pythian oracle ; thereby denoting that every large and populous city, as well as Athens, should have its pelas- gics, or vacant pieces of ground, as so many reservoirs of pure air for the purpose of counteracting the effects of contagion when, introduced. 9SG APPEND. S! ILLUSTRATIVE NOTES. NOTE A. {Seepage 960.) The American publishers of the New-York edition of Neale's trans- lation of the work of Assalini on the plague of Egypt, in their intro- ductory observations, have, among others, the following singular re- mark : " The existence of such contagion [of the plague] has never been proved by the evidence of one of the senses. The contagion is a mere conceit of the mind ; and all reasoning upon such a visionary and fan- cied agent can be but hypothesis, and have no better claim to our as- feent than the fluid of magnetism, and the ether of gravitation ; an as- sumption not near so worthy of our assent, as if it had been said, that the invisible angel of destruction had literally and bodily descended, sword in hand, to execute a heavy judgment of his Lord." In refutation of these extraordinary and unwarrantable assertions, it were an easy matter to cite a volume of evidence. The following facts, selected from Others of a similar kind, will, 1 trust, be sufficient for the purpose of demonstrating the fallacy of the doctrine of the American publishers referred to, and the correctness of the view that has been contended for, relative to the contagious character of the plague. Dr. Guthrie, a celebrated physician of St. Petersburg, in bis in* quiries relative to the contagiousness of the plague, observes : " Chance threw in my way an excellent opportunity of examining into the merits of this opinion, by consulting the physicians and sur- geons of the Russian army, lying in the conquered Turkish provinces of Moldavia and Wallachia, where the plague ever obtained more or less during the whole war, and at the beginning raged with destructive vio- lence ; and on addressing myself to Baron Ash, physician general, I had an answer that met my ideas on the subject. " The difficulty of ascertaining the exact time when the infection i's received, and, consequently, the interval that takes place before the attack of the pestilential fever, must appear upon the faee of the case, except experiments were to be made on purpose, which is scarcely to be expected. However, the intrepidity of a single man has thrown Some light upon the matter : this was Mathias Deggio, one of the sur- geons of the hospital at Bucharest, a building appropriated to the cure of the plague in the Russian army. " He, perceiving the gentlemen of his profession condemned, in a manner, to death, if punctual in their duty, had the resolution to ino- culate himself for the plague, in the full confidence of its efficacy, and ever afterwards found himself invulnerable, whilst his companions around him were falling victims to its fury. He produced the disease by inserting, with a point of a lancet, under the epidermis of his arm, matter from a pestiferous abscess, and followed the cold regimen ob- served in the small-pox, as he had imitated its mode of inoculation ; on the fourth day of #ie puncture the fever declared itself." APPENDIX,, $8-1 Dr. Guthrie adds, " the Baron then said a great deal in favour of ino- culation of the plague, and supported his opinion with the case of Ma- thias Deggio given above ; and the analogy that has been observed be.- tween the plague, small-pox," &c. (Medical Commentaries Edin. vol 8.) Another fact of a similar nature is recorded by Sir Robert Wilson : " That daring spirit of investigation into the causes and effects of those diseases, whose principles are yet unknown, and which has so much distinguished the profession, was not to be intimidated by the menacing consequences of a bold examination into the powers and properties of the plague. " Dr. Whyte, an English physician, determined to discover if this malady, so destructive to a large portion of the globe, and which filled with apprehension the remainder, could not be checked, or rendered less virulent, by the introduction of inoculation. " Resolved to become the patient of his own speculation, during the time the plague raged again at Rosetta, (which it did towards the fall of the year, when numbers of Sepoys died,) he inoculated himself with matter taken from the buboes of an infected person. The attempt fail- ed twice ; the third proved fatal; in three days after the symptoms ap- peared, he died, falling a much-to-be-lamented victim to a disinterested zeal, benevolently and intrepidly directed for the benefit and happiness of the community." Wilson's Hist', of the British Expedition to Egypt, Ato page 257. The highly respectable Dr. M'Gregor, (see Medical Sketches of the Expedition to Egypt from India,) relates the same fact more circumstan- tially. Another instance of the same intrepid, but benevolent effort to dimi- nish the sufferings of humanity, is recorded by Sonnini, Tratels into Greece and Turkey, London ed. p. 496.) " Every physician," says that writer, " has not the courage, or, to speak more correctly, the madness of that Russian surgeon, prisoner at Constantinople with a number of his countrymen, who took it into his head to inoculate these unfortunate beings with the plague, in order to render the contagion less destruc- tive : by this means he killed two hundred of these prisoners ; and, fortunately for the rest, the inoculator, after having performed the operation on himself, died of his own treatment." M. Assalini has stated, in corroboration of his own opinion of the noncontagiousness of the plague, that M. Desgenettes, the chief physi- cian to the army of the East, while in Syria, inoculated himself with the matter of the plague, without taking the disease, and that he made this inoculation under the persuasion that the plague was not contagious. The observations taken from the work of M. Desgenettes himself, clearly show the incorrect statement of M. Assalini on this subject, and that Dr. Desgenettes considered the contagiousness of the plague as ab- solutely demonstrated. See Histoyre Medicate de I'Armte d'Orient, p$r le Medicin en Chef, R. Desgenettes, a Paris, an x. 1802. In addition to the testimony of Dr. Desgenettes, I subjoin the follow- ing interesting extract of a letter from Professor Alire R. Delile, M. D., who accompanied the French army in their expedition to Egypt, and who, as a member of the Institute, had the most ample opportunity of obtaining correct information relative to the opinions of the me/lica*i fitaff on thi> subject. ^9Jj2 APPENDIX. Dear Sir, I am happy of any opportunity which reminds you of me, and on the ■subject upon which you desired an answer, I am ready to give it to you. Comparisons have been made between contagious diseases, viz. the plague of the east, and the yellow fever of America. Opinions have been deduced from the examination of facts in different cases ; but facts have not always been sufficiently ascertained for us to rest our opinions indiscriminately upon them. I was in Egypt a witness to many facts which I recollect perfectly. A report that the inoculation of the plague had been attempted in vain must have originated from letters sent from Syria to France, and notes. spread afterwards through Europe and America. From several of my friends and colleagues of the commission of arts, namely, M. Coquebert and M. Champy, who died of the plague, M. Pothier, who recovered, having been attended by M. Desgenettes, I have had strong reasons to convince myself of the contagiousness of the plague. The quarantine laws established of old, with a great deal of severity in France, after many distressful events, the preventive means used by the Europeans settled in the cities of the east, who, by shutting themselves and their families in houses, and by avoiding contact with people, and with every thing from out of doors, except when well washed, and who are never attacked with the disease ; while the loss of those who have remained exposed to the contagion, often lamented, have been sufficient examples to convince me early, of the truth of that opinion. Further I cannot say any thing from my own experience. The French physicians differed in their opinions whether the plague was indigenous or accidentally imported into Egypt, but none of them denied its contagiousness. Owing, perhaps, to the same opinion that I had, and to the natural propensity to imitate what others did with suc- cess, in avoiding, as much as they could, communication and contact, I escaped the danger, and I am happily placed in the situation to express to you the sentiments of esteem with which I remain, Sir, your most obedient, humble servant, ALIRE R. DELILE. Without further enlarging on this head, we are, I believe, prepared to conclude with the learned Dr. Parr, " that those who have suggested and disseminated doubts of the contagiousness of plague, are answerable for the lives of thousands, and, in some instances, have paid the forfeit with their own." London Medical Dictionary. NOTE B. (Seepage 972.) • I have remarked in the text, as an evidence, among other's, that the yellow fever which prevailed in New-York in the year 1798, was not produced by putrid beef; that those persons who were employed in re^ moving such putrid provisions from the city escaped the yellow fever. The same respectable gentleman, Mr. Edmund Prior, who furnished me with that fact, has also informed me, that offorty persons who were •engaged in that particular service, under his immediate inspection.. APPENDIX. 983 fairly eight were attacked with a complaint of a very different character, the dysentery; which disease it is well known to all practical writers, frequently arises from decomposed animal and vegetable matter, as its' exciting cause. The remaining two persons who had been thus employed by Mf. Prior, escaped the dysentery, with which their comrades were afflict- ed ; but upon leaving that service, and being afterwards exposed to the contagion of yellow fever, while working on board of ships, they fell victims to that disease ; a circumstance which clearly shows that dysen* tery and yellow fever derive their origin from different sources : for additional particulars on this head, see Sketch of the Rise and Progress of the yellow fever, &c. by William Currie, Philadelphia, 1800. That the yellow fever of 1798, did not proceed from the putrid beef,. to w hich many physicians ascribed its origin in that year, is also evident from the faets stated in the following extract from a letter which 1 received from the Rev. Dr. M'Knight, of New-York, dated November 6th 1809. " In the year 1798, Melancthon Smith, and another man whose name- I do not reeollect, were the two first instances of the yellow fever in New-York. They had both been on board the ship Fame, as she came up to the New-Slip in the East River, where she unloaded her ballast* and emptied her bilge water. The stench occasioned thereby was so intolerable, that, the wind being south, the inhabitants.On the north side of the dock had to shut up their doors and windows, and some of them left their houses. To my knowledge, as many as twelve or fif- teen died in that neighbourhood, in the course of two weeks, several of whose funerals I attended. This same vessel was afterwards removed to a dock in the vicinity of the Coffee-House : there several persons, who wrought on board of her, who resided in Eden's Alley, took the fe- ver, and carried it up into that part of the town. Just at this time, there was a very heavy rain, which filled most of the cellars, in the lower part of the city. The fever raged with alarming violence on Golden Hill. It assumed the appearance of the plague." Thus, then, it appears that many cases of the fever of that year, ex- isted in the city before the heavy fall of rain took place, and its effeets upon the stored provisions were perceived ; consequently the yellow fever of that season did not proceed from those putrid materials as its source. That the foul state of the air which ensued lent wings to the1 contagion, I trust will by all be admitted. NOTEC. (See Page 972.) Td employ the language of that distinguished medical philosopher, Dr. Chisholm, it has become a kind of axiom in medical physics, that the effluvia of decomposed animal bodies are the most certain and fre- quent cause of malignant and pestilential fevers. This opinion, which has been promulgated from age to age, and which has been so generally received, because it has not been in- vestigated, has, at length, been most ably examined and refuted by Dr. Chisholm. See his learned and elaborate essay on this subject in the. Edinburgh Medical and Surgical Journal; also, his letter to Haygarth. It is also a proof of the innocence of dead animal matter, and of the communication of the plsgue by a specific secrcetion from the living m APP'E.NDIK. body, that the corpses of those who die of plague do not convey the disease. " It is remarkable" says Mr. Howard, " That when the corpse is cold bf a person dead of the plague, it does not infect the air by any noxious exhalations. This is so much believed in Turkey, that the people there are not afraid to handle such corpses. The governor at the French hospital in Smyrna told me, that in the last dreadful plague there, his house was rendered almost intolerable by an offensive scent, (especial- ly if he opened any of those windows which looked towards the great burying ground, where numbers every day were left unburied ;) but that it had no effect upon the health either of himself or his family. An opulent merchant in this city likewise told me, that he and his fa- mily had felt the same inconvenience, without any bad consequences.'7 "Howard mi Lazarettos, 2d ed. Lond. 4to, page 25. Rondeletius, as quoted by Sennertus, asserted that he had dissecteii bodies dead of the plague in presence of many of his pupils with per- fect safety. Much interesting information on this subject will be found in the first volume of Dr. Ferriar's Medical Histories and Reflections. Dr. Ferriar remarks. " It is a general opinion, that pestilential disorders are occasioned by the effluvia of dead bodies ; but there is reason to question the truth of this. When plague has appeared in the neighbourhood of places where many bodies had remained unburied, after general engagements, other- causes can be pointed out as more likely to have produced it. But many instances can be produced in which thousands of dead bodies have been left to putrefy on the field of battle, without causing pestilential distem- pers. This was not unnoticed by the attentive Diemerbroek." It has also been stated, that decomposed vegetable matter is not, as contended for by many physicians, the cause of yellow fever. The following fact, stated by Dr. John Stewart, of Grenada, abundantly proves that''vegetable filth has no more agency in the production of that peculiar type of fever than putrid animal substances." That vegetable and animal matters in a state of putrefaction do produce disease is not to be denied ; but that vegetable matter in a state of corruption is, on many occasions, harmless is evident, from the very offensive heaps of cotton-seed, and the pulpy covering of the coffee-berry, which are daily to be met with in Demerara, without being considered as a cause of fever; nor should this circumstance be omitted, that when fever does prevail, it is at a season when those causes do not act powerful- ly ." See Observations on the Nature and Treatment of the Malignant or Yellow Fever which prevailed in the island of Grenada, (W. I.) in the years 1793, 1794, and 1795, in a Letter to David Hosack, from Jofm Stewart, M. D., fyc. o/c. Amer. Med. and Phil. Register, vol. 3, p. 183. It may also be remarked as an additional testimony to that stated by Dr. Stewart, to prove that the yellow fever does not derive its origin from decomposed vegetable matter, that whenever that disease has pre- vailed in the United States, it has not appeared in the country, where such vegetable matter is most abundant; but has been chiefly confined to our largest cities, and those towns which are situated on our sea- board ; a fact totally inexplicable upon the principle that the yellow fever is the product of vegetable putrefaction. I am fully aware the opinion has been entertained that this form of fever prevails in the in- terior of our country, and especially in the vicinity of the lakes ; but APPENDIX. 905 whoever will "consult the statements furnished by physicians residing there, and who have had the best means of obtaining correct information, will find ample refutation of that opinion. See Frisbre's Sketch of the Medical Topography of the Military Tract of the State of New-York; and Brown's Sketch of the Country watered by the Mowhawk River, fyc. Amer. Med. and Phil. Register vol. 4. ; Needham's Sketch of the Medical Topo- graphy of Onandago, State of New-York. See Barton's Med. and Phys. Journ. 1st supplement. A distinguished American writer, the late Andrew Ellicot, Esq. has been often triumphantly quoted in support of the assertion that the bili- ous fevers, the produce of marsh effluvia in every part of our country, are identical with the yellow fever of our cities. But in a conversation with him on this subject a short time previous to his death, and in the presence of one of my fellow professors, Dr. Francis, he declared to me, that the fevers which he had noticed wanted the more violent symptoms associated with yellow fever. Professor Ellicot remarked that at the time he made the observations in his Journal, he had had very little acquaintance with the malignant yellow fever, as described by Dr. Rush and others ; but that, subsequently, he had seen much, both of the pestilential fever of New-York and Philadelphia, and of the lake or marsh fevers in different districts of the United States. He was now convinced that the yellow fever and the fevers of the interior of the country were of an entirely distinct character. See Dr. Fran- cis' communication in Appendix to the Discourse on improving the Me- dical Police of the city of New-York, &c. 1820. But the facts are innu- merable which show the absurdity of resorting to vegetable or animal putrefaction, as the source of the malignant fever with which the Uni- ted States have been visited. When we advert to the condition of the city of New-York anterior to the American revolution, and before any system of police regulations was adopted ; to the offensive state of the town during the revolutionary war, when crowded with British troops ; to the immense collection of foul materials of every sort in the cellars of the numerous buildings destroyed by the great fire of 1776, during the whole of which period this city enjoyed a total exemption from the pestilential fever, we must be convinced of the limited and incorrect views of those who look no further for the origin of this evil. In like manner, the offensive state of our slips, our wharves, and our market-places, until within a very few years ; the putrefactive processes attendant upon our tanne- ries, morocco, starch, and glue manufactories, slaughter-houses, tallow chandleries, sugar-houses, &c. &c. the filthy and neglected condition of our streets, and we may add, of many of our burial grounds, furnish in- contestable evidence that these are innocent when considered as the pri- mary causes of the mortal epidemics which have desolated our cities. The influence of such an impure state of the atmosphere, resulting from these various causes, as a secondary agent in multiplying and diffusing the poison of fever when introduced, has already, I trust, been made sufficiently manifest. Mr. Howard, in his remarks on the plague, (see History of Lazarettos, p. 43.) adverting to the opinions of those who questioned the contagious- ness of that disease, asks, " Have not some of our professors sullied their names with such dangerous doctrines ? From no other cause," he continues, "than the errors of physicians, who continuallv main- 125 986 APPENDIX. tained that the disease, then epidemic, was not contagious happened that terrible visitation which, in 1743, ravaged the city of Messina and its vicinity, with the loss of above forty-three thousand individuals, in the short space of only three months." In the correctness of the observation, "that the material of conta- gion itself is not constituted by putrid animal or vegetable matters," I am also confirmed by the observations of our present health officer, Dr. Joseph Bayley, who informs me, that upon several occasions he has witnessed the arrival, at the Quarantine, of vessels coming from sickly ports, and conveying disease, yet in all other respects in a perfectly clean condition ; and on the other hand, that vessels laden with some thousand hides and many hundred bags of coffee, in the most offensive and putrid state, have frequently arrived with a healthy crew ; nor did they, while at Quarantine, communicate disease to any persons, whose duty or business made it necessary to hold communication with them, or who were occupied in the discharge of the cargo of such vessels. One instance he relates, which fell under his notice, of a vessel in so offen- sive a condition from the causes mentioned, as to convey the effluvia to the extent of more than half a mile, insomuch that the passengers of a packet boats at the leeward, passing the Quarantine at that distance, were compelled to leave the deck, to avoid the stench with which they were assailed—still no disease was communicated to any person holding in- tercourse with those vessels : vessels, too, from South America, laden with beef in bulk, and frequently in a very offensive state, are never- theless in the most healthy condition. May it not with great propriety be asked, can the physicians of the United States, who shall carefully have reflected upon the facts which have just been stated, and others of a similar nature which might easily be adduced, persist in the belief they have expressed, that the pestilen- tial fever that has appeared in our cities and seaport towns is the pro- duct of decomposed animal and vegetable matter ? NOTE D. (See page 974.) The following statement fully illustrates the principle, that those who are accustomed to breathe an impure air frequently escape disease, while those who, from their better condition in life, enjoy the more pure atmos- phere, are readily attacked with contagious fever when exposed to its exciting cause. " The most pernicious infection," says Lord Bacon, "next the plague, is the smell of the jail, when the prisoners have been long, and close, and nastily kept; whereof we have had in our time experience twice or thrice, when both the judges that sat upon the jail, and numbers of those who attended the business, or were present, sickened upon it and died. Therefore, it were good wisdom that in such cases the jail were aired before they be brought forth." Nat. Hist. exp. dccccxiv. In Stowe's Chronicle a more particular account is given of the same circumstances, as occurring at the fatal assizes held in the year 1577, in the following words : " On the 4th, 5th, and 6th days of July were the assizes held at Oxon, where was arraigned and condemned Rowland Jenkins for a seditious tongue ; at which time there arose amidst the people such a damp, that almost all were smothered. Very few escaped that were not taken. Here died in Oxon three hundred persons ; and APPENDIX. 987 sickened there, but died in other places, two hundred and odd." " Of the same kind of infection," says Sir John Pringle, "we have an un- happy instance so fresh in our memory, that I needed not to have men- tioned here, had it not been for such as live at a distance, or those whe are to come after us. In the year 1750, on the ll.th of May, the ses- sions began at the Old Bailey, and continued for some days ; in which time there were more criminals tried, and a greater multitude was pre- sent in the court, than usual. The hall in the Old Bailey was a room of only about thirty feet square." "The bench consisted of six per- sons, viz. the lord mayor, three of the judges, one of the aldermen, and the recorder, whereof four died, together with two or three of the counsel, one of the under-sheriffs, several of the Middlesex jury, and others present, to the amount of above forty : without making allowance for those of a lower rank, whose death may, not have been heard of; and without including any that did not sicken within a fortnight after the. sessions." Similar instances of infection are related to have taken place at the Black Assizes, at Taunton, and at those of Exeter, in 1586. SeeRees's Cyclopaedia, art. Contagion. Facts of. a like nature have fallen under the notice of that accurate observer, Sir Gilbert Blane. An extract from his letter on this subject is here inserted. Extract of a Letter from Sir Gilbert Blane, M. D. 4*c. to the Hon. Rufus. King, Esq. Minister at the Court of St. James, from the United States of America, dated London, 26th November, 1798. Sir, I sit down to perform the promise I made you this morning, of putting on paper some remarks on the nature of the yellow fever, and the means of preventing it. In doing this I shall chiefly confine myself to those views of it in which the magistrate is concerned. The adopting of measures for the prevention of disease is one .of the most important duties of a wise and patriotic government; and the discovery of these means, as well as the efficiency of the steps to be taken, must depend on a thorough knowledge of the causes by which it is excited and influenced. My opportunities. upon actual service in the West Indies in the late war, when physician to the fleet under the command of Lord Rodney and Admiral Pigot, and my present official duty as a member of the Medical Board of the Navy, have necessarily brought to my knowledge a number of facts relating; to this subject, and I shall be extremely happy if the communication of some of the most important of them can throw any light, which may prove useful to the American government in checking an evil so afflict- ing and calamitous. The first question that occurs with a view to preventive measures is, whether this disease be infectious, and under what circumstances it is so 1 In those situations in which I observed it in the West Indies it was evidently so. There was the most incontestable evidence of this, both on board of ships and at hospitals, and the doubts which have been started on this point, seem to have arisen from the operation of infec- 988 APPENB1X. tion being blended with that of other causes, which must concur with it in order to give it effect. But whatever doubts there may be on this subject in the West Indies, there can be none in the climate of North America. This will be best proved and illustrated by an example. On the 16th of May, 1795, the Thetis and Hussar frigates captured two French armed ships from Gaudaloupe on the coast of America. One of these had the yellow fever on board, and out of fourteen men sent from the Hussar to take care of her, nine died of this fever before she reached Halifax on the 28th of the same month, and the five others were sent to the hospital sick of the same distemper. Part of the prisoners were removed on board of the Hussar, and though care was taken to select those seemingly in perfect health, the disease spread rapidly in that ship, so that nearly one third of the whole crew was more or less affected by it. This fact carries a conviction of the reality of infection, as irresistible as volumes of argument; and it further affords matter of important and instructive information, by proving that the infection may be conveyed by the persons or clothes of men in health. Blane*s Diseases of Sea- men, p. 605—607, 3d edit. The principle which we have endeavoured to illustrate relative to the operation of febrile infection upon individuals unaccustomed to its influence has, in several instances, been strikingly exemplified by circum- stances which have occurred in the Debtor's Prison, and in the Bride- well of New-York. The following memorandum, made at my request by Dr. J. W. Francis, is in point on this subject. " In the month of September, 1811, a febrile disorder of the typhoid character made its appearance in the Debtor's Prison of this city : its origin was owing to causes similar to those which usually produce a vi- tiated state of the atmosphere in confined apartments, the want of pure air, and the crowding of a large number of persons together, &c. &c The contagion thus engendered was observed to operate with peculiar severity upon those individuals who were suddenly introduced into this vitiated air. About the 16th of July, 1814, several cases of the typhus carcerum occurred in the Bridewell of New-York. The disease was first observed to exist in an apartment of the institution commonly called the eastern wing, a room about fifty feet long and twenty-five broad. Within a very few days after, the complaint became more general; and out of eighty-five individuals at that time confined in this part of the building, nearly forty were taken ill with symptoms characteristic of typhoid fever. The disease, in this instance, as in the former, was produced from the local circumstances of the place ; the crowded con- dition of the ward, the want of cleanliness about the persons and in the clothing of the prisoners, and the neglect of free ventilation. The in- creased impurities of the atmosphere of the apartment seemed to give additional activity to the virulence of the disease : of the persons thus affected, a large majority were those who had come from a pure air, and were but recently subjected to the noxious air of the place, several not more than thirty or forty hours, and many not more, than three or four days. The infection was more readily communicated to those, too, who were naturally possessed of vigorous and robust constitutions, and its effects were, in most cases, more violent upon persons of this de- APPENDIX. 989 scription than upon others. That the sphere of the infection was con- fined within certain limits, as affirmed by Dr. Lind of the malignant fe- ver at the naval hospital at Haslar, and lately most satisfactorily shown by induction from well-attested facts concerning typhoid infection in general, (See Letter of Dr. Haygarth to Dr. Percival,) was abundantly manifest from the healthy condition of the prisoners in other apartments of the Bridewell. The progress of the disease, which I have thu9 brifly noticed, was arrested by the removal of the sick, and the mate- rials impregnated with the morbific poison ; by the introduction of pure air, by ablution, and by other means now most generally had recourse to for the purification of fever wards and houses of recovery, as recom- mended by Dr. Ferriar. " It has again and again been observed, by the keepers of our prisons, that those criminals who have long been accustomed to breathe the vi- tiated air of the crowded apartments of these institutions very frequent- ly escape febrile contagion : the poison itself might, at first view, ap- pear to have lost a portion of its virulence ; but it has with more pro- priety been maintained, that the individuals thus inured to its influence are, from habit, exposed to it with impunity ; while, on the other hand, the reverse is the case with the unassimilated, when subjected to the operation of an impure air, deriving its noxious properties from concen- trated human effluvia. It is a remark of most writers, that the infection of typhus, whether occurring in jails, ships, or elsewhere, becomes concentrated, and consequently, more active by the cold of winter. This opnion is strengthened by the well known fact, that a greater number of deaths takes place from fevers of this nature, in our prisons, during the winter than in the summer season." NOTE E. (See page 975.) I have expressed the belief that the changes which the atmosphere undergoes during the prevalence of certain pestilential disorders are as- cribable to a fermentative or assimilating process. 1 am strengthened in this opinion, which I have for many years maintained, by the recent and elaborate investigations of M. M. Gay Lussac, De Saussure, and other distinguished chemists, which have thrown much light upon the subject of fermentation, and also by some interesting observations lately published in the Edinburgh Review. See Edinburgh Review for April, 1814. For a perspicuous elucidation of the manner in which the poison of diseases of specific contagion operates upon the human constitution, in assimilating the mass of fluids to its own peculiar nature, the reader may consult an Essay published by Dr. J. W. Francis, then Professor of Ma- teria Medica in the University of the State of New-York, and inserted in the American Medical and Philosophical Register, (vol. 4. p. 476— 519.) also a valuable Dissertation on the Pathology of the Human Fluids, by Dr. Dyckman, of New-York. NOTE F. (See page 976.) There is scarcely to be found on record a series of facts which so conclusively prove the specific character of the pestilential or yellow fever, or points out the circumstances under which it is propagated or 990 APPENDIX. extinguished, as those referred to in the text: e. g. we have seen this disease introduced at the Wallabout on Long Island in the summer of 1804, and the poison diffusing itself in that neighbourhood as far as the impurity of the air extended ; while the same disease conveyed from the Wallabout into the city of New-York, was instantly extinguished by means of the relative purity of the atmosphere, the effect of the rigid system of police then observed. See American Med. and Phil. Register, vol. 2. In like manner, in the summer of t809, (See Statement by Dr. Giles- pie, Amer. Med. and Phil. Register, vol. 1.) the yellow fever was intro- duced and spread in the village of Brooklyn, Long Island ; at the same time, that the city of New-York, within eight hundred yards' distance, enjoyed the most perfect exemption from it; a fact which at once dis- proves the dependence of yellow fever upon a general constitution of atmosphere, which many physicians believe to be necessary both for the origin and propagation of this form of fever. We are led to the same conclusion by a perusal of the report relative to the introduc- tion of the yellow fever into the city of Amboy, New-Jersey, in the summer of 1811. See Amer. Med. and Phil. Register, vol. 3. NOTE G. (See page 976.) The following extract of a letter from the Rev. Dr. Samuel S. Smith,. the late president of Princeton College, shows that the fact I have stated of an interval having taken place between the first and subse- quent cases of fevers is of so frequent occurrence, that it even attracts the notice of those who are unconnected with the medical profession. Dear Sir, Princeton, July 24th, 1808. I have not any doubt, but that yellow fever contains a specific conta- gion, essentially variant from that of small-pox, with which it has so often been compared in order to deny contagion being incident to it. It re- quires a certain putrid state of the atmosphere as a conductor, in order to impart it; and it mav inoculate and assimilate any confined portion of atmosphere which has been exposed to the requisite causes of con- tamination, so that every part of it shall have power to communicate the poison. In the pure atmosphere of the country the poison is com- monly so diluted, that it is too weak to excite the fever, except under peculiar circumstances. In every instance in which yellow fever has been introduced into Philadelphia, one circumstance has invariably taken place : after the persons who have first taken the disease have either died or recovered, there has been an interval of health for several days, usually from ten to thirteen or fourteen, before the alarm has been renewed. From this circumstance I have concluded, that during that space of time the infection secretly works in the blood before it appears in fever. Of- ten there is a second interval of apparent health, but not of so long a continuance. I hope that your view of the subject will carry more con- viction with it than we have hitherto perceived ; and I hope it will even contribute, among the more sensible part of the profession, who do not think merely by authority, to unite jarring opinions and to set- tle common principles. SAMUEL S. SMITH. APPENDIX. 991 By physicians who have recorded our epidemics such interval ha* been repeatedly observed. NOTE H. (See page 977.) In the official document of the Board of Health of New-York, pub- lished on the 14th of September, 1805, they thus addressed the inha- bitants of this city : " The Board have formed a decided opinion, that the principal seat of the prevailing disease [the malignant epidemic fever] is that part of the city included between Burling-slip, and Old- slip as far west as Pearl-street. Almost all the cases of disease which have occurred, can be distinctly traced to a communication with that part of the city. It is a matter of extreme regret, that the repeated admonitions of the board, to remove from this quarter, have been dis- regarded by a number of individuals who have remained the self-devo- ted victims of disease and death. They conceive it their duty again to enjoin it upon their fellow-citizens who have continued there to remove immediately." Again, and in the same address : " All persons who do not comply forthwith with this advice of the board, to remove from the above described part of the city, which is deemed the principal seat of the disease, and which does not contain more than thirty-three acres, will be considered guilty of a wanton exposure of their lives, and will justify the board in resorting to compulsory measures." The epidemic fever which prevailed in Philadelphia in 1793, spread in a similar man- ner, according to Dr. Rush and others. " For a while," says Dr. Rush, " this fever was confined to the above-mentioned part of the city; but the disorder is spreading, and now appears in other places, so that seve- ral are affected in other parts of Water-street : some in Second-street; some in Vine-street; some in Carter's-alley ; some in other streets ; but, in most cases, the contagion can be traced to Water-street." Proofs of the same kind might be taken from the most authentic accounts of the yellow fever, as it has prevailed at other seasons, and in "other cities and seaports of the United States : proofs wholly irreconcilable with the assertions of those who have declared that the malignant yellow fever arises at " distant and unconnected points:" that " no relation is observed between the source of the supposed contagion and the spread- ing of the disease to individuals or families ;" and who have maintained that there " never was any successful attempt to trace, in regular series, the propagation of it to any number of persons from the first case, or from any single point of infection." See Rush's Account of the Bilious Remitting Yellow Fever as it appeared in Philadelphia in 1793 ; Account of the Yellow Fever of New-London in 1798 ; Hardie on the Malignant Fever of New-York in 1805; Chisholm's Letter to Haygarth; Official Documents published by the Board of Health of New-York; Amer. Med. and Phil. Register, fyc. <$*c. NOTE I. (Seepage 978.) Hints on Purifying the air of Infected Apartme?its, by the late Dr. T. Garnett, Professor in the Royal Institution, fyc. " If the air contained in a phial, be rendered offensive by putrid ani- mal and vegetable substances, it may almost instantly be made sweet by 992 APPENDIX. dropping into the phial a few drops of oxygenated muriatic acid ; or more effectually still, by introducing into it a small quantity of oxygena- ted muriatic gas. " This experiment may be easily made ; and il will be found that the air will, in this way, be deprived of the most putrid taint possible. Mor- veau and Berthollet have found, that if oxygenated muriatic gas be dis- engaged in a dissecting room, the bad smell from the subject will be corrected for a time ; and that if the subject be washed with oxygena- ted muriatic acid, it will exhale no bad smell for a considerable time. These curious, but well-ascertained facts, naturally lead us to inquire into the action of the oxygenated muriatic acid, in correcting the putrid affluvia. " It is now well known, that almost all the putrid smells disengaged by putrefying substances, are owing%to the extrication of inflammable air, or hydrogen gas, loaded with some or all of the three following substances, sulphur, phosphorus, or ammonia ; and these substances do not give out any very disagreeeable smell, except when dissolved in hy- drogen gas ; but in that state we know the smell to be very unpleasant. " Sulphurated hydrogen gas, or hepatic air, smells very disagreeably, but the hydrogen gas in which phosphorus has been dissolved, often smells most intolerably, resembling the refuse of blubber. The super- abundant oxygen of the muriatic acid, unites with the hydrogen, and forms water ; and the sulphur and phosphorus being no longer in a state of solution, become concrete, and the bad smell disappears. " Though it is not yet proved, it seems very likely, from the experi- ments of Mr. Wall, and others, that the effluvia from the human body communicating infection, is hydrogen gas, charged with some animal substances. " Is it not natural, from analogy, to conclude, that if these were de- prived of their solubility in hydrogen gas, they would become innocent? and may we not reasonably suppose, that the oxygenated muriatic gas will deprive them, as well as other putrid effluvia, of their solubility ? " It certainly, I think, deserves a trial, which may be made at a very small expense, in the following manner : " Take an ounce of the black oxyd of maganese in powder, and mix with it a quarter of a pound of common salt; put this mixture into an earthen vessel, and place it upon a chafing dish of coals in the room where the person labours under an infectious complaint; then pour upon it two ounces of sulphuric (vitriolic) acid, diluted with the same quantity of water. " Oxygenated muriatic acid gas will be instantly disengaged, and per- ceived in all parts of the room, and will at least destroy any putrid or offensive smell; and I am inclined to hope, that it will likewise correct the contagious effluvia. " When this gas is extricated in too great quantity, it will excite a cough ; but I think that it will not be the case with the quanity I have mentioned ; if it should, a less portion must be used, or the mixture may be made without heat; but we know that bleachers are continually inhaling this gas in considerable quantity, without any disagreeable con- sequences. I should think there could be no difficulty in doing it in the house of any poor person ; but it certainly might be very easily done in a fever-ward." APPENDIX. 993 As connected with the same subject and illustrative of the condition of atmosphere produced by the introduction of an infectious ferment, and the means of destroying the noxious compound, I subjoin the fol- lowing valuable communication from Samuel Bard, M. D. LL. D. the late venerable and learned President of the College of Physicians and Surgeons, in the University of the State of New-York. Dear Sir, Hyde Park, July 27, 180S. I have read, with great pleasure, your arrangement and explanation of contagious diseases, and am, by your arguments, confirmed in the opinion 1 have always entertained of the agency of a ferment, sui gene-. ris, in the propagation of contagious and infectious diseases. I use these terms here indiscriminately: indeed, I believe the analogy between fermentation and its various products, and the progress and fomes of contagious distempers, applies more closely, and to a greater extent,—"-'' than has been generally supposed. For instance ; under certain circumstances of heat and moisture, all vegetable aud animal matters run into fermentation ; that of vege- tables passes through the stages of vinous and acetous to a species of putrefactive ; that of animals likewise has its stages, as is evident in the fermentation of milk ; and its products differ conspicuously according, as flesh, fish, fat, blood, or eggs are the subjects of it. An increased degree of heat always increases the rapidity^ with which fermentation goes on ; and other circumstances of the atmos- phere, a greater or less degree of moisture and dryness, a violent storm, thunder and lightning, moonlight, and probably many other less evident causes combining with the heat, variously change, hasten, or retard the process of fermentation, as every person conversant with these subjects well knows. Again, the different constitutions, (or, if you please, a certain pre- disposition in vegetable and animal substances) have the same effect in hastening, retarding, and variously modifying the products of fermenta- tion ; thus rich vegetable juices readily assume, and stop at, the vinous stage, and with difficulty can be made to go on to the acetous; poor and crude vegetable juices can hardly be arrested at the vinous stage, but run rapidly into the acetous ; and cabbages, and all vegetables of that class, can hardly be made to produce either wine or vinegar, butquickly run into a kind of putrefactive fermentation. Fish putrefies more readily than flesh ; and there is a great difference in this respect between the flesh of different animals. All these circumstances are hastened, rendered more certain, and va- riously modified, by the addition of a ferment, and, lastly, a certain de* gree of cold prevents all fermentation, and stops it where it has already begun. So it is with infectious epidemics ; certain degrees of heat and moisture in the atmosphere are necessary to their production ; high degrees of heat always increase the spread, and add to the malignancy of the disease ; filth, and other qualities of the atmosphere less known, vary their tvpes and exalt their grades ; the constitution of the patient renders him more or less susceptible of particular diseases ; the addi- tion of a ferment (^ which is found wherever the disease exists) most certainly communicates and characterizes it; and lastly, under certain ' circumstances of purity and temperature of the atmosphere, it is found almost impossible to propagate those diseases, even by the aid of afer- 994 APPENDIX. ment; and this observation applies, in some measure, even to small-pox, measles, &c. The sentiment, therefore, which you express, and so well illustrate, that the contagious diseases of your third class, although they may ori- ginate in circumstances of heat, moisture, and filth, and some other less evident qualities of the atmosphere, yet are unquestionably, and with more certainty, produced and propagated by the introduction of a fer- ment characterizing the type and grade of the disease, is, 1 believe, strictly and literally true ; and upon this'opinion only can a well-regu- lated police and quarantine laws be founded. The question you ask, why A after visiting B, ill of dysentery, plague, yellow fever, &c. is seized with the identical disease of B, when you consider the universa- lity of the fact, is decisive as to the existence of a peculiar virus, or fomes sui generis, producing that particular form of disease ; and the observation of Sydenham, that the prevailing epidemic swallows up all other diseases, confirms it; and I think you treat the non-contagonists with too much lenity, when you say they differ from us only in terms : far from it; they differ in fact, and most dangerously so ; for, by de- nying, the generation of a peculiar ferment in and about the bodies of the sick, and the propagation of contagion from patient to patient, they deny the utility, and are led to the neglect, of some of the most import tant precautions against the introduction, importation, and propagation of such diseases. Your first class of contagious diseases is strictly and clearly defined ; they can be communicated by contact only : is not the materies morbi of these diseases always generated within the body : and whether it consists of animalculas, or a chemical mixt, are they to be found any where else ? The fact that the diseases of the second class are communicable at every season of the year, during the heat of summer as well as during the severest cold of winter, in a pure as well as an impure atmosphere, forms the best distinction between this class and the third. But in as far as it is true that none of the second class can be suffered more than once in a lifetime, I am almost led to conclude, that in these too, the materies morbi can be generated only in the bodies of the sick: the first origin of these diseases, and their occasional re-appearance in places where they had not been seen for years before, I confess forms a difficulty, but I do not think a contradiction to this opinion ; the materies morbi in these seems to be of a grosser nature, not so readily assuming a very elastic asriform state as that of the diseases of the third class ; and hence the circle of contagion is much more restricted near the bodies of the sick. Of the third class the fomes may certainly be, in some instances, in the first place, generated in the atmosphere, and for that reason requires particular circumstances of heat, moisture, &c. but finding materials in the bodies of the sick to act upon, it readily assimilates a large portion to its own nature, which being very elastic and aeriform, spreads to a wider extent, and contaminates the atmosphere, particularly a foul at- mosphere, in which similar ingredients are found to a great extent. Your's sincerely, SAMUEL BARD. APPENDIX. 995 Though my observations on fever and febrile contagion have already extended to a greater length than I anticipated, yet I am induced to add the following extracts of a letter from Dr. Francis, the then Professor of the Institutes of Medicine in the University of the State of New- York, communicated to me during his residence in London in 1816. It is interesting on many accounts, but chiefly as making known the im- portant decisions of two of the most learned and distinguished medical bodies of Europe on this momentous subject. Dear Sir, London, June 16, 1816. Within a few days I set out for Bristol, and in all probability this is the last letter you will receive from me dated London. The present communication might be devoted to many interesting subjects, medical and philosophical; but I am induced from many considerations to re- strict my attention particularly to one. You have long been acquainted with the important controversies that have existed on that grand subject of medical disputation, contagion ; with the various and contradictory opinions that have been promulgated as to its nature and effects ; and with the manner in which those controvercies have been conducted, especially by American physicians. The question of contagion and in- fection has also occupied, as you well know, a large share of the atten- tion of the Medical writers of Great Britain, especially within the last few years Much less diversity of sentiment, however, exists in this country than in our own, and in the discussion much less of asperity has been manifested. A single exception occurs in the case of Dr. Bancroft in his late " Essay on the Disease called Yellow Fever :" a work in- tended by the author to prove that this form of fever is occasioned by the operation of marsh miasmata, and is noncontagious ; and of which performance it is due to the talents of the author to admit that he has displayed great learning and research. As one practically acquainted with the disease during its visitations in America for a period of more than twenty years, your own ample experience will have enabled you at once to perceive the fallacy of such speculations. Indeed, the vo- lume of Dr. Bancroft has most materially aided in the establishment of the very doctrines which it was his object to overturn. Few writers seem to have entered the field of controversy with stronger prejudices, and perhaps none have communicated their thoughts with less defe- rence to authority, and in more illiberal language. It would appear to be the opinion of Dr. Bancroft, judging from his conduct, that gross in- vective and personal abuse may supply the place of well authenticated fact and legitimate deduction. The revival in England of the controversy relative to the specific form and contagious nature of yellow fever has been the means of giving birth to several works of great practical value, and in my opinion of deciding the great question ; if indeed any thing had been wanting after the laborious investigations of yourself and of other American physicians. The volumes of Sir James Fellowes and Dr. Pym have just made their appearance here, and may not yet have reached you. The former author has published the results of his practice under the title of Reports of the Pestilential Disorder of Andalusia, which appeared at Cadiz in the years 1800, 1804, 1810, and 1813 ; with a detailed Account yat; APPENDIX. of that fatal Epidemic as it prevailed at Gibraltar during the autumnal months of 1804, fyc.: the latter under the name of Observations upon the Bulam Fever which has of late years prevailed in the West Indies, on the Coast of America, at Gibraltar, Cadiz, and other parts of Spain ; with a Collection of Facts proving it to be a highly Contagious Disease. As of- ficers of high trust in the medical department of the Army, they have enjoyed opportunities of unwonted observation : the manner in which they have drawn up the respective accounts of their labours is highly satisfactory, and the accuracy of each work is fully confirmed by oflicial documents. Sir James Fellowes, as long ago as 1795, had numerous opportunities of witnessing the pestilential fever which committed such ravages among the British soldiery of St. Domingo, and he describes the peninsular fever as appearing under a similar form of malignity, and showing many of the strongly marked characters of the St. Domingo fever. His history of the origin and progress of the disease clearly points out that there is a real foundation for the distinction between fe- vers arising directly from the miasmata of marshes and decomposed ve- getable matter, and those that are the offspring of human effluvia, or specific contagion. The account furnished by Dr. Bancroft under this head is clearly proved to be erroneous, and his statements, deficient as they are in the most essential requisites, will have little weight when compared with the judicious relation of the Spanish Professor Arejula. In his observations on the disorder called the Walcheren fever, which prevailed so fatally among the troops of Zealand in 1809, and after their return to Great Britain, Sir James maintains that it possessed no con- tagious property, at least no evidence existed that the complaint ever had been propagated or communicated to those in attendance upon the sick. " This fact," says he, " was confirmed by my own experience, and by the testimony of all the medical officers of the army." " On the ether hand" adds Sir James " the numerous facts which have been recorded of the contagious nature of the pestilential fever of Spain are incontrovertible ; they are detailed with simplicity and truth, and they must speak for themselves." Dr. Pym, in his Observations, has attempted to prove that the fever of Gibraltar was the same as the Bulam fever, so happily described by the learned and distinguished Chisholm ; that it is a disease totally dis- tinct from the bilious remittent fever of warm climes ; that it has no connexion with or relation to marsh miasmata ; that it appears in the West Indies only under peculiar circumstances ; that it is contagious, and under a certain degree of temperature may be propagated from one country to another ; that it attacks in a comparatively mild form, natives of a warm climate or Europeans whose constitutions have been assimi- lated to a warm climate; and that it differs from all other fevers in having its contagious powers increased by heat, and destroyed by cold, or even by a free circulation of moderately cool air. According to Dr. Pym, uncter the name yellow fever, have been confounded three fe- vers, which he considers as totally distinct. The agency of marsh effluvia, I have already observed, he wholly rejects as a cause of the Bulam, Gibraltar, or real yellow fever. This you will perceive is stri- king at the root of that most pernicious error that has been so zealously and so widely propagated, notwithstanding the evidence of facts to the contrary, and the happy nosological distinctions made long since by such authors as Blane, Chisholm, Jackson, Lempriere, Clark of Dominica, APPENDIX. 997 Stewart, Bard, and numerous other practical observers of undoubted* veracity. For I believe you will agree with me that from the want of a due discrimination on the part of many writers who have professed to describe the fevers of the U. States, as they have prevailed in our seaport towns and in different inland places of our country, have pro- ceeded most of the dissentions that have existed on this subject. This want of discrimination too may justly be considered adequate to the pro- duction of many of the histories of the diseases of America that have ap- peared, and in which we find confounded fevers arising from dissimilar causes, characterized by different train of symptoms, and varying most essentially in the methods of treatment they require. Dr. Pym's is no feeble attempt to counteract the influence, which the unwarrantable opinions of Dr. Bancroft may have had in relation to this point. But I have to solicit your attention to a much more important cir- cumstance made known in the volumes of Dr. Pym and*Sir James Fel- lowes, and to communicate which this letter has been written. Dr. Pym, who had the advantage of seeing the disease not only in Europe but in the West Indies, contends, that the Bulam fever attacks the human frame but once ; and supports this position with the strongest proof. I will not do injustice to his statements by attempting to abridge them. Irrefragable evidence is advanced by Dr. Pym, that the Gibraltar, West India or Bulam fever, are the same disease. In a subsequent essay, Dr. Pym has enlarged on the subject of the disease affecting the human body but once. This same peculiarity marked the pestilential fever of Spain. Ac- cording to Sir James Fellowes, it never has been known to attack the same person a second time in that country. " This fact," says Sir James, " vvhich was first observed by the native practitioners, has now been confirmed by the experience of several years, and by the concur- rent testimony of all the surviving inhabitants of those places where the disorder had most prevailed." Introduction, p. xxiii. I have dwelt so long on the performances of Sir James Fellowes and Dr. Pym, as almost to be deterred from referring to any other authori- ty ; yet I cannot forbear making a short extract from an account of the epidemic fever which occurred at Gibraltar, and for which the public are indebted principally to Dr. Gilpin, one of the inspectors of the hos- pitals. The paper throughout is of singul r merit, and eminently cal- culated to do away the doubts of the sceptical, and strengthen the faith of the wavering. It is gratifying to the philanthropist to read the answer given by Dr. Gilpin to the eighteenth query, addressed him by the Medical Board of the army. *' At the commencement of the disease" replies Dr. G. "last year, . it was calculated that there were about five thousand persons within the walls who had previously passed through it; and, after car ful inquiry, tfiere does not appear to be one well authenticated case of a person's having received the infection a second time. I heard, indeed, of three or four ; but as the nature of the previous fever could not be exactly known, these exceptions have but little weight in so momentous a ques- tion. The exemption from a second attack, I am credibly informed, is firmly believed in Spain. At Cadiz, last year, though the fever put on the very worst symptoms, and destroyed the patient frequently in forty- eight hours, the deaths did not exceed, in a population of upwards of seventy thousand, fifty a day ; and these were chiefly strangers. The 998 APPENDIX. Spaniards are so fully convinced they cannot receive the infection a second time, that having passed the disease is matter of great rejoicing among them : and a medical certificate of the fact, is a sufficient pass- port into an infected town, which they enter without the smallest appre- hension." Consult the Transactions of that active and distinguished association, the Medical and Chirurgical Society of London, vol. 5, for more ample details. The immunity of the constitution from a second attack of yellow fever is a peculiarity so strikingly characteristic of most disorders of an acknowledged specific nature, and of such great practical interest both in a social and political point of view, that it is extraordinary it should have met with so little notice before Professor Arejula made mention of it in the year 1806. Dr. Pym, however, enjoys the repu- tation of being the first English physician who promulgated this princi- ple. I have not the sources of information at hand to enable me to de- termine how many of the writers on the malignant fever, as it has pre- vailed in our country, have entertained this opinion, though I well recollect Dr. Lining to have been one ; as may be seen in his aecount of the fever of Charleston, published more than sixty years ago in the Edinburgh Physical and Literary Essays, volume second. In the inte- resting correspodence on the yellow fever which was maintained a short time anterior to this period by Dr. John Mitchell, of Virginia, and Lieutenant Governor Colden, of New-York, nothing is alluded to from which we might infer their knowledge of this law of the disorder. See the American Medical and Philosophical Register, vol 1st and 4th. In the Facts and Observations of the College of Physicians of Philadelphia, on the nature and origin of the pestilential fever, after establishing the identity of the yellow fever which existed in that city in 1793, 1797, and 1798, with the West India pestilence, the College state, that it is a circumstance that deserves particular attention, that " very few, if any, of the Creole French in this city, [Philadelphia,] suffered from the contagious malignant fever which prevailed here in 1793, 1797, and 1798, though the disease was introduced into their families ; and chil- dren born in this country of Creole parents, died with it last autumn, while the parents and the children born in the West Indies were en- tirely exempt from it." We look in vain, if my memory serves me, for any thing of the same sort in the Additional Facts and Observations, a subsequent publication of the College of Philadelphia. In his Sketch of the malignant contagious fever as it appeared in the same city in 1793, Dr. Cathrall observes, "it does not appear to affect the same person twice. Although careful inquiry" adds he, " has been made by several of my medical friends and myself, it only appears that some of the patients had a slight relapse of fever, but without any of the distinguishing symptoms of the disease, and very soon recovered." It is much to be regretted that the several histories of this disease pub- lished by that able medical annalist, the late Dr. Rush, should have been so confused and unsatisfactory on so momentous a matter. In his ac- count of the bilious yellow fever of 1793, you will, nevertheless, find, that the refugees from the French West Indies " universally escaped the disorder." On the other hand, Dr. Currie, of Philadelphia, in his treatise on the Synochus Icterodes, states, that several instances occur- red of the disease affecting the same individual a second time, and under circumstances so unequivocal that it could not be fairly ascribed to a APPENDIX. 999 relapse. This assertion, you will see, is not strongly made, and may be deemed rather matter of opinion than matter of fact. But at present I am not duly prepared to enlarge on this point, by reference to Ame- rican authorities. Dr. Pym has referred me to a passage in Sauvages on this disease, in which it is asserted that it operates upon the constitution but once. " Typhus icterodes contagiosus est. Albos tantum, maxime peregrinos ex regionibus frigidis advenas, Indos, Hybridos, mulatros omnes, excep- tis infantibus, una tantum vice afficit: nigri vero ab eo morbo nunquam afficiuntur." See Nosologia Methodica, torn. 1. p. 316 of the quarto edition of 1768. Does your own extensive experience in the malig- nant epidemics of New-York, agree with the opinion that the human constitution is invulnerable to a second attack of yellow fever, and cor- responding in this respect with small-pox, and other specific disorders 1 In answer to this question, which has been frequently put to me by practitioners of medicine in England, I have uniformly ventured to assert that it holds good as a general fact. Those who have once had the disease are certainly less susceptible of its influence a second time. Permit me now to make known to you the important results of the recent deliberations of two of the most distinguished medical associa- tions of this kingdom. The decisions of the Royal College of Physi- cians of London, and of the Army Medical Board are at length brought to a close. These two learned bodies, alike distinguished for a scien- tific attainment and practical knowledge, have been for a considerable time past devoted to a consideration of all the facts connected with the nature and character of the yellow fever, particularly as it has of late years appeared in Spain. The Royal College have pronounced that the yellow fever is a highly contagious disease, which decision they have reported to the Lords of the Privy Council. With respect to its attacking the human frame but once, they say they think it extremely probable, but that upon a point of such importance they cannot venture to give a decided opinion. The Army Medical Board, at the head of which presides Sir James M'Gregor, have also given it as their opinion, that the yellow fever is in its nature contagious ; and they further add their conviction, that the fever of Spain is not only strictly contagious, but that, like other disorders of a specific character, it affects the human frame but once. I have been kindly favoured with an abstract of these proceedings, and I herewith enclose an extract from the official report upon Dr. Pym's publication, by the Army Medical Board. The ope- ration of climate, soil, and other local causes, in adding virulence to febrile contagion, may be considered almost an axiom in physic ; and the necessity of a strict adherence to your improved system of qua- rantine laws, and all municipal regulations for the purposes of domestic cleanliness, cannot be too strongly enforced. On this subject the Royal College and the Army Medical Board are united in opinion. 1000 APPENDIX. (COPY.) Extract from the Report upon Dr. Pym's publication by the Army Medical Board. (inl80L " l °* 1Q23 APPENDIX? effectual means of restraining those excessive bilious and serous secro tions which occur at this season of the year. It is not to be understood that the lancet is to be had recourse to indiscriminately in every case of cholera. The prostration of strength induced by the evacuations spon- taneously produced, as in cases of hemorrhage, will forbid the use of this remedy. But where the disease occurs under the circumstances before stated, in a full habit of body, and the physician is called before great debility has come on, blood-letting as in restraining sanguineous discharges from the larger vessels, will frequently produce immediate relief, by dimininishing the excessive evacuation which takes place from the liver and serous vessels of the intestinal canal in these diseases. Cases of this sort have frequently fallen under my observation, in which I have been compelled to employ the lancet, where the remedies ordi- narily prescribed, viz. rhubarb, magnesia, emetics, &c. have been ad- ministered without success. In those cases attended with great pain in the stomach and bowels, or with spasmodic affections of this organ, the Warm bath and blisters have also been applied, in conjunction with the lancet, with manifest advantage, and probably have afforded relief up- on the same principle, by diverting the irritation from the internal or- gans to the external surface of the body. Diabetes. As far as experience enables me to decide, Diabetes depends prima*- rily upon a diseased action of the digestive organs, or a want of tone in the assimulating powers of the system : the kidneys are secondarily af- fected. The stomach may become impaired from various causes : in four cases out of five of diabetes which have come under my notice, this condition of the stomach was produced by the intemperate use of ardent spirits : and in three other patients, by the immoderate use of fruits, and confinement to a vegetable diet. Sydenham was the first who considered it a disease of debility, in which the system was unable to assimulate the nourishment to itself, a fault in the assimilating process ; but he did not consider it an idiopathic affection. Dr. Ferriar adopted the same belief, that it is a disease of pure debility, but supposed at the same time some local disorder in the kidneys :—in the last communica- tion I received from him he retracts this opinion. That the kidneys, because they are the channel or outlet of the dis* ease, are the seat of its proximate cause, is far from conclusive reason- jug. We do not infer that the kidneys are diseased, because in jaundiu they pour out more or less of bile. The most successful treatment of diabetes is that originally proposed by Sydenham : the use of animal food, and abstinence from all vegetables and fruits. In his letter to Dr. Brady he even particularizes the meats • viz. such as are of easy digestion, " veal, mutton, and the like." Upon the principle of correcting the acetous or fermentative process in the stomach, Dr. Rolla has recommended the hepatized ammonia. But this medicine is so nauseating and debilitating to the already debilitated sto- mach, that it cannot but fail of doing more harm than good. Ferriar judiciously prescribes, beside animal food, various tonics, as bark, bitters chalybeates, &.c. and in the 4th vol. of his Med. Histories and Reflec- tions, he has published details of thirteen cases of which he kept mi- Uiifes ; ten of the^-e recovered, and two were relieved. In the. case of APPENDIX. 1023 a child recently under my care, the disease was removed by animal food alone. In the third volume of the Medico Chirurgical Transactions, Dr. Bos- tock, of Liverpool, has offered some interesting observations on Diabetes Insipidus. This disorder, though but seldom noticed, Dr. Bostock is inclined to believe is of more frequent occurrence than is generally imagined. In the case, the particulars of which are noticed in the work just mentioned, Dr. Bostock effected a cure by the use of preparations of iron and the warm bath. Phthisis Puhnonalis. The chapter of our author on pulmonary consumption is upon the whole extremely satisfactory ; though it is to be wished he had more forcibly insisted upon the division of the disease into two stages, a prin- ciple all-important for the practitioner to keep in view. The older as well as the more modern writers have attempted to describe various species of the disorder unnecessary here to enumerate. In my opi- nion, the best distinction that can be made in pulmonary consumption will be to divide it into two stages, the acute and the chronic, analagous to the arrangement of Morton into the incipiens and eonfirmata Acute and chronic are preferable terms, as they convey a correct idea of the nature of the inflammation attending upon the first stage of phthisis, and of the termination of such inflammation in the last stage, in which, either ulceration or an excessive excretion of pus takes place. For this rea- son too I have thought proper to give it a 'place among the phlegmasiae, instead of considering it as one of the hemorrhagies, in which order it is arranged by Dr. Cullen. The causes of phthisis pulmonalis are pretty amply noticed by Br» Thomas ; and, from all that can be adduced, I think the disorder on the increase in our own country as well as in Great-Britain. These causes, however, are not exactly in both countries the same ; with the increase of manufacturing establishments in England, we find an increase of the evils which induce pulmonary disorders ; and of these evils, scrofula may properly be considered among the principal. In theUnited States scrofula is comparatively little known ; but while we admit the influenee of particular employments and modes of living in inducing consumption, this disease in most instances in this country, may be ascribed to the sudden vicissitudes we experience in this climate, particularly on the seaboard ; to imprudence in dress, and improprieties in the use of ardent drink, and other species of dissipation. A common catarrh, « especially if frequently renewed, may be placed at the head of the cau- ses of the disorder in this country ; it is one of those causes too, which, while it attracts the least attention, commonly does the greatest mischief. The inflammatory character of the forming stage of pulmonary con- sumption cannot be too constantly kept in view, and the treatment in- dicated for the removal of other inflammatory affections of the chest will be found to be most successful in this more insidious disease. In the quarterly reports on the diseases of this city, 1 have already noticed this point of practice. " We have in many instances employed blood- letting with the most happy effects in many cases of incipient phthisis, even where strong hereditary predisposition existed. Indeed, we are indnced, from some late observations on this subject, to express the- 10^4 APPE-\D1X. opinion, that in the commencement of phthisis, as in peripneumoir., blood-letting is not sufficiently employed, but is too frequently neglect- ed until the inflammation has so far extended that suppuration becomes inevitable. Nor do physicians in general appear to have been suffi- ciently attentive in describing the symptoms characteristic of the first or inflammatory stage of phthisis, and consequently, have been regardless of that active antiphlogistic treatment which alone can prevent the tu- berculous or suppurative stage. In as much as suppuration, or a puru- lent secretion from the lungs necessarily implies preceding inflamma- tion, we conceive too early attention cannot be given to the premonito- ry symptoms which announce the inflammatory stage, but which are fre- quently so inconsiderable, being seated in the less sensible, the cellular portion of the lungs, that both physician and patient are alike regardless of the present symptoms, and of the consequences to which they lead. Instead, therefore, of trusting to syrups, anodynes, pectorals, ptisans, the Iceland moss, or the divine alcomoque, to allay the hacking cough and pains in the chest which indicate the first approach of the disease, we earnestly recommend the same active treatment by blood-letting, blisters, and other means of diminishing excitement, as are employed in the treat- ment of a pleurisy, or any other acute inflammation ; and we could add, in confirmation of this view of the subject, many recent cases in which the practice here recommended has been attended with the most benefi- cial results."—Vide Amer. Med. $r Phil. Reg. Much might here be said of the utility of mild emetics in the form- ing stage of phthisis, given occasionally after blood-letting, and other evacuants have been employed. But recommended as they are by Dr. Reid, indiscriminately in all stages of the disease, they cannot fail to do serious mischief. During the two last years of my attendance at the New-York hospi- tal, as well as in private practice, I have made use of the Prussic acid in many cases of confirmed Phthisis. In some instances this medicine was exhibited to the extent of sixty or eighty drops in twenty-four hours, but in no one instance has deci- ded benefit been obtained from its use ; on the contrary, in a majority of the cases in which it was administered, it rapidly prostrated the powers of life without an evident abatement of the cough, expectora- tion, fever, or night-sweats. In some few instances in the private practice of others, I am told it has been found useful, and has effected an entire cure ; but from my own observation, 1 cannot bear testimony to its use : like the fox-glove it exercises a deleterious influence upon the system, without effecting any beneficial change in the character of the disease. The reader will advert with practical advantage to " Thoughts on Pulmonary Consumption" by Dr. Rush, in the Medical Inquiries and Observations. Dropsies. Of the disorders arising from a general plethora of the system, the Various species of dropsy may be mentioned. Experience has lon« since taught me that morbid accumulations of watery or serous fluids arise as often, nay, more frequently, from increased exhalation, the effect of an overloaded state of the blood vessels, than from diminished APPENDIX. IQ'25 absorption occasioned from a loss of tone in the absorbent vessels, and* consequently that dropsy may, and frequently does, proceed from the want of blood-letting, as well as from the excessive use of that evacua- tion. I have seldom, if ever, attended a case of hydrothorax that did not arise from increased exhalation ; the same may be said of hydrocepha- lus which is almost always, 1 consider, preceded by, or accompanied with inflammation of the brain. Did the limits to which these notes are restricted permit, it were easy to relate many instances of hydrothorax, ascites, and anasarca, pro- duced by such fulness of the vessels, relieved by blood-letting, calomel, and squills, and other depleting remedies ; and the powers of the sys- tem again restored by chalybeates and other tonics. Digitalis, so gene- rally and so freely administered in dropsies, can only be serviceable when the disorder is in its forming state. In the secondary stage of the disease, when symptoms of fulness or preternatural excitement do not exist, this active narcotic cannot fail to do harm. Hydrocephalus, in its acute form, is an affection of frequent occurrence in this city : in three cases for which I not long since prescribed, a cure was effected by blood-letting, active cathartics, and blisters, all which were made use of during the inflammatory stage of the disease, before the symptoms of effusion had taken place in their greatest extent. In those cases mercury was not administered except as a cathartic in com- bination with large doses of jalap. This fact reminds us of the remark of Dr. Rush, that in consequence of his unsuccessful use of mercury in dropsy of the brain, he has declined the use of that medicine altogether in this disease, except when combined with some purging medicine, and that he administers it in this form, chiefly with a view of dislodging worms. Query. Does not mercury, by the excitement it produces, add to the inflammation which characterizes the first stage of hydrocepha- lus ?—Mercury, in my opinion, has oftentimes been the exclusive cause of this disease. Certain it is, that dropsy of the. brain has become of much more fre- quent occurrence since the general, and I had almost said the indiscri- minate use, of this metal in febrile and inflammatory diseases. In the fourth volume of the Medical Histories and Reflections, the author, Dr. Ferriar, appears to have been solicitous to find a more cer- tain kydragogue than any of those now in use; and from the successful results of his own ample experience he recommends an extract of the elaterium as surpassing every other medicine in the power of removing serous accumulations, and as affording astonishing relief in the dyspnoea arising from hydrothorax and ascites. Pliny, as stated by Dr. Ferriar, though he was not acquainted with the power of the elaterium in drop- sical complaints, considered it highly valuable, " ad magnos mortalium usus." Dr. Ferriar has briefly related the particulars in twenty cases in which the elaterium was prescribed with various success. Upon its first exhibition to a patient it is nearry as active and as dangerous, if incautiously given, as arsenic. " The sensible effects of the elaterium are, severe and constant nau- sea, frequent watery stools, and, in considerable doses, vomiting. It does not uniformly increase the urine, and for this reason it is generally proper to combine it with more certain diuretics. After continuing the use of the medicine for some days, the patient will sometimes bear a considerable increase of the dose. I have gone to the extent of five or 130 102.6 APPEND! i. six grains a day in this manner, without producing ariy inconvenience But it is always proper to begin with the lowest dose, which is the six- teenth part of a grain of the extraet." Since the last edition of this appendix, I have frequently had recourse to the elaterium both in hospital and private practice. My experience coincides with that of Dr. Ferriar : the elaterium is a powerful, and in every instance in which I have used it, a certain hodragouge. I have begun with the eighth of a grain four times a day, and given it to the ex- tent of two grains three times a day. It produces copious liquid evacua- tions from the bowels, under circumstances of great torpidity of the in- testinal canal, when other powerful means have failed, and at times causes an additional increase in the urinary discharge. Thi9 latter ef- fect, however, as remarked by Dr. Ferriar, is very uncertain. I have deemed it most expedient, notwithstanding its vigorous action, to unite the pulv. extr. elat. with small doses of cream of tarter, in preference to either calomel or squills. It does not appear to add to the debility of the system, as some other remedies employed to fulfil the indications answered by the elaterium. Doctor Yeats of London, in his letter to Dr. Wall, has lately publish- ed some highly interesting observations on dropsy of the brain. In his Dissertation on the Pathlogy of the Fluids Dr. Dyckman has also treat- ed, at some length, of dropsies arising from plethora of the vessels. Venereal Disease. Notwithstanding all our author has so ingeniously said to the contrary, it is deemed unnecessary here to attempt to show that gonorrhoea, or urethritis, as I have denominated it, and lues venerea, are diseases of a different nature ; that each originates from different causes, and that the modes of treatment each requires is different. In the treatment of gonorrhoea regard must ever be had to the stage of the disorder. The usual prescription, especially among young prac- titioners, is lead water : many years since I became acquainted with the pernicious consequences of that injection. Indeed in every case of gleet following gonorrhoea, for which I have ever been consulted, the disease has been, without a single exception, traced to the debilitating sedative effects of that metal. Most cases too of the inflammed testis which I have seen attendant upon gonorrhoea, have been produced by the same cause, viz. the too early and sudden check of the secretions of the urethra by the use of lead injections. In gonorrhoea, as in inflam- mation of the eyes, the treatment of the first stage consists chiefly in abstinence from stimulant drinks and animal food ; the free use of bar- ley water, lemonade, and other diluents, mild* cathartics, and other evacuants where they are indicated, bathing the part affected with warm water, or the use of the warm bath ; and after the pain, ardor urinse, and other symptoms of inflammation have somewhat subsided, the use' of an injection of a solution of,the sulphate of zinc, from two to four grains, in proportion to the sensibility of the parts affected, to an ounce of rain water, employed six or eight times a day until the purulent dis- charge has totally disappeared. In like manner in the treatment of an inflamed testis, which I may remark I have never seen produced by the vitriolic injection, as stated by Dr.. Thomas, instead of cold Saturine ap- plication?, I have* for many years past prescribed, in addition to the usual APPENDIX. 1027 antiphlogistic means, tepid fomentations of vinegar and water with the most beneficial consequences. Were not the remarks in some degree misplaced, I might here consider the treatment frequently adopted with regard to inflammation when affecting other parts, as inflammation of the eyes, &c. In the inflammation of the capsular ligaments, the effect of strains, the practice just stated may be safely recommended, until the pain, tumour, and inflammation are removed. When debility alone re- mains, and the parts are free from irritation, cold applications of vine- gar, water, or spiritous liniments may then be advantageously prescrib- * ed ; but with many practitioners a different practice prevails. Instead of warm, cold applications are directed from the very commencement of the injury, and which rarely fail to stiffen the joint, to increase the pain, and ultimately to add to, instead of diminishing the inflammation. Mercury is wholly unnecessary in the treatment of gonorrhoea. In the constitutional disease called syphilis, as a general rule I hare found the internal preferable to the external use of mercury, and the mercurial salt, which from experience I recommend as combining most advantages, and as agreeing best with the greatest number of cases, is the corrosive sublimate or oxymuriate of mercury. This salt either in the form of pill or solution I have uniformly employed with success for the cure of syphilis, not only when the disease may have been recently contracted, but in the most malignant form which it assumes when it has been neglected or injudiciously managed. A valuable auxiliary will al- so be found in the decoction of the lignum guiaci and the radix sarsapa- rillae, as powerful alteratives. Here I cannot but protest against the salivating system by friction with mercurial ointment, and the use of ca- lomel, so commonly had recourse to. It is true that those forms of ex- hibiting mercury very soon affect the gums, but it is no less true, that when mercury exerts its influence upon the salivary glands, in propor- tion as this influence is manifested, it ceases to operate upon the other excretions of the system, and consequently is less active in eliminating from the body the poison of the disease. Salivation, it is now well as- certained, is wholly unnecessary in the treatment of syphilis, and the knowledge of this truth cannot be too extensively circulated in a coun- try where, notwithstanding the present respectable state of its medical science, many of the most pernicious errors of some of the older prac- titioners are still sedulously inculcated. As the introduction of the corrosive sublimate is calculated to remove many absurdities in the present practice of treating syphilitic disorders in this country, I am induced to make a quotation of some extent from an Essay on this subject inserted in the Amer. Med. and Phil. Register. I am aware that in certain of the public hospitals of Great Britain, as well as of the United States, the corrosive sublimate is rigidly proscribed as inefficient for the cure both of the primary and secondary stages of lues venera; but it deserves to be recollected, that this form of mercury still retains, throughout the European continent, the high celebrity it acquired long since as an anti-venereal. In the Venereal hospital at Paris, the largest and one of the best conducted establishments of Eu- rope, the corrosive sublimate is the only form of mercury employed ; and Professor Cullelier, after the most ample experience at this charity, knows not an instance of failure with this remedy, or one in which it has produced injurious effects. In the Essay just alluded to, after having considered the mpdas operandi of mercury upon the human constitution, 1023 APW,NTaIX» and the abuse of this medicine a3 an article of the Materia Meilica, Dr. Francis observes : " Among the principal advantages which the corrosive sublimate (the oxymuriate of mercury,) possesses over that of every other prepara- tion of mercury are, that injudiciously administered, it is particularly mild and safe in its operation, will admit of a more extensive use in all the various forms of lues venera, and subject the patient to fewer incon- veniences : that it readily enters into the general circulation, becomes miscible with the several fluids of the body, the soonest arrests the pro- gress of the complaint, and eliminates the morbid matter through those emunctories best calculated for that purpose : that it supersedes the necessity of salivation, by its action on all the secretions, and by pro- moting especially the cuticularjdischarges, and the evacuations from the kidneys : that it is the Only preparation to be depended on in those pe- culiar habits of body so susceptible to become salivated by every other form of mercury now in use ; that in its ultimate effects upon the con- stitution, it is attended with comparatively no injury. These facts are indeed truly important, and many of them are granted by those who alto- gether reject the use of this preparation. " It is not a little unfortunate for the advocates of other combinations of mercury, that the objections which have been brought against the corrosive sublimate are so dissimilar. It has been assigned as a reason against the preparation itself, that it has failed of its salutary effects by being given in too small doses.. By some its anti-venereal properties are said to be lost on account of its too readily exciting the cuticular discharge ; by others it is owing to its defective action on the secretions of the skin and mouth. By some it is admitted to be beneficial in the primary stage of the disease, and by others it is contended that it is cal- culated to remove only secondary symptoms. It is also declared that it is violent and uncertain in its operation, and that it does not render the cure permanent.* Some of these objections are, indeed, weighty, and, were they well founded, would fully justify the abandonment of this peculiar combination of mercury; but if the least reliance is to be plaeed upon the experience and observation of those who have employed the corrosive sublimate with the most disinterested and honourable views, and solely to determine upon its anti-venereal powers, evidence suffi- cient to prove the fallacy of these objections, and derived from indubi- table sources, might be adduced. The testimony of Dr. Locher, of the Vienna hospital, is so full nnd explicit, that it were an omission not to insert it. Having witnessed the ' horrid calamities' arising from sali- vation and other abuses which existed in that institution in the manage- ment of venereal patients, upon the recommendation of Van Swieten, he made trial of the corrosive sublimate. From the year 1754 to 1762, he cored by it no less than four thousand eight hundred and eighty per- sons, without inducing salivation; and testifies, that ' no persons died, or experienced the least painful and dangerous symptoms, in consequence of this remedy.'f In the cases in which the same preparation was re- commended by Pringle,J the cures that were effected were permanent, and from the repeated experience of many other distinguished practi- * Hunter, Howard, Pearson, Mathias, and others. + Locher's Ohservat. Pract. as quoted by Van Swieten, Commentaries, vol. 17. p. 294> IGorden, Lond. Med. Obs. and Inq. vol. 1. p. 36S. vol. % p. 73. APPENDIX. 1029 doners, the same result ensued. Multa nobis exempla visa Bint lnis venereae, mercurio sublimato corrosivo perfecte sanatse.* " To enter into a consideration of the treatment of the various symp- toms which characterize lues venera in its simple and in its more con- firmed state, is not deemed necessary, nor will it here be attempted. Fully convinced, as the writer is, of the decided advantage which the corrosive sublimate, as an anti-vinereal remedy, possesses, in most cases, over other mercurial preparations, he cannot forbear adding a few fur- ther observations for the purpose of recommending to more general use this combination of mercury. " A very forcible reason why a preference ought to be given to the corrosive sublimate as an anti-venereal remedy, is the mildness of its operation when compared with most other mercurial preparations. In the mind of the judicious practitioner there need exist no apprehensions of the severity of its action ; few articles of the materia medica can be more readily accommodated to the peculiar condition of the patient and the nature and stage of the disease. The evidence of its mildness may be adduced from the salutary effects which it produces in the constitu- tions of delicate children, and even of infants. In not a single instance, within the recollection of Dr. Hosack, has it ever been followed by per- nicious consequences, though long employed by him in many cases in which the patient laboured under some hereditary taint, obstinate cuta- neous eruption, or other symptoms indicating an alterative course of remedies. The destructive effects which have been mentioned as at- tending its administration, such as excessive pain and irritation of the stomach and bowels, headach, fever, &c. may, in certain cases, arise from some peculiarity of constitution obnoxious to mercurial remedies, but are doubtless, in general, to be attributed either to the improper preparation of the corrosive sublimate, or to its having been given in undue quantity. It has been asserted that this mercurial salt is parti- cularly injurious to those labouring under pulmonary affections. That this objection is ideal, or rather that, of all mercurial preparations, it applies with least force against the corrosive sublimate, must be evident upon considering the general operation of this form of mercury. Every combination of this mineral may prove more or less injurious in the forming stage of consumption, on account of the active inflammation which is then present, and the additional irritation attendant upon mer- curial action. For it may be laid down as a general principle, that mercury is in itself injurious when administered to any considerable extent during the existence of inflammation and febrile excitement, and before the employment of blood-letting or other evacuants. " From the mild operation of the corrosive sublimate, properly prepared, may be inferred the utility of its employment in persons of delicate habit, and in those cases especially where the constitution is materially impaired. In cases of this kind its exhibition is followed with the best effects. That the tonic powers of the system may, however, in certain instances, be so far weakened as to render the employment of every,form of mercury not only inefficacious in the removal of syphilitic complaints, but productive of the most distres- * Ratio Medendi, pars secunda, p. 229. See also Medica Clinica, bv Christian Gottlieb $e!fe, Berlin. 1802. IQ3'D AJPENDUS, sing symptoms, and consequently, that the use of the oxygenated nfa« riate will at times be the cause of much inconvenience and real suffer ring, there is left no room to doubt. In irregular cases of this nature, the remedy necessarily fails of producing its ordinary beneficial ef- fects ; and as it becomes an additional source of irritation, it greatly increases the debility which already prevails. These effects, as has just been remarked, do not result from the exclusive employment of any particular form of mercury ; they seem to arise less frequently from the corrosive sublimate, but are common to all mercurial prepara*- tions. For if the constitution has not the power to support the action of mercury, vain is the attempt to eliminate from the system the virus of lues venerea. Hence, in the treatment of certain diseases of hot climates, especially in unhealthy situations, it is not an uncommon prac- tice to administer the bark daily during the whole course, for the pur- pose of enabling the constitution to bear a sufficient quantity of mer- cury to subdue the complaint.* Upon the same principle, that learned physician and distinguished writer, Dr. Chisholm, maintains, that in the management of disease a reduction of plethora at the commencement, and the augmentation of the vis vitaj in the advancement, are to be particularly attended to, in order to ensure the successful administra- tion of mercury.f Dr. Ferriar has observed instances hi which the venereal disease itself assumed a peculiar character owing to debility, where the debility so far prevailed that the constitution had not power to form a genuine syphilis. When this happens, mercury will not ef- fect a cure. ' Under these circumstances,' adds Dr. Ferriar, ' I have advised with success a course of tonics without mercury, to raise up the constitution to a higher level. Mercury may then be expected tp cure.'|—Again, says Dr. F. " That the corrosive sublimate, of all mercurial preparations, soon- est affects the system and arrests the action of the venereal virus, is a truth grounded upon the concurring experience of the most distin- guished practitioners. " It is but proper to state, that the preparation of mercury now re- commended, has been employed for the last twenty years in the pri- vate practice of Doctor Hosack, and during his attendance at the New- York State Prison, New-York Hospital, and the Aims-House of this city, as physician of these institutions. It has invariably been found to he the remedy best calculated for the removal of lues venerea, both in its primary and secondary stages j and not a single case is recollected in which the cure has toot been permanent. Those injurious effects upon the stomach and bowels, which are so much apprehended, were avoided by a cautious employment of the medicine, and by a due con- sideration of the peculiarities in the constitution and state of the pa*- tient. From this form of mercury, salivation scarcely ever was indu- ced ; and while under its influence, the employment of the decoct. guaiac. et sarsaparil. was found to be an excellent auxiliary in recent -cases; and in the secondary stage of the disease, where the*patient had been neglected, or when improprieties in the cure had been com- mitted, it was almost indispensable. * Fide Clarke on the Diseases of Long- Voyages. * Essay on the Malignant Pestilential Fever, vo'U 1' T3jVd'. HPst. aud Reflect, vol. 3. £. TS3-. , ' APP^NDiX*; 1031 v Though Satisfied that the oxymuriate of mercury possessed full claims to the title of a powerful anti-venereal remedy, from a perusal of the testimony published in its favour, and from a personal knowledge Of the result of several eases in which it had been employed ; with the view of more fully determining so important a matter, and to ascertain, as far as practicable, whether the objections which have been stated against it, particularly those of the distinguished Mr. John Pearson, were founded in reality, at the suggestion of the writer, the use of the corrosive muriate of mercury was adopted in the spring of the year 1811, in the New-York Hospital. From the extensive charity which this excellent institution afforded, there was abundant opportunity of seeing almost every form of this disease, from the more mild to the most aggravated ; cases of recent infection, and those of long standing. Af- ter a careful examination of the histories of a great variety of cases, a selection was made of several of those patients who were affected with the primary, and of others labouring under the secondary stages of this disease. The corrosive sublimate was given in some instances in the form of the spirituous solution, and in other instances made into pills ; the decoction of guaiacum and sarsaparilla was employed as an auxiliary, and occasional recourse was had to the application of the lunar caustic; but the external use of every preparation of mercury was omitted. In no one instance were unpleasant effects produced by the action of this mercurial salt; and, contrary to the opinion entertained by Mr. Pearson of the efficacy, of this remedy, the result of these several cases was attended with complete success. " To multiply further arguments, or other additional proofs in favour of the oxygenated muriate of mercury does not seem necessary. It may be confidently pronounced a safe, convenient, and efficacious re- medy in lues venera. How far a two ready acquiescence in the force of authority may be assigned as the cause of that want of confidence in the virtues of the corrosive sublimate, and of that apprehension of its pernicious qualities which at present prevail among many practi- tioners, it is impossible to ascertain. It is evident that the opinions of Mr. Pearson are those chiefly which have been adopted and reitera- ted by every subsequent writer who has opposed the use of this mer- curial combination. But the success attendant upon the administration of the oxymuriate of mercury furnishes the most satisfactory answer that can be given to those who have denied its efficacy. Upon the success- ful result of the cases of lues venerea which existed in the New-York Hospital in 1811, the corrosive sublimate again became the principal anti-venereal remedy in that extensive establishment. This form of mercury, since that period, has also been in general use in the New- York Aims-House, in the treatment of syphilis in its different stages; and in most instances it is now employed for the same purpose by the physcians of the City Dispensary. The observation and experience df the writer during the last three years, in a number of unequivocal cases of lues venerea, have tended to corrobate the favourable opinion he formerly expressed, and induce him to recommend with increased confidence a more extended application of this preparation of mecury. " Various are the forms in which the corrosive sublimate has been used in the different stages of lues venerea, and in other disorders indi- cating an alterative course of remedies. Its external application, in the fdryn of ointment, has been recommended by some; but against this 1032 APPENDIX*. practice many forcible objections might be brought. The internal usi; of the spirituous solution of Turner, in which the proportion of ardent spirits to the mercurial salt was remarkably small, has justly been ac- cused as the source of much mischief. The formula of Van Swieten deserves a decided preference ; for the muriated quicksilver dissolved in spirits and exhibited in doses limited to the quantity of one eighth of a grain, two, or, at most, three times in twenty-four hours, seldom produces the least nausea, or any derangement of the stomach or bowels. " The corrosive sublimate, dissolved in common brandy, in the propor- tion of two grains of the salt to one ounce of the liquid, is a valuable and convenient preparation for delicate children. It may be given with the greatest safety, in a little sweetened water, to the amount of three or four drops to a child of one year, and repeated three times a day ; and to a child of two or three years old six or eight drops three times a day. After its employment two or three days the dose may be in- creased to ten or twelve drops. "A solution of the oxymuriate of mercury in common distilled water, with the addition of a little muriated ammonia, (sal ammoniac,) is also a judicious and safe pharmaceutical combination. " But the best form of administering the corrosive sublimate is that in which this mercurial salt, united by solution with the muriate of am- monia, is made into a mass with the crumb of wheat bread, and then divided into pills. R-. Oxymuriat. Hydrarg. Muriat. Ammon. aa gr. xv. Aq. distillat. vel font. 3iss. Solutioni addatur Panis medul. sic. q. s. Ut fiat massa, in pil. cxx. dividenda. " Every pill in this prescription contains, if the materials be uni- formly combined, the eighth of a grain of the corrosive sublimate. The dose can therefore easily be regulated with the greatest accuracy. Of these pills one is to be taken every night and morning, though, in some aggravated cases, another pill may be taken in the middle of the day. with additional advantage. In this manner a quarter of a grain of this preparation of mercury will, in ordinary cases, be taken in twenty-four hours ; and in the more severe form of lues venerea the additional eighth of a grain. Instances may occur in which it may be advisable to administer half a grain daily. Mr. Bell has given a grain of the corro- sive sublimate divided into four or five doses, but has not been able to continue this quantity for more than two or three days together. " The corrosive sublimate to the amount of one quarter of a grain a day, and, in some cases, an additional eighth of a grain, in pills, may be continued for a long time without producing the least inconvenience in the stomach and bowels, and with greater certainty and more beneficial effects than the same quantity of this salt in the form of the spirituous solution. The use of the corrosive sublimate ought to be continued two or three weeks after the disappearance of the disease, in order more effectually to accomplish a radical cure. " It has already been observed, that the oxygenated muriate of mer- cury operates more readily on the constitution than any other form of this mineral, and that even in very small quantity it soonest arrests the progress of veneral symptoms, and, by its general action, eliminates the poison of the disease. It deserves to be stated, that during the use cf APPENDIX. 1033 this preparation, all those precautionary measures with regard to diet and regimen, which are generally recommended by writers, need not be regarded with the same scrupulous attention, while in the use of the corrosive sublimate, as during the employment of other mercurial me- dicines. For as the corrosive sublimate rarely affects, to any conside- rable degree, the salivary glands, those subjected to its use are not ren- dered so susceptible of the influence of cold, and the physician is sel- dom under the necessity of devising means for the purpose of obviating the pernicious consequences of salivation. Instances of peculiarity of constitution may occur which require much management and discre- tion in the use of this remedy. Mr. Bell has observed, that opiates have not the same influence in preventing an undue. action of the oxy- muriate of mercury upon the stomach and intestinal canal which they commonly have with other mercurial preparations.* The limited ex- perience of the writer has not in any case corroborated this opinion : on the contrary, he has found an occasional recourse to small quantities of opium highly serviceable. " As some one or more articles of the vegetable kingdom are, in general, employed in those cases in which the corrosive sublimate is administered, it perhaps would not be irrelevant to examine how far they are entitled to particular confidence. It may be proper to remark, that of the many substances which have been employed as auxiliary re- medies, or are now in use, the lignum guaiaci and the radix sarsapa- rilloz unquestionably claim the first notice. They are acknowledged to be useful during the administration of the oxymuriate of mercury, in cases of recent affection ; and in the secondary symptoms of the disease, for the removal of the evils which have taken place from the injudi- cious employment of mercury, &c. their salutary operation has been uniformly evineed. " The compound decoction of guaiacum and sarsaparilla may readily be prepared in the following manner : Bj. Rasur. ligni guaiac. Rad. sarsapar. fissae. aa.. |i. Coq. in aq. font. Ibiij. ad ft>. ij. "Of this decoction the above quantity, taken warm, ought to be drunk within the twenty-four hours. Of its effects as a powerful alte- rative for the removal of some of the most painful symptoms of lues venerea and obstinate cutaneous affections, indubitable evidence exists in the pages of the old and in those of the most eminent modern au- thors.! During a period of more than forty-five years its virtues for these purposes have been tested in the practice of that learned and distinguished Physician, Dr. Samuel Bard, and for more than twenty- five years in the practice of Dr. David Hosack. Its salutary properties appear to be owing chiefly to the general excitement which it produces, and to its action as a diaphoretic. When had recourse to, while in the use of mercury, particularly in the treatment of those cases where the disease is of long continuance, it proves eminently useful by promoting the natural tendency which the corrosive sublimate possesses to increase the cuticular discharge. * Treatise on Gonor, and Lues, Ven. vol. 2. p. 248. * Vide Aphrodisiacus, Ed. Boerhaavii. Also, Hunter, Bell, £'■ 131 i034 APPENDIX. " The compound decoction of the guaiacum may be taken with suc- cess for the removal of many of the morbid effects produced by the im- proper employment of the different preparations of mercury, and for restoring the constitution to its wonted vigour. The advantages arising from the use of the Rob Anti-syphilitique* for which so enormous a con- sideration is demanded, may with confidence be attributed principally to the sarsaparilla which enters into its composition." For further information the reader is referred to the improved edi- tion of Bell on the Venereal Disease, edited by Drs. Low and Beck of Albany ; and to the papers on Mercury, published in the American Me- dical and Philosophical Register, vols. 3d. and 4th. Anaphrodisia, or Impotency. Dr. Thomas has, in general terms, stated the means best calculated to fulfil the indications of cure in those cases in which, from general weak- ness, a debility of the genital system is induced, and a consequent loss of the venereal appetite and powers is the result. Many are the causes which may be assigned for disorders of this nature : the abuse of mer- cury in the treatment of syphilis and of some other diseases, the unsuc- cessful management of gonorrhoea, the still popular and pernicious prac- tice of using lead injections, neglected gleet, excessive venery, and par- ticularly onanism may be enumerated as the principal. In this condi- tion of the physical system the intellectual powers of the patient often largely participate, and few cases indeed, have stronger claims on the attention of the practitioner than those in which these circumstances, arising from these causes, are united. Too frequently the representa- tions and sufferings of the patient are regarded merely as the phantoms of the mind, and from an indifference both as to the real disease and a want of confidence in the means that maybe successfully employed, the most deplorable consequences ensue. To enumerate, in detail, the various methods had recourse to in or- der to renovate the constitution thus imprudently broken down, would -well this note to an inconvenient extent, and be, moreover, unnecessa- ry, as most physicians are fully apprised of the means employed for this purpose. " The tincture of lytta, says Dr. Thomas, might likewise be of service if given in small doses." The truth is, there is not an arti- cle of the materia medica used in any individual disease the value of which ought to be estimated more highly than the lytta in cases of se- minal weakness and impotency when arising from the sources just sta- ted. Though until within a few years its internal administration was pronounced to be almost uniformly productive of dangerous effects, yet it is now fully established, by numerous facts, that the instances in which it disagrees with the constitution are extremely rare, and that when, from unforeseen circumstances or peculiarity of habit, the mischief is produced, it can generally be removed by the readiest and mildest means. Occasionally, indeed, an active antiphlogistic treatment, such as blood letting, saline cathartics, or senna and manna; the free use of diluents, as soda water, barley water, Sac. and the warm bath, may be demanded. The claims of camphor in counteracting the action of the * Fide M'Neven's Account, of the Rob of Laffacteur, in the Netv-York Med. and Phi' J3l. Vol. 3. p. 23 \PPENDIX. 1030 iytta do not appear to be clearly established. My own experience does not enable me to recommend it: if camphor relieves the morbid symp- toms, so seldom excited by the lytta, it must, I think, do it by its ano- dyne or sedative properties, and not by any peculiar virtues attributed to it; and, if such be the case, I would much rather depend on the use of opium in small doses.* Most generally any uneasy or distressing symptoms from the internal use of the lytta disappear of themselves by ceasing for a while to take the medicine, and that too within twenty-four or thirty-six hours afterwards. The lytta is not, as is generally supposed, local in its action, but pro- duces a general excitement: it increases the sanguineous circulation, the flow of urine, and the discharges by perspiration : from its diffused action the whole system becomes invigorated, and this altered state is manifested by an enlivened condition both of the mind and body. The morbid discharge from the urethra becomes altered and assumes a thick and opaque aspect, and ultimately the wonted functions of the body are restored. The lytta has been recommended to be given in powder, in the form of pills, and in tincture. The only pharmaceutical preparation which I have employed, for internal use, is the last. The tincture seems to bt the most agreeable, and, in general, the most manageable form. The extent of the dose depends materially on the peculiarity of the case. Roberton observes, " It seems an invariable rule that the greater the •existing debility either of the general habit or of the generative organs, the greater quantity of the lytta is requisite to effect and keep up the irritation in the urinary passages ; and in such cases the cure is always more tedious. In those apparently stout, small doses, comparatively speaking, can be taken ; while in those whose general health, or whose generative organs only are most morbidly affected, can take the most; and, as they approach to health the doses requisite to keep up the irri- tation must be diminished, the system and also the generative organs being more susceptible of its action." % Experience strengthens the preceding remarks of Mr. Roberton, to whom we are so much indebted for his valuable work on the Generative System. The dose of the preparation with which I have generally com- menced is twenty or five and twenty drops three times a day, in a little wine, tinctura amara, or water. After the use of the article a few days ihe dose is to be increased to thirty or forty drops, and as often repeated within the twenty-four hours. It has happened, at times, that on the third or fourth day, and now and then even earlier, that the patient com- plains of some little uneasiness in passing water : this, if it does not in- crease, may be, for a while, disregarded : if the pain becomes severe the remedy must be laid aside, until the distress abates, after which it may again be prescribed to the same extent, if not greater, until similai effects are again induced : in this manner the use of the lytta is to be continued. A practical precept must be here enforced, perseverance in the use of the remedy. The extent to which it may be carried would, unaided by experience, seem incredible. Cures have been effected within a few days ; at other times from peculiarity of condition, as many months or years have been required to accomplish the object in view. But such disconsolate cases as call for this prescription demand all the prescri- * See also Orfila on poison* 1036 APPENDIX. ber's skill; yet the great success which has followed this practice jus- tifies the firmest perseverance equally on the part of the physician and the patient. In a case (a Mr. R-----aet. 27 years,) which came under the care of Dr. Francis and myself, in the month of November, 1816, the lamenta- ble condition to which the sufferer had been previously reduced, by the bad management of a neglected syphilis, and afterwards still further by an injudicious use of lead injections of an unwarrantable strength for nearly two years, led him, in a state of extreme mental anguish, to disregard the advice given him, and to seek the termination of his anxiety by self-destruction. With this view he took nearly six ounces of the tincture of cantharides during the night. Yet no dangerous symptoms occurred: he admitted he felt a degree of warmth throughout his body to which he had been a long time a stranger, and that his mind was less depressed than before the commission of this act of folly. He nevertheless went out as usual the next morning : he after this became persuaded that his situation was not altogether hopeless, and that his constitution, as he said, had still some stamina left to justify hopes of a recovery. He was now induced to take the tincture of lytta in the manner and quantity prescribed : two drachms and a half three times a day united with a dessert spoonful of the tinctura amara; a gene- " rous diet was also recommended. Within about three weeks from this i period he was renovated ; and considered himself an altered man. His virile powers resumed their wonted energy; nor has he to the slightest degree relapsed into his former state of weakness. This is unquestion- ably a rare instance in which the lytta rashly taken and to an inordinate amount was not followed by any serious injury. It nevertheless proves that the accounts in general given of this article exciting in moderate doses, deleterious effects are not to be received but with the greatest caution The lytta, like the common spirit of turpentine, the effect of which was once supposed to prove fatal, even in small quantity, experi- ence has now shown may be taken to an extent our predecessors could not have imagined. In obstinate gleets, after the ordinary vegetable and mineral tonics, the iron and gentian pills, the balsams and terebin- thinates have failed, I have also given the tincture of lytta in the pro- portion of a drachm with a tea-spoonful or two of bitters three times a day with permanent advantage. An error of Mr. J. Hunter ought here perhaps to be guarded against. '• I think, says he, 1 have been able to ascertain the fact that when bal- sams, turpentine, or cantharides are of service, they are almost imme- diately so ; therefore, if upon trial they are not found to lessen or to- tally remove the gleet in five or six days, I have never continued them longer." The beneficial effects of the use of the cantharides will occasionally speedily follow its administration ; but this is an effect which in a ma- jority of cases is the result of a continuance of the remedy for a con- siderable time. The introduction of this practice in the treatment of cases of this nature, in the United States is due, I believe, to Dr. Francis, the Profes- sor of the Institutes and of Legal Medicine in tbis University. APPENDIX. WM Obstipatio. I have no experience of the effect of carbon or charcoal for the re- moval of costiveness. When the ordinary means have failed, I have always had recourse to calomel, given in small and frequent doses, un- til the gums have become affected. In the Annals of Medicine for 1796, published at Edinburgh, I inserted a case of obstinate constipation of the bowels, which continued twenty-two days, and was finally remo- ved by calomel. The patient, took, besides other medicine, this pre- paration of mercury to the extent of four hundred and eighty grain?. Ischuria. In addition to the means pointed out by our author, and in confirma- tion of the advantages derived from producing great nausea and relaxa- tion, such as are sometimes the effect of blood-letting, warm bathing, to- bacco injections, and of the muriated tincture of iron, it may be observed that great benefit has been experienced in many cases, in the New-York Hospital, from the exhibition of tartarized antimony, and that this me- dicine has in some cases afforded relief where the former have failed. Scirrhus and Cancer. One of the most frequent errors in the operation for scirrhus and cancerous affections, is the non-removal of the entire gland, the seat of the disease ; and our author does well when he so forcibly recommends the complete extirpation of the whole glandular substance of the breast, in order to secure against a relapse. With the exception of a single instance, I have uniformly taken out the whole mamma, however small may have been the portion affected with cancer, and I have hither- to had reason to be satisfied with this practice, first recommended, as I believe, by the learned Professor Richter, of Gottingen. Arsenic most lamentably is too frequently and too freely employed for the removal of tumours of a supposed cancerous nature. It is not long since, that a very respectable citizen of New-York fell a victim to this empirical method of treatment. An encisted tumour existed on the side of the neck, and arsenic, in the form of unguent, was applied for the purpose of removing it. The removel of the tumour was indeed effected, but the patient, by the long continuance of the application lost the use of his right arm, and the muscles of the back of his neck, and also those on that side of it from which the tumour was taken. In consequence of this paralysis, his head to a considerable degree was thrown upon his breast, from an inability in the muscles necessary to elevate it. This distressing affection constantly increased, and finally terminated in the sudden death of the sufferer. Similar facts have fre- quently come within my knowledge, of the injurious effects arising from the application of this mineral, as employed for the purpose of remo- ving supposed cancerous tumours. The process by mechanical pressure, lately adopted by Samuel Young, of the Middlesex Hospital, for the cure of scirrhus and cancer, and which Dr. Thomas notices at sufficient length, has not been, as I am creditably informed, attended with the success its author anticipated : 1038 APPENDIX. an inference, indeed very obvious to one in any wise acquainted with the pathology of the disorder. Tic Douloureux, or JYeuralgia. This disease seems to be nearly allied to rheumatism, but is consi- dered by most physicians as idiopathic. Professor Chaussier has very correctly denominated it Neuralgia. As a distinct disease affecting the nervous system, it attracted the attention of physicians at a period much earlier than is generally supposed. It was noticed as such by Dr. Da- niel Ludwig in 1673,* by John Hartmann Degener, a practitioner at Nimeguen, in 1724 ;t by Andree, a French surgeon, in 1756,f and by Dr. John Fothergill of London, in 1776 ;§ by the latter it is described under the appellation of a painful affection of the face. By most physicians who have written upon this disease, and even by systematic writers, it has been generally considered as seated in the second branch of the fifth pair of nerves, or in the portio dura of the seventh. Mr. Abernethy, however,|| has related a case which was seated in the nerves of the ring finger of the left hand. Mr. Home, in his Cfoo- nian lecture,** has also related some instances of this disease, the effect of an injury to the thumb. In the Edinburgh Medical and Surgical Journal, a case is recorded by Dr. Verpinet as occurring in one of the nerves of the fore-arm, the consequence of a wound from a knife. The first case of this disease which fell under my notice was that of the late Mr. Charles Apthorpe, of New-York, in 1794. The disease was seated in the lower as well as the upper jaw, and occasionally, as in the case of Mr. Bosworth, related by Mr. Leigh Thomas,tt embraced all the three branches of the fifth pair of nerves. Previously to this affection of the face and head, Mr. Apthorpe had suffered many years from regular gout. In this case the neuralgic affection was probably induced by the same cause, as the gout was totally suspended upon the appearance of the latter disease. Mr. Apthorpe had then passed the 60th year of his age. In three other cases the disease occurred in fe- males between thirty and forty years of age ; in all three the nervous temperament was strongly marked, and predisposed them to the com- plaint ; in one the ophthalmic branch of the fifth pair of nerves was exclusively the seat of the disease, each paroxysm being attended with violent action of the muscles of the eye, a compression of that organ and a copious discharge of tears : this lady for several years previous' to this affection, had suffered repeated attacks of acute rheumatism which never recurred after the appearance of her new complaint. " In the second, the nerves extending over the side of the head, as in hemi crania, were the seat of the disease. In the third it commenced in *Miscel. Nat. Cur. Dec. 1, Ann. Ill Observ. 252, "de dolore superciliari ascerbi^.mr, f Acta Natur. Curios. « de dolore quoclam perraro acerboque maxilfe sinistra nart„ £. pante et per paroxvsmos recurrente," vol. 1. p. 347. Fd"es occa- a }Sfo, mt^^S."63 SUr US MaladieS ^ LUrethre Ct SU1'Ie9 pleUSieUrS faits convulsift, } Med Obs. and Inq vol. 5th. || Surg Observ. vol. 1. p. 244. ** Phil. Trans for 1801. ft The very interesting case of Mr. Bosworth the reader will find recorded bv Pi- n win, in which all the three branches of the fifth pair and the several branch^ r>7 S? Ul\.°ai> nerve were successively divided before the patient obtained relief Sp* 7™™ • « , ^ T.ond. vol. 3. p. 218. Y oee ^oonomia, 3d. edft. APPENDIX. igsb the fifth pair, but soon involved the whole nervous system, produ- cing convulsions, to subdue which, required the most liberal use of opium and aether. In all of these cases the patients suffered repeated returns of the disease, especially in the fall, winter, and spring ; but by the use of tonic medicines, exercise, the cold bath, and attention to diet and mode of life, at the same time avoiding exposure to the changes of the weather, they have for some years past escaped the usual visita- tions of this distressing malady. Another lady, far advanced in life, in consequence of an injury of the extremity of the fore-finger of the right hand, has endured for several years the most severe paroxysms of this complaint, not only affecting the branch of the injured nerve, but those distributed Upon the fore-arm and occasionally extending to those of the neck. In August, 1813, I was called upon to visit Mrs. S. aged about 52 ; she was confined to her room by an attack of neuralgia seated in the fourth toe of the left foot. She was first affected with this disease about three years before ; but knows no cause to which she can ascribe it. She has made use of blood-letting, opium, warm bathing, and fo- mentations without effect and upon one occasion the pain was so acute that she plunged the part affected in boiling water, but without relief— I directed the toe to be involved in a blister, which was continued to the part twenty-four hours, but this, like the other means that had been resorted to, was of no avail. As there is a manifest resemblance be- tween the severe pain frequently suffered in acute rheumatism, and that of neuralgia, it occurred that benefit might be obtained by the use of the volatile tincture of guaiac; a tea-spoonful of this medicine was accordingly directed to be taken every two hours in half a glass of wine. After taking a few doses, the patient experienced more relief than from any other medicine she had taken.—Since that time, when- ever she has the least irritation in the affected part, she has immediate recourse to the tincture, and uniformly with relief. From these facts it also appears that neuralgia is not confined to the nerves of the face, as most physicians have supposed ; but that it is fre- quently connected with the general condition of the nervous system, and that we are not in all instances to rely upon the division of the nerve affected for the cure, but to direct our remedies according to the temperament of the patient, the peculiar condition of body and vice of the habit from whence the disease may have originated. Dr. J. Fothergill in some instances traced it to a cancerous or vitiated habit of body, and in three cases has removed the disease by the use of hem- lock : some French physicians have cured it by mercury,* believing that in some cases it may have arisen from a syphilitic taint; others, treating it as rheumatism, have employed calomel and opium with suc- cess.! As the complaint tor the most part occurs late in life, and in females most generally after the natural cessation of the menses, or, if in early life, from the suppression of the evacuation, may it not also derive its origin from the state of the blood-vessels, an arthritic habit. or that condition of body which induces rheumatism.+ especially in persons of the nervous temperament, who are generally the subjects of neuralgia? In cases of this nature, the lancet, warm bathing, alterative * Recueil periodique de Medicine, Paris, 1702, torn. iv. See also Edin. Med. and Sure: Journal, vol. 3. p. 273. b f Edin. Med. and Surg. Journ. vol. 4. p. 306. | S\?c fwo cases thus induced related by Dr. Pearson, do. vol. 3. p. 2?2 1040 APPENDIX. drinks, and the vol. tinct. guaiac, with other means calculated to ope- rate upon the whole system, may, according to the peculiar circum- stances, of the case, take the place of the knife, now restored to for the division of the nerve affected, and which, in some instances, disappoints , both the patient and practitioner.—Dr. Jackson, of Boston, has pub- lished an excellent paper on neuralgia in the New-England Journal of Medicine and Surgery, vol. 2. p. 165. Vermes. With the exception of the tape-worm and the ascaris vermicularis, inhabiting the mucus accumulated in the lower portion of the rectum, I have been long in the habit of considering worms among the symp- toms of dyspepsia.; and, in no instance, as constituting an idiopathic disease. Nor have I ever been in the practice of directing the various anthelmintic medicines usually prescribed for the removal of worms ; my only prescriptions have been, after an active cathartic of calomel and jalap, and the removal of all febrile symptoms, to put the patient upon the use of the tincture of aloes, with myrrh, (the elixir propri- etatis,) in doses sufficient to keep the bowels soluble ; say from two drachms to half an ounce, mixed in sweetened water every morning, fasting for three days successively ; renewing it afterwards as occasion may require. I then direct, if the child be greatly debilitated, the use of some preparation of iron ; either the filings or the carbonate, in combination with a small portion of ginger. Eight or ten grains of the former with two of the latter, administered twice a day, in syrup as its vehicle. These medicines, with a diet calculated to impart vigour to the diges- tive'organs, are, in my opinion, infinitely more successful in the removal of worms, and other symptoms of derangement of the gastric organs, than all the anthelmintics I have ever seen directed as such. Indeed the practice of worm-hunting, so fashionable among practitioners, as well as of calomel and other forms of mercury, are to be reprobated as empi- rical, and not unfrequently productive of worse evils than those they were intended to remove. The Black or Livid Colour of Infants. The disease to which Dr. Thomas alludes under this name, is doubt- less that complaint of infancy which Underwood has given a sketch of, as proceeding from " an imperfect closure of the foramen ovale." As Dr. Thomas states, that he knows of no remedy for this disorder, I am induced to offer the following account of two of several cases which I have had under my care, with the mode of treatment that proved successful ; more especially, as Dr. Underwood also, even in the last edition of his work on the Diseases of Infants, has not given us a satisfactory history of this formidable disorder. Case I.—On the morning of the 30th of October, 1797,1 was sent for to visit a child of N. P. of this city : it was seven days old, of appa- rently good constitution, and had been in perfect health from its birth. I was informed it had been suddenly taken ill in the night, and that it- awoke with an unnatural screaming, which was the first symptom of its aUpead'aX. 1041 indisposition. Mrs. P. considering its complaint to proceed from some disorder in the bowels^ gave it a dose of castor oil, which operated free- ly, but without any abatement of its symptoms : a drop of laudanum was then administered, but without the smallest benefit: the child still continued screaming every few minutes, but after each fit it was per- fectly quiet, and apparently free from pain ; but would not take the breast. Finding no relief from the oil or opiate, Mrs. P. became alarm- ed, and early in the morning I was called to visit it. In a few minutes after I had entered the room, it suddenly screamed out two or three times. I at once perceived that this was not the natural cry of the child, and took a seat with the view to examine its symptoms more particu- larly. The fits of screaming returned about every ten or fifteen mi- notes ; immediately after each fit, the countenance appeared natural, both as to the complexion and composure of its features, and the pulse beat with its usual frequency ; but in the course of about five or six minutes, respiration became entirely suspended ; the eyes now assumed a vacant stare ; the countenance changed its colour; instead of the natural florid hue, it became of a dark livid bluish colour: this change was first perceived about the upper lip and chin, and was apparent to every by-stander ; the pulse became less frequent, and very irregular; in about eight or ten minutes the blueness was extended over the whole face ; the extremities underwent a similar change of colour, attended with some coldness : at this time the pulse was scarcely to be perceiv- ed ; in a word, the child, at this moment, manifested every symptom of approaching death. In this critical state of things it again suddenly screamed, throwing out its arms and legs as in convulsions, and took two or three violent inspirations ; after these efforts, respiration was again entirely suspended ; but, notwithstanding, its circulation was again for a short time restored, the leaden colour of its countenance disap- peared, and its natural complexion, for the moment, perfectly returned. These last favourable symptoms did not continue : as before, in a few minutes, respiration being entirely suspended, the countenance became livid and blue ; the circulation became slower and very irregular, and the extremities lost their heat. Such was the condition of the child, un- til another fit of screaming restored the respiration for a moment, which gave new energy to the circulation. I was now satisfied that the bowels had no connexion with its present complaints. Having seen the disease in three other children, 1 readily recognized it; but as, in all those, it proved fatal, I had not the smallest hope of its recovery. In those cases evacuations were first employed, and afterwards anodyne medicines were administered, upon the principle that the disease was of a spasmodic nature ; but as these remedies were not attended with any relief or advantage, I resolved to try the effect of a stimulant mode of treatment. Accordingly, I applied a small blister upon the breast, and two others behind the ears ; cataplasms, composed of rye meal, vinegar and mustard, to the soles of the feet; bathed its whole body with warm brandy—afterwards, with diluted spirits of sal. ammoniac ; and, from time to time, we attempted to give it a spoonful of wine whey, but to no purpose, as it was incapable of swallowing. This treatment was pursued for two or three hours ; in the beginning it ap- pealed to promise relief; the fits of screaming did not return so fre- quently ; respiration continued a longer time, and the circulation be- came more vigorous. In about four hours the blisters produced their 132 i.042 AP,PEN.DJ>;, effect; upon thiir operation we had great reliance ; but they produced no sensible alteration in the state of the disease : the fits still continued to rfeturn as in the beginning, and with the same succession of symptoms as above described. Six hours had now elapsed ; the cries of the child became more febrile ; respiration was suspended for a greater length of time than in the commencement of the disease, and the circulation became less vi- gorous : these, with the greater coldness of the extremities, confirmed \is in our fears of the event. Having frequently employed a stimulating bath, prepared with bark and spirits, in the latter stages of malignant fevers, and diseases of great debility, I determined, as a last resource, to give it a trial in the present case. I therefore directed four ounces of Powdered Peruvian bark to he boiled for a few minutes, in about two gallons of water ; to this. When fit for use, a pint of Jamaica spirits was added: when it was cooled to a temperature rather above that of the body, the child was iirfmersed in it up to its neck ; and to render the bath more stimulating, I added, from time to time, a small quantity of the spirits of sal. ammo- niac. In a very short time a favourable and very apparent change took place ; respiration, while the child remained in the bath, was perfectly restored ; the circulation became vigorous and active ; the countenance resumed its lively hue ; the eyes recovered their natural expression ; the power of swallowing returned, and, in every respect, the child manifested symptoms of relief. In this state of things we removed it from the bath, wrapped it in warm dry flannels, and put it to the breast- To the great joy of its mother, it returned to it with eagerness ; it re- mained composed, and free from complaints a considerable time, per- haps for the space of half an hour. At the end of that time, respira- tion became irregular, and was again interrupted, followed with the same change in the circulation and in the colour of the skin as has al- ready been described. The bath was employed a second time, and With the same relief as before. It now fell into a sleep, remained so for an hour, breathing freely ; its circulation regular, and the child, to all appearance, freed from its complaints. At the end of this time we were again alarmed with the same distressing symptoms of screaming, and interrupted respiration, with which it was first attacked ; but the hath as readily relieved it a third time. As far as I can recollect, it had two or three more paroxysms, but they were of shorter duration, returned after long intervals, and were uniformly relieved by the use of the bath. Since that time the child has had no return of the disease, and is at present in perfect health. Case //.—In the month of December, a child of my brother, Doctor Alexander Hosack, was suddenly seized with the same disease, and at- tended with precisely similar symptoms : it was six weeks old, of good constitution,, and had been remarkably healthy. I was immediately called to visit it, and upon entering the room was told that 1 had come too late> and that the child was dying. At this time respiration was completely suspended, the face of a dark bluish colour, the circu- lation weak, and very irregular, and the extremities were almost cqKI. I instantly directed a bath to be prepared in the same man- ner as I had done for Mr. P.'s child: in the meantime the disease underwent nearly ihe same change and succession of symptoms as APPENDIX. i-04'3 tvere described in the preceding case. Whgn the bath was pre- pared, the child was immersed in it: in a short time, the respiraticta became regular ; the child was continued in the bath about fifteen mi- nutes, but was by no means relaxed, as by the operation of the bath of warm water alone. When it was removed, it appeared to be perfectly relieved, and remained so for the space of twenty minutes, or half an hour; when the fit returned, but was of shorter continuance, and lefi9 violent: the bath was employed a second time which completely re» moved all complaint. The child is now living, and in good healths Puerperal Fe'ver. To the excellent observations of Dr. Thomas, on tliis subject, I sliall only add, that puerperal fever ought to be divided into the idiopathic and symptomatic kinds : in the former we may observe the characteris- tics of an active and pure inflammatory disorder, while in the latter are to be seen those of a typhoid affection. This typhoid state is to bet Considered as depending upon a peculiar condition of the system, and previous exposure to the sources of typhus fever. In this case, puerperal fever is not unfrequently highly contagious. These tiva forms of the disease evidently call for different, and sometimes oppo- site, modes of treatment. Ctwitis, or Phlegmatia Dolens'. The inflammatory nature of this disease, after the vie'w taken of it by Dr. Hull, and the late Dr. Ferriar, of Manchester, seems to me hardly questionable.. It may, and frequently does, arise from causes similar to those which produce inflammation, and of these causes cold may be con- sidered as the most frequent.—I have recently had under my care a formidable case of this disease, induced by the injudicious use of ardent drink, prescribed immediately after delivery. This complaint some- times occurs independently of parturition; and where it attends the puerperal state, 1 have known it to take place many days after the lo- chial evacuation had totally ceased :—this discharge therefore in those instances, could have had no agency in the production of the disorder as supposed by Dr. Trye and Dr. Denman: but the fact that phlegma- tia dolens never arises from the offensive discharges of the womb that take plaCe in the numerous diseases with which that organ is affected, affords an abundant refutation of that doctrine. The comparatively rare occurrence of this disease, even after parturition, is opposed to that view of the subject. Dr. Francis witnessed a striking case of phlegmasia dolens, occurring in a male subject, aged about twenty- two years. In this instance the disease succeeded to a long-continued t\rnhus. In the treatment of phlegmatia dolens, regard must be had to the stage of the disease : during the inflammatory or first stage those means should be employed which are calculated for the removal of general and local excitement, viz. blood letting, saline cathartics, nauseating doses of an- timony or ipecacuanha—and the use of tepid vinegar and water as a fomentation to the limb : in some cases blisters to the parts rriost affected have been found serviceable, 1044 .Mi»EKDfX. In the second stage of the disease, when the febrile and inflammatory Symptoms have subsided, great advantage has been obtained from small doses of calomel and squills, while stimulating liniments, friction, and the flannel roller, are among the most beneficial applications to be made td the part. •In the first stage of the disease, the diet should be strictly antiphlo- gistic—in the last the moderate use of wine, and the more stimulating nourishments may be administered, proportioned to the degree of debi- lity induced. I have never known phlegmatia dolens to terminate fatally, nor in my opinion is it likely to do so, or even to leave any permanent dis- ease of the limb, where active depletion is employed in the commence- ment of the complaint before an effusion has taken place in the cellular membrane. Cholera Infantum. Cholera Infantum is a disorder of a very fatal nature in this climate, especially in the summer and fall months. It may properly be consi- dered as similar to the autumnal remittent of adults. Dr. Mann of Wrentham, (Mass.) in his valuable prize dissertation on the autumnal diseases of children, has taken a similar view of the disease : accord- ingly, instead of prescribing anodyne and astringent mixtures to lessen the discharges by the bowels, which are probably the effect of the severe excitement of the system occasioned by the heat of the season, and fre- quently the additional irritation of teething, we more rationally direct those remedies calculated to allay the general febrile excitement, and thereby to remove the irritations of the intestinal canal. Accordingly, it has been found, that the most successful mode of treatment is in the first instance to empty the stomach and bowels with small doses of ipe- cacuanha and rhubarb. Calomel and antimonial medicines are also fre- quently prescribed with good effect in this stage of the disease. When the stomach and bowels are freely evacuated by these means, if the fever continues, small doses of ipecacuanha may still be continued with advantage for the purpose of preserving a perspirable state of the sur- face of the body. Warm bathing is also at this time made use of with advantage. When the febrile symptoms are removed, weak brandy and water, or port wine and water, beef tea, the liquor of clams or oysters, are most grateful, and also most useful in restoring the tone of the sto- mach and bowels. But if the irritations of the intestinal canal continue after the febrile symptoms are removed, the chalk julep of the dispen- satory, with the addition of laudanum or paragoric elixir, is very advan- tageously prescribed. In some instances where the diarrhoea is attend- ed with tenesmus, severe gripings, and the discharges are tinged with blood, small injections, composed of starch and laudanum, are more effectual in relieving the sufferings of the patient than anodynes admi- nistered by the stomach, while they are less apt to disturb the functions of that organ : in other instances astringent remedies are indicated to restrain the profuse liquid evacuations from the bowels. For this pur- pose, nothing will be found more effectual than an infusion of the root of the marsh rosemary, the statice limonium of Linnseus. But of all the remedies prescribed, either for the purpose of preventing or of cr> MfPE'SDlX* 1045 ring this disease, I know of none so effectual as removal to the cool air of the country, particularly near the sea shore, where the atmosphere is not only cooler, hut in a peculiar manner restores the appetite and strength of the patient. " It is extremely agreeable, says Dr. Rush, to see the little sufferers revive as soon as they escape from the city air* and inspire the pure air Of the country."* But among the means.of prevention may be recommended the use of flannel worn next the skin ; this preserves the action of the vessels on the surface, at the same time that, as a non-conductor, it guards the tender infant from the extreme heat and vicissitudes frequently experienced in the hot season of the year. Warm bathing, at this season, by lessening the effects of heat upon the system, is no less useful to children than to adults. Syphilis Infantum. M&ny authenticated cases have been published by Mead, Jenner, and Others, of small-pox communicated to the foetus in utero; and in Dr. Pearson's paper in the Medical Commentaries of Edinburgh, the readei? will find abundant evidence of this truth. Two cases of this sort oc- curred to me in 1791 while I practised physic in Alexandria, Virginia. The foetu3 in utero, may, and occasionally does, become affected with the venereal disease, derived from the mother labouring under the dis- order of a constitutional form. The ulcers which at times occur in the mouths of children, the offspring of such infected mothers, have pro- duced the same disease upon the nipples of nurses by whom they have been suckled. These women have imparted the affection to other chil- dren, and these children again to other nurses. Facts of this nature most satisfactorily established the principle that not only the blood itself may be vitiated by the matter of certain diseases, but that the se- cretions themselves are capable of communicating the virus of certain specific affections to the healthy constitution. It were easy to relate the particulars of several cases for which I have prescribed, the patho- logy of which is capable of being explained upon no other principle. Two instances have fallen under my notice, and several are recorded upon respectable authority. It ought, therefore, no longer to be a dis- puted point with writers on medical jurisprudence. The mode of treating these affections of infants is satisfactorily sta- ted by Dr. Thomas. The corrosive sublimate in solution made in the manner already mentioned, is the form I constantly use. It may be given to the mother or nurse, and produce all the salutary effects de- sired on the constitution of the child ; it may likewise be administered to the child itself with perfect security. Infantile Hemittmt Fever. To this disease the attention of practitioners was long since directed by the valuable publication of Dr. Butter. Recently, by the excellent practical observations on the same subject, by Mr. Coley, the profes- sion has again been called upon to notice this form of fever ; which, although of daily occurrence, and frequently fatal in its consequences, has not been sufficiently regarded by physicians. Med. Inquir. & Observ. vol. 3, p. "7i> 1146 APPF.NniX. In this country, as I was early taught by my preceptors, Docld;'^ Hush and Kuhn, and as I have witnessed in my own practice since the year 1791, the remittent fever of children, if we except croup, pneumonia, and the diarrhoea attendant upon teething, is more fre- quently met with than perhaps any other disease of infancy or child- hood. Nor is the infantile remittent confined, as observed by our author, to children under six years of age ; but is oftentimes met with between that period and the twelfth year. As in the bilious remittent of adults, it may be remarked of the in- fantile remittent that it is very generally traceable to a derangement of the digestive organs as its primary seat and source. This is evinced by the loss of appetite, the foul tongue, the offensive breath, and the confined state of the belly, in the forming stage of this disease, and which are generally considered as the evidence of worms, and treated accordingly.* These symptoms in a few days are succeeded by those Of fever, which is of very uncertain duration and violence, and not un- frequently displays itself either in irritation of the chest, producing op- pressed respiration and cough, resembling pneumonia, or upon the brain, followed by the evidences of phrenitic inflammation, and ulti- mately terminating in hydrocephalus internus. This last termination, Such is the natural tendency and force of the circulation upon the brain at that early period of life, may very generally be anticipated, if active means be not early employed to empty the stomach and intestines ; and to unlock the surface of the body by warm bathing, the free use of an- timony, and other diaphoretics ; or by blisters, to create a new and re- latively safe seat of irritation, upon which the febrile symptoms may ex- pend themselves. Indeed so constantly is hydrocephalus the sequel of other febrile diseases, that it may, with very few exceptions, be consi- dered as exclusively symptomatic. I have even known pneumonia t6 be its forerunner. Teething is frequently productive of fever, ending, in phrenitis and hydrocephalus ; and I believe, as already intimated in another place, the arterial excitement occasioned by the use of mer- cury, so frequently and indiscriminately given in the diseases of chil- dren, has been a prolific parent of this fatal malady ; and which has oftentimes been remarked to have greatly increased in frequency and mortality, since the very general prescription of that metal. In as far, therefore, as increased arterial excitement of long.continuance, what- ever may be its type or its source, has a peculiar tendency to oppress the brain at this period of life, the same consequence is to be apprehended from the form of fever under consideration : and, on this account, not only calls for the most active means of obtaining a solution of such fever, but, in an especial manner, suggests the employment of such remedies as are calculated to divert the current from the brain to other parts of the system. ,When, therefore, in the progress of fever, the brain begins to manifest inordinate irritation, either by pain, or by stu- por, blisters to the extremities, and active cathartics, viz. an infusion of senna, manna, and cream of tartar, frequently administered until plen- tiful evacuations are obtained, are among the most effectual means of arresting the progress of the fatal train of symptoms now to be appre- hended. I notice, particularly, the infusion of senna, having admin\« * See OlrrrvatioTre on Worm?. Appendix. ApfEjsmx, 1Q4? tered it m" many cases of approaching hydrocephalus with the most decided advantage. Mineral Waters of BaUston. 1 have considered it not wholly foreign to the object of these Notes to add a few remarks on the medicinal properties of the Ballston and Saratoga Springs. No mineral waters in the United States enjoy an equal celebrity, and as none are more generally resorted to by invalids, perhaps none are more indiscriminately used. Correctly to ascertain their properties becomes, therefore, an object of importance to-every physician.* Several analyses of the Ballston waters have been communicated to the public ; according to the analyses made by Mons. Caizalet, a teacher of chemistry at Bordeaux, a bottle of the Ballston water containing 25 ounces afforded 1. Carbonic acid, three times its volume. 2. Muriate of soda, 31 grains. 3. Super saturated carbonate of lime, 22 grains. 4. Muriate of magnesia, 12| grains. 5. Muriate of lime, 5 grains. 6. Carbonate of iron, 4 grains. This subject has also recently received the attention of Dr. William JVIeade of Philadelphia, a gentleman well skilled in practive chemistry, ■and who has made frequent visits to the springs both of Ballston and Saratoga, for the express purpose of making an accurate analysis of those celebrated waters. The reader desirous of further information on this subject is referred to the work published by Dr. Meade, entitled " An Experimental En- quiry into the chemical properties, and medicinal qualities of the prior. cipal mineral waters of Ballston and Saratoga." The Ballston waters have been long known to yield a great quantity of fixed air, and to hold in solution a large portion of iron. By the ana- lysis now given, it appears that they yield a much larger proportion of fixed air, and that they contain a greater quantity of iron, than any other mineral water that has hitherto been discovered, not excepting that of Vichy, in France, one of the strongest chalybeate waters in Europe. But it appears, that they also contain another substance, viz. the imri-. ate of lime, which, with the other ingredients with which it is associa- ted, promises to be of great and extensive utility. We are accordingly from the above analysis induced to ascribe more virtues to the Ballston waters than physicians have generally believed them to possess. Although much is due to exercise, change of air, and an agreeable occupation of the mind, which the amusements of wa- tering places usually afford, I have no doubt, from the sensible effects produced upon the system by the waters themselves, that they are also *■ The Yellow Springs of Virginia, and the waters of Stafford Spring, ia the state of Conv necticut might be noticed anions; the mineral waters of the United States. The Schooley's Mountain Waters in the State of New Jersey have lately attracted a considerable degree of attention, and been resorted to by many. A minute and interesting analysis of these waters has been published by Dr. M'Neven, professor of Chemistry, in the Transactions of the Lite- rary and Philosophical Society of New-York, vol. 1.—This water sirenls Co be c6jefty»vaiua> "Hie in calculous complaints-. 1Q4S APP£JNi»l>» productive of great good in a variety of diseases, some of which I shaft now briefly enumerate. 1st. From the effects of the Ballston waters, as a strong chalybeate, they may be employed with advantage in most diseases of debility, whether directly or indirectly such. But in those complaints which are attended with an increased excitement of the whole system, or with local inflammation, they are manifestly prejudicial. These principles are deducible from the qualities of the waters alone ; but they are also confirmed by the experience and observation of physicians who have attended to their operation. Accordingly in intermittent fever, dropsy, dyspepsia, hypochondriasis, 0hd hysteria, connected with, or proceeding from debility of the diges- tive organs ; in paralysis, chronic rheumatism, gout, in its chronic state, chlorosis, fluor albus; in suppression of the menses when arising from weakness, in worms, and in other diseases of debility, whether of the intestinal canal, or of the whole system, the Ballston waters have been long and justly celebrated. On the other hand, in a plethoric state of the system, as in pregnancy, in consumption of the lungs, inflammation of the liver, acute rheumatism, dysentery, and other diseases of an inflam- matory nature, in which they are oftentimes resorted to, they invariably do injury. We may, perhaps, except from this remark a species of con- sumption which arises in females about the time of puberty, in which, from want of energy in the system, menstruation does not take place at the period in which it usually appears ; dyspepsia ensues, followed with general irritation of the nervous system, pain in the breast, cough, sometimes hemorrhage from the lungs, and ultimately terminating in confirmed consumption. These consequences have frequently been prevented by a course of iron, and vegetable tonics, aided by generous diet, and exercise, especially riding on horseback. Under similar cir- cumstances I have no doubt that the Ballston waters maybe serviceable in this species of phthisis in its incipient state ; but they should never be employed in diseases of this nature without the advice of a phy- sician. 2d. From the saline impregnation of these waters, and their operation upon the urinary organs, as well as by perspiration, they are indicated in diseases of the kidneys and bladder, in gout, chronic rheumatism, and eruptions upon the skin, all which diseases are most frequently produ- ced by, or connected with a morbid condition of the fluids, and an im- paired state of the secretions. In these complaints, I have repeatedly prescribed these waters with the best effects. Dr. Thacher, the author of " The American modern Practice," a work containing much original and valuable information, concurs in the opinion of the general efficacy of the Balston waters in diseases of de» bility, and that they are peculiarly beneficial in calculus and gravel, Some cases of which have come within his own particular knowledge— and upon the information of Dr. Powell, whose residence at the springs gave him a free opportunity of ascertaining the fact, he adds, that rarely a case of gravel occurred in which relief was not obtained.* But according to the foregoing analysis, they contain an ingredient of great value, besides those already enumerated ; I mean the muriate of ■lime. It appears upon the authority of Dr. Beddoes, Dr. R. Pearson, '*■ See Tfocneu's Anlerican modem Pr.acfrce. APPENIDX. 1049 Dr. Wood, and Dr. Schraud of Vienna, that this substance has lately been discovered to be a remedy for scrofula, which hitherto has been the opprobrium of our profession. It is true, cases have been recorded by Russel and others of the cure of this disorder by the use of sea water. But as it has been ascertained by chemists, that the muriate of lime enters into the composition of sea water, it is very possible that much of the efficacy of the latter, in that disease, may be derived from the muriate of lime which it has been found to contain. But as scrofula is usually attended with a general debility of the sys- tem, as well as a morbid condition of the fluids, the Ballston waters will probably be found peculiarly serviceable, inasmuch as they possess the means of invigorating the system, at the same time that they contain the antidote to the peculiar virus of that disease. But to obtain the benefits of the Ballston waters in any of the diseases which have been noticed, it is necessary that in the use of them, as it regards the time of taking them, the quantity taken, the stage of the disease, and other circumstances which must govern their exhibition, the directions of the physicians be particularly attended to. As well might the patient make use of any other article of the materia medica without medical advice, as drink these waters in the manner in which they are usually taken. It is but a short time since that a very valua- ble life was destroyed by the imprudent use of them during a state of pregnancy. I was lately consulted by two gentlemen who had left the springs much worse than they had gone to them. The one laboured under dyspepsia, attended with habitual costiveness. Neglecting to relieve his bowels, he commenced the use of the waters ; the conse- quences were, an aggravation of his disease, followed with fever, acute pain in the head, and other symptoms of general excitement. The other person referred to, had come from Virginia, on account of an obstinate chronic diarrhoea, attended with great debility, and general emaciation. Withou tadvice, he immediately began to drink the waters to the quantity of several quarts daily. The consequences may readily be imagined ; an increase of his disease, and a degree of debility from which he with difficulty recovered.—See Amer. Med. and Philos. Reg. vol. 1. " This water," says Dr. Steel, " if drank in large quantities, or when taken by persons whose stomachs are extremely irritable, operates as a cathartic : it is likewise, in most instances, a powerful diuretic ; and like the other strong chalybeates in the vicinity, is of eminent service to an impaired or capricious appetite, and weakness of the assimilating organs in irregular digestion, flatulent distention of the abdomen, anxiety about the praecordia, difficult respiration from sympathy with the stomach, occasional vomiting of rigid mucus, &c." The administration of these remedies therefore requires some atten- tion. Upon this subject, the following judicious remarks by Dr. Dyck- man, contained in his excellent American edition of Dr. Duncan's New Dispensatory, merit the observance of those who visit Ballston and Sara- toga, to obtain the benefit of those waters. " The doses must be regulated by the constitution of the patient, the state of the stomach, the nature and stage of the disease, and the effects produced. In large quantities, as from a pint to a quart, they usually operate gently as a cathartic ; but in small doses their action is deter- mined more particularly to the kidneys and skin. In general, they 133 1050 APPENDIX. should be drank till they produce a slight evacuation from the bowels. Care, however, should be taken never to distend the stomach so as to occasion inconvenience. If from one to two or three pints daily pro- duce no sensible effect, the quantity of fluid will be apt to prove more injurious as a load, than useful as a medicine. In most instances, per- haps, it will be advisable to begin with small quantities, and repeat them often. When taken to an improper extent, particularly if they do not , * produce some effect as a purgative or diuretic, they not unfrequently occasion much distress and disturbance of the whole system, being fol- lowed by anxiety, headach, or vertigo, perturbation, pains in the sto- mach and bowels, or spasms. They should not be employed when the stomach and bowels are overloaded, or just before or after meals. When intended to act as an aperient, the proper time for administering them is in the morning before breakfast. Their operation will be facilitated by the exercise of walking or riding. Taken after a meal, they are less apt to affect the bowels than they are the kidneys and skin-." FINIS. national library of medicine nlm 03275012 t NLM032780929