taw ^i^jyw^rt*,"'*^? ' ,* ■■;.,■>& V ■98B ) " \*pa„ <^ ,^| Surgeon General's Office |j f ........... At a Meeting of the Dutchess Medical Society, it was resolved, that Dr. Sherrill be desired to pre- pare for the press, and take measures to have printed, the Papers on the Diseases of our County, which he has formerly read before this Society; and that the Members of the Society be requested to subscribe for the Book when offered for publication. A true copy from the Minutes. CALVERT CANFIELD, Secretary. April 9th, 1826. TO THE MEMBERS OF THE DUTCHESS MEDICAL SOCIETY: AS A TESTIMONY OF REGARD AND ESTEEM FOR YOUR ACQUIREMENTS AND JUDICIOUS EXERCISE OP THE JJtofisstou, AND AS A GRATEFUL ACKNOWLEDGMENT FOR THE ATTENTIONS CONFERRED, THESE PAGES ARE MOST RESPECTFULLY INSCRIBED, BY THE AUTHOR, Hyde-Park, May 1826- X" PREFACE. In attempting to comply with the regulations of our County Medical Society, while filling an official station in it, a short historical account of its prominent diseases was drawn up for the occasion, compiled from notes and memoran- dums, collected at various times. The manu- scripts having answered the purpose for which they were written, were laid aside, with an expectation that they would remain in private obscurity. A number of friends have latterly solicited their publication: in compliance with which, and the resolution of the Medical So- ciety, they have been corrected, and fitted for that purpose. The general and cursory manner in which the several subjects noticed must be touched vlii preface. on in an Essay of this kind, will necessarily frequently lose the advantage of detail and elu- cidation : but it is cursory history, a collection of some facts, and general principles only, that is attempted; with a hope, and leaving oppor- tunity for some one better qualified, to improve upon the hints and elucidate the subjects. In addition to the original manuscripts, with some slight corrections, such remarks as fur- ther observation and experience has suggested. are added in notes. AN ADDRESS, DELIVERED BEFORE THE DUTCHESS MEDICAL SOCIETY, AT THEIR ANNUAL MEETING IN NOVEMBER 1810. GENTLEMEN, Connected as I am with this Society, agreeably to its by-laws it becomes my duty, on this anniversary, to deliver before them an address. In turning the attention to the nu- merous branches of medical science, some of which naturally present themselves as a sub- ject for this discourse, one finally has been selected, which, more than others, may be in- teresting to this audience and this generation; one with which we are all somewhat acquaint- ed ; and the facts connected with which, the community at large have had an opportunity, in a greater or less degree, of witnessing. The subject to which your attention is di- rected, is a retrospective view of the diseases of our county for ten years past. I beg you would forget the abilities necessary to execute this task with propriety, and listen with can- dour to the efforts of a member, whose regard for this Society was his principal qualification that entitled him to your choice. 12 In progressing with this review, it is not to be expected we should detain you to notice and investigate the occasional and incidental diseases that are the occurrence of every day and every year, under almost all circumstan- ces ; but will aim, with impartial faithfulness, to trace the progress of the train of epidemical and endemial excitement, and notice the pro- minent features of diseases as they have arisen and affected the human system, and point out a general outline of the method that proved most successful in the cure. Permit me to claim much indulgence for selecting this sub- ject, which is approached with diffidence ; for, independent of the want of qualification to do justice in so extensive and important a field of inquiry, the nature of it is such, that, to give it something near a fair and full consideration, will trespass more upon your time than the Society probably had expected, and more than I could have wished. But when it is recol- lected, that it is an investigation of health and disease—that the theme before us is a consi- deration of the preservation of life, or its ter- mination in death,—it is trusted this respected audience will yield indulgence patiently to hear us through. I proceed now to observe, that in 1809, when I commenced the practice of medicine in this county, I found it very subject to fevers 13 of the intermittent and remittent type, and in the autumn assuming symptoms of high bilious Fevers of grades of disease. I learned that the district of country in the town of Clinton (now Hyde- Park), along the east bank of Hudson River, and also along Crum Elbow Creek, which emp- ties itself into the river at Hyde-Park, had for several years been very subject to those types of disease; so much so, that the creek fever and the Hyde-Park fever had become pro- verbial in this part of the county. The same types of disease spread more or less through the county, particularly along the banks of Wappinger's Creek, which traverses this coun- ty nearly from north-east to south-west, espe- cially near the alluvial lands as you approach its source in the town of Stanford and North East (since Pine Plains), where the disease obtained various local and popular names; still it was all remittent bilious fever, and go- verned by the same general laws. The vernal season opened with intermittent fevers of a mild character, and occasional remittents. As the season advanced, and the weather became warm, the intermittents became more severe and obstinate, and the remittents increased in proportion to number as well as in severity. To- ward autumn and in the fall, real bilious remit- tents became very prevalent. These frequently were attended with symptoms of great seve- rity : many of the cases were ushered in with 14 rigors, restlessness, nausea, and sometimes vo- miting; violent pain in the head, back, and limbs, generally; and in many cases during autumn, such was the severity of the pains, that the suffering patient, in describing his case, would give vent to his feelings by a flood of tears. In a number of cases, a great simi- larity was discovered to that disease noticed by Dr. Rush, called the break-bone fever, which appeared in and about Philadelphia, as connected with or influenced by the yellow fever of 1780. The skin, tongue, and eyes, often showed a yellow bilious tinge in the incipient stage, and never failed to exhibit these symptoms during the progress: the skin often became of an orange yellow. In the progress of the disease, where the remedies had not been well direct- symptoms. e(j \n the early stage, the tongue became co- vered with a dry brown or black scurf; the skin dry and husky, attended in some cases with delirium, though this was not a very com- mon symptom: cases sometimes ran into a pro- tracted state, and continued twelve or thirteen days, and then terminated favourably. But the more general character of the disease, when the patient had early and proper attend- ance, was to intermit on the fifth, seventh, or ninth day, and form a salutary crisis. The dis- ease sometimes fell with its principal force on the bowels, producing a dysenteric affection. 15 This was the constitutional character of the diseases during the summer and fall of 1809, 1810, and 1811, though there was less sickness in 1811 than in the preceding years, and those cases were of a milder grade. The remainder of those years were generally healthy, al- though there were more or less cases of phleg- masial disease, as catarrh, pneumonia, enteritis, croup, &c. This period of 1811 was also at- tended with a peculiarly obstinate cutaneous eruption, which frequently extended into blotches and sores; from what circumstance I know not, but it obtained the popular name of merino itch. This eruption often resisted the obstinate eruption. usual remedies for common cutaneous affec- tion. To effect a cure, it was often necessary to have recourse to active mercurials exter- nally, and alteratives internally. May not this disease have been a precursor of one of more violence that followed it—the winter epi- demic ? (1) The method which proved most successful in the cure of those fevers, was—in the inter- mittents, effectually to cleanse the alimentary canal; and in the intermission, to administer bark (cinchona) bitters, wine, &c.; and during the febrile stage, diluents and sudorifics. The patient was sometimes much benefited, by an- ticipating the fit, by an anodyne, or an anodyne combined with sudorifics. It was sometimes J6 necessary to vary the mode, by anticipating the fit, with blisters, or substituting mineral preparations instead of, or combined with the bark. From the difficulty of getting children to Fowiers take bark, Fowler's arsenic solution appeared solution fTinuthe well adapted to their cases, and it was used with advantage: but it was observed that in adults, as well as in children, this remedy had a much better effect in the vernal than in the autumnal cases. This may probably be ac- counted for, from the vernal cases partaking more of the phlegmasial character; whereas in the autumnal, the system was more satu- rated with bile, and acted upon by its effects: and to effect a cure, evacuations from the sto- mach and bowels were among the most effec- tual remedies. In a number of cases which proved obstinate, and did not yield to ordinary medicines, there Biood let- sometimes was a preternatural tension and ful- tinginobsti- , mktentsn,er" ness in *ne system. In such cases, a cure was effected by suspending the use of the bark and tonics, and making use of blood-letting, with blisters to the wrists and ankles, as recom- mended by Dr. Rush; after which, tonic? effected a cure. In treating the remittent type of the disease. evacuating the stomach and bowels, and the usual sudorific course was pursued, with u 17 frequent repetition of cathartics. When an in- termission supervened, tonics were adminis- tered; and as the fever subsided, the strength was supported and kept up by nourishment and invigorating remedies. The vernal and sum- mer cases pretty readily yielded to this disci- pline. But at the approach of autumn, when the disease assumed more of a bilious charac- ter—when the system was operated on by fever, attended with high grade of bilious affec- tion—when it was decidedly the autumnal bi- lious remittent fever,—something more than refrigerants, diluents, sudorifics, &c. appeared necessary to overcome the febrile excitement. From taking a view of the symptoms, evacua- tions seemed most strongly indicated to pro- duce that effect, and they were the remedies mostly relied on. The method of evacuating selected, was generally from the bowels. This practice was founded on such authority as Dr. Rush, who used cathartics as a leading remedy in curing bilious fevers. Townsend, in his Guide, repeatedly recommends cathartics as the most useful remedy in fevers of this type, and in other diseases. Dr. Hosack and Dr. Miller, in their Lectures, strongly recommend alvine evacuations in fevers of this type. But the usefulness of purgatives in fevers, as well as in many other diseases, is more fully pointed out, and their effects detailed, by Dr. Hamilton, c 18 in his Treatise on Purgative Medicine, whose method was more particularly followed. When there was actual puking in the commencement Remittent of the disease, an emetic was administered: nf 1810- c , Treatment. vvnere this was not the case, a course ot cathar- tics was commenced, or those followed the emetic when that was given. They were given in small divided doses, so as to administer about a quarter of an ordinary dose at a time, and that repeated every three or four hours, till six, eight, or ten evacuations were pro- duced. This generally pretty well evacuated the bile and crudities of the intestinal canal j relieved the depression, and much of the pain and fever; and was generally followed by easy perspiration. Gentle sudorifics were then in- troduced, with diluents; and where there was much pain, as was frequently the case, opiates were given in sufficient quantity to allay that. As a diluent, simple cold water (2) was always most palatable to the patient, and perhaps as salutary as any. Cathartics were again repeat- ed, either alone, or combined with sudorifics, so as to procure six or eight stools as often as every alternate day. Much might be said on the immediate salutary effect of those remedies on the system: but as there will be occasion to notice them more at large in the account of the winter epidemics, we pass on to observe, that when an intermission in the fever occur- 19 red, nourishment, bitters, bark, wine, &c. were exhibited, according to circumstances. The articles of medicine generally used for cathar- tics, were sulphate of potash, rhubarb, jalap, and calomel, differently combined, or all well ground together: the quantities of each admi- nistered could exactly be determined, having always practised accurately weighing all ac- tive medicine. It was stated that the disease formed a crisis on the fifth, seventh, or ninth day. It may, however, be remarked, that an intermission was frequently had on the third day: but the greater number of critical days were the fifth and seventh. Sometimes the disease assumed an irregular intermittent or remittent type, and became somewhat protracted; but generally the patient convalesced pretty readily after the crisis. Of the cases treated in this way, there was seldom a black scurfed tongue or much delirium, or those symptoms supervening that would warrant our calling it a typhoid case. From some memoranda which were kept of the disease, it seems there were more than one hundred cases, of the remittent type of fever, came under my prescription in 1810. There was but one case that assumed symp- toms strictly of a typhoid state of disease. This patient had a turn of the fever on the thir- teenth day, and recovered. This was the most 20 protracted and most typhoid case that occur red during those three years. As an external application, blisters were used with apparent good effect. We have remarked, that the fever was more mild in the autumn of 1811, than it had been during the preceding years. It exerted less force in its action, and the cases were less nu- Termina merous. The disease declined early in the tion of re- « SeTnisn. foR'- it seemed to have spent its force, and finally suspended its operation on the human system, not only for this year, but nearly so for every year since; so that it may be considered that here terminated the train of summer and autumnal bilious disease; and our county has been subject to very little of that character of disorder since. In the latter part of 1811 and the commence- ment of 1812, an unusual degree of health ex- isted. We had no fevers of any particular description, and few other diseases, until about February. Cases of disease began to occur, somewhat novel in their appearance and pro- gress, which operated with unusual force on the human system, and in many cases termi- nated fatally and unexpectedly. It was no less winter ePi- than the commencement of a disease, that called forth an exertion of the medical faculty; that excited much anxiety and solicitude in the community; and called upon its members fre- 21 quently to witness its melancholy effects, and frequently to draw forth their sympathies or mingle their tears with bereaved friends or re- latives, from bereavements of those who had fallen victims to the winter epidemic. (3) In describing the epidemic now commenced, it will be necessary to take into view the symp- toms as they more generally occurred, as there was no particular set of symptoms that cha- racterised each case, and perhaps no one that was present in every case. The general cha- racter of the disease was a pneumonic affec- tion, combined with a fever of a remittent and bilious type; or a remittent and bilious type of fever, without pneumonic symptoms. Some- times one type of disease predominated, some- times the other; at other times they were very equally combined. Whether the bilious symptoms were owing to a redundant secretion of bile, or a diminish- ed quantity of that fluid; or whether the quan- tity or quality of the bile was a cause of the bilious symptoms, or the state and secretion of it a consequence of disease, although worthy of notice, is not a subject for present investi- gation. The case was generally ushered in with agues, or chills, which frequently continued an unusual period. (4) Generally, the longer time they continued, the more obstinate was the O') case. Sometimes there was a sudden prostra- tion of strength, and great want of action of symptoms, the skin. Frequently at the commencement, the patient was affected with violent pain in the chest, difficulty of breathing, pain in the head, back, and some one or all the limbs, and nausea, and puking of bilious matter. Some- times they were attacked with the usual symp- toms of autumnal bilious fever, attended with a yellowness of the skin, yellow eyes, a yellow- ish tinge on the tongue, &c. Sometimes the patient was attacked with dysenteric affection, together with pain, and some of the other symptoms noticed. Appearances showing an accumulation of bile in the system, or an error loci of it, was an almost uniform symptom in some stage of the case; though some of the pneumonic cases differed very little from a common peripneumonia. When the chest was affected, at times the pain was very acute; at others, they complained of very little acute pain, but rather of a stricture and heaviness, and obstruction to respiration, from apparent inability to dilate the chest. The tongue, at the beginning, generally exhibited a white scurf, or that tinged in the middle with yellow : the edges were generally of a lively red; though in some cases it retained its natural appearance. 23 At the attack, when the chest was affected, there was some cough, more or less expecto- ration, and that frequently tinged or mixed with blood. When the chest was not affected, there was no cough or expectoration, and perhaps all the other train of symptoms. The patient often showed great apparent debility, and sometimes a disposition to syncope, or even fainting. The heat of the skin frequently was not increased, and sometimes diminished. The pulse in many cases was very little altered: sometimes it was in a morbid, healthy state; in general it was considerably varied. It may be arranged under six different heads: 1. A state of the 0 pulse. slow pulse. 2. An intermitting pulse. 3. A de- pressed pulse. 4. A frequent pulse, without much tension, feeling like an elastic tube, par- tially filled with fluid. (5) 5. A hobbling pulse; and, 6. A tense, full pulse. The fourth variety was the most common. Although the bowels were sometimes loose, and operated on in a dysenteric manner, they were generally cos- tive, and frequently required active and re* peated purgative medicine to move them. The patient was apt to be restless: there was a good deal of disposition to pain in the head; false perception, and delirium or stupor: sickness at the stomach, and puking, were very trou- blesome symptoms in the cure. u I did not perceive that any class was particu- larly subject to it, or exempt from it, but those of intemperate habits; and with those, like all acute diseases, it was most apt to prove fatal. Typhoid There was a disposition in the disease to disposition. *■ assume a malignant or typhoid type, particu- larly where evacuations were not early used. This, I am informed, was also the case in seve- ral instances in the city of New-York, where the disorder appeared sporadic. The system often laboured under great depression; the pulse almost uniformly rose, and became more natural or full after early evacuations. This description applies principally to the incipient stage of the disease. The symptoms which succeeded in the progress, were much influenced by the method of treatment. In some of the violent cases the powers of life were suspended, somewhat similar to as- phyxia, or a deprivation of a supply of oxy- gene to the lungs, by the inhalation of carbonic gas. Dissections after death, showed the lungs, and the blood-vessels of the lungs, and the heart, to be distended, and engorged with blood, and in such a situation as to be unable to admit the air into the bronchial cells; and of course the blood was deprived of its neces- sary supply of oxygene. Whether the disease put on those appear- ances in all parts of the county, I do not under- 25 take to say; but in some parts it appeared to be attended with more fatality than others. The nature of my business happened to be such, that I saw cases of it in several towns; in all of which there appeared no material difference. The Rev. L. Birch of Stanford, The Rev. L. Birch's who devoted the most of his time, in his pious stateme,t and sacerdotal office, among the sick, the dy- ing and the dead, kept an accurate list of the number of deaths that occurred in that town of the epidemic of 1812, and politely furnished the result, which is as follows :—January, 4; February, 4; March, 18; April, 24; May, 11; June, 2 : total, 63. The town contains about 50 square miles, and 2350 inhabitants. He observed that the lungs in many cases were , affected, and in many they were not diseased. A yellowness of the skin and eyes was very common: many raised blood, or bloody mat- ter. He did not observe any spots on the skin. From the best observations he could make, he thought that out of the whole number that sick- ened, one-third died. He visited in the dis- ease, a good deal in the adjacent towns, where it exhibited about the same character, and was attended with the same result. A physi- cian of extensive business in that part of the county, gave me a very similar account of the disease, except he thought, in about one half n 20 A all that were actively seized, the case ter- minated fatally. The great business of a practitioner of me- dicine, at the appearance of numerous and vi- olent cases of disease, which he is called upon to alleviate, or conduct the suffering patient through, is to investigate the nature of it, to refer it to some general laws of morbid excite- ment, to observe the manner in which it pro- duces its effects on the system, and to adopt some rational, and if possible, a successful me- Accounts of thod of cure. Some time previous to the ap- ihe Eastern •* * lisease pearance of this disease among us, we had had numerous and various accounts of a complaint that had prevailed in several parts of the East- ern States with a good deal of violence and mortality. Those accounts of the disease in the East, together with the method of treating it, were frequently contradictory, as they were brought to us by common intercourse and ver- bal communication, by newspaper intelligence, and by some professed medical publications. The opinion respecting the nature of the dis- ease to the Eastward, which was more gene- rally held in this county, which was the most popular and generally received, was, that it was a spotted (6) fever from debility, or that it was a disease of a direct typhoid character, and that all evacuating remedies were injuri- ous in the cure of it. 27 Prepossessed as we were in this doctrine, we were ready to believe that we had the same disease, which so much had been heard of, as that which had prevailed to the Eastward; therefore the same remedies were thought to be the only proper ones in the cure. Whether there was a similarity or dissimilarity in the two diseases, is not a subject for present in- quiry. Perhaps it ought to be remarked, when the disease first appeared, that with others I did passively receive the doctrine that we had an epidemic of a direct typhoid character; and this was so much in accordance with po- pular opinion, that it required very considera- ble firmness to resist the current that set in from every direction against every species of depletion : hence nurses, old women, and un- informed individuals soon appeared with hem- locks, essences, cordials, and a vast host of heating sudorifics, the use of which was com- menced with the commencement of the case, ready to lop off* the heads of the hydra epi- demic. (7) To show on what grounds the treatment which proved most successful was founded, and by which it was confirmed, I beg leave to introduce the opinions of some of the most eminent authorities in our profession. Per- haps there is no epidemic, or other general disease which attacks the human frame at the 28 present day, which is not nearly allied to, or corresponds with, some disease which has pre- ceded it. Having adopted the alexipharmic (heating, sweating means, to drive the disease out through the skin) method in treating a few of the first cases, the result was unsatisfactory; when inclination and duty urged to an investi- gation of the nature of it, as it was exhibited, and to endeavour to ascertain what disease it might be associated with, and adopt a course of treatment accordingly. Authon- It appeared that epidemics were treated of ties. 1Ci by Sydenham, under three general heads. First, stationary fevers, or those produced by a peculiar constitution of the air: they exist for a certain time as the standing disease, pre- side over all others, or all others are affected by them. Of this kind may be enumerated plague, yellow fever, bilious autumnal fever, &c. The second he calls stationary intercur- rent fevers, or those that take place more or less in every year, and at particular seasons of the year; such as pleurisies, peripneumonies, quinsies, &c. Under the third head, he ar- ranges symptomatic intermittents, by which he means those diseases that partake of the sta- tionary and intermittent diseases combined. When it was taken into consideration that the intermittent, remittent, and bilious fevers had prevailed in the summer seasons for several 29 years; when also it was recollected, that the diseases which generally are met with in the winter and vernal seasons, were those of the phlegmasia! (inflammatory) type, or the sta- tionary intercurrents of Sydenham; it was pretty readily perceived that the epidemic partook of both of those sets of diseases, and was to be referred to the last groupe, or that of symptomatic intercurrent fevers, exhibiting mingled symptoms of peri pneumonic or phleg- masia!, and remittent or bilious morbid excite- ment. Therefore we met with cases putting on nearly the character of usual phlegmasial fe- ver; and we saw it receding from that, through the varied grades of excitement, to the typhoid state of disease. It may now readily appear why the diseases were called and described by the different names of peripneumonia, pe- ripneumonia notha, peripneumonia typhoides, bilious pleurisy, bilious fever, typhus fever, spotted fever, and many others, either of whicli was probably more correct than the delusive ones of typhus fever, or spotted fever. (8) Among other sources of information on the subject of the Eastern fever, we had Dr. Dr. North North's book, in which that disease is describ- ed with much accuracy and candour, and the treatment detailed, of a liberal, high, musti- lating nature, which, however, proved very 30 »r. Mott. unsuccessful with us. Dr. Mott is of opinion that ours was a different disease as he saw it Dr. Mann, on Long-Island. Dr. Mann, Hospital Surgeon during the late war, who perhaps saw his full share of the Eastern disease, being an Eastern man, and no doubt, as Hospital Surgeon during the war, saw more than most others of the dis- ease under consideration, as it spread along the Northern frontier, extending from Green- bush to Burlington, and from Plattsburgh to Niagara, thinks they are diseases of different grades of action. (See Med. Repository, also Dr. Mann's book.) Mixed dis- Mixed diseases, with similar symptoms, it appeared had often been described, and some of the leading remedies pointed out. Syden- ham describes a peripneumonic affection com- bined with a preceding fever, which occurred in England in 1675: the symptoms in many respects agreed with those of ours. He ob- serves, " it always began with pain in the head, back, and limbs." With respect to the cure, he proceeds—" The symptoms were best relieved by moderate bleeding, applying blis- ters, giving clysters every day," &c. Dr. Rush compares with this, bilious pleurisy of the United States. uiiious in- This author also describes a disease which n. the immortal Dr. Cullen, leads to place much reliance on sweating as a remedy to overcome the atony and spasm of the superficial and cutaneous vessels, he has important caution- ary observations, that " sweating has been ge- nerally hurtful, when excited by stimulating, heating, and inflammatory medicines; that it has been hurtful when excited by much exter- nal heat; that it has been hurtful when it does not soon relieve, but rather increases the fre- quency and hardness of the pulse, the anxiety and difficulty of breathing, the head-ache, and delirium; that it is always hurtful if it be urged, when it is not fluid and when it is partial." I inferred the disease to require evacuations, from observing that the pulse did not readily 38 raise by the use of alexipharmic remedies; that the skin remained obstinately dry under their use; and that the delirium and stupor were apt to be increased by omitting evacua- tions. I also inferred it to require evacuations, from observing it nearly allied in many cases to the bilious remittent fever which had pre* ceded it, and from those diseases being pro- tracted, and rendered obstinate, if not fatal, by omitting them; in which respect the epi- demic under consideration agreed. I inferred those remedies to be indicated, by observing spontaneous hemorrhages being attended with salutary effects. It often hap- pened, that a favourable crisis was formed immediately after a considerable discharge of blood. I will select one instance. A young woman in the family of William Bard, Esq., who had a severe pneumonic case, had bleed- ing from the nose nearly all night on the sixth day of the disease: a crisis was formed the next day, and she recovered. From what had been learnt respecting epidemics, I perceived it was the general opinion, that when they prevailed, all diseases partook of their charac- ter, or u were compelled to wear their livery:" ind when the disease first appeared, accord- ing to popular report, 1 was expecting to find all diseases exhibit a typhoid character. This position soon proved incorrect, that all di^- 39 eases were typhoid. On the contrary, it ap- peared that we had a disease of an inflamma- matory type, either uncombincd or mixed with that said to be of a different character; for, soon after its appearance, I was called upon in the night to visit Dr. S. Bard. On entering Dr Ba,r v ~ o case ot his chamber, I found him labouring under a croup violent attack of disease, attended with difficul- ty of breathing, restlessness, barking hoarse- ness, and symptoms of croup. The prevailing disease had been described as violently seiz- ing local parts at first, before it produced its general, or prostrating effects on the system. I hesitated as to the remedies. The first im- pressions were, that it might be a case of epi- demic, disguised in this form of disease, and that bleeding might prove fatal. There had been many fatal cases of it in the county; and if the disease was what popular opinion repre- sented it, that remedy might prove fatal here. Bleeding, however, was thought advisable; and the symptoms were such, that in about ten hours it was repeated, by which, with other remedies, he recovered. It was inferred that evacuations would be proper, by observing difficulty of respiration, pain in the chest, and suppressed cough and Distress iU expectoration in the latter stage of the disease, «»deatl< and until death (11); and from noticing a white scurf on the tongue, with a lively red- 10 ness of its edges, in the early periods of the case, which Dr. Rush says is an invariable sign of an inflammatory diathesis. A similar fact is taught by Dr. Hosack, in his Lectures. It was inferred that evacuations would be proper, by noticing a suffocated state of the lungs and ghastly appearance of the counte- nance, and sudden loss of the animal functions, which, in the commencement of disease, I could not perceive could be produced by debility from abstraction, but might be by de- bility from action. I inferred the use of evacuations by the lan- cet to be indicated, by observing the small and irregular states of the pulse ; in which Dr. Rush recommends its use in the com- mencement of disease. The blood was usually of a dark appear- ance, showing signs of not being properly oxy- dated; and at the first, bleeding did not always show the sizy coat, when it afterwards did. It often had the colour and consistence of mo- lasses. Blood of those appearances, is placed in a scale of inflammatory action or depression^ above that which has a buffy coat. With this view of the subject, we now come to the method of treatment which has, in some measure, been anticipated. The use of the lancet (12) was commenced cautiously, parti- cularly it was used in those cases where there 41 was a pneumonic attack. After bleeding, an Treatm*.. emetic was given, which was followed by a course of cathartic medicines, according to cir- cumstances, so as to produce repeated and thorough alvine evacuations; or, as sometimes was the case, an emetico-cathartic of calomel and tartarised antimony was exhibited. The emetic seldom failed to discharge quantities of bile, which was frequently very viscid and glairy. In some cases friction, with moderate warmth, was applied to the skin. Sudorifics and expectorants, with a pretty liberal quantity of calomel, were given in the progress. The calo- mel was generally given so as to operate on the bowels, connected with an extensive use of blisters; and as the disease yielded or shaped, those were followed by nourishment, cordials, tonics, stimulants, &c. In many of the cases, it was of service to begin with the latter re- medies pretty early after the evacuations; and at this or the latter stage, it was frequently necessary to use stimulants freely in the pro- gress. The case sometimes assumed that situ- ation in which Dr. Currie advises the external use of cold water; when it was used in affusion and ablution with great advantage. After hav- ing lost five patients in 1812, my gratification may be conceived on the recovery of the first First case » of ep: lemii patient, Mr. I. Vandusen,(l3) by the use of ™£M those remedies. He had a very violent attack p 42 of pneumonic bilious disease. His skin was yellow, and his tongue covered with a brown scurf. Within twenty-four hours from the at- tack, he was bled twice, 12 ounces each time. The emetics given brought off large quantities of bilious matter: after which the skin became softer and moister, and the pulse more regular. In the operation of the cathartics, there was generally a copious discharge of bilious, feculent matter. After the bleeding, the pulse commonly became more full and fair, which was particularly the case after the other eva- cuations; and then the patient was pretty readily got into an easy moisture, by diluting drinks and gentle sudorifics. The case occasionally so far partook of the phlegmasial type, as to require a repetition of the bleeding, and that sometimes on the sixth or seventh day, particularly in the latter part of the spring. In 1812, R. Nelson, Esq., now Editor of the Indiana Herald, who was very much prostrated in the attack, was bled at first: after which, the symptoms were such as to require two more bleedings to remove the disease. The system appeared to be relieved, and re-acted much better in many cases by Kg* l^ing a small quantity of blood at first, and me3some' repeating it. This was in imitation of the slow manner in which nature discharged the blood in those cases of spontaneous hemorrhage. 43 There was much benefit derived in many cases, by occasionally repeating the emetic or the purgative medicines. As there was a great determination to the brain, (14) blisters to the neck and between the shoulders were of much advantage: they Were also of much benefit to other parts, where local pain and affection existed, or to translate excitement. The dis- ease frequently had a disposition to assume a suffocated or typhoid character, particularly where early evacuations had not been made; so that it was important to watch its progress, importance r r o ' ofdetermin- and obviate those symptoms by a timely use j"r com-1116 of tonics and stimulants. There were, how- mutants. ever, probably many unfavourable consequen- ces, from anticipating the approach or acces- sion of the typhoid state before it had arrived. Many facts might be adduced corroborating this remark. In that type of the disease in which the Remittent J r type. lungs were not affected, blood-letting gene- rally appeared unnecessary. The first remedy, therefore, was an emetic, or a course of cathar- tics. The purgative medicine was given so as to produce a number of copious evacuations: these were followed, intervened, or combined with diluents and sudorifics, and externally blisters, or some other application to parts locally affected. I was often agreeably disap- pointed, on making a second or third visit, to 44 find the patient, particularly children, who had been considered dangerously ill, sitting up, or in a playful, or comfortable, or convalescent state, after the operation of the evacuating medicines. In this type of the disease, the re- medies varied very little from those which had been successfully used in the bilious remittent fever of the preceding years; except an earlier and more liberal use of wine appeared ser- viceable. It appeared that by many practitioners much reliance was placed on calomel as a remedy; and very deservedly so, in the pneumonic type of the disease, when the case did not yield to the early use of the evacuating remedies. But in the bilious type only, it was seldom neces- MercurM- sary, except as an evacuant: for in the maio- jzing not J 7 * ' J requ.red. T^ Qf tne caseg9 tne patient would begin to convalesce sooner than the system could be placed under a mercurial action. A very important period, which in the coun- try we often lost the advantage of, was to see the patient early after the attack, and early to make use of vigorous remedies; for such was the rapidity of the progress of the disease, that the vital functions were soon impaired or de- stroyed, where they were not early relieved from the morbid action; for, like all acute or inflammatory diseases, the more violent the attack, the sooner it changed its type, and 45 assumed a malignant character when left to itself, or aggravated by remedies. For most diseases with which our systems are subject to be affected, there are popular, and frequently unfounded, remedies in the hands of almost all sorts of prescribers: there are Quack re * medies. also in the same hands, remedies and prescrip- tions as preventives of those diseases. The truth of this remark was strongly exemplified respecting this disease; and in this, as in most cases, they hit upon one of the most pernicious tendency. The most general and popular pre- ventives were heating, stimulant, and spirit- uous potations. Perhaps there is no remedy preventive *■ , remedies more universally resorted to by patients, and urged on them by their friends, at the ap- proach of indisposition of any kind, than that of heating sweats and stimulants ; and perhaps there is none that is more universally injurious in the forming stage, or early periods of all diseases of our climate. Hence those who are the nearest relatives and best friends, by their officiousness and ill-timed prescriptions, in a majority of cases, become the patient's worst enemy. (15) Whatever might have been the cause, there appeared to be a torpor on the vital and nervous system; and evacuations from the stomach and bowels were more particularly- indicated where blood-letting was adopted. 16 Evacua- Perhaps blood-letting, without being followed is from roc ess°aryls by those evacuations, might in some instances have been attended with unfavourable effects. By emptying the blood-vessels, and leaving the bile and colluvies in the alimentary canal, their effects on the system probably became increased, and produced a greater degree of torpor and malignant tendency than though no evacuation from the blood-vessels had been made. The depressed, overloaded state of the system in many cases was such, that by using blood-letting largely at once, no doubt would have been injurious; or to have used it with- out following it by free evacuations from the stomach and bowels, re-action would not rea- dily have taken place, and then bad effects might have ensued. It required the steady, persevering use of all those remedies to secure a successful result. By relying on sweating and heating remedies in this state, increased the depression, and carried down the pulse instead of raising it. The whole number of cases which came under my care in 1812, cannot exactly be de- termined, having kept only some general notes. They were, however, more in number than in the succeeding year: the number of deaths were ten, five of which were among the first cases. The disease subsided in June, and there was little or no general febrile excite- 47 ment in the human system during the remain- der of the year. The year 1813 commenced with the train of epidemic excitement in about the same form that we had witnessed in the preceding year. With a view of determining the number of cases, the manner of attack, the result of the treatment, &c., for my private satisfaction I kept a register of the cases of epidemic disease for 1813. It commenced with the commence- ment of the disease, and daily entries were made as the cases occurred. By this register Number of J ° cases. it appears that one hundred and twelve cases came under my care, exclusive of those which I had an opportunity of seeing, which were attended by other physicians. Of this number, sixty-three were bled, five were bled twice, and one was bled three times. Sixty-one of those were pneumonic cases; of course there were fifty-one in which the lungs were not dis- eased. Out of the whole number there were seven deaths. Respecting those who died, some remarks are proper. Four of them were of intemperate habits: one had been in the habit of drinking from a pint to a quart of spi- rits a day; so said his friends: the disease seized him like a whirlwind, and soon carried him off! The other three intemperates having recently come into the place, had their pre- judices about them, and obstinately refused 48 being bled, though their situation urgently re- quired it. One of them died in a state of furi- ous delirium, with full symptoms of depression and turgescence of the system. One of the others took few or none of the medicines di- rected, and got little or no nursing. If those four that literally destroyed themselves are deducted, one hundred and eight cases remain, out of which there were three deaths—equal to one in thirty-six. The disease again disappeared in 1813 on the approach of warm weather. A very healthy summer and autumn ensued. The train of the remittent bilious autumnal fever has been nearly extinct since the appearance of the winter epidemic. The summers and autumns in general have been healthy: the winter and vernal seasons have produced some cases of disease, in addition to the ordinary diseases of the season, which assumed more or less the character of the epidemic, which may be con- sidered sporadic cases of that disease. Diseaaeor In the autumn of 1814, our citizens were affected, and in some instances fatally so, in consequence of a febrile disease, which ap- peared to have its origin with the militia who were doing camp duty at Harlem and Brook- lyn, in the vicinity of the city of New-York. From this circumstance the disease received the appellation of the Harlem or Brooklyn 49 fever. There might have been some propriety for it as a common or popular name. Owing to a pretty large detachment of the militia of this county being sent there on military duty, a number sickened there, and some died; some sickened, and came home on parole, and others sickened after their return: so that the first cases were among the militia soldiery, who had been serving their country in a mili- tary tour. By the influence of fell disease, they were compelled to retrograde from the bustle of war to recline upon a couch of sickness; and in some instances, to part with that vital spark which, no doubt, their valour and patri- otism would have induced them more wil- lingly to have relinquished on the field of conflict, in defence of their country and the principles of liberty. The disease, however, was not confined to this class of people; it occasionally attacked others, though the principal part of the cases were among those of the family or attendants of those who had been in the army. The symptoms attending the disease, were symptoms. rigors, pain in the head, back, and limbs; the stomach was more or less disordered; the eyes were red, or blood-shot, tongue slightly furred; pulse sometimes full and firm, and at others small or yielding. In tracing the cause and nature of this disease, reference might be G 50 had to the place of its origin. It is an old ob- servation, that when troops are collected toge- ther, and new armies raised, particularly when they are composed of militia, there are a vari- ety of causes which operate to generate febrile disease. The general change in the mode of life and in the habits of the individual, are among those which operate powerfully to pre- dispose the system to morbid excitement. Dr. Mitchill no doubt had this in view, when, in his report to the commander-in-chief in 1818, he observes,—" In case the militia should be called into actual service, many inconvenien- ces arise from the sudden change of life. Men must be seasoned by degrees to the fare of a garrison, the camp, and the field ; fresh habits must be formed ; the powers of the body must bend to martial impulse. The habits of a mili- tary life are at length formed; and habit, as has been observed of old, is a second nature. But in moulding the frame of man by those modifying causes, it often suffers severely while it bends, and the old habit gives way. In some individuals this is so rigid and unyielding, that it breaks before it bends. To preserve its pliancy and elasticity, and to prevent the cracking and snapping of its fibres, are of the utmost importance." To smooth the way from the citizen to the soldier—to avoid generating a predisposition in the body to disease—to 51 palliate the rigours of a camp life, and to pre- serve the vigour of the body of the army gene- rally,—seem to be the leading and humane views of the Surgeon General. In that early day, the great Jewish lawgiver seems to have been sensible of the importance of cleanliness and regularity in a camp, to avoid disease and pestilence, by his so strongly enjoining it in his system of laws delivered to the Israelites in the wilderness. The disease did not differ in any essential degree from those ordinarily produced under similar circumstances, where the body is pre- disposed to disease, not only by those causes enumerated, but by the action of miasma, ge- nerated by animal and vegetable substances in a state of decomposition. The complaint was a fever of a remittent character, some- times alternating with or combined with dysen- teric affection, and attended with much heat, action, and fulness. The remedies most serviceable in this dis- Remedies? ease were blood-letting: after that, or when it was not used, or when it was not thought to be indicated, the other remedies were vomits, followed by cathartics; and after repeated alvine evacuations, sudorifics, with occasional laxatives, were used; and in the progress, nourishment, tonics, wine, &c. In observations on the diseases of the army during the revolu- 52 tionary war, Dr. Rush says, t; an emetic seldom failed of checking the fever, if exhibited while it was in a forming stage, and before the pa- tient was confined to his bed." I have reason to believe that several cases were cut short in the same way, or rendered mild by early evacuations. Diseases have been losing their complex character of 1812 and 1813. The winter dis- eases have gradually lost the bilious type, and appeared more in the simple form of phlegma- sial excitement; and the bilious or remitting character has been reserved, and is again ap- pearing in the more usual autumnal season. While this change has been taking place dur- ing two or three years past, there has bben a disease peculiar to each season, though none very extensively prevailing, and no particular epidemic. Disease ot About the beginning of the year 1819, al- though not very sickly, there were produced a variety of disease and grades of morbid excite- Discases of ment. There appeared a complaint of the the throat r r r throat and fauces: many cases were mild, others were severe; and some of them proved tedious, and in some instances very obstinate. The patient was attacked with some febrile affection; a general soreness of the throat and difficulty of swallowing, which was in some cases followed by a swelling of the pharynx 53 or tongue, or a thickening of the membrane lining the upper part of the oesophagus. Some patients fancied that a preternatural substance was growing in the oesophagus. In a number of cases the swelling became large externally, and in some instances suppurated. After the first, or febrile stage was over, a debility and relaxation of the parts about the pharynx (throat) and the ligaments of the voice took place, producing a hoarseness and difficulty of speech. This disease required an antiphlogistic treatment in the incipient stage; that followed by stimulant applications to the throat and adjacent parts. Those cases which became tumified externally, were benefited or cured by continued blistering. Mingled with this complaint, and immedi- ately following it, we had cases of pneumonia, influenza, rheumatism, &c.; in all which, as well as in all febrile diseases of the forepart of the year, there has been a peculiar disposition to affection of the head, with pain, stupor, Di! and sometimes delirium. Those cases of ca- tarrhal pneumonia and affection of the head, with fulness, stupor, and some delirium, came near proving fatal in several cases: they were cured by large bleedings, and other active evacuations. 54 During the winter and spring seasons of this year, among other types and characters of dis- ease, there appeared one which we have been very little accustomed to in this county within the period under consideration: it was the reCvaerret cynancha? maligna, or scarlet fever. In the vicinity of Hyde-Park there were a number of severe cases, and some of milder attack. Early in the case, the throat became sore, and exhi- bited a fiery redness, which was followed by an eruption on the fauces (throat), and that by an aphthous scurf and ulceration of the part. In the progress, the skin exhibited a cadave- rous appearance. When the throat was not much affected, the scarlatinas flush or eruption appeared more on the skin. The best reme- dies for it, were an emetic in the early stage, or gentle cathartics, and those followed by cordial sudorifics: in some cases, a liberal use of tonics and wine became proper, as the dis- ease advanced. I do not know of any death occurring with this disease in the county, and have not learnt that it prevailed in many dis- tricts of the county. One of our distinguished citizens, the Hon. James Tallmadge, may long have occasion with parental affection to lament the fatal effects of transferring an only son into an atmosphere predisposed to generate and produce this disease in Connecticut, where it prevailed to a considerable extent. 55 Nearly for the first time since the appear- J"*g""^_ ance of the winter epidemic, a few mild cases turDed of intermittent fever have appeared. As the warm season advanced, some cases of the cho- lera morbus have been produced. Dr. Bard says, the principal remedies that he has found necessary in this disease, are laudanum and chicken-broth. As the season farther ad vane- cnoieraand dysentery. ed, the bowels became generally affected with mild diarrhoea, though in some cases, and in some parts, it put on pretty severe dysenteric symptoms. As there are so many details on the method of curing dysentery, by systematic and other writers, it may be thought presump- tive for me to say any thing on the subject. It may, however, be remarked, that the plan which seems to be attended with the best suc- cess, is that by evacuations in the early periods, succeeded by, or combined with, anodyne su- dorifics. Sydenham used emetics as a first remedy to discharge the contents of the sto- mach, which otherwise became acrid, and set- tled on the bowels, producing troublesome or incurable gripes. The surgeons of the army during the late war, bear testimony to the injurious effects of a too free use of astringents in this disease. The late Dr. E. Hunting of Ffshkill, who, Dr HU»t- during a long and successful practice, saw sentery. much of the dysentery epidemically, informed 56 me, that the method which proved almost inva- riably successful, was to give an emetic of ipecacuanha, a cathartic of rhubarb, then small doses'of ipecacuanha, rhubarb, and opium. Yeiiow fe- While the inhabitants of our metropolis, and ver of 1819. # # * the cities along the sea-board, almost from one end of the territory to the other, have been excited by fears and anxieties, and shunning the seats of pestilence, and fleeing their homes in " wild confusion," in consequence of the prevalence of malignant disease,(16) which appeared with threatening and alarming de- vastation,—our county has in general this sea- son enjoyed an unusual degree of health. The autumn brought with it some cases of remittent fever, attended more or less with bilious symp- toms, which in some instances has showed a disposition to protract its existence to a very considerable length. Whether this is owing to some peculiarity of the season or the type of the disease, or to some other cause, remains for further observation to determine. In treating the successions and catenations of morbid and epidemical excitement, and witnessing the effects which disease, in various ways, produces on the human system, in im- pairing the regular operations of the functions of the body, we are in some measure shown the numerous avenues which prove outlets to human life: at the same time is brought to 57 view the multiplicity of ills which man is heir to—which, without the balm conveyed by the medical art, would swell the long and gloomy lists of painful affection, and premature termi- nations of our existence! It will be perceived, that the practice of medicine is not a business of nostrum or spe- cific—that diseases are not to be met with, simply confined within the lines of nosological arrangement, nor cured by specific remedies for specific diseases; but that the character of the disease, the stage of the case, and the grade of excitement, ought to govern the pre- scriptions—that a faculty of discrimination in detecting and applying remedies to them, con- stitutes the most correct and most skilful phy- sician. In such reflections, the members of this Society will see the importance of their situation. Organized under the patronage of an enlightened legislature, they become the guardians of the public health, and may be enabled to overawe empiricism, and promote a rational and systematic method of managing diseases. While we bring to mind, that dur- ing the short period reviewed, many of our brethren have been attacked in such a manner as to suspend their labours, and remove them from the scene of action—that our friends and acquaintances have sometimes been caught in the rounds of morbid affection, of such a grade H 58 as to baffle our art and mock our skill; but that our healths and lives are preserved, and that the prospect before us is, that by a hum- ble and judicious exercise of the iEsculapian art, we may continue to be useful to our fellow- citizens; for which favours, "what shall we render as a thank-offering unto the Great Fa- ther and Redeemer of Men? Here utterance falters—here language fails!"---- " Come, then, expressive silence, muse His praise J" ADDRESS, DELIVERED BEFORE THE DUTCHESS JVIEDICAL SOCIETY, AT THEIR ANNUAL MEETING IN NOVEMBER 1825. ADDRESS. GENTLEMEN, When I had the honour, six years ago, of addressing you from this station, I improved that opportunity in laying before you an imper- fect review of the diseases of Dutchess for the preceding ten years. And perhaps I cannot better discharge the duty which your laws(17) have at this time imposed upon me, than by taking a brief notice of those that have pre- vailed since, with a generalized account of what appears to be the best method of treat- ment. It is again to be remarked, that it is not the diseases that are occurring every day and every year, under almost all circumstances, that will here claim our attention ; but to trace the most prominent symptoms of those of an epidemical nature, as they have arisen, and displayed their characteristic effects on the human system. After the termination of the epidemic con- stitution of our climate, which had prevailed for a number of years, and been more or less 62 connected with the late military operations, or influenced by them, there was a period of very general health. The year 1820 commenced under very fa- vourable circumstances of exemption from general disease. A very few cases of phleg- masial affections marked the winter and ver- nal period. A few intermittents and mild remittents were the principal train of diseases bny82oDtery °f tne fipst summer months. As the season advanced, the dysentery became epidemic: in some sections of the county it was attended with obstinate and alarming symptoms, and in many instances with fatality. The various ordinary derangements incident to this dis- ease of the alimentary canal took place, which was frequently attended with considerable arterial action and fever. Bloody discharges from the bowels was almost an invariable symptom. The evacuations were sometimes scanty, attended with tenesmus; but frequently they were copious, particularly after cathar- tics were used, and they frequently had the appearance of thick, bloody water. Treatment Treatment. In the early stage, particularly as the cold season approached, blood-letting in some cases was beneficial. This was best to be succeeded by emetics of ipecacuanha, or cathartics, of which calomel was a leading article, with something to aid its operation, 63 when it was very serviceable to give remedies to determine to the skin, and sheath the lining of the bowels. It was also found highly bene- ficial to give opiates occasionally, and parti- cularly as an anodyne at night, in sufficient quantity to allay the pain and irritation. These remedies were to be followed by astringents, tonics, &c. as soon as the case would bear it. In several instances, as is perhaps too apt to be the case, time was lost by beginning with astringents too early, before the vascular ex- citement had been removed in the early stage. The fatal cases w*re about in proportion of one to twenty. (18) A very successful method of treating dysen- tery, was communicated to me by Dr. Ford of Dr. Ford's South Carolina, which is used there with suc- *"»h«s among the blacks. It is by giving an infusion of ipecacuanha once in about six hours, so as to keep up a nausea, and occasion- ally vomit. Every year has produced a few sporadic cases of this disease: but since that time (viz. 1820), its occurrence has not been as frequent as during the past season. Sue- Dysentery • i i-i /• of ,825- ceeding the extreme heat, derangements of the alimentary canal became very common, exhibiting choleric and dysenteric symptoms. Among the variety of plans proposed and adopted for the cure of dysentery, a very soothing and successful one was pursued by a 64 surgeon in General Packenham's army, that was near New-Orleans in 1816. A plan some- what similar has been used by some practition- caiomeund ers in this county with success. It consists in opium plan. . .. , giving opiates, in sufficient quantity to allay the pain and irritation, and calomel, either com- bined or alternated with it, enough to open the bowels, aided by castor oil, or some laxa- tive mucilages. To adapt this practice to our climate, it will be necessary frequently to pre- Biood-iet- cede its use by blood-letting or an emetic, or , tins "i °7m J sentery. botn. The success of this course was eminently exemplified in the case of General Lewis, in a violent attack of this disease on the 12th Sep- tember last. He lost 24 ounces of blood, took opium enough to quiet the pain, and large doses of calomel, which was aided in its opera- tion by castor oil. The cure was speedy. Diseases or In | K91, nothing ueculiai marked the early part of this year. In some sections of the J county, phlegmasial diseases prevailed to a moderate degree, particularly those of a perip- neumonic type. They generally yielded to Dr. Bards antiphlogistic remedies. It was a peripneu- monic attack of this kind in May, that termi- nated the life of the first President of this So- ciety, Dr. Samuel Bard. In passing this event, a short digression, it is presumed, will be ex- cused, to cherish the memory of a patron and friend. As a physician, he had an active, 65 discriminating mind and discerning judgment, well calculated to detect the intricate and obscure operations of morbid action, and to devise means to effect their removal. By his benevolent disposition, and perseverance in laudable undertakings, he perhaps did more for the advancement and cultivation of medical science than any of his cotemporary country- men. Much is due to him for procuring the passage of the law by our Legislature, under the auspices of which we are this day assem- bled, and out of which has grown that ad- vancing respectability of the medical cha- racter which, by the irradiating influence of science, has overawed, and almost obscured empiricism. (19) Those who had an oppor- tunity of meeting him within these walls, will readily bring to mind our then flourishing situ- ation, when we were stimulated by his exam- ple, and edified by his maxims and his ad- dresses. Although for many years retired from the city and from active business, he was not withdrawn from professional usefulness or benevolent purposes. He constantly, when required, gave counsel to those around him; and among the poor, sought out cases of sick- ness and want, on which to bestow gratuitous services. His wife, who was first attacked with the same disease, was his last patient, and 66 he her last physician! He being soon attacked, was obliged to end his medical labours, and withdraw from her the day before she died— and in his turn became a patient. During hi» short illness, he displayed his usual vigour of mind and promptness of decision. He con- versed with me and with his friends, with calmness, on the nature of his disease and the approach of death. More than once he ex- pressed in substance a couplet that he had used on another occasion: " O God ! direct my erring mind to things above ; Teach me to place my bliss in faith, and hope, and love!" He dwelt on the importance of early subduing arterial action, and of preventing effusion in the lungs, which he anticipated would with him be the case. All he dreaded, he said, was the suffocating distress that that would give him. In the former opinion his anticipations were realised—in the latter they were not. Al- though effusion took place, he became calm, and died in full assurance of receiving a Chris- tian's reward for a life well spent. Every year, for several years, our county has been more or less visited with intermittent and remittent fevers, which in the autumn have assumed the bilious character. The parts most subject to these diseases, are the towns along the river, and some other sections in 67 the vicinity of ponds, creeks, and marshy exposures. The fevers of a remittent character among f8e25ertef us, generally, exhibit symptoms, in the early stage, of increased arterial action or conges- tion in the system, more or less attended with symptoms of a bilious(20) affection; though the latter are not so prominent as they have been at former periods, and those of the pre- sent year have generally been attended with more decided symptoms of fiery, increased excitement or depression. Whether, in some sections of the county, fevers do occur that partake of the typhoid diathesis at the commencement or not, appears to be a question not wholly settled. But as far as my observation has extended,—and I have taken considerable pains to investigate the subject,—I am induced to believe they are very rare. In making this remark, I am aware that in the progress and treatment, a variety of circumstances may concur to give them a pro- tracted form. Unless in the commencement arterial action is restrained, or congestion and the causes of depression removed, or the mor- bid action transferred to the alimentary canal, and the feculent matter eliminated from the system, a train of tedious, perplexing, and ty- phoid symptoms may supervene. 68 The numerous modes of curing intermittent fevers, are too well known to be detailed here. It may, however, be fairly observed, that those of this year have required more evacuations and less tonics than they did formerly.(21) In the treatment of the remittent or bilious remittent fevers, emetics are frequently indi- cated. The best plan in the progress, seems to be that of purging, somewhat on the plan of Hamilton, by calomel, aided by other laxative articles, gently and perseveringly pursued; and by sudorifics, with, occasionally, opiates, (22) large enough to quiet all pain and the com- motion raised in the system; which plan 1 formerly detailed in the treatment of the remit- tent and bilious fevers of 1810. This course, with occasional blood-letting, in the early stage of the case, can be recommended from long and successful use. By emptying the blood- vessels and evacuating the system, we not only remove the tension and disposition to in- creased arterial action, but place the disease more under the control of remedies, and often prevent the occurrence of those obstinate and difficult symptoms that otherwise may super- Typhoid vene. In those cases that assume the typhoid cases. m Treatment, character, the indications of cure appear to be best answered by frequently evacuating the stomach and bowels, particularly in the early 69 stage, and arousing them to action; then at- tempting to equalize the circulation, by pro- moting the action of the skin, and in the pro- gress to support the strength. The method by purgatives, combined with, or followed by calomel, opium, and sudorifics, appears best to answer those indications. This course is essen- tially pursued by Dr. Miner, in his treatment of the typhoid diseases of Connecticut. But the nature of typhus, or what is by Armstrong called congestive or inflammatory typhus, is by that author ably investigated, and the gene- ral use of evacuant remedies clearly detailed. In those cases when the proper period has arrived forgiving calomel, with an intention of having it enter the system, it is well to exhibit it in sufficient quantities to operate on the bowels. I believe it may be considered that mercu- Bowels to be acted on, rials soonest enter the system when they pro- j^^,a duce a laxative effect, by which the lacteal ab- actlon sorbents are aroused to action, to take them up: whereas, when the action of the bowels is not increased, the absorbents act sluggishly, and the mercurials may lie dormant in the sys- tem. It is probably on this principle, that ca- thartic remedies, by brushing the mucous cru- dities from the mouths of those absorbents, and stimulating them to action, to take up nu- 70 tritious matter, frequently become the best sti- mulants used. Hence, after the disease is broken up, instead of giving cathartics, to stop or carry off a salivation, is it not better to cease giving mercurials and omit cathartics, and let the bowels become inactive; and allay the ir- ritation of the system by opium, and the use of cold gargles ? niercurui The great perplexity in managing a mercu- treated. r[a\ sore mouth, in the old common way, con- nected with the frequent irritability of the sys- tem, and often dissatisfied looks of the patient, will, in a great measure, be obviated by this course. When the state of the system will bear it, a free exhibition of wine will prove a great auxiliary to this treatment. Whether it is that, by taking off excitement, or removing congestion, in the early stage of disease, or some other circumstance not now to be inquired into, when these remittent dis- eases have been treated upon those principles, I have not observed an occasion to prescribe for a typhoid, or a long protracted case. It may be considered an improvement in the art, that the evacuating method of treating fe- vers in the early stage, is gaining in fashion, and becoming a substitute for the tedious and protracted one of relying upon sudorifics, mer- curializing and alexipharmics. 71 With a very few exceptions, I have not, for a softorcom- J pressible number of years, until this fall, observed those \f£of cases of fever that, in the early stage, have ex- hibited the peculiar, small, soft, obscure pulse, which I have attempted to describe, as taking place in the epidemic of 1812; since which a number have occurred. The attack of disease, in some cases, is rather mild; perhaps the case is some days in forming; though in others it comes on quickly. Some complain of very little or no pain, others of considerable: the head is generally affected, producing dull heaviness, and a sleepy dulness of the eyes. Some have been attended with insidious, others with severe peripneumonic symptoms. The skin is very dry and husky; tongue not much furred, but of a fiery red appearance; bowels commonly torpid; discharges of blood from the nose have occurred in several cases. I believe attempts have been made to relieve this state of disease by relying upon alexiphar- mic, sweating means, mercurializing, &c. which will sometimes succeed, but often fail. When this plan finally succeeds, it is generally after a long, tedious, protracted illness. The patient is affected with a black tongue, a black scurf on the teeth, delirium, nervous irritation, and a train of those symptoms called typhus. 72 Those cases are beneficially treated by one or two bleedings early, and these followed by remedies that produce evacuations from the stomach and bowels, and in some cases the warm bath. Although in some instances I have bled largely, which corresponds with Arm- strong's method of treatment, yet 1 here take occasion again to remark, as is stated in the treatment of the disease of 1812 and 1813, if there are well-founded anticipations of debil- ity ensuing, the bleedings had better be small, and repeated, and those followed by a course of cathartics, which gives the vessels an op- portunity to remove the congestion, and the Appearan- system a chance to re-act. The blood in this ces of the biood. state of disease is very dark, thick, and heavy; whereas in the advanced state, when there is real typhoid action, or debility from abstrac- tion, the blood is said to be dark, but thin and light. I have not observed it to form a sizy coat, in either case. In the first, as it flows, it becomes more florid, and more disposed to exhibit signs of inflammatory action. After this, calomel, opium, and sudorifics may usefully be exhibited. Under this treat- ment the pulse rises and becomes more free, and by this course, judiciously pursued, the disease generally goes off in a few days. 73 As this is an important state of disorder, for which we occasionally have to prescribe, it is trusted no excuse will be required for intro- ducing an abstract account of two cases, to show the nature of it more at large. October 20th. A. B., aged 10 years, after se- veral days of slight indisposition, attended with a want of activity and languor, had chills and rigors for a long time, followed by mild fever, slight pain in the chest, skin dry, very little heated, followed by great lassitude, fiery red- ness of the tongue, which was slightly furred, pulse small, soft and irregular; had a conside- rable discharge of blood from the nose, during the night previous. She took an emetic, whidi was followed by cathartic remedies. 21st. The medicine operated as desired. Symptoms very little relieved. Took eight ounces of blood from the arm, which was dark and thick. Repeated the cathartic remedies. Directed to take freely of water and other cold drinks, and a large anodyne after the free operation of the cathartics. 22nd. Medicine produced free and copious evacuations from the bowels. A copious sweating succeeded. Pulse more free and full. She now commenced the use of calomel, opium. and sudorifics. and continued the drinks. K 74 25th. The disease nearly left her, but in a state considerably debilitated; when she com- menced the use of wine and strengthening remedies; from which time she gradually recovered. The following case is of recent occurrence, in a gentleman who had experienced conside- rable fatigue at a meeting of the Alumni of Columbia College. May 20th. W. B., aged 4 b, after some slight indisposition from a catarrhal affection, was seized with lassitude, attended by moderate rigors, which continued ten or twelve hours. These symptoms were succeeded by a slight fever. 22d. Pulse soft and small; skin dry, attend- ed with an inactive feel; tongue fiery red on the edges, and very slightly furred in the mid- dle. Countenance dull and heavy. Says he has no pain, but complains of a tired, uneasy, horrid feeling. Gave him an emetic, and fol- lowed it by 10 grains of calomel, and a dose of sulphate of magnesia. 23d. The emetic operated well. Bowels very little moved. The symptoms of yesterday in- creased. He was bled twelve ounces. Blood very dark and heavy. Directed calomel and jalap, each five grains, once in four hours, and to drink freely of cold water and whey. 75 24th. Medicine operated very slightly. Has experienced very little relief. Pulse more full and tense. Bled him one pound. Blood dark and thick, but became more florid while running. Continued the cathartic powders with an infusion of senna and manna. 25th. Medicine operated freely as a cath- artic. Symptoms all apparently relieved. Took calomel, opium, and sudorifics. 26th. Some fever arose towards night, which rendered him rather restless. Pulse very little excited. Tongue somewhat furred. Continued the remedies. 28th. Symptoms all relieved. From this time he gradually recovered. It is an observation long ago made, that dis- smaii pox. eases perform revolutions by forming groups or peculiar trains of diseased action, which appear, and exist for a length of time, produc- ing their devastating effects, and again disap- pear, and are no more heard of perhaps for years. This remark will be, in some mea- sure, exemplified by tracing the succession of diseases of a country for a series of years, but more particularly in that of the small pox. After the introduction of the kine pox, (23) the small pox gradually diminished, and became almost extinct; till in July 1808, a pauper was introduced into the New-York Alms House, 76 who soon broke out with small pox. It spread rapidly through the house, where about se- venty cases occurred in the natural way, one in nine of which was fatal. Considering the close confined situation and the heat of sum- mer in which it prevailed, it was thought to be attended with not very great mortality. Some of the nurses had what was termed nurse pox, which differed very little, or perhaps none, from what is now termed varioloid. From this, the disease spread northerly and exten- sively through the state. Its progress was such, that it prevailed and spread widely in this county in the winter following of 1808-9, ex- citing much anxiety, and being attended in many cases with mortality. By the prompt and general use of kine pox, much of its influ- ence was resisted. From the use of kine pox, and probably in some measure from the sub- siding or passing by of the atmospheric pre- disposition to produce small pox, the disease disappeared in the spring of 1809. From this period we hear but little of the existence of small pox, till in 1821-22, when it again made its appearance in an epidemic form, in Philadel- phia and some of the southern cities, and sub- sequently in New-York. This was accompa- nied by a disease of much more general and extended influence, though milder in degree, 77 producing very similar effects, particularly in the early stage: it was denominated the varioloid. There seemed to be very strong atmosphe- ric predisposition to produce those diseases, so that cases became very numerous, and ap- peared almost to overcome the influence of kine pox in shielding the system from their effects. From thence these complaints made their appearance in this county. In December 1823, the small pox was in- ,823. var troduced from one source, and the varioloid °™» p°x- from another. Of the former several cases occurred, but the latter were much the most numerous, being produced by both diseases. From this introduction of small pox there was no fatal case.- Again in May 1824, two very severe cases of small pox occurred in Hyde Park, both of which terminated favourably. From these a number of cases of varioloid pro- ceeded. Again in the autumn, the small pox appeared in Red Hook, and some cases of va- rioloid in Pleasant Valley. In Red Hook these diseases became epidemic, and several cases of small pox terminated fatally. From this place those diseases spread east, into Pine Plains; north-east, around to Stanford, Washington, Pleasant Valley, and Poughkeepsie, producing some cases of fatality in their progress. In 78 smaiipox August 1825, the varioloid was again introdu- ced into Hyde-Park, by a young lady who had been in company with a varioloid patient in the city of i\ew-York. From her a sister, a young child, who had not been vaccinated, took the small pox. It had a very thick, full eruption, and went through all the regular stages of small Tarioioid pox. From each of these instances a number amaii pox 0f cases of varioloid were produced. These diseases wore the decided inflammatory cha- racter, and required the antiphlogistic treat- ment, modified by the peculiarity of the disor- der and state of the case. An abstract from remarks made on the dis- ease as it prevailed in the Hospital in 1808, will very conclusively show what was the pro- per course of treatment, as it prevailed in our county. In the first cases, the fever partook much of the inflammatory type. The patient bore depletion and the antiphlogistic treat- ment very well, which was attended with evi- dent advantage. If the pustules did not fill well, a cathartic generally promoted their fill- ing. The secondary fever was inflammatory, and was relieved by cathartic and refrigerent means. During its prevalence, at about the twentieth case, the disease in some measure changed its type, and debility supervened after the turn of the pock, and the patient required 79 stimulants. In some of those cases Dr. Hosack directed the warm bath; to which was added a decoction of bark and Castile soap, which appeared to be an important remedy in re- straining the septic tendency, and saving the lives of some that used it. The appearance of the varioloid in those subjects who had had the kine pox, seemed at first to shake the public faith in favour of that protecting disease. But when it was ob* served that those who had had the small pox, were equally or more subject to the varioloid than those who had had the kine pox, and that the varioloid was a mild disorder, the reputation of the kine pox again resumed its former station, and has proved itself of as much importance in protecting the system from the influence of small pox as it was for- merly supposed to be. Among the hundreds Kme po» . . prevents vaccinated in the county, there has been no smallP°* well-attested instance, in which the kine pox had been genuine, that the small pox has super- vened. Among the various subjects of medical investigation which have lately occupied at- tention, none, perhaps, is more intricate and mysterious than the various operations and connexions of small pox, varioloid, and kine pox. Whether they are distinct diseases, or mere modifications of the same virus, appears 80 to be a question yet to be discussed. It i^ attended with considerable difficulty in some cases to determine the line of distinction be- tween small pox and varioloid, though in most cases it is, however, easily ascertained. varioloid, From the writings of others, and from my its charac- ° ter own observation, I can state a fair character of varioloid to be, more or less indisposition, attended with pain in different parts, and fre- quently with considerable fever. This is fol- lowed by an eruption, generally scattered, though sometimes very thick, so as to be con- fluent. The pustules are small, and not gene- rally attended with the circular inflammation of small pox: they go on increasing from three to seven days, and have a peculiar horny pro- minent top. Many of them fill with a watery matter. Before the ninth day they generally recede, and entirely return into the skin, or go off in branny scales. It is not commonly fol- lowed by secondary fever, nor has it produced any death in the county. Whereas in small pox, the eruptions appear, and continue enlarg- ing beyond the ninth day, even to the sixteenth, and then fill with pus. The pustules dry into scabs, and peel off, followed by secondary fever, &c. Opinions held at present respecting those diseases, as established by facts and observa- 81 tion, appear to warrant the following conclu- sions : 1st. That varioloid will produce varioloid. 2d. That in a subject that has not had kine pox or small pox, varioloid will produce small pox. 3d. That vaccination, in most or all cases, is a preventive of small pox; or so modifies the access of small pox, as to take away all danger of fatality. 4th. That varioloid will attack after small pox or kine pox; but is most severe after small pox. It is stated in an essay on this subject by Dr. Bell, that a patient may have kine pox four times, and that the virus pro- duces less and less effect on the system, till at the fifth time it produces none at all; when the patient becomes saturated, and resists the influence of both small pox and varioloid. The small pox character of disease seems to have run its course; and that and the varioloid have disappeared, and we hear no more of them. The measles have prevailed more or less every year under consideration, in some dis- tricts of our county, to a moderate extent. But Measles of 1824 in the spring of 1824 they became a general epidemic, and spread nearly, or all over the county. In many instances they were attended i, 82 with fatality. The diathesis of the disease was of a high inflammatory character, although great numbers of cases went safely through without medical aid. But those that required medical treatment, succeeded best by anti- phlogistic means ; and frequently the case was benefited by copious bleeding. When the disease terminated fatally, it was commonly by a secession of the eruption, and a peripneu- monic attack. The term black measles, which it sometimes obtained, appeared to be a gangre- nous state consequent upon fullness and inflam- matory action. (24) Penpneu- The disease, which is more general than monia of ° 1825 any other among us—which terminates more lives than any or all others to which our com- munity is subject—which prevails every year, and at every season of the year, but more gene- rally in cold weather,—is the different grades of inflammation of the chest, arranged by noso- logists under the various terms of bronchitis, influenza, peripneumonia, pleurisy, pneumoni- cula, &c. When this character of disease becomes epidemic, it produces the most general influ- ence on the human system of any variety of morbid excitement. It may prevail under a inflamma- sthenic or an asthenic diathesis; but with very tory type. # m few exceptions, in our climate, it partakes of the inflammatory character. It has been three 83 times epidemic within our time. In 1807, the influenza, with peripneumonia, spread through the county, and extended itself over the United States. It was so universal in its operation, that all, or nearly all, felt its influence. The late Dr. Wheeler of Red Hook, observed that he did not know a person in that town who had escaped it. There are many interesting facts on this disorder, recorded in the New-York Medical Repository, Philadelphia Medical Museum, by Coxe, and the American Medical and Philosophical Register, edited by Dr. Ho- sack and Dr. Francis. The peripneumonia, with bilious disease Prevalence i 1 •/¥• • • ofperipneti under different names and modifications, again gEJJftgJ^ prevailed from 1812 to 1814, and continued 1816 sporadically to 1816. The influenza and pe- ripneumonia again prevailed the last spring. Besides those wide-extended epidemics, these diseases are every year more or less prevalent, and have their annual returns during the ver- nal season. There is no class of diseases that exercises the skill and ingenuity of the physician more than this, and particularly that of the perip- neumonic type; none in which there is so much danger of mistaking the present diathe- sis, by taking congestion or suppressed inflam- mation for a state of debility or incipient 84 typhoid action; or none in which the inexpe- rienced in the profession would be more likely to attempt to remove oppression and apparent debility by stimulant means, when remedies of a different kind would be most proper. (25) Indications * * x ' of cure. rpne genera[ indications of cure, are to re- strain arterial action; to remove congestion of blood in the pulmonary vessels, with its at- tendant inflammation; to prevent or obviate the effects of a secretion of mucus or of effu- sion in the lungs; and to support the strength. It will readily occur, that these indications are to be answered by depletory, antiphlogistic means. If the disease is not arrested in the early stage, effusion or suffocation takes place, or a protracted or typhoid state frequently supervenes. For a more particular detail of the plan of managing these diseases, permit me, besides the systematic writers, to refer for principles to the works of Sydenham and Rush. Bisease of The disease that prevailed last spring, was 1825 very l i o infumma- 0f a Very active phlegmasial type. As is observed by John Bell, " the lungs were fre- quently stuffed and crammed with blood." When exhibiting a small pulse, prostration of strength, and a pallid countenance, there was Treatment, the most urgent call for bleeding. And I have not met with a disease where the patient re- 85 quired more bleeding, or in which he bore it better. Although some cases recovered with- out the use of the lancet, yet in most cases of much activity it was used with advantage, and frequently it was necessary to be several times repeated. (26) It has been considered that in many instan- ces this disease is connected with a typhoid diathesis, or that there is a great proneness to that state of the system. Hence we hear of pneumonia typhoides, of typhus supervening, and that the patient may be run down if deple- tion is used, &c. As far as my observation has extended, I have not observed such a state. In addition to the testimony of a number of my medical brethren in favour of the sthenic nature of those diseases, their inflammatory character will appear, when it is observed, that the antiphlogistic depletory course of treatment was uniformly pursued, and that Result of cases. out of the numerous cases that passed under my prescription, there was but one death (a child), and one case which terminated in consumption. (27) The patient has since died. There was no case that exhibited a black tongue, or in which a typhoid state supervened. Whatever the diathesis of disease may be, as we leave the banks of the Hudson and ap- proach the Connecticut river, I have not been 86 able fully to determine. But, as it relates to our county, it will prove a dangerous delusion to adopt the position of Dr. Miner, that the inflammatory nature of disease has entirely left our country, and that " all diseases par- take of a typhoid character." Numerous facts are not wanting to show the generally decided inflammatory or congestive nature of our dis- eases. (28) !ever*bed The last disease, though in importance not the least, (for an account of which you will be detained,) is one of a peculiar nature. It is confined to the female sex, and, more than most others, nearly connected with the procreation of our species: it is the puerperal fever.(29) It has not fallen to our lot to have this disease prevail epidemically among us; but it occa- sionally occurs in all places, and latterly it has appeared in our county much oftener than for- merly ; so much so, that in some districts it has been very frequent; and too true it is to evade, these occurrences have been attended with great fatality. For the character and descrip- tion of this disease, reference is to be had to systematic writers, as it has been observed by one, "in this almost all agree." During my practice, I have had a few mild sporadic cases of this affection, such I believe as generally occur in the country. They have yielded to 87 moderate bleeding, purging, sudorifics, ano- dynes, &c. 1 have been well informed, that in the southern parts of the county it has lately prevailed with a good deal of frequency and much fatality. What proportion have been cured or died, or what mode of treatment has been pursued, I have been unable to ascertain. Since the beginning of this year it has appear- ed, and exhibited almost an epidemic charac- ter near my residence, attended with such violence and pain as is attributed to the most malignant cases. It is considered an active inflammatory dis- Diathesis. ease by Denman, Gordon, Hey, and Armstrong, of Europe; by James, Bard, Hosack, and Fran- cis, of our own country. Burns and some others have their doubts on that subject; out of which probably proceeds Burns' vacillat- ing mode of treatment, when he says, u I find it much easier to say what remedies have failed, than what have done good." He evi- dently labours under a mind of typhoid associ- ation, and is one of those who furnish the disastrous reports of those who consider the disease of a typhoid character. At the present day, I believe, and in our climate especially, there is, or ought to be, but little diversity of opinion on that subject. By taking a view of Pathology what may be considered the true pathology of 88 the disease, it will farther exhibit its inflamma- tory nature. The uterus and surrounding ves- sels after labour, are in a lax, dilated, and irri- table state; and this may not be improperly termed a state of predisposing debility. This being the state of the parts, the blood flows into them in inordinate quantities, distending and cramming them, producing an inflamma- tion somewhat sui generis, which readily extends to the surrounding parts. It is nearly allied in its nature to violent peripneumonia in its suffocating effects on the lungs. From this may proceed the great pain and sudden dis- tension of the abdomen: and the disease pro- duces similar fatal gangrenous results, unless the vessels are unloaded, and the circulation equalized at the very onset. It ought not to detract from the reputation of a practitioner to lose his patient in this dis- ease, after the avowal of such men as Burns, that he could say what had failed, rather than what had cured; of Bard, who declared it to 4 be a most fatal disorder; of William Hunter, who used bleeding and cathartics in one wo- man, and she died—sudorifics and fomenta- tions in another, and she died ; who tried the stimulant plan in another, and she died: in short, all plans failed: or of a Professor in Edinburgh, who, as we are informed, lately 89 told his class that he considered it an incura- ble disease. Several valuable treatises have lately ap- peared on the subject of puerperal fever; but none of them has so forcibly recommended the use of the lancet, as that by Mr. Hey of Leeds. "I have employed blood-letting in this disease, (says he,) to a greater extent than any other practitioner with whose writings I am acquaint- ed ; and have hazarded the opinion, that the quantity of blood is scarcely to be limited, but by the removal or considerable diminution of the pain : but let it be recollected, as a neces- sary appendage to this opinion, that the period for bleeding is confined to an early, though not a very definite, stage of the disease." Some writers, more especially those of our own country, have warmly recommended the liberal use of cathartic medicines; and feel themselves fortified in this practice, by reflect- ing on the advantages which so generally arise from an open state of the bowels during the advanced period of pregnancy, and imme- diately subsequent to labour. In the very fatal fever, puerperal epidemic of Aberdeen, we are told by Dr. Gordon, that of those who were freely purged the day after delivery, only one died of puerperal fever. That the puer- M 90 peral fever may at times become contagious, when its form is that of typhus, is a position countenanced by the recent remarks of several able clinical observers. " The contagious cha- racter of the puerperal fever, (says Dr. Fran- cis, in his Notes on Denman,) has been denied by some writers, while others have represented it to be so in an eminent degree. The records of the Lying-in Hospital of Great Britain confirm this latter opinion. While I visited the Royal Infirmary of Edinburgh in 1816, Dr. Duncan, jun. informed me that six cases had at that time occurred, in three of which the disease was satisfactorily ascribed to attend- ance on the puerperal women. The contagion was communicated by the nurses." These facts are confirmatory of the views and illustrations of Dr. Gordon. Others might be cited from clinical observers. Dr. Francis has recently stated to me, that four cases of puerperal fever occurred in the city of New-York during the spring of 1825, which were strongly marked by all the charac- teristics of malignant typhus. Dr. Hosack was informed, upon very respectable authority, that it prevailed in Elizabeth Town and its neighbourhood, in the state of New-Jersey, several years ago, and proved fatal to a num- ber of lying-in women. It is almost superfluous 91 to add, that these two forms of the disorder require different modes of treatment. Yet, notwithstanding these few special in- stances of the puerperal fever assuming a ty- phoid character, my original position, I con- ceive, holds good,—that the complaint may be classed among the most strikingly inflam- matory. Exceptions can only confirm the general rule. Moreover, we all know that there is scarcely a disorder of the system that may not, under certain circumstances, take on the typhoid aspect. In the treatment, it is observed by Bard, that " all practical men are agreed, that early and free bleeding, moderate purging, &c. are pro- per." Little or nothing can be done with pro- bable success after collapse supervenes. It is observed by Gordon and some others, that nearly every patient died who was not bled freely in the beginning: and it appears in general, that where depletion has been copi- ously used, the patient recovers most readily. If the semblance of debility and prostration, that is frequently attendant upon the ushering in of the disease, should deter from the use of the lancet, it will be found a fatal delusion. In the language of Dr. Rush on another occasion, the disease should be taken out of the hands 92 of nature, and the system held under medical control. r-reatment. After bleeding freely, it is recommended to give large doses of calomel, and to aid its operation by some other cathartic and nause- ating medicines, which are to be repeated, if necessary. This course has frequently suc- ceeded; but in many instances it has failed, either from not commencing sufficiently early, or from a want of courage in the first stage to carry the remedies to the extent required; or some other cause not easily ascertained. But a symptom which proves very aggravating, and which it is a great desideratum to overcome, is the extreme pain attending the complaint. With a view of relieving the pain, restrain- ing morbid irritation, and equalizing the circu- lation, I would, with due diffidence, propose the following plan: Bleed largely at once, or if practicable, take blood enough within the first twenty-four hours. Circumstances must govern as to the quantity to be taken. From twenty to sixty ounces during the time above mentioned, may be required. After the first bleeding give calomel, ipecacuanha, and opi- um. (30) Let there be opium enough given to quiet all pain; say three grains at first, and one or two to be repeated every three hours till it has that effect; and ipecacuanha and 93 calomel enough to nauseate, and to insure a cathirtic operation in due time, with the aid of some laxatives. In the progress, strong sina- pisms should be applied to the feet, and alka- line fomentations to the abdomen and pubes. After the operation of the first cathartics, a large blister should be applied to the abdomen. It is of much consequence to sooth the dis- tressing anguish and anxiety of the patient, and friends attending these cases. Pain, it is known, has a direct tendency to irritate the heart and arteries, and thus will increase or prolong inflammation. By giving opium enough, it operates as a sedative, and in abdo- minal disease, aids more than retards the ope- ration of cathartics. Within twenty-four hours, as I have found to occur, the cathartics pro- duced a copious operation: after which the opium ought to be repeated, so as to allay the pain during the progress of the cure. (31) In the progress of the cure, sometimes heat of skin, fever, and restlessness come on, even after the operation of the cathartics, when the most urgent symptoms are relieved; at which time much benefit is derived from exhibiting small doses of antimonials, at proper intervals. In this disease, as in some others,(32) much depends on an exact timing of remedies. The Bleed be- ... fore givinj large quantities of blood drawn, without being °m*- 04 succeeded by opium, might, in many instances, prove injurious; and to give very large quan- tities of opium before the tension of the sys- tem (33) is taken off, and relaxation produced by bleeding, would prove equally unfavoura- ble. In this situation the system, if I may use the term, is buoyed up by opium, and irritabil- ity allayed, while the cathartics perform their office, and the circulation becomes equalized. Of the number of cases that have occurred in my vicinity, three have proved fatal; two of which I prescribed for, one I did not. All the others which have come under my care, and in which the plan of treatment here pro- posed was pursued, those patients have all recovered. The two cases which I prescribed for, that terminated fatally, the patients were bled largely, cathartics and sudorifics were freely given, which produced a free, desirable effect, and blisters were applied. In one case, a large anodyne procured a good night's rest; after which all medicines were rejected: the pain through the small of the back and uterine region was very severe, and continued to the last. An abstract of some cases, taken from my case-book, will give a more correct idea of the treatment and the result. 95 Mrs. L----, after a severe labour, in about case*. forty-eight hours from the delivery was vio- lently attacked. I first saw her about eight hours after, which was after 12 A.M. on the 3d of June. She was immediately bled forty ounces; commenced taking calomel and jalap, ipecacuanha, and opium, the doses of which were repeated at proper intervals; so that in less than twenty-four hours she took thirty grs. of calomel, ten of jalap, and eight grs. each of opium and ipecacuanha. In a short time after beginning with the opium the pain abated, and the tension of the abdomen subsided. In about twenty-four hours, sweating and the pur- gative effect commenced. Within twelve hours she had fifteen evacuations, which were at- tended with severe pain. During this time she took seventy drops of laudanum, twenty grains of Dover's powder, six grains of ipecacuanha, and injections with two drachms of laudanum. A large blister was applied to the abdomen, which again entirely relieved the pain, and a copious sweating continued. On the 4th, the pulse became sharp and tense, the skin dry, and the pain increased. She was bled six ounces, and the cathartic repeated during the night. She became easy, and perspired freely. On the 5th, and during the night, rested well. The puerperal disease was entirely gone : she 90 had only mercurial disease and debility, from which she gradually recovered. Mrs. N----, aged 28, had a tedious, pro- tracted labour, which was attended with such violent pain in the right side, and through the region of the diaphragm, as to require f'r^e bleedings and large anodynes before delivery took place, which was on the 17th of August. She was comfortable, and even cheerful, to the 19th, when she was violently attacked, so much so, that it was thought she could not have lived many hours. The case was ushered in with severe chills, and violent pain in the right side, uterine region, and small of the back; the pulse was small and tense, tongue covered with a white fur; extreme anxiety in the countenance, and great difficulty of breath- ing: there was a universal soreness, and the system was very irritable. She was then bled again. In all, she lost fifty-two ounces of blood. She then began taking calomel, opium, and ipecacuanha. In less than twenty-four hours she took ten grains of opium, forty of calomel, and four of ipecacuanha. She also took an infusion of senna, and had a blister applied to the abdomen, which course nearly suspended the disease. A free perspiration came on. In about eighteen hours the purging commenced: 97 numerous free evacuations ensued. The pain again came on, and was again quieted by opi- ates. In about forty-eight hours from the at- tack, the disease seemed entirely removed. She had no mercurial affection of the mouth, and recovered strength rapidly. Mrs. B----, aged 24, after a labour in no wise peculiar, was delivered on the 30th of September. October 2nd. Forty-eight hours after deli- very, she was attacked with severe pain in the head, small of the back, and sacrum, together with general soreness and tension of the abdo- men. The pain through the uterine region was also particularly severe. The tongue was slightly furred, white in the middle, and fiery red on the edges: the skin was very little heated, rather inclining to clamminess. Her breathing was laboured, somewhat resembling that of a lady in tight-laced corsets, seeming to exert the diaphragm only. (33) The secretion of milk was partially suspended, and the lochia totally suppressed. She was bled at 9 o'clock a.m. twenty ounces, and commenced taking five grains of calomel, one of opium, and two of ipecacuanha, to be repeated every three hours. Warm alkaline fomentations were ap- 98 plied to the abdomen. The bleeding was re- peated to sixteen ounces in ten hours. 9 o'clock P. M. Some nausea, and a little vomiting induced. The breathing rather im- proved; pain considerably abated; the pulse rounder and softer. The lochial discharge has appeared : she sweats copiously. Omitted the fomentation, and applied a blister to the abdomen. Oct. 3d. The medicine began to purge at 10 this morning; before which the pulse be- came quicker (120 in a minute) and smaller, and the tongue more furred. 10 P.M. The pulse has fallen to 95, and become more natural; the heat and fever con- siderably abated. She sweat gently; had some stranguary: very little pain, except from the cathartic effect of the medicine. The calomel and ipecacuanha were discontinued, and two grains of opium given. Oct. 4th. 7 A. M. During the night, she has had several stools, attended with some pain. Sweat freely the whole time, and ob- tained some easy and natural sleep. The scurf mostly removed from the tongue. She took twenty drops each of laudanum and tincture of kino after each stool. 10 P. M. During the day, took a gill of wine. After it she had a little fever, and the 99 pulse became more tense. The wine was omitted, and simple nourishment recommend- ed. At evening, fifty drops of laudanum were given as an anodyne, and the laudanum and kino mixture continued as before. Oct. 5th. Rested well last night, and ap- pears very tranquil: has strength to assist her- self quite well; and seems free of disease. 6th. Convalescent. (34) Remarks. These patients, with no stimulant except nourishment, got rid of the disease, and gained strength rapidly. The first patient had a mercurial sore mouth; the others were not affected in that way. In the third case, the small quantity of wine given aggravated the symptoms. In this case, during three days she lost thirty-six ounces of blood; took forty grs. of calomel, twelve grs. of ipecacuanha, ten grs. of opium, and three hundred drops of lauda- num. In nineteen hours the purging commen- ced, and continued rather copiously. The irritability and pain was allayed by opium, and the too free purging restrained by that and kino. Whether the excellent plans of treatment, by bleeding and purging, among others, recom- mended by Mr. Gordon and Mr. Hey, would 100 have succeeded in those cases, under any mo- dification, is difficult to determine: from the result of my two first cases, it would seem somewhat doubtful. It is probable there was more pain and irritability attending these cases, than those described by them. But the severe pain and anxiety present in all my cases, and particularly in the late stage of those that terminated fatally, is an unpleasant symptom, that I know of no remedy to coun- teract, except opium. This is a symptom that Mr. Hey admits was troublesome, even in his successful cases. Without presuming to draw a comparison between any former recom- mended plan of treatment, and the one here proposed in favour of this, it may be said, that by this the disease is generally cut short in two or three days; the patient is secured from pain, and lies easy, and the system preserved from the deranging effects of long-continued morbid action. Dr. Gordon seems to be of opinion that purging, and a free loss of blood, during, or directly after delivery, prevents the attack of this disease. Mr. Hey did not find that to be the case with his patients, for several of them that had lost much blood, had an attack after- wards—which corresponds with my observa- 101 tions. In my first two, and fatal cases, cathar- tics were given soon after delivery, so as to produce a full effect. In the second success- ful one, here reported, the patient lost about forty ounces of blood from the arm, before delivery; and after delivery, a copious flood- ing came on, so as to require very active means to check it: notwithstanding which, in about forty-eight hours the puerperal disease came on, as noted in the case. (35) Before so enlightened an audience, it is pre- sumed no apology will be required to avoid the imputation of temerity in the use of reme- dies in some of our violent diseases; when it is recollected, that the doses of medicines proper in a state of health, or in a small remove from it, bear but little proportion to what is requir- ed to ward off from the system a violent attack of disease, and preserve it from the sudden derangements of excessive morbid action. In medicine, that alone is the proper dose which answers the indication. And while we are exercising the all-important duties of our pro- fession, may our leading emulation be to sus- tain principles in our minds, and command remedies in our hands, ready to control the various and violent grades of diseased action to which our fellow-creatures are subjected. ON CARIES OF THE JAWS OF CHILDREN: READ BEFORE THE MEDICO-CHIRURGICAL SOCIETY OF THE In 1808. BY THE AUTHOR, While Resident Physician of the New-York Almshouse. PREFACE. Since the following little Essay was written, it seems the disease treated of, is not confined to the Hospitals of New-York; but a similar one has occurred in our county. The beneficial tendency of investigations of this kind, especially of the diseases of our own county, is the only apology that will be offered for its pub- lication. The cases communicated to the author, by so worthy a practitioner as Dr. Beers, tend very much to show the nature and extent of this class of disease: and if the whole, taken together, leads to a successful method of stopping the pro- gress of the disorder, or of curing similar cases. our labours will be amply compensated. o CV1 PREFACE. I have added to the present discourse, a letter on this disorder, by Dr. Francis, Professor in the College of Physicians and Surgeons, New-York. This communication shows sufficiently well that this affection is not so rarely to be seen as has been generally supposed, and adds to existing facts on the subject. Several of my inquiries in relation to this formidable complaint, have been answered by this communication from Dr. Francis. ON CARIES THE JAWS OF CHILDREN. GENTLEMEN, In compliance with the regulations of Disease ot the jaw- this Society, it becomes my duty, in rotation, bones to read a paper on some medical subject. I have undertaken the task of offering some re- marks on a disease which has come within my observation within a few months past, a de- scription of which I have not met with in any author, and which I shall term a Caries of the Jaws of Children. This disease seems to be somewhat peculiar to the Almshouse of this city. I have formed this opinion, from never having been able to hear of a case out of it; and am confirmed in the remark, from the like observations of seve- ral respectable medical characters, who have 108 seen the disease in question. (36) It has been known only to attack children under the age of twelve years, and generally over the age of three years. The first symptoms are commonly a slight swelling and pain in some particular part of the jaw, and generally in the upper one, as the under one is seldom affected. The child is otherwise in good health, and takes its usual exercises. One, two, three, or four teeth be- come loose, according to the extent of the dis- ease, and begin to turn black about the cervix: the gums are detached from them, and evi- dently corroded, so that the jaw-bone becomes visible, black, and dead. The teeth are now quite loose and painful, and the little sufferer finds much difficulty in taking its food. The breath is remarkably fetid : the lips now gene- rally swell, which is the case with the face on the affected side. The bowels are frequently affected with loose fetid discharges by stool. If the disease is not arrested here, the jaw continues to be denuded, though sometimes the affection and death of the bone proceeds without any other very serious symptoms. In one case, the bone .became affected over the front teeth, to the extent of an inch square, so that the teeth and 109 bone were easily taken out together. In an- other case which came under our observa- tion, the bone was affected over the molares of the right side to the extent of three teeth, and extended up higher than the alveolar sockets; the teeth were taken out, and soon after the mortified part came away, the disease extending both inside and out. The separa- tion took place quite through the bone at once. These two cases recovered without any other alarming symptoms supervening. But unfortunately the disease is not always very bad so favourable; for the disorder sometimes grows worse in spite of all remedies. The lips, face, tongue, and fauces become swelled : the tongue covered with a dark-coloured scurf, the patient is unable to swallow, except some liquid ; more or less fever of course always attends ; the bowels are affected with frequent and extremely fetid discharges; languor and debility pervade the whole frame; the dis- charge from the affected bone is so sharp as to corrode the lips and skin over which it spreads. Sulphuretted hydrogen gas can hardly be more offensive than their breath; and in this stage death generally soon closes the scene. 110 In the inquiry into the causes (37) of this affection, it will be proper to take into consi- deration the situation and diet of those who are subject to it. In an institution like the Almshouse, there is necessarily a numerous collection of persons in one room. In the nur- series appropriated solely for children, there are about fifty or sixty inhabiting the same apartment, who consequently sleep, eat, and respire within a small compass. Medical his- tory informs us, that the diseases of confined and crowded places have a gangrenous ten- dency; and experience confirms the remark. Though particular attention is paid to clean- liness in those rooms, there is more or less miasma generated and floating in the confined atmospheres, which will assist other causes in producing diseases, or render diseases obsti- nate which are otherwise produced. Their food is principally brown bread and molasses, though sometimes they have white bread; and latterly, considerable sugar in- stead of molasses. Rye bread, we know, is much less digestible, particularly in delicate stomachs, than wheat. When it does not di- gest well, a kind of acetous fermentation takes place, and a corrosive acid is formed; and there is scarcely no material more susceptible Ill of fermentation than molasses, when somewhat diluted, and exposed to a moderately increas- ed temperature. Thus we have materials, very susceptible of fermentation, mixed and moist- ened in the mouth, and conveyed to the sto- mach, where, if the powers of digestion are not strong, this acetous matter will be formed, and by eructations or exhalations from the stomach, it will be passing over the teeth and gums, which in process of time must be much affect- ed by it. Likewise, the particles of food re- maining in actual contact with the teeth and gums, and there forming a corrosive matter, may be considered as another cause of the dis- ease in question. Perhaps no one of these causes would pro- duce this affection alone; but all acting in concert, are doubtless sufficient, particularly in previously debilitated constitutions, which we find are most subject to this disease. In the treatment (38) of this disease, a va- Treatme* riety of remedies have been had recourse to; as alkaline gargles, alkalies combined with astringents, and tonics exhibited internally, though with very little effect. The tincture of Peruvian bark has been used as a gargle, in a diluted state, with but slight success, except in moderate cases. Several other remedies have been tried without success. V 112 We find that the only alternative is to ex- tract the teeth surrounded by disease, as soon as it has made any considerable progress; and as soon as the diseased portion of bone begins to separate from the sound, that should be re- moved likewise. The gargle which is found to have the best effect, is a solution of sulphate of copper (blue vitriol). When the affection is slight, this may be made weak, but in the more advanced stages it should be as strong as the parts will bear. When the patient is robust, and not constitutionally affected, these means gene- rally cure, with nutritious diet and good nur- sing. But when the constitution is debilitated, and the bowels become irregular, it is neces- sary to have recourse to antiseptics and tonics internally, together with the aid of local reme- dies. The bark is indicated, but it is attended with much difficulty to get children of that age to take it in substance; therefore we have had recourse to the tincture,(>9) which is more palatable, and easily exhibited. In slight cases, three or four drachms of the tincture a day, with a glass or two of wine, might be suffi- cient. But in more alarming cases, five or six drachms should be given, or as much as the stomach will conveniently bear, with a free 113 exhibition of wine. At this stage of the disease, no rule is necessary for giving wine, but to give as much as the patient can be made to take. By thus persevering in this mode of treatment, the gangrenous tendency of the dis- ease may generally be arrested; the strength of the system will be restored; healthy action will take place at the margins of the mortified bone; the carious portion will be thrown off, and the patient restored to health. Case. In 1816,1 was desired to see a child, about six years old, with a singular affection of the mouth, as it was termed. On examina- tion, I found the gum detached from two of the teeth, which were carious, as was also the ad- jacent jaw-bone. I immediately recognised the disease, in the treatment of which I had previously had some experience. The diseas- ed teeth were extracted, and remedies used to correct the state of the digestive organs. The parts were bathed with a lotion of sulphate of copper, and tonics and stimulants given pretty liberally internally. In a short time the patient recovered. The following cases were communicated to me by Dr. Beers, a respectable practitioner in the town, of Clinton, in this county. Ill 1817. Sarah Giffbrd of Stanford, aged 11 years, of a scrofulous habit, for some time complained of pain in the teeth of the upper jaw of the right side. The friends opposed a solicitation I made, to have the diseased teeth extracted. About this time she was attacked with a pretty severe inflammation of the lungs. On her recovery from this attack, the gums and parts adjacent became swollen, and the cheek externally very much tumefied: soon after which, a black gangrenous spot appeared in the centre of the cheek. On examination, the jaw-bone under it was found carious, and the gums in a gangrenous state. One tooth was easily pushed through the socket into the antrum. On a little moving with the probe, it dropped out. She was now very much debili- tated. The disease extended rapidly. The whole of the right portion of the upper jaw be- came carious, and a part of the malar bone. All the molares of that part came away. Ulcera- tion took place through the cheek, and extend- ed from the angle of the mouth nearly to the ear. From the acrid matter falling upon the lower jaw, that also became diseased. Nearly, or all the molares, with a considerable portion of the jaw-bone, came away. In all, she lost ten teeth. 115 When the gangrenous tendency of the sys- tem was discovered, the patient was treated with vigorous antiseptic and stimulant reme- dies. The debility and prostration, a part of the time, were so great as to require the most liberal use of these remedies. The strength was supported, and the diseased portions of the bone were separated from the sound. The space was filled with a new growth of parts, after a long and tedious process. The wound closed up, and the patient recovered, and is still enjoying tolerable health. Robert Doty, aged 30, of a good constitu- tion and temperate habit, in 1819 complained some time of a catarrhal affection, with some swelling of the glands about the throat, which was succeeded by some small abscesses, or boils, that considerably debilitated him. Dur- ing this period, a double tooth became painful, and was extracted. Soon after this, he was afflicted with general pain through the upper jaw. On my first seeing him, he had a gangre- nous spot in the roof of the mouth, together with a general tumefaction and gangrenous appearance of the parts. The whole circle of the upper jaw was diseased ; so that in a few days, by taking hold of the front teeth, the 116 whole jaw could be moved, forming a separa- tion about as high as the upper parts of the sockets. The teeth might mostly have been taken out with the fingers. He was put upon the use of active stimulant remedies. In about ten days, however, his strength failed, and the disease made such progress that he died. LETTER On Caries of the Jaws of Children; addressed to Dr. Sheurill, by John W. Francis, M. D. Professor of Obstetrics, fyc. New-York. New-York, 31st December, 1825. dear sir, The memoranda which I possess, con- cerning the particular subject of your inquiry, are few and imperfect. Yet I can have no hesitation in communicating, for your disposal, such information as I am able. The disorder which you denominate a Caries of the Jaws of Children, and which others have named a Gangrenous Ulcer of the Face of Children, though comparatively speaking a complaint seldom to be met with, is nevertheless found to occur under different circumstances of age, 117 modes of living, climate, and country. I be- lieve it to be, moreover, a disorder by no means so novel as is supposed by some. Pearson, in his Principles of Surgery, has evident allusion to it; and long before his time, Huxham states that he witnessed a mortification of the fauces and mouth in infants, besides a caries of the cheeks and os vomeris, which occasioned a very painful kind of death. This followed after measles. Willan has observed almost the same occurrence to take place subsequent to scarlatina. Hall, of Nottingham, has described several cases, which he terms a peculiar spe- cies of gangrenous ulcer, affecting the face in children.* Burns, in the last edition of his Mid- wifery, has a section on the diseases of chil- dren, entitled Erosion of the Cheek, and Sloughing Ulcer of the Pudendum.^ This is indeed blending two affections not wholly alike; yet many of his facts are strikingly applicable. And even the cases of Mr. Kinder Wood, which are de- scribed under the title of a fatal affection of the pudendum of female children, enable us the better to understand the character of the * Edinburgh Medical and Surgical Journal. f Burns' Midwifery, sixth edition. 118 peculiar caries of the jaws you have de- scribed.* In this last mentioned complaint, the ulcera- tion ensues within a few hours after vesication of the part; it becomes deep and foul; but mortification rarely occurs. In the treatment of it, bark, and cordials internally, and stimu- lating applications externally, have proved most serviceable. Many practitioners have been familiar with this disorder, who have ^-\ never seen an instance of caries of the jaws. jjffu^PtsT*v The late distinguished Dr. Riuhuud Btij It j \ of ' this city, was an ardent advocate in these cases /J"^£—» of ulceration of the pudendum, of the treat- ment by tonics generally, and of the local application of the ungt. basil, nig. It is report- ed that his practice was eminently successful. I am strongly inclined to think, that if refer- ence be made to the continental authors, we shall find the disorder of the jaws of children to be noticed by several of them. In his class Cachexias, order Anomalae, the father of noso- logy, Sauvages, enumerates several kinds of necrosis; as those which arise from the secale cornutum—from particular virus—from scor- * See Medico-Chirurgical Transactions of London, vol. vii. 119 butus, &c. From the section entitled Necrosis Infantilis, I quote the following. " 6. Necrosis Infantilis. Morbus est novus, seu nullibi descriptus, frequens tamen apud infantes quinquennes, potissimum in orphano- trophio; illis vel in gena, vel in vulva apud puellas, supervenit, sine febre, macula rubra vel livescens, sine dolore, tumore, calore, quae acu pertusa non dolet, post paucos dies sponte laceratur a levissimo tactu, sine ulla sanguinis vel alterius humoris effusione: sensim vicina carnes, gingivae v. g. eroduntur, pulsu, fame, caeteris vix mutatis, et intra paucos dies fato cedunt, omnind absumtis, nigris, siccis, vel vulva eodem modo erosa. " Pluribus scorbuticis superveniebat ad ge- nam ulcus exiguum, album, in ambitu durum, quod neglectum livescebat, nigredine et faetore accedente, unde tota, gena, perforata, erosa, dentes in conspectum se prodebant; hujus ulceris indolentis, gangrenosi, sicci, progressus sistit, spiritus vitrioli. Similes casus vidi plu- ries, sed gena sine ulcere statim livescebat, altero die perforata, sine dolore, inappetentia, febre, debilitate, interiora oris patefaciebat, letho intra paucos dies subsequente: idem vidi apud virgunculas in vulva."—(Poupart Hist de VAcad. R. des Sc. 1699, p. 175.) 120 On the other hand, some of the most promi- nent clinical observers of the present day have neither seen nor even heard of this disorder. In the Bristol Infirmary, one of the largest and best organized institutions of Great Britain, neither Dr. Chisholm nor Dr. Pritchard ever witnessed a case: and in a letter to me, em- bracing this topic, Dr. Chisholm remarks, that to him the complaint was wholly novel; he had seen no case of it during his long and ex- tensive practice in the Indies. Mr. McGregor, in his Report of the principal Diseases that have prevailed at the Royal Military Asylum at Chelsea, from its establishment in 1804 to 1814, gives no instance of such an affection. At this Asylum, twelve hundred children are fed, clothed, and educated, under the protec- tion of government: they are admitted from five to twelve years of age. We find them to suffer from measles, scarlet fever, and the like, but from no sequela, like the disorder now under consideration. Dr. Bateman, who has so well described the diseases of London, from 1804 to 1816, makes no allusion to an instance of it in his valuable Reports. (London, 1819.) Still in our country we may occasionally observe it. The late Dr. Dyckman, who was for some time Surgeon to the New-York Alms- 121 house and Penitentiary, saw some cases of it at that institution in the season of 1821-22. I have been well informed that it has occasion- ally occurred there since. I have known caries of the jaws in children to occur in the Almshouse in different years, and at different seasons, since your attendance in 1809. The accompanying circumstances were such as for the most part you have de- scribed. In some cases the disorder was pre- ceded by derangement of the digestive organs —by fever of a malignant form—and in a few instances it followed diseases of specific con- tagion, variola and scarlatina. I have had no positive proof of a single instance of the com- plaint arising from the use or abuse of mer- cury : and moreover, the effects of calomel on the mouth and salivary glands, are different from those characteristic of this disease, even when this mineral induces sloughing, and proves fatal. This remark coincides with the observation of Dr. Hall. Those most vulnerable to an attack of this disorder, were from the age of two to five years, and whose muscular strength was debi- litated or reduced by irritation. At the time it prevailed in 1812-13, several instances were Q 122 seen affecting patients somewhat older. I saw one of a female child, aged about seven years. Cases of the complaint were always more frequent in the winter season than at any other; and during the periods when a humid atmo- sphere prevailed. It existed in the apartment? on the ground-floor of the Almshouse; and the little sufferers were generally, upon the ap- pearance of it, removed to a higher and better ventilated situation. Every medical man knows the pernicious effects which cold and moisture produce in children; and that those thus ex- posed, rarely escape disease of some sort. No doubt can exist that the diet of the house had also an agency in creating this disorder. We cannot deny the connexion and influence of local disease with general disorder of the di- gestive functions. To a vitiated or depraved state of the chylopoietic organs, must be at- tributed many of the cases we observe of local derangement of structure and function, whe- ther of the muscular fibre or of the osseous system. The sceptical may consult on this head, Abernethy on the Constitutional Origin and Treatment of Local Disease. The rapidity of this disorder was often asto- nishing, though in particular instances the patient lingered out some ten or fourteen days 123 from its commencement; and instances hap- pened in which the disorder persevered in its course, and did not terminate until twenty or thirty days. Cases also repeatedly occurred, in which an extensive sphacelus would be formed, and life itself be cut off within the first thirty or forty hours after the complaint manifested itself. Sometimes the upper jaw, at others the lower, and occasionally both jaws, would be the immediate seat of its inva- sion. The specimens I have, (presented me by the late Dr. De Puy,) are of the upper jaw; and this was in fact the part which, in a majo- rity of cases, was first attacked. In these specimens there is an entire necrosis. I regret I have not at command the interesting obser- vations this excellent man drew up concerning this disease, and which he read at a meeting of the Medico-Chirurgical Society. The disease frequently began about the edge of the gums, in contact with the necks of the teeth, say the incisors. The parts became tumid, with hardness and pain. Sometimes the larger part of the side of the face, about the seat of disease, assumed, with scarcely any premonitory signs, an erythematic aspect, and this was subsequently marked by spots of a dark purple or brown colour. Sometimes the 124 part became dark, and sphacelus speedily ensued; the flesh became loose and separated, and the whole emitted a fetid exhalation. The tongue was loaded with a foul sordes, and the breath was now excessively fetid. Coma took place, and the patient seemed to enjoy a truce from suffering. Death often suddenly occurred under these circumstances. In other instances, the teeth became loose at a very early stage: in these last cases, it was not uncommon for many of them to drop out by the slightest effort or motion. The necrosis would, in some subjects, involve full one side of the jaw, and the ulceration affect an equal portion of the soft parts, as also the alae nasi, the nose itself, and also extend to the cheek nearly up to the'orbit of the eye. When the sphacelated flesh fell in, the internal por- tion of the mouth was exposed. The lower lip also, in some few cases, be- came tumid, painful, and discoloured, and underwent morbid changes similar to those of the upper lip and parts. They spread in like manner from the gums, affected the teeth sock- ets, mucous surface, and cheeks. I do not recollect seeing any case in which other parts of the body participated in this peculiar ulceration. Authors have cited in- / 125 stances where superficial gangrene has taken place about the nates and genitals. I question, however, whether any such morbid recipro- city was observed in this disease at any season by the medical prescribers of the Almshouse. At the different seasons in which caries of the jaws of children occurred in the New- York charity, the disorders especially noticed as anywise prevalent in the city, were the measles, the varioloid disorder, pneumonia, and intermittent and remitting fevers. On the subject of treatment in this disorder, little need be said. After due attention to the state of the stomach and intestinal canal, bark, in substance or in tincture, was freely given, and the bark and yest poultice applied to the affected parts. The decoction of the snake- root and wine were also prescribed as a valu- able antiseptic. But the remedy of most available efficacy, was the saturated solution of the sulphate of copper, freely applied seve- ral times a day to the excoriated surface and ulcerations. A weak solution of the sulphas cupri was generally used as a gargle, and at times the ordinary washes of borax, alum, &c. But, as before said, the most general and cer- tain remedy was the saturated solution of the sulphate of copper. 126 If I have written to you at greater length than you desire, I trust the nature of the sub- ject will plead my excuse. Very truly your friend, JOHN W. FRANCIS. Dr. Sherrill. NOTES AND ELUCIDATIONS, NOTES AND ELUCIDATIONS. (1.) Page 15. Similar affections of the skin have been noticed by writers, as preceding great epi- demics. (2.) Page 18. The time has been, when cold water and cool air were in a measure shut out of a sick- room ; but modern doctrines and experience admit a free use of both, particularly in the early stage of disease. Although my patients have been indulged in the use of cold water, I do not recollect an instance in which it has proved injurious. It is the quantity of fluid taken into the stomach in most cases, more R 130 than the temperature, or any specific quality of the herb infused in it, that is serviceable in curing fevers, by diluting the fluids, and fur- nishing matter for perspiration: and when there is increased action in the system, the cold has a tendency to diminish that and les- sen heat. It is often difficult to get patients to take warm drinks in quantity enough to do much good, when they will take freely those that are cold. (3.) Page 21. Some part of the description of this disor- der, and the principles of treatment here de- tailed, are taken from a paper I wrote in 1813, while the disease was prevailing, which was published under the signature of " Medicus? in the Republican Herald of Poughkeepsie. (4.) Page 21. In some cases the ague lasted ten or twelve hours. A very long ague was commonly at- 131 tended with a torpid state of the system, when remedies, in ordinary doses, failed to produce the desired effect. This combination of cir- cumstances indicated an obstinate or severe casr of disease, which experience will teach is ..,wt confined to this disorder, but will prove so in other cases. It is an indication for greater perseverance in the use of remedies. (5.) Page 23. This appears to be the kind of pulse de scribed by Armstrong, and called a compres- sible pulse. It is particularly noticed by him as taking place in diseases of congestion. It is similar to what Dr. Rush terms a pulse from depression. When it takes place in the early stage of disease, I have uniformly known the pulse to become fuller and fairer after evacu- ations. This pulse is increasing in frequency in the diseases latterly prevailing. Dr. Rush, in his Observations on Hydro- phobia, has described a condition of the system, in which a pulse denominated the soap-bubble pulse may occur. The language is expressive of the fact. " The bilious fever in the South- 132 em States, we are told (says Dr. Rush), fre- quently exhibits this transition from an active to a feeble state of the arterial system. This soap- bubble form of disease appears likewise in madness, when it occurs in hard drinkers. After one or two bleedings, which are called for by the pulse, the system sinks into a prostrate state; and unless it be restored by prompt and liberal doses of opium, volatile alkali, and in some cases by ardent spirits, the disease some- times terminates in death." Dr. Rush adds— "The hydrophobia appears to be a fever of this kind." (See Dr. Rush's Letter to Dr. Ho- sack, in the American Medical and Philosophical Register, vol. iv.) This pulse is essentially different from what Dr. Rush terms the depressed pulse, or what others have termed the flaccid pulse of con- gestion. There is a striking practical prin- ciple always to be kept in view on the subject of the pulse of persons intemperate in the use of ardent or spirituous drinks; and nothing on this head can militate against what has been advanced in the text. 133 (6.) Page 26. The idea that spots or circular eruptions, or discolorations occasionally attendant on fe- vers, are an evidence of a state of real debil- ity, or of a typhoid state of the system, is found to be erroneous. It will be recollected, that it was an argument used in favour of the sti- mulant practice, and opposed to evacuations; that the disease was a spotted fever. Spots may be attendant on violent inflammatory action or depression; or they may be the conse- quence of real debility and exhaustion. When they occur in the early stage of disease, they are generally considered of the first kind, and are red and fiery. In the advanced stage of the case, they are likely to be connected with typhoid debility : in such cases they are dark, or of an inky colour. The character of this disease appears to differ somewhat from that which occurred in the Eastern States. An elaborate Essay on this disorder, the spotted fever, was published by Dr. Strong of Hartford; and the Massachusetts Medical Society also gave an interesting history of the complaint, in the second volume of their Com- munications. It is evident from these accounts, that under peculiar circumstances the com- 134 plaint exhibited a variety of character, both in the several affections, and in the order in which they occurred. Speaking of the spots on the skin, the Committee of the Boston Me- dical Society observe: " The spots on the skin are of various de- scriptions. They occur in all stages of the disease; less frequently, however, on the first than on the subsequent days. Frequently a rash, or miliary eruption only appears, or a few blotches on the inside of the elbow, and other similar parts; and it has been suggested, that these may be produced by the mode of treatment usually adopted. The blotches are florid, or red and fiery. An appearance like measles has also been noticed, and likewise vesicles and pustules, which have been com- pared to the vaccine and variolous eruptions. In some cases, these spots and eruptions have appeared at periods two or three times in the course of the disease. The vesicles and pus- tules are very frequently torn by scratching: after which, or without being torn, they are commonly followed by scabs of a brown colour; but occasionally they are followed by ulcera- tions, which do not heal until after recovery. " These affections of the skin are often at- tended with itching; and, independent of them, itching very frequently occurs, especially on 135 the third day, when the symptoms become more favourable at that time. This itching is sometimes extremely violent, so that the pa- tient will almost tear up his skin in endeavour- ing to alleviate it. All these affections are frequently noticed at the time when the more important symptoms abate, or subside. " In a few instances, vesicles containing a bloody fluid occurred in the county of Wor- cester. These vesicles were compared to blood-blisters, and were about the size of a large pea: they appeared in various parts of the body and limbs; in a few days they broke, discharged a bloody fluid, and scabbed over. In one case, in which the attack was very vio- lent, blisters resembling those produced by cantharides, appeared on the second and third day, on the breast and on one foot. They were about five inches in length, and nearly one in breadth. On the fourth day from the attack, some of those on the breast and that on the foot became black and dry, and the skin was sphacelated. The eschars, with due treat- ment, left clean ulcers, which healed without difficulty. The appearance of petechiae and vibices has been noticed: they occur in com- paratively few cases of the disease. They are of worse portent in proportion as they are 136 more dark-coloured. They do not, however, always occur in fatal cases, nor are they con- fined to such cases." In his observations on the epidemic pneu- monia, Dr. Low of Albany states, that in seve- ral instances the disease terminated by the supervention of an anomalous rash, which was very prevalent in that city during the whole winter. (See his Letter to Dr. Francis, in the American Med. and Philos. Register, vol. iv.) (7.) Page 27. In the attack from the diminished action of the vessels, of the skin, and the flow of blood to the heart and lungs, or from the depressing effects of the crudities of the alimentary canal, a chilling syncope or torpor was produced, which required, and was benefited by, cordials and stimulants, to aid the re-action of the sys- tem, which generally took place in a few hours, though in some extreme cases it appeared to last a long time; when it was proper that those remedies should be omitted, and the re- action met by the lancet, or some other eva- cuating remedy. 137 In Dr. Mann's Medical Observations and Collections on the Diseases of the Army, dur- ing the late war, are to be found some inter- esting remarks on the injurious effects of the stimulant practice, as used among the soldiers, as well as among the inhabitants, in many in- stances, in the vicinity of the army. The course of treatment, which Dr. Mann says was gene- rally attended with success, was very similar to that detailed in these pages. (8.) Page 29. Names in themselves are harmless, when they do not exert an improper or controlling influence over the minds or actions of men. They are, however, apt to have too much in- fluence in the treatment of diseases, by having associated with them a certain set of remedies in the cure, instead of taking into view the operations of the functions of the body, the beat of the pulse, the grade of excitement, and the state of the system generally. Thus, with intermittent fever, tonics and stimulants are associated as remedies; with pleurisy, blood- letting and other evacuations; with syphilis. s 138 mercurials, &c.; and with typhus fever, cor- dials, stimulants, &c. But in all these, and other cases, the system frequently requires a preparatory course of remedies, before com- mencing withlhose ordinarily used in the sim- ple systematic treatment. If the disorder which receives the name of typhus, does not happen to be that state of disease, but rather disguised inflammation or congestion, and early evacua- tions are omitted or prohibited, through fear of producing debility, there is great danger of bringing about that typhoid state of the system that had been so much feared. (9.) Page 36. From information received from various sources, respecting the mode of treatment pur- sued, and a comparison of the results, drawn from the various essays that have appeared on the subject, it would seem that the sweat- ing and stimulating plan, either alone, or com- bined with mercurials, was frequently unsuc- cessful in this part of the country. The plan of relying upon mercurials and sudorifics, un- less they were given in sufficient quantities to 139 produce free operations on the stomach and bowels, and bring about an early mercurial action in the system, was very frequently at- tended with unfavourable results. In what was termed the sweating stimulat- ing plan, the patient was put upon the use of hot stimulating teas and drinks, which were rendered more heating by adding to them ar- dent spirits, and that frequently in large quan- tities : hot fomentations, and other heating applications, were applied externally, so as to get the patient (as it was termed) into a hot sweat; and frequently this course was conti- nued throughout, under various modifications. This course was sometimes successful. Dr. Rush states, that stimulant remedies may, in some cases, be used in such an excess as to over- power the stimulus of the disease, by carrying the excitement of the system over the diseased action. This, however, he considers a course much more hazardous than to let it fall back, and take off the diseased action. It is, how- ever, to be observed, that the transition from the active to the passive state of the system, was sometimes quick, and in many cases it was proper to commence earlier with the use of nine and stimulants, than in many other diseases; and at this stage of the disease, 140 stimulants were sometimes called for very liberally. The heating sweating practice in the cure of diseases, has but recently been somewhat refined, and introduced with an ostentation of patent remedy, by what is termed Thompson's Steam or Vapour Bath;—by the process of which, it is said the patient is subjected to hot vapour for a length of time, without regard to the state of the system or grade of excitement. If this course, in many instances, does not pro- duce direct death, by forcing the fluids into vital parts, it is likely at least to convert a mild disease into one of a more obstinate and malignant character. The evil effects of using such remedies, in this way particularly, while there is fulness and increased excitement in the system, will appear in various ways. (10.) Page 37. Has there not latterly been rather a dispo- sition to recede in medical doctrines and practice from the cooling evacuating method, and to adopt the alexipharmic course, which Sydenham and many of his successors labour- ed to oppose and correct ? 141 (11.) Page 39. A lasting impression was made on my mind, in the early part of the prevalence of the dis- ease, on calling on an acquaintance in a town some distance of£ who was very ill with it. It was about the sixth day of his illness. He had tightness and pain in the chest, bloody expectoration, and a deathly countenance. He sat up in a chair, and showed me the spots, as he called them, on his legs, and concluded he was dying, as he really was. He expired in a few hours afterwards.. His legs exhibited the striped mottled appearance attendant on cases of depression or inflammatory action in the late stage, where evacuations have not been made. None had been made in this case. The kind of spots, or mottled appearance in this case, I believe were the principal ones attendant on the disease among us. (12.) Page 40. It so happened, that in the treatment of this disease, a considerable difference of opinion 142 occurred, and those who adopted the evacu- ating plan, met with much opposition and some obloquy from the prejudice that existed against it. But after a while, the prejudice so far subsided, (at least in most cases as far as I was concerned,) that there was no difficulty in carrying the course of evacuants into full opera- tion. How much this prejudice against evacua- tions has continued to sway the minds of medi- cal men, will not be attempted to be shown. After the adoption of these principles and re- medies, and this lapse of time, it is gratifying to find so valuable a writer as Armstrong ob- serve,—" But notwithstanding the improve- ments that have taken place in the practice of physic, there is still too general a dread of blood-letting in idiopathic fevers. The cool- ing mode of treatment has lessened in modern times the frequency of the putrid appear- ances, and the introduction of the purgative plan by Dr. Hamilton, has tended to diminish the number of malignant cases. Remarkable as it may appear, the fevers accounted the most malignant, require the most vigorous means in the onset. Cut short the inflammatory or congestive symptoms in the beginning, and nothing putrid or malignant will appear." 143 4 (13.) Page 41. The nursing of this poor man was humanely undertaken by Mr. J. Rogers, by whose kind- ness and constant attention much was done toward a successful termination of the case. (14.) Page 43. The general affection of the brain, attended with stupor and delirium, particularly in the early stage of the case, was an evidence of the determination of the fluids to that organ ; and the depressing effects produced by them, may be taken as one cause of the diminished cir- culation, smallness of the pulse, and torpor of the skin. The symptoms, taken together, seem to have produced that state termed de- bility from action or depression, by Dr. Rush, and congestion, by Dr. Armstrong. (15.) Page 45. Such is the disposition of many people to make use of ardent spirits, that they are ready 144 to seize upon any excuse of disease or medical authority to gratify that propensity. As a pre- ventive and a remedy for this disease, its use became very fashionable. This practice had its full share in exciting the disease into action, and of aggravating it when formed. But the evil did not end here. Its effects on the moral faculty became very perceptible; it operated as a passport to drunkenness; so that, amid the anxiety and gloom that was often spread in a vicinity, their use and effects were observ- ed so that intemperance mingled in the scene ! (16.) Page 56. The yellow fever. (17.) Page 61. The President is to deliver an address to the Society, at the end of each year after his election to office. {Extract from the By-Laws of the Dutchess Medical Society.) 14.; (18.) Page 63. Although blood-letting was occasionally used at times, the case became perplexing, connected with a wiry hardened state of the pulse, pain and soreness of the bowels; a state that opiates do not relieve, and astringents ag- gravate—it is more readily relieved by sudo- rific or evacuating means. In some late wri- tings, blood-letting is urged as an important remedy in the treatment, and a recent extensive opportunity for observing the progress of this disease, and the effect of remedies in it, has tended to confirm the remark made in the text, that in our climate it is advisable, in active cases, to use blood-letting, or some other active evacuating remedy, either before or soon after the free exhibition of opium. When these remedies are combined, united with calomel in liberal doses, and judiciously managed, a favourable influence is produced on the dis- ease. In many cases, particularly those of a mild nature, the method of giving ipecacuanha in infusion, or in small doses, with occasional opiates, is a very pleasant and successful way of effecting a cure. After all the plans pro- posed for curing this disease, it requires to be 14G treated somewhat according to the nature of the prevailing epidemic and peculiarity of the ease, which will show the uncertainty of a reliance on a particular plan, and the futility of recommending the various specifics and nostrums yearly published for the cure of dysentery. Where there is a congestive state of the system, or an active fever attending it, with a fiery red tongue and hot or husky state of the skin, as, when the disease is epidemic frequently occurs, blood-letting is very essen- tial, and in that state the use of opium in the early stage without it, is attended with un- happy results. (19.) Page 65. No one thing, perhaps, is better calculated to correct medical abuses and professional jealousies, than well regulated medical soci- eties. To effect that object, it is advisable to have judicious laws, and those regularly en- forced. 147 (20.) Page 67. The remittents that have prevailed latterly have not been attended with any prominent external symptoms of bilious affection, such as were exhibited at some former periods. The skin is seldom very yellow, and the tongue not particularly coated with bilious scurf; the substance of it rather partaking of a fiery redness. In many cases, considerable torpor of the system and huskiness of the skin has occurred. The remittent type of fever in some parts has, latterly, partaken of a very inflammatory character, and been frequently attended with much depression, which is to be relieved only by the liberal use of remedies adapted to this state of disease. (21.) Page 6& Such changes have taken place in the cha- racter of our intermittents, in many instances, that they frequently require the liberal use of 148 remedies to reduce increased excitement, be- fore the case is benefitted by tonics. The majority of cases that have occurred recently have recovered with the very sparing use of the latter remedies.* (22.) Page 68. The practice of giving opium is beneficial after the operation of cathartic remedies, par- ticularly at evening, and then in such doses as to allay the pain and insure sleep. For this purpose, from 50 to 100 drops of laudanum are often required. This practice aids very much in the cure, and is generally agreeable to the patient. * In the excellent remarks on intermittent fevers, in the nineteenth number of the New-York Medical and Physical Journal, it is observed, " sometimes, however, arterial action is elevated from the commencement, constituting the inflammatory diathesis of authors. Hence, in such cases, if the excitement be reduced by venesection, an emetic or a cathartic, according to existing circumstances, a less quan- tity of the curative agents will be required." 119 (23.) Page 73. On this very peculiar and interesting dis- ease, the reader might consult, with great ad- vantage, the interesting work of Mr. Cross, of Norwich, entitled, a History of the Variolous Epidemic which occurred in Norwich, in the year 1819, and destroyed five hundred and thirty individuals, with an estimate of the pro- tection afforded by vaccination, &c. This author's remarks on modified small-pox, are highly valuable. Several other able pens have been recently employed on the same subject. (24.) Page 82. In the town of Poughkeepsie, where the measles prevailed to an extensive degree, I am informed by Dr. Cooper, that the disease exhibited such an inflammatory character, as to be benefited, in many instances, by a libe- ral use of the lancet. He also observed, in that stage when there was a determination to 150 the lungs, emetics were used with beneficial effects. Dr. Barnes observed, he found occasion to use blood-letting frequently with great ad- vantage. (25.) Page 84. A number of cases of this description have been observed. One of the nicest points of discrimination, particularly in pneumonic dis- ease, is, when to give stimulants and when to withhold them. A pretty early use of them is, generally, agreeable to the friends, but sometimes fatal to the patient. (26.) Page 85. In some instances four or five bleedings were advisable. The necessary quantity had better be drawn early after the attack, though no pre- cise rule can be adopted for some time, parti- cularly in congestive cases. A[stricture across 151 the chest and tension of the pulse take place in the advanced progress of the case, when a small bleeding is of much service. It is fortunate that diseases are frequently removed and health restored by different modes of treatment, and perhaps most practi- tioners have one to which they are somewhat partial: but if we can arrive at a mode that is most likely to carry the patient safely through, it is an important point gained. That which appears to be among the best, the result of much research and observation, from its proving very successful, is the following. In an acute attack of inflammation of the chest, bleed from one and a half to two pounds, or until a disposition to fainting is induced. If the pain, stricture, and tension of the pulse continue, or return in twelve or fourteen hours, let the bleeding be repeated. Armstrong's direction is to continue it until the pulse flut- ters under the finger. Give Glauber or Ep- som salts, with tartarized antimony in small doses, so as to nauseate or vomit and gently operate on the bowels. After the arterial action is pretty well subdued, if the disease continues, though it frequently terminates here, give calomel, opium, and sudorifics; but before giving opium the evacuations ought to be such 152 as to produce a relaxation in the system, and take off inflammatory tension. The propriety may be doubted of giving calomel in these acute inflammations until about this period, as the preceding may be considered the stage or time most appropriate for venesection; after this, calomel and opium most readily affect the system. When it becomes necessary to contnue the bleedings to three or four times, as is fre- quently the case, a state of irritability of the system sometimes takes place, and a pulse of irritability supervenes, which is better learnt by observation than by description;* which state is most readily relieved by opium and calomel. At this period there ought to be a steady free exhibition of those remedies, until the circulation becomes equalised and a mer- curial impression is made on the system, when the patient is generally safe. The patient ought to be encouraged to drink freely, to which they are generally inclined, and commonly have a preference, for cold wa- ter, in the use of which I have often had plea- sure in seeing them freely indulge, notwith- standing the general prejudice against its use * For some useful observations on diseases and states of irritability, see New-York Medical and Physical Journal. 153 when they are taking mercurials. The force of this objection I have not been able to dis- cover—on the contrary, facts and experience prove it to be unfounded. It appears to be one of those errors about remedial means that have crept along through nurseries, and in the traditions of the good old women, without be- ing much noticed. By frequently gargling the mouth with cold water and drinking it, if pre- ferred, we prevent the mouth becoming sore, as it otherwise would. It is the application of cold, either of water or air to the skin, that is injurious during the use of mercurials-—by checking the perspiration and determining the medicine and action to the internal parts and glands of the mouth. This view of cold water is, I am aware, in a considerable degree, at variance with the views of John Pearson of London, concerning the treatment of the mer- curial eczema and excessive salivation. The use of opium to relieve a mercurial sore mouth, as alluded to in page 70, must be libe- ral to have the effect. Where disease has sud- denly given way, and the effect of the medi- cine on the mouth has become excessive, I have given large quantities at intervals of five or six hours, with very beneficial results. u 154 (27.) Page 85. The increasing number of consumptive cases in our climate, in some measure grows out of the frequent epidemic prevalence of inflammatory affections of the lungs : those being ill cured from the want of early deple- tion, or from a want of efficient means: or the patient neglecting to take proper advice, a consumptive predisposition is formed; and fre- quently not thinking themselves very sick, they are decoyed into the use of some of the nu- merous nostrums offered for the cure of coughs, colds, and consumptions!/ It is pro- per to observe, that this remark refers only to that species of consumption succeeding inflam- matory affection of the chest, or the pneumo- nicula of Dr. Rush. (28.) Page 86. Although there are many valuable practical maxims in Dr. Miner's book, his positions against the use of depleting remedies, if ap- 155 plied and carried into operation in the dis- eases of Dutchess County, as far as my obser- vation has extended, would be attended with serious and unfortunate consequences. Many of his views correspond with those of Armstrong, but the indications and use of the lancet, con- nected with the other remedies as recommend- ed by the latter, make an important part of the treatment. (29.) Page 86. It may be somewhat incorrect to state, that this disease is confined exclusively to the fe- male sex, although true childbed fever must necessarily be so. It seems one somewhat analogous may extend to other persons. In Campbell's Treatise on Puerperal Fever, it is observed, " we find a disease in no respects dif- ferent in males and in virgins in the unimpreg- nated state"—and " that women who were not in childbed, pregnant, or nursing, and even men, while the puerperal fever was epidemic, (in Edinburgh) were seized with symptoms resembling it, and died precisely in the same condition with those who fell victims to the dis- 156 ease of childbearing." Since the prevalence of this disease, more cases of inflammation of the abdominal viscera have occurred than I have observed in the same time at any other period. They have uniformly yielded to the same general remedies, that is, blood-letting, calomel, cathartics, opium, &c. Under this class of abdominal affections, the disease termed bilious cholic may properly be placed. This disorder, in a number of in- stances within our knowledge, has recently proved fatal. It may be successfully treated by liberal blood-letting, succeeded by calomel and opium. These remedies should be fol- lowed by gentle cathartics. It is not so impor- tant to produce a speedy evacuation from the bowels, as to relieve inflammation, and remove the stricture. When this is done, the bowels are generally easily moved. By irritating them at first with active cathartics, the complaint may be aggravated, and the object not attained. (30.) Page 92. The plan of treatment here proposed it is proper to observe, as far as bleeding is used, 157 is in conformity with the authority of Gordon, Hey, and Campbell, only it seems unnecessary to continue the bleeding as late in the disease as they, in some instances, recommend. In- stead of pursuing their subsequent treatment of purging with salts, &c. the practice is drawn from the principles of Armstrong, of using ca- lomel and opium in liberal quantities, and for the external treatment we have the authority of Campbell, " that while we are using the lancet the abdomen should be fomented." (31.) Page 93. By keeping the patient under the continued action of opium, so as to produce what may be termed an opium pulse, and allay the irri- tability. In this stage of the disease, opium does not appear to prevent the operation of cathartics, and perspiration is promoted. 158 (32.) Page 93. See note 26, on the use of blood-letting, ca- lomel, opium, &c. in cases of inflammation of chest. Also, refer to note 28, on the cure of dysentery. (33.) Page 94. In most cases where it is advisable to give large doses of opium in the early stage of dis- ease, it will be better to precede it by blood- letting, so as to produce a relaxation of the system, and partially empty the vessels. Oth- erwise, opium may have a tendency to increase the tension and fulness, and produce restless- ness and heat. May it not be from a want of attendingto this circumstance, that opium and the remedies used with it, often fails in reliev- ing tetanus and other spasmodic affections ? 159 (33.) Page 97. This symptom is somewhat peculiar to the disease, and is a very good characteristic. It is attended with difficulty of speaking, as though the patient was out of breath from running. (34.) Page 99. Since reading this paper, several other cases of this disease have occurred, that have come under our direction. They have all been successfully treated upon the same gene- ral plan. From among these, the following case is introduced. It shows that the loss of blood beforehand, does not prevent the dis- ease, as is remarked in page 100 and 101. Nov. 1825. B. P., aged 25, of a full ple- thoric habit, was taken in labour on Thursday the 24th. The labour was tedious, and the delivery was not accomplished until Saturday morning. She had been bled six times during her pregnancy, and once largely after labour had commenced. She took cathartic medi- 160 cines which operated freely, and seemed very comfortable until the 29th. 29th. This morning, at eight o'clock, she was attacked with severe pain across the ab- domen, and in the sacral region, attended by a very burning heat. The abdomen tumefied and extremely tender; skin dry; pulse mode- rately full, and the tongue white. Respiration difficult, and the countenance anxious. At two o'clock, took sixteen ounces of blood and gave three grains of opium, with ten of calomel. Applied strong sinapisms to the feet and fomentations to the abdomen. Eight o'clock p. m. Pain and tension some- what abated. Skin still dry. Pulse 100. Took sixteen ounces of blood. Directed ten grains of calomel, two of ipecacuanha, with the same quantity of opium to be taken du- ring the night. 30th. Six a. m. Rested tolerably well last night. Perspired very little. Skin still dry. Pain not severe, and tension gradually abating. Gave fifteen grains of calomel and one of opi- um, to be followed by an infusion of senna and manna. During the day, continued the infu- sion. The opium was also repeated twice in two grain doses. 161 Eight o'clock p. m. Has had several stools during the day. Very little pain. Skin still dry. Gave ten grains of Dovers' powder, and left two grains of opium to be taken at twelve o'clock. Dec. 1st. Eight a. m. Took the opium as directed. Pain and distension entirely subsi- ded. Pulse 90. Skin not moist, but felt natu- ral. Encouraged the evacuations by castor oil and gruel. From this period she gradually re- covered. (35.) Page 101. The puerperal fever, like other diseases, will, no doubt, be influenced by the nature of what other epidemic may be prevailing at the time, and have symptoms more or less varied in character, which will have a tendency to ren- der the case more difficult and perplexing, and sometimes may require a variation in the mode of treatment. In further showing the authority for the ex- tent to which remedies may be used in this and some other diseases, the following quota- tion from Campbell is appropriate:—" In any v 162 case, the condition of the circulation alone is to be our guide during the flow of blood, and the arm must be secured when the pulse begins to flutter. I have often heard men of great experience say, and I have had many oppor- tunities of knowing their sentiments to be cor- rect, that we seldom do harm by bleeding too much, but very frequently by bleeding too lit- tle. I wish this to be particularly kept in view in the disease under consideration; for 1 am persuaded, that if our assistance is called for, we have very little to apprehend from using the lancet too freely: and I am no less satis- fied, that in some cases, the contracted or ap- parently enfeebled state of the pulse, so cha- racteristic of abdominal inflammation, has often deterred persons from performing vene- section when it might have been done to ad- vantage." (Campbell on Puerperal Fever.') (36.) Page 108. Drs. Hosack and Macneven, at that time visi- ting physicians of the Alms House, were of the number. 163 (37.) Page 110. It may be stated, that when there is disco- vered a disposition to this disease, it would be advisable to pay particular attention to the state of the digestive organs. The blue pill, combined with some gentle laxative or tonics, would be very appropriate remedies. In this and some other diseases, when the general health needs improving, the best remedies are those that correct the secretions and actions of the bowels, combined with, or followed by, tonics. (38.) Page 111. The sulphate of quinine now in use, would doubtless be a useful remedy. 164 CARIES OF THE JAWS OF CHILDREN. Since the observations on this disorder in a former part of this work have been printed off, I have received the following : New-York, November 1,1826. dear sie, Since the date of my communication to you on the subject of Caries of the Jaws of Children, Dr. Coates of Philadelphia has pub- lished an excellent paper on the disease, in the third number of the North American Me- dical and Surgical Journal, which I am pur- suaded it would be serviceable to insert in your contemplated work. Dr. Hosack has fa- voured me with an interesting notice of an analogous disorder, which he has generally no- ticed in his annual course of lectures on the practice of medicine. I take the liberty of enclosing to you his remarks. " Analogous to this peculiar disease is the sphacelus of the cheek, which follows the ulce- ration so often occurring in the mouths of chil- dren, as symptomatic of teething and a de- ranged condition of the digestive organs." " I saw this disorder many years ago. Se- 165 veral cases I have noticed in my lectures, one of which occurred in a child, aged about six years, in the Alms House of Alexandria, du- ring my residence there in 1791, and which proved fatal within a few hours from its com- mencement ; sweeping away the soft parts of the cheek and jaw, even to the internal fauces. The nature of this disease of the animal body may be, in no imperfect manner, illustrated by reference to that occurring in the vegetable structure, especially in the cactus coccinelli- fer, denominated by Monsieur Thierry, in his Natural History of the Nopal of the West- Indies, la dissolution, so called from the rapid destruction which the disorder produces in this plant. In the morning the cactus is, to all appearance, in perfect health; the disease begins by small spots; in the course of a few hours these diffuse themselves, and terminate in the decomposition or sphacelus of a great portion of the plant. It is for the most part ascribed to an inordinate plethora, occasioned by excessive rains." With due regard, I remain yours, John W. Francis. 166 Extracts from Dr. Coates's Essay. Locality of the Disease.—The Philadelphia Children's Asylum is situated in South Fifth- street, between Prime and Federal streets, in the district of Southwark. The soil is what is called alluvial, or rather diluvial; as is well known to be the case with all that district, lying south of Philadelphia, as well as the southern part of the city itself. The house was built, and for many years occupied, as a mansion, by the head of a most respectable and wealthy family. Its situation possesses some of the qualities usually selected in choosing the site of a country seat. The buildings stand on a swell of ground, leaving an open lawn, now interrupted by several un- occupied streets, and extending, on the right hand, to the banks of the Delaware, and, on the left, to the Navy Yard and part of the suburb of Southwark. Towards the north, it is not far from the edge of a thickly built ap- pendage of the city. The district immediately south of the Asy- lum is marshy, and has long been noted for the prevalence of intermittent fevers ; but the slightly elevated site of the building had been 167 generally healthy, and continued so, till the universal and distressing epidemic, which in- fested all the outskirts of Philadelphia, in 1822 and 1823. Even at this period, the per- sons resident at the Asylum, were far from suf- fering so severely as the adjacent neighbour- hood ; and, since those years, it has again be- come, in general, tolerably healthy. In 1819, 1820, 1821, and 1822, a lot, situated at a short distance, on which were deposited the con- tents of a number of privies, proved a source of great inconvenience, and some disease, at the Asylum. This focus of effluvia, together with the general and copious use of similar materials in manuring the adjacent fields, oc- casioned an intolerable stench, and generated diarrhoeas, in the early part of the spring. When the grass and weeds, however, were grown sufficiently to protect the surface of the soil from the sun and wind, this effect en- tirely ceased; and I know not that any other inconvenience was experienced from the same source, unless we attribute to this, as may fairly be done, the destruction of the purity of the well. This formerly afforded very good water; and, since that period, it has much improved. When the corporations of South- wark and Moyamensing shall introduce, as it 168 is to be hoped they will, the Fairmount water into their streets, one remaining cause of in- convenience and ill health will be removed from the Children's Asylum. Description of the Disease.—The ulcer of which we speak, may begin in many parts of the mouth. In by far the greater number of cases, however, it commences immediately at the edges of the gums, in contact with the necks of the teeth, and, most generally, of the two lower incisors. A separation is found here; which exhibits a slight loss of substance at the extreme edge of the gums, and, as far as I have observed, a whitishness of the dis- eased surface. In some instances, though not very frequently, this is preceded by a slight swelling and redness. In this state, the disease may continue for a long time; and I have reason to believe, that pa- tients have remained thus affected, during the whole period of three months, for which I at- tended the Asylum. At one time, when the disease was at its height, threatening seve- ral patients with destruction, I found up- wards of 70 children, out of a population amounting to about 240, more or less affected with these ulcerations. No remarkable change 169 is at this stage observable in the functions of the little sufferer, except a general air of lan- guor and weakness. The appetite and the muscular activity continue, but are somewhat reduced; not sufficiently, however, to disable the child from attending school, taking the air, or continuing his ordinary practices. In this state, no symptoms of irritation have been at all discovered. The skin is cool during the day, no pain is complained of; and no account has ever been given me of any nocturnal pa- roxysm of fever. It would appear to be purely a state of asthenia. We are, however, by no means certain, that there was no concealed irritation in the system. We were, of neces- sity, obliged to depend, in a great measure, upon the reports of nurses, and other females : and these were liable to overlook, or mistake for mere weakness, the signs of an obscure disease. In this manner, commencing cases were frequently not discovered, and nothing was done till the affection had made further progress; and this continued until the ascer- tained existence of the epidemic in the house, combined with the recollection of its former ravages, had excited an alarm which led to an inspection of all the mouths of the children in the institution. w 170 The disease, in this form, must be within the curative powers of nature; as, if this were not the case, we should hear of more nume- rous unfavourable terminations. It has sel- dom, however, if at all, been within my power to witness this tendency; and, when not con- trolled by a particular treatment, the cases have almost always either remained stationary, or increased in severity. Its first progress is, most generally, by extending to the edges of the gums round other teeth; frequently affect- ing a large portion of the dental arches. A very early progress is, however, mostly effect- ed, down the length of the tooth, in the direc- tion of the socket; and, in this way, the dis- ease commits great and unexpected ravages. When it reaches the edges of the bony socket, the tooth begins to be loose, and when drawn, exhibits portions of the fang, including parts which had been contained within the alveolus, entirely denuded of their periosteum. Indeed, from observation, I should say, that the latter membrane was the part, which was the most peculiarly liable to injury and death from this disease; and it is by no means clear, to my apprehension, that this is not frequently the commencement of the complaint. The injury generally proceeds with augmenting rapidity; 171 especially when it has affected the deeper parts: and it is while in the act of rapidly spreading, that it occasions gangrene. In the production of gangrenous sloughs, it much resembles the descriptions usually given of sloughing ulcers. A portion of the parts immediately subjacent to the ulcer loses its life; this rapidly separates: and, before or after a complete removal, a fresh slough is formed in the same manner. The sloughs are generally black, with ash-coloured edges. I have not been able to discern a change of co- lour, the production of vesicles, or any mate- rial tumefaction, as antecedent to the gangrene. There is, generally, by this time, an increased heat in the parts; with the sensation termed " calor mordens." The discharge now, for the first time, becomes acrimonious; giving pain when it comes in contact with cuts in the finger; and excoriations are produced on all parts in contact with the sloughing ulcerations; as the lips, the cheeks, the tongue, and the ad- joining surface of the part where the ulcer is situated. As soon as the external gangrene has reach- ed the level of the edge of the bony socket, and frequently much sooner, the adjacent por- tion of the latter is found deprived of its life; 172 forming a necrosis. The death of the perios- teum in the socket, at least that of the fang of the tooth, precedes, by some interval of time, that of any portion of the bone itself. When gangrene is formed, a fever of irrita- tion is generally developed. In regard to the time at which this takes place, there is a great diversity in different constitutions. It has ap- peared to me to depend, principally, upon the inflammation of the mouth, which is secondary to the original disease, and, in most cases, to arise from the acrimony of the discharge. It is aggravated by loss of rest, want of nourish- ment, and, probably, by putrid matter finding its way into the stomach. To the latter cause I also refer a diarrhoea, which almost uniformly comes on, towards the close. There are accounts of a similar disease having begun on the inside of the cheeks. I have, however, never seen a well-marked in- ' stance of this; the cases which were sup- posed to be such, having, in every instance, been also found to exhibit ulcerations at the edges of the gums. That the disease spreads from the gums to the cheek, is a fact which I have often seen exemplified. It is, indeed, the most usual termination of bad cases. After producing gangrene and necrosis in the gums 173 and alveoli, and after the discharge becomes, as above stated, acrimonious, a gangrenous spot is not unfrequently found about the open- ing of the Stenonian duct, on the inside of the upper or lower lip, opposite the incisors, in some other part of the inside of the lip or cheek, or in more than one of these situations at the same time. Whether this be owing to excoriation from the discharge, or to some other cause, I cannot say; it has, however, in every instance which 1 have seen sufficiently early to witness its rise, been subsequent to the symptoms previously described. When the gangrene reaches the cheek or lip, however, very active inflammatory symp- toms are uniformly developed. In the cellular substance of these parts, they assume the well known characters which have been attributed to the phlegmonous species. We have a great thickening, forming, in the cheek, a large, rounded, prominent tumour, with great heat and pain. Sometimes redness is perceived externally; but, more frequently, the great distension of the skin of the cheek seems to empty the cutaneous vessels; giving to the part a smooth, polished, dense, white appear- ance, very much resembling the effect of a violent salivation. I have no doubt that this is 174 the tumour described by Poupart, and alluded to in an earlier part of this paper. Great thickness and hardness have always occurred, in the other situations where this gangrene has approached the external cellular masses of the face; in the lip, however, they are less re- markable, perhaps from the smaller amount of cellular matter. After reaching this stage, a black spot is frequently seen on the outer surface of the swelling. This spreads rapidly; and has always been, in my own experience, the immediate harbinger of death. It is pro- per to state, however, that I have heard it said, that cases had recovered in this city, in which the gangrene had produced a hole through the cheek. Under what physician's care this oc- curred, I have never learned. In two cases it commenced in the fauces; and was marked by the same unsuspected pro- gress. In one of these, the little patient was remarked to be languid, but had no positive external marks of disease. The mouth was examined, and found healthy; but no suspi- cion of the real situation of the disease was entertained, till after three or four days more, when he complained of a slight sore throat. ' A large gangrene of the tonsils, half-arches 175 and pharynx, was now found; and the event need hardly be told. The closing stage of this affection is mark- ed by large gangrenous patches in the gums ; deep fissures between these and the teeth; the latter loose, or falling out; large pieces of the alveolar processes, often containing the roots of several teeth, in a state of entire ne- crosis; the whole lining membrane of the mouth suffering a violent excoriation; the whole adjacent external cellular substance, hard and swelled; large gangrenous spots in the inside of the cheek or lips, occasionally extending quite through to the outer surface; a total incapability to sleep, or to take the least food; fever; a swelled abdomen, and diar- rhoea. AN ACCOUNT OF THE DYSENTERY, AS IT PREVAILED AT HYDE PARK, N. YORK, In the Summer and Autumn of 1826. An unavoidable and unexpected delay in get- ting this Work through the press, has furnished an opportunity of complying with a request of several of my friends, to add a short account of the Dysentery that has prevailed at Hyde Park this season, with unusual severity. The early part of this year and during the spring months, an inflammatory affection of the chest prevailed to a considerable degree, and extended through the whole county. It as- sumed the different types of pneumonia, pe- ripneumonia, &c. During the first summer months, the weather became extremely dry, so that from the beginning of May to July the greatest drought occurred, atthisseason,known in this part of the country by the oldest inha- bitants. After this, the weather became rainy, x 178 the temperature variable, and the changes sudden. The period of the drought was unu- sually healthy. After the damp weather set in, the fevers of the intermittent and remit- tent kind occurred to a moderate degree. They partook of such a character as to exhi- bit symptoms of more congestion, or increased excitement, than we usually meet in remittent fever at this season of the year. About the first of August, a disease of a dif- ferent description made its appearance at the landing, on the east bank of the Hudson river. It was a severe case of dysentery, combined with a fever of the character that had been moderately prevailing. The case terminated fatally. It is worthy of remark, that this case occurred in a temperate young man who had laboured about the dock and on a farm. He bad not been in any way exposed to dysentery, or impure air. The banks of the Hudson here are elevated, dry, and rocky. This and one other were the, only cases that occurred in that house, although it contained a large family. But several of the attendants who had been with him and gone away, took the disease. It spread regularly along the street east from the river about a mile, and from this, moderately about the country; so that the only family in 179 the street that escaped having more or less cases, (and in some instances almost every one had an attack) was a French family. Around this place there are four of these families, who all escaped the disease. North or south of this street, there were only a few cases. In several instances patients who sickened with it here, were moved out of the place; some of them some miles into the country, where they had the disease severely. The families to which those cases were carried, all took the disease, and in most instances they suffered very much from it; several of those cases ter- minated fatally. Except those families, very few cases occurred in those neighbourhoods. But from all the information we have been able to collect, the sporadic cases were, in pro- portion to the number, the most severe; as among them the proportion of deaths were the greatest. When the dysentery made its ap- pearance there seemed to be a struggle be- tween that and the fever that preceded it, for the ascendancy in their action on the system, so that the cases frequently became perplex- ing and obstinate. It exemplified the obser- vation long since made by Sydenham, and re- peated by some of our older practitioners, that every epidemic return of dysentery re- 180 quired a study of its character anew, and from a want of sufficient time from the sudden and violent manner in which it commenced, to ac- quire this knowledge, may be, in some mea- sure, attribuled the fatal termination of the two first cases. In making this confession, I am no less candid than were Sydenham, Rush, and Bard, who admitted that they generally lost some of their first cases in an epidemic, before they could have an opportunity of stu- dying the peculiarities of the disorder. In some cases the dysenteric symptoms com- menced with severity and run on several days, when they abated and a fever, more or, less severe, became the principal disease. In others, the fever was antecedent, and conti- nued some days, when it would terminate par- tially, and severe dysentery supervene, and frequently both were united in an active form. The termination of the active form of dysen- tery, was as sudden as it commenced. After the fifth of September new cases rarely oc- curred, and a fever of an active, inflammatory, remittent type succeeded, and spread more extensively around the country. The mildest form of dysentery commenced with languor, wandering pains in the abdomen, nausea, and sometimes vomiting, followed by 181 mild diarrhoea, the patient still attending tahis usual occupation The stools gradually be- came more frequent as the disease advanced, accompanied with a dull heavy bearing down pain. The discharges were of a whitish slimy appearance, and streaked with blood. The skin was generally dry, but not hot; the pulse a little quickened, and rather fuller than natu- ral. The tongue was of a fleshy red colour on the edges, and the middle covered with a yellowish white scurf. Cases of this description were most success- fully treated by emetics of ipecacuanha, suc- ceeded by cathartics of senna and manna. with sulphate of magnesia or castor oil. The emetic produced the best effects when give»~ in small doses, so as to produce considerable nausea before it operated. These evacua- tions, if the disease continued, were immedi- ately to be followed by calomel and opium in liberal doses, as recommended by Armstrong. Five grains of calomel with as many of Do- vers' powder, were repeated every third hour until the evacuations changed to a yellowish green. Fifteen or twenty drops of laudanum after each stool were frequently required to quiet the griping and tenesmus. With these remedies were also recommended the free use 182 of mild diluents, such as barley water, weak chicken tea, or a mixture of isinglass with gum arabic. Under this treatment, the disease rarely continued longer than the fourth or fifth day. But in the more violent cases, all the symp- toms assumed an aspect of severity. The skin was hot' and dry. The tongue contracted in its substance, and thickly coated. On being thrust out of the mouth, it was very sharp- pointed, and had a peculiar tremulous motion. The pulse was sometimes firm and tense, but generally soft, quick, and compressible. This kind of pulse, probably attends conges- tive diseases of the abdomen where there is a partial reaction. The dejections were small in quantity, but frequent and extremely pain- ful. They were principally blood, accompa- nied with small quantities of slime and detach- ed portions of the mucous membrane. The tenesmus was almost constant, and in children, prolapsus ani very troublesome. The abdo- men was not much distended, but very tender to the touch. The countenance appeared heavy, and the respiration laboured. In the treatment of this variety, those cases in which reaction had not come on were most benefited, at first, by the warm bath and an 183 emetic. By this course, reaction was most ge- nerally brought on in six or eight hours. Af- ter this was fairly established, blood-letting was attended by the most happy effects. The quantity of blood drawn, was governed solely by its effects. In the commencement it was continued until fainting, or some degree of re- laxation was produced. A dry hot skin was rendered moist by this remedy, and the exces- sive discharges of blood much less frequent and copious. At this stage of the disease, if the urgency of the pain required it, opium was given in doses from one to four grains; b ut when the pain was not severe, it was better to withhold it entirely, until further evacuations had been made by cathartics. While the tongue retained the peculiar thickened sharp form, and red and fiery edges, opium was sel- dom of service, often otherwise, although the pain sometimes rendered it indispensable. One of the best indications of the mitigation of the disease, and for the use of opiates when the symptoms otherwise indicated them, was the changing of the tongue towards its natural colour and shape. As a cathartic, that for- merly mentioned, seemed, also, well adapted to this stage. After evacuations had been freely made, the bowels were still kept open 184 by mild cathartics and opium combined with calomel, in doses sufficient to quiet all pain and irritation, was continued until the disease was subdued. If the skin was not rendered moist, the pulvis antimonialis or. ipecacuanha combined with the above remedies generally answered that indication. It was generally unnecessary to continue calomel after the stools had become of a yellowish green. The mouth rarely became sore. When the dysenteric symptoms abated, and a remittent supervened, the treatment recom- mended for that disease, without any regard to the dysenteric affection, was adopted. It gene- rally required a continuation of sudorifics, ca- thartics, &c. ERRATA. Page 13, line 17, for town read towns. 25, .. 3 from bottom, for that read another. 29, .. 2 from bottomjjfor mustilating read stimulating. 58, .. 8 from bottom,/or treating read tracing. V" ',*V . ;t I* * 'V VV/Y-- :»**; ;« **?ji ?*: