NIC. UNITED STATES OF AMERICA FOUNDED 1836 WASHINGTON, D. C. OPO 16—67244-1 52540668 X** . _ PRACTICAL ATTON£ ON THE MATURE AND TREATMENT MARASMUS^ AND OF THOSE DISORDERS ALLIED TO IT. WHICH MAT BE S^BICTLT DENOMINATED .^BILIOUS. Vol . - r- yj Bf .JOSEPH AyRE, M.D. Member of the Royal Medical SoeiKy of Edinburgh, one of tb<" Physicians to the General Infirmary at Hull, Senior Physician «^o the Hull and Sculcoates Dispensary, and Physician in ordinary to the Lying-in Charity at Hull, NORTHAMPTON, Mass. 2TTBLISHED BY SIMEON BUTJ.FR. J. Melcalf....Printer. 18.2. A',' vMX'x A/ A often unexpectedly relieved by a return of the spontaneous and more productive loose- ness, which carrying off the irritating matters from the bowels, relieves the system, and sometimes restores the morbidly craving ap- petite. The relief thus afforded is, however, only of a partial kind, for the wasting of the flesh and strength proceeds, notwithstanding the renewal of the appetite ; the infant dying at length in a state of extreme emaciation and weakness, discharging the food from its stom- ach and bowels, during the last few days of its life, in a most offensive and putrid state. The complaint, as it appears in children un- til the age of three or four, will often resem- ble in its symptoms, and in the rapidity of its course, the form which it assumes at the ear- lier periods. As we advance, however, be- yond this latter age, there is some variation observable, the chronic form of it running less readily into the acute state, from the diminish- ed tendency to febrile and convulsive action which is manifested by children as they ad- vance in age. The chronic stage of this disorder in child- ren, commonly makes its approach insidiously little more being remarked at first than a crav- ing appetite for food, which is easily mistaken 15 for a fuller indication of health. In a short time, the countenance begins to lose some- thing of its natural animation and blooming look, and the child is reluctant to rise at his usual hour in the morning, and when he has risen, is importunate to be nursed, or is desir- ous of sitting still near the fire, abandoning those active amusements in which he before delighted. He complains of being chilly and tired, and of having an aching pain principally in the knees and lower part of the thighs, and which is worst when first sitting down after walking. He is dull, fretful, and readily weeps from causes that he would formerly have dis- regarded. The breath is foetid, and there is commonly an itching about the nose, and an increased mucous discharge from it, along with a slight pain or dizziness in the head, and sometimes an uneasiness in the stomach or bowels. As the afternoon approaches, the child appears more languid, and is desirous of going to bed early. He falls asleep readily, and sleeps more soundly through the night than usual. The tongue is white before the breakfast is taken, and the bowels are either regular or loose, the discharge being scanty, and rather unnatural in its appearance. As the disorder advances, there is a dispo- sition in the patient to faint, and he is inclin- 16 ed to sleep during the afternoon, becoming watchful for the first few hours of the night. When asleep, he often perspires about the head and neck, and moans or talks, or grinds his teeth, and sometimes starts, awaking sud- denly from fear inspired by his dreams. A tickling spasmodic cough, coming on in the evening, and recurring at intervals through the night, is a very common symptom. When violent, it gives rise to retching, and some phlegm is brough up into the throat from the stomach, which often excites a suspicion in the attendants of an incipient pertussis or con- sumption. The breathing, during sleep, is hur- ried and louder than usual, and the pulse is full and preternaturally quick. The tongue is white, and the bowels alternately loose and costive; the craving appetite generally fail- ing as the looseness abates. The motions are scanty, and altogether unnatural, being dark and slimy, and often of different shades of green, and sometimes of a light colour. The appearance of the water is various, and its indications uncertain ; the skin is harsh and dry. Through the whole progress of the disorder, the flesh and strength waste, whilst the body frequently becomes swelled. Dur- ing some time, the appetite continues to be craving, for, however plentiful has been the 17 meal, the desire to eat again is soon renew- ed. The patient at length begins to throw up his food, and as the complaint advances, he becomes difficult in the choice of it, and though frequently asking for it, yet eating but little, the appetite being only good when a choice or novel kind is offered, and a pref- erence is often shewn for that which is dry, as bread that has been some days baked, pie crust, &ic. Should any of the remote causes of the disorder be even now slightly applied, such as cold or improper diet, &c. the acute stage becomes immediately formed. Nausea is now felt when an attempt is made to eat. There is much thirst, with considerable quickness of pulse, and a high degree of fever during the afternoon and night, with only slight and im- perfect morning remissions. The restlesness until some hours after midnight, is often ex- cessive ; the breathing during sleep, is hurri- ed and louder than natural, and the skin hot, particularly about the head and body. The child screams, and sometimes raves in its sleep, and awakes in such distress and fear, as to be with difficulty pacified. There is oft- en considerable pain in the head, or stomach, or bowels, which is increased during the night. The tongue is covered with a white 18 fur at its middle and posterior part, and the tongue itself appears redder than usual, the inflamed and tumid papilloe projecting through the white fur : during the night it is dry. The urine is scanty, and high coloured, and turbid, and often discharged with pain. The bowels are commonly costive, and are moved with difficulty ; their contents are dark and sometimes slimy, yeasty in colour and consis- tence, and of a sour and highly offensive and unnatural smell: the complexion is sallow and the whole countenance appears languid and sunken, and somewhat fatuous. The complaint, when it attacks the adult in the chronic form, generally comes on in the same gradual manner, and with nearly the same symptoms as in the child. The craving appetite is among the earliest observ- ed. The patient complains that the food ap- pears to do him no good, having an empty and sinking feeling at the stomach, which is only temporarily relieved by eating, for he feels shortly after a meal as if he had long fasted, and is again desirous of taking food. He is listless and drowsy, and chilly, during the day ; complains of an aching in the knees and ankles, and of slight vertigo and dimness of sight, and feels an inaptitude for mental exertion, and dejected from no assignable 19 cause, becoming fatigued, and readily pers- piring, from even moderate exercise. In the early stage, the sleep is often unusually sound, but at the same time unrefreshing. As the complaint advances, there is consid- erable restlesness for a few hours during the early part of the night, and the sleep is often broken by frightful dreams, from which the person may fully awake, yet feel a difficulty for some little time in satisfying himself of the unreal nature of the danger with which the vision threatened him. His complexion ac- quires a decidedly sallow hue, which is partic- ularly seen in the forehead and back part of the hands, and the eye loses a portion of its accustomed animation. There is constantly a loss of strength, and generally, though not invariably, a wasting of the flesh from the commencement of the complaint. The bow- els are sometimes declared to be regular, though more generally they are admitted to be costive. Their contents are various in their appearance, but always unnatural, being fre- quently of a black green and slimy, and often parti-coloured, and sometimes of a drab col- our and more or less offensive. The urine is commonly turbid and high coloured, but it is sometimes clear without being accompani- ed with any distinguishable variation in other 20 symptoms. The tongue differs much in its appearance in different individuals, under ap- parently the same circumstances, and in the same individual at different periods of the complaint. It is generally dry and likewise furred of a morning, especially at its posteri- or part, becoming sometimes nearly clean af- ter breakfast. The pulse undergoes scarce- ly any sensible alteration, excepting in irrita- ble habits, when it is quicker than natural. There is seldom much thirst, but there is commonly a little heat about the head and breast in the early part of the night, with a ready disposition to perspire profusely, at the same time that the feet are cold. On first rising of a morning, the patient is ready to persuade himself that he is well, and generally begins, as he terms it, to fall off towards eleven or twelve o'clock, becoming more indisposed as the evening approaches. The cough, which is met with so commonly in infancy and youth, in both forms of the complaint, is of less fre- quent occurrence in those of the middle and advanced age, excepting in the acute stage. The duration of the chronic stage varies con- siderably. I have known it continue several months, and even years, with only an occasional abatement or aggravation of its symptoms, and '•■t length suddenly pass info the acite state 21 When the acute stage is fully formed, the appetite is commonly extinguished, the very sight and smell of meat having a sickening effect. The patient, indeed, has a great re- pugnance to every sort of sustenance, espe- cially to the kind that he has been accustomed and even partial to, and finds a very particu- lar dislike to bread, and to his hitherto, per- haps, favourite beverage, tea. There is con- stantly, either an oppressive feeling, or an acute pain in the region of the stomach, or in one of the sides, generally the left, or in the bowels, striking to the back, which is worse towards night; where the pain is very se- vere, it is commonly aggravated by the re- cumbent posture. The patient is greatly dis- turbed in his sleep, awaking sometimes in considerable and unde finable terror, and rising hastily from his bed, under the impression that he cannot continue to breath in it. The restlesness during the night, is commonly in- deed excessive ; and even in those cases where the pain and fever are inconsiderable, there is often such a degree of watchfulness, and so great a dislike to lying down in bed, as not only to preclude the power, but even the desire, to sleep. There is always some heat of skin, with thirst towards evening, and dur- ing the night, and an increase generally in 23 vhe quickness, although but little in the force, of the pulse. The tongue is furred, and dur- ing the night it is dry. The water is scanty and turbid, and high coloured, resembling frequently the highest coloured porter, par- ticularly in those cases where the '■fain in the region of the stomach is greatest. The bow- els are costive, though they are sometimes believed by the patient to be regular ; occa- sionally they are loose. Their contents are frequently of the colour of light yeast, or they are dark and even perfectly black, re- sembling tar in colour afld consistence, and of an exceedingly offensive, and often putrid smell. In the foregoing account of the symptoms of this complaint, there are included all those which are usually met with in it. It is not, however, to be understood, that they are all present in every case, though a very consid- erable proportion of them will be found to be so. Sometimes, as we shall now proceed to notice, one or more of the symptoms so predominate over the rest, as to impart to the disorder a striking resemblance to some important disease; and at other times, we meet with it under appearance so disguised, as to give to it something of the character of an anomalous and undefinable affection ; for there are few disorders, perhaps, in the whole range of nosology, which present great- er variety of morbid, and what to many must seem anomalous, appearances, than is afford- ed by this, nor concerning which there is at times more difficulty in forming an accurate diagnosis. In infancy, it is frequently con- founded with the irritation proceeding from difficult dentition, or from the presence of worms in the intestinal canal. Sometimes, it resembles the tabes mesenterica so closely, as to require the most minute inquiries to be made respecting its history and progress, whilst on other occasions I have seen it as- sume many of the generally supposed diag- nostic symptoms of hydrocephalus internus. In its ordinary and chronic form, it is sever- ally confounded with dyspepsia, and with the mild hysteria of women, and hypochondriasis of men ; and whilst it passes under the name ef chlorosis in the youth of one sex, it is fre- quently denominated a chronic weakness in the other. The more important diseases, however, with which it is perhaps most lia- ble to be confounded, and from which it is of most importance to distinguish it, are the an- asarca of debility, phthisis pulmonalis, and the organic and inflammatory affections of the 24 liver; to all of which it occaisonally bears a striking resemblance. The swelled, inflamed and irritable state of the gums of infants, which is attributed to some natural difficulty in dentition, may be considered generally as a symptom only, and not as it is commonly thought, a cause, of this complaint ; for it has frequently occur- red to me to observe, that symptoms, suppos- ed to arise from teething, have yielded read- ily to the remedies adapted for this com- plaint ; the inflamed and tumid appearance of the gums, at the same time, subsiding with- out any visible advancement of the process of dentition. On these occasions, it appears, that the vessels subservient to dentition, are sympathetically excited, whereby the growth of the teeth is accelerated, or otherwise de- ranged, and a sensibility induced in parts, which in their healthy state, are free from it. And that the connexion betwixt difficult teething, and disordered states of the diges- tive organs, admits of this explanation, will appear the more probable, if we reflect upon the numerous instances, which are daily pre- sented to us, of apthae and other inflammato- ry affections of the mouth, orginating from such disorders; and that as dentition is most painful and most dangerous, to those infants) 25 which are reared without the breast, so as I have had frequent opportunities of knowing, it is a simple and easy process to those, who, for the first six or eight months of their lives, are exclusively confined to it. The ease, in fact, with which the teeth are cut, depends upon the healthy state of the digestive organs of the infant; and hence the prevalency of that popular notion among the peasantry of Scotland, that frequent exercise in the air will insure their infants from all suffering in dentition. That the pain and irritation of the parts surrounding the teeth, rendered morbidly sensible by inflammation, will be capable of aggravating the complaint that induced it, and be, even of itself, sufficient to excite con- vulsive and febrile action, must certainly be admitted, as well as the propriety of reliev- ing the inflamed and distended parts about the teeth by lancing them ; but the disorders, aggravated or induced by this stale of the gums, and the relief afforded by the lancet^ no more prove its idiopathic nature, than can the irritation excited by apthae in the mouthy or the relief procured in that disease from to- pical applications, be allowed to invalidate the facts, which establish the nature of their origin. Nor is the view here entertained,. 36 respecting the relation which marasmus beans to difficult dentition, of little practical impor- tance ; for if, instead of being regarded as the cause, it be viewed as an effect of that complaint, it will necessarily be treated as such, and those important means, medicinal and dietetic, for its removal or prevention, be consequently neglected. Nearly similar observations are applicable to the generally supposed connexion of worms with the fever, and other symptoms of this Complaint; for, after several years' attention directed to this subject, I am satisfied of the justness of the opinion entertained by many, that the round long worm (the only kind that is considered capable of exciting this disorder in children) is never a direct cause of fever, for I have repeatedly known them to be pas- sed without any accompanying indisposition, and have, comparatively speaking, but rarely met with them in this disorder ; and seldom indeed, in the instances where they wer« met with, have 1 had reason to conclude, that their removal had promoted the recovery. Sometimes a very considerable and per- manent swelling of the body, is met with as a prominent symptom, in some cases, of the marasmus in children, and then the complaint assumes much of the appearance of the tabes ■S7 mesenterica. There is in these cases, very often, the craving appetite, and, at other times the contrary state, and the bowels are not unfrequently thought by the attendants to be regular: they have sometimes the ap- pearance of being too loose. The swelling is generally accompanied by the other symp- toms. I have seen it sometimes, however, so free from them, as to lead me to regard and treat it as merely the effect of the disor- der, that had existed and been removed. The large foecal accumulations, which, along with the wind, give rise to the swelling, hav- ing but an inconsiderable effect upon the sys- tem, and requiring only larger and more ac- tive, and more frequently repeated doses of purgative for their removal, than are usually required in cases of common constipation. And in such cases, a variation of the purga- tive means is frequently more successful for this purpose, than a long adherence to the use of any particular one; and even chaly- beates, as the solution of the sulphate of iron, or the simple carbonate, will often prove use- ful alone, by apparently strengthening, and thus keeping up, the action of the bowels. But in general, the other symptoms proper to marasmus, are present, and in such cases the diagnosis is often difficult; for, though a con- 28 siderable swelling of the body is not by any .means a constant symptom in mesenteric af- fections, yet being more so in them than in marasmus, and many of the symptoms of both being alike, an attention somewhat minute to the previous history of the complaint, is ne- cessary to enable the physician to distinguish them. In the mesenteric affection, I believe it will be found, that the abdomen is harder and less elastic, and uneasiness is excited by the presure of the hand upon it. The pains in it are likewise more lancinating, and strike from and to the back, and are commonly increased by a perfectly erect posture, and by any sud- den agitation of the body, as that from jump- ing, or accidentally slipping off a step, though only a few inches high. The appetite is less craving also, and the stools are more abun- dant and more unnatural, preserving much of the appearance of the ingesta; and where there is a diarrhoea, this symptom will be ag- gravated by purgatives, if repeated, whilst it is relieved by them in marasmus. The tongue in mesenteric affections, is generally clean and florid, and the tunica adnata of the eye has much of that pearly whiteness so charac- teristic of scrophulous atrophy. The even- ing exacubations are free likewise from that 29 drowsiness and torpor, which distinguish those of the other complaint, and there is not in the latter that preternaturally strong wiry feel of the pulse, which is often present in the former, and which is so remarkably the case in the scrophulous affections of impor- tant organs. When the chronic form of marasmus at- tacks young women, at the period of life of an expected change, it commonly prevents it, and the complaint then passes under the name of chlorosis. In others, it generally, either renders the menstruation irregular or exces- sive, obstructs it through several periods, giving rise, at the same time, to leucorhea. In a few instances, the pain of the back proper to this complaint, is excessive, and ex- tends sometimes apparently to the uterus, and also to the hip and groin, the least false step or hurried action, occasioning very consider- able pain in those parts. Some years since, I had, under my care, two very strongly marked instances of this singular modification of the complaint. The first that I saw, was from the neighbourhood of Ipswich, and had been of several years standing, and been treated with a great variety of means, with- out relief. I did not suspect, at first, that the uterine affection was a symptom of tbiB 3* 30 complaint, and was agreeably surprised to find it yield with those other symptoms, for which I more particularly prescribed. In the other case, of some months standing, and which likewise occurred in a married lady from a distant county, there were very con- siderable emaciation, and loss of appetite and strength, and so much pain and other symp- toms indicative of uterine derangement, as to excite a suspicion in the minds of herself and friends, of the existence of some organic dis- ease. Having ascertained, from account of an examination transmitted me by an eminent surgeon, that no disease existed, I was satisfi- ed at once concerning the real nature of the complaint, and, by treating it according to the mode hereafter to be noticed, every symptom of disorder disappeared, the lady having enjoyed ever since an uninterrupted state of good health. It has been noticed, in the enumeration of the symptoms of marasmus, that dispirited- ness is commonly present in it. It may here be observed, that sometimes this symptom ac- quires a sort of pre-eminence in the com- plaint, which gives to it, improperly, the ap- pearance of an hysterical or hypochondriacal affection. These disorders, however, differ from that under consideration, by their be- 31 coming better towards evening, whilst every form of the other is worse at that period. The full and free evacuations from the. bow- els, likewise, which are so useful in the ma- rasmus, are decidedly injurious in hypochon- driasis ; and, according to my observation, only admissible in that form of hysteria, notic- ed by Sydenham, which is met with in wo- men of a firm and vigorous habit, and in whom there is the tendency to strongly convulsive action. When, however, a bilious affection is thus accompanied in a female by depres- sion of mind, there is always some danger of regarding it as a purely nervous complaint. This error, from the imitative nature of hys- terical affections, can often be only corrected by examining the appearances of the tongue, and the fcecal discharges. The former, in pure hysteria, is clean, and the latter, though sometimes.green, are in other respects natur- al. Much assistance will be also derived by an attention to the history of the case, for the symptoms of marasmus are comparatively few and definable, and will often vary bqt lit- tle in the same individual for several weeks; whilst those of hysteria and hypochondriasis, vary almost every hour, and exhibit the sem- blance of diseases that differ so widely from each other, in their nature and causes, as to 33 preclude the possibility of their co-existence, in the sara-^ individual. The depression of mind, observed in bilious affections, proceeds, it may be also remarked, from no assignable cause, and the mind itself is rarely occupied with an object; whilst in those disorders, it is commonly in full activity, imagining every new feeling to be the prelude or the symp- tom of some fatal disease An acute form of the bilious affection is oc- casionally met with, in which the derange- ment about the liver is so considerable, as to occasion a strong resemblance to an active in- flammation of that organ. It comes on, most commonly, after fatigue, joined with cold and wet, anJ particularly where they have been endured under an anxiety of mind, and with much interruption to the natural rest. In these cases, the spirits and powers of the pa- tient appear to be broken, and he often makes but little complaint. His countenance exhibits, however, anxiety, and where the disorder has existed some time, pressure made in the region of the liver, will now and then produce an oppressive feeling there, compelling the patient to a forcible and sud- den expiration of the breath. The complex- ion is sallow, and the water remarkably high coloured, turbid and scanty; the stools are 33 generally of a clay colour, and the feet and legs are aedemitous, with sometimes more or less of that state in other parts of the body. Large boils occasionally appear in different parts of the body, and at other times, the true carbuncle is met with, as a direct effect of this complaint. The tongue is foul, the pulse very compressible, and the appetite is extinguished, whilst the thirst is considera- ble, and the restlesness during the night com- monly excessive. The sense of weight, and sometimes the pain at the pit of the stomach, with the thirst and other symptoms, give to this disorder much of the appearance of in- flammation ; whilst often the state of exhaus- tion, in which the patient seems to be, and in which, as denoted by the pulse, he actually is, militates against such an opinion. In the acute inflammation of the liver, there are not that excessive watchfulness and prostration of the spirits, and almost entire interruption in the secretory function of that organ, noi that absolute derangement of the health, and tendency to general anasarca, which are so dis- tinguishable in this complaint. If any feeling be excited in this disorder in the region of the liver, upon taking an inspiration, it is rather of weight than pain ; and where there is a cough, the same remark appliqs to it. 1 34 may add, likewise, that blistering affords but little, and venoesection usually no relief in this complaint, and the blood drawn exhibits no buffiness, but commonly a slight green hue. On some occasions, the seat of the disor- der appears to reside in the bowels, giving to the complaint many of the characters of pe- ritoneal or enteritic inflammation. In these cases, the body will be painful when pressed, and considerably swelled, and, it is chiefly by these circumstances, that it differs from that form of the complaint just noticed, in which an inflammatory affection of the liver is suspected to be present. The motions are commonly of a clay colour and frothy, being frequently voided in a putrifying and ferment- ing state. The distention and pain of the body are sometimes very great, and from these being constantly present, by which it is distinguished from common colic, and from the high degree of febrile excitement and nervous irritability of the patient, the diag- nosis becomes, in many cases, exceedingly difficult. A few years since, I was requested by a gentleman, residing at some distance, to visit his wife, who had been ill for a short 4ime, as he informed me, of an inflammation xf the bowels, which, in the opinion of the 3j medical gentlemen in attendance, had alreudv terminated in mortification. As the order was absolute for my visiting her, I according- ly set off, though I could not arrive until the third day from the date of the letter. On my arrival, I found her living, but with still no hopes entertained of her recovery. From having seen, however, several cases of the kind before, where the same difficulties had occurred to myself of discriminating between this disorder and inflammation, and having likewise the advantage of reviewing, at this stage of the patient's complaint, all the cir- cumstances belonging to it, I was enabled to decide upon its nature ; and having explained to the gentlemen who favoured me with a meeting, my opinion respecting it, they agreed in my views, and in the propriety of the plans proposed for the relief of our patient. We accordingly gave her small doses of calomel, repeated at short intervals, following them up, after some hours, with a weak solution ef the sulphate of magnesia in repeated doses, until full purging was produced. Under this treatment, in the course of twelve hours, co- pious evacuations were procured of yeasty coloured, and frothy, and excessively offen- sive motions, and with such complete relief tf» the tension and pain of the body, and other 36 unfavourable symptoms, as to leave no room for anxiety about the event of the case. In the course of a few days, by persevering in this plan, our patient became convalescent and was soon restored to health. To those practitioners, who have seen and attentively observed puerperal inflammation, the diagnosis between this disease and the complaint under consideration, may in most cases be easy ; but where the knowledge of both is derived from description alone, there will be considerable risk of confounding them. Such of my experienced professional readers, who may honour these pages with perusal, will, I doubt not, remember several instances, in the course of their practice, in puerperal cases, where this complaint assumed so much of the appearance of peretoneal inflammation, as to make them hesitate about the propriety of employing, or regret the omission of venoe- section, when a brisk calomel purge has dis- played to them at once the real nature of the malady, by the prompt and entire relief which its single operation has afforded. In other cases, they will have remarked, bow little relief vencesection gave to the pain and general disturbance of the system, though fully perhaps employed, until free bilious evacuations from the bowels were procured ; 37 purging thus appearing, in such cases, what it undoubtedly is not, a more powerful means than vencesection, for subduing of puerperal inflammation. It was stated, at the commencement of this chapter, that the marasmus, or as it has been termed, the remittent fever of children, and the bilious disorder, are the same ; and it has just been noticed, that the acute form of this disorder is not unfrequently occurring in the puerperal state, exhibiting many of the symp- toms of puerperal inflammation. In a work, written some years ago, by the late Dr. But- ter, on these complaints, an attempt is made, by that otherwise accurate observer, to iden- tify this disorder of children with the in- flammation of the puerperal state, considering the difference, observable in their symptoms, to arise merely from the influence which age and other circumstances might be expected to produce. That the fever, however, here contemplated, was only the bilious affection which was mistaken for it, and that, as such, it was curable without vencesection, is an opinion that may be hazarded with little chance of contradiction. For, however the two complaints may resemble each other, an;i sometimes their resemblance is very strong, it may be laid down as an incontrovertible 38 truth, that the true puerperal fever is in its es- sence inflammatory, and its most active and indispensable remedy is free and early vence- section. Other means, and especially full evacuation from the bowels, are important auxiliary agents to bleeding, but they are not to be relied on, excepting as such. Every - case of puerperal fever that I have seen, has been in its advanced state, and every one ap- peared to me to prove fatal, from either de- laying the employment, or from the neglect altogether, of vencesection. Of the maras- mus, which resembles it, I have seen nume- rous instances in the puerperal state, and I have known some of these cases treated by bleeding, and the usual antiphlogistic means • and others, remain more than a week without any medical attendance ; and others, again, treated by stimulants; and all the patients ultimately receiving relief, sometimes, under circumstances, which, to the attendants, seem- ed hopeless, by a free evacuation from the bowels. So frequently, indeed, have these facts come under my notice, that there is no point 1 feel more anxious to press upon the attention of the younger part of my readers than the necessity there is to guard against the mistake of identifying marasmus with the true puerperal lever, and against the se* 39 rious practical error, resulting from it, of be- lieving that purging alone will be available for the cure of both. Puerperal inflamma- tion, except where it occurs epidemically, ac- cording to my observation, is comparatively a very rare disease ; whereas marasmus, oc- curring in the puerperal state, and which considerably resembles it, and which is com- monly mistaken for it, is by no means an un- frequent one. Full and free purging, is the suitable remedy for it, though venoesectiou may be often safe, and even necessary, where the fever, and local and general irritation, are considerable. But in the latter, differing as it does from the former, in being essential- ly, and in its very nature inflammatory, copi- ous ahd early bleeding is justly insisted on as of t\ie first importance.* The tendency of every secretiog organ, when long morbidly excited, is probably to assume a certain degree of disease, though the period of its occurrence will be influenced by many circumstances, and must be necessa- * I have not pointed out here the circumstances, by which the puerperal inflammation may be distinguished from this fever, when this last occurs in the puerperal state; prefering to recommend the reader to study the works of Dr. Armstrong and Mr. Hey, and some other authors, who hsvc written fully and ably concerning it. 10 nly uncertain. With respect to the liver, in the chronic form of this complaint, I have had frequent opportunities for ascertaining, that it may continue in a disordered state for several years, assuming, during that period, many of the supposed symptoms of chronic hepatitis, and recover suddenly and perma- nently its healthy state, by means directed merely to effecting a change in its action. Nor can it be said, that, in such cases, there may still have existed a change in the struc- ture of the liver, constituting organic disease ; for no instance is afforded of any such healthy change taking place so early in apy other or- gan, where the disease of structure here con- templated had been induced ; and certainly not in those cases of liver disease, where un- equivocal symptoms of it existed. From causes, perhaps not easily explained, a disposition has arisen in many practitioners to refer the origin of all disorders of the di- gestive organs, and sometimes even consump- tion itself, to some specific organic disease of the liver; and a practice has grown out of these opinions of employing long and severe courses of mercury, and a debilitating regi- men, for its removal. Such views, when thus reduced to practice, cannot fail to exhib- it their fallacy, since they are founded on the 41 error of regarding the liver as diseased, when it is only impeded or disordered in its action ; and of employing means for reducing the force of the arterial action of the organ and of the system, instead of those proper for re- newing and sustaining its secretory function. To those of my readers, who may have im- bibed such views, I would take the liberty to recommend the instructive practice of dissec- tion ; for from it they will soon learn for themselves to distrust such speculations. In the prosecution of their examinations, they will find but very few cases of diseased strur- ture of the liver, compared with those which they had perhaps classed as such ; for, how- ever the contrary opinion may be generally entertained and expressed, a disease of the liver, according to the observation which I have made from such repeated examinations, is comparatively rare. It is, for instance, seldom met with, excepting where it has ex- isted as a prominent and marked disease. I have never seen it, therefore, in those dying of phthisis pulmonalis, except in the case of notoriously hard drinkers, in whom the breast affection was only a late, and scarcely an auxiliary, cause of death ; and 1 have found it as healthy in those dying at an advanced a*e, a" in those cut off in youth, and even .e 4* 42 the persons where it might have been leas.* expected to be so, whose health had been many years declining, and in whom it might be said that life was" a long disease." Some time since, 1 was present at the exam- ination of the body, after death, of an individ- ual who had been subject, during many years, to more considerable and more frequent ir- regularities in the functions of the liver, than I have often witnessed, as evidenced by the appearance of the alvine discharge. The disorder had been considered by practition- ers, whom the patient consulted when from home, as a confirmed liver complaint, and a short trial of means for its removal was, I un- derstood, resorted to. The examination de- tected the fallacy of the view entertained; for, as it had been anticipated, not a trace of any disease was discoverable in any part of that organ. In illustration of the same gen- eral fact, of the unfrequency of disease of structure occurring from a disordered action of the liver, in its chronic stage, I might here adduce numerous instances that have fallen under my observation. A few years since, I attended an elderly lady at Cottingham, near this town, in the acute form of the dis- order, with my friend Mr. Watson, a gentle- man of considerable practice and experience. 43 m that place. Our patient had been ill in the chronic form of the complaint, with con- siderable symptoms of jaundice, during most of the preceding summer. 1 saw her a few days after the commencement of her acute attack, and such was its severity from the pain and distention about the abdomen, and general restlesness and fever, as to lead the la- dy's friends to apprehend, that all our attemps to relieve her would be fruitless, as they did not expect her surviving the ensuing night. By means, however, directed by us, merely to renew the healthful actions of the liver, this lady very soon recovered, and has enjoy- ed ever since an entire exemption from every appearance of liver disease.* But here, it must be remarked, that though I am thus disposed to consider the instan- ces of liver disease, consequent upon this • " I have examined a considerable number of persons, who have died of cancer, lumbar abscesses, and other great local diseases. I knew that these patients had their diges- tive organs disordered in the manner that I have described, and that in many of them the secretion of the bile had been suppressed for a great length of time, and, when it was re- newed, that it was very deficient in quantity, and faulty in quality : yet, on dissection, no alteration was discovered in the structure of the chylopoietic viscera, which could be decidedly pronounced to be the effect of disease."—Abcr- nethy's Surgical Observations, page 43. 14 complaint, in its chronic form, to be consider- ably less frequent than they are commonly judged to be, and that a large proportion of the supposed cases of that disease are mere- ly those of disordered action, yet it must be conceded, that some of those cases of that disease, whose intractable and fatal charac- ters set the physician's art at defiance, may possibly derive the first germs of their exist- ence from this source. Where such exam- ples occur, it is probable they depend upon local or constitutional peculiarities, favouring the operation of the common causes, or up- on some obvious and habitual excess in the use of spirits ; and of them, it may be observ- ed, that in proportion generally as their ap- proaches are slow and insidious, so their de- velopement is at length complete, and their nature irremediable. The symptoms, however, of such disease, and those proper to disordered action, are often considerably alike, and it is difficult to convey, by words, a knowledge of the means by which they may be always distinguished. Much will be obtained by a careful comparison of them, and of all the circumstances about the patient, as they respect his previous habits, &c. In many cases of diseased liver, there is but little change in the appearance of the al 45 vine discharges, these being often surprisingly healthy up to the period even of its fatal ter- mination ; whilst, in the case of disorder in the function of that organ, and which consti- tutes this complaint, they are necessarily and uniformly unnatural. In the diseased state, the decrease in flesh and strength generally exceeds the pain and uneasiness ; whilst, in the simply disordered action of the liver, the case is commonly re- versed. In many cases of disease of this or- gan, there is no pain felt in the neighbour- hood of the liver, nor any of the other symp- toms that are usually noticed as present in it. This was the case with a gentleman, whom I attended during several years until his death, and in whom there was found, upon dessection more extensive disease about the liver and neighbouring parts, than I ever before wit- nessed ; yet, at no period up to his decease, had he ever any pain in the region of the liver, or between the shoulders, or any difficulty in ly- ing on either of his sides. The complexion of the bilious patient, is commonly sallow, whilst that of the other, is either deeply jaun- diced or of a dirty yellow, or of a pallid hue, with only a tinge of that colour. In the lat- ter, there is but little fever, and the pulse is often slow and compressible ; and as the dis- 40 ease advances, there is an expression of the countenance that is peculiar and distinctive, and to those familiar with it, as significant of the fatal nature of the complaint, as the ful- lest assemblage of its proper symptoms could render it. That tendency, however, in the liver to assume organic disease, which may be consid- ered as comparatively rare in the chronic form of the bilious disorder, may be justly re- garded as constituting a prominent featuie in the severer forms of the acute one. The liver, in these cases, frequently acquires in increase in its bulk, so as to be very readily felt externally; and I have observed, that, in addition to its general enlargement, there is often a distinct circumscribed swelling in the epigastric region of great firmness, and ex- ceedingly tender when pressed, the least presure giving rise, in some patients, to a hurried and agitated, but involuntary, expira- tion of the breath. This swelling, from the position it occupies, and from its definable and rounded form, might be thought to be a schirrus tumour, fixed in some other part; but its true seat is the liver, and, generally, the left and lower part of its right lobe, which, by losing its fine edge, and being pro- jected forward, acquires thus its apparently 47 circumscribed and circular shape. The pa- tients, in whom 1 have met with this disease, have always had it as an effect of the acute state of the bilious disorder. The symptoms of the latter complaint, in such cases, are al- ways severe. The fecal discharge is of a yeasty colour; the urine excessively high coloured, turbid and scanty; and the pain in the region of the stomach, peculiarly severe during the night, and commonly increased by the recumbent posture. In all the cases I have met with, bleeding and blistering had been employed several times, and in none did there appear to have been any perma- nent relief afforded by these means. In sev- eral, the complaint had existed for some months; and in one, it had commenced in South America, continuing, with little abate- ment of its severer symptoms, until the per- son arrived at Hull. The complaint, in this instance, was attributed to the offensive smell which the patient and his crew were expos- ed to, form their cargo of raw hides, acciden- tally fermenting, and becoming nearly one mass of putrid jelly. The probable cause was, the constant exposure to the cold night air, to which the stench, in the interior of (he ship, compelled him to sul mit. This enlargement of the liver, might be 48 supposed to arise from the actual presence of that congestive state of the vessels of this organ, which will presently be noticed, as oc- curring in the bilious disorder; but I have, in one or two instances, found it continue aft- er that state had been nearly removed, as evidenced by the renewal, in a considerable degree, of the healthy biliary secretion, and by a marked improvement in the general health. I have, therefore, been led to re- gard it as an actual enlargement of the liver, from the disposition of a serous or coagulablc fluid into the parenchymatous substance of that viscus. At its early stage, and before the new matter acquires an organic structure, the removal of the disease is not difficult, as it does not at that period appear to partake of those characters which so fatally mark the other forms of liver disease ; yielding readily to those means which promote the action of the absorbants. The cough, sometimes met with in contin- ued fever, not unfrequently originates froto bilious irritation. This was remarkably the case with that which accompanied the epi- demic fever of 1817-18. Out of nearly one hundred and fifty cases, that I saw of this fe- ver during its continuance, full one-fourth were affected with this cough. From the 49 tightness and oppression about the chest, is exhibited many of the characters of pneumon- ic inflammation, particularly where it affect- ed children. In some cases, the fever com- menced with vomiting, in others, with pur- ging, or with both. Where these stopped suddenly, which frequently happened, the cough often supervened, attended with con- siderable difficulty in the breathing and fe- ver. The cough, however, did not always come on in this way, nor did its appearance seem to be regulated by any variation in the remote causes. It occurred equally in those whose fever was attributed to contagion, as in those where cold was reputed to have caused it; and even some had it in a relapse of the fever, who had been free from it in the first attack. The function of the liver was so remarkably affected from the very commencement, and during the whole pro- gress of the fever, as to give to the disorder a completely bilious character. The stools were either black or clay coloured; the cough, and the other symptoms of the fever subsiding only as they recovered their natur- al state. A spontaneous looseness appeared in a great many of the cases, in the course of the disease ; but in none did it prove saluta- ry, excepting where it was decidedly bilioi'.a 5 50 The symptoms of fever and the cough, were aggravated by opiates, which stopt the alvine discharge ; but the fever and frequency of the discharge, as well as the cough, and other symptoms, were all reduced, and I believe only reduced, by those free purgative means, which promoted the secretion and the des- cent of the bile. The symptoms, commonly called putrid, frequently shewed themselves early, the cough acquiring, at the same time, a corresponding aggravation of its force. The fever was decidedly contagious, every indi vidual in some poor families having become, in succession, affected by it. In one room that was exceeding ill ventilated, and where a family of six persons dwelt, the disease con- tinued three months, all of them having be- come ill in it in the course of that period. The fever, in many, ran a protracted course of six and seven weeks, and the cough, in many of these cases, continued even some time after the fever was apparently removed, a hectic state supervening. At this time, I have a person under mv care, who is just recovering from a cough that commenced with this fever, which, he in.Vrm j me he had about eight months since ■ and 1 b-ive lately discharged a patient from our infirmary, cured, whom 1 admitted eio-h. 51 weeks before, convalescent from every symp- tom of his fever but the cough. This how- ever, was now the prominent symptom, there being the hectic fever and an anasarcous state of the legs, with several of the common symptoms of pulmonary phthisis. Many such cases have fallen under my care since the disappearance of the fever, and in all, there was the same morbid biliary secretion ; and the remedy for the cough, and other symp- toms attending it, have been the correction of that state, and the removal of the morbid accumulations from the bowels. In the first case, occurring in a child, that came under my care of this complaint, I was induced, from the difficulty in the breathing and severity of the cough, to direct leeches and blisters to be applied to the breast; and general bleeding twice in the first adult case. From the observations which I made, howev- er, upon the appearance of the blood, and particularly from the little benefit that result- ed from these general and topical means, I was led to view them as unnecessary in this particular epidemic, and to confide principal- ly in those which produced bilious evacua- tions from the bowels ; nor had I once an occasion to regret the plan 1 pursued.* • The following observations of our English Hippocra- 52 Of the thrfe adult cases that terminated fatal- ly under my care, one had been bled twice, and prescribed for by a druggist, before I saw her. The second was in a lady, who had nursed her daughter in the same disease. Her treatment and general management, had beenconducted.with skill, from the beginning, by the gentleman who preceded me, but the disease had exhibited an inveterate char- acter from the first; and our patient sunk un- der symptoms the most decidedly putrid. The third, was admitted into the Infirmary, un- der my care, in the second week of the dis- ease. He was in nearly dying circumstances when received, having been taking, during the preceding ten days, a quantity of ale and gin, which his ignorant friends had giv- tss, Sydenham, on the cautious mode pursued by him in the treatment of fever, are of great importance, and cannot be too attentively considered : "When I had once happily fallen upon a genuine method of treating any species of fe- ver suitably to its nature, I always proved successful (pro- per regard being had to the constitution, age, and other par- ticular circumstances of the patient) till that species became extinct, and a new one arose, when I was again doubtful how to proceed; and, notwithstanding the utmost caution, could scarcely ever preserve one or two of my first patients from danger, till I had thoroughly investigated the nature of the distemper, and then I proceeded in a direct and safer way to the cure."—Sydenham, icct i, chap. %, ^ 3. 53 en him. His death, which took place a few days after his admission, afforded me an op- portunity of ascertaining, by an examination of the body, the truth of those conjectures which 1 had formed concerning the condition of the liver in this disease. As I had predic- ted, this organ, without exhibiting any marks of inflammation, was literally gorged with very dark venous blood, which spouted forth at every incision ; and the inferior surface of it was quite of a dark colour, from the large accumulation of the blood in the ves- sels of that part. There were no morbid appearances in any of the organs. Among the causes, to which may be ascrib- ed the comparatively small mortality of this epidemic among the poor, I think I may ven- ture to range their destitute condition in the foremost place ; for no instance of fever ever came under my care, where an abstemious regimen, as well with respect to the quanti- ty as the kind of food, was ever more neces- sary than in this. Even during the convales- cent state, nearly the same rigid prohibition of food and stimulant drink was needful; for where it was neglected, relapses were com- mon, and sometimes the second attack was severer than the first. But I must here observe, that my omitting 5* 54 o employ venajsection in this fever, is not to be understood as conveying a tacit disappro- bation of the use of the lancet in fevers in general. On the contrary, I esteem the gen- eral conviction, now prevailing, of its utility in several forms of continued fever, when employed early, as one of the late triumphs, achieved by science and observation, over prejudices long established. Nor do I wish it to be understood, that I consider the employ- ment of the lancet to have been inadmissible in every case of this fever. When used at the very commencement, it might in some be proper; and if I had recourse to it only in one case, it was partly because I seldom saw the complaint at its commencement, when venisection would be beneficial, but princi- pally because I considered it unnecessary along with those curative means, which I was early induced to rely on, and which ex- perience taught me to be fully sufficient. :\Iy dependence, chiefly, was upon those med- icines, which procured biliary evacuations from the bowels, by promoting the secretion and descent of the bile ; by mild diaphoretics, by a cool regimen, and by a spare diet, as well in regard to the quantity as to the quali- ty of the diet. The amount of blood, drawn from the whole number of patients whom I 5a attended, did not exceed three pints, and the quantity of wine consumed by them did not double that. Of the patients that died, three were the adults already noticed, and five were children ; and of these last, three were scarcely able to take any thing when I first saw them; a fourth had hydrocephalus inter- ims, which appeared to have followed the disorder; and the fifth died suddenly, at the end of the fourth week, in a relapse of her disorder, after a few days convalescence. In the fever just noticed it has been ob- served, that where a bilious diarrhoea took place, it became critical, and carried off the complaint. It now remains to be observed, that wherever a bilious diarrhoea occurs iu this disorder, it is equally efficient as a cure, the renewal of the secretion of the bile, be- ing, in fact, its natural remedy. In many cases it happens, especially at the autumnal period of the year, that this disorder is reliev- ed, a few hours after its attack, by a sudden re-action occurring in the secretory vessels of the liver, by which a very copious secre- tion of bile is produced, giving rise to sick- ness and purging, and constituting thus the proper cholera morbus. For the symptoms, which precede the discharge of bile in these cases, are, in fact, precisely those which are 56 present in the acute form of the bilious disor- der, and which denote impeded secretion; and hence, in their worst forms, as I have of- ten ascertained by an examination of the mo- tions, instead of or along with bile, there are discharges from the liver of blood, which the attendants compare to the colour of soot, and which, if not early relieved, will terminate in a fatal malaena. The symptoms of the complaint being too well known to requre any description of them, and as the cholera morbus, which is little more than a symptom of the other, will be more particularly noti- ced, when we have to treat on the pathology of marasmus, we may defer its farther con- sideration until we come to that part of our subject. A considerable number of the symptoms of the bilious affection, are produced by the op- oration of that law of the animal economy which we term sympathy ; for, besides the general and local disturbance, which is ob- served to arise directly from the disordered actions of the liver, and the other chylopoetic viscera, there are several important affections produced through the sympathetic connex- ion subsisting between these organs and dif- ferent [»ats of the system, whereby an irrita- tion, present in the former, is communicated 57 to parts of the body with which they have no local nor apparent relation. Of these ef- fects resulting from the agency of this law, there may be said to be several kinds. The first we may notice, is an increased action of the serous and mucous membranes, whereby a larger secretion of their proper fluids, or a morbid change in them, is produc- ed. The most familiar example of this, is in the tongue, whose secretions are always more or less affected by a derangement of the bil- iary function. The ankles are a common seat of this symphathetic irritation, being sometimes swelled from an effusion of serum, when the parts are observed to pit; and at other times they swell from the deposition of a lymphatic fluid, when they feel more firm. These swellings I have observed to arise in- dependently of any debility, and occur as well in those who confined themselves to bed, as in those who sat up. They are, seemingly, produced by an excited action of the vessels of the parts, analogous to inflammation, being attended with some pain and stiffness, and with sometimes a sense of heat in the parts. They are most frequently met with in adult females, and occasionally constitute the lead- ing symptoms of the complaint. I have a pa- rent at present under my care, at our Iniir 5S mary, in whom there is a regular swelling of this kind, from the knee downwards, which came on in the course of a bilious fever, with which he was affected. The whole leg is firm, and even hard, and the skin tense. Those sudden attacks of anasarca, which we sometimes meet with supervening upon other disorders, and which have been called (as I conceive erroneously) a translation of them, are probably of this kind, and arise from an increased, though modified action, of the vessels of the cellular membrane, by which the cerous fluid is poured out. The cases that 1 have met with of this kind, have sometimes proceeded to general anasarca; and, indeed, I have seen a few instances, where hydrothorax and ascites appeared to originate from an action of this kind taking place in the serous membranes lining the tho- rax and abdomen. In some cases, the swell- ings produced by lymphatic effusions, are par- tial and insulated, giving rise to an apprehen- sion of some serious disease in the part. The following is an example of an affection of this kind in the breast. Case—A young woman, servant to a lady at Bridlington, applied to me, on account of an enlargement of her breast, which had ^een gradually becoming bigger for several 59 months, attended by darting pains through it, and which was now of nearly twice the di- mensions of the other. On examining it, 1 found that the enlargement was general, and without any perceptible hardness in any part of it, or any other change in it, than its be- ing considerably larger, and rather more firm than the other. She had been under surgical treatment for some months, and had applied leeches, and various lotions to it, with- out any relief On inquiring of her concern- ing her health, I found that she was labouring under a considerable derangement of the bilia- ry function, and that this disorder had preced- ed the affection of her breast. I therefore de- sired the outward applications to be discontin- ued, directing for her, at first, a small dose of calomel to be taken nightly, and a dilute solu- tion of the sulphate of magnesia, the following mornings; giving her afterwards, for a short time, a slightly tonic medicine*. Under this treatment, the cause was soon removed, and I had the satisfaction to learn from herself, about a month afterwards, that no appearance of dis- order about the breast remained. Of the effect of this sympathetic irritation on mucous membranes, we have an example afforded us in the itching of the nostrils, which is among the symptoms most constantly occur- 60 ring in bilious derangement. In many cas*.'.^ this irritation occasions a copious discharge from the parts, attended with frequent sneez- ing ; producing, in this respect, so strong a resemblance to a common cold, as to excite in patients the belief, that thqy really depend upon it. The frequency of their recurrence and brief continuance, and their not being at- tended with, or followed by, any other symp- toms of cold, are distinguishing circumstances, however, which fully prove their nature. When this irritation is directed to the mem- brane lining the larynx and trachxa, it gives rise to the bilious cough, which in many cases very strongly resembles some of the forms of phthisis pulmonalis. Indeed, so strong is some- times this resemblance, that practitioners, the most familiar with them, may be ready often to confound them. For in both, there is with the cough, which is worse during the night, an expectoration of secretions, not much un- like in their sensible qualities ; a fever towards evening, preceded by chilliness ; perspi/ations about the head and breast in the night; great loss of flesh and strength ; pain in the side, commonly the left, and often the moderately good appetite. The condition of the breathing, and gener- ally of the pulse, especially in its advanced 61 stage, may, however, be commonly appealed to as distinguishing characters of phthisis. The breathing in the cough of marasmus, if hurried in the evening from the accumulation of phlegm, or on the accession of fever, is gen- erally calm and natural in a morning; and though the pulse is not invariably rapid in phthisis, excepting in that from tubercles, yet it is nearly constantly so ; and it always has a preternatural degree of strength and wiry- ness in the evening, and even during the day which is seldom met with in the same degree in the other. The discharges from the bow- els in phthisis, are likewise of commonly a healthy appearance; whilst, in marasmus, they are uniformly and necessarily of an un- natural colour and faetor. There is, also, in forming a diagnosis, no little assistance to be gained from observing the manner and gener- al appearance of the patients; for, whilst the one, affected with the bilious cough, when. acutely formed, is in the advanced stages of this disorder, comparatively indifferent about himself, and gives his answers apparently with reluctance, the phthisical sufferer is more or less animated at the view of a new physician, and with the hope of a new remedy ; and is careful, perhaps, to note, that it is but a little troublesome cough that he merely wants re- 6 62 moving, or some little strength that he needs restoring, for him soon to obtain his health again. Notwithstanding, however, these seemingly distinguishing circumstances in the two disor- ders, the bilious cough, as has been already observed, in some cases, particularly when occurring in youth, so strongly assumes the appearance of an incipient phthisis, as to re- quire a greater degree of attention and dis- crimination than the younger part of my read- ers may readily believe to be necessary. The dyspnoea, which, in the bilious cough, ordina- rily arises from a morbid excess of the mu- cous secretion of the larynx, is sometimes found to exist independently of that cause, from the sympathy between the lungs, and the disordered organs of digestion, inducing a modified and mild form of asthma. The de- bility also produced, will, in irritable habits, render the system highly excitable by slight causes, so as to occasion, in this complaint, an unnatural quickness both in the circulatiou and the breathing; though the difficulty ia the breathing, in this case, is, strictly speak- ing, only apparent; for, on requesting a per- son, so affected, to inhale deeply, he does it without any of that obstruction in the chest, which is observable in the consumptive j and 63 the pulse, though quick, has not much pre- ternatural strength. In general, it may be observed, where the two disorders are confounded, the error con- sists in considering the bilious cough to be of ■a consumptive nature. Of mistakes of this kind, I have seen several, and some of them have been my own ; having been led to view the cough of this complaint as depending up- on a disease within the chest, I have only dis- covered the real nature of the case by an ex- amination myself of the stools (a measure never to be neglected, where a precise knowl- edge of their condition is required) followed up perhaps by a closer inquiry, concerning other circumstances about the patient. A case of this kind, some time ago, occurred to myself and another gentleman in attendance with me. It was of a young woman, about eighteen years of age, who had been ill for some months, and whom, at my first inter- view, 1 considered to be affected with the bilious cough; informing her friends of the opinion I entertained of her complaint, and prescribing for her disorder accordingly. On the occasion of my next seeing her, which was nearly a fortnight after, and when she was confined to her bed, 1 was informed that the alvine discharge was not unnatural; that 64 she had not been relieved by the medicine* ordered for her ; and that her weakness, and other unfavourable symptoms, had increased. From these circumstances, and from finding her cough and other symptoms decidedly worse, I was led to doubt the correctness of my first opinion, and to yield to the one en- tertained by her friends, of her being indeed consumptive. I now saw her daily, and with the exception of a distressing pain in the head, and some equivocal appearances in the pulse, there was not a symptom about this pa- tient, which did not exhibit very strongly- marked indications of phthisis pulmonalis. A necessity for some aperient medicine, hav- ing led me, however, to make a farther in- quiry concerning the condition, and subse- quently to an inspection myself of the alvine discharges, I found them in a morbid and un- natural state, which renewed in me the sus- picion, that her cough and other symptoms, apparently consumptive, depended upon a dis- ordered biliary secretion ; and means were directed for the correction of this state, and for the evacuation of the bowels, omittin^ the use of all other medicines. Almost im- mediately after the commencement of this plan, the appearances of the motions became improved; and having combined cold spong- 65 ing with the other means, she soon lost her cough and other unfavourable symptoms, re- covered rapidly her strength, and has had no return since of her disorder. In some cases, this difficulty of deciding concerning the true nature of the bilious cough, and its attendant symptoms, is further increased by these being accompanied with a hemorrhage from the lungs. A poor woman, of a strong habit of body, fifty-three years of age, a patient under my care at the Dispen- sary of this place, is now just recovering from the eighth attack of this kind, which she has had during the last three years. The blood coughed up, has sometimes amounted, in quan- tity, to nearly a pint in the course of two or three days. I was present, on some occa- sions, when it was thus discharged, and was convinced that it proceeded from the lungs. Her cough at these times, was excessive, and attended by a very copious expectoration, with fever, quick pulse and thirst, and imped- ed breathing, and very considerable emacia- tion and loss of strength. Her attacks were always preceded by, and accompanied with, the most marked derangement ot the organs of digestion, and as regularly relieved by those means which procured bilious evacua- tion from the bowels. In the interval ho 6* 66 tween two of her attacks, she had menorrhu gia. She is now free from the cough, her appetite is good, the secretions from the bow- els are natural, and her strength sufficiently recovered to enable her to work labourously for her living. But the bilious cough, which is thus ob- served to put on the appearance of phthisis pulmonalis, and which is generally removable with its cause, has sometimes, I have been led to suspect, as fatal a result as the disease it resembles; for where a mucous membrane has been for some time, under the influence of symphathetic irritation, it takes on in some instances a purulent action, that after some time terminates in ulceration. This appears to be the case in the worst forms of ozonna, and in some affections of the mouth, and I think likewise in that fatal disease of the bronchia, noticed lately by several writers, which has been thought to be allied to phthisis pulmonalis, but which, I have some grounds for believing, may originate from an irritation in the digestive organs, and be properly a termination of the bilious cough. It consists in an ulceration of the bronchia, at- tended by a purulent expectoration and a hectic fever, with its concomitant symptoms. The cough is generally very severe and dis- 67 tressing, and the matter expectorated is of a whiter colour than that raised in phthisis from tubercles. The nature and seat of the disease are discoverable by the cough, it being hoarse and often harsh, varying, however, much in these respects according to the seat and du- ration, and consequently, the extent of the ulceration. The voice is not less peculiar than the cough, being hoarse and partly whispering as if injured by previous long and and vehement speaking. There is a pain felt at the seat of the disease, which is in- creased by coughing and speaking. Tbn difficulty in the breathing, depends upon the presence of matter in the bronchia, and is sometimes inconsiderable, and at other times exceedingly urgent. Where the ulceration is in one only of the bronchia, there is usually much inconvenience in lying on the opposite side, from tne aggravation it occasions in the cough, and in the difficulty of breathing. The recumbent posture, is often more fa- vourable for the cough and breathing than the erect one. The pulse is quicker and harder than natural, but it has not that pecu- liar sharp wiry feel, which distinguishes it in phthisis from tubercles. The countenance of the patient is sallow and depressed, hav- ing none of that animation which is so char- 68 acteristically marked in the other form 01 phthisis. The debility nnd wasting, previous to death, are usually v*»rv great, the appetite is variable throughout the disease, and the bowels are costive in its early periods, be- coming regular as the disease advances, and very frequently continjing so to its close. All the cas** which I have met with, that had reached the ulcerative stage, have termin- ated fatally. Since the time my attention became more particularly directed to the subject, I have observed that this disease has always been preceded by, and accompanied with bilious irritation. In two instances of it, the de- rangement of the digestive organs was so strongly marked, as to lead me to entertain hopes of affording relief by removing this state ; but this disease, like many others, may perhaps survive its cause ; and though pro- duced by symphathetic irritation, yet become, when once established, a distinct disease, the lungs it is probable, in some instances, partak- ing of the ulceration. In its early symptoms, as well as in its confirmed state, it bears a strong analogy to ozoena, of which I have seen several examples, distinctly arising from a bilious cause. The ulceration in the bron- chia, indeed appears to differ only from ezoe- 69 na in the importance of the part where it is seated. The irritation of the nose, and a dis- position to rub or pick it, and the frequent sneezing, especially when passing into a cool apartment, and the occasional discharges from the nostrils, resembling a cold, are the symp- toms most commonly preceding both. With respect to ozoena, where the irritation in the nostrils is great, the discharge from them be- comes very considerable, especially in a morning, and forms a prominent and distress- ing symptom. By correcting the disordered state of the digestive organs, this symptom yields with the others that are proper to it; but if the cause be neglected, it is found of- ten to terminate in a purulent discharge, and at length in ulceration, constituting the true ozoena. And what thus takes place, after long continued or severe irritation in the nos- trils, appears to me likely to occur in the bronchia. There is, at first, no discharge from the cough ; at length there is mucous, which may be succeeded by a purulent secre- tion, and this last by ulceration. The increased secretion of mucous in the early states of ozoena and the bilious cough, is the result of an inflammatory action of the parts, of a chronic kind, which, from being of t specific nature, and arising sympathetically 70 rom a specific irritation, is not relieved by topical applications, but requires the removal of its cause. When the disease has assumed the purulent or ulcerative form, it seeming- ly becomes independent of its cause, and though admitting of alleviation by general remdies, yet perhaps only curable by those of a topical kind. For several years past, I have had occa- sion to prescribe at times for a person, in whom the bilious cough is exceedingly vio- lent. It occurs iu paroxysms, and is usually brought on by entering a cold apartment, or immediately upon rising from bed, or by talking. There is commonly much soreness felt at the lower part of the trachea, and the voice is whispering, and sometimes scarce- ly audible. The itching of the nostrils is considerable, and there is constantly the ap- pearance of renewed colds, from the sneez- ing and copious discharges from the head. The bowels, at these times, are exceedingly sluggish, and demand active medicines, and their contents are of an unnatural appear- ance ; the appetite is weak, the tongue re- markably foul, and the complexion sallow. Some years since, this person was affected with a complaint, in many respects, strongly resembling the one now occurring, and was 71 then reduced to a state of extreme weakness. from which the recovery was both difficult and unexpected. About four years since, I had a young lady under my care, in whom this fatal disease appeared to be forming. Her cough was ex- ceedingly severe, and attended by a copious expectoration and much soreness in the bron- chia, with considerable wasting of the flesh and strength. Her voice, whilst in bed, was natural, but on leaving her room, or after speaking a sentence or two, it became hoarse and whispering. Considering that the cough and other symptoms depended upon the condi- tion of her general health, I directed her along with other means, to use horse exer- cise daily, notwithstanding its being then win- ter, and to take lodgings at a village in the neighbourhood. This plan was followed in every particular, and happily succeeded ; the cough and expectoration, with the fever and hoarseness, gradually declined as the gener al health improved, and she has continued ev- er since perfectly free from the complaint.* * Though I have notiaed only the bronchia, as beii:^ probably affected sympathetically by bilious irritation, yet there are affections likewise occurring in the trachea and la- rynx of the same nature, and w'nich undoubtedly derive their origin from the same source. Whether mv conjee- Among the symptoms of a symphathetic kind, most constant in marasmus, may be re- marked those affecting the head. In the chronic form of the disorder, there is always more or less of pain and dizziness, and a cloud- iness in the vision, with dark spots passing before the eye, and a decided failure in the powers of the mind. Where the irritation, existing in tiie digestive organs, is not direct- ed to the membrane lining the trachea, occa- sioning the bilious cough, or to the skin, &c. producing eruptive or other diseases, it fre- quently affects the head, particularly of chil- dren, in the acute stage, giving rise to sever- al of the symptoms that are esteemed charac- teristic of hydrocephalus internus. Indeed, so marked is the resemblance in many cases, between the symptoms of this disorder, and those proper to that fatal disease, that 1 have been led, on a great many occasions, to sus- ture, respecting the cause of these be correct or not, must be left to future inquiry and experience to determine. It is deserving observation, however, that the aptha: infantum, which arise from an irritation in the digestive organs, are said by Lieutaud to have been discovered in these passages, and even in the lungs—si vero laryngem subeant, et ad tra- chram bronchiam et pulmones difrundatur ; tussem fero- cem, spirandi difficultatem; aliaque truculei.tioria symp- lomataconcitant.—Synopsis med, pract. Lieutaud. 73 pect that this fatal disease was commencing, and in two or three instances 1 have been in- duced to believe that it was actually present , and have been gratified to find, by the result, that in the latter cases at least, I had been mis- taken. In two of the instances, there wa? blindness for several days, with an unusually slow pulse in one of them. In another, a boy of seven years of age, whose sister I had seen in that fatal disease, there were consider- able pain and conTusion in the head, and a permanent double vision for some days, which were removed by free bilious evacuations from the bowels. On another occasion, I at- iended a youth, about twelve years of age, in whom the disorder, commencing in the biliary system, produced, after some time, an affection of the head, which appeared in its turn to give rise, for several days, to a com- plete rigidity of most of the muscles of vol- untary motion, resembling catalepsy, and at- tended with an excruciating pain in the course of the spine, leaving behind, on the return of health, a permanent fatuity of mind, and the most entire relaxation and paralytic de- bility of the muscles previously affected. It was not until after some months, that the pa- tient became able to support himself upright when seated, and he did not recover his nat- 71 ural strength until the end of nearly two years. Having been requested by a woman, on three successive occasions, to prescribe for three of her children, labouring under hy- drocephalus internus, which terminated fatal- ly in all, I desired her to watch in any future children she might have, the least approach of the disorder that caried off these, and to procure advice for them early. She has had four since, and during the last seven years these children have been repeatedly under my care in marasmus, which the poor woman considered, and I suspect justly, as the same disorder that terminated so fatally in the others. There is, in fact, often considerable diffi- culty, especially in infancy, to determine where the symptoms proper to the marasmus terminate, and those belonging to hydroceph- alus internus begin ; and it is frequently b\ the result alone, that an opinion of their na- ture can be formed. To me indeed, I must confess, it appears probable, that many of the symptoms, reputed as proper to water in the head, may exist before the actual effusion of water into the ventricle ; and that the cases of that disease, reported to have been cured, have been cases of marasmus, which 75 were about to terminate in that disease, hav- ing reached the line which divides the incipi- ent and curable form of it from that, its fatal stage, where an effusion has actually taken place. For it seldom happens, that children are affected with the acute form of maras- mus, without there appearing some sympa- thetic affections, denoting cerebral irritation The imperfection in the powers of speech and of vision, and the sometimes sudden and paralytic feebleness of the muscles of volun- tary motion, and the decided imbecility of mind, which are occasionally met with in this complaint, are plain indications of this state ; and, as they are accompanied with apparently the same general symptoms, which precede the hydrocephalus internus, it is reasonable to presume that they owe their origin to the same complaint, the boundary which divides the two disorders, lying between that moderate cerebral irritation, which gives rise to these and to some of the other symptoms of marasmus, and that intenser degree of it, by which the wa- tery effusion is produced. When the irrita- tion, in fact, has reached no higher state, than what is met with in marasmus, it is re-. movable ; but when it exceeds this, and rises to that point in which a fluid is poured out in- to the ventricles, it becomes, I believe, ir- remediable. 76 lu many cases, we find the cerebral irrita- tion in marasmus so considerable, as to lead 1 us to apprehend an immediate termination in effusion. Some years ago, I attended a child, in the acute form of this disorder, who had been convulsed when an infant from the irri- tation, as it was supposed, of difficult denti- tion, and whose mouth in consequence, had become, and had continued to be, in a certain, degree distorted. In the course of the ill- ness, in which I saw the child, there were several symptoms that threatened water in the head; and during the several days these symptoms continued, the distortion entirely disappeared, shewing that the contrary side of the brain had become affected, and that a temporary paralysis had been induced in the muscles, antagonists to those which were al- ready paralyzed, and that thus the distortion had become relieved. On the patient's final- ly recovering, the original distortion returned. It is no unusual circumstance for children, who are several times affected with maras- mu., to have, on each of the occasions, some single symptom present, which did not ap- pear in the other attacks of the complaiut. Thus, in one instance, there may be an ir- ruption on the skin, and in another a cough, and in a third the cerebral irritation, which 77 terminates in hydrocephalus internus. Some months since, I was requested to visit a child, about two years of age, whom I found labour- ing under the advanced and fatal stage of hy- drocephalus internus. From the intelligent mother, I learnt that the little patient, about three months before, had been affected with, and had completely recovered from, precise- ly the same symptoms, which preceded and attended the disease I now found him in ; ex- cepting, in the former attack, there had been the irritating cough, which belongs to maras- mus, whilst, in this attack, there had been no cough, and the first symptom of an alarming kind, which appeared after three weeks in- disposition, was in the head. In some cases these several symphathetic affections appear in succession, during the same illness, producing effects more or less severe, according to the importance of the parts concerned. In this way, the sudden disappearance of an irruption, from the sym- pathetic irritation changing its seat, appears frequently to produce an affection about the head, which may be either relieved by the return of the irruption, or by those means which remove the cause of both. A itw weeks since, 1 was requested to visit a child, whose brother I had attended in a fatal ca^ - * 78 of hydrocephalus internus. In this second pa- tient, a very general rash broke out shortly after the commencement of his indisposition. After some days. I understood it disappared, and was immediately succeeded, as I found, by general anasarca, and with considerable stupor, and imperfection of vision, and an in- termitting and remarkably slow pulse, with ye.i ty coloured and sometimes dark stools, and such intensely high coloured urine, that half a wine glass full, which was sometimes all that passed in twenty-four hours, was suf- ficient to give the proper colour and smell ■of that secretion to more than two quarts of water. After no ordinary struggle, the pa- tient recovered, and during his convalescence the original rash re-appeared. It has just been observed, that there is a difficulty in determining where the symptoms of marasmus terminate, and those proper to hydrocephalus internus begin ; it is not how- ever, to be understood, that there are no symptoms which clearly attest the presence of hydrocephalus internus. Where there are sudden screamings, and the carrying of the hand to the head, with an importunate desire to have the head kept low, and pressed be- tween the occiput and forehead, and a delir- ious raving in the day time disnroportioned 79 io the fever, with the double vision or blind- ness, and the slow intermitting pulse, the practitioner may assure himself, with little risk of error, of the immediate approach, or the presence, of that fatal disease. From these symptoms, indeed, I never have seen a patient recover, and I conclude that they de- note either the effusion of the fluid into the ventricle, or that condition of the brain, which no local or general means have hith- erto been able to remove. But it is not merely to secreting and exhal- ing surfaces, that this symphathetic irritation is limited; the cellular membrane is often the seat of it, and indeed it is probable that many of those abscesses, which take place in deep seated parts, and even those which are discovered in the brain, derive their origin from the same source ; for there is scarcely any part of the body that seems exempt from the influence of biliary irritation, nor scarce- ly any of the various morbid actions, local or general, of the system, which it does not sometimes produce. I once witnessed mania from this cause, that continued unabated for three weeks, and which was immediately re- moved by procuring copious evacuations from the bowels, that in colour and consistence closely resembled tar. During the recovery 80 of this patient, large phlegmons appeared, in succession, in different parts of the body, some of which became troublesome sores. In one patient, a married lady, there was a blindness that continued upwards of thirty hours, and which, after the recovery of sight, was twice renewed, for a short time, upon eating fish. The various and changing forms of scrofu- la, originate, very often, from this source ; and those hepetic irruptions, occurring about the ears of children, and sometimes of adults, are generally to be traced to this cause. At their early appearance, they may be often re- moved, and they may at all times be relieved, by correcting the disorder of the digestive functions : and this I believe, not merely by the relief afforded to the general health (though this effect is nevertheless important) but by destroying an irritation, which sympa- thetically excites the local disease. I have at present a patient, under my care at the Infirmary, who has been ill frequently during the last two years in a bilious derange- ment, and who, for a month previous to his applying for relief, was affected with an her- petic ulceration, which occupied a part of the cheek and the whole of the right ear. By means, applied merely to relieve the dis- 81 ordered state of the digestive organs, and without employing any topical remedies, the principal part of this diseased state of the skin was removed in the course of a week. Some years since, I visited a farmer at Be- wick, in Holderness, who had been for some time affected with a pustular irruption, which covered a part of his face, extending down- ward under the chin, and over a part of the throat. The disease had commenced in the form of small and detached pustules, which, spreading and uniting with each other, pre- sented the appearance of a mass of newly formed substance of a granular surface, and elevated nearly one third of an inch above the sound parts. There was no scabbing, but the whole was covered with a thin cuticle, having a thin sharp ichor dicharging from dif- ferent openings in it. The disease had been preceded by a general derangement of the function of digestion, brought on by cold and fatigue, and, at the period of my visit, this derangement, with its attendant symptoms, was very great. The nature and origin of the morbid affection of the face and throat, were, therefore, evident, and by correcting the disordered state of the biliary function, and thus removing the source of the morbid irritation, a check was immediately given to 83 the disease on the chin and neighbouring parts ; and, by the aid of stimulant dressings of the unguentum hydrargyri nitrati, the healthy state of the skin was in a week ov two restored. It is now several years since, and he has, 1 understood, had no return of his disorder; which, in some degree, further proves, if further proof were necessary, that the disease did not arise from any local cause, but from a morbid and distant irritation. In reflecting upon these and the other sym- pathetic affections, just noticed, and upon those symptoms of biliary derangement which precede and accompany these states, it is dif- ficult to consider them as standing to each other in any other relation than as cause and effect. And wilh respect to the cerebral af- fections, which terminate in hydrocephalus internus, there appears to be as intimate a connexion between them and biliary derange- ment, as there is between this latter state and some of the other symptoms that unques- tionably arise from it. The cough .and itch- ing about the nostrils, the herpetic and other irruption, the anasarcous and lymphatic swell- ings, with the phlegmonous affections, and the marked imperfection in the vision and memory, symptoms so common in biliary dis order, apparently depend upon an irritation 83 of the same kind, differing only in degree or in locality, from that which excites the hy- drocephalus internus. Diseases enumerated, which may be produced by bilious irritation.—Of these several sympa- thetic affections, there are, indeed, a great variety; but there are also a great variety of causes, acting in the system itself, which in these, as in other cases, are capable of modifying the effects of any morbid agent. As causes for the variation in the several sympathetic affections, we may, I think, look to those peculiarities which depend upon dif- ferences in age or constitution, and previous habits, as it is probable they have likewise a considerable influence in modifying the ef- fects, or in determining the direction, of any noxious irritant; and that thus, the same cause may produce hydrocephalus internus in the scrofulous subject, and chorea in the merely nervous or irritable one ; or chorea in the child, and convulsions in the infant; or the irritation may be directed to the skin, and produce herpetic or other diseases; or to the lungs, as the most susceptible part in those asthmatically or consumptively dispos- ed ; or it ni!) act upon the mucous or serous membranes, and produce an :ncreased secre- tion of them; or it may act locally, and give 84 vise to tabes mesenterica; or both locally and generally, and give rise to the various forms of scrofula. It would be exceeding the scope and ob- ject of this essay, to enter upon an inquiry- concerning the precise nature of the several diseases, thus produced by sympathetic irrita- tion, since many of them become early inde- pendent of their cause ; giving rise, in many cases, to morbid actions of a local or general nature, which may either perpetuate the dis- eases after the removal of their cause, or fa- vour the generation of others. I shall, there- fore, close this part of my subject with mere- ly remarking, in reference to these facts, that, in treating diseases which originate from a disorder of the digestive organs, it is important to observe, that, whilst the prima- ry symptoms proper to it are removable with their cause, that those of a secondary kind, and which result from the first, may demand in many cases a treatment essentially differ- ent from them; and that it is only by atten- tion to these distinctions, that errors can be avoided in our notions respecting the nature, and suitable mode, of treating these diseases. 8_» PATHOLOGICAL REMARKS Having given, in the last section, a brief view of the symptoms of marasmus, or of that derangement in the digestive function denominated bilious, I shall now proceed to make a few observations upon those facts which serve to illustrate its pathology : for facts, it is scarcely necessary to observe, are comparatively of little practical worth, until, by their rigid induction, they have establish- ed general principles, as it is only upon these last, that a consistent and rational method of treatment can be founded, for the relief or removal of disease. As preliminary to an inquiry, concerning the phenomena and causes of disordered di- gestion, it will be proper to take a. slight view of that function in a state of health. For this purpose, I shall begin by observing, that the changes which the food undergoes, from its being first taken into the stomach, until the expulsion of its foeculent part from the body, may be said to be of three kinds, namely, digestion, chylification, and what may be termed foeculent separation. The first part of the process of digestion, is performed in the stomach, by means of the 8 86 gastric juice ; and the second, or chylification in the duodenum and small intestines ; the bil- iary and pancreatic fluids, mixing with the chyme immediately after its passing from the stomach, and contributing in modes, hitherto but imperfectly understood, to the separation and recombination in new proportions of its principles, the colouring and other disengag- ed principles of the bile and pancreatic fluid serving to separate and carry forward the foe- culent parts to the large intestines, where the entire process of digestion is completed. These several processes are caried on by- organs, whose actions are rendered accordant and co-operative by means of a nervous con- nexion subsisting between them, which has been denominated sympathy ; and it is by the agency of this sympathetic union, that the quantity of the fluids secreted, and the periods of their secretion, are adjusted. The food, when taken into the mouth, excites there, by its own stimulus, the action of the salivary glands ; and it is by the* same proper and direct stimulus, that the glands, secret- ing the fluids of the stomach, are affected. But as the liver and pancreas lie out of the reach of direct stimulation, they must be ex- cited into action by an indirect impulse, com- municated by sympathy from the stomach, 87 In this case, this latter organ, in all probabil- ity, receives from the digesting or digested food, that kind of stimulus intended for, and by sympathy communicated to, these other organs subservient to chylification, by which the bile and other fluids may be provided at the proper period, and in the necessary quan- tity, to mix with the chyme, as it descends into the duodenum ; where the whole, thus mixed, is destined in its turn, to excite those particular actions in the course of the intestinal canal, which are required to complete the entire process of cfiylification, and foeculent separa- tion and expulsion. If any one of these functions become de- ranged, it is liable to throw one or more of the others into disorder, the measure, as well as the nature of this derangement, varying from variations in the degrees of the sympa- thetic relation of the organs to each other. Thus, the stomach may be disordered in its functions, by a cause directly applied to it, and may induce a correspondent derange- ment in the liver ; or it may become so, by means of the same sympathies, from a com- plaint commencing in this latter organ. In the former instance, where the primary de- rangement is in the stomach, an imperfect or morbid stimulus may be given to the liver, 88 from the stimulus communicated to the stom- ach by its own disordered secretions, or by the imperfectly digested food accumulated there ; in which case, the biliary secretion will be scanty and otherwise defective, whilst in the latter case, where the disorder com- mences in the liver, it may be communicated by a direct sympathy to the stomach, or by the connexion which subsists between this latter organ and the alimentary canal, where- by a series of irregular actions in the chylo- poetic viscera will ensue. As to what the particular deranged states of the stomach are, which give rise to disorder in the functions of the liver, or in what they differ from those, as in mere dyspepsia and some other affec- tions of that organ, in which no such effects are produced ; and whether the stomach be constantly, or only occasionally, the first in the series of organs to be affected, it is diffi- cult fully to determine. It seems, indeed, probable, from the tough phlegm, which is early and constantly present in the stomach and bowels of those affected with marasmus, that it has a considerable influence in many cases in aggravating, if not in causing, this complaint; and this partly, perhaps, by its own morbid irritation, but chiefly by the per- manent interruption given to a healthful di- 89 gestion by its presence, whereby that particu- lar stimulus is prevented from being given to the stomach, which has been noticed as nec- essary to excite the liver, and other subor- dinate organs, into their full and proper ac- tion. And this notion, may be allowed to de- rive some support from the fact, that benefi- cial effects are generally found to result from an emetic exhibited at an early stage of the complaint, when much of this phlegm is al- ways thrown off from the stomach, and from the uniform observation, that an unnatural and tough slime is always dischaged from the bowels before a cure can be effected. But upon whatever hypothesis, we may found our explanation of the origin of marasmus, or of the nature of those morbid states of the stomach and bowels which lead to it, or of the precise modes of action of those remote causes, which are found to act successively in increasing or in continuing it, it appears to me indubitable, that its seat is always in the liver, and that the means directed for the re- lief of the deranged action of this organ, are adequate to restore the other disordered func- tions to a healthy state. It has, I believe, been generally supposed, that the marasmus, as it appears in children, consists in a merely loaded and constipated 8* 90 state of the bowels. This notion, however, of the nature of the disorder, appears to ma ir- reconcileable with the phenomena exhibit- ed by the complaint, and with the observed effects of the medicines found useful in re- moving it. That it does not consist in a mere constipation or torpor of the bowels, appears to me evident from the consideration, that the acute form of the complaint some- times comes on suddenly from cold or other causes, and that sudden relapses are also common in it; that mere purging is general- ly inadequate to relieve the complaint, and that relief is very often afforded to it, many hou s before an evacuation takes place from the bowels; that, though their appearances are always unnatural, yet the motions them- selves are not always abundant in the sense to warrant the assumption of the bowels being loaded ; and that it is not until the foeces have acquired their natural bilious colour, that the disorder itself is relieved. Neither can it be admitted, as some have supposed, that the disorder consists in a merely torpid or weakened state of the alimentary canal, for this condition exists in many cases without this complaint occurring, and the medicines most suitable for it, are not among the class of remedies that could relieve such a state ; 91 for it cannot be assumed, upon any legitimate principles of reasoning, that simple purging, which removes the constipation, can be avail- able for the removal of the debility which occasioned that state. The following considerations, are among those which more particularly appear to war- rant the conclusion, that the disorder consists in a deranged condition of the biliary secre- tion. The colour of the motions of a person, whose digestion is healthy, depends upon the tinge imparted to them by the bile, and which is too well known to require to be des- cribed. The other secretions poured into, or supplied by the bowels, are for the most part colourless ; any change, therefore, from the natural appearance which takes place in feces, must result from a change in the bile. This change can only be produced at the pe- riod of its secretion, or after its passage into the bowels, by the action of some mor- bid agent it meets with there. That the for- mer mode is that to which this change is mainly to be attributed, may be inferred from the fact, that similar appearances of the motions are observed in cases where actual disease of the liver is present, and where a consequent disorder in its functions is evident; and that, as in the organic disease, so also in 92 the mere disorder of that organ, the variation in the symptoms, is attended by a correspond- ing variation in the appearances of the stools, they being sometimes of the yeasty colour, thence acquiring, perhaps, a slightly yellow- ish tinge, changing to a light yellow, and then to the natural colour; or they may be of the dark colour of tar, or of a black green, changing, by almost imperceptible gradations, to lighter colours, and thence, in a gradual manner, to the healthy one. Now, the first of these appearances, clearly attests a de- rangement in the secreting function, and, though the greenish tinge may be increased by an acid generated from the food in the prima} viae, yet, it certainly does not always depend upon that cause alone, since a green, and otherwise unnaturally coloured bile, is sometimes on dissection met with in the gall bladder. In those cases, where the motions are clay coloured, there is incontestable evi- dence afforded of an interruption in the se- cretory progress ; for, generally, neither the skin, nor the secretion by the kidneys, exhibit any greater signs of the absorption of bile in- to the system, than are manifested under other states of the alvine discharge. But the assumption of the secretions of the bowels being colourless, may be further 93 shewn to be true from the fact, that, where a complete obstruction is opposed to the pas- sage of the bile into the duodenum, the stools are never black, but are generally of a colour partaking more or less of that belong- ing to the food. And yet it is in these par- ticular cases, that there is often the most dis- order in the bowels, and when of course their secretions might be expected to be most deranged, and consequently the darkest. About a year ago, a gentleman of this town died, who, during eight years, was jaundiced from a permanent obstruction existing in the biliary duct. During the whole of this time, the bowels were often extensively and vari- ously disordered, yet, at no period, as 1 learnt from him, and as I had often occasion to ob- serve myself, were the discharges from the bowels black. The question will now, therefore, occur, as to what are the nature and source of the exceedingly black stools, so frequently met with in this disorder. To which I would re- ply, that, from every observation that I have been enabled to make upon the appearance of the foecal discharges, and from every con- sideration I have been able to give to the subject, I feel warranted in concluding, that they derive their black colour from an ad- 94 mixture of blood with them, and that this blood is derived from the extremities of the branches of the vena portarum. It was stated, in the account of the symp- toms of this complaint, that there are two stages, namely, an acute and a chronic one, into which it may be divided. These states, I think, may be considered as depending up- on different conditions of the liver, there be- ing a congestive state of the vena portarum and its branches in both forms of the com- plaint ; but in the* acute one, there is a high- er degree of this congestive state, giving rise, in its turn, to a certain degree of venous con- gestion in those organs of the abdomen, whose circulation is associated with that of the liver. The circumstances under which this organ is placed, are, it is well known, of a peculiar kind, the venous blood, returning from the chylopoetic viscera to tbe heart, being ap- pointed, in its passage thither, to circulate through the secretory vessels of the liver, as the pabulum of the biliary secretion. A por- tion of the venous blood, thus circulating through the liver, is therefore intended to be carried off from the mass, in the form of bile, by vessels destined for this purpose. Any in- terruption to the due performance of their runctions, will necessarily occasion an accu- 95 mulation of the blood in the vena portarum and its branches, and an impeded circulation will ensue, producing a congestive state of those vessels. And, that congestion will fol- low in those cases where the secretion is checked or interrupted, we have the justest reason from analogy to conclude. The female breast, for instance!, falls readily into a state of congestion upon any interruption occur- ring in its function, though the congestion, in this latter case, is arterial, and the effects in- flammatory ; whilst, in the instance of the liver, the congestion is necessarily venous, and the immediate effect, that of increased disorder in the secreting organ. In all cases of disorder in the function of a secreting organ, there is, however, a provis- ion made by nature for its final relief. The congestive and inflamed state of the female breast, if not removed by the local abstrac- tion of blood, or other artificial means, or nat- urally by a renewal of the secretion, termin- ates in suppuration, by which the congestive state of the vessels is removed, and a health- ful state of them at length restored. But pur- ulent secretion is the result of arterial ac- tion, and cannot take place in vessels whose character and structure are venous, and which, as far as our observations go, are incapable ot 96 taking on the proper inflammatory action, The mode, therefore, by which the venous congestion of the liver can be permanently removed, is by a renewal of the biliary se- cretion. Where this does not take place, and the congestion is considerable, there may be relief afforded to the organ by the escape from it, though the pori biliarii, of a portion of blood, which, by passing along the ductus communis, will descend into the duodenum. Of the first of these forms, we have a strik- ing instance afforded in the cholera morbus. which, as consisting in a copious secretion of bile, is produced by those efforts which na- ture usually makes, and by which she often succeeds, to free herself from disorder. The symptoms of the cholera morbus, which pre- cede the discharge of bile, are precisely, and indeed identically, those which distinguish the commencement of the acute form of this complaint, and consist of an oppressive weight and sense of fulness about the region of the stomach, with much anxiety, and general rest- lesness and languor. As soon as the secre- tion is renewed, these symptoms subside. The secretion, however, is in excess, and produces more or less of disorder ; for the first effect of the morbid cause having been to check the secretory functions, the re-ac- 97 tion which ensues occasions it to become ex- cessive. Appearances, somewhat analogous, for instance, are observed after taking cold, in the mucous membrane which lines the nos- trils, the first effect being a sense of heat and fulness about that part, which, in a few hours, is followed and alleviated by a copious secretion of mucous. The same inordinate secretion of bile, is not unfrequently occurring spontaneously even some weeks after the commencement of the bilious disorder, and always with relief to this complaint. Some time since, a man brought to our Infirmary a letter of recommendation to be admitted a patient under my care. He had been ill nearly a month, from this complaint in its acute form; but on the evening preceding his application, and after procuring his rec- ommendatory letter, he w.as attacked with the bilious diarrhoea, passing, as he informed me, during the night, nearly thirty motions of a pale yellow colour, and with such relief to his complaint, as scarcely to require a single prescription from me. But in some cases, as we have just noticed, it happens, that instead of the congestive state of the liver being removed by a renew- al of the biliary secretion, it is temporally re- lieved from that state by the escape of blood 9 98 from the branches of the vena portarum. This effect I have seen in a variety of instan- ces in this disorder, since my attention be- came more particularly directed to inquire concerning the cause of foecal discolouration, tracing the changes in the colour of the fe- ces, from a deep brown to black, and from this last to the complete venous hemorrhage ; this state yielding, as the cause removed, to the black, and this to the lighter shades, un- til the healthy colour was resumed. When the venous blood, thus discharged, passes through the bowels, it constitutes the mela- ena, and where there is an obstruction to its descent through the bowels from a constipa- ted state of them, or from other causes, it re- gurgitates into the stomach, producing the complaint known by the name of haemate- roesis. This hemorrhage, from its being of- ten thus thrown up from the stomach, ha9 been commonly, but as 1 conceive, errone- ously, considered to arise from a rupture of the vessels of that organ ; for when this dis- charge is idiopathic, it may, I believe, be justly referred to the liver, and be viewed and treated as the consequence of a conges- tive state of it. To the intelligent author of the work on purgative medicines, Dr. Hamilton oY Edia- 99 burgh, we are indebted for the first hint) leading to juster views of this disorder, and for a plan of treatment that enables us to combat it with success; and though I cannot agree in the opinion entertained by that en- lightened physician, regarding the cause and seat of this disorder, 1 fully subscribe to the utility of his mode of treating it, as the treat- ment he recommends has an important effect upon the functions of the liver, and owes, I conceive, its success to this cause. Indeed, if we reflect upon the comparative unimport- ant connexion, which the sanguineous sys- tem of the stomach holds with the viscera of the abdomen, and the intimate union which, in this respect, subsists between them and the liver ; and if, at the same time, it be consid- ered with what facility bile in other cases is thrown up into the stomach, we may per- ceive the reasonableness of the notion that this hemorrhage proceeds from the liver. There does not indeed appear, from any knowledge we possess, either of the anatomy or physiology of the stomach, sufficient grounds for concluding, that mere constipa- tion could give rise to apparently so serious an accident as the rupture of its vessels, or an exudation of blood from them; nor is it 100 conceivable that the stomach, under such cir- cumstances, could be benefitted by, or even admit of, the action of those active purgative medicines, which are so necessary and so effi- cient in this complaint. But a constipated or loaded state of the bowels, which is assumed as the cause of ha> matemesis, is by no means a regular or neces- sary attendant upon it; and cases of long and obstinate constipation are daily falling under our observation, without giving rise to it. Neither will the supposition of either this dis- order or melaena, arising from constipation, explain the well known fact, of their frequent- ly following the stoppage of accustomed evac- uations, as if vicarious of them, as in hemor- rhoidal and menstrual obstructions. Whereas, if we view these hemorrhages as proceeding from the liver, and arising from a congestive state of it, we have at once explained the rea- son why such obstructions should produce it, and why relief is afforded by the discharge, to the oppression and uneasiness about the stom- ach, and to the other symptoms of disorder; and likewise, the principles upon which the purgative treatment is so useful, as well as the origin and nature of those black putrid stools, which are so frequently met with in marasmus, 101 and which, in colour and consistence, so close- ly resemble tar.* In the accounts which are given us, of tbe examinations, after death, of persons who have died of idiopathic hsematemesis, it is acknowl- edged by many writers, that in several cases no rupture of vessels, nor other marks indica- tive of the seat of the disorder being in the stomach, were discoverable in it ;t and where others mention appearances, that seemed to. give some warrant to such a notion ; they con- sist chiefly of small discolourations in the mu- cous membrane of that organ, which may be justly regarded as the consequences of the ir- ritation excited by the morbid bile that has * " I have known," observes Mr. Abernethy, in his ex- cellent observations on this subject, " persons whose bow- els were ordinarily costive, and whose general health was much deranged by disorder of the digestive organs, though they were unconscious of its existence, feel pleased that their bowels were in a comfortably lax state ; yet in observing the stools, they resembled pitch in colour and appearance." Surgical Observations, page 47. t The late justly celebrated Dr. Heberden mentions the case of a patient who laboured occasionally, for several years, under a vomiting of blood, and in whom, upon an examination after death, no marks of ruptured vessels of the stomach or bowels could be traced—cujus tamen ven- triculuset intestina, postmortem, nullum morbi indicium ferebant, quod duo expertissimi ac sagacissimi anatomici possent detergere. Heberden Com. p. 403. 9* 102 been poured out with the blood, and which k often found so acrid in the severer forms of the cholera morbus, as to give rise to the pro- per dysenteric symptoms. By one writer we are told, that an habitual hsematemesis, in one instance, was useful and.even necessary, a dis- order having followed, of a bilious nature, up- on attempting to stop it; and that an emetic in another, which excited a vomiting of bile, was found to be useful in removing it. Now in the first of these two cases, there was the renewed congestion of the liver from a deficient secretion of the bile, and the hem- orrhage, by relieving the congestion, remov- ed the lassitude and other symptoms of the bilious affection ; and in the last, there was the renewed secretion of the bile, which, whether produced or not by the emetic, had the usual effect of removing the congestion, and in that way curing the complaint. Some years since, I was called to attend a gentle- man, who, after two or three days indisposi- tion, became suddenly seized with faintness, from which he recovered so as to be able to walk a few hundred yards to his house. In a few hours afterwards, he was seized with a slight paralytic affection of the left side, and immediately after this he began to vomit very considerable quantities of blood. After a trial 103 of the various means, usual on these occa- sions, for the space of twenty-four hours, with- out any abatement of the vomiting of blood, small doses of calomel, frequently repeated, were employed, and in a few hours the dis- charge ceased. The paralytic affection was, after some time, recovered from, and the pa- tient has enjoyed ever since an uninterrupted state of good health.* The following well marked case of maras- mus, accompanied by the bilious cough, and which terminated in a fatal melaena, occur- * In a valuable and practical paper by Dr. Abercrom- bie of Edinburgh, and published lately in the excellent Quarterly Medical Journal of that city, there is a case relat- ed of a young lady, that illustrates strongly the views which I entertain on this subject. This patient, Miss P. aged 21, had been affected with continued fever during three weeks, when the pulse came down to 84, and the tongue became clean. Shortly after this, a headach occurred, with tran- smit delirium and considerable stupor, bordering on coma, the pulse rising to 120. " In this state she continued a fortnight, with every appearance of a head affection of the most dangerous character; repeated topical bleeding, blis- tering, purgatives, and large doses of calome!, being em- ployed without relief. The calomel did not affect the mouth, and had very little effect upon the bowels. At the end of a fortnight, she was suddenly seized with a copious discharge of blood from the bowels, this continued three days, and left her extremely pale and exhausted, but free from stupor, and the headach was much relieved ; in five or six days more she was well." lOi red some little time since in my practice. The history of the case was procured from the patient and her mother at my first visit, and affords a good example ofthatformof the disorder, in which there is a strong re- semblance to phthisis pulmonalis. Mary Jacks, aged thirteen, admitted a pa- tient of the Dispensary. She complained of being affected with a severe cough, that was worse during the night, attended with an ex- pectoration of a thick, but whitish matter; of being much troubled in her breathing, and of reching occasionally when she coughed, and bringing up from the stomach a tough and sourish phlegm. Likewise, of pain in her left side, and an increase in her cough when lying on that side ; of chilliness, follow- ed by fever and thirst towards evening; and of profuse perspiration about the head and breast duriug the night, at the same time that ber feet were cold. She had also much pain in her head and stomach and bowels. Appe- tite extremely bad, pulse quick, tongue foul and dry during the night; bowels alternately loose and costive, and the discharge from them exceedingly black and offensive ; and her strength and flesh so reduced, as to be unable to walk without assistance. By her mother I was further informed, that her 105 daughter had been ill during the last six months, and that during the first three of them she had had a craving appetite, and dark and slimy stools ; was drowsy and list- less, complaining often of chilliness during the day; sleeping unusally sound in a night, and so reluctant to rise at the usual hour in the morning, as to weep when required to get up. That afterwards the appetite failed, whilst the fever and debility increased, the cough and unnatural appearances in the stools at the same time becoming worse; and that, about two months since, she had a fit which continued half an hour, and during which there was a blackness about her mouth and under her eyes, an appearance, she often ob- served afterwards in a slighter degree when- ever she was worse. Had been under med- ical treatment, and had been taking lately twenty drops of a mixture, consisting, in equal proportions, of the tincture of digitalis and the spiritusetheris nitrosi. Means were now directed to correct the derangement of the liver, though the ex treme emaciation and weakness, to which the patient was reduced, afforded little prosper of success. During three days, she continu- ed to part with the same black stools that she bad been discharging for some time before, iOfj and which I found, upon examination, to be excessively offensive, and of a tar-like ap- pearance. The cough had become very much abated, but her other symptoms were unre- lieved, and the general appearance of the pa- tient continued to indicate the most immedi- ate danger. On the fourth day there was an indistinct tinge of a dark venous blood through the fecal mass, and on the following morning I learnt that more unequivocal signs of it had appeared in the evening ; and that during the night, the motions consisted of little else but dark venous blood, which poured from her as she laid. Her pulse I found to be fee- ble and fluttering, and her complexion blanch- ed to a degree of whiteness, that I never witnessed before. There was, in fact, every symptom of an approaching dissolution, and in a few hour* she expired. Having obtained permission to examine the body, my friend and colleauge, Mr. Dunning, very obligingly atteded with me to do it. On opening the chest, we found some old adhe- sions of the pleura op the right side, but not the least disease in any part of the lungs; the right auricle of the heart, and the large vessels leading to it, were empty. There was some nearly colourless fluid in the stom- jch, and a very small quantity of bile in fh': 107 gall bladder. In making incisions in different parts of the liver, no blood scarcely issued from it, or from the vessels leading to it; it- texture and bulk were, however, perfectly natural, but it had that blanched appearance that might be expected to be seen in an or- gan which had been emptied of its blood and washed. The other contents of the chest and abdomen were likewise perfectly healthy. The foil wing case of an idiopathic melae- na, which also proved fatal, occurred shortly after the last, and was preceded by the same well marked symptoms of derangement in the function of the liver. M. C. aged seventy-five, admitted a patient of the Dispensary. At my visit, l learnt that there had been two discharges from her bow- els of a very large quantify of dark blood, preceded and attended by much sickness, and an oppressive weight at the stomach. The appetite was extinguished, tongue foul, the pulse feeble but of natural frequency; had been indisposed during the preceding five months, having been weary and languid, and particu- larly drowsy, falling asleep at her meals, aud even lying down on the floor to sleep ; appe- tite had been gradually becoming worse, au. latterly felt the desire to eat, but was u.iable to do so upon making the attemut; her knee?; 108 and ankles had ached considerably, her spir- its had been depressed, and her memory, and vision, and hearing impaired. During the last ten days, she had had the feeling of a load at the pit of her stomach, with frequent nausea; the bowels had been kept regular by some pills. During the following six hours after my seeing her, she parted with seven more discharges, each one consisting of upwards of two pints of pure venous blood. The excessive debility, thus induced, render- ed her situation utterly hopeless, and during the three days she survived, she had all the symptoms of the worst form of typhus. Permission having been obtained for an examination of the body, my friend and col- league, Mr. Casson, obligingly attended to perform it. There were the same appear- ances exhibited in this as in the former case. The liver was completely emptied of its blood, as well as the right auricle and ventricle of the heart, and the large veins leading to it. The liver, and all the other organs, notwith- standing her great age, were apparently healthy. Both the liver and intestines had a blanched appearance. The latter were lined throughout with a dark coloured slimy mat- ter, similar to what passed after the hemor- rhage stopped. There was some bile in the 109 gall bladder of a darker colour than natural, and a few inches of the inner part of the du- odenum were tinged with bile, which was probably owing to an escape of some of it from the gall bladder after death. The stomach contained some nearly colourless fluid, and exhibited, in every respect, a nat- ural and healthy appearance. In this and the foregoing cases, if I mistake not, there may be seen the same assemblage of symptoms which are proper to the biliary derangement, so as to warrant the conclusion* that the hemorrhage owed its origin to that disorder. For that the blood did not proceed from the stomachs of the patients whom we examined, is sufficiently apparent from the fact, that the contents, when examined, were found to be nearly colourless ; and that, if it proceeded from the intestines, it must have been by a rupture of their vessels, of which there was no sign, and for which there cer- tainly appeared no adequate cause. From these and other considerations which havo been noticed, I think the inference is. that melaena, as well as hrematemesis, are only modifications of the cholera morbus. arising, like this, from a congestive state of the secretory vessels of the liv.er; and differ- :ng from it chiefly in there being an e-rape 10 11U of blood from the extreme branches of the vena portarum, instead of the copious secre- tion of bile, which constitutes the latter com- plaint. RECAPITULATION. The view which has been attempted to be taken of the pathology of marasmus, I may here briefly repeat to be I. That this disorder consists in a derang- ed and imperfect action in the secretory func- tion of the liver, and a consequent deficient and unhealthy secretion of bile, as is mani- fested by the alvine discharges not having that colour, which is always imparted to them by it, when it is secreted in a healthy state, and in the proper quantity. II. That this derangement in the function of the liver, commonly arises from a disorder commencing in the stomach ; for the func- tion of digestion is performed by organs, whose actions, by means of a nervous union established among them for this purpose, are rendered accordant and co-operative ; the healthful action of the liver depending upon a stimulus imparted to it by the stomach, in obedience to this law. III. That in certain deranged states, there- fore, of the stomach, the precise nature of which is unkown, there is either a morbid or Ill an imperfect stimulus given to the liver, by which its secretory function is impeded, and a bilious fluid produced, that is deficient in its quantity, and commonly of a morbid kind. IV. That, as an interruption in the accus- tomed actions of a secreting organ occasions a congestion of its vessels, the diminished se- cretion of the bile gives rise to a congestive state of the vena portarum and its branches; and, in some cases, to a similar state in those organs, whose venous system is associated with that of the liver. V. That in consequence of those efforts which nature makes to free herself from disor- der,this congestive state is sometimes spontane- ously removed by a copious secretion of bile, constituting the bilious diarrhoea, or the chol- era morbus ; and that in other cases it is tem- porarily relieved by an hemorrhoidal flux, or by the discharge of blood from the loaded ex- tremities of the vena portarum ; occasioning in this latter case, and when in small quanti- ties, the black and tar-like, and often pu. rid and fetid stools; and when in excess, the idiopathic haematemesis or melaena. VI. That whilst this congestive state of the liver produces an assemblage of symptoms, re- sembling in many points the acute inflammation of that organ, it differs essentially from that 112 state in many important particulars. For in the acute inflammation of the liver, it is the arterial action of the organ that is excited, and the congestion (if the expression be allowable) is arterial; the secretory function of the or- gan, from its being carried on by a distinct class of vessels, partaking only secondarily, and partially, in its effects ; whilst in the ven- ous congestion of the liver, consequent upon an interruption in its secretory action, the ar- terial system of the liver is necessarily but little, if at all, affected; the congestive state in that organ being in all probability limited to the vena portarum and its branches. VII. And lastly, that the indications for the removal of these morbid but dissimilar states, will, therefore, necessarily be different. The inflammation in the liver will demand the same treatment which is applicable to inflammation in other parts of the body, for it differs noth- ing from that state in them, either in its origin or nature ; whereas, in the other disorder, from its having nothing in common with in- flammation, it will not, as I have repeatedly found, be benefitted by vencesection, or by blistering, and the severe antiphlogistic regi- men; but the principal object to be attained, will consist in a renewal of the healthy secre- tory action of the liver, as it is from the inter- 113 ruption of this, that the congestive state, with its immediate train of painful symptoms has arisen. REMOTE CAUSES. The remote causes of this disorder are cold, irregularities in diet, excess in the use of spir- its, the impure air of crowded or close situa- tions, certain eruptive fevers, sedentary em- ployments, &c. &c. These act, in some cases, as predisposing, and in others as occasional causes. We may notice them briefly in their order. Cold.—We need not stop to consider here the hitherto unsettled question respecting the mode, by which cold acts upon the system in inducing disease ; nor whether, in reference to its power in producing the complaint un- der consideration, its primary action be exert- ed on the liver or on the stomach. The modes by which, to adopt the common phraseology, it may be taken, are as various as are the mor- bid effects resulting from it, these being more dependant upon the state of the system, at the period of its being received, than upon the manner in which the cold is applied ; though lying on damp ground, getting wet about the 114 feet, or drinking any cold fluid, when the bo- dy is heated and fatigued by exercise, are the circumstances which appear to favour most the production of this complaint. The au- tumnal season, from the predisposition indu- ced in the system by the previous heats of summer, and from the greater variations of temperature,and probably from some unknown atmospheric influence, appears to Ire the sea- son when cold received is most liable to dis- turb the functions of the stomach and livei The cholera morbus, so frequent at this period of the year, originates, as it has been already observed, from precisely the same causes, and i:-, in fact, only a modified state of this disor- der; for the symptoms which precede the bil- iary discharge, are the same which constitute that complaint, the copious secretion of bile being its natural and efficient remedy. When a cold fluid is drank, the body being at the time heated and fatigued, the effects, where disorder ensues, are often rendered more severe if the fluid be of a digestible na- ture, as milk, &c. In these cases, the pain and sense of oppression about the stomach are sometimes so great, and are followed by so much faintness and sickness, and other symp- toms of extreme disorder, as to excite a suspi- cion of something poisonous having been mix- 113 ed with the drink. Such instances have sev- eral times fallen under my notice, and, in one or two cases, there appeared to require only some one upon whom the unjust suspicion could rest, to warrant judicial proceedings. And indeed it is probable, that many of those examples of death, which have occurred after drinking a cold fluid, or even after fluids not cold, when taken under certain states of the stomach, have been of this kind ; and it is to be apprehended, that in some of these cases the criminal prosecutions, which have been instituted in consequence, have terminated by the conviction of the innocent. About two years since, being accidentally in that neigh- bourhood, I saw, with my friend, Mr. Clifford, an intelligent and experienced surgeon, at Fatrington in Holderness, a farmer who sud- denly fainted away, shortly after taking break- fast with his family, having been up a consid- erable part of the preceding night, and active- ly employed in making preparations for an important trial at York, to which he was on the point of setting off. For nearly two hours, the pulse was imperceptible at the wrist, and it was for a considerable time doubtful wheth- er his nearly extinguished animation would be restored. An illness, of a completely bilious character^ followed this attack, and it was not 116 until after two or three weeks, that he recov- ered his accustomed health. Irregularities in Diet.—In those cases, where irregularities of diet produce the complaint, it will be found, that some of the predisposing causes, such as sedentary employments, &c. by weakening the system and the stomach, have previously laid a foundation for the com- plaint. Thus, it is a circumstance of daily ob- servation, that many of the most common arti- cles of diet, as that of bread and milk, will prove unwholesome to children, and particu- larly the female part of them, when living in the centre of a crowded town, and yet prove perfectly wholesome to them in the country ; and even sometimes, as I shall again have oc- casion to notice, food that has for some time disagreed with a child, becomes suitable for it during the employment of sponging with cold water, or the use of the shower bath, the stomach along with the general system be- coming thereby strengthened. In considering, therefore, the diet which may appear improper, we must always take into account the circumstances under which it is used ; for many things will be found to dis- agree, under certain states of the stomach and of the system, which would have proved wholesome at another time: so that that 117 which is suitable in health, becomes often de- cidedly injurious under disease ; and even the same dietic regimen, which is useful in secur- ing the system from disorder, will prove im proper when it is present. But it must not be here understood, that there are no articles of diet which are capa- ble of themselves, unaided by other causes, of producing biliary derangement. Rich pastry, in all its various forms, unripe fruit, and the different kinds of confectionary, are of diffi- cult digestion with most persons, and are un- fitted under all circumstances for children. In a few persons we observe indeed peculiar- ities of a constitutional nature, which render some of the simplest articles of food unsuita- ble ; but these constitute exceptions, and, gen- erally speaking, we shall find in our refine- ment about the kinds of food which are inju- rious or otherwise, that more attention is re- quired in a healthy person to guard against an excess in the use, than any minute discrimina- tion in the choice of his food ; for it is more from the abuse of what is proper, than from the temperate use of that which is esteemed unwholesome, that the bilious disorder arises. Nor ought we to overlook our neglect of simplicity in our diet; for the various unnatu- ral mixtures, which an artificial cookery brings 118 to our tables, have contributed more toward? the production of this complaint, than perhaps any single article of food is capable of doing, however exceptionable it may generally be regarded. And the remark, which applies to the effects resulting from an excess in the use of food, is especially applicable to an improper use of wine and other fermented liquors, and in- cludes, perhaps, all that is required to be said concerning them; for, after what has been written by professional and other writers upon the subject, there are few persons guilty of such excess, who are ignorant of the conse- quences likely to be entailed by it, and proba- bly still fewer, that can be deterred from such misconduct by any considerations affecting their health. If, however, much of the food esteemed un- wholesome, may be considered to be so only as its effects are aided by an excess in its use, or by the improper modes of preparing it, yet it cannot be too strongly pointed out as being the principal cause of this disorder in infancy. Indeed, it may be laid down as an incontrovertible fact, that, during the first six or eight months of an infant's life, the only suitable food for it is the milk of its mother, all artificially prepared food having the strong- 119 c^t tendency to disorder it, and producing too commonly symptoms of a biliary derangement in their most marked and fatal form. But here I must crave the indulgence of the reader, whilst I proceed to notice the improp- er plans pursued in this respect in the nurse- ry ; for most of the disorders of this age, and many of those at other periods of life, derive their origin from this source; it having been justly observed, " that where mismanagement in infancy does not actually destroy the life, it often very essentially impairs the health, the foundation of a future good or bad consti- tution being frequently laid at this period."* I shall, therefore, now proceed to offer a few observations concerning the causes why so ma- ny mothers are thought incapable of becoming nurses, or why so simple and so natural a mode of nourishing an infant, as that by nursing, is considered by some as unsuitable for it.t And first, with respect to the causes why mothers are unable to be nurses. These may be considered to be of three kinds, and are • Underwood on the Diseases of Children. f •• Believe this solemn truth, almost every woman is Capable of supporting her babe, aud great will prove the advantages both to herself and her infant. When it is confined altogether to the breast, it gains strength every day and defies disease."—Letters to Married Women on J leave it, in a considerable degree, to the pa- tient to determine when, and in what quantity, he shall take food ; and where an absolute disgust is felt for food, it is certainly prcpei 156 fo abstain from it. And this rule applies with equal force to those cases, where a morbidly craving and voracious appetite ex- ists, as it is proper to permit the patient to indulge it; observing only that the food be of a wholesome kind ; for in some, this constant returning desire to take food is so strong, and attended by such faint depressing feelings at the stomach, as to occasion considerable suf- fering. From the benefit which opiates afford in some states of watchfulness, it might be ex- pected they would have some effect in pro- curing rest in this disorder. The effect of them, however, is always unfavourable ; for they aggravate the cause which occasions the restless state, and interfere with the opera- tion of those medicines which are required to remove it. The same, likewise, is true with respect to the various means which are directed for the cough in this complaint; for many of them are sickening to the stomach, and in its disordered state are very likely to do further injury to the digestion, and are, at the same time, of little even temporary ser- vice. When no disease is induced in the tra- chea or bronchia by it, which 1 have reason to believe occasionally happens, the cough i" very quickly relieved by the means which 157 are directed for the correction of its cause, being generally one of the first of the urgent symptoms that disappears. Sometimes there is, in this complaint, an appearance of spontaneous diarrhoea, which, though arising from the irritating nature of the morbid matters in the prima? viae, may be mis- taken for that which arises from an increased mucus secretion into the bowels, and attempts be made to check it by opiates and astrin- gents. Such a practice will not fail, howev- er, to prove unsuccessful ; for those means have but a very limited control over this kind of diarrhoea, and all they have is injurious. A slight examination, indeed, of the motions, will convince the practitioner that the diar- rhoea depends upon a disorder in the functions of the liver, and that the only mode to check the loose state of the bowels, will be found to consist in restoring the proper biliary se- cretion. The fact is, that in this state of the » bowels there is, however extraordinary it may seem, the same need of purgatives, as where actual constipation exists; and that, instead of increasing, they lessen the number of the evacuations: for these repeated mo- tions are the consequences of a stimulus, im- parted to the bowels by the food, which pas- ses undigested through them, in a ferment- 11 158 ing and acid, and sometimes in a putrid state. By restoring the secretion of the bile, which corrects this putrid and acid tendency in the - ingesta, and aiding the descent of its foeculent parts through the bowels, the morbid stimu- lus, which produced the diarrhoea, is no longer giren, and the diarrhoea itself is re- moved. In all cases, therefore, of diarrhoea, attendant upon this disorder, it is absolutely necessary to inquire concerning the colour of the dis- charge ; for, if it be of a bilious kind, opi- ates will be improper and aperients unneces- sary, as the discharge, in this case, is the nat- ural remedy for the complaint, and only re- quiring attention upon its becoming exces- sive. In many cases, where improper means are employed to stop it, in its descent through the bowels, a feverish state of the system en- sues, from the irritation produced by its ac- cumulation. The febrile symptoms, attended with heat of skin and thirst, may, in many cases, from their urgent nature, be thought to require some of those saline and antrmonial diaphor- etic medicines, which formerly shared so much of the confidence of physicians ; but the reasoning that applied to remedies for the cough and debility, is equally applicable 159 here. The fever and thirst derive their ori- gin from the conjoint irritation of morbid matters in the primae viae, and the deranged action of the liver; and until these states are removed, no subordinate evacuations are available. Besides, the action of the calo- mel, which is designed for the liver, will be diverted to the skin if diaphoretic medi- cines are combined with it, and its pursued operation will be lost. From observations repeatedly made upon this fever, and upon the effects of medicines in subduing it, it has always appeared to me to be more relieved by the medicine, which was directed to cor- rect the disordered biliary secretion, than by evacuations from the bowels ; as I have found it often indeed as intense on the evening succeeding considerable evacuations, as it had previously been. And on the other hand, there is often a marked abatement of it be- fore any evacuation has taken place, evident- ly shewing, that its principal cause consists in a disordered action of the liver, rather than an irritation from morbid accumulations in the primae viae; a small dose of calomel, in fact, taken at bed time, having more effect in subduing the fever and procuring rest, than any combination of those medicines, which are in the highest estimation for these purposes. 160 The apthous affection of the mouth, which is so common an attendant upon this disorder in children, is not unfrequently treated with topical applications ; and where the cause of the disease is not neglected, there is no objec- tion to be offered against their use; but as it is a complaint which, when originating from bilious irritation, yields immediately with the cause that produces it, I have never of late had recourse to them; a few minute doses of calomel, repeated at short intervals, hav- ing generally the effect of removing it. The good appetite, which attends the ear- ly and chronic stage of this disorder, fre- quently leads the friends of persons affected with it to believe, that the listlesness, and in- activity, and dispiritedness depend upon some moral causes, and they are importunate with them to shake them off. The fretfulness of temper, likewise, which is a symptom of the complaint, and which is observable iti children and infants, while labouring under it; and that dulness also which children ex- hibit in this disorder when appointed to get their tasks, are improperly considered in the same light, and punishments, as undeserved as they are unprofitable, are improperly re- sorted to for their correction. In directing the treatment of this complaint, 161 it is of considerable importance to be precise in the rules which are given, respecting the food, for it is no unusual thing, for the pa- tient to abandon the use of the accustomed and proper kind, and choose some other de- cidedly injurious. In general, children in this disorder, dislike their accustomed meal of bread and milk in a morning, and it is prop- er to substitute some other one in its place ; but on the accession of the febrile stage of the complaint, they often demand cold milk with avidity, for the purpose of allaying the thirst, by which they considerably increase the disorder. In every stage of this complaint, the milk of cows appears to act unfavourably ; the prevailing acidity in the stomach and bowels in this complaint, having the effect of changing the cbeesy part of the fluid into a strong curd, so that portions of considerable hardness, are often thrown up from the stom- ach, or passed from the bowels, in an undi- gested state, and presenting an appearance not unlike the white of an egg that has been boiled and cut into pieces. As a general rule, with respect to the diet for children and adults, it may be stated, that, where the appetite is good or morbidly craving, too much care cannot be taken to allow nothing that is not of a perfectly plain kind, both _3 14* 162 »t regards the nature and culinary prepara- tion of it ; and that, where the appetite is impaired or extinguished, it is better to wait for a natural appetite than tempt it by an im- proper diet. For if the plentiful appetite for plain food, which attends the first stage, be inadequate to strengthen the system, there can be little hopes entertained, in its second stage, of benefit from a food that i-* unwhole- some in its nature, and which, though taken in but small quantities, is, nevertheless, swal- lowed with disgust. And here it may be re- marked, that, generally speaking, that food may be accounted plain which is cooked plainly; and that those articles of food which are accounted improper, are partly so by the unnatural combinations which the cook or confectioner forms with them ; not forget- ting, at the same time, that we may render the simplest unwholesome, and the compound- ed food poisonous, by the manner in which we indulge in their use. It is proper to no- tice, however, that beef, and likewise most young meats, are often found to be difficult of digestion, and malt liquor will seldom agree with the patient ; whilst wine fre- quently produces a distressing acidity in the stomach. To children, indeed, these last are inadmissible at every stage of the disor- 163 der ; and to adults they are rarely required, and may be often injurious, particularly malt liquor, if they be given before the healthy secretion of the liver is to a certain extent renewed. But on these points, an important distinc- tion must be attended to : the principle upon which a cautious, and somewhat abstemious regimen is recommended, is founded on the imperfect powers of the stomach, and not upon any organic disease of the liver, which is erroneously believed to exist as the cause of this disorder; for, when the stomach be- comes equal to the digestion of a full and nourishing diet, with a moderate allowance of wine, there is a positive advantage in al- lowing it; since it seems to strengthen, in a very material degree, both the stomach and the system, thereby more readily confirming the recovery of the patient. It has been stated that the most common cause of this complaint in infants, is the im- proper food with which they are fed, some being incapable of digesting any artificial preparations of it; becoming, where the at- tempt is made to bring them up by what is termed the hand, so severely affected by this disorder, as to leave no alternative between a fatal result, and an immediate return to the 164 use of their natural sustenance. For though an infant, under these circumstances, may be temporarily relieved for a day or two from its disorder, it seldom fails to relapse again to its former state ; and if not carried off by convulsions, it gradually wastes under, what is supposed, some internal organic disease, but in reality, from a congestive state of the liver, as I have several times ascertained by examination after death, and which is the con- sequence of an indigestion, commencing in the stomach, from the improper nature of the food. To attempt, therefore, to relieve an infant from this disorder, whilst the cause of it is permitted to remain, will prove as fruitless as it must appear irrational. So often, indeed have I witnessed the infants of the poor per- ish, notwithstanding every attempt to save them, solely from their being deprived of the breast of their mothers, that there is no fact upon which 1 can speak more confidently than upon this, nor which 1 feel more anxious to press upon the attention of the reader. The justificatory plea, which is sometimes set up for neglecting this duty, and which, I regret to add, is countenanced by some prac- titioners, that nursing is weakening to the mother, or unsuited to the infant, is an error I do not hesitate to pronounce to be of vital 165 importance, and which merits the most un- qualified reprobation. For, where an infant is confined exclusively to the breast, I am authorized by observations long directed to the subject to declare, that, with respect to the mother, there is none of that debility which an erroneous view of the subject leads so many to expect; but that, on the contra- ry, there is a feeling of the highest health, the appetite and digestion being vigorous, whilst the supplies of milk are both regular and abundant; and that, with regard to the infant, the process of dentition being neither premature nor difficult, it enjoys, as far as it depends upon the food, an absolute exemp- tion from disorder; the thin, and seemingly spare, diet afforded by the milk, satisfying its utmost wants, and invariably imparting to it a degree of vigour and firmness, which no ar- tificial mode of rearing can bestow. Among the means that may be accounted most valuable, as auxiliaries to the strictly medical treatment of this disorder, there is no one upon which I so much rely as on the use of the shower bath, or on what is equal- ly useful and more generally acceptable, the practice of sponging the body with cold wa- ter, upon first rising in a morning. The power which this possesses of strengthening the system, and of improving the digestion, 166 and of imparting a feeling of health and vig- our to a convalescent in this disorder, is of- ten remarkable; the invalid frequently be- ing enabled, under its use, to digest food, which on all former occasions had disagreed with him, and to resist the influence of many of those causes, which had before either pro- duced or aggravated his complaint. In this disorder, it seems, indeed, to answer all the valuable purposes which sea bathing has been distingished for ; and where change of air is not required, it appears fully suited to accomplish them. Vinegar or salt is some- times added to the water, and probably with the advantage of increasing its activity.* The substitute, however, which sponging is capable of becoming for sea bathing, is not to be understood as rendering a removal to the sea side, or a change of air, undesirable ; for in many cases, it is of the utmost conse- quence as the means for establishing the health. But of them both, it must be ob- served, that the advantage which they afford consists chiefly in confirming the recovery, being seldom of service until the principal cause of the complaint is removed, or in the course of removal; for, where sponging is * As a good substitute for sea water, I am accustomed to advise the napkin, with which the patient is wipo. dry, ro be rendered salt by being dipt, the preceding day, in water containing some common salt. 167 employed early in the disorder, there is no* that glow upon the surface, which is at once the proof, and perhaps the cause of its use- fulness : and where a change of air is em- ployed, under the same circumstances, the pa- tient is seldom rendered better by it. It is usual for patient3, in the early stage of this disorder, to feel better when walking out; and afterwards, as the complaint advan- ces, to feel a repugnance to every species of exercise ; the wind in particular being rarely agreeable to them, however warm the weath- er may be. In these cases, I have seldom seen advantage in urging them to take exer- cise, having generally found them ready to take it as they become better, and were able to enjoy it. And this rule applies, likewise, to indulging the desire, which is sometimes manifested by the patients, to continue late in bed in a morning ; for, in general, it will be found proper for them to remain there, as it is often only at that time they are able to sleep, or to be refreshed by it. The cause of the debility which is observed, in those who lie much in bed, is in a majority of cases im- properly referred to the bed ; the attendants in this, as in many other cases, erecting an effect into a cause. Where, indeed, a pa- tient has been much disturbed in his sleep during the night, the refreshing sleeps of the 168 morning afford him strength ; for I have known many labouring people complain, that, in consequence of their dreams relating to their work, they have felt more fatigued on their rising in a morning, than they ever did from a common day's work in health. The clothing of patients in this complaint should be tvarm, especially about the feet and legs, which are peculiarly liable to become cold, even when the other parts of the body per- haps are preternaturally hot. In the course of a patient's recovery from the acute form of the complaint, in which the secretion of the bile had been scanty in quantity and inert in quality, it is a very usu- al and a very favourable symptom, to find the pain, which had been previously fixed about the stomach, complained of as affect- ing the bowels ; as such pain is at once the proof and the effect of a more healthy and active biliary secretion passing through them. From the occurrence of this pain, and some- times from the copious evacuations which t ike place at first from the bowels, there is often a suspicion entertained of the patient's becoming worse ; and in many cases the .voting practitioner will feel his confidence v. ;iv:;• hoin the slow decrease, or occasional ;'^-orr;»v,;'.'.')n of the symptoms of the com- plaint. In a!! such cases, the surest guide 169 that can be offered is the appearance of the tongue and of the alvine discharge; for,aslong as these present unnatural appearances, and there is no organic disease to account for them, he may assure himself that there is no path that will lead him so surely to the result he desires, as a steady, but temperate, employ- ment of the means which correct the deranged condition of the biliary function, and unload the primae vise of their morbid contents. It not unfreqently happens, indeed, that the patients in this complaint, are reduced to the last state of emaciation and weakness, and yet, by a steady perseverance in these means, the health and strength are perfectly, though sometimes onlys!owly,restored. So great, indeed, in some cases, is the weakness, that I have seen adult patients regaining their strength so slowly, as to be unable to walk alone at the end of a month after the commencement of their recov- ery. In fact, this disorder has no period, if organic disease be not induced by it, nor any degree of weakness or irritation proper to it, which should discourage the practitioner from attempting its removal; for there is uo state of suffering and weakness in it, that may not be lessened by correcting the biliary secre- tion, and unloading the bowels of their mor- bid and often putrid accumulations. 15 170 CASES. SECTION I. The following cases are given to illustrate the views entertained concerning the nature of the bilious diarrhoea, of the cholera mor- bus, and of melaea, and of the power which calomel posseses of exciting the imperfect, or in subduing the inordinate actions of the liver, present in these disorders. The cholera morbus, it has been already observed, is to be viewed as only one of the modes, by which the congestive state of the liv- er, constituting marasmus, is relieved. From the violent and more palpable symptoms, which attend the copious secretion of bile, it has been usual to view these as forming the whole complaint. The disorder, however, commences before the discharge of bile, and there may be, therefore, said to be two sta- ges of it. In the first stage, there is present a con- gestive state of the liver, giving rise, whea severe, to that condition of the system, which 171 in fevers is known by the name of collapse. When occurring in infancy and youth, espec- ially in the former, it is not unfrequently fa- tal ; and even in adults, it is often accompa- nied with fainting and other symptoms of an alarming character. In this stage, there oc- curs an irregularity in the circulation, and an imperfect supply of blood to the brain, and to the extremities. The powers of the system appear oppressed ; the extremities lose a por- tion of their heat, and often acquire a livid colour ; there is a general restlesness, along with much anxiety and oppression about the stomach, attended with nausea and retching. In the infant, there is frequently the fatal convulsion, which arises from the diminished energy of the brain, and which is indeed on- ly a modified and higher degree of the gen- eral restlesness. In this stage, there is, in fact, a manifest struggle between the oppres- sive influence of the complaint, and the vital energies of the system; the copious secre- tion of bile, which is produced, being the consequence of those energies acting to ex- cess, to repel and remove it. In many cases in infants, and in some instances, as well in adults as in children, for a want of energy, or from other causes, the natural efforts of the system do not remove the congestive state of 172 the liver; and hence, become established thf proper symptoms of the acute form of ma- rasmus. When that secretion of bile is induced which forms the second stage, it is usually in excess, and of an acrid and morbid nature, becoming, when very considerable, the source of other disorders. Of the two stages of this complaint, the first is that in which there is most danger, and in the treatment of which, the most decisive measures are required. From the exhausting and almost incessant nausea and retching, which attend the sever- er form of this stage, with the coldness and Iividness of the extremities, and the sunk and torpid countenance, and feeble pulse, it is sometimes thought that wine and cordials, and even opiates, are imperatively called for, and that they are all that can be, in these cases, trusted to. Such a view of the case, howev- er, I can confidently affirm, is fraught with practical evil; for the wine and cordials thus employed, as I have too often had occasion to observe, only aggravate the cause of those symptoms which they are designed to relieve. In the first stage, the motions are always highly unnatural, and if there be a lax, it is attended with much straining, and the dis- charge is watery and slimy, and sometimes of 173 the colour of tar, or is chiefly composed of dark venous blood. The pain of the bowels, in the severe forms of the disorder, is some- times excessive, and arises, probably, from their partaking of the congestion of the liver, as well as from the irritating and acrid quali- ty of the small portion of bile secreted, and from the distention produced by the ferment- ing state of the undigested matters passing through the bowels. In the second stage, the motions are of a pale yellow or yellowish green colour; and the pain, in these cases, arises from the irritation, given to the bowels by the more stimulant quality of the bile, or from the natural mucous secretions of the bowels, which should have perhaps defended them, having been previously purged away. In the first stage, therefore, it is the secretion of the bile which requires to be renewed, and rendered healthy ; and it is only in the second, or that in which the secretion is ex- cessive, and when, by the excess, the powers of the system have become exhausted, that wine and cordials are admissible or necessary. It has been already observed, that calomel possesses the power of increasing the biliary secretion when deficient, and of lessening it when in excess. This, to some, perhaps, may appear an unusual property in a med- 15* 174 icine ; but the deficient and excessive action? of the liver, which constitute the two stages of the disorder, are both morbid states, and it is one of the properties of this medicine to correct the disordered actions of the liver. In the following cases, it will be seen that the practice pursued, in the treatment of the cholera morbus, consists in giving a third, or a fourth part of a grain of calomel, according to the age or other circumstances of the pa- tient, every half hour, for five or six succes- sive hours, or until the sickness abates; and with such success in renewing the secretion when interrupted, or in lessening it when ex- cessive, and in allaying the sickness conse- quent upon these states, as rarely to require, excepting in cases of unusual severity, a con- tinuance of the medicine beyond the sixth or eighth dose. To those accustomed to con- sider calomel to be only useful when admin- istered in large doses, because it requires to be so employed in puerperal inflammation, and in some other acute diseases, the minute quantities here given may be thought perhaps unlikely to be efficient; but to such it may be observed, that, until we know something more of the manner in which this nv.'dicine acts, it is impossible to determine by any other rule than actual experience, the dose required to render it available for any specific purpose 175 Of the subjoined cases, the first is a bilious diarrhoea; the five which succeed it, are those of cholera morbus in its second stage ; and the seventh, eighth and ninth, are those of the first stage, and which, along with other symptoms denoting severity, were attended, and to a certain degree relieved, by the oc- currence of melaena. These cases, of chol- era morbus, it is necessary, I trust, to observe, are not selected from others where the suc- cess was less decisive ; for, among the great number, which my public appointments occas- ion me to see, I do not remember that 1 have hud any, during a period often years, where the practice here recommended was less suc- cessful than in those now given.* * The view here given, of the nature and mode of treat ing cholera morbus, h;is been entertained and acted on hy me during the ten years that I have resided in Hull ; and 1 owe it to Dr Curry, the distinguished Lecturer on the practice of medicine, at Guy's Hospital, to acknowledge that it was from hints, derived from observations delivered by him in the course of his lectures, on the power which calomel possesses of promoting the secretory function of the livi-r, that I was led to adopt this treatment Within these few years, a view of the pathology of cholera mor- bus, similar to the above, has heen given in an able work on the discasesof tropical climates, by James Johnson, Esq but which \ feel it necessary to observe, I did not s^e, un- til directed to it by a marginal note, in a work lately pub- lished, and after these pages were prepared and announ- ced for publication. 176 Case I.-——F. aged 36, admitted May 23c?, an out-patient of the Infirmary. Has been affected with a diarrhoea during the last five weeks, having daily, from ten to fifteen fluid motions of a light vellow colour, with considerable pain in the bowels. Appe- tite good, pulse natural, urine high coloured. Has employed all the usual medicines, under a skilful pracititoner, during most of this peri- od, but without any abatement of the com- plaint. Has passed a considerable number of motions this morning.—R. Calomelanos gr. iv. mica* panis q. s. ft. pilulae xvi. e quibus, St. i. sexta quaque hora. 4th day.—Was taken a pill regularly every six hours. Was only moved thrice on the day following her admission, and has had only one motion daily since, but has still some pain in the bowels. 5th day.—Has had only one movement to-day, and feels quite well. Pills to be discontinued for two days, when she will be seen again. 1th day.—The lax returned two days ago in the evening, and had eight discharges on the following day. Began to take the pills again last night, and has had only three movements to-day.—The pills to be continued. 10th day.—Has had only one motion daily since last report, and has taken the pills reg- ularly. Ha9 still some pain in the bowels. 177 \3th day.—Has continued to have only one movement daily. Two days since, the alvine discharge acquired its natural colour. Has still some pain in the bowels. The pills were now discontinued, and some slight means were ordered to relieve the spas- modic affection. On the 20th day, reported herself free from complaint. Case II.—M. R. aged 20, Jhtgust 1th. Began in the night to be affected with a se- vere nausea and sickness, and with an oppres- sion and pain at the stomach, vomiting up a considerable quantity of a green and bitter flu- id. Has been sick almost every few minutes during the morning; pulse natural; bowels have not been moved since yesterday.--^ third part of a grain of calomel to be taken every half hour, during six hours, or until the sichiess is removed. 2d day.—Took the twelve pills that were ordered, and was not sick after taking the third pill. Has left her bed room to-day, and is able to eat, and feetaquite free from complaint. Case 111.-----Cole, aged 50, admitted August 1th a patient of the Dispensary. Has been affected with vomiting and purg- ing during the last four days. Took a metli- c'me which stopt the latter, but the sickness 178 continued. Had much pain and uneasiness about the stomach, before the sickness began. The fluid, brought up from the stomach, is of a dark yellow colour, and of a bitter taste, la sick nearly every few minutes.—A third part of a grain of calomel to be taken every lialf hour. 2d day.—The sickness stopt after the sev- enth pill; has had no sickness since, but com- plains of weakness, and has no appetite.—To have a draught of bitter infusion every four hours. 3d day.—Has had no return of sickness, and is free from every symptom of her complaint. Case IV.—Jane Wilkinson, aged 12, admitted August 8th a patient of the Dispensary. Has been vomiting almost constantly, dur- ing the last twenty-four hours, a greenish and bitter fluid, preceded by much pain and op- pression about the stomach.—To have a third part of a grain of calomel every half hour. 2d day.—Was not sick after the fifth pill. and has continued well since. Case V.—Mary IV. aged 5, August 4tft. Is affected with a vomiting nearly every half hour, of a yellowish green fluid, attended with pain and frequent purging. Has been ill of this complaint during the last three days. Has much thirst and fever.—To have a quarter if a grain of calomel every half hour. 17(J ■:d day.—Ceased throwing up after the thin: dose, and has not been sick since. Bowels arc now regular. Has no complaint but weakness Case VI.----Bcnlle.y, aged 76, New Dock-street, admitted a patient of the Dispensary Aug. 3d. Eight days ago, became affected at the stom- ach with great oppression and pain, which were soon succeeded by nausea and vomiting, along with a looseness of the bowels. On the third day after the attack began, he became much worse, and has been throwing up and purging almost constantly ever since. Ha*. much pain in the stomach and bowels, and se- vere cramps in the legs. Has had a great many stools during the last night and this morning, and throws up almost every half hour. The discharge upward is very bittei and green, and that from the bowels is of the same colour. Pulse feeble, the countenance sunk, and the mind indistinct.—To have a quarter of a grain of calomel every half hour. Eight p. m.—Has taken only six pills since the morning, not having been able to guess the time. Has been affected with sickness and pur ging thrice.—Pills to be taken every half hour. 2d day, Ten a. in.—Has had only one move- meut from the bowels since last night, and has thrown up twice, once last night, and again this morning. The fluid thrown up is le«s 180 yellow and bitter than it was. Has not had so good a night before, since he began to be ill. Does not feel sick. Has taken eleven pills.— The pills to be continued every hour. Eight p. m.—Has passed a good day. Has been sick once, and had one movement from the bewels, but not of so loose a kind. Has no nausea, and no pain in his body. Has taken twenty-two pills since he began their use. —To take a pill every four hours. 3d day, Ten a. m.—Has been sick once this morning, but the fluid thrown up was not bitter. Has had a very good night. Has taken only one pill during the night, as he was fearful they contained opium, and were making him costive. Bowels quite regular.—Pills to be discontinued. To have an infusion ofcolumbo every four hours. Eighth p. in.—Has passed a good day. 4th day.—Slight nausea at times. Has eat- en a little, and had some wine. bth day.—Has passed a good night. Has thrown up his medicine once, but there was nothing with it. Has eaten some bread- Bowels regular. 6th day.—Has passed a good night, and only thrown up a little, nearly colourless, fluid this morning. Has eaten some meat, and relished it. 1th day.—Has had no returns of sickness, and the bowels are regular, and their contents of 181 a natural appearance. During the following days, he continued to recover, having no com- plaint but weakness. Case VII.—Mary Brown, aged 70, Mylon-strcet, admitted a patient of the Dispensary, Sept. 8. Two p. m.—Became affected last night, af- ter returning from gleaning, with great pain and oppression at the stomach, attended with slight delirium and frequeut fain ling, and a vomiting of an intensely green fluid, and a purging of a fluid of the colour of soot; and this morning there has been a stool, consisting chiefly of dark venous blood. The sickness is nearly incessant, the patient is very indis- tinct, and the pulse intermitting and very fee- ble.—To take one third of a grain of calomel a eery half hour. Eight p. m.—Had no sickness or motion af- tcv the sixth pill, but complains still of paiot in the bowels.—To take one of the pills every hour, if the sickness should return. 2d day.—lhxs passed a pretty good night, and has had no return of the sickness, and has had no movement from the bowels. Has taken some breakfast. Has still pain in the bowels.—To have a dose of a cordial mixture every four hours. 3d day.—Found her up, and making no complaint but of weakness. 183 Case VIII.—Thomas Carr, Dicksotis-Entn, Mytongate, aged 73, admitted a patient of the Dispensary, Aug. 6. Has been sick nearly constantly during the last eight days, throwing up, with little inter- ruption, a yellowish green and bitter fluid. Is much affected with a looseness and pain in hia bowels, and the sickness and vomiting continue. Has much thirst, tongue foul, pulse feeble and irregular. Has been ill during the last three months, with pain at the stomach and loss of appetite; with weariness,and an unusual aching in the limbs, and drowsiness in the day, with great watchfulness in the night.—A third part of a grain of calomel was directed to be tak- en every half hour, during six hours, or until the. sickness should be subdued. 2d day.—Had no sickness after taking the fourth pill. Has had only one stool since. Has no sickness now, but has still some pain in the bowels, and complains of great weakness Pulse regular, tongue nearly clean.—The pills were discontinued, and a cordial mixture ordered. As this patient was considerably relieved, he was not visited on the following day, and on my calling on the next one, I found he had had a severe return of his complaint, having passed, after,suffering much pain and oppression about the stomach, several loose stools, which the 183 attendants stated were of the colour of soot, and of a nauseous and death-like smell. This morn- ing has had two discharges, consisting chiefly of dark blood. Has much pain about his stom- ach and bowels, and has had no sleep during the last night. Tongue very foul, pulse feeble and irregular, countenance considerably sunk. Is very indistinct.—To resume the use of the pills, taking them as before. 3d day.—Has passed during the night several stoolf, of the colour of coffee grounds. Pulse and other symptoms improved.—The pills to be taken every hour. 4th day.—Fceces of a much better colour, having a slight yellow tinge. Has had a good deal of sleep during the night. Has still pain in his bowels. All the symptoms, with the exception of the appetite, decidedly better.— Pills to be taken every four hours, with a dose of the mistura cretacoea. The appearance of the motions, on the fol- lowing day, were quite natural, and in a few days he became, in every respect, well, an>l has had no return of his complaint since. Caes IX— T. W. aged 14, September \2th. Is affected with a considerable degree of pain and oppression about the region of the stomach, ind with an almost incessant retching and vom- 184 iting, and a death-like coldness and lividnoa- of the hands and feet, and blackness about the mouth ; the countenance expressing much anx- iety and restlessness, the pulse quick and com- pressible, the bowels confined, the surface of the body and head is covered with a cold pers- piration, the matter discharged by vomiting, bour and greenish. Was seized last night, sud- denly, with these symptoms, after a fortnight's indisposition, under the chronic form of maras- mus. Wine has been given to him, under a per- suasion that he was at the point of death, and various means have been employed to restore warmth to the extremities without effect.— A third part of a grain of calomel was ordered to be given every half hour, during six hours, un- less the sickness were previously stopt. 2d day.—Only a few of the pills ordered have been taken, as he was considered by his friends to be dying, and that no means could be useful. The coldness and discolouration of The extremities continue, and the sickness and oppression are unrelieved. Has had no stool.— One of the pills to be taken, punctually, every half hour, during six hours, unless the sickness be previously relieved. 3d day.—Has taken all his pills, and the warmth and natural colour of the extremities bv/e returned, and the sickness, and pain and 183 oppression very much abated ; the bowels are confined.—To have a draught, consisting of a •weak solution of the sulphate of magnesia, every four hours, until an evacuation be procured; and the pills to be omitted. • 4th day.—The sickness and other symptoms returned, in a considerable degree, during the night, and passed this morning several stools, which are said in colour to resemble soot; the extremities, however, are warm, and of their natural colour.—To have his pills again every half hour, during six hours, if the sickness and other symptoms are unrelieved. 5th day.—Has taken all the pills, and has had several discharges from his bowels of a better colour. Has no sickness, and the oppression and pain are very much relieved. - Has taken some food.—To discontinue the pills—to con- tinue the use of the aperient mixture. The alvine discharge, on the succeeding day, was much improved in colour, and the other symptoms, likewise, were further relieved. Had, however, still some pain in his bowels. On the following days he gradually got relieved from the pain, and was able to sit up and to take some food, and became shortly afterwards eon valescent. 18(5 SECTION II. '"t this section are given seven cases of marasmus, as it is found Occurring in children, each one exhibiting some symptoms which are not observed in the others. The first is an example of the complaint, as preceded and brought on by measles, exhibit- ing the symptoms usually met with in it, and affording, at the same time, an instance of the power which calomel possesses of subduing this disorder, by correcting the biliary secre- tion ; for in this case, calomel is the only med- icine which is taken, and there is no purga- tive effect from it, the changes which are pro- duced, consisting in a renewal of the healthy and bilious appearance of the alvine dischar- ges, and a consequent regular and natural evacuation of them. The second, is also an example of the disor- der under its common form. This case had continued two years, having preserved its chronic state during most of that period, but passing, at length into the acute stage. Among the other early and beneficial effects of the medicine employed, is the correction of the loose state of the bowels, by the influence which it exerts over the biliary secretion. 187 The third case, is a well marked instance of the chronic form of the disorder, when about to pass into the acute stage. The fourth, is an example of a mild form of the bilious cough, which is sometimes met with in this complaint, and which, with the pain in he left side and other symptoms attending it, occasions a strong resemblance between it and an incipient phthisis pulmonalis. In the fifth, there is a permanent strabismus from cerebral irritation ; this last being suc- ceeded, and most probably relieved, by the sympathetic irritation b_ing transferred to the mouth; producing a tumid state of the gums, and an apthous ulceration of them and of the tongue, with a carious condition of the teeth. In the affections of the head, arising sympa- thetically from biliary derangement, a slight and temporary strabismus is by no means an uncommon symptom; though the affection, most commonly occurring from cerebral irri- tation, is deafness. This symptom, I have met with in different degrees of severity, and of various duration. In some, I have known it to continue permanently ; though, generally, it yields to the means directed for the removal of its cause. The sixth, is an instructive instance of the complaint, in which the cerebral irritation 188 induces a complete hemiplegia. The child, who is the subject of it, is of a scrofulous family, and had been, during the space of two years, almost constantly affected with the dis- order under the chronic form, and in the last attack, and before my seeing her, a violent purging had for some time been induced by a vermifuge nostrum, though without affording relief. Having, in the course of a few days, become relieved from the disorder, a relapse is suddenly brought on by an improper indul- gence in diet; giving rise to so much irritation about the head, as to induce the hemiplegic af- fection. The renewal of the healthy secretion of the liver, removes again the irritation from the head, and the child is restored to health ; the state occasioned in the brain having, in this instance, no influence on any of these organs upon which the health depends, nor producing any visible diminution in the vigour of the in- tellectual faculties. The seventh, is also an example of the dis- order in the acute stage ; and in which there is that degree of cerebral irritation, as to induce not only a paralytic state of some of the mus- cles of voluntary motion, but such a degree of rigidity in others, as to render the back and lower extremities inflexible. Indeed, the rigid- ity was so considerable, during a month, that 189 the patient was unable at any time to be bent into a sitting posture, and he could be lifted in a perfectly stiff and extended state, by merely raising at the same time his ankles and head. A partial rigidity of this kind, is not very unusu- al in this complaint. I have seen it continue, uninterruptedly,for several days, in the flexor muscles of the toes of children, and in the mus- cles which turn the head. In this patient, the tongue was slightly paralyzed ; and this is a symptom which, if I mistake not, is often pres- ent in the severe forms of the disorder, for few children have that distinct utterance whilst la- bouring under it, which they possess in health. And this state, as well as the marked imperfec- tion in the memory, &c. which is observed both in children and adults, and the feebleness and trembling in the knees, may be considered as originating from an irritation of the same kind, differing only perhaps from the other in intensity. In six of the following cases, I have con- tented myself with giving the symptoms, to- gether with the result of the treatment, consid- ering any detailed report of their progress un- necessary. There was in all of them, some occasional variation in the doses that were first ordered of the medicine, as the circumstances of each demanded ; and this I have likewise- 190 omitted to note, as these cases are given rather to illustrate the principle upon which the treatment is to be conducted, than to de- termine the doses of a medicine that may be needed, under the ever varying circumstances of patients. Of the seventh, I have given a detailed report. Case. I.— Thomas Cox, aged 2, July 15 admit- ted a patient of the Dispensary. Is affected with much pain in the body and head, sleep much disturbed, appetite very bad, bowels sometimes loose, and at other times costive, the foeces white and slimy, has much fever and thirst, is listless, tedious, never stand- ing down, perspires, and frequently starts dur- ing his sleep. Has been affected with these complaints during the last six weeks, and worse for the last fortnight. They began im- mediately after a mild attack of measles, was very well before. A small dose of calomel was ordered to be taken nightly, with magne- sia the following mornings. 5th day.—Bowels have only been slightly moved, the alvine discharge dark, passes hi,s water with difficulty. In other respects, is much better and plays about, and perspires but little during the night. Has not taken the magnesia, having resisted the attempts made 191 to give it. Has taken the powder, containing the calomel, readily. 10th day.—Stools of a much better colour, appetite good, and not craving. Has still some pain in his body. Is playful, and always on his feet. Has been much better during the last five days. 14th day.—Is free from complaints. Case II.—Mary Parsons, aged 9, admitted May fith a patient of the Dispensary. Has been unwell during the last two years, having generally had a pain in the body and an aching in the legs, with much weariness. Sleep greatly disturbed, hot about the head, and perspiring considerably during the night, appetite always good, and frequently craving, bowels sometimes loose, at other times cos- tive, and their contents black and foetid. Has been always worse towards the afternoon. About three weeks since, began to be affected with a throwing up of her food, and a consider- able looseness, both which symptoms continue. The appetite, during the latter period, until within a few days, has been very craving, at present it is bad. Is very considerably re- duced in her flesh and strength, complexion sallow, and the countenance depressed ani fretful. A dose of calomel was directed to 192 be given nightly, and a draught of an infusion of senna on each succeeding morning. At the end of a week, all her symptoms were better, looseness in particular being much lessened ; and on the 22d, the bowels became regular, and their contents of a natural colour, the ap- petite good without being craving, and had no complaint but weakness.—The medicines were discontinued. On the 25th, was quite well. On June 8th, returned, as directed, to the Dispensary, and was found to continue free from complaint. Case III.—John Jackson, aged 12 years, admit- ted June 4th a patient of the Infirmary. Complains of pain in his back and loina, which extends to his groin. Bowels some- times loose, and at other times costive ; appe- tite has been craving during the last year, but feels no benefit from his food. Has much pain in passing his water, which is thick and high coloured, feels listless and indisposed to walk, from a weariness and aching about his thighs and knees, and the middle of his back. Is best in a morning, becoming unwell towards the afternoon, sweats much during the night, and is unrefreshed by his sleep, is much re- duced in his flesh and strength, complexion lm Mow, tongue foul. Began to have these complaints about a year ago, soon after his return from the West Indies, where he was born. Was ordered a small dose of calomel nightly, and his bowels were kept in an open state by a mixture, consisting of an infusion of senna. On the 17th, his medicines were discontinu- ed and he was ordered the decoctum cinchona?. On the 24th, was discharged free from com- plaints. Case IV.—Alfred Pullan, aged 15, admitted June 4th an out-patient at the Infirmary. Complains of a severe cough, which i3 worse towards night, attended with an expec- toration of a tough phlegm, pulse quick, bow- els stated to be at present regular, sometimes they are loose, tongue foul, appetite craving, :sdrowsy,dispirited,listless,sweatsduringmost of the night, and often during the day under exercise, has some thirst with fever and pain in the left side, complexion sallow, is much reduced in his flesh and strength, and has been ill for several weeks. A small dose of calomel was ordered to be taken nightly, and an aperient draught on the following mornings. Dismissed on the 17th, cured. 17 194 Case V.— Mary C. aged 3, May 25th. Has been generally ill since she was six months old, sleeping very badly, and having commonly some thirst and fever in the night, with profuse perspirations. The appetite has been either good or craving, bowels alternate- ly loose and costive ; their contents of a yeasty colour and foetid. Has been always better in a morning, becoming worse towards the after- noon. Had frequently fits until six months ago In one of these, a strabismus was produced, which still continues. Is now so much wast- ed in flesh and strength, as to be unable to stand. The gums are very much swelled, teeth are black, and the tongue is covered with apthoe. Has had a great deal of medi- cine without relief, and the mother was advis- ed, by the last practitioner who attended, to try no further means. Has five other chil- dren, who are healthy. A small dose of cal- mel was directed to be given nightly, and a draught consisting of the infusum sennae, the following morning. During the first week, there were three and four discharges from the bowels daily, which were dark and slimy ; the appetite became good, without being craving; slept better, having had less fever and less pirspiration: the mouth became well, and the child wa< 195 able to stand a few minutes at a chair. At the end of the second week, the stools had become more natural, the appetite good, had little thirst, and sat up through the day, and was able to walk with assistance given to both hands. These favourable symptoms con- tinued ; and the child, at theexpiration of five weeks, had nearly perfectly recovered her flesh and strength. Case VI.—E. Burton, aged three years and a half, admitted May 3d a patient of the Dispensary. Is affected with a considerable degree of fever, particularly during the night, attended with profuse pirspiration and frequent scream- ing. Has much thirst, no appetite, stools dark and slimy, and foetid. Has a troublesome cough, and is much reduced in her flesh and strength. When a year and a half old, was ill in the same disorder, and was then very much reduced. After a short recovery, she relapsed, and her body became large and hard, and attended with much feebleness and listlesness, and very loose and unnatural stools, having a pale and sunk countenance, with great thirst and often a craving appetite. Had a great propensity to eat sand and chalk, and considerable itching about the nose. These symptoms continued for three or four weeks, having occasional 196 short intervals of relief. She is the fifteenth child, and one of the family has died from a scrofulous disease of the hip. Has been ill in this last attack about two months, and has been taking a nostrum for worms, which operated very powerfully upon her bowels, but with- out bringing away any worms.—Habeat caU omelanos gr. ss. hora somni et haustum infusi .senna mana sequente. For five days, there was little visible im- provement, but very offensive motions were discharged; at length the fever and thirst abated ; she slept well, and the stools acquir- ed a natural colour, and the appetite returned, and the patient sat up and played about as usual. Having discontinued seeing her, I was requested a few days afterwards to visit her, and was informed that she had had a relapse of her complaint in the night; and that she had been out a part of the preceding day at the house of a friend, where she was, contrary to my strict injunctions, indulged in some very improper food. At my visit, I found her in convulsions, and her right leg and arm com- pletely paralyzed, with a considerable drag- ging of her mouth in the same direction. Pulse quick, but regular, bowels cotive. A common purgative glister was ordered, with leeches and a blister to the head, and the for- 197 mer medicines were directed to be resumed as soon as they could be given. 2d day.—Has been constantly in convulsions since yesterday, and neither food nor medi- cine has been taken. Pulse quick, and pre- ternaturally strong, bowels costive. 3d day.—Took one of the powders last evening, and a dose «f the mixture this morn- ing, and has had some dark slimy stools. The convulsions are less severe, and the patient is occasionally sensible. On the following days she continued to im- prove, and the motions became at length of a natural colour; she sat up and assisted her- self to food, and eat and slept well, and became soon perfectly free from her complaint. The paralytic affection, however, was unrelieved ; and I was prevented shortly afterwards from knowing the further state of my little patient, by her embarking with her family for America. Cask VII.—James T. aged 12, High-Street, ad- mitted March 3d a patient of the Dispensary. Is affected with considerable pain in his head and bowels, and a sense of a load at his stom- ach, or, as he expresses it, at his heart; ans- wers questions by monosyllables, and in an ut- terance scarcely intelligible ; is confined to his bed, and, from an unyielding rigidity in the 17* 198 muscles of the body and lower exlremitie*, is unable to be bent into a sitting posture, being so stiff as to be held extended straight, when supported only by the back of his neck and by his heels. This rigid state has existed for a fort- night. Tongue foul, bowels obstinately cos- tive, pulse about 100 and of moderate strength, appetite bad, especially for meat, sleep* sel- dom more than two hours during the night, and becomes feverish towards evening,the feet being often at the same time cold. Takes no notice scarcely of any thing passing, and sel- dom speaks, but moans loudly and uninterrup- tedly whilst awake. Was attacked on the 6th of January with sickness and fainting, and threw up a considerable quantity of phlegm. On the day following his attack, he was bet- ter, but continued listless for three weeks, tak- ingvery little support,and constantly complain- ing of uneasiness in his head and bowel-, and of a sense of a weight at his stomach; his bow- els were very costive, and sleep much disturb- ed. During five weeks, he was attended by two medical gentlemen in succession. The use of milk was now prohibited, and the following medicines were ordered.—R. Calomelanos gr. iv. micce panis q. s.ft. pil. vi. e quibus, St. i. omni nocte. Ilabeat infusi senna *i. bisin die, vel svpius, ad ahum solvendam. 199 2d day.—Has had one evacuation, which was lumpy, but reported to be not of a bad colour ; is in other respects as before. 3d day.—Has had one evacuation from his bowels, consisting of half a pot full of formed, and lumpy, and dark foeces; moans incessant- ly, and is in other respects as before. 4th day.—Has had one slight and slimy stool. In every respect as before. 5th day.—Has had no stool. Has not taken any medicine this morning, none having been procured from the Dispensary. A dose to be taken immediately, and repeated every two hours until a movement be procured. 6th day.—Has taken all the mixture with- out effect. In other respects as before.—Ila- beat pilule ex aloe c colocynthide gr. x2da. qua- que hora donee respondent alvus—Repr. alia. 1th day.—Had a copious motion last even- ing and one this morning; reported to be- lumpy, but not of a bad colour. Appetite im- proved, having asked for food, which he has not done for some time past.—Contin. pit. ex calomelane, et mist. 8th day.—Has had one motion, lumpy, and in small quantity; passed a restless night, wak- ing as usual at two, and seldom sleeping after- wards ; feet frequently become cold. Com- plains more of his head and of sickness. His 200 moaning is stiil as loud and unceasing as ever, and his utterance as imperfect, and the rigidi- ty of the body and lower extremities continue. 9th and \0th days.—Has had a stool daily of not a bad colour; other symptoms as before. 11 th, 12th, \3th and \4th days.—Wns taken the aloetic pills ordered before, and the mix- ture, and pills with calomel, as usual. Has had two dark stools daily, some of which were copious. No distinguishable improvement. The moaning and rigidity as usual. \5th day.—Has had three stools this morn- ing, which, for the first time, have been mix- ed with slime. One of the motions was copi- ous, and of a yellowish green appearance ; the slime in it was quite tenacious, and admitted of being separated and washed in one undivided mass. Takes his food much better, sleep much disturbed, but the moaning is rather less loud. 16th day.-.—Slept remarkably well last night. In other respects is much the same, but moans less. Has had three stools, which are of a bet- ter colour, but slimy. 11th day.—Had an indifferent night, but has not moaned since he awoke. Was able to be bent into a sitting posture yesterday, and ac- knowledges himself to be better. Has had one stool of a black green colour and slimy. 18th day.—Slept indifferently. Has had one 201 stool of a belter colour. Continues to ac- knowledge himself better; sat up for about half an hour. 19th day.—Slept well last night. Had a stool early this morning of a better colour. Appetite good; sat up for two hours, assisting himself better. Takes still but little interest in any thing around him. 20th day.—Passed a very good night. Two stools of an improved appearance. In other respects is also better. 21st day.—Did not pass so good a night. Parted with a dark and green loose motion, highly offensive; always strains two or three times ineffectually before having such stools; acknowledges himself to be better, and speaks decidedly better. His countenance denotes that he takes some interest in what is said and done. 22d, 23d, 24th and 25th days.—Has contin- ued to improve. Sits up every day for some hours, and has walked across the floor with as- sistance. Has bad two or three stools daily, some of which were offensive and lumpy, but the colour of the others have become much improved. Appetite good, pulse natural, sleeps well. Mis speech, though much improved, is still vcrv imperfect, which arises, he informs iv.v. from his tongue feeling heavy, and his be- ing unable to move it readily. During the month of April, he gradually recovered his flesh and strength, and was able to walk out unassisted. He afterwards went into the coun- try, and is now (September) in the entire pos- session of his speech and faculties, and per- fectly strong and healthy. SECTION III. The next, and last series of cases, will coi> sist of the two forms of the disorder, as it is met with in the adult. i The first, is an exceedingly well marked instance of the disorder, as it is found to run on its course when neglected or mismanaged ; be- ginning first, suddenly, in the acute, and ter- minating in the chronic form. This case, when it came under my care, had existed eighteen months, and had been treated some- times as a disease of the liver, by venoesection and active purging, and at other times by cin- chona, as a case of debility of the stomach; and though none of these modes were calcu- lated to remove the complaint, yet it is worth observing, the latter plan appeared to the pa- tient to afford him the most relief. 203 The second is a case also of the acute form, and was treated, like the first, as an inflamma- tory affection of the liver, by very copious bleediags. The third, is an example of the disorder, accompanied with the bilious cough, assuming so much of the appearance of phthisis pulmo- nalis, as to lead the gentleman, who preceded me, to regard and treat it as such.* The fourth, and last, is an instance of the disorder in a female, and which terminated, at the end of three months, in haematemesis. This case affords a good example of the disor- der, and illustrates at once the view which has been given of the origin and causes of this hemorrhage, and of the power which calomel possesses of arresting the discharge, by renew- ing the secretion of the liver. During the pe- riod of her iudisposition, the foecal discharge was stated to resemble the colour of soot, be- coming more natural as she advanced to a state * tn these, ns well as in the foregoing cases, T have sup- pressed the names of the patients where they occurred in r.iv private practice, or where I have been obliged to no. tiee the plan ot treatment previously pursued. In a pro- vincial town this is ncccssai-% ; for, though the interests of truth domand, in argument, the most unreserved examin- ation of errors, there is no advantage, which a liberal mind could de&ire to derive, from censuring an indivklu- •il vho commits them. 204 ef convalescence ; for, though no blood was apparently passed by stool during the period of the vomiting, yet the unnatural state of the foeces was undoubtedly owing to the admix- ture of a portion of blood. Of these four cases, two, it may be observ- ed, had been considered and treated as inflam- matory affections of the liver. The vencesec- tion employed, was considered by the patients as rendering them worse. In this they might be mistaken, though that it did not render them better is evident. The acute inflammation of the liver, accor- ding to my observation, is comparatively a rare disease. When occurring, it demands for it.s relief, among the other strictly antiphlogistic means, the most active depletion by the lancet; for it differs in nothing from the inflammatory affection of other internal organs. And here I must observe, that I cannot help differing in opinion from ;hose, who esteem the exhibition of calomel to be useful in frequently renewed doses, in the treatment of inflammation of the liver, from the power it possesses of promot- ing the secretion of the bile. The practice is avowedly founded on the well known bene- fit which is derived from evacuating the fe- rn tie breast, when affected with an intlamma- to-v cor^estion. But there is but little aual- 205 otty between the cases. The congestive ves- sels of the female breast, are those whose of- fice it is to secrete,and whose direct evacuation is therefore produced by a renewal of the se- cretion. But the vessels, engaged in the in- flammatory state of the liver, have no secre- tory office to perform, and can be only very partially relieved from their congestive state by the freest secretion of bile. In the inflam- matory state of the breast, the secretion is stop- ped, whilst this is by no means necessarily the case in that of the liver. In those cases, in which calomel has been employed with the particular view of promoting biliary secretion, and where it was thought to be so successful, as to render the employment of frequent venoe- section unnecessary, I cannot help suspecting, there may have been some error; the symp- toms attendant on a venous congestion of the liver, having, as in these cases, been probably mistaken for those of inflammation. Under such circumstances, the practice would indeed be efficient, and would prove the means of ren- dering all other evacuations unnecessary. But should calomel be exhibited in actual inflam- mation of the liver, and at the same time, be in any degree trusted to, on account of its prop- erty of promoting the secretions of that organ, in 206 fhere can be little hesitation in affirming that . the event would be disastrous. But on this point I could desire to guard against misconception ; and I must therefore add, that, though I cannot regard calomel to be useful in acute hepatitis, by its promoting a se- cretion of bile, yet it has a powerful effect upon the inflammatory affections of internal organs, and among others of the liver, when combined with opium and the tartrite of antimony, and given to act upon the system, according to the mode first recommended by that excellent practical physician, Dr. R. Hamilton, of Lynn Regis. When given in this form, its power, in subduing these affections, is often striking, as I have frequently witnessed. But its operation is never beneficial in these cases, until the medicine has slightly affected the mouth; when almost at the instant this latter affection occurs, it appears to act like a charm, the inflamma. tory affection becoming at once subdued by it. But, though thus powerfully acting in remov- ing inflammation, it is not to be relied on, or re* commended as a general remedy in their treat- ment ; for these diseases demand an immediate remedy, and the ptyalism, which the medicine is required to produce before it acts upon them, cannot always be early, and at the same 207 time safely, brought on, and any delay in such cases may be fatal.* From the foregoing views, therefore, it is intended to be inferred, that vencesection is indispensable in the inflammatory affections of the liver, and calomel, as a means of promot- ing the secretions of the liver, is only to be used subordinately ; whilst in the venous con- gestion of the liver, brought on by au inter- ruption in its secretory function, and some- times inducing a hemorrhage from that organ, constituting the melaena or haematemesis, ven- cesection is unnecessary and useless ; calomel being, by its power of renewing the biliary secretion, and thus removing its cause, the * In the treatment of dysentary, the combination of cal- omel with opium, may be esteemed almost a specific ; its power in subduing the morbid action of the liver, and of the mucous membrane lining the intestines, constituting this disorder, being indeed extraordinary. But in exhib- iting this medicine, it is necessary to affect the mouth, as it is not until this proof is afforded of its action on the sys- tem, that it succeeds in subduing the disease. As soon as this takes place, however, there is an almost instantane- ••us improvement visible A few years ago, a dysentary, following the cholera morbus, prevailed extensively in this place, and at that time 1 combined ipecacuanha with the opium and calomel; but, considering the latter to be the efficient medicine, I have omitted of late the use of the former as unnecessary, 208 efficient remedy for it, and in many cases the only one required. In the watchfulness, which often forms so distressing a symptom of the acute stage of the disorder, there is something peculiar, and meriting observation. In two of these cases it was so excessive, and so greatly dispropor- tioned to the degree of pain or fever, as to shew that it did not originate from them. In many of these cases, indeed, there is some- times the utmost horror felt at making the attempt to procure rest by lying down in bed; the general restlesness, and nervous agitation, being greatly aggravated by it. In a few instances of paralysis, arising from, or, perhaps, accidentally combined with thi9 disorder, I have seen this watchful state so considerable, as to be accompanied with a nervous irritability, bordering on mania. In an example of this kind, which I had under my care some time since at the Dispensary, there had been symptoms of the biliary de- rangement previous to an attack of hemiple- gia, and which so increased after this last com- plaint, that the patient was never in bed for twenty-three nights, and was said to have rarely slept during that period ; but to have exhibited, as each night returned, the m^ 209 distressing symptoms of nervous, and almost maniacal agitation. Having tried the effects of powerful doses of the tinctura opii to pro- cure hirn rest, and finding them not only una- vailable but injurious, I was led to inquire more particularly concerning the appearance of the alvine discbarge ; and learning that though passed regularly, it was of a yeasty colour, 1 examined his body, and was for once gratified by finding a distinct circumscribed tumor seated in the epigastric region, and con- siderably tender on pressure. The cause of the excessive watchfulness and nervous agita- tion, and which I had erred in overlooking, was now explained, and was happily, within the reach of a remedy. By correcting the disorder of the liver, the patient, in fact, was enabled in a few nights to lie down; and, though subject occasionally to restlesness, has never since either required an opiate, or been absent a night from his bed. Whether in this case the paralytic affection, as well as the nervous irritability which attended it, derived its origin from the biliary derangement, it is difficult to decide. In another part of this es- say, I have noticed a case where such a con- nexion appeared to exist, and in children I hey confessedly thus stand to each other in the relation of cause and effect. But it is 18* 210 not necessary, in these cases of extreme dis- order of the nervous system from biliary de- rangement, to attempt an explanation of its cause, by having recourse to the supposition, that the paralytic affection itself originated from it; for it may be reasonably concluded, that to those diseased, though not always dis- coverable states of the brain, existing in pa- ralysis, a morbid and sympathetic irritation will prove unusually injurious, and give rise to a degree of nervous irritability, which would not have been produced under a more health- ful or more vigorous condition of the brain. Case I.—Thomas Jackson, aged J?, from the Country, admitted March 30th a patient of the Dispensary. Complains of great weariness, listlesness and dizziness, and of an aching of the knees and ankles. Appetite craving, but feels no better for the food which he eats, having always a sinking feeling at the stomach, tongue foul, bowels costive, pulse full, but of natural fre- quency, complexion sallow, urine of a pale colour, sleep much disturbed and broken by dreams, being seldom able to sleep after hav- ing been awoke by one. Is very much re- duced in his flesh and strength ; feels himself best of a morning, becoming more unwell as 211 the evening comes on. Has been ill during the last eighteen months, and was seized sud- denly, at first, when in bed, feeling as if, to adopt his own language, all his passages were stopt, and was obliged to rise and walk about the chamber during the rest ©f the night. Was seldom in bed for the period of three months, and rarely slept or felt the inclination for sleep. Appetite during that time was bad. and he had much thirst, and his bowels were costive. He applied for advice immediately, and was attended for three month. Was lied once during that time, and was purged very much, but without relief. Was never regu- lar in his bowels but when taking physic, and then open to excess. The alvine discharge was always black. Finding that he received no benefit from his first medical attendant, he consulted others, and was blistered five times, and bled from the arm four times and once iu the temples for the dizziness, but always felt himself worse after these evacuations. By one practitioner, he was ordered bark, and he thought himself a little relieved by it. Ha* not done any work for the last twenty weeX and» before that period seldom worked more than one or two half days in the week. Having ordered him a dose of calomel ai bed-time, with an aperient draught on tlu- £12 following morning, and given the necessary directions for his increasing or lessening the doses of his medicines, as circumstances should require, he returned into the country, coming up to see me once a week. After some time, a to.iic medicine was given along with the other medicines, and, at the expiration of sev- en weeks, he was so well, that his medicines were discontinued, and he came at the end of another month to inform me, that he had continued free from conplaint since the time of my last seeing him, and had been able reg- ularly to follow his work as a labourer. Case II.—John T. aged 62, sailor, admitted May 14th a patient of the Infirmary. Complains of an acute pain at the pit of the stomach and on the left side, which is worse towards evening and during the night, and is troubled with a severe cough, loss of appetite, throwing up the little food that is taken, pro- fuse perspirations when in bed, excessively disturbed sleep, and a sense of great weari- ness and aching of the knees and ankles dur- ing the day, and is much reduced in his flesh and strength, pulse of natural frequency, but feeble, tongue foul, bowels costive, water high coloured and scanty, complexion sallow, and countenance depressed. Has been ill during the last four months, but worst during the last two ; and has been bled, under the direction of a medical attendant, five times, and thought himself worse for it, and blistered four times, with only slight relief to the pain. The blood had a slightly greenish tinge. Has never en- joyed good health since he was shipwrecked eight years ago.—Habeat calomelanos gr. i- omni nocte et sutphatis magesice 3 iss. ex aqua: 7i ij. omni mane. 3d day.—Had four copious black and slimy stools yesterday, cough and appetite better to-day, and has had no vomiting, slept better last night, and was less disturbed by dreams, and had no perspiration, pain at the pit of the stomach less severe, and feels himself better in all respects.—Contin. med. 8th day.—Has passed two and three stools daily, which were completely black and very foetid. Appetite much improved, the cough is still troublesome during the night, and has some thirst.—Conlinr. med. habeat elixir vitri- olici gtls. xij. ex aqua bis in die. 14th day.—Has bad two or three motions daily. Is very much better, eats and sleeps well, cough much better, and no pain in the region of the stomach or in the side, wate. Still turbit1 — -C 'in. med. 211 \ltk day.—Two motions daily, of a natural colour, but rather slimy, sleeps tolerably well but perspires a little, appetite good, cough better, continues to feel weak, with some re- mains of the aching in the knees and ankles. 20th day.—Eats and sleeps well, bowels reg- ular, and their contents natural. Has no pain about the seat of the stomach, tongue clean, but still rather dry in a morning on first wak- ing.—Omittr. elix. continr. pil. et mist. 21th day.—Dismissed, free from complaint. Case III.— William. D. aged 37. Complains of a most acute pain in the re- gion of the stomach, which is worse in the re- cumbent posture, and is slightly relieved by bending forward. Has a troublesome cough, attended with a slight degree of dyspnoea and some little expectoration. Pulse preternatu- rally quick, bowels stated to be regular, the tongue furred, and the water thick and high coloured and scanty, appetite entirely gone, and the smell of food sickening. The nights are passed in the chair and without sleep, as his sleep, to use the patient's own expression, is quite gone from him ; for, when not in pain, is still unable to rest. Has become much re- duced in flesh and strength, and has much pain lad aching about the knees and ankles; the 210 complexion is sallow, and the couiiLeL.anec- km guid. Has been indisposed during the but. two months, and beeu particularly worse about ten days. Is taking at present a medicine., containing an opiate for the cough, and an al- oetic pill to keep the bowels regular.—Hal~ at calomelanos gr. i. hora somni et haustum Cj. sulphatis magnesia: mane sequcntc. 2d and 3d days.—Bowels but little acted on. Symptoms unrelieved. The present aperient draught to be substituted for one containing the infusuin sennae. 4th day.—Bowels been relieved, alvine discharge dark and very foetid, cough an- other symptoms relieved, but still sleepless, and spending much of the night in his chair. 5th day.—Been plentifully moved, fceces very dark and foetid, pain abated, water clear, the disgust at the smell of food less considera- ble, cough gone. Gtk day.—Pain removed considerable lower down, bowels freely moved, and the foeces of a better colour. Has taken some foou, spent much of the night in bed, looks much improve!. 1th day.—Very considerably relieved in all his symptoms, no pain at the stomach, but some still in the bowels, slept well last night. Qth day.—Had a bad night and not so well to-dav. which is attributable to <=nme improp- 216 er food taken yesterday.—&. calomelanos gr. ij. hac nocte. 9th, 10th, 11th and 12th days.— Continues to improve rapidly, eating and sleeping as in health,thebowels becomingnatural and tongue clean. The medicines were omitted, and a tonic mixture was taken for a short time, un- til his full recovery rendered it unnecessary. Case IV.—Charlotte Turner, admitted a patient of the Dispensary October 14th. I Three days since, began to be affected with a vomiting up of blood, which still continues, having thrown up from a quarter to nearly half a pint each day. The quantity discharg- ed is commonly brought up at once. Is con- stantly sick at other times, and throws up whatever she takes, but without an admixture of blood. The bowels are costive, appetite extinguished, sweats much during the night, has thrown up a quarter of a pint of blood this morning, and threw up some in the night, has some difficulty in passing her water, which is high coloured and turbid, has considerable pain in the head, sleep very much disturbed, the feet particularly cold, tongue foul, pulse * rather quicker than natural. About three months ago, took cold when the catamenia \ were present, by which they were stopt, and 217 ■ •she became immediately ill. During three ! weeks, she was troubled with a looseness, • and after that period she became costive, hav- ing for a short time a craving appetite, with » constantly a sinking feeling at the stomach ; was listless, and languid and spiritless, and so drowsy as to fall asleep over her work. Her knees ached and her sleep was unrefreshing, \ and she was much disturbed by dreams. Was j always worse towards the afternoon, and fre- i quently chilly in the day. Has wasted in her 1 flesh and strength. About three weeks since, these symptoms became worse, having been constantly sick of late. About eleven years ago was affected in a similar way with a vom- iting of blood, and was ill during ten months ; and was repeatedly bled, during that time, for her complaint, and so often, on one occas- ion as three times during the same day. The foeces at that time were always black. Hav- ing directed for her the medicines, which I have noticed as employed by me in the chol- era morbus, and ordered an aperient draught to be taken some hours after finishing her pills, the following is the report. 3d day.—Did not take her pills regularly, ] having taken only four or five of them on the day they were ordered, and the remainder j on the following one. Threw up some blood 218 each day, and this morning the quantity was considerable. The nausea and retching, and other symptoms, continue, and has a consider- able stoppage in her water. Has had no movement.—Habt. pulv. jalapia gr. xv. ex cal- omelanos gr. ij. statim. 4th day.—Has been freely moved in the night. The motions are of the colour of soot. The sickness and other symptoms are unre- lieved. Has thrown up considerable quanti- ties of blood this morning.—R. calomelanos gr. vi. mica; Panis q. s.ft. pilulm xii. e quibus St. i. 2da. quaque hora. 5th day.—Has taken all the pills but three, and has not thown up since she began to take them. Has not had so good a night before for some time past. The oppression about the stomach and nausea, and the other symp- toms, are very much relieved. Had two stools yesterday, which were perfectly black. —Continr. pil. 4ta. quaque hora. , 6th day.—Has had no farther sickness, and j took yesterday some food, which she relished and kept down for the first time during the last three weeks. Has some slight soreness' of the mouth. Bowels costive.—Hub. mixturu aperient. 7if 2da. quaque hora donee responded it alvus—St. pilulam unom mane noctcqv. 219 'Uh day.—Passed three stools in the course of the night of an improved appearance. Has had no farther discharge of blood, and has had a pretty good night. Takes food and relishes' it, and is quite free from nausea and oppression at the stomach.—Contr. pil.—mist. et aperient. 8th day.—Has not had so good a night, hav- ing had some pain in her bowels. In all other respects is very much better, being free from sickness ; and is capable of taking, and keeping her food. Had several stools last evening, which were slimy, but of a much better colour. Her mouth is very sore.— Omittr. pil.—Contin. mist, aperient. On the following days, this patient continu- ed to improve, the appetite becoming much better, and the appearance of the alvine dis- charge more natural, and in a short time she became free from conplaint. TABLE OF CONTENTS Of Marasmus, Page 9 Pathological Remarks, . 85 Remote Causes, 113 Treatment, . 110 CASES AND OBSERVATIONS. Section 1. Cholera Morbus—Melaena, 170 2. Marasmus in Children, . 186 3. --- in Adults-Haematemesis, 202 ' EttRAT_^.-—Page 4% line-J_, for disposition, read deposition.'*_P. 92,1.'S3, Tor progress, read procew. P. 122, L 28,K&r .vacate, tfhd vjolate. P. 1.16,1. 99, for higher, ffead tighter. TP. t59, 1. 9, for punned, read purpoted, i P. 175,1. 9, for necessary, rtad un- flecesijiuy, ' ' t #> "* • V**4 ■ _j__ Jfc -—x-*» ■---— —*—"^^ W»V' *i 'iWiiuaW ^M H bEDLEThO U~IN AUVdan ivnoiivn NLM041390294