4< ■/./ ? r^QZQZ£K2>QZQZ>QZ}QZ>QZQ Z>Q<0&Z)QZ~3$* li 8?.»• W j. Uw »« y* vv V T11E ,4*. » 2U-J&1 MODERN PRACTICE OF PHYSIC, > EXHIBITING THE CHARACTERS, CAUSES, SYMPTOMS, PROGNOSTIC, MORBID APPEARANCES, AND IMPROVED METHOD OF TREATING, t THE DISEASES OF ALVCLIMJTES. ^^ BY ROBERT THOMAS, M. D. OF SALISBURY. FROM THE THIRD LONDON EDITION, CORRECTED AND CONSIDERABLY ENLARGED. WITH AN APPENDIX, BY EDWARD MILLER, M. D. RROFESSOR OF THE PRACTICE OF PHYSIC IN THE V1HVBRSITY OF NEW-YORK. f■*&'•**■ ^T NEW-YORK :\£>b^. PRINTED AND SOLD BY COLLINS & CO. Printers and Importers of Medical Books to the College of Physicians and Surgeons in New-York, and to the New-York Hospital. NO. 189, PEARL-STREET, 1811. District of New- York, ss. rX «5 1 "13 ^ ** rememDere^) ^at on ^e twenty-fifth day of December in the thir- ls *v Jj ty-fifth year of the independence of the United States of America, Thomas & William Collins of the faid Diftridt, have depofited in this office the title of a book, the right whereof they claim as Proprietors in the words following, to wit— The Modern Practice of Physic, exhibiting the Characters, Causes, Symptoms, Prog- nostic, Morbid Appearances, and Improved Method of Treating, the Diseases tf all Climates. By Robert Thomas, M. D. of Salisbury. From the Third London Edition, corrected and con- siderably enlarged. With an Appendix, By Edward Miller, M. D. Professor of the Prac- tice of Phasic in the Uni-vtrsity of New-Tori. IN CONFORMITY to the Act of the Congrefs of the United States, entitled, " A« A, to continue 21 Synocha (Inflammatory Fever,) from ditto . . 33 Typhus Mitior (Low or Nervous Fever,) from rvtpoc, stupor 36 -------Gravior (Malignant or Putrid Fever,) from ditto . 44 -------. Icterodes (Yellow Fever,,)from rv, to burn . . .73 Phlegmon (Phlegmonous Inflammation) . . . .74 Erysipelas (Erysipelatous ditto,) from e^v&i, to draw, and znXui, adjoin- ing ; named from the neighbouring parts being affected by the eruption . . . . .82 Phrenitis (Inflammation of the Brain and its Membranes^) from f/wr/s, a frenzy or distraction . . . . .86 Ophthalmia (Ditto of the Flye,) from o06*Xy.cc., the eye . . 89 Otitis (----------Ear) from m, the ear . . 99 Cynanche Tonsillaris (Inflammatory Sore Throat,) from zvav, a dog, and «v%;7rc.%, the liver . .131 Splenitis (----------------Spleen,) from g-kXw, the spleen . 139 Nephritis (----------------Kidney,) from vs^pos, the kidney I 39 Cystitis (—————,-—. Bladder.) from »vfciXvai, to loose . . .253 order n. Adynamic (Defect of Vital Powers,) from « privative, and Jw^/s, l-f ~r . • . . . . . 26Q Syncope (Fainting,) from o-w, with, andxow7«», to strike down 260 Vertigo (Giddiness) . . . . 261 Dyspepsia (Indigestion,) from , to fear 311 Colica (Colic,) from xoXov, the colon, one of the large intestines 322 Colica Pictonum (Dry Belly-ach, or Devonshire Colic) . 325 Cholera Morbus (Vomitingand Purging,) from^oA^, bile,and/£o),toflow330 Diarrhoea (Purging,) from haj»pt*>, to flow through . .333 Diabetes (Excessive Discharge of Urine,)ivom hx, through, and fixim, to pass ..... 338 ORDER IV. Vesanije (Mental Diseases,) from vesania, madness . 347 Mania (Madness,) from yMt,of^xt, to rage .... 347 Incubus (Night-mare) . . • . 361 CLASS III. CACHEXIA. (Cachectic Disease,) from xcato<;, ill, and fg/j, a habit 362 Marcores {Universal Emaciation) . . . 362 Atrophia (Atrophy,) from x priv. and rpo|, the night, and u-^, an eye 506 Amaurosis, or Gutta Serena, from xftxivgu-ic., obscurity . 507 Paracusis (Deafness) from nx^<*, wrong, and xkhu, to hear . 509 ORDER II. Increased Appetites. Dysorexie (Depraved Appetites) from £vc, bad, and «fe|/«, appetite 512 Bulimia (Canine Appetite) from fin;, an ox, and X>,/m>c., hunger 512 Furor Uterinus, or Nymphomania (Uncontrollable Desire of Venery in Women,J from wu/px, a nymph, and y.u\ix, madness 514 Defective Appetites. Anorexia (/-oss of Appetite,) from x priv. and sfe|<5, appetite 514 Anaphiodisia (Impotence,) from x priv. and x, to be unable to retain urine • • • • • . .516 SYSTEMATIC ARRANGEMENT OF DISEASES. ix Gonorrhoea Dormientium (Involuntary Emission of Semen during Sleep) from-yovjj, semen, and .'*», to flow . . Page 517 Leucorrhoea (Whites,) from Xwkos, white, and pea, to flow . 518 order v. Epischeses (Obstructions,) from tzna-yjonc,, a suppression, or retention 521 Obstipatio (Constipation or Costivencss,) from obslipo. to stop up 521 Ischuria (Suppression of Urine,) from trjQu, to restrain, and xgov, the urine . . . . . . .523 Dysuria (Difficulty of voiding Urine,) from <5Vs, difficulty, and »£«v, the urine ..... 523 Amenorrhcea (Partial or total Obstruction of the Menses from other Cau- ses than Pregnancy,) from x priv. wvtocioc., monthly, and pea to flow 526 Chlorosis (Retention of the Menses, or Green Sickness) from fcXapit^oa, to look green ...... 527 Amenorrhcea Suppressions (Suppressed Menses) . &27 ---------— Difficilis (Difficult and painful Menstruation) 532 ORDER VI. Tumores (Tumours) . . . .533 Carcinoma (Cancer) . . ... 533 Bronchocele (Derbyshire Neck,) from Spov^a?, the windpipe, and mMt a tumour . . 539 Dracunculus (Guinea Worm) . . . . 542 ORDER VII. Dolorosi (Painful Affections, unaccompanied by Pijrexia,) 544 Cephalalgia (Head-ach) from x.e-w*A) . . . 648 Prolapsus A.ni {Falling of the Fundament) . . 650 Atrophia Ablactatorum (JVeaning Brash) . _. 650 Ophthalmia Purulenta {Purulent Inflammation of the Eyes) 65 1 Dentitio (Teething) . . . . . 651 Convulsiones .... (,£$.. 654 Syphilis • .... 656 EXPLANATION OF THE TABLE OF WEIGHTS AND MEASURES USED BY APOTHECARIES. The Pound, or lb. ~] f 12 Ounces. Ounce, or gj. I „_.•„„ J 8 Drachms. Drachm, or Jj. > ™**™ RDER I. INFLAMMATORY FEVER. $?> Of the INFLAMMATORY FEVER, or SYNOCHA. J- HIS fever is so named from its being attended with symptoms de- noting general inflammation in the system, by which we shall always be able readily to distinguish it from either the nervous or putrid. It makes its attack at all seasons of the year, but is most prevalent in the spring ; and it seizes persons of all ages and habits, but more particularly those in the vigour of life, with strong elastic fibres, and of a plethoric constitu- tion. It is a species of fever almost peculiar to cold and temperate cli- mates, being rarely, if ever, met with in very warm ones, except among Europeans lately arrived ; and even then, the inflammatory stage is of short duration, as it soon assumes the typhoid type. The exciting causes are, sudden transitions from heat to cold, swal- lowing cold liquors when the body is much heated by exercise, too free a use of vinous and spirituous liquors, great intemperance, violent passions of the mind, exposure to the rays of the sun, topical inflammation, the suppression of habitual evacuations, and the sudden repulsion of erup- tions. It may be doubted if this fever ever originates from personal in- fection ; but it is possible for it to appear pretty generally among such as are of a robust habit, from a peculiar state of the atmosphere. It comes on with a sense of lassitude and inactivity, succeeded by ver- tigo, rigors, and pains over the whole body, but more particularly in the head and back ; which symptoms are shortly followed by redness of the face, throbbing of the temples, great restlessness, intense heat, and un- quenchable thirst, oppression of breathing, and nausea. The skin is dry and parched ; the eyes appear inflamed, and are incapable of bearing the light; the tongue is of a scarlet colour at the sides, and furred, with white in the centre ; the urine is red and scanty, the body is costive, and there is a quickness, with a fulness and hardness in the pulse, not much affect- ed by any pressure made on the artery. Its pulsations are from 90 to 130 in a minute, and when blood is drawn, it exhibits a yellowish or buffy crust on its surface. If the febrile symptoms run very high, and proper means are not used at an early period, stupor and delirium come on ; the imagination becomes much disturbed and hurried, and the patient raves violently. The disease usually goes through its course in about fourteen days, and terminates critically, either by a diaphoresis, diarrhoea, hemorrhage from the nose, or the deposit of a copious sediment in the urine ; which crisis is usually preceded by some variation in the pulse. In some in- stances, it, however, terminates fatally. Our judgment as to the termination of the disease must be formed from the violence of the attack, and the nature of the symptoms. If the fever runs high, or continues many days, with stupor and delirium, the event may be doubtful; but if to these are added, picking at the bed-clothes, startings of the tendons, involuntary discharges by stool and urine, and hiccups, it will then certainlv be fatal. On the contrarv, E 34 PYREXIA OR FEBRILE DISEASES. CLASS I> if the febrile heat abates, the other symptoms moderate, and there is a tendency to a crisis, which is marked by a universal and natural perspi- ration on the body ; by the urine depositing a lateritious sediment, and by the pulse becoming more slow or soft ; or by a hemorrhage from the nose, diarrhoea supervening ; or the formation of abscesses ; we may then expect a recovery. In a few cases, this fever has been succeeded by mania. On opening those who die of an inflammatory fever, an effusion is of- ten perceived within the cranium ; and now and then, topical affections of some of the viscera are to be observed. From the symptoms which attend this disease, it is evident our en- deavours should be early exerted to avoid the mischief that may ensue from general inflammation ; and as evacuation by bleeding is the chief mean we can confide in, it should be resorted toon the first of its attack ; and one large bleeding at this period will have a much better effect than repeated small ones afterwards. If the symptoms run high, therefore, and the person is young and plethoric, twelve or fourteen ounces may be drawn off at once, from a large orifice. In repeating the operation, we are to be governed by the effect it produces on the pulse, and by the ap- pearance the blood puts on after standing some time. If the former continues full, strong, and tense, and the latter exhibits a buffy sizy coat on its surface, the bleeding should be repeated by all means, but in small- er quantity than before. Where the patient is too weak to bear a considerable loss of blood, from the disease having been of some duration when advice is applied for, it has been recommended to place him in an erect posture while the blood is drawn off, by which means a tendency to syncope will be induc- ed by the loss of a small quantity, and a temporary, if not a permanent relief, be obtained. When the fever has been of several days standing, and the head is much affected either with severe pain or delirium, topical bleeding, by the application of three or four leeches to each temple, may be prefera- ble to using the lancet a second time, or perhaps even once. Applying linen cloths wetted in cold water or aether to the forehead and temples, may be attended with some advantage in such cases. With the view of diminishing inflammation and general excitement, digitalis has been proposed as a remedy in this disease, after having em- ployed proper venesection, and probably may prove serviceable. If any nausea prevails at the commencement of the disease, the sto- mach may be relieved by making the patientdrink one or two cupfulls of chamomile tea ; but should these simple means not be attended with the desired effect, he may then take a table-spoonful of an emetic solution," every quarter of an hour, until sufficiently eased. To obviate costiveness, one or two motions should be procured daily, * ]$. Antimon. Tartarifat. gr. ij. Aq. Fontana; 3 iij. Syr. Carycphil. R. 31J. M. ORDER I. INFLAMMATORY FEVER. oi> by means either of some aperient medicine,* or by laxative clysters.! In synocha, cathartics will prove singularly useful. If the stomach is in an irritable state, we can substitute a few grains of calomel made up into pills, with a small quantity of cathartic extract, instead of the other laxative medicines. To abate thirst, and determine to the surface of the body, the patient should be directed to drink frequently of diluting tepid liquors, acidulated with lemon-juice or crystals of tartar. He may likewise take small and frequently repeated doses of nitre ;| or, as a refrigerant, he may be allowed to drink freely of cold water. For the purpose of moderating or extracting the morbid excess of heat, various parts of the body should be sponged frequently with cold water. Sudorifics do not appear to be proper in this fever, as they might bring on profuse sweating ; and it is not possible to keep the body warm without producing a considerable in- crease of heat. The neutral salts will be far preferable, and may be giv- en in any of the forms advised under the head of Simple Fever, every two or three hours. Should the breathing be oppressed, or should stupor or delirium arise, it will then be right to apply a blister in the neighbourhood of the part so affected. If the pulse sinks, and the extremities become cold, the appli- cation of sinapisms to the soles of the feet will be proper. Camphor, xther, ammonia, and cordials, will be proper remedies on such occasions. In this fever, as in most others, sleep is much interrupted, and from a want of this, delirium often arises ; opium here would be an uncertain medicine, for, should it fail to procure rest, the delirium would be greatly increased by it. It should therefore be given only in cases of imminent danger, and even then, only in small doses frequently repealed, paying a strict attention to the effect it produces. In other instances, we should be contented with giving directions for the patient to be kept as quiet as possible. Probably, we might employ some of the preparations of the humulus lupulus (hop,) or hyoscyamus, in this fever with benefit in lieu of opium. Incases of severe delirium threatening phrenitis, might not a use of the circular swing, noticed under the head of Mania, produce a good effect ? * ft. Pulp. Tamarind, gfs. Cryft. Tartar, zij. Aq. Bullientis ^v. Colat. adde Aq. Cinnam. ^j. Antimon. Tartarifat. gr. j. M. Sumat Cochl. iv. et repetatur dos. poft ho- ras duas nifi alvus prius rcfpondeat. Vet l£. Infus. Scnnx J^jfs. Magncs. Vitriolat. £vj. Manns Optim. gij. M. ft. Hauftus aperiens. | ft. Nitri Purif. ^ij. Cryftal. Tartar, giij. Antimon. Tartarifat. gr. jfs. M. ft. Pulvis dividend, in Chart No. vj. Sumat j. tenia nor. (• ft. Fol. Sennse giij. Aq. Fontanas 5>cvj. Coque leniter ad ^xij. et Colat. adde Magnes. Vitriolat. 5;, 01. Olivx §j. M. ft. Enema. 36 PYRKXIJE OR FEBRILE DISEASES. CLASS I. Throughout the whole course of the disease, the patient is to abstain from solid food and animal broths, supporting nature with gruel, and pre- parations of barley, sago, tapioca, &c His chamber is by no means to be kept warm, either by fires or by be- ing closely shut up, as is too generally the case : on the contrary, it should be of a proper temperature, by allowing the admission of cool air into it from time to time. His bed ought to be lightly covered with clothes. On his recovery, a strict attention should be paid to regimen, scrupu- lously avoiding to overload the stomach, and partaking only of such things as are light, nutritive, and easy of digestion : all other causes like- ly to induce a relapse, are also to be carefully shunned. Fresh air, gentle exercise on horseback or in a carriage, agreeable com- pany, and a moderate use of wine, will greatly contribute to the recove- ry of convalescents. Should the appetite not readily return, or the di- gestion prove weak, stomachic bitters,* conjoined with the bark, may be advised. See Dyspepsia. Of the NERVOUS FEVER, or TYPHUS MOTOR. J. HIS fever is so named from the effects it produces on the nervous system, typhus being derived from tvQoc,, stupor. It does not affect the habit so universally as the one last described ; neither do the exacerba- tions produce a hot fit, in order to bring about a crisis. It may be distin- guished from typhus gravior at its commencement, by the attack being more gradual, and the symptoms much milder : in the progress of the disease, by the absence of those symptoms of putrescence enumerated in typhus gravior ; and by its being accompanied with less heat and thirst, less frequency of the pulse, and no bilious vomitings. It principally attacks those of weak lax fibres; those who lead a se-? dentary life, and neglect proper exercise ; those who study much ; and those who indulge freely in enervating liquors. It likewise is apt to at*- tack those who are weakened from not using a quantity of nutritive food, proportionable to the exercise and fatigue they daily undergo: hence it is very prevalent among the poor. Owing to the relaxed habits of those who reside in warm climates, this type of fever frequently occurs, and all other continued fevers are apt to degenerate into this, or typhus gravior. It is often generated in jails, hospitals, transport and prison ships, ill- constructed and crowded barracks, work-houses, and the ill-ventilated apartments of the poor. It is also to be met with very frequently in the damp and dirty cellars of the poorer class of manufacturers in large towns. * R. Infus. Gentian. C. §v. Tincft. Cort. Peruv. C. Jj. 1 Columbae giij. M- Capiat Cochl. iij. ter in die. Adde pro re natar Acid. Suiph. Dilut. gutt. xv. ad xxx. ORDER I? NERVOUS FEVER. 37 Typhus mitior may be induced by whatever impoverishes the blood, debilitates the general system, or depresses the mind: hence severe eva- cuations, great fatigue, a low diet, continued want of sleep, excessive venery, grief, fear, anxiety, intense study, a moist atmosphere, and con- fined and unwholesome air, may give rise to it. The most general cause, however, of this fever, is contagion. From Dr. Haygarth's experiments* it appears that not one in twenty- three, or even one in thirty-three, escapes infection, when exposed for a sufficient length of time, and that as many persons are liable to receive typhus as the variolous contagion. A short exposure to pestilential at- mosphere may, in some instances, produce a fever ; but still there is rea- son to presume that the poisonous miasms do not generate a fever, till they have been respired without interruption for some days ; and hence it is probable, that in most cases an accumulated quantity of the poisoa may be required to give rise to it. It appears, from the example of me- dical practitioners, that air strongly impregnated with infectious miasms may be breathed for a short time, and air weakly impregnated for a long time, without injury. A certain dose of infection, as also a certain time of exposure, seem to be necessary, in order to the effect being produced. Persons confined in the midst of contagion are enabled, however, to bear up against a much larger dose of it than others. Thus it is a well- known fact, that felons have worn clothes without injury, which, never- theless, communicated infection to fresh persons, in a court of justice. With respect to the period at which typhus fever becomes infectious after its commencement, Dr. Haygarth has not been able to determine. The latest period of infection appeared to him to vary from a few days to two months, without any regularity as to this point. Sometimes the season of the year is such as to predispose to attacks of this fever, and to render it epidemical: the months of October and No- vember are those in which it is usually most prevalent. Typhus mitior generally comes on with a remarkable mildness in all its symptoms ; and although the patient experiences some trifling indis- position for several days, still he has no reason to suspect the approach of any severe disease. At first, no rigors are perceived, there being only a slight chilliness, which is not succeeded by any increase of heat, or red- ness of the face ; on the contrary, it is unusually pale and sunk. He perceives, however, some degree of lassitude and debility, with anxiety, dejection of spirits, sighing, and a loathing of food ; and towards even- ing these affections are somewhat increased. In the course of a few days, and as the disease advances, there arise a difficulty of breathing, oppression at the chest, pains in the head, accompanied with a confusion of ideas ; there is great depression of strength, even to fainting, whenever the patient attempts to sit up ; the tongue becomes dry, and is covered with a dark brown fur ; the teeth are thickly incrusted with the same ; the pulse is small, low, and fre- quent, and now and then intermits; cold clammy sweats break out on ■* See his L -*ter to Dr. Percival on the Prevention of infectious Fevere. 38 PYREXIA OR FEBRILE DISEASES. CLASS I. the forehead and backs of the hands, while the palms glow with heat; the urine is pale and watery, like whey ; the whole nervous system is much affected with tremors and twitchings ; involuntary motions of the muscles and tendons arise ; the patient picks at the bed-clothes almost incessantly, and either mutters to himself or talks incoherently. There is seldom, however, any great delirium, nor is this fever ever attended with violent ravings, or with any fulness of the vessels of the head ; but there is usually a dilatation in the pupils of the eyes. In the progress of the disease, the system is unequally affected ; for sometimes head-ach, restlessness, and uneasiness, prevail in a high de- gree, while at the same time the tongue is clean and moist; and at other times, while there is no head-ach or restlessness, the tongue will be dry and foul, and profuse sweats will break out. This fever, moreover, is not only thus irregular in affecting various parts of the body differently, but it is also irregular in its exacerbations ; and these, instead of taking place in the evening, will arise often in the morning. Again, sometimes the fever is very violent for the first three or four days ; it then diminish- es for a time, and then perhaps increases again. Evacuations, such as sweating and purging, are very apt to ensue in the course of the disease, which never fail to exhaust the patient. In about the middle of typhus fever, a great discharge of saliva sometimes occurs, which has been thought critical ; but as it now and then continues two, or even three weeks, without affording any relief to the patient, it may be concluded to arise from some accidental cir- cumstance, perhaps not unlike to the ptyalism that sometimes takes place in hysteria. Typhus mitior frequently runs on for some weeks, and produces such a state of debility as to destroy the person from that cause alone, or it degenerates into typhus gravior ; but when it terminates fa- vourably, it usually goes off about the fourteenth or twentieth day, per- haps, either by a diarrhoea, or by a gentle moisture diffused equally over the whole body ; but often it exceeds a month in duration, and there is no other evident crisis than the urine becoming turbid, and depositing a sediment. Profuse evacuations by sweating or purging, much watchfulness, sinking of the pulse, great incoherency of ideas, mutterings, picking at the bed-clothes, considerable dilatation of the pupils of the eyes, in- voluntary discharges by urine and stool, starting of the tendons, and hiccups, point out the near approach of death ; whereas, on the con- trary, the pulse becoming fuller and more slow, the tongue moist, re- spiration free, a gentle moisture coming on about the fourteenth day, tumours appearing behind the ears, or miliary eruptions, unattended by profuse sweats, being perceived on the body, promise a favourable termination. The usual appearances on dissection are, a softness and flaccidity in the solids ; a dissolved state of the fluids, particularly of the blood ; col- lections of sanious matter in the different cavities; turgescence and in- flammation of the thoracic and abdominal viscera; and in the interior narts of the brain, collections of a serous fluid. ORDER I. NERVOUS FEVER. 3,9 From the very gradual manner in which this fever comes on, the great mildness of the symptoms at its commencement, and the time that usu- ally elapses previous to absolute confinement, it is seldom that practition- ers have it in their power to cut short its progress by a timely exhibition of proper remedies. If there is any nausea or vomiting at the time of applying for advice, it will be right to recommend a gentle emetic of about fourteen or six- teen grains of ipecacuanha, to be immediately taken ; or should any cos- tiveness prevail, we may prescribe some laxative medicine, to carry off the feculent matter ; and to insuie and keep up a regular alvine evacua- tion in the further course of the disease, it will be proper to repeat this from time to time, or to have recourse to emollient laxative clysters. In many instances, however, the stimulus of the latter being limited merely to the rectum, may not be adequate to procure so complete an evacuation as may be necessary ; and therefore, in these cases, we ought to employ aperient medicines that will dislodge, and bring off whatever feculent matter may be contained in the bowels, which by long retention might be likely to prove highly offensive, as well as irritating. In administering purgatives, we ought, at the same time, to guard against employing them in such doses, as to excite unusual secretion into the intestines, or watery stools, as we should thereby induce great debility. Small doses of calomel, and jalap, or a solution of some mild neutral salts, will be the most proper medicines of this class. Bleeding is a remedy not to be resorted to in this fever. In temperate and cold latitudes, and in the winter season of the year, it is by no means an uncommon occurrence to meet with typhus compli- cated with more or less of topical inflammation of the thoracic? viscera. In such cases, I have known venesection to have been employed ; but even in these, it has appeared to me to be detrimental, and in two in- stances which lately fell under my observation, seemed indeed to have destroyed the patients. Instead, therefore, of having recourse to the lan- Get, where topical inflammation of the viscera of the thorax attends on typhus, I would recommend drawing blood from the chest, either by means of eight or ten leeches, or by the application of a scarificator and cupping-glass, and repeating them as the occasion may require. Affusing the body with cold water, is one of the most powerful and efficacious means which we can make use of in typhus fever ; but its ef- fects will be more salutary in proportion as it is adopted early, or during the first stage of the disease. Such being an indisputable feet, establish- ed upon the firmest basis, we ought always to employ it very soon after we have evacuated the contents of the alimentary tube in the manner just mentioned. We are informed by Dr. Currie,* that the safest and most advan- tageous time for using cold water, either in aspersion or affusion (but he gives a preference to the latter,) is. when the exacerbation is at its height, which is marked by increased flushing, thirst, and restlessness ; or immediately after its declination has begun, which induced him to • Sec his Medical Reports on the Effects cf Water in Fevers, &c. 40 PVRE.yi.1i OR FEBRILE DISEASES. CLASS I. direct its being employed from six to nine o'clock in the evening ; but he thinks that it may be used at any time of the day, when there is no sense of chilliness present; when the heal is steadily above what is na- tural, and when there is no general or profuse perspiration. During the Cold stage of the paroxysm of fever, while there is any considerable sense of chilliness present, or where the body is under profuse sensible perspi- ration, this remedy ought never to be employed, as we might extinguish life by it. When cold affusion is used in the advanced stage of typhus, where the heat is reduced, and the debility great, some cordial, such as wine warm- ed with an addition of spice, or even brandy, should be given immedi- ately after it. In the early stage of the disease, cold affusion appears to cut short the progress of the disease. At more advanced periods, when the strength of the patient, and other circumstances, will admit of its ap- plication, it will seldom fail to moderate the symptoms, and materially contribute to a favourable termination. Whilst cold water dashed forcibly from a pail, or falling from a height in considerable quantity from a garden watering-pot, is decisively impres- sive, and ordinarily safe, when employed in an early stage of this, and other typhoid fevers ; so aspersion, or ablution of the body by means of a sponge, will be more eligible and safe in the advanced periods. The effects produced by both modes are grateful and refreshing to the patient, and they usually bring about an abatement of fever, followed by more, or less, of a diaphoresis, and this again by a refreshing sleep. We have lately been gratified with an ingenious publication from the pen of Dr. Jackson, on the subject of cold affusion ;* and although he agrees with Dr. Currie as to its utility and propriety in the milder forms' of fever (whether infectious, and such as is usually called typhus, or en- demic, such as arise from the action of common causes in a diffused form,) in the early stages of fever, still he differs from this gentleman on other important points. Dr. Currie had employed the affusion of cold water in the mild and open forms of fever, without any previous preparation, and likewise in those which are violent, concentrated, and complicated, provided the temperature of the body, on being measured by a thermometer, was higher than the natural standard ; but when lower than this, he advises us to abstain from its application. Dr. Jackson, in resorting to it, is guided by what he terms the evidences of a susceptible condition of the system, connected with a simple condition of the disease being obvious, of the presence of which, he judges by the sensation communicated to his hand in touching the patient's body. Where he finds this deficient in any degree, or where it is unusually distributed on the surface, and un- accompanied by any primary mark of local inflammation, or congestion of any one of the internal organs being discernible, he endeavours to restore the susceptibility of impression, by conducting the patient into an apartment, where the air is of a high temperature ; by applying waim * See his Expofitfon on the Practice of applying Cold in Fevers. ORDER I. NERVOUS FEVER. 4i fomentations to the extremities ; by purifying the skin by warm water, soap and brushes, and then by immersing the whole body in a warm bath, or by affusing warm water generally over its surface. Where there is either a violent or rapid action, or a sluggish circulation, he does not consider these as proper conditions for the cold affusion, but to make them so, he recommends the preparatory process of general bleeding, and other evacuations ; whereas Dr. Currie considered venesection unneces- sary to a previous use of cold affusion, except in cases of idiopathic in- flammation. The affusion of cold water on the surface of the body, is considered by Dr. Jackson as a power which makes a strong and general impression on the system, and which arrests the disease, or changes its condition in vir- tue of that impression ; but not by subtracting increased heat, as suppo- sed by Dr. Currie. Indeed, the good effects of the remedy in question cannot, I think, be wholly owing to the mere subtraction of heat; for it has been used with great advantage in many cases of fever, where there has been no perceptible increase of temperature, and where, by affusion, ablution, or aspersion with cold water, the disease has been cut short abruptly, as well as in those where it had risen to a high point. Although medicines which might excite profuse sweating would be highly improper in this fever, still we may venture to give those * pos- sessed of a mild diaphoretic power. Antimonials do not seem very ad- visable in the true typhus. In the progress of the disease, it has been usual, when particular af- fections arise, such as either a difficulty of breathing, violent pains in the head, delirium, or stupor, to excite an inflammation in the neighbourhood o£ the part affected by the application of a blister, and not unfrequently the poor patient has been tortured with half a dozen at a time in the ad- vanced stage of the disorder. This practice is certainly very reprehen- sible. The application of even a single blister to the back or head in this fever, with the view of relieving stupor and coma, is much disapproved of by many physicians, and Dr. Darwin mentions:}: that he has seldom seen any beneficial effects derived from it, but on the contrary a prejudicial one. The observation is perfectly just, and therefore I cannot advise the remedy. Where stupor, coma, or delirium prevail, the pediluvium, together with frequent washings of the temples, and whole of the head (having it \ See his Zoonomia. ft. Succi Limon. 3fs. , Kal Prxpar. ^j. Aq. Cinnam. 5J. Confedt. Aromat. gr. xv. Syrup. Zingib. !jij. M. ft. Hauftus 4tis horis fumendus. Vd ft. Mifturae Camphorat. gx. Aq. Ammon. Acetat. 3[iij. Spirit. JEther. Nitros. gfs. M. ft. Hauftus 3tia hora capiendus. Vel ft. Camphor, gr. iv. Pulv. Contrayerv. C. gr. %■ ---- Ipecac, gr. ij. Conferv. Rofae q. s. M. ft. Bolus 6tis horis fumendus. F 42 PYREXIAS OR FEBRILE DISEASES. CLASS I. properly shaved,) with cold water and vinegar, or applying linen cloths dipped in aether to these parts, may be substituted. If a purging arises, it is to be stopped by having recourse immediately to astringents,* as advised below ; but in the progress of the disease, if a gentle diarrhoea takes place, and seems likely to prove critical, it should by no means be checked. Profuse sweats are to be obviated by the person being lightly covered with bed-clothes ; by keeping his hands and arms uncovered ; by ad- mitting fresh air freely into his chamber, and by giving him whatever he drinks, cool, and properly acidulated with lemon or orange juice. Delirium is very apt to arise in typhus from a want of sleep, and to make it necessary to have recourse to opium in order to procure it. The most advisable way of using it in such cases, is to combine it with some gentle diaphoretic! By giving it in this manner early in the evening, we shall in general experience the most beneficial effects from it. Opiates are indeed more admissible in this species of fever than in any other ; and it seems now to be the universal practice to give one every night during its whole continuance. The best effects have been obtained from this mode of proceeding, as I have witnessed in innumerable in- stances, and therefore I almost invariably adopt it. To support the patient's strength, it will be necessary to allow a libe- ral use of wine, which is preferable to all other cordials. Its quantity should be proportioned to the degree of debility present, and to the effect it produces on the patient. Sago, gruel, panado, arrow-root, and the like, mixed with a due proportion of it, must be given to him as food ; and wine-whey, or small negus, sharpened with the juice of orange, will be most proper for ordinary drink. Wonderful, indeed, are the effects pro- duced by wine in typhus fever, as we often see persons recover by a free use of it, under the most unpromising circumstances. A late physician^: of great celebrity recommends wine and opium, in small quantities, repeated every three hours alternately, and this with the view of rousing the system from a state of torpor and debility. Where wine disagrees with the patient, or fails to produce the desired | Dr. Darwin. • ft. Mifturas Cretac. riv. Extradt. Lign. Camp. ^j. Tinft. Catechu gij. Aq. Cinnam. Spirit. Pimento aa 3J. Tin<5t. Opii gutt. xl. M. ft. Miftura cujus fumat Cochl. ij. mag. na 3tia quaq. hora. Vel ft. Pulv. e Cret. cum Opio gr. xij. Gum. Kino gr. v. Gonfec"t. Aromat. gr. x. Syrup. Zingib. q.s. M. ft. Bolus ter quaterve die fumendus. f R- Aq. Ammon. Acetat. ^iij. -----Cinnam. ^j. Tindt. Opii gutt. xl. Syrup. Zingib. gij. M. ft. Hauftus. Vel ft. Miftur. Camphorat. §j. Vin. Antim. gutt. xx. Syrup. Papav. Alb. 311J. M. ft. Hauftus. ORDER I. NERVOUS FEVER. 43 effect, brandy, properly diluted, may be substituted. In advising a free use of wine with opium, I must at the same time caution the practition- er not to run into excess, and over-stimulate the patient, as this might destroy him. Throughout the whole course of the disease he should be kept per- fectly quiet, and none but those whose business it is to attend on him ought to go near him, except in those cases where the symptoms are very mild, and where there is little or no affection of the head. In such ca- ses, the presence of a friend may soothe the mind, and help to dispel gloomy ideas. The chamber should be kept freely ventilated and cool, and his bed be lightly covered with clothes ; he should be solaced and comforted with the hope of a speedy recovery, and his thoughts be divert- ed from that anxiety and dread of danger which invariably attend the com- plaint. Many practitioners are in the habit of giving the Peruvian bark in this fever, without waiting for even the most imperfect crisis ; some having in view its supposed febrifuge qualities, and others, its tonic powers. In mild cases, where there prevails hardly any stupor, or other affection of the head, and where the remissions are regular, it may perhaps be of ser- vice ; but in a state of convalescence it will prove highly beneficial, and may therefore be given either in substance, decoction, or infusion, as may be found to sit best on the stomach. Where the skin and tongue are dry, where the remissions are irregular, and where the fever abates for a day or two, and then returns with violence, I have always found it prove pre- judicial. Miliary eruptions sometimes appear as the crisis to this fever ; they ought therefore by no means to be checked by any kind of evacuation, nor should the patient, on the contrary, be kept loo warm in order to force them out. Where there prevails any unusual coldness in the lower extremities, the application of a couple of small blisters to the inside of the legs, or of stimulating cataplasms to the soles of the feet, will be proper. In bad cases, where startings of the tendons and hiccups arise, besides making use of the means advised, it may be necessary to have recourse to antispasmodics,* such as musk, ammonia, asther, camphor, and opium. If this fever threatens in its progress to degenerate into typhus gravior, we should administer the mineral acids, but more particularly the mu- * ft. Mofch. gr. x. Aq- Cinnam. ^jfs. iEther. Vitriolic, gutt. xx. TincSt. Opii. gutt. xv. M. ft. Hauftus ter in die fumendus. Vel ft. Caftor. gr. x. Camphor, gr. iv. Opii gr. fs. ConfecT:. Aromat. q. s. M. ft. Bolus 6ta quaq. hora fumendus. Vel ft. Miftura; Mofchat. ■ ■ Camphor, aa^iij. Spirit. iEther. Vitriol. C. Xi). M. ft. Miftura de quo capiat Cochl. ij. mag- na tertia quaque hora. 44 PYREXIA OR FEBRILE DISEASES. CLASS I. riatic, in such doses as the patient is capable of bearing. To prevent its affecting the stomach and bowels, a few drops of tinctura opii may be ad- ded to each dose. An infusion of cinchona or columbo may be employed as the vehicle, or we may give the acid in a little wine and water. See Typhus Gravior. In an advanced stage of .this disease, it sometimes happens that little white ulcers or aphthae appear in the inside of the mouth and fauces. In such cases, a gargle composed of borax, honey, and an infusion of roses, should be used three or four times a day. When the fever goes off, and the patient has somewhat regained his strength, he may take daily exercise on horseback or in a carriage ; and in order to remove the irritability and weakness which are left behind, he should enter on a course of the bark and other tonics. After a little time, the cold bath will be a proper remedy, if the season of the year is such as to admit of it. If the appetite does not readily return on the cessation of the fever, stomachic bitters * will be proper. See Dyspepsia. A degree of mania, or temporary alienation of the mind, sometimes arises at the close of typhus. All that can be done in such a case is, to support the patient with a generous nutritive diet; to keep him as quiet and tranquil as possible; and to put him under a course of tonics, care- fully avoiding all evacuations. As this fever is of an infectious nature, every endeavour should be ex- erted for suppressing its further propagation, and for wholly destroying its contagion, by a strict attention to cleanliness, free ventilation and fu- migations, as recommended under the following head. As circumstances may occur for rendering it necessary to remove pa- tients labouring under typhus fever to some distance, it is important to know that this may be effected without subjecting them to any risk. In- deed, considerable benefit has been derived on such occasions by con- veying the sick in open carriages, or spring waggons,t for several miles, freely exposed to the air. Of the PUTRID and MALIGNANT FEVER, or TY- PHUS GRAVIOR. X HIS fever takes its name from the malignancy of its nature, and the evident symptoms of putrefaction which are to be observed, after a con- f See Outlines of the Hiftory and Cure of Fever, by J. Jackfon, M. D.—Remarks on the Conftitution of the medical Department of the Army, by the fame. ft. Infus. Gentian. Comp. ^iv. Tin61. Card. C. _____Columb. aa. ^fs. M. Capiat Cochl. ij. mane, hora meridiana, et vefpere. Adde pro re nata Acid. Sulphur. Dilut. gutt. xx. Vel ft. Pulv. Sem. Card. ----- Gentian. Columb. aa gr. x. Syrup. Zingib. q.s. M. ft. Bolus ter in die fumendu: ORDER I. PUTRID FEVER. 45 tinuance of some days. It is to be readily distinguished from the in- flammatory, by the smallness of the pulse, the sudden and great debili- ty which ensues on its first attack, the brown, or black tongue, the dark and fetid sordes about the teeth, the livid flush of the countenance, and the acrid and more intense heat of the skin ; and, in its more advanced stage, by the petechix, or purple spots, which come out on various parts of the body, and the fetid stools which are discharged ; and it may be distinguished from typhus mitior, by the great violence of all the symp- toms on its first coming on. The most general cause which gives rise to this disease is contagion, applied either immediately from the body of a person, labouring under it, or conveyed in clothes or merchandize, &c.; but it may be occasion- ed by the effluvia arising either from animal or vegetable substances, in a decayed or putrid state; and hence it is, that in low or marshy coun- tries it is apt to be prevalent when intense and sultry heat quickly suc- ceeds any inundation. A want of proper cleanliness, and confined air, are likewise causes of this fever; hence it prevails in hospitals, gaols, camps, and on board of ships, especially when such places are much crowded, and the strictest attention is not paid to a free ventilation and due cleanliness. A close state of the atmosphere, with damp weather, is likewise apt to give rise to typhus gravior. Those of lax fibres, and who have been weakened by any previous de- bilitating cause, such as poor diet, long fasting, hard labour, continued want of sleep, Sec. are most liable to attacks of it. We are, therefore, to look on these as so many predisposing causes. It has been denied by some physicians of the present time, that either the plague, yellow fever, or typhus, are contagious diseases; and it is true, indeed, that we cannot, in every case, ascertain that the complaint originated from a communication with diseased persons; nor will the actual communication always produce fever : many predisposing causes are requisite, and moreover, the human constitution is evidently less susceptible of disease at one time, than at another. Whoever has paid proper attention to the symptoms of typhus, may, however, be induced readily to conclude that the surrounding atmosphere, to an extent more or less great, particularly in small, close rooms, may become sufficient- ly impregnated with the particles continually exhaling from the diseased body, to infect other persons with a similar disease. Some writers have supposed infants to be as liable to fevers as adults, and from the same causes, but I cannot agree with them ; for I have observed that infants do not readily take fevers, although exposed for a long time to that contagion which has appeared to affect adults round them; and every physician who attends lying-in hospitals must not only have known many infants suckled without injury, through the whole stage of bad fevers, from which their mothers have recovered ; but also, in other instances, sucking greedily within an hour or two of their mo- ther's death. On the first coming on of typhus gravior, the person is seized with languor; dejection of spirits; amazing depression and loss of muscular strength; universal weariness and soreness ; puns in the head, back. 46 PYREXIA OR FEBRILE DISEASES. CLASS I. and extremities, and rigors; the eyes appear full, heavy, yellowish, and often a little inflamed; the temporal arteries throb violently ; the tongue is dry and parched; respiration is commonly laborious, and in- terrupted with deep sighing ; the breath is hot and offensive; the urine is crude and pale; the body is costive, and the pulse is usually quick, small, and hard, and now and then fluttering and unequal. Sometimes a great heat, load, and pain, are felt at the pit of the stomach, and a vomiting of bilious matter ensues. As the disease advances, the pulse increases in frequency (beating of- ten from 100 to 130 in a minute) ; there is vast debility; great heat and dryness in the skin; oppression at the breast, with anxiety, sighing, and moaning ; the thirst is greatly increased ; the tongue, mouth, lips, and teeth, are covered over with a brown or black tenacious fur; the speech is inarticulate, and scarcely intelligible ; the patient mutters much, and delirium arises. The fever continuing to increase still more in violence, symptoms of putrefaction shew themselves; the breath becomes highly offensive ; the urine deposits a black and fetid sediment; the stools are dark, disagreeable, and pass off insensibly ; hemorrhages issue from the gums, nostrils, mouth, and other parts of the body; livid spots or petechias appear on its surface; the pulse intermits and sinks; the extremities grow cold ; hiccups ensue; and death at last closes the tragic scene. When this fever does not terminate fatally, it generally begins, in cold climates, to diminish about the commencement of the third week, and goes off gradually towards the end of the fourth, without any very evident crisis ; but in warm climates it seldom continues above a week or ten days, if so long. Our opinion as to the event, is to be formed by the degree of violence in the symptoms, particularly after the ap- pearance of petechia, although, in some instances, recoveries have been effected under the most unpromising appearances. An abatement of febrile heat and thirst; a gentle moisture diffused equally over the whole surface of the body; loose stools; turbid urine ; rising of the pulse ; a free secretion of saliva; tumor and suppuration of the parotid, axillary, or inguinal glands ; a scabby eruption about the mouth, and the absence of delirium and stupor, may be regarded in a favourable light. On the contrary, great muscular debility, very difficult and laborious respiration, stupidity and listlessness of the eyes, perpetual writhing of the body, pe- techia, with dark, offensive, and involuntary discharges by urine and stool, fetid and cadaverous sweats, hemorrhages, subsultus tendinum, and hiccups, denote the almost certain dissolution of the patient. The appearances usually perceived on dissection are, inflammations of the brain and viscera, but more particularly of the stomach and intes- tines, which are now and then found in a gangrenous state. In the muscular fibres there seems likewise a strong tendency to gangrene. On the very first taking place of any of the symptoms of this fever, we should immediately attend to them, and endeavour to prevent any bad consequences from ensuing, as they will never go off of themselves, but will continue to increase, until a disease of a most dangerous nature takes place. This being the case, we should resort to proper remedies ORDER I. PUTRID FEVER. 47 at the first onset, and not wait until the body is enervated. The most proper remedy at first, will be an emetic of about fifteen grains of ipeca- cuanha with one grain of tartarized antimony, which may be worked off with an infusion of chamomile flowers ; and after the operation of this is over, the bowels may be opened with some gentle laxative.* Pos- sibly, calomel may be preferable to any other. Should the desired ef- fect not be produced by the medicine, an aperient clyster may be admin- istered.! These steps being pursued, and the nature of the disease clearly as- certained, I would advise the ablution of the patient with cold water, or rather a general affusion, provided the heat of the body is steadily above the temperature of health. The good effects of this mode of practice I have often experienced. The late Dr. Currie, of Liverpool, reports, that this fever having made its appearance in a regiment quartered in that town, he had the men drawn up and examined, seventeen of whom were found with symptoms of it upon them: these he subjected to the cold affusion once, or sometimes twice a day. In fifteen of this number, the conta- gion was extinguished, and in the remaining two the fever went through its course. The healthy part of the regiment bathed in the sea daily, and by these means he effectually destroyed the contagion. He further relates, that of thirty-two who went through the disease, by its being too confirmed to be removed at the time of his first seeing them, only two died; and with these, the.cold affusion was not had recourse to. This gentleman's report, with the authorities of other practitioners of eminence, clearly prove the application of cold water by affusion on the first attack of the complaint to be, under certain restrictions, an effica- cious remedy for stopping its progress, as likewise that of other low contagious fevers. Doctor Currie found, that the most advantageous time for using the cold affusion is, when the exacerbation is at its height, or immediately after it is begun, which is generally from six to nine in the evening; but he observes it may be used with safety at any time of the dayi when there is no great sense of chilliness present; when the heat of the sur- face is steadily above what is natural; and when there is no general or profuse perspiration. The same remedy has likewise been successfully employed by him and many others, in the more advanced stage of the fever, so as seldom ft. Mann. Optim. ^fs. Cryftal. Tartar.''5 Aq. Fervent. Jiij. M. ft. Solutio pro dos. Vel ft. Kali Tartarifat. ^iij. Mann. Optim. ~ij. Aq. Fervent. 5iij. — Cinnam. 363. M. Capiat dimidium pro dos. Vel ft. Calomelanos gr. v. Extract. Colocynth. C. gr. iij. Fiant pilulae No. iij. pro dos. f ft. Decoct, pro Enemate ^xij. Magnes. Vitriolat. Jfs. 01. Olivae §j. M. ft. Enema, 48 pyrexia; or febrile diseases. lLASS I. to fail of procuring a safe termination. He relates the case of a soldier who was in the ninth day of the disease when he first saw him : his pulse was 100 and feeble, his heat about 104, his thirst very great, his tongue foul and black, his mind much confused, and at times he was delirious, and petechia were dispersed over his whole body.—The mode of treat- ment was as follows: his strength was directed to be supported by admin- istering a bottle of wine a day, with an equal quantity of gruel; every night he took an opiate draught, and his body was kept open by laxative clysters, and when these failed, by a few grains of calomel. A bucket- full of salt water was directed to be thrown over him immediately, which was to be repeated according to circumstances. The effect was, that, in a few minutes after the affusion, the heat les- sened to 98, the pulse moderated to 96, and his mind became more calm and collected. Two hours afterwards he had relapsed nearly into his former state, but the night was passed with greater tranquillity. The whole of this practice was continued, with nearly the same result, until the twelfth day of the disease, the affusion having been performed in the evening, and occasionally at noon. The fever continued its usual period; but on the twelfth day, the heat having sunk to its natural stand- ard, the cold affusion was thenceforth omitted, and instead of it, the body was sponged all over once or twice a day with vinegar. In those cases where the fever had been of eleven, twelve, or thirteen days standing, and the heat of the body was inconsiderable, he thought it prudent to make the degree of cold very moderate, and in some in- stances he substituted tepid ablution, or sponged the body over with vine- gar by itself or diluted with water. Some communications to Dr, Currie from Mr. Marshall, surgeon of the Cheshire regiment, bear further testimony of the good effects of this remedy in typhus fever. In sixty cases out of sixty-four, in which it was employed at an early period, the disease was arrested by having recourse to it three or four times, and in the other four which were advanced in their progress, although the disease was not stopped from going through its natural course, still all the patients recovered. Mr. Marshal! men- tions, that from the time he began the cold affusion he used little or no wine, no opium, nor indeed scarcely any other remedy in any one case in wdiich the cold affusion was employed ; which report is of itself suffi- cient to establish its decisive superiority over every other mode of treatment. It is, however, in the early stages of low contagious fevers, that we can employ it with most advantage. It has indeed been used by many practitioners, in some instances, so late as the twelfth or even the four- teenth day with safety and success; but it can only be employed at this advanced period, in the instances in which the heat keeps up steadily above the natural standard, and the respiration continues free. In such cases it has been observed to appease agitation and restlessness, dissipate delirium, and, as it were, snatch the patient from impending disso- lution. When the remedy is to be had recourse to, every arrange- ment should be made for the affusion before the patient is moved at all, and fatigue as well as disquiet should be avoided as much as possible. ORDER I. PUTRID FEVER. 49 In those cases where the delicacy of the system, or the apprehensions of the patient or of the by-standers, may prevent cold affusion from being employed, we may substitute tepid affusion for the more powerful rem- edy, or we may recommend either ablution or aspersion. A memorable instance of the good effects of cold affusion came under my immediate knowledge some years ago, whilst I practised in the West Indies. A professional gentleman of my acquaintance, residing in the island of Nevis, was attacked with this fever, and it proceeded with such violence, that in a few days petechia appeared on different parts of his body, and a hemorrhage of blood issued from his nostrils, mouth and other places. Under these unfavourable circumstances he was freely exposed to the open air, and one or two buckets of cold water were thrown over him ; he was then wiped perfectly dry, and replaced in his bed ; which plan of proceeding was repeated twice and sometimes thrice a day. By means of this application, the administration of an opiate at night, and a liberal allowance of wine, his life was preserved to the great, but pleasing, astonishment of all his friends. Of late years I have been much in the habit of recommending cold af- fusion or ablution in most cases of typhus fever, and with very beneficial effects. The same practice has been adopted in the London house of re- covery, and apparently with the most decided success. Obvious, how- ever, as are the advantages to be derived from the remedy in question, still there are many practitioners, who look on it as an innovation, and are therefore averse to it. This prejudice, I hope, will soon subside. In the early stage of typhus, the superior efficacy of affusion over ab- lution is unquestionable ; its operation extends beyond the mere abstrac- tion of heat from the surface ; it acts powerfully on the nervous system. Besides its effectually removing the uneasy sensation of heat in the beginning of febrile diseases, and thus indirectly recruiting the animal powers, it induces sleep. We well know that when any disagreeable sensation is removed, sleep soon follows ; and it happens so in this in- stance. After the fourth or fifth day of fever, the influence of both af- fusion and ablution is greatly diminished, and not sufficient to interrupt the morbid actions ; at a still more advanced stage the heat is removed nearly in the same degree by washing the surface of the body with a wetted sponge, or cloths dipped in water, as by pouring cold water on the naked body ; and the patient is relieved nearly the same by one mode of treatment, as by the other. Thus much for the comparative merits of affusion and ablution. In the advanced stages of typhus gravior as well as of typhus mitior, where either the affusion of water of a low temperature, the immersion of the patient, or even the sprinkling his body with cold water, might in the least endanger our arresting the movements of life, we should al- ways take the precaution of giving a glass of warm wine, or some other powerful cordial, immediately after employing the remedy. It is no uncommon occurrence for the symptoms to run very high at the commencement of this fever, so as to give it rather an inflammatory 5G PYREXIAE OR FEBRILE DISEASES. CLASS I. appearance, which has induced practitioners, at times, to draw off blood, by opening a vein ; but sad experience has fully evinced the impropriety of so doing. Contagion certainly weakens the force of the solids ; for winch reason, whenever we suspect a fever to have arisen from this cause, we should proceed with the greatest caution in drawing blood, even al- though the symptoms may run pretty high at the beginning, and may seem actually to demand the taking away a considerable quantity. Instead, therefore, of bleeding, or using any other evacuation than keeping the body open with mild laxative medicines, we should support the patient by allowing a iiberal use of wine. It may be given in pana- do, gruel, or whatever he takes for food, and likewise in his drink, obser- ving to dilute it properly, and to add some grateful acid, such as the juice of oranges. The mineral acids likewise are, beyond all doubt, better remedies in this and other malignant diseases, than we have been accustomed to re- gard them ; and from having employed them, but more particularly the muriatic, for several years with very great success in typhus gravior, I can vouch for their efficacy. My usual plan of proceeding is as follows : Having relieved the stomach by a gentle emetic where nausea prevails, cleared the bowels of their feculent contents by a proper dose of calomel joined with a few grains of the extract, colocynth. c, and subjected the patient to cold affusion when the circumstances already noticed have ad- mitted of it, I prescribe for adults, ten or twelve drops of the muriatic acid guarded with five drops of tinctura opii, and as a vehicle I employ about an ounce and a half of an infusion of columbo. This draught I direct to be repeated every four hours, gradually increasing the quantity of the acid in each, to eighteen or twenty drop3 or more W hen the fever begins to decline, or to shew remissions, I substitute a decoction of cinchona instead of the infusion of columbo. The effects of the muriatic acid in all febrile diseases of a malignant nature are truly great ; and from using it in all such cases, my practice has been attended with the most decided success. As a confirmation of its utility, it is proper to mention that a considerable pension has been granted by the King of Prussia to Dr. Reich, professor of medicine at the university of Erlingin Franconia, for making known a remedy by the use of which, all danger was removed in acute diseases of a malignant na- ture, and that, on a disclosure of the secret, it proved to be the acids con- taining oxygen, but particularly the muriatic. In cases of extreme dan- ger, we are told by him,* that one or two drachms of the acid may be given at once. The discovery, however, cannot be claimed by the Prus- sian professor, as it is well known that the late Sir William Fordyce highly recommended the muriatic acid to be given internally in diseases of a putrid or malignant nature, and likewise to be applied in the form of gargle to the sloughs of the throat which often accompany such fevers. A material circumstance to be attended to, not only at the com- * See a tranflation of his German work, by Dr. Parry, of Bath. OltDKR I. PUTRID FEVER. 51 mencement of this fever, but through its whole course, is to cover the pa- tient lightly with bed-clothes, and to keep his apartment cool and pro- perly ventilated, by allowing a regular and free admission of fresh air in- to it; and in order to render it pleasant both to himself and his attendants, it ought to be sprinkled several times a day with warm vinegar and cam- phorated spirits. Fumigations in the manner herein after noticed will also be advisable. Cleanliness in the strictest sense of the word is to be most carefully attended to ; and therefore not only the bed and body lin- en should be changed frequently, but whenever a motion takes place, it ought immediately to be removed. The viscid phlegm which collects about the tongue and teeth should be coagulated by some austere acid, and then it may be scraped off by a knife ; or be wiped away with a bit of flannel clipped in vinegar or salt and water. Although there is not usually any regular crisis to this fever, still na- ture sometimes endeavours to throw it off by a gentle moisture diffused equally over the whole surface of the body : to piomote this, we may ad- vise some gentle diaphoretic ;* but we are carefully to guard against ex- citing profuse sweats, which would certainly prove highly prejudicial A physician § of some eminence, speaks highly of the effects of the spiritus actheris vitriolici in this fever, when given with antimonials, as having an advantage over most cordials in not increasing the heat of the body or quickening the pulse ; but, on the contrary, rendering the action of the heart more regular and slow, and, moreover, proving serviceable in pro- moting a diaphoresis, and lessening anxiety and tremors. In the first stage of the disease, where there arises any violent affection of the head, or any great difficulty of breathing, it has been usual to apply a blister to the neighbourhood of the part affected ; but blistering seems a doubtful remedy in typhus gravior, as well as in the mild species of the disorder. Where stupor prevails, with little or no delirium, we need not employ it ; but where the delirium is violent and accompanied with great wildness of the eyes, so as to threaten a phrenitis, we may recommend it. After symptoms of putrescency have become obvious, the application of a blister would be highly improper. When hemorrhages ensue and petechia have appeared on the body, we should have recourse to the most powerful antiseptics, such as ve- getable and mineral acids, carbonic acid in every form, liquors in a state of fermentation, oxygen gas, oxygenated muriate of potash,t § Dr. Carmichael Smyth. • ft. Camphor, gr. iv. Pulv. Ipecac, gr. iij. Confecf. Aromat. Qj. M. ft. Bolus 6ta hora fumendus. j- ft. Muriat. Potaflae Oxygenat. gfs. Tincf. Cinnam. Comp. sjij. Aq. Cinnam. ^jfs. Syrup. Cort. Aurant. gj. M. ft. Hauftus 2da vel 3tia hora capieti- dus. 52 PYRKXI.S OR FEEU1LE DISEASES. CLASS. I. aerated waters, wine, cold affusion, and bark.* We may also administer clysters of diluted vinegar,! or crystallized acid of lemons in moderate quantities, that they may remain in the rectum, and thereby be likely to be absorbed. The exhibition of fixed air has been recommended in this fever. The Rev. Edward Cartwright, having read of the power of fixed air in pre- serving meat from putrefying, was induced to make trial of it on a boy of fourteen years of age who had been ill several days of a putrid fever, for which bark and wine had been exhibited without any apparent advantage, and where there was but little hope of a recovery. He directed two ta- ble-spoonfuls of yeast to be taken every three hours, which having been complied with, the boy found almost immediate relief, and recovered very quickly. Mr. Cartwright reports, that he gave the same remedy to above fifty patients in this fever, without losing one. With respect to the use of yeast internally in this fever, some practi- doners have looked upon it rather as a doubtful remedy, although they readily subscribed to its good effects as an external application in fetid putrid ulcers. I have made trial of it, and, as I conceive, with some advantage ; nor did it in a single instance excite any commotion or dis- order, either in the stomach or bowels of my patients, as some have re- ported to have happened with them on making use of it. As the good effects of yeast seem to depend on the fixed air which it contains, it is probable that we might substitute water impregnated with the gas to great advantage, as we should thereby avoid the disagreeable consequen- ces attributed to it. The mode in which I administered yeast was by adding one or two table-spoonfuls of it to a quart of an infusion of malt or mild porter, of which the patient took a wine-glassful very frequently. Whatever may be the mode of action of yeast in typhus, the fact ap- pears to be indisputable that fixed air takes off that extreme debility of the stomach so conspicuously marked in disorders of this nature ; and in proportion as that subsides, the pulse rises, becomes slower and fuller, the burning heat on the skin disappears, and a truce is gained for the recep- tion of nourishing supplies. ft. Cort. Peruv. Crafs. |fs. Rad. Serp. Virg. 3113. Coque in Aq. Fontan. ibj. ad Jfefs. Colat. adde Tindt. Cinnam. 5J. M. ft. Decodtum, cujus fumat uncias duas fecunda quaque hora cum Acid. Nitros. guttis x.—xv. Vel ft. Pulv. Cinchon. ^fs—£j. Tindt. Ejufdem ^ij. Aq. Cinnam. ^jis. Tinft. Opii gutt. viij. Acid. Muriat. gutt. viij.—xv. M. Pro hauftu fecunda vel tertia quaque hora fumendo. Vel ft. Decoct. Cinchon. ^jf». Tindl. Fjufdem Sjirj. Acid. Muriat. Oxygenat. gutt. xv.— xx. M. ft. Hauftus 3tia quaque hora capien- dus. t R- Infus. Chamremel. Flor. ~v. Aceti Communis ^iij. M- Pro Enemate. ft. Decodl Vel pro Enemate ^vj. Aceti Communis ^ijls. M ft. Enema. ORDER I. PUTRID FEVER. 53 For the healing of ulcers in the mouth, we may employ a solution of alum in water (an ounce of the former to a pint of the latter,) as a gargle, which will quickly take away the stench that arises from them. In typhus gravior it is of the utmost consequence to procure rest, and therefore, where there is no great delirium, we may give an opiate to- wards bed-time. Combining it with some diaphoretic* will prevent any deleterious effects from it, and therefore it will be best to give it in this way. A slight purging, attended with a gentle moisture on the skin, not un- frequently arises towards the close of this fever, and now and then assists in carrying it off; but where it does not seem to produce a critical effect, it ought to be stopped as quickly as possible by astringents.f When we succeed in removing the symptoms entirely, by the means which have been pointed out, or in procuring a cessation of the fever, we are to endeavour to prevent its return by a free use of Peruvian bark, the cortex angusturae, infusions of gentian and orange-peel, and other stomachic tonics ; and in order to recruit the strength, the patient should be directed to use a nourishing diet, with wine in moderation ; and he should take such gentle exercise as his state of convalescence will admit. Having pointed out the mode of treatment to be adopted when the disease actually takes place, it seems proper likewise to mention the precautions it may be necessary to pursue, in order to prevent its conta- gion from being communicated to others. When the disease arises, the sick ought to be removed to the most' remote part of the house, and as much separated from the rest of the family as possible ; his bed-linen should be changed frequently ; his bo- dy be kept clean ; whatever comes from him, be immediately removed and emptied; and his chamber be well ventilated, by allowing a free admission of fresh air into it; it may likewise be sprinkled frequently with warm vinegar, in which some of the aromatic herbs have been in- fused. None but the necessary attendants should have any communi- cation with the sick, and these, to guard against contagion, should avoid sitting down on the patient's bed; and they must likewise carefully avoid inhaling the vapour arising immediately from his body. When near him, they may keep a sponge or handkerchief, moistened in cam- phorated spirits or vinegar, to the nose and mouth. In hospitals, camps, and on board of ships, where a number are una- voidably crowded together, so as to render it impossible to cut off the communication between the healthy and the diseased, these simple means will not prove sufficiently powerful for destroying the contagion, ft. Aq. Amnion. Acet. ^iij. —— Cinnam. 5J. Tinft. Opii gutt. xl. Svrup. Zingib. qI). M. if. hauftus. f ft. Elect. Catechu gj. Aq. Cinnam. ----Pimento aa ^jfs. ----Fontan. ^ij. TinA. e Kino ^ij. ----Opii gutt. L. M. ft. Miftura cujus fumat Cochl. ij. magna 4tis horis. 54 PYREXIAE OR FEBRILE DISEASES. CLASS I. and therefore others must be adopted. In all such instances, besides well fumigating the apartments, clothes, beds, bedding, and hammocks, of the sick, as hereafter advised, changing them frequently for fresh ones, paying the strictest attention to cleanliness in every respect, well ventilating every place where they are lodged by a constant and free ad- mission of fresh air, we should oblige those in health, as well as those tainted by the contagion, to undergo daily ablution with cold water. Nitrous acid has been used by Dr. Carmichael Smyth as a fumigation, with the greatest success in this fever. In the year 17S0, the disease broke out among the Spanish prisoners confined in Winchester castle ; he embraced the opportunity of giving the remedy a fair trial, and ob- tained the most decisive evidence of its happy power in preventing the spreading or farther communication of the infection. He found he could use it without risk or inconvenience to respiration, and therefore thought it the most proper antidote to be applied, where persons are un- avoidably obliged to be present. At the suggestion of Dr. Smyth, important experiments were made, by desire of the Lords of the Admiralty, with the nitrous acid vapour, on»board the Union hospital-ship, in November, 1795, to correct the contagion of a very malignant fever which had made great ravages among the crews of the Russian ships at Sheerness ; the success of which was so complete, as not to leave the least reason to doubt of the high efficacy of this fumigation. Many subsequent trials have confirmed this opin- ion, and have induced the House of Commons to vote a reward to Dr. Smyth for his valuable and easy method of destroying the contagion of infectious fevers. The Doctor's mode of obtaining nitrous acid is by decomposing nitre by means of heated sulphuric acid, which may be done as follows : Put half an ounce of this acid into a crucible, glass, china cup or saucer, and warm this over a lamp, or in heated sand, adding to it, from time to time, some nitre: these vessels he directs to be placed at 20 or 30 feet distance from each other, according to the height of the ceiling, and the virulence of the contagion. In hospitals and prisons, he advises the lamps or vessels containing heated sand to be placed on the floor ; but on board of ships, he recommends to hang them to the beams by Avaxed silk cords. From the well-known efficacy of the sulphuric acid in destroying con- tagion, he advises it to be employed as a fumigation for clothes and fur- niture, Sec.; but for purifying empty prisons, hospital wards, and ships, he gives the preference to the nitrous, its vapour being mote volatile and penetrating, and not leaving the disagreeable smell which the sul- phuric does, and thinking it at the same time equally efficacious. Monsieur Guyton Morveau, in his Treatise on the Means of purifying- infected Air, claims the merit of being the discoverer of the power of the mineral acids to destroy contagion, and endeavours'to establish the su- periority of the muriatic acid over all others. Upon a full investigation of the matter it appears, however, that the power of the mineral" acids to destroy contagion was known to Sir John Pringle as early as the year ORDER I. PUTRID FEVER. 55 1750, and their utility for that purpose was mentioned by Dr. Johnstone in his pamphlet published in 1758, in which we are told that the vapour of muriatic acid was successfully employed by him in correcting the con- tagion of a very malignant fever, which had raged at Kidderminster two years before that period. Dr. Smyth has also claimed the having been the first who used the mineral acid gases in the apartments of the sick, and has alleged that they never had been employed by Dr. Johnstone, but in places where no one was present, or whence the sick were removed. This opinion has been refuted by Dr. Johnstone's son, and the invention of his father most in- contestably established.* What Dr. Smyth seems therefore entitled to is the merit of having brought the discovery into public notice, and of having applied and extended it to general use. It seems of little consequence whether we employ the nitrous acid or the muriatic in the form of gas for the purpose of destroying contagion and purifying infected air, as the powers of both are extensive and cer- tain. The muriatic is however thought to be more diffusible than the other. When we give it the preference, it may be used in the following manner: Put one pound of common salt into an earthen vessel, and pour over it from time to time a small quantity of sulphuric acid, till the whole salt is moistened. If the air is foul and peculiarly offensive, apply a gen- tle heat under the vessel, to extricate a larger quantity of vapour ; but in general, the simple addition of the acid to the salt will be found sufficient, unless the apartment is very large. On the appearance of any infectious disorder in a gaol, hospital, work- house, garrison, transport-ship, or any other place where many persons are crowded together, we should not fail to advise one of these gaseous fumigations in every room, in addition to a free ventilation and the great- est cleanliness. The same steps should be adopted in academies, board- ing-schools, and even our dwelling-houses. Other methods of annihilating contagion are noticed under the heads of Dysentery and the Plague. Of the YELLOW FEVER, or TYPHUS ICTERODES. F ORTUNATE has it been for the inhabitants of this country, that the disease I am now to treat of, has never been introduced among them, not- withstanding their great intercourse with America and the West Indies, in which places it has spread universal terror and desolation, and in its fa- tality has equalled, if not exceeded, the plague itself, to which malady it indeed bears a strong similarity in many of its symptoms. Possibly the North of Europe may not be susceptible of its contagion. With respect to the origin of the yellow fever there has prevailed a great difference of opinion ; some supposing it to have been introduced into America from the West Indies ; and others, that it took its rise from the exposure of putrid animal and vegetable substances on the public wharfs of the city of Philadelphia ; which opinion is firmly sup- * See Dr. John Johnftone's Reply to Dr. Smyth. 56 PYREXIA OR FEBRILE DISEASES. CLASS I. ported by Dr. Rush, as he found that the streets adjoining to these wharfs were the first in which the disease made its appearance, and that in several instances it could clearly be traced from thence to other parts of the city. Let this be as it may, it is evident, from the report of Dr. Chisholme, and others, who have written on the disease, that the fever which prevailed in Philadelphia, was exactly the same with that which raged in the West India colonies. Dr. Clarke informs us, that there appears to have been such an exten- sive and very peculiar deranged state of the atmosphere in the towns of the West Indies and in North America, that it is more probable the dis- ease was produced by this general cause breaking out nearly at the same time in these different places, than that it was carried from the one to the other, either by persons or in any kind of goods or merchandise. We are informed by Dr. Miller, of New-York, that the yellow fever in America always begins in the lowest part of a populous mercantile town near the water, and continues there without much affecting the higher parts. It rages most where large quantities of new ground have been made by banking out the rivers, for the purpose of constructing wharfs. The appearance and prevalence of the yellow fever in high situations, have led to the belief, he tells us, that the disease was imported by ships from the West Indies. But a person seized with this fever in an affect- ed part of the town, and conveyed to one that is healthy, or carried into the country, does not communicate it, he asserts, to the neighbourhood, nor to those immediately around him. He therefore is of opinion that the yellow fever is generated by the impure air or vapour which issues from the new-made earth or ground raised on the muddy and filthy bottom of rivers, and which deteriorates the air above it, in like manner as air be- comes offensive and injurious when it approaches or passes over a body of vegetable or animal matter in a state of putrefaction. It appears that the shores of the rivers of New-York and Philadelphia have undergone great and rapid alterations from their natural state with- in a few years, on account of the vast increase of commerce, and for the sake of making wharfs ; and Dr. Miller mentions, it is only in such parts where these alterations have taken place, that the yellow fever has been produced. The parts where little or no alteration has taken place on the East and North river, aftd which continue nearly in their natural state, do not produce the yellow fever. He adds, eighty new wharfs have been made since the war, the consequence of which has been, that great quan- tities of filth and corruptible matter, deposited in the muddy bottom of the river, contiguous to the shore, and which produced no ill effect while ex- posed to the air and washed twice every four-and-twenty hours, have been covered over several feet deep with new earth, and closely pent up so as to exclude the tide. It is in these places, and these only, that the yel- low fever is produced, we are told. Some have imagined, that the fever, which has within these few years occasioned such havoc and devastation, is totally of a different nature from the yellow fever formerly met with in the West Indies and other tropical climates ; but in my opinion, it seems to be the same, 0R0ER I. YELLOW Fl-VER. ST and that its only difference consists in its having prevailed as an epidemic, from the subsisting vitiated state of the atmosphere, and from its having, from other concurring circumstances, acquired a degree of malignancy and virulence unknown before. During a residence of nine years in the West Indies, from 1776 to 1785, I had frequent opportunities of meeting with the yellow fever among seamen and such new-comers as were imprudent on their first arrival; and although the disease never prevailed during that period as an epidemic, still I always looked on it as highly contagious, and never failed to recommend the adoption of proper precautions to prevent its spreading. It is probable that marsh exhalations, and the effluvia arising from putrid vegetable and animal substances, under a concurring vitiated state of the atmosphere, were the causes which gave rise to this fever, and that it was afterwards kept up by contagion, heightened, by various ac- cidental circumstances, to a pestilential degree of violence. Very hot and sultry weather, with a long drought, will greatly predispose to the prevalence of this fever as an epidemic, in all tropical climates ; and it may have a similar effect in America, where the summer months are intensely warm. Dr. Rush is of opinion that the yellow fever is not contagious in its simple state, and that it spreads exclusively by means of exhalations from putrid matters, which are diffused in the air; and a few other phy- sicians have, indeed, entertained the same idea, to the great injury of the societies among whom they lived, by preventing the adoption of pro- per means for annihilating its contagion. Some facts have, however, been brought forward by Mr. M'Gregor in his Medical Sketches, which ap- pear to me to establish the point very satisfactorily, that this fever may be communicated by contagion. The persons most liable to be attacked by it in the West India islands, were the Europeans who had lately arrived ; and hence it was, that the troops sent out to recruit our armies, and the seamen to strengthen our fleet, fell its earliest victims. Women were observed to be less liable to its attacks than men, and children still less so than these ; and the people of colour were by no means so apt to be seized with it as the whites. When the disease did appear among them, it was always much milder, owing most likely to their necessary temperance. Those of a full ple- thoric habit, and that were intemperate in their mode of living, were much greater sufferers by it than those of a lax fibre, and who were guil- ty of no irregularity. There is evidently something peculiar in the constitution of people from a cold country, which renders them more obnoxious to fever in a warm climate than either the natives or those who have been assimilated to it by a long residence. Accordingly we find, that the same exposure to the causes, predisponent and occasional, will produce fever in a stranger, while the native or old inhabitant remains in good health ;. and the symptoms will be tenfpjkt more urgent in the one than the other, supposing both are attacketh Hence it happens that long residents, and natives in general, are nof-liable to the yellow fever ; but when they are 1 II 58 PXRl-.XI-E OR FKBRILE DISEASES. CLASS I. attacked with the remittent of the country, the symptoms partake more or less of the malignancy of the prevailing epidemic. The heat of the body of new-comers in the West Indies has been no- ticed by Dr. M'Kittrick to be between three and four degrees above that of the temperature of the natives, and to this he ascribes in part the pre- disposition of new-comers to the yellow fever. Dr. Pinckard, late a physician to the army in the West Indies, from having observed this fever exhibited such instability, and varied so incessantly in its character, that he could not discover any one symptom to be decidedly diagnostic, has been induced to offer it as his opinion (see Vol. V. of Dr. Rush's Medical Observations of the Uni- versity of Pennsylvania) that the yellow fever so called is not a distinct or specific disease, but merely an aggravated degree of the common remittent or bilious fever of hot climates, rendered irregular in form, and augmented in malignity, from appearing in subjects unaccustomed to the climate. The yellow fever usually attacks with lassitude and weariness, chilly fits, listlessness of every thing around, faintness, giddiness, flushing of the face, redness of the eyes, pains in the eyeballs and lower part of the fore- head, as likewise in the back, debility and sighing, thirst, and a tendency to coma : the urine is high-coloured, small in quantity, and turbid ; the perspiration is irregular, interrupted, and greatly diminished ; the saliva is viscid ; the tongue is covered over with a dark fur ; the bile is secret- ed in unusual quantities, and thrown into the stomach, from which it is again speedily ejected ; and the skin is hot, dry, and hard. The disease continuing to advance, the eyes become of a deep yellow, the face and breast are tinged with the same hue ; an incessant retching and vomiting of frothy bile ensues ; great costiveness prevails, and a pe- culiar delirium arises, which is attended with a permanent dilatation of the pupils of the eyes. There is hardly ever an evident remission until the fever has entirely- gone through its first stage, which is generally in thirty-six or forty-eight hours ; when there is often such an abatement of symptoms as to induce the patient to think himself tolerably well ; but an early recurrence of the symptoms in an aggravated form, accompanied with extreme debili- ty, soon convinces him of the contrary. In the last stage of the disease, the greatest debility prevails, and symptoms of universal putrefaction arise; large patches of livid spots are to be observed on different parts, the tongue becomes dry and black, the teeth are incrusted with a dark fur, the breath is highly offensive, the whole body exhibits a livid yellow in many cases, but not in all, he- morrhages break forth from the mouth, ears, and nostrils, dark and fetid stools are discharged, hiccups ensue, the pulse sinks, and death follows very quickly. These are the usual appearances to be mef with ; but great irregula- rities have been observed by different practitioners. Dr. Chisholme mentions, that he often found patients, without any previous complaint, suddenly become giddy, lose their sight, fall down almost insensible, and remain in that state for half an hour or upwards ; the body then be- came overspread with a cold sweat, and this was succeeded by intense ORDER I. YELLOW FEVER. 59 heat, a quick, small, hard pulse, violent pain of the head, particularly in the forehead, great anxiety about the prsecordia ; the eyes were much inflamed, watery, protruded, and wildly rolling; the face was much flushed; there was great heat at the pit of the stomach, with nausea, frequent retching and vomiting, as also severe pains in the small of the back and calves of the legs. During 12, 18, 24, or 36 hours, he found all these symptoms conti- nue to increase, except the quickness and hardness of the pulse, which were not materially changed, and that they were then succeeded by ge- neral coldness, clammy sweats, and a greater or less degree of coma or delirium. Life, in this case, was lengthened out to sixty or ninety hours from the attack. A short interval of reason perhaps took place, the pa- tient considered himself better, and flattered himself for the moment with the hope of recovery; but a fit, as sudden and as unexpected as the first, came on, during which he rolled his eyes dreadfully, foamed at the mouth, and threw out and pulled back his extremities in violent and quick alternate succession. Dr. Chisholme observes, that, in general, the patient expired in this fit ; but, in a few instances, he recovered from it, and continued rational for a short time, when another has ensued and carried him off. He noticed, that, in a few instances, the patient complained of vio- lent pains in the testicles, and, on examination, he perceived them much lessened in size and retracted, with an excoriation of the scrotum : now and then he found a remarkable change in the voice, and that it became weak and shrill; in a few instances he could discover little or no yellow- ness of the skin. Dr. Rush says, the disease appeared with different symptoms in dif- ferent people: he observed the premonitory signs of it were, costiveness, a dull pain in the right side, defect of appetite, flatulency, perverted taste, heat in the stomach, giddiness or pain in the head, a dull, watery, brilliant yellow or red eye, dim and imperfect vision, a hoarseness or slight sore throat, low spirits, a disposition to sweat at nights or after moderate exercise, or a sudden suppression of night sweats. More or less of these symptoms frequently continued for two or three days be- fore the patients were confined, and in some they continued during the whole time of the prevalence of the fever in the city of Philadelphia, without producing the disease. Many went to bed in good health, and awoke in the night with a chilly fit; many rose in the morning after natural and regular sleep, and were seized at their work, or after a walk, with a sudden and unexpected attack. He observes, that it frequently came on with a weak pulse, and often without any preternatural frequency or quickness; and that, in some instances, it was so low as not to be perceived without pressing hard on the artery ; in some cases, the pulse intermitted, and these intermissions occurred in several persons who were infected, but who were not confined by fever ; in others there was a more than ordinary slowness of the pulse, which was now and then accom- panied with a dilated pupil of the eye. Hemorrhages happened at the commencement of the disorder, chiefly of the nose and uterus; and * "0 pyrexi.t: or febrile diseases. class I. s it advanced, the discharge of blood became more universal, and then •sued from the gums, ears, stomach, bowels, and urinary passage. Many complained of a dull pain in the region of the liver, but few •It any soreness to the touch, or pain at the pit of the stomach: in ome, a determination of blood took place to the lungs, but the brain vas chiefly affected with morbid congestion, which \vas»indicated by the uffusion of blood in the face, redness of the eyes, dilatation of the pupils, >ain in the head, hemorrhages from the nose and ears, by sickness or 'omiting, and by an almost universal costive state of the bowels. With respect to the secretions and excretions, there appeared to be a ireternatural secretion of bile, which was discharged from the stomach ind bowels in large quantities, and of very different qualities and colours, being in some cases yellow and in others black. The urine was some- times plentiful and of a high colour; sometimes it was pale, and at others it was small in quantity and turbid : moreover, sweats of a yellow co- lour, and highly offensive to the smell, often broke out. On the first and second day, the tongue was invariably moist and white ; but as the disease advanced, it became red, and put on a smooth shining appear- ance ; towards the close, a dry black streak appeared in its middle, which gradually extended to every part of it. The effects produced on the nervous system were different, according as the fever affected the brain, the muscles, the nerves, or the mind. In a few instances, apoplexy was induced, which usually proved fatal; i..-emorsof the limbs and twitchings of the tendons were common ; de- lirium was a frequent symptom, but many passed through the disease without the least derangement of ideas: in some cases, the pain in the head was acute and distressing, and the stomach, towards the close, was affected with a burning or spasmodic pain of the most severe nature. The senses and appetites exhibited several marks of the ravages of this fever upon the body. Deafness and dimness of sight sometimes took place. Thirst, and want of appetite, were present, as in most other fevers. The convalescence was marked by a sudden renewal of the propensity to venery.* Swellings in the inguinal and parotid glands took place in a few instances, which did not proceed to suppuration. In some cases, the skin was preternaturally warm; in others, it was cooler than in health. The yellow colour was by no means universal; when it took place, it was seldom to be observed before the third day, but more frequently about the fifth or seventh from the first attack. The eyes seldom escaped a yellow tinge. There were eruptions of va- rious kinds on the skin, and, in the latter stage, petechias were common ; carbuncles also took place in some. The disease ended in death in various ways. In some, it was sud- len; in others, it came on gradually. The last hours of some were narked with great pain and strong convulsions ; but, in many, death ?emed to insinuate itself into the system with all the gentleness of na- tral sleep. • The fame is frequently noticed on recovering from the plague. ORDER I. YELLOW FEVER. 61 In every case that came under Dr. Rush's care, there were evident re- missions or intermissions of the fever, or of such symptoms as were sub- stituted for it. The disease continued for 15, 20, or 30 days in some people. He observed that all were affected by it; but persons in the prime of life were most liable to it. Men were more subject to its at- tacks than women. He likewise observed, that the refugees from the West Indies universally escaped it; whereas the natives of France, who were settled in the city of Philadelphia, were much annoyed by it ; and he found, that the people of colour took the disease in common with the white people, but in them it was usually much milder. Critical days were hardly ever distinguishable in this fever, nor was the crisis often very evident. Sometimes a copious perspiration put an end to it ; and at others, the return of sleep, an hemorrhage from the nose, or sudden diarrhoea, carried it off. Dr. Fordyce is of opinion * that typhus icterodes ought to be regarded rather as an irregular semi-tertian than as a continued fever ; for it often happens, that a patient becomes greatly relieved, and appears to be re- covering, when all at once a fresh attack takes place and carries him off. He thinks that the dark brown colour of the skin in this fever arises rather from a greater secretion of the matter secreted by the sebaceous glands of the skin, than owing to a quantity of bile getting into the blood- vessels. In support of this opinion, he observes, that the colour is very different from that which takes place in jaundice. The evacuations from the intestines have not that clay-like appearance which is common in jaundice. The secretion from the kidneys has not that dark yellowish i brown, nor that thick sediment, which have almost always been noticed in those persons in whom bile has got into the blood-vessels. The dark brown matter which the patient throws up by vomiting, he thinks, has the appearance of the matter observed upon the tongue in very violent fevers, and that probably it is formed on the surface of the sto- mach, and perhaps of the duodenum, or even on the beginning of the jejunum. The force of the exertions in vomiting, often occasions a greater quantity of bile to be secreted, and so to be thrown back into the stomach, and be brought up with the dark brown matter. When this happens, it gives to the matter thrown up, he observes, the taste and appearance of bile. At other times, however, there is no appearance of bile at all, but only of this dark brown matter. Concerning the nature of the black vomit, various opinions have been entertained. Some have considered it as consisting of putrid bile, some as composed of a mixture of blood and bile, some of the villous coat of the stomach dissolved in the progress of inflammation, terminating in sphacelus, and others, of bile mixed with the septic acid contained in the alimentary canal; but Dr. Cathrall of Philadelphia t considers all * See his Fourth Diflertation on Fever. f See the New-York Repofitory of 1800, for his Memoir on the Analyfis of the black Vomit, ejected in the laft ftage of this fever. 62 PYREXIJK OR FEBRILE DISEASES. CLASS I. these opinions as erroneous, and offers it as his, that the black vomit is an altered secretion from the liver. Wre are informed by him, that the black vomit, or matter so called, appears to be of two kinds : one consist- ing of a number of flaky particles, resembling the grounds of coffee ; the other, of a dark-coloured inspissated mucus. From various and re- peated experiments, he concludes, that the black vomit, besides a con- . sideraMe proportion of water tinctured with resinous and mucilaginous substances, contains a predominant acid, which is neither the carbonic, phosphoric, nor sulphuric, but hints it may be the muriatic. It appears from Dr. Cathralf s experiments, that the black vomit, when applied to the most sensible parts of the body, produced little or no effect. It likewise appears that large quantities of this fluid may pass through the stomach and bowels of quadrupeds and other animals, without ap- parently disturbing digestion or affecting the health. This fact incon- testably proves the inactivity of this fluid, and renders it probable that the speedy death which ensues after this discharge in yellow fever, is not from any destructive effect of this matter on the stomach and bowels, but most likely from the great degree of direct and indirect debility, which had been previously induced. Another fact which has been proved by this gentleman's experiments is, that an atmosphere highly impregnated with the odour of the black vomit recently obtained, would not produce fever, apparently under the most favourable circumstances. In forming an opinion as to the event of the yellow fever, we must have in view the nature of the symptoms, the mode of attack, and the age and habit of the patient. Youth anda plethoric state, are invariably circum- stances of danger. A sudden oppression of all the functions at once; great debility ; weak irregular pulse ; sighing ; severe vomiting of dark matter ; tremors of the body when moved, with a tendency to faint on the slightest exertion ; pensive sadness in the countenance ; and a dila- tation of the pupils of the eyes, with coma ; are signs of great danger. Black and fetid discharges by urine and stool, the breath being highly of- fensive, and the appearance of petechia:, portend almost certain death. The symptoms that we may regard as favourable are, a settled state of the stomach, lessened h-jad-ach, eyes lively, appearance of an eruption on the skin, known in tropical climates by the name of prickly heat, free perspiration, copious and high-coloured urine, bilious flux, and sound sleep. No disease, however, exhibits a greater variety of symptoms, and often less to be depended upon, than this; for sometimes it goes on with favourable appearances, then suddenly changes to the worst, and sometimes patients apparently almost in a state of convalescence, expire in a few hours. Dissections of the bodies of those who have died of the yellow fever have shewn the coats of the oesophagus corroded ; the stomach and in- testines loaded with a black fetid matter, or both to be often much in- flated, inflamed, and sphacelated ; the liver, in many cases, to be shrunk to less than half its natural size, very flaccid, and of a colour approach- ing to buff; and the gall-bladder to be flaccid and greyish, having but ORDER I. YELLOW FEVER. 63 little bile contained in it. In some instances, the lungs have been found inflamed ; and the bladder has been observed to be much thickened, and to contain a considerable quantity of urine. In those cases where there has been a discharge by vomiting of a black coagulated matter resembling the grounds of coffee, the gall-bladder and biliary ducts have been found distended with the like substance. The same difference of opinion which arose among the professional gentlemen of Philadelphia, with regard to 'the origin of the disease, seems likewise to have subsisted between them, as to the mode of treat- ment to be pursued ; some recommending and adopting the antiphlo- gistic plan, by bleeding, purging, and a low diet ; some, the stimulant plan, with a liberal use of the bark, wine, opium, and the cold affusion ; and others, again, either purged moderately with calomel, or bled on the first or second day of the fever, and then resorted to a free use of bark, wine, laudanum, and aromatic tonics ; and this practice they adopted on the supposition that the disease was inflammatory in its first stage, and putrid in its last. According to the report of Dr. Rush, this last mode of treatment was scarcely more successful than the tonic and stimulant one ; and that which he found to succeed best was the antiphlogistic, pursued even to a degree of extreme rigour ; for we are given to understand, that although in some instances he allows of one or two moderate bleedings being suf- ficent, still, in most cases, he was in the habit of repeating the operation much oftener, and of-drawing off a considerable quantity each time, even from the poor who resorted to his house for advice. Whether or not bleeding may be practised with advantage to the pa- tient in America, or to what length it may be carried, I am not capable of determining, never having been in that country ; but being well ac- quainted with the climate of the West Indies, from a long residence there, and having often met with the disease (although not under its present malignant form,) I must concur with the objectors, who contend, that bleeding cannot there be resorted to with advantage. If ever it is advi- sable, it can only be where the fever has made its attack on a newly ar- rived Furopean of a full plethoric habit and vigorous constitution, and on the very first appearance of indisposition. Fven here it is probable that it may be more likely to do harm than good. By the communications of Dr. M'Larty of Jamaica, inserted in the Medical and Physical Journal,* we are to understand that the principal practitioners of Kingston consider bleeding as a remedy, which in no case of the fever of new-comers is productive of advantage ; but in most instances of much evil. The case of a seaman who was bled the same morning that he was taken ill, is reported by this gentleman. The patient was a remarkably stout young man, nineteen years of age, and laboured under a violent head-ach, flushings in the face, redness of the eyes, and general uneasiness. A vein was opened in the arm while sitting ; but no sooner had he lost three or four ounces of blood, than surprising syncope compelled him to lie down. In this posture, when * See vol. ix. p-ge ;-. 64 PYREXIAE OR FEBRILE DISEASES. CLASS I. about eight ounces more were taken away, he became so extremely lan- guid as to make it advisable to tie up the arm. He never again got up ; from that moment he continued feeble, and debility advanced pro- gressively in spite of every thing given to obviate it, till the third day, when he died. It seemed, indeed, as if the powers of life had been so exhausted by the loss of blood, as to be incapable of being again roused into action. Dr. Clarke, in his treatise on this disease, mentions, that no native re- covered when the lancet had been used; and Dr. Chisholnie observes, that although the blood drawn, in the cases where this remedy was em- ployed, appeared remarkably florid, and always threw up an inflamma- tory crust of greater or less thickness, and although the pains seemed to undergo a temporary mitigation, yet the consequence, at the expiration of a few hours, was always fatal, notwithstanding the patients were re- markably robust, florid, and generally in the vigour of life. These observations fully justify the remarks which I thought it neces- sary to make under the head of Typhus Gravior, and which I beg leave again to repeat, viz. that the contagion certainly weakens the force of the solids ; for which reason, whenever we suspect a fever to have arisen from this cause, we should proceed with the greatest caution in drawing off blood, even although the symptoms may run high at the beginning, and may seem actually to demand the taking away a consid- erable quantity. Dr. Hector M'Lean, who has likewise published on this fever, is one of the few West India practitioners who approves of bleeding.—He ob- serves, that the determinations to particular organs, which take place in the disease, and which constitute its greatest danger ; the marks of in- flammation, which dissections have shewn in the stomach and biliary organs, evidently point out the propriety of this evacuation. He adds, that experience confirmed its utility ; for his practice was much more successful, after he had adopted blood-letting, than before. By way of caution he mentions, however, that it is only in the very early stages he thinks it advisable to have recourse to the operation, and that if it is not performed as early as the second, or at farthest the third day, he appre- hends it will not be successful. Dr. Jackson, in his Exposition of affusing cold Water in the Cure of Fever, tells us, that he holds a subtraction of blood in large quantity to be a most decisive process in the more intense and concentrated forms of the endemic fever of the West Indies, and that the remedy produces a condition, susceptible of being more readily acted upon afterwards by cold affusion, and the other means we may employ. He adds, that what- ever may be the precise quantity necessary to produce the effect, it must always be supposed to stand high, and seldom lower than thirty ounces ; in strong athletic European soldiers, recently transported to a tropical climate, sometimes far above it. To obviate the inflammatory diathesis which prevails (Hiring the first stage of the disease, and to take off the determination from the head, as weil as to cleanse the prims via: of acrid and offending humours, we may employ gentle purging with a good effect; but as the stomach ORDER I. YELLOW FEVER. 65 is seldom in such a btate as to be capable of retaining those purgatives which are in common use, besides a triple dose being generally necessary to produce sufficient evacuations, it has been found best to administer ca- lomel, either by itself or combined with jalap, as below,* which may be repeated every four or six hours, until a proper effect is produced. In no stage of typhus icterodes can emetics or antimonials be adminis- tered with safety, owing to the irritable state of the stomach which usu- ally prevails. Mercury being known to be a kind of specific In local inflammations of the liver, and there being evidently a great determination of blood to this viscus in the yellow fever, practitioners have been induced to employ it likewise with the view of exciting a degree of salivation ; and where an incessant vomiting has prevented their using calomel in sufficient doses to effect this, they have substituted mercurial frictions. In some of the cases where calomel was administered with this view, its quantity was obliged to be increased to an almost incredible extent. Dr. Chisholme mentions a case, where 400 grains were given before the salivary glands were affected ; and in the Medical Commentaries for the year 1795, Dr. Duncan, of Edinburgh, takes notice, that a correspondent in Jamaica had reported an instance where, within the space of a few days, the pa- tient had taken 270 grains of calomel, and had rubbed in twenty drachms of the strongest mercurial ointment, from which the happiest effects were at last produced. On such authorities, and from the well-known efficacy of mercury in inflammations of the liver, it may, probably, be a proper and valuable re- medy in typhus icterodes. To ensure its success, it should, however, be employed at the very commencement of the disease, and be so conducted as to affect the mouth before the dangerous symptoms of the second stage of the fever make their appearance. Dr. Currie of Philadelphia informs us f that in every case in which he has seen mercury employed after the distressing and dangerous symptoms of the second stage had come on, it aggravated them and increased the danger ; and that when resorted to after signs of what is called putrescency have made their appearance, it has invariably accelerated the fatal event, notwithstanding the declaration of Dr. Chisholme to the contrary. These restrictions apply, however, only to the internal use of mer- cury : for it may be employed externally at any period of the disease, so long as the extremities continue warm, and the absorbents preserve their power. In having recourse to mercury, we may direct half a drachm, or even a drachm of the strongest ointment to be rubbed into the thighs, hams, legs, and arms, every four hours, and we may give t See voi. ix. page 102, of the Med. and Phys. Journal. * ft. Calomel, gr. iv. Pulv. Jalap, gr. viij.—xvj. Syrup. Zingib. q. 3. M. ft. MafT.t. in Pilulas iij. pro dos. dividend.!. I 66 PYREXIAE OR FEBRILE DISEASES. CLASS U calomel internally, either by itself, or combined with opium,* according to the state of the bowels. When a gentle ptyalism takes place, its use ought immediately to be omitted, and only nourishment and wine be giv- en, as all danger is then supposed to be over, and the recovery of the pa- tient to be almost certain. As the safety of the person in typhus icterodes is said thus to depend on the being aide to excite a gentle spitting at an early period, and as large doses of calomel, even assisted by inunction with mercurial oint- ment, have sometimes failed to produce this desirable effect until after a lapse of several days, query, might it not be advisable in desperate cases, where we wish to excite a rapid ptyalism, to give a solution of muriated quicksilver in the manner noticed under the head of Hydrophobia and Gonorrhoea ? That many more patients have recovered by a mercurial treatment, if early adopted, than by bleeding, or any other mode, appears from Dr. Chisholme's excellent work, as well as from the practice of the naval and military hospitals in the different West India islands, and the reports given in by various private practitioners. In typhus icterodes, possibly, there may be congestions in the liver, bothirom an accumulated and im- perfect secretion of bile; and mercury certainly possesses very stimula- ting and deobstruent qualities. At the first commencement of this fever, it is not unusual for a nausea and frequent vomiting to prevail. In such cases, it may be advisable to wash out the stomach with an infusion of chamomile-flowers ; but should they continue throughout its progress, so as to prevent both food and medicine from being retained, stupes wrung in a decoction of bruised poppy-heads, with an addition of one third part of camphorated spirits, may be kept constantly applied to the region of the stomach, and the saline medicine may be administered so as that the effervescence shall take place in the stomach, with an addition of about ten or twelve drops of tinctura opii to each dose. Warm clysters made of mucilaginous and aromatic vegetables infus- ed in boiling water, with an addition of sixty or eighty drops of the tinc- ture of opium, have been attended with the most immediate and sensible benefit in cases where vomiting, oppression about the precordia, and great irritability appeared to be owing to exhaustion from too copious depletion. Dr. Currie mentions, in the communication before alluded to, that in cases of black vomiting, more relief has been obtained by giving from one to four table-spoonfuls of an equal quantity of lime-water and new milk mixed together, every hour, or oftener, than by any other remedy, when employed on the first appearance of that symptom. In cases of great irritability of the stomach, where excessive vomit- ing prevails, the early application of a blister immediately over the part • ft. Calomel gr. ij.—iv. Opii gr. fs. Conscrv. Rofse q. s. M. ft. Pilula pro dos. 4ta hora repctenda.. 9RDER I. YELLOW FEVER. 61 may be attended with the best effect; but this remedy is m general ap- plied too late, and a determination to that important organ is suffered to take place before any attempt is made to counteract it, which at last proves too powerful to be removed. In some instances, the vomiting has been known to cease upon the ap- plication of a large poultice of mustard-flour to the stomach and feet, which occasioned a very extensive and painful inflammation of the skin. By employing cold affusion on the first onset of typhus icterodes, we may, probably, in some instances, arrest its progress, and interrupt the morbid actions, and even in cases of some days continuance we shall be able, by means of it, to abstract heat, induce sleep, and recruit the animal powers. In an advanced stage, it will be best to substitute aspersion, or ablution with a wet sponge. In all cases where there may be the small- est danger of arresting the movements of life by either affusion or asper- sion, a glass of wine, or some other more powerful cordial, should be ta- ken immediately after using the remedy. Dr. M'Lean has seen the best effects to arise from cold affusion in this fever, and tells us, in order to heighten its power, that he often premised the warm bath, and while the patient was sitting in it, he dashed two or three buckets of cold water suddenly on him. In those cases where the remedy was happily applied, the general effects observed from it were, an improved recollection, greater cheerfulness of aspect, a diminution of heat and anxiety, the pulse becoming more full and equable, a tendency to sleep, and sometimes a distinct remission. Some communications of Dr. O'Leary's, through the medium of the London Medical Journal,* further establish the good effects of the affu- sion of cold water in typhus icterodes. We are told by him, that he was ordered, soon after his arrival at Barbadoes, from Europe, to attend the sick of the 70th regiment at Antigua, where on his arrival he found they amounted to about an hundred. They were chiefly affected with the yellow fever, and the mortality had been very great; but on his employ- ing cold affusion judiciously, agreeable to the rules advised by Dr. Currie (see Typhus Mitior and Gravior,) very few died afterwards. He men- tions, that so sensible were the men of its efficacy being superior to any other remedy, and of the relief obtained from it, that in his absence they frequently entreated the officers, where duty led them to visit the hospi- ■ tab to have it repeated on them. In a short history of the yellow fever which prevailed at Norfolk in America and communicated by Drs. Selden and Whitehead to Dr. Miller of New-York,t further testimony in favour of an early use of the cold affusion is produced. From the great benefit which these physicians experienced in their two or three first trials of it, they pro- ceeded to recommend it afterwards with confidence. They have re- ported, that of all those patients to whom they had an opportunity t>l exhibiting this remedy, on or before the second day of the attack, they * See vol. xvi. page 490. 1 f See vol. x. page 266, Mtd.and Phys. Journal. i 68 PYREXIA: OR FEBRILE DISEASES. CLASS I. had the good fortune not to lose one ; but after this period, when the fe- ver had begun to subside, without symptoms of amendment, the affu- sion of cold water seemed to hasten the fatal catastrophe. In no instance did they employ the remedy in question without the exhibition of calo- mel at the same time. No disagreeable effect was produced by combin- ing the use of calomel with the affusion of cold water ; nor did the mer- cury occasion a salivation in a single instance, although the discharge from the bowels was scarcely as great as when it was used alone in the cure of the disease. In temperate and cold climates where we employ affusion, it will be sufficient to take the water fresh from the spring, pump, or the sea ; but in warm climates, in order to command the full and expected effect, it will be necessary that its temperature be reduced to a low degree (as about 40 of Fahrenheit's thermometer) by exposing it to the night air previously, or by adding some salt to it. For reducing the temperature of the body to its natural and healthy standard, and for producing a refrigerant effect in this and other fevers of the typhoid type, we have been informed by Dr. Cumming * that he has derived the highest benefits from either sprinkling or sponging the bodies of ^he sick with ardent spirits, or alcohol, and that he considers these to be in every respect superior to cold water. The effect, no doubt, will be quicker from using spirit, as the evaporation will be more rapid ; but it has been questioned, and very properly, whether or not the great advan- tages which are derived from the cold affusion or washings, are to be at- tributed solely to the abstraction of heat in fever. Should proper means not have been adopted sufficiently early, or should they have failed in procuring the desired effect, and symptoms of putre- faction have made their appearance, our endeavours must be directed to- wards stopping the putrid disposition of the fluids, by the most powerful antiseptics. West India practitioners have of late administered the capsi- cum, in the form of pills, as a stimulant, and with a very good effect. Spirituous baths have likewise been employed. The Peruvian bark must be given in as large doses as the stomach will bear ; and if it will not re- tain any quantity, either in substance, decoction, or infusion, it may then be given in the form of clyster. A pint of decoction, made by boiling an ounce of the powder in a quart of water, until one half is evaporated, may be injected every three or four hours. Acid fruits may likewise be given liberally, and the ordinary drink should be wine, sufficiently diluted with water, and acidulated with lemon or orange juice. The mineral acids might likewise be serviceable in this fever, as well as in typhus gravior and scarlatina anginosa, and I much wish that a fair trial may be made of them, but more particularly the muriatic, in an early stage of the disease. The sooner it is administered, the more likely will it be to prove efficacious. Its wonderful effects in other ma- lignant disorders I have often witnessed ; and typhus icterodes being * Sec Med. and Phys. Journal, vol. xviii. p. 197. ORDER I. YELLOW FEVER. 69 evidently of this nature, is it not reasonable to suppose that its use might prove highly serviceable in this also ? Throughout the whole course of the disease, but more particularly under the above circumstances, the strictest attention ought to be paid to cleanliness, by not only changing the patients linen frequently, and immediately removing and emptying whatever comes from him, but likewise by sprinkling his chamber every now and then with warm vine- gar, and allowing a perfect and free ventilation of air through it. To destroy contagion, and assist in correcting the fetor, the gaseous fumi- p, itions recommended under the head of Typhus Gravior ought to be employed. The patient's strength is to be supported throughout the disease with preparations of barley, sago, tapioca, Indian arrow-root, &c. mixed with wine. Dr. M'Lean observes, that he always found opium to be injurious in the beginning of this fever, although restless nights and anxiety often tempted him to prescribe it in large doses. It procured no settled rest; for a time, the delirium was increased, to which stupor rather than sleep succeeded; and the next day, languor, irritability, and weakness, pre- vailed. When remissions had commenced, and where a return was ap- prehended, he gave opium freely, and apparently with a good effect. It was likewise useful when convulsions took place, and to procure sleep towards the decline of the disease. When a severe head-ach with great depression of spirits is com- plained of, camphor and aether may probably be administered with some advantage. In cases where violent delirium prevails, the application of a blister to the neck or shoulders may be advisable; but where there is only coma, this remedy will not be necessary. When remissions are obtained, and the disease shews a disposition to yield, the Peruvian bark may betaken with advantage, and its use should be continued during the whole stage of convalescence, which is often te- dious and long, owing to the great debility that is always left behind, and from which the patient cannot readily recover, unless by a change of climate. Quassia in a cold infusion is a valuable medicine during convalescence; and here the cold bath may also be serviceable. The Angustura bark has likewise been found a useful medicine to- wards the close of this fever, when debility is the chief symptom. An infusion of it* sits easy on the stomach, and is attended with the most beneficial effects in restoring the strength and appetite. Other tonics may be used at the same time : for these, see Dyspepsia. The fever which lately committed such havoc and devastation at Gib- raltar and Malaga, appears to have been no other than the typhus ic- terodes ; and of all the calamities with which mankind are afflicted, it ft. Tnfus. Cort. Anguft. ^v. Tinift. Cinchon Columb. aa Hji's. M. Capiat Cochl. magna ij. tcr quaterve in die. 70 PYREXIA OR FEBRILE DISEASES. CLASS I. seems the greatest, the plague excepted. As we may justly consider its contagion as one of the most subtile and powerful vapours of the pu- trid kind, every possible endeavour should be exerted as soon as possi- ble to overcome and destroy it. We are, therefore, to have recourse to the fumigations, and other means, which have been noticed under the head of Typhus Gravior. Where the disease breaks out in a garrison, the healthy should im- mediately be separated from the sick, and, if possible, be encamped at a considerable distance. Subjecting the former to cold ablution daily, might possibly enable them to resist the powers of contagion the bet- ter. Having pointed out the most approved method of treating the yellow fever, it seems advisable to offer a few hints, by an attention to which Europeans may often be enabled to withstand its attack, or, if seized, to go through it with the least danger. The plethoric and robust being the subjects most liable to this malignant disease, all such, on their ap- proach to the warm latitudes, ought to be bled in proportion to their strength; but should this have been neglected during the voyage, it may be done immediately on their arrival on shore. It will easily be understood here, that bleeding, as a preparative, will have a very dif- ferent effect from what it would have in a curative intention ; for in the former, it prevents morbid action, and gives time for assimilation; whereas in the latter, it induces debility, and morbid associations, very dangerous to life. After bleeding, if the patient is of a full and plethoric habit, the bow- els are to be opened by some cooling purgative; and if he is naturally of a bilious habit, it may be advisable to premise a gentle emetic. Hav- ing adopted these steps, he may then begin a slight course of mercury, taking from two to four grains of calomel, according to his age and other circumstances, every other night, either in the form of a pill, or that of a powder mixed in some thick vehicle, until the gums become some- what affected. Should the medicine run through the bowels, a grain of opium, or a few drops of tinctura opii, may be added to each dose. When the mouth shews the mercurial action, a dose of cooling' physic ought to be administered after one or two days intermission of the medi- cine. In some constitutions, not easily affected by mercury, it will be necessary to persevere with steadiness, until the system be thoroughly impregnated, for thereon depends the safety of the patient. On the voyage being completed, and his landing, he must observe the greatest temperance in his diet, and carefully guard against any ex- posure to the sun in the middle of the day, and to the cool air of the night, until he becomes somewhat habituated to the climate. The effects of temperance as a prophylactic are strikingly demonstrated by Dr. Chisholme, who observes, that while the yellow fever raged at the island of Grenada, the utility of this was remarkably illustrated by the almost total exemption of the French inhabitants from the disease, whose mode of living, compared with that of the English, is temperate * and regular in an uncommon degree. Dr. Clarke tells us that new settlers, who could be prevailed upon i»HDER I. YELLOW FEVER. 71 to undergo a gentle course of mercury, taking a few laxative medicines, afterwards confining themselves to a moderate use of wine, and living •hiefly on vegetables and fruits for the first two or three months, may rely almost to a certainty on escaping this fever. The remark is, I think, well founded, excepting that, notwithstanding all these precautions, it may arise from contagion, and in this case its virulence, in all proba- bility, will be greatly diminished. Such are the means which have been recommended for enabling Eu- ropeans to withstand an attack of the yellow fever; and by paying a strict attention to the following precautions, which I offer on my own knowledge of the subject, they possibly may be enabled to enjoy a long and uninterrupted state of good health in warm climates, unassailed by any other disease whatever. Men who exchange their native for a dis- tant climate, may be considered in a light somewhat analogous to that of plants removed into a foreign soil, where the utmost^ .care and atten- tion are required to inure them to their new situation, and keep them healthy. Every European, in changing his own climate for a warm one, should, if possible, avoid arriving in his new situation during the rainy season of the year. This, with some small variation, commences in the month of August, and terminates in October. If he has it in his power to choose the place of his residence, he ought to prefer that situation which is somewhat elevated, dry, open to the air and sun, and remote from woods, stagnant waters, or marshy grounds. Most of the towns in the West-Indies, as likewise the factories on the coast of Africa, with some of our settlements in the East-Indies, are, for the convenience of trade, situated on low grounds, either contiguous to the sea, or on the banks of some large river. Swamps and marshes therefore exist in their neigh- bourhood, and when acted upon by a powerful sun, particularly after heavy rains, they send forth noxious vapours and exhalations, which prove a never-failing source of intermittent and remittent fevers, fluxes, Sec. to all descriptions of inhabitants, but more particularly to Europe- ans lately arrived. Persons of this description ought therefore to pass as little of their time as possible in such a situation, and, where obliged by business to resort there by day, they should retire early in the evening, before the dews begin to fall, to one that is elevated, and that has the advantages before described. If no such situation is to be procured without great inconvenience, sleeping on board a vessel in an open road or healthy harbour, will then be preferable to passing the night on shore. Where unfavourable circumstances do not admit of either of these advantages, and new-comers are obliged to remain constantly in an unhealthy spot, they will act prudently in adopting such means as will tend in some measure to lessen the danger to which they are exposed. The highest apartment in the house should be chosen to sleep in ; if fur- nished with a stove, a small fire should be kept in it; and the win- dows that front the swampy ground, if the house is to the leeward of this, are to be kept shut, admitting the light and air by the others. Tobacco may be smoked freely, and about half an ounce of the com- 72 PYREXI.E OR FEBRILE DISEASES. CLASS I. pound tincture of bark be taken every morning on an empty stomach, repeating the dose again in the evening. The diet of Europeans newly arrived in a warm climate, should consist of a greater proportion of vegetable food than of animal, avoiding such articles of the latter as are either salted, or very highly seasoned. To all such, a free use of ripe sub-acid fruits will be highly proper, as they will not only assuage thirst, but serve to correct any tendency in the fluids to putrefaction. The unbounded hospitality of the islanders in the West Indies, fre- quently proves a source of much evil and danger to new-comers ; for they are no sooner arrived, than they are engaged by invitation in a daily round of visiting and feasting, committing therein excesses, which, to- gether with an unavoidable exposure to the dews of the evening, are not unfrequently productive of a severe attack of illness. To all new set- tlers I beg leave; therefore, to recommend a very moderate indulgence in the delicacies of the table; a spare and temperate use of all kinds of vinous and spirituous liquors; a proper self-command in sensual gratifi- cations; the carefully avoiding any exposure to a current of air, or mois- ture, particularly when the body is heated by exercise ; their return ear- ly to their respective homes before the night dews begin to fall; and their cautiously obviating a costive habit, by taking from time to time some gentle cooling laxative, until they are able to establish a proper regularity in this point, by visiting the temple of Cloacina at certain hours every day, and soliciting natural evacuations. The custom of going early to bed, and rising betimes in the morning, is conducive to health every where, but more especially so in hot coun- tries. If gentle exercise, either on foot or horseback, be added in the morning, it will prove highly salutary ; and should cold bathing be first used, the body would thereby be much invigorated, and rendered less susceptible of external impressions. Where the convenience of a proper bath is not to be procured, water properly cooled, by having been ex- posed all night to the air in pots, or a tub, may be thrown over the bo- dy. Minor ablutions at other periods in the day, may also have a good effect. Dancing is an amusement cautiously to be shunned by Europe- ans newly arrived. The dress of such persons should consist of coats made of thin wool- len cloth, with waistcoats and breeches of dimity or nankeen. What is worn next to the skin should be made of cotton in preference to linen, as this last, when moistened with perspiration, in consequence of any severe exercise, is very apt to convey a sense of chilliness, when the body becomes inactive again. Calico shirts will therefore be preferable to linen ones. Those who are afflicted with rheumatic pains may substi- tute a waistcoat of flannel next to the skin. New settlers should ob- serve the greatest precaution in changing their clothes of every kind as soon as possible after-getting wet, a circumstance too frequently made light of and neglected, and which often, therefore, proves the cause of an attack of some severe disease. » The rules to be observed for preserving the health of seamen in warm 1 climates, are inserted under the head of Scurvy. ORDER II. INFLAMMATIONS. 75 ORDER II. Of INFLAMMATIONS, or PHLEGMASIA. 1 HE character of this order of diseases is Synocha fever, with inflam- mation or topical pain ; the function of an internal part being at the same time injured ; the blood upon venesection exhibiting a buffy surface. Before I proceed to speak of the different inflammatory diseases to which the human frame is liable, it seems proper to make a few observa- tions on inflammation in general, and likewise to point out the different species of it which are to be met with in practice. In every inflammation there is an increased action of the blood-vessels, propelling forward a greater quantity of blood than usual into the part affected, by which means its sensibility and irritability are increased, its vessels distended beyond their natural tone, and the circulation of blood through them rendered more rapid. A variety of opinions have however been entertained with respect to the nature of inflammation. Hoffman, and Dr. Cullen, supposed the proxi- mate cause to consist in an increased action of the blood-vessels, with a spasmodic stricture of their extremities ; but as the beginning veins are in a state of over-distention in an inflamed part, as well as the arteries, it is evident that no such spasmodic stricture can exist. Dr. M'Bride's hy- pothesis on the nature of inflammation is, that, besides the action of the blood-vessels being increased, the resistance to the course of the blooti is diminished ; and a third doctrine has lately been advanced, which teaches, that instead of an increase of action in the vessels of the part, as is com- monly supposed, the direct contrary takes place, and that there is a defi- ciency of action and paralysis of the vessels affected, instead of spasm. The principal argument in favour of this hypothesis is drawn by its foun- der, Mr. Latta,* from the swelling of the inflamed part, which he attri- butes to a partial stagnation of blood ; but the great heat of the part, the throbbing pain, and, in many cases, the accelerated action of the whole sanguiferous system, clearly point out an increase of action in the vessels. When an inflammation is confined to one particular part, without pro- ducing any general affection in the system, it is called local or topical ; but when it produces effects on the whole system, it is known by the name of general inflammation. Inflammation is properly of two kinds ; viz. the phlegmonous and erysipelatous. By the phlegmonous is to be understood, an inflam- matory circumscribed affection of the skin and cellular membrane, with a swelling rather prominent in the centre and of a bright red colour, at- tended with pain and distention, and in winch any effusion that happens to take place, is usiuily converted into pus. By the erysipelatous is implied an inflammatory affection confined principally to the skin, when * See his Syftem of Surgerv. K 74 PYREXIAE OR FEBRILE DISEASES. CLASS I. seated outwardly, and to the mucous membrane when internally, with hardly any evident swelling, being of a mixed red colour, readily disap- pearing upon pressure, but quickly returning again, the redness being of no regular circumscription ; but spreading unequally, with a pain like to that of burning, which gives rise to a number of small blisters, and ter- minating usually in a desquamation of the scarf skin, and now and then in gangrene, but never in a suppuration, unless combined with phlegmon. Besides these differences in the circumstances of these two kinds of inflammation, there is another very evident one, which is, that a phlegmon, when considerable, is generally accompanied with more or less of the symptoms of general inflammation ; whereas erysipelas is usually attend- ed with symptoms of irritation when perfectly pure, from which circum- stance it will be necessary to adopt a different mode of treatment in each of them. Of the erysipelas there are two cases : one, when it is merely an affec- tion of the skin alone with very little of the whole system, which is called erythema; the other, when it is an affection of the system, and is named erysipelas. Persons in the prime of life and in full health and vigour, and of a ple- thoric habit of body, are most liable to the attacks of phlegmonous inflam- mation ; whereas those advanced in years, and those of a weak, irritable, and spare habit, are most apt to be attacked with erysipelatous inflamma- tion. The more moderate the different symptoms, the better is the chance of the inflammation terminating by resolution ; when it does not readily yield to proper remedies, and is unusually obstinate or deep-seated, there is reason to believe that it will terminate by suppuration. When the symp- toms are very violent, especially if the inflammation is of the erythematic kind, there will be reason to fear gangrene. Resolution is always a favourable termination ; suppuration is also fa- vourable, if the inflammation be external and the habit good, but in inter- nal inflammations we shall find it is generally to be dreaded. Internal gangrene is always fatal. It is only when the gangrene is external that medicine can avail, and then it often fails. Of PHLEGMON. X HIS species of inflammation is occasioned by the application of sti- mulants, such as fire or burning ; by external injuries, either bruising, wounding, over-stretching, or compressing the parts ; by extraneous substances which have lodged, and either by their form, bulk, or quality, produce irritation ; by the application of cold ; and by any thing that de- termines an increased impetus of blood to the part. The chief seat of the phlegmon is the inner surface of the true skin and the cellular substance contiguous to it, from which it extends to the adjoining parts of the cellular membrane and skin , so that the surface soon assumes a florid colour, the tumour at the same time extending both in depth and circumference. • RDER II. PHLEGMON. 75 It comes on with an itching, dryness, redness, and increased heat and circulation in the affected part; which symptoms are shortly succeeded by a circumscribed tumour, through which shooting and throbbing pains extend. If the inflammation runs high, and is of considerable extent, then an increased action of the heart and arteries takes place ; the pulse becomes full, hard, and quick ; the skin dry and hot; great thirst arises, and a feverish disposition ensues. A phlegmon usually terminates either by resolution, suppuration, or gangrene. By resolution we are to understand the natural cure or going off" of the inflammation by a gradual cessation of all the symptoms, the state and texture of the part remaining entire. By suppuration is im- plied the conversion into matter or pus of the lymph and blood which have been extravasated in the adjoining cellular substance, in consequence of which a cavity, termed an abscess, is formed. By gangrene is meant the total loss of sensibility, irritability, and circulation in the part, with a state approaching, more or less, to putrefaction in the vessels and mus- cles, as well as in the effused matter. Such are the most common terminations of this species of inflamma- tion, but in the scnools a fourth has been noticed, which is by a scirrhus, implying an indolent, knotty hardness of the part, unattended by any dis- colouration, but accompanied with lancinating pains, the tumour after a time ulcerating and becoming cancerous. This termination of inflam- mation is, however, confined to glandular parts. Wnen the patient is seized with reiterated shiverings ; when the fever and inflammatory appearance cease quickly without any perceptible rea- son ; wnen a heavy, cold, and dull uneasiness is experienced in the part affected, instead of acute pain ; when the most elevated portion of the tumour appears soft and white, while the rest has its redness increased ; and wiien at the same time the surgeon can feel the fluctuation of a fluid, we may be assured that a termination in suppuration has ensued. The latter symptom, however, occurs only where the matter lies superficially; but a man endued with great nicety of touch may be able, in many cases, to perceive the undulations of matter, even when deeply lodged. In most instances, indeed, of this nature, the quick subsidence of all the in- flammatory symptoms, the repeated rigors, and the sense of weight and coldness in the part, are the only obvious appearances ; but the pa- tient being afterwards attacked with emaciation, nocturnal sweats, and other hectic signs, very clearly point out that there is a hidden collection of matter. The symptoms which denote the termination of inflammation in incipient mortification are ; first, a sudden diminution of the pain and sympathetic fever: secondly, a livid discolouration of the part, and which, from being yellowish, becomes of a green hue : thirdly, a de- tachment of the cuticle, under which a turbid fluid is effused : and fourthly, the swelling, tension, and hardness subsiding, while, at the same time, a crepitus is perceived on touching the part, owing to a generation of air in the cellular membrane. The term gangrene has been applied to the disease in this stage ; but when the part has become black and fibrous, 76 PYREXIA OR FEBRILE DISEASES. CLASS I. and destitute of natural heat, sensation, and motion, it is denominated sphacelus. In phlegmon, our prognostic should be drawn from the symptoms which are present, as well as from the seat of the inflammation. If ihe inflammatory appearances cease suddenly, and blisters discharging a thin ichorous matter arise, together with the part affected losing its sen- sibility and becoming of a livid colour, then a gangrene will certainly en- sue. On the contrary, a gradual abatement of the inflammatory symp- toms by a termination, either in resolution, or a suppuration where pro- per pus is formed, may be regarded as prognosticating a favourable event. This remark holds good, however, only with respect to external suppurations, as internal ones are always dangerous, and not unfrequent- ly fatal. In the incipient state of a phlegmon, it will always be proper to attempt the cure by procuring a resolution of the tumour, if possible ; and there- fore an early attention should be paid to the removal of the cause which has excited it, as likewise to obviate the phlogistic diathesis, either of the whole system or of the particular part which is affected. If the inflammation has proceeded from a lodgment of some extrane- ous body, such as a bullet discharged from any kind of fire arms, or has been occasioned by a thorn or splinter of wood, it ought immediately to be removed, and, if necessary, thcwound must be dilated to such a size as to admit of its being readily got at. In cases of local inflammation, the phlogistic, diathesis may be obviated by drawing a proper quantity of blood immediately from the neighbour- hood of the part affected, either by scarifications with the aid of cupping- glasses, or by the application of several leeches, which will be the prefer- able way if they can be procured ; promoting the flow 01 b;ooa by cloths dipped in warm water, and renewed as soon as they cool : but in internal inflammations, it will be advisable to draw blood from the sys- tem, by opening a vein or artery, taking care to proportion the quantity drawn off'to the age and strength of the patient, as well as to the sever- ity of the symptoms. With a view of obviating the phlogistic diathesis, we may likewise have recourse to purgative medicines. In inflammations of any of the external parts of the body, as likewise in those of the head and chest, a frequent use of purgatives will be attended with a good effect : but in a similar affection of the bowels, active purgatives should be administered with due caution. Those of a mild nature, together with emollient laxa- tive clysters, deserve a preference. To assist these means, and terminate the inflammation by resolution, if possible, it will be right to make use of some drscutient application, as remedies of this nature are, in some mild cases, of themselves suffi- cient to disperse an incipient phlegmon. In cases of violent contusion or fracture, where a considerable degree of tension prevails, a poultice of rye-meal or crumbs of bread moistened with the aq. lithargyri acetati composita, properly diluted with water (viz. about 80 drops of the former to about a pint of the latter,) will be a very proper application, ORDER II. PHLEGMON. 77 and this may be renewed twice or thrice a day, until the swelling and in- flammation subside ; but in a common phlegmon, or where the part is so tender and painful as not to be able to bear the weight of a poultice, we must be content to apply pieces of soft linen moistened in some sedative application.* It is to be understood, however, that these remedies are to be applied cold, whether we use poultices or wet pledgets, and that they are 10 be renewed as often as they become stiff, hard, or warm. The application of cold is indeed one of the most powerful means which we possess for abstracting heat and subduing inflammation, and it has been carried so far in some instances, that pounded ice and snow have been employed for the purpose. When these are not to be obtained, we may substitute as a refrigerant, pieces of soft linen moistened in a solu- tion of nitre and muriated ammonia in water, or even in simple cold wa- ter ; but they are to be renewed frequently. In some cases of phlegmon, the pain and inflammation are so violent as to deprive the patient of his natural rest. When this happens, we may give opiates both with advantage and safety, provided sufficient eva- cuations have been premised. The dose, however, should be considera- ble ; otherwise opium, instead of proving serviceable, will have a contra- ry effect. About fifty or sixty drops of tinctura opii may be given to an adult, an hour or two before bed-time, and in a like proportion to those of a younger age. Children at the breast may take a small quantity of the syrup, papav. albi, instead of the tinct. opii. When the inflammatory symptoms run so high as to affect the gener- al system, it is not unusual for a febrile disposition to prevail. In such cases, we may order some febrifuge medicine to be taken every three or four hours, combined with nitre.f If, notwithstanding these means, the tumour should shew an evident tendency to suppurate, we are then to accelerate its progress by the ap- plication of warm emollient cataplasms, which ought to be renewed three or four times a day. If linseed can be procured, a poultice made of this, slightly bruised and boiled up with milk and water, will be preferable, on account of its emollient quality : but when it is not to be obtained, the white . bread poultice, with a small addition of oil, may be used ; previous, however, to the application of the poultice, • ft. Aq. Ammon. Acetat. ----Diftillat. Spirit. Vinos. Re&ific. aa 31J. M. Vel ft. Ammon. Muriat. £j. Acet. Diftillat. 31J. Spirit. Camphorat. ^j. Aq. Litharg. Acetat. C gutt. xx. M. ft. l.otio. f ft. Nitri Purif. £fs._3J. Aq. Fervent. J viij. Antimon.Tartarifat.gr. ij. Syr. Violas ^j. M. ft. MiftuiM cujus fumat Cochl. maorna ij. pro. dos. Vel ft. Hauft. Salin. 5jfs. Nitri gr. x.—xv. Vini Antimon. gutt. xij. Syrup. Simpl. ^j. M. ft. Hauftus ^tia quaque hora lumen- 78 PYREXIA!: OR FEBRILE DISEASES. GLASS I. the part affected should be well fomented with flannels wrung out of a warm decoction or infusion of emollient herbs.* When the suppuration is completed, and the tumour is become very soft to the toucli, and is near the surface, it is to be opened, either with a lancet or a trocar, in the part which is most dependent, taking care to press the matter perfectly out ; after which the wound is to be dressed with dry lint, and a pledget spread with the unguentum resins flavx to be laid over all. If the wound does not heal readily, the cinchona with other tonics should be used, till the patient is restored to health. in very large abscesses, particularly in that of the psoas muscle, it has been found a judicious practice to evacuate the matter by means of ase- ton, or by a flat trocar in a canula, which is to be insinuated between the skin and cellular membrane for some space, and then to be plunged in a slanting direction down into the abscess, leaving the canula, and with- drawing the trocar. The orifice in the skin and deep-seated parts by this mean will not be in a direct line, and the severe constitutional symptoms which are apt u> arise from an exposure of extensive cavities to the air, are thereby avoided. In the like cases, it will also be proper to direct the patient to fake, at least, an ounce of Peruvian bark a day, in order to pro- mote the production of proper pus ; and to support his strength under the discharge, anutritive diet, with a moderate use of wine, should be allowed. The matter of an abscess is either absorbed or discharged, but more generally the latter; and in either case, if it is well conditioned, the cavi- ty is gradually filled up by an operation of nature, which is termed gran- ulation, from the new parts appearing in the form of small red grains. When this process goes on favourably, the granulations are of a florid red colour, and proceed in a regular manner till the cavity is accurately filled, its edges (if the matter of the abscess has been discharged exter- nally) being even, or nearly so, with the sound skin. When the granulation is too languid, it is to be forwarded by the same means which promote a favourable secretion of pus. It is however sometimes too luxuriant, forming irregular masses, which project be- yond the lips of the wound. In such cases it will be necessary to check the granulating process, and destroy the projecting parts by escharotics ; but for more particular information on this head, I must refer to the works on surgery. Should phlegmonous inflammation have terminated in gangrene, we are then to stop the progress of the mischief, and promote the speedy separation of the dead parts from the living. To effect this, it was for- merly customary to make slight scarifications, and afterwards to apply warm antiseptic fomentations, and poultices ; but modern practitioners, * ft. Flor. Chamxmel. Fol. Althaeas aa £j. Papav. Alb, Exficcat. ^fs, Aq. Ferventis Ibiv. M. ft. Fomentum. ORDER II. PHLEGMON. 79 particularly Mr. Bell, and the late Mr. John Hunter, have highly disap- proved of this mode of proceeding, and recommend a reliance to be plac- ed on a liberal use of the Peruvian bark, together with a nutritive diet, and such a quantity of wine as will be sufficient to keep up the pulse, and induce the necessary slight degree of inflammation. To give energy to the system, to restore vitality to the affected parts, and to lessen the mor- bid irritability in them, are the objects which we should keep in view in all cases of gangrene. Where gangrene arises from debility, opium frequently proves useful; and as it by no means counteracts the effects of the bark, it may be given along with it: indeed opium will prove generally beneficial, and particu- larly in that variety of the complaint in which no previous inflammation existed, but which is accompanied by violent pain The efficacy of the bark is in every instance indeed much increased by its junction with opium in these affections, and therefore they catu.ot be too early employed in the curative plan of treatment conjoined together. In cases of gangrene, accompanied with convulsive spasms, or arising from any local injury, such as a fracture, &c. producing irritation, a com- bination of musk with ammonia has been found by Mr. White of Man- chester, and other practitioners on his recommendation, to have been at- tended with a happy effect in abating subsultus tendmum, stopping the progress of mortification, and occasioning the dead parts to separate from the living. A bolus consisting of ten grains of musk, and the same quantity of ammonia, repeated every three hours, is what is advised on such occasions. Musk combined with the volatile salt of amber, might probably prove a still more powerful remedy for checking the progress of gangrene arising from any local injury producing irritation. By modern practitioners we are instructed to keep the parts cool, and that all applications to them ought to be cold, instead of warm, as was formerly practised. As an application to parts in a gangrenous state, there can be none better than a poultice made by stirring into an infusi< n of malt (such as may be readily obtained from the ale or porter bieweis) as much oatmeal as is required to make it of a proper thii kness, and af- terwards adding about a spoonful of yeast.* In applying it, due care must be taken not to bind it on too closely, as the fermentation, a short time after its application, will be considerable, ant! its bulk, of course, so increased, as to put the cloths and bandages which confine it, very much on the stretch. The cataplasma carbonis (which is prepared by mixing two ounces of wood charcoal, reduced to a very fine powder, with half a pound of the common farinaceous poultice) is another application which has lately been much used in gangrenous ca^ts, as well as in sweetening fetid ulcers, and disposing them to granulate favourably. By some communications through the medium of the Medical and Physical Journal,! we are given to understand that the progress of • This i* the Cataplafma Effervefcens of the Pharmacopoeia Chirurgica. f Sec vol. xi. page 206. SO PYREXIA OR FEBRILE DISEASES. CLASS I. mortification has been checked, and the offensive stench issuing from the wound entirely removed in a very short space of time, by sprinkling the diseased parts thickly over with nitre pulverised very fine. In the in- stances alluded to, the dressing was renewed twice or thrice a day. When the diseased parts separate and slough off, dry lint is to be laid on the wound with a pledget, spread with some digestive ointment, ap- plied over all. In the second volume of the Transactions of a Society for the Improve- ment of medical and chirurgical Knowledge, is inserted a paper from Dr. Harness, at that time a Physician to the Fleet, on the good effects of the application of the gastric fluid of graminivorous animals to parts in a gan- grenous state. By this gentleman we are informed, that he found its application to succeed in more than a hundred cases of sphacelus in en- tirely removing the sloughs, and occasioning healthy granulations. As a gentle stimulus to parts in a state of gangrene, where any is thought proper, and in preference to warm gums and balsams, ardent spirits, and even alkohol, Mr. B. Bell advises * the use of a weak solu- tion of sal ammoniac (ammonia muriata) in vinegar and water. We are informed by him that a drachm of the salt, to two ounces of vinegar, and six of water, form a mixture of a proper strength for every purpose of this kind ; but the degree of stimulus can be easily either increased or diminished, by using a larger or smaller proportion of the salt. In similar affections of the toes and feet, Mr. Pcftt very much disap- proves of all stimulating applications, and in their stead recommends soothing and emollient ones,f and this with the view to avoid exciting pain. A case which somefime ago came under my inspection has, in my mind, decidedly established the superiority of the latter mode of treat- ment over the former. On meeting, in consultation, the professional gentlemen who had the management of it, I strongly urged the necessi- ty of soothing and emollient applications (the good effects of which I had before witnessed on other similar occasions ;) and these were adopted for a time with the greatest relief to the sufferings of the patient, as likewise arresting the progress of the mortification. Not happening to call again for three or four days, this prudential mode of proceeding was discontinu- ed by the chief surgeon, and a stimulant one was substituted, to which plan, as a disciple of the old school, he was strongly bigoted. The consequences were, that the pains, which had before been much alleviated, became highly aggravated, and the mortification, which had been arrested in its progress, spread so very considerably as to threaten the greatest danger. Being now thoroughly convinced of his error, he was glad once more to have recourse to the soothing and emollient plan ; by a strict pursuance of which ; by administering opium to the amount of six or efeht grains a day, so as to keep up a constant effect; by al- lowing a iiberal use of wine ; and by giving the Peruvian bark in sub- • See his Syftem of Surgery, vol. i. p.' 112. f See his Chirurgical Works, p. 799 and See. ORDER II. THLEGMON. 81 stance, in the quantity of about an ounce a day, joined with camphor (which combination seems to possess strong antiseptic powers,) the pa- tient appeared for many weeks to have a great chance of recovering. The prospect, however, proved delusive ; for he soon afterwards paid the debt of nature. From his having been withdrawn from under my care during the last six weeks, I cannot speak as to the mode of treatment which was latterly pursued. It seems almost superfluous to observe, that it was found necessary to obviate the effect of the opium on the intestines, by a frequent use of some mild laxative or emollient clyster, so as to procure one or two eva- cuations daily. In the early stage of the disease, the cataplasma effer- vescens was employed, and seemingly with a most happy effect. In this species of mortification, Mr. Pott reports, he found the Peruvi- an bark had little or no influence, but that opium in large doses, frequent- ly repeated, proved an effectual remedy in many cases. To give the pa- tient every possible chance of recovering, it will be best, I think, to ad- minister both. The termination of inflammation in a scirrhus is (as was before observ- ed) confined to glands. Upon a gland becoming scirrhous, we should use every means to disperse it, if possible ; and if we cannot effect this, then we should endeavour to keep it stationary, and prevent its ulcera- ting and degenerating into a cancer. In some cases of recent scirrhus, topical bleeding frequently repeated, by the application of several leeches, has been found highly serviceable.! A gentle course of mercurial friction applied in the neighbourhood of the part affected, has likewise, in some recent cases, been attended with a happy effect; an instance of which occurred to me some years back. A.P. residing at Shennington, in Gloucestershire, aged 43 years, of a corpulent but irritable habit, was, about six weeks previous to her application to me, attacked with a tumour in her left breast, which had, during that time, gradually increased in size, and had at length become knotty and irregu- lar, and was attended with severe lancinating pains extending into the ax- illa, with every other appearance of scirrhus, and such had it indeed been pronounced by the surgeon who had been called upon for his advice. Un- der the above circumstances, and without any hopes of success, I must acknowledge, I directed her to rub in, morning and night, about the size of a bean, of anointment composed of anounceof the unguentum hyifeur- gyri fortius, and the same quantity of the unguentum cene, in which two drachms of camphor were dissolved, and to take, twice a day, two of the pills advised below,* washing them down with half a pint of the decoctum sarsaparillx compositum, with the addition of thirty drops of the vinum antimonii. She was likewise enjoined to keep her body open, to make f See Mr. Henry Fearons Treatife on Cancers. * ft. Extraft. Cort. Peruv. gij. ---------Cicutai 3J. M. ft. M..fla in pilulas Ix. dividenda. L 82 PYREXIAE OR FEBRILE DISEASES. CLASS !■ use of a spare diet, consisting principally of vegetables and milk, and to abstain from all spirituous and fermented liquors. After a pursuance of this plan for about three weeks (some slight affection of the sahvaiy glands having taken place during that period,) the tumour wholly disap- peared, as well as every other symptom. With regard to the use of mercury in scirrhous tumours, it is to be observed, that, whether given internally or applied externally, it can only be of service in the first stage of the affection, when simple obstruction, and not altered organization, forms the disease. By its tendency to has- ten ulceration (a natural consequence of its action,) it might prove highly prejudicial in cancerous cases ; but in those of a scirrhous nature which are of a recent date, mercury joined with antimony, and given in small doses, long continued, with the strict observance of a spare regimen, has sometimes proved successful. If the tumour, on a fair trial of these or any other means which the prac- titioner may think proper to employ, should not disperse ; but, on the contrary, shew an evident tendency to ulcerate, and degenerate into a cancer, then, in my opinion, the sooner it is extirpated, the better will it be for the patient, as it is more than probable, that the affection is not originally connected with the system, but is merely local, and that the constitution or habit does not become tainted, until ulceration takes plate. The treatment of a scirrhus terminating in ulceration is noticed under the head of Cancer. •e. Of ERYSIPELAS. JL HIS disease is an inflammatory affection, principally of the skin, when it makes its appearance externally, and of the mucous membrane when it is seated internally ; and is more liable to attack women and children, and those of an irritable habit, than men, or those of a plethoric and ro- bust constitution. It is remarkable that erysipelas sometimes returns periodically, attack- ing the patient once or twice in the year, or even once every month, and then by its repeated attacks it often gradually exhausts the strength, es- pecially if he be old and of a bad habit. When the inflammation is principally confined to the skin, and is un- attended by any affection of the system, it is called Erythema ; but when the system is affected, it is named Erysipelas.* It sometimes happens that the inflammation extends to the cellular membrane beneath the skin, whence a real phlegmon and collection of matter become joined to the erysipelas; but this is mostly the case where there has been a previous scratch or injury of the skin. Every part of the body is equally liable to erysipelatous inflammation, but it more frequently appears on the face, legs, and feet, than any * In Dr. Cullen's nofological arrangement of difeafes, eryfipelas is placed among the exanthemata, but I have thought it beft not to fcparute it from erythema, that the tw» fpecies may thereby be fcen at one view. ORDER II. ERYSIPELAS. 83 where else when sealed externally ; and it occurs oftener in warm cli- mates than phlegmonous inflammation. It is brought on by the several causes that are apt to excite inflamma- tion ; such as injuries of all kinds, the external application of stimulants, exposure to cold, an obstructed perspiration ; and it may likewise be oc- casioned, perhaps, by a certain matter generated within the body, and thrown out on its surface. A particular state of the atmosphere seems sometimes to render it epidemical, as we often find the angina scarlatina, which is a species of internal erysipelas, prevail as such. in slight cases, where it attacks the extremities, it makes its appear- ance with a roughness, heat, pain, and redness of the skin, which be- comes pale when the finger is pressed upon it, and again returns to its former colour, when it is removed. There prevails likewise a small febrile disposition, and the patient is rather hot and thirsty. If the attack is mild, these symptoms will continue only for a few days, the surface of the part affected will become yellow, the cuticle or scarfskin will fall off in scales, and no further inconvenience will perhaps be experienced ; but if the attack has been severe, and the inflammatory symptoms have run high, then there will ensue pains in the head and back, great heat, thirst, and restlessness ; the part affected will slightly swell ; the pulse will become small and frequent; and about the fourth day, a number of little vesicles, containing a limpid, and in some cases a yellowish fluid, will arise. In some instances, the fluid is viscid, and instead of running out, as generally happens when the blister is broken, it adheres to, and dries upon the skin. In unfavourable cases, these blisters sometimes degenerate into ob- stinate ulcers, which now and then become gangrenous. This, how- ever, does not happen frequently ; for although it is not uncommon for the surface of the skin, and the blistered places, to appear livid or even blackish, yet this usually disappears with the other symptoms of the complaint. The period at which the vesicles shew themselves is very uncertain. The same may be said of the duration of the eruption. In mild cases it often disappears gradually, or is carried off by spontaneous sweating. In some cases, it continues without shewing any disposition to decline for twelve or fourteen days, or longer. The trunk of the body is sometimes attacked with erysipelatous in- flammation, but less frequently so than the extremities. It is not un- common, however, for infants to be attacked in this manner a few days after birth ; and in these it makes its appearance about the genitals. The inflamed skin is hard, and apparently very painful to the touch. The belly often becomes uniformly tense, and sphacelated spots sometimes are to be observed. From disseccions made by Dr. Underwood, it ap- pears, that in this form of the disease the inflammation frequently spreads to the abdominal viscera.—See Infantile Erysipelas. Another species of erysipelatous inflammation which most usually attacks the trunk of the body, is that vulgarly known by the name of Shingles, being a corruption of the French word ceingle, which implies 84 PYREXIA OR FEBRILE DISEASES. CLASS I. a belt. Instead of appearing an uniform inflamed surface, it consists of a number of small pustules, extending round the body a little above the umbilicus, which have vesicles formed on them in a short time. No danger attends this species of erysipelas, as I have experienced in innu- merable instances. When erysipelas attacks the face, it comes on with chilliness, suc- ceeded by heat, restlessness, thirst, and other febrile symptoms, with a drowsiness or tendency to coma or delirium, and the pulse is very fre- quent and full. At the end of two or three days, a fiery redness appears on some part of the face, and this at length extends to the scalp, and then gradually down the neck, leaving a tumefaction in every part the redness has occupied. The whole face at length becomes turgid, and the eye- lids are so much swelled, as to deprive the patient of sight When the redness and swelling have continued for some time, blisters of different sizes, containing a thin colourless acrid liquor, arise on different parts of the face ; the skin puts on a livid appearance in the blistered places ; but in those not affected with blisters, the cuticle, towards the close of the disease, falls off in scales. No remission of the fever takes place on the appearance of the inflam- mation in the face ; but on the contrary, it is increaseu as the latter ex- tends, and both will continue probably for the space of eight or ten days. In the course of the inflammation, the disposition to coma and delirium is sometimes so increased, as to destroy the patient between the seventh and eleventti days of the disease When the complaint is mild, and not marked by a fatal event, the inflammation and fever generally cease gra- dually without any evident crisis. If the disease arises in a bad habit of body, occupies a part possessed of great sensibility, is accompanied with much inflammation, fever, and delirium, and these occur at an early period, we may suppose the patient exposed to imminent danger. Where translations of the morbid matter take place, and the inflammation falls on either the brain, lungs, or ab- dominal viscera, we may entertain the same unfavourable opinion. Ery- sipelas never terminates in suppuration, unless combined with a conside- rable degree of phlegmonous inflammation, which is however sometimes' the case ; but in a bad habit, it is apt to terminate in gangrene, in which case there will also be great danger. When the febrile symptoms are mild, and unaccompanied by delirium or coma, and the inflammation does not run high, we need not be apprehensive of danger. Where the disease has occupied the face, and proves fatal, inflammation of the brain, and its consequences, are to be met with on dissection. Great diversity of opinion has prevailed among the practitioners in medicine, concerning the mode of treatment to be adopted in erysipelas; some pursuing the same antiphlogistic plan advised in phlegmonous in- flammation ; others again, disapproving of all evacuations, and treating it as a disease dependent on irritability. To reconcile these jarring opinions, I shall consider the complaint as sometimes combined with phlegmonous inflammation, as now and then happens, when it arises in a full plethoric habit. In such a case, ORDER II. ERYSIPELAS. 85 if the skin is hot and dry, the pulse full, strong, hard, and frequent, and the head affected with stupor or delirium, it will undoubtedly be proper to have recourse to bleeding, cooling purgatives, diaphoretic medicines, > and the strict observance of an antiphlogistic regimen, as recommended in phlegmon. Topical bleeding, however, by means of leeches, which proves so useful in other varieties of inflammation, is not admissible in erysipelas, as the orifices by which it is drawn, are very apt to degenerate into those troublesome ulcers, which the disease, when it terminates in effusion, sometimes produces. When we have occasion, therefore, to draw off blood, in order to counteract the inflammatory diathesis, we must do it by opening a vein ; and where the head is the part diseased, the jugular will be the most proper. As to the quantity to be taken away, we are to be regulated in this, by the violence of the inflammatory symp- toms, the appearance of the blood when drawn, and the strength of the patient. If the disease is perfectly pure or local, does not affect the head, is unaccompanied with symptoms of general inflammation, and has arisen in a weak irritable habit, or is accompanied with a fever of the typhoid kind, bleeding will be highly improper. The same observation will likewise apply to the making use of strong pmgatives ; but although I disapprove of such medicines in the latter instance, still it will be right to keep the body open by gentle saline laxa- tives, so as to procure one or two motions daily. Where the inflammation is of a piilegmonous nature, and the head is much affected, a liberal use of active purgatives will undoubtedly be advisable. In those cases where the fever and inflammation run high, diaphoretic medicines will be proper, and they may be given conjoined with nitre, as advised in phlegmon, or as directed under the head of Inflammatory Fever. As erysipelatous fevers often terminate by sweat, mild diaphoretics, with plentiful dilution, become a necessary part of the treatment, and should never be neglected. In those cases where the head and face are affected, and coma prevails, the semicupium, together with sinapisms applied to the feet, will be highly advisable. It has been observed, that when the disease has made some progress, blisters of various sizes usually arise. The most proper application will be some dry mealy powder, such as starch, wheat-flour, oatmeal, or chalk ; but oatmeal may perhaps be preferable to the rest, on account of its not being likely to cake and become hard by the humour which weeps from the parts affected. Probably external applications that re- duce the heat of the skin, such as linen cloths wetted with cold water, might oe employed with advantage. Any application of the stimulant kind, as solutions of lead, copper, or of alum, used early in the disease, must be injurious. When effusion is found to have occurred in any considerable quan- tity, it ought to be discharged by making a small opening in the most dependent part. It has been usual to employ emollient fomentations S6 PYREXIAE OR FEBRILE DISEASES. CLASS I. and poultices in this state of the complaint, in order to bring on a proper suppuration ; but the effusion which sometimes happens in erysipelas, not being of a nature to be converted into pus, as in the case of a pure phlegmon, they certainly cannot prove serviceable. Theceratum lithargyri acetati, or the unguentum cerussae acetatx, will be the best applications. These are the means to be employed when erysipelas happens to be combined with phlegmonous inflammation. When it arises in a weak delicate habit, and is accompanied with symptoms of irritation, such as depression of strength, a quick small pulse, &c. ; then, to take off the ir- ritability, and guard against a termination in gangrene, which sometimes ensues, we should give the Peruvian bark, mineral acids, Virginian snake- root, camphor, aromatic confection, and wine. In those cases where the disease is confined to the trunk and extremities, and where there is con- siderable pain and irritation, the employment of opium seems advisable ; indeed I have used it on such occasions seemingly with much advantage. In erysipelas of the face, even without coma or delirium, from the ten- dency of this form of the disease to affect the brain, opium is to be regard- ed as a more doubtful remedy. Where a tendency to mortification becomes apparent, the above medi- cines, with wine and other antiseptics, will be the more necessary. (See Phlegmonous Inflammation terminating in gangrene.) Ammonia joined with aromatic confection may be given internally, with some probability of advantage, in all cases of erysipelatous inflammation of the extremi- ties, or other parts, which threaten to terminate in gangrene. When erysipelas is accompanied with a tendency to the worst kinds of hemorr- hagy, from being of a malignant nature, alum and the sulphuric acid are particularly indicated. If the disease is mild, and unaccompanied with febrile symptoms, it will be sufficient to keep the patient within doors, without confining him to his bed. In those cases where the inflammatory symptoms run high, the diet should consist of light nourishing things, such as preparations of barley, sago, tapioca, rice, Indian arrow-root, panado, and the like ; and his drink should be lemonade, tamarind-beverage, or barley-water, acidulated with some vegetable acid ; but in those cases where symptoms of irrita- tion prevail, a more generous diet, such as animal broths, and a mode- rate use of wine, ought to be allowed. For the treatment of the erysipelas with which infants are liable to be attacked, see the diseases peculiar to them at the end of this work. Of INFLAMMATION of the BRAIN anj» its MEMBRANES, or PFJRENIT1S. X HRFNITIS is an inflammation of the parts contained in the cavity of the cranium, and may affect either the membranes of the brain, or the brain itseif. It is called primary, or idiopathic, when it exists in- ORDER II. PHRENITIS. 87 dependent of any other disorder ; and symptomatic, when it arises in consequence of some other disease, as fevers and inflammatory affec- tions ; which species is that most universally met with, the other occur- ring but very seldom. Its characteristics are a severe pain in the head, redness of the face and eyes, intolerance of light and sound, watchfulness, and violent delirium. The causes which give rise to idiopathic phrensy are such as directly stimulate the membranes, or substance of the brain, or increase the im- petus of the blood in its vessels : hence violent fits of passion, intense stu- dy, excessive venery, severe exercise, external violence of any kind, an immoderate use of vinous and spirituous liquors, and a long-continued exposure to the heat of the sun, may be regarded as the remote causes. Many acute diseases, and a long want of sleep, may give rise to sympto- matic phrensy. The idiopathic is usually preceded by long-continued, and almost con- stant watching, or frightful dreams, acute pains at first in the neck and occiput, afterwards extending to the head, deep respiration, inability to recollect circumstances which have lately happened, suppression of urine, and irregular pulse. As the disease advances, the eyes sparkle, and are violently agitated ; there is a ferocity in the countenance, with universal restlessness, deafness, great confusion of ideas, violent ravings, intole- rance of light, evident pulsation in the temporal and carotid arteries, and the most furious delirium. The tongue is dry, rough, and of a yellow or black colour, the face is of a deep red, and the pulse is small, quick, and hard. The symptomatic phrensy is constantly preceded by acute fever, or some inflammatory complaint, and is usually accompanied with inability to sleep, constant watching, delirium, picking at the bed-clothes, redness and fierceness of the eyes, wild look, and deep breathing. Phrenitis is distinguished from mania, by the quickness of the pulse, and the attendant fever and pain in the head ; and from that species of delirium which occurs in low fevers, unaccompanied with inflammation ; by the appearance of the countenance and eyes ; for in true phrensy the face is red, the features are rather enlarged than shrunk, and the eyes protuberate, and sparkle ; whereas in the delirium supervening to low fe- ver, the face is pallid, the features are shrunk, and the eyes pearly. It is to be distinguished from synochaby the state of the pulse, as in the latter it is strong and full; whereas in the former it is small, hard, and more rapid. In phrenitis, the delirium is the primary affection ; but in syno- cha, it is consequent upon the general fever. A phrensy, whether idiopathic or symptomatic, may always be re- garded as a dangerous and alarming complaint; it often proves fatal between the third and seventh day ; and if long protracted, is apt to terminate in mania, or great prostration of strength : it often terminates in stupor and insensibility. Grinding of the teeth, white or ash-coloured faxes, suppression of urine, startings of the tendons, with convul- sions, cold sweats, a fluttering pul^e, and coma supervening on deli- rium, denote a fatal termination : on the contrary, when there is a co- 88 PYREXIA OR FEBRILE DISEASES. CLASS. I. pious hemorrhage from the nose, mouth, or lungs, or even from the uri- nary passages or hemorrhoidal vessels ; or when diarrhoea ensues ; when the delirium is relieved by sleep, and the patient remembers nisdreams ; when the perspiration is free and general; the deafness diminished or re- moved ; the pulse less frequent, but fuller and soft; and the febrile symptoms become milder, there are hopes of a recovery. The appearances on dissection are pretty much the same with those to be observed in cases of inflammatory fever, viz. a determination of blood to the vessels of the head, producing either effusion or suppuration in the ventricles, or adhesions of the dura mater to the scull. In some instances, the pia mater is converted into a membrane, resembling in thickness and consistence the dura mater. On the first coming on of idiopathic phrensy, immediate recourse should be had to bleeding, proportioning the quantity that is drawn off', to the age and constitution of the patient, and the severity of the symptoms. Opening the jugular vein, or temporal artery, may, perhaps, be preferable to drawing blooa from the arm ; and taking away a considerable quanti- ty at once, will certainly be better than drawing off only a little at a time, and repeating the operation frequently. If the patient is perceived to be much reduced by the largeness of the first and second evacuations, and the disease should nevertheless still continue with violence, the applica- tion of several leeches to each temple will be more advisable than any third bleeding from the system. When leeches are not to be procured, blood may tv abstracted by means of a cupping-glass and scarificator. The next proper step to be taken, will be to direct the head to be shav- ed, and to apply a large blister over it. Linen cloths wetted with vinegar and water, or iced water, may likewise be kept constantly to the temples. With the view of obviating the inflammatory diathesis, and of divert- ing the humours from the head, a strong purge * may be ordered ; and this ought to be repeated every second or third day, during the continu^ ance of the complaint. In all inflammatory affections of the head, a copious discharge from the intestines will be found highly beneficial, and experience has indeed ascertained that venesection itself is often less powerful. To assist in diminishing the determination of blood to the head, the patient should be kept as near the erect posture as can easily be borne. Warm bathing of the lower extremities, and the application of rubefacients to them, for the purpose of revulsion, have been very gene- rally employed in idiopathic phrenitis. By some physicians, and particu- larly by Dr. Cullen, they have, however, been regarded as ambiguous re- medies ; and it is probable that they will be likely to do harm, if employ- ed before the excitement has been sufficiently induced. * ft. Calomelanos gr. viij—x. I ft. Pulv. Jaiapiigr. xv. Kxtradt. Colocynth. gr. vj. M. J Calomelanos gr. vjr**M. fiant pilulas iij. pro dos I ft. Pulvis catharticus. ORDER II. PHRENITIS. 89 In symptomatic phrenitis, particular attention should be paid to the primary disease which has given rise to it, and the treatment ought to be varied according to the nature and progress of the disorder which has oc- casioned it. If it is in its first stage, and inflammatory, copious bleeding from the system will be necessary ; but if it has been of some continuance, drawing blood from the temples, by means of leeches or cupping with scarifications, will be preferable. Symptomatic phrenitis will not require our using active purgatives ; on the contrary, we should keep the body open only with gentle aperients, or laxative clysters, administered from time to time, as the occasion may requ.re. In most cases, the application of a blister to the neck, or between the shoulders, will be proper. As a medicine, the patient may take in both species of phrenitis a diaphoretic bolus* every three hours, washing it down with two or three table-spoonfuls of some febrifuge mixture.f From the well-known powers of digitalis in lessening the action of the heart and arteries, might not small doses of it be administered with ad- vantage in phrenitis, but more particularly the idiopathic ? If phrenitis arises in consequence of some suppressed evacuation, or eruption, we must endeavour to restore it, by the proper means, which will be understood from the nature of the former discharge. During the whole course of the disease the patient ought to be kept cool and as quiet and undisturbed as possible, excluding light from him, and his food should be light and nourishing, consisting of preparations of barley, sago, gruel, 8cc. Cold acidulated liquors should be allowed with freedom. In idiopathic phrenitis, every part of the antiphologistic regi- men will be necessary. Of an INFLAMMATION of the EYE,or OPHTHALMIA. v.-'PHTHALMIA is of two kinds, viz. the idiopathic and symptomatic; the latter proceeding either from diseases of the eye, or parts in its neigh- bourhood, or from diseases of the system ; and the former from the cau- ses assigned below. In ophthalmia, the inflammation is seated either in the membranes of the eye, its deep-seated parts, muscles, and the lachrymal gland, or in the sebaceous glands placed in the edges of the eyelids ; but sometimes all these parts are affected in consequence of sympathy, and indeed it rarely happens, that any of these suffer in a considerable degree without the inflammation extending further. It readily spreads along the con- junctiva, from the tarsi to the eye, or in the contrary direction. When • ft. Camphor, gr. iv. f. ft. Succ. Limon. ^jfs. Amnioni;*; ^1 •>. vel q. s. Pulv. An(jwon. gr. ijfs. Aq. Menth. Sativ. rj. ■ Fontan. ^iv. Conferv. Rofa? cj. *. M Nitri Purif. 5J. Syrup. Rofse 3J. M. ft. Bolus ft. Miftura. M 90 PYREXIA; OR FEBRILE DISEASES. CLASS I. the conjunctiva is much inflamed, the adnata soon partakes of the in- flammation ; and if the complaint increases, it gradually spreads to the deep-seated parts. With some people there is a great tendency to a recurrence of the disease, and in many cases it has been observed to renew its attacks, or to have regular exacerbations at a particular time of the day. The causes producing ophthalmia are, external injuries, such as blows, contusions, and wounds on the eyes ; extraneous bodies of an irritating nature, introduced under the eyelids ; exposure to bleak winds and cold ; too free a use of vinous and spirituous liquors ; the suppression of accus- tomed discharges ; the long application of a strong light, or fixed atten- tion to minute objects ; and an acrimony prevailing in the mass of blood. It is likewise often symptomatic of other diseases, such as measles, small- pox, scurvy, scrofula, and syphilis. Mons. Sonnini, in his Travels through Egypt, mentions, that ophthal- mia is a complaint which is endemial in that country, and that eyes per- fectly sound, or which are not swelled, are rarely to be seen. rI his he attributes to the excessive heat, the air being impregnated with noxious particles, and the acrid and burning dust which the winds scatter in the atmosphere. Another cause of -the cecity so general at Cairo, he says, is the frequent watering of the streets and houses. Water, thrown abun- dantly and frequently upon a burning soil, containing a great many saline particles, produces, he observes, acrid vapours, which may be considerei as one of the principal causes of blindness in Egypt. Sir Robert Wilson mentions * that the Egyptian ophthalmia is sup- posed to originate in the nitrous particles emitted from the ground by the force of the sun, which are of a quality so pungent and pene- trating as to injure the fine vessels of the eye. The acrid and burning dust flying continually in the atmosphere, irritates still more the already affected part ; while the reflection of the soil, the heat of the air, and vivid light of the sky, tend to weaken the sight, at last occasioning exces- sive inflammation. According to the best information which we have received, this species of ophthalmia arises in the first instance soon after the overflowing of the Nile, or rather on its recession, when a vast quantity of slimy mud is deposited on its banks and other places which were overflowed, and which being acted upon by a powerful sun, send forth miasmata or effluvia that excite inflammation in the eyes of this peculiar nature. The custom in l-'.gypt of sleeping in the open air, possibly, may increase the power of the cause. Ophthalmia has not been considered in Great Britain as a contagious disease, although it has often been known to appear as a prevailing epi- demic at different times, and probably the common species cannot be transferred from one person to another by any kind of intercourse, or even by the immediate application to a sound eye, of any secreted fluid, * »r matter from a diseased one ; but it is an undoubted fact, that the ' Sec his Hiftory of die Expedition to Egypt. tRDER II. OPHTHALMIA. 91 Egyptian species is highly contagious. During the campaign in Egypt our troops were dreadfully atfiicted with it, and many returned with a total loss of sight; whilst others, stilf labouring under the disease, prop- agated it at Malta and Gibraltar, where they first landed ; and from which places it was at length brought into this country. It seems to be established, I think, on the most indisputable evidence, that the Egyptian ophthalmia may be propagated by contagion, and that in this way it has been introduced into our united kingdom, and has spread in the same manner as in its native soil. The influence of cli- mate, and other local circumstances, on the general character and pro- gress of the disease, cannot, however, be denied. In most of the instan- ces in which this species of ophthalmia has prevailed in this country, it has appeared with mitigated symptoms, in comparison with the disorder, as it occurs in Egypt; but it has nevertheless been observed, that where the patients were exposed to the influence of a marshy soil, it equalled in the severity of its symptoms the Egyptian ophthalmia. A modern writer t assures us, that its spreading is not owing to contagion in the ordinary sense of the word (that is, to any infectious matter thrown off from the system of those labouring under the disease, and operating at a greater or less distance from its source,) but to the actual conveyance of the purulent matter from the inflamed organ to the eye of a person in health. Indeed Dr. Edmonston has also pointed out,$ that the sphere of action of this contagion is very limited, and that most of the cases which came under his observation, arose from the direct application of virus from diseased, to sound eyes. Mr. Ware is of opinion, § that the disease which has appeared as a pre- vailing epidemic among soldiers since the return of our troops from Egypt, ought to be denominated the purulent ophthalmia instead of the Egyptian, since one of its chief symptoms, and that which distinguishes it from any other, is the profuse discharge of a purulent coloured fluid, closely resembling the pus or matter that issues from an ulcerated sur- face. He also thinks, that it greatly resembles, in many respects, a dis- order, which he has described with minuteness in his Observations rela- tive to the Eye (see vol. i. page 129 and 309,) under the title of the Pu- rulent Eye of new-born Children, and in which, no less than in that under consideration, the discharge of matter is always profuse. With due de- ference, however, to Mr. Ware, I cannot help considering the two dis- eases in question, as perfectly distinct. The common ophthalmia usually comes on with a sensation, as if some gritty particles had insinuated themselves under the eyelids, ac- companied with great heat, redness, and pricking, darting pains. As it increases, the parts swell, and the vessels of the eye become not only increased in size, and turgid, but appear more numerous than in the ■f- See an Account of the Ophthalmia \vhi:h has appeared in England fince the Re- turn of the Britifh Army,by J. Wteh. M. 1L | See Edmo:iil'■■!>'.■> Account of an Ophthalmia which appeared in ;he id Regiment of Aiyjlrfliirc lViuibles in 18c., with Obfervations on Egyptian Ophthalmia. § ace his Remarks on Purulent Oplwh.ilmy. 92 PYREXIAE OR FEBRILE DISEASES. CLASS 1 riatural state. Great pain is excited upon the least motion of the ball of the eye ; the patient cannot bear the light, and an effusion of tears from the lachrymal gland ensues, which is of so acrid a nature as to excoriate every part on which it happens to fall. When the inflammation runs high, a slight febrile disposition often attends. These appearances, af- ter some days continuance, gradually abate, and at length entirely cease ; but, in some cases, a discharge of thick glutinous matter ensues, which collects in considerable quantities about the angles of the eye, particular- ly during sleep. Where only one eye has been affected, it is often suc- ceeded by an inflammation of the other, particularly in a scrofulous habit. The symptoms to be met with in the Egyptian ophthalmia are, in some respects, obviously distinct from those of the common species. At the commencement, the internal lining of the palpebrse appears to be the chief seat of the disease ; it is affected through its whole extent by a purulent exudation, and a quantity of pus is afterwards secreted by the eye itself, unattended, however, by any considerable derangement of its functions. The discharge of tears is likewise copious, but no great intolerance of light is found to prevail. This state of the eye remains for some time, the patient expressing no great uneasiness, and the purulent exudation not being very perceptible, unless the lower lid be depressed. Unfortunately, the symptoms are apt to be overlook- ed, and the complaint is not much regarded, till it has attained a consid- erable height. Now all the morbid symptoms become suddenly and greatly aggravat- ed ; the lids are extremely swelled ; the discharge of pus is augmented; the pain becomes very acute, and the eye itself assumes the appearance of chemosis. In most cases, the pain observes periodical paroxysms of three or four hours continuance. During these local complaints, scarce- ly any general affection of the system occurs ; the pulse is a little quick- ened, but is not fuller than in its natural state ; nor are any marks of in- flammatory fever exhibited. When the discharge of pus ceases,a num- ber of granulations arise from the interior of the eyelids, and present a shocking spectacle. On their subsiding, the surface of the cornea is fre- quently found to be opaque, sometimes covered with granulations, and occasionally-ulcerated. The most unfortunate termination, however, is a rupture of the cornea; an occurrence which is apt to attend the disease in its most violent form, and which is usually followed by irremediable blindness. From the detail now given, it is evident that the absence of the intole- rantia lucis ; the regularity of the paroxysms of pain ; the unembarrassed state of the functions ; the absence of general fever, and the formation of purulent matter, in particular ; are the symptoms which characterize the Egyptian ophthalmia. With some, the disorder lasts only nine or ten days ; in others, the pa- tients have suffered for months : and, unfortunately, there is no security, we are informed, against a new attack, even after a perfect recovery. If ophthalmia is slight, and not symptomatic of any other disease, it will readily give way to proper means ; but if it is very violent, or has continued for any length of time, it is apt to occasion specks, or to t«.-i ORDER II. OPHTHALMIA. 93 minate in a dimness of sight or opacity of the crystalline lens. In some case", the inflammation terminates in suppuration of the cornea and deep-seated parts. When it arises in a scrofulous habit, or is sympto- matic of syphilis, the cure is often tedious. In the treatment of ophthalmia, its varieties of idiopathic and sympto- matic, and of acute and chronic, ought duly to be considered, and to form the basis of our practice. Our object therefore should be, to determine with precision, how far each particular case is to be referred to one or other of these kinds, and to adopt our plan accordingly. Those who are engaged in an extensive practice, now and then meet with cases of idiopathic and acute ophthalmia, accompanied not only with a high It-gree of organic inflammation, but likewise with much systema- tic derangement, such as thirst, great heat of the body, fulness and fre- quency of the pulse, severe pains in the head, and violent throbbings of tiie temporal arteries. Such instances are, however, rare ; but when they do occur, general bleeding or venesection ought not to be neglect- ed ; and we should take care to proportion the quantity we draw off to the existing circumstances. In the very worst cases, where there may be some danger of phrenitis ensuing, the blood ought to be drawn from the jugular vein or temporal artery, in preference to taking it from the arm In general, however, ophthalmia is only a local affection, accompanied with little or no fever, except what is excited by the irritation or pain in the organ, and this but trifling ; and therefore it seldom will be necessa- ry to resort to general bleeding : the preferable way will be to draw blood from the neighbourhood of the affected part, by applying several leeches round the eye ; which process we may repeat again and again, as long as the inflammation continues. Where leeches cannot be procured, blood must be drawn from the temples by scarifying and cupping. If the in- flammation runs high, so as to endanger vision, by producing an opacity, it will be advisable to make scarifications daily with the edge of a lancet, on the turgid vessels of the adnata itself; which, if done by a steady hand, will be attended with no kind of danger, but, on the contrary, with infinite advantage. It is almost unnecessary to observe, that when ophthalfltfifr has arisen from any extraneous body getting into the eye, as particles of sand, dust, lime or metal, small flies, the hairs of the eyelids, &c. the irritating cause ought immediately to be removed, and the part be defended from the light by the patient's wearing a deep shade of green silk, and sitting in a darkened room. Having adopted topical bleeding, we may then order some active pur- gative to be taken ; and this should be repeated every third or fourth day, as long as may be found necessary. A few grains of calomel, with a sufficient quantity of jalap, or a solu- tion of any of the neutral salts, will best answer the intention. Where the complaint has arisen from exposure to cold, or other cau- ses suppressing the perspiration, it is probable that the patient may re- ceive benefit from small doses of some antimonial preparation given so as to excite a proper diaphoresis. (See SynochuO The pediluvium may also be employed with the same intention. 94 PYREXIJE OR FEBRILE DISEASES. CLASS I. To abate the inflammation and irritation, it is customary to have re- course to the frequent application of some cooling and astringent wash. Such remedies applied to the eye by means of an eye-cup, or by wet pledgets, prove, beyond a doubt, highly serviceable. Any of the under- mentioned * may be used. Where the pain is very acute, forty or fifty drops of the vinous tincture of opium may be added to any of the foregoing applications, or the eyes may be bathed frequently with a decoction of bruised poppy-heads. In such cases, an internal use of opium will also be advisable, and it may therefore be taken in doses of a quarter of a grain, repeated every four or six hours. For the purpose of appeasing heat and inflammation in the eyes, some practitioners prefer warm collyriums to cold ones ; and among this num- ber, I think, is Mr. Ware. Ophthalmia, when acute, is frequently accompanied with a severe and distressing pain in the temples, for the alleviation of which a late author t strongly recommends a tincture of tobacco, prepared as below, J: to be employed as an embrocation frequently over the part that is painful. He likewise advises a little of it to be dropped into the eye where the organ is tender, and its vessels much enlarged. It has been mentioned, that the eyes are apt to be glued together (par- ticularly during sleep) by a thick" glutinous matter which is secreted. To prevent this inconvenience, some kind of emollient liniment § may be in- serted between the eyelids every night before the patient retires to rest. In the ophthalmia tarsi the unguentum hydrargyri nitrati is one of the . most powerful remedies we can employ. It will seldom be necessary to use poultices for an inflammation of the eye, except it is of the purulent kind, in which case we may apply with advantage one made by stirring a lump of alum in the whites of two eggs until they form a coagulum, and this is to be laid to the eye between two pieces of thin linen or muslin. Cold poultices of rasped potatoes and turnips are often used on such occa- sions. In the purulent ophthalmia, to which children are subject, Mr. Ware advises the use of a collynum prepared as mentioned below.|| t See Edward M. Noble's Treatife on Ophthalmia, Part II. • R. Zinc. Vitriolat. Ceruffae Acetat. aa gr. viij. Aq. Diftillat. ^vj. M. J-R Fol. Nicotian. Incis. ibfs. Camphors sjij. Spirit. Vin. Reclificat. ft. Collyrium. Vel Aq. Diftillat. aa. tbj. &■ Aq. Ammon. Acetat. ----Rofsefingul. 5ij. M. Vet § R- Tutiae Praeparat. 5[j. Unguent. Sperm. Ccti §j. M. Vet R. Collyrii Amnion. Acet. R- Unguent. Adipis Suillae ^j. Mifturae Camphorat. aa ^ij. M. Zinc. Vitriolat. jfs. M. Vel Vet R- Aluminis Purif. 3«rs. Aq. Rofe^vj. M. Unguent. Cerufs. Acctit. Vel 1! R- Aquas Cupri Vitriolat. R Aq. Rofac 5 iij. -----Camphorat. aa gij. «---Litharg. Acetat. gutt. xv M. -----Diftillat. £iv. M. BRDER II. OPHTHALMIA. 95 He is of opinion that the purulent is very similar to the gonorrhoeal ophthalmia He foundthe purulent eye, we are told,* most commonly to oc- cur in thechildren of those women who have had an acrimonious discharge from the vagina at the time of delivery ; and the purulent ophthalmia of adults, he thinks, is very generally found connected with some gonorr- hoeal affection. In public schools, he noticed the disease to spread ob- viously in consequence of the indiscriminate use of basins and towels among the children. Hence, he believes that the purulent ophthalmia arises from the direct application of some poisonous matter to the eyes. When the complaint is found not to give way to topical bleeding, pur- ging, and the astringent applications which have been advised, it may be proper to put on a blister at the back of the neck, or behind the ear on the same side with the eye which is affected, and it may be kept open by dressing it with some stimulating ointment.J In those cases where the disease appears to be constitutional, issues near the part, or a seton in the neck, may be very proper. In very inveterate cases of ophthalmia, it might probably be of advan- tage to drop into the eye a strong infusion of digitalis, or the extract of belladona dissolved in water, as has been proposed by Dr. Rimarus of Hamburgh, previous to the operation of the extraction of the crystalline lens, incases of cataract, in order to produce a temporary paralysis of the retina. The former of these is much employed by an eminent veterinary surgeon (I understand) for the purpose of subduing violent inflammation in the eyes of horses, and has been found a very efficacious remedy. In a case of obstinate ophthalmia, which had resisted the usual means, the application of oleum terebinthina:, in a diluted state, was found to be attended with the most beneficial effects.! Spirits of wine is another ap- plication of a similar nature, which has been employed in some cases of ophthalmia with much advantage.5 Covering the parts with pieces of bladder, softened-by dipping them in warm water, and then keeping the outer surface constantly wetted with the spirits, is the mode which has been advised to be adopted. In chronic inflammation of the eye, the tinctura thebaica, or vinous tincture of opium, constitutes one of the best applications we can employ, and it is much used by Mr. Ware on such occasions. If ophthalmia is dependent on a venereal taint, mercury is the remedy we must rely on to remove it. When it arises in a scrofulous habit, af- fecting chiefly the tarsi, and is attended with ulcerations, as is often the case, Peruvian bark, with alteratives, mineral waters, and sea- bathing, will be the most proper remedies, and their effect may be in • See his Remarks on the Purulent Ophthalmia, t See Memoirs of the Medical Society, vol. v. Art. 3®. § See the fame..........Art. 7. J R. Unguent. Cantharid. ijij. --------Refin. Flav. 3J. M. ft. Unguentum. 96 pyrexia; or febrile diseases. CLASS I. creased by the topical application of mercury or copper,* in the form of liniment or wash. In these cases hemlock, combined with Peruvian l>ark, has sometimes proved serviceable. Cinchona, with prepared na- tron, may also have a good effect. When specks have ensued, in consequence of previous inflammation, which has destroyed the transparency of the cornea, a powder composed of equal parts of white sugar and alum, or of sugar and nitre finely pul- verized, may be applied to the diseased part two or three times a day, on the point of a fine camel's hair pencil. If these do not remove them, we may make trial of another, composed of one part of verdegris, or hydrar- gyr. nitrat. ruber, levigated with about six parts of fine sugar. A weak solution of hydrargyr. muriatus, applied to the eye as a wash, is some- times attended with a good effect, and will by no means interfere with a use of the powder, if applied separately. (See the prescription below.) An ointmentf, much used by Mons. Pellier for the like purpose, has been recommended by Mr. Bell. In employing escharotics for the removal of opacities of the cornea, much care and attention will, however, be requisite, otherwise they may prove more frequently injurious than serviceable. That species of opacity which appears situated on the external surface of the cornea, may sometimes be removed by the knife, but not always; as it is frequently so much diffused, as to render such an operation im- practicable. A bad case of this kind of opacity, which arose from a local injury, and which extended over the whole lucid cornea, was entirely removed under my care, by having a few drops of the aq. cupri ammo. niati admitted daily into the eye, and this in a very short space of time. In opacities of the cornea, the application of animal gall to the part has been found to be efficacious, when other remedies have failed. Being a stimulant, it ought never to be applied while the inflammatory action is increasing, but should not be delayed one minute after the in- flammation is at a stand, as an indolent unhealthy state is apt to take place, which too often terminates in opacities, that no applications can afterwards remove. It may either be used pure, or diluted ; perhaps the latter may be most advisable at first, as it is apt to occasion a painful sen- sation : but this, however, soon goes off. Its effects seem to be sim- ilar to those of the unguentum hydrargyri nitrati, and a solution of the argentum nitratum. In all cases of ophthalmia it will be requisite to avoid every thing Unguent. Hydrarg. Nitrat. Vet ]\. Hydrarg. Muriat. gr. ij. Ammon. Muriat. gr. v. Aq. Fontan. gvj. M. ft. Collyrium. Vel \\. Zinci Vitriolat. 7)j. Adipi* Suillae *£ M. t R- Hydrargyri Nitrat. Ruhr. Lapid. Calamin. Praparat. a.; sflfs. Lithargyr. Lsevigat. 5J. Tutiae Prneparat. ^fc. Hydrargyr. Sulph'urat. Rubr. 7}) Balfam. Peruvian, gutt. xv. Adipis Suillx ^ij. M. ORDER II. OPHTHALMIA. 9r which might occasion irritation ; for which reason the patient ought to be confined to a dark chamber, or, at least, he should wear a blind of green silk over the eye, to prevent too great a glare of light; and he ought likewise to abstain from all food of a heating or stimulating nature, and from a use of vinous and spirituous liquors. In very severe cases, his diet should consist chiefly of some mild fari- naceous decoction, which, while it allays thirst and supplies sufficient nourishment, tends both to moderate excitement and promote perspira- tion. After the removal of ophthalmia it may sometimes be necessary to em- ploy means to prevent its return, by continuing the use of blisters behind the ears, or the insertion of an issue. In some instances, however, it may be connected with a debilitated habit, and then the best means of pre- venting its return are those which tend to strengthen the vessels of the eye, or the system in general; and these will sometimes remove habitu- al ophthalmia when all others have failed. One of the most powerful of these means is the cold bath, which may be employed either by immersing the whole body, or by washing the head in cold water once or twice a day. The application of cold water to the eyes themselves, or of any astringent collyrium, by means of an eye-cup, twice or thrice a day, may likewise be serviceable in preventing the re- turn of ophthalmia, or removing it after it has become habitual. The bark and other tonics have also been resorted to with a good effect. We are informed by Mr. Ware,* that he has had occasion to attend a considerable number of cases, in which an opacity of the crystalline hu- mour was produced by some violence done to the eye ; and in most of these, the opacity was dissipated, and the sight restored, during the ex- ternal application of aether. In using this remedy, he says, " Sometimes I have diluted it with a third or fourth of a weak solution of hydrargyrus muriatus ; but in ge- neral, I have used the aether alone, which has been applied by means of a camel's hair pencil to the eye itself. The application of the remedy oc- casions a very pungent pain in the eye, with considerable redness in the tunica conjunctiva ; but these go off in a few minutes, and leave the eye as easy, and the conjunctiva as pale, as they were before the aether \vas used." The principal remedy that has been productive of any good effect in the ophthalmia which has so universally prevailed among the British soldiers since the return of our troops from Egypt, and which from this circumstance has been named the Egyptian ophthalmia, is bleeding from the arm ; but in order to insure its full power, it has been found necessary, Dr. Vetch tells us,f to carry the evacuation to a great extent, and with a freedom far beyond what we have been ac- customed to recommend. In short, he says, that he found it abso- lutely necessary to draw off upwards of twenty ounces at a time, or * See his Second Edition of Obfc rvations on the Cataract and Gut fa Serena. f Sec his'Freatifc on the Egyptian Ophthalmia. N 98 pyrexia; or febrile diseases. CLASS I. rather to bleed the patient ad deliquium animi, and to repeat the opera- tion to this extent pretty frequently. With the liberal evacuation of blood from the system, and likewise from the eye itself, by the topical means before noticed under the head of Common acute Ophthalmia, the use of purgatives repeated every se- cond or third day, with an appropriate antiphlogistic regimen should be conjoined. In treating on common ophthalmia it has been recommended to make frequent scarifications on the ball of the eye, but perhaps it may be the better way to carry the lancet along the inside of the lower lid, parallel to its edge, and not far distant from it. Scarifications made in this way will be far preferable to pricking the eyelid repeatedly in quick succession, as is sometimes practised. The issue of blood from the scarifications may be assisted by gently everting the lid with the end of the finger, and it will be more useful to take off the finger occasionally, and then to apply it again, and thus renew the eversion, than to continue the finger steadily on the lid. W'hilst by large and sudden evacuations of blood from the system, as well as from the affected eye, we lessen the violence of the disease, and prevent either an opacity of the crystalline lens, or a rupture of the cor- nea from ensuing ; we are, at the same time, to moderate the external symptoms and lessen the secretion by local applications—linen cloths dipped in some cooling lotion (see those before prescribed) should there- fore be kept constantly to the eye, or eyes, if both are affected, and such applications as experience seems to have accommodated to the different stages of the diseases ought to be carefully dropt into the eye. The best appear to be the aq. lithargyr. acet. properly diluted, solutions of alum, or vitriolated zinc, or the camphorated collyrium prescribed below, * or be- fore mentioned. When we consider, however, that the morbid mucus is confined be- tween the swelled conjunctiva that lines the eyelids and that part of it which covers the globe of the eye, it must be evident that in order to bring the matter effectually away, the lotion must be propelled over the eye with some degree of force, and this cannot be better effected than by the use of a small blunt-pointed syringe, by means of which the medicated li- quor may be conveyed over the whole surface of the eye, and the retain- ed matter be each time entirely cleared away. The injection ought to be repeated at least once an hour during the height of the disease ; but when the violence of the inflammation has abated, and the quantity of the dis- charge is decreased, a longer period may be allowed to intervene be- tween the times of applying it. In those cases where the pain of the eye and tumefaction of the con- * ft. Cupri Vitriolat. Bol. Armen. aa gr. viij. Camphors gr. ij. Mifce, et afTunds Aq. Bullientis ^viij. ✓Cum lotio fit frigida effundatur liquor limpidus etfxpiifime injiciatur paululum inter oculum et palpebras omni hora. 0RDER II. OPHTHALMIA. 99 junctiva are very considerable, it may be advisable not only to make the lotion of a weak standard, and to leave longer intervals between the times of employing it, but occasionally to interpose the injection of merely te- pid water. Under the like circumstances the frequent application of hot water also, or of a warm decoction of poppy-heads, by means either of a flannel or of a large sponge, may likewise prove serviceable. During the inflammatory stage of the disease, and when the irritation is great, a warm .poultice of bread and milk may be applied to the eye, renewing it fre- quently throughout the clay. Possibly it might be of service to shave the head and keep cloths wetted with vinegar to it and the temples. In severe cases a blister on the neck might likewise prove useful. The introduction of the vinous tincture of opium by a few drops at a time into the eye will have a very good effect when employed in the early stage of the disease. Such are the means to be adopted in the treatment of this variety of ophthalmia. It sometimes happens, however, that, in spite of our utmost endeavours to subdue the inflammation, we cannqt succeed, and that there is great danger of a rupture of the cornea taking place, and disco- verable by the cornea losing its transparency, and a white ring forming round its circumference. In such cases, it will be highly advisahle to evacuate the aqueous humour, by making a puncture with a common lancet into the anterior chamber of the eye. This operation, it appears, has been performed in several instances with perfect safety and the highest advantage by Mr. WTardrop,* of Edin- burgh, under the like circumstances ; and he thinks it probable that the great and immediate relief afforded by it, arises chiefly from the sudden removal of tension. Mr. Ware f coincides with Mr. Wardrop on the propriety of punc- turing the cornea to evacuate the aqueous humour when a rupture of it is threatened, and he very properly observes, that by suffering this to happen spontaneously, it may take place in such a part of it as afterwards to im- pede the passage of light, but that when the opening is made by a sur- geon, it may be clone in such a place as to obviate any impediment of the kind. Of OTITIS, or INFLAMMATION or the EAR. INFLAMMATIONS of the ear are for the most part unaccompanied by pyrexia, although the sufferings of the patient are sometimes very great ; but in some instances they are attended with fever, assume a for- midable appearance, coma, delirium, and convulsions supervene, and even a fatal termination has been the consequence. Otitis is produced by the same causes with other inflammations, but by none more readily than a partial exposure to cold. In the treatment of this complaint we should proceed on the same principles as in that of ophthalmia. While it is merely a local af- • See vol; iii. of the Edinl'iirgh Journal, p. 56. + ; ^ e his Remarks on purulent Ophthalmia. 100 PYREXIA OR FEBRTLE DISEASES. CLASS I. fection, local remedies alone are necessary, if we except cathartics for the purpose of dislodging the contents of the prims viae. Local blood-letting, the application of blisters behind the ear, and of warmth, are the means chiefly to be relied on. If the pain does not abate, but, on the contrary, should continue to in- crease, we may expect a suppuration to ensue. This we may then en- courage by the application of emollient poultices and warm vapour ; and when the abscess bursts, or is opened, we may syringe the ear from time to time with some mucilaginous and gently astringent decoction. When otitis is accompanied with universal pain diffused over the whole head, fever, delirium, or coma, the most powerful general means are to be combined with the local ones, as recommended in Phrenitis. Suppuration is generally the consequence of these violent forms of the disease, and then the structure of the whole internal ear is often destroy- ed, the bones being discharged through the meatus auditorius with much purulent and fetid matter. In such cases the sense of hearing in the ear affected is woolly lost of course. Fistulous ukers of the internal ear are now and then the consequence of suppuration, and prove very troublesome. Ear-ach sometimes continues many days without any apparent inflam- mation, and is then frequently removed by filling the ear with tincture of opium or aether, or even with warm oil, or warm water. Sometimes a pain in the ear is the consequence of association with a diseased tooth, in which case the aether should be applied to the cheek over the suspected tooth, or a grain of opium with a little camphor, be applied to the tooth itself. Of the INFLAMMATORY SORE THROAT, or CYNANCHE TONSILLARIS. -IN this complaint the inflammation principally occupies the glands, such as the tonsils ; but it often extends through the whole mucous mem- brane of the fauces, so as essentially to interrupt the speech, respiration, and deglutition of the patient. It is readily to be distinguished from cynanche maligna by the strength of the pulse, the greater difficulty of deglutition, the absence of ulcers in the throat, and the accompanying fever being inflammatory. The causes which usually give rise to it are, exposure to cold, either from sudden vicissitudes of weather, from being placed in a partial current of air, wearing damp linen, sitting in wet rooms, or getting wet in the feet; all of which may give a sudden check to perspiration. It may also be occasioned by violent exertions of the voice, blowing wind instruments, acrid substances irritating the fauces, and by the sup- pression of accustomed evacuations. It principally attacks the youthful, and those of a full and plethoric habit, and is chiefly confined to cold climates, occurring usually in the spring and autumn ; whereas the cynanche maligna chiefly attacks those of a weak irritable habit, and is most prevalent in warm climates. The former differs from the latter, ORDER II. INFLAMMATORY SORE THROAT. iOl likewise, in not being contagious. In many people there seems to be a particular tendency to this disease, as from every considerable application of cold it is readily induced. An inflammatory sore throat discovers itself by a difficulty of swallow- ing and breathing, accompanied by a redness and tumour in one or both tonsils, dryness of the throat, foulness of the tongue, lancinating pains in the parts affected, hoarseness of the voice, a frequent but difficult excre- tion of mucus, and some small degree of fever. As the disease advan- ces, the difficulty of swallowing and breathing becomes greater, the speech is very indistinct, the dryness of the throat and thirst increase, the tongue swells, and is incrusted with a dark fur, and the pulse is full, hard, and frequent. In a few cases, small white sloughy spots are to be ob- served on the tonsils, and in very violent ones there is complete deafness. When the symptoms of cynanche are considerable, the whole face par- takes of it, the eyes are inflamed, and the cheeks florid and swelled, res- piration is performed with difficulty, and the patient is obliged to be sup- ported in nearly an erect posture to prevent suffocation. Lven delirium and coma sometimes supervene. If the inflammation proceeds to such a height as to put a total stop to respiration, the face will become livid, the pulse will sink, and the patient will quickly be destroyed. The chief danger arising from this species of quinsy is, the inflamma- tion occupying both tonsils, and proceeding to such a degree as to pre- vent a sufficient quantity of nourishment for the support of nature from being taken ; or its occasioning suffocation : but this seldom happens, and its usual termination is either in resolution or suppuration. When proper steps are adopted early, it will in general readily go off by the for- mer. Cynanche tonsillaris rarely terminates either in gangrene or scir- rhus. Little fever, free respiration, deglutition not much impeded, the inflam- mation being of a vivid red colour, universal but gentle diaphoresis, and a copious ptyalism or moderate diarrhoea coming on about the fifth day, are to be regarded as symptoms which denote a termination of the disease in resolution. When suppuration is likely to ensue, the parts affected become more pale and less painful, a sense of pulsation is felt in them, and there are slight rigors. If gangrene is to take place, the parts affected lose their red and shining colour, and from being tense and tumid, they become flaccid, brown, and livid ; the pulse, from being strong, becomes small, weak, and irregular ; the face assumes a cadaverous appearance ; cold clammy sweats breakout; the extremities are cold; coma, and symp- toms of debility, make their appearance, and destroy the patient. Where cynanche tonsillaris has proved fatal by suffocation, little more than a highly inflamed state of the parts affected, with some morbid phe- nomena in the head, have been observed on dissection. In the treatment of this complaint, our first and chief endeavour should be to carry off the inflammation ; for which reason an antiphlo- gistic plan must be pursued. If the inflammatory symptoms run high, twelve or fourteen ounces of blood (supposing the patient to be an adult) 102 PYREXIA OR FEBRILE BISEASES. CLASS U ought to be drawn from the jugular vein, in preference to the arm ; but if rhey do not, it will be sufficient to draw blood by the application of se- veral leeches under the ears, particularly on the side most affected. Draw- ing blood from the tonsils by internal scarifications, is likewise a power- ful remedy in this species of quinsy, and when employed with freedom on its first appearance, will greatly tend to prevent a suppuration from ensuing. At the commencement of cynanche tonsillaris, and before the febrile symptoms are any way violent, the timely exhibition of an emetic-often proves extremely useful, and now and then checks its complete formation. To assist in removing the inflammatory diathesis, gentle evacuation from the intestines, by means of laxative medicines, should be advised oc- casionally. Saline cathartics, or calomel with jalap, may be most proper. In those cases where the inflammation is considerable, the early appli- cation of a blister round the throat, or to the back of the neck, will most probably be attended with a good effect: but in slight cases, it will be sufficient to have these parts rubbed twice or thrice, a day with some sti- mulating embrocation, such as the linimentum camphorae vel ammoniac, putting a piece of flannel round them afterwards. In this complaint it is found of service to wash the mouth and fauces frequently with mild astringent gargles* somewhat acidulated, and likewise to scrape and cleanse the tongue from the fur which is apt to collect on it. Gargles composed of a few grains of the cerussa acetata have some- times proved highly serviceable in abating the inflammation, when other remedies have failed ; but from the general prejudice against the use of this preparation in the form of gargle, lest any of it should happen to be swallowed, it is seldom prescribed. Wnen white sloughy specks are observed on the tonsils, we may sub- stitute the gargles advised in cynanche maligna for those mentioned here. If a tendency to gangrene should appear, we should immediately have recourse to those of an antiseptic nature, the best of which are composed of bark, myrrh, and Port wine, or of capsicum and vinegar. See Cynanche maligna. Gargling is the best means of washing the internal fauces ; but its motion is sometimes so painful or irksome, as to prevent the patient from having recourse to it. In such cases the medicine may be thrown into the fauces by means of a syringe. Frequently inhaling the vapour arising from warm water mixed with Vel ft. Aluminis Purif. gj. DecodL Hordei Itjfs. Mellis Rofae Jjj. M. Vet ft. Infus. Rofse ^vj. Tincl. Myrrh. ^fs. Mellis Commun. gj. M. • R. Conferv. Ros. Ruhr. f jfs. Aq. Bullient, ifefs. Acid. Sulphuric. £j. M. ft. Gargarifmus. Vel ft. Decoct. Hordei gvj. Mel.Rofe.^j. Acid. Sulphuric, gutt. xxxv. M. ORDER II. INFLAMMATORY SORE T3ROAT. 103 a little vinegar throughout the course of the day, will greatly assist the effects of gargles ; and where a proper inhaler cannot he procured for the purpose, we must be content to substitute an inverted funm-?. When a febrile disposition prevails, it will be proper to employ dia- phoretic medicines with the view of determining to the surface of the bo- dy. Any of those advised under the head of Simple Continued Fever may be used ; and to increase their effect, the patient should take frequent small draughts of whey, barley-water, or any other diluting liquor. Neu- tral salts, as recommended under the same head, will likewise be proper medicines. If our endeavours to resolve the inflammation have proved fruitless, and it seems likely to terminate in a suppuration, we ought then to has- ten it by the frequent application of warm fomentations and emollient poultices to the throat, and by directing the patient to receive the vapour arising from warm milk and water into the fauces several times a day, in the manner before recommended. Warm gargles composed of a decoction of figs and barley-water may also be employed, and the best way of using them will be to permit as large a quantity as can conveniently be retained to lie on the part till it cools to the temperature of the mouth. When the matter is formed, if the tumour does not break readily, a lancet may be applied to it. During this stage of the disease, the passages to the stomach and lungs are sometimes so closed by the size and pressure of the tumour, as to endanger the life of the patient, either by suffocation, or the wantof nourishment. In the first case, recourse should be had in proper time to the operation of bronchotomy, in order to keep up respiration ; and in the last, the strength must be supported by nutritive and mucilaginous clys- ters, consisting of animal broths, thick gruel, arrow-toot, barley-water, or a solution of starch, which should be thrown up the intestines in a small quantity at a time, as they will thereby be absorbed the more readily, and will not be so apt to pass off again, without affording any benefit. Before we resort, however, to bronchotomy, it may be worthy of a trial to endeavour to break the tumour, either by exciting vomiting, or by making the patient receive, through an inhaler, the steams arising fiom warm water, to which a sufficient quantity of aether has been added. The stimulus will prove so great, as to succeed in many cases, particularly where the suppuration is nearly completed. In cynanche tonsillaris every part of the antiphlogistic regimen is ne- cessary, and should be more or less strictly enjoined according to the de- gree of general excitement. Even where this is not very considerable, all kinds of animal food and fermented liquors must be avoided, ut;d the diet should bt: light and diluent, a huge quantity even of the mildest solid food often increasing the affection of the fauces. 104 PYREXIA OR FEBRILE DISEASES. CLASS I. Of the MUMPS, ou CYNANCHE PAROTID J v\. T J- HIS disease chiefly affects children among the lower class of people; is often epidemic, and manifestly contagious. It is distinguished by an external moveable swelling that arises most commonly on both sides of the neck, but in some instances it is confined to one. These tumours occupy the maxillary and parotid glands ; are large, hard, and somewhat painful ; and sometimes they attain to such a considerable size, as greatly to impede the powers of respiration and de- glutition, giving rise thereby to pyrexia. The swelling usually continues to increase till the fourth day ; but from that period it declines, and in a few days more goes off entirely, and then the febrile disposition likewise ceases. As the swelling of the fauces subsides, it not unfrequently hap- pens that some tumour affects the testicles in the male sex, or the breasts in the female, but this generally goes away in a few days. Sometimes the tumour in the fauces becomes suddenly suppressed, and is not atten- ded with the last-mentioned symptom, or if so, this is quickly repressed ; in which case the fever becomes very considerable, is attended with de- lirium, and at length proves fatal. There is, however, seldom much danger from this disease, except when symptoms of congestion in the brain or its membranes arise. The mumps do not often require the assistance of medicine ; and all that is in general requisite, is to keep the head and face warm, to avoid taking cold, and to open the bowels by the mildest cooling laxatives ; but should the tumour in the neck suddenly disappear, and the febrile symp- toms increase, so as to induce an apprehension that the brain will be affect- ed, it will be advisable to promote and reproduce the swelling by warm fomentations and stimulating liniments ;* and to obviate the fatal con- sequences that might ensue from its suddenly receding by means of ven- esection, nauseating doses of emetic medicines,t cathartics, and blisters, according to the violence of the disease. When the testicles become affected and are much swelled, every en- deavour shoidd be exerted to prevent suppuration from ensuing, and we are therefore to have recourse to bleeding, both general and topical, ca- thartics, cooling and discutient applications, and a suspensory bag. Much the same means are to be adopted, when, on a retrocession of the tumour in the neck, the female breast becomes indurated and swelled. * R. Liniment. Ammonise 5J. Tind. Cantharid. gutt. xx. M. Vel ft. Spirit. Camphorat. 5J. Aq. Ammonia: jij. Tindt. Cantharid. jfs. M. ft. Linimentum. t R. Kali Nitrati gj. Antim. Tartarifat. gr. ij. M. Et in Chartulas No. vj. divid. quarum fumat unam 4tis horis. Vet ft. Hauft.Salin.3jfs. Vini Antimon. £v.tt. xv. Syrup. Cort. Aurant. gj. ft. Hauftus 3tia quaque hora capien- dus. ORDER II. JUTRID SORE THROAT. 105 Of the PUTRID SORE THROAT, or CYNANCHE MALIGNA. 1 HE putrid sore throat is readily to be distinguished from the inflam- matory quinsy by the soreness and white specks which appear in the fauces, together with the great debility of the system, a small fluttering pulse, and an eruption on the skin of the same nature with that of scar- latina, which are to be observed in the former; whereas in the latter there is always great difficulty of breathing, a considerable degree of tumour, with a tendency in the parts affected to suppurate, and a hard full pulse. Moreover, in the former disease, the inflammation is seated principally in the mucous membrane of the mouth and throat, and the accompanying fever is of the typhoid type ; whereas in the latter, it chiefly occupies the glandular parts, and the fever is of the inflamma- tory kind. The putrid sore throat often arises from a peculiar or humid state of the atmosphere, and so becomes epidemical, making its attacks chiefly on children, and those of a weak lax habit, principally about autumn and the beginning of winter. It is produced likewise by contagion, as it is found to run through a family, when it has once seized any persoa in it; and it proves often fV.t:d, particularly to those in an infantile state. In some instances the symptoms of scarlatina and cynanche maligna are so blended together, that it is difficult to say of which disease they partake most; in a practical view, this is however of no importance. Cynanche maligna usually makes its attack with cold shiverings, anxiety, nausea and vomiting, succeeded by hsat, restlessness, thirst, debility, and oppression at the chest; the face looks flushed, the eyes are red, and a stiffness is perceived in the nee!;, with a hurried respira- tion, hoarseness of voice, and soreness in the throat; end upon viewing the internal fauces, there appears a fiery redness in eveiy part, with some slight degree of swelling in the tonsils, which, however, is by no means so great as to impede either respiration or deglutition. The inflammation, after a short time, takes a peculiar termination ; for, upon a further inspection intc the throat, a number of sloughs of a shade between a light ash colour and a dark brown are to be observed on the tonsils, velum pendulum palati, and uvula ; the breath is highly offensive ; the tongue is covered with a thick brown fur ; and the inside of the lips is beset with vesicles, containing an licrid matter, which fall- ing on the corners of the mouth and other parts, occasions excoriations. With these symptoms there is likewise a coryza, which pours out a thin acrid matter, excoriating the nostrils. A pjrging often attends also, particularly in infants, and a thin acrid matter flows from the anus, exco- riating this, and the neighbouring parts. From the first attack of the complaint there is a considerable degree of fever, with a small, frequent, and irregular pulse; and every evening there occurs a manifest exacerbation, and in the morning some slight O 106 rVREXlAv OR FEBRILE DISEASES. CLASS X. remission, together with general loss of strength and debility. In some cases the brain is affected with delirium or coma. About the second or third day, large patches of a dark red colour make their appearance about the face and neck, which by degrees be- come dispersed over every part of the body,- even to the extremities of the fingers, which feel swelled and stiff. These eruptions, after con- tinuing for about four days, depart without producing any remission of the symptoms. The inflammation, as in the cynanche tonsillaris, sometimes spreads along the eustachian tube to the internal ear, occasioning ulceration, and sometimes wholly destroying its structure. In other cases it extends to the parotid, maxillary, and other glands of the fauces, which become swelled and painful. The whole neck, indeed, sometimes swells, and assumes a dark red colour. As the sloughs spread, they generally become of a darker colour, the interstices at the same time assuming a purple hue ; new specks arise, and the whole internal fauces are at length covered with thick sloughs, which, when they fall off, discover ulcers sometimes very deeply seated. In the worst cases, the fauces appear quite black, the sloughs cor- rode deeper and deeper, and spread throughout the whole of the ali- mentary tube, so as to terminate at last in gangrene ; and the symptoms of irritation continuing to increase, together with a severe purging coming on, the patient is cut off; which event happens usually before the seventh day, and, in some cases, so early as on the third. Where there is a great increase of the evening paroxysm of fever, with vast debility, depression or irregularity in the pulse, much fetor of breath, and a livid appearance in the ulcers, with a purging, petechia, or hemorrhage, the disease will certainly terminate fatally ; but where the pulse becomes more moderate and stronger, the respiration freer, the skin soft and moist, the florid colour begins to return to the fauces, and a better matter to be discharged from the ulcers, with less acri- mony in that which flows from the nares, we may expect a favourable termination. In slight cases, where the fever is of a less putrid nature and the symptoms are moderate, and where the appearance of the efflo- rescence is succeeded by a remission, and this remission of the fever in- creases daily in the progress of the disease, we need not be apprehensive of danger. Cynanche maligna generally arrives at its height about the fifth or sixth day, and in cases which terminate favourably declines in five or six clays. It has, however, been observed to run through its course more slowly in adults than in children. It sometimes happens that cynanche maligna appears without any affection or efflorescence of the skin, in the same manner as we meet with the scarlatina without any ulceration in the throat: in general, however, the affections of the throat and skin are combined, and seem wonderfully influenced by the state of each other. But while the ab- sence of the sore throat in scarlatina always denotes a favourable pro- ORDER II. PUTRID SORE THROAT. 107 gnosis, that of the eruption in cynanche maligna generally affords an unfavourable one. The eruption in cynanche maligna is seldom uniformly diffused, but comes out in blotches or small points scattered over the trunk and ex- tremities, which are rarely of a florid red, but of a dark purplish or livid hue, and which terminate in but a very scanty desquamation. As in other eruptive fevers, the eruption in this sometimes suddenly recedes, and an alarming train of symptoms arise. The patient becomes drop- sical, the countenance assumes a cadaverous appearance, and convul- sions supervene, which terminate in death. The same consequence has ensued on the eruption suddenly assuming a very pale or livid appearance. A florid colour of the eruption, with a uniform diffusion of it over the body, and a copious desquamation, afford a favourable prognosis. From dissections, it appears that in this disease the fauces are in- flamed, suppurated, and gangrenous ; and that the trachea and larynx are likewise in a state of inflammation, and lined with a viscid fetid matter. In many instances, the inflammatory affection extends to the lungs themselves. Large swellings of the lymphatic glands about the neck, occasioned by an absorption of the acrid matter poured out in the fauces, are now and then to be found. The same morbid appear- ances which are to be met with in typhus gravior present themselves in other parts of the body. In the treatment of the putrid sore throat, we should abstain from all kinds of bleeding either topical or general, as it would infallibly prove injurious by increasing the irritability, and likewise the debility, which naturally are very great. The same precaution is necessary with respect to the employment of active purgatives, and we are sufficiently deterred indeed from the use of them, by observing that a diarrhoea arising even spontaneously, always does harm, and often proves fatal. The regular expulsion of the faeces is therefore to be solicited by clysters, or the most gentle aperients, and even these are only to be had recourse to when nature is defective. It has often happened in this complaint, that from a want of due attention to this precaution, a cathartic has been followed by a retrocession of the eruption, and a train of the most alarming symptoms. If active cathartics are ever admissible in cynanche ma- ligna, they can only be so at its very commencement, or at the termina- tion of those cases, where, although there is a healthy appearance in the throat, with an abatement of all the febrile symptoms, still the ab- domen becomes swelled from a collection of putrid colluvies ; or glan- dular obstructions are formed. In such instances, a few grains of calo- mel with rhubarb may be administered with caution. At the commencement of the disease, it has been found of service to give a gentle emetic ; wherefore a few grains of ipecacuanha may be taken. It will not fail to bring off a considerable quantity of acrid matter, which by getting into the bowels, might induce a diarrhoea ; an affection to be avoided by every possible means, as always adding to de- bility, and endangering the life of the patient. At an advanced stage of the disorder, vomiting might be attended with bad consequences. l08 PYREXI* OR FEBRILE DISEASES. CLASS I. The grand objects to be kept in view in this malignant disease, should be. to check or counteract the septic tendency Vvhich prevails ; to wash off from time to time the acrid matter from the fauces, and to ob- viate debilitv. Should any particular symptoms arise during its pro- gress which may tend to aggravate it, such as diarrhoea, hemorrhage, &c they ought to be immediately attended to. In the year 1787, at vvhich period I was in the West Indies, this disease prevailed in the island of Saint Christopher's, as a universal epi- demic among children, and a vast number of them fell martyrs to it, in spite of the utmost endeavours of the profession to save them, when at last the most happy effects were derived from the use of a remedy, the basis of which was Cayenne pepper. The medicine was prepared by infusing two table-spoonfuls of this pepper and a tea-spoonful of salt, in half a pint of boiling water, adding thereto the same quantity of warm vinegar. After standing for about an hour, the liquor was strained through a fine cloth, and two table-spoonfuls were given every half hour. The speedy and good effect produced by the use of this medicine in every case in which it was tried, evidently points out the utility of giving warm aromatics, which will bring on a timely separation of the sloughs, as well as other antiseptics, to correct the tendency in the parts to gangrene. Since the period above mentioned, many practitioners have become vouchers for the very beneficial effects which were derived in various instances of cynanche maligna from this medicine. My own experience induces me to speak well of it also. To assist the effect of the pepper remedy, it will be highly advisable to give the Peruvian bark at the same time in doses of, from two scruples, to a drachm, every two hours; and if the inflammatory symptoms do not run high, it may be mixed in a little Port wine. Should the stomach not be able to retain the powder, we may then sub- stitute the extract or strong decoction or infusion of it, adding to each dose about two drachms of the tincture. If the least degree of diarrhoea is produced by a use of the bark, a few drops of the tincture of opium may be added to each dose. With many children it may be impossible to prevail on them to take the bark in any form. In such cases, it ought to be administered in a clyster. Two drachms of the fine powder may be given in four or five ounces of barley-water, every three or four hours, to young children ; and about half an ounce, in a proportionate quantity of the liquid, to those of eight or ten years of age. Should the first clyster come away too soon, one or two grains of opium may be added to the subsequent ones. The extract of cinchona may be employed in the same way. In cynanche maligna, a junction of the muriatic acid with the bark, as advised under the head of Typhus Gravior, or of the oxygenated mu- riatic acid, as noticed under that of Scarlatina, will be very proper. "Where we give these acids in considerable doses, it may be necessary to add a few drops of tinctura opii to each, in order to prevent any dis- agreeable effect on the stomach and bowels from ensuing. ORDER lit PUTRID SORE THROAT. 109 To check the septic tendency in the parts, as well f.s to remove the acrid matter which is secreted, it will be necessary to wash out the fauces with some proper gargle,* making frequent use of the pepper remedy in the same manner ; bu' as young children cannot be prevailed on to gargle, it ought to be injected into the mouth and throat with a syringe. After washing the parts in this manner, the steams arising from warm vinegar and water may be received into the fauces by means of an inha- ler. Oxygen gas may also be inhaled Where there is any difficulty in inducing the patient to sit up in bed to inhale this gas, or we are not furnished with the necessary apparatus, we may substitute the following method, which perhaps may answer equally well. Cause the windows and doors of the person's apartment to be closed, and then taking a chafing-dish with some live coals, throw in- to it half an ounce of purified nitre in powder, which will fill the room with a thick white cloud, that will continue for a considerable time. This process ought frequently to be repeated in the course of the day. Many judicious practitioners have thought that the greater fatality among children than adults, in such as have laboured under cynanche maligna, is in a great measure to be attributed to their swallowing the morbid secaetion from the throat. This, beyond all doubt, induces vo- miting, griping pains, and a purging of the worst kind, by causing the complaint to spread along the alimentary tube ; and it is very frequently by these affections that children are destroyed. Possibly they might be prevented by removing the acrid matter from time to time by a small sponge fastened to the end of a quill or piece of wood ; and by means of another sponge at the other end, the ulcerated fauces may be touched with the mixtures best calculated to promote their healing. This mode of proceeding will be the more necessary when gargling is not freely em- ployed. No force whatever is to be used for occasioning a separation of the sloughs; and if after a continuation of the gargles for some time, the sloughs should not begin to separate, all that can be done with safety is to touch them with a little alum, or the marine acid mixed with honey, &c applied with a small piece of soft rag or hair pencil. When any considerable degree of fever attends, and the skin is very dry, it may be advisable to give small and frequently repeated doses of some diaphoretic medicine ; but as antimonials are apt to turn down- * R. Md Hofx 3J. _ Decodl. Hordei %x. Tin CLASS I, it will likewise be advisable to apply a large blister immediately over the part affected ; and to prevent the coming on of a strangury, the patient should be directed to drink plentifully of barley-water, in which a small quantity of gum arabic has been dissolved. If it heals up too quickly, and the pain is not relieved by the first, a fresh one ought to be applied as near to the former as possible. Where the pain is trifling, or the patient cannot be persuaded to sub- mit to the application of a blister, flannel cloths wrung out in a warm decoction of emollient herbs, or bladders containing warm water, may be applied in its stead. In pleurisy the application of cold on or near the part affected has been used with a salutary effect. Nitre, as being a powerful refrigerant, is likely to be a useful medicine in pleurisy as well as in peripneumony. It may be given in doses often grains, repeated every three or four hours. As strong purgatives are found to determine the flow of blood to inter- nal parts, they are improper remedies to be used in pleurisy ; and there- fore when it is found necessary to obviate costiveness on the first attack of the disease, it will be best to do it by means of gentle laxatives, such as the neutral salts, manna, or an infusion of senna, and the body may afterwards be kept open by emollient clysters, administered so as to pr* eure one or two stools daily. An early use of diaphoretics, particularly those of the antimonial class (as prescribed under the head of Simple Continued Fever,) will be very proper in the cure of pleurisy ; as they not only determine the circula- tion to the surface of the body, but will likewise greatly assist in promo- ting an expectoration. They ought, however, to be given in such small doses as not to excite vomiting (which might be attended with bad con- sequences,) and to be repeated every two or three hours. To assist their operation, the patient should take frequent small draughts of some tepid liquor, such as barley-water, or herb-tea. The pediluvium, or semicupium, frequently repeated, might prove good auxiliaries. A free expectoration being the mean which nature usually adopts to relieve herself of this inflammation, it ought therefore to be encouraged by every possible method, such as inhaling the steams arising from warm water and milk, or from a decoction of emollient herbs, and giving mucilaginous * and oily f medicines frequently throughout the course R. Mucilag. Gum. Arab. ^iv. Aq. Fontan. ^ij. Nitr. Purific. 5J. Vin. Antimon. gutt. xxx. Svrup. Limon. ^j. M. ft. Miftura cujus fumat Cochl. ij. pro dos. fubinde vel tafle urgenti. f R. Ol. Oliv. Optim. %). Mucil. Gum. Arab. §iv. Oxymel. Scillas Sfiij. Ammonia ^j. Aq. Pulegii Jij. M. ft. Miftura. Vel ft. Ol. Amygdal. Dulc. gj. Syrup. Althaeas ^ij. Mucilag. G. Arab. gj. Aq. Fontan. ^iij. ----Ammon. 2fs. M, ft. Miftura. ORDER II. PLEURISY. 119 of the day, as here advised, or recommended under the head of Peri- pneumony. These will likewise serve to sheathe the throat, and other parts, from the acrimonious mucus, which is thrown out, and which pro- vokes frequent fits of coughing. As opiates evidently tend to give a check to expectoration, they ought, if possible, to be avoided ; but if it is absolutely necessary to have re- course to them, by the patient being exhausted from the want of sleep, they may then be given, joined with some diaphoretic* Throughout the whole course of the disease the patient is to abstain from animal food, and from all kinds of fermented and spirituous liquors, supporting his strength with gruel, sago, preparations of barley, and such-like vegetable productions. On his recovery, he is carefully to guard against any fresh exposure to cold, as a return of the complaint might be attended with Worse consequences than the first attack. Of PERIPNEUMONY, or PNEUMONIA. Ix PERIPNEUMONY, or inflammation of the lungs, is denoted by a difficulty of breathing, obtuse pain in some part of the chest, cough, a fre- quent full pulse, vibrating under the finger, like the tense string of a mu- sical instrument, white tongue, high-coloured urine, and other symptoms of inflammatory fever. The disease is divided into the true and spuri- ous peripneumony. When it arises from sizy blood obstructing the ves- sels of the lungs, it is called by the former appellation ; and when it pro- ceeds from a thick viscid matter, producing a similar effect, it is known by the name of the latter. Pneumonia is sometimes met with as super- vening on typhus gravior, and then appears under a different character from its usual one. The most general cause of peripneumony is, the application of cold to the body, which gives a check to the perspiration, and determines a great flow of blood to the lungs. It attacks principally those of a robust con- stitution and plethoric habit, and occurs most frequently in the winter season, and spring of the year ; but it may arise in either of the other seasons, when there are sudden vicissitudes from heat to cold. Other causes, such as violent exertions in singing, speaking, or playing on wind instruments, by producing an increased action of the lungs, have been known to occasion peripneumony. Severe exercise, external injuries, a free indulgence in the use of fermented liquors, re- pelled eruptions, suppressed evacuations, and metastasis from other • ft. Aq. Ammon. Acetat. 5 fs. ----Menth. Sativ. gj. Vin. Antimon. gutt. xxx. Spirit. iEther. Niiros. gutt. xx. Tind. Opii gutt. xl. Syrup. Althaea; ,^ij. M. ft, Hauftus hora decubitus sumendus. 120 PYREXIAE OR FEBRILE DISEASES. CLASS I. diseases, such as gout, rheumatism, Sec. may also give rise to it. Those who have laboured under a former attack of this complaint, are much predisposed to returns of it. The true peripneumony comes on with an obtuse pain in the chest ov side, great difficulty of breathing (particularly in a recumbent position, or when lying on the side affected,) together with a cough, dryness of the skin, heat, anxiety, flushing of the face, and thirst. At the first commence- ment of the disease, the pulse is usually full, strong, hard, and frequent ; but in an advanced stage it is commonly weak, soft, and often irregular. In the beginning the cough is frequently dry, and without expectoration ; but in some cases it is moist even from the first, and the matter spit up is various both in colour and consistence, being often streaked with blood. If relief is not afforded in time, and the inflammation proceeds with such violence as to endanger suffocation, the vessels of the neck will be- come turgid and swelled; the face will alter to a purple colour ; an effu- sion of blood will take place into the celiular substance of the lungs, so as to impede the circulation through that organ, and the patient will soon ~be deprived of life. Should these violent symptoms not arise, and the proper means for carrying off the inflammation have either been neglected, or have proved ineffectual, although adopted at an early period of the disease, a suppura- tion may ensue, which event is to be known by frequent slight shiverings; by an abatement of the pain, and sense of fulness in the part; by the pa- tient being able to lie on the side which was affected, with greater ease than before ; by a remission of the previous febrile symptoms and ac- cession of hectic, and by the respiration being less painful but more oppressed. Sometimes lymph is effused into the cavity of the chest, and gives rise to hydrothorax ; at others, adhesions to the ribs are formed. When peripneumony proves fatal, it is generally by an effusion of blood taking place into the cellular texture of the lungs, so as to oc- casion suffocation, which usually happens between the third and seventh day ; but it may likewise prove fatal, by terminating either in suppura- tion or gangrene. In those cases where it goes off by resolution, some very evident eva- cuation always attends it, such as a great flow of urine, with a copious sediment, diarrhoea, a sweat diffused over the Avhole body, or a he- morrhage from the nose ; but the evacuation which most frequently terminates the complaint, and which does it with the greatest effect, is a free and copious expectoration of a thick white or yellow mucus, slight- ly streaked with blood ; and by this the disease is carried off in the course of twelve or fourteen days. Our opinion as to the event is to be drawn from the symptoms which are present. A high degree of fever, attended with delirium, much difficulty of breathing, acute pain, a dry cough, or an expectoration of a dark black colour, sudden cessation of pain, followed by a change of countenance, and a sinking or irregularity of the pulse, denote great danger : on the contrary, an abatement of the febrile symptoms, and of • RDER II. PERIPNEUMONIA 121 the difficulty of breathing, and pain, taking place on the coming on of a free expectoration, or the happening of any other critical evacuation, such as a hemorrhage from the nose, diarrhoea, or free diaphoresis, the urine at the same time depositing a copious sediment, promise fair for the re- covery of the patient. When the inflammation terminates either in sup- puration, or an effusion of lymph, it is always to be considered as dange- rous. On dissection, the lungs usually appear inflamed, and there is often found an extravasation either of blood or of coagulable lymph in their cellular substance. The same appearances likewise present themselves in the cavity of the thorax, and within the pericardium. The pleura, connected with the lungs, is also in an inflamed state, having its surface every where crowded with red vessels. Besides these, abscesses are fre- quently found in the substance of the lungs, as likewise tubercles and ad- hesions to the ribs are formed. A quantity of purulent matter is often discovered also in the branchiae. As in many cases of peripneumony the patient is destroyed in the course of a few days by the passage of the blood through the lungs being obstructed, hemorrhage of blood ensuing, or the inflammation proceed- ing on rapidly to a suppuration, the antiphlogistic plan, in its most rigo- rous extent, ought to be adopted on the very first attack of the disease. A quantity of blood proportioned to the violence of the symptoms and the vigour of the person, should be drawn from the arm; taking care to make the orifice large (see Pleurisy, page 117;) and if the difficulty of breathing and pain are not relieved while it flows, the bleeding should be continued until the patient seems likely to faint, as one copious evacuation will be far preferable to repeated small bleedings. If the pain and difficulty of breathing continue violent, or return after a short interval (which they are very apt to do,) the bleeding may be re- peated the succeeding or even on the same clay, and a considerable quan- tity may again be'drawn off; but when the inflammatory disposition is trifling, and the difficulty of breathing and pain are not very great (the patient complaining perhaps only of a rawness and soreness in the throat,) it will not be necessary to have recourse to the operation a second or third time. It is according to the state of the symptoms, the effect produc- ed, and the appearance which the blood puts on when allowed to cool, that bleedings are to be repeated, and the more early they are prac- tised, the more effectual they will prove. They will, however, be high- ly serviceable at any period of the disease, previous to the taking place of the expectoration, should they have been neglected at first; but after this comes on in any considerable degree, it would be highly improper to bleed. Where there has been a considerable lapse of time, and the patient is in a weak debilitated^ state, instead of repeating venesection a second or third time, we may apply several leeches to the chest immediately over the part which is most painful. To diminish the action of the heart and arteries, it has been proposed in this disease, as well as in pleurisy, to administer the digitalis. In Q 12.2 PYREXIAE OR FEBRILE DISEASES. CLASS I. addition to early and copious bleeding, this remedy may, probably, have a good effect, but it ought never to be relied on alone. Where much systematic debility and pulmonic irritation prevail, with frequent cough- ing, difficult respiration, dry heated skin, and a rapid hard pulse, not- withstanding we have bled freely in the early stage of the disease we may then give the foxglove, either in the form of powder or tincture. About half a grain of the former, or from fifteen to twenty drops of the latter, may be administered every four hours. Inflaming the skin immediately over the part affected with pain, by the application of a large blister ; is another proper step to be adopted after bleeding ; and should it shew a disposition to heal up soon, a fresh one ought to be applied in the vicinity of the other, so as to keep up a constant effect; which mode of proceeding will be far preferable to keep- ing the blistered parts open with any kind of stimulating ointment, as is often practised. Emollient fomentations and cataplasms are sometimes made use of, but they evidently interfere with the application of a more powerful re- medy, as a blister cannot be kept on at the same time that they are em- ployed. A free expectoration being the means vvhich nature most usually adopts for carrying off the inflammation, we ought, therefore, to promote it as much as possible, by giving such medicines as are supposed to have a power of promoting a secretion from the glands of the throat, and bron- chia; ; and likewise such as will serve to alleviate the cough, by sheathing the parts against that acrimony of the mucus which gives rise to it. It may be at the option of the practitioner to use any of the forms mention- ed below,* or to substitute those advised under the head of Pleurisy. To assist their effect, as well as to relax the vessels of the lungs, it will be right to recommend the steams arising from a warm infusion of emollient herbs, such as marshmallow, chamomile-flowers, &c. with an addition of vinegar, to be inhaled repeatedly throughout the course of the day. Few auxiliary remedies have proved more efficacious in this disease, than the steam of warm water impregnated with vinegar, and copiously inhaled by means of Dr. Mudge's machine. A common objection made by patients to take medicines containing spermaceti, is, that, in the usual way of preparing them, the mixture R. Sevi Ceti gij. Vitell. Ovi q. s. ad folut. et adde Aq. Pulegii 3*iv. Nitri Purif. gj. Oxymel. Scillx 3'iij. M. ft. Miftura. Cochl. ij. pro dos. ■ fubinde vel tuffe urgenti. Vel ft. Mucilag. Gum. Arab. 3 V. Syrup. Limon. ^j. Tincft. Tolutan. ^fs. M. ft. Miftura. Vel ft. Gum. Ammon. 5J. Solve in Aq. Puleg. giv. et adde Acet. Scillx sjiij. Syrup. Tolutan. =fs. M. ft. Miftura. Vd ft. Ol. Amygdal. Duic Syrup. Tolutan. aa 3J. Spermaceti (Gum. Arab, permixt.) 5!]. Conferv. Cyuosbat. ^fs. M. ft. Lindusde quo fiepius lambat aegcr. ORDER II. TERIPNEUMONY. 123 is not smooth and uniform. It has been found, that by first melting the spermaceti, and pouring it into a mortar which has been previously warmed, then adding a sufficient quantity of the yolk of eggs, and after- wards the water, this inconvenience is entirely avoided, and that much less time is required than in the usual way of preparing it. With the view of assisting expectoration, and determining to the sur- face of the body, we may give antimonials in small nauseating doses, taking care, however, not to excite any vomiting. With these medi- cines, * it will be proper to direct the patient to take frequent small draughts of some mild diluent liquor, such as barley-water, or thin gruel, to which may be added a little lemon-juice, so as to give it a pleasing acidity. Nitre, and some other neutral salts f, will likewise produce a good effect in peripneumony, as well as antimonials, and may therefore be given. Making use of a pediluvium every evening, might probably be at- tended with much benefit. ' If the bowels require evacuation in the course of the disease, strong purgatives ought not to be employed; but gentle laxatives of a cooling nature, and emollient clysters, should be used. It is nearly an universal opinion that purgatives are not proper remedies in pneumonic affec- tions ; that drastic ones ought not to be administered, is very obvious ; but nevertheless we are not to neglect giving those of a mild nature, such as an infusion of senna, a solution of vitriolated magnesia, or those prescribed below $. At the commencement of pneumonic inflammation opiates would evi- dently prove injurious by interrupting expectoration, and therefore they should not be prescribed in this stage of the disease, unless the cough proves so troublesome, as to exhaust the patient from the want of rest; or at least, until previous bleeding and blistering have somewhat relieved the difficulty of breathing and pain. In a more advanced stage of peripneumony, where a cough is the only urgent symptom, and * R. Pulv. Antimonial. gr. ij. Conserv. Rosaj gr. xij. M. ft. Bolus 3tia hora sumendus. Vel ft. Pul. Jacob. Ver. gr. iv. pro dos. Vel ft. Antimon. Tartarisat. gr. ij. Aq. Fontan. 3"vijfs. Syrup. Rosx 3Is. M. ft. Mist, cujus sumat Cochl. magna ij. tertia vel quarta hora^ •J- ft. Succ. I.imon. 3jfs. Kal. Prxparat. 5Jj. _ Aq. Menth. Sativ. 3J. —Fontan. 3iij. Nitr. Purific. 3J. Syrup. Tolutan. 3fs. M. ft. Mtstura cujus sumat Cochl. iij. pro do . Vel ft. Aq. Ammon. Acetat. giij. — Purae £x. Nitri Purif. gr. vj.—x. Vini Antimon. gutt. x. Syrup. Althaex^j. M. ft. Hauftus quartishoris sumendus. \ ft. Mannae Optim. §fs. Kal. Tartarisat. giij. Aq. Fervent. §ij. M. ft. Hauftus. Vel ft. 01. Ricini gj. pro dos. 124 PYREXIAE OR FEBRILE DISEASES. CLASS I. proves the chief cause either of the continuance of the pain, or of the want of sleep, opiates will prove highly useful, and may therefore be given, combined with the pectoral medicines before advised, or in the form of a draught * to be taken about bed-time. During the whole of the complaint the patient should be confined to bed, lying with his head and shoulders as much elevated as possible ; his chamber is to be kept of a proper temperature, and his strength sup- ported with food of a light nutritive nature. His drink should be thin gruel and barley-water, sweetened with honey, or a decoction of liquorice, in which a small portion of currant-jelly is dissolved, to give it a pleas- ing tartness. On recovering, he should carefully guard against any ex- posure to cold, or any irregularity which might occasion a relapse; for no inflammation is so apt to recur, as the pneumonic, and a return of it might lay the foundation of phthisis pulmonalis. If in consequence of the violence of the disease, an effusion of lymph takes place, and hydrothorax ensues, the means advised under this head must be employed. If suppuration is the termination, and we cannot evacuate the matter in any other way than by having recourse to the ope- ration of paracentesis, this should be performed rather than suffer the patient to die, without some effort being made to save him. In the putrid pneumonia, which, as before observed, sometimes super- venes on typhus gravior, the general plan of treatment should be a combination of that of typhus with the local treatment of pneumonia. Bleeding from the system would certainly prove injurious ; and where the debility has been great, there are instances on record, in which even topical blood-letting by means of scarifications of the side in this com- plaint has become so obstinate and profuse, as to baffle every attempt to 6top it, till the patient expired. Dry cupping, together with fomenta- tions, cataplasms, and rubefacient liniments applied over the part, will be far more advisable, the person at the same time drawing in with the breath watery vapours repeatedly throughout the day and night, by means of an inhaler. When there is considerable tendency to gangrene and hemorrhagies, blisters would be improper, both on account of the evacuation which they occasion, and because they sometimes give rise to gangrenous sores. In this disease every thing that might derange the prima vix should be guarded against. The presence of noxious matter in these passages often has, however, a share in producing the putrid pneumonia ; and in such cases, clearing the alimentary canal ought to form an essential part of the treatment; but as the operation of cathartics would be too de- bilitating, and it seems very generally admitted that the chief cause of irritation is in most instances lodged in the stomach, it would appear that an emetic will be the best means of removing it. To avoid ex- ■PHP^—————— * R. Aq. Ammon. Acet. sjiij. — Menth. Sativ. gj. Tinct. Opii gutt. lx. Syrup. Tolutan. 31J. Vin. Antimon. gutt. xx. M. ft, Hauftus. ORDER II. PERIPNEUMONY. 125 citing purging, instead of vomiting, which would be certain to prove prejudicial, we should prescribe ipecacuanha in preference to any anti- monial emetic. When the skin is very dry and hot, saline draughts, or the aqua am- moniac acetats, may be administered with advantage. To allay pain, ease the cough, stop diarrhoea when it arises, or procure sleep, we'may employ opium. i'o support the vital powers, and resist the tendency to putrescency, it will be right in all cases of this species of pneumonia to allow a mo- derate use of wine, proportioning the quantity to the degree of debility which is present. If the inflammatory symptoms do not run high, and the fever shews any tendency to remit, we may add a joint use of the bark of cinchona. When we have succeeded in removing the symptoms of putrid pneu- monia, it will be necessary to have recourse to bitters and aromatics, in order to strengthen the stomach and system in general. Of SPURIOUS PERIPNEUMONY, or PERIPNEUMONIA NOTHA. T J. HIS disease commonly makes its attack on those who are some- what advanced in life, especially such as are of a phlegmatic habit, or who have had frequent catarrhal affections; and, like the other species of peripneumony, is occasioned by cold, being most prevalent in the autumn and spring, or when there are frequent vicissitudes of the weather from heat to cold. It comes on usually with alternate chills and heats, flushing in the face, pain and giddiness in the head, a sense of lassitude over the whole body, difficulty of breathing great oppression at the chest, with ob- scure pains there, together with a cough, accompanied by some degree of expectoration, and often with the throwing up of a considerable quan- tity of viscid mucus. Spurious peripneumony is sometimes so slight as to resemble only a violent catarrh, and, after the employment of a few proper remedies, goes off by a free and copious expectoration ; but sometimes the symp- toms run high, and an effusion of serum into the bronchias takes place, which destroys the patient. If advice is applied for at an early period of the disease, and there is great difficulty of breathing, with much pain, it will be proper to bleed, in order to facilitate the circulation of the blood through the lungs ; but where these do not prevail, we need not have recourse to the lancet, for much harm may be done by inducing a considerable degree of debility unnecessarily, as the disease principally attacks elderly people, and such as are of a phlegmatic habit. To relieve the difficulty of breathing, and oppression at the chest, it will be advisable to apply a large blister immediately over the part af- fected, after which, if there is any nausea present, we may prescribe a gentle emetic ; but if there is not, we may be content with giving small doses of antimonials, as advised in the true peripneumony, to procure a 126 fvrexije or febrile diseases. class i, perspiration ; and in order to keep up a constant effect, they should be repeated every two or three hours ; the patient drinking plentifully at the same time of tepid liquors. These means having been adopted, we ought then to give pectoral medicines combined with squills, as recommended under the head just mentioned. If costiveness arises in the course of the disease, it must be removed by emollient clysters, or gentle laxatives, such as manna, crystals of tartar, &c taking care to avoid strong purgatives, which would be hurt- ful, by inducing a state of debility. Throughout the whole course of the disease an antiphlogistic regi- men will be most proper. Where great debility prevails, or the patient has long been accustomed to a free use of fermented liquors, a small quantity of wine will be admissible. Considering Bronchitis as only a milder species of pneumonic inflam- mation, and requiring somewhat of a similar treatment, I have not thought it necessary to notice it under a distinct head ; but a late writer* has looked upon it as deserving of a separate investigation. With respect to Carditis, or inflammation of the heart; Pericarditis, or inflammation of the pericardium ; and Diaphragmitis, or inflamma- tion of the diaphragm ; they are on many occasions scarcely to be dis- tinguished from pneumonia, and probably are usually combined with it. Happily the treatment which has been recommended in this, is equally suited to these inflammations, with this difference, however, that as the parts affected are immediately necessary to life, the means of cure must be employed with promptness and diligence. Of an INFLAMMATION of the STOMACH, or GASTRITIS. X HIS disease is divided into two species ; the phlegmonous and ery- sipelatous : but it is the former which is .here to be treated of, the latter arising chiefly towards the close of other diseases, marking the certain approach to dissolution, and being unaccompanied with any marks of general inflammation, or by any burning pain in the stomach. Phlegmonous gastritis is produced by acrid substances of various kinds, such as arsenic, corrosive sublimate, &c taken into the stomach, as likewise by food of an improper nature, by potations of spirituous li- quors, by taking large draughts of any cold liquor when the body is much heated by exercise, dancing, &c. : and by repelled exanthemata and gout. Besides these, it may arise from an inflammation of some of the neighbouring parts extending to the stomach. This species of gastritis is readily to be distinguished from any other disease, by the burning pain, heat and tension in the region of the stomach ; by the aggravation of that pain when any thing is swallowed, * See the Treatise on Bronchitis by Dr. Badham. • RDER II. INFLAMMATION OF THE STOMACH. 127 with the immediate rejection of it; and by the sudden and greater de- pression of strength in this than in any other inflammation. Indeed en- teritis is the only disease it can be confounded with ; and from this it may easily be discerned by the seat of pain or pressure with the hand. The symptoms which attend it are, a violent burning pain in the re- gion of the stomach, with great soreness, distention, and flatulency, a severe vomiting, especially after any thing is swallowed, whether it be li- quid or solid, most distressing thirst, restlessness, anxiety, and a continu- al tossing of the body, with great debility, constant watching, and a quick, hard, and contracted pulse. In some cases a severe purging attends. If the disease increases in violence, symptoms of irritation then ensuej there is great loss of strength, with faintings, a short and interrupted re- spiration, cold clammy sweats, hiccups, coldness of the extremities, an intermitting pulse, and the patient is soon cut off. The event of gastritis is seldom favourable, as the person is usually, either suddenly destroyed by the violence of the inflammation, or else it terminates in suppuration, ulceration, or gangrene. Perhaps it may sometimes occasion scirrhosity of the pylorus. If the symptoms are very mild, and proper medicines have been em- ployed at an early period of the disease, it may, however, terminate in resolution, and that in the course of the first, or at farthest, the second week. The pulse becoming more soft and full about the fourth day, and diminishing in frequency ; the pain gradually ceasing; the urine depositing a sediment; or diarrhoea supervening ; are to be regarded as favourable symptoms. Its termination in suppuration may be known by the symptoms, al- though moderate, exceeding the continuance of eight or ten days, and a remission of pain occurring, whilst a sense of weight and anxiety still re- main ; and on the formation of an abscess, cold shiverings ensue, with marked exacerbations, in the evening, which are followed by night sweats, and other symptoms of hectic fever ; and these at length prove fatal, un- less the pus is thrown up by vomiting, and the ulcer heals. Its tendency to gangrene may be dreaded from the violence of its symp- toms not yielding to proper remedies early in the disease, and when be- gun, it may be known by the sudden cessation of the pain ; by the pulse continuing its frequency, but becoming weaker ; and by delirium, with other marks of increasing debility, ensuing. In consequence of previous inflammation, a scirrhosity of the pylorus is sometimes induced, but unfortunately we know of no symptoms which are characteristic of it. When it has ulcerated and formed what is called cancer, there is generally an eructation of very fetid air, and a frequent vomiting of a dark-coloured mucus, which is offensive. The pain is con- stant, though varying in'degree : it is increased by taking an acrid or acid substance into the stomach ; whereas mild fluids, such as milk, gruel, Sec. occasion little or no uneasiness ; and this circumstance may help to distinguish it from that pain which is occasioned by mere distention, for there the pain equally follows, whatever is the food taken. Fatal cases of this disease shew, on dissection, a considerable redness on the inner coat of the stomach, having a layer of coagulable lymph lin- 128 PYREXIA OR FEBRILE DISEASES. CLASS I. ing its surface. They likewise exhibit a partial thickening of the sub- stance of the organ at the inflamed part, the inflammation seldom exten- ding over the whole of it. Where ulceration has taken place, the ulcers sometimes are found to penetrate through all its coats, and sometimes only through one or two of them. The cure of gastritis is to be attempted by copious and repeated blee- dings employed at an early period of the disease, not regarding, or being intimidated by the smallness of the pulse, as it usually becomes softer and fuller after the operation. After venesection, topical bleeding by means of several leeches over the stomach, or scarifying and cupping, may also be immediately adopted. A large blister may next be applied to the region of the stomach, and the cure be assisted by fomentations of the whole abdomen, as well as by the frequent administration of emollient and laxative clysters. A warm bath will prove highly beneficial. Pedi- luvia may also be used. The irritable state of the stomach prevents any kind of medicine from being received into it ; and it is only after the violence of pain and the frequency of vomiting are somewhat abated, that we can venture to admi- nister opiates, even in the form of clysters. To sheathe the stomach, particularly in those cases where the inflam- mation has been occasioned by any acrid matter received into it, we should advise the patient to take frequent small draughts of some mild diluent drink, such as chicken-broth, linseed-tea, or barley-water, in which may be dissolved a small quantity of gum arabic. The other means recommended under the head of Mineral and Veget- able Poisons, may likewise be adopted according to the nature of the poi- son. When we cannot ascertain this, we may recommend a saline draught, in the act of effervescence, to be taken every two or three hours, particu- Iy as long as the stomach continues in an irritable state. The acidulated soda water is also proper. The tendency to suppuration is to be obviated by pursuing the steps which have been mentioned ; and when it has actually taken place, must be left to nature, only avoiding all irritation. To allay pain and irritabil- ity of the stomach, opium may be administered in small doses. Mild farinaceous nourishment will be most proper. / A. gangrene is likewise to be obviated by the means which have been advised. When it takes place, it admits of no relief from medicine. Where either scirrhosity or cancerous ulceration of the pylorus has en- sued, only a temporary relief can be expected. In the former, small do- ses of calomel conjoined with cicuta, together with a milk diet, maybe most proper: in the latter, opium, cicuta, and hyoscyamus, with a simi- lar diet, may be tried. • RDEE II. INFLAMMATION OF THE INTESTINES. 129 Of an INFLAMMATION of the INTESTINES, or ENTERITIS. T i- HIS, as well as gastritis, is of two species, viz. the phlegmonous and erysipelatous ; the latter of which, arising only in consequence oF some other disease, is not here to be noticed. The only disease with which enteritis can be confounded, is colic ; but from this it may readily be distinguished, as the former is accompanied with fever, and a quick and hard small pulse, and the pain is increased on pressure, which does not occur in colic. The causes of enteritis are much the same with those of gastritis, be- ing occasioned by acrid or irritating substances, indurated fasces, long- eontinued and obstinate costiveness, spasmodic colic, intus-susception, and a strangulation of any part of the intestinal canal; but another very ge- neral cause is the application of cold to the lower extremities, or to the belly itself. It is a disease which is most apt to occur at an advanced period of life, and is very liable to a relapse. It comes on with an acute pain, extending in general over the whole of the abdomen, but more especially round the navel, which is greatly ag- gravated on pressure ; accompanied with eructations, sickness at the sto- mach, a vomiting of bilious matter, obstinate costiveness, thirst, heat, great anxiety, and a quick and hard small pulse. After a short time the pain becomes more severe, the bowels are affected with spasms, the whole region of the abdomen is highly painful to the touch, and seems drawn together in lumpy contractions ; invincible costiveness prevails, and the urine is voided with great difficulty and pain. The inflammation continuing to proceed with violence, terminates at last in ulceration or gangrene ; or it goesoffby resolution. Enteritis is always attended with considerable danger, as it often ter- minates in gangrene in the space of a few hours from its commence- ment : this event is marked by a sudden remission of pain, sinking of the pulse, shrinking of the features, suppression of urine, hiccup, and disten- tion of the belly, which sounds, on being struck with the finger ; and it frequently proves fatal likewise, during the inflammatory stage. If the, pains abate gradually, if natural stools be passed, if a universal diaphore- sis, attended with a firm equal pulse, comes on, or if a copious discharge of loaded urine, with the same kind of pulse, takes place, a resolution and favourable termination may be expected. Its termination in ulceration, which is not common, can only be known by the febrile symptoms remitting ; by occasional pains and rigors ; and by pus being mixed with the evacuations from the bowels. Dissections of this disease shew, that the inflammation pervades the intestinal tube to a very considerable extent ; that adhesions of the dis- eased portion to contiguous parts are of en formed ; and that, in some cases, the intestines are in a gangrenous state, or that ulcerations have formed. They likewise shew, that, besides obstinate obstructions, intus- susception, constrictions, and twistings, are often to be met with; and R 130 pyrexia: or febrile diseases. CLASS I. that, in most cases, the peritoneum is more or less affected, and is per- ceived, at times, to be covered with a layer of coagulable lymph. The mesentery and omentum are also found much inflamed. On the first coming on of the disease it will be necessary to have re- course to copious bleeding, which may be repeated according to the se- verity and violence of the symptoms, and the age and strength of the pa- tient. After plentiful venesection, topical bleeding by means of muny leeches applied to the abdomen, will be advisable. These steps being ta- ken, the body should be opened by some laxative * administered by the mouth, if the stomach is not in an irritable state ; but if a frequent vomi- ting prevails, we must be content with substituting emollient clysters, of- ten repeated ; the effects of which may be forwarded by warm fomenta- tions applied over the whole region of the abdomen. The application of a blister immediately over the part affected will also be advisable. When the violence of the symptoms abates, we may then venture to give some opening medicine, so as to procure a free passage. The warm bath will be proper, but it ought not to supersede the use of blisters. A preference on such occasions must be given to the semicupium. In enteritis attended with constipation, calomel given in the dose often or twenty grains after due venesection, is the most efficacious cathartic we can employ, and, if made into very small pills, is not likely to be reject- ed by vomiting, which generally attends the disease. In the usual order of proceeding in cases of enteritis, purgative medi- cines are certainly essential to the plan of treatment; but bleeding, al- though considered as of the greatest importance, is not always employed so as to produce a powerful impression upon the system at large. Our attention should always be directed principally at first to the subduing of the inflammation by repeated large venesections on the very onset of the disease ; by local bleedings ; by the warm bath, and the application of a blister to the abdomen ; and when we have effected this, we may then re- sort to purgatives, to remove the constipation. This latter being the ef- fect, and not the cause of the disease, should not be the symptom first at- tended to. It is, indeed, too much the custom to have recourse to active pur- gatives at the very commencement of enteritis, and this too in very con- siderable doses—-a practice which cannot fail to prove highly prejudicial. The intention is to evacuate the bowels, but it should be considered that purgatives empty the intestinal canal by means of their specific, sti- mulus, which increases the secretions, and quickens its peristaltic motion: ft. Ol. Riclni 5j. Aq. Menth. ^l"s. Tin oi Pyrexiae. U4_ pyrexia: or febrile diseases. class I. Dr. Darwin observes, it is a common opinion that this disease is as frequently owing to gluttony in eating, as to intemperance in drinking fermented or spirituous liquors ; but that he has never seen any person afflicted with the gout who has not drank freely of fermented liquors, as beer or wine ; though, as the disposition to all the diseases which have originated from intoxication is in some degree hereditary, a less quantity of spirituous potation will induce the gout in those who inherit the dis- position from their parents. It may likewise be brought on by great sensuality and excess in vene- ry, intense and close application to study, long want of rest, grief, or un- easiness of mind, exposure to cold, too free a use of acidulated liquors, a sudden change from a full to a spare diet, the quick suppression of any accustomed discharge, or by excessive evacuations ; and that it some- times proceeds from an hereditary disposition is beyond all doubt, as fe- males who have been remarked for their great abstemiousness, and youths of a tender age, have been attacked with it. A peculiar saline acrimony existing in the blood, in such a proportion as to irritate and excite to morbid action the minute terminations of the arteries, in certain parts of the body, has been assigned by some physi- cians as the proximate cause of gout. Dr. Cullen supposed it to be a loss of tone in the extremities of the system, while it is in a vigorous and ple- thoric state, and the energy of the brain still retains its vigour. Dr. Dar- win supposes that it arises from the inirritability or defective irritation of some part of the system, the consequence of which is torpor and in- flammation ; but no hypotheses hitherto advanced, are of a satisfactory nature. A paroxysm of regular gout sometimes comes on suddenly, without any warning ; at other times it is preceded by an unusual coldness of the feet and legs, a suppression of perspiration in them, and numbness, or by a sense of pricking along the whole of the lower extremities; and with these symptoms the appetite is diminished, the stomach is troubled with flatulency and indigestion, a degree of torpor and languor is felt over the whole body, great lassitude and fatigue are experienced after the least exercise, the body is costive, and the urine pallid. On the night of the attack the patient perhaps goes to bed in tolerable health, and after a few hours is awaked by the severity of the pain, which has affected either the joint of the great toe, the heel, calf of the leg, or perhaps the whole of the foot; and this becoming at length still more violent, is succeeded by rigors, and other febrile symptoms, together with a severe throbbing and inflammation in the part. Sometimes both feet become swelled and inflamed, so that neither of them can be put to the ground, nor can the patient endure the least motion without suffering excruciating pain. Towards morning he falls asleep, and a gentle sweat breaks out, and terminates the paroxysm, a number of which constitutes what is called a fit of the gout, the duration of which will be longer, or shorter, according to the disposition of the body to the disease, the season of the vear, and the age and strength of the patient. ORDER II. GOUT. 145 When the paroxysm has thus taken place, although there is an alle- viation of pain at the expiration of some hours, still the patient is not en- tirely relieved from it, and for some evenings successively he has a re- turn both of pain and fever, which continue with more or less violence until morning. In time the paroxysms, however, prove more mild every day, till at length the disease goes off either by perspiration, urine, or some other evacuation ; the parts which have been affected becoming itchy, the cuticle falling off in scales from them, and some slight degree of lame- ness remaining. At first, an attack of gout occurs, perhaps, only once in two or three years ; it then probably comes on every year, and at length it becomes more frequent, and is more severe and of longer duration each succeed- ing fit. In the progress of the disease various parts of the body are affected, and translations take place from one joint or limb to another, and after frequent attacks the joints lose their strength and flexibility, and become so stiff as to be deprived of all motion. In some instances, little swell- ings of a very hard nature arise in the joints of the fingers, to which a late writer* has applied the title of nodosities. Concretions of a chalky nature are likewise formed upon the outside of the joints, and nephritic affections of the kidneys arise from a deposit of the same kind of matter in them, which although fluid at first becomes dry and firm at last, and when put into acids is perfectly soluble. It sometimes happens, that although a gouty diathesis prevails in the system, yet from certain causes no inflammatory affection of the joints is produced ; in which case, the stomach becomes particularly affected, and the patient is troubled with flatulency, indigestion, loss of appetite, eructations, nausea, vomiting, and severe pains ; and these affections are often accompanied with much dejection of spirits, and other hypochon- driacal symptoms. In some cases the head is affected with pains and giddiness, and now and then with a tendency to apoplexy ; and in other cases the viscera of the thorax suffer from the disease, and palpitations, faintings, cramps, and asthma arise. This is what is called atonic gout. It likewise happens sometimes, that after the inflammation has occu- pied a joint, instead of its continuing the usual time and so going off gradually, it ceases suddenly, and is translated to some internal part. The term of retrocedent gout is applied to occurrences of this nature. When it falls on the stomach, it occasions nausea, vomiting, anxiety, or great pain, with a sensation of coldness in the epigastric region ; when on the heart, it brings on a syncope ; when on the lungs, it produces an affection resembling asthma ; and when it occupies the head, it is apt to give rise to apoplexy or palsy. A third species of irregular gout is the misplaced, which implies where the gouty diathesis, instead of producing the inflammatory affec- tion of the joints, occasions an inflammatory affection of some internal * See Dr. Haygarth's Clinical History of Diseases. T 146 PYREXIAE OR FEBRILE DISEASES. CLASS I. part, and which appears with the same symptoms that attend inflamma- tions of those parts from other causes. All occurrences of this nature, as well as of the two former, are to be regarded as attacks of irregular gout, and are to be guarded against as much as possible. Gout is seldom attended with danger, unless translations take place to some vital part, such as the head, heart, lungs, and stomach ; in which instances it often proves fatal. Many constitutions suffer severely, how- ever, from the effects of atonic gout. In youth, the disease admits more readily of alleviation than in an advanced period of life, and its attacks may be rendered milder when acquired, than when it proceeds from an hereditary disposition ; moreover the fit is generally shorter in proportion to the violence of the febrile symptoms and the length of in- termission. When the constitution has suffered great ravages from frequent and severe attacks of the gout, various morbid affections of the viscera are to be observed on dissection : calculi of different sizes and colour are to be found in the kidneys; and on examining the joints which have been rendered stiff and immoveable, it appears as if their motion had been destroyed by the formation of chalky concretions of a similar na- ture with those lodged in the kidneys. These calculous concretions, or chalk-stones, as they are called, are supposed to be the consequence of local diseased action, and not of systematic origin ; or, in other words, that they are only the effects, and not causes of gouty action. In a paper read before the Royal Society June 22d, 1797, Dr. Wol- laston demonstrated that the concretions which form on the joints of gouty persons are composed of the lithic acid and soda, forming a com- pound salt, the lithiate or urate of soda. Dr. G. Pearson likewise, in a paper read before the same Society in December 171)7, in which he re- lates the result of the analysis of upwards of three hundred urinary cal- culi, particularly mentions the existence of this acid in arthritic con- cretions. The word lithic, borrowed from the term lithiasis, he recom- mends to be changed to that of uric. Fourcroy also about the same time discovered the uric acid in these concretions. Notwithstanding the many remedies which have been highly extolled at different times for the cure of the gout, it is a fact well established, that not one which has yet been offered possesses any such power; and all that can be done with safety to the patient, is to conduct him through the paroxysm when it has once commenced, and afterwards by a strict and proper attention to diet, and the making use of gentle daily exer- cise, to render recurrences of the disease less frequent and more mild than they otherwise might be. In a regular fit of the gout the aid of medicine is seldom necessary; and all that may in general be requisite, is to keep the inflamed parts mo- derately warm by wrapping them up in flannel, wool, or fleecy hosiery, and to confine the patient, if young and plethoric, to a spare regimen, carefully abstaining from every thing that might add to the irritation. In elderly people, where the tone of the stomach is weak, or where the patient has been in the constant habit of using strong liquors, and of ORDER II. GOUT. 147 living principally on animal food, a more generous diet, with a moderate use of wine, may be allowed ; and as Madeira and Sherry wines are the least apt to become acid on the stomach, they ought therefore to be used in preference to any other kind. During the paroxysm the patient should be kept as quiet and still as possible, and his mind should not be ruffled ; but, on the contrary, be soothed and calmed by giving way to his humours; gouty persons being generally captious from the severity of the pain which they suffer. By adopting an antiphlogistic mode of treatment, we might perhaps, in many instances, be able to remove a fit of the gout; but in so doing, we might occasion a translation to some vital part; for vvhich reason, bleeding from the system and purging ought never" to be used ; neither should external applications be resorted to ; for although liniments, fo- mentations, and emollient poultices have sometimes been employed with impunity, still at times they have proved pernicious by occasioning a re- trocession of gout. The fostering of arthritic inflammation by the topical use of increased temperature, or covering the parts with flannel, 8cc. together with the in- ternal employment of stimulant medicines, with a view to obviate its re- trocession, and insure its final extinction on the part affected, is supposed by Dr. Kinglake* to be a very erroneous practice, and as repugnant to the indication of relief furnished by every constitutional feature of the disease. He tells us, that observation and reflection have forced on his convic- tion the fact, that, however loose the analogy might be between the res- pective proximate causes of ordinary phlegmonous and arthritic inflam- mations, the resemblance is sufficiently close in the degree of concomi- tant temperature. In both, the vascular actions of the system and of the part affected, generate a morbid excess of heat, alike referable to distem- pered conditions of motive power. Impressed with the persuasion, that with regard both to inordinate temperature, and to its general as well as topical manifestations, a radical similitude subsists between these nomi- nally different inflammations, it has appeared to him strictly warrantable to institute a perfectly similar plan of cure, viz. that of reducing heat by keeping cloths wetted with cold water constantly to the parts affected. In support of the efficacy of this plan he recites several cases which were successfully treated by topically abstracting the stimulus of heat from the parts by water, and such other cold media. We are further told by him, that he thinks himself justifiable in drawing the following inferences, viz. that a high temperature, whether the cause or effect of the morbid conditions of vital power, which proximately constitute gout, is safely and speedily controllable by the simple application of cold water ; that the prevailing opinion relative to the critical nature of that disease on the extremities is liable to much distrust ; that the local deposit is not, as commonly supposed, a parti- cular preponderance and detention of the constitutional disorder, but that it originates in the parts themselves, and is thence distributed by • See his Treatife on the Gout. 148 VTREXIJE OR 'FEBRILE DISEASES. CLASS I. associated influence over the system ; and lastly, that the longer the lo- cal affection endures, the greater probability there will be of morbid sympathies being generated and established on the vital organs, which may terminate in rapid and painful death. Such is Dr. Kinglake*s theory, and being somewhat vague, is not, I think, likely to make many proselytes. Popular prejudice is, moreover, very strong against the remedy recommended by him, and therefore the young practitioner, in particular, should be cautious in advising it. The application of cold water in gouty paroxysms has not, however, originated with this physician, for it is a mode of treatment noticed by Hippocrates and Celsus, and even by some modern writers.* It is there- fore only the revival of a practice which has frequently been brought for- ward, and again abandoned, from its being somewhat hazardous. If the cooling or refrigerant treatment is ever adopted, I think it should not be ventured upon until the stomach, and other viscera, have shewn indubita- ble signs of performing their functions with their proper and accustomed energy, and till the local inflammation has existed for a day or two ; and even then, no greater degree of cold should be applied, or be continued for a longer duration, than will be sufficient to subdue the local inflam- mation. If, notwithstanding this precaution, symptoms of constitutional disturbance should arise, we ought then immediately to remove the re- frigerant application, and endeavour to relieve the torpor by suitable sti- mulants. In no case should the application of cold to the extremities be resorted to without keeping the stomach all the time in a moderate state of activity. Another physician f tells us, that, with regard to external applications in the gout, none out of the many which he had tried, proved so effectual as steam, and occasionally confining the inflamed part in a rarer at- mosphere ; for which purpose he recommends a steady use of the air-pump vapour-bath every other or third day. This treatment, we are informed, has not only the happiest effects on the paroxysms while present, but renders subsequent ones more mild, protracting likewise the intervals between them. Gout not being, however, a mere local complaint, as Dr. Kinglake and some others seem to imagine, but really a constitutional one, local appli- cations, when resorted to, should, I think, always be joined with internal remedies. Of the two external applications just mentioned, the latter seems to be the safer, although it may not probably remove or carry off inflammation in the limb so quickly as the former. Blistering, stinging with nettles, burning with moxa, as practised in the East Indies, rubbing the part with camphorated spirits, pediluvium of simple water, a tepid bath of water and muriatic acid, in the propor- tion of one ounce to a gallon of water, and covering the part with oil- skin, are remedies which have been proposed for relieving and carry- * See Mr. Rigby's Treatife on Animal Heat.—Medical Obfervations, vol. vj. f See Dr. Blegborough's Communications on Gout, vol. xii. p. 62, of the Medical and Phyfical Journal. ORDER II. COUT. 149 ing off a paroxysm of gout; but they are all attended with risk, and ought therefore to be avoided. In those cases where it has been repelled, the application of a blister to the part originally affected, is often attended, however, with the best effect. As soon as the inflammation has been brought back to its original place, the blister ought immediately to be removed, and a bit of fine lint, dipped in fresh oil, be applied as a dressing, wrapping the limb in flannel or fleecy hosiery immediately afterwards. When medicines are necessary in a regular fit of the gout, in conse- quence of the inflammation and febrile symptoms running high, those possessed of the power of determining gently to the surface of the body, will be most proper, and may therefore be given as below.* To promote their effect, the patient ought to drink plentifully of mild diluents. With the view of exciting a gentle diaphoresis, and thereby shortening the paroxysm, a solution of guaiacum is sometimes administered ; out where there is much febrile heat, this medicine would be improper. If costiveness prevails in so high a degree as to render it necessary to evacuate the intestines, it will be best to give a proper quantity of the tincture of rhubarb, or some such warm stomachic laxative. From the severity of the pain in gout, opiates are sometimes resorted to ; but when given in the beginning of gouty paroxysms, or where there is much inflammation, they often make them return with greater vio- lence ; but in those cases where the person is far advanced in life, has had frequent attacks, and where there is little or no inflammation, but merely restlessness, they may be given with safety and advantage. About two scruples or a drachm of the confectio opiata, taken at bed-time, may be preferable to the tinctura opii. Hemlock and other narcotics have of late been much employed in gout, and some practitioners have bestowed high encomiums on the former ; but from the few trials I have made, I cannot report favourably of it. On the termination of a fit of the gout, a fresh paroxysm is to be de- layed or rendered less violent by observing great temperance during the intervals; by avoiding the exciting causes of the disease ; by moderate exercise ; by a use of mild cathartics ; by avoiding cold, and by strength- efiing the body. When any swelling and stiffness remain in the joints after the pa- roxysms have ceased, the stimulus of galvanism, conjointly with the frequent use of a flesh-brush, may be attended with some benefit. * ft. Pulv. Antimonial. gr. ij. ft. Succi Limon. gfs. Ammoniae q. s. ad ejus faturation- Ammoni.-e gr. viij. em Aq. Purse ^vj. Conferv. Rofx q. s. M. Vini Antimonii gutt. xij. Syrup. Cort. Aurant. £j. M. fr. Eolus 3tia vel 4U hora fumendus. ft. Hauftus 4ta vel 6ta hora fumendus. Vd 1-50 PYREXIAE OR FEBRILE DISEASES. CLASS I. In consequence of frequent attacks of the gout, assisted, probably, by some peculiarity of the patient's constitution or habit of body, little swel- lings or nodosities arise on or near the joints of the fingers, for the remo- val of which we are told by a late writer t that the following indications should be observed, viz. first, to diminish the increased action of the ves- sels in the part by which the secretion of the morbid matter is perform- ed ; secondly, to promote a free perspiration of the part affected ; and thirdly, to correct the prevailing disposition to acidity in the primae via, and in the system in general. To accomplish the first of these indica- tions, leeches are to be applied to the tumefied part, their number being determined by the extent of the tumour and degree of the disease. To obtain the object of the second indication, the part is to be surrounded by a plaster of equal parts of simple diachylon and white soap, the adhesion of which to the skin becomes in a few days so slight as to admit the free exit of the perspirable matter through the skin, and which being hinder- ed from escaping farther, condenses on the surface of the plaster. To fulfil the third indication, a due attention is to be paid to the mode of liv- ing, by avoiding acid and acescent matters, and particularly such fermen- ted liquors as have begun to manifest marks of acescency. To neutral- ize that acidity which, being present in the stomach, would secure its in- crease by acting as a ferment, it may be advisable to give the soda in do- ses from five grains to ten or fifteen in the day. From the combined influence of these measures it appears, by Mr. Parkinson's account, that the utmost success that hope could look for has been obtained. The gradual diminution, and finally, the complete re- moval of nodosities which had existed for several months, have been thus procured ; while those which had existed for some years have been se much reduced as to allow of considerable motion in joints which had be- come nearly immoveable. Dr. Bardsley, physician to the Manchester Infirmary, mentions, in his Medical Reports, that he looks on nodosities of the joints to be more near- ly allied to chronic rheumatism than to gout. He has therein given the history of three cases of this nature, in the'last of which, after a fair but unsuccessful trial of arsenic, cod-liver oil (a remedy much used in Lan- cashire,) bark, guaiacum, and warm bathing, he had recourse to mercu- rial frictions ; and by establishing and keeping up for some time a gen- tle salivation, with the assistance of tepid bathing, and topical bleedings by leeches, he effected a cure. From this instance he appears to think that mercury is capable of destroying the,disease, when in its incipient state. In irregular, or atonic gout, where no inflammation of the joints is produced, although the gouty diathesis prevails in the system, but the stomach is affected with indigestion, flatulency, acid eructations, and pain, the patient ought not only to avoid all debilitating causes, but f See Obfervations on the Nature and Cure of Gout, &c. by Mr. James Parkin for. ORDER II. GOUT. 151 should employ proper means for strengthening the system in general, and the stomach in particular. To support the tone of the system, a proper quantity of animal food ought to be taken, and that which is most nutritive and plain should be preferred. Gout, when in the system, and not regularly formed, re- quires an excess of animal food to drive it to the extremities, though in some measure it mayfaggravate the disease should a paroxysm ensue. With the same view, a moderate allowance of wine will be proper; but all kinds of acescent wines, such as hock, claret, 8cc. ought to be avoided. Madeira and Sherry are those which will be most suitable. If the acidity in the stomach is perceived to be increased by a use even of these wines, weak brandy and water, without any addition of either sugar or lemon, may then be substituted. Cold bathing is a powerful tonic ; but in gouty habits it appears to be rather a hazardous remedy, and ought not therefore to be used. To strengthen the stomach, aromatics, the Peruvian bark,* and chaly- beates, may be given. (See Dyspepsia.) The cinchona is not apt, when long continued, to produce atony in the stomach, like other bitter remedies, and therefore a preference should be given to it over all others by persons of a gouty habit. In those cases where gout produces anomalous affections of the head, stomach, and bowels, the greatest benefit may be derived from the Bath water ; and it is here a principal advantage to be able to bring by warmth that active local inflammation in any limb which relieves all the other troublesome and dangerous symptoms. Hence it is, that this water is commonly said to produce the gout, by which is meant only, that where persons have a gouty affection, shifting from place to place, and thereby much disordering the system, the internal and external use of the Bath water will soon bring on a general increase of action, indi- cated by a flushing in the face, fulness in the circulating vessels, and re- lief of the dyspeptic symptoms, and the disorder will at length terminate in a fit of the gout, which is the crisis to be wished for. In various cases of gout, especially where the high inflammation of particular limbs has gone off, and where it has left either a number of dyspeptic symptoms, or a rigidity or impaired action in the seat of the disease, an internal use of Buxton water has been recommended. As an external application in gout, it has also been found serviceable in re- storing the functions to parts so diseased. „____-_ * R. Infus. Rad. Columb. £iv. ( Tinct. Cort. Peruv. W ------Cardam. C. a!i Jfs. M. y ft. Mistura cujus sumat .xger Cochl. ij. magna oi^tefw in die. Vet Wrj ft. Rubig. Ferri £ij. ^ J ' Pulv. Cort. Peruv. s-j. Aromat. £jfs. Syrup. Cort. Aurant. q. s- M. i'. Electnarium dc quo capiat quantkatem juglandis bis in die. 152 PYREXIA OR FEBRILE DISEASES. CLASS I. When any costiveness arises, it is to be removed by some laxative* that will keep the body open without occasioning much purging ; and if the stomach is troubled with acidities, a gentle emetic may be taken now and then, with a daily use of some absorbentf. In severe attacks of atonic gout, some practitioners have advised the application of blisters to the lower extremities ; but they ought to be avoided in those cases which are attended with much pain in the parts. When the stomach or intestines become affected in consequence of retrocedent gout, immediate relief ought to be attempted by making the patient drink freely of wine, or even brandy, joined with aromatics. In affections of this nature, strong spirits impregnated with asafcetida or garlic may also be given with much advantage. Opiates} joined with aromatics, or with camphor, musk, or volatile alkali, may be of service. From one to four tea-spoonfuls of equal parts of camphorated tincture of opium, and ammoniated tincture of guaiacum, in any suit- able vehicle, will be a proper medicine. jEtherwill Jikewise be a useful remedy. At the same time that we administer these medicines internally, warmth should be applied externally to the region of the stomach by hot cloths, fomentations, or a bladder filled with warm water, and hot bricks wrapped in flannel must be put to the feet. Frictions with brandy, or the linimentum ammoniae fortius, over the stomach, will also be proper. If nausea and vomiting come on, the stomach is to be relieved by taking a few draughts of wine, somewhat diluted with warm water, having recourse afterwards to opiates combined with cam- phor. If there is a translation of the disease from the extremities to the head, so as to threaten apoplexy or palsy, a large blister ought to be applied to the back, as likewise small ones to the inside of the legs, with cataplasms to the soles of the feet, and the patient must take from twenty-five to forty drops of the spiritus ammonias compositus, every three or four hours, or a combination of volatile alkali, aether, and aro- • ft. Elect, e Cassia Jij. Pulv. Rhabarb. jij. —Jalapii 3J. Ol. Carui gutt. v. Syrup. Zingib. q. s. M. ft. Elec'uarium cujus capiat magnitudi- nem juglandis pro re nata. Vel ft. Tinct. Sennx Comp. ^j. pro dos. Vel ft. Aloes Socotorin. Sapon. Hispan. aa £ij. Ol. Cinnam. gutt. v. Syrup. Spinas Cervin. q. s. M. fiat Massa in Pilulas aequales 48 dividen- da, quarum sumat ij. vel iij. hora somni. f R. Magnes. Alb. ^fs. Pulv. Rhabarb. gr. vij. Aromafe. gr. v. M. ft. Pulv. mane et vesp. sumendus. t R- Opii gr. j. Camphor, gr. vj. Alcohol, q. s. Confect. Aromat. gr. xv. M. ft. Bolus pro re nata sumendus. Vel ft. Misturae Camphorat. ^jfs. Ammonia; gr. x. Tinct. Opii gutt. xij. iEther. Vitriol, gutt. xv. ft. Haustus tenia quaque hora sumen- dus. ?RDER "• GOUT. 153 matics. About six drachms or an ounce of the tinctura aloes may also be taken as a gentle purgative. When the gout attacks the lungs, and produces asthma, blisters should be applied to the breast or back, and stimulating cataplasms to the soles of the feet, and opiates and antispasmodics should be administered inter- nally. From twenty to fifty drops of vitriolic ather may be taken every two or three hours in a glass of wine, and an opiate * may be repeated as the necessity of the occasion requires. In this particular retrocession of gout, where the attack is sosevere as to threaten suffocation, might not venesection be resorted to with advantage ? Whpre the disease attacks the kidneys, and imitates a fit of the gravel, the patient ought to kepp warm fomentations, or bladders filled with warm water, constantly applied over the parts affected ; he should drink freely of tepid diluting liquors', and an emollient clyster, with an addition of a small quantity of tinctura opii, ought frequently to be injected. In order to alleviate the pain, thirty or forty drops of the same tincture may likewise be taken by the mouth in any kind of vehicle. The gout imitates many diseases, as lias just been observed ; and by being mistaken for them and treated improperly, is often diverted from its regular course, to the great danger of the person's life ; for which rea- son, those who have had the gout ought to pay particular attention to any complaint that may happen to take place about the time they may have reason to expect another attack of it. Those likewise who never had the gout, but who, from constitution or manner of living, have reason to ex- pect it, ought also to be very circumspect with regard to its first approach, as by any wrong conduct or improper treatment it might be diverted from its right course, and be thrown upon some vital parti It has already been observed, that the gout does not admit of a cure by medicines, notwithstanding that many have been extolled as possessing such a power. Some time ago, the Portland powder t was held in the greatest celebrity, but from having been found in many instances to have proved pernicious, is now wholly laid aside. Dr. Cullen mentions in his Practice of Physic, that in every instance which he knew of the exhibition of this remedy being persevered in for the time prescribed, the persons who had taken it were, indeed, after- wards free from any inflammation of the joints, but they soon were af- f This medicine is made of equal parts of the roots of round birthwort and gentian : of the leaves of germander and ground-pine, and of the tops of the letter centaury. Thefe arc to be well dried, pounded and fitted, fo as to make a fine powder. The dofe is a drachm every morning for the firft three months, three quarters of a drachm for the enfuing three months, and half a drachm for the next fix months. In the fecond year, only half a drachm is to be taken every other day. * R. Confed. Aromat. £j. Aq. Cinnam. ^jfs. Tinility, buboes, carbuncles, petechia, he- morrhages, colliquative diarrhoea, and such other symptoms arise. By some writers the disease has been divided into three species: that attended with buboes ; that attended with carbuncles ; and 'hat accom- panied with petechia;. This division appears wholly superfluous. Dr. Russell, in his Treatise on tin; Plague, makes mention of manv varieties; 2C 202 PYREXIAE OR FEBRILE DISEASES. CLASS I. but when these have arisen, they seem to have depended in a great mea- sure on the temperament and constitution of the air at the period the dis- ease became epidemical, as likewise on the patient's habit of body at the time of his being attacked with it. Mr. M'Gregor, in his Medical Sketches of the Expedition from India to Egypt, notices, that the plague is subject to considerable varieties in different seasons and circumstances. In the Indian army, he observed, that when the disease first broke out, the cases sent from the crowded hospitals of the 61st and 88th regiments were from the commencement attended with the typhoid or low symptoms. Those which were sent from the Bengal volunteer battalion, and from the other corps, when the army was encamped near the marshy ground at El-Hammed, were all of the intermittent and remittent type. The cases which occurred in the cold rainy months of December and January had much of the inflammatory diathesis ; and in the end of the season, at Cairo Ghiza, Boulac, and on crossing the isthmus of Suez, the disease wore the form of a mild continued fever. The plague is by most writers considered as the consequence of pes- tilential contagion, which is propagated from one person to another by association, or by coming near infected materials. Some, however, have doubted whether the disease is really contagious or not. The fact that it is evidently contagious is fully established in Mr. MkGregor's opinion ; but the laws of its transmission are not more accurately known than the specific nature of the contagion. Dead bodies, we are told, did not seem to convey it; the heated animal body, and still more with a febrile moisture on the skin, appeared to transmit it most readily. Among the most obvious causes vvhich contribute to induce the plague besides contagion, may be enumerated the following, viz. corrupt or damaged grain, putrid fish or other animal substances, noxious exhalations arising from stagnant waters or slimy mud, a resi- dence in confined situations where the current of air is obstructed, and the want of due cleanliness. In some eastern countries, but more particularly Persia and Japan, thi disease is wholly unknown. In those where it is prevalent, it rages most violently during the summer ; its effects are somewhat diminished in autumn; and during the winter it is greatly reduced or totally sup- pressed. It attacks persons of all ages and both sexes indiscriminately; but women, young people, and infants at the breast, have been observed in general to resist infection more than robust men. Those who were exposed to vicissitudes of heat and cold, such as bakers, cooks, and smiths, were noticed, during the campaign in Egypt, to be more particu- larly attacked with it. The plague is said to be most prevalent in that country soon after the inund ition of the Nile, or rather its recession ; for a quantity of slimy mud being deposited on the banks of the river, and other places it has overflowed, occasions humid mephitic exhalations to arise, and which are supposed to occasion the disease. From Sir Robert Wilson's ac- count of the diseases of Egypt,* there is great reason to suppose that a - Sec hia Histury of the Expedition to Ejypt. •RDKR III. THE PLAGUE. $02 humid state of the atmosphere is favourable to the production of the plague; for the English and Turkish armies, which marched to Cairo« escaped contagion, notwithstanding almost every village was infected; while the troops that remained stationary on the moist shore of Abou- kir, were severely affected, and lost many men. A dry atmosphere ap- peared to him, not only to be a preventive of the plague in some de- gree, but likewise to act as a remedy ; for we are told, that several men, confined with this disorder in the hospital at Jaffa, escaped into the de- sert, and endeavoured to reach the army ; but finding the attempt im- practicable, they returned in three days perfectly recovered. It has been observed, that the plague generally appears as early as the fourth or fifth day after infection; but it has not yet been ascertained how long a person who has laboured under the disease is capable of in- fecting others ; nor how long the contagion may lurk in an unfavour- able habit without producing the disease, and may yet be communi- cated, and the disease excited, inhabits more susceptible of the infec- tion. It has generally been supposed, however, that a quarantine of forty days is much longer than is necessary for persons, and probably for goods also. Experience has not yet determined how much of this term may be abated. If I mistake not, the Board of Trade has however, lately, under the sanction of the College of Physicians, somewhat abridged it. It sometimes happens, that, after the application of the putrid vapour, the patient experience^pnly a considerable degree of languor and slight head-ach for a f *w da™ previous to a perfect attack of the disease ; but it more usually comes to pass, that he is very soon seized with great depression of strength, tremor of the limbs, anxiety, palpitations, syn- «ope, stupor, giddiness, violent head-ach and delirium, the pulse becom- ing at the same time very weak and irregular. These symptoms are shortly succeeded by uncommon fetor of the breath, nausea, and a vomiting of dark bilious matter: in the further progress of the disease, carbuncles make their appearance ; buboes arise in different glands, such as the parotid, maxillary, cervical, axil- lary, and inguinal ; or petechia;, hemorrhages, and a colliquative diarr- hoea ensue, which denote a putrid tendency prevailing to a great degree in the mass of blood. Such are the characteristic symptoms of this malignant disease, but it seldom happens that they are all to be met with in the same person. Some, in the advanced state of the disease, labour under buboes, others under carbuncles, and others again are covered with petechia;. In no disease do patients bear motion worse than in this. The least motion has been known to induce syncope, and even death, particularly in the last stages of the complaint. The plague is always to be considered as attended with imminent danger, and when it prevailed in this country about two hundred years ago, proved fatal to most of those who were attacked with it. It is probable, however, that many of them died from want of care and proper nourishment, the infected being forsaken by their nearest 20-i PYREXIA OR FEBRILE DISEASES. CLASS 1« friends; because in Turkey and other countries, where attention is paid to the sick, a great many recover. Of the French army that invaded Egypt, little more, however, than one third of all that were attacked with the plague recovered, as appears by the report made by M. Desgenettes,* who was the chief physician to that army. The duration of the disease is various. In some instances the effect of the pestilential contagion is the immediate extinction of life ; and cases have occurred wherein the patient has survived but a few hours the first sensation of illness. In other instances again, he has lived till the thirteenth, and even the seventeenth day of the disease. When the plague is unattended by buboes, it runs its course more rapidly, and is more generally fatal, than when accompanied by such inflammations. The earlier they appear, the milder usually is the dis- ease. When they proceed kindly to suppuration, they always prove critical, and ensure the patient's recovery. It is generally a favourable sign when the bubo does not adhere, but shakes on its base. A gentle diaphoresis, arising spontaneously, has been known in many instances likewise to prove critical. When carbuncles shew a disposition to be- come gangrenous, the event will be fatal. Furuncles, petechia;, hemorr- hages, and a colliquative diarrhfea, denote the same termination. The worst forms of the disease are always accompanied with the usual symptoms of putridity and malignity ; and such rarely terminate favourably. It has been remarked, that if a patient, after an access of delirium, was suddenly restored to his senses,Tie seldom recovered. !Most cases terminate fatally wherein the patient is comatose from the beginning. The typhomania may be regarded as a more fatal form of delirium, than the inflammatory. Dissections of the plague have discovered the gall-bladder full of black bile, the liver very considerably enlarged and diseased, the heart much increased in size, and the lungs, kidneys, and intestines beset with carbuncles. They have likewise discovered all the other appearancts of putrid fever, with the blood black and loose in its texture. In many instances, the glandular system has been found in a very diseased state. Under the supposition that a person has been exposed to contagion, and in consequence of this becomes much indisposed, the first step to be adopted is to give him an emetic, particularly where nausea or vomiting ensues. If a severe retching should prevail after the operation of the emetic, this may possibly be relieved by administering the saline medi- cine in the act of effervescence; but if it should not, we may make an addition of a few drops of tinctura opii to each dose. To obviate costiveness, and draw off any putrescent matter which may be lodged in the bowels, it will be necessary to make use ol some gentle laxative ; but large evacuations, by the aid of strong pur- • See his Histoire Medicale de TArmee de l'Orient. ORDER III. THE PLAGUE. 205 gatives, would be very improper. In an advanced stage of the dis- order, emollient clysters would be most advisable, as being less apt to excite diarrhoea, which, when it arises towards the close, gene- rally destroys the patient. So careful are the Eastern nations in avoiding this occurrence, that they most commonly make use of sup- positories only. When a diarrhea does occur, either spontaneously or from an im- proper use of cathartics, it should be suppressed as quickly as possible by astringents, opiates, and every other means we can employ. We are informed by Dr. Russell, that many, particularly the Asi- atics, make it a rule to let blood in all cases of the plague, if they see the patient ai an early period ; and some recommend it as late as the fourth, fifth, sixth, or seventh day; and even some European practi ioners have gone nearly as far. To him it appeared that very plentiful blted.ng at the first appearance of the disease was of great Service. i)r. Buchan was in the habit of occasionally resorting to bleeding, \\\ are told by Mr. M'Gregor, and that during the first season he had met with several cases where the operation proved of the greatest service. The Turks, we are informed, employ local instead of general blood-letting, most commonly, and in the latter they draw off only a very snv 11 quantity. The advantages of blood-letting in this disease appear to be of a vow dubious nature, and I think we may safely presume that for the most part it is unnecessary, and that in many cases it might prove highly prejudicial. Such likewise is the doctrine laid down by Dr. Cullen. We are given to understand that Dr. Whyte, one of the physicians to the forces in Egypt, used the lancet very freely, but that every one of his patients died. It has been observed that a gentle diaphoresis sometimes proves critical, and carries off the disease, but more particularly when it arises spontaneously. To assist nature in throwing off the morbid matte*', by the pores, if possible, it will be right to employ diapho- retics, such as the neutral salts, small doses of antimonials, or the pulv. ipecac, compos, as advised under the head of Simple Fever ; the effects of which may be increased, by directing the patient to drink plentifully of diluent acidulated liquors ; and where the heat of the body is not very considerable, his strength may be supported under this operation, by means of a little wine. Profuse sweating is, how- ever, by all means to be avoided, as, by inducing debility, it would prove injurious. Dr. Falconer of Bath, in a late Essay on the Plague, seems to in- sinuate, that no small share of the mortality formerly observed in this disease, may be attributed to the sweating regimen, then commonly employed for its cure. Instead of adopting this plan, he advises the avoidance of a warm bed, and indeed of a bed altogether, if possible, in the daytime ; a circulation of free and cool air, light clothing, cool drinks, and particularly cold water ; and he mentions, that if any 206 PYREXIA OR FEBRILE DISEASES'. GLASS ft benefit is to be expected from the use of this regimen, it must be tried largely and steadily ; not as if cold liquor were an indulgence per- mitted or allowed, but as a remedy enjoined, on which the principal de- pendance was to be placed. In addition to these means Dr. Falconer recommends the external use of cold water in the manner pointed out by the late Dr. Currie of Liverpool, and noticed under the head of Typhus Gravior. Savary, in his Letters on Egypt, mentions an anecdote which is considered by Dr. Falconer as much to his purpose. The captan of a ship, whose sailors had contracted the plague at Constantinople, caught it himself by attending on them : he felt, as he expressed him- self, excessive heat, which made his blood boil : the disease seized his head, and he perceived (as he thought) that he had only a few mo- ments to live. The little remaining reason he had, taught him to attempt an experiment : he laid himself down quite naked on the deck : the heavy dews that fell, penetrated, according to his sensations, to his very bones. In a few hours he could breathe better ; his agi- tated blood became calm, and bathing the morning after in the sea, he was perfectly cured. This case brings to my recollection another of a French soldier, and reported by M. Desgenettes, who being afflicted with the plague, threw himself into the Nile under a high degree of delirium, and on being taken out of the water after a short lapse of time, soon recovered from the disease, seemingly in consequence of his im- mersion. Camphor is a medicine which has been much recommended in the plague. For the purpose of allaying irritation and procuring sleep, opiates are advisable, and when used have by no means been found to produce coma. They seem equally proper as in typhus. If we are so fortunate as to procure a crisis by the remedies which have been advised, the bark should be given in as large doses as the stomach will bear, and be repeated every two hours ; but if there is no chance of obtaining this desirable end, then, besides the bark, we should adopt the other means recommended under the head of Malignant Fever, with the view of obviating extreme debility and the disposition to putrescency. A free use of both vegetable and mineral acids seems advisable in the plague, as well as in typhus gravior. Mr. M'Gregor, in his tract before mentioned, indeed hints that he found the nitric acid, and other irregular remedies, to be serviceable. He likewise employed mer- cury, as he thought, with some advantage ; and when the mouth was speedily made sore by it, recoveries oftener took place in the same man- ner as in yellow fever, than when .the system proved unsusceptible of the mercurial action. It appears from this gentleman's report, that some patients were kept under the influence of wine and opium for a time, according to the Brunonian theory, but that the practice never proved successful. ORDER III. TIIE PLAGUE. aor Where the patient survives the disease, the treatment of the carbun- cles or buboes becomes the province of surgery. OF THE MODE OF PREVENTION. It is well known that the pestilential virus which emanates from the human body may adhere for a long time to other substances, and preserve its power of producing and propagating future infection ; and that in this manner it may be conveyed from the Eastern countries into any other ; the persons first attacked by being exposed to the contagion, then be- coming the source of infection to others. This fact being well established, it has been judged proper by the le- gislature of this kingdom, and of some others, to oblige ships, persons, and all kinds of merchandise coming from places apt to be infected with the plague, to procure bills of health, or to undergo a certain quarantine, during which period the goods are. or ought to be, properly ventilated. An adherence to these regulations has of late years prevented the impor- tation of the disease ; but should it unfortunately ever be introduced, the following steps must be pursued for destroying the infection, and pre- venting its lurther propagation : 1st, The infected should be confined in lazarettos, surrounded by strict guards, and no kind of communication be held with them, except by such attendants as may be absolutely necessary. 2dly, The nurses or others employed in attending the sick, must take care to come in actual contact with them as seldom as possible, or place themselves in such a situation as that a stream of air may carry the efflu- via towards them* Medical attendants will act prudently in changing their linen and clothes, and in well washing, their whole body, but more particularly their hands, with warm water and vinegar, as soon as they quit the lazaretto. 3dly, All substances capable of being impregnated with the effluvia, or of vitiating the atmosphere, ought to be removed from the apart- ments of the sick to situations where the healthy cannot suffer by them * Tt is a fact well known, that the peftilential poison, unlike other ordinary epide- mics, is confined to the vicinity of the affected body, and becomes fo dilute at the dis- tance of a very few paces, as to be incapable of lurther action. Mons. Samoilowitz, a celebrated Ruffian phyfician, and author of a very good Memoir on the Plague, in- fills, that this difeafe exifts neither in the air, nor is communicated by the air, but by contact alone ; and Mons. Sonini tells us, that it is fufficient for Europeans fettled in Turkey to (hut themfeves up in their houfes in order to be preferved from the conta- gion, even when it makes the greateft ravages in towns which they inhabit, and al- though they draw from without their provisions and daily food. The report made by Mr. M'Grcgor likewife (hews how very limited in extent is t!i.- action of contagion in the plague. Thirteen of the medical gentlemen of the ar- my of Egypt were directly in the way of contagion, for it was their duty to come in- to contact with the infected : of thefe, feven caught the infection, and fcur died. To the atmofphere of the difeafe, all the medical men of the army were erpofed, as they (aw and examined the cafes in the firft inftance; but, except from actual contact, there never appeared to be ar.y danger of c ;i.t g' ; . 208 PYREXIA OR FEBRILE DISEASES. CLASS I. and where they may undergo a proper purification by exposing them to the heat of about 120 of Fahrenheit, and then freely ventilating them. The linen and other clothes of the patients should be washed frequently besides. 4thly, The atmosphere surrounding the infected ought to be kept as pure as possible, so that neither the patient nor his attendants may suffer from the exhalations : with which view, the strictest attention should be paid to cleanliness, a free ventilation, and fumigating with the nitric or muriatic acid, as advised under the head of Malignant Fever. Sthly, To avoid whatever weakens the body, by giving way to intem- perance or sensuality, or by making use of a poor diet, great fatigue, or considerable evacuations. 6thly, To keep the mind cheerful, and as free from care, anxiety, fear, and lowness of spirits, as possible. 7thly, As it is supposed that by strengthening the bodies of men we can thereby enable them to resist contagion the better, .some advantages may pro'vubly be derived from using cold bathing, with wine, bark, and other touic medicines. In Dr. Duncan's Annals of Medicine for 1797, is inserted an article relating to the cure and prevention of the plague by frictions of the whole surface of the body with olive-oil, and communicated, as we are given to understand, by George Baldwin, Esq. His Britannic Majesty's agent and consul-general in Egypt. It is mentioned, that there is no instance of the person rubbing a pa- tient having taken the infection ; but, by way of precaution, it is advised to anoint himself all over with oil, and to avoid receiving the breath of the infected person into his mouth and nostrils. The prevention to be used in all circumstances, is that of carefully anointing the body, and living upon light and easily digestible food. A striking observation made by Mr. Baldwin is, that among upwards of a million of inhabitants carried off by the plague in Upper and Lower Egypt, during the space of four years, he could not learn that a single oilman, or dealer in oil, had suffered.* Mr. Jackson, in his Reflections on the Commerce of the Mediterrane- an, likewise informs us, that in the kingdom of Tunis, where the plague frequently rages in the most frightful manner, destroying some thousands of the inhabitants, there never was known an instance of any of the coo- lies or porters who work in the oil-stores, being in the least affected by this disorder, their bodies being always well smeared with the oil, as well as their clothes being imbued with it. The evidence produced in behalf of the plan communicated by Mr. Baldwin, seems more satisfactory as to the preventive powers of the application, than as to its sanative properties alter the disease has once taken place. It seems, however, right to notice, that Dr. Assalini, who was a medical officer in the French army which invaded Egypt, .* It has been faid that when the plague raged in London about two hundred yean ago, the dealers in pitch, tar, and tobacco, were particularly obferved to cfcape the contagion. ORDLR III. THE PLAGUE. 2Q9 makes a favourable mention of oily frictions in his Observations on the Plague, as being generally followed by copious sweating ; and to this, he thinks, their beneficial operation is to be attributed. Inoculation for the plague has been tried by some physicians, in order to discover if this malady could not be checked or rendered less virulent thereby ; and it appears from Sir Robert Wilson's History of the Ex- pedition to Egypt, that Dr. Whyte, resolving to become the patient of his own speculation during the time this disease raged at Rosett'a, inocu- lated himself with matter taken from the buboes of an infected person. The attempt failed twice ; the third proved fatal in three days after the symptoms shewed themselves. It likewise appears that Dr. Desgenettes, in order to lessen the gene- ral alarm, and to inspire confidence among the French troops, inoculated himself both in the groin and arm-pit, with a lancet dipped in the pus of a bubo in a convalescent patient. The inoculation, however, failed ; and the only consequence was a slight inflammation on the inoculated parts, vvhich continued for more than three weeks. As the future susceptibility to the disease is by no means, however, destroyed, for the same person may be afflicted with it repeatedly, and even may be attacked twice in the same season with it, as Dr. Desgen- ettes experienced, (many of the convalescents from the plague who were appointed to take care of the sick, having been, he observes, seized a se- cond time,) this experiment would not be advisable, unless it could be as- certained that the disorder is rendered milder by the inoculation. This is a point not yet, however, established ; indeed, the information afforded to us by Monsieur Sonnini* seems to lead to a contrary conclusion ; for he mentions that a Russian surgeon, who was a prisoner at Constantinople, with a number of his countrymen, took it into his head to inoculate these unfortunate men with the plague, under the supposition of rendering the contagion less destructive ; but by doing so, he killed two hundred of these prisoners ; and fortunately for the rest, the inoculator, after having per- formed the operation on himself, soon died of his own treatment. Of MILIARY FEVER, oe MILIARIS. J_ HIS fever takes its name from the small pustules or bladders vvhich appear on the skin, resembling in shape and size the seeds of millet, be- ing in general numerous on the breast, back, and other parts where there is most moisture on the skin. It may be distinguished from the other exanthemata by its pathognomic symptoms, the peculiar sour and rank odour of the sweat, attended with dejection of spirits, oppression and sense of constriction about the precordia, anxiety, and frequent sighing. Many of our modern physicians seem to think that the disease is never a primary one, but arises in consequence of some other; particularly where much sweating has been excited, either by keeping the patient to* warm, or by giving heating medicines. • Travels into Greece and Turkey, p. 49-'. 2 D 310 PYREXIAE OR FEBRILE DISEASES. CLASS J. AH debilitating powers, such as a lax habit of body, weakness however induced, excessive evacuations, the presence of irritating matter in the prima; vise, the period of child-birth, long-continued menstruation, See may be regarded, most probably, as predisposing causes, while the hot re- gimen is to be looked upon as the principal exciting cause of the erup- tion. This conclusion seems justifiable, as it is found, that, whatever the state of the patient may be, miliary eruption is very generally avoided by exposure to cool air, and administering cold liquors. It has been observed to affect both sexes, and persons of all ages and constitutions, but that females of a delicate habit are most liable to it, particularly in childbed. It is, however, by no means a contagious dis- ease, and has rarely, if ever, been known to prevail epidemically. Moist variable weather predisposes most to this eruption, and its oc- currences are more usual in the spring and autumn than in the other sea- sons. Winter is the least favourable to its appearance. Miliary fever makes its attack with a slight shivering succeeded by heat, restlessness, loss of strength, depression of spirits, anxiety, diffi- culty of breathmg, oppression at the chest, and a low quick pulse. The tongue appears white, the mouth is dry, the body costive, and when the disease is violent, coma or delirium is apt to arise. Great dejection of spirits and anxiety, with fetid sweats, are, however, the most common forerunners of the miliary eruption. The patient after a short time feels an itching or pricking pain under the skin, soon after which innumerable small pustules, of a red colour, come out. These are usually distinct, but now and then we may per- ceive them clustered together. About the second day after the appearance of the eruption, a small vesicle may be observed on the top of each pimple, and in two or three days more they break, and are succeeded by small crusts, which fall off in scales. Sometimes it happens, that when one crop of eruptions had disappeared, another will succeed it. On the eruption being visible, most of the foregoing symptoms are usually relieved. The sweating is apt, however, to continue, unless proper means are used to check it, and to be attended for many days with a fresh crop of eruptions. Very violent symptoms, such as coma, delirium, and convulsive fits, now and then attend miliary fever, in which case it is apt to prove fatal. A numerous eruption indicates more danger than a scanty one. The eruption being steady, is to be considered as more propitious than its fre- quently disappearing and coming out again ; and it is more favourable when the places covered with the eruption appear swelled and stretched, than where they remain flaccid. The more severe the preceding symp- toms, and particularly the greater the debility and depression of spirits, the more unfavourable is the prognostic. The appearances to be observed on dissection, will depend on the na- ture of the fever which accompanies the eruption, and which most usual- ly is of the typhoid kind. 6RDER III. MILIARY FEVER. 211 As the disease is evidently brought on by the application of too much heat, an early attention ought to be paid to the means of preventing it from appearing in those affections which it is apt to accompany. With this intent, the patient should not to be covered with too many bed- clothes ; neither should the chamber be kept hot by means of too much fire, or by being closely shut up : on the contrary, a sufficient ventilation ought to be allowed, so as to keep it of a proper temperature. In doing this, we are, however, to take care not to run into the opposite extreme, and allow too free an admission of cold air. Sweats which are not followed by an abatement of the febrile symp- toms, cannot of course prove critical, and may therefore be safely and ad- vantageously checked, by keeping the patient's apartment cool, by cover- ing him lightly and loosely with bed-clothes, by making him lie with his arms exposed, and by giving him whatever he drinks perfectly cold ; but in sweats which are likely to be critical, the practitioner must take care to regulate the admission of air, so as that it shall not prove prejudicial. By adopting these precautions at an early period, we may often pre- vent miliary eruptions, which might otherwise have appeared ; and after they have made their appearance, we probably may be able to moderate them, by using the same means. Miliary eruptions sometimes accompany inflammatory affections ; in which case it will be necessary to have recourse to gentle aperients or laxative clysters ; but bleeding ought seldom or never to be used. They are found to attend more usually on diseases where much debility pre- vails, or where there is a disposition to putrescency ; in vvhich instances the patient's strength must be supported with wine and a nutritive diet, making use at the same time of tonics, the Peruvian bark, and other an- tiseptics, as advised under the head of Typhus Gravior. Whatever debilitates, is in most cases of miliary fever pernicious ; whatever supports the vigour of the system, beneficial. Great sickness at the stomach is apt to precede any fresh eruptions that come out in the course of the disease, and to prove very distressing. To allay it, we may order small and frequently repeated doses of the mistura camphorata. Where delirium or coma comes on, in consequence of a sudden strik- ing in of the eruptions, cordials, ammonia, camphor, and blisters will be proper. When a retrocession of the eruption happens, our principal view should be to bring out and support a sweat by powerful diaphoretics, ex- ternal warmth, pediluvium, &c Where any considerable evacuation en- sues on a retrocession, we must be careful not to check it. Should con- vulsions supervene on a retrocession, camphor, musk, and opium, are particularly recommended. To prevent the disease from arising in pregnant women, costiveness ought carefully to be guarded against; and when in childbed, they should strictly observe a cool regimen, and keep their chamber of a proper temperature, being at the same time lightly covered with clothes. 21-2 PYREXIA OR FEBRILE DISEASE*. CLASS I. Of the VESICULAR ERUPTION, or PEMPHIGUS. X HIS disease consists in eruptions dispersed over different parts of the body, internal as well as external, vvhich gradually rise up into vesicles of about the size of a large nut, containing a yellow serous fluid, that is in some instances of an ichorous nature, and which again disappear in the course of three or four days. By some authors it is described as being attended both by fever and contagion ; and'by others as being accompani- ed by neither. It is therefore supposed that there are two species of it, the chronic and the acute. The disease is, however, of very rare occur- rence. Dr. Willan * describes three varieties of it, viz. pemphigus vul- garis, pemphigus contagiosus, and pemphigus infantilis ; but he has never seen any instance of the two first. The last, he says, occurs some- times in weak emaciated children, who are destroyed by the pain and ir- ritation of the successive vesications and ulcerations. By the generality of the physicians who have favoured us with their opinions, the principal of whom is Dr. Dickson, f it has not been con- sidered as contagious. This gentleman saw six cases of the complaint, in none of vvhich it was received by contagion, nor communicated to those who attended the sick. Dr. Cullen informs us, that the blisters are fill- ed with a thin ichor which is discharged, not absorbed, as mentioned by Dr. Dickson; but during his whole practice it appears that he met only with a single case of pemphigus. Some slight degree of lassitude, sickness, and head-ach having pre- vailed for a day or two, small vesicles of about the size of a pea make their appearance over different parts of the body, and not unfrequently in the mouth, and other parts of the alimentary canal; and these gradually increase till they become as large as a nut or almond. Now and then they are to be met with of the size of a walnut. They are surrounded by an inflamed margin or areola, and distended with a faintly yellow serum. They often are accompanied with difficulty of deglutition, nausea, vomit- ing, and a sense of soreness in the abdomen. Sometimes they are so numerous as to run into each other. The pulse during this time, is small and frequent, and the patient is sensible of a considerable degree of de- bility. If the vesicles are not broken, they fill with a yellowish serum, which is again absorbed into the system in the course of three or four days. This appears to be the most favourable termination, as they have been known to leave troublesome ulcers behind them when they broke. Pemphigus resembles the small-pox, in frequently leaving pits in the skin, and in the parts which the vesicle occupied remaining of a dark colour for a considerable time afterwards. In the third volume of Me- * See his Treatife on Cutaneous Difeafes, f See his Paper on Pemphigus, in the Tranfactions of the Royal Irifh Academy in r787. ORDER III. PEMPHIGUS. 213 dical Facts and Observations, Dr. Winterbottom takes particular notice of this occurrence. We are to be influenced in our prognosis by the seat and appearance of the vesicles!. When they appear only on external parts, and are not numerous, they demand little attention ; when they are numerous, when they attack the alimentary canal, and are attended with a small hard pulse, and great prostration of strength, the danger is considerable. The danger is likewise very great, when the ulcers left by the vesicles shew a tendency to gangrene by becoming livid, which seldom happens, how- ever, unless a fever of the true typhoid kind has accompanied the eruption. On taking a comprehensive survey of what has been recorded by re- cent writers on the subject, we must, I think, conclude that pemphigus is an affection merely sporadic, and not of a contagious nature, and that the symptoms accompanying one or other instances of this affection are those which attend febrile diseases, whether inflammatory or putrid. The most important distinctions necessary to be ascertained appear therefore to be, > 1st, Whether the fever is of an inflammatory nature, and accompanied with a strong and increased action of the vascular system ; or, 2dly, Whether the fever has a tendency to the typhoid type, and is marked by great debility, and other symptoms which denote a tendency of the fluids to putrefaction. It will be obvious that in the first case evacuation and other antiphlogistic remedies will be proper; and that in the second, it will, on the contrary, be necessary to shun all evacua- tions, and to employ those remedies alone which support the strength, and give tone and vigour to the system. In most cases the disease seems to be connected with a certain state of debility, and a tendency of the fluids to putrefaction, and therefore the indications of cure are obvious. Having cleansed the stomach by a gentle emetic, where nausea pre- vails, and dislodged the contents of the intestines by some mild laxative, such as the saline purgatives, or small doses of calomel; we may then give the Peruvian bark either in infusion, decoction, or powder, along with wine. The mineral acids in a state of proper dilution, if adminis- tered early, will likewise be of service in obviating the effects of debility, and any tendency to putrefaction. On the first accession of the disorder, if the skin is hot and dry, it may be of service to give the saline medicine with small doses of some mild antimonial, in order to excite a gentle diaphoresis ; but these should not be continued long. To diminish the effects of irritation, opiates combined with vitriolic aether will be proper. Where vesicles arise in the mouth, and break, so as to become ulcers, we should then employ detergent gargles, as advised under the head of Cynanche Maligna. If there is reason to apprehend that the eruption has extended to the alimentary canal, it will be necessary to order copious draughts of some £14 PYREXIA OR FEBRILE DISEASES. CLASS I, mucilaginous decoction, as mentioned under the head of Aphtha Chronica. When obstinate ulcers are formed on any exterior part of the body in consequence of the vesicles breaking, the assistance of a surgeon will be requisite. Some practitioners are in the habit of opening the larger vesicles; but the propriety of this step is not yet fully established. On recovery, the patient's strength is to be recruited by tonics and other auxiliaries, as noticed under the head of Dyspepsia. Of the NETTLE-RASH, or URTICARIA. J- HIS disease takes its name from its being attended by an eruption of the skin, similar to what is produced by the stinging of nettles. Dr. Willan, in his Treatise on Cutaneous Diseases, notices six varieties of it. See Order III. In some instances a slight degree of fever either precedes or attends the eruption : this is not confined to any particular parts of the body, but is somewhat dispersed, being always accompanied with a considerable de- gree of heat and itching. In some cases, urticaria is characterized by large wheals or bumps, which on pressure appear of a solid nature, with- out any cavity or head ; nor do they contain any kind of fluid. The causes of urticaria are by no means obvious, but it has been sup- posed to arise from suppressed perspiration, or some irritating matter in the stomach. A disease very similar to febrile urticaria is produced in particular constitutions by substances received into the stomach, which prove offensive, such as almonds, mushrooms, crab-fish, muscles, lobsters, herrings, 8cc. When a person is poisoned by fish of a deleterious nature, it frequently shews itself as a consequence thereof. (See Animal Poi- sons.) The effect is rapid, and the symptoms are violent for some hours. In consequence of such circumstances, physicians have been induced to conclude, that urticaria, attended with fever, originates generally from indigestion, or from some substance of a noxious quality taken into the stomach. The nettle-rash readily gives way in general to a cool regimen, and keeping the body open with mild laxatives, such as the crystals of tartar, or any of the neutral salts. When it has arisen from any thing noxious being eaten, an emetic should be administered at the commencement of the attack.* * According to the nofological arrangement of Dr. Cullen, Aphtha fhould have followed next as one of the Exanthemata ; but being more frequently met with among infants than perfons of a mature age, it has been inferted among the difeafes of the in- fantile ftate. Aphthoides Chronica, or chronic thrufli, not being an idiopathic difeafe, but fymp- tomatic of fdme other, fuch as general debility, is placed in the clafs Cachexia. •RDER IV. HEMORRHAGE FROM THE tfOSE, 2J£ ORDER IV. OF INVOLUNTARY DISCHARGES OF BLOOD, OR HEMORRHAGIM. \J NDER this title are comprehended active hemorrhages only, that is, those attended with some degree of symptomatic fever, and which de- pend upon an increased impetus of the blood in the vessels from which it flows, chiefly arising from an internal cause. The general remote causes of hemorrhages of this nature are, external heat, a sanguine and plethoric habit, whatever increases the force of the circulation, as violent exercise, strong exertions, anger, and other active passions, particular postures of the body, ligatures producing local con- gestion, a determination to certain vessels, rendered habitual from the frequent repetition of hemorrhage, the suppression of accustomed eva- cuations, external violence, and exposure to cold. The general treatment of such hemorrhages must consist in putting a stop to the discharge of the blood ; in preventing its recurrence, by removing the causes by which they were excited, and by destroying the inflammatory diathesis when any exists. These means remain to be pointed out under each distinct hemorrhage, as in the subsequent pages. Of the HEMORRHAGE from the NOSE, or EPISTAXIS. T IN the nose there is a considerable net-work of blood-vessels expanded on the internal surface of the nostrils, and covered only with a thin tegument ; hence upon any determination of a greater quantity of blood than ordinary to the vessels of the head, those of the nose are easily ruptured. In general the blood flows only from one nostril; but in some cases it is discharged from both, then shewing a more consider- able disease. Persons of a sanguine and plethoric habit, and not yet advanced to manhood, are very liable to be attacked with this complaint ; females being much less subject to it than males, particularly after menstruation has commenced. Peculiar weakness in the vessels of the part, and the decline of life, may also be considered as predisposing causes. Great heat, violent exertion, external violence, particular postures of the body, and every thing that determines the blood to the head, are to be looked upon as its exciting causes. Epistaxis comes on at times, without any previous warning; but at others, it is preceded by a pain and heaviness in the head, flushing in the face, heat and itching in the nostrils, a throbbing of the temporal arteries, and a quickness of the pulse. In some instances, a coldness of the feet, and shivering over the whole body, together with a costive bel- ly, are observed to precede an attack of this hemorrhage. The complaint is to be considered as of little consequence when os* 216 pyrexia: or febrile diseases. class i. curring in young persons, being never attended with any danger ; but when it arises in those who are more advanced in life, flows profusely, and returns frequently, it indicates too great a fulness of the vessels in the head, and not unfrequently precedes apoplexy, palsy, &c. and therefore in such cases is to be regarded as a dangerous disease. When this hemorrhage arises in any putrid disorder, it is to be con- sidered as a fatal symptom. As a bleeding from the nose proves salutary in some disorders, such as vertigo and head-ach, and is critical in others, such as phrensy, apo- plexy, and inflammatory fever, where there is a determination of too great a quantity of blood to the head ; we ought properly to consider at the time that it happens, whether it really is a disease, or intended by nature to remove some other. When it arises in the course of some inflammatory disorder, or in any other where we have reason to suspect too great a determination of blood to the head, we may suppose that it will prove critical, and there- fore we should suffer it to go on, at least as long as the patient is not weakened by it. Neither should it be suddenly stopped, when it happens to persons in good health, who are of a full and plethoric habit. In short, where a bleeding at the nose relieves any disagreeable symptom, and does not proceed so far as to induce debility, it ought not to be hastily checked. When it arises in elderly people, or returns too frequently, or con- tinues till the patient becomes faint, it ought to be put a stop to as quickly as possible : to effect this, the person is to be exposed freely to cool air, and to be placed nearly in an erect position, with his head somewhat inclined backwards ; to drink freely of cold liquors, and to make use of an antiphlogistic regimen. Besides these means, he may inrmerse his head in water impregnated with ammonia muriata, and snuff vinegar and water frequently up the nose, or he may throw some astringent wash* repeatedly up the nostril from which the hemorrhage proceeds, by means of a syringe. If these means fail, a dossil dipped in strong spirits of wine, or in a solution of blue vitriol, or ferrum vitriolatum dissolved in brandy ; or a tent wetted in the white of an egg well beat up, and afterwards rolied in equal parts of alum and vitriolated zinc, may be applied up the nostril. To assist the effect of the application, the genitals may at the same time be immersed in colcfwater, and linen cloths wetted in a solution of nitre be kept to the forehead and temples. Dr. Darwin mentions in bis Zoonomia the case of a lady who had a continued hemorrhage from her nose for several days ; the ruptured ft. Aluminis in pulv. trit. £ij. Aq. Rosa ~vj. Aceti Diftillat. %\. M. Vel ft. Tinct. Ferri Muriat. ^j, Aq. Diftijht. gvj. M. * ft. Zinc. Vitriolat. gj. Cerussae Acetat. gr. x. Aqua? Distiilat. sjx. M. fr. Injectio. Vel ORDER IV. HEMORRHAGE FROM THE NOSE. 217 vessel was not to be reached by plugs up the nostrils, and the sensibility of her fauces was such, that nothing could be borne behind the uvula. After venesection, and other common applications, she was directed to immerse her whole head in a pail of water, which was made colder by the addition of several handfuls of salt; in consequence of which, the hemorrhage immediately ceased and returned no more ; but her pulse continuing hard, she was necessitated to lose blood from the arm on the succeeding day. In epistaxis the application of pressure to the mouth of the bleeding vessel is often attended with a good effect, when other means prove un- successful ; to effect which, a piece of hog's gut that has been previ- ously dried, and moistened again, may be used. One end of it being firmly tied with a bit of small packthread, is, by means of a probe, to be pushed along the course of the nostril from which the blood is dis- charged to the upper part. The gut is then to be filled with cold vinegar and water by means of a syringe inserted at the end hanging out of the nostril, and as much being injected as the gut will admit, the whole is to be pressed up as fur as possible, and to be then secured in this situation by a proper bandage. While we are pursuing these steps, we are at the same time to open the body, if necessary, with cooling purgatives, in order to make some derivation from the vessels of the head, and the patient is carefully to avoid all those circumstances which might either determine the blood to the head, or prevent its free return from it. Refrigerants, such as the saline medicine, with nitre, may be advised every hour or so, the patient drinking cold acidulated liquors, and ex- posing himself freely to cool air. Astringents, such as vitriolated zinc, alum and acetated ceruse, with opium, are sometimes given internally ; but their effect seems doubtful, as they seldom have time to act. When the complaint is of long dura- tion, they may be used as below.* Alum, catechu, and gum kino, are astringents more applicable for hemorrhages from the lungs, stomach, and intestines, than for epistaxis. In this hemorrhage as well as in all other active ones, the tincture of digitalis, given in doses of thirty drops from a two-ounce phial (the size will make some difference in the drops) every six hours for four or five doses, may prove an efficacious remedy, particularly in full robust habits, or where there is a quickened circulation. * ft. Infus. Rofa; Acid, ^vj. Nitri 3j. M. ft. Miftura cujus fum.\t Cochl. larg. iij lerfiu quaq. hora. Vel ft. Acid. Sulph. Dibit, gutt. xx. Aq. Font. ^jfs. Syrup. Rofx Jjij. Tindl. Opii gutt. xv. M. ft. Hauftus ter quatervi die. fi.men- dus. V.' ft. Zinc. Vitriolat. gr. -*—* 'V:uminis gr. x. Ir.fus. Roi.c 5jfs. Syrup Ljufdem :jj. M. ft. Hauftus btis horis fumendus. Vel ft. Aq. Diftillat. gjfs. Ccrus. Acetat. gr. fs.—j. Tirol. Opii gutt. xij —xx. Syrup. Rofae £j. M. ft. Hauftus fexta quaque hcra dus. r capier- 218 PYREXIAE OR FEBRILE DISEASES. CLASS I. After the bleeding has ceased, the patient must be careful not to re- move the tents or clotted blood, but should allow them to come awi.y of themselves ; and in order to avoid any return of the hemorrhage, tie must be kept as still and quiet as possible, taking care not to apply any thing of a stimulating nature to the nose. It sometimes happens, that when the bleeding is stopped outwardly, it nevertheless continues inwardly, and prevails in so high a degree as to threaten suffocation, particularly when the person falls asleep. In such cases, the passage may be stopped by introducing a pliable probe up the nostril, through the eye of which some strong threads have been passed, and so bringing it out at the mouth, then fasten- ing pieces of sponge to their extremities, afterwards drawing them back, and tying them on the outside with a sufficient degree of tightness. Where epistaxis arises in adults of a full plethoric habit, bleeding from the system may be performed with advantage, and with a frequent use of cooling purgatives, and an antiphlogistic regimen, may probably prevent any return of the complaint. When occasioned by too great a determination of blood to the head, topical bleeding by means of leeches to the temples will be advisable. When it is occasioned by the suppression of some accustomed evacu- ation, such as the menstrual or hemorrhoidal flux, this is to be restored if possible ; but if we do not succeed, some other discharge, by means either of an issue or seton, must be substituted. Of a SPITTING of BLOOD, or HAEMOPTYSIS. AN hxmoptysis there is a discharge of blood from the mouth, brought! up with more or less of coughing, and preceded usually by a saltish taste in the saliva, a sense of weight about the precordia, and a pain ift some part of the thorax. It is readily to be distinguished from hsematemesis, as in this last the blood is usually thrown out in considerable quantities, and is moreover of a darker colour, more grumous, and mixed with the other contents of the stomach ; whereas blood proceeding from the lungs is usually in small quantity, is of a. florid colour, and mixed with a little frothy mucus only. A spitting of blood arises most usually between the ages of sixteen and twenty-five, and may be occasioned by any violent exertion, either in running, jumping, wrestling, singing, speaking loud, or blowing wind- instruments ; as likewise by wounds^ plethora, weak vessels, hectic fever, coughs, irregular living, excessive drinking, or the suppression of some accustomed discharge, such as the menstrual or hemorrhoidal. It may likewise be occasioned by breathing air which is too much rarefied to be able properly to expand the lungs. Persons in whom there is a faulty proportion either in the vessels ;i the lungs, or in the capacity of the chest, being distinguished by,a narrow thorax and prominent shoulders, or who are of a delicate ♦RDER IV. SPITTING OF BLOOD. €19 make and sanguine temperament, seem much predisposed to this he- morrhage ; but in these, the complaint is often brought on by the con- currence of the various occasional and exciting causes before mentioned. A spitting of blood is not however always to be considered as a pri- mary disease. It is often only a symptom, and in some disorders, such as pleurisies, peripneumonies, and many fevers, often arises, and is the presage of a favourable termination. Sometimes it is preceded (as has already been observed) by a sense of weight and oppression at the chest, a dry tickling cough, and some slight difficulty of breathing. Sometimes it is ushered in with shiverings, coldness of the extremities, pains in the back and loins, flatulency, cos- tiveness, and lassitude. The blood which is spit up is sometimes thin, and of a florid red colour; and at other times it is thick, and of a dark or blackish cast ; nothing, however, can be inferred from this circum- stance, but that the blood has lain a longer or shorter time in the chest before it was discharged. An hxmoptoe is not attended with danger, where no symptoms of phthisis pulmonalis have preceded or accompanied the hemorrhage, or where it leaves behind no cough, dyspncea, or other affection of the lungs ; nor is it dangerous in a strong healthy person of a sound con- stitution, unless the hemorrhage is very great; but when it attacks persons of a weak lax fibre, and delicate habit, it may be difficult to re- move it. It seldom takes place to such a degree as to prove fatal at once ; but when it does, the effusion is from some large vessel. The danger, there- fore, will be in proportion as the discharge of blood comes from a large vessel, or a small one. When the disease proves fatal in consequence of the rupture of some large vessel, there is found on dissection a considerable quantity of clot- ted blood between the lungs and pleura, and there is usually more or less of an inflammatory appearance at the ruptured part. Where the dis- ease terminates in pulmonary consumption, the same morbid appearan- ces are to be met with as described under that particular head. In an hsemoptoe, the effusion is to be moderated by a strict observ- ance of the antiphlogistic plan; by carefully avoiding heat, and every kind of bodily exertion ; by employing occasionally cooling purgatives, such as manna, tamarinds, phosphorated soda, vitriolated tartar, 8cc. and by making use of a light diet with refrigerants.* Dr. Darwin is of opinion, that one immersion in cold water, or a sudden sprinkling all • ft. Infus. Rosa: gij. Kali Nitrat. gr. xv. Tinct. Opii gutr. xx. M. ft. Hauftus 3tia vel 4ta quaque hora su- mendus. Vel ft. Crystal. Tartar, giij. Kal. Nitrat. 3IJ. M. ft. Pulv. 5fs. pro dos. Vel ft. Acid. Sulph. Dilut. gutt. xxx. Aq. Fontan. 3Jfs. Tinct. Opii gutt. xx. Syrup. Roek gj. M. ft. Hauftn*. 220 PYREXIA OR FEBRILE DISEASES. CLASS I. over with it, might probably stop a pulmonary hemorrhage. Indeed the application of cold to the genitals, or immersing the feet, or even the lower part of the body, ought in no case of hxmoptysis to be neg- lected. If the patient is hot and feverish, of a plethoric habit, and has a hard pulse, bleeding from the arm may be used with advantage, provided the pulse has not been lowered by the effusion ; and whatever he drinks may be acidulated with a little lemon-juice ; but on the contrary, where there are marks of debility and laxity, and the blood is of a dark colour, deple- tion will be improper. In those cases where the hemorrhage is considerable, and has not proceeded from plethora, besides adopting the means just recommend- ed, with the exception of blood-letting, we ought to give astringents,* in order to stop it as quickly as possible ; and if we find mild ones to fail, we must then employ others of a more powerful nature,t taking care to exhibit some laxative, such as the oleum ricini, now and then, to prevent their having any deleterious effect. The acetate of lead has been used freely, and with great advantage, in haemoptysis. One grain every four or six hours may be employed with perfect safety. In cases attended with imminent danger we may venture on two grains. It may be given in an infusion of roses, with a few drops of tinctura opii. The remarkable operation of digitalis in retarding the pulse has suggested its use in cases of active hemorrhage, and particularly in hamoptoe, in which disease it has been used by many practitioners, and ft. Gum. Kino gr. x. Alumin. Ust. gr. iij. Opii gr. fs. Conserv. Rosa; q. s. M. ft. Bolus. Vel ft. Vitriol. Cupri gr. v. Aq. Rosas J;viij. Tinct. Opii gutt. lx. M. ft. Mistura cujus sumat asger Cochl. larg. j. 4ta quaq. hora. Vel ft. Tinct. Saturnin. gutt. xv. pro dosi Vel ft. Infus. Rosa? §jfs. Aluminis gr. x. Zinci Vitriolat. gr. \. Tinct. Opii gutt. x. Syrup. Rosas gj. M. ft. Hauftus 4tis horis capiendus. Vel ft. Tinct. Benzoes C. - Saturnin. aa gij. Capiat guttas xxv.—xxx. pro dos. * R- Gum. Kino gr. viij. Aluminis gr. x. Opii gr. is. Conserv. Rosa; q. s. M. ft. Bolus 4ta quaq. hora sumendus. Vel ft. Aluminis gr. viij. Terr. Catechu gr. x. Conserv. Rosae q. s. M. ft. Bolus 3tia quaq. hora sumend. super- bib. Cochl. iij. magna Infus. Rosas. Vel ft. Tinct. Kino. . Catechu aa gfs. ------Opii gij. M. Capiat guttas xxx.—xl. pro dos. f ft. Vitriol. Virid. 1 Opii aa gr. fs. Conserv. Rosa; gr. xij. M. ■! ft. Bolus ter die sumendus. Vel ORDER IV. SPITTING OF BLOOD. 221 repeatedly by myself, with a very happy effect. It may be given in small doses, repeated twice or thrice a day, as prescribed here.* If the hemorrhage resists all the means which have been advised, and there is reason to fear that the patient may sink under the loss of blood, it will be proper to apply a blister to the chest; which remedy has often been attended with much advantage in cases of this nature. Dr. Rush tells us, that a table-spoonful or two of common salt is often successful, when other means will fail. When much coughing attends on hxmoptoe, it will be necessary to have recourse to opium, exhibited in small and frequently repeated doses, along with the other remedies. Different preparations of the hyoscyamus have been successfully em- ployed in hsmoptoe, by the German physicians, but more particularly the oil ;t but being in the possession of so active a remedy as the digi- talis for suppressing pulmonic hemorrhage, it seems unnecessary to re- sort to this. After the effusion is stopped, we are to use every possible means for preventing its return. If the complaint has arisen from predisposition, and where an inflammatory diathesis prevails, it may be necessary to obviate this by small bleedings, repealed according to the urgency of the symptoms ; besides which, we may employ refrigerants and cooling purgatives occasionally, the patient at the same time adhering strictly to an antiphlogistic regimen, and avoiding all vigorous exertions of the bo- dy, agitations of the mind, and other occasional causes. Sailing, travelling in an easy carriage, swinging, and riding gently on horseback, will be the most proper exercises. Where the disease arises in persons of a lax fibre and delicate habit, it has been customary to exhibit the Peruvian bark and chalybeates. These seem, but more particularly the latter, to be unsafe medicines in all ca- ses of active hemorrhage, and have been experienced frequently to prove prejudicial in hsemoptoe, by increasing the phlogistic diathesis. f See Extracts from Hufeland's Journal, in vol. iii. p. 576, of the Medical and Physical Journal. * ft. Pulv. Digitalis Purp. gr. j. Conserv. Rosas gr. x: M. ft. Bolus mane, hora meridiana, et vespere sumendus. Vel ft. Fol. Digital. Purp. Sice. £j. Spirit. Vin. Rectif. Aq. Puras aa v^ij. ft. Infus. Post horas xxiv. Col. et capiat asger guttas xxx. his terve die in Aq. Menth. Sativ. Jj. Vel ft. Infus. Rosae §jfs. Tinct. Digitalis gutt. xx. ------ Opii gutt. x. M. ft. Hauftus 6tis horis capiendus. 222 TVREXIA: OR FERR1LE ■ ISEASES. CLASS r. Whenever there is a fixed pain in the chest, a blister may be applied over the part with considerable advantage. To prevent a recurrence of hsemoptoe, issues and setons have been employed in some cases, and probably with a good effect. Of a VOMITING of BLOOD, or HiEMATEMESIS. A HEMORRHAGE of blood from the stomach is readily to be distinguished from one which proceeds from the lungs, by its being usu- ally preceded by a sense of weight, pain, or anxiety in the region of the stomach ; by its being unaccompanied by any cough ; by its being dis- charged in a very considerable quantity ; by its being of a dark colour, and somewhat grumous; and by its being mixed with the other con- tents of the stomach. The disease may be occasioned by any thing received into the sto- mach, which stimulates it violently or wounds it; or may proceed from blows, bruises, or any other cause capable of exciting inflammation in this organ, or of determining too great a flow of blood to it: but it arises more usually as a symptom of some other disease (such as a suppression of the menstrual or hemorrhoidal flux, or obstructions in the liver, spleen, and other viscera) than as a primary affection. Towards the close of scarlatina maligna, typhus gravior, and other disorders of alike nature, where symptoms of putrescency prevail in a high degree, a hemorrhage from the stomach is very apt to arise. Haematemesis is seldom so profuse as to destroy the patient suddenly; and the principal danger seems to arise, either from the great debility vvhich repeated attacks of the complaint induce, or from the lodgment of blood in the intestines, which by becoming putrid might occasion some other disagreeable disorder. The appearances to be observed on dissection, where it proves fatal, will depend on the disease of which it has been symptomatic. Where this complaint has arisen in a plethoric habit, and is attended with some febrile symptoms, it may be necessary to take away a small quantity of blood from the arm ; but the great debility which the dis- ease produces of itself, will not admit of this operation under any other circumstances, except where it has taken place in consequence of sup- pressed menstruation; in which case we may take away about six ounces of blood, a day or two previous to the period at which the hemorrhage would have returned. In moderate attacks of the disorder it may be sufficient to make use of refrigerants, as advised under the head of Haemoptysis, together with small doses of opium repeated twice or thrice a day, confining the pa- tient at the same time to food of a light nutritive nature, and directing him to take some kind of acidulated beverage for his ordinary drink : but if these means do not quickly allay the hemorrhage, we ought then to employ powerful astringents and sedatives, as advised under the last- mentioned disease. During the use of tnese medicines, it will be necessary, 9RBER IV. VOMITING OF BLOOD. 2U3 however, to give some gentle laxative (such as the oleum ricini) now and then, in order to obviate costiveness, and prevent any deleterious effects. In hxmatemesis, I have the strongest reasons for presuming that there is not a more effectual astringent than the tinctura ferri muriati ; for by being applied here immediately to the mouth of the bleeding vessel, it acts as a styptic. It may be given in doses of twenty or thirty drops in a little cokl water, and be repeated every hour till the he- morrhage ceases. It is said that large doses of spermaceti have been given in this dis- order with success ; but its use seems more likely to prove beneficial after it has ceased, than during its continuance, particularly where the effusion is considerable. If the practitioner is disposed to make a trial of it in mild cases, he can give it as below.* When the hemorrhage has stopped, it will be advisable to discover, if possible, the cause from which it proceeded, and, by removing that or the primary disease, to prevent any return of the complaint! Where hamaatemesis arises in putrid diseases, we must have recourse to the most powerful antiseptics. A modern writerf informs us, that he has met with a variety of this disease in females from eighteen tothirty years of age, and by no means originating in organic affection of the stomach or viscera connected with it, that resisted the usual routine of treatment with cold acidulated liquors and different emmenagogues, but which readily gave way by- procuring copious and free alvine evacuation by the exhibition of purgatives. Of the VOIDING of BLOOD by URINE, or HEMATURIA. X HIS disease is sometimes occasioned either by falls, blows, bruises, or some violent exertion, such as hard riding and jumping; but it often arises from a small stone lodged either in the kidney or ureter, which by its size or irregularity wounds the inner surface of the part it comes in contact with ; in which case the blood discharged is most usually somewhat coagulated, and deposits a sediment of a dark brown colour, resembling the grounds of coffee. It is rarely, if ever, an idiopathic disease. f See Observations on the Utility of Purgative Medicines, by Dr. Hamilton, page 109. * ft. Sevi. Ceti. ^fs. Vitel. Ovi q. s. Teranturin Mortar, marmoreo, etadde Aq. Pulegii |j. Fontan. 5v. Nitri Purif. Jj. Syrup. Tolutan. ~ij. Tinct Opii gutt. L. M. ft. Mistura, cujus sumat Cochl. larg. iij. 3tia vel 4ta quaq. hora. 224 PYREXIA OR FEBRILE DISEASES. CLASS I. A discharge of blood by urine, when proceeding from the kidney 01 ureter is commonly attended with an acute pain in the back, and some difficulty of making water, the urine which comes away first being muddy and high-coloured, but towards the close of its flowing becoming trans- parent, and of a natural appearance. When the blood proceeds imme- diately from the bladder, it is usually accompanied with a sense of heat and pain at the bottom of the belly. The voiding of bloody urine is always attended with some danger, particularly when mixed with purulent matter. When it arises in the course of any malignant disease, it shews a highly putrid state of the blood, and always indicates a fatal termination. The appearances to be observed on dissection will accord with those usually met with in the disease which has given rise to the complaint. In the treatment of haematuria we must be guided by the cause which has occasioned it. If it has arisen in consequence of some external injury, such as a*t blow or fall, it may then be proper to make use of evacuation by bleed- ing, the patient taking a couple of table-spoonfuls of an infusion of roses, with a small quantity of nitre dissolved in it, every two or three hours, and employing some gentle purgative, such as the oleum ricini, every second or third day, to keep the body open. When it proceeds from a stone either in the kidney, ureter, or bladder, it is only to be cured by removing the cause ; but as this may not be always practicable, we must then be contented to moderate the symp- toms, by making the patient drink plentifully of mucilaginous liquors, such as thick barley-water, solutions of gum arabic, or a decoction of marsh-mallows sweetened with honey ; by giving him repeated small doses of opium joined with refrigerants, as advised under the head of Haemoptysis, and by throwing emollient clysters frequently up the intestines. A case of hematuria is recorded in the 8th volume of Medical Facts and Observations, vvhich had resisted repeated bleedings and warm bathing, saline purgatives, emetics of different kinds, camphor and opium in large doses, uva ursi, mephitic alkaline water, &c. and which was quickly and effectually removed by giving the patient a pint a day of a decoction of peach-leaves. This was prepared by boiling an ounce of dried leaves of the peach-tree (Amygdala Persica, Linn.) in a quart of water, till it was reduced to a pint and a half. When haematuria is symptomatic of some malignant disease, as putrid fever, &c. powerful antiseptics must be administered. Of an IMMODERATE FLOW of the MENSES, or MENORRHAGIA. J\ FLOW of the menses is to be considered as immoderate, when it either returns more frequently than what is natural, continues longerthan ordinary, or is more abundant than is usual with the same person at other times. • RDER IV. JMMODERATE FLOW OF THE MENSES. 295 The usual period of its visitations is from twenty-seven to thirty days. As to the time of its continuance, this is various in different women ; •but it seldom continues longer than six days, or less than three, and does not cease suddenly, but in a gradual manner. The quantity gene- rally discharged in.a healthy and regular woman, is from four to six ounces at each visitation. Those of a lax and delicate constitution have, however, a more copious and longer continued discharge than persons of a robust habit. The causes of menorrhagia may be referred to, 1 st, A plethoric state, or general fulness of habit. 2dly, Accidental circumstances determining the blood more copiously and forcibly into the uterine vessels, as violent exercise in dancing, strokes or contusions on the belly, strains, and violent passions of the mind. 3dly, Irritations acting particularly on the uterus, as great costiveness obliging the person to much straining at stool ; excess in venery, par- ticularly during menstruation, or the application of wet and cold to the feet, which may determine a greater flow of blood than natural to the uterus. 4thly, Laxity and debility of the organ, arising from frequent child- bearing, difficult and tedious labours, or repeated miscarriages. Sthly, Those which induce debility of the whole system, as a seden- tary and inactive life, indulging much in grief and despondency, living upon a poor low diet, drinking freely of warm enervating liquors, (such as tea and coffee,) and living in warm chambers; and, 6thly, Organic affections, such as scirrhus, polypus, ulceration, &c An immoderate flow of the menses arising from plethora, is often pre- ceded by head-ach, giddiness, or dyspnoea, and is afterwards attended with pains in the back and loins, some degree of thirst, universal heat, and a frequent, strong, hard pulse ; but where it arises in consequence of a laxity of the organ, or of general debility, and such attacks are fre- quently repeated, the symptoms vvhich attend are, paleness of visage, chilliness, laxity and flabbiness in the muscular fibres, unusual fatigue in exercise, a hurried respiration on the slightest effort, pains in the back, on remaining any. length of time in an erect posture, and coldness of the extremities, together with loss of appetite, indigestion, and a long train of nervous complaints. If the disease has induced much debility by frequent and severe at- tacks, it is no uncommon occurrence for the feet to be affected with (edematous swellings, particularly towards the evening, and for a leuco- phlegmatic habit to take place. In forming our prognostic in this disease, we must be directed by the nature of the cause which has given rise to it. If occasioned by pletho- ra, or a general fulness of the system, we need apprehend no danger, as a temporary debility will be the only inconvenience the woman will experience; but where it is produced by a laxity of the vessels of the organ, and is profuse, long continued, and of frequent recurrence, there will always be a risk of its inducing much general debility, and a leucophlegmatic habit. "Where it arises from an organic affection of 226 PYREXIA ©R FEBRILE DISEASES. CLASS 1. the part, which is sometimes the case after the age of 45, it is usually deemed incurable. When menorrhagia proves fatal in consequence of a scirrhus of the uterus, this organ is observed on dissection to be much increased in size, and its substance to be thick and hard, and when cut into, shews a firm structure intersected with membranous septa. The internal surface is at the same time usually ulcerated, and beset with ragged processes, and from these ulcerated parts the hemorrhage proceeds. If polypi are the organic affection, these on dissection are generally to be found adhering to some part near the neck of the womb, and they are surrounded with varicose vessels, which throw out the blood in conside- rable quantity, when a rupture of any of them happens to take place. Where a profuse flow of the menses is attended with pains in the back/ and the patient is of a full and robust habit, it may be proper to draw off a few ounces of blood ; but in other instances, venesection may very safely be omitted. In general, it will be sufficient to employ the other antiphlogistic means, such as keeping the body gently open with laxative medicines that give but little stimulus ;* administering refrigerants,! such as nitre ; making use of a spare regimen ; drinking freely of cool acidulated li- quors, such as lemonade or tamarind beverage, and keeping the chamber of a moderate temperature, and the bed lightly covered with clothes. Besides adopting these means, the patient is to avoid an erect posture, and all such things as might prove exciting causes. By avoiding these, and moderating the first beginnings of the disease, it is probable that women might in most cases prevent that debility which repeated and severe attacks are apt to occasion. When no symptoms denoting an increased action in the vessels of the uterus are present, and we suppose that the hemorrhage has arisen in consequence of a laxity of the vessels, besides keeping the woman in a recumbent posture, shunning much external heat, making use of refri- gerants internally, and avoiding venery, costiveness, and the other remote causes, we should have recourse to sedatives and astringents, both of which may be used externally, as well as internally. Linen cloths dipped in vinegar and water, and kept constantly ap- plied to the back and private parts, have a powerful effect in many cases of uterine hemorrhage. These means ought therefore always ft. Kal. Tartarifat. gfs. Manna; Optim. giij. Aq. Fervent, ^iij. Tind. Lav. C. ajfs. M. ft. Miftura cujus fumat dimidium pro dos. Vel ft. Magnes. Vitriolat. gij. Aq. Fervent, j^vj. Tinfft. Senna: C. ^fs. Syr. Rofse ^ij. M. Cochl, larg. iv. pro dos. funienda. \ ft. Kal. Prseparat. Succ. JLimon. Jjfs. Nitri Purif. gr. xv. Aq. Font. ^jfs. Syr. Viola 5|ij. M. ft. Hauftus 3tiahora capiendus. Vel ft. Infus. Rofas §ij. Nitri ^fs. adde pro re nata Tinct. Opii gutt. xv. M. ft. Hauftus 4ta hor. repetendus. O-RDER IV. IMMODERATE FLOW OF THE MENSES. 227 to be employed in those instances where the discharge of blood is pro- fuse. Opium has been much used internally in menorrhagia, and where the patient experiences spasmodic pains in the uterus, it undoubtedly will prove a very valuable and useful medicine. On such occasions it may be given in small and frequently repeated doses, combined either with re- frigerants or astringents ; but as opium possesses the power of greatly relaxing the system when used liberally, it ought not to be administered in cases of general debility, unless under the circumstance just mentioned. The astringents most employed in this disease are, alum, catechu, gum kino, and Armenian bole, which may be given as advised below,* or as prescribed under the heads of Haemoptysis and Abortions. Vitriolat- ed zinc, or cerussa acetata, may be substituted in cases of profuse he- morrhage. (See Haemoptysis.) We may give the latter in doses of one, two, or even three grains, every three or four hours, according to the ur- gency of the symptoms. In those cases where the hemorrhage is profuse, and resists the means already recommended, it will be proper to throw up astringent injections into the uterus. Any of thpse here t prescribed may be used on the oc- casion. Where symptoms denoting an increased action in the vessels of the uterus are observable, it would probably be right to give the digitalis as advised under the heads of Abortions and Hxmoptysis. In a few cases of this nature, I have employed it with a good effect. Where menorrhagia proceeds from a scirrhous or ulcerated state of the uterus, all that can be done is to afford a temporary relief by ad- ft. Aluminis gr. xij. Gum. Kino gr. viij. Conferv. Rofse q. s. M. ft. Bolus 3tia vel 4ta hora fumendus. Adde pro re nata Opii gr.fs. Vel ft. Terr. Catechu gr. xij. Aluminis Purif. gr. x. Conferv. Rofas q. s. M. ft. Bolus. Vel ft. Bol. Armen. Alum. Rup. aa "2\k. M. ft. Pulvis. Vel ft. Seri Aluminos. ^iij. pro dos. Vel ft. Decoct. Cinchon. ,§ij. Alum. Purif. gr. xij. Tind. Kino $. ----- Opii gutt. xx. M. ft. Hauftus 3tia quaque hora fumendus. \ ft. Infus. Cort. Querc. §vj. Aluminis £j. M. ft. Inject. Vel ft. Zinc. Vitriolat. gr. xv. Ceruss. Acetat. ^j. Aq. Distillat. ibj. M. Vet ft. Aluminis J)iv. Zinc. Vitriolat. gr. x. Aq. Rosx j^viij. M. Vel ft. Galls Contus. ^fs. Aq. Fervent, fbii. M. 225 pyrexia; or febrile diseases. class i« ministering opium in considerable doses. A combination of it with the extract of hemlock might possibly add somewhat to its palliative effect. Hyoscyamus may likewise be tried. In those cases where menstruation becomes profuse, continues longer than ordinary, or returns more frequently than what is natural in conse- quence of general laxity in the system, it will be proper for the patient, during its intervals, to enter on a course of tonic medicines, such as the yellow Peruvian, or Angustura bark, myrrh, and preparations of steel, which may be given as advised below,* or under the head of Dyspepsia* To assist the effect of these remedies, shemaymake use of cold bathing, together with gentle horse exercise and a generous nutritive diet. Where chalybeate springs can be resorted to with convenience, a use of these waters will be likely to afford much benefit. When, from great weakness and relaxation in the uterine parts, the patient is troubled with a profuse menorrhagia, or with fluor albus, she will often experience great relief from Tunbridge wateri or any other such chalybeate spring; and as this state of local de- bility is very frequently a cause of abortion or barrenness, these waters have often been the means of removing such unpleasant cir- cumstances. With regard, however, to hemorrhagy from the uterus, it is often accompanied with a degree of general fever, pains in the back and loins, and local irritation, when every internal stimulant medicine would aggravate the disorder; and therefore the use of chalybeate waters in these cases, requires much judgment and a proper dis- crimination. To repress the too great or permanent menstruation, which occurs in weak constitutions at the time of life when it ought to cease, we should have recourse to chalybeates, alum, bitters, and opium, the last of which may be administered in the dose of a grain every night, with about five grains of rhubarb. ft. Gum. Myrrh, gj. solve in Mortario cum Aq Alexet. Simpl. ^vj. ----Cinnam. §j. et adde Kal. Praeparat. ^fs. Ferri Vitriolat. J)j. Syrup. Simpl. £ij. M. t ft. Mistura in Haustus iv. distribuenda, quorum sumat j. mane, hora quinta post meridiem, ethora decubitus. Vel ft. Decoct. Cort. Peruv. ,§jfs. Tinct. ----Angustur. ----■— Card. C. aa gj. M. ft. Hauftus. Adde pro re nata ^ Acid. Sulph. Dilut. gutt. xx. ORDER IV. PILES. 229 Of the PILES, or H^MORRHOIS. A HE piles consist of small tumours situated on the verge of the anus, which are sometimes separate, round, and prominent, but sometimes the tumour consists only of one tumid or varicose ring surrounding it. In some cases there is a discharge of blood from these tumours, particularly when the patient goes to stool, and then the disease is known by the name of bleeding piles ; and in others there is no discharge, when it is called blind piles. These affections may be occasioned by habitual costiveness, plethora, hard riding, excesses of various kinds, the suppression of some long-ac- customed evacuation, and by a use of strong aloetic purges ; and are most apt to arise in those of a robust habit, and who lead a sedentary life. Pregnant women are frequently afflicted with the piles, owing to the pres- sure of the uterus upon the rectum, which interrupts the return of venous blood from that part, and the costive habit to which such women are usu- ally liable. The piles are sometimes accompanied by a sense of weight in the back, loins, and bottom of the belly, together with a pain or giddiness in the head, sickness at the stomach, and flatulency in the bowels. On going to stool, a pungent pain is felt in the fundament, and small tumours are perceived to project beyond its verge. If these break, a quantity of blood is then voided, and a considerable relief from pain is obtained ; but if they continue unbroken, the patient in that case experiences great tor- ture every time he goes to stool, and feels an inconvenience even in sit- ting down on any hard seat. Haemorrhoids are by no means dangerous, but they often prove both troublesome and disagreeable. ' In some instances they are to be regard- ed as a salutary evacuation. Hemorrhoidal tumours are sometimes at- tended with a considerable degree of inflammation, which proceeding to a suppuration, terminates in sinuous ulcers. Dissections of piles shew that the tumours consist partly of the fine skin round the anus on the outside, and partly of the interna! membrane of the gut. In general, they are entire, but they sometimes have small openings in them through which the blood issues. In the treatment of piles, due attention should be paid to the cause from which they have arisen: and as costiveness is one of the most frequent, the bowels ought to be kept open and regular by medicines which will prove gently laxative,* without irritating the rectum; and ft. Elect, e Senn. ~iij. Pulv. Jalap. 51J. Kali Nitrat. gji's. Syr. Spin. Cervin. q. s. M. ft. EJectuarium de quo sumat magnitud iuglandis pro re nata. Vel ft. Flor. Sulph. 3J. Elect, e Senn. Jjij. Crystal. Tart. ^iij. Syrup. Ross q. s. M. ft. Eiectuarium. Vel R. Oi. Ricini5vj~5J. Vet 230 PYREXIAE OR FEBRILE DISEASES. CLASS I, as a habit may be acquired, it will be right for the patient to observe statt ed times in the day for endeavouring to obtain motions. When the tumours are attended with much pain, and a considerable degree of inflammation, it may be advisable to apply a few leeches ; after which, pledgets wetted in a solution of cerussa acetata may be laid on, the patient taking care after each stool to anoint the parts with some kind of emollient ointment.* In these cases, fomentations and poultices are likewise employed. In plethoric habits, small doses of nitre may prove serviceable, particularly if mixed with sulphur. Balsam of copai- ba given to the extent of forty or fifty drops morning and evening, often relieves the pains so frequently produced by piles. In some cases, where the tumours are numerous and tumid, relief may be obtained by making a firm and gentle pressure of each pile be- tween the finger and thumb. In a most violent case of external and internal haemorrhoidal affection, which had resisted judicious treatment for five weeks, Dr. M'Lean men- tions t that almost immediate relief was obtained by giving the patient forty drops of the tinctura digitalis, and that a rapid recovery was effected by repeating thirty-five drops evening and morning. It is observed, that when he first applied for advice, his countenance was pale and sallow, his strength and flesh much exhausted ; he walked with extreme pain and difficulty, his pulse was quick and small, and his appetite impaired ; in a week the contrast was very striking. If a prolapsus ani attends the piles, the part is carefully to be re- placed each time after going to stool, by laying the patient in a hori- zontal posture, and pressing gently with the fingers, till the reduction is effected. Its return is to be prevented by avoiding the occasional causes as much as possible ; and where it proceeds from a laxity of the rectum, besides applying a proper bandage, we may employ astringents both internally \ and externally. Pledgets dipped in a strong infusion of galls, or oak bark, may be kept constantly to the parts as an ex- ternal astringent, and they may be anointed from time to time with an f See Medical and Phyfical Journal, vol. iv. p. 134. Vel ft. Pulv. Jalap, ^j. Cryft. Tartar. Qij. M, ft. Pulv. pro dos. * R> Unguent. Spermat. Ceti gij. Tinct. Opii £j. M. ft. Unguentum. Vel ft. Unguent. Ceruss. Acet. £ij. Opii "zij. M. Vel ft. Unguent. Sperm. Ceti. „ '.. Camphor, aa Sjfs. Pulv. Opii Jfs. M. i ft. Pulv. Terr. Catechu gr. viij. ----Aluminis gr x. M. ft. Pulvis ter in die sumendus. Vel ft. Gum. Kino gr. vj. Aluminis gr. x. Conserv. Rosas q. s. M, ft. Bolus. ORDER IV. PILES. 231 ointment * possessing similar virtues. As a general tonic, cold bathing may be employed with advantage. It has been noticed that haemorrhoids are to be regarded in some in- stances as a salutary evacuation. In all such, therefore, the hemorrhage should not be stopped. In those cases where it is so profuse as to occasion great loss of strength, we must have recourse to astringents both internally and ex- ternally, as has just been advised, taking care to obviate costiveness by some gentle laxative. Where the hemorrhage has been very considerable, good effects have been derived from the early application of pressure, made by introducing up the rectum, a piece of sheep's or pig's gut tied at one end, and by fill- ing it at the other extremity with any cold liquid, such as vinegar and water, forcing up the liquid so as to increase the degree of pressure, and then securing it with a proper bandage. When the hemorrhage proceeds from tumours seated high up in the rectum, and is so severe as to induce great debility, we may throw up some astringent injection, f if it cannot be stopped by the means just re- commended. In those cases where the discharge has become habitual, arising from plethora, this state of fulness must be prevented by moderate exer- cise on foot, or in a carriage, by the use of a spare diet, by taking cooling purgatives from time to time, and by carefully avoiding all strong liquors. An internal use of Harrogate water is a remedy from which great be- nefit is derived in the piles. The advantages of sulphur as a mild un- irritating purgative, and one which seems to continue its operation through the whole of the intestinal tube, has long established its virtue in those hemorrhoidal affections that require this evacuation ; and the neutral salts, with which it is united in this mineral water, cannot but con- tribute to its efficacy. Those who are afflicted with piles should shun all such causes as may either increase the determination of blood into the hemorrhoidal vessels, or prevent its return back from them, but more particularly riding on horseback. During the continuance of this complaint the diet should be cool and nutritious, consisting principally of vegetables, ripe fruits, jellies, ft. Adipis Suillae %'y Camphor. Jfs. Pulv. Gallarum Subtilis. jij. Tina. Opii Jj. M. ft. Unguentum. t B- Cort. Querc. Contus. ^j. Aq. Fontan. Hjij. Coque ad ifej. Colaturae adde Aluminis jij. Tinct. Opii 3J. M. fit. InjetSio. Vtl R. Zinc. Vitriolat. Jfs, Aq. Rofae ifej- M. Vel ft. Galls Contus. gfs. Aq. Fervent, ifeij. Co!. 232 .pyrexia: or febrile diseases. CLASS I. broths, &c. Fermented and spirituous liquors will be hurtful, and there- fore the patient should only drink cooling acidulated liquors, water, or toast and water. When, in consequence of piles, the rectum becomes so much affected as to threaten the patient with a fistula, we may recommend a use of Dr. Ward's celebrated paste,* as inserted in the Pharmacopoeia Chirurgica, which is to be prepared in the following manner : The three first ingre- dients are to be finely powdered and well mixed, after which, the honey and sugar melted together over the fire, and formed into a clear syrup, are to be added, and the whole beaten together into a mass. ORDER V. OFFROFLUVIA, OR FLUXES WITH PYREXIA. X YREXIA with an increased excretion, not naturally bloody, is the de- finition given of this order of diseases. Of the CATARRH, or CATARRHUS. il CATARRH consists in an increased excretion from the mucous membrane of the nose, throat, and bronchias, attended with some slight degree of fever. It attacks persons of all ages and constitutions, but more particularly the young, and those who have had any former affection of the lungs ; and it may take place at any time of the year when there are sudden changes of the weather from heat to cold, and vice versa. In the former instance, the application of cold to the body seems evidently to be the re- mote cause of the disease ; and in the latter, it appears to depend on a specific contagion, having, in the years 1732 and 17S3, spread in a pro- gressive manner over the whole of Europe, and part of America, and in 1785 and 1803, over the whole of Britain. When the disease has pre- vailed epidemically in this manner, the term of influenza has been appli- ed to it. The proximate, or immediate cause of catarrh, seems to be an increas- ed afflux of fluids to the mucous membrane of the nose, fauces, andbron- cni«e, producing some degree of inflammation in these parts. Catarrh is to be distinguished from the measles by the great mildness of the febrile symptoms, and by the absence of many of the symptoms accompanying the latter. * ft, Rad. Enul. Campan. Piperis Nigri fingul. rfefs. 45eminum Fcenicul. Dulc. fbjfs. Mellis Defpumati. Sacchar. Purificat. fingul. ibj. M. ft. Pafta de qua capiat quantit. nuc. mosch, bis tcrve de. die. ORbER V. CATARRH. 233 The disease usually comes on with a dull pain, or sense of weight iri the forehead, a redness of the eyes, and a fulness and heat in the nos- trils, which symptoms are soon followed by the distillation of a thin acrid fluid from these parts, together with a soreness in the trachea, hoarse- ness, frequent sneezing, some difficulty of breathing, a dry cough, loss of appetite, general lassitude over the whole body, and chilliness ; to- wards evening, the pulse becomes considerably quickened, and a slight degree of fever arises. In the progress of the disorder, the cough is attended with an ex- cretion of mucus, which at first is thin, white, and expectorated with some difficulty ; but becoming gradually thicker and of a yellow colour, is at length brought up with greater ease and less coughing. Even Where there is not much affection of the system, it often hap- pens, that the natural evening paroxysm is considerably increased ; and from restlessness, and frequent coughing, the patient is prevented from sleeping till the morning, at vvhich time a crisis takes place for the pre- sent, and he then remains tolerably easy until the return of the evening paroxysm. When the secretion of mucus ceases, the inflammation goes off also, so that a natural cure almost always arises in the disease. Catarrh is seldom attended with fatal consequences, except when it either arises in elderly persons, attacks those of a consumptive habit, or has been much aggravated by some fresh application of cold, or by improper treatment; and it usually terminates in the course of a few days, either by an increased expectoration, or a spontaneous sweat. In some instances it, however, lays the foundation of phthisis pulmonalis. The inner membrane of the trachea usually appears on dissection, in fatal cases of catarrh, to be much inflamed, and its cavity to be filled with a considerable quantity of mucous fluid. The same morbid state is likewise communicated to the lungs, which seem loaded with matter of a similar nature, producing suffocation. In mild attacks of this disease, it may not be necessary to have recourse to the aid of medicine. In general it will be sufficient to confine the patient, to bed, and to make him use an abstemious regimen, and drink plentifully of warm diluent mucilaginous liquors, such as barley-water, &c. acidulated with a small quantity of lemon-juice, or crystals of tar- tar ; but in violent attacks, where there is great difficulty of breathing, much febrile heat, and a full frequent pulse, it will be -Necessary, besides adopting these means, to guard against the effects of general inflamma- tion, and to employ various remedies. In those cases, therefore, where there is much general affection of the system, we should have recourse to the lancet, proportioning the quan- tity of blood which we draw off, to the violence of the symptoms, and the age of the patient. If the difficulty of breathing and oppression at the chest are not soort relieved by venesection, local blood-letting will be advisable, after which it will be proper to apply a blister either to the back, or over the part affected ; which application will seldom fail to afford relief. 2 G 234 PTREXI/X OR FEBRILE DISEASES. CLASS I. To encourage a determination to the surface of the body, and pro- mote expectoration, it will be necessary to administer small and frequent- ly repeated doses of antimonials, as advised under the head of Simple Continued Fever, or other diaphoretics, as prescribed below ;* the ef- fect of vvhich may be assisted by making the patient drink plentifully of mucilaginous diluent liquors acidulated, and confining him to bed. Volatile alkali is a very powerful diaphoretic, and particularly if administered in wine-whey. Twenty or thirty drops of liquor vol. corn. cervi, in half a pint of wine-whey, if the patient is kept in a moderately warm bed, will soon elicit a profuse sweat. Neutral salts promote in- sensible perspiration, when the skin is not warmed much externally. When these are sufficiently diluted with water, and given, a copious perspiration is procured. Half an ounce of vinegar saturated with vo- latile alkali (as in the aqua ammon. acetata,) and taken every two or three hours, will answer this purpose very well. Nitre is a medicine which is often given in this disease, as well as in gonorrhoea. In the latter it will be sure to augment the pain by its sti- mulus on the excoriated or inflamed urethra; and, in the former, where the discbarge is too thin or saline, it cannot fail to increase the coughing. The secretion of mucus in the lungs and fauces may likewise be as- sisted by administering pectorals of the attenuating class, such as squills, gum ammoniac, &c.f and by applying to them repeatedly, throughout the course of the day, the steams arising from warm vinegar and water, by means of Dr. Mudge's inhaler. When the cough is troublesome, and there is great soreness and rawness in the fauces, demulcents^ may be used with advantage ; and * R. Succ. Limon. §jfs. Ammon. Prseparat. ^jfs. Aq. Fontan. §v. Antimon. Tartarisat. gr. jfs. Syrup. Tolutan. gfs. M. ft. Mistura cujus sumat Cochl. larg. ij. tertia quaq. hora. Vel ft. Aq. Ammon. Acetat. $fc. Mistur. Camphorat. ^j. Vin, Antimon. gutt. xxv. Syr. Althsese Ji^ M. ft. Hauftus.. Vel ft. Camphor, gr. iv. Pulv. Antimon. gr. Conserv. Rosa; q. s. ft. Bolus. M. ft. Lact. Ammon. ^vfs. Oxymel. Scilhegfs. M. ft. Mistura cujus sumat Cochl. larg. ij. quarta quaq. hora vel tusse urgenti. \ ft. Mucilag. Gum. Arab. §v. Ol. Amygdal. D. ^j. . Syrup. Tolutan. ^fs. Aq. Ammon. Jfs. M. ft. Emulsio cujus sumat Cochl. larg. j. pro dos. Vel ft. Sevi Ceti (G. Arab, permixt.) :$ Syrup. Tolutan. §jfs. Ol. Amyd. Dulc. Conserv. Rosa; aa §fs. M. ft. Linctus de quo saepe lambat ajger ur- genti tusse. Vel ft. Mel. Optim. Ol. Amygd. D. aa ^ij. Sue. Limon. 3J. Syrup. Tolutan. Jij. M. ft. Linctus. GRDE* V. CATARRH. 235 after the inflammatory symptoms have abated, opiates will afford effect- ual relief, and may be joined with the former. Where the patient's rest is particularly disturbed in the night, an opi- ate* at bed time will be highly necessary, but it should be combined with some diaphoretic. If costiveness prevails in the course of the disease, it ought to be re- moved by gentle laxatives. When the mucous membrane of the nose is much affected, it may be smeared from time to time with a little tallow, or spermaceti oint- ment. These are the remedies to be employed during the first stage of the disease: but it often happens, that after the inflammatory symptoms have subsided, a weakness remains, and there is an increased secretion from the lungs, which perhaps continues for many months, without the least appearance of purulence. In such cases, the patient is carefully to avoid all fresh exposures to cold, and he should defend himself by go- ing warmly clothed. Where the disease runs on for any length of time, or has become habitual, the patient should continue long in bed in the morning, so that the natural evening paroxysm of fever may be entirely carried off there, and he should go early to bed at night. He is likewise to abstain from wine, and all food which is hard of digestion ; to breathe as pure open air as possible ; and to use gentle exercise daily on horseback; which will take off the blood from the interior parts, and thereby diminish the internal secretions. By paying a proper attention to the means which have been advised, by keeping up a constant inflammation on the breast by plasters of Bur- gundy pitch and blisters, or substituting a large scapulary issue, and by employing opiates to mitigate the cough, and tonics, we shall in general be able to remove all consequences of the disease. If, notwithstanding these means, the cough should be dry, or be unattended with proper expectoration, and, together with a soreness, produce shooting pains through the breast and between the shoulders, accompanied with difficulty of breathing, flushing in the cheeks after meals, a burning sensation in the hands and feet, and other symptoms of hectic fever, no time should be lost, as there is reason to fear that tubercular suppurations will follow. Under such circumstances, the' steps advised in the treatment of phthisis pulmonalis ought immediately to be adopted. It is necessary here to notice a species of catarrh, with which persons advanced in life, and who have had frequent attacks of such af- * ft. Aq. Ammon. Acetat. jiij. Mucilag. Gum. Arab. ^j. Syrup. Limon. jij. Tinct. Opii gutt. xl. M. ft. Hauftus hora decubitus sumendus. Vel ft. Pulv. Ipecac. Comp. gr. xij. ft. PuhY sudoritkus. 236 pyrexia: or febrile diseases. CLASS I, fections, are apt to be afflicted. They are seized with a cough, which at length becomes habitual and chronic, and continues for many years, proving extremely distressing. Its attacks are most common in the morning, and the ill-fated patient, otherwise in good health, is thrown into fits of coughing, which last a long time, and are only terminated by a free expectoration taking place, when relief is immediately obtain- ed. Next morning, however, the same distressing symptoms again Seize the enfeebled patient, and thus the little strength he may have to support him through the fatigues of the day, is nearly exhausted. In northern climates in particular, this species of catarrhal affection is very frequently to be met with among elderly people ; and it seems to arise from an unusual quantity of mucus secreted in the branchiae, and per- haps in the lungs themselves, which by impeding respiration, or me- chanically irritating these parts, produces the cough. From an inability to spit up the secreted phlegm, the patient is sometimes suffocated, as happened in a late instance which fell under my care. The best medi- cines we can employ in this species of catarrh are a combination* of myrrh, squill, and gum ammoniac. Digitalisf will be very likely to pro- duce much benefit also in chronic coughs, accompanied with dyspnoea, great secretion of viscid phlegm, and any tendency to effusion into the cells of the lungs. The catarrhal fever known by the name of Influenza, which prevailed so universally in most parts of this kingdom in 1803, as well as in France, where it was called La-gripe, first shewed itself in London towards the latter end of the month of February, when a damp and mild state of the atmosphere had succeeded to severe cold, and when this again had been followed towards the beginning of March by frost and keen easterly winds. Like preceding epidemics of the same kind, this disease exhibited va- rious degrees of morbid affection, having been in some instances so slight as not to incapacitate persons from following their ordinary occu- pations and pursuits, and scarcely to require the aid of medicine ; while in others the attack was of so severe a nature as to endanger life, and even to destroy it. To young children and elderly people it proved very fatal indeed, but more particularly so to the latter. Those likewise of a middle age, who either laboured under habitual asthma, or had any pre- disposition to phthisis, experienced its dire effect. It was generally preceded by chilliness and shiverings, which were ft. Pulv. Gum. Myrrh, jj Gum. Ammoniac, jfs. Scillaj Pulv. gr. X. Syrup. Tolutan. q. s. M. ft. Massa in pilulas gr, v. dividenda. Capiat ij. pro dos. omni mane et nocte Vel ft. Gum. Myrrh, jfs. Solve in Aq. Puras ^j. et adde Lactis Ammoniac, ^jv. Oxymel. Scilla s;fs. Tinct. Opii Camphorat. jj. M. Capiat Cochl. amplum pro .dos. \ ft. Lactis Ammoniac, ^v. Ojfymel. Scillae gfs. Tinct. Digitalis gutt. xxx. M. Capiat Cochl. amplum subinde, vel tusse urgenti. ORDER V. CATARRH. 237 succeeded by some degree of heat, pains in the head, a discharge from the eyes and nostrils, severe sneezing, hoarseness, and cough. In the course of a few hours the head-ach became much increased, as well as the heat; the pulse was quickened but small; the breathing was difficult and op- pressed, or transitory stitches across the chest were felt. Some patients complained of pains in the shoulders and limbs, very much resembling chronic rheumatism, and there were instances in which tne difficulty of breathing might be, in part, attributed to a similar affection of the inter- costal muscles. The tongue was usually white ; the thirst considera- ble ; the bowels were costive ; the urine was high-coloured and clear ; and very frequently there was nausea at the stomach, with more or less of vomiting. Towards the second or third night the cough became greatly aggra- vated, and was strong and almost incessant, being usually accompanied, even on its first coming on, with an expectoration of thin sharp mucus. The evening paroxysm of fever was likewise more severe, being attended with extreme anxiety and restlessness, as well as considerable heat, and often with a great confusion in the head and rambiing. At this stage of the disease the pulse was usually from 100 to 120 strokes in a minute. Towards the morning there was commonly a remission of the febrile symptoms, but the cough continued urgent, and greatly interfered with the patient's getting any sleep after this time. Where gentle perspirations came on early, and the bowels, were kept open, the fever usually declined about the fifth or sixth day, and the urine, which was before high-coloured and clear, now became turbid, or depo- sited a copious sediment ; but the cough continued for many clays, the sputum being however of a milder quality and thicker consistence, and the expectoration more free. Depression of spirits, languor, and debili- ty, which were universal attendants on this epidemic, together with rest- less nights, harassed the patients for a considerable length of time after the decline of the fever. Such was the most common form of the disease, but its modifica- tions were extremely numerous ; for in some instances there was a violent head-ach with a swelling of the eyes or inflammation of the conjunctiva, or pains in the limbs, with but little catarrhal affection ; in others, the throat was principally affected, and in others again, a peri- pneumonic condition existed. In a few instances the fever assumed the typhoid type. In the treatment of the influenza, bleeding was not much employed, and it was only had recourse to in those cases where the symptoms of pneumonia were very urgent, and the patient complained of great dif- ficulty of breathing, or an acute pain in the side. Where dyspnoea pre- vailed, the application of a blister to the chest usually afforded considera- ble relief. If nausea was complained of at the commencement, a gentle emetic proved serviceable ; and where costiveness existed, as was usually the case, it was necessary to give some gentle laxative. When there was no great degree of heat or fever present, it was by no means requisite to keep patients in bed: in such cases, confine- 23S pyrexia: or febrile diseases. class i. ment to their chamber, with plentiful dilution, and a spare regimen, was sufficient; but when the febrile symptoms ran high, it was necessary to keep them in bed, and to administer diaphoretics. Small doses of the pulvis antimonialis, assisted by a solution of some neutralized salt, and given every three or four hours, seldom failed to excite a gentle determi- nation to the surface of the body. Further than this was not proper ; for immoderate sweating, and particularly at the decline of the disease, was sure to prove injurious, by adding to the languor and debility. Some advantages were derived from a free use of the compound de- coction of barley, and solutions of gum arabic, with the addition of a little syrup of lemons, in those cases where the fauces and throat were affected by rawness and soreness. Towards the decline of the disease, where the expectoration was both viscid and difficult, squills were employed with benefit. Where the cough proved very troublesome, and the febril* symptoms had subsided, an anodyne at night had a very good effect. To counteract the languor and debility which invariably attended this epidemic, it was necessary, during a state of convalescence, to have re- course to tonics, such as decoction of the bark of cinchona, with the mi- neral acids ; or some preparation of myrrh, with an infusion either of columbo-root or gentian, various formula! of which are inserted under the head of Dyspepsia. At the commencement of the disease, a spare, mild, and vegetable diet Was most advisable ; but at its decline, a generous one, with a moderate quantity of wine, was proper. Many persons seemed to have relapses, and therefore it was found'ne- cessary to guard carefully against any fresh exposure to cold. In many instances, the period of convalescence was much protracted ; and during the debility vvhich prevailed in consequence of it, patients were liable to the attack of some chronic disorder that proved obstinate and tedious, but more particularly to chronic rheumatism. By some physicians the disease was supposed to be contagious ; by others not so : indeed its wide and rapid spread made many suspect some more generally prevailing cause in the atmosphere, as alone capable of accounting for its extensive and speedy diffusion. It arose, probably, at first from a peculiar state of the atmosphere, like other epidemics, and was afterwards kept up and propagated by contagion. Op the DYSENTERY, or DYSENTERIA. X HE dysentery is a disease of a contagious nature, in which there is an inflammation of the mucous membrane of the intestines, accom- panied with frequent stools, severe griping pains, a tenesmus, and some degree of fever; the stools, although frequent, being small in quantity, and without any natural faeces intermixed, but consisting principally of mucus streaked with blood. When the natural faces do appear, it is ORDER V. DYSENTERY. 23? usually under the form of small, compact, hard substances, known by the name of scybala. Dysentery occurs chiefly in summer and autumn, and is often occa- sioned by much moisture succeeding quickly to intense heat or great drought, whereby the perspiration is suddenly checked, and a determi- nation made to the intestines. It is likewise occasioned hy a use of un- wholesome and putrid food, and by noxious exhalations and vapours $ hence it appears often in armies encamped in the neighbourhood of low marshy grounds, and proves highly destructive ; but the cause which most usually gives rise to it is a specific contagion ; and when it once makes its appearance, where numbers of people are collected together, it not unfrequently spreads with great rapidity. A particular disposition in the atmosphere seems often to predispose, or give rise to the dysentery, in which case it prevails epidemically. It frequently occurs about the same time with autumnal intermittent and remittent fevers, and with these it is often complicated. It is like- wise frequently combined with typhus. A late writer * supports the proposition that the simple dysentery is of itself never contagious, nor the intermittent and remittent forms of the disease ; that the combination with typhus is alone possessed of that property, and this, he insists, ori- ginates not in the virus specific to the dysentery, but in the contagion of fever. Others have however given it as their opinion, that the contagious matter consists in the mucous or purulent discharge from the membrane which lines the intestines, and not in the febrile perspiration or breath of the patients. The dysentery is much more prevalent in warm climates than in cold ones ; and in the months of August, September, and October, which is the rainy season of the year in the West Indies, it is apt to break out, and to become very general among the negroes on the different plantations in the colonies. It likewise prevails much in the unhealthy parts of the East Indies, and in our factories on the coast of Africa, both during the wet season and some time after it. The body having been rendered irri- table by the great heat of the summer months, and being exposed sud- denly to much moisture with open pores, the blood is thereby thrown from the exterior vessels upon the interior, so as to give rise to dysenteries. A distinction necessary to be made between the dysenteries of all cli- mates is, that those which attack persons in perfect health may be consi- dered in the light of what physicians term original diseases ; whereas those fluxes which we meet with in persons much weakened by a feverr and reduced to a very low condition of body, are properly symptomatic, as they proceed chiefly from the patient's debility and weakness. Dysentery may readily be distinguished from diarrhoea by the absence of fever in the last, the less degree of griping and tenesmus : the ap- pearance of the stools, and the other symptoms, will further assist us. * See Obfervations on fimple Dyfentery and its Combinations, bv William Ksrty, M.B, 540 Pyrexia: or febrile Diseases. class i. An attack of dysentery is sometimes preceded by loss of appetite, cos- tiveness, flatulency, sickness at the stomach, and a slight vomiting, and comes on with chills succeeded by heat in the skin, and frequency of the pulse. These symptoms are in general the forerunners of the griping and increased evacuation vvhich afterwards occur. When the inflammation begins to occupy the lower part of the intes- tinal tube, the stools become more frequent and less abundant, and in passing through the inflamed parts, they occasion great pain, so that every evacuation is preceded by a severe griping, as also a rumbling noise. The motions vary both in colour and consistence, being sometimes composed of frothy mucus streaked with blood, and at other times, of an acrid watery humour, like the washings of meat, and with a very fetid smell. Sometimes pure blood is voided ; now and then, lumps of coag- ulated mucus, resembling bits of cheese, are to be observed in the evacu- ations, and in some instances a quantity of purulent matter is passed. Sometimes what is voided consists merely of a mucous matter, with- out any appearance of blood, exhibiting that disease which is known by the name ofdysenteria alba, or morbus mucosus. While the stools consist of these various matters, and are voided fre- quently, it is seldom that we can perceive any natural faeces among them, and when we do, they appear in small hard balls, called scybala, which being passed, the patient is sure to experience some temporary relief from the griping and tenesmus. It frequently happens from the violent efforts which are made to dis- charge the irritating matters, that a portion of the gut is forced beyond the verge of the anus, which in the progress of the disease proves a trou- blesome and distressing symptom, as does likewise the tenesmus, there being a constant inclination to go to stool, without the ability of voiding any thing, except, perhaps, a little mucus. More or less of pyrexia usually attends with the symptoms which have been described, throughout the whole course of the disease, where it is inclined to terminate fatally, and is either of an inflammatory or pu- trid tendency. In the other case the febrile state wholly disappears after a time, while the proper dysenteric symptoms probably will he of long continuance. When the symptoms run high, produce great loss of strength, and are accompanied with a putrid tendency, and fetid and involuntary dis- charges, the disease often terminates fatally in the course of a few days : but when they are more moderate, it is frequently protracted to a con- siderable length of time, and so goes off at last by a gentle perspira- tion diffused equally over the whole body ; the fever, thirst, and griping then ceasing, and the stools becoming of a natural colour and consistence. When the disease is of long standing, and has become habitual, it seldom admits of an easy cure, and when it attacks a person labouring under an advanced stage of scurvy or pulmonary consump- tion, or whose constitution has been much impaired by any other dis- order, it is sure to prove fatal. It sometimes appears at the same time ORDER V. DYSENTERY. 2*1 with autumnal intermittent and remittent fevers, as has before been ob- served, and is then more complicated and difficult to remove. A great degree of tenesmus, severe griping pains, frequent inclination to go to stool and but little voided, much depression of strength, fetor of the evacuations, a tense abdomen, violent pyrexia, cold clammy sweats, coldness of the extremities, aphthae, hiccup, petechia;, and a weak irregu- lar pulse, are to be regarded as very unfavourable symptoms. Whereas a gentle and universal diaphoresis, moderate pyrexia, the evacuations be- coming less frequent and more of a natural consistence, and a gradual di- minution of the griping and tenesmus, are favourable appearances. Upon opening the bodies of those who die of dysentery, the internal coat of the intestines (but more particularly of the colon and rectum) ap- pears to be affected with inflammation, and its consequences, such as Ulceration, gangrene, and contractions. The peritonaeum and other co- verings of the abdomen, in many instances, have likewise an inflammato- ry appearance. Two different stages seem evidently to exist in the course of this dis- ease ; wherefore, to treat it properly, due attention should be paid to that which is present at the time when advice is applied for. In its first stage, if the patient is young and plethoric, and there are symptoms of an inflammatory disposition present to justify bleeding, we may then take away a small quantity of blood ; but if the febrile or in- flammatory symptoms do not run high, and the pulse is not very full and strong, we should by no means have recourse to the operation, as the fe- ver which accompanies a dysentery is very apt in the course of the dis- ease to assume a typhoid type, particularly in warm climates. It has been a matter of doubt with some physicians whether to consi- der the inflammation that attends on dysentery, as the consequence, or cause, of the disease. My own opinion is certainly in favour of the lat- ter; but nevertheless I do not recommend an indiscriminate use of the lancet, but, on the contrary, a cautious one. In most cases we may begin the cure by giving a gentle emetic in the evening, and the next morning we may administer some proper laxa- tive,* which should be repeated every second or third day, in order to procure an evacuation of natural faeces, which seldom pass off in any quantity, unless by artificial means. * ft. Natri Vitriolat. gj. Mann. Optim. 3is. Aq. Fervent, ^iij. — Cinnam. Jjfs. M. ft. Hauftus. Vet ft. Fruct. Tamarind, ^jfs. Decoque ex Aq. Pura: ^x. ad ^vij. Colat. adde Mann. Opt. g]. Kal. Tartarisat. ||fs. M. ft. Solutio cuju> sumat dimidium primo mane, et quod restat post horas duas, si sit necesswas. Vel ft. Ol. Ricini ^j. pro dos. 2 H 242 PYREXIAE OR FEBRILE BISEASES. CLASS I. Should these prove too mild, and not procure copious stools, we must then employ stronger purgatives, t Some practitioners are in the habit of combining emetic and purgative medicines,^ such as some of the mild neutral salts, with tartarised antimony, and often with a very good effect. With the view of determining the circulation to the surface of the body, small doses of some diaphoretic § may be taken every three or four hours, after proper evacuations, so as to produce and keep up a gentle perspiration without exciting much nausea. By these means we may be able sometimes to cut the disease abruptly short and arrest its progress. Cerated glass of antimony has been much extolled by Sir John Pringle for its great efficacy in the cure of dysentery, and may there- fore be given if the other medicines are not found to answer. The dose for an adult is about eight grains ; but it will be most advisable to begin with four or five grains, increasing the dose according to the effect produced. A novel method of using emetic medicines in dysentery has been re- commended by a late writer ;|| and we are assured by him, that he has, found the practice highly successful. This is in the form of a clyster ; and that which he has experienced to answer best, has been about three drachms of ipecacuanha-root, bruised and boiled in a quart of water down to a pint, which he repeats twice or thrice in twenty-four hours. If dysentery is accompanied with violent retchings or a severe vomit- ing on its attack, so as to threaten the patient with cholera morbus, neither emetics, purgatives, nor diaphoretics will be advisable at first. % In such cases the stomach must be evacuated of its contents by the gentle stimu- lus of large draughts of chamomile-tea. The same, or weak broth, may, be thrown up the intestines in the form of clysters until these are cleans- ed ; after which an opiate should immediately be given. If the opium is rejected, a double quantity of it is then to be administered in a clyster. Should the vomiting continue very obstinate notwithstanding these means, the safety of the patient will then depend on bathing the || See Observations on the Nature and Cure of the Diseases of the East and West Indies, by Thomas Clarke, Surgeon. f ft. Calomel, gr. v. Pulv. Jalapii jfs. Syr. e Spin. Cerv. q. s. M. ft. Mass. in Pilulas vj. pro dos. dividen- da. | ft. Infus. Sennas Simp. 3 v. Kal. Tartarisat. Jj. Antimon. Tartar, gr. ij. Solv. Hujus Misturse sumantur Cochl. iv. quolibet trihorio, donee venter rite so lutus fuerit. § ft. Pulv. Ipecac, gr. iij. Conserv. Rosse gr. xij. M. ft. Bolus 4tis hcris sumendus. Vel ft. Pulv. Ipecac. Comp. gr. v. Confect. Aromat. gr. x. M. ft. Bolus. •RDER V. UYSENTERY. 243 region of the stomach well with tincture of opium and camphorated spirits ; on repeating the clysters frequently with a proper quantity of opium in each ; and on adopting the other steps advised under the head of Cholera Morbus. In dysentery, when the abdomen is hard, tense, and painful to the touch, and the gripings are frequent and severe, the application of flan- nels wrung out in a warm decoction of chamomile-flowers and poppy- heads with a small addition of camphorated spirits, to the part, may afford considerable relief; but should fomentations not procure the de- sired effect, a blister ought to be put on. Most cases of dysentery, and particularly during the acute stages of the disease, may be relieved by immersing the patient in a warm bath of a moderate temperature, and keeping him in it for some time. Perhaps rubbing the abdomen with some warm and stimulating oil on his being taken out of the bath, might increase its effect. To defend the inner coat of the intestines from the acrimony of its contents, and to counteract the vain attempts at evacuation, it will be necessary to give something to be discharged. Here then we should not only administer mucilaginous substances, such as solutions of gum arabic in milk, preparations of barley, rice, arrow-root, &c* by the mouth ; but we should likewise inject a clyster of a similar naturef three or four times in the course of trie day. All vain attempts to go to stool, as also all violent strainings in evacuating the contents of the bow- els, ought carefully to be avoided by the patient. If the fundament becomes inflamed or excoriated, the parts should be anointed with a little soft pomatum or hog's lard, after each evacuation. In the cure of Indian dysentery, mercury is the remedy}: now much relied on, but it is to be employed in an early stage of the disease. The plan recommended is, to give calomel in a considerable dose night and morning Without interruption, accompanied by a mercurial friction of the abdomen until the mouth becomes sore. If diarrhoea ensues; this symptom is not to be interfered with, but rather encouraged by an oc- casional purgative of vitriolated natron, or rhubarb. In addition to mercury, the nitric acid, it appears, has also been often employed. I am much inclined to doubt, however, whether these re- medies, even in moderate doses, will be found useful, or even innocent, in the cure of real dysentery. Indeed I should think they could not f See M'Gregor's Medical Sketches; Clarke on the Difeafes of warm climates; Milne's Account of the Difeafes that prevailed during two Voyages to the Eaft Indies. • ft. Gum. Arab. 3 ij - Solv. in Decoct. Hordei ifeij. et adde Syrup. Limon. ^ij. Bibat pro potu ordinario. Vel Decoct. Corn. Cerv. t R- Gelatin. Amyli 3V Gum. Arab. Sol. |jfs. 01. Olivae 3J. M. ft. Enema. 244 PYREXIJE OR FEBRILE DISEASES. CLASS I. fail in many instances to prove exceedingly hurtful, and particularly in the doses which are mentioned. There are some grounds for presuming that the disease vvhich the authors just quoted have called the dysentery of India, is in its nature, symptoms, and causes, and likewise in its method of treatment, very different from that which is described under this name in other countries ; that it differs in nothing from the bilious fluxes so commonly to be met with there, and arises from an affection of the liver, for they describe the stools as being copious and liquid ; frequently bilious, and seldom or never as containing scybala—symptoms by no means characteristic of true dysentery. In the beginning of the disease it would be improper to employ either opiates or astringents ; but in the second stage, where the patient's strength is exhausted by frequent returns of the complaint, proceeding rather from a weak relaxed state of the bowels, than from any remains of malignancy, a use of these remedies will prove both proper and benefi- cial, taking care to obviate costiveness, and evacuate the contents of the intestines from time to time, by administering a few grains of rhubarb, or some such gentle laxative. In this stage of the disease, should the patient's rest be much dis- turbed throughout the course of the night from the frequency of the motions, we may direct an opiate* to be taken at bed-time. The hyoscyamus, by its anodyne and gently laxative qualities, seems a medicine well adapted to this disease, and may be tried in preference to opium. In habitual fluxes, which are complaints frequent with those who have suffered much sickness abroad, it is seldom indeed that relief can be obtained without the aid of opium, and it is often found necessary to add it to all the other medicines we administer. Opiates, especially those of the warmer kind, such as the confectio opiata, &c. are as valu- able in these cases, as the bark of cinchona is in intermittents. When the bowels have been effectually relieved, it often happens, \ after the disease has continued for some time, from the tender state of the rectum, that a severe and troublesome tenesmus remains. Under such circumstances, anodyne clysters are often beneficial ; and where the introduction of a pipe may be likely to excite greater irritation in the rectum, speedy and effectual benefit may be derived from the insertion of a grain or two of opium in the form of a pill into it. Opium combined with the nitric acid, agreeable to the prescrip- tion! here advised, has on various trials been found to have been at- * ft. Aq. Cinnam. ^j. Spirit. Pimento gfs. Tinct. Opii gutt. xl. M. ft. Hauftus. Vel ft. Confect. Aromat. gr. xv. Opii gr. j—ij. Ol. Cinnam. gutt. iij. M. ft. Bolus. f ft. Acid. Nitr. jij. Opiigr. ij. Aq. Pura; ijiij. M. Capiat Cochl. i minimum ter quaterve die in quovis vehiculo. J ORDER y« DYSENTERY. 245 tended with the best effects in the advanced stage of dysentery, when all other remedies have proved ineffectual, and even in cases where death seemed almost inevitable.* The astringents best adapted for the cure of a dysentery, are the dif- ferent preparations of Japan earth, gum kino, logwood, &c which may be given as below,t the patient at the same time taking Port wine pro- perly diluted with water for his ordinary drink. Lime-water, mixed with an equal proportion of milk, has been much recommended as a useful remedy in the latter stage of the disease. During my residence in the West Indies I was in the habit of recommending a strong decoc- tion of logwood with the barks of pomegranate-fruit and the cushoo- cherry-tree, as an astringent drink, from which my patient seldom fail- ed to experience a good effect. In the advanced and chronic stage of the disease, as acidity at the stomach is apt to prevail at that period, absorbents, such as the mistura cretacea, pulvis cretae compositus, aqua calcis, &c. combined with opi- ates, will be useful. Where there exists an extreme degree of atony, and a frequent dis- charge of faeces without pain, small doses of zincum vitriolatum com- bined with opium have proved of singular utility in many instances. The impaired tone of the intestines is likewise to be restored by a use of tonics and bitters,}: together with a light nutritive diet and moderate exercise. The application of cold water to the abdomen, and particu- • See Obfervations on the Effects of nitrous Acid and Opium in the Cure of Dysen- tery, in vol. iii. p. 413, of the Medical and Phyfical Journal. f ft. Extract. Lign. Campech. 3J, Mist. Cretae. 3;iv. Tinct. Catechu jij. Spirit. Nuc. Mosch. J-j. M. ft. Mistura cujus sumat Cochl. larg. ij. tertia vel quarta hora. Vel ft. Confect. Aromat. Jj. Aq. Cinnam. £v. Spirit. Pimento, ^j. Tinct. Kino jij. M. ft. Mistura. Adde pro re nata Tinct. Opii gutt. xxxv. Vel ft. Confect. Opiatae gr. x. Aq. Cinnam. §jfs. Tinct. Catechu, jjfs. M. ft. Hauftus quarta quaque hora sumen- dus. Vel ft. Extract. Lign. Campech. gr. xv. Aq. Pimento 5jfs. Tinct. Kino Jj. Syr. Zingib. Z\]. M. ft. Hauftus. | ft. Cort. Simarouba; Contus. ----Cascarill. aa ^fs. Coque ex Aq. Bullient. ifej. ad ^viij. Colat. adde Spirit. Cinnam. ^ij. Tinct. Opii gutt. xxx. M. Capiat Cochl. larg. iij. quarta quaque hora. Vel ft. Infus. Cort. Angustur. §"vj. Tinct. Columbae g). ------Catechu jij. ------Lavend. C. 3fs. Vel ft. Decoct. Cort. Peruv. g]fs. Tinct. Columb. jij. —— Cort. Aurant. Jj. ------Kino gutt. xxx. M. ft. Hauftus ter quaterve die sumendus. Vel ft. Infus. Cort. Peruv. gjfs. Tinct. Ejusd. C. jij. Acid. Sulph. Dil. gutt. xv. Tinct. Opii gutt. x. M. ft. Hauftus. Vel 246 PYREXIA" «K JEBRILE DISEASES. CLASS I. larly to the lower parts of it by means of cloths, or sponges ; or the im- mersion of the lower part of the trunk in a tub of water, may probably prove a good auxiliary mean. The fever accompanying this disease sometimes appears under an intermittent form, and is protracted much longer than it otherwise would have been in consequence of its being so complicated. In such cases, its treatment is to be regulated as directed under that head by a use of Peruvian bark, &c. In the first stage of the disease, a use of ripe fruits will be proper : but in a more advanced period, where any morbid acidity seems to pre- vail in the stomach, they should not be recommended. Every sort of food which readily tends to putrefaction Ought carefully to be avoided throughout the whole course of the disorder, as also all kinds of fermented and spirituous liquors; supporting the patient's strength with preparations of barley, rice, sagOy flour, panado; Indian arrow-root, and gelatinous broths. During the state of convalescence, Port wine or Madeira, or even a moderate quantity of brandy, properly diluted with water, may be allowed. Persons recovering from a dysentery should observe the greatest cau- tion and regularity in their mode of living, and they should go warmly clothed, as the disease is very liable to relapses. The importance of warm clothing, both in the prevention and cure of bowel complaints, is too obvious to require my saying much on the subject: I will therefore only observe, that warmth ought not to be a secondary object; on the contrary, it ought to be the first; for if a patient only wears his ordinary clothing, he will receive comparatively little benefit from any medicine. A waistcoat of flannel or fleecy hosiery next to the skin ought always to be worn, as likewise sliders of the same, and these should be laid aside with caution, and by slow degrees. The writer* of a small tract on dysentery lays much stress on swathing the abdomen with flannel bandages, as being the best mode of confining a certain degree of heat over that part of the body which is the seat of the disease. Dysentery being of a very contagious nature, every precaution should be taken, particularly in situations where many people are crowded to- gether (as in camps, and on board of ships) to prevent the disease from spreading. The sick ought immediately to be separated from those in health, or who labour under any other disorder ; they should be lodged, * See H. Dewar's Observations on Diarrhoea and Dysentery, as those Diseases ap- peared in the British Army during the Campaign in Egypt in 1801. \ Vel ft. Extract. Gentian. ------Lign. Camp, aa gjfs. Ferri Vitriolat. Gum. Myrrh, aa gj. Syrup. Zingib. q. s. M. Fiant Pilulae lx. quarum sumat iij. ter die cum Decoct. Simaroub. ^ij. ORDER V. DYSENTERY. 247 if possible, in distinct rooms, or tents, and the strictest attention should be paid to cleanliness, taking care to remove the stools as soon as voided, and to have them quickly buried ; to ventilate the chamber sufficiently, and sprinkle it now and then with a little warm vinegar ; and to change the linen both of the body and beds frequently. In addition to these means the fumigations advised under the head of Typhus Gravior may be re- sorted to. For the destruction of contagion of every species, where a number of persons are collected together, Dr. Rollo,* in addition to free ventilation and cleanliness, recommends the following as being an easy, safe, and very effectual method, and which is pursued at the Royal Artillery Hospital: Take of pulverized manganese, two parts ; common salt, four parts ; sulphuric acid, three parts ; water, one part. A suitable proportion of this mixture is to be put into an earthen vessel, and suffered to remain until no vapours arise from it, or its peculiar smell is not perceptible. He mentions, that when a patient is admitted with an infectious disease, one or two gallipots are placed in the wards with about three ounces of the manganese and salt, to which is added half an ounce of water, and then is gradually poured on the whole a part of the ounce of sulphuric acid, the remainder occasionally. These quantities are according to the proportions previously stated, and they answer the consumption of a day. A pot or two is placed, we are in- formed by the Doctor, on the outside of the doors of the same wards in the gallery. The vapour is diffused over the whole ward, penetrates everywhere, and destroys every other smell than what itself conveys. Even the contagion of the small-pox has been noticed to be destroyed bj? this vapour, and of course it is likely to prove destructive of other conta- gions. In the manner here described, it can be used with due effect, an<$ without the least prejudice to the sick. Its application, besides annihilating contagion, may also prevent its for- mation ; and its use is recommended by Dr. Rollo in all situations where a number of persons in health are confined together, as on board of trans- ports, especially in bad weather. Two or three gallipots, with the quan- tities before mentioned, he says, would be sufficient, and it would, not be necessary to use them oftener than twice or thrice a week. It has been recommended to make trial of the remedy in marshy sit- uations, where there may be an unavoidable exposure : in these places, the gallipots with the materials should be placed in the inside of the win- dows and doors of the habitations next to the marshes. • See his Account of the Royal Artillery Hofpital at Woolwich. 243 NEUROSES OR NERVOUS DISEASES- CLASS II. CLASS II. NEUROSES OR NERVOUS DISEASES. X HE character assigned to this class of diseases is, preternatural affec* tion of sense and motion, without idiopathic or primary pyrexia, and with- out local disease. ORDER I. C 0 M A T A. DIMINUTION of voluntary motion, with sleep or a suspension of sense, is the character of this order of diseases. Of APOPLEXY, or APOPLEXIA. THIS disease consists in a sudden diminution of all the senses exter- nal and internal, and of all voluntary motion, while, at the same time, the heart and lungs continue to perform their action. In some cases it may be difficult to distinguish it from intoxication, and which can only be done by the smell, the appearance of the face, and the duration of the fit, which in the latter seldom exceeds ten or twelve hours. The state of the pulse, difficult respiration, stertorous breathing, profound sleep, and the affec- tion of all the powers of volition, will distinguish apoplexy from palsy : the stertor, sopor, diminution of the power of volition, and the absence of convulsions, will distinguish it from epilepsy. It makes its attack chiefly at an advanced period of life, and most usu- ally on those who are of a corpulent habit, with a short neck and large head, and who lead an inactive life, make use of a full diet, or drink to ex- cess. The immediate cause of apoplexy is most generally a compression on the brain, produced either by an accumulation of blood in the vessels of the head, and distending them to such a degree as to compress the me- dullary portion of the brain ; or by an effusion of blood from the red ves- sels, or of serum from the exhalants, which fluids are accumulated in such a quantity as to occasion compression ; but it takes place sometimes without extravasation, exudation, or effusion being the consequence, as in many instances we see patients recovering quickly from a fit of apo- plexy without any paralytic affection being left behind, which could not happen if either of these had existed. When the disease arises from an accumulation of blood in the vessels of the head, or by an effusion of blood from the red vessels, it is called • RDER t. APOPLEXY. 249 sanguineous apoplexy, and when occasioned by serum from the exhalants, it is known by the name of serous apoplexy. The states of over-distention and effusion may be brought on by what- ever increases the afflux and impetus of the blood in the arteries of the head ; such as violent fits of passion, great exertions of muscular strength, severe exercise, excess in venery, stooping down for any length of time, wearing any thing too tight about the neck, overloading the stomach, long exposure to intense cold or a vertical sun, the sudden suppression of any long-accustomed evacuation, the application of the fumes of certain narcotic and metallic substances, such as opium, alcohol, mercury, &c. ; and by blows, wounds, and other external injuries. In short, apoplexy may be occasioned by whatever fills, distends, obstructs, ruptures, lace- rates, corrodes, or compresses the vessels of the brain and its meninges too much, and thereby urges, retards, or entirely impedes the flow of blood through the same ; or in any manner destroys the intimate fabric and structure of the brain. A loss of vitality in the brain has been assigned as a cause of apoplexy in those cases where neither extravasation, exudation, nor effusion, are to be discovered on dissection. The circumstances disposing to sanguineous apoplexy are a full and luxurious mode of living, with but little exercise, a sanguine tempera- ment, a full habit, middle age, short neck, suppressed evacuations, and warm weather. Those which dispose to serous apoplexy are a phleg- matic temperament, cachectic habit of body, and old age. Sanguineous apoplexy is sometimes preceded by giddiness, dimness of sight, drowsiness, loss of memory, or faltering of the tongue in speak- ing ; but it more usually happens, that, without much previous indisposi- tion, the person falls down suddenly, the face is red, and appears puffed up, the veins of the head, particularly the eyes, temples, and neck, seem turgid, the head feels hot, the eyelids are half open and rigid, the eyes are prominent and fixed, the breathing is difficult and stertorous, and for the most part the pulse is full and strong. In a few instances, a grind- ing of the teeth, with slight convulsive motions, is observable. When the disease continues for any length of time, the pulse becomes languid, weak, and slow, and the breathing is shortened, until at length it ceases altogether. In serous apoplexy the attack is more gradual in general, the face is pale and tumid, the veins are depressed, the pulse is small, weak, irre- gular, and intermittent, respiration is impeded and stertorous, and the ex- tremities are cold and flaccid. Sometimes these appearances are pre- ceded by vertigo, torpor, and an impediment in the speech, together with a failure of memory. Although the whole body is affected with the loss of sense and motion in apoplexy, it takes place nevertheless very often more upon one side than the other, vvhich is called a hemiplegia, and in this case the side least affected with palsy is somewhat convulsed. In forming our opinion as to the event, we must be guided by the violence of the symptoms. If the fit is of long duration, the respi- 2 I 250 NEUROSES OR NERVOUS DISEASES. CLASS IX* ration laborious and stertorous, and the person much advanced in years, the disease in all probability will terminate fatally. In some cases it goes off entirely, either by diarrhcea, hemorrhage, return of the hemorrhoidal or any other habitual discharge, and sometimes by the appearance of le- ver, but more frequently it leaves a state of mental imbecility behind it, or terminates in a hemiplegia, or in death. Even when a person reco- vers from an attack of this disorder, it is very apt to return after a short period of time, and in the end to prove fatal. Where there is extravasation, the patient's recovery will be slow and difficult ; for the power of absorption cannot be equal to its being imme- diately taken up. When the person's recovery is immediate, it is a pre- sumptive evidence that there has been neither extravasation, effusion, nor exudation, but that the compression arose from a repletion in the vessels of the brain. In the dissections of those who have died of apoplexy, blood is often found effused on the surface and in the cavities of the brain , and in oth- er instances, a turgidness and distention of its blood-vessels are to be ob- served. In some cases, tumours have been found attached to different parts of the substance of the brain, and in others no traces of any real af- fection of it could be discerned. In the cure of sanguineous apoplexy, no time should be lost in em- ploying powerful remedies. On the person's being seized, due care must be taken to remove all compression from about the neck, to support him in as erect a position as possible, and to allow a free admission of cool air. These steps being adopted, twelve or fourteen ounces of blood should be taken away, and if it can be drawn from the jugular veins instead of the arm, it will be the more likely to be attended with a good effect. When any branch of the temporal artery seems so turgid as to admit of being easily opened, drawing blood from thence may probably prove a still more effectual way of unloading the vessels of the brain. In those cases where one side of the body is perceived to be more af- fected with loss of motion than the other, the bleeding should be made, if possible, on the opposite side to that affected, as dissections shew that the congestions producing apoplexy are always on the side vvhich is not af- fected. After general bleeding, leeches may be applied to the temples, or the scarificator and cupping-glass to the occiput; and when sufficient evacu- ations have been procured by these means, we may then apply a large blister to the head or neck, and small ones to the extremities, together with cataplasms to the soles of the feet. If the power of swallowing remains, some active purgative * should be given by the mouth in divided portions, and at proper intervals, * ft. Infus. Senna? 31 v. Kal. Tartarifat. Jvj. Tindt. Jalapii ~ij. Syrup, e Spin. Cerv. jiij. M Capiat dimidium pro dos. Vel i>RDER I. APOPLEXY. 251 so as not to excite any vomiting ; but if not, the contents of the intestines are to be dislodged by a strong clyster,* which is 'to be repeated every three or four hours, until a sufficient effect is procured. Emetics are made use of by some practitioners. Where the disease has been brought on by a large indigested meal distending the stomach, pressing upon the aorta descendens, obstructing the free expansion of the lungs, and thus crowding the arteries of the head with more blood than ought to be there, the exhibition of an emetic may be admissible and pro- pe provided it has been preceded by copious venesection ; or should vomiting arise naturally, the stomach may be relieved by washing it out with a little chamomil'e-tea ; but where the disease is occasioned by an extravasation either of blood or serum on the brain, more particularly the former, it cannot be denied, I think, that an emetic would be a very ha- zardous remedy. A supposed case of apoplexy which fell under the care of Dr. Langslow, of Halesworth, and Mr. Crowfoot, of Beccles, gave rise to much controversy with respect to the propriety of administering eme- tics in this disease. Those who wish to peruse the arguments which have been brought forward on the occasion by these gentlemen, as well as by many other practitioners, will find the subject amply discussed in the sixth and seventh volumes of the Medical and Physical Journal. When the fit goes off we may advise some of the cephalic and nervous medicines recommended under the head of Palsy ; and in order to obvi- ate any costiveness that may happen to arise, a little tincture of rhubarb may be taken occasionally. In serous apoplexy, blood-letting should either be omitted entirely, or be sparingly used. To promote an absorption of the effused serum, it will be proper to have recourse to warm purgatives, sternutatories,! and a free application of blisters to the head, back, and extremities, and of sin- apisms to the soles of the feet. Emetics in this species of apoplexy, as well as the former, seem of doubtful effect. Stimulants of various kinds, such as volatile salts, cephalic elixirs and cordials, have been much employed in serous apoplexy ; but as they de- termine the circulation to the head, their use appears not altogether advi- sable. When they are employed, sufficient evacuations should always precede their use. Out of a fit of serous apoplexy, the cephalic and nervous medicines, advised under the head of Palsy, will be proper, taking some stomachic purgative now and then. When apoplectic symptoms proceed from opium, or any other nar- /•'■/ ft. Gum. Gambog. gr. iij. Terito bene cum Tine!:. Sennx C. ^j. ——— Jalapii jj. M. ft. Hauftus. Vel ft. Calomelanos gr. vj. Extrad. Colocynth. C. gr. x. Tiant Pilulse iij. pro dos. * ft. Fol. Senna: giij. Aq. Fontan. ibj. Coque leniter a^ lbfs. ' Colat. adde Magnes. Vitriolat. !f j. 01. Ricini gjfs. m\ ft. Enema. f Pulv. Afari Compos. 3/52 NEUROSES OR NERVOUS DISEASES. CLASS II. cotic poison taken into the stomach, the offending matter ought to be got rid of as soon as possible, by exciting vomiting, with tartarised antimony or vitriolated zinc, should none have arisen spontaneously. Having pro- cured its discharge, we are to have recourse to bleeding, and the exhibi- tion of acrid clysters, with the view of relieving the congestion in the brain and lungs, together with the other means recommended under the head of Vegetable Poisons. Although stimulants are improper in apoplexy arising from other cau- ses, still they may be employed with great safety and utility in those ca- ses where it proceeds from any narcotic poison taken into the stomach, or otherwise applied to the body ; but here too, proper evacuations should be premised. The external stimulants in general use, are volatile spir-. its applied to the nose and temples, rubefacient ointments to the breast and back, blisters, sinapisms with horse-radish, and warm fomentations to the extremities, together with frictions with flannels or a flesh-brush, impregnated with flour of mustard, and throwing cold water over several parts of the body, which in general proves one of the most effectual means of rousing apoplectics of this kind, particularly if the person is first carried out into the open air. The internal stimulants to be employed, are the volatile alkaline salts or spirits, white mustard-seed, horse-radish, white scurvy-grass, and various aromatics, such as rosemary, lavender, Sec. used either in substance, tincture, or in their essential oils. If the disease arises in consequence of the suppression of piles, leeches should be applied to the hsemorrhoidal veins, fomentations must be em- ployed, and the intestines be stimulated by means of aloetic purges. Those who from a plethoric state of the blood-vessels of the head are predisposed to an attack of apoplexy, will act prudently in confining themselves to a very spare diet, carefully abstaining from strong liquors, from all high-seasoned food, and from meat suppers. A limitation of the use of fluids in habits predisposed to plethora and apoplexy will likewise be worthy of attention. Dr. Mossman tells us * he is taught by long observation and experience to expect effects highly beneficial from the adoption of this plan ; for he constantly noticed the pheno- mena of plethora and obesity are referable, not to the taking in of solid, but of liquid nutriment. Persons predisposed to apoplexy should likewise be careful to keep their body open by some gentle laxative taken occasionally, and such moderate exercise ought to be used, as will support the perspiration without hurrying respiration, or exciting heat. Nothing tight should be worn round the neck ; and when in bed, the head ought to be supported of a proper height. The feet should be kept warm and dry, and the extremes of heat and cold must be avoided. Nothing has a better effect in preventing apoplexy in those who are predisposed to its attacks, than a perpetual issue between the shoulders, or a seton in the neck ; but great care must be taken not to allow them to dry up without opening some other drain in their stead. * See Med. and Phys. Journal, vol. ix. p. 412. ORDER I. APOPLEXY. 253 When an attack of apoplexy is immediately threatened, blood-letting is the remedvmost to be relied on, and the blood should be drawn either from the jugular vein or temporal artery, as before advised. Under doubtful circumstances, where the symptoms are not very urgent, the ap- plication of leeches to the temples, or scarifications with cupping, at the back of the head, may prove amply sufficient. The coup de soleil, or stroke of the sun, vvhich so frequently occurs in warm climates to those who are long exposed under its immediate influ- ence, seems evidently to be an attack of apoplexy, and is to be treated in the same manner as pointed out in the preceding pages. The applica- tion of linen cloths wetted in cold vinegar and water to the temples, may likewise be tried. It may not be improper to remark here, that as the vital principle fre- quently remains in a latent state for some time, and as we are yet un- acquainted with any certain criterion between positive and apparent death, besides that of putrefaction, some appearances of incipient decomposition should therefore be allowed to take place, in every case of sudden decease, before interment. In warm countries, where it is customary to bury the body within four-and-twenty hours, I have great reason to fear that pre- mature interment sometimes happens. Of the PALSY, PARALYSIS, or HEMIPLEGIA. 1 ALSY is a diminution or total loss of the powers of motion and sensi- bility in certain parts of the body, often attended with drowsiness. In some instances, the disease is confined to a particular part; but it more usually happens, that one entire side of the body from the head down- wards is affected, which is known by the name of hemiplegia. If the power of motion and sense of feeling in the lower half of the bo- dy be impaired, the complaint is denominated paraplegia. Palsy may arise in consequence of an attack of apoplexy, and, like it, may be occasioned by any thing that prevents the flow of the nervous power from the brain, into the organs of motion ; hence tumours, over- distention and effusion, distortions of the spine, and a thickening of the ligaments that connect the vertebrae together, often give rise to it. It may also be occasioned by translations of morbid matter to the head, by the suppression of usual evacuations, and by pressure made on the nerves by luxations, fractures, wounds, or other external injuries. The long-conti- nued application of sedatives will likewise produce palsy, as we find those whose occupations subject them to the constant handling of white lead, and those who are much exposed to the poisonous fumes of metals or minerals, are very apt to be attacked with it. Whatever tends to.relax and enervate the system, may likewise prove an occasional cause of this disease : hence those who lead sedentary or luxurious lives ; those who are guilty of frequent irregularities or great debaucheries ; those who are engaged in intense studies during the night, or labour under great dis- tress or anxiety, are very subject to this malady. 254 NEUROSES OR NERVOUS DISEASES. CLASS II. All its varieties more generally appear in the aged and infirm than in the young and robust. The left side is more frequently affected than the right. Palsy usually comes on with a sudden and immediate loss of the mo- tion and sensibility of the parts ; but in a few instances it is preceded by a numbness, coldness, and paleness, and sometimes by slight convulsive twitches. When the head is much affected, the eye and mouth are drawn on one side, the memory and judgment are much impaired, and the speech is indistinct and incoherent. If the disease affects the extre- mities, and has been of long duration, it not only produces a loss of mo- tion and sensibility, but likewise a considerable flaccidity and wasting away in the muscles of the parts affected. It has been mentioned that a curvature of the spine, owing to one or more of the vertebra being displaced, sometimes induces paralytic affec- tions of the lower extremities, from the pressure that they make upon the nerves of those parts, and that sometimes the disease appears to arise solely from a thickening of the ligaments that connect the vertebra to- gether, without any particular affection of the bones. When one of the vertebra; only is diseased, it is observed that the patient is more complete- ly deprived of the power of his limbs than when two or more of them are displaced, owing, as Mr. Bell * thinks, to the angle being more acute, and consequently the pressure on the medulla spinalis greater, when one bone only is thrown out of the range. This also accounts for the paralytic symptoms in some being less remarkable in the more advanced stages of the disease than they were at first; for although one bone only is displac- ed at first, yet one or both of the contiguous vertebrae almost constantly yield at last; and the difference arising from this is so great, that pa- tients almost always linger and die in the course of a year or two, often in less time, when one bone only is deranged ; while they live for a great length of time, frequently as long as if no such circumstance had occur- red, when the curvature of the spine becomes more extensive. Paralytic affections from distortions occur in all ages ; but more fre- quently about puberty than at any other period, and more commonly in girls than in boys. In general, the effects that result from them are observed before the cause is suspected, for there is seldom much pain in the part immediately affected. When distortion of the spine occurs during infancy, the patient appears to be suddenly deprived of the use of his limbs ; but at more advanced periods, he complains first of feebleness and languor, and of numbness or want of feeling in the under extremities. By degrees this want of sensibility is found to in- crease, and he is often observed to stumble and to drag his legs, instead of lifting them properly ; nor can he stand erect for any length of time without much difficulty. At last he loses the use of his legs entirely, which become altogether paralytic; and when the spine is distorted much forward, so as to compress the thoracic and abdominal vis- cera, he becomes distressed with dyspncea, or with complaints in * See his System of Surgery, vol. vii. p. at8. ORDER I. PALSY. 255 the stomach and bowels, according to the part of the spine that is dis- eased. Palsy is to be distinguished from apoplexy by the pulse, vvhich in the former disease is soft and slow, and likewise by the other symptoms. When palsy attacks any vital part, such as the brain, heart, or lungs, it soon terminates fatally. When it arises as a consequence of apoplexy, it generally proves very difficult of cure. Paralytic affections of the lower extremities ensuing from any injury done to the spinal marrow, by blows and other accidents, usually prove incurable. Palsy, although a dangerous disease in every instance, particularly at an advanced pe- riod of life, is sometimes removed by the occurrence of a diarrhoea, or fever. A feeling of warmth, and a slight pricking pain, or sensation as if stung by ants in the parts affected, ate favourable symptoms. The morbid appearances to be observed on dissections in palsy, are pretty similar to those which are to be met with in apoplexy: hence collections of blood, and of serous fluids, are often found effused on the brain, but more frequently the latter, and in some instances the substance of this organ seems to have suffered an alteration. In palsy, as well as in apoplexy, the collection of extravasated fluid is generally on the opposite side of the brain to that which is affected. When this disease arises in a young person of a full plethoric habit, comes on suddenly, and the head appears to be much affected, or seems to arise from the causes producing apoplexy, it will be advisable to take away some blood, by opening the jugular vein or temporal artery ; after which, it will be proper to give an active purgative, as advised under the head of Apoplexy ; but in old age, or where palsy arises in a debilitated constitution, neither bleeding nor purging should be resorted to. Where costiveness prevails in such habits, it may be obviated by some stomachic laxative, such as the tinctura rhabarbari composita. In all cases, but more particularly where the disease has arisen in aged or decrepit persons, the external application of stimulants will be highly proper; wherefore the parts affected, as^vell as all along the spine, may be rubbed several times a day with flafthels' or a flesh-brush impregnated with flour or essence of mustard, or else with the palms of the hand, and some kind of rubefacient liniment ;* and in addition to these remedies, we may recommend the application of blisters, sina- pisms,t and warm fomentations. • ft. 01. Olivte gij. — Terebinth. 3J. M. ft. Linimentum. Vel ft. Ol. Camphorat. §j. Tinct. Cantharid. jij. Aq. Ammon. Pur. :;fs. M. Vet ft. Spirit. Camphorat. ijij. Aq. .Amn.o!, Fur. Ziij. Essent. 01. Berg. gutt. x. M. Vel ft. 01. Olivx giij. Aq. Ammon. Pur. 5J. Tinct. Cantharid. Jj. M. j- ft. Semin. Sinap. Puiv. ' Rad. Raphan. Contus. aa Hjj MicsePanisSjij. Acet. Acerrint q- s. M. ft. • Cataplafma piantis pedum arulkan- dum. 256 NEUROSES OR NERVOUS DISEASES'. CLASS II* As a gentle stimulus to parts affected by paralysis, urtication may sometimes be used. Warm bathing is a remedy which has been much employed in most cases of palsy, as an external stimulant. In those, however, which arise in sanguineous habits, from a congestion of blood in the vessels of the brainj its use would in all probability prove injurious, both by stimulating the solids and rarefying the fluids, and thereby becoming a stimulus to the sanguiferous system ; but in those cases where palsy has arisen in consequence of the application of narcotic powers, diminished vital heat, or an enfeebled constitution, the use of warm bathing will be likely to prove highly beneficial. In palsy, we ought therefore most cautiously to ascertain whether an increased or diminished degree of vi- tal heat or action in the sanguiferous vessels, is the cause of the disease. Whether the natural baths, such as those of Bath in Somersetshire, &c. possess more efficacious qualities than the ordinary warm ones, seems a matter of doubt with many practitioners, as the substances with which i the former are impregnated, are but trifling in point of quantity. In my opinion, they are entitled to a decided preference. When a natural warm bath cannot be resorted to, an artificial one may be substituted; and this may be made by dissolving a proper quan- tity of the ferrum vitriolatum in the water, and impregnating it with fixed air. Electricity, both sparks and shocks, is another remedy which is uni- versally employed in the cure of the palsy as an external stimulant, and often with the most happy effect; but in using it, proper care should be taken to apply it only with a moderate force, as more is to be expect- ed from its repetition than from employing it with violence, and like- wise to confine its application to parts which are somewhat remote from the head, as in those cases which depend upon a compression of the brain, it might do injury, by acting on the vessels of this organ. Galvanism is also a remedy from which advantages might probably be derived. Indeed some practitioners have gone so far as to declare, that they have experienced its effects in palsy to be superior to elec- tricity. Dr. Bardsley tells us,* he has found it to succeed, when the latter has failed. When the disease affects several different parts of the body, as in he- miplegia, we should use stimulants internally as well as externally. Those in most general use are mustard-seed, horse-radish, garlic, and volatile alkaline salts, or spirits, which may be taken agreeably to the prescriptions advised below, t The arnica montana is a remedy much recommended. • Sec his Medical Reports and Cafes, p. 183. f ft Sem. Sinap. Alb. |j. Capiat a?ger Cochl. min. ij. ex Aq. Frigid. Cyatho bis terve die. *W ft Rad. ORDER I. PALSV. 257 Resinous substances, such as guaiacum and the turpentines, have sometimes been employed with advantage in palsy ; but from being apt to prove too inflammatory, their use is by no means general in this disease. When palsy has arisen in consequence of the system being enervated by any debilitating cause, besides applying stimulants externally, and likewise administering them internally, we should make use of tonics joined with aromatics, as advised under the head of Dyspepsia. The arsenical solution is a remedy which promises some benefit in this disease, particularly when confined to particular parts. In that palsy of the lower extremities vvhich is occasioned by a de- formity of the spine, or which arises from a thickening of the ligaments that connect the vertebras together, without any particular affection of the bones, no mode of treatment has proved so successful as the inser- tion of issues. The late Mr. Pott, to whom we are much indebted for his observations on this subject, speaks highly of the effects of drains placed as near as possible to the tumour. He recommends an issue to be opened with caustic on each side of the swelling, large enough to admit of a kidney-bean, and the bottom of the sore to be sprinkled from time to time with powder of cantharides. My advice was some time ago requested on the case of a young lady about seventeen years of age, who had gradually lost all sense of feeling as well as motion in her lower extremities. The disease had then been of two years standing; she had consulted two or three practitioners, and had gone through a gourse of the usual medicines, together with blistering and other stimulating external applications, and she had made trial both of warm and cold bathing ; but all without avail. Independent of the paralytic affection in the lower extremities, she seemed to suffer no inconvenience ; her countenance was healthy, and her appetite ft. Rad. Raphan. Contus. Jij. Sem. Sinap. Alb. Rad. Valer. Sylv. aa Jfs. Rhabarb. Incis. jiij. Infund. in Vin. Alb. ifeij. Saepe agl- tetur et coletur usus tempore Cochl larg. iv. quarta hora sumenda. Vtl £. Sem. Sinap. Alb. Contus. Rad. Raphan. Incis. aa Jij. Cort. Aurant. Jfs. Aq. Fontan. ifeij. Coque ad Ibj. Fiat Decoctum cujus sumat Cyath. j. amplum ter in die. Vel ft. Spirit. Ammon. Comp. Jj. Gutta: x.—1. pro dos. sumenda?. Vel 2K ft. Tinct. Lav. Comp. jij. Spirit. Ammon. FceticL Jfs. M. Capiat gutt. xx.—xl. frequenter in quovis vehiculo appropriate Vel ft. Ammonia? Praeparat. gr. x. Camphor, gr. iij. Conserv. Ros. q. s. ft. Bolus ter quaterve die sumendus. Vel ft. Spirit. Raphan. C. Jfs. - ------ Ammon. Foetid, gutt. xxx. Tinct. Valerian, jjj. Aq. Anethi Jj. M. ft. Hauftus. Vel ft. Ammon. Prceparat. gr. vj. Tinct. Cardam. Cnmii. jij. Aq. Menth. Sativ. Jj\ M. ft. Hauftus 6ta hora capiendus. 253 NEUROSES OR NERVOUS DISEASES. CLASS tU good ; she slept well, and felt no pain. She rode on horseback every day when the weather permitted, and when it did not, she went out in a carriage for the benefit of the air. Upon being informed of the his- tory of the case, 1 immediately suspected that the disease was occa- sioned by some injury done to the spine, or that there was a thickening of the ligaments that connect the vertebra; together ; and in this suppo- sition I was confirmed by passing my hand down the back, as I soon perceived an evident fulness on one side of the lower extremity of the spine. I ordered issues to be inserted in the manner just advised, and had the satisfaction to see my patient soon recover the feeling in her feet, so as to be sensible when they touched the ground, and at the end of about three months she was capable of walking alone. I have every reason, however, to conclude, that the disease was in the ligaments only, and that the bones of the spine were not affected. When the vetebrse are diseased, a complete cure, I am afraid, can seldom be obtained ; but the symptoms may certainly be greatly mitigated, and the pressure upon the spinal marrow diminished, by exciting a discharge in the neigh- bourhood of the parts. Dr. Clutterbuck informs us, in a pamphlet published not very long ago, that he had found mercury to be an excellent antidote to lead, and that he had used it with the most happy effects in many instances of pa- ralytic affections, which had arisen among those who were employed in manufacturing the several preparations of lead, and in applying them to their respective uses. In confirmation of the success of the remedy, he has recited several cases, which seem cleaily to prove its utility ; and he has likewise added a letter from Dr. Bradley, physician to the West- minster Hospital, bearing testimony in favour of the use of mercury in such cases. The paralysis or loss of nervous power in particular limbs, which arises as a consequence of that painful and obstinate colic produced by the poison of lead, is found to be peculiarly relieved by a use of the Bath waters, more especially when applied externally, either generally or upon the part affected. In the treatment of that species of palsy of the hands which is pro- duced by the poison of lead, the use of an ingenious mechanical con- trivance adapted to place the muscles in a favourable state is highly re- commended by a late writer,* and it appears also to have been em- ployed by him with much advantage. It is a splint, made somewhat in the form of a battledore, to be fastened under the fore-arm, and con- tinued to the extremities of the fingers. The object of the instrument is to take off the weight appended to the extremities of the muscles, under the idea that this weight is a principal object to the restoration of the muscular power. In the first trial which our author made, the splint was applied to the right arm only, and the result, we are told, was as follows : In one month from the first application he had the satisfaction to find that the right hand was able to raise an eight-ounce weight into a line * See Dr. Pemberton's Treatife on the Difeases of the abdominal Vifcera. »jRCER I. PALSY. 259 with the fore-arm by the power of the extensor muscles ; whereas at this time the left hand remained as perfectly paralytic as before. In five weeks more, the extensor muscles of the right hand had regained their natural strength, but the left hand continued paralytic. For the purpose of ascertaining how far this improvement could be conceived to have arisen from any change of the constitution, and not from the local mean which was used, it appears that he discharged the patient from under his care for one month, at the end of which time he returned to him with the left hand still perfectly paralytic, but the right hand en- joying its full and natural powers. The splint was then applied to the left hand, and in seven weeks the power of the extensor muscles of that hand was also perfectly restored. The result of the experiment certainly places the use of this mechani- cal contrivance in a favourable light ; but it is proper to observe at the same time that it failed in producing the desired effect in some cases of palsy which were not occasioned by the poison of lead. In palsy the diet should be light, nutritive, and of a warm aromatic na- ture. If the patient is able to walk, he should take such daily exercise as his strength will admit; but if deprived of the use of his legs, he ought then to be carried abroad in a carriage, or on horseback ; and frictions with strong stimulants should frequently be applied to the parts affected. Flannel should be worn next to the skin, and all exposures to cold, damp, and moist air, ought carefully to be avoided. If possible, a warmer climate should be resorted to. In those cases where the appetite fails, and the person sinks into a state of debility, from the long continuance of the disease, it will be proper to employ the Peruvian bark, stomachic bitters, and other tonics, to strength- en the system, as advised in dyspepsia. The inhabitants of the East Indies are very subject to a species of pal- sy which is called Barbiers, but known by the natives under that of Beri- berii, a word signifying a sheep. The disease probably has received this denomination, because those who are seized with it, have a tottering of the knees and a peculiar manner of walking, exhibiting to the fancy a rep- resentation of the gait of that animal. It attacks both natives and strangers, especially during the rainy sea- son, commencing in November and terminating in March or April, but is most violent on the Malabar coast. During this season the land winds issue every morning about sun-rise from the neighbouring mountains with remarkable coolness ; and such as are tempted by the serenity of the atmosphere to sleep exposed to these winds, are often suddenly seiz- ed with the disease. Among the chief symptoms by vvhich it is characterized, is a lassitude over the whole body. The motion and sensation, especially of the hands and feet, are languid and depraved. Sometimes only a part of the ex- tremities are affected, and at others, the whole of them. The speech is now and then so much obstructed, that the patient can scarcely pro- nounce a syllable articulately. The disease seldom proves fatal; but the cure is generally te- dious, and notwithstanding a use of the most powerful medicines, is 260 NEUROSES OR NERVOUS DISEASES. CLASS II. said * seldom to be effected till after the shifting of the monsoons, unless the patients are removed to the coast of Coromandel, or to any place to the eastward of the Balagat mountains, where, by a change of air, they quickly recover. The means principally employed by the native practitioners, however, are fomentations and baths made of aromatic herbs, together with strong frictions. The Indians likewise adopt earth-bathing by putting the pa- tient into a hole dug in the ground, and covering him with sand up to his neck. This is performed in the middle of the day, and he remains there as long as he can bear the heat of the sand. Where the disease is chronical and of long standing, sudorific medi- cines are proper ; and therefore camphor, volatile salts, and gum guaia- cum, are frequently given. To obviate costiveness, aloetic purges must be interposed. Due exercise, either on horseback or by walking, will be necessary to restore the action and strength of the extremities, together with warmth, and frictions with rubefacients. ORDER II. AD YNAMIM. ±\- DIMINUTION of the involuntary motions, whether vital or natu- ral, is the character of this order. Of FAINTING, or SYNCOPE. THIS disease consists in a decreased action, and sometimes total cessa- tion ol* the pulse and respiration. It is sometimes preceded by anxiety about the prsecordia, a sense of fulness ascending from the stomach to- wards the head, vertigo, or confusion of ideas, dimness of sight, and cold- ness of the extremities. Attacks of syncope are frequently attended with, or end in vomiting, and sometimes in convulsions, or in an epileptic fit. The causes of this affection are sudden and violent emotions of the mind, pungent and other kinds of odours, derangement of the prims vise, debility from preceding disorders, defect of the stimulus of distention, as after bloodletting, haemorrhage, or the operation of paracentesis in ascites ; organic affection of the heart, or of the parts immediately connected with it, such as aneurism either of the heart itself, or of the arch of the aorta ; ossification of the valves of the heart, or its large blood-vessels, or polypi. During the paroxysm, the nostrils are to be stimulated with volatile spirits or salts, and the face to be sprinkled with cold water. Where the disease arises as the consequence of am hxmorrhage, the patient should be placed in a recumbent posture, and in all cases a free admission of pure cool air should be allowed. If the disease arises as the conse- * See Dr. Lind on the Difeafes of warm Climates, p. %%6. ORDER II. FAINTING. 261 quence of debility or excitability, the system should be strengthened by the use of cinchona, sulphuric acid, stomachic bitters, and chalybeates, to- gether with cold bathing. It need hardly be added, that avoiding the oc- casional causes, and removing them, if in our power, is a matter we should always keep in view. Of a GIDDINESS in the HEAD, or VERTIGO. V ERTIGO proceeds most usually either from too great a fulness of blood in the vessels of the head, or is symptomatic of dyspepsia, hypo- chondriasis, or hysteria. The patient is seized on a sudden with a swimming in the head ; every thing appears to him to go round, he staggers, and is in danger of fall- ing down. This complaint is attended with no danger, when it arises as a symp- tom of hysteria, or any other nervous disease ; but when it takes place in consequence of an over-fulness of blood in the vessels of the head, and is not timely relieved by proper evacuation, it may terminate in apoplexy or palsy. Where vertigo prevails as a symptom of some nervous disease, recourse must be had to the medicines and remedies which are most suitable to the removal of the primary affection ; but where it is occasioned by an over-distention of the vessels of the head, either general or topical bleed- ing, together with a frequent use of cooling purgatives, and a spare re- gimen, ought to be employed. Should the complaint not be removed by these means, scapulary issues will be advisable. Of INDIGESTION, or DYSPEPSIA. A HIS disease chiefly arises in persons between thirty and forty years of age, and is principally to be met with in those who devote much time to study, or who lead either a very sedentary or irregular life. A great singularity attendant on it is, that it may, and often does continue a great length of time, without any aggravation or remission of the symptoms. The disease is pretty similar to chronic weakness. Great grief, and uneasiness of mind, intense study, indolence, profuse evacuations, excess in venery, hard drinking, particularly of spirituous li- quors ; irregularity of life, too frequent a use of warm diluent liquors, and of tea, tobacco, and opium, and other narcotics, immoderate reple- tion, and over-distention of the stomach, very frequent rejection of the saliva, or a diminution or interruption of the due secretion of it, a deficien- cy in the secretion of the bile, pancreatic, or gastric juice, and the being much exposed to moist and cold air, when without exercise, are the cau- ses which usually occasion dyspepsia. The proximate one appears to be atony or debility of the muscular coat of the stomach. A long train of nervous symptoms generally attend on this disease, such as loss of appetite, nausea, heart-burn, flatulency, acid eructations, 262 NEUROSES OR NERVOUS DISEASES. CLASS II. a gnawing in the stomach when empty, a sense of constriction and unea- siness in the throat, with pain in the side, or sternum, so that the patient at times can only lie on his right side ; great costiveness, habitual chilli- ness, paleness of the countenance, languor, unwillingness to move about, lowness of spirits, palpitations, vertigo, and disturbed sleep. The number of these symptoms varies in different cases : with some being felt only in part; in others being accompanied even with addi- tional ones equally unpleasant, such as severe transient pains in the head and breast, and various affections of the sight, as blindness, dou- ble vision, &c. Dyspepsia never proves fatal, unless when, by a very long continuance, it produces great general debility and weakness, and so passes into some other disease, such as dropsy ; but it is at all times very difficult to re- move, but more particularly in warm climates. The morbid appearances to be observed on dissections of this disease, are principally confined to that part of the stomach which is called the pylorus, this being often found either in a contracted, scirrhous, or ulcer- ated state. In every instance the stomach is perceived to be considerably distended with air. In the treatment of the disease, three indications must be attend- ed to. The first is to avoid or remove the remote causes which have been enumerated. The second is to obviate the symptoms which contribute to continue or aggravate the disease. The third is to restore the tone of the organ. To effect the first of these intentions, it must be the business of the physician to point out to the patient the indispensable necessity of re- nouncing such habits or pursuits as may have tended to give rise to the disease, as the continued application or frequent repetition of these causes may defeat the use of what remedies are employed. If he leads a fashionable life, it will be necessary for him to forsake the haunts and habits of dissipation ; to leave the crowded city, and its alluring amusements, conducted in rooms, where the air he breathes is vitiated and contaminated by the great number of persons collected to- gether ; to shun luxurious tables, indolence, and late hours ; to retrace the footsteps by which he had deviated from simple nature, and to court the country, pure air, moderate exercise, early rising, simple diet, the society of a few select friends, and pleasing occupations. To accomplish the second intention of obviating the symptoms which contribute to continue or aggravate the disease, it will be necessary to remove the crudities in the stomach, by giving a gentle emetic. It will also be necessary to correct the morbid acidity in the stomach, by alkalis and absorbents,* as the kali prseparatum, soap, aqua calcis, magnesia, * ft. Aq. Calcis tbj. Capiat sger gij.—giv. bis in die. Vet ft. Magnes. •RDER II. INDIGESTION. 265 chalk, &c ; to assuage the pain and flatulency in the stomach and intes- tines by carminatives,! antispasmodics,^ and opiates ; and, lastly, to obviate costiveness, by a use of such gentle laxatives,§ joined with aro- matics, as will promote a ready discharge of the contents of the intes- tines, without hurrying their action, or increasing the excretions made into their cavity. An habitual attention to the removal of costiveness by instituting a regular custom of periodically soliciting an evacuation by voluntary and persevering efforts, will powerfully aid the beneficial effects of the other means we employ. The morning is the proper time for the attempt, and the trial should be prosecuted during at least fifteen minutes, if the peristaltic be not earlier excited to adequate motion. Perhaps a week may be unavaihngly employed in this endeavour, but the proposed effect will probably be attained within a month ; one month has indeed in nu- merous instances fully established an habitual call to intestinal evacu- M. ft. Magnes. Alb. Jiij. Pulv. Rhabarb. £)ij. Aq. Fontan. giv. — Cinnam. Jj. Tinct. Lavend. C. jfs. ft. Mistura cujus sumat Cochl. ij. ter in die. Vel ft. Cret. Praeparat. gr. xv. Aq. Nuc. Mosch. Jfs. ----Fontan. Jj. Syrup. Zingib. 313. M. ft. Hauftus bis die sumendus. Vel ft. Magnes. Alb. ^ij. Pulv. Rhabarb. gr. x. ----Nuc. Mosch. gr. iij. M. ft. Pulvis mane et vespere sumendus. f ft. Mistur. Cretae. Jjfs. Spt. Nuc. Mosch. jij. Tinct. Opii gutt. xv. M. ft. Hauftus mane et vesp. capiendus. Vel ft. Cret. Praeparat. gr. xij. Aq. Menth.^Pip. Jfs. ----Font. Jj. Spirit. Pimento Jij. Tinct. Opii gutt. xij. M. ft. Hauftus ter die sumendus. Vel ft. Sacchar. Alb. Jfs. Ol. Anisi gutt. xv. Aq. Fontan. Jiv. Spirit. Carui Jj. ------Lav. C. Jj. M. ft. Mistura eujus sumat Cochl quaterve die. J ft. Aq. Anethi Jiij. Spirit. Cinnam'. Jj. Tinct. Valerian. Vol. jij. ■ Opii gutt. xx. iEther. Sulphuric, jfs. M. Capiat Cochl. larga ij. bis terve in die. ij. ter $ ft. Pil. ex Aloe cum Myrrh, gr. xv. in Pilulas iij. pro dos. divid. Vel ft. Aloes Socot. Pulv. Rhabarb. aa Jj. ----Aromat. £)j. Sapon. Venet. jfs. Syrup, q. s. M. fiat Mass. in Pilulas L. dividenda, quarum sumat ij. vel iij. pro dos. Vel ft. Elect, e Senna Jij. Pulv. Jatapii Jij. ----Aromat. ^j. Cryst. Tart. Pulv. Jj. Syrup. Zingib. q. s. M. ft. Electuarium cujus capiat quantitarciB juglandis hora somni. Vel ft. Ol. Ricin. Jvj. pro dos. Vel ft. Tinct. Rhabarb Jvj. pro dos. Vel ft. Pulv. Rhabarb. Jfs. —— Zingib. pr. v. Sal Polychreft 9,. M. ft. Pulvis pro re m.fa sv-rnendus 264 NEUROSES OR NERVOUS DISEASES. CLASS II. ation, under circumstances that previously required the almost daily use of aperient medicines. For the removal of cardialgia and vomiting which attend on dys- pepsia, the application of a blister over the stomach often proves ser- viceable. In such cases, blisters invigorate the exertions of the arterial and lymphatic vessels of the skin, produce an increase of insensible per- spiration and of cutaneous absorption, and increase the action of the sto- mach, and consequently its power of digestion. To accomplish the third intention of restoring the tone of the sto- mach, the loss of which is to be considered as the chief and immediate cause of dyspepsia, we are to employ such medicines as operate directly on this organ, and such remedies, and other means, as have a tendency to strengthen the system in general. The medicines best calculated to restore the tone of the stomach, are aromatics and astringents combined with bitters,* as likewise the Peru- vian bark,t the mineral acids, and chalybeates. J • ft. Infus. Gentian. C. Jjfs. Tinct. Card. C. jiij. - Myrrh, jj. M. ft. Hauftus. Vel ft. Quassias jij. Aq. Fervent. Jv. • Colat. adde Tinct. Columb. ------ Card. C. aa Jfs. M. Capiat Cochl. iij. ter in die. Vel ft. Infus. Gentian. C. Jv. Tinct. Cinnam. C. Jj. M. Vet ft. Rad. Gentian. C. Jiij. i Calam. Aromat. C —— Columbae C. Cort. Aurant. Sic C. aa jij. Vin. Alb. Hispan. ifeij- Hujus Infus. capiat Cochl. iij. ter in die. |- ft. Decoct. Cort. Peruv. Jjfs. Tinct. Columb. jij. ------Myrrh, jj. M. ft. Hauftus ter in die sumendus. Vel ft. Pulv. Cort. Peruv. jj. Aq. Cinnam. Jjfs. Acid Sulph. Dilut. gutt. xx. M. ft. Hauftus. Vel ft. Infus. Cort. Peruv. Jv. Tinct. Ejusd. C. ------Card. C. aa Jvj. M. Sumat Cochl. iij. ter in die. Adde pro re nata Acid. Sulph. Dilut. gutt. xx. i ft. Tinct. Ferri Muriat. Jfs. Guttas x.—xx. ter die sumendx in quovis vehiculo. Vel Aq. Chalybeatas. Vel ft. Vin. Ferri Jfs. Infus. Gentian. Jj. Tinct. Columb. -jij. M. ft. Hauftus. Vel ft. Pulv. Myrrh, jfs. Spirit. Cinnam. jfs. Ferri Vitriolat. gr. iij.—vj. Kal. Praeparat. gr. x. Aq. Pimento ^j. M. ft. Hauftus ter die sumendus. Vel ft. Extract. Cort. Peruv. . Gentian, aa gj. Ferri Vitriolat. jfs. Pulv. Myrrh. Jj. 01. Carui gutt. x. Syrup. Zingib. q. s. M. fiant Pilulae lx. quarum sumat iij. bis terve die cum Infus. Gent. Comp. Jij. Vet ft. Pulv. C. Peruv. Jj. ----Myrrh, jij. —— Cascarill. jj. Rubig. Ferri Jij. Syrup. Cort. Aurant. q. s. M. ft. Electuarium, cujus sumat quantt- tatem juglandis ter in die cum Infus. Quassia; Jij. • RDER II. INDIGESTION. 26 S Besides the vegetable bitters that we have long been accustomed to, two others have very lately been recommended, and brought forward, as deserving our notice. The one is the humulus lupulus, or common hop, different preparations of which, such as the powder, extract, and tincture, are to be procured at the shops of many druggists ; the other is the ra- dix rhataniai, or rhatany root. This last, we are told, by Dr. Reece,* who seems to have been the, first to give it notoriety, has been found to invi- gorate the digestive organs, produce a relish for food and promote diges- tion. He further mentions, that it is more grateful to the palate than Peruvian bark, and that he has found it to succeed better. This has not, however, been the case in the trials which I have made of it; neither has it answered the expectations of most others who have administered it. An aromatic tincture f of it seems to be its best preparation. Chalybeates, in particular, are of eminent service in an impaired or ca- pricious appetite, and weakness of the assimilating organs, irregular di- gestion, flatulent distention of the abdomen, anxiety about the prsecordia, difficult respiration from sympathy with the stomach, and occasional vo- miting of viscid mucus. In cardialgia, gastrodynia, pyrosis, and such other complaints of the stomach, the oxyd of bismuth is a remedy which has been employed with considerable advantage in a variety of instances.}: The proper dose is from three to ten grains, with about twenty-five grains of gum tragacanth, repeated three times a day. It will be best, however, to begin with a dose of only three grains, increasing it gradually. The remedy is said to be perfectly safe, as well as useful. As a diminution of the due quantity of gastric juice is sometimes a cause of dyspepsia, it may not be improbable, that in such cases the symptom may be relieved by supplying the patient with the gastric liquor of those animals whose food is mostvsimilar to that of man. Dr. Scott, in a thesis published some years ago, makes mention, that an Italian phy- sician, finding every thing else fail in a dyspeptic case, had recourse to the gastric liquor of brutes, which proved completely successful. To strengthen the system, whereby the powers of the stomach will be made stronger, the patient should take daily exercise on horseback, which will be preferable to walking, as being less fatiguing; he should >breathe a pure, dry, and temperate air, rise early every morning, go soon to bed at night, lead a temperate life, partake of food of a light nutri- * See his Treatife on the Radix Rhatania?, | See Memoirs of the London Medical Society, vol. v. —— Medical Reports, by Dr. Bardsley. f ft. Rad. Rhatan. Contus. Jiij. Cort. Aurant. Sic. C. §b. ----Canel. Alb. C. 5jfs. Spirit. Vinos. Ten. Ibij. Digere, per dies decern et Cola. 2 I, 266 NEUROSES OR NERVOUS DISEASES. CLASS II. tive nature, adapt his dress to the climate and changes of the weather, and bathe frequently in cold water. - The use of a tepid bath of about 96 or 98 degrees of heat for half an hour every other day for two or three months, has likewise in many in- stances proved of great service to dyspeptic persons. Indeed it would be best to begin with tepid bathing, and so reduce the temperature gra- dually. Tepid bathing communicates heat to the system, and it likewise stimulates it, and causes absorption more than exhalation. The mind is to be amused at the same time that the body is employ- ed ; hence it is that mineral waters, and places of public resort, have al- ways been found very efficacious in removing dyspeptic complaints. Mineral waters are indeed of themselves powerful remedies in cases of dyspepsia ; but their efficacy is greatly increased by drinking them at the spring, where the patient's mind being constantly engaged by the company, and a great variety of amusements, he is sure to receive both hope and entertainment. The advantages of air, exercise, particularly on horseback, and agreeable prospects, admirably coincide, in most cases, with the general curative effect of the spring itself. Buxton water is found of considerable service in removing many of the symptoms of defective digestion and derangement of the alimentary organs consequent to a life of high indulgence and intemperance. A ju- dicious use of this simple remedy, Dr. Saunders * observes, will often re- lieve the distressing symptoms of heart-burn, flatulency, and sickness ; and if persevered in, will increase the appetite, render the secretions more regular, and improve the general health and spirits that are so in- timately connected with the functions of the digestive organs. A spon- taneous diarrhoea is sometimes a consequence of its use at first; but it is more common, especially in habits where the action of the bowels is naturally sluggish, for costiveness to come on during a course of this wa- ter, which must be remedied by laxative medicines. In dyspeptic affections, spasms of the stomach, or intestinal canal, and similar disorders, great benefit is derived from a use of Bath water ; but it ought to be persisted in for a considerable length of time. Dyspepsia, foulness of the stomach, bilious vomiting, acidity, heart-burn, and spas- modic pains in any part of the alimentary canal, are complaints in which a use of Seltzer water affords likewise the greatest relief. Pyrmont water is another remedy which may . be advantageously used in all cases of debility, where the constitution requires an active tonic, and which at the same time does not excite a permanent heat. It in- creases the secretion of urine, and sometimes occasions a temporary eruption on the skin. It is of an agreeable, though strongly acidulated taste, and emits a large portion of gas, which affects those who drink it with a sensation somewhat resembling that produced by intoxication. The dose must vary according to circumstances, and the nature of the pa* * See his Treatife on Mineral Waters. ORDER II. INDIGESTION. 267 tient's complaint, but in general the quantity to be taken ought not to ex- ceed three pints per clay. If a person residing in a warm climate should labour under chronic weakness for any length of time, he will act prudently in removing to a colder one before the disease becomes inveterate, and lays the foundation of some dangerous complaint. If his circumstances or business will not admit of such a change, he ought then to remove to the coolest situation that can be procured, or, in preference to remaining on shore, he may sleep on board of some vessel, and as often as opportunities offer, he should make short voyages, as wonderful recoveries have been effected by sea air, in cases of this nature. The diet in dyspepsia ought to be nutritive and generous, consisting chiefly of animal food on account of the disposition to acescency, and it should be taken every three or four hours, and never exceed a few oun- ces at any one time. Moreover, due care is to be taken to masticate it properly, in order that it may be reduced by comminution and salival commixture to a semi-fluid state. Instead of fermented bread, the pa- tient should eat biscuit with his food. No diluent fluids should be taken with the food, nor until some time after each repast, lest the solvent pro- perty of the mixed saliva should thereby be diminished ; nor should the quantity of fluid taken at once ever exceed half a pint, nor be repeated oftener than at intervals of three hours. About half an hour before swal- lowing the portion of aliment proposed, brisk friction should be perform- ed with a flesh-brush over the region of the stomach during some minutes, and a similar operation may follow the meal. A moderate use of wine ought to be allowed ; but should it disagree with the patient and become acid on his stomach, weak brandy and water may be substituted for ordinary drink. Under no other circum- stances should a use of ardent spirits be resorted to, as, by an indulgence in them, a habit imperceptibly steals on, before the person is aware of the consequences to which it leads. By too free a use of spirituous liquors, obstructions in the principal organs ensue ; the nervous system becomes blunted and depraved to every feeling; the energies of the mind suffer; loss of memory takes place; a train of nervous disorders come on ; and an attack of jaundice, dropsy, or consumption, soon terminates existence. In this progress, even the passages to the stomach lose their feeling, become indurated and callous, and the organ itself, taking on the same state, has its digestion impaired, and becomes unfit to prepare nourish- ment for the body. Pure wine in a moderate quantity gently stimulates, increases the action of the heart and arteries, and augments the nervous energy over the whole body, communicates a serenity and ease of mind, a liveliness of imagination, and a powerful exertion of every faculty; but on the other hand, if taken immoderately, these favourable ap- pearances are changed ; the powers of the nervous system are weak- ened, the mind is deranged, and in the end both motion and sensation are lost. In that species of chronic debility which is brought on by drinking 268 - NEUROSES OR NERVDUS DISEASES. GLASS If.1 spirituous or fermented liquors to excess, there is not much reason to ex- pect a return to healthful vigour, where the power of digestion is consi- derably destroyed ; but in Other cases the person may probably recover his health by a prudent and gradual diminution of the quantity of spirits. In such a case, he should at first omit one fourth of the quantity of spirit he has lately been accustomed to, and if in a fortnight his appetite in- creases, he should be advised to omit another fourth ; but if he perceives that his digestion becomes more impaired from the want of the usual quantity of spirituous potation, he should then be advised to continue as he is, and rather bear the ills he has, than risk the encounter of greater. Animal food, with or without spice, is at the same time to be recom- mended, as likewise the Peruvian bark with myrrh and steel between his meals. At night he may take half a grain or a grain of opium, with five or eight grains of rhubarb. Of the HYPOCHONDRIAC AFFECTION, or HYPOCHOxYDRIASIS. ri-i X HIS disease, known likewise by the name of low spirits or the va- pours, is a certain state of the mind along with dyspepsia, wherein the greatest evils are apprehended upon the slightest grounds, and the worst.. consequences imagined from any unusual feeling even of the slightest - kind ; and in respect to such apprehensions and feelings, there is always* the most obstinate belief and persuasion. st Hypochondriasis bears a strong resemblance to dyspepsia ; but there is this difference between them, that the former prevails at an advanced period of life, and is more an affection of the mind than of the body ; whereas the latter occurs principally from the age of puberty to that of 35, and depends chiefly on debility. Hypochondriasis may moreover be distinguished from dyspepsia by the languor, listlessness, want of resolu- tion and activity, fear of death, and suspicious disposition being always present, and by the dyspeptic symptoms being often absent, or when pre- sent, they are in a much slighter degree. Men of a melancholic temperament, whose minds are capable of great attention, and whose passions are not easily moved, are at an advanced period of life most liable to be attacked with this disease, and when it has once taken place, it goes on increasing as life advances, being usually most troublesome in the autumnal and winter seasons, which accounts for more acts of suicide being committed at these limes of the year than at any other. The English have been accused as the nation of all others vvhich is ad- dicted to suicide ; and perhaps this proneness ought more reasonably to- be attributed to an indulgence in unhappiness, and domestication of mise- ry from trivial circumstances, than to the influence of fogs, or the physi- cal effects of coal fires, as have been assigned by foreigners. Hypochondriasis seems to depend on a loss of energy in the brain, or on a torpid state of the nervous system, induced by various remote causes, such as close and intense study, long and serious attention to abstruse ORDEa II. ITTPOCH©NDRIAe AFFECTfON. 269 subjects, the constant remembrance of some material loss or disappoint- ment which has occurred, great anxiety of mind, leading an inactive, in- dolent or sedentary life, immoderate venery, or a use of crude, flatulent, and unwholesome food, being guilty of great irregularity and intemper- ance ; as likewise by obstructions in the viscera, and by long-continued evacuations. The hypochondriac affection is attended with inactivity, a want of re- solution with respect to all undertakings, lownessand dejection of spirits, great despondency, and apprehension of evil upon the slightest grounds, and a dread of danger from any unusual feeling, even of the slightest kind, together with flatulency in the stomach and bowels, acid eructa- tions, costiveness, a copious discharge of pale urine, spasmodic pains in the head and other parts of the body, giddiness, dimness of sight, and palpitations. In short, it is attended with such a long train of symptoms, that it would fill many pages to enumerate them all, as there is no func- tion or part of the body that does not suffer in its turn by its tyranny ; the miserable patient entertains wild imaginations, and fancies that he la- bours under almost every disease ; and with respect to these feelings and apprehensions, he entertains the most obstinate belief being highly dis- pleased if any attempt is made to reason with him on the absurdity of his persuasions. There are few examples of hypochondriacal people, who find them- selves worse at night than in a morning : the generality of them, like most of those who are afflicted with any of the complaints styled nervous* are seemingly hurt by their sleep, little as it is ; and the longer they hap- pen to sleep, the worse they are ; they awake out of it with confusion, and do not come immediately to themselves ; and when they do, they can think only of melancholy subjects, and feel the worst horrors of their disorder. This state continues till dinner, with very little abatement: af- ter dinner they feel themselves a little revived ; and at night the tide of their spirits returns, which being desirous to enjoy, and dreading their certain ebb when they lie down, they go late and with reluctance to bed. In hysteric women the operations of the animal powers seem to be the most disturbed and perverted ; but in men the mind is most affected ; involuntary' exclamations, faintings and convulsions of all sorts, being most common in women, and silent despair in men. Hence, perhaps, suicide occurs more frequently with men than among women. As to the prognostic, the disease, if recent, is rather to be regarded as troublesome than dangerous ; but if long-continued, it is apt to produce scirrhiof the viscera, cachexy, dropsy, incurable melancholy, or madness- On dissections of hypochondriacal persons, some of the abdominal vis- cera (particularly the liver and spleen) are usually found considerably en- larged. In some few instances, effusion, and a turgescence of the ves- sels, have been observed in the brain. The indications of cure in this disease seem to be, 270 NEUROSES OR NERVOUS DISEASES. CLASS II. 1st, To excite the nervous energy which has been depressed, and that particularly, by attending to the state of the mind. 2dly, To remove or alleviate the symptoms which serve to continue and aggravate the disease. 3dly, To strengthen the alimentary canal, and promote the secre- tions. To answer the first of these indications, the patient's attention is to be engaged and diverted to other objects than his own feelings ; he is to be directed to vary the scene frequently by going from one piace to another; to associate as much as possible vvith agreeable cheerful company ; to engage in such pursuits as will afford him moderate exercise in the open air, which riding on horseback and field sports, as hunting and shooting, are particularly calculated to do ; and by all means to avoid absolute idle- ness ; but in doing this, all application to former studies, especially pro- fessional ones, is to be forbid : entertaining books will, however, be ser- viceable, as assisting to divert the mind from itself. Compassion, and not raillery, is to be bestowed on him, as the firm persuasion which he entertains will not allow his feelings to be treated as imaginary, nor his apprehension of danger to be considered as ground- less, however the physician may be of opinion, that it is the case in both respects. To gain his confidence, it will be necessary to attend to his complaints, as if they were all real ; and to satisfy him, it will by all means be advisable to give him some kind of innocent medicine or place- bo, changing it from time to time, whenever he expresses any disap- pointment of relief. The general health is at the same time to be put into the best state possible. The complaints of hypochondriacs should be treated by the physi- cian as of real existence ; and from whatever cause they may arise, it is his province to employ his art to subdue it; not to ruffle an ir- ritable mind by unseasonable levity, or expose a morbid sensibility to insult and reproach. From the slow evacuation of the stomach in melancholic tempera- ments, acidity often prevails in a high degree with hypochondriacs ; to obviate which, and answer the second indication of cure, it will be neces- sary for the patient to make use of absorbents, and alkalies, as advised under the head of Dyspepsia. Vomiting, though sometimes employed, is by no means suited to this disease. Costiveness, which is another frequent symptom in hypochondriasis, is to be obviated by instituting a regular custom of periodically soliciting an evacuation by voluntary and persevering efforts once or twice a day at certain hours ; and until the desired intention can be established in this way, some' gentle laxative may be taken occasionally, as mentioned un- der the head of Dyspepsia. Harrogate water may be used with a fair prospect of advantage in correcting the obstinate costive habit of body that accompanies hypo- chondriasis ; and this habit, when removed by mineral waters, appears ORDER II. HYPOCHONDRIAC AFFECTION. 271 to be less liable to return, than when only the resinous and ,drastic ca- thartics are employed. Flatulency is another constant attendant, and is to be prevented by making use of carminatives, essential oils, and spices, formula; of which will likewise be found under the head of Dyspepsia. Besides these affections, hypochondriacs are apt to be troubled with spasmodic pains in the head and stomach ; to relieve which, it may be proper to employ such medicines as sether, musk, and opium, either given separately, or combined together.* Asafcetida, castor, camphor, valerian, volatile salts, salt and oil of amber, are medicines which are likewise much employed in the cure of the disease : and therefore when the patient loses a confidence in the one, we can readily substitute another, hypochondriacs being seldom satisfied, unless they are liberally supplied with some drug or other. Various forms of these remedies will be found under the heads of Hys- teria and Epilepsv. In hypochondriasis, as well as in most other nervous diseases, it is too much the custom with many, to addict themselves to a frequent and im- moderate use of opium in some form or other ; but this remedy should be carefully shunned, unless on urgent occasions; for although it may afford some little relief for the present, it will nevertheless, by a constant use, greatly add to the disease. The immediate effect produced by opi- um upon such as addict themselves to its use is, that with an increase of the frequency of the pulse, the heat of the body is generally somewhat augmented, so as to produce very often flushings in the face ; and from a depressed state, they become active and alert with an exhilaration of spirits; but after the operation of the remedy is over, depression of mind ensues, the body is cold and heavy, and in this dull and indolent condi- tion it remains until the dose is repeated ! The peculiar power which the citric acid possesses of counteracting the noxious effects of opium is deserving of attention by those who ac- custom themselves to a regular use of this drug; and it has indeed been recommended by some physicians, that with every dose of opium a pro- portion of the juice of lemons, or oranges, in the quantity of two ounces to the grain of opium, should be taken ; by this means the uneasiness which the medicine often occasions will be prevented, its depressing consequences avoided, and the tendency to constipation obviated. To • ft .ffither. Sulph. gfs. Capiat gutt. xx.—xxx» pro dos. Vel ft. Mosch. gr. xv. Aq. Anethi 5Jfs. JEther. Sulphur, gutt. xx. M. ft. Hauftus ter die sumendus. Vel ft. Infus. Gentian. C. Sjjfs. Tinct. Card. C. jij. .flither. Sulphur, gutt. xxv. Tinct. Opii gutt. x. M. It. Hauftus. Vel ft. Spt. Carui gij. Aq. Fontan. ^iv. JEther. Sulph. gj. Tinct. Opii gutt. xl. ----Lavend. C. 5fs. M. ft. Mistura cujus sumat Cochl. larg. ij ter quatcrve die. 272 NEUROSES OR NERVOUS DISEASES. CLASS II. a very free use of the vegetable acids is ascribed the slight effect which opium produces on the Turks, and not to the influence of coffee, as has been alleged by some. These people, as well as others of the eastern nations, are in the habit of drinking daily large quantities of sherbet, which is a liquor composed of the juice of lemons or oranges, mixed with water and sugar. Many of those who labour under a lowness of spirits have recourse to wine, and, what is still worse, to spirituous liquors, in order to raise them. No words can be too strong to point out the danger of such a practice in its proper colours. The momentary relief which is ob- tained is much too dearly bought by the far greater langour which suc- ceeds : and the necessity of increasing the quantity of these liquors in order to obtain the same effect, irrecoverably ruins the health, and this in the most miserable manner, as has been noticed under the head of Dyspepsia. It is indeed difficult to determine whether the use of opium or of strong fermented liquors is most detrimental to the human constitu- tion ; unluckily the victims who addict themselves to either are ensnared by a habit which they find it impossible to relinquish, because the consti- tution, when habituated to a strong stimulus, becomes incapable of car- rying on the functions of life without continual excitement, which of iSself brings on debility and premature decay. To answer the third indication of strengthening the alimentary canal, and promoting the secretions, a plaster of Burgundy pitch or laudanum is to be applied to the abdomen, and chalybeates are to be employed, as advised under the head of Dyspepsia. Mineral waters, particularly those of Bath and Tunbridge, have been used in hypochondriacal cases with infinite advantage to the patient, which perhaps may be attributed as much to the amusements and avo- cations accompanying the drinking of these waters at the springs, as to the tonic power they possess, from the small quantity of iron with which they are impregnated. Perhaps the elementary water, by favouring the excretions, may have a share in relieving the disease. Bitters and astringents are generally supposed to be improper in hy- pochondriasis, because there is not a loss of tone, as in dyspepsia ; but only a torpor, or want of activity. Chalybeates, however, may be ad- visable. As a general stimulant, cold bathing may sometimes seem useful to the hypochondriac, as well as to the dyspeptic ; but this does not often happen, as tepid bathing proves in general much more useful, from the rigidity of the solids which prevails. A bath of about 96 or 98 degrees of heat used for half an hour once a day, or every other day, has in many instances proved of great service. Where a natural warm bath can be procured, a preference should be given to it. Frictions of the whole body every morning and evening for ten min- utes or longer, vvith coarse flannel cloths, will be likely to prove benefi- cial ; and so will be also gentle exercise on horseback in the open air every day. The diet in this disease should consist of what is light, generous, and ORDER II, HYPOCHONDRIAC AFFECTION, 273 nutritive, avoiding what is apt to prove either acescent or flatulent; and therefore animal food will be most proper. The stomach ought never to be overloaded ; neither should it be suffered to remain perfectly empty. If a faintness is perceived at any time between meals, a bit of cake or biscuit may be taken with a glass of wine ; vvhich precaution will be the more necessary vvith those in high life, from the late hour at which dinner is usually served up. Port wine, or good Madeira, pro- perly diluted with water, may be used for ordinary drink, instead of beer or ale ; but should these disagree with the stomach, water, with a small proportion of brandy, may be drank in their stead. Tea and coffee are improper articles of diet for hypochondriacs ; but more particularly when taken very warm. For breakfast, cocoa, chocolate, and infusions of aromatic herbs and roots, such as balm, sage, and ginger, may be substituted instead of these. ORDER III. S P A S M I. IRREGULAR or preternatural motions of the muscles or muscular fibres are the characteristics of this order of diseases. Of the HYSTERIC DISEASE, of HYSTERIA. THIS complaint appears under such various shapes, imitates so many other diseases, and is attended vvith such a variety of symptoms, which denote the animal and vital functions to be considerably disordered, that it is difficult to give a just character or definition of it; and it is only by taking an assemblage of all its appearances, that we can convey a pro- per idea of it to others. The disease attacks in paroxysms or fits. These are sometimes pre- ceded by dejection of spirits, anxiety of mind, effusion of tears, diffi- culty of breathing, sickness at the stomach, and palpitations at the heart; but it more usually happens that a pain is felt on the left side, about the flexure of the colon, with a sense of distention advancing upwards, till it gets into tll€ stomach ; and removing from thence into the throat, it occasions by its pressure a sensation, as if a ball was lodged there, which by authors has been called globus hystericus. The disease having arrived at this height, the patient appears to be threatened with suffocation, becomes faint, and is affected vvith stupor and insen- sibility ; while at the same time the trunk of the body is turned to and fro, the limbs are variously agitated, wild and irregular actions take place in the alternate fits of laughter, crying, and screaming ; incohe- rent expressions are uttered, a temporary delirium prevails, and a frothy saliva is discharged from the mouth. The spasms at length abating, a quantity of wind is evacuated upwards, vvith frequent sighing and sobbing, and the woman recovers the exercise of sense and motion 274 NEUROSES OR NERVOUS DISEASES. CLASS II, without any recollection of what has taken place during the fit, feeling, however, a severe pain in her head, and a soreness over her whole body. In some cases there is little or no convulsive movement, and the per- son lies seemingly in a state of profound sleep, without either sense or motion. Hiccup is a symptom which likewise attends in some instances on the hysteric disease ; and now and then it happens that a fit of hysteria con- sists of this alone. In some cases of this nature it has been known to continue for two or three days, during vvhich it frequently seems as if it would suffocate the patient, and proceeds gradually weakening her, till it either goes off, or else occasions death by suffocation ; but this last fe extremely rare. Besides hiccup, other slight spasmodic affections sometimes wholly form a fit of hysteria, which perhaps continue for a day or two, and then either go off of themselves, or are removed by the aid of medicine. In some cases the patient is attacked with violent pains in the back, which extend from the spine to the sternum, and at length become fixed upon the region of the stomach, being evidently of a spasmodic nature, and often prevailing in so high a degree, as to cause clammy sweats, a pale cadaverous look, coldness of the extremities, and a pulse hardly perceptible. Hysteric affections occur more frequently in the single state of life than in the married, and most usually between the age of puberty and that of thirty-five years ; and they make their attack oftener about the period of menstruation, than at any other. They are readily excited in those who are subject to them, by passions of the mind, and by every considerable emotion, especially when brought on by surprise : hence sudden joy, grief, fear, &c. are very apt to occa- sion them. They have also been known to arise from imitation and sympathy. Women of a delicate habit, and whose nervous system is extremely sensible, are those who are most subject to hysteric affections ; and the habit vvhich predisposes to their attacks, is acquired by inactivity and a sedentary life, grief, anxiety of mind, late hours, dissipation, a suppres- sion or obstruction of the menstrual flux, excessive evacuations, and the constant use of a low diet, or of crude unwholesome food. Hysteria differs from hypochondriasis in the following particulars, and by paying attention to them may always readily be distinguished from it. Hysteria attacks the sanguine and plethoric ; comes on soon after the age of puberty ; makes its onset suddenly and violently, so as to deprive the patient of all sense and voluntary motion; is accompanied with the sensation of a ball rising upwards in the throat, so as to threaten suffocation ; is attended usually with much spasmodic affection ; is more apt to terminate in epilepsy than in any other disease ; and, on dissection, its morbid appearances are confined principally to the uterus and ovaria. The reverse happens in hypochondriasis. It attacks the melan- cholic ; seldom occurs till after the r,ge of thirty-five } comes on gra- ORDER HI. HYSTERIC DISEASE. 275 dually ; is a tedious disease, and difficult to cure ; exerts its pernicious tffecls on the membranous canal of the intestines, as well by spasms as wind; is more apt to terminate in melancholy or a low fever than in any other disease ; and on dissection exhibits its morbid effects princi- pally on the liver, spleen, and pancreas, which are often found in a hard, scirrhous, or other diseased state. Another very material difference might be pointed out between these two diseases, which is, that hysteria is much relieved by advancing in age, whereas hypochondriasis usually becomes aggravated. The two diseases have been often confounded together; but from con- sidering the foregoing circumstances, it appears that a pioper line of distinction should be drawn between them. The hysteric passion likewise differs from a syncope, as in this there is an entire cessation of the pulse, a contracted face, and a ghastly coun- tenance ; whereas in the uterine disorder there is often something of a colour, and the face is more expanded ; there is likewise a pulse, though languid ; and this state may continue two or three days, vvhich never happens in a syncope. It also differs from apoplexy, in vvhich the abolition of sense and vo- luntary motion is attended with a sort of snoring, great difficulty of breath- ing, and a quick pulse ; which do not take place in hysteric cases. It differs from epilepsy, in that this is supposed to arise in conse- quence of a distention of the vessels of the brain ; whereas in hysteria, the spasmodic and convulsive motions arise from a turgescence of blood in the uterus, or in other parts of the genital system. Hysteria may be distinguished from epilepsy by the globus hystericus, by the great flow of limpid urine, by the sudden transitions from laughing to crying, and by the fear of death preceding and succeeding to the paroxysm. However dreadful and alarming an hysteric fit may appear, still it is seldom accompanied with danger, and the disease never terminates fa- tally, unless it changes into epilepsy, or mania, or the patient is in a very weak reduced state. In the cure of hysteria two indications are to be attended to. The first is to allay the spasmodic symptoms which contitutes the fit; and The second, to lessen the excitability of the nervous system, and strengthen the whole frame during the intermissions of the paroxysms. The first of these indications is to be answered by bleeding, if the patient is young and plethoric, the pulse full, and the attack quite of a recent nature ; but in weak and delicate constitutions, or where the dis- ease has been of long standing, we should never have recourse to this operation. During the fit it will be the safest practice to rouse the patient by applying burnt feathers, asafcetida, or volatile salts or spirits, to the nose ; by rubbing the temples vvith xther, and by putting her feet into warm water. In case of costiveness, a laxative clyster, with an addition of asafcetida or castor, may be thrown up into the intestines; and where the fit con- 276 NEUROSES OR NERVOUS DISEASES. CLASS II. tinues for any length of time, a small blister may be applied to the in- side of each leg. During the fit, due care is to be taken that the patient sustains no injury from the violence of her struggles. As soon as she is perceived to be capable of swallowing, some anti- spasmodic, as asafoetida, castor, ammoniated tincture of valerian, oil of amber, &c. should be given to her frequently. Such medicines may either be administered separately, or be combined together, as in the formula! below.* In those cases where the spasms are very violent, and the fit of long duration, opium may be employed in addition toother antispasmodics. In common cases it will, however, be best to avoid its use, as it seldom fails to leave the patient remarkably low, particu- larly if long continued. In cardialgic paroxysms of the hysteric kind, the aqua kali, in doses of from thirty to forty drops, frequently repeated, has been found an ex- cellent palliative remedy, and may therefore be prescribed. The second indication is to be answered by giving medicines during the intermissions of the paroxysms to strengthen the system, such as the Peruvian bark, and other bitters, vvith the sulphuric acid, and chaly- beates ; proper formulae of which have been inserted under the head of Dyspepsia ; but if more agreeable to the practitioner, those mentioned belowf may be used. Mineral waters are found to be very efficacious in hysteric affections, and their powers may greatly be increased by proper exercise, particu- larly riding on horseback, together with early rising, a generous nutritive diet, cool dry air, and cold bathing. In addition to these, the mind is to be kept constantly easy and cheer- ful, and, if possible, to be always engaged in some agreeable and in- teresting pursuit; for which reason, watering-places are well adapted ft. Gum. Asafoetid. gj. Solve in Aq. Puleg. ^vj. et adde Tinct. Castor. sjiij. ------Valerian. V. gij. iEther. Sulphuric, ^j. M. ft. Mistura cujus sumat Cochl. ij. tertia hora. Vel ft. Tinct. Valerian. Vol. gj. ------Lavend. C. gij. Spirit. Ammon. C. gj. Aquae Puraj 5v. M. ft. Mistura Capiat Cochl. j. pro , dos. Vel ft. Aq. Cinnam. gjfs. Tinct. Castor, gij. Spirit. Ammon. Foetid, gutt. xx. .SLther. Sulphuric, gutt. xv. M. ft. Hauftus 4ta quaq. hora sumendus. Vel ft. Spirit. Ammon. Foetid, sjfs. Guttae xx.—xxx. pro dos. sumendae. Vel ft. JEther. Sulphuric, ^fs. Capiat, gutt. xx.—xxx. in quovis vehiculo. •f- ft. Ferri Rubigin. gr. vj. Extract. Cort. Peruv. £)j. M. ft. Bolus bis in die sumendus cum Infus. Quassias ^ij. Vel ft. Extract. Cort. Peruv. Pulv. Myrrh, aa gjfs, Ferri Vitriolat. gfs. Ol. Cinnam. gutt. v. Syrup. Zingib. q. s. M. fiant Pilula; lx. quarum capiat aeg*a iij. vel iv. ter in die ; fuperbibendo Infus. Gentian. C. §ij. ORDER III. HYSTERIC DISEASE. 277 for those who are subject to hysteric affections, and particularly where they have taken their origin from grief, anxious thoughts, or other dis- tresses of the mind. If the stomach is affected at any time vvith phlegm, so as to excite nau- sea, a gentle emetic may be taken to remove it; or if there is a tenden- cy to costiveness, it may be obviated by some gentle laxative, as advised under the head of Dyspepsia. When hysteric affections arise from a suppression or obstruction of the menses, these evacuations must again be promoted by adopting the means recommended under those particular heads. Hysterical women are often afflicted with slight spasmodic affections in various parts of the body, and particularly vvith cramps, which are most apt to seize them in bed, and when asleep. In mild cases of this nature, immersing the feet and legs in warm water will often be sufficient to re- move them ; but where the spasms are violent, and of some duration, we must attempt the cure by opiates, musk, aether, camphor, &c. internally, and by the warm bath, and frictions with anodyne liniments externally. In those cases where the stomach becomes affected with cramp, we must have recourse to considerable doses of aether combined vvith opium.* Its external region may likewise be anointed with a liniment of the same nature.f If the feet are cold, bottles filled with warm water should be applied to them. Throwing up an emollient clyster into the intestines may also be proper, particularly where costiveness accompanies the spasmodic affection of the stomach. To lessen the irritability or excitability of the system, and produce per- manent effects, some physicians have recommended a use of antispasmo- dics along with tonics. The undermentioned formulae J may be advised on the occasion, the patient washing them down with a little valerian tea. From the great disposition of the stomach to acescency in this disease, as well as in hypochondriasis, a diet of animal food will be most proper. Wine diluted vvith a sufficient quantity of water should be preferred to all other liquors for common drink. ft. Aq. Cinnam. Jj. ./Ether. Sulphuric, jj. Tinct. Opii gutt. xx. -----Caftor. gfs. Spirit. Carui Jfs. M. it. Hauftus ter quaterve die capien. dus. •v ft. Spirit. Camphorat. Jij, Tinct. Opii Jfs. -Ether. Sulphuric, giij. M. \ B- Mofch. gr. vj. Camphor, gr. iij. Extract. Cinchon. 3fs. M. ft. Bolus bis terve die fumendus. Vel ft. Pulv. Myrrh. ------ Caftor. aa ^j. Ferri Vitriolat. Qj. Extract. Chamjemel. gfs. 01. Succin. gutt. v. Syrup. Simpl. q. s. M. fiant Pilul. xxxvj. quarum capiat Jegra iv. mane et hora decubitus cum Cochl. ij. magnis. Infufi Column. 278 NEUROSES OR NERVOUS DISEASES. CtASS tl. Of EPILEPSY, or EPILEPSIA. X HIS disease consists in a sudden deprivation of the senses, accom- panied with a violent convulsive motion of the whole body. It attacks by fits, and after a certain duration goes off, leaving the per- son most commonly in his usual state ; but sometimes a considerable de- gree of stupor and weakness remains behind, particularly where the dis- ease has frequent recurrences. It isoftener met with among children than grown persons, and boys seem more subject to its attacks than girls. Its returns are periodical, and its paroxysms commence more frequently in the night than in the day, being somewhat connected vvith sleep. It is a disease sometimes counterfeited, in order to extort charity or excite commiseration. Epilepsy is properly distinguished into sympathic and idiopathic, be- ing considered as sympathic, when produced by an affection in some other part of the body, such as acidities in the stomach, worms, teething, &c.; and idiopathic, when it is a primary disease, neither dependant on, nor proceeding from any other. The causes which give rise to epilepsy, are blows, wounds, fractures, and other injuries done to the head by external violence, together with lodgments of water in the brain, tumours, concretions, and polypi. Vio- lent affections of the nervous system, sudden frights, fits of passion, great emotions of the mind, frequent intoxications, acute pains in any part, worms in the stomach or intestines, teething, the suppression of some long accustomed evacuation, too great emptiness or repletion, and poi- sons received into the body, are causes which likewise produce epilepsy. Sometimes it is hereditary, and at others it depends on a predisposition arising from a mobility of the sensorium, which is occasioned either by plethora or a state of debility. An attack of epilepsy is now and then preceded by a heavy pain in the head, dimness of sight, noise in the ears, palpitations, flatulency in the stomach and intestines, weariness, and a small degree of stupor, and in a few cases there prevails a sense of something like a cold vapour or aura rising up to the head ; but it more generally happens, that the patient falls down suddenly without much previous notice ; his eyes are distort- ed or inverted, so as that only the whites of them can be seen ; his fin- gers are closely clenched ; his limbs and the trunk of his body, particular- ly on one side, are much agitated ; he foams at the mouth, and thrusts out the tongue, which often suffers great injury from the muscles of the lower jaw being also affected ; he loses all sense of feeling, and not un- frequently voids both urine and faxes involuntarily. The spasms abating, he recovers gradually ; but on coming to him- self, feels very languid and exhausted, and retains not the smallest recol- lection of what has passed during the fit. When the disease arises from an hereditary disposition, or comes on after the age of puberty, or where the fits recur frequently, and are of long duration, it will be very difficult to effect a cure ; but when it at- ORDER HI. EPILEPSY. 579 tacks at an early age, and is occasioned by worms, or any accidental cause, it may in general be removed. In some cases it has been entire- ly carried off by the recurrence of a fever, or by the appearance of the menses, or of a cutaneous eruption. It has been known to terminate in apoplexy, and in some instances to produce mental derangement, or a loss of the powers of the mind, and so to end in idiotism. Epilepsy has been perceived to disappear suddenly about the age of puberty where it has attacked children of five or six years old, and where no treatment has had any effect. The number of fits are always increas- ed by parturition, and by every other thing which has a tendency to de- bilitate the system. The appearances usually to be observed on dissection, are serous and sanguineous effusion, a turgid tense state of the vessels of the brain with- out any effusion, a dilatation of some particular part of the brain, excre- scences, polypi and hydatids adhering to it, and obstructing its functions, and likewise ulcerations. '" . In epilepsy, the intentions of cure should vary according to the cause which occasions the disease. When it is sympathic, and arises from worms, medicines possessed of the power of destroying or dislodging these vermin ought to be employ- ed. When it proceeds from teething, that part of the gum which appears to be inflamed should be scarified, the body should be kept open by laxative medicines or emollient clysters, and the feet be bathed in warm water. When it is suspected to arise from acidities in the sto- mach, a gentle emetic should be given, and absorbents and alkalies after- wards be used. If the disease appears to proceed from any suppressed discharge, in particular the haemorrhois, leeches should be applied to the hemorrhoidal vessels, together with fomentations, and we should at the same time ad- minister aloetic cathartics. Where it attacks children of a costive habit, and seems to take its. rise merely from a foulness of the bowels, active purgatives should be employed. A combination of calomel and jalap will be very proper. If it arises from any stimulus, which, by exciting pain, occasions the complaint, this ought to be removed as quickly as possible. Ifitisa case of sympathic epilepsy, and is accompanied vvith the aura epileptica, we should then endeavour to destroy the part either by cutting it out, or by applying caustic to it; and when these means cannot be adopted, we ought then to endeavour to correct the morbid affection in it either by blisters, or by inserting an issue in the part. Should the disease seem to proceed from the partial division of a nerve, and it can be got at readily, we ought to cut through it in the same man- ner asin tetanus. Cutting off the communication with the brain has llke- wiu been attempted, by the application ol ligatures upon the limb, above the part from vvhic!' 'he ;. iia arises. A cse vnTch wis buoc^ssYliy treated in this way, is toco Yitd by Mr. \r!oIp-.Vi's Y. iconic-, '..'. Yjssor at YYona, hi !.Y Y'lservations on 280 NEUROSES OR NERVOUS DISEASES. CLASS II. Medicine and Surgery. An epileptic patient felt on every attack a sense of coldness at the sole of the foot, and which gradually ascended till it reached the head. It occurred to the Professor to make a strong ligature above the knee of the affected limb before the cold sensation had proceeded so high. The method succeeded ; and as often as he took this precaution sufficiently early, he prevented the attack from ta- king place. In the idiopathic epilepsy the cure consists in avoiding the occasional causes, and in removing or correcting those which predispose to it. The occasional causes which are to be avoided, are over-disten- tion. turgescence, intoxication, fits of passion, and all other emotions of the mind; and as the disease is confirmed by repetition and ha- bit, so the avoiding frequent recurrences of it, is of the utmost im- portance. It is a fact well supported, that in some instances the disease has been found to continue from custom alone, after the original cause had long ceased to act. In such cases our endeavours should be ex- erted to make nature discontinue this custom if possible. When an attack can be foreseen, no medicine perhaps under such circumstan- ces will be more likely to prevent an epileptic fit, than an emetic given about an hour before its approach. Removing to another country, and changing former habits and the manner of living, may likewise be service- able in such cases. If the predisposition to the disease has arisen from a plethoric state of the system, or from a turgescence in the vessels of the head, this is to be obviated by bleeding, both generally and topically, but more par- ticularly the latter ; by an abstemious diet and proper exercise, and by issues. These last may not only be supposed to be good remedies for obviating the plethoric state of the system, but may likewise be the means of determining occasional turgescences to such places, and therefore of diverting them in some measure from their action up- on the brain. Fpilepsy is one of the diseases in which the digitalis has been found serviceable, but most so in those cases where a plethoric state or turges- cence in the vessels of the head prevails. To produce, however, a per- manent effect, the constitution must be kept under its influence for some weeks, by giving from half a grain to one grain of the powder, or from fifteen to thirty drops of the tincture, three or four times a day. Under the head of Mania I have mentioned a severe case of epilepsy in a mid- dle-aged married woman, accompanied with mental derangement, where- in by administering the digitalis in the manner just noticed, and carefully guarding against the exciting cause ^frequent intoxication,) a complete cure was effected. When the predisposition is owing to a state of debility, which is most usually the case, we are to obviate and prevent its effects by re- commending the patient to breathe a cool air, to make use of a generous nutritive diet, to take daily exercise adapted to his strength, particularly on horseback, and to go frequently into a cold bath ; and besides adopt- ORDER lit. EPILEPSY. 281 ing these steps, he may enter on a regular course of antispasmodic, astringent, and tonic medicines. The antispasmodics in most general use are valerian, castor, musk, aether, oil of amber, oleum animale, oleum cajeputse, arnica montana, belladona, hyoscyamus, digitalis, and opium, all of which may be given, as advised under the heads of Hysteria, Hypochondriasis, and Palsy, or as prescribed below.* A combination of opium and valerian, or of opium and musk, will be likely to prove valuable remedies. In parti- cular, they snould be given a short time before the expected return of the paroxysm, and be repeated at proper intervals, increasing the dose in a gradual manner in proportion to the violence or frequent.recurrence of the fits. Where the disease depends Upon a plethoric state, it would be highly improper to give opium, but where no plethora exists, and it seems to depend upon irritation, or upon increased excitement, opium will prove a safe and powerful remedy. When given in a large dose, such as two grains in substance, or sixty or seventy drops in tincture, on the approach of a fit, it has been known to prevent it altogether ; but should it even fail in this, it will infallibly be found to lessen its violence. If the stomach rejects the internal use of opium, its external applica- tion may possibly be resorted to with much advantage, and it may like- wise be employed in this way during the convulsions The whole spine of the back may be moistened with tinctura opii, or a liniment consist- ing of iix grains of pure opium well triturated with a little hog's-lard may be rubbed in. The astringent medicine most celebrated formerly in the cure of epi- lepsy, was the misletoe, or viscus quercinus. It was given in doses of from half a drachm to a drachm of the powder, or about an ounce of the infusion repeated twice a day. It was indeed looked upon by many, more as an object of superstition than of real utility, and for many years past has experienced almost total neglect. A modern writer on epilep- sy! speaks, however, highly in its favour, and has recited several cases which were radically cured by it. f See Dr. Henry Frafer's Treatife on this difeafe. ft. Aq. Anethi Jjfs. Tinct. Valer. Vol. gfs. ------■ Castor. 5J- ./Ether. Sulphuric, gutt. xx. M. ft. Hauftus bis terve die sumendus. Vel ft. Mosch. Castor. Rus. aa gr. x. Opii gr. fs.—j. Conserv. Rosx q. s. M. ft. Bolus 6t3 quaq. hora cap kudus. ! R. Tinct. Valerian. Vol. Jfs Vet ' Capiat gutt. >>:.-—rl. pro do: 2 N ft. Ol. Succin. Rectific. Jfs. Guttas ::.—xxv. supra sScchar. instiL pro dcs. sumendx. Vel ft Ol. Animal. Jfs. Capiat gutt. xx.—xxx. pro dos. Vel ft. JEther. Sulphuric. Jfs. Cuttse xx.-—xxx. in Aquae cyatho pro dos. sumendce. Vel \ 5$2 NEUROSES OR NERVOUS DISEASES. CLASS It, As a tonic, the Peruvian bark has been much employed in the cure of this disease. Its use seems, however, best adapted to those epilep- sies which recur at certain periods, and which are without plethora ; in which cases, if it is given in a considerable quantity some little time before the expected recurrence, it will be very likely to prove service- able. When taken for a constancy, it may be combined with valerian, Sec. as below.* Metallic tonics having been found more powerful than the vegetable ones, have therefore been more generally employed. The prepara- tions of iron most used are the ferrum vitriolatum, the ferrum ammo- niacalct and the ferri rubigo. That of copper is the cuprum ammo- niacum} of the Edinburgh Dispensary, which may be given in small doses, at first of about a grain, repeated twice a day, increasing them gradually to as much as the stomach will bear. The pulvis stanni, and other preparations of tin, have likewise been used in the cure of epilepsy j but .heir effects seem doubtful. Flores zinci (now zincum calcinatum) have been much extolled for their virtues in this disease. The dose is from one grain§ to three, four, or five, which may be taken either in pills or a bolus. It will al- ways be the best way to begin with a single grain, repeated three or four times a day, and so to increase the dose gradually according to the effect it produces on the stomach. Zincum vitriolatum is another metallic tonic much recommended in this disease. Arsenic has likewise been employed in the cure of epilepsy with some success. It will be best administered in the form of solution, as recommended under the head of Intermittent Fever. Some instances of the cure of epilepsy having occurred from an acci- dental use of mercury ; this also has been proposed as a remedy. * ft. Cort. Peruv. Pulv. Jj. Pulv. Valerian. Jfs. Rubig. Ferri gij. Syr. Cort. Aurant. q. s. M. ft. Electuarium cujus sumat Cochl. min- im. 4ta quaq. hora. f ft. Ferri Ammoniac, gr. x.—9j. Conserv. Rosas q. s. M. ft. Bolus ter in die sumendus. Vel ft. Tinct. Ferti Ammoniac. Jj. Capiat guttas xx. bis terve die in Aquas frigid, cyatho. ft. Cupri Ammoniac, gr. ij. Conferv. Aurant. gr. x. ft. Bolus. M, § ft. Zinc. Calcinat. gr. xij. Pulv. Aromat. ----Chel. Cancr. ----Sacchar. Alb. aa Qj. M. et in Chartul. xij. divid. Vel ft. Zinc. Calcinat. gr. iij. Conferv. Rofa; q. s. M. ft. Bolus bis in die sumendus. ft. Zinc. Calcinat. gr. xxiv. Extract. Gentian, 3). M. ft. Maffa in Pilulas xij. dividenda, qua" rum fumat j. mane et vefpere. ORDER III. EPILEPSY. 265 The nitrat of silver * has lately been found to be a valuable medicine in the cure of epilepsy, even where the disease has been of many years standing. Two cases of this nature are recorded in the Medical and Physical Journal.t It will be best to begin with a quarter of a grain thrice a day, which dose will be sufficient for an adult. In some of the worst cases of epilepsy, in which the fits were long and violent as well as frequent throughout the course of the day, and where the disease had been of some standing, electricity has been found to ren- der them weaker, and to reduce their number very materially in a short space of time. When other means fail to procure the desired effect, we ought therefore to have recourse to this remedy, or galvanism. The diet in epilepsy should consist of such things as are light, nutri- tive, and easy of digestion taking care to avoid whatever is apt to prove fluulent During the intervals, the patient is to keep himself as cheer- ful and tranquil as possible, carefully guarding against all violent pas- sions or other emotions, and he should take care never to put himself in a hazardous situation, lest a fit should happen to attack him at that pe- riod. When it is present, due care must be taken to prevent him from bruis- ing himself; and especially that he does not get his tongue between his teeth. Rubbing the nose, temples, and pit of the stomach vvith vitri- olic aether, may possibly help to abbreviate the fit by its action on the olfactory organ. A smaller degree of epilepsy is where the sensibility and irritability remain, but there are spasmodic contractions of the muscles ; hence we see many persons affected with twitchings of the face. There are also certain spasmodic pains that come on by paroxysms, which seem like- wise of the epileptic kind. When any of these arise as sympathic affections, they are only to be cured by removing the primary disorder upon which they depend ; but where they take place independent of any other disease, they are to be treated in the manner just recommended to be pursued in the cure of epiiepsy, Of the DANCE of St. VITUS, or CHOREA SANCTI VITI. T X HIS disease is a convulsive action, most generally confined to one side, and affecting principally the arm and leg. When any motion is attempted to be made, various fibres of other muscles act vvhich ought not, and thus a contrary effect is produced from what the patient in- f See vol. i. p. 184, and vol. ii. p. 70. ft. Argent. Nitrat. gr. iij. Solve terendo in Aquae Diftillatx guttis aliquot, et adde Micas Panis q. s. ft. Maffi in Pilulas viginti diftribuenda. Capiat dna.s vel tres bis die. 284 NEUROSES OR NERVOUS DISEASES. CLASS II. tended. It is chiefly incident to young persons of both sexes, but parti- cularly those of a weak constitution, or whose health and vigour have been impaired by confinement, or by the use of scanty and improper nourishment, and makes its attacks between the age of ten and fifteen, occurring but seldom after that of puberty. By some physicians it has been considered rather as a paralytic affec- tion than as a convulsive disorder, and has been thought to arise from a relaxation of the muscles, which being unable to perform their functions in moving the limbs, shake them irregularly by jerks. Chorea Sancti Viti is occasioned by various irritations, as teething, worms, acrid matter in the bowels, offensive smells, poisons, &c It ari- ses likewise in consequence of violent affections of the mind, as horror, fear, and anger. In many cases it is produced by general weakness, and in a few it takes place from sympathy at seeing the disease in others. The fits are sometimes preceded by a coldness of the feet and limbs, or a kind of tingling sensation, that ascends like cold air up the spine, and there is a flatulent pain in the left hypochondrium, with obstinate costiveness. At other times the accession begins with yawning, stretch- ing, anxiety about the heart, palpitations, nausea, difficulty of swallowing, noise in the ears, giddiness, and pains in the head and teeth, and then come on the convulsive motions. These discover themselves at first by a kind of lameness or instability of one of the legs, which the person draws after him in an odd and ridi- culous manner; nor can he hold the arm of the same side still for a mo- ment ; for if he lays it on his breast, or any other part of his body, it is forced quickly from thence by an involuntary convulsive motion. If he is desirous of drinking, he uses many singular gesticulations before he can carry the cup to his head, and it is forced in various directions, till at length he gets it to his mouth, when he pours the liquor down his throat with great baste, as if he meant to afford amusement to the by-standers. Sometimes various attempts at running and leaping take place, and at others the head and trunk of the body are affected with convulsive mo- tions. The eye loses its lustre and intelligence, and the countenance is pale and expressive of vacancy ; deglutition is occasionally performed with difficulty, and articulation is often impeded, and sometimes com- pletely suspended. In the advanced periods of the disease, flaccidity and wasting of the muscular flesh take place, the consequence of constant irri- tation, of abated appetite, and impaired digestion. In many instances the mind is afflicted with some degree of fatuity, and often shews the same causeless emotions, such as weeping and laugh- ing, which occur in hysteria. When this disease arises in children, it usually ceases again before the age of puberty, and in adults is often carried off by a change from the former mode of life. Unless it passes into some other disease, such as epilepsy, it is never attended with danger. Where chorea arises in those of a weak irritable habit, and is wholly unconnected with any species of irritation, either of teething, worms, or ORDER III. DANCE OF ST. VITUS. 285 acrid matter in the first passages, we should not employ evacuants, but have recourse to strengthening remedies. Peruvian bark in large doses, with the assistance of cold bathing, has often effected a cure ; but the metallic tonics which have been advised under the head of Epilepsy, will be more likely to prove efficacious than those of the vegetable class. To tonics we may join antispasmodics, such as opium, musk, and camphor. Hyoseyamus and belladona are medicines sometimes employed in chorea. During a use of these medicines, if costiveness prevails, it should be removed by some gentle laxative. Should the disease resist these means, it probably may be carried off by strong electrical shocks directed through the whole body. The application of a perpetual blister to the os sacrum has in addition to electricity been found a valuable remedy. Dry cupping has in Some instances been thought to have proved useful. Chorea has pretty generally been considered by systematic writers as a disease of debility, and this opinion has been almost universally adopt- ed by practical physicians, inducing them to employ tonics, stimulants, and antispasmodics for its cure ; but in many cases this has proved very difficult; and when not removed by the change which the system un- dergoes at the age of puberty, the disease has continued to harass the wretched sufferer ever afterwards. This fact being well established, we should undoubtedly regard the symptoms of chorea as sometimes de- pending on local irritation and not on debility, and in such cases they are to be obviated by removing the causes of irritation, by scarifying the gums, by expelling worms, or by a use of brisk purgatives. From some cases reported in the first number of the Edinburgh Medical and Surgical Journal, and which were received into the Royal Infirmary of that city, it appears ihat very complete cures \vere effected by the frequent exhibi- tion of drastic purges consisting of mercury and jalap. Irritation in the first passages no doubt had Occasioned the chorea in these instances. A modern writer tells us,* that having met with many cases of chorea which he treated in the usual way, but without success, he was induced to desert the practice, and to consider the disease in a different light from that in which it had been commonly viewed. He conceived that the de- bility and spasmodic motions hitherto so much considered, might not be the leading symptoms of the disease, but might depend upon previous and increasing derangement of health, as indicated by irregular appetite and constipation of the bowels. Under this impression, he resolved to alter the mode of treating the disease, and began trying the effects of purgative medicines, given regularly in moderate doses. The success of the new practice established, he mentions, the just- ness of his opinion, and encouraged him to persevere vvith steadiness and activity. To procure a discharge of the indurated and fetid fasces, he fodnd it necessary to employ active and strong purgatives in the '* Sec Obfervations on the Utility of Purgative Medicines, by Dr. Hamilton. 236 NEUROSES OR NFRVOUS DISEASES. CLASS II. confirmed stage of the disease, given in successive doses, in such a man- mer that the latter doses might support the effect of the former ; but in the first stage of chorea, while the intestines yet retain their sensibility, and before the accumulation of feces is great, gentle purgatives, repeated as occasion may require, he experienced readily to effect a cure, or rather prevent the full formation of the disease. He mentions, that an occa- sional stimulus from purgatives will be requisite to support their due ac- tion, and to restore their healthy tone, even after a regular appetite for food, a more intelligent eye and lightened countenance, cheerfulness, in- creasing aptitude for firmer motions, the restoration of articulation and the power of deglutition, and a renovation of flesh and strength, succeed each other. Some people, particularly women in a state of pregnancy, are very subject to spasmodic contractions of the joints, coming on periodically and attended with very violent pain: for the removal of these, anodyne frictions appear to be the best remedy. Of the SARDONIC LAUGH, or RISUS SARDONICUS. IN this disease there prevails a fit of laughing, arising from no evident cause, vvhich continues often in a violent degree for three or four nights, so as to prevent the patient from sleeping. By its duration in this way, great debility is produced ; and frequency of the pulse, and other febrile symptoms, arise. It then either proves fatal by its violence, or goes off spontaneously. Antispasmodics, such as musk, castor, asafcetida, camphor, and xther, have usually been employed to remove the disease, but without effect, so that we are unacquainted with any remedy that will prove effectual, and the spontaneous cessation of the fit is more to be trusted to than any aid from medicine. Large doses of opium might probably afford some relief. Of the CRAMP, or TETANUS. JL ET ANUS is an involuntary, and almost constant contraction of all or several of the muscles, while the senses remain perfect and entire. It may be considered as of two kinds, viz. idiopathic and symptomatic. By practical writers, tetanic complaints have been distinguished into opisthotonos, emprostholonos, and trismus, in allusion to the situation of the parts affected ; but they are all evidently only different degrees of one and the same disease. These affections arise more frequently in warm climates than in cold ones, and are very apt to occur there when much rain or moisture quickly succeeds excessively dry and sultry weather. They attack per- sons of both sexes, of all ages, temperaments, and complexions, but the male sex more frequently than the female, and those of a robust and OflDER III. CRAMP. 287 Vigorous constitution oftener than those of a weak habit. An idea is en- tertained by many, that negroes are more predisposed to attacks of teta- nus than white people : they certainly are more frequently afflicted with it ; but this circumstance does not arise from any constitutional predis- position, but from their being more exposed to punctures and wounds in the feet, by nails, splinters of wood, pieces of broken glass, &c. from go- ing usually barefooted. Tetanic affections are occasioned either by exposures to cold when under profuse perspiration, sleeping in the open air on damp ground, or by some irritation of the nerves, in consequence of local injury by punc- ture, incision, or laceration. Lacerated wounds of tendinous parts prove, in warm climates, a never-failing source of these complaints. In cold climates, as well as in warm ones, the locked-jaw, or trismus, frequently arises in consequence of various surgical operations, particularly the am- putation of a limb, or of gun-shot wounds. Some cases have been recor- ded where trismus was supposed to be owing to the presence of worms in the intestinal canal. When the disease has arisen in consequence of a puncture, or any other external injury, the symptoms shew themselves generally about the eighth day ; but when it proceeds from an exposure to cold, they gene- rally make their appearance much sooner. In some instances tetanus comes on suddenly, and with great violence ; but it more usually makes its attack in a gradual manner; in which case a slight stiffness is at first perceived in the back part of the neck, which, after a short time, becomes considerably increased, and at length renders the motion of the head both difficult and painful. With the rigidity of the head there is likewise an uneasy sensation at the root of the tongue, together with some difficulty of swallowing,- and a great tightness is perceived about the chest, with a pain at the extremity of the sternum shooting into the back. A stiffness also takes place in the jaws, vvhich soon increases to such a height that the teeth become so closely set together as not to admit of the smallest opening. When the tetanic affection is confined to the jaws, the disease is called trismus. » In some cases the spasmodic affection extends no farther: in others, the spasms at this stage of the disease returning with great frequency, become likewise more general, and now affect not only the muscles of the neck and jaws, but likewise those of the whole of the spine, so as to bend the trunk of the body very forcibly backwards, and this is what is named opisthotonos. Where the body is bent forwards, the disease is called emprosthotonos. During the whole course of the disorder the abdominal muscles are violently affected with spasm, so that the belly is strongly retracted^ and feels very hard, most obstinate costiveness prevails, and both the flexor and extensor muscles of the lower extremities are commonly affected at the same time, so as to keep the limbs rigidly extended. Tlic flexors of the head and trunk Income at length so strongly af. fected, as to balance the action of the extensors, and to keep the head 288 NEUROSES OR NERVOUS DISEASES. CLASS !!• and trunk so rigidly extended and straight as to render it incapable of be- ing moved in any direction. The arms, which where little affected be- fore, are now likewise rigidly extended, the tongue also becomes affect- ed with spasm, and being convulsively darted out, is often much injured by the teeth at that moment snapping together. It is to this state of the disease that the term of tetanus has been strictly applied. The disorder continuing to advance, every organ of voluntary motion becomes affected, the eyes are rigid and immoveable in their sockets, the countenance is hideously distorted, and expresses great distress, the strength is exhausted, the pulse becomes irregular, and one universal spasm puts a period to a most miserable state of existence. Attacks of tetanus are seldom attended with any fever, but always with violent pain, and the spasms do not continue for a constancy, but the muscles admit of some remission in their contraction, which is renewed every ten or fifteen minutes, especially if the patient makes the least at- tempt to speak, drink, or alter his position. When tetanic affections arise in consequence of a wound, puncture, or laceration, they are almost sure to prove fatal, as I never but once met with a recovery under such circumstances, during a very extensive prac- tice and long residence in the West Indies. The locked-jaw arising in consequence of an amputation, or gun-shot wounds, likewise proves usuT ally fatal. When these affections are produced by an exposure to cold, they may in most cases be removed by a timely use of proper remedies) notwithstanding a considerable space will probably elapse before the pa? tient will be able to regain his former strength. Although there is some- times a great abatement of the spasms in tetanus, still they are apt to re- turn with renovated force. In some cases, the patient is destroyed in four days ; in others, he may linger for a fortnight. On dissections of this disease, slight effusions within the cranium have been observed in a few instances; but in by far the greater number no- thing particular has been discovered either in the brain or any other or- gan. In some instances, however, the blood is not found in coagula, but fluid like molasses, as in animals killed by lightning, appearing to indi- cate, that the whole muscular fibres of the arterial system had partaken of the general spasmodic action. Although our endeavours may not be crowned with success, where te- tanus arises from a lacerated wound, or a puncture in some tendinous part, still we should by no means suffer the patient to remain in so mise- rable a state of existence, without making some efforts to afford even a temporary relief or alleviation of his sufferings. On being applied to for advice, the practitioner should therefore endea- vour, in the first place, to find out the cause which has given rise to the disease. If supposed to proceed from a wound or puncture, he ought carefully to examine the injured part, and to extract, as quickly as possi- ble, any extraneous body that may have lodged therein, taking care, at the same time, to dilate the wound to a sufficient size, in order that the dressings may afterwards be applied in close contact with it. ORDER III. CRAMP. 289 These steps being taken, it may possibly be attended with some ad- vantage to pour a small quantity of a strong solution of opium into the wound, dressing it afterwards with a little lint dipped in the same, and laying a pledget spread vvith some digestive ointment over the whole. Every time the dressings are renewed, the wound is again to be wetted with the solution. The partial division of a nerve being sometimes supposed to occasion tetanic affections, the practitioner ought, when this is suspected to be the case, to make a deep incision into the part which has been injured, so as to divide the tendinous and nervous fibres entirely, after which he should adopt the mode of treatment that has just been recommended. Pencilling the wound freely with lunar caustic, and afterwards cover- ing it with a poultice of bread and milk, with the view to obtain suppura- tion as soon as possible, is another mode of proceeding which has been pursued in tetanus arising from external injury. Dr. Darwin recommends* the wound to be dilated, and then to fill it with lint moistened with spirits of turpentine, which brings on an in- flammation in it, and thereby cures or prevents the convulsions. Opium is the medicine which has been employed with the best effect in all cases of tetanus ; but it should always be given in moderate doses at first, and so be increased gradually. In administering opium in this disease, the attention must, however, be directed to the effect that it produces on the patient, and not to the quantity which is taken, as many cases are on record, where an ounce of it in substance has been given in the course of twenty-four hours, the spasms having been very frequent and violent. By many it has been supposed that joining it with musk and camphor has greatly added to its effect. A combination of these medicines (as in the formula belowf) had therefore best be used, taking care to in- crease the quantity of opium in each succeeding dose. Giving the mild alkali internally, and administering opium at the saim time in alternate doses, together vvith the use of a hot bath, im- pregnated vvith kali, and a few ounces of quick lime, is a mode'of treat- ment much recommended by Dr. Stutz of Suabia, in tetanus and tris- mus traumaticus-l An alternate internal use of opium and carbonate of potash is said to have been employed in the hospitals of Germany among the wounded soldiers in the late war vvith a most happy effect. The remedy is there- fore worthy of our attention in tetanic affections. • See Zoonomia, vol. iv. page 47. \ See Medical and Phyfical Journal, vol. iii. p. 572, and vol. v. p. 472. •f- ft. Mofchi gr. xv. Spirit. Cinnam. ^'j. Miftur. Camphorat. ^jfs. Tinct. Opii gutt. xxxv. M. ft. Hauftus 3tia vel 4ta hora fumendus. 2 O 290 NEUROSES OR NERVOUS DISEASES. CLASS II. In those cases where the jaws are so firmly locked together as to pre- vent a spoon from being introduced between them, and where the teeth) are quite perfect in front, it will be necessary to extract some of them, for the purpose of giving the patient his medicines and food. When he lpses the power of deglutition, opium is then to be administered in clysters. Besides giving opium internally, it may likewise be employed exter- nally, by rubbing the parts frequently which are most affected by spasm, with equal parts of the linimentum saponis and tinctura opii, or witb thfi ointments prescribed below.* This mode of introducing opium into the system will more particu- larly be necessary where the patient loses the power of swallowing, and by being applied to the parts immediately affected, promises fair for affording essential relief. Dr. Mosely asserts,! that opiates applied externally are not of the smallest utility either in the prevention or cure of tetanus. In this I roust beg leave to differ from him, as, during my practice in the West Indies, 1 met with many instances where the most evident advantages. were derived by using it in this way. To procure a relaxation of the spasms, it has been customary to makes use of a warm bath ; but in all the instances of a recovery from tetanus which have taken place under my care, the cold bath was substituted in-? stead of the warm. These, however, were cases (one excepted) whichi arose from exposures to cold. The plan generally pursued was, to throw. a large pailfull of cold water every two hours on the patient, after whichi he was wiped dry, and again put into bed ; an opiate draught, similar to what has been advised, was then given to him, and the parts most affected were well rubbed with a strong anodyne liniment. When he was so far recovered as to be able to swallow with facility, the Peruvian bark was given to him with a very free allowance of wine ; which course was pursued for a considerable time after the spasmodic affection had ceased. It has been recommended by some physicians to endeavour to excite a salivation by using mercury both internally and externally ; but 1 must say, I never found it answer. My trials of it were however few; for having experienced the method which I have recommended to be so ve- ry successful, in almost every instance where the disease arose from an exposure to cold, I should not have thought myself justified in losing- time by using any remedy which was attended with uncertainty. Where mercury is employed in the cure of tetanus with the view of exciting a salivation, the patient should be put now and then into a warm bath ; and that he may have every chance of recovering, I would recommend a joint use ofopiumatthe same time. f See his Tratife on Tropical Difeafes, p. 49/4. * ft. Opii Purif. Pulv. Subtilis. 3J. 1 Vel Camphor, gr. xv. I ft. Adipis Suillae Praeparat. §j. Adipis Suillae 51k M. Olei Succin. Rectificat. gh ft. Unguentum. J Opii Pulverifat. ^ij. M. URDER III. CRAMP. 291 In the Transactions of the College of Physicians of Philadelphia, ♦ol. i. part 1, is inserted a case of tetanus, from the extraction of two teeth, which was successfully treated by Dr. Rush, by a use of mer- cury and wine ; and others are elsewhere recorded on indisputable au- thorities. In the New-York Medical Repository for 1799, is mentioned another case of tetanus arising from the puncture of a pin in the wrist, vvhich was successfully treated by Dr. Hosack vvith wine (Madeira) alone; the woman having taken three gallons in a few days, in doses of a wine-glass- ful (containing about two ounces) every hour. It seems necessary to observe however, that in this case the wound was freely pencilled with lunar caustic, after which it was covered with an emollient poultice. In those affections where inflammation of the system might be of service, Dr. Darwin thinks wine might be preferable to opium. He mentions that he has observed a mixture of spirits of wine and warm water, given alternately with the doses of opium, has soonest and most certainly produced that degree of intoxication which was necessary to re- lieve the patient in the epilepsia dolonfica.* Dr. James Clark, in his Treatise on West India Diseases, informs us, that, being unable to cure the symptomatic tetanus, he endeavoured to prevent it, and for this purpose, after wounds and punctures, he gave two or three grains of calomel twice a day till a gentle salivation came on, and he pursued the same plan after operations. Out of fifteen patients, after amputation, that were treated in this way, only one died, and he was in so irritable a state before, that bad consequences were dreaded. In those who had been wounded or punctured, the success was greater; two only having been lost, out of a great number, since this mode of practice was begun. Dr. Donald Munro, in the third volume of the Edinburgh Physical and Literary Essays, has reported several cases of tetanus that were communicated to him by a physician who had practised many years in the island of Jamaica, which were perfectly cured by exciting a saliva- tion. It is necessary to mention, however, that not one of these had arisen in consequence of a puncture, wound, or any Other external inju- ry, but were all occasioned by exposures to cold. To prevent tetanic affections from arising after wounds and chirur- gical operations, I understand it is almost an universal practice on board of ships of war, to mix tincture of opium vvith the dressings, and that since this practice has been adopted, these complaints seldom occur. As a prophylactic, 1 should be much inclined to adopt this mode of treatment in preference to that proposed by Dr. Clark. When the disease has proceeded from an exposure to cold, it is apt to be attended with some slight inflammatory symptoms ; to remove which, bleeding is sometimes had recourse to, but it usually proves in- jurious instead of beneficial. As costiveness is a constant attendant on. tetanus, it should be ob- * See Zoonotr.ia, vol. ii. p. 431. 292 NEUROSES OR NERVOUS DISEASES. CX. ASS II. viated by the frequent exhibition of active aperients,* while the power of swallowing remains ; and after it has ceased, by the regular exhibition of clysters. Among the remedies of tetanus, it may be proper to mention the ole- um petrolei, or Barbadoes tar, which, by being taken internally, has been said in some instances to have effected a cure. Electricity is reported to have lately been employed in some cases of the locked jaw, with a happy effect. The remedy seems deserving of further trials. Throughout the whole course of all tetanic affections, the patient's strength is to be supported by wine, mixed vvith such things as he can easily swallow ; and where this power ceases, nutritive clysters must be substituted. The trismus nascentium is a species of tetanus; but this is inserted among the diseases peculiar to infants. Of the HICCUPS, or SINGULTUS. Hi -ICCUPS are a spasmodic affection of the stomach and diaphragm, arising from some peculiar irritation. They are in general symptomatic, but in some instances they appear as a primary disease. When they are idiopathic, they usually arise from an error in diet, or from an acidity in tne stomach. When symptomatic, they either come on towards the termination'of some acute disease, attend on injuries done to the stomach and other viscera, or prevail as an hysteric affection. Hiccups prevailing as a primary affection, are never attended with dan- ger, and are in general easily removed ; but when they arise in any acute disorder, or after a mortification has taken place, they may always be looked upon as the forerunners of death. The appearances on dissection will depend entirely on the disease of which they have appeared as a symptom. A common hiccup is often removed by taking a few small draughts of cold water, in quick succession, or by a sudden excitement of some de- gree of fear or surprise. When these simple means do not answer, re- course must be had to antispasmodics, the most useful of which for this disease, seem to be aether, musk, and opium; These may either be com- bined together, or be given separately. In the accidental hiccup of youth or of very old people, a pretty cer- tain remedy is a small quantity of any powerful acid, such as a tea- ft. 01. Ricini Mucil. Gum. Arab, aa gfs. Aq. Fervent. Jjj. , Kali Tartarifat. gij. M. ft. Hauftus. Vel ft. Infus. Sennx Jjfs. Natri Vitriolat. _^fs. Tinct. Jalapii ^fs. Syrup. Koix gij. M. ft. Hauftus. ORDER III. HICCUPS. 293 spoonful of vinegar or lemon-juice, or a little peppermint-water acidulat- ed'with a few drops of sulphuric acid. Where hiccups prove violent as well as obstinate, the application of a large plaster of Venice treacle to the patient's stomach, sometimes affords relief; but should it fail, a blister may then be substituted. Hiccups sometimes proceed from an acidity in the stomach, and hence it is that infants are very apt to be affected with them. When they arise from this cause, a little prepared chalk or magnesia joined vvith some carminative, such as the oleum anisi, will be the most proper medicine. When hiccups arise at the close of any acute or malignant disease, or in consequence of a mortification, no advantage can be obtained from me- dicine, or any other means whatever. Of the HOOPING COUGH, or PERTUSSIS. 1. HIS is a convulsive cough, interrupted by a full and noisy inspiration, and returning in fits that are usually terminated by a vomiting. Children are most commonly the subjects of this disease, and it seems to depend on a specific contagion, which affects them but once in their life. The disease being produced, the fits of coughing are often repeated without any evident cause ; but in many cases, the contagion may be considered as only giving the predisposition, and the frequency of the fits may depend upon various exciting causes, such as violent exercise, a full meal, the having taken food of difficult digestion, and irritation of the lungs by dust, smoke, or disagreeable odours. Emotions of the mind may likewise prove an exciting cause. Its proximate or immediate cause seems to be a viscid matter or phlegm lodged upon the bronchia:, trachea, and fauces, vvhich sticks so close as to be expectorated with the greatest difficulty. Some have sup- posed it to be a morbid irritability of the stomach, with increased actions of its mucous glands ; but the affection of the stomach which takes place in the disease is clearly only of a secondary nature, so that this opinion must be erroneous. The hooping cough usually comes on vvith an oppression of breathing, some degree of thirst, a quick pulse, and other slight febrile symptoms, which are succeeded by a hoarseness, cough, and difficulty of expectora- tion. These symptoms continue perhaps for a fortnight or more, at the end of which time the disease puts on its peculiar and characteristic form, and is now evident, as the cough becomes convulsive, and is atten- ded with a peculiar sound, which has been called a hoop. When the sonorous inspiration has happened, the coughing is again renewed, and continues in the same manner as before, tid either a quan- tity of mucus is thrown up from the lungs, or the contents of the stomach arc evacuated by vomiting. The fit is then terminated, and the patient remains free from any other for some time, and shortly after- 2§4 NEUROSES OR NERVOUS DISEASES. CLASS If. wards returns to the amusements he was employed in before the acces- sion of the fit, expresses a desire for food, and when it is given to him, takes it greedily. In those cases, however, where the attack has been severe, he often seems much fatigued, makes quick inspirations, and is rather faint. On the first coming on of the disease there is little or no expectoration, or, if any, it consists only of thin mucus ; and as long as this is the case* the fits of. coughing are frequent, and of considerable duration ; but on the expectoration becoming free and copious, the fits of coughing are less frequent, as well as of shorter continuance. By the violence of coughing, the free transmission of blood through the lungs is somewhat interrupted, as likewise the free return of the blood from the head, which produces that turgescence and suffusion of the face which commonly attend the attack, and in some instances brings on a he- morrhage either from the nose or ears. The disease having arrived at its height, usually continues for some weeks longer, and at length goes off gradually. In some cases it is however protracted for several months, or even a year. Although the hooping cough often proves tedious, and is liable to re- turn with violence on any fresh exposure to cold, when not entirely re- moved, it nevertheless is seldom fatal, except to very young children, who are always likely to suffer more from it than those of a more advanc- ed age. The danger seems indeed always to be in proportion to the youth of the person, and the degree of fever and difficulty of breathing which accompany the disease, as likewise the state of debility which pre- vails. It has been known in some instances to terminate in apoplexy and suf- focation. In the predisposed, it lays the foundation for asthma, scrofula,' and phthisis pulmonalis. If the fits are put an end to by vomiting, it may be regarded as a favourable symptom, as may likewise the taking place of a moderate and free expectoration, or the ensuing of a slight he- morrhage from the nose or ears. Dissections of those who die of the hooping cough, usually shew the consequence of the organs of respiration having been affected, and parti- cularly those parts which are the seat of catarrh. When the disease has been long protracted, it is apt to degenerate into pulmonary consump- tion, asthma, or visceral obstructions, in which last case the glands of the mesentery are found in a hard and enlarged state. Where the disease takes place in a child of a full plethoric habit, and is accompanied with a difficulty of breathing, full pulse, and other febrile symptoms, it may probably be attended with advantage to take away a small quantity of blood, and this will be done best, by applying a sufficient number of leeches either to the neck or chest; which operation may be repeated after a time, if the degree of dyspncea is not lessened ; but in common cases, where no such symptoms prevail, bleeding of any kind will not be necessary. In those cases where there is much difficulty of breathing, the appK- ORDER III. Hooping couch. 395 cation of a blister to the chest will likewise be highly proper at the com- mencement of the disease. Some practitioners have recommended the lower region of the sto- mach to be rubbed very frequently with a stimulating einbrocatioB,* co- vering the part afterwards with flannel. Inhaling the steam of warm- water with an addition of vinegar or aether twice or thrice a day,, may also be of service. The body being usually very costive, it will be necessary to have re- course to gentle laxatives to remove it. In many instances, an attention. to diet may probably be sufficient to answer the purpose of removing or preventing this symptom ; and therefore stewed prunes, roasted apples, 85c. may be given, which things children take very readily. Emetics administered frequently, have been found the most useful of all remedies in hooping cough, for which reason they ought never to be neglected ; and as children may easily be deceived by what has no ap- pearance of medicine, a solution of tartarised antimony f seems the most proper for the occasion. The best way, however, will be to give about a table-spoonful every fifteen minutes or so, until it takes effect, as- dangerous consequences might ensue from the medicine happening to operate harshly, and producing much vomiting, which in some cases a very small quantity of it is apt to do. Where the patient is grown up to an adult state, an emetic of oxymel of squills may be substituted. Bathing the feet frequently in warm water, has been supposed toaffbwfr relief in many cases. The acetite of lead has been lately recommended in the hooping cough, and is said to relieve the symptoms of the disease very speedily, without producing any bad effects on the stomach and bowels. It may be given as in the formula; inserted below.\ For obviating, the fatal tendency of the disease, and putting it into a< safe train, the remedies which have been advised are evidently the most proper ; but in its second stage, where it may be considered as continu- ing from the power of habit alone, all danger and violence being over, we must alter the plan of treatment, and have recourse to antispasmodics and tonics. Of the first class, musk, castor, asafcetida, oleum-succini rect., cam- phor, and opium, have principally been used; but their effects seem rather doubtful, and as they are all nauseous medicines, particularly the three first, it may not be easy to persuade children to take them. The uncertainty of the dose of opium, as well as the inconvenient * ft. Antimon. Tartarifat. ^ , J ft. CerufTaj Acetat.gr. ij.—v. tLF Candli'rid. 5ft. M. A* Rofx •?'> Ti*:ct. Cantharid. 3ft. M. * R. Antimon. Tartarifat. gr. iij. Aq. Purs ^vj. Syr. Simpl. 5ji|. M. Syrup. Viols gij. M. ft. Miftura. Cn^at Cochl. parvulum /,tia vel jta quaque hora. 296 NEUROSES OR NERVOUS DISEASES. CLASS II. effects produced by it on children, operate somewhat against the internal use of this drug, but its external use promises much benefit. In order to disguise tincture of opium, a few drops of aether may be added, and in this way it may be employed as an embrocation twice or thrice a day over the chest and stomach. Artificial musk is a medicine which is reported to have been given in the hooping cough with the most decided advantage, even when other remedies have failed. A small quantity may be dissolved in a little alco- hol, and about three or four drops be given twice a day, gradually in- creasing the dose to six, thrice in the twenty-four hours. Hemlock having been considered as an antispasmodic, has been admi- nistered in this disease, and frequently vvith considerable success. In a few cases where I made trial of it, some advantage seemed to be obtain- ed from its use ; but as I gave it combined with other remedies as be- low, * probably it was not entitled to the whole merit. The tincture of digitalis is another medicine which has of late been re- commended in the hooping cough. I have prescribed it in a few cases with seeming advantage. Combining it with opium might, perhaps, in- crease its efficacy. Hyoscyamus has likewise been proposed. Exciting a slight degree of strangury has been attended with a good effect in some instances of this disease.- A combination of tinctura can- tharidis, and tinctura opii camphorata,t may be used for this purpose, giving it in doses of about twenty drops repeated every three or four hours, until some slight effect of this nature is produced ; when the dose : may either be lessened, or be given at longer intervals. Its efficacy is owing to the counter-irritation excited by it. In order to take off the irritation from the mucous membrane, which is the principal seat of the disease, as well as to strengthen the general habit, it will be advisable to employ the Peruvian bark, and other tonic medicines. It may be given joined with the other remedies, as in the annexed prescription ;\ and as it is often impossible to persuade children to take it in substance, we must be content with substituting a decoction, or strong infusion of it. Arsenic has lately been recommended in pertussis by Mr. Simmons of Manchester ;§ and he asserts that it is attended with the most salu- tary effects, moderating the symptoms in a few days, and generally making a complete cure-in the space of a fortnight. It has been given to children of a year old with safety, in the closes recommended by Dr. Fowler of York, (see Intermittents,) whose solution was used. It ap- pears however, that Mr. Simmons employed venesection and emetics § See Annals of Medicine for 1797. * ft. Extract. Cicutje gr. j.—ij. \ ft. Decoct. Cinchon. gn'jk. Decoct. Cort. Peruv. ^j. Tinct. Opii gutt. v. M. Tinct. Opii Camph. gfs. fiat Hauftus ter in die sumendus. ------ ------Cantharid. gutt. xl. M. f ft. Tinct. Opii Camphont. 5J. .------ Cantharidis ^ij. M. Capiat Cochl. j.—-ij. quartis horis. ORDER III. HOOFING COUGH. 297 occasionally ; and he recommends, after the solution has been omitted for a week, to repeat it, in order to guard against a relapse. A frequent change of air having always been found very serviceable in this disease, ought therefore to be advised. A flannel waistcoat should be worn by the patient, as no doubt it promotes absorption, and prevents the vicissitudes of the climate taking* that effect on the skin, which we know it does, acting thereby as an exciting cause of coughing. Young children should lie with their heads and shoulders raised, and should be cautiously watched, that, when the.cough occurs, they may be held up, so as to stand upon their feet, bending a little forwards. Their diet should be light and of easy digestion, and mucilaginous diluents should be taken freely. Of the WATER-BRASH, or PYROSIS. A L2A. DISCHARGE of a thin, watery, or glairy fluid from the stomach, with eructations, and likewise a sense of burning heat in the epigastric region, are the chief characteristics of this disease. It principally attacks those of a middle age, and more frequently af- fects females than males, particularly the unmarried. Those who are afflicted with fluor albus have been found to be much predisposed to it. Being a disease not much known, and occurring but seldom, its causes have not been properly ascertained, but a low diet has been ascribed, as being apt to give rise to it. The application of cold to the lower extre- mities, and violent emotions of the mind, are likewise enumerated among its occasional causes. The fits of pyrosis usually come on in the morning and forenoon, when the stomach is empty; and the first symptom which the patient per- ceives, is a pain at the pit of the stomach, vvith a sense of constriction, as if it was drawn towards the back, and this is usually much increased by an erect posture. The pain, after proving severe, and continuing for some time, is followed by eructations, and the discharge of a considera- ble quantity of a thin watery fluid. In some instances, however, it is ve- ry ropy, and of an appearance somewhat similar to the while of an egg, as happened in a case which some time ago came under my observation. On a frequent repetition of the eructation and discharge, the fit at length goes off'. It is seldom that any of the symptoms of dyspepsia at- tend on it. This disease never proves fatal, but is often tedious, and troublesome to remove, being apt to recur occasionally, a long time after it has once taken place. For its cure, no certain method has yet been proposed ; but its fits are relieved by antispasmodics, such as xther, musk, castor, volatile alkali, oleum cajepuis, and opium. In the intervals, the cinchona, with the acidum sulphuricum, and chalybeates, will be advisable. .3 P 2$8 NEUROSES OR NERVOUS DISEASES. CXASS tU In pyrosis as well as in gastrodynia and other like affections of the stomach the oxyd of bismuth has been found to afford much relief, interposing now and then gentle aperients. It appears to be a remedy recommended on the ground of safety as well as utility. An adult may take five grains of it with about a scruple of gum tragacanth three times. a day. A case of pyrosis, accompanied by gastrodynia of a year's standing, is recorded in Dr. Bardsley's Medical Reports, which was effectually re- moved by the oxyd of bismuth in a very short time. The complaint had been so constant and severe as to prevent the patient from following his occupation as a weaver. The pain was fixed and dull, and the quantity of acid discharged from the stomach, in a watery form, was abundant* After clearing the stomach with an active emetic, the bowels were empti- ed by castor oil, and the patient then entered upon the bismuth. He took twenty grains of a powder, consisting of one part of the oxyd and five of gum tragacanth thrice a day for the space of a week, and then in- creased the dose gradually to forty grains. A short time effected the re- moval of the pyrosis. The bismuth was then discontinued, and the bark with sulphuric acid substituted, which soon completed the cure. It ap- pears likewise, that some other cases of pyrosis, accompanied with spas- modic pains, were treated with uniform success. Linnaeus, by whom the disease seems first to have been noticed, re- commends a use of the nux vomica: the dose is from ten grains to a scru- ple three times a day. Chewing tobacco has been known to effect a cure ; probably, smoking it might be attended vvith a still better effect The case which I have just alluded to in the preceding page was at first treated with antispasmodics ; but these being attended with no good effect, the physician who was called in advised the use of vitriolated zinc combined with opium and the extract of Peruvian bark, vvhich seemed at first to be wonderfully efficacious ; but the disease shortly afterwards returned, and the patient having lost confidence in the remedy, it was discontinued. Of ANGINA PECTORIS. JtvN acute constrictory pain at the lower end of the sternum, inclining; rather on the left side and extending up into the left arm, accompanied with great anxiety, violent palpitations at the heart, laborious breathing, and a sense of suffocation, are the characteristic symptoms of this disease. It is found to attack men much more frequently than women, par- ticularly those who have short necks, who are inclinable to corpu- lency, and who at the same time lead an inactive or sedentary life. Although it is sometimes met with in persons under the age pf twenty, still it more frequently occurs in those who are between for- ty and fifty. •RDEtt III. ANGINA PECTORIS. 39$ In slight cases, and in the first stage of the disorder, the fit comes on by going up hill, up stairs, or by walking at a quick pace after a hearty meal; but as the disease advances, or becomes more violent, the parox- ysms are apt to be excited by certain passions of the mind ; by slow walk- in ^. by riding on horseback or in a carriage, or by sneezing, coughing, speaking, or straining at stool. In some cases they attack the patient from two to four in the morning, or while sitting or standing, without any previous exertion or obvious cause. On a sudden he is seized with an acute pain in the breast, or rather at the extremity of the sternum, in- clining to the left side, and extending up into the arm as far as the in- sertion of the deltoid muscle, accompanied by a sense of suffocation, great anxiety, and an idea that its continuance or increase would certainly be iatal. In the first stage of the disease the uneasy sensation at the end of the sternum, with the other unpleasant symptoms which seemed to threaten a fotal suspension of life by a perseverance in exertion, usually gooff up- on the person's standing still, or turning from the wind ; but in a more advanced stage they do not so readily recede, and the paroxysms are much more violent. During the fit the pulse sinks in a greater degree, and becomes irregular, the face and extremities are pale, and bathed in a cold sweat, and for a while the patient is, perhaps, deprived of the powers of sense and voluntary motion. The disease'having recurred more or less frequently during the space of some years, a violent attack at last puts a sudden period to his existence. Angina pectoris had passed unnoticed among practitioners until Dr. Heberden published a description of it about forty-five years ago in the Transactions of the College of Physicians of London ; since which, many gentlemen of eminence in their profession have attempted to investigate its nature, and have obliged us with their observations By most of them it has been judged spasmodic. Dr. Parry, physician to the Bath Gene- ral Hospital, who is the last author that has published his sentiments on it, is of opinion, however, that it is in reality a case of fainting or syncope, which Dr. Cullen defines " motus cordis imminutus, vel aliquamdiu quiescens ;" and as differing from the common syncope only, in being preceded by an unusual degree of anxiety or pain in the region of the heart, and in being readily excited, during a state of apparent health, by any general exertion of the muscles, more especially that of walking. The supposed cause of angina pectoris (for which he has thought proper to substitute the name of syncope anginosa) is referred by him to a dis- eased state (generally ossification) of the coronary arteries of the heart. The rigidity of the coronary arteries, thus induced, may act, he thinks, proportionably to the extent of the ossification, as a mechanical impedi- ment to the free motion of the heart ; and though a quantity of blood may circulate through these arteries, sufficient to nourish the heart, as appears in some instances, from the size and firmness of that organ, yet there may probably be less than what is requisite for ready and vigorous action. Hence, though a heart so diseased may be fit for the purposes of common circulation, during a state of bodily and mental tranquillity, 300 NEUROSES OR NERVOUS DISEASES. CLASS IL and of health otherwise good ; yet, when any unusual exertion is requir- ed, its powers may fail under the new and extraordinary demand. In conformity with this notion, Dr. Parry endeavours to shew that the chief symptoms of the disease are the effect of blood retarded and accumulated in the cavities of the heart and neighbouring large vessels ; and that the causes exciting the paroxysms, are those which produce this accumula- tion ; either by mechanical pressure, or by stimulating in an excessive degree the circulating system ; in consequence of which, the heart, weakened by the mal-organization, readily sinks into a state of quiescence, while the blood continues to advance in the veins. After this quiescence has continued for a certain period, the heart may recover its irritability, so as again to carry on the circulation, in a more or less perfect degree, from the operation of the usual stimuli ; or death may at length ensue, from a remediless degree of irritability in the heart. Such is Dr. Parry's theory. In objection to it, it may however be urg- ed, that dissections of many of the cases of angina pectoris, which have terminated fatally, have not discovered any morbid appearances in the heart or its appendages, so that ossification of the coronary arteries can- not be the sole cause of this disease. In a few instances, such a state in these vessels has indeed been observed, but the occurrence is by no means general or even frequent. Neither have the lungs been discovered on dissection to be at all altered. In one or two cases, the blood was observ- ed not to coagulate, but to remain of a cream-like consistence, without any separation into serum or crassamentum. We should always consider angina pectoris as attended with a consi- derable degree of danger, and it usually happens that the person is carri- ed off suddenly. When it really depends upon an ossification of the co- ronary arteries, it is evident that we can never expect to effect a cure. During the paroxysms, considerable relief is to be obtained from blood letting, and from administering powerful antispasmodics, such as opium and aether combined together.* The application of a blister to the breast is likewise attended sometimes with a good effect. Two remarkable cases of this disease are recorded in the sixth volume of the Medical and Physical Journal, which were cured by applying pieces of calico to the sternum, wetted with a solution of tartarised antimony in the proportions mentioned below, t several times a day. The stimulus from this application produced an uncommon and violent eruption on the skin in a short time, having the peculiar malignant ap- pearance of carbuncles, itching and smarting excessively, many of which suppurated, while hundreds were continually rising up, some as large as peas, others as small as pins heads. As soon as the erup- * ft. Aq. Anethi gjfs. f ft. Antimon. Tartar. ?j. iEther. Sulphuric, gutt. xxx. Tinct. Opii gutt. xv.—xx. Spirit. Camphorat. -fs. ■■■ Lav. C. gutt. xx. M. ft. Hauftus 4taquaq. hora repetendus. Aq. Fervent. Ifej. M ORDER III. ANGINA PECTORIS. 301 tion appeared, considerable relief from the spasmodic affections was ob- tained in both instances, and the patients went on gradually recovering, after continuing the remedy two or three times a day for about a month. As the painful sensation at the extremity of the sternum often admits of a temporary'relief from an evacuation of wind by the mouth, it may be proper to give moderate doses of carminatives, such as the aqua menth. pip. aqua pimento, or spiritus carui. Where these fail in the desired ef- fect, a few drops of the oleum anisi on a little sugar may be substituted. With the view of preventing the recurrence of the disorder, the patient should carefully guard against passion or other emotions of the mind ; he should use a light generous diet, avoiding every thing of a heating na- ture, as spices, spirits, wines, and fermented liquors, and he should take care never to overload the stomach, or to use any kind of exercise imme- diately after eating. Besides these precautions, he should endeavour to counteract any disposition to obesity, which has been considered as a pre- disposing cause ; and this is to be effected most safely by a vegetable di- et, moderate exercise at proper times, early rising, and keeping the body perfectly open with laxative medicines. To establish the general health, and remove the mobility or excitabili- ty of the system, tonics, particularly the metallic ones, together with an- tispasmodics, may be given in the same manner as recommended under the head of Kpilepsy. It has been observed, that angina pectoris is a disease always attend- ed with considerable danger, and in many instances has proved fatal un- der every mode of treatment. We are given, however, to understand by Dr. Macbride,* that of late, several cases of it have been treated with great success, and the disease radically removed, by inserting a large is- sue in each thigh. These therefore should never be neglected. In one case, vvith the view of correcting or draining off the irritating fluid, he or- dered, instead of issues, a mixture of lime-water with a little of the spiri- tus juniperi comp. and an alterative proportion of Huxham's antimonial wine, together vvith a plain, light, perspirable diet. From this course the patient was soon apparently mended ; but it was not until after the inser- tion of a large issue in each thigh, that he was restored to perfect health. Dr. Darwin likewise makes mention t that four patients who laboured under the angina pectoris in a severe degree, were all recovered, and continued well three or four years, by the use (as he believes) of issues on the inside of each thigh, being large enough at first to contain two peas each, but afterwards only one. They took besides some slight antimo- nial medicine for a short time. * See Medical Obfervations and Inquiries, vo^ yj, + Sec Zoonomia, vol. iv. p. 43. S02 NEUROSES OR NERVOUS BISEASES. CLASS tl,. Of PALPITATION, or PALPITATIO. X HIS disease consists in a vehement and irregular motion of the heart, and is induced by organic affections, a morbid enlargement of the heart | itself, or of the large vessels, plethora, debility or mobility of the system, mal-conformation of the thorax, and many of the causes inducing syncope. During the attacks, the motion of the heart is performed with greater rapidity, and generally with more force than usual, which is not only to be felt vvith the hand, but may often be perceived by the eye, and in a few » instances even be heard ; there is frequently dyspncea, a purplish hue of , the lips and cheeks, and a great variety of anxious and painful sensations. In some instances the complaint has terminated in death, but in many others it is merely symptomatic of hysteria and other nervous disorders. In the treatment of this disease, it should be our study, if possible, tp find out the exciting cause, and to remove this. If it arises from pletho- ra, bleeding with purgatives and the rest of the antiphlogistic course should be adopted ; if from debility, bitters with chalybeates and cold bathing, &c. will be proper ; when symptomatic of any nervous disorder, xther, castor, musk, and other antispasmodics, conjoined with tonics, wilt be advisable. As the disease, however, arises from an organic affection of the heart itself in many instances, or of the aorta, or other large vessels, connected with it, all that may be in our power in such cases will be to caution the patient against exposing herself or himself to such circumstances as may increase the action of the sanguiferous system, particularly fits of passion, sudden surprises, violent exercise, or great exertions of the body. Of ASTHMA. A HIS disease is a spasmodic affection of the lungs, which comes on by fits, and is attended by a frequent, difficult, and short respiration, togeth- er with a wheezing noise, tightness across the chest, and a cough ; all of which symptoms are much increased when the patient is in an horizon- tal position. Asthma rarely appears before the age of puberty, and seems to attack men more frequently than women, particularly those of a full habit, in whom it never fails, by frequent repetition, to occasion some degree of emaciation. Dyspepsia always prevails, and appears to be a very promi- nent feature in the predisposition. Its attacks are most frequent during the heats of summer in the dog-days, and in general commence at mid- night. When the disease is attended with an accumulation and discharge of humours from the lungs, it is called the humid asthma; but when it is 9RDER III. ASTHMA. SQ3 unaccompanied by any expectoration, it is known by the name of the dry or spasmodic asthma. On the evening preceding an attack of asthma the spirits are often much affected, and the person experiences a sense of fulness about the stomach, with lassitude, drowsiness, and a pain in the head. On the approach of the succeeding evening he perceives a sense of tightness and stricture across the breast, and a sense of straitness in the lungs impeding respiration. The difficulty of breathing continuing to increase for some length of time, both inspiration and expiration are performed slowly, and with a wheezing noise ; the speech becomes difficult and uneasy, a pro- pensity to coughing succeeds, and the patient can no longer remain in an horizontal position, being as it were threatened vvith immediate suffoca- tion. These symptoms usually continue till towards the approach of morn- ing, and then a remission commonly takes place; the breathing becomes less laborious and more full, and the person speaks and coughs with greater ease. If the cough is attended with an expectoration of mucus, he experiences much relief, and soon falls asleep. When he awakes in the morning, he still feels some degree of tight- ness across his breast, although his breathing is probably more free and easy, and he cannot bear the least motion without rendering this more difficult and uneasy ; neither can he continue in bed, unless his head and shoulders are raised to a considerable height. Towards evening he again becomes drowsy, is much troubled with flatulency in the stomach, and perceives a return of the difficulty of breathing, which continues to increase gradually, till it becomes as vio- lent as on the night before. After some nights passed in this way, the fits at length moderate, and suffer more considerable remissions, particularly when they are attended by a copious expectoration in the mornings, and that this continues from time to time throughout the day ; and the disease going off at last, the patient enjoys his usual rest by night without further disturbance. During the fits the pulse is not usually much affected, but in a few cases there is a frequency of it vvith some degree of thirst, and other fe- brile symptoms. In some persons the face becomes turgid and flushed during the continuance of the fit, but more commonly it is pale and shrunk. Urine voided at the beginning of a fit is generally in consider- able quantity, and with little colour or odour ; but after the fit is over, what is voided is in the ordinary quantity, of a high colour, and sometin.es deposits a sediment. Congestions of blood, or of serous and pituitous humours in the lungs, noxious vapours arising from a decomposition of lead or arsenic, impure and smoky air, cold and foggy atmosphere ; scrofulous, rheu- matic, gouty, psoric and scorbutic acrimony ; a weak digestion, attended with great flatulency ; general debility ; water in the chest; aneurisms ; polypi, or concretions of grumous blood in the large vessels, and tne like, are the causes from which this formidable disease may arise in £04 NEUROSES OR NERVOUS DISEASES. CLASS It. different individuals. In some instances it proceeds from an hereditaiy predisposition, and in others from mal-conformation of the chest. Asthma having once taken place, its fits are apt to return periodi- cally, and more especially when excited by certain causes, such as by a sudden change from cold to warm weather, or from a heavier to a lighter atmosphere ; by severe exercise of-any kind, which quickens the circulation of the blood ; by an increased bulk of the stomach, either from too full a meal or from a collection of air in it; by exposures to cold, obstructing the perspiration, and thereby favouring an accumulation of blood in the lungs; by violent passions of the mind ; by disagree- able odours, and by irritations of smoke, dust, and other subtile particles floating in the air. A consequence of convulsive motions is the habit of repetition the muscles have contracted by laws peculiar to the animal economy ; so asthma is believed to depend frequently upon this cause. It has also in some instances been supposed to proceed from irrita- tion in the stomach, uterus, and other abdominal viscera; but whether the cause of convulsive asthma may be extraneous to the thoracic cavity, is a point not clearly decided. Many facts appear, however, to support the conclusion. The proximate or immediate cause of the disease has by Dr. Cullen, and most other writers, been supposed to be a preternatural or spasmo- dic constriction of the muscular fibres of the bronchia, vvhich not only prevents their being so dilated as to admit of a free and full inspiration, but also gives them a rigidity, which interferes with a free and full ex- piration. This doctrine has, however, been disputed by Dr. Bree, who, in a very ingenious treatise on this disease, offers it as his opinion, that irrita- tion seated within the air-cavities, and arising either from an effusion of serum, or from aerial acrimony, is the true proximate cause of convul- sive asthma. The mucus which is excreted in the course of the dis- ease, and vvhich has been looked upon by Dr. Cullen, and others, as only an effect, Dr. Bree views as a prominent cause of the parox- ysm ; or, when it is absent, only yielding to a different cause equally irritating to the organ, and exciting spasmodic contractions of the respi- ratory muscles. Dr. Darwin says, that whatever may be the remote cause of the pa- roxysms of asthma, the immediate cause of the convulsive respiration, whether in the common asthma, or in what is termed the convulsive, vvhich are perhaps only different degrees of the same disease, must be owing to violent voluntary exertions to relieve pain, as in other convul- sions ; and the increase of irritability to internal stimuli, or of sensibility during sleep, must occasion them to commence at this time. The sudden accession of the paroxysms generally after the first sleep, their returning at intervals, and the sense of constriction about the dia- phragm, occasioning the patient to get into an erect posture, and to fly for relief to the cold air, will readily distinguish asthma from other diseases. ORDER III. ASTHMA. SQ£ If the attacks of asthma are neither frequent nor severe, and the pa- tient is young-, there may be a possibility of removing the disease entirely; but where it comes on at an advanced period of life, has frequent parox- ysms, and proceeds either from an hereditary predisposition, or from a condition of the body subject to serous defluxions, it will be impossible to eradicate it By changing into other diseases, as consumption and hy- drothorax, or by occasioning an aneurism of the heart, or of some large vessel, it is apt to prove fatal ; but without such occurrences it is bv no means attended vvith danger, although it may seem in many instan- ces to threaten almost immediate death by suffocation. Anasarcous swellings of tiie lower extremities, and some degree of diabetes, are com- plaints which frequently attend on asthma, where it has been of long du- ration. The respiration becoming suddenly quick and short, paralysis of the arms, great depression of strength, a scanty secretion of urine, and froth- ing at the mouth, indicate much danger. The inspection of dead bodies has thrown but little light either on the naiure or cause of this disease. A series of observations from Morgagni, and the works of many other anatomists, have however proved the existence of extravasated serum in the vesicles of the lungs of asthmatics, in most instances. Where the disease has been of long con- tinuance, various morbid affections of the system have been discovered on dissection. In the treatment of asthma, it is too much the practice to adopt bleed- ing during the paroxysms, vvith the view of preventing any danger from the difficult transmission of blood through the lungs, and of obviating the plethoric state of the system, which might be supposed to have a share in producing a turgescence of the blood in the lungs ; but bleeding has proved highly injurious in almost every instance of the disease, by delay- ing the expectoration, and is certain to be attended vvith bad consequen- ces, where asthma lias arisen in elderly persons, or has been of long standing. In full plethoric habits, possibly cupping between the shoul- ders might be of some service. On blood-letting, Dr. Bree makes the following judicious observa- tions : " Many doubts," iie says, " occur on the propriety of bleeding in any species of this disease. Before the pulmonary vessels have at- tempted to relieve themselves by their exhaling orifices, blood may pos- sibly be drawn with advantage ; but when effusion has taken place, a certain debility is indicated, and a loss of contractile power in the coats of the vessels, vvhich prudence will rather submit to during the fit, and attempt to remedy in the intermission. In this state of the disease, na- ture pursues the path best adapted to her circumstances ; the escape of serous fluid gradually relieves the vessels, and respiration and absorption must be relied on, with a salutary cough, to clear the air-cells of the lymph. If evacuations of blood are directed, the sudden depletion of the vessels will leave their axits without the stimulus necessary to pro- duce a contraction equsft to the space which the blood hud occupied; the heart will participate in the injury, and will also be deficient in vigour of contraction. If, therefore, blood is to be taken away, it 2 Q 306 NEUROSES OR NERVOUS DISEASES. CLASS II. should be drawn from the vessels at intervals, and in small portions, which would allow of the contractile power being exerted, in proportion as the vessel loses its contents, and would not finally take so much fluid away as would leave it without the stimulus of distention, so essential to the return of health. " But bleeding is an imprudent operation in every species of asthma, unless it be the second. In the first species I have repeatedly directed it; but have never had reason to think that the paroxysm was shortened an hour by the loss of blood ; and I have often been convinced, that expectoration was delayed, and more dyspneea remained in the inter- mission, than was common after other paroxysms. In old people who have been used to the disorder, it is certainly injurious. In the second species there are occasional topical inflammations, which this operation may relieve ; but if it is carried far, there is the strongest reason to apprehend that the patient may be plunged into asthma of the first species.'' That the reader may have a clear idea of Dr. Bree's meaning, it is ne- cessary to say, that he divides convulsive asthma into four species : The first species, arising from pulmonic irritation of effused serum. The second species, arising from pulmonic irritation of aerial acri- mony. The third species, arising from abdominal irritation in the stomach, uterus, or other viscera. The fourth species, secondary and dependent upon habit, after irritation is removed from the thoracic or abdominal viscera. Purging is attended with the same injurious effects as bleeding, in all species of this disease ; but as asthmatics are hurt by an accumulation or stagnation of matters in the alimentary canal, so costiveness must be ob- viated by a proper attention to diet ; and where this proves insufficient, by the employment of gentle laxatives, such as magnesia, with the addi- tion of a few grains of rhubarb. During a paroxysm, costiveness may be removed by an emollient clyster. Emetics, by their taking off the determination of blood from the lungs, and supposed power of assisting expectoration, have been found highly useful in all species of asthma, except that which depends on habit. A vomit given in the evening, when a fit has been expected to come on in the night, has in some instances appeared to prevent its attack. It there- fore seems an advisable practice to make use of gentle emetics, and to re- peat them frequently. Ipecacuanha being more mild and certain in its operation than any of the preparations of antimony, ought therefore to be used. Even during the paroxysms of asthma the administration of an emetic may not be improper. The remedy can only be resorted to with safety, however, where no symptoms of inflammation are discoverable ; where the respiration is not extremely impeded ; and where the patient's strength is not much exhausted. Blistering and issues have been much employed in asthmatic cases, but they seem only to be serviceable in those vvhich have arisen from the stoppage of some long-accustomed or habitual discharge, or in the com- ORDER III. ASTHMA. 307 plicated cases of old people. In pure spasmodic asthma they have not been found either to prevent or relieve the fit. Under the supposition that asthma arises frequently from predisposi- tion, or from a preternatural mobility or irritability of the lungs, antispas- modics have been much used to moderate the paroxysms. Of this class, aether and opium have been found most useful, and particularly the latter; but its value is frequently much enhanced by combining it vvith the for- mer, as below.* These medicines seem, however, to have no certain efficacy in shor- tening the paroxysms, except in those cases where the disease arises from a preternatural mobility or irritability of the lungs, or is continued from habit, in these instances they may prove highly serviceable, but in no others. The fetid gums have also been much employed in asthma ; but from their heating quality, they have been observed in some cases to prove hurtful. Dr. Bree mentions, " that having been afflicted with asthma, he took, during a paroxysm of the first species, four grains of solid opium, vvhich produced nearly an apoplectic stupor for two days. After a few hours the most debilitating sickness came on, with incessant efforts to puke. The labour of the respiratory muscles was abated, but the wheezing evi- dently increased; a countenance more turgid than usual, and intense head- ach, attended. The pulse was increased in strength and quickness for a few hours, but then sunk into great weakness.'' He further observes, " that the paroxysm shewed itself four hours ear- lier than usual the next day, and two grains more were taken when it was perceived to commence ; respiratory labour seemed again to abate, but the anxiety increased to an alarming degree, as the stupor became less. The pulse was now weaker, and frequently irregular. Loose motions succeeded, and a general sweat. The energy of the paroxysm then re- vived with exquisite distress. A medical friend, who attended with great care to the progress of these trials, became alarmed, and endeavoured to promote puking, without effect. Blisters were applied, and draughts of vinegar and pepper were given, interposed with strong coffee and mustard. The patient was at last brought back to a state more usual in former pa- roxysms ; but with every care, the exacerbations were no fewer than nine, before expectoration, becoming gradually more copious, concluded the fit. Notwithstanding the bad success of this experiment, opium was used in another paroxysm, after an active vomit, and bad consequen- ces still ensued, though not so extensively." To prevent the frequency and severity of the paroxysms in asthma, smoking, or chewing of tobacco, has been had recourse to, and some- times with a good effect, particularly in the spasmodic asthma. * ft. Aq. Pulegii ^jfs. Either. Sulphuric, gutt. xxx. Tinct. Opii gutt. xv. ------Lav. C.2ls. M. ft. Hauftus 4ta vel oca quaq. hora sumendus. 308 NEUROSES OR NERVOUS DISEASES. CLASS II. As the free passage of air to and from the lungs is obstructed in the first species of asthma, by a lodgment of mucous matter, the expulsion of this should be promoted by pectorals, such as gum ammoniac, squi Is, &c. combined as below,* or as prescribed under ti.e head of Peripneumo- ny ; but oily demulcents ought to be avoided, as being injurious. .'-. de- coction of madder-root has in some cases been used as an attenuant and expectorant with a good effect. In most cases of asthma, dyspepsia is a prominent symptom, and the patient is much troubled with flatulency of the stomach, acidities, and other symptoms of indigestion. To remove these, it will be necessary to make use of absorbents with stomachics and bitter infusions, as recom- mended under the head of Dyspepsia. Dr. Bree observes, that chalk and opium will astonish the asthmatic., by the excellence of their effects, when the irritation proceeds from dyspepsia of the first passages only. Vine- gar separately exhibited, was likewise found by him to counteract the flatulence and distention of the stomach. Diaphoretics are a class of medicines which may prove useful in that species of asthma which is dependent upon pulmonic irritation of aerial acrimony, by promoting exhalation from the vessels of the lungs. Small doses of opium may be conjoined vvith a good effect, as in the pulv. ipe- cac, c. and the patient should not be subjected to the influence of irrita- ting causes, such as are known to exist in towns and manufactories. Warm pediluvia may be ordered. The digitalis is a medicine which has lately been administered in asth- ma. In the fourth volume of the Medical and Physical Journal, ptige 329, mention is made of a case by Dr. Sugrue of Cork, in which its salu- tary effects were speedily and decisively produced. The tincture (as ad- vised to be prepared by Dr. Darwin) was the preparation had recourse to, and this was administered in doses of fifteen drops, repeated twice a day. We are informed, that when his patient applied for advice, he was pale and emaciated ; complained much of a sense of suffocation and tightness about the chest ; he scarcely slept, but after dozing about an hour on go- ing to bed, he awoke very much oppressed, was obliged to sit up in the bed during the remainder of the night, and very often believed that he could not live until morning. His pulse was about 120, and very feeble. * ft. Lact. Ammon. §iv. Oxymel. Scillas giij. Vin. Antimon. gutt. 1. Acet. Diftillat. gfs. M. ft. Miftura cujus sumat Cochl. ij. subinde. Vel ft. Gum. Ammon. gij. Pulv. Scillas gj. Sapon. Hispan. ^ij. Bals. Sulph. Anisat. q. s. M. fiant Pilula? lx. quarum fumat segcr iv. vel v. pro dos. Vel ft. Gum. Ammoniac, gjfs. Florum Benzoin, gj. Bals. Peruv. gutt. xv. ----Sulphurat. q. s. M. et in Pilul. No. xij. e singul. drachma divid. Capiat iij. mane ct vefpere. QRDER III. ASTHMA. 309 Dr. Sugrue states, that he put him under a course of the digitalis, as just mentioned. As he lived in a remote part of the city, he did not see him again for a fortnight; at the end of which time he again called upon him. The remarkable change which had taken place in his ap- pearance was astonishing ; he had got rid of the wheezing and oppres- sion at his chest; his countenance was much fuller, and his complexion was much less pale ; . his pulse was about 90, and tolerably strong. It appears from the account the patient gave of himself, that after he had taken the medicine about three days, he no longer felt himself obliged to sit up at night, but was able to take a comfortable nap, after which he felt himself refreshed, a sensation with vvhich he had been for some months unacquainted. At the expiration of a week he could sleep five or six hours, and his appetite and strength improved in the same proportion ; he no longer experienced the necessity of stopping to take breath on ascending an eminence. From continuing the medicine, he was, at the time of making this report, in better health than he had been for ten years before. We are further informed by Dr. Sugrue, that in every other case of asthma in which the digitalis was exhibited by him, the most violent symptoms were mitigated, and the general state of health visibly im- proved. One effect which took place in every patient, and which particu- larly attracted his attention, was, that the expectoration was diminished, and at the same time the necessity of it seemed to be removed, which shewed how different its action was from that of antimonials. Another striking difference between its action and that of antimonials was, that it appeared less efficacious in relieving the symptoms of asthma, in those cases in which it produced nausea or vertigo. The digitalis in conjunc- tion with opium, by suspending the symptoms, has been found highly serviceable in cases of spasmodic asthma. It does not admit of the smallest doubt but that a combination of digi- talis with opium has proved highly advantageous in spasmodic asthma when given in the dose of half a grain of each every four or five hours. I have tried it, and found it to answer in two or three cases. In addition to the means vvhich have been recommended to be employ- ed during a fit of asthma, it may be necessary to mention, that recourse has been had to the assistance of pneumatic medicine, and that the gas- es, or factitious airs, have been much used by a few physicians, but more particularly by Dr. Beddoes and Dr. Thornton. By the former of these gentlemen we are told, that such is the miraculous effect of oxygen, vital or dephlogisticated air, when applied in asthma, that no sooner does it touch the lungs, than the livid colour of the countenance disappears, la- borious respiration ceases, and the functions of all the thoracic organs go on easily and pleasantly again. Of pneumatic remedies, Dr. Bree speaks with little confidence as to their efficacy in curing asthma. He however proposes oxygen as an auxiliary with other means of relief in that species arising from mu- cous irritation. In the dry asthma, oxygen was observed by him to be i, 310 NEUROSES OR NERVOUS DISEASES. CLASS II. manifestly hurtful, and hydrogen and hydrocarbonate were tried without benefit. Inhaling the vapour arising from xther has been found in some cases of asthma greatly to relieve the paroxysms. These are the remedies which are to be employed during a paroxysm of asthma ; but in the intermission we should have recourse to tonics, such as the Peruvian bark, bitter infusions, chalybeate waters, and pre- parations of iron, particularly the ferri rubigo, and ferrum vitriolaium, various formulae of vvhich will be found under the head of Dyspepsia. To assist the effects of these remedies, cold bathing may be used during the intermissions ; and where this cannot be obtained, washing the breast frequently with cold water, may probably be of some service. In addi- tion to other tonics, exercise either in sailing, riding in a carriage, or on horseback, but particularly the latter, together vvith a change of air, will be beneficial to asthmatics: they should try different situations, until by perseverance one is found out to live in, in which the disease is rendered less distressing, or is entirely removed. Whatever preparation of iron we may employ, it should always be giv- en in small doses at first, increasing the quantity-by degrees. If heat, or any other unpleasant symptom, is occasioned by it, its use must be sus- pended for a time, and saline draughts with opium be substituted. A want of firmness in continuing the use of tonics, when properly indicated, is however a great source of their discredit. In case of some temporary inconvenience being experienced from employing any particular medi* cine, or form, the practitioner should change it for another, never aban- doning the general intention of strengthening the system, and thereby preventing a return of the disease. As in many cases of asthma, and perhaps in the great majority of them, some effusion of serum into the lungs takes place, and the disease being long protracted, particularly at an advanced age, is very apt to ter- minate in hydrothorax, it would appear that the digitalis combined with the other remedies which have been mentioned, during the intervals of the paroxysms, will be a very judicious mode of treatment. Indeed its diuretic powers on such occasions have, in some cases, produced a happy effect. A dry and settled atmosphere is most friendly to asthmatical people, not only because it is free from impure vapours, but also as having more elasticity to press upon the vesicles of the lungs. While some asthma- tical persons cannot live, however, with any comfort, in the atmosphere of large cities ; there are others again who feel themselves better in an air replete with gross effluvia, and breathe with greater ease in a crowded room where there are candles and a fire. In every species of asthma the patient's diet should consist of such things as are light, and easy of digestion, carefully avoiding, at the same time, whatever may tend to generate flatulency ; and as many kinds of vegetables are apt to be attended with this effect, they are almost all im- proper. Animal food of the lightest kind, taken in a moderate quan- tity, so as not to overload the stomach, will be the most proper for asthmatics ; and for ordinary drink, they may use toast and water, or ORDER III* ASTHMA. 311 other cool watery liquors. All vinous, spirituous, and fermented liquors will be injurious to them. Tea will likewise be improper, from its be- ing usually drank warm, and from its supposed power of weakening the nerves of the stomach. Coffee has been employed in asthma with much advantage when taken in a powerful dose. In the pure spasmodic kind, if made so strong as an ounce to the cup, without milk or sugar, and re- peated, if necessary, at the distance of a quarter or half an hour, the fit has been entirely removed ; and this practice has been continued by pa- tients labouring under the disease for years, affording certain relief to their paroxysms. Some practitioners have, however, disapproved of the use of coffee. Garlic is a vegetable production which is found of service to asthma- tical people. Acids usually agree with them- Of CANINE MADNESS, or HYDROPHOBIA. JTTYDROPHOBIA is attended with fever, and a general disorder of all the functions; but is particularly marked by a horror, or morbid aver- , sion at all iiquids, which, when presented, excite convulsive spasms in the throat. It arises from the introduction of a small portion of the poison by the bite of a rabid animal, and that commonly of the canine or cat kind, as being those which are most domesticated. Some of the old writers have asserted, that the disease has occurred from the contact of this saliva, without the intervention of the poison of a rabid animal with the skin, in- dependently of any bite, or the infliction of any apparent injury ; but the possibility of this I much doubt. At any rate, the occurrence is to be considered as very rare indeed. There can be no doubt, however, but that symptoms exactly resem- bling those of genuine rabies canina have arisen in the human body from other causes. Local irritation from wounds in irritable habits, especially when conjoined with a perturbed state of the passions, and also violent affections of the mind, independently of corporeal injury in hysterical and hvpochondriacal constitutions, have at limes produced all the pa- thognomic symptoms of canine madness. Violent alternations of heat and cold, and all other causes which induce great debility, and at the same time increase the irritability of the system, have also at times prov- ed adequate to the production of symptoms, exactly corresponding vvith those of rabies canina. Such cases have been denominated by medical writers, spontaneous hydrophobia. A few have gone so far as to doubt the existence of this affection, as arising from the bite of a rabid animal; but this has been proved in the clearest manner, in various instances. Many have doubted whether madness can arise in animals without preceding contagion. Some cases recorded by M. Rossi, in the Mem. de I'Academie de Tu- rin, torn. 6th, evidently demonstrate, however, that animals, previously healthy, become capable, when enraged or irritated to a high degree, of S12 NEUROSES OR NERVOUS DISEASES. CLASS I/- communicating disease by their bite; a circumstance which, although long credited by the vulgar, wanted the support of direct evidence to establish it satisfactorily. Food of a highly putrid nature, a deficiency of water to assuage thirst, severe exercise during very sultry and dry weather, and a certain state or peculiarity in the atmosphere, similar to what produces epidemics of other kinds in the brute species, may possibly be capable of giving rise to madness in the canine and cat species, as well as a long-con'imied worrying of the animal. Some physicians, however, are disposed to dispute the efficiency of these remote causes, and maintain the actual infection from a diseased animal, by an inoculation of the poison, to be the sole exciting cause. There are, however, strong presumptive proofs that rabies does originate spontaneously in some quadrupeds; and car- nivorous animals seem most, if not alone, liable to it as a spontaneous disease. It does not appear, however, that madness is so prevalent among dogs in warm climates as in cold ones; for during a residence of many ytirs in the West Indies, 1 never heard of or met with a single occur- rence of the kind. We are also informed by various writers that canine madness is a stranger to South-America, and according to the testimony of Volney* it is equally unknown in Egypt and Syria. Mr. Barrowf also tells us, that, notwithstanding the heat of the climate at the Cape of Good Hope, and though the dogs are fed in the interior by the Kafiers on meat in a highly putrid state, still this disease is unknown there. The disease seems to arise from a specific contagion, which, being once produced, by causes unknown, continues to be propagated by the intercourse which dogs have with one another. It is alleged that the distemper is not communicable from one hydrophobous person to ano- ther, by means of a bite, or any other way ; but this seems to require further confirmation. We know of no instance of the disease being returned from the human species to tiie quadruped, for it has been attempted by inoculation, and failed : neither have we any proof that any of the secretions of a rabid animal but the saliva can excite hydrophobia. A large portion of such persons as have really been wounded by the bite of a rabid animal are never affected with the disease. Mr. Hunter mentions an instance of twenty persons being bitten by the same dog, and only one was seized with it. It is therefore obvious that different persons are not alike predisposed to be acted upon by the same conta- gion, ,-nd likewise that the predisposition to receive contagion varies in the same person at different periods. The depressing passions, as well as other causes producing debility, probably may predispose the system to the action of this virus. In the canine and cat species about seven or eight days may be con- sidered as a fair average of the shortest period in vvhich hydrophobia * See his Travels, vol. r. f-------------into the Interior of Africa, from the Cape of Good Hope. « <*fcDER til. CANINE MADNESS. 313 Shews itself after the animal is bitten, and six or seven weeks the longest period from the date of the bite. In the human species, only a few days liave in some instances elapsed previous to the symptoms shewing them- selves ; but the most common time of their appearance is from twenty to forty days after the bite. There are no well-authenticated instances of the poison lying dormant longer than eleven or twelve itadnths ; and vfe may therefore consider a person pretty salfe at the expiration of a year without any symptom appearing. In the cases quoted by authors where canine madness is said to have (occurred at the distance of many years from the communication of the supposed poison, we may justly consider them either as instances of spon- taneous hydrophobia as before mentioned, or of such other diseases as Occasionally exhibit the anomalous symptoms of an inability to swallow fluids, and an aversion to the sight of them : the poison of a rabid animal has had no share in their production. The frequent occurrence of an aversion to fluids, and of great difficulty in swallowing them in wometa affected with hysteria, have been noticed by many Writers, and some of these facts demonstrate that all the symptoms of canine madness have been brought on by violent affections of the mind in irritable and delicate habits. The fatal termination of some Of these instances, tends farther to confirm the strictness of analogy between canine madness and hysteria. Possibly some cases also of tetanus, in Which there has been thiirch local irritation in an excitable habit, conjoined with a perturbed state off the passions, may have been mistaken for hydrophobia, by exhibiting symp- toms exactly corresponding with those of rabies canina. Hydrophobia, in a dog, is usually preceded by a dull heavy look, •hanging of the ears and tail, stuptfr, surliness, and snapping at by- standers ; soon after which, his breathing becomes quick and laborious, his tongue hangs out of his mouth, and changes to a leaden Cblour ; he discharges a frothy saliva, refuses all food arid drink, runs about, bites at every thing that comes near him, and at last becomes quite furious. This is the last stage, in which he seldom lives above thirty hours. The hearer to this state the more dangerous will be the bite, arid the mbre direful its effects. In the human species, the general symptoms attendant upon the bite of a mad dog, or other rabid animal, are ; The part bitten, after some time, begins tb be painful; then come on wandering pains, with an uneasiness and heaviness, disttirbed sleep and frightful dreams, accompanied with great restlessness, sudden startihgs and spasms, sighing, anxiety, and a love for solitude. These symptoms continuing to increase daily, the cicatrix of the wound becomes hard and elevated, a peculiar tingling sensation is felt in the part, and pains begin to shoot from the place which was Wounded, all along tip to the throat, with a straitness and sensation of choking, and a horror and dread at the sight of water and other liquids, together \vith tremors and a toss bf ap- petite. The person is, however, capable of swallowing any solid sdb- fitance with tolerable ease ; but the moment that any thing in a fluid form is brought in contact with his lips, it occasions him to start back 2R 314 NEUROSES OR NERVOUS DISEASES. CLASS II. with much dread and horror, although he labours, perhaps, under great thirst at the time. This appears to be a circumstance peculiar to the human race ; for rabid animals do not evince any dread of water. Some practitioners are of opinion that this peculiar symptom or start- ing back with horror at the sight of water and other fluids, does not pro- ceed from any dread of them, but from the fear of swallowing them, ow- ing to the diseased state of the parts in consequence of inflammation. To swallow liquids, a greater contraction of the muscles of deglutition is re- quisite than to get down solids, and of course it produces a higher degree of pain and spasm, which explains the greater capability in the patient of being able to swallow solid substances than fluids. Dr. Vaughan, who has favoured the public with his opinions on hydro- phobia, denies, however, that the excruciating pain, which never fails to attend every attempt to drink, is felt in the fauces and throat. He says, that it is the scrobiculus cordis which is principally affected, this being the part to which the patient always applies his hand. From this circum- stance, therefore, from the presence of risus sardonicus, from the muscles of the abdomen being forcibly contracted, and from the sense of suffoca- tion which seems to threaten almost immediate death, he is led to think, that in hydrophobia a new sympathy is established between the fauces, the diaphragm, and the abdominal muscles. Dr Rush, from some appearances which he observed on dissecting a boy who died of hydrophobia, from the bite of a mad dog, has been in- duced to suppose that it is the temporary closure of the glottis which produces the dread of swallowing liquids ; hence the reason why they are taken in suddenly and at intervals. The same danger and difficulty attend the swallowing saliva ; and hence, he thinks, the symptom of spitting, which has been so often noticed in hydrophobia. In the case here alluded to, the morbid appearances were as follow : the epiglottis was inflamed, and the glottis so thickened and contracted, as barely to admit of a probe of the common size. The trachea below it was like- wise inflamed and thickened, and contained a quantity of mucus in it. The oesophagus exhibited noT marks of the disease, but the stomach had several inflamed spots upon it. A vomiting of bilious matter soon comes on in the course of the dis- ease, and an intense hot fever ensues, attended with continual watching, great thirst, dryness and roughness of the tongue, hoarseness of the voice, and the discharge of a viscid saliva from the mouth, which the patient is constantly spitting out ; together with spasms of the genital and urinary organs ; in consequence of which the evacuations are forcibly ejected. His respiration is laborious and uneasy, but his judgment is unaffected, and as long as he retains the power of speech, his answers are distinct. In some few instances, a severe delirium arises, and closes the tragic scene ; but it more frequently happens, that the pulse becomes tremulous and irregular, that convulsions arise, and that nature, being at length exhausted, sinks under the pressure of misery. ORDER III. CANINE MADNESS. 3l5 Our prognostic in this disease must always be unfavourable, as in most instances a cure has been attempted in vain. Death commonly takes place about the third or fourth day from the first appearance of the symptoms. The appearances to be observed on dissection in hydrophobia are un- usual aridity of the viscera and other parts ; marks of inflammation in the lower portion of the oesophagus and cardia, and the stomach and intestines are frequently much distended with flatus. Some marks of inflamma- tion are likewise to be observed in the brain, consisting in a serous effu- sion on its surface, or in a redness of the pia mater ; which appearances have also presented themselves in the dog. Now and then we meet with an accumulation or effusion of blood in the lungs. In some cases of dissection, not the least morbid appearance has been observed either in the fauces, diaphragm, stomach, or intestines. The poison has therefore been conceived by some physicians to act upon the nervous system, and to be so wholly confined to it, as to make it a mat- ter of doubt whether the qualities of the blood are altered by it or not, or whether the poison at all enters the system by the absorbents. As far as my knowledge extends, the lymphatic glands in the course of absorption have never been found diseased. In the treatment of canine madness, our attention should be directed to the stopping short the disease, by preventing, if possible, the absorption of the poison into the system. To effect this, we ought to extirpate the wounded part, then apply a cupping-glass with scarifications to it, so as to make it bleed freely, and afterwards dress it with some irritating oint- ment, such as the unguentum cantharidis, that the wound may be kept discharging for a considerable length of time. Many persons who have been treated in this manner, have been known to escape the disease ; while others, who have neglected these means, and who were bitten by the same animal, have become affected. The sooner, however, that the wounded part is extirpated after the accident, the better ; but it will be right to do it, even at the distance of several days, rather than that the person should be debarred of the chance which extirpation affords, as^there is great reason to presume that the canine poison does not enter the system so quickly as a variety of others are per- ceived to do. This conclusion we are somewhat authorized to draw, as in several well-attested cases many weeks, nay months, have intervened between the accident of being bitten, and the appearance of the disease. Dr. Darwin observes,* that if the patient is bitten in a part which could be totally cut away, as a finger, even after the hydrophobia ap- pears, it is probable it might cure it, as he suspects the cause still remains in the wounded tendon, and not in a diffused infection tainting the blood. Hence there are generally uneasy sensations, as cold or numbness in the old cicatrix, before the hydrophobia commences. Where, either from the timidity of the patient, or the wounded par? * See Zoonomia, vol. iv. p. 50. 316 NEUROSES OR NERVOUS DISEASFS. CLA«S IX. being so situated as to render the extirpation of it inadmissible, other means must be adopted* ft has been thought that the infectious matter, or poison may be removed from the wound made by the teeth of a rabidi animal, by washing it well with persevering attention, quickly after the accident, vvith vinegar or salt and water, or caustic alkali, so diluted that it can be applied with safety. Under the above circumstances, it will therefore be right to, have recourse to this remedy ; but previous to its use, it would be proper to dilate or enlarge the wound sufficiently so as to allow it to bleed freely. Having done so, and washed it for a considera-. ble time, either the actual cautery or caustic may be applied to it. Liga* tures above and below the wounded part have been recommended by Dr. Percival during the ablutions, when they can be put on. Under the head of Animal Poisons it will be mentioned that the exter- nal application, as well as the internal exhibition of the aqua ammotnsq purs was found on many trials entirely to do away the injurious; conse* quences arising from the bite of the cobra de capello, a snake of the most venomous kindj and productive of symptoms pretty similar to those ari- sing from a rabid animal. The same remedy would therefore seen> worthy of a, trial in cases of hydrophobia; but as there would be great difficulty in administering caustic volatile alkali in a state necessarily dit luted; with, some mild bland liquor, where the increased sensibility of the fauces and the dread of liquids are so strongly felt, we might convey it into the stomach in the manner practised by Mr. John Hunter and here- in-after mentioned, or we might mix the volatile alkali-with crumbs of bread, and form the mass into pills, or a bolus. From some experiments made by Dr. Linke of Jena with the saliva taken from a mad dog after it was dead, and that had bitten other ani- mals with a fatal effect, the external application of a strong solution of white arsenic in water to wounds besmeared with the poison, appears to have been attended with the happy effect of destroying the virus, and of preventing the disease from taking place. The remedy seems therefore worthy of further trials in wounds made by rabid animals. In addition to these modes of prevention, it has strongly been recom> mended to commence, very speedily, a course of mercurial unction, which is to be continued regularly, and, to be applied in a considerable quantity at once, so as to occasion some degree of salivation, to expedite which, warm bathing may be used occasionally. Mercurial fumigations may also assist. With the design of exciting a rapid salivation in hydrophobia,. Dr. Darwin has suggested that one grain and a half of muriated quicksilver dissolved in half an ounce of rectified spirits, may be given frequently to the patient with a prospect of advantage. From a paper by Mr. Addington of West Bromwich, inserted in the Contributions of Medical Knowledge, published by Dr. Beddoes, it appears that a similar mode is adopted by him for the cure of gonorrhoea virulenta, and that he has cured hundreds in a very short time in this manner without the least dis- agreeable consequence. He directs us to proceed as follows : Three grains of muriated quicksilver are to be dissolved in one ounce of K'Y •RDER III. CANINE MADNESS. 317 fiedspirit of wine. Half of this mixture is to be taken undiluted at go- ing to bed; it produces a copious salivation for an hour and a half, or longer, during which the patient spits about a quart. Some Glauber's salts are to be taken on the second day after this operation, and on the evening of that day he is, to repeat the draught, and the salts.on the day. but one following. Dr. Thomas Reid, in a pamphlet which bears the title, of Observa*- tions on. the Application of warm and cold Sea-bathing, recites a case which strongly attests the preventive effect of mercury. He makes mention that a man, a woman, and several dogs, were bitten by a sup- posed mad, dog, vvhich was soon after destroyed. A fortnight after the accident, he saw them; the woman was slightly wounded in the little finger, a black scab remained on the puncture: she had great pain in the arm, shooting up to her head, particularly in the night, with disturb- ed and frigbtful dreams, and great depression of spirits. The man had been bitten in the hand also, but had not so much pain. He directed mercury for them in the manner published by Dr. Jame9. In a few days the symptoms abated ; and as the woman's mouth was sore, she de- sisted, from