leaf – A B  leaf – B #14 Philadelphia January 1st. 1827 A few of the Lectures as delivered by Dr. Chapman Professor of Theory & Practice of Physic in the University of Pennsylvania copied during the Winter of 1827 by Asa J Driggs  1 The order in which Professor Chapman treats of Diseases. 1st. The Circulatory system consisting of y Heart & Blood vessels. – 2nd. The Digestive, consisting chiefly of the alamentary Canal. 3rd. The Respiratory consisting of y Pulmonary organs. 4th. The Absorbant. consisting of y Lacteals & Lymphatics. 5th. The Secretory consisting of the Glands 6th. The Sensitive consisting of the organs of Sense. Nerves. Brain & Spinal Marrow 7th. The Muscular consisting of y Muscles Tendons & aponeurosis. – 8th. The Cutaneous consisting of the external covouring of the surface of the body. 9th The Osseous consisting of Bones & there imediate apendages. 2 10th. Generation consisting of the Genitals of both sexes. – It will be eddy under these heads to comprehend all the diseases to which our nature is liable without any reference to their alliance & Affinities. Though I drop the old arrangement I shall however retain the names these being sufficiently expressive & having been generally adopted have become the language of Medicine. To change is always more or less evil & I am not sensible that in any case is it more inconvenient than in y nomenclature of Sciance 3 1st. Diseases of the Circulatory System. – Of Fevers. – I shall now commence with dis of y circulatory system & first of Fevers. – They are by far y most common of y complaints of our nature & as they afford general principals on which y treatment of y dis must be founded I shall dwell on thru at some length & with more than ordinary minuteness. It is computed that more than half of the deaths amoung y human species are produced by febrile affections alone, What is y nature of that Dis which has been denominated Fever! Ever since y dawn of Med. sciance this question has been [???ated] & still remains the febrile affections are so numerous & diversified, fluctuating & so much under y dominion of those causes which [moaf???] dis, action that they perceplably change thin character & one description cannot be appropriated to y whole class. – Cullen who is chiefly followed on this subject defines Pyrexia to Consist in an increased heat 4 frequency of y pulse comeing after shivering accompanied with a disturbance of many of y functions & diminution of strength especially in y limbs. – Now though this diffinition is as unexceptional as any which has been advanced it will not be difficult to show that haraby symptom which has been mentioned is an universally necessary attendant. That an increased [crossed out] of [y] heat is not a sign of fever is allowed by every one are this not onaua cases where y animal heat arises above the natural standard & do we not often see instances when it is lower. The senses here are not y proper means for measuring y degree of heat. The feeling of y individual is often entirely delusive so much so that at the moment when he complains of excessive wampth he is often really colder then sedual is converse equally hot as true sensations of cold often accompany a high degree of Thermometeral temperature. Now is it true that it is always preceded by a chill? it is indeed except in some 5. particular cases comparatively of rare occourance in febrile affections. _ As relates to y Pulse there is every variety as a general rule it is more than naturally frequent in Fever. but y exceptions are numerous & in certain cases when y Brain is effected it sinks to hlf its standard. Besides by exercise & other causes the pulse may be made to beat with much more than ordinay quietness without impairing health or assuming a morbid condition. Frequency of the pulse therefore is not a nessary ingredient in fevers. – That a disturbance of y Functions & Lasitude occour in this dis is not demed but they are also insecdent to many depraved conditions of the system is sufficient of itself to deviate from fever. – Y But to arrive at a satisfactory conclusion we must consider all assembled & also circumstances hereafter to be mentioned. – The most natural Division of Fever is into the Intermittant, Remittant & Continued 6. 1st. of Intermittant. By Intermitt is ment that fever in which there is a [crossed out] sucession of Paraxsms between which there is a distinct & perfect suspension of symptoms take place. _ The Interval between the Paroxisms is in Pathological Language denominated Apyrexia. – Different wordes have been used to name fever according to the length of [crossed out] y interval. When the [crossed out] Parox returns every 24 hours the the fever is called Quotidian. When it occours every other day or when the interval is 48 hours it is called Tertian. But when it is protracted 72 hours it is called a Quartan. – Of each of this primary types almost infinite varieties have been enumerated by authers as y double & triple Quartan by double & triple Tertian etc. By some of y antiant writers it was asserted by [crossed out] of that cases occoured in which of interval was protracted to y 5th. 6th. 7th or even to the 8th. day. This was affirmed by Hypocrates & confirmed by the testimony of 7. Boerhaave. – There are not wanting writers who have extended the period to 1 month 2 most even a Yr. conferring in these cases the title of Menstruae Bemen [stru??] & analar. When these peculiarities [crossed out] takes place they must be considered as anomalous deviating from the general character of the Dis & therefore deserving of little attention.- The 3 primary forms is all i wish you partic to recollect.– The Tertian is by far the most frequent & easy to cure Next to this in both respects is by Quotidian & y Quartan least: commonly accouring & is always obstinate in its management._ The 1st. occours generally in Spring & has therefore been called Vernal & the last appears at the close of fall & has been called Atumnal. By Cullen it is said that y Quart: is more common than y Quotia: wheather this was y case where he resided I cannot say but y whole current of experiance is against him & certainly in y W. of & those parts in which I am acquainted y fact is entirely different y Quartan in this city is seldem seen & when it 8: does occour arises from a protracted condition of y Quart. Each parox: of an Intermitt: is divided into y Cold, Hot & Sweating Stages y symp connected with y different stages are so elaborately detailed by most writers on this subject & y case so familial to you that a minute recitation on my part is rendered unnecessary. The Cold Stage is ushered in by Langour & sluggishness of motion yawning & stretching with some nausea or Debility of y stomach y face becomes pale & features shrink & y skin over y whole body is constricted as if aching with cold.- Not long after this rigors come on accompanied with spasm in y back & loins & Extremities y Respiration now becoming short & [difficult] distressing pulse small & sometimes very irregular copious discharges of pellucid urine is usual at this conjuncture. Somet: more allarming symp: appear as Coma Stupor which is some instances amount to Apoplexy. Y first stage somet continues for 1 or 2 hours when y symp. gradually 9. abate & y 2nd. stage comes on |Notes| the regors are somet. so severe that the teeth are shattered. Second Stage. This is marked by Heat extending over the body, redness of y face. throbing of of y Temples pain in Head Anxiety & Resttiness & some tendancy to Delirium. Y pulse slowly rises untill it becomes strong & exceedingly vehement these symp. continue for sometime but finally moisture appears on y forehead & is soon followed by a general sweat Y heat abates & y thirst ceases. Y respiration becomes free y circulation tranquilized & y functions are generally restored to their healthy condition. Y preceeding is a discription of a parox of Intim: fever as it usually appears. but it is somet: marked with anomalous circumstances. By Cleghorn & other writers we learn that y cold stage in some cases is entirely wanting. Somet. y hot stage is wanting & somet. preceeds the cold & it has been further remarked by Dr. Jackson that a paxoxcom somet. terminates by a copious secretion of Urine or Evacuation 10. from y Bowels without any perspiration or other irregularities not occasionally observable in Intims: they have been known the attack restricted to some one part of the body where y rest remained unaffected thus in Intim. it is located in one of the legs which goes through y cold hot & sweating stage with perfect regularity. I have seen it affect y eyes every other day it was attacked with extreme pain which after a while was cured which could only be affected but by y usual remedies employed for the cure of this Dis. – Not long since a young Lady consulted me on account of a violent pain she felt every other day in y lower part of her abdomen. As she came from J.S. it occoured to me that it might be another irregularity of Intermitt: accordingly after every remedy had failed which is usually employed she was cured with Fowlers Solution In y progress of our enquiries we shall have occasion to point out some curious facts of this 11. nature. Prehaps no Dis is more disguised under its forms than Intim: Fever, & as it exacts a prectum treatment it becomes important that y nature of y case should be understood.– As regards the course of Treat. a little controversy has existed. It is now pretty generally admitted that y most sources of this Dis are marsh Exhalations from Vegit & Anemic substances. Cold is a cause of this when connected with moisture or Bile in y stomach. Y origine of this was first sugested by Lanciss & Blalin who lived not long after the revival of Luting in Europe The observation of practitioners in many sections of y Globe confine y accuracy of his hypotheses but of y precise nature of this pestiferous miasmatas we are still entirely ignorant.– This much however is certain that they are, of exhalations of Vegetable & animal matter in a state of decomposition. Y origine of Intim: is sometimes involved in much obscurity.– It will occasionally makes, its appearance where there is no obvious source 12. of exhalations. In endeavouring to ascertain the cause we should not loose sight of this fact that y Miasmata are wafted by winds to y distance of 8 or 10 miles in a condition sufficient to produce the ordinary effects. No paint has been deseeded from [crossed out] more indisputable evidence evidance than that which we have just mentioned. but it is not less true that other causes produce fevers the paroxisms arising at stated periods. Whatever disposes the body so as to cause extream debility as. poor diet, great fatigue, mental anxiety, excessive evacuations &c. Are all known to excite Intermitt fevers when there is no reason to expect marhy exhalations. Next to these causes Cold is undutedly if most productive of y dis especially when united with moisture as in Damp Rooms. Beds Clothing etc. It has always been said that contagion is amoung the causes of this complaint this has been so well attested that it would be an 13. unwarantable species of [????p??oism] to doubt it But whenever Contagion proves y cause of Intim it always assumes as low type as we find sometimes in Goals. Hospitals & other crowded places: It has also been said to arise from Planatory influance by more than one writer. Tina believes it to aside from Lunar influance in some instances But there is no reason to suspect that these were the cause of y complaint. – Treatment. divides itself into two parts viz That which is proper during the paroxism & that which is required during the intermission or Apyrexia.– Taught by the example which nature affords us as soon as possible in the Cold State of an Intim then we imediately resort to y meds, which are best circulated this effect. We should have y patient placed in a warm bed drect as topical applications 14. hot bricks to y feet & a bottle of hot water should be applied to the extremities. warm beverages are now to be administered pure teas & when we wish any thing stimulating slightly Wine Whey or something of a Stim nature will answer very well.– Opii has been found particularly useful it is stated on y authority of [?rote??at] 1 or 2 grs of Opium at this time had Y effect of removing the Headache & rigors. – of exciting a universal glow followed by perspiration & thus producing a solution of y cold stage.– To y efficacy of this plan I can bare ample testimony of all y remedies that I have seen employed in this case Opii is followed by y most agreable consequences. 25 or 30 yrs since this treat. was recommended by Mr Nellie a Surgeon in Edinburgh we are told that y cold stage was imediately checked.– Y Tornequete acts very intelligibly by interupting y circulation through y Extremities such an accumulation of Blood takes place in y Heart 15. & great arteries that it exerts an increased action in these organs & a consequent diffusion of temperature over y Body. However plausible in Theory this plan was not found to answer y expectations of Practitioners. In y Hospital at Edinburgh it was tried & found of little of little advantage. Nothwithstanding y failure in y Hospital y auther is a man of high standing in y Medical World & published a Book to prove its great efficacy. This is one out of a Thousd. instances where different practitioners have obtained different results with y same remedy. – When y cold stage is very resolute fatal consequences ensues one of y best remedies to be employed is an Emetic it generally puts an end to this stage as soon as it operates. Hot. Stage. The Indications in y hot stage are 1st It remove y Irritation 2nd. To produce perspiration. Y irritation is generally produced by y presence of Bile in y Stomach & in such cases we should not hesitate to give an Emetic but if Vomiting has already occurred & there still be nausea you should 16. you are to assist nature by warm beverages as Camomile Tea or Warm. Water. – 2nd. Indication we must resort to Diaphoretics but all y European Meters & especially those of G. Britain highly recommend James's Powders but in this here it cannot always be obtained pure it is almost universally abandoned & some other Antim: preparations whose whose composed on & properties are better known have been substituted for it. as Antim: Wine. Small doses Tart. Antim: are commonly used & it is very common in y country to used strong decoct. of Cupatimune for purpose of producing perspiration. – It is an exelent remedy where others cannot be procured. On y authority of Dr. Lind Opii has been much employed in y hot Stage it is asserted by him to produce a solution of the [crossed out] paroxism & prepare y system for Bait. diminishes y danger of congestion in Viscera thus hinders y occurance of Schirrous alterations. Induced by my opinion for Dr Lind I prescribed it in 17. y Hot Stage though in direct opposition timing Theoretical views, in may instances it agrevated y sympts: y Headache was always increased y patient rendered, restless & y fever protracted. It is probable in Hot Climates as E & W. Indies where Dr. Lind practised Opii might have been of service in Hot stage on a/c of its tendancy to perspiration. but in this city & in y most temperate parts of y U.S. you will find my sentiments perfectly correct. – Where ever opii is at all indicated I give y preference to Dovers Powders thus a aminis. it proves diaphoritic & its stimulating powers counteracted. The Spts. Menderic is by fac the best diaphoretic [acetate ammonia]. this is to be preferred on several a/cs it is more prompt & certain its effects than any other it is moreover exceedingly grateful to the stomach & will stay when other articles are rejected. Dose tablespoon of y saturated Solution repeated if necessary. – Y practice above – [delai?] is applicable to mild or ordinary cases. But Intim: are [s?n?t] of an Inflam nature & y parox: is somewhat different 18 different from that already stated. They generally adopt this character in Spring & during y prevalance of Epidemics but y circumstances may be accurately ascertained from y case when if fever is m y type actuated to. the pulse is Vigorous & Strong. y face is exceedingly flushed. Respiration dificult – laborous acute local pain in Head. Sides. or Chest. Where y paroxisms are attended with these symp: it is necessary to V.S. copiously. y alamentary canal should be evacuated with powerful purges. – Intim: somet. appear in a very different Type insted of Inflam they adopt y Typhus Intermitt. when these cases occour & they often do in Hospitals & crowded places & During y prevalance of Typhus Epidemics a different treat. is demanded. – The paroxisms are to be treated with cordials & stimulating drinks & by y administration of all these remedies which are calculated to support y strength & tone of y system. 19 Treatment during y Apyrexia. – or y history of these remedies which are best calculated to ward off y paroxysm y most important of which is y Peruvian Bark originally introduced to y practice of Physicians in this Dis. It has maintained an undoubted superiority over all y remedies & y fluctuations of opinion & vicisitudes of practice to which our sciance has been subjected. Little adversity prevails at present as regards y rules forits administration though formaly no point was more unsetled. Among y absurd notions [of fever] it was though that y morbific matter might be thrown out by y paroxisms this was advanced by Boerhaave who said y bark was to be used “cum morbus [ale??otic] [d????] Van Swaten in his Comentaries united with him in this sentiment which was also conceived by Sydenham & all y eminent practitioners of that period Secretly y revers of this is more generally held to be y proper course & y fact is fully established that y earlier we commence with y Bark y more speady & prompt will be y cure 20. Y only circumstance of account which would cause delay is y condition of y Alamentory Canal & somet: perhaps of y system generally. Doubts are entertained by several writers wheather it is really necessary to prepare y system in any way for y reception of Bark & I am acquainted with some practitioners who says it is of no utility in this dis. But this is by no means y common opinion of y established practice It is now pretty generally conceeded that though y Bark will occasionally affect a cure without previous evacuating yet as a general rule it is y custom either to evacuate by Vomiting by purging previously & for this purpose y Emetic Tart. et Calomel are preferred. Harvene in times especially in this part of U.S. they have in a great measure given way to y Mercurial [crossed out] preparations they enerally answer where Emetics can hardly if at all be dispensed with they [op??ly] in such cases not only evacuating y Alamet: Canal 21. but also make a powerful impression on y Stomach & thus disarming & braking down that chain of & perverted association which Intim: & other Penoacedl Drs. seem to depend. Of y nature of Emetics my own observation affords me abundant conclusive evidence But besides these evacuants V.S. is demanded. – In y commencent of Intim: there is always more or less Inflam: Diathesis kept up with considerable pertinacity without y loss of blood & pretty copiously too y Bark would be rejected from y Stomach & of no utility & if it was retained it would only aggrevate y symptoms by its effects. My rule is never to resort to bark untill I have prepared y system by Evacu: so as to receive the proper impression from this valuable, remedy. By pursuing this course adopting y remedy to 1 state of y system I can pronounce that y certainly of its effects are such as almost entitle it to be considered at present as it formally was a Specific in Intim: fever: This species of fever is not unfrequently associated with obstructions in 22. y Viscera. Obstructions of y Viscera. when this exists Bark has been held to be inadmisable. That cases of this kind exist says Cullen where it is improper to administer y Bark I have not to determine; but I am well persuaded it is dangerous to adopt any such plan as a rule. I am convinced that in y cold stage of this fever an accumulation of Blood takes place in y Liver & Spleen which is increased every repetition of y cold stage &c. Y practice in regard to this point may be readily adjusted. In Visceral obstructions when Inflam: accompanies y Dis I would never hesitate for a moment to employ y Bark so as to put an end to y Dis. In other cases where there is pain in y Viscera & actively of y pulse indicating some local Inflam. Bark is mischievous. – We should have restort to y Vesicating applications or a slight degree of Saluvation which will commonly do away y obstructions. But if there be severe pains & y case is decidedly Inflame: we 23. should use directly evacuating remedies & of these V.S. is decidedly y best. – There was at one time much debate wheather or no y Bark should be given emediately preceding y paroxism. Cullen was decidedly in favor of this practice but I consider him to be wrong determining from my own experiance I should avoid administering it at y moment of y anticipated attack as I have found it aggrevate y paraxism by increasing y fever & distressing y Stomach. Some practitioners go so far as to contend that there should be no remission in its use that it should be employed in every stage y paroxism. Dr. Clark who wrote with great ability on y Dis of Tropical Climates is among those who strenuously recommends its use in this way as yet I have never been induced to follow it because I have always observed when Bark was given even when there is a slight disposition to fever it is productive of mischief. It is a rule established by y ablest practioners is rare there is a slight indication of an accession of y paraxism y Bark should be discontinued 24. Y ordinary mode of administering Bark is in Substance with water. Wine. Milk or Deluded Ardent spts. But milk has always appeared to me to be y most agreeable veicle. y Dose of y powder in ℥i or ℥ii repeated as often as y stomach will bear so that ʒi may be given in y ordinary intermission In y Tertian more than this is necessary it is y practice in y W. Indies to take ʒii in y morning at once & to omit in y other part of y Day. y tale Dr. Dallas was from that part of y country & was y practice that prevailed there whoever had an Intermitt took ʒi Bark early in y morning y sucess was in this case complete I never knew him fail to effect a cure in 2 or 3 ds. I doubt wheather y practice would be imitated fur stomachs will bear y Bark in as large a dose the fact however is interting & I thought worth recording as cases may occour where y method proposed may be advantageous. But in some persons such as y irritability of y Stomach that Bark in Substance 25. even in y minutest doses cannot be retained on y Stom: In such cases we must apply to y Infusion or Decoction either by itself or in combination with some aromatic such as cloves. Cinnamon or Orange peel. or Serpentaria y last to be prefered it renders y mixture agreeable to y tale & comfortable to y Stomach & much more efficatious a combination of this kind may be employed when Bark must be forbidden tis particularly adopted to Children & delicate persons.– But sometimes Bark purges its efficacy is abated when this appears. Small doses of Laudnum are to be given. When it produces constipation of Bowels as it sometimes does small portions of Rheii may be used. – [N.B. y Sulph Quinine is y active principle in Bark one gr. is equivalent to ℥i of Bark either given in Solutio: or Pill. R Sulph. Quinine qr.viii. Acid Sul: dramatic: ℥ss Sac alba ℥i Ess.menth aqua font ziii frat. mist. This forms a super sulphate Dose at: spirm: It is restricted aperxia y Est. 26. is y radium remaining from y manufacture of Quinine. Dose same as Sulph. Quinine. – Now & then Intim: is attended with great Acidity of y Stomach it is customary under such circumstances to combine with y Bark a little Magnesia & a minute quantity of Veritable alkali. – Notwithstanding y variety of means in order to attain a proper administration of y Peru Bark they are often defective during to a peculiar irritation in y Prime Via causing it to be rejected by vomiting & carried off two suddenly by y Bowels so that it can produce, no salutay effect. In cases of this kind it is usual to resort to Injections. – I have never used Bark in this way except in Children & therefore can say but little as to its efficacy. Possibly it may be useful in some cases but you will hardly ever prevail upon an adult who has used it once in y form of our Enema to submit to a repetion as often at least as will be necessary to effect a cure. – Besides you will 27. after be defeated by y irritation which exists in y Bowels. either previously or inaua by y measure & which amounts to such a degree as to render it almost imposible to retain y Injection. However as you may have occasion to use y Bark in this way I will give you y proper formula R. ℥ii or iii of y Dowan is to be intimately mixed with some mucilage, as common starch. Flaxseed tea made rapy or a Solution G. Arabic to sooth y irritation of y bowels. – It is customary to add a small quantity of Laudnum as y desine is not that y Bark should be evacuated but retained. – Bark also has been applied to y surface of y body y method of doing this is different. By some it is recommend. to apply in y form of a Cataplasm or poultice med of y article placed over y pit of y Stomach. By others a W. Bath either topical or general of y Decoction is prefered. – It is stated in authority of sufficient respectability to be entitled to confidance that Intim: may sometimes be cured by an emission 28. of y feet in a decoct. of Bark. – It is probable that a general Bath imersing y whole body would be much more efficacious. As a remedy in Intim: I have never employed y Baths but they have been used by practioners in y county who report in its favour one of a decided nature. When I have use it, it has been with a design to check violant vomiting especially in Pestilential Fevers. Cholera morbus. Cholera Infantum under such circumstances it will as soon sooth y irritability of y Stomach as any other remedy that can be employed. Its mode of Operation is very inteligible Creating a Tonic impression on y Skin between which there is a consent of a very intimate kind impacts tone to that viscus & thus retains its ordinary motions. Bark has also been employed in a dry state in this Dis: as an external application. It is said by Darwin that if y sheets are thougherly strewed with y powder of a Bark y Individual who sleeps in them will be cured if he had y: Dis. To believe 29. this even on y respectability of Darwin requires a considerable strech of credulity.– But when y Bark is applied differently there can be no doubt of its efficacy. the mode alluded to is that of Quilting it into a jacket & wearing it next to y body doubts have been entertained wheather thus used it had any effects most indisputably it does. When applied to Children in early life & Women of extreme delicacy. After all however it will be found to fail & when compared to its internal administration is entitled to very little confidance. next to Bark in Intim: may be marked Serpent. Serpentaria. The mode of using it origianlly employed by Sydenham. was with Wine. – As a general rules says he all case of Intim: where wine is indicated its efficacy will be increased by Serpentaria. – “Wheath it is adequate to y cure of confirmed cases of y Dis. I cannot tell with certainly. But in y milder shape or where y type is contagious partaking in some degree of y Remitt 30. character it is a very efficatious remedy & a preparation of Serpentaria has been employed with advantage in y worst forms of Ague & Fever y formula is as follows viz Rx Cort. Peru: ℥ss. Rad. Serpent: ℥i Curb Soda gr 30. This are to be imediately mixed & divided into 4 powders one of which is to be taken every 4 or 8 hours. Why y serpentaria thus combined & with so small a portion of vegitable alkali should have its powers extrordinarily increased is difficult to determine but of its efficacy there can be no doubt y preperation was employed for more than ½ a Centaury ago in this section of y Union & has received in its favour to y extent y testimony of established practitioners. – Nothing is more idle than a prior speculation of y Modus Operandi of meds. we are never certain entirely with respect to y accompanying circumstances & in most instances are content with fact alone if it be fully corroborated. Of y remedies afforded by 31. Our own country for Intim: y Eupatorium Perfoliatum. is possed of great powers. It may be so prepared as to be Diaphoretic. Diuretic. Emetic or eminently Tonic. by its Tonic powers it is most efficatious in this dis. for its diaphoretic powers it adopted to every stage in y Dis possesing in this respect a diseased superiority over other remedies. It may be employed indeferently either in y hot or Cold stage of y Paroxism. Its tonic powers are best obtained by administering it in powder or even in Decoction, This remedy has been much employed in Philadelphia & my Friend Dr. Hossack has informed me that it has completely supplanted y Cinchona & Fowlers Solution in y practice of several Physicians in New Jersey. – There is another species Eupatorium Pilosum known by y name of Hour Hound which is possesed of equal virtues though it is some what medicinal. Y Dose of C. Perfoliatum is 20 or 30 grs or a Wine Glass of strong decoct every hour or two. – In our enumeration of articles adapted to cure Intim. 32. y Chirona Angular is or Centaury is not to be overlooked it is different in appearance & medical effects from y Eupatorium. – It may be employed under all circumstances of y Dis. & is somet: given to advantage when y Bark is inadmisable. – It should be administered in Infus or Decoct: & in such quantities as y Stomach will bear. Though mosily employed by country practitioners it is also used in y city & we have abundant reason to be satisfied with its effects. Bane fored we have 2 species of Dogwood which are possesed of Tonic Properties y Cornus Florida & Cornus Terecia or swamp Dogwood. The Back is y only part used in Med. & may be given in doses & in same manner as Cinchona to which from a careful examination of a graduate of this University it is closely allied in its chemical Compo. & medical properties. – As regards myself I have no experiance in this article. But it is so highly extolled by others that I though it my duty to mention 33. mention it. Athia to y Dogwood in med. properties is y Prunus Virgmiend or Wild Cherry Tree. I have little doubts of its beneficial effects; Professor Barton & other practitioners have used in with advantage. – Another of our Native Tonics is y Prunes Verticelalus Black Elder this has also been used. what powers it posses I am not able to determine from my own experiance. By y late Profess Barton his correspondance it was highly recommended y Bark of y Root is y part employed & is given in same manner at Cort Peru. Many of y Oaks have been used in Intim: & not without success. y White Oak approaches nearest to y nature if Peru. Cort. in its general property but y Chestnut Oak is prefered by y City practitioners I have no experiance with uthre. – Several Species of Willow are not without power in y cure of this dis. y White Willow has been found superior in this respect. This bark may be given in substance or decoction same as Cinchona The Willow of England has been much used in 34. this dis of late & y writing of Willingham & others are in favour of its efficacy. It is now 30 or 40 yrs. ago since y Liriodendron Tulipifera or y common Poplar has been used in y management of this dis I have no experiance with it but by Dr. Rush & Barton it was commended y former introduced this article into practice in Fever & Ague. when that Dis prevailed in y Revolutionary Army, he considers it inferior to cinchona y Bark of y Root is employed in substance or decoction & same dose as y above articles. These are all y articles which have been found useful & which are indigenous to our Country. They possess [crossed out] different powers by which they are adapted to peculiar cases. Some of them are productive of much good & as they are read to access to those who have settled in y country & thought it right to bring them before you. Next I am to address your attention to some remedies whose qualities we are well acquainted 35. with & which therefore not only this account but they posses superior virtues & are therefore more worthy our regard. Nota little has been said within y last, 20 or 30 yrs. of Angustura as a remedy in this dis. When originally introduced into y management of this dis, & such was y confidance it inspired that it proved for a long time superior to Cinchona & other established remedies. But though known only for 20 or 30 yrs yet so completely has its virtues repressed that it becomes exploded from y treat of y Dis. Recently however it has been revived by some of y Europan practitioners those of London & some speak so confidently of its powers that must have been precipitately rejected. It is highly Aromatic & Cordial moreover it is not a little Astringent & perhaps will be found best adopted to these cases which are accompanied with irritability of y Stomach & Bowels. It will sometimes be retained when Bark is rejected y dose is generally from 36. ℥ss to ℥i at time repeated pretty much as y Cinchona. Not many yrs ago Mahogany called in Sciantific Language Casyania febrifuga or Angusturæ was recommended very strongly Dr Rocklove in Intim & Experiments lately made by many practioners revive y sentiments of that writer. As it has in some degree y properties Angustura it will be found prehaps proper to administer it under y same circumstance. A variety of [crossed out] remedies have been used as remedies in this dis. in a grater or less degree they are all possessed of y same properties with y preceding articles & should be used in a similar manner but from my own experiance with them I should not recommend them strongly. They may all be employed in decoction. Infusion or Powder as y Cinchona. – The wood Quassia. has been much used I have employed it but have no occasion to 37. think it at all calculated to meet y severe attacks of Intim: - Though temperate in his opinions & cautions of recommending Meds. Dr. – in this particular instance departed from his general practice & displayed some enthusiasm in y praise of Gum Kind. it is undeservedly stated by him that in Intim: of y most obstinate character may be cured by this medicine as soon as the Peru Cort & other active valuable meds. - In this light it was used much some practitioners rely much on y authority of Dr. Fothergill he had great confidance in its powers. In acting from my own experiance & those of other physicians for whose opinion I have great respect I should say it is incompetent to cure intractable cases. But exhibited with Bitters & Opii its efficacy is greatly increased & in some cases those combined have formed a valuable remedy. Y best form for using is y following R. ls. Kino Zii Rad. Gentian zss Opii grii y whole to be divided into 10 or 12 powders one of which may be given every 2 hours. – It does not appear 38. why this combination should increase y powers of this remedy, but of y fact there can be no doubt. The last of y Vegetable remedies is Charcoal. This has very recently been mentioned among y others it appears about 6 or 8 yrs ago Dr. Fr – in Salisbury tried it in this dis y Physician on this station in y British forts Dr Lalbect was induced to try this Med Determinging from respect to this writer we should be led to conclude that it is a ralnath remedy connected with Bowel Dis especially dysentary. o On y authority of this writer y remedy within y last 12 mos. has been used in this city in 2 or 3 [cases] practitioners have employed it in y public Institutions & not without advantage It has been prescribed by some in a great quantity of cases. But what I have seen of this it is entitled to your confidance One of y members of y Class has had an an Ample opportunity with this Med: & I have learned it proved successful where y Bark & Arsenic had failed for reasons 39. hereafter to be mentioned. I should prefer it where there was a little Dysenteria connected with y Dis, a t. spoon should be given every 2 or 3 hours during y apyrexia. – Sulpher. not y least valuable of y remains employed is sulpher. – It was first used about 30. yrs ago by Dr. Lysenger who writes In y anomalous Fever of y Isle of Batavia he prescribed a t spoon mixed with a little ardent: Spts: At one time I was inclined to believe its efficacy was ascubable to y ardent Spts. associated with it but wide experiance has taught me different during y Cast few yrs I have used it much in this Dis & am persuaded that it is possed of great powers. It acts independantly of y Spts. which is proved by y circumstance that it is not less efficatious when mixed with Milk. Molasses or any other inert vehicle. But y power of Sulpher is not restricted to Intim. fever no remedy I have used is so efficatious in checking y fever of Irritation I mean y Hectic Fever 40. wheather arising from absess of y Lungs or else where It affords me great pleasure that I have y authority of Dr. Physic for views which I present to you on y powers of Sulpher. He goes father & declares that judging from his own experience there is no remedy so useful in anomalous fevers especially of y periodical type. He does not limit it to Intim fevers but extends it to all such Dis. as occour periodically especially Periodical Headache I am inclined to believe that it is not without in such Chronic Nervous affections of an Intim: nature. It is true that we do not perceive its secret effects on y system but on this account it is no less powerful. – We see y same thing in Arsenic Mercury &c. Y mode in which I am acustomed to use it is at such times & in such doses that it will not exert its purgative effects this end is generally answered by giving 30 or 40 grs every 3 or 4 hours. On y authority of Dr. Monroe & one or 2 others y Blue Vitriol or 41. Sulphas Cupri has not been a little prescribled in this dis. It is allegra by more that while Physicians in general to y British Army in y Netherlands he was able to arrest Intim: fevers by this remedy where all others failed to y same point goes y testimony of Dr. Adams & others y following was y formule Rx Pulv. Cinchona grs 32. Sulph. Copper gr. 4 to be made into XV pills one of which is to be given every 4 hours. Wheather this remedy is always as powerful as represented I cannot pronounce. Those Intim: in which I have employed it I have found it most advantageous in old Quartans. On y whole y evidance is not so strong y as to induce me to recommend it highly. – Dispersed through practical writers some evidance may be found of y Virtues of y Cuprum Amoniacum. It has not been strongly recommended to our attention. When used it should be administered as y preceeding remedy Nearly on a footing y same should I place y several preparations of zinc those have also been employed 42. employed by different practitioners but I do not know that proof is strong enough in their favour. They are all used in Chronic Periodical Affections & might prehaps be useful in some Intim. but I can say nothing from my own experiance. – Amoung y remedies we are enumerating few have a higher claim than Alum. It was long ago prescribed by Cullen in combination with mutiny But he says though combined with this Aromatic it often produces naucea & is rejected from y Stomach so that he has not much confidance. By y celebrated Dr. Lina who used it in y same manner a different statement is given he ranks it next to Cort. Peru: & observes that it is greatful to y stomach & if continued with aromatics rarely occasions distress in that organ. As regards my own Experience I cannot say much respecting it. It would appear however by y testimony of others that it is not destitute of powers. Dr. Chalmers of Charlston thinks it paticularly 43. useful in this Dis, & in Remitt: fever of that part of y Country y same statement is made by Dr. Adams with redard to y fevers of yc W. Indies. Dr. Darwin says that it has considerable powers over Intim: but more especially when associated with Dysentary y proper doses is from 5 to 10 grs. but y Stomach will not always bear so much in such circumstances y quantity should be reduced. – Sugar of Lead is one of y articles lately [aar??] to y Catalogue by some practitioners particularly of y U: States it has been highly extolled. It was a favorite remedy of y late Dr. Barton during y late War It was used in Intim: which occoured amoung y troops on y Canadian frontiers. – I received an account from Physician attached to y Army that it had exerted greater powers than y Bark or Arsenic but I believe there was some deception in y case Determining from what I have see of y Article it does not deserve much esteem my own experiance is much against it. As nearly allied to y preparations 44. of lead I shall [mention] say a few words on Arsenic. In y estimation of y generality of practioners this article stands not on point of efficacy to y Peruvian. Bark, that it has done good in Intim. cannot be denied but when a physian expects from it uniform sucess he will often be disappointed. Wheather this proceeds from an inherent deficiency of y powers of arsenic or from y indiscriminate mode of prescription I am prepared to say this much however. I can inform you that in weak and debilitated states arising from old age or debauchery y arsenic will unfirmly fail. this is a feat might be expected & Barks many other remedies employed in this dis. are Tonic in their nature & act by imparting tone to y stomach & through y system generally. Arsenic has no such properties though commonly ranks with this class of meds. by writers on Mat. Med. Its principle opration is to create nausea weakness of y stomach & debility 45. of y system which is indicated by a feeble pulse cold surface loss of general strength & muscular relaxation. But even when employed it sometimes fails compared with. Bark it is acutialy inferior to bark & should never be employed when that article can be obtained, The cases in which it is best suited are such as occour in children & in [person?] possesing considerable vigor of Constitution associated with febrile condition. It acts powerfully on y system of children & on account of its berry without taste & in small bulk will be taken when others would be rejected. It has been a subject of debate wheather y arsenic should be continued during y different stages of y dis. My own experiance has taught me there is no precise rule on y subject the only objection against its employment during paroxism is y Nausea & Vomiting which it is apt to produce especially in y cold stage where there is great imitability of y Stomach, Arsenic is prompt in its of operation therefore if no decided 46. operation or advantage is experianced in 6 or 8 ds. it should be discontinued. It only debilitates y. system & produces a long train of unpleasant symp. as. Debility of y Stomach. pain in y Head. Oedematous swell in qs of Extremities. It has lately ban alleged by high authority that when arsenic does. not suceed by itself it may be renamed very efficatious by combining it with Cinchona this is Sound practice & I have imitated it with advantage. Arsenic is said to prepare y System for Bark & when Intim: does not early yeald it has been recommended to have recourse to this article & afterwards to use y Bark. – It is not [crossed out] more a yr that y Web of a common Spider was considered by me as a remedy exceedingly efficatious y fact I derived from Dr. Jackson who was inspector of y British army. On a revisit to this city he informed me that he has found y web one of y best narcotics exceedingly efficatious in quieting irritability Cordial to y whole 47. system & often producing sleep. he farther added that it was y best remedy known to him in y toat of Intim in all y stages. It is not in my power to testify to y accuracy of this account from a great number of experiments but y few trials I have made satisfied me perfectly well that y statement of Dr. Jackson was correct y article certainly is Sedative & Narcotic I am not without reason to be lure that it is useful in Ague & Fever. A gentleman of this class has written a valuable assay on this article from his own experiance & those of others who have been made this communications. I believe it to be a valuable remedy I recommend it to you. You need not be careful in selecting y Web. if any spider particularly as y species of spider are possed of y same properties. – Before dismissing y Meds. employed me Intim: I will notice one which deserves our notice. It is more than 15 or 20 yrs since y practitioners of France in a tone of confidance recommended Animal Gelatin. Gelatine In Intimittant 48. Gelatine: From y Known properties of this article little credid was given to y accounts. but I find at length y English practitioners have recommended its use & some concour in granting it thier surport. By y writers common Glue was employed. The English physicians believing that Calfs foot. Gelly is equally powerful & knowing it to be much more agreeable they commonly have recourse to that preparation. The only case in which this remedy has been used in this city was mentioned in this city. Dr. Griffiths told me that in y case of his daughter who for many months had been affected with Intim: & in whome y other remedies had been used in vain succeeded at once affected a cure by y administration of this remedy. Nothwithstanding y numerous remedies which had been used or mentioned for y cure of Intim: it will sometimes baffle our best directed efforts & continue its course in spite of all any exertions Cases of this particular Obstinate Character 49. depends most commonly on congestion or some other dis of y Viscera & confirmed by long habit. It is our duty in such cases to resort to Mercury. Mercury in Congestion gradually inseminating it into y system untill saliration which is to be kep up 2 or 3 weeks without interruption. This properly called a Revolution going remedy by which such changes are produced in y system as to suppression decour y prexisting dis. As a substitute for Mercury Blisters have been found highly useful these should be applied to y extremities & not dressed or hastily they operate nearly on y same principle as Mercury viz they create a counter impression which interupts & destroys this contamination associations on which y Dis: depends. When all these remedies fail however as a resort we should direct our patient to take a protracted journey so that exercise of Gestation change of Scenery y noval impresions derived from a different climate & other causes may operate 50. in producing a chain of [cross out] actions which may supercuary old; I will now speak of those remedies which are calculated to [produce] meet our indications in y Apyrexia or those which are given just before y expected recourance of y paroxisms. It is y common practice to order y patient go to bed & to take Opium as Dr. Frotter has recommended it Warm Beverages are also directed for y purpose of producing perspiration: Ether is a prompt. powerful & diffusible Stimulant & from these properties answers very well. At y time under consideration you should warn your patient not to over load his stomach about y period of y expected paroxism as nausea & Violant Vomiting might thus be occasioned. Cases are indeed recovered when 6 or 8 hours fasting has cured y dis. Any great change my condition of y Stomach would answer y same purpose. By some practitioners a very different mode is employed 51. They make y strongest possible impression on this Viscus by stimulating meds. strong spts Liquors either alone or impregnated with Spices have often been used & no doubt have proved advantageous. In fact whatever makes a strong impression on y system whether through y mind or Body will often suceed. – In every Intim Emetics given before y paroxysm have a powerful effect & Blisters applied at same conjunction not universally of y attack It is y imperious duty of practitioners to endeavour to cure Intim: as speech as possible there is modis. no Dis. so disagreable to y patient & though not imediately fatal is apt to degenerate into complaints of a very serious nature thus Intim: after runing into Continued fever sometimes of a Typhus nature & nothing is more common in children than for it to terminate in Hydrocephalous Internus y more common remote consequences are Congestion of the Viscera. Schirrus. Indurations & cancer conjoined with Dropsy & deprivation 52. of y system. No opinion is so absurd & mischievous than that which was advanced by Boerhaaves & adopted by many other practitioners. That Intim: are salutary in their primary operations & unless of a malignant type are not to be suddenly supposed by artificial means, nevertheless it cannot be denied that Intim: sometimes supercedes other diseases of a very formidable character. Gout. Rheumatism & cutaneous affections. In many of y Spasmodic or Nervous Dis. as Chorea. Epilepsy Asthma. Hysteria. Dyspoenea are some of y affections which yeald to an attack of Fever & Ague It has been ascertained that Intim: after they have become completely established in y system are sometimes competent to y cure of Pill Consumption I have already mentioned that it was y practice of some of our older physicians of this Town to induce this species of fever as a remedy for Consumption. But I will hereafter show more particularly y advantage of this treatment. 53. y same effect is sometimes produced in melancholic & y periods forms of Insanity. It was y custom of y physicians to take y maniacs out of y Hospitals expose them to y sun & send them to Miasmatic countries that they might be attacked by y fever & Ague. Though this practice did not always affect cures yet a sufficient member occoured to show y power of y Intim, action over such affections. As y predispositions to Intim. is in y system for a long time after y cure has apparently been affected y patient should studiously avoid all exciting causes as Exposure to night air or to cold & damp atmospheres under any circumstances. It is always proper for some time after y cessation of y Dis that y use of Tonic meds. should be continued Rubigo Terri never to leave y house with an empty stomach. Wine Porter Strong Cider &c 54. 56. Remittant Fever. – This is mere modification of y preceding Dis Cullen very properly condemned who considered it a distinct species of fever most undoubtedly he observes each arises from y Same causes each is epidemic & each are cured by y Same remedies insome instances in y same person y Dis alternates All this must be added as perfectly true but as they demand a treat. somewhat different so they ought not to be confounded. By Remitt we mean that species of Fever in which y attack abates without entirely going off y remission occours at irregular periods & is uncertain in its duration. Somet: it continues for several hours & at others y interval is so short as hardly to be perceptible. Remitt is produced by all y causes which was said to give rise to Intermittant hence it is most common in low mash situations in y autumnal season & when there is great vicisitudes in y weather as intense heat succeded suddenly by heavy rains. As in y Pyrexia 57. of Intim: y attack is proceeded by languor heaviness restlessness & alternate fits of heat & Cold. As soon as y fever proceeds to y 2nd stages y patient experiances pain in y Head & back & heat over y surface of y body. When this stage is fully formed there is difficulty of respiration & depression of spts. to these are added a White fured tongue a full strong pulse a sallow skin & eyes tinged with Bile. Nausea & Vomiting of Billious matter, a sensation of heat & pain in y pit of y stomach. After a continuance of these symptoms for a time y fever abates considerably & goes off with perspiration more or less copious But in a few hours it returns with y same appearance as before & thus with Exacerbations & Remissions it proceeds untill it terminates fatally or is cured or as sometimes happens in another form as y Intim: or Continued fever. Such is y Ordinary character of this dis. But under different circumstances of Climate Situation or Constitution of y patient assumes different appearances & is 58. associated especially with y inflamatory & malignant Diathesis. As regards our Country it is generally a Dis. of increased action requiring active antiphlogistic measures & in this this light I shall now consider y Treatment of Remittant Fever. The principle Indications is to induce an Intimission & y course is pointed out y Symptoms it is proper always to commence with V.S. This is particularly indicated by y pulse a hot dry skin determination to y Head & a variety of other sympt. The next remedy is an Emetic with a view of xciting Vomiting when called for by y State of y Stomach y Tartarized Antimony is always preferable. I mention this more particularly because it is generally y practice of Country practitioners to use Ipecac. But this is much less efficatious y Antim: preparations not only more completely empty y Stomach but makes a powerful impression on it so much so that it puts an end to y Dis: by in tempting & removing y primary morbid impression 59. In many instances I have known Intim & Remit: cured by an Antim. Emetic operating in y manner I have prescribed to you To meet y same indication that is to evacuate y Alamentary Canal y Mercurial Cathartics are resorted to they are like y Antim: are to be prefered for they are Rinared articles they operate more efficiently in evacuating y Bile than other purges as soon however as y Mercurial evacuation is over we should resort to purgatives if a milder nature of these y saline are most generally used & y best are y Epsom & Cheltenham Salts y latter are made by evacuating y Cheltenham Waters or in imitation of Salts thus obtained & have been recently introduced into practice they operate in much smaller doses than y other neutral Salts are less disagreable to y patient & more evacuating y Aliment. Canal ʒi is equal to ℥i of Epsom. After such direct & powerful depletion from y Stomach & Intestines it will be proper to resort to y milder means of producing 60. Diaphoresis y remedy best adapted to this end are y Antim: preparations & y neutral mixtures y Spts Mendiri is also a valuable remedy in this place y action of these may be prompted by y Vapor Bath y best way of applying this is to pour Vinegar on heated bricks are to be wraped in flannel & applied to y truth & Extremities by this we can generally excite a copious perspiration. The Dis under such treat will most generally yeald in 2 or 3 ds. but if not y Emetic & Mercurial purgatives should be repeated again, evacuations of this kind are called for by y accumulation of Bile my Stomach which by irritation &c febrile action is kept up. – I have found Emetics to succeed y best as cooperating in y same intention. Vesicating Applications should be mad to y uper & lower extremities y mode in which they do good is sufficiently inteligible. by making a strong impression on y Skin they interupt that chain of actions constituting [fel??dles]. During y continuance of y fever some Subordinate affections occour which claim attention 61. There is after great heat on y surface of y Body which is very distressing to y patient. When this happens it may be relieved occasionally by sponging y surface with Cold Vinegar or very Cold water. You will thus reduce y temperature allay y irritation & render y patient much more comfortable. – 2nd. A determination to y head in this fever often occours & is indicated by a flushed face, wild expression of y eyes & Delirium or a tendancy to it. – This condition of y head is especially relieved by y application of Cups & Leeches & 8 or 10 z Blood may be thus taken with advantage. But when y Delirium appears to be fixed with y above may tie added shaveing y Head & apply a Blister to be continued at least 24 hours. It is a fact which ought to be rembered that [V.S?] should always preceed y application of a Blister. You will very generally find that a few ℥ of Blood taken by Cups & Leeches will do away y necessity of this last remedy. – It is proper to suffer 9 or 10 hours 62 to elapse after shaveing y head before y blister is applied as by thus doing you obviate y necessity of employing it. How y mere removal of y Hair should do away y Symptoms of Delirium is not very intelligible. Besides this advantage we derive another Viz an opportunity of applying cold to y head by means of cloths rung out in cold water or by use of Ice itself. – 3rd The common Symptom which call for relief during y continuance of Remitt: is Nause & Vomiting of Billious matter arising either from an accumulation of Bile in y stomach or peculiar irritability of that Organ, It is right to repeat y evacuations either by Emetics or saline purges but in a second case a different course is pursued; to quiet irritability is now y Indication for this purpose we have a great variety of remedies The common Effervessing or foaming Draught is exceeding useful when it can be obtained y Sedletz Water administered in small doses at short intervals will often prove advantageous 63. Mint Tea is also useful but infinitely y best is Lime Water & Milk y mode of employing it is a tablespoon of each mix them together and administer every 20 or 30 minutes according to circumstances not y least valuable of remedies for soothing irritability of Stomach is y infusion of Serpentaria dose a table spoon full. It is much resorted to in this city & posseses y confidance of many practioners. When y irritability of Stomach arrises from want of tone in that organ as sometimes happens when Emetics have often been given. Nothing is better than y tinct. Cloves given at short intervals in spoon full doses. As auxiliary to y above mentioned remedies. Fomentations over y region of y Stomach have often proved beneficial & y best of these is made by quilting Pulv. Cloves in flannel & wringing this out in heated Brandy. ℥ii Cloves is sufficient. Pediluvium of Water bath is also highly beneficial. But when y Vomiting is excedingly violant you 64. should apply Synapisms to y Extremities & Blister over y Stomach. But above all y articles calculated to check Billious Vomiting Opium stands prominent. It is a fact well worthy of attention that a pill of Opii which as been kept for 2 or 3 yrs will remain on y Stomach & Check vomiting when administered recent it would be rejected. If y Stomach will not retain y Opii though taken in this way we must resort to Anodyne Injections ʒi or more of Laudnum should be enveloped on a little mucilage & thrown up y Rectum. A favourate practice in this city instead of using anodyne injections is to employ Opii 3 or 4 grs. made into a pill & introduced 2 inches into y Rectum will often prove exceedingly efficatious. Y advantage of this mode are that it can be early employed, that we shall not have to encounter y prejudices of y patient & when y desired effect is produced we may easily withdraw y pill & thus prevent y consequences of an overdose. An intermission being effected 65. effected y Cinchona combined with decoctions may be given. But when any doubt of y absence of y fever exists, you should prescribe y Serpentaria. Quassia Angusturia, Eupatorium, Centaury etc. for reason which I explained on a former occasion. Arsenic will be found in some of these caces to answer very well. The only circumstances which allow y use of Bark while there is y least remaining fever is a palpable tendancy to a Typhus condition. But even here y Meds. will often be rejected & we should confide more in Tonics which add too then principle property that also of producing perspiration. Upon y whole however y Remitt of this country is of an highly Inflam: nature demanding copious depletion with y Lancet & evacuating from y Bowels – when these in y stage are so managed as to correspond with y Violance of y Symptoms no other remedy being imperiously required. – 66. Continued Fevers. These run their course without any intermission though some degree of remission & exercabation daily takes place. – It has been held by some writers that y deffinition is deficient is exceptionable because all continued fevers they say consists of a single paroxism without abdomen untill final termination. But I believe no such fever exists & am surported in my opinion by y highest authority except y fever denominated [in] which begins is perfectly formed & runs through its course in 24 hours which is of short duration & rare occourance. Every other febrile affection is made up as a repetition of paroxisms. – It may be remarked as a general rule that y Exacerbations take place towards morning & evening by consulting nosological writers you will find that this class of Fevers is ranously arranged however Inflam y fever is there is a local affection. I shall treat of them under y general head of Synocous & Typhus y different forms of continued fever may then be disposed of without - 67. deficiency of perspicuity or too great generalization Synocha. As ordinarily defined. I believe has no real existance. Every case at least which has met my observation has been attended with some local affection which has marked it as one of y Phlegmasia continued fever y most common in this country y Billious Inflamatory. This prevails in y U.S. to a great extent, with y greatest violance to y South & is varied not a little by y Climate & y Conditions of Society. Like y Dis already treated it arises chiefly from marsh exhalations but is common without them. It is also produced by other causes. Considering y close analogy of y origine of y Symp. & mode of cure & not to mention y other slight resemblances [t???un] y Intim: Remitt & Continued fever we have good reasons to believe they are y same disease with some differance in type & external Physiology. 68. Physiology. During an Exacerbation a Remitt. is precisely similar to a Continued Fever Billious so that an account of one will precisely answer for y other each being ushered in by y same train of symp. & attended by y same set of affections. Discharged therefore from y necessity of occupying our time with recapitulation of that which has already been said we will proceed to y Cure of y Dis before us but can we arrest y progress of y Fever after it is once established or must we be content with abating y more violant sympts. till it shall terminate spontaneously, this is a question of great moment has been tally discused by Cleghorn Hillary. Pringle & Fordyce. It has been answered in y negative. It is contended by y last particularly Note. Prognosis. If y pulse becomes full soft y skin moist y tongue clean y Urine depositing a White Sedament y prognosis is favourable. Dark tongue parched skin a cold dry surface irritable & quick pulse gastric distress etc y prognosis is unfavorable. – 69. But not only are we enabled to interrupt y carear but also that either addition too or subtraction from y cause producing it will not have y slightest influance. – In support of this opinion they appeal to Small Pox Measles & Dis which y fact is undoubtedly stated. Neither of these cases however abated in Violance can be cured by artificial means & neither of them are affected by y further application of y cause this is particularly true as regards Small Pox. But their reasoning is fallacious in as much as it is deduced from y cure of dis. peculiar in term & provided & governed by their own laws. As respects y common fever we see them daily checked by y remedies we employ. cant it be denied that they are interupted in their course by a timely recurrance to [V.S?] Evacuations from y alimentary canal & of a similar nature. Most admirably we see this happen every day of our lives & sucess are y trophies of our profession. At y same time we must concede that there is much difficulty on may occasions & hence 70. y precept with practical Writers “to attack y obis in the first stage” as there it is most easy to obtain a Victory Y doctrine above alluded to is highly pernicious in its particular tendancy & haveing arisen in y dark ages of Medicine Sciance & kept up as a respect for y authority. – It will not fail if credited to take away energy of practice to sink to irresolution & indescision in y management of diseases at y very moment too when exertion is most required. According to that you must remain an Idle spectator of y Ravages effected by y unrestrained & vehement attacks of fever on y Constitution. Let it not be supposed from what has escaped me that I am not at all inclined to deny that in fever there is a tendancy to solution or Crisis. This was early remarked by Hypocrates & has since been abundantly confirmed. Hence arose y Doctrine of Critical Days by which is ment those days [by] in which y fever is disposed to a Solution These according to Hypocrates are y 3. 5. 7. 9. 11. 14. 17 & 20. or as some authers will have it on y 21st 71. Every practioner of enlarged experiance must have witnessed a more than ordinary tendancy to a remission of y symptoms on some of those days. But such tendancy is not so clearly manifested our dis. as as in those which have occurred amoung y antients y reason of this is not obscure. You all know that y climate of Greece is equable & serene & that y people of that country in y time of Hypocrates still cherished y symplicity of their Republican habits. Diseases therefore prevailed with uniformity of character not being disturbed as amoung its by deviations from nature & by y changes of y climate. – Eternally fluctuating & unsettled attempts have been made to explain y recourance of critical as, on y supposition that Intim. are y primary types of all fevers & hence that continued fevers at first are Quotidian then Tertian & after y 11 day very generally Quartan. Wheather this be admitted or not y facts are important they teach us to watch y efforts of nature, to bring about a crisis 72. which is marked by Remission of Symptoms & that such is y case & time [cross out] most propitious for y administration of our remedies. – Treatments. – Early in this discussion it was remarked that y Billious Fevers are far y most Inflam: in their nature. This being y case y principle indications are very obvious viz to reduce arterial action to y ordinary standard. Confessedly to obtain this no means are equal to y Lancet. – Its operation under such circumstances is prompt & effectual. But in this dis it should be directed by judgment & tempered [cross out] by discretion. The same Complaint may be varied & none more than y one under consideration by Climate. Season by personal Idiosyncracy & by many other causes. This while in this part of y Country y practitioner found to bleed copiously was y only method of cure. while in y Southern parts y practitioners hardly ever opened a vein. – But no matter in what part of y wourld you settle do not refrain from depleting with y Lancet when it [was] is indicated 73. by a strong pulse a hot skin. delamination to y Head & other symp: of increased action. those symp. wheather They occour beneath y burning Trophies or amidst y Polar Snow’s or in y more genial Clime of y Temperate zone must be considered as signals held out by nature for succor from y Lancet & other evacuants in her difficulties & oppressing. Bleed often in Small quantities. – Next in importance are those Meds. which produce evacuations from y Alamentary Canal. These are called for in all Fevers but particularly in this on account of y large accumulations of Bile which are apt to occour. – My general practice when I can prevail on my patients to consent is a Emetic & as I remarked on a former occasion antimonial preparations are decidedly to be prefered. It will be perceived that I am decidedly an advocate for Emetics in this Order of Dis. any experience has pursuaded me of their superior efficacy to purge & I am surported in my belief by those. physicians who are acquainted 74. with y more inveterate shapes of Billious Inflamatory Fever. But that one may reap their good effects they must be repeated & in some cases several as in sucession. There is a fashion in Medicine as well as in other things. Emetics which at one time were universally resorted too & of whose efficacy undoubled testimony was afforded in one of y revolutions to which our art is subject was suddenly supplanted for purgatives, but they have recently revived. By consulting y French & English Authers who wrote on y Dis. of their respective armys in Egypt 20 yrs ago. it was found that y Vehement Billious fever of that Climate they were obliged to submit to other modes of evacuation Emetics therefore were adopted by y whole medical corpse of both armies without regard to those habits of Country & prejudice of Education which have so much influance in y generality of cases of this Kind. Y efficacy of Emetics are equally attested by East & West India practitioners as well as by those of our country. – When Billious fever 75. prevails to great extent they are marked by great violance of symptoms. Determining from my own observation I should say that when early administered they hardly ever fail to check y Dis & that in y advanced stage by their operation when free & copious y pulse is reduced y pain in y head relieved. sickess of Stomach quieted y temperature of y surface lowered & diaphoresis produced by which y patient is quieted & y critical solution of y fever hastened. But when Emetics cannot be administered either for y prejudice of y patient or some peculiarity, a predisposition to apoplexy after active [cross out] Vomiting. We may with propriety & advantage [recoar?] to y use of purges. Combination of Calomel with a Drastic purgative as Jalap. Rheii Gamboge will succeed best in y management of continued fever. – It is a favorite practice with some when y Stomach is loaded with Billious Acumulations to unite Emetics with purges so as to induce an artificial Cholera or as Sailors say “to clear y ship fore & Aft. Rx Sub. murials Hyd: oss Ext. Elatenum gr. ss. 76. Jalap. & Rhii aa gr.v ol. Cennam. [gtt?] pills 6 two to be taken every hour this clears fore & aft. Of y utility of this practice there can be no doubt. It has been occasionally resorted to in y Billious fever of this city with sucess & it is more employed in y Southern States where there is great necessity from y great vehemance of Bill: faction Combination Calomel with Tart. Antim: is [cross out] commonly prescribed to which some add Gamboge. This in a large dose from 10 to 12 grs. will produce y effect without y addition of Emetic Med. But to justify a remedy so violant y fever must be of a dangerous character & y indication of Billious Accumulations must be strong & unequivocal. In presenting purgatives if delay is at all admissible it is proper to wait for that period of y fever where a partial remission of y Symptoms take place. Given at this time they act powerfully & effectually. But exhibited during y rage of y fever they are either rejected by y Stomach or lie inactive. By y pocess above [detailed?] y Alimentary Canal being emptied 77. we are now to resort to Saline Laxatives. Employed in small doses they are beneficial by Ruping y bowels in a soluble state & from their action on y exhalent vessels of y inner surface of y intestines they detract y watery parts from y circulating fluid & thus keeps down y arterial Excitement & produces a demunition of y Violance of y Paroxisms. Of y Saline purges y best have been already mentioned, A prescription very much used by myself & other practioners in y city is as follows ꝶ Sulph. Soda ℥i Tart. Antimony gr. i Suc Limin ℥ss Water ℥4 y dose of this is a tablespoonfull every 1 or 2 hours according to circumstances. It keeps y bowels in a locative state & produces a mild Diaphoresis reduces y arterial action & lessons y Sufferings of y patient. – As cooperating remedies Enemata are not over looked they are useful for promoting y action of purges. they are also beneficial as a substitute for cathartices when y alamentary has been much evacuated. Several formula have been used 78. y best for common purposes is that I will now mention. Take a pt. of Water & a table spoon of common salt & molasses & one of Olive [a] Castor ol. mix them & Inpect. When you wish an Enema a little more Stimulating or where there is flatus in y bowels as often happens at y close of fevers. Terbinth injection, may be used & be adapted to y cure. It is made by mixing a table spoon full of y ol. Terpentine the White or Yolk of an Egg & adding a pt. of Waters It relieves flatus more readily & spedily than any other remedy & in this affords great relief to y patient. By y combined operation of y remedies already mentioned y excitement of y system being reduced we are next to employ y meds. which are calculate to produce Sweating. Of all y modes of managing fever y practice of sweating is y most popular & general. By y vulgar on all occasions this is thought safe & most effectual nor is this opinion confined to y low & Illiterate of mankind. Every class of Society acquires y prejudice & entertains y 79. y same view same views. It is obviously however that remedies which act so powerfully on y System as many Diaphoretics are apt. to do should not be want only trifeled with by imediately employment. On y contrary they should never be used in Inflam. fever untill arterial action & general Excitement is reduced by V.S. & evacuations from Alamentary Canal. Diaphoretics then come with advantage & mitigates the dis. or arrestes its future progress & even here y milder diaphoretics should be employed & those should be combined with auxilliary means which have y same tendancy. As a general precept from which you must never depart it may be stated that in Inflam. fevers it may be stated that in Inflam: [cross out] fevers we are rather to solicit perspiration by limited means than to extort it by violant measures. To bring a continued fever to a crises y Antimonials are generally prefered. early introduced into y practice of med. they were occasionally used & with variable reports their efficacy were declared 80. by Hoffman & then successfully used by Cullen Fordge Antimony [cross out] affords an infinite number of preparations each may be so given as to produce Diaphoresis though few of them are employed at present In England even to this time y cellebrated Puties Jacobe or James Powder has no small portion of confidance that it often excites perspiration in fever can hardly be disputed but so far as I have observed its effects it is in no way superior to its kindred preparations The composition better known & hence administered more easily & certainly regulated on y Continant of Europe & certainly France is y Golden Sulphuret of Antimony. & has an indisputable asendancy over all y preparations of that metal. – Wheather it is entitled to this confidance does not allow me to decide. Compared to y Emetic Tartar I think it inferior in every point of view. This latter med. may be made to supersede all y rest of y Antim: preparations, Nearly Tasteless quite inodorous & minute in its dose, it may be administered 81. with facility prehaps equal it not transcend a wt. powers. – Of y precise manner in which y several preparations of Antimony operate in continued fever or y principles which should guide us in its use we are not accurately informed. Cullen maintains that they are of no advantage unless they vomit or produce considerable nausea but on y contrary it is continued by Forage & there can be no higher authority on y subject that by exciting vomiting y febrifuge powers of Antimony preparations are impaired & that they are always most effectual when y [?h?ght?s] degree of Gastric distress is excited by them. To this point I have directed a considerable careful attention & I am led to concour in this latter opinion. Nausea by whatever means excited or whatever way induced is not in itself salutary in directing y fever to a crisis or favourable solution. During continuance of Nausea Arterial action Macular power & animal temperature are undoubtedly lessened but afterward & reaction of y 82. body & consequent exacerbations of y Fever takes place. But did such a state of y stomach operate in y same every beneficially as contended for by Cullen practitioners generally: y utility of medicine should be proportioned to y to y effect thus created & various other Diaphoretics infinitely more violant & lasting in their operation as digitalis. Tobacco should be prefered. But this is contradicted by y lessons of experiance & y united voice of practitioners in every country. Meds do good in fever by exerting their own specific or peculiar action & when they disorder y Stomach by Nausea & Vomiting they are always productive of more or less mischief To illustrate this would be easy but it would take too much of your time & can be acquired by any one who will direct his mind to y subject. There are many febrifuge Meds. as y Effervesing Draught “Neutral Mixture” y principle effect of which is to subdue nausea & Vomiting & to sustain y tone of y Stomach. But while contend that y Antim: press: Arsenic. Bark. Mercury & Lead &c 83. act by a peculiar power I conceive that as this is y case with y articles enumerated y effect will be proportionate to y quantity taken provided they produce this genuine mode of action which is independant of any Nausea. Curious as are y views in Speculation they are inconceivebly more interesting when applied to practice. Let it be allowed that they are correcttive do away all objections against y employment of a rememedy of undoubtedly high utility nevertheless it is not to be infered in y preceding remarks that we should not have recourse to Emetics in y early & forming stage of y fever here they act on different principles & their efficacy is too well attested to be shaken by any thing that can be said concerning it. To obtain from from Antim. Remedies y precise effect to which I have above alluded is not always very easy. Y febrile affections are various as regards irritating so that y Dose as well as is in intervening as different in different individuals. As a general Rule 84. 1/10 to ¼ gr. of Tart Antim dissolved in water & united with a little spts. Sav: Comp: to give it colour may be taken every 2 or 3 hours as prorenata. But some Stomachs are so irritable that they retain it under no circumstances & here we must have recourse to other meds. of this nature as y Saline or Neutral Mixture which is prepared as follows viz ꝶ Lemon juice or sharp Vinegar ℥ii add Sab, Tart: till a complete Saturation is effected then add Loaf Sugar ʒii aq. font. ℥ii. – sometimes it is good to add a little Laudanum & a small portion Spts. Nitre Dose is a tablespoonfull every hour or two. To meet y same indication many of y Diaphoretics have been used some of which possess in an small degree y confidance of practitioners. – Combinations: of Ipecac & Opium are of this nature but though of y highest utility in Phlegmasia they do not succeed so well in y general febrile affections Why this should be y case it is difficult to tell but such is y fact & with it we must be contented not less do these remarks apply to others if y same class 85. most of them act as promptly & copious as y Antim: press: in aresting y progress of Continued fever. [illegible] this fact we find new reason for y supposition that y Tart. Antim: posseses specific powers in febrile affections in dependant of Diaphoresis or nausea. certain it is that y efficacy of Antimonials is not proportional to y degree of perspiration excited. Notwithstanding all that has been said in y management of fever some [cross out] practitioners hardly ever recour to this plan. by them y Neutral Salts. Refrigerants are prefered y precise Modus Operand of these meds is not understood attempts were [??dde] to explain their operation on chemical principles Though this hypothesis is not without plausibility yet it does not afford us & solution of y difficulty. But whatever may be there method of operating y Refrigerants reduce arterial action. lower animal temperature & partials relieve y surface though this really occasion perspiration. The principle article in this class of remedies is [cross out] Silon or Potassa & no Meds 86. more employed in fever & Inflamatory Dis. Z increases its powers it is customary to combine it with Cal. & Tart. Antim. forming a combination well known by Nitros Antimonial Powder viz ꝶ nitras Potassa ʒi Calomel gr-xvi Tart. Antim gr i to be divided into 8 powders one of which is to be taken every two hours according to circumstances. This is suited to y more robust of our patients & on a/c of y Cal: which it contains is very apt to purge it is prudent in some cases to exclude y Case lest Catharsis should be induced when not demanded or excite salivation as it is known to do sometimes under such circumstances, y Tart. Antim: is also to be graduated to y case. Even [cross out] in so small a quantity as 1/8 of gr. it sometimes distress y Stomach & even Vomiting, - Cooperating to y same end viz y reduction of diurnal febrile excitement. Cold applied to y surface has lately been recommended. I shall subsequently enter on y consideration of his subject I shall antisipate very few of y [former] future observations 87. Cold Water. may be applied in 3 ways either by Ablution. Aspersion or Effusion each adopted to y particular circumstances. But in y case before us I prefer y Sponge. It is much more agreable & less Dangerous than y others. But cold applications Are never called for unless y Pulse is active Skin hot & dry there they are very useful. they remove y uncomfortable secretion causesly y hot skin or heated surface & lessen y force of y circulation. induce mild diaphoresis & sooth that irrestlessness which generally accompany febrile Dis. But under other circumstances it is perilous when y system is exausted by y fiber would at y period be unable to react. Such is an outline of y 2 plans for treating fever one Refrigeratory y other Sweating. This is not y place for instituting a comparison between them nor could it be easily done y fact that they cannot be received as several measures each adapted to different circumstances. – 88. Before we use Diaphoretics in Inflam: cases we should first deplete in proportion to y vehemance of y Symptoms by V.S & evacuations from y Alamentary Canal & exactly at this point Refreg: remains maybe called into use with signal advantage. Before dismissing y Subject I wish to impression you y value of Sweating in y cure of fevers. It was formely y practice to treat Inflam: Dis by forcing a perspiration by heating Alexipharmics or antidotes. But those are productive of wide spreading mischief they were soon discarded. But it is wrong to argue against y employment of an article from its abuse sweating like Vesication is useful or as it is directed. When under y control of sound discretion it is highly important & indisputably acts powerfully in combatting Diseases Diaphoretics by determining y Blood to y Surface lessons Internal Congestion they relieve y constriction of y extreme vessels & thus renders y patient more comfortable y more we reduce y circulating fluid [cross out] thus they reduce arterial action by direct depletion Finally they equalize excitement & retain that just 89. Cheshire June 9th 1827 Cheshire March 31 1828 Equipois in y various actions of one system in which perfect health depends. Let us not therefore throw away remedies so useful on account of y objections which theory may raise or false refinement indicate. When hereafter we shall take y field against diseases you will it not enough to combat it with one remedy on the contrary you wish to be victorious over these to human happiness you call into requisition all y recourses which have been put in your hands. – by your God & all those which can be derived from a complete Knowledge of your art. We have now arrived to that stage of Continued Billious & Inflamatory Fevers where Vesiccating applications are found useful. They should be applied to y extremities sometimes both upper & lower but by some modern practitioners they are altogether condemned & strongly prohibited in this form of fever. Of those who entertain such views by far y most distinguished weight is that of Fordyce.. 90. It was one of y sayings of that great man that resicating applications had not y least effect in arresting y progress of Fever but on y contrary they never fail by creating an additional excitement or occasioning [cross out] exacerbations of y Dis. It seems to me not very difficult to reconcile y contraruly of sentiment that has prevailed on this point. Nothing is more different than y effects of Blisters applied in y early & late sap of y Dis. When there is much arteriae actions febrile excitement they never fail to do harm & it is not less certain that they are of y utmost utility in a reduced state of y system. Let y Body be reduced by V.S. Emetics & Purges & then resort to Blisters to quite y pulse, equalize excitement put an end to y action of Dis. & establish y regular order of health After y remedies above enumerated prove unavailing much confidance is placed in Mercury. Urged to a moderate extent or Salivation there can be little doubt of its utility when y system can be brought under its operation. But in most cases before y mercury 91. Cheshire January 21 1827 A. 1828 can be made to act feaver from its rapid carear terminates to be of use therefore it must be properly employed & as y bowels are weak & irritable it should be applied in y shape of. It is difficult to excite Ptialemo while y pulse is active Mercury therefore should never take y place of depletion & y remedies which effect this are generally sufficient to remove y fever. * I have thus concluded y history of y remedies which are best calculated to cure Billious Inflamatory Fever. Much however depends upon dericing a proper attention to y Minor circumstances which often so powerfully influance y result. Of these by far y most important are Drinks Diet & General Management of y patient during y progress of y Dis much * In y Billious of this country Bark does not suceed y Remissions being short, tong moisten skin relaxed it is useful. Cullen says that every fever proceeding from marsh miasmata after sufficient evacuations may be treated with Bark beneficially. All Fevers arising in y spring should be treated by Calomel. – 92. dryness of y fauces & extreme thirst generally prevails. It has been a question wheather y patient should be indulged in this ardent desire for Drink. y Physicians of antiquely were much divided on this point while one set to totally forbade. y other allowed y use of Water. – It requires little Sagacity to discovour that y medium between y two is y proper practice By denying altogether y occasional use of Drinks we shall cause great anxiety & distress & rather increase y Dis & by allowing y unrestrained employment of it we shall find that y Stomach will be disturbed & certain Nausea & Vomiting with other mischievous consequences will result. We should therefore direct now & then a table spoon of some Acidulated Drink as Lemonade Vinegar & Water. Apple Water. Toast Water. Tamarind Water & a variety of herb Teas as Barley Water, Balsam Tea. Sago Tea. & a Solution of G. Arabic. But what I have found to be y most effectual in allaying Vomiting 93. William R Hitchcock Esqr. Vomiting & distress at y stomach is a table spoon of Lime Water or a tablesoon of new Milk from y Cow or a decoction of Snake Root, even common water provided y quantity be small & y temperature not too cold, should not be refused. It is a precept worthy of your attention that drink in moderate proportions & moderate temperature will relieve y thirst quicker than Cold Drinks immoderately taken During y continuance of y fever y Drinks above enumerated will afford sufficient nourishment to y patient. – It sometimes happens that y appetite solicits more solid food & y demand of y patient is loud & clamerous but y propensity is always an unfavourable indication & should not be indulged. Every practioner must have seen y eble consequences which results from y gratification of a depraved appetite & in many instances cases from this cause have terminated fatally which would otherwise have been cured. An Old Opii pill checks vomiting. Enema or supporting of 94. Samuel Johnson [Esgr?] Oppi. Blisters over y Stomach & a lump of Ice held in y mouth. a piece of Liquorice or an Infusion of Liquorice will allay y thirst grii of Calomel will be of service. Strong coffee [no cream or sugar] ¼ or ½ gr Calomel with G. Arabic. Sacch. Saturni grs every ½ hour. Mint. Brandy with a Lump of Sugar are all good in irritable stomach of Billious Fever. – In y History of Pathology of y dis I mentioned y causes which accelerate y increased action these should be studiously avoid in y febrile condition. As prehaps y most operative cause you should direct partie: light to be excluded & also that conversation should not take place in y chamber of y Sick. – Before leaving y subject I will give some some directions for y Management during Convalescence. Febrile affections of every kind leave behind them an accumulated state of excitability which it not properly directed may be productive of a relapse a condition of things more Dangerous & intractable 95. than y original Dis. The first step when y patient is recovered is to remove him to another room or to order that all y apparatus of sickness as Phials. Bases, Plasters &c should be placed out of sight from seeing these a remamtrance of his sickness is kept up. & his spirits being depressed retards y progress of cure. Y changin his skirt & cloths has a great effect in promoting y possess of Convalescence. 2nd. Be careful to regulate y Diet according to y excitement, you should begin with faranaceous articles & more are better than Tapioca. Arrow Root. Sago & Rice. Next you may allow Eggs & Oysters raw or very slightly cooked. Boil a Chicken or any other article of a light & digestible kind may be allowed. – But whatever is taken should be in small quantities at a time. This is a rule of extreme importance & rembember to direct often & a little at a time. As regards Drink pure water is y best. If something more is required by y condition 96. of y patient & from his solicitations y best liquid which you can direct is Porter diluted very much with water Malt Liquors & especially Porter is infinitely more agreable [cross out] & less injurious than Wine or ardent spts. however diluted. 3rd It is hardly less important that y patient should gradually return to y employment occupations & habits of Life. He is especially to avoid much exercise of his intellectual faculties. – To prevent this he must be kept from study & from attention to business of any description Company could be avoided. Be not too precipitate in permitting your patient to take exercise & especially out of doors. There is generally much eagerness on his side backed by y intercession of his friends under [illegible] that it would afford him strength confirm his recovoury. – But you must recollect that there is great liability to take cold & from this irritable state in y commencement of convalescence y stimulus of riding instead of strengthing would probably give a return of fever. Even when you allow him 97. to take exercise direct him to be warmly clad & should particularly enjoin it on his attendants not to protract y ride so as to fatigue him. Y preceding are instructions [cross out] relative to y management under ordinary circumstances. But now & then certain symptoms arise during Y course of Med. treat. which demands [cross out] particular attention. Sometimes patients in y convalescence from a long spell of fever remain very feeble & have a total loss of apetite. To meet y indication of these cases Tonics should be given amoung which y Tinct: Cinchona alone or combined with a portion of Tinct. Gentian is highly beneficial. But there is a great variety of articles of nearly a similar Character which may be used in sucession according to y circumstances of y case or to y taste & caprise of y patient. As y leading ones, may be mentioned all y Vegetable Bitters as Columbo Quassia Gentian, & these should be employed in watery infusion. 98. y Chur. Vitriol is also an excelent remedy & establish y a restoration of apetite. Not y least distressing affection which is incident to a state of [cross out] convalescence is extreme watchfulness & inability to sleep this is very unpleasant often retards recovery & somet: aggrevates y fever here Small Opiates are useful. The best preparation in this case is y Black Drop. This preparation posseses 3 times y Strength of Laudanum & has a more powerful anodyne effect than any other with which I am a aquainted. It never so far as I know produces y nausea & other disagreable effects which sometimes results from y use of opii & its Spts. Tinct. When Opii in this form fails you are to resort to Hops Tinct. & what I know to succeed very well is y Camphoretic Julep this often quiets irritation existing in y system & disposes y patient to slap. Sometimes watching proceeds from an empty stomach & when this is y case stimulating food conjoined with porter is generally effectual. – 99. Somet. Diarrhoea & more commonly Costiveness attend recovery from fever. As to y Diarrhoea it will generally yeald to y Cretaceous preparations where on y contrary there is a tendancy to Costiveness it will generally yeald to small doses of Rheii. This cath. should be prefered because it impartis tone to y Bowels & when taken by itself never purges copiously. It is worthy of [cross out] recollection that however beneficial evacuations from y Alamentary Canal may prove in y early stage. – It is not less injurious in y convalescence more than any other cause. Copious evacuations at this time induce a state of exhaustion & not unfrequently brings back an allarming degree of Fever. I have see this more than 100 times in y condition of convalescence These are y applications which have some claim to notice but considering which I have protracted y discussion. I will detain you with only with 1 or 2 observations. y Billious Inflamatory 100. may terminate in Typhus but more frequently in chronic fever. As y treat of y former differs on nothing from y Idiopathic Dis of y same name it will not anticipate y observations which I shall have occasion to make here after. y Chronic nature of y Fever claims our particular notice it is called Febricular from its from its diminution & indistinct symptoms which attend it. In y country it is known by y name of Inward fever. Y pulse is small corded & hard, much heat on y surface. a Billious complexion & a tenseness of y forehead combined with Headach or pain in y side. y Patient has always Edematous swelling of extremities, scanty high coloured urine & ash coloured Stools, y Type of fever is either Remitt. or Intermitt. & not continued, y course of this condition of things is too obvious It arises from Congestion in y Large Viscera partic: of y Spleen & Liver. Y appropriate remedy is a slight salivation or what answers very well as a substitute a course 101. Nitric acid ʒi of y latter should be given every day for 8 or 10 ds. Commonly however there is much fever & pain so that it is necessary to resort to frequent & small V.S. vesicating applications at same time are very important placed on y side if there is pain there. But if this is absant & we wish to interupt y association on which this small fever depends I would greatly prefer them on y ankles & wrists. It is a common practice to treat y case with Tonics particularly with cinchona but it is highly prejudicial they Lock in y Dis. instead of Liberating it from y system. After y evacuations have been premised then y Tonic Meds. may be employed. of them by far y best is Cinchona but where this fails we may resort with great advantage to Fowlers Solution. – Delirium. very often in y progress of y Dis there is delirium y patient becomes wild in his conduct get up from his bed & uses singular expressions there is at y 102. same time great turgesance of y Eyes & Face fulness of y Head &c. In order to remove this it will be necessary to remove y Hair & shave it close to y Head. apply cups to y temples. here Blisters should not be applied untill Inflam- is subdued. Note. To cure Headache in fever apply 2 or 3 leaves of y Wild Popular. imersing both arms in cold water, sprinkling y Head &c. – Note, This prescription is good in fevers viz ꝶ Tinct Opii ʒi Acid Tart. gr. 10. Aqua font, ℥ii Dose table spoon 103. Remittent Billious Fever. The Continued Billious Fevers are very apt to terminate in Billious Remitt: in which case there is perfect & distinct Remissions. It is a common practice in y U.S. wheather Remitt: are assumed form of Continued to treat it from y very commencement with Cinchona It is laid down by Cullen that even in y Continued form arising in Miasmatic countries always to make use of Cinchona without there being any Intermission or Remission. Whatever may have been his sucess at Edinburgh it is not applicable here in y U.S. when y remission is not complete y Bark will be rejected or oppress y Stomach & this aggrevates y Dis. The practice here is when there is some remission to substitute for y Bark y other Tonics as Serpenta: Quassia. Angustura & our own Indigenous articles of y same nature. Arsenic is much better adapted to this form of Bill: fever than y Bark & in general it will be y best plan to resort to it. It will however be found in y generality of cases that, V.S. 104. Emetics & Purges will be necessary before y Tonics can be administered. Yellow Fever as an Dis of autumnal occourance & allied in some respects at least to y dis fever already Described, I proceed in order to y consideration of Yellow Fever. It is not my intention to occupy your time with a very minute history of this Dis. To y writings of y late Dr. Rush I refer you for details relative to y subject & more partic: for his account of this dis. as it appeared in 1793. some deffects for y time it was written] undoubtedly is y most perfect muddled & best historical narrative [in y whole compass of medical Literature] pestilentia dis. contained in y whole compass of Med. Literature As prehaps you all know that. Y.F. is an Epidemic of Tropical Climates – to W India Isles it seems to belong particularly. – It appears occasionally to have occoured in y U.S. from y earliest state of settlement but it was not until y yr. 1793 – on a/c of its ravages & y Terror which it created that it 105. first attracted Med. Curiosity & attention. Notwithstanding all y writers on y subject & y ardent continued enquiries which have been made hardly one solitary point connected with it is better settled or less a matter of dispute than when investigation first began. – Its origine nature & Treatment are points, still as much disputed now. as they were before. It is far from my desire to review y disputes which were carried on with none of that complaysancy which should characterize all Sciantific discussions still however it is my duty to afford you some information on y subject. though I trust in giveing it I shall be able to temper my an imadversity by y sincere & respectable attachment which I entertain towards [both] all parties engaged in y controversy. – As regards y mode of production y disputes have been chiefly on of meaning of words. It is attributed on all hands that in each instance y discus procds in some way from Vessels. It is true that local filth as y 106. contents of Docks. Gutters & common Sewers has been assigned by some as y accessary cause of this pestilance but was this true for y extent to which they argued it would appear that y dis must appear every season for y sources above mentioned crest now just as much as on former times besides we have a complete repetition of y doctrin in y fact – the Scavengers a class employed in 2 cleaning y city of y filth universally escape y Dis. Dr. Rush states out of 50 Scavengers only 1 took y dis in 1790. But it may be said that these persons are so habituated to y exhalations of y filth [universally escaped y Dis] as to be insensible to its action, This however cannot be justly alleged because owing to y great scarcity of y Scavengers at this time many of them having left y city individuals were employed pro tempore But while I so far accused to y importation of Yellow Fever I do not believe for a single moment that in any 1 case it was introduced in a palpable & well formed condition. My impression is 107. that ships coming from tropical climates in a filthy state bringing with them y materials out of which this pestilance is produced. Wheather such exhalations excite y fever under all circumstances I am not prepared to determine. It is more than probable that a certain condition of y atmosphere is necessary to give actively to y cause. This would seen to be y case since y fever is of occasional occourance though vessels arrive every day from y W. Indies. Long ago it was suspected wheather y Dis was imported or generated in our own country it would not take place except under a degree of temperature – but it has been proved as satisfactorily as any problem can be proved that unless y mean temperature of y summer months June & July is as high as 79 or 80 Fahrenh: y Yellow Fever cannot prevail in our climate. This have taken from a register kept in Philadelphia in 1793 to y present time. From this it appears that when y media heat of June & July has been 80° 108. not in one solitary instance has y fever appeared but on y contrary when y temperature was above 80 so was y greater violance of y Dis. Nor does y truth of y observation rest on y register on Philad. alone by a similar one in N.Y. weare waranted it arriving to y same conclusion. Much controversy has existed as to y Contagious nature of Y.F. that it is not y generals uniform character of y Dis & think has most satisfactorily explained. Not to protract by discussion to any length I shall compress y argument on both sides into as narrow & compass as possible. It has been said it is not contagious for it is of y nature of Epidemics & therefore depends on more general causes. It is also said by them that y diseases imediately proceeding y Y.F. from one end of y union to y other assume more or less y inflamatory type of that dis. 2nd.. It is moreover said not to be contagious because it never proceeds beyound y sphere of y city infected by it. – In surport of this argument 109. strong & almost irresistable arguments have been added. It appears that during y prevalance of y fever in this city that though several hundred people were received into y Hospitals & crowded together into small & comparatively ill ventilated apartments get no one instance of extention of y Dis occoured y Phys. Med. attendants & nurses whoever constantly amoung y such y dying & y dead escaped without one exception even though dissection was carried on [even to] an almost incredible extent 3rd. It is alleged not to be contagious because it is uniformly suppressed by cold weather. Whatever may have been its ravages however universal its prevalance y moment it first appears its carrear is checked or terminated. This is undoubtedly contrary to y nature of contagious diseases. 4th we are assured that cases have occoured in y country remote from y city & where it could not have been excited by contagion or intercourse with y sick. But on y other hand facts are 110 adduced too important to be over loocked. 1st. It is alleged that y dis in every situation commences at some point from which I gradually spreads & diffuses itself – In 1793. It could be distinctly traced to a Cargo of putrid coffee thrown out of a vessel from y W. Indies upon Arch St. wharf. y persons employed in unloading y vessels were first seized next y inhabitance contiguous to y wharf & from this it gradually extended itself untill it involved y whole population. In 1805 y dis originated in Southwark & was traced gradually diffusing itself from square to Square untill it covoured a great part of y city. – 2nd. It is answered by respectable physicians that y fever actually proved contagious in y country. to this point we have y attestation of Doct. Wistar who recorded several instances in which y dis happened in Germantown & which was distinctly traced to y city. There are a number of facts of y same kind in y publication of 111. y College of Physicians. It has also been [impactd?] by y cloths of those that died. 3rd. It is maintaind that y Y.F. does not take place twice in y same persons in this respect obeys y laws of Contagions dis. On this point Medical men are exceedingly divided. While on one hand it is asserted by a large member of Practioners of this city that it never occours more than once in y same person It is rejoined by a large number that eases often occour where one individual had this dis twice In a recent publication by Dr. Hossack contained in y last edition of Thomas. it is state that on a recent vursit to Philaa. y Doct. had conversed with several medical men on this point & had not found one who did not declare that y dis is incapable of being twice taken, but he was mistaken. It so happened that his that his communicates on this subject was a particular set who maintained this opinion. – If he had addressed his interrogatories to Dr. Physic or to 112 Dr. Dorsey he would have found that they no more believe it than they do transit – or thus y New York school was superior to ours. – It is however stated by Dr. Griffith that though he attended thousands yet he never met with one instance where y dis occoured twice in y same person. By consulting foreign writers you will find no more union than in our own. Most of y W. Indie practitioners entertain y first [sentim?] y question has lately engaged much attention y British Government inconsequence of y occourance of Y.F. in various parts of Europe partic. in their ports in y Meditaranean Sea instituted injuries relative to this point on an extensive scale. Two bords were instituted of Med. men who were to collect all y evidance y subject admitted of. After a full examination of witnesses & documentary evidance y College of Physicians of Lond. as well as y Med. board reported as y consequence of their deliberation & extensive enquiries y following [103.] 113 conclusions were 1st. That it cannot be taken more than once – In support of this point facts were adduced of a very conclusive description. Amoung others it was stated in y authority of almost all y med. men in that regiment which had previously served in y W. Indies y soldiers who had been affected were not more instance again attacked by it. – This fact as so well ascertained that y soldiers were employed as nurses to y sick & did not experiance any in convenience Nor as regards y origine of y dis. is y Epidemic less direct at Cadis it was traced imediately to a Vessel from y W. Indies. It was shown that it could not leave arisen from any local cause from y circumstance that it did not occour in y most dirty parts of y city. It was farther shown that Marsh. Miasmatic could not have given rise to it because on one side of [Cause?] there is great marsh which every season 114 [104.] occasions y different kinds of Billious Fever get during y cariers of this pestilential dis. that part of y city was perfectly healthy. Strong however as y facts appear to be one still more conclusive may be added. Y Garrson at Geberatter is situated on a bank exempt from all Mail Exhalations & kept perfectly clean from filth of every kind by y severity of y military police. No place is so little favourable to y production of Pestilential fevers yet it prevailed there to an enormous extent. It is affirmed that y dis in this instance was imported in a vessel from [??dis] & could be traced to y wharf where y vessell was lying. Enough has been said how contradictory all y efforts on this subject are when facts so opposite in their tendancy related by respectable authority. It is imposible for a circumspect mind to arrive at any satisfactory conclusion. It would not be safe in such cases to trust to any [opinion] ceasing & even if we were to employ it we might arise at oposite inferances. but really there is [105.] 115 nothing very repugnant or absurd to reason in y belief at least of occasional contagion of Y.F. Typhus confesedly is very often contagious but it is said when this proves so it [is] arises from y exhalations produced by y excretions in a state of petrifaction of this statement I do not believed single sellable. Typhus Fever has again & again occoured when y greatest cure was taken to remove all filth. During my residance in Edinburgh y British fleet which was cruising in y North Sea was infected with Ship fever. The Sailors who had been attacked were landed at Edinborough & taken to y Hospitals of that city. More than hlf y Students who attended on y sick were attacked with y fever & many of them died besides were y dis. occasioned by y effluvia from secretion or excretions it would be as diversified in its nature as y causes are from whence it is produced & each of these 116 [106.] different excretions would produce a different disorder but this is not y fact. All y cases which occoured in y Hospital were precisely y same or marked only by such differance as may arise from y violance of y attack & idiocincracies of y patient or their peculiar constitution. – What also do experiments prove in regard to this point? It has been most satisfactorily shown by Hogarth & other European writers that Typhus is not always Contagious dis. as much so as Small Pox itself but y sphere of action was not extended beyond a few feet. From y experiments of Dr. Gregory of Edinborough it appears that Typhus does not prove contagious beyond 5 or 6 feet. If a person remains within that sphere he was sure to be attacked with that dis. Does not this show that fever may be contagious & that it is not propogated from y putrid excretions but from y patient himself. All contagion is owing to a secretory action of y vessels. & differs [107.] 117 according to y nature of y stimulus by which y vessels are excited. Thus y Contagion of Small Pox differs from that of Syphilis only by being produced by a different action of y secreting action of y secretory vessels resulting from y disimular nature of y Stimulous by which they are called into action. Now if y extreme vessels in T. secrete contagion why should they not perform y office in A fever where y dis assumes y Typhus inclination that they do so I am perfectly persuaded but it is only when it puts on y Typhus [grade] condition that Y.F. proves contagious we observe y same in Dysentary which in its ordinary form is not of this character but when it becomes Typhus y whole tenor of Med., Sciance goes to show that it is propogated by contagion. – By consulting y best writers on this subject you will find that other complaints though not contagious under ordinary circumstances but when they assume y Typhus Type do become so. 118 [108.] This I believe is a law of universal prevelance amoung Diseases. I do not see much force in y argument. that Intim: fever is not communicated in Hospitals & by dissections. It is in this respect on a footing with Typhus fever & Plague. We have reason to believe that Typhus fever is not contagious when y apartments are well ventilated. It has been ascertained that as soon as vitality in y Plague was destroyed by – of communicating y dis is destroyed. As I have stated them such are y facts arranged on each side of y controversy my wish is not to impact any Hypothesis to you y facts are so contrary in their tendancy that it is impossible for anyone who gives credit to both parties to form a conclusive opinion The controversys scene to be have governed more by y pride of Victory than by any honest wish to advance the Interest of Med. Sciance. As relates to nature & treatment of Yellow Fever scarcely less diversity of Opinion has prevailed. – [109.] 119 Treat. Yellow Fever. consists in V.S. & mercurial purges & was in y year 1793. adopted by some of y most distinguished practitioners of y city. Y French physicians washed out y Stomach & then poured in Glysters or diluant beverages Calomel was exhibited largely by others but their sucess was precarious. Mercury seldom produced Salivation. More correct judges of its pathology a change of treatment. In y commencement V.S. by cups. Mercurial purges &c this was y treat. of 1793. Last summer often mild evacuations from y bowels, we used spts. Turpentine in doses according to y symptoms with cups to y Epigastrium. this should however be done early in y dis y Turpentine was to subdue Inflam: in y Stomach. – 120. Dysentary. Cullen defines this to be a contagious fever in which y patient has frequent mucous & bloody discharges accompanied with Griping & Tenesmus y foeces being for y most part detained. Except as regards contagion which is of rare occourance I do not know that this celebrated deffinition could be a mended. As y History of y dis is familiar to most of you & may be learned by Books which are easy of access it is not necessary for me to enter into a minute description. An attack of Dysentary according to Sydenham whose a/c of y dis with few alterations has since been capsized by most writers on y subject comes on with a Chill suceeded by flushed of heat frequency of pulse to these symp. are added severe griping & a constant propensity to go to stool. But in many cases y local affection is first perceived & prehaps not less frequantly y dis is preceded by loss of appetite. Costiveness flatulency; Nausea, Vomiting, & often these take 121. place with y irritation & uneasiness of y bowels above mentioned. As y dis extends itself y evacuations from y Bowels becomes more frequent & painful & preceeding every stool there is griping & tormina & tenesmus. y matter discharged by stool is very various sometimes consisting of frothy mucous though more generally it is streaked with blood & small coagulated lumps like bits of cheese are observable & some cases hemorrage of pure blood takes place from y Anus these are y ordinary appearances of y Stools in Dysentary. Now & then there is mingled with y morbid discharges natural forces may be assuming y appearance of Gallnuts & denominated Sybala y voiding of which is attended with temporary relief. We commonly meet with fever more or less marked with y usual symp. of increased heat thirst & restlessness though y pulse is neither very full or very active. This may be considered as y crisis of y Dis. which commonly occours in a few days though it is frequently much more 122. protracted. Not arrested by our remedies y dis henceforth puts on a sensible aspect. To an increase of y principle affections incident to y case we add. A rapid depression of strength, cold extremities. tension of y abdomen. Cold clamy swets, pitched. Hiccough. Aptha. a small pulse & discharge of a acrid fluid resembling y washings of meat, latered canine, [these] are generally y precursors of death. But they should not be deemed invariable so as much as recovouries from Dysentary somet. takes place where y most of them have been exhibited. On y contrary when y case terminates favourabley we find most commonly a remission of fever, y surface becomes moist & relaxed y evacuations less frequent & more natural y Tormina & Tenesmus subside altogether or are grately diminished. To this a/c I have only to add one observation. Y complain occours sometimes without any discharge whatever, such cases are by far y most fatal. The want of an evacuation arises from y existance 123 of an inflame. so violant as to transend y secretory [action] functions. I have seen instances of this kind & others on record in Sydenham & y Older Writers. They resemble Gonorrhoea in y circumstance that y [sooner] later y discharge was on y occourance of violant inflamation. Thrush has been said to be a Cause of dysentary. y dis was once thought to originate exclusively from a species of contagion generated in y system of an individual & by him communicated to another. – But by the most careful observation it will be perceived that such is not y uniform & general character of y dis. By a later writer it has been stated with no little plausibility that Dysentary only where y original fever is Typhus or assumes that character in its progress. Determining from what I have seen I should conclude y doctrin he advanced was perfectly sound & correct. – It has however been suposed that y contagion arises from y alvine evacuations & more plausably 124 that it arose from y stagnated secretion & excretions which have been suffered to remain untill they putrefy. But neither of these supositions is well founded. No evidance has been adduced to prove that y Excretions in Dysenteria are capable of producing y effect alleged. And y same may be said of y collection of filth from y patient which has purified. As I mentioned did y perspiration or Urine under any circumstances give rise to Dysentary. Y cases should be as diversified as y causes from which they originated from. On y contrary when contagion is y cause it is an uniform description of morbid action or at least diversified from peculiarity of constitution or Grage of force with which attacks were made. However it has already been shown that dys. & other contagious dis. may be propagated though y utmost cure be observed in clenliness in all respects. What then are we to conclude except that in y Typhus state of this dis. The extreme vessels take on an 125. action by which contagious matter is eliminated & elaborated out y system. But Dys. may most generally be traced to y causes amoung which are to be mentioned y many sources of autumnal fevers. Now & then it is excited by acrid matter taken in y Stomach & it has been known to occour as in Epidemic depending like other Dis of that class on some peculiar dis temperature of y atmosphere. Nor prehaps does it less frequently arise from y sensible qualities of y air. Cold suddenly attended with heat & moisture succeeding dryness equally produces y complaint As in y other bowel affections whatever suddenly checks perspiration in many instances proves y Cause. This complaint somet. accompanies Catarrh & I have seen it in many instances alternate with Rheumatism. But whatever may be y cause of Dys. it is evidently a febrile affection & directed to y Aliment. Canal. Even as long ago as y time of Sydenham such a 126. view of pathology was taken y opinion is surported by y fact that y dis asumes different shapes being remittant, sometimes continued, which last form may be highly Inflam: or may partake in various degrees of Typhus malignancy. Most generally when it arises from musk effluvia y primary seat of Dys. is always in y Stomach. Here it manifest itself by nausea & Vomiting & from this point it gradually extends downward to y bowels as revealed to us by dissection it appears that y force of y dis expands itself on y large intestines. In this part of y A: Canal we find most marks of preexisting Inflam: & other phenomena of dis. action. Enough has been said to expose my sentiments relative to y nature of Dysentary & if what I have said be correct y indications of cure are suficiently obvious. – But that y treat. may be applicable we must consider it under y various modifications which it occasionally assumes. – As Dys. generally presents itself y Indications 127. are to remove inflamation with y Spasmodic action which attends it over coming of y primal Vic & there by producing natural stools. To restore y Surface of y Body which is hot & dry to its usual healthy condition. – Taught by y example of Sydenham practitioners have generally been in y habit of commencing y treat. by Emetic - Enarmoured as I have thrown myself with this set of Meds. in most of y Bowel affections – I am not an adovocate for this universal employments of Emetics in Dysentary. The case in which they are peculiarly applicable & to which we should limit them use are those in which y stomach is loaded with Bile & other foul accumulations creating nausea & other Gastric uneasiness. It is common to meet with such cases in miasmatic districts associated with y Intim: type of fever. Cosulted end case of Dysentary under ordinary circumstances it would be 128. right to V.S. previous to remedies by thus early drawing Blood you will check y progress of Inflam: & is no less important to open [y war] a new. y susceptibility of y system to y operation of other remedies may be produced. V.S, is y most effectual & as y affections of y alimentary canal are eminently characterised by y want of this susceptibility to y operations of meds. y Lancet in those cases is imperiously demanded. But independent of y reason just stated there is another motive for copious & early V.S. Commenced with this affection of bowels there is commonly a degree of Spasmodic constriction which is productive of acute pain & appears an inseparable barrier in many cases to y evacuation of y bowels. to overcome y constriction in this case V.S. posseses [universal] unrivaled powers & with y removal of y spasm serves also [for] as a remedy for y hot & dry surface which it exchanges for one moist & relaxed. Haveing asserted this much of V.S. 129 we must resort to purgatives to clense y bowels of their vitiated contents. Castor. Oil is y article most commonly rised & answers very well in y forms of dysentary it cannot be denied but that it should be liberally employed my pursuasion is that in this case practitioners give y med. in infinitely to small doses to be of any decided advantage. In y same violant forms of Dys. seveal ℥ Castor Ol. should be given daily. It must be recollected that in Dysentary y ol. runs rapidly through y bowels passing off very little changed & makeing so light an impression as scarcely to remove any portion of Excrement. matter even y Bile. – I have seen it discharged from y bowels in y course of hlf. an hour or an hour after taken. – As regards our own Dys. especially such as occours in Warm weather I cannot help metaling y opinion that mercurial purges are infinitely better adopted to y treat. 130. treat. Do we not find them preferable wherever evacuations are demanded. We give them in Billious fevers & positively we should give them in y case now before us. In my own practice I prescribe Cal. alone or in combination with Rhubarb. & where y med. lingers in y bowels I promote its operation by mild laxitives. I resort to injections after I have thus evacuated y bowels y mercurial meds. are not again demanded. Now y Castor Ol. comes in with good advantage. y Epsom Salts would prehaps form a better substitute for Calomel & its combinations. No practicable point has been more debated than wheather we should continue purging. It appears however at present that y fact is pretty well asertained that we should give purgatives untill y natural forces appear. This I am induced to believe is a rare practice. Every one is conversant with Dysentary I will know that when y foecal 131 are suffered to remain in y Bowels they are irritated & y pain & other unpleasant symp. are considerably aggrevated. Let it however be recollected the discharges which accompany y dis. are mearly y effect of preexisting irritation & to remove them we must correct y preexisting disorder. – Acting on this principle I have been in y habit of resorting to Opii earlier than y general practice of Physicians would seem to warrant. Nevertheless I am perfectly convinced of y prosperity of this course by my large & faithful observation of its effects. Even since age of Sydenham with a very few exceptions which I Shall not at present notice there, has been a very marked aversion to opium. in y treatment of Dysentary even by cullen & those writers of his time y practice was either noticed with great distrust or universally condemned. But all these writers seem to have been influenced more or less by y old notions of y humeral pathology. They confounded causes and 132 & effects. As much are y discharges [in Dis y effect] from y intestines in Dys. y effect or consequence of previous Inflam. of y stom: & bowels. as y matter of Gonorrhoea is Inflam: of y urethra & a flow of tears in Inflam: Eyes when they have been offended with atoms of dust or grs. of Sand. But in resorting in y early stages to Opii I do not hesitate to allow of y necessity of uniting it with OC. Or some other evacuating remedy. My more general object however while endeavoring to remove y contents of y bowels is also to determine to y surface of y body. This last is indicated by y condition might be surported by y most distinguished authorities which we can afford. – But still it must be remembered that previously to any attempt to excite perspiration. – The pulse & other inflame: symptoms must be reduced by direct depletion. When this is not attended to sweating would only accelerate y dis. Less than any other Dis does dysentary admit of a substitute for y Lancet A late practitioner in this city has declared that 133 with y Lancet & Opii he could manage any Dys: I am not prepared to go so far though I am will convinced of y signal benefit of y Lancet in allaying irritation y early stage of it I do believe that y most important effects are gained by it. – It is now more than hlf: a centaury since Dr. d- introduced or proclaimed y superiority of y sweating plan over all others in Dys: His view of y pathology & treat. was soon adopted by several respectable physicians. It partic. Was adopted by Richter a writer of y highest authority that Dys: is a calanhol or Rheumatic affection of y large intestines & that y Billious & other discharges are necessary to y main dis. & mere efforts & not to be regarded much in y treat of y case As deduced from y Hypothesis y practice which he leays down consist y exclusively of measures calculated to excite perspiration. I do not go to y full extent with this author in his speculative order of y dis. or in his practical deduction. 134 This is one out of many instances in which injury has been done by a generalization. what holds in practical cases is made to apply to all cases of a catarrhal Rheumatic affection of y al: canal do now & then occour sweating will somet. suceed without n evacuations. But y instances are very rare & he who enters in y practice of his profession with such a view of pathology of Dys will inevitably be traced along his path of business by y dreadful mortality which he will inflict on his patients. In detailing y cure of Dys. we have reached so far as [Dysentary] Diaphoresis y modus operandi of such [illegible]. I have more than explained. It remains therefore to point out y lust mode of affecting y purpose. My own experiance has led me to prefer at this juncture a combination of Opii Ipecac & Cal. ꝶ Opii grs IV. Cal 16grs. Ipecac 8grs make 8. pills one every 2 or 3 hours. or pulv. Confedidly this is not y most action diaphoretic Med. but it is productive of effects which prehaps at this crisis is still more important than mere diaphoresis. - 135. It composes intestinal irritation relaxes y surface of y body, gently opens y bowels & causes other impressions which though not very intelligent are eminently salutary in their consequences. Every one who has noticed carefully y operation of Cal: in small doses in Bowel affections must have witnessed y beneficial effects of Vomiting from y article. It probably does good not less by y change it produces in y Intestinal & Hepatical secretion than by its directly purgative effect. As on infinitely more certain & powerful Diaphoretic y Dovers powders will seldom fail when copious perspiration is demanded. But it should never be resorted to in preferance to y preceeding article. – When it is necessary to evacuate y bowels no article in y Mat. Med. has been more extolled in Dysentary than Ipecac. Given either by itself or in various states of Combination. By some practitioners it has been more partic adopted to that state of Dis with which such 136. copious discharges of Blood from y Rectum as to amount almost to an Hemorrage. This opinion determining from y general properties of y article would appear perfectly correct. – But in every form & variety of Dysentary it is highly beneficial & well suited though I have prescribed it with y best advantage y pain thus been most violant y desire to go to stool very frequent & inefectual. – y great power of Ipecac over y dis does not rest on my own authority alone for more than hlf. a centaury ago it has been employed by practitioner in every section of y Globe & has brought from then very general if not unanimous approbation as to y precise mode of operating in this case all writers are not so well agreed. I do not agree with Sir Geo. Barker & Cullen who says its efficacy depends as upon its purgative operation for y med. produces an oposite effect. Nor do I believe it owes all its powers to y perspiration it produces we have numerous Diaphoretics not less active than 137. Ipecac but very inferior to it in y treat of Dysent: Much however of its good affects may be ascribed to its operation on y surface of y Body & such an explanation comports best with y properties of y article & its known effects on y system. Two other modes of administering Ipecac in Dys. has lately been proposed by Clark who wrote on y nature & cure of y Dis. It is recommended in y shape of injection. ʒiii of y bruised Root boiled in a qt. of Water down to a pt. & this quantity to be given 3 times pr. dic. by this he observes y bowels are thourougherly evacuated & y tormend & tenesmus & other painful affections are completely & perfectly retieved. Of this mode of administering Ipecac I know nothing from experiance though I have always been taught to believe that a decoct. of y article under consideration is whole by inert all y writers of mat. Med. agree in this a/c of y Medicine. Much more confidance should in my opinion be reposed in y 2nd. mode of prescribing 138. to which I allude. Defeated in this attempts to cure Dysentery in y ordinary manner Mr. Playfair Surgeon in y British Establishment in India has according to his own statement used Ipecac with great advantage in doses of ʒss to ʒi combined with 30. 60 & even 80 gtt Laudanum Confining y patient for hours in a horizontal position, If y first dose was rejected a 2nd. was generally retained. This practice reported to be efficatious was confessed by y author to be adopted only on y onset of y Dis. for if y dis is so far advanced y stomach becomes so irritable as to reject y Med: at once. By Mr. English surgeon to y British troops in India y mode above described was sucessfully followed In my own practice I have never employed it but I entertain a very favorable opinon. It seems to me well calculated to evacuate y alim: Canal in y commencement & y Laud. Or Opii entering into y prescription to allay intestinal irritation which is undoubtedly y proximate Cause of Dysentary. Much also 139. has been said of Antimonials under y same circumstances they have been fairly tried by me & though in some cases & though in some cases they proved very sucessful I think they are not at all in point of efficacy to be compared to Ipecac. But many of y most respectable writers report very differently on y comparative[ly] value of there two remedies. It is exprestly stated by Sir. Geo. Bark. that y result of an extensive experiance with them both gives a decided preferance to y Antim: preparations. To y same point goes also y evidance of J. Pringle not to mention writers of no less authority whose evidance is so strongly relieved. Y Glass of Antimony was y preparation used by Pringle in y cure of Dysentary. Casus may occour in which on article may be better than another. It is thought right that each of these should be retained but it is by no means easy to day at what or in what they are to be employed. I am unable to discriminated & on y whole 140. I expect that when you encounter y Dysentary you will find y Ipecac so well to your views that you will not feel inclined to exchange it for y preparations of antim: As a measure or needful auxiliary to sweating great advantage may sometimes be derived in this stage from y application of wampth to y extream surface. All of you are acquainted with y benefit derived from fomentations applied to y stomach & bowels. They are particularly adapted or calculated to allay spasms & uneasiness which exist is on taking a profuse diaphoresis. It is unecessary for me to recapitulate y method of making such fomentations Not a little has been said of Linaments applied to y abdomen at this stage of Dys. These for y most part consists of into which Laudnum enters largely. But lately it has been alledged that much more advantage results from [deciding?] stimulating Lotions & among one of there is Spts. Turpentine. This I have no doubt would produce 141. very good effect. In Dysentary where there is much distention & pain in y Abdomen. As might be expected y W. Bath in Dys. as well as in other Bowel complaints is highly servisable. It acts precisely on y principle of fomentation though much more effectual. It is not a remedy adopted to general practice & may in a great majority of cases be dispensed with. It is however one of y recourses of our art which practitioners ought to keep in mind but which need only resort to in cases of Emergency. As regards Children y objections do not apply to these. It is easy to administer y remedy & we shall also perceive that in children it is infinitely more efficatious of late however a remedy has been proposed [preser] which goes to prescribe both y Warm Bath & Fomentations I allude to y bandage a flannel Roler applied around y trunk. 4 or 5 [gas?] of Flannel are to be wraped around y body from y hips to y arms. – As relates to y acute stage of 142 Dysentary. I have experiance whatever with y bandage. But long before I had seen y work in y Practice recommended I was in y habit of using it in Diarrhoea in y declining or advanced stage y Dysentary & more particularly in Cholera Inf antum. The fact is perfectly well known to a great number of my patients & also a great member of my Med. friends in this city. To y employment of this remedy I was led by analogical deduction. but more of this when I treat of Diarrhoea. You should never use y flannel Roler in y early stage to y exclusive of other remedies As yet I have said nothing of y use of Blisters they are however an important remedy & in many cases cannot be dispensed with they may be placed on y abdomen or on either extremities But here as in other cases it is most useful when applied nearest seat of y dis. We prefer y extremities sometimes on accout of y inconveniance experianced by y patient on going to stool with his abdomen 143 raw. & Inflamed by y vesicating application. But judging from what I have observed myself I answer that y degree of pain has been greatly aggravated Besides considerations of this kind should never deter us from y use of Blisters to y abdomen when y symptoms indicate y necessity of y remedy. – My own practice in this respect is previously to Evacuate y Bowels & to order for 2 copious V.S. & if I perceive no great salutary suppression of y dis. I then cover y whole surface of y abdomen with Blisters. – As in other case of Inflamation especially intestinal you will here also have reason to be delighted with y effect of this application. I enjoin it on you in y treat of Dysentary & especially when it presents a formidable aspect to keep your eye steadily fixed on y blister & never permit any false tenderness or delicacy towards your patients induce you to overlook so valuable a remedy. Under such circumstances you will have dificulty to encounter 144. generally against y remedy & unless you interpose y whole weight of your authority which your profession invests you. It will very often be applied too late or totally neglected. – I have now completed y general treat of Dysentary but one or 2 local affections attend y complaint which are so troublesome as to demand our particular attention. I allude more particularly to Tenesmus. & Tormina these are occasionally met with at every stage of y complaint. Many remedies have been suggested for y relief of these in y combination of which Opii enters largely. – As regards Tormina & especially when connected with foul & acrid accumulations in y bowels great advantage may be derived from y following ꝶ Ol: Recini ℥i G:Arabic ʒii Sachar. Alba ʒi Tinct. Opii 50 or 60 gtt. This is called y oleaginous mixture in this city a small tablespoon every 2 or 3 [or 4] hours. It remans only stomach infinitely better than y Ol alone & after a few doses have been taken it very much relieves 145. relieves y Symptoms. But even better than this is y mix there I mentioned to you while speaking of Cholera Infantum in [many] some of these cases much advantage is derived from y use of Julep y method of prescribing it I have already mentioned. Not of less utility under such circumstances is a combination of Ipecac & Opii in y proportion Ipecac igr to Opii gr. ¼. But in relation both to Tormina & Tenesmus Opii directly applied to y Rectum is often eminently beneficial. It may be used in y shape of an anodyne where there us much irritability & excoritation of y Rectum a pill of 3 or 4 grs may be introduced & all y beneficial results are decided which would or could be expected from y same article taken into y Stomach. It has y advantage also that where y patent is prejudiced so as to forbid injections it may be introduced without his knowledge. But of all y means I have ever employed with a view to 146. y relief if Tormina & Tenesmus Melted Butter free from rancidity & deprived of its salt is y best from ½ a pt to 1 pt. melted should be thrown up every hour or two y relief occasioned by it is inconceivably great. It is a fact worthy of notice that animal ols. are infinitely less irritable [to] & offensive to a delicate surface than those that are derived from. Veditables, Thus Lard & Butter may be applied with southing effect to an irritable surface which would be aggrevated with olive oil. Nothing as yet has been said of Mercury given with a view to salivate. By consulting writers more partic: East & W. Indies. it will be found that in y management of Dys. Murcury thus employed is almost exclusively confided in not only is it given in y largest possible doses internally but it is also externally employed in y shape of friction. y object of thus exhaling it profusely is to induce Salivate on as soon as possible, there can be little doubt of y superior 147. efficacy of this plan in y treat of Dysentary occouring in Tropical Climates. y Dis in y C & W. Indies is almost always associated with with a greater or less degree of Hepatic Derangement. But in our country it is Inflamatory nature & so rapid in its progress that long before y system could be brought under its impression Gangrene would take place. But in protracted & lingering cases of [Du?] especially where there is any tendancy to Typhus condition there cannot be y slightest doubt as to y usefulness of Mercury. – When however I can speak of this form of Meds. more partic as a [substitute?] for mercury y Nitric Acid has also been recommended. To conclude y consideration of Inflam: Sys. it only remains for me to indicate y diet proper to be observed in this case. Y Dis being an active Inflamation of y alimentary canal it is obvious that we should [not] use articles y least irritating & offensive to y stomach & then 148. in order that y power of Digestion may be exercised as little as possible it should be of y nature. Demulcent Drinks have been used by y common consent of practitioners & by y prejudices of y vulgar to y case before us y neatest & most agreeable of them is Barley Water or Rice Water. Mucillage G. Arabic. Flax seed Tea. Mucillage Slipry Elm Loaf Sugar Water. preparations arrow Root Sago & Tapioca etc. While they constitute y poper nourishment of y patient they are thought not to be without utility in the dis. itself. – Many practitioners prescribe them with a view of diluting y acrimonious fluid & sheathing y surface of y Stomach & Intestines against their irritating influence; but such are derived from old antiquated pathology. Y Idea of sheathing a liveing acting surface by mechanically spreading over it mucilaginous fluids is altogether abandoned. Diluant Drinks are beneficial in Dys. as articles of nourishment & when we grant this much we have 149. we have decided all that our enlightend understanding & sound med. reasoning & Experiance – will admit Typhus Dysentary. With these remarks we conclude y treatment of y common Inflammatory Dys. but in Crowded places or Ships Camps Hospitals & Jails a peculiar ous temperature of y atmosphere prevails. Dysentary in its & through all its subsequent stages is decidedly of a Typhus Character. It appears obvious that in all such circumstances y Dis requires a different treat: from that already detailed. It is right to pursue of same mode of treat. as in other low states of dis. adopting however more partic: to y symp: as in y genuine or real Typhus Fever y early use of Emetics is very beneficial & after moderate evacuation of y bowels y Cordial & Stimulating remedis as Opii Vol. Alkali & Wine Whey with y liberal application of Blisters constitute y 150 treat: most generally resorted to. But as I before mentioned whenever Dysentary anounces in its Origine or acquires with progress a Typhus condition it is safest at once to resort to mercury with a view to salivation. As yet I am of haveing y system completely under y impression with a spedy mitigation of all y symp: & an ultimate recovoury, They causes why we should not resort to mercury has already been stated. But y objection which I stated to preclude y med. in y active inflam: species of Dysentary does not apply to y low & lingering form of y dis. & as regards this cause a salivation may in many instances be effected. The Mercury should be employed internally externally & be supported by y active & diffusible Stim: In y advanced stage of y Dis y Nit: Acid posesses valuable properties. It is not at all suitable in y commencement of y dis but after y dis has advanced to its final Stage. Then it is that y [mercury] acid is of signal advantage. But I give y preferance to 151. Mercury. It is known to most of you that Dys. sometimes takes y type of Intim: fever. Cleghorn describes it of very common occourance in y Isle of Minorca & I have seen y same form of y Dis amoung y paupers in y alms House especially among those from Miasmatic Countries where y inhabitants are subject to Intim: fever now & then y case presents such a complication of symp: as to occasion no little difficulty in management. By Morton y contemporary & rival of Sydenham who first pointed out this form of [fever] Dys. it was recom: that while we pursue y usual practice we should employ Peruvian Bark in y A pyrexia. Exactly y same course was followed by Cleghorn & several others more acute practitioners notwithstanding however all this weight of authority in favour of y practice. I am strongly inclined to think in this case it is not correct or faiseble. Of y cases of Dys. associated with intim: fever. I have 152 some opportunity for y exhibition of Bark & if it had been given it would undoubtedly have proved mischievous. No article of y Mat. Med. proves more offensive to irritable & inflamed bowels than this Med. & so much so is y case that even when y Al. Canal is perfectly sound & healthy it very often so disagrees with y patient as to be precluded. 153 154 155 156. Pathology. Causes seats & signs of Dis Dis. although an evil leads to many advantages 1st. It induces us to study Anatomy & Physiology 2nd. To conciliate us to death. Pain is useful to point out y disd. part. absance of it is a bad sign in a disd Rib, frozen Bone or carious limb. – y Causes of disease are y Remote, Exciting & Proximate likewise Predisposing or Remote Proximate Predisposing & Exciting. – y Remote are Contagion & Miasmata. y Predisposing is Debility this is either natural or acquired. If natural it depends on what was called Temperament. – Predisposition there is 1st. Arterial. disposing to Hemorrage. Pulmonary Consumption 2nd. Phrenic. disposing to Delirium & Mania 3rd. Cephalic. disposing to Headache. Apoplexy Epilepsy &c 4th. Alimentary. disposing to Dysentary. Colic Diarrhoea. 157 Pathology. 5th. Cutaneous. Disposing to Small Pox. 6th. Muscular. ” to Tetanus as great irritability but nosens ability 7th. Nervous. – disposing to Hyphochondrase. 8th. Lymphatic. ” to Dropsy. 9th. Hepatic. ” to Diabetes. Artinal Predisposition prevails in spring. Alamentary in Summer & Fall. Cutaneous in Winter. – A dis always attacks y weakest part of y system a part however may become callous to a dis by haveing its excitability wasted so that stimuli cannot throw it into Morbid action. Dis in thus state is called Disorder y effects are viz 1st. Torpor. absance of Irritability. 2nd. Stupor. absance of sensibility. 3rd. absance of both instances of Disorder as Chronic Ulcers. Calculous Obstructions. Schirrus these induce death & hence become subjects of Medium Acquired Debility is of two kinds from 158 Actions or Obstructions, when it proceeds from this last if an irritant be applied – it first elevates y excitement then depresses it. In y former case if y stimulus remains depressed it is induced y debility of both causes & is y same except in y last y excitability is accumulated & readily thrown into morbid action. In Debility from action when y stimulus which produces it is withdrawn y excitability is accumulated, hence after great fatigue we should not sit down but gradually keep moveing to carry off y redundant excitability – hence y they lead horses who race round y course to prevent stifness – Rheumatism abstracted from important parts in y bowels Signs of Dis by y Pulse. These are 1st Frequency & Quickness. These are not necessarily connected y pulse may be very Frequent & not very Quick or vice versa as in Yellow Fever & y last stage of other fevers. – By Frequency is ment [y number] y number of strokes performed in a given time. – 159 Pathology. Signs of Dis by A/ Pulse Quickness is y time in which y stroke is performed. – y pulse [differs] varies in fevers & other acute dis. in y first stage from 60 to 88 or 180 & sometimes to 200. In a minute it falls in some cases to 40-30-20 & sometimes to 9. – y Frequency & Quickness of y pulse seems to depend on a morbid irritability in y arterial system. y Morbid slowness depends on 3 causes 1st. Pressure on y Brain. – 2nd. Spasm of y Heart 3rd. defect of irritability in y arteries y pulse varies from health in regularity & force this is of much more importance than its duration in frequency & fulness. It sometimes Intermitts. Somet: imparts a sensation to y fingers resembling a shattered Quite. We are now to [examine] consider y different states of y pulse in Fever. – by Depressed Pulse. This state of pulse is caused by stimuli acting so violantly as to depress y system be low y point of reaction or by pressure on some great vessel. It is frequently 160 Signs of Dis by y Pulse. preternaturally quick [crossed out] often slow & sometimes scarcely perceptable often descends a low as 40. 30. 20 & is sometimes so depressed that it is almost imperceptate. It is raised by V.S. It is sometimes preternatural quick slow & attended with intermission & sometimes it is natural. It occours in Plague Y: Fever Malignant & Small Pox & in Pleuracy. It is either general or partial [y latter] occouring in y extremities y former & y latter [occouring in y extremities] occasioned by stimuli depressing y strength below y healthy state. It resembles a low or Typhus pulse & may be distinguished from it 1st. By occouring in y commencement of acute diseases & in y paroxisms of such dis. as are periodical 2nd.. by imparting a sense of tention along y fingers when long & attentively felt. 3rd.. By occouring in morbid affections of y Brain. Heart. Stomach & Bowels more frequently than dis of other parts of y Body. & in Apoplexy. 4th. By occouring rising after V.S. or purging takeing off y suffocated excitement 161 Signs of Dis by y Pulse 5th. By its being attended with preternatural slowness & intermission. Thus y pulse may be compared to a tree bent by y Wind & arising to its proper state after y storm has blown over Whilst y Typhus resembling a Free shattered by lightning which cannot be raised by y hand of art 2nd y Locked Pulse [or Sulkey] This is small quick time & distinct pulse which is imparts to y fingers a sensation similar to that produced by fretting a piece of Cat. gut. tense from whence I have named it. Cat gut Pulse occouring in Malignant fever. – 3rd. y Cynothus Fortis. This is y reverse of y 2 former a full round vigorous frequent & quick pulse without hardness which occours in y highest grade of Bilious Fever in affections of Brain in Pneumonia Notha & congestion of Brain. Exercise produces a pulse somewhat like this. – 162 Signs of Dis by y Pulse 4th. y Synocha or Inflam: Pulse. – Being full, quick, frequent & tense & not round & is known by heat & thirst. This pulse exists sometimes in y Plague. Y. Fever & in common Inflam: but more frequent in Pneumonic affections in Rheumatism & Arthrisis. – 5th.. y Synoch [ous] Pulse A quick, frequent & immoderately tense but a small pulse imparting a sensation to y finger similar to quill & occours in Chronic Rheumatism. Gout & Intim. Fever & in 2nd. Stage of other fevers It is y Synocha on a concracted scale from which it may be distinguished by y column of y Artery. – 6th. y Synochous Mitis Pulse full round & soft. 7th. Synochoid Pulse. This is alternately soft & & may be placed between Synocha & Synochous it occours in y passage of fevers from y low to y Inflam. 163. Signs of Dis by Pulse. State & Visa Versa according to Dr. Butler it imparts a sensation to y fingers like a quill that has been trodden under foot 8th. Typhoid Pulse. – Small frequent & less tense pulse than full it is a compound of synocha & y low chronic states of fever & occours in Hectic & Purperal fever, & in Scatitana. – 9th y Typhus Pulse. This is a weak, small. frequent but full or tense pulse. It differs from y depressed pulse 1st. In tention. 2nd. y arteries in y depressed state still retain their irritability & y pulse rises after V.S. It occours on y low chronic state of fever or in y first stage of some malignant fevers. Cordials are indicated in y close of Inflam: [fever] Diseases when depleting remedies have been used in y 1st stage. It is here V.S. is forbidden & stimuli to be used. 164 Signs of Dis by Pulse. 10th y Hectic Pulse Is quick. frequent & often full & very soft, it is occasionally Synochoid, Typhoid & Typhus & occours in Chronic Fevers. Pthisis Pulmonalis, also Chronic Gout & from Lues Veneri & Scrophula. – 11th. y Hobbling Pulse Is unequal fluctuating, tense quick & very frequent. It may be known from y irregularity of its pulsations. It may be divided thus 1.2.3 [quick] slow [slow] strokes sucseeding & quick one. 2 or 3 [slow] quick stroke sucseeding a slow one. – 12th. y Serrated Pulse Strikes y fingers like a saw one part elevated above y other. – 13th. y Vermicular Pulse. – Small frequent & resembling y motion of a Worm 14th. y Creeping Pulse Weak & small it occours in y last stage of Dis. 15th. y Apparantly Natural Pulse. – A pulse perfectly natural in Violant Fevers 165. Signs of Dis by y Pulse. ~ is one of y worst symptom. It occours in y most Malignant in Y. Fever & can only be distinguished from y Pulse of Health but by y other symp. of Dis. Great danger is to be apprehended by it – Scarsely any of these are always present they are therefore combined 1st. in double proportion as Full & Weak, Full & Frequent Depressed & Weak. Slow & Intermitt: 2nd. In a three fold state as Full Strong Quick & frequent at y same times 16th, a full, bounding, slow, & moderately tense pulse as in Palsy Apoplexy or Dropsy it is especially full & slow in y affected side as in Hemiplegia. Dr. Rush examined y pulse of a parylitic patient whose artery beat on y affected side 50 whil on y other it beat from 80. to 90. – 17th – A weak & low pulse without irregularity occours in debility without fear or is [distinguished?] from y weak & low pulse of malignant fevers 166. by its occouring in y last Stage of Dis y usual pulse of y low Hypochondria state of y system 18th.. There is sometimes a total Absance of. Pulse in dis which somet. occour in violant affections of y Stomach & bowels. It lasts sometimes for hours. Dr. Rush kew a lady to be without pulse 36 hours in consequence of eating some Oysters she has since perfectly recovoured. – 19th. Gaseous State of y Pulse soft full & round 20th. Aneurismatic Pulse is full & tense & imparts to y fingers a disagreable jarring sensation which when once felt can never be forgotten It occours only in cases of aneurisms. – The pulse is much influanced by y strength of y animal in a Pigeon 100 Ox 30 to 38. – 167. 1 Intermittant Fever. Wine. – John Hunter’s remarks on use Wine in Remitt: and Intimitt: as they occoured in Jamaca. With regard to y quantity to be used it is dificult to give precise directions I have generally found upon careful examination that y quantity which has the best effects is less than has generally been given. I have rarely given more than a Pint in 24 hours a larger quantity did more hurt than good y strength quantity & quality of Cordials must bear direct proportion to y strength of y patient. Opium The above applies to opii in y same States of y system I think that O. in the last stage combined with Ipecac or antimony will be more safely given than by itself where there is tendancy to the continued form. – In those cases of Intim: in which the cold stage was preceeded and accompanied with a violant cough I have used O: with y best success Case W.B. a Man of 50 living in Hampden plains had I. of this Kind. The cough was very frequent an Iritating particularly so previous & during y cold stage He tried y Bark & most of y Veg & Min tonicts and among other things arsenic. also Depletion. V.S. Emet: Cathartic Intimitt Fever Epispast: His cough & fever were finally removed by a pill composed of Opii gri Calomel gr.ss repeated every 8 hours. In my opinion this was a case of I: from irritation which prehaps may have depended upon Visceral obstruction [see page 7.5. for more cases]. – Intimittants threatning to run into Typhus. Opii should be combined with Bark, Serpentarid. Vol. Alcali & Camphor. In such cases a torpid state of y bowels should be obviated. In cases of this Kind it will be very difficult to restore y system to healthy action when y Liver Stomach & Intestines do not perform their function These are to be excited to action by gentle Laxatives such as soap. Rheii. Soluble Tartar & by external irritation to y Bowels. – If these parts perform their functions they will have great influance by association of action to bring the other parts of the system to healthy action. In almost all cases of Intim: it will be a safe and efficatious practice to give opii in y very commencement or at y time when y cold stage is expected O: may be given in pills or Laudnum combined with aromatic Teas and Dilunts & other means of producing perspiration the 2 Intimitt Fever temperature & y action of y Body should be equalized. – As a general Rule it will be necessary all cases of Intim to deplete y system before giving Stimulent Tonics. An Emet: Cath: & sometimes V.S. will be necessary. Exceptions to this rule are rare. – In all cases you must be governed by y [Cases] state of y system & y laws of yt. part of the system which is the principle seat of y dis: or the point to which it determins Antimony Ipecac Neutral Salts. Em: Tart. Camph: & Ammonia qualify y action of O: & operate by determining its action to y skin. If O. excites uniform perspiration there is no danger of congestion or derangement of y functions When it produces partial perspiration of y Head & Breast it only coincides with & aggrevates the morbid action of y dis: Dovers Powders are a very safe & useful composition of Opii ꝶ Ipecac & Opii ā ʒi Sulphate Potash ℥i Dose fm. 5 to 15 grs. In cases when diuretic effects are wished from the powder. Nitre may be substituted in y place of Vit: Tartar. – In my practice I have usually made y powder of Em: Tartar instead of Vit: Tartar & added ʒii Camphor with y Intimitt: Fever alteration thus ꝶ Ives Dovers Powders Ipecac & Opii - ʒi Camphor ʒii Em. Tartar ℥i. Acids combined with Stimulating Diaphoretics have been very useful in ourt fevers during y present diathesis which prevailed since y year 1805 with occasional variations. – Hyoceamus Niger. Dr. Smith of So. Carolina used y Ext with sucess he gave at y same time Sul. Zinc. – Atropa Belladona. In obstinate Intim: Bitter Almons. Their efficacy was established Barron Stork who used them very largely & sucessfully in this dis The Laurus no doubt has many Med: Virtues which doubtless will be brought by future experiments y Narcotic principle is intimately connected with Prusic acid. – Amica Montana. recommended as a substitute for Bark Spigelia Marylandica in Tinct: has been used. – Iron. a good auxiliary to y treat: in feble & lax habits yet it ought to be used with great caution in cases threatening congestion Liver & Spleen 3 Intimitt: Fever Copper in Intim: & Remit: but has now given place to Tonic Solution. Zinc in ordinary Intim. without cough or any peculiar irritation in y system or chronic Vis: Obstruction. I give y White Vitriol & Myrrh āā gri in a pill. Giving fm 1 to 6 pills in a day during y Intermission previous to giving y pills y Stom: & Bowels should be evacuated. It is y remedy on which I most depend in I: of an ordinary type. It very rarely offends y stomach. I have given as much as 4 grs W. Vitriol in pills at a dose without producing nausea It excites appetite, promotes digestion & produces vigorous action of y system generally. No debility follows y use of this remedy though it has been continued for Mos: [see page 236 Vol 1 for case West part York State] Arsenic may produce the same effect as a ligature on y leg & opposite arm at y commencement of y dis. y A: may determine y action to y minute vessels & prevent y engorgement of y Heart & Large vessels which takes place in y cold stage. This is infered fm: y fact that Arsenic produces Œdema. When it produces sensible  Intimitt Fevers though not violant effects they are analogous to y combined action of Tart: Antimony & Calomel. – In Intermitts. it is safe & efficatious remedy. I have not in my practice seen any ill consequences follow y use of Arsenite of Potash. In its effects it is not inferior to Bark. It is [cross out] adapted to y same cases which indicate Bark & indeed will often cure cases in which y Bark has been thorougherly tried & failed It is more particularly adapted than y Bark to those cases in which there us some excess of action. – Its action in such cases may be like that of Mercury reducing y system to that state in which Bark is adapted. I should not be administered in those cases which have a tendancy to Typhus & require Stimulating Tonics. It is not so well adapted to In: of long standing. Here Nutral Salts with Bark & somet: Opii & Calomel must be given. Camphor combined with Bark. Cuprum has frequently ben given to children in Intim: & Remitt: but has given place to Tonic Solution 4 Intimitt: Fever Bark. Tho a valuable remedy in this Dis still it has no specific powers ie it will not cure in every case. has an action peculiar to itself. In ordinary cases especially in cold climates y administration of B should be preceeded by evacuation of y bowels or. Stom or both as y symp. may require & frequently V.S. is necessary previous to y B. best mode to give is in substance if stom. will not bear it give in Decoct Tinct. Cold Infus. Dose it may be given 10 grs to ʒi repeated every 2 hours in y Intermission. Not to be given in our climate in y in y Hot stage. /given in this stage in hot Climes) It is y practice to give y B imediately after evacuating first passages. Dropsy. Jaundice & other Dis have followed y use of B. in I. In such cases there probably was not evacuations enough made. In Penn. hospital I saw. an Anasarca fm. Injudicious use of B cured by V.S. In I. with+ Visceral Congestion y B must be combined with Rheii or its action qualifyed by frequent small doses of Neutral Salts. as Sol. Tartar &c +(See Linac on Fever) [Remittant Fever]. – Intimittant [Porter. – is more particularly useful which occour in Intu August & September when y Stomach is very irritable with general prostration of strength. It is a very grateful stimulant to y stomach on account of y fixed air which it contains, corrects morbid secretions of y Stom & is very nutritions to convalesants. – It is admisable in all fevers affecting y Stom: & Bowels after y first Stage & relieves]. – Y Nutral Salts even if they do not operate as bath yet they prevent y system fm rising to y Inflam. point Those cases in which there was very little perspiration y bath has not suceeded well unless given with Nutral Salts or Rheii. It is a common practice to in case y dose just before y expected paroxism It certainly at this time has more effect yet it is without danger. A Tertian has somet. put on y form of Apoplexy (not seen much of this dis.) I have not suceeded well in treating Intim With Cough with y B. but usually with Calomel. Opii & somet: Epispas are necessary. Y several preparations of B may be 5 used together. Angustura Bark has been recom. in powder in Intermission dose 20 grs every 3 or 4 hours I have used as above directed in this dis somet. with complete sucess but it is rare that y Stom: will bear such large doses. Cascarilla useful in In. which terminate in Typhus. – Snake Root partic. useful in those In. whose parox. terminates with little or no perspiration & y skin hot & dry in y Intermission. combined with Bark. S.R. is a very valuable addition to y B. in treat. of In. Y. Comp. Tinct Bark is taken in ℥ss does in y cure of In. Some phys. Give an Emetic of Tart. Antim in a strong decoct. of Serpent. & give a cath of Nutral Salt in y same decoct. in this mode they operate very kindly & leave y Stom. & Bowl in a better State. – Cornus Florida. highly recom. has cured where bark has failed dose powder ʒss to ʒi Intermittant Fever sucessfully used in Middle & Western states Y most useful preparation is y Extract dos 5 to 10 grs. Astringents are servisable when combined with aromatics. Those Veg. substances are best adapted to I. which contain y Bitter. Astring & Aromatic principle. Ast. are more partic indicat. in Ints in constitutions of lax fiber (leucophley. temp.) Galls. sucseed best comb. with Aromat. & Bitters sometimes G. have cured I. which have not yialded to Bark. I presume G. succeeded best where then general relaxation in y system. Int. in there different stages & different forms often require as different as Synocha & Typhus. - 6 Typhus. Alcohol. is used diluted & is a good remedy to increase y arterial action. It may be given fm: ℥ss to ℥i every hour. Old Spirits sets kindly on y stomach in this dis. when Wine & Porter will not. – Wine is useful after y evacuations of first passages to keep up an uniform excitement Some Physians give a bottle each day through y whole course of y dis. This mode of Practice succeeds very well in those cases where there is no considerable local [derangement] determination & y secretions & excretions are not much interrupted. – In 1805 & 6 wine was very much used in a fever which prevailed in this Town. I suceded best at y time of a crisis or when some symptoms indicated a change in y [symptoms] system or when y dis had spent itself. In these cases I gave fm 2 to 3 pts of the best white wine in 24 hours & thus producing a favourable crisis. But if y strength or excitability had been worn out by this article would not produce that effect. With Wine it is common to combine Bark & Opii. – Aqua Ammonia is a good addition to y Wine its use in T:F. is indicated by y same symptoms & has y advantage of correcting y stomach & preventing y Wine fm: becoming acid. Porter when y patient is Tympanitic I think it has increased that unpleasant symptom. – Ether. Diluted given in T.F. to keep up y action of y system & to produce perspiration. In Flatulance & in Tympanitic state of y Bowels in T. In y last stages of T. E is given mixd with wine or diluted alkahol & it adds much to y virtues of these articles. E. qualifies Wine & Alkahol as aromatics qualified Tonics. It stimulates y skin by external application. If confined to y part it increases heat if it evaporates diminishes heat Camphor – is advantageously combined with Lime juice Vinegar and other acids in effervessing mixtures It has been a very useful article in y treatment of y dis: which have occoured since y year 1805 This Grade of dis. are very much like those described by Sir John Pringle. The Dis has been more or less Typhus in its progress in some cases Typhoid in 7 others Synocus in its commencement partaking more or less of y Tertian Type with a determination to y viscera of y abdomen like an intermittant affecting y secretions sometimes causing profuse secretions at others interupting all secretions accompanied very generally by Tympanitic state of y bowels attended with local critical determinations with Inflamation & supuration of y part at y same time y state of y system Typhus When this local determination fixed on y brain Heart & Lungs it invariably produces death unless y action was overcome or determined to some other part less essential to life. Prehaps this Fever might be called y Intestinal State of Fever In this fever Camph: has been of great servise combined with opii in y form of Dovers Powders or Diaphoretic: It appears to equalize y action of y opii by determining to y surface & preventing that dryness of y tongue which sometimes follows y use of Opii. It has been useful in cases of this Fever attended with Tympanites both by Injection and Camphorated Liniment applied to y Bowels Typhus Fever. Opium. should not be administered in Typhoid Fevers with Visceral congestion or obstruction or when there is a determination to y head & local supuration threatened although y diathesis of y system is Typhus Such a fatal determination is produced by a dry skin & tongue deafness & disterbance in y intellectual faculties y Rules which Sir John Pringle gave concerning y use of Wine in Goal Fevers & y direction of Lenac on y use of Bark in Intim: & Remitt: will apply to y use of Opii in such states of y system. – Castor. – In T.F of the mild kind combined with valerian Snake Root or Orange Peel with advantage Valerian. – is used. – Phosphorised Ether viz ꝶ 3grs Phosporus divided into small pieces & put into ℥i Sulph. Ether in a week y med: will be fit to use. If any [Ether] Phos: remains at y button y Ether should be carfully strained off dose 3 to 12 gtts in any convenient vehicle has been given in T F & in other forms of Fever in which y dis action has worn out the 8 excitability of y system in such cases it has sometimes roused the patient in y very article of Death & been the means of saving them – In Typhus in y low state where there was no particular determination it has been given & no injury followed. – Phosphoric Acid has been given for y same indicatins as J: Ether and when it has been used in y last stage if T: it has often Excited a desire for Animal food. – Cantharides in T accompanied with very frequent pulse it diminishes its frequency. When y system becomes over charged with cantharides y stools became mucous & Bloody with Tenesmus & extreme pain y urine suppressed or in Small quantities and Bloody. When large doses have excited Inflam: y symp: are similar to those of Inflam. Dysentary. – (see page 212 Ives Lectures Vol 1) Chapman continued at back (reverse direction) Extracts from a Treatise on Cholera Asphyxia or Epidemic Cholera as it appeared in Asia and more recently in Europe. with practical remarks on y dis. in Europe an appendix of cases & y reports and regulations of the Boards of Health of London and Edinburgh by George Hamilton Bell Fellow of the Royal College of Surgeons Edin: late residency sugeon Janjore and joint medical secretary to the Edinburgh Board of Health. ~ Second Edition 1832 9 Cholera Asphyxia. In describing this dis. it may be useful to attend to what may be cal’d 4 Stages. 1st. The invasion of Cholera is so insidious that the individual attacked may be quite unconcious of the presence of the 1s Stage of it. Very often it is only to be detected by those well acquainted with y dis. Not only in this stage but throughout the whole course of the dis the appearance of the countenance is one of y most highly characteristic symptoms. An intimate find may observe the the person has an expression of anxiety. That his complexion is unnaturally earthy & his eyes seem sunk in his head. In reply to inquiries he will deny that he is unwell he may say he is a little deaf & if minutely questioned may admit that he has an indescribable sensation of being out of Order that he has oppression at y chest & is unaccountably depressed & listless. he may have no nausea but has Tormina of the bowels & prehaps an uncomfortable sensation of heat at the pit of y Stomach His pulse is quick & weak (I have seen one case in which it had the febrile throb.) the hands & feet feel cold. the nails are blue & he has had one or more unnatural discharges. The first of these is generally characteristic. there is a sudden call, & the whole intestines seem to be at once emptied followed by a feeling of weakness 2d Stage Cholera is more easily recognized: The pathognomic character of the countenance to those who have seen the dis is no longer doubtful. The eyes are sunk in the head lips are blue, there is a ghastly look about the mouth & the whole features are shrunk. The patient does not now deny being unwell he acknowledges haveing passed some [pecution?] stools & probably has had vomiting these have been followed by great prostration of strength 10 there is tinnitus aurium often slight deafness & Vertigo. The pulse is more decidedly affected it is weak & thready: Skin is cold there is much thirst & a burning pain at the pit of the stomach but y tongue is not dry it is moist, white & cold. The fluid passed from the stomach & bowels is like water in which grain has been boiled with pee as more or less numerous of opaque white or yellowish coagulated matter floating in it. The manner in which the discharge takes place is characteristic. The desire is sudden unaccompanied by griping or nausea & y the stomach & bowels are emptied at once & with some violence: the gastric & intestinal evacuations are nearly similar. In their appearance & nature 3 Stage In this stage the sinking of the countenance is still the most prominently characteristic symptom. The eyes Surrounded by a dark circle are completely sunk in their sockets. the whole countenance is collapsed y skin is livid & the expression is so altered that the patients most intimate friends cannot recognize him. The surface is now generally covered with cold sweat y nails are pearly blue & y skin of y hands & feet are corrugated as if they had been long stupid in water the sensibility of the whole surface is deficient but it is by no means uncommon for patients to complain of a burning heat in there cold skin. Vesicatories do not act even boiling water does not raise a blister. If the case be attended with spasms the suffering of y patient is much aggravated & is sometimes excruciating The spasms commence in the hands and feet like cramp they stretch up the limbs to the trunk which however they do not always reach. In some cases again 11 the muscles of y abdomen are principally affected & they are drawn towards the spine during y whole course of y dis. These spasms may have commenced early in y dis being on some occasion y very first symptom. The discharges fm. y Stomach & bowels at this stage are very irregular in some cases they are still very frequent in others after one or two evacuations they wholly cease The pulse at y wrist if it have not ceased is scarcely perceptible & y heart beats feebly. When y spasms are severe they frequently, even though y pulse be still quite distinct stop it arising the paroxysms y same effect is produced by excessive vomiting. The breathing is slow & oppressed, this also sometimes occours early in y dis. The voice is low & but few words can be spoken without expiration. The exhaled breath is cold & though y heat of y body is many degrees below the standard y patient throws off the bed clothes & enterals the bye standers to allow him cold dis & cold water. Hiccup is not uncommon & is rather a favourable than an unfavourable symptom. – 4th Stage. In y last stage the intestinal evacuations have most likely ceased; y eyes completely sunk in there orbits are glazed & flaccid turned upwards & half covered with the eyelids. Y spasms are now commonly at an end y extremities indeed y whole body is that of a corpse & the impression communicated by y skin has been well. listened to “damp hide”. Every artery has ceased to pulsate & y action of y heart if perceptible is a mere flutter. y whole body is bathed in a Cold & Clammy sweat. It is painful to witness y oppression of respiration & jactitation of y sufferer 12 The dying man can still be roused but when undisturbed he generally appears in in a state approaching to stupor: & though prehaps in a humor which might almost be termed sulkas is in most cases coherent to the last. These symptoms are y immediate forerunners of death. If blood be drawn during the progress of y dis. it is found in y Outset dark coloured as y cases advances y blood becomes thick there is a deficiency of serum it coagulates quickly & does not assume y buffy coat. In y latter stages of y dis y current in y veins has stopped & the blood is so gramous that it can scarcely be forced out in y smallest quantity through a large orifice. The whole course of these stages generally does not exceed 16 hours & unluckily y practitioner is seldom called in untill the first & part of the 2d stage has passed The period consumed by each of y above artificial divisions varies in every case. I have seen instances in which death ensued in less than 4 hours after y commencement of y dis. & others in which its latter stage with y pulse quite imperceptible had already lasted a whole day. The condition of y mind is remarkably collected during y whole progress of terible illness for tho. Patients, as y malady advances are unwilling to be disturbed with questions this appears rather to result from y want of physical energy than from any intellectual failure. Indeed as the fatal event approaches y only wish a patient seems to have is to be allowed cold water & to be left to die in peace It has been well said that a patient in y last stages of Cholera may be called a “living Corpse.” 13 It curious phenomenon has been several times observed. After a patient has been some time to all appearances dead & when y attendance even dressing the corpse, Spasmodic twitches have taken place in y limbs having in some instances even extended to y muscles of y body & general spasmodic contractions have supervened. Cases often occour in which one or more of y above detailed symptoms do not appear There may be no spasms y Vomiting & purging may early cease or there may have been only one large alvine discharge, follow’d by a mortal collapse y patient seeming to be at once struck with death, and tho’ on [y] the very first appearance of y dis. he has walked to y Surgeon his pulse is found to be gone, his heart has ceased to beat blood can be got only in drops from the veins he lays down his head & dies without a complaint. These anomalies are not confined to individuals instances but are found to occour as M. Scott well expresses it in “local epidemic visitations.” Thus he says “when the dis appears epidemically in a town or district or in y lines of a corps or y camp of a marching Regiment, it may on one occasion be [distinguished?] throughout by y absence of vomiting & y prevalence of purging, & on another by y excess of vomiting & tho’ more rarely by y absence of purging. Spasm may be generally present in one instance of invasion, in another it may not be distinguishable. I was on one occasion called upon to send assistance to a district in which y dis. was thus described “It commences by attacking y sufferer with an agonizing heat in y stomach vomiting & purging & lock-jaw. death ensues in 2 hours & often more rapidly it bids defiance to every remedy” 14 But in all cases in which y dis has established itself, there are y collapsed Countenance blue lips & nails, shrunken fingers. The total failure if y usual secretions, deficient animal heat, suspension of y pulse, & remora in the venous circulation. Treatment of Cholera asphyxia The following may be considered the indications of Cure. 1st. To relieve y oppressed circulation 2d. To stimulate the system 3d To restore y heat of y body 4th To guard against local congestion 5th To keep down reaction 6th. To produce a healthy condition of the alamentary secretions. 1 Blood letting in cholera is obviously in a great degree mechanical. The power of circulation has been injured it is no longer capable of duly distributing y mass of blood in y system & y cessation of y usual secretion the deficient pulmonary function & the effect of y discharges have rendered y blood wholely unfit for vital purposes. By V.S. in such [cases] circumstances we relieve the gorged vessels & thus enable the 15 weakened energies of y circulating power to act on y distendened organs of circulations & to restore the current of y blood. The Lungs recover their function pure blood is thrown into y left heart y arteries are again filled with with a fluid fit to support life. this it may be supposed reacts on y sympathetic system & by its energies are completely restored. In this way only can the of V.S. in cholera be explained. No other method will account for y almost instantaneous recovery which so often follows V.S. in such a condition of y system as has been described a recovery more immediate than that which follows y removal of mechanical pressure fm. y brain. And I should say very confidently that in no case in which it is possible to persevere in V.S. untill Blood of a healthy colour & consistance flows freely fm. the vein will y patient die fm. collapse. in commencing the treatment of cholera then no time is to be lost in endeavouring to bleed y patient. He should be laid in a warm bed & y great object being to get Blood to flow it is important that the operation should be performed with as little fatigue to him as possible. He should be kept in a recumbent posture and as answering y two next indications will be y means of forwarding this important object immediate recourse should be had to stimulants – applying artificial heat using frictions &c. The rule as to y extent to which y removal of blood should be carried is very simple it has no reference to the prostration of strength or to the constitutional stamina of y patient. The power [to give motion] [often] of circulation is unable to give motion to y volume of 16 blood which has accumulated in the venous system & which has been rendered by y cessation of secretion, y diminish function of y Lungs & y disordered actions incapable of supporting life & blood is let until it appears that is fatal a condition of y vital fluid has been changed. In other words the blood ought to be allow’d to flow until the natural current in the veins has been restored & there is evidence in the improved colour of y Blood that the Lungs have recovered their function. If opening one vein be not sufficient let others be tried & until y dis. yealds the practitioner must persevere in his endeavours to accomplish this great object. In y outset prehaps only a few drops of tar like blood can be obtained by y use of internal & external stimulants some good appears to be done & the pulse rises: - renew’d attempts should immediately be made to remove blood nor should these be desisted form while life remains. – In addition to the lancet leeches or cupping glasses should be tried. It is be remembered that added to y general vinos congestion there may be a tendancy to morbid plethora in particular organs. There is sometimes confusion of head & more obtuseness of y intellectual faculties than usual. This is not only a bad symptom with reference to y [patient] present condition of y patient but may be attended by fatal effects after y primary dis is relieved. In such cases I should bleed fm y Jugular vein & as many leeches as well adhere should be applied to y temples & throat The abdomen is in every case y principle seat of congestion. Leeches ought therefore to be applied to y belly also & partic. over y seat of y Liver care being taken to avoid as much as possible exposing y patients 17 body to cold. It is unfortunate however that like blisters leeches during extreme collapse are quite useless. – 2nd. To stimulate y system. The classes as the second indication of y treatment of Cholera. Yet in their application V.S. & attempts to stimulate the system, ought to go hand in hand. The object is to restore the suspended circulation. Blood is let in order to diminish y quantity of Blood to be acted upon & stimuli are administered in order to excite the source of power. Indeed it is often impossible to render V.S. efficient until after stimulants have produced some effect. It is not merely by internal remedies that this indication is to be an severed. Frictions over y whole surface, rubefacients and sinapisms to different parts of the body are in truth important portions of y stimulating remedies. The internal remedies which have been resorted too with must confidence & sucess in y Treatment of Cholera are Opium. Ether: Camphor. Ammonia pepermint. Strogue-amer, spirits and Calomel. The general mistake in y treatment of Cholera has been y administering of too large doses of those medicine which have obtained a high character among practitioners. The large doses of Calomel & Opium which many are in y habit of prescribing are especially pernicious. This practice seems to arise from y nature of y dis being misunderstood. A patient is suffering from violent Vomiting & purging & excruciating spasms & indication appears to be to allay these high actions. Hence Calomel & opii are prescribed in quantities amounting to what are considered sedative doses. There can be little doubt that more injury than benefit. has resulted from this practice for should y dis be overcome & y medicins not 18 have been evacuated 10 or 20 grs Opii & 60 or 100 grs Calomel must act as poison on the restored functions. The object being there to stimulate y system Meds. should be prescribed in such quantities as are known to act as stimuli. In fever a scruple of Calomel no doubt will very often allay as once y irritation of y stomach & experiments seem to prove that in large doses this Med. acts sedatively on y gastro:-enteric mucous membrane. It has been ascertained by experiance that most narcotic in large doses act as sedatives very soon after being administered; while it is unquestionable that y same Med. in small quantities, excite y circulation and are consequently to be regarded as stimulants. Early in my practice in Cholera I found reason to believe that while there was positive good to be done by small quantities of these Meds. frequently repeated their good effects were very questionable in y powerful doses which were commonly prescribed. – In y treatment of y dis. this is a point of so much importance particlularly as regards opium that I think it necessary to add a few words on y subject Opii is generally administered in Cholera as an antispasmodic & if this Med. does not act as a narcotic so long as it has Spasm to allay, it has been thought that y largest doses of Opium are safe during y collapse Stage of Cholera. Now the spasms of Cholera are not Tetanic nor of cerebral origin, but evidently result from y condition of y circulation acting on y extreme branches of y nerves. & these spasms are immediately removed by y restoration of y balance of the circulation. When large doses of Opii are administered to a patient labouring under Tetanus the functions of y stomach being unimpaired y drug is at once digested & absorbed, but as y Cerebral nerves are y seat of y disease y narcotic effects of y med. appear to be 19 rendered inert by y state of y nervous system or are expended in allaying its irritability. In Cholera however thou seems to be no reason for believing that y nervous system of y Brain or spinal marrow is directly in a morbid condition. Opium therefore y not indicated as in Tetanus but even if it were so y function of y stomach being unquestionably suspended meds. are only [partly] partially digested & absorbed. Hence it happens that when y stomach no longer rejects what is swallow’d repeated doses of Opii remain in it little acted upon & when that organ recovers its function if Opii has been largely administered there remains a dangerous if not a poisonous quantity of y narcotic to be digested & absorbed. There being now no spasms to nutralize its effect the Consequence is that reaction is interupted the brain instead of being able to assist y other powers of y system in reestablishing health has its functions interfered with, Congestion takes place in that important organ & death ensues either from this cause or from rapid Typhus. It is therefore one of y most important points in y treatment of Cholera to avoid all over doses of Meds. & with regard to Opii or Laudanum in particular extreme caution ought to be used in administering it or in recommending it to y public, for both in Asia & in Europe the most fatal effects have followed over doses of these meds. – The condition of y stomach in cholera generally renders y exhibition of Meds. in a liquid [state] shape in y outset of y treatment wholely useless as they are immediately rejected by y stomach or bowels. It is therefore advisable at least while y vomiting to administer y remedies in form of pill. The following ꝶ which was not only given with great benefit to patients (adults) immediately on my being called to them, but which was distributed 20 in large quantities for y use of y sick wherever cholera was reported to exist in y district over which my professional charge extended. ꝶ Calomel grs iij} Camphor gr ij} Opium gr. ss} Mis. ft. Pil} (one of these was given every ½ hour & sometimes oftener, while y urgent symptoms continued. The nature assistant had orders not to persevere in this practice longer than 3 hours if they had reason to believe that all pills were retained.) Such pills should be washed down with a small quantity of Brandy & Water & as soon as y stomach seems quieted y following draught should be administered ꝶ Ether Sulphuric gt xxx Tinct. Opiium gt x Mistura Camphor ℥i Mis ft. Haust . (draught to be taken immediately & repeated every ¼ or ½ hour according to y urgency of y case) It was at one time the opinion that cold drinks in Cholera were dangerous. Mr. Annesley found by experiment that Tartaric Acid dissolves y viscid matter which is so often found after death, lining the enteric mucous membrane & he latterly allowed his patients lemonade which was found delight fully refreshing. He also gave a drink containing nitric acid in y hope that while it was agreable to y patient it might communicate oxygen to y system. Wheather we admit y importance while y dis exists, y fibrinous matter on which Tartaric acts or imagine that that Oxygen can reach y system in the way M.D. seems to expect when it is no longer absorbed in y Lungs the practice of M.D. is certainly a real comfort to y patient & can be attended with no bad effects. – In the very outset of y treatment, frictions over y whole body, & shampooning y extremities should be resorted to. Frictions is best applied by means of hot flannel. It may be necessary however to use hot spirrits 21 of Turpentine. & rubbing with y flannel should be continued until y turpentine is rubbed dry. Bags of hot Sand or Salt should be applied to y extremities or other parts of y body but this will often while y extremities of collapse continues, prove unsupportable to y patient. – Blisters during extreme collapse are quite inert & y emplastrum Lytta is too slow in its operation to prove serviceable. Mustard cataplasms are a more valuable remedy: these may be applied with advantage all over y abdomen & to y calves of y legs soles of y feet & even to y chest. Nitric Acid has been resorted to in order to produce an immediate blister – it does not seem to have been attended by any marked benefit & it is apt to produce an escar which may prove afterwards extremely troublesome. Boiling Water is also recommended with y same view & has apparently in some practitioners hands been found useful. Partial Topical applications however are not much to be depended on & as has been already observed, Vesication cannot be produced during Cholera. The dis. is a failure of an important power of y system & y object in simulating y skin is to assist y internal remedies in exciting this suspended power. But as yet there is no local affection to be removed by topical applications altho. these may become very valuable the after indications of cure. In the present stage of y treatment, therefore an extensive application of sinapisms, or y general embrocation of spirrits of Turpentine alone or combined with Tinct. Cantharides or of Oil & [Hartshorn?] or any other powerful rubefacient is to be regarded as y best means of assisting y internal stimulants in their operation 22 3rd. To restore y heat of y body. The heat of y body can only be effectually brought back by reestablishing the circulation of y blood. At y same time remedies having in view restoration of y deficient animal heat have been considered by most practitioners an important part of y treatment; & therefore they are not unworthy of a separate consideration. No one of these three indications however altho classed seriation should precede or wait upon y others. The treatment should be commenced with any one of the three which can be most easily answered, & y whole of them ough to be considered as belonging to y first branch of y treatment of y dis. There is one very remarcable circumstance attending y worst description of Cholera which has been already repeatedly alluded to viz the morbid sensibility of y patient, skin & apparently of his stomach to y presence of any thing raised above y temperature of y air. A warm bath for instance of a heat some degrees below y healthy temperature of y body has been found so insupportable, that a patient after being immersed in it for a few minutes has sprung out of it almost with spasmodic energy & entreated that he might not again be exposed to so painful a remedy. A similar feeling is very commonly produced in y patient by swallowing liquids not more than lukewarm. Notwithstanding however y instinctive dislike to artificial heat exhibited by so many patients labouring under y dis. still it is advisable that attempts should be made to prevent a fatal reduction of y animal temperature. This is particularly necessary in a cold climate. The patient therefore on his being attacked ought to be placed in warm blankets, & every endeavour should be rised to keep 23 his extremities warm preventing as much as possible his throwing off y bed clothes or removing himself from y heated articles which are applied to him. The restoration of animal heat has been reconed so important, that it has led to various contrivances for applying wamth, The hot water bath was at one time much used. but y delay. y fatiegue of using it. exposure & fatigue in drying y patient renders generally the hot bath more usurious than beneficial. The principle which should regulate y application of heat to Cholera patients is that it should be done with the least possible fatigue to them. With this view various descriptions of Vapour Baths have been proposed. The simplest & most expeditions is Dalton’s Bath made by putting burning spirits and the cot or couch which is surrounded by blankets. Poles of ignited Charcoal answer y same purpose. When there are not such [contrivances] conveniences as these at hand use hot Blanket. Bottles of Hot Water. Bags of heated Sand &c. But unfortunately it often happens that y best contrived me thoads are so painful to y patient that they cannot be presisted in. The general result of y steps which must be taken to overcome y dis. is that Venesection is to be immediately resorted to & every endeavour made to get Blood to flow until the congestion is relieved & until there is evidence that y function of y Lungs & action of y heart are so far restored. For y same purpose stimulants are prescribed & artificial heat is applied to assist y returning circulation in raising y temperature of y body to y natural standard. – Such was y practice resorted to by me [in] [India] & others with great sucess in India & from all that I can learn a similar course of treatment had proved equally beneficial in this country. 24 I am informed that a Mustard Emetic has provd very serviceable in y North of England ½ oz Mustard given in cup of Water: it produces full vomiting & appears to stimulate y circulation [so?] as to enable y surgeon to bleed. The removal of blood to y necessary extent has invariably so far as my experiance goes to spasms. oppression & to y Vomiting & purging & has relieved y prostration of strength The effect of V.S would indeed sometimes appear miraculous. A patient will be brought in oil a cot. Unable to move a limb & but that he can speak & Breathe, having y character (both to touch & sight) of a Corpe, yet will he by free V.S. alone be rendered in 1/2 an hour able to walk home with his friends. Case a man was reported to have been suffering from Cholera during y whole afternoon His Skin was cool pulse weak thready had spasms in y extremities urgent thirst. I immediately bleed him & with difficulty obtained a full stream, When about 20 oz of Blood had been taken y mean felt complete relief, Some Brandy & Water was given him & he returned with his friends to his own quarters He was able to accompany y detatchment of troops next morning. There cannot be a more decided proof that this dis, becomes one of pure contagion & that y immediate care of remove in y circulation whatever that may have been no longer exists than y almost instantaneous effect produced by removing a portion of y redundant & [what] to say y least of it what venous blood. All know that however sucessful V.S. may be in relieving the most urgent symptoms of inflamation complete restoration is not y immediate [effect] result that inflamation is not a mere fulness of y vessels of y affected part but that y arteries are in a morbid condition, & that time is required to restore them to healthy action not uncommonly y most difficult part of y treatment 25 And we are therefore fully warranted in concluding that if Cholera consisted of a diseased condition of any portion of y arterial system recovery could not be instantaneous. Breathing Oxygen or Oxygen diluted is worthy of trial. I should also if possible throw the Galvanic stream through the abdomen. But having arrived at y conclusion that y great object is to stimulate y sympathetic system of nerves it is to be hoped that experiance may enable us to attain this object more effectually than we have hitherto done. Prognosis. The most satisfactory symptoms in y early stages of y treatment of Cholera are y return of y natural colour of y lips & nails arising of arterial action in y extremities & recovered animal heat. The proof that y dis is overcome is y restoration of y function of secretion which is most satisfactorily evinced by y patient making water. Such decided symptoms of sucess may not immediately make their appearance partic. if blood has been removed with timidity but let it be remembered that 8 or 10 or may in one case be sufficient while in others depletion [may] must be carried to y extent of 40 or 50 ozs before there shall be reason to believe that y over burthened [valsartan?] system is relieved. It frequently happens that when there is not sufficient confidence in V.S. y case is painfully protracted that for several hours y patients life will seem hanging as if by a thread. y pulse at y wrist will repeatedly fail & return; oppressive deafness Vomiting purging & spasms will continue y body will remain cold & there will be every reason to dread a fatal termination. 26 The restored circulation, return of animal heat & reestablishment of secretion are to be regarded as proofs that y patient is safe. When on y contrary collapse continues, arterial action is no where perceptible; when y temperature of y body becomes more & more death like & above all when a profuse cold & clamy perspiration breaks out over y whole surface accompanied with jactitation there is little reason to hope for a favourable change. It sometimes happens that notwithstang means apparently favourable symptoms y case terminates [favourably] fatally (in dissipated habits & broken down constitution.) It has been found that y more violent the prominent symptoms are y more likely is a cure to be effected: & that when y dis is attended with rapid collapse little or no vomiting purging & no spasm y prognosis is very unfavourable. But it may be again observed that even in y most hopeless cases it is y duty of y surgeon to continue to watch his patient to y last as instances have occourred in which recovery has taken place when to every appearance y patient was in articule mortis 4th To guard against local congestion most men either from original organization or accident have some weaker point in their constitution which is liable to manifest itself when y system receives any serious shock. Thus in a London Hospital death following a great operation [generally] frequently does not appear [from] to result from y local injury: the wound may seem to be going on most favourably, when y patient is seized with low inflamation of y chest & he dies of dis of y Lungs. So also in Tropical Climates as serious injury may not destroy the person by its immediate effects y fractured limb or 27 broken head appears in a fair way to do well: but y patient is attacked with Hepartitis or Dysentary & is carried off. These facts illustrate y necessity in cases of great constitutional derangement of extending our attention beyond y mere original dis. In Cholera this is particularly necessary. When y primary dis is relieved it is y duty of y practitioner to look most carefully to y condition of y Head of y Lungs of y Liver and of y bowels. The great risk appears to be that a local congestion shall follow a general one. This from the nature of y circulation in y Liver & Lungs is prehaps more likely to happen in these organs than in y head. But should congestion take place in any of those great organs active measures must be immediately resorted to. Leeches Blisters & Mercuric purgatives will be requisite; & instances occour in which in which from y condition of y hepatic system, it is necessary to give Mercury until it produces salivation. The affection of y head [in cholera are] after an attack of cholera, are generally rather of y nature of reaction than of congestion. A mixed & obscure case is occasionally met with in which there are both conditions of y vessels of y brain. But unquestionably pure congestion sometimes takes place within y head which is to be overcome by free topical depletion & active purgatives. When y lungs & consequently y heart have their functions deranged after an attack of Cholera it is generally difficult to discover what is going on. The pat: does not recover as usual he is troubled with depression & debility; his skin is ill coloured & prehaps his pulse is irregular. In such circumstances Leeches should be applied to y chest & a blister over y seat of y heart & alteratives should 28 be prescribed. As it may be [possible] advisable to reach y source of respiration a blister should be applied to y nape of y neck. The tendancy to local congestion may not be immediately disclosed partic: when it takes place in y Liver. This arises from y obscure nature of y symptoms of derangement in y substance of y Liver. It is consequently always advisable to pay y utmost attention to y hepatic system after recovery fm. Cholera: may owe permanent loss of health & much [fatigue] future suffering to neglect of this great venous organ, while convalescent fm. Cholera asphyxia 5th.. To guard against reaction. It is remarkable that in India reaction should so seldom have taken place after attacks of C. when symptoms of this condition did occour, they were generally partial & seemed rather to be attributable irregularity in y balance of y circulation than to pure reaction: so that even its one & y same organ there were deranged arterial action & venous congestion. In India a patient on being relieved from y symptoms of Cholera. usually falls into a sound & reposition sleep & on awaking has y feeling of being quite well. There may be still however tinitus aurium & a slight feeling of confusion of head & giddiness. These symptoms no doubt very often arise from y effects of y powerful narcotic remedies which have been used & will be most likely removed by acting on y bowels. But if there be superadded pain, intolerance of light, a contracted pupil & a hard pulse immediate attention must be paid to y head. Local depletion in these cases is prehaps better than general bloodletting 1b or 20 Oz Blood should be drawn fm. y temples by. leeches or cupping glasses & active mercurial purges should be given. If y these means y symptoms be not immediately removed – y head 29 must be Shaved cold applied with Blisters to y occiput & nape of y neck; & should y pulse continue hard general depletion may be advisable, though topical Bleeding when relieve it can be carried to y necessary extent it as effectual & safer in cases where y removal of blood has already taken place to considerable extent. Such was my opinion as y result of my Indian [practice] experiance of C. & I still think that when we have got rid y state of Asphyxia & restored y circulation we have overcome y dis properly so called. But in Europe it has been found very generally that y collapse stage is followed by a fever of a Typhoid character which protracts y recovery and frequently proves fatal. This fever therefore demands our particular attention & in y outset I may observe, that, in this country the usual treatment of fever appears to have been inquired by y doctrin of Critical days It is said that fever must be allowed to take its course. I do not think so. On y contrary I have seen y greatest benefit result from doing y utmost to cut short fevers of all kinds. In addition therefore to constantly regulating y bowels & y skin through the circulation. I have in my practice both in y East & in Europe commenced Quinine at a earlier stage than it is usually thought of in this country, & in most instances with very hupp effects. In reference to y same subject I consider it by no means impossible that y rapid recoveries fm. C. which took place in India were attributable in no inconsiderable degree to y very decided steps by y Indian practitioners. Thus in that Country a patient with C. was not only freely bleed but lead large doses of Calomel administered followed by active purgation. 30 Dr Mackintosh of Edinburgh I believe has y credit of having called y attention of y public to y good effects of Bloodletting in y cold stage of fever. Before I was aware of his practice I had come to a conclusion similar for altho’ I have not found this remedy universally necessary in ague I look upon it as of great value in relieving y system from a load of unhealthy blood likely to prove injurious when reaction is established. On y same principle I am inclined to regard full venesection & y free use of mercurial cathartics during & immediately after y collapse in C. as y most likely means of saving y patient fm. y subsequent fever. In y treatment of this fever therefore I should continue to act freely on y bowels & loose no time in prescribing Quinine & Camphor giving such a pill as y following every 2 or 3 hours ꝶ Sulph. Quinine. Camphor āā gr.SS. ft Pill And I should watch for local congestion resorting to local depletion in y manner already described in case that appear’d to be necessary. 6th To produce a healthy condition of y bowels. This is an indication which must in every case be attended to for however short y cessation of secretion may have been & however easily y secretions of C. may have been removed y restored function seem to pour into y intestinal canal colluvics which must not be allowed for a moment to look in it. Calomel is a med. of y greatest [power] value when y urgent symptoms have been removed: particularly if as sometimes happens watery alvine discharges continue. As soon as y circulation is restored ten grs, or əj of Calomel should be exhibited & followed up after patient has had a few hours rest with a large dose of 31 Castor Oil; a draught of Infus. Senna. Tinct. Jalap. & Tartrate Potash; or by a dose of Comp. powder of Jalap. It is however advisable not to risque bringing back y irritability of y Stomach & when there is any fear of this it is better to give y Cathartics in form of pills. The follow ꝶ has been found a valuable one after cholera ꝶ Ext: Colocynth. gr.X Divide into Calomel} 4 Pills – et sint Ext. Hyoscyamus} āā gr.V pro. dose. Glysters. large & purgative are very valuable in cases in which y Stomach is still irritable & they may also be used in order to assist y purgative taken by y mouth when slow in these operation. The object at this period of y treatment is to procure feculent discharges & to have evidence that Bile is not only flowing freely into y intestines but that its secretion as restored to its healthy [secretion] condition & y practitioner must be satisfied that the Kidnies have recovered their function as soon as there is reason to believe that these important secretion are restored y patient may be pronounced perfectly safe altho’ it is always advisable to strengthen him by Tonics diet & regimen. And as a relapse is to be much decided y patient must not be allowed to be led by his own feelings of recovery to undue exertion of strength or unnecessary exposure to fatigue cold or any of y exciting causes of [fatigue] disease. It sometimes happens that without being able to truce y symptoms to local congestion or reaction it is extremely difficult to restore y functions of y stomach & bowels to a healthy condition & y patient continues to suffer cramps in y extremities even for many days after y urgent symp. of Cholera have been removed. 32 In all cases of this kind it will be found that it is not only y alamentary secretions that are at fault but that y kidnies have not recovered their healthy function: & y thirst of y patient will show that y salivary & gastric secretions are still deficient. These cases may be explained by y supposition that y sympathetic system has been more permanently injured than is usual. The treatment in such circumstances should consist in persevering in active purgatives prescribing a course of alteratives & freely exhibiting Quinine & it may even be advisable to produce slight ptyalism. Proximate Cause. In y course of y authors enquiries into the nature of C. it became evident to him that y systems course & effects of y dis. could not be explained on y received doctrins of pathology 1. Is this [dis] a general or local affection? 2d. Is it vascular or nervous? Though no doubt a severe extensive affection of y alamentary canal will produce serious. interference with y circulation still under such circumstances we should have no reason to expect to complete, a state of asphyxia as occours in C. In an Inflamatory condition of y gastro-enteric canal the action of y heart may be affected & y pulse become thready but y skin does not become livid nor y body cold & every one who has considered y post mortem examinations of victims of C. is aware, that it is even questionable wheather partial appearances of inflamatory action can be discovered far less those of 33 of extensive inflamation. Besides the complete immediate recovery fm. a state nearly of death which so frequently follows successful treatment of Cholera is [wholly?] at variance with y doctrin that y dis is an extensive inflamation If y symptoms were entirely restricted to depraved secretion into y stomach & Intestines we might be justified in considering y dis a local affection of y gastro-enteric mucous membrane. But truly y vomiting & purging are of very secondary consideration. The skin is blue y surface cold y arteries empty y veins loaded & y current of their blood stopped throughout y whole periphery; & in such a condition of y system we cannot be justifyed in supposing that there is an increased even tho’ depraived secrection going on within y alamentary Canal. And if we are to consider y dis as y result of a local affection y [eivle] evil might with more properly be be described to y pulmonary function. But that it is not result of a future in this important function is proved by there being frequently no marked symptoms referable to y chest & by y dis. being generally advanced in its course before y respiration becomes oppressed. This supposition is also incconcilable with y known immediate effect which y suspended function of y Lungs produces on y sensorium. Were y lungs to fail in their function so far as to render y blood unfit for its purposes it would follow that wherever arterial blood was required the defect would be apparent & hence y brain would immediately feel the injury. Accordingly we find this to be case in circumstances in which y system suffers from y sudden decarbonization of y blood. For example when a bed room gradually fills with y fumes of charcoal insensibility is 34 y first symptom of danger of y sufferer. C. therefore cannot be refered to a topical affection of any of y great organs – y sensorial respiratory or alamentary. The difficulty of accounting for all y symptoms on y supposition that y cause of C. is “local affection of some of y great viscera has lead to y hypothesis that it is an affection of every mucous surface & that it consists of a depraived condition of y decreasing [surfaces of those] functions of those surfaces. But this implies that secretion is excited on y most extensive surface of body when that surface is nearly or entirely deprived of arterial blood for in C. y discharges continue after y circulation has to all appearances ceased. 2d every dissection after death fm C. proves that this dis. produces great venous congestion & there can be no doubt that such a state of y system invariably exists in C. But this must be regarded as y effect & not y cause of y dis. Blood drawn fm. a patient labouring under C. is not only much blacker than usual but is generally grumous: and late in y disease attains y consistence of tar. This must still be regardes as y effect & not y cause of y dis for were y immediate cause of [y] a dis such a morbid condition of y circulating blood as to destroy those organic functions which are found to have failed in y very commencement of C. y sensorium would likewise suffer & insensibility would accompany y other symptoms. It is not therefore likely that C.A. results from a morbid state of y circulating Blood. When in y animal body we find a [se] circle of actions performed, distant path united in function & y flow of fluids to partic. organs determined controlled or suspended as may be necessary for certain 35 purposes: whatever may be our notion with regard to contractility, we must attribute such combined actions to y power of y nervous system. And whatever may be our opinions as to y nature of those processes from which y various secretions immediately result wheather we consider them chemical or mechanical or ascribe them to an unknown vital principle – still y determination of y pabulum to y secreting surfaces must be attributed to a general & not a local agent. The nervous system stretches itself out to every point of y body & we find it distributed most largely where we may expect y energy of such an agent to be most required demonstrating as it were that those actions on which y performance of y various organic functions depend are traceable directly to this system. Hence we seem to be justified in concluding that if we find by dis. or accident that an entire class of y functions of y living body is at once suspended, such suspension must be ascribed to an injury to that portion of y nervous system by which these functions are carried on. In C. in y very outset of y dis all secretions property so called are found to have failed; the alimentary ejecta are not gastric juice pancreatic fluid. Bile, mucous, or excrementitious matter. The kidnies cease to secrete urine saliva no longer flows into y mouth nor are y eyes moistened with tines. Carbonic acid gas is not thrown off in its usual quantity from y Lungs & animal heat is not evolved in y Body. Here there is a dis which suspends secretion in every part of y body. The functions of y parts which are thus rendered powerless are unquestionably dependant on nervous 36 energy, y involuntary nerves being y class which have failed & hence it seems to follow . that y immediate cause of this dis is to be sought in y nervous system. But here it may be asked. How can a dis be considered a nervous failure in which we find y sensorium y respiratory & y voluntary powers unaffected? The answer to this difficulty may be comprehended in y following propositions which embody y conclusions on this subject at which y Author has arrived 1st. The great ganglionic or sympathetic system of nerves is possed of a power wholelly unconnected with cerebral influance which it may retain after y brain & spinal marrow are removed & which may cease to exist while these retain y full exercise of their functions 2d. To this system belongs y circulation & distributive of y blood, & it consequently has a most important share in regulating secretion – in carrying on y involuntary functions & 3rd. To y suspension of this power of y system as I conceive is to be ascribed y dis which is called Cholera asphyxia. These conclusions are y result of an intimate practical acquaintance with y dis. I an axious study of all its phenomena: & they are supported by a careful & minute enquiry into y nervous system in all its bearings. A disquisition [cross out] on y subject would be out of place here, But still it is necessary to state some physiological distinctions not generally received but which appear to me to be well founded & which I think may be [regarded] rendered of much value in pathological enquiries. (See Mr. Bill's Work for his arguments &c page 31. 37 Post mortem appearances. Cholera As: The appearance of y body is peculiar. Whole surface livid, countenance collapsed, body shrunken resembling body of a patient who has suffered fm. a long illness. Y present description is confined to dissections made on bodies in which death has proceeded immediately from an active attack of y dis. & that organic lesions are not included which the evidently unconnected with y cause of death has frequently been particularly noted in descriptions in dissections of y bodies of persons who have died from Cholera. On opening y abdomen the full peculiarity which presents itself is y gorged appearance of y veins & semi fluid state of venous blood. Peritoneum & Omentum natural. Characteristic colour of y Viscera is light pinky hue, shading to purple. And y vein where ever they are to be seen appear loaded with black Blood. The floating viscera generally feel more palsy than 38 usual, as if their coats were thickened y solid viscera look purple or are mottled. y Stomach may appear full, in general it is partially contracted, small intestines tho’ full are not always distended & I have almost alway found alternate portions of y great intestines. contracted & delated. Whole canal sometimes distended with flatus. Mesenteric veins are in a state of great congestion. The contents of alimentary canal is a muddy fluid resembling that passed fm. y Stomach & Bowels during y dis. No foeces but always more or less flatus. The enteric mucous membrane particular but y upper portion of y canal is often coated with a glary & tenacious matter which would appear to be an accumulation of y coagulated opaque substance which is passed with y serous fluid. This is sometimes in such quantities at partic: parts. of y canal as almot to fill use y tube its colour is not always opaque white. has been describes as a dark grey & a greenish tinge said to be sometimes bloody. These variations in y colour of this matter does not appear to affect y nature of y dis. & fm: Mr. Annesleys experiments they would appear often to be attributable to admixture with y meds. prescribed nor. is this matter invariably present. The internal coat of y stomach & sometimes a portion of y duodenum has very generally a peculiar appearance;. There are vascular patches not of inflamation but as if vessels had burst & blood had been extravasated between y coats. These spots the no doubt commonly a congeries of congested [vessels] veins do certainly somet. arise from extravasation. Patches also are described as having y character of Inflamation generally near y pelorus which are by some considered by some y result of local 39 irritation produced by portions of y remedies prescribed having adhered [th] these parts of y stomach & they must be taken as a proof that reaction had commenced before death. Worms are very frequently found in y intestines. Having removed y alimentary canal venous congestion is still few to be y most remarcable feature of y dissection. The large veins are gorged & there is nowhere a trace of arterialized blood perceptible indeed this has been found to be y case during life: for one surgeon in voice attempted to get blood fm. y brachial artery. The Liver is in most cases dark coloured and mottled being at its dependant parts unusually gorged with black blood, but it is said to have been found in some dissections natural in its appearance. Gall Bladder generally full of Bile. I have alway found marks of congestion in y spleen appearances variable Dr Christie fund y spleen empty. the Ceylon practitions found it smaller than usual. y Bladder alway contracted & empty. Kidnies. healthy but partake of V. congestion Liver when cut into found gorged with black blood not coagulated but thicker than usual Bile in Gall bladder green. I have seen it healthy in appearance. Seriat Veins Trunk & Liver full of thick impure blood as are y right Auricle & Ventricle of y heart. Lungs black & appearance almost of a fleshy structure & when cut into freely give out y same grumous black blood in some instances this impure blood is even found in y left side of y heart & to have reached y aorta & cases are mentioned where black blood was found in y carotids. In y Brain there is a same character of venous congestion. but here there is generally some slight appearance of arterial blood 40 There is often found a small quantity of serum in y ventricles of at y base of y brain. The descriptions that have been given as if portions of y brain had been in a state of high inflamation are wholly at variance with y character of y dis in its course & seem rather to belong to a disordered state of y circulation than to this dis. except indeed in cases in which death had not proceeded immediately from cholera & when reaction had taken place. Such is generally y condition of y body after death arising fm: a pure case of Cholera. It may be remarked however that in particular disections some of y organs here described as being in a state of Congestion are found not perceptibly different from their healthy condition & instances are said to have been met with in which y whole abdominal viscera presented nothing very peculia in appearance. In such cases (none of which have [followed] fallen within my experiance) the Lungs or encephalon will no doubt be found highly congested & y external veins much loaded. It is important to say a few words on y general question of V.S. not only to satisfy that y removal of blood may remove prostration of strength but to clear y way for authors explanation of y nature of Cholera a: There are two opposite conditions of y system in which it may be advisable to [withdraw] bleed. The 1st. when high general arterial action exists or when local inflam; has taken place. In such circum: V.S. is called for because it is necessary to lower y hearts action or it may be said because arterial blood unduly preponderates in y system indeed this may be regarded as y fact for in cases of highly exited action y blood circulating in y veins will be found to retain y arterial hue 41 y 2d state of y system in which V.S. is expedient is when y balance of y circulation is depressed on y other side & y venos blood is in excess Fever. Peritonitis, & Acute Rheumatism are example of y first & Cholera Asphyxia is y most remarkable example of y 2d. which practice presents. The condition of y system in C. has been already spoken of but a case of more common occourence which affords an example of bleeding being indicated to remove an excess of venos blood will supply a father illustration. When there is a broaken ribs the action of y Chest being impeded respiration is checked y blood [drawn] thrown into y Lungs is not purified y circulation is obstructed & venos blood soon preponderates in y system. In such a case therefore we bleed not merely to ward off inflamation but in order to reduce y blood requiring y function of y Lungs so that y quantity thrown into those organs being proportioned to their restricted capacity they may be enabled to prepare it for arterial circulation. But in y latter class of cases it is not indifferent wheather we draw blood from an artery or a vein – a practitioner who would open y temporal artery of a patient whose lungs were clogg'd with unarterialized blood would increase y risk of suffocation. Yet we actually find Indian writers so completely mistaken in y rationale of V.S. in C: that they narrate their attempts to remove blood by y temporal artery when y surface is livid and after y arteries have ceased to beat. There is another preliminary consideration which has been lost sight of by many inquiries into y nature of C. viz That diseases of sudden collapse are not necessarily preceded by a state of high arterial action. – Where it may be asked is such a stage in y instantaneous debility produced by y poison of y viper. But to 42 illustrate this fact we need not leave y doctrin of diseases. Intermittant fever supplies an opposite illustration: on y approach [of a pt of ague lung nor y symp. are] of a fit of ague y symptoms are those of great depression lassitude weariness followd. by chilliness nails & lips blue. Countenance sinks shivering ensues in some cases spasms of y extremities. In short y condition of y system approaches to that which prevails in cholera asphyxia. & there can be hardly a doubt that in y cold stage of fever y balance of y circulation is interupted & that venos. blood preponderates in y system. I have seen y occurrence of death in what there was every reason to consider y cold stage of an Intermittent Collapse then may occour without previous high action, it is produced by many poisons. We see it in ague & it occurs in cholera The conclusion & inferences at which I have arrived are 1st That there are 3 powers in y system viz The sensorial. Respiratory & Sympathetic & that each of these on all common occasion is enabled to perform its functions without y active interference of y others. 2d. That y destruction of any one of these powers does not immediately annihilate the other two. (1st) Y [circulation] sensorium may be suspended & y circulation & respiration continue unimpaired (2nd) Y circulation may be supported after y source of respiratory power & y brain have been removed (3d.) [That y] Y circulation of y body may be stopped & y sensorium remain unaffected 3rd. That y source of y sensorial [power] & voluntary power is in y. Cerebrum & Cerebellum. That of y respiratory power in y upper power of y 43 Medulla spinalis, & that of y circulating power in y ganglionic system of y great sympathetic nerves. 4th.. That secretion requires y integrity of y upper portion of y spinal column & of y sympathetic system; & that when y power of either of these sources of nervous energy is suspended any appearance of secretion is fallacious. 5th. That secreting surfaces may throw off component parts of y Blood after their power of secretion is at an end. 6th. That C. asphyxia is suspension of y power by which y circulation of y blood is carried on. 7 that y fluid which during a fit of C. is poured into y alamentary Canal and which extrudes from y skin, mouth, eyes, & mucous lining of y bronchia is excreted after secretion has ceased, when animal heat is no longer evolved & when arterial action is at an end: & therefore must be regarded as an exudation fm. y venous capillaries or if fm. y arterial capillaries is occasioned by them being supplied with blood by regurgitation. – Remote Cause of Choler. A: Y remote cause of any partic. dis is frequently y most obscure question connected with its nature & I much fear that practically we should give little by becoming acquainted with y remote Cause of C. Y dis to whatever origin it is to be traced, seems to be now gradually diffusing itself over y Globe – uninfluanced apparantly by climate - & hither to setting at defiance all human means of retarding its progress or of lessening to any considerable extent its average mortality. Were it of any importance to hazard conjectures as to 44 its remote cause I should be disposed to say that y theory most consonant with the phenomena of y dis is that which as cubes it to certain galvanic changes on y earth surface, but really such speculations are of little value nor is there any theory of y dis. which has led to any important practical results except that which traces its origin to Contagion alone. There can be no serious doubt but that a dis. similar to cholera. has been known in Asia fm. time immemorial. Bontius upward of 2 centuries ago in treating of C. Morbids describes very correctly y prevailing disorder. There is also frequent mention of what was undoubtedly this dis. by y Med. Offices of y East India Companys service in y latter portion of y last centaury & in 1775 it seems to have assumed y character of Epidemic in India & to have extended itself to y Island of Mauritius. Dr. J. Johnson in his Dis. of Tropical Climates speaks of a Dis which Prevailed in Brazils which fm. y sucess of V.S. I have little doubt must have been C.A & I think it by no means improbable that the English. “Sweating Sickness” partook of the Character of this Epidemic. I have admiral Fleming authority that a dis very like the Indian C. prevailed at y Havannah in 1810. & in 1827 several cases resemble C. A. in its most malignant form made their appearance in a public School at Clopham all that I would venture to suggest is that possibly Galvanism may present phenomena which might aid us in our enquiries into y remote cause of y dis. Ritter found that while positive Electricity seemed augnum y vital powers. Negative Electricity diminished them y former increased y pulse y latter lowered it y former caused sensation of 45 heat y latter of cold. We again have seen that y distinctive character of C.A: is y sudden deprivation of y nervous energy of y sympathetic system & all y length to which I go is to suppose it not impossible that y source of y dis may be found in some sudden change of y electric & galvanic condition of y surface of y Earth – I say this however with no intention of supporting y Hypothesis that Galvanism is identical with nervous energy: but unquestionably that agent is so intimately connected with every portion of y creation that any sudden withdrawal of it from y animal system might not improbably produce such a dis a Cholera: a conjecture which receives some countenance fm. y very extraordinary effects which Thunder Storms are said to have had on many occasions on y progress of this dis. in India note. page 66 [a remarcable instance of y sudden cessation of C. after a Thunder Storm is said to have occoured at Jussy. One of y most accurate observers of y peculiarities of y dis. also says “several instances have been known of its (y C) having suddenly ceased on y occourance of a Thunder Storm & say “I witnessed a remarcable instance of this at Kulladghee in 1824 after y dis. had prevailed for several weeks in y troop of horse artillery there was a violent Thunder Storm after which not a single case occoured (Dr. J Christie Observations on C. p 97. 98) It is a circumstance calculated so far to give support to y theory which ascribes C. to some terrestial influance that in India y bower animals such as Cattle. Monkeys & poultry suffered fm. y dis. & if News paper reports are to be credited a simular phenomena has been observed in some of y European Continental towns; & in Hamburgh in partic it is said that y fish also in y rivers were affected. 46 y latter circumstance is very remarkable & if well founded may had to some interesting speculations In Connection with y remote cause of C. I may mention that my friend Dr. Meikle of Edinburgh who saw much of y dis in India & who himself suffered no fewer than five attacks of it, is subject to a very peculiar sensation when exposed to y hidden sources of y dis. which enabled him repeatedly in India to announce its approach before any actual case had occoured. The sensation he describes is that of numbness in y fingers & it is singular that y other day in Hadolington he had again y same feeling] After all however y result at which we arrive is that we know absolutely nothing of y remote cause of C. This is y conclusion to which all practical writers have come.  47  48 Pulse labarynth in which y student is lost & y master wanders to no purpose. – (Good). ~ Pulse Heart or [any] y quantity of y circulating fluid & In Hunter concours in Kriviews. They measure y degree or vascular tone or power of resistance & where y same effect wheather above or below y natural standard takes place in y capillary arteries it produces that change in y pulse which he distinguishes by the names of obstruction & freedom but which it is not alway easy to discriminate fm: severall of y preceding qualities nor is it of great importance as we have in such cases other symptoms that more strikingly manifest y same [effect] fact. – Thus far prehaps y doctrine of pulsation may be studied with advantage but when beyond this we come to a distinction between y free & delated pulse as proposed also by Dr. Fordice. The quick & y frequent of stahl & y dicrotic conturnizing & insidious of Salano as mere sub varieties of y rebounding or redoubling itself a variety of y irregular pulse we perplex patharolog with 49 Pulse. – y vigour or debility & y system which a mere variation in y state of y frequency of y pulse Full &} Small} This M I hunter ascribes to y state of y arteries but I think givers no rather y quantity of blood circulating through y system than of y muscular strength of y arteries or of y Heart itself which is often a very important indication & especially where combined with y preceeding signs it will then be our best guide in cases where we have determined upon [opening] V.S. as far as we do it without danger. Hardness &} Softness} Together with that Vibratory thrill which has been called Wireness are not so easily learnt as its fullness & Smallness but a nice finger will readily discriminate them & practice will point out y difference to every one. Dr. Fordice makes these & I think with great reason dependdant on y state of y arteries rather than on y Pulse. it there: sometimes put a sudden stop to y hearts motion with a deadly shock & killed y patient in a moment. – There are many Drugs that afford examples. Digitalies & Hyoceamus are expressly used on account of this property. Y Prusic Acid & plants that contain it when given in free doses destroy y irritability & extinguish y pulse instantly & so effectually that y heart when imediately is arrived was insensible to concentrated acids & puncture. – Frequency} &} Slownes of} y Pulse} taken by themselves indicate little more than y degree of irritability of y heart or y force of y stimulus that is operating upon it. – Or Weakness & Irregularity Strength &} Regularity} are as palpable to y finger as y preceeding signs & show in characters nearly as deceive y degree of Vigour or debility of y Heart & hereby except where y organ is labouring under some local affection 50 Pulse. – estimates y pulse on the day of his birth & while asleep fm 130 to 140 & fixes it at a little less than the same rate or that of 120 for the first month During y 1st year he calculates it at from 120 to 108. y 2d fm: 100 to 90 y 3d. fm: 108 to 80 at which it continues for 3 ensuing years. In y 7th yr. it is frequently reduced to 72 & in y 12th. to 70. In advanced age from y small quantity of sensorial power secreted & y general inertness of y organs y pulse sinks often below 60. – The Pulse is Quickned by very slight excitement both external & internal. The stimulus of air is sufficient. light & of sounds is sufficient to make that of an infant awake 15 or 20 strokes more frequent than when it is asleep & beyond their control. The Pulse of an Adult is usually Quicker 8 or 10 during y digestion of a meal. Running or any sudden or rapturous emotion will double y ordinary scale The Depressing Passions on y contrary check Pulse two patients who in y best health had always very unequal pulses as well in their strength as in the spaces between them but which constantly became regular as y patient grew ill, and gave a never failing in recovery in their once more returning to a state of irregularity. – In Women y pulse is generally speaking 6 or 8 strokes in a minute quicker than in men and hence many women of firm health & lively disposition have a standard pulse of 85. – In a Weakly Frame y pulse is usually rapid for debility is almost always accompanied with irritation & y heart partakes of y general infirmity In this case also fm y feblness with which y heart contracts y ventrical is but imperfectly emptied & consequently soon filled again & sooner stimulated to contraction. – Hence In Infancy y pulse is peculiarly quick & gradually becomes slower as y child increases in strength. Dr Heberden who paid particular attention to this subject 51 Pulse. – Varies in different individuals fm. 60 to 80 being greatly affected by y temperament and partly by y habit of life. – In y Man of high Sanguinary character it rarely sinks below 80 & is often at 90. – And in the Melancholic it seldom rises above 60 & sometimes sinks to 40. – In Idiosyncrasies y discrepancy is so considerable & complicated with other changes than those of frequency & tardiness that there is no reducing them to any rule. – Lizzari tells of a person whose pulse was not more than 10 in a minute. Dr. Heberden saw a person whose pulse he was told whose pulse in y begining of his illness did not number more than 12 or 16 he suspects in this & all other instances where it is below 40 that y beats oftener than it can be felt because such slow pulses are usual unequal in their strength & some of y beats are so faint as but just to be perceived so that others probably still fainter are to weak to [be] make a sensible impression on y finger. Heberden had attended Pulse beats in Early Infancy 140 strokes a minute towards y end of 2d. Year 100 ” ” [at] at Puberty 80 ” ” about Virility 75 ” ” seldom more than (after 60 yrs) 60 ” ” More frequent in persons of short statue, those of strong passions of mind, those of great muscular exertion and in Females. “Good.” Quantity of Blood in the entire System. – Muller & Abeildgaard estimates y weight even in an adult at very little more than 8℔s Borelli at 20th Planch 28℔s Haller 30 Dr Young 40. Hamberger 80 & Keil 100℔s. (Good) Blumenbach states the proportion in an adult healthy man to be 1 to 5 of the entire weight of y Body. – The mean numbers as those of Haller & Young making y Amount fm: 30 to 40℔s appear most reasonable. – “Good”. – Pulse in an adult male of good health and not too corpulent the Common Standard of y Pulse may be fixed at 70 strokes in a minute 52 Asthma Spasmodic. visceral obstruction Stram, overcomes this action or irritates & produces one of its own. Digitalis 149 Asthma Musk 179 Castor 181 Amber 184 ” Spasmodic Asafoetida 197 Asthma Iron 231 is recomended by Dr Bree during the intermission [Angina 55] Asthma 56. Camphor do Spasmodic 94 Opii is paliative if there is [no] of y Lungs (blood vessels) hence it should be combined with Ipecac or Antimony in y form of Diaphoretic powders. Stramonium I have used y seeds with y best effects one patient to whom I gave it had been skillfully treated in this Country & in England had taken Antispasmodics. Had recd more relief fm. Lobelia Inflata than any thing else this after several paroxisms lost its Effects He consulted me about Smokeing Stram: I told him to use it. if no effect to send to me for some pills which he did I sent them told him to take 1 every hour untill relieved 4 grs completely removed y parox: he had taken as many as 6 in 4 hours ꝶ Stram: ʒi Myrrh ʒi make 60 pills. Asthma often arises in consequence of [Viceral] irritation fm: 53  54                            leaf – A B  leaf – B #14 Philadelphia January 1st. 1827 A few of the Lectures as delivered by Dr. Chapman Professor of Theory & Practice of Physic in the University of Pennsylvania copied during the Winter of 1827 by Asa J Driggs  1 The order in which Professor Chapman treats of Diseases. 1st. The Circulatory system consisting of y Heart & Blood vessels. – 2nd. The Digestive, consisting chiefly of the alamentary Canal. 3rd. The Respiratory consisting of y Pulmonary organs. 4th. The Absorbant. consisting of y Lacteals & Lymphatics. 5th. The Secretory consisting of the Glands 6th. The Sensitive consisting of the organs of Sense. Nerves. Brain & Spinal Marrow 7th. The Muscular consisting of y Muscles Tendons & aponeurosis. – 8th. The Cutaneous consisting of the external covouring of the surface of the body. 9th The Osseous consisting of Bones & there imediate apendages. 2 10th. Generation consisting of the Genitals of both sexes. – It will be eddy under these heads to comprehend all the diseases to which our nature is liable without any reference to their alliance & Affinities. Though I drop the old arrangement I shall however retain the names these being sufficiently expressive & having been generally adopted have become the language of Medicine. To change is always more or less evil & I am not sensible that in any case is it more inconvenient than in y nomenclature of Sciance 3 1st. Diseases of the Circulatory System. – Of Fevers. – I shall now commence with dis of y circulatory system & first of Fevers. – They are by far y most common of y complaints of our nature & as they afford general principals on which y treatment of y dis must be founded I shall dwell on thru at some length & with more than ordinary minuteness. It is computed that more than half of the deaths amoung y human species are produced by febrile affections alone, What is y nature of that Dis which has been denominated Fever! Ever since y dawn of Med. sciance this question has been [???ated] & still remains the febrile affections are so numerous & diversified, fluctuating & so much under y dominion of those causes which [moaf???] dis, action that they perceplably change thin character & one description cannot be appropriated to y whole class. – Cullen who is chiefly followed on this subject defines Pyrexia to Consist in an increased heat 4 frequency of y pulse comeing after shivering accompanied with a disturbance of many of y functions & diminution of strength especially in y limbs. – Now though this diffinition is as unexceptional as any which has been advanced it will not be difficult to show that haraby symptom which has been mentioned is an universally necessary attendant. That an increased [crossed out] of [y] heat is not a sign of fever is allowed by every one are this not onaua cases where y animal heat arises above the natural standard & do we not often see instances when it is lower. The senses here are not y proper means for measuring y degree of heat. The feeling of y individual is often entirely delusive so much so that at the moment when he complains of excessive wampth he is often really colder then sedual is converse equally hot as true sensations of cold often accompany a high degree of Thermometeral temperature. Now is it true that it is always preceded by a chill? it is indeed except in some 5. particular cases comparatively of rare occourance in febrile affections. _ As relates to y Pulse there is every variety as a general rule it is more than naturally frequent in Fever. but y exceptions are numerous & in certain cases when y Brain is effected it sinks to hlf its standard. Besides by exercise & other causes the pulse may be made to beat with much more than ordinay quietness without impairing health or assuming a morbid condition. Frequency of the pulse therefore is not a nessary ingredient in fevers. – That a disturbance of y Functions & Lasitude occour in this dis is not demed but they are also insecdent to many depraved conditions of the system is sufficient of itself to deviate from fever. – Y But to arrive at a satisfactory conclusion we must consider all assembled & also circumstances hereafter to be mentioned. – The most natural Division of Fever is into the Intermittant, Remittant & Continued 6. 1st. of Intermittant. By Intermitt is ment that fever in which there is a [crossed out] sucession of Paraxsms between which there is a distinct & perfect suspension of symptoms take place. _ The Interval between the Paroxisms is in Pathological Language denominated Apyrexia. – Different wordes have been used to name fever according to the length of [crossed out] y interval. When the [crossed out] Parox returns every 24 hours the the fever is called Quotidian. When it occours every other day or when the interval is 48 hours it is called Tertian. But when it is protracted 72 hours it is called a Quartan. – Of each of this primary types almost infinite varieties have been enumerated by authers as y double & triple Quartan by double & triple Tertian etc. By some of y antiant writers it was asserted by [crossed out] of that cases occoured in which of interval was protracted to y 5th. 6th. 7th or even to the 8th. day. This was affirmed by Hypocrates & confirmed by the testimony of 7. Boerhaave. – There are not wanting writers who have extended the period to 1 month 2 most even a Yr. conferring in these cases the title of Menstruae Bemen [stru??] & analar. When these peculiarities [crossed out] takes place they must be considered as anomalous deviating from the general character of the Dis & therefore deserving of little attention.- The 3 primary forms is all i wish you partic to recollect.– The Tertian is by far the most frequent & easy to cure Next to this in both respects is by Quotidian & y Quartan least: commonly accouring & is always obstinate in its management._ The 1st. occours generally in Spring & has therefore been called Vernal & the last appears at the close of fall & has been called Atumnal. By Cullen it is said that y Quart: is more common than y Quotia: wheather this was y case where he resided I cannot say but y whole current of experiance is against him & certainly in y W. of & those parts in which I am acquainted y fact is entirely different y Quartan in this city is seldem seen & when it 8: does occour arises from a protracted condition of y Quart. Each parox: of an Intermitt: is divided into y Cold, Hot & Sweating Stages y symp connected with y different stages are so elaborately detailed by most writers on this subject & y case so familial to you that a minute recitation on my part is rendered unnecessary. The Cold Stage is ushered in by Langour & sluggishness of motion yawning & stretching with some nausea or Debility of y stomach y face becomes pale & features shrink & y skin over y whole body is constricted as if aching with cold.- Not long after this rigors come on accompanied with spasm in y back & loins & Extremities y Respiration now becoming short & [difficult] distressing pulse small & sometimes very irregular copious discharges of pellucid urine is usual at this conjuncture. Somet: more allarming symp: appear as Coma Stupor which is some instances amount to Apoplexy. Y first stage somet continues for 1 or 2 hours when y symp. gradually 9. abate & y 2nd. stage comes on |Notes| the regors are somet. so severe that the teeth are shattered. Second Stage. This is marked by Heat extending over the body, redness of y face. throbing of of y Temples pain in Head Anxiety & Resttiness & some tendancy to Delirium. Y pulse slowly rises untill it becomes strong & exceedingly vehement these symp. continue for sometime but finally moisture appears on y forehead & is soon followed by a general sweat Y heat abates & y thirst ceases. Y respiration becomes free y circulation tranquilized & y functions are generally restored to their healthy condition. Y preceeding is a discription of a parox of Intim: fever as it usually appears. but it is somet: marked with anomalous circumstances. By Cleghorn & other writers we learn that y cold stage in some cases is entirely wanting. Somet. y hot stage is wanting & somet. preceeds the cold & it has been further remarked by Dr. Jackson that a paxoxcom somet. terminates by a copious secretion of Urine or Evacuation 10. from y Bowels without any perspiration or other irregularities not occasionally observable in Intims: they have been known the attack restricted to some one part of the body where y rest remained unaffected thus in Intim. it is located in one of the legs which goes through y cold hot & sweating stage with perfect regularity. I have seen it affect y eyes every other day it was attacked with extreme pain which after a while was cured which could only be affected but by y usual remedies employed for the cure of this Dis. – Not long since a young Lady consulted me on account of a violent pain she felt every other day in y lower part of her abdomen. As she came from J.S. it occoured to me that it might be another irregularity of Intermitt: accordingly after every remedy had failed which is usually employed she was cured with Fowlers Solution In y progress of our enquiries we shall have occasion to point out some curious facts of this 11. nature. Prehaps no Dis is more disguised under its forms than Intim: Fever, & as it exacts a prectum treatment it becomes important that y nature of y case should be understood.– As regards the course of Treat. a little controversy has existed. It is now pretty generally admitted that y most sources of this Dis are marsh Exhalations from Vegit & Anemic substances. Cold is a cause of this when connected with moisture or Bile in y stomach. Y origine of this was first sugested by Lanciss & Blalin who lived not long after the revival of Luting in Europe The observation of practitioners in many sections of y Globe confine y accuracy of his hypotheses but of y precise nature of this pestiferous miasmatas we are still entirely ignorant.– This much however is certain that they are, of exhalations of Vegetable & animal matter in a state of decomposition. Y origine of Intim: is sometimes involved in much obscurity.– It will occasionally makes, its appearance where there is no obvious source 12. of exhalations. In endeavouring to ascertain the cause we should not loose sight of this fact that y Miasmata are wafted by winds to y distance of 8 or 10 miles in a condition sufficient to produce the ordinary effects. No paint has been deseeded from [crossed out] more indisputable evidence evidance than that which we have just mentioned. but it is not less true that other causes produce fevers the paroxisms arising at stated periods. Whatever disposes the body so as to cause extream debility as. poor diet, great fatigue, mental anxiety, excessive evacuations &c. Are all known to excite Intermitt fevers when there is no reason to expect marhy exhalations. Next to these causes Cold is undutedly if most productive of y dis especially when united with moisture as in Damp Rooms. Beds Clothing etc. It has always been said that contagion is amoung the causes of this complaint this has been so well attested that it would be an 13. unwarantable species of [????p??oism] to doubt it But whenever Contagion proves y cause of Intim it always assumes as low type as we find sometimes in Goals. Hospitals & other crowded places: It has also been said to arise from Planatory influance by more than one writer. Tina believes it to aside from Lunar influance in some instances But there is no reason to suspect that these were the cause of y complaint. – Treatment. divides itself into two parts viz That which is proper during the paroxism & that which is required during the intermission or Apyrexia.– Taught by the example which nature affords us as soon as possible in the Cold State of an Intim then we imediately resort to y meds, which are best circulated this effect. We should have y patient placed in a warm bed drect as topical applications 14. hot bricks to y feet & a bottle of hot water should be applied to the extremities. warm beverages are now to be administered pure teas & when we wish any thing stimulating slightly Wine Whey or something of a Stim nature will answer very well.– Opii has been found particularly useful it is stated on y authority of [?rote??at] 1 or 2 grs of Opium at this time had Y effect of removing the Headache & rigors. – of exciting a universal glow followed by perspiration & thus producing a solution of y cold stage.– To y efficacy of this plan I can bare ample testimony of all y remedies that I have seen employed in this case Opii is followed by y most agreable consequences. 25 or 30 yrs since this treat. was recommended by Mr Nellie a Surgeon in Edinburgh we are told that y cold stage was imediately checked.– Y Tornequete acts very intelligibly by interupting y circulation through y Extremities such an accumulation of Blood takes place in y Heart 15. & great arteries that it exerts an increased action in these organs & a consequent diffusion of temperature over y Body. However plausible in Theory this plan was not found to answer y expectations of Practitioners. In y Hospital at Edinburgh it was tried & found of little of little advantage. Nothwithstanding y failure in y Hospital y auther is a man of high standing in y Medical World & published a Book to prove its great efficacy. This is one out of a Thousd. instances where different practitioners have obtained different results with y same remedy. – When y cold stage is very resolute fatal consequences ensues one of y best remedies to be employed is an Emetic it generally puts an end to this stage as soon as it operates. Hot. Stage. The Indications in y hot stage are 1st It remove y Irritation 2nd. To produce perspiration. Y irritation is generally produced by y presence of Bile in y Stomach & in such cases we should not hesitate to give an Emetic but if Vomiting has already occurred & there still be nausea you should 16. you are to assist nature by warm beverages as Camomile Tea or Warm. Water. – 2nd. Indication we must resort to Diaphoretics but all y European Meters & especially those of G. Britain highly recommend James's Powders but in this here it cannot always be obtained pure it is almost universally abandoned & some other Antim: preparations whose whose composed on & properties are better known have been substituted for it. as Antim: Wine. Small doses Tart. Antim: are commonly used & it is very common in y country to used strong decoct. of Cupatimune for purpose of producing perspiration. – It is an exelent remedy where others cannot be procured. On y authority of Dr. Lind Opii has been much employed in y hot Stage it is asserted by him to produce a solution of the [crossed out] paroxism & prepare y system for Bait. diminishes y danger of congestion in Viscera thus hinders y occurance of Schirrous alterations. Induced by my opinion for Dr Lind I prescribed it in 17. y Hot Stage though in direct opposition timing Theoretical views, in may instances it agrevated y sympts: y Headache was always increased y patient rendered, restless & y fever protracted. It is probable in Hot Climates as E & W. Indies where Dr. Lind practised Opii might have been of service in Hot stage on a/c of its tendancy to perspiration. but in this city & in y most temperate parts of y U.S. you will find my sentiments perfectly correct. – Where ever opii is at all indicated I give y preference to Dovers Powders thus a aminis. it proves diaphoritic & its stimulating powers counteracted. The Spts. Menderic is by fac the best diaphoretic [acetate ammonia]. this is to be preferred on several a/cs it is more prompt & certain its effects than any other it is moreover exceedingly grateful to the stomach & will stay when other articles are rejected. Dose tablespoon of y saturated Solution repeated if necessary. – Y practice above – [delai?] is applicable to mild or ordinary cases. But Intim: are [s?n?t] of an Inflam nature & y parox: is somewhat different 18 different from that already stated. They generally adopt this character in Spring & during y prevalance of Epidemics but y circumstances may be accurately ascertained from y case when if fever is m y type actuated to. the pulse is Vigorous & Strong. y face is exceedingly flushed. Respiration dificult – laborous acute local pain in Head. Sides. or Chest. Where y paroxisms are attended with these symp: it is necessary to V.S. copiously. y alamentary canal should be evacuated with powerful purges. – Intim: somet. appear in a very different Type insted of Inflam they adopt y Typhus Intermitt. when these cases occour & they often do in Hospitals & crowded places & During y prevalance of Typhus Epidemics a different treat. is demanded. – The paroxisms are to be treated with cordials & stimulating drinks & by y administration of all these remedies which are calculated to support y strength & tone of y system. 19 Treatment during y Apyrexia. – or y history of these remedies which are best calculated to ward off y paroxysm y most important of which is y Peruvian Bark originally introduced to y practice of Physicians in this Dis. It has maintained an undoubted superiority over all y remedies & y fluctuations of opinion & vicisitudes of practice to which our sciance has been subjected. Little adversity prevails at present as regards y rules forits administration though formaly no point was more unsetled. Among y absurd notions [of fever] it was though that y morbific matter might be thrown out by y paroxisms this was advanced by Boerhaave who said y bark was to be used “cum morbus [ale??otic] [d????] Van Swaten in his Comentaries united with him in this sentiment which was also conceived by Sydenham & all y eminent practitioners of that period Secretly y revers of this is more generally held to be y proper course & y fact is fully established that y earlier we commence with y Bark y more speady & prompt will be y cure 20. Y only circumstance of account which would cause delay is y condition of y Alamentory Canal & somet: perhaps of y system generally. Doubts are entertained by several writers wheather it is really necessary to prepare y system in any way for y reception of Bark & I am acquainted with some practitioners who says it is of no utility in this dis. But this is by no means y common opinion of y established practice It is now pretty generally conceeded that though y Bark will occasionally affect a cure without previous evacuating yet as a general rule it is y custom either to evacuate by Vomiting by purging previously & for this purpose y Emetic Tart. et Calomel are preferred. Harvene in times especially in this part of U.S. they have in a great measure given way to y Mercurial [crossed out] preparations they enerally answer where Emetics can hardly if at all be dispensed with they [op??ly] in such cases not only evacuating y Alamet: Canal 21. but also make a powerful impression on y Stomach & thus disarming & braking down that chain of & perverted association which Intim: & other Penoacedl Drs. seem to depend. Of y nature of Emetics my own observation affords me abundant conclusive evidence But besides these evacuants V.S. is demanded. – In y commencent of Intim: there is always more or less Inflam: Diathesis kept up with considerable pertinacity without y loss of blood & pretty copiously too y Bark would be rejected from y Stomach & of no utility & if it was retained it would only aggrevate y symptoms by its effects. My rule is never to resort to bark untill I have prepared y system by Evacu: so as to receive the proper impression from this valuable, remedy. By pursuing this course adopting y remedy to 1 state of y system I can pronounce that y certainly of its effects are such as almost entitle it to be considered at present as it formally was a Specific in Intim: fever: This species of fever is not unfrequently associated with obstructions in 22. y Viscera. Obstructions of y Viscera. when this exists Bark has been held to be inadmisable. That cases of this kind exist says Cullen where it is improper to administer y Bark I have not to determine; but I am well persuaded it is dangerous to adopt any such plan as a rule. I am convinced that in y cold stage of this fever an accumulation of Blood takes place in y Liver & Spleen which is increased every repetition of y cold stage &c. Y practice in regard to this point may be readily adjusted. In Visceral obstructions when Inflam: accompanies y Dis I would never hesitate for a moment to employ y Bark so as to put an end to y Dis. In other cases where there is pain in y Viscera & actively of y pulse indicating some local Inflam. Bark is mischievous. – We should have restort to y Vesicating applications or a slight degree of Saluvation which will commonly do away y obstructions. But if there be severe pains & y case is decidedly Inflame: we 23. should use directly evacuating remedies & of these V.S. is decidedly y best. – There was at one time much debate wheather or no y Bark should be given emediately preceding y paroxism. Cullen was decidedly in favor of this practice but I consider him to be wrong determining from my own experiance I should avoid administering it at y moment of y anticipated attack as I have found it aggrevate y paraxism by increasing y fever & distressing y Stomach. Some practitioners go so far as to contend that there should be no remission in its use that it should be employed in every stage y paroxism. Dr. Clark who wrote with great ability on y Dis of Tropical Climates is among those who strenuously recommends its use in this way as yet I have never been induced to follow it because I have always observed when Bark was given even when there is a slight disposition to fever it is productive of mischief. It is a rule established by y ablest practioners is rare there is a slight indication of an accession of y paraxism y Bark should be discontinued 24. Y ordinary mode of administering Bark is in Substance with water. Wine. Milk or Deluded Ardent spts. But milk has always appeared to me to be y most agreeable veicle. y Dose of y powder in ℥i or ℥ii repeated as often as y stomach will bear so that ʒi may be given in y ordinary intermission In y Tertian more than this is necessary it is y practice in y W. Indies to take ʒii in y morning at once & to omit in y other part of y Day. y tale Dr. Dallas was from that part of y country & was y practice that prevailed there whoever had an Intermitt took ʒi Bark early in y morning y sucess was in this case complete I never knew him fail to effect a cure in 2 or 3 ds. I doubt wheather y practice would be imitated fur stomachs will bear y Bark in as large a dose the fact however is interting & I thought worth recording as cases may occour where y method proposed may be advantageous. But in some persons such as y irritability of y Stomach that Bark in Substance 25. even in y minutest doses cannot be retained on y Stom: In such cases we must apply to y Infusion or Decoction either by itself or in combination with some aromatic such as cloves. Cinnamon or Orange peel. or Serpentaria y last to be prefered it renders y mixture agreeable to y tale & comfortable to y Stomach & much more efficatious a combination of this kind may be employed when Bark must be forbidden tis particularly adopted to Children & delicate persons.– But sometimes Bark purges its efficacy is abated when this appears. Small doses of Laudnum are to be given. When it produces constipation of Bowels as it sometimes does small portions of Rheii may be used. – [N.B. y Sulph Quinine is y active principle in Bark one gr. is equivalent to ℥i of Bark either given in Solutio: or Pill. R Sulph. Quinine qr.viii. Acid Sul: dramatic: ℥ss Sac alba ℥i Ess.menth aqua font ziii frat. mist. This forms a super sulphate Dose at: spirm: It is restricted aperxia y Est. 26. is y radium remaining from y manufacture of Quinine. Dose same as Sulph. Quinine. – Now & then Intim: is attended with great Acidity of y Stomach it is customary under such circumstances to combine with y Bark a little Magnesia & a minute quantity of Veritable alkali. – Notwithstanding y variety of means in order to attain a proper administration of y Peru Bark they are often defective during to a peculiar irritation in y Prime Via causing it to be rejected by vomiting & carried off two suddenly by y Bowels so that it can produce, no salutay effect. In cases of this kind it is usual to resort to Injections. – I have never used Bark in this way except in Children & therefore can say but little as to its efficacy. Possibly it may be useful in some cases but you will hardly ever prevail upon an adult who has used it once in y form of our Enema to submit to a repetion as often at least as will be necessary to effect a cure. – Besides you will 27. after be defeated by y irritation which exists in y Bowels. either previously or inaua by y measure & which amounts to such a degree as to render it almost imposible to retain y Injection. However as you may have occasion to use y Bark in this way I will give you y proper formula R. ℥ii or iii of y Dowan is to be intimately mixed with some mucilage, as common starch. Flaxseed tea made rapy or a Solution G. Arabic to sooth y irritation of y bowels. – It is customary to add a small quantity of Laudnum as y desine is not that y Bark should be evacuated but retained. – Bark also has been applied to y surface of y body y method of doing this is different. By some it is recommend. to apply in y form of a Cataplasm or poultice med of y article placed over y pit of y Stomach. By others a W. Bath either topical or general of y Decoction is prefered. – It is stated in authority of sufficient respectability to be entitled to confidance that Intim: may sometimes be cured by an emission 28. of y feet in a decoct. of Bark. – It is probable that a general Bath imersing y whole body would be much more efficacious. As a remedy in Intim: I have never employed y Baths but they have been used by practioners in y county who report in its favour one of a decided nature. When I have use it, it has been with a design to check violant vomiting especially in Pestilential Fevers. Cholera morbus. Cholera Infantum under such circumstances it will as soon sooth y irritability of y Stomach as any other remedy that can be employed. Its mode of Operation is very inteligible Creating a Tonic impression on y Skin between which there is a consent of a very intimate kind impacts tone to that viscus & thus retains its ordinary motions. Bark has also been employed in a dry state in this Dis: as an external application. It is said by Darwin that if y sheets are thougherly strewed with y powder of a Bark y Individual who sleeps in them will be cured if he had y: Dis. To believe 29. this even on y respectability of Darwin requires a considerable strech of credulity.– But when y Bark is applied differently there can be no doubt of its efficacy. the mode alluded to is that of Quilting it into a jacket & wearing it next to y body doubts have been entertained wheather thus used it had any effects most indisputably it does. When applied to Children in early life & Women of extreme delicacy. After all however it will be found to fail & when compared to its internal administration is entitled to very little confidance. next to Bark in Intim: may be marked Serpent. Serpentaria. The mode of using it origianlly employed by Sydenham. was with Wine. – As a general rules says he all case of Intim: where wine is indicated its efficacy will be increased by Serpentaria. – “Wheath it is adequate to y cure of confirmed cases of y Dis. I cannot tell with certainly. But in y milder shape or where y type is contagious partaking in some degree of y Remitt 30. character it is a very efficatious remedy & a preparation of Serpentaria has been employed with advantage in y worst forms of Ague & Fever y formula is as follows viz Rx Cort. Peru: ℥ss. Rad. Serpent: ℥i Curb Soda gr 30. This are to be imediately mixed & divided into 4 powders one of which is to be taken every 4 or 8 hours. Why y serpentaria thus combined & with so small a portion of vegitable alkali should have its powers extrordinarily increased is difficult to determine but of its efficacy there can be no doubt y preperation was employed for more than ½ a Centaury ago in this section of y Union & has received in its favour to y extent y testimony of established practitioners. – Nothing is more idle than a prior speculation of y Modus Operandi of meds. we are never certain entirely with respect to y accompanying circumstances & in most instances are content with fact alone if it be fully corroborated. Of y remedies afforded by 31. Our own country for Intim: y Eupatorium Perfoliatum. is possed of great powers. It may be so prepared as to be Diaphoretic. Diuretic. Emetic or eminently Tonic. by its Tonic powers it is most efficatious in this dis. for its diaphoretic powers it adopted to every stage in y Dis possesing in this respect a diseased superiority over other remedies. It may be employed indeferently either in y hot or Cold stage of y Paroxism. Its tonic powers are best obtained by administering it in powder or even in Decoction, This remedy has been much employed in Philadelphia & my Friend Dr. Hossack has informed me that it has completely supplanted y Cinchona & Fowlers Solution in y practice of several Physicians in New Jersey. – There is another species Eupatorium Pilosum known by y name of Hour Hound which is possesed of equal virtues though it is some what medicinal. Y Dose of C. Perfoliatum is 20 or 30 grs or a Wine Glass of strong decoct every hour or two. – In our enumeration of articles adapted to cure Intim. 32. y Chirona Angular is or Centaury is not to be overlooked it is different in appearance & medical effects from y Eupatorium. – It may be employed under all circumstances of y Dis. & is somet: given to advantage when y Bark is inadmisable. – It should be administered in Infus or Decoct: & in such quantities as y Stomach will bear. Though mosily employed by country practitioners it is also used in y city & we have abundant reason to be satisfied with its effects. Bane fored we have 2 species of Dogwood which are possesed of Tonic Properties y Cornus Florida & Cornus Terecia or swamp Dogwood. The Back is y only part used in Med. & may be given in doses & in same manner as Cinchona to which from a careful examination of a graduate of this University it is closely allied in its chemical Compo. & medical properties. – As regards myself I have no experiance in this article. But it is so highly extolled by others that I though it my duty to mention 33. mention it. Athia to y Dogwood in med. properties is y Prunus Virgmiend or Wild Cherry Tree. I have little doubts of its beneficial effects; Professor Barton & other practitioners have used in with advantage. – Another of our Native Tonics is y Prunes Verticelalus Black Elder this has also been used. what powers it posses I am not able to determine from my own experiance. By y late Profess Barton his correspondance it was highly recommended y Bark of y Root is y part employed & is given in same manner at Cort Peru. Many of y Oaks have been used in Intim: & not without success. y White Oak approaches nearest to y nature if Peru. Cort. in its general property but y Chestnut Oak is prefered by y City practitioners I have no experiance with uthre. – Several Species of Willow are not without power in y cure of this dis. y White Willow has been found superior in this respect. This bark may be given in substance or decoction same as Cinchona The Willow of England has been much used in 34. this dis of late & y writing of Willingham & others are in favour of its efficacy. It is now 30 or 40 yrs. ago since y Liriodendron Tulipifera or y common Poplar has been used in y management of this dis I have no experiance with it but by Dr. Rush & Barton it was commended y former introduced this article into practice in Fever & Ague. when that Dis prevailed in y Revolutionary Army, he considers it inferior to cinchona y Bark of y Root is employed in substance or decoction & same dose as y above articles. These are all y articles which have been found useful & which are indigenous to our Country. They possess [crossed out] different powers by which they are adapted to peculiar cases. Some of them are productive of much good & as they are read to access to those who have settled in y country & thought it right to bring them before you. Next I am to address your attention to some remedies whose qualities we are well acquainted 35. with & which therefore not only this account but they posses superior virtues & are therefore more worthy our regard. Nota little has been said within y last, 20 or 30 yrs. of Angustura as a remedy in this dis. When originally introduced into y management of this dis, & such was y confidance it inspired that it proved for a long time superior to Cinchona & other established remedies. But though known only for 20 or 30 yrs yet so completely has its virtues repressed that it becomes exploded from y treat of y Dis. Recently however it has been revived by some of y Europan practitioners those of London & some speak so confidently of its powers that must have been precipitately rejected. It is highly Aromatic & Cordial moreover it is not a little Astringent & perhaps will be found best adopted to these cases which are accompanied with irritability of y Stomach & Bowels. It will sometimes be retained when Bark is rejected y dose is generally from 36. ℥ss to ℥i at time repeated pretty much as y Cinchona. Not many yrs ago Mahogany called in Sciantific Language Casyania febrifuga or Angusturæ was recommended very strongly Dr Rocklove in Intim & Experiments lately made by many practioners revive y sentiments of that writer. As it has in some degree y properties Angustura it will be found prehaps proper to administer it under y same circumstance. A variety of [crossed out] remedies have been used as remedies in this dis. in a grater or less degree they are all possessed of y same properties with y preceding articles & should be used in a similar manner but from my own experiance with them I should not recommend them strongly. They may all be employed in decoction. Infusion or Powder as y Cinchona. – The wood Quassia. has been much used I have employed it but have no occasion to 37. think it at all calculated to meet y severe attacks of Intim: - Though temperate in his opinions & cautions of recommending Meds. Dr. – in this particular instance departed from his general practice & displayed some enthusiasm in y praise of Gum Kind. it is undeservedly stated by him that in Intim: of y most obstinate character may be cured by this medicine as soon as the Peru Cort & other active valuable meds. - In this light it was used much some practitioners rely much on y authority of Dr. Fothergill he had great confidance in its powers. In acting from my own experiance & those of other physicians for whose opinion I have great respect I should say it is incompetent to cure intractable cases. But exhibited with Bitters & Opii its efficacy is greatly increased & in some cases those combined have formed a valuable remedy. Y best form for using is y following R. ls. Kino Zii Rad. Gentian zss Opii grii y whole to be divided into 10 or 12 powders one of which may be given every 2 hours. – It does not appear 38. why this combination should increase y powers of this remedy, but of y fact there can be no doubt. The last of y Vegetable remedies is Charcoal. This has very recently been mentioned among y others it appears about 6 or 8 yrs ago Dr. Fr – in Salisbury tried it in this dis y Physician on this station in y British forts Dr Lalbect was induced to try this Med Determinging from respect to this writer we should be led to conclude that it is a ralnath remedy connected with Bowel Dis especially dysentary. o On y authority of this writer y remedy within y last 12 mos. has been used in this city in 2 or 3 [cases] practitioners have employed it in y public Institutions & not without advantage It has been prescribed by some in a great quantity of cases. But what I have seen of this it is entitled to your confidance One of y members of y Class has had an an Ample opportunity with this Med: & I have learned it proved successful where y Bark & Arsenic had failed for reasons 39. hereafter to be mentioned. I should prefer it where there was a little Dysenteria connected with y Dis, a t. spoon should be given every 2 or 3 hours during y apyrexia. – Sulpher. not y least valuable of y remains employed is sulpher. – It was first used about 30. yrs ago by Dr. Lysenger who writes In y anomalous Fever of y Isle of Batavia he prescribed a t spoon mixed with a little ardent: Spts: At one time I was inclined to believe its efficacy was ascubable to y ardent Spts. associated with it but wide experiance has taught me different during y Cast few yrs I have used it much in this Dis & am persuaded that it is possed of great powers. It acts independantly of y Spts. which is proved by y circumstance that it is not less efficatious when mixed with Milk. Molasses or any other inert vehicle. But y power of Sulpher is not restricted to Intim. fever no remedy I have used is so efficatious in checking y fever of Irritation I mean y Hectic Fever 40. wheather arising from absess of y Lungs or else where It affords me great pleasure that I have y authority of Dr. Physic for views which I present to you on y powers of Sulpher. He goes father & declares that judging from his own experience there is no remedy so useful in anomalous fevers especially of y periodical type. He does not limit it to Intim fevers but extends it to all such Dis. as occour periodically especially Periodical Headache I am inclined to believe that it is not without in such Chronic Nervous affections of an Intim: nature. It is true that we do not perceive its secret effects on y system but on this account it is no less powerful. – We see y same thing in Arsenic Mercury &c. Y mode in which I am acustomed to use it is at such times & in such doses that it will not exert its purgative effects this end is generally answered by giving 30 or 40 grs every 3 or 4 hours. On y authority of Dr. Monroe & one or 2 others y Blue Vitriol or 41. Sulphas Cupri has not been a little prescribled in this dis. It is allegra by more that while Physicians in general to y British Army in y Netherlands he was able to arrest Intim: fevers by this remedy where all others failed to y same point goes y testimony of Dr. Adams & others y following was y formule Rx Pulv. Cinchona grs 32. Sulph. Copper gr. 4 to be made into XV pills one of which is to be given every 4 hours. Wheather this remedy is always as powerful as represented I cannot pronounce. Those Intim: in which I have employed it I have found it most advantageous in old Quartans. On y whole y evidance is not so strong y as to induce me to recommend it highly. – Dispersed through practical writers some evidance may be found of y Virtues of y Cuprum Amoniacum. It has not been strongly recommended to our attention. When used it should be administered as y preceeding remedy Nearly on a footing y same should I place y several preparations of zinc those have also been employed 42. employed by different practitioners but I do not know that proof is strong enough in their favour. They are all used in Chronic Periodical Affections & might prehaps be useful in some Intim. but I can say nothing from my own experiance. – Amoung y remedies we are enumerating few have a higher claim than Alum. It was long ago prescribed by Cullen in combination with mutiny But he says though combined with this Aromatic it often produces naucea & is rejected from y Stomach so that he has not much confidance. By y celebrated Dr. Lina who used it in y same manner a different statement is given he ranks it next to Cort. Peru: & observes that it is greatful to y stomach & if continued with aromatics rarely occasions distress in that organ. As regards my own Experience I cannot say much respecting it. It would appear however by y testimony of others that it is not destitute of powers. Dr. Chalmers of Charlston thinks it paticularly 43. useful in this Dis, & in Remitt: fever of that part of y Country y same statement is made by Dr. Adams with redard to y fevers of yc W. Indies. Dr. Darwin says that it has considerable powers over Intim: but more especially when associated with Dysentary y proper doses is from 5 to 10 grs. but y Stomach will not always bear so much in such circumstances y quantity should be reduced. – Sugar of Lead is one of y articles lately [aar??] to y Catalogue by some practitioners particularly of y U: States it has been highly extolled. It was a favorite remedy of y late Dr. Barton during y late War It was used in Intim: which occoured amoung y troops on y Canadian frontiers. – I received an account from Physician attached to y Army that it had exerted greater powers than y Bark or Arsenic but I believe there was some deception in y case Determining from what I have see of y Article it does not deserve much esteem my own experiance is much against it. As nearly allied to y preparations 44. of lead I shall [mention] say a few words on Arsenic. In y estimation of y generality of practioners this article stands not on point of efficacy to y Peruvian. Bark, that it has done good in Intim. cannot be denied but when a physian expects from it uniform sucess he will often be disappointed. Wheather this proceeds from an inherent deficiency of y powers of arsenic or from y indiscriminate mode of prescription I am prepared to say this much however. I can inform you that in weak and debilitated states arising from old age or debauchery y arsenic will unfirmly fail. this is a feat might be expected & Barks many other remedies employed in this dis. are Tonic in their nature & act by imparting tone to y stomach & through y system generally. Arsenic has no such properties though commonly ranks with this class of meds. by writers on Mat. Med. Its principle opration is to create nausea weakness of y stomach & debility 45. of y system which is indicated by a feeble pulse cold surface loss of general strength & muscular relaxation. But even when employed it sometimes fails compared with. Bark it is acutialy inferior to bark & should never be employed when that article can be obtained, The cases in which it is best suited are such as occour in children & in [person?] possesing considerable vigor of Constitution associated with febrile condition. It acts powerfully on y system of children & on account of its berry without taste & in small bulk will be taken when others would be rejected. It has been a subject of debate wheather y arsenic should be continued during y different stages of y dis. My own experiance has taught me there is no precise rule on y subject the only objection against its employment during paroxism is y Nausea & Vomiting which it is apt to produce especially in y cold stage where there is great imitability of y Stomach, Arsenic is prompt in its of operation therefore if no decided 46. operation or advantage is experianced in 6 or 8 ds. it should be discontinued. It only debilitates y. system & produces a long train of unpleasant symp. as. Debility of y Stomach. pain in y Head. Oedematous swell in qs of Extremities. It has lately ban alleged by high authority that when arsenic does. not suceed by itself it may be renamed very efficatious by combining it with Cinchona this is Sound practice & I have imitated it with advantage. Arsenic is said to prepare y System for Bark & when Intim: does not early yeald it has been recommended to have recourse to this article & afterwards to use y Bark. – It is not [crossed out] more a yr that y Web of a common Spider was considered by me as a remedy exceedingly efficatious y fact I derived from Dr. Jackson who was inspector of y British army. On a revisit to this city he informed me that he has found y web one of y best narcotics exceedingly efficatious in quieting irritability Cordial to y whole 47. system & often producing sleep. he farther added that it was y best remedy known to him in y toat of Intim in all y stages. It is not in my power to testify to y accuracy of this account from a great number of experiments but y few trials I have made satisfied me perfectly well that y statement of Dr. Jackson was correct y article certainly is Sedative & Narcotic I am not without reason to be lure that it is useful in Ague & Fever. A gentleman of this class has written a valuable assay on this article from his own experiance & those of others who have been made this communications. I believe it to be a valuable remedy I recommend it to you. You need not be careful in selecting y Web. if any spider particularly as y species of spider are possed of y same properties. – Before dismissing y Meds. employed me Intim: I will notice one which deserves our notice. It is more than 15 or 20 yrs since y practitioners of France in a tone of confidance recommended Animal Gelatin. Gelatine In Intimittant 48. Gelatine: From y Known properties of this article little credid was given to y accounts. but I find at length y English practitioners have recommended its use & some concour in granting it thier surport. By y writers common Glue was employed. The English physicians believing that Calfs foot. Gelly is equally powerful & knowing it to be much more agreeable they commonly have recourse to that preparation. The only case in which this remedy has been used in this city was mentioned in this city. Dr. Griffiths told me that in y case of his daughter who for many months had been affected with Intim: & in whome y other remedies had been used in vain succeeded at once affected a cure by y administration of this remedy. Nothwithstanding y numerous remedies which had been used or mentioned for y cure of Intim: it will sometimes baffle our best directed efforts & continue its course in spite of all any exertions Cases of this particular Obstinate Character 49. depends most commonly on congestion or some other dis of y Viscera & confirmed by long habit. It is our duty in such cases to resort to Mercury. Mercury in Congestion gradually inseminating it into y system untill saliration which is to be kep up 2 or 3 weeks without interruption. This properly called a Revolution going remedy by which such changes are produced in y system as to suppression decour y prexisting dis. As a substitute for Mercury Blisters have been found highly useful these should be applied to y extremities & not dressed or hastily they operate nearly on y same principle as Mercury viz they create a counter impression which interupts & destroys this contamination associations on which y Dis: depends. When all these remedies fail however as a resort we should direct our patient to take a protracted journey so that exercise of Gestation change of Scenery y noval impresions derived from a different climate & other causes may operate 50. in producing a chain of [cross out] actions which may supercuary old; I will now speak of those remedies which are calculated to [produce] meet our indications in y Apyrexia or those which are given just before y expected recourance of y paroxisms. It is y common practice to order y patient go to bed & to take Opium as Dr. Frotter has recommended it Warm Beverages are also directed for y purpose of producing perspiration: Ether is a prompt. powerful & diffusible Stimulant & from these properties answers very well. At y time under consideration you should warn your patient not to over load his stomach about y period of y expected paroxism as nausea & Violant Vomiting might thus be occasioned. Cases are indeed recovered when 6 or 8 hours fasting has cured y dis. Any great change my condition of y Stomach would answer y same purpose. By some practitioners a very different mode is employed 51. They make y strongest possible impression on this Viscus by stimulating meds. strong spts Liquors either alone or impregnated with Spices have often been used & no doubt have proved advantageous. In fact whatever makes a strong impression on y system whether through y mind or Body will often suceed. – In every Intim Emetics given before y paroxysm have a powerful effect & Blisters applied at same conjunction not universally of y attack It is y imperious duty of practitioners to endeavour to cure Intim: as speech as possible there is modis. no Dis. so disagreable to y patient & though not imediately fatal is apt to degenerate into complaints of a very serious nature thus Intim: after runing into Continued fever sometimes of a Typhus nature & nothing is more common in children than for it to terminate in Hydrocephalous Internus y more common remote consequences are Congestion of the Viscera. Schirrus. Indurations & cancer conjoined with Dropsy & deprivation 52. of y system. No opinion is so absurd & mischievous than that which was advanced by Boerhaaves & adopted by many other practitioners. That Intim: are salutary in their primary operations & unless of a malignant type are not to be suddenly supposed by artificial means, nevertheless it cannot be denied that Intim: sometimes supercedes other diseases of a very formidable character. Gout. Rheumatism & cutaneous affections. In many of y Spasmodic or Nervous Dis. as Chorea. Epilepsy Asthma. Hysteria. Dyspoenea are some of y affections which yeald to an attack of Fever & Ague It has been ascertained that Intim: after they have become completely established in y system are sometimes competent to y cure of Pill Consumption I have already mentioned that it was y practice of some of our older physicians of this Town to induce this species of fever as a remedy for Consumption. But I will hereafter show more particularly y advantage of this treatment. 53. y same effect is sometimes produced in melancholic & y periods forms of Insanity. It was y custom of y physicians to take y maniacs out of y Hospitals expose them to y sun & send them to Miasmatic countries that they might be attacked by y fever & Ague. Though this practice did not always affect cures yet a sufficient member occoured to show y power of y Intim, action over such affections. As y predispositions to Intim. is in y system for a long time after y cure has apparently been affected y patient should studiously avoid all exciting causes as Exposure to night air or to cold & damp atmospheres under any circumstances. It is always proper for some time after y cessation of y Dis that y use of Tonic meds. should be continued Rubigo Terri never to leave y house with an empty stomach. Wine Porter Strong Cider &c 54. 56. Remittant Fever. – This is mere modification of y preceding Dis Cullen very properly condemned who considered it a distinct species of fever most undoubtedly he observes each arises from y Same causes each is epidemic & each are cured by y Same remedies insome instances in y same person y Dis alternates All this must be added as perfectly true but as they demand a treat. somewhat different so they ought not to be confounded. By Remitt we mean that species of Fever in which y attack abates without entirely going off y remission occours at irregular periods & is uncertain in its duration. Somet: it continues for several hours & at others y interval is so short as hardly to be perceptible. Remitt is produced by all y causes which was said to give rise to Intermittant hence it is most common in low mash situations in y autumnal season & when there is great vicisitudes in y weather as intense heat succeded suddenly by heavy rains. As in y Pyrexia 57. of Intim: y attack is proceeded by languor heaviness restlessness & alternate fits of heat & Cold. As soon as y fever proceeds to y 2nd stages y patient experiances pain in y Head & back & heat over y surface of y body. When this stage is fully formed there is difficulty of respiration & depression of spts. to these are added a White fured tongue a full strong pulse a sallow skin & eyes tinged with Bile. Nausea & Vomiting of Billious matter, a sensation of heat & pain in y pit of y stomach. After a continuance of these symptoms for a time y fever abates considerably & goes off with perspiration more or less copious But in a few hours it returns with y same appearance as before & thus with Exacerbations & Remissions it proceeds untill it terminates fatally or is cured or as sometimes happens in another form as y Intim: or Continued fever. Such is y Ordinary character of this dis. But under different circumstances of Climate Situation or Constitution of y patient assumes different appearances & is 58. associated especially with y inflamatory & malignant Diathesis. As regards our Country it is generally a Dis. of increased action requiring active antiphlogistic measures & in this this light I shall now consider y Treatment of Remittant Fever. The principle Indications is to induce an Intimission & y course is pointed out y Symptoms it is proper always to commence with V.S. This is particularly indicated by y pulse a hot dry skin determination to y Head & a variety of other sympt. The next remedy is an Emetic with a view of xciting Vomiting when called for by y State of y Stomach y Tartarized Antimony is always preferable. I mention this more particularly because it is generally y practice of Country practitioners to use Ipecac. But this is much less efficatious y Antim: preparations not only more completely empty y Stomach but makes a powerful impression on it so much so that it puts an end to y Dis: by in tempting & removing y primary morbid impression 59. In many instances I have known Intim & Remit: cured by an Antim. Emetic operating in y manner I have prescribed to you To meet y same indication that is to evacuate y Alamentary Canal y Mercurial Cathartics are resorted to they are like y Antim: are to be prefered for they are Rinared articles they operate more efficiently in evacuating y Bile than other purges as soon however as y Mercurial evacuation is over we should resort to purgatives if a milder nature of these y saline are most generally used & y best are y Epsom & Cheltenham Salts y latter are made by evacuating y Cheltenham Waters or in imitation of Salts thus obtained & have been recently introduced into practice they operate in much smaller doses than y other neutral Salts are less disagreable to y patient & more evacuating y Aliment. Canal ʒi is equal to ℥i of Epsom. After such direct & powerful depletion from y Stomach & Intestines it will be proper to resort to y milder means of producing 60. Diaphoresis y remedy best adapted to this end are y Antim: preparations & y neutral mixtures y Spts Mendiri is also a valuable remedy in this place y action of these may be prompted by y Vapor Bath y best way of applying this is to pour Vinegar on heated bricks are to be wraped in flannel & applied to y truth & Extremities by this we can generally excite a copious perspiration. The Dis under such treat will most generally yeald in 2 or 3 ds. but if not y Emetic & Mercurial purgatives should be repeated again, evacuations of this kind are called for by y accumulation of Bile my Stomach which by irritation &c febrile action is kept up. – I have found Emetics to succeed y best as cooperating in y same intention. Vesicating Applications should be mad to y uper & lower extremities y mode in which they do good is sufficiently inteligible. by making a strong impression on y Skin they interupt that chain of actions constituting [fel??dles]. During y continuance of y fever some Subordinate affections occour which claim attention 61. There is after great heat on y surface of y Body which is very distressing to y patient. When this happens it may be relieved occasionally by sponging y surface with Cold Vinegar or very Cold water. You will thus reduce y temperature allay y irritation & render y patient much more comfortable. – 2nd. A determination to y head in this fever often occours & is indicated by a flushed face, wild expression of y eyes & Delirium or a tendancy to it. – This condition of y head is especially relieved by y application of Cups & Leeches & 8 or 10 z Blood may be thus taken with advantage. But when y Delirium appears to be fixed with y above may tie added shaveing y Head & apply a Blister to be continued at least 24 hours. It is a fact which ought to be rembered that [V.S?] should always preceed y application of a Blister. You will very generally find that a few ℥ of Blood taken by Cups & Leeches will do away y necessity of this last remedy. – It is proper to suffer 9 or 10 hours 62 to elapse after shaveing y head before y blister is applied as by thus doing you obviate y necessity of employing it. How y mere removal of y Hair should do away y Symptoms of Delirium is not very intelligible. Besides this advantage we derive another Viz an opportunity of applying cold to y head by means of cloths rung out in cold water or by use of Ice itself. – 3rd The common Symptom which call for relief during y continuance of Remitt: is Nause & Vomiting of Billious matter arising either from an accumulation of Bile in y stomach or peculiar irritability of that Organ, It is right to repeat y evacuations either by Emetics or saline purges but in a second case a different course is pursued; to quiet irritability is now y Indication for this purpose we have a great variety of remedies The common Effervessing or foaming Draught is exceeding useful when it can be obtained y Sedletz Water administered in small doses at short intervals will often prove advantageous 63. Mint Tea is also useful but infinitely y best is Lime Water & Milk y mode of employing it is a tablespoon of each mix them together and administer every 20 or 30 minutes according to circumstances not y least valuable of remedies for soothing irritability of Stomach is y infusion of Serpentaria dose a table spoon full. It is much resorted to in this city & posseses y confidance of many practioners. When y irritability of Stomach arrises from want of tone in that organ as sometimes happens when Emetics have often been given. Nothing is better than y tinct. Cloves given at short intervals in spoon full doses. As auxiliary to y above mentioned remedies. Fomentations over y region of y Stomach have often proved beneficial & y best of these is made by quilting Pulv. Cloves in flannel & wringing this out in heated Brandy. ℥ii Cloves is sufficient. Pediluvium of Water bath is also highly beneficial. But when y Vomiting is excedingly violant you 64. should apply Synapisms to y Extremities & Blister over y Stomach. But above all y articles calculated to check Billious Vomiting Opium stands prominent. It is a fact well worthy of attention that a pill of Opii which as been kept for 2 or 3 yrs will remain on y Stomach & Check vomiting when administered recent it would be rejected. If y Stomach will not retain y Opii though taken in this way we must resort to Anodyne Injections ʒi or more of Laudnum should be enveloped on a little mucilage & thrown up y Rectum. A favourate practice in this city instead of using anodyne injections is to employ Opii 3 or 4 grs. made into a pill & introduced 2 inches into y Rectum will often prove exceedingly efficatious. Y advantage of this mode are that it can be early employed, that we shall not have to encounter y prejudices of y patient & when y desired effect is produced we may easily withdraw y pill & thus prevent y consequences of an overdose. An intermission being effected 65. effected y Cinchona combined with decoctions may be given. But when any doubt of y absence of y fever exists, you should prescribe y Serpentaria. Quassia Angusturia, Eupatorium, Centaury etc. for reason which I explained on a former occasion. Arsenic will be found in some of these caces to answer very well. The only circumstances which allow y use of Bark while there is y least remaining fever is a palpable tendancy to a Typhus condition. But even here y Meds. will often be rejected & we should confide more in Tonics which add too then principle property that also of producing perspiration. Upon y whole however y Remitt of this country is of an highly Inflam: nature demanding copious depletion with y Lancet & evacuating from y Bowels – when these in y stage are so managed as to correspond with y Violance of y Symptoms no other remedy being imperiously required. – 66. Continued Fevers. These run their course without any intermission though some degree of remission & exercabation daily takes place. – It has been held by some writers that y deffinition is deficient is exceptionable because all continued fevers they say consists of a single paroxism without abdomen untill final termination. But I believe no such fever exists & am surported in my opinion by y highest authority except y fever denominated [in] which begins is perfectly formed & runs through its course in 24 hours which is of short duration & rare occourance. Every other febrile affection is made up as a repetition of paroxisms. – It may be remarked as a general rule that y Exacerbations take place towards morning & evening by consulting nosological writers you will find that this class of Fevers is ranously arranged however Inflam y fever is there is a local affection. I shall treat of them under y general head of Synocous & Typhus y different forms of continued fever may then be disposed of without - 67. deficiency of perspicuity or too great generalization Synocha. As ordinarily defined. I believe has no real existance. Every case at least which has met my observation has been attended with some local affection which has marked it as one of y Phlegmasia continued fever y most common in this country y Billious Inflamatory. This prevails in y U.S. to a great extent, with y greatest violance to y South & is varied not a little by y Climate & y Conditions of Society. Like y Dis already treated it arises chiefly from marsh exhalations but is common without them. It is also produced by other causes. Considering y close analogy of y origine of y Symp. & mode of cure & not to mention y other slight resemblances [t???un] y Intim: Remitt & Continued fever we have good reasons to believe they are y same disease with some differance in type & external Physiology. 68. Physiology. During an Exacerbation a Remitt. is precisely similar to a Continued Fever Billious so that an account of one will precisely answer for y other each being ushered in by y same train of symp. & attended by y same set of affections. Discharged therefore from y necessity of occupying our time with recapitulation of that which has already been said we will proceed to y Cure of y Dis before us but can we arrest y progress of y Fever after it is once established or must we be content with abating y more violant sympts. till it shall terminate spontaneously, this is a question of great moment has been tally discused by Cleghorn Hillary. Pringle & Fordyce. It has been answered in y negative. It is contended by y last particularly Note. Prognosis. If y pulse becomes full soft y skin moist y tongue clean y Urine depositing a White Sedament y prognosis is favourable. Dark tongue parched skin a cold dry surface irritable & quick pulse gastric distress etc y prognosis is unfavorable. – 69. But not only are we enabled to interrupt y carear but also that either addition too or subtraction from y cause producing it will not have y slightest influance. – In support of this opinion they appeal to Small Pox Measles & Dis which y fact is undoubtedly stated. Neither of these cases however abated in Violance can be cured by artificial means & neither of them are affected by y further application of y cause this is particularly true as regards Small Pox. But their reasoning is fallacious in as much as it is deduced from y cure of dis. peculiar in term & provided & governed by their own laws. As respects y common fever we see them daily checked by y remedies we employ. cant it be denied that they are interupted in their course by a timely recurrance to [V.S?] Evacuations from y alimentary canal & of a similar nature. Most admirably we see this happen every day of our lives & sucess are y trophies of our profession. At y same time we must concede that there is much difficulty on may occasions & hence 70. y precept with practical Writers “to attack y obis in the first stage” as there it is most easy to obtain a Victory Y doctrine above alluded to is highly pernicious in its particular tendancy & haveing arisen in y dark ages of Medicine Sciance & kept up as a respect for y authority. – It will not fail if credited to take away energy of practice to sink to irresolution & indescision in y management of diseases at y very moment too when exertion is most required. According to that you must remain an Idle spectator of y Ravages effected by y unrestrained & vehement attacks of fever on y Constitution. Let it not be supposed from what has escaped me that I am not at all inclined to deny that in fever there is a tendancy to solution or Crisis. This was early remarked by Hypocrates & has since been abundantly confirmed. Hence arose y Doctrine of Critical Days by which is ment those days [by] in which y fever is disposed to a Solution These according to Hypocrates are y 3. 5. 7. 9. 11. 14. 17 & 20. or as some authers will have it on y 21st 71. Every practioner of enlarged experiance must have witnessed a more than ordinary tendancy to a remission of y symptoms on some of those days. But such tendancy is not so clearly manifested our dis. as as in those which have occurred amoung y antients y reason of this is not obscure. You all know that y climate of Greece is equable & serene & that y people of that country in y time of Hypocrates still cherished y symplicity of their Republican habits. Diseases therefore prevailed with uniformity of character not being disturbed as amoung its by deviations from nature & by y changes of y climate. – Eternally fluctuating & unsettled attempts have been made to explain y recourance of critical as, on y supposition that Intim. are y primary types of all fevers & hence that continued fevers at first are Quotidian then Tertian & after y 11 day very generally Quartan. Wheather this be admitted or not y facts are important they teach us to watch y efforts of nature, to bring about a crisis 72. which is marked by Remission of Symptoms & that such is y case & time [cross out] most propitious for y administration of our remedies. – Treatments. – Early in this discussion it was remarked that y Billious Fevers are far y most Inflam: in their nature. This being y case y principle indications are very obvious viz to reduce arterial action to y ordinary standard. Confessedly to obtain this no means are equal to y Lancet. – Its operation under such circumstances is prompt & effectual. But in this dis it should be directed by judgment & tempered [cross out] by discretion. The same Complaint may be varied & none more than y one under consideration by Climate. Season by personal Idiosyncracy & by many other causes. This while in this part of y Country y practitioner found to bleed copiously was y only method of cure. while in y Southern parts y practitioners hardly ever opened a vein. – But no matter in what part of y wourld you settle do not refrain from depleting with y Lancet when it [was] is indicated 73. by a strong pulse a hot skin. delamination to y Head & other symp: of increased action. those symp. wheather They occour beneath y burning Trophies or amidst y Polar Snow’s or in y more genial Clime of y Temperate zone must be considered as signals held out by nature for succor from y Lancet & other evacuants in her difficulties & oppressing. Bleed often in Small quantities. – Next in importance are those Meds. which produce evacuations from y Alamentary Canal. These are called for in all Fevers but particularly in this on account of y large accumulations of Bile which are apt to occour. – My general practice when I can prevail on my patients to consent is a Emetic & as I remarked on a former occasion antimonial preparations are decidedly to be prefered. It will be perceived that I am decidedly an advocate for Emetics in this Order of Dis. any experience has pursuaded me of their superior efficacy to purge & I am surported in my belief by those. physicians who are acquainted 74. with y more inveterate shapes of Billious Inflamatory Fever. But that one may reap their good effects they must be repeated & in some cases several as in sucession. There is a fashion in Medicine as well as in other things. Emetics which at one time were universally resorted too & of whose efficacy undoubled testimony was afforded in one of y revolutions to which our art is subject was suddenly supplanted for purgatives, but they have recently revived. By consulting y French & English Authers who wrote on y Dis. of their respective armys in Egypt 20 yrs ago. it was found that y Vehement Billious fever of that Climate they were obliged to submit to other modes of evacuation Emetics therefore were adopted by y whole medical corpse of both armies without regard to those habits of Country & prejudice of Education which have so much influance in y generality of cases of this Kind. Y efficacy of Emetics are equally attested by East & West India practitioners as well as by those of our country. – When Billious fever 75. prevails to great extent they are marked by great violance of symptoms. Determining from my own observation I should say that when early administered they hardly ever fail to check y Dis & that in y advanced stage by their operation when free & copious y pulse is reduced y pain in y head relieved. sickess of Stomach quieted y temperature of y surface lowered & diaphoresis produced by which y patient is quieted & y critical solution of y fever hastened. But when Emetics cannot be administered either for y prejudice of y patient or some peculiarity, a predisposition to apoplexy after active [cross out] Vomiting. We may with propriety & advantage [recoar?] to y use of purges. Combination of Calomel with a Drastic purgative as Jalap. Rheii Gamboge will succeed best in y management of continued fever. – It is a favorite practice with some when y Stomach is loaded with Billious Acumulations to unite Emetics with purges so as to induce an artificial Cholera or as Sailors say “to clear y ship fore & Aft. Rx Sub. murials Hyd: oss Ext. Elatenum gr. ss. 76. Jalap. & Rhii aa gr.v ol. Cennam. [gtt?] pills 6 two to be taken every hour this clears fore & aft. Of y utility of this practice there can be no doubt. It has been occasionally resorted to in y Billious fever of this city with sucess & it is more employed in y Southern States where there is great necessity from y great vehemance of Bill: faction Combination Calomel with Tart. Antim: is [cross out] commonly prescribed to which some add Gamboge. This in a large dose from 10 to 12 grs. will produce y effect without y addition of Emetic Med. But to justify a remedy so violant y fever must be of a dangerous character & y indication of Billious Accumulations must be strong & unequivocal. In presenting purgatives if delay is at all admissible it is proper to wait for that period of y fever where a partial remission of y Symptoms take place. Given at this time they act powerfully & effectually. But exhibited during y rage of y fever they are either rejected by y Stomach or lie inactive. By y pocess above [detailed?] y Alimentary Canal being emptied 77. we are now to resort to Saline Laxatives. Employed in small doses they are beneficial by Ruping y bowels in a soluble state & from their action on y exhalent vessels of y inner surface of y intestines they detract y watery parts from y circulating fluid & thus keeps down y arterial Excitement & produces a demunition of y Violance of y Paroxisms. Of y Saline purges y best have been already mentioned, A prescription very much used by myself & other practioners in y city is as follows ꝶ Sulph. Soda ℥i Tart. Antimony gr. i Suc Limin ℥ss Water ℥4 y dose of this is a tablespoonfull every 1 or 2 hours according to circumstances. It keeps y bowels in a locative state & produces a mild Diaphoresis reduces y arterial action & lessons y Sufferings of y patient. – As cooperating remedies Enemata are not over looked they are useful for promoting y action of purges. they are also beneficial as a substitute for cathartices when y alamentary has been much evacuated. Several formula have been used 78. y best for common purposes is that I will now mention. Take a pt. of Water & a table spoon of common salt & molasses & one of Olive [a] Castor ol. mix them & Inpect. When you wish an Enema a little more Stimulating or where there is flatus in y bowels as often happens at y close of fevers. Terbinth injection, may be used & be adapted to y cure. It is made by mixing a table spoon full of y ol. Terpentine the White or Yolk of an Egg & adding a pt. of Waters It relieves flatus more readily & spedily than any other remedy & in this affords great relief to y patient. By y combined operation of y remedies already mentioned y excitement of y system being reduced we are next to employ y meds. which are calculate to produce Sweating. Of all y modes of managing fever y practice of sweating is y most popular & general. By y vulgar on all occasions this is thought safe & most effectual nor is this opinion confined to y low & Illiterate of mankind. Every class of Society acquires y prejudice & entertains y 79. y same view same views. It is obviously however that remedies which act so powerfully on y System as many Diaphoretics are apt. to do should not be want only trifeled with by imediately employment. On y contrary they should never be used in Inflam. fever untill arterial action & general Excitement is reduced by V.S. & evacuations from Alamentary Canal. Diaphoretics then come with advantage & mitigates the dis. or arrestes its future progress & even here y milder diaphoretics should be employed & those should be combined with auxilliary means which have y same tendancy. As a general precept from which you must never depart it may be stated that in Inflam. fevers it may be stated that in Inflam: [cross out] fevers we are rather to solicit perspiration by limited means than to extort it by violant measures. To bring a continued fever to a crises y Antimonials are generally prefered. early introduced into y practice of med. they were occasionally used & with variable reports their efficacy were declared 80. by Hoffman & then successfully used by Cullen Fordge Antimony [cross out] affords an infinite number of preparations each may be so given as to produce Diaphoresis though few of them are employed at present In England even to this time y cellebrated Puties Jacobe or James Powder has no small portion of confidance that it often excites perspiration in fever can hardly be disputed but so far as I have observed its effects it is in no way superior to its kindred preparations The composition better known & hence administered more easily & certainly regulated on y Continant of Europe & certainly France is y Golden Sulphuret of Antimony. & has an indisputable asendancy over all y preparations of that metal. – Wheather it is entitled to this confidance does not allow me to decide. Compared to y Emetic Tartar I think it inferior in every point of view. This latter med. may be made to supersede all y rest of y Antim: preparations, Nearly Tasteless quite inodorous & minute in its dose, it may be administered 81. with facility prehaps equal it not transcend a wt. powers. – Of y precise manner in which y several preparations of Antimony operate in continued fever or y principles which should guide us in its use we are not accurately informed. Cullen maintains that they are of no advantage unless they vomit or produce considerable nausea but on y contrary it is continued by Forage & there can be no higher authority on y subject that by exciting vomiting y febrifuge powers of Antimony preparations are impaired & that they are always most effectual when y [?h?ght?s] degree of Gastric distress is excited by them. To this point I have directed a considerable careful attention & I am led to concour in this latter opinion. Nausea by whatever means excited or whatever way induced is not in itself salutary in directing y fever to a crisis or favourable solution. During continuance of Nausea Arterial action Macular power & animal temperature are undoubtedly lessened but afterward & reaction of y 82. body & consequent exacerbations of y Fever takes place. But did such a state of y stomach operate in y same every beneficially as contended for by Cullen practitioners generally: y utility of medicine should be proportioned to y to y effect thus created & various other Diaphoretics infinitely more violant & lasting in their operation as digitalis. Tobacco should be prefered. But this is contradicted by y lessons of experiance & y united voice of practitioners in every country. Meds do good in fever by exerting their own specific or peculiar action & when they disorder y Stomach by Nausea & Vomiting they are always productive of more or less mischief To illustrate this would be easy but it would take too much of your time & can be acquired by any one who will direct his mind to y subject. There are many febrifuge Meds. as y Effervesing Draught “Neutral Mixture” y principle effect of which is to subdue nausea & Vomiting & to sustain y tone of y Stomach. But while contend that y Antim: press: Arsenic. Bark. Mercury & Lead &c 83. act by a peculiar power I conceive that as this is y case with y articles enumerated y effect will be proportionate to y quantity taken provided they produce this genuine mode of action which is independant of any Nausea. Curious as are y views in Speculation they are inconceivebly more interesting when applied to practice. Let it be allowed that they are correcttive do away all objections against y employment of a rememedy of undoubtedly high utility nevertheless it is not to be infered in y preceding remarks that we should not have recourse to Emetics in y early & forming stage of y fever here they act on different principles & their efficacy is too well attested to be shaken by any thing that can be said concerning it. To obtain from from Antim. Remedies y precise effect to which I have above alluded is not always very easy. Y febrile affections are various as regards irritating so that y Dose as well as is in intervening as different in different individuals. As a general Rule 84. 1/10 to ¼ gr. of Tart Antim dissolved in water & united with a little spts. Sav: Comp: to give it colour may be taken every 2 or 3 hours as prorenata. But some Stomachs are so irritable that they retain it under no circumstances & here we must have recourse to other meds. of this nature as y Saline or Neutral Mixture which is prepared as follows viz ꝶ Lemon juice or sharp Vinegar ℥ii add Sab, Tart: till a complete Saturation is effected then add Loaf Sugar ʒii aq. font. ℥ii. – sometimes it is good to add a little Laudanum & a small portion Spts. Nitre Dose is a tablespoonfull every hour or two. To meet y same indication many of y Diaphoretics have been used some of which possess in an small degree y confidance of practitioners. – Combinations: of Ipecac & Opium are of this nature but though of y highest utility in Phlegmasia they do not succeed so well in y general febrile affections Why this should be y case it is difficult to tell but such is y fact & with it we must be contented not less do these remarks apply to others if y same class 85. most of them act as promptly & copious as y Antim: press: in aresting y progress of Continued fever. [illegible] this fact we find new reason for y supposition that y Tart. Antim: posseses specific powers in febrile affections in dependant of Diaphoresis or nausea. certain it is that y efficacy of Antimonials is not proportional to y degree of perspiration excited. Notwithstanding all that has been said in y management of fever some [cross out] practitioners hardly ever recour to this plan. by them y Neutral Salts. Refrigerants are prefered y precise Modus Operand of these meds is not understood attempts were [??dde] to explain their operation on chemical principles Though this hypothesis is not without plausibility yet it does not afford us & solution of y difficulty. But whatever may be there method of operating y Refrigerants reduce arterial action. lower animal temperature & partials relieve y surface though this really occasion perspiration. The principle article in this class of remedies is [cross out] Silon or Potassa & no Meds 86. more employed in fever & Inflamatory Dis. Z increases its powers it is customary to combine it with Cal. & Tart. Antim. forming a combination well known by Nitros Antimonial Powder viz ꝶ nitras Potassa ʒi Calomel gr-xvi Tart. Antim gr i to be divided into 8 powders one of which is to be taken every two hours according to circumstances. This is suited to y more robust of our patients & on a/c of y Cal: which it contains is very apt to purge it is prudent in some cases to exclude y Case lest Catharsis should be induced when not demanded or excite salivation as it is known to do sometimes under such circumstances, y Tart. Antim: is also to be graduated to y case. Even [cross out] in so small a quantity as 1/8 of gr. it sometimes distress y Stomach & even Vomiting, - Cooperating to y same end viz y reduction of diurnal febrile excitement. Cold applied to y surface has lately been recommended. I shall subsequently enter on y consideration of his subject I shall antisipate very few of y [former] future observations 87. Cold Water. may be applied in 3 ways either by Ablution. Aspersion or Effusion each adopted to y particular circumstances. But in y case before us I prefer y Sponge. It is much more agreable & less Dangerous than y others. But cold applications Are never called for unless y Pulse is active Skin hot & dry there they are very useful. they remove y uncomfortable secretion causesly y hot skin or heated surface & lessen y force of y circulation. induce mild diaphoresis & sooth that irrestlessness which generally accompany febrile Dis. But under other circumstances it is perilous when y system is exausted by y fiber would at y period be unable to react. Such is an outline of y 2 plans for treating fever one Refrigeratory y other Sweating. This is not y place for instituting a comparison between them nor could it be easily done y fact that they cannot be received as several measures each adapted to different circumstances. – 88. Before we use Diaphoretics in Inflam: cases we should first deplete in proportion to y vehemance of y Symptoms by V.S & evacuations from y Alamentary Canal & exactly at this point Refreg: remains maybe called into use with signal advantage. Before dismissing y Subject I wish to impression you y value of Sweating in y cure of fevers. It was formely y practice to treat Inflam: Dis by forcing a perspiration by heating Alexipharmics or antidotes. But those are productive of wide spreading mischief they were soon discarded. But it is wrong to argue against y employment of an article from its abuse sweating like Vesication is useful or as it is directed. When under y control of sound discretion it is highly important & indisputably acts powerfully in combatting Diseases Diaphoretics by determining y Blood to y Surface lessons Internal Congestion they relieve y constriction of y extreme vessels & thus renders y patient more comfortable y more we reduce y circulating fluid [cross out] thus they reduce arterial action by direct depletion Finally they equalize excitement & retain that just 89. Cheshire June 9th 1827 Cheshire March 31 1828 Equipois in y various actions of one system in which perfect health depends. Let us not therefore throw away remedies so useful on account of y objections which theory may raise or false refinement indicate. When hereafter we shall take y field against diseases you will it not enough to combat it with one remedy on the contrary you wish to be victorious over these to human happiness you call into requisition all y recourses which have been put in your hands. – by your God & all those which can be derived from a complete Knowledge of your art. We have now arrived to that stage of Continued Billious & Inflamatory Fevers where Vesiccating applications are found useful. They should be applied to y extremities sometimes both upper & lower but by some modern practitioners they are altogether condemned & strongly prohibited in this form of fever. Of those who entertain such views by far y most distinguished weight is that of Fordyce.. 90. It was one of y sayings of that great man that resicating applications had not y least effect in arresting y progress of Fever but on y contrary they never fail by creating an additional excitement or occasioning [cross out] exacerbations of y Dis. It seems to me not very difficult to reconcile y contraruly of sentiment that has prevailed on this point. Nothing is more different than y effects of Blisters applied in y early & late sap of y Dis. When there is much arteriae actions febrile excitement they never fail to do harm & it is not less certain that they are of y utmost utility in a reduced state of y system. Let y Body be reduced by V.S. Emetics & Purges & then resort to Blisters to quite y pulse, equalize excitement put an end to y action of Dis. & establish y regular order of health After y remedies above enumerated prove unavailing much confidance is placed in Mercury. Urged to a moderate extent or Salivation there can be little doubt of its utility when y system can be brought under its operation. But in most cases before y mercury 91. Cheshire January 21 1827 A. 1828 can be made to act feaver from its rapid carear terminates to be of use therefore it must be properly employed & as y bowels are weak & irritable it should be applied in y shape of. It is difficult to excite Ptialemo while y pulse is active Mercury therefore should never take y place of depletion & y remedies which effect this are generally sufficient to remove y fever. * I have thus concluded y history of y remedies which are best calculated to cure Billious Inflamatory Fever. Much however depends upon dericing a proper attention to y Minor circumstances which often so powerfully influance y result. Of these by far y most important are Drinks Diet & General Management of y patient during y progress of y Dis much * In y Billious of this country Bark does not suceed y Remissions being short, tong moisten skin relaxed it is useful. Cullen says that every fever proceeding from marsh miasmata after sufficient evacuations may be treated with Bark beneficially. All Fevers arising in y spring should be treated by Calomel. – 92. dryness of y fauces & extreme thirst generally prevails. It has been a question wheather y patient should be indulged in this ardent desire for Drink. y Physicians of antiquely were much divided on this point while one set to totally forbade. y other allowed y use of Water. – It requires little Sagacity to discovour that y medium between y two is y proper practice By denying altogether y occasional use of Drinks we shall cause great anxiety & distress & rather increase y Dis & by allowing y unrestrained employment of it we shall find that y Stomach will be disturbed & certain Nausea & Vomiting with other mischievous consequences will result. We should therefore direct now & then a table spoon of some Acidulated Drink as Lemonade Vinegar & Water. Apple Water. Toast Water. Tamarind Water & a variety of herb Teas as Barley Water, Balsam Tea. Sago Tea. & a Solution of G. Arabic. But what I have found to be y most effectual in allaying Vomiting 93. William R Hitchcock Esqr. Vomiting & distress at y stomach is a table spoon of Lime Water or a tablesoon of new Milk from y Cow or a decoction of Snake Root, even common water provided y quantity be small & y temperature not too cold, should not be refused. It is a precept worthy of your attention that drink in moderate proportions & moderate temperature will relieve y thirst quicker than Cold Drinks immoderately taken During y continuance of y fever y Drinks above enumerated will afford sufficient nourishment to y patient. – It sometimes happens that y appetite solicits more solid food & y demand of y patient is loud & clamerous but y propensity is always an unfavourable indication & should not be indulged. Every practioner must have seen y eble consequences which results from y gratification of a depraved appetite & in many instances cases from this cause have terminated fatally which would otherwise have been cured. An Old Opii pill checks vomiting. Enema or supporting of 94. Samuel Johnson [Esgr?] Oppi. Blisters over y Stomach & a lump of Ice held in y mouth. a piece of Liquorice or an Infusion of Liquorice will allay y thirst grii of Calomel will be of service. Strong coffee [no cream or sugar] ¼ or ½ gr Calomel with G. Arabic. Sacch. Saturni grs every ½ hour. Mint. Brandy with a Lump of Sugar are all good in irritable stomach of Billious Fever. – In y History of Pathology of y dis I mentioned y causes which accelerate y increased action these should be studiously avoid in y febrile condition. As prehaps y most operative cause you should direct partie: light to be excluded & also that conversation should not take place in y chamber of y Sick. – Before leaving y subject I will give some some directions for y Management during Convalescence. Febrile affections of every kind leave behind them an accumulated state of excitability which it not properly directed may be productive of a relapse a condition of things more Dangerous & intractable 95. than y original Dis. The first step when y patient is recovered is to remove him to another room or to order that all y apparatus of sickness as Phials. Bases, Plasters &c should be placed out of sight from seeing these a remamtrance of his sickness is kept up. & his spirits being depressed retards y progress of cure. Y changin his skirt & cloths has a great effect in promoting y possess of Convalescence. 2nd. Be careful to regulate y Diet according to y excitement, you should begin with faranaceous articles & more are better than Tapioca. Arrow Root. Sago & Rice. Next you may allow Eggs & Oysters raw or very slightly cooked. Boil a Chicken or any other article of a light & digestible kind may be allowed. – But whatever is taken should be in small quantities at a time. This is a rule of extreme importance & rembember to direct often & a little at a time. As regards Drink pure water is y best. If something more is required by y condition 96. of y patient & from his solicitations y best liquid which you can direct is Porter diluted very much with water Malt Liquors & especially Porter is infinitely more agreable [cross out] & less injurious than Wine or ardent spts. however diluted. 3rd It is hardly less important that y patient should gradually return to y employment occupations & habits of Life. He is especially to avoid much exercise of his intellectual faculties. – To prevent this he must be kept from study & from attention to business of any description Company could be avoided. Be not too precipitate in permitting your patient to take exercise & especially out of doors. There is generally much eagerness on his side backed by y intercession of his friends under [illegible] that it would afford him strength confirm his recovoury. – But you must recollect that there is great liability to take cold & from this irritable state in y commencement of convalescence y stimulus of riding instead of strengthing would probably give a return of fever. Even when you allow him 97. to take exercise direct him to be warmly clad & should particularly enjoin it on his attendants not to protract y ride so as to fatigue him. Y preceding are instructions [cross out] relative to y management under ordinary circumstances. But now & then certain symptoms arise during Y course of Med. treat. which demands [cross out] particular attention. Sometimes patients in y convalescence from a long spell of fever remain very feeble & have a total loss of apetite. To meet y indication of these cases Tonics should be given amoung which y Tinct: Cinchona alone or combined with a portion of Tinct. Gentian is highly beneficial. But there is a great variety of articles of nearly a similar Character which may be used in sucession according to y circumstances of y case or to y taste & caprise of y patient. As y leading ones, may be mentioned all y Vegetable Bitters as Columbo Quassia Gentian, & these should be employed in watery infusion. 98. y Chur. Vitriol is also an excelent remedy & establish y a restoration of apetite. Not y least distressing affection which is incident to a state of [cross out] convalescence is extreme watchfulness & inability to sleep this is very unpleasant often retards recovery & somet: aggrevates y fever here Small Opiates are useful. The best preparation in this case is y Black Drop. This preparation posseses 3 times y Strength of Laudanum & has a more powerful anodyne effect than any other with which I am a aquainted. It never so far as I know produces y nausea & other disagreable effects which sometimes results from y use of opii & its Spts. Tinct. When Opii in this form fails you are to resort to Hops Tinct. & what I know to succeed very well is y Camphoretic Julep this often quiets irritation existing in y system & disposes y patient to slap. Sometimes watching proceeds from an empty stomach & when this is y case stimulating food conjoined with porter is generally effectual. – 99. Somet. Diarrhoea & more commonly Costiveness attend recovery from fever. As to y Diarrhoea it will generally yeald to y Cretaceous preparations where on y contrary there is a tendancy to Costiveness it will generally yeald to small doses of Rheii. This cath. should be prefered because it impartis tone to y Bowels & when taken by itself never purges copiously. It is worthy of [cross out] recollection that however beneficial evacuations from y Alamentary Canal may prove in y early stage. – It is not less injurious in y convalescence more than any other cause. Copious evacuations at this time induce a state of exhaustion & not unfrequently brings back an allarming degree of Fever. I have see this more than 100 times in y condition of convalescence These are y applications which have some claim to notice but considering which I have protracted y discussion. I will detain you with only with 1 or 2 observations. y Billious Inflamatory 100. may terminate in Typhus but more frequently in chronic fever. As y treat of y former differs on nothing from y Idiopathic Dis of y same name it will not anticipate y observations which I shall have occasion to make here after. y Chronic nature of y Fever claims our particular notice it is called Febricular from its from its diminution & indistinct symptoms which attend it. In y country it is known by y name of Inward fever. Y pulse is small corded & hard, much heat on y surface. a Billious complexion & a tenseness of y forehead combined with Headach or pain in y side. y Patient has always Edematous swelling of extremities, scanty high coloured urine & ash coloured Stools, y Type of fever is either Remitt. or Intermitt. & not continued, y course of this condition of things is too obvious It arises from Congestion in y Large Viscera partic: of y Spleen & Liver. Y appropriate remedy is a slight salivation or what answers very well as a substitute a course 101. Nitric acid ʒi of y latter should be given every day for 8 or 10 ds. Commonly however there is much fever & pain so that it is necessary to resort to frequent & small V.S. vesicating applications at same time are very important placed on y side if there is pain there. But if this is absant & we wish to interupt y association on which this small fever depends I would greatly prefer them on y ankles & wrists. It is a common practice to treat y case with Tonics particularly with cinchona but it is highly prejudicial they Lock in y Dis. instead of Liberating it from y system. After y evacuations have been premised then y Tonic Meds. may be employed. of them by far y best is Cinchona but where this fails we may resort with great advantage to Fowlers Solution. – Delirium. very often in y progress of y Dis there is delirium y patient becomes wild in his conduct get up from his bed & uses singular expressions there is at y 102. same time great turgesance of y Eyes & Face fulness of y Head &c. In order to remove this it will be necessary to remove y Hair & shave it close to y Head. apply cups to y temples. here Blisters should not be applied untill Inflam- is subdued. Note. To cure Headache in fever apply 2 or 3 leaves of y Wild Popular. imersing both arms in cold water, sprinkling y Head &c. – Note, This prescription is good in fevers viz ꝶ Tinct Opii ʒi Acid Tart. gr. 10. Aqua font, ℥ii Dose table spoon 103. Remittent Billious Fever. The Continued Billious Fevers are very apt to terminate in Billious Remitt: in which case there is perfect & distinct Remissions. It is a common practice in y U.S. wheather Remitt: are assumed form of Continued to treat it from y very commencement with Cinchona It is laid down by Cullen that even in y Continued form arising in Miasmatic countries always to make use of Cinchona without there being any Intermission or Remission. Whatever may have been his sucess at Edinburgh it is not applicable here in y U.S. when y remission is not complete y Bark will be rejected or oppress y Stomach & this aggrevates y Dis. The practice here is when there is some remission to substitute for y Bark y other Tonics as Serpenta: Quassia. Angustura & our own Indigenous articles of y same nature. Arsenic is much better adapted to this form of Bill: fever than y Bark & in general it will be y best plan to resort to it. It will however be found in y generality of cases that, V.S. 104. Emetics & Purges will be necessary before y Tonics can be administered. Yellow Fever as an Dis of autumnal occourance & allied in some respects at least to y dis fever already Described, I proceed in order to y consideration of Yellow Fever. It is not my intention to occupy your time with a very minute history of this Dis. To y writings of y late Dr. Rush I refer you for details relative to y subject & more partic: for his account of this dis. as it appeared in 1793. some deffects for y time it was written] undoubtedly is y most perfect muddled & best historical narrative [in y whole compass of medical Literature] pestilentia dis. contained in y whole compass of Med. Literature As prehaps you all know that. Y.F. is an Epidemic of Tropical Climates – to W India Isles it seems to belong particularly. – It appears occasionally to have occoured in y U.S. from y earliest state of settlement but it was not until y yr. 1793 – on a/c of its ravages & y Terror which it created that it 105. first attracted Med. Curiosity & attention. Notwithstanding all y writers on y subject & y ardent continued enquiries which have been made hardly one solitary point connected with it is better settled or less a matter of dispute than when investigation first began. – Its origine nature & Treatment are points, still as much disputed now. as they were before. It is far from my desire to review y disputes which were carried on with none of that complaysancy which should characterize all Sciantific discussions still however it is my duty to afford you some information on y subject. though I trust in giveing it I shall be able to temper my an imadversity by y sincere & respectable attachment which I entertain towards [both] all parties engaged in y controversy. – As regards y mode of production y disputes have been chiefly on of meaning of words. It is attributed on all hands that in each instance y discus procds in some way from Vessels. It is true that local filth as y 106. contents of Docks. Gutters & common Sewers has been assigned by some as y accessary cause of this pestilance but was this true for y extent to which they argued it would appear that y dis must appear every season for y sources above mentioned crest now just as much as on former times besides we have a complete repetition of y doctrin in y fact – the Scavengers a class employed in 2 cleaning y city of y filth universally escape y Dis. Dr. Rush states out of 50 Scavengers only 1 took y dis in 1790. But it may be said that these persons are so habituated to y exhalations of y filth [universally escaped y Dis] as to be insensible to its action, This however cannot be justly alleged because owing to y great scarcity of y Scavengers at this time many of them having left y city individuals were employed pro tempore But while I so far accused to y importation of Yellow Fever I do not believe for a single moment that in any 1 case it was introduced in a palpable & well formed condition. My impression is 107. that ships coming from tropical climates in a filthy state bringing with them y materials out of which this pestilance is produced. Wheather such exhalations excite y fever under all circumstances I am not prepared to determine. It is more than probable that a certain condition of y atmosphere is necessary to give actively to y cause. This would seen to be y case since y fever is of occasional occourance though vessels arrive every day from y W. Indies. Long ago it was suspected wheather y Dis was imported or generated in our own country it would not take place except under a degree of temperature – but it has been proved as satisfactorily as any problem can be proved that unless y mean temperature of y summer months June & July is as high as 79 or 80 Fahrenh: y Yellow Fever cannot prevail in our climate. This have taken from a register kept in Philadelphia in 1793 to y present time. From this it appears that when y media heat of June & July has been 80° 108. not in one solitary instance has y fever appeared but on y contrary when y temperature was above 80 so was y greater violance of y Dis. Nor does y truth of y observation rest on y register on Philad. alone by a similar one in N.Y. weare waranted it arriving to y same conclusion. Much controversy has existed as to y Contagious nature of Y.F. that it is not y generals uniform character of y Dis & think has most satisfactorily explained. Not to protract by discussion to any length I shall compress y argument on both sides into as narrow & compass as possible. It has been said it is not contagious for it is of y nature of Epidemics & therefore depends on more general causes. It is also said by them that y diseases imediately proceeding y Y.F. from one end of y union to y other assume more or less y inflamatory type of that dis. 2nd.. It is moreover said not to be contagious because it never proceeds beyound y sphere of y city infected by it. – In surport of this argument 109. strong & almost irresistable arguments have been added. It appears that during y prevalance of y fever in this city that though several hundred people were received into y Hospitals & crowded together into small & comparatively ill ventilated apartments get no one instance of extention of y Dis occoured y Phys. Med. attendants & nurses whoever constantly amoung y such y dying & y dead escaped without one exception even though dissection was carried on [even to] an almost incredible extent 3rd. It is alleged not to be contagious because it is uniformly suppressed by cold weather. Whatever may have been its ravages however universal its prevalance y moment it first appears its carrear is checked or terminated. This is undoubtedly contrary to y nature of contagious diseases. 4th we are assured that cases have occoured in y country remote from y city & where it could not have been excited by contagion or intercourse with y sick. But on y other hand facts are 110 adduced too important to be over loocked. 1st. It is alleged that y dis in every situation commences at some point from which I gradually spreads & diffuses itself – In 1793. It could be distinctly traced to a Cargo of putrid coffee thrown out of a vessel from y W. Indies upon Arch St. wharf. y persons employed in unloading y vessels were first seized next y inhabitance contiguous to y wharf & from this it gradually extended itself untill it involved y whole population. In 1805 y dis originated in Southwark & was traced gradually diffusing itself from square to Square untill it covoured a great part of y city. – 2nd. It is answered by respectable physicians that y fever actually proved contagious in y country. to this point we have y attestation of Doct. Wistar who recorded several instances in which y dis happened in Germantown & which was distinctly traced to y city. There are a number of facts of y same kind in y publication of 111. y College of Physicians. It has also been [impactd?] by y cloths of those that died. 3rd. It is maintaind that y Y.F. does not take place twice in y same persons in this respect obeys y laws of Contagions dis. On this point Medical men are exceedingly divided. While on one hand it is asserted by a large member of Practioners of this city that it never occours more than once in y same person It is rejoined by a large number that eases often occour where one individual had this dis twice In a recent publication by Dr. Hossack contained in y last edition of Thomas. it is state that on a recent vursit to Philaa. y Doct. had conversed with several medical men on this point & had not found one who did not declare that y dis is incapable of being twice taken, but he was mistaken. It so happened that his that his communicates on this subject was a particular set who maintained this opinion. – If he had addressed his interrogatories to Dr. Physic or to 112 Dr. Dorsey he would have found that they no more believe it than they do transit – or thus y New York school was superior to ours. – It is however stated by Dr. Griffith that though he attended thousands yet he never met with one instance where y dis occoured twice in y same person. By consulting foreign writers you will find no more union than in our own. Most of y W. Indie practitioners entertain y first [sentim?] y question has lately engaged much attention y British Government inconsequence of y occourance of Y.F. in various parts of Europe partic. in their ports in y Meditaranean Sea instituted injuries relative to this point on an extensive scale. Two bords were instituted of Med. men who were to collect all y evidance y subject admitted of. After a full examination of witnesses & documentary evidance y College of Physicians of Lond. as well as y Med. board reported as y consequence of their deliberation & extensive enquiries y following [103.] 113 conclusions were 1st. That it cannot be taken more than once – In support of this point facts were adduced of a very conclusive description. Amoung others it was stated in y authority of almost all y med. men in that regiment which had previously served in y W. Indies y soldiers who had been affected were not more instance again attacked by it. – This fact as so well ascertained that y soldiers were employed as nurses to y sick & did not experiance any in convenience Nor as regards y origine of y dis. is y Epidemic less direct at Cadis it was traced imediately to a Vessel from y W. Indies. It was shown that it could not leave arisen from any local cause from y circumstance that it did not occour in y most dirty parts of y city. It was farther shown that Marsh. Miasmatic could not have given rise to it because on one side of [Cause?] there is great marsh which every season 114 [104.] occasions y different kinds of Billious Fever get during y cariers of this pestilential dis. that part of y city was perfectly healthy. Strong however as y facts appear to be one still more conclusive may be added. Y Garrson at Geberatter is situated on a bank exempt from all Mail Exhalations & kept perfectly clean from filth of every kind by y severity of y military police. No place is so little favourable to y production of Pestilential fevers yet it prevailed there to an enormous extent. It is affirmed that y dis in this instance was imported in a vessel from [??dis] & could be traced to y wharf where y vessell was lying. Enough has been said how contradictory all y efforts on this subject are when facts so opposite in their tendancy related by respectable authority. It is imposible for a circumspect mind to arrive at any satisfactory conclusion. It would not be safe in such cases to trust to any [opinion] ceasing & even if we were to employ it we might arise at oposite inferances. but really there is [105.] 115 nothing very repugnant or absurd to reason in y belief at least of occasional contagion of Y.F. Typhus confesedly is very often contagious but it is said when this proves so it [is] arises from y exhalations produced by y excretions in a state of petrifaction of this statement I do not believed single sellable. Typhus Fever has again & again occoured when y greatest cure was taken to remove all filth. During my residance in Edinburgh y British fleet which was cruising in y North Sea was infected with Ship fever. The Sailors who had been attacked were landed at Edinborough & taken to y Hospitals of that city. More than hlf y Students who attended on y sick were attacked with y fever & many of them died besides were y dis. occasioned by y effluvia from secretion or excretions it would be as diversified in its nature as y causes are from whence it is produced & each of these 116 [106.] different excretions would produce a different disorder but this is not y fact. All y cases which occoured in y Hospital were precisely y same or marked only by such differance as may arise from y violance of y attack & idiocincracies of y patient or their peculiar constitution. – What also do experiments prove in regard to this point? It has been most satisfactorily shown by Hogarth & other European writers that Typhus is not always Contagious dis. as much so as Small Pox itself but y sphere of action was not extended beyond a few feet. From y experiments of Dr. Gregory of Edinborough it appears that Typhus does not prove contagious beyond 5 or 6 feet. If a person remains within that sphere he was sure to be attacked with that dis. Does not this show that fever may be contagious & that it is not propogated from y putrid excretions but from y patient himself. All contagion is owing to a secretory action of y vessels. & differs [107.] 117 according to y nature of y stimulus by which y vessels are excited. Thus y Contagion of Small Pox differs from that of Syphilis only by being produced by a different action of y secreting action of y secretory vessels resulting from y disimular nature of y Stimulous by which they are called into action. Now if y extreme vessels in T. secrete contagion why should they not perform y office in A fever where y dis assumes y Typhus inclination that they do so I am perfectly persuaded but it is only when it puts on y Typhus [grade] condition that Y.F. proves contagious we observe y same in Dysentary which in its ordinary form is not of this character but when it becomes Typhus y whole tenor of Med., Sciance goes to show that it is propogated by contagion. – By consulting y best writers on this subject you will find that other complaints though not contagious under ordinary circumstances but when they assume y Typhus Type do become so. 118 [108.] This I believe is a law of universal prevelance amoung Diseases. I do not see much force in y argument. that Intim: fever is not communicated in Hospitals & by dissections. It is in this respect on a footing with Typhus fever & Plague. We have reason to believe that Typhus fever is not contagious when y apartments are well ventilated. It has been ascertained that as soon as vitality in y Plague was destroyed by – of communicating y dis is destroyed. As I have stated them such are y facts arranged on each side of y controversy my wish is not to impact any Hypothesis to you y facts are so contrary in their tendancy that it is impossible for anyone who gives credit to both parties to form a conclusive opinion The controversys scene to be have governed more by y pride of Victory than by any honest wish to advance the Interest of Med. Sciance. As relates to nature & treatment of Yellow Fever scarcely less diversity of Opinion has prevailed. – [109.] 119 Treat. Yellow Fever. consists in V.S. & mercurial purges & was in y year 1793. adopted by some of y most distinguished practitioners of y city. Y French physicians washed out y Stomach & then poured in Glysters or diluant beverages Calomel was exhibited largely by others but their sucess was precarious. Mercury seldom produced Salivation. More correct judges of its pathology a change of treatment. In y commencement V.S. by cups. Mercurial purges &c this was y treat. of 1793. Last summer often mild evacuations from y bowels, we used spts. Turpentine in doses according to y symptoms with cups to y Epigastrium. this should however be done early in y dis y Turpentine was to subdue Inflam: in y Stomach. – 120. Dysentary. Cullen defines this to be a contagious fever in which y patient has frequent mucous & bloody discharges accompanied with Griping & Tenesmus y foeces being for y most part detained. Except as regards contagion which is of rare occourance I do not know that this celebrated deffinition could be a mended. As y History of y dis is familiar to most of you & may be learned by Books which are easy of access it is not necessary for me to enter into a minute description. An attack of Dysentary according to Sydenham whose a/c of y dis with few alterations has since been capsized by most writers on y subject comes on with a Chill suceeded by flushed of heat frequency of pulse to these symp. are added severe griping & a constant propensity to go to stool. But in many cases y local affection is first perceived & prehaps not less frequantly y dis is preceded by loss of appetite. Costiveness flatulency; Nausea, Vomiting, & often these take 121. place with y irritation & uneasiness of y bowels above mentioned. As y dis extends itself y evacuations from y Bowels becomes more frequent & painful & preceeding every stool there is griping & tormina & tenesmus. y matter discharged by stool is very various sometimes consisting of frothy mucous though more generally it is streaked with blood & small coagulated lumps like bits of cheese are observable & some cases hemorrage of pure blood takes place from y Anus these are y ordinary appearances of y Stools in Dysentary. Now & then there is mingled with y morbid discharges natural forces may be assuming y appearance of Gallnuts & denominated Sybala y voiding of which is attended with temporary relief. We commonly meet with fever more or less marked with y usual symp. of increased heat thirst & restlessness though y pulse is neither very full or very active. This may be considered as y crisis of y Dis. which commonly occours in a few days though it is frequently much more 122. protracted. Not arrested by our remedies y dis henceforth puts on a sensible aspect. To an increase of y principle affections incident to y case we add. A rapid depression of strength, cold extremities. tension of y abdomen. Cold clamy swets, pitched. Hiccough. Aptha. a small pulse & discharge of a acrid fluid resembling y washings of meat, latered canine, [these] are generally y precursors of death. But they should not be deemed invariable so as much as recovouries from Dysentary somet. takes place where y most of them have been exhibited. On y contrary when y case terminates favourabley we find most commonly a remission of fever, y surface becomes moist & relaxed y evacuations less frequent & more natural y Tormina & Tenesmus subside altogether or are grately diminished. To this a/c I have only to add one observation. Y complain occours sometimes without any discharge whatever, such cases are by far y most fatal. The want of an evacuation arises from y existance 123 of an inflame. so violant as to transend y secretory [action] functions. I have seen instances of this kind & others on record in Sydenham & y Older Writers. They resemble Gonorrhoea in y circumstance that y [sooner] later y discharge was on y occourance of violant inflamation. Thrush has been said to be a Cause of dysentary. y dis was once thought to originate exclusively from a species of contagion generated in y system of an individual & by him communicated to another. – But by the most careful observation it will be perceived that such is not y uniform & general character of y dis. By a later writer it has been stated with no little plausibility that Dysentary only where y original fever is Typhus or assumes that character in its progress. Determining from what I have seen I should conclude y doctrin he advanced was perfectly sound & correct. – It has however been suposed that y contagion arises from y alvine evacuations & more plausably 124 that it arose from y stagnated secretion & excretions which have been suffered to remain untill they putrefy. But neither of these supositions is well founded. No evidance has been adduced to prove that y Excretions in Dysenteria are capable of producing y effect alleged. And y same may be said of y collection of filth from y patient which has purified. As I mentioned did y perspiration or Urine under any circumstances give rise to Dysentary. Y cases should be as diversified as y causes from which they originated from. On y contrary when contagion is y cause it is an uniform description of morbid action or at least diversified from peculiarity of constitution or Grage of force with which attacks were made. However it has already been shown that dys. & other contagious dis. may be propagated though y utmost cure be observed in clenliness in all respects. What then are we to conclude except that in y Typhus state of this dis. The extreme vessels take on an 125. action by which contagious matter is eliminated & elaborated out y system. But Dys. may most generally be traced to y causes amoung which are to be mentioned y many sources of autumnal fevers. Now & then it is excited by acrid matter taken in y Stomach & it has been known to occour as in Epidemic depending like other Dis of that class on some peculiar dis temperature of y atmosphere. Nor prehaps does it less frequently arise from y sensible qualities of y air. Cold suddenly attended with heat & moisture succeeding dryness equally produces y complaint As in y other bowel affections whatever suddenly checks perspiration in many instances proves y Cause. This complaint somet. accompanies Catarrh & I have seen it in many instances alternate with Rheumatism. But whatever may be y cause of Dys. it is evidently a febrile affection & directed to y Aliment. Canal. Even as long ago as y time of Sydenham such a 126. view of pathology was taken y opinion is surported by y fact that y dis asumes different shapes being remittant, sometimes continued, which last form may be highly Inflam: or may partake in various degrees of Typhus malignancy. Most generally when it arises from musk effluvia y primary seat of Dys. is always in y Stomach. Here it manifest itself by nausea & Vomiting & from this point it gradually extends downward to y bowels as revealed to us by dissection it appears that y force of y dis expands itself on y large intestines. In this part of y A: Canal we find most marks of preexisting Inflam: & other phenomena of dis. action. Enough has been said to expose my sentiments relative to y nature of Dysentary & if what I have said be correct y indications of cure are suficiently obvious. – But that y treat. may be applicable we must consider it under y various modifications which it occasionally assumes. – As Dys. generally presents itself y Indications 127. are to remove inflamation with y Spasmodic action which attends it over coming of y primal Vic & there by producing natural stools. To restore y Surface of y Body which is hot & dry to its usual healthy condition. – Taught by y example of Sydenham practitioners have generally been in y habit of commencing y treat. by Emetic - Enarmoured as I have thrown myself with this set of Meds. in most of y Bowel affections – I am not an adovocate for this universal employments of Emetics in Dysentary. The case in which they are peculiarly applicable & to which we should limit them use are those in which y stomach is loaded with Bile & other foul accumulations creating nausea & other Gastric uneasiness. It is common to meet with such cases in miasmatic districts associated with y Intim: type of fever. Cosulted end case of Dysentary under ordinary circumstances it would be 128. right to V.S. previous to remedies by thus early drawing Blood you will check y progress of Inflam: & is no less important to open [y war] a new. y susceptibility of y system to y operation of other remedies may be produced. V.S, is y most effectual & as y affections of y alimentary canal are eminently characterised by y want of this susceptibility to y operations of meds. y Lancet in those cases is imperiously demanded. But independent of y reason just stated there is another motive for copious & early V.S. Commenced with this affection of bowels there is commonly a degree of Spasmodic constriction which is productive of acute pain & appears an inseparable barrier in many cases to y evacuation of y bowels. to overcome y constriction in this case V.S. posseses [universal] unrivaled powers & with y removal of y spasm serves also [for] as a remedy for y hot & dry surface which it exchanges for one moist & relaxed. Haveing asserted this much of V.S. 129 we must resort to purgatives to clense y bowels of their vitiated contents. Castor. Oil is y article most commonly rised & answers very well in y forms of dysentary it cannot be denied but that it should be liberally employed my pursuasion is that in this case practitioners give y med. in infinitely to small doses to be of any decided advantage. In y same violant forms of Dys. seveal ℥ Castor Ol. should be given daily. It must be recollected that in Dysentary y ol. runs rapidly through y bowels passing off very little changed & makeing so light an impression as scarcely to remove any portion of Excrement. matter even y Bile. – I have seen it discharged from y bowels in y course of hlf. an hour or an hour after taken. – As regards our own Dys. especially such as occours in Warm weather I cannot help metaling y opinion that mercurial purges are infinitely better adopted to y treat. 130. treat. Do we not find them preferable wherever evacuations are demanded. We give them in Billious fevers & positively we should give them in y case now before us. In my own practice I prescribe Cal. alone or in combination with Rhubarb. & where y med. lingers in y bowels I promote its operation by mild laxitives. I resort to injections after I have thus evacuated y bowels y mercurial meds. are not again demanded. Now y Castor Ol. comes in with good advantage. y Epsom Salts would prehaps form a better substitute for Calomel & its combinations. No practicable point has been more debated than wheather we should continue purging. It appears however at present that y fact is pretty well asertained that we should give purgatives untill y natural forces appear. This I am induced to believe is a rare practice. Every one is conversant with Dysentary I will know that when y foecal 131 are suffered to remain in y Bowels they are irritated & y pain & other unpleasant symp. are considerably aggrevated. Let it however be recollected the discharges which accompany y dis. are mearly y effect of preexisting irritation & to remove them we must correct y preexisting disorder. – Acting on this principle I have been in y habit of resorting to Opii earlier than y general practice of Physicians would seem to warrant. Nevertheless I am perfectly convinced of y prosperity of this course by my large & faithful observation of its effects. Even since age of Sydenham with a very few exceptions which I Shall not at present notice there, has been a very marked aversion to opium. in y treatment of Dysentary even by cullen & those writers of his time y practice was either noticed with great distrust or universally condemned. But all these writers seem to have been influenced more or less by y old notions of y humeral pathology. They confounded causes and 132 & effects. As much are y discharges [in Dis y effect] from y intestines in Dys. y effect or consequence of previous Inflam. of y stom: & bowels. as y matter of Gonorrhoea is Inflam: of y urethra & a flow of tears in Inflam: Eyes when they have been offended with atoms of dust or grs. of Sand. But in resorting in y early stages to Opii I do not hesitate to allow of y necessity of uniting it with OC. Or some other evacuating remedy. My more general object however while endeavoring to remove y contents of y bowels is also to determine to y surface of y body. This last is indicated by y condition might be surported by y most distinguished authorities which we can afford. – But still it must be remembered that previously to any attempt to excite perspiration. – The pulse & other inflame: symptoms must be reduced by direct depletion. When this is not attended to sweating would only accelerate y dis. Less than any other Dis does dysentary admit of a substitute for y Lancet A late practitioner in this city has declared that 133 with y Lancet & Opii he could manage any Dys: I am not prepared to go so far though I am will convinced of y signal benefit of y Lancet in allaying irritation y early stage of it I do believe that y most important effects are gained by it. – It is now more than hlf: a centaury since Dr. d- introduced or proclaimed y superiority of y sweating plan over all others in Dys: His view of y pathology & treat. was soon adopted by several respectable physicians. It partic. Was adopted by Richter a writer of y highest authority that Dys: is a calanhol or Rheumatic affection of y large intestines & that y Billious & other discharges are necessary to y main dis. & mere efforts & not to be regarded much in y treat of y case As deduced from y Hypothesis y practice which he leays down consist y exclusively of measures calculated to excite perspiration. I do not go to y full extent with this author in his speculative order of y dis. or in his practical deduction. 134 This is one out of many instances in which injury has been done by a generalization. what holds in practical cases is made to apply to all cases of a catarrhal Rheumatic affection of y al: canal do now & then occour sweating will somet. suceed without n evacuations. But y instances are very rare & he who enters in y practice of his profession with such a view of pathology of Dys will inevitably be traced along his path of business by y dreadful mortality which he will inflict on his patients. In detailing y cure of Dys. we have reached so far as [Dysentary] Diaphoresis y modus operandi of such [illegible]. I have more than explained. It remains therefore to point out y lust mode of affecting y purpose. My own experiance has led me to prefer at this juncture a combination of Opii Ipecac & Cal. ꝶ Opii grs IV. Cal 16grs. Ipecac 8grs make 8. pills one every 2 or 3 hours. or pulv. Confedidly this is not y most action diaphoretic Med. but it is productive of effects which prehaps at this crisis is still more important than mere diaphoresis. - 135. It composes intestinal irritation relaxes y surface of y body, gently opens y bowels & causes other impressions which though not very intelligent are eminently salutary in their consequences. Every one who has noticed carefully y operation of Cal: in small doses in Bowel affections must have witnessed y beneficial effects of Vomiting from y article. It probably does good not less by y change it produces in y Intestinal & Hepatical secretion than by its directly purgative effect. As on infinitely more certain & powerful Diaphoretic y Dovers powders will seldom fail when copious perspiration is demanded. But it should never be resorted to in preferance to y preceeding article. – When it is necessary to evacuate y bowels no article in y Mat. Med. has been more extolled in Dysentary than Ipecac. Given either by itself or in various states of Combination. By some practitioners it has been more partic adopted to that state of Dis with which such 136. copious discharges of Blood from y Rectum as to amount almost to an Hemorrage. This opinion determining from y general properties of y article would appear perfectly correct. – But in every form & variety of Dysentary it is highly beneficial & well suited though I have prescribed it with y best advantage y pain thus been most violant y desire to go to stool very frequent & inefectual. – y great power of Ipecac over y dis does not rest on my own authority alone for more than hlf. a centaury ago it has been employed by practitioner in every section of y Globe & has brought from then very general if not unanimous approbation as to y precise mode of operating in this case all writers are not so well agreed. I do not agree with Sir Geo. Barker & Cullen who says its efficacy depends as upon its purgative operation for y med. produces an oposite effect. Nor do I believe it owes all its powers to y perspiration it produces we have numerous Diaphoretics not less active than 137. Ipecac but very inferior to it in y treat of Dysent: Much however of its good affects may be ascribed to its operation on y surface of y Body & such an explanation comports best with y properties of y article & its known effects on y system. Two other modes of administering Ipecac in Dys. has lately been proposed by Clark who wrote on y nature & cure of y Dis. It is recommended in y shape of injection. ʒiii of y bruised Root boiled in a qt. of Water down to a pt. & this quantity to be given 3 times pr. dic. by this he observes y bowels are thourougherly evacuated & y tormend & tenesmus & other painful affections are completely & perfectly retieved. Of this mode of administering Ipecac I know nothing from experiance though I have always been taught to believe that a decoct. of y article under consideration is whole by inert all y writers of mat. Med. agree in this a/c of y Medicine. Much more confidance should in my opinion be reposed in y 2nd. mode of prescribing 138. to which I allude. Defeated in this attempts to cure Dysentery in y ordinary manner Mr. Playfair Surgeon in y British Establishment in India has according to his own statement used Ipecac with great advantage in doses of ʒss to ʒi combined with 30. 60 & even 80 gtt Laudanum Confining y patient for hours in a horizontal position, If y first dose was rejected a 2nd. was generally retained. This practice reported to be efficatious was confessed by y author to be adopted only on y onset of y Dis. for if y dis is so far advanced y stomach becomes so irritable as to reject y Med: at once. By Mr. English surgeon to y British troops in India y mode above described was sucessfully followed In my own practice I have never employed it but I entertain a very favorable opinon. It seems to me well calculated to evacuate y alim: Canal in y commencement & y Laud. Or Opii entering into y prescription to allay intestinal irritation which is undoubtedly y proximate Cause of Dysentary. Much also 139. has been said of Antimonials under y same circumstances they have been fairly tried by me & though in some cases & though in some cases they proved very sucessful I think they are not at all in point of efficacy to be compared to Ipecac. But many of y most respectable writers report very differently on y comparative[ly] value of there two remedies. It is exprestly stated by Sir. Geo. Bark. that y result of an extensive experiance with them both gives a decided preferance to y Antim: preparations. To y same point goes also y evidance of J. Pringle not to mention writers of no less authority whose evidance is so strongly relieved. Y Glass of Antimony was y preparation used by Pringle in y cure of Dysentary. Casus may occour in which on article may be better than another. It is thought right that each of these should be retained but it is by no means easy to day at what or in what they are to be employed. I am unable to discriminated & on y whole 140. I expect that when you encounter y Dysentary you will find y Ipecac so well to your views that you will not feel inclined to exchange it for y preparations of antim: As a measure or needful auxiliary to sweating great advantage may sometimes be derived in this stage from y application of wampth to y extream surface. All of you are acquainted with y benefit derived from fomentations applied to y stomach & bowels. They are particularly adapted or calculated to allay spasms & uneasiness which exist is on taking a profuse diaphoresis. It is unecessary for me to recapitulate y method of making such fomentations Not a little has been said of Linaments applied to y abdomen at this stage of Dys. These for y most part consists of into which Laudnum enters largely. But lately it has been alledged that much more advantage results from [deciding?] stimulating Lotions & among one of there is Spts. Turpentine. This I have no doubt would produce 141. very good effect. In Dysentary where there is much distention & pain in y Abdomen. As might be expected y W. Bath in Dys. as well as in other Bowel complaints is highly servisable. It acts precisely on y principle of fomentation though much more effectual. It is not a remedy adopted to general practice & may in a great majority of cases be dispensed with. It is however one of y recourses of our art which practitioners ought to keep in mind but which need only resort to in cases of Emergency. As regards Children y objections do not apply to these. It is easy to administer y remedy & we shall also perceive that in children it is infinitely more efficatious of late however a remedy has been proposed [preser] which goes to prescribe both y Warm Bath & Fomentations I allude to y bandage a flannel Roler applied around y trunk. 4 or 5 [gas?] of Flannel are to be wraped around y body from y hips to y arms. – As relates to y acute stage of 142 Dysentary. I have experiance whatever with y bandage. But long before I had seen y work in y Practice recommended I was in y habit of using it in Diarrhoea in y declining or advanced stage y Dysentary & more particularly in Cholera Inf antum. The fact is perfectly well known to a great number of my patients & also a great member of my Med. friends in this city. To y employment of this remedy I was led by analogical deduction. but more of this when I treat of Diarrhoea. You should never use y flannel Roler in y early stage to y exclusive of other remedies As yet I have said nothing of y use of Blisters they are however an important remedy & in many cases cannot be dispensed with they may be placed on y abdomen or on either extremities But here as in other cases it is most useful when applied nearest seat of y dis. We prefer y extremities sometimes on accout of y inconveniance experianced by y patient on going to stool with his abdomen 143 raw. & Inflamed by y vesicating application. But judging from what I have observed myself I answer that y degree of pain has been greatly aggravated Besides considerations of this kind should never deter us from y use of Blisters to y abdomen when y symptoms indicate y necessity of y remedy. – My own practice in this respect is previously to Evacuate y Bowels & to order for 2 copious V.S. & if I perceive no great salutary suppression of y dis. I then cover y whole surface of y abdomen with Blisters. – As in other case of Inflamation especially intestinal you will here also have reason to be delighted with y effect of this application. I enjoin it on you in y treat of Dysentary & especially when it presents a formidable aspect to keep your eye steadily fixed on y blister & never permit any false tenderness or delicacy towards your patients induce you to overlook so valuable a remedy. Under such circumstances you will have dificulty to encounter 144. generally against y remedy & unless you interpose y whole weight of your authority which your profession invests you. It will very often be applied too late or totally neglected. – I have now completed y general treat of Dysentary but one or 2 local affections attend y complaint which are so troublesome as to demand our particular attention. I allude more particularly to Tenesmus. & Tormina these are occasionally met with at every stage of y complaint. Many remedies have been suggested for y relief of these in y combination of which Opii enters largely. – As regards Tormina & especially when connected with foul & acrid accumulations in y bowels great advantage may be derived from y following ꝶ Ol: Recini ℥i G:Arabic ʒii Sachar. Alba ʒi Tinct. Opii 50 or 60 gtt. This is called y oleaginous mixture in this city a small tablespoon every 2 or 3 [or 4] hours. It remans only stomach infinitely better than y Ol alone & after a few doses have been taken it very much relieves 145. relieves y Symptoms. But even better than this is y mix there I mentioned to you while speaking of Cholera Infantum in [many] some of these cases much advantage is derived from y use of Julep y method of prescribing it I have already mentioned. Not of less utility under such circumstances is a combination of Ipecac & Opii in y proportion Ipecac igr to Opii gr. ¼. But in relation both to Tormina & Tenesmus Opii directly applied to y Rectum is often eminently beneficial. It may be used in y shape of an anodyne where there us much irritability & excoritation of y Rectum a pill of 3 or 4 grs may be introduced & all y beneficial results are decided which would or could be expected from y same article taken into y Stomach. It has y advantage also that where y patent is prejudiced so as to forbid injections it may be introduced without his knowledge. But of all y means I have ever employed with a view to 146. y relief if Tormina & Tenesmus Melted Butter free from rancidity & deprived of its salt is y best from ½ a pt to 1 pt. melted should be thrown up every hour or two y relief occasioned by it is inconceivably great. It is a fact worthy of notice that animal ols. are infinitely less irritable [to] & offensive to a delicate surface than those that are derived from. Veditables, Thus Lard & Butter may be applied with southing effect to an irritable surface which would be aggrevated with olive oil. Nothing as yet has been said of Mercury given with a view to salivate. By consulting writers more partic: East & W. Indies. it will be found that in y management of Dys. Murcury thus employed is almost exclusively confided in not only is it given in y largest possible doses internally but it is also externally employed in y shape of friction. y object of thus exhaling it profusely is to induce Salivate on as soon as possible, there can be little doubt of y superior 147. efficacy of this plan in y treat of Dysentary occouring in Tropical Climates. y Dis in y C & W. Indies is almost always associated with with a greater or less degree of Hepatic Derangement. But in our country it is Inflamatory nature & so rapid in its progress that long before y system could be brought under its impression Gangrene would take place. But in protracted & lingering cases of [Du?] especially where there is any tendancy to Typhus condition there cannot be y slightest doubt as to y usefulness of Mercury. – When however I can speak of this form of Meds. more partic as a [substitute?] for mercury y Nitric Acid has also been recommended. To conclude y consideration of Inflam: Sys. it only remains for me to indicate y diet proper to be observed in this case. Y Dis being an active Inflamation of y alimentary canal it is obvious that we should [not] use articles y least irritating & offensive to y stomach & then 148. in order that y power of Digestion may be exercised as little as possible it should be of y nature. Demulcent Drinks have been used by y common consent of practitioners & by y prejudices of y vulgar to y case before us y neatest & most agreeable of them is Barley Water or Rice Water. Mucillage G. Arabic. Flax seed Tea. Mucillage Slipry Elm Loaf Sugar Water. preparations arrow Root Sago & Tapioca etc. While they constitute y poper nourishment of y patient they are thought not to be without utility in the dis. itself. – Many practitioners prescribe them with a view of diluting y acrimonious fluid & sheathing y surface of y Stomach & Intestines against their irritating influence; but such are derived from old antiquated pathology. Y Idea of sheathing a liveing acting surface by mechanically spreading over it mucilaginous fluids is altogether abandoned. Diluant Drinks are beneficial in Dys. as articles of nourishment & when we grant this much we have 149. we have decided all that our enlightend understanding & sound med. reasoning & Experiance – will admit Typhus Dysentary. With these remarks we conclude y treatment of y common Inflammatory Dys. but in Crowded places or Ships Camps Hospitals & Jails a peculiar ous temperature of y atmosphere prevails. Dysentary in its & through all its subsequent stages is decidedly of a Typhus Character. It appears obvious that in all such circumstances y Dis requires a different treat: from that already detailed. It is right to pursue of same mode of treat. as in other low states of dis. adopting however more partic: to y symp: as in y genuine or real Typhus Fever y early use of Emetics is very beneficial & after moderate evacuation of y bowels y Cordial & Stimulating remedis as Opii Vol. Alkali & Wine Whey with y liberal application of Blisters constitute y 150 treat: most generally resorted to. But as I before mentioned whenever Dysentary anounces in its Origine or acquires with progress a Typhus condition it is safest at once to resort to mercury with a view to salivation. As yet I am of haveing y system completely under y impression with a spedy mitigation of all y symp: & an ultimate recovoury, They causes why we should not resort to mercury has already been stated. But y objection which I stated to preclude y med. in y active inflam: species of Dysentary does not apply to y low & lingering form of y dis. & as regards this cause a salivation may in many instances be effected. The Mercury should be employed internally externally & be supported by y active & diffusible Stim: In y advanced stage of y Dis y Nit: Acid posesses valuable properties. It is not at all suitable in y commencement of y dis but after y dis has advanced to its final Stage. Then it is that y [mercury] acid is of signal advantage. But I give y preferance to 151. Mercury. It is known to most of you that Dys. sometimes takes y type of Intim: fever. Cleghorn describes it of very common occourance in y Isle of Minorca & I have seen y same form of y Dis amoung y paupers in y alms House especially among those from Miasmatic Countries where y inhabitants are subject to Intim: fever now & then y case presents such a complication of symp: as to occasion no little difficulty in management. By Morton y contemporary & rival of Sydenham who first pointed out this form of [fever] Dys. it was recom: that while we pursue y usual practice we should employ Peruvian Bark in y A pyrexia. Exactly y same course was followed by Cleghorn & several others more acute practitioners notwithstanding however all this weight of authority in favour of y practice. I am strongly inclined to think in this case it is not correct or faiseble. Of y cases of Dys. associated with intim: fever. I have 152 some opportunity for y exhibition of Bark & if it had been given it would undoubtedly have proved mischievous. No article of y Mat. Med. proves more offensive to irritable & inflamed bowels than this Med. & so much so is y case that even when y Al. Canal is perfectly sound & healthy it very often so disagrees with y patient as to be precluded. 153 154 155 156. Pathology. Causes seats & signs of Dis Dis. although an evil leads to many advantages 1st. It induces us to study Anatomy & Physiology 2nd. To conciliate us to death. Pain is useful to point out y disd. part. absance of it is a bad sign in a disd Rib, frozen Bone or carious limb. – y Causes of disease are y Remote, Exciting & Proximate likewise Predisposing or Remote Proximate Predisposing & Exciting. – y Remote are Contagion & Miasmata. y Predisposing is Debility this is either natural or acquired. If natural it depends on what was called Temperament. – Predisposition there is 1st. Arterial. disposing to Hemorrage. Pulmonary Consumption 2nd. Phrenic. disposing to Delirium & Mania 3rd. Cephalic. disposing to Headache. Apoplexy Epilepsy &c 4th. Alimentary. disposing to Dysentary. Colic Diarrhoea. 157 Pathology. 5th. Cutaneous. Disposing to Small Pox. 6th. Muscular. ” to Tetanus as great irritability but nosens ability 7th. Nervous. – disposing to Hyphochondrase. 8th. Lymphatic. ” to Dropsy. 9th. Hepatic. ” to Diabetes. Artinal Predisposition prevails in spring. Alamentary in Summer & Fall. Cutaneous in Winter. – A dis always attacks y weakest part of y system a part however may become callous to a dis by haveing its excitability wasted so that stimuli cannot throw it into Morbid action. Dis in thus state is called Disorder y effects are viz 1st. Torpor. absance of Irritability. 2nd. Stupor. absance of sensibility. 3rd. absance of both instances of Disorder as Chronic Ulcers. Calculous Obstructions. Schirrus these induce death & hence become subjects of Medium Acquired Debility is of two kinds from 158 Actions or Obstructions, when it proceeds from this last if an irritant be applied – it first elevates y excitement then depresses it. In y former case if y stimulus remains depressed it is induced y debility of both causes & is y same except in y last y excitability is accumulated & readily thrown into morbid action. In Debility from action when y stimulus which produces it is withdrawn y excitability is accumulated, hence after great fatigue we should not sit down but gradually keep moveing to carry off y redundant excitability – hence y they lead horses who race round y course to prevent stifness – Rheumatism abstracted from important parts in y bowels Signs of Dis by y Pulse. These are 1st Frequency & Quickness. These are not necessarily connected y pulse may be very Frequent & not very Quick or vice versa as in Yellow Fever & y last stage of other fevers. – By Frequency is ment [y number] y number of strokes performed in a given time. – 159 Pathology. Signs of Dis by A/ Pulse Quickness is y time in which y stroke is performed. – y pulse [differs] varies in fevers & other acute dis. in y first stage from 60 to 88 or 180 & sometimes to 200. In a minute it falls in some cases to 40-30-20 & sometimes to 9. – y Frequency & Quickness of y pulse seems to depend on a morbid irritability in y arterial system. y Morbid slowness depends on 3 causes 1st. Pressure on y Brain. – 2nd. Spasm of y Heart 3rd. defect of irritability in y arteries y pulse varies from health in regularity & force this is of much more importance than its duration in frequency & fulness. It sometimes Intermitts. Somet: imparts a sensation to y fingers resembling a shattered Quite. We are now to [examine] consider y different states of y pulse in Fever. – by Depressed Pulse. This state of pulse is caused by stimuli acting so violantly as to depress y system be low y point of reaction or by pressure on some great vessel. It is frequently 160 Signs of Dis by y Pulse. preternaturally quick [crossed out] often slow & sometimes scarcely perceptable often descends a low as 40. 30. 20 & is sometimes so depressed that it is almost imperceptate. It is raised by V.S. It is sometimes preternatural quick slow & attended with intermission & sometimes it is natural. It occours in Plague Y: Fever Malignant & Small Pox & in Pleuracy. It is either general or partial [y latter] occouring in y extremities y former & y latter [occouring in y extremities] occasioned by stimuli depressing y strength below y healthy state. It resembles a low or Typhus pulse & may be distinguished from it 1st. By occouring in y commencement of acute diseases & in y paroxisms of such dis. as are periodical 2nd.. by imparting a sense of tention along y fingers when long & attentively felt. 3rd.. By occouring in morbid affections of y Brain. Heart. Stomach & Bowels more frequently than dis of other parts of y Body. & in Apoplexy. 4th. By occouring rising after V.S. or purging takeing off y suffocated excitement 161 Signs of Dis by y Pulse 5th. By its being attended with preternatural slowness & intermission. Thus y pulse may be compared to a tree bent by y Wind & arising to its proper state after y storm has blown over Whilst y Typhus resembling a Free shattered by lightning which cannot be raised by y hand of art 2nd y Locked Pulse [or Sulkey] This is small quick time & distinct pulse which is imparts to y fingers a sensation similar to that produced by fretting a piece of Cat. gut. tense from whence I have named it. Cat gut Pulse occouring in Malignant fever. – 3rd. y Cynothus Fortis. This is y reverse of y 2 former a full round vigorous frequent & quick pulse without hardness which occours in y highest grade of Bilious Fever in affections of Brain in Pneumonia Notha & congestion of Brain. Exercise produces a pulse somewhat like this. – 162 Signs of Dis by y Pulse 4th. y Synocha or Inflam: Pulse. – Being full, quick, frequent & tense & not round & is known by heat & thirst. This pulse exists sometimes in y Plague. Y. Fever & in common Inflam: but more frequent in Pneumonic affections in Rheumatism & Arthrisis. – 5th.. y Synoch [ous] Pulse A quick, frequent & immoderately tense but a small pulse imparting a sensation to y finger similar to quill & occours in Chronic Rheumatism. Gout & Intim. Fever & in 2nd. Stage of other fevers It is y Synocha on a concracted scale from which it may be distinguished by y column of y Artery. – 6th. y Synochous Mitis Pulse full round & soft. 7th. Synochoid Pulse. This is alternately soft & & may be placed between Synocha & Synochous it occours in y passage of fevers from y low to y Inflam. 163. Signs of Dis by Pulse. State & Visa Versa according to Dr. Butler it imparts a sensation to y fingers like a quill that has been trodden under foot 8th. Typhoid Pulse. – Small frequent & less tense pulse than full it is a compound of synocha & y low chronic states of fever & occours in Hectic & Purperal fever, & in Scatitana. – 9th y Typhus Pulse. This is a weak, small. frequent but full or tense pulse. It differs from y depressed pulse 1st. In tention. 2nd. y arteries in y depressed state still retain their irritability & y pulse rises after V.S. It occours on y low chronic state of fever or in y first stage of some malignant fevers. Cordials are indicated in y close of Inflam: [fever] Diseases when depleting remedies have been used in y 1st stage. It is here V.S. is forbidden & stimuli to be used. 164 Signs of Dis by Pulse. 10th y Hectic Pulse Is quick. frequent & often full & very soft, it is occasionally Synochoid, Typhoid & Typhus & occours in Chronic Fevers. Pthisis Pulmonalis, also Chronic Gout & from Lues Veneri & Scrophula. – 11th. y Hobbling Pulse Is unequal fluctuating, tense quick & very frequent. It may be known from y irregularity of its pulsations. It may be divided thus 1.2.3 [quick] slow [slow] strokes sucseeding & quick one. 2 or 3 [slow] quick stroke sucseeding a slow one. – 12th. y Serrated Pulse Strikes y fingers like a saw one part elevated above y other. – 13th. y Vermicular Pulse. – Small frequent & resembling y motion of a Worm 14th. y Creeping Pulse Weak & small it occours in y last stage of Dis. 15th. y Apparantly Natural Pulse. – A pulse perfectly natural in Violant Fevers 165. Signs of Dis by y Pulse. ~ is one of y worst symptom. It occours in y most Malignant in Y. Fever & can only be distinguished from y Pulse of Health but by y other symp. of Dis. Great danger is to be apprehended by it – Scarsely any of these are always present they are therefore combined 1st. in double proportion as Full & Weak, Full & Frequent Depressed & Weak. Slow & Intermitt: 2nd. In a three fold state as Full Strong Quick & frequent at y same times 16th, a full, bounding, slow, & moderately tense pulse as in Palsy Apoplexy or Dropsy it is especially full & slow in y affected side as in Hemiplegia. Dr. Rush examined y pulse of a parylitic patient whose artery beat on y affected side 50 whil on y other it beat from 80. to 90. – 17th – A weak & low pulse without irregularity occours in debility without fear or is [distinguished?] from y weak & low pulse of malignant fevers 166. by its occouring in y last Stage of Dis y usual pulse of y low Hypochondria state of y system 18th.. There is sometimes a total Absance of. Pulse in dis which somet. occour in violant affections of y Stomach & bowels. It lasts sometimes for hours. Dr. Rush kew a lady to be without pulse 36 hours in consequence of eating some Oysters she has since perfectly recovoured. – 19th. Gaseous State of y Pulse soft full & round 20th. Aneurismatic Pulse is full & tense & imparts to y fingers a disagreable jarring sensation which when once felt can never be forgotten It occours only in cases of aneurisms. – The pulse is much influanced by y strength of y animal in a Pigeon 100 Ox 30 to 38. – 167. 1 Intermittant Fever. Wine. – John Hunter’s remarks on use Wine in Remitt: and Intimitt: as they occoured in Jamaca. With regard to y quantity to be used it is dificult to give precise directions I have generally found upon careful examination that y quantity which has the best effects is less than has generally been given. I have rarely given more than a Pint in 24 hours a larger quantity did more hurt than good y strength quantity & quality of Cordials must bear direct proportion to y strength of y patient. Opium The above applies to opii in y same States of y system I think that O. in the last stage combined with Ipecac or antimony will be more safely given than by itself where there is tendancy to the continued form. – In those cases of Intim: in which the cold stage was preceeded and accompanied with a violant cough I have used O: with y best success Case W.B. a Man of 50 living in Hampden plains had I. of this Kind. The cough was very frequent an Iritating particularly so previous & during y cold stage He tried y Bark & most of y Veg & Min tonicts and among other things arsenic. also Depletion. V.S. Emet: Cathartic Intimitt Fever Epispast: His cough & fever were finally removed by a pill composed of Opii gri Calomel gr.ss repeated every 8 hours. In my opinion this was a case of I: from irritation which prehaps may have depended upon Visceral obstruction [see page 7.5. for more cases]. – Intimittants threatning to run into Typhus. Opii should be combined with Bark, Serpentarid. Vol. Alcali & Camphor. In such cases a torpid state of y bowels should be obviated. In cases of this Kind it will be very difficult to restore y system to healthy action when y Liver Stomach & Intestines do not perform their function These are to be excited to action by gentle Laxatives such as soap. Rheii. Soluble Tartar & by external irritation to y Bowels. – If these parts perform their functions they will have great influance by association of action to bring the other parts of the system to healthy action. In almost all cases of Intim: it will be a safe and efficatious practice to give opii in y very commencement or at y time when y cold stage is expected O: may be given in pills or Laudnum combined with aromatic Teas and Dilunts & other means of producing perspiration the 2 Intimitt Fever temperature & y action of y Body should be equalized. – As a general Rule it will be necessary all cases of Intim to deplete y system before giving Stimulent Tonics. An Emet: Cath: & sometimes V.S. will be necessary. Exceptions to this rule are rare. – In all cases you must be governed by y [Cases] state of y system & y laws of yt. part of the system which is the principle seat of y dis: or the point to which it determins Antimony Ipecac Neutral Salts. Em: Tart. Camph: & Ammonia qualify y action of O: & operate by determining its action to y skin. If O. excites uniform perspiration there is no danger of congestion or derangement of y functions When it produces partial perspiration of y Head & Breast it only coincides with & aggrevates the morbid action of y dis: Dovers Powders are a very safe & useful composition of Opii ꝶ Ipecac & Opii ā ʒi Sulphate Potash ℥i Dose fm. 5 to 15 grs. In cases when diuretic effects are wished from the powder. Nitre may be substituted in y place of Vit: Tartar. – In my practice I have usually made y powder of Em: Tartar instead of Vit: Tartar & added ʒii Camphor with y Intimitt: Fever alteration thus ꝶ Ives Dovers Powders Ipecac & Opii - ʒi Camphor ʒii Em. Tartar ℥i. Acids combined with Stimulating Diaphoretics have been very useful in ourt fevers during y present diathesis which prevailed since y year 1805 with occasional variations. – Hyoceamus Niger. Dr. Smith of So. Carolina used y Ext with sucess he gave at y same time Sul. Zinc. – Atropa Belladona. In obstinate Intim: Bitter Almons. Their efficacy was established Barron Stork who used them very largely & sucessfully in this dis The Laurus no doubt has many Med: Virtues which doubtless will be brought by future experiments y Narcotic principle is intimately connected with Prusic acid. – Amica Montana. recommended as a substitute for Bark Spigelia Marylandica in Tinct: has been used. – Iron. a good auxiliary to y treat: in feble & lax habits yet it ought to be used with great caution in cases threatening congestion Liver & Spleen 3 Intimitt: Fever Copper in Intim: & Remit: but has now given place to Tonic Solution. Zinc in ordinary Intim. without cough or any peculiar irritation in y system or chronic Vis: Obstruction. I give y White Vitriol & Myrrh āā gri in a pill. Giving fm 1 to 6 pills in a day during y Intermission previous to giving y pills y Stom: & Bowels should be evacuated. It is y remedy on which I most depend in I: of an ordinary type. It very rarely offends y stomach. I have given as much as 4 grs W. Vitriol in pills at a dose without producing nausea It excites appetite, promotes digestion & produces vigorous action of y system generally. No debility follows y use of this remedy though it has been continued for Mos: [see page 236 Vol 1 for case West part York State] Arsenic may produce the same effect as a ligature on y leg & opposite arm at y commencement of y dis. y A: may determine y action to y minute vessels & prevent y engorgement of y Heart & Large vessels which takes place in y cold stage. This is infered fm: y fact that Arsenic produces Œdema. When it produces sensible  Intimitt Fevers though not violant effects they are analogous to y combined action of Tart: Antimony & Calomel. – In Intermitts. it is safe & efficatious remedy. I have not in my practice seen any ill consequences follow y use of Arsenite of Potash. In its effects it is not inferior to Bark. It is [cross out] adapted to y same cases which indicate Bark & indeed will often cure cases in which y Bark has been thorougherly tried & failed It is more particularly adapted than y Bark to those cases in which there us some excess of action. – Its action in such cases may be like that of Mercury reducing y system to that state in which Bark is adapted. I should not be administered in those cases which have a tendancy to Typhus & require Stimulating Tonics. It is not so well adapted to In: of long standing. Here Nutral Salts with Bark & somet: Opii & Calomel must be given. Camphor combined with Bark. Cuprum has frequently ben given to children in Intim: & Remitt: but has given place to Tonic Solution 4 Intimitt: Fever Bark. Tho a valuable remedy in this Dis still it has no specific powers ie it will not cure in every case. has an action peculiar to itself. In ordinary cases especially in cold climates y administration of B should be preceeded by evacuation of y bowels or. Stom or both as y symp. may require & frequently V.S. is necessary previous to y B. best mode to give is in substance if stom. will not bear it give in Decoct Tinct. Cold Infus. Dose it may be given 10 grs to ʒi repeated every 2 hours in y Intermission. Not to be given in our climate in y in y Hot stage. /given in this stage in hot Climes) It is y practice to give y B imediately after evacuating first passages. Dropsy. Jaundice & other Dis have followed y use of B. in I. In such cases there probably was not evacuations enough made. In Penn. hospital I saw. an Anasarca fm. Injudicious use of B cured by V.S. In I. with+ Visceral Congestion y B must be combined with Rheii or its action qualifyed by frequent small doses of Neutral Salts. as Sol. Tartar &c +(See Linac on Fever) [Remittant Fever]. – Intimittant [Porter. – is more particularly useful which occour in Intu August & September when y Stomach is very irritable with general prostration of strength. It is a very grateful stimulant to y stomach on account of y fixed air which it contains, corrects morbid secretions of y Stom & is very nutritions to convalesants. – It is admisable in all fevers affecting y Stom: & Bowels after y first Stage & relieves]. – Y Nutral Salts even if they do not operate as bath yet they prevent y system fm rising to y Inflam. point Those cases in which there was very little perspiration y bath has not suceeded well unless given with Nutral Salts or Rheii. It is a common practice to in case y dose just before y expected paroxism It certainly at this time has more effect yet it is without danger. A Tertian has somet. put on y form of Apoplexy (not seen much of this dis.) I have not suceeded well in treating Intim With Cough with y B. but usually with Calomel. Opii & somet: Epispas are necessary. Y several preparations of B may be 5 used together. Angustura Bark has been recom. in powder in Intermission dose 20 grs every 3 or 4 hours I have used as above directed in this dis somet. with complete sucess but it is rare that y Stom: will bear such large doses. Cascarilla useful in In. which terminate in Typhus. – Snake Root partic. useful in those In. whose parox. terminates with little or no perspiration & y skin hot & dry in y Intermission. combined with Bark. S.R. is a very valuable addition to y B. in treat. of In. Y. Comp. Tinct Bark is taken in ℥ss does in y cure of In. Some phys. Give an Emetic of Tart. Antim in a strong decoct. of Serpent. & give a cath of Nutral Salt in y same decoct. in this mode they operate very kindly & leave y Stom. & Bowl in a better State. – Cornus Florida. highly recom. has cured where bark has failed dose powder ʒss to ʒi Intermittant Fever sucessfully used in Middle & Western states Y most useful preparation is y Extract dos 5 to 10 grs. Astringents are servisable when combined with aromatics. Those Veg. substances are best adapted to I. which contain y Bitter. Astring & Aromatic principle. Ast. are more partic indicat. in Ints in constitutions of lax fiber (leucophley. temp.) Galls. sucseed best comb. with Aromat. & Bitters sometimes G. have cured I. which have not yialded to Bark. I presume G. succeeded best where then general relaxation in y system. Int. in there different stages & different forms often require as different as Synocha & Typhus. - 6 Typhus. Alcohol. is used diluted & is a good remedy to increase y arterial action. It may be given fm: ℥ss to ℥i every hour. Old Spirits sets kindly on y stomach in this dis. when Wine & Porter will not. – Wine is useful after y evacuations of first passages to keep up an uniform excitement Some Physians give a bottle each day through y whole course of y dis. This mode of Practice succeeds very well in those cases where there is no considerable local [derangement] determination & y secretions & excretions are not much interrupted. – In 1805 & 6 wine was very much used in a fever which prevailed in this Town. I suceded best at y time of a crisis or when some symptoms indicated a change in y [symptoms] system or when y dis had spent itself. In these cases I gave fm 2 to 3 pts of the best white wine in 24 hours & thus producing a favourable crisis. But if y strength or excitability had been worn out by this article would not produce that effect. With Wine it is common to combine Bark & Opii. – Aqua Ammonia is a good addition to y Wine its use in T:F. is indicated by y same symptoms & has y advantage of correcting y stomach & preventing y Wine fm: becoming acid. Porter when y patient is Tympanitic I think it has increased that unpleasant symptom. – Ether. Diluted given in T.F. to keep up y action of y system & to produce perspiration. In Flatulance & in Tympanitic state of y Bowels in T. In y last stages of T. E is given mixd with wine or diluted alkahol & it adds much to y virtues of these articles. E. qualifies Wine & Alkahol as aromatics qualified Tonics. It stimulates y skin by external application. If confined to y part it increases heat if it evaporates diminishes heat Camphor – is advantageously combined with Lime juice Vinegar and other acids in effervessing mixtures It has been a very useful article in y treatment of y dis: which have occoured since y year 1805 This Grade of dis. are very much like those described by Sir John Pringle. The Dis has been more or less Typhus in its progress in some cases Typhoid in 7 others Synocus in its commencement partaking more or less of y Tertian Type with a determination to y viscera of y abdomen like an intermittant affecting y secretions sometimes causing profuse secretions at others interupting all secretions accompanied very generally by Tympanitic state of y bowels attended with local critical determinations with Inflamation & supuration of y part at y same time y state of y system Typhus When this local determination fixed on y brain Heart & Lungs it invariably produces death unless y action was overcome or determined to some other part less essential to life. Prehaps this Fever might be called y Intestinal State of Fever In this fever Camph: has been of great servise combined with opii in y form of Dovers Powders or Diaphoretic: It appears to equalize y action of y opii by determining to y surface & preventing that dryness of y tongue which sometimes follows y use of Opii. It has been useful in cases of this Fever attended with Tympanites both by Injection and Camphorated Liniment applied to y Bowels Typhus Fever. Opium. should not be administered in Typhoid Fevers with Visceral congestion or obstruction or when there is a determination to y head & local supuration threatened although y diathesis of y system is Typhus Such a fatal determination is produced by a dry skin & tongue deafness & disterbance in y intellectual faculties y Rules which Sir John Pringle gave concerning y use of Wine in Goal Fevers & y direction of Lenac on y use of Bark in Intim: & Remitt: will apply to y use of Opii in such states of y system. – Castor. – In T.F of the mild kind combined with valerian Snake Root or Orange Peel with advantage Valerian. – is used. – Phosphorised Ether viz ꝶ 3grs Phosporus divided into small pieces & put into ℥i Sulph. Ether in a week y med: will be fit to use. If any [Ether] Phos: remains at y button y Ether should be carfully strained off dose 3 to 12 gtts in any convenient vehicle has been given in T F & in other forms of Fever in which y dis action has worn out the 8 excitability of y system in such cases it has sometimes roused the patient in y very article of Death & been the means of saving them – In Typhus in y low state where there was no particular determination it has been given & no injury followed. – Phosphoric Acid has been given for y same indicatins as J: Ether and when it has been used in y last stage if T: it has often Excited a desire for Animal food. – Cantharides in T accompanied with very frequent pulse it diminishes its frequency. When y system becomes over charged with cantharides y stools became mucous & Bloody with Tenesmus & extreme pain y urine suppressed or in Small quantities and Bloody. When large doses have excited Inflam: y symp: are similar to those of Inflam. Dysentary. – (see page 212 Ives Lectures Vol 1) Chapman continued at back (reverse direction) Extracts from a Treatise on Cholera Asphyxia or Epidemic Cholera as it appeared in Asia and more recently in Europe. with practical remarks on y dis. in Europe an appendix of cases & y reports and regulations of the Boards of Health of London and Edinburgh by George Hamilton Bell Fellow of the Royal College of Surgeons Edin: late residency sugeon Janjore and joint medical secretary to the Edinburgh Board of Health. ~ Second Edition 1832 9 Cholera Asphyxia. In describing this dis. it may be useful to attend to what may be cal’d 4 Stages. 1st. The invasion of Cholera is so insidious that the individual attacked may be quite unconcious of the presence of the 1s Stage of it. Very often it is only to be detected by those well acquainted with y dis. Not only in this stage but throughout the whole course of the dis the appearance of the countenance is one of y most highly characteristic symptoms. An intimate find may observe the the person has an expression of anxiety. That his complexion is unnaturally earthy & his eyes seem sunk in his head. In reply to inquiries he will deny that he is unwell he may say he is a little deaf & if minutely questioned may admit that he has an indescribable sensation of being out of Order that he has oppression at y chest & is unaccountably depressed & listless. he may have no nausea but has Tormina of the bowels & prehaps an uncomfortable sensation of heat at the pit of y Stomach His pulse is quick & weak (I have seen one case in which it had the febrile throb.) the hands & feet feel cold. the nails are blue & he has had one or more unnatural discharges. The first of these is generally characteristic. there is a sudden call, & the whole intestines seem to be at once emptied followed by a feeling of weakness 2d Stage Cholera is more easily recognized: The pathognomic character of the countenance to those who have seen the dis is no longer doubtful. The eyes are sunk in the head lips are blue, there is a ghastly look about the mouth & the whole features are shrunk. The patient does not now deny being unwell he acknowledges haveing passed some [pecution?] stools & probably has had vomiting these have been followed by great prostration of strength 10 there is tinnitus aurium often slight deafness & Vertigo. The pulse is more decidedly affected it is weak & thready: Skin is cold there is much thirst & a burning pain at the pit of the stomach but y tongue is not dry it is moist, white & cold. The fluid passed from the stomach & bowels is like water in which grain has been boiled with pee as more or less numerous of opaque white or yellowish coagulated matter floating in it. The manner in which the discharge takes place is characteristic. The desire is sudden unaccompanied by griping or nausea & y the stomach & bowels are emptied at once & with some violence: the gastric & intestinal evacuations are nearly similar. In their appearance & nature 3 Stage In this stage the sinking of the countenance is still the most prominently characteristic symptom. The eyes Surrounded by a dark circle are completely sunk in their sockets. the whole countenance is collapsed y skin is livid & the expression is so altered that the patients most intimate friends cannot recognize him. The surface is now generally covered with cold sweat y nails are pearly blue & y skin of y hands & feet are corrugated as if they had been long stupid in water the sensibility of the whole surface is deficient but it is by no means uncommon for patients to complain of a burning heat in there cold skin. Vesicatories do not act even boiling water does not raise a blister. If the case be attended with spasms the suffering of y patient is much aggravated & is sometimes excruciating The spasms commence in the hands and feet like cramp they stretch up the limbs to the trunk which however they do not always reach. In some cases again 11 the muscles of y abdomen are principally affected & they are drawn towards the spine during y whole course of y dis. These spasms may have commenced early in y dis being on some occasion y very first symptom. The discharges fm. y Stomach & bowels at this stage are very irregular in some cases they are still very frequent in others after one or two evacuations they wholly cease The pulse at y wrist if it have not ceased is scarcely perceptible & y heart beats feebly. When y spasms are severe they frequently, even though y pulse be still quite distinct stop it arising the paroxysms y same effect is produced by excessive vomiting. The breathing is slow & oppressed, this also sometimes occours early in y dis. The voice is low & but few words can be spoken without expiration. The exhaled breath is cold & though y heat of y body is many degrees below the standard y patient throws off the bed clothes & enterals the bye standers to allow him cold dis & cold water. Hiccup is not uncommon & is rather a favourable than an unfavourable symptom. – 4th Stage. In y last stage the intestinal evacuations have most likely ceased; y eyes completely sunk in there orbits are glazed & flaccid turned upwards & half covered with the eyelids. Y spasms are now commonly at an end y extremities indeed y whole body is that of a corpse & the impression communicated by y skin has been well. listened to “damp hide”. Every artery has ceased to pulsate & y action of y heart if perceptible is a mere flutter. y whole body is bathed in a Cold & Clammy sweat. It is painful to witness y oppression of respiration & jactitation of y sufferer 12 The dying man can still be roused but when undisturbed he generally appears in in a state approaching to stupor: & though prehaps in a humor which might almost be termed sulkas is in most cases coherent to the last. These symptoms are y immediate forerunners of death. If blood be drawn during the progress of y dis. it is found in y Outset dark coloured as y cases advances y blood becomes thick there is a deficiency of serum it coagulates quickly & does not assume y buffy coat. In y latter stages of y dis y current in y veins has stopped & the blood is so gramous that it can scarcely be forced out in y smallest quantity through a large orifice. The whole course of these stages generally does not exceed 16 hours & unluckily y practitioner is seldom called in untill the first & part of the 2d stage has passed The period consumed by each of y above artificial divisions varies in every case. I have seen instances in which death ensued in less than 4 hours after y commencement of y dis. & others in which its latter stage with y pulse quite imperceptible had already lasted a whole day. The condition of y mind is remarkably collected during y whole progress of terible illness for tho. Patients, as y malady advances are unwilling to be disturbed with questions this appears rather to result from y want of physical energy than from any intellectual failure. Indeed as the fatal event approaches y only wish a patient seems to have is to be allowed cold water & to be left to die in peace It has been well said that a patient in y last stages of Cholera may be called a “living Corpse.” 13 It curious phenomenon has been several times observed. After a patient has been some time to all appearances dead & when y attendance even dressing the corpse, Spasmodic twitches have taken place in y limbs having in some instances even extended to y muscles of y body & general spasmodic contractions have supervened. Cases often occour in which one or more of y above detailed symptoms do not appear There may be no spasms y Vomiting & purging may early cease or there may have been only one large alvine discharge, follow’d by a mortal collapse y patient seeming to be at once struck with death, and tho’ on [y] the very first appearance of y dis. he has walked to y Surgeon his pulse is found to be gone, his heart has ceased to beat blood can be got only in drops from the veins he lays down his head & dies without a complaint. These anomalies are not confined to individuals instances but are found to occour as M. Scott well expresses it in “local epidemic visitations.” Thus he says “when the dis appears epidemically in a town or district or in y lines of a corps or y camp of a marching Regiment, it may on one occasion be [distinguished?] throughout by y absence of vomiting & y prevalence of purging, & on another by y excess of vomiting & tho’ more rarely by y absence of purging. Spasm may be generally present in one instance of invasion, in another it may not be distinguishable. I was on one occasion called upon to send assistance to a district in which y dis. was thus described “It commences by attacking y sufferer with an agonizing heat in y stomach vomiting & purging & lock-jaw. death ensues in 2 hours & often more rapidly it bids defiance to every remedy” 14 But in all cases in which y dis has established itself, there are y collapsed Countenance blue lips & nails, shrunken fingers. The total failure if y usual secretions, deficient animal heat, suspension of y pulse, & remora in the venous circulation. Treatment of Cholera asphyxia The following may be considered the indications of Cure. 1st. To relieve y oppressed circulation 2d. To stimulate the system 3d To restore y heat of y body 4th To guard against local congestion 5th To keep down reaction 6th. To produce a healthy condition of the alamentary secretions. 1 Blood letting in cholera is obviously in a great degree mechanical. The power of circulation has been injured it is no longer capable of duly distributing y mass of blood in y system & y cessation of y usual secretion the deficient pulmonary function & the effect of y discharges have rendered y blood wholely unfit for vital purposes. By V.S. in such [cases] circumstances we relieve the gorged vessels & thus enable the 15 weakened energies of y circulating power to act on y distendened organs of circulations & to restore the current of y blood. The Lungs recover their function pure blood is thrown into y left heart y arteries are again filled with with a fluid fit to support life. this it may be supposed reacts on y sympathetic system & by its energies are completely restored. In this way only can the of V.S. in cholera be explained. No other method will account for y almost instantaneous recovery which so often follows V.S. in such a condition of y system as has been described a recovery more immediate than that which follows y removal of mechanical pressure fm. y brain. And I should say very confidently that in no case in which it is possible to persevere in V.S. untill Blood of a healthy colour & consistance flows freely fm. the vein will y patient die fm. collapse. in commencing the treatment of cholera then no time is to be lost in endeavouring to bleed y patient. He should be laid in a warm bed & y great object being to get Blood to flow it is important that the operation should be performed with as little fatigue to him as possible. He should be kept in a recumbent posture and as answering y two next indications will be y means of forwarding this important object immediate recourse should be had to stimulants – applying artificial heat using frictions &c. The rule as to y extent to which y removal of blood should be carried is very simple it has no reference to the prostration of strength or to the constitutional stamina of y patient. The power [to give motion] [often] of circulation is unable to give motion to y volume of 16 blood which has accumulated in the venous system & which has been rendered by y cessation of secretion, y diminish function of y Lungs & y disordered actions incapable of supporting life & blood is let until it appears that is fatal a condition of y vital fluid has been changed. In other words the blood ought to be allow’d to flow until the natural current in the veins has been restored & there is evidence in the improved colour of y Blood that the Lungs have recovered their function. If opening one vein be not sufficient let others be tried & until y dis. yealds the practitioner must persevere in his endeavours to accomplish this great object. In y outset prehaps only a few drops of tar like blood can be obtained by y use of internal & external stimulants some good appears to be done & the pulse rises: - renew’d attempts should immediately be made to remove blood nor should these be desisted form while life remains. – In addition to the lancet leeches or cupping glasses should be tried. It is be remembered that added to y general vinos congestion there may be a tendancy to morbid plethora in particular organs. There is sometimes confusion of head & more obtuseness of y intellectual faculties than usual. This is not only a bad symptom with reference to y [patient] present condition of y patient but may be attended by fatal effects after y primary dis is relieved. In such cases I should bleed fm y Jugular vein & as many leeches as well adhere should be applied to y temples & throat The abdomen is in every case y principle seat of congestion. Leeches ought therefore to be applied to y belly also & partic. over y seat of y Liver care being taken to avoid as much as possible exposing y patients 17 body to cold. It is unfortunate however that like blisters leeches during extreme collapse are quite useless. – 2nd. To stimulate y system. The classes as the second indication of y treatment of Cholera. Yet in their application V.S. & attempts to stimulate the system, ought to go hand in hand. The object is to restore the suspended circulation. Blood is let in order to diminish y quantity of Blood to be acted upon & stimuli are administered in order to excite the source of power. Indeed it is often impossible to render V.S. efficient until after stimulants have produced some effect. It is not merely by internal remedies that this indication is to be an severed. Frictions over y whole surface, rubefacients and sinapisms to different parts of the body are in truth important portions of y stimulating remedies. The internal remedies which have been resorted too with must confidence & sucess in y Treatment of Cholera are Opium. Ether: Camphor. Ammonia pepermint. Strogue-amer, spirits and Calomel. The general mistake in y treatment of Cholera has been y administering of too large doses of those medicine which have obtained a high character among practitioners. The large doses of Calomel & Opium which many are in y habit of prescribing are especially pernicious. This practice seems to arise from y nature of y dis being misunderstood. A patient is suffering from violent Vomiting & purging & excruciating spasms & indication appears to be to allay these high actions. Hence Calomel & opii are prescribed in quantities amounting to what are considered sedative doses. There can be little doubt that more injury than benefit. has resulted from this practice for should y dis be overcome & y medicins not 18 have been evacuated 10 or 20 grs Opii & 60 or 100 grs Calomel must act as poison on the restored functions. The object being there to stimulate y system Meds. should be prescribed in such quantities as are known to act as stimuli. In fever a scruple of Calomel no doubt will very often allay as once y irritation of y stomach & experiments seem to prove that in large doses this Med. acts sedatively on y gastro:-enteric mucous membrane. It has been ascertained by experiance that most narcotic in large doses act as sedatives very soon after being administered; while it is unquestionable that y same Med. in small quantities, excite y circulation and are consequently to be regarded as stimulants. Early in my practice in Cholera I found reason to believe that while there was positive good to be done by small quantities of these Meds. frequently repeated their good effects were very questionable in y powerful doses which were commonly prescribed. – In y treatment of y dis. this is a point of so much importance particlularly as regards opium that I think it necessary to add a few words on y subject Opii is generally administered in Cholera as an antispasmodic & if this Med. does not act as a narcotic so long as it has Spasm to allay, it has been thought that y largest doses of Opium are safe during y collapse Stage of Cholera. Now the spasms of Cholera are not Tetanic nor of cerebral origin, but evidently result from y condition of y circulation acting on y extreme branches of y nerves. & these spasms are immediately removed by y restoration of y balance of the circulation. When large doses of Opii are administered to a patient labouring under Tetanus the functions of y stomach being unimpaired y drug is at once digested & absorbed, but as y Cerebral nerves are y seat of y disease y narcotic effects of y med. appear to be 19 rendered inert by y state of y nervous system or are expended in allaying its irritability. In Cholera however thou seems to be no reason for believing that y nervous system of y Brain or spinal marrow is directly in a morbid condition. Opium therefore y not indicated as in Tetanus but even if it were so y function of y stomach being unquestionably suspended meds. are only [partly] partially digested & absorbed. Hence it happens that when y stomach no longer rejects what is swallow’d repeated doses of Opii remain in it little acted upon & when that organ recovers its function if Opii has been largely administered there remains a dangerous if not a poisonous quantity of y narcotic to be digested & absorbed. There being now no spasms to nutralize its effect the Consequence is that reaction is interupted the brain instead of being able to assist y other powers of y system in reestablishing health has its functions interfered with, Congestion takes place in that important organ & death ensues either from this cause or from rapid Typhus. It is therefore one of y most important points in y treatment of Cholera to avoid all over doses of Meds. & with regard to Opii or Laudanum in particular extreme caution ought to be used in administering it or in recommending it to y public, for both in Asia & in Europe the most fatal effects have followed over doses of these meds. – The condition of y stomach in cholera generally renders y exhibition of Meds. in a liquid [state] shape in y outset of y treatment wholely useless as they are immediately rejected by y stomach or bowels. It is therefore advisable at least while y vomiting to administer y remedies in form of pill. The following ꝶ which was not only given with great benefit to patients (adults) immediately on my being called to them, but which was distributed 20 in large quantities for y use of y sick wherever cholera was reported to exist in y district over which my professional charge extended. ꝶ Calomel grs iij} Camphor gr ij} Opium gr. ss} Mis. ft. Pil} (one of these was given every ½ hour & sometimes oftener, while y urgent symptoms continued. The nature assistant had orders not to persevere in this practice longer than 3 hours if they had reason to believe that all pills were retained.) Such pills should be washed down with a small quantity of Brandy & Water & as soon as y stomach seems quieted y following draught should be administered ꝶ Ether Sulphuric gt xxx Tinct. Opiium gt x Mistura Camphor ℥i Mis ft. Haust . (draught to be taken immediately & repeated every ¼ or ½ hour according to y urgency of y case) It was at one time the opinion that cold drinks in Cholera were dangerous. Mr. Annesley found by experiment that Tartaric Acid dissolves y viscid matter which is so often found after death, lining the enteric mucous membrane & he latterly allowed his patients lemonade which was found delight fully refreshing. He also gave a drink containing nitric acid in y hope that while it was agreable to y patient it might communicate oxygen to y system. Wheather we admit y importance while y dis exists, y fibrinous matter on which Tartaric acts or imagine that that Oxygen can reach y system in the way M.D. seems to expect when it is no longer absorbed in y Lungs the practice of M.D. is certainly a real comfort to y patient & can be attended with no bad effects. – In the very outset of y treatment, frictions over y whole body, & shampooning y extremities should be resorted to. Frictions is best applied by means of hot flannel. It may be necessary however to use hot spirrits 21 of Turpentine. & rubbing with y flannel should be continued until y turpentine is rubbed dry. Bags of hot Sand or Salt should be applied to y extremities or other parts of y body but this will often while y extremities of collapse continues, prove unsupportable to y patient. – Blisters during extreme collapse are quite inert & y emplastrum Lytta is too slow in its operation to prove serviceable. Mustard cataplasms are a more valuable remedy: these may be applied with advantage all over y abdomen & to y calves of y legs soles of y feet & even to y chest. Nitric Acid has been resorted to in order to produce an immediate blister – it does not seem to have been attended by any marked benefit & it is apt to produce an escar which may prove afterwards extremely troublesome. Boiling Water is also recommended with y same view & has apparently in some practitioners hands been found useful. Partial Topical applications however are not much to be depended on & as has been already observed, Vesication cannot be produced during Cholera. The dis. is a failure of an important power of y system & y object in simulating y skin is to assist y internal remedies in exciting this suspended power. But as yet there is no local affection to be removed by topical applications altho. these may become very valuable the after indications of cure. In the present stage of y treatment, therefore an extensive application of sinapisms, or y general embrocation of spirrits of Turpentine alone or combined with Tinct. Cantharides or of Oil & [Hartshorn?] or any other powerful rubefacient is to be regarded as y best means of assisting y internal stimulants in their operation 22 3rd. To restore y heat of y body. The heat of y body can only be effectually brought back by reestablishing the circulation of y blood. At y same time remedies having in view restoration of y deficient animal heat have been considered by most practitioners an important part of y treatment; & therefore they are not unworthy of a separate consideration. No one of these three indications however altho classed seriation should precede or wait upon y others. The treatment should be commenced with any one of the three which can be most easily answered, & y whole of them ough to be considered as belonging to y first branch of y treatment of y dis. There is one very remarcable circumstance attending y worst description of Cholera which has been already repeatedly alluded to viz the morbid sensibility of y patient, skin & apparently of his stomach to y presence of any thing raised above y temperature of y air. A warm bath for instance of a heat some degrees below y healthy temperature of y body has been found so insupportable, that a patient after being immersed in it for a few minutes has sprung out of it almost with spasmodic energy & entreated that he might not again be exposed to so painful a remedy. A similar feeling is very commonly produced in y patient by swallowing liquids not more than lukewarm. Notwithstanding however y instinctive dislike to artificial heat exhibited by so many patients labouring under y dis. still it is advisable that attempts should be made to prevent a fatal reduction of y animal temperature. This is particularly necessary in a cold climate. The patient therefore on his being attacked ought to be placed in warm blankets, & every endeavour should be rised to keep 23 his extremities warm preventing as much as possible his throwing off y bed clothes or removing himself from y heated articles which are applied to him. The restoration of animal heat has been reconed so important, that it has led to various contrivances for applying wamth, The hot water bath was at one time much used. but y delay. y fatiegue of using it. exposure & fatigue in drying y patient renders generally the hot bath more usurious than beneficial. The principle which should regulate y application of heat to Cholera patients is that it should be done with the least possible fatigue to them. With this view various descriptions of Vapour Baths have been proposed. The simplest & most expeditions is Dalton’s Bath made by putting burning spirits and the cot or couch which is surrounded by blankets. Poles of ignited Charcoal answer y same purpose. When there are not such [contrivances] conveniences as these at hand use hot Blanket. Bottles of Hot Water. Bags of heated Sand &c. But unfortunately it often happens that y best contrived me thoads are so painful to y patient that they cannot be presisted in. The general result of y steps which must be taken to overcome y dis. is that Venesection is to be immediately resorted to & every endeavour made to get Blood to flow until the congestion is relieved & until there is evidence that y function of y Lungs & action of y heart are so far restored. For y same purpose stimulants are prescribed & artificial heat is applied to assist y returning circulation in raising y temperature of y body to y natural standard. – Such was y practice resorted to by me [in] [India] & others with great sucess in India & from all that I can learn a similar course of treatment had proved equally beneficial in this country. 24 I am informed that a Mustard Emetic has provd very serviceable in y North of England ½ oz Mustard given in cup of Water: it produces full vomiting & appears to stimulate y circulation [so?] as to enable y surgeon to bleed. The removal of blood to y necessary extent has invariably so far as my experiance goes to spasms. oppression & to y Vomiting & purging & has relieved y prostration of strength The effect of V.S would indeed sometimes appear miraculous. A patient will be brought in oil a cot. Unable to move a limb & but that he can speak & Breathe, having y character (both to touch & sight) of a Corpe, yet will he by free V.S. alone be rendered in 1/2 an hour able to walk home with his friends. Case a man was reported to have been suffering from Cholera during y whole afternoon His Skin was cool pulse weak thready had spasms in y extremities urgent thirst. I immediately bleed him & with difficulty obtained a full stream, When about 20 oz of Blood had been taken y mean felt complete relief, Some Brandy & Water was given him & he returned with his friends to his own quarters He was able to accompany y detatchment of troops next morning. There cannot be a more decided proof that this dis, becomes one of pure contagion & that y immediate care of remove in y circulation whatever that may have been no longer exists than y almost instantaneous effect produced by removing a portion of y redundant & [what] to say y least of it what venous blood. All know that however sucessful V.S. may be in relieving the most urgent symptoms of inflamation complete restoration is not y immediate [effect] result that inflamation is not a mere fulness of y vessels of y affected part but that y arteries are in a morbid condition, & that time is required to restore them to healthy action not uncommonly y most difficult part of y treatment 25 And we are therefore fully warranted in concluding that if Cholera consisted of a diseased condition of any portion of y arterial system recovery could not be instantaneous. Breathing Oxygen or Oxygen diluted is worthy of trial. I should also if possible throw the Galvanic stream through the abdomen. But having arrived at y conclusion that y great object is to stimulate y sympathetic system of nerves it is to be hoped that experiance may enable us to attain this object more effectually than we have hitherto done. Prognosis. The most satisfactory symptoms in y early stages of y treatment of Cholera are y return of y natural colour of y lips & nails arising of arterial action in y extremities & recovered animal heat. The proof that y dis is overcome is y restoration of y function of secretion which is most satisfactorily evinced by y patient making water. Such decided symptoms of sucess may not immediately make their appearance partic. if blood has been removed with timidity but let it be remembered that 8 or 10 or may in one case be sufficient while in others depletion [may] must be carried to y extent of 40 or 50 ozs before there shall be reason to believe that y over burthened [valsartan?] system is relieved. It frequently happens that when there is not sufficient confidence in V.S. y case is painfully protracted that for several hours y patients life will seem hanging as if by a thread. y pulse at y wrist will repeatedly fail & return; oppressive deafness Vomiting purging & spasms will continue y body will remain cold & there will be every reason to dread a fatal termination. 26 The restored circulation, return of animal heat & reestablishment of secretion are to be regarded as proofs that y patient is safe. When on y contrary collapse continues, arterial action is no where perceptible; when y temperature of y body becomes more & more death like & above all when a profuse cold & clamy perspiration breaks out over y whole surface accompanied with jactitation there is little reason to hope for a favourable change. It sometimes happens that notwithstang means apparently favourable symptoms y case terminates [favourably] fatally (in dissipated habits & broken down constitution.) It has been found that y more violent the prominent symptoms are y more likely is a cure to be effected: & that when y dis is attended with rapid collapse little or no vomiting purging & no spasm y prognosis is very unfavourable. But it may be again observed that even in y most hopeless cases it is y duty of y surgeon to continue to watch his patient to y last as instances have occourred in which recovery has taken place when to every appearance y patient was in articule mortis 4th To guard against local congestion most men either from original organization or accident have some weaker point in their constitution which is liable to manifest itself when y system receives any serious shock. Thus in a London Hospital death following a great operation [generally] frequently does not appear [from] to result from y local injury: the wound may seem to be going on most favourably, when y patient is seized with low inflamation of y chest & he dies of dis of y Lungs. So also in Tropical Climates as serious injury may not destroy the person by its immediate effects y fractured limb or 27 broken head appears in a fair way to do well: but y patient is attacked with Hepartitis or Dysentary & is carried off. These facts illustrate y necessity in cases of great constitutional derangement of extending our attention beyond y mere original dis. In Cholera this is particularly necessary. When y primary dis is relieved it is y duty of y practitioner to look most carefully to y condition of y Head of y Lungs of y Liver and of y bowels. The great risk appears to be that a local congestion shall follow a general one. This from the nature of y circulation in y Liver & Lungs is prehaps more likely to happen in these organs than in y head. But should congestion take place in any of those great organs active measures must be immediately resorted to. Leeches Blisters & Mercuric purgatives will be requisite; & instances occour in which in which from y condition of y hepatic system, it is necessary to give Mercury until it produces salivation. The affection of y head [in cholera are] after an attack of cholera, are generally rather of y nature of reaction than of congestion. A mixed & obscure case is occasionally met with in which there are both conditions of y vessels of y brain. But unquestionably pure congestion sometimes takes place within y head which is to be overcome by free topical depletion & active purgatives. When y lungs & consequently y heart have their functions deranged after an attack of Cholera it is generally difficult to discover what is going on. The pat: does not recover as usual he is troubled with depression & debility; his skin is ill coloured & prehaps his pulse is irregular. In such circumstances Leeches should be applied to y chest & a blister over y seat of y heart & alteratives should 28 be prescribed. As it may be [possible] advisable to reach y source of respiration a blister should be applied to y nape of y neck. The tendancy to local congestion may not be immediately disclosed partic: when it takes place in y Liver. This arises from y obscure nature of y symptoms of derangement in y substance of y Liver. It is consequently always advisable to pay y utmost attention to y hepatic system after recovery fm. Cholera: may owe permanent loss of health & much [fatigue] future suffering to neglect of this great venous organ, while convalescent fm. Cholera asphyxia 5th.. To guard against reaction. It is remarkable that in India reaction should so seldom have taken place after attacks of C. when symptoms of this condition did occour, they were generally partial & seemed rather to be attributable irregularity in y balance of y circulation than to pure reaction: so that even its one & y same organ there were deranged arterial action & venous congestion. In India a patient on being relieved from y symptoms of Cholera. usually falls into a sound & reposition sleep & on awaking has y feeling of being quite well. There may be still however tinitus aurium & a slight feeling of confusion of head & giddiness. These symptoms no doubt very often arise from y effects of y powerful narcotic remedies which have been used & will be most likely removed by acting on y bowels. But if there be superadded pain, intolerance of light, a contracted pupil & a hard pulse immediate attention must be paid to y head. Local depletion in these cases is prehaps better than general bloodletting 1b or 20 Oz Blood should be drawn fm. y temples by. leeches or cupping glasses & active mercurial purges should be given. If y these means y symptoms be not immediately removed – y head 29 must be Shaved cold applied with Blisters to y occiput & nape of y neck; & should y pulse continue hard general depletion may be advisable, though topical Bleeding when relieve it can be carried to y necessary extent it as effectual & safer in cases where y removal of blood has already taken place to considerable extent. Such was my opinion as y result of my Indian [practice] experiance of C. & I still think that when we have got rid y state of Asphyxia & restored y circulation we have overcome y dis properly so called. But in Europe it has been found very generally that y collapse stage is followed by a fever of a Typhoid character which protracts y recovery and frequently proves fatal. This fever therefore demands our particular attention & in y outset I may observe, that, in this country the usual treatment of fever appears to have been inquired by y doctrin of Critical days It is said that fever must be allowed to take its course. I do not think so. On y contrary I have seen y greatest benefit result from doing y utmost to cut short fevers of all kinds. In addition therefore to constantly regulating y bowels & y skin through the circulation. I have in my practice both in y East & in Europe commenced Quinine at a earlier stage than it is usually thought of in this country, & in most instances with very hupp effects. In reference to y same subject I consider it by no means impossible that y rapid recoveries fm. C. which took place in India were attributable in no inconsiderable degree to y very decided steps by y Indian practitioners. Thus in that Country a patient with C. was not only freely bleed but lead large doses of Calomel administered followed by active purgation. 30 Dr Mackintosh of Edinburgh I believe has y credit of having called y attention of y public to y good effects of Bloodletting in y cold stage of fever. Before I was aware of his practice I had come to a conclusion similar for altho’ I have not found this remedy universally necessary in ague I look upon it as of great value in relieving y system from a load of unhealthy blood likely to prove injurious when reaction is established. On y same principle I am inclined to regard full venesection & y free use of mercurial cathartics during & immediately after y collapse in C. as y most likely means of saving y patient fm. y subsequent fever. In y treatment of this fever therefore I should continue to act freely on y bowels & loose no time in prescribing Quinine & Camphor giving such a pill as y following every 2 or 3 hours ꝶ Sulph. Quinine. Camphor āā gr.SS. ft Pill And I should watch for local congestion resorting to local depletion in y manner already described in case that appear’d to be necessary. 6th To produce a healthy condition of y bowels. This is an indication which must in every case be attended to for however short y cessation of secretion may have been & however easily y secretions of C. may have been removed y restored function seem to pour into y intestinal canal colluvics which must not be allowed for a moment to look in it. Calomel is a med. of y greatest [power] value when y urgent symptoms have been removed: particularly if as sometimes happens watery alvine discharges continue. As soon as y circulation is restored ten grs, or əj of Calomel should be exhibited & followed up after patient has had a few hours rest with a large dose of 31 Castor Oil; a draught of Infus. Senna. Tinct. Jalap. & Tartrate Potash; or by a dose of Comp. powder of Jalap. It is however advisable not to risque bringing back y irritability of y Stomach & when there is any fear of this it is better to give y Cathartics in form of pills. The follow ꝶ has been found a valuable one after cholera ꝶ Ext: Colocynth. gr.X Divide into Calomel} 4 Pills – et sint Ext. Hyoscyamus} āā gr.V pro. dose. Glysters. large & purgative are very valuable in cases in which y Stomach is still irritable & they may also be used in order to assist y purgative taken by y mouth when slow in these operation. The object at this period of y treatment is to procure feculent discharges & to have evidence that Bile is not only flowing freely into y intestines but that its secretion as restored to its healthy [secretion] condition & y practitioner must be satisfied that the Kidnies have recovered their function as soon as there is reason to believe that these important secretion are restored y patient may be pronounced perfectly safe altho’ it is always advisable to strengthen him by Tonics diet & regimen. And as a relapse is to be much decided y patient must not be allowed to be led by his own feelings of recovery to undue exertion of strength or unnecessary exposure to fatigue cold or any of y exciting causes of [fatigue] disease. It sometimes happens that without being able to truce y symptoms to local congestion or reaction it is extremely difficult to restore y functions of y stomach & bowels to a healthy condition & y patient continues to suffer cramps in y extremities even for many days after y urgent symp. of Cholera have been removed. 32 In all cases of this kind it will be found that it is not only y alamentary secretions that are at fault but that y kidnies have not recovered their healthy function: & y thirst of y patient will show that y salivary & gastric secretions are still deficient. These cases may be explained by y supposition that y sympathetic system has been more permanently injured than is usual. The treatment in such circumstances should consist in persevering in active purgatives prescribing a course of alteratives & freely exhibiting Quinine & it may even be advisable to produce slight ptyalism. Proximate Cause. In y course of y authors enquiries into the nature of C. it became evident to him that y systems course & effects of y dis. could not be explained on y received doctrins of pathology 1. Is this [dis] a general or local affection? 2d. Is it vascular or nervous? Though no doubt a severe extensive affection of y alamentary canal will produce serious. interference with y circulation still under such circumstances we should have no reason to expect to complete, a state of asphyxia as occours in C. In an Inflamatory condition of y gastro-enteric canal the action of y heart may be affected & y pulse become thready but y skin does not become livid nor y body cold & every one who has considered y post mortem examinations of victims of C. is aware, that it is even questionable wheather partial appearances of inflamatory action can be discovered far less those of 33 of extensive inflamation. Besides the complete immediate recovery fm. a state nearly of death which so frequently follows successful treatment of Cholera is [wholly?] at variance with y doctrin that y dis is an extensive inflamation If y symptoms were entirely restricted to depraved secretion into y stomach & Intestines we might be justified in considering y dis a local affection of y gastro-enteric mucous membrane. But truly y vomiting & purging are of very secondary consideration. The skin is blue y surface cold y arteries empty y veins loaded & y current of their blood stopped throughout y whole periphery; & in such a condition of y system we cannot be justifyed in supposing that there is an increased even tho’ depraived secrection going on within y alamentary Canal. And if we are to consider y dis as y result of a local affection y [eivle] evil might with more properly be be described to y pulmonary function. But that it is not result of a future in this important function is proved by there being frequently no marked symptoms referable to y chest & by y dis. being generally advanced in its course before y respiration becomes oppressed. This supposition is also incconcilable with y known immediate effect which y suspended function of y Lungs produces on y sensorium. Were y lungs to fail in their function so far as to render y blood unfit for its purposes it would follow that wherever arterial blood was required the defect would be apparent & hence y brain would immediately feel the injury. Accordingly we find this to be case in circumstances in which y system suffers from y sudden decarbonization of y blood. For example when a bed room gradually fills with y fumes of charcoal insensibility is 34 y first symptom of danger of y sufferer. C. therefore cannot be refered to a topical affection of any of y great organs – y sensorial respiratory or alamentary. The difficulty of accounting for all y symptoms on y supposition that y cause of C. is “local affection of some of y great viscera has lead to y hypothesis that it is an affection of every mucous surface & that it consists of a depraived condition of y decreasing [surfaces of those] functions of those surfaces. But this implies that secretion is excited on y most extensive surface of body when that surface is nearly or entirely deprived of arterial blood for in C. y discharges continue after y circulation has to all appearances ceased. 2d every dissection after death fm C. proves that this dis. produces great venous congestion & there can be no doubt that such a state of y system invariably exists in C. But this must be regarded as y effect & not y cause of y dis. Blood drawn fm. a patient labouring under C. is not only much blacker than usual but is generally grumous: and late in y disease attains y consistence of tar. This must still be regardes as y effect & not y cause of y dis for were y immediate cause of [y] a dis such a morbid condition of y circulating blood as to destroy those organic functions which are found to have failed in y very commencement of C. y sensorium would likewise suffer & insensibility would accompany y other symptoms. It is not therefore likely that C.A. results from a morbid state of y circulating Blood. When in y animal body we find a [se] circle of actions performed, distant path united in function & y flow of fluids to partic. organs determined controlled or suspended as may be necessary for certain 35 purposes: whatever may be our notion with regard to contractility, we must attribute such combined actions to y power of y nervous system. And whatever may be our opinions as to y nature of those processes from which y various secretions immediately result wheather we consider them chemical or mechanical or ascribe them to an unknown vital principle – still y determination of y pabulum to y secreting surfaces must be attributed to a general & not a local agent. The nervous system stretches itself out to every point of y body & we find it distributed most largely where we may expect y energy of such an agent to be most required demonstrating as it were that those actions on which y performance of y various organic functions depend are traceable directly to this system. Hence we seem to be justified in concluding that if we find by dis. or accident that an entire class of y functions of y living body is at once suspended, such suspension must be ascribed to an injury to that portion of y nervous system by which these functions are carried on. In C. in y very outset of y dis all secretions property so called are found to have failed; the alimentary ejecta are not gastric juice pancreatic fluid. Bile, mucous, or excrementitious matter. The kidnies cease to secrete urine saliva no longer flows into y mouth nor are y eyes moistened with tines. Carbonic acid gas is not thrown off in its usual quantity from y Lungs & animal heat is not evolved in y Body. Here there is a dis which suspends secretion in every part of y body. The functions of y parts which are thus rendered powerless are unquestionably dependant on nervous 36 energy, y involuntary nerves being y class which have failed & hence it seems to follow . that y immediate cause of this dis is to be sought in y nervous system. But here it may be asked. How can a dis be considered a nervous failure in which we find y sensorium y respiratory & y voluntary powers unaffected? The answer to this difficulty may be comprehended in y following propositions which embody y conclusions on this subject at which y Author has arrived 1st. The great ganglionic or sympathetic system of nerves is possed of a power wholelly unconnected with cerebral influance which it may retain after y brain & spinal marrow are removed & which may cease to exist while these retain y full exercise of their functions 2d. To this system belongs y circulation & distributive of y blood, & it consequently has a most important share in regulating secretion – in carrying on y involuntary functions & 3rd. To y suspension of this power of y system as I conceive is to be ascribed y dis which is called Cholera asphyxia. These conclusions are y result of an intimate practical acquaintance with y dis. I an axious study of all its phenomena: & they are supported by a careful & minute enquiry into y nervous system in all its bearings. A disquisition [cross out] on y subject would be out of place here, But still it is necessary to state some physiological distinctions not generally received but which appear to me to be well founded & which I think may be [regarded] rendered of much value in pathological enquiries. (See Mr. Bill's Work for his arguments &c page 31. 37 Post mortem appearances. Cholera As: The appearance of y body is peculiar. Whole surface livid, countenance collapsed, body shrunken resembling body of a patient who has suffered fm. a long illness. Y present description is confined to dissections made on bodies in which death has proceeded immediately from an active attack of y dis. & that organic lesions are not included which the evidently unconnected with y cause of death has frequently been particularly noted in descriptions in dissections of y bodies of persons who have died from Cholera. On opening y abdomen the full peculiarity which presents itself is y gorged appearance of y veins & semi fluid state of venous blood. Peritoneum & Omentum natural. Characteristic colour of y Viscera is light pinky hue, shading to purple. And y vein where ever they are to be seen appear loaded with black Blood. The floating viscera generally feel more palsy than 38 usual, as if their coats were thickened y solid viscera look purple or are mottled. y Stomach may appear full, in general it is partially contracted, small intestines tho’ full are not always distended & I have almost alway found alternate portions of y great intestines. contracted & delated. Whole canal sometimes distended with flatus. Mesenteric veins are in a state of great congestion. The contents of alimentary canal is a muddy fluid resembling that passed fm. y Stomach & Bowels during y dis. No foeces but always more or less flatus. The enteric mucous membrane particular but y upper portion of y canal is often coated with a glary & tenacious matter which would appear to be an accumulation of y coagulated opaque substance which is passed with y serous fluid. This is sometimes in such quantities at partic: parts. of y canal as almot to fill use y tube its colour is not always opaque white. has been describes as a dark grey & a greenish tinge said to be sometimes bloody. These variations in y colour of this matter does not appear to affect y nature of y dis. & fm: Mr. Annesleys experiments they would appear often to be attributable to admixture with y meds. prescribed nor. is this matter invariably present. The internal coat of y stomach & sometimes a portion of y duodenum has very generally a peculiar appearance;. There are vascular patches not of inflamation but as if vessels had burst & blood had been extravasated between y coats. These spots the no doubt commonly a congeries of congested [vessels] veins do certainly somet. arise from extravasation. Patches also are described as having y character of Inflamation generally near y pelorus which are by some considered by some y result of local 39 irritation produced by portions of y remedies prescribed having adhered [th] these parts of y stomach & they must be taken as a proof that reaction had commenced before death. Worms are very frequently found in y intestines. Having removed y alimentary canal venous congestion is still few to be y most remarcable feature of y dissection. The large veins are gorged & there is nowhere a trace of arterialized blood perceptible indeed this has been found to be y case during life: for one surgeon in voice attempted to get blood fm. y brachial artery. The Liver is in most cases dark coloured and mottled being at its dependant parts unusually gorged with black blood, but it is said to have been found in some dissections natural in its appearance. Gall Bladder generally full of Bile. I have alway found marks of congestion in y spleen appearances variable Dr Christie fund y spleen empty. the Ceylon practitions found it smaller than usual. y Bladder alway contracted & empty. Kidnies. healthy but partake of V. congestion Liver when cut into found gorged with black blood not coagulated but thicker than usual Bile in Gall bladder green. I have seen it healthy in appearance. Seriat Veins Trunk & Liver full of thick impure blood as are y right Auricle & Ventricle of y heart. Lungs black & appearance almost of a fleshy structure & when cut into freely give out y same grumous black blood in some instances this impure blood is even found in y left side of y heart & to have reached y aorta & cases are mentioned where black blood was found in y carotids. In y Brain there is a same character of venous congestion. but here there is generally some slight appearance of arterial blood 40 There is often found a small quantity of serum in y ventricles of at y base of y brain. The descriptions that have been given as if portions of y brain had been in a state of high inflamation are wholly at variance with y character of y dis in its course & seem rather to belong to a disordered state of y circulation than to this dis. except indeed in cases in which death had not proceeded immediately from cholera & when reaction had taken place. Such is generally y condition of y body after death arising fm: a pure case of Cholera. It may be remarked however that in particular disections some of y organs here described as being in a state of Congestion are found not perceptibly different from their healthy condition & instances are said to have been met with in which y whole abdominal viscera presented nothing very peculia in appearance. In such cases (none of which have [followed] fallen within my experiance) the Lungs or encephalon will no doubt be found highly congested & y external veins much loaded. It is important to say a few words on y general question of V.S. not only to satisfy that y removal of blood may remove prostration of strength but to clear y way for authors explanation of y nature of Cholera a: There are two opposite conditions of y system in which it may be advisable to [withdraw] bleed. The 1st. when high general arterial action exists or when local inflam; has taken place. In such circum: V.S. is called for because it is necessary to lower y hearts action or it may be said because arterial blood unduly preponderates in y system indeed this may be regarded as y fact for in cases of highly exited action y blood circulating in y veins will be found to retain y arterial hue 41 y 2d state of y system in which V.S. is expedient is when y balance of y circulation is depressed on y other side & y venos blood is in excess Fever. Peritonitis, & Acute Rheumatism are example of y first & Cholera Asphyxia is y most remarkable example of y 2d. which practice presents. The condition of y system in C. has been already spoken of but a case of more common occourence which affords an example of bleeding being indicated to remove an excess of venos blood will supply a father illustration. When there is a broaken ribs the action of y Chest being impeded respiration is checked y blood [drawn] thrown into y Lungs is not purified y circulation is obstructed & venos blood soon preponderates in y system. In such a case therefore we bleed not merely to ward off inflamation but in order to reduce y blood requiring y function of y Lungs so that y quantity thrown into those organs being proportioned to their restricted capacity they may be enabled to prepare it for arterial circulation. But in y latter class of cases it is not indifferent wheather we draw blood from an artery or a vein – a practitioner who would open y temporal artery of a patient whose lungs were clogg'd with unarterialized blood would increase y risk of suffocation. Yet we actually find Indian writers so completely mistaken in y rationale of V.S. in C: that they narrate their attempts to remove blood by y temporal artery when y surface is livid and after y arteries have ceased to beat. There is another preliminary consideration which has been lost sight of by many inquiries into y nature of C. viz That diseases of sudden collapse are not necessarily preceded by a state of high arterial action. – Where it may be asked is such a stage in y instantaneous debility produced by y poison of y viper. But to 42 illustrate this fact we need not leave y doctrin of diseases. Intermittant fever supplies an opposite illustration: on y approach [of a pt of ague lung nor y symp. are] of a fit of ague y symptoms are those of great depression lassitude weariness followd. by chilliness nails & lips blue. Countenance sinks shivering ensues in some cases spasms of y extremities. In short y condition of y system approaches to that which prevails in cholera asphyxia. & there can be hardly a doubt that in y cold stage of fever y balance of y circulation is interupted & that venos. blood preponderates in y system. I have seen y occurrence of death in what there was every reason to consider y cold stage of an Intermittent Collapse then may occour without previous high action, it is produced by many poisons. We see it in ague & it occurs in cholera The conclusion & inferences at which I have arrived are 1st That there are 3 powers in y system viz The sensorial. Respiratory & Sympathetic & that each of these on all common occasion is enabled to perform its functions without y active interference of y others. 2d. That y destruction of any one of these powers does not immediately annihilate the other two. (1st) Y [circulation] sensorium may be suspended & y circulation & respiration continue unimpaired (2nd) Y circulation may be supported after y source of respiratory power & y brain have been removed (3d.) [That y] Y circulation of y body may be stopped & y sensorium remain unaffected 3rd. That y source of y sensorial [power] & voluntary power is in y. Cerebrum & Cerebellum. That of y respiratory power in y upper power of y 43 Medulla spinalis, & that of y circulating power in y ganglionic system of y great sympathetic nerves. 4th.. That secretion requires y integrity of y upper portion of y spinal column & of y sympathetic system; & that when y power of either of these sources of nervous energy is suspended any appearance of secretion is fallacious. 5th. That secreting surfaces may throw off component parts of y Blood after their power of secretion is at an end. 6th. That C. asphyxia is suspension of y power by which y circulation of y blood is carried on. 7 that y fluid which during a fit of C. is poured into y alamentary Canal and which extrudes from y skin, mouth, eyes, & mucous lining of y bronchia is excreted after secretion has ceased, when animal heat is no longer evolved & when arterial action is at an end: & therefore must be regarded as an exudation fm. y venous capillaries or if fm. y arterial capillaries is occasioned by them being supplied with blood by regurgitation. – Remote Cause of Choler. A: Y remote cause of any partic. dis is frequently y most obscure question connected with its nature & I much fear that practically we should give little by becoming acquainted with y remote Cause of C. Y dis to whatever origin it is to be traced, seems to be now gradually diffusing itself over y Globe – uninfluanced apparantly by climate - & hither to setting at defiance all human means of retarding its progress or of lessening to any considerable extent its average mortality. Were it of any importance to hazard conjectures as to 44 its remote cause I should be disposed to say that y theory most consonant with the phenomena of y dis is that which as cubes it to certain galvanic changes on y earth surface, but really such speculations are of little value nor is there any theory of y dis. which has led to any important practical results except that which traces its origin to Contagion alone. There can be no serious doubt but that a dis. similar to cholera. has been known in Asia fm. time immemorial. Bontius upward of 2 centuries ago in treating of C. Morbids describes very correctly y prevailing disorder. There is also frequent mention of what was undoubtedly this dis. by y Med. Offices of y East India Companys service in y latter portion of y last centaury & in 1775 it seems to have assumed y character of Epidemic in India & to have extended itself to y Island of Mauritius. Dr. J. Johnson in his Dis. of Tropical Climates speaks of a Dis which Prevailed in Brazils which fm. y sucess of V.S. I have little doubt must have been C.A & I think it by no means improbable that the English. “Sweating Sickness” partook of the Character of this Epidemic. I have admiral Fleming authority that a dis very like the Indian C. prevailed at y Havannah in 1810. & in 1827 several cases resemble C. A. in its most malignant form made their appearance in a public School at Clopham all that I would venture to suggest is that possibly Galvanism may present phenomena which might aid us in our enquiries into y remote cause of y dis. Ritter found that while positive Electricity seemed augnum y vital powers. Negative Electricity diminished them y former increased y pulse y latter lowered it y former caused sensation of 45 heat y latter of cold. We again have seen that y distinctive character of C.A: is y sudden deprivation of y nervous energy of y sympathetic system & all y length to which I go is to suppose it not impossible that y source of y dis may be found in some sudden change of y electric & galvanic condition of y surface of y Earth – I say this however with no intention of supporting y Hypothesis that Galvanism is identical with nervous energy: but unquestionably that agent is so intimately connected with every portion of y creation that any sudden withdrawal of it from y animal system might not improbably produce such a dis a Cholera: a conjecture which receives some countenance fm. y very extraordinary effects which Thunder Storms are said to have had on many occasions on y progress of this dis. in India note. page 66 [a remarcable instance of y sudden cessation of C. after a Thunder Storm is said to have occoured at Jussy. One of y most accurate observers of y peculiarities of y dis. also says “several instances have been known of its (y C) having suddenly ceased on y occourance of a Thunder Storm & say “I witnessed a remarcable instance of this at Kulladghee in 1824 after y dis. had prevailed for several weeks in y troop of horse artillery there was a violent Thunder Storm after which not a single case occoured (Dr. J Christie Observations on C. p 97. 98) It is a circumstance calculated so far to give support to y theory which ascribes C. to some terrestial influance that in India y bower animals such as Cattle. Monkeys & poultry suffered fm. y dis. & if News paper reports are to be credited a simular phenomena has been observed in some of y European Continental towns; & in Hamburgh in partic it is said that y fish also in y rivers were affected. 46 y latter circumstance is very remarkable & if well founded may had to some interesting speculations In Connection with y remote cause of C. I may mention that my friend Dr. Meikle of Edinburgh who saw much of y dis in India & who himself suffered no fewer than five attacks of it, is subject to a very peculiar sensation when exposed to y hidden sources of y dis. which enabled him repeatedly in India to announce its approach before any actual case had occoured. The sensation he describes is that of numbness in y fingers & it is singular that y other day in Hadolington he had again y same feeling] After all however y result at which we arrive is that we know absolutely nothing of y remote cause of C. This is y conclusion to which all practical writers have come.  47  48 Pulse labarynth in which y student is lost & y master wanders to no purpose. – (Good). ~ Pulse Heart or [any] y quantity of y circulating fluid & In Hunter concours in Kriviews. They measure y degree or vascular tone or power of resistance & where y same effect wheather above or below y natural standard takes place in y capillary arteries it produces that change in y pulse which he distinguishes by the names of obstruction & freedom but which it is not alway easy to discriminate fm: severall of y preceding qualities nor is it of great importance as we have in such cases other symptoms that more strikingly manifest y same [effect] fact. – Thus far prehaps y doctrine of pulsation may be studied with advantage but when beyond this we come to a distinction between y free & delated pulse as proposed also by Dr. Fordice. The quick & y frequent of stahl & y dicrotic conturnizing & insidious of Salano as mere sub varieties of y rebounding or redoubling itself a variety of y irregular pulse we perplex patharolog with 49 Pulse. – y vigour or debility & y system which a mere variation in y state of y frequency of y pulse Full &} Small} This M I hunter ascribes to y state of y arteries but I think givers no rather y quantity of blood circulating through y system than of y muscular strength of y arteries or of y Heart itself which is often a very important indication & especially where combined with y preceeding signs it will then be our best guide in cases where we have determined upon [opening] V.S. as far as we do it without danger. Hardness &} Softness} Together with that Vibratory thrill which has been called Wireness are not so easily learnt as its fullness & Smallness but a nice finger will readily discriminate them & practice will point out y difference to every one. Dr. Fordice makes these & I think with great reason dependdant on y state of y arteries rather than on y Pulse. it there: sometimes put a sudden stop to y hearts motion with a deadly shock & killed y patient in a moment. – There are many Drugs that afford examples. Digitalies & Hyoceamus are expressly used on account of this property. Y Prusic Acid & plants that contain it when given in free doses destroy y irritability & extinguish y pulse instantly & so effectually that y heart when imediately is arrived was insensible to concentrated acids & puncture. – Frequency} &} Slownes of} y Pulse} taken by themselves indicate little more than y degree of irritability of y heart or y force of y stimulus that is operating upon it. – Or Weakness & Irregularity Strength &} Regularity} are as palpable to y finger as y preceeding signs & show in characters nearly as deceive y degree of Vigour or debility of y Heart & hereby except where y organ is labouring under some local affection 50 Pulse. – estimates y pulse on the day of his birth & while asleep fm 130 to 140 & fixes it at a little less than the same rate or that of 120 for the first month During y 1st year he calculates it at from 120 to 108. y 2d fm: 100 to 90 y 3d. fm: 108 to 80 at which it continues for 3 ensuing years. In y 7th yr. it is frequently reduced to 72 & in y 12th. to 70. In advanced age from y small quantity of sensorial power secreted & y general inertness of y organs y pulse sinks often below 60. – The Pulse is Quickned by very slight excitement both external & internal. The stimulus of air is sufficient. light & of sounds is sufficient to make that of an infant awake 15 or 20 strokes more frequent than when it is asleep & beyond their control. The Pulse of an Adult is usually Quicker 8 or 10 during y digestion of a meal. Running or any sudden or rapturous emotion will double y ordinary scale The Depressing Passions on y contrary check Pulse two patients who in y best health had always very unequal pulses as well in their strength as in the spaces between them but which constantly became regular as y patient grew ill, and gave a never failing in recovery in their once more returning to a state of irregularity. – In Women y pulse is generally speaking 6 or 8 strokes in a minute quicker than in men and hence many women of firm health & lively disposition have a standard pulse of 85. – In a Weakly Frame y pulse is usually rapid for debility is almost always accompanied with irritation & y heart partakes of y general infirmity In this case also fm y feblness with which y heart contracts y ventrical is but imperfectly emptied & consequently soon filled again & sooner stimulated to contraction. – Hence In Infancy y pulse is peculiarly quick & gradually becomes slower as y child increases in strength. Dr Heberden who paid particular attention to this subject 51 Pulse. – Varies in different individuals fm. 60 to 80 being greatly affected by y temperament and partly by y habit of life. – In y Man of high Sanguinary character it rarely sinks below 80 & is often at 90. – And in the Melancholic it seldom rises above 60 & sometimes sinks to 40. – In Idiosyncrasies y discrepancy is so considerable & complicated with other changes than those of frequency & tardiness that there is no reducing them to any rule. – Lizzari tells of a person whose pulse was not more than 10 in a minute. Dr. Heberden saw a person whose pulse he was told whose pulse in y begining of his illness did not number more than 12 or 16 he suspects in this & all other instances where it is below 40 that y beats oftener than it can be felt because such slow pulses are usual unequal in their strength & some of y beats are so faint as but just to be perceived so that others probably still fainter are to weak to [be] make a sensible impression on y finger. Heberden had attended Pulse beats in Early Infancy 140 strokes a minute towards y end of 2d. Year 100 ” ” [at] at Puberty 80 ” ” about Virility 75 ” ” seldom more than (after 60 yrs) 60 ” ” More frequent in persons of short statue, those of strong passions of mind, those of great muscular exertion and in Females. “Good.” Quantity of Blood in the entire System. – Muller & Abeildgaard estimates y weight even in an adult at very little more than 8℔s Borelli at 20th Planch 28℔s Haller 30 Dr Young 40. Hamberger 80 & Keil 100℔s. (Good) Blumenbach states the proportion in an adult healthy man to be 1 to 5 of the entire weight of y Body. – The mean numbers as those of Haller & Young making y Amount fm: 30 to 40℔s appear most reasonable. – “Good”. – Pulse in an adult male of good health and not too corpulent the Common Standard of y Pulse may be fixed at 70 strokes in a minute 52 Asthma Spasmodic. visceral obstruction Stram, overcomes this action or irritates & produces one of its own. Digitalis 149 Asthma Musk 179 Castor 181 Amber 184 ” Spasmodic Asafoetida 197 Asthma Iron 231 is recomended by Dr Bree during the intermission [Angina 55] Asthma 56. Camphor do Spasmodic 94 Opii is paliative if there is [no] of y Lungs (blood vessels) hence it should be combined with Ipecac or Antimony in y form of Diaphoretic powders. Stramonium I have used y seeds with y best effects one patient to whom I gave it had been skillfully treated in this Country & in England had taken Antispasmodics. Had recd more relief fm. Lobelia Inflata than any thing else this after several paroxisms lost its Effects He consulted me about Smokeing Stram: I told him to use it. if no effect to send to me for some pills which he did I sent them told him to take 1 every hour untill relieved 4 grs completely removed y parox: he had taken as many as 6 in 4 hours ꝶ Stram: ʒi Myrrh ʒi make 60 pills. Asthma often arises in consequence of [Viceral] irritation fm: 53  54                            leaf – A B  leaf – B #14 Philadelphia January 1st. 1827 A few of the Lectures as delivered by Dr. Chapman Professor of Theory & Practice of Physic in the University of Pennsylvania copied during the Winter of 1827 by Asa J Driggs  1 The order in which Professor Chapman treats of Diseases. 1st. The Circulatory system consisting of y Heart & Blood vessels. – 2nd. The Digestive, consisting chiefly of the alamentary Canal. 3rd. The Respiratory consisting of y Pulmonary organs. 4th. The Absorbant. consisting of y Lacteals & Lymphatics. 5th. The Secretory consisting of the Glands 6th. The Sensitive consisting of the organs of Sense. Nerves. Brain & Spinal Marrow 7th. The Muscular consisting of y Muscles Tendons & aponeurosis. – 8th. The Cutaneous consisting of the external covouring of the surface of the body. 9th The Osseous consisting of Bones & there imediate apendages. 2 10th. Generation consisting of the Genitals of both sexes. – It will be eddy under these heads to comprehend all the diseases to which our nature is liable without any reference to their alliance & Affinities. Though I drop the old arrangement I shall however retain the names these being sufficiently expressive & having been generally adopted have become the language of Medicine. To change is always more or less evil & I am not sensible that in any case is it more inconvenient than in y nomenclature of Sciance 3 1st. Diseases of the Circulatory System. – Of Fevers. – I shall now commence with dis of y circulatory system & first of Fevers. – They are by far y most common of y complaints of our nature & as they afford general principals on which y treatment of y dis must be founded I shall dwell on thru at some length & with more than ordinary minuteness. It is computed that more than half of the deaths amoung y human species are produced by febrile affections alone, What is y nature of that Dis which has been denominated Fever! Ever since y dawn of Med. sciance this question has been [???ated] & still remains the febrile affections are so numerous & diversified, fluctuating & so much under y dominion of those causes which [moaf???] dis, action that they perceplably change thin character & one description cannot be appropriated to y whole class. – Cullen who is chiefly followed on this subject defines Pyrexia to Consist in an increased heat 4 frequency of y pulse comeing after shivering accompanied with a disturbance of many of y functions & diminution of strength especially in y limbs. – Now though this diffinition is as unexceptional as any which has been advanced it will not be difficult to show that haraby symptom which has been mentioned is an universally necessary attendant. That an increased [crossed out] of [y] heat is not a sign of fever is allowed by every one are this not onaua cases where y animal heat arises above the natural standard & do we not often see instances when it is lower. The senses here are not y proper means for measuring y degree of heat. The feeling of y individual is often entirely delusive so much so that at the moment when he complains of excessive wampth he is often really colder then sedual is converse equally hot as true sensations of cold often accompany a high degree of Thermometeral temperature. Now is it true that it is always preceded by a chill? it is indeed except in some 5. particular cases comparatively of rare occourance in febrile affections. _ As relates to y Pulse there is every variety as a general rule it is more than naturally frequent in Fever. but y exceptions are numerous & in certain cases when y Brain is effected it sinks to hlf its standard. Besides by exercise & other causes the pulse may be made to beat with much more than ordinay quietness without impairing health or assuming a morbid condition. Frequency of the pulse therefore is not a nessary ingredient in fevers. – That a disturbance of y Functions & Lasitude occour in this dis is not demed but they are also insecdent to many depraved conditions of the system is sufficient of itself to deviate from fever. – Y But to arrive at a satisfactory conclusion we must consider all assembled & also circumstances hereafter to be mentioned. – The most natural Division of Fever is into the Intermittant, Remittant & Continued 6. 1st. of Intermittant. By Intermitt is ment that fever in which there is a [crossed out] sucession of Paraxsms between which there is a distinct & perfect suspension of symptoms take place. _ The Interval between the Paroxisms is in Pathological Language denominated Apyrexia. – Different wordes have been used to name fever according to the length of [crossed out] y interval. When the [crossed out] Parox returns every 24 hours the the fever is called Quotidian. When it occours every other day or when the interval is 48 hours it is called Tertian. But when it is protracted 72 hours it is called a Quartan. – Of each of this primary types almost infinite varieties have been enumerated by authers as y double & triple Quartan by double & triple Tertian etc. By some of y antiant writers it was asserted by [crossed out] of that cases occoured in which of interval was protracted to y 5th. 6th. 7th or even to the 8th. day. This was affirmed by Hypocrates & confirmed by the testimony of 7. Boerhaave. – There are not wanting writers who have extended the period to 1 month 2 most even a Yr. conferring in these cases the title of Menstruae Bemen [stru??] & analar. When these peculiarities [crossed out] takes place they must be considered as anomalous deviating from the general character of the Dis & therefore deserving of little attention.- The 3 primary forms is all i wish you partic to recollect.– The Tertian is by far the most frequent & easy to cure Next to this in both respects is by Quotidian & y Quartan least: commonly accouring & is always obstinate in its management._ The 1st. occours generally in Spring & has therefore been called Vernal & the last appears at the close of fall & has been called Atumnal. By Cullen it is said that y Quart: is more common than y Quotia: wheather this was y case where he resided I cannot say but y whole current of experiance is against him & certainly in y W. of & those parts in which I am acquainted y fact is entirely different y Quartan in this city is seldem seen & when it 8: does occour arises from a protracted condition of y Quart. Each parox: of an Intermitt: is divided into y Cold, Hot & Sweating Stages y symp connected with y different stages are so elaborately detailed by most writers on this subject & y case so familial to you that a minute recitation on my part is rendered unnecessary. The Cold Stage is ushered in by Langour & sluggishness of motion yawning & stretching with some nausea or Debility of y stomach y face becomes pale & features shrink & y skin over y whole body is constricted as if aching with cold.- Not long after this rigors come on accompanied with spasm in y back & loins & Extremities y Respiration now becoming short & [difficult] distressing pulse small & sometimes very irregular copious discharges of pellucid urine is usual at this conjuncture. Somet: more allarming symp: appear as Coma Stupor which is some instances amount to Apoplexy. Y first stage somet continues for 1 or 2 hours when y symp. gradually 9. abate & y 2nd. stage comes on |Notes| the regors are somet. so severe that the teeth are shattered. Second Stage. This is marked by Heat extending over the body, redness of y face. throbing of of y Temples pain in Head Anxiety & Resttiness & some tendancy to Delirium. Y pulse slowly rises untill it becomes strong & exceedingly vehement these symp. continue for sometime but finally moisture appears on y forehead & is soon followed by a general sweat Y heat abates & y thirst ceases. Y respiration becomes free y circulation tranquilized & y functions are generally restored to their healthy condition. Y preceeding is a discription of a parox of Intim: fever as it usually appears. but it is somet: marked with anomalous circumstances. By Cleghorn & other writers we learn that y cold stage in some cases is entirely wanting. Somet. y hot stage is wanting & somet. preceeds the cold & it has been further remarked by Dr. Jackson that a paxoxcom somet. terminates by a copious secretion of Urine or Evacuation 10. from y Bowels without any perspiration or other irregularities not occasionally observable in Intims: they have been known the attack restricted to some one part of the body where y rest remained unaffected thus in Intim. it is located in one of the legs which goes through y cold hot & sweating stage with perfect regularity. I have seen it affect y eyes every other day it was attacked with extreme pain which after a while was cured which could only be affected but by y usual remedies employed for the cure of this Dis. – Not long since a young Lady consulted me on account of a violent pain she felt every other day in y lower part of her abdomen. As she came from J.S. it occoured to me that it might be another irregularity of Intermitt: accordingly after every remedy had failed which is usually employed she was cured with Fowlers Solution In y progress of our enquiries we shall have occasion to point out some curious facts of this 11. nature. Prehaps no Dis is more disguised under its forms than Intim: Fever, & as it exacts a prectum treatment it becomes important that y nature of y case should be understood.– As regards the course of Treat. a little controversy has existed. It is now pretty generally admitted that y most sources of this Dis are marsh Exhalations from Vegit & Anemic substances. Cold is a cause of this when connected with moisture or Bile in y stomach. Y origine of this was first sugested by Lanciss & Blalin who lived not long after the revival of Luting in Europe The observation of practitioners in many sections of y Globe confine y accuracy of his hypotheses but of y precise nature of this pestiferous miasmatas we are still entirely ignorant.– This much however is certain that they are, of exhalations of Vegetable & animal matter in a state of decomposition. Y origine of Intim: is sometimes involved in much obscurity.– It will occasionally makes, its appearance where there is no obvious source 12. of exhalations. In endeavouring to ascertain the cause we should not loose sight of this fact that y Miasmata are wafted by winds to y distance of 8 or 10 miles in a condition sufficient to produce the ordinary effects. No paint has been deseeded from [crossed out] more indisputable evidence evidance than that which we have just mentioned. but it is not less true that other causes produce fevers the paroxisms arising at stated periods. Whatever disposes the body so as to cause extream debility as. poor diet, great fatigue, mental anxiety, excessive evacuations &c. Are all known to excite Intermitt fevers when there is no reason to expect marhy exhalations. Next to these causes Cold is undutedly if most productive of y dis especially when united with moisture as in Damp Rooms. Beds Clothing etc. It has always been said that contagion is amoung the causes of this complaint this has been so well attested that it would be an 13. unwarantable species of [????p??oism] to doubt it But whenever Contagion proves y cause of Intim it always assumes as low type as we find sometimes in Goals. Hospitals & other crowded places: It has also been said to arise from Planatory influance by more than one writer. Tina believes it to aside from Lunar influance in some instances But there is no reason to suspect that these were the cause of y complaint. – Treatment. divides itself into two parts viz That which is proper during the paroxism & that which is required during the intermission or Apyrexia.– Taught by the example which nature affords us as soon as possible in the Cold State of an Intim then we imediately resort to y meds, which are best circulated this effect. We should have y patient placed in a warm bed drect as topical applications 14. hot bricks to y feet & a bottle of hot water should be applied to the extremities. warm beverages are now to be administered pure teas & when we wish any thing stimulating slightly Wine Whey or something of a Stim nature will answer very well.– Opii has been found particularly useful it is stated on y authority of [?rote??at] 1 or 2 grs of Opium at this time had Y effect of removing the Headache & rigors. – of exciting a universal glow followed by perspiration & thus producing a solution of y cold stage.– To y efficacy of this plan I can bare ample testimony of all y remedies that I have seen employed in this case Opii is followed by y most agreable consequences. 25 or 30 yrs since this treat. was recommended by Mr Nellie a Surgeon in Edinburgh we are told that y cold stage was imediately checked.– Y Tornequete acts very intelligibly by interupting y circulation through y Extremities such an accumulation of Blood takes place in y Heart 15. & great arteries that it exerts an increased action in these organs & a consequent diffusion of temperature over y Body. However plausible in Theory this plan was not found to answer y expectations of Practitioners. In y Hospital at Edinburgh it was tried & found of little of little advantage. Nothwithstanding y failure in y Hospital y auther is a man of high standing in y Medical World & published a Book to prove its great efficacy. This is one out of a Thousd. instances where different practitioners have obtained different results with y same remedy. – When y cold stage is very resolute fatal consequences ensues one of y best remedies to be employed is an Emetic it generally puts an end to this stage as soon as it operates. Hot. Stage. The Indications in y hot stage are 1st It remove y Irritation 2nd. To produce perspiration. Y irritation is generally produced by y presence of Bile in y Stomach & in such cases we should not hesitate to give an Emetic but if Vomiting has already occurred & there still be nausea you should 16. you are to assist nature by warm beverages as Camomile Tea or Warm. Water. – 2nd. Indication we must resort to Diaphoretics but all y European Meters & especially those of G. Britain highly recommend James's Powders but in this here it cannot always be obtained pure it is almost universally abandoned & some other Antim: preparations whose whose composed on & properties are better known have been substituted for it. as Antim: Wine. Small doses Tart. Antim: are commonly used & it is very common in y country to used strong decoct. of Cupatimune for purpose of producing perspiration. – It is an exelent remedy where others cannot be procured. On y authority of Dr. Lind Opii has been much employed in y hot Stage it is asserted by him to produce a solution of the [crossed out] paroxism & prepare y system for Bait. diminishes y danger of congestion in Viscera thus hinders y occurance of Schirrous alterations. Induced by my opinion for Dr Lind I prescribed it in 17. y Hot Stage though in direct opposition timing Theoretical views, in may instances it agrevated y sympts: y Headache was always increased y patient rendered, restless & y fever protracted. It is probable in Hot Climates as E & W. Indies where Dr. Lind practised Opii might have been of service in Hot stage on a/c of its tendancy to perspiration. but in this city & in y most temperate parts of y U.S. you will find my sentiments perfectly correct. – Where ever opii is at all indicated I give y preference to Dovers Powders thus a aminis. it proves diaphoritic & its stimulating powers counteracted. The Spts. Menderic is by fac the best diaphoretic [acetate ammonia]. this is to be preferred on several a/cs it is more prompt & certain its effects than any other it is moreover exceedingly grateful to the stomach & will stay when other articles are rejected. Dose tablespoon of y saturated Solution repeated if necessary. – Y practice above – [delai?] is applicable to mild or ordinary cases. But Intim: are [s?n?t] of an Inflam nature & y parox: is somewhat different 18 different from that already stated. They generally adopt this character in Spring & during y prevalance of Epidemics but y circumstances may be accurately ascertained from y case when if fever is m y type actuated to. the pulse is Vigorous & Strong. y face is exceedingly flushed. Respiration dificult – laborous acute local pain in Head. Sides. or Chest. Where y paroxisms are attended with these symp: it is necessary to V.S. copiously. y alamentary canal should be evacuated with powerful purges. – Intim: somet. appear in a very different Type insted of Inflam they adopt y Typhus Intermitt. when these cases occour & they often do in Hospitals & crowded places & During y prevalance of Typhus Epidemics a different treat. is demanded. – The paroxisms are to be treated with cordials & stimulating drinks & by y administration of all these remedies which are calculated to support y strength & tone of y system. 19 Treatment during y Apyrexia. – or y history of these remedies which are best calculated to ward off y paroxysm y most important of which is y Peruvian Bark originally introduced to y practice of Physicians in this Dis. It has maintained an undoubted superiority over all y remedies & y fluctuations of opinion & vicisitudes of practice to which our sciance has been subjected. Little adversity prevails at present as regards y rules forits administration though formaly no point was more unsetled. Among y absurd notions [of fever] it was though that y morbific matter might be thrown out by y paroxisms this was advanced by Boerhaave who said y bark was to be used “cum morbus [ale??otic] [d????] Van Swaten in his Comentaries united with him in this sentiment which was also conceived by Sydenham & all y eminent practitioners of that period Secretly y revers of this is more generally held to be y proper course & y fact is fully established that y earlier we commence with y Bark y more speady & prompt will be y cure 20. Y only circumstance of account which would cause delay is y condition of y Alamentory Canal & somet: perhaps of y system generally. Doubts are entertained by several writers wheather it is really necessary to prepare y system in any way for y reception of Bark & I am acquainted with some practitioners who says it is of no utility in this dis. But this is by no means y common opinion of y established practice It is now pretty generally conceeded that though y Bark will occasionally affect a cure without previous evacuating yet as a general rule it is y custom either to evacuate by Vomiting by purging previously & for this purpose y Emetic Tart. et Calomel are preferred. Harvene in times especially in this part of U.S. they have in a great measure given way to y Mercurial [crossed out] preparations they enerally answer where Emetics can hardly if at all be dispensed with they [op??ly] in such cases not only evacuating y Alamet: Canal 21. but also make a powerful impression on y Stomach & thus disarming & braking down that chain of & perverted association which Intim: & other Penoacedl Drs. seem to depend. Of y nature of Emetics my own observation affords me abundant conclusive evidence But besides these evacuants V.S. is demanded. – In y commencent of Intim: there is always more or less Inflam: Diathesis kept up with considerable pertinacity without y loss of blood & pretty copiously too y Bark would be rejected from y Stomach & of no utility & if it was retained it would only aggrevate y symptoms by its effects. My rule is never to resort to bark untill I have prepared y system by Evacu: so as to receive the proper impression from this valuable, remedy. By pursuing this course adopting y remedy to 1 state of y system I can pronounce that y certainly of its effects are such as almost entitle it to be considered at present as it formally was a Specific in Intim: fever: This species of fever is not unfrequently associated with obstructions in 22. y Viscera. Obstructions of y Viscera. when this exists Bark has been held to be inadmisable. That cases of this kind exist says Cullen where it is improper to administer y Bark I have not to determine; but I am well persuaded it is dangerous to adopt any such plan as a rule. I am convinced that in y cold stage of this fever an accumulation of Blood takes place in y Liver & Spleen which is increased every repetition of y cold stage &c. Y practice in regard to this point may be readily adjusted. In Visceral obstructions when Inflam: accompanies y Dis I would never hesitate for a moment to employ y Bark so as to put an end to y Dis. In other cases where there is pain in y Viscera & actively of y pulse indicating some local Inflam. Bark is mischievous. – We should have restort to y Vesicating applications or a slight degree of Saluvation which will commonly do away y obstructions. But if there be severe pains & y case is decidedly Inflame: we 23. should use directly evacuating remedies & of these V.S. is decidedly y best. – There was at one time much debate wheather or no y Bark should be given emediately preceding y paroxism. Cullen was decidedly in favor of this practice but I consider him to be wrong determining from my own experiance I should avoid administering it at y moment of y anticipated attack as I have found it aggrevate y paraxism by increasing y fever & distressing y Stomach. Some practitioners go so far as to contend that there should be no remission in its use that it should be employed in every stage y paroxism. Dr. Clark who wrote with great ability on y Dis of Tropical Climates is among those who strenuously recommends its use in this way as yet I have never been induced to follow it because I have always observed when Bark was given even when there is a slight disposition to fever it is productive of mischief. It is a rule established by y ablest practioners is rare there is a slight indication of an accession of y paraxism y Bark should be discontinued 24. Y ordinary mode of administering Bark is in Substance with water. Wine. Milk or Deluded Ardent spts. But milk has always appeared to me to be y most agreeable veicle. y Dose of y powder in ℥i or ℥ii repeated as often as y stomach will bear so that ʒi may be given in y ordinary intermission In y Tertian more than this is necessary it is y practice in y W. Indies to take ʒii in y morning at once & to omit in y other part of y Day. y tale Dr. Dallas was from that part of y country & was y practice that prevailed there whoever had an Intermitt took ʒi Bark early in y morning y sucess was in this case complete I never knew him fail to effect a cure in 2 or 3 ds. I doubt wheather y practice would be imitated fur stomachs will bear y Bark in as large a dose the fact however is interting & I thought worth recording as cases may occour where y method proposed may be advantageous. But in some persons such as y irritability of y Stomach that Bark in Substance 25. even in y minutest doses cannot be retained on y Stom: In such cases we must apply to y Infusion or Decoction either by itself or in combination with some aromatic such as cloves. Cinnamon or Orange peel. or Serpentaria y last to be prefered it renders y mixture agreeable to y tale & comfortable to y Stomach & much more efficatious a combination of this kind may be employed when Bark must be forbidden tis particularly adopted to Children & delicate persons.– But sometimes Bark purges its efficacy is abated when this appears. Small doses of Laudnum are to be given. When it produces constipation of Bowels as it sometimes does small portions of Rheii may be used. – [N.B. y Sulph Quinine is y active principle in Bark one gr. is equivalent to ℥i of Bark either given in Solutio: or Pill. R Sulph. Quinine qr.viii. Acid Sul: dramatic: ℥ss Sac alba ℥i Ess.menth aqua font ziii frat. mist. This forms a super sulphate Dose at: spirm: It is restricted aperxia y Est. 26. is y radium remaining from y manufacture of Quinine. Dose same as Sulph. Quinine. – Now & then Intim: is attended with great Acidity of y Stomach it is customary under such circumstances to combine with y Bark a little Magnesia & a minute quantity of Veritable alkali. – Notwithstanding y variety of means in order to attain a proper administration of y Peru Bark they are often defective during to a peculiar irritation in y Prime Via causing it to be rejected by vomiting & carried off two suddenly by y Bowels so that it can produce, no salutay effect. In cases of this kind it is usual to resort to Injections. – I have never used Bark in this way except in Children & therefore can say but little as to its efficacy. Possibly it may be useful in some cases but you will hardly ever prevail upon an adult who has used it once in y form of our Enema to submit to a repetion as often at least as will be necessary to effect a cure. – Besides you will 27. after be defeated by y irritation which exists in y Bowels. either previously or inaua by y measure & which amounts to such a degree as to render it almost imposible to retain y Injection. However as you may have occasion to use y Bark in this way I will give you y proper formula R. ℥ii or iii of y Dowan is to be intimately mixed with some mucilage, as common starch. Flaxseed tea made rapy or a Solution G. Arabic to sooth y irritation of y bowels. – It is customary to add a small quantity of Laudnum as y desine is not that y Bark should be evacuated but retained. – Bark also has been applied to y surface of y body y method of doing this is different. By some it is recommend. to apply in y form of a Cataplasm or poultice med of y article placed over y pit of y Stomach. By others a W. Bath either topical or general of y Decoction is prefered. – It is stated in authority of sufficient respectability to be entitled to confidance that Intim: may sometimes be cured by an emission 28. of y feet in a decoct. of Bark. – It is probable that a general Bath imersing y whole body would be much more efficacious. As a remedy in Intim: I have never employed y Baths but they have been used by practioners in y county who report in its favour one of a decided nature. When I have use it, it has been with a design to check violant vomiting especially in Pestilential Fevers. Cholera morbus. Cholera Infantum under such circumstances it will as soon sooth y irritability of y Stomach as any other remedy that can be employed. Its mode of Operation is very inteligible Creating a Tonic impression on y Skin between which there is a consent of a very intimate kind impacts tone to that viscus & thus retains its ordinary motions. Bark has also been employed in a dry state in this Dis: as an external application. It is said by Darwin that if y sheets are thougherly strewed with y powder of a Bark y Individual who sleeps in them will be cured if he had y: Dis. To believe 29. this even on y respectability of Darwin requires a considerable strech of credulity.– But when y Bark is applied differently there can be no doubt of its efficacy. the mode alluded to is that of Quilting it into a jacket & wearing it next to y body doubts have been entertained wheather thus used it had any effects most indisputably it does. When applied to Children in early life & Women of extreme delicacy. After all however it will be found to fail & when compared to its internal administration is entitled to very little confidance. next to Bark in Intim: may be marked Serpent. Serpentaria. The mode of using it origianlly employed by Sydenham. was with Wine. – As a general rules says he all case of Intim: where wine is indicated its efficacy will be increased by Serpentaria. – “Wheath it is adequate to y cure of confirmed cases of y Dis. I cannot tell with certainly. But in y milder shape or where y type is contagious partaking in some degree of y Remitt 30. character it is a very efficatious remedy & a preparation of Serpentaria has been employed with advantage in y worst forms of Ague & Fever y formula is as follows viz Rx Cort. Peru: ℥ss. Rad. Serpent: ℥i Curb Soda gr 30. This are to be imediately mixed & divided into 4 powders one of which is to be taken every 4 or 8 hours. Why y serpentaria thus combined & with so small a portion of vegitable alkali should have its powers extrordinarily increased is difficult to determine but of its efficacy there can be no doubt y preperation was employed for more than ½ a Centaury ago in this section of y Union & has received in its favour to y extent y testimony of established practitioners. – Nothing is more idle than a prior speculation of y Modus Operandi of meds. we are never certain entirely with respect to y accompanying circumstances & in most instances are content with fact alone if it be fully corroborated. Of y remedies afforded by 31. Our own country for Intim: y Eupatorium Perfoliatum. is possed of great powers. It may be so prepared as to be Diaphoretic. Diuretic. Emetic or eminently Tonic. by its Tonic powers it is most efficatious in this dis. for its diaphoretic powers it adopted to every stage in y Dis possesing in this respect a diseased superiority over other remedies. It may be employed indeferently either in y hot or Cold stage of y Paroxism. Its tonic powers are best obtained by administering it in powder or even in Decoction, This remedy has been much employed in Philadelphia & my Friend Dr. Hossack has informed me that it has completely supplanted y Cinchona & Fowlers Solution in y practice of several Physicians in New Jersey. – There is another species Eupatorium Pilosum known by y name of Hour Hound which is possesed of equal virtues though it is some what medicinal. Y Dose of C. Perfoliatum is 20 or 30 grs or a Wine Glass of strong decoct every hour or two. – In our enumeration of articles adapted to cure Intim. 32. y Chirona Angular is or Centaury is not to be overlooked it is different in appearance & medical effects from y Eupatorium. – It may be employed under all circumstances of y Dis. & is somet: given to advantage when y Bark is inadmisable. – It should be administered in Infus or Decoct: & in such quantities as y Stomach will bear. Though mosily employed by country practitioners it is also used in y city & we have abundant reason to be satisfied with its effects. Bane fored we have 2 species of Dogwood which are possesed of Tonic Properties y Cornus Florida & Cornus Terecia or swamp Dogwood. The Back is y only part used in Med. & may be given in doses & in same manner as Cinchona to which from a careful examination of a graduate of this University it is closely allied in its chemical Compo. & medical properties. – As regards myself I have no experiance in this article. But it is so highly extolled by others that I though it my duty to mention 33. mention it. Athia to y Dogwood in med. properties is y Prunus Virgmiend or Wild Cherry Tree. I have little doubts of its beneficial effects; Professor Barton & other practitioners have used in with advantage. – Another of our Native Tonics is y Prunes Verticelalus Black Elder this has also been used. what powers it posses I am not able to determine from my own experiance. By y late Profess Barton his correspondance it was highly recommended y Bark of y Root is y part employed & is given in same manner at Cort Peru. Many of y Oaks have been used in Intim: & not without success. y White Oak approaches nearest to y nature if Peru. Cort. in its general property but y Chestnut Oak is prefered by y City practitioners I have no experiance with uthre. – Several Species of Willow are not without power in y cure of this dis. y White Willow has been found superior in this respect. This bark may be given in substance or decoction same as Cinchona The Willow of England has been much used in 34. this dis of late & y writing of Willingham & others are in favour of its efficacy. It is now 30 or 40 yrs. ago since y Liriodendron Tulipifera or y common Poplar has been used in y management of this dis I have no experiance with it but by Dr. Rush & Barton it was commended y former introduced this article into practice in Fever & Ague. when that Dis prevailed in y Revolutionary Army, he considers it inferior to cinchona y Bark of y Root is employed in substance or decoction & same dose as y above articles. These are all y articles which have been found useful & which are indigenous to our Country. They possess [crossed out] different powers by which they are adapted to peculiar cases. Some of them are productive of much good & as they are read to access to those who have settled in y country & thought it right to bring them before you. Next I am to address your attention to some remedies whose qualities we are well acquainted 35. with & which therefore not only this account but they posses superior virtues & are therefore more worthy our regard. Nota little has been said within y last, 20 or 30 yrs. of Angustura as a remedy in this dis. When originally introduced into y management of this dis, & such was y confidance it inspired that it proved for a long time superior to Cinchona & other established remedies. But though known only for 20 or 30 yrs yet so completely has its virtues repressed that it becomes exploded from y treat of y Dis. Recently however it has been revived by some of y Europan practitioners those of London & some speak so confidently of its powers that must have been precipitately rejected. It is highly Aromatic & Cordial moreover it is not a little Astringent & perhaps will be found best adopted to these cases which are accompanied with irritability of y Stomach & Bowels. It will sometimes be retained when Bark is rejected y dose is generally from 36. ℥ss to ℥i at time repeated pretty much as y Cinchona. Not many yrs ago Mahogany called in Sciantific Language Casyania febrifuga or Angusturæ was recommended very strongly Dr Rocklove in Intim & Experiments lately made by many practioners revive y sentiments of that writer. As it has in some degree y properties Angustura it will be found prehaps proper to administer it under y same circumstance. A variety of [crossed out] remedies have been used as remedies in this dis. in a grater or less degree they are all possessed of y same properties with y preceding articles & should be used in a similar manner but from my own experiance with them I should not recommend them strongly. They may all be employed in decoction. Infusion or Powder as y Cinchona. – The wood Quassia. has been much used I have employed it but have no occasion to 37. think it at all calculated to meet y severe attacks of Intim: - Though temperate in his opinions & cautions of recommending Meds. Dr. – in this particular instance departed from his general practice & displayed some enthusiasm in y praise of Gum Kind. it is undeservedly stated by him that in Intim: of y most obstinate character may be cured by this medicine as soon as the Peru Cort & other active valuable meds. - In this light it was used much some practitioners rely much on y authority of Dr. Fothergill he had great confidance in its powers. In acting from my own experiance & those of other physicians for whose opinion I have great respect I should say it is incompetent to cure intractable cases. But exhibited with Bitters & Opii its efficacy is greatly increased & in some cases those combined have formed a valuable remedy. Y best form for using is y following R. ls. Kino Zii Rad. Gentian zss Opii grii y whole to be divided into 10 or 12 powders one of which may be given every 2 hours. – It does not appear 38. why this combination should increase y powers of this remedy, but of y fact there can be no doubt. The last of y Vegetable remedies is Charcoal. This has very recently been mentioned among y others it appears about 6 or 8 yrs ago Dr. Fr – in Salisbury tried it in this dis y Physician on this station in y British forts Dr Lalbect was induced to try this Med Determinging from respect to this writer we should be led to conclude that it is a ralnath remedy connected with Bowel Dis especially dysentary. o On y authority of this writer y remedy within y last 12 mos. has been used in this city in 2 or 3 [cases] practitioners have employed it in y public Institutions & not without advantage It has been prescribed by some in a great quantity of cases. But what I have seen of this it is entitled to your confidance One of y members of y Class has had an an Ample opportunity with this Med: & I have learned it proved successful where y Bark & Arsenic had failed for reasons 39. hereafter to be mentioned. I should prefer it where there was a little Dysenteria connected with y Dis, a t. spoon should be given every 2 or 3 hours during y apyrexia. – Sulpher. not y least valuable of y remains employed is sulpher. – It was first used about 30. yrs ago by Dr. Lysenger who writes In y anomalous Fever of y Isle of Batavia he prescribed a t spoon mixed with a little ardent: Spts: At one time I was inclined to believe its efficacy was ascubable to y ardent Spts. associated with it but wide experiance has taught me different during y Cast few yrs I have used it much in this Dis & am persuaded that it is possed of great powers. It acts independantly of y Spts. which is proved by y circumstance that it is not less efficatious when mixed with Milk. Molasses or any other inert vehicle. But y power of Sulpher is not restricted to Intim. fever no remedy I have used is so efficatious in checking y fever of Irritation I mean y Hectic Fever 40. wheather arising from absess of y Lungs or else where It affords me great pleasure that I have y authority of Dr. Physic for views which I present to you on y powers of Sulpher. He goes father & declares that judging from his own experience there is no remedy so useful in anomalous fevers especially of y periodical type. He does not limit it to Intim fevers but extends it to all such Dis. as occour periodically especially Periodical Headache I am inclined to believe that it is not without in such Chronic Nervous affections of an Intim: nature. It is true that we do not perceive its secret effects on y system but on this account it is no less powerful. – We see y same thing in Arsenic Mercury &c. Y mode in which I am acustomed to use it is at such times & in such doses that it will not exert its purgative effects this end is generally answered by giving 30 or 40 grs every 3 or 4 hours. On y authority of Dr. Monroe & one or 2 others y Blue Vitriol or 41. Sulphas Cupri has not been a little prescribled in this dis. It is allegra by more that while Physicians in general to y British Army in y Netherlands he was able to arrest Intim: fevers by this remedy where all others failed to y same point goes y testimony of Dr. Adams & others y following was y formule Rx Pulv. Cinchona grs 32. Sulph. Copper gr. 4 to be made into XV pills one of which is to be given every 4 hours. Wheather this remedy is always as powerful as represented I cannot pronounce. Those Intim: in which I have employed it I have found it most advantageous in old Quartans. On y whole y evidance is not so strong y as to induce me to recommend it highly. – Dispersed through practical writers some evidance may be found of y Virtues of y Cuprum Amoniacum. It has not been strongly recommended to our attention. When used it should be administered as y preceeding remedy Nearly on a footing y same should I place y several preparations of zinc those have also been employed 42. employed by different practitioners but I do not know that proof is strong enough in their favour. They are all used in Chronic Periodical Affections & might prehaps be useful in some Intim. but I can say nothing from my own experiance. – Amoung y remedies we are enumerating few have a higher claim than Alum. It was long ago prescribed by Cullen in combination with mutiny But he says though combined with this Aromatic it often produces naucea & is rejected from y Stomach so that he has not much confidance. By y celebrated Dr. Lina who used it in y same manner a different statement is given he ranks it next to Cort. Peru: & observes that it is greatful to y stomach & if continued with aromatics rarely occasions distress in that organ. As regards my own Experience I cannot say much respecting it. It would appear however by y testimony of others that it is not destitute of powers. Dr. Chalmers of Charlston thinks it paticularly 43. useful in this Dis, & in Remitt: fever of that part of y Country y same statement is made by Dr. Adams with redard to y fevers of yc W. Indies. Dr. Darwin says that it has considerable powers over Intim: but more especially when associated with Dysentary y proper doses is from 5 to 10 grs. but y Stomach will not always bear so much in such circumstances y quantity should be reduced. – Sugar of Lead is one of y articles lately [aar??] to y Catalogue by some practitioners particularly of y U: States it has been highly extolled. It was a favorite remedy of y late Dr. Barton during y late War It was used in Intim: which occoured amoung y troops on y Canadian frontiers. – I received an account from Physician attached to y Army that it had exerted greater powers than y Bark or Arsenic but I believe there was some deception in y case Determining from what I have see of y Article it does not deserve much esteem my own experiance is much against it. As nearly allied to y preparations 44. of lead I shall [mention] say a few words on Arsenic. In y estimation of y generality of practioners this article stands not on point of efficacy to y Peruvian. Bark, that it has done good in Intim. cannot be denied but when a physian expects from it uniform sucess he will often be disappointed. Wheather this proceeds from an inherent deficiency of y powers of arsenic or from y indiscriminate mode of prescription I am prepared to say this much however. I can inform you that in weak and debilitated states arising from old age or debauchery y arsenic will unfirmly fail. this is a feat might be expected & Barks many other remedies employed in this dis. are Tonic in their nature & act by imparting tone to y stomach & through y system generally. Arsenic has no such properties though commonly ranks with this class of meds. by writers on Mat. Med. Its principle opration is to create nausea weakness of y stomach & debility 45. of y system which is indicated by a feeble pulse cold surface loss of general strength & muscular relaxation. But even when employed it sometimes fails compared with. Bark it is acutialy inferior to bark & should never be employed when that article can be obtained, The cases in which it is best suited are such as occour in children & in [person?] possesing considerable vigor of Constitution associated with febrile condition. It acts powerfully on y system of children & on account of its berry without taste & in small bulk will be taken when others would be rejected. It has been a subject of debate wheather y arsenic should be continued during y different stages of y dis. My own experiance has taught me there is no precise rule on y subject the only objection against its employment during paroxism is y Nausea & Vomiting which it is apt to produce especially in y cold stage where there is great imitability of y Stomach, Arsenic is prompt in its of operation therefore if no decided 46. operation or advantage is experianced in 6 or 8 ds. it should be discontinued. It only debilitates y. system & produces a long train of unpleasant symp. as. Debility of y Stomach. pain in y Head. Oedematous swell in qs of Extremities. It has lately ban alleged by high authority that when arsenic does. not suceed by itself it may be renamed very efficatious by combining it with Cinchona this is Sound practice & I have imitated it with advantage. Arsenic is said to prepare y System for Bark & when Intim: does not early yeald it has been recommended to have recourse to this article & afterwards to use y Bark. – It is not [crossed out] more a yr that y Web of a common Spider was considered by me as a remedy exceedingly efficatious y fact I derived from Dr. Jackson who was inspector of y British army. On a revisit to this city he informed me that he has found y web one of y best narcotics exceedingly efficatious in quieting irritability Cordial to y whole 47. system & often producing sleep. he farther added that it was y best remedy known to him in y toat of Intim in all y stages. It is not in my power to testify to y accuracy of this account from a great number of experiments but y few trials I have made satisfied me perfectly well that y statement of Dr. Jackson was correct y article certainly is Sedative & Narcotic I am not without reason to be lure that it is useful in Ague & Fever. A gentleman of this class has written a valuable assay on this article from his own experiance & those of others who have been made this communications. I believe it to be a valuable remedy I recommend it to you. You need not be careful in selecting y Web. if any spider particularly as y species of spider are possed of y same properties. – Before dismissing y Meds. employed me Intim: I will notice one which deserves our notice. It is more than 15 or 20 yrs since y practitioners of France in a tone of confidance recommended Animal Gelatin. Gelatine In Intimittant 48. Gelatine: From y Known properties of this article little credid was given to y accounts. but I find at length y English practitioners have recommended its use & some concour in granting it thier surport. By y writers common Glue was employed. The English physicians believing that Calfs foot. Gelly is equally powerful & knowing it to be much more agreeable they commonly have recourse to that preparation. The only case in which this remedy has been used in this city was mentioned in this city. Dr. Griffiths told me that in y case of his daughter who for many months had been affected with Intim: & in whome y other remedies had been used in vain succeeded at once affected a cure by y administration of this remedy. Nothwithstanding y numerous remedies which had been used or mentioned for y cure of Intim: it will sometimes baffle our best directed efforts & continue its course in spite of all any exertions Cases of this particular Obstinate Character 49. depends most commonly on congestion or some other dis of y Viscera & confirmed by long habit. It is our duty in such cases to resort to Mercury. Mercury in Congestion gradually inseminating it into y system untill saliration which is to be kep up 2 or 3 weeks without interruption. This properly called a Revolution going remedy by which such changes are produced in y system as to suppression decour y prexisting dis. As a substitute for Mercury Blisters have been found highly useful these should be applied to y extremities & not dressed or hastily they operate nearly on y same principle as Mercury viz they create a counter impression which interupts & destroys this contamination associations on which y Dis: depends. When all these remedies fail however as a resort we should direct our patient to take a protracted journey so that exercise of Gestation change of Scenery y noval impresions derived from a different climate & other causes may operate 50. in producing a chain of [cross out] actions which may supercuary old; I will now speak of those remedies which are calculated to [produce] meet our indications in y Apyrexia or those which are given just before y expected recourance of y paroxisms. It is y common practice to order y patient go to bed & to take Opium as Dr. Frotter has recommended it Warm Beverages are also directed for y purpose of producing perspiration: Ether is a prompt. powerful & diffusible Stimulant & from these properties answers very well. At y time under consideration you should warn your patient not to over load his stomach about y period of y expected paroxism as nausea & Violant Vomiting might thus be occasioned. Cases are indeed recovered when 6 or 8 hours fasting has cured y dis. Any great change my condition of y Stomach would answer y same purpose. By some practitioners a very different mode is employed 51. They make y strongest possible impression on this Viscus by stimulating meds. strong spts Liquors either alone or impregnated with Spices have often been used & no doubt have proved advantageous. In fact whatever makes a strong impression on y system whether through y mind or Body will often suceed. – In every Intim Emetics given before y paroxysm have a powerful effect & Blisters applied at same conjunction not universally of y attack It is y imperious duty of practitioners to endeavour to cure Intim: as speech as possible there is modis. no Dis. so disagreable to y patient & though not imediately fatal is apt to degenerate into complaints of a very serious nature thus Intim: after runing into Continued fever sometimes of a Typhus nature & nothing is more common in children than for it to terminate in Hydrocephalous Internus y more common remote consequences are Congestion of the Viscera. Schirrus. Indurations & cancer conjoined with Dropsy & deprivation 52. of y system. No opinion is so absurd & mischievous than that which was advanced by Boerhaaves & adopted by many other practitioners. That Intim: are salutary in their primary operations & unless of a malignant type are not to be suddenly supposed by artificial means, nevertheless it cannot be denied that Intim: sometimes supercedes other diseases of a very formidable character. Gout. Rheumatism & cutaneous affections. In many of y Spasmodic or Nervous Dis. as Chorea. Epilepsy Asthma. Hysteria. Dyspoenea are some of y affections which yeald to an attack of Fever & Ague It has been ascertained that Intim: after they have become completely established in y system are sometimes competent to y cure of Pill Consumption I have already mentioned that it was y practice of some of our older physicians of this Town to induce this species of fever as a remedy for Consumption. But I will hereafter show more particularly y advantage of this treatment. 53. y same effect is sometimes produced in melancholic & y periods forms of Insanity. It was y custom of y physicians to take y maniacs out of y Hospitals expose them to y sun & send them to Miasmatic countries that they might be attacked by y fever & Ague. Though this practice did not always affect cures yet a sufficient member occoured to show y power of y Intim, action over such affections. As y predispositions to Intim. is in y system for a long time after y cure has apparently been affected y patient should studiously avoid all exciting causes as Exposure to night air or to cold & damp atmospheres under any circumstances. It is always proper for some time after y cessation of y Dis that y use of Tonic meds. should be continued Rubigo Terri never to leave y house with an empty stomach. Wine Porter Strong Cider &c 54. 56. Remittant Fever. – This is mere modification of y preceding Dis Cullen very properly condemned who considered it a distinct species of fever most undoubtedly he observes each arises from y Same causes each is epidemic & each are cured by y Same remedies insome instances in y same person y Dis alternates All this must be added as perfectly true but as they demand a treat. somewhat different so they ought not to be confounded. By Remitt we mean that species of Fever in which y attack abates without entirely going off y remission occours at irregular periods & is uncertain in its duration. Somet: it continues for several hours & at others y interval is so short as hardly to be perceptible. Remitt is produced by all y causes which was said to give rise to Intermittant hence it is most common in low mash situations in y autumnal season & when there is great vicisitudes in y weather as intense heat succeded suddenly by heavy rains. As in y Pyrexia 57. of Intim: y attack is proceeded by languor heaviness restlessness & alternate fits of heat & Cold. As soon as y fever proceeds to y 2nd stages y patient experiances pain in y Head & back & heat over y surface of y body. When this stage is fully formed there is difficulty of respiration & depression of spts. to these are added a White fured tongue a full strong pulse a sallow skin & eyes tinged with Bile. Nausea & Vomiting of Billious matter, a sensation of heat & pain in y pit of y stomach. After a continuance of these symptoms for a time y fever abates considerably & goes off with perspiration more or less copious But in a few hours it returns with y same appearance as before & thus with Exacerbations & Remissions it proceeds untill it terminates fatally or is cured or as sometimes happens in another form as y Intim: or Continued fever. Such is y Ordinary character of this dis. But under different circumstances of Climate Situation or Constitution of y patient assumes different appearances & is 58. associated especially with y inflamatory & malignant Diathesis. As regards our Country it is generally a Dis. of increased action requiring active antiphlogistic measures & in this this light I shall now consider y Treatment of Remittant Fever. The principle Indications is to induce an Intimission & y course is pointed out y Symptoms it is proper always to commence with V.S. This is particularly indicated by y pulse a hot dry skin determination to y Head & a variety of other sympt. The next remedy is an Emetic with a view of xciting Vomiting when called for by y State of y Stomach y Tartarized Antimony is always preferable. I mention this more particularly because it is generally y practice of Country practitioners to use Ipecac. But this is much less efficatious y Antim: preparations not only more completely empty y Stomach but makes a powerful impression on it so much so that it puts an end to y Dis: by in tempting & removing y primary morbid impression 59. In many instances I have known Intim & Remit: cured by an Antim. Emetic operating in y manner I have prescribed to you To meet y same indication that is to evacuate y Alamentary Canal y Mercurial Cathartics are resorted to they are like y Antim: are to be prefered for they are Rinared articles they operate more efficiently in evacuating y Bile than other purges as soon however as y Mercurial evacuation is over we should resort to purgatives if a milder nature of these y saline are most generally used & y best are y Epsom & Cheltenham Salts y latter are made by evacuating y Cheltenham Waters or in imitation of Salts thus obtained & have been recently introduced into practice they operate in much smaller doses than y other neutral Salts are less disagreable to y patient & more evacuating y Aliment. Canal ʒi is equal to ℥i of Epsom. After such direct & powerful depletion from y Stomach & Intestines it will be proper to resort to y milder means of producing 60. Diaphoresis y remedy best adapted to this end are y Antim: preparations & y neutral mixtures y Spts Mendiri is also a valuable remedy in this place y action of these may be prompted by y Vapor Bath y best way of applying this is to pour Vinegar on heated bricks are to be wraped in flannel & applied to y truth & Extremities by this we can generally excite a copious perspiration. The Dis under such treat will most generally yeald in 2 or 3 ds. but if not y Emetic & Mercurial purgatives should be repeated again, evacuations of this kind are called for by y accumulation of Bile my Stomach which by irritation &c febrile action is kept up. – I have found Emetics to succeed y best as cooperating in y same intention. Vesicating Applications should be mad to y uper & lower extremities y mode in which they do good is sufficiently inteligible. by making a strong impression on y Skin they interupt that chain of actions constituting [fel??dles]. During y continuance of y fever some Subordinate affections occour which claim attention 61. There is after great heat on y surface of y Body which is very distressing to y patient. When this happens it may be relieved occasionally by sponging y surface with Cold Vinegar or very Cold water. You will thus reduce y temperature allay y irritation & render y patient much more comfortable. – 2nd. A determination to y head in this fever often occours & is indicated by a flushed face, wild expression of y eyes & Delirium or a tendancy to it. – This condition of y head is especially relieved by y application of Cups & Leeches & 8 or 10 z Blood may be thus taken with advantage. But when y Delirium appears to be fixed with y above may tie added shaveing y Head & apply a Blister to be continued at least 24 hours. It is a fact which ought to be rembered that [V.S?] should always preceed y application of a Blister. You will very generally find that a few ℥ of Blood taken by Cups & Leeches will do away y necessity of this last remedy. – It is proper to suffer 9 or 10 hours 62 to elapse after shaveing y head before y blister is applied as by thus doing you obviate y necessity of employing it. How y mere removal of y Hair should do away y Symptoms of Delirium is not very intelligible. Besides this advantage we derive another Viz an opportunity of applying cold to y head by means of cloths rung out in cold water or by use of Ice itself. – 3rd The common Symptom which call for relief during y continuance of Remitt: is Nause & Vomiting of Billious matter arising either from an accumulation of Bile in y stomach or peculiar irritability of that Organ, It is right to repeat y evacuations either by Emetics or saline purges but in a second case a different course is pursued; to quiet irritability is now y Indication for this purpose we have a great variety of remedies The common Effervessing or foaming Draught is exceeding useful when it can be obtained y Sedletz Water administered in small doses at short intervals will often prove advantageous 63. Mint Tea is also useful but infinitely y best is Lime Water & Milk y mode of employing it is a tablespoon of each mix them together and administer every 20 or 30 minutes according to circumstances not y least valuable of remedies for soothing irritability of Stomach is y infusion of Serpentaria dose a table spoon full. It is much resorted to in this city & posseses y confidance of many practioners. When y irritability of Stomach arrises from want of tone in that organ as sometimes happens when Emetics have often been given. Nothing is better than y tinct. Cloves given at short intervals in spoon full doses. As auxiliary to y above mentioned remedies. Fomentations over y region of y Stomach have often proved beneficial & y best of these is made by quilting Pulv. Cloves in flannel & wringing this out in heated Brandy. ℥ii Cloves is sufficient. Pediluvium of Water bath is also highly beneficial. But when y Vomiting is excedingly violant you 64. should apply Synapisms to y Extremities & Blister over y Stomach. But above all y articles calculated to check Billious Vomiting Opium stands prominent. It is a fact well worthy of attention that a pill of Opii which as been kept for 2 or 3 yrs will remain on y Stomach & Check vomiting when administered recent it would be rejected. If y Stomach will not retain y Opii though taken in this way we must resort to Anodyne Injections ʒi or more of Laudnum should be enveloped on a little mucilage & thrown up y Rectum. A favourate practice in this city instead of using anodyne injections is to employ Opii 3 or 4 grs. made into a pill & introduced 2 inches into y Rectum will often prove exceedingly efficatious. Y advantage of this mode are that it can be early employed, that we shall not have to encounter y prejudices of y patient & when y desired effect is produced we may easily withdraw y pill & thus prevent y consequences of an overdose. An intermission being effected 65. effected y Cinchona combined with decoctions may be given. But when any doubt of y absence of y fever exists, you should prescribe y Serpentaria. Quassia Angusturia, Eupatorium, Centaury etc. for reason which I explained on a former occasion. Arsenic will be found in some of these caces to answer very well. The only circumstances which allow y use of Bark while there is y least remaining fever is a palpable tendancy to a Typhus condition. But even here y Meds. will often be rejected & we should confide more in Tonics which add too then principle property that also of producing perspiration. Upon y whole however y Remitt of this country is of an highly Inflam: nature demanding copious depletion with y Lancet & evacuating from y Bowels – when these in y stage are so managed as to correspond with y Violance of y Symptoms no other remedy being imperiously required. – 66. Continued Fevers. These run their course without any intermission though some degree of remission & exercabation daily takes place. – It has been held by some writers that y deffinition is deficient is exceptionable because all continued fevers they say consists of a single paroxism without abdomen untill final termination. But I believe no such fever exists & am surported in my opinion by y highest authority except y fever denominated [in] which begins is perfectly formed & runs through its course in 24 hours which is of short duration & rare occourance. Every other febrile affection is made up as a repetition of paroxisms. – It may be remarked as a general rule that y Exacerbations take place towards morning & evening by consulting nosological writers you will find that this class of Fevers is ranously arranged however Inflam y fever is there is a local affection. I shall treat of them under y general head of Synocous & Typhus y different forms of continued fever may then be disposed of without - 67. deficiency of perspicuity or too great generalization Synocha. As ordinarily defined. I believe has no real existance. Every case at least which has met my observation has been attended with some local affection which has marked it as one of y Phlegmasia continued fever y most common in this country y Billious Inflamatory. This prevails in y U.S. to a great extent, with y greatest violance to y South & is varied not a little by y Climate & y Conditions of Society. Like y Dis already treated it arises chiefly from marsh exhalations but is common without them. It is also produced by other causes. Considering y close analogy of y origine of y Symp. & mode of cure & not to mention y other slight resemblances [t???un] y Intim: Remitt & Continued fever we have good reasons to believe they are y same disease with some differance in type & external Physiology. 68. Physiology. During an Exacerbation a Remitt. is precisely similar to a Continued Fever Billious so that an account of one will precisely answer for y other each being ushered in by y same train of symp. & attended by y same set of affections. Discharged therefore from y necessity of occupying our time with recapitulation of that which has already been said we will proceed to y Cure of y Dis before us but can we arrest y progress of y Fever after it is once established or must we be content with abating y more violant sympts. till it shall terminate spontaneously, this is a question of great moment has been tally discused by Cleghorn Hillary. Pringle & Fordyce. It has been answered in y negative. It is contended by y last particularly Note. Prognosis. If y pulse becomes full soft y skin moist y tongue clean y Urine depositing a White Sedament y prognosis is favourable. Dark tongue parched skin a cold dry surface irritable & quick pulse gastric distress etc y prognosis is unfavorable. – 69. But not only are we enabled to interrupt y carear but also that either addition too or subtraction from y cause producing it will not have y slightest influance. – In support of this opinion they appeal to Small Pox Measles & Dis which y fact is undoubtedly stated. Neither of these cases however abated in Violance can be cured by artificial means & neither of them are affected by y further application of y cause this is particularly true as regards Small Pox. But their reasoning is fallacious in as much as it is deduced from y cure of dis. peculiar in term & provided & governed by their own laws. As respects y common fever we see them daily checked by y remedies we employ. cant it be denied that they are interupted in their course by a timely recurrance to [V.S?] Evacuations from y alimentary canal & of a similar nature. Most admirably we see this happen every day of our lives & sucess are y trophies of our profession. At y same time we must concede that there is much difficulty on may occasions & hence 70. y precept with practical Writers “to attack y obis in the first stage” as there it is most easy to obtain a Victory Y doctrine above alluded to is highly pernicious in its particular tendancy & haveing arisen in y dark ages of Medicine Sciance & kept up as a respect for y authority. – It will not fail if credited to take away energy of practice to sink to irresolution & indescision in y management of diseases at y very moment too when exertion is most required. According to that you must remain an Idle spectator of y Ravages effected by y unrestrained & vehement attacks of fever on y Constitution. Let it not be supposed from what has escaped me that I am not at all inclined to deny that in fever there is a tendancy to solution or Crisis. This was early remarked by Hypocrates & has since been abundantly confirmed. Hence arose y Doctrine of Critical Days by which is ment those days [by] in which y fever is disposed to a Solution These according to Hypocrates are y 3. 5. 7. 9. 11. 14. 17 & 20. or as some authers will have it on y 21st 71. Every practioner of enlarged experiance must have witnessed a more than ordinary tendancy to a remission of y symptoms on some of those days. But such tendancy is not so clearly manifested our dis. as as in those which have occurred amoung y antients y reason of this is not obscure. You all know that y climate of Greece is equable & serene & that y people of that country in y time of Hypocrates still cherished y symplicity of their Republican habits. Diseases therefore prevailed with uniformity of character not being disturbed as amoung its by deviations from nature & by y changes of y climate. – Eternally fluctuating & unsettled attempts have been made to explain y recourance of critical as, on y supposition that Intim. are y primary types of all fevers & hence that continued fevers at first are Quotidian then Tertian & after y 11 day very generally Quartan. Wheather this be admitted or not y facts are important they teach us to watch y efforts of nature, to bring about a crisis 72. which is marked by Remission of Symptoms & that such is y case & time [cross out] most propitious for y administration of our remedies. – Treatments. – Early in this discussion it was remarked that y Billious Fevers are far y most Inflam: in their nature. This being y case y principle indications are very obvious viz to reduce arterial action to y ordinary standard. Confessedly to obtain this no means are equal to y Lancet. – Its operation under such circumstances is prompt & effectual. But in this dis it should be directed by judgment & tempered [cross out] by discretion. The same Complaint may be varied & none more than y one under consideration by Climate. Season by personal Idiosyncracy & by many other causes. This while in this part of y Country y practitioner found to bleed copiously was y only method of cure. while in y Southern parts y practitioners hardly ever opened a vein. – But no matter in what part of y wourld you settle do not refrain from depleting with y Lancet when it [was] is indicated 73. by a strong pulse a hot skin. delamination to y Head & other symp: of increased action. those symp. wheather They occour beneath y burning Trophies or amidst y Polar Snow’s or in y more genial Clime of y Temperate zone must be considered as signals held out by nature for succor from y Lancet & other evacuants in her difficulties & oppressing. Bleed often in Small quantities. – Next in importance are those Meds. which produce evacuations from y Alamentary Canal. These are called for in all Fevers but particularly in this on account of y large accumulations of Bile which are apt to occour. – My general practice when I can prevail on my patients to consent is a Emetic & as I remarked on a former occasion antimonial preparations are decidedly to be prefered. It will be perceived that I am decidedly an advocate for Emetics in this Order of Dis. any experience has pursuaded me of their superior efficacy to purge & I am surported in my belief by those. physicians who are acquainted 74. with y more inveterate shapes of Billious Inflamatory Fever. But that one may reap their good effects they must be repeated & in some cases several as in sucession. There is a fashion in Medicine as well as in other things. Emetics which at one time were universally resorted too & of whose efficacy undoubled testimony was afforded in one of y revolutions to which our art is subject was suddenly supplanted for purgatives, but they have recently revived. By consulting y French & English Authers who wrote on y Dis. of their respective armys in Egypt 20 yrs ago. it was found that y Vehement Billious fever of that Climate they were obliged to submit to other modes of evacuation Emetics therefore were adopted by y whole medical corpse of both armies without regard to those habits of Country & prejudice of Education which have so much influance in y generality of cases of this Kind. Y efficacy of Emetics are equally attested by East & West India practitioners as well as by those of our country. – When Billious fever 75. prevails to great extent they are marked by great violance of symptoms. Determining from my own observation I should say that when early administered they hardly ever fail to check y Dis & that in y advanced stage by their operation when free & copious y pulse is reduced y pain in y head relieved. sickess of Stomach quieted y temperature of y surface lowered & diaphoresis produced by which y patient is quieted & y critical solution of y fever hastened. But when Emetics cannot be administered either for y prejudice of y patient or some peculiarity, a predisposition to apoplexy after active [cross out] Vomiting. We may with propriety & advantage [recoar?] to y use of purges. Combination of Calomel with a Drastic purgative as Jalap. Rheii Gamboge will succeed best in y management of continued fever. – It is a favorite practice with some when y Stomach is loaded with Billious Acumulations to unite Emetics with purges so as to induce an artificial Cholera or as Sailors say “to clear y ship fore & Aft. Rx Sub. murials Hyd: oss Ext. Elatenum gr. ss. 76. Jalap. & Rhii aa gr.v ol. Cennam. [gtt?] pills 6 two to be taken every hour this clears fore & aft. Of y utility of this practice there can be no doubt. It has been occasionally resorted to in y Billious fever of this city with sucess & it is more employed in y Southern States where there is great necessity from y great vehemance of Bill: faction Combination Calomel with Tart. Antim: is [cross out] commonly prescribed to which some add Gamboge. This in a large dose from 10 to 12 grs. will produce y effect without y addition of Emetic Med. But to justify a remedy so violant y fever must be of a dangerous character & y indication of Billious Accumulations must be strong & unequivocal. In presenting purgatives if delay is at all admissible it is proper to wait for that period of y fever where a partial remission of y Symptoms take place. Given at this time they act powerfully & effectually. But exhibited during y rage of y fever they are either rejected by y Stomach or lie inactive. By y pocess above [detailed?] y Alimentary Canal being emptied 77. we are now to resort to Saline Laxatives. Employed in small doses they are beneficial by Ruping y bowels in a soluble state & from their action on y exhalent vessels of y inner surface of y intestines they detract y watery parts from y circulating fluid & thus keeps down y arterial Excitement & produces a demunition of y Violance of y Paroxisms. Of y Saline purges y best have been already mentioned, A prescription very much used by myself & other practioners in y city is as follows ꝶ Sulph. Soda ℥i Tart. Antimony gr. i Suc Limin ℥ss Water ℥4 y dose of this is a tablespoonfull every 1 or 2 hours according to circumstances. It keeps y bowels in a locative state & produces a mild Diaphoresis reduces y arterial action & lessons y Sufferings of y patient. – As cooperating remedies Enemata are not over looked they are useful for promoting y action of purges. they are also beneficial as a substitute for cathartices when y alamentary has been much evacuated. Several formula have been used 78. y best for common purposes is that I will now mention. Take a pt. of Water & a table spoon of common salt & molasses & one of Olive [a] Castor ol. mix them & Inpect. When you wish an Enema a little more Stimulating or where there is flatus in y bowels as often happens at y close of fevers. Terbinth injection, may be used & be adapted to y cure. It is made by mixing a table spoon full of y ol. Terpentine the White or Yolk of an Egg & adding a pt. of Waters It relieves flatus more readily & spedily than any other remedy & in this affords great relief to y patient. By y combined operation of y remedies already mentioned y excitement of y system being reduced we are next to employ y meds. which are calculate to produce Sweating. Of all y modes of managing fever y practice of sweating is y most popular & general. By y vulgar on all occasions this is thought safe & most effectual nor is this opinion confined to y low & Illiterate of mankind. Every class of Society acquires y prejudice & entertains y 79. y same view same views. It is obviously however that remedies which act so powerfully on y System as many Diaphoretics are apt. to do should not be want only trifeled with by imediately employment. On y contrary they should never be used in Inflam. fever untill arterial action & general Excitement is reduced by V.S. & evacuations from Alamentary Canal. Diaphoretics then come with advantage & mitigates the dis. or arrestes its future progress & even here y milder diaphoretics should be employed & those should be combined with auxilliary means which have y same tendancy. As a general precept from which you must never depart it may be stated that in Inflam. fevers it may be stated that in Inflam: [cross out] fevers we are rather to solicit perspiration by limited means than to extort it by violant measures. To bring a continued fever to a crises y Antimonials are generally prefered. early introduced into y practice of med. they were occasionally used & with variable reports their efficacy were declared 80. by Hoffman & then successfully used by Cullen Fordge Antimony [cross out] affords an infinite number of preparations each may be so given as to produce Diaphoresis though few of them are employed at present In England even to this time y cellebrated Puties Jacobe or James Powder has no small portion of confidance that it often excites perspiration in fever can hardly be disputed but so far as I have observed its effects it is in no way superior to its kindred preparations The composition better known & hence administered more easily & certainly regulated on y Continant of Europe & certainly France is y Golden Sulphuret of Antimony. & has an indisputable asendancy over all y preparations of that metal. – Wheather it is entitled to this confidance does not allow me to decide. Compared to y Emetic Tartar I think it inferior in every point of view. This latter med. may be made to supersede all y rest of y Antim: preparations, Nearly Tasteless quite inodorous & minute in its dose, it may be administered 81. with facility prehaps equal it not transcend a wt. powers. – Of y precise manner in which y several preparations of Antimony operate in continued fever or y principles which should guide us in its use we are not accurately informed. Cullen maintains that they are of no advantage unless they vomit or produce considerable nausea but on y contrary it is continued by Forage & there can be no higher authority on y subject that by exciting vomiting y febrifuge powers of Antimony preparations are impaired & that they are always most effectual when y [?h?ght?s] degree of Gastric distress is excited by them. To this point I have directed a considerable careful attention & I am led to concour in this latter opinion. Nausea by whatever means excited or whatever way induced is not in itself salutary in directing y fever to a crisis or favourable solution. During continuance of Nausea Arterial action Macular power & animal temperature are undoubtedly lessened but afterward & reaction of y 82. body & consequent exacerbations of y Fever takes place. But did such a state of y stomach operate in y same every beneficially as contended for by Cullen practitioners generally: y utility of medicine should be proportioned to y to y effect thus created & various other Diaphoretics infinitely more violant & lasting in their operation as digitalis. Tobacco should be prefered. But this is contradicted by y lessons of experiance & y united voice of practitioners in every country. Meds do good in fever by exerting their own specific or peculiar action & when they disorder y Stomach by Nausea & Vomiting they are always productive of more or less mischief To illustrate this would be easy but it would take too much of your time & can be acquired by any one who will direct his mind to y subject. There are many febrifuge Meds. as y Effervesing Draught “Neutral Mixture” y principle effect of which is to subdue nausea & Vomiting & to sustain y tone of y Stomach. But while contend that y Antim: press: Arsenic. Bark. Mercury & Lead &c 83. act by a peculiar power I conceive that as this is y case with y articles enumerated y effect will be proportionate to y quantity taken provided they produce this genuine mode of action which is independant of any Nausea. Curious as are y views in Speculation they are inconceivebly more interesting when applied to practice. Let it be allowed that they are correcttive do away all objections against y employment of a rememedy of undoubtedly high utility nevertheless it is not to be infered in y preceding remarks that we should not have recourse to Emetics in y early & forming stage of y fever here they act on different principles & their efficacy is too well attested to be shaken by any thing that can be said concerning it. To obtain from from Antim. Remedies y precise effect to which I have above alluded is not always very easy. Y febrile affections are various as regards irritating so that y Dose as well as is in intervening as different in different individuals. As a general Rule 84. 1/10 to ¼ gr. of Tart Antim dissolved in water & united with a little spts. Sav: Comp: to give it colour may be taken every 2 or 3 hours as prorenata. But some Stomachs are so irritable that they retain it under no circumstances & here we must have recourse to other meds. of this nature as y Saline or Neutral Mixture which is prepared as follows viz ꝶ Lemon juice or sharp Vinegar ℥ii add Sab, Tart: till a complete Saturation is effected then add Loaf Sugar ʒii aq. font. ℥ii. – sometimes it is good to add a little Laudanum & a small portion Spts. Nitre Dose is a tablespoonfull every hour or two. To meet y same indication many of y Diaphoretics have been used some of which possess in an small degree y confidance of practitioners. – Combinations: of Ipecac & Opium are of this nature but though of y highest utility in Phlegmasia they do not succeed so well in y general febrile affections Why this should be y case it is difficult to tell but such is y fact & with it we must be contented not less do these remarks apply to others if y same class 85. most of them act as promptly & copious as y Antim: press: in aresting y progress of Continued fever. [illegible] this fact we find new reason for y supposition that y Tart. Antim: posseses specific powers in febrile affections in dependant of Diaphoresis or nausea. certain it is that y efficacy of Antimonials is not proportional to y degree of perspiration excited. Notwithstanding all that has been said in y management of fever some [cross out] practitioners hardly ever recour to this plan. by them y Neutral Salts. Refrigerants are prefered y precise Modus Operand of these meds is not understood attempts were [??dde] to explain their operation on chemical principles Though this hypothesis is not without plausibility yet it does not afford us & solution of y difficulty. But whatever may be there method of operating y Refrigerants reduce arterial action. lower animal temperature & partials relieve y surface though this really occasion perspiration. The principle article in this class of remedies is [cross out] Silon or Potassa & no Meds 86. more employed in fever & Inflamatory Dis. Z increases its powers it is customary to combine it with Cal. & Tart. Antim. forming a combination well known by Nitros Antimonial Powder viz ꝶ nitras Potassa ʒi Calomel gr-xvi Tart. Antim gr i to be divided into 8 powders one of which is to be taken every two hours according to circumstances. This is suited to y more robust of our patients & on a/c of y Cal: which it contains is very apt to purge it is prudent in some cases to exclude y Case lest Catharsis should be induced when not demanded or excite salivation as it is known to do sometimes under such circumstances, y Tart. Antim: is also to be graduated to y case. Even [cross out] in so small a quantity as 1/8 of gr. it sometimes distress y Stomach & even Vomiting, - Cooperating to y same end viz y reduction of diurnal febrile excitement. Cold applied to y surface has lately been recommended. I shall subsequently enter on y consideration of his subject I shall antisipate very few of y [former] future observations 87. Cold Water. may be applied in 3 ways either by Ablution. Aspersion or Effusion each adopted to y particular circumstances. But in y case before us I prefer y Sponge. It is much more agreable & less Dangerous than y others. But cold applications Are never called for unless y Pulse is active Skin hot & dry there they are very useful. they remove y uncomfortable secretion causesly y hot skin or heated surface & lessen y force of y circulation. induce mild diaphoresis & sooth that irrestlessness which generally accompany febrile Dis. But under other circumstances it is perilous when y system is exausted by y fiber would at y period be unable to react. Such is an outline of y 2 plans for treating fever one Refrigeratory y other Sweating. This is not y place for instituting a comparison between them nor could it be easily done y fact that they cannot be received as several measures each adapted to different circumstances. – 88. Before we use Diaphoretics in Inflam: cases we should first deplete in proportion to y vehemance of y Symptoms by V.S & evacuations from y Alamentary Canal & exactly at this point Refreg: remains maybe called into use with signal advantage. Before dismissing y Subject I wish to impression you y value of Sweating in y cure of fevers. It was formely y practice to treat Inflam: Dis by forcing a perspiration by heating Alexipharmics or antidotes. But those are productive of wide spreading mischief they were soon discarded. But it is wrong to argue against y employment of an article from its abuse sweating like Vesication is useful or as it is directed. When under y control of sound discretion it is highly important & indisputably acts powerfully in combatting Diseases Diaphoretics by determining y Blood to y Surface lessons Internal Congestion they relieve y constriction of y extreme vessels & thus renders y patient more comfortable y more we reduce y circulating fluid [cross out] thus they reduce arterial action by direct depletion Finally they equalize excitement & retain that just 89. Cheshire June 9th 1827 Cheshire March 31 1828 Equipois in y various actions of one system in which perfect health depends. Let us not therefore throw away remedies so useful on account of y objections which theory may raise or false refinement indicate. When hereafter we shall take y field against diseases you will it not enough to combat it with one remedy on the contrary you wish to be victorious over these to human happiness you call into requisition all y recourses which have been put in your hands. – by your God & all those which can be derived from a complete Knowledge of your art. We have now arrived to that stage of Continued Billious & Inflamatory Fevers where Vesiccating applications are found useful. They should be applied to y extremities sometimes both upper & lower but by some modern practitioners they are altogether condemned & strongly prohibited in this form of fever. Of those who entertain such views by far y most distinguished weight is that of Fordyce.. 90. It was one of y sayings of that great man that resicating applications had not y least effect in arresting y progress of Fever but on y contrary they never fail by creating an additional excitement or occasioning [cross out] exacerbations of y Dis. It seems to me not very difficult to reconcile y contraruly of sentiment that has prevailed on this point. Nothing is more different than y effects of Blisters applied in y early & late sap of y Dis. When there is much arteriae actions febrile excitement they never fail to do harm & it is not less certain that they are of y utmost utility in a reduced state of y system. Let y Body be reduced by V.S. Emetics & Purges & then resort to Blisters to quite y pulse, equalize excitement put an end to y action of Dis. & establish y regular order of health After y remedies above enumerated prove unavailing much confidance is placed in Mercury. Urged to a moderate extent or Salivation there can be little doubt of its utility when y system can be brought under its operation. But in most cases before y mercury 91. Cheshire January 21 1827 A. 1828 can be made to act feaver from its rapid carear terminates to be of use therefore it must be properly employed & as y bowels are weak & irritable it should be applied in y shape of. It is difficult to excite Ptialemo while y pulse is active Mercury therefore should never take y place of depletion & y remedies which effect this are generally sufficient to remove y fever. * I have thus concluded y history of y remedies which are best calculated to cure Billious Inflamatory Fever. Much however depends upon dericing a proper attention to y Minor circumstances which often so powerfully influance y result. Of these by far y most important are Drinks Diet & General Management of y patient during y progress of y Dis much * In y Billious of this country Bark does not suceed y Remissions being short, tong moisten skin relaxed it is useful. Cullen says that every fever proceeding from marsh miasmata after sufficient evacuations may be treated with Bark beneficially. All Fevers arising in y spring should be treated by Calomel. – 92. dryness of y fauces & extreme thirst generally prevails. It has been a question wheather y patient should be indulged in this ardent desire for Drink. y Physicians of antiquely were much divided on this point while one set to totally forbade. y other allowed y use of Water. – It requires little Sagacity to discovour that y medium between y two is y proper practice By denying altogether y occasional use of Drinks we shall cause great anxiety & distress & rather increase y Dis & by allowing y unrestrained employment of it we shall find that y Stomach will be disturbed & certain Nausea & Vomiting with other mischievous consequences will result. We should therefore direct now & then a table spoon of some Acidulated Drink as Lemonade Vinegar & Water. Apple Water. Toast Water. Tamarind Water & a variety of herb Teas as Barley Water, Balsam Tea. Sago Tea. & a Solution of G. Arabic. But what I have found to be y most effectual in allaying Vomiting 93. William R Hitchcock Esqr. Vomiting & distress at y stomach is a table spoon of Lime Water or a tablesoon of new Milk from y Cow or a decoction of Snake Root, even common water provided y quantity be small & y temperature not too cold, should not be refused. It is a precept worthy of your attention that drink in moderate proportions & moderate temperature will relieve y thirst quicker than Cold Drinks immoderately taken During y continuance of y fever y Drinks above enumerated will afford sufficient nourishment to y patient. – It sometimes happens that y appetite solicits more solid food & y demand of y patient is loud & clamerous but y propensity is always an unfavourable indication & should not be indulged. Every practioner must have seen y eble consequences which results from y gratification of a depraved appetite & in many instances cases from this cause have terminated fatally which would otherwise have been cured. An Old Opii pill checks vomiting. Enema or supporting of 94. Samuel Johnson [Esgr?] Oppi. Blisters over y Stomach & a lump of Ice held in y mouth. a piece of Liquorice or an Infusion of Liquorice will allay y thirst grii of Calomel will be of service. Strong coffee [no cream or sugar] ¼ or ½ gr Calomel with G. Arabic. Sacch. Saturni grs every ½ hour. Mint. Brandy with a Lump of Sugar are all good in irritable stomach of Billious Fever. – In y History of Pathology of y dis I mentioned y causes which accelerate y increased action these should be studiously avoid in y febrile condition. As prehaps y most operative cause you should direct partie: light to be excluded & also that conversation should not take place in y chamber of y Sick. – Before leaving y subject I will give some some directions for y Management during Convalescence. Febrile affections of every kind leave behind them an accumulated state of excitability which it not properly directed may be productive of a relapse a condition of things more Dangerous & intractable 95. than y original Dis. The first step when y patient is recovered is to remove him to another room or to order that all y apparatus of sickness as Phials. Bases, Plasters &c should be placed out of sight from seeing these a remamtrance of his sickness is kept up. & his spirits being depressed retards y progress of cure. Y changin his skirt & cloths has a great effect in promoting y possess of Convalescence. 2nd. Be careful to regulate y Diet according to y excitement, you should begin with faranaceous articles & more are better than Tapioca. Arrow Root. Sago & Rice. Next you may allow Eggs & Oysters raw or very slightly cooked. Boil a Chicken or any other article of a light & digestible kind may be allowed. – But whatever is taken should be in small quantities at a time. This is a rule of extreme importance & rembember to direct often & a little at a time. As regards Drink pure water is y best. If something more is required by y condition 96. of y patient & from his solicitations y best liquid which you can direct is Porter diluted very much with water Malt Liquors & especially Porter is infinitely more agreable [cross out] & less injurious than Wine or ardent spts. however diluted. 3rd It is hardly less important that y patient should gradually return to y employment occupations & habits of Life. He is especially to avoid much exercise of his intellectual faculties. – To prevent this he must be kept from study & from attention to business of any description Company could be avoided. Be not too precipitate in permitting your patient to take exercise & especially out of doors. There is generally much eagerness on his side backed by y intercession of his friends under [illegible] that it would afford him strength confirm his recovoury. – But you must recollect that there is great liability to take cold & from this irritable state in y commencement of convalescence y stimulus of riding instead of strengthing would probably give a return of fever. Even when you allow him 97. to take exercise direct him to be warmly clad & should particularly enjoin it on his attendants not to protract y ride so as to fatigue him. Y preceding are instructions [cross out] relative to y management under ordinary circumstances. But now & then certain symptoms arise during Y course of Med. treat. which demands [cross out] particular attention. Sometimes patients in y convalescence from a long spell of fever remain very feeble & have a total loss of apetite. To meet y indication of these cases Tonics should be given amoung which y Tinct: Cinchona alone or combined with a portion of Tinct. Gentian is highly beneficial. But there is a great variety of articles of nearly a similar Character which may be used in sucession according to y circumstances of y case or to y taste & caprise of y patient. As y leading ones, may be mentioned all y Vegetable Bitters as Columbo Quassia Gentian, & these should be employed in watery infusion. 98. y Chur. Vitriol is also an excelent remedy & establish y a restoration of apetite. Not y least distressing affection which is incident to a state of [cross out] convalescence is extreme watchfulness & inability to sleep this is very unpleasant often retards recovery & somet: aggrevates y fever here Small Opiates are useful. The best preparation in this case is y Black Drop. This preparation posseses 3 times y Strength of Laudanum & has a more powerful anodyne effect than any other with which I am a aquainted. It never so far as I know produces y nausea & other disagreable effects which sometimes results from y use of opii & its Spts. Tinct. When Opii in this form fails you are to resort to Hops Tinct. & what I know to succeed very well is y Camphoretic Julep this often quiets irritation existing in y system & disposes y patient to slap. Sometimes watching proceeds from an empty stomach & when this is y case stimulating food conjoined with porter is generally effectual. – 99. Somet. Diarrhoea & more commonly Costiveness attend recovery from fever. As to y Diarrhoea it will generally yeald to y Cretaceous preparations where on y contrary there is a tendancy to Costiveness it will generally yeald to small doses of Rheii. This cath. should be prefered because it impartis tone to y Bowels & when taken by itself never purges copiously. It is worthy of [cross out] recollection that however beneficial evacuations from y Alamentary Canal may prove in y early stage. – It is not less injurious in y convalescence more than any other cause. Copious evacuations at this time induce a state of exhaustion & not unfrequently brings back an allarming degree of Fever. I have see this more than 100 times in y condition of convalescence These are y applications which have some claim to notice but considering which I have protracted y discussion. I will detain you with only with 1 or 2 observations. y Billious Inflamatory 100. may terminate in Typhus but more frequently in chronic fever. As y treat of y former differs on nothing from y Idiopathic Dis of y same name it will not anticipate y observations which I shall have occasion to make here after. y Chronic nature of y Fever claims our particular notice it is called Febricular from its from its diminution & indistinct symptoms which attend it. In y country it is known by y name of Inward fever. Y pulse is small corded & hard, much heat on y surface. a Billious complexion & a tenseness of y forehead combined with Headach or pain in y side. y Patient has always Edematous swelling of extremities, scanty high coloured urine & ash coloured Stools, y Type of fever is either Remitt. or Intermitt. & not continued, y course of this condition of things is too obvious It arises from Congestion in y Large Viscera partic: of y Spleen & Liver. Y appropriate remedy is a slight salivation or what answers very well as a substitute a course 101. Nitric acid ʒi of y latter should be given every day for 8 or 10 ds. Commonly however there is much fever & pain so that it is necessary to resort to frequent & small V.S. vesicating applications at same time are very important placed on y side if there is pain there. But if this is absant & we wish to interupt y association on which this small fever depends I would greatly prefer them on y ankles & wrists. It is a common practice to treat y case with Tonics particularly with cinchona but it is highly prejudicial they Lock in y Dis. instead of Liberating it from y system. After y evacuations have been premised then y Tonic Meds. may be employed. of them by far y best is Cinchona but where this fails we may resort with great advantage to Fowlers Solution. – Delirium. very often in y progress of y Dis there is delirium y patient becomes wild in his conduct get up from his bed & uses singular expressions there is at y 102. same time great turgesance of y Eyes & Face fulness of y Head &c. In order to remove this it will be necessary to remove y Hair & shave it close to y Head. apply cups to y temples. here Blisters should not be applied untill Inflam- is subdued. Note. To cure Headache in fever apply 2 or 3 leaves of y Wild Popular. imersing both arms in cold water, sprinkling y Head &c. – Note, This prescription is good in fevers viz ꝶ Tinct Opii ʒi Acid Tart. gr. 10. Aqua font, ℥ii Dose table spoon 103. Remittent Billious Fever. The Continued Billious Fevers are very apt to terminate in Billious Remitt: in which case there is perfect & distinct Remissions. It is a common practice in y U.S. wheather Remitt: are assumed form of Continued to treat it from y very commencement with Cinchona It is laid down by Cullen that even in y Continued form arising in Miasmatic countries always to make use of Cinchona without there being any Intermission or Remission. Whatever may have been his sucess at Edinburgh it is not applicable here in y U.S. when y remission is not complete y Bark will be rejected or oppress y Stomach & this aggrevates y Dis. The practice here is when there is some remission to substitute for y Bark y other Tonics as Serpenta: Quassia. Angustura & our own Indigenous articles of y same nature. Arsenic is much better adapted to this form of Bill: fever than y Bark & in general it will be y best plan to resort to it. It will however be found in y generality of cases that, V.S. 104. Emetics & Purges will be necessary before y Tonics can be administered. Yellow Fever as an Dis of autumnal occourance & allied in some respects at least to y dis fever already Described, I proceed in order to y consideration of Yellow Fever. It is not my intention to occupy your time with a very minute history of this Dis. To y writings of y late Dr. Rush I refer you for details relative to y subject & more partic: for his account of this dis. as it appeared in 1793. some deffects for y time it was written] undoubtedly is y most perfect muddled & best historical narrative [in y whole compass of medical Literature] pestilentia dis. contained in y whole compass of Med. Literature As prehaps you all know that. Y.F. is an Epidemic of Tropical Climates – to W India Isles it seems to belong particularly. – It appears occasionally to have occoured in y U.S. from y earliest state of settlement but it was not until y yr. 1793 – on a/c of its ravages & y Terror which it created that it 105. first attracted Med. Curiosity & attention. Notwithstanding all y writers on y subject & y ardent continued enquiries which have been made hardly one solitary point connected with it is better settled or less a matter of dispute than when investigation first began. – Its origine nature & Treatment are points, still as much disputed now. as they were before. It is far from my desire to review y disputes which were carried on with none of that complaysancy which should characterize all Sciantific discussions still however it is my duty to afford you some information on y subject. though I trust in giveing it I shall be able to temper my an imadversity by y sincere & respectable attachment which I entertain towards [both] all parties engaged in y controversy. – As regards y mode of production y disputes have been chiefly on of meaning of words. It is attributed on all hands that in each instance y discus procds in some way from Vessels. It is true that local filth as y 106. contents of Docks. Gutters & common Sewers has been assigned by some as y accessary cause of this pestilance but was this true for y extent to which they argued it would appear that y dis must appear every season for y sources above mentioned crest now just as much as on former times besides we have a complete repetition of y doctrin in y fact – the Scavengers a class employed in 2 cleaning y city of y filth universally escape y Dis. Dr. Rush states out of 50 Scavengers only 1 took y dis in 1790. But it may be said that these persons are so habituated to y exhalations of y filth [universally escaped y Dis] as to be insensible to its action, This however cannot be justly alleged because owing to y great scarcity of y Scavengers at this time many of them having left y city individuals were employed pro tempore But while I so far accused to y importation of Yellow Fever I do not believe for a single moment that in any 1 case it was introduced in a palpable & well formed condition. My impression is 107. that ships coming from tropical climates in a filthy state bringing with them y materials out of which this pestilance is produced. Wheather such exhalations excite y fever under all circumstances I am not prepared to determine. It is more than probable that a certain condition of y atmosphere is necessary to give actively to y cause. This would seen to be y case since y fever is of occasional occourance though vessels arrive every day from y W. Indies. Long ago it was suspected wheather y Dis was imported or generated in our own country it would not take place except under a degree of temperature – but it has been proved as satisfactorily as any problem can be proved that unless y mean temperature of y summer months June & July is as high as 79 or 80 Fahrenh: y Yellow Fever cannot prevail in our climate. This have taken from a register kept in Philadelphia in 1793 to y present time. From this it appears that when y media heat of June & July has been 80° 108. not in one solitary instance has y fever appeared but on y contrary when y temperature was above 80 so was y greater violance of y Dis. Nor does y truth of y observation rest on y register on Philad. alone by a similar one in N.Y. weare waranted it arriving to y same conclusion. Much controversy has existed as to y Contagious nature of Y.F. that it is not y generals uniform character of y Dis & think has most satisfactorily explained. Not to protract by discussion to any length I shall compress y argument on both sides into as narrow & compass as possible. It has been said it is not contagious for it is of y nature of Epidemics & therefore depends on more general causes. It is also said by them that y diseases imediately proceeding y Y.F. from one end of y union to y other assume more or less y inflamatory type of that dis. 2nd.. It is moreover said not to be contagious because it never proceeds beyound y sphere of y city infected by it. – In surport of this argument 109. strong & almost irresistable arguments have been added. It appears that during y prevalance of y fever in this city that though several hundred people were received into y Hospitals & crowded together into small & comparatively ill ventilated apartments get no one instance of extention of y Dis occoured y Phys. Med. attendants & nurses whoever constantly amoung y such y dying & y dead escaped without one exception even though dissection was carried on [even to] an almost incredible extent 3rd. It is alleged not to be contagious because it is uniformly suppressed by cold weather. Whatever may have been its ravages however universal its prevalance y moment it first appears its carrear is checked or terminated. This is undoubtedly contrary to y nature of contagious diseases. 4th we are assured that cases have occoured in y country remote from y city & where it could not have been excited by contagion or intercourse with y sick. But on y other hand facts are 110 adduced too important to be over loocked. 1st. It is alleged that y dis in every situation commences at some point from which I gradually spreads & diffuses itself – In 1793. It could be distinctly traced to a Cargo of putrid coffee thrown out of a vessel from y W. Indies upon Arch St. wharf. y persons employed in unloading y vessels were first seized next y inhabitance contiguous to y wharf & from this it gradually extended itself untill it involved y whole population. In 1805 y dis originated in Southwark & was traced gradually diffusing itself from square to Square untill it covoured a great part of y city. – 2nd. It is answered by respectable physicians that y fever actually proved contagious in y country. to this point we have y attestation of Doct. Wistar who recorded several instances in which y dis happened in Germantown & which was distinctly traced to y city. There are a number of facts of y same kind in y publication of 111. y College of Physicians. It has also been [impactd?] by y cloths of those that died. 3rd. It is maintaind that y Y.F. does not take place twice in y same persons in this respect obeys y laws of Contagions dis. On this point Medical men are exceedingly divided. While on one hand it is asserted by a large member of Practioners of this city that it never occours more than once in y same person It is rejoined by a large number that eases often occour where one individual had this dis twice In a recent publication by Dr. Hossack contained in y last edition of Thomas. it is state that on a recent vursit to Philaa. y Doct. had conversed with several medical men on this point & had not found one who did not declare that y dis is incapable of being twice taken, but he was mistaken. It so happened that his that his communicates on this subject was a particular set who maintained this opinion. – If he had addressed his interrogatories to Dr. Physic or to 112 Dr. Dorsey he would have found that they no more believe it than they do transit – or thus y New York school was superior to ours. – It is however stated by Dr. Griffith that though he attended thousands yet he never met with one instance where y dis occoured twice in y same person. By consulting foreign writers you will find no more union than in our own. Most of y W. Indie practitioners entertain y first [sentim?] y question has lately engaged much attention y British Government inconsequence of y occourance of Y.F. in various parts of Europe partic. in their ports in y Meditaranean Sea instituted injuries relative to this point on an extensive scale. Two bords were instituted of Med. men who were to collect all y evidance y subject admitted of. After a full examination of witnesses & documentary evidance y College of Physicians of Lond. as well as y Med. board reported as y consequence of their deliberation & extensive enquiries y following [103.] 113 conclusions were 1st. That it cannot be taken more than once – In support of this point facts were adduced of a very conclusive description. Amoung others it was stated in y authority of almost all y med. men in that regiment which had previously served in y W. Indies y soldiers who had been affected were not more instance again attacked by it. – This fact as so well ascertained that y soldiers were employed as nurses to y sick & did not experiance any in convenience Nor as regards y origine of y dis. is y Epidemic less direct at Cadis it was traced imediately to a Vessel from y W. Indies. It was shown that it could not leave arisen from any local cause from y circumstance that it did not occour in y most dirty parts of y city. It was farther shown that Marsh. Miasmatic could not have given rise to it because on one side of [Cause?] there is great marsh which every season 114 [104.] occasions y different kinds of Billious Fever get during y cariers of this pestilential dis. that part of y city was perfectly healthy. Strong however as y facts appear to be one still more conclusive may be added. Y Garrson at Geberatter is situated on a bank exempt from all Mail Exhalations & kept perfectly clean from filth of every kind by y severity of y military police. No place is so little favourable to y production of Pestilential fevers yet it prevailed there to an enormous extent. It is affirmed that y dis in this instance was imported in a vessel from [??dis] & could be traced to y wharf where y vessell was lying. Enough has been said how contradictory all y efforts on this subject are when facts so opposite in their tendancy related by respectable authority. It is imposible for a circumspect mind to arrive at any satisfactory conclusion. It would not be safe in such cases to trust to any [opinion] ceasing & even if we were to employ it we might arise at oposite inferances. but really there is [105.] 115 nothing very repugnant or absurd to reason in y belief at least of occasional contagion of Y.F. Typhus confesedly is very often contagious but it is said when this proves so it [is] arises from y exhalations produced by y excretions in a state of petrifaction of this statement I do not believed single sellable. Typhus Fever has again & again occoured when y greatest cure was taken to remove all filth. During my residance in Edinburgh y British fleet which was cruising in y North Sea was infected with Ship fever. The Sailors who had been attacked were landed at Edinborough & taken to y Hospitals of that city. More than hlf y Students who attended on y sick were attacked with y fever & many of them died besides were y dis. occasioned by y effluvia from secretion or excretions it would be as diversified in its nature as y causes are from whence it is produced & each of these 116 [106.] different excretions would produce a different disorder but this is not y fact. All y cases which occoured in y Hospital were precisely y same or marked only by such differance as may arise from y violance of y attack & idiocincracies of y patient or their peculiar constitution. – What also do experiments prove in regard to this point? It has been most satisfactorily shown by Hogarth & other European writers that Typhus is not always Contagious dis. as much so as Small Pox itself but y sphere of action was not extended beyond a few feet. From y experiments of Dr. Gregory of Edinborough it appears that Typhus does not prove contagious beyond 5 or 6 feet. If a person remains within that sphere he was sure to be attacked with that dis. Does not this show that fever may be contagious & that it is not propogated from y putrid excretions but from y patient himself. All contagion is owing to a secretory action of y vessels. & differs [107.] 117 according to y nature of y stimulus by which y vessels are excited. Thus y Contagion of Small Pox differs from that of Syphilis only by being produced by a different action of y secreting action of y secretory vessels resulting from y disimular nature of y Stimulous by which they are called into action. Now if y extreme vessels in T. secrete contagion why should they not perform y office in A fever where y dis assumes y Typhus inclination that they do so I am perfectly persuaded but it is only when it puts on y Typhus [grade] condition that Y.F. proves contagious we observe y same in Dysentary which in its ordinary form is not of this character but when it becomes Typhus y whole tenor of Med., Sciance goes to show that it is propogated by contagion. – By consulting y best writers on this subject you will find that other complaints though not contagious under ordinary circumstances but when they assume y Typhus Type do become so. 118 [108.] This I believe is a law of universal prevelance amoung Diseases. I do not see much force in y argument. that Intim: fever is not communicated in Hospitals & by dissections. It is in this respect on a footing with Typhus fever & Plague. We have reason to believe that Typhus fever is not contagious when y apartments are well ventilated. It has been ascertained that as soon as vitality in y Plague was destroyed by – of communicating y dis is destroyed. As I have stated them such are y facts arranged on each side of y controversy my wish is not to impact any Hypothesis to you y facts are so contrary in their tendancy that it is impossible for anyone who gives credit to both parties to form a conclusive opinion The controversys scene to be have governed more by y pride of Victory than by any honest wish to advance the Interest of Med. Sciance. As relates to nature & treatment of Yellow Fever scarcely less diversity of Opinion has prevailed. – [109.] 119 Treat. Yellow Fever. consists in V.S. & mercurial purges & was in y year 1793. adopted by some of y most distinguished practitioners of y city. Y French physicians washed out y Stomach & then poured in Glysters or diluant beverages Calomel was exhibited largely by others but their sucess was precarious. Mercury seldom produced Salivation. More correct judges of its pathology a change of treatment. In y commencement V.S. by cups. Mercurial purges &c this was y treat. of 1793. Last summer often mild evacuations from y bowels, we used spts. Turpentine in doses according to y symptoms with cups to y Epigastrium. this should however be done early in y dis y Turpentine was to subdue Inflam: in y Stomach. – 120. Dysentary. Cullen defines this to be a contagious fever in which y patient has frequent mucous & bloody discharges accompanied with Griping & Tenesmus y foeces being for y most part detained. Except as regards contagion which is of rare occourance I do not know that this celebrated deffinition could be a mended. As y History of y dis is familiar to most of you & may be learned by Books which are easy of access it is not necessary for me to enter into a minute description. An attack of Dysentary according to Sydenham whose a/c of y dis with few alterations has since been capsized by most writers on y subject comes on with a Chill suceeded by flushed of heat frequency of pulse to these symp. are added severe griping & a constant propensity to go to stool. But in many cases y local affection is first perceived & prehaps not less frequantly y dis is preceded by loss of appetite. Costiveness flatulency; Nausea, Vomiting, & often these take 121. place with y irritation & uneasiness of y bowels above mentioned. As y dis extends itself y evacuations from y Bowels becomes more frequent & painful & preceeding every stool there is griping & tormina & tenesmus. y matter discharged by stool is very various sometimes consisting of frothy mucous though more generally it is streaked with blood & small coagulated lumps like bits of cheese are observable & some cases hemorrage of pure blood takes place from y Anus these are y ordinary appearances of y Stools in Dysentary. Now & then there is mingled with y morbid discharges natural forces may be assuming y appearance of Gallnuts & denominated Sybala y voiding of which is attended with temporary relief. We commonly meet with fever more or less marked with y usual symp. of increased heat thirst & restlessness though y pulse is neither very full or very active. This may be considered as y crisis of y Dis. which commonly occours in a few days though it is frequently much more 122. protracted. Not arrested by our remedies y dis henceforth puts on a sensible aspect. To an increase of y principle affections incident to y case we add. A rapid depression of strength, cold extremities. tension of y abdomen. Cold clamy swets, pitched. Hiccough. Aptha. a small pulse & discharge of a acrid fluid resembling y washings of meat, latered canine, [these] are generally y precursors of death. But they should not be deemed invariable so as much as recovouries from Dysentary somet. takes place where y most of them have been exhibited. On y contrary when y case terminates favourabley we find most commonly a remission of fever, y surface becomes moist & relaxed y evacuations less frequent & more natural y Tormina & Tenesmus subside altogether or are grately diminished. To this a/c I have only to add one observation. Y complain occours sometimes without any discharge whatever, such cases are by far y most fatal. The want of an evacuation arises from y existance 123 of an inflame. so violant as to transend y secretory [action] functions. I have seen instances of this kind & others on record in Sydenham & y Older Writers. They resemble Gonorrhoea in y circumstance that y [sooner] later y discharge was on y occourance of violant inflamation. Thrush has been said to be a Cause of dysentary. y dis was once thought to originate exclusively from a species of contagion generated in y system of an individual & by him communicated to another. – But by the most careful observation it will be perceived that such is not y uniform & general character of y dis. By a later writer it has been stated with no little plausibility that Dysentary only where y original fever is Typhus or assumes that character in its progress. Determining from what I have seen I should conclude y doctrin he advanced was perfectly sound & correct. – It has however been suposed that y contagion arises from y alvine evacuations & more plausably 124 that it arose from y stagnated secretion & excretions which have been suffered to remain untill they putrefy. But neither of these supositions is well founded. No evidance has been adduced to prove that y Excretions in Dysenteria are capable of producing y effect alleged. And y same may be said of y collection of filth from y patient which has purified. As I mentioned did y perspiration or Urine under any circumstances give rise to Dysentary. Y cases should be as diversified as y causes from which they originated from. On y contrary when contagion is y cause it is an uniform description of morbid action or at least diversified from peculiarity of constitution or Grage of force with which attacks were made. However it has already been shown that dys. & other contagious dis. may be propagated though y utmost cure be observed in clenliness in all respects. What then are we to conclude except that in y Typhus state of this dis. The extreme vessels take on an 125. action by which contagious matter is eliminated & elaborated out y system. But Dys. may most generally be traced to y causes amoung which are to be mentioned y many sources of autumnal fevers. Now & then it is excited by acrid matter taken in y Stomach & it has been known to occour as in Epidemic depending like other Dis of that class on some peculiar dis temperature of y atmosphere. Nor prehaps does it less frequently arise from y sensible qualities of y air. Cold suddenly attended with heat & moisture succeeding dryness equally produces y complaint As in y other bowel affections whatever suddenly checks perspiration in many instances proves y Cause. This complaint somet. accompanies Catarrh & I have seen it in many instances alternate with Rheumatism. But whatever may be y cause of Dys. it is evidently a febrile affection & directed to y Aliment. Canal. Even as long ago as y time of Sydenham such a 126. view of pathology was taken y opinion is surported by y fact that y dis asumes different shapes being remittant, sometimes continued, which last form may be highly Inflam: or may partake in various degrees of Typhus malignancy. Most generally when it arises from musk effluvia y primary seat of Dys. is always in y Stomach. Here it manifest itself by nausea & Vomiting & from this point it gradually extends downward to y bowels as revealed to us by dissection it appears that y force of y dis expands itself on y large intestines. In this part of y A: Canal we find most marks of preexisting Inflam: & other phenomena of dis. action. Enough has been said to expose my sentiments relative to y nature of Dysentary & if what I have said be correct y indications of cure are suficiently obvious. – But that y treat. may be applicable we must consider it under y various modifications which it occasionally assumes. – As Dys. generally presents itself y Indications 127. are to remove inflamation with y Spasmodic action which attends it over coming of y primal Vic & there by producing natural stools. To restore y Surface of y Body which is hot & dry to its usual healthy condition. – Taught by y example of Sydenham practitioners have generally been in y habit of commencing y treat. by Emetic - Enarmoured as I have thrown myself with this set of Meds. in most of y Bowel affections – I am not an adovocate for this universal employments of Emetics in Dysentary. The case in which they are peculiarly applicable & to which we should limit them use are those in which y stomach is loaded with Bile & other foul accumulations creating nausea & other Gastric uneasiness. It is common to meet with such cases in miasmatic districts associated with y Intim: type of fever. Cosulted end case of Dysentary under ordinary circumstances it would be 128. right to V.S. previous to remedies by thus early drawing Blood you will check y progress of Inflam: & is no less important to open [y war] a new. y susceptibility of y system to y operation of other remedies may be produced. V.S, is y most effectual & as y affections of y alimentary canal are eminently characterised by y want of this susceptibility to y operations of meds. y Lancet in those cases is imperiously demanded. But independent of y reason just stated there is another motive for copious & early V.S. Commenced with this affection of bowels there is commonly a degree of Spasmodic constriction which is productive of acute pain & appears an inseparable barrier in many cases to y evacuation of y bowels. to overcome y constriction in this case V.S. posseses [universal] unrivaled powers & with y removal of y spasm serves also [for] as a remedy for y hot & dry surface which it exchanges for one moist & relaxed. Haveing asserted this much of V.S. 129 we must resort to purgatives to clense y bowels of their vitiated contents. Castor. Oil is y article most commonly rised & answers very well in y forms of dysentary it cannot be denied but that it should be liberally employed my pursuasion is that in this case practitioners give y med. in infinitely to small doses to be of any decided advantage. In y same violant forms of Dys. seveal ℥ Castor Ol. should be given daily. It must be recollected that in Dysentary y ol. runs rapidly through y bowels passing off very little changed & makeing so light an impression as scarcely to remove any portion of Excrement. matter even y Bile. – I have seen it discharged from y bowels in y course of hlf. an hour or an hour after taken. – As regards our own Dys. especially such as occours in Warm weather I cannot help metaling y opinion that mercurial purges are infinitely better adopted to y treat. 130. treat. Do we not find them preferable wherever evacuations are demanded. We give them in Billious fevers & positively we should give them in y case now before us. In my own practice I prescribe Cal. alone or in combination with Rhubarb. & where y med. lingers in y bowels I promote its operation by mild laxitives. I resort to injections after I have thus evacuated y bowels y mercurial meds. are not again demanded. Now y Castor Ol. comes in with good advantage. y Epsom Salts would prehaps form a better substitute for Calomel & its combinations. No practicable point has been more debated than wheather we should continue purging. It appears however at present that y fact is pretty well asertained that we should give purgatives untill y natural forces appear. This I am induced to believe is a rare practice. Every one is conversant with Dysentary I will know that when y foecal 131 are suffered to remain in y Bowels they are irritated & y pain & other unpleasant symp. are considerably aggrevated. Let it however be recollected the discharges which accompany y dis. are mearly y effect of preexisting irritation & to remove them we must correct y preexisting disorder. – Acting on this principle I have been in y habit of resorting to Opii earlier than y general practice of Physicians would seem to warrant. Nevertheless I am perfectly convinced of y prosperity of this course by my large & faithful observation of its effects. Even since age of Sydenham with a very few exceptions which I Shall not at present notice there, has been a very marked aversion to opium. in y treatment of Dysentary even by cullen & those writers of his time y practice was either noticed with great distrust or universally condemned. But all these writers seem to have been influenced more or less by y old notions of y humeral pathology. They confounded causes and 132 & effects. As much are y discharges [in Dis y effect] from y intestines in Dys. y effect or consequence of previous Inflam. of y stom: & bowels. as y matter of Gonorrhoea is Inflam: of y urethra & a flow of tears in Inflam: Eyes when they have been offended with atoms of dust or grs. of Sand. But in resorting in y early stages to Opii I do not hesitate to allow of y necessity of uniting it with OC. Or some other evacuating remedy. My more general object however while endeavoring to remove y contents of y bowels is also to determine to y surface of y body. This last is indicated by y condition might be surported by y most distinguished authorities which we can afford. – But still it must be remembered that previously to any attempt to excite perspiration. – The pulse & other inflame: symptoms must be reduced by direct depletion. When this is not attended to sweating would only accelerate y dis. Less than any other Dis does dysentary admit of a substitute for y Lancet A late practitioner in this city has declared that 133 with y Lancet & Opii he could manage any Dys: I am not prepared to go so far though I am will convinced of y signal benefit of y Lancet in allaying irritation y early stage of it I do believe that y most important effects are gained by it. – It is now more than hlf: a centaury since Dr. d- introduced or proclaimed y superiority of y sweating plan over all others in Dys: His view of y pathology & treat. was soon adopted by several respectable physicians. It partic. Was adopted by Richter a writer of y highest authority that Dys: is a calanhol or Rheumatic affection of y large intestines & that y Billious & other discharges are necessary to y main dis. & mere efforts & not to be regarded much in y treat of y case As deduced from y Hypothesis y practice which he leays down consist y exclusively of measures calculated to excite perspiration. I do not go to y full extent with this author in his speculative order of y dis. or in his practical deduction. 134 This is one out of many instances in which injury has been done by a generalization. what holds in practical cases is made to apply to all cases of a catarrhal Rheumatic affection of y al: canal do now & then occour sweating will somet. suceed without n evacuations. But y instances are very rare & he who enters in y practice of his profession with such a view of pathology of Dys will inevitably be traced along his path of business by y dreadful mortality which he will inflict on his patients. In detailing y cure of Dys. we have reached so far as [Dysentary] Diaphoresis y modus operandi of such [illegible]. I have more than explained. It remains therefore to point out y lust mode of affecting y purpose. My own experiance has led me to prefer at this juncture a combination of Opii Ipecac & Cal. ꝶ Opii grs IV. Cal 16grs. Ipecac 8grs make 8. pills one every 2 or 3 hours. or pulv. Confedidly this is not y most action diaphoretic Med. but it is productive of effects which prehaps at this crisis is still more important than mere diaphoresis. - 135. It composes intestinal irritation relaxes y surface of y body, gently opens y bowels & causes other impressions which though not very intelligent are eminently salutary in their consequences. Every one who has noticed carefully y operation of Cal: in small doses in Bowel affections must have witnessed y beneficial effects of Vomiting from y article. It probably does good not less by y change it produces in y Intestinal & Hepatical secretion than by its directly purgative effect. As on infinitely more certain & powerful Diaphoretic y Dovers powders will seldom fail when copious perspiration is demanded. But it should never be resorted to in preferance to y preceeding article. – When it is necessary to evacuate y bowels no article in y Mat. Med. has been more extolled in Dysentary than Ipecac. Given either by itself or in various states of Combination. By some practitioners it has been more partic adopted to that state of Dis with which such 136. copious discharges of Blood from y Rectum as to amount almost to an Hemorrage. This opinion determining from y general properties of y article would appear perfectly correct. – But in every form & variety of Dysentary it is highly beneficial & well suited though I have prescribed it with y best advantage y pain thus been most violant y desire to go to stool very frequent & inefectual. – y great power of Ipecac over y dis does not rest on my own authority alone for more than hlf. a centaury ago it has been employed by practitioner in every section of y Globe & has brought from then very general if not unanimous approbation as to y precise mode of operating in this case all writers are not so well agreed. I do not agree with Sir Geo. Barker & Cullen who says its efficacy depends as upon its purgative operation for y med. produces an oposite effect. Nor do I believe it owes all its powers to y perspiration it produces we have numerous Diaphoretics not less active than 137. Ipecac but very inferior to it in y treat of Dysent: Much however of its good affects may be ascribed to its operation on y surface of y Body & such an explanation comports best with y properties of y article & its known effects on y system. Two other modes of administering Ipecac in Dys. has lately been proposed by Clark who wrote on y nature & cure of y Dis. It is recommended in y shape of injection. ʒiii of y bruised Root boiled in a qt. of Water down to a pt. & this quantity to be given 3 times pr. dic. by this he observes y bowels are thourougherly evacuated & y tormend & tenesmus & other painful affections are completely & perfectly retieved. Of this mode of administering Ipecac I know nothing from experiance though I have always been taught to believe that a decoct. of y article under consideration is whole by inert all y writers of mat. Med. agree in this a/c of y Medicine. Much more confidance should in my opinion be reposed in y 2nd. mode of prescribing 138. to which I allude. Defeated in this attempts to cure Dysentery in y ordinary manner Mr. Playfair Surgeon in y British Establishment in India has according to his own statement used Ipecac with great advantage in doses of ʒss to ʒi combined with 30. 60 & even 80 gtt Laudanum Confining y patient for hours in a horizontal position, If y first dose was rejected a 2nd. was generally retained. This practice reported to be efficatious was confessed by y author to be adopted only on y onset of y Dis. for if y dis is so far advanced y stomach becomes so irritable as to reject y Med: at once. By Mr. English surgeon to y British troops in India y mode above described was sucessfully followed In my own practice I have never employed it but I entertain a very favorable opinon. It seems to me well calculated to evacuate y alim: Canal in y commencement & y Laud. Or Opii entering into y prescription to allay intestinal irritation which is undoubtedly y proximate Cause of Dysentary. Much also 139. has been said of Antimonials under y same circumstances they have been fairly tried by me & though in some cases & though in some cases they proved very sucessful I think they are not at all in point of efficacy to be compared to Ipecac. But many of y most respectable writers report very differently on y comparative[ly] value of there two remedies. It is exprestly stated by Sir. Geo. Bark. that y result of an extensive experiance with them both gives a decided preferance to y Antim: preparations. To y same point goes also y evidance of J. Pringle not to mention writers of no less authority whose evidance is so strongly relieved. Y Glass of Antimony was y preparation used by Pringle in y cure of Dysentary. Casus may occour in which on article may be better than another. It is thought right that each of these should be retained but it is by no means easy to day at what or in what they are to be employed. I am unable to discriminated & on y whole 140. I expect that when you encounter y Dysentary you will find y Ipecac so well to your views that you will not feel inclined to exchange it for y preparations of antim: As a measure or needful auxiliary to sweating great advantage may sometimes be derived in this stage from y application of wampth to y extream surface. All of you are acquainted with y benefit derived from fomentations applied to y stomach & bowels. They are particularly adapted or calculated to allay spasms & uneasiness which exist is on taking a profuse diaphoresis. It is unecessary for me to recapitulate y method of making such fomentations Not a little has been said of Linaments applied to y abdomen at this stage of Dys. These for y most part consists of into which Laudnum enters largely. But lately it has been alledged that much more advantage results from [deciding?] stimulating Lotions & among one of there is Spts. Turpentine. This I have no doubt would produce 141. very good effect. In Dysentary where there is much distention & pain in y Abdomen. As might be expected y W. Bath in Dys. as well as in other Bowel complaints is highly servisable. It acts precisely on y principle of fomentation though much more effectual. It is not a remedy adopted to general practice & may in a great majority of cases be dispensed with. It is however one of y recourses of our art which practitioners ought to keep in mind but which need only resort to in cases of Emergency. As regards Children y objections do not apply to these. It is easy to administer y remedy & we shall also perceive that in children it is infinitely more efficatious of late however a remedy has been proposed [preser] which goes to prescribe both y Warm Bath & Fomentations I allude to y bandage a flannel Roler applied around y trunk. 4 or 5 [gas?] of Flannel are to be wraped around y body from y hips to y arms. – As relates to y acute stage of 142 Dysentary. I have experiance whatever with y bandage. But long before I had seen y work in y Practice recommended I was in y habit of using it in Diarrhoea in y declining or advanced stage y Dysentary & more particularly in Cholera Inf antum. The fact is perfectly well known to a great number of my patients & also a great member of my Med. friends in this city. To y employment of this remedy I was led by analogical deduction. but more of this when I treat of Diarrhoea. You should never use y flannel Roler in y early stage to y exclusive of other remedies As yet I have said nothing of y use of Blisters they are however an important remedy & in many cases cannot be dispensed with they may be placed on y abdomen or on either extremities But here as in other cases it is most useful when applied nearest seat of y dis. We prefer y extremities sometimes on accout of y inconveniance experianced by y patient on going to stool with his abdomen 143 raw. & Inflamed by y vesicating application. But judging from what I have observed myself I answer that y degree of pain has been greatly aggravated Besides considerations of this kind should never deter us from y use of Blisters to y abdomen when y symptoms indicate y necessity of y remedy. – My own practice in this respect is previously to Evacuate y Bowels & to order for 2 copious V.S. & if I perceive no great salutary suppression of y dis. I then cover y whole surface of y abdomen with Blisters. – As in other case of Inflamation especially intestinal you will here also have reason to be delighted with y effect of this application. I enjoin it on you in y treat of Dysentary & especially when it presents a formidable aspect to keep your eye steadily fixed on y blister & never permit any false tenderness or delicacy towards your patients induce you to overlook so valuable a remedy. Under such circumstances you will have dificulty to encounter 144. generally against y remedy & unless you interpose y whole weight of your authority which your profession invests you. It will very often be applied too late or totally neglected. – I have now completed y general treat of Dysentary but one or 2 local affections attend y complaint which are so troublesome as to demand our particular attention. I allude more particularly to Tenesmus. & Tormina these are occasionally met with at every stage of y complaint. Many remedies have been suggested for y relief of these in y combination of which Opii enters largely. – As regards Tormina & especially when connected with foul & acrid accumulations in y bowels great advantage may be derived from y following ꝶ Ol: Recini ℥i G:Arabic ʒii Sachar. Alba ʒi Tinct. Opii 50 or 60 gtt. This is called y oleaginous mixture in this city a small tablespoon every 2 or 3 [or 4] hours. It remans only stomach infinitely better than y Ol alone & after a few doses have been taken it very much relieves 145. relieves y Symptoms. But even better than this is y mix there I mentioned to you while speaking of Cholera Infantum in [many] some of these cases much advantage is derived from y use of Julep y method of prescribing it I have already mentioned. Not of less utility under such circumstances is a combination of Ipecac & Opii in y proportion Ipecac igr to Opii gr. ¼. But in relation both to Tormina & Tenesmus Opii directly applied to y Rectum is often eminently beneficial. It may be used in y shape of an anodyne where there us much irritability & excoritation of y Rectum a pill of 3 or 4 grs may be introduced & all y beneficial results are decided which would or could be expected from y same article taken into y Stomach. It has y advantage also that where y patent is prejudiced so as to forbid injections it may be introduced without his knowledge. But of all y means I have ever employed with a view to 146. y relief if Tormina & Tenesmus Melted Butter free from rancidity & deprived of its salt is y best from ½ a pt to 1 pt. melted should be thrown up every hour or two y relief occasioned by it is inconceivably great. It is a fact worthy of notice that animal ols. are infinitely less irritable [to] & offensive to a delicate surface than those that are derived from. Veditables, Thus Lard & Butter may be applied with southing effect to an irritable surface which would be aggrevated with olive oil. Nothing as yet has been said of Mercury given with a view to salivate. By consulting writers more partic: East & W. Indies. it will be found that in y management of Dys. Murcury thus employed is almost exclusively confided in not only is it given in y largest possible doses internally but it is also externally employed in y shape of friction. y object of thus exhaling it profusely is to induce Salivate on as soon as possible, there can be little doubt of y superior 147. efficacy of this plan in y treat of Dysentary occouring in Tropical Climates. y Dis in y C & W. Indies is almost always associated with with a greater or less degree of Hepatic Derangement. But in our country it is Inflamatory nature & so rapid in its progress that long before y system could be brought under its impression Gangrene would take place. But in protracted & lingering cases of [Du?] especially where there is any tendancy to Typhus condition there cannot be y slightest doubt as to y usefulness of Mercury. – When however I can speak of this form of Meds. more partic as a [substitute?] for mercury y Nitric Acid has also been recommended. To conclude y consideration of Inflam: Sys. it only remains for me to indicate y diet proper to be observed in this case. Y Dis being an active Inflamation of y alimentary canal it is obvious that we should [not] use articles y least irritating & offensive to y stomach & then 148. in order that y power of Digestion may be exercised as little as possible it should be of y nature. Demulcent Drinks have been used by y common consent of practitioners & by y prejudices of y vulgar to y case before us y neatest & most agreeable of them is Barley Water or Rice Water. Mucillage G. Arabic. Flax seed Tea. Mucillage Slipry Elm Loaf Sugar Water. preparations arrow Root Sago & Tapioca etc. While they constitute y poper nourishment of y patient they are thought not to be without utility in the dis. itself. – Many practitioners prescribe them with a view of diluting y acrimonious fluid & sheathing y surface of y Stomach & Intestines against their irritating influence; but such are derived from old antiquated pathology. Y Idea of sheathing a liveing acting surface by mechanically spreading over it mucilaginous fluids is altogether abandoned. Diluant Drinks are beneficial in Dys. as articles of nourishment & when we grant this much we have 149. we have decided all that our enlightend understanding & sound med. reasoning & Experiance – will admit Typhus Dysentary. With these remarks we conclude y treatment of y common Inflammatory Dys. but in Crowded places or Ships Camps Hospitals & Jails a peculiar ous temperature of y atmosphere prevails. Dysentary in its & through all its subsequent stages is decidedly of a Typhus Character. It appears obvious that in all such circumstances y Dis requires a different treat: from that already detailed. It is right to pursue of same mode of treat. as in other low states of dis. adopting however more partic: to y symp: as in y genuine or real Typhus Fever y early use of Emetics is very beneficial & after moderate evacuation of y bowels y Cordial & Stimulating remedis as Opii Vol. Alkali & Wine Whey with y liberal application of Blisters constitute y 150 treat: most generally resorted to. But as I before mentioned whenever Dysentary anounces in its Origine or acquires with progress a Typhus condition it is safest at once to resort to mercury with a view to salivation. As yet I am of haveing y system completely under y impression with a spedy mitigation of all y symp: & an ultimate recovoury, They causes why we should not resort to mercury has already been stated. But y objection which I stated to preclude y med. in y active inflam: species of Dysentary does not apply to y low & lingering form of y dis. & as regards this cause a salivation may in many instances be effected. The Mercury should be employed internally externally & be supported by y active & diffusible Stim: In y advanced stage of y Dis y Nit: Acid posesses valuable properties. It is not at all suitable in y commencement of y dis but after y dis has advanced to its final Stage. Then it is that y [mercury] acid is of signal advantage. But I give y preferance to 151. Mercury. It is known to most of you that Dys. sometimes takes y type of Intim: fever. Cleghorn describes it of very common occourance in y Isle of Minorca & I have seen y same form of y Dis amoung y paupers in y alms House especially among those from Miasmatic Countries where y inhabitants are subject to Intim: fever now & then y case presents such a complication of symp: as to occasion no little difficulty in management. By Morton y contemporary & rival of Sydenham who first pointed out this form of [fever] Dys. it was recom: that while we pursue y usual practice we should employ Peruvian Bark in y A pyrexia. Exactly y same course was followed by Cleghorn & several others more acute practitioners notwithstanding however all this weight of authority in favour of y practice. I am strongly inclined to think in this case it is not correct or faiseble. Of y cases of Dys. associated with intim: fever. I have 152 some opportunity for y exhibition of Bark & if it had been given it would undoubtedly have proved mischievous. No article of y Mat. Med. proves more offensive to irritable & inflamed bowels than this Med. & so much so is y case that even when y Al. Canal is perfectly sound & healthy it very often so disagrees with y patient as to be precluded. 153 154 155 156. Pathology. Causes seats & signs of Dis Dis. although an evil leads to many advantages 1st. It induces us to study Anatomy & Physiology 2nd. To conciliate us to death. Pain is useful to point out y disd. part. absance of it is a bad sign in a disd Rib, frozen Bone or carious limb. – y Causes of disease are y Remote, Exciting & Proximate likewise Predisposing or Remote Proximate Predisposing & Exciting. – y Remote are Contagion & Miasmata. y Predisposing is Debility this is either natural or acquired. If natural it depends on what was called Temperament. – Predisposition there is 1st. Arterial. disposing to Hemorrage. Pulmonary Consumption 2nd. Phrenic. disposing to Delirium & Mania 3rd. Cephalic. disposing to Headache. Apoplexy Epilepsy &c 4th. Alimentary. disposing to Dysentary. Colic Diarrhoea. 157 Pathology. 5th. Cutaneous. Disposing to Small Pox. 6th. Muscular. ” to Tetanus as great irritability but nosens ability 7th. Nervous. – disposing to Hyphochondrase. 8th. Lymphatic. ” to Dropsy. 9th. Hepatic. ” to Diabetes. Artinal Predisposition prevails in spring. Alamentary in Summer & Fall. Cutaneous in Winter. – A dis always attacks y weakest part of y system a part however may become callous to a dis by haveing its excitability wasted so that stimuli cannot throw it into Morbid action. Dis in thus state is called Disorder y effects are viz 1st. Torpor. absance of Irritability. 2nd. Stupor. absance of sensibility. 3rd. absance of both instances of Disorder as Chronic Ulcers. Calculous Obstructions. Schirrus these induce death & hence become subjects of Medium Acquired Debility is of two kinds from 158 Actions or Obstructions, when it proceeds from this last if an irritant be applied – it first elevates y excitement then depresses it. In y former case if y stimulus remains depressed it is induced y debility of both causes & is y same except in y last y excitability is accumulated & readily thrown into morbid action. In Debility from action when y stimulus which produces it is withdrawn y excitability is accumulated, hence after great fatigue we should not sit down but gradually keep moveing to carry off y redundant excitability – hence y they lead horses who race round y course to prevent stifness – Rheumatism abstracted from important parts in y bowels Signs of Dis by y Pulse. These are 1st Frequency & Quickness. These are not necessarily connected y pulse may be very Frequent & not very Quick or vice versa as in Yellow Fever & y last stage of other fevers. – By Frequency is ment [y number] y number of strokes performed in a given time. – 159 Pathology. Signs of Dis by A/ Pulse Quickness is y time in which y stroke is performed. – y pulse [differs] varies in fevers & other acute dis. in y first stage from 60 to 88 or 180 & sometimes to 200. In a minute it falls in some cases to 40-30-20 & sometimes to 9. – y Frequency & Quickness of y pulse seems to depend on a morbid irritability in y arterial system. y Morbid slowness depends on 3 causes 1st. Pressure on y Brain. – 2nd. Spasm of y Heart 3rd. defect of irritability in y arteries y pulse varies from health in regularity & force this is of much more importance than its duration in frequency & fulness. It sometimes Intermitts. Somet: imparts a sensation to y fingers resembling a shattered Quite. We are now to [examine] consider y different states of y pulse in Fever. – by Depressed Pulse. This state of pulse is caused by stimuli acting so violantly as to depress y system be low y point of reaction or by pressure on some great vessel. It is frequently 160 Signs of Dis by y Pulse. preternaturally quick [crossed out] often slow & sometimes scarcely perceptable often descends a low as 40. 30. 20 & is sometimes so depressed that it is almost imperceptate. It is raised by V.S. It is sometimes preternatural quick slow & attended with intermission & sometimes it is natural. It occours in Plague Y: Fever Malignant & Small Pox & in Pleuracy. It is either general or partial [y latter] occouring in y extremities y former & y latter [occouring in y extremities] occasioned by stimuli depressing y strength below y healthy state. It resembles a low or Typhus pulse & may be distinguished from it 1st. By occouring in y commencement of acute diseases & in y paroxisms of such dis. as are periodical 2nd.. by imparting a sense of tention along y fingers when long & attentively felt. 3rd.. By occouring in morbid affections of y Brain. Heart. Stomach & Bowels more frequently than dis of other parts of y Body. & in Apoplexy. 4th. By occouring rising after V.S. or purging takeing off y suffocated excitement 161 Signs of Dis by y Pulse 5th. By its being attended with preternatural slowness & intermission. Thus y pulse may be compared to a tree bent by y Wind & arising to its proper state after y storm has blown over Whilst y Typhus resembling a Free shattered by lightning which cannot be raised by y hand of art 2nd y Locked Pulse [or Sulkey] This is small quick time & distinct pulse which is imparts to y fingers a sensation similar to that produced by fretting a piece of Cat. gut. tense from whence I have named it. Cat gut Pulse occouring in Malignant fever. – 3rd. y Cynothus Fortis. This is y reverse of y 2 former a full round vigorous frequent & quick pulse without hardness which occours in y highest grade of Bilious Fever in affections of Brain in Pneumonia Notha & congestion of Brain. Exercise produces a pulse somewhat like this. – 162 Signs of Dis by y Pulse 4th. y Synocha or Inflam: Pulse. – Being full, quick, frequent & tense & not round & is known by heat & thirst. This pulse exists sometimes in y Plague. Y. Fever & in common Inflam: but more frequent in Pneumonic affections in Rheumatism & Arthrisis. – 5th.. y Synoch [ous] Pulse A quick, frequent & immoderately tense but a small pulse imparting a sensation to y finger similar to quill & occours in Chronic Rheumatism. Gout & Intim. Fever & in 2nd. Stage of other fevers It is y Synocha on a concracted scale from which it may be distinguished by y column of y Artery. – 6th. y Synochous Mitis Pulse full round & soft. 7th. Synochoid Pulse. This is alternately soft & & may be placed between Synocha & Synochous it occours in y passage of fevers from y low to y Inflam. 163. Signs of Dis by Pulse. State & Visa Versa according to Dr. Butler it imparts a sensation to y fingers like a quill that has been trodden under foot 8th. Typhoid Pulse. – Small frequent & less tense pulse than full it is a compound of synocha & y low chronic states of fever & occours in Hectic & Purperal fever, & in Scatitana. – 9th y Typhus Pulse. This is a weak, small. frequent but full or tense pulse. It differs from y depressed pulse 1st. In tention. 2nd. y arteries in y depressed state still retain their irritability & y pulse rises after V.S. It occours on y low chronic state of fever or in y first stage of some malignant fevers. Cordials are indicated in y close of Inflam: [fever] Diseases when depleting remedies have been used in y 1st stage. It is here V.S. is forbidden & stimuli to be used. 164 Signs of Dis by Pulse. 10th y Hectic Pulse Is quick. frequent & often full & very soft, it is occasionally Synochoid, Typhoid & Typhus & occours in Chronic Fevers. Pthisis Pulmonalis, also Chronic Gout & from Lues Veneri & Scrophula. – 11th. y Hobbling Pulse Is unequal fluctuating, tense quick & very frequent. It may be known from y irregularity of its pulsations. It may be divided thus 1.2.3 [quick] slow [slow] strokes sucseeding & quick one. 2 or 3 [slow] quick stroke sucseeding a slow one. – 12th. y Serrated Pulse Strikes y fingers like a saw one part elevated above y other. – 13th. y Vermicular Pulse. – Small frequent & resembling y motion of a Worm 14th. y Creeping Pulse Weak & small it occours in y last stage of Dis. 15th. y Apparantly Natural Pulse. – A pulse perfectly natural in Violant Fevers 165. Signs of Dis by y Pulse. ~ is one of y worst symptom. It occours in y most Malignant in Y. Fever & can only be distinguished from y Pulse of Health but by y other symp. of Dis. Great danger is to be apprehended by it – Scarsely any of these are always present they are therefore combined 1st. in double proportion as Full & Weak, Full & Frequent Depressed & Weak. Slow & Intermitt: 2nd. In a three fold state as Full Strong Quick & frequent at y same times 16th, a full, bounding, slow, & moderately tense pulse as in Palsy Apoplexy or Dropsy it is especially full & slow in y affected side as in Hemiplegia. Dr. Rush examined y pulse of a parylitic patient whose artery beat on y affected side 50 whil on y other it beat from 80. to 90. – 17th – A weak & low pulse without irregularity occours in debility without fear or is [distinguished?] from y weak & low pulse of malignant fevers 166. by its occouring in y last Stage of Dis y usual pulse of y low Hypochondria state of y system 18th.. There is sometimes a total Absance of. Pulse in dis which somet. occour in violant affections of y Stomach & bowels. It lasts sometimes for hours. Dr. Rush kew a lady to be without pulse 36 hours in consequence of eating some Oysters she has since perfectly recovoured. – 19th. Gaseous State of y Pulse soft full & round 20th. Aneurismatic Pulse is full & tense & imparts to y fingers a disagreable jarring sensation which when once felt can never be forgotten It occours only in cases of aneurisms. – The pulse is much influanced by y strength of y animal in a Pigeon 100 Ox 30 to 38. – 167. 1 Intermittant Fever. Wine. – John Hunter’s remarks on use Wine in Remitt: and Intimitt: as they occoured in Jamaca. With regard to y quantity to be used it is dificult to give precise directions I have generally found upon careful examination that y quantity which has the best effects is less than has generally been given. I have rarely given more than a Pint in 24 hours a larger quantity did more hurt than good y strength quantity & quality of Cordials must bear direct proportion to y strength of y patient. Opium The above applies to opii in y same States of y system I think that O. in the last stage combined with Ipecac or antimony will be more safely given than by itself where there is tendancy to the continued form. – In those cases of Intim: in which the cold stage was preceeded and accompanied with a violant cough I have used O: with y best success Case W.B. a Man of 50 living in Hampden plains had I. of this Kind. The cough was very frequent an Iritating particularly so previous & during y cold stage He tried y Bark & most of y Veg & Min tonicts and among other things arsenic. also Depletion. V.S. Emet: Cathartic Intimitt Fever Epispast: His cough & fever were finally removed by a pill composed of Opii gri Calomel gr.ss repeated every 8 hours. In my opinion this was a case of I: from irritation which prehaps may have depended upon Visceral obstruction [see page 7.5. for more cases]. – Intimittants threatning to run into Typhus. Opii should be combined with Bark, Serpentarid. Vol. Alcali & Camphor. In such cases a torpid state of y bowels should be obviated. In cases of this Kind it will be very difficult to restore y system to healthy action when y Liver Stomach & Intestines do not perform their function These are to be excited to action by gentle Laxatives such as soap. Rheii. Soluble Tartar & by external irritation to y Bowels. – If these parts perform their functions they will have great influance by association of action to bring the other parts of the system to healthy action. In almost all cases of Intim: it will be a safe and efficatious practice to give opii in y very commencement or at y time when y cold stage is expected O: may be given in pills or Laudnum combined with aromatic Teas and Dilunts & other means of producing perspiration the 2 Intimitt Fever temperature & y action of y Body should be equalized. – As a general Rule it will be necessary all cases of Intim to deplete y system before giving Stimulent Tonics. An Emet: Cath: & sometimes V.S. will be necessary. Exceptions to this rule are rare. – In all cases you must be governed by y [Cases] state of y system & y laws of yt. part of the system which is the principle seat of y dis: or the point to which it determins Antimony Ipecac Neutral Salts. Em: Tart. Camph: & Ammonia qualify y action of O: & operate by determining its action to y skin. If O. excites uniform perspiration there is no danger of congestion or derangement of y functions When it produces partial perspiration of y Head & Breast it only coincides with & aggrevates the morbid action of y dis: Dovers Powders are a very safe & useful composition of Opii ꝶ Ipecac & Opii ā ʒi Sulphate Potash ℥i Dose fm. 5 to 15 grs. In cases when diuretic effects are wished from the powder. Nitre may be substituted in y place of Vit: Tartar. – In my practice I have usually made y powder of Em: Tartar instead of Vit: Tartar & added ʒii Camphor with y Intimitt: Fever alteration thus ꝶ Ives Dovers Powders Ipecac & Opii - ʒi Camphor ʒii Em. Tartar ℥i. Acids combined with Stimulating Diaphoretics have been very useful in ourt fevers during y present diathesis which prevailed since y year 1805 with occasional variations. – Hyoceamus Niger. Dr. Smith of So. Carolina used y Ext with sucess he gave at y same time Sul. Zinc. – Atropa Belladona. In obstinate Intim: Bitter Almons. Their efficacy was established Barron Stork who used them very largely & sucessfully in this dis The Laurus no doubt has many Med: Virtues which doubtless will be brought by future experiments y Narcotic principle is intimately connected with Prusic acid. – Amica Montana. recommended as a substitute for Bark Spigelia Marylandica in Tinct: has been used. – Iron. a good auxiliary to y treat: in feble & lax habits yet it ought to be used with great caution in cases threatening congestion Liver & Spleen 3 Intimitt: Fever Copper in Intim: & Remit: but has now given place to Tonic Solution. Zinc in ordinary Intim. without cough or any peculiar irritation in y system or chronic Vis: Obstruction. I give y White Vitriol & Myrrh āā gri in a pill. Giving fm 1 to 6 pills in a day during y Intermission previous to giving y pills y Stom: & Bowels should be evacuated. It is y remedy on which I most depend in I: of an ordinary type. It very rarely offends y stomach. I have given as much as 4 grs W. Vitriol in pills at a dose without producing nausea It excites appetite, promotes digestion & produces vigorous action of y system generally. No debility follows y use of this remedy though it has been continued for Mos: [see page 236 Vol 1 for case West part York State] Arsenic may produce the same effect as a ligature on y leg & opposite arm at y commencement of y dis. y A: may determine y action to y minute vessels & prevent y engorgement of y Heart & Large vessels which takes place in y cold stage. This is infered fm: y fact that Arsenic produces Œdema. When it produces sensible  Intimitt Fevers though not violant effects they are analogous to y combined action of Tart: Antimony & Calomel. – In Intermitts. it is safe & efficatious remedy. I have not in my practice seen any ill consequences follow y use of Arsenite of Potash. In its effects it is not inferior to Bark. It is [cross out] adapted to y same cases which indicate Bark & indeed will often cure cases in which y Bark has been thorougherly tried & failed It is more particularly adapted than y Bark to those cases in which there us some excess of action. – Its action in such cases may be like that of Mercury reducing y system to that state in which Bark is adapted. I should not be administered in those cases which have a tendancy to Typhus & require Stimulating Tonics. It is not so well adapted to In: of long standing. Here Nutral Salts with Bark & somet: Opii & Calomel must be given. Camphor combined with Bark. Cuprum has frequently ben given to children in Intim: & Remitt: but has given place to Tonic Solution 4 Intimitt: Fever Bark. Tho a valuable remedy in this Dis still it has no specific powers ie it will not cure in every case. has an action peculiar to itself. In ordinary cases especially in cold climates y administration of B should be preceeded by evacuation of y bowels or. Stom or both as y symp. may require & frequently V.S. is necessary previous to y B. best mode to give is in substance if stom. will not bear it give in Decoct Tinct. Cold Infus. Dose it may be given 10 grs to ʒi repeated every 2 hours in y Intermission. Not to be given in our climate in y in y Hot stage. /given in this stage in hot Climes) It is y practice to give y B imediately after evacuating first passages. Dropsy. Jaundice & other Dis have followed y use of B. in I. In such cases there probably was not evacuations enough made. In Penn. hospital I saw. an Anasarca fm. Injudicious use of B cured by V.S. In I. with+ Visceral Congestion y B must be combined with Rheii or its action qualifyed by frequent small doses of Neutral Salts. as Sol. Tartar &c +(See Linac on Fever) [Remittant Fever]. – Intimittant [Porter. – is more particularly useful which occour in Intu August & September when y Stomach is very irritable with general prostration of strength. It is a very grateful stimulant to y stomach on account of y fixed air which it contains, corrects morbid secretions of y Stom & is very nutritions to convalesants. – It is admisable in all fevers affecting y Stom: & Bowels after y first Stage & relieves]. – Y Nutral Salts even if they do not operate as bath yet they prevent y system fm rising to y Inflam. point Those cases in which there was very little perspiration y bath has not suceeded well unless given with Nutral Salts or Rheii. It is a common practice to in case y dose just before y expected paroxism It certainly at this time has more effect yet it is without danger. A Tertian has somet. put on y form of Apoplexy (not seen much of this dis.) I have not suceeded well in treating Intim With Cough with y B. but usually with Calomel. Opii & somet: Epispas are necessary. Y several preparations of B may be 5 used together. Angustura Bark has been recom. in powder in Intermission dose 20 grs every 3 or 4 hours I have used as above directed in this dis somet. with complete sucess but it is rare that y Stom: will bear such large doses. Cascarilla useful in In. which terminate in Typhus. – Snake Root partic. useful in those In. whose parox. terminates with little or no perspiration & y skin hot & dry in y Intermission. combined with Bark. S.R. is a very valuable addition to y B. in treat. of In. Y. Comp. Tinct Bark is taken in ℥ss does in y cure of In. Some phys. Give an Emetic of Tart. Antim in a strong decoct. of Serpent. & give a cath of Nutral Salt in y same decoct. in this mode they operate very kindly & leave y Stom. & Bowl in a better State. – Cornus Florida. highly recom. has cured where bark has failed dose powder ʒss to ʒi Intermittant Fever sucessfully used in Middle & Western states Y most useful preparation is y Extract dos 5 to 10 grs. Astringents are servisable when combined with aromatics. Those Veg. substances are best adapted to I. which contain y Bitter. Astring & Aromatic principle. Ast. are more partic indicat. in Ints in constitutions of lax fiber (leucophley. temp.) Galls. sucseed best comb. with Aromat. & Bitters sometimes G. have cured I. which have not yialded to Bark. I presume G. succeeded best where then general relaxation in y system. Int. in there different stages & different forms often require as different as Synocha & Typhus. - 6 Typhus. Alcohol. is used diluted & is a good remedy to increase y arterial action. It may be given fm: ℥ss to ℥i every hour. Old Spirits sets kindly on y stomach in this dis. when Wine & Porter will not. – Wine is useful after y evacuations of first passages to keep up an uniform excitement Some Physians give a bottle each day through y whole course of y dis. This mode of Practice succeeds very well in those cases where there is no considerable local [derangement] determination & y secretions & excretions are not much interrupted. – In 1805 & 6 wine was very much used in a fever which prevailed in this Town. I suceded best at y time of a crisis or when some symptoms indicated a change in y [symptoms] system or when y dis had spent itself. In these cases I gave fm 2 to 3 pts of the best white wine in 24 hours & thus producing a favourable crisis. But if y strength or excitability had been worn out by this article would not produce that effect. With Wine it is common to combine Bark & Opii. – Aqua Ammonia is a good addition to y Wine its use in T:F. is indicated by y same symptoms & has y advantage of correcting y stomach & preventing y Wine fm: becoming acid. Porter when y patient is Tympanitic I think it has increased that unpleasant symptom. – Ether. Diluted given in T.F. to keep up y action of y system & to produce perspiration. In Flatulance & in Tympanitic state of y Bowels in T. In y last stages of T. E is given mixd with wine or diluted alkahol & it adds much to y virtues of these articles. E. qualifies Wine & Alkahol as aromatics qualified Tonics. It stimulates y skin by external application. If confined to y part it increases heat if it evaporates diminishes heat Camphor – is advantageously combined with Lime juice Vinegar and other acids in effervessing mixtures It has been a very useful article in y treatment of y dis: which have occoured since y year 1805 This Grade of dis. are very much like those described by Sir John Pringle. The Dis has been more or less Typhus in its progress in some cases Typhoid in 7 others Synocus in its commencement partaking more or less of y Tertian Type with a determination to y viscera of y abdomen like an intermittant affecting y secretions sometimes causing profuse secretions at others interupting all secretions accompanied very generally by Tympanitic state of y bowels attended with local critical determinations with Inflamation & supuration of y part at y same time y state of y system Typhus When this local determination fixed on y brain Heart & Lungs it invariably produces death unless y action was overcome or determined to some other part less essential to life. Prehaps this Fever might be called y Intestinal State of Fever In this fever Camph: has been of great servise combined with opii in y form of Dovers Powders or Diaphoretic: It appears to equalize y action of y opii by determining to y surface & preventing that dryness of y tongue which sometimes follows y use of Opii. It has been useful in cases of this Fever attended with Tympanites both by Injection and Camphorated Liniment applied to y Bowels Typhus Fever. Opium. should not be administered in Typhoid Fevers with Visceral congestion or obstruction or when there is a determination to y head & local supuration threatened although y diathesis of y system is Typhus Such a fatal determination is produced by a dry skin & tongue deafness & disterbance in y intellectual faculties y Rules which Sir John Pringle gave concerning y use of Wine in Goal Fevers & y direction of Lenac on y use of Bark in Intim: & Remitt: will apply to y use of Opii in such states of y system. – Castor. – In T.F of the mild kind combined with valerian Snake Root or Orange Peel with advantage Valerian. – is used. – Phosphorised Ether viz ꝶ 3grs Phosporus divided into small pieces & put into ℥i Sulph. Ether in a week y med: will be fit to use. If any [Ether] Phos: remains at y button y Ether should be carfully strained off dose 3 to 12 gtts in any convenient vehicle has been given in T F & in other forms of Fever in which y dis action has worn out the 8 excitability of y system in such cases it has sometimes roused the patient in y very article of Death & been the means of saving them – In Typhus in y low state where there was no particular determination it has been given & no injury followed. – Phosphoric Acid has been given for y same indicatins as J: Ether and when it has been used in y last stage if T: it has often Excited a desire for Animal food. – Cantharides in T accompanied with very frequent pulse it diminishes its frequency. When y system becomes over charged with cantharides y stools became mucous & Bloody with Tenesmus & extreme pain y urine suppressed or in Small quantities and Bloody. When large doses have excited Inflam: y symp: are similar to those of Inflam. Dysentary. – (see page 212 Ives Lectures Vol 1) Chapman continued at back (reverse direction) Extracts from a Treatise on Cholera Asphyxia or Epidemic Cholera as it appeared in Asia and more recently in Europe. with practical remarks on y dis. in Europe an appendix of cases & y reports and regulations of the Boards of Health of London and Edinburgh by George Hamilton Bell Fellow of the Royal College of Surgeons Edin: late residency sugeon Janjore and joint medical secretary to the Edinburgh Board of Health. ~ Second Edition 1832 9 Cholera Asphyxia. In describing this dis. it may be useful to attend to what may be cal’d 4 Stages. 1st. The invasion of Cholera is so insidious that the individual attacked may be quite unconcious of the presence of the 1s Stage of it. Very often it is only to be detected by those well acquainted with y dis. Not only in this stage but throughout the whole course of the dis the appearance of the countenance is one of y most highly characteristic symptoms. An intimate find may observe the the person has an expression of anxiety. That his complexion is unnaturally earthy & his eyes seem sunk in his head. In reply to inquiries he will deny that he is unwell he may say he is a little deaf & if minutely questioned may admit that he has an indescribable sensation of being out of Order that he has oppression at y chest & is unaccountably depressed & listless. he may have no nausea but has Tormina of the bowels & prehaps an uncomfortable sensation of heat at the pit of y Stomach His pulse is quick & weak (I have seen one case in which it had the febrile throb.) the hands & feet feel cold. the nails are blue & he has had one or more unnatural discharges. The first of these is generally characteristic. there is a sudden call, & the whole intestines seem to be at once emptied followed by a feeling of weakness 2d Stage Cholera is more easily recognized: The pathognomic character of the countenance to those who have seen the dis is no longer doubtful. The eyes are sunk in the head lips are blue, there is a ghastly look about the mouth & the whole features are shrunk. The patient does not now deny being unwell he acknowledges haveing passed some [pecution?] stools & probably has had vomiting these have been followed by great prostration of strength 10 there is tinnitus aurium often slight deafness & Vertigo. The pulse is more decidedly affected it is weak & thready: Skin is cold there is much thirst & a burning pain at the pit of the stomach but y tongue is not dry it is moist, white & cold. The fluid passed from the stomach & bowels is like water in which grain has been boiled with pee as more or less numerous of opaque white or yellowish coagulated matter floating in it. The manner in which the discharge takes place is characteristic. The desire is sudden unaccompanied by griping or nausea & y the stomach & bowels are emptied at once & with some violence: the gastric & intestinal evacuations are nearly similar. In their appearance & nature 3 Stage In this stage the sinking of the countenance is still the most prominently characteristic symptom. The eyes Surrounded by a dark circle are completely sunk in their sockets. the whole countenance is collapsed y skin is livid & the expression is so altered that the patients most intimate friends cannot recognize him. The surface is now generally covered with cold sweat y nails are pearly blue & y skin of y hands & feet are corrugated as if they had been long stupid in water the sensibility of the whole surface is deficient but it is by no means uncommon for patients to complain of a burning heat in there cold skin. Vesicatories do not act even boiling water does not raise a blister. If the case be attended with spasms the suffering of y patient is much aggravated & is sometimes excruciating The spasms commence in the hands and feet like cramp they stretch up the limbs to the trunk which however they do not always reach. In some cases again 11 the muscles of y abdomen are principally affected & they are drawn towards the spine during y whole course of y dis. These spasms may have commenced early in y dis being on some occasion y very first symptom. The discharges fm. y Stomach & bowels at this stage are very irregular in some cases they are still very frequent in others after one or two evacuations they wholly cease The pulse at y wrist if it have not ceased is scarcely perceptible & y heart beats feebly. When y spasms are severe they frequently, even though y pulse be still quite distinct stop it arising the paroxysms y same effect is produced by excessive vomiting. The breathing is slow & oppressed, this also sometimes occours early in y dis. The voice is low & but few words can be spoken without expiration. The exhaled breath is cold & though y heat of y body is many degrees below the standard y patient throws off the bed clothes & enterals the bye standers to allow him cold dis & cold water. Hiccup is not uncommon & is rather a favourable than an unfavourable symptom. – 4th Stage. In y last stage the intestinal evacuations have most likely ceased; y eyes completely sunk in there orbits are glazed & flaccid turned upwards & half covered with the eyelids. Y spasms are now commonly at an end y extremities indeed y whole body is that of a corpse & the impression communicated by y skin has been well. listened to “damp hide”. Every artery has ceased to pulsate & y action of y heart if perceptible is a mere flutter. y whole body is bathed in a Cold & Clammy sweat. It is painful to witness y oppression of respiration & jactitation of y sufferer 12 The dying man can still be roused but when undisturbed he generally appears in in a state approaching to stupor: & though prehaps in a humor which might almost be termed sulkas is in most cases coherent to the last. These symptoms are y immediate forerunners of death. If blood be drawn during the progress of y dis. it is found in y Outset dark coloured as y cases advances y blood becomes thick there is a deficiency of serum it coagulates quickly & does not assume y buffy coat. In y latter stages of y dis y current in y veins has stopped & the blood is so gramous that it can scarcely be forced out in y smallest quantity through a large orifice. The whole course of these stages generally does not exceed 16 hours & unluckily y practitioner is seldom called in untill the first & part of the 2d stage has passed The period consumed by each of y above artificial divisions varies in every case. I have seen instances in which death ensued in less than 4 hours after y commencement of y dis. & others in which its latter stage with y pulse quite imperceptible had already lasted a whole day. The condition of y mind is remarkably collected during y whole progress of terible illness for tho. Patients, as y malady advances are unwilling to be disturbed with questions this appears rather to result from y want of physical energy than from any intellectual failure. Indeed as the fatal event approaches y only wish a patient seems to have is to be allowed cold water & to be left to die in peace It has been well said that a patient in y last stages of Cholera may be called a “living Corpse.” 13 It curious phenomenon has been several times observed. After a patient has been some time to all appearances dead & when y attendance even dressing the corpse, Spasmodic twitches have taken place in y limbs having in some instances even extended to y muscles of y body & general spasmodic contractions have supervened. Cases often occour in which one or more of y above detailed symptoms do not appear There may be no spasms y Vomiting & purging may early cease or there may have been only one large alvine discharge, follow’d by a mortal collapse y patient seeming to be at once struck with death, and tho’ on [y] the very first appearance of y dis. he has walked to y Surgeon his pulse is found to be gone, his heart has ceased to beat blood can be got only in drops from the veins he lays down his head & dies without a complaint. These anomalies are not confined to individuals instances but are found to occour as M. Scott well expresses it in “local epidemic visitations.” Thus he says “when the dis appears epidemically in a town or district or in y lines of a corps or y camp of a marching Regiment, it may on one occasion be [distinguished?] throughout by y absence of vomiting & y prevalence of purging, & on another by y excess of vomiting & tho’ more rarely by y absence of purging. Spasm may be generally present in one instance of invasion, in another it may not be distinguishable. I was on one occasion called upon to send assistance to a district in which y dis. was thus described “It commences by attacking y sufferer with an agonizing heat in y stomach vomiting & purging & lock-jaw. death ensues in 2 hours & often more rapidly it bids defiance to every remedy” 14 But in all cases in which y dis has established itself, there are y collapsed Countenance blue lips & nails, shrunken fingers. The total failure if y usual secretions, deficient animal heat, suspension of y pulse, & remora in the venous circulation. Treatment of Cholera asphyxia The following may be considered the indications of Cure. 1st. To relieve y oppressed circulation 2d. To stimulate the system 3d To restore y heat of y body 4th To guard against local congestion 5th To keep down reaction 6th. To produce a healthy condition of the alamentary secretions. 1 Blood letting in cholera is obviously in a great degree mechanical. The power of circulation has been injured it is no longer capable of duly distributing y mass of blood in y system & y cessation of y usual secretion the deficient pulmonary function & the effect of y discharges have rendered y blood wholely unfit for vital purposes. By V.S. in such [cases] circumstances we relieve the gorged vessels & thus enable the 15 weakened energies of y circulating power to act on y distendened organs of circulations & to restore the current of y blood. The Lungs recover their function pure blood is thrown into y left heart y arteries are again filled with with a fluid fit to support life. this it may be supposed reacts on y sympathetic system & by its energies are completely restored. In this way only can the of V.S. in cholera be explained. No other method will account for y almost instantaneous recovery which so often follows V.S. in such a condition of y system as has been described a recovery more immediate than that which follows y removal of mechanical pressure fm. y brain. And I should say very confidently that in no case in which it is possible to persevere in V.S. untill Blood of a healthy colour & consistance flows freely fm. the vein will y patient die fm. collapse. in commencing the treatment of cholera then no time is to be lost in endeavouring to bleed y patient. He should be laid in a warm bed & y great object being to get Blood to flow it is important that the operation should be performed with as little fatigue to him as possible. He should be kept in a recumbent posture and as answering y two next indications will be y means of forwarding this important object immediate recourse should be had to stimulants – applying artificial heat using frictions &c. The rule as to y extent to which y removal of blood should be carried is very simple it has no reference to the prostration of strength or to the constitutional stamina of y patient. The power [to give motion] [often] of circulation is unable to give motion to y volume of 16 blood which has accumulated in the venous system & which has been rendered by y cessation of secretion, y diminish function of y Lungs & y disordered actions incapable of supporting life & blood is let until it appears that is fatal a condition of y vital fluid has been changed. In other words the blood ought to be allow’d to flow until the natural current in the veins has been restored & there is evidence in the improved colour of y Blood that the Lungs have recovered their function. If opening one vein be not sufficient let others be tried & until y dis. yealds the practitioner must persevere in his endeavours to accomplish this great object. In y outset prehaps only a few drops of tar like blood can be obtained by y use of internal & external stimulants some good appears to be done & the pulse rises: - renew’d attempts should immediately be made to remove blood nor should these be desisted form while life remains. – In addition to the lancet leeches or cupping glasses should be tried. It is be remembered that added to y general vinos congestion there may be a tendancy to morbid plethora in particular organs. There is sometimes confusion of head & more obtuseness of y intellectual faculties than usual. This is not only a bad symptom with reference to y [patient] present condition of y patient but may be attended by fatal effects after y primary dis is relieved. In such cases I should bleed fm y Jugular vein & as many leeches as well adhere should be applied to y temples & throat The abdomen is in every case y principle seat of congestion. Leeches ought therefore to be applied to y belly also & partic. over y seat of y Liver care being taken to avoid as much as possible exposing y patients 17 body to cold. It is unfortunate however that like blisters leeches during extreme collapse are quite useless. – 2nd. To stimulate y system. The classes as the second indication of y treatment of Cholera. Yet in their application V.S. & attempts to stimulate the system, ought to go hand in hand. The object is to restore the suspended circulation. Blood is let in order to diminish y quantity of Blood to be acted upon & stimuli are administered in order to excite the source of power. Indeed it is often impossible to render V.S. efficient until after stimulants have produced some effect. It is not merely by internal remedies that this indication is to be an severed. Frictions over y whole surface, rubefacients and sinapisms to different parts of the body are in truth important portions of y stimulating remedies. The internal remedies which have been resorted too with must confidence & sucess in y Treatment of Cholera are Opium. Ether: Camphor. Ammonia pepermint. Strogue-amer, spirits and Calomel. The general mistake in y treatment of Cholera has been y administering of too large doses of those medicine which have obtained a high character among practitioners. The large doses of Calomel & Opium which many are in y habit of prescribing are especially pernicious. This practice seems to arise from y nature of y dis being misunderstood. A patient is suffering from violent Vomiting & purging & excruciating spasms & indication appears to be to allay these high actions. Hence Calomel & opii are prescribed in quantities amounting to what are considered sedative doses. There can be little doubt that more injury than benefit. has resulted from this practice for should y dis be overcome & y medicins not 18 have been evacuated 10 or 20 grs Opii & 60 or 100 grs Calomel must act as poison on the restored functions. The object being there to stimulate y system Meds. should be prescribed in such quantities as are known to act as stimuli. In fever a scruple of Calomel no doubt will very often allay as once y irritation of y stomach & experiments seem to prove that in large doses this Med. acts sedatively on y gastro:-enteric mucous membrane. It has been ascertained by experiance that most narcotic in large doses act as sedatives very soon after being administered; while it is unquestionable that y same Med. in small quantities, excite y circulation and are consequently to be regarded as stimulants. Early in my practice in Cholera I found reason to believe that while there was positive good to be done by small quantities of these Meds. frequently repeated their good effects were very questionable in y powerful doses which were commonly prescribed. – In y treatment of y dis. this is a point of so much importance particlularly as regards opium that I think it necessary to add a few words on y subject Opii is generally administered in Cholera as an antispasmodic & if this Med. does not act as a narcotic so long as it has Spasm to allay, it has been thought that y largest doses of Opium are safe during y collapse Stage of Cholera. Now the spasms of Cholera are not Tetanic nor of cerebral origin, but evidently result from y condition of y circulation acting on y extreme branches of y nerves. & these spasms are immediately removed by y restoration of y balance of the circulation. When large doses of Opii are administered to a patient labouring under Tetanus the functions of y stomach being unimpaired y drug is at once digested & absorbed, but as y Cerebral nerves are y seat of y disease y narcotic effects of y med. appear to be 19 rendered inert by y state of y nervous system or are expended in allaying its irritability. In Cholera however thou seems to be no reason for believing that y nervous system of y Brain or spinal marrow is directly in a morbid condition. Opium therefore y not indicated as in Tetanus but even if it were so y function of y stomach being unquestionably suspended meds. are only [partly] partially digested & absorbed. Hence it happens that when y stomach no longer rejects what is swallow’d repeated doses of Opii remain in it little acted upon & when that organ recovers its function if Opii has been largely administered there remains a dangerous if not a poisonous quantity of y narcotic to be digested & absorbed. There being now no spasms to nutralize its effect the Consequence is that reaction is interupted the brain instead of being able to assist y other powers of y system in reestablishing health has its functions interfered with, Congestion takes place in that important organ & death ensues either from this cause or from rapid Typhus. It is therefore one of y most important points in y treatment of Cholera to avoid all over doses of Meds. & with regard to Opii or Laudanum in particular extreme caution ought to be used in administering it or in recommending it to y public, for both in Asia & in Europe the most fatal effects have followed over doses of these meds. – The condition of y stomach in cholera generally renders y exhibition of Meds. in a liquid [state] shape in y outset of y treatment wholely useless as they are immediately rejected by y stomach or bowels. It is therefore advisable at least while y vomiting to administer y remedies in form of pill. The following ꝶ which was not only given with great benefit to patients (adults) immediately on my being called to them, but which was distributed 20 in large quantities for y use of y sick wherever cholera was reported to exist in y district over which my professional charge extended. ꝶ Calomel grs iij} Camphor gr ij} Opium gr. ss} Mis. ft. Pil} (one of these was given every ½ hour & sometimes oftener, while y urgent symptoms continued. The nature assistant had orders not to persevere in this practice longer than 3 hours if they had reason to believe that all pills were retained.) Such pills should be washed down with a small quantity of Brandy & Water & as soon as y stomach seems quieted y following draught should be administered ꝶ Ether Sulphuric gt xxx Tinct. Opiium gt x Mistura Camphor ℥i Mis ft. Haust . (draught to be taken immediately & repeated every ¼ or ½ hour according to y urgency of y case) It was at one time the opinion that cold drinks in Cholera were dangerous. Mr. Annesley found by experiment that Tartaric Acid dissolves y viscid matter which is so often found after death, lining the enteric mucous membrane & he latterly allowed his patients lemonade which was found delight fully refreshing. He also gave a drink containing nitric acid in y hope that while it was agreable to y patient it might communicate oxygen to y system. Wheather we admit y importance while y dis exists, y fibrinous matter on which Tartaric acts or imagine that that Oxygen can reach y system in the way M.D. seems to expect when it is no longer absorbed in y Lungs the practice of M.D. is certainly a real comfort to y patient & can be attended with no bad effects. – In the very outset of y treatment, frictions over y whole body, & shampooning y extremities should be resorted to. Frictions is best applied by means of hot flannel. It may be necessary however to use hot spirrits 21 of Turpentine. & rubbing with y flannel should be continued until y turpentine is rubbed dry. Bags of hot Sand or Salt should be applied to y extremities or other parts of y body but this will often while y extremities of collapse continues, prove unsupportable to y patient. – Blisters during extreme collapse are quite inert & y emplastrum Lytta is too slow in its operation to prove serviceable. Mustard cataplasms are a more valuable remedy: these may be applied with advantage all over y abdomen & to y calves of y legs soles of y feet & even to y chest. Nitric Acid has been resorted to in order to produce an immediate blister – it does not seem to have been attended by any marked benefit & it is apt to produce an escar which may prove afterwards extremely troublesome. Boiling Water is also recommended with y same view & has apparently in some practitioners hands been found useful. Partial Topical applications however are not much to be depended on & as has been already observed, Vesication cannot be produced during Cholera. The dis. is a failure of an important power of y system & y object in simulating y skin is to assist y internal remedies in exciting this suspended power. But as yet there is no local affection to be removed by topical applications altho. these may become very valuable the after indications of cure. In the present stage of y treatment, therefore an extensive application of sinapisms, or y general embrocation of spirrits of Turpentine alone or combined with Tinct. Cantharides or of Oil & [Hartshorn?] or any other powerful rubefacient is to be regarded as y best means of assisting y internal stimulants in their operation 22 3rd. To restore y heat of y body. The heat of y body can only be effectually brought back by reestablishing the circulation of y blood. At y same time remedies having in view restoration of y deficient animal heat have been considered by most practitioners an important part of y treatment; & therefore they are not unworthy of a separate consideration. No one of these three indications however altho classed seriation should precede or wait upon y others. The treatment should be commenced with any one of the three which can be most easily answered, & y whole of them ough to be considered as belonging to y first branch of y treatment of y dis. There is one very remarcable circumstance attending y worst description of Cholera which has been already repeatedly alluded to viz the morbid sensibility of y patient, skin & apparently of his stomach to y presence of any thing raised above y temperature of y air. A warm bath for instance of a heat some degrees below y healthy temperature of y body has been found so insupportable, that a patient after being immersed in it for a few minutes has sprung out of it almost with spasmodic energy & entreated that he might not again be exposed to so painful a remedy. A similar feeling is very commonly produced in y patient by swallowing liquids not more than lukewarm. Notwithstanding however y instinctive dislike to artificial heat exhibited by so many patients labouring under y dis. still it is advisable that attempts should be made to prevent a fatal reduction of y animal temperature. This is particularly necessary in a cold climate. The patient therefore on his being attacked ought to be placed in warm blankets, & every endeavour should be rised to keep 23 his extremities warm preventing as much as possible his throwing off y bed clothes or removing himself from y heated articles which are applied to him. The restoration of animal heat has been reconed so important, that it has led to various contrivances for applying wamth, The hot water bath was at one time much used. but y delay. y fatiegue of using it. exposure & fatigue in drying y patient renders generally the hot bath more usurious than beneficial. The principle which should regulate y application of heat to Cholera patients is that it should be done with the least possible fatigue to them. With this view various descriptions of Vapour Baths have been proposed. The simplest & most expeditions is Dalton’s Bath made by putting burning spirits and the cot or couch which is surrounded by blankets. Poles of ignited Charcoal answer y same purpose. When there are not such [contrivances] conveniences as these at hand use hot Blanket. Bottles of Hot Water. Bags of heated Sand &c. But unfortunately it often happens that y best contrived me thoads are so painful to y patient that they cannot be presisted in. The general result of y steps which must be taken to overcome y dis. is that Venesection is to be immediately resorted to & every endeavour made to get Blood to flow until the congestion is relieved & until there is evidence that y function of y Lungs & action of y heart are so far restored. For y same purpose stimulants are prescribed & artificial heat is applied to assist y returning circulation in raising y temperature of y body to y natural standard. – Such was y practice resorted to by me [in] [India] & others with great sucess in India & from all that I can learn a similar course of treatment had proved equally beneficial in this country. 24 I am informed that a Mustard Emetic has provd very serviceable in y North of England ½ oz Mustard given in cup of Water: it produces full vomiting & appears to stimulate y circulation [so?] as to enable y surgeon to bleed. The removal of blood to y necessary extent has invariably so far as my experiance goes to spasms. oppression & to y Vomiting & purging & has relieved y prostration of strength The effect of V.S would indeed sometimes appear miraculous. A patient will be brought in oil a cot. Unable to move a limb & but that he can speak & Breathe, having y character (both to touch & sight) of a Corpe, yet will he by free V.S. alone be rendered in 1/2 an hour able to walk home with his friends. Case a man was reported to have been suffering from Cholera during y whole afternoon His Skin was cool pulse weak thready had spasms in y extremities urgent thirst. I immediately bleed him & with difficulty obtained a full stream, When about 20 oz of Blood had been taken y mean felt complete relief, Some Brandy & Water was given him & he returned with his friends to his own quarters He was able to accompany y detatchment of troops next morning. There cannot be a more decided proof that this dis, becomes one of pure contagion & that y immediate care of remove in y circulation whatever that may have been no longer exists than y almost instantaneous effect produced by removing a portion of y redundant & [what] to say y least of it what venous blood. All know that however sucessful V.S. may be in relieving the most urgent symptoms of inflamation complete restoration is not y immediate [effect] result that inflamation is not a mere fulness of y vessels of y affected part but that y arteries are in a morbid condition, & that time is required to restore them to healthy action not uncommonly y most difficult part of y treatment 25 And we are therefore fully warranted in concluding that if Cholera consisted of a diseased condition of any portion of y arterial system recovery could not be instantaneous. Breathing Oxygen or Oxygen diluted is worthy of trial. I should also if possible throw the Galvanic stream through the abdomen. But having arrived at y conclusion that y great object is to stimulate y sympathetic system of nerves it is to be hoped that experiance may enable us to attain this object more effectually than we have hitherto done. Prognosis. The most satisfactory symptoms in y early stages of y treatment of Cholera are y return of y natural colour of y lips & nails arising of arterial action in y extremities & recovered animal heat. The proof that y dis is overcome is y restoration of y function of secretion which is most satisfactorily evinced by y patient making water. Such decided symptoms of sucess may not immediately make their appearance partic. if blood has been removed with timidity but let it be remembered that 8 or 10 or may in one case be sufficient while in others depletion [may] must be carried to y extent of 40 or 50 ozs before there shall be reason to believe that y over burthened [valsartan?] system is relieved. It frequently happens that when there is not sufficient confidence in V.S. y case is painfully protracted that for several hours y patients life will seem hanging as if by a thread. y pulse at y wrist will repeatedly fail & return; oppressive deafness Vomiting purging & spasms will continue y body will remain cold & there will be every reason to dread a fatal termination. 26 The restored circulation, return of animal heat & reestablishment of secretion are to be regarded as proofs that y patient is safe. When on y contrary collapse continues, arterial action is no where perceptible; when y temperature of y body becomes more & more death like & above all when a profuse cold & clamy perspiration breaks out over y whole surface accompanied with jactitation there is little reason to hope for a favourable change. It sometimes happens that notwithstang means apparently favourable symptoms y case terminates [favourably] fatally (in dissipated habits & broken down constitution.) It has been found that y more violent the prominent symptoms are y more likely is a cure to be effected: & that when y dis is attended with rapid collapse little or no vomiting purging & no spasm y prognosis is very unfavourable. But it may be again observed that even in y most hopeless cases it is y duty of y surgeon to continue to watch his patient to y last as instances have occourred in which recovery has taken place when to every appearance y patient was in articule mortis 4th To guard against local congestion most men either from original organization or accident have some weaker point in their constitution which is liable to manifest itself when y system receives any serious shock. Thus in a London Hospital death following a great operation [generally] frequently does not appear [from] to result from y local injury: the wound may seem to be going on most favourably, when y patient is seized with low inflamation of y chest & he dies of dis of y Lungs. So also in Tropical Climates as serious injury may not destroy the person by its immediate effects y fractured limb or 27 broken head appears in a fair way to do well: but y patient is attacked with Hepartitis or Dysentary & is carried off. These facts illustrate y necessity in cases of great constitutional derangement of extending our attention beyond y mere original dis. In Cholera this is particularly necessary. When y primary dis is relieved it is y duty of y practitioner to look most carefully to y condition of y Head of y Lungs of y Liver and of y bowels. The great risk appears to be that a local congestion shall follow a general one. This from the nature of y circulation in y Liver & Lungs is prehaps more likely to happen in these organs than in y head. But should congestion take place in any of those great organs active measures must be immediately resorted to. Leeches Blisters & Mercuric purgatives will be requisite; & instances occour in which in which from y condition of y hepatic system, it is necessary to give Mercury until it produces salivation. The affection of y head [in cholera are] after an attack of cholera, are generally rather of y nature of reaction than of congestion. A mixed & obscure case is occasionally met with in which there are both conditions of y vessels of y brain. But unquestionably pure congestion sometimes takes place within y head which is to be overcome by free topical depletion & active purgatives. When y lungs & consequently y heart have their functions deranged after an attack of Cholera it is generally difficult to discover what is going on. The pat: does not recover as usual he is troubled with depression & debility; his skin is ill coloured & prehaps his pulse is irregular. In such circumstances Leeches should be applied to y chest & a blister over y seat of y heart & alteratives should 28 be prescribed. As it may be [possible] advisable to reach y source of respiration a blister should be applied to y nape of y neck. The tendancy to local congestion may not be immediately disclosed partic: when it takes place in y Liver. This arises from y obscure nature of y symptoms of derangement in y substance of y Liver. It is consequently always advisable to pay y utmost attention to y hepatic system after recovery fm. Cholera: may owe permanent loss of health & much [fatigue] future suffering to neglect of this great venous organ, while convalescent fm. Cholera asphyxia 5th.. To guard against reaction. It is remarkable that in India reaction should so seldom have taken place after attacks of C. when symptoms of this condition did occour, they were generally partial & seemed rather to be attributable irregularity in y balance of y circulation than to pure reaction: so that even its one & y same organ there were deranged arterial action & venous congestion. In India a patient on being relieved from y symptoms of Cholera. usually falls into a sound & reposition sleep & on awaking has y feeling of being quite well. There may be still however tinitus aurium & a slight feeling of confusion of head & giddiness. These symptoms no doubt very often arise from y effects of y powerful narcotic remedies which have been used & will be most likely removed by acting on y bowels. But if there be superadded pain, intolerance of light, a contracted pupil & a hard pulse immediate attention must be paid to y head. Local depletion in these cases is prehaps better than general bloodletting 1b or 20 Oz Blood should be drawn fm. y temples by. leeches or cupping glasses & active mercurial purges should be given. If y these means y symptoms be not immediately removed – y head 29 must be Shaved cold applied with Blisters to y occiput & nape of y neck; & should y pulse continue hard general depletion may be advisable, though topical Bleeding when relieve it can be carried to y necessary extent it as effectual & safer in cases where y removal of blood has already taken place to considerable extent. Such was my opinion as y result of my Indian [practice] experiance of C. & I still think that when we have got rid y state of Asphyxia & restored y circulation we have overcome y dis properly so called. But in Europe it has been found very generally that y collapse stage is followed by a fever of a Typhoid character which protracts y recovery and frequently proves fatal. This fever therefore demands our particular attention & in y outset I may observe, that, in this country the usual treatment of fever appears to have been inquired by y doctrin of Critical days It is said that fever must be allowed to take its course. I do not think so. On y contrary I have seen y greatest benefit result from doing y utmost to cut short fevers of all kinds. In addition therefore to constantly regulating y bowels & y skin through the circulation. I have in my practice both in y East & in Europe commenced Quinine at a earlier stage than it is usually thought of in this country, & in most instances with very hupp effects. In reference to y same subject I consider it by no means impossible that y rapid recoveries fm. C. which took place in India were attributable in no inconsiderable degree to y very decided steps by y Indian practitioners. Thus in that Country a patient with C. was not only freely bleed but lead large doses of Calomel administered followed by active purgation. 30 Dr Mackintosh of Edinburgh I believe has y credit of having called y attention of y public to y good effects of Bloodletting in y cold stage of fever. Before I was aware of his practice I had come to a conclusion similar for altho’ I have not found this remedy universally necessary in ague I look upon it as of great value in relieving y system from a load of unhealthy blood likely to prove injurious when reaction is established. On y same principle I am inclined to regard full venesection & y free use of mercurial cathartics during & immediately after y collapse in C. as y most likely means of saving y patient fm. y subsequent fever. In y treatment of this fever therefore I should continue to act freely on y bowels & loose no time in prescribing Quinine & Camphor giving such a pill as y following every 2 or 3 hours ꝶ Sulph. Quinine. Camphor āā gr.SS. ft Pill And I should watch for local congestion resorting to local depletion in y manner already described in case that appear’d to be necessary. 6th To produce a healthy condition of y bowels. This is an indication which must in every case be attended to for however short y cessation of secretion may have been & however easily y secretions of C. may have been removed y restored function seem to pour into y intestinal canal colluvics which must not be allowed for a moment to look in it. Calomel is a med. of y greatest [power] value when y urgent symptoms have been removed: particularly if as sometimes happens watery alvine discharges continue. As soon as y circulation is restored ten grs, or əj of Calomel should be exhibited & followed up after patient has had a few hours rest with a large dose of 31 Castor Oil; a draught of Infus. Senna. Tinct. Jalap. & Tartrate Potash; or by a dose of Comp. powder of Jalap. It is however advisable not to risque bringing back y irritability of y Stomach & when there is any fear of this it is better to give y Cathartics in form of pills. The follow ꝶ has been found a valuable one after cholera ꝶ Ext: Colocynth. gr.X Divide into Calomel} 4 Pills – et sint Ext. Hyoscyamus} āā gr.V pro. dose. Glysters. large & purgative are very valuable in cases in which y Stomach is still irritable & they may also be used in order to assist y purgative taken by y mouth when slow in these operation. The object at this period of y treatment is to procure feculent discharges & to have evidence that Bile is not only flowing freely into y intestines but that its secretion as restored to its healthy [secretion] condition & y practitioner must be satisfied that the Kidnies have recovered their function as soon as there is reason to believe that these important secretion are restored y patient may be pronounced perfectly safe altho’ it is always advisable to strengthen him by Tonics diet & regimen. And as a relapse is to be much decided y patient must not be allowed to be led by his own feelings of recovery to undue exertion of strength or unnecessary exposure to fatigue cold or any of y exciting causes of [fatigue] disease. It sometimes happens that without being able to truce y symptoms to local congestion or reaction it is extremely difficult to restore y functions of y stomach & bowels to a healthy condition & y patient continues to suffer cramps in y extremities even for many days after y urgent symp. of Cholera have been removed. 32 In all cases of this kind it will be found that it is not only y alamentary secretions that are at fault but that y kidnies have not recovered their healthy function: & y thirst of y patient will show that y salivary & gastric secretions are still deficient. These cases may be explained by y supposition that y sympathetic system has been more permanently injured than is usual. The treatment in such circumstances should consist in persevering in active purgatives prescribing a course of alteratives & freely exhibiting Quinine & it may even be advisable to produce slight ptyalism. Proximate Cause. In y course of y authors enquiries into the nature of C. it became evident to him that y systems course & effects of y dis. could not be explained on y received doctrins of pathology 1. Is this [dis] a general or local affection? 2d. Is it vascular or nervous? Though no doubt a severe extensive affection of y alamentary canal will produce serious. interference with y circulation still under such circumstances we should have no reason to expect to complete, a state of asphyxia as occours in C. In an Inflamatory condition of y gastro-enteric canal the action of y heart may be affected & y pulse become thready but y skin does not become livid nor y body cold & every one who has considered y post mortem examinations of victims of C. is aware, that it is even questionable wheather partial appearances of inflamatory action can be discovered far less those of 33 of extensive inflamation. Besides the complete immediate recovery fm. a state nearly of death which so frequently follows successful treatment of Cholera is [wholly?] at variance with y doctrin that y dis is an extensive inflamation If y symptoms were entirely restricted to depraved secretion into y stomach & Intestines we might be justified in considering y dis a local affection of y gastro-enteric mucous membrane. But truly y vomiting & purging are of very secondary consideration. The skin is blue y surface cold y arteries empty y veins loaded & y current of their blood stopped throughout y whole periphery; & in such a condition of y system we cannot be justifyed in supposing that there is an increased even tho’ depraived secrection going on within y alamentary Canal. And if we are to consider y dis as y result of a local affection y [eivle] evil might with more properly be be described to y pulmonary function. But that it is not result of a future in this important function is proved by there being frequently no marked symptoms referable to y chest & by y dis. being generally advanced in its course before y respiration becomes oppressed. This supposition is also incconcilable with y known immediate effect which y suspended function of y Lungs produces on y sensorium. Were y lungs to fail in their function so far as to render y blood unfit for its purposes it would follow that wherever arterial blood was required the defect would be apparent & hence y brain would immediately feel the injury. Accordingly we find this to be case in circumstances in which y system suffers from y sudden decarbonization of y blood. For example when a bed room gradually fills with y fumes of charcoal insensibility is 34 y first symptom of danger of y sufferer. C. therefore cannot be refered to a topical affection of any of y great organs – y sensorial respiratory or alamentary. The difficulty of accounting for all y symptoms on y supposition that y cause of C. is “local affection of some of y great viscera has lead to y hypothesis that it is an affection of every mucous surface & that it consists of a depraived condition of y decreasing [surfaces of those] functions of those surfaces. But this implies that secretion is excited on y most extensive surface of body when that surface is nearly or entirely deprived of arterial blood for in C. y discharges continue after y circulation has to all appearances ceased. 2d every dissection after death fm C. proves that this dis. produces great venous congestion & there can be no doubt that such a state of y system invariably exists in C. But this must be regarded as y effect & not y cause of y dis. Blood drawn fm. a patient labouring under C. is not only much blacker than usual but is generally grumous: and late in y disease attains y consistence of tar. This must still be regardes as y effect & not y cause of y dis for were y immediate cause of [y] a dis such a morbid condition of y circulating blood as to destroy those organic functions which are found to have failed in y very commencement of C. y sensorium would likewise suffer & insensibility would accompany y other symptoms. It is not therefore likely that C.A. results from a morbid state of y circulating Blood. When in y animal body we find a [se] circle of actions performed, distant path united in function & y flow of fluids to partic. organs determined controlled or suspended as may be necessary for certain 35 purposes: whatever may be our notion with regard to contractility, we must attribute such combined actions to y power of y nervous system. And whatever may be our opinions as to y nature of those processes from which y various secretions immediately result wheather we consider them chemical or mechanical or ascribe them to an unknown vital principle – still y determination of y pabulum to y secreting surfaces must be attributed to a general & not a local agent. The nervous system stretches itself out to every point of y body & we find it distributed most largely where we may expect y energy of such an agent to be most required demonstrating as it were that those actions on which y performance of y various organic functions depend are traceable directly to this system. Hence we seem to be justified in concluding that if we find by dis. or accident that an entire class of y functions of y living body is at once suspended, such suspension must be ascribed to an injury to that portion of y nervous system by which these functions are carried on. In C. in y very outset of y dis all secretions property so called are found to have failed; the alimentary ejecta are not gastric juice pancreatic fluid. Bile, mucous, or excrementitious matter. The kidnies cease to secrete urine saliva no longer flows into y mouth nor are y eyes moistened with tines. Carbonic acid gas is not thrown off in its usual quantity from y Lungs & animal heat is not evolved in y Body. Here there is a dis which suspends secretion in every part of y body. The functions of y parts which are thus rendered powerless are unquestionably dependant on nervous 36 energy, y involuntary nerves being y class which have failed & hence it seems to follow . that y immediate cause of this dis is to be sought in y nervous system. But here it may be asked. How can a dis be considered a nervous failure in which we find y sensorium y respiratory & y voluntary powers unaffected? The answer to this difficulty may be comprehended in y following propositions which embody y conclusions on this subject at which y Author has arrived 1st. The great ganglionic or sympathetic system of nerves is possed of a power wholelly unconnected with cerebral influance which it may retain after y brain & spinal marrow are removed & which may cease to exist while these retain y full exercise of their functions 2d. To this system belongs y circulation & distributive of y blood, & it consequently has a most important share in regulating secretion – in carrying on y involuntary functions & 3rd. To y suspension of this power of y system as I conceive is to be ascribed y dis which is called Cholera asphyxia. These conclusions are y result of an intimate practical acquaintance with y dis. I an axious study of all its phenomena: & they are supported by a careful & minute enquiry into y nervous system in all its bearings. A disquisition [cross out] on y subject would be out of place here, But still it is necessary to state some physiological distinctions not generally received but which appear to me to be well founded & which I think may be [regarded] rendered of much value in pathological enquiries. (See Mr. Bill's Work for his arguments &c page 31. 37 Post mortem appearances. Cholera As: The appearance of y body is peculiar. Whole surface livid, countenance collapsed, body shrunken resembling body of a patient who has suffered fm. a long illness. Y present description is confined to dissections made on bodies in which death has proceeded immediately from an active attack of y dis. & that organic lesions are not included which the evidently unconnected with y cause of death has frequently been particularly noted in descriptions in dissections of y bodies of persons who have died from Cholera. On opening y abdomen the full peculiarity which presents itself is y gorged appearance of y veins & semi fluid state of venous blood. Peritoneum & Omentum natural. Characteristic colour of y Viscera is light pinky hue, shading to purple. And y vein where ever they are to be seen appear loaded with black Blood. The floating viscera generally feel more palsy than 38 usual, as if their coats were thickened y solid viscera look purple or are mottled. y Stomach may appear full, in general it is partially contracted, small intestines tho’ full are not always distended & I have almost alway found alternate portions of y great intestines. contracted & delated. Whole canal sometimes distended with flatus. Mesenteric veins are in a state of great congestion. The contents of alimentary canal is a muddy fluid resembling that passed fm. y Stomach & Bowels during y dis. No foeces but always more or less flatus. The enteric mucous membrane particular but y upper portion of y canal is often coated with a glary & tenacious matter which would appear to be an accumulation of y coagulated opaque substance which is passed with y serous fluid. This is sometimes in such quantities at partic: parts. of y canal as almot to fill use y tube its colour is not always opaque white. has been describes as a dark grey & a greenish tinge said to be sometimes bloody. These variations in y colour of this matter does not appear to affect y nature of y dis. & fm: Mr. Annesleys experiments they would appear often to be attributable to admixture with y meds. prescribed nor. is this matter invariably present. The internal coat of y stomach & sometimes a portion of y duodenum has very generally a peculiar appearance;. There are vascular patches not of inflamation but as if vessels had burst & blood had been extravasated between y coats. These spots the no doubt commonly a congeries of congested [vessels] veins do certainly somet. arise from extravasation. Patches also are described as having y character of Inflamation generally near y pelorus which are by some considered by some y result of local 39 irritation produced by portions of y remedies prescribed having adhered [th] these parts of y stomach & they must be taken as a proof that reaction had commenced before death. Worms are very frequently found in y intestines. Having removed y alimentary canal venous congestion is still few to be y most remarcable feature of y dissection. The large veins are gorged & there is nowhere a trace of arterialized blood perceptible indeed this has been found to be y case during life: for one surgeon in voice attempted to get blood fm. y brachial artery. The Liver is in most cases dark coloured and mottled being at its dependant parts unusually gorged with black blood, but it is said to have been found in some dissections natural in its appearance. Gall Bladder generally full of Bile. I have alway found marks of congestion in y spleen appearances variable Dr Christie fund y spleen empty. the Ceylon practitions found it smaller than usual. y Bladder alway contracted & empty. Kidnies. healthy but partake of V. congestion Liver when cut into found gorged with black blood not coagulated but thicker than usual Bile in Gall bladder green. I have seen it healthy in appearance. Seriat Veins Trunk & Liver full of thick impure blood as are y right Auricle & Ventricle of y heart. Lungs black & appearance almost of a fleshy structure & when cut into freely give out y same grumous black blood in some instances this impure blood is even found in y left side of y heart & to have reached y aorta & cases are mentioned where black blood was found in y carotids. In y Brain there is a same character of venous congestion. but here there is generally some slight appearance of arterial blood 40 There is often found a small quantity of serum in y ventricles of at y base of y brain. The descriptions that have been given as if portions of y brain had been in a state of high inflamation are wholly at variance with y character of y dis in its course & seem rather to belong to a disordered state of y circulation than to this dis. except indeed in cases in which death had not proceeded immediately from cholera & when reaction had taken place. Such is generally y condition of y body after death arising fm: a pure case of Cholera. It may be remarked however that in particular disections some of y organs here described as being in a state of Congestion are found not perceptibly different from their healthy condition & instances are said to have been met with in which y whole abdominal viscera presented nothing very peculia in appearance. In such cases (none of which have [followed] fallen within my experiance) the Lungs or encephalon will no doubt be found highly congested & y external veins much loaded. It is important to say a few words on y general question of V.S. not only to satisfy that y removal of blood may remove prostration of strength but to clear y way for authors explanation of y nature of Cholera a: There are two opposite conditions of y system in which it may be advisable to [withdraw] bleed. The 1st. when high general arterial action exists or when local inflam; has taken place. In such circum: V.S. is called for because it is necessary to lower y hearts action or it may be said because arterial blood unduly preponderates in y system indeed this may be regarded as y fact for in cases of highly exited action y blood circulating in y veins will be found to retain y arterial hue 41 y 2d state of y system in which V.S. is expedient is when y balance of y circulation is depressed on y other side & y venos blood is in excess Fever. Peritonitis, & Acute Rheumatism are example of y first & Cholera Asphyxia is y most remarkable example of y 2d. which practice presents. The condition of y system in C. has been already spoken of but a case of more common occourence which affords an example of bleeding being indicated to remove an excess of venos blood will supply a father illustration. When there is a broaken ribs the action of y Chest being impeded respiration is checked y blood [drawn] thrown into y Lungs is not purified y circulation is obstructed & venos blood soon preponderates in y system. In such a case therefore we bleed not merely to ward off inflamation but in order to reduce y blood requiring y function of y Lungs so that y quantity thrown into those organs being proportioned to their restricted capacity they may be enabled to prepare it for arterial circulation. But in y latter class of cases it is not indifferent wheather we draw blood from an artery or a vein – a practitioner who would open y temporal artery of a patient whose lungs were clogg'd with unarterialized blood would increase y risk of suffocation. Yet we actually find Indian writers so completely mistaken in y rationale of V.S. in C: that they narrate their attempts to remove blood by y temporal artery when y surface is livid and after y arteries have ceased to beat. There is another preliminary consideration which has been lost sight of by many inquiries into y nature of C. viz That diseases of sudden collapse are not necessarily preceded by a state of high arterial action. – Where it may be asked is such a stage in y instantaneous debility produced by y poison of y viper. But to 42 illustrate this fact we need not leave y doctrin of diseases. Intermittant fever supplies an opposite illustration: on y approach [of a pt of ague lung nor y symp. are] of a fit of ague y symptoms are those of great depression lassitude weariness followd. by chilliness nails & lips blue. Countenance sinks shivering ensues in some cases spasms of y extremities. In short y condition of y system approaches to that which prevails in cholera asphyxia. & there can be hardly a doubt that in y cold stage of fever y balance of y circulation is interupted & that venos. blood preponderates in y system. I have seen y occurrence of death in what there was every reason to consider y cold stage of an Intermittent Collapse then may occour without previous high action, it is produced by many poisons. We see it in ague & it occurs in cholera The conclusion & inferences at which I have arrived are 1st That there are 3 powers in y system viz The sensorial. Respiratory & Sympathetic & that each of these on all common occasion is enabled to perform its functions without y active interference of y others. 2d. That y destruction of any one of these powers does not immediately annihilate the other two. (1st) Y [circulation] sensorium may be suspended & y circulation & respiration continue unimpaired (2nd) Y circulation may be supported after y source of respiratory power & y brain have been removed (3d.) [That y] Y circulation of y body may be stopped & y sensorium remain unaffected 3rd. That y source of y sensorial [power] & voluntary power is in y. Cerebrum & Cerebellum. That of y respiratory power in y upper power of y 43 Medulla spinalis, & that of y circulating power in y ganglionic system of y great sympathetic nerves. 4th.. That secretion requires y integrity of y upper portion of y spinal column & of y sympathetic system; & that when y power of either of these sources of nervous energy is suspended any appearance of secretion is fallacious. 5th. That secreting surfaces may throw off component parts of y Blood after their power of secretion is at an end. 6th. That C. asphyxia is suspension of y power by which y circulation of y blood is carried on. 7 that y fluid which during a fit of C. is poured into y alamentary Canal and which extrudes from y skin, mouth, eyes, & mucous lining of y bronchia is excreted after secretion has ceased, when animal heat is no longer evolved & when arterial action is at an end: & therefore must be regarded as an exudation fm. y venous capillaries or if fm. y arterial capillaries is occasioned by them being supplied with blood by regurgitation. – Remote Cause of Choler. A: Y remote cause of any partic. dis is frequently y most obscure question connected with its nature & I much fear that practically we should give little by becoming acquainted with y remote Cause of C. Y dis to whatever origin it is to be traced, seems to be now gradually diffusing itself over y Globe – uninfluanced apparantly by climate - & hither to setting at defiance all human means of retarding its progress or of lessening to any considerable extent its average mortality. Were it of any importance to hazard conjectures as to 44 its remote cause I should be disposed to say that y theory most consonant with the phenomena of y dis is that which as cubes it to certain galvanic changes on y earth surface, but really such speculations are of little value nor is there any theory of y dis. which has led to any important practical results except that which traces its origin to Contagion alone. There can be no serious doubt but that a dis. similar to cholera. has been known in Asia fm. time immemorial. Bontius upward of 2 centuries ago in treating of C. Morbids describes very correctly y prevailing disorder. There is also frequent mention of what was undoubtedly this dis. by y Med. Offices of y East India Companys service in y latter portion of y last centaury & in 1775 it seems to have assumed y character of Epidemic in India & to have extended itself to y Island of Mauritius. Dr. J. Johnson in his Dis. of Tropical Climates speaks of a Dis which Prevailed in Brazils which fm. y sucess of V.S. I have little doubt must have been C.A & I think it by no means improbable that the English. “Sweating Sickness” partook of the Character of this Epidemic. I have admiral Fleming authority that a dis very like the Indian C. prevailed at y Havannah in 1810. & in 1827 several cases resemble C. A. in its most malignant form made their appearance in a public School at Clopham all that I would venture to suggest is that possibly Galvanism may present phenomena which might aid us in our enquiries into y remote cause of y dis. Ritter found that while positive Electricity seemed augnum y vital powers. Negative Electricity diminished them y former increased y pulse y latter lowered it y former caused sensation of 45 heat y latter of cold. We again have seen that y distinctive character of C.A: is y sudden deprivation of y nervous energy of y sympathetic system & all y length to which I go is to suppose it not impossible that y source of y dis may be found in some sudden change of y electric & galvanic condition of y surface of y Earth – I say this however with no intention of supporting y Hypothesis that Galvanism is identical with nervous energy: but unquestionably that agent is so intimately connected with every portion of y creation that any sudden withdrawal of it from y animal system might not improbably produce such a dis a Cholera: a conjecture which receives some countenance fm. y very extraordinary effects which Thunder Storms are said to have had on many occasions on y progress of this dis. in India note. page 66 [a remarcable instance of y sudden cessation of C. after a Thunder Storm is said to have occoured at Jussy. One of y most accurate observers of y peculiarities of y dis. also says “several instances have been known of its (y C) having suddenly ceased on y occourance of a Thunder Storm & say “I witnessed a remarcable instance of this at Kulladghee in 1824 after y dis. had prevailed for several weeks in y troop of horse artillery there was a violent Thunder Storm after which not a single case occoured (Dr. J Christie Observations on C. p 97. 98) It is a circumstance calculated so far to give support to y theory which ascribes C. to some terrestial influance that in India y bower animals such as Cattle. Monkeys & poultry suffered fm. y dis. & if News paper reports are to be credited a simular phenomena has been observed in some of y European Continental towns; & in Hamburgh in partic it is said that y fish also in y rivers were affected. 46 y latter circumstance is very remarkable & if well founded may had to some interesting speculations In Connection with y remote cause of C. I may mention that my friend Dr. Meikle of Edinburgh who saw much of y dis in India & who himself suffered no fewer than five attacks of it, is subject to a very peculiar sensation when exposed to y hidden sources of y dis. which enabled him repeatedly in India to announce its approach before any actual case had occoured. The sensation he describes is that of numbness in y fingers & it is singular that y other day in Hadolington he had again y same feeling] After all however y result at which we arrive is that we know absolutely nothing of y remote cause of C. This is y conclusion to which all practical writers have come.  47  48 Pulse labarynth in which y student is lost & y master wanders to no purpose. – (Good). ~ Pulse Heart or [any] y quantity of y circulating fluid & In Hunter concours in Kriviews. They measure y degree or vascular tone or power of resistance & where y same effect wheather above or below y natural standard takes place in y capillary arteries it produces that change in y pulse which he distinguishes by the names of obstruction & freedom but which it is not alway easy to discriminate fm: severall of y preceding qualities nor is it of great importance as we have in such cases other symptoms that more strikingly manifest y same [effect] fact. – Thus far prehaps y doctrine of pulsation may be studied with advantage but when beyond this we come to a distinction between y free & delated pulse as proposed also by Dr. Fordice. The quick & y frequent of stahl & y dicrotic conturnizing & insidious of Salano as mere sub varieties of y rebounding or redoubling itself a variety of y irregular pulse we perplex patharolog with 49 Pulse. – y vigour or debility & y system which a mere variation in y state of y frequency of y pulse Full &} Small} This M I hunter ascribes to y state of y arteries but I think givers no rather y quantity of blood circulating through y system than of y muscular strength of y arteries or of y Heart itself which is often a very important indication & especially where combined with y preceeding signs it will then be our best guide in cases where we have determined upon [opening] V.S. as far as we do it without danger. Hardness &} Softness} Together with that Vibratory thrill which has been called Wireness are not so easily learnt as its fullness & Smallness but a nice finger will readily discriminate them & practice will point out y difference to every one. Dr. Fordice makes these & I think with great reason dependdant on y state of y arteries rather than on y Pulse. it there: sometimes put a sudden stop to y hearts motion with a deadly shock & killed y patient in a moment. – There are many Drugs that afford examples. Digitalies & Hyoceamus are expressly used on account of this property. Y Prusic Acid & plants that contain it when given in free doses destroy y irritability & extinguish y pulse instantly & so effectually that y heart when imediately is arrived was insensible to concentrated acids & puncture. – Frequency} &} Slownes of} y Pulse} taken by themselves indicate little more than y degree of irritability of y heart or y force of y stimulus that is operating upon it. – Or Weakness & Irregularity Strength &} Regularity} are as palpable to y finger as y preceeding signs & show in characters nearly as deceive y degree of Vigour or debility of y Heart & hereby except where y organ is labouring under some local affection 50 Pulse. – estimates y pulse on the day of his birth & while asleep fm 130 to 140 & fixes it at a little less than the same rate or that of 120 for the first month During y 1st year he calculates it at from 120 to 108. y 2d fm: 100 to 90 y 3d. fm: 108 to 80 at which it continues for 3 ensuing years. In y 7th yr. it is frequently reduced to 72 & in y 12th. to 70. In advanced age from y small quantity of sensorial power secreted & y general inertness of y organs y pulse sinks often below 60. – The Pulse is Quickned by very slight excitement both external & internal. The stimulus of air is sufficient. light & of sounds is sufficient to make that of an infant awake 15 or 20 strokes more frequent than when it is asleep & beyond their control. The Pulse of an Adult is usually Quicker 8 or 10 during y digestion of a meal. Running or any sudden or rapturous emotion will double y ordinary scale The Depressing Passions on y contrary check Pulse two patients who in y best health had always very unequal pulses as well in their strength as in the spaces between them but which constantly became regular as y patient grew ill, and gave a never failing in recovery in their once more returning to a state of irregularity. – In Women y pulse is generally speaking 6 or 8 strokes in a minute quicker than in men and hence many women of firm health & lively disposition have a standard pulse of 85. – In a Weakly Frame y pulse is usually rapid for debility is almost always accompanied with irritation & y heart partakes of y general infirmity In this case also fm y feblness with which y heart contracts y ventrical is but imperfectly emptied & consequently soon filled again & sooner stimulated to contraction. – Hence In Infancy y pulse is peculiarly quick & gradually becomes slower as y child increases in strength. Dr Heberden who paid particular attention to this subject 51 Pulse. – Varies in different individuals fm. 60 to 80 being greatly affected by y temperament and partly by y habit of life. – In y Man of high Sanguinary character it rarely sinks below 80 & is often at 90. – And in the Melancholic it seldom rises above 60 & sometimes sinks to 40. – In Idiosyncrasies y discrepancy is so considerable & complicated with other changes than those of frequency & tardiness that there is no reducing them to any rule. – Lizzari tells of a person whose pulse was not more than 10 in a minute. Dr. Heberden saw a person whose pulse he was told whose pulse in y begining of his illness did not number more than 12 or 16 he suspects in this & all other instances where it is below 40 that y beats oftener than it can be felt because such slow pulses are usual unequal in their strength & some of y beats are so faint as but just to be perceived so that others probably still fainter are to weak to [be] make a sensible impression on y finger. Heberden had attended Pulse beats in Early Infancy 140 strokes a minute towards y end of 2d. Year 100 ” ” [at] at Puberty 80 ” ” about Virility 75 ” ” seldom more than (after 60 yrs) 60 ” ” More frequent in persons of short statue, those of strong passions of mind, those of great muscular exertion and in Females. “Good.” Quantity of Blood in the entire System. – Muller & Abeildgaard estimates y weight even in an adult at very little more than 8℔s Borelli at 20th Planch 28℔s Haller 30 Dr Young 40. Hamberger 80 & Keil 100℔s. (Good) Blumenbach states the proportion in an adult healthy man to be 1 to 5 of the entire weight of y Body. – The mean numbers as those of Haller & Young making y Amount fm: 30 to 40℔s appear most reasonable. – “Good”. – Pulse in an adult male of good health and not too corpulent the Common Standard of y Pulse may be fixed at 70 strokes in a minute 52 Asthma Spasmodic. visceral obstruction Stram, overcomes this action or irritates & produces one of its own. Digitalis 149 Asthma Musk 179 Castor 181 Amber 184 ” Spasmodic Asafoetida 197 Asthma Iron 231 is recomended by Dr Bree during the intermission [Angina 55] Asthma 56. Camphor do Spasmodic 94 Opii is paliative if there is [no] of y Lungs (blood vessels) hence it should be combined with Ipecac or Antimony in y form of Diaphoretic powders. Stramonium I have used y seeds with y best effects one patient to whom I gave it had been skillfully treated in this Country & in England had taken Antispasmodics. Had recd more relief fm. Lobelia Inflata than any thing else this after several paroxisms lost its Effects He consulted me about Smokeing Stram: I told him to use it. if no effect to send to me for some pills which he did I sent them told him to take 1 every hour untill relieved 4 grs completely removed y parox: he had taken as many as 6 in 4 hours ꝶ Stram: ʒi Myrrh ʒi make 60 pills. Asthma often arises in consequence of [Viceral] irritation fm: 53  54                            leaf – A B  leaf – B #14 Philadelphia January 1st. 1827 A few of the Lectures as delivered by Dr. Chapman Professor of Theory & Practice of Physic in the University of Pennsylvania copied during the Winter of 1827 by Asa J Driggs  1 The order in which Professor Chapman treats of Diseases. 1st. The Circulatory system consisting of y Heart & Blood vessels. – 2nd. The Digestive, consisting chiefly of the alamentary Canal. 3rd. The Respiratory consisting of y Pulmonary organs. 4th. The Absorbant. consisting of y Lacteals & Lymphatics. 5th. The Secretory consisting of the Glands 6th. The Sensitive consisting of the organs of Sense. Nerves. Brain & Spinal Marrow 7th. The Muscular consisting of y Muscles Tendons & aponeurosis. – 8th. The Cutaneous consisting of the external covouring of the surface of the body. 9th The Osseous consisting of Bones & there imediate apendages. 2 10th. Generation consisting of the Genitals of both sexes. – It will be eddy under these heads to comprehend all the diseases to which our nature is liable without any reference to their alliance & Affinities. Though I drop the old arrangement I shall however retain the names these being sufficiently expressive & having been generally adopted have become the language of Medicine. To change is always more or less evil & I am not sensible that in any case is it more inconvenient than in y nomenclature of Sciance 3 1st. Diseases of the Circulatory System. – Of Fevers. – I shall now commence with dis of y circulatory system & first of Fevers. – They are by far y most common of y complaints of our nature & as they afford general principals on which y treatment of y dis must be founded I shall dwell on thru at some length & with more than ordinary minuteness. It is computed that more than half of the deaths amoung y human species are produced by febrile affections alone, What is y nature of that Dis which has been denominated Fever! Ever since y dawn of Med. sciance this question has been [???ated] & still remains the febrile affections are so numerous & diversified, fluctuating & so much under y dominion of those causes which [moaf???] dis, action that they perceplably change thin character & one description cannot be appropriated to y whole class. – Cullen who is chiefly followed on this subject defines Pyrexia to Consist in an increased heat 4 frequency of y pulse comeing after shivering accompanied with a disturbance of many of y functions & diminution of strength especially in y limbs. – Now though this diffinition is as unexceptional as any which has been advanced it will not be difficult to show that haraby symptom which has been mentioned is an universally necessary attendant. That an increased [crossed out] of [y] heat is not a sign of fever is allowed by every one are this not onaua cases where y animal heat arises above the natural standard & do we not often see instances when it is lower. The senses here are not y proper means for measuring y degree of heat. The feeling of y individual is often entirely delusive so much so that at the moment when he complains of excessive wampth he is often really colder then sedual is converse equally hot as true sensations of cold often accompany a high degree of Thermometeral temperature. Now is it true that it is always preceded by a chill? it is indeed except in some 5. particular cases comparatively of rare occourance in febrile affections. _ As relates to y Pulse there is every variety as a general rule it is more than naturally frequent in Fever. but y exceptions are numerous & in certain cases when y Brain is effected it sinks to hlf its standard. Besides by exercise & other causes the pulse may be made to beat with much more than ordinay quietness without impairing health or assuming a morbid condition. Frequency of the pulse therefore is not a nessary ingredient in fevers. – That a disturbance of y Functions & Lasitude occour in this dis is not demed but they are also insecdent to many depraved conditions of the system is sufficient of itself to deviate from fever. – Y But to arrive at a satisfactory conclusion we must consider all assembled & also circumstances hereafter to be mentioned. – The most natural Division of Fever is into the Intermittant, Remittant & Continued 6. 1st. of Intermittant. By Intermitt is ment that fever in which there is a [crossed out] sucession of Paraxsms between which there is a distinct & perfect suspension of symptoms take place. _ The Interval between the Paroxisms is in Pathological Language denominated Apyrexia. – Different wordes have been used to name fever according to the length of [crossed out] y interval. When the [crossed out] Parox returns every 24 hours the the fever is called Quotidian. When it occours every other day or when the interval is 48 hours it is called Tertian. But when it is protracted 72 hours it is called a Quartan. – Of each of this primary types almost infinite varieties have been enumerated by authers as y double & triple Quartan by double & triple Tertian etc. By some of y antiant writers it was asserted by [crossed out] of that cases occoured in which of interval was protracted to y 5th. 6th. 7th or even to the 8th. day. This was affirmed by Hypocrates & confirmed by the testimony of 7. Boerhaave. – There are not wanting writers who have extended the period to 1 month 2 most even a Yr. conferring in these cases the title of Menstruae Bemen [stru??] & analar. When these peculiarities [crossed out] takes place they must be considered as anomalous deviating from the general character of the Dis & therefore deserving of little attention.- The 3 primary forms is all i wish you partic to recollect.– The Tertian is by far the most frequent & easy to cure Next to this in both respects is by Quotidian & y Quartan least: commonly accouring & is always obstinate in its management._ The 1st. occours generally in Spring & has therefore been called Vernal & the last appears at the close of fall & has been called Atumnal. By Cullen it is said that y Quart: is more common than y Quotia: wheather this was y case where he resided I cannot say but y whole current of experiance is against him & certainly in y W. of & those parts in which I am acquainted y fact is entirely different y Quartan in this city is seldem seen & when it 8: does occour arises from a protracted condition of y Quart. Each parox: of an Intermitt: is divided into y Cold, Hot & Sweating Stages y symp connected with y different stages are so elaborately detailed by most writers on this subject & y case so familial to you that a minute recitation on my part is rendered unnecessary. The Cold Stage is ushered in by Langour & sluggishness of motion yawning & stretching with some nausea or Debility of y stomach y face becomes pale & features shrink & y skin over y whole body is constricted as if aching with cold.- Not long after this rigors come on accompanied with spasm in y back & loins & Extremities y Respiration now becoming short & [difficult] distressing pulse small & sometimes very irregular copious discharges of pellucid urine is usual at this conjuncture. Somet: more allarming symp: appear as Coma Stupor which is some instances amount to Apoplexy. Y first stage somet continues for 1 or 2 hours when y symp. gradually 9. abate & y 2nd. stage comes on |Notes| the regors are somet. so severe that the teeth are shattered. Second Stage. This is marked by Heat extending over the body, redness of y face. throbing of of y Temples pain in Head Anxiety & Resttiness & some tendancy to Delirium. Y pulse slowly rises untill it becomes strong & exceedingly vehement these symp. continue for sometime but finally moisture appears on y forehead & is soon followed by a general sweat Y heat abates & y thirst ceases. Y respiration becomes free y circulation tranquilized & y functions are generally restored to their healthy condition. Y preceeding is a discription of a parox of Intim: fever as it usually appears. but it is somet: marked with anomalous circumstances. By Cleghorn & other writers we learn that y cold stage in some cases is entirely wanting. Somet. y hot stage is wanting & somet. preceeds the cold & it has been further remarked by Dr. Jackson that a paxoxcom somet. terminates by a copious secretion of Urine or Evacuation 10. from y Bowels without any perspiration or other irregularities not occasionally observable in Intims: they have been known the attack restricted to some one part of the body where y rest remained unaffected thus in Intim. it is located in one of the legs which goes through y cold hot & sweating stage with perfect regularity. I have seen it affect y eyes every other day it was attacked with extreme pain which after a while was cured which could only be affected but by y usual remedies employed for the cure of this Dis. – Not long since a young Lady consulted me on account of a violent pain she felt every other day in y lower part of her abdomen. As she came from J.S. it occoured to me that it might be another irregularity of Intermitt: accordingly after every remedy had failed which is usually employed she was cured with Fowlers Solution In y progress of our enquiries we shall have occasion to point out some curious facts of this 11. nature. Prehaps no Dis is more disguised under its forms than Intim: Fever, & as it exacts a prectum treatment it becomes important that y nature of y case should be understood.– As regards the course of Treat. a little controversy has existed. It is now pretty generally admitted that y most sources of this Dis are marsh Exhalations from Vegit & Anemic substances. Cold is a cause of this when connected with moisture or Bile in y stomach. Y origine of this was first sugested by Lanciss & Blalin who lived not long after the revival of Luting in Europe The observation of practitioners in many sections of y Globe confine y accuracy of his hypotheses but of y precise nature of this pestiferous miasmatas we are still entirely ignorant.– This much however is certain that they are, of exhalations of Vegetable & animal matter in a state of decomposition. Y origine of Intim: is sometimes involved in much obscurity.– It will occasionally makes, its appearance where there is no obvious source 12. of exhalations. In endeavouring to ascertain the cause we should not loose sight of this fact that y Miasmata are wafted by winds to y distance of 8 or 10 miles in a condition sufficient to produce the ordinary effects. No paint has been deseeded from [crossed out] more indisputable evidence evidance than that which we have just mentioned. but it is not less true that other causes produce fevers the paroxisms arising at stated periods. Whatever disposes the body so as to cause extream debility as. poor diet, great fatigue, mental anxiety, excessive evacuations &c. Are all known to excite Intermitt fevers when there is no reason to expect marhy exhalations. Next to these causes Cold is undutedly if most productive of y dis especially when united with moisture as in Damp Rooms. Beds Clothing etc. It has always been said that contagion is amoung the causes of this complaint this has been so well attested that it would be an 13. unwarantable species of [????p??oism] to doubt it But whenever Contagion proves y cause of Intim it always assumes as low type as we find sometimes in Goals. Hospitals & other crowded places: It has also been said to arise from Planatory influance by more than one writer. Tina believes it to aside from Lunar influance in some instances But there is no reason to suspect that these were the cause of y complaint. – Treatment. divides itself into two parts viz That which is proper during the paroxism & that which is required during the intermission or Apyrexia.– Taught by the example which nature affords us as soon as possible in the Cold State of an Intim then we imediately resort to y meds, which are best circulated this effect. We should have y patient placed in a warm bed drect as topical applications 14. hot bricks to y feet & a bottle of hot water should be applied to the extremities. warm beverages are now to be administered pure teas & when we wish any thing stimulating slightly Wine Whey or something of a Stim nature will answer very well.– Opii has been found particularly useful it is stated on y authority of [?rote??at] 1 or 2 grs of Opium at this time had Y effect of removing the Headache & rigors. – of exciting a universal glow followed by perspiration & thus producing a solution of y cold stage.– To y efficacy of this plan I can bare ample testimony of all y remedies that I have seen employed in this case Opii is followed by y most agreable consequences. 25 or 30 yrs since this treat. was recommended by Mr Nellie a Surgeon in Edinburgh we are told that y cold stage was imediately checked.– Y Tornequete acts very intelligibly by interupting y circulation through y Extremities such an accumulation of Blood takes place in y Heart 15. & great arteries that it exerts an increased action in these organs & a consequent diffusion of temperature over y Body. However plausible in Theory this plan was not found to answer y expectations of Practitioners. In y Hospital at Edinburgh it was tried & found of little of little advantage. Nothwithstanding y failure in y Hospital y auther is a man of high standing in y Medical World & published a Book to prove its great efficacy. This is one out of a Thousd. instances where different practitioners have obtained different results with y same remedy. – When y cold stage is very resolute fatal consequences ensues one of y best remedies to be employed is an Emetic it generally puts an end to this stage as soon as it operates. Hot. Stage. The Indications in y hot stage are 1st It remove y Irritation 2nd. To produce perspiration. Y irritation is generally produced by y presence of Bile in y Stomach & in such cases we should not hesitate to give an Emetic but if Vomiting has already occurred & there still be nausea you should 16. you are to assist nature by warm beverages as Camomile Tea or Warm. Water. – 2nd. Indication we must resort to Diaphoretics but all y European Meters & especially those of G. Britain highly recommend James's Powders but in this here it cannot always be obtained pure it is almost universally abandoned & some other Antim: preparations whose whose composed on & properties are better known have been substituted for it. as Antim: Wine. Small doses Tart. Antim: are commonly used & it is very common in y country to used strong decoct. of Cupatimune for purpose of producing perspiration. – It is an exelent remedy where others cannot be procured. On y authority of Dr. Lind Opii has been much employed in y hot Stage it is asserted by him to produce a solution of the [crossed out] paroxism & prepare y system for Bait. diminishes y danger of congestion in Viscera thus hinders y occurance of Schirrous alterations. Induced by my opinion for Dr Lind I prescribed it in 17. y Hot Stage though in direct opposition timing Theoretical views, in may instances it agrevated y sympts: y Headache was always increased y patient rendered, restless & y fever protracted. It is probable in Hot Climates as E & W. Indies where Dr. Lind practised Opii might have been of service in Hot stage on a/c of its tendancy to perspiration. but in this city & in y most temperate parts of y U.S. you will find my sentiments perfectly correct. – Where ever opii is at all indicated I give y preference to Dovers Powders thus a aminis. it proves diaphoritic & its stimulating powers counteracted. The Spts. Menderic is by fac the best diaphoretic [acetate ammonia]. this is to be preferred on several a/cs it is more prompt & certain its effects than any other it is moreover exceedingly grateful to the stomach & will stay when other articles are rejected. Dose tablespoon of y saturated Solution repeated if necessary. – Y practice above – [delai?] is applicable to mild or ordinary cases. But Intim: are [s?n?t] of an Inflam nature & y parox: is somewhat different 18 different from that already stated. They generally adopt this character in Spring & during y prevalance of Epidemics but y circumstances may be accurately ascertained from y case when if fever is m y type actuated to. the pulse is Vigorous & Strong. y face is exceedingly flushed. Respiration dificult – laborous acute local pain in Head. Sides. or Chest. Where y paroxisms are attended with these symp: it is necessary to V.S. copiously. y alamentary canal should be evacuated with powerful purges. – Intim: somet. appear in a very different Type insted of Inflam they adopt y Typhus Intermitt. when these cases occour & they often do in Hospitals & crowded places & During y prevalance of Typhus Epidemics a different treat. is demanded. – The paroxisms are to be treated with cordials & stimulating drinks & by y administration of all these remedies which are calculated to support y strength & tone of y system. 19 Treatment during y Apyrexia. – or y history of these remedies which are best calculated to ward off y paroxysm y most important of which is y Peruvian Bark originally introduced to y practice of Physicians in this Dis. It has maintained an undoubted superiority over all y remedies & y fluctuations of opinion & vicisitudes of practice to which our sciance has been subjected. Little adversity prevails at present as regards y rules forits administration though formaly no point was more unsetled. Among y absurd notions [of fever] it was though that y morbific matter might be thrown out by y paroxisms this was advanced by Boerhaave who said y bark was to be used “cum morbus [ale??otic] [d????] Van Swaten in his Comentaries united with him in this sentiment which was also conceived by Sydenham & all y eminent practitioners of that period Secretly y revers of this is more generally held to be y proper course & y fact is fully established that y earlier we commence with y Bark y more speady & prompt will be y cure 20. Y only circumstance of account which would cause delay is y condition of y Alamentory Canal & somet: perhaps of y system generally. Doubts are entertained by several writers wheather it is really necessary to prepare y system in any way for y reception of Bark & I am acquainted with some practitioners who says it is of no utility in this dis. But this is by no means y common opinion of y established practice It is now pretty generally conceeded that though y Bark will occasionally affect a cure without previous evacuating yet as a general rule it is y custom either to evacuate by Vomiting by purging previously & for this purpose y Emetic Tart. et Calomel are preferred. Harvene in times especially in this part of U.S. they have in a great measure given way to y Mercurial [crossed out] preparations they enerally answer where Emetics can hardly if at all be dispensed with they [op??ly] in such cases not only evacuating y Alamet: Canal 21. but also make a powerful impression on y Stomach & thus disarming & braking down that chain of & perverted association which Intim: & other Penoacedl Drs. seem to depend. Of y nature of Emetics my own observation affords me abundant conclusive evidence But besides these evacuants V.S. is demanded. – In y commencent of Intim: there is always more or less Inflam: Diathesis kept up with considerable pertinacity without y loss of blood & pretty copiously too y Bark would be rejected from y Stomach & of no utility & if it was retained it would only aggrevate y symptoms by its effects. My rule is never to resort to bark untill I have prepared y system by Evacu: so as to receive the proper impression from this valuable, remedy. By pursuing this course adopting y remedy to 1 state of y system I can pronounce that y certainly of its effects are such as almost entitle it to be considered at present as it formally was a Specific in Intim: fever: This species of fever is not unfrequently associated with obstructions in 22. y Viscera. Obstructions of y Viscera. when this exists Bark has been held to be inadmisable. That cases of this kind exist says Cullen where it is improper to administer y Bark I have not to determine; but I am well persuaded it is dangerous to adopt any such plan as a rule. I am convinced that in y cold stage of this fever an accumulation of Blood takes place in y Liver & Spleen which is increased every repetition of y cold stage &c. Y practice in regard to this point may be readily adjusted. In Visceral obstructions when Inflam: accompanies y Dis I would never hesitate for a moment to employ y Bark so as to put an end to y Dis. In other cases where there is pain in y Viscera & actively of y pulse indicating some local Inflam. Bark is mischievous. – We should have restort to y Vesicating applications or a slight degree of Saluvation which will commonly do away y obstructions. But if there be severe pains & y case is decidedly Inflame: we 23. should use directly evacuating remedies & of these V.S. is decidedly y best. – There was at one time much debate wheather or no y Bark should be given emediately preceding y paroxism. Cullen was decidedly in favor of this practice but I consider him to be wrong determining from my own experiance I should avoid administering it at y moment of y anticipated attack as I have found it aggrevate y paraxism by increasing y fever & distressing y Stomach. Some practitioners go so far as to contend that there should be no remission in its use that it should be employed in every stage y paroxism. Dr. Clark who wrote with great ability on y Dis of Tropical Climates is among those who strenuously recommends its use in this way as yet I have never been induced to follow it because I have always observed when Bark was given even when there is a slight disposition to fever it is productive of mischief. It is a rule established by y ablest practioners is rare there is a slight indication of an accession of y paraxism y Bark should be discontinued 24. Y ordinary mode of administering Bark is in Substance with water. Wine. Milk or Deluded Ardent spts. But milk has always appeared to me to be y most agreeable veicle. y Dose of y powder in ℥i or ℥ii repeated as often as y stomach will bear so that ʒi may be given in y ordinary intermission In y Tertian more than this is necessary it is y practice in y W. Indies to take ʒii in y morning at once & to omit in y other part of y Day. y tale Dr. Dallas was from that part of y country & was y practice that prevailed there whoever had an Intermitt took ʒi Bark early in y morning y sucess was in this case complete I never knew him fail to effect a cure in 2 or 3 ds. I doubt wheather y practice would be imitated fur stomachs will bear y Bark in as large a dose the fact however is interting & I thought worth recording as cases may occour where y method proposed may be advantageous. But in some persons such as y irritability of y Stomach that Bark in Substance 25. even in y minutest doses cannot be retained on y Stom: In such cases we must apply to y Infusion or Decoction either by itself or in combination with some aromatic such as cloves. Cinnamon or Orange peel. or Serpentaria y last to be prefered it renders y mixture agreeable to y tale & comfortable to y Stomach & much more efficatious a combination of this kind may be employed when Bark must be forbidden tis particularly adopted to Children & delicate persons.– But sometimes Bark purges its efficacy is abated when this appears. Small doses of Laudnum are to be given. When it produces constipation of Bowels as it sometimes does small portions of Rheii may be used. – [N.B. y Sulph Quinine is y active principle in Bark one gr. is equivalent to ℥i of Bark either given in Solutio: or Pill. R Sulph. Quinine qr.viii. Acid Sul: dramatic: ℥ss Sac alba ℥i Ess.menth aqua font ziii frat. mist. This forms a super sulphate Dose at: spirm: It is restricted aperxia y Est. 26. is y radium remaining from y manufacture of Quinine. Dose same as Sulph. Quinine. – Now & then Intim: is attended with great Acidity of y Stomach it is customary under such circumstances to combine with y Bark a little Magnesia & a minute quantity of Veritable alkali. – Notwithstanding y variety of means in order to attain a proper administration of y Peru Bark they are often defective during to a peculiar irritation in y Prime Via causing it to be rejected by vomiting & carried off two suddenly by y Bowels so that it can produce, no salutay effect. In cases of this kind it is usual to resort to Injections. – I have never used Bark in this way except in Children & therefore can say but little as to its efficacy. Possibly it may be useful in some cases but you will hardly ever prevail upon an adult who has used it once in y form of our Enema to submit to a repetion as often at least as will be necessary to effect a cure. – Besides you will 27. after be defeated by y irritation which exists in y Bowels. either previously or inaua by y measure & which amounts to such a degree as to render it almost imposible to retain y Injection. However as you may have occasion to use y Bark in this way I will give you y proper formula R. ℥ii or iii of y Dowan is to be intimately mixed with some mucilage, as common starch. Flaxseed tea made rapy or a Solution G. Arabic to sooth y irritation of y bowels. – It is customary to add a small quantity of Laudnum as y desine is not that y Bark should be evacuated but retained. – Bark also has been applied to y surface of y body y method of doing this is different. By some it is recommend. to apply in y form of a Cataplasm or poultice med of y article placed over y pit of y Stomach. By others a W. Bath either topical or general of y Decoction is prefered. – It is stated in authority of sufficient respectability to be entitled to confidance that Intim: may sometimes be cured by an emission 28. of y feet in a decoct. of Bark. – It is probable that a general Bath imersing y whole body would be much more efficacious. As a remedy in Intim: I have never employed y Baths but they have been used by practioners in y county who report in its favour one of a decided nature. When I have use it, it has been with a design to check violant vomiting especially in Pestilential Fevers. Cholera morbus. Cholera Infantum under such circumstances it will as soon sooth y irritability of y Stomach as any other remedy that can be employed. Its mode of Operation is very inteligible Creating a Tonic impression on y Skin between which there is a consent of a very intimate kind impacts tone to that viscus & thus retains its ordinary motions. Bark has also been employed in a dry state in this Dis: as an external application. It is said by Darwin that if y sheets are thougherly strewed with y powder of a Bark y Individual who sleeps in them will be cured if he had y: Dis. To believe 29. this even on y respectability of Darwin requires a considerable strech of credulity.– But when y Bark is applied differently there can be no doubt of its efficacy. the mode alluded to is that of Quilting it into a jacket & wearing it next to y body doubts have been entertained wheather thus used it had any effects most indisputably it does. When applied to Children in early life & Women of extreme delicacy. After all however it will be found to fail & when compared to its internal administration is entitled to very little confidance. next to Bark in Intim: may be marked Serpent. Serpentaria. The mode of using it origianlly employed by Sydenham. was with Wine. – As a general rules says he all case of Intim: where wine is indicated its efficacy will be increased by Serpentaria. – “Wheath it is adequate to y cure of confirmed cases of y Dis. I cannot tell with certainly. But in y milder shape or where y type is contagious partaking in some degree of y Remitt 30. character it is a very efficatious remedy & a preparation of Serpentaria has been employed with advantage in y worst forms of Ague & Fever y formula is as follows viz Rx Cort. Peru: ℥ss. Rad. Serpent: ℥i Curb Soda gr 30. This are to be imediately mixed & divided into 4 powders one of which is to be taken every 4 or 8 hours. Why y serpentaria thus combined & with so small a portion of vegitable alkali should have its powers extrordinarily increased is difficult to determine but of its efficacy there can be no doubt y preperation was employed for more than ½ a Centaury ago in this section of y Union & has received in its favour to y extent y testimony of established practitioners. – Nothing is more idle than a prior speculation of y Modus Operandi of meds. we are never certain entirely with respect to y accompanying circumstances & in most instances are content with fact alone if it be fully corroborated. Of y remedies afforded by 31. Our own country for Intim: y Eupatorium Perfoliatum. is possed of great powers. It may be so prepared as to be Diaphoretic. Diuretic. Emetic or eminently Tonic. by its Tonic powers it is most efficatious in this dis. for its diaphoretic powers it adopted to every stage in y Dis possesing in this respect a diseased superiority over other remedies. It may be employed indeferently either in y hot or Cold stage of y Paroxism. Its tonic powers are best obtained by administering it in powder or even in Decoction, This remedy has been much employed in Philadelphia & my Friend Dr. Hossack has informed me that it has completely supplanted y Cinchona & Fowlers Solution in y practice of several Physicians in New Jersey. – There is another species Eupatorium Pilosum known by y name of Hour Hound which is possesed of equal virtues though it is some what medicinal. Y Dose of C. Perfoliatum is 20 or 30 grs or a Wine Glass of strong decoct every hour or two. – In our enumeration of articles adapted to cure Intim. 32. y Chirona Angular is or Centaury is not to be overlooked it is different in appearance & medical effects from y Eupatorium. – It may be employed under all circumstances of y Dis. & is somet: given to advantage when y Bark is inadmisable. – It should be administered in Infus or Decoct: & in such quantities as y Stomach will bear. Though mosily employed by country practitioners it is also used in y city & we have abundant reason to be satisfied with its effects. Bane fored we have 2 species of Dogwood which are possesed of Tonic Properties y Cornus Florida & Cornus Terecia or swamp Dogwood. The Back is y only part used in Med. & may be given in doses & in same manner as Cinchona to which from a careful examination of a graduate of this University it is closely allied in its chemical Compo. & medical properties. – As regards myself I have no experiance in this article. But it is so highly extolled by others that I though it my duty to mention 33. mention it. Athia to y Dogwood in med. properties is y Prunus Virgmiend or Wild Cherry Tree. I have little doubts of its beneficial effects; Professor Barton & other practitioners have used in with advantage. – Another of our Native Tonics is y Prunes Verticelalus Black Elder this has also been used. what powers it posses I am not able to determine from my own experiance. By y late Profess Barton his correspondance it was highly recommended y Bark of y Root is y part employed & is given in same manner at Cort Peru. Many of y Oaks have been used in Intim: & not without success. y White Oak approaches nearest to y nature if Peru. Cort. in its general property but y Chestnut Oak is prefered by y City practitioners I have no experiance with uthre. – Several Species of Willow are not without power in y cure of this dis. y White Willow has been found superior in this respect. This bark may be given in substance or decoction same as Cinchona The Willow of England has been much used in 34. this dis of late & y writing of Willingham & others are in favour of its efficacy. It is now 30 or 40 yrs. ago since y Liriodendron Tulipifera or y common Poplar has been used in y management of this dis I have no experiance with it but by Dr. Rush & Barton it was commended y former introduced this article into practice in Fever & Ague. when that Dis prevailed in y Revolutionary Army, he considers it inferior to cinchona y Bark of y Root is employed in substance or decoction & same dose as y above articles. These are all y articles which have been found useful & which are indigenous to our Country. They possess [crossed out] different powers by which they are adapted to peculiar cases. Some of them are productive of much good & as they are read to access to those who have settled in y country & thought it right to bring them before you. Next I am to address your attention to some remedies whose qualities we are well acquainted 35. with & which therefore not only this account but they posses superior virtues & are therefore more worthy our regard. Nota little has been said within y last, 20 or 30 yrs. of Angustura as a remedy in this dis. When originally introduced into y management of this dis, & such was y confidance it inspired that it proved for a long time superior to Cinchona & other established remedies. But though known only for 20 or 30 yrs yet so completely has its virtues repressed that it becomes exploded from y treat of y Dis. Recently however it has been revived by some of y Europan practitioners those of London & some speak so confidently of its powers that must have been precipitately rejected. It is highly Aromatic & Cordial moreover it is not a little Astringent & perhaps will be found best adopted to these cases which are accompanied with irritability of y Stomach & Bowels. It will sometimes be retained when Bark is rejected y dose is generally from 36. ℥ss to ℥i at time repeated pretty much as y Cinchona. Not many yrs ago Mahogany called in Sciantific Language Casyania febrifuga or Angusturæ was recommended very strongly Dr Rocklove in Intim & Experiments lately made by many practioners revive y sentiments of that writer. As it has in some degree y properties Angustura it will be found prehaps proper to administer it under y same circumstance. A variety of [crossed out] remedies have been used as remedies in this dis. in a grater or less degree they are all possessed of y same properties with y preceding articles & should be used in a similar manner but from my own experiance with them I should not recommend them strongly. They may all be employed in decoction. Infusion or Powder as y Cinchona. – The wood Quassia. has been much used I have employed it but have no occasion to 37. think it at all calculated to meet y severe attacks of Intim: - Though temperate in his opinions & cautions of recommending Meds. Dr. – in this particular instance departed from his general practice & displayed some enthusiasm in y praise of Gum Kind. it is undeservedly stated by him that in Intim: of y most obstinate character may be cured by this medicine as soon as the Peru Cort & other active valuable meds. - In this light it was used much some practitioners rely much on y authority of Dr. Fothergill he had great confidance in its powers. In acting from my own experiance & those of other physicians for whose opinion I have great respect I should say it is incompetent to cure intractable cases. But exhibited with Bitters & Opii its efficacy is greatly increased & in some cases those combined have formed a valuable remedy. Y best form for using is y following R. ls. Kino Zii Rad. Gentian zss Opii grii y whole to be divided into 10 or 12 powders one of which may be given every 2 hours. – It does not appear 38. why this combination should increase y powers of this remedy, but of y fact there can be no doubt. The last of y Vegetable remedies is Charcoal. This has very recently been mentioned among y others it appears about 6 or 8 yrs ago Dr. Fr – in Salisbury tried it in this dis y Physician on this station in y British forts Dr Lalbect was induced to try this Med Determinging from respect to this writer we should be led to conclude that it is a ralnath remedy connected with Bowel Dis especially dysentary. o On y authority of this writer y remedy within y last 12 mos. has been used in this city in 2 or 3 [cases] practitioners have employed it in y public Institutions & not without advantage It has been prescribed by some in a great quantity of cases. But what I have seen of this it is entitled to your confidance One of y members of y Class has had an an Ample opportunity with this Med: & I have learned it proved successful where y Bark & Arsenic had failed for reasons 39. hereafter to be mentioned. I should prefer it where there was a little Dysenteria connected with y Dis, a t. spoon should be given every 2 or 3 hours during y apyrexia. – Sulpher. not y least valuable of y remains employed is sulpher. – It was first used about 30. yrs ago by Dr. Lysenger who writes In y anomalous Fever of y Isle of Batavia he prescribed a t spoon mixed with a little ardent: Spts: At one time I was inclined to believe its efficacy was ascubable to y ardent Spts. associated with it but wide experiance has taught me different during y Cast few yrs I have used it much in this Dis & am persuaded that it is possed of great powers. It acts independantly of y Spts. which is proved by y circumstance that it is not less efficatious when mixed with Milk. Molasses or any other inert vehicle. But y power of Sulpher is not restricted to Intim. fever no remedy I have used is so efficatious in checking y fever of Irritation I mean y Hectic Fever 40. wheather arising from absess of y Lungs or else where It affords me great pleasure that I have y authority of Dr. Physic for views which I present to you on y powers of Sulpher. He goes father & declares that judging from his own experience there is no remedy so useful in anomalous fevers especially of y periodical type. He does not limit it to Intim fevers but extends it to all such Dis. as occour periodically especially Periodical Headache I am inclined to believe that it is not without in such Chronic Nervous affections of an Intim: nature. It is true that we do not perceive its secret effects on y system but on this account it is no less powerful. – We see y same thing in Arsenic Mercury &c. Y mode in which I am acustomed to use it is at such times & in such doses that it will not exert its purgative effects this end is generally answered by giving 30 or 40 grs every 3 or 4 hours. On y authority of Dr. Monroe & one or 2 others y Blue Vitriol or 41. Sulphas Cupri has not been a little prescribled in this dis. It is allegra by more that while Physicians in general to y British Army in y Netherlands he was able to arrest Intim: fevers by this remedy where all others failed to y same point goes y testimony of Dr. Adams & others y following was y formule Rx Pulv. Cinchona grs 32. Sulph. Copper gr. 4 to be made into XV pills one of which is to be given every 4 hours. Wheather this remedy is always as powerful as represented I cannot pronounce. Those Intim: in which I have employed it I have found it most advantageous in old Quartans. On y whole y evidance is not so strong y as to induce me to recommend it highly. – Dispersed through practical writers some evidance may be found of y Virtues of y Cuprum Amoniacum. It has not been strongly recommended to our attention. When used it should be administered as y preceeding remedy Nearly on a footing y same should I place y several preparations of zinc those have also been employed 42. employed by different practitioners but I do not know that proof is strong enough in their favour. They are all used in Chronic Periodical Affections & might prehaps be useful in some Intim. but I can say nothing from my own experiance. – Amoung y remedies we are enumerating few have a higher claim than Alum. It was long ago prescribed by Cullen in combination with mutiny But he says though combined with this Aromatic it often produces naucea & is rejected from y Stomach so that he has not much confidance. By y celebrated Dr. Lina who used it in y same manner a different statement is given he ranks it next to Cort. Peru: & observes that it is greatful to y stomach & if continued with aromatics rarely occasions distress in that organ. As regards my own Experience I cannot say much respecting it. It would appear however by y testimony of others that it is not destitute of powers. Dr. Chalmers of Charlston thinks it paticularly 43. useful in this Dis, & in Remitt: fever of that part of y Country y same statement is made by Dr. Adams with redard to y fevers of yc W. Indies. Dr. Darwin says that it has considerable powers over Intim: but more especially when associated with Dysentary y proper doses is from 5 to 10 grs. but y Stomach will not always bear so much in such circumstances y quantity should be reduced. – Sugar of Lead is one of y articles lately [aar??] to y Catalogue by some practitioners particularly of y U: States it has been highly extolled. It was a favorite remedy of y late Dr. Barton during y late War It was used in Intim: which occoured amoung y troops on y Canadian frontiers. – I received an account from Physician attached to y Army that it had exerted greater powers than y Bark or Arsenic but I believe there was some deception in y case Determining from what I have see of y Article it does not deserve much esteem my own experiance is much against it. As nearly allied to y preparations 44. of lead I shall [mention] say a few words on Arsenic. In y estimation of y generality of practioners this article stands not on point of efficacy to y Peruvian. Bark, that it has done good in Intim. cannot be denied but when a physian expects from it uniform sucess he will often be disappointed. Wheather this proceeds from an inherent deficiency of y powers of arsenic or from y indiscriminate mode of prescription I am prepared to say this much however. I can inform you that in weak and debilitated states arising from old age or debauchery y arsenic will unfirmly fail. this is a feat might be expected & Barks many other remedies employed in this dis. are Tonic in their nature & act by imparting tone to y stomach & through y system generally. Arsenic has no such properties though commonly ranks with this class of meds. by writers on Mat. Med. Its principle opration is to create nausea weakness of y stomach & debility 45. of y system which is indicated by a feeble pulse cold surface loss of general strength & muscular relaxation. But even when employed it sometimes fails compared with. Bark it is acutialy inferior to bark & should never be employed when that article can be obtained, The cases in which it is best suited are such as occour in children & in [person?] possesing considerable vigor of Constitution associated with febrile condition. It acts powerfully on y system of children & on account of its berry without taste & in small bulk will be taken when others would be rejected. It has been a subject of debate wheather y arsenic should be continued during y different stages of y dis. My own experiance has taught me there is no precise rule on y subject the only objection against its employment during paroxism is y Nausea & Vomiting which it is apt to produce especially in y cold stage where there is great imitability of y Stomach, Arsenic is prompt in its of operation therefore if no decided 46. operation or advantage is experianced in 6 or 8 ds. it should be discontinued. It only debilitates y. system & produces a long train of unpleasant symp. as. Debility of y Stomach. pain in y Head. Oedematous swell in qs of Extremities. It has lately ban alleged by high authority that when arsenic does. not suceed by itself it may be renamed very efficatious by combining it with Cinchona this is Sound practice & I have imitated it with advantage. Arsenic is said to prepare y System for Bark & when Intim: does not early yeald it has been recommended to have recourse to this article & afterwards to use y Bark. – It is not [crossed out] more a yr that y Web of a common Spider was considered by me as a remedy exceedingly efficatious y fact I derived from Dr. Jackson who was inspector of y British army. On a revisit to this city he informed me that he has found y web one of y best narcotics exceedingly efficatious in quieting irritability Cordial to y whole 47. system & often producing sleep. he farther added that it was y best remedy known to him in y toat of Intim in all y stages. It is not in my power to testify to y accuracy of this account from a great number of experiments but y few trials I have made satisfied me perfectly well that y statement of Dr. Jackson was correct y article certainly is Sedative & Narcotic I am not without reason to be lure that it is useful in Ague & Fever. A gentleman of this class has written a valuable assay on this article from his own experiance & those of others who have been made this communications. I believe it to be a valuable remedy I recommend it to you. You need not be careful in selecting y Web. if any spider particularly as y species of spider are possed of y same properties. – Before dismissing y Meds. employed me Intim: I will notice one which deserves our notice. It is more than 15 or 20 yrs since y practitioners of France in a tone of confidance recommended Animal Gelatin. Gelatine In Intimittant 48. Gelatine: From y Known properties of this article little credid was given to y accounts. but I find at length y English practitioners have recommended its use & some concour in granting it thier surport. By y writers common Glue was employed. The English physicians believing that Calfs foot. Gelly is equally powerful & knowing it to be much more agreeable they commonly have recourse to that preparation. The only case in which this remedy has been used in this city was mentioned in this city. Dr. Griffiths told me that in y case of his daughter who for many months had been affected with Intim: & in whome y other remedies had been used in vain succeeded at once affected a cure by y administration of this remedy. Nothwithstanding y numerous remedies which had been used or mentioned for y cure of Intim: it will sometimes baffle our best directed efforts & continue its course in spite of all any exertions Cases of this particular Obstinate Character 49. depends most commonly on congestion or some other dis of y Viscera & confirmed by long habit. It is our duty in such cases to resort to Mercury. Mercury in Congestion gradually inseminating it into y system untill saliration which is to be kep up 2 or 3 weeks without interruption. This properly called a Revolution going remedy by which such changes are produced in y system as to suppression decour y prexisting dis. As a substitute for Mercury Blisters have been found highly useful these should be applied to y extremities & not dressed or hastily they operate nearly on y same principle as Mercury viz they create a counter impression which interupts & destroys this contamination associations on which y Dis: depends. When all these remedies fail however as a resort we should direct our patient to take a protracted journey so that exercise of Gestation change of Scenery y noval impresions derived from a different climate & other causes may operate 50. in producing a chain of [cross out] actions which may supercuary old; I will now speak of those remedies which are calculated to [produce] meet our indications in y Apyrexia or those which are given just before y expected recourance of y paroxisms. It is y common practice to order y patient go to bed & to take Opium as Dr. Frotter has recommended it Warm Beverages are also directed for y purpose of producing perspiration: Ether is a prompt. powerful & diffusible Stimulant & from these properties answers very well. At y time under consideration you should warn your patient not to over load his stomach about y period of y expected paroxism as nausea & Violant Vomiting might thus be occasioned. Cases are indeed recovered when 6 or 8 hours fasting has cured y dis. Any great change my condition of y Stomach would answer y same purpose. By some practitioners a very different mode is employed 51. They make y strongest possible impression on this Viscus by stimulating meds. strong spts Liquors either alone or impregnated with Spices have often been used & no doubt have proved advantageous. In fact whatever makes a strong impression on y system whether through y mind or Body will often suceed. – In every Intim Emetics given before y paroxysm have a powerful effect & Blisters applied at same conjunction not universally of y attack It is y imperious duty of practitioners to endeavour to cure Intim: as speech as possible there is modis. no Dis. so disagreable to y patient & though not imediately fatal is apt to degenerate into complaints of a very serious nature thus Intim: after runing into Continued fever sometimes of a Typhus nature & nothing is more common in children than for it to terminate in Hydrocephalous Internus y more common remote consequences are Congestion of the Viscera. Schirrus. Indurations & cancer conjoined with Dropsy & deprivation 52. of y system. No opinion is so absurd & mischievous than that which was advanced by Boerhaaves & adopted by many other practitioners. That Intim: are salutary in their primary operations & unless of a malignant type are not to be suddenly supposed by artificial means, nevertheless it cannot be denied that Intim: sometimes supercedes other diseases of a very formidable character. Gout. Rheumatism & cutaneous affections. In many of y Spasmodic or Nervous Dis. as Chorea. Epilepsy Asthma. Hysteria. Dyspoenea are some of y affections which yeald to an attack of Fever & Ague It has been ascertained that Intim: after they have become completely established in y system are sometimes competent to y cure of Pill Consumption I have already mentioned that it was y practice of some of our older physicians of this Town to induce this species of fever as a remedy for Consumption. But I will hereafter show more particularly y advantage of this treatment. 53. y same effect is sometimes produced in melancholic & y periods forms of Insanity. It was y custom of y physicians to take y maniacs out of y Hospitals expose them to y sun & send them to Miasmatic countries that they might be attacked by y fever & Ague. Though this practice did not always affect cures yet a sufficient member occoured to show y power of y Intim, action over such affections. As y predispositions to Intim. is in y system for a long time after y cure has apparently been affected y patient should studiously avoid all exciting causes as Exposure to night air or to cold & damp atmospheres under any circumstances. It is always proper for some time after y cessation of y Dis that y use of Tonic meds. should be continued Rubigo Terri never to leave y house with an empty stomach. Wine Porter Strong Cider &c 54. 56. Remittant Fever. – This is mere modification of y preceding Dis Cullen very properly condemned who considered it a distinct species of fever most undoubtedly he observes each arises from y Same causes each is epidemic & each are cured by y Same remedies insome instances in y same person y Dis alternates All this must be added as perfectly true but as they demand a treat. somewhat different so they ought not to be confounded. By Remitt we mean that species of Fever in which y attack abates without entirely going off y remission occours at irregular periods & is uncertain in its duration. Somet: it continues for several hours & at others y interval is so short as hardly to be perceptible. Remitt is produced by all y causes which was said to give rise to Intermittant hence it is most common in low mash situations in y autumnal season & when there is great vicisitudes in y weather as intense heat succeded suddenly by heavy rains. As in y Pyrexia 57. of Intim: y attack is proceeded by languor heaviness restlessness & alternate fits of heat & Cold. As soon as y fever proceeds to y 2nd stages y patient experiances pain in y Head & back & heat over y surface of y body. When this stage is fully formed there is difficulty of respiration & depression of spts. to these are added a White fured tongue a full strong pulse a sallow skin & eyes tinged with Bile. Nausea & Vomiting of Billious matter, a sensation of heat & pain in y pit of y stomach. After a continuance of these symptoms for a time y fever abates considerably & goes off with perspiration more or less copious But in a few hours it returns with y same appearance as before & thus with Exacerbations & Remissions it proceeds untill it terminates fatally or is cured or as sometimes happens in another form as y Intim: or Continued fever. Such is y Ordinary character of this dis. But under different circumstances of Climate Situation or Constitution of y patient assumes different appearances & is 58. associated especially with y inflamatory & malignant Diathesis. As regards our Country it is generally a Dis. of increased action requiring active antiphlogistic measures & in this this light I shall now consider y Treatment of Remittant Fever. The principle Indications is to induce an Intimission & y course is pointed out y Symptoms it is proper always to commence with V.S. This is particularly indicated by y pulse a hot dry skin determination to y Head & a variety of other sympt. The next remedy is an Emetic with a view of xciting Vomiting when called for by y State of y Stomach y Tartarized Antimony is always preferable. I mention this more particularly because it is generally y practice of Country practitioners to use Ipecac. But this is much less efficatious y Antim: preparations not only more completely empty y Stomach but makes a powerful impression on it so much so that it puts an end to y Dis: by in tempting & removing y primary morbid impression 59. In many instances I have known Intim & Remit: cured by an Antim. Emetic operating in y manner I have prescribed to you To meet y same indication that is to evacuate y Alamentary Canal y Mercurial Cathartics are resorted to they are like y Antim: are to be prefered for they are Rinared articles they operate more efficiently in evacuating y Bile than other purges as soon however as y Mercurial evacuation is over we should resort to purgatives if a milder nature of these y saline are most generally used & y best are y Epsom & Cheltenham Salts y latter are made by evacuating y Cheltenham Waters or in imitation of Salts thus obtained & have been recently introduced into practice they operate in much smaller doses than y other neutral Salts are less disagreable to y patient & more evacuating y Aliment. Canal ʒi is equal to ℥i of Epsom. After such direct & powerful depletion from y Stomach & Intestines it will be proper to resort to y milder means of producing 60. Diaphoresis y remedy best adapted to this end are y Antim: preparations & y neutral mixtures y Spts Mendiri is also a valuable remedy in this place y action of these may be prompted by y Vapor Bath y best way of applying this is to pour Vinegar on heated bricks are to be wraped in flannel & applied to y truth & Extremities by this we can generally excite a copious perspiration. The Dis under such treat will most generally yeald in 2 or 3 ds. but if not y Emetic & Mercurial purgatives should be repeated again, evacuations of this kind are called for by y accumulation of Bile my Stomach which by irritation &c febrile action is kept up. – I have found Emetics to succeed y best as cooperating in y same intention. Vesicating Applications should be mad to y uper & lower extremities y mode in which they do good is sufficiently inteligible. by making a strong impression on y Skin they interupt that chain of actions constituting [fel??dles]. During y continuance of y fever some Subordinate affections occour which claim attention 61. There is after great heat on y surface of y Body which is very distressing to y patient. When this happens it may be relieved occasionally by sponging y surface with Cold Vinegar or very Cold water. You will thus reduce y temperature allay y irritation & render y patient much more comfortable. – 2nd. A determination to y head in this fever often occours & is indicated by a flushed face, wild expression of y eyes & Delirium or a tendancy to it. – This condition of y head is especially relieved by y application of Cups & Leeches & 8 or 10 z Blood may be thus taken with advantage. But when y Delirium appears to be fixed with y above may tie added shaveing y Head & apply a Blister to be continued at least 24 hours. It is a fact which ought to be rembered that [V.S?] should always preceed y application of a Blister. You will very generally find that a few ℥ of Blood taken by Cups & Leeches will do away y necessity of this last remedy. – It is proper to suffer 9 or 10 hours 62 to elapse after shaveing y head before y blister is applied as by thus doing you obviate y necessity of employing it. How y mere removal of y Hair should do away y Symptoms of Delirium is not very intelligible. Besides this advantage we derive another Viz an opportunity of applying cold to y head by means of cloths rung out in cold water or by use of Ice itself. – 3rd The common Symptom which call for relief during y continuance of Remitt: is Nause & Vomiting of Billious matter arising either from an accumulation of Bile in y stomach or peculiar irritability of that Organ, It is right to repeat y evacuations either by Emetics or saline purges but in a second case a different course is pursued; to quiet irritability is now y Indication for this purpose we have a great variety of remedies The common Effervessing or foaming Draught is exceeding useful when it can be obtained y Sedletz Water administered in small doses at short intervals will often prove advantageous 63. Mint Tea is also useful but infinitely y best is Lime Water & Milk y mode of employing it is a tablespoon of each mix them together and administer every 20 or 30 minutes according to circumstances not y least valuable of remedies for soothing irritability of Stomach is y infusion of Serpentaria dose a table spoon full. It is much resorted to in this city & posseses y confidance of many practioners. When y irritability of Stomach arrises from want of tone in that organ as sometimes happens when Emetics have often been given. Nothing is better than y tinct. Cloves given at short intervals in spoon full doses. As auxiliary to y above mentioned remedies. Fomentations over y region of y Stomach have often proved beneficial & y best of these is made by quilting Pulv. Cloves in flannel & wringing this out in heated Brandy. ℥ii Cloves is sufficient. Pediluvium of Water bath is also highly beneficial. But when y Vomiting is excedingly violant you 64. should apply Synapisms to y Extremities & Blister over y Stomach. But above all y articles calculated to check Billious Vomiting Opium stands prominent. It is a fact well worthy of attention that a pill of Opii which as been kept for 2 or 3 yrs will remain on y Stomach & Check vomiting when administered recent it would be rejected. If y Stomach will not retain y Opii though taken in this way we must resort to Anodyne Injections ʒi or more of Laudnum should be enveloped on a little mucilage & thrown up y Rectum. A favourate practice in this city instead of using anodyne injections is to employ Opii 3 or 4 grs. made into a pill & introduced 2 inches into y Rectum will often prove exceedingly efficatious. Y advantage of this mode are that it can be early employed, that we shall not have to encounter y prejudices of y patient & when y desired effect is produced we may easily withdraw y pill & thus prevent y consequences of an overdose. An intermission being effected 65. effected y Cinchona combined with decoctions may be given. But when any doubt of y absence of y fever exists, you should prescribe y Serpentaria. Quassia Angusturia, Eupatorium, Centaury etc. for reason which I explained on a former occasion. Arsenic will be found in some of these caces to answer very well. The only circumstances which allow y use of Bark while there is y least remaining fever is a palpable tendancy to a Typhus condition. But even here y Meds. will often be rejected & we should confide more in Tonics which add too then principle property that also of producing perspiration. Upon y whole however y Remitt of this country is of an highly Inflam: nature demanding copious depletion with y Lancet & evacuating from y Bowels – when these in y stage are so managed as to correspond with y Violance of y Symptoms no other remedy being imperiously required. – 66. Continued Fevers. These run their course without any intermission though some degree of remission & exercabation daily takes place. – It has been held by some writers that y deffinition is deficient is exceptionable because all continued fevers they say consists of a single paroxism without abdomen untill final termination. But I believe no such fever exists & am surported in my opinion by y highest authority except y fever denominated [in] which begins is perfectly formed & runs through its course in 24 hours which is of short duration & rare occourance. Every other febrile affection is made up as a repetition of paroxisms. – It may be remarked as a general rule that y Exacerbations take place towards morning & evening by consulting nosological writers you will find that this class of Fevers is ranously arranged however Inflam y fever is there is a local affection. I shall treat of them under y general head of Synocous & Typhus y different forms of continued fever may then be disposed of without - 67. deficiency of perspicuity or too great generalization Synocha. As ordinarily defined. I believe has no real existance. Every case at least which has met my observation has been attended with some local affection which has marked it as one of y Phlegmasia continued fever y most common in this country y Billious Inflamatory. This prevails in y U.S. to a great extent, with y greatest violance to y South & is varied not a little by y Climate & y Conditions of Society. Like y Dis already treated it arises chiefly from marsh exhalations but is common without them. It is also produced by other causes. Considering y close analogy of y origine of y Symp. & mode of cure & not to mention y other slight resemblances [t???un] y Intim: Remitt & Continued fever we have good reasons to believe they are y same disease with some differance in type & external Physiology. 68. Physiology. During an Exacerbation a Remitt. is precisely similar to a Continued Fever Billious so that an account of one will precisely answer for y other each being ushered in by y same train of symp. & attended by y same set of affections. Discharged therefore from y necessity of occupying our time with recapitulation of that which has already been said we will proceed to y Cure of y Dis before us but can we arrest y progress of y Fever after it is once established or must we be content with abating y more violant sympts. till it shall terminate spontaneously, this is a question of great moment has been tally discused by Cleghorn Hillary. Pringle & Fordyce. It has been answered in y negative. It is contended by y last particularly Note. Prognosis. If y pulse becomes full soft y skin moist y tongue clean y Urine depositing a White Sedament y prognosis is favourable. Dark tongue parched skin a cold dry surface irritable & quick pulse gastric distress etc y prognosis is unfavorable. – 69. But not only are we enabled to interrupt y carear but also that either addition too or subtraction from y cause producing it will not have y slightest influance. – In support of this opinion they appeal to Small Pox Measles & Dis which y fact is undoubtedly stated. Neither of these cases however abated in Violance can be cured by artificial means & neither of them are affected by y further application of y cause this is particularly true as regards Small Pox. But their reasoning is fallacious in as much as it is deduced from y cure of dis. peculiar in term & provided & governed by their own laws. As respects y common fever we see them daily checked by y remedies we employ. cant it be denied that they are interupted in their course by a timely recurrance to [V.S?] Evacuations from y alimentary canal & of a similar nature. Most admirably we see this happen every day of our lives & sucess are y trophies of our profession. At y same time we must concede that there is much difficulty on may occasions & hence 70. y precept with practical Writers “to attack y obis in the first stage” as there it is most easy to obtain a Victory Y doctrine above alluded to is highly pernicious in its particular tendancy & haveing arisen in y dark ages of Medicine Sciance & kept up as a respect for y authority. – It will not fail if credited to take away energy of practice to sink to irresolution & indescision in y management of diseases at y very moment too when exertion is most required. According to that you must remain an Idle spectator of y Ravages effected by y unrestrained & vehement attacks of fever on y Constitution. Let it not be supposed from what has escaped me that I am not at all inclined to deny that in fever there is a tendancy to solution or Crisis. This was early remarked by Hypocrates & has since been abundantly confirmed. Hence arose y Doctrine of Critical Days by which is ment those days [by] in which y fever is disposed to a Solution These according to Hypocrates are y 3. 5. 7. 9. 11. 14. 17 & 20. or as some authers will have it on y 21st 71. Every practioner of enlarged experiance must have witnessed a more than ordinary tendancy to a remission of y symptoms on some of those days. But such tendancy is not so clearly manifested our dis. as as in those which have occurred amoung y antients y reason of this is not obscure. You all know that y climate of Greece is equable & serene & that y people of that country in y time of Hypocrates still cherished y symplicity of their Republican habits. Diseases therefore prevailed with uniformity of character not being disturbed as amoung its by deviations from nature & by y changes of y climate. – Eternally fluctuating & unsettled attempts have been made to explain y recourance of critical as, on y supposition that Intim. are y primary types of all fevers & hence that continued fevers at first are Quotidian then Tertian & after y 11 day very generally Quartan. Wheather this be admitted or not y facts are important they teach us to watch y efforts of nature, to bring about a crisis 72. which is marked by Remission of Symptoms & that such is y case & time [cross out] most propitious for y administration of our remedies. – Treatments. – Early in this discussion it was remarked that y Billious Fevers are far y most Inflam: in their nature. This being y case y principle indications are very obvious viz to reduce arterial action to y ordinary standard. Confessedly to obtain this no means are equal to y Lancet. – Its operation under such circumstances is prompt & effectual. But in this dis it should be directed by judgment & tempered [cross out] by discretion. The same Complaint may be varied & none more than y one under consideration by Climate. Season by personal Idiosyncracy & by many other causes. This while in this part of y Country y practitioner found to bleed copiously was y only method of cure. while in y Southern parts y practitioners hardly ever opened a vein. – But no matter in what part of y wourld you settle do not refrain from depleting with y Lancet when it [was] is indicated 73. by a strong pulse a hot skin. delamination to y Head & other symp: of increased action. those symp. wheather They occour beneath y burning Trophies or amidst y Polar Snow’s or in y more genial Clime of y Temperate zone must be considered as signals held out by nature for succor from y Lancet & other evacuants in her difficulties & oppressing. Bleed often in Small quantities. – Next in importance are those Meds. which produce evacuations from y Alamentary Canal. These are called for in all Fevers but particularly in this on account of y large accumulations of Bile which are apt to occour. – My general practice when I can prevail on my patients to consent is a Emetic & as I remarked on a former occasion antimonial preparations are decidedly to be prefered. It will be perceived that I am decidedly an advocate for Emetics in this Order of Dis. any experience has pursuaded me of their superior efficacy to purge & I am surported in my belief by those. physicians who are acquainted 74. with y more inveterate shapes of Billious Inflamatory Fever. But that one may reap their good effects they must be repeated & in some cases several as in sucession. There is a fashion in Medicine as well as in other things. Emetics which at one time were universally resorted too & of whose efficacy undoubled testimony was afforded in one of y revolutions to which our art is subject was suddenly supplanted for purgatives, but they have recently revived. By consulting y French & English Authers who wrote on y Dis. of their respective armys in Egypt 20 yrs ago. it was found that y Vehement Billious fever of that Climate they were obliged to submit to other modes of evacuation Emetics therefore were adopted by y whole medical corpse of both armies without regard to those habits of Country & prejudice of Education which have so much influance in y generality of cases of this Kind. Y efficacy of Emetics are equally attested by East & West India practitioners as well as by those of our country. – When Billious fever 75. prevails to great extent they are marked by great violance of symptoms. Determining from my own observation I should say that when early administered they hardly ever fail to check y Dis & that in y advanced stage by their operation when free & copious y pulse is reduced y pain in y head relieved. sickess of Stomach quieted y temperature of y surface lowered & diaphoresis produced by which y patient is quieted & y critical solution of y fever hastened. But when Emetics cannot be administered either for y prejudice of y patient or some peculiarity, a predisposition to apoplexy after active [cross out] Vomiting. We may with propriety & advantage [recoar?] to y use of purges. Combination of Calomel with a Drastic purgative as Jalap. Rheii Gamboge will succeed best in y management of continued fever. – It is a favorite practice with some when y Stomach is loaded with Billious Acumulations to unite Emetics with purges so as to induce an artificial Cholera or as Sailors say “to clear y ship fore & Aft. Rx Sub. murials Hyd: oss Ext. Elatenum gr. ss. 76. Jalap. & Rhii aa gr.v ol. Cennam. [gtt?] pills 6 two to be taken every hour this clears fore & aft. Of y utility of this practice there can be no doubt. It has been occasionally resorted to in y Billious fever of this city with sucess & it is more employed in y Southern States where there is great necessity from y great vehemance of Bill: faction Combination Calomel with Tart. Antim: is [cross out] commonly prescribed to which some add Gamboge. This in a large dose from 10 to 12 grs. will produce y effect without y addition of Emetic Med. But to justify a remedy so violant y fever must be of a dangerous character & y indication of Billious Accumulations must be strong & unequivocal. In presenting purgatives if delay is at all admissible it is proper to wait for that period of y fever where a partial remission of y Symptoms take place. Given at this time they act powerfully & effectually. But exhibited during y rage of y fever they are either rejected by y Stomach or lie inactive. By y pocess above [detailed?] y Alimentary Canal being emptied 77. we are now to resort to Saline Laxatives. Employed in small doses they are beneficial by Ruping y bowels in a soluble state & from their action on y exhalent vessels of y inner surface of y intestines they detract y watery parts from y circulating fluid & thus keeps down y arterial Excitement & produces a demunition of y Violance of y Paroxisms. Of y Saline purges y best have been already mentioned, A prescription very much used by myself & other practioners in y city is as follows ꝶ Sulph. Soda ℥i Tart. Antimony gr. i Suc Limin ℥ss Water ℥4 y dose of this is a tablespoonfull every 1 or 2 hours according to circumstances. It keeps y bowels in a locative state & produces a mild Diaphoresis reduces y arterial action & lessons y Sufferings of y patient. – As cooperating remedies Enemata are not over looked they are useful for promoting y action of purges. they are also beneficial as a substitute for cathartices when y alamentary has been much evacuated. Several formula have been used 78. y best for common purposes is that I will now mention. Take a pt. of Water & a table spoon of common salt & molasses & one of Olive [a] Castor ol. mix them & Inpect. When you wish an Enema a little more Stimulating or where there is flatus in y bowels as often happens at y close of fevers. Terbinth injection, may be used & be adapted to y cure. It is made by mixing a table spoon full of y ol. Terpentine the White or Yolk of an Egg & adding a pt. of Waters It relieves flatus more readily & spedily than any other remedy & in this affords great relief to y patient. By y combined operation of y remedies already mentioned y excitement of y system being reduced we are next to employ y meds. which are calculate to produce Sweating. Of all y modes of managing fever y practice of sweating is y most popular & general. By y vulgar on all occasions this is thought safe & most effectual nor is this opinion confined to y low & Illiterate of mankind. Every class of Society acquires y prejudice & entertains y 79. y same view same views. It is obviously however that remedies which act so powerfully on y System as many Diaphoretics are apt. to do should not be want only trifeled with by imediately employment. On y contrary they should never be used in Inflam. fever untill arterial action & general Excitement is reduced by V.S. & evacuations from Alamentary Canal. Diaphoretics then come with advantage & mitigates the dis. or arrestes its future progress & even here y milder diaphoretics should be employed & those should be combined with auxilliary means which have y same tendancy. As a general precept from which you must never depart it may be stated that in Inflam. fevers it may be stated that in Inflam: [cross out] fevers we are rather to solicit perspiration by limited means than to extort it by violant measures. To bring a continued fever to a crises y Antimonials are generally prefered. early introduced into y practice of med. they were occasionally used & with variable reports their efficacy were declared 80. by Hoffman & then successfully used by Cullen Fordge Antimony [cross out] affords an infinite number of preparations each may be so given as to produce Diaphoresis though few of them are employed at present In England even to this time y cellebrated Puties Jacobe or James Powder has no small portion of confidance that it often excites perspiration in fever can hardly be disputed but so far as I have observed its effects it is in no way superior to its kindred preparations The composition better known & hence administered more easily & certainly regulated on y Continant of Europe & certainly France is y Golden Sulphuret of Antimony. & has an indisputable asendancy over all y preparations of that metal. – Wheather it is entitled to this confidance does not allow me to decide. Compared to y Emetic Tartar I think it inferior in every point of view. This latter med. may be made to supersede all y rest of y Antim: preparations, Nearly Tasteless quite inodorous & minute in its dose, it may be administered 81. with facility prehaps equal it not transcend a wt. powers. – Of y precise manner in which y several preparations of Antimony operate in continued fever or y principles which should guide us in its use we are not accurately informed. Cullen maintains that they are of no advantage unless they vomit or produce considerable nausea but on y contrary it is continued by Forage & there can be no higher authority on y subject that by exciting vomiting y febrifuge powers of Antimony preparations are impaired & that they are always most effectual when y [?h?ght?s] degree of Gastric distress is excited by them. To this point I have directed a considerable careful attention & I am led to concour in this latter opinion. Nausea by whatever means excited or whatever way induced is not in itself salutary in directing y fever to a crisis or favourable solution. During continuance of Nausea Arterial action Macular power & animal temperature are undoubtedly lessened but afterward & reaction of y 82. body & consequent exacerbations of y Fever takes place. But did such a state of y stomach operate in y same every beneficially as contended for by Cullen practitioners generally: y utility of medicine should be proportioned to y to y effect thus created & various other Diaphoretics infinitely more violant & lasting in their operation as digitalis. Tobacco should be prefered. But this is contradicted by y lessons of experiance & y united voice of practitioners in every country. Meds do good in fever by exerting their own specific or peculiar action & when they disorder y Stomach by Nausea & Vomiting they are always productive of more or less mischief To illustrate this would be easy but it would take too much of your time & can be acquired by any one who will direct his mind to y subject. There are many febrifuge Meds. as y Effervesing Draught “Neutral Mixture” y principle effect of which is to subdue nausea & Vomiting & to sustain y tone of y Stomach. But while contend that y Antim: press: Arsenic. Bark. Mercury & Lead &c 83. act by a peculiar power I conceive that as this is y case with y articles enumerated y effect will be proportionate to y quantity taken provided they produce this genuine mode of action which is independant of any Nausea. Curious as are y views in Speculation they are inconceivebly more interesting when applied to practice. Let it be allowed that they are correcttive do away all objections against y employment of a rememedy of undoubtedly high utility nevertheless it is not to be infered in y preceding remarks that we should not have recourse to Emetics in y early & forming stage of y fever here they act on different principles & their efficacy is too well attested to be shaken by any thing that can be said concerning it. To obtain from from Antim. Remedies y precise effect to which I have above alluded is not always very easy. Y febrile affections are various as regards irritating so that y Dose as well as is in intervening as different in different individuals. As a general Rule 84. 1/10 to ¼ gr. of Tart Antim dissolved in water & united with a little spts. Sav: Comp: to give it colour may be taken every 2 or 3 hours as prorenata. But some Stomachs are so irritable that they retain it under no circumstances & here we must have recourse to other meds. of this nature as y Saline or Neutral Mixture which is prepared as follows viz ꝶ Lemon juice or sharp Vinegar ℥ii add Sab, Tart: till a complete Saturation is effected then add Loaf Sugar ʒii aq. font. ℥ii. – sometimes it is good to add a little Laudanum & a small portion Spts. Nitre Dose is a tablespoonfull every hour or two. To meet y same indication many of y Diaphoretics have been used some of which possess in an small degree y confidance of practitioners. – Combinations: of Ipecac & Opium are of this nature but though of y highest utility in Phlegmasia they do not succeed so well in y general febrile affections Why this should be y case it is difficult to tell but such is y fact & with it we must be contented not less do these remarks apply to others if y same class 85. most of them act as promptly & copious as y Antim: press: in aresting y progress of Continued fever. [illegible] this fact we find new reason for y supposition that y Tart. Antim: posseses specific powers in febrile affections in dependant of Diaphoresis or nausea. certain it is that y efficacy of Antimonials is not proportional to y degree of perspiration excited. Notwithstanding all that has been said in y management of fever some [cross out] practitioners hardly ever recour to this plan. by them y Neutral Salts. Refrigerants are prefered y precise Modus Operand of these meds is not understood attempts were [??dde] to explain their operation on chemical principles Though this hypothesis is not without plausibility yet it does not afford us & solution of y difficulty. But whatever may be there method of operating y Refrigerants reduce arterial action. lower animal temperature & partials relieve y surface though this really occasion perspiration. The principle article in this class of remedies is [cross out] Silon or Potassa & no Meds 86. more employed in fever & Inflamatory Dis. Z increases its powers it is customary to combine it with Cal. & Tart. Antim. forming a combination well known by Nitros Antimonial Powder viz ꝶ nitras Potassa ʒi Calomel gr-xvi Tart. Antim gr i to be divided into 8 powders one of which is to be taken every two hours according to circumstances. This is suited to y more robust of our patients & on a/c of y Cal: which it contains is very apt to purge it is prudent in some cases to exclude y Case lest Catharsis should be induced when not demanded or excite salivation as it is known to do sometimes under such circumstances, y Tart. Antim: is also to be graduated to y case. Even [cross out] in so small a quantity as 1/8 of gr. it sometimes distress y Stomach & even Vomiting, - Cooperating to y same end viz y reduction of diurnal febrile excitement. Cold applied to y surface has lately been recommended. I shall subsequently enter on y consideration of his subject I shall antisipate very few of y [former] future observations 87. Cold Water. may be applied in 3 ways either by Ablution. Aspersion or Effusion each adopted to y particular circumstances. But in y case before us I prefer y Sponge. It is much more agreable & less Dangerous than y others. But cold applications Are never called for unless y Pulse is active Skin hot & dry there they are very useful. they remove y uncomfortable secretion causesly y hot skin or heated surface & lessen y force of y circulation. induce mild diaphoresis & sooth that irrestlessness which generally accompany febrile Dis. But under other circumstances it is perilous when y system is exausted by y fiber would at y period be unable to react. Such is an outline of y 2 plans for treating fever one Refrigeratory y other Sweating. This is not y place for instituting a comparison between them nor could it be easily done y fact that they cannot be received as several measures each adapted to different circumstances. – 88. Before we use Diaphoretics in Inflam: cases we should first deplete in proportion to y vehemance of y Symptoms by V.S & evacuations from y Alamentary Canal & exactly at this point Refreg: remains maybe called into use with signal advantage. Before dismissing y Subject I wish to impression you y value of Sweating in y cure of fevers. It was formely y practice to treat Inflam: Dis by forcing a perspiration by heating Alexipharmics or antidotes. But those are productive of wide spreading mischief they were soon discarded. But it is wrong to argue against y employment of an article from its abuse sweating like Vesication is useful or as it is directed. When under y control of sound discretion it is highly important & indisputably acts powerfully in combatting Diseases Diaphoretics by determining y Blood to y Surface lessons Internal Congestion they relieve y constriction of y extreme vessels & thus renders y patient more comfortable y more we reduce y circulating fluid [cross out] thus they reduce arterial action by direct depletion Finally they equalize excitement & retain that just 89. Cheshire June 9th 1827 Cheshire March 31 1828 Equipois in y various actions of one system in which perfect health depends. Let us not therefore throw away remedies so useful on account of y objections which theory may raise or false refinement indicate. When hereafter we shall take y field against diseases you will it not enough to combat it with one remedy on the contrary you wish to be victorious over these to human happiness you call into requisition all y recourses which have been put in your hands. – by your God & all those which can be derived from a complete Knowledge of your art. We have now arrived to that stage of Continued Billious & Inflamatory Fevers where Vesiccating applications are found useful. They should be applied to y extremities sometimes both upper & lower but by some modern practitioners they are altogether condemned & strongly prohibited in this form of fever. Of those who entertain such views by far y most distinguished weight is that of Fordyce.. 90. It was one of y sayings of that great man that resicating applications had not y least effect in arresting y progress of Fever but on y contrary they never fail by creating an additional excitement or occasioning [cross out] exacerbations of y Dis. It seems to me not very difficult to reconcile y contraruly of sentiment that has prevailed on this point. Nothing is more different than y effects of Blisters applied in y early & late sap of y Dis. When there is much arteriae actions febrile excitement they never fail to do harm & it is not less certain that they are of y utmost utility in a reduced state of y system. Let y Body be reduced by V.S. Emetics & Purges & then resort to Blisters to quite y pulse, equalize excitement put an end to y action of Dis. & establish y regular order of health After y remedies above enumerated prove unavailing much confidance is placed in Mercury. Urged to a moderate extent or Salivation there can be little doubt of its utility when y system can be brought under its operation. But in most cases before y mercury 91. Cheshire January 21 1827 A. 1828 can be made to act feaver from its rapid carear terminates to be of use therefore it must be properly employed & as y bowels are weak & irritable it should be applied in y shape of. It is difficult to excite Ptialemo while y pulse is active Mercury therefore should never take y place of depletion & y remedies which effect this are generally sufficient to remove y fever. * I have thus concluded y history of y remedies which are best calculated to cure Billious Inflamatory Fever. Much however depends upon dericing a proper attention to y Minor circumstances which often so powerfully influance y result. Of these by far y most important are Drinks Diet & General Management of y patient during y progress of y Dis much * In y Billious of this country Bark does not suceed y Remissions being short, tong moisten skin relaxed it is useful. Cullen says that every fever proceeding from marsh miasmata after sufficient evacuations may be treated with Bark beneficially. All Fevers arising in y spring should be treated by Calomel. – 92. dryness of y fauces & extreme thirst generally prevails. It has been a question wheather y patient should be indulged in this ardent desire for Drink. y Physicians of antiquely were much divided on this point while one set to totally forbade. y other allowed y use of Water. – It requires little Sagacity to discovour that y medium between y two is y proper practice By denying altogether y occasional use of Drinks we shall cause great anxiety & distress & rather increase y Dis & by allowing y unrestrained employment of it we shall find that y Stomach will be disturbed & certain Nausea & Vomiting with other mischievous consequences will result. We should therefore direct now & then a table spoon of some Acidulated Drink as Lemonade Vinegar & Water. Apple Water. Toast Water. Tamarind Water & a variety of herb Teas as Barley Water, Balsam Tea. Sago Tea. & a Solution of G. Arabic. But what I have found to be y most effectual in allaying Vomiting 93. William R Hitchcock Esqr. Vomiting & distress at y stomach is a table spoon of Lime Water or a tablesoon of new Milk from y Cow or a decoction of Snake Root, even common water provided y quantity be small & y temperature not too cold, should not be refused. It is a precept worthy of your attention that drink in moderate proportions & moderate temperature will relieve y thirst quicker than Cold Drinks immoderately taken During y continuance of y fever y Drinks above enumerated will afford sufficient nourishment to y patient. – It sometimes happens that y appetite solicits more solid food & y demand of y patient is loud & clamerous but y propensity is always an unfavourable indication & should not be indulged. Every practioner must have seen y eble consequences which results from y gratification of a depraved appetite & in many instances cases from this cause have terminated fatally which would otherwise have been cured. An Old Opii pill checks vomiting. Enema or supporting of 94. Samuel Johnson [Esgr?] Oppi. Blisters over y Stomach & a lump of Ice held in y mouth. a piece of Liquorice or an Infusion of Liquorice will allay y thirst grii of Calomel will be of service. Strong coffee [no cream or sugar] ¼ or ½ gr Calomel with G. Arabic. Sacch. Saturni grs every ½ hour. Mint. Brandy with a Lump of Sugar are all good in irritable stomach of Billious Fever. – In y History of Pathology of y dis I mentioned y causes which accelerate y increased action these should be studiously avoid in y febrile condition. As prehaps y most operative cause you should direct partie: light to be excluded & also that conversation should not take place in y chamber of y Sick. – Before leaving y subject I will give some some directions for y Management during Convalescence. Febrile affections of every kind leave behind them an accumulated state of excitability which it not properly directed may be productive of a relapse a condition of things more Dangerous & intractable 95. than y original Dis. The first step when y patient is recovered is to remove him to another room or to order that all y apparatus of sickness as Phials. Bases, Plasters &c should be placed out of sight from seeing these a remamtrance of his sickness is kept up. & his spirits being depressed retards y progress of cure. Y changin his skirt & cloths has a great effect in promoting y possess of Convalescence. 2nd. Be careful to regulate y Diet according to y excitement, you should begin with faranaceous articles & more are better than Tapioca. Arrow Root. Sago & Rice. Next you may allow Eggs & Oysters raw or very slightly cooked. Boil a Chicken or any other article of a light & digestible kind may be allowed. – But whatever is taken should be in small quantities at a time. This is a rule of extreme importance & rembember to direct often & a little at a time. As regards Drink pure water is y best. If something more is required by y condition 96. of y patient & from his solicitations y best liquid which you can direct is Porter diluted very much with water Malt Liquors & especially Porter is infinitely more agreable [cross out] & less injurious than Wine or ardent spts. however diluted. 3rd It is hardly less important that y patient should gradually return to y employment occupations & habits of Life. He is especially to avoid much exercise of his intellectual faculties. – To prevent this he must be kept from study & from attention to business of any description Company could be avoided. Be not too precipitate in permitting your patient to take exercise & especially out of doors. There is generally much eagerness on his side backed by y intercession of his friends under [illegible] that it would afford him strength confirm his recovoury. – But you must recollect that there is great liability to take cold & from this irritable state in y commencement of convalescence y stimulus of riding instead of strengthing would probably give a return of fever. Even when you allow him 97. to take exercise direct him to be warmly clad & should particularly enjoin it on his attendants not to protract y ride so as to fatigue him. Y preceding are instructions [cross out] relative to y management under ordinary circumstances. But now & then certain symptoms arise during Y course of Med. treat. which demands [cross out] particular attention. Sometimes patients in y convalescence from a long spell of fever remain very feeble & have a total loss of apetite. To meet y indication of these cases Tonics should be given amoung which y Tinct: Cinchona alone or combined with a portion of Tinct. Gentian is highly beneficial. But there is a great variety of articles of nearly a similar Character which may be used in sucession according to y circumstances of y case or to y taste & caprise of y patient. As y leading ones, may be mentioned all y Vegetable Bitters as Columbo Quassia Gentian, & these should be employed in watery infusion. 98. y Chur. Vitriol is also an excelent remedy & establish y a restoration of apetite. Not y least distressing affection which is incident to a state of [cross out] convalescence is extreme watchfulness & inability to sleep this is very unpleasant often retards recovery & somet: aggrevates y fever here Small Opiates are useful. The best preparation in this case is y Black Drop. This preparation posseses 3 times y Strength of Laudanum & has a more powerful anodyne effect than any other with which I am a aquainted. It never so far as I know produces y nausea & other disagreable effects which sometimes results from y use of opii & its Spts. Tinct. When Opii in this form fails you are to resort to Hops Tinct. & what I know to succeed very well is y Camphoretic Julep this often quiets irritation existing in y system & disposes y patient to slap. Sometimes watching proceeds from an empty stomach & when this is y case stimulating food conjoined with porter is generally effectual. – 99. Somet. Diarrhoea & more commonly Costiveness attend recovery from fever. As to y Diarrhoea it will generally yeald to y Cretaceous preparations where on y contrary there is a tendancy to Costiveness it will generally yeald to small doses of Rheii. This cath. should be prefered because it impartis tone to y Bowels & when taken by itself never purges copiously. It is worthy of [cross out] recollection that however beneficial evacuations from y Alamentary Canal may prove in y early stage. – It is not less injurious in y convalescence more than any other cause. Copious evacuations at this time induce a state of exhaustion & not unfrequently brings back an allarming degree of Fever. I have see this more than 100 times in y condition of convalescence These are y applications which have some claim to notice but considering which I have protracted y discussion. I will detain you with only with 1 or 2 observations. y Billious Inflamatory 100. may terminate in Typhus but more frequently in chronic fever. As y treat of y former differs on nothing from y Idiopathic Dis of y same name it will not anticipate y observations which I shall have occasion to make here after. y Chronic nature of y Fever claims our particular notice it is called Febricular from its from its diminution & indistinct symptoms which attend it. In y country it is known by y name of Inward fever. Y pulse is small corded & hard, much heat on y surface. a Billious complexion & a tenseness of y forehead combined with Headach or pain in y side. y Patient has always Edematous swelling of extremities, scanty high coloured urine & ash coloured Stools, y Type of fever is either Remitt. or Intermitt. & not continued, y course of this condition of things is too obvious It arises from Congestion in y Large Viscera partic: of y Spleen & Liver. Y appropriate remedy is a slight salivation or what answers very well as a substitute a course 101. Nitric acid ʒi of y latter should be given every day for 8 or 10 ds. Commonly however there is much fever & pain so that it is necessary to resort to frequent & small V.S. vesicating applications at same time are very important placed on y side if there is pain there. But if this is absant & we wish to interupt y association on which this small fever depends I would greatly prefer them on y ankles & wrists. It is a common practice to treat y case with Tonics particularly with cinchona but it is highly prejudicial they Lock in y Dis. instead of Liberating it from y system. After y evacuations have been premised then y Tonic Meds. may be employed. of them by far y best is Cinchona but where this fails we may resort with great advantage to Fowlers Solution. – Delirium. very often in y progress of y Dis there is delirium y patient becomes wild in his conduct get up from his bed & uses singular expressions there is at y 102. same time great turgesance of y Eyes & Face fulness of y Head &c. In order to remove this it will be necessary to remove y Hair & shave it close to y Head. apply cups to y temples. here Blisters should not be applied untill Inflam- is subdued. Note. To cure Headache in fever apply 2 or 3 leaves of y Wild Popular. imersing both arms in cold water, sprinkling y Head &c. – Note, This prescription is good in fevers viz ꝶ Tinct Opii ʒi Acid Tart. gr. 10. Aqua font, ℥ii Dose table spoon 103. Remittent Billious Fever. The Continued Billious Fevers are very apt to terminate in Billious Remitt: in which case there is perfect & distinct Remissions. It is a common practice in y U.S. wheather Remitt: are assumed form of Continued to treat it from y very commencement with Cinchona It is laid down by Cullen that even in y Continued form arising in Miasmatic countries always to make use of Cinchona without there being any Intermission or Remission. Whatever may have been his sucess at Edinburgh it is not applicable here in y U.S. when y remission is not complete y Bark will be rejected or oppress y Stomach & this aggrevates y Dis. The practice here is when there is some remission to substitute for y Bark y other Tonics as Serpenta: Quassia. Angustura & our own Indigenous articles of y same nature. Arsenic is much better adapted to this form of Bill: fever than y Bark & in general it will be y best plan to resort to it. It will however be found in y generality of cases that, V.S. 104. Emetics & Purges will be necessary before y Tonics can be administered. Yellow Fever as an Dis of autumnal occourance & allied in some respects at least to y dis fever already Described, I proceed in order to y consideration of Yellow Fever. It is not my intention to occupy your time with a very minute history of this Dis. To y writings of y late Dr. Rush I refer you for details relative to y subject & more partic: for his account of this dis. as it appeared in 1793. some deffects for y time it was written] undoubtedly is y most perfect muddled & best historical narrative [in y whole compass of medical Literature] pestilentia dis. contained in y whole compass of Med. Literature As prehaps you all know that. Y.F. is an Epidemic of Tropical Climates – to W India Isles it seems to belong particularly. – It appears occasionally to have occoured in y U.S. from y earliest state of settlement but it was not until y yr. 1793 – on a/c of its ravages & y Terror which it created that it 105. first attracted Med. Curiosity & attention. Notwithstanding all y writers on y subject & y ardent continued enquiries which have been made hardly one solitary point connected with it is better settled or less a matter of dispute than when investigation first began. – Its origine nature & Treatment are points, still as much disputed now. as they were before. It is far from my desire to review y disputes which were carried on with none of that complaysancy which should characterize all Sciantific discussions still however it is my duty to afford you some information on y subject. though I trust in giveing it I shall be able to temper my an imadversity by y sincere & respectable attachment which I entertain towards [both] all parties engaged in y controversy. – As regards y mode of production y disputes have been chiefly on of meaning of words. It is attributed on all hands that in each instance y discus procds in some way from Vessels. It is true that local filth as y 106. contents of Docks. Gutters & common Sewers has been assigned by some as y accessary cause of this pestilance but was this true for y extent to which they argued it would appear that y dis must appear every season for y sources above mentioned crest now just as much as on former times besides we have a complete repetition of y doctrin in y fact – the Scavengers a class employed in 2 cleaning y city of y filth universally escape y Dis. Dr. Rush states out of 50 Scavengers only 1 took y dis in 1790. But it may be said that these persons are so habituated to y exhalations of y filth [universally escaped y Dis] as to be insensible to its action, This however cannot be justly alleged because owing to y great scarcity of y Scavengers at this time many of them having left y city individuals were employed pro tempore But while I so far accused to y importation of Yellow Fever I do not believe for a single moment that in any 1 case it was introduced in a palpable & well formed condition. My impression is 107. that ships coming from tropical climates in a filthy state bringing with them y materials out of which this pestilance is produced. Wheather such exhalations excite y fever under all circumstances I am not prepared to determine. It is more than probable that a certain condition of y atmosphere is necessary to give actively to y cause. This would seen to be y case since y fever is of occasional occourance though vessels arrive every day from y W. Indies. Long ago it was suspected wheather y Dis was imported or generated in our own country it would not take place except under a degree of temperature – but it has been proved as satisfactorily as any problem can be proved that unless y mean temperature of y summer months June & July is as high as 79 or 80 Fahrenh: y Yellow Fever cannot prevail in our climate. This have taken from a register kept in Philadelphia in 1793 to y present time. From this it appears that when y media heat of June & July has been 80° 108. not in one solitary instance has y fever appeared but on y contrary when y temperature was above 80 so was y greater violance of y Dis. Nor does y truth of y observation rest on y register on Philad. alone by a similar one in N.Y. weare waranted it arriving to y same conclusion. Much controversy has existed as to y Contagious nature of Y.F. that it is not y generals uniform character of y Dis & think has most satisfactorily explained. Not to protract by discussion to any length I shall compress y argument on both sides into as narrow & compass as possible. It has been said it is not contagious for it is of y nature of Epidemics & therefore depends on more general causes. It is also said by them that y diseases imediately proceeding y Y.F. from one end of y union to y other assume more or less y inflamatory type of that dis. 2nd.. It is moreover said not to be contagious because it never proceeds beyound y sphere of y city infected by it. – In surport of this argument 109. strong & almost irresistable arguments have been added. It appears that during y prevalance of y fever in this city that though several hundred people were received into y Hospitals & crowded together into small & comparatively ill ventilated apartments get no one instance of extention of y Dis occoured y Phys. Med. attendants & nurses whoever constantly amoung y such y dying & y dead escaped without one exception even though dissection was carried on [even to] an almost incredible extent 3rd. It is alleged not to be contagious because it is uniformly suppressed by cold weather. Whatever may have been its ravages however universal its prevalance y moment it first appears its carrear is checked or terminated. This is undoubtedly contrary to y nature of contagious diseases. 4th we are assured that cases have occoured in y country remote from y city & where it could not have been excited by contagion or intercourse with y sick. But on y other hand facts are 110 adduced too important to be over loocked. 1st. It is alleged that y dis in every situation commences at some point from which I gradually spreads & diffuses itself – In 1793. It could be distinctly traced to a Cargo of putrid coffee thrown out of a vessel from y W. Indies upon Arch St. wharf. y persons employed in unloading y vessels were first seized next y inhabitance contiguous to y wharf & from this it gradually extended itself untill it involved y whole population. In 1805 y dis originated in Southwark & was traced gradually diffusing itself from square to Square untill it covoured a great part of y city. – 2nd. It is answered by respectable physicians that y fever actually proved contagious in y country. to this point we have y attestation of Doct. Wistar who recorded several instances in which y dis happened in Germantown & which was distinctly traced to y city. There are a number of facts of y same kind in y publication of 111. y College of Physicians. It has also been [impactd?] by y cloths of those that died. 3rd. It is maintaind that y Y.F. does not take place twice in y same persons in this respect obeys y laws of Contagions dis. On this point Medical men are exceedingly divided. While on one hand it is asserted by a large member of Practioners of this city that it never occours more than once in y same person It is rejoined by a large number that eases often occour where one individual had this dis twice In a recent publication by Dr. Hossack contained in y last edition of Thomas. it is state that on a recent vursit to Philaa. y Doct. had conversed with several medical men on this point & had not found one who did not declare that y dis is incapable of being twice taken, but he was mistaken. It so happened that his that his communicates on this subject was a particular set who maintained this opinion. – If he had addressed his interrogatories to Dr. Physic or to 112 Dr. Dorsey he would have found that they no more believe it than they do transit – or thus y New York school was superior to ours. – It is however stated by Dr. Griffith that though he attended thousands yet he never met with one instance where y dis occoured twice in y same person. By consulting foreign writers you will find no more union than in our own. Most of y W. Indie practitioners entertain y first [sentim?] y question has lately engaged much attention y British Government inconsequence of y occourance of Y.F. in various parts of Europe partic. in their ports in y Meditaranean Sea instituted injuries relative to this point on an extensive scale. Two bords were instituted of Med. men who were to collect all y evidance y subject admitted of. After a full examination of witnesses & documentary evidance y College of Physicians of Lond. as well as y Med. board reported as y consequence of their deliberation & extensive enquiries y following [103.] 113 conclusions were 1st. That it cannot be taken more than once – In support of this point facts were adduced of a very conclusive description. Amoung others it was stated in y authority of almost all y med. men in that regiment which had previously served in y W. Indies y soldiers who had been affected were not more instance again attacked by it. – This fact as so well ascertained that y soldiers were employed as nurses to y sick & did not experiance any in convenience Nor as regards y origine of y dis. is y Epidemic less direct at Cadis it was traced imediately to a Vessel from y W. Indies. It was shown that it could not leave arisen from any local cause from y circumstance that it did not occour in y most dirty parts of y city. It was farther shown that Marsh. Miasmatic could not have given rise to it because on one side of [Cause?] there is great marsh which every season 114 [104.] occasions y different kinds of Billious Fever get during y cariers of this pestilential dis. that part of y city was perfectly healthy. Strong however as y facts appear to be one still more conclusive may be added. Y Garrson at Geberatter is situated on a bank exempt from all Mail Exhalations & kept perfectly clean from filth of every kind by y severity of y military police. No place is so little favourable to y production of Pestilential fevers yet it prevailed there to an enormous extent. It is affirmed that y dis in this instance was imported in a vessel from [??dis] & could be traced to y wharf where y vessell was lying. Enough has been said how contradictory all y efforts on this subject are when facts so opposite in their tendancy related by respectable authority. It is imposible for a circumspect mind to arrive at any satisfactory conclusion. It would not be safe in such cases to trust to any [opinion] ceasing & even if we were to employ it we might arise at oposite inferances. but really there is [105.] 115 nothing very repugnant or absurd to reason in y belief at least of occasional contagion of Y.F. Typhus confesedly is very often contagious but it is said when this proves so it [is] arises from y exhalations produced by y excretions in a state of petrifaction of this statement I do not believed single sellable. Typhus Fever has again & again occoured when y greatest cure was taken to remove all filth. During my residance in Edinburgh y British fleet which was cruising in y North Sea was infected with Ship fever. The Sailors who had been attacked were landed at Edinborough & taken to y Hospitals of that city. More than hlf y Students who attended on y sick were attacked with y fever & many of them died besides were y dis. occasioned by y effluvia from secretion or excretions it would be as diversified in its nature as y causes are from whence it is produced & each of these 116 [106.] different excretions would produce a different disorder but this is not y fact. All y cases which occoured in y Hospital were precisely y same or marked only by such differance as may arise from y violance of y attack & idiocincracies of y patient or their peculiar constitution. – What also do experiments prove in regard to this point? It has been most satisfactorily shown by Hogarth & other European writers that Typhus is not always Contagious dis. as much so as Small Pox itself but y sphere of action was not extended beyond a few feet. From y experiments of Dr. Gregory of Edinborough it appears that Typhus does not prove contagious beyond 5 or 6 feet. If a person remains within that sphere he was sure to be attacked with that dis. Does not this show that fever may be contagious & that it is not propogated from y putrid excretions but from y patient himself. All contagion is owing to a secretory action of y vessels. & differs [107.] 117 according to y nature of y stimulus by which y vessels are excited. Thus y Contagion of Small Pox differs from that of Syphilis only by being produced by a different action of y secreting action of y secretory vessels resulting from y disimular nature of y Stimulous by which they are called into action. Now if y extreme vessels in T. secrete contagion why should they not perform y office in A fever where y dis assumes y Typhus inclination that they do so I am perfectly persuaded but it is only when it puts on y Typhus [grade] condition that Y.F. proves contagious we observe y same in Dysentary which in its ordinary form is not of this character but when it becomes Typhus y whole tenor of Med., Sciance goes to show that it is propogated by contagion. – By consulting y best writers on this subject you will find that other complaints though not contagious under ordinary circumstances but when they assume y Typhus Type do become so. 118 [108.] This I believe is a law of universal prevelance amoung Diseases. I do not see much force in y argument. that Intim: fever is not communicated in Hospitals & by dissections. It is in this respect on a footing with Typhus fever & Plague. We have reason to believe that Typhus fever is not contagious when y apartments are well ventilated. It has been ascertained that as soon as vitality in y Plague was destroyed by – of communicating y dis is destroyed. As I have stated them such are y facts arranged on each side of y controversy my wish is not to impact any Hypothesis to you y facts are so contrary in their tendancy that it is impossible for anyone who gives credit to both parties to form a conclusive opinion The controversys scene to be have governed more by y pride of Victory than by any honest wish to advance the Interest of Med. Sciance. As relates to nature & treatment of Yellow Fever scarcely less diversity of Opinion has prevailed. – [109.] 119 Treat. Yellow Fever. consists in V.S. & mercurial purges & was in y year 1793. adopted by some of y most distinguished practitioners of y city. Y French physicians washed out y Stomach & then poured in Glysters or diluant beverages Calomel was exhibited largely by others but their sucess was precarious. Mercury seldom produced Salivation. More correct judges of its pathology a change of treatment. In y commencement V.S. by cups. Mercurial purges &c this was y treat. of 1793. Last summer often mild evacuations from y bowels, we used spts. Turpentine in doses according to y symptoms with cups to y Epigastrium. this should however be done early in y dis y Turpentine was to subdue Inflam: in y Stomach. – 120. Dysentary. Cullen defines this to be a contagious fever in which y patient has frequent mucous & bloody discharges accompanied with Griping & Tenesmus y foeces being for y most part detained. Except as regards contagion which is of rare occourance I do not know that this celebrated deffinition could be a mended. As y History of y dis is familiar to most of you & may be learned by Books which are easy of access it is not necessary for me to enter into a minute description. An attack of Dysentary according to Sydenham whose a/c of y dis with few alterations has since been capsized by most writers on y subject comes on with a Chill suceeded by flushed of heat frequency of pulse to these symp. are added severe griping & a constant propensity to go to stool. But in many cases y local affection is first perceived & prehaps not less frequantly y dis is preceded by loss of appetite. Costiveness flatulency; Nausea, Vomiting, & often these take 121. place with y irritation & uneasiness of y bowels above mentioned. As y dis extends itself y evacuations from y Bowels becomes more frequent & painful & preceeding every stool there is griping & tormina & tenesmus. y matter discharged by stool is very various sometimes consisting of frothy mucous though more generally it is streaked with blood & small coagulated lumps like bits of cheese are observable & some cases hemorrage of pure blood takes place from y Anus these are y ordinary appearances of y Stools in Dysentary. Now & then there is mingled with y morbid discharges natural forces may be assuming y appearance of Gallnuts & denominated Sybala y voiding of which is attended with temporary relief. We commonly meet with fever more or less marked with y usual symp. of increased heat thirst & restlessness though y pulse is neither very full or very active. This may be considered as y crisis of y Dis. which commonly occours in a few days though it is frequently much more 122. protracted. Not arrested by our remedies y dis henceforth puts on a sensible aspect. To an increase of y principle affections incident to y case we add. A rapid depression of strength, cold extremities. tension of y abdomen. Cold clamy swets, pitched. Hiccough. Aptha. a small pulse & discharge of a acrid fluid resembling y washings of meat, latered canine, [these] are generally y precursors of death. But they should not be deemed invariable so as much as recovouries from Dysentary somet. takes place where y most of them have been exhibited. On y contrary when y case terminates favourabley we find most commonly a remission of fever, y surface becomes moist & relaxed y evacuations less frequent & more natural y Tormina & Tenesmus subside altogether or are grately diminished. To this a/c I have only to add one observation. Y complain occours sometimes without any discharge whatever, such cases are by far y most fatal. The want of an evacuation arises from y existance 123 of an inflame. so violant as to transend y secretory [action] functions. I have seen instances of this kind & others on record in Sydenham & y Older Writers. They resemble Gonorrhoea in y circumstance that y [sooner] later y discharge was on y occourance of violant inflamation. Thrush has been said to be a Cause of dysentary. y dis was once thought to originate exclusively from a species of contagion generated in y system of an individual & by him communicated to another. – But by the most careful observation it will be perceived that such is not y uniform & general character of y dis. By a later writer it has been stated with no little plausibility that Dysentary only where y original fever is Typhus or assumes that character in its progress. Determining from what I have seen I should conclude y doctrin he advanced was perfectly sound & correct. – It has however been suposed that y contagion arises from y alvine evacuations & more plausably 124 that it arose from y stagnated secretion & excretions which have been suffered to remain untill they putrefy. But neither of these supositions is well founded. No evidance has been adduced to prove that y Excretions in Dysenteria are capable of producing y effect alleged. And y same may be said of y collection of filth from y patient which has purified. As I mentioned did y perspiration or Urine under any circumstances give rise to Dysentary. Y cases should be as diversified as y causes from which they originated from. On y contrary when contagion is y cause it is an uniform description of morbid action or at least diversified from peculiarity of constitution or Grage of force with which attacks were made. However it has already been shown that dys. & other contagious dis. may be propagated though y utmost cure be observed in clenliness in all respects. What then are we to conclude except that in y Typhus state of this dis. The extreme vessels take on an 125. action by which contagious matter is eliminated & elaborated out y system. But Dys. may most generally be traced to y causes amoung which are to be mentioned y many sources of autumnal fevers. Now & then it is excited by acrid matter taken in y Stomach & it has been known to occour as in Epidemic depending like other Dis of that class on some peculiar dis temperature of y atmosphere. Nor prehaps does it less frequently arise from y sensible qualities of y air. Cold suddenly attended with heat & moisture succeeding dryness equally produces y complaint As in y other bowel affections whatever suddenly checks perspiration in many instances proves y Cause. This complaint somet. accompanies Catarrh & I have seen it in many instances alternate with Rheumatism. But whatever may be y cause of Dys. it is evidently a febrile affection & directed to y Aliment. Canal. Even as long ago as y time of Sydenham such a 126. view of pathology was taken y opinion is surported by y fact that y dis asumes different shapes being remittant, sometimes continued, which last form may be highly Inflam: or may partake in various degrees of Typhus malignancy. Most generally when it arises from musk effluvia y primary seat of Dys. is always in y Stomach. Here it manifest itself by nausea & Vomiting & from this point it gradually extends downward to y bowels as revealed to us by dissection it appears that y force of y dis expands itself on y large intestines. In this part of y A: Canal we find most marks of preexisting Inflam: & other phenomena of dis. action. Enough has been said to expose my sentiments relative to y nature of Dysentary & if what I have said be correct y indications of cure are suficiently obvious. – But that y treat. may be applicable we must consider it under y various modifications which it occasionally assumes. – As Dys. generally presents itself y Indications 127. are to remove inflamation with y Spasmodic action which attends it over coming of y primal Vic & there by producing natural stools. To restore y Surface of y Body which is hot & dry to its usual healthy condition. – Taught by y example of Sydenham practitioners have generally been in y habit of commencing y treat. by Emetic - Enarmoured as I have thrown myself with this set of Meds. in most of y Bowel affections – I am not an adovocate for this universal employments of Emetics in Dysentary. The case in which they are peculiarly applicable & to which we should limit them use are those in which y stomach is loaded with Bile & other foul accumulations creating nausea & other Gastric uneasiness. It is common to meet with such cases in miasmatic districts associated with y Intim: type of fever. Cosulted end case of Dysentary under ordinary circumstances it would be 128. right to V.S. previous to remedies by thus early drawing Blood you will check y progress of Inflam: & is no less important to open [y war] a new. y susceptibility of y system to y operation of other remedies may be produced. V.S, is y most effectual & as y affections of y alimentary canal are eminently characterised by y want of this susceptibility to y operations of meds. y Lancet in those cases is imperiously demanded. But independent of y reason just stated there is another motive for copious & early V.S. Commenced with this affection of bowels there is commonly a degree of Spasmodic constriction which is productive of acute pain & appears an inseparable barrier in many cases to y evacuation of y bowels. to overcome y constriction in this case V.S. posseses [universal] unrivaled powers & with y removal of y spasm serves also [for] as a remedy for y hot & dry surface which it exchanges for one moist & relaxed. Haveing asserted this much of V.S. 129 we must resort to purgatives to clense y bowels of their vitiated contents. Castor. Oil is y article most commonly rised & answers very well in y forms of dysentary it cannot be denied but that it should be liberally employed my pursuasion is that in this case practitioners give y med. in infinitely to small doses to be of any decided advantage. In y same violant forms of Dys. seveal ℥ Castor Ol. should be given daily. It must be recollected that in Dysentary y ol. runs rapidly through y bowels passing off very little changed & makeing so light an impression as scarcely to remove any portion of Excrement. matter even y Bile. – I have seen it discharged from y bowels in y course of hlf. an hour or an hour after taken. – As regards our own Dys. especially such as occours in Warm weather I cannot help metaling y opinion that mercurial purges are infinitely better adopted to y treat. 130. treat. Do we not find them preferable wherever evacuations are demanded. We give them in Billious fevers & positively we should give them in y case now before us. In my own practice I prescribe Cal. alone or in combination with Rhubarb. & where y med. lingers in y bowels I promote its operation by mild laxitives. I resort to injections after I have thus evacuated y bowels y mercurial meds. are not again demanded. Now y Castor Ol. comes in with good advantage. y Epsom Salts would prehaps form a better substitute for Calomel & its combinations. No practicable point has been more debated than wheather we should continue purging. It appears however at present that y fact is pretty well asertained that we should give purgatives untill y natural forces appear. This I am induced to believe is a rare practice. Every one is conversant with Dysentary I will know that when y foecal 131 are suffered to remain in y Bowels they are irritated & y pain & other unpleasant symp. are considerably aggrevated. Let it however be recollected the discharges which accompany y dis. are mearly y effect of preexisting irritation & to remove them we must correct y preexisting disorder. – Acting on this principle I have been in y habit of resorting to Opii earlier than y general practice of Physicians would seem to warrant. Nevertheless I am perfectly convinced of y prosperity of this course by my large & faithful observation of its effects. Even since age of Sydenham with a very few exceptions which I Shall not at present notice there, has been a very marked aversion to opium. in y treatment of Dysentary even by cullen & those writers of his time y practice was either noticed with great distrust or universally condemned. But all these writers seem to have been influenced more or less by y old notions of y humeral pathology. They confounded causes and 132 & effects. As much are y discharges [in Dis y effect] from y intestines in Dys. y effect or consequence of previous Inflam. of y stom: & bowels. as y matter of Gonorrhoea is Inflam: of y urethra & a flow of tears in Inflam: Eyes when they have been offended with atoms of dust or grs. of Sand. But in resorting in y early stages to Opii I do not hesitate to allow of y necessity of uniting it with OC. Or some other evacuating remedy. My more general object however while endeavoring to remove y contents of y bowels is also to determine to y surface of y body. This last is indicated by y condition might be surported by y most distinguished authorities which we can afford. – But still it must be remembered that previously to any attempt to excite perspiration. – The pulse & other inflame: symptoms must be reduced by direct depletion. When this is not attended to sweating would only accelerate y dis. Less than any other Dis does dysentary admit of a substitute for y Lancet A late practitioner in this city has declared that 133 with y Lancet & Opii he could manage any Dys: I am not prepared to go so far though I am will convinced of y signal benefit of y Lancet in allaying irritation y early stage of it I do believe that y most important effects are gained by it. – It is now more than hlf: a centaury since Dr. d- introduced or proclaimed y superiority of y sweating plan over all others in Dys: His view of y pathology & treat. was soon adopted by several respectable physicians. It partic. Was adopted by Richter a writer of y highest authority that Dys: is a calanhol or Rheumatic affection of y large intestines & that y Billious & other discharges are necessary to y main dis. & mere efforts & not to be regarded much in y treat of y case As deduced from y Hypothesis y practice which he leays down consist y exclusively of measures calculated to excite perspiration. I do not go to y full extent with this author in his speculative order of y dis. or in his practical deduction. 134 This is one out of many instances in which injury has been done by a generalization. what holds in practical cases is made to apply to all cases of a catarrhal Rheumatic affection of y al: canal do now & then occour sweating will somet. suceed without n evacuations. But y instances are very rare & he who enters in y practice of his profession with such a view of pathology of Dys will inevitably be traced along his path of business by y dreadful mortality which he will inflict on his patients. In detailing y cure of Dys. we have reached so far as [Dysentary] Diaphoresis y modus operandi of such [illegible]. I have more than explained. It remains therefore to point out y lust mode of affecting y purpose. My own experiance has led me to prefer at this juncture a combination of Opii Ipecac & Cal. ꝶ Opii grs IV. Cal 16grs. Ipecac 8grs make 8. pills one every 2 or 3 hours. or pulv. Confedidly this is not y most action diaphoretic Med. but it is productive of effects which prehaps at this crisis is still more important than mere diaphoresis. - 135. It composes intestinal irritation relaxes y surface of y body, gently opens y bowels & causes other impressions which though not very intelligent are eminently salutary in their consequences. Every one who has noticed carefully y operation of Cal: in small doses in Bowel affections must have witnessed y beneficial effects of Vomiting from y article. It probably does good not less by y change it produces in y Intestinal & Hepatical secretion than by its directly purgative effect. As on infinitely more certain & powerful Diaphoretic y Dovers powders will seldom fail when copious perspiration is demanded. But it should never be resorted to in preferance to y preceeding article. – When it is necessary to evacuate y bowels no article in y Mat. Med. has been more extolled in Dysentary than Ipecac. Given either by itself or in various states of Combination. By some practitioners it has been more partic adopted to that state of Dis with which such 136. copious discharges of Blood from y Rectum as to amount almost to an Hemorrage. This opinion determining from y general properties of y article would appear perfectly correct. – But in every form & variety of Dysentary it is highly beneficial & well suited though I have prescribed it with y best advantage y pain thus been most violant y desire to go to stool very frequent & inefectual. – y great power of Ipecac over y dis does not rest on my own authority alone for more than hlf. a centaury ago it has been employed by practitioner in every section of y Globe & has brought from then very general if not unanimous approbation as to y precise mode of operating in this case all writers are not so well agreed. I do not agree with Sir Geo. Barker & Cullen who says its efficacy depends as upon its purgative operation for y med. produces an oposite effect. Nor do I believe it owes all its powers to y perspiration it produces we have numerous Diaphoretics not less active than 137. Ipecac but very inferior to it in y treat of Dysent: Much however of its good affects may be ascribed to its operation on y surface of y Body & such an explanation comports best with y properties of y article & its known effects on y system. Two other modes of administering Ipecac in Dys. has lately been proposed by Clark who wrote on y nature & cure of y Dis. It is recommended in y shape of injection. ʒiii of y bruised Root boiled in a qt. of Water down to a pt. & this quantity to be given 3 times pr. dic. by this he observes y bowels are thourougherly evacuated & y tormend & tenesmus & other painful affections are completely & perfectly retieved. Of this mode of administering Ipecac I know nothing from experiance though I have always been taught to believe that a decoct. of y article under consideration is whole by inert all y writers of mat. Med. agree in this a/c of y Medicine. Much more confidance should in my opinion be reposed in y 2nd. mode of prescribing 138. to which I allude. Defeated in this attempts to cure Dysentery in y ordinary manner Mr. Playfair Surgeon in y British Establishment in India has according to his own statement used Ipecac with great advantage in doses of ʒss to ʒi combined with 30. 60 & even 80 gtt Laudanum Confining y patient for hours in a horizontal position, If y first dose was rejected a 2nd. was generally retained. This practice reported to be efficatious was confessed by y author to be adopted only on y onset of y Dis. for if y dis is so far advanced y stomach becomes so irritable as to reject y Med: at once. By Mr. English surgeon to y British troops in India y mode above described was sucessfully followed In my own practice I have never employed it but I entertain a very favorable opinon. It seems to me well calculated to evacuate y alim: Canal in y commencement & y Laud. Or Opii entering into y prescription to allay intestinal irritation which is undoubtedly y proximate Cause of Dysentary. Much also 139. has been said of Antimonials under y same circumstances they have been fairly tried by me & though in some cases & though in some cases they proved very sucessful I think they are not at all in point of efficacy to be compared to Ipecac. But many of y most respectable writers report very differently on y comparative[ly] value of there two remedies. It is exprestly stated by Sir. Geo. Bark. that y result of an extensive experiance with them both gives a decided preferance to y Antim: preparations. To y same point goes also y evidance of J. Pringle not to mention writers of no less authority whose evidance is so strongly relieved. Y Glass of Antimony was y preparation used by Pringle in y cure of Dysentary. Casus may occour in which on article may be better than another. It is thought right that each of these should be retained but it is by no means easy to day at what or in what they are to be employed. I am unable to discriminated & on y whole 140. I expect that when you encounter y Dysentary you will find y Ipecac so well to your views that you will not feel inclined to exchange it for y preparations of antim: As a measure or needful auxiliary to sweating great advantage may sometimes be derived in this stage from y application of wampth to y extream surface. All of you are acquainted with y benefit derived from fomentations applied to y stomach & bowels. They are particularly adapted or calculated to allay spasms & uneasiness which exist is on taking a profuse diaphoresis. It is unecessary for me to recapitulate y method of making such fomentations Not a little has been said of Linaments applied to y abdomen at this stage of Dys. These for y most part consists of into which Laudnum enters largely. But lately it has been alledged that much more advantage results from [deciding?] stimulating Lotions & among one of there is Spts. Turpentine. This I have no doubt would produce 141. very good effect. In Dysentary where there is much distention & pain in y Abdomen. As might be expected y W. Bath in Dys. as well as in other Bowel complaints is highly servisable. It acts precisely on y principle of fomentation though much more effectual. It is not a remedy adopted to general practice & may in a great majority of cases be dispensed with. It is however one of y recourses of our art which practitioners ought to keep in mind but which need only resort to in cases of Emergency. As regards Children y objections do not apply to these. It is easy to administer y remedy & we shall also perceive that in children it is infinitely more efficatious of late however a remedy has been proposed [preser] which goes to prescribe both y Warm Bath & Fomentations I allude to y bandage a flannel Roler applied around y trunk. 4 or 5 [gas?] of Flannel are to be wraped around y body from y hips to y arms. – As relates to y acute stage of 142 Dysentary. I have experiance whatever with y bandage. But long before I had seen y work in y Practice recommended I was in y habit of using it in Diarrhoea in y declining or advanced stage y Dysentary & more particularly in Cholera Inf antum. The fact is perfectly well known to a great number of my patients & also a great member of my Med. friends in this city. To y employment of this remedy I was led by analogical deduction. but more of this when I treat of Diarrhoea. You should never use y flannel Roler in y early stage to y exclusive of other remedies As yet I have said nothing of y use of Blisters they are however an important remedy & in many cases cannot be dispensed with they may be placed on y abdomen or on either extremities But here as in other cases it is most useful when applied nearest seat of y dis. We prefer y extremities sometimes on accout of y inconveniance experianced by y patient on going to stool with his abdomen 143 raw. & Inflamed by y vesicating application. But judging from what I have observed myself I answer that y degree of pain has been greatly aggravated Besides considerations of this kind should never deter us from y use of Blisters to y abdomen when y symptoms indicate y necessity of y remedy. – My own practice in this respect is previously to Evacuate y Bowels & to order for 2 copious V.S. & if I perceive no great salutary suppression of y dis. I then cover y whole surface of y abdomen with Blisters. – As in other case of Inflamation especially intestinal you will here also have reason to be delighted with y effect of this application. I enjoin it on you in y treat of Dysentary & especially when it presents a formidable aspect to keep your eye steadily fixed on y blister & never permit any false tenderness or delicacy towards your patients induce you to overlook so valuable a remedy. Under such circumstances you will have dificulty to encounter 144. generally against y remedy & unless you interpose y whole weight of your authority which your profession invests you. It will very often be applied too late or totally neglected. – I have now completed y general treat of Dysentary but one or 2 local affections attend y complaint which are so troublesome as to demand our particular attention. I allude more particularly to Tenesmus. & Tormina these are occasionally met with at every stage of y complaint. Many remedies have been suggested for y relief of these in y combination of which Opii enters largely. – As regards Tormina & especially when connected with foul & acrid accumulations in y bowels great advantage may be derived from y following ꝶ Ol: Recini ℥i G:Arabic ʒii Sachar. Alba ʒi Tinct. Opii 50 or 60 gtt. This is called y oleaginous mixture in this city a small tablespoon every 2 or 3 [or 4] hours. It remans only stomach infinitely better than y Ol alone & after a few doses have been taken it very much relieves 145. relieves y Symptoms. But even better than this is y mix there I mentioned to you while speaking of Cholera Infantum in [many] some of these cases much advantage is derived from y use of Julep y method of prescribing it I have already mentioned. Not of less utility under such circumstances is a combination of Ipecac & Opii in y proportion Ipecac igr to Opii gr. ¼. But in relation both to Tormina & Tenesmus Opii directly applied to y Rectum is often eminently beneficial. It may be used in y shape of an anodyne where there us much irritability & excoritation of y Rectum a pill of 3 or 4 grs may be introduced & all y beneficial results are decided which would or could be expected from y same article taken into y Stomach. It has y advantage also that where y patent is prejudiced so as to forbid injections it may be introduced without his knowledge. But of all y means I have ever employed with a view to 146. y relief if Tormina & Tenesmus Melted Butter free from rancidity & deprived of its salt is y best from ½ a pt to 1 pt. melted should be thrown up every hour or two y relief occasioned by it is inconceivably great. It is a fact worthy of notice that animal ols. are infinitely less irritable [to] & offensive to a delicate surface than those that are derived from. Veditables, Thus Lard & Butter may be applied with southing effect to an irritable surface which would be aggrevated with olive oil. Nothing as yet has been said of Mercury given with a view to salivate. By consulting writers more partic: East & W. Indies. it will be found that in y management of Dys. Murcury thus employed is almost exclusively confided in not only is it given in y largest possible doses internally but it is also externally employed in y shape of friction. y object of thus exhaling it profusely is to induce Salivate on as soon as possible, there can be little doubt of y superior 147. efficacy of this plan in y treat of Dysentary occouring in Tropical Climates. y Dis in y C & W. Indies is almost always associated with with a greater or less degree of Hepatic Derangement. But in our country it is Inflamatory nature & so rapid in its progress that long before y system could be brought under its impression Gangrene would take place. But in protracted & lingering cases of [Du?] especially where there is any tendancy to Typhus condition there cannot be y slightest doubt as to y usefulness of Mercury. – When however I can speak of this form of Meds. more partic as a [substitute?] for mercury y Nitric Acid has also been recommended. To conclude y consideration of Inflam: Sys. it only remains for me to indicate y diet proper to be observed in this case. Y Dis being an active Inflamation of y alimentary canal it is obvious that we should [not] use articles y least irritating & offensive to y stomach & then 148. in order that y power of Digestion may be exercised as little as possible it should be of y nature. Demulcent Drinks have been used by y common consent of practitioners & by y prejudices of y vulgar to y case before us y neatest & most agreeable of them is Barley Water or Rice Water. Mucillage G. Arabic. Flax seed Tea. Mucillage Slipry Elm Loaf Sugar Water. preparations arrow Root Sago & Tapioca etc. While they constitute y poper nourishment of y patient they are thought not to be without utility in the dis. itself. – Many practitioners prescribe them with a view of diluting y acrimonious fluid & sheathing y surface of y Stomach & Intestines against their irritating influence; but such are derived from old antiquated pathology. Y Idea of sheathing a liveing acting surface by mechanically spreading over it mucilaginous fluids is altogether abandoned. Diluant Drinks are beneficial in Dys. as articles of nourishment & when we grant this much we have 149. we have decided all that our enlightend understanding & sound med. reasoning & Experiance – will admit Typhus Dysentary. With these remarks we conclude y treatment of y common Inflammatory Dys. but in Crowded places or Ships Camps Hospitals & Jails a peculiar ous temperature of y atmosphere prevails. Dysentary in its & through all its subsequent stages is decidedly of a Typhus Character. It appears obvious that in all such circumstances y Dis requires a different treat: from that already detailed. It is right to pursue of same mode of treat. as in other low states of dis. adopting however more partic: to y symp: as in y genuine or real Typhus Fever y early use of Emetics is very beneficial & after moderate evacuation of y bowels y Cordial & Stimulating remedis as Opii Vol. Alkali & Wine Whey with y liberal application of Blisters constitute y 150 treat: most generally resorted to. But as I before mentioned whenever Dysentary anounces in its Origine or acquires with progress a Typhus condition it is safest at once to resort to mercury with a view to salivation. As yet I am of haveing y system completely under y impression with a spedy mitigation of all y symp: & an ultimate recovoury, They causes why we should not resort to mercury has already been stated. But y objection which I stated to preclude y med. in y active inflam: species of Dysentary does not apply to y low & lingering form of y dis. & as regards this cause a salivation may in many instances be effected. The Mercury should be employed internally externally & be supported by y active & diffusible Stim: In y advanced stage of y Dis y Nit: Acid posesses valuable properties. It is not at all suitable in y commencement of y dis but after y dis has advanced to its final Stage. Then it is that y [mercury] acid is of signal advantage. But I give y preferance to 151. Mercury. It is known to most of you that Dys. sometimes takes y type of Intim: fever. Cleghorn describes it of very common occourance in y Isle of Minorca & I have seen y same form of y Dis amoung y paupers in y alms House especially among those from Miasmatic Countries where y inhabitants are subject to Intim: fever now & then y case presents such a complication of symp: as to occasion no little difficulty in management. By Morton y contemporary & rival of Sydenham who first pointed out this form of [fever] Dys. it was recom: that while we pursue y usual practice we should employ Peruvian Bark in y A pyrexia. Exactly y same course was followed by Cleghorn & several others more acute practitioners notwithstanding however all this weight of authority in favour of y practice. I am strongly inclined to think in this case it is not correct or faiseble. Of y cases of Dys. associated with intim: fever. I have 152 some opportunity for y exhibition of Bark & if it had been given it would undoubtedly have proved mischievous. No article of y Mat. Med. proves more offensive to irritable & inflamed bowels than this Med. & so much so is y case that even when y Al. Canal is perfectly sound & healthy it very often so disagrees with y patient as to be precluded. 153 154 155 156. Pathology. Causes seats & signs of Dis Dis. although an evil leads to many advantages 1st. It induces us to study Anatomy & Physiology 2nd. To conciliate us to death. Pain is useful to point out y disd. part. absance of it is a bad sign in a disd Rib, frozen Bone or carious limb. – y Causes of disease are y Remote, Exciting & Proximate likewise Predisposing or Remote Proximate Predisposing & Exciting. – y Remote are Contagion & Miasmata. y Predisposing is Debility this is either natural or acquired. If natural it depends on what was called Temperament. – Predisposition there is 1st. Arterial. disposing to Hemorrage. Pulmonary Consumption 2nd. Phrenic. disposing to Delirium & Mania 3rd. Cephalic. disposing to Headache. Apoplexy Epilepsy &c 4th. Alimentary. disposing to Dysentary. Colic Diarrhoea. 157 Pathology. 5th. Cutaneous. Disposing to Small Pox. 6th. Muscular. ” to Tetanus as great irritability but nosens ability 7th. Nervous. – disposing to Hyphochondrase. 8th. Lymphatic. ” to Dropsy. 9th. Hepatic. ” to Diabetes. Artinal Predisposition prevails in spring. Alamentary in Summer & Fall. Cutaneous in Winter. – A dis always attacks y weakest part of y system a part however may become callous to a dis by haveing its excitability wasted so that stimuli cannot throw it into Morbid action. Dis in thus state is called Disorder y effects are viz 1st. Torpor. absance of Irritability. 2nd. Stupor. absance of sensibility. 3rd. absance of both instances of Disorder as Chronic Ulcers. Calculous Obstructions. Schirrus these induce death & hence become subjects of Medium Acquired Debility is of two kinds from 158 Actions or Obstructions, when it proceeds from this last if an irritant be applied – it first elevates y excitement then depresses it. In y former case if y stimulus remains depressed it is induced y debility of both causes & is y same except in y last y excitability is accumulated & readily thrown into morbid action. In Debility from action when y stimulus which produces it is withdrawn y excitability is accumulated, hence after great fatigue we should not sit down but gradually keep moveing to carry off y redundant excitability – hence y they lead horses who race round y course to prevent stifness – Rheumatism abstracted from important parts in y bowels Signs of Dis by y Pulse. These are 1st Frequency & Quickness. These are not necessarily connected y pulse may be very Frequent & not very Quick or vice versa as in Yellow Fever & y last stage of other fevers. – By Frequency is ment [y number] y number of strokes performed in a given time. – 159 Pathology. Signs of Dis by A/ Pulse Quickness is y time in which y stroke is performed. – y pulse [differs] varies in fevers & other acute dis. in y first stage from 60 to 88 or 180 & sometimes to 200. In a minute it falls in some cases to 40-30-20 & sometimes to 9. – y Frequency & Quickness of y pulse seems to depend on a morbid irritability in y arterial system. y Morbid slowness depends on 3 causes 1st. Pressure on y Brain. – 2nd. Spasm of y Heart 3rd. defect of irritability in y arteries y pulse varies from health in regularity & force this is of much more importance than its duration in frequency & fulness. It sometimes Intermitts. Somet: imparts a sensation to y fingers resembling a shattered Quite. We are now to [examine] consider y different states of y pulse in Fever. – by Depressed Pulse. This state of pulse is caused by stimuli acting so violantly as to depress y system be low y point of reaction or by pressure on some great vessel. It is frequently 160 Signs of Dis by y Pulse. preternaturally quick [crossed out] often slow & sometimes scarcely perceptable often descends a low as 40. 30. 20 & is sometimes so depressed that it is almost imperceptate. It is raised by V.S. It is sometimes preternatural quick slow & attended with intermission & sometimes it is natural. It occours in Plague Y: Fever Malignant & Small Pox & in Pleuracy. It is either general or partial [y latter] occouring in y extremities y former & y latter [occouring in y extremities] occasioned by stimuli depressing y strength below y healthy state. It resembles a low or Typhus pulse & may be distinguished from it 1st. By occouring in y commencement of acute diseases & in y paroxisms of such dis. as are periodical 2nd.. by imparting a sense of tention along y fingers when long & attentively felt. 3rd.. By occouring in morbid affections of y Brain. Heart. Stomach & Bowels more frequently than dis of other parts of y Body. & in Apoplexy. 4th. By occouring rising after V.S. or purging takeing off y suffocated excitement 161 Signs of Dis by y Pulse 5th. By its being attended with preternatural slowness & intermission. Thus y pulse may be compared to a tree bent by y Wind & arising to its proper state after y storm has blown over Whilst y Typhus resembling a Free shattered by lightning which cannot be raised by y hand of art 2nd y Locked Pulse [or Sulkey] This is small quick time & distinct pulse which is imparts to y fingers a sensation similar to that produced by fretting a piece of Cat. gut. tense from whence I have named it. Cat gut Pulse occouring in Malignant fever. – 3rd. y Cynothus Fortis. This is y reverse of y 2 former a full round vigorous frequent & quick pulse without hardness which occours in y highest grade of Bilious Fever in affections of Brain in Pneumonia Notha & congestion of Brain. Exercise produces a pulse somewhat like this. – 162 Signs of Dis by y Pulse 4th. y Synocha or Inflam: Pulse. – Being full, quick, frequent & tense & not round & is known by heat & thirst. This pulse exists sometimes in y Plague. Y. Fever & in common Inflam: but more frequent in Pneumonic affections in Rheumatism & Arthrisis. – 5th.. y Synoch [ous] Pulse A quick, frequent & immoderately tense but a small pulse imparting a sensation to y finger similar to quill & occours in Chronic Rheumatism. Gout & Intim. Fever & in 2nd. Stage of other fevers It is y Synocha on a concracted scale from which it may be distinguished by y column of y Artery. – 6th. y Synochous Mitis Pulse full round & soft. 7th. Synochoid Pulse. This is alternately soft & & may be placed between Synocha & Synochous it occours in y passage of fevers from y low to y Inflam. 163. Signs of Dis by Pulse. State & Visa Versa according to Dr. Butler it imparts a sensation to y fingers like a quill that has been trodden under foot 8th. Typhoid Pulse. – Small frequent & less tense pulse than full it is a compound of synocha & y low chronic states of fever & occours in Hectic & Purperal fever, & in Scatitana. – 9th y Typhus Pulse. This is a weak, small. frequent but full or tense pulse. It differs from y depressed pulse 1st. In tention. 2nd. y arteries in y depressed state still retain their irritability & y pulse rises after V.S. It occours on y low chronic state of fever or in y first stage of some malignant fevers. Cordials are indicated in y close of Inflam: [fever] Diseases when depleting remedies have been used in y 1st stage. It is here V.S. is forbidden & stimuli to be used. 164 Signs of Dis by Pulse. 10th y Hectic Pulse Is quick. frequent & often full & very soft, it is occasionally Synochoid, Typhoid & Typhus & occours in Chronic Fevers. Pthisis Pulmonalis, also Chronic Gout & from Lues Veneri & Scrophula. – 11th. y Hobbling Pulse Is unequal fluctuating, tense quick & very frequent. It may be known from y irregularity of its pulsations. It may be divided thus 1.2.3 [quick] slow [slow] strokes sucseeding & quick one. 2 or 3 [slow] quick stroke sucseeding a slow one. – 12th. y Serrated Pulse Strikes y fingers like a saw one part elevated above y other. – 13th. y Vermicular Pulse. – Small frequent & resembling y motion of a Worm 14th. y Creeping Pulse Weak & small it occours in y last stage of Dis. 15th. y Apparantly Natural Pulse. – A pulse perfectly natural in Violant Fevers 165. Signs of Dis by y Pulse. ~ is one of y worst symptom. It occours in y most Malignant in Y. Fever & can only be distinguished from y Pulse of Health but by y other symp. of Dis. Great danger is to be apprehended by it – Scarsely any of these are always present they are therefore combined 1st. in double proportion as Full & Weak, Full & Frequent Depressed & Weak. Slow & Intermitt: 2nd. In a three fold state as Full Strong Quick & frequent at y same times 16th, a full, bounding, slow, & moderately tense pulse as in Palsy Apoplexy or Dropsy it is especially full & slow in y affected side as in Hemiplegia. Dr. Rush examined y pulse of a parylitic patient whose artery beat on y affected side 50 whil on y other it beat from 80. to 90. – 17th – A weak & low pulse without irregularity occours in debility without fear or is [distinguished?] from y weak & low pulse of malignant fevers 166. by its occouring in y last Stage of Dis y usual pulse of y low Hypochondria state of y system 18th.. There is sometimes a total Absance of. Pulse in dis which somet. occour in violant affections of y Stomach & bowels. It lasts sometimes for hours. Dr. Rush kew a lady to be without pulse 36 hours in consequence of eating some Oysters she has since perfectly recovoured. – 19th. Gaseous State of y Pulse soft full & round 20th. Aneurismatic Pulse is full & tense & imparts to y fingers a disagreable jarring sensation which when once felt can never be forgotten It occours only in cases of aneurisms. – The pulse is much influanced by y strength of y animal in a Pigeon 100 Ox 30 to 38. – 167. 1 Intermittant Fever. Wine. – John Hunter’s remarks on use Wine in Remitt: and Intimitt: as they occoured in Jamaca. With regard to y quantity to be used it is dificult to give precise directions I have generally found upon careful examination that y quantity which has the best effects is less than has generally been given. I have rarely given more than a Pint in 24 hours a larger quantity did more hurt than good y strength quantity & quality of Cordials must bear direct proportion to y strength of y patient. Opium The above applies to opii in y same States of y system I think that O. in the last stage combined with Ipecac or antimony will be more safely given than by itself where there is tendancy to the continued form. – In those cases of Intim: in which the cold stage was preceeded and accompanied with a violant cough I have used O: with y best success Case W.B. a Man of 50 living in Hampden plains had I. of this Kind. The cough was very frequent an Iritating particularly so previous & during y cold stage He tried y Bark & most of y Veg & Min tonicts and among other things arsenic. also Depletion. V.S. Emet: Cathartic Intimitt Fever Epispast: His cough & fever were finally removed by a pill composed of Opii gri Calomel gr.ss repeated every 8 hours. In my opinion this was a case of I: from irritation which prehaps may have depended upon Visceral obstruction [see page 7.5. for more cases]. – Intimittants threatning to run into Typhus. Opii should be combined with Bark, Serpentarid. Vol. Alcali & Camphor. In such cases a torpid state of y bowels should be obviated. In cases of this Kind it will be very difficult to restore y system to healthy action when y Liver Stomach & Intestines do not perform their function These are to be excited to action by gentle Laxatives such as soap. Rheii. Soluble Tartar & by external irritation to y Bowels. – If these parts perform their functions they will have great influance by association of action to bring the other parts of the system to healthy action. In almost all cases of Intim: it will be a safe and efficatious practice to give opii in y very commencement or at y time when y cold stage is expected O: may be given in pills or Laudnum combined with aromatic Teas and Dilunts & other means of producing perspiration the 2 Intimitt Fever temperature & y action of y Body should be equalized. – As a general Rule it will be necessary all cases of Intim to deplete y system before giving Stimulent Tonics. An Emet: Cath: & sometimes V.S. will be necessary. Exceptions to this rule are rare. – In all cases you must be governed by y [Cases] state of y system & y laws of yt. part of the system which is the principle seat of y dis: or the point to which it determins Antimony Ipecac Neutral Salts. Em: Tart. Camph: & Ammonia qualify y action of O: & operate by determining its action to y skin. If O. excites uniform perspiration there is no danger of congestion or derangement of y functions When it produces partial perspiration of y Head & Breast it only coincides with & aggrevates the morbid action of y dis: Dovers Powders are a very safe & useful composition of Opii ꝶ Ipecac & Opii ā ʒi Sulphate Potash ℥i Dose fm. 5 to 15 grs. In cases when diuretic effects are wished from the powder. Nitre may be substituted in y place of Vit: Tartar. – In my practice I have usually made y powder of Em: Tartar instead of Vit: Tartar & added ʒii Camphor with y Intimitt: Fever alteration thus ꝶ Ives Dovers Powders Ipecac & Opii - ʒi Camphor ʒii Em. Tartar ℥i. Acids combined with Stimulating Diaphoretics have been very useful in ourt fevers during y present diathesis which prevailed since y year 1805 with occasional variations. – Hyoceamus Niger. Dr. Smith of So. Carolina used y Ext with sucess he gave at y same time Sul. Zinc. – Atropa Belladona. In obstinate Intim: Bitter Almons. Their efficacy was established Barron Stork who used them very largely & sucessfully in this dis The Laurus no doubt has many Med: Virtues which doubtless will be brought by future experiments y Narcotic principle is intimately connected with Prusic acid. – Amica Montana. recommended as a substitute for Bark Spigelia Marylandica in Tinct: has been used. – Iron. a good auxiliary to y treat: in feble & lax habits yet it ought to be used with great caution in cases threatening congestion Liver & Spleen 3 Intimitt: Fever Copper in Intim: & Remit: but has now given place to Tonic Solution. Zinc in ordinary Intim. without cough or any peculiar irritation in y system or chronic Vis: Obstruction. I give y White Vitriol & Myrrh āā gri in a pill. Giving fm 1 to 6 pills in a day during y Intermission previous to giving y pills y Stom: & Bowels should be evacuated. It is y remedy on which I most depend in I: of an ordinary type. It very rarely offends y stomach. I have given as much as 4 grs W. Vitriol in pills at a dose without producing nausea It excites appetite, promotes digestion & produces vigorous action of y system generally. No debility follows y use of this remedy though it has been continued for Mos: [see page 236 Vol 1 for case West part York State] Arsenic may produce the same effect as a ligature on y leg & opposite arm at y commencement of y dis. y A: may determine y action to y minute vessels & prevent y engorgement of y Heart & Large vessels which takes place in y cold stage. This is infered fm: y fact that Arsenic produces Œdema. When it produces sensible  Intimitt Fevers though not violant effects they are analogous to y combined action of Tart: Antimony & Calomel. – In Intermitts. it is safe & efficatious remedy. I have not in my practice seen any ill consequences follow y use of Arsenite of Potash. In its effects it is not inferior to Bark. It is [cross out] adapted to y same cases which indicate Bark & indeed will often cure cases in which y Bark has been thorougherly tried & failed It is more particularly adapted than y Bark to those cases in which there us some excess of action. – Its action in such cases may be like that of Mercury reducing y system to that state in which Bark is adapted. I should not be administered in those cases which have a tendancy to Typhus & require Stimulating Tonics. It is not so well adapted to In: of long standing. Here Nutral Salts with Bark & somet: Opii & Calomel must be given. Camphor combined with Bark. Cuprum has frequently ben given to children in Intim: & Remitt: but has given place to Tonic Solution 4 Intimitt: Fever Bark. Tho a valuable remedy in this Dis still it has no specific powers ie it will not cure in every case. has an action peculiar to itself. In ordinary cases especially in cold climates y administration of B should be preceeded by evacuation of y bowels or. Stom or both as y symp. may require & frequently V.S. is necessary previous to y B. best mode to give is in substance if stom. will not bear it give in Decoct Tinct. Cold Infus. Dose it may be given 10 grs to ʒi repeated every 2 hours in y Intermission. Not to be given in our climate in y in y Hot stage. /given in this stage in hot Climes) It is y practice to give y B imediately after evacuating first passages. Dropsy. Jaundice & other Dis have followed y use of B. in I. In such cases there probably was not evacuations enough made. In Penn. hospital I saw. an Anasarca fm. Injudicious use of B cured by V.S. In I. with+ Visceral Congestion y B must be combined with Rheii or its action qualifyed by frequent small doses of Neutral Salts. as Sol. Tartar &c +(See Linac on Fever) [Remittant Fever]. – Intimittant [Porter. – is more particularly useful which occour in Intu August & September when y Stomach is very irritable with general prostration of strength. It is a very grateful stimulant to y stomach on account of y fixed air which it contains, corrects morbid secretions of y Stom & is very nutritions to convalesants. – It is admisable in all fevers affecting y Stom: & Bowels after y first Stage & relieves]. – Y Nutral Salts even if they do not operate as bath yet they prevent y system fm rising to y Inflam. point Those cases in which there was very little perspiration y bath has not suceeded well unless given with Nutral Salts or Rheii. It is a common practice to in case y dose just before y expected paroxism It certainly at this time has more effect yet it is without danger. A Tertian has somet. put on y form of Apoplexy (not seen much of this dis.) I have not suceeded well in treating Intim With Cough with y B. but usually with Calomel. Opii & somet: Epispas are necessary. Y several preparations of B may be 5 used together. Angustura Bark has been recom. in powder in Intermission dose 20 grs every 3 or 4 hours I have used as above directed in this dis somet. with complete sucess but it is rare that y Stom: will bear such large doses. Cascarilla useful in In. which terminate in Typhus. – Snake Root partic. useful in those In. whose parox. terminates with little or no perspiration & y skin hot & dry in y Intermission. combined with Bark. S.R. is a very valuable addition to y B. in treat. of In. Y. Comp. Tinct Bark is taken in ℥ss does in y cure of In. Some phys. Give an Emetic of Tart. Antim in a strong decoct. of Serpent. & give a cath of Nutral Salt in y same decoct. in this mode they operate very kindly & leave y Stom. & Bowl in a better State. – Cornus Florida. highly recom. has cured where bark has failed dose powder ʒss to ʒi Intermittant Fever sucessfully used in Middle & Western states Y most useful preparation is y Extract dos 5 to 10 grs. Astringents are servisable when combined with aromatics. Those Veg. substances are best adapted to I. which contain y Bitter. Astring & Aromatic principle. Ast. are more partic indicat. in Ints in constitutions of lax fiber (leucophley. temp.) Galls. sucseed best comb. with Aromat. & Bitters sometimes G. have cured I. which have not yialded to Bark. I presume G. succeeded best where then general relaxation in y system. Int. in there different stages & different forms often require as different as Synocha & Typhus. - 6 Typhus. Alcohol. is used diluted & is a good remedy to increase y arterial action. It may be given fm: ℥ss to ℥i every hour. Old Spirits sets kindly on y stomach in this dis. when Wine & Porter will not. – Wine is useful after y evacuations of first passages to keep up an uniform excitement Some Physians give a bottle each day through y whole course of y dis. This mode of Practice succeeds very well in those cases where there is no considerable local [derangement] determination & y secretions & excretions are not much interrupted. – In 1805 & 6 wine was very much used in a fever which prevailed in this Town. I suceded best at y time of a crisis or when some symptoms indicated a change in y [symptoms] system or when y dis had spent itself. In these cases I gave fm 2 to 3 pts of the best white wine in 24 hours & thus producing a favourable crisis. But if y strength or excitability had been worn out by this article would not produce that effect. With Wine it is common to combine Bark & Opii. – Aqua Ammonia is a good addition to y Wine its use in T:F. is indicated by y same symptoms & has y advantage of correcting y stomach & preventing y Wine fm: becoming acid. Porter when y patient is Tympanitic I think it has increased that unpleasant symptom. – Ether. Diluted given in T.F. to keep up y action of y system & to produce perspiration. In Flatulance & in Tympanitic state of y Bowels in T. In y last stages of T. E is given mixd with wine or diluted alkahol & it adds much to y virtues of these articles. E. qualifies Wine & Alkahol as aromatics qualified Tonics. It stimulates y skin by external application. If confined to y part it increases heat if it evaporates diminishes heat Camphor – is advantageously combined with Lime juice Vinegar and other acids in effervessing mixtures It has been a very useful article in y treatment of y dis: which have occoured since y year 1805 This Grade of dis. are very much like those described by Sir John Pringle. The Dis has been more or less Typhus in its progress in some cases Typhoid in 7 others Synocus in its commencement partaking more or less of y Tertian Type with a determination to y viscera of y abdomen like an intermittant affecting y secretions sometimes causing profuse secretions at others interupting all secretions accompanied very generally by Tympanitic state of y bowels attended with local critical determinations with Inflamation & supuration of y part at y same time y state of y system Typhus When this local determination fixed on y brain Heart & Lungs it invariably produces death unless y action was overcome or determined to some other part less essential to life. Prehaps this Fever might be called y Intestinal State of Fever In this fever Camph: has been of great servise combined with opii in y form of Dovers Powders or Diaphoretic: It appears to equalize y action of y opii by determining to y surface & preventing that dryness of y tongue which sometimes follows y use of Opii. It has been useful in cases of this Fever attended with Tympanites both by Injection and Camphorated Liniment applied to y Bowels Typhus Fever. Opium. should not be administered in Typhoid Fevers with Visceral congestion or obstruction or when there is a determination to y head & local supuration threatened although y diathesis of y system is Typhus Such a fatal determination is produced by a dry skin & tongue deafness & disterbance in y intellectual faculties y Rules which Sir John Pringle gave concerning y use of Wine in Goal Fevers & y direction of Lenac on y use of Bark in Intim: & Remitt: will apply to y use of Opii in such states of y system. – Castor. – In T.F of the mild kind combined with valerian Snake Root or Orange Peel with advantage Valerian. – is used. – Phosphorised Ether viz ꝶ 3grs Phosporus divided into small pieces & put into ℥i Sulph. Ether in a week y med: will be fit to use. If any [Ether] Phos: remains at y button y Ether should be carfully strained off dose 3 to 12 gtts in any convenient vehicle has been given in T F & in other forms of Fever in which y dis action has worn out the 8 excitability of y system in such cases it has sometimes roused the patient in y very article of Death & been the means of saving them – In Typhus in y low state where there was no particular determination it has been given & no injury followed. – Phosphoric Acid has been given for y same indicatins as J: Ether and when it has been used in y last stage if T: it has often Excited a desire for Animal food. – Cantharides in T accompanied with very frequent pulse it diminishes its frequency. When y system becomes over charged with cantharides y stools became mucous & Bloody with Tenesmus & extreme pain y urine suppressed or in Small quantities and Bloody. When large doses have excited Inflam: y symp: are similar to those of Inflam. Dysentary. – (see page 212 Ives Lectures Vol 1) Chapman continued at back (reverse direction) Extracts from a Treatise on Cholera Asphyxia or Epidemic Cholera as it appeared in Asia and more recently in Europe. with practical remarks on y dis. in Europe an appendix of cases & y reports and regulations of the Boards of Health of London and Edinburgh by George Hamilton Bell Fellow of the Royal College of Surgeons Edin: late residency sugeon Janjore and joint medical secretary to the Edinburgh Board of Health. ~ Second Edition 1832 9 Cholera Asphyxia. In describing this dis. it may be useful to attend to what may be cal’d 4 Stages. 1st. The invasion of Cholera is so insidious that the individual attacked may be quite unconcious of the presence of the 1s Stage of it. Very often it is only to be detected by those well acquainted with y dis. Not only in this stage but throughout the whole course of the dis the appearance of the countenance is one of y most highly characteristic symptoms. An intimate find may observe the the person has an expression of anxiety. That his complexion is unnaturally earthy & his eyes seem sunk in his head. In reply to inquiries he will deny that he is unwell he may say he is a little deaf & if minutely questioned may admit that he has an indescribable sensation of being out of Order that he has oppression at y chest & is unaccountably depressed & listless. he may have no nausea but has Tormina of the bowels & prehaps an uncomfortable sensation of heat at the pit of y Stomach His pulse is quick & weak (I have seen one case in which it had the febrile throb.) the hands & feet feel cold. the nails are blue & he has had one or more unnatural discharges. The first of these is generally characteristic. there is a sudden call, & the whole intestines seem to be at once emptied followed by a feeling of weakness 2d Stage Cholera is more easily recognized: The pathognomic character of the countenance to those who have seen the dis is no longer doubtful. The eyes are sunk in the head lips are blue, there is a ghastly look about the mouth & the whole features are shrunk. The patient does not now deny being unwell he acknowledges haveing passed some [pecution?] stools & probably has had vomiting these have been followed by great prostration of strength 10 there is tinnitus aurium often slight deafness & Vertigo. The pulse is more decidedly affected it is weak & thready: Skin is cold there is much thirst & a burning pain at the pit of the stomach but y tongue is not dry it is moist, white & cold. The fluid passed from the stomach & bowels is like water in which grain has been boiled with pee as more or less numerous of opaque white or yellowish coagulated matter floating in it. The manner in which the discharge takes place is characteristic. The desire is sudden unaccompanied by griping or nausea & y the stomach & bowels are emptied at once & with some violence: the gastric & intestinal evacuations are nearly similar. In their appearance & nature 3 Stage In this stage the sinking of the countenance is still the most prominently characteristic symptom. The eyes Surrounded by a dark circle are completely sunk in their sockets. the whole countenance is collapsed y skin is livid & the expression is so altered that the patients most intimate friends cannot recognize him. The surface is now generally covered with cold sweat y nails are pearly blue & y skin of y hands & feet are corrugated as if they had been long stupid in water the sensibility of the whole surface is deficient but it is by no means uncommon for patients to complain of a burning heat in there cold skin. Vesicatories do not act even boiling water does not raise a blister. If the case be attended with spasms the suffering of y patient is much aggravated & is sometimes excruciating The spasms commence in the hands and feet like cramp they stretch up the limbs to the trunk which however they do not always reach. In some cases again 11 the muscles of y abdomen are principally affected & they are drawn towards the spine during y whole course of y dis. These spasms may have commenced early in y dis being on some occasion y very first symptom. The discharges fm. y Stomach & bowels at this stage are very irregular in some cases they are still very frequent in others after one or two evacuations they wholly cease The pulse at y wrist if it have not ceased is scarcely perceptible & y heart beats feebly. When y spasms are severe they frequently, even though y pulse be still quite distinct stop it arising the paroxysms y same effect is produced by excessive vomiting. The breathing is slow & oppressed, this also sometimes occours early in y dis. The voice is low & but few words can be spoken without expiration. The exhaled breath is cold & though y heat of y body is many degrees below the standard y patient throws off the bed clothes & enterals the bye standers to allow him cold dis & cold water. Hiccup is not uncommon & is rather a favourable than an unfavourable symptom. – 4th Stage. In y last stage the intestinal evacuations have most likely ceased; y eyes completely sunk in there orbits are glazed & flaccid turned upwards & half covered with the eyelids. Y spasms are now commonly at an end y extremities indeed y whole body is that of a corpse & the impression communicated by y skin has been well. listened to “damp hide”. Every artery has ceased to pulsate & y action of y heart if perceptible is a mere flutter. y whole body is bathed in a Cold & Clammy sweat. It is painful to witness y oppression of respiration & jactitation of y sufferer 12 The dying man can still be roused but when undisturbed he generally appears in in a state approaching to stupor: & though prehaps in a humor which might almost be termed sulkas is in most cases coherent to the last. These symptoms are y immediate forerunners of death. If blood be drawn during the progress of y dis. it is found in y Outset dark coloured as y cases advances y blood becomes thick there is a deficiency of serum it coagulates quickly & does not assume y buffy coat. In y latter stages of y dis y current in y veins has stopped & the blood is so gramous that it can scarcely be forced out in y smallest quantity through a large orifice. The whole course of these stages generally does not exceed 16 hours & unluckily y practitioner is seldom called in untill the first & part of the 2d stage has passed The period consumed by each of y above artificial divisions varies in every case. I have seen instances in which death ensued in less than 4 hours after y commencement of y dis. & others in which its latter stage with y pulse quite imperceptible had already lasted a whole day. The condition of y mind is remarkably collected during y whole progress of terible illness for tho. Patients, as y malady advances are unwilling to be disturbed with questions this appears rather to result from y want of physical energy than from any intellectual failure. Indeed as the fatal event approaches y only wish a patient seems to have is to be allowed cold water & to be left to die in peace It has been well said that a patient in y last stages of Cholera may be called a “living Corpse.” 13 It curious phenomenon has been several times observed. After a patient has been some time to all appearances dead & when y attendance even dressing the corpse, Spasmodic twitches have taken place in y limbs having in some instances even extended to y muscles of y body & general spasmodic contractions have supervened. Cases often occour in which one or more of y above detailed symptoms do not appear There may be no spasms y Vomiting & purging may early cease or there may have been only one large alvine discharge, follow’d by a mortal collapse y patient seeming to be at once struck with death, and tho’ on [y] the very first appearance of y dis. he has walked to y Surgeon his pulse is found to be gone, his heart has ceased to beat blood can be got only in drops from the veins he lays down his head & dies without a complaint. These anomalies are not confined to individuals instances but are found to occour as M. Scott well expresses it in “local epidemic visitations.” Thus he says “when the dis appears epidemically in a town or district or in y lines of a corps or y camp of a marching Regiment, it may on one occasion be [distinguished?] throughout by y absence of vomiting & y prevalence of purging, & on another by y excess of vomiting & tho’ more rarely by y absence of purging. Spasm may be generally present in one instance of invasion, in another it may not be distinguishable. I was on one occasion called upon to send assistance to a district in which y dis. was thus described “It commences by attacking y sufferer with an agonizing heat in y stomach vomiting & purging & lock-jaw. death ensues in 2 hours & often more rapidly it bids defiance to every remedy” 14 But in all cases in which y dis has established itself, there are y collapsed Countenance blue lips & nails, shrunken fingers. The total failure if y usual secretions, deficient animal heat, suspension of y pulse, & remora in the venous circulation. Treatment of Cholera asphyxia The following may be considered the indications of Cure. 1st. To relieve y oppressed circulation 2d. To stimulate the system 3d To restore y heat of y body 4th To guard against local congestion 5th To keep down reaction 6th. To produce a healthy condition of the alamentary secretions. 1 Blood letting in cholera is obviously in a great degree mechanical. The power of circulation has been injured it is no longer capable of duly distributing y mass of blood in y system & y cessation of y usual secretion the deficient pulmonary function & the effect of y discharges have rendered y blood wholely unfit for vital purposes. By V.S. in such [cases] circumstances we relieve the gorged vessels & thus enable the 15 weakened energies of y circulating power to act on y distendened organs of circulations & to restore the current of y blood. The Lungs recover their function pure blood is thrown into y left heart y arteries are again filled with with a fluid fit to support life. this it may be supposed reacts on y sympathetic system & by its energies are completely restored. In this way only can the of V.S. in cholera be explained. No other method will account for y almost instantaneous recovery which so often follows V.S. in such a condition of y system as has been described a recovery more immediate than that which follows y removal of mechanical pressure fm. y brain. And I should say very confidently that in no case in which it is possible to persevere in V.S. untill Blood of a healthy colour & consistance flows freely fm. the vein will y patient die fm. collapse. in commencing the treatment of cholera then no time is to be lost in endeavouring to bleed y patient. He should be laid in a warm bed & y great object being to get Blood to flow it is important that the operation should be performed with as little fatigue to him as possible. He should be kept in a recumbent posture and as answering y two next indications will be y means of forwarding this important object immediate recourse should be had to stimulants – applying artificial heat using frictions &c. The rule as to y extent to which y removal of blood should be carried is very simple it has no reference to the prostration of strength or to the constitutional stamina of y patient. The power [to give motion] [often] of circulation is unable to give motion to y volume of 16 blood which has accumulated in the venous system & which has been rendered by y cessation of secretion, y diminish function of y Lungs & y disordered actions incapable of supporting life & blood is let until it appears that is fatal a condition of y vital fluid has been changed. In other words the blood ought to be allow’d to flow until the natural current in the veins has been restored & there is evidence in the improved colour of y Blood that the Lungs have recovered their function. If opening one vein be not sufficient let others be tried & until y dis. yealds the practitioner must persevere in his endeavours to accomplish this great object. In y outset prehaps only a few drops of tar like blood can be obtained by y use of internal & external stimulants some good appears to be done & the pulse rises: - renew’d attempts should immediately be made to remove blood nor should these be desisted form while life remains. – In addition to the lancet leeches or cupping glasses should be tried. It is be remembered that added to y general vinos congestion there may be a tendancy to morbid plethora in particular organs. There is sometimes confusion of head & more obtuseness of y intellectual faculties than usual. This is not only a bad symptom with reference to y [patient] present condition of y patient but may be attended by fatal effects after y primary dis is relieved. In such cases I should bleed fm y Jugular vein & as many leeches as well adhere should be applied to y temples & throat The abdomen is in every case y principle seat of congestion. Leeches ought therefore to be applied to y belly also & partic. over y seat of y Liver care being taken to avoid as much as possible exposing y patients 17 body to cold. It is unfortunate however that like blisters leeches during extreme collapse are quite useless. – 2nd. To stimulate y system. The classes as the second indication of y treatment of Cholera. Yet in their application V.S. & attempts to stimulate the system, ought to go hand in hand. The object is to restore the suspended circulation. Blood is let in order to diminish y quantity of Blood to be acted upon & stimuli are administered in order to excite the source of power. Indeed it is often impossible to render V.S. efficient until after stimulants have produced some effect. It is not merely by internal remedies that this indication is to be an severed. Frictions over y whole surface, rubefacients and sinapisms to different parts of the body are in truth important portions of y stimulating remedies. The internal remedies which have been resorted too with must confidence & sucess in y Treatment of Cholera are Opium. Ether: Camphor. Ammonia pepermint. Strogue-amer, spirits and Calomel. The general mistake in y treatment of Cholera has been y administering of too large doses of those medicine which have obtained a high character among practitioners. The large doses of Calomel & Opium which many are in y habit of prescribing are especially pernicious. This practice seems to arise from y nature of y dis being misunderstood. A patient is suffering from violent Vomiting & purging & excruciating spasms & indication appears to be to allay these high actions. Hence Calomel & opii are prescribed in quantities amounting to what are considered sedative doses. There can be little doubt that more injury than benefit. has resulted from this practice for should y dis be overcome & y medicins not 18 have been evacuated 10 or 20 grs Opii & 60 or 100 grs Calomel must act as poison on the restored functions. The object being there to stimulate y system Meds. should be prescribed in such quantities as are known to act as stimuli. In fever a scruple of Calomel no doubt will very often allay as once y irritation of y stomach & experiments seem to prove that in large doses this Med. acts sedatively on y gastro:-enteric mucous membrane. It has been ascertained by experiance that most narcotic in large doses act as sedatives very soon after being administered; while it is unquestionable that y same Med. in small quantities, excite y circulation and are consequently to be regarded as stimulants. Early in my practice in Cholera I found reason to believe that while there was positive good to be done by small quantities of these Meds. frequently repeated their good effects were very questionable in y powerful doses which were commonly prescribed. – In y treatment of y dis. this is a point of so much importance particlularly as regards opium that I think it necessary to add a few words on y subject Opii is generally administered in Cholera as an antispasmodic & if this Med. does not act as a narcotic so long as it has Spasm to allay, it has been thought that y largest doses of Opium are safe during y collapse Stage of Cholera. Now the spasms of Cholera are not Tetanic nor of cerebral origin, but evidently result from y condition of y circulation acting on y extreme branches of y nerves. & these spasms are immediately removed by y restoration of y balance of the circulation. When large doses of Opii are administered to a patient labouring under Tetanus the functions of y stomach being unimpaired y drug is at once digested & absorbed, but as y Cerebral nerves are y seat of y disease y narcotic effects of y med. appear to be 19 rendered inert by y state of y nervous system or are expended in allaying its irritability. In Cholera however thou seems to be no reason for believing that y nervous system of y Brain or spinal marrow is directly in a morbid condition. Opium therefore y not indicated as in Tetanus but even if it were so y function of y stomach being unquestionably suspended meds. are only [partly] partially digested & absorbed. Hence it happens that when y stomach no longer rejects what is swallow’d repeated doses of Opii remain in it little acted upon & when that organ recovers its function if Opii has been largely administered there remains a dangerous if not a poisonous quantity of y narcotic to be digested & absorbed. There being now no spasms to nutralize its effect the Consequence is that reaction is interupted the brain instead of being able to assist y other powers of y system in reestablishing health has its functions interfered with, Congestion takes place in that important organ & death ensues either from this cause or from rapid Typhus. It is therefore one of y most important points in y treatment of Cholera to avoid all over doses of Meds. & with regard to Opii or Laudanum in particular extreme caution ought to be used in administering it or in recommending it to y public, for both in Asia & in Europe the most fatal effects have followed over doses of these meds. – The condition of y stomach in cholera generally renders y exhibition of Meds. in a liquid [state] shape in y outset of y treatment wholely useless as they are immediately rejected by y stomach or bowels. It is therefore advisable at least while y vomiting to administer y remedies in form of pill. The following ꝶ which was not only given with great benefit to patients (adults) immediately on my being called to them, but which was distributed 20 in large quantities for y use of y sick wherever cholera was reported to exist in y district over which my professional charge extended. ꝶ Calomel grs iij} Camphor gr ij} Opium gr. ss} Mis. ft. Pil} (one of these was given every ½ hour & sometimes oftener, while y urgent symptoms continued. The nature assistant had orders not to persevere in this practice longer than 3 hours if they had reason to believe that all pills were retained.) Such pills should be washed down with a small quantity of Brandy & Water & as soon as y stomach seems quieted y following draught should be administered ꝶ Ether Sulphuric gt xxx Tinct. Opiium gt x Mistura Camphor ℥i Mis ft. Haust . (draught to be taken immediately & repeated every ¼ or ½ hour according to y urgency of y case) It was at one time the opinion that cold drinks in Cholera were dangerous. Mr. Annesley found by experiment that Tartaric Acid dissolves y viscid matter which is so often found after death, lining the enteric mucous membrane & he latterly allowed his patients lemonade which was found delight fully refreshing. He also gave a drink containing nitric acid in y hope that while it was agreable to y patient it might communicate oxygen to y system. Wheather we admit y importance while y dis exists, y fibrinous matter on which Tartaric acts or imagine that that Oxygen can reach y system in the way M.D. seems to expect when it is no longer absorbed in y Lungs the practice of M.D. is certainly a real comfort to y patient & can be attended with no bad effects. – In the very outset of y treatment, frictions over y whole body, & shampooning y extremities should be resorted to. Frictions is best applied by means of hot flannel. It may be necessary however to use hot spirrits 21 of Turpentine. & rubbing with y flannel should be continued until y turpentine is rubbed dry. Bags of hot Sand or Salt should be applied to y extremities or other parts of y body but this will often while y extremities of collapse continues, prove unsupportable to y patient. – Blisters during extreme collapse are quite inert & y emplastrum Lytta is too slow in its operation to prove serviceable. Mustard cataplasms are a more valuable remedy: these may be applied with advantage all over y abdomen & to y calves of y legs soles of y feet & even to y chest. Nitric Acid has been resorted to in order to produce an immediate blister – it does not seem to have been attended by any marked benefit & it is apt to produce an escar which may prove afterwards extremely troublesome. Boiling Water is also recommended with y same view & has apparently in some practitioners hands been found useful. Partial Topical applications however are not much to be depended on & as has been already observed, Vesication cannot be produced during Cholera. The dis. is a failure of an important power of y system & y object in simulating y skin is to assist y internal remedies in exciting this suspended power. But as yet there is no local affection to be removed by topical applications altho. these may become very valuable the after indications of cure. In the present stage of y treatment, therefore an extensive application of sinapisms, or y general embrocation of spirrits of Turpentine alone or combined with Tinct. Cantharides or of Oil & [Hartshorn?] or any other powerful rubefacient is to be regarded as y best means of assisting y internal stimulants in their operation 22 3rd. To restore y heat of y body. The heat of y body can only be effectually brought back by reestablishing the circulation of y blood. At y same time remedies having in view restoration of y deficient animal heat have been considered by most practitioners an important part of y treatment; & therefore they are not unworthy of a separate consideration. No one of these three indications however altho classed seriation should precede or wait upon y others. The treatment should be commenced with any one of the three which can be most easily answered, & y whole of them ough to be considered as belonging to y first branch of y treatment of y dis. There is one very remarcable circumstance attending y worst description of Cholera which has been already repeatedly alluded to viz the morbid sensibility of y patient, skin & apparently of his stomach to y presence of any thing raised above y temperature of y air. A warm bath for instance of a heat some degrees below y healthy temperature of y body has been found so insupportable, that a patient after being immersed in it for a few minutes has sprung out of it almost with spasmodic energy & entreated that he might not again be exposed to so painful a remedy. A similar feeling is very commonly produced in y patient by swallowing liquids not more than lukewarm. Notwithstanding however y instinctive dislike to artificial heat exhibited by so many patients labouring under y dis. still it is advisable that attempts should be made to prevent a fatal reduction of y animal temperature. This is particularly necessary in a cold climate. The patient therefore on his being attacked ought to be placed in warm blankets, & every endeavour should be rised to keep 23 his extremities warm preventing as much as possible his throwing off y bed clothes or removing himself from y heated articles which are applied to him. The restoration of animal heat has been reconed so important, that it has led to various contrivances for applying wamth, The hot water bath was at one time much used. but y delay. y fatiegue of using it. exposure & fatigue in drying y patient renders generally the hot bath more usurious than beneficial. The principle which should regulate y application of heat to Cholera patients is that it should be done with the least possible fatigue to them. With this view various descriptions of Vapour Baths have been proposed. The simplest & most expeditions is Dalton’s Bath made by putting burning spirits and the cot or couch which is surrounded by blankets. Poles of ignited Charcoal answer y same purpose. When there are not such [contrivances] conveniences as these at hand use hot Blanket. Bottles of Hot Water. Bags of heated Sand &c. But unfortunately it often happens that y best contrived me thoads are so painful to y patient that they cannot be presisted in. The general result of y steps which must be taken to overcome y dis. is that Venesection is to be immediately resorted to & every endeavour made to get Blood to flow until the congestion is relieved & until there is evidence that y function of y Lungs & action of y heart are so far restored. For y same purpose stimulants are prescribed & artificial heat is applied to assist y returning circulation in raising y temperature of y body to y natural standard. – Such was y practice resorted to by me [in] [India] & others with great sucess in India & from all that I can learn a similar course of treatment had proved equally beneficial in this country. 24 I am informed that a Mustard Emetic has provd very serviceable in y North of England ½ oz Mustard given in cup of Water: it produces full vomiting & appears to stimulate y circulation [so?] as to enable y surgeon to bleed. The removal of blood to y necessary extent has invariably so far as my experiance goes to spasms. oppression & to y Vomiting & purging & has relieved y prostration of strength The effect of V.S would indeed sometimes appear miraculous. A patient will be brought in oil a cot. Unable to move a limb & but that he can speak & Breathe, having y character (both to touch & sight) of a Corpe, yet will he by free V.S. alone be rendered in 1/2 an hour able to walk home with his friends. Case a man was reported to have been suffering from Cholera during y whole afternoon His Skin was cool pulse weak thready had spasms in y extremities urgent thirst. I immediately bleed him & with difficulty obtained a full stream, When about 20 oz of Blood had been taken y mean felt complete relief, Some Brandy & Water was given him & he returned with his friends to his own quarters He was able to accompany y detatchment of troops next morning. There cannot be a more decided proof that this dis, becomes one of pure contagion & that y immediate care of remove in y circulation whatever that may have been no longer exists than y almost instantaneous effect produced by removing a portion of y redundant & [what] to say y least of it what venous blood. All know that however sucessful V.S. may be in relieving the most urgent symptoms of inflamation complete restoration is not y immediate [effect] result that inflamation is not a mere fulness of y vessels of y affected part but that y arteries are in a morbid condition, & that time is required to restore them to healthy action not uncommonly y most difficult part of y treatment 25 And we are therefore fully warranted in concluding that if Cholera consisted of a diseased condition of any portion of y arterial system recovery could not be instantaneous. Breathing Oxygen or Oxygen diluted is worthy of trial. I should also if possible throw the Galvanic stream through the abdomen. But having arrived at y conclusion that y great object is to stimulate y sympathetic system of nerves it is to be hoped that experiance may enable us to attain this object more effectually than we have hitherto done. Prognosis. The most satisfactory symptoms in y early stages of y treatment of Cholera are y return of y natural colour of y lips & nails arising of arterial action in y extremities & recovered animal heat. The proof that y dis is overcome is y restoration of y function of secretion which is most satisfactorily evinced by y patient making water. Such decided symptoms of sucess may not immediately make their appearance partic. if blood has been removed with timidity but let it be remembered that 8 or 10 or may in one case be sufficient while in others depletion [may] must be carried to y extent of 40 or 50 ozs before there shall be reason to believe that y over burthened [valsartan?] system is relieved. It frequently happens that when there is not sufficient confidence in V.S. y case is painfully protracted that for several hours y patients life will seem hanging as if by a thread. y pulse at y wrist will repeatedly fail & return; oppressive deafness Vomiting purging & spasms will continue y body will remain cold & there will be every reason to dread a fatal termination. 26 The restored circulation, return of animal heat & reestablishment of secretion are to be regarded as proofs that y patient is safe. When on y contrary collapse continues, arterial action is no where perceptible; when y temperature of y body becomes more & more death like & above all when a profuse cold & clamy perspiration breaks out over y whole surface accompanied with jactitation there is little reason to hope for a favourable change. It sometimes happens that notwithstang means apparently favourable symptoms y case terminates [favourably] fatally (in dissipated habits & broken down constitution.) It has been found that y more violent the prominent symptoms are y more likely is a cure to be effected: & that whe