1^^ CHEYNE .., ?.,,.->/? "J on ■':■<:' v'1 BOWEL COMPLAINS ] •Hip.-lSHF.li BV j 1 ANI 11OI^ FINJ fv, ^ South E- cornei if Cti- - "i and Fourth Street^ ,< ^rtte&_> ■■■'•". |H'.; ;■ ■' yf 4H> 'tei NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland . / #...,.. --*~v- m^ '....-, s■rr«-;<>c ■ }■■■•■. ■■■ ■ < f}'f-'-t' >*., w^Ui,^ y\r L^^o^yL ir r^t, x L a salutary exertion of the constitution, to remove the cause of the irritation from the intestinal canal. But I think it likewise probable, that the fre- quent repetition of this effort brings the liver into such a state, that it cannot re- turn to the performance of its ordinary or natural function, when the demand for its unusual action ceases; and it is in this manner that the disease may con- tinue, after the original stimuli have been removed, by again putting the child upon a proper diet. It may arise partly from the remissness of the nurse, and from a relaxation in that care which per- haps prevented the weaning brash from coming on sooner, that this disease is produced even many weeks after wean- ing- 47 The dejections are sometimes okery, or even clay coloured, which does not seem to favour the idea of a redundant secretion of bile. However, they con- tinue pale only for a short time, and soon resume the thin consistence, with their dark colour. The explanation of this I presume to be, that, during this interval, the spastic contraction may have seized the duodenum, at that part where the common duct emulges the bile into the intestines. And farther, I presume that the intestines have now become so irri- table, that they are stimulated to inordi- nate action by the aliment, even at the time when, from the supposed stricture of the duct, the bile may be deficient; and hence the griping pain still con- tinues. But it may be, and most probably is, in the ducts, that the explanation of this 48 irregularity, in a great measure, is to be looked for. I have, on dissection, found the bile collected in such quantity in the gall-bladder, that this accumulation be- came the cause of the confinement of the bile; for then the natural curve which the cystic duct takes becomes so acute, and the distended bladder presses 49 so much upon it, that the bile is pre- vented from flowing, or flows in very small quantity. By this retention, the bile becomes more concentrated, and thence perhaps more acrid. And finally, by some action of the stomach or duo- denum, by which the very enlarged gall-bladder is compressed, part of its contents is forced out, the distended ducts are relieved, and the intestinal canal is inundated with bile. That the whole abdominal viscera are in an extremely irritable state, is evident from the symptoms. When it is obser- ved, during dissection, that the liver is affected; that the gall-bladder and ducts are sometimes unusually distended, at another time empty, and yet empty as if recently overcharged; when, again, it is found that no aliment is contained in the canal, but, on the contrary, that the in- 50 testines are empty and pellucid, and in some parts violently contracted, it can- not be doubted that the secretion of the liver is the principal cause of the irrita- tion, and of the distressing symptoms. The mesenteric glands are enlarged, nay, in some instances; inflamed. May not this proceed from the acrid nature of the alimentary matter to which their ab- sorbing mouths are exposed? (3) (3) May not the tabes mesenterica often arise in this way? The glands of the mesentery and mesocolon in adults are often enlarged and indu- rated from dysenteric attacks (Lemjvriere, Dis- eases in Jamaica, Vol. II. p. 207. Cruikshanks, Absorbent System, &c.) And in scrophulous chil- dren, where a carious tooth, a running' from be- hind the ears, or a scratch on the chin, will pro- duce tumor in the neighbouring lymphatic glands of the neck, it is not improbable that a continued absorption from a mass of irritating aliment, will 51 This disease, too, chiefly arises in the autumn, a season in which scrophula is occasion incurable obstructions of the mesente- ric glands. I was led to this opinion by the fol- lowing case of a girl fourteen months old, whom I saw on the 30th of May last. CASE III. This girl is quite wasted in flesh, with a very large and prominent belly, hard, and somewhat irregular, and the liver is plainly much enlarged. Several of the lymphatic glands in both groins are swelled, and she has all the appearance of a scrophulous child. Her eye is quick, her com- plexion sallow, and her face and body are cover- ed with an eruption of small and distinctly florid pimples. Her breathing is laborious, and there appears to be a considerablee scretion in the tra- chea. Her tongue is white and furred, her gums look perfectly healthy, and she has cut five teeth. She evidently labours under two diseases, one in the abdomen, the other of the lungs. 52 not apt to become active in the constitu- tion. It arises after a material change in At four months old, she was seized with a green purging, and vomiting of sour and bilious mat- ter. The bowel complaint was so violent, that it was attended with convulsions, and reduced her to extreme weakness, from which she never re- covered. At this time, the eruption first appear- ed, and, while it kept out, she was always better, and seemed recovering, until, by some unfortu- nate circumstance, it disappeared for a time, and then she became hectic. Two or three months after the attack of the bowel complaint, her bel- ly became plainly fuller than natural; but her purging had now stopped, and she took her vic- tuals well, even greedily; and therefore the ful- ness was not much attended to, until it was ac- companied with thirst and hectic sweatings. The sweatings were always most profuse when the eruption was absent. Her father being a com- mon soldier, little was done for her, and her com- plaints were allowed to run their course. Three weeks ago, she took the inflammation, which,as I have mentioned in note 5. p. 12. was 53 diet, (4) from a diet less irritating to one more so, and at a season when, to use then epidemical, and still she was neglected, until I saw her by accident. She has now a cough, which not unfrequently brings on distressing fits of vomiting. Since the swelling of her belly came on, she has been quite regular in her bowels. Her urine generally is high coloured, and she has had con- siderable thirst and fever. She is still sucking her mother. The gradual cahexy and swelling of the belly, with the general strumous appearance of the child, leave me in little doubt as to the mesente- ric obstruction; and surely, without straining a point, I may trace the disease to the original bowel complaint, which was of many weeks duration. How matters may have stood soon after the violence of the primary disease ceased, may be (4) For this note, see page 55. E 54 the words of Dr. Saunders, " The he- " patic system in this country is more learned from the following short case from Smel' lie's Midwifery, Vol. III. p. 369. " I was called " in to a child four months old, who had been for " three weeks afflicted with curdled green stools, " and at last was brought very low by a thin wa- " tery purging. The looseness frequently return- " ed, and all methods of cure had been unsuc- " cessfully tried. The child being opened soon " after it expired, I found all the glands of the " mesentery swelled, and in hard knots." June 13. The soldier's child died yesterday, and, upon opening the body, I found, as I expected, the mesenteric glands inflamed and enlarged; the liver nearly twice its natural size, firm and pale; the gall-bladder containing a straw-coloured liquor, scarcely resembling bile; the intestines full of flatulency. In the left side of the cavity of the chest, a considerable effusion showed that this side of the lungs had been chiefly affected. " A French 55 " irritable than at any other, and when 11 the diseases which prevail are obvious- A French physician, M. Baumes, who treats of the mesenteric disease, says, " Parmi les ma- " ladies dont le carreau est, le plus souvent, la " suite, je compte la diarrhee opiniatre." Me- moir e, &c. par M. Baumes. (4) My learned friend Dr. Girdlestone, in his account of hepatitis and spasmodic complaints in India, p. 24, has some important observations on the effects of great changes in diet, which I shall transcribe. " Every change of diet, from a long continued " one, seems to act as a stimulus on the biliary " ducts. " The officers and men who were prisoners in « chains with Tippoo Sahib, in the East Indies, " were allowed only rice, water and capsicum, " for the many months they were with him. « When 56 4< ly connected with the state of the bili- li ary secretion, and approach in their " When they were released, the animal food " of every kind which they attempted to eat, " purged them so violently, that they could take " it only in the smallest quantities for a consi- f' derable time. " The British fleet not appearing with the " store-ships, the army was reduced to the ne- " cessity of living almost entirely on animal food. " The natives of the army, whose customary diet " is chiefly rice, were all purged by this change. " The like happens both to men and officers, '»' after living some months at sea on the same " diet. On making a port, the vegetables always " produce such copious secretions of bile, as " oblige them to be moderate in their use. " The patent dried cabbage was laid in for the " use of the 101st regiment. They had none of it " for the first month of the voyage; but as soon " as they began to eat it, they were all purged. " From 57 " nature to those which occur in warm " climates." Children in this country are weaned generally from the seventh to the six- teenth month; and nurses, and all those who are unacquainted with the profes- sion of medicine, whose reasonings upon it are either without any foundation, or rest on the most absurd analogies, ima- gine that the weaning brash arises from some morbid change in the bowels, oc- casioned by the process of dentition, which is going on at the same time. I shall here observe, that notwith- standing my most diligent inquiries, I have seldom been able to deduce any of the derangements of the infantine sys- " From fish also the same effects have been •'< seen." E2 58 tem from teething; (5) and I have been inclined to think, that those physicians (5) The gentleman from whom the following quotation is taken, writes from great experience: " In paucis casibus, semitam deviam natura non- " nunquam tenet, et violentia exoriuntur symp- " tomata. Exempli gratia, Si dentis radix vel radi- " ces citius quam corpus ipsum crescit, vasa gin- " givae membranseque investienti propria excitari " in abnormem actionem et inflammari possint. " Exempla hujusmodi tamen rarissima esse ses*- " timo, neque judico hunc naturalem corporis " processum inter quern nulla animalia, si homi- " nem excipias, vel minimum molestiae pati vi- " dentur, pro morbo haberi oportere." Blake, Disputatio Medica de Dentium Formatione, p. 137. In a page or two after, he gives the opinion of Dr. Hudson, which I shall likewise transcribe, respecting scarifying the gums, which is often made a cruel operation; and when it is so, it is always an unnecessary one: " Concerning your " question about lancing the gums of children, I 59 who have represented this function as teeming with danger, have not accus- tomed themselves to that careful inves- tigation, without which these diseases '« have avoided making it a source of revenue to " myself, convinced from experience of its futi- " lity, except in inflammatory cases, and where " the teeth are near the surface. In such cases, " the lancet gave relief; and I believe seldom or « never on other occasions. Where I have ope- « rated by the advice of the attending physician, " it is true, many children have recovered after " the operation; but I could never fairly say, that " the recovery was in consequence thereof." P. 141. When the gum of an infant is inflamed at the base, at the same time that there is a soft whitish spot on the ridge of it, it may be right to scarify slightly; but I shall never think this necessary at any other time; nor can I image any danger in teething, where no increased action appears in the gums. 60 cannot be understood. The weaning brash, I have the strongest reason to be- lieve, has no connection with teething, farther than that they sometimes meet in the same child. I have known this disease, in many instances, where the gums were neither swelled, nor indu- rated, nor inflamed, and where there was no salivation, nor any appearance of pain in the mouth. I have seen it where chil- dren were cutting their teeth easily; and where many of them have come without difficulty before weaning; still the dis- ease has supervened. But perhaps the strongest argument that can be used, would arise from the observation which I have frequently made, that this disease occurs in children of three months; and I have often known it several months before teething came on. 61 The history of the disease instructs us in the precautions to be used for pro- viding against it. If the observation which I have made be just, that it hap- pens much oftener in the autumn than at any other time of the year, it will be readily agreed, that delicate children should, at that season, be kept a month or two longer on the breast than might be thought necessary at any other, ra- ther than be exposed to the aches and hazards which never fail to accompany this distemper. And although I do not admit, that this disease is in any degree to be attri- buted to teething, yet I should certainly recommend it as a general rule, not to wean children before they have two teeth in each jaw; for this seems to be the natural period at which the food of infants should be changed; and, if I am 62 not deceived, I have observed that those children who are late in cutting their teeth, are very much exposed to the at- tacks of weaning brash. The exciting cause of this disease I consider to be, too sudden an alteration of the diet of a child at an unfit season; and if this opinion be just, it follows of course, that children ought at all times, but more particularly in the autumn, to be weaned gradually, and well accus- tomed to the food on which they arc afterwards to subsist, before they are finally taken from the breast. C6) When (6) Breast milk is the proper food for infants under six months; but, after that period, I think that they should be accustomed to bread and milk, eggs and weak broths, once a-day, and thus gradually weaned from the breast. This will be less likely to produce violent effects on the con- stitution, than weaning all at once, which is some- times recommended. 63 the children of affluent parents are de- prived of their nurse in the early months of infancy, no time is to be lost in pro- curing another, with milk suitable to the age and condition of the child. That an accidental diarrhoea, in an in- fant leaving off the breast, may, especial- ly in the autumn, soon degenerate into this disease, is not improbable. To pro- vide against this, attention should be given to the cause of the diarrhoea. It should be carefully observed, whether it arose from cold, and in consequence of the sympathy which the intestines, and more particularly the hepatic system, have with the skin, or with the extremi- ties; or whether it was not occasioned by improper food. In the former case, no remedy proves so useful as flannel worn nearest to the skin; and with regard to the latter, I must here refer to the di- 64 rections for diet which I shall have occa- sion to deliver in treating of the cure of the disease. Before I had formed the opinion of the disease which I now hold, I limited my attempts to the alleviating of the more urgent symptoms, endeavouring some- times to restrain the purging by opiates, and at others anxious and happy to re- store it again. I therefore used opiates in all ways, with aromatics; then the tes- taceous powders, with occasional doses of rhubarb. I tried laxatives in the be- ginning of the disease, and I think that they were useful. Then imagining the disease to be dysenteric, I gave ipeca- cuan, both as an emetic, and in small doses, mixed with prepared chalk, as an antispasmodic, to restrain the irregular action of the bowels, and certainly with some effect. Although I had some sue- 65 cess from these remedies in the early stages of the disease, I found invariably, that when the disease had taken a firm root, it frustrated all my exertions. In the beginning of the disease, and even at all periods of it, when the attack is slight, I should certainly recommend a dose or two of rhubarb, to the extent of five or six grains, at the interval of two days between each dose; and that, in the mean time, the child should take half or a third part of a grain of ipeca- cuan powder, mixed with six or eight grains of prepared chalk, and a small portion of some aromatic powder, as cassia, every four or five hours. Should there be much griping along with the purging, a glyster of mucilage of starch with five or six drops of laudanum in it, administered at bed-time, will be attend- ed with much advantage. F 66 The success of these remedies will depend upon a strict attention to diet. An animal diet produces less irritation than one which is solely composed of vegetable matter. Eggs, the finer kind of light ship biscuit, or arrow root, cus- tard, the juice of lean meat, plain animal jellies, and broths freed from their oily part, and milk, are the chief articles of nourishment which I have ordered: The last is often the only one which children will take. I have wished for an opportu- nity of restoring the breast milk to a child, as I am convinced that it would be useful, (7) more particularly where (7) This opinion is strengthened by the follow- ing history. It is a description of the disease in question, pretty accurately represented, although the author from whom it is taken does not ap- pear conscious that he is describing a frequent and specific disease. His object is to prove, that breast milk is the proper and only food for in- fants; a proposition which no one will deny. "The 67 children have been prematurely weaned; but I never yet had it in my power. " The little infant alluded to was very healthy " when it was three months old, and was then " weaned, on account of the sickness of the wet" " nurse, but soon afterwards ceased to thrive, " and had continual bowel complaints. At the " age of nine months, I was requested to visit it, " and was informed that it slept very little, was " almost incessantly crying, and had for many " days brought up nearly all its food; was be- " come very rickety, and had the appearance of " an infant nearly starved. Trial had been made '« pf almost every kind of food, except the breast; " and the child had been many weeks under the " care of an experienced apothecary, was con- " stantly in a state of purging, and seemed to be " kept alive by art. " On the first sight of the child, and on the " face of this account, it was very evident that " this infant was not nourished by the food it re- " ceived, and that the complaint lay wholly in the " first passages. But reduced as it was, I had little 68 Thin rice, or barley water, mixed with a small proportion of skim-milk, is a very proper drink for children under this dis- ease. Vegetables of all sorts, particular- ly fruits, acids, and compositions of " expectation from medicines, and therefore gave " it as my opinion, that either the child still pined " for the breast, in which case I doubted not that " it would take it, though it had now been weaned " six months; or that it ought to be carried im- " mediately into the country, and supported for " some lime upon asses' milk only, or perhaps be " fed now and then with a little good broth. " My advice being taken, a good breast was " procuredj which the infant seized the moment " it was put to it, and, after sucking sufficiently, " soon fell asleep for several hours, waked with- " out screaming, and took the breast again. It is " sufficient to add, that the child ceased to puke " or be purged, and recovered from that hour, " and, after sucking eight or nine months longer, " became in the end a fine healthy child." 69 - which sugar or butter form a part, and fermented liquors of every kind, have been strictly prohibited. Every one is aware of the bad effects of cold feet to those whose stomachs and intestines are irritable. I have, therefore, always recommended Woollen stockings, and every precaution against cold irre- gularly applied; and I have added to the flannel which is worn nearest to the skin, a broad bandage, tied firmly round the loins. To take off the continual spasms, I have generally ordered that fomenta- tions, and the warm bath, should be fre- quently used. But I found that the utmost attention to regimen and medicine failed in the advanced stage of weaning brash. After having, with the greatest mortification, witnessed in one season, the death of F2 70 seven children, I thought myself war- ranted in changing the medicines, which I had used, for others which might have a greater effect on the liver, and produce a change in the biliary secretion. From the powerful influence of calo- mel on the body, and more particularly on the system of the liver, and from ob- serving that, in many diseases and con- stitutions, after the first or second dose, it ceased to exercise its cathartic pow- ers W; and, lastly, from considering it as (8) In one child, who, in three days, took be- tween forty and fifty grains of calomel, in croup, I found that the bowels became exceedingly slow, and at length I was obliged to excite them by a dose of jalap. It happens with the use of other laxative medicines, that the bowels become cos- tive. " After Wyatt had long taken an ounce of « cream of tartar a-day, she even became costive " with that dose, and required the use of gam- " boge." Ferriar, Medical Histories and Reflec- tions, Vol. I. p. 90. 71 a less violent medicine with children than adults, I was led to the trial of it in this disease. 1 began with a child who had been ill for some months, and who appeared not likely, under the common treatment, to survive long. She was the second of a family, and, I may almost say, she was predisposed to the disease; for her elder sister had been very ill, and had with difficulty recovered from wean- ing brash. She had unfortunately been weaned in her fourth month, as her mo- ther was deprived of her milk by a fever; so that likewise, in the exciting cause, every thing was unfavourable. She had half a grain of calomel evening and morn- ing; and although the other directions which I had given, I had reason to be- lieve, were disregarded, yet under this medicine she was in a fortnight perfectly restored. 72 Since this case, I have had the useful- ness of calomel evinced by many addi- tional cases, and now I have the firmest belief, that it will prove effectual, at a stage of the disease, when no other me- dicine that I am acquainted with, would be attended with any permanent benefit. As, however, it must be a day or two before the calomel has any effect upon the liver, it may be proper, in the mean time, to prevent the disease from debili- tating the child by a continued griping, purging, or vomiting. This-can often be done, in a certain degree, by glysters con- taining a few drops of laudanum. I have seldom, of late, ventured to give lauda- num by the mouth; for I think that no accident connected with the disease, can account for the changes which I have seen take place after laudanum and 73 large doses of absorbents have thus been given. The success which I have had with calomel has induced me to give it in di- arrhoeas <9) of children. Wherever I have (9) Calomel is recommended both by Drs. Armstrong and Underwood, in different diseases of children. The former prescribes it in what he calls The Hectic Fever, during the time of teeth- ing, and in The Tooth Rash. The latter, in the fourth edition of his treatise, which I saw only a few days ago, in some very desultory remarks upon diarrhoea, recommends calomel. " In a cer- " tain disordered state of the bowels, which fre- " quently occurs, and is disposed to continue for " a long time, during w*hich infants, though not " precisely ill, do not thrive, nor look well." The species of diarrhoea which he alludes to, I suspect is weaning brash, from what follows: " The stools " are said to be always bad, being sometimes of " a green colour, at others of a pastey consist- " ence; sometimes very numerous, and at others, " infants are for several days costive." He re~ 74 suspected a morbid state of the bile, which is one ofthe most common causes, I have used it with great success. I have, by half a grain of calomel evening and morning, or by giving a grain every even- ing for a week or ten days, removed di- arrhoeas, even when the medicine was administered under the most unpromis- ing appearances. I have also found it a most effectual medicine in the chronic state ofthe bilious diarrhoea of children at the breast. After the third or fourth dose of calo- mel, there is generally a great change in the colour of the alvine discharge. It be- commends calomel in the following vague terms: " In this as well as in other bowel affections be- " fore described, when laxative, alkaline, and ab- " sorbent medicines have been found to procure " no permanent good effect, calomel often proves " a sovereign remedy." Article Diarrh*a\ 75 comes of a dark mahogany colour, and is in general more noisome. When this change takes place, it promises a favour- able crisis in the disorder. Soon after- wards, the children become free from fever, more placid, and in a day or two - after their appetite returns, with their former complexion, and every other de- monstration of health. I never found, in the many cases in which I have given calomel, that it produced salivation, or any other unpleasant effect; and I am now convinced, that it is not only one of the most general and active medicines in the pharmacopoeia, but that it is likewise one of the least hurtful. G A S E S OF WEANING BRASH. I need scarcely mention, that the first four cases which I am to detail, occurred before I had tried the effects of calomel. G 79 CASE IV. October 5. P----S----'s child, twelve months old, blue eyes. A month ago this child was weaned. Nearly a week after the weaning, a purging commenced, fre- quent, but particularly so during the night. The stools were very liquid, and generally green. The evacuation was at- tended with griping pains, and the child, who was healthy before, became pale and weak. After the purging had continued a fortnight, a vomiting came on, with which the child was frequently seized. He had scarcely any appetite for food, but a very great thirst; he was intolera- bly fretful, and was becoming emaciated. He had little intermission from fever; and this febrile state had been encou- raged, by small quantities of ardent spi- 80 rits, which his parents ignorantly were frequently giving him. He was very fond of this kind of medicine, and was in some degree continually intoxicated. About eight days ago this was the itate of the boy. I then put him on the following diet: Boiled skim-milk and bread for breakfast, and, to be taken oc- casionally, the yolk of an &gg, or a little weak beef tea, for dinner; a small pro- portion of milk, in thin rice gruel, as his usual drink; and, when griped, a tea spoonful of prepared chalk stirred up in it. He had a small dose of rhubarb, and next day I began to give him a third of a grain of ipecacuan every three hours. Under this medicine, which has been continued since, the frequency of the 81 purging has gradually abated, and now he is recovered from every thing but weakness. G2 82 CASE V. October 10. Benjamin H----n's child, near thir- teen months old. She was weaned at eleven month's, and about a fortnight after, a purging came on. This lasted about a month. Her stools were in general green, and sour smelling, and the disease was slow- ly gaining ground. About a week ago, the purging was checked by testaceous powders; and whether from this, or from a sudden change in the disease, the day after the purging stopped she was seized with slight but general convulsions, which daily increased, until yesterday morning, when they carried her off. When the spasms commenced, the re- turn of the purging was procured by 83 laxative medicines; then she had ano- dyne injections given, and every imagin- able antispasmodic, without the smallest effect. The day after the purging was check- ed, I observed an irruption all over her skin, which, upon examination, proved to be the strophulus candidus 0). In this child, the original disease had by no means arrived at so great a height as I have seen it. The emaciation was not so great as is usual, nor the purging nor derangement in the alimentary canal so determined. I had permission to ex- amine the abdomen. (1) See the first number of Dr. Willan's ex- cellent book on eruptive diseases. 84 DISSECTION. Upon opening the belly, the intestines appeared peculiarly white and free from blood, unless on some places on the mesentery, where there were some small congeries of turgid veins, but which Were far from being inflammations. In several parts of the intestinal canal, there were remarkable contractions of the diameter of the gut, even to the di- mensions of a common earth worm; and of these contractions, at least five or six were apparent, without deranging the natural situation ofthe viscera. This was exactly the state of the in- testines, which should have led me to expect intus-susception of some portion of them; and accordingly, upon turning up some ofthe convolutions ofthe ilium, I observed a perfect intus-susception of 85 a few inches of the gut, but without in- flammation or adhesion of the inclosed portion. Upon spreading out the mesentery, some of the lacteal glands were ob- served much enlarged and considerably inflamed. The liver was enlarged and firm, and the gall-bladder, and the hepatic and cystic gut were gorged, and greatly distended, with a light green-coloured bile. 86 CASE VI. December 11. William B—'s child, thirteen months old. In this child, the weaning brash was seen in its last stage. He was weaned at eleven months, and was at that age healthy. Three days after he was taken from the breast, he was attacked with a purg- ing, which was neglected, and allowed to become habitual, the stools, however, varying very much. After the purging had continued five weeks, and emaciated and weakened the child, it became less frequent, but his health did not improve; he took little sustenance, and had a con- stant fever, with colic pains. The purg- 87 ing was suspended in frequency only; for the stools were still lose and clay-colour- ed, or rather okery; but, instead of troub- ling him incessantly during the night, they only occurred once in thirty-six hours. After a week passed in this way, the purging returned, and it was so con- firmed, that his mother observed that he purged within three or four minutes af- ter taking drink of any sort. At the end of the seventh week, his extremities swelled, and were with difficulty kept in heat; his purging was again repressed, but still he continued declining. He has been ill now for two months; he has con- stant fever, thirst, and fretfulness. His limbs are swelled, but he is quite flabby and wasted in flesh; he sleeps very little, and requires to be kept constantly in mo- tion in hi§ mother's arms; he has much of that peevish expression which appears to be the effect of the irritation of con- 88 stant pain; his urine is scanty and high- coloured, like the urine of a jaundiced person. Round the anus there is a con- siderable excoriation, from the acrimony of the dejections. His breath has a heavy, sour, and singularly disagreeable smell; his tongue is foul and sore, and, together with the rest of his mouth, is threatened with aphtha?. I do not recollect that he was troubled with the vomiting which so often attends this complaint. His mother remarked to me, that when the purging comes on after the costive state of the bowels, the excrement is greener than when the stools are less frequent. In this boy, the tunica albuginea has lost its beautiful transparent colour, and is of a dead yellowish hue. December 18. This boy died yesterday. 89 DISSECTION. The intestines, floating in a consider- able quantity of deep yellow fluid, ap- peared white, and almost pellucid. In several parts, there were the same strait- enings, from spasmodic stricture, as in the preceding case. I reckoned seven such contractions in the course of the canal: The most remarkable was a con- traction of the sigmoid flexure and rec- tum, which at first seemed impervious; and at one part of the canal there was an intus-susception. The mesenteric glands were some- what enlarged and inflamed, but so slightly, that I was in doubt whether I should note this deviation. The gall-bladder was greatly distend- ed, insomuch, that from the acute turn which the cystic duct took, it required H 90 such pressure of the gall-bladder betwixt the fingers, as I feared should have burst it, in order to force the dark bile from the common duct into the duodenum. The liver was large, firm, and of a deep red colour. The bladder was so much distended, as to rise from the pelvis, and its fundus reached the umbilicus. The ureters were likewise enlarged, and the kidneys felt small and hard. 91 CASE VII. I did not see the child who is the sub- ject of this case, until within a few days of his death. The disease came on soon after weaning, and he had been ill many weeks. The appearances of the stools were various; but the purging gradually wasted him. The purging had abated before he died; but its effects were fatal. His limbs were swelled, and his feet, al- most to bursting; and in each of his hams there was a large discoloured spot, of a copper colour. His pain was often very great. Towards the end of his illness, his stools were paler than before. He had always been subject to diarrhoea, from the slightest causes. DISSECTION. In this case, the whole of the intestinal canal was not so pale nor transparent as 92 I have seen it, but it was so in many parts. The arch of the colon was so much dis- tended, as to fill the upper part of the abdomen. The small intestines were very irregu- larly contracted. This was observable in all the contractions, that they were firm luid solid to the feeling, but, when fin- gered or distended, the thickness and solidity entirely vanished, and they were in no way distinguishable from the other portions of the gut. Again, when a por- tion of the gut, thus contracted, was lift- ed up, it was not round, but irregular, as if moulded by the surrounding intes- tines. In one of the contracted portions, there was an intus-susception. The gut had slipped in but a very little way, and was easily withdrawn; and, from the de- gree of stiffness which remained, it ap- peared as if the gut had been doubled >. 93 before it was drawn in. The stomach was much contracted. The liver was large, firm, and of a bright red colour. The gall-bladder was large and empty, at least it appeared so, although there was a large spoonful of bile contained in it. The bile was of a dark green colour, and had flakes float- ing in it. H2 94 CASE VIII. July 12. Mr. L----'s daughter was weaned at six months, when she was fed upon pa- nada chiefly, and weak broths. Three weeks after and about a fortnight ago, the disease began. The stools were slimy and sour smelling, and the disease was reducing her very fast. A severe vomit- ing came on the day before yesterday, and has been constant ever since. Yes- terday the purging was suspended, but it returned in the night, and is very se- vere. Her urine is high coloured; the child is alarmingly weak; she has great thirst; her tongue is very foul, and she has a hectic glow upon the cheek. 95 July 13. She died last night, quite exhausted by the vomiting and purging. The dissection was not-allowed. In this case, no attempt had been made either by medicine or change of diet to check the progress of this disease, and the rapid termination of it is to be ascribed to the stimuli, which had pri- marily occasioned it, continuing to act upon the highly irritable intestines. 96 CASE IX. February 12. Mr. T----'s child, eight months old. This child was weaned between her fourth and fifth month, from her mother having been deprived of her milk by an epidemic fever about the beginning of November. About eight days after wean- ing, she took a purging, which has never left her since. She is now constantly fretful; her sleep is unrefreshing, and her appetite is much depraved; her counte- nance is alternately of a sallow paleness and flushed. She has a considerable heat of skin, and thirst, and her urine is scanty and high coloured, dying linen cloths of a deep yellow; her stools are quite wate- ry, very frequent, and of a brownish co- lour. She generally vomits - every thing 97 which she takes at her meals; and some- times the aliment thus rejected is mixed with bile. With strict attention to be paid to her diet, I ordered her to have half a grain of calomel, mixed with six grains of prepared chalk, and four grains of pow- dered cassia, night and morning, and a flannel dress. February 13. She was last night no better; her purg- ing was rather more frequent. February 14. Last night much as before; her purg- ing not quite so frequent; the dejections are changed to a dark brown colour. 98 February 15. Her mother declared, that since this child was weaned, she has not had so good a night, which she attributes en- tirely to the powders. She had only two stools in the last twelve hours, which were very dark and fetid; her thirst and fever are somewhat abated. February 17. Her stools are exceedingly dark. She continues to recover her health. And now I have an additional proof that the calomel has had the principal effect in her amendment; for the flannel which her mother was desired to apply, had been neglected or withheld. February 24. The looks of this girl are much im- proved, and I consider her as rapidly re- 99 covering. All the febrile symptoms are gone. She has not more than two stools in the twenty-four hours, and they are of a more natural appearance, although it does not appear from them as if the nu- tritive process were as yet perfect, as part of her diet passes crude and unconcocted. February 26. This child continues very well. Upon examining the mouth to-day, I observed the first tooth about to pierce the under gum. In summing up this case, I am natu- rally led to compare it with the sixth case. The children seemed to me, when I first saw them, to be very much in the same state. The course and termination of the cases will suggest a useful lesson. 100 In the beginning of April, the same little girl had a return of the purging, which was again removed by a short course of calomel. ( 101 CASE X. May 6. Mr. N----*6 child, eleven months old, had been remarkably healthy and cheer- ful, and had never taken any thing but breast milk, until the day she was wean- ed. Her mother, from having had an at- tack of acute rheumatism, was forced, without preparation, to wean her exactly five weeks ago. On the day after wean- ing, she was taken with a purging, which has been violent ever since. The dejec- tions were green at first, and attended with tenesmus, which made her com- plain violently before each stool. Her stools have varied much—yesterday they were quite watery, so that the linen look- ed as if it had been stained by the mat- ter of a gonorrhoea; and by their acrimo- ny they have occasioned some excoria- I 102 tion. Her urine is high coloured and hot, her tongue is white, and her breath is heavy smelling. As usual, she has be- come ill tempered, particularly during the night; she has lost her former rosy complexion; and there is rather a loose- ness in the muscles, than an absolute emaciation. She has great thirst. The drink she takes is chiefly milk and water, and, for these two days she has vomited it curd- led. Before she was weaned, she had two teeth in each jaw, which came without any difficulty. About a fortnight ago, two more came through in the upper jaw; but the disease has been more violent since. The gums are perfectly healthy, and there is, for the present, no appearance of any more teeth coming forward. 103 Mav 7. She-had an anodyne glyster last night, which she kept a good many hours. She had half a grain of calomel, which is to be repeated every night and morning. May 8. She has had four doses of calomel, and her belly is already more regular. The stools appear of a very brown colour. May 11. Since bed-time last night, she has had only one motion. Her looks are improv- ed, and her thirst has left her. She is in every respect better. In this child, the disease was increas- ing. It had not, however, arrived to such a height as to make it improbable that it 104 should yield to the remedies which I used before I thought of calomel. But I had observed, that children so immedi- ately recover their appetite upon the ad- ministration of calomel, that 1 thought it proper to give the medicine which would most speedily restore the patient to per- fect health. 105 CASE XI. September 9. C----A----, two years three months old, has a frequent purging, which began four days ago, and which arose from the carelessness of his attendant, in having permitted him to eat some potatoes. The excretions from the intestines are green- ish and slimy. The child is so much re- duced by them, that he totters as he walks, and is quite pale and sickly. He has considerable thirst; his appetite, how- ever, is not much impaired; his skin is hot, and his pulse is quickened by the least exertion. This child has been, all his life, liable to diarrhoea, from the slightest causes. He had it frequently while on the breast; and, upon being weaned, he had a severe 12 106- attack of weaning brash; since which time, from the least deviation in the re- gimen or diet which is pointed out for him, he invariably suffers in his bowels. He has had several attacks similar to the present; and indeed, to a certain degree, he has had an habitual looseness, which has kept him a pale and puny child. He has afforded several proofs of the efficacy of calomel in removing these complaints; for he has always recovered in a few days after the administration of it. September 15. I ordered for this child, previously to giving him the powders with calomel, a dose of eight grains of rhubarb, from thinking that the irritation might be kept up by some indigested food lodging in the bowels (a thing which I have known to take place many days after it had been taken); and after the rhubarb had prodo- 107 ced a considerable effect upon the bowels, I recommended that a dose of calomel should be given twice a-day. The child very soon recovered from the purging, and is again restored to his usual state of health. 108 CASE XII. Saturday, September 19, 1801. To-day I was again sent for, to visit the child whose case is related in p. 15. I had not seen her since the 16th of June; but I understand that she has never been altogether well, that she has, ever since, had a looseness, although to no very great extent. About three weeks ago, she was sent to the country, in the expectation that she would benefit by change of air; but, being thus removed from the more immediate observation of her mother, she was not so well attended to in her diet; in particular, she was allowed con- stantly to swill down new milk. This nourishment proved too heavy for her stomach, and aggravated the purging, and brought away great quantities of slime, mixed with green feeces. She was 109 brought home some days ago much worse, and on Thursday her mouth was observed to be sore. To-day her friends were much alarmed at the appearance of it, and at the state of her bowels. On her tongue there are several ulcers, each about the size of a herring scale, with inflamed edges, and, judging from the expression of the child when any dry food is put into the mouth, very painful. The lips resemble the dry and chopped lips of a person in typhus, smeared with sordes, and with the ragged cuticle hang- ing from them in shreds. She has just got one double tooth in the upper jaw; and, judging from the breadth of the gums of the under jaw, there are double teeth about to free themselves on each side. The excretion from the belly is slimy, frequent, and sour. The child sleeps none, has considerable thirst, 110 would take sustenance, but is almost convulsed with pain when any thing is put into her mouth. Hab. Tulv. Rhei, gr. vi. September 22. She has had half a grain of calomel morning and evening since the 19th. The looseness is somewhat checked in fre- quency; die aphthous state of her mouth is not worse; the child is still in conside- rable pain, and does not sleep at night. The diet has been particularly attended to, and no drink allowed, but rice gruel, with a little milk in it. R. Mucil. amyl. ^ ij. Tinct. Kin. 3 to. Theb. gt. v. M. f. Enem. Injic. h. f. September 25. The prescribed plan has been adhered to, and the child is strikingly relieved. Ill The glyster has procured regular sleep for the child, and the ulcers in the mouth are skinned over. The dejections are much less frequent; and, although it will require a longer course of the calomel to effect a complete restoration, yet they are much more of a healthy and concocted nature. From my Notes, I could add a great many cases more which have been for- tunately treated by calomel; but I think it unnecessary to multiply the proofs, as those which I have adduced will demon- strate its usefulness. The examples which I have already given, are quite sufficient to illustrate the symptoms of this disease, which indeed admits of less variety than might be imagined. THE END. 0 Book taken apart, leaves deacidified with magnesium bicarbonate. Folds re- inforced, leaves supported with lens tissue where weak* Resewed on linen cords* Old endpapers re-used with unbleached linen hinges. Rebaoked with rope manilla paper dyed to matoh old sides. Original front cover label re-used and old paper sides re- used. February 1975- /-/i?i6/"//5t* Carolyn Horton & Assoc. A fff\ 1+30 West 22- Street «^ £, New York, N.Y. 10011 C 5 3/ OS W$ c