National Library of Medicine Bethesda, Maryland Surgeon General’s Office Library Section, …. No 106859. Sam[uel] Barrington, M.D. Notes on the Practice of Medicine; taken from the Lectures of N. CHAPMAN, M.D. Professor of the Institutes of Practice of Physic &c, in the University of Pennsylvania: By Sam[uel] Barrington. 1818-19, 1820-1821, 1821-22. i Contents. _____ _____ Classification of Diseases. . . . . page. 2. _____ _____ Class. 1. Diseases of the Circulation System. _____ ____ Fevers. . . . . . . . . . . . . . .2 Intermittent fever. . . . . . . 4 Continued fevers. . . . . . . .19 Bilious Inflammatory. . . . . [19] Inward fever. . .. . . . . . . 31 Typhus fever. . . . . . . . . [31] Winter Epidemic. . . . . . . . 44 Yellow fever. . . . . . . . . .50 Plague. . . . . . . . . . . . .57 Hectic fever. . . . . . . . .. 62 Hoemorhagies. . . . . . . . . . .67 Hoemoptysis. . . . . . . . . . 69 Hoematemesis. . . . . . . . . .76 Epistaxis. . . . . . . . . . . 78 Uterine hoemorhagy. . . . . . .80 Hoemorhois. . . . . . . . . . .83 ii. Class. 2. Diseases of the Digestive System. _________ Gastrites. . . . . . . . . . . .. 85 Poisons. . . . . . . . . . . . . .89 Mania a Potec. . . . . . . . . . .92 Corrosive poisons. . . . . . . . .94 Dyspepsia. . . . . . . . . . . . .97 Worms . . . . . . . . . . . . . .108 Enteritis . . . . . . . . . . . .114 Peritonitis. . . . . . . . . . ..115 Colic . . . . . . . . . . . . . .119 Flatulent . . . . . . . . . .___ Bilious . . . . . . . . . . . 120 Colica Pictonum. . . . . . . .123 Cholera morbus. . . . . . . . . .125 Cholera Infantum. . . . . . . . .128 Dysentery. . . . . . . . . . . . 135 Diarrhoea. . . . . . . . . . . . 144 Constipation. . . . . . . . . . .149 ________ Class. 3. Diseases of Respiratory System _______ _______ Catarrh. . . . . . . . . . . . .151 Influenza. . . . . . . . . . . .155 Cynanche trachealis. . . . . . .156 iii Cynanche larangea. . . . . . . . . 160 [Cynanche] tonsillaris. . . . . . . .161 [Cynanche] parotidea. . . . . . . . .163 Pneumonic Inflammation. . . . . . . .164 Pleurisy. . . . . . . . . . 165 Bilious Pleurisy. . . . . . 167 Peripneumonia notha . . . . 168 Pertussis. . . . . . . . . . . . . . 173 Asthma. . . . . . . . . . . . . . . .179 Angina Pectoris. . . . . . . . . . . 183 Phthisis Pulmonalis. . . . . . . . .187 Tuberular Consumption. . . .188 Catarrhal [Consumption]. . .195 Phthisis Laryngea. . . . . .197 Apostimatous Consumption . .198 __________ __________ Class. 4. Diseases of the Absorbent System __________ Dropsy. . . . . . . . . . . . . . .200 Anasarca. . . . . . . . . . 201 Ascites. . . . . . . . . . .209 Encystis. . . . . . . . . . 210 Hydrathoroa. . . . . . . . .211 Hydrocephalus. . . . . . . .216 Scrofula. . . . . . . . . . . . . . 222 Marasmus. . . . . . . . . . . . . . 230 ____________ iv Class. 5. Diseases of the Cutaneous System. __________ __________ Exanthemata . . . . . . . . .232. Erysipelas. . . . .233. Scarlatina . . . . 237 Measles. . . . . . 244 Small Pox. . . . ..248 Cow Pox. . . . . . 256 --------------- --------------- Class. 6. Diseases of the Muscular System. _________ _________ Gout. . . . . . . . . . . . . 258 Rheumatism. . . . . . . . . . 269 _________ _________ Class. 7. Diseases of the Secretory System. ________ ________ Hepatitis. . . . . . . . . . .277 Icterus. . . . .. . . . . . .284 Nephritis . . . . . . . . . .287 Splenitis . . . . . . . . . [287] _______ _______ End. __ __ Practice of Physic. The question here presents itself. In what manner shall we class disease? The best arrangement excepting that of Dr. Hosacke lately published, is that of Cullen. Notwithstand- ing all that has been said against nosology, it induces at least order and perspicuity. Dr. Brown classes diseases under two of the general heads of Sthemic and Asthmetic : or those above and those below the natural standard of health. All above 50, he considered sthmetic : all below, asthmatic. Asclepiades made three classes. 1. Those con- sisting in too great rigidity. 2. Into great lax- ity. 3. Those of an intermedial degree. Aris- totle is the original author of the Brunonian doctrine. Diseases may be classed according as they affect different systems of the body; and, may be arranged under the following ten. The Circulatory System, which consists of the heart and blood vessels. ------------------------------------------------------------- *vide also Good’s system of nosology. 2 2. The Digestive System, which consists chiefly of the alimentary canal. 3. The Respiratory system, of the lungs and their appendages. 4. The Absorbent system, of the absorbent vessels. 5. The Secretory system, of the larger glands. 6. The Sensitive system, the organs of sense, brain and spinal marrow. 7. The Muscular system, the muscles, their tendons and apponcurves. 8. The Cutaneous system, the external covering. 9. The Osseous system, the bone & appendages. 10. The Generative system, which consists of the genital organs. Under these heads may be included all the diseases to which we are all liable. _______ _______ Class. 1 Diseases of the Circulatory System. _______ _______ Fevers ____ ____ These are by far the most common complaint of our nature. It is comperted that more than one half of mankind die of febrile diseases. They are so numerous and fluctuating that they often shift their character so as to put on very different appearances. Febrile affections, according 3 to Cullen, begin with some degree of chilliness, followed by increased heat & frequency of pulse. With the interruption or disorder of the animal functions : the strength of the limbo being par- ticulary diminished. The chilliness is not an uniform attendant. Boer have supposed that ri- gors only proceed fevers which proceed from some internal cause. The heat sometimes does not ex- ceed the natural standard : as happens in typhus fever. In these diseases the senses cannot be a criterion to judge the degree of the heat; because sometimes, when the patient complains of exerpine warmth, he is in reality cold : the reverse is also true. As relates to the pulse there is every variety. There are fevers of the brain in which it is reduced to 30 or 40 : therefore the pulse cannot be consid- ered a criterion in fevers. Neither can a disturbance in the animal function. Febrile affection have usually been divided into Idiopathic & symptomatic; or such as are original & without any local affec- tion, and such as occasioned by some other dis- ease. This division is altogether unfounded & I shall of course reject it. Every fever is secondary or sympathetic. Idiopathic fevers (so called) are caused by miasmata being entangled with the saliva & this swallowed. The effect is thus first produced upon the stomach, & is hence 4 extended to the bloodvessels. It has been sup- posed that the lungs were primarily affected in fever. That this not the case is proved by miasmata not acting when the digestive powers are called into action. Cold acts first upon this skin & is extended by sympathy to the lungs or other parts which may be in a state of predisposition. If the lungs be in this state, the consequence is Pleurisy or some other pulmonic affection. But if the joints be predisposed, then rheumatism is the consequence. If the throat, cy- nanche &c. Sympathy is either Direct or Re- verse. Direct sympathy is when the internal parts are first affected : the action extending to the exter- nal. Reverse, the contrary. I shall divide fevers into Intermitten & Continued. Intermittent Fever. An intermittent fever is one consisting of a succession of paroxysm with an intermission be- tween them; and this interval is called apypexia. These internals are of different lengths : in the quo- tidian it is 24 hours, Tertian 48, & quartan 72 hours. The tertian is the one most commonly met with, & most easily cured : next the quotitdian, & this uncommon is the quarter, which is always difficult to manage. The paroxysm of the quotidian 5 generally occurs in the morning : that of the tertian, at noon; & that of the quarter in the evening. In intermittent there is a pretty constant ten- dency to return on the 7th, 14th, or 21st day. There is also a disposition to return annually. The tertian mostly occurs in the spring : it is called vernal, & is more inflammatory. The quarter is met with mostly in the fall, & is called autumnal. It partakes more of the weak bilious character. Cul- len supposed the quarter to be of more frequent occurrence than the quotidian : it is not so in this country. Each paroxysm is divided into the Cold, Hot & Sweating stage. The cold stage is whered in by languor & sluggishness of motion, attended with nausea, the face pale, the skin con- stricted, taking on the appearance of goose flesh. Afterwards pain in the heart, loins & extremities comes on, with universal rigors; the respiration is disturbed; the pulse is small & often irregular; but the most alarming symptom is coma or stupor. In the Hot stage is redness in the face, a throbbing in the temples, pain in the head, anxiety, restlessness & tendency to delirium, these continuing for some time, the Sweating stage comes on when a slight moisture breaks out on the forehead, which afterwards becomes cover[e]d in sweat, the pulse now becomes softer, respiration more free, and the other 6 symptoms gradually subsides, which puts an end to the paroxysm. It is remarked by Lenac and others, that the cold stage is sometimes wanting: the hot stage occurring first, & sometimes the stages are reversed. Among the other anomalies attendant on Intermittent, they sometimes go off by copious per- spiration or urinary discharges. The disease now & then confines itself to one particularly part : sometimes fastening itself on one of the extremities, & going thro[ugh] the different stages with great regularity. The eyes are occasionally affected; & are cured by those remedies which cure the intermittent fever. The origin of this disease is involved in great obscurity. Its most common causes are miasmata from vegetable or animal matter in a state of putrifaction, which are often carried to the dis- tance of 8 or 10 miles. Whatever brings the sys- tem to a state of extreme debility, as low and pernicious diet, anxiety &c., may be consider[e]d as a cause of intermittent fever. Cold, if connected with moisture, especially if in a damp room, and even extreme heat, may produce the disease. In- crease of bile is frequently the exciting cause. A singular fact, & one very difficult to explain is that during the last summer (1821) those portions of country which were formerly accustomed to Inter- mitten fever, escaped it : while those in the moun- 7 tainous country, where it was never before known, were principally affected. Prognosis – when the paroxysm are long and violent, attended with coma & delirium, and the apyrxyia short, there is reason to apprehend a tedious & difficult cure. When the paroxysm comes on earlier at every period, it is unfavor- able : it is then apt to become continued. A de- position of red sand in the urine is the most certain sign of a speedy termination of the dis- ease. A deposition of a whitish substance is also favorable; tho[?] not so much so as that of red sand. When a paroxysm of unusual violence occurs, without any obvious reason, it generally proves a final one. Intermittents may be con- verted into continued fever, or may lay the foundations of other diseases, or may suddenly terminate fatally, & this generally takes place in the cold stage. If death take place in the during the hot stage, it is from apoplexy or convulsions. It never happens in the sweating stage. Appearances in Dissection. In recent cases, marks of inflammation are seen in the [primae vise ?]. accumulations of blood, especially in the liver and spleen, when death has taken place in the cold stage. These viscesra are also sometimes found in the schirrous state : especially when the 8 disease happens in old people, or has been of long standing. Treatment. This very properly divides itself into that which is necessary in the paroxysm, & that in the apyrexia. In the Cold stage we should place the patient in bed & induce warmth by warm bricks or bpttles of warm water to the extremities, or even other parts if necessary, and make use of diffusible stimulants : the best of which is opium. When the Cold stage is more violent, we must recur to more stimulating ar- ticles, as Ether or vol : Alkali. Emetic may be used when the disease is very obstinate, on attend- ed with nausea, or where there is an oppressed condition of the stomach. [M?] Kelly, an English surgeon, used a tourniquet as a substitute for opium. He applied it on the thigh & arm of opposite sides, with a view to confine the blood to the heart & arteries, & thus invigorate the circulation; but there is not much to be gained by it. By some writers emetics have been strongly recommen- ded during the cold stage ; but since the introduction of opium, they have been altogether supplanted. The cold stage is that which injures the consti- tution most, & it is of great importance to put an end to it as soon as possible. The Hot stage is to be treated by the copious * For profuse sweating – alum in Brandy : [?] ; to a pint. – opium excellent. [?] Blister about 10 or 12 inches [illegible]. 9 exhibition of warm beverages, if necessary : we next produce diaphoresis, & for this purpose the antimonial preparations are generally used. The dia- phontic I am in the habit of employing, is the Spiritus mindireri. When there is much nausea the effervescent draught or neutral mixture may be given. We sometimes experience considerable diffi- culty, especially when the system refuses to react. This state is to be relieved by tubefacients. Opium is sometimes useful. Venesection is always followed by exhaustion ; but topical bleeding will often afford relief. Eupatorium will sometimes answer very well in this stage; & in country practice, both it & the centaury are much used. Opium has been much recommended by Lind in the hot stage ; but, by others, the accounts of it are not quite so favorable. According to my experience, it is inju- rious in the hot stage, when the patient is pleth- oric & inflammatory ; but in opposite states, it is an excellent remedy. The Sweating stage is sel- dom an object of medical care. * Intermittents are sometimes inflammatory ; & the paroxysms then have a different appearance. They are of this character generally in the spring. The symptoms are a strong, full pulse, laborious respir- ation, and pain in the head. These are to be relieved by bloodletting. About a pint of blood may be 10 drawn, & at the same time a mercurial purge given. Treatment of the apyrexia. This should be with a view of sustaining the system, & for this purpose Peruvian bark is most commonly employed. The red when pure is best. The earlier we commence with the bark, the more complete & speedy will be the cure. It was the opinion of Boerhave, van Sweiten & Lydenham, that some time should elapse before commencing the use of the bark. They sup- posed that the morbific cause should be shaken off by a succession of paroxysms. At present it is custom to evacuate the alimentary canal by emetics. They do not act merely as evacuants ; but by destroying the train of diseased [apoxia- tion ?] on which intermittents & other periodical diseases depend. Of the emetics the Tart emetic is generally used ; but of late they have given way in a great measure to mercurial purges. These will sometimes answer very well ; but many cases occur in which the antimonial emetic is indispen- sible. It is sometimes necessary to repeat it daily. Venesection is sometimes demanded : as the disease is often inflammatory in the commencement, & this diathesis is kept up for some time. The system should always be evacuated previous to the use of the bark. It is in the cold stage that accu- mulations of blood are formed in the liver and 11 spleen. The bark is here said to be inadmissible. In cases of visceral obstruction, when no inflam- mation exists. I always use the bark ; but when there is inflammation, with pain in the obstructed viscus & some activity of pulse, the bark never does good, & we must resort to venesection, to blisters, & sometimes to a slight salivation. This will remove the obstruction & at the same time cure the intermittent. The blue pill in some cases will answer. The bark should never be given immediately preceding a paroxysm. The dose is commonly [?i[ in 24 hours : [?i] to be given at a time. It is frequently used in much larger doses : even [?i] has been taken at once, in the morning. As a general rule, give as much in the apyxsia as the stomach will bear. Sometimes the irritability of the stomach & such that the bark cannot be retained for any length of time : in such cases it is to be mixed with virginia snake root, or with cloves, which sometimes answer better : in the propor- tion of [?i] to [?i]. Cremor tarter will also answer very well. The Infusion of Bark has generally been considered inert ; but the Peruvians commonly used it in this way. I have tried it in several cases & have been pleased with it. A teaspoonfull of Husham’s tincture may be added. When the bark purges, it may be restrained by uniting opium with it. *1 gr. morn & nightime 12 When there is acidity unite with it magnesium. If the bark cannot at all be retained, or runs off speedily from the bowels, it may be injected ; but I cannot recommend the practice; having used it in a few cases only among children. - Rx Powdered Bark [?ii] to be mixed with the mucilage of gum Arabic, starch, or flaxseed, & a little water. A small por- tion of laudanum may be added. – Bark has also been used in the form of extract, & as a pede- luvium & semicupium. The French chemists have extracted from bark two substances of an alkaline nature, kinine & cinchonine : found most abundant- ly in the red bark. They use the latter in the form of sulphate of cinchonine , in the dose of 3 or 4 gr. & it is said with great success. - In a dry state the bark may be used externally ; but whether it does much good I cannot positively say. Darwin says that if the bark be strewn plentifully in the bed of a patient with inter- mitten, it will cure him. The bark jacket is used in violent cases : it may fail in the vigorous & robust ; but in children & delicate females, it will do good. It operates by making a tonic infusion upon the skin, which is im- parted by reverse sympathy to the stomach. As [cross out] substitutes for the Bark, or as remedies when the bark has failed, many vegetable substances 13 have been introduced into the Materia Medica. I shall first notice our native plants ; & of these, by far the most effective in intermittents is the Serpentaria Virginiana. This was used by Lyd- enham united with wine. Whether it will by it- self cure the disease I have doubts; but when combined with bark, it will certainly do so. It is well adapted to cases of children, given in combination with bark : thus, Rx. P. Cort : Peruv : . . . . [??s] Pul : Serpentar : . . . . [?i] Carb : Sodae . . . . . . .gr. XXX. [m crossed out] Div. In pulv. Iv. One to be given every 2 or 3 hours. In diseases of a periodical character, the alkalies have proved an excellent remedy : even in Epelisroy & Pertussis. Another native vegetable , is the Eupatorium Perfoliatum (Thorro’ wort). It is best to give it in the state of powder, or cold de- cretion. It may be given both in the paroxysm & apyrexia. (vid. Therapeut. vol . I. p. 344). another spe- cies of the Euopatorium is the Eupat Pilosum, or Hoarhound, - in the Garden Cantaury [illegible] [illegible] is a native veg- etable of some powers in intermittent. It is to be ta- ken in as a great a quantity as the stomach will retain. It has an advantage over the bark in being diuretic as well as tonic, & may be used both in the paroxysm & apyrexia. The Dogwood (Cornus 14 Florida) has considerable powers in this disease. The bark of the tree is used in the same manner, & in the same doses, as the peruvian bark. The bark of the Wild Cherry tree, (Prunus Virgiana) has also been used. It has a narcotic quality apoci- ated with its tonic power. The Black Alder of our swamps (Prinos verticillatus) is possessed of near- ly the same properties. The bark of the White Oak (Quercus Alba) has been tried ; but much bet- ter is the Chestnut Oak (Quercus Primus). The Willow (Salix Alba & S. Latifolia) & the Tulip tree (Liri- odendron Tulipiferum) have also been used. I shall next consider some articles derived from other parts of the world. Angustura ([cross out] Carsparin [cross out] Angulares). This, tho’ not introduced into the ma- teria medica for more than 30 years, ceased to be a remedy ; but within a few years it has been re- vived by many celebrated European practitioners: especially by Brand. From what I know of it, I think it much inferior to the Peruvian bark. It is, however, very cordial in its nature & agreea- ble to the palate. If we should have occasion to resort to it, it must be when the Peruvian bark has failed : the dose is grs. XXX to Xl. It is most useful in intermittents accompanied with intestinal disease. The Carscarilla (Cro- ton Eluntheria) is possessed of nearly similar properties. 15 Sweetenia Febrifuga, a species of mahogany has also been used. (vid. Therap.). next I am to men- tion some more affectual remedies. Kino. This was originally employed by Dr. Fothergill of London. It has been much used in this city in the following manner. Rx. Gum : Kino : . . . . . .[?ij]. Pul : Gentian . . . . . .[???]. Opii . . . . . . . .gr. [?ij] – Div. in Pulse xii. One to be given every 2 or 3 hours. [It is a remarkable fact that Kino & Columbo, both astringents, constitute, when combined, a pow- erful purge.] Charcoal has been recom- mended in this disease. It may be found useful in intermittents associated with dysentery. The dose is about [?i] to be repeated as often as the barks. Sulpher is also a remedy in intermittent fever. It was used originally Dr. Grainger, of the Cape of Good Hope, who gave it in brandy. (vid. Therap.) when administered in milk it is quite as effica- cious as when given with spirituous liquors of any kind. I do not doubt of its affects. By Dr. Physick it is considered the best remedy in every disease of a paroxysmal tendency. It is equally efficacious in Hectic fever or that arising from irritation. Many diseases of the head of a periodical nature. Have been relieved by it. Sulphate of Copper (Blue Veterial). This article Popular remedies in Intermittent. Remedy of the late Dr. Stewart of Philad[elphia]. – opii [?i]. Sulph. Cupri [?i]. Sap. venet. q.s. ft. pil. n. CXX. (120) 3 to be taken in a day. – Combination of Calomel, opium & Camphor is good. – Roasted spider (Dr. Rush}. Hard cider, horse radish & rush of iron - urine – pear – Barks, serpen taria & carb. Potas. – Dogum – tobacco to the wrists – Pulv. Conos, sublim. – on a plaster to the extremities. – Sulphur in Brandy – Sulph: ferri gr. X at a dose, in solution, used with great success by Dr. Potter & Mr. Rensie of Balt. – Sal. Ammoniac from grs. X to [?i] - ! [Dr. Potter.]. 16 I have prescribed very much of late in pro- tracted intermittents, on the authority of Dr. Adair & Dr. Monroe, physicians to the British army in Handers. – The latter of whom used it in the fol- lowing manner. Rx. vit. carul: . . . . . . . . . . gr. iv Ext : Cord. Peruv: . . . . . . . .gr. .XXXij. Syrup : Com: . . . . . . . . . . s. – m. div. in pill. XVj. One to be given 4 times a day. To quartan agues it is especially adapted, & in such cases I have never failed in a single instance in which employed it. My mode of prescribing it is to commence with 1/4 of a grain at a dose, united to a small portion of opium, to be repeated 3 or 4 times a day, gradu- ally increasing the quantity. Cuprum ammoniacum. as to this my experience is exceedingly limited. From its use in epilepsy & other diseases of a periodical recurrence, we may suppose from analogy, that it might also be useful in intermittents. The dose is 1,2,3 or 4 grs. Sulphas Lince. The dose is the same as Cup : am : - Alum. is a remedy of high esteem in intermit- tents. Dr. Lind rates it next to the bark. Cullen combined it with nutmeg in equal parts; but observing it to disagree with the patient he aban- doned it. My experience with it is not very great. It may be of some advantage in intermittents. 17. associated with affections of the stomach. The dose should not be more than 4 or 5 grs., & then com- bined with some aromatic, as nutmeg. It has been recommended by Dr. Chalmes of S. Caroiina, & by Dr. Adair in Handers, who gave it with canella alba. Darwin thinks it best suited to intermit- tents associated with bowel affections, especially dysentery. Sacchurum Saturni. This was highly extolled by the late Dr. Barton. I never derived much benefit from it. The dose is the same as in hoemorrhage. (q.v.). Arsenic. This is mischievious in all weak & debilitated forms of intermittent fever, and when it is accompanied with a cachectic state of the system. It is sometimes useful when the bark has failed, & is well suit- ed to cases of children; & is perhaps, in their cases, superior to the bark. White oxyd of Bismuth, (or Sub-nitrate) I am inclined to think well of this. It is greatly recommended by Dr. learmichael, of Vir- ginia. The dose is 5 to 10 grs. In 24 hours. – Tela Aranei. (Spider’s web). This I rank very high, & the confidence in it is well founded. I have used it with great success in doses of 5 grs. repeated every 4th. or 5th. hour. That found in cellars or dark places is to be used. That which is met with in light places in altogether inert. The recent web (known by its being glutinous) is to 18 be preferred. Spiritus Terebinthina, in the dose of a teaspoonful 4 or 5 times in the 24 hours, is an excellent remedy. – Simarouba. – [?] Gelatin, or animal gluten, has been used as a remedy in intermittent fever. The French have made was of common glue. Calf’s foot jelly is more pleasant ; & some very bad cases of the disease have yielded to this simple remedy. Dr. Griffith, an imminent practitioner of this city, has done much good with it. Intermittent will not always yield to these remedies, & it is sometimes necessary to resort to mercury. In the same cases Blisters may be employed. They should be applied first to the wrists & then to the ankles. The mercurial infusion should be kept up for 2 or 3 weeks. Small & repeated bleedings are sometimes called for: especially when the pulse is hard & chorded. Diet. – When inflammatory the diet must be light ; But in weak & valitudinary habits, a contrary course is required. It is a common practice to take wine largely, to keep off the attack : this sometimes succeeds ; but when it does not, the paroxysm is more violent, & upon the whole it is a dangerous plan. When cases resist all these remedies, a long journey on horseback, or a change of climate by voyage to sea, may 19 be of service. Intermittents are some times con- verted into Continued fever, & in children, into Hydrocephalus. It was supposed by Bouhaave that these are diseases & should not be checked too soon. It is true that gout & rheumatism, & some other diseases have been cured by an attack of intermittent fever ; but it is our duty to arrest it as promptly as pos- sible. Continued Fevers. Continued fevers are those which run their course with no intermission : though some remission and exacerbation take place daily. It may be laid down as a general rule that the remission takes place in the morning & the exacerbation in the evening. Continent fevers are those which run their course with no remission. Except the day fever, or ephemera, no such fever exists. I will divide continued fever into Synocha & typhus ; but Synochal fever, in the common definition of it, has no real existence. Of the Continued fevers, the most in our country is the Bilious Inflammatory Fever. This prevails throughout the U.S., but more particularly to the south. It arises chiefly rrom marsh miasmata, during the autumnal 20 season, & especially after sudden vicissitudes of weather. Excessive heat will also produce it. The exciting causes are the same in general as of other fevers. This fever is preceeded by languor & heaviness, anxiety, sighing, listlessness, yawn- ing, & alternate heat & cold. The tongue becomes furred ; there is heat & pain in the stomach, & difficulty of respiration. As the fever progress- es, the is generally great heat over the body ; nausea, or vomiting of bilious matter ; pain in the back ; a full strong pulse ; determination to the head ; sallowness of the skin & often of the eyes ; suffused countenance & even delirium sometimes takes place. Generally in the morn- ing there is some abatement of febrile action, but this is of short duration ; & the paroxysm returns with increase vigor. – It is uniformly in this section of our country a disease of in- creased action & requires depleting measures. Diagnosis. Distress of stomach, vomiting of bile, & sallowness of skin, distinguish it from all other diseases. – Prognosis. – The pulse being soft, slow & natural ; the skin soft, the tongue clean & moist, alvine discharges regular, rationality of mind, a perfect state of the nervous system, & the urine depositing a sediment like brick dust, are fa- vorable symptoms. Dissections reveal nearly 21 the same appearances as noticed in intermittent fever : as inflammation of the stomach & duodenum, congestion of the brain & liver &c. – Treatment. It has been said by Cleghorn, Fordyce & others, that this fever cannot be cured, & that we must trust to this vis medicatrix: this doctrine is highly pernicious, & is both foolish & wicked. The critical days, so called by Hippocrates, are 3rd . . 5th. .7th. .9th. . 11th. 14th. 17th. & 20th. or 21st. ., but this last is a point not exactly ascertained. There is a ten- dency to a remission on some one of these days. This, however, is not so apparent as formerly ; & the reason is obvious. In the days of Hippocra- tes, the habits of the people were distinguished by their great simplicity ; the climate of Greece was mild, & the remedies then used were of a sim- ple & more lenient kind. An attempt has been made to explain the tendency to remit on these days, on the supposition that they are only spurious intermittents. In Georgia & S. Caro- lina this fever is not always inflammatory, & venescection is seldom practiced; but in what- ever part of the world it may occur, when there is a strong full pulse, hot skin & de- lirium, the lancet must be used. In the first place, in this part of the country, the disease 22 being inflammatory, venesection is to had re- course to ; but it must be done with great judgement. next to this, or perhaps equal, is evacuation from the alimentary canal. In the early stage, when there is nausea or vomiting with little or no fever, the proper treatment is an emetic or purge ; but after the fever is established, venesection is generally necessary. To have the full effect of the emetic, it must be repeated, & sometimes for several days in succession. The one generally used is Tart : emet: alone, or combination with Ipecac :. The symptoms which indicate an emetic are, much gastric irritation, nausea or vomiting ; & while these continue, it must be repeated. Emetics were at one time supplanted by purgatives ; but have again been revived, & their powers attest- ed by the E & W. India practitioners, as well as those of our own country ; & when early ad- ministered, & even in advanced stage, when the pulse is low, delirium relieved, & there is a tendency to diaphoresis, emetics constitute an important part of the treatment. When, on ac- count of the constitution of the patient, they cannot be given, we may take to purgatives: as Calomel, with some of the drastics, as gamboge rheubarb or jalap. In certain states of the 23 stomach, as when it is loaded with bile , some unite emetics with purgatives, so as to produce an artificial cholera morbus. Of the utility of this there can be no doubt. Formula. – Rx. Calomel : grs. Iv – v. Tart : emet : gr. i. Gamboge - -gr. i. – ij. [m crossed out]. Purgatives act with more certainty when there is a remission of the fever : during the violence of the paroxysm then have little or no effect. When the alimentary can is sufficiently evacua- ted, we may resort to the saline laxatives to the saline laxatives to keep down arterial ex- citement, & thus subdue fever : as in the fol- lowing formula. Rx. Sal: Glaub:, Epsom: v. Rochel: [?j]. Tart: emet: . . . . . . . .gr. [?j]. Suce: Limon: (v. Sharp venegar] [?i]. Aquoe. . . . . . . . . . . .[?iij] v. iv. Of which a tablespoonfull is to be taken every 2 or 3 hours. – An infusion of senna with the crem : tartar : answers very well at this period, or Epsom salts & Calcined magnesia, a spoon- full of the former with half the quantity of the latter. When these do not answer, we must resort to enemata ; which should be made of the mildest materials, as molasses & water, or tepid water, castor or sweet oil & water, or 24 warm water in which a little Glaubers’ salts, or common salt has been dissolved. Cold applications have been much recom- mended at this conjuncture. It may be applied in 3 ways. Ablution, affusion & aspersion. In the case before us the sponge is to be preferred; & is to be used when skin is hot & dry. Refrigerant & Sweating plans. – Each is appli- cable to different stages of the disease. Of the value of sweating there can be no doubt. It determines blood to the surface of the body, reduces the quantity of circulating fluid, and consequently arterial action. The chief action, however, in this case is upon the capillary vessels. We should never employ remedies to excite perspiration until arterial action is re- moved by venesection & alvine evacuations. Preparations of antimony are at present gen- erally preferred: tho’ very few are retained in practice. They are to be given in very minute doses. James’ powder is an excellent diaphoet- ic; but it is no better than its kindred prep- arations. The Golden sulphur of antimony is much used in Europe : especially in France & Germany; but it is inferior to the Emetic Tartar, & this is superior to all other antimon- ial preparations. These medicines appear to 25 do good in fever by exciting their own specif- ic action. To attain the precise effect of the antimonial preparations is not always very easy; but as a general rule we may direct from 1/4 to 1/10 of a grain of Tart: emet: dissolved in warm water, sometimes coloured with cochineal merely to disguise it, repeated every half hour. The saline or neutral mixture is less offensive to the stomach & keeps the bowels gently open. It is prepared in the following manner. Rx. Suce : Limon : (or sharp vinegar). .[?ij]. Sal : Tartar : q.s. ad saturand : Sacc : Alb : . . . . . . . . . . .[?ij]. Aquae.. . . . . . . . . [?ij]. [m crossed out]. The dose is a tablespoonfull every hour or two. To this is sometimes added the Dule. Spts. Nitri: or vin : antim : or Laudanum. – Combinations of Ipecacuanha & opium have been used ; but they do not appear to answer so well in the more genuine fevers. Nitri is frequently used, in combination with tart: emet: & calomel, forming the nitrous or Antimonial powders, pre- pared thus. Rx.Nitri. . . . . . . . . .[?i]. Calomel : . . . . . .grs. [?ij]. Tart : emet :gr. . . . . . j [m crossed out]. div. In pulv, viii – X. One to be given every 2, 3 or 4 hours. – This is suited to our more 26 robust patients. The calomel contained in this occasionally, promotes purging or salivation : when this happens, it will be necessary to exclude it. It is also sometimes necessary to lessen the quan- ity of emetic tartar. When fevers of this kind are lingering and of typhoid tendency, the Bark may be resor- ted to; but even here, not until the tongue be moist & the thirst removed. During the apy- rexia we pour in the bark in the form of de- coction: sometimes with supentaria or other articles, sulphur is perhaps the best. Of the External means of exciting perspiration. It is common practice to use heated bricks, or bottles filled with boiling water : which should be applied not only to the extremities, but to the thighs, body & under the arm pit. Bags of hot sand, from their flexible nature, are far less inconvenient that hot bricks or bottles ; but the vapor bath is infinitely much safer. (vide Therapeutics vol.I. p. 369.) In inflammatory cases the vapor bath is to be preferred to dry heat. We have now arrived at the period in which It is proper to use Blisters. The should be applied to the ankles & wrists, unless some to- pical affection elsewhere demand their appli- cation. Nothing is worse than a blister in the 27 early stage of the disease, when there is much arterial excitement ; but in the reduced state nothing is more effectual. Sir G. Fordyce considered them a new irritant in fever. When these remedies fail, it is common to use mercury to salivation. But, as the bowels are weak and irritable in this stage, it must be applied in the form of unction, as freely & profusely as possible. Salivation is more de- manded towards the south, where the liver is generally affected. Much more of the article is also there demanded. These are the usual remedies in continued bil- ious fever ; but these are some local affections to be attended to. 1st A heat over the body : for this, apply vinegar with a sponge. Venesection is sometimes necessary. 2nd There is often a great determination of the blood to the head, with delir- ium or a tendency to it : this is to be relieved by cold applications of vinegar or ice water, to the head (the hair having been previously cut off), but if these do not answer we must use cups, leaches, or open the temporal artery. If these do not succeed, apply a blister to the head, which must remain on for 24 hours. – 3rd In the course off this fever there is often great anxiety, restlessness, or total want of sleep, with 28 heat over the surface. Placing the extremities in cold water will generally relieve this, and bring on sleep. Something maybe done by a pedeluviam. Camphor, in small doses, has done some good; & the anodyne liquor of Hoff- man. If this symptom occur when the system is reduced we use opium in preference to any other remedy. It should by the rectum rather than by the mouth. 4th There is often great gastric distress or inclination to vomit, or a nauseous state of the stomach. In such we use emetics or the milder cathartics : of which the best is magnesia. When this is disagreeable to the patient we may use the Epsom salts, which is the least nauseous of all the cath- artics. But one of the best remedies is the effervescent mixture. Seltzer water may be used. Lime water & milk, a tablespoonfull of each every 10 or 15 minutes, will answer very well. But what seldom fails is Pot- ash mixture, thus. Rx. Carb : Potafsoe. . .[?i]. Gum : Arab : . . . . [?i]-ii. Ol : Menthae . . . .g[?] X. Laudan : . . . . . .g[?} XXX. Aquae . . . . . [?iv]-v. [m crossed out] The dose is a tablespoonful every 10 or 15 minutes. A favorite remedy of the late 29 Dr. Poole for this purpose was an infusion of Serpenteria. Columbo with quassia has been used. Stimulating articles, as a tea made of bay- enne pepper; or the Tincture of Cloves, a teaspoon- full every 15 or 20 minutes. – Ginger tea will some- times answer. Spts. Terebinth : , 8 or 10 drops every hour has frequently proved effectual. Powdered Cloves, put in a bag & applied to the epigastrium, have often afforded immediately relief. A pedeluvium, in which some stimulating articles have been mix- ed, as Cayenna pepper or mustard, has often done much good. If all these remedies prove ineffec- tual, we must apply a blister to the stomach; but the best remedy is laudanum or an Opium pill which has been made for a considerable time. When the stomach cannot bear the opium, thus prepared, we must use anodyne injections, or opium introduced into the rectum. Strong coffee, without cream or sugar, a teaspoonfull for a child, every 10 or 15 minutes, often answers very well. Calomel, in very small doses, often succeeds when everything else has failed. - - 5th During the whole progress of the fever, much thirst & dryness of the fauces prevails. This is to be relieved by cleaning the tongue with sharp vin- egar, porter, ale or yest, with a [?ap]; & by giving minute portions of some acidulated drinks: as 30 lemonade, tamarind water, boiling water poured upon stewed, or when preferred, barley water or rennet whey, toast & water, some herb tea, or a tablespoonfull of water at a moderate temperature: for, at a moderate temperature, & in minute portions, it will more effectually quench thirst. Ice or cold water may be held in the mouth. An infusion of licorice or the root chewed, or the root of ginseng, or hard bread, or tobacco will sometimes answer. When the thirst depends upon a depraved secretion of the stomach or bowels, give calomel in small doses, 1/2 gr. every 2 or 3 hours. - - - Great light should be exclu- de from the chamber, & the noise & bustle of company prevented. The chamber should be well ventilated. The patient should not be permitted to get out of his bed. In cases of relapse the patient must be put into another room, be shaved, & put on clean linen. As respects Diet, we must begin with the farinace- ous articles, as sage, tapioca &c. : afterwards beef tea, raw oysters, venison, &c. His drinks should be porter & water or ale and water. He must grad- ually return to his former habits of life: es- pecially study & conversation. He must not take exercise out of doors. (v. page 61). Continued Belious fever may terminate 31 in various ways: sometimes in typhus; at other times it assumes the chronic form. This is some- times known by the name of Febricula, & in the southern states, by the name of Inward fe- ver. It is attended with a small, hard, chorded pulse, much heat of the surface, sallow coun- tenance, pain in the side, tumid abdomen, aedem- atous extremities, & scanty high colour[e]d urine. The fever is either of the intermittent or remit- tent type ; with diseased liver, spleen, or pan- creas. The treatment is, in the first place, purging. Mercury, in the form of blue pill, has been used to salivation. A course of Ni- tric acid, I have known to do good. Nitas- muriatic bath has done good when mercury could not be administered. In some cases there is so much action in the pulse that we must resort to small & repeated bleed- ings : [?vi]-v at a time. If much pain be felt in the side, vessicating applications are of much service. Tonics have been used ; & when employed in the proper they are serviceable. Typhus Fever. The word Typhus is derived from the Greek word [????] signifying dullness or stupor. Typhus fever has been considered of two kinds: 32 Typhus mitior & Typhus Gravior ; but there is no foundation for this division : the one is only the aggravated state of the other. Whether this disease is idiopathic or the consequence of some other disease, it is always of the same nature & cured by the same remedies. Typhus mitior comes on with greater mildness of its symptoms, & runs several weeks before it comes to a crisis. The patient complains of debility with loss of appetite & dejection of spirits, for some time without chills or fever. Typhus Gravior, being of a more malignant nature, comes on with a greater prostration of strength, in which the mind fully participates. There is souness of the muscles, pain in the head back & extremities, & alternate chills & flushes. These symptoms are followed, by well defined fever ; the wild and depraved eyes, suffused face & tendency to delirium. The tongue becomes dry, hard & incrusted ; & the teeth & gums covered with the same filth. In the commencement the pulse is quick, chordid, & active denoting great disturbance in some of the functions of the animal economy ; the respiration is laborious, and the breath offensive ; the bowels at first are always costive ; much heat & pain is felt at the pit of the stomach ; there is a vomiting of bile or foul- 33 er matter, & unquenchable thirst attends. As the disease advances these symptoms are ag- gravated & attended with worse ones: as deliri- um, coma, dilatation of the pupils; the pulse is small, weak, tremulous & so quick as hardly to counted. The temperature of the surface is very unequal; & sometimes subsultus tendinum attends. It is not uncommon, at this period, for the bowels to give way, and large discharges of feculent dark matter involuntarily takes place, & sometimes of urine. Hemorrhages of dark blood takes place from gums, nose, & mouth & some- times from the eyes. These symptoms are often attended with vibices & petechiae. The pulse now sinks ; hiccup ensues ; the extremities become cold, & death takes place. – I have now mentioned one of the most violent cases of typhus. Prognosis. When the tongue begins to clean off, in 99 cases out of 100 you may consider the patient convalescent. Soft natural evacuations from the bowels, & depositions in the urine are also favor- able. Glandular swellings, buboes, scabby erup- tions about the mouth are favorable. When the disease runs beyond the 14th day, the type of the fever is changed & recovery generally takes place. Typhus fever is said to arise from contagion: in crowded places this cannot be denied ; & in 34 such cases, Small pox itself is not a more contagious disease. The contagion never extends to an adjoining apartment, &, if well ventilated to no considerable distance in the same room: about 6 or 8 feet, or ac- cording to Hagarth, only 3 feet, except when the apartment is crowded. The disease may be con- tracted by wearing the apparel, bed clothes &c. of the one labored under the disease. The clothes of one person may be infected & impart the disease to another, while the one wearing the clothes may escape. It is said by Cullen that [?omits] im- parts it sooner the one laboring under it, & that the disease is in this case more violent. Dirt floors are not retentive of the contagion: walls & plaister are eminently so. The [cross out] period at which the disease appears after the contagion, is most generally 8 or ten days. It is sometimes immediately manifested : at other times it lies dormant for 50, 60, or 70 days. – Bancroft says that many months may elapse, provided that warm weather intervenes : thus an inter- mittent contracted in the fall will not appear until spring ; typhus contracted in the spring will not appear until the fall or cold weather. Typhus may arise from other causes. Whatever debilitates will produce it, as low [per???cious] diet, marsh miasmata, or long watching or cold. - By 35 dissection, the morbid appearances in the more violent cases, are a dissolution of the constitution both of the solids & fluids of the body ; blood dark & grumous ; accumulations of sanies, or of bloody effusion in the great cause ; & most of the viscera, especially the brain, are marked by congestion. Treatment. Every practitioner concurs in commencing the treatment of typhus fever by emetics. They do more in the cure than is gen- erally supposed, & produce effects in another way than merely evacuating the stomach. It is upon this organ that contagion , marsh miasmata &c. primarily act, & to expel the offending cause & subvert the nascent infussion before it becomes fixed, an emetic is best for the purpose. Ex- hibited in a more advanced stage of the dis- ease, or when it is confirmed ; emetics are not only useless, but do injury : unless the stomach be much distressed by nausea &c. Having thus evacuated the stomach, it was formerly the custom to give antimonials in minute doses, to keep up nausea : this was the practice of Cullen ; but not being satisfied with this treatment of typhus, Hamilton substituted purgatives ; as Calomel or Jalap, or both united, used day after day. I have not the slightest 36 doubt that they be of service. In the com- mencement of the disease the bowels are always loaded & constipated, & there is considerable gas- tric distress, with sensation of internal heat, & when this state continues no one can doubt of the utility of purging. As one of the auxiliary remedies, cold applications to the surface have been used with great success. They are deman- ded by the burning heat of the surface & active pulse. By some of the medical men of this city cold affusion is used in our autumnal diseases to allay the heat of the skin, & in the European hospitals nothing is more com- mon than to see patient placed under a show- er bath, or a bucket of cold water poured over them. Cuniq says that affusion with cold water may be resorted to whenever the heat of the body is steadily above its natural stand- ard, when there is no sense of chilliness, and especially when is no general or profuse perspiration”, to which, however, must be excepted, the cases attended with local conges- tion, & particularly of the lungs. The princi- ple on which he supposes the remedy to act, is merely by the abstraction of the excess of heat of the surface ; but V. Jackson supposes that it acts by the making a powerful & general impression 37 on the system ; by which the existing actions are essentially changed ; & which is effected inde- pendently of the reduction of temperature. (vide Therap : vol. I. p. 374.). When the system is inflam- matory & cold should not be used, he says it should be reduced by venesection. Cold as before mentioned may be applied either in the form of affusion, ablution or aspersion. The application of cold water or vinegar with a sponge, is, in this case, to be preferred. Simply immersing the hands in cold water will often answer. The disease not being cured by the preceding rem- edies, & there being much determination to the brain, it is proper to resort to topical bleeding, & next to the means of exciting a moderate per- spiration. It is best to prefer the mild to the stimulating diaphoretics , as the saline mixture, antimonials, or the Spts : nitri : Dulc : freely given & at short intervals. The disrepute into which the medicine has fallen, is owing to the small doses in which it is given. The dose, in this case, should be [?i] . every hour or 2, & may be combined with vin: antim : & laudanum. Still more effectual is the spiritus mindireri. Such are the remedies & the order in which they are used, with which we combat the first stage of typhus fever. This species of fever is gen- 38 -erally, in the begining attended with more or less of an inflammatory diathesis. After death we may discover many marks of inflammation, & particularly in the brain & pulmonary organs. I am convinced of the superiority of treating this disease by stimulants, & of sometimes employing the lancet ; but it must be done with great dis- crimination , & is more applicable to the cases we meet with in private practice, rather than in public institutions. Most medical writers are in favor of venesection, & that to a consid- erable extent: especially Syderham, Hoffman & others. As relates to the treatment of typhus fever, the doctrine & the practice of Cullen are wrong. In the commencement of all diseases [hash mark above and after word diseases] the system is in an oppressed, not an exhausted con- dition. A ship is not in danger of being sunk on account of her rotten timber ; but by the violence of the gale & weight of her cargo. And thus we relieve the system by evacuating, or throw- ing over a part of the cargo. Treatment of the 2nd stage. At this period there is a reduction of excitement, & symptoms of prostration are disclosed. We must here sustain the system by cordial & diffusible stimulants, & particularly those which act on the surface. Of these the best is the volatile 39 alkali in small doses. The best way of giving it is in the form of julup : thus, Rx. Carb : Ammon : . . .[?i]. Gum : Arab : . . . . . [?ij]. Sace : Alb : . . . . . [?i]. Aquae [?vi]. [m crossed out]. The dose is a tablespoonfull every hour or 2. It is best to give it in small doses & at at short intervals : exhibited in a large dose, it increas- es the excitement. The Wine Whey is generally given with the vol: alkali, & it always pro- motes its action very much. It is made by ad- ding 2 parts of boiled milk, 1 part of white wine : madeira is the best. Camphor is by some preferred to the vol : alk; but I believe it to be much inferior. It may be better suited to more advanced stages of the disease. It is sometimes united with the vol: alk: the ‘oftener given in substance ;but this is inconvenient. It may be given in Seltzer water,or suspended in milk, or with loaf sugar & opium, or in the form of julup : thus. Rx. Camphora . . . . . . .[?i]. Gum : Myrrh : [??s]. Sac : Alb : . . . [?ij]. Aquae. . . . . . . .[?iv] – vi. [m crossed out]. When we wish to sweat in typhus fever, a pain of blisters is one of our best remedies. 40 Sinapisms have been said to answer better, as they do not deplete. It is not a fact. Opium has also been used as remedy in typhus fever) & when prop- erly managed there can be no doubt of its utility. It was used by Brown, & first objected to by Fordyce. For its stimulating effects, it should be given in small doses: about gr. i every 3 or 4 hours. There are medicines which are preferable to opium in this state of the fever: among which is wine. Madeira is the best ; but if it cannot be had, Sherry, or Lisbon will answer. Claret will also answer; but whatever kind is used, it is always right; in this stage of the disease, to commence with a moderate exhibition of it: 2 pints of strong wine in the 24 hours is about the average. (vide Therap.). Peruvian Bark was formerly much used in typhus; but at present it has lost much of its celebrity : tho’ there is still great contrariety of opinion with respect to it. The are some cases of typhus in which it should not be overlooked; but it should not be used in the early or the advanced stage. The period at which the bark is to be used, is when there is a tendency to remit or give way; which is most generally about the middle of the disease. The stomach will not always bear it in substance, & in such cases, it may be combined with some other substances, as Huxhams tincture, aromatics &c. 41 (vide Intermittent). But when the bark will not in any agree with the stomach, we must use the bitter tonics; & of these Serpentaria is the best. Cascarilla or Angustera may be used. Antispas- modics have been used: as Musk, assafalida & Castor. The musk julep is the best manner of giving the musk. Rx. Mosch: . . . .[?ii]. Sac: Alb : . . .[?i]. Gum: Arab: [?ii]. Aquae . . . . .[?vi]. [m crossed out]. The dose is a tablespoonfull every hour or 2. Assafatida may be used in the form of tincture, pill, or watery solution: the latter way is the best. Rx. Gum: Assafoet : [?ii]. Aquoe . . . . . . .[?vi].-vi. The dose is the same as the musk. – Carbonic acid was at one time very highly esteem- ed, on account of its antiseptic properties; but pu trefaction does not take place in the living body. It is one of the most cordial & agreeable of the stim- ulants. It relieves the stomach of nausea, & may be given either in the form of seltzer water, effervescent draught, or malt liquors, of which porter is the best. When perfectly ripe & sound it is an agreeable stim- ulant & tonic. Cyder or champagne may also be used. The mineral acids have been recommend- ed in this disease. Sir Wm. Fordyce first used them; 42 But I am disposed to rate them very low indeed. The muriatic is generally employed. (vide Therapeut). Mercury. When the bowels are loaded & oppressed As they always are in this disease, mercurial pur- ges are of great service. At this period there is of- ten a dark incrustation of the tongue, gums & fauces; & in such cases mercurials are of great use. They excite the mercurial fever, which supplants the other. At this conjucture I prefer the Spts : Ter- ebinth :. It changes the secretions of the primae vina. Dose [?i]. every hour or 2. – If I were to use the mercury, I should unite it with stimulants, as vol: alkali or wine whey. There are certain local affections attending this disease. 1st a determination to the head. The phenomena of the disease & dissections have shown that the brain, tho’ not the primary, is the chief seat of typhus fever. The brain is here to be re- lieved by leeches, by cups, or by opening the tem- poral artery. Removing the hair from the head is of great utility. When this does not succeed, cold applications may be used; & if these fail, a blister should be applied to the cranium, and remain on for 24 hours. Fordyce, Darwin and Thomas object to blisters at this period. As well might a man deny the efficacy of mercury in syphilis or bark intermittent fever. The 43 2nd of the local affections is Delirium. To remove this in the advanced stage of typhus, opium is unrivalled in its powers & is the only remedy capable of affording relief. 3rd Hiccup. This, tho’ it cannot be altogether cured, may be pal- liated by lime water & milk, or Elixir vitriol, antispasmodics &c. 4th Diarrhea often attends this stage of the disease. For this we may give opium in combination with camphor or other stimulants. The room in typhus should be well ventila- ted. When this cant be done, we must remove the patient in another chamber. The motion may prove serviceable. He must be attentive to clean- liness. The bed clothes should be changed often, &, when removed, they should frequently be sprink- led with vinegar. The Diet in the first stage of typhus should be the same as in ordinary fever. But when the patient sinks we may give arrow root & wine. In the more advanced stage, weak broths & spices. If, in spite of all, the disease runs on, we must increase the doses of our rem- edies. Vessicating applications are not useful here. Rubefacients are of much more service, and should extend over the whole surface of the body. The best is Cayenne pepper & brandy. The brandy bath is often beneficial. Wrap the Patient in a blanket & pour hot spirits over *Sometimes called Cold Plague (S.B.) 44 him. (Case of Mr. Denman). It sometimes hap- pens that the patient cannot swallow: in such cases we must resort to injections. Winter Epidemic. * This disease made its appearance as early as the year 1806 in different parts of N. Hampshire & Massachusetts, & in a few years it spread all over the N. England states. It then reached N. York & the Canadian provinces & the interior of this state ; then in Ohio & Kentucky ; next the n.w. of Virginia, & finally it extended itself all over the U. States. Its first appearance in Philad[elphi]a. was in the winter of 1813. At this time there was nothing remarkable in the appearance of the weather. In the succeeding winters its prev- alence was greater & the victims of its ravages more numerous. This disease puts on a great variety of shape & diversity of treatment. (vide. therap: vol. I p. 314). It is preceeded by a sudden prostration of strength; alternate chills & heat, the skin being hot & cold in rapid succession, & soon becomes dry & pale ; the aloe of the nose are contracted ; the eyes wild & glassy ; the fore- head smooth & polished ; & the physiognomy of the patient evinces an uncommon degree of distress. The pulse, which was at first low & 45 apparently depressed, is now like a strong Chord, & ultimately sinks so low as scarcely to be percep- tible. Sometimes wandering of the mind take place, & often delirium. When the disease is vi- olent, excruciating pains are felt in the small joints; in the side, stomach, back & neck, or head, com- pared to the sting of a bee, or to the pounding of a hammer on the part; coma & delirium at- tend; but such cases are of rare occurrence. The sight sometimes becomes affected. If the attack be not checked, these symptoms in- crease. Delirium exists in various gradations. If the patient continue in his senses, his spir- its are dejected. In another form of the disease, there is in the commencement some prostration of muscular power; but in these cases there is neither chill nor fever. The pulse is feeble, irregular & quick, at about 140 or 150 in a min- ute; but the reverse sometimes happens. After a while, pains in the head come on, with vertigo, stricture across the eyes & delirium. It is often ushered in with all the symptoms of pneumonic inflammation. The most common symptoms are pain in the side & chest, incessant cough & panting & bloody expectoration & laborious res- piration. There is here an unusual determina- tion to the lungs. In the southern states there 46 is some degree of gastric distress, vomiting of bile, the pulse full, voluminous & strong : tho’ soft & easily compressible. It often puts on the appear- ance of Common Bilious Pleurisy; but the pulse, in the case before us, soon loses its inflammatory & assumes the typhoid character. Cases occur- red in which the throat was the principal seat of the attack. There is, however, no enlargement of the tonsils; nor the mahogany colour which is seen in cynanche maligna. The mind becomes distracted & sinks into heavy slumbers; the tongue fauces are incrusted with a dry, hard substance; & petechia & vibices make their appearance; &c on this account it has been called the Spotted Fever. When death takes place, it is very sudden. The shape it assumes does not show any symptoms of common febrile affections. I consider it a var iety of typhoid action. The leading peculiarity consists in its assuming the congestive, rather than the inflammatory condition. In the congestive, it would appear that the veins are affected: in the inflammatory, the arteries. In the latter the blood is sizy: in the congestive it is dark & grumous. From this it follows that the pulse cannot serve as a guide in practice. A disease similar to this has been described by Lavauge, (called Peripneumonia Typhoides), & by more ancient 47 writers, under the name of Cold Plague. The winter epidemic prevails mostly in the country, & seldom in large cities. Yellow fever, the reverse. Causes of our winter Epidemics. Concerning this all that we know is that it commences in cold & is dissipated by the warmth of spring. Cold alone cannot be the case ; because it will not invariably produce the disease, & it occasionally occurs in warm weather. It does not originate in contagion : for, if thus communicated, it could not have spread over the country in 1000 years. Whatever tends to promote the derangement of the system may be considered as predisposing to the disease. Treatment. The lancet & other depleting remedies were abandoned by our practitioners. – Stimulants as Wine, Brandy, Cordials, Camphor &c, were employed by one set, while others recommended sweating. Of the superiority of the latter plan I have no doubt. As the best means of exci- ting & keeping up perspiration, nothing answers better than Dove’s powder, repeated every 3 hours. Also wine whey, warm fermentations to the extremities, bricks with vinegar poured upon them or the vapor bath. – The volatile alkali is, in the diseases, the “ipse agmin” ; but it must be used by a skillfull hand. It is sometimes necessary to give 48 5 or 10 grs. every half hour, assisted by wine whey. ol: Terebinthinae. Of this [?i] or more may be given, every 1/2 hour or hour, according to the emergency of the case. Phosphorus may be used with advantage in this disease. Even when life was lingering, it has been used with success. I have used it in several cases, & its effect was that of a diffusible stimulant. There are different modes of employing it. It has been recommended to make it into pills; but this is dangerous ; & it should always be exhibited in the state of solution. It may be rubbed down with mucilage of gum arabic, then adding sulphuric ether, or it may be dissolved in Ni- trous ether, which is perhaps the best form. The dose should never exceed 1/4 of a grain at a time. – Notwithstanding all these stimulants, the pulse lowers, & in such cases, a decoction of Canthorides in Spts: Terebinth: so as to ex- cite vessication, or what is better, Cayenne pep- per dissolved in brandy, with which the whole body is to be rubbed. In more violent cases a different practice is required. Evacuations from the stomach are to be attended to, & in some cases we must use was the Tart: emetic. These should be followed by mercurial purges. The James’ powder has been used at this period; but combinations of Calomel & tart: emetic are to be 49 preferred. We are next to use Blisters, if there be any topical congestion or pain. They are to be ap- plied to the head or chest as the case may de- mand. They are especially indicated in the an- ginose or pulmonia symptoms. The lancet is seldom required; even under immense congestion, venesection affords no relief. In these cases there is a great effusion of blood in the large viscera; & more particularly in the lungs. A few ounces of blood drawn is followed by great prostration of strength; but the application of cups to the back may be of utility: especially when follow ed by vessicating applications. Such was the practice of this city; but in the other parts of the U. States, & even in the interior of this state, where it is attended with inflammation, venesec- tion may be usefully employed. Prognosis. An expussion of restlessness in the countenance, the skin polished and of a leader here, are generally fatal symptoms. I do not deem this a necessary fatal disease. In this city the deaths were less than those produced by Yellow Fever. Happi- ly by it no longer prevails, as an epidemic, among us. – Rush, Wister & Dorsey fell victims to it. – Of Yellow fever. –S. B. 50. Yellow Fever This is an endemic for the most part, of tro- pical climates but it sometimes affects the more temperate regions. It was in the year 1793 that it first attracted general attention among us. Its origin was ascribed to a cargo of rotten coffee thrown on the wharf. It also occurred in 1797. Its origin, nature & treatment are still a matter of great con- troversy. It may originate either from a foreign or domestic cause. Vessels coming from a hot climate & in a foul condition, may supply the materials from which the disease is generated; but I do not believe that it is ever brought here by fomites. The pestiferous air between the limbers of vessels coming from warm climates will most undoubtedly produces Yellow Fever. At Amboy in 1805 & at Boston in 1818 this was proved. At the former place a vessel in this foul state arrived from the W. Indies. Every one engaged in discharging the vessel, & all the in- inhabitants of the town in the direction of the wind, were seized with the fever. In such cases it may be asked, why did not the crew of the vessel take the disease? The reason is obvious: they were not at all exposed to the pestiferous air; as it was confined by the hatches & tarpaulins during the voyage. – In 1805 in this city the 51. disease was caused by an accumulation of filth; and within the last 3 years, in Baltimore & this city, it has always been of local origin. Every year in which the Yellow Fever has prevailed in this city since ’93, the thermometer has shown the average temperate of ‘79[?] in the months of June & July; & every year we have escaped it, it has been less. Vegetable putrefaction alone cannot produce the disease, or we would have it throughout the country. Filth removed from the sphere of water is not productive of Yellow Fever, as is seen in the suburbs of the city, when there are great collections of filth of every kind. The same thing is seen in the neighborhood of farm houses. The disease there originates from putrid effluvia, either from a foreign or domestic source, influenced by water, & some occult cause that has without eluded research. It is stated by one of the most respectable of our physicians, that this disease, in this city, has never, even in the worst of times, extended beyond 4th st. It is stated by Ferguson, one of the physicians in the W. Indies, that the disease never extends, in any of the islands, beyond the margin of the water. This account is confirmed by Humbolt as regards the Spanish main. No large collection of putre- fied matter is necessary; but it may proceed 52 from a very small one. The following are the chief arguments against the contagious nature of Yellow fever. 1. It is an epidemic in its nature, laws & effects. It may prevail either as a general or partial epidemic. 2. It never spreads, when removed from the sphere of the city. 3. It has been invariably suppressed on the accession of cold weather, & in this respect differs from all con- tagious fever. Typhus fever never prevails in warm climates. It is said by Lind that when typhus attacked their vessels, it was immediately arrested by running them down into warm climates. 4. The sphere in which contagion operates is so small that the disease could not be diffused by it. The disease has been contracted with- -out any intercourse with the sick, but merely passing thro’ the infected district. Nurses have been known to lie down with impunity, on a bed on which a person, a few minutes previous- ly, had died of black vomit. The same is ex- emplified in those engaged in dissections, & atten- dance on the sick. The miasma which produces Yellow fever & Plague is of a peculiar kind, more malignant than that which produces ordinary fever, and is called malaria. It is probably subterranean, & escapes thro’ fissures in the earth. The degree 53 of malignancy is perhaps owing to the quantity taken: thus when a person takes a small quan- tity of arsenic, a mild disease is produced; but in a large amount , death is the con- sequence. In this city the disease has always been typhoid, except in the years '93 & '97. It has always been sup- posed to be a form of Bilious fever; but the distinction between the two, is very evident. 1. In Yellow fever the stomach is the seat of the dis- ease: in Bilious fever, the liver. 2. Yellow fever is a continent fever. 3. Bilious fever leaves be- hind it a tendency to a recurrence ; but an at- tack of Yellow fever rather protects the system against a succeeding one: tho’ by spending a few years in a cool climate the susceptibil- ity will be revived. 4. Convalesence from Yel- low fever is rapid: from Bilious fever, slow. – In dissections made by Dr. Physick, the morbid appearances were confined to the stomach , which was effected with eysipelatous inflammation. The black vomit is an altered secretion of the stomach. I have seen it in Gastritis, Hydrophobia & from poisons. Dr. Reese, last summer, by microscopic ob- servations found it consists of vermisuloe. Dr. Physick found no signs of disease in any of the great viscera, except in a few instances in the Yellow fever sometimes attacks in its most malignant form without any particular pain or complaint. The patient is walking about his room in the moving & dead at night. Dr. Potter saw two men in a hospital amending themselves, by trying who could spit the black vomit the farthest. They both died before 11 o’clock at night. 54. brain. - Symptoms of Yellow fever. It comes in general with languor & debility, chills, pain in the lower extremities, back & head, about the frontal sinuses. The eye becomes swimming and watery; the lips dropping; mouth slobbering; an umeaning expression of countenance; but in some cases there is no change whatever, being perfectly tranquil & serene. The face is of a bronze colour; epigastrium tender; there is a sensation of burning heat at the stomach by pressure : even tho’ the patient consider himself perfectly well. The bowels in the commencement are constipated, & dont yield to the usual remedies, the pulse is active ; the skin hot & dry. The stomach af- ter a while gives way. There is deep sighing, nausea, & vomiting, in a peculiar manner, by a sort of singultus. There is great inquietude & restlessness. The eyes now love their redness & assume a dirty yellow colour; the throat be- comes sore ; there is great thirst, & often a paral- ysis of the upper extremities & sometimes of the lower. Discharges of black vomit take place; there is in general a great diminution of muscu- lar power: tho’ it is sometimes retained to the last extremity. The signs of dissolution are a feeble pulse, cold sweats, delirium &c. – Convulsions are a common termination of Yellow *also in the cases of Capt., M.Cull, while sick at navy yard Pensacola, Sept. 1830. S.B. – *Case of Benj. Smith the same at first. U.S.SC. [gram???s], 1829. – S.B. - *Doggets case, - Grampus - [mi?] Rufeil & nv. [Resign??] It generally requires, bloosing in the commencement to a consid- erable extent. often 7, 8 or 10 times. Dr. Physick was bled 28 times for the Y. fever in 1798. Even in the plague V. S. has been successfully water to vide Dr Doveis work, in which there is an account of 100 patients being bled & cared. When there is inconsiderate sweating with a hard pular, bleed: there is no other remedy. Opium is fatal in this disease. If you use it your patient is dead as sure as you are born. It produces hemor[????], particularly from the gums. [Dr. Patter.]. 55 fever. Death sometimes takes place as suddenly as from a blow. Dr. Physick once met with a case in which the only suffering was in the great toe* : the disease was discovered upon dissec- tion. Dr. Rush had a case in which the calf of the leg was the only part complained of; & another, in which the pain was confined to the or- gans of generation. * Prognosis. Unfavorable symptoms. Eagerness to eat: especially animal food; frequent sighing; tenderness of the epigastrium; dry rough tongue; hiccup; suppression of urine; delirium; prurien- cy, desire of coition; leaden or bronze countenance, hemorrhages of dark blood; vibices; petechia; coma; black vomit; total absence* of all disease, in the patient’s opinion. Recovery from black vomit is said now & then to take place. Dr. Rush mentions two instan- ces of it. I have never met with one. – Treatment. By the French it was the custom to check vomiting, & next to wash out as it were the offending case, & then to pour in dil- erent beverages. Mercury is used in the Yellow fever of the W. Indies, & many practitioners there depend upon it entirely. Their object is to excite salivation. In the W. Indies the liver is generally affected; & on this account mercury is useful; nothing is to taken that has even the smell of alcohol. Drinks containing it will produce a relapse. Water greul made of corn meal, & sweetened with brown sugar; or barley or rice water, are quite sufficient. Sp. nitri. dule. is not to be used. I use Calomel in doses of 20 grs. every 2 hours. 5 or 6 times a day. Small doses are of little use. Excite salivation if possible. Unj.* by drug : Don’t use Emotics nor any preparation of Antimony. [Dr. Potter] Success of Dr. P’s practice. – In the first year of the fever out of 72 patients only 3 died. – 2nd year , out of 400 only 5 died. – 3rd. year, out of 48 not one died. – He frequently bled 8 or 10 times, or oftener. – I have never known a patient to die after venesection, in Yellow fever , --as it occurred on board the Hornet & [GramXiers?], 1828 & 1829. – S.B. – At the Pensacola Hospl. The result was different. – vide notes on that disease 56 but it is impracticable to salivate when there is much arterial action. The result of Bare- croft’s observations is, that in vehement cases the patients die before they become salivated, & in mild cases it is unnecessary. In ’93 the disease was at first treated as a species of typhus (typhus icterodes) with bark, wine &c, until the dissections of Dr. Physick, when it was considered a disease of the stomach, & evacuating, venesection, purging &c, were employed. Last year (1820) in this city of out 125, 82 died. The treatment was commencement with Calomel & assisted by aromatics, vol: alk: &c. - The Spts: Terebinth in the last stage was unavailing : the vitality of the stomach is destroyed in a few hours, by the action of the poison upon it. Boiling turpentine poured on the skin had no effect, & substances taken into the stomach remained unchanged. Spts. Ter- ebinth: & all other remedies should be given in the early stage. Patients in Y. Fever die oedem- atous or bloated, & the surface is yellow. The same is seen when death takes place from arsenic or other poisons. - There are two modes of checking inflammation: one by reducing action, the other by producing a counter action. In the latter way the turpentine acts. It was found to be the best remedy in the Plague at Malta; 57 & Orfila says it is the best remedy against the effects of arsenic, & corrosive sublimate. In peritonial inflammation I have for many years prescribed it with success. In Dysentery, when gangrene is threatened, it is the best remedy. Dr. _______ of Dublin, used in peritonial inflam- mation. (vide. Phila. Imn. of med. & Phys. seuria for nov. 1821). As respects Yellow fever, the more violent forms of it are wholly inemudiable. In no case do I depend on the turpentine a- lone, but call in the auxiliary remedies: some- times venesection, sometimes cold applications &c. As Dr. Rush says, we must “attack the disease horse, foot & artillery.” In this fe- ver, the bark is wholly inadequate, & the vol: alk : & Spts: Terebinthinae are most to be relied upon. - - - - - As a preventive of Yellow fever, avoid entering the infected district with an empty stomach ; or early in the morning, or at night: at these times the miasma is condensed by the cold & precipitated near the surface of the earth. Plague On Pestis Vera. I have never had opportu- nity of seeing an instance of this disease. By Cullen it is elapsed among the exanthemata; but It is not well treated. It is undoubtedly a 58 febrile affection. It is not contagious in any high degree, if at all; & casual intercourse with the sick does not produce it. The dis- ease, it would appear, never proves contagious except in crowded places; & even then not more so than ordinary fevers. It is supposed to be an endemic, depending upon the causes which produce such diseases. In Egypt it is supposed to be owing to the overflowing of the Nile. Like all fevers originating from miasmata, the plague assumes different types: being sometimes intermittent or remittent, & at other times typhoid. Persons in crowded places, as hospitals, were attacked with it in the typhoid shape: those in marshy sit- uations had it in the intermittent or remittent; & those in open fields had it of the inflamma- tory character. In 1657 at Rome, those se- cluded in monasteries remained free from the dis- sease. Plague has sometimes resulted from inocu- lation: tho’ this is denied by some. Even those who contend that it may proceed from inoculation, do not deny that it might have taken place in- dependent of that. From the observations of Var- ri it appears that plague is contagious: those who have had it once seldom have it a second time. If the matter of plague & that of small pox be mixed, it will communicate a mild 59 plague. If mixed with sweet oil, a mild plague follows; but does not secure the per- son from a second attack. – It is not pre- cisely ascertained at what period the disease makes it appearance after exposure to the causes. The symptoms are rigors succeeded by heat, pros- tration of strength, syncope, anxiety, stupor, & delirium. The pulse is at first active & chord- ed, but soon becomes weak & tremulous. These symptoms are followed by factor of breath, vomiting of dark matter, & in a more advanced stage, carbuncle, cold sweats & death. Life is sometimes extinguished in a few hours. By dissections, the morbid appearances are nearly the same as in Y. Fever; but is some respects differ from it entirely. The liver sometimes shows marks of derangement. The Plague & Y. Fever are similar in many respects. They arise from similar causes, & prevail at the same season. They are both contagious under certain cir- cumstances. They attack strangers in preference to natives. The progress of both is arrested by cold weather. But the two diseases also differ in many instances: owing to influence of climate, modes of living &c. Carbuncle and other affections of this nature have been consid- ered as distinguished this disease from all others; [It generally requires bleeding in the commencement to a con- siderable extent. Often repeated 7 ,8 or 10 times. Dr. Physick was bled 28 times for the yellow fever in 1798. Bleeding has even been suc- essfully used in the Plague.] [intended for page 55] = 60 but it is sometimes seen in Y. Fever & typhus gra- vior. The carbuncle of plague, however, contains a noxious matter which imparts the disease. It would appear from most accounts the Plague is highly malignant typhus fever. During the prevalence of Plague at Malta & Sicily, all other diseases partook of its character: even Dysentry was accompanied by pestilential buboes. This fact is sufficient to con- vince me of its epidemic nature. Prognosis. Carbuncle becoming gangrenous, hemor- rhage, coma, typhomania & delirium are unfavor- able symptoms. Treatment. There would appear to be no ma- terial difference in the treatment of plague & yellow fever. Plague is commenced with emetics; but this is not generally the case in yellow fever. Evac- uations from the alimentary canal are proper, and after this venesection is sometimes resorted to, & is an old practice. As respects the use of the lancet a great difference of opinion prevails between the English & French physicians. A moderate use ap- pears to be the most proper. Sweating has been much recommended in this disease; but as to that, modern writers differ very much. There is perhaps a stage in the disease in which we may use it effectually. The mild diaphoretics are found most useful. The vapor bath or cold applications may also be 61 used : the latter is to be preferred, & should be ap- plied by means of a sponge. Accidental expo- sure to rain has cured patients in plague. Ex- ternal applications of another nature, vig. annerint- ing the surface of the body with oil, were said to be very useful. This is an ancient custom; & while its utility is admitted by some of the best authorities, it is altogether denied by others. Vol: Alkali, Camphor, Opium, Bark & other stimulants & tonics have been given with success. Turpentine has also been used successfully. Mercury, as in Y. Fever, was employed & with nearly the same results. It appears that the plague is a more destructive disease than Yellow Fever; but upon the whole they ap- pear to originate from the same causes, put on similar appearances, & require similar treatment. ====================== Before concluding the history of febrile dis- eases, it still remains for me to say something of the great degree of excitability which all febrile affections leave behind them, & which is sometimes even worse than the original dis- ease. The first thing to be done, is to re- move the patient into another chamber, and take from his sight all phials &.c. which he used 62 2. Be careful to accommodate the diet to the state of the patient. At first give him tapioca, rice &c.; afterwards he may be allowed eggs & the more digestible species of game. The best drink is pure water; but porter & water may be given. 3. The patient should gradually re- turn to his former indulgences in life. He should keep from study & the occupations of business of any kind, & company should be excluded. 4. Be careful not to let him take cold. There is no necessity for any means of strength- ening except by regimen. When it is necessary to resort to tonics, we may use the tinct: of gen- tian, vegetable bitters, Columbo, quassia, cam- omile tea &c. Insanity is to be overcome by o- piates: these failing we may resort to tinct: of hops, or Hoffman’s Anodyne. The state of the bowels must also be attended to. To over- come constipation Rheubarb is to be preferred, because it never purges copiously. – Hectic Fever. Hectic fever is most commonly connected with Pulmonary consumption. It is a disease purely of irritation & may be caused by whatever acts in this way. It was supposed by some to be owing to an absorption of pus; but Mr. Hunter has Heart acts in the hot stage of In- termittent : - not in Hectic. Bowels generally regular in Hectic. 63 shown this to be incorrect. Hectic fever is often associated with & arises from other diseases: as 1. White swellings & rheumatisms. 2. Schirrus & Scrofulous ulcers; more particularly when they are seated in glandular structure. 3. Congestions & obstructions of the viscera. 4. From cases of simple irritation, as from calculus in the bladder, or in the gall ducts, or from structure in the urethra. 5. Pregnancy, from irritation to the system from the uterus & its contents. 6. From irritated states of the primae viae from worms &c. This fever par- takes very much of the type & nature of intermit- tent fever; but there are many circumstance in which they differ. 1. The paroxysms of hectic are seldom regular for any number of days in succession, but are generally irregular: happening at almost every hour of the day & night. There are generally two paroxysm of hectic in 24 hours : one at noon, & the other in the evening. 2. The paroxysms are very often not associated preceeded by a chill; & sometimes very violent rigors take place without the hot stage. 3. The paroxysms in hectic are not relieved by per- spiration. 4. The hot stage of hectic is uniformly attended with a peculiar blush, called the hectic blush. The pulse is generally considerably irritated. The apyrexia is irregular. – 5. The tongue in hectic is always clean & somewhat florid & polished: 64 In intermittent it is cover[e]d with a fun of a white or bilious appearance. 6. In hectic the appetite & powers of digestion are unimpaired, & the bow- els remain in their natural condition; but in intermittent the stomach is always distressed by nausea & loss of apetite, & the bowels are costive. 7. The urine in hectic is turbid; but when the paroxysm goes off, it becomes clear. 8. The mind in hectic is proverbially cheerful: in intermittent, on the contrary, it is gloomy & despondent. Treatment. This, as in intermittent, divides it- self into that necessary in the paroxysm, & that in the apopexia. As a preventive of the parox- ysm opium is useful. All those remedies are used, in the absence of the paroxysm, which are required under similar circumstances, in intermittent. Hectic fever may be either inflammatory or other- wise. When there is much action we must reduce the system by venesection, & the blood uniformly a sizy appearance. The operation must generally be repeated: about [?v].-vi.to be drawn at a time. Evacuations from the alimentary are not often demanded; but in certain cases of hectic emetics are of great utility; & it may be laid down as a general rule, that in all diseases of a period- ical nature, emetics are useful. Active vomit- ing has been strongly recommended by a late 65 writer, on the principle of imitating a sea voy- age. After this we may give tonics: of these Cullen considers the peruvian bark the best; But my confidence in it is not very great. It proves very offensive to the stomach: on which account it has been recommended to unite it with myrrh ; but I prefer the myrrh in combination with other articles : as in Griffiths’ Mixture’s, thus, Rx. Gum : Myrrh : . . . . . . [?ii]. Sulph : Ferri . . . . . . . [?i]. Carb : Potas : . . . . . .[?i]. Sac : Alb : . . . . . . . [?ii] Aquae . . . . . . . . . . [?vi]. [m crossed out]. Of this a tablespoonfull is to given every 1 , 2 , or 3 hours. – Camomile, quassia, colum- bo, gentian, & serpentaria have all been used, & are of more service than the peruvian bark. The cherry tree bark is of much service in hectic. With its tonic is combined a narcotic property, owing perhaps to the prussic acid it contains, & is, for this reason peculiarly suited to these cases. Cascarilla has succeeded when other arti- cles have failed. Much has been said of the uva ursi in this disease. I have not used it a great deal, but have generally derived good effects from it. Arsenics has been used; but in the few trials I have made with it I have 66 made with it, I have been disappointed. The Saccharum Saturni has been highly recommen- ded by Dr. Irwin of Charleston. I have prescri- bed it in several cases, but with no great ad- vantage. Mineral acids have been used. Of these the Nitric is most efficacious as a cure, & the Sulphuric as a palliative. As much nitric acid as can be taken in the day, & a dose of opium every night, & one just before the paroxysm, is a very effectual remedy in this disease. Vegetable acids have been recommend- ed by Dr. Roberts. Of these the Common vinegar is most useful, in the dose of a tablespoonfull sev- eral times in the 24 hours. In colligerative di- arrhoea it acts as a powerful astringent. The Pela aranei, or Spiders web, I have often used, & it appears to be productive of effects very analogous to opium. Sulphur is a rem- edy in hectic fever, & is useful in all diseases of a paroxysmal type. It may be given in the dose of 1/2 a teaspoonfull 3 or 4 times in the 24 hours. Dr. Physick supposes it to be one of the best means of removing hectic fever. Charcoal has also been used. Ventilation is of great im- portance. Exercise on horseback or in a carriage is also necessary. If there be much febrile ir- ritation, exercise will aggravate the disease; 67. but after this is reduced exercise will prove beneficial. – ================= Hoemorrhagies ======= These are divided by Cullen into Active & Passive. Then active, according to him, are always attended with some degree of pyrexia. As a gen- eral rule we are most liable to hemorrhagies about the period of puberty, when the body does not re- quire all the blood elaborated. Early in life they generally proceed from the arteries; laterly from the veins, Hoemorrhages from the Liver, Spleen, Stomach & hemorrhoidal vessels are veinous: from the nose, lungs & uterus, arterial. Some cases of hemorrhage observe all the laws of fever, especially of the intermittent type. The causes of hemorrhagy are very numerous. They are, a change in the balance of circulation, occurring at the age puberty; but generally irregularities of circulation. The active hemorrha- gies mostly occur in full, plethoric habits, and generally in the Spring & Summer. To these may be added accidental, subordinate & accessory causes. Among the latter, whatever is calculated to invigorate the circulation, or direct it to any 68 part of the body : these are 1. Violent exercise, as running &c. 2. External heat : this acts, in the first place, as a stimulus to the circulation, secondly, by relaxing the blood vessels. 3. Cold to the surface, & particularly to the feet: the mode of action here is very intelligible. A vast shock is given to the system, & the blood is thrown back upon the internal parts. 4. Diminution in the weight or density of the atmosphere. There are other circumstances which cause hemorrhagies, as ligatures, wounds, blows, vehement passions, intem- perance in eating or drinking &c. Treatment. It was said by Stoll that these discharges of blood were occasioned by the efforts of nature to remove too great repletion of the vessels, & should not be checked. It is true that checking hemorrhagies after proves injurious when there is a tendency to apoplexy. Sometimes blood, instead of being discharged from the nostrils or hemorrhoidal vessels, is poured into the lungs or some cavity of the body from which it cannot be easily removed, & death is the consequence. As preliminary to the treatment of particular hem- orrhagies, I shall offer a few remarks applicable to the whole. When there is much action this is to be done. 1st by evacuations. 2ndly by refrigerants: these are external & internal, one consisting of 69 cold application, the other of neutral salts. 3rd by sedative articles, or such as are supposed to reduce the circulation, as digitalis. 4th by the preparations of lead, copper, zinc, and the miner- al acids: which have used to restringe the mouths of the vessels. It is customary to resort to a stim- ulating pedeluvium, embrocations, cupping & of- ten to vessicating applications, as near as possible to the seat of the disease, or the principal of re- vulsion. To prevent the return of hemorrhagy, all the causes should be removed; and, as the dis- ease is founded in plethora, such a course of diet must be attended to, as is least calculated to fill the blood vessels or excite their movements. Venesection is only temporary, & in its remoter con- sequences is as injurious as the disease itself. The same may be said of purging. More is to be expected from exercise, and a properly regula- ted diet. – Hoemoptysis. Or strictly a spitting of blood. This is a hem- orrhagy from the lungs, trachea or fauces. When the hemorrhage proceeds from the trachea or fauces, there is generally hauking without any febrile affection or cough. Hemorrhages from the larynx are sometimes of a serious import, & are often 70 precursors to pulmonary consumption. In hem- orrhage from the lungs there is a discharge of blood of a florid colour, brought by more or less coughing. It may be produced by all the causes of hemorrhagy in general. People of a nar- row thorax, prominent shoulders, delicate make & sanguine temperament are predisposed to it. But there are other causes, as loud & long con- tinued speaking or singing, great exertion, anger, vicissitudes of weather, irregular habits of living, or the suppression of some customary discharge. It more frequently occurs at night, when there is least corporeal of mental execution. There are several species of hemoptysis. 1. It may occur from the mere accidental rupture of vessels, from a blow, fall or wound: that is a matter of little consequence, if the vessel be small. 2. From excessive inflammation of the lungs, as in the early stages of pleurisy: this is not very serious. 3. From translation from some other part: as from hemorrhois or epistaxis. This is not very important unless the discharge be copious. 4. From mere plethora in the vessels of the lungs. 5. From an abscess or ulcer in the lungs, generally following pneumonic inflammation, ill cured: in this case it is mixed phlegm or purulent matter. 6. From tubercles, associated, as usually happens, 71 with the scrofulous diathesis: this generally ends in pulmonary consumption. In hemoptysis there is a sense of weight; a dry, hard cough; difficulty of respiration; full, hard, irregular pulse; flushed countenance; chill; cold– ness of extremities; pain in the back & loins, flat- ulency, costiveness & extreme lassitude: the remedy in this case is the reduction of arterial action by ve- nesection. Dr. Heberden objected to this practice. He asks, how can the opening a vein in the arm check the flow of blood from the lungs? I would answer, by opening a vein in one part of the body, we invite the flow of blood to that part. Thus it is that relief is afforded in hemoptysis: on the principle of revulsion. In violent cases the bleeding should be large: as much blood should be taken away at once as to make a decided impression. Some say that the lancet should be restricted to cases in which there is much action & in plethoric habits: though perhaps more effectual in such cases there is no limitation. The lungs in hoemoptysis are liable to take on inflammation & suppuration: conse- quently venesection is the proper remedy. As soon as a sufficient quantity of blood is detracted we may give a teaspoonfull of common salt every 10 or 15 minutes. How the salt operates under such circumstances is not well known. It may be 72 by its constringing impression made upon the fauces, which is extended by continuous sympathy to the lungs: thereby constringing the the patuluous mouths of the bleeding vessels. The manner of using the salt is to let a teaspoonfull dissolve in the mouth. If given in solution it is apt to vomit. If the case be critical we must use cold applications to the thorax and arm pit, or let the whole body be wrap- ped in a sheet wet with vinegar or cold water. The late Dr. Bond of this city was in the habit of using this. The only objective to the practice, is that hem- optysis is generally associated with pulimonary dis- ease: in such cases cold is injurious. It may be resorted to, however, in cases of emergency. The Saccharum Saturni has been much used in these cases. The use of the lead should be always be pre- mised by copious venesection. The general rule is to deplete as long as there is any vigor in the cir- culation, & then the lead may be used with bene- fit. - It should be given in the dose of gr. ii or iii, combined with a small portion of opium; every hour or 2. I have known many instances in which it has been given in large quantities, even [?i] at once, without any bad effects except violent purging, with more or less tormena & tenesmus. No astringent effects what- ever were produced. Alum has been much recom- mended by some practioners. I cannot place it very 73 high in hemorrhagy from the lungs. To profuse hemorrhage it is utterly unsuited. If I were to pre- scribe it, it would be after bleeding. Emetics were introduced into the treatment of this disease by Dr. Bryan Robinson. Active vomiting, especially when spontaneously induced, has in some cases sup- pressed hemorrhage from the lungs. Dr. Willis of London was in the habit for 50 years of treating this species of hemorrhagy by emetics. They should only be used in cases of emergency. They may be of utility in small & nauseating doses. Emetics tar- tar has been employed with advantage. It is best suit- ed to febrile hemorrhage; & to this alone I think it is adapted. The vitriolic solution has been much ex- tolled by Mosely & the late Dr. Barton. I do not place much confidence in it. On the same footing I place the preparations of Copper. Ipecacuan- -ha is an important remedy in such cases. It should be given so as to create a slightly nausea, which is to be kept up for considerable length of time: about gr. ii. of ipecac: & a small portion of opium, to be often repeated. Refrigerants have been used, of these the best is the nitrate of Potash. It is useless if given while the blood is flowing freely; but, having a manifest effect in reducing vascular action, it is auxiliary to the lancet. It may be given either alone or with some of the antimonial 74 preparations: thus Rx. Tart: emet: gr. 1/8 or 1/10. Nit : Potas: gr. 6 – 8. – Mineral acids have been used ; but we should not rely upon them in exclusion to some of the rem- edies I have mentioned. The sulphuric is the best: dose g. [?] XX-XXX. diluted with a little water. Chixir virtual will answer very well. Purgatives have also been recommended. Of these magnesia should never be used: some particles being apt to stick about the fauces & excite coughing. Narcotics, as cicuta, henbane, & opium have been used. (vide Therapeutics). Of Digitalis I will say more when treating of uterine hemorrhage. It is ineffectual as a substitute for the lancet & should never be trusted. By giving it in large doses we excite vomiting, which is not very good in hemorrhage from the lungs, & in the ordinary doses much time elapses before it effects the pulse. - - Of Local applications. Of these the most common is cold, to the body & arm pit. We are sometimes obliged to make use of vesicating applications: the chest is the best place to apply the blister. Dry cupping is also useful: operating as a diverticulum of the blood, & at the same time as an irritant. In relieving pulmonary hemorrhage there are other circumstances to be attended to. 1. The situation of the patient in bed is of great importance. The lower extremities should always be 75 kept extended. 2. The chamber should be cool & well ventilated. 3. Company should be ex- cluded & no talking allowed. 4. The stomach should never be loaded. Acid drinks may be given. 5. The bowels should be kept in a soluble condition. Hoemorrhage from the Lungs is sometimes Passive, or consequent to weakness. In such cases, when not accompanied with a febril affection, the Peruvian bark is to be used. It is commonly used alone; but it is much better to unite it with the chalybeate preparations. The tinctura ferri muriatis is the best, but the sulphat of iron will answer very well. Much better are the mineral acids. The sulphuric answers best to suppress the hemorrhage; but the nitric is best, when it is ac- companied with ulceration of the lungs & hectic fever. Exercise, especially on horseback, is useful, except when there is an excited pulse & a febrile condition of the system. Hemoptysis, particularly when connected with a constitutional affection, sometimes returns after being cured. To prevent this the 1st rule is, to avoid every cause of increased impetus to the circulation. 2. When a strong predisposition appears, we must at- tempt to the stomach & pulse. Small bleedings & the antiphlogistic regimen are demanded. 3. Avoid taking cold: nothing is so apt to reproduce hem- 76 optysis as a catarrh. 4. Much good may be de- rived from perpetual blisters to the chest, when there is considerable local affection, but in other cases they may be applied to the extremities. 5. On the same principle salivation should be tried, in obstinate cases, to transfer the diseased action from the lungs to the mouth; by the general revolu- tionary action of mercury. Exception to the mer- curial practice are found when there are tubercles in the lungs. 6. Emetics frequently repeated are entitled to much credit in the same cases. They operate by reverting the blood from the lungs, and “dislocate” (as it has been termed) the disease from its seat. But, as a dernier alternative, we may order a journey to a warm climate, &, if practicable, by a sea voyage. This has effected cures when every thing else has failed, & under circumstances the least promising. Hoematemesis. Or hemorrhage from the stomach. This has been some times confounded with hoemoptysis; but hem- orrhage from the stomach is neither preceeded, nor attended with any pulmonary affection; & the blood is of a dark grumous colour: that in hemorrhage from the lungs is florid. Homatemesis may be produced by the causes of hemorrhage in general; an emetic of ipecac. When the patient is apparently in articulo mortis has effects a cure in some cases. 77 but more frequently by violent blows, powerful emetics, cold taken into the stomach, as ice water or ice creams. Hard drinking is often the cause of it. We often meet with hemorrhage from the stomach which is secondary or vicarious in its nature, as when it takes place from the liver or spleen. The hemorrhage from the liver is called meloena, or morbus niger. Evacuations of blood sometimes takes place both upwards & downwards in large quantities. [Dr. C mentions a case in which as much dark blood as filled eleven chamber pots, was discharged from the stomach & rectum in 3 days: coming probably from the spleen by the vasa brevia]. Treatment. We are here to be governed by circum- stances. To check the bleeding when it is profuse, we may use alum, bad water, or 20 or 30 g [?] of the muriated tincture of iron. Ice & water has been used; but how far this is prudent, I do not know. The first object when there is great irritability of the stomach is to apply a blister to the epigastric region. This serves a two-fold purpose: it checks the vom- iting & suppresses the hemorrhage. We are next to ascertain whether it be dependant in any degree upon viscual obstruction or suppression of any cus- tomary discharge. The treatment here is too evident to require a statement. There is a species of hoem- atemesis which takes place in females about the age 78 of puberty, which is said to be successfully man- aged by the liberal use of purgatives, & resists all remedies. It had generally been supposed to be owing to a retention or suppression of the menstrual discharge; but it is now contended to be owing to a constipated state of the bowels: the foeces being always copious, & of an unnatural colour, consistence & smell. (vid. Therap. vol. 1. p. 180). Epistaxis. Or bleeding from the nose. We are most liable to this species of hemorrhage about the age of puberty. The causes of hemorrhage in general may produce it; but there are others, such as hanging of the head, tight ligatures about the neck, and every thing that determines the blood to the head. It comes on at times without premonition; but it is generally preceeded by vertigo, flushed counte- nance, & throbbing of the temporal arteries. It some- times assumes the febrile character, & is generally as- sociated with constipation state of the bowels. Treatment. In this there are two leading indica- tions. To check the flow of blood when it is consid- erable, & to prevent it’s recurrence. To effect the first, the patient should be placed in a cool position, either erect or sitting. The head should be held back, & cold applied to the nose itself, 79 to the back of the neck , to the ascilla , or scrotum, The nostrils should be stopped up with lint, either dry, or wet with any styptic, as a solution of alum, sugar of lead, or white or blue vitriol. A dossil of lint cover’d with powder’d charcoal or flour will answer. A Dr. Sims of London says he has never known burnt cork, snuffed up the nostrils, to fail in putting a stop to bleeding from the nose. It sometimes happens that when the hemorrhage is stopped externally, the blood contin- ues to flow in the fauces. This is dangerous, es- pecially in children: as it is most apt to take place in a recumbent position. In excessive cases we must resort to water made cold by sal ammoniac, or common salt. Place the patient in it & let him remain for 10 or 15 minutes. But as a dernier alternative we must make use of compression by drawing lint thro’ the nostrils. To obviate a return of the complaint; all the causes should be avoided. Attend to the anti phlogistic regimen. Venesection may be occasion- ally be resorted to. When there is a determination to the head, topical bleeding may be useful. Purgatives are indicated by the habit of consti- pation which commonly prevails. They may be aided by the continued use of nitre. All these failing, we must apply a blister to the wrists, 80 neck, or back of the head. These hemorrhages should not suddenly checked when there is an apoplectic tendency; but it should be done gradually. Uterine hemorrhagy. Discharges of blood from the uterus may take place either in the impregnated or unimpregna- ted state. When flooding takes place to an alarm- ing degree before the delivery of the child, it must be removed, so as to allow the uterus to contract the vessels. When hemorrhage takes place in the unim- pregnated state of the uterus it is called menorrhagia; but menorrhagia, properly so called, is a rare occur- rence, & seldom requires any more treatment than rest, & when there is much irritation an anodyne. Uterine hemorrhage may be produced by all the causes of other hemorrhagies; but more commonly by constipation, excessive venery, dancing, or certain organic affections as schirrus &c. Treatment. When there is much activity of pulse, the lancet freely employed is indespensible, & the bowels are to be kept open by mild saline laxa- tives. A state of repose & low regimen are to be strict- ly enjoined. Astringents may then be resorted to; but must always be preceeded by copious venesection when activity of pulse a febrile excitement exists. 81 At the head of the class of Astringents is the Saccharum Saturni. This is considered by Heb- erden as a specific. When properly applied it dis- plays extraordinary powers. It may be given in the dose of grs. ii-iii, with a small portion of opium, repeated every hour or two according to the emergen- cy of the case. When the discharge is profuse I have given [???]. in a day. Ipecacuanha is nearly equal to the Sac: Sat: & is in some cases prefer- able. It is to be used only in nauseating doses. (vid. Therap.) – Its effects are not owing to its astrin- gency, as the most powerful astringents will not pro- duce them; but it is by inducing debility & thereby reducing arterial action. It is alleged by Murray that it is owing to its antispasmodic property, but more powerful antispasmodics have no such ef- fect. The proper dose is about grs. ii. with grs. ss. of Opium. Alum was formerly much used, but has of late years been superceeded by Sac: Saturni. I have derived some advantage from it in doses of gr. V-X. – Much has been said of Digitalis in this complaint, as a substitute for the lancet; but there is no substitute for the lancet in active hemorrhagy. Digitalis, in the case before us, is to be placed among the remedies last noticed: to be used when arterial action is reduced. Upon the whole it is inferior to the proportions of lead & Passive uterine hem: ^ 82 Ipecacuanha (vide Therap.). It was the custom in Europe to exhibit opium freely; but the prac- tice has been abused by a too general & indiscrim- inate recurrence to it. After a large bleeding opium may be of utility, & in spasmodic pains of the uterus it will prove better than any other remedy whatever. In uterine hemorrhage the system is generally in a state of atony, especially of the uter- ine vessels. The complexion is pale and sallow; the surface cold; pulse weak, & when the debility is great, oedematous swellings appear. In such cases we must use tonics. About [?j]. of coarsely powder’d peruvian bark in a quart of lime water, is one of the best remedies I have tried. Alum was used by Van Helmont. The mineral acids have been used: also kius & catechu. The regular use of the cold bath, & whatever tends to invigorate the system is here necessary. In addition to these there are certain topical applications, from which we may derive great advantage, as cold, which may be applied to the pudendum, abdomen, or vagina, in various ways. It has been suggested to stop up the vagina with ice. The most effectual way is to pass cold water from a height in a small stream on the abdomen. Injecting into the vagina or rectum (especially the latter) a solution of saccha- rum saturni has been of great utility. Hardi paste, a celebrated remedy for the Piles, is made thus. Rx. Piper Nigr. Rad. Inul. campan. aa[line drawn horizontally above aa] [?viij] Sem. Foenicul…[?xxij] Mel: et Sacchari aa[line drawn horizontally above aa] [??j]. m [m crossed out]. Make into a paste. – A favorite remedy with Su Astley Cooper, after inflammation was reduced. 83 There is another form of uterine hemorrhage. When menstruation is about to cease, the secretory office is imperfectly performed & we have pure blood instead of the genuine menstrual fluid. In a more advan- ced life uterine hemorrhage sometimes occurs. About 1 or 2 tablespoonfulls are discharged in a day, & is atten- ded with pain. This is called hemoptac of the uter- us. There is here either schirrus or a tendency to it. Treatment. The patient is to be placed under a milk diet. Small bleedings are sometimes necessary; and mercury is to be given, so as to attain its alterative rather than its salivant effects. When there is schirrus of the os uteri, arsenic & circuta may be used. Hoemorrhois Or piles. – In hemorrhoidal tumors, the following leniment is very useful. – Take of Fresh lard [?ii]. Spermaceti [?iii]: to be made into a liniment. Then add Laudanum [?ii]. Goulard’s extract [?i]. Galls are used as an ointment with much success where inflammation is previously reduced. I generally direct it to be made of 3 parts of lard & 2 parts of finely powdered galls. – Extract of cicula, and lead water & laudanum have been tried with success. When the pain is excessive 100 g[rs]. of Laudanum, on a suppository of opium, have been used with ad- vantage. Much relief has been obtained from 84. Spts: Terebinth: or Bals: Copaib:. The former was used by Dr. Kuhn in the dose of 10 or 15 g[rs] 3 or 4 times a day. Tar ointment is also useful. After inflammation is completely reduced, exercise on horseback is serviceable. Leeches to the anus have afforded relief. To restore piles (which is sometimes desireable) alactic purges may be used. With some of the medical men of France, it is a custom to apply leeches to the anus in all acute diseases, to produce piles: so important do they consider this discharge. The sympathy between the rectum & lungs is very great. Fistula in and of long standing is generally attended by pulmonary consumption. ======== Class. 2. Diseases of the Digestive System. ======= I shall begin with diseases of the stomach. This viscus occupies the highest rank & pos- sesses the greatest influence in the animal economy. By some physiologists it is called “the animal”, & by others it is considered the seat of the soul itself. Destitute of a stomach no animal can exist. Fe- tuses have born without a heart, lungs, liver, uterus or brain; but in no instance have I known the stomach to be wanting. It is an organ most 85 liable to derangement & most acceptable by our remedies. It is probably the throne of the vital principal, giving support to the other organs & en- abling them to perform their various functions. Languido ventriculo omnia languent. Gastritis. Or simple inflammation of the stomach. This is divided by most writers into Phlegmonous, or Erythematic; & Erysipelatous, ascending to the coat of the stomach inflamed. This division is without foundation. The different appearances which the disease presents are owing to the difference of causes which produce it. Erysipelatous inflammation of the stomach arises from a peculiarity of action, & is generally attendant on malignant diseases. I shall now speak more particularly of the phleg- monous inflammation. Gastritis may be excited by all the causes of inflammation generally; but more especially by cold, cold drinks, a blow on the part, or by re- trocendent of gout. It is also produced by the stri- king-in of certain eruptions, by crudities in the stomach, & sometimes from indigestible articles ta- ken into that organ. This disease often pursues its course without the appearance of any of its symptoms. Many cases of death have happened 86 without the cause being known, until dissection has shown it to be gastritis. The symptoms of this disease are, a sensation of acute pain at the scrobiculus cordis, soreness to the touch, great irritability, copious vomiting, tension at the epigastric & umbilical regions, pulse small, hard & chorded, tho’ not always quick in the commencement; great prostration of strength, & if the disease advance, the patient faints, has the wild eye, lank countenance, low muttering delir- ium, & often vomiting of dark matter as in yellow fever: the latter symptoms are precursors of gan- grene or indicate its actual existence. Among the anomalous symptoms attendant on this disease, are pain in the ball of the great toe, sometimes pain the groin, & in women there is frequently a pain in pudendum, which is considered a fatal symptom. Gastritis often puts on some of the symp- toms of hydrophobic, as great aversion to water, difficulty of deglutition, & frequently nervous tre- mours, a case is mentioned by Innes, in which there even all the symptoms of hydrophobia; & which was ultimately cured by copious bleeding. Diagnosis. It can only be confounded with Enter- itis & Peritonitis. I shall mention the distinction when I speak of those diseases. Treatment. Administer without delay the 87. depleting remedies. Venesection is to be largely employed, notwithstanding the state of the pulse. It will right to take away [?XX]. –XXX. at once, and sometimes to repeat the bleeding in the course of the same day. Next in importance to this, is topical depletion by cups or leeches, & after this it is proper to apply a blister to the epigastric region. By these applications we subdue inflammation & quiet the irritability of the stomach. Fomentations to the abdomen consisting merely of mush or corn meal put in a bag & applied to the abdomen, are of service. After a sufficient quantity of blood has been taken away & the disease is brought to that state in which it is proper to use purgatives, Calomel will be found the best. From its weight it is not often rejected, & it will remain without producing irritation. Either alone or united with opi- um it is of service. When a large dose fails, I have known 1/4 or 1/6 of a grain to answer. Of the neutral salts which it may be found necessary to use, the Epsom salts are much the best. – It is important to open the bowels by emollient injections: a pint of water, in which a small por- tion of oil is mixed, will answer. The irritation of the stomach may be allayed by lime water & milk, or the effervescent draught; & I have derived much advantage from the warm bath. 88 Demulcents may be used: not, as is supposed by some, to sheath the coat of the stomach; but merely for the purpose of nutrition, & to relieve thirst. The mucilage of gum arabic in small quantities may be used; of which a tablespoonfull may be taken several times in the course of the day. As little drink as possible should be given. The thirst is more effectually relieved by small quan- tities of some beverage, as toast & water; but above all seltzer water should be selected. When we are obliged to desist from the depleting remedies, we next use opium to prevent gangrene. If the opi- ate treatment fail, we must rely on turpentine; which is one of our best remedies. The dose should be about a teaspoonfull. The appearance upon dissection, in Gastritis, are those of violent inflammation: generally red streaks extending over the inner surface of the stomach. It sometimes presents the appearance of small stars: at other times, tho’ rarely, a suffusion or blush. Ul- ceration has been seen. Dr. Yelloly, of London, mentioned that the stomach often presents some of these appear ances when there has been no inflammation; but takes place after decapitation, or death in any way suddenly induced. This arise from the blood being determined to the stomach & injecting the arteries there. It is impossible to distinguishing precisely these 89. appearances from those produced in the early stage of inflammation; but generally in the more violent cases there is an effusion of coagulable lymph, & often ulceration. Evidence in such cases should be given with great caution. Poisons. The term Poison, is relative. What at one time will prove even salutary, may at others be highly pernicious. It was one of the earliest maxims of the medieval schools, that all poisons in a small degree are our best medicines, & vice versa. They may be arranged under the two heads of Narcotics & Cor- rosive poisons. Under the first head Opium is the most common article from which mischief arises. Af- ter opium has been taken in large quantities, the indication is to evacuate the stomach. The best means of performing this is not by the instrument invented by Dr. Physick. When this is not at hand, & often when it is, an emetic will answer. The most active are to be employed, when the poison has remained a considerable time in the stomach. Sulph: Zinci has been used in these cases; but it has been much overrated & is not adapted to cases of poisons. The Sulph: Cupri has also been used; but the best is a combination of Ipecac: & Tart: emet: The dose most be very large, & repeated every 5 or 10 min- 90 utes until vomiting is produced. If the patient can swallow, a large draught of water, so as to produce distortion, will have a good effect. In the same cases cataplasms of tobacco to the stom- ach have succeeded in exciting vomiting, when all other remedies have failed. They are only appro- priate when there is great vigor of circulation. Tickling the fauces with a feather often answers, or injecting [?i] of emetic tartar into the rectum. Propensity to sleep, stupor, laborious respiration, & other apoplectic symptoms are generally attend- ant. In such cases it has been advised to endea- vour to keep the patient awake by shaking him &c; but more may be done by sinapism, stimulating injections, strong coffee, or vegetable acids: these lat- ter, however, are only to be used after the opium has been evacuated. They are only counteragents to the impression left by opium. The volatile alka- li has been considered an antidote to the effects of opium; but strong irritation on the surface of the body is much better. Kaaw Boerhaave tried severe castigation with success upon dogs, & the same thing might be applied to men. After the patient has recovered from the immediate effects of the poison, there is generally a fever, with a full large pulse, easily compressible, heat of skin &c. Here the deple- ting remedies cannot be carried to any great extent, 91 and we must use moderate purging. If there be determination to the head, cups may be applied. Digitalis, henbane, belladonna, tobacco & laurel, are different in their operation from opium. They are directly sedative. No reaction takes place; but the patient gradually sinks and dies. In these cases, after evacuations, we must use diffusible stimulants, as ether, vol: alkali, brandy &c. Strong brandy & water, in great quantities, with the vol: alkali, is the best counteragent to digitalis. Beddoes considers opium the best: Orfila , Spirits of turpentine. Of Poisons from Strong Liquors. Too much strong drink will sometimes extinguish life at once; but more commonly determination to the head & other symp- toms of apoplexy take place; or the system reacts & we have what is called intoxication. These cases are distinguished from apoplexy by the order of the breath, & inquiring into the nature of the cases. The first thing to be done is to evacuate the stomach by an emet- ic, & then we may give acidulated drinks or coffee. Cold water applied to the head, or taking the patient under a pump & pumping upon him, is often the best thing that can be done. If there be any apo- plectic symptoms, which is very common, we must bleed generally, & resort to cupping, leeches, or arteri- otomy & cold applications, & afterwards to the cor- dial stimulants. The fever which follows, is the 92 same as that from opium & is managed in the same way. – It is said by a late writer, that, in these case of poison, when the pupil is incapable of contracting by light, the patient invariably dies, & visa versa. Mania a Potu. This is met with in habitual & confirmed drunkards, & generally on the subsidence of the im- mediate effects of the liquor. It is induced by the sud- den subtraction of drink. The sympoms are, a pe- culiar state of countenance; eyes red & wild, and looking at different objects; face tumid & suffuse; the vessels of the head are pulsatory, & the bowels are always constipated; the pulse is full & easily compressible. As the disease advances, the nervous system becomes affected. Tremors, muscular relaxa- tion, subsultus tendinum & loss of power attend; but there is sometimes a paroxysm of strength, which is generally the prelude to convulsions. The mind, which in the commencement was more or less dis- turbed, now becomes exceeding so. The patient is sometimes timid, at other times furious. He is often fearful of the house falling upon him, & endea- vours to prop up the walls with his hand. Treatment. We must first endeavor to quiet the irritability of the stomach, & put it in a state for 93 receiving the stimulating remedies. For this purpose we may give the effervescent draught with laudanum; but the best thing is strong hot toddy, & sinapisms to the extremities. In the next place opium and camphor may be used; but often, on account of the great insusceptibility of the stomach, it will be best to give a large quantity of some emetic. I have known 20 or 30 grs. of tart: emetic, & [?ii] or iii, of ipe- cac: necessary for this purpose. If the emetic oper- ate well, the difficulty terminates & we may then use the opium & camphor. The patient should be placed in a dark room so as to let him sleep. When he awakes we continue the stimulating & cordial treatment. His diet should be nourish- ing, may consist of rich soups, or if he prefer it, solids. When there are nervous tremors, stimulants & malt liquors are to be used. Hot tea or the tinct- ure of hops often produces great tranquility & relieves morbid vigilance. Bloodletting is rarely demanded; but if the patient be of a robust constitution and with a vigorous pulse [?X]-Xii. may be taken away. If there be determination to the head, cups may be applied. The disease sometimes becomes typhoid: in these cases opium & camphor, volatile julip &c. are to be used. There is here no inflammation, but a state of commotion of the system, & the only de- pletory measures that are demanded emetics. 94 or moderate purging. In place of the stimulating plan Dr. Klapp of this city relies almost entirely on active vomiting. From my own experience I think he carries the practice to an undue extent. Emetics are important in preparing the way for stimulants; but the practice of depending upon them alone is often followed by fatal consequences. In some cases no reaction takes place & death ensues. In the administration of emetics in mania a potu it is best always to watch their operation. Dissections in this disease show the stomach much inflamed, & the liver is always variously affected. It is sometimes schirrous, sometimes abscesses are found, & it is often tuberculated &c. The brain is sometimes much inflamed & congested: at other times there are serious effusions. Water is often found in the chest, & even in the pericardium. Patients in Mania a Potu should be treated with the greatest mildness. – Mineral or Corrosive Poisons. In the two classes of poisons the treatment is an– alagous. Emetics are used in both; but as regards the mineral poisons we have antidotes which change or decompose the poisonous matter & neutralize or destroy its effects. As respects Mercurial preparations & especially Corrosive Sublimate, which when taken 95 in a large amount, causes pallid face, great thirst, burning of the throat & fauces, nausea, vomiting re- sembling black vomit, & finally cold skin, cramps of the stomach, syncope, convulsions & death, the antidote is Albumen. The whites of 10 or 15 eggs should be given, or, when these are not at hand, we may use new milk: the stomach being previously evac- uated as in other poisons. The antidote to all the preparations of copper, which produces a copperish taste in the mouth, & frequent eructations of the same taste, is sugar or molasses, or any saccharine matter; but according to Orfila albumen is better. For the prepar- ations of Tin, & particularly of the muriate of tin, the white of eggs, or milk , is the antidote. For the Nitrate of Silver the antidote is common salt in so- lution. Dissolve [?i] of salt in [?v]-vi of water, & given him a spoonfull every 10 or 15 minutes: having previously vomited him. The antidote to the preparations of Lead or Barytes is Sulphate of Soda or magnesia. To the Antimonial preparations, as tartar emetic, the distinctive symptoms of which are vehement vomiting & extreme debility, the antidote is decoction of peru- vian bark, or strong green tea, an infusion of galls, or any other vegetable astringent that may be at hand. To the mineral acids, which produce intense heat in the stomach, the antidote is Calcined magnesia, or the alkalies; but must be given largely. [?i] of Carb. ammonia is the antidote of Prussic acid. - 96. Cale. Magnesia in a pint of water: of which a spoonfull may be repeatedly given. To the Alkalies , which produce a caustic taste in the mouth which remains for some time, the antidote is the acetic acid given in large quantities. To Arsenic no antidote has yet been discover- ed. A Mr. Bertrand, a few years ago, published an account of the efficacy of charcoal, as an an- tidote to arsenic; but by repeating his experiments before a committe of the National Institutes of France, the whole turned out to be a mere fab- rication. All that can be done in a case of poi- son by arsenic, is to use demulcents, as flaxseed tea, barley water &c., after vomiting. No oily mat- ter is to be taken into the stomach: the same of alkalies & hepar sulphuris. When the system is laboring under the effects of arsenic, we should use sinaprisms, & spts: terebinth: by the mouth & rectum. Orfila used it in that state of this stomach to prevent gangrene, & says it is the best remedy for this purpose. Arsenic does not immediately destroy life, but generally keeps it lingering for a few days. In the closing stage of the disease from arsenic, the black vomit is thrown up. There is intense heat at the stomach, nervous tremors, palpitations, strangury, pulse some times slow but generally it 97 is quick & tremulous, cold sweats, delirium, and dimness of vision. Dyspepsia. This is a disease of very ordinary occurrence & often proves very perplexing in the management. It is usually attended with nausea, vomiting or a gnawing sensation about the stomach, constriction about the throat, sour eructations, gastrodynia or spasms, flatulence, furred tongue, foetid breath, constipation, cardialgia & palpitations, languor, py- rosis, small chorded pulse, irregular & disturbed sleep, appetite apt to be depraved, as eating chalk, diet &c. The disease frequently extends itself to the mind, producing hypochondriasis. The anomalous symptoms are acute pain in the side & head: this pain in the side is often so acute as to make us believe it an affection of the lungs. The vision is often disorder’d: sometimes it is double; at other times inverted, & in one case I knew temporary blindness to happen. Some pathologists refer nearly all the diseases of the eye, & particularly amaurosis, to the stomach. A tenderness of the scalp with violent pain often attends, caused by a depraved stomach. Sick headach is also of gastric origins. There is also sometimes a very troublesome vertigo, headach, & palpitations of the heart are often exceedingly 98 violent. The Causes of Dyspepsia are of two kinds: such as act directly on the stomach; & such as affect it indirectly, through the intervention of the general system. Of the first kind are excess in eat- ing or drinking; & some articles when not taken in excess: as long continued use of vegetables, or pork, fish, the habitual use of tea or coffee, sour drinks as punch, lemonade &c. Emetics too often repeated are often hurtful in this way, & the neutral salts generally but nitre in particular. Still more in- jurious is the practice of using opium; & many cases of dyspepsia arise from the use of tobacco in any form, but especially chewing. In these cases a cure is often affected by leaving it off for a few weeks. Of the second kind of cause, or those which act in- directly, are a sedentary & indolent course of life, intense study, grief, anxiety, vexation of mind, in- ordinate venemy, cold to the surface, but more par- ticularly cold feet. No man can have cold feet for any length of time, without his stomach suf- fering more or less. These are the causes of what is called idiopathic dyspepsia; but it is also pro- duced by diseases in other parts of the body. The appearance upon dissection when the disease has existed for any length of time, are the following: the coat of the stomach is smooth, the villi being all removed. There are sometimes marks of chronic 99 inflammation, with a thickening of the coats of the stomach; there is frequently a schirrosity, and it sometimes relaxed & flabby. The stomach of an old drunkard is as smooth as a pane of glass. Treatment. As dyspepsia usually presents itself we must first attend to the stomach. Ipecacuanha is to be given; & must be repeated sometimes for 2 or 3 weeks, once every week. Evacuate the intes- tinal canal which is always in a state of constipation. Avoid the saline & drastic purgatives. Rheubarb, how- ever, is an exception, & is very important in dyspepsia, while it opens the bowels, it also adds tone to them. There is only one objective to its use; it is apt to induce constipation; but this may be overcome by combining it with Cale: magnesia , or Castile soap. A mixture of lac sulphuris & magnesia in equal parts will be useful: the dose is a teaspoonfull; but sometimes two teaspoonfulls may be given in a wine glass full of new milk. Magnesia alb with creta ppt, or calcined oyster shells, which is better, will also be found useful. Calcined oyster shells alone restrain purging; but with magnesia, they promote it. The dose is a teaspoonfull. We may now resort to the tonic medicines. Vegetable bitters, particularly Gentian, Quassia, Colombo, Hop, & the Peruvian bark, have all been used. The latter is generally given in decretion or infusion with some 100 aromatic;but, much as has been said of it, I can- not recommend the bark in dyspepsia. Its failure may perhaps be owing to the bad state it is met with in this country. The hop & graphia I have tried with success. The infusion of the hop is more use- ful in dyspepsia arising from intemperance or debauchery. The mineral tonics have also been employed. Of these the preparations of iron are gen- erally used. The rust of iron may be given in the form of Chalybeates wine: thus Rx. Rubig : Ferri . . . 3iso Rad : Gentian :...3SO Port wine . . . . . one quart. Cort : Aurant : (bruised). .3SO These are to be exposed to a moderate heat for 2 or 3 days, to be well shaken during that time. The dose is half a wineglass full 3 or 4 times a day. The Sal Martis is another preparation of iron which has been used with success. Rx. Sal. Mart: 3i. Mucilage of gum arabic q.s. An. Yt map diem in pill. XX. of which 3 or 4 may be taken every day. The Phosphate of iron has also been with advan- tage. When these dont succeed we may give the Tinct : ferri muriat - dose 9# XX-XXX Among the troublesome affections attendant on dyspepsia, are 1. Cardialgia, Or Heart burn. This proceeds from a morbid accumulation of acid matter in the stomach. When 101 this exists in any great quantity , an emetic is re- quired & it may be the necessary to repeat it. But in a generality of cases this is not necessary, & the antacid medicines are to be used. Lime water & milk is excellent. Of the same nature are the alkalies & absorbent medicines : thus. Rx. Sal : Tartar: Spts. Lav: Comp: Gum: Arab: Sac: Alb: aa.....3i Laudan : . . . . . . . . . . . . . . . . . . . . . . . . . .g# XXX. Aquae . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3IV-V When the stomach is debilitated from drunken- ness, or in pregnant women, or from other causes, the volatile alkali is to preferred : thus. Rx. Aquae Ammon : Magnes : Calcin : aa +AFs-slash above the aa+AF0- +AFshJQ- or +ApIAXQ-i. Aq : Cinnamon : . . . . +AFshJQ- or +ApIAXQ-ii. Aq : Font : . . . . . . . . . . +AFshJQ- or +ApIAXQ-vi. m +AFs-m crossed out+AF0- The dose is a tablespoonful. Under similar circum- stances lye may be used. Hickory ashes and soot have also been used with success: thus Rx. Hickory ashes . . . One quart Clean Soot . . . . . . .a teacupfull Boiling water. one gallon. The dose is a wineglass full 3 or 4 times a day. , +AD0APQA9- 102 2. Gastrodynia. By this we understand violent spasms of the stomach, which are so painful at times as to call for immediate relief. Opium is here one of the best remedies. Spts : of turpentine, with 8 or 10 g# of the essence of mint has often afforded relief. A tumbler full of new milk has often succeeded when other remedies have totally failed. Distending the stomach with boiling water, or sipping it by the spoonfull often overcomes the spasms. [The celebra- ted Edmond Burke was accustomed to take a draught of hot water, previous to those display of eloquence for which he was so famous]. To prevent the re- currence the hiera picra , in the form of the elixir proprectatis , may be used. The dose is a teaspoon- full 2 or 3 times a day. Warner’s cordial may also be of some use: a wineglass full may be given twice a day. But the best of all is the volatile tinct- ure of Guaiacum, in the dose of a teaspoonful,3, or 4 times a day. The oxyd of Bismuth has also been used. When all these fail a large blister may be applied to the region of the stomach. This is important in the chronic as well as acute affections of that organ. 3. Pyrosis. Or water brash. This is caused by excessive indulgence in eating, or by distention of the stomach, 103 & hence drinking much water often produces it. In this country it is generally attributed to a mean mode of living ; but I have met with it among the rich & luxurious. The fluid discharged is generally colourless, but it sometimes has a greenish or blackish appearance. It is a vitiated secretion from the surface of the stomach. Treatment. An emetic is often demanded: especially when the stomach is much overloaded. Antacid remedies, particularly Lime water & milk are to be used. Opium has been recommended by Cullen ; but I cannot say much of it. The Oil of Amber in doses of g# XV to XX has been used with success. Kins grs. V. & a small portion of opium to be repeated 3 or 4 times a day has done good. Dr. Physick says he has never known spts. of turpentine to fail. A blister over the stomach is often productive of advantage. The oxide (or sub-nitrate) of Bismuth is the best of all remedies. I have employed it pretty exten- sively & have frequently derived advantage from it in the dose of gr. V either in the form of a pill or with gum Arabic. 4. Palpitations. There may arise from the heart itself, or a disorganization of some of the neighboring organs, as aneurism of the aorta , dropsy of the pericardium, schirrus of the stomach &c. As connected with 104 dyspepsia we treat it with antacids ; but when violent, a little laudanum , or Hoffman’s anodyne liquor may be used. Ether, Musk (natural or artificial) & Oil of Amber has also been given with benefit. – 5. Vertigo. This is to be treated by emetics ; & on the principle of revulsion by application to the sole of the feet, of Cayenne pepper in soap suds, or a piece of the leather spread with shoemaker’s wax. Dyspepsia, whether in its simple or complica- ted form, often proves exceedingly difficult, notwith- standing the remedies mentioned. These cases appear to depend on habit. They have been treated by the gastric liquor of animals; & sometimes with success. The Bile of the ox has also been used ; but much more is to be accomplished by an alternate course of mercury , as recommended by Mr. Abernathy. 4 or 5 grs. of the blue pill may be given every or every other night, & worked off by castor oil , rheubarb , or cal- cined magnesia. I am now to speak of a less common form of the disease. I allude to Chronic inflammation of the stomach. This is often mistaken for Pulminary consumption. It is met with in persons the most regular. There are strong sensations of heat & pain at the stom- ach ; dry & parched skin; tenderness of epigastrium; 105 acute pain in the side ; the pulse is hard, chorded & quick , & attended with a diminutive fever of the hectic type. It arises from a disordered state of the stomach in which the lungs sympathise. The same appearances often take place from worms. A case is related by Dr. Percival in which all the symp- toms of phthisis was produced by a nutmeg re- maining a long time in the stomach. The symptoms ceased upon the discharge of the nutmeg. – Treatment. Venesection is here an important rem- edy. Small & repeated bleedings are found to answer best. Very small doses of Ipecac : , so small as not even to excite nausea, may be used with advantage. Irritation on the stomach by means of the tart : emet : plaisters has proved serviceable. In this form of the disease mercury may be used either as recommended by Mr. Abernathy , or small doses of calomel. All these remedies are to be preceeded by evacuation from the primae viae. Dyspepsia arising from the use of Spirituous Liquors is attended with flatulence , acid eructa- tions , nausea & vomiting. The treatment here is to lessen the more violent symptoms : for this purpose we must use opium. Cordial drinks may be allowed after the strength is gained in some degree ; but a permanent cure is to be sought only in a complete reformation of the individual. 106 I have now mentioned the remedies for idiopathic dyspepsia. That arising from disease of the Liver is to be treated by the mineral acids, or the dandelions (or Gentleman’s button) 4 or 5 grs. of the extract 2 or 3 times a day. In all cases of Dyspepsia , those articles are to be used , which are least offensive to the stomach. A milk diet is to be preferred; but to be effectual, the patient must be confined exclusively to it, & the milk must be taken fresh from the cow. It is most effectual when it does not well agree with the patient in the commen- ement. It often relieves spasms of the stomach. A tumblerfull may be taken every hour or 2, through- out the day. When milk does not answer, we must use Chocolate, prepared as follows. Boil it in water – set it by to cool – scum off the oily mat- ter on top – boil it again, & then pour it on cream & sugar. – Green tea , or coffee should never be allowed to a dyspeptic patient. He may use mut- ton, beef steaks, or essence of beef, made thus. Cut the lean part of the beef into small slices – put them into a broth – cork it & place it in boiling water until the essence is extracted. Veal may be treat- ed in the same way. He may also eat oysters and white fowl, but no salt meat, lamb, veal , pork , ducks , geese , nor fish. Stale leavened bread may 107 be used, but no cakes nor deserts. Toast is injuri- ous, being apt to sour. Crackers may be used. The only vegetables to be allowed are potatoes , and rice. No butter is to be allowed. In relation to diet the following rules must be attended to. 1. Enjoin upon the patient to eat frequently & even at night. The stomach has been aptly compared by Sir Wm. Temple to a schoolboy – “always doing mischief when idle.” 2. Never to miss his food: but to eat one kind exclusively. 3. Direct him to drink little or none at all while he is eating. 4. Don’t let him know what he is to eat; & dont let him be disgusted at the smell of it. To avoid this it may sometimes be brought to him cold. The dishes should be small. As regards drink , water should, perhaps, be pre- ferred. Old ripe porter may sometimes be allowed , but it generally sours & disagrees with the pa- tient. Wine is generally pernicious & sours on the stomach, but when it does agree , Madeira , or old sherry may be used. Brandy , or spirits, & water, when the patient has been accustomed to them may be used. The warm bath once or twice a week has been found useful. It acts as a tonic & re- establishes the healthy condition of the surface. 108 In some cases the warm & cold bath may be used alternately. The flesh brush & frictions of fine salt have been used with much advantage. Exer- cise , especially on horseback is important. Walking is useful & should not be neglected. Riding to mineral springs, as Ballstown & Saratoga, is advanta- geous. The latter to be visited first, on account of its purgative properties; & then Ballstown : the waters of which are tonic. Flannel should be worn at all seasons. Cold to the feet often induces dyspepsia, & to guard against it, woolen stockings should be worn, or Cayenne pepper put in the foot of the stock- ing, or a piece of leather spread with shoemakers’ wax. Buckskin drawers are excellent for preventing the effect of the cold. The remote causes should all be avoided. If the patient lived in intemperately , he must become sober. If studious he must abandon the midnight lamp. If he use tobacco in excess he must abandon it. If afflicted , we must sooth his misfortunes. He must always be encouraged in his cure, & never in this or in any other case should we abandon a patient in despair. Worms The worms which infest the alimentary canal of the human subject, are of two kinds : the Round & Flat. The species of the round worm are, Lumbricoides ; As- carides & Trichuris. The teres lumbricoides , as the first 109 of these is sometimes called, resembles very much the common earth worm. Its residence is in the duodenum , jejunum , & ileum. They are from 5 to 10 inches long , & exist in very large numbers. 200 are recorded to have been voided, by a child 8 years old, in a week. The as- carides (ascaris vermicularis) are very dimunitive , not more than ½ inch long , & commonly occupy the rectum , & are called the thread worm. In some instances they are met with in the stomach & then called maw worm. They are the most numerous species. The tricuris, or long thread worm is of rare occurrence. It is about 2 inches long, & is said to reside principally in the ileum. Of the Flat worm, the taenia is the only one. It is from 10 to 250 feet in length & resembles a bunch of tape. There are said to be two species of the taenia , taenia osculis marginalibus, & taenia osculis superficialibus ; the first of these consists of many small pieces, resembling gourd seed , & called taenia cucurbitini. The taenia resides in the small intestine. Professor Brela describes two other species of worms, the 1st of which is found in the intestines & also in the brain : the 2nd is rarely met with. Causes of worms. The circumstances which fa- vor their production are generally a disorder’d con- dition of the stomach & alimentary canal , dim- inution of strength & emaciation. Children from the 1st to the 5th year are said to be more subject to 110 them than at any other period of life. This has been imputed to their having at this period a large quantity of mucus in their bowels , which serves as a nidus for them. It is said by some that the pri- mordial principle is taken into the stomach with the food ; but this is unfounded: because they are pe- culiar to the human species , & have been found in foetuses. It has long been a question whether worms are noxious to the system or ever prove a cause of disease. It is supposed by some that they are high- ly useful, acting as scavengers in cleaning out the bowels ; but this is absurd. I have known many dis- eases excited or kept up by worms. (vide Therapeut.) There is a peculiar fever attendant on worms , term- ed Febris verminosa. It is a slow irregular remit- tent. The exacerbations are attended with a heavy drowsiness, & the remissions with great vigilance. The head is much affected. There is sometimes de- lirium ; the eyes are wide ; the pupil dilated ; the alae of the nose contract ; the cheeks flushed , & the forehead polished as if it were glazed. But there are two symptoms which are peculiar & dis- tinctive : these are, a strange alteration of the voice, & in some instances a total loss of speech. 1st. Of the Lumbricoides. – worms may be suspected in a child when there is much emacia- tion , & weakness of the bowels, with discharges of 111 slime or mucus. But the reverse of this sometimes happens, & worms are found in the most robust children; but this is very rare. The more uniform symptoms are, intestinal irritation, pains in the belly, alternations of diarrhea & costiveness, great thirst, variable & often voracious appetite , & it is sometimes feeble & depraved , soliciting dirt &c. Be- sides these there is, fetid breath early in the morn- ing, pale complexion with occasional flushes , dis- tention of the belly at night , & sometimes dry cough or slow fever. Treatment of the Lumbricoides. One of the most efficacious remedies here is Calomel in large doses, to be worked off in the morning by castor oil. The drastic purgatives possess in a greater or less de- gree the power of expelling worms. One of the best Anthelmintics is the Spigelia marylandica. It may be given in powder in the dose of gr. V.- X. or in de- coction , but some active purgative should be added. If it be given in powder add to it Calomel , & if in decretion add senna. Spigelia & Senna in equal proportions & a small portion of savin, form a pow- der which is sold as a nostrum in this city & has acquired great repute in the cure of worms. The Jerusalem oak (Chenopodium Anthelm.) is an excel- lent worm medicine. The oil may be given to a child in the dose of 6 or 8 drops. The Pride of 112 India (Melia Azedarach) has of late become a very popular remedy. The most common preparation is a saturated decoction, of which the dose for an adult is a small teacup full every morning for several in succession. Helleborous foetidus has been used as an anthelmintic. In the exhibition of it some caution is necessary. The dose for a child is 4 or 5 grs. All the preceeding remedies are of our country. I shall now mention one which is a native of the W. Indies. It is the bark of the Geoffroea inermis. It is a dangerous medicine. The dose for a child is about a tablespoonfull of the decoction. Of the powder 10 or 15 grs. may be exhibit- ed for 2 or 3 days , & then a brisk purge to be given. Of the Ascarides. These may be known by the itching kept up in the anus, & which is gen- erally aggravated in bed. Sometimes even inflam- mation & swelling about the fundament take place. To these may be added all the signs which denote the presence of other kinds of worms. They often creep out of the rectum & may be seen entangled in the excrementitious discharges. Of the general remedies Calomel combined with some dras- tic purgative is perhaps the best. Aloetic prep- arations have often been serviceable. The Hiera picra, which is a combination of aloes & camella alba , is an excellent remedy. The watery solution 113 might answer as well as the spirituous; but the latter is more commonly used. Injections will be perhaps be of more service than all the preceeding. The best 3i-ii of aloes in a pint of milk; but we may try lime water, olive oil, juice of the rue or tan- sey, wormwood, garlic, an infusion or the smoke of tobacco , camphor tea. The late Dr. Kuhn said he never knew an injection of common salt to fail in bringing away ascarides. After these have been re- peated as often as necessary, it will be right to give an active purgative. Of the Trichuris, not much can be said. It may be managed in the same way as ascarides. Of the Taenia, or tape worm. This is by far the most difficult to remove. It is more generally at- tended by a steady gnawing sensation at the pit of the stomach. Emaciation is said to take place more rapidly than from any other worm. An anomalous symptom of taenia is a sense of extreme tension of the nose. In the treatment of this the mercurial pur- ges are the most efficacious. I have used Calomel, Ethias mineral , Corrosive sublimate. The latter should given in solutions in the dose of 1/4 or 1/6 of a grain. Drastic purgatives have been used in taenia , as Jalap , scammony & above all, gamboge. The Polypodium filix mas. (or male fern) has been much used, but I am disposed to rate it very low. The dose is about 114 3ii. which may be simply washed down with water. Dolichos puriens (cowhage) has also been extolled. I have never employed it. Tin, in filings , or powder, has been given as a remedy for taenia. The dose is 3i-ii mixed with syrup , the purged off. It has been given in doses of 3i. Many other remedies have been suggested at different times as sulphur , blue + white vitriol, of late the Rectified Spts. of tur- pentine,& this last is the only entitled to attention. The dose is 3So-3ii to be taken in the morning when the stomach is empty. My own experience does not enable me to say much of this remedy in taenia : yet of its utility there can be no doubt. If it be em- ployed in small doses, strangury is likely to occur. To prevent the reproduction of worms , the causes that promote their generation & nourishment must be removed. The digestive organs must be restored to their proper degree of vigor, by bitter tonics , prepar- ations of steel, & a due regulation of diet. Enteritis. Or Inflammation of the Bowels. This is nearly similar in every way respect to Gastritis. It is produced by the same causes, puts on similar symptoms,& requires nearly the same treatment. The only dif- ference is the great attention that must be paid to opening the bowels in this disease, being always in 115 a state of constipation. It is been the custom to give enemata in preference to purgatives; but the practice is unfounded , & I always treat it otherwise. Calomel is to be given in divided doses , & worked off by castor oil or epsom salts. But the best remedy in such cases is venesection. It operates here by causing a subduction of inflammation , & conse- quently restores the peristaltic motion. The pulse is not to be our guide. I never saw a case of con- stipation in Enteritis , which did not yield to the loss of 3XX or XXX. of blood. Peritonitis. Or Inflammation of the Peritoneum. The peritone- um is liable to acute as well as chronic inflam- mation. It is of more common occurrence this is gen- erally imagined. It is caused by whatever produ- ces inflammation: mostly by cold , standing in damp places, wearing damp clothes , violent blows , infil- tration of urine or other acrid matter , metastasis from rheumatism or gout. The acute comes on with chills , flushes , & shivering , attended by pains in the limbs & back; the pulse is small , quick & chorded skin sometimes warm; there is a sense of heat, & pain over the whole abdomen , which is much increased by pressure & the bowels are uniformly costive in the com- mencement; there is likewise considerable heat & dryness 116 of the tongue & fauces, & the tongue is some times in- crusted as in typhus fever, but more generally clean & polished. Sometimes the pain is so great that the bed clothes cannot be borne by the patient. The pulse is often from 130 to 140 in a minute. The pa- tient generally lies on his back with his knees drawn up involuntarily, & in that posture continues through- out the disease. Swelling of the abdomen is not an unfrequent symptom. The stomach is very ir- itable, discharging its contents every 10 or 15 minutes. Black matter, similar to the black vomit, is sometimes thrown by hiccup. Sudden cessation of the pain is not an auspicious omen. When this happens gangrene has taken place ; but when it is brought about gradually , & is accompanied with a correspon- ding diminution of the other symptoms , it is favor- able. Cold clammy sweats often break out & termi- nate life. On dissection the peritoneum has the appearance of violent inflammation , which attacks only its internal membrane. Gangrene is common ; but no ulceration takes place : pus is discharged by secretion. Diagnosis. Peritonitis is often confounded with colic & enteritis. The best diagnostic is that there is no inclination to go to stool , however violent the pain. In peritonitis the pain is more acute & is increased by the erect posture : hence the patient generally lies on his back with his knees drawn up. In colic & enteritis 117 evacuations from the bowels mitigate the pain, which is not the case in peritonitis. This disease, like gastritis, sometimes runs through all its stages without any symptoms by which we can distinguish it. Treatment. This was supposed by some to be of the typhus action, & was treated by opium & its ad- juncts : such was the opium of Fordyce. My plan in the early stage is to urge the lancet as far as can pos- sibly be done in conformity with the strength of the patient. The pulse is not to be regarded, being al- ways oppressed. 3XXV or 3XXX are to be taken away at once, & if relief be not afforded, repeat it to the same extent in the course of the day. But simple depletion by the lancet does not always cure peritoni- tis; & when it fails, we must call to its aid topical bleeding by leeches or cups. The tissue of the per- itoneum is serous (used in contradistinction to mucous) & does not carry red blood, unless in disease. Hence 3So. of blood, taken immediately from the membrane , will effect more than a large amount by general bleeding. Blisters do harm when applied too early; & I would always preceed their use by venesection & fomentations to the abdomen : of these the common poultice made of mush is the best. It should always be applied warm; & not in any great quantity. It may be kept on an hour or an hour & a half. Cold applications have been recommended by some of the 118 English writers, & by Dr. Abercrombie of Edingburgh. When the brain is inflamed cold applications are cer- tainly useful ; but who would think of applying cold in Pleurisy? It would certainly be productive of harm : so also would it be in Peritonitis. Evac- uations from the bowels are not to be overlooked ; & for this purpose large enemata are to prefer- ed. Tho’ the pain be not mitigated, inflammation will be reduced. We are next to endeavor to ex- cite perspiration. It sometimes acts like a charm. Dover’s powder, aided by the vapor bath , is to be pre- ferred. The disease not being checked, we now have the sinking stage. Spts : Terebinth : should now be employed to arrest the tendency to gangrene; & the utility of this practice has been fully confirmed in this city. It is given by some internally & applied over the abdomen as a rubefacient. I cannot recom- mend this practice. The most common termina- tion of this disease is in gangrene. In imperfect cures there are effusions , constituting ascites ; & it sometimes assumes a Chronic form. Of Chronic Peritonitis. This was first no- ticed by a Mr. Sutton. It makes its appearance gradually : sometimes by weeks , & even months. (vide Pemberton on the viscera.). All that is felt in the begin- ing is some pain the abdomen , distinct from flat- ulency or any other affection of the bowels. The Colic , Diarrhoea Dysentry or Peritonitis is induced according as the remote cause (cold) affects the mus- cular , mucous or peritoneal coat ; the two latter are concerned in dysentery. 119 pulse is accelerated ; the tongue furred in the morn- ing ; there is thirst , tho’ no apparent fever ; languor ; great distress , & the disease is sometimes changed into acute or active inflammation. Always when acute inflammation is preceeded by chronic , it is much worse. The vessels have here taken on a wrong action. Morgagni says that the pleura has been des- troyed by ulceration from chronic inflammation , when there have been no symptoms by which disease could be known. The same is said of the peritoneum. The French considers this an incurable disease ; but in the early stage something may be done by venesection , blis- ters , purging & the antiphlogistic treatment. Then small doses of calomel may be given , & occasionally diaphoretics. The mercury is given rather as an altera- tive than as a salivary. –(vide French authors ). Colic. Colic may be defined , a painful distinction of the lower regions of the belly , with a twisting sen- sation around the navel , accompanied by vomiting & obstruction of the bowels. The several forms may be reduced under the heads of Flatulent colic , Bil- ious colic & Colica Pictonum. – 1st of Flatulent Colic. This may be known by the wind or flatus which getting the feet wet ipecacuanha (1826-7) tr. of clover, cinnamon or Rx. Ol. Terebinth : 3i Ol. Menthe . . 3i. m a teaspoonful every half hour or so. Colic often mistaken for hernia -examine. 120 attends it. It may be caused by indigestible vegetable food, as cabbage, by coldX, constipation, or by in- digestion. When from the latter it is attended by nau- sea & vomiting. In this case we must relieve the stomach from its offensive contents by warm water, or camomile tea, & when these will not answer , by a small dose of tartar emetic. We are next to calm irritation by Hoffman Anodyne, Ether, Tr: Cardamon: Ginger , or Spts. of turpentine , or Laudanum , or Spts. of turpentine with oil of mint: about a teaspoonfull of the former , with 5 or 10 g# of the latter. When it is produced by cold, the application of warmth is some- times necessary to its relief, as hot bricks, or bags with hot salt, sand, ashes, or oats, to the feet. When the pain is removed we must attend to the bowels. Great difficulty often attends the management of this disease. Colic sometimes attacks children within the month. It is not a very alarming circumstance. It is perhaps owing to overfeeding them. It is to be treated by carminatives & if very violent we may give laudanum. Common sort is an excellent remedy. The bowels should be kept open. The Peruvian bark has often proved serviceable: a tablespoonfull of the infusion 2 or 3 times a day. Bilious Colic. This is a disease common to our climate , & 121 particularly to the Southern states. It is by some supposed to be a form of bilious fever. The causes are excessive indulgence in eating & drinking , & all those which produce the autumnal fever. Symptoms. The pulse is full , strong & soft but not chorded nor quick; the bowels are costive; the skin is generally soft & tinged yellow; the eyes are of the same colour; there is sometimes total blindness : by giving drastic purges & restoring the disease to the intestines , the eyes are relieved. The pain is very great about the umbilicus , & there is a violent vom- iting of bile. Treatment. As a highly inflammatory case , venesection is here demanded; but it must not be sparingly employed. Take 3XXV. or XXX. at once. We are next to open the bowels, which are in general very costive in this disease; but the stomach is often too irritable to use cathartics & we must resort to the rectum. From 100 to 150 g# of laudanum as an enema will generally relieve the symptoms & pave the way for other remedies. The warm bath should be used as an auxiliary. These failing detract blood co- piously again & use enemata. A strong infusion of senna thrown up the rectum has often succeeded when all other remedies have failed, or the terebin- thinate injection , made thus: take , oil of turpentine 3So. beat it up with the yolks of a couple of When the bile is discharged by the mouth & rectum it is a favorable Symptom. 122 eggs, & then add a pint of water. An injection of very cold water or ice water has done much good. Tobacco injections have been tried , but they are very distressing to the patient. A suppository is to be preferred, or the fumes : the latter is most active. The decoction of tobacco , 3So. to a pint of water, has also been used. A decoction of Jalap is excellent. Warm water will answer very well. 20 , 30 or 40 grs. of tartar emetic dissolved in a pint of water & thrown into the rectum, has been attended with great advantage. I have relieved constipation with tepid water alone, when the most powerful remedies had fail. Lax- atives may be used to overcome spasm. Castor oil, magnesia & epsom salts are among the best. Combin- ations of opium & Calomel I have found to answer still better: 2 or 3 grs. of the one , with 12 or 15 grs. of the other, to be repeated every 3 or 4 hours. An excellent purge is composed of about 3iS of Spts. : Terebinth : 3i of Castor oil. For promptitude of action , this is one of the best: it generally produces its effects in about an hour after it is taken. A common cath- eter attached to a bladder , may be introduced even beyond the value of the colon & will certainly relieve constipation when all medicines have failed. A common candle will often answer the same purpose. Bleeding ad deliquium anime has been practiced. Blisters constitute an important part of the treat- 123 ment of this disease. After the other remedies have failed, a blister large enough to cover the whole abdomen, will often afford great relief , even when life is in the utmost danger. When the patient becomes delirious with a cold clammy skin, gan- grene may be apprehended. In such cases blis- ters are of no service whatever. Spts. of turpentine is the best remedy. Colica Pictonum. This is known in England by the name of Devonshire colic, & was formerly a common disease in this city. It is induced by various causes, as acid drinks , sour cider, lemonade , unripe fruit, cold , & by accumulations of acrid bile , or a disorder of the alimentary canal; but lead in some shape taken in- to the stomach is the most cause. The symptoms, when caused by lead, are a twisting sen- sation about the navel ; nausea ; a frequent but ineffectual desire to go to stool; the pulse is very small, quick & chorded. After a short time the pain increases in the abdomen & a vomiting of dark porraceous bile takes place. As it advances all these symptoms are increased; there are irregular contrac- tions of the abdomen muscles, & symptoms of paralysis appear, which commences generally in the muscles of the arm, the deltoid &c. 124 Treatment. This is nearly the same as in Bilious colic. Venesection is called for in the commencement of the disease , notwithstanding the state of the pulse. It must be proportioned to the urgency of the disease & is more demanded than in bilious colic. The bow- els may then be opened by castor oil ; but the opium & calomel , as before mentioned, is better. The castor oil is much used in the W. Indies where the disease is very prevalent. The tobacco may here be found useful. The fumes are perhaps safest. Mr. Earl used it in the form of a suppository. Cold water , to the extremities or abdomen , or injected into the bowels , is said to be useful. Blisters to the ab- domen are of great utility. Alum has been recom- mended by Mosely & Percival in the dose of 10 or 15 grs. every 5 or 6 hours. The vitriolic solution of Mosely has been used : a tablespoonfull every 4 or 5 hours. The volatile tinct: of Guaiacum may be of service ; but my practice is to resort to mercury to salivation. This as soon as the mouth is affec- ted, will always remove all symptoms of col- ica pictonum & prevents palsy. It seems to be a counteragent to all the ill effects resulting from lead, & constitutes the only effectual method of removing this species of palsy. To prevent a recurrence, an at- tendance to diet is necessary : not much vegetable matter is to be used. Avoid cold, & attend to the bowels. Chol. morbus often caused by eating shell fish, as Lobster &c. After eating such articles, a glass of brandy & water , half & half , will have a good effect. [Dr. Potter) Opium is a specific in this disease. Laudanum is the best form of using it. Not less than 100 drops should be taken at a time : - generally much more. – [Dr. P.] 125 Cholera Morbus. Copius discharges of bilious matter , both up & down, constant Cholera morbus. It generally pre- vails in warm climates , & in the same season. It seems to partake of the nature of fever thrown upon the alimentary canal. It is generally caused by indigestible matter taken into the stomach ; anger ; exposure to cold or night air , or cold feet. It comes on usually with pain , distention & flatulency. As it advances, the pulse which in the commencement was weak, is now more so. There is great restlessness , pallid sur- face, cold extremities & spasms of the abdomen mus- cles. It may be distinguished from colic by the absence of constipation, & the evacuations being pure bile : from Dysentery & Diarrhoea , by the discharges being chiefly bile & not mixed with blood. Prognosis. Restoration of temperature, some moisture of the surface, sleep undisturbed & the discharge dim- inished are favorable symptoms. This disease is primarily a gastric affection. The first discharges are the contents of the stomach : the liver is then stimulated to increase efforts & biliary discharges take place. Cholera often runs its course in 24 hours , & some times in half that period. Treatment. We occasionally meet with cases of Cholera , in which irritation is to be calmed before 126 evacuating remedies are administered : in such cases opium checks the disease at once. When the stomach is too irritable it may be given in the form of an enema. In general, however, we must first rid the stomach of its contents by diluent drinks, as camomile tea, or by emetics, which are preferable. 20 grs. of ipecac: & warm drinks are to be given: this fre- uently releases the spasms. These failing we must next calm irritation with venesection. This is to be reg- ulated by the condition of the system : the pulse is not to be the only guide. In the early stage of all diseases attended by much pain, we find the pulse low, & evacuating remedies are necessary. But the lancet must be used with great caution. We must draw away the blood very slowly, watching its effects & allowing time for the recuperative efforts of the system to restore itself. In doubtful cases of cholera the lancet should be preceeded by the warm bath & stimulating embrocations , & this never fails to rouse the system from its torpor. The clove bag applied to the epigastrium has done good. When this cannot be had or does not prove affectional , we may use cayenne pepper & brandy , to be rubbed all over the body. Opium in the shape of injection, every 3 or 4 hours , has been used. If we must give it by the stomach, it should be given in a solid state. Warm fomentations to the stomach , lime water and 127 milk , or the alkaline preparations, to check vom- iting may be tried. Vessicating remedies should be applied to the extremities & stomach. Nitric acid 2 parts & water 1 part, to be rubbed , by a feather , on the epigastrium. In two or 3 minutes the surface becomes raw. It is to be dressed as a blister. Saccarum Saturni, a few grains, (3) is said to check the vomiting of bile. Calomel in very small doses ¼ or 1/5 grs. repeated at short intervals , will calm irritation & arrest gangrene. Spirits of tur- pentine is useful in the same cases. Cholera morbus is a complaint very liable to a recurrence. To prevent this all the exciting causes should be avoided, such as night air , & the sun, excess in eating or drinking &c. , cold to the extremities. The stomach & bowels should be should be attended to. The bitter tonics may be given; of which Quassia & Colombo, with a small portion of elixir vitriol , are the best. Flannel should be worn. An al- teration course of mercury will be of service. Cholera morbus frequently exists as an epidem- ic: some times preceeding & sometimes preceeded by Bil- ious fever; & it is often the immediate precursor of yellow fever. In India a fatal disease of this nature raged, known by the name of “mort de chien”. In Hindostan 3.500.000 fell victim to cholera morbus. (vide med. & Phys. Journal). It A red or pink areola around the margin of the Stools is a fatal Symptom. Mortification had then commenced. 128 still prevails to a great extent throughout India. Cholera Infantum. This is a complaint almost peculiar to the cli- mate of the Ale. States , & is very mortal in its effects. Children are most liable to it between 12 & 18 months of age , or during the second summer ; but they are some- times attacked within a month. It seldom appears in Philad. until June or July. It sometimes begins in Diarrhea , but more frequently comes on with a violent vomiting & purging , with some spasmodic uneasiness. Worms are frequently discharged. The pulse is quick, small & irritated , & for the most part, weak. Fever of the remittent kind attends, & the exacerbations are greatest in the evening. Swelling of the abdomen frequent- ly occurs. The eyes denote a cerebral affection & are either fierce or languid , & when the patient sleeps they are about half closed. The extremities are cold while other parts of the body are hot. The stools are sometimes thin & watery : at other times the reverse. The smell is that of sourness or putridity : tho’ they are some times inordorous. Sometimes vomiting continues without pur- ging & vice versa. The disease is sometimes fatal in a few days. Emaciation takes place very rapidly, & the facies hippocratica appears ; but even under these circumstances life may continue for weeks & recovery at length take place. The mind often becomes Dr. Potter of Baltimore says heat is the cause. To prevent the disease children should be kept from the sun, cold bath used daily; flannel next to the skin, & pump water avoided. Children should not be weaned except between the months of November and May. 129 affected & the mouth sore : when this latter symptom makes its appearance , few children recover. The dis- ease sometimes assumes a dysentery state after 4 or 5 days. Causes. It is often occasioned by dentition , worms , & many other circumstances produce it , as eating too much fruit , changes in the weather &c. The exciting causes are sometimes changes in diet & clothing. Dissections inform us of the seat of this disease. The brain exhibits no morbid appearances in recent cases , but in protracted forms of the disease , effusions of coagulable lymph are found. Inflammation is traced throughout the alimentary canal ; but principally in the mucus membrane. A large dark livid spot is seen on the surface of the stomach & another at the duodenum. The peritoneum sometimes exhibits similar appearances : tho’ not to the same extent. The large intestines are seldom inflamed. The liver is some- times very much enlarged , so as to occupy 2/5 of the cavity of the abdomen ; but there is very little de- rangement in its structure : the swelling being in- duced by torpor of the circulation in the vena por- tarum. The gall bladder is generally distended. Cholera infantum is analogous to the acute affec- tions of the bowels in advanced life. It is a gastric affection : the impression, first made upon the stom- ach, is extended to the liver. Treatment. As the disease generally commences 130 with a disordered state of the alimentary canal , our treatment should be commenced with evacua- tions from the stomach & bowels. Purgatives are gen- erally preferred; especially Castor oil to which a little laudanum should be added. The irritation , however, often is so great as not to have such rem- edies: in such cases it must be allayed by anodyne injections , or lime water & milk , fomentations , alka- line mixtures , or strong coffee, after which purgatives may be used. A combination of Calomel & Opium is excellent , except in very young children. From the smallest of its bulk it is readily exhibited , & while the one evacuates the bowels , the other relieves the spasms. For a child two years old the folling is the proportion. Rx. Calomel : grs. v – vi. Opii. Grs. 1/5 or 1/8. (1/4 in cases of emergency). There is sometimes a great degree of gastric distress , pain at the umbil- icus , febrile heat on the surface , & a small , frequent , & irritated pulse. In this case the best practice is to poke gently with ipecac. Emetics should not be used when there is great debility. In all bowel affections attended with fever , venesection is demand- ed. Cases of this complaint are of frequent oc- currence in which the lancet is most fatally neglect- ted. We must bear in mind the insidious charac- ter of the disease. It is my practice bleed several times in the progress of cholera infantum ; but it The discharge from the bowels is sometimes principally or wholly of serum , this indicates great irritation , & in whatever disease occurring the treatment is the same , viz. Calomel & Opium , to be followed in 6 or 8 hours by a dose of Ol. ricini. The discharges after this will be at first tarry & then of more pure bile. 131 must be regulated by a sound & discriminating judgement. As soon as the bowels are ready mercu- rial purges may be used. One or two active ones are generally sufficient. In this as in some other bowel complaints (in all the profluvia) purging is sometimes urged to too great an extent. My plan is to do away irritation & at the same time the cause of the complaints: for which purpose I generally use the following prescription. Rx. Opii . . . . . grs. i. Calomel : . . . grs. ii. Ipecac : . . . . .grs. iii. m. div. in pulv. viii : one to be taken every 2 or 3 hours. – Combinations of opium & calomel were originally recommended by Dr. Miller of New York , 25 or 30 years ago. If the pain be violent I resort to anodyne injections. We must next attend to those means which make a direct impression on the surface. The warm bath is here the best remedy ; distinct in some measure from its diaphoretic property. The effects of the bath are not very lasting , & it is necessary to repeat it daily & sometimes twice a day. To render it more effect- ual cayenne pepper may be added , or brandy or the bitter herbs. After coming out of the bath frictions must be used over the whole of the body. Blisters are not to be overlooked : they often do good by ex- citing perspiration, even after the usual diapho- retics have failed. They may be applied to the stom- 132 ach or extremities. Irritating embrocations may also be used to the surface. The disease sometimes puts on the appearance of diarrhea or lienling. The remedies here are the alkalies on the cretacious mixture. Thus .. Rx, Cretae. ppt : . . . . ℥or ii. Tr : Thebaie : . . g# XV. Sac : Alb : . . . . . .℥ i. Aquae . . . . . . . . .℥ iii. m Or the following. Rx. Sal : Tartar : . . ℥ i. Tr. Thebaie : . . .g# XV. Sac : Alb : . . . . . ℥ i. Aquae . . . . . . . . ℥ iii. m. The dose to be influenced by the age of the child. Rheubarb may be used : either in the form of Spiced Rheubarb, (vide Therap:) or in the following manner. Rx. P. Rhei . . . grs X. Magnesiae . . grs. XXX. Tr : Thebaie : .g# XV. Sem : Anis : . . gr. iii – iv. Sac : Alb : . . . .℥ i. Aquae . . . ℥ iii. m When there is tormena & tenesmus , the Oleaginous made with lime water is useful : thus. Rx. Ol. Ricini. ℥ i. Sac: Alb: ℥ or ʒi. Album ovi. Aquae Caleis. ℥V. Tr: Thebaie: g# XX. m. The dose to be determined by the age of the child. 133 If this do not afford relief we must resort to ano- dyne injections , as flaxseed tea or barley water. When the disease is decidedly diarrhoea , we must use astrigents. Of the mineral astringents alum is the best , in the dose of 1 , 2 or 3 grs. with about 1/8 grs of opium. It is sometimes combined with sac: saturni. Chalk, with the tinct. of Kins, has done good. Colom- bo has been used. Of the chalybeate preparations the following is the best. Rx. Sal: Martis . . .grs ii. Acid: Sulph : g# X. Sac: Alb : . . .℥i. Aquae . . . . . .℥i. m The dose is a teaspoonful 3, 4 or 5 times in 24 hours. The Logwood has been recommended by some prac- titioners of this city ; especially by Dr. Physick. The best of all I have tried is a strong infusion of either the blackberry or dewberry root : especially the latter. An infusion of the pomegranate has been used. When all these remedies fail to check the diarrhoea we must resort again to small doses of calomel : ¼ , 1/6 or 1/8 grs. with a little opium , 2 or 3 times a day. The disease is now kept up by a disordered liver. While we are using the calomel we may sustain the child by tonics. The flannel roller , applied from the hips to the arm pits , may be of service. In all stages of the complaint much advantage may be 134 gained by a removal into the country. When we cannot command a country residence, the child may be rode out to the country even an hour or 2, or be taken over the river 2 or 3 times a day. To pre- vent the recurrence of the disease, there are several circumstances to be attended to. viz. 1. Never permit the child to be weaned during the first year. No food is better than the milk of the mother. Weaning always predisposes to this complaint. 2. The daily use of the cold bath. The morning is the best time for using it. It operates by reverse sym- pathy , as well as by its cleansing effect. 3. Direct the weaning of flannel next the skin , and worsted stocking. 4. Be careful of the Diet of the child , an excess of all fruit is to be avoided. The proper diet is milk or farinaceous matter. The biscuit food is the best. When there is much intestinal weaknesses , the following may be used : Take of flour, a double- handful – put it in linen – tie it as tight as possible – boil it for 3 or 4 hours until it is hard : it is then to be grated , & milk thickened with it : a little cinnamon may sometimes be added. In the advanced stage arrow root is an excel- lent article of diet. It is prepared thus. – About a tablespoonfull of arrow root is to be mixed with 2 or 3 , of cold water : this is to be added 135 gradually to a pint of boiling water. A little loaf sugar may be added, to sweeten it. Lago is prepared in the same manner. Wine, spices, or lemon acid may sometimes be added. In the prep- paration of arrow root milk is often substituted for the water. After a few months a little animal food may be allowed. Very ripe fruit is sometimes serviceable: especially the peach. A piece of fat ham may be allowed when there is nothing but the diarrhoea. 5. During dentition the teeth should be examined, & if any inflammation or swelling exist, the gums should be lanced. As an objection to this it is said by some that a cicatrix is formed; which by its induration prevents the tooth from protruding. This is not the case: a cicatrix never forms in the gums. The proper mode of cutting the gum is to cut on each side, as when about to extract a tooth. During hot weather dentition always predisposes to chol- era infantum. When consulted on the best mode of preventing this disease, always recommend a removal to the country. It has gradually diminish- ed in this city , for the last three years. Dysentery. Cullen defines this, a contagious fever in which the patient has bloody stools accompanied with much Dysentery sometimes caused by eating grass fed cattle, putrid meat, - not by marsh mismata. Negroes can live longer than whites without oxygen. Saddingtons cure for the Dysentery in composed of the cerated glass of antimony, opium & the blue pill, mass. – [Dr. Potter.] 186 griping & followed by a tenesmus. According to Lyd- enham it comes on with chilliness succeeded by flushes of heat & frequency of pulse. To these symptoms follow severe griping & disposition to go to stool. Nausea, vom- iting & uneasiness of the bowels generally attend. Every evacuation is attended with tormena, sometimes prolap- sus ani, with which there is an augmentation of the tormena & tenesmus. The matter discharged by stool is generally bloody; but sometimes consists only of mucus: it is then called Dysenteria alba or mucosa. There is often intermixed with the discharge, small portions of natural faeces in the shape of indurated balls , called seybala: the voiding of which is always pro- ductive of temporary relief. There is occasionally a dis- charge of a membrane substance, which is a portion of the bowel sloughed off. The discharges are, in some cases, pure blood: this not an alarming symp- tom, but denotes violent inflammation. There is gen- erally increased heat; great thirst & restlessness; (this is the crisis), the pulse is never very full. We next have a rapid depression of strength, sweat, & dis- charges of a very acrid matter, like the washings of meat. – The seat of dysentery is in the large intestines. Prognosis. Remission of the fever; the surface be- coming moisture & relaxed; the stool becoming natu- ral, & tenesmus ceasing or being relieved, are favorable. Causes. – Dysentery is supposed by some to be 137 Altogether contagious; but it only so when the fever which attends it assumes in its progress the typhus condition, or is originally so. It also proves contagious in crowded & ill ventilated places, as hospitals, camps &c. It is also caused by the ordinary sour- ers of autumnal fever, or by acrid matters taken into the stomach. Moisture succeeding dry weath- er often produces it, & it often prevails as an epi- demic. It is for the most part a disease of the country, & elevated situations contiguous to low, flat countries. It rarely appears in the center of large cities, but mostly in the suburbs. During the fall dysentery & autumnal fever prevail at the same time; the former in elevated situations, the latter in low lands contiguous. Dysentery sometimes assumes the form of intermittent, remittent or continued fever. When it originates from marsh effluvia its primary seat is in the stomach: it is afterwards extended to the large intestines which it principally affects. The colon is much contracted. When the stomach & small intestines are affected, the pain is acute. Treatment. As dysentery usually presents itself, we must reduce the inflammation & spasm which at- tend it, evacuate the alimentary canal &c. It is the custom in Europe to begin the cure with emetics. They do good in those cases in which the stomach is loaded with bile or focelu matter. In ordinary cases we After suff. evacuation the Sac. Saturni will be found a most important remedy. It relieves termina & tenesmus, diminutes the fever, & adds to the general comfort of the patient. 138 must begin with the lancet. There is always a degree of spasmodic constriction connected with an inflamed state of the bowels; & to overcome this venesection is unrivalled. ℥XXV or XXX. of blood are to be taken away in a robust patient. In the first stage of dysentery it is best to detract blood largely. ℥X-Xii. will do no good. After this, if the disease be not ar- rested, we must purge the bowels of their vitiated con- tents. For this purpose Castor oil is generally used; & to be of any service several ounces should be given in the course of the day: for in dysentery oil runs thro’ the bowels very rapidly & very little altered. Mercu- rial purges are infinitely better adapted: especially in the southern states. Calomel may be used either alone or in conjunction with rheubarb. Epsom or Chel- tenham salts may be used when the bowels have been purged by mercurials. Opium may now be resorted to. It should be used much earlier than is commonly done. It should be so combined as to produces a de- termination to the surface; but prior to any attempt to excite perspiration, all the inflammatory symptoms should be reduced by the depleting remedies. The practice of sweating in this disease originates with Dr. Akenside. (vide Therap: vol 1. P. 319.) Richtic and some others supposed dysentery to be a catarrhal or rheumatic affection of the large intestines, & that the leading indication is to excite perspiration. 139 The best means of effecting this is by the following Combination . Rx. Opii . . . . . . grs iv. Calomel : . .gs. XVi. Ipecac : . . grs. viii. m. fo. pill, viii. one to be taken every 2, 3 or 4 hours. This will tend to relax the surface & at the same open the bowels. Dovers’ powder should be used when copious perspiration is demanded; but it should never be re- sorted in preference to the former, when evacuations from the bowels are necessary, or the matter discharg’d is vitiated or unnatural. I have prescribe Ipecac: with advantage when the pain is violent & the desire to go to stool frequent & ineffectual. Some practitioners have thought it better adapted to those cases where there are great discharges of blood amounting almost to hemorrhage from the bowels. (vide Therap: vol 1. P. 107). Ipecac: has also been used in the shape of a glyster by Dr. Clarke; but now successfully by Mr. Playfair, in the dose of ℥ss - ʒi with from XXX – ]X g# of laudanum. (vide Therap.). Much has been said of the antinomial preparations; but I don’t think them at all equal to the ipecac: Cases of dysentery may perhaps occur in which the antimony may be pre- ferable. Sir G. Baker & I. Pringle were in favor of it. The latter used the cerated glass of antimony. As aiding in this case the application of warmth is of service, as fomentations to the abdomen. The 140 warm bath often proves beneficial; but on account of its inconvenience is not generally employed. It should be used, however, in cases of emergency. In children it is of more service & attended with less trouble. The vapor bath, in adults, will answer best, if profuse perspiration be required. A bandage or roller of flannel to the body has been tried. I have had no experience with it in acute cases of dysentery; but was long ago in the habit of using it in diarrhea & chronic dysentery. Blisters constitute an important part of the treatment. They give less pain & are of more service when applied to the abdomen. They are to be used only after bleeding & purging have been pre- mised. It is hardly necessary to resort to salivation. Cleghorn used 6 or 8 grs. of Calomel with 1 gr. of opium. He also urged it to salivation. In this section of the country it is rarely demanded; but when excited it is beneficial. The mercurial treatment of dysentery is much more called for in warm climates, where the liver is generally affected. In the sinking state of the disease, the spts: terebinth, has of late been used in this city. It is given either alone or with opium & vol. alkali: a teaspoonfull of turpentine to grs. V or Vi of vol: alk: & ½ grs. opium, every hour & sometimes oftener. Among the poorer classes dysentery frequently puts on the Typhus type: in the form depletion cannot be urged to 141. any great extent. The mercurial course is here attended with great advantage. One or two local affections are generally to be met with throughout the complaint; but more common- ly towards the close, the tormena & tenesmus are very troublesome. When attended with any foulness of the mouth the Oleaginous mixture may be given with utility. – thus . .Rx. Ol: Ricini . . . . . . . . .. . . ℥i. Sac: Alb: . . . . . . . . . . . . ʒi. Tr: Theabaic: . . . . . . .g#. v. lx. Gum: Arab: . . . . . . . . . ʒii. Aq: Cinnam: v. Menth: ℥ii. m. s.a. The dose is a tablespoonful to be given occasionally. Should this disagree with the patient the following will answer : Rx. Ol: Ricini . . . . . . .℥?i. Sac: Alb: . . . . . . ʒi. Album ovi. . Bene triturentur. Adde gradation Aq: Calcis . . . . . ʒii. Tr. Thebaic. g# xl – lx. The cutaceous julep sometimes answers exceedingly well. A tablespoonful of common salt in 3 or 4 ounces of vinegar (a tablespooonfull every hour or 2) will sometimes relieve the most distressing tormena. For the same purpose the sac: saturni has been used with advantage: about grs. ii – iii with ½ grs. of opium , repeated occasionally. Opium has been used by the rectum both in the form of injection and pill. 142 Of all the means that have been tried, an injection of ½ a pint of melted butter, every hour or 2, is among the best. When butter cannot be had lard will answer, provided there be no salt in it. Animal oils are much milder in their effects than vegetable. With respect to Diet, it is proper to select such articles as are least irritating & offensive, as demulcent drinks, barley or rice water, mucilage of gum arabic, slippery elm, tapioca, arrow root, sage &c. Dysentery sometimes wears the Typhus con- dition & requires a different plan of treatment. The same course is to be pursued as in other low states of disease. After emetics & evacuation from the bowels, the cordial & stimulating diaphoretics, as opium, vol:, wine whey, are to be used. Blisters have been applied. Mercury, to salivation, in the case ought never to be neglected; & the patient must be sustained by the cordial & dif- fusible stimulants. Nitric acid has been used; & in the advance stage of the complaint much advantage may be derived from it. Dysentery often puts on the type of Intermit- tent fever: especially among the poor. Claghorn des- cribes such a disease in his work on the diseases of Minorca. For this it is customary to give the bark in the apyrexia. No article is more offensive to 143. irritable & inflamed bowels. My plan of proceeding is to disregard the fever until the bowel affection is removed, & then give the bark. Charcoal is well adapted to this state of the disease. Of Chronic Dysentery. This is to a certain extent a very different kind of affection. There is here a considerable tenderness of the bowels, which are excited to action frequently, & by the slightest causes producing small stools, mostly consisting of mucus, & very offensive. Every evacuation is at- tended with more or less griping, & which often becomes exceedingly painful. Little apetite exists, & what food is taken, is not digested. The skin is dry & parched; the complexion sallow; & the eyes sunk, with a shriveled & meager expression of face. Evidently there is here a confinement of the blood to the great vessels, & on this account the determi- nation to the surface is considerably diminished. The treatment here is small & repeated bleed- ings, aided by Dover’s powder & all those means which are necessary to promote, & keep up a gentle relaxation of the surface, & a moderate degree of perspiration. Perhaps the flannel bandage may be usefully applied. When associated with complaints of the liver, calomel in small doses may be united with the medicines just mentioned. Nitric acid has been used in the same cases. 144. The nitro–muriatic is perhaps preferable. Equal portions of each acid are used by us. ℥i. of the mixture is to be added to a gallon of water, of which ʒi-ii. may be taken in the 24 hours: begining, however, with smallest doses. Diarrhoea. Diarrhoea is defined a morbid increase of the peristaltic motion of the bowels. The most common division of this ^ disease is into Idiopathic & Symptomatic: the practice in both cases is the same. A better division is into Acute & Chronic; but even here in practice we will have to make other distinctions. The causes are of two kinds: those which act immediate- ly, & those which act remotely. Of the first are in— digestible matter taken into the stomach, checked & per- spiration, & all the causes of bowel affections in general. But it is also occasioned by deranged state of the stomach or liver, or of the bowels themselves. It is also produced by vehement passions or emotions. The symptoms are those of Dysentery in a much milder degree. The stools are some times thin & watery, at other times thick & tenacious, & are often clay or ash coloured. Diagnosis. It is often confounded with dysentery in certain forms; but diarrhea is not not conta- gious; it is not attended with fever & inflammation; Small doses of Rheubarb in diarrhea. [Dr. Potter] Dr. Potter infallible in chronic diarrhea. – Rx. Rhei torrefact : ʒii Tr. Opii . . . g#XXX. Tr. Cinnam : q.s. Aquae . . . . . . . ℥iv. M Salivation, in the gouty diarrhea of people frees them from the disease for 10 years. [Dr. P.] 145 the discharges are not bloody, & there is an absence of tormena & tenesmus. It is nevertheless difficult to distinguish between mild dysentery & a severe case of diarrhea. One disease frequently runs into the other. The appearances on dissection in acute cases are the same as in dysentery, but in chronic diarrhea we often find the bowels in a state of chronic inflammation, with induration of the small glands of the intestines, &c. Treatment. Two things are to be attended to. 1. To remove the morbid cause. 2. To check the inordinate intestinal discharge; either by allaying irritation, or imparting tone to the bowels. An e- metic may be given in the beginning; but if this be not required, as dose of rheubarb will answer. Venesection is called for when there is fever. When it proceeds from checked perspiration, diaphor- etics, of which opium is the basis, are to be used. The warm bath is useful in the same cases, & some of the combinations of Ipecac: & Spts: mindireri. This species of diarrhea is of little importance. Of Chronic Diarrhoea. This is most dif- ficult in its cure, & is always attended with some disorder of the chylopoietic viscera. It is attended with a dry skin, furred tongue, small, chorded pulse, & more or less fever. Treatment. If the pulse be tense or chorded, 146 Small bleedings are demanded in the commencement, to be repeated every 2 or 3 days. While we are bleeding we may also give an emetic of ipecac: once or twice a week: it operates by changing the condition of the whole alimentary canal. After this we may use Rheubarb, Ipecac: & Opium com- bined: thus, Rx. Pulo: Rhei . . . . grs XXX. Ipecac:. . . . . . . grs X. Opii . . . . . . . . .grs iv – v. m. H. mass. div. in pill X. one of which is to be taken every hour or two; & direct grs X of Pulo: Doveri to be taken on going to bed. Some mild beverage is to used at the same time. A bath of tanner’s bark has been of service. The patient after entering his bed is to be rubbed with a flesh brush until a universal glow is excited. Aloes have been used. This is tonic to the bowels, & may be so prescribed as to prove mod- erately laxative: about grs V. with g. ss. of opium, to be repeated 4 or 5 times in 24 hours. Sometimes we may add an aromatic with advantage. An addition of a small portion of ipecac: may also be of service. The vitriolic solution has been much recommended. I have several times been pleased with its effects. It was a favorite remedy of the late Dr. Barton. Mercury is of indispensable utility in this species of diarrhoea. The blue pill is the best form 147 in which it can be used. It is not always ne- cessary to urge it to a salivation. The good effects are owing to its changing the morbid action, as when the liver or pancreas is affected. Under the same circumstances the nitro – muriatic acid is of service. Vessicating applications are of great utility in these cases. They are of more benefit when ap- plied to the ankles & wrists alternately; on the prin- ciple of revulsion. There is a species of Diarrhoea which may be called a Gleet of the Bowels. For this the best remedy is Bals. Copaiva, or Common rosin, in the dose of grs X. 3, 4 or 5 times a day. There is another species of Diarrhoea which appear to depend upon a relaxation or debility of the bowels, & is generally met with among emaciated or infirm people. This is to be treated by tonics & astringents, as alum with a little opium; or galls in brandy burnt, or in the following manner: Rx. Gallar : Infus: . . . . . . . ℥iv. Cret: Ppt: . . . . . . . . . . ʒii. Tr: Thebaic: . . . . . . . . ʒi. m. The dose is a tablespoonful every hour or two. Kino, in the following manner is useful in every form of diarrhoea: Rx. Tr: Kino: Cret: ppt: aa. ʒiv. Tr: Thebaic: ʒi. Aq: Pont: n. Cinn :. ℥iv. m. Of this 148. a tablespoonful may be taken every 2 or 3 hours. The roots of the Black berry & Dew berry, are use- ful in all excessive purging, from whatever cause proceeding, especially in the diarrhoea of very old people, or when it occurs at the close of the diseases. A strong decoction is to be used, in the dose of wine- glassfull every 2 or 3 hours. The Geranium mac- ulatum (the root boil’d in milk), & the log wood (a tablespoonfull of the decoction) have been given with benefit. Clove tea (℥i of cloves to a pint of water) in the dose of a spoonfull , is among the best. The mineral acids are of great use in old or protracted diarrhoea. Both the sulphuric & nitric have been used; but the nitric is preferable: in the dose of X or XV g#, given in combination with laudanum. The quantity is to be increased until it amounts to ℥i. or more in the 24 hours. – Mercury has succeeded when every thing else has failed: ½ grs of Calomel 2 or 3 times a day. It is more particularly useful in idiopathic diarrhoea, in small doses. Many cases of diarrhoea originate from dys- pesia, & all the rules of diet mentioned under that disease should here be part in force; or as men- tioned under Cholera infantum; but it is sometimes necessary that the more astringent articles should be used. The drink in choleric diarrhoea may be weak brandy & water. The clothing should 149 be warm. The flesh brush, rendered more irri- tating by salt, is important. The bath of nitro- muriatic acid has been used by Scott. The feet should always be kept warm. The chalybeate preparations, & vegetable bitters of which colombo is to be preferred, are sometimes serviceable. Many cases of diarrhoea have been relieved by the flan- nel roller. Regular exercise particularly on horse- back is very important; & as a last resort we recommend a sea voyage to some warm climate. Constipation. By Constipation is meant a retention of the excrementitious discharges, which become indura- ted & occasion a great deal of difficulty in their evacuation. While a large majority of mankind require, for the preservation of health, a daily evac- uation, there are some who are said to have passed weeks, months & even years with an opening. Many cases of this kind are recorded in Haller: Physiol- ogy. The discharge in such cases is performed by some vicarious function, as perspiration &c. But still this habit of the body is generally wholly incom- patible with health, & is marked by headache, vertigo, nausea, foetid breath, offensive excretions, & many other symptoms of a highly unpleasant, & even disgusting nature. Numerous causes produce 150 this condition of the bowels; but they may, perhaps, be arranged under the two heads of irritatblity of the intestines, & deficiency of bile or vitiation of its properties. Treatment. When there is a want of irritabil- ity in the intestines, we may use stimulants & then the mercurial purges, as Calomel. Sulphur is also useful in this case. When the bile is vitiat’d, it will be right to awaken the action of the liver by mercurial purges. If this do not succeed, a slight salivation may be produced. 5 grs of the Blue pill to be taken every other night, & worked off by some saline laxative. The bowels are then to be kept open by the mild laxatives. A combination of magnesia & sulphur is excellent. Rheubarb has been used in these cases; but it is said to leave the bowels in a costive state. This may, in part, be done away by adding aloes or castile soap. The aloes are not admissible in long continued constipation, from their tendency to produce the hemorrhoidal dis- charge. The Bile of the ox has been much re- commended in these cases: about 5 or 8 grs of the bile of the ox, inspissated over a sand bath, may be made into a pill with flour or similar article. When other medicines fail we must resort to mercury. Charcoal is said by some to be an excellent remedy here. In pretty doses (a tablespoonfull at a time) it 151. may be useful. The cases to which it is best - a – dapted are those in which the tongue is furred, & the breath foetid. The Diet is to be attended to. Avoid all the astringent, farinaceous article, and salt provisions. Vegetables may be used; but above all, mush & molasses. Recommend the patient to endeavor to procure a stool daily. ====== Class. 3. Diseases of the Respiratory System. Under this head are included diseases of the lungs , their appendages, & immediate connections. Catarrh. Catarrh may defined an inflammation, and increased secretion from the mucous membrane of the nose, throat, larynx & bronchiae, generally attended with more or less fever; & is in common language de- nominated a cold. It is caused by any circumstance calculated to check perspiration, as sleeping in damp rooms, exposure to a draught of air, sudden changes of temperature &c. It is generally attended by a con- siderable degree of lassitude & muscular soarness, cold shivering, followed by a hoarseness. There is, in the commencement, a sensation of fullness & tightness about the chest, fullness in the head, chills & flushes alternately. When the defluxion is very copious, it 152 is termed a coryza. There is generally connected with it a cough & more or less difficulty of respiration. Cold in children, if neglected, an apt to terminate in cynanche trachealis, or peripneumony, which is more dangerous. In adults 99 cases of consumption out of 100 proceed from cold. A neglected cold, in aged people, often terminate in peripneumony, or catarrhus suffocativus, & sometimes in asthma, or hy drothorax. Treatment. This divides itself into that which is necessary in the forming stage, & that in the con- firmed. Opium taken on going to bed is an ex- cellent remedy. I have used it frequently, & always with success in the forming stage of the disease. But if the idiosyncrasy will not permit its use we must have recourse to the mild diaphoretics; a pedeluvium, & Dulc: spts: nitri: or vin: antim, promoted by warm drinks, as eupatorium. The best beverages for a cold are, molasses or vinegar, & water; currant jelly; molasses whey, or vinegar whey: both made the same as wine whey. The following inhalation often proves of much service: Rx. Hoffman’s Anodyne, & Laudanum, of each, a teaspoonfull, - to be inhaled. It proves a counter agent to the inflammation. In similar cases, an in- halation of cicuta in either may be used. In the confirmed stage venesection is necessary. 153 The quantity of blood to be drawn must depend upon the pulse & other considerations. One bleeding will gen- erally suffice. As auxiliary to the lancet purging becomes necessary. The saliva articles are preferable: thus. Rx. Sal: Glaub: . . . . . ℥i. Nitri . . . . ..ʒi. Tart: Antim: . . . . grs. ss. m. Div. in pulse: iv. One to be taken every hour or two. This keeps the bowels in a soluble condition, & relaxes the surface. Nauseating doses of antimony have been used with much success in Europe; but they do not answer in the catarrh of our country. Em- etics early in the disease generally remove or allevi- ate it, but it is unpleasant to most people, & can – not be used when there is inflammation of the chest: in this case venesection alone is the proper remedy. After the bowels have been well emptied the ni- trous powders may be used. Blisters are useful in the latter stage of the disease, where there is a hard & lingering cough with pain in the chest. The disease being broken, those medicines called Cough mixtures may be used with benefit. They nearly all contain opium as the leading ingredient. They are beneficial in the same cases in which blisters are useful, viz. when there is a pain in the chest with a hard, lingering cough. The one must commonly used is that called 154 The Brown mixture made in the following manner: Rx. Extr: Glycirrh: ʒiii. Aq: Fervent: ℥iv. m ft. solute. Adde Vin: Antim: . . ʒi. Sp: nitri: Dulc : . . ʒii. Tr: Thebaic: . . . . . .g#xl. m. The dose is a tablespooonfull. Or this. Rx. Scilli: Oxym: vol Acet: ℥i. Vin: Antim: . . . . . . . . .ʒi. Gum: Arab: . . . . . . . . .ʒiii. Sp: Nitri: Dulc: . . . . .ʒii. Tr: Thebaic: . . . . . . . .g#xl. Aquae . . . . . . . . . . . . . . ℥iv – v. m. Dose the same as of the former. Or this. Rx. Carb: Potas: v. Sodae. Vin: Antim: aa. ʒi. Tr: Thebaic: . . . g# Xl. Sp: Lav: Comp: ʒi-ii. Aquae . . . . . . . . ℥iv – v. m. Demulcent as barley water, flaxseed tea &c. will be found useful: or the following. Rx. Gum: Arab: Sac: Alb: (v. sugar candy). Crem: tart: aa. ℥i. to be dissolved in a quart of water & used as a common drink. Molasses & water may be used. Catarrh should always be treated with a 155 low diet. Nothing is more erroneous than the com- mon saying: “feed a cold & starve a fever.” Vegetable matters, as rice, turnips, potatoes, hominy &c., are to be used. A useful & agreeable article of diet in Catarrh is the following. Rx. Gum arabic ℥ii. water a quart. Simmer it away to a jelly: then add a little vinegar or lemon acid, & some sugar. – The vegetable broth is excellent: pre- pared thus: Take 2 turnips, 2 potatoes, 2 onions or a little celery, a slice of bread, & ½ a gallon of water, to be boil’d down to a point: then strain it in a cullender & add a little salt. In the preparation of this broth no vessel is to be used in which meat has been cooked: as it always gives it a disagreeable taste. If, in catarrh, the patient be confined to his bed, he will get well in half the usual time. Epidemic Catarrh. Or Influenza. This is perhaps the most wide spreading disease with which we are acquainted. It has been denominated by the italians, influen- za, on account of the vast extent to which it spreads, & by that name it is now commonly known. It is said generally to proceed from North to South; but it sometimes takes an opposite direction. The difference between simple & epidemic catarrh, 156 is that the former arises from the sensible qual- ities of the air, but influenza, arises from some unknown distemperature of the atmosphere, & is uniformly distinguished by all the laws common to epidemics. It puts on different forms: ap- pearing in some seasons as if inflammatory, & sometimes of typhus malignity: in the latter case we must the same practice as in our late winter epidemic. The inflammatory form is to be treated on the principle of evacuation. Cynanche Trachealis. To this disease various other names have been given by different writers, as croup, hives &c. The best nosological title, perhaps is Trachitis. It is con- sidered a disease of modern date. (said to have been first described by monroe of Edingb., but it was no- ticed by vezey in 1740). It is, for the most part con- fined to the early stages of life; & most commonly occurs between the age of 1 & 5 years; but it fre- quently attacks infants within the month, & sometimes adults. It is well known that Genl. Washington is said to have died of this disease. It is asserted by some writers that croup never occurs after the age of puberty, which they account for by the change which the larynx &c. undergoes at that age. It is caused by a cold & moist atmosphere, 157. & hence commonly happens in the spring. Some wri- ters consider it an epidemic, & perhaps it is in some cases. There is no reason to believe it is ever prop- egated by contagion. It is endemical to particu- lar places, & occurs near the sea & other large col- lections of water, rather than in inland places. This is exemplified at Leith near Edinburgh; & at Fell’s Point near Baltimore. Croup has been divided into Spasmodic & Inflammatory. It appears to me that, when it suddenly attacks, it must partake of the nature of spasm. But where the disease slowly comes on, or is the effect of inflammation of other parts, as from measles, scarlatina, cynanche trachealis &c., it must be of an inflammatory nature: this, however, does not lead to any practical difference. Croup sometimes comes on without any premonition. The child awakes at night, with a dry hoarse cough compared to the barking of a dog, or crowing of a cock. In these cases the disease is generally spasmodic, & is at this period confined to the upper part of the trachea. After continuing for 8 or 10 hours, inflammation comes on & the disease extends itself to the bronchiae. The voice is now hoarse, the cough hard, there is more less or less fever, with great anxiety & the child is very uneasy without . Tart. Emet. Ipecac. Calomel makes an excellent puke. *which are preferable. ‡This practice originated with Dr. Dick of Alexandria (viz) nearly 30 years ago (Feb. 4. 1826) - 158 suffering much from pain. Treatment. Called in the commencement of an attack, I puke the child freely with tart: emet: alone, or with Ipecac: & Calomel, at short in- tervals, & at the same time direct the child to be placed in a warm bath for 10 or 15 minutes. This failing to afford relief I bleed copiously & then repeat the warm bath & emetic. This not an- swering, I resort to leaches*or cups, or blisters or sin- apism over the throat or to the back of the ear. (Cups must never be applied to the front of the neck.) All these failing bleed ad deliqium animi‡: when this takes place, the fever, cough & difficult res- piration generally disappear. A large bleeding alters action: a small one only lessens it. Calomel may now be given; not in a small dose, but in the largest possible one; that it may speedily purge. An opening of the bowels in this stage car- ries off the lingering &c., attendant on the disease. When there is cough, hoarseness & tightness of the chest the Polygala senega may be used with advantage. It is highly recommended by Dr. Archer. In the advanced stages the lungs are loaded; the eyes prominent & inflamed, the pupil dilated; with an expression of the countenance wild, hag- gard & ghastly; laborious respiration, full pulse & a flushing of the cheeks. The disease is now About a teaspoonful of the juice of onion or garlic will often succeed in vomiting when other articles have failed. 159 Peripneumonia notha. The child should be pla- ced in a warm bath, & an emetic of tartar emet: Calomel & ipecac: given. The juice of onion or garlic will sometimes answer. Then venesection should be employed: taking away little at a time, & watching its effects. When the lancet is forbidden, we must substitute local bloodlet- ting. Blisters applied over the breast are very useful in this case; or vessications by boiling water, or pledgets of lint dipped in decoction of canthar- ides in Spirits of turpentine. The subsequent treatment consists in expectoration by vinegar of squills &c. Much advantage may be derived from Calomel in this stage of the disease; and some physicians, both of this country & Europe trust almost exclusively to it. Much has been said by some of the existence, in this disease, of membrane in the larynx, & has been considered by some, as the chief cause of the danger. (See Cheyne, Baillie, & Bard of N.Y.) That this does some times exist there can be no doubt; but it is a rare occurrence, & I have never met with it. The appearances I have found are marks of inflammation in the larynx, and effusions of mucus or coagulable lymph. There are two causes which render the disease so fatal: 1. An erroneous notion of its pathology, & 2. The 160 careless manner in which it is managed. A writer has said that the hepar sulphuris will effect a cure. This is incorrect. The more active reme- dies are required. Children are found better to sustain the more active remedies, as emetics, purges & even bleeding. The require, from the fullness of their vessels, oftener to be bled, & venesection may be resorted to in their cases with more safe- ty & advantage. They recover more speedily from wounds & injuries; & on this account, I never con- sider the case of a child as altogether of a des- perate nature. Our practice in this disease should be prompt & energetic. It is a rule with me never to leave a child, in cynanche treachalis, until all the violent symptoms have abated Cynanche Laryngea. This is divided up into Acute & Chronic: the latter will be treated of under Pulmonary consumption. The symptoms of the Acute, or Laryngitis, are, fever, pain referable to the larynx, difficult respiration & deglutition, loss of voice, hoarseness, sense of suf- focation, the pain augmented by pressure on the thyroid gland, & difficulty of protruding the tongue. In milder cases deglutition is but little impeded; but in more violent cases spasms & convulsions at- tend every attempt to swallow. The general du- 161 ration of this disease is from 2 to 4 days. It is caused by cold & generally attacks person advaned in life. By dissections effusions of coagulaable lymph, or sometimes pus, are seen on the surface of the larynx. Diagnoses. It is distinguished from Cynarche trachealis by the pain upon pressure on the larynx, & the peculiar wheezing noise in that disease. Treatment. Large bleeding is required in the commencement: sometimes ad deliquium animi. Leeches should be applied to the throat & after that a large blister. Evacuation from the bowels are of great importance. This disease has not been known above 6 or 8 years. Cynanche Tonsillaris. By this is meant an inflammation of the mucous membrane of the fauces, more particularly the tonsils, which extends itself to the membrane lining the back part of the nose. It occasionally extends to the eustachian tube, & produces in the ear and some times deafness. The febrile symptoms are generally urgent; difficult deglutition; the pulse is generally vigorous & accelerated, & the tongue coated. It frequently terminates by suppuration. The matter of the abscess is foetid & nauseus, & its discharge is followed by great relief. Sloughs sometimes appear resembling 162 apthae; but generally go off in a few days, & produces no great inconvenience. This most occurs in scrofulous habits. In very delicate persons, & particularly children, schirrus tonsils are apt to be the consequence. Diagnosis. It is distinguished from Cynanche maligna by the floridness of the inflammation, the absence of ulcers &c. It is a disease of little or no danger: the only danger arises from the tonsils pressing upon the glottis. – It is caused by cold, affects generally the young & those of a plethoric habit; occurs in Spring & autumn, & liable to a recurrence. Treatment. This is divided into that neces- sary in the forming , & that in the subsequent stage. In the very early stage, a stimulating gargle, as an infusion of cayenne pepper, will often completely check it. Embrocations of opedeldoc, or soap liniment, or spts. turpentine are useful. An emollient poultice, such as is most retentive of the heat, the best for which is boiled potatoes mashed should be applied to the throat. Corn mush is also excellent. These not succeeding we must reduce inflammation by evacuations. Emetics, if not too long delayed, will generally afford relief. They are to be followed by evacuations from the alimentary canal. Venesection is not often 163 demanded, & is not here productive of the same relief as in ordinary inflammation; but if the system have been brought into sympathy with the local affection, it is indispensible. Local bleeding, by cups or leeches, is of more service. Next , a blister should be applied to the throat. These not succeeding we endeavour to promote suppuration by poultices. Gargles are only to be used when there are foul ulcers to be cleansed. Loaf sugar & nitre, equal parts, to be dissolved in the mouth & the throat kept moist with it, is much better. When the tumors have reached maturity they should at once be opened. This was formerly done by emetics; but the opening should always be made with a lancet. After the rupture of the abscess, gargles of milk & water or barley water should be used. The erysipelatous form of this disease is to be treated nearly in the same manner. Enlarged tonsils from Cynanche Tonsillaris sometimes spontaneously disappear; they are sometimes reduced by gargles; but generally a surgical operation is necessary. Cynanche Parotidoea. Or Mumps. This comes on with fever, which is soon followed by an enlargement of the paratid, & some times of the submaxillary, gland. The tumor is situated at the corner of the jaw, & increases until 164 The 4th or 5th day, & then terminates by resolution. It generally attacks children, but it has also appeared in adults. In a few instances it has terminat’d in suppuration. By metastasis the testicle & mammae often swell, when the enlargement of the parotid gland subside. The brain is sometimes attacked in the same way. Treatment. Flannel should be kept to the neck, mild purgatives administered & sometimes topical bleeding may be necessary. In cases of metastasis to the testicle or mammae, the antiphlogistic treatment is demanded; & the disease is to invited back to its original situation, by warm fomentations &c. . . Pneumonic Inflammation. I shall treat of this under the heads of Pneumonia vera & Peripneumonia notha. Under the first is included Pleurisy, or Pleuritis, which is an inflammation of the pleura; Peripneumonia, so called when there is an inflammation of the parenchyma or substance of the lungs; & Pleurodine, when the inflammation attacks the pleura costalis, or muscles on the side. (intercostals). By Peripneumonia notha is meant an apoplectic state of the lungs, or an engaged condition, either from blood or effusions of any kind. 1st of 165 Pleurisy. This is always known by pyrexia, pain in some part of the chest, either in one side or the other; a strong, hard, active pulse; violent cough without expectoration, except now & then a little phlegm, which is sometimes mixed with blood, but this is no alarming symptom; difficult respiration etc. It is generally caused by vicissitudes of weather, or the application of cold to the body, especially if it be previously heated. It generally attacks the robust & those of an inflammatory diathesis, & prevails in the winter & Spring, when there are sudden changes in the weather. Diagnosis. It is mostly confounded with diseases of the liver. The distinction is known by pyrexia, in pleurisy, dry hard cough & pain in some part of the thorax: some say in the right side; but I have seen it most frequently in the left. Prognosis. The unfavorable symptoms are, high fever with delirium, difficult respiration attended with raising of the shoulders, dry hard cough with no expectoration, & dropping of the lips. The favorable are, free expectoration of a thick yellow matter, bleeding from the nose, turbid urine. Now & then a diarrhoea is critical. In the sinking condition of the system, it is generally a 166 fatal symptom. On dissection we observe inflammation of the pleura, sometimes abscesses. The lungs are occasionally gangrenous, & effusion of water are some times found in the pericardium. Treatment. In the early stage of common pneumonia, we must employ very copious venesection. The orifice should be large, so as to allow a large stream of blood to flow. This fact should be remembered, as it is of much importance. Much more is to be apprehended from a timid use of the lancet than from any excess. In a robust person the common quantity to be drawn is ℥XXX, but this does not always answer, & even we are sometimes obliged to repeat the operation to the same extent. My practice is never to tie up the arm until the difficulty of breathing is removed. We must in many cases resort to topical depletion by cups or leeches. When pleurisy is confirmed it is almost impossible to make the patient faint by bleeding. It is a complaint which bears the loss of blood very well. We are next to resort to local remedies: of these the best are Blisters, when applied at the proper time. My practice is to postpone the blister until arterial action is reduced. When applied earlier, they generally aggravate the disease. Dr. Griffiths of this city, & Dr. Jackson of Boston, use venesection & blisters at the same time. More 167 is to be expected from topical bleeding. Where cups are not attainable, fomentations or bags filled with hot ashes will answer. Respecting Purging in this disease there is some difference of opinion. All that is desirable is to keep the bowels gently open, by castor oil or the neutral salts. Sweating is proper in the forming stage. The best diaphoretic in this case is the asclipias decumbers or Pleurisy root of our country. Combinations of nitre & ipecac: or antimonials, so as to produce a slight nausea, are useful. A combination of Calomel, opium & ipecac is often of service in promoting expectoration. After this we must use the demulcent drinks, & the cough mixture. (see page 154). – (For the proper time for using opium vide Cullen, or Therapeutics vol. 2. page 197). Sometimes a tightness of the chest & slight cough continue, with a slight pain or uneasiness; for this a combinations of calomel, opium & ipecac: may be given; ½ gr. of each, every hour or hour & a half. Should it salivate, it is a favorable symptom. Of the mercurial practice in the complaint I shall speak hereafter. Bilious Pleurisy This is a complaint very common in our country. It has, together with the symptoms of common pneumonia, many of the appearances of autumnal 168 Bilious fever. It is attended with head ache, so violent that the disease is sometimes called pleurisy of the head; gastric disorder, violent vomiting of bile, dark furred tongue, & the pulse is hard, but easily compressible. Treatment. This does not be a depletion to the same extent as common pneumonia. After evacuating the alimentary canal, first by an emetic & then mercurial purges, the infusion of serpenteria may be given, & a profuse perspiration kept up for 10 or 12 hours. Other diaphoretics are useful, as Dover’s powder, in combination with calomel. This disease puts on in a certain degree the intermittent type, & prevails in places subject to that disease. Serpentaria is here the best remedy. It is also useful in checking bilious vomiting. Topical depletion by cups, or blisters, is not to be overlooked. Peripneumonia notha. Much difference of opinion has prevailed as to the nature & treatment of this disease. There are two distinct species of it, & they require different treatment. The first is the Catarrhus Suffocativus or notha. This commonly attacks people advanced in life, & those of a feeble frame. It may be known by a sudden onset, through it. 169 is sometimes gradual. The respiration is laborious & panting; accumulations of phlegm take place in the bronchia, which cannot be discharged. The pulse is feeble & irregular; & there is no fixed pain in the chest. It sometimes proceeds from a debility of the bowels; but most commonly from a neglected catarrh. Treatment. Venesection is here to be used; but must not one time be urged to any great extent. It is perhaps best to substitute cupping. Where this cannot be resorted, or even sometimes in anticipation of it, an emetic may be used. Active vomiting is necessary; & ipecac: vit: alb: may be used for this purpose, but on the whole I prefer combination of Ipecac: Calomel & tart: emet. After the emetic has operated, a blister large enough to cover the chest should be applied. Opium may be used in all stages after sufficient evacuation. By itself it is useful; but it is more common to combine it with one of the active expectorants, as squill, musk, or assafoetida, senega, tolu or other balsamic articles. The best expectorant is the Gum Ammoniac in the form of Lac Ammoniaci. To this may be added some preparation of squills or elix. paregoric: this. RX. Lac: Ammoni . . . . . . . . . . . ℥viii. Oxym: Scill: . . . . . . . . . . . . . ℥ii. Elix: Pareger: . . . . . . . . . . . ℥ss. m. 170 Where large accumulations of purulent or viscid matter existed, with feeble & difficult respiration, I have witnessed very good effects from an addition of nitric acid to the ammonic: thus Pour very gradually ʒii. of nitric acid, diluted in ℥viii. of water, on ʒii. of Gum Ammoniac, & triturate them in a glass mortar until the gum is dissolved, forming a milky fluid. Of this a tablespoonfull may be taken every 2 or 3 hours, in sweetened water. Laudanum in some cases may be usefully added. The volatile alkali, or a decoction of seneka may be found serviceable. If these fail, inhalations of tolu, vinegar, or simple water, will be of benefit. Children are also liable to this disease. It commences like a common cold, with a wheezing, & little or no expectoration. As the disease advances all the phenomena of congestion in the lungs appear. The treatment is nearly the same as in adults. If not attacked in its early stage it always proves fatal. Upon Dissection in this disease, the trachea is generally found full of fluid: some times mucus, at other times pus, or coagulable lymph. The bronchiae are generally stopped up. The lining membrane is much inflamed. The substance of the lungs is not generally affected. The pleura is oftener in- 171 flamed. The disease at times involves the alimentary canal: particularly the stomach, & sometimes the liver &c. The brain is always congested with blood. – Prognosis. Much anxiety & oppression, without expectoration, quick fluttering pulse, coma, & cold skin, are unfavorable symptoms. ========== The second species of Peripneumonia notha is that in which a congestion of blood takes place in the lungs, constituting an apoplectic state of those organs. This also comes on without any premonition, & attacks the debauched, & generally the young. There is a pain about the thorax, a wild expression of the eye, great anxiety & restlessness, which appear to suffocate in a attempting to move. Treatment. Prompt venesection is here demanded. Relief must be given before we close the orifice of the vein. In one case I know 60 ounces of blood to be drawn at once; but the bleeding cannot always be carried to this extent: in such cases drawn away a small portion at a time, & if the patient bear it well, take away a little move. When venesection is inadmissible we must substitute local bleeding. Of the congestive state of this disease, little has been said. The veins are liable to a congestive, & the arteries to an inflammatory state. In the latter case there is 172 a strong vigorous pulse & some local pain or uneasiness. The arteries are never affected without producing phlegmasia: in which the blood is sizy; but when the veins are affected, it is black, without any appearance of inflammation. The pulse does not serve here as a guide to venesection. As soon as depletion is effected we may give a large dose of opium, & after this a blister is to be applied over the whole chest. As auxiliary means, inhalations are not to be overlooked: even the steam of warm water is beneficial; but it would be better to impregnate it with, ether, Hoffman’s Anodyne, or bals: tolu. Fumes of common rosin is sometimes answers very well, especially in old & debilitated persons. The case being relieved by this treatment, then a combination of opium, calomel & ipecac: is one of our best remedies. It repulses difficulty of respiration, promotes the discharge from the bronchiae, allays cough & confirms recovery. As an expectorant the modus operandi of mercury is very intelligible. By powerfully stimulating the excretories, it enables them to throw off the impacted mucus or phlegm, which is afterwards coughed up & expelled. But it is not alone as an expectorant that we are to ascribe the effects of this remedy. Directed with skill, there is something in the union of calomel & opium exceedingly striking, in all cases of reduced inflammation, & particularly so of the lungs. Either 173 too early or too late in the case, it proves alike ineffectual. The exact point to recur to it, is when, the regular depleting measures having been urged as far as seems consistent with safety, the disease still continues unsubdued. Pertussis. Hooping cough, Chin cough or his cough. This is a disease of modern date. It was described about the middle of the 17th century by Willis, & appears to be an endemic. It often begins like a common cold. It is generally about 3 weeks forming, continues for 3 weeks & goes off in about 3 weeks more. Expectoration is in general very deficient, & there is a dry cough which continues until great exhaustion takes place. It is most difficult to manage in winter & when it occurs at that season, generally continues until warm weather. Prognosis. It is always unfavorable when it attacks very young children; & when it is attended with fever the case is of a serious nature, & still more so if there be any symptoms of peripneumonia notha. The most favorable symptoms are when there is least fever, & when expectoration comes on. It generally ends by suffocation: the patient dying in convulsions. This disease some times depends upon contagion; but it occasionally prevails as an epidemic, and most 174 generally in the Spring & Autumn. It is best to proceed in practice under the impression of its contagious nature. There is much diversity of sentiment respecting the nature & seat of this disease. By some it is supposed to be on the air cells of the lungs; some place it in the larynx, & pharynx, & other with no little probability, in the aliment- ary canal, with which some part of the pulmonary apparatus sympathises. It is supposed by some to be of an asthmatic nature. Dr. Watt of Glasgow says that it is an inflammatory disease, & that its seat is in the mucous membrane of the larynx, trachea, bronchiae & air cells, & that the inflammation in that membrane is so great as to stop respiration. The mucus, he says, fills up the air cells so as to prevent the access of air. Some times the inflammation extends to the deeper seated parts & terminates in ordinary pneumonic inflammation, or in pulmonary consumption. Some think that the immediate cause is cold operating on the mucous membrane & producing inflammation, which causes it to throw out the fluid which fills the air cells &c. It is dependent upon some unknown cause that eludes investigation. Diagnosis. The peculiar whooping noise distinguishes it from every other disease. Treatment. Few leading indications present 175 themselves: to subdue the inflammation & violence of the disease; & to subvert the wrong associations. In a child robust, florid & with a febrile pulse, venesection may be practiced. The bleeding must in general be repeated; but must be regulated by a sound discretion. Evacuations from the alimentary canal are not to be neglected. Emetics are more proper in the early stage, & must sometimes be repeated twice a day. The ipecac: squills or vit. alb: are generally preferred on account of the promptness of their operation; but the tart: emet: is quite as effectual as either of them. In the interval nauseating doses may be given. The milder laxatives are generally recommended to keep the bowels open; but they do not answer as well as the mercurial purges. Calomel has the effect of breaking the force of the disease, & should always be selected for this purpose: it should be repeated every 2 or 3 days. Local remedies are also called for. Congestion in the lungs is to be relieved by Blisters. We may also resort to leeches or cups when the bowels suffer much from engorgement or inflammation. As the disease generally presents itself venesection is seldom demanded. In this stage the proper remedies are the narcotics & antispasmodics: opium particularly; but it must not be used until all inflammation is removed, as it is supported to be in this stage. 176 Cicuta has been much recommended; but I am not aware that much can be expected from it. It may sooth irritation. We may derive much more advantage from Strammonium in cases of adults. The antispasmodic have all been recommended. Castor is of no value. Musk is a valuable medicine, but can seldom be used. Artificial musk, made by pouring nitric acid on the oil of amber, is strongly recommended by Bailey of London. I have used it in some cases & have not found it as useful as some medicines to be presently noticed. It is, no doubt, powerful antispasmodic, & may be used thus: (Tincture). Rx. Mosc: Artif : . . . . . ʒii. Alchohol: . . . . . . . . ℥viii. Of this 5 or 6 drops may be used 5 or 6 times a day. The oil of amber itself may be in the dose of 6 or 8 drops, on sugar. Of all the antispasmodics I have employed the best is a watery solution of assafoetida. Of late the alkalies have been much recommended, & my experience with them is now sufficient to enable me pronounce with some certainty upon their efficacy. The soda was thus used by Dr. Pearson. Rx. Carb : Sodae . .grs iii. Vin: Ipecac: . g# v. Tr: Thebaic: . .g# i. Aquae . . . . . . . ʒI. For 177 a child one year old, to be repeated every 3 or 4 hours. The Potash has been used in the following nausea. Rx. Carb: Potas: . . . Qi. Coccinel: . . . . . .grs X. Sac: Alb: . . . . . ʒi. Aquae . . . . . . . .℥iv. m. The dose is a tablespoonful, every 2 or 3 hours, for a child one year old. In the last stage of pertussis the various tonics are employed, & by most writers the Peruvian bark is considered the best: especially by Cullen. Of its efficacy there can be no doubt, but it is difficult to be used in cases of children, being generally rejected from the stomach. Arsenic has of late been much recommended by Simmons & Ferrier. It is directed to be given in small doses: ½ grs # of Fowler’s solution 2 or 3 times a day. I have tried it, & with but little advantage. The saccharum saturni has also been used: of its powers I have very little knowledge. The nitrate of silver has been pretty much used in Eng.d by Dr. Jones. It is given in very small doses & made into a pill with bread. The tincture of Cantharides is an excellent remedy in this disease, & is entitled to a great share of credit. I have used it in many cases with great advantage. It is in the low & final stage that it is used; but it does no good 178 unless strangury is produced. Dr. Barton recommends it to be used in the following manner: (cantharides). Rx. Cantharid: Camphor: aa . . . .Qi. Ext: Cort: Peruv: . . . . . . . . . . . . .ʒiii. m. of This 8 or 10 grs. are to be given every 3 or 4 hours in a spoonfull of water or julip. Sometimes a little bals: copaiva may be added. The following may also be used. Rx Tr: Cort: Peruva: . . . . ℥vi. Elix: Paregor: . . . . . . . . ℥ss. Tr: Cantharid: . . . . . . . ʒi. In the declining stages of this complaint, fumes, & liniment of different kinds have been used. The juice of garlic rubbed in the course of the spinal column is said to have proved serviceable. The famous liniment of Struve (which is essentially the same as Roche’s Royal embrocation) is made by dissolving 20 grs. of tart: emet: in 2 ounces of water, to which is added one ounce of the tincture of Cantharides. The region of the stomach is directed by Struve to be well bathed this every night. The fumes of tar, (which have been used with advantage) are produced by introducing a red hot poker into a vessel containing tar. – Attention should be paid to regimen. We should keep up a moderate glow on the skin. The cold bath may some times be employed with advantage. Exposure 179 to cold air has been said to be useful. It is not so in the early stage, but after the inflammatory stage has subsided it may be used with advantage. Change of air, as from town to country & vice versa ) will prove beneficial. An impression has of late gone abroad in this country that Pertussis is stopped by the vaccine disease. This is no new opinion. It was advanced 20 years ago in Eng.d. Many practitioners do now believe that it is a counteragent to hooping cough. Dr. Watt of Glasgow says that the vaccine disease rather predisposes to Pertussis & Scarlatina. These statements want confirmation, & are generally denied by practitioners. Asthma. This has most commonly been considered a spasmodic disease of the lungs. It does not, in general, observe very strictly the laws of periodical recurrence. The Causes are such as act directly upon the lungs, or indirectly, thus the medium of the general system. Of the first are, certain acrid matter inhaled, as the vapor of arsenic, mercury & other minerals. The odor of ipecac: has in some cases brought on on an attack. To these may be added some of the irrespirable gases, as Carbonic acid &c. It is also produced by an excess of heat or cold,moisture or dryness, with some occult peculi- 180 arity with which we are not yet acquainted. Baltimore is subject to asthma: Philad.a is not. Elevated countries are generally subject to it. Asthmatic patients are generally more comfortable in low countries or in large cities. Of those causes which affect the lungs secondarily are, some morbid affections of the alimentary canal, as worms, indigestible food, inanition, excess in eating or drinking, constipation of the bowels, suppression of the natural discharges, recession of eruptions, indulgences in very vehement passions. Symptoms. In the commencement of an attack, the lungs are seized with a sense of tightness & oppression; there is a dry cough, sometimes with expectoration; the distress is aggravated by motion & a recumbent posture; the countenance is turgid , & the cheeks purple and livid. In the violence of the paroxysm there is considerable fever; a profuse perspiration breaks out, & in many cases during the paroxysm there is a large discharge of pellucid urine. By Cullen this disease is supposed to consist in a spasmodic construction of the muscular fibres of the bronchiae. Dissections have not afforded much information on the subject. The lungs now & then are found congested with blood, & the pleura & parenchyma of the lungs inflamed. By Morgagni it is said that the lungs show masks of high morbid action. It appears to me highly probable that asthma is a disease of the lungs, but that the spasm 181 is often secondary in its nature, originating generally in the stomach or bowels, as would appear from some of its causes. Asthma is generally divided into Spasmodic or Dry, & Humoral, which is accompanied with pituitous expectoration. This division leads to no difference in the treatment. The spasmodic generally occurs in advanced life. I think a more correct division would be into Idiopathic & Symptomatic. Diagnosis. Its periodical recurrence, the peculiar nature of the dyspnea sufficiently distinguish it. Prognosis. In advanced age, or when there is a contracted chest, or it prevails as an hereditary disease, a cure is not to be expected. Death never takes place in the paroxysm. Treatment. This divides itself into such as is demanded in the paroxysm, & such as is necessary to prevent its recurrence. In the first place venesection is require, & in the more violent paroxysms is indispensible: yet it must only be resorted to in plethoric cases. Tho’ it does not afford immediate relief, it is called for by the interrupted circulation in the lungs, suffused countenance &c. We must not always rely on the indication of the pulse. Cases sometimes occur in which venesection is inadmissible, though there be some degree of congestion in the lungs: In such cases topical depletion, by cups along the dorsal vertebrae, is of service. Emetics are useful in the paroxysm. Vomiting generally relieves it, & if timely recurred to, prevents 182 the recurrence. Ipecac: is generally preferred. It was originally used by Akenside. He give Qi during the paroxysm , & in the intervals, from 3 to 5 grs. every morning. Whether it produces vomiting or not, under such circumstances, he says it is equally effectual. Much has been said of the mild expectorants, as squills, lac ammoniaci & nit: acid, & of the combination of squills & ipecac: The white vitriol has also been recommended. Purgatives do mischief when urged to too great an extent. They may be used in the early stage. Calomel has done good in the dose of 8 or 10 grs. given 4 or 5 times in the 24 hours. Opiates have been much prescribed in this disease; but with very opposite results. The effects are not the same in different stages of the disease. The may be of use when the disease is subdued by the active measures above detailed. All the narcotics & antispasmodics have been tried, & with nearly the same effects as opium. Blisters to the chest have been used; but I don’t put much confidence in them. It would, perhaps be better to substitute some other vessicating application: especially the tart emetic plaister. Dr. Rush used blisters to the extremeties. Drinking very freely of cold, or ice water, or coffee has afforded relief. A pint of the strongest coffee without cream or sugar is one of the best things I have tried. Exposure to cold, or walking out in the air, or keeping the feet to the fire, have at times proved beneficial. Inhalations of vapor have 183 been used in many instances with advantage: even the steam of water, but it may be improved by some of the impregnations before mentioned. Certain gases were used by Thornton & Beddoes. Strammonium has been much used in the paroxysm of asthma. Smoking tobacco also affords relief. These article, I think are most suited to the dry stage, & when there is little expectoration. To prevent a recurrence of this disease, the most effectual remedies in common cases are the tonics, particularly the chalybeate preparations. Garlic has been used with advantage, & tar in the form of pills; & in domestic practice they are generally used together. Diuretics have sometimes proved of service, as digitalis, squills, seneka &c. Mercury is useful as an alternative. Blisters to the extremities, & issues have been used. Myrrh is useful, but its powers are increased by uniting it with the peruvian bark. The cold bath is serviceable, except when the patient is pallid, chilly, & has a cold surface. When all these have failed, we must recommended a change of residence. As regards diet there should be no excess in eating or drinking. Warm clothing should be worn, & flannel next the skin. Angina Pectoris. This is comparatively a new disease: first noticed by Heberden about 50 years ago. It is a spasmodic affection of the lungs, & is so nearly allied to asthma, 184 & of such rare occurrence, that it is doubted by some whether such a disease exists. Some consider it a modification of asthma. Symptoms. Without any premonition a pain is felt in the sternum, extending to one or both arms, but most commonly to the left arm, & generally at first no farther than the deltoid muscle, but afterwards to the wrists & even the fingers. It sometimes comes on when the person is in bed. – Its causes, are generally, exercise, inordinate passion, but the most common is ascending a flight of stairs, a hill or any other height, producing some disturbances of respiration; & it is more apt to occur when the stomach is full. There is generally great anxiety; palpitations of the heart, difficult respiration & a sense of suffocation. The attack is often so violent that the patient believes himself expiring. The sensation at the chest generally partakes more of uneasiness than pain. This disease is said generally to attack the middle aged; men more than women; & commonly the robust & those with short necks; & of indolent & sedentary habits; but I have known it happen in persons of an opposite habit. It was generally supposed to be spasmodic in its nature. This is probable from its analogy to spasmodic diseases, mode of cure &c. It was called by Darwin, Asthma dolorificum, & by Elsden, Asthma convulsivum. By Dr. Parry it was supposed to be a species of syncope (syncope anginosa) occasioned 185 by an ossification of the coronary arteries; but we have no reason to believe that the distress of angina pectoris would be the consequence of that. Cases are recorded by Morgagni, Cowisart & Senac, when the coronary arteries were ossified, without any of the symptoms of Angina pectoris, & some cases which terminate fatally without any appearance of disease about the heart. It is supposed by Dr. Hosack of N. Y. to proceed from a plethoric state of the large vessels about the heart. Most generally the heart has been found diseased; water in the chest; abscess in the mediastinum; membrane adhesions of the lungs, schirrus of the liver &c. My impression is that the primary seat is in the stomach, the heart & lungs affected secondarily, & that its nature is gouty; for all the cases that have come under my care turned out to be gout & were treated as such; by sinapisms to the feet &c. This opinion was originally suggested by Dr. Smith, a German physician, who called it asthma authriticum; & afterwards by Dr. Butter, about 40 years ago, who called it Podagra Diaphragmatica. Diagnosis. It is distinguished from asthma by the paroxysms of the latter generally coming on at night: - from Hydothorax (vide. Dropsy). – Treatment. This divided into that necessary in the paroxysm, & that in the interval. In the paroxysm the patient must be placed in a state of rest; vene 186 section had recourse to. About ℥XX or XXV. of blood are to drawn; & the bleeding must be urged until relief is afforded. If this prove ineffectual cups may be applied to the back, & a blister to the breast. After this we may purge with Calomel & Jalap: then Warners Cordial & wine whey may be used, & at the same time sinapisms to the feet. Antispasmodics are to be used, as musk, opium, vol. alk. &c; but any one will answer very well. At the commencement of an attack, a dose of laudanum, ether, or musk julep may be given. The paroxysm can only be subdued by venesection & its auxiliary evacuations. But sometimes the system sinks under the vehemence of the action, the countenance becomes pallid, extremities cold &c: ve- nesection is here a hazardous plan. To invite the disease to the extremities is a rule never to be lost sight of at this period. The next remedies to be mentioned are those which are proper in the interval. These are either topical or general. 1. Of the topical. A perpetual blister to the chest was formerly used; but now the tart: emetic plaister is preferred. Issues introduced into the inside of the thighs were recommended by McBride & Darwin; but they are not entitled to any show of credit. Blisters to the extremities have been used. 2. Of the general remedies. The bark & valerian were at one time much employed. The mineral tonics are more useful: especially the preparations of copper; white vitriol, or the nitrate of 187 silver; but I have never employed either of these articles. My plan is to avoid all the exciting causes of a paroxysm, & to do away the predisposition to spasm. For this purpose the diet should be light & digestible; the bowels should never be constipated; & exercise on horseback or in a carriage should be used. As regards medicines those mentioned under Dyspepsia may be used: especially the chalybeate preparations. To prevent the attack we may guard against plethora by the occasional use of venesection, or purging, & the lightest articles of food. When the disease is confirmed by time it will generally prove incurable. Phthisis Pulminalis. There is no case of disease involved in more abscurity than this. An ulcer of the lungs, which is one form of the disease, is necessarily difficult to cure, owing to the parynchematous structure of those organs; & this difficulty is increased by their constant motion & exposure to the air. Notwithstanding, however, these impediments we know that such ulcers do sometimes heal: it hence follows that the obstacle to the cure must be proceed from an altered condition of the lungs by disease; of which the ulcer is the consequence. It has been our misfortune to include under one general head many diseases of the lungs. The word Pthisis is of Greek origin, signifying destruction or wasting, & in common 188 language means an ulcerated condition of the lungs. Every writer considers ulceration a necessary concomitant of the disease. (Vide Cullen). It is very difficult, if not impossible, to define consumption. To attain perspicuity it will be better to give some description of each division of the complaint, & this is the plan I intend to pursue. Tubercular Consumption. Tubercles are small masses of an indurated substance, of a white, smooth, or cartilaginous nature, found in the lungs. They are of various sizes, from that of a grain of sand, to that of a horse bean. Stark says they are found accumulated in clusters like a bunch of grapes: the large are white internally; but in the smaller there is no such appearance. In the larger, he says, are found sacs, into each of which enters a branch of the windpipe, & that they are dependant on a scrofulous diathesis of the lymphatic glands; but the number of tubercles often exceeds that of the lymphatics. Baillie says that they are sometimes cascous, sometimes osseous &c, formed by deposition of coagulable lymph from the smaller vessels. They often remain indolent for many years, until, excited by some of the causes of inflammation, they produce the disease called Pulmonary Consumption. By a vomica, we are to understand the conver- 189 sion of a tubercle into an abscess. Before it is ruptured it is called occult, & when ruptured, an open vomica. After the rupture of the abscess, ulceration rapidly advances, until the lung is wholly destroyed. Now & then the ulcer heals, & there is a temporary remission of the disease, until another tubercle is excited, when it is renewed. (Vide Baille, a late work). Of the exciting causes the most common are, ill cured catarrh or pneumonic inflammation, such occupations as require the body to be habitually bent, as shoemaking, tailoring, working at metals &c. To these may be added, playing on wind instruments, debauchery, suppression of customary discharges, as menses or hemmorhoids; certain peculiarity of climate &c. Tubercular consumption prevail most among females, & generally about the age of puberty. But it affects all ages: even children within the year, & sometimes persons of 80 years of age. – It commences with a short, dry cough & a little tough mucus is discharged, which seems to come from the fauces. The first manifestation of the disease becoming confirmed is some pneumonic symptom, as cough, pain in the side &c.; but I have known consumption to go through its course without any of these symptoms. It is common for some small bloodvessel to break; & from this time the disease increases. The pulse becomes hard & chorded. This disease is always associated with a peculiar construction of the body, as 190 prominent cheek bones, & all the signs denoting a scrofulous disathesis. – In the beginning of the disease the cough is accompanied by a change in the eye. Prognosis. Absence of pain & cough (when other signs of the disease are present) is a fatal symptom. Treatment. This varies exceedingly in the different stages of the disease. In the first stage we must arrest inflammation by venesection. This was first practiced nearly a century ago by Dr. Dover. He repeated it every day for 8 or 10 days. For a time this practice fell into discredit; but Dr. Rush renewed it in this country, & regulated it by a much sounder discretion. We should, however, bear in mind on the one hand, the importance of subduing the case, & on the other the debility attending the case. After venesection, or as an auxiliary remedy, topical bleeding may be recurred to with great advantage. If we wish to avoid depletion, dry cupping may be used. This operates by drawing blood from the deeper seated parts, & also on the principle of irritation, or vessicating applications. Blisters are of great use in these cases. The tendency of the common blisters to dry up has been urged as an objective to it; but by repeating it we derive more advantage, than from a perpetual one of the tart: emet: plaister. Next in importance are emetics. They do good by equating the circulation, by promoting absorption, & in some degree by equalizing the general excitement of the body. 191 Ipecac: has generally been used for this purpose. The Blue vitriol, in the form of dry vomit, has also been much extolled; but I dont think it at all superior to the ipecac: Emetics to be of service should be frequently repeated. As a part of the same treatment, it is customary to resort to those medicines which reduce the force of the circulation. The saline articles are generally employed for this purpose; but the antimonial powders, without the calomel, are preferable, & are greatly employed in the practice of this city. Mercury is injurious in this species of consumption. The form to which it is applicable will be stated hereafter. Digitalis has been much prescribed. It effects are various. When the disease is advanced it will not be of much service. It is only in the early stage, when there is a slight hemoptysis, or dry, short cough, that it is advantageous. (vide Therapeutics. vol. 2. p. 269.). In the same stage the Prussic acid may be of service, & may be given in the following manner. Rx. Of the Concentrated acid gr+i. water ℥i. & a small quantity of gum arabic. – Of this a teaspoon is to be taken 4 times in the 24 hours. (Diuretics in consumption. - Nitre?) – These are the principal remedies used in the early or inflammatory stage of consumption. When this is not arrested abscesses form, hectic fever takes place, & the disease may be considered beyond the powers of medicine. Humanity, however, as well as a sense of professional 192 duty, requires that we should not withhold our assistance. Cures in the advanced stage are sometimes effected in the other forms of consumption; but never in the genuine tubercular cases. The leading indication is to abate or remove the Hectic fever. Whether it arise from an abscess in the lungs or in any other part of the body, its character is the same & requires the same remedies. It wears the intermittent type & demands the remedies of that disease generally: such as Peruvian bark, arsenic &c. Sugar of lead, opium, myrrh & spider’s web have all been used, & in some instances I have done good with vinegar in the dose of ½ a tablespoonfull every 2 or 3 hours. As this disease so generally partakes of the nature of scrofula, the remedies for the latter should not be overlooked, as opium, dulcamara, hemlock, guaiacum, sarsaparilla &c.; but they have as yet been used with little or no advantage. Nitric acid has been found useful. The nitrate of silver, oxide of bismuth, ammoniaret of copper, phosphoric acid &c., were tried by Dr. Roberts of London; but did not at all succeed. The practice of attempting to heal the ulcers of the lungs by certain fumes or vapors, has been tried. I will not altogether condemn the practice: it has been used by Dr. Parish. I have found the terebinthinate preparations so irritating to the lungs, that they have generally done injury. Crude antimony was used by Stoll; & Bennet in his work 193 on Consumption recommends Sulphur. Hypericum (St. John’s wort) has been used. Ether has been prescribed by some; but I think more may be expected from the tar fumes: procured thus. Put the tar in an earthen vessel over a lamp, or put a heated iron into it until the room be filled with the fumes. This must be repeated 3 or 4 times a day , ½ or ¼ of an hour at each time, if the patient can bear it. A residence among the cedar & pine swamps of this country, during the summer months, has been attended with advantage. Within the last 2 or 3 years, the vapor from burning unwashed wool has been used successfully by Dr. Physick. The irrespirable gases, as carbonic acid &c. were tried by Beddoes; but the practice totally fails. The vapor from cows has been supposed to do good, & several cases are recorded of its efficacy: among which is that of the daughter of the late Dr. Priestly. I cannot place much confidence in the practice; but it a curious fact that persons, as butchers, who are subjected to the vapor from animals lately killed are never affected with this complaint. The earth bath has been recommended by the Spanish physicians. As Tubercular consumption advances certain circumstances of a symptomatic nature occur. 1. night sweats. All that can be done here is to afford temporary relief by merely sleeping in flannel, or rubbing the surface with 194 some stimulating article, as warm brandy or salt. Of the internal remedies the mineral acids are useful. Sugar of lead or Elixir vitriol may be given. Creta ppt. or lime water may be of service. Diaphoretics have been used with advantage in some cases. The practice is, however, of doubtful utility. 2. As regards Diarrhoea which is common in this stage, the remedies are the same as mentioned in a former lecture. Purging should not be resorted to, on account of the exhaustion it produces; although the dyspnea & cough are some times suspended by it. Anodyne injections are the best remedy. The cough now becomes exceedingly troublesome; & most of the mixtures recommended in catarrh may here be used. Demulcents, as hoarhound, licorice &c., & the volatile alkali, are useful. The balsamic articles are also of great service. Tolu is the best, but the bals: copaiva may be used when the other fails. The balsam of honey is useful in the same cases, & is sometimes preferable to the tolu. After all our chief reliance must be placed in opium. This can rarely be dispensed with; & it affords the only comfort at this distressing moment. There is some property besides its narcotic power by which it does good in these cases. When there is pain with tightness of the chest, blisters are of service. When the cough is very troublesome much advantage will be afforded by certain inhalations, of tolu &c. With the same view Sulph: ether has been used. I have tried the following with great advantage. Rx. ℥ss. of the leaves of 195 cicuta, digest it for several days in ℥i of sulph: ether, 2 or 3 teaspoonfulls to put in a wine glass & inhaled. The practice of smoking certain articles as tobacco &c. is said to be beneficial. Stoll says that tobacco is useful in tubercular consumption, but not in catarrh, & this he considers a diagnostic between the two. I have tried the Strammonium with great utility. Opium smoked in a pipe has also proved of service. An inhalant has been introduced by a Dr. Middleton of this city: consisting probably of myrrh & some other articles. It is introduced into the lungs by means of a grinding machine. It may act on the principle of escharotics; by dusting the surface of the ulcers, which it is said to heal. I am inclined to believe it has no such effect. The concentrated Prussic acid has been used as a remedy in this disease. For an account of it vide Therap: vol. 2. – Catarrh Consumption. This arises independent of any scrofulous diathesis. Its seat is generally in the membranes lining of the larynx & trachea, & may be easily distinguished from tubercular consumption. It has at first all the appearances of common catarrh, & is indeed no more than that disease neglected. Diagnosis. It is distinguished from tubercular consumption by the soreness of the thoat, & the matter discharged being generally phlegm or mucus, but finally pus. 196 Dissections have shown that it is a morbic secretion from the membrane of the trachea, which resembles the villous coat of the stomach when its vessels have been filled by a successful injection. (vide Brussais). No ulcer of the lungs exists. This disease is never attended by hemoptysis, & the expectorated matter is seldom mixed with blood ; or if at all, it is in small streaks caused by the rupture of some small vessel on the surface of the membrane. Treatment. Being more inflammatory in its nature, & connected with a sound & more robust state of the system, all the depleting remedies are called for, or should be urged to a greater extent than in the other forms of consumption. Emetics are useful & should be used as soon as the inflammation is in some degree reduced. In these cases the Balsamic medicines manifest some decided powers. Fothergill denounced the practice, but he carried his objections too far. I am perfectly persuaded of their utility; & they are only productive of harm when injudiciously resorted to. Tolu, copaiva, or the balsam of honey, (the tincture of tolu disguised) may be used. The whole of the balsamic articles some to have some specific determination to the secreting surfaces. The Bals: Copaib: may be used in the following manner. Drops of the dose into ½ a wine glassfull of sweetened water: the trickle down the side of the glass a few drops of tinct: amara or any such article. The balsamic collects in a small globule & may be swallowed without leaving any unpleasant 197 taste. It may be used in the same way in Gonorrhoea. Blisters may also be of service. These failing the system should be put under a mercurial course. To relieve congestions, emetics are proper. Inhalations are useful in that form of consumption resembling chronic bronchitis. In the same cases tar may be used, either in the form of tar pill or tar water. – Pthisis Laryngoea. This is nothing more than chronic laryngitis. The symptoms are pain in the larynx, fever, cough, peculiar noise similar to that in C. Trachealis, long inspiration, pulse never full nor strong, skin hot, tongue dry, & the bowels costive. As the disease advances respiration becomes more difficult. It is a very incurable form of disease. Upon dissection ulceration has been discovered in the larynx, & sometimes ossification. When it reaches the lungs it puts on the form of confirmed consumption. Treatment. In the commencement local depletion is necessary. The whole of the throat should be covered with leeches. After this a blister is to be applied. I have sometimes derived advantage from emetics, & an alterative course by mercury & cicuta. The general cause of Laryngeal consumption is cold; but there is another, that has never, until lately, been noticed. Elongation of the uvula has been observed by 198 Dr. Physick to produce it. In these cases there is generally a hard, dry cough, frequent effort to swallow, which beings on a violent cough, & danger of the suffocation for 10 or 15 minutes. The uvula is generally very much relaxed. It may occasionally be cured by gargles of kino, oak bark or catechu; but these generally fail, & the treatment is then to cut off the uvula. Apostematous Consumption. Or abscess in the lungs. This is common in all cold climates, & may be caused by wounds, catarrh &c. The symptoms are, a deep seated pain in the breast, which never changes nor fluctuates. It is attended with great dyspnoea. The discharge, until the abscess is ruptured, is generally mucus or phlegm. Treatment. The object is to prevent the formation of an abscess, & form the commencement to salivate with mercury without regard to the pulse. This remedy should never be delayed when there is any apprehension of an abscess taking place. When the abscess is formed, which may be known by rigors &c. it must be opened. It sometimes breaks spontaneously. It occasionally happens that the matter is not brought up, & it is then necessary to promote expectoration, by the inhalation of the vapor of water, vinegar, ether, tolu &c. A mixture of nitric acid & lac ammoniaci I have used with great advantage in relieving cough & dyspnea in apostematous 199 cases, & it may be useful in promoting the healing of ulcers. We must always attack the disease as early as possible. – To prevent its recurrence, the first step is to move the patient to a milder climate. A dry & temperate one has generally been selected. ========= It is said by some of the medical men of England the action of Intermittent fever is incompatible with consumption. In the language of one of them “It (intermittent) is a despot that will bear no brother near the throne.” They consequently endeavour to show to utility of removing the patient into miasmatic countries. The city of Valentin is chosen by the Europeans for this purpose; & in this country the best place to which we can send our consumptive patients is the W. Indies: particularly to Bermuda. Cuba is perhaps best place; or to Augusta in Georgia, or Columbia (S.C.) or St. Augustine. (E. Florida). The sea coast should be avoided as much as possible. (vide Baillie, Young, Southey). If this cannot be accomplished, confining the patient in a room at home, well regulated, may answer. The temperature of the room should be regulated by a thermometer. From 62◦ to 65◦ of Farenheit is the standard generally adapted. It is best to employ a stove: the temperature being more easily regulated. A sea voyage may be useful in the early stage. The utility of exercise, especially on horseback is well known. It was highly spoken of by 200 Lyndeham ; but , being both stimulant & tonic in its ef- effects , it should never be resorted to when the pulse is full , or when there is an inflammatory diathesis. When the patient is prepared for it , it will be of great util- ity. The diet should be light & of easy digestion. A course consisting of milk alone , or with farina ceres matter , is preferable. Ripe fruit may be of service. The Lichen Icelanders (vide. Therap:) may be useful. All the exciting causes, especially cold, should be avoided. Warm clothes should be worn, & especially flannel next to the skin. – ========== Class. 4. Diseases of the Absorbent System. ===== Dropsy. – Dropsy is said to be a preternatural collection of serous or watery fluid in the cellular membrane or cavities of the body. It receives different appellations according to the parts in which this fluid is deposited. The most important forms of the disease are Anasarca, Ascites & Hydrothorax. When the system is in its natural state, a watery fluid is poured out into every cavity, or cysts, of the body, & is taken up by the absorbents; & Dropsy may be owing to some excess in the secretions, or to some imperfection in the state of the absorbents. I should rather say that that dropsy of every description consists in pre-  201 ternatural effusion. The proximate cause of the disease is a derangement of the arteries : the effusion is the proximate ef- fect , & acts as an error loci , stimulating the arteries to an increased action. Europeans maintain that dropsy has its origin in debility , & suppose it to be a lax or cachectic state of the system : their practice consequently consists of the stimulating & tonic remedies. There is, however, great obscurity as regards this disease. It is connected with different states of the system, being sometimes accompanied with a febrile pulse, & at other times a disease of feeble action. - It is most commonly the effect of some preceeding disease by which the animal economy has been much disorder’d, as intermittent fever, jaundice, diarrhoea, gout, pulmonary consumption, scarlet fever, erysipelas &c. Stoll & Botellus maintain that when hemorrhagy is suddenly checked, the consequence is dropsy. Now & then it comes on from mere debility: there being in this case what is called the dropsical diathesis. The absorbents are here in fault. Anasarca. The species of dropsy shows itself by a swelling of the feet & ankles towards evening; which disappears in the morning. The tumefaction is soft & inelastic; the skin is much paler than usual; the face & eyelids are full & bloated. As the disease advances, the internal parts become affected; the respiration is difficult owing to effusion 202 in the cellular membrane of the lungs, or to effusion at the same time in the thorax or abdomen; the bowels are constipated; the skin is hot & dry without perspiration; the pulse is febrile & there is great thirst. After this the complaint increases, with much torpor & heaviness, & some fever. Mortification & gangrene often ensue. Anasarca may be connected either with a debilitated or excited state of the system. Treatment. Two indications present themselves in the cure of this disease. 1. To evacuate the serous fluid already collected. 2. To change the condition of the system which has produced the disease. The powers of the arteries & lymphatics being in an inverse ratio, the practitioners of this country resort to those means which deplete, & reduce the force of the circulation. Venesection in such cases is of great utility; but it must be regulated by a sound judgement. The pulse in the early stage is hard, tense & chorded; & the size of the blood evinces a high degree of inflammation; the skin is dry, & other symptoms of a febrile state appear. As long as this state continues detract blood. As auxiliary to the lancet we must use the evacuation measures. It was once the custom to prescribe emetics in this stage of the complaint. That they have some effect cannot be denied; but they have now lost ground, so that they are now rarely prescribed except to relieve a loaded or oppressed stomach, or in dropsy associated with 203 intermittent fever. They have given way to purgatives. These are called for on account of subduing febrile action. To evacuate the bowels in dropsy is of great advantage. It was the practice adapted by Lydenham & his followers. In the selection of cathartics some judgement is necessary. Drastics were one time preferred, but they are very injurious in the febrile state of dropsy: the are only useful when the disease is old. Much better are the saline purges: the best of which is cremor tartar in combination with jalap, in the proportion of ℥i or ii. of the former to grs X - XV. of the latter, to be repeated every 4 or 5 hours. In some cases of the disease this is very effectual, & the swelling has sometimes been entirely removed by it alone. It does not, however, answer in all cases; & we must then resort to those means which act on the lymphatics & kidneys. Of all the diuretics the best is the cream of tartar. Every modern practitioner now speaks well of this & of digitalis, but they are endow'd with different properties & are not at all applicable to the same cases. The cream of tartar when properly administered is much the best. It acts by a combined operation on the kidneys & bowels. There are two ways of giving it: dissolved in a large quantity of water, it operates only as a diuretic; but given with some other cathartic, it operates as a hydrogogue. The latter mode is to be preferred when we wish to remove large accumulations 204 of fluid. Dr. Physick prefers the soluble tartar. Much has been said of the Alkalies; but they have not been greatly employed. By some the potash (carbonate of potash of the shops) is preferred. The cases of dropsy in which they are useful are those in which the powers of digestion are impaired, as in drunkards. Cullen supposed that the potash owed all its diuretic properties to its being converted, in the stomach, into a neutral salt; but this is not the case. Combined with gentian or columbo, its powers are much improved. The alkali is, however, inferior to some of the neutral salts formed from it. Of these the sal diuretics (acetate of Potash) is perhaps the best: though in the few trials I have made with it, I have been disappointed. It appears to act more on the bowels than on the kidneys. The manner of giving it, is to dissolve ʒss. in a little water, which is to be taken 3 or 4 times a day. Much better is the sal: tartar & lemon juice; or the carb: potas & crem: tart: aa. ℥i. The nitrate of potash is much better, in dropsy of high action, than the former, on account of its powers over the arterial system. The objection to its use is that in large doses it excites nausea, but this may in part be obviated by giving it in free dilution: ʒi. to a quart of water, to be taken in the 24 hours: a wineglassfull at a time. As a substitute less offensive is the spts: nitr: Dulc:. This sometimes acts very powerfully on the kidneys. It is commonly prescribed in too small doses. Not less 205 than ℥ii – iv. several times in the 24 hours: in smaller doses it has no effect upon the kidneys. The following diaphoretic mixture will often answer as a diuretic. RX. Spts: Nitr: Dulc: . ʒi. Vin: Antim: . . . . . .g# XXX. Laudan: . . . . . . . . .g# XXV. Common parsley often proves very useful, & I have derived much advantage from it. It is given in the form of tea (of the root); & it is customary to unite with it the seeds of watermelon. An indigenous plant called scabious; a species of lichen, is much used as a diuretic in dropsy. Among the London practitioners the gipsissewa (winter green) is a favorite remedy; but it has not been much tried in the U. States. It operates on the absorbents, & I think it may be a good remedy. It is very efficacious in scrofula; & hence among the vulgar has been called kings cure. Such are the remedies which are most appropriate to inflammatory dropsy; but the disease often assumes a different shape & demands the other means for its cure. In these cases, the system being sufficiently reduced, we dispense with venesection; & the bowels being costive, we use articles of a drastic nature, as Calomel with gamboge. Scammony or Elaterium is generally used, & the purging should be continued for a considerable time. Diuretics are beneficial; & of these the digitalis is the most useful. (vide Therap.) Experience has generally been in 206 its favor, & its reputation in dropsy remains unimpaired. In its administration we must see that the case is a proper one: when there is much activity in the pulse the digitalis is unserviceable. It is only in the weak & low stages in which it is used. I have tried it in an inflammatory pulse without deriving an advantage from it; but when subdued, it is of great utility. Withering was much in favor of digitalis in these cases; but Darwin supposed it was best suited to cases brought on by debauchery. Withering used the watery infusion. I find the tincture more effectual. Nausea is an evidence of the system being under its impression. Tobacco has, of late years, been used in dropsy. It was introduced by Fowler. What its degree of value is, I cannot assert. The mode of giving it is infusion. Rx. Tobacco ℥i. on which pour a pint of water. The dose is g# XXX. It should not be used to the exclusion of remedies of greater utility. The squill is the most effectual of all remedies in dropsy; but it is highly stimulant, & should be given with judgement. (vide Therap. – Home & Cullen). I give it in combination with calomel, in the proportion of grs ii. of the squill, with grs i. of calomel. Cullen gave it in combination with neutral salts. When the calomel purges unite with it a small portion of opium. I would be inclined to urge it to a salivation. We are sometimes called to cases of dropsy connec- 207 ted with a weak & cachetic condition of the system. In these cases Cantharides have often been prescribed. In the weakened forms given in dose of ʒi – ii. several times a day, it produces copious discharges of urine. The success of the practice is corroborated by many respectable writers. It is stated by Cullen that it has no diuretic powers; but that its action is confined to the neck of the bladder: in this he is wrong. In febrile or excited dropsy it will do no harm. Of the oleum terebinthinae I cannot say much. It may prove serviceable in doses not exceeding g# XV – XX. at a time. The polygala Senega is an excellent remedy in dropsy. (vide Therap.) It is of late gaining ground both in Europe & this country; but it is only to a certain state of the disease that it is applicable. It is most serviceable in those cases of universal dropsy attended with enfeebled absorption, & a vitiated state of the body which often extends to the lymphatics. Its efficacy may be improved by uniting with it small portions of calomel: about grs XV – XX of powder’d senegas to grs i –ii of calomel, to be repeated 2 or 3 times in the 24 hours. The colchicum Autumnale was introduced into the treatment of dropsy by Baron Stärk. He recommended it in old & desperate cases of atonic dropsy. Of its powers I cannot say much. It is used either in the form of oxymal, syrup or vinous tincture: the dose in either case is ʒi. – Many of the aliacea & siliquosoe has been used in dropsy. The volatile 208 tincture of guaiacum in repeated doses has done much good. Diaphoretics are another class of remedies used in this disease, & they are certainly sometimes of great service in dropsical effusions. They act by transferring action from the interval to the external exhalents. They are most useful in such cases as are associated with intermittent fever, & are kept up by visceral congestion, where there is great debility & emaciation, with a small, tense, chorded pulse, & other circumstances denoting an enfeebled state of system. The external means often answer very well, as the vapor bath, or enveloping the limb in silk oil cloth. It acts by stimulating the vessels of the surface & exciting profuse perspiration. Warm oil acts in the same way. Combinations of Opium, Calomel & Ipecac: are more useful. Some cases of dropsy have been cured by opium alone. The Eupatorium Perfoliatum has been much used. It is presumable that it most serviceable in dropsy generated in marshy districts of country; & in these cases it is generally accompanied with intermittent fever. Mercury is not so well suited to anasarca, as to ascites & hydrothorax; but there are some cases of anasarca which depend upon visceral obstruction: to these cases mercury is applicable. In dropsy also where there is considerable tone, it is useful after vascular action is reduced. We must sometimes resort to local remedies in this disease. Small punctures with a lancet often do 209 much good; but we must be careful that we do not produce gangrene & mortification. Blisters cannot be used with safety: they are apt to produce gangrene. What is much more useful is tightly to compress the limb, above & below the affected part, with a flannel roller. By this we impart warmth & tone to the part, & prevent mortification. Blister are only useful in atonic dropsy. To prevent a relapse, the best remedy is tightly lacing the limb, or occasionally bathing it with brandy or cold water. Ascites. This is a collection of water in the abdomen, mostly met with between the peritoneum & abdomen muscles. It is attended with loss of apetite, sluggishness, inactivity, dryness of the skin, cough, sometimes a diminution of the customary discharges, & considerable constipation. It is often confounded with pregnancy & tympanites; but may generally be known by pressing with the hand on one side of the belly & striking on the opposite with other. This disease is most curable in adults, & is incurable in advanced life & very young children. The causes are in general the same as of anasarca; but it is more frequently occasioned by visceral obstruction. It is sometimes occasioned in a way that has not hither to been noticed. Dropsy has been often known to follow flatulent colic: in these case I have thought that the bloodvessels 210 secrete a gas, which is afterwards condenses into a fluid state. The same course of remedies as I mention’d in anasarca is necessary here; but as ascites generally procures from a morbid condition of some of the viscera, it requires for its cure mercury. Combinations of calomel, digitalis & Squills have long been used. The mercury should be gradually introduc’d into the system. When it cant be given by the mouth, it may be used in the form of a glister; & if not in this way we may use the nitric acid. The manner of discharging water in dropsy will be learnt from another chair. I shall only observe that it should be done as early as possible with propriety, & should be gradually evacuated. Before proceeding to this it would be well to try a large blister to the abdomen. Compression of the abdomen by a flannel roller has been often removed the swelling. – As a modification of ascites, I shall next take some notice of what is called Encystis. By this is meant a collection of water in some small sac of the viscera; & is by some writers considered under the same head with ascites. It is usual for acites to be preceeded by a dropsical diathesis, & swelling of the abdomen, extremities & particularly of the face; but in encysted dropsy there is an absence of these signs. The swelling is local & protuberant, being inclined to one side 211 of the belly; there is little or no thirst or febrile affecttion, & the urine is not decreased nor sensibly changed. When it occurs in women menstruation continues, which is not the case in ascites. The same plan of treatment is to be pursued as in the latter case. The mercurial practice is the only one entitled to any share of confidence. It is more necessary here, as there is generally a schirrosity of the viscus with which the tumor is connected. Being local in its nature, topical remedies are more useful in this than in other forms of dropsy. Blisters are sometimes used with advantage. When water collects it should be drawn off as soon as possible, without the caution necessary in ascites. === Hyydrothorax. == On Hydrops Pectoris. As this is generally held to be the most unmanaged of all the forms of dropsy, I shall be more minute with it. It often happens that this disease takes place to a considerable extent before it is perceptible. It comes on with uneasiness about the lower end of the sternum, with great difficulty of breathing, which is increased on any attempt to move & is most considerable during the night. The complexion is pale; the feet & legs are swelled; there is some degree of thirst, & the flow of urine is diminished. It is generally accompanied by emancipation & debility. These symptoms increase, but their progress is slow. Difficulty of respira- 212 tion & palpitations comes on; the head must be supported in an erect posture; the patient cant rest in a recumbent position for any length of time & the sleep is disturbed by alarming dreams. When afflicted with these symptoms the patient must continue erect. The face & extremities are generally cold; the pulse, irregular & intermits; a pain extends itself from the heart to the insertion of one or both the deltoid muscles. Drowsiness, coma & delirium often attend the latter period of Hydrothorax. Bloody expectoration some times takes place. Death is brought on by the slow wasting of strength, or dyspnea & often from some unknown cause. It sometimes takes place in moving from one chair to another. Dissections show that the water may be collected either in one side of the chest or in both, or in the pericardium, called then, Hydrops Pericardii. In these cases it is that death takes place suddenly. The water is most commonly met with in both sides of the chest, & it is accompanied by a collection in the cellular texture, which is of a yellow colour. When the quantity is considerable, the lungs are much oppressed by it. Some of the abdominal viscera are often found in a schirrous state. This disease is often confounded with angina pectoris, or disease of the large vessels about the heart; but there are two circumstances affording criteria of water in the chest. By striking the sternum, Corvisart says, we can feel the fluctuation of the water; & Bichat tells us that 213 by striking the abdomen the symptoms are increased. This disease is produced by all the causes of dropsy in general, by ill cured pneumonia inflammation, asthma &c. or by frequent drunkenness, & sometimes without any obvious cause. It is most frequently met with in old people. Treatment. The same remedies which are applicable to the other forms of dropsy are to be used here. It may be connected either with a tonic or atonic condition of the system; but if the early stage it is almost always inflammatory, & as such we must treat it. The remedy with which we should commence is venesection, & by this we will always find much relief afforded to the patient. It should be repeated periodically for weeks or months, as the symptoms may demand. Next to venesection is topical bleeding. Cupping is very general in this city. The best place for applying them is the back or shoulders. After thus depleting we may call to our aid the application of a blister on the breast, & the irritation must be kept up by dressing the blister or renewing it as fast as it dries. Much has been said of issues, but they are not equal to blisters. After this we may resort to diuretics. In the commencement nitre may be used: then a combination of Squills & Calomel. The mouth being affected is always an auspicious sign. When the case is not very serious we may use the squills by itself. In some cases I have derived great advantage from the oxymel of garlic, to be used for a week or more. It is better, however, to give 214 the juice mixed with honey. At one time the oxymel of colchicum or meadow saffron was highly extolled in the cure of the complaint. It may be, probably, found useful in some cases. Besides its diuretic, it has also expectorant properties. Much has been said of the digitalis; but the more I try it, the less is my confidence in it in this disease. My disappointments have been so frequent that I now prefer other remedies. (vide Therap.) It is much inferior to the Squill, which was used by Dr. Ferrier in the following manner. Rx. Ext: Elaterii . . . . . . . . . . . . . .gr i. Ether: Nitros: . . . . . . . . . . . ʒii. Tr. Scill: . . . . . . . . . . . . . . . . . . . Oxym: Colchic: aa . . ℥ss. Syrup: Rhamni . . . . . . . . . . . . ℥i. m. The dose is a teaspoonful 4 or 5 times in 24 hours. This he considers useful in all dropsies, but more especially in Hydrothorax. I do not hesitate to recommend it; but I think I have derived more advantage from Elaterium alone, in the dose of grs. ss. several times a day. Emetics it would seem might be useful in hydrothorax; but, except relieve the lungs, from phlegm, they are of very little advantage, & sometimes even aggravate the symptoms. Purgatives, a priori, we might suppose would be useful here; but the fact is otherwise, & in some cases they are very injurious. The system sinks under their operation: except in women, who seem to 215 be more tenacious of life than men. It has been observed by Dr. Physick that women will bear purging to almost any extent without injury. When they are to be used Jalap or Senna may be selected: a small quantity of potash will prevent the griping of senna. These are the remedies which are chiefly employed in the disease before us: the best of which I believe to be the combination of squills & calomel. It has been said by Cullen that Hydrothorax is an incurable disease. I have found more manageable than either ascites or anasarca. The diet in active or febrile dropsy should be low, & even abstinence has proved of great service. It lessens the force of arterial action, & increases the power of absorption. In atonic dropsy, however, the case is different, & we must support the system by a more generous diet, as oysters, eggs &c; but the stomach should never be overloaded. It has been recommended to abstain from drink, but it is a difficult matter to resist it under such circumstances. Cullen says that by abstaining from drink the kidneys become relaxed & the secretion of urine suspended. Diluent beverages may be used. Common water impregnated with a vegetable acid will answer very well; or an infusion of juniper berries, or gin & water; or an infusion of pine tips; or watermellons. When, as sometimes happens, the drink, instead of promoting the discharge of urine & perspiration, increases the effusion, it must be stopped. We now come to the 216 2nd indication in dropsy; which is , to preserve the return of the effusion. For this purpose we must observe the following rules. 1. Avoid all the exciting causes of the disease. 2. Strengthen the system by tonics. Of these the best is the Peruvian bark, alone or in combination with the chalybeate preparations; but sometimes the bitter tonics are preferable. The cold bath may be used when it agrees with the patient. While we are pursuing the tonic practice, it is sometimes necessary to interpose diuretics: of which potash is the best. 3. Exercise is very important: commencing with the passive as sailing &c. A journey on foot alone has effected a cure. (vid. case by Dr. Rush, of the man from S. Carolina). In some cases the tonic remedies are superfluous, & often nothing more is requisite than avoiding the predisposing causes of the complaint. – == Hydrocephalus. Under this title are included several forms of disease. The only division I shall notice is into Acute & Chronic: the latter is congenital. The brain gradually yields to the effused fluid, & finally becomes a mere sac formed by its membranes; the whole of the parenchyma being completely destroyed. The brain is said by Gall to be composed of membranes alone, which can be pulled out, forming a bag like the peritoneum. What seems to support this is that acaphali possess 217 intellectual faculties. By the older writers hydrocephalus was divided into Internal & External. This distinction is now abandoned. The acute species is called Hydrencephalus or water in the brain. It is generally confined to children; but sometimes attacks adults, & girls not menstruating at the proper time: in this case the brain is attacked by metastasis. Two causes have been assigned for the appearance of the disease in early life. 1. The size of the head at that period. 2. Its peculiar exposure to falls, blows &c. Another cause has been mentioned by some: The preponderance of the head inclining it to one side. I am inclined to believe that in a majority of cases it commences in a disordered state of the stomach, or some one of the chylopoietic viscera. To this conclusion I am led by the well known association which exists between all these parts, & by various considerations which may be deduced from the history of the disease, such as great disorder observed in the chylopocitic viscera, sometimes for weeks before the appearance of hydrocephalic symptoms, the removal of these symptoms by purgatives & other remedies directed to the alimentary canal, the extreme tenderness felt in the regions of the stomach & liver, the obstinate constipation attending at this period, in the peculiarity of the stools indicating extreme vitiation of the biliary secretion, & the phenomena exhibits on dissection, proving the previous exit - 218 ence of no slight disease in most of the abdominal contents, especially in the stomach & liver, & sometimes none at all in the brain. Hydrocephalus attacks in different ways, but generally with ordinary symptoms of fever, nausea & vomting, dry skin, flushed face, throbbing of temporal arteries &c.. Three stages are observed in this disease. 1. That of augmented sensibility, in which there is a great aversion to light & sound. 2. That of diminished sensibility: the pupil is here dilated, the stools watery, & of a clay colour, appearing as if they were covered with oil. 3. The paralytic or convulsed stage: attended by delirium low or raving, squinting, rolling of the head, & a rapid & thready pulse. Diagnosis. From verminosa febris , by the exacerbations of the latter being attended with heavy drowsiness, & the remissions with a morbid vigilance. The proximate cause of the disease, or the disease itself, consists in an increased & altered action of the vessels of the brain, producing an effusions of water into the ventricles, or some derangement in its organic structure from the continuance of morbid impression upon it. Dr. Rush supposed it to a be a less degree of the inflammation which produced Phrenitis. I suspect that the action in this disease is peculiar one. The collection of water I take to be the effect of prëëxisting action, as all the symptoms of this disease have been present when no water was 219 collected. A tendency to hydrocephalus has been cured by epistaxis. When the discharge from the schneiderian membrane is increased, the symptoms of the hydrophalus are relieved. Cheyne says that the effusion has nothing at all to do with the disease. In this I do not altogether agree with him. Certain it is, however, that water will continue in the ventricles, or, at least we have every reason to suspect its existence in some instances for weeks, months, or years without destroying life. – Dr. Rush considered this one of the most curable of diseases. Dr. Monroe, the most incurable. This is owing to their different views of the pathology of the disease. Treatment. The leading indication at this period is to subdue arterial action, by venesection, copious purging by calomel &c, the application to the head of cups, leeches & blisters, with a most strict adherence to the antithlogistic plan in all its parts. But venesection is much less effectual than would be anticipated from its known power in reducing arterial action. We are chiefly to rely on unremitting purging by the most active articles, as calomel & jalap. Venesection, however, is not to be neglected when there is much vascular action, & above all, topical bleeding, by cups, leeches or arteriotomy. Emetics have sometimes removed the symptoms of hydrocephalus, especially when of gastric origin, & even when there is no reason to suspect a disordered stomach. In this case they act as in some other cerebral affections, as apoplexy, tic 220 douloureux, amaurosis &c. When there is a throbbing of the temporal arteries, red eye, flushed face &c, they are inadmissible. It is by no means rare, at the expiration of 10 or 15 days for the more violent symptoms to subdue, so as to induce an expectation of a speedy recovery. This is sometimes a most treacherous & fatal calm, as it results from effusion having taken place. The vessels which had previously been so much excited, are in this way relieved & the attack is completely suspended. After a short interval, however, the extraneous fluid acts as a reexciting cause, & the disease returns with redoubled vigor. Under such circumstances, the case may be considered as desperate, or nearly so. Effusions into other cavities may be taken up, but experience teaches us that it rarely happens in these cases. As yet no one, except Museagni, has pretended to have detected absorbents in any portion of the brain, & by many their existence, even at the present day, is denied. But surely their not having been satisfactorily ascertained, is owing to the imperfection of our anatomical research, as the phenomena of growth, not to mention other facts, sufficiently attest, that they must belong to every organ and part of the animal machine. An absorbent is as necessary an ingredient in the composite of a living body as a blood vessel, each being indispensibly necessary to the execution of its primary & most important vital functions. Even admitting, however, the existence of lymphatics in the 221 brain, it is still not less true, that they act very feebly & incompetently in the hydrocephalic affections. Yet, on this account we should not be discouraged from urging the use of mercury in these cases. By the common consent of practitioners, it seems now to be conceded, that no plan of treatment holds out such prospects of success. Even when effusion has not taken place, it is serviceable by changing the action of the vessels, & diverting the complaint from the head. But, if water exist, it is the only remedy entitled to any confidence. To be effectual under such circumstances, the mercury must be applicable in a very bold & decisive manner. It should be exhibited in as large a quantity as the stomach & bowels will bear, & externally applied in the shape of frictions, with the strongest ointment, most diligently & copiously. To do less than this, in these desperate cases, is to trifle with the remedy, to practice injustice to ourselves, & to cut off the only chance which the patient has of salvation. Hydrocephalus is in sometimes of a different nature, & far less curable. It is occasionally the consequence of low fever & now & then depends upon a scrofulous diathesis. In these cases its effects are much slower and less distinctly characterized. The child takes his head from side to side, his generally in a recumbent posture, & the pupil is dilated. This form commonly proves incurable. Direct depletion is seldom admissible. Leeches 222 are to be applied to the head, to be followed by a blister. But we must rely principally on purgatives. Carmichael Smith used calomel & squills. Prognosis. When originating in the chylopoietic viscera, it is manageable than when the brain is the seat of it. – Difficulty of keeping the child in an erect position, the pupil much dilated, tinnitus aurium, discharges of great quantities of transparent urine, are dangerous symptoms. The stools becoming natural are favorable. – The ordinary period of the acute form of the disease is about 3 weeks; but this generally runs for 6 or 7 weeks, or it may terminate fatally in 5 or 6 days. In the chronic form of the disease, no remedy I know of, is of any service. Tapping the brain has been performed 5 times: twice with success. The water must be discharged gradually. It may be done with the common couching needle. The operation should only be resorted to, in Acute Hydrocephalus, when there is considerable effusion, with some remission of the symptoms, & before the disease is re-excited by the stimulus of the effusion, or where the ordinary remedies have failed. Mr. J. Bell says that when an injury, however violent, is confined to a portion of the brain only, it is not so dangerous as a very slight one extending over the whole organ. ======= Scrofula Or King’s Evil. This is a disease which generally 223 appears between the 1st & 5th years of life; but is sometimes developed at a more advanced period: tho’ rarely after puberty. The first appearance is generally small oval or round tumors under the skin without any discolourization. They generally appear at the side of the neck, or under the ear, but sometimes about the joints. After some time they increase, & become livid or purple & at length suppurate. The matter is at first puriform; but it afterwards has the appearance of curd of milk. The tumors then subside gradually; & in this manner the disease continues for some years. This is the mildest form under which scrofula appears: in more violent cases the eyes are the seat of it, & become affected with ophthalmia, terminating frequently in opacity of the cornea. In other violent cases the joints become affected: they are swelled & painful, & this increasing, the muscles & ligaments become involved, & the bones are often in a carious state. By irritation, hectic fever at length arises & puts an end to the disease . On dissection, the viscera are sometimes found in a diseased state; the mesenteric glands are enlargened, the lungs are frequently cover’d with tubercles, or cysts which contain matter of various kinds. – Of the causes of Scrofula we are still inperfectly informed. It is supposed to be hereditary & to descend from the father more generally. Every writer on this subject has remarked the strumous diathesis is associated with certain constitutional peculiarities, 224 indicated by beauty, light or flaxen hair, rosy cheeks, great delicacy of skin, blue eyes & large pupils. Though the disease may be traced to hereditary origin, there are other causes which excite it. Of these the most powerful is climate, or certain states of the weather. It prevails generally in mild latitudes, or where the weather is variable & moist, as in Great Britain. Extremes of heat & cold are adverse to it. It generally appears in the spring & disappears again in the summer. Wearing wet clothes has often excited an attack of the complaint, as also low & penurious diet, close confinement & want of comfortable , & inattention to cleaniless. It would appear that scrofula is sometimes developed by certain diseases. By Wm. Hunter it is said that syphilis has this effect, & by Dr. Haen, the small pox. It is probable that all the exanthemata have this tendency. As respects contagions there is not the least foundation for supposing it a cause of the disease: it cannot be propagated by inoculation. The humoral pathologists suppose it to be owing to an acrimonious state of the blood. Cullen supposed it to depend upon a morbid state of the lymphatic system. My opinion is that it consists in a highly deranged state of the chylopoietic viscera, & all the apparatus subservient to digestion absorption &c. (see Carmichael on Scrofula). Treatment. Two stages are distinctly marked in scrofula, & in some degree require different treatment. The first is called the occult: in this stage there is no con- 225 siderable tumor, ulcer or other local affection: tho’ at the same time the system is considerably disordered. The course here is to recommend a removal of the patient from the sphere of those causes which produce the disease; & the diet should be low. The alimentary canal is usually affected, as is indicated by nausea, loss of apetite, indigestion, furred tongue & constipated bowels. In these cases I premise the tonic treatment, by copious & long continued evacuations. Emetics are proper when there is much gastric disorder; but purgatives are preferable, & are generally used. They must be repeated every 3rd or 4th day, for several weeks in succession. The stools at first and dark & offensive. The alimentary canal is now ready for the reception of tonics. Of these the Peruvian bark, alone, or in combination with the chalybeates, is the best. The cold bath has been recommended; but it sometimes proves injurious: this is the case when, instead of exciting a glow, it produces chilliness &c. In such cases it would be right to exchange the cold for the warm bath, which may be improved by the addition of a little salt. This operates in two ways: it restores the surface to its natural state, & also prepares the way for the cold bath. Seabathing has proved of service. The diet is of great importance. It may be vegetable or animal according to circumstances. As a general rule, it is best to select the light & easily digested meats, with a considerable intermixture of milk; avoiding whatever has a tendency to 226 heat or stimulate the system. Steady & uniform exercise on horseback into the country should be used; but immoderate exercise will prove injurious. Russel says that after a forced march, many of the soldiers of the British army under Wellington were affected with scroffula. A certain condition of the weather, as cold & moisture, which generates the disease, must be avoided by confining the patient in a room where the temperature is equal, as directed in pulmonary consumption. But above all we should recommend a removal to a warm climate until after the age of puberty. This brings us to the second stage of the disease, or where it is accompanied with tumors or ulcerations. The practice here is general & topical depletion as there is generally some febrile action. Evacuations from the bowels are important. These, instead of debilitating, invigorate the patient. I have often seen white swellings cured by long continued purging; & its effects are now universally admitted in the morbus coxarius & diseases of the spine. This plan must be persisted in for weeks & even months. Venesection is called for by the state of the pulse, pain, swelling & induration of the tumors. Should this treatment we are to resort to mercury. It must be gradually insinuated into the system by being used only as an alterative: a deep mercurial impression should be avoided. There is no general rule as to the use of mercury: so various are the cases & so 227 different its effects. I have found grs ss. of Calomel 3 or 4 times a day, for 3 or 4 weeks to be about the proper quantity. To increase its alternative powers some practioners recommend uniting sulphur with it. Corrosive sublimate will sometimes answer very well. Opium or circuta with the calomel has been found useful. These are the remedies best suited to the early or inflammatory stage; but there are some local remedies for expelling the tumors, as topical bleeding. When the tumors are painful & inflamed, leeches must be applied. The swellings are often indolent: in these cases stimulating applications, as salt & water, or frictions of mercury; either the simple ointment or with camphor, have been found useful. Plaisters of emetic tartar have been used with advantage. When these do not answer we must wash the part with ley, or ardent spirits. When a tumor comes to a head it is right to open it. This is the most favorable form of scrofula, but when the disease advances, or when it is from the commencement associated with a disorder’d state of the system, it puts on a more formidable aspect, & the ulcer become painful; sometimes they are flabby & phagedenic & at other times fungous. The leading indication here is to restore tone & healthy action to the system. The Alkalies were at one time much in use, but I am not sensible that they are productive of any great advantage. Upon the same footing do I place the lime water. Two new medicines have of late attracted our attention in 228 this disease. These are the muriate of barytes & the muriate of lime. They have now lost their reputation & are no longer prescribed: they, in fact, make no impression on the disease, & are extremely nauseous & distressing to the stomach. Much more is to be expected from the narcotics, especially when the morbid condition of the system is associated with ulcers. Of these remedies, the Cicuta has the least equivocal reputation. It was originally recommended by Baron Stoesk. My experience is very much in its favor, & I have used it in almost every stage of the complaint with advantage. To attain its effects, it must be liberally used. Begin with moderate doses & gradually increase them. I have given as much as ʒi. in 24 hours. The rule is to continue it until there are some signs of its effects upon the system, as nausea &c. The strammonium has been much praised; but I do not think it equal to the former. It, & the cicuta may be used alternately. Belladona, henbane, opium & dulcamara have been employed. Of the use of opium much has been said. The cases in which it is proper are those marked by great irritability of the system & local affections. In some cases it is right to unite with the narcotics some preparations of mercury, particularly corrosive sublimate. Diaphoretics have been much, & beneficially employed, as guaiacum, sarsaparilla, megereon & sassafras, either alone or in the form of the Lisbon diet drinks. Arsenic has been used in scrofula; but, so far as I know, 229 the testimony in its favor is very limited & wants confirmation. The ulcerations next demand our particular notice; but as this belongs to the province of surgery, I shall make but a few remarks upon it. Weak solutions of sac: saturni are useful. Salt & water will answer very well, or even water alone applied by cloths. Simple cerate, when ointments are demanded will do very well. It is often necessary to make use of the stimulants. White vitriol has been used. A strong solution of blue vitriol, I would suppose from analogy to be of service. A poultice made of ℥i. of Glauber’s salts to 3 pints of water worked up with crumbs of bread is an excellent application. There are sometimes ulcers of a different kind which must be destroyed by escharotics. They often resemble cancer: in such cases dulcamara & other narcotics are useful. Cloths wetted with a solution of opium afford temporary relief. Covering the surface of the ulcer with powdered hemlock is also serviceable; or a common carrot poultice. The treatment must always be regulated by the character of the ulcer. There are two more remedies of much importance to be mentioned. The first is the nitric acid. I have been more satisfied with this than with any other remedy. It should be given in the dose of about ʒii. in the 24 hours: at the same time dressing the ulcer with citrin ointment. The other remedy is the Pipsissewa. It is to be taken internally, & at the same time the ulcer 230 washed with the decoction. This is probably one of those diuretics which act directly on the lymphatic system. Mr. Carmichael used the chalybeates. – After the complaint is removed there is generally left an extreme degree of debility, which predisposes to a relapse & should be removed. For this the whole class of tonics have at one time or other been recommended. The best of all, however, are the Peruvian bark & chalybeate preparations, sometimes separately, but generally in combination, & myrrh is occasionally added. If these should prove unavailing we must recur to sea bathing as a dernier resort. This disease affects every part of the body; but most generally the larger glands, as the testicles & mamma. Cases of this belong to Surgery. ======= Marasmus. This is a disease generally confined to children, & mostly makes its appearance soon after weaning: it, sometimes, however, occurs in advanced life. The symptoms are, an irregular appetite, pain in the abdomen & emaciation of the whole body. It was long the custom to treat this disease by steel & other tonics; but this is far less efficacious than the purgative plan, which I have invariably pursued. Marasmus has been imputed to worms, & to obstruction in the mesenteric glands. It may occasionally arise from both of these causes, tho’ I am disposed to think, that it has most commonly 231 its origin in a torpid & weakened state of the alimentary canal, with which the whole of the chylopoietic viscera sympathise. Dissections show the intestines filled with black foetid sordes, or impacted mucus, the liver much enlarged & the mesenteric glands considerably tumified. Whatever theory is adapted the treatment is the same. Two stages are very distinctly marked is the marasmus of children; the incipient & confirmed. The bowels in the first stage are not altogether inactive , & mild purgatives repeated at proper intervals are to be employed. But in the second, there being little sensibility & the accumulation of feculent matter prodigious, we must purge actively. Calomel should be given in as large doses, & as frequently repeated, as circumstances will admit. This, instead of debilitating the child, will be found to add to his strength. After this we may make use of tonics, as the Peruv: bark or preparations of steel, or the cold bath. Exercise or a removal into the country will also be found useful. This disease is not an incurable one: the want of success is generally owing to the empiricism practiced in it. A cure is often effected by the spontaneous operation of nature. This generally takes place about the age of puberty: hence the superstition of some who suppose that the hand of a man who has been hung, a mouse’s blood, or the lead of the coffin, will effect a cure, when in fact it is owing to nature. 232 Class. 5. Diseases of the Cutaneous System. ======= Exanthemata. ========= This is derived from two Geek words εξ from, & avθoδ a flower: because they are distinguished from all other complaints by an efflorescent or florid appearance of the skin. Cullen adds to this, two other characteristics. 1. That they are propagated by contagion. 2. That they can attack the same person but once. To these belong Small pox, Cow pox, Chicken pox, Measles & Erysipelas. Cullen includes also Pestis; but this appertains to another, & very dissimilar place, in nosological arrangement. That small pox is contagion can easily be shown, & also that it can in general affect the same person but once; but in relation to chicken pox, measles, scarlatina & erysipelas the case is different. Chicken pox cannot, like small pox & cow pox be propagated by inoculation: it is more like a circumscribed epidemic than a contagious disease, & may arise from a morbid condition of the atmosphere, as children of the same neighborhood are affected with it at the same time. Few complaints exhibit a more satisfactory evidence of gastric origin than the exanthemata. In small pox, the stomach is always primarily affected, & the 233 confluent small pox is usually ushered in by incessant vomiting. Gastric disorders occasioned by putrid food very often put on the appearance of certain eruptions. The primary irritation in the exanthemata would appear to be in the mucus membrane of the primoe vioe, & is generally confined to the upper part of the alimentary canal, & principally, according to Mr. Alcock of London, the stomach & duodenum. The skin is reflected from the external parts to the trachea, bronchiae &c. & to the mouth, oesophagus & alimentary canal. There are other reasons for believing the stomach the seat of the primary affection; but the most conclusive is the difference which exists between the casual & the inoculated disease; & if we admitted that the poison does not enter the blood, but is entended by sympathy, then every difficulty cleared: hence the reason why casual small pox is dangerous & the inoculated not. - The first disease of this class I shall mention is Erysipelas. Or St. Anthony’s fire. This is a disease which makes its appearance on any part of the body, especially the lower extremities; but I shall treat more particularly of that of the face; & the treatment of this is applicable to all forms of the disease. Nosologists make a distinction between Erysipelas & Erythema: the one being a general, & the other a local affection. Erysipelas 234 rarely penetrates beneath the true skin. It is ushered in by coldness or shivering, with other symptoms of incipient pyrexia; the hot stage is often marked by confusion of mind, & even delirium & frequently coma. The skin is hot & dry; the pulse frequent & generally full & hard. These symptoms having continued for 2 or 3 days, some part of the face becomes red, without any thickening of the skin, & there is more of the venous than the scarlet or arterial hue. The swelling is not at first of very great extent; but it gradually spreads all over the face; then the hairy scalp & neck are affected, & as it spreads it is marked by more swelling. The whole face is now turgid, & they eyes are swelled & often closed. Blistes or vessications of different sizes sooner or later appear in the face. The fluid in them is thin; the colour is sometimes yellow, at other times nearly colourless. Desquamation sometimes takes place in the skin, & imperfect suppuration often occurs in the eyelids. The febrile symptoms increase as the inflammation spreads. The duration of the disease is about 8, 10, or 12 days. Sometimes the patient dies on the 3rd or 5th day. The complaint is marked by no evident crisis. Prognosis. In general the higher the delirium & the deeper the coma, the greater is the danger. Dark colour of the skin & much swelling are also unfavorable signs. The chance of recovering is more doubtful in old age, or where there is a broken down condition of 235 body. Entire suppression of urine is a deadly symptom. Erysipelas is not contagious. This is supported by the solitary or isolated existence of the disease: except when it happens in crowded places. It often supercedes & sometimes alternates with attacks of podagra, & it generally attacks at the same age that gout does. It also most frequently affects the debauched & intemperate, & those of a temperament full & solid. Intemperance in the use of liquor has often been known to produce it, & it is often caused by some kind of gastric derangement, usually accompanied by acid eructations or bilious vomitings. I believe that a derangement of the stomach is its constant & invariably precursor. Upon dissection there is always an appearance of inflammation in some of the abdominal viscera. Treatment. In the management of the disease great attention must be paid to the evacuation of the alimentary canal. An emetic in the beginning will often arrest its progress, & even failing in this, it mitigates the more violent symptoms. The evacuation of the stomach should be immediately followed by that of the bowels: for this purpose Calomel should be selected, & worked off by Calc: magnesia. A diaphoresis should then be produced by some of the mildest diaphoretics, & diluent drinks. But this must be done before the complaint is fully formed. After the disease is established, another plan of treatment must be pursued. If there be fever, pulse full & 236 hard, delirium or a tendency to coma, venesection should be practiced to a great extent, except when there is much debility; & evacuations from the alimentary canal are again demanded. Vomiting is first to be excited by ipecac: & tart: emet: , & then mercurial purges are to be given. When the alimentary canal is sufficiently evacuated, & coma & delirium still continue, recourse must be had to leeches or cups to the forehead. If this do not answer let the head be shaved & covered with a blister. I have known good effects, even at this period from an emetic; or taking blood from the nostrils by a few leeches, irritating epistaxis which is always salutary in erysipelas of the brain. Much good may also be derived by applying leeches to the inside of the eye when the vessels are much inflamed. When the system sinks it must be supported by the usual remedies: these are either external, as rubefacients, sinapisms & blisters; or internal, as opium, camphor, wine & bark. To allay irritation of the surface a watery solution of opium is very good. – This practice is different from that of the English. The Scotch are more correct as regards this country. Erysipelas may be either inflammatory or typhoid. In the U. States & especially in private practice, it is always inflammatory & requires the depleting remedies. When typhoid it demands another course of practice. Venesection is impracticable. After purging we give the vol: alkali & opium. The London 237 practitioners rely chiefly on the Peruvian bark. In Erysipelas of the extremities, we may dust of part the part with rye meal or common hair powder. A watery solution of opium, or laudanum & lead water have been used. The mercurial ointment is an important remedy, & was extensively used by Dr. Physick. Corrosive sublimate, in the proportion of grs i. to ℥i. of water, is especially useful in erysipelas from poisons to the skin. It has been used with success by Dr. Schott of this city. I have found citron ointment very beneficial in that species of erysipelas called the Shingles. In case of erysipelas behind the cases of children, an ointment made of ʒi. of calomel to ℥i. of simple cerate, will be found useful. Dusting the part with calomel will answer. There is a species of Erysipelas which makes its appearance a few days (5, 6 or 10) after birth, commencing on the belly & extending to the breast & legs. It sometimes attacks the neck; & at the other times the toes. It is at first florid, but soon becomes dark or of a mahogany colour. It sometimes resembles Phlegmatia dolens. The vesicating applications are here of no service. Vol: alkali has effected a cure. But the only certain remedy is mercurial ointment, applied in a cloth. – vide Underwood. – Scarlatina. Or Scarlet fever. This is a so called on account of the peculiar florid appearance of the skin, by which 238 it is commonly attended. It is a disease frequent in its occurrence, extensive in its prevalence, & sometimes very fatal in its ravages. It attacks the youthful in preference to those advanced in years, & is a disease of the spring & winter, rather than of summer or autumn. It is divided by nosologists into 3 forms, which are nothing more than the same disease into different degrees of violence, viz. Scarlatina simplex, Scarlatina anginosa & Scarlatina maligna, more commonly called the putrid sore throat. By Scarlatina simplex is meant the simple constitutional disease without any affection of the throat. In Scarlatina anginosa, there is a higher degree of the same complaint, the throat is inflamed & swelled; & in the Maligna, it is of greater violence, & the symptoms are of a malignant nature. It may occur without the sore throat. Cullen supposes it to be a different disease from cynanche maligna. Each form of scarlatina may prevail at the same time in the same family of children; but two epidemics different from each other cannot exist at the same place at the same time: yet Cullen supposes the 3 forms of scarlatina to be different diseases. Like most other forms of fever, Scarlatina begins with anorexia, chilliness, fullness of the head & lassitude, to which succeeds prostration of strength, nausea & vomiting. The surface becomes hot & red. At this period there is more or less of a catarrhal affection, & 239 pain in the frontal sinuses. If these symptoms be very slight, the disease is the Simplex; if more violent, the Anginosa; & if very much so, the Maligna. In the worst forms of scarlatina maligna the patient becomes pale, sick & faint; his head is giddy & confused rather than painful, the heart palpitates; uneasiness is felt in the stomach, but he does not vomit: the stomach being prostrated below the point of reaction. In some cases the patient sinks at once. The face is pale or livid; the eyes exhibit a glary appearance, & are marked by a fatuitous or inebriated expression. On the 3rd or 4th day the febrile symptoms become visible; the skin is sensible to the touch, & is of a red colour, which extends to the face & fauces, but this is not an incurable symptom. The pulse is preternaturally frequent, quick & forcible in the simplex; more so & full in the Anginosa; less full, but resisting & firm in the maligna. The eruption has sometimes the appearance of red points, but generally of red patches which unite so as to cover the whole surface. They first appear about the face & neck, & in a few days on the lower extremities & on the hands. The eruption is not very regular: it generates continues for 4 days, & goes off with a desquamation of the cuticle. The tonsils swell & become marked with specks which slough off about the 8th or 10th day. As the disease proceeds, the neck & lower jaw become stiff. In the more malignant cases the danger is greater. The slough in the tonsils are larger, 240 & discharge an exceedingly acrid matter; there is a pain in the glands of the neck; & a diarrhea, supposed to proceed from the acrid discharge from the ulcers. This disease is said to be a contagious one; but on this point the evidence is very equivocal. It may be contagious when it assumes the low & typhus character; & it is always best to act in practice under an impression of its contagious nature. When the attack is violent the system is, in some measure, secure from a revisitation of the disease. I have never seen the disease occur twice in the same individual. Diagnosis. Scarlatina has a great similarity to measles; but in the latter disease there is more of the catarrhal & ophthalmic appearance; the eruption is smaller & more defined, & the cuticle is rougher to the touch. The eruption in measles never appear until the 4th or 5th day, or even later, & is of a dark raspberry red; while in scarlatina it appears on the 3rd day, & sometimes on the 2nd, & is of a bright red. In the cough of measles there is a peculiar harshness which cannot be mistaken. In measles the throat is rarely, tho’ sometimes, affected, & there is seldom any swelling of the glands of the neck, which is almost always the case in scarlatina. In scarlatina anginosa the tongue is red like raw beef. – Dissection proves that the original seat of this is in the primoe vioe, & more particularly the stomach. Scarlatina maligna has often put on the form of cholera morbus, & terminated fatally in a few hours. The opinion that it has its 241 seat in the throat cannot for a moment be sustained: topical affection of this nature, infinitely more extensive than in this disease, do not prove fatal. Inflammation soon run on to gangrene, in this disease. Prognosis. It is unfavorable in proportion as this malignant form is more or less complete. When it puts on the mahogany appearance, I have never known a patient to recover. The termination of this disease is sometimes very abrupt & unsuspected: in such cases the stomach is literally dead. Treatment. In its simple form scarlatina requires very little aid. Emetics of ipecac: or tart: emet: & evacuations from the bowels by Calomel & afterwards the neutral salts, sometimes venesection, & a well regulated diet, are all that is required. But in the Anginosa state we must rely on a thorough & entire evacuation of the alimentary canal. Unless the violence of the symptoms call for immediate venesection, we commence by vomiting by tart: emet: & follow it by a purge of Calomel & Jalap. Calomel is the best purge on account of its preventing & removing obstructions of the viscera, & this is a disease in which congestions of the great viscera are very apt to take place. Vomiting & purging are to be repeated according to circumstances. In the more advanced stage the milder laxatives may be substituted. The stomach & bowels being evacuated & the pulse full, tense or hard, recourse may be had to 242 venesection, which must be regulated by the skill of the practitioner. Much has been said of the comparative utility of the warm & cold bath in this disease, by the Europeans. In the beginning when there is much arterial action & vast augmentation of heat on the surface, cold ablutions will afford much relief to the patient. Dr. Gregory of Edinburgh recommends immersing the patient in a tub of cold water: but this is not a safe plan, & it has proved fatal, as was the case with one of his own children. In the advanced stage, or when the eruption imperfectly comes out, & especially when it is attended by coldness of the surface, or when eruption has disappeared, I have known much good to be derived from the warm bath. The action of the system being reduced by general means, topical remedies may now be used. When delirium, stupor or coma takes place, we may resort to leeches, cups or a blister to the head. To relieve the swelling of the throat, warm poultices, as corn mush, or bags of ashes, or mashed potatoes may be used, & finally local depletion by leeches, to follow by a blister. To cleanse the foul ulcers in the throat nothing is better than an emetic if ipecac: or tart: antim: the sub-sulphate of mercury has been recommended by European writers. After this detergent gargles may be used: of these the best is a decoction of Peruv: bark, with the tinct. of myrrh; or barley water with a small 243 quantity of the muriate of soda. In W. India, the following is used. Rx. Cayenne pepper . . . . . . . . . .2 tablespoonfulls. Common Salt . . . . . . . . . . . . . ʒii. Warm Water . . . . . . . . . . . . . .ʒviii. Vinegar . . . . . . . . . . . . . . . ℥viii. To be strained & used as a gargle. - Cups should be applied & purging continued with activity. If the disease be chronic, a salivation might be resorted to. In the Malignant Scarlatina purging should be carried to a greater extent. Calomel should be used, and may sometimes be carried to the extent of a salivation. In this form of the disease venesection is admissible only in the early stage, & in many cases not at all. Cordials & stimulants external & internal, as vol: alkali, camphor, turpentine, wine &c. are to be used when the patient is low. – Deafness sometimes follows this disease, proceeding from an obstruction of the eustachian tube from inflammation: it requires no particular treatment. After the disease is subdued an edematous swelling often takes place in the extremities. The best practice here is to purge moderately & then give digitalis. I have found it more useful in this than any other case of dropsical swelling. It may be aided by friction & bandages, if the swelling be large. The patient should also take well regulated exercise. (Prognosis) Measles. - 244 Prognosis of Scarlatina Measles. Called in medical language Rubeola. This is a complaint in many respects curious & interesting. Like scarlatina it is more prevalent in spring than at any other period. It also has the character of an epidemic & is carried through a vitiated atmosphere. It is a complaint incident only once to the same individual, & attacks the young rather than the old. It occasionally occurs in summer & autumn; & all extremes of weather increase its violence: in winter it is apt to be highly inflammatory. It is a common opinion that this disease occurs regularly once in 7 years. From the year 1772 to the present time, it occurred generally every 6 years as an epidemic, in this city & its vicinity. This cannot be accounted for on the principle of contagion. Excepting Influenza it is the most extensive epidemic. In less than 4 months, in 1801, the disease spread over the greater part of the U. States. It is one of the complaints to which in part some domestic animals are subject; & in the year 1801 many of them in this city were affected with it. Persons having this disease are generally affected with the Rubeolus fever. Professor Home of Edingburgh says that measles may be propagated by inoculation, & a mild disease produced; but experiments since made prove the contrary. As a general rule measles cannot be take a second time; but 245 there is a sphere of it called Rubeola seni catarrho, or French measles, which is apt to occur twice. Measles is ushered in by languor, chilliness, anorexia, heat, thirst, anxiety & vomiting. The fever, tho’ at times very slight, is generally considerable from the beginning, & becomes more severe just before the eruption, which usually appears about the 4th day. This fever is accompanied with more or less hoarseness and difficult respiration, pain in the chest, considerable coryza, the eyelids are inflamed & swelled, & there is frequent sneezing & drowsiness. About the 4th day the eruption appears, first on the face & neck, then successively on the other parts of the body. In 2 or 3 days it assumes a brownish colour, & is followed by a mealy or branny desquamation. The fever generally continues until the desquamation is complete, & sometimes even to a later period. The cough is generally more protracted in its duration than the fever. The affection of the chest sometimes amounts to peripneumony: this may take place at any period of the disease, but generally about the time of desquamation. Diarrhoea sometimes occurs. Persons who have laboured under scrofula & hepatitis have these diseases generally caused again by measeles. – Diagnosis. – vide scarlatina. – Prognosis. - It is unfavorable in proportion as the gastric affection is more violent. A painful eruption, accompanied by vomiting, soreness of the abdominal 246 region, & diarrhoea, is unfavorable: the absence of these symptoms is favorable. This disease might be supposed to have its primary seat in the lungs, but there is reason to believe that this is not the case. It is more probable that its seat is in some abdomen visceras, & this, no doubt, in the stomach: the lungs & skin being affected by sympathy. As a general rule it is complaint more purely inflammatory than any other of the class of exanthemata. This, however, is not always the case: it sometimes assumes a malignant character, & has no appearance of inflammation; but this fever is of the typhus kind, & the disease is now called Putrid measles, or Rubeola Nigra. In cases of this kind the gastric character predominates. It may be said that no disease is malignant unless the stomach is affected. Treatment. This must vary according to the character of the disease. In the lightest forms no medical aid is necessary. In attacks of greater severity, the temperature of the room is of much consequence, & should be such as to favor cutaneous action. That from 62◦ to 68◦ of Farenheit is about the proper standard. In commencing the treatment one leading object is to evacuate the alimentary canal by a dose of ipecac: or tart: emet: to be followed by a purge with the Sulph: Soda or some other neutral salt. After this the milder diaphoretics & diluent drinks may be used. 247 If the fever be high & the pulse full & hard, venesection must be practiced, & repeated as often as circumstances may demand. When symptoms of peripneumony occur the general bleeding must be assisted by cups &c. The quantity of blood to be taken away must be regulated by the experience of the practitioner. Convulsions sometimes ocur, to remove which the warm bath or an emetic will be of service. In the course of the disease the bowels must be kept open by the mild purgatives. To allay thirst flaxseed tea may be given. To promote rest an anodyne of opium, nitre & ipecac:, or laudanum, & with the same view a stimulating pedeluvium. To allay cough & promote expectoration, we must use a combination of the squills and antimonial wine. If pneumonia symptoms exist we have recourse to venesection & blisters, & the vol: alkali has often been used with benefit. In the Malignant form, or Rubeola nigra, venesection cannot be used. When the lungs are congested topical bleedings will be of service, but we chiefly rely on evacuations from the primoe vioe, commencing with emetics, & then mercurial purges. The warm bath may afterwards be used, aided by cordial drinks. If the eruption be deficient in quantity or colour, we must resort to sinapisms or rubefacients: these failing we must use cordials & internal stimulants, as vol: alk & wine whey or the peruv: bark. The consequences or sequelae of this 248 disease next demand our attention. These are for the most part, Ophthalmia & Dropsy. Scrofula sometimes follows ill cured measles; & sometimes hoarseness or loss of voice. This is to be relieved first by emetics, & then inhalations of laudanum & Hoffman’s anodyne. The diarrhoea in the close of measles requires no particular mode of treatment; but perhaps our remedies should be directed to the surface. Astringents will produce no effect whatever. We must resort to venesection ℥v – vi. at a time, interposing at night the Pulv: Doveri: this was originally the practice of Sydenham. The patient must avoid cold, be warmly clad, and guard against every thing that tends to check perspiration. If it be obstinate, we must order a change of climate especially by a sea voyage. Small Pox. Or variola. As regards any district of country Small Pox can be annihilated. But a century ago it was the scourge & terror of nations. Cases of small pox will perhaps never fall under your care; but it is proper to become acquainted with, if only as a matter of curiosity. Our earliest knowledge of this disease is derived from the Arabians. There is some account of it in an old Arabian manuscript in Leyden, written by Rhazes in the year 572. In that year, says the author, the small pox & measles made their first appearance 249 in Arabia. From this account it is to be regarded as a disease of Asia. About the 11th or 12th century the intercourse between nations becoming greater, it was extended throughout Christendom, & for 600 years, its ravages were terrible. Afterwards extending to Europe, it passed, by the emigrants to the aborigines of this country. The first step in the mitigation of its evil was the antiphlogistic treatment of Lydenham. The second was the process of inoculation which was the practiced in Europe early in the 18th century. The next was vaccination, which has left nothing but the history of its former ravages. – As regards small pox depending on a specific contagion, no one can doubt; but its extent is limited: it is perhaps not more in the open air than a few feet. But as far as the peculiar odour extends, so far will the contagion operate. Hagarth says that the contagion does not extend beyond the limit mention’d under Typhus fever. Whether the disease can be carried by fomites is uncertain. Hagarth, from a number of facts, entirely denies that it can. The opinion of medical men transmitting the disease is not well established. Of small pox there are two varieties. The Distinct, or Discreet, as it is sometimes called, & the Confluent. In the former the eruption fever is moderate, & of the true inflammatory character. It commences with chilliness succeeded by languor, drowsiness & uneasiness in the head, & on the 3rd day the fever comes on: at this 250 time children are subject to startling in their sleep. In the perspirable matter there is a peculiar ordour, which cannot be mistaken by those who have ever seen a case of small pox. About the eve of the 3rd day the eruption appears & continues until the 5th. It appears first on the face & then extends to other parts of the body. On the commencement of the eruption the fever abates. The pimples remain distinct from each other & are round & will defined. On the 4th or 5th day, they become pustules containing a colourless fluid. A secondary fever, when the pustules are numerous, takes place on the 10th or 11th day: this ceases as soon as the pustules are mature. In this disease there are 4 stages. 1. The febrile. 2. The eruptive. In 4 days more maturation takes place which is the 3rd stage; & in 4 days more desquamation takes place, leaving the skin of a brownish colour, this is the 4th stage. Between each of the stages there is an internal of 4 days. The fever is sometimes of the typhus character, & is, in some cases, attended with coma, & in infants, convulsions: these is the Confluent are said always to be fatal. In the Confluent the pustules are more numerous & run together so as to form one mass, & never contain the yellowish fluid as in Distinct. The throat is commonly very sore; there is sometimes a salivation, & in children, diarrhoea. The secondary fever is very high, & is sometimes attended by petechiae, vibices, bloody urine, or hemorrhagy from other 251 parts. The only case with which I have known small pox to be confounded is varicella; but the latter is preceeded by little or no uneasiness, febrile or otherwise; the pustules make their appearance on the 2nd day, & dry away on the 4th or 5th: at which time those of the small pox have not gone through the maturation stage. The varicella appears in several successive crops. The pustule is more deeply seated, extending to the cutis vera, & contains a pellucid matter like water. In varicella the vesicle is pointed. But when the latter disease is more violent, it is so much resembles mitigated small pox, that it is very difficult to distinguish them: even Willan has been decieved. There is yet a disease, which has lately made its appearance in this country, called the varisloid disease, with which small pox is very apt to be confounded: of this I shall speak hereafter. Examinations post mortem, in Confluent small pox, show the same appearance as in typhus gravior: the stomach, abdominal viscera & brain being affected by the weaker species of inflammation or by congestion. It is a curious circumstance that the eruption is limited to places where the air has access; but if the anus or uterus be protruded so as to let the air come in contact with them, they become covered with pustules also. It is proved by experiment that the virus of small pox cannot act on the skin unless it be denuded: in which case it gives rise to local irritation, & inoculated disease 252 in the production of natural small pox, the virus must act upon some interior surface; but the lungs are seldom affected: the stomach then, being the only one to which it can approach, is the seat of the disease. Hence, the difference between the casual & inoculated disease. A disease is violent in proportion to the extent of the sympathies of the organ primarily affected. The stomach in casual small pox being the source of the disease, it is more extensive than when originating in the skin, the sympathies which are weaker. If, according to the humoral pathologists, the virus enter the circulation, the disease should be equally violent, whether the casual or the inoculated: as in both cases the virus is carried into the blood. Treatment. This is an incurable disease; & as all others depending on a specific contagion will run its course. All we can do is to mitigate symptoms. It is a good practice to begin with an emetic, although it is not always required. After the stomach is evacuated we must recur to the saline purgatives, to be repeated as often as necessary. These are to be followed by the mild diaphoretics, as antimony alone or with the neutral salts. When the fever is high, with a dry skin & much local determination, venesection must be had recourse to, & repeated until the symptoms that called for it are removed. Cold applications are said to be useful when the skin is hot & dry: even dashing water upon the patient has been 253 tried; but it is much better to lower the temperature by the application of the sponge. In children conulsions are apt to occur, but they are not alarming: little is required but exposure to a draught of cold air, or the warm bath. But if they return, so as to excite solicitude, venesection to followed by a dose of laudanum, & as preventative, sinapisms to the extremities, are the remedies. The eruption sometimes does not come out well, or, if it has appeared may be stuck in; but the practice in both cases is the same: viz. emetics, diaphoretics, wine whey &c. aided by a pedeluvium or warm bath. When the sleep is disturbed we may prescribed opiates, Hoffman’s anodyne, or the camphor emulsion. The leading object in this disease is to keep down fever: this is done by the antiphlogistics. The room is to be kept cool, more so than in any other disease, & the patient laid on a matress or sacking bottom; or he may be exposed to the cool external air. Before the time of Lydenham the practice was the reverse of this. Considering the poising to be in the blood, all the alexipharmic medicines were used. Before the eruption, the patient was placed near the fire, stimulating drinks given &c, & after the eruption he was placed in bed & covered up warm. The mortality from such treatment was immense. In the secondary fever from irritation, not much in general is demanded, except some cooling medicines; but if the fever be high, we must resort to more efficient remedies. 254 in the Confluent small pox, we must pursue a different treatment. This is a case of weak action & must be managed accordingly. As in all typhoid affections we begin by evacuations from the alimentary canal, but in this form of small pox must not be urged to any great extent: in this next place we must invigorate the system. To promote the filling of the pustules a combination of bark & opium, or vol. alkali is best: the warm bath has also proved beneficial; & when there is prostration of strength we may make use of sinapisms or blisters to the feet, & diffusible stimulants, or wine, vol: alkali, bark, turpentine &c. One desideratum in this disease is the preservation of female beauty, by preventing the pits of small pox. This is effected by covering the face with cambria smeared with sulphur ointment to prevent the contact of air. Camphor is said to have the same effect. These failing inflammation is to be subdued by saturnine lotions, & as soon as the pustule fills, it should be opened by a puncture & the matter discharged. Equally efficacious is the application of camphor in the ophthalmia and sore throat which follows: in the latter case the camphor emulsion may be gargled. This fact is mentioned on the authority of Rosenstein. In the diarrhoea &c. no perculiar treatment is necessary. I shall dismiss the subject of casual small pox & make a few remarks upon Inoculation. By whom this was discovered is still a matter of uncertainty. It was said to be by Lady 255 Montague. The practice probably originated with the Circassians, who are remarked for the beauty of their females. It is not always a safe operation: the wife of George the 1st fell a victim to it. The best season for performing it, is the spring or autum; & the age should not be under 6 months. The best age is 2 or 3 years. Children of debilitated constitutions should be excepted. In former times the preparations of the system was considered of great importance. It consisted chiefly in a regulation of diet & it was customary to pursue a mercurial course for 8 or 10 days. When the patient is perfectly sound it is best not to make any change in his diet or habit of life, until the fever commences. It is then to be treated in the ordinary manner. But if the system be any way in a depraved state, then the preparatory plan is proper. It was also considered of great importance to get the matter from a mild case of the disease. The operation consists in introducing the matter under the cuticle, or rubbing it into a small crack or incision made by a lancet: the quantity is of no importance. About the 4th or 5th day the part begins to inflame; & a small red speck appears, which increases until the 7th day, when the constitutional symptoms manifest themselves. The treatment is the same as in the casual disease. – Swelling of the glands in the axilla is one of the best signs that it is taken. 256 Cow Pox. Variola vaccina. As a preventative of small pox, vaccination has been known in some places for more than a century; but the credit of establishing it is due to Dr. Jenner. About the year 1768 when a student of medicine in Gloucestershire (Eng. ?) he heard of an eruption which appeared on the udders of the cows. This afforded him an opportunity of examining it, which he found to prevent the operation of the small pox. In 1798 Dr. Jenner published his treatise on vaccination. To Dr. Coxe of this city, & Dr. Waterhouse of Boston we are indebted for the introduction of vaccination into the United States. Experiments to prove that the vaccine disease & small pox are two distinct diseases. If the matter of the cow pox & small pox be introduced into the arm near each other, so as to form one pustule, each preserves its peculiar character; & if matter be taken from that part of the pustule, where the variolas matter was introduced, we will have genuine small, & visa versa. Variola is peculiar to the human species. (Hunter.) It was supposed by Jenner that the vaccine disease could be reproduced at pleasure in the same person: even after having had the variola, or the cow pox. The operation of the vaccination should not be performed before the third week; or when the child has any cutaneous affection, however slight. If the operation 257 under such circumstances, a mixed disease is produced, which affords no protection against small pox. Jenner recommended the pellucid matter to be used, which should be taken before the 9th day. It is perhaps better to substitute the scab altogether, for several reasons. 1. The disease has an opportunity of running its full course. 2. It may be preserved for a year or upwards. 3. It affords a larger supply for the propagation of the disease. There is a choice in the scab. Those of a dark mahogany colour, hard, compact, & with a well defined margin, should be selected. Those of a pale or grey colour, scaly, & with irregular ragged edges should be avoided. Before using the scab, all the ragged edges & scaly matter on the internal surface should be scraped off. A small portion of the hard internal part should be powdered & wetted, & introduced into a scratch made by a lancet. Care should be taken not to bring blood. Progress of the Disease. About the 3rd day a small red spot appears, which gradually enlarges until the 6th day, when it changes to a deep red & the vesicle forms. On the 7th 8th or 9th day it is surrounded by an efflorescence like a ring, & in a few days more it is at its height. The crust drops off spontaneously in the course of the 3rd week. About the 7th day some fever is manifested, & sometimes tumors form in the axilla; when this happens the child should not be raised up by the arms. Difference between the genuine & the spurious disease. In 258 the spurious disease there is a premature itching; the edges are irregular & not well defined; the matter is purulent & resembles that of a common abscess. The spurious pustule is of a dusky colour & more liable to be broken, & when this happens ulceration is apt to take place. In the spurious disease there is always more fever & constitutional affection. The genuine pustule leaves a small superficial indented impression: the spurious more resembles a cicatrix from a common wound, & the scar is larger, white & polished. Treatment. The local affection sometimes calls for attention. When much inflamed, a solution of sugar of lead, or cold water may be applied. Mercurial ointment has been used. We are not to make use of such lotions as will do away the inflammation altogether. No medicine is required to prepare the system for the reception of the disease. – The patient is to be seen on the 4th day, & again on the on the 8th or 9th day, & at the time of desquamation: to see that the pustule has gone through its proper course. ___________________ Class. 6. ___________________ Diseases of the Muscular System. __________ Gout. Or Arthritis. This disease has different names according to the part affected: thus, when in the hand, it is termed chiragra; in the humerus, oumagra; in the clavicle, Kleisagra; in the foot, podagra &c. Gout is 259 commonly divided into tonic & atonic; but more properly into regular & irregular. When it attacks the limbs it is called regular; when the internal parts, irregular. A paroxysm of regular gout sometimes comes on without any premonition; but generally it is preceeded by coldness of the feet or legs, & an unusual sensation in them; the appetite is generally diminished; a degree of torpor & languor is felt all over the body; great lassitude & fatigue after exercise; the bowels are costive; the urine pallid , & the mind much disturbed. The patient may go to bed very well, & soon be awakened by violent pains, which increase & are succeeded by rigors. Some times both feet become swelled & inflamed, so that neither can be put to the ground without pain. Towards morning he falls asleep, when a gentle perspiration breaks & parts a stop to the fit. But still he is not perfectly relieved: some pain & fever continuing. In the progress of the disease the paroxysm becomes easier every day, until it finally goes away by urine or perspiration &c.: at which time a desquamation of the skin takes place. It occurs at first, perhaps only once in 2 or 3 years; then once a year, & then more frequently. Translations take place from one joint or limb to another, & after frequent attacks they become so rigid as scarcely to admit of motion. There are sometimes calculous appearances, called nodositus. Great difference prevails as to pathology of the disease. It is undoubtedly primarily a gastric affection, & is connected in 260 a great degree with lithiasis. When the arthritic matter is carried to the extremities, regular gout is the consequence, when to the urinary organs, calculus. The urinary & gouty calculi both consist of the urate of soda. Causes of Gout. It is produced by excess in eating or drinking; indolent habits, vexation of mind, & by hereditary predisposition. Wine excites it: some wines more than others. Claret is said to be pernicious. In England they say that light wines are the parents of gout: on the continent they hold a contrary opinion. In New Eng? where cider is much used, gout is little known. In the southern states, where cider is not much used, but malt liquors & wine, gout is more prevalent. But I have never known cider to be taken with impunity by a gouty person. Leudamore says that exercise is the best preventative of gout. In Edinburgh, where carriages are much used, the disease is very prevalent. In Glasgow, on the contrary, where exercise on foot is more used, the disease is little known. Gout generally attacks men of a robust frame & inflammatory diathesis; sometimes the old & infirm, & in a few cases delicate women, & often children whose parents were gouty. Treatment. We can have little expectation of completely effecting a cure when the disease has been established. All we can do is to conduct the patient through the paroxysm, with as little pain as possible. The most efficacious course is long continued, active purging. This is 261 an old practice, & was used from the time of Hippocrates to that of Lydenham, who opposed it. But practitioners now generally concur in the practice. Lydenham says that emetics & cathartics bring back the disease to the alimentary canal: this is not correct. It is my impression that gout is connected with certain states of the alimentary canal; & the symptoms denote a disordered condition of the stomach & bowels, as flatulence, sour eructations, a strong sensation of internal heat, nausea, depraved appetite &c. It seems absurd to place a disease in the stomach, which affects the extremities; but the practice deduced from it is sound & fully proved by experience. I have for several years employed purgatives in the paroxysms of gout: this being done all the painful sensations of the stomach are removed, & the pain & inflammation gradually subside. It is often necessary to recur to purgatives very repeatedly. The best article is Calmel, alone or with Rheubarb; and when the bowels have been opened by this active purge, we may use rheubarb by itself; or sulphur will answer very well, which may be combined with magnesia. In defence of this mode I can bring reason & authority. Admitting the symptoms in the bowels to be present, no one can doubt of the propriety of purging. In support of it also may be said that this paroxysm is always abated or removed by the coming on of a diarrhoea, dysentery or cholera morbus. Lendenham says that if 262 the diarrhoea be stopped the gout “comes thundering back” to the extremities: nothing more proves the use of purgatives than this. It is also a curious circumstance that nearly all the quack remedies for the gout act for the most part on the bowels, & generally contain the extract of scammony. The most drastic of the purgatives have been used; & of these the Elaterium has been much recommended. It has certain powers in the disease & was at one time considered the chief ingredient of the French nostrum. Gamboge was also considered a powerful remedy in gout; hence acquired the name of gutta ad podagram. Emetics are said to mitigate the pain & abridge the paroxysm. Gout is sometimes acquired in miasmatic countries, & associated with intermittent fever: emetics are here very useful; & it is often necessary in the same cases to resort to the Peruvian bark. Some cases occur in which it may be necessary to recur to the lancet, which may be known by a local tendency of the blood to the head &c.; but such cases do not often happen. It is one of the great advantages of purging, that all the febrile symptoms are removed: the pulse being initiated sympathetically. In sweating the humoral pathologists indulged very much; & certainly does as a secondary remedy afford some relief. The paroxysms of regular gout when spontaneously cured go off either with a diarrhoea, diaphoresis, or diuresis. The cordial & stimulating diaphoretics are almost 263 to be preferred. A combination of carb: ammonia with opium or wine whey is perhaps the best. Dover’s powder has proved beneficial. As a part of the general treatment of gout, diuretics have been a great deal employed. The mild diuretics are most suitable. I have never seen a cure for gout or rheumatism, which was not preceeded by a lateritious sediment in the urine. The Spts: Nitr: Dulc: will answer very well; & much has been said of Pipsissewa; but, as a remedy in Gout, the Eau Medicinale has acquired great reputation in Europe, & in some degree in this country. Its effects on the system are very distinctly marked. It purges actively, & sometime vomits violently, & at the same time produces perspiration or diuresis, upon which the pain & swelling of the joint rapidly subside; & very frequently the patient is relieved in 12 or 24 hours. Its operation on the system generally commences in an hour or 2 after taking it. This practice is condemned by some, & they say it injures the constitution. From my own experience, which, however, is not very extensive with it, I should say much in its favor. I have tried it several times & always with advantage: its effects resembled very nearly those from an anodyne. Major Pierce Butler, of this city, who was very liable to attacks of the gout, used this for several years, & until lately enjoyed perfect health. [Died a few days ago of old age. Feb. 1822]. This article is much condemned by many eminent practitioners of Great Britain, 264 & particularly Dr. Gregory. All that I have learnt confirms the opinion the colchicum is the basis of the French Nostrum. (vide Therap: ) The colchicum has been called anima articulorum (the soul of the joints) & it enters into many of the specifics for gout; as the dia hermodactyle, Pulv: Turmeri Arthriticus &c. It is also contained in the famous pienna gout composition. When gout attacks the kidneys or resembles lumbago, the colchicum will seldom fail: this is the only case of the disease in which it is useful. The manner of using it is in the form of the vinous tincture, in the dose of about ʒi every 2 or 3 hours: beginning with a small quantity & gradually increasing it. The colchicum which grows in this country is good for nothing. That imported from Europe is very active. The tincture made from the seeds is more powerful than that from the root. The plant should be gathered in full maturity, and dried. Of the Local affection. In this the pain is very great. Much has been said of opium in this case, & it is prescribed by many practitioners, but it has a tendency to aggravate the symptoms, producing constipation, fever, and restlessness. Brown & his disciples treated it by stimmulants, & said that none was better than opium. I have often derived great advantage from Dover’s powder. It has been recommended to apply a blister to the part affected; but on trial we have been disappointed. As a * The leaf of the Yellow poplar (Liriod: tulipifera) is a good local application. In our common autum nal fever it is one of the best things for relieving the pain of the head. 265 palliative more advantage will be derived from topiccal bleeding by leaches; but when these cannot be procured we may use warm fomentations; the common hop will answer very well, or camomile flowers steeped in hot brandy. Much has also been said of the use of vapour. Enveloping the joint in flannel, or what is better, in cotton is of great service & should not be neglected. It acts probably in the same manner as in burns. This practice is condemned by Kingslake & others, who recommend putting the feet in cold water. That this will sometimes succeed there can be no doubt; but the experience of the wise does not justify the practice. The only cases in which it should be used, are those where the patient is of a sound & vigorous constitution, & where there is much pain & inflammation: it is always to fortify the stomach previously by laudanum or a draught of wine. Cold in any form is apt to repel the disease. I have frequently found much relief afforded by a slice of raw beef steak, to be repeated as often as it becomes hard. * Scudamore recommended a mixture of 3 parts of Camphorated spirits & 1 part of alcohol; with which cloths are to be wetted & laid on the affected part. After all, however, these local applications are of little service. The disease is a morbid secretion going on in the stomach; & until this is removed, all local remedies are useless: as soon as this is done the local affection subsides, or will perhaps be entirely 266 removed. The Diet in the inflammatory stage should be light, & of a digestible nature; except in cases where there is a want of tone & a tendency in the disease to recede: in such cases wine may be allowed; & a more stimulating food. It has been mentioned that gout sometimes takes hold of some of the vital parts, as the alimentary canal, brain, heart &c.: this is called Retrocedent Gout. The most common part affected is the stomach. In the cases we should resort to the most powerful of the diffusible stimulants, as madeira wine, opium, or the antispasmodics, as musk, assafoetida, ether, or vol. alkali. Ardent spirits either pure or made into hot toddy may be used. The musk julep is an invaluable remedy in these cases. The dose of all these articles must be greatly augmented: especially opium, which may be given in 3, 4 or 5 times its common quantity. As cööperative means hot fomentations to the epigastric region should not be overlooked: they make way for the exhibition of the medicines I have just mentioned. We may sometimes make a liberal use of the lancet. To bleed while we are most powerfully stimulating is the only way to manage this disease. Much discrimination, however, is necessary; & the pulse is not to be regarded. Take into view the strength of the patient, the vehemence of the pain, the temperature of the surface, & degree of probability of the system to react. 267 Translated to the lungs, gout puts on the appearance of pneumonic inflammation; but more commonly that of Asthma: in both cases the treatment is the same as if the attack had proceeded from any of the common causes of these complaints. When gout seizes the brain, we should apply a blister to the head & purge. The kidneys are sometimes attacked: in these cases warm fomentations will commonly answer; but, if the attack be violent, we must resort to bleeding, blisters, opium &c. In the same cases Colchicum is useful. These are the several shapes which gout generally assumes. It rarely attacks the heart; but sometimes puts on the form of angina pectoris: when this happens, unless it is very slight, it always terminates fatally; but when time will allow us to administer our remedies, venesection should be used. In all cases of Retrocedent Gout, we are to endeavour to restore the disease to the extremities, by pedeluvia rendered stimulating by salt, hickory ashes, cayenne pepper &c. or by sinapisms, or blisters to the ankles. – Misplaced Gout, or of the nosologists, will sometimes appear in the head, lungs, alimentary canal, & many of the great viscera, especially the kidneys. I have met with it as an eruption on the skin. It sometimes occurs in the genital organs; but whatever part it attacks, the treatment is the same: viz. Translate it to the extremities. 268 Atonic Gout. Or Irregular gout. By this is meant that form of the disease in which there is not vigor enough to induce the inflammation affection in the limb. It is generally met with in women. The symptoms are, a loss of appetite, vomiting, gastrodynia &c., generally accompanied by cramps in different parts of the body; the bowels are sometimes constipated; at other times in an opposite state. Hypochondriasis is an occasional symptom. To these may be added palpitation, vertigo & often asthma, apoplexy & palsy. The treatment here is to restore tone to the stomach particularly, & to invigorate the whole system, nearly the same as in dyspepsia: & to guard against constipation by magnesia, sulphur &c. Tonics are to be used, as preparations of steel, either alone or in combination with the Peruvian bark. The protracted use of bitters is to be avoided. Warner’s Cordial, aided by wine whey, often affords relief. Mercury is sometimes useful; but a deep mercurial impression is always prejudicial in arthritic affections. But all these will not avail unless the diet & exercise be properly regulated. The best diet is one of milk alone, or with a slight addition of animal food that is very digestible. The drink should consist of water alone: malt liquors & wines are injurious. When something more than water is required, a little ardent spirits 269 may be used. - The soles of the feet should be kept moderately stimulated: for which purpose cayenne pepper should be worn in the bottom of the stockings. All the exciting causes of the disease should be avoided. (vide Cullen). As a preventative of gout, when there is a sourness of the stomach, I have known it put off by magnesia or a draught of new milk. Rheumatism. This is so nearly allied to Gout in many of its characterisitcs, & the two diseases have so many points of resemblance, that they cannot always be easily distinguished. Diagnosis. Rheumatism is generally caused by cold, & it has no antecedent complaint. Gout is preceeded by all the symptoms of great gastric disorder. The seat of Rheumatism is in the large joints: that of gout, in the smaller. The joints in rheumatism are red & swollen; but not in gout. Gout always originates in the stomach; rheumatism never does. They both intermit & remit. Rheumatism is divided into Acute & Chronic; but we had better denominate then into tonic & atonic. It is called acute when attended by inflammation & chronic when it is not. The cause of Acute rheumatism is generally vicissitudes in the weather, sudden changes from hot to cold; & hence is most prevalent in spring and fall. Acute rheumatism may attack persons of any age: though generally the middle aged are most subject 270 to it. In children it sometimes appears like hydrocephalus. Cullen places it among the Phlegmasioe. That there is a high degree of action in the affected part, there can be no doubt; but it scarcely ever ends in suppuration: the same is the case as regards gout. It attacks in a variety of ways; but generally the loins, back or hip, occasionally sciatica; sometimes the head, & I have known attack the skin & external layers of muscles. It comes on with pyrexia; the pulse is full, & when there is fever, fluctuating. After a short interval the joint swells & inflames, & the pain is mitigated. The bowels are generally constipated; the urine deposits a lateritious sediment; perspiration sometimes comes on spontaneously, & when this happens, it never affords any relief; but rather aggravates the symptoms. The fever is of the remittent type, with the exacerbations in the evening. It is generally supposed by pathologists to be centrifugal disease; but it is known that all the viscera, even the heart & alimentary canal, are often affected either by primary or retrocedent rheumatism. Treatment. In acute or inflammatory rheumatism it is analogous to that of gout. It will always be right to commence with venesection, & it should be repeated as long as the indications continue. There is no substitute for the lancet in this disease. By some writers the peruvian bark is preferred. This practice was introduced by Morton, & followed by Heberden, Sir G. Baker, For- 271 dyce & those of London generally. Whatever may be the propriety of this practice in Eng.?, it will not answer in our country. After subduing arterial action the bowels must be opened by mercurials & the saline purges. At one time emetics were greatly used in rheumatism: especially the antimonials, so as to produce nausea. I have not used them often: they may be serviceable when the disease is associated with intermittent fever, & when the stomach is oppressed by bile or other vitiated contents. Sweating constitutes an important part of the treatment in this case; but it can only be resorted to where much direct depletion has been premised: unless arterial action has been very much subdued, it will aggravate the symptom. At first the antimonials & nitrous preparations may be used; but as the disease advances & febrile excitement continues, more stimulating articles are to employed. The best of these is Dover’s powder. It must not be too hastily discontinued, nor given when much excitement prevails. The sweating must be maintained for 24 hours, & be continued until the disease be completely subdued. It is to be aided by warm fomentations & the vapor bath. Serpentania, Pleurisy root &c. have been used with success. When sweating does not succeed, we must resort to the diuretic remedies. In treating of gout, it was mentioned that one of its terminations was by the kidneys: the same sometimes happens in rheumatism. In the use of diuretics, articles of a stimulating are to be preferred. 272 Much has been said about the Pipsissawa; & so highly has it been rated in this disease that it has recieved the provincial title of rheumatism weed. This will often produce diaphoresis, but is generally diuretic, & is very frequently found to be useful. Colchicum has been much used, & is a remedy of undoubted power, in rheumatism. My experience is not much in its favor. I have used it now & then with advantage, but upon the whole there is not much to be gained from it. Of the Local affection. It has of late become a practice to make use of cold applications, as snow or ice: this is used by some of the N. England practitioners, & also in Spain. I believe that experience is against the practice. The inflammation in rheumatism is a peculiar one. We should resort to topical bleeding by cups or leeches, & afterwards a succession of blisters, so as to keep up a perpetual discharge. As in gout, the infusion of hops or camomile flowers has done good. Opium increases the pain. – I mentioned that rheumatism sometimes appears as a disease of some of the internal organs. This is to be managed by diaphoretics. Attacking the bowels it has all the symptoms of dysentery. When the bowels become affected, the complaint ceases in the joints, & visa versa. Rheumatism attacking the stomach is to be treated by venesection. We often meet with rheumatism in the skin: this is to be relieved by warm or vapor bath; & rubbing the surface with oil or laudanum. 273 Sulphur & cold bath are also useful. There are two other forms of rheumatism: Lumbago & Sciatica. Lumbago affects the lumber region. It is very acute in its attack, & sometimes comes on like an electric shock, & conveys the idea of the back being broken. Paralysis generally follows & continues for several days. It is to be treated at first by copious venesection. If this do not afford relief, we must make use of cups; & if this do not answer, a blister must be applied to the part, or external irritating applications. Of these the best is a tablespoonfull of cayenne pepper to a glass of brandy. Much has also been said of the common tea. Purging must not be overlooked. Applications to the soles of the feet are of service: a sinapism has often removed the disease. The treatment of Sciatica is much the same. Rheumatism sometimes attacks the head, especially in children 3 or 4 years of age. This is generally chronic. It is to be treated principally by venesection. Rheumatism of the face (Jaw ache) is cured by an active emetic. Chronic Rheumatism. In this the pain is not accompanied by active inflammation or fever. It is always connected with an atonic condition of the system, & demands of course a similarity of treatment. Depletion by the lancet is not often demanded; but when the pain is violent the loss of a few ounces of blood will afford relief. Active purging 274 will prove of great advantage. This disease is often associated with diarrhoea: it is a translation of the disease from the skin; & generally submits to those remedies which act upon the surface. Of these the warm bath is the best; to be repeated often, & followed by friction so as to excite a glow on the surface. Dover’s powder is sometimes given; but profuse perspiration often proves injurious. Much more is to be expected from those medicines which act on the surface without producing much perspiration, such as there terebinthinates, camphor, vol: alkali, mezereon, sassafras, sarsaparilla, guaiacum &c. Of these the volatile alkali & guaiacum are the best, combined in the form of the volatile tinct. of Guaiacum. The common dose in which it is given is very inert: as much should be given as the stomach will bear. ℥ss, & sometimes increasing it to ℥i, with some wine whey, taken on going to bed is the proper quantity. The guaiacum is sometimes used in decoction with sarsaparilla &c. in the form of the Lisbon diet drink. Among the remedies in the advanced stage of chronic rheumatism I know of none more deserving of attention than Savin. (vide Therap.). The system must be fully under its impression before the disease yields. The proper mode of administering it, is to commence with grs Xii – XV. of the powdered leaves 3 times a day, & gradually increasing it until 3 or 4 times that quantity be given. To accomplished a cure it must be continued for several weeks. We ought not to be discour- 275 aged at first. The peruvian bark will sometimes prove benefical, either alone or with the volatile alkali. Arsenic, in some cases, is also useful; but it requires to be continued for some length of time, to be productive of any good effect. Sulphur is by many also considered a valuable remedy. The three last articles are best suited to rheumatism originating in miasmatic countries, & which observes a paroxysmal type. They are not, however, limited to these. To be productive of any great advantage, they should be continued for at least 10 days or a fortnight, or until some signs of their effects are produced upon the system. A cold infusion of pipsissewa may be used with benefit. Colchicum has been used in nephritic rheumatism. It is useful here perhaps on account of its diuretic properties. Mercury is used in all the phlegmasia when other remedies have failed. I have it beneficial both in acute & chronic rheumatism; perhaps more so in the latter. It is sometimes given by itself; but it generally combined with opium; & & sometimes ipecac added: from this combination I have often derived great advantage. Some substitute other narcotics, & particularly cicuta, in place of opium, but whether any advantage is derived from this my own experience will not allow me to say. In some of these cases, it is useful to accompany the mercury with the Lisbon diet drink. It is proper to urge the mercury to salivation; & it is by no means rare to meet 276 with cases which do not yield until the mouth becomes sore. Relapses of this complaint often take place: in such we should continue the salivation for several weeks together. Nitric acid has of late been much used in the disease. In some cases I have been well pleased with it. Many Europeans writers speak well of it; &, from its analogy to mercury, we might suppose it beneficial in rheumatism. I generally prescribed it after a mercurial course; or when, from debility or other causes, mercury is inadmissible. The local treatment here is nearly the same as in acute rheumatism. When the joints are much swollen we may apply leeches, & afterwards a succession of blisters to the affected part, or they may be kept discharging by savin. Of late the tartar emetic plaister has been substituted for the vessicating applications, but it is not equal to the blister. Caustic issues to each side of the joint have been of great advantage. The joint should be rubbed with a flesh brush. Lastly, the flannel roller is an important remedy. It will fail in acute rheumatism; but in the case before us, when the inflammation is less active, & sensibility correspondently reduced, it is very useful. Apply it as tight as can be borne by the patient. It acts by compressing & giving support to the vessels. Frictions are also useful on the same principle, & by promoting the power of absorption. – After rheumatism has resisted For Rheumatism of the heart, tinct. digitalis or tr. Sem. colchici. – generally incurable 277 all our remedies, I have often known it removed by some of our mineral water. The warm & Sulphur springs of Virginia are to be preferred for this purpose. To prevent a relapse of this disease the patient must guard against all the exciting causes; & should always wear warm clothes, particularly flannel next the skin. A change of climate might be of service. ________ Class. 7. Diseases of the Secretory System. ========= Hepatitis. Or Inflammation of the Liver. This disease is divided into Acute & Chronic. The Acute comes on, for the most part, with the ordinary symptoms of pyrexia. Immediately succeeding this there is a pain in the right hypochondrium, sometimes acute, at other times dull. It is frequently, however, felt in the left side. It generally extends to the right shoulder blade, & even to the arm; & the pain is sometimes greater here than in the shoulder itself. It is often felt in the left shoulder: when this happens, the disease is in the left lobe of the liver. The alimentary discharges exhibit all the appearances of a deficiency of bile. Nausea & vomiting are among the first symptoms. The fever in the commencement is high; the pulse is full & strong; the skin is hot & dry; there is some head ache; tongue is furred, & in a few days 278 the eyes become yellow; the urine is diminished, & of the colour of Saffron: - The attack is not now inflammatory. * In India this disease runs its course very rapidly, & suppuration comes on in a few days. It is sometimes ushered in like Cholera morbus: it sometimes also puts on the appearances of pneumonia; & it occasionally attacks the head with the most excruciating pain. When this happens, there is no pain in the liver or shoulder: it is probably the effect of delusive sympathy. Cullen endeavours to explain this on the supposition that different parts of the liver are affected: thus, he says, when the convex surface of the liver is inflamed the pulmonic symptoms present themselves; when there is much gastric disorder, the concave surface: but I expect there is no foundation for this distinction. It is said men are more liable to this disease than women, & that it rarely affects children; but children in miasmatic countries are subject to it. There is a complaint similar to this, known throughout the country by the name of “liver grown”, & is generally most prevalent in miasmatic districts. – The most common causes of hepatitis are, changes of weather, marsh miasmata & heat; strong liquors; blows &c. Certain mental emotions, as envy, jealousy, & other malignant passions may also be enumerated among the causes. People most liable to it are those commonly called “white liver’d” – the “tumidum jecur” of Horace. Disease of the liver, unlike those of the lungs, are productive of gloom & melancholy. 279 Diagnosis. Tho’ the pain in hepatitis is in the region of pneumonic inflammation, it is always less acute, the cough is always dry, & the dyspnea not so oppressive. The pain in the shoulder is another mark by which they may be distinguished. In hepatitis there is also a sallow countenance. – When acute inflammation of the liver is not timely arrested, it is apt to suppurate, & the abscess generally points to the surface: it sometimes, however, rupture internally, & in this case, unless the pus be thrown into the intestines, the disease is sure to terminate fatally; & this often happens in an hour or two: even when it discharges into the bowels the patient seldom recovers. Cases are of frequent occurrences in which the abscess bursts into the cavity of the abdomen. It sometimes bursts into the thorax, into the diaphragm, or even into the substance of the lungs, when the matter is brought up by expectoration. In these cases also death speedily follows. Cases happen in which it opens into the stomach, & is brought up by vomiting; also into the pericardium; & it is supposed that now & then the matter is evacuated by the hepatic ducts: this is perhaps the most favorable course. Hepatitis sometimes terminates by resolution: in this case there is some critical discharge, as by diarrhoea, perspiration, urine &c. Convalescence is known by the subsiding of fever, & by the state of the stomach being rectified, & by a general amelioration of the symptoms. 280 Dissections show the liver much enlarged, & indurated or congested, & sometimes the surface inflamed & altered in colour. Treatment. The lancet here must be urged to a very great extent. ℥XXX. must be taken away at once, & must sometimes be repeated in the 24 hours. In the more unrelenting cases of the disease, we must repeat the operation day after day, until frequently 2 or 300, - ounces are lost. In timid practice an abscess is inevitably formed. While we are thus depleting by the lancet, we call to its aid cups over the region of the liver. After this we must apply a large blister; which must either be kept discharging, or be renewed when the discharge begins to cease. Caustic issues have been used, but they are inferior to blisters. Purging is also an important remedy. The proper article here is Calomel, either by itself or in combination: to be given in a larger dose at night & worked off the next morning by Sal. Epsom. Next, if the patient be not relieved, we must recur to a salivation. In this country the mercury is generally postponed for a few days, or until the system is sufficiently reduced; but in India & the southern parts of this country, this course of procrastination will not answer; & we must, while purging & blistering, rub in the mercury until a deep impression is evident, which must be continued for a considerable time. In spite of all, suppuration will sometimes follow. This is known by a full & active 281 pulse, intimations of a more intense degree of excitement; there is a more obtuse sensation in the liver, & the patient complains of throbbings, sweats &c. In this stage there are often some anomalous symptoms, such as inability to sneeze (even when the most powerful sternutations are applied), & paralysis of the lower extremities. When the abscess points it should always be opened: when this is done, cures sometimes take place; but when it opens spontaneously a cure never happens. This is so well known in India, that whenever there is any appearance of suppuration, they thrust a lancet into the liver, & discharge the pus. Mercury has been recommended in these cases; but we should not salivate in any disease, & especially in hepatitis, while suppuration is going on. For the same reason it should never be given in venereal bubo, while suppurating. The proper remedy under such circumstances is the nitric acid, to be given in a manner of which I shall hereafter to speak. Chronic Hepatitis. As the effect of ill cured hepatitis, or as sometimes happens, from a feeble operation of the same causes, Chronic hepatitis is induced. Cullen would lead us to suppose that, in this case, the parenchyma of the liver is inflamed; &, in the acute, the external membrane; but this is without foundation. This 282 disease is marked by an assemblage of symptoms indicative of constitution derangement, as sallow complexion, dry, crusty skin; depraved stomach; costive bowels; clay coloured stools; the wine is scanty & deposits a lateritious sediment; the pulse is quick & feeble, & sometimes hard & chorded, & sometimes intermittent, as in the acute cases; there is also considerable local pain, which extends itself to the scapula, & there is sometimes dyspnea. As the disease proceeds, the bowels are harassed by tormena or flatulence, & sometimes colliquative diarrhoea, & hydropic appearances frequently present themselves. To remove all the doubts, an examination should be made. – The “tactus eruditus. “ To detect an enlargened liver, the patient should be laid flat on his back, with his knees drawn up, to relax the abdomen muscles: we then feel under the short ribs, where we discover something like a stone or indurated cake. If it cant be felt on the right side, try the left. Request him to take a deep inspiration, so as to push down the diaphragm & liver. The causes of chronic hepatitis are essentially the same as those of the acute form, operating more slowly or feebly, as drunkenness, marsh effluvia &c. The liver in this disease is susceptible of various degrees of derangement: it is sometimes tubercular; at other times steatomatous, cheesy, or having the appearance of osseous matter; but what is more common is schirrus of greater of less extent. Sometimes the whole 283 parenchyma is eaten out, nothing but the vessels, as in anatomical preparations. (case of Sir Wm. Jones.) These states are known by no peculiar set of symptoms. Treatment. Believing the disease to be of recent date, & that there is no material alteration of structure, we are to make use of moderate & repeated venesection, & cups, to be followed by a perpetual blister on the region of the liver. Caustic issues have been recommended by some: the manner of using them is to make a small blister of the size of a dollar, & then apply the lapis infernalis, & afterwards dress it with the savin. We must also have recourse to long continued purging. Calomel should be given every night or two, & worked off the next morning by epsom salts & magnesia: ʒi. of the former, with one or two teaspoonfulls of the latter. For the same purpose various deobstruents, as they are called, have been used. The Gum Ammoniac has been employed with great success by Dr. Wistar; but my experience is not much in favor of it. The Dandelion (Leontodon Taraxacum) has been much praised by Heberden, & of late by Dr. Rush, in simple obstruction of the liver. Its efficacy I cannot state from any experience of my own; but, coming from such high authority, we have no reason to doubt it. I have learnt from an intelligent butcher that cattle stall fed during the winter are known to be subject to an enlarged liver; but when turned out, in the spring, into 284 the meadows in which the dandelion grows, they are soon cured. – In these cases a salivation is to be avoided; but mercury is to be given as an alternative. For this purpose the calomel or blue pill may be used, until the system is fully under its impression, which must be kept up for weeks or even months. Some of the narcotics, as Cicuta, have been united with the mercury. Opium is necessary in some cases to relieve pain. Nitric acid, & more particularly the nitromuriatic acid, has been used both internally & externally. (vide Therapeutics, new edition). Within the last year or two I have derived great advantage from applying it in the form of a pedeluvium, & in some cases a slight salivation has attended its use. Even after these remedies have failed, cures have been accomplished by sending the patient to some of our mineral springs: either Ballstown & Saratoga; the York springs in this state; or the Sulphur springs in virginia, or the Bedford springs; but the patient should never be sent to any of these places, while any febrile action exists. – The diet, in acute hepatitis should be low: in Chronic a more nourishing one may be allowed. Icterus, Or Jaundice. This is a disease which arises from very different causes. It may proceed from a primary affection of the liver, or as a secondary effect of some the colour is owing to ----- is a disease action of the Capellaries a disease of Stomach not by absorption of bile - 285 prëëxisting disease of that organ; or an obstruction of the biliary ducts of calculi, inspissate bile, spasm, pregnancy &c. It may also proceed from topor or paralysis of the biliary ducts. It is ushered in by much languor & inactivity, headache, nausea or vomiting, & sometimes cramps or colicy uneasiness; the bowels are uniformly costive, & the stools, when procured, are of an ash colour; there is a bitter taste in the mouth, & the tongue is loaded with a thick brown or yellow fur. A pain is felt in the right hypochondrium. The pulse in this case is full & strong, & sometimes hobbling & even feeble. The vision is much depraved; but these derangements of the eye are sympathetic. The pain from an obstruction of the duct is circumscribed, but it is so great that the patient is obliged to lie down while the calculi are pressing: it is often attended by vomiting. When this disease is the result of chronic hepatitis or other causes of that nature, there is a sallow complexion, emaciated habit & edematous swelling, or confirmed dropsy of the cellular tissue, or great cavities. Treatment. Our remedies must be varied according to circumstances. In general, when but little fever or pain exists, we commence with evacuations from the primoe vioe, & by emetics especially. They sometimes do good by removing the cause of obstruction; but I think more is done by rousing the liver from its torpor by the strong concussion given to it. Cathartics are also a 286 very powerful means of cure: beginning with Calomel, either alone or in combination, & then keeping the bowels open by the milder laxatives, as Epsom salts & magnesia. Jaundice is sometimes cured by a spontaneous diarrhoea. It sometimes, however, assumes a more complicated aspect & demands a more powerful plan of cure. When there is fever & a strong, full pulse, venesection must be practiced. The pain occasioned by the passage of calculi, is to be relieved by relaxing the ducts by copious venesection, which in some cases may be carried ad delquium animi. Much benefit may be derived from the use of the warm bath, on the same principle, & now & then warm fomentations. After the bath an anodyne of 150 or 200 drops of laudanum may be thrown into the rectum. Cups & blisters to the region of the liver are sometimes demanded. The case now calls for those measures which are calculated to destroy the biliary concretions. For this purpose ʒi of ether may be given in the 24 hours; or Spts: terebinthinae g# XX – XXX. in a teaspoonfull of ether; or a combination of the fixed alkalies, in the form of castile soap, with rheubarb or aloes, in equal parts, with or without calomel. But the preparation I have known, is the following popular nostrum. Rx. Carb: Potas: ℥i. Castile soap Gum: Arab: āā. ℥ss. Brandy . . . . . ɫƀ.i. to be 287 frequently stirred until entirely dissolved. The dose is half a wineglassfull to be taken 3 successive mornings fasting. If benefit do not result, intermit it for a few days & then resume it. Many cases of Confirmed Jaundice , in this city have been cured by it. Great advantage is sometimes derived from the mineral waters recommended in other hepatic derangements. Exercise on horseback may be service. On the same principle electricity may be beneficial, by rousing the action of the liver. Vegetable & mineral tonics are sometimes of great use. =========== Nephritis is to be managed as inflammation of the liver. When it proceeds from calculi it is to be treated as jaundice, under similar circumstances. - vide Therapeutics. vol. 1. p. 301. - & vol 2. p. 202. – ======= Splenitis is to be treated as inflammation of the liver. – ========= End. == Med. Hist. MS. B 56 Chapman. _________ National Library of Medicine Bethesda, MD Condition On Receipt: The full leather binding was ____________________ extremely dirty, worn, abraded and deteriorated, particularly at the corners, edges, endcaps and joints. Small portions of the spine were missing. The front board was detached. The sewing was sound. The pages were in relatively sound condition even though they were dirty, discolored, acidic and weak. They had a few small tears. The manuscript inks present were acidic and varied in intensity. Treatment: The volume was collated and disbound __________ retaining the original sewing. The inks were tested for solubility. The head, tail and pages were dry cleaned and nonaqueously buffered (deacidified) with methoxy magnesium methyl carbonate solution. Tears were mended where necessary with Japanese paper and rice starch paste. The sewing was reinforced. Windsor handsome paper ends with a linen hinge were attached. The volume was case bound in full cloth. Title information and lines were stamped in gold foil onto the spine. Northeast Document Conservation Center April 1986 SO:SO/JN/MW