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ARMY MEDICAL LIBRARY
FOUNDED  1836
WASHINGTON, D.C
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OBSERVATIONS      / / ? /
un*
ON THE
VOX A1TID &BWBIB
OF
MERCURIAL MEDICINES

                IN

      VARIOUS DISEASES.



                BY

     JAMES HAMILTON, Jun. M. D.
FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, AND
   PROFESSOR OF MIDWIFERY IN THE UNIVERSITY
             OF EDINBURGH.           "^
                             mis
With Notes and an Appendix, by ANSEL W. IVES, M. D.
NEW-YORK
PUBLISHED BY E. BLISS & E. WHITE, 128 BROADWAY.



          J. Desnoues, printer, 11 Nassau-st.
1821. 
<a\/
                            rfZ/8o       •

                             182.1

                   DISTRICT OF NEW-YORK, ss.

   BE IT REMEMBERED, That on the twentieth day of September,
 in the forty-sixth jear of the independence of the  United States ol
 America, E. Bliss, & E.  White of the said district, have deposited iu
 this office the title ol*a Book, the right whereof they  claim as pro-
 prietors, in the words following, to wit;

  " Observations on the  Use and Abuse of Mercurial Medicines ?'?t
 various diseases. By James Hamilton, Jun. M. D. Fellow of the Royal
 College of Physicians, and Professor of Midwifery in the University
 of Edinburgh. With Notes and an Appendix by Ansel W. Ives, M.D."

  In conformity to the act of the Congress of the United States, enti-
 tled,  " An  act for  the encouragement of learning, by securing the
 copies of maps, charts and  books tn  the authors and proprietors of
such copies during the times therein mentioned." And also to an act,
 entitled, "An act, supplementary to an act, entitled an act, for the
encouragement of learning, by securing tbe^copies of maps, charts and
books to  the  authors and proprietors of such copies during the time
therein mentioned,  and extending the benefits thereof to the arts of
designing, engraving and etching historical and other prints."

                              GILBERT L. THOMPSON,
Clerk of the District of New-York. 
TO
         JOSEPH  M. SMITH, M. D.

Fellow of the College of Physicians and Surgeons of the University of
  the State of New York, President of the Physico Medical Society, 8fc.

    SIR,
       Permit me to inscribe  to you, the Ame-
rican  edition of Professor Hamilton's Observa-
tions  on the Use and Abuse of Mercurial Me-
dicines.
   Our frequent and free discussions,  embracing
a liberal interchange of professional  experience
and opinions,  have, for many years,  been to me
a delightful source of impiovement.  The sub-
ject of the following pages  has, perhaps, more
frequently than any other been the theme of our
remark, and if aught is added  to the value of the
Observations  of the  distinguished  author, it is
owing in no small degree to your friendship.   I
take pleasure, therefore, in thus publicly acknow-
ledging my gratitude, and  expressing the high
respect and unfeigned esteem

    with which I am, Dear  Sir,

         Your friend and obedient servant,
A. W. IVES. 
 
ERRATA.
Page 11  line 11 for offered, read added.
     27   "   8 line, (in note,) for physicians, read physician.
     gO   it   7   •» for page 16, read 13 & 14.
     87   "  12   "  for medicine, read medicines.
     96   "      last line but two, for spasms, read spasm.
      97  "   4
     101   "  12 for symptom,  read symptoms,
     103  "   5 for prove, read proved.
     105  «•  13 for preparations, read  preparation.
     176  •«  18  (in note) for it is not,  read is it not.
     189  "  18 for medical, read remedial. 
..  »,-«*t**J*««   •-*• 
              vhnhhmnb
                       TO THE

          AMERICAN  EDITION.


Much has been written in favour of the use of mercurial
medicines,—much to  show  the  injurious consequences
that have resulted from  them;  and  as  mercury, in  its
various forms, has  probably been  the means of more good
and  of more  evil than any  other article in the materia
medica, partiality  and prejudice  have both been amply
supported by facts.
  In the following pages, so far as the observations of the
learned  Professor  extend,  they  are impressed with the
value of clinical experience,  and the reader will not look
in vain for the practical  wisdom which he will anticipate
from the name and celebrity of the author.  His remarks
are confined to a  small  number of diseases, in compari-
son with the whole to which the abuse of mercury extends;
still, there is enough in this volume, in conjunction with
the writings of Pierson, Carmichael, Mathias, Trotter, and
others, to show conclusively, that  mercurial medicines have
been wantonly abused,—that  they have  often aggravated
existing diseases and produced new ones, and that it is not
an  unimportant part of the physician's study,  to learn to
designate and remove the maladies which are caused  by
them.
  But it  is to be regretted, that  for want of a more pre-
cise knowledge of  the  peculiar properties of mercury and
the modes of its operation, writers have not yet assigned to 
11
PREFACE.
 it an appropriate place among the curatives of disease, nor
 agreed  upon such general principles for its administration
 as will enable the best judgment to use, without sometimes
 abusing it.
   Instead of being  prescribed to fulfil clear  and well de-
iined indications, as are blood-letting, opium, and most other
 efficient remedies, is not mercury by many rather given as
 a specific,  or for symptoms of disease for which they know
 Dot what  to give ?  It is acknowledged, that the difficul-
 ties connected with this subject are  more easily pointed
 out than  corrected.  Though the wrijer has offered some
 observations to those of Professor Hamilton, with the de-
sign to show the various modes in which mercurial medi-
cines operate, and the condition of the system most suscep-
tible to their operation j still, he is  aware that objections
may be offered to theory, and different inferences deduced
from practice;  that the conclusions which appear irresisti-
ble to him, may be thought absurd by his readers, for " men
are incompetent judges of the nature and force of evidence
necessary  to leave  on others,  the impression they them-
 selves feel."                       .
  The circumscribed limits of an appendix, have precluded
any thing  more than  some general remarks on the use of
mercury in fevers,  and the  illustration of these by authori-
ties which have just, claims  to deference.   The writer
would, however, take this opportunity to observe, that for
valuable practical information, on the subject of mercurial
medicines, there is perhaps no individual work which may
be more  profitably consulted than Professor Chapman's
Therapeutics. 
CONTENTS.
                                                     Page.
Introduction,                                            1
                        SECTION I.
On the Effects of Mercury,         -        - '       -        4
                       SECTION II.
On the Powers of Mercury in subduing the Syphilitic Virus,      27
                       SECTION III.
Of the Cautions necessary during the U*e of Mercury,           60
                      SECTION IV.
On the Means of relieving the Morbid Effects of Mercury,       64
                       SECTION V
On the Use of Mercury in diseases of the Liver,         -       66
                       SECTION VI.
On the Use of Mercury in Affections of the Stomach,     -       74
                      SECTION VII.
Of an Affection of the Duodenum which imitates Chronic Hepatitis, 89
                      SECTION VIII.
Of Affections of the Pancreas and Spleen,      -              101
                      SECTION IX.
Of the Use of Mercury in Affections of the Intestinal Canal,      103
                       SECTION X.
On the Use of Mercury in Dropsical Affections,          -      126
                      SECTION XI.
Of the Use of Mercury in Croup, and in Inflammation of the Iris, 170
Appendix       -                                        188 
 
INTRODUCTION.
Among the numerous poisons which have been
used for the cure or alleviation of diseases, there
are few which possess  more active, and of course
more dangerous powers than mercury. Even the
simplest and  mildest forms of that mineral exert
a most extensive influence over the human frame,
and many of its chemical preparations are so de-
leterious, that in the smallest doses they speedily
destroy life.  Accordingly, for  some ages after
mercury became an article of the Jjlateria Medi-
ca, physicians recommended it only on the most
urgent occasions—but within these few years Bri-
tish practitioners seem to have overlooked  the
necessity for such caution, and to  exhibit that
medicine with very little  scruple.
                        B 
2
   The late eminent Dr. Parr, in his Medical Dic-
tionary,  (Vol. I. page  177)  thus expatiates on
the  virtues and u^es of  that mineral.  " As  a
medicine, there is scarcely  an  indication that
mercury cannot supply.  There is no more cer-
tain and active emetic than the mercurius vitrio-
latus; a more powerful laxative than the calo-
mel ; a  more effectual and  steady diaphoretic
and stimulant than the mercurius muriatus ;  a
more certain emmenagogue  than calomel  ;  a
more effective errhine than the turpeth mineral; a
more infallible sialagogue than either of its pre-
parations."

  Although few physicians, in prescribing an e-
metic, would select the mercurius vitriolatus, or
for promoting a diaphoresis  would  advise  the
muriate of mercury, there can be no doubt, that
many practitioners of the first respectability pre-
scribe on every trifling occasion calomel, or the
blue pill.  Thus, calomel is now in Great-Britain
almost the universal  opening medicine recom-
mended for infants and children, and a course of
the blue pill (which is one of the  mildest prepa-
rations of mercury) is advised, without any dis-
crimination, for the cure of trifling irregularities
of digestion in grown persons. 
3
  Dr. Falconar of Bath (in  a  paper inserted in
the First Volume of the Transactions of the Me-
dical Society of London, dated May 1809) has in
strong language reprobated this practice, and has
pointed out many of the dangerous effects of the
indiscriminate  use of  mercury.  His  warning
voice, however, has not been  listened to ; for the
employment of mercurial medicines has, for sev-
eral years, become more and more extensive.

  But when the effects of mercury upon the hu-
man body are  accurately investigated and duly
considered, it cannot fail to appear, that  infinite
injury must  accrue from its u*e in many cases,
and .that whenever, from the  nature of the indis-
position, violent remedies are not absolutely re-
quired, a safe substitute for so hazardous a medi-
cine ought to be found.  It  is  the object  of the
author, in the following pages,  to illustrate those
propositions ; and in  doing so, he readily avails
himself of the recorded facts and observations of
thctse respectable  members of  the profession, to
whom proper deference is due.
                      b 2 
[
                SECTION I.

          On the Effects of Mercury.

  In detailing  the changes produced upon the
system by  preparations of mercury, it is neces-
sary to premise the  well  known fact, that there
are some individuals  on whom such medicines,
though continued for a  considerable length of
time, have little or no perceptible influence, un-
less the activity of their form, or the magnitude
of their dose, be calculated to excite immediate
effects. . For example, whatever the constitution
of the person may he, a very few grains of the
muriate of mercury given in substance,  prove
rapidly fatal, and large doses of the submuriate
are quickly followed by  vomiting and purging.
On the other  hand,  instances  of constitutions
which  are unsusceptible  of the influence of the
ordinary doses  and  preparations of  mercury,
are very few in comparison with  those  wftich
are affected by the  smallest quantities of that
mineral.

   Preparations of mercury,  exhibited either in-
ternally or externally for any length of time, in- 
5
crease in general the action of the heart and ar-
teries, and produce salivation, followed by ema-
ciation and debility, with an extremely irritable
state  of the  whole system.

  These effects of mercury  are expressly men-
tioned, or virtually admitted, by  every author,
ancient  and modern,  who has directed its use ;
and it must appear very extraordinary, that their
full influence should  have been hitherto misun-
derstood, or at least not sufficiently regarded.

  The  first effect enumerated, is an  increased
action of the heart and arteries,  that is, a more
than  usually  rapid  circulation  of the  blood
through every part of the body.  This also oc-
curs  in feverish  and  in inflammatory disorders,
and in all is accompanied with an augmentation
of the animal heat.  But in feverish  disorders
there is  neither  any  apparent change  upon the
sensible qualities of the blood, nor any unusual
flow of the ordinary secretions ; while in inflam-
matory affections the sensible qualities of the
blood are materially altered, and  either some of
the secretions are furnished in greater abundance,
or topical congestions, that is, obstructions in the
vessels of particular parts, take place. 
6
  Accelerated circulation of the blood, in conse-
quence  of the  use  of mercury, is attended with
the  most  obvious of the  circumstances  which
arise from inflammation.  Blood drawn from the
arm of the most delicate and debilitated individ-
ual, subjected to a course of mercurial medicines,
exhibits the same buffy  crust with blood drawn
from a person labouring under pleurisy, and the
secretions from the skin or from the kidneys are
greatly increased.

  In inflammatory  complaints, topical conges-
tions occur more frequently than increase of se-
cretions, while the reverse of this happens  where
the inordinate action of the heart and arteries is
occasioned by the use of mercury.

  There is  another  remarkable difference.  In
inflammatory diseases, the muscular strength, in
many instances, continues unimpaired till towards
the termination  of the complaint.  Thus, every
practitioner knows that individuals labouring un-
der pleurisy have walked  several miles within a
few hours of death.  But from the time that the
influence  of mercury becomes evident, the gener
ral strength declines rapidly. 
7
  It appears, therefore, that the increased action
of the heart and arteries excited by mercurial
medicines, produces not only the same injurious
changes  upon the body with those arising from
inflammation, but also certain effects peculiar to
itst-If.  This important fact has been incidentally
noticed by numerous authors, although the natu-
ral inference to be deduced from it  has been
very much overlooked.  Dr. Carmichael express-
ly says, " Mercury induces a specific, fever, diffe-
rent from all others, and attended  with  an  in-
crease of the various secretions."*

   Reasoning upon the subject,  it might be con-
cluded, that if there  be an inordinate action of
the  heart and arteries, attended with an altered
state of the blood and with  debility,  while the
increased secretions  accompanying this inordin-
ate  action  have no tendency  to  allay  it, the
health must be rapidly undermined ; and if there
be ulcerations in any part of the body, they must
as certainly degenerate into malignant sores, as
blistered surfaces or scarifications mortify in ca-
ses where the living powers are much exhausted.
* Essay on the Venereal Disease, &c page 58. 
8
  Experience has proved the reality of such con-
clusions, but prejudice and inaccurate  observa-
tion led many practitioners of deserved reputa-
tion to attribute those effects of mercury to other
causes, till Mr. Mathias published his  valuable
remarks  on what he terms the mercurial disease.
Thus, before  Mr. Mathias's publication,  the in-
jurious effects of mercury in some syphilitic cases
were attributed to the original virus operating on
scrofulous, or cancerous, or scorbutic  constitu-
tions,—or  to  some complication  or  anomaly
which was inexplicable.

  Mr.  Mathias  has unequivocally shewn, that
certain dangerous changes upon ulcerations orig-
inally syphilitic, and certain  derangements of
health, occur wherever mercury has been admin-
istered in too acrid  a form, or in too large a quan-
tity ; and his  remarks are  confirmed by the ex-
perience  of every practitioner who has, with ex-
tensive opportunities of observation, been atten-
tive  to the phenomena.  He  imagines  that the
action of the mercury in such cases is of a spe-
cific or  a  peculiar nature ; it more probably,
however, is merely in an inordinate or excessive
degree,  and in  no  other respect different from 
9
what it is in every case.*  It is a well known fact,
that exposure to cold, bodily fatigue,  and irreg-
ularities of diet, particularly indulgence in intox-
icating liquors, have aggravated the severity and
malignancy of syphilitic ulcerations, whether pri-
mary or  secondary.   But  as all  those different
causes concur  only in one respect, viz.  in exci-
ting inflammation, it is  evident  that  mercury,
when it affects the system, must  be productive
of equally injurious changes  upon the  ulcera-
tions in question  and upon the general  health,
because it probably  induces  a more  violent de-
gree  of inflammation, than exposure  to  cold or
irregularities of diet.

   Upon the same principle may be explained the
fact noticed by all practical writers, that scrofu-
lous sores, and scirrhous  tumours, and cancerous
affections, in certain  stages of their  progress, are
much aggravated by preparations of mercury.

   Dr. Blackall has shewn, that,  from the same
cause, thickening of various membranes,  particu-
larly the  pericardium and pleura  coslalis, has en-
sued,—and  it  is  more than  probable, that the
aching pains which so often follow courses of mer-
  * Fide Mathias on the Mercurial Disease, 8vo. Lond. 1810. passim,
                         C 
10
 cury, are owing to partial adhesion and thicken-
 ing of the cellular membrane in contact with the
 fascia and extremities of the  muscles.  From Dr.
'BlackalFs cases, too, there  is reason to believe,
 that the inflammatory diathesis induced by  mer-
 cury may continue  for a very considerable  time
 after the mercury had been  laid aside, and with-
 out any manifest signs.  When individuals in this
 state are subjected to accidental exposure to cold,
 or indulge in irregularity of living, a violent and
 anomalous indisposition takes place, which is apt
 to terminate fatally, or to occasion a broken  state
 of health.*

  Secondly,—Salivation, or an excessive and un-
 usual flow  of saliva, in general follows the in-
 creased  action of the heart and arteries, and is
 preceded by a certain metallic taste in the mouth,
 and is  attended with a peculiar  odour  of the
 breath, different from what is ever perceived in
 any natural  disease.

 ' When an increase of any of the ordinary secre-
 tions takes  place during the course of inflamma-
 tory affections, the local complaints are relieved.
 But the excessive flow of saliva, in consequence
         * Blackall's Treatise on Dropsy, page ill. 
11
of mercury, is accompanied with more  or less
local  inflammation of all  the  parts within the
mouth.   In some  cases, besides the ordinary ul-
ceration of the gums, and loosening and final sep«
aration of the teeth, the tongue, moveable palate,
&c. swell  and ulcerate  to a frightful degree.

  Thirdly,—Emaciation so commonly  follows a
course of mercury, that several  eminent physi-
cians, about the  beginning  of last century,  ima-
gined that mercury had a natural tendency to de-
stroy the  fatty particles.   The celebrated  Van
Swieten ($ 147) says, " All the pinguid humours
are dissolved by the action of mercury, all the
viscid are attenuated, and  discharged out  of the
body, through various  outlets,  together with the
virus adhering to them ; therefore, when the pa-
tient's body is totally emaciated," &c.

  This emaciation has generally been supposed
to proceed, partly from the diminished appetite
for food,  and  chiefly  from the increased secre-
tions and excretions ; but  as the  observations of
Dr. Blackall  have proved that the serum of the
blood passes  off with  the  urine,  it is more than
probable that  the  excessive rapidity of the ema-
ciation is occasioned by that circumstance. 
12
  Fourthly,—Debility, with an irritable  state of
the whole system, accompanies the emaciation,
and of course occurs in various degrees  in diffe-
rent individuals.  The  late Mr.  Benjamin Belb
whose practical knowledge was so pre-eminent,
comprehends in one short paragraph*(page  188,
of the Second  Volume of his  valuable  Treatise
on the Lues Venerea) an  emphatic list  of those
effects of mercury.  He  remarks,  that besides
the usual symptoms of fever, "Mercury  is apt to
excite restlessness, anxiety, general debility,  and
a very distressful  irritable state of the whole sys-
tem.

  The consequences of this effect upon the nerves
are different upon different subjects.  In some,
temporary delirium takes place—in  others, palsy
or epilepsy supervene, and in  many the  memory
and judgment are more  or less permanently im-
paired.   Instances, too,  have occurred, where
sudden death has  supervened,  apparently in  con-
sequence of a very trifling exertion or agitation.
Mr. Pearson has well described such cases under
the title  of  Erethismus.   He  says, this state " is
characterised by great depression of strength, a
sense of anxiety  about the  precordia, irregular
action of the heart, frequent sighing, trembling, 
13
partial or universal, a small, quick, and sometimes
intermitting pul-e, occasional vomiting, a pale
contracted countenance, a sense of coldness ; but
the tongue is seldom furred,  nor are the vital or
natural functions much disordered."

   It may be alleged, that these are extreme cases,
and it must be admitted, that in  many instances,
those very violent effects do not  follow.  Deli-
cate individuals, however, particularly those who
have  been accustomed to a  sedentary life, and,
therefore, in  an especial degree, females, gene-
rally experience, after a course of mercury, va-
rious modifications of disordered feelings, com-
municating the idea of imaginary diseases, which
unfit them for the duties of life, and render exis-
tence a burden.

   Among the anomalous complaints arising from
this cause, may be enumerated, impaired or ca-
pricious  appetite  for  food, with all the ordinary
symptoms of indigestion, particularly retchings
in the morning, and flatulency—disturbed sleep,
 with frightful dreams—impaired  or depraved vi-
sion—frequent aches and pains in different parts
 of the body—occasionally such sudden failure of
 strength, as if just dying, and at other times vio- 
14
lent palpitations at the  heart, accompanied  with
difficulty of breathing. Along with all these com-
plaints, there is such a wretchedness of look, with
$uch a propensity to brood over their miserable
feelings,  that it is extremely difficult to persuade
the relations  or the attendants of the patient that
there is no serious  indisposition.  Indeed medi-
cal practitioners who are not accustomed to Weigh
with mature deliberation all the complications of
symptoms, are generally deceived in such cases,
and involuntarily  add  to the alarm  both of the
unhappy sufferer and of the attendants.

  " I might cite all writers on the Materia  Med-
ica," Dr. Falconar, in the paper alluded to, (page
110)  says, "for authorities that the long contin-
ued and frequent use of mercury is not free from
danger ;  that  among other ill effects, it tends to
produce  tremors and  paralysis, and not unfre-
quently incurable mania.  I have myself seen re-
peatedly, from this cause, a kind of approxima-
tion to these  maladies, that imbittered life to such
a degree, with a shocking depression of spirits,
and other  nervous  agitations with  which it was
accompanied, as to make it more than common-
ly probable,  that many  of the suicides, which dis-
grace our country,  were occasioned by the intol- 
15
erable feelings that result from such a state of the
nervous system."—To the truth of these remarks
every unprejudiced  physician who  has been in
extensive practice must bear testimony.

  Such  are the  ordinary and well known effects
of mercury when given in sufficient quantity to
act upon the human body,—but in  many cases
other deviations from health ensue.

   Of these, the  most common is excessive diar-
rhoea, accompanied often with discharges of blood
from the bowels. This is so apt to occur in some
individuals, even though the mercury be admin-
istered  by being rubbed  upon the surface, that
every writer upon lues venerea has mentioned
this effect as one of the great obstacles to the
cure of the disease.

   The random experiments of speculative physi-
cians upon patients labouring under scrofulous
affections have  proved, that in some cases ulce-
rations  of the soft parts, and caries of the bones,
originally  arising from ill-conditioned states  of
the system, are much accelerated  in  their pro-
gress by  mercurial medicines.  Of this many
luelancholy examples  might  be cited.—A  boy 
16
about eleven years old had a sore on one cheek,
with an affection of the jaw, which  were attribu-
ted to the mismanagement of a dentist in extract-
ing a carious tooth.  A physician was consulted,
(after the patient had suffered for some months),
who immediately prescribed a  regular  and full
course of mercury.  In a short time ulcerations
in the throat appeared, the nose sunk, and one of
the eyes was nearly destroyed, while the general
health  became  so  seriously injured, that death
followed  in  a few  months.  Can it be for a mo-
ment doubted, that all those  morbid changes pro-
ceeded from the inflammatory action of the mer-
cury 1

   Some medical  men,  from  misunderstanding
such cases, have supposed that the affections of
the throat and nose, with caries  of the bones,
which  have   so  notoriously  accompanied  lues
venerea since that disease became known to man-
kind, are  chiefly,  or entirely occasioned by the
use of mercury.  But the uniform  experience of
all physicians  practising in  tropical  climates
strongly contradicts this hypothesis.  Both in the
East and West  Indies  immense quantities of ca-
lomel,  together with mercurial frictions, are pre-
scribed for the cure of various diseases, and are 
17
productive often of long and continued salivation,
without affecting  any other bones than the teeth
and their sockets.

  Mental derangement, with eventual fatuity, has
sometimes followed a  course of mercury;  and
the probable  reason why it does not do so more
frequently, is,  that  the irritable state of mind
which usually precedes actual derangement, com-
monly alarms the attendants, and leads  to active
precautionary measures.

   Another consequence of the use of mercury is
a very violent affection  <>f the skin, originally
hinted at by Mr.  Benjamin Bell—and more late-
ly particularly  described  by Dr. Alley of Dub-
lin*, Dr. Spens of Edinburghf,  and Mr. Pearson
of London J.  It has been styled hydrargyria by
Dr.  Alley, erythema  mercuriale by Dr. i?pens,
and eczema mercuriale by Mr. Pearson.

   This  eruption  is usually  preceded by  heat
and itching of  the  skin,, a frequest  pulse, and a

  * Essay on a peculiar Eruptive Disease, by Dr. Alley, Dublin 1804
  f Edinburgh Medical and Surgical Journal. No. I
  \ Observations on the Effects of Various Articles of the Materia
Medica in the  Cure  of Lues Venerea, by John Pearson, F. R. S.
Second Edition, page 166.
                         D 
18
white tongue.   Most commonly it begins on the
inside of the thighs, or about  the flexures of the
arms ; and Mr. Pearson asserts, that it generally
attacks the anterior parts of the body  before the
posterior.   The parts affected are first of a faint
red colour, and  gradually the  shade  becomes
deeper. The eruption proceeds by slow degrees
over the whole surface, accompanied with an evi-
dent tumefaction of the skin, with great tender-
ness and heat, and most troublesome itching.

  Examined by a magnifying glass, the eruption
appears distinctly vesic ular,  though the vesicles
are so minute  that they cannot be distinguished
by  the naked eye.   These minute vesicles con-
tain at first a  pellucid fluid, and  are each sur-
rounded by a circular redness.   From the great
itching they  are soon and inevitably ruptured,
and discharge  a  thin acrid fluid, which irritates
and excoriates the surface, and  aggravates great-
ly the patient's sufferings.  In this way the dis-
ease proceeds from one part  to another, till the
whole person becomes affected.

  When the vesicles are first ruptured, the fluid
which exudes, though thin, stiffens the linen, but
after a few days the discharge becomes thick, and 
19
emits a most offensive smell.  As  the  different
parts of the body are affected in succession, the
exudation is thin in  one part, and thick and ad-
hesive in another.  In a  day or two the adhesive
discharge ceases, the cuticle loosens,  assuming
first a pale brown colour, and then  turning near-
ly black, when it separates in large flakes, leaving
a faint redness on the exposed  suiface.  Some-
times this desquamation  is succeeded by a second
or third, in the form of white scales, like farina-
ceous powder.   In some cases the hair and even
the nails have also separated along with the epi-
dermis.

   The duration of the disease varies from a fort-
night to eight or ten  weeks, or even longer.  Dr.
Alley  has described three  varieties, viz. hydrar-
gyria mitis, simplex febrilis, and maligna ; and out
of forty-three cases which  he  witnessed within
ten years, eight patients died.  Mr. Pearson, on
 the other hand, asserts that he has not seen  a sin-
 gle fatal case.—For a more particular account of
 this loathsome and distressing affection, the read-
 er is referred to Dr. Spens's Observations already
 quoted, Dr.  Alley  on  Hydrargyria,  Mr. Pear-
 son, second edition, page 166, and Dr. Bateman,
 page 254. 
20
  These morbid effects of mercury do not seem
to depend entirely upon the quantity or mode of
preparation of  that medicine which may be ad-
ministered to the individual, for while it is an es-
tablished fact, that the mildest preparations em-
ployed externally, if exhibited in too large doses,
or continued for too great a length of time, are
followed by some of the bad effects above enu-
merated, it  is  also notorious, that very small
quantities of mercury  have  suddenly proved e-
qually injurious.   Thus, in a lady,  (whom the
authoi attended some  years  ago along with his
intelligent friend Dr. Farquharson,) who had had
such small doses of the blue pill, combined with
opium,  for three nights successively,  that the
whole quantity  amounted to no  more than five
grain of the  mass, salivation begun on the  fifth,
day, and  notwithstanding every attention, the
tongue and gums became swelled to an enormous
degree, bleeding ulcers  of the mouth and fauces
took place,  and such excessive  irritability and
debility followed, that for nearly a whole month
her life was in the utmost jeopardy.—Every prac-
titioner must have met with similar cases.

  Another common consequence of a very small
dose of mercury, is an excessive bowel complaint. 
21
In many individuals a permanent irritability of
the stomach and intestinal canal has followed the
accidental exhibition of a few grains of calomel.

  Various other anomalous  affections have been
known to succeed the use of mercury.  Thus,
Dr. Falconar mentions, (Memoirs of the Medical
Society of London, Vol. III. page 381), that "he
one e saw a dropsy of the breast produced by the
use of a mercurial  remedy for a redness in the
face, whieh it effectually removed, but  instantly
produced a dropsy of the chest, terminating in
death." Dr.  Blackall has recorded similar cases.

  In his observations on the hydrargyria, page
40, Dr. Alley asserts, that he had seen  " that e-
ruption appear over the entire body  of a boy
about seven years old, for whom but three grains
of calomel had been prescribed  ineffectually as
a purgative."

  Many other instances of violent effects from a
small dose of mercury might be cited.  Besides,
the following case seems to prove, that  mercury
may remain  inert for a considerable  time in the
habit, and afterwards, by some  inexplicable cir-
cumstance, may become active. 
22
  A lady, the mother  of four  children, in the
twenty-eighth  year of her age, had a bad miscar-
riage at the end of the fourth month.  When the
author was called, she  was very much reduced
from the loss of blood, and required the ordinary
palliative remedies.  Three days after the first
visit she  complained of a bad taste in her mouth,
with soreness of her gums, and on  the  following
day salivation took place.   On inquiring into the
circumstances  of her previous  history, it  was
learned,  that four years  before, she had had for
a fortnight a course of the blue pill, which had
only slightly touched the gums, and it was solemn-
ly asserted, that she had  never  again taken any
preparation of mercury, and had been in general
good health.

  The salivation was therefore at first attributed
to some accidental cause,  but  when it was found
to be proceeding with great violence, the medi-
cines which the lady had been taking for the pal-
liation of the  complaints  produced by the abor-
tion, were carefully analyzed, from a suspicion
that some mercurial preparation might have been
mixed with them, but it  turned out that they con-
tained no mercury.  The most anxious and un-
remitting attention, and the careful exhibition  of 
23
all  the  ordinary remedies which have been em-
ployed in similar cases,  proved unavailing.   The
salivation, with the usual consequences of exces-
sive emaciation, debility, and irritability, contin-
ued for above twelve  months.   Occasionally for
a day or two it was checked, but alarming vomi-
ting, with  threatening sinking of the  living  pow-
ers, supervened.   The  patient, however, eventu-
ally recovered.*
  * I am indebted for the following case to J. M. Smith, M. D.  It
was not so long in this instance, after the mercury was taken, before it
excited its specific action as it was in Professor Hamilton's case ; but
if a medicine will produce effect after lying dormant in  the system
three months, I know not why it may not after three years.  The ju-
dicious and practical observations of Dr. Smith on the suscrptibility of
the system to the operation  of medicines, render unnecessary any a-
pology for the length of this note.
  " In November, 1811, I was requested to visit a lady about 55 years
of age.  Her symptoms were small and frequent pulse, tongue white
with a brownish discoloration through the middle, protracted consti-
pation of  bowels, hot  skin, head ach, delirium,  and great prostration
Of »trength.  After premising purgative medicines which effectually
relaxed the bowels without  mitigating the febrile symptoms, I put her
on the use of sub-muriate of mercury, combined with pulvis antimo-
nialis and opium.  This preparation, containing about two grains of the
sub-muriate in a dose, was repeated every three or four hours with the
design of exciting ptyalism. This plan of treatment was continued three
 or four days, with the occasional administration of other remedies as
 the circumstances of the case seemed to require.  At the expiration
 of this period, symptoms  of ptyalism not being manifested, and the
 patient rapidly sinking into typhus, I was induced to abandon the mer-
 curial treatment, and to  pursue a more stimulant course ;  accor-
 dingly I advised the liberal use of wine and other  cordial remedies.
 The good effects of this  plan were  soon  discernible.  In  a short
 time she became convalescent, and in a few weeks was able to leave
 her apartment and visit abroad. 
24
    It is universally acknowledged,  that although

 the  morbid  effects  of  mercuiv may  be  induced

 very  suddenly,  and  by very small quantities of

 the  medicine,  in certain  constitutions, there   are

   I have thus stated in general terms the history of her case, as pre-
 paratory to the understanding of the subsequent effects which the
 mercury is supposed to have occasioned.
   Three months after her first attack, I was again desired to visit her.
 She exhibited at this time all the violence of a mercurial salivation, and,
 with much difficulty, related the manner of its accession.  Three days
 before,  after considerable exposure to humidity and  cold, she obser-
 ved her breath to smell disagreeably, and the saliva to flow copiously.
 The fcetor of breath inrreased to  that degree  that she avoided com-
 pany, fearing her  presence would  be offensive.  At the same time her
 gums  became sore  and tumid, and  at  length ulcerous ;  the tongue
 was swoln and loaded  with mu^h white  mucus,  and  excessively sen-
 sible ; the  salivary  glands, generally,  were  also affected with intu-
 mescenre : indeed, so severely  was she affected, that she bad scarcely
 the power of utterance. So correspondent  were her symptoms with those
 which mercury is known to occasion, that I did not hesitate recognising
her present illness as the effect of that medicine. Not suspecting at this
 time that the affection of her mouth was  produced by mercury receiv-
 ed  into the system at a period so long previous as whpn she laboured
 under typhus, I made special  inquiry whether she had recently taken
 any medicine, and was answered  in the  negative, and informed, that
 she had taken nothing, of a medicinal  nature, since she was under my
 direction while sick with fever.  Not doubting her veracity, and being
 persuaded that her disease was a mercurial ptyalism, I was led to in-
 quire  to what source it could be  attributed.  While  engaged in this
 inquiry her former illness occurred to  me, and  the quantity of calomel
 taken  at that time without producing any sensible  effects.  To ac-
 count for the disease from this source appeared to be deviating  from
correct etiological  reasoning, yet so decidedly marked was her disease,
 that I felt no hesitation in assigning this as the cause.  For her relief
 I prescribed the occasional use of flowers  of sulphur and cream of tar-
 tar, with a  view to keep the bowels in a soluble state ; and directed
 the mouth to be frequently washed with a detergent gargle : under this
 treatment she. soon recovered a state of  perfect health. 
25
no marks by  which such peculiarities of habit can

be distinguished,  and  there is no method  of ar-

resting their  progress.—Inflammatory  complaints

may  be  subdued by bloodletting and other reme-

dies ; but in  many cases where  the  mercurial ac-


  The susceptibilities of the  system form a highly interesting and im-
portant part of its economy.   They vary at different periods of life,
and are either changed or modified by  all the circumstances which
tend to diversify the states of health aud disease.  Some constitutions
are extremely sensible to the action  of certain agents,  while others
will receive the full force of their impressions without imparting any
evidence of their operation.  A similar remark will apply to the same
individual, under different conditions of body, and  at distant periods of
time.
  In the case just related, the patient  was not susceptible of the
effect of mercury  at the time of its  administration, nor until three
months afterwards.  That this medicine should  remain in the body
during that period, and then produce its  specific  disease, is indeed a
surprising anomaly.  But on reflection,  it  will be  perceived that the
phenomena of the case are analogous to others with which physicians
are familiarly  acquainted.  The contagious principles  of smallpox
measles, syphilis and hydrophobia, and I may add,  the miasmata arising
from corrupted animal and vegetable  matter, remain in the system
for a considerable time before they show their specific action  on the
body.   The poisons of smallpox, measles, and some other diseases,
usually evince their morbid powers  within a definite period,  while
miasmata,  and the virus of hydrophobia  are in this respect extreme-
ly variable, producing disease sometimes within a few  days, and at
other times not until after a lapse of several weeks or months.  Con-
tagious disorders  are,  for the  most part, so regular and certain in
their accession after the reception of their  respective poisons in  the
system, that  we  must regard their occurrence as arising out of a sus-
ceptibility which  is common to every individual.  On  the  contrary,
the  comparatively few  who sicken  on exposure to the influence of
miasmata and the hydrophobic virus, and the difference of  time in
their several attacks, show conclusively that the susceptibilities of
the constitution are numerous and changeable.—The nature  of these
                                 E 
                              26

tion takes place, such  means  are  either  inadmis-

sible, or  inefficacious.—That in warm  climates

susceptibilities would form an interesting subject  of medical inquiry,
which  would comprehend some of Hie most important considerations
which  relate to life in all its stages, as well as the cardinal principle
of hygiea,
   I have long; been of opinion, that in order to the successful operation
of mercury on the system, there should be a  peculiar susceptibility of
receiving its impressions ; and that when this condition  of body does
not exist, it is impossible to effect the objects for which that medicine
is usually prescribed.  To define particularly in what this susceptibility
consists, is'incompatible with these remarks.  We may however gen-
erally  observe, that it seems to depend upou that state  of the system
in which there i> neither a morbidly energetic, or very feeble action
of the  heart and arteries ; and in which the functions of these organs
are not disturbed in any considerable degree by the immediate opera-
tion of morbid agents upon them.   A state of perfect health is proba-
bly the most favourable for mercury  to show its effects on the consti-
tution  ; and every deviation from that state  which involves the vas-
cular system in diseased  action  beyond certain  limits, destroys the
susceptibility of the body of being  affected by mercury, and conse-
quently renders it necessary to alter  the condition of the system be-
fore that medicine ran be made to operate.   In  the  case under con-
sideration, it is difficult to determine in  what situation  the mercury
was located, in the  interval of its administration  and its action on the
body.   But whether it remained  in the stomach  or  bowels, or  was
assimilated and carried iato the circulation, it is of no consequence to
know,  since in either case, our exposition of the phenomena would be
the same.   The novelty of the case consists in the 'gradual develope-
naent of a susceptibility of being  affected by mercury.   The steps of
this process we are unable to trace, having no  particular knowledge
of the state of the patient from  the time of her advanced convalescence
to  the occurrence  of plyaiism.  The question here presents itself,
whether if  calomel had  been given  in considerable doses, imme-
diately  subsequent to  her recovery  from  fever, ptyalism would
not have been  readily excited.   This matter is extremely  doubt-
ful.  Some constitutions resist  the operation  of  mercury, when
freely  applied, both  internally and  externally.   In  some  instances,
however, quantity may compensate for diminished susceptibility,  and
in this  way it is possible that salivatiou might have been induced".—I. 
27
those violent effects of mercury occur infinitely

less frequently than in countries where there  are

considerable alternations of heat and cold, cannot

be denied, and  ought to be especially noticed.*

But that they sometimes do take place even with-

in the tropics, can be proved by the most conclu-

sive  evidence.

                   SECTION  II.

On the Powers of Mercury  in subduing the  Syphi-
                     litic  Virus.

   Notwithstanding all the hazards resulting from

the use of mercury, there can  be no  doubt that

it has certain medicinal virtues, the most remark-

able  of which is the  power  of curing the diseases

occasioned by the Syphilitic virus.

  * There is a practical inference to  be drawn from this well known
fact, which if duly regarded, in determining  on the propriety and
mode of a mercurial course, would no doubt frequently serve to lessen
exceedingly the  danger and uncertainty of the result.  Although the
susceptibility, so favourable to the operation  of mercury, which is
induced by a residence  in a warm climate, can not be artificially
formed in a cold one, still, the existing  difference,  arising as it does
from well known causes, presents, a general principle to the physicians
of no small importance in determining on the use and prognosticating
the effects of mercurial medicines. If  he relax the rigid fibre ol his pa-
tient by the lancet; if he regard his age, temperament, habit, and con-
dition ; if he impose on him confinement in an elevated and uniform
temperature; restrict him to a vegetable and milk diet, and encourage
by plentiful ddution and the frequent use of the  warm bath  a tree
discharge from  the skin ; he will be able to form a pretty correct
judgement with  regard to the requisite quantity, and the effects  which
will be produced by it.—I, 
28
  It is inconsistent with the object of thi* work,
to enter into any minute details respecting those
diseases; and therefore a very brief notice of the
influence of mercury in removing them is all that
could  have been required, had these pages been
published ten years ago.

  That various  animal poisons, such  as those of
smallpox, measles, scarlatina, &c. produce  defi-
nite symptoms, which, after a certain  number of
days, spontaneously cease, leaving the individual
no longer susceptible of the influence of the poi-
son, is a f tct too familiar to need illustration. On
the other hand, it has been commonly supposed,
(till within these very few years), that the disea-
ses arising from the Syphilitic virus, if left to the
natural powers of the  constitution, at least  among
the  inhabitants of the northern  parts of Europe,
are seldom removed*; and even  at the  present
time, it is not  doubted, that where such diseases
have been artificially cured, the  individual re-

  * " I have asked the opinion of several surgeons of great practice
and abilities respecting this question.   Whether  constitutional symp-
toms of Syphilis do ever spontaneously amend? and no one has de-
cidedly replied in the affirmative ;  whilst  all, without hesitation
agreed that they were generally progressive till checked by  the effect
of mercury."  Abernethy's Surgical Observations on Diseases  re-
sembling Syphilis, page 47. 
29
mains liable to be affected in the same way by a
fresh application of the same virus.

  Fallopius, and  several other writers of the  six-
teenth century, quoted or referred to by Astruc,
have well described the ravages produced by the
Syphilitic virus, when it  first attracted the notice
of Europeans.  And hundreds of modern authors
might be named,  whose observations establish the
fidelity of the ancient descriptions, but it is suffi-
cient to  refer to the works of two of  the most
eminent British  surgeons, w7hose authority  on
practical  subjects is universally acknowledged,
viz. the late Mr  John Hunter, and  the late  Mr.
Benjamin Bell.

  The account of the natural progress of Syphi-
lis given by Mr.  Hunter, was founded  not only
on observation, but upon actual experiment, as
he had the boldness to insert with a lancet the vi-
rus into the parts liable to that disease, of a male,
probably and apparently himself.  The result of
the experiment he details in page 325, of his va-
luable treatise.

  It was discovered about the beginning of  the
sixteenth  century,  that  mercurial  preparations
have the power of removing all the morbid affec- 
30
 tions produced by the poison in question, and the
 impartial  observation of the wisest  and the be*t
 of the profession, in different parts of the world,
 during successive generations, seems to have esta-
 blished the fact of its efficacy in that respect.

  Every now and then, indeed, speculative men
have urged objections against that remedy. Mr.
Pearson, senior surgeon to the Lock Hospital of
London, whose practical knowledge cannot  be
questioned,  and  who,  enjoying so many oppor-
tunities of studying the broad page of nature,
has not bewildered himself with fanciful lucuhra-
ions, has noticed these  objections  in the follow-
ing words.

  *" Amidst the  several  discordant  opinions
 which have been  maintained and  defended con-
 cerning the most successful mode of treating lues
venerea, the fortunes of mercury have been vari-
 ous and fluctuating.

  " With a certain proportion of medical practi-
 tioners it  maintained a steady and undiminished
 reputation ; by many it was disparaged and  un-
 dervalued, as a mineral  possessed  of no  decided
Pearson, second edition, as before quoted, p. xvi. 
31
efficacy;  and by some the administration of it
was exploded altogether.   Even  in the time  of
Morgagni this medicine was interdicted by some
of the most  eminent physicians  in Italy ; and
strong prejudices against the use  of it subsisted,
according to the testimony of Murray, so late as
the middle of the present century.

  " How  far reason, or fashion,  or caprice, was
predominant in conducting to such a determina-
tion, I presume not to decide :  Certain it is, that
notwithstanding the puny clamours of ignorance,
the crafty  discourse  of  interested empiricism,
and even the imperious voice of  authority, mer-
cury continues to this day the medicine common-
ly employed,  and  alone relied on, in all truly
venereal cases.  And although there are  many
who pretend to exclude it from  their nostrums,
yet their perfidious declarations are occasionally
betrayed by the salivating qualities of that min-
eral,  which, in defiance  of every disguise and
combination, will sometimes appear,  to the de-
tection of the impostor."

   Mr. Blair, also surgeon to the  Lock Hospital,
concurs cordially in Mr. Pearson's sentiments on
this subject*.               ^___________
  * Fide Memoirs of the London Medical Society, vol. 5. page 2a6. 
32
  Infinite trials  have from  time to time  been
made with numerous vegetable and mineral sub-
stances, both in  private  practice and  in public
hospitals, and the result, till lately, has hitherto
been, a conviction that mercury alone  seems ca-
pable of arresting the progress of complaints ari-
sing from the Syphilitic virus, and of eradicat-
ing altogether that poison from the human con-
stitution.

  Almost all the empirical  or patent medicines
for the cure of Syphilis contain mercury in a dis-
guised form, although the venders pretend that
their remedies are vegetable preparations, as was
long ago remarked by Mr. Bloomfield  and by
Mr. Pearson, and by every physician  capable of
reasoning.  Those who, trusting to their own im-
agination,  may  entertain any  doubt on the sub-
ject, are referred to a pretty authentic document,
viz. an act of parliament passed in the year 1812.
containing an enumeration of all the  patent me-
dicines sold in  this empire.  Besides  numerous
kinds  of pills, (the  active ingredient  of  which
must be some mineral substance), there are about
twenty-five or twenty-six preparations, under the
title of syrups, drops, specifics, lotions, &c. and
although some of them are disguised with sarsapa- 
33
rilla,  or  guaiac,  or sdme  other  vegetable  sub-
stance, their occasional effects upon patients have
long ago proved that they  contain some concen-
trated form of mercurial oxyde.  Perhaps the diet
drinks may form an exception, and certainly the
only one, to this remark'.

  While these pages were preparing for the press,
the auihor had occasion  to learn accidentally,
that a diet drink had obtained so much celebrity
in a certain district of America,  as to be consi-
dered infallible by the best informed  individuals
over an immense extent of country.  It was pre-
pared by an old female slave, on an estate which
was purchased by a friend of the author.  The
gentleman, on learning that one of his people pos-
sessed such an invaluable  vegetable  remedy for
Syphilis, made a very minute and particular in-
quiry into the subject, and he obtained the  most
satisfactory evidence, (confirmed at last by the
confession of  the  old  woman herself), that the
vegetable infusion contained in solution the cor-
rosive sublimate.  It was proved that she procu*
red annually a quantity of that medicine  from
a considerable distance, and that her only rule in
the strength of the solution was the taste of the
medicine.
                          F 
34
   That in some parts of Europe mercury has
been for many years discontinued as the remedy
for Syphilis,  was a  historical fact,  which till
lately, made little impression upon British prac-
titioners.  They  considered it, like  the prepos-
sessions in the same countries against removing
the itch  by means of sulphur, to be a  melan-
choly evidence of the low state of science.   Ac-
cordingly, when the medical officers  of the
British army, employed on Ihe Continent during
the late war, found that both in the German  and
Portuguese regiments Syphilitic complaints were
treated without mercury, the  prejudice was (as
Dr. Fergusson has strongly expressed it) attack-
ed  without quarter. But the obstinacy  with
which even official orders for the employment of
that mineral in the complaints alluded to were
resisted,  led that intelligent physician to a mi-
nute investigation of the consequences of the
foreign practice.  He ascertained, that the  pri-
mary sores were healed  without  mercury,  and
that the secondary symptoms gradually disappear-
ed under the use of vegetable decoctions.

  Facts so contrary to what had been expected,
were very naturally explained, on the supposi-
tion that  the  Syphilitic  virus had become  ex- 
35
tremely mild among the natives of Portugal,  in
consequence of habit and of universal diffusion.
But it was soon found, that  although  the  Portu-
guese seemed to suffer  nothing from Syphilitic
complaints,  the  infection communicated  from
them  to the British officers and soldiers was of
the most virulent nature.

  This  difference in effect of the same virus evi-
dently arose from  the constitutions of the indi-
viduals subjected to its influence having been in
very opposite states ; for while the inhabitants of
Portugal, from their vegetable diet, &c. were ex-
tremely relaxed,  the British soldiery were much
predisposed to inflammatory affections.

  It has been long understood, that the effects of
several of the varieties of morbid animal poisons
are not in proportion to the intensity of the virus,
but apparently according to the constitution  of
the person  affected.  If any illustration of this
were  required, it would  be sufficient to state a
single one, which must be quite familiar to all
the older members of the profession.  WThen in-
oculation for the smallpox was universally prac-
tised,  different children, inoculated at the same
time with matter obtained from the same subject, 
36
had the disease in every degree, from the mildest
form to the most confluent variety.

  The observations made by Dr. Fergusson (of
which  he  has  given  a  valuable  sketch in the
Fourth Volume of the  Memoirs of the Medico
Chirurgical Society of London, page 1), and of
several other intelligent army practitioners, upon
the treatment of Syphilis in Portugal by vegeta-
ble medicines, led Mr. Guthrie and Mr. Rose, in
the year 1815,  to make  certain experiments on
patients affected with  such complaints in military
hospitals in England.   Similar  experiments have
since 1816  been conducted in the military hospi-
tals of Edinburgh, under the very able superin-
tendence of Dr. Hennen,  Deputy-Inspector of
Hospitals,  and of Dr. Thomson, Regius Profes-
sor of  Military Surgery  in  the  University of
Edinburgh.*

  From  those  experiments it  has been  suppo-
sed,—that  all sores on  the sexual parts may be
healed without mercury in any form whatever—
ferr lt VTj .J °f """ exPeriment'' the reader is re-
Zt   /.h t   g  Me4iCa' a°d Cbln,rSicai Jo»™», No. 53
and 54  and the Memo.rs of the Medico Chirurgical Society of Lon-
don, vol. 8 pages 349 aud 550.                   y 
37
That where  that  medicine has  not been  used,
secondary  symptoms do not  appear in a larger
proportion than in one in ten—that such symp-
toms are of a milder nature than similar ones oc-
curring after the use of mercury—and, that those
secondary  symptoms  gradually  cease, under the
very simple  treatment  of confinement  to bed,
quiet, and  a vegetable diet.

  With  great deference  to  the  gentlemen who
have conducted  those experiments,  the  author
ventures to draw the following conclusions, trust-
ing  that they are  fully warranted  by the facts
which they themselves have recorded.

  .Firs/,-~That, as Mr.  Abernethy* Mr. Mathiasf,
and Dr. CarrnichaelJ, had previously advised, pri-
mary sores ought  not to be dressed with topical
applications, at any rate till  their real nature be
ascertained.

   Secondly,—That in  the treatment of Syphilis
every possible  precaution ought to be adopted,
 * Surgical Observations on Diseases resembling Syphilis, page 49.
 f The Mercurial Disease, &c. page 114.
 X An Essay on the Venereal Disease, &c. by Dr. Carmichael, &c
page 31. 
38
 to guard against the occurrence of general or lo-
 cal  inflammation,  such  as,  confinement within
 doors, quiet,  warmth,  vegetable diet,  &c. — It
 should, however, be remarked, that every intelli-
 gent practitioner, from the days  of Astruc, had
 learned this most important lesson, and it had
 been  very strongly impressed on  the minds  of
 army surgeons, by  many  untoward and  distress-
 ing cases, during the active campaigns of the la=t
 war.

  Thirdly,—That a much milder course of mer-
 cury, provided the  above precautions he attend-
ed to, is sufficient for the cure  of Syphilis, than
had in general been hitherto supposed ; thus con-
firming the observations of Mr. Mathias* and Dr.
Carmichaelf.

  Fourthly,—That decoctions of sarsaparilla,
guaiac, &c. are, in the complaints under conside-
ration, not superior in efficacy to water-gruel.—
In Dr. Fordyce's cases, and in those recorded by
Mr. John Hunter, Mr. Abernethy, Mr. Mathias,
Dr. Carmichael, &c. where sarsaparilla  seemed
beneficial, the patients had previously taken more
* On the Mercurial Disease, page 76.
t Essay on the Venereal Disease, &c. page 48. 
39
mercury than had been necessary, and it is prob-
able that any other mild  diluent,  such  as that
prescribed in military hospitals, would have been
equally  efficacious.—Diluents, under  such cir-
cumstances, operate  chiefly by lessening the in-
flammatory  tendency, and partly  also, perhaps,
by altering the peculiar state of the blood, occa-
sioned by the use of mercury.

  In the original MSS. sent to press, a fifth  con-
clusion was inserted, objecting very strongly to
the farther prosecution of the experiment of trust-
ing,  in military hospitals, complaints really Sy-
philitic, to the unassisted powers of the constitu-
tion.   But through the favour of a friend, the au-
thor has received a copy of a Circular Letter
(dated April 2, 1819,) on this subject,  addressed
by Sir James M'Grigor to the Medical Officers
of the army, which renders it unnecessary for
him to urge this advice.

  From the reports of Mr. Guthrie, Mr. Rose,
&c. it appeared  that one in ten  of the soldiers
treated by  the new method had been liable to
secondary symptoms, and that the primary sores
had  healed  more  slowly than they usually do
where mercury is employed.   As the same gen* 
40
 tlemen admitted, that  only one in seventy-five of
 the  patients treated  with mercury in military
 hospitals  had  been found  liable  to  secondary
 symptoms,  and as the  following  pages contain
 certain evidence, that the Syphilitic  viius affec-
 ting the infant  in  utero  cannot be subdued by
 the  natural  powers of  the  constitution, he felt
 himself called  upon to express in emphatic  lan-
 guage his objections to a farther trial of the ex-
 periment in  question.

  He has great pleasure  in  paying the tribute
 (small as it is) of his approbation to the liberality
of sentiment which pervades Sir J. M'Grigor's
 circular.  It confirms the  opinion,  with which he
 had  always  been  impressed, that the integrity »
and intelligence of British surgeons have invaria-
bly been  such,  as to secure, for the seamen and
the soldiers  of our fleets and  armies, the  best
 medical and surgical  assistance  which humanity
and knowledge  can afford.

  Some facts are stated  in that circular, which
are more in favour of the new method than the
reports previously published.  Thus,  nineteen
hundred and forty patients treated  without  mer-
cury, no more  than ninety-six, had  secondary 
41
symptoms,—all of. these ninety-six,  but twelve,
were cured without that mineral, and they all re-
covered so completely as to continue fit for duty.
Whereas of two thousand eight hundred and twen-
ty-seven treated with  mercury, fifty-one had  sec-
ondary symptoms in  a more violent  degree than
the above ninety-six, and  two of them were dis-
charged as unfit for service. It is admitted, how-
ever,  that although the above be the general re-
sult, there is  a great discrepancy, in respect to
the several particulars, in the reports from  diffe-
rent regiments.

   Had it not been for Sir James  M'Grigor's cir-
cular,  the author should have recalled to the re-
collection of  army  surgeons  certain facts  well
known to the  profession,  of which  many  cases
have been recorded by Mr. J. Hunter, Mr. Aber-
nethy, &c. tending to shew, that the Syphilitic
virus,  like some other animal poisons,  may, in
particular constitutions, remain  dormant for  a
considerable time, and afterwards break out with
great  virulence.—In  that  circular, there seems,
however, to  be an  illusion  to those facts,  and
therefore the author does not cite instances which
have fallen within his own knowledge, wh^re the
poison, after having lurked without any apparent
                         G 
                      42
injury to the individual for four or five year*, 01
longer, has at last become suddenly active, seem-
ingly in consequence of exposure to cold, or ex-
cessive fatigue,  or  indulgence in  intoxicating
liquors.

   As he confidently expects,  that, if due atten-
tion be paid to  the  directions  contained in the
circular alluded to,  all  uncertainty  upon  the
question at issue will  cease, among  army sur-
geons, before the end of three years, he does not
dwell farther upon this subject.

  Whether this  prediction be verified or not, he
takes the liberty, with great earnestness, to enter
his most solemn protest against the introduction
of this experiment (of treating  Syphilis without
mercury) into private practice.—Patients  in the
ordinary ranks of society cannot possibly be kept
under the same strict regulations and unremitting
vigilance of superintendence with soldiers in a
military hospital.  It would be absurd to expect,
that even the majority of persons in the higher
stations would submit  to  confinement  to  bed,
perfect quiet, and vegetable  diet, for any length
of time. Nay,  upon the supposition  that  many
were  to acquiesce in such privations,  and that in 
                     43
consequence the  Syphilitic  symptoms were  to
cease, it is little probable that such persons would
apply for medical advice on the immediate ap-
pearance of secondary symptoms.  But any de-
lay in doing so might be most fatal, of which med-
ical records bear ample testimony ;  and as there
is a  chance that  one in ten  may have secondary
symptoms, it is not too much to fear, that, before
long, many melancholy victims of this ill-fated
experiment might appear to  execrate the experi-
menters.

   I has indeed been alleged, particularly by Mr.
Rose, (Medical Chirurgical  Transactions, vol. 8,
page 425) thai the  affections  of the bones, &c.
which were so  common, and so much dreaded,
both by patients and practitioners, in  former
times, were the  effects of  mercury, and not of
Syphilis.  But all this is contradicted by the de-
scription of the ravages of that  disease when first
noticed, and before  the use of mercury was re-
sorted to,  and by the testimony of Dr. Fergus-
son  and of Mr. Guthrie, that at present in Portu-
gal (where no  mercury is  employed) there are
numerous individuals of all  ranks with mutilated
nose", and other personal  defects, from the dis-
ease in  question ; aad  also by the fact, already 
44
 specified,  that in India, where such long contin-
 ued courses  of mercury are prescribed for affec-
 tions of the liver, no disease of the bones, except-
 ing the teeth  and  alveolar processes,  was ever
 known to occur under such circumstances.—This
 is perfectly  consistent with what  has  been  al-
 ready explained*,  that  under peculiar circum-
 stances, the use of mercury aggravates greatly
 any tendency  to caries or  ulceration,  whether
 that proceed f om  scrofula or Syphilis—hut in
 such cases it does so, by inducing  the  inflamma-
 tory diathesis ; and  exposure to cold, irregulari-
 ties in diet, and other  causes of inflammation,
 have the same effect, as is  so  notoriously shewn
 in the disfigured visages of many of the inhabi-
 tants of Portugal.

  That the secondary  symptoms  have  proved
milder in military hospitals, where the new mode
of treatment has been pursued, can be satisfacto-
rily explained on the same  principle, (already so
repeatedly stated in these  pages), viz.  that as
such symptoms are  invariably  aggravated  by
whatever tends  to increase  the inflammatory dia-
thesis,  the  low  diet to which the soldiers are re-
* Page 19. 
45
stricted,  and the  other  precautions  adopted in
military  hospitals, effectually preclude the pos-
sibility of such tendency.

  A solemn protest  against any attempt at cu-
ring complaints which are really  Syphilitic, in
private  practice,  without  the use of  mercury,
founded  on  these obviou: reasons,  may be treat-
ed  with levity by  those who find it inconvenient
to submit to a course of that mineral, and also by
some visionary  or inexperienced medical  men,
and therefore it is necessary to* state another ar-
gument,  derived  from facts which no sophistry
can evade, and which it  is hoped, will rouse the
attention,  both of the profession  and of the
public.

  There can be no doubt that the infant in the
womb is liable  to be infected by  the Syphilitic
virus, and to be  destroyed by that  poison long
before the ordinary period  of birth.  ^Monsieur
Bertin,  physician  to I'Hopital des Veneriens at
Paris, published in the year  1810 an account of
the infants affected with  Syphilis, who had  been
under treatment in that hospital,  during  the pre-
ceding nine years.
  * Trait! de la Maladie Venerienne par M. Bertin, a Paris, 1810. 
46
   The account is truly appalling.—No less than
 one thousand four hundred and  fifty infected in-
 fants  had been attended within that short space
 of time.—Of these, one thousand and eighty-five
 had been born either in that hospital or in FHos-
 pice de la Maternite, and therefore had been in-
 fected by their parents,  and* three  hundred and
 sixty-five were brought in from the  city or coun-
 try, many of whom had had  the disease from nur-
 ses.   Monsieur Bertin had  adduced numberless
 proofs, that the infants  in whom the disease ap-
peared soon after birth, infected the nurses, and
that these communicated the disease to their hus-
bands.

   This fact is of the utmost importance in eluci-
 dating the progress and the cure of Syphilis, and
 is  so well established, that it would  be a work of
 supererogation to adduce the proofs on which it
 is  assumed.  It cannot possibly be  urged as any
 objection against it,  that medical men  of  great
eminence have differed materially from each other
 in  the explanation of the precise mode through
 which the infant in utero is infected by this poi-
 son, although it certainly evinces the importance
 of drawing a line  of distinction between the ob- 
47
ser vat ions and the inferences  or speculations  of
physicians.

   Mr. John Hunter, for example, supposed that
the only way in which the infant could be affect-
ed by the Syphilitic virus, is by contact with the
diseased parts of the mother.  Were it necessary
to state any additional evidence to that brought
forward by Mr. Benjamin Bell (page 416 el sea.
of his second Volume) of the fallacy of this opin-
ion, the author could cite many cases which have
fallen under his own  observation—but  he con-
tents himself with recording the  two following,
as being, he apprehends, perfectly conclusive.

   A married lady, after bearing three or four
healthy children, was  delivered of an  infant,
which   at birth  had its  nates, &c. covered with
copper  coloured  blotches.   As  this lady had
never had  any Syphilitic complaint, and her hus-
band arid she were of the most respectable rank
and character,  it was necessary to proceed with
great caution in giving any opinion on the  nature
of the appearances, and therefore the author re-
quested a meeting with the  family medical atten-
dant.   On seeing the infant, that practitioner im-
mediately  recollected, that he had been consulted 
                      48
 by the male parent, about a year  before, on ac-
 count of an ugly eruption on  his skin, which was
 attributed to the h-ai  of the weather, and  which
 had seemed to yield to the use of  bark, &c.  He
 was now however convinced,  that the gentleman
 (who had been absent from his wife for several
 months previous to that time) had had some Sy-
 philitic complaint, for which he had been secret-
 ly taking mercury.  The  infant was eventually-
 cured, but it required the  appropriate remedytfor
 many months.

  The other case may appear still more decisive
against Mr. Hunter's  hypothesis.  The mother
of a numerous  family of healthy children became
diseased through the profligacy of her husband,
and at the same time fell  with child.  A number
of chancres formed on the external parts, which,
notwithstanding the irregular use of  mercury,
continued till the time of delivery.  The  labour
proved preternatural, and  the infant's arm was
actually protruded for seven hours before the as-
sistance of the  author of these  pages was request-
ed. The infant was born  alive, and a few days
after birth had its nates and soles of the feet cov-
 ered with copper coloured blotches   The  dis-
 ease proceeded in the ordinary way, and the in- 
49
fant's life wras  protracted for several months, in
consequence of the strength  of its constitution,
and of the occasional though irregular exhibition
of mercurial  medicines.   Scabby  incrustations
broke  out  upon the lower extremities and upon
the face and head, but no affection whatever ap-
peared upon the arm which had been in contact
with the diseased part  of the  parent.

  That the male parent,  although apparently in
health, and while the female  parent  is  totally
free from disease, may infect the infant, Mr. Ben-
jamin Bell has taken particular pains to prove*  ;
and he has stated several  cases in illustration,
some of which fell also  under the notice of the
late Dr. Alexander Hamilton, and of the author
of these pages.-—The concurrent observations of
many other practitioners warrant the conclusion,
that in married persons the Syphilitic virus may
lurk for a considerable time in the  habit of the
male, without at all affecting his health, and with-
out communicating any disease to the female,
and may nevertheless infect the offspring of the
parties.
' Vol. 2. page 416 et seq.
         H 
                       50
   A late practitioner in this city,  acquired the
 reputation  of curing the  disorders alluded to,
 with more rapidity and less severity than the rest
 of his brethren.  His  method was to apply caus-
 tic  very liberally to  the primary  sores, and to
 give a few mercurial pills, without subjecting the
 sufferer to any other restriction  than  abstinence
 from intoxicating liquors.  But many of the pa-
 tients of that  gentleman had the  mortification to
 discover after marriage, that their cure had not
 been quite so perfect as it had been expeditious.
 Their wives  repeatedly  miscarried of  dead in-
 fants.

   In several cases where that gentleman had at-
 tended, the author of these pages ascertained that
 three, four, or five years elapsed between the dis-
 appearance of all Syphilitic complaints (together
 with the possible chance of infection)  and the
 marriage of the individual, notwithstanding which
 a succession of still-born infants had followed the
 connection.

  It is equally certain,  that the disease  may be
transmitted from the female parent.—According-
ly it is well known, that numerous instances have
occurred in public hospitals as well as in private 
51
practice, where women affected  with  lues  have
been  delivered of dead  children,  evidently de-
stroyed by the Syphilitic virus.

  Where both male and female parents have had
the affection in question, and, though apparently
cured, have had  a diseased offspring, it is diffi-
cult to trace  the source of the infection ; but
there is every reason, from the cases which the
author  has  witnessed, to believe that  the poison,
under such circumstances, lurks  in the system of
the male.

   Cases of congenile Syphilis  obviously afford
the most ample opportunities of ascertaining both
the natural powers of the  constitution, and also
the efficacy of mercury, in  overcoming the effects
of that disease.

   In fact, the embryo infected with the  Syphili-
tic virus, enclosed in the  body of a healthy wo-
 man, kept  constantly in  an equable degree of
heat, excluded completely from the atmospheri-
 cal air, and nourished by blood not formed by its
 own digestion, must be admitted to enjoy at least
 as many advantages as soldiers in military  hospi-
 tals, confined to bed, and fed upon water-gruel. 
52
   Experience, however, proves that these advan-
 tages are of very little avail  to the  infected em-
 bryo, for it either dies in utero, or  is born  alive
 in a diseased state.   Under these latter circum-
 stances, the morbid effects of the virus are some-
 times evident at  birth, and sometimes  not till a
 feW days after ; but in both instances the appear-
 ances are quite characteristic, and  the  progress,
 if left to the resources of nature, is sufficiently
 uniform.—Copper coloured  blotches  of a  cir-
 cumscribed form  first appear, on the nates  and
contiguous parts,  and soles of the feet, gradually
 scabbing and ulcerating, and if these  are over-
 looked or misunderstood, ulcerations soon  take
 place in the  throat and palate, (with a purulent
 discharge from the nostrils  and eyelids),   and
 scabby incrustations form upon the limbs, accom-
 panied with great debility and emaciation, which
 more on  less quickly destroy life, the nose in
 many cases sinking previous to death.

  In some instances, apparently  in  consequence
 of the  occasional exhibition  of small  doses of
mercury, the infant thus affected has been known
to drag  on  a  miserable existence for several
 months, in the course  of which some of  the deci-
duous teeth have been protruded, and have drop- 
53
ped out.—The ravages of the diseased virus, un-
der those  circumstances,  are not confined to the
infant, for they extend also to the nurse, if  very
particular  precautions be not adopted.  Thus,
her nipples ulcerate, swellings of the  axillary
glands follow, and soon after,  ulcerations of the
throat are discovered, and the general system be-
comes tainted.

   That the Syphilitic virus in infants is of a pe-
culiarly inveterate nature, was the opinion of Mr.
Benjamin Bell.—He says, (page 428.) " The vi-
rus is in  this state of a more deleterious nature,
than  it ever appears to  be in any other form of
the disease.   Besides being more particularly apt
to communicate the infection, it proceeds with
more rapidity to destroy the constitution,  in so
much that if mercury be not employed immedi-
ately on the disease being  perceived, it usually
makes such quick progress, that a fatal termina-
tion can scarcely be afterwards prevented."—The
extreme delicacy of the infant's constitution is
probably  the cause of the  virulence thus de-
 scribed.

   It is established, therefore by innumerable facts,
that  Syphilis, when a congeriite affection in in- 
54
lanls, cannot possibly be conquered by the natu-
ral powers of the constitution.

   To appreciate the full value of this fact, it is
necessary to recall to the recollection of the pro-
fessional reader, that other animal poisons besides
that of Syphilis, and also the tendency to various
diseases, are communicated to the infant in utero,
and that such poisons and diseases do not so reg-
ularly prove fatal.  The infection of smallpox,
for example, has been transmitted from the female
parent in many cases,  and the infant has been
found to have  had the  disease in  a mild degree.
Measles and scarlatina, it is more than probable,
have been also communicated with impunity to
the infant in the womb.  If it be urged, that when
women in the early months of pregnancy are af-
fected with  measles, or smallpox, or  scailatina,
in a violent degree, they commonly miscarry, af-
fording  presumption that the infant had been de-
stroyed by  the disease  of the parent, the objec-
tion  may with  great confidence be repelled, for
the abortion commonly happens at a period an-
tecedent to that at which the infection could take
place,—and  besides, the phenomena unequivocal-
ly denote, that the miscarriage arises from an in- 
55
ordinate action  of the  uterus, and not from the
previous death of the foetus.

  On the other hand, the efficacy  of mercury in
curing the infant under all those various circum-
stances, has been fully ascertained by the expe-
rience of every practitioner who has attended to
the subject.

  Where  the male parent alone  had  formerly
had the complaints alluded to, it was the practice
of the late Mr.  B. Bell, and of Dr. A. Hamilton,
to put both  parties under a course of mercury ;
and  the result certainly has  been  uniformly suc-
cessful, the  future progeny of  the individuals
having been born alive and healthy.

  But some  cases several years ago occurred to
the author, where, from circumstances,  it was im-
possible to adopt this plan, and he was compelled
to limit the use of mercury to the male parent.
He had the satisfaction of finding the experiment
efficacious in the utmost degree, and since then
he has always recommended the  same  treatment
 wherever he had conclusive evidence that the fe-
male parent  had never had any suspicious symp-
toms. 
56
   In some cases where the female had repeated-
 ly born dead children, although she lier^elf had
 never had any Syphilitic complaint, mercury was
 exhibited to her alone, in consequence  of her
 being pregnant, before the nature of the case was
 understood.—The effect <»f the practice in such
 cases has not been  so invariably fortunate as in
 the former.   Some of the infants were still-born,
 others, though alive at  birth, shewed in  a few
 days symptoms of the disease, which  soon proved
 fatal ; and a certain  proportion were born heal-
 thy, or had the complaint in  so slight  a degree,
 that it yielded to the appropriate remedies.

   Where both parties had had the complaints al-
luded  to  after marriage, (cases  comparatively
 rare in this part of  the wold), and had been ap-
 parently cured, although their offspring were ev-
 idently infected, a  course  of mercury properly
 conducted has  never failed to secure a healthy
 progeny.—In one case of that kind, which  occur-
 red many years ago, (where the late  Mr. B. Bell
 also attended), the mercurial course, by the pre-
judice of the parties, was not continued for the
 length of time  recommended by the medical at-
 tendants.  The  lady soon  after fell with child,
 and  was  delivered,  between the seventh  and 
57
eighth month, of an  infant, who infected three
healthy nurse> in sue cession.   The parties in that
case eventually submitted.to a proper mercurial
course, and afterwards had three healthy infants.

  Many other facts might be stated by the au-
thor, (as having fallen under his own observation,
and concerning which he believes there could be
no mistake), to prove, that by  means of mercury,
the Syphilitic virus lurking in the constitution of
one or both parents,  and thereby capahie of in-
fecting the infant, may be eradicated.  And there
can be as  little doubt, that infants in whom the
disease in  question is congenite, as well as those
infected by nurses, invariably  die, as Mr. Bell
has remarked, if  mercury  be  not employed ;
while, on  the other hand, a  large proportion is
saved  by that mineral.   Thus  Monsieur Bertin
mentions, that four hundred out of one thousand
and sixty-nine of the infants treated in 1'Hdpital
des Veneriens of Paris, were  cured by means of
mercury, exhibited either directly to themselves,
or mediately through the nurse, and were dismis-
sed, weaned, and in good health, at the end of the
year after  birth. 
                      58
  Controversies on trifling or 'speculative  sub-
jects have so often employed the time and talents
of medical men, without any benefit to  science,
that it is incumbent on every one who wishes to
improve the practice  of physic, to abstain scru-
pulously from such disquisitions.  But where the
question is one of the highest  importance,  both
to individuals  and  to the public, such as he ap-
prehends that respecting the cure of Syphilis to
be, the author  should consider  it a most serious
dereliction of duty, were he to allow any feelings
of deference for the opinions of others, to deter
him from expressing strongly his own conviction.

  If the facts detailed in the preceding pages, re-
specting the  liability of the infant in the womb
to the infection of Syphilis, can  be depended up-
on—and he ventures to assert, without any haz-
ard of contradiction, that they can be  neither
controverted nor extenuated—the irresistible con-
clusion must be, that mercury affords the only
safe and efficacious remedy for complaints really
Syphilitic,

  While it is  not to be inferred that the trials
which have been made, to find  a safer substitute
for  that active medicine, have been useless, .since 
59
they have suggested many  important  means,  by

which its deleterious  effects  may  be guarded a-

gainst, it is  to be  hoped, that in this empire any

future attempts to cure so  alarming a  disease  as

Syphilis by  any  other  medicine than mercury,

will  be  regarded  with the reprobation  they mer-

it.—The trite apophthegm, that in the practice of

physic, errors of omUsion are often of more inju-

rious consequence than errors of commission, ap-

plies  most correctly in the  piesent  instance.*


  * The author's candour and practical good sense, are particularly
evinced in  the foregoing section.  His extreme caution in the use of
mercury, in various other diseases, serves to give weight to his testi-
mony in favour of it, as the  only safe and certain antidote to syphilis.
Fortunately, most of the physicians in this country have been induced
to await the result of the groat experiment which  has been making
on this subject,  during  the last four  or five years, by their English
brethren. An unbounded confidence in the curative properties of mer-
cury in this disease, and  an invincible skepticism, founded on the fre-
quent failure and fatal consequences of every other course of treat-
ment,* (as had been too often shown in the practice of quacks and
nostrum-venders), probably  caused most physicians to be suspicious of
innovation. A few opportunities have occurred to the writer, favour-
able for the treatment of Syphilis, agreeable to the plan  lately  pur-
sued by the  English and Scotch  physicians ; but  alter  prosecuting
the antiphlogistic course as long as was thought consistent with the
safety of the patient, he  was in every  instance obliged to resort to the
use of mercuiy to cure  the primary symptoms of the disease.   But
whatever else may be the result of the anti-mercurial  practice, it will
undoubtedly be beneficial in confirming and establishing the observa-
tions of Abernethy, Carmichael, and others,  that  every ulceration on
the genitals is uot venereal.—I.
  * The muriate of Gold forms an exception.  This remedy  if given
during the  existence of primary symptoms  of Syphilis will no doubt
generally exterminate the disease, and in constitutions peculiarly un-
favorable to the effects of mercury, it is a highly valuable remedy. 
60
               SECTION III.
  Of the Cautions necessary during the Use of
       , '         Mercury.
  The first precaution to be adopted in this cli-
mate during a course of mercury, is  confinement
withindoors, with a regulated temperature of the
apartments.—Both the utility and the  necessity
of this precaution must be so obvious,  from the
remarks already made, that it is unnecessary to
expatiate  upon the subject : not that it is meant
that the patient should be confined to an ill-ven-
tilated room ; for,  on the  contrary,  a  plentiful
supply of fresh air is of essential utility.—While
the boldness with which Mr.  Pearson  exposes
such patients to cool, dry, open air, may be well
suited to persons  who  have been immured in a
crowded hospital, with a mercurial  atmosphere,
it certainly would be most prejudicial to the bet-
ter ranks of society in private practice.

  Secondly,—The  diet  ought to consist of the
mildest possible food, such as  preparations of
milk and farinaceous matters,  with weak animal
mucilages.  In short, all  stimulant  food, or drink
of every  description, ought to be most scrupu-
lously refrained from. 
61
  Thirdly,—If the  individual  be robust, sixteen
or twenty ounces of blood should be drawn from
the arm  before any preparation of mercury be
exhibited.  Where, from  the delicacy of the pa-
tient, blood-letting  cannot be advised,  confine-
ment within doors, and low diet, should be perse-
vered in for at least a week  previous to begin-
ning the  mercury, and during that time one or
more doses of cooling physic ought to be  taken.

  Fourthly,—The mercury must not be given in
such quantity,  or with such activity, as to pro-
duce a sudden  effect upon the system*   This is
certainly one of the most important practical im-
provements,  suggested  by Mr.  Abernethy and
others, and  confirmed by the late experiments ;
for irreparable  mischief was often committed by
the hurry with  which the system was loaded with
mercury. If the other precautions be implicitly
adopted, the  more slowly  the mercury is admin-
istered, the more certainly, and perhaps speedily,
will the primary sores  heal.

   Fifthly,—Although in particular cases some of
the more active mercurial oxydes may be useful,
the blue pill  or the blue ointment furnish in gen-
eral the  safest  and  mildest preparations of mer-
cury. 
62
   Sixthly,- Salivation  is to be guarded against,
by lessening the dose,  or suspending  the  medi-
cine,  whenever  the  brassy  taste in the mouth is
perceived. The same measures are to be pursued
if any irritation of the  bowels threaten.

  Seventhly,—Some  vegetable  diluent  ought to
be drank in  large  quantities,  for the  purpose
principally of preventing the peculiar state of the
blood which mercury is so apt to produce.   The
decoctions of sarsaparilla, guaiac, sassafras, &c.
answer this purpose, and perhaps they  are  all e-
qually efficacious, if drank  tepid, and  in suffi-
cient quantity.

  Eighthly,—It is extremely difficult to establish
any general rule for the duration of a mercurial
course, as that must be regulated very much by
the circumstances of each particular case.  From
two to three months may perhaps be sufficient in
the majority of cases.

  ISinthly,—The  daily use  of  the warm  bath,
where that can be conveniently commanded, is
found particularly beneficial. 
63
   Tenthly,—If any irritable feelings occur while
under  the  influence of mercury, the use of the
medicine should be instantly suspended,  and the
most active measures  for checking the progress
of such complaints ought to be carefully adopted.
Preparations of camphor, of the spiritus ammo-
niae aromaticus, of opium, of cicuta, &c.  are sev-
erally  useful,  according to the circumstances of
such cases.

   Eleventhly,—After the mercurial course is fin-
ished, the patient ought to remain within doors
for at least a fortnight, improving the diet, (though
still abstaining from  wine and stimulating li-
quors), and taking gentle exercise, progressively
increasing it according to the return of strength.

 Lastly,-The flannel and woollen dress, in which
those under a  course of mercury should be (lite-
rally speaking) encased, is to be changed daily,
and besides the ordinary  precaution of having
those articles of dress well washed, it is necessary
that they  be  exposed  for  at  least twenty-four
hours to the open air, and afterwards to the in-
fluence of a large fire, before  being again used. 
64
                SECTION  IV.

 On the  Means of relieving  the morbid Effects of
                   Mercury.

  Where a mercurial.course has been improper-
ly conducted, or  where great debility or irrita-
bility has followed the use of that medicine,  it is
extremely difficult to restore health.—Mr. John
Hunter seems to have depended principally upon
country air and  cold bathing ;  while Mr.  Aber-
nethy, Mr.  Mathias,  Mr.  Pearson, and  others,
place great  confidence  in preparations of sarsa-
parilla,  of cicuta, of the nitric or nitrous acid,
with country air, and generous diet.  Dr. Carini-
chael has, in  addition to these means, employed
with great advantage antimonial preparations.

  From the experience of these and other respec-
table practitioners, it appears, that the sarsapa-
rilla, the cicuta,  and the tartrite of antimony, are
chiefly useful in cases of cutaneous affections, or
of ulceration of the throat, or of thickening of the
periosteum,  which is exactly what might be ex-
pected on the principles already  explained in
these pages.—On  the supposition that all those
consequences  of mercury arise  chiefly from the 
65
peculiar  change upon the state  of the blood,
medicines calculated to counteract that condition
must be the best adapted to the removal of such
complaints.  The  preparations of opium and of
cicuta serve the purpose of relieving pain, and al-
laying inordinate action in particular parts.  The
nitric, or nitrous acid, tends also to improve  di-
gestion.

  But many cases occur in real practice, where
these several means prove of little avail in arres-
ting the progress of the nervous complaints, or in
allaying the irritations of the  stomach and  bow-
els, which  occasionally follow a  course of mer-
cury ; and every practitioner of extensive expe-
rience must admit, that such cases are among the
most embarrassing and troublesome modifications
of disease  which are met  with.  The unhappy
prepossessions  of the patient under such circum-
stances  add not a little to the difficulty of the
cure, as  it is almost impossible to command the
confidence of such persons, without stooping to
artifices, which no man of integrity can submit to.

  It should however be universally known, that
in cases of that description a great deal  may  be
done by the regulation of the diet and of the ex-
                        K 
66
ercise of the body and mind, and by *he occasion-
al exhibition of some of the vegetable tonics, pro-
vided time be allowed ; for several  months at
least are always required  before any material
change in the constitution can be effected.—Ac-
cording to the state of convalescence, swinging,
riding on horseback, and 1 he use of the cold bath,
are severally extremely  useful.  In very young
subjects, dry friction, and the internal  use of pre-
parations of iron,  seem to  have  the happiest
effects*

                SECTION V.

On the Use of Mercury in Diseases  of the  Liver.

   Inflammation and infarction of the liver it has
been long known  occur frequently in hot cli-
mates, both as idiopathic and symptomatic affec-
tions, for they follow almost every disease of the
system,—and experience has fully  established
the efficacy  of mercury in arresting their  pro-
gress.   The  violence of the symptoms, and the
rapidity of their succession in many of those ca-
ses in tropical regions,  have  necessarily  led  to
the most active modes of exhibiting mercury, the
life of  the patient  seeming to depend upon the 
67
celerity with which the system can be subjected
to the influence of that mineral.  Accordingly,
immense quantities  of calomel,  and extensive
mercurial friction, are prescribed with great ad-
vantage  in the East and West Indie9  in such
diseases.

   But in Great Britain, the change  of structure
of the liver, which eventually ends in suppura-
tion or scirrhosity,  is found  to arise only from
mismanaged intermittents,  or from scrofula, or
from the abuse of intoxicating liquors.  Enlarge-
ment of that part, however, is the effect of other
causes, viz. tubercles, hydatids, and what are call-
ed tubera.

   As it is  not intended in these pages to  investi-
gate minutely  the various diseases of that impor-
tant viscus, it is sufficient for the purpose of this
publication, to state, that in  the living subject it
has been found extremely difficult to distinguish
the different alterations of texture, which take
place even in cases where the progess of the dis-
 ease is so  far advanced that the patient is almost
 moribund.

   From inattention to this well established fact,
 it has been too generally supposed, that when en- 
60
largement of the liver can be recognised by care-
ful examination,  it is warrantable to  prescribe
mercurial medicines, unless the circumstances of
the case unequivocally denote that the disease is
beyond human reach, in consequence of a change
of texture, which no efforts of the constitution
can conquer.  But the  proofs of this mortal al-
teration  in any  individual case are  extremely
doubtful.

  Of this Dr. Farre has  recorded a most striking
example, in the instance of a lady, in whom the
enlargement of the liver, from  innumerable tube-
ra, was such, that on dissection, the diseased vis-
cus was found to have descended as low  as the
pelvis.—Dr. Farre says, (page 30) that* " She
was examined this day by an old physician, who
gave it as his opinion, that mercury was  the fit
and only remedy.—Another medical gentleman,
who did  not see her, but merely beard that she
had an enlarged liver, sent to assure her husband
that, in such a case, mercury was the sheet an-
chor."

  These  facts explain  what has  been long ac-
knowledged by  every candid practitioner, that
* Morbid Anatomy of the Liver, by J. R. Farre, M. D. 
69
no  mode of practice is successful,  even in the
majority of cases of enlarged or indurated liver.
Where, indeed, the induration has succeeded to
a protracted intermittent, there is always a better
chance of recovery, than where it has been occa-
sioned by scrofula, or  by the abuse of intoxica-
ting liquors, because in these latter cases there is
often some complication, arising from diseased
changes in the stomach or bowels, or other parts
concerned in digestion.

  The ordinary mode of exhibiting  mercury for
the cure of chronic hepatitis in this  country, not
unfrequently hurries on  the disease, or, by im-
pairing the constitution, lays the foundation for
paralytic affections, and it may be truly affirmed,
that it thus often shortens life.  As there are sev-
eral cases on public record which justify this re-
mark, the author need scarcely offer any illustra-
tion.—But he cannot refrain from availing him-
self of  the unbiassed  testimony of Dr. Farre,
whose liberal and  scientific researches  demand
the respect and the imitation of the profession.

  * "It is therefore one important use of morbid
anatomy,  to point out  the  boundaries  beyond
         ~"  *"" '  ' '~   ■■■■■! * m,  ■ ..... ,  m. i.,i , ,Mi,n    m
     * Loco citato, page 21, 
70
which it is not only unavailing, but injurious for
art to interfere, except to diminish suffering.  I
venture to oppose this truth to the reverse  prac-
tice, apparently  founded on a maxim, that  if an
organ  be subject to many obscure diseases, of
which one or more can be cured, but the others
are incurable, then all should be treated like the
curable disease.

  " Patients suffering under  the  diseases above
described, are not, as far as I have observed, ben-
efited by the operation of mercury.  Few  medi-
cal men now attempt to cure by these  means tu-
mours, in the restricted  sense of the word, at or
near the surface  of the body ; but it is more es-
pecially true, that such  efforts  prove altogether
fruitless, when directed to the cure either of the
tubera circumscripta or diffusa  ; for by the time
that the most careful examiner can distinguish
them,  the progress of the disease has been al-
ready so considerable, that the  mercurial action
tends only to exhaust powers, which art will sub-
sequently in vain attempt to restore.

   " On a review of the method of treating cases
I. III. and IV. it appears that too much was done
by ineffectual efforts to cure ;  but in case II. a 
71
palliative plan, the result of a more correct diag-
nosis of the disease, was adopted from the com-
mencement of the treatment.   Thus medicine
effected  in this case all  that  was possible ; it
clearly diminished, but  did not inflict any suffer-
ing.  The  erythema of the mucous membranes
of the mouth and  alimentary canal, and the di-
arrhoea, which probably  depended upon it, in-
stead of being hurried on  in a distressing degree,
were certainly retarded and moderated.—This
view of the  subject is  not derogatory ; for the
perfection of medicine consists, not  in  vain  at-
tempts to  do more than  nature permits, but in
promptly  and effectually  applying   its healing
powers to those diseases which are curable, and
in soothing those  which are incurable."

   Dr. Pemberton  had long ago given an accurate
view of this subject—but there is much reason to
apprehend that his valuable remarks have been
too often disregarded.  * He says, " When mer-
 cury is exhibited, where the structure of the  vis-
 cus is  not totally destroyed,  although  another
 source of irritation may be introduced into  the
 system by this new stimulus, yet this disadvantage
* Femberton oa the Viscera, Second Edition, page 4S. 
72
will be more than counterbalanced by the benefit
received in the removal of that disorder, under
the influence  of which the constitution was be-
fore labouring from  the  excitement of the de-
ranged viscus.  If,  on the contrary, mercury is
used where the structure of a viscus  is totally de-
stroyed,  another source of disturbance is added
to the system, without the diminution of any ex-
isting evil ; so that, in fact, we subject the con-
stitution  to two  sources of destruction, and  thus
the dissolution of the patient  is rather accele-
rated than.retarded."

  It must therefore be evident, that in certain
stages  of congestion  of the liver, as well as of
other viscera, the  inflammatory  diathesis  ex-
cited by  the use of mercury, instead  of removing
the congestion, accelerates the diseased changes
which had begun.

  As it  is the  object of the author to improve
the science of medicine, and not to expose the er-
rors of the individuals who practise  it, he avoids
mentioning many instances which have fallen un-
der his observation,  where patients were  pro-
nounced  to be labouring under an affection of 
73
the liver upon the  most superficial inquiry into
the symptoms.*            #

  Every conscientious  practitioner  will  allow,
that in  many  cases  the most minute and delibe-
rate investigation is insufficient to decide on the
true nature of the case, as is more fully explain-
ed in the two following sections—and hence it is
of the  utmost  importance to  proceed cautiously
in the exhibition  of so powerful a  medicine as
mercury.

  Instead, therefore, of directing mercurial oint-
ment to be rubbed upon the side and at the same
time the blue pill  or calomel  to  be taken inter-
nally,  so as to affect the mouth as soon as possi-
ble,  and  keeping up the soreness of the  mouth
for many weeks, the prudent practice is to com-
bine  the mercurial  with  antimonial  prepara-
tions, and with occasional doses of neutral salts
in a  very dilute form,  so as to increase the secre-
tion  from the skin and from the kidneys, without
  * One old lady, nearly seventy years of age, was actually put upon
a severe course of mercury by a physician, who declared that he felt
her liver to be enlarged, though the examination was made while she
lay on her left side in bed, and without removing her dress,  which
consisted of a thick flannel shift, besides the ordinary linen one.  In
this case, however, the liver proved to be quite sound.
                      L 
74
at all affecting the mouth or irritating the bowels.
Along with these medicines, a diet consisting  of
weak animal mucilages, and of the lightest farina-
ceous matter, ought to  be advised, and warm clo-
thing, and strict confinement within doors, should
be enjoined.  The  daily use of the warm bath i?
also to be recommended.

  In those  violent  degrees  of chronic hepatitis-,
where  bleedings at  the nose or other hemorrha-
ges attend, or where dropsical symptoms, with foul
blotches of the skin, have supervened, there can
be little other resource than palliative  means,  a-
dapted to the sufferings of the individual.


               SECTION VI.


Of the  Use of Mercury in Affections of the Stomach.


  The most common disorder  of the  stomach,
Dyspepsia, resembles in its chief symptoms, viz.
want of appetite—sickness—sometimes vomiting
                                            Si
—sudden and  transient distention of the stomach
— eructations—heartburn—pain in  the  epigas-
tric region, and most usually costiveness—several 
75
other  affections of the digestive organs ;—and
theiefore Dr.  Cullen  has  expressly  limited the
term to cases where the above symptoms  occur,
independent of any alteration in the structure of
the stomach, though he has not specified the means
by which this latter circumstance may be ascer-
tained.

   In the majority of cases, if there be  no percep-
tible hardness in the region of the stomach, and
no pain upon pressure when that is not in a state
of distention, it may be assumed that there is no
actual  change  in  its  organization.  But  every
practitioner must be aware, that the incipient al-
terations of texture, which eventually  terminate
in scirrhosity or  cancer,  cannot be detected by
any examination.   This fact is perhaps the only
plausible, though it cannot be allowed to be a
reasonable apology for the use of mercury in
stomach complaints.

   When the usual symptoms of dyspepsia are
attentively considered, it can scarcely be doubt-
ed, that they are occasioned by a diseased secre-
tion of the fluids which are mixed with the food
in the  stomach, and at the  same time  an unnatu-
ral change in the food  itself.  Thus, retching of 
76
 phlegm, the uneasy  sense of fulness of the stom-
 ach, relieved by  fetid or acrid eructations, the
 acidity setting the teeth on edge,  which follows
 the taking of food, the heartburn,  the  irregular
 action of the bowels, and the appearance of what
 is vomited, either naturally or artificially, une-
 quivocally denote that the  gastric liquor  (per-
 haps also the  secretion from the oesophagus, and
 even from  the salivary glands)  is different  from
 what  it  should be, and  that the food is not sub-
jected to the natural changes essential  to diges-
 tion.

   It would be inconsistent with the object of this
 work,  to explain  that  all the other symptoms of
indigestion are variously  modified in  different
constitutions, according to the susceptibility, nat-
ural or acquired,  of the  several bowels  subser-
vient to  the conversion of the food  into blood.

   With a perfect knowledge of these facts, Dr.
Cullen attributed  dyspepsia to debility  of the
muscular fibres of the stomach, although even in
his time many arguments might have been urged
to shew, that the secretions from the blood-vessels
and glands of that part depend upon the influence 
77
of the nerves, and not upon the state of the mus-
cular fibres.

  Thus,  (as  Dr. Cullen himself has admitted),
passions of the mind, and  sympathy  with other
parts of the  body, induce dyspepsia ;  and it is
not easy to imagine how he could have  supposed
that such causes could  debilitate  the  muscular
fibres of the stomach, when the more  obvious ex-
planation surely must have been, that they affect
its nerves.  All doubts on this subject, however,
seem now removed  by  the  interesting  experi-
ments of Mr. Brodie, the result  of which  was
communicated to the Royal Society  of London,
February 10, 1814*.

  Although the author certainly deems it to be
of considerable importance to determine, wheth-
er the diseased secretions which occasion dyspep-
sia arise from debility of the muscular fibres, or
from some affection of the nerves of the stomach,
he  should have  avoided  any discussion of the
subject, had his intention been merely to object
to the use of mercury in  that disease ; for  it is

  * Experiments and Observations on the Influence of the Nerves of
the  Eighth Pair on the secretions of the stomach, by B.  C. Brodie,
Esq. F. R. S. 
78
perfectly  obvious,  that  mercurial  preparations
can be neither safe nor  beneficial  according to
either hypothesis.—Nothing indeed but his own
experience could have led him to believe, that in
cases of well  marked  dyspepsia, where there is
no evidence ol organic affection, a course of mer-
cury could have been  prescribed,

  In slight cases of indigestion, popular prejudi-
ces may perhaps have led  practitioners into this
error, for within these last twenty years  it has
been fashionable for patients in the better ranks
of society in  this  empire,  to attribute the most
usual symptoms of indigestion to a retention of
bile, and to suppose that nothing else than calo-
mel or the blue pill can  afford them relief.

  Hazardous  as it  always  must be for any indi-
vidual to  oppose popular  prejudice, it is  incum-
bent on practitioners, in  every instance of serious
indisposition, to act according to their own delib-
erate judgment respecting the nature of the case,
and not in compliance with the caprice of the pa-
tient.  If there  be evidence that the food  has un-
dergone a diseased change  in the stomach itself,
they ought absolutely to refuse  sanctioning the
use of mercury. 
79
  7'hose who are  subject to occasional  fits of
dyspepsia, particularly those who have resided in
hot climates,  are  accustomed to appeal to their
own personal experience, as directly evincing the
great utility of calomel in such complaints.  But
if those persons  could attend  impartially  to the
effects of that medicine, they would find, that its
immediate operation is severe, and that  it  is fol-
lowed for some time by uncomfortable  feelings,
and by an unusual susceptibility of derangement
of the stomach  and bowels.  Perhaps, indeed,
these  very effects of calomel furnish in the ma-
jority of cases an antidote to the poison, for they
compel the sufferers to adopt restrictions in diet,
and other necessary  precautions,  which the im-
mediate relief that would ensue from  the  opera-
tion of safer medicines might make them suppose
to be  useless.

  Sometimes, it  is true, a single  dose  of calomel
seems to remove in a few hours the  oppressive
feelings produced by indigestion, and this hap-
pens from the sudden discharge of the acrid con-
tents  of the stomach and duodenum.  But a repe-
tition of the same medicine, instead of  being
equally serviceable, generally aggravates the suf-
ferings, inducing alarming fits of palpitation, or 
BO
.of faintings, or of such unaccountable feelings as
lead to the dread of immediate death.

   The author can truly affirm, that in several ca-
ses to which he has been called, where patients
had been  put  under a  course  of  mercury for
stomach  complaints, the irritable feelings descri-
bed in page 16, were in a much more violent de-
gree than he ever witnessed from the same medi-
cine given in other  diseases.  Nor is it wonder-
ful that this.should happen, since  it is well known
that one  of the  most common disorders occasion-
ed by the use of mercury is indigestion.

   When  symptoms resembling those of dyspep-
sia arise  from organic disease of the stomach, or
through  sympathy,  from tubercles in the lungs,
or altered texture of any other part than the liver,
it may be much questioned whether any benefi-
cial effects were ever produced by mercury.  In
almost all the instances of this kind which have
fallen under the author's notice, the original af-
fection was hurried on.   Scirrhosity of the pylo-
rus has been always considered to be quite incu-
rable ; and tubercles of the lungs, and  affections
of the mesenteric glands, which  seem by sympa-
thy to produce dyspepsia, are as little under the
control of medicine. 
81
  On this account, the objects to be held in view
in the treatment of dyspepsia, where the exciting
causes are neither organic diseases nor affections
of the mind, should be, to relieve the  urgent
symptoms, and to restore the healthy condition
of the secreted fluids of the stomach.

   To fulfil the former of those indications, the
old established practice ought to be again resort-
ed to, viz. the use  of such emetics and laxatives
as  shall  completely remove  the  accumulations
within the stomach and duodenum.  At first a
combination of ipecacuan and tartrite of antimo-
ny is to  be employed,  and if a quantity of tough
ropy phlegm  be ejected, the vomiting  should be
again excited  by means of flour of mustard mixed
with warm  water ,  and the same  is to be repeat-
ed daily, while the  tough phlegm appears in what
is vomited.  It is seldom necessary to prescribe
more than  five or  six of such emetics in succes-
sion.

   The laxative medicines to be advised after the
 operation of  the first emetic, ought to be calcu-
 lated to act upon the stomach and duodenum, and
 therefore should consist of  rhubarb  combined
 with magnesia or  jalap, or  both together, with
                       M 
82
some aromatic.  After the first dose, if the mus-
tard emetics be not followed by a proper clear-
ance from the bowels, some of the compound ex-
tract of colocynth, or some  similar preparation,
must be exhibited.

  To restore the healthy condition of the secre-
ted fluids of the stomach (which is the second in-
dication) may be accomplished by a due regula-
tion of the diet and exercise, and by the use of
medicines calculated to induce  a new  action of
the vessels and glands, from which the gastric li-
quor, and other fluids, commonly mixed with the
food in the stomach, proceed.

  Animal diet, that is, total abstinence from all
vegetable food,  has been  long known to have a
very  great  influence,  not only  in altering  the
state of the secreted fluids  of the stomach, &c.
but also in relieving the sensation of giddiness,
or faintings, or sinking, or violent palpitations of
the heart, which  are so alarming.to dyspeptic pa-
tients.   Thus under animal  diet,  the acidity  of
the stomach, the heartburn, and flatulency, gradu-
ally cease, and the natural feelings of health are
eventually restored.  But these good effects can-
not be expected, unless the diet be, in the strict- 
83
est sense of the word, animal food.  By this, it is
not meant that  patients, under such circumstan-
ces, should live upon solid meat, for, on the con-
trary, animal mucilages, in every variety of form,
are required  in particular constitutions, but not a
particle of vegetable matter is admissible.

   It cannot be expected that patients can be per-
suaded to adopt at once so great a change of food,
and physicians are under the necessity of  yield-
ing a little to their feelings and prejudices.—On
this account a very small proportion of wheaten
flour (in the form  of ship biscuit), or of boiled
rice, must at first be allowed, on condition that
every effort be made to relinquish as soon as pos-
sible that indulgence.

  Invalids are to be encouraged to submit to these
privations in  diet, by being assured that they are
to be only temporary.  The late celebrated Dr.
Cullen,  who fully appreciated the value of this
practice, has expressly stated the bad consequen-
ces of persevering in it beyond a certain time.
He says, " Animal food cannot be continued long
without  corrupting the state of our blood."  As
this unlucky  expression seems founded upon hu-
moral  pathology, although Dr. Cullen, it is well 
84
known, contributed mainly to overturn that sys-
tem, some practitioners have been led to disre-
gard the important fad  which it records notwith-
standing the testimony which every officer in the
navy, since the days of Captain Cooke, can bear
to its truth.

  On land,  it is true, a diet consisting of a very
undue proportion of animal food, may be perse-
vered in for a much longer time than on  board
ship, without occasioning scurvy, or other marks
of " corruption of the blood."—This may be ex-
plained on various principles—but sooner or la-
ter, individuals who live on such diet, have either
foul blotches  on the skin of a very obstinate de-
scription, or fall a  sacrifice to the first accidental
febrile or inflammatory affection, by which they
may happen to be seized.

   Precise rules applicable to every case cannot
possibly be established, but in general, it is sel-
dom necessary to continue the strict animal  diet
longer than from eight to twelve  weeks, though
it may be useful to recur to it occasionally, for a
week at a time, so long as any tendency to weak-
ness of digestion may continue.   In returning to
the  ordinary  diet, prudence  suggests  that the 
85
change should be made in the most gradual man-
ner.  At the same time,  it is  readily admitted,
that, in some constitutions, a larger proportion
than usual of animal  food  may be required to
support the necessary  exertions of persons enga-
ged in trades or manufactures, &c—But it will
always be found, that in those exceptions, bitters
in the  form-of malt liquor,  and vegetable acids,
are indulged in,  and these  unquestionably tend
to counteract the bad effects of the animal food.

   As it is not the object of the author to explain
fully the practice in cases of dyspepsia,  he must
confine himself to such hints  upon  the subject
as  are consistent with his  views in this publica-
tion.  The ordinary  rules of avoiding indigesti-
.ble substances, and of being truly abstemious and
temperate,  are  too well  understood to require
being  insisted on.  But there is one restriction in
diet of the most  essential importance in dyspep-
sia, and  in  many other complaints, which  re-
quires being particularly pointed  out,  as it  has
not hitherto been sufficiently attended to by  the
 profession.

   Abstinence from liquids is the restriction  al-
 luded to.  By this is meant a considerable dimi- 
86
notion of the ordinary proportion of liquids ta-
ken by way of food or drink.

   Inattention to this restriction counteracts in
many cases, both of chronic and of acute diseases,
the remedies employed by physicians.  Of this
the author has been so fully convinced for many
years, that he had at one time a serious intention
of publishing his thoughts upon the subject.  On
the present occasion, it is sufficient for him to re-
mark,  that in all diseases  dependent upon a su-
perabundance of the circulating mass, or upon
an increased  or diseased secretion of the  fluids
poured into  the alimentary canal, or furnished
by mucous membranes,  abstinence from liquids
to the utmost extent which can be submitted to,
will be found essentially necessary to the cure.-
In dyspeptic  complaints, this restriction in diet
possesses all the advantages of temporary starva-
tion, without any of its disadvantages.  It ought,
therefore, to be an invariable rule with all those
who have a tendency to indigestion, to confine
themselves, as soon as their constitution can bear
the change, strictly to an English pint of fluid at
the utmost within the twenty-four hours.

   On the  importance of exercise in the open air
it is unnecessary to say  much.   Those individu- 
87
als who dare not venture out of doors during bad

weather,  ought to take regular walking  exercise

in an  apartment with the windows open, guard-

ing against cold by a proper adaptation of  dress.


   Different  medicines  contribute  to restore the

healthy  secretions  of the  stomach,  &c.  such  as

lime-water, the supercarbonates of soda  and pot-

ass,  the  white  oxyde of bismuth,  the  mineral

acids,* numerous  varieties of bitters, the  capsi-

cum, and preparations of iron.  By due attention

to the nature of the case, and to the  effect  of reme-

dies,  the  appropriate medicine  in any given in-


 *The nitric Acid is an article, which in connection with this subject,
deserves to be particuhrly noticed.  For some time after its introduc-
tion in the East Indies, as a remedy in diseases of the Liver, in Syphilis
&c* it was extolled beyond its merits, but when it was found unable
to sustain the character of a catholicon.  It was depreciated and al-
most abandoned.  For the  last two or three years, however, it ap-
pears to have been regaining: reputation.   It certainly is a medicine
of great value, and its efficacy in chronic diseases of the  digestive or-
gans, seems to warrant the opinion of its early advocates, that its ef-
fects on the human system, are in many respects analogous to mercury.
Like mercury, it operates as an alterative or deobstruent, in remo-
ving bilious obstructions  and correcting  morbid secretions; but in-
stead of increasing, like that medicine, irritation and debility, it has
the effect of a powerful tonic.  In inveterate cases of dyspepsia, con-
nected with a torpid state of the  liver and bowels, I have given the
Nitric  Acid  with perfect success, after haviug  failed  with every
other remedy in common use. It is also singularly useful when combi-
ned with laudanum in chronic diarrhoea depending on too great relaxa-
tion of the intestines.—I.
   * See Duncan's Annals of Medicine, second  edition p, 374. 
88
stance are to be selected.  In some obstinate ca-
ses a very small dose of diluted alcohol an hour
or two before breakfast, continued for  two or
three weeks, has succeeded in restoring the heal-
thy secretions after every other means have fail-
ed.  But it is  obvious, that this practice must be
advised with great caution, and should be perse-
vered in no  longer than necessity warrants.

  Laxative medicines, calculated to act principal-
ly upon the great guts, are essentially necessary.
The compound extract of colocynthis perhaps the
best medicine  of this description, and it may be
occasionally combined  with rhubarb, or resin of
jalap, or such other medicines as have an influ-
ence upon the stomach and duodenum.  Aloes too
has a very excellent effect in this respect.   The
socotrine aloes, so commonly used, is inferior to
the hepatic, but it may be persevered in with im-
punity for a longer time.   There  is good  cause
for the popular prejudice againt aloetic medi-
cines, that they are  apt to produce hemorrhoids ;
and even though united with extract of cicuta or
hyociamus; they seem to have that effect.  Such
medicines,  therefore, are  only  to be employed
pro  re  nata ;  and  for an ordinary laxative the 
89
the compound extract of colocynth is much pre-
ferable.

  In some  cases where the dyspepsia seems con-
nected with an undue action of the great guts, the
ol. terebenth. rect. combined with ol. recini, forms
the very best temporary  laxative  which can be
prescribed.  It not only  completely clears the
alimentary canal—but also, while it produces un-
equivocally an  increased formation  of faeces,
sometimes  in a wonderful degree, it  occasions
none  of the  feelings  of  exhaustion,  which  so
usually follow the operation  of many  purgative
medicines.

               SECTION VII.

Of an Affection of the Duodenum which imitates
               Chronic Hepatitis.

  Where  cases of diseased liver prove intracta-
ble, it is a common allegation, especially of physi-
cians who have practised in hot climates, that the
failure has been occasioned by delaying too long
the  adoption of active  measures.—This may
sometimes be true, and yet it is often  unavoida-
ble, because in  Great  Britain  the marks of inci- 
90
pient disease of the liver are so  extremely ob-
scure, that they may be very readily confounded
with the symptoms occasioned by disordered ac-
tions of various parts of  the alimentary canal.—
Thus oppression of the  spirits—impaired or ca-
pricious appetite—thirst and dry tongue—sallow
complexion—an occasional pain  in  the right hy-
pochondrium, extending to the top of the shoul-
der—or a sense of weight or dull pain in the right
side, increased while lying on the left side—diffi-
cult breathing on quick motion—heartburn—fla^
tulency—occasional painful griping after taking
food-very irregular state of the bowels, the stools
being sometimes scanty,  and at other times very
copious  and acrid—and  gradual diminution  of
the strength and flesh—which are the symptoms
most commonly enumerated as characterizing the
early stages of chronic hepatitis, have all occur-
red, singly or conjunctly, in cases where the  liver
has remained perfectly sound.  The same obser-
vation may  be truly applied  to two other symp-
toms enumerated by  Dr. Pemberton, viz. an in-
termitting pulse, and  a sensation of fluttering  at
the  pit of the stomach.

   Yellowness of the eyes has been  often regard-
ed as a pathognomic sign of diseased liver.  But 
91
a slight yellow tinge is perceptible in many chro-
nic aflections of the digestive organs ; and some
cases have occurred, where on dissection the liver
was discovered to  have  been greatly  diseased,
though there had been no yellowness of the eyes
during the patient's life.   One instance of this kind
is  recorded by Morgagni, Epistle XXXVI. Art.
25.—-another by  Dr. Blackall,  page 149.---and
another by Dr. Farre, page 33.

   Whoever has attentively considered the vari-
ous modifications  of dyspepsia,  must have seen
many cases where all the above symptoms  were
evidently produced by that disease.  But there
is another affection which still  more nearly re-
sembles chronic hepatitis,.and which, though  ve-
ry particularly described by Sylvius,  Hoffman,
and others, has been lately not much attended to.
The disease seems at first to consist chiefly  of a
diminished  power of the duodenum, so that  the
food, in passing through  it, does not undergo the
 usual healthy changes ;  but after a  certain conti-
 nuance of this impaired.power, it (the duodenum)
 becomes  so tender, that  pain is occasioned, both
 by its being distended and by its being  pressed
 upon.  It is in this stage that it  is most apt to be
 mistaken for hepatitis, and the symptoms of the 
92
 two diseases so nearly resemble each other,  that
 it is scarcely possible  to discover the diagnostic
 marks peculiar to each.

   Where the symptoms alluded to arise from an
 affection of the duodenum, Dr. Ferriar supposed
 that the following circumstances occur.—* "The
 pain may be felt to  change its place a little on the
 expulsion of wind.  The pulse likewise is soft,
 though very irregular.  The secretion of mucus
 from the  schneiderian membrane is interrupted,
 and sometimes nearly ceases, though the patient
 feels a frequent inclination to discharge if.  He
 is generally,  but  not  obstinately costive,  and
 subject to torpor and  nervous oppression.  A
 slight inflammation  of the fauces also attends the
 disorder, returning once in eight or ten days."—-
 He remarked too,  that before the  exacerbation
 of pain in this disease the urine is of a bright green
 colour.

  Notwithstanding his high  respect for the prac-
 tical discernment  of Dr. Ferriar, the author must
 say, that these marks of distinction are not to be
relied  upon.—The  appearance,  and especially
* Ferfiar*s Medical History, vol. 2, page 28 et seq. 
93
the colour of the  evacuations  from  the bowels,

have been  considered  by  Mr.  Abernethyin his
valuable remarks on biliary affections, as afford-

ing the best evidence of the true condition of the

liver.  But the author's experience has led him to
a different conclusion; and indeed he has been al-
ways inclined to believe that several of the cases
detailed by Mr. Abernethy, as instances of affec-

tions of the liver,  were, in fact, disorders of the

duodenum.  This supposition is founded,  parti)

on the rapidity with which Mr. Abernethy's cases

yielded, and partly on the nature of the means
employed, viz. frequent doses of rhubarb, with a
very small proportion of the blue pill, for rhubarb
seems to exert a special influence  upon the  sto-
mach and duodenum.*


  For these reasons the author has generally pla-

ced  more dependence on the history of the disease,

  * It appears not to be very important to decide, whether Mr.
Abernethy or the author be most correct with regard to the seat of the
disease described by Mr. Abernethy, for it is agreed that by pursuing
the course of treatment pointed out by him, the patient will speedily
recover.
  Every one who has attentively examined the valuable paper refer-
red to in  the text, and tested its practical utility by his own expe-
rience, must be too well satisfied with the result not to concede gene-
rally to the views of its author.  But, at the same time, the injurious
and sometimes fatal effects of a full mercurial course in diseased duo
denum, to which Dr. Hamilton bears testimony in the sequel, p. 99,
shows the necessity of great caution where there is danger of con-
founding th« diseases.—!. 
94
than on the presence or absence of any particular
symptoms.  He admits,  however, that  it some-
times is impossible to acquire  accuiate  informa-
tion respecting the previous history, and that the
practitioner  is then reduced to the necessity of
deciding according to the symptoms.

  On this  principle, in doubtful cases, where* a-
long with lassitude, sallowness of the complexion,
occasional sickness, total  want  of appetite, thirst,
irregular state of the bowels, occasional palpita-
tion of the heart, flatulency, frequency or irregu-
larity of pulse, dull pain in the  right side, extend-
ing to the top of the shoulder,  aggravated by
pressure, by exercise, or by lying on the left side,
and  becoming occasionally acute  after taking
food, with loss of flesh, there be a daily evacua-
tion from the bowels exceeding considerably in
the quantity of real faeces the food actually swal-
lowed, the author considers the disease to depend
upon the state of the duodenum,  if there be no
tangible hardness or enlargement  of the liver.—
When along with the same  symptoms, there  is a
milky white appearance of the  urine, as if it were
mixed with chalk, he never has any doubt on the
subject, because he has invariably  found the duo-
denum affected under such circumstances, and he 
95
never observed the same appearance of the urine
in diseased liver.  He owns, that in several cases
where  the  duodenum  was  certainly  affected*
that peculiar state of the urine did not attend.

  In some of the  cases to which he has been  call-
ed,  the practitioner in previous  attendance had
supposed the faeces to  be of a chalky colour, in
consequence of having been covered  with the u-
rine, and it was necessary to separate the two ex-
cretions before the error was acknowledged.—
The expression  of the  faeces being covered by
the urine, is intended  to mark the fact, that the
faeces in those cases form an adhesive mass on be-
ing passed, and therefore  are literally  covered
by  the urine discharged at the same time, and
not at  all  mixed with it.   In every case hitherto
under  the author's  charge,  this  relative state of
the two evacuations has not  been  altered by the
operation of any  variety of purgatives.

  The bright green colour of the urine mention-
ed by  Dr. Ferriar, as preceding the exacerbation
of pain in affections of the duodenum, has not hi-
therto fallen under the  notice of the author of
the.se pages.  In  some cases, the pain in the  duo-
denum is characterized by its occurring common- 
9*6
ly about an hour  after eating, by its being diffe-
rent from  that arising  from distention  of  the
stomach from flatulence, and by its not being re-
lieved by the expulsion of wind by eructations.

  Different opinions  have been  formed  on  the
nature of those changes in the duodenum which
produce symptoms so  nearly resembling those of
chronic hepatitis.   Sylvius attributed  them to a
fermentation  of the bile,  and of the  secretions
from  the pancreas and  spleen.   Hoffman and
Ferriar supposed that  they are occasioned by a
spasmodic state of the  duodenum.  It seems more
probable that there is at first some impaired ac-
tion of the  minute vessels or glands on the inter-
nal surface  of that second stomach, as it has been
truly called, in consequence of wThich  the secre-
tions necessary for the conversion of the food be-
come diseased, and hence an unusual stimulus is
formed, which either induces chronic  inflamma-
tion, or a degree of tenderness  approaching to
it. Whether this explanation be admitted or not,
it must be conceded,  that  there are insuperable
objections  against Dr. Ferriar's hypothesis.   He
has alleged, that there  is spasms of the duodenum
depending  upon acidity in the stomach; but if
spasm of the duodenum were produced by acidi- 
97
ty in the stomach, it would  be one of the most
frequent diseases in crowded cities.—Besides, it
could not account for the symptoms.  Thus  the
spasms must  be partial or  complete.  If it be
partial, definite symptoms should follow, such as
obstruction  of the bile, or of the pancreatic
juice; and if it be complete, the food could  not
possibly  pass from the duodenum into the rest of
the alimentary canal.—On  the other hand,  the
explanation now offered satisfactorily accounts
for the symptoms, and seems to be confirmed by
the means of cure which experience has proved
to be useful.

  Individuals who have formerly resided in warm
climates, and have suffered from affections of the
liver, are particularly  liable to this disorder of
the duodenum ;  and from the  sympathy existing
between all  the parts  concerned in digestion,
it is not unreasonable to suppose  that if this dis-
ease be neglected in such constitutions, the liver
may eventually suffer.

   Nature has furnished a most efficacious reme-
dy for the removal of that  tendency to diseases
of the liver,  which is so apt  to occur in  Europe-
ans who have inhabited hot climates, viz. the  mu-
                       tt 
98
riateoflime, which forms the active  ingredient
of almost  all the natural mineral waters.   Thus
Cheltenham water has long been known to afford
great relief to Ihose invalids who return from In-
dia and the West Indies, and there can be no
doubt that its chief active ingredient is the mu-
riate of lime.

   That in many cases the relief experienced from
that mineral water proves merely temporary, is
readily admitted.  But this is probably owing to
some mismanagement in its use.  In many cases,
for example, it is  not continued for a sufficient
length of  time; in others, due attention is not
paid to the clothing,  diet, air, and  exercise, &c.
which  in impaired constitutions, are  so essential
to the restoration  of health ;  and  in  other cases
still, the laxative effect of the Cheltenham water,
after a week or two, proves debilitating.

   If instead of the Cheltenham water, the  mu-
riate of lime be taken in  doses adapted to the
constitution of the patient, and be steadily perse-
vered  in,  there can be no risk of disappointment;
for it  may be continued for many months, not
only with perfect safety, but also without any in-
convenience or restriction whatever, and it may 
99
be combined with diluents, and occasionally with
neutral  salts, and with preparations of antimony
or of iron, according to the circumstances of the
individual cases.  But as this medicine produces
no sensible operation,  unless when exhibited in
disproportionate doses,  and  acts slowly  and im-
perceptibly, so that no rapid amendment follows
its use, it is not wonderful  that the impatience
and the prejudices which so commonly  attend a
broken state of health,  make invalids apt to be-
come tired of it.

  When mercury is prescribed in this disorder
of the duodenum on the supposition that the liv-
er is diseased, fatal event sometimes takes place
with unusual celerity;  coffee coloured vomiting,
with excruciating pain in the region  of the stom-
ach, followed by delirium, suddenly supervening.
In the majority of cases, however, there is only
such  a  considerable aggravation of  the  symp-
toms, as to  render it necessary to suspend the
course  of mercury, and to employ palliative
means.

  Professor Burns of  Glasgow, (on whose vera-
city and practical  acumen  it is unnecessary to
expatiate), mentioned some time ago in a private 
                     100
communication to the author, that the use of the
nitro- muriatic-acid  bath  has a tendency  some-
times to excite a  discharge of blood from the
coats of the stomach, inducing vomiting of a fluid
something like hare-soup, mixed with dark coagu-
la, which the patient and attendants suppose to
be vitiated bile, and do not consider to  be dange-
rous, although death invariably follows in a short
time.-—In  the instances of this kind which have
fallen under Mr. Burns's notice, the  acid  bath
had  not been  employed  with his sanction; and
from what  has been already stated, there is a pro-
bability that the original disease, in most of those
cases, had been the affection of the duodenum al- •
luded to, and not a disease of the liyer.

  The nitro-muriatic-acid bath exerts a powerful
stimulus on every part of the  alimentary canal,
and  when prudently employed, is most useful  in
particular  complications of disorder;  but where-
ever there is a tendency to inflammation in any
of the chylppoetic viscera, it cannot fail to aggra-
vate the symptoms.

  For the  cure of this disorder of the  duodenum
different  means are  required, according  to its
progress.  In slight cases, repeated doses of rhu- 
101
barb, combined with magnesia or other laxatives,
and a course of the white oxyde of bismuth, with
mild food, are generally sufficient.   But in the
more violent degrees, it is  necessary to  begin
with the application of leeches to the epigastric
region, after which one or more antimonial eme-
tics  must  be directed, and  nauseating doses of
the same, with occasional laxatives,  ought to  be
continued for some time, the  patient being kept
all the while upon the lowest possible diet, with
respect both to the  quality and the quantity of
the food.  After the urgent symptom have yield-
ed, the  same  mode of diet as that  recommend-
ed for the cure of dyspeptic complaints ought to
be adopted, and  the white  oxyde  of bismuth
combined with some aromatic, is to  be advised.

              SECTION VIII.

    Of Affections  of the Pancreas and Spleen.

  During the late war the various modifications
ef fever to which  the British troops  were  expos-
ed from insalubrious  climates, fatiguing  duties,
and the deprivations incident to a state of active
warfare, were very frequently followed  by en-
largement of the spleen, and perhaps of the pan- 
102
creas,  as  well  as  of the  liver; and hence the
symptoms of diseases of the spleen became fami-
liar to the army surgeons.

  These are, in the incipient stage, a  peculiar
clearness of the eyes, with a particular expres-
sion of the  countenance,  and a pain in the left
side, increasing on taking a deep inspiration, or
when pressed upon,—-together with an  inability
to lie in any other posture than on the left side.
As  the disease increases, fulness of the left hypo-
chondre, sensible enlargement of the spleen itself,
difficulty of breathing, in many instances vomit-
ing of blood, and  dropsical symptoms,  succeed.
The marks of an affection of the pancreas are not
so characteristic.

  It has been a prevalent  opinion among the ma-
jority of the medical officers of the British army,
that mercury furnishes the only cute for those
affections of the  spleen and  pancreas.- -And it
consists with the author's  knowledge, that many
of the individuals who had suffered from the ill-
fated Walcheren expedition,  were subjected, on
their return home, to repeated and severe  cours-
es  of that  medicine.   An impartial considera-
tion, however, of those cases  has impressed on 
103
him the conviction, that safer means would have
been more efficacious ; and he is confirmed in
this opinion by the fact, that in several instances
where  mercury  failed, a course of Cheltenham
water was supposed to have prove successful.

  In those affections of the  spleen or pancreas
which follow remittent or intermittent fevers, it
seems therefore  probable that a continued course
of the supertartrite of potass, or of the muriate
of lime, combined with antimonials, with a pro-
per regulation of  the diet, would be both a safe
and a beneficial  mode of practice.

                SECTION IX.

Of the Use of Mercury in Affections of the Intesti-
                  nal Canal.

  Preparations of mercury having a tendency
to excite diarrhcea, it seems very natural to em-
ploy  them for the cure of  habitual constipation ;
and  there can he  no doubt, that on many occa-
sions a course of the blue pill, with a due regula-
tion of the diet, has restored the healthy actions
of the bowels.  This may  be conceded,  without
admitting in its  full extent the  accuracy of Mr. 
101
Carlisle's eulogium upon the powers of that pre-
paration of mercury.

  "It," he says, c< seems to have no intrinsic pur-
gative quality, but to act indirectly by exciting
the flow of that natural intestinal stimulus the
bile.   It seldom induces a watery or exhausting
catharsis; given in doses of five grains to adults
for three successive nights, or alternate nights, it
usually induces a copious flow of the bile, and a
large  and weil conditioned  evacuation of the
bowels.  It does not seem  to impair the diges-
tion ; and  the natural stimulus which it calls forth
appears to . cleanse the whole alimentary  tube,
without leaving a propensity to costiveness. The
profession  are  indebted to Mr. Abernethy for
the present general use of this valuable medi-
cine."*

  As  to the more active chemical  preparations
of mercury, besides promoting the  speedy flow
of bile, they augment greatly the secretions na-
turally poured into the alimentary canal.  But
it is  not  merely by the addition to the bulk or
  * Professor Carlisle on the Use of Cathartics.—London Medical
Repository, Vol. I. page 187. 
105
fluidity of the contents of the intestines, that the
peristaltic  motion is  accelerated ,  for there  is
certain evidence, that in proportion as the secre-
ted fluids in question  are abundant, they become
acrimonious.  From this acrimony, the intestinal
fibres are violently irritated, and hence excessive
griping is not unfrequently induced, and often al-
so bloody  dejections  ensue.  Some  of the  mer-
curial  oxydes (as the  muriate) act so powerfully
on the villous coat of the stomach and bowels, as
to occasion inflammation, with all its consequen-
ces.

   The chemical preparations most  generally in
use as a purgative in this country  is the Calo-
mel.—«lt has," as Mr.  Carlisle has remarked,
"a direct purgative power, as a metallic salt;
and it operates powerfully on the  large intes-
tines.—It  disorders the digestive powers of the
stomach;  and,  in  debilitated  persons,  the fre-
quent employment of it sinks the strength, and
provokes haemorrhoids."

   From what  has been stated in the preceding
pages, respecting the injurious effects of all the
preparations of mercury, and especially of calo-
mel, upon some constitutions, and the impossibil-
                     p 
106
ity of distinguishing those individuals to whom
that mineral, in  every form, is apt to prove nox-
ious, it  must be evident  that no physician can
calculate, with any degree of certainty, on the
safe operation of mercurial purgatives, unless in
cases where the experiment has  been  already
tried.

  When, on the other hand, habitual torpor of
the bowels, is owing to a deficiency of bile, or to
some unusual state of the mucous and other se-
cretions of the intestinal tube, it is unquestionable
that there are many medicines which can reme-
dy those  defects with  more safety than mercury.
For example,  preparations of antimony and of
rhubarb both stimulate the biliary  system, and
increase the secretions from the stomach and  in-
testines, and magnesia and gamboge, and  innu-
merable  neutral salts, produce  the latter effect;
and therefore, by a proper combination of differ-
ent medicines, all the advantages of mercurial pur-
gatives may be obtained, without incurring any
 of the hazards.—In short, whether it be required
 to promote the  flow of bile, or to increase the se-
 cretion of the fluids furnished by the stomach and
 intestines, or to excite the peristaltic action  of
 these  latter, it is possible  to select medicine 
107
which  shall definitively  produce  those  effects,
without injuring in any way the general habit.—
Whereas no  preparation of mercury can be ad-
ministered  without the risk of some consequences
ensuing, which could neither be intended nor ex-
pected.

  By these remarks, the author does not mean to
allege, that there are no cases whatever, in Which
the blue  pill or calomel ought to be employed
for the purpose of opening the bowels, but he has
strong objections to the  trequent and indiscrim-
inate use of such powerful and dangerous means.
No prudent traveller would climb a precipice, if
he had a sure road along the  foot of the moun-
tain.  The general rule ought undoubtedly to be*,
to avoid prescribing any preparation of mercury
as a purgative, wherever safer means can  be reli-
ed on.

  Daily experience may perhaps be urged against
this rule ;  for it may  be alleged, that in every
complaint  of  infancy  and childhood, calomel,
within these few years, has been had  recourse to,
not only by practitioners, but by parents and
nurses ; a  practice which must have  long ago
been exploded, if bad effects had ensued. 
108
  This argument, when duly examined, will be
found more specious than valid.—The operations
of many medicines, and particularly of metallic
oxydes, are not easily  ascertained, even by  pro-
fessional men, and far less can they be traced by
ordinary observers.  Although a dose of calomel
may seem merely to affect the stomach or bow-
els, it may by its influence upon some latent dis-
order,  such  as tubercles  in the lungs, or slight
enlargements of the mesenteric or other internal
glands, give  activity to a disease, the source of
which  might otherwise have  been removed by
the natural powers of the constitution.  The au-
thor has for  several years been impressed  with
the conviction of this important truth.

   That there are many individuals who have of-
ten with impunity taken calomel as a purgative,
is not to be denied ; but it is equally true, that
extreme  irritability of the  stomach and bowels,
ulcerations of the  mouth with caries of the teeth,
dropsy, epilepsy, and various other modifications
of disease, have followed the use of that prepara-
tion.  In  several cases the author has decidedly
ascertained, that ulcerations of the villous coat of
the intestines in infants and young children,  have
been induced by the frequent repetition of doses
of that medicine. 
109
  Had these injurious  effects  of calomel upon
delicate constitutions been hid from the rest of the
profession, and known only to the author, some
apology might be offered for the pertinacity with
which that medicine is still  prescribed—but  so
far is this from being true, that it may be confi-
dently asserted, that no  medical man of compe-
tent knowledge and observation could administer
calomel as a purgative, in a hundred instances,
without being convinced of its injurious tenden-
cy.  Of this, innumerable  proofs could be cited,
but it is sufficient to appeal to the testimony of
Professor Carlisle and of Dr. Blackall.

   Mr. Carlisle has expressed himself very strong-
ly  on this subject.—" That grave men should vio-
lently persist in directing large doses of calomel,
(and I consider any dose above four grains to be
large,) and order these  doses to be daily  reitera-
ted in chronic and  debilitated cases, is  passing
strange.—Men,  starting into the exercise of  the
 medical profession  from a cloistered  study  of
 books,  and  from  abstract  speculations—men,
 wholly unaware of the  fallibility of medical evi-
 dence, and  unversed in the doubtful effects  of
 medicines—may be themselves deluded,  and  de-
 lude others for a time ; but when experience  has 
110
 proved their errors, it would be magnanimous,
 and yet no more than just, to renounce both the
 opinion and the practice."*

   Dr. Blackall's remarks being more specific, af-
 ford a still more satisfactory proof of the validity
 of  the author's opinions.—*' It appears to me,"
 he says, " that no accidents proper to the disease
 can account for all those fatal conversions to the
 head, which of late years have so frequently ta-
 ken place  in  the  fevers of children ; and I have
 on  some occasions  been disposed  to  attribute
 them to excessive and repeated doses of calomel,
 which either not moving the  bowels, as was ex-
pected, have  given  evidence of  being absorbed,
or, on the other hand, have purged too violently,
and been succeeded by  diarrhoea  without bile,
 and a prostration of  strength, from which  the lit-
tle patient has never risen.  Its less severe effects
are sometimes of no slight importance :  a slow
and'imperfect recovery, a languid feverish habit,
and a  disposition to  scrofula.

  " It need not surprise us, that,  in  children, this
disposition, particularly if so excited, should of-
: Loco citato, p. 187. 
Ill
ten fall on the part most liable to every impres-
sion,  and most actively developing itself,  the
brain ; since,  even in adults, mercury is inimical
to the nervous system.   Parents have something
to regret, who are so perpetually giving calomel
to their children, without any distinction or care,
as a common domestic remedy.  And it is diffi-
cult  to  conceive on what view of  the subject
even practitioners proceed, who indulge  in  its
use with less scruple than ever, with  less cau-
tion as to management, whilst they are observing
and lamenting the  daily  increasing ravages of
hereditary  scrofulous disorders.  It can hardly
be in the present day from want of calomel, that
such a taint is propagated."*

   The facility with which calomel can be exhibit-
ed to patients who are reluctant  to take what-
ever has the semblance of a drug, is probably the
chief motive for this unfortunate prejudice in fa-
vour of so hazardous a remedy.—In  reprobating,
as he strenuously does, this sacrifice of conscience
to convenience, the author does  not deem it ne-
cessary  to shew the importance of teaching indi-
viduals, at the most early period of life, to ac-
* Blackali on Dropsies, page 248. et seg. 
112
quire  the  habit  of readily swallowing  drugs,
though he must remark by the by, that he annu-
ally sees many melancholy instances of the fatal
consequences of inattention  to so obvious a max-
im.  It is because he knows that there are seve^
ral tasteless medicines which are equally effica-
cious with calomel, and are  at the same time per-
fectly definite in their operation and safe in their
effects, that he blames the practice.  Some  of
those medicines have been already hinted at, and
are now to be considered more particularly.

  One of the most powerful certainly is the tar-
trite of antimony.  In  solution, its good effects
are nearly the same as those of calomel, and it
can be exhibited with perhaps still greater facil-
ity, because  it may be mixed, without exciting
suspicion, with any of the ordinary drinks.  It is
not indeed pretended that  this medicine is per-
fectly harmless in its operation—on the contrary,
it may be truly said to be poisonous if not admin-
istered cautiously—but it may be as certainly af-
firmed, that proper precautions ensure the abso-
lute  safety of its effects.

  Orfila's experiments  have most satisfactorily
elucidated this point.   He ascertained unequivo- 
113
cally,  that the injurious  effects  are  invariably
proportionate  to the strength of  the solution of
that medicine.  Thus,  he  found, that four grains
of the tartrite  of antimony dissolved in an ounce
of water, and received into  an empty stomach,
produced most deleterious effects ; whereas the
same four grains,  dissolved in a pound of water,
or although dissolved only in an ounce, swallow-
ed when  the stomach was full of fluid, excited no
dangerous symptoms.
<
  In prescribing, therefore, this  medicine, it  is
only necessary to take care that it be given  in
the form of  a very  weak solution, and while
the stomach is not empty.—On thig account, per-
haps no  larger dose than a tenth or an eighth  of
a grain ought ever to be administered at  once  to
a young  subject, and attention is to be paid, that
at the time this dose  is exhibited, the stomach
contain at least several ounces of fluid.

  With these precautions, this medicine  will be
found, not only to evacuate any offensive matter
contained in the  alimentary canal, but also  to
promote all the ordinary secretions of the chylo-
poetic viscera, without the hazard of eventual
bad consequences.
                      o 
114
  One obvious objection may be urged  against
this medicine, viz. that if these precautions be in-
dispensible, its operation must in some cases be
too slow to be beneficial.  The force of this ob-
jection must indeed appear very striking to those
who have been accustomed to the extensive em-
ployment of calomel, the agency of which is of-
ten so rapid ; and if there were no medicine  that
could assist with safety the tartrite of antimony,
it would be unanswerable.  But  whenever there
is occasion for  the speedy action of a purgative,
the gamboge, which is devoid both of smell  and
of taste, can with the utmost facility be employ-
ed as an auxiliary to the  antimonial  preparation.

  These remarks apply  to cases  where  the ob-
ject  of  the purgative medicine is to promote the
flow of bile, or to increase the secretions of the
alimentary canal, but there is an infinite  number
of complaints in which all that is required from
purgatives is to expel the contents of some  por-
tion of the intestines.  Even  in such instances, a
solution of the tartrite of antimony greatly assists
other medicines, and renders a very small  dose
of them extremely efficacious.   Thus, a  few
grains of rhubarb, or of jalap, if preceded by the
solution in question, quickly empty  the  duo- 
115
denum and small guts, while cold drawn castor
oil, the compound extract of colocynth,  prepara-
tions of senna, &c. excite the action of the  large
intestines.

  Magnesia, and the different neutral salts, which
are so useful as purgatives in febrile  and inflam-
matory disorders, can,  in the  same way,  be com-
bined with the antimonial solution, and  with the
gamboge,—and  it may with perfect  confidence
be asserted, that a safe  substitute for calomel can
be  selected in nine  tenths of the cases  in which
that mercurial oxyde is now prescribed.

  Every physician knows that some medicines pro-
duce different, and even opposite effects; accor-
ding to the quantity  exhibited as a  dose.—For
example, in certain affections of the bowels, twen-
ty grains of ipecacuan  given at once,  excite full
vomiting ; but if the same twenty grains be divi-
ded into forty pills, and one of them be adminis-
tered every  half hour, till  the whole  be taken,
neither nausea nor sickness follow,  while in gen-
eral the irritation in the bowels is allayed.—Per-
haps a still more striking illustration of  the same
fact is afforded by the muriate of lime.—Half a
drachm of the ordinary solution of that salt, mix- 
116
sed with eight or ten ounces  of water,  agreea-
bly sweetened, may  be taken twice a-day,  for a
great length of time, without producing any im-
mediately sensible operation, and in most instan-
ces, with an obvious improvement of the  general
health.—But if three or four drachms of the same
solution  be  given as a dose, a most violent and
debilitating  diarrhoea is commonly excited  ; and
if the same dose be  persevered in for even a few
days, the  most  alarming  emaciation speedily
follows.

  It has therefore been supposed that small  doses
of calomel may check looseness, although  large
ones  would certainly increase it, and with this
view, such means have been recommended, both
in the bilious diarrhoea of adults, and in the green
scour of young children.  Thus Dr. Clarke of
Dublin  has  advised, in  these  latter cases, half a
grain of calomel to be  given  every  night, as a
dose to  an infant.

  But it has always appeared to the author, that
wherever looseness is accompanied with an in-
creased flow, or any unusual acrimony of the bile
or of the intestinal secretions, evinced by the ap-
pearance of the stools, which are bilious, or  acrid 
117
and watery, or slimy, or bloody, or dark colour-
ed and-offensive, preparations of  mercury, how-
ever small the  dose may be, add greatly  to the
irritation, unless they happen to pass unchanged
through the alimentary canal.  As he has been
called  in  to several cases where young children
had most obstinate and violent diarrhoea- in con-
sequence  of mercurial friction, and as he has re-
peatedly seen ulcerations on the  surface  of the
colon, where small doses of calomel had been
employed for a considerable time  in  order  to
moderate  habitual  diarrhoea  in infants, he  has
been led to  suspect, that upon many occasions,
in very young subjects, the calomel,  from  being
involved in the contents of the stomach and bow-
els, or from  some other cause, does not act at all
as medicine.

  Should this be admitted, a ready explanation
is afforded of the impunity with which in  many
instances calomel is administered ;  and on the
same hypothesis, it may be understood, that small
doses of calomel may seem useful in bowel com-
plaints, when in reality the amendment is  to be
attributed to the regulation of diet,  and to the
opiates  which are  commonly recommended at
the same time. 
118
  According to the author's experience, in com-
mon with that of many other practitioners with
whom he has consulted on those affections, the
safe mode of practice, in all cases where there  is
an increased flow, or an unusual acrimony of the
bile, or of the fluids naturally poured into the in-
testinal tube, is to pursue such measures as shall
allay irritation, and at the same time lessen the
quantity and the acrimony of the increased se-
cretion.—Diluents—the testacea—occasional opi-
ates, combined  with ipecacuan—mild  prepara-
tions  of neutral  salts—gum-arabic, and various
other means, may  with great propriety and ad-
vantage  be employed  for those purposes.—At
any rate, he can confidently  declare, that he has
seen a number of infants, and very young chil-
dreni destroyed, as he positively apprehends, by
the indiscriminate use of calomel for complaints
of the bowels.

  There is however, one variety  of diarrhoea,
common both to adults and to children, in which
preparations of mercury appear to give relief
more speedily and more certainly than any other
medicines.—It usually supervenes  to  cases  of
protracted indisposition, and is characterized by
the faeces  being very liquid, and of a light clay 
119
colour, with a most offensive smell, and by the
extreme debility which attends.

  This variety  of diarrhoea seems  to be owing
partly to some irregular action of the liver, and
partly to some  unusual  state of the great guts.
That the functions of the  liver are interrupted, is
presumed by the diminished  quantity of bile in
the stools, and that there is some  unusual state of
the great guts, is proved by there being no solid
faeces discharged.  It may be that the duodenum
and  other small intestines are also  disordered;
for it is not easy to  explain  the  emaciation and
the debility on any other  supposition.

  Probably the  alteration in  the state of  the
great guts is rather in the secretion from their in-
ternal surface than in any change of texture,  not
only  because the disease very  often yields to
medicines,  but  also because in  fatal cases  the
whole tract of those intestines has been  found in
a healthy condition in respect  to structure, al-
though quite empty of any thing like solid faeces.

   From his reluctance to employ mercurial pre-
parations, the author at one  time tried a number
of different remedies'for the cure of this dieor- 
120
der ; but he is from attentive observation convin-
ced, that small doses of some of the mildest pre-
parations of mercury, such as the blue pill, com-
bined with opium with or without ipecacuan, are
singularly efficacious in such cases.  Those med-
icines are to be repeated every eight or ten hours,
or  oftener, till  healthy stools appear,  and  are
then to be  slowly withdrawn,  If calomel be pre-
ferred to-the blue pill, the dose ought never to
exceed one grain, even to an adult.

   It has long been a popular belief, that mercu-
ry in every form is a certain poison for worms in
the alimentary canal.—In this work it would be
improper to enter at full length into the discus-
sions which  have  lately prevailed respecting the
influence of intestinal worms, in occasioning dis-
orders of  the organs of  digestion,  and through
 sympathy,  of other  parts of the  system.—But
 since many intelligent physicians have expressed
 their  conviction,  that lumbrici  produce  none
 of the injurious effects so vulgarly  attributed to
 them, it  is  necessary  to advert to this opinion,
 before noticing the  safety or efficacy of anthel-
 mintic medicines.

    That the tenia and the ascaris excite a specific
 irritation upon the intestines, has not been deni- 
121
ed by the most sceptical,—probably for the plain
reason, that the signs of such irritation are as ob-
vious to the  uninitiated as to  the  most learned
member of the  profession.  But the symptoms
supposed to denote the presence of luinbrici are
so often the effects of other causes, such as acri-
monious collections within the  primse viae, or ir-
regular actions of some portions of the intestines,
that  it is  often  impossible to determine  in any
given case, whether they arise  from the one or
the other of those causes.

  Another, and perhaps a still more plausible ar-
gument in favour of the allegation that  lumbiici
are not productive of morbid effects, is derived
from the fact,  that children in perfect health oc-
casionally pass (with their stools) those worms,—
and that sometimes the same event  happens du-
ring the course of some disease, such as measles,
or typhus, or smallpox, where  it is impossible
that lumbrici could be the cause of the disease.—
Some American  physicians, reasoning on those
facts, have even  alleged,  that intestinal worms,
by consuming what is superfluous or acrimonious
in the  food,  may serve some useful  purpose
in the animal economy.
                    R 
122
  There  are,  it must be  admitted, only two di-
rect proofs  that  lumbrici frequently  do  inju-
ry.—The first is, that a  worm of  that kind has
been found,  as the author can vouch  from his
own observation, in the introsuscepted portion
of the gut,  where  fatal event had taken place  in
consequence of introsusception.—And  the other
is, that all the distressing symptoms of an alarm-
ing  indisposition have  rapidly ceased after the
expulsion of one or more  lumbrici.*—Of  the ne-
gative proofs in favour of this opinion, which are
numerous, and the  author  apprehends conclusive,
it is unnecessary in this place to offer any detail
■—more  especially as the  means  for  expelling
lumbrici, which he ventures  to recommend, can-
not be prejudicial,  though  the symptoms  of dis-
ordered bowels, &c.  should be found to proceed
from other causes.

  An  objection to  such apparently  harmless
means for destroying worms, as  drinking water

  * The following case shows pretty conclusively that worms may
be the source of so much irritation in the intestinal canal, as to cause
general and violent disease. A child four or five years old was attack-
ed suddenly with epileptie fits, which continued in quick  succession
from morning till noon.  As the child never had had fits before, they
were suspected to be owing to some irritating matter in the intes-
tines.  A large dose of calomel was  given, which was followed by a
discharge of forty lumbrici.  The convulsions soon ceased, and never
after returned.—I. 
123
in which quicksilver has been boiled, or wearing
a belt containing that mineral, may be consider-
ed to be fastidious, and yet there is pretty conclu-
sive evidence, that in some  instances even those
means  have  proved  injurious.—Calomel,  how-
ever, seems within these few years to be the chief
mercurial preparation employed as an anthelmin-
tic.—It forms the active ingredient of every pat-
ent medicine for the expulsion of worms, from
Waite's gingerbread nuts to Ching's  worm loz-
enges.

  Of the  efficacy of calomel in poisoning intes-
tinal worms, and in promoting their expulsion,
no practitioner can  doubt, although, at the same
time, the safety  of its operation may be very
much questioned. Every newspaper has for many
years blazoned forth the  superiority  of Ching's
lozenges,  and other patent  medicines, over  the
ordinary  prescriptions  of physicians,  probably
because the successful cases have alone been re-
corded, while all the unfortunate ones have been
carefully  concealed.

  This boasted superiority  of the patent worm
medicines, arises entirely  from the doses of calo-
mel, which they contain, being much larger than 
121
those usually prescribed by regular practitioners.
The author does  not  scruple to admit, that  his
knowledge of this  fact led him, at an early period
of his professional  life, to prescribe greater doses
of laxative medicines for infants and children than
he had been taught to consider proper.*  While
he derived this lesson from  marking  the opera-
tion of Ching's lozenges, &c. he had  occasion to
witness the frequency of very deleterious effects
from those  medicines, such as convulsions—in-
flammation of the  bowels, and excessive debility,
terminating in  dropsy.

   Mercurial anthelmintics being thus dangerous,
it is obvious that their use could only be sanc-
tioned on the principle of necessity, viz.  that no
other equally efficacious medicines for the expul-
sion of worms were known.—Fortunately, how-
ever, this is not the case, as  there are  many  dif-
ferent articles of the materia medica  which pos-
sess the same vermifuge power, and are  perfect-
ly safe in their operation.   Sea  salt—the  muri-
ate of lime—garlic—the semen santonicum—the
chamomile flowers in powder, and several  other
vegetables, seem  to poison lumbrici; and com-

  *He has much satisfaction in finding that his practice in this re-
spect is now adopted by the most judicious of the profession. 
                     125
binations of rhubarb—of senna—of gamboge—
and of scammony—and more especially the rec-
tified oil of turpentine mixed with cold drawn cas-
tor oil, readily promote their expulsion.—As to
ascarides, where stimulant glysters cannot be ad-
ministered, suitable doses of aloes, followed up
(at  the distance  of ten  or twelve hours) by a
combination of jalap  and senna, seldom  fail to
dislodge  them.

  The late celebrated Dr. Parr,  on whose practi-
cal knowledge the author, from his earliest years,
was taught to place the most implicit reliance*
and to whose instructions he owes more than he
can ever acknowledge, considered the Hellebo-
rus fcetidus, or  bears-foot, to be the safest and
most .powerful anthelmintic hitherto discovered.
While his  respect  for  the  memory of Dr. Parr
leads him to mention this,  he deems it his duty
to add,  that he  has  had no experience of that
medicine.  The bears-foot, and the 01. Terebinth.
were recommended to his notice about the same
time ; and  having ascertained  the safety, and
utility, and activity of the latter medicine, (for it
has never yet in his practice failed to clear the
alimentary canal from every kind  of worms), he
did not think.himself warranted in making experi-
ments with the other  medicine. 
126
                SECTION  X.

  On the Use of Mercury in Dropsical Affections.

   The indiscriminate use of mercury for the cure
of the various modifications of dropsy, which  is
too well known to require any proof or illustra-
tion, is so inconsistent with the opinions respect-
ing the  nature of that disease which prevailed in
the days of Dr. Cullen, as to  lead to the supposi-
tion, that within the last thirty years, either a sud-
den revolution in the  laws of the human machine
had taken place, or that  medical men had ceased
to reason on the operations of medicines, and on
the varieties of disease.  The slightest conside-
ration, indeed, of the  several  phenomena and ex-
citing causes of dropsy,  must satisfy every im-
partial inquirer,  that no single medicine can be
useful in every case of that disease.
  Such  complications occur  in  general dropsy*
that it is extremely difficult to give,  within the
limits of a work like this, even an outline of the
phenomena  of the  disease.  Sometimes it pro-
ceeds insidiously and  slowly,  the  patient  at first
having an impaired appetite for food,  feeling list-
less and languid,  being  fatigued by slight exer-
tions, having a short dry  cough, or a little quick- 
127
ness of breathing on ascending acclivities or walk-
ing faster than usual, and looking pale and thin.
By and by, swelling of the feet and ancles occurs
towards night, and gradually increases, together
with an aggravation of all the former symptoms.

   On many occasions  little attention is paid by
the sufferer himself to these circumstances, till
the disorder ha* proceeded thus far ; and when
an investigation of the symptoms is  at last insti-
tuted, it is found that, along with  want of appe-
tite, there  are costiveness, lessened  discharge of
urine, a feeble irregular pulse, a pasty or sallow
complexion, and  great dulness of the  eyes, and
relaxation of the features.—If the anasarca of the
lower limbs be considerable, it subsides while in
bed, but in the morning the face,  and especially
one or both eyelids, or  one or both hands, are
swelled.   The surface of the skin does not  feel
hot, on the contrary,  rather cool, especially on
the lower  extremities.

   In the further progress of the disease, the swell-
ing extends over the whole body, the abdomen
enlarges, and from the fluctuation which  can be
perceived, it becomes  obvious that an effusion
 has taken  place into the peritonaeal sac, and this 
128
is  soon followed by increasing debility, breath-
lessness in the horizontal posture, disturbed sleep,
and  transient'delirium.  Previous  to death, in
some cases  erysipelatous  inflammation  appears
on some part of the skin, and advances to sphace-
lation.—In other cases the  breathing grows more
and more  laborious, and insensibility,  with exces-
sive irregularity in the action of the heart, super-
venes, succeeded by one  or  more convulsions,
which terminate life.

  When anasarca comes on after protracted de-
bilitating  disorders  of the general  system, the
symptoms differ very considerably in different
cases.   If it occur after excessive evacuations, or
much loss of blood,  the pallidness of the coun-
tenance, especially of the lips, is greater than in
the former cases, and the impression of the finger
on the swelled parts remains longer, but there is
not the same want of appetite, and confined state
of the bowels.

   If scarlatina have preceded the anasarca, the
swelling takes place more suddenly than in the for-
mer instances ; the  surface of the skin feels hot-
ter,  and it admits much less readily  the impres-
sion of the finger ; thirst, and total loss of appe- 
129
tite, and great uneasiness and restlessness, attend.
The pulse too is extremely rapid, and a pain in
the side or in the head is apt to supervene.—Un-
der such circumstances, cramps of the limbs,  or
delirium, sometimes suddenly occur, and termin-
ate in violent convulsions.

  Irregularities of digestion,  with erratic pains,
and slight feverishness, are now and then follow-
ed  by dropsical  swellings of the limbs, with a
scanty discharge  of urine, and great depression
of spirits, with excessive debility.   In some  of
those  cases bleedings  from the nose occasionally
happen, and afford temporary relief.  Jaundice
accompanies the  swelling in other cases.   Great
irregularity and inequality of pulse are common-
ly evident in such instances.

  Many other complications of ailments are met
with which end in general dropsy ; so that  al-
though there  is no difficulty whatever in distin-
guishing the disease when it  actually exists, it is
not easy in many cases to foresee its approach.

   Notwithstanding the variety in the symptoms
of general  dropsy, the several modifications of
that disease may be divided into two  kinds— 
130
those in  which the urine  contains coagulable
serum, and those where there is no such unusual
change in the state of the urine.  This distinction
has  been suggested by Dr.  Wells, and particu-
larly by  Dr. Blackall; and as it lays the founda-
tion for some practical conclusions of the utmost
importance, it demands the serious consideration
of the profession.

  Having been led, by  the  experiments of Dr.
Rollo and Mr. Cruikshank, to subject  the  urine
of dropsical patients to the influence of heat, Dr.
Blackall  found, that even under the boiling point
it contained, in some instances, coagulable serum,
in various proportions and of various degrees  of
firmness, and  that in other  cases no such co-
agulable   matter  could be detected.   He also
ascertained, that  sometimes  the  red particle*
of the blood are  mixed  with coagulable serum
in the  urine.  The utility of this  arrangement
in  illustrating the  causes, and  in  directing the
treatment, will appear in the  sequel.

  No apology need be offered for inquiring into
the causes of dropsy, since it must be obvious
                                             i
that unless  the causes of disease  can  be ascer-
tained, no method  of cure can be adapted to the 
131
several cases, except in those very rare instances
where chance has made known a specific remedy.

  The commonly received opinion, that the col-
lections of watery fluid within the  cellular mem-
brane, or within the several cavities which consti-
tute the varieties of dropsy, arise either from an
increased  discharge from  the exhalents, or a di-
minished absorption by the lymphatics, or a com-
bination of both  causes, may be  said to be in
general correct, and therefore any  minute detail
in illustration of those  causes must be unneces-
sary.

  Increased discharge from the exhalent arteries,
(the first  of the  causes enumerated), has been
commonly supposed to be  the consequence of a
mechanical obstruction to the return  of veinous
blood,  or  of such extreme relaxation of all the
simple solids, that the thinner parts of the circu-
lating  mass may readily transude through the
coats of the  arteries, and  many proofs of both
these causes might be enumerated.  Thus, indu-
ration  of  the  liver compressing  the principal
branches  of the  vena porta?, and aneurisms of
some of the large arteries, or other tumours con-
tracting the area of large veins,  have  been seen,
on dissection, in dropsical subjects.  And where 
132
there is great feebleness  of the body, anasarca
happens whenever the patient is for any time in
such a posture that the blood is prevented  from
returning to the heart by its own weight.

  Another cause, and perhaps not an unfrequent
one, is an increased activity of the exhalent arte-
ries occurring independent of any mechanical
obstruction, and  arising from  some stimulus di-
rectly affecting  those  minute  vessels.—It is not
easy to explain  the  suddenness  of the  appear-
ance of anasarca in  some  instances on  any other
principle.   On the  same  hypothesis, the sudden
diminution of anasarca, while an effusion into the
 ventricles  of the brain or cavities of the pleura
takes place, may be readily understood.

   Diminished absorption may arise, either from
 a mechanical pressure upon  the trunks of some
 of the large lymphatic vessels, or from some un-
 usual state of their minute orifices, or from some
 languid action of  the lymphatic system.—The
 evidences in proof of those several causes of di-
 minished absorption are, it is apprehended, quite
 satisfactory.

   Thus the enlargement  and swelling of an en-
 tire cluster of glands (as of the axillary or inter- 
133
nal inguinal glands) are followed by a dropsi-
cal affection of the corresponding limb.—Again,
many instances have happened, which seem to
shew, that the minute orifices of the lymphatics
sometimes refuse  to admit the fluids presented to
them.  This has led practitioners to suppose that
they  possess a .kind of elective  powe'r, though
the more probable explanation is, that they are
closed by the inflammation of their extremities
in consequence of the  acrimony of the effused
fluid.—As to the  languor of the  lymphatic sys-
tem in general, it has been commonly supposed
to  follow,  very frequently, the febrile, and in-
flammatory, and exanthematous affections.

   It  would be impossible to explain many cases
of anasarca without supposing that there may be
both  an  increased discharge from the exhalents,
and a diminished absorption.  Perhaps the  most
familiar example of this is that which follows pro-
tracted acute diseases, where there is an increas-
 ed action  of the arterial system, in order to re-
 pair the waste, while at the same time the absor-
 bent vessels are in a state of debility, in common
 with the rest of the system.

    Besides these obvious causes of the  various
 phenomena  of dropsy, there is  another,  which, 
134
although it has not entirely escaped the observa-
tion of practitioners, has not received due  atten-
tion,  and that  is,  the peculiar  condition of the
fluid poured out by the exhalents.   No one can
doubt, that this must  vary  according to the state
of the circulating mass, and that if any poisonous
matter be mixed with the  blood, or if there be
any unusual combination  or proportion of the
several constituent parts of that fluid,  the dis-
cbarge from the exhalent  arteries cannot be of
the usual quality.  But the full  influence of this
altered condition of  the interstitial fluid is not
perhaps sufficiently understood.—This however
may be illustrated by considering the succession
of events in two different cases, one of general,
and the other of partial dropsy.

  The former of these is  the  anasarca already
described as supervening to scarlatina.  In that
instance, it is probable, that after the declension
of  the eruption, the  circulating mass  becomes
tainted with the specific poison of the disease,
and that the fluid poured  out  by the exhalents
irritates, by its acrimony, the extremities  of all
the  vessels with which it  comes in contact, in
consequence of which  a kind  of  inflammatory
state of those  parts is induced.   In the cellular 
135
membrane, there  must therefore be an accumu-
lation of the interstitial fluid, because the orifices
of the lymphatics are constrioted, while  the  ex-
halent arteries are stimulated to increased activi-
ty.  But  the surfaces of the  serous membranes
lining  the internal cavities must suffer still more
from this  acrimonious state of the exhaled fluids,
since they are so very  susceptible  of inflamma-
tion.   This, and perhaps this alone, can  explain
the suddenness of attack of the anasarca, the heat
and tenderness of the surface, and the occasional
alarming  affections of the head  and thorax ; for
these latter symptoms evidently arise from the in-
flammation of the surfaces of the ventricles of the
brain,  or of the cavities lined by the pleura.

   Perhaps it may appear to many, that the par-
tial dropsy alluded to affords a still  more satis-
factory illustration of the influence of the condi-
tion of the circulating mass upon the  phenomena
of this interesting disease. The affection  which is
meant, is  that which follows swelling  and inflam-
mation of the glands within Poupart's ligament.

   When  this occurs in the male, as  it has done,
from a fracture  of one of the  innominata, aedema
of the limb, without any unusual symptoms, fol-
lows.  But when the same circumstance happens 
136
!
in women after  delivery, the thigh and  leg are
affected with a shining, hot, tense, elastic, painful
swelling, which  does not pit on  piessure,  and
which pursues a very different course from the
ordinary local aedema.  In the above  swelling of
the male, if  the affected  limb be punctured, a
watery  fluid is discharged, but no such  fluid is-
sues from punctures  in the swelled leg of puer-
peral women.

  The  cause of obstruction cannot constitute
the difference in the phenomena of those  two ca-
ses : for in both instances it must be the same
viz.  the mechanical  pressure of the enlarged
dands ; but in the male the condition of the cir-
culating mass may be supposed to be natural ;
whereas in the  female, after delivery, it is well
known that the blood contains an unusual propor-
tion of  fibrine, and consequently  it possesses an
extraordinary disposition to coagulation/  The
shining, hot, tense,  elastic,  and  painful state of
the  limb, are the consequences  of the  effused
fluid having coagulated.  Dr. Blackall (page 104)
has recorded the case of a sailor, whose constitu-
tion, by the  by, had been  ruined "by mercury,
which  still  farther elucidates this subject.   In 
137
 describing  the  appearances  on  dissection,  he
 gives, inter aliaf the following account.

   "The cellular membrane of .the trunk and  ex-
 tremities was every where loaded  with a  coasru-
 lated semi-transparent  effusion,  which gave  an
 unusual  resistance to the knife.   This was par.
 ticularly the case in the parietes of the abdomen
 and in the loins, and certainly explained the ten-
 sion and soreness  to the touch,  not common in
 anasarca.  The fluid which  drained off from  the
 incisions was very glutinous, and on exposure to
 air for some time, formed into an apparently  ge-
 latinous  substance, which, on being heated, sepa-
 rated into  a solid  lymph and thin  fluid.  The
 serum of the pericardium coagulated strongly by
 heat; that from the thorax and abdomen in a less
 degree ;  and the  water of the ventricles  of  the
brain was the most diluted, though still coagula-
ting to an unusual extent."*

  This explanation, it may be alleged, is found-
 ed upon the exploded doctrine of Boerhaave ; but
 while the author admits, in common with the rest
of the profession, that the humoral pathology, so
universally adopted  about a hundred years ago,
                           -------'-------—--------
   * Blackall on Dropsies, p. 110.
                    T 
138
Was  both unphilosophical and  inconsistent with
the phenomena of diseases, he must be permitted
to express his opinion,  that in the present day
too little attention has been paid to the condition
of the blood.  Experiments  have shewn, that the
injection of the most harmless fluids, such as milk,
into  a vein, has produced most  injurious effects ;
—they have equally proved, that certain poison-
ous substances received into the stomach increase
or diminish, in a remarkable degree, the circum-
stances  which favour  the  coagulation of  the
blood—and observations upon the effects of dis-
ease have unequivocally evinced,  that those  ex-
periments are not fallacious.

  Besides, the author suspects,  that the intersti-
tial fluid  may be rendered  acrimonious by  the
increased activity of the exhalent arteries,  al-
though the circulating  mass may be natural and
healthy,  just as  increased discharges  from  the
same vessels upon the  surface of the intestines,
excited by certain purgative medicines, are well
known to  be acrimonious.   He  does not how-
ever, deem it necessary  to insist upon hypotheti-
cal points.

  Such being the different causes of dropsy, it
becomes an object of great importance to distin- 
139
guish them in the several cases which are met
with in practice, and it must be admitted, that
before the  publications of Dr. Wells and of Dr.
Blackall, it was exceedingly difficult to do so.
Judicious  practitioners formed their diagnosis
from a consideration of the previous history, and
from the state of the pulse, and of the skin, and
other symptoms ;  but although now and then
they were  correct in their decision, cases  often
occurred which baffled their skill.—The  method
of distinguishing those different cases  suggested
by  Dr. Blackall,  furnishes a certain mark  by
which  the  nature of the disorder  in  any given
instance, can at once be ascertained.

  It may  be laid down as a general rule, that
wherever the urine contains coagulable serum
discoverable  by any degree of heat, not exceed-
ing the boiling point, there must be either an in-
creased activity of the exhalents, or such a con-
dition of the  circulating mass, that  when exhaled
it  becomes acrimonious or stimulating, or that
there is a  combination of both causes.  It may
also be concluded, that wherever the urine is de-
void of coagulable serum, the cause is diminish-
ed  absorption, from some mechanical compres- 
                     J10
sion  of the lymphatics, or from some impaired
power in their branches or extremities, or that it
is an increased flow from  the exhalent9, depen-
dent on laxity of the fibres, or defect of the red
globules of the blood.   By this very simple cha-
racteristic of the urine,  all  cases of general drop-
sy may be comprehended  under two classes—an
arrangement which  is  calculated to direct the
practice, and  to secure the patient from having
the disease  aggravated by the remedies prescri-
bed.—It is manifest that there must be many ca-
ses where no cure can be expected.

  First.—Of  dropsies attended  with coagulable
urine.—As in all  such  cases there  is either in-
creased activity of the exhalents, or some altered
condition of the circulating mass, which renders
it acrimonious or stimulating when exhaled, it is
perfectly obvious, that  all medicines capable of
aggravating such  causes ought to be most care-
fully avoided.  And since it is clearly establish-
ed,  that preparations of mercury have  a direct
tendency both to increase  the action of the arte-
rial  system, and to alter the constituent  parts  of
the  blood, they must be regarded as most espe-
cially inadmissible. 
141
  The author has never met in consultation with
any practitioner of discernment and experience,
who  has not admitted the fact, both  that mer-
cury  and squills frequently fail to  give relief
in cases  of general  dropsy ;  and  also,  that
in many instances their exhibition ha- been suc-
ceeded by a rapid and mortal aggravation ef the
symptoms.  If any reliance can be placed on the
validity  of  the  observations  in  the  preceding
pages, the reasons for those failures may  be easi-
ly comprehended.

•  Were any  further  illustration  required, the
author  could  state several  distressing cases  to
which he has been  called,  even since the  pub-
lication of Dr. Wells' and Dr. Blackall's valuable
hints.   The patients alluded  to,  while  under a
course  of mercury and  squills, had  been unex-
pectedly seized with alarming breathlessness,  or
violent pain in the side, or sudden delirium, with
a sharp pulse, for which they had  been  very
properly  bled and purged, while the mercurial
medicines had been discontinued.  But although
a rapid amendment had followed this change of
treatment, the use of the mercury had  been re-
sumed whenever the aiarm had fairly subsided,
and  a hopeless  recurrence of  all the bad symp-
toms had ensued. 
142
  Errors  so detrimental  in  their consequence,
may be always guarded against by the obvious
expedient of boiling the  urine ; and it may be
truly said, that without this preliminary  investi-
gation, no physician is warranted in prescribing
a single dose of mercury  for the cure of dropsy.

  An exception  against this rule may probably
be claimed in favour of cases where some organ-
ic disease is complicated with dropsy,  but expe-
rience has shewn, that mercury is even more in-
jurious  under such  circumstances, for it accele-
rates the progress of the organic affection.   The
facts recorded  by Dr. Ferriar and by  Dr Black-
all, and by several other impartial observers, are
confidently  referred to, as furnishing a strong
confirmation of this assertion.

  Although  the  squill certainly does not exert
the  same baneful influence on the sanguiferous
system  that mercury does, it cannot be deemed a
safe medicine where the dropsical symptoms are
attended with coagulable  urine.  Its stimulating
property may  indeed be  said to be corrected by
the sickness at stomach which it occasions, but
there is every probability that it  increases the
action  of the  exhalents  before it  affects the
 stomach. 
143
  The necessary inferences from this account of
the means to be avoided in the treatment of such
cases of dropsy is,, that the only proper remedies
are to be found  in  whatever can allay the inor-
dinate action of the exhalent vessels, and restore
the healthy condition of the  circulating  mass.
Keeping this principle in view, the suitable med-
icines  are to be adapted to the circumstances of
individual cases ; and all that  can be  expected
in this work, is a  short enumeration of the prin-
cipal means.

  Bleeding has in modern times been seldom prac-
tised, unless an acute pain of the  side, or exces-
sive breathlessness,  indicate topical congestion ;
but there  are few instances  where  there is a
pretty firm coagulum in the urine in which  ve-
nesection will not be found useful.   The prudent
plan  is to  draw  a small quantity at first,  and to
repeat the operation as  it  may seem necessary.
In all cases where the dropsical symptoms have
 come on suddenly, and where they have follow-
 ed scarlatina, this is of such essential importance,
 that if performed early, it  always shortens, and
 often checks the progress of the complaint, where-
 as if it be neglected, effectual  relief is seldom
 afforded. 
144
  Next in efficacy to the subtraction of blood, is
the cautious use of the digitalis.—This medicine,
in small doses, repeated every three, or four, or
five hours, as the urgency of the  symptoms may
demand, proves a most useful auxiliary to blood-
letting in all inflammatory  affections, and  also
particularly in the cases under consideration.

  The most certain preparation of the digitalis
in this part of the world is the saturated tincture,
the dose of which ought not  in  chronic cases to
exceed  from five to ten drops ; and if any unto-
ward symptom, such as pain over either eyebrow,
or sickness, or giddiness, take place, its use must
be instantly discontinued.  At any rate, it is sel-
dom  necessary  to persevere in  this  remedy
longer than  from ten  days to a fortnight.

  To these rules for the employment of digitalis
there is  one exception, viz. where the symptoms,
from neglect or mismanagement, are so urgent as
to threaten immediate  death.  In several instan-
ces of that kind, as well as in cases of pneumo-
nia, where there was every evidence of effusion,
the author has seen an unexpected recovery, ap-
parently in consequence of repeating the digitalis
every hour till  its influence on the system  was 
145
distinctly marked.  As cases of that description
admit of no delay in the means employed, he has
been directed in the doses which he has prescri-
bed, rather by  the violence of the symptoms,
than by the age  or constitution of the patient.

  Thus he  was  called some time ago to visit an
infant under six  months of age, affected with epi-
demic  catarrh,  in whom apparent effusion into
the lungs had occurred, notwithstanding the most
active  and  judicious  treatment—and to this in-
fant a drachm  of the saturated tincture of digi-
talis was given, in divided doses, within twenty-
four hours, with the most perfect success.  When
it is mentioned, that  the  little  patient was un-
der  the  charge  of Dr. Abercrornbie,  it is un-
necessary to add, that there could be no mistake,
either in the quality of the medicine, or in the
regular administration of the doses advised.

   An  opinion  having been lately  disseminated
on high authority, that frequent and large doses
of fox-glove are absolutely poisonous, the author
has deemed it  necessary to state explicitly, that
in cases seemingly desperate, large doses of that
medicine can do no harm, and may effect a sud- 
146
den  change  in  the  symptoms.   He  cordially,
however, assents to the propriety, and even ne-
cessity, of prescribing small doses in all chronic
cases.

  Cooling  laxatives are highly useful in the ca-
ses of general dropsy, comprehended under this
head, but  the saline  purgatives commonly em-
ployed, often disappoint the expectation of the
practitioner, probably in consequence of the de-
bility which they produce.—Inexplicable  as the
fact may appear, it is  found that a combination
of medicines calculated to  act upon the different
portions of the alimentary  canal, produces fully
as copious a discharge from the bowels as any of
the saline  purgatives, without occasioning any
inconvenience.

   Nothing but experience, it must  be  owned,
 could make one  believe that a  scruple  of rhu-
 barb, as much jalap, half a drachm of powdered
 senna leaves, and  two scruples of the crystals of
 tartar, taken six hours after eight or ten grains
 of the compound  extract of colocynth, debilitate
 by their operation far less than a single ounce of
 Epsom salts.  The  repetition   of the  laxative
 must be  regulated by the circumstances of the
 individual case. 
147
   On some urgent occasions, preparations of an-
 timony, and also gamboge, ought to be added to
 the  other laxatives.  Of the utility of the elate-
 rium the author cannot speak from his own ex-
 perience, as he never has recourse to doubtful
 means when he can depend upon those with the
 powers of wThich he is acquainted.

   After these preliminary measures,  the most
 useful remedy in the cases under consideration,
 is the super-tartrite of potass, a medicine which,
 in the practice of the late Dr.  Home  and  Dr.
 Ferriar, was  found  to be far superior to every
 other diuretic employed for the cure of dropsy.
 It is probable that two  circumstances have con-
 curred to throw discredit  upon  the cremor  tar-
 tari,  viz.  its indiscriminate use  in  all cases of
 dropsy, whatever may be the cause, and the form
 and  dose in which it has  been given.

   It  requires  only a very little  reflection to be
 convinced, that wherever dropsy arises from lax-
 ity of the simple solids, or deficiency of the  red
 globules of the blood, this  medicine, in common
 with all other  neutral salts, must be highly pre-
judicial, and that it can only be useful, where the
 circulating mass contains an undue proportion of 
148
coagulable matter, or where there are glandular
obstructions.

  With respect to the dose and formula of the
medicine, many errors,  it  is  apprehended, are
committed.—Half an ounce,  the dose  recom-
mended by Dr. Ferriar, is much too  large for
daily use, two drachms  being quite sufficient,
and these ought to be dissolved in at least a quart
of water.—Physicians who  profess to imitate the
operations of nature, ought to have remarked,
that in all mineral waters, the saline substances
are in a state of great dilution.  The addition of
the subborate of soda, in the  proportion of one
drachm to two of the super-tartrite, will be found
to add to the efficacy of this remedy, and to the
facility with which it can be taken.

  'None of the other saline diuretics seem to pos-
sess the same efficacy as the cream of tartar ; but
when it  is necessary  to vary  the  preparation,
from peculiarity of constitution or other reasons,
the nitrate, or carbonate,  or tartrite  of potass,
 may be employed with the same precautions  re-
 specting the dose and the  dilution.  The latter
 of those preparations was in high  credit about
 thirty years  ago, and has probably  fallen into 
149
desuetude, from the improper manner in which
it has been administered.

  In  the  cases under  consideration,  all other
medicines which have the power of stimulating
the kidneys, and  have  in consequence obtained
the name  of diuretics, such as squill, (as already
stated), oleum juniperi,  infusions  of broom tops,
juniper berries, &c. are obviously inadmissible.

  Sudorifics were  at one time  much employed
for the cure of dropsy, and have been, the author
thinks, improperly relinquished within these few
years, for cases every  now  and  then  happen
where the urgent symptoms are  not relieved  by
venesection and by purgatives, and where, from
peculiarity  of constitution, the fox-glove is inad-
missible-  In such cases, the aqua acetitis ammo-
nias, combined with a solution of the tartrite of
antimony, produces, through a copious diaphore-
sis, the beneficial effects which commonly result
from  the digitalis.  The more stimulant diapho-
retics are not to be hazarded.

   It  is not necessary  in this work  to give any
 minute directions respecting the diet,  air, and
 exercise, &c, of patients labouring under the dis- 
150
ease in question.  The nature of their complaint
plainly indicates the necessity for mild food, and
for plentiful dilution.

   Secondly,—Of dropsies where the urine contains
no coagulable serum.—In those cases the cause of
the disease, as already mentioned, being diminish-
ed absorption from some state of the lymphatic
vessels, or being an increased flow from the ex-
halents, in consequence of laxity of  the fibres or
a defect of the red globules of the blood, it is evi-
dent that the remedies to be employed ought to
be calculated, either to promote absorption, or
to improve the tone of the simple solids, or to
increase the red globules of the  blood.

   The first circumstance to be attended to in all
those cases,  is of course to distinguish the cause
of the complaint, and it must be owned, that  on
many occasions this is a  matter of great  diffi-
culty.

   When there is imperfect absorption, there are,
a languid action of the heart  and arteries, a slug-
gishness of mind as well as of body,  a sallowness
of the skin, and commonly, even in the early sta-
ges of the disease, a short dry cough, or a slight 
151
degree of breathlessness, excited by trifling ex-
ertions.   The tongue too is generally more or
less loaded, and the urine high coloured, as well
as scanty.

  On the other hand, those cases where the effu-
sion arises from laxity of the fibres, or deficiency
of the red globules of the blood, are marked by
a whiteness of the complexion, with more clear-
ness of the skin than in other cases, pallidness of
the lips, the faculties of the mind not being weak-
ened in proportion with the  powers of the body,
the tongue being usually clean, and (at the be-
ginning  of the  complaint)  there being neither
cough  nor  breathlessness on making slight exer-
tions, and the urine being pale and watery.   The
anasarca, too, more readily shifts from one part
to another, according to the  posture  of the body,
and pits  more deeply on being pressed upon than
in the former cases.

   Although  these marks of distinction, together
with a  knowledge of the previous history  of the
patient, enable the practitioner to decide in many
instances on  the cause of the complaint, it is not
to be  concealed, that complications every  now
and then occur which embarrass the most expe- 
152
rienced of the profession.   It cannot be doubted
too, that defect of absorption may be combined
with laxity of the fibres and with decrease of the
red globules of the blood, and thus an additional
difficulty is occasioned.

  Till the state of the  urine was understood, the
impossibility of distinguishing  the cases arising
from such different causes,  was a very common
source of the frequent disappointments in the
cure of dropsy, which are  so well known.  But
as it may be  assumed, that wherever the urine
contains no coagulable  serum, tonic remedies can-
not do irreparable mischief, there is less chance
than formerly of any fatal mistake in the employ-
ment  of the remedies  now to be considered un-
der the heads already specified.*

  I. Medicines which promote  absorption.—It is
to be  particularly noticed, that on some  occa-
sions torpor of the lymphatics  seems to be con-
nected with disordered functions of the chylopo-
etic viscera, and cannot be removed till the reg-
ularity of those functions be restored.  Such are,
probably, the cases where Dover's electuary, and
* Page 150. 
153
 other combinations of  laxatives,  with  metallic
 tonics, appear to be successful.  It is a good rule,
 therefore, in all cases where  there is any  evi-
 dence of languor in the action of the lymphatics,
 to premise one or more doses of the laxative medi-
 cine, described page 146.

   When the course of the absorbents is obstruct-
 ed by mechanical causes, such as enlargement of
 the internal  glands, aneurisms, or other organic
 diseases, it is little probable, that any other means
 than the removal of the mechanical cause can be
 of any avail, and it can  scarcely be controvert-
 ed that in all such cases  mercurial medicines are
 of doubtful  efficacy.

   But when the  diminished power of the absor-
bents arises from some torpid state of the extremi-
ties or branches of those vessels, a cautious course
of mercury  and  squills  may be prescribed with
great advantage, provided  it be not continued
too long.  Perhaps the  most effectual  way of
guarding against this error, is by having the state
of the urine examined from time  to time ;  for
whenever there is the slightest appearance of co-
agulable serum, the mercury must be instantly
discontinued, even although it seem to have  ex-
                      v 
154
erted in other* respects little influence upon the
system.

  That with these precautions mercurial medi-
cines may be had recourse to in many instances
not only without hazard, but with manifest advan-
tage, is fully admitted ; but it merits considera-
tion in every individual case,  from the  circum-
stances already explained,  whether some other
medicine might not be equally conducive to the
cure of the dropsical affections alluded to.   The
various preparations of iron, combined with some
of the  vegetable tonics, as  the  cinchona, or the
myrrh, or with some of the neutral salts,  may of-
ten be substituted with great advantage for mer-
cury.

   II. Medicines  which improve the tone of the
simple solids, and increase the red globules of
the  blood.—For laxity of the fibres the appro-
priate remedies are what have been called tonics.
The cinchona, the kino, and the several prepara-
tions of iron, with nourishing diet, and a dimin-
ished allowance of liquids, are the means chiefly
to be depended upon.

   Cases now and then occur where  small  doses
of .the  mild preparations of mercury, alternated 
155
with the bark, or other vegetable tonics, fulfil
completely  the  above  views ;  and it may be
added, that unless mercury be given most  indis-
creetly in such cases, it cannot do much  harm.
At the same time, the author is perfectly convin-
ced, that in the cases under consideration, pre-
parations of iron, and where these  disagree, the
kino, produce all the good effects, without occa-
sioning any of the hazards of mercury.

  With respect to the usefulness of Kino, he feels
it necessary to offer some  explanation, because
at one period  of his professional life he thought
very differently of that drug.  Having for seve-
ral years after beginning practice, seen prescrip-
tions containing kino prove totally  inefficacious,
he formed a  most unfavourable opinion  of the
powers of that medicine ; but  the  interesting
views  which the experiments of Dr.  Orfila and
Mr.  Brodie upon poisons suggested, induced him
to subject it  to a farther  trial, more especially
because he was often disappointed in the effects
of metallic tonics.   Many  patients  in whom the
simple  solids  were remarkably  relaxed,  had  a
sense of tightness in the chest,  or a distressing
pain over the eyebrows, after  a very few days
perseverance in the use of the sulphate of iron, to 
156
the extent of only three grains daily, and others
suffered  equally  from ten drops of the muriated
tincture twice a-day.

   Reflecting upon the cases which he had witness-
ed, it occurred to him, that  the inefficiency of
kino might be owing to some error in the  formu-
la or the dose, or in the selection  of the  proper
disease in which  it should be administered, and
he resolved therefore, in his trials, not to  be lim-
ited by established rules.  The result has been
his conviction, that  there  is  no vegetable tonic
hitherto  discovered  which in many cases more
certainly increases the firmness of the simple sol-
ids, and adds to the coagulability of the  blood,
without  disturbing the powers of digestion,  and
without injuring the nervous system.

   If the  kino be given in the form of tincture,  it
agrees with constitutions which cannot bear the
cinchona, and it produces a more rapid influence
both upon the circulating mass and upon the sim-
ple solids, than any other medicine which the au-
thor has  seen.  Dr. Pemberton,  (page 96),  and
several other eminent physicians, have appreci-
ated fully the value of this  drug ; but as they
sanctioned this use in a substantial form,  and as 
157
many of them reommended it for the purpose of
restraining hemorrhages, it is not wonderful that
it has fallen into discredit.  Kino made into pills
probably  passes through the bowels, unchanged
in nine cases out of ten ; and as to its utility in
hemorrhages, every  physician who understands
the subject must be convinced, that its operation
upon the system is too  gradual  to produce the
immediate effect required.   The proper formula
should be the tincture, of which  from two to four
drachms may be given daily.

  The regulation  of the diet in the cases under
consideration is of the very first importance.   It
ought to  consist of light nourishing food, with a
very  small proportion of fluids, and should al-
ways be  particularly directed   by  the practi-
tioner.

  These remarks on general dropsy, which have
extended  much beyond the limits the author had
prescribed to himself, supersede  the necessity for
any minute discussion on the dropsies of the sev-
eral  cavities,—and therefore a  few brief hints
need only be offered.

  Ascites, being the most ordinary  form of wa-
tery accumulations within the great cavities, de- 
158
mands the first attention.—Its characteristic symp-
toms are sufficiently well known—and its causes
are those already detailed.  In one particular it
differs from the usual cases of anasarca, viz. in
the state  of  the  accumulated fluid, which often
is thick and gelatinous.—This, which, although
well known, has not been attended to as it ought
to be, might have furnished a safe guide for the
practice, had the more sure one of the state of the
urine been still undiscovered.

  From the ample details  in the preceding pa-
ges, it  would be a needless repetition to point
out the marks by which it may  be determined
whether mercury ought to be employed in any
given case of ascites.—It is sufficient to mention,
that  even where there  is evidence that the
liver is diseased, that mineral  is not to be ven-
tured  upon  if the  urine contain  coagulable
serum.

   In the hydrothorax, which on many occasions
is with great difficulty distinguished in  its early
stages, the digitalis  has lately been commonly
preferred to mercury.—And there is every reason
to  conclude, that in more than  the majority of
 cases  mercurial medicines would be  most detri- 
159
mental.  Undoubtedly, wherever symptoms re-
sembling those which terminate in  hydrothorax
followed the exanthemata, their violence is, inva-
riably, aggravated rapidly by the use of mercu-
ry, of which medical records  bear ample testi-
mony.

   In all such cases, both the progress of the dis-
ease, and the coagulable serum  contained in the
urine,  unequivocally denote an altered  state of
the pleura, approaching more or  less to inflam-
mation, as  already  explained,  page  135 ;  and
consequently  every article of  medicine and of
diet which does  not.contribute towards the re-
moval  of inflammation and the  alteration of the
state of the circulating fluids, is to be most anxi-
ously avoided.  It may be unnecessary to add,
that on many  occasions the  timely use of the
lancet produces  an  almost  immediate abate-
ment of all the distressing and alarming symp-
toms.

   But the modification of dropsy which seems at
present to  be most commonly  managed injudi-
ciously,  is the hydrocephalus.—Practitioners
who differ totally in their explanation of the na-
ture of that alarming  disease, cordially agree in 
160
 recommending mercury for its cure.  Indeed, it
 wTould appear  incredible,  were it not  that  the
 fact  could be  established  by the clearest evi-
 dence, that practitioners  who declare  hydroce-
 phalus to be  incurable, invariably prescribe  the
 most active exhibition of mercurial medicines.

   In estimating the effects of remedies, scientific
 practitioners  and ignorant  persons  often  draw
 very opposite conclusions.—The  former make
 every allowance, both for accidental coinciden-
 ces, and for those invisible minute changes in the
 internal parts of the body, which have been call-
 ed metaphorically, the efforts of the constitution,
 and by observing carefully the sensible Operation
 of any particular drug, and its influence upon
 the disease, in  numerous  and various instances,
 they learn its  true virtues.

   The latter on  the contrary, consider that every
 alteration in the disease is owing to the immedi-
 ately antecedent occurrence, and  consequently
 they attribute, most commonly, the cure of any
 protracted  or  dangerous illness to the last medi-
 cine which  had  been exhibited,  without  taking
 at  all  into account  the influence of the means
previously  employed, or the progressive opera- 
161
 tions of the  system which  naturally happen in
 the individual disorder.—It might, however, be
 expected, that both the scientific  and the unin-
 formed observer could draw no other than one
 inference, in  every instance in which the disease,
 from experience; is found to be incurable.

   Obvious, and even trite, as these remarks may
 appear, they cannot be  misplaced, if they lead
 the profession to adopt a consistent mode of prac-
 tice in the disease  under consideration.

   All  the  phenomena, both  of the  acute and
 symptomatic hydrocephalus, imitate so precisely
 the symptoms which arise from a mechanical in-
jury of the head,  followed by inflammation of
 the membranes of the brain, that it is quite sur-
 prising  that the coincidence has escaped the no-
 tice of practitioners.  Thus the violent pain 6f
 the head exciting great irritation of the stomach
 and prima? via?, and afterwards the convulsions,
 the delirium, the stupor, and the slerterous breath-
 ir%-»-which may be said to  be in general the on-
 ly invariable symptoms in  hydrocephalus—are
 precisely the same which occur in injuries of the
 head under the circumstances specified.
                     w 
162
   Although the consideration  may  be humilia-
ting, it is too instructive  to be passed over, that
the very reason urged by practitioners of deser-
ved eminence for the employment of mercury in
hydrocephalus, are  not  unfrequently in direct
contradiction to their own explanation of the na-
ture of the disease.  A late writer  on this sub-
ject of high reputation,  for example, attributes
hydrocephalus acutus to increased action of the
arteries, with  at  the same  time veinous  con-
gestions  within the cranium,  and  recommends
mercury for the purpose  of substituting a new
action.   But the most ample proofs, it is presu-
med, have been brought  forward in the preceding
pages, to shew that mercury increases the arte-
rial action, that it alters the nature of the circu-
lating mass, and that it impairs the energy of the
nervous  system—and  therefore its  operation
must tend directly  to  aggravate those alleged
causes.

   On this subject the author can  express his sen-
timents  with more than usual confidence, hajjifg
from his earliest years had innumerable opportu-
nities of attending to the effects of mercury in
this disease.   In no instance under his observa-
tion has that  medicine  ever proved successful, 
163
 —and he fully agrees with Dr. Blackall in opin-
 ion, that on many occasions the injudicious use
 of that  mineral  has actually  occasioned  the
 disease.

   Should it be asked what  substitute for mercu-
 ry the author would propose for the cure of hy-
 drocephalus, the answer may be readily anticipa-
 ted from the preceding observations.   Where in
 any  individual case  the  disease  is curable,  the
 only remedies to be depended upon  are blood-
 letting, both general and topical, repeated doses
 of powerful purgatives  combined with diapho-
 retics, especially preparations of gamboge and of
 antimony, digitalis in doses  exhibited every hour
 or two according to circumstances, and large and
 successive  blisters.

   In these brief notices on this interesting sub-
ject, the  author has purposely declined a particu-
 lar investigation of the signs by which hydroce-
 phalus may  be distinguished from the several
 diseases  which it resembles in  many of its most
 striking characters, and also any disquisition on
 its causes.—He cannot avoid however remarking,
 hat complications are  occasionally  met  with
 vhich  perplex the most experienced  and atten- 
164
tive  practitioners, and  that much mischief has
arisen from the hasty decision of rash and super-
ficial observers. To his certain knowledge, affec-
tions of the stomach and bowels have been con-
verted into hydrocephalus, by the use of mercu-
ry prescribed  on  the  presumption that the pa-
tient already laboured under that disease.

  Another dropsical affection requires particular
notice in  this  work, because mercury has been
hitherto considered to furnish the only remedy,
although no practitioner can produce competent
testimony in  favour of  its  ever having accom-
plished a cure. The disease alluded to is dropsy
of the OVARY.

  This is  perhaps the  most ordinary example of
encysted dropsy, and the  phenomena  which  it
occasions  are so various, that it would  be  incon-
sistent with the views  of this work to enumerate
them particularly.—But it is necessary to  state,
that wrhere in an enlarged ovary  fluctuation can
be perceived, it is often impossible to determine
whether the fluid  be contained within the proper
coat of the ovarium, or within  large hydatids.
Even in the advanced stages of the disease, where,
irom the  equable diffusion of the swelling over 
165
the whole abdomen, it may be so easily mistaken
for ascites, dissections have shewn that there were
one  or more  large  hydatids.  Sometimes,  too,
indurations, which advance at  irregular periods
to inflammation and  ulceration, are complicated
with hydatids.

  In general,  where the surface  of the swelling
is not unequal, and where fluctuation can be per-
ceived before the bulk  of the tumour has become
considerable, it may be presumed, that the watery
collection is contained Within the coat of the ova-
rium ; and when the swelling has  attained such a
size as to require tapping,  this conclusion  may
be  drawn with great certainty, if the fluid dis-
charged prove to be thick and gelatinous.

  This latter mark of distinction is of much more
importance  than  might at first sight be apparent.
It is of the same nature with the effusion in those
cases of ascites  in which the urine contains co-
agulable serum,  a circumstance  which has hith-
erto very unaccountably been disregarded.

  Upon what  principle mercury has been so uni-
versally employed in all cases of enlarged ovari-
um, notwithstanding the variety of age, constitu- 
166
tion, and state of general  health of the individ-
uals affected with it, no satisfactory explanation
has hitherto been given.

  Analogical reasoning is little in  favour of the
practice.  Hydatids  have  never been  cured  by
mercury, even when  situated in parts of the  body
where that mineral could exert a ready influence.
As to accumulations within the proper coat of
the ovary, they are too isolated and unconnect-
ed with the absorbent system, to be affected by
medicines capable of increasing the  actions of
the lymphatics.

  Far less can experience be  pleaded  in justifi-
cation  of this practice, for  the author speaks
within bounds, when he avers, that he has known
mercury employed in some hundred cases of dis-
eased ovarium, without its having  proved useful
in a single instance.   A few apparent exceptions
have been  reported  to him by  old pupils; but
from the uniform result  of all  the cases which
have been under his  own notice, he is induced to
believe, that  in those alleged  exceptions,  the
disease  had not been enlargement of the ovary. 
167
  But while mercury can be of no utility what-
ever, it may, and  certainly often  has  produced
irreparable  injury, not only upon  the general
constitution, (for the reasons so fully explained
in this work),  but also in all cases where indura-
tions of portions  of the ovary are complicated
with  serous collection.  Instances of this kind
every now and then occur, and  cannot  be dis-
tinguished till their progress towards cancerous
ulceration be so far advanced as to become mani-
fest.  A most  impartial attention  to  many  of
those cases  has convinced the author, that indu-
rations, which  might have remained  for years
without inconvenience to the patient, have been
forced into morbid activity by a course of mer-
cury.

  From the inutility or injurious tendency of the
various means  commonly employed in cases  of
enlarged ovarium, the author for many years con-
fined his views  in  the treatment of that disease,
to promoting the general health,' and to palliating
distressing symptoms; and as he not unfrequent-
ly saw instances where the local affection, after^a
certain progress became stationary, and ceased to
give any uneasiness, he supposed that  no other
resource could  be  safely relied on, 
168
  Within these five years, however, he was indu-
ced, by particular  circumstances, to  make some
experiments, for the purpose of determining whe-
ther the enlargements in question could possibly
be removed ; and in doing so, he did not neglect
the necessary precaution, of avoiding every thing
which could at all injure the general health.

  Adverting  to the effects  of percussion and of
pressure in chronic rheumatism, and knowing the
influence of the continued use of the muriate of
lime in indolent glandular swellings, he was led
to the trial of those several means, as  being at
any rate perfectly safe.  He advised, therefore,
that moderate and equal pressure of the  abdomen
should be made by means of a suitable bandage,
that the enlarged part should be  subjected twice
a-day to gentle percussion, and that  a course of
small doses of the muriate of lime should be con-
tinued for  at least several  months.  Where pain
or tenderness was experienced on the ovary being
pressed upon, he recommended, in addition to the
above means, the  daily use  of the warm bath.

   This plan of treatment has been much more
successful than he had anticipated. In seven cases,
in which it has been tried, the enlargement has so 
169
completely subsided that it is no longer tangi-
ble.—There could be no mistake in the majority
of those cases, not only because the size of the
diseased ovary was very  considerable, the fluctu-
ation was distinct, and all the ordinary character-
istics were well marked,  but also because the na-
ture of the affection  had been previously ascer-
tained by some of the most experienced practi-
tioners in London.

  In the first three cases, the  author considered
that there might be some accidental coincidence
independent of the remedies employed, and there-
fore he did  not venture to allude to them even
in lecturing, being always unwilling to give any
hints which might lead  to delusive speculations
in the practice of physic. But the fortunate issue
of four additional cases, entitles him to presume,
that the above means of cure bid fair to prove
extensively useful.

  He may  venture thus far, he trusts, without
the imputation of holding out ill-founded hopes
on  this subject ; but to prevent all risk of mis-
leading, he thinks it right to  specify  explicitly,
that the difficulty of distinguishing the presence
of hydatids,  must,  in every individual case, ren-
                         x 
170
der the efficacy of the practice doubtful, even
although further experience should establish the
fact, that where the effusion is within  the proper
coat of the ovary, this method of cure invariably
succeeds.

  Previous to the diminution of bulk  in all the
successful cases, it  is proper to add, that the  cir-
cumscribed enlargement of the ovary has invari'
ably become soft.  This change  was  so remark-
ably obvious in the first of the successful  cases,
that the indentation of the patient's finger upon
it  was similar to  what occurs in anasarca, al-
though it had been formerly quite incompressible.
As the tumour extended as high as the right hy-
pochondre, this important change was first per-
ceived by the lady herself.—The author refrains,
on this occasion, from making any  detailed com-
mentary on the result of the above practice.

               SECTION XI.

Of the Use of Mercury in Croup, and in Inflam-
              mation  of the Iris.

   In some parts of America,  calomel  has been
employed for many years, as  the  chief remedy 
171
in  cynanche trachealis* and it had been re-

peatedly prescribed  in this city,  by medical  men

who had practised in the West Indies, before the

author  could  be  persuaded  to  sanction its  use.


  • The  observations of the author on the treatment of croup in
America  can be meant to apply only to some limited section of the
country *  There is no disease, the nature and treatment ot which is
more settled in the United  States  than  the  on. in question -It  is
known to be of a highly inflammatory  character, and exceedingly ra-
pid in its progress and terminatiou-when encountered in the attack
almost certainly subject to medical control, but as certainly fatal if
left to itself or improperly treated.  The customary mode of treat-
ment is in perfect conformity to this view of the disease ; viz. hy emet-
ics  copious blood-letting, active cathartics, blisters, warm  bath, &c.
Emetics are first mentioned because they are  generally prescribed on
the invasion of the disease, for at that period it generally appears  to
be  eutirely local, and, whether at this  time it  depend on spasm or
inflammation, it is commonly arrested by an emetic before symptomatic
fever ensues.
  Witb regard to the use of calomel in croup, it is now. so far as my in-
formation extends, only employed as an auxiliary ;  indeed I know not
that it has ever been regarded in this country in any  other light.  Mer-
cury was used, combined with other medicines, in this disease, in
New-England, as early  as  the middle of the last  century,  and  Dr.
Rush in an essay on Cynancbe Trachealis written  more than twenty
years ago, advised the use of calomel after blood-letting, vomits and
purging.   At the present time calomel is also in general use when the
disease is protracted and dangerous.
  An abstract of the case of my own child, which occurred during the
last winter, may serve to shew under what circumstances and in what
quantity  it is  sometimes given.  The child  was twenty months old.
In the afternoon of the day  of the attack he slept  some hours in a

   * I know it is said by Dr.  Chapman that «« some of the respectable
 nractiUoners both  of this country and of Europe, trust exclusively o
 SmerTn croup, but ifthere be any who  are thus presumptuous in
 Seirpractice in this country,  they have not had the courage to pub-
 lish it to the world. 
172
He was informed that the method of exhibiting

it,  was to give to a child  of three  or four years

old, five grains evening and morning, and  that  it

cured the disease without producing any sensible

operation.—Such an account held  out no induce-

ment  for trying  so hazardous  a  remedy,  more


room where the floor  was wet.   In  the  evening he slept  without
manifesting any symptoms of indisposition till fen o'clock, when he
awoke with a dry shrill cough and wheezing, difficult respiration.—
Gave him instantly half an ounce of ol. olivar.—no relief—in ten min-
utes gave a dose of antim. tart, in solution—in fifteen minutes he was
sickened,  and  continued  to  puke, at short intervals,  till twelve
o'clock—was much exhausted but not perfectly  relieved—at  two
o'clock took ten grains of calomel,—slept till  morning without any
apparent aggravation of symptoms—(a fallacious aud dangerous inter-
val—) at  nine o'clock bowels freely evacuated, cough and difficulty
of breathing returned—surface became heated and the pulse frequent
aud  hard—kept him  constantly  nauseated with antimony—Twelve
o'clock lost twelve ounces of blood from a large orifice in the jugular
vein—a  large  epispastic was applied to  his throat ;  was partially
relieved for two or three hours, when all its symptoms began to in-
crease ;—put him into a warm bath—increased the dose of the antimo-
nial solution until be vomited—Five o'clock lost two or three ounces
of blood from  the same orifice—bowels opened by a stimulating in-
jection—Eight o'clock,  same evening, the cough still sonorous—breath-
ing  difficult and the pulse wiry—took eight ounces of blood from the
temporal artery, which induced complete syncope.  From this time,
from three to five grains of calomel, according to the frequency of the
evacuations from  the bowels,  were given every three hours— symp-
toms much abated during the night ; next  morning the difficulty of
breathing aud symptomatic fever increased, notwithstanding the contin-
ued use of nauseating  medicines,  and the evacuations produced by
the calomel from the bowels.—Eleven o'clock A. M. pulse hard and
one hundred and thirty in a minute,  and the skin still flushed, took
from 6 to  8 ouuees blood from the temporal  artery which again  in-
duced  fainting,—twelve  o'clock  began to give three  drops Tine.
Digitalis every  two hours—Four o'clock, P. M. bath repeated—the 
173
especially since he knew that the practice, under
the direction of the  late Dr. Wright,  and some
other physicians, who  had resided in hot climates,
proved so unsuccessful,  that on  more than one
occasion, two children in the same family, treated
according to this plan, died within a few days  of
each other.

   About  sixteen  years ago, however,  in conse-
quence  partly  of the  urgent representations  of
an old  pupil  (the  late  Dr. J.  Anderson), and
chiefly because the ordinary remedies frequently
circulation is less rapid—heat more natural—bas frequent evacuations
of green nuaiter from the bowels,—the calomel is continued—during
the  night give alternately the antimony  and  digitalis.  The  next
morning, the third day of the disease,  gave him a strong decoction of
Polygala Senega, so as occasionally to  cause vomiting—the calomel is
continued—he is rapidly convalescing—In one week from the time of
the  attack  he was walking about the room, after having lost in less
than twenty-four  hours about thirty  ounces of blood, and taking in
three days from ninety to One hundred grs. of calomel—He. is now
in perfect  health.
  This case is perhaps  profitable to show what a child labouring un-
der violent disease can  endure rather tnau to point out what in ordina-
ry cases is required. I am fully of opinion, however, that no treatment
milder than what  has been described would have subdued the disease,
probably a more active one the child could not have borne. With
these views of the case. 1 take great pleasure in expressing the warm-
est  gratitude to  my friends Drs. Cock  &, Stevens.  It was treated
principally by them dtiriug the most critical period ; and to their ener-
gy aud caution I am iudebied as the means of preserving my child's
life.—I. 
J 74
 proved uncertain, he was induced to give calomel
 a fair trial—and he must  say, that the result of
 his experience has  been  so very different from
 that of the American  practitioners, that  he can
 only explain it on the  supposition, that in differ-
 ent climates  the  same disease is relieved in dif-
 ferent ways.  At  any rate, he can  solemnly as-
 sert, that according to  all  that he has seen, no re-
 lief whatever has  been  afforded by that medicine,
 unless copious dark green-coloured stools, like
 boiled spinage, have been discharged, and that it
requires large and repeated doses of the medicine
to produce that effect.   For example, to  a child
of seven years old, one hundred  and thirty-three
grains were given within sixty hours.

  These circumstances led to the conclusion, that
in this part of the world at least, wherever calo-
mel has seemed to cure croup without affecting
the bowels, the symptoms had not been those of
that disease, but of the spurious croup  ; and this
opinion is confirmed by the fact,  that in the only
cases in which the medicine has  failed  under the
author's direction (being in the proportion of four
out of fifty), no evacuation whatever through the
bowels could be produced, although antimonials,
and jalap, and gamboge, and glysters,  were em-
ployed as auxiliaries. 
175
  In reasoning upon this subject, it is extremely
difficult to explain, in the first place, the safety
with which a hundred and thirty-three grains of
calomel could be  given  in  this climate, within
sixly hours, to a patient  of seven years of age* ,—
and, secondly,  the relief which has invariably
followed the  discharge  of the  dark  coloured
evacuation.   This  latter circumstance, in  par-
ticular, is the more  perplexing, seeing that in all
those cases the evacuations from the bowels were
not faeces, but  were combinations  of bile  and
mucus in a substantial form, resembling, as al-
ready  stated, boiled spinage, or the contents of
the second stomach in  ruminating animals.

   Topical inflammation, it has been long known,
 may be relieved by watery, or as they have been
 called, chylous  discharges from the bowels, and
 their  efficacy  in  that respect  has been usually
 explained, on the supposition, that a considerable
 portion of  the circulating mass  is in that way
 thrown off, through the exhalents and other mi
 nute vessels of the surface of the alimentary canal.
   * In that instance, two very  intelligent gentlemen then attending
 the author's class, voluntarily  watched the patient by turns and ad-
 ministered the medicine ; and from their zealous attention on that oc.
 casion, be regrets that, through defect  of memory, he cannot record
 their names. The child was a daughter of a respectable  tradesman
 in College-Street. 
176
   But the immediate opeiation of calomel, where
successful in croup, is  most  obviously  upon the
Liver,  and  yet  there  is no reason to suppose  so
direct a sympathy of the Larynx with that organ,
as with the other viscera concerned in digestion.
It would lead, however, to discussions totally in-
consistent with the purpose of this work, to pur-
sue this inquiry further, though it certainly merits
the most  minute  investigation.*
  * It was the opinion of Dr.  Rush that the good effects of calomel
in croup depended on its exciting a counter-action in the whole in-
testinal canal ; and there  are some facts  which  seem to show that
they are at least partly to be attributed  to that cause.  The dark
green  coloured evacuations mentioned in the text, which are a mix-
ture of mucus and bile, are peculiar to the operation of mercury, and
in almost every instance where this discbarge is produced the patient
recovers.   In these cases  the action of the medicine is obviously ex-
tended to the liver, as is proved by a continued and copious secretion
of bile ; but probably it has less effect towards subduing the disease
in this way, than it has by the powerful impression which it makes
on the mucous membrane of the intestines.  Its utility cannot be
owing altogether to its operation as a  cathartic, for free evacuations
produced  by any  other purgative medicine, have comparatively but
little effect in subduing or suspending the violence  of the disease-
  The counter-action excited iu the intestines, Dr. Rush  supposes  to
lessen the disposition of the tracheal blood-vessels to discharge the
mucus, S<c. but it is not reasonable to suppose, that besides weakening
the force of the disease by the powerful counter impression which it ex-
erts on a  distant part, that calomel also operates in the cure of croup,
by continuous sympathy,  on the mucous membrane which is the seat
of the disease, increasing the action of the excretories during the pas-
sive or secondary stage of the  inflammation, and thereby, unloading,
find restoring to their healthy action the contiguous blood-vessels.—I 
177
   However  inexplicable the modus eperandi of
 calomel, in  cases of croup, appears to be, the
 success of the practice was such, as to encourage
 the expectation of its proving a safe and certain
 cure for that formidable disease ;—though, while
 he indulged this hope, the author, even from the
 beginning, was not inattentive to  the probable
 dangers  which might  arise from the indiscreet
 employment  of so active a medicine.

   Thus he stated expressly, that " In some cases
 considerable  weakness remains after the crouping
has ceased, in consequence, partly of the violence
of the symptoms, and partly of the operation of
the calomel,"* He added, that he had seen " two
cases, where, although all symptoms of the croup
were removed by the use of calomel, the patients
sunk from the weakness which followed ;"f—and
concluded, that " those  cases enforce the neces-
sity for carefully watching the progress  of the
disease, so as to stop the calomel whenever the
symptoms begin to yield."J

  Since that publication, he has been favoured
with numerous communications on the subject
 * Hamilton's Female Complaints, 1813. page 367.
 f Hamilton's  do.     do.    p. 369.
 t Hamilton's  do.     do.    p 370.
                         Y 
178
 from old pupils, settled  in  distant parts of the
 kingdom, which confirm his former account, that
 the disease occurs in various degrees of violence
 in different situations,*  and which convince him,
 that  the  severe forms  of this  affection do  not
 yield to the exclusive use of calomel.—He has
 suggested, therefore, in such cases, that the  chief
 reliance should be put in  the remedies more usu-
 ally employed to subdue inflammatory affections
 viz. bleeding, blisters, antimonials, and brisk pur-
 gatives.   In giving this advice,  he has commonly
 taken the liberty to add minute directions for
 the employment of  those  means, being aware,
.  that in every acute disease, the progress of which
  is so rapid, every thing depends upon the timeous
  and steady application of remedies.

    With  respect to  bleeding, there  is often con-
  siderable difficulty in  having it  effectually per-
  formed.—The  application  of leeches  in very
  young children, certainly, is followed by a con-
  siderable flow  of blood, in  consequence of the
  great vascularity of their skin; but this discharge

    * " It is a curious and instructive fact, that, in proportion to the
  dampness of the atmosphere, is the violence of the disease,—Thus, in
  Leith it is more severe than in Edinburgh  ; and in some marshy dis-
  tricts it is much more violent than in Leith."—Hamilton's Female
  Complaints,  1813, page 365, 
179
is so tardy, that, in many instances, it does not at
all check the progress of the  disease.   The lan-
cet therefore ought  always to  be first had re-
course to, and in every point of view, the exter-
nal jugular is  the  proper vein  to be opened.
Any quantity of blood may be  quickly drawn
from that vein  in the  youngest subjects, and in
the violent cases alluded to, there is more risk in
drawing  too little  than  too  much.   Leeches
may be employed with great  advantage as auxil-
iaries.

   Blisters have been commonly applied  as near
as  can be to the seat of the inflammation, but
they appear to have a better effect when put on the
sternum.—The best purgatives are solutions of
the tartrite of antimony combined with gamboge
and jalap, and they ought to be given as soon as
possible after the invasion of the disease.  If they
operate both upwards and downwards, so much
the better.—Should the breathing be not reliev-
ed after the free operation of the purgatives, the
bleeding from the jugular is  to be repeated.

   From the information he has obtained, he has
 reason to believe, that in the violent  degrees of
 croup, this plan of treatment is much more sue- 
180
cessful than the exhibition of calomel, and it
therefore becomes a question worth serious con-
sideration,  whether, even in the milder degrees,
the same method might not be preferred.

  Two objections  may be urged against this pro-
posal ; first, that the simple plan of giving calo-
mel every hour or  two  till  the  dark-coloured
stools be discharged, and then gradually discon-
tinuing it, is  much  more  easily accomplished ;
and secondly, that the prejudices  of the  atten-
dants might not unfrequently prevent the practi-
tioner from having recourse to the lancet,  with-
out  which (it is obvious) the other  means would
prove of very little avail in many  instances.

  Probably a conviction of this truth is the rea-
son that in some parts of this island, particularly
on  the sea-coast,  where  croup is  more violent
than in this city,  several judicious practitioners
have directed the application of  a  number of
leeches, at the same time that they have  admin-
istered the calomel  with  great  activity.   This
practice has succeeded much better than the use
of digitalis, which has been repeatedly  tried.

   The other  inflammatory affection included in
this section, for the cure  of which calomel has 
181
been strongly recommended, is ophthalmia iri-
dis.  This remedy was originally suggested  in
inflammation of the Iris, from its being compli-
cated with syphilitic  symptoms, and it was em-
ployed most successfully by the late  Mr. John
Cunningham  Saunders of London.—It is to be
particularly noted, however, that he recommend-
ed, at the same time, the most powerful measures
for subduing  inflammation, such  as,  bleeding
largely from the temporal artery, the application
of a number of leeches as near the eye as possi-
ble, and large doses of tartarised antimony.—He
always too besmeared the eye  externally  with
the extract  of  belladona, repeating it at such in-
tervals as to keep the iris in a continued state of
extreme  dilatation.

   In the  preface to the second edition of Mr.
Saunders's book, Dr.  Farre mentions, that  he
himself has employed the calomel as successfully
in cases  of simple  iritis, as in cases complicated
with syphilis ;  and he has added  the  following
observations on the action of mercury,  which the
author deems it necessary to notice.

   " The  certainty  with which the mercurial ac-
tion arrested the deposition of coagulable lymph 
182
in syphilitic inflammation of the iris, led the edi-
tor to give this remedy a fair trial in simple in-
flammation of the iris, in which the disorganizing
process by the adhesive inflammation is precisely
the same, however it may differ from the former
in its exciting cause.  The  result of the trial has
perfectly satisfied him, that the mercurial action
alone, when properly kept up,  is sufficient to sub-
due the ophthalmia iridis in its most acute stage.
—Although the  full action of mercury is often
efficient in  arresting  that disorganization of the
various parts of the body, which results from the
gradual deposition  of coagulable lymph,  within
their interstitial textures; yet the free abstraction
of blood is still essential to prevent its bolder and
more immediate  destructive  effusions  in  phleg-
monous inflammation.  It is,  however, too low an
estimate of the  operation  of mercury, to con-
sider it only as a specific against syphilis, or as an
evacuant and promoter of certain secretions and
excretions—it powerfully alters the action of in-
flamed arteries, more especially in respect to the
effusion of coagulable lymph,  which it in various
degrees controls,  or even altogether suspends.

  " In  relation  to the  general practice, this is
perhaps  the most important view which can  be 
183
taken of the operation of mercury on the vascular
system ; but it is not the place to inquire into the
state of the body under which mercury is either
capable or incapable of arresting  the effusion  of
coagulable lymph.  The curative result is suffici-
ently uniform in ophthalmia iridis, if  the  mercu-
rial action be excited in the early  stages of the
inflammation, to urge the adoption of this treat-
ment in preference to any other; but  if the disor-
ganizing  process be very  rapid, the use of this
important remedy,  which  demands  time to  be
efficient,  may  be aided  by  general  or  topical
bleeding.   It is not the quantity of mercury,
but  the mercurial action,  which is  required  to
interrupt the disorganizing  process  ; and the
former must be kept up till the  latter  is  sub-
dued.   The observations  of the  author on the
application of the belladona to prevent the con-
traction of the  pupil, must be strictly attended
to.  If smeared over the brows and eyelids,  its
effect is produced without irritating  the eye."*

   Admitting in its full extent the  signal  success
of the late  ingenious Mr. Saunders, and of  his
very intelligent editor Dr. Farre,  in cases of  in-

  * Preface to the second edition of Saunders on the Diseases of the
Eye, page xxxviii, et seq. 
184
riammation of the iris, which the author most wil-
lingly does, he ventures, with much deference, to
suggest,  that  calomel  had no other influence in
the cure  than  in subduing the syphilitic virus.—
He is inclined to attribute the success chiefly to
the external application of the  extract of bella-
dona, which was so happily employed by Mr.
Saunders ; for it cannot  be doubted, that if the
radiated  fibres of the Iris  be kept in a constant
state of contraction, so as to dilate the pupil to the
utmost extent, the minute vessels of that delicate
part must undergo mechanically such a change
as shall probably prevent effusion from their ex-
tremities.  But  as  the  author cannot appeal to
experience in this disease, he  should  perhaps
have waved its consideration in this work.

   It is, however, the reasoning  of Dr. Farre on
the action of  mercury to which he wishes parti-
cularly to allude.  Dr. Farre asserts,  that *' it
powerfully alters the action of inflamed arteries,
more especially in respect to the effusion of co-
agulable  lymph, which it,  in  various degrees,
controls, or even altogether suspends."

   But  in the very section of this work it has
been shewn, that the action of mercury tends, by 
185
exciting inflammation and  effusion, to produce
thickening of various membranes, particularly of
the pleura—and several instances of that  kind
are recorded by Dr. Blackall, where the fact was
proved by  the appearances on dissection.   This
effect of mercury has been long remarked by the
author, and  it suggested to him, many  years ago,
a practical inference of some importance.

   Every surgeon knows, that in cases of abscess
of the mamma in the puerperal  state,  sinuses are
apt to form, which are little disposed to heal, and
which discharge a thin sanies.  It is acknowledg-
ed, that the operation for the fistula ani is some-
times followed  by a flabby pallid state  of the
parts, a tendency of the sinus to elongation, and
an ichorous discharge.  In  many instances  of
both  those  affections, the author has  advised the
use of the  blue pill, so as very slightly to affect
the gums; and he has generally found, that when-
ever  that event took place, the granulations be-
came healthy, a well conditioned discharge ap-
peared, and the healing process advanced rapid-
ly .—These facts are quite inconsistent with the
hypothesis, that Mercury  suspends  the effusion
 of coagulable lymph. 
186
  The Author intended  originally to have con-
sidered  the  utility  of mercurial medicines  in
Glandular Affections, in Chronic Rheumatism,
in Chronic Eruptions of the Skin, and  in Anom-
alous Complaints, but these pages have extended
so much beyond his expectation, that he feels it
necessary to conclude.  He does this the more
readily, because the remarks he has offered upon
the effects of Mercury on the arterial system, and
on  the  condition of the circulating  mass, may
serve to illustrate the cases where that Medicine
can be useful or prejudicial.

  Particular combinations  of Mercurial Oxydes
with other medicines,  may, he is well aware, be
employed advantageously on various occasions—
and accordingly he believes that in certain stages
of Glandular Affections, of Chronic Rheumatism,
and of Chronic Eruptions of the Skin, the addi-
tion of a very small proportion of  the  Muriate
of Mercury to some of the compounds  of Anti-
mony,  increases the activity, without lessening
the safety of those latter medicines.   But he  has
always found, that when Mercury in any form is
employed  as  an auxiliary, it can scarcely  be
given in  too  small doses  ; and at  any rate, he
ventures to advise, that  when so administered, it 
187
ought never to be allowed to produce its proper
sensible effects upon the system.

  He takes the liberty to add, that in the prece-
ding pages, (as has been  repeatedly  stated), his
observations  apply exclusively to the Use and
Abuse of Mercury in this part of the world.—
Although,  through the favour of a most intelli-
gent Medical Friend, he has had access to some
official documents,  which  convince him that
Calomel has been most injudiciously and injurious-
ly employed in the remittent fever of the West
Indies, he  has purposely refrained from making
any  animadversions upon that practice 
 
mwm
BY A. W. IVES, M. D.
 Observations on the modus operandi of mercurial medicines,
           and on their use in febrile  diseases.
 IVIercury has become so fashionable a remedy  at  the
 present day, particularly the sub muriate of mercury, that
 by many it is esteemed as almost an  indispensable  agent
in the treatment of febrile diseases; and yet so vague and
 discordant are  the opinions of physicians, with regard to
its modus operandi, that scarcely two can agree on  the
time, manner, and extent of its use.  Each one has marked
out imaginary rules for the regulation  of his own practice :
 and though he may perhaps find himself unable to explain
definitely, at all times, the reasons on  which his judg-
ment is determined,  or the precise object which  he de-
signs to fulfil, still he thinks, there are certain symptoms,
which he has learned from observation to regard as indi-
cating a condition of the system which calls for the medi-
cal influence of a  mercurial course.  Indeed so imperfect
and unsettled is our knowledge on this subject, that no
 one  can  be  impugned for empiricism,  how improper
soever  his practice may appear; for there is no  incon-
sistency so extravagant that it cannot be supported by pre-
 cedent, and no hypothesis so absurd, that it cannot be
 defended by books.
  The writer has not the arrogance to imagine,  that  the
 following remarks will divest the subject of all its difficul-
 ties,  when it has  been  so often unsuccessfully attempted
 by abler hands, but by availing himself of their knowledge
 and experience, he hopes. to  deduce some genera) prin-
                         a a 
190
APPENDIX.
ciples illustrative of the operation of mercurial medicines,
which may be applied to their use in fevers."
  Without adverting particularly to the contradictory opi-
nions of numerous respectable writers, as to the propriety
of the mercurial practice in various febrile diseases, it will
be sufficient, for the present purpose, to show that some of
the most approved and popular authors on the subject are
inconsistent with themselves;  and, that the medicinal pro-
perties  of mercury are either misrepresented,  or its ope-
ration must be incompatible with the indications which it
is given to fulfil.   .
   It was  said by Cullen,  that mercury acted as a stimulus
to every sensible and moving fibre of the body, and this
opinion has been received and propagated, with some unes-
sential  modifications,  to the present period.  In the mean
time, and with this view of its modus operandi, it has been
confidently recommended  and most extensively  used in
the treatment of acute inflammatory  fevers.  It was intro-
duced  in New England,  for this purpose, as early as the
middle  of the last  century,  and still  continues to  be  a
popular remedy.  Dr. John Warren,  in his treatise  on the
mercurial practice, published in 1813, says, " mercurial pre-
parations increase  the action  of the  heart and  arteries,
quickening the pulse in some instances, and in  others ren-
 dering  it stronger and fuller; consequently increasing the
 momentum of the circulating blood, and in this way rous-
 ing the whole system  into action," &c. page 16th.   At the
 35th page he says," The general testimony of practitioners,
 who have been much in the use of this medicine, is in favour
 of its  exhibition in  all stages of febrile disease, even in
 the commencement of the fever, or  before it  is formed.''
 In Europe also the introduction of mercury in the.  treat-
 ment  of acute phlegmasial diseases is registered as an im-
 portant era in the profession.  The name of Robert Ham-
 ilton is immortalized  by its association with the mercurial 
APPENDIX.
191
practice in inflammatory fevers.  Blood-letting, in diseases
of this character, has generally been thought advisable as
preliminary to the use of mercury, but even this has not
been deemed requisite by all; there have  been those, it
would seem, whose partiality for this remedy has led them
to believe that it  would supersede the necessity  of all
others.  " Quicksilver," says Dr. Gilchrist, " is a power-
ful antiphlogistic, and removes inflammation without acce-
lerating the motion of the fluids, which is rather reduced,
by its subduing their inflammatory  disposition."  And Dr.
Warren remarks, " Mercury quickens the pulse in  health,
in disease  it renders it slower."
  Now notwithstanding this testimony in favour of mercu-
rial medicines during the violence of inflammatory fevers, it
is impossible  not to perceive  an astonishing incongruity
in the opinions entertained of their medicinal qualities, and
of their agency in the cure of disease.  There is a para-
dox involved in the  theory and  practice  of the  same au-
thors, which shows conclusively that the  subject is yet but
imperfectly understood: it implies either a want of preci-
sion in language, an ignorance  of the  peculiar properties
of the medicine, or gross absurdity in the exhibition  of it
in the sthenic  type of disease.   But independent of inter-
nal evidence, there  is, at least, circumstantial testimony of
the fallacy of the doctrine, in the  dissenting opinions of
some of the most learned and experienced  of the profes-
sion.   It  cannot be considered a want of deference to the
distinguished advocates of the mercurial practice (as it has
very properly been  denominated from their exclusive ad-
herence to it)  to distrust the soundness of their deductions,
when they are  not only  opposed by the  acknowledged
principles of medical philosophy, but by the judgment and
experience of such men as Robert Jackson  and Dr. Lind.
To these  might be added numbers of the most celebrated
physicians of England, France,  and America, all of whom. 
192
APPENDIX.
from clinical observation, have decided against the practice
of resting the issue of febrile disease on the  constitutional
operation of mercury.
  It is true that those who have most zealously commend-
ed this medicine, have not denied the danger and uncer-
tainty  of its operation ; still they appear rather  to  have
laboured to give  to it the character of a specific, than to
establish general principles which would reconcile the dis-
crepancy of their theory and practice.  " Could  a line be
fairly drawn,"  says Doctor Warren, " between the diseases
in which it is prejudicial, and those in which it is advanta-
geous ; and could the mode of administration be accurately
prescribed,  much of that mischief which  has originated
from this most active class of medicines might be avoided,
and many a constitution saved from ruin."   But this is a
knowledge which we can never hope to attain, and even if
it were attainable, what would be the avail  ?  There  is a
diversity in the character of the same diseases, arising from
a difference in the circumstances or condition of the pa-
tients,  which forbid the expectation that the  science of me-
dicine will ever be so perfected, and the labours of the phy-
sician so simplified, that a medicine can be safely prescrib-
ed for a name.  It will continue to be the province of the
physician to establish general principles from facts,  and
to mete out from these, such particulars as may be suitable
to the multifarious characters and  symptoms of disease;
and  until some general principles shall be  settled for the
better regulation of the mercurial practice in fevers, how-
ever extensive and popular it may be, it will  continue to be
empirical.
   With  a view to this object, I shall proceed to inquire
in what  manner mercurial medicines exert  their  influence
on  the  human system, the various phenomena produced
by them, and  how far and under what circumstances they
are applicable to the cure of fevers. 
APPENDIX.
193
   It would be incompatible with the brevity of these re-
marks, to enter into the controversy,  or even to review the
arguments that have been urged by the respective parties,
relative to the modus operandi of medicines; nor would the
subject have been mentioned, were it  not that the following
observations are founded on the belief, that mercury some-
times  produces its effect by being absorbed into  the  cir-
culation, sometimes by a direct impression on the nerves
with which it is in contact, and  at others, by a sympathe-
tic action extended to distant parts through the  medium
of the  nervous system, and consequently that neither of the
popular theories of the day are alone sufficient to explain
its diversified operation.
   It cannot be denied, that modern  improvements in the
knowledge  of the animal economy and in the science of che-
mistry, have disproved and exploded  many vague notions
of the ancient humoral pathologists; but  they  have  not
conclusively proved, that medicines are not sometimes re-
ceived unchanged, as it respects their medicinal  character,
into the circulation, nor do they afford positive testimony
that they operate exclusively through the agency of the
nerves.  Those  who embrace the latter theory, avoid the
errors and  inconsistencies chargeable to  the former,  and
from the undefinable nature and unbounded application of
their fashionable hypothesis, it is ingeniously but speciously
defended against their objectors; but still the doctrine ap-
pears to be better fitted to resist opposition than to  ex-
plain  facts, for though every,  otherwise  unaccountable,
action  in the  animal economy, may  be safely ascribed to
nervous sympathy,  yet  it neither explains, defines,  nor
proves the nature of the phenomena.   Instead therefore of
exclusively  adhering to  any  of  the foregoing doctrines, I
shall attempt  to  show,  that the  operation of mercury
evinces to a certain extent the truth of them all.
  Where mercury produces its specific action on the con- 
194
APPENDIX.
stitution, it appears to be previously absorbed into the blood
vessels. It there becomes a new and peculiar source of irri-
tation  to all the  organs concerned in the  circulation and
the various  secretions;—it extends  its influence through
the medium of the blood to the nervous system, increasing
its irritability,  and  thereby reacting upon  the heart and
arteries, and thus perpetuates the train of constitutional
morbid associations which constitute mercurial fever.   The
class of medicines denominated stimulants, have generally
been supposed  to exert their first agency on the nerves of
the stomach, and  from thence, through the medium of the
brain and nerves, on the other parts of the system ; but from
the following considerations, it is contended  that such is
not the operation of mercury.

  I. From its general effects on the system.

  1st. One of the  earliest evidences that the system is mer-
curialized, is an increased action in the heart and arteries,
manifested by a quick and fretful pulse ;—a pulse so pecu-
liar, that by an  accurate and experienced observer, it may
often be detected,though he were previously ignorant of the
patient's being  under the influence of the medicine.  This
symptom  is ordinarily  less regarded  as an indication  of
mercurial excitement than the more obvious one of saliva-
tion ; and, indeed, it seldom  attracts attention till the ner-
vous system is also affected j but it is  more uniformly atten-
dant on general mercurial action than any local symptom ;
and it always precedes that morbid  irritability of the ner-
vous system which is evinced by restlessness, languor and
debility.  The salivary glands are more susceptible of mer-
curial  irritation than any other  part  of the  system, and
hence  an increased flow of saliva with swelling, or sore-
ness of the  gums  are  generally  regarded as  the  surest
indication  of constitutional mercurial action.   This as a 
APPENDIX.
195
general rule  is certainly  a  very  correct one, but  it  is
far  from being  infallible; for there are  some  instances
where  salivation  cannot  be  produced though mercury be
administered ever so judiciously for that purpose, when at
the same time we have satisfactory assurances that the sys-
tem is constitutionally affected by it.   Another evidence
that at this time the  action  of the medicine is principally
confined to the blood-vessels is, that it does not cause  as
much constitutional excitement as is usually attendant on
a rapid circulation produced  by  other artificial stimuli  or
by  febrile  irritation.   The irritability seems to be almost.
exclusively confined to the heart and arteries, and to be ow-
ing to a change in the quality of their natural stimulus the
blood.
  2nd.  From the diseases in which mercury is most effi-
cacious as a remedy.  These are fever,—the proximate
cause of which is generally believed to be  a morbid con-
dition of the blood-vessels, aud also diseases of the secre-
tory organs,  whose  functions are intimateb  connected
with, and  almost  solely dependent on  the  circulation.
Whereas diseases seated more particularly in  the nervous
system are but remotely  or  indirectly influenced  by mer-
curial action.*
  3rd. From the extreme difficulty  there  is in mercurial-
izing the constitution when there exists considerable devia-
tion from the healthy action of the heart and arteries;—
a circumstance which will be more fully considered  here-
after, and which is mentioned as having an important bear-
ing on the  subject in question.
  4th. Large quantities of mercurial medicines frequently lie
dormant in the stomach or intestines for a great length of
time ;  and again, the minutest portion will excite violent

  * The operation of mercury in  the cure of syphilis, though foreign
to the present inquiry, might also  be cited as evidence of its being dif-
liised through the escalation. 
196
APPENDIX.
mercurial fever.  Such  would not be the case,  did they
operate through the agency of the nerves.
  5th. The disparity there is in the local and constitu-
tional effects of mercury.  When it abrades the surface of
the alimentary canal so as to cause the most extreme local
irritation, it is seldom diffused  through the constitution ;
and where the  constitution is affected by it, the local im-
pression is most commonly imperceptible.
  6th  Experiments have conclusively proved, that animal
poisons exert their influence through the medium of the
blood-vessels,  and there is the closest  analogy in  their
operation and that of mercury.  The action of both appears
to depend greatly upon the susceptibility of the system to
their operation. The variolous infection  which proves fatal
to one person, causes but a mild disease in another.  The
same  remarks will  apply to the  operation of  mercury.
Both so  far contaminate the circulating  fluids  as to  keep
up a permanent  excitement for a  considerable  length of
time, for as their properties can be destroyed by no anti-
dote, their effects will continue  till they are carried out of
the system by its emunctories.

  II.   Mercury  is proved to  be absorbed into the cir-
culation  by the changes induced on the  animal fluids.

  1st.  Blood drawn from a mercurialized patient not only
exhibits the buffy coat indicative of an irritable condition of
the heart and arteries, but its tenacity  is sometimes partially
or wholly destroyed.
  2d.  Mercury has been  detected in the fluids.  Metallic
globules have been seen in the milk of a salivated woman.
And it is well known, that the exhalation from the skin dur-
ing mercurial action forms an amalgum with metals.
   3d.  From the  sensible  changes exhibited in the secre-
tions generally as exemplified by metallic taste and  offen- 
APPENDIX.                  197
 sive odour of the breath, &c.  And finally, from the pecu-
 liar influence of mercurial medicines being communicated
 from the mother to the nursing child.

   When  mercury is given in small doses and for a consi-
 derable length of time, so as to produce an alterative ef-
 fect, it evidently operates through the medium of the circu-
 lation.  Though its ultimate influence on the system when
 thus administered, is different from what it is when suddenly
 crowded to the extent of salivation, still its immediate ef-
 fect if carefully observed, will be  found  to differ only in
 degree.  If its action on the hiart and arteries is less per-
 ceptible  in the  pulse, and  from its milder operation its
 effects are  not obviously extended to the nervous system,
 there are nevertheless  positive  evidence that it is silently
 operating changes,  through  the agency of the circulating
 fluids.   The result is shown  in the minutest ramifications
 of the blood vessels ; sometimes stimulating them to a new
 and healthy action, as in  the removal of various tumours,
 ulcers, topical  congestions, Sic;  at  other  times by tho-
 roughly, though perhaps insensibly, changing the character
 of some one or all of the secretions.
  Whether the effects of mercury in these cases are owing
to a change produced in the properties of  the blood, or in
the functions of the secretory organs, or  by both operating
 as successive means to the same end, it is not easy, nor is
it  important to  this inquiry to decide; but the general
analogy in  the  phenomena exhibited when   mercurial
action  is  suddenly  produced,  and   to such  an extent as
to manifest itself in  constitutional  febrile  irritation; and
when it is excited so slowly and gradually as to effect imper-
ceptibly, but radically  and permanently a change  in the
various secretions, leaves little doubt that in both cases its
agency is exerted through the medium of the circulation.
  Such appears to be the most usual operation of mercury
                          Bb 
198
APPENDIX.
when it is absorbed into the circulation; but its action is
not uniformly the same, though administered apparently
under the same circumstances.  There is sometimes a pe-
culiar susceptibility to its operation in a particular organ ;
and though in such cases the strongest evidences  exist that
the constitution is more or less affected by it, and there-
fore that it must have been received into the circulation,
still its force is so much spent on the part thus predisposed
to its action, that the constitution is sometimes but slightly
affected when  its local violence is great.   It is impos-
sible to foretell with certainty the partial operation of mer-
cury,  the  organ to which its action will be determined, or
to what degree it may be diverted from the constitution by
local susceptibility.
   Again, do we not sometimes see in the treatment of sy-
philis,  a few grains of calomel produce a copious ptyalism,
which  lasts  for many weeks, while in the  mean time the
constitution  is so little affected, that the disease  continues
unabated or sometimes to increase ? It is acknowledged, as
observed  above, that where such  a salivation exists, with
soreness of the gums, swelling of the glands, metallic taste,
and offensiveness of the breath, the whole system may  be,
and generally is, thoroughly mercurialized, but this is not
invariably the case. The writer of these remarks, has been
twice salivated without any perceptible effects of the mer-
cury on the constitution.  The first time it was  by taking
ten grains of calomel with the same quantity of jalap, which
in three hours operated briskly as a cathartic.  Two days
afterwards a tenderness  of the gums and copious ptyalism
ensued which continued for many days.  The second time,
three grains of calomel  were  taken in combination with
ipecacuana ; it operated as an emetico-cathartic,  neverthe-
less salivation came on the next day.
   When ptyalism is thus suddenly produced by  a small 
APPENDIX.
199
quantity of mercury, it may be of great practical impor-
tance to know, whether  it be  owing to constitutional or
local  susceptibility.   If  the constitution be unusually sus-
ceptible to mercurial action, the salivary glands in common
with other parts of the system are liable to be suddenly
and  severely  affected—and where from this general pre-
disposition ptyalism is produced, it is unnecessary, nay dan-
gerous to increase the  dose of the m- dicine or to continue
its use,  on the supposition  that  enough has not already
been taken to  thoroughly mercurialize the constitution; for
nothing is  more obvious than that the beneficial effects of
mercurial  medicines  are not  to be estimated by  their
quantity.
  On the other hand if ptyalism result from a peculiar sus-
ceptibility of the salivary glands, the action of the mercury
on the local parts may be violent, but in the mean time so
partial on the constitution,  that there is no certainty of its
eradicating constitutional disease.   This is not an imagi-
nary speculation; the  truth of it has been confirmed not
only by extensive observation in the treatment of syphilis,
but by the effects of mercury in fevers; and it  is believed,
that in most cases of fever where death ensues  after saliva-
tion  comes on, that, notwithstanding the evidence of local
mercurial action, the constitution is but very  partially af-
fected.
  If these observations are true, they show that too much
confidence may be attached to the effects of mercurial me-
dicines  on  the salivary glands; but this is not all, for as has
been  observed, though  these  parts are in  most instances
more susceptible  to  mercurial irritation  than any other,
still they are not uniformly so.   It is not an uncommon oc-
currence for mercury to show its effects exclusively on the
skin, and apparently to be conveyed  entirely  out  of the
system by copious perspiration; and although it is imprac-
ticable in these cases  to  diffuse its influence  through the 
200                  APPENDIX.
constitution,  or to produce ptyalism, still  there  is  the
Strongest  evidence from  the odour emitted  from the skin
and the change product d on metals in contact with it, that
the mercury  i- passing off ihrough itsemunctories.   There
is sometimes a similar determination  of this  medicine to
the kidneys.   I have recently prescribed for a syphilitic
patient, who, during four or five weeks, took  various prepa-
rations of mercury without any other obvious effect than
to increase the secretion of urine to more than double the
ordinary  quantity.  During this  local determination  the
disease continued  to increase, nor were the salivary glands
at all effected.   There are other  instances  in which  the
whole force of the medicine is exerted on the liver.*
   I have hitherto  spoken of the effects of mercury as they
are exhibited when it is absorbed into the circulating mass,
and diffused through the system by the agency of the blood
vessels.  When administered under various  and different
circumstances, however,  its operation appears to be local,
and to be exerted  chip fly on the nervous system.  When
calomel, for instance, is taken into the stomach in doses of
from  ten  to  fifteen grains, its action  is  principally spent
upon the bowels; and there is no medicine which  under
ordinary circumstances more certainly increases  their pe-
ristaltic motion.   The turpeth mineral operates with still
greater certainty as an emetic.  In these cases the effects
of the medicines  seem to result from an  impression made
directly  on the parts with which  they are  in contact. It
would seem, also, that the effects of calomel on the bow-
els are sometimes two fold ; for when given in large and re-
peated  doses in diseases attended with obstinate constipa-

   * How far the susceptibility to the operation of mercury is increas-
ed or  modified by disease, it is not easy to determine. If. for instance,
a diseased liver is ciirnd  by a mercurial course, is it  rendered  pecu-
liarly  sum-, ptibh  to the action of the medicine by disease, or is it only
operated on id common with the other parts of the system ? 
APPENDIX.
201
lion  of the bowels, it excites a counter irritation through
the whole course of the alimentary canal, which has a pow-
erful arid salutary influence in diverting the  force of the
disease from the part affected.  Such is supposed to be its
operation in the cure of croup.
  But  the local operation of mercury  is not  exclusively
on the parts  with  which  it  comes in contact.  It ope-
rates also by nervous sympathy. In the first place, by irri-
tating  the  mouths  of the  excretory  ducts  which open
into the  intestines, its action appears  to be  sympatheti-
cally extended to their corresponding glands, and thereby
to exert a very important influence on all the secretory or-
gans which are subservient  to the process  of digestion.
Thus  in order to secure suddenly the deobstruent effects of
mercurial medicines  on  these parts,  it is necessary to ad-
minister them uncombined  with  more active  evacuents,
and in small and repeated doses.  If for instance  six  or
 eight  grains of calomel, or of the black oxyde of mercury
 be given, in combination with twice the quantity of jalap,
 the compound will  pass so  rapidly through  the bowels as
 to produce little or no effect on the secretory organs whose
 excretories open upon the surface of the intestines ; but if
 the same quantity of the mercurial preparation be taken in
 doses of two or three grains at intervals of as many hours,
 or if  but half the quantity be taken, and five or six hours
 afterwards a  mill dose of jalap or castor oil, the action of
 the mercury  will have extended to the secretions, and will
 be  manifested by a plentiful discharge of bile and mucus.
    If  mercury be given in very  small  quantities, and  re-
 peated  for a considerable length of time, the same sym-
 pathetic action and  important  changes appear to  be  pro-
 duced on the chylopoetic functions, only varying in degree
 according to the quantity of the medicine administered and
 the duration of its continuance.   There is this difference,
  however; in the latter case, from the gradual operation of 
202                   APPENDIX.
the mercury the secretions are more effectually and perma-
nently  changed, even though  it be not given in  sufficient
quantity to obviously affect the constitution.*
   It  has been shown by the experiments  of M. Bichat,
and  it  is  confirmed by daily observation, that the  secre-
tory  action  of glands  is increased by stimulating   the
mouths  of their excretory ducts :  it is  in  this  way  that
mercurial  preparations usually excite their deobstruent ef-
fects  as  noticed in the foregoing  pages; but they appear
also to have a sympathetic action which  is much  more ex-
tensive.  It is that which Mr. Hunter, in order to illustrate
the spread  of disease,  has  denominated continuous,  and
which Bichat has pointed out as being maintained with pe-
culiar vigour between membranes of the closest similarity of
  * I have  now a patient under my direction whose case may illus-
trate the local and sympathetic action of mercury.  He  is a middle
aged man, and has for many years been the subject of dispepsia so
inveterate,  that be  has tried unsuccessfully almost every means that
promised relief in medicine and regimen. One symptom of bis disease
has been constant irregularity in the functions of the liver,—some-
times its secretion being entirely  suspended; at other* so abundant
that for weeks and even for months, successively, be has been obliged,
when he rose in the morning,  to press with bis hands upon his sides
and eject from the stomach from six to eight ounces of bile to prepare
hire for passing a comfortable day.  Connected with this symptom, has
been, alternately, obstinate  constipation and unnatural  laxity of the
bowels.   No medicines ever  had  the effect to regulate the action of
these organs till accident taught him the use of small doses of calomel;
not as an  alterative or cathartic, for  attempts bad been  made  again
and again to mercurialize his system, and that too by different physi-
cians and with various mercurial medicines;  but by taking one grain
of calomel at bed time,  it has  the effect uniformly to produce one
copious bilious evacuation from the bowels the succeeding day.  This
custom he has followed for months, and he informs me, that if the ca-
lomel be omitted for a single day costiveness ensues.  Although he is
without the  hope of ever enjoying  good health, bis life is rendered
comparatively comfortable by this course. 
APPENDIX.
203
structure.  In this way it seems that mercurial  medicines
when taken into the stomach, extend  their operation to
other and distant portions of the mucous membrane, pro-
ducing an  increased  discharge from the kidneys,  lungs,
skin, &c.  Other medicines frequently exert their influence
by  this sympathetic action, particularly on  the mucous
membranes; astringents are often applied to one portion oi
this membrane, to check a hemorrhage in another portion.
  That  mercurial  medicines  may increase  the mucous
secretions by operating at one time  through the medium
of the circulation, and at another  time by sympathy, ap-
pears obvious from the following considerations.
   When  mercury  operates through the medium  of the
circulation, its action is gradually excited and permanently
continued, and its presence is demonstrable,  in the ex-
cretions ; as for instance, by the amalgam formed with the
 exhalation of the skin with metals.  There L, also in most
 instances a general increased irritability in the system indi-
 cated by  restlessness, tremors, and a frequent pulse.  On
 the contrary, the sympathetic action of mercury is mani-
 fested suddenly.  If it operate on the skin, it is no sooner
 received into the stomach than a  diaphoresis ensues, more
 copious than when the whole system is mercurialized ; but
 it is only continued for a short time, unless the impression
 be renewed by a repetition of the medicine.  It does not
 increase the rapidity of the circulation, or  the irritability
 of the nervous system ; for the sweating has a tendency to
 diminish the force of the heart and arteries,  and further
 than this the constitution is not affected.
    If the foregoing observations be  correct, there is a wide
 difference between the action of mercurial  medicines and
 that  of any other  belonging to the  class of stimulants:
  if such a distinction is in any case allowable, mercury may
  with more propriety be denominated an irritant than a sti- 
204
APPENDIX.
mulant; whether we consider its constitutional  or its local
action, this term is better suited to  express the peculiarity
of its operation.  Its agency in superseding febrile action
is exerted on the heart and arteries as a counter-irritant:
and as an irritant, it quickens the action of the stomach and
bowels, and that of the distant secretory organs sympathe-
tically associated with them.
  Nor does mercury, as has often been contended, possess
the properties of a tonic:—so far from increasing the  tone
of the muscular fibre, or the excitability of the nervous sys-
tem,  it  diminishes both in  a direct  ratio to the irritation
which it excites.  When the constitution is suddenly mer-
curialized, this is obviously  the case, as  appears from  the
attendant debility and  emaciation; and when administered
as an alterative, there is reason to believe  that its immediate
effects are  the same, though the salutary change  wrought
in  the secretory functions, together  with the beneficial ef-
fects  of tonics, which  are  generally administered at  the
same  time,  may more  than  counterbalance  the irritation
and consequent  exhaustion  induced by  the mercury,  and
thus the strength of the patient may increase and his gene-
ral health improve under a  mild mercurial course, though
the action of mercury be opposite to that of atonic.

  In recapitulating the  foregoing remarks, it.appears that
mercury operates as an Irritant, and that its  operation is
either Constitutional, or Local.
  1. When its action is Constitutional, mercury is absorbed
into the circulation ; it  imparts new qualities to the blood,
becomes a  source of irritation to the heart  and arteries,
and through them to  the secretory  and nervous  systems.
Its  action varies in degree, according to  the  mode  of
its administration.
   1.  When mercury is administered at  short  intervals, it
excites a peculiar irritability in the heart  and arteries, and a 
APPENDIX.
205
corresponding irritation in the nervous system ; constituting
 mercurial fever.
   2nd. When administered at longer intervals and in smaller
quantities, it causes little or no perceptible alteration in the
rapidity of the circulation,  or the energy of the nervous  in-
fluence ; but its  operation  is evinced by  an increase  or
change  in some one or all of the secretions.   Such  is  its
operation as an alterative.
   3rd. Sometimes, when administered for the purpose of
mercurializing the constitution,  its action is not equalized
as in the foregoing cases; but from an unaccountable local
predisposition, its influence is principally spent upon one
organ, so that it  has  but a  slight effect upon the constitu-
tion.  In this  case  its operation  may  be  denominated
partial.

   II. The operation of mercury is Local.

   1st.   It acts upon the parts with which  it is in contact:
this action is manifested by an increase of the peristaltic
motion of the intestines, and it is  believed  also to excite
a  counter irritation  on  their surface, and thus divert the
force of disease from a distant part.
   2nd.  By  continuous  sympathy;—its  action  being ex-
tended  from that portion  of the  mucous membrane  on
which it was first exerted to the contiguous glands through
the agency  of their excretory ducts, and also to the more
remote  organs of similar structure, embracing the lungs,
skin, &c.

   Such  appear to be the various  modes in which mercu-
rial medicines operate, and such their diversified action in
removing disease : it remains to inquire how far they are
applicable to the cure of fevers.  A full investigation of this
subject would far exceed the limits prescribed to this essay,
                           Co 
206
APPENDIX.
so that the following desultory remarks will be  principally
on the propriety of administering them  for the  purpose of
exciting constitutional mercurial fever.*
  The mercurial practice in fevers is founded  on  the hy-
pothesis of Mr. Hunter, that  two diseased  actions cannot
exist in the constitution at the same time.   The mercury
is given with a  view to excite a diseased action,  less dan-
  * It is necessary to observe, that the subject has been thus far consi-
dered, on the supposition that the characteristic properties and effects
of mercury are romniou to all its medicinal preparations; but notwith-
standing their general  analogy, each one possesses virtues peculiar to
itself, and under some circumstances is preferable to any other;  and
perhaps the  roost important duty of the practitioner, next to that of
suitably preparing the system for the constitutional operation of mer-
cury, is to select the preparation best adapted to his particular case.
  Where the speedy  effects of the medicine are required, as in the
treatment of febrile diseases, calomel, or the sub-muriate of mercury is
to be preferred; for whether it be administered for the purpose of eva-
cuating the bowels, or of promoting the secretions, or of exciting gene-
ral mercurial action, it is more prompt in its operation  than any other
mercurial remedy.
  The blue pill, or black oxyde of mercury, is the mildest form in use,
and that which  is liable to the fewest objections.  From the difficulty
and labour of preparing it. and the uncertainty of obtaining it properly
prepared from druggists, it is not so commonly  employed as calomel;
but as a deobstruent in diseases of the digestive organs, particularly in
those of children, aud in the  primary forms of syphilis, it is equally
efficient, more mild, and less  hazardous in its operation tbau any other
form of mercury ; nor is it inferior to calomel in ordinary cases as a
cathartic.
   The corrosive sublimate, or  muriate  of mercury, is particu-
larly applicable to the cure of chronic  congestions  and obstinate
cutaneous diseases, lor it appears to pervade more  extensively than
any other preparation, the  extreme  parts of the circulation, and thus
to exert its influence more thoroughly as an alterative.   With regard
to the peculiar virtues of the mercurial  ointment, nothing need  be
added to the  observations in  the text in the  author's excellent direc-
tions for conducting a mercurial course.  See page 60. 
                      APPENDIX.                  207

gerous than the primary fever, yet sufficiently powerful to
supersede it.  That such is sometimes its effect will not be
denied;  it is the unanimous verdict of experience,  that
constitutional mercurial action and idiopathic fever seldom
exist together, and the foregoing is a very plausible expla-
nation of the phenomenon.   It will be perceived, therefore,
that in febrile diseases, and particularly in those of a dan-
gerous or malignant character, this course of treatment pre-
sents high claims, and such as are  not readily rejected.
  He who can persuade himself, that after making every
effort to  mercurialize his febrile  patients, his  professional
duty is fulfilled, and rest satisfied with  the issue, from the
conviction that that being  done, he has given  them  the
fairest means of recovery which the  present state of the
healing art affords, will not  only  avoid the pain of fear, but,
what is infinitely more distressing to most minds, the pain of
thought.
  It is well known, that there are those of high rank in our
profession, who without regard to  circuinstances, have re-
lied almost exclusively and with much complacency, upon
this theory,  in the  treatment  of epidemic fevers.
  If it were  always practicable suddenly to excite mercu-
rial action, the objections,  that  the fever in some  few  in-
stances is not subdued by it, and that  in  others the effects
of the medicine have been known to prove fatal, are not so
formidable but that it would be prudent practice to hazard
them  in  all fevers of dangerous character, rather than to
forego the superior advantages which a mercurial course of
treatment would still offer to any other.  In the first case,
the exceptions are  by no means sufficiently  numerous to
destroy the force of a general rule, and  the second objec-
tion might be principally obviated by the skill and care of
the physician.
  But there are other and  more weighty objections  than
these; for though  we are assured by  those who advocate 
208                  Aivr.xnix.
the use of mercury, and place their chief reliance upon it
in the treatment of febrile diseases, that it is a sovereign
remedy, whenever it excites ptyalism, still it is  to be  re-
collected, that this is by no means a uniform effect,  and
that it is yet a question of dispute, whether more lives have
been prolonged by a timely salivation, than have been lost
by the unsuccessful use  of mercury to  the exclusion of
other means.  To estimate correctly, therefore, the merits
of this practice, and to be able to judge of the extent  to
which it should be carried,  it is necessary  to inquire what
condition of the  system is most favourable to mercurial
action, and how far and  by what artificial means such a
susceptibility can be created.
   I have attempted to show, that mercurial medicines ope.
rate on the constitution through the medium of the blood j
and if this supposition be correct, the susceptibility to their
operation would  naturally be  supposed to depend on the
condition of the heart and arteries.  Such is unquestionably
the fact, and although writers appear to  have  dwelt  less
upon the subject than its importance deserves, yet almost
every one who has recorded his own observation on this sub-
ject,  has given ample proof that where  mercury has failed
to produce its specific, effects, it has most commonly been
in those fevers where there was the greatest derangement
in the circulation.
   Mercurial action then, cannot readily be produced where
there is  much morbid excitement, or a feeble and exhausted
condition of the vascular system; so  that the  indications, most
unfavourable to this action,  are the rapid tense pulse of an
acute inflammatory fever, and the low and languid circulation
 of asthenic disease.
  There is perhaps more truth than  novelty in this position,
but certainly,  it appears  not to have been much  regarded
in practice,  or at least, that too  little stress  has been laid
upon the importance of avoiding the use of mercury  under 
APPENDIX.
209
such  circumstances, till  a preparatory course of means
should be instituted to secure its operation.
   Doctor Chisholm, who values mercurial medicines as
paramount to all others, incidentally mentions their failure
in the low and comatose  state  of fever, and says, that by
increasing the stimulus or tone of the system by bark, the
mercury was enabled to act; and afterwards, he remarks,
" I have a thousand times seen (on  the contrary,) that the
operation of the mercury is forwarded by diminishing the
tone of the system by very liberal bleedings."  By exam-
ining the cases of  Doctor Chisholm and others,  in  which
mercurial action was produced, and comparing them  with
those in which it was unsuccessfully attempted,  the results
will be  found in almost every instance to corroborate the
position which is  laid down above;  the same remark is
applicable to all the various epidemic fevers in which mer-
cury has been  extensively employed.  Whenever the fever
has been characterised by a  high  degree of arterial ex-
citement, mercurial action has never been readily produc-
ed, unless preceded by copious depletion ; and on the other
hand, whenever it has been attended with a feeble and
languid  circulation, if mercury has been efficacious, it has
been  after the energy of the heart and  arteries has been
partially restored by tonics.  It  has been  observed,  that
the object of this paper  is to  deduce general principles,
rather than to  detail facts ; otherwise it would  be easy to
cite authorities in proof of this statement; the observation,
however, of every reader who has been conversant with the
operation of mercurial medicines, will furnish testimony in
support  of it.
  If it be asked, why  less discrimination should have been
exercised in the administration of this than in that of other
medicines, the answer is, because  it has too often  been
regarded  as a specific;—a term which, with science, has
no legitimate relation.  This remark  is illustrated by the 
2'0
APPENDIX.
daily use  of mercury  in  syphilis.  Notwithstanding the
precautionary directions wh>ch books  afford,  how  often
do we see mercury prescribed in thi^ disease (till error is
corrected by experience) without a preparatory course of
treatment,  without auxiliary medicines, and  without re-
strictions in  regimen or diet.  The consequence is the
greatest uncertainty when and how it will operate.   Most
commonly, however, if the patient happen to be of a  ple-
thoric habit,  and if there be much arterial excitement, the
medicine is crowded for weeks  without affecting the con-
stitution, and without benefit to the disease; and when it
ultimately takes possession of the  system, (perhaps  from
the  patient being  driven from his excesses by the  increas-
ing violence of his  disease,) its ravages upon the constitution
are vastly more formidable than those which it was design-
ed to correct.  The frequent opportunities there are for
observing the operation of  mercurial  medicines in  this
disease, serve to exemplify very clearly, the peculiarity of
their action,  and to show  what condition of the system is
most favourable to their constitutional effects ;  and as they
evince most  conclusively,  the  necessity of  regulating the
action of the heart and arteries, in order to secure a salu-
tary mercurial action in syphilis, it is the strongest evidence
that it is still more necessary, that it should  be  done  in the
wide range  of  arterial action exhibited in various febrile
diseases.
   It has been observed by my  friend Doctor Smith, (see
note, page 25.) that the system is probably most susceptible
of mercurial action in perfect health, but it  appears to me,
 that when  moderate  depletion is  premised,  either  with
 the lancet  or  by cathartics, according to the tempera-
 ment and habit of the patient,  so  as to lessen the natural
 force of the circulation,  and to open pretty  freely  the
 emunctories of the skin, mercury operates more speedily
 and more mildly  than it  does under  any  other circum- 
APPENDIX.                 211
stances.  Cutaneous perspiration has such an intimate con-
nection with, and dependence on the circulation, that it is
perhaps the best criterion of the susceptibility of the sys-
tem to mercurial  action.  I have never known ptyalism
produced in fever where  the skin was perpetually dry, and
even in diseases unattended with febrile excitement, have
generally been able to  form a correct prognosis of the
effects of mercury from the state of this secretion.  Hence
th<' importance of combining antimonial preparations with
calomel : their effects in diminishing the force of the heart
and arteries are  the same, though milder in  degree, as
those of blood letting; and  in  febrile diseases, they may
sometimes be safely and  advantageously employed lor that
purpose, when the  abstraction  of blood would  be dan-
gerous.
   Although  in the foregoing observations fever has been
represented as being always accompanied with  a morbid
condition of the heart and arteries, and mercurial action as
incompatible with the extremes of such a condition of the
blood-vessels, still there are unquestionably some febrile
diseases, in the treatment of which, mercury is clearly indi-
cated,  and during which its constitutional  effects may be
readily  excited.    If in  designating  diseases,  nosologists
have not yet been able to draw the lines of demarkation so
distinctly,  that a remedy so potent as the one in question
can be  made uniformly applicable to a name; there is,
nevertheless, sufficient consistency in  the  association of
febrile  symptoms, to enable a careful observer to avoid
empiricism.   Dr. Robert Jackson, the most experienced
and accurate clinical observer of the age, sums  up the
result of his observations on this subject in the  following
general remarks.
   " I think I am  warranted from an unprejudiced review
of the whole" [subject of the mercurial practice in fevers,]
 « to confide in  the following conclusion, viz.  1st. Thar 
212                  APPENDIX.
where the disease is of the intermittent or remittent type.
the intermission or remissions distinct, the skin  soft,  thin.
warm and perspirable,  the pulse free and expansible; in
short, where the symptoms are  of a secondary degree of
violence, the salivary glands are for the most part  soon
affected by mercury,  whether given internally or applied
externally by friction ;  and that where  the salivary glands
are affected, and a free and copious  salivation established,
the  disease ordinarily abates  in force,  even  sometimes
ceases altogether.   The rule is general, but not absolute.
Instances occur, and not unfrequently, where the paroxysms
return after salivation is fully  established ; even some are
recorded, where death has not been  averted  though the
reputed sign of safety was present.  2nd. Where fever is
of the  continued kind, whether endemic, epidemic, or con-
tagious, the symptoms violent,  the heat ardent,  the  skin
thick and compacted, dry and torpid,  as connected with
excessive excitement  and  precipitate action,  or thick,
greasy, damp, and  inanimate, as connected with  constric-
tion and diminished energy of the capillary system,  calo-
mel is sometimes given internally in  great extent, mercu-
rial ointment being at  the same time rubbed upon the sur-
face in great quantity, without the salivary glands being
in  any degree affected by it; in other cases the gums be-
come  spongy and  livid,  the  breath emits the mercurial
foetor, but no increase  takes place in the salivary secretion,
and no change is effected on the course of the disease,
which proceeds  uninterruptedly to a  fatal  or favourable
termination, independently of saturation of the system with
mercury.   The conditions now described are extremes;
they comprehend what is most important  relative to  the
effects of mercury  as a remedy  for the-cure of recent
fevers.  3rd. In fevers of slow  movement  and protracted
duration, more particularly in such as are complicated with
 congestion in the more important organs within the abdo- 
APPENDIX.
213
minal cavity, the  internal  exhibition of mercury and the
external application of it by friction,  carried to the  extent
of producing more or less of ptyalism,  has appeared  to
myself to be a  remedy of value ; in fact, to be often the
only remedy, especially as aided by medicated diets,  by
bathing,  frictions, the occasional  abstraction of blood  in
small quantity, with exercise by  gestation,  on which any
dependance can be placed for effecting a cure or even for
prolonging of life  ; it appears, as conducted in this manner,
to operate changes on diseased organization, or to lay a
foundation on which such changes as lead to health may
be effectually operated by other means."—Jackson on Fe-
vers, vol.  i page  284-5, 1820.
   In connection  with the  foregoing remarks,  it ought  to
be recollected, that in the low latitudes of the West India
islands, the character of disease more frequently indicates
the use of mercury, and the constitution is, ceteris paribus,
more susceptible  to its operation than in this climate.
   Our  intermittent fevers are seldom so obstinate as not
to yield readily to milder remedies; and, excepting in those
cases, which from repeated  attacks  or  long continuance
are complicated  with local  congestion,  mercury is very
properly prohibited.
   In typhus, it is at least questionable whether mercurial
salivation ought  ever to  be  attempted ;—indeed, in most
instances, until by the natural course of the  disease, or the
aid of other remedies,  the violence  of the  fever  is sub-
dued, it is found impracticable to effect it.  There is some-
times during the  progress of this form of fever, a deranged
state of the secretions which may be corrected by small
dose? of calomel, or the blue pill. I have observed them to
effect a favourable change when the appearance of the tongue
was peculiarly clean, dry, smooth, and shining,—a symptom
which I have supposed to be owing to a suspension of the
secretion  of the  mucous membrane of  the alimentary
                       D d 
 214                  ^PPENDIX.

 canal.  I  have often  seen mercury administered where
 this symptom existed, with a view to excite  ptyalism, but
 have never known it to be produced in a single instance.
   In continued fevers, both of an inflammatory and typhus
 character, there is danger in attempting to excite mercu-
 rial action, from the uncertainty there is when and to what
 extent it  will be produced.  While there continues much
 morbid derangement in the action of the heart and  arte-
 ries, there is no reason to expect that the  mercury will
 be absorbed  into the circulation; and if it be exhibited for
 that  purpose, till by the progress  of the disease  and the
 agency of other means, the system is rendered susceptible
 to its operation, it may be accumulated in such quantity in
 the alimentary canal, (if not carried off by catharsis,) that
 when it once takes effect, the violence of its action  will
 be more  to  be  dreaded  than  the  consequences of the
 fever.
   Such is not unfrequently the  result where mercury is
 exhibited  in  large  quantities to  children labouring under
 inflammatory disease.   From the rapidity of their circula-
 tion, young children, ordinarily, are not very susceptible of
 mercurial action, and they  are still less so when excited by
 fever; but there has been instances where the most alarm-
 ing  ptyalism  and ulceration have ensued after the  crisis of
 the fever.
   As a general rule, therefore, it is believed that mercurial
 excitement should only be attempted in fevers of a remit-
 tant form, and in those which  are  symptomatic  of local
 inflammation; and, in such cases of these only, as are  pro-
 tracted or dangerous after liberal depletion.   Chronic con-
gestions may  exist as the sequel  of phlegmasia! fever, and
it may require the use  of mercury to remove them, but
in  this state they are not necessarily identified with febrile
disease.
  With remittent fever, there is connected a morbid  con- 
APPENDIX.
215
 dition of the bilious secretion,  and not unfrequently some
 local inflammation;—symptoms, which, independent of -thfe
 attendant fever, indicate  the use  of mercury;  and  when
 the circulation  is  moderated, and  the secretions freely
 opened by the necessary evacuants, there is generally suf-
 ficient remission  of the fever to favour the action of the
 medicine.—Under  such circumstances  mercurial  action
 may be  easily and  advantageously excited.
   With  regard to  the specific effects of mercury in dis-
 eases belonging to  the  order phlegmasia, there can be no
 doubt that it is sometimes of great service after the ardour of
 the fever is diminished by copious depletion, and  particu-
 larly, after the  local inflammation assumes a pnssive cha-
 racter; but it is of no  small importance  to  recollect,
 that there is sometimes a quick and rapid pulse in this
 stage of these diseases, which is unfavourable to the action
 of mercury, and which is rather increased than dimioished
 by the  lancet.  This state of the circulation seems to de-
 pend on the irritation of the vascular system, and is not
 unlike that which I  have attempted to  describe occasioned
 by the action of  mercury.  It  is during  this condition  of
 the  circulation, that so much  benefit is derived from the
 use of antimonial  medicines, ofcholchicum, of digitalis, and
 of opium ; and hence the correctness of the observation of
 Chene, that " If it be wished to place the constitution sud-
 denly under the influence of mercury, there are but two
 means, apparently  opposite, namely, blood-letting and
 opium."   It cannot be supposed that these preparatory
 remedies are alike applicable to the same state of the sys-
 tem, and therefore that they may be employed indifferently,
 but if it  be true, that any considerable deviation from a
healthy action of  the blood vessels,  whatever may  be the
cause, is unfavourable to  the operation of mercury, it is
clear that opposite means may be adapted to the same end.
  The contradictory statements that have, been  made  as 
216                APPENDIX.
to the effects of mercury, and the narcotics above  men-
tioned, in phlegmasial diseases, can only be reconciled on
the supposition, that writers have not been sufficiently care-
ful  to discriminate  between the rapid circulation which is
kept up by extreme irritability of the heart and arteries,
and which is rather increased than lessened by blood-letting;
and the quick and corded pulse which is characteristic of
those diseases before depletion. In one instance the action
of  the  blood-vessels is moderated  by the lancet, in the
other by nauseating doses or by narcotics.   The ageqcy of
some one or  all of these means may be necessary to pre-
pare  the  system for mercurial action, but judgment  and
discrimination are  necessary to adapt them suitably to the
 nature of the case.
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