OBSERVATIONS ON THE UTILITY AND ADMINISTRATION AiP!?iB(B^miTO MsiDa©asm^ SEVERAL DISEASES. BY JAMES HAMILTON, M. D. Fellow of the Royal College of Physicians, of the Royal Society of Edinburgh, Senior Physician to the Royal Infitmary of that city, and Corresponding Member of the Medical Lyceum of Philadelphia. SECOND AMERICAN E&ITfmf-- --- I Vt 0// A / PHILADELPHIA; i Qty Q T H * J TAMES WEBSTER, 24 SOUTH EIGHTH-STREET^ '~T™'; William Brown, Printer. 1823. QV TO JAMES RUSSELL, Esq. * PROFESSOR 0 -.INICaL SURGERY IN THE UNIVERSITY OF ' EDINBURGH. v Dear Sir, If the following Observations had been of that importance in .^pect of science, as to have made a particular Dedication of them necessary, or proper; and if I had been to select a patron of distinguished literary endowments, and of extensive and correct professional acquirements, there is no one who would have sooner occurred to me than yourself. Sentiments, however, prompting an address less formal, and therefore, I trust, to you not less agreeable, induce me, in a man- ner more familiar and more sincere, to acknowledge my obliga- tions to you for many instances of your private friendship; and to thank you for the encouragement you gave me on the present oc- casion, without which, I probably neither would have under- taken, nor have accomplished this little work. I am, Dear Sir, With much regard, Your faithful and obedient Servant, JAMES HAMILTON. EDINBURGH, -> 1st November, 1805.5 PREFACE TO THE FIRST EDITION. As the doctrine which I maintain, with respect to the exhibition of purgative medicines, may have the appearance of novelty, in order to obviate any preju- dice, it is incumbent on me to state the rise and pro- gress of the opinions which I entertain upon this sub- ject, and to produce the facts on which the practice I recommend is founded. With this view, I hope it will not be thought pre- sumptuous, to give some account of the opportunities which I have enjoyed for collecting accurate and ex- tensive information, in the different diseases of which I treat in the following Observations. I have occupied places of professional trust and re- sponsibility in Edinburgh for upwards of thirty years. During the whole of this period, I have dicharged the duties of Physician to the Royal Infirmary, to George Heriot's Hospital, and to the Merchants and Trades Hospitals of this city. In the midst of these constant, and sometimes labo- VI PREFACE. rious occupations, in which I have been engaged, my attention was, many years ago, attracted to the purga- tive effect of medicines given in Typhus fever. The facts which then presented themselves to my notice, in- duced me to repeat these medicines again and again; till, by slow advances, I at last acquired confidence in the practice. Many opportunities have since occurred to me of confirming these observations, which, in my apprehension, clearly establish the safety and utility of giving purgative medicines in the course of Typhus fever, under the limitations which I point out. I was afterwards disposed to judge favourably of the same practice in Scarlatina; and the utility of it in this disease has been confirmed by much experience. Thus my views respecting the use of purgative me- dicines became more and more extended; and, in pro- cess of time, I employed them with a freedom not usual, but with manifest advantage, in several other diseases. My own experience of the utility of this practice is the circumstance which encourages me to pursue it with steadiness.' But to inspire others with the same degree of confidence, it will be requisite to adduce proofs which have satisfied me of its superiority to that in c*ommon use. The number, the authenticity, and the apposite ap- plication of the cases inserted in the Appendix, will I trust, prove sufficient to establish the soundness of the principles upon which I proceed, and to satisfy PREFACE. Vll the most sceptical. Many of these cases are those of patients who have been under my own care in the In- firmary: and they are transcribed from the records of that institution, by the permission of the Managers. To show the consequence and authenticity of these cases, I shall mention some particulars relative to the arrangement of medical practice in the Hospital. The University of Edinburgh had already attained a high and deserved reputation as a school of medi- cine, when the Royal Infirmary was opened in the year 1741. It was soon perceived, that the Univer- sity and the Infirmary might be made to afford mutual and valuable aid to one another. The medical educa- tion, it was evident, would be rendered more complete, by giving the students of the University access to the Infirmary, where they might learn the practical part of their profession; while the funds of the Hospital would be augmented by the fees which the students would pay for the liberty thus granted to them to visit the patients, and observe the practice as conduct- ed in it. Accordingly, arrangements respecting the detail of practice in the Hospital, suited to these views, were made; which, while they secured to the patients be- nefits superior, I believe, to what are experienced in most similar institutions, at the same time afforded to the medical student opportunities of acquiring the prac- tical knowledge of his profession, seldom to be found in other hospitals. VI11 PREFACE. By the regulations of the Managers, the Physicians of the Royal Infirmary give daily attendance, at a cer- tain hour; take the full charge of their respective pa- tients, and interpose directly in every circumstance re- lative to the conduct of their cure. The two Physicians named by the Managers have an equal share of duty, ajid divide the patients equally between them. i A clerk is attached to each Physician. He is com- monly a young Gentleman who is advanced in his stu- dies. He resides in the Hospital, and has a general superintendance of the patients who are under the charge of the Physician with whom he is connected. Besides other duties, it is his business to prepare a writ- ten account of the symptoms of those patients who fall under the care of the Physician whose clerk he is. He inserts this account in the journal-book, and reads it to the Physician at the bed-side of the patient, on the following daily visit. The Physician either admits this account simply, or makes additions and alterations, as he may think proper. Regular reports of the subsequent state of the symp- toms, of the remedies prescribed, and of the effects of these, are given daily, or as often as the chronic na- ture of the case may make them necessary. These reports are the result of the accounts which the pa- tients give of themselves, of the accounts which are re- ceived from the nurses, or of both together; they are PREFACE. IX dictated by the Physician to his clerk, who at the time enters them into the journal-book. All these proceedings take place in public, in the presence, and in the hearing, of a number of young Gentlemen, who attend the Hospital, many of whom are competent judges of what is going forward. Thus, the Physician must include, in his reports, all the circumstances, as they arise in particular cases; circumstances over which he has no control, and which must inevitably direct his practice. Further, the Physician of the Royal Infirmary, in consequence of his attendance every day, is enabled to follow out his practice with peculiar precision and accuracy; to do which he is also stimulated by the interest which he cannot but take in his patients, not unfrequently friendless strangers; and, by the unavoidable publicity of his whole procedure respecting them, which places him often in delicate and trying situations. Cases then of this description, which, in their pro- gress, cannot be perverted to particular purposes, and which cannot afterwards be altered, by any retrospec- tive emendation of the practitioner, possess an authen- ticity peculiar to themselves; and, in the establishing of medical facts, may be produced as an authority, that cannot be controverted. Indeed, I esteem myself fortunate in having documents of this kind to adduce, in support of a practice which may be thought to re- quire all the confirmation which the most incontrover- tible evidence can afford. These cases, inserted in 6 X PREFACE. the different numbers of the Appendix, are dated from the Royal Infirmary. Again, in further support of the exhibition of purga tives, in the diseases of which I treat, I insert, in the proper numbers of the Appendix, histories of cases from my private practice;—and although these are not supported by the same public testimony as those which are extracted from the records of the Hospital, yet I trust they will be received with all the credit due to cases which rest upon the authority of any individual practitioner The favour of my friends, who have had the good- ness to oblige me with communications from their pri- vate practice, likewise enables me to give farther evi- dence of the utility of the plan which I recommend. This is the more gratifying to me, as it thus appears, that gentlemen of high professional respectability ap- prove and adopt, in the instances to which their com- munications refer, the practice which I have endea- voured to introduce. Before I conclude these preliminary remarks, I beg leave to observe, that I do not willingly obtrude my- self on the public, in the character of an author; but different reasons concur to overcome my backward- ness to do so, and even to render a full exposition of my practice a measure of'prudence and of self-de- fence. A number of intelligent, well informed young gentlemen, who attend the Hospital, have become converts to the free exhibition of purgative medicines PREFACE. XI which they have seen me employ with so much advan- tage. By this means, the peculiarities of my practice here have passed silently into the world, unexplained and unsupported by the proofs and illustrations which it was in my power to produce; they have been par- tially noticed in one periodical publication; and made the subject of hasty and mistaken criticism in another. Dreading, therefore, that under these disadvantageous circumstances the practice might be prejudged, and of course neglected, I have endeavoured to procure for it a fair and unprejudiced hearing, by placing it before the public, in my own words. To the public decision I will submit, with deference and respect; at the same time, I rely with confidence on its impartiality; and trust, that no person of cha- racter will condemn the practice, which I now recom- mend, till after repeated trials, agreeably to the plan which I have myself observed. Edinburgh, 1st Nov. 1805. PREFACE TO THE FOURTH EDITION. My acknowledgments are equally due to the profes- sion and to the public, for their candid reception of the following work. It has now been submitted to their consideration for six years; and if I am not misinform- ed, the practice which it recommends still continues to rise in general estimation. I have thus been gratified with the thoughts of having contributed something to the improvement of medicine, and to the health and happiness of mankind. At the same time, it is my duty to state, that seve- ral instances have come to my knowledge, in regard to which the failure of purgative medicines has been as- cribed to some fallacy or some insufficiency of the principle on which they had been administered. These instances I have considered with all the care and patience which they seemed to deserve; and have found reason to believe, that, with respect to them, there existed either some misconception of the princi- ple itself, or some want of attention to those circum- stances, by which I have repeatedly said that the ap- plication of it ought to be regulated. A few additional PREFACE. Xlll explanations on my part may not, therefore, be alto- gether unnecessary. By the misconception to which I have alluded, I am understood to recommend full purging: and this erroneous conclusion appears to have originated in the very common associatioa established in the mind be- tween that effect and the exhibition of purgative me- dicines; while some of my early remarks on the sub- ject have not been duly weighed. For when speak- ing of the distinction that is usually made between purgative and laxative medicines, and objecting to it as not quite correct, I say, page 14, " As this distinction, however, has acquired the sanction of ages, I might have passed it in silence, had it not been necessary for me to notice it; as, from experience of their superior usefulness, I employ almost solely what are under- stood to be purgative medicines, while I avoid their full effect of purging/' And again, page 14, "This explanation obviates one objection, not unfrequently made to the employment of purgative medicines, name- ly, that they are apt to reduce farther the strength of a patient already too weak. Purging will undoubtedly debilitate the body, by causing a flow of fluids greater than usual into the cavity of the intestines, and proba- bly by hurrying off the chyle, and precluding its pas- sage into the system. It is in this manner useful and advantageous in some diseases. This effect, however, is not required in the diseases which are the subject of the following observations, in which the sole intention XIV PREFACE. is to evacuate the contents of the bowels, which, being out of the course of the circulation, are in a manner already extraneous to the body. Purgative medicines, given under this condition, will not induce debility; on the contrary, in the state of disease of which I treat, the bowels, being excited to propel their contents, their functions are restored; appetite and digestion are im- proved; and the patient, so far from being weakened, is nourished, supported, and strengthened." Thus I institute a course of purgative medicines, to effect the salutary purpose of restoring and supporting regularity in the alvine evacuation. A course of purging would defeat this end: in fact it would quickly exhaust and destroy the patient. The principle, then, on which I steadily proceed, is to obviate constipation, and, at the same time, to avoid purging. Many passages in my book bear directly on this point, pages 24, 33, 34, 31, 50, 70; the general scope of my observations attests its importance; and the detail of cases in the Appendix shows with what scrupulous uniformity I adhere to it. But if a right understanding of the principle be ne- cessary for conducting the practice, the inspection of the alvine evacuations, and the guarded prosecution of a course of purgative medicines, are not less necessary to insure its ultimate success. Every one knows, that purgative medicines act ac- cording to peculiarities of constitution, and the nature and progress of disease. Hence the inspection of the PREFACE. XV feces is requisite to regulate the strength of subsequent doses of the medicine, and the frequency with which they ought to be repeated, in order that the desired effect may be obtained, while purging is carefully avoided. Whether these medicines operate in the chronic dis- eases, of which I treat, by unloading or by stimulating the bowels, a course of them is necessary to the attain- ment of either effect; and it is equally necessary to per- severe in this course till the cure is complete; other- wise the disease, subdued only, in part, may soon re- appear, to the mortification of the practitioner, and to the distress and danger of the patient. From these considerations arise the earnestness and anxiety with which I press the circumstances I have now mentioned upon the notice of the reader; and the final remarks which I have made concerning them at pages 120, 121, show how important I conceive them to be in guiding the course of practice. In my opi- nion, indeed, it is chiefly through them that safety may be combined with success fn the administration of pur- gative medicines. These quotations, and the passages to which I have referred, explain and illustrate the principle of my practice, and the rules by which it is guided, in so dis- tinct and precise a manner, that I was willing to hope they could not easily have been mistaken. It would appear, however, that they have not always been read and considered with the attention which the novelty, of XVI PREFACE. my views with regard to some diseases, and the suc- cess of my mode of treating them, might have claimed. Against inadvertencies of this kind, of which, on the appearance of a new work, I was not unaware, I la- boured to guard the reader in the last paragraph of the Preface to the first edition. " To the public deci- sion I will submit, with deference and respect; at the same time, I rely with confidence on its impartiality; and trust, that no person of character will condemn the practice, which I now recommend, till after repeated trials, agreeably to the plan which I have myself ob- served." Edinburgh, March, 1811. PREFACE. XVII On revising the following Work, previous to its be- ing sent to the press for the fifth edition, some altera- tions, more or less important, and a few additions, ap- peared to me to be proper. I give an extract from Mr. Price's letter, bearing on the subject to which it relates, in the twelfth chapter, instead of inserting it entire, as formerly, in the Ap- pendix. A short account of an haemorrhagy, which, so far as I know, has not been noticed hitherto, is subjoined to the eighth chapter. At the 128th page of the Appendix, I insert a case of Chorea, that of James Palmer; my reasons for doing so are annexed to the case. Two cases of Tetanus find place for the first time, that of John Lapsley at page 148, and that of Andrew Warrender at page 153, of the Appendix. With the former I submit a few remarks, of which, as well as of the case itself, the reader will form his own judgment. EDINBURGH, 22, St. Andrew's Square, May, 1815. e CONTENTS. Page CHAP. I. Observations on Impediments to the Improvement of Medi- cine, --.......- 1 II. Observations on the Functions of the Stomach and Intestines, 6 III. General Observations on Purgative Medicines, - . 12 iV. Observations on the utility and Administration of Purgative Medicines in Typhus Fever, ..... 17 V. On Purgative Medicines in Scarlatina, ... 28 On Purgative Medicines in Cynanche Maligna, - - 36 VI. On Purgative Medicines in the Marasmus which appears in Childhood and early youth, .....44 VII. On Purgative Medicines in Chlorosis, ... 54 VIII. On Purgative Medicines in Vomiting o'f Blood, - - 64 IX. On Purgative Medicines in Hysteria, ... 71 X. On Purgative Medicines in Chorea Sancti Viti, or St. Vitus's Dance, -._......81 Xf. On Purgative Medicines in Tetanus, .... 96 VII. Conclusion, - - - - - . . . 109 APPENDIX. \PPENDIX 1. ........ Tabula Prima, exponit medicaminum titulos priores et poste- riores, - - - - - Tabula Secunda, exponit medicaminum titulos posteriores et priores,..... Tabula Tertia exhibet formulas medicaminum compositorum, quorum mentio fit in hisce paginis, et quae Pharmacopoeia: Nosocomii Regii Edinensis, propria sunt, II. TYPHUS, - .... Sect. I. Cases of Patients who laboured under Typhus Fever CONTESTS. xix I'age Sect. II. Sentiments of Authors on the use of Purgative Me- dicines in Fever, -.......30 ————— of Lommius,......ib. -----------of Glass,.......31 -----------of Langrish,......32 -----------of Cullen, .....v 33 -----------of Huxham,......ib. -----------of Currie, -.....34 U'PENDIX III. SCARLATINA,..... 36 Sect. I. Cases of Patients who laboured under Scarlatina, ib. Sect. II. Narrative of Scarlatina, as it affected the children in George Heriot's Hospital in Autumn 1804, - - 45 Sect. III. Testimony of Authors who are favourable to the use of Purgative Medicines in Scarlatina, ... 49 -----------of Cullen, - - - - - - ib. -----------of Rush, - .....50 -----------of Sims,.......ib. -----------of Blackburne, .....ib. IV. MARASMUS, ........52 Sect. I. Cases of Patients who laboured under Marasmus, - ib. Sect. II. Case of Euphemia Winter, from the Trades Maiden Hospital, - -....... - 61 Sect. III. Communications on the Treatment of Marasmus by Purgative Medicines, - - - - - - 62 Case of H. T. by Mr. Stewart, Surgeon at Gogar, - - ib. Letter from Mr. James Russell, Surgeon, Edinburgh, to the Author,.......- - 64 Letter from Mr. Benjamin Bell to the Author, - - 65 V. CHLOROSIS,.........69 Cases of Patients who laboured under Chlorosis, - - ib. VI. VOMITING OF BLOOD, - - • - - - 74 Cases of Patients.who laboured under Vomiting of Blood, ib. VII. HYSTERIA,.......- _- 82 Sect. I. Cases of Patients who laboured under Hysteria, - ib. Sect. II. Letter from Mr. James Law, Surgeon in Edinburgh, addressed to the Author,......88 VIII. CHOREA, 90 Sect. I. Cases of Patients who laboured under Chorea, - ib. IX. TETANUS, -......- * - 138 Sect. I. Cases of Patients who laboured under Tetanus, - ib. Sect. II. Letter from Mr. John Burns, Surgeon in Glasgow, to +he Author, ' - - - - - ' " " ^^:i XX CONTENTS. Page APPENDIX X. ANOMALOUS DISEASES, .... 158 Case of a Boy, in Heriot's Hospital, ... - ib. —■ — a Young Woman, ..... 160 Substance of the Narrative of her own case, transmitted by a Lady to the Author,.......161 Letter from Mr. James Anderson, Surgeon, Edinburgh, to the Author, ........I63 Case of Constipation, transmitted by Dr. King, of Glasgow, to the Author,........I64 Conclusion, ... . - - - - - 167 OBSERVATIONS UTILITY AND ADMINISTRATION 05 PURGATIVE MEDICINES. CHAP. I. OBSERVATIONS ON IMPEDIMENTS TO THE IMPROVEMENT OF MEDICINE. JTHYSICIANS are guided in their more early pro- fessional pursuits, by the doctrines which they have im- bibed in the schools, by the sentiments of authors whom they have chiefly consulted, and by the example of those whose practice they have proposed to follow. Subse- quent information, however, derived from new disco- veries and from personal intercourse with the sick, inclines them not unfrequently to make some changes, sooner or later, in those speculative opinions, and in that course of practice, which they may have at first adopted. It has been remarked, on this account, that medicine is fluctuating and uncertain, but, in my opinion, with no 0 OBSERVATIONS ON IMPEDIMENTS good reason. The innovations which are introduced are unavoidable; they result from the situation in which practitioners are placed; and indicate neither want of steadiness on their part, nor of certainty in the profes- sion. They always tend to improve the science, when they originate in good sense and attentive observation. To represent, therefore, the practice of medicine as variable, in consequence of changes inseparable from its progressive state, is to take an unfair and a partial view of the case. On the same ground, and with equal justice, all the principal employments of life are liable to a similar objection. The improvement of medicine has indeed been slow, when compared with that of some of the other arts and sciences. The extent and intricacy of the subject will in part account for this circumstance: while, at the same time, it must be evident, that its progress will be influenced by the character, the genius, and the learn- ing of its cultivators, and by the spirit of prevailing philosophies, always interwoven with reasoning in me- dicine. The symptoms and modifications of diseases, which unfold themselves gradually to the attentive observer, are so various, that he often finds it difficult to express them in words, and still more to convey the ideas he has formed of their intricate relations.' Were this task however more easily accomplished, yet every one has neither the leisure nor the opportunity necessary for committing his observations to writing. This kind of information, therefore, which constitutes, in a great neasure, what is understood to be experience in medi- cine, too often dies with the individual, and is lost to the accumulative stock of medical knowledge. TO THE IMPROVEMENT OF MEDICINE. 3 Practitioners, during a long period, forged shackles for themselves, by placing too implicit a confidence in the opinions of the ancient physicians. They not only respected these opinions, but defended them as the standards of medical .truth, and considered them as the only sure and safe guides. Satisfied with the practice which they had found sanctioned by men of eminence, nothing, they thought, was to be expected, or inquired for beyond the pale of their authority. Thus they had never presumed to think or reason for themselves with that free and unfettered mind which they ought to have preserved. Nay, even we, in our day, are still dispos- ed to bend with too humble deference to the fathers of physic. A prepossession in favour of early speculations re- presses that freedom of inquiry so necessary to the im- provement of medicine. Under this prepossession, practitioners do not always see what is passing before their eyes in a just and proper light. They are thus apt to be deceived themselves, and to give to their ob servations a shade or colouring which deceives others. Physicians, in conducting the cure of painful and dangerous diseases, have been led, by an anxiety cre- ditable to their feelings, to. the promiscuous employment of different active remedies, or to the adoption of them in so quick a succession, as to make it frequently un- certain to which of these remedies, changes which may take place in the course of the ailment are to be refer- red. Much of the slow progress of medical improve ment.may be attributed to this circumstance. The history of medicine, also, clearly shows, that theory or reasoning has contributed in no small degree to impede its progress. Physicians have at all times i OBSERVATIONS ON IMPEDIMENTS indulged the propensity, natural to man, to form hypo- theses, and have raised up systems, on which they have sought to repose in the midst of doubt and difficulty. They have been unsuccessful, however, in establishing sound theory, from their not being fully acquainted with the structure of the organs of the human body, and from not possessing correct and enlarged views of their functions. Hence have arisen, in the forms of in- dependent systems, the humoral or chemical, the me- chanical, and nervous pathologies. Each of these sys- tems, considered separately, affords many just and im- portant conclusions, which do not however serve as a basis for general theory. Again, a strong passion for distinction and fame in the professors of medicine themselves, has prevented the happy combination of these systems, and counter- acted the utility which might have been thence derived. The glory of establishing a new theory, and of consti- tuting a new era in medicine, has induced the leaders of each succeeding sect to attempt the overthrow of the systems of their predecessors, in order that their own particular doctrines might be more firmly established, and shine with unrivalled lustre. It may also be observed, that dogmatists, in forming their systems, have sometimes assumed data, which, unsupported by facts and experience, rest on a train of conjectural reasoning. Systems of this description have checked rational inquiry; have brought into dis- credit useful practice, because discordant with the prin- ciples on which they are founded; and, leading us to reject the most obvious explanation of important facts, have on many occasions introduced much obscure lan- guage and vague reasoning into medical doctrines. TO THE IMPROVEMENT OF MEDICINE. 5 from which, it is to be feared, and therefore to be re- gretted, that erroneous practical conclusions have been drawn. I do not dwell with pleasure upon these causes, which [ apprehend have retarded the progress of medi- cine. I venerate the memory of those of our predeces- sors, whose labours have obtained for the healing art an important rank in the estimation of mankind. As they have occasionally failed, however, in promoting the advancement of medicine, we ought to take a lesson from their failure, and avoid the circumstances which have occasioned it. We should not tamely acquiesce in opinions, how respectable soever from age and autho- rity. We should receive, with laudable distrust, state- ments of facts proposed by others, till such time as we ascertain their accuracy. We should restrain within. due bounds an overweening self-confidence, and scru- pulously examine whatever may have appeared to us of importance in theory or practice, before we either adopt it ourselves, or bring it under the review of others. And, above all, we ought carefully to shun hasty conclusions and generalizations, which proceed only upon reasoning from matter of opinion. Be it our busi- ness, by a circumspect induction from facts, to establish sound principles, which will lead to the discovery of other facts, and these again to the introduction of more general doctrines, or a comprehensive and connected theory of medicine. This is safe dogmatism ; by it we will acquire useful knowledge more quickly, and be enabled to combine and arrange its different parts with greater facility and precision, than by means of that meagre empiricism, so much vaunted at one time, but which, I believe, never did, and never can exist, in- dependent of theory or reasoning, however incorrect D a CHAP. II. OBSERVATIONS ON THE FUNCTIONS OF THE STOMACH ANlt INTESTINES. The nutritious part of our food is prepared and se- parated.by the changes which it undergoes in the mouth. oesophagus, stomach, and intestines. The process of digestion begins in the stomach, and, with the assist- ance of fluids secreted from the liver, spleen, and pan- creas, is perfect in the smaller intestines ; while the lacteal vessels, opening on their internal surface, absorb and convey the nutrimental fluid into the circulating system. The residue of the food, which is not adapted to afford nourishment, constitutes part of the fecal evacuation which is made directly from the intestinal canal. It is probable that this fecal residue is discharged into the more capacious colon, where the ilium enters it by a lateral opening, so contrived, that the contents of the colon cannot be returned. This circumstance makes a distinction between the functions of the smaller and larger intestines, which is not commonly noticed. The former complete the preparation of the nourishment and afford opportunity of its being absorbed; while the latter receive and detain the fecal part till after it has accumulated, and perhaps undergone certain changes when it is voided in a given quantity, and at stated in- tervals. Besides, the intestines exhale and throw off fluids OBSERVATIONS ON THE FUNCTIONS, &C. 7 which have become noxious in consequence of changes which they undergo in the body. The intestinal canal, therefore, serves the double purpose of repairing waste and of preventing decay. In this latter function, which I am solely to consider, the intestines co-operate with the other excretory organs, the skin, the lungs, and kid- ney. All these organs have, in respect of this their common relation to the system, a dependence upon one another, and any of them will compensate, to a certain extent, and for a limited time, the interrupted action of the others. Nevertheless, their full activity is neces- sary to the enjoyment of perfect health, and the conti- nuance of life; and the regularity of the intestinal eva- cuation is connected, in a particular manner, with the well-being and healthy state of the stomach and intes- tines themselves. The urine and perspirable matter pass off immediately after being secreted, and do not load the organs which separate them The unnatural detention of these excretions has indeed a more or less remote, and often fatal, effect upon the general system; but the skin and the kidney remain uninjured. It is otherwise with the intestines: secluded from that com- munication with the atmosphere by which the perspira- ble matter is carried off, and unprovided with an ap- pendage resembling the urinary bladder connected with the kidneys, they are the reservoirs of fecal matter as it is poured out, which they retain till the accustomed pe- riod of evacuation comes round. Different circumstances are apt to induce irregularity in this evacuation; these, together with the facility with which the larger intes- tines admit of distention without uneasiness being ex- cited, give frequent opportunity for a progressive accu- mulation of feces, whence arise interrupted action of 8 OBSERVATIONS ON THE FUNCTIONS the stomach and smaller intestines, and consequent dangerous and fatal ailments. In infancy, the alvine evacuation is frequent, and the feces are abundant and fluid. In mature years, the body is generally moved once in twenty-four hours; and the feces, although soft, preserve a form too well known to require description; they are of a yellow co- lour, and they emit a peculiar odour. When, there- fore, the feces are evacuated less frequently than the age of a person demands; when they are indurated; when they change their natural colour and odour, de- rangement of the stomach and bowels is indicated, and the approach of disease, if disease be not already form- ed, is to be apprehended. For it is not to be imagined, that organs of so great importance in the animal eco- nomy, as the stomach and bowels are, can be long in a state of inaction, and the general health remain unim- paired. I am indeed aware, that constipation may sometimes prevail, even to a great extent, in robust and otherwise healthy people, without immediate injury. In such persons, the circulating system is powerful; the excrementitious fluids, therefore, maybe so quickly discharged by the other organs, as to leave a compara- tively small proportion to be secreted into the intes- tines, incapable, from its bulk, to give a stimulus suffi- cient to excite a regular propensity to evacuate the bowels; this bulk, however, being gradually acquired, the feces are at last voided under the appearance of a costive stool. This constitutional constipation, however, is not unattended with danger, and it is at all times desirable to obviate it. The propulsion of the contents of the intestines is effected by means of a vermicular, or, as it has been OF TtfE STOMACH AND INTESTINES. 9 called, a peristaltic motion of the bowels from above downwards; hence torpor, or loss of tone in the mus- cular coat of the intestines, by which this motion is thought to be interrupted, is understood to be the cause of much distress, and tonic or stimulant medicines are employed to remedy this torpid state. I use this lan- guage, and speak of the torpor of the bowels, although my ideas respecting it do not correspond with those of others. I am inclined to think, that the symptoms re- ferred to loss of tone, proceed, on many occasions. more directly from the impeded peristaltic motion, the consequence of constipation. In this situation, we may easily understand that the distended colon cannot, for want of space, receive the contents of the smaller in- testines, which will of course stagnate throughout the whole canal; the action of which being thus interrupt- ed, will soon altogether cease, and be at last inverted. The various ailments which thence ensue are daily be- fore our eyes; and the relief which, under these cir- cumstances, we observe to follow soon after the exhibi- tion of a purgative, and the cessation of complaint, which takes place upon its operating freely by stool, are in proof that this opinion is well founded. If, again, we further consider, that the greater part of the exhalations made into the cavity of the intestines is excrementitious, and will, if retained beyond the usual period, undergo changes, and acquire injurious acri- mony; and if, moreover, we advert to the sympathy which many of the organs of the complicated animal frame have with the stomach and intestines, we cannot recognise the great influence which these must pos- sess over the comfort, the health, and the life, of the individual. 10 OBSERVATIONS ON THE FUNCTIONS These are weighty considerations, and ought to ex- cite our attention to any irregularity of the alvine eva- cuation. The necessity for this will farther appear, when we reflect that many circumstances, unavoidable in social life, expose mankind in a peculiar manner to constipation; such as improper food, intemperance, se- dentary occupations in confined or otherwise tainted air. Besides, in a therapeutic view, we are encouraged to exercise this attention. It is admitted that diapho- retic and diuretic medicines, employed to remedy in- terrupted secretion by the skin and kidney, operate circuitously, often possess deleterious qualities, or are uncertain and irregular in their effect; while the means of removing constipation act directly on the seat of disease, are safe, and seldom disappoint us in the attain- ment of our object. The diseases of the stomach and bowels are many and important; they have excited much theoretical dis- cussion, and have called forth a variety of practice. To enter, however, upon so wide a subject, and to investi- gate it in a satisfactory mannor, would be to engage myself beyond my present intention. I propose to con- fine my observations within narrower limits, and to take a practical view of a few diseases only, which 1 have ascertained to originate in constipation of the body, or at least to have an intimate connection with it. There is certainly nothing new in the position, that the loaded state of the intestinal canal commonly in- duces general bad health. But when I allege that this state accompanies and aggravates other symptoms of fever, and that it is the immediate cause of certain disorders incident to children and young people, I know that I advance opinions in which there is consi- OF THE STOMACH AND INTESTINES. 11 derable novelty, but in which, I trust, the following sheets will satisfy the medical reader, there is an equal degree of soundness. For I have learned, that the due regulation of the alvine discharge constitutes much of the prophylactic part of medicine, and teaches the propriety of advising those who wish to preserve good health, or to recover it when it is impaired, to attend carefully to this circumstance. In this view, it may be proper on some occasions to counsel the valetudinarian to forsake the haunts and habits of fashionable life; to quit the crowded city, alluring amusements, and vari- ous occupations carried on in airless, or even in tainted rooms; to shun luxurious tables, indolence, ana* late hours; to retrace the steps by which he has deviated from simple nature, and to court the country, pure air, and simple diet. It may. not, however, be convenient at all times to follow this advice; and although followed, it may not always remove constipation and its attendant evils. In this event, as well as in those cases where constipation induces or accompanies disease, the inter- position of purgative medicines becomes necessary. 12 CHAP. III. GENERAL OBSERVATIONS ON PURGATIVE MEDICINES The connection which subsists between organs that are distant from one another, and whose functions are distinct, has always presented difficulties to that arrange- ment of the articles of the Materia Medica, which is founded on the operation or effect of medicines upon the living body. This has been the case particularly with the classification of purgatives; for it is well known, that emetic, diuretic, and diaphoretic medicines have this in common, that in certain doses, and under certain circumstances, they will deviafe^rom their usual course, and excite the alvine evacuation. In like manner, differ- ent applications to the surface move the belly. Among these, that of cold is conspicuous, although this effect, however much it deserves to be noticed, and however much it may serve to regulate the practice of cold bath- ing, both in.health and in disease, appears to have been, in a great measure^ if not altogether, overlooked by late writers on the interesting and popular subject oi the cold effusion. Practitioners, however, avail them- selves of this diversified operation of medicines, while they disregard the difficulties of arrangement which it involves, and admit as purgative such medicines only as have a direct effect on the bowels in a short or given time after exhibition, whether they have-been received through the stomach, or applied more immediately to the rectum. In the dawn of physic, purgative medicines were GENERAL OBSERVATIONS, &C 13 employed. But although they have been recommended by the earlier as well as by later writers, and although the indications they are meant to fulfil have been an object of attention to practitioners in all ages, yet I do not think that the extent of their utility has been al- ways clearly perceived, or that their administration has been always properly directed. Physicians, tinctured with -the notions of judicial astrology, prescribed purgatives at certain times and seasons, conceiving that they would prove beneficial or hurtful, according to the junction or opposition of the planets, the seasons of the year, or the age of the moon. These reveries, happily, have long since vanished in the course of regular practice; and can now be traced only in directing the sage advice of the matron of the village and the hamlet. The favourers of the humoral pathology called in the aid of purgative medicines to expel peccant matter, supposed to have been previously separated from the mass of blood by an appropriate fermentation. They also taught, that different purgatives possessed distinct powers, and moved different fluids by a specific action. Hence they talked of cholagogues, phlemagogues, hy- dragogues, melanagogues; and they displayed no little sagacity in the selection of the purgative adapted to the expulsion of the fluid supposed to be prevalent at the time. This fermentation, however, and consequent deposition of peccant humours, have ceased to hold a place in the doctrines of physic; while the specific ope- ration of purgatives, in expelling particular fluids, is neither confirmed by subsequent experience, nor allow- ed to have much influence in practice. Modern physicians have two objects in view in ad- ministering purgative medicines; the one to empty the E 14 GENERAL OBSERVATIONS bowels; the other to increase the secretion of fluids into the cavity of the intestines, or, in other words, to induce purging. A distinction is therefore made be- tween laxative and purgative medicines, which is not perhaps altogether correct. Purgative medicines act by their stimulating power, which will be in propor- tion to the quantity or dose in which they are given. Four or six grains of subniuriate of murcury, as many of aloes, and eight or ten drachms of Rochelle salt, will, in ordinary cases, prove purgative, and any of them in reduced doses will have a laxative effect only. As this distinction, however, has acquired the sanction of ages, I might have passed it in silence, had it not been necessary for me to notice it, as, from experience of their superior usefulness, I employ almost solely what are understood to be purgative medicines, in the diseases of which I am to treat, while I avoid their full effect of purging. This explanation obviates one objection not unfre- quently made to the employment of purgative medi- cines, namely, that they are apt to reduce farther the strength of a patient already too weak. Purging will undoubtedly debilitate the body, by causing a flow of fluids, greater than usual, into the cavity of the intesti- nal canal, and probably by hurrying off the chyle, and precluding its passage into the system. It is in this manner useful and advantageous in some diseases. This effect, however, is not required in the diseases which are the subject of the following observations, in which the sole intention is to evacuate the contents of the bowels, which, being out of the course of the circu- lation, are in a manner already extraneous to the body. Purgative medicines, given under this condition, will not induce debility; on the contrary, in the state of ON PURGATIVE MEDICINES. id disease of which I treat, the bowels being excited to propel their contents, their functions are restored; ap- petite and digestion are improved; and the patient, so far from being weakened, is nourished, supported, and strengthened. Another objection to the use of purgatives is urged with a force that seems to carry conviction along with it. It is observed, that the constant application of sti- mulating articles creates a habit not only of using them, but entails also the necessity of occasionally in- creasing their stimulating power. Habit or custom will indeed reconcile us to the impression produced by unu- sual stimuli, and will counteract their effect in such manner, that, if the stimulus be suddenly withdrawn, or, which is the same thing, be not gradually increased, the functions of the organ to which it had been applied will become languid and irregular. This law of the economy no doubt extends to the promiscuous use of purgatives given unnecessarily during the enjoyment of perfect health. In many instances, however, of dis- ease, constipation and accumulation of feces demand this stimulus to restore tfie healthy state of the intes- tines, and to promote the expulsion of their indurated contents. In proportion as these objects are accom- plished, the stimulus from the same purgative becomes more and more powerful; and so little is the necessity for continuing it, or for increasing its dose, that, on the contrary, were not the activity of the purgative dimi- nished, or were it not withdrawn altogether, as conva- lescence advances, we should be in danger of inducing weakness by excess of purging. Purgative medicines have also been thought unne- cessary, on this account, that in many diseases little food is taken; and, therefore, regular alvine evacua- 16 GENERAL OBSERVATIONS tions are neither requisite nor to be expected. The re- sidue of food unfit for the purpose of nutrition contri- butes, no doubt, its share of feculent matter; yet the abundant secretion from different organs, and the exha lation of excrementitious fluids made into the cavity of the intestines, constitute the bulk of the feces collected within them. So long, therefore, as fluid is supplied, and so long as the circulation is supported, it is equally easy to understand how feces are produced, indepen- dently of much solid food, as to perceive the necessity of their daily evacuation during the course of fever, and of other diseases of long continuance. If the people at large, only, had entertained the above objections to the use of purgative medicines, I might have left it to medical men to obviate them by a prudent opposition; but, unhapply, they make part of the creed of many practitioners, and, leading to narrow and improper views, they give an unpropitious direc- tion to the conduct of the cure of diseases: for this rea- son I have thought proper thus to state my sentiments freely on the subject. Besides unloading the bowels, purgative medicines are said to stimulate the ducts of different glands con- nected with the stomach and intestines, and to promote their respective secretions; and, to this effect, much of the utility of purgatves is attributed. I think it unne- cessary to inquire whether this opinion be well or ill founded; for, without derogating from the good effects of purgatives acting in this way, I will only observe, that I refer the benefits arising from them to their sen- sible effect in unloading the bowels rather than to one which is less obvious; and that, for the sake of perspi- cuity, I speak of this effect, as removing a cause of irri- ON PURGATIVE MEDICINES. 17 tation, without, however, meaning to advance or support any theory on the subject. I am now to consider more particularly the utility and administration of purgative medicines, according to these views which I entertain of them. In prosecuting this subject, when I question the opinions of respectable men, I trust I shall speak with that deference which I feel to be due to them; and when I propose changes in practice, which experience has taught me to be useful, I will do so with a confidence commensurate with that experience which has been my guide. CHAP. IV. OBSERVATIONS ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES IN TYPHUS FEVER. Febrile diseases, which constitute a great propor- tion of the disorders to which mankind are liable, have attracted much attention; though the numerous and daily discussions, with regard to their nature, their causes, and the conduct of their cure, are a proof how little the medical world are satisfied with the explana- tions that have hitherto been given. Great learning and ingenuity have been shown in their classification. It will, however, be admitted, I believe, that Dr. Cullen has proposed the best arrangement of this subject in his Synopsis Nosologice Methodical. The class Pyrexiae, according to him, comprehends five orders; and the first order is that of fever. Dr. Cullen admits two genera of fever only, the intermitting and the continued; of the latter, typhus or nervous fever is most frequent, and is 18 ON PURGATIVE MEDICINES indeed so general, as to be endemial to every country with which we are acquainted. It is so common in Britain, that few in this island reach the years of man- hood without having passed through it. Symptoms peculiarly distressing always accompany it, and in no instance can it be said to be without danger. Different opinions have been entertained respecting the cause of typhus fever; but physicians seem now to be agreed in referring its origin to contagion. The presence of typhus fever is known by the fol- lowing symptoms; some derangement of the stomach, marked by loss of appetite, thirst, sickness, white or loaded tongue, disagreeable taste of the mouth, and most commonly by constipation of the bowels, precedes headach, languor, debility, and inaptitude for the usual mental and bodily exertions; morbid affections of the surface of the body, of the sanguiferous system, and of different secretions, soon succeed; to which, in the more advanced stage, delirium, subsultus tendinum, floccita- tio, and singultus, are superadded. These are generally supposed to arise from a considerable impression made upon the nervous system. The above symptoms follow in succession, and com- monly in the order in which I have enumerated them. As those which affect the stomach appear first, so they are the most permanent throughout the fever; they ac- company the others as they arise, and may possibly influence their mildness or severity. They are, there- fore, of great import, and demand particular attention in the treatment of fever. I was appointed physician to the Royal Infirmary forty years ago. At this time, the cure of typhus was thought to consist chiefly in the removal of atony and IN TYPHUS FEVER. 19 spasm of the extreme vessels of the surface of the body. For this purpose, together with other medicines, weak antimonials were given freely. An emetic and a purga- tive medicine were commonly exhibited on the first ap- proach of the attack, but the state of the stomach and bowels was little regarded in the after periods of fever. An alvine evacuation was occasionally procured by a mild clyster, while purgatives were given with extreme diffidence, lest by their operation they should rivet the spasm of the extreme vessels, and increase debility, one of the supposed direct causes of death in fever. These apprehensions may still bias the practice of many, as they certainly did bias mine for a long time. A typhus fever, with symptoms more than usually malignant, appeared in Edinburgh in summer 1779. It originated in the hospital appropriated for the sick pri- soners of war who were confined in the castle. Every precaution which prudence could suggest was employed, without effect, to prevent the spreading of contagion. Many of the soldiers in the garrison, and some of the inhabitants of the city, were seized with the fever. In summer 1781, a fleet of merchantmen from Ja- maica, with their convoy, consisting of several ships of war, anchored in Leith roads. The passage had been tedious, the crews were sickly, and they had been for some time on short allowance of provisions. Neverthe- less, they had been obliged, by the circumstances of the war, to avoid the channel, and to come round by the north of Scotland. From the beginning of July to the 9th day of August, 126 men in fever were sent on shore from his Majesty's ship Suffolk, one of the con- voy; of these, twenty-three died; and of forty men who were landed from the Egmont, another of the con- voy, eight died. Such of the sick as could not be ac- 20 ON PURGATIVE MEDICINES commodated in a temporary hospital were quartered in Leith, two, three, or four, being billeted in one house, Many of the inhabitants were seized of course with a fever of the same kind with that which affected the seamen, and it prevailed in town for several years after- wards. These circumstances, the proximity of Leith to Edinburgh, and the reciprocal intercourse of the in- habitants, will account for the typhus gravior, which was frequent in both places at this time. Having been often disappointed in promoting the cure of this fever by mild antimonials, which were then so much in use, I was induced, by the same views which directed the employment of these, to use the calx anti- monii nitrata, Ph. Edin. editce anno 1774. I gave four or six grains of this preparation for a dose, which was repeated three or four times, at an interval of two hours, unless sweating, vomiting, or purging, were previously excited. I resorted to this practice towards the termination of the fever, and in the treatment of those patients only of whose recovery I was exceedingly doubtful. I enter- tained hopes that a favourable crisis might be procured by the efficacy of the antimonial medicine; and, in the mean time, I thought I supported the strength of my patients by the moderate use of wine. This antimonial remedy was not ineffectual; but I remarked that it was beneficial only when it moved the belly. In this case the feces were black and fetid, and generally copious. On the discharge of these, the low delirium, tremor, floccitatio,. and subsultns tendinum, which had prevailed, were abated; the tongue, which had been dry and furred, became moister and cleaner; and a feeble creeping pulse acquired a firmer beat. On reflecting afterwards on these circumstances, it ap- EN TYPHUS FEVER. 21 peared to me to be probable, that, as the purgative effect of the calx antimonii nitrata had been the useful one, any purgative medicine might be substituted for it, and that, by this substitution, the unnecessary debilitation of an exhausted patient, by sweating and vomiting, would be avoided. More extended experience confirmed these conjec- tures; and I was gradually encouraged to give purga- tive medicines during the course of typhus, from the commencement to the termination of the disease. I have directed a strict attention to this practice for a long time, and I am now thoroughly persuaded, that the full and regular evacuation of the bowels relieves the oppression of the stomach, cleans the loaded and parched tongue, and mitigates thirst, restlessness, and heat of surface; and that thus the latter and more for- midable impression on the nervous system is prevented, recovery more certainly and speedily promoted, and the danger of relapsing into the fever much diminished. I am disposed to refer the superior utility of purga- tive medicines in typhus fever to the circumstance of their operating throughout the whole extent of the in- testinal canal; to their acting upon an organ, the healthy functions of which are essential to recovery, in a manner that is consonant to the course of nature, by propelling its contents from above downwards; and to their moving, and completely evacuating, the feculent matter which, in this case, becomes offensive and irri- tating. Constipation, together with the change which fever appears to produce in the fluids secreted into the intestines, seems to be the cause of this alteration in the state of the feces. The necessity of expelling this nox- ious mass is therefore apparent; and, if my opinion be correct, the operation of a clyster, the stimulus of which F 22 ON PURGATIVE MEDICINES is confined to the rectum, must be altogether inadequate to procure the full evacuation which the circumstances of the case require. Accordingly, it is now some years since I have relinquished almost entirely the use of emetics and clysters in fever; I trust to a purgative medicine to insure a regular alvine evacuation, although the daily exhibition of a purgative for this purpose is not always required. By this mode of treatment, I avoid the harassing distress which the operation of an emetic occasions, as well as the trouble and fatigue which accompany the exhibition of clysters. This practice, by means of purgative medicines, does not supersede other remedies employed to fulfil other indications, particularly the free access to pure and fresh air. I am even ready to allow, that although I exclude emetics and clysters from my general practice in typhus fever, yet particular circumstances may arise to make both the one and the other necessary. I cannot, however, avoid remarking, that, for many- years past, I have found these other remedies, and wine in particular, to be less necessary than I formerly thought. This may be owing in part to typhus fever being less malignant than it was some time ago, and in part to the purgative medicines, which I employed with freedom, removing and obviating symptoms of debility. If this be a just view of the case, the plain inference is, that while purgative medicines preserve a regular state of the body, they do not aggravate the debilitating effects of fever. This doctrine is at variance with that which is com- monly entertained; but I am confident that it is conso- nant to the fact. The complete and regular evacuation of the bowels, in the course of fever, is the object to be attained. Within this limit I have had much satisfac- IN TYPHUS FEVER. 23 tion in prosecuting the practice; nor have I, in a single instance, had occasion to regret any injury proceeding from it; for I am not an advocate for exciting unusual secretion into the cavity of the intestines, and for pro- curing copious watery stools; these, while they are not necessary, might increase the debility so much dreaded. In most instances of fever, this practice, by purgatives, is conducted with ease, and a tolerable degree of cer- tainty. The observation and experience of individuals may be necessary, on some occasions, for directing measures where it is not easy to lay down precise rules. The effect of purgative medicines may not be foreseen in every instance, or be altogether immediately under command; at any rate, however, the subsequent doses of purgatives, and the frequency of their repetition, will be regulated by the effect of preceding ones. It is of importance to consult, in all respects, the ease and comfort of patients in fever. The exhibition of purgatives, therefore, should be so timed, that their effects may be expected during the day, when proper assistance can be best procured for the sick. The purgative medicines which I have chiefly used in fever are, calomel, calomel and jalap, compound pow- der of jalap, aloes, solutions of any of the mild neutral salts, infusions of senna, and sometimes the two last conjoined. My experience, in the treatment of typhus, enables me to draw the following conclusions : 1st, Purgative medicines are given with safety in typhus, to evacuate the contents of the bowels. 2d, Under this limitation, they may and ought to be exhibited at any period from the commencement to the termination of the fever. 24, ON PURGATIVE MEDICINES 3d, The early exhibition of purgatives relieves the first symptoms, prevents the accession of more formida- ble ones, and thus cuts short the disease. 4th, In the advanced period of typhus gravior, symp- toms that indicated the greatest danger were relieved by the evacuation of the bowels, and the patients, in this instance, recovered. 5th, Reconvalescence from typhus is greatly promoted and confirmed, by the preservation,of a regular state of the body. The same means secure against the dan- ger of a relapse. In corroboration of these conclusions, and in confirm- ation of the practice of exhibiting purgative medicines in the co- rse of fever, I have inserted, in the Appen- dix, p. 9, several cases of fever from the records of the ►Royal Infirmary, which I treated almost solely with pur- gative medicines. And I subjoin, at p. 30 of the Ap- pendix, the sentiments of several respectable authors on the use of purgatives in typhus. Although I consider the cases from the books of the Royal Infirmary to be highly important, and recommend them to be studied by those who are entering upon the profession of physic, I here subjoin an abstract of each case of typhus fever, for the satisfaction of others, whom leisure does not permit, and whom inclination does not lead, to engage in the perusal of histories of disease given so much in detail. These abstracts are in the order in which the cases follow one another in the Ap- pendix. John Denham, aged eleven.—Was convalescent on the ninth day of fever, and on the sixth from the com- mencement of the use of purgatives. No other medi- cine was given, except an emetic on the second day, before I saw him. IN TYPHUS FEVER. 25 James M'Kechny, aged twenty.—No medicines being previously given, he had a purgative without effect on the eleventh day of fever. The purgative was repeated on the twelfth day, when he had a free passage of belly. No other remedy was employed; and he was convalescent on the fifth day from the com- mencement of the treatment. Robert Grant, aged twenty-one.—Had an eme- tic on the second day of fever, without relief. No other medical interposition took place till the ele- venth day of the disease, when he became my patient, and when a purgative and a clyster were given. Two copious alvine evacuations were procured, and the pa- tient was convalescent on the following day, the twelfth of the fever. Jonathan Green, aged twenty-two.—An emetic given on the third day of fever was followed by full vomiting, three stools, and abatement of symptoms. These being aggravated on the seventh day, purga- tives were given freely, and besides them one ano- dyne draught only. The patient was convalescent on the fourteenth day of the fever. During ten days that he remained afterwards in the hospital, slight headach occurred, for which cinchona was given in small doses. Robert Muckle, aged seventeen.—Had an eme- tic on the second day of fever, with relief. On the fourth and fifth he had a purgative medicine, and on the seventh day he was convalescent. John Fairgrave, aged nineteen.—Had an emetic on the first day of fever, with relief; a purgative on the second, which operated well; and on the third day he was convalescent. Donald Watson, aged twenty-three.—Had no me- 26 ON PURGATIVE MEDICINES dicines besides purgatives. He was convalescent on the twelfth day of the fever, and the eighth from the commencement of the treatment. James Dennet, aged twelve.—Became my patient on the fourth, and was convalescent on the tenth day of fever. Besides purgative medicines, he had an anodyne draught for two nights, the mistura salina ammoniata, and one emetic, which operated by stool. James Grant, aged eighteen.—When convalescent from fever, suffered a relapse, attended with pain of abdomen, pain of internal fauces, and eruption of red- dish spots over the surface of the body. He had taken an emetic and some laxative pills before he became my patient, on the sixth day after the relapse; and on the ninth day from this period he was convalescent. Pur- gatives were given freely. He had besides an ano- dyne draught for five nights, and two pounds of sack whey daily for three days. John Baird, aged eleven.—Became my patient on the sixth day of fever, in the progress of which sus- picion of the presence of hydrocephalus internus arose. He was convalescent on the eleventh day from the commencement of the treatment, during which he had three purgatives, with good effect. Besides these, he had eight ounces of wine for one day, the mistura diaphoretica salina for several days, a mercurial pill for four, and an anodyne draught for two nights, and his head was blistered. Donald Stewart, aged nineteen.—In this case, the febrile were combined with pectoral symptoms, at one time, and with an inflammatory affection of the throat at another. The fever was protracted; and it affords an instance of the freedom with which purga- IN TYPHUS FEVER. 27 tives were given in its advanced period, and in the re- duced state of a patient. Margaret Man son, aged twenty.—Became my patient on the third day of fever. She had two brisk purgatives, and no other medicine; and she was conva- lescent on the third day from the commencement of the treatment. Margaret Kennedy, aged seventeen.—Became my patient at an uncertain period of fever. She has had no medicine besides three purgatives, which procured two full alvine evacuations, the first of feces which were dark coloured and fetid, the second of feces in all re- spects natural. She was convalescent on the fourth day of the treatment. Jean Wyllie, aged twenty-five.—Had a purgative medicine on the fourth day of fever, which procured two copious and natural stools. She was convalescent on the seventh day from the attack. William Mackay, aged thirty.—Had an emetic, with relief, on the second day of fever. He became my patient on the third day of the disease, when he had a purging dose, which procured an easy alvine eva- cuation, and he was dismissed cured on the fifth day from the attack. Mary Stalker, aged eighteen.—Had a purgative and an opiate on the third day of fever; the former was repeated on the fourth, and the latter on the fifth; and she was dismissed convalescent, on the sixth from the attack. Ann Henderson, aged eighteen.—Laboured under pectoral complaints, along with symptoms of typhus. She had been blooded, and a blister had been applied previous to her becoming my patient on the eighth day of the fever. On the eleventh day from the attack, she 28 on purgative medicines had a full alvine evacuation, in consequence of a large dose of a purgative medicine; an anodyne injection hav- ing been premised, to insure the reteption of the pur- gative. The febrile symptoms immediately ceased, and, on the seventh day after her appearance in the hospi- tal, she was dismissed cured. CHAP. V. observations on the utility and administration OF PURGATIVE MEDICINES IN SCARLATINA. No disease has attracted greater attention than scar- latina. Its frequent appearance, and its fatal tendency, have claimed the exertion of practitioners, and have stimulated them to inquire into its nature, and the most successful mode of treating it. The ancients do not seem to have had any very ac- curate views with regard to scarlatina. Various authors, from an early period of the six- teenth century, downwards, mention an ulcerated sore throat, accompanied with a scarlet efflorescence on the surface of the body, as frequently desolating different parts of the continent of Europe. Sydenham describes scarlatina, as we often see it, to be a mild disease, requiring only common attention, quiet, and simple diet; and more likely to be aggravat- ed than relieved, by the " nimia medici diligentia." p. 225, editio tertia, London, 1705. Huxham and Fothergill afterwards wrote on scarla- tina, and the ulcerated sore throat: and since their time, man^ British and foreign physicians have published IN SCARLATINA. 29 their sentiments with regard to this disease, and have generally spoken of it under the title of scarlatina angi- nosa. These different accounts of scarlatina have given rise to much nosological discussion respecting the iden- tity of the disease, as described under different names. Little doubt is now entertained on the subject, so far as scarlatina and scarlatina anginosa are concerned. It appears to be admitted that the affection of the throat in the latter may give a variety, while the diseases are the same in their origin, progress, and termination. Greater uncertainty prevails in regard to this ques- tion, respecting the ulcerated sore throat, or cynanche maligna, the name by which it is now generally known. This very name may have contributed to confirm the opinion, that it is a distinct disease from scarlatina; an opinion which, sanctioned by authors of respectability, and by our intelligent and latest nosologist, has been, and is still prevalent. It is altogether foreign to my purpose to engage in this controversy; and the more so, as I apprehend that the distinction begins to lose ground as our knowledge of the disease becomes more comprehensive and accu- rate. The time may not be far distant, when scarla- tina will be received as the generic disease, the full history of which will include the more aggravated symptoms as they appear in scarlatina anginosa, and in cynanche maligna; in the same manner as the history of variola comprehends the varieties of the distinct and of the confluent small-pox. Indeed, Dr. Willan, in his description of Cutaneous Diseases, edition 1805, page 254, adopts this opinion decidedly. " The generic term, Scarlatina, comprises three varieties, which may G 30 ON PURGATIVE MEDICINES be denominated scarlatina simplex, scarlatina anginosa, and scarlatina maligna/' And again, page 281, " It is truly singular, that the slightest of all eruptive fevers, and the most violent, the most fatal disease known in this country, should rank together, and spring from the same origin. Experience, however, decides, that the simple scarlet fever, the scarlatina anginosa, the scarla- tina (or angina) maligna, and the scarlet ulcerated sore throat, without efflorescence on the skin, are merely varieties of the same disease." Scarlatina, as an epidemic, does not always assume precisely the same appearance. This diversity depends, in part, upon the varying nature and constitution of scarlatina itself, independently of all extrinsic circum- stances; in part upon certain contingencies, which are common to all the inhabitants of a whole district of country,—such as the season of the year, the tempera- ture of the air, the kindliness or inclemency of the weather, together with other unknown qualities of the atmosphere, and in part upon circumstances which ap- ply to individuals subjected to the disease,—their ge- neral habit of body and constitution, their particular state of health at the time of the attack, and their situa- tion with respect to lodging, ventilation, and cleanliness, These circumstances concur in modifying the cha- racter of the epidemic; and while they introduce a va- riety in the symptoms of scarlatina, they likewise point out the necessity of making a corresponding change in the method of cure, and of accommodating our prac- tice to the particular nature of the case. Hence different opinions have been entertained of the nature of scarlatina, and apparently discordant me- thods of cure have been proposed. Undoubtedly va- IN SCARLATINA. 31 rying epidemics of scarlatina have led to the practice of blood-letting, in some instances, and to the rejection of it in others; to the adoption of emetics and of blis- ters, by some practitioners, while others neglect and positively forbid them. It is owing to the same cause, that cinchona is warmly recommended, and almost ex- clusively trusted, for the cure of scarlatina; while, on the other hand, it is reprobated, as tending to induce sloughs, and putrid ulcers in the throat, which it was expected to have obviated or removed. In like man- ner, purgatives have been condemned as useless, if not dangerous; and lately, the effusion of cold water over the surface, or the ablution of the skin, by means of tepid water, have been recommended and practised in scarlatina, according to circumstances, by men whose opinions have great weight and authority. Thus the young and timid practitioner is distracted, and at a loss what course to pursue, that he may em- brace a safe and decided line of conduct. It will be a difficult task to dispel the clouds that overshadow medical practice in scarlatina. The only way of ac- complishing it, will be to give a full statement of the leading symptoms of the different epidemics noticed by authors; and to appropriate to each the general and topical remedies which they require. Whoever em- barks in this undertaking, and executes it with success, will render an useful service to the public. These reflections occurred to me, upon turning my thoughts towards the subject of scarlatina; and I con- ceive them of sufficient importance to merit the atten- tion which I have bestowed upon them. I proceed now to the proper object of this paper, in prosecuting which, I beg to be understood as consider- ing scarlatina, and scarlatina anginosa, to be the same 32 ON PURGATIVE MEDICINES disease, using always the term scarlatina as including both. And, in compliance with common custom, and for a reason which will afterwards appear, I shall treat of this modification of the disease separately from cy- nanche maligna, of which I shall take notice in the sequel. SCARLATINA. An inflammatory diathesis frequently prevails on the first attack, and during the early period of scarlatina. For this reason, venesection has been ranked, by some practitioners, among the remedies which ought to be employed; and it is said to have been practised with advantage. Possibly, too, the existence of the inflam- matory diathesis may have disposed others to give pur- gative medicines more freely in scarlatina than in ty- phus. But this practice has not been universal; for many physicians do not admit the good effects of pur- gatives, while others deny them altogether, and consider them to be highly prejudicial, by inducing a dangerous and fatal tendency in the disease. This question, one of great importance in practice, is not, as yet, satisfactorily decided; although I think the opinion gains ground, that purgatives are useful in scarlatina. Many years ago, when the prejudices against them were more prevalent than they are at this time, I ventured to employ them. My doing so was, indeed, a necessary consequence of the benefit I had experienced from purgative medicines in typhus. I had learned, that the symptoms of debility which take place in typhus fever, so far from being increased, were obviously relieved by the evacuation of the bowels. I was, therefore, under little apprehension IN SCARLATINA 33 from them in scarlatina; and I have never, in a long course of experience, witnessed sinking and fainting, as mentioned by some authors, and so much dreaded by them; neither have I observed revulsion from the surface of the body, and consequent premature fading, or, in common language, striking in of the efflorescence, from the exhibition of purgatives. Accordingly, in treating scarlatina, I have confided much in the use of purgative medicines; and no variety of the disease, as appearing in different epidemics, or in the course of the same epidemic, has hitherto prevented me from following out this practice to the extent which I have found necessary. I have observed the pungent heat of the surface, violent headach, turgescence of features, flushing of counte- nance, and full and quick pulse, the earliest symptoms in some epidemics of scarlatina, and which may have suggested and warranted the practice of blood-letting to be quickly subdued by one or two brisk purgatives. Full purging is not required in the subsequent periods of the disease, in which the sole object is to remedy the impaired action of the intestines; to secure the com- plete and regular expulsion of their contents; and thus to prevent the accumulation of feces, which never fails to aggravate the symptoms, and to prove the source of farther suffering to the patient. It is generally, I believe, admitted, that purgative medicines are useful in removing dropsical swellings, the consequence of scaralatina, and are given with this view towards the decline of the disease, when the weakness of the patient is often very great. I con- ceive that purgatives also afford a mean of preventing this swelling, and other derangements of health; and for this reason I give purgatives during the fever, when 34 ON PURGATIVE MEDICINES the strength is not altogether broke down, and for some time after convalescence has commenced. The termination of scarlatina is generally doubtful, particularly as to the dropsical tendency, in respect of which the mildness or severity of preceding symptoms afford no certain prognosis. I have been involved in the greatest distress by the supervention of a fatal dropsy, upon the termination of scarlatina, apparently mild on the first attack. Practitioners, therefore, in treating scarlatina, cannot be too much on their guard against unexpected changes, and unfavourable appear- ances; they ought never, even in the slighter cases, to lose sight of the " diligentia medici," although Syden- ham seems to ridicule this, by applying to it the epi- thet " nimia;" and I am satisfied that they cannot ex- ercise this diligence better, than in the due and regular exhibition of purgative medicines. Besides these motives for the exhibition of purga- tives, I have observed, that the ferbrile state in scarla- tina is more apt to induce costiveness, and to change the nature of the contents of the bowels, than it is in typhus; for in most cases of scarlatina, the feces have an unnatural appearance, and in general a peculiarly fetid smell. The same activity, however, in the exhibition of purgative medicines, is not required in every epidemic, and in every case of scarlatina. In some instances, the belly is moved with ease, and in others, not with- out difficulty. Scarlatina was frequent'in Edinburgh in autumn 1804, and in winter 1804-5. In this epi- demic, as will be seen from the cases contained in the Appendix, p. 46, the bowels were peculiarly constipat- ed, the termination in dropsy was frequent, and, from this circumstance, the mortality was great. I have not IN SCARLATINA. 35 ascertained to what this different state of the bowels in scarlatina is to be ascribed. But, on whatever cause the difference depends, it will be necessary for us to adapt our practice, in the use of purgatives, to the na- ture of the prevailing epidemic. It is not perhaps of great moment to be solicitous about the selection of purgative medicines. In gene- ral, I have chiefly employed those which I have men- tioned in my observations on typhus. Children can- not always be easily induced to take medicines of any kind. Submuriate of mercury may, on this account, be proper for them. We ought, however, to be on our guard against too great an affection of the mouth, from the necessity of frequently repeating the mercury. In scarlatina, as in typhus, we should keep in view the procuring the effect of purgatives during the day, and the avoiding, in this manner, the disturbance of the sick in the night-time. It is of moment to examine the feces, to ascertain their state and their quantity, cir- cumstances necessary to determine the subsequent dose of the purgative, and the frequency of its exhibition. The use of purgative medicines in scarlatina does not supersede the other sources of relief and comfort which have been found proper in the treatment of the disease, and which our patients, or their friends and attendants, may expect, and which the habits of prac- titioners may suggest. Upon a dispassionate review, however, of the whole of the present enquiry, I feel myself at liberty to say, that, under the regulated exhi- bition of purgative medicines, conjoined with personal cleanliness, and access to pure air, I have not found the necessity of employing other remedies to be great, and certainly not so urgent as I at one time thought it to be. 30 ON PURGATIVE MEDICINES In corroboration of these my sentiments, I give, in the Appendix, p. 36, the cases of a few of my patients in the Royal Infirmary, who laboured under scarlatina; also, p. 45, a narrative of an epidemical scarlatina which prevailed in Edinburgh in 1804-5, as it appeared among the children in George Heriot's Hospital; and, at p. 49, I adduce the testimony of respectable authors who approve of the exhibition of purgative medicines in scarlatina. CYNANCHE MALIGNA. The generally received opinion that scarlatina and cynancbe maligna are distinct diseases, had been lately controverted. Had this distinction been well founded, a different practice suited to each must, one would think, have been adopted. It is true, that evacuating medicines are used with more caution in cynanche maligna than in scarlatina; while high stimulants are thought to be more appropriated to the former than to the latter. This, however, is no more than a variety of the same practice, applicable to the same disease, according as it is more or less virulent in different epi- demics, and in particular cases. This practical view of the question constitutes the identity of scarlatina and cynanche maligna, independent of the proofs which the history of the disease affords. I have declined, however, to enter upon any argu- ment on this subject, that I might be at liberty to consi- der scarlatina and cynanche maligna separately, lest any doubt should arise respecting the utility of purga- tive medicines in scarlatina. For while in this, the more simple form of the disease, almost every one con- siders these medicines to be dangerous, they are more IN SCARLATINA. 37 universally condemned in cynanche maligna. Had I therefore spoken in a general way, and recommended purgative medicines in all the varieties of scarlatina, my proposal would have been received with distrust, and the practice might have been neglected and passed from, without a trial of its expediency. The progress of cynanche maligna is sometimes so rapid as to preclude the interposition of any medicine whatever. This circumstance, along with the extreme debility which attends it, has raised a formidable objec- tion to evacuations of any kind in the treatment of it, and particularly to that procured by purgative medicines. It would indeed appear that this objection has been urged with effect against the use of purgatives, even in scarlatina, in consequence of the connexion which had been observed to subsist between it and cynanche ma- ligna; for it was imagined, that the danger from cynanche maligna which supervenes upon scarlatina, a supervention not unfrequent, would be increased, in proportion to the debility previously induced by the purgatives used in scarlatina. The restricted use of purgative medicines, however, to the extent of unloading the bowels only, does not increase this debility, while it relieves the symptoms of the general fever; and may thus prevent either its termination in cynanche maligna, or alleviate the attack. Writers also condemn purgatives in cynanche malig- na, from an apprehension that they serve to diffuse the acrid matter, descending from the throat into the sto- mach, over the whole surface of the intestines, and thus to increase the source of contagion, and to aggra- vate the irritation which arises from the presence of this acrid matter. But, in stating this objection, they do not consider, that this matter accumulating, and be- h 38 ON PURGATIVE MEDICINES coming more offensive, in consequence of retention in the stomach and bowels, will produce greater mischief, and greater irritation, than can possibly proceed from the gentle operation of a purgative medicine, while they lose the benefit ensuing from the movement and expul- sion of an acrimonious feculent mass. An exhausting diarrhoea, or even a dysentery, it is said, are troublesome and common consequences of cynanche maligna; on which account purgatives are con- ceived to be injurious. But I cannot see the force of this objection. For were I to devise a mean of pre- venting these consequences, or of removing them when they had taken place, none more likely would occur to me, than the use of those very purgatives, which are thus so dogmatically proscribed. While I employed them, however, I would carefully limit their effect to the express purpose of unloading the bowels, and shun the inconvenience of inducing weakness, by full purg- ing. Under these impressions, I have formed a favourable opinion of the utility of purgative medicines in cynanche maligna. But let me here caution the reader, that I have, in this instance, departed from the rule which I had formed to myself. It is a theoretical opinion on my part, and not so fully supported by experience, as to enable me to deliver it with confidence. This opinion, however, is not exclusively mine; it is that of respectable authors, and is supported by their practice. Huxham, in a dissertation on the malignant ulcerous sore throat, London, 1757, remarks, page 297, "How- ever improper purging might be at the beginning of this distemper, gentle easy cathartics, as rhubarb, manna, &c. were necessary at the end, to carry off the putrid IN SCARLATINA. 39 colluvies of the intestines, which otherwise protracted the feverish heats, and occasioned great weakness, want of appetite, tumid bellies, and great obstruction of the glands."—" But in general," page 295, " after a purge or two, the sick soon recovered a keen appetite, strength and spirits; many however required frequent purging." In the Gentleman's Magazine for June 1772, an anonymous correspondent, (Mr. Rodbard of Ipswich,) an ingenious practitioner and respectable man, as the late Dr. Ford, physician in Chester, has informed me, mentions an epidemic scarlatina which prevailed at Ipswich. His letter on this subject is little known, and is not readily accessible, as the depository of it has be- come scarce, and is generally to be found only in pub- lic libraries; I insert it therefore at length, for the gra- tification and information of my readers. "Mr. Urban, " If the following comports with the design of your useful collection, please to give it a place the first op- portunity, and you will oblige'a constant reader." " To Dr.-----------, London. " Sir, " Notwithstanding you are an absolute stranger to me, your character as a physician, and as a candid, humane, and benevolent gentleman, has emboldened me to trouble you with the contents of this, without any further apo- logy than the goodness of the intention. " The ulcerated sore throat, and scarlet fever, has been very rife in this place and the neighbourhood, for some months past, and has been, in a considerable number of instances, fatal. It has, in every respect, 40 ON PURGATIVE MEDICINES answered the description given of it by Dr. Fothergill; and therefore a repetition of the symptoms and appear- ances would be needless. I shall only relate what ap- pears to me to be the predisposing cause, the proximate cause, the pabulum morbi, the treatment I have given it, and the success. " The predisposing cause is, whatever generates a quantity of acrid bile in the prima? viae. " The proximate cause is, the sudden transition from heat to cold, and the contrary. This has been so very evident, that whenever the wind has changed from the south or west to the north or east, a considerable num- ber of people have been instantly seized with the dis- ease. " The pabulum morbi is acrid bile. This is cer- tainly known by the immediate cure of the sick, who apply very soon after the seizure, and take such me- dicines as act smartly on the stomach and bowels; by the great relief all others find by vomiting and purging; and is confirmed by the contents of the evacuations, which are little else but acrid or putrid bile. " The treatment I have given the sick is, immediately to evacuate them, in proportion to the strength of the patient, the violence of the symptoms, the time of the disease, and the particular state of the constitution. " The evacuating medicines I have given are the fol- lowing: " Recipe—Ras. c. c. antimon crud. pulv. an. p. se. calcinentur simul in crucibulo donee fumi sulphuris eva- nescant, et regulus antimonii manifestus sit; deinde ab igne remove, et in pulverem subtilissimum redige. "Recipe—Pulv. supradict. partes tres.—Mercurii dulcis sexies sublimati, et subtiliasime triturati, partem unam. Misce. IN SCARLATINA. 41 " Of this I have given from half a scruple to half a drachm, to adults, and have found it constantly to an- swer the intention. But to children, I have given the mercurius dulcis only, from five grains to a scruple; and if the symptoms are very violent, and the child very robust, I have given even half a drachm with the greatest success. After the sick has had several stools, I gave him the following julep: " Recipe—Mann. aq. pur. unciis septem solut. un- ciam, crem. tartar, drachmam, aq. nucis moschat. un- ciam dimidiam. M. Capiat cochlearia tria, quartis horis, if he is an adult; if a child, according to his age and strength. It is an agreeable medicine, and answers the intentions of keeping the bowels lax, the bile insipid, and the mouth and fauces quite clean. " If the patient is in the first stage of the disease, I direct him to gargle frequently with Spiritus Minde- reri in cold water, which prevents an ulceration: If in the second stage, with Spiritus Mindereri, tincturae myrrhae uncia dimidia, decoti hordeati, unciis septem M. If in the third, and the sloughs begin to separate, with mel rosar. tincturae myrrhae,—corticis Peruvian. a. uncia dimidia, decoct, hordeati unciis septem, M. and made just tepid. " If the ears are affected, I have used the last men- tioned mixture, as soon as they discharge, just tepid, as an injection, several times a-day. " After the sloughs are all off, and the fever gone, I have found it necessary, in some few cases, to give the following tincture: Recipe—Infus. corticis Peruviani Huxhami,inciam unam et dimidiam,—Rhabarbari spirit. unciam dimidiam; drachmam unam vel drachmas duas, bis indies, horis medicinas in aqua pura. " The liquors I have used have been water-gruel, 42 ON PURGATrVE MEDCINES barley-water, chicken-water, sage tea, rosemary tea, or baum tea, occasionally. Of these I have recommend- ed the sick to drink freely, cold or just tepid; keep- ing them at the same time cool, and admitting fresh air freely into the room, remembering always Piso's maxim, " putredo fit a calore aleno et interne" " The success has been beyond my most sanguine expectations; I have had considerably more than one hundred patients, and have not buried one." " Ipswich, June 3." * This letter was written some months ago, since which time the number of patients have increased to near three hundred, with the same success." The facts set forth in this letter afford abundant evi- dence of the safety and efficacy of purgative medi- cines in cynanche maligna; for the epidemic herein described appears to have been of this nature. Mr. Rodbard verifies my observation, that different epidemics of scarlatina require a variety of the same practice. In the scarlatina of 1772, at Ipswich, the bowels appear to have been easily moved; I believe, however, the gentle purgative, employed in the course of that epidemic, for I do not take into account the highly active one given in the first instance, would have been of no avail in the scarlatina which prevailed in Edinburgh in 1804; as will be evident from my narrative of this epidemic, as it appeared in George Heriot's Hospital, Appendix, p. 57. Dr. Willan, in his description and treatment of cutane- ous diseases, gives extracts from an account of scarlatina, as prevaling among the children at Ackworth school, drawn up by Dr. Binns. In a note, page 281, edit. 1805, we have a description of this epidemic, as it af- fected the throat. " The affection of the throat has IN SCARLATINA. 43 occurred with us in every possible state; mere ery- thema, sometimes with a swelling of the tonsils: aph- thous specks; deeper ulcerations, with white sloughs; ash-coloured sloughs, which I consider as gangrenous; also darker-coloured sloughs, with extreme faetor." On the subject of wine as a remedy, Dr. Binns, among other remarks, makes the following, pages 364, 365. " It is impossible to specify, with certainty, the quantity of wine taken by individual patients; but, from the general consumption, when a number of bad cases occurred together, it appeared that children about twelve years of age must have taken each a bottle of red port and a bottle of raisin wine, in twenty-four hours, for several successive days."—" Although the state of the pulse, and other symptoms, were, in many cases, such, that a small proportion of bark and wine were sufficient; yet, in other instances, the debility was so great as to require even the addition of brandy to the red port. Sometimes strong brandy and water, some- times brandy unmixed, was given with comfort and ad- vantage to the patient." In this epidemic, which the above symptoms, as well as the high stimuli necessary in conducting the cure, evince to have approached, if not in some instances to have emulated cynanche maligna, Dr. Binns speaks thus of laxatives, page 357: " My acknowledgments are due to Thomas Oxley, of Pontefract, not only for his fre- quent attendance, but for his removal of a prejudice against laxatives in the early stage of the disease, im- bibed from various authors, and confirmed by the dreadful consequences I had seen when a diarrhoea come on in this fever. By his persuasion, small doses of calomel and other laxatives were occasionally ad- ministered; and, so far from producing injury, I be- 44 ON PURGATIVE MEDICINES lieve, that, by evacuating the acrid matter, which is often swallowed, they had a tendency to prevent the excoriations of the intestinal canal, and the consequent diarrhoea which I dreaded. But it should be remarked, that particular care was taken to support the patient during the operation." CHAP. VI OBSERVATIONS ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES IN THE MARASMUS, WHICH AP PEARS IN CHILDHOOD AND EARLY YOUTH. I comprehend under the general title Marasmus, a variety of symptoms which affect the young of both sexes. A sluggishness, lassitude on slight exertion, depravity and loss of appetite, wasting of the muscular flesh, ful- ness of the features and paleness of the countenance, swelling of the abdomen, an irregular and generally a costive state of the bowels, a change in the colour and odour of the feces, fetid breath, swelling of the upper lip, and itching of the nose, mark the beginning of the disease. When these symptoms have continued for some time, they are followed by alternate paleness and flushing of the countenance, heat and dryness of skin, feeble and quick pulse, thirst, fretfulness, increasing debility and disturbed sleep, during which the patients grind or gnash their teeth, and are subject to unvolun- tary starting, and twitching of different muscles. Every case of marasmus does not necessarily in- clude all the symptoms which I have enumerated. IN MARASMUS. 45 Different combinations of them give a variety of the disease, which is, however, in general, readily known and distinguished. Marasmus appears most commonly among weak and infirm children; whether they are so from delicacy of constitution, or from incidental causes. It is parti- cularly prevalent in large and populous cities, where children are deprived of ready access to exercise in the pure air, and sicken and pine in the nursery; or when they are confined in crowded and airless school- rooms, whether they are sent, partly for the purposes of education, and partly, to use a common phrase, with the view of being kept out of harm's way. Chil- dren also, who are employed in manufactories, where their occupation and confinement in impure air are such as to weaken and enervate them, are liable to be attacked with this disease. Irregularity in diet and improper food also give rise to marasmus. We accordingly observe it to prevail most commonly in autumn, the season which affords opportunity for eating unripe fruit and vegetable articles from the garden. In proof of the operation of these causes, I remark, that I have held the office of Physician to George He- riot's Hospital for forty-two years. During this long period, I scarcely recollect an instance of this maras- mus among the children entertained in that institution. This may be attributed to the healthy site of the build- ing; to the cleanliness and free ventilation of every part of it; to the wholesome nourishing food of the children; and to their exposure to pure air while en- joying their infant sports. See Appendix, p. 57. Marasmus has been generally attributed to the pre- sence of worms in the alimentary canal. This suppo- i 46* ON PURGATIVE MEDICINES sition, however, is questionable. Ascaris, Tenia, and Lumbricus, are the worms most commonly found in the human intestines. Ascarides, which are often passed in great numbers by children when at stool, are not accompanied by the symptoms of marasmus. Except an itching about the anus, they give little other uneasiness. The tenia or tape-worm, the presence of which is known by peculiar symptoms, and which is the source of much suffering in after periods of life, is altogether unknown in infancy and childhood. The lumbricus, or round worm, therefore, must be the generally supposed cause of the symptoms of ma- rasmus. Medical gentlemen, who have practised in tropical climates, speak much of the lumbricus, and mention the number of them that is occasionally pass- ed to be very great. There may be something in the climate, soil, or state of the air of these regions, in the mode of life or constitution of the inhabitants, with which we are unacquainted, which may account for this circumstance. But in our cooler latitudes, no such instances of numerous lumbrici have been noticed. On the contrary, after the best directed course of an- thelmintic medicines, when the symptoms of the dis- ease are going off, no lumbrici have been seen, unless we admit, that the worms destroyed by the efficacy of the medicines, constitute the unnatural and fetid feces which, in such instances, are voided in great abund- ance. This admission, however, is not to be readily grant- ed; for similar feces are passed upon the exhibition of an early purgative, and before any specific vermifuge is employed. Farther, the presence of lumbrici in the bowels is IN MARASMUS. 47 by no means an uniform cause of bad health. They have been known to exist in the intestinal canal with- out any disease ensuing. These instances are not rare, and are not confined to childhood. They militate against the received opinion, that lumbrici, within the intestines, are the cause of marasmus; for if they are so in a single case, they should be so in every one. This opinion, however, that worms exist in the in- testines, and exert a baneful influence on the health, has been so prevalent for ages, that a great many an- thelmintic medicines, some peculiar to the nursery, others to the regular practitioner, have been mention- ed and extolled. Of these, some have been consider- ed as specific poison to the insect, and others are con- ceived to destroy it by mechanical triture. Most of them have had their partisans for the day, and have passed in succession, through the ordeal of experience, into oblivion. The utility of such anthelmintics as have been found to be most beneficial, has, in my opi- nion, been in proportion to the purgative powers which they possessed. When I consider the languor and lassitude which precede this marasmus; when I recollect the constitu- tional or acquired debility of those who are more parti- cularly exposed to be affected by it, instead of adopt- ing the common opinion, of its being occasioned by worms, I am more disposed to think that a torpid state, or weakened action of the alimentary canal, is the im- mediate cause of the disease; whence proceed costive- ness, distention of the bowels, and a peculiar irritation, the consequence of remora of the feces. I have ac- cordingly been long in the habit of employing purga- tive medicines for the cure of this marasmus; the ob- ject is, to remove indurated and fetid feces, the accu= 48 ON PURGATIVE MEDICINES mulation perhaps of months; and, as this object is ac- complishing, the gradual return of appetite and vigour mark the progress of recovery. , The history of the disease, from the first indisposi- tion, to the appearance of more urgent symptoms, dis- poses me to consider it as consisting of two stages or periods; the incipient, and the confirmed. The first period extends from the commencement of the disease till the accession of the febrile symptoms. These usher in the confirmed stage, which continues to the end. This is not a frivolous remark; it is of use in practice. In the incipient stage, the bowels are not altogether torpid and inactive, neither are they overloaded with accumulated feces. Mild purgatives, therefore, repeat- ed at proper intervals, effect a cure. They preserve the bowels in proper action, carry off feces which had begun to be offensive and hurtful, and prevent farther accumulation. Neglect, on some occasions, and too great confi- dence in inert medicines on others, allow the confirmed stage of marasmus to steal on imperceptibly. Mani- fest danger now threatens the young sufferer, whose remaining flesh and strength are rapidly wasted by the supervening fever: prostration and depravity of appe- tite withhold necessary nourishment, while the more inactive bowel, and greater bulk of feculent matter, throw additional difficulties in the way of a cure. Un- der these circumstances, I adopt active practice, in the view of stimulating the intestines, and of putting the collected mass in motion without delay. I find these ends are best obtained by giving small doses of the purgative medicine which I employ, and by repeating these frequently; so that the latter doses may support IN MARASMUS. 49 the effects of preceding ones. When the bowels are once opened, stronger purgatives, given at longer in- tervals, will accomplish the cure. In selecting purgative medicines, we must flatter the taste of our young patients. Powder of jalap is not altogether unpleasant. The mild neutral salts, dis- solved in a suitable quantity of beef tea, are also con- venient purgatives; but calomel will prove, on several accounts, the most certain and useful remedy of this kind. I observe calomel to be equally useful in both states of the disease; but great attention must be given during the exhibition of it, without which, as the fetor of the breath prevents us from recognising the mercu- rial fetor accurately, the mouth may be affected unne- cessarily and unexpectedly. While I thus give appropriate purgative medicines, I find it necessary, in order to have full information of their effects, to inspect daily what is passed at stool The smell and appearance of the feces are a criterion of the progress we make in the cure, and direct the far- ther administration of the purgatives. This inspection is the more necessary, as we cannot expect the informa- tion we want from our little patients; and we will of- ten look for it in vain from the attendants, whose pre- judices, and whose ignorance of our views, prevent their seeing the propriety of the inquiry. During the prevalence of the disease, the feces are dark and fetid; they vary from a hard consistence to that of clay, and are often fluid; and such they appear upon the first exhibition of the purgative medicines I observe that the recovery of the sick keeps pace with the return of feces of natural colour, form, and smell: a change which the repetition of purgatives does not fail to produce. 50 ON PURGATIVE MEDICINES While purgative medicines are given after this man- ner, in the confirmed stage of marasmus, in which the obstinacy of the disease is sometimes great, and the danger attending it imminent, nourishing food, of light and digestible quality, and suited to the taste of the patient, and the moderate use of wine, are much wanted. For some time after the symptoms have disappeared, it is expedient to continue a mild stimulus to the bow- els. As they have recently suffered, and have been weakened by over-distention, they are apt to favour subsequent accumulation of feces, the forerunner of a relapse, which is to be dreaded the more, as the pa- tients have been weakened by the previous disease. This gentle solicitation of the alvine evacuation, for it ought to be gentle, is not attended w7ith danger; on the contrary, it is the greatest promoter of recovery in this case, with which I am acquainted. It relieves the stomach and improves the appetite and digestion. Be- sides, nothing more is intended by this practice, than to establish a regular action of the bowels, after long constipation, by procuring daily one or two easy mo- tions, which are indeed at all times necessary to the healthy condition of childhood. With this precaution, I do not feel the necessity of employing tonic and bracing medicines to complete the cure; this object is readily.obtained, in general, by the use of light nourishing food, and by the patient being much in the open air. I do not, however, say that strengthening medicines may not be useful towards the close of the disease, and many practitioners set a value upon them. Lime-wa- ter, infusions of vegetable bitters and chalybeates, are of this description; and, provided they do not, by any IN MARASMUS. 51 peculiar effect on the stomach, prevent nourishment be- ing taken, will advance the return of the tone and vigo- rous action of the stomach and alimentary canal. As marasmus proceeds from symptoms of slight in- disposition, through a series of others which become daily more and more obstinate and dangerous; as the first deviation from health is easily obviated by the sti- mulus of purgative medicines, which brings the slug- gish bowels into regular action, and evacuates their con- tents; and as the disease attacks the young and thought- less, who can hardly explain their feelings, it behoves mothers, nurses, superintendants of nurseries and of manufactories, to whom the care of the young is com- mitted, to watch over their charge with assiduity. Pros- tration and depravity of appetite, a changing com- plexion, tumefaction of the abdomen, scanty and unna- tural stools, and fetid breath, indicate approaching dan- ger. When these, therefore, are observed, assistance should be asked; by the prompt interposition of which much eventual distress, and even death itself, may be prevented. But other considerations weigh with me also, when I call for this assiduity. Marasmus has a close con- nexion with other formidable diseases, and either pre- cedes or seems to accompany them; of these, I shall at present notice two, hydrocephalus and epilepsy. Hydrocephalus internus, the bane of infancy and of childhood, a disease big with much suffering, and of a fatal tendency, has at all times occupied the attention of physicians. They have endeavoured to investigate its nature, to assign the causes which induce it, and to propose curative indications. Different sentiments on these subjects have led them to employ numerous and discordant remedies. Nevertheless, even now they 52 ON PURGATIVE MEDICINES are not agreed as to the causes of hydrocephalus, so in- volved are these in obscurity. Neither have they made the most distant approaches towards the discovery of a certain remedy for it. This much is known, that hydrocephalus often steals slowly on, with symptoms resembling those of incipient marasmus. Till some better theory, therefore, is es- tablished, it is not unreasonable to suppose, that the marasmus, of which I have treated, may on some occa- sions give rise to hydrocephalus, by impairing the vigour of the constitution, and by favouring serous effusion into the ventricles of the brain. This conjecture merits the greater attention on this account, that while the symptoms of hydrocephalus re- semble those of incipient and even of confirmed maras- mus, they have been removed by the diligent exhibition of purgative medicines. The truth of this observation has been repeatedly confirmed in my private practice ; and it affords an additional reason for the exercise of watch- ful attention to prevent the confirmed state of maras- mus, which may, in more instances than we are aware of, have been the forerunner, if not the cause of hydro- cephalus. Epilepsy, than which no disease is so afflicting to the patient, and perplexing to the physician, often ap- pears in childhood. It acquires a hold, and is confirm- ed by the repetition of the fits, till their frequency and the force of habit fix it, and make it a constitutional dis- ease for life. It is not my present purpose to inquire in what man- ner the functions of the organs more immediately af- fected by epileptic paroxysm are influenced, so as to give permanency to the disease. The uncertainty of the theories proposed on this subject, and the little be- IN MARASMUS. 53 nefit that arises from them in practice, hold out little inducement to enter on the discussion. It is, however, I believe, generally understood, that the first attacks of epilepsy are not always idiophatic, but are frequently the effect of particular irritation of the mind or body. There are many instances of irrita- tion of the body inducing epilepsy. When no other is evident the loaded intestine, and the change induced on its contents in the course of the marasmus, of which I have spoken, may be suspected of giving the irrita- tion in question. In fact, practitioners have had this circumstance in view; for they enumerate worms in the intestines, or marasmus, as I understand their language, among the causes of epilepsy. Surely, therefore, this considera- tion suggests another cogent reason for watching the rise and progress of marasmus. And it will induce us, on the first attack of epilepsy in children, arising from an uncertain cause, to set on foot the most decided and active course of purgative medicines; and not peradven- ture to allow the disease to strike root, while we are idly employed in the exhibition of inert and useless ver- mifuge medicines; or are groping in the dark in quest of other causes of the disease, or of uncertain remedies for their removal. In the Appendix, page 52, I give the history of cases of marasmus from the records of the Royal Infirmary, and the narrative of a case of it from the Trades Hos- pital, page 61, and of one by Mr. Stewart, surgeon at Gogar, page 62. I insert also, pages 64, 65, commu- nications from Mr. James Russell, and from Mr. Ben- jamin Bell, in confirmation of the connexion that sub- sists between the marasmus of infancy, and hydroce- phalus. The practice therein set forth coincides with. K 54 ON PURGATIVE MEDICINES and corroborates, the sentiments I entertain respecting marasmus, as inducing, or as being connected with, hy- drocephalus internus. Stronger and more decided proofs of the utility of purgatives given in these in- stances, which had so much of the character and ap- pearance of hydrocephalus, cannot be desired. They inspire confidence in the prosecution of a simple prac- tice, which will rob this scourge of infancy, of child- hood, and early youth, of much of the terror which its most distant approach has been wont to excite, by ob- viating, in many instances, a tendency to a disease, for which, when once fully formed, we are without a re- medy. CHAP. VII. ON THE UTILITY AND ADMINISTRATION OF PURGATrVE MEDICINES IN CHLOROSIS. The young of either, but particularly of the female sex, are exposed, about the age of puberty, to a series of symptoms, which, although slight in the beginning, become, by slow degrees, abundantly distressing and severe. They are ushered in by a disagreeable ex- halation from the mouth, not unfrequently of a fecu- lent ordour; by acid and fetid eructations, by prostra- tion, and depravity of appetite, marked by an aversion from usual food, and a desire for substances which are not digestible, such as chalk, cinders, sand. These symptoms are generally preceded by costiveness, which prevails throughout the disease. \ rosy complexion now gives place to a pale, and IN CHLOROSIS. 55 sometimes to a greenish, and at other times to a yel- lowish colour of skin. The lips and gums exchange their vermilion tint for a death-like paleness; the eyes are dull, and the inferior part of their orbits is puffy, and of a dark hue; the motions become languid and feeble; the pulse, which is generally small and slow, is readily excited to a quick and irregular beat; palpitation of the heart, and hurried and labouring re- spiration are brought on by slight mental agitation, or bodily exertion; syncope often occurs; headach, ver- tigo, dulness, and impaired memory and judgment, afterwards supervene. To these succeeds a peevish and recluse turn of mind, which makes the unhappy sufferer shun society, and court darkness and solitude. In the progress of the disease, the flesh becomes loose and flaccid, the urine is diminished, and the per- spiration seems to be ehecked. Serous effusions into the cellular membrane, produce at first oedema of the lower extremities, and afterwards anasarca. Languor and debility continuing, death, in some instances, closes the scene. Authors have arranged these symptoms indiscrimi- nately under different names, Chlorosis, Leucophleg- matia, and Cachexia. Chlorosis has attracted the no- tice of the earliest medical writers, and various opi- nions respecting its nature and causes have been enterr tained. It is not perhaps necessary at this era, to consider at length the doctrines of the humoral pathology, which prevailed in physic from a remote period, and about which the Boerhaavian school was so much occupied. The dogmata respecting spontaneous gluten, the lentor and fluidity of the blood, and the alkaline and acid acrimonies of the fluids, do not now arrest much atten- 56 ON PURGATIVE MEDICINES tion. Even in the present improved state of chemis- try, we are little able to ascertain the nature of the ani- mal fluids, either in a state of health or of disease; so as to say in what the former consists, or by what devia- tions the latter is induced. Nevertheless, the above- mentioned symptoms of chlorosis have been referred to this supposed cachectic state of the juices; and, to promote a cure, recourse has been had to diluting, in- crassating, and strengthening medicines, and to recti- fiers of peculiar acrimonies. Accordingly, a crude, multifarious, and often inert practice has been adopted,; little calculated for the speedy removal of a disease, which gains strength by delay, and which, in some in- stances, becomes quickly too formidable to be cured by any means that can be devised. WThen the humoral pathology sunk in estimation, other opinions arose, on which the explanation of the symptoms of chlorosis, and the indications for its cure, were founded. As chlorosis generally appears about the age of pu- berty, and in the female, either before, or soon after the first flow of the menstrual flux, many have supposed the retention or suppression of the menses to be the im- mediate cause of the disease. This supposition, how- ever, is liable to objections. We cannot ascertain the precise time at which the retention of the menses may, be considered as a circumstance connected with dis- ease. The age of puberty is not the same in every fe- male : chlorosis may therefore exist long before the, agency of the menstrual flux is felt in the constitution, But, opposed to this theory, a still more conclusive argu- ment is adduced, from the circumstance of chlorosis ap- pearing occasionally among the more feeble and deli- cate of the male sex; for although females are attach IN CHLOROSIS. 57 ed more frequently and more severely with chloiiosis, yet it is not peculiar to them. For these reasons, this doctrine is now generally rejected. Another, founded on the state of the geni- tal organs, occupies its place; it comes from most re- spectable authority, and it has obtained many prose- lytes. Dr. Cullen thus expresses himself in paragraphs M, Ml, MIL MIH, of his First Lines of the Practice of Physic, edition 1789: "These symptoms," namely, some of those which I have enumerated; above, and which the Doctor details, " when occurring in a high degree, constitute the chlorosis of authors; hardly ever appearing separate from the retention of the men- ses; and attending to these symptoms, the cause of this retention may, I think, be perceived. " These symptoms, manifestly, shew a considerable laxity and flaccidity of the whole system, and there- fore give reason to conclude, that the retention of the menses accompanying them, is owing to a weaker action of the vessels of the uterus, which therefore do not impel the blood into their extremities, with a force sufficient to open these, and pour out blood by them. " How it happens, that, at a certain period of life, a flaccidity of the system arises in young women, not ge- nerally affected with such weakness or laxity, and of which, but a little before, they had given no indica- tion, may be difficult to explain; but I would attempt it in this way. " As a certain state of the ovaria in females prepares and disposes them to the exercise of venery, about the very period at which the menses first appear, it is to be presumed, that the state of the ovaria, and that of the uterine vessels, are, in some measure, connected 5g ON PURGATIVE MEDICINES together; and as, generally, symptoms of a change in the state of the former appear before those of the latter, it may be inferred, that the state of the ovaria has a great share in exciting the action of the uterine vessels, and in producing the menstrual flux. But analogous to what happens in the male sex, it may be presumed, that in females a certain state of the genitals is necessary to give tone and tension to the whole sys- tem; and therefore, that if the stimulus arising from the genitals be wanting, the whole system may fall into a torpid or flaccid state, and thence the chlorosis and retention of the menses may arise. " It appears to me, therefore, that the retention of the menses is to be referred to a certain state or affec- tion of the ovaria; but what is precisely the nature of this affection, or what are the causes of it, I will not pretend to explain; nor can I explain in what manner that primary cause of retention is to be removed." In the uncertainty in which Dr. Cullen admits the affection of the ovaria, to which he refers suspended menstruation, as well as the causes of this affection, to be involved, he recommends, in conducting the cure of retention of the menses, to obviate particular symp- toms, by restoring the tone of the system in general, and by exciting the action of the uterine vessels in particular: the same means being subservient to the cure of chlorosis. By this theory, Dr. Cullen attempts to establish, that the retention of the menses, and chlorosis, are coexis- tent diseases, appearing about the age of puberty, and originating in a defective communication of a due stimu- lus from the genital organs, on which the tone and tension of the whole system depend. While I acknowledge the great importance of the IN CHLOROSIS. 59 sexual organs; while I perceive that they influence the character and disposition of the adult of every species of animals; I cannot help thinking that these organs, and the doctrines of their functions, have had too great a share in our pathological reasonings, and too great weight in directing our conduct in the cure of diseases. And having experienced the uncertain- ty of the usual means which these doctrines suggest, for the cure of chlorosis, and the utility of another mode of treatment, I have been led, greatly hesitating, to question the theory of the Cullenian school on this subject. The assumption, that the state of the ovaria, and that of the uterine vessels, have a connexion; and that the former has a great share in exciting the ac- tion of the latter, anu in producing the menstrual flux; the presumption, that a certain state of the genitals is necessary to give tone and tension to the whole sys- tem, and that, if the stimulus arising from this state be wanting, the whole system may fall into a torpid, or flaccid state, whence chlorosis may arise; appear to to be merely a begging of the question, and lead to no certain conclusion, as to the nature or cause of this state of the genitals, the supposed prime mover in the retention of the menses, and in the introduction of chlorosis; or to a knowledge of the means of curing either. The partial and temporary suspension of the influ- ence of the genitals, according to this theory, greatly affects the general system. But there are instances where this influence is altogether and irretrievably lost, and where no disease ensues. Castrated and spayed animals suffer certain changes of constitution, but they retain the enjoyment of perfect health. And. 0Q ON PURGATIVE MEDICINES in our own species, eunuchs, however much degraded in the estimation of society, in consequence of their emasculation, are neither a short-lived nor an unhealthy set of men. Reasoning from this analogy, I do not understand how the influence of the female genitals can be so great, as that its partial suspension should occasion retention of the menses, or should induce chlorosis. Another theory has been broached on this subject, which it elucidates by a reference to sexual desire. In- sinuations, injurious to the purity of mind, and offen- sive to the modesty of the fair sufferers, have been thrown out. The medical moralist talks of the chlo- rosis amatoria, and follows up his notion with appo- site counsel. Into what contradictions do the refine- ments of dogmatism lead us! Can passion exist, when the organs which rouse it have not been, as yet, evolv- ed into action, or if evolved, have been afterwards rendered effete by disease? What bounds can we set to regret, if, in consequence of this ungenerous, and, as I think, groundless supposition, delicacy and reserve have allowed concealment to feed on the damask cheek, and to lead their pale victims to an untimely grave! I could not avoid entering upon these discussions, which I have conducted with all brevity ; I thought it was necessary to show, that the doctrines on the sub- ject of chlorosis are neither so clear nor so well found- ed as to warrant the conclusions which follow neces- sarily from them. In this manner, I prepare the rea- der for the candid consideration of what I have to pro- pose; a candour perhaps not the less wanted on this account, that my opinion of the disease may appear at first sight too simple; and my practice too little adorn- ed with the show of varied prescription. IN CHLOROSIS. g J It would have been fortunate, if medical inquirers had always followed the progress of diseases, step by step, and viewed them as a whole, from the first de- viation from health to their termination. A contrary procedure has often betrayed them into confusion and error. Thus in chlorosis, the doctrine of the cacochymia of the juices, and that of the peculiar state of the genitals affecting the whole system with flaccidity and laxity, are evidently founded on the appearances which the disease exhibits, when it is fully formed; and from which appearance also, it has its name; when, at the same time, the history of its incipient state has been little regarded. The slightest attention to the history of the disease evinces, that costiveness precedes, and accompanies the other symptoms. Costiveness induces the feculent odour of the breath, disordered stomach, depraved ap- petite, and impaired digestion. These preclude a suf- ficient supply of nourishment, at a period of growth when it is most wanted: hence paleness, laxity, flac- cidity, the nervous symptoms, wasting of the muscu- lar flesh, languor, debility, the retention of the menses, the suspension of other excretions, serous effusions, dropsy, and death. This view of chlorosis is confirmed by the explana- tion which it affords of some circumstances connected with it. The feeble and delicate of either sex, in whom the languid action of the bowels readily gives place to costiveness, are more exposed to chlorosis than the robust. Females are, in general, more deli- cate, and in certain ranks of life, are more sedentary than males; hence costiveness and chlorosis are more common with the former than with the latter. It is L <>2 ON PURGATIVE MEDICINES well known, that the alvine evacuation is periodical, and subjected to the power of habit: if the regular call be not obeyed, the necessity for the evacuation passes away; and the call being again and again neglected, habitual costiveness is the consequence. Hence, from the feelings of the sex, and frequently from the want of proper opportunities, costiveness, and its attendant chlorosis, are more prevalent among girls than among boys. Again, the greater capacity of the female pelvis gives more room for that part of the intestinal canal which is contained within it, to dilate, and, of course, to admit of greater accumulation of feculent matter, which, in proportion to its remora, becomes more and more abundant, and more impacted. Hence costiveness is more obstinate, and chlorosis, and other diseases ori- ginating in costiveness, are more severe, and are of more difficult cure in the female than in the male. Impressed with these considerations, and with a pre- vious favourable opinion of the utility of purgative me- dicines in other ailments, I many years ago adopted the use of them in chlorosis. I expected, by obviat- ing costiveness, to remove the stomachic symptoms, and, of course, others that depended upon them. I pursued this practice with the greater readiness be- cause I had experienced, on many occasions, the un- certain and protracted cure of chlorosis, by the reme- dies in common use. Scarcely had I begun the exhibition of purgative medicines in chlorosis, when I had the satisfaction to find that the opinion which I had formed of them was well founded, and that they proved at once safe, and quickly salutary. As chlorosis proceeds by slow degrees, from its commencement to its confirmed state; so I found, ac- IN CHLOROSIS. 63 cording to the progress which it had made, that the bowels were more or less easily moved; for as the fe- culent matter is often accumulated in great quantity, so the expulsion of it is sometimes difficult. Great atten- tion and assiduity, therefore, are requisite in the exhi- bition of purgative medicines in chlorosis, and the strength of their dose, and the frequency of its repeti- tion, must be varied according to circumstances, which are best ascertained by the inspection of the alvine egesta. The practitioner who is not aware of this, and who, yielding to the importunity of his patients, or the caprice of their relations, does not steadily pur- sue his plan of cure, will be disappointed, his abilities will be called in question, and his practice vilified and neglected. When the intestinal canal has been duly evacuated, recovery may be promoted by the interposition of to- nic medicines. If such, however, abate appetite, and induce sickness, they will be of doubtful efficacy. In this case the patient may be directed to trust to the use of nourishing food of easy digestion, and to fre- quent exposure to the open air, when the weather is good. After all, I am not singular in this practice. The favourers of the humoral pathology have recommended a gentle purge, at intervals, to carry off whatever loads the intestines. Others advise the same practice, that the stimulus excited by the purgative may be commu- nicated to the vessels of the uterus, which have con- nection with those of the rectum. But as the objects, in these instances, were only secondary, the direct good effects of purgative medicines seem not to have been understood, or to have been lost in other views, directing other treatment. g4 0N PURGATIVE MEDICINES In concluding this subject, I must observe, how much it behoves those who have the charge of young people, particularly of the female sex, to impress them with the propriety, nay, with the absolute neces- sity of attention to the regular state of the bowels ; and to put in their power, by the use of proper means, to guard against constipation; at the same time, to watch over them, lest, through carelessness or indo- lence, they neglect a circumstance, which promoting, in the gay season of youth, the enjoyment of health and happiness, opposes a sure barrier against the in- roads of chlorosis, always a distressing, and some- times a fatal ailment. The Appendix, page 67, contains cases of chlorosis, which I treated in the Royal Infirmary. They illus- trate the utility of purgative medicines in this disease. CHAP. VIII. ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES IN VOMITING OF BL^OOD. Vomiting of blood is an alarming and often a dis- tressful disease; but having been generally considered to be symptomatic of other affections, it has not found a place in any regular system of physic. I do not propose to attempt a general history of vo- miting of blood. But there is one variety of it, which attacks females who are from eighteen to thirty years of age, and it rarely appears sooner or later than these periods, which I shall endeavour to illustrate. As I confine my attention to this variety, the obser- in vomiting of blood. 65 vations which I am about to make will not apply to vomiting of blood, which originates in organic affec- tion of the stomach, and viscera connected with it, either as a constitutional disease, or as the consequence of previous irregularities and intemperance. I have seen several instances of this vomiting of blood, the cure of which is doubtful in the extreme, and difficult. The attack of the haemorrhagy, of which I am to speak, is preceded by great languor and oppression, both about the chest and the prascordia; and by a sense of fulness of the prascordia; by cough, dysp- noea, and sometimes by pain of breast, by loss of ap- petite, headach, vertigo, and disturbed sleep; the eye is dull, the countenance is expressive of much distress, the pulse is feeble, and the bowels are constipated. In this state of impaired health, a particular fit of sickness and nausea is the immediate forerunner of the attack of the vomiting of blood. The blood vo- mited is sometimes florid, and at other times black, and grumous. The quantity brought up at one time, varies from a few ounces to a pound or more. The distressing symptoms are relieved by this discharge of blood; but are again aggravated, previously to the re- turn of a similar attack. This disease, under the usual management, is of un- certain duration, and of unequal severity. The time of life, at which this haemorrhagy takes place, and the circumstance of being peculiar to the female sex, have induced practitioners to imagine, that it is intimately connected with the menstrual flux; the suppression of which has been generally considered as the sole cause of the disease. It has been said to be a haemorrhagy vicarious of the menses. (Jg ON PURGATrVE MEDICINES The high importance of the uterine system in the animal economy cannot be doubted; but the functions of this system are veiled in deep obscurity, and will not perhaps be at any time clearly understood. They have occupied much of the attention of the speculative inquirer; and ingenuity has been taxed so invent theo- ries in explanation of them, and of their influence, in health and in disease. The menstrual flux, the most obvious of the uterine phenomena, has afforded a wide field for discussion. It is interwoven with the opinions we entertain of al- most every disease to which the female sex is exposed. Its overflow, or its suppression, are the ready ex- pounders of many symptoms; and the fruitful, though perhaps imaginary, source of many diseases. This flux is a constant object of attention to females, who are, in general, well instructed, as to the importance and necessity of it. These theories of the schools, and these early im- pressions on the female mind, give a consequence to this subject, and force it upon the notice of the medi- cal practitioner, who must subscribe to the general opi- nions respecting the menses, and seem to adopt them, although he may question, in some respects, the foun- dation on which they rest, and the conclusions to which they lead. Too curious a research into the arcana of nature is nugatory. These, doubtless, for wise reasons, are placed beyond the ken of mankind. When, there- fore, we adopt the views, and the language of the schools, on points merely theoretical, and deduce practical conclusions from them, it is probable we may err. I, for one, am inclined to think, that too much has been imputed to the influence of the menses, in IN VOMITING OF BLOOD. 67 circumstances of disease. In explaining these circum- stances, we seem to have reasoned too much on a sub- ject that is but too little understood. Interruption of the menses frequently takes place for a length of time, without prejudice to the health. Females often complain, about the usual period of menstruation; and if the menses do not appear, the previous disease is hastily attributed to this circum- stance, which, however, may be said, with greater rea- son, to have caused the suppression. If these things be so, we cannot but regret theoretical disquisitions, which have, in other instances, as well as in the pre- sent one, led us to an attempt of difficult accomplish- ment, and of uncertain issue, the restoration of sup- pressed menstruation; while a different practice, more certain, and more useful, and founded on different views of the case, has either never been devised, or has been entirely neglected. I feel myself at perfect liberty to make these re- flections; because, in the case now before us, the cause assumed, to account for vomiting of blood, proceeds upon limited, or mistaken information. Suspended menstruation is not a necessary concomitant of this haemorrhagy, which appears when the menses are re- gular. I do not know in what proportion of instances this is the case; but if it be so in one instance, this one instance overturns the theory, does away the vicarious nature of the ailment, and gives it a place, where I con- ceive it ought to have one, among idiopathic diseases. About twenty years ago, Dr. Gasking, of Plymouth, passed a season in Edinburgh.—I had the pleasure to be acquainted with him, and I cultivated his friend- ship. At this time I had ascertained the efficacy of 68 ON PURGATIVE MEDICINES purgative medicines in several diseases: f conversed freely with Dr. Gasking on these subjects, communi- cating the observations I had made. Dr. Gasking frequently walked the hospital with me. He observed a patient labouring under vomiting of blood, whom I had been treating in the usual rou- tine, with cooling acidulous medicines, and with dif- ferent emmenagogues, to no good purpose. He request- ed me to open her bowels with calomel; he spoke with the decision which experience gives, and I fol- lowed his advice. This patient was from the country; of a robust make, and hale constitution. She was about twenty years of age. The alvine evacuation, procured on the exhi- bition of the purgative, was copious, and of unnatural appearance. She obtained immediate relief; vomiting of blood did not return; and a few more purgatives established her recovery. She left the hospital, strong- ly enjoined to preserve a regular state of her body, means for this purpose being furnished to her. In three or four months this patient returned, labour- ing under constipation and vomiting of blood. The constipation was again removed, by means of calomel, and a great load of indurated and fetid feces was brought off. In a short time she left the hospital, again cured, and again admonished to be more atten- tive to the state of her bowels. This instructive lesson was not lost upon me; it taught me, that the vomiting of blood of which I speak, depends upon constipation of the belly, a circumstance which I had not before suspected. I have followed the practice which this case suggest- ed, in the instances of the disease which I have since met with; and my success has been so uniform, that I IN VOMITING OF BLOOD. m now lay it down as a certain position, that the proper exhibition of purgative medicines affords sure and ef- fectual means of removing the vomiting of blood of which I speak. The purgatives which I have used in these cases, have never excited vomiting; and, what may be thought singular, I have never been able to ascertain the pre- sence of blood in the feces. As the strength of patients labouring under this vo- miting of blood is generally pretty entire, we need not dread full purging; but this effect is not wanted; if we unload the bowels, we accomplish the cure. The feces which are brought off are copious, unna- tural in colour, consistence, and smell, as they gene- rally are after long remora, the consequence of obsti- nate and protracted constipation. The different circumstances, which not only expose women to costiveness more readily than men, and when it does occur, to a more obstinate kind of it, as mentioned in the chapter on chlorosis, may explain, why they are exclusively the subjects of this disease: —A consideration, which affords me a strong addi- tional argument, for inculcating the most sedulous at- tention to the careful support of a regularly acting state of the bowels: the only security against costiveness, that bane of health, and source of manifold distress. In conducting the cure of vomiting of blood, I have not confined myself to the use of calomel alone; I have occasionally substituted other purgative medi- cines, as will be instructed by the cases inserted in the Appendix, page 74. M 70 ON PURGATIVE MEDICINES, &.c I embrace the opportunity, which the printing of the fifth edition of my Observations affords me, to give a short notice of an ailment, analogous to the one which is the subject of this chapter, and of which I have seen no account in authors. This disease consists in the discharge of blood by the anus, when the patient is at stool. It is not- accompanied with haemorrhoidal or local affection, or with pain. It takes place at uncer- tain intervals, and is of longer or shorter duration on each attack. It generally excites alarm, and is so profuse at times, as to induce weakness and leuco- phlegmatic tendency. I have witnessed this haemor- rhagy more frequently in the male than in the female; upon inquiry, constipation was found to attend it in every instance; and I have not failed in general to re- move it, in a short time, by means of purgative medi- cines, so exhibited as to insure satisfactory alvine eva- cuations. The discharge has sometimes ceased after the first purgative; and I have reason to believe that my patients, b) observing my directions respecting a regular state of the bowels, obtained complete cures, as none of them have applied to me a second time for the same ailment. I have found aloes to be the most useful purgative in this species of haemorrhagy. In one instance my expectations of a cure were not ful- filled: but there was some ambiguity in the case, and the patient had for years indulged freely in the plea^ sures of the table. 11 CHAP. IX. OBSERVATIONS ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES IN HYSTERIA. The symptoms of hysteria are numerous, and being differently modified in different instances, they give a variety of the disease which is embarrassing to young practitioners. The most common symptoms of hysteria, and those which are esteemed to be pathognomonic, are acute pain in the forehead, or over either orbit, which is con- fined to a small spot; shifting pains of th© abdomen, flatulence, constipation of the body; sometimes, though rarely, vomiting and purging; acid and fetid eructa- tions; and irritable, and occasionally a despondent state of mind; unquiet sleep, which is frequently dis- turbed by incubus and frightful dreams. These symptoms produce the chronic state of hys- teria, and predispose to the excitement of the more violent hysteric affections, fits, or convulsions. These fits sometimes attack suddenly, but are more frequent- ly preceded by other symptoms, which give warning of their approach; such as a sense of oppression over the chest, palpitation of the heart, a dry cough, a co- pious flow of pale-colm^ed urine; and above all, by the sensation, as if a ball, formed in the lower part of the belly, traversed the abdomen, ascended by the left side, and reached the stomach, and from it the oeso- phagus and larynx, producing difficult deglutition and sense of suffocation After this the patient falls down, and is violently 12 ON PURGATIVE MEDICINES agitated with convulsions of different muscles, particu- larly of those of the abdomen, which is thereby greatly contracted and drawn inwards. This convulsive mo- tion continues for some time, when sleep supervenes, From this sleep, the patient awakes sobbing and sigh- ing, and with a murmuring noise throughout the abdo- men; and most commonly without any recollection of What has passed during the fit. This fit is frequently renewed for a length of time in the same person, who enjoys tolerable health during the intervals. Hysteria is more frequent and more severe in women than in men. Hence it has been thought, although erroneously, to be peculiar to females. The period when it prevails most, is from puberty to the age of thirty-five. Women of a plethoric habit, or of what is called the sanguine temperament, are most commonly exposed to it; and in them it often ac- companies the regular flow of the catamenia. Different slight causes readily induce hysteric pa- roxysms, in persons predisposed to them, such as fa- tigue, great and sudden evacuations, peculiar odours, and certain objects, which, either from a constitutional or acquired aversion, occasion unpleasant or uneasy sensations. Mental agitations, also, from surprise, grief, joy, and other passions, are common exciting causes of hysteria. Here too the medical moralist again appears; but I believe his insinuations, equally groundless and indelicate, exist only in his own pru- rient imagination. 1 have felt the necessity of premising this short histo- ry of a disease, which it is indeed difficult to describe, because I shall refer to it in the subsequent part of this chapter. Frequent disappointments in curing hysteria led me IN HYSTERIA. 73 to take a full, and I hope an impartial review of the subject. This review has inclined me to doubt the solidity of the opinions which have been entertained respecting hysteria, and the soundness of that uniform practice, which has been so long followed in the treat- ment of it. Hysteria, ^s this name implies, has been conceived to proceed from affections of the uterus. Accord- ingly, suffocation of the womb, and effluvia from cor- rupted semen and depraved menstrual blood, are, by the suffrage of the ancient, and even of some of the more modern physicians, accounted to be its immediate cause. This doctrine, however, is now so little re- garded, that it is unnecessary to adduce arguments in refutation of it. Our countryman, Sydenham, who reasoned more than he seems to have been aware of, and often in a manner not very intelligible, in dissertatione episto- lari ad Gulielmum Cole, third edition, page 362, speaks thus of hysteria. " Pendent ergo, affectiones istse, quas in feminis hystericas, in maribus hypochon- driacas insignire libet, quantum ego judico, a spirituum animalium *t<*|<* unde facto impetu in hanc illamve partem plus quam pro rata densi nimiique ferunter, spasmos uti et dolorem excitantes ubi in partes sensu exquisito praeditas irruunt, atque organorum, tum ejus in quod se ingerunt, tum istius a quo abscedunt, func- tiones pervertentes; cum utrumque ab hac tarn iniqua partitione, quae naturae oeconomiae penitus adversatur, ■baud parum detrimenti capiat/' rt Hie jam spiritus, facto quasi agmine in ventre in- feriore, catervatim, magnoque impetu in fauces irruen- tes, spasmos excitant per omnem quam transeuent re- gionem, ventrem inflantes ad instar globi prae grandis, 74 ON PURGATIVE MEDICINES qui tamen nihil aliud est quam partium spasmo tenia- tarum convolutio et quasi conglobatio quaedam, quae non nisi magna vi reprimi potest et coerceri." Page 363. " Satis itaque jam constat opinor, omnem hunc mor- bum ad spiritus animales non rite dispositos referri de- bere; nee a semine aut sanguine menstruo corruptis, quod asserunt nonnulli authores, et halitus malignos in partes affectas elevantibus, produci; nee a succorum nescio qua perversa depravatione, sive etiam humorum acrium congestione, ut alii volunt; sed ab iis quas modo assignavimus causis." Page 368. To quote these passages, setting forth Sydenham's doctrine on this subject, is, I apprehend, pace tanti viri, to refute it. For indeed it is not easy to comprehend what Sydenham understands by the animal spirits; or in what manner they are impelled by rapid motion from one place or organ into another, so as to produce precisely the hysterical convulsion. When the nervous pathology attracted the notice and admiration of the public, another opinion was formed of this disease. Dr. Cullen, in his First Lines of the Practice of Physic, paragraphs MDXX, MDXXI, MDXXII, MDXXIII, says—"Having thus endeavoured to dis- tinguish hysteria from every other disease, I shall now attempt its peculiar pathology. With respect to this, I think it will, in the first place, be obvious, that its paroxysms begin by a convulsive and spasmodic affection of the alimentary canal, which is afterwards communicated to the brain, and to a great part of the nervous system. Although the disease appears to begin in the alimentary canal, yet the connection which the paroxysms so often have with the menstrual flux, IN HYSTERIA. 75 and with the diseases that depend on the state of the genitals, shows that the physicians have at all times judged rightly in considering this disease as an affec- tion of the uterus and other parts of the genital system. " With regard to this, however, I can go no farther. In what manner the uterus, and in particular the ova- ria are affected in this disease; how the affection of these is communicated, with particular circumstances, to the alimentary canal; or how the affection of this, rising upwards, affects the brain, so as to occasion the particular convulsions which occur in this disease, I cannot pretend to explain. " But although I cannot trace this disease to its' first causes, or explain the whole of the phenomena, I hope that with respect to the general nature of the disease, I may form some general conclusions, which may serve to direct our conduct in the cure of it. "Thus, from a consideration of the predisponent and occasional causes, it will, I think, appear, that the chief part of the proximate cause is a mobility of the system, depending generally upon its plethoric state. " Whether this disease ever arises from the mobility of the system, independent of any plethoric state of it, I cannot positively determine; but in many cases, that have subsisted for some time, it is evident that a sensi- bility, and consequently a mobility, are acquired, which often appear, when neither a general plethora can be supposed to subsist, nor an occasional turgescence to have happened. However, as we have shown above, that a distention of the vessels of the brain seems to occasion epilepsy, and that a turgescence of the blood in the vessels of the lungs seems to produce asthma: so analogy leads me to suppose, that a turgescence of ^(j ON PURGATIVE MEDICINES blood in the uterus, or in other parts of the genital sys- tem, may occasion the spasmodic or convulsive motions which appear in hysteria. It will, at the same time, be evident, that this affection of the genitals must es- pecially occur in plethoric habits; and every circum- stance mentioned in the history of the disease, serves to confirm this opinion, with respect to its proximate cause." It is not without hesitation, that I oppose any opi- nions which Dr. Cullen has promulgated and support- ed. But my observations respecting the influence of the uterine or genital system in vomiting of blood and chlorosis, and my conclusion from thence, that this in- fluence, if it does exist, is not of that magnitude which is commonjy supposed; militate equally against the opinion that hysteria originates in this influence. I cannot, therefore, but consider Dr. Cullen's theory as resting more upon supposition, and a consequent train of reasoning, than upon facts and experience; and as meriting less attention now than it has commanded for many years. There is a coincidence and similarity between the doctrine of Sydenham and that of Dr. Cullen, on the subject of hysteria. At least the «r«|<«, or irregular mo- tions of the animal spirits, proposed by the former, ap- pear to convey the same idea, as the sensibility and mobility of the system of the latter. Setting aside, therefore, the antiquated notion of the suffocation of the womb, we may be said to have only one theory of this disease; a theory which has engrossed the atten- tion of the speculative physician, and which has direct- ed the conduct of the practitioner for upwards of a century. But although this coincidence may not be perceived IN HYSTERIA. 77 or admitted by others; yet whatever difference, whe- ther apparent or real, may exist between the opinions of Sydenham and of Dr. Cullen, the practice of both, with some slight variations, is nearly the same. Fetid and antispasmodic medicines, are employed to alle- viate tbe violence and shorten the duration of particu- lar fits; blood-letting is not excluded from the practice of either in hysteria, but Sydenham is disposed to em- ploy it more freely than Dr. Cullen. I do not perceive that Dr. Cullen any where mentions purgative medicines as proper in hysteria; Sydenham gives them, previous to the exhibition of other medicines, for three or four following mornings, page 371. Dr. Cullen proposes to remove plethora, by blood-letting, a spare diet, and regularexercise; while, at the same time, he cautions us, that increased mobility may, on some occasions, proceed from inanition, when a fuller supply of nou- rishment, and tonic medicines are indicated, as in epi- lepsy, paragraphs MCCCXXV, and following ones. For the rest, both these learned and justly celebrat- ed men, treat hysteria with astringent, stimulant, and tonic medicines, in the view of restraining and regulat- ing the irregular motion of the animal spirits, or of ob- viating the too great sensibility and mobility of the system. The cure of hysteria, by this management, is often difficult, and generally tedious. Physicians have had correct views with regard to the history and appearance of hysteria. But the pecu- liarity and violence of the fits seem to have attracted all their thoughts, and prevented them from bestowing the necessary attention on other circumstances of the disease. For this reason, I premised a history of hysteria, which does not differ from other histories, except in the arrangement of the symptoms, by which, N 78 ON PURGATIVE MEDICINES those which precede the fit, those which accompany the fit, and those which immediately follow it, are clearly ascertained and distinguished. Among the symptoms which mark the hysteric con- stitution, shifting pains of the abdomen, flatulence, con- stipation at one time, at another vomiting and purging, together with acid and fetid eructations, are conspi- cuous. The sensation of a ball wandering through the ab- domen, and ascending to the stomach, and from thence through the oesophagus to the pharnyx, is a promi- nent symptom among those which immediately pre- cede, and give warning of the approach of the fit. Convulsive motions of the muscles of the abdomen, which is thereby greatly contracted and drawn in- wards, accompany the paroxysm: upon the cessation of which, a murmuring noise throughout the abdomen is frequently heard. These symptoms undoubtedly denote a preternatu- ral affection of the stomach and alimentary canal. In my opinion, they afford conclusive evidence, that this affection is primary, and that the other multifarious symptoms of hysteria depend upon it. I have, there- fore, thought it reasonable to attend particularly to the state of the stomach and intestines, and to employ, in the first place, purgative medicines, to remove the constipation of the body, which most commonly pre- vails in hysteria. I have seldom seen vomiting and purging in cases of pure hysteria; but even their pre- sence would not deter me from exhibiting purgatives, the efficacy of which, in removing these symptoms in other'circumstances of disease, is well known. I was the more disposed to adopt this practice in hysteria. from my experience of its general safety and peculiar IN HYSTERIA. 79 utility in other diseases, that are commonly supposed to be of a nervous nature I have not been disappointed in my expectations in thus treating hysteria; my success has been equal to my wishes, and the source of much satisfaction to me. Yet my experience is not so complete as to enable me to say to what extent purgatives may be employed in hysteria, exclusively of other medicines. Within cer- tain limits, I accordingly call in the aid of fetid and tonic medicines; but, in my estimation, they are merely subsidiary, and, on some occasions, may be altogether overlooked, as they were in the treatment of Isabel Black and Sarah Macmillan, whose cases are inserted in the Appendix, pages 84 and 86. In particular instances, where great anxiety prevails, re- course may be had to wine in moderate quantity, till such time as relief is obtained by purgatives. I may add, by way of caution, that in hysteria, as well as in chlorosis, and vomiting of blood, the full exhibition of active purgatives is necessary to procure even moderate evacuations from the bowels; and that this exhibition must be continued from day to day, un- til such time as the feces are natural, or until the dis- ease ceases. The first purgatives that we use may seem, on some occasions, to aggravate the symptoms; but the practice must not be deserted on this account. The additional irritation which purgatives may give in the first in- stance, soon passes away; and perseverance in the use of them removes that irritation which gave rise to the disease, which, of course, disappears in proportion as the bowels are relieved of the oppressive mass of ac- cumulated feces. There are instances of counterfeited hysteria, when 8(5 ON PURGATIVE MEDICINES, &c. persons of a perverse turn of mind, or who wish to excite compassion, or solicit charity, often imitate the paroxysm of hysteria so exactly, as to deceive com- mon observers. It is plain, that any remedy used in these cases must fail, so long as the impostor finds it convenient to carry on the deception. The practi- tioner who proposes to adopt the use of purgative me- dicines in hysteria, ought previously to satisfy himself that the disease really exists; otherwise the failure of promoting a cure, as in feigned cases he must fail, will bring discredit on the practice, which, having found useful, I have endeavoured to recommend. I have subjoined, in the Appendix, page 82, cases of hysteria which I have treated by purgatives;—to these I refer the reader, who will, in them, find a de- tail of my practice, and of my general mode of con- ducting it. The reader will find also in the Appendix, page 88, a letter from Mr. Law, one of the surgeons of the Royal Infirmary, and surgeon to the Bridewell of Edinburgh, addressed to me, in which he gives an account of a case of hysteria, which he treated suc- cessfully by purgative medicines. *i CHAP. X. OBSERVATIONS ON THE UTILITY AND ADMINISTRATION Of PURGATIVE MEDICINES IN CHOREA SANCTI VITI, OR ST. VITUS'S DANCE. Systematic writers have paid little attention to Chorea Sancti Viti; and practitioners have regarded it with indifference. These circumstances will surprise us the more, when we consider the formidable appear- ance of the disease, the obstinacy with which it holds its course, and the distressful state to which it always reduces, and the danger in which it sometimes involves, those whom it attacks. Dr. Sydenham described chorea Sancti Viti a hun- dred and twenty years ago; and his description, with little variation or addition, has been copied by the few succeeding authors who have written on the subject. Sydenham, in his " Schedula Monitoria de novae febris ingressu," gives the history of chorea Sancti Viti, in the following words: (i Chorea Sancti Viti convulsionis est species, quae ut plurimum pueros puellasve a decimo aetatis anno, ad pubertatem usque invadit; primd se prodit clau- dicatione quadam vel potius instabilitate alterutrius cruris quod seger post se trahit fatuorum more; postea in manu ejusdem lateris cernitur, quam, hoc morbo affectus, vel pectori, vel alii alicui parti adplicitam, nullo pacto potest continere in eodem situ vel horae momento, sed in alium situm, aliumque locum convul- sione quadam distorquebitur quicquid aeger contra nitatur. Si vas aliquod potu repletum in manus por- 82 ON PURGATIVE MEDICINES rigatur, antequam illud ad os possit adducere, mille gesticulationes, circulatorum instar, exhibebit; cum enim poculum recta linea ori admovere nequeat, de- ducta a spasmo manu, hue illuc aliquamdiu versat, donee tandem forte fortuna illud labris propius appo- nens, liquorem derepente in os injicit, atque avide haurit, tanquam misellus id tantum ageret, ut dedita opera, spectantibus risum moveret." This history, so far as it goes, is correct. It ex- hibits a faithful picture of the disease, of the various contortions and gesticulations of the patient. But it is silent on other circumstances, the affections of the na- tural and animal functions, which are essential to the disease, and which ought not to have been omitted. Besides, Sydenham details the symptoms of the ad- vanced and confirmed state only, while he either has not perceived, or has altogether overlooked, the rise and progress of chorea. For these reasons, I give the following more extended narrative of the symptoms of chorea. Chorea Sancti Viti attacks boys and girls indiscri- minately; and those chiefly, who are of a weak con- stitution, or whose natural good health and vigour have been impaired by confinement, or by the use of scanty or improper nourishment. It appears most commonly from the eighth to the fourteenth year. I saw it in two young women, who were from sixteen to eighteen years of age. The approaches of chorea are slow. A variable, and often a ravenous appetite, loss of usual vivacity and playfulness, a swelling and hardness of the lower belly in most cases; in some a lank and soft belly, and, in general, a constipated state of the bowels, ag- gravated as the disease advances, and slight irregular IN CHOREA SANCTI VITI. S3 involuntary motions of different muscles, particularly of those of the face, which are thought to be the effect of imitation, precede the more violent convulsive mo- tions, which now attract the attention of the friends of the patient. These convulsive motions vary. The muscles of the extremities, and of the face, those moving the lower jaw, the head, and the trunk of the body, are at dif- ferent times, and in different instances, affected by it. In this state, the patient does not walk steadily; his gait resembles a jumping or starting; he sometimes cannot walk, and seems palsied; he cannot perform the common and necessary motions with the affected arms. This convulsive motion is more or less violent, and is constant, except during sleep, when, in most in- stances, it ceases altogether. Although different mus- cles are sometimes successively convulsed, yet, in ge- neral, the muscles, affected in the early part of the disease, remain so during the course of it. Articulation is now impeded, and is frequently com- pletely suspended. Deglutition is also occasionally performed with difficulty. The eye loses its lustre and intelligence; the countenance is pale, and expres- sive of vacancy and languor. These circumstances give the patient a fatuous appearance. Indeed, there is every reason to believe, that, when the disease has subsisted for some time, fatuity to a certain extent in- terrupts the exercise of the mental faculties. Fever, such as arises in marasmus, is not a neces- sary attendant on chorea; nevertheless, in the ad- vanced periods of the disease, flaccidiy and wasting of the muscular flesh take place, the consequence of constant irritation, of abating appetite, and impaired g 4 ON PURGATIVE MEDICINES digestion, the common attendants of protracted chorea, and which, I doubt not, may, in some instances, al- though contrary to the opinion that chorea is not fatal, have been the forerunners of death. From this history, chorea may be considered as con- sisting of two states or stages; the incipient and the confirmed. The incipient state takes place from the first derangement of health, till the full formation of the involuntary motions; with these the confirmed state commences, and continues to the end of the dis- ease. After detailing the history, Sydenham proceeds, in the Schedula Monitoria, to deliver his theory and his conduct of the cure of chorea. " Cftm affectus iste," (chorea scilicet,) rt ab humore aliquo in nervOs irruente, quorum irritatione istius- modi motus praeternaturales producuntur, pendere mihi videretur; indicationes curativas primum ad humores illos tain venaesectione, quam purgatione minuendos, dein ad corroborandum genus nervosum omnino diri- gendas censebam. Quern in finem hac utor methodo. Sanguinem ex aegri brachio ad uncias septem, plus vel minus, pro ratione aetatis, educi jubeo. Die se- queute vel dimidiam partem, vel quiddam amplius, (pro ratione vel aetatis, vel etiam majoris minorisve corporis, ad subeundam catharsin, aptitudine), potionis purgantis communis exhibeo. "Recipe—Tamarind, unciam dimidiam; fol. senn. drachmas duas; rhabarb. drachmam unam et dimi- diam; coq. smI*. quant, aq. ad uncias tres, in colat. dis- solv. mann. et syr. rosar. solutiv. utriusque unciam. " Et vespere haustulum paregoricum propino. " Potionem istam catharticam ad tres vices alternis diebus repetendam prescribo, et haustum paregoricum IN CHOREA SANCTI VITI. 85 iisdem noctibus. Postea sanguinem rursus extrahi euro, dein ut ad catharsin, uti prius, aeger revertatur. Atque ita, alternatim sanguinem mitto, et subduco alvum donee aegro vena ter quaterve fuerit incisa, et post singulas venaesectiones toties fuerit purgatus, quo- ties vires ferre posse viderentur; eo tamen temporis spatio inter alternas evacuationes diligenter observato, ut nihil inde periculi aegro immineat. Diebus a purga- tion evacuis, sequentia prescribe" Ho3c sunt medi- camenta stimulantia, uti dicuntur, corroborantia, et alierantia quce hie recensere inutile est. " Quanto magis convalescit aeger, tanto minus pe- dem ducit, tanto parjter et diutiiis, et constantius ma- num in eodem situ continet, et scyphum ori magis di- rects via admovet: quae certissima sunt indicia quan- tum profecerit in sanitate redintegranda. Ad quam quidem consummates perficiendam, licet author non sim ut plus ter quaterve ut plurimum sanguinem emit- tat aeger, attamen remedia cathartica et alterantia eousque in usum sunt revocanda donee rectissime tan- dem valeat." Sydenham mentions his success under this ma- nagement: "Quo morbo,'' chorea scilicet, "haud pau- ciores quinque laborantes et vidi, et sanavi ipsemet." Sydenham passes over in silence the time requisite for the cure of chorea. The intervals, however, be- tween the three or four bleedings, during which purga- tive and paregoric medicines were given, and the in- junction to continue the use of cathartics and alteratives, after the last blood-letting, till the patient is at length completely recovered, make it probable, that many weeks, if not months, must have elapsed before the cure was effected. The theory of the present day differs from that of o 86 ON PURGATIVE MEDICINES Sydenham, which, although not very intelligible, may be as good as its substitute; and the only useful part of his practice has been overlooked. Later physi- cians, therefore, instead of elucidating the theory, and of improving the method of curing chorea, appear to me to have been retrograde in both respects. It is now difficult to say, for what length of time the authority of Sydenham, and the credit which his opi- nions obtained, encouraged and protected the practice which he recommended. It is certain, however, that a doctrine and practice discordant with his have long prevailed. And it is probable, that the anxiety ex- pressed by Sydenham, that, in the administration of blood-letting and purging, his patients should catch no harm; together with the weakness, both of body and mind, characteristic of the disease, may have in- troduced this change. Be this as it may, physicians are now inclined to refer chorea to a certain debility, or loss of tone, in which the convulsive involuntary mo- tions originate. They of course neglect the " humor aliquis in nervos irruens;" they convert the caution of Sydenham into a total prohibition of blood-letting and purging; and in the cure of chorea they adopt the ex- clusive employment of stimulant and tonic medicines. Under this practice, opium, camphor, sulphuric aether, valerian, cinchona, and different vegetable bit- ters, zinc, steel, ammoniaretum cupri, cold-bathing, and electricity, are the medicines which have been chiefly used. Most of these are casually mentioned in periodical publications, and are supported by that au- thority only which attaches to solitary facts. De Haen is an advocate for electricity. In his Ratio Medendi he gives several cases, in which it appears to have been IN CHOREA SANCTI VITI. 87 exhibited with success. Medical electricity has, how- ever, lost much of its early celebrity. Notwithstanding the employment of these remedies, chorea has been found a tedious disease; experienced practitioners having admitted that it has continued for many months, nay, for years, terminating only on some occasions about the age of puberty. This confession is not much in favour of the modern practice, or of the doctrine on which it rests. It is me- lancholy to reflect, that months, and years, the most valuable in respect of after life, should glide on, while an effectual check is given to the improvement of the mind, the cultivation of useful learning, or the acqui- sition of the necessary arts; with the hazard of perma- nent fatuity, to a certain extent, or of a grotesque ap- pearance, from the unconquerable remains of irregular motions being imposed on the young sufferers for life. To these certain consequences of protracted chorea I will add, the danger which attends it; I have no doubt but that it must have, on some occasions, proved fatal. In the course of my practice I have seen about forty cases of chorea; a greater number than may have fallen to the lot of many to observe. I cannot say, with Sydenham, that I have succeeded in curing all of these. For several of my patients presented them- selves while I yet employed tonic and stimulating me- dicines; when my practice shared the common fate, and met with disappointment. I am afraid I may even sometimes have done harm, by the indiscriminate use of the cold-bath, a remedy not always suited to the ex- hausted and irritable state of the subjects of chorea. I now began to desert a practice in which I had lost confidence, and to consider chorea in a different light from that in which it had been commonly viewed. Qg ON PURGATIVE MEDICINES I conceived that the debility and spasmodic motions, hitherto so much considered, might not be the leading symptoms of the disease, but might depend upon pre- vious and increasing derangement of health, as indi- cated by irregular appetite, and constipation of the bowels. Under this impression with regard to the erroneous opinions which I had heretofore entertained concerning the nature of the disease, and the consequent improper practice which I had employed for the cure of it, I re- Solved to alter my mode of treatment, in order that I might fulfil those indications which the new, and, as I flattered myself, the more correct view of the disease had suggested. If my conjectures were well founded, that first and principal object of practice would be to remove the constipated state of the bowels. In pursuance of this object, I began to try the effects of purgative medicines, given regularly in moderate doses. At first, I confess, I acted with all that caution and diffidence which the adoption of a line of practice at variance with that which had been long approved and established naturally inspires. But experience had convinced me of the safety of exhibiting purgative me- dicines in typhus fever; I therefore did not think any great risk would ensue from a cautious use of them in the most debilitated state, which chorea might induce. The conjecture proved to be well founded; the suc- cess of the practice confirmed the justness of the opi- nion on which it was formed, and encouraged me to persevere with steadiness and decision. The purgatives which I employed in the first in- stance were of the weaker kind, and inadequate to the object iO be obtained. Stronger ones were found to be IN CHOREA SANCTI VITI. 89 necessary to move and discharge the indurated and fetid feces. I observed the quantity of feculent matter collected, to vary in different subjects, and at different periods of the ailment. I could not ascertain this by any pre- vious circumstance. One would think, that the accu- mulation would be in proportion to the fulness and prominence of the abdomen; and I do not find that this is the case. Perhaps the lengthened duration of the ailment, and the reduced state of the patient, the consequence of this, are attended with the greatest fe- culent accumulation. I think my observation bears me out in this conjecture, as in the instance of David Anderson, the history of whose case will be found at page 94 of the Appendix. This boy was emaciated and exceedingly puny, and his abdomen was lank; yet, from the fifteenth day of December, when the commencement of his recovery was observable, to the 25th day of the same month, the quantity of feces dis- charged was most wonderful, such as I had never seen before. It appeared to me, during the above period, to have nearly equalled in weight that of the whole body of the extenuated patient. I have already noticed, that chorea consists of two stages. In the first, while the intestines yet retain their sensibility, and before the accumulation of feces is great, gentle purgatives, repeated as occasion may require, will readily effect a cure, or rather prevent the full formation of the disease. In the confirmed state, more sedulous attention is necessary. Powerful purgatives must be given in suc- cessive doses, in such manner that the latter doses may support the effect of the former, till the movement and expulsion of the accumulated matter are effected, 90 ON PURGATIVE MEDICINES when symptoms of returning health appear. Whoever undertakes the cure of chorea by purgative medicines, must be decided, and firm to his purpose. The con- fidence which he assumes is necessary to carry home, to the friends of the patient, conviction of ultimate success. Their prejudices will otherwise throw in- surmountable obstacles in the way. Half measures, in instances of this kind, will prove unsuccessful; and were it not for perseverance in unloading the alimen- tary canal, the disease would be prolonged, and would place the patient in danger, and thus bring into discredit a practice which promises certain safety. Here, as in all other cases of extreme debility in- duced by disease, the recovery is at first slow and gra- dual. A regular appetite for food, a more intelligent eye, and lightened countenance, cheerfulness, and playfulness of temper, increasing aptitude for firmer motions, the restoration of articulation, and of the power of deglutition, a renovation of flesh and strength succeed each other, and being more and more confirm- ed, are, ere long, followed up by complete recovery. For some time after these salutary changes take place, the state of the bowels must continue an object of attention. An occasional stimulus from purgatives will be requisite to support their regular action, and to restore their healthy tone, the only security against the renewed accumulation of feces and of a consequent re- lapse. About this time, also, remedies, possessed of tonic and stimulant powers, may be used with propriety and effect; they restore energy to the torpid bowels, aid the purgative medicines in obviating costiveness, and thus confirm a recovery already advanced. Vegeta- ble bitters, or the preparations of steel, may perhaps IN CHOREA SANCTI VITI. 91 be the most useful for accomplishing these ends. I have not felt the necessity of having recourse to medi- cines of this kind; under a proper regimen of light and nourishing food, and of exercise in the open air, my patients, in general, quickly recover their strength. But many practitioners set a value upon tonic medi- cines; and the usual routine of practice demands them. By this treatment, which I have endeavoured to* re- commend, chorea is speedily cured, generally in ten days or a fortnight, from the commencement of the course of purgative medicines. I had lately two pa- tients, Anne Ross, and Elizabeth Webster, under my care, whose cases proved obstinate; four or five weeks elapsed, before I could pronounce them in the way of recovery. The history of these cases is given at pages 99 and 107 of the Appendix. Some time ago I visit- ed a boy, about twelve years of age, labouring under chorea, who was the object of my daily attention for five months. During this time, the amount of purga- tive medicines which were given, and the quantity of unnatural feces which were passed, would, I own, have appeared incredible to myself, had I not given the one, and had I not been an eye-witness of the other. By perseverance, I effected a complete cure of this protracted case. In the structure of the female pelvis, and in the pre- vious duration of chorea, we may find in part the rea- son why it admits of a more or less difficult cure. When the disease is protracted, or when it occurs in girls, greater opportunity for the accumulation of fe- culent matter is afforded, than in more recent cases, or than where it attacks boys. Of course, a longer time, and brisker purgatives, will be required to move, and expel the offending mass, in the former, than in the Q2 ON PURGATIVE MEDICINES latter instances. This observation is aptly illustrated by the case of Elizabeth Webster, inserted at page 107 of the Appendix. This girl, after a protracted chorea, was dismissed cured from the Royal Infir- mary, on the eleventh of June 1805, but through ne- glect, the disease returned, and she again became a pa- tient on the third of February 1806, Appendix, page 116; the relapse, however, being recent, the cure at this time was completed in ten days. This rule, how just soever it may be in most instances, is not applica- ble to every case of chorea. Nelly Parker, Appen- dix, page 118, had laboured under chorea for two years ; and yet was nearly cured by the use of purga- tive medicines in little more than two months. Other circumstances, therefore, besides those now mentioned, must be taken into consideration, when we attempt a prognosis in chorea; but what these are I have not learnt. During the exhibition of purgative medicines in chorea, practitioners will learn the propriety and ne- cessity of inspecting the alvine evacuations. They are, in this important point, generally careless; the attendants, in sick rooms, are of course ignorant on the subject, and cannot give the information necessary for ascertaining the effect of the medicines, the extent of the subsequent dose, or the frequency of its repeti- tion. I have said that chorea consists of two stages, a cir- cumstance which should induce those who have the superintendance of children to attend most carefully, at all times, to the state of their bowels. For the timely interposition of purgative medicines will be the best means of averting the accession of chorea, which is so formidable, and which, on some occasions, has IN CHOREA SANCTI VITI. 93 been found an obstinate, and, I doubt not, on others, a fatal ailment The caprice of children will often thwart us, and oblige us to employ purgatives, not because they are such as we would prefer, but because they are such as will be taken. I have in general used the purgative medicines in chorea, which I had found useful in ma- rasmus. I have inserted, in the Appendix, page 90, the histories of some cases of chorea, which, while they illustrate the practice I have endeavoured to re- commend, will, at the same time, show the manner in which I have conducted it. This exhibition of purgative medicines in chorea is, I apprehend, countenanced by the practice of Syd- enham, De Haen, and Dr. Stoll of Vienna. It is probable, that the purgative medicine was the only useful one which Sydenham employed; and that his protracted cures may be attributed to the interrup- tion of the use of it, during the interposition of blood- letting, and of alterant and paregoric medicines. De Haen, in the eighth chapter of his first volume of the Ratio Medendi, narrates a case, in the follow- ing words:—" Novem annorum puellam, cui post vario- las morbillosque, primo tussis frequens, deinde sputum purulentum aderat, sputum demum plane cessabat, chorea Sancti Viti prehendit, sinistro potissimum bra- chio pedeque, ac diversimoda faciei convulsio. Bime- stri spatio, adhibita vi electrica, pustulae copiosae, eaeque turpiter crustosae, brachium et crus cingunt, in- terpolatis purgantibus perfecta salus redivit." Maximillian Stoll, supposed to have been the sue- p Qi ON PURGATIVE MEDICINES cessor of De Haen, gives, in a clinical work, not much known in this country, two cases of chorea which he treated successfully. I transcribe these as translated by Dr. Kellie, from a paper in the second volume of the Edinburgh Medical and Surgical Journal, page 423. " A young man of sixteen was, on the 23d May 1779. affected with sickness and giddiness of the head, being in other respects well enough. On the follow- ing days, the head was still more affected, and he complained besides of heat, and a sense of oppression about the praecordia, distention of the hypochondria, subacid eructations, nausea, retching, feverishness, a kind of rheumatic pain, with a sense of prickling of the left arm, immediately followed by startings and momentary convulsions of that extremity. His nights were disturbed. " 26th May.—The gesticulations and motions of the left arm more and more irregular, and less obedient to the will. The other symptoms as before. «27th.—Became irascible. The left leg also af- fected, and its motions irregular. The other symp- toms worse. «-;3Sth.—The tongue covered with small pustules. The mouth drawn somewhat to the left side. « 30th.—A few pustules have also appeared on the face. All the former symptoms aggravated. He was blooded both on this and the following days, without experiencing any relief. Nights very restless. "With these symptoms, he was received into the hospital on the first of June. The tongue was white; and the belly was, as it had been all along, very cos- tive. Some opening saline medicines being premised, he had an emetic—what he vomited was bitter. The IN CHOREA SANCTI VITI. 95 fever and uneasiness of the praecordia disappeared, and the limbs became steadier. Purgative medicines were afterwards given; and thus, by the 7th of June, he was so far cured, that he complained of nothing but the rheumatic pain of the left shoulder and arm. A blister was applied between the shoulders, and a diaphoretic draught was administered. But on the following day, without any obvious cause, he began to weep, and talk very foolishly, and every limb, the trunk of the body, the head even, and the muscles of the face, were affected with inordinate gesticulations. The disease advanced under the use of the fetid gums, and became still worse after the administration of camphor. Now, the mouth was clammy and foul, and the teeth covered with sordes. " At length the symptoms were relieved by saline laxatives, but the disease was not cured. " The extract of belladonna was tried; but occasion- ing vertigo, headach and delirium, it was omitted, and then it was thought best to purge the bowels with rhubarb, neutral salts, and. the oxymel of squills. He passed slime, and one lumbricus; and he said that he had formerly discharged others. The belly was mo- derately but daily purged; and thus his tongue became clean, his limbs strong, and the other symptoms disap- peared, so that, by the end of the month, he returned home cured. " Another case of chorea Sancti Viti I have treated in the same way. The patient was a girl subject to rheumatism, which being neglected, terminated spon- taneously in chorea. She was cured by solvents, ec- coprotics, rhubarb, arcanum duplicatum (sulphat of potass), and oxymel scillicum. Stimulants, belladonna, the flowers of zinc, and electricity, have appeared 96 ON PURGATIVE MEDICINES hurtful in that species of chorea which arises from pi- tuita and worms of the intestinal canal."—M. Stoll Ration, Medendi, pars Stia, page 219, observat. VII. and VIII. Edit. Paris, 1787. Dr. Kellie concludes with the following remarks: " No examples can be more decisive than these cases, and none surely could more happily illustrate the pathology and treatment of chorea recommended by Dr. Hamilton. For first, we remark, as precursors of the disease, symptoms of disordered and loaded bowels, heat or oppression of the praecordia, acid eruc- tations, nausea, and vomiting, and costiveness; next, the inefficacy of antispasmodic and stimulant reme- dies; then relief from laxatives, and disorder from narcotics; and lastly, the speedy completion of the cure, on the administration of medicines evacuating the bowels moderately, but daily." CHAP. XI. ON THE UTILITY OF PURGATIVE MEDICINES IN TETANUS. Tetanus literally means a tension; and, in a me- dical sense, implies a spasm of the muscular fibres. It affects most commonly the muscles which are sub- servient to voluntary motion. Tetanus has been de- scribed by many writers, from the time of Hippocrates downwards. But notwithstanding the attention which this singular disease has attracted, no certain means have yet been discovered of relieving the misery which it occasions, or of obviating its fatal tendency. IN TETANUS. 97 Tetanus often approaches in a gradual manner; the £ first symptoms of the disease appearing, on many oc- casions, at a period more or less remote from the ex- posure to the causes which induce it. On the attack, the patient usually complains of an uneasy sensation and small tenseness about the prae- cordia; which is followed by stiffness of the hind neck and about the shoulders, and lassitude, which make the attempt to move the head difficult and trou- blesome. The jaws become stiff, and cannot be open- ed without pain.. The patient, about this time, feels a sudden and painful traction about the cartilago ensi- formis, which tends towards the spine, with an aggra- vation of the above symptoms, 'and a drawing of the head backwards. Thus circumstanced, the patient refuses nourish- ment, as deglutition is painful, and excites a return of the spasms. The lower extremities are enfeebled, and incapable of affording their usual support; the pulse is slow and very hard, and the body is constipated. The traction or spasm under the cartilago ensiformis, or the pain, as it appears to be, of the epigastrium, which is accounted the pathognomonic symptom of tetanus, becomes now more violent, and returns every ten or fifteen minutes, and is instantly succeeded by a stronger retraction of the head, and greater rigidity and pain around the neck, which, extending in the course of the spine to the lower extremities, these are instant- ly put to the stretch. The jaws are at this moment locked together, and cannot afterwards be opened so wide as to receive the end of the little finger. The at- tempt to force them open hurries on the general spasm. The muscles concerned in deglutition, and the pec- toral and deltoid muscles, are most violently contract- go ON PURGATIVE MEDICINES ed. The shoulders are pushed forward; the arms are stretched out, or are drawn across the body; but the muscles moving the wrists and fingers are not af- fected with spasm. The cheeks are often drawn to- wards the ears, and the teeth are exposed as in the spasmus cynicus. This paroxysm ceases in a few minutes, and leaves the patient in a comparatively relaxed and easy state. He breathes quick for some minutes, as if he had been excessively exercised. The face is sometimes pale during the intervals of the spasm, but is oftener flush- ed, and is expressive of the most melancholy distress. Fluid passes with difficulty into the stomach; the at- tempt to swallow frequently induces the spasm, when the fluid is returned with some force through the nose. Blood drawn at this time appears to be of a dis- solved texture; the pulse varies in respect of quick- ness, fulness, and hardness, the tongue is not loaded; the urine is high-coloured; and the body continues so constipated, that the alvine evacuation is procured with difficulty. The disease is now advanced, and reduces the pa- tient to the most distressful and calamitous state. He is as it were in a continual rack of torture, the spasm, hardly suspended for the space of a minute, being more severe on each attack, and of longer duration. The contraction of the muscles is more general; and according as one set of muscles is more strongly con- tracted than their antagonists, the body is forced into different and highly painful postures. The belly feels to be hard; it is flat and drawn inwards. The abdo- minal muscles do not yield on pressure, and do not seem to favour the descent of the diaphragm, in in- IN TETANUS. 99 spiration. The body is often projected with violence in different directions, and the patient is only secured from injury by the care of the attendants. Geniturae jactura inopinata saepe sequitur tentiginem invitam. The tongue is frequently darted forward and misera- bly torn between the teeth. The countenance is much contracted; copious sweat flows; the pulse becomes quick and irregular; respi- ration is variable, sometimes it is hurried and labori- ous, and again it is less so, and natural. Articulation is indistinct; the sound of the voice is changed, it is grating and horrible to the ears. The heart throbs violently, and a palpitating motion is felt over the epi- gastric region. The eyes are watery and languid; the jaws are so fast locked, that drink or nourishment, even if they could be swallowed, cannot be introduced. During this distressful progress, the comfort of sleep, as may well be imagined, is denied to the suf- ferer; what he may enjoy is short, interrupted, and unrefreshing. In this state, delirium and a mortal anxiety ensue. A continued and severe spasm often finishes the tra- gedy; but oftener a general convulsion brings life to a period. The patients, for the most part, are complete- ly relaxed and sensible just before death. Tetanus is a rapid disease; its fatal termination generally takes place on the fourth or fifth day from the first attack. In some rare instances, when the disease is protracted for a few days more, a patient fr will accidentally survive, and with care and attention make a slow recovery; and, in the course of some months, feel himself restored to a certain share of comfort and happiness. Tetanus is a disease of every country, but it is 100 ON PURGATIVE MEDICINES much more frequent in warm than in temperate cli- mates; and in the warmer than in the cooler seasons of the year. People of all ages, and of both sexes, are obnoxious to tetanus; but it is said to be more prevalent in those of middle age, than in the old and the young; in males than in females; and in robust and vigorous people, than in the weak and the infirm. Tetanus is known under different appellations, ac- cording as particular muscles are affected; or accord- ing as one set of muscles, under a stronger spasm than their antagonists, give a particular curvature or pos- ture to the body. Thus trismus, emposthotonos, and opisthotonos, denominate varieties, which are now re- cognised as constituting the generic disease, tetanus. I have taken this account of tetanus from the his- tories which have been given of it by Dr. Hillary, in his observations on the epidemic diseases in the Island of Barbadoes, London, 1766: and by Dr. Lionel Chalmers, in a communication printed in the first volume of the London Medical Observations and In- quiries. Authors mention a great many occasional causes of tetanus; passions of the mind; interrupted menstrua- tion; too copious evacuations, particularly such as happen in cholera morbus; retrocedent gout and ex- anthemata; putrid fevers; and worms. Hysteria, hy- pochondriasis, and chorea, have also, in the excess of their spasmodic affection, on some occasions, emulated the milder symptoms of tetanus, while at the same time they have retained their own generic character. In the Appendix, page 94, the case of David Ander- son, and that of Anne Ross, page 99, exhibit proofs of tetanic affection in chorea. Tetanus, induced by the above-mentioned causes, IN TETANUS* 101 must be considered as a symptomatic disease; and the cure must be conducted according to the indications which apply to the particular case. Idiopathic tetanus is said to be owing, in the first place, to exposure to the vicissitudes of the atmosphere, as varying from hot to cold, and from dry to moist, when the body has been, at the same time, overheated by exercise, or by the warmth of the climate or season. In the second place, wounds of the soft parts, whe- ther severe or slight, are mentioned as causes of teta- nus, which sometimes supervenes soon after the acci- dent, but oftener at a distant period. Thirdly, tetanus arises in children, from the reten- tion of the meconium, or from the presence of other matters conveyed too early into the stomach, under the form of nourishment; in this case it is known by the name of trismus nascentium. I have remarked that, in some of the diseases of which I have treated, physicians, disregarding their general history, have Confined their attention too much o the consideration of a single symptom, and have "M thereby committed mistakes both in theory and prac- tice. In my apprehension, tetanus affords another in- stance of the bad effects which arise from a limited, or perhaps erroneous view of a disease. From the days of Hippocrates to the present time, the agonizing spasms, the prominent symptom of teta- nus, have arrested the notice of every one. To re- solve the spasm, and to cure the disease, seem to have been conceived to be one and the same thing. Ac- cordingly, opium, musk, warm-bathing, cold-bathing, and mercury, the most powerful of the antispasmodic remedies, have been chiefly employed in tetanus. They have been recommended by the earlier writers, |02 9N PURGATIVE MEDICINES and their praises have been re-echoed by succeeding practitioners. But what claim have these medicines to be extolled? have they mitigated the severity of teta- nus, or obviated its fatal tendency? The records of physic bear a sad testimony in the negative. It is unnecessary to enter upon a minute detail of the specious practice by antispasmodics in tetanus; such a detail might, indeed, afford an opportunity of shewing that some of them may be productive of mischievous effects. Dr. Hillary has observed, that instantaneous death has followed warm-bathing in te- tanus. And I greatly suspect, that the after conse- quence of the high and frequently-repeated doses of opium, which many authors recommend, and which neither alleviate pain nor induce sleep, must be inju- rious. But such discussions as these might be thought to be invidious, while they would lead to no useful inference. However just the foregoing observations may be, 1 should yet have been sorry to have advanced any thing to shake the tottering fabric of medical practice in tetanus, unless I thought it had been in my power to substitute one more efficacious, originating in other views of the disease. These views I apprehend will warrant the expectation of considerable benefit from the full and free exhibition of purgative medicines; and they are supported by the following considera- tions: In the first place, it appears, from the history of teta- nus, that it often approaches in a gradual manner; hence it is probable, that the attack is generally pre- ceded by symptoms of bad health, although these may not be always observed. We also learn from the his- IN TETANUS. J03 tory, that an uneasy sensation or tenseness about the praecordia is among the first symptoms, and is at the same time a permanent one of tetanus; and that as this is aggravated, all the other spasms are increased in the frequency and severity of their attack. The history farther shews that the body is obstinately con- stipated throughout the whole of the disease. These circumstances, which present themselves with great uniformity, make it exceedingly probable, that the functions of the stomach and intestines are ma- terially deranged, previous to the attack, and during the prevalence of tetanus, and point out the propriety of using purgative medicines in the treatment of it. In the second place, the influence of exposure to long continued heat on the biliary system is ascertain- ed; and it is well known that the diseases thence arising, such as bilious or yellow fever, cholera, and dysentery, are accompanied with great stomachic dis- tress, as marked by sickness, vomiting, and thirst. It is probable, therefore, that tetanus, appearing under similar circumstances of exposure to heat, must also be accompanied with derangement of the biliary sys- tem, and of the stomach and intestines, which will excite a predisposition to the disease, and require the interposition of purgative medicines. In the third place, I have proved that chorea and hysteria, both of them convulsive or spasmodic dis- eases, are accompanied with disorders of the stomach and bowels, and with costiveness; and that these dis- eases have, in a great number of instances, been re- lieved, if not cured, by a due perseverance in the use of purgatives. I infer, therefore, that tetanus, a spas- modic disease, and accompanied with costiveness, may |04 0N PURGATIVE MEDICINES also be relieved, if not cured, by a proper administra- tion of the same remedies. In the fourth place, I may adduce, from the prac- tice of others, presumptive evidence of the utility of purgative medicines in tetanus. These medicines have not been altogether excluded from medical prac- tice in this disease; but they have been exhibited with a secondary view only; while little or no attention has been paid to their effect on the bowels; for in some instances they appear to have been useful, with- out this effect having been so much as suspected or ac- knowledged. Dr. Wright revived the practice of cold-bathing in c tetanus, about forty years ago, In the sixth volume of the London Medical Observations and Inquiries, he gives an account of six cases successfully treated, in Jamaica, by the affusion of cold water. In the two first patients a natural stool was voided soon after the affusion of the water; a frequent consequence of simi- lar applications to the surface of the body. The third patient had a cooling purge before the cold wa- ter was used; and attention had been paid to the state of the belly of the fourth patient, previous to the affu- sion of the water. No notice is taken of the state of the bowels of the fifth and sixth patients. Thus, it is probable, that the salutary termination of four of these cases, adduced in proof of the utility of cold- bathing in tetanus, was in a great measure owing to the open state of the body. Dr. Thomas Cochrane practised medicine in the Island of Nevis, upwards of thirty years ago, A com- munication from him, " On the use of cold-bathing in the cure of tetanus," is printed in the third volume of the Euinbuigh Medical and Philosophical Comments- IN TETANUS. 105 ries. The narrative bears, that the subject of the ex- periment opened his jaws pretty freely, and walked tolerably upright, in a few days from the affusion of the cold water. It also bears, that on the first attack, a dose of castor oil procured several stools; and that clysters and gentle laxatives were frequently given. I am therefore led to a conclusion, which did not oc- cur to Dr. Cochrane, that the cure effected in this case was owing, in a great measure, to the preservation of the open state of the body throughout the course of the disease. Dr. Monro gives a communication, which is printed in the third volume of the Edinburgh Literary Essays and Observations, in illustration " of the usefulness of mercury in convulsive disorders." The case to which the Doctor's observations refer is of tetanus, supposed to have proceeded from a wound. The mercury was not used till three weeks after the attack of the spasm, when, from its protracted state, as appears from the history of tetanus, the disease may have been supposed to have yielded, and the patient to have been in the way of recovery. The spasms remitted in about thir- ty-six hours from the first application of the mercurial ointment, and before it could have made any material impression on the habit. In the meanwhile, several purgatives had been given early in the disease, occa- sional clysters were thrown up during its course, and laxative ptisans were exhibited in its decline. To these, therefore, while the effects of the mercury were hardly to be perceived, I am inclined to assign the salutary protraction, and the happy termination of the disease. In the fifth place, the utility of purgatives in the treat- ment of tetanus, appears to be established by the di- 106 ON PURGATIVE MEDICINES rect and useful employment of them in the disease. Dr. Hillary, in the work quoted above, page 242, and Dr, Lionel Chalmers, in the Medical Observations and Inquiries, London, 1771, page 109, have shewn, that in trismus nascentium, purgative medicines, if exhi- bited early, dislodge a quantity of unnatural matter that seems to have been collected in the stomach and intestines, and arrest the formation and progress of the disease which, previous to the adoption of this practice, had, like tetanus in other instances, proved too generally fatal. Lastly, I adduce proofs, from my own practice, of the good effects of purgative medicines, in what ap- peared to me to have been instances of incipient teta- nus; these proofs, transcribed from the records of the Royal Infirmary, are inserted in the Appendix, page 138. The communication from Mr. John Burns, sur- geon in Glasgow, Appendix, page 155, strengthens the opinion I had formed of the utility of purgative medicines in tetanus. It will not be easy to account, upon the principle of derangement of the stomach and intestines inducing tetanus, for its appearing as the consequence of wounds. But, without engaging in any argument on this subject, I will observe, that when the attack of tetanus is long posterior to the accident, it is probable that derange- ment of the stomach, also subsequent to the accident, may be the cause of the disease; and that when teta- nus follows the injury immediately, and when ex- cision, scarification, and cauterizing of the wounded part, have failed of procuring relief, and they almost always fail, I would in both instance resort to the use of purgatives, rather than to that of antispasmodic me- dicines, which have so often disappointed our hopes. J HST TETANUS. 107 If I am not mistaken, in the view which I have taken of the communication from Dr. Monro, it affords an in- stance of the utility of purgatives in tetanus from wounds. Such are the facts, and such the reasoning, on which I rest the probable utility of purgative medicines in tetanus. Every one will judge of, and appreciate them for himself. It would have been more agreeable to me, however, to have withheld my sentiments on this sub- ject, till such time as I had brought them to the test of experience. But living in the 55th degree of northern latitude, and advancing in years, I have no prospect of meeting with proper opportunities of doing so. And although these speculations may not be con- firmed by the experience of others, yet I trust they will at least display a sincere desire, on my part, to promote and extend the usefulness of practical medi- cine. To my observations on spasmodic diseases, I beg to subjoin an extract from Camper's Anatomico-Pa- thological Demonstrations, which has been lately point- ed out to me. I submit it without comment to the rea- der's consideration. u Nervis descriptis ad symptomata accedo, quae ex eorum unionibus facile explanantur; ordiar autem a pedum tremore, qui hystericis familiaris est. In an- tecessum vere monere debeo, omnia terribilia hysterica symptomata, quae tum in singulis, tum in universi cor- poris locis quotidie videmus, ab acrimonia putrida primas vias occupante omnino dependere; excremen- torum enim foetor intolerabilis, fauces, et alia quae praeter naturam sunt, rigorum et convulsionum acces- sum annuntiant. Res igitur ita se habere videtur; plexu 108 ON PURGATIVE MEDICINES, &c. mesenterico inferiori affecto, nervi omnes cum eo con- juncti, lumbales scilicet, et proinde crurales atque ob- turatores nervi afficiuntur. Si acrimonia tanta e*t ut etiam rectum intestinum irritare queat, nervi Ischadici in concensum trahentur, rigebitque pes integer, concu- cietur, et per vices quiescet, donee animi deliquium tumultum sedet. " Infantum inferiorum extremorum convulsiones, ex ascaridibus rectum intestinum occupantibus, hanc theo- riam confirmant. " Purgantia, etiam drastica licet imprudenter adhi- bita, propterea forsan, epilepsias spurias, choream Sancti Viti, aliosque spasmodicos sanarunt morbos, qui desperati a medicis habebantur." Petri Camperi, Demonstrationum Anatomico Pa~ thologicarum, liber secundus p. 8. Amstelaedami, 1762, 109 CHAP. XII. CONCLUSION. The inductive reasoning employed in this chapter, and the histories of anomalous diseases contained in the tenth number of the Appendix, are intended to shew the extensive utility of the practice by purgative medicines, and to incite to a farther investigation of a subject, which I conceive to be far from being exhaust- ed. But as I have proposed to give the result of my own experience only, it would not become me to insist, how guardedly soever, on the seeming tendency of speculative disquisitions, which I merely open, and which I leave to be prosecuted by others, when the number of well authenticated facts will render it safer than at present to generalize. From the facts detailed in the foregoing pages, I am enabled to infer, that purgative medicines may be employed with more freedom, and with greater bene- fit, than has been commonly imagined'. The practice which leads to this conclusion is presented in a sim- ple form. It is neither disguised by hypothesis, nor obscured by the simultaneous employment of various remedies. At the same time, it is supported by proofs of unquestionable authenticity, which, in point of ap- positeness and accuracy, are not surpassed by any in the records of medicine. On these accounts the truth or fallacy of my opinions may be easily investigated, and an adequate judgment of them readily formed. With the exception of a few observations on cy- nanche maligna and tetanus, the preceding work con- R j |0 CONCLUSION. tains the results of my own experience. The follow- ing deductions from the facts which that experience has enabled me to establish, will farther disclose my views with respect to a subject that has been occupy- ing my attention for years. typhus. To confine medical practice in fever to one class of remedies, when various symptoms require a diversity of treatment, would be equally vain and improper. But if I have succeeded in showing the importance of preserving a regular state of the body throughout the course of typhus, by means of purgative medicines; if I have made it appear that, by these means, sto- machic symptoms, and others which depend upon them, and which are the source of much distress, and not unfrequently of danger, are relieved and obviated; I think I am warranted to infer, that the same benefit may be obtained in other fevers, which, although dif- fering in some things from typhus, yet agree with it in being accompanied with symptoms of stomachic dis- tress. The justness .of this inference is exemplified in the bilious remitting fever of warmer climates, and in the plague. Practitioners seem now to be agreed, that the safety of those attacked with these fevers is intimately connected with the early, the full, and regularly con- tinued evacuation of the bowels. Dr. Rush, in his account of the fever, as it appeared in Philadelphia, in the year 1793, Edinburgh edition, 1796, page 173, says, "The effects of purging were as follows: rt 1st, It raised the pulse when low, and reduced it when preternaturally tense or full. CONCLUSION, 111 " 2d, It revived and strengthened the patient. This was evident in many cases, in the facility with which patients who had staggered to a close-stool walked back again to their beds after a copious evacuation. " 3d, It abated the paroxysm of the fever. Hence arose the advantage of giving a purge in some cases in the evening, when an attack of the fever was expected in the course of the night. " Uh, It frequently produced sweats, when given on the first or second day of the fever, after the most powerful sudorifics had been taken to no purpose. " 5th, It sometimes checked that vomiting which occurs in the beginning of the disorder; and it always assisted in preventing the more alarming occurrences of that symptom, about the fourth or fifth day. " 6th, It removed obstructions in the lymphatic system. rt 1th, By discharging the bile through the bowels, as soon and as fast as it was secreted, it prevented, in most cases, a yellowness of the skin." Mr. Bryce, surgeon in Edinburgh, formerly of the Busbridge East Indiaman, gives an account, publish- ed at Edinburgh 1796, of a fever which broke out among the ship's company of the Busbridge, during a passage from England to Madras and Bengal, in sum- mer 1792, which, on perusing the publication of Dr. Rush and Dr. Chisholm, after his return in 1795, he found to be the same with that described by these gen- tlemen, and which had proved so destructive in the west, page 8. In the treatment of this fever Mr. Bryce was eminently successful, notwithstanding the nature of the fever, and the disadvantages and priva- tions arising from situation. Of two hundred and 1 1 g CONCLUSION. fifty that were attacked with the disease, he lost only three, page 7; and in these instances it would appear the fatal termination was owing in part to incidental circumstances, pages 37, 38, 39. A history of this fever is given, and the method of cure detailed; in conducting which, drastic purgatives were employed, by means of which, provided early re- course was had to them, complete control over this cruel distemper, even in its most formidable attacks, was acquired, page 49. Calomel, either by itself, or combined with other powerful cathartics, is Mr. Bryce's favourite remedy, page 41. Clysters were frequently of use in accele- rating the action of the calomel, but not in the ad- vanced stage of the disease, page 61.—u The stools," says Mr. Bryce, " procured by medicine were dark co- loured, often quite black, of a shining appearance, very viscid, and emitted an excessively putrid fetor." " To these evacuations by stool only, however, did the above threatening symptoms yield; and it was always observable, that the more dark coloured and fetid such discharges were, the more easily and certainly did the symptoms disappear; their good effects were so in- stantaneous, that a man carried upon deck perfectly delirious, with subsultus tendinum, and in the state of the greatest apparent debility, after a copious evacua- tion of this kind, has returned of himself, composed, astonished at his newly acquired strength, and declar- ing himself to be infinitely recovered; which was in- deed evident to every one from his changed counte- nance and general appearance." Here Mr. Bryce re- marks, '* that he never saw a disease where the coun- tenance so surely indicated either danger or returning health." Pages 33, 84. CONCLUSION. 113 Mr. James Anderson, late Surgeon of his Majesty's 60th Regiment, published at Edinburgh, 1798, "Afew facts and Observations on the Yellow Fever of the West Indies." Mr. Anderson says, page 19, " lam of opinion, that there is one grand object to be held in view, in almost every fever of the West Indies, viz. proper evacua- tions downwards; and if that practice is pursued in a requisite manner, at an early period of the disease, I have every reason to think, it will be attended with the happiest effects." After employing different purgative medicines, Mr. Anderson remarks, page 20.—" A short time after this I had an opportunity of experiencing the good effects of calomel, conjoined with James's powders, as superior to every other medicine I had tried, and in which I would place the greatest dependence, in the cure of this dreadful scourge of our army in the West Indies." " Judging a priori" page "30, a person would be apt to suppose, that free evacuations downwards would very much debilitate the patient in that hot climate; but the sensation of the patient is quite the reverse, as he feels himself wonderfully relieved after a few eva- cuations; and is by no means so depressed with lan- guor and anxiety, as before the operation of the me- dicine. " I found nothing so effectually removed the great irritation of the stomach, which is so much to be dread- ed in this disease, as the operation of these medicines; and the James's powder had likewise the effect of bringing on a free and equal perspiration." 114 CONCLUSION. Extracts from a Letter addressed to the Author by John Price, Esq. deputy purveyor of the Forces, on the Egyptian Expedition, dated Edinburgh, 15th March, 1807. "The diseases in which I have employed the re- medies alluded to, 'Purgative Medicines,' were the remittent and intermittent fevers of certain countries in the Mediterranean and Archipelago, and in the plague in Egypt. " In the fevers of those countries I was first led to employ purgatives very freely, particularly mercurial purgatives, in consequence of having observed, upon opening the bodies of several who died of those disor- ders, that the intestinal canal was filled with indurated feces. In most of these cases, the vomiting of bile, the tension of the abdomen, and the torpor of the bowels, had been remarkable. I have often exhibited the bark without the least success in a remittent or in- termittent, which has ultimately yielded to repeated purges of calomel and rhubarb. "The various quality and great quantity of feculent matter discharged, and the subsequent relief of the most distressing symptoms, gave me confidence in a practice, which neither the authorities then in my pos- session, nor the usages of the practitioners of those cli- mates, would have sanctioned. But as it may be most interesting to you to be informed of the success of those remedies in the treatment of the plague, I shall confine myself to the statement of a few facts relative to that disease only. " In treating the disease, the remedy I principally relied on was mercury, given internally, so as to pro- CONCLUSION. 115 cure a complete evacuation of the bowels, and an af- fection of the mouth. With the latter intention, I used mercurial friction, but was never able to produce the least effect upon the system through the medium of the" skin. As the affecting of the mouth by mercury was frequently a remote and always an uncertain effect, and as I am inclined to believe that the good effects of » that remedy were fairly'referrible to its operation as a cathartic, I shall proceed to treat of it as such, though, at the same time, I must not suppress this fact, that no one of my patients died whose mouth was affected by mercury, yet many recovered who never experienced any such affection; among others, I may mention my- self. " In violent spontaneous vomitings of bile, and a viscid glairy matter, which could not be restrained by opium, calomel was successfully exhibited; as soon as the bowels were opened this symptom disappeared. " When the affection of the head, the tension and tumour of the abdomen, the pain of the stomach, were considerable, six grains of calomel, and as many of jalap, were given every two or three hours, till a full evacuation was procured, the patients being allowed to drink as much lemon juice and water as they wish- ed. This being a grateful drink, was generally taken in large quantities, and that without producing any un- pleasant effects, either in the stomach or bowels. I have exhibited sixty grains of calomel and jalap, in the space of twelve hours, without producing more than three evacuations by stool, accompanied by a vast quantity of high-coloured urine. In most cases there was voided a great quantity of indurated feces, of a dark colour, the matter apparently of the consistence and colour of chocolate; lastly, pure bile, with a glairy H5' CONCLUSION. matter like the whites of eggs. Matter of the lastde- scription I have often seen voided without any admix- ture of bilious or feculent matter. I have frequently observed worms and putrid substances of a most offen- sive smell. When a full evacuation was effected, the fever abated, and the head was considerably relieved. "In some cases I observed the fever to terminate upon the evacuation taking place, there being no evi- dence of the recurrence of the paroxysms, although in seasons when the fever accompanying the eruptions as- sumed the remittent or intermittent type. It is to be remarked, that notwithstanding the fever was frequent- ly terminated in this way, yet there was a tendency to constipation during the state of convalescence, accom- panied with violent spasms of the stomach. To re- move the latter symptoms, opium, aether, volatile al- kali, &c. were administered unsuccessfully, yet they always yielded to a purgative. The remedies I gene- rally employed were aloes and rhubarb. u I cannot precisely state what proportion of my pa- tients recovered; but that a far greater number reco- vered than has hitherto been known in this disease, I think I could ascertain, by a reference to two of my very respectable friends, now resident in this city, Thomas Young, Esq. who was inspector-general of hospitals in Egypt in 1801; and Dr. Shapter, inspector, who was at the head of the medical department from the departure of Mr. Young for Europe till the Bri- tish army left that country." scarlatina. The benefits which I have shewn to follow the ex- hibition of purgatives in scarlatina, might be expected CONCLUSION. 117 From a similar practice in some other exanthemata. Experienc* has, I believe, proved this inference to be just in respect of measles and erysipelas; and it is well known, that much of the cooling regimen, so much valued in small-pox, consisted in the free use of purga- tive medicines. MARASMUS. If I might depend on the opinion which results from my own observation, I should say, that the marasmus of which I have spoken attacks most generally chil- dren of scrofulous constitutions. If purgatives, there- fore, be employed successfully, as I have shown them to be, in the cure of this marasmus, it follows, that they will be serviceable in scrofula, if not the most useful remedies that can be employed for relieving that malady. And the more so, when we advert to this circumstance, that scrofulous children have frequently tumid bellies, the effect of tardy bowels, and of accu- mulated feces, which are again undoubtedly a seconda- ry cause of some symptoms, improperly referred to the general scrofulous contamination, and for which re- medies are sought in various specifies, which, though innocent in themselves, lead to the postponement or careless exhibition of the more efficacious and certain purgative. CHLOROSIS. The early, and indeed the principal symptoms of chlorosis are those of dyspepsia, or deranged state of the stomach and bowels. These again give rise to others, which characterise the latter periods of the dis- s |1 g CONCLUSION. ease. As I have shewn that chlorosis in all its stages, perhaps indeed the last of extreme debility excepted, is to be cured by purgative medicines, I conclude, that dyspepsia whether simple, or complicated with a dis- eased state of the mind, under the appearance of hys- terical or hypochondriacal mania, may be very much re- lieved, if not entirely cured, by purgative medicines duly administered, as the remedy upon which the pa- tient's recovery depends, and not as at present, with a secondary view only in aid of tonic and stimulant me- dicines, on which the practitioner rests his hopes of a cure. HYSTERIA.—CHOREA SANCTI VITI. The spasmodic affections in hysteria and chorea Sancti Viti are removed by the sole efficacy of purga- tive medicines. Spasms, therefore, which attack the extremities, and sometimes the stomach, or rather the diaphragm, and which are known by the name of cramp, may, in some instances, arise from the loaded state of the stomach and bowels, and may be reme- died by a proper course of purgative medicines. My experience leads me to think that this is the case. Palpitation of the heart deserves particular notice in this place. It is not an uncommon attendant on dis- orders of the stomach; it is considered, indeed, as a symptom of dyspepsia. On some occasions, when it has been of long standing, and so violent and perse- vering as to have been the immediate cause of death, no organic disease has been discovered to which it might have been referred. I have repeatedly witness- ed the power of purgative medicines over this species of spasm; and I have been astonished at the complete CONCLUSION. 119 cures which I have made of it, in the most forbidding, and apparently desperate cases. I am now accustom- ed not to despair of any patient labouring under this formidable disease, till 1 am satisfied that purgative medicines have been fully employed, and employed in vain. TETANUS. If my reflections on tetanus, the most painful and most fatal of all spasmodic ailments, tend to elucidate this intricate disease, and to give sanction to a practice at once grateful and salutary to the sufferer, a practi- tioner, without indulging too much in the application of speculative principles, may extend similar views to those cases of hydrophobia that are not the effect of specific contagion; but which, in their cause and lead- ing features, bear a striking resemblance to tetanus, and equal it in severity and fatality. Under the im- pression which I entertain of the utility of purgative medicines, and of the inefficacy of the tonic plan of treatment in tetanus, no doubt would remain with me, respecting the mode of attempting the cure of hydro- phobia: for this disease has hardly, in any instance, yielded to the most powerful antispasmodics, even when carried to an extent which has bordered on the extinction of life. Antispasmodics are directed, how fruitlessly soever, with the view of alleviating a single symptom. Purgatives are proposed to remove* cause which frequently induces, and which may always ag- gravate spasmodic affections. 3 While I have been thus occupied in ascertaining the utility of purgative medicines, and the safety of them in the administration, it will not be thought sur- \20 CONCLUSION. prising that there are some things respecting these me- dicines themselves, of which I cannot give a satisfac- tory account. I am at a loss to distinguish precisely between those that act more particularly on the smaller, and those whose influence is exerted on the larger in- testines. I am likewise unable to speak always de- cisively on the mode of exhibiting purgative medicines, whether in full doses at long intervals, or in reduced doses more frequently repeated; whether, on some oc- casions, a course of purgatives at home, will not be equally serviceable as one of purging mineral waters at their fountain heads; and whether and how far col- lateral aid may be derived from blood-letting, from warm and cold bathing, and from mercury, to promote the efficacy of purgatives. Although I undoubtedly have my opinion on these points, yet it is not so fully established as to enable me to give it with confidence to the public in a detailed or systematic manner. These, and other circumstances connected with the important practice by purgatives, will therefore remain the sub- jects of future investigation. But in whatever manner purgatives are given for the cure of the diseases of which I have treated, I must again solicit attention to two circumstances, of infinite importance to the success of the practice. One is, the regular and accurate examination of every alvine eva- cuation; and the other, the steady exhibition of the purgative medicine, so that its full effect may be daily procured during the continuance of the disease for which it is given. The present state of the practice, and of the public mind respecting it, requires this ad- monition. By inspection, the practitioner learns the nature of the alvine discharge, is enabled to form a probable con- CONCLUSION, 121 jecture with regard to the ailment; and to regulate the strength, and to determine the frequency of the repeti- tion of each succeeding dose of the purgative. With- out this inspection, he will be constantly deceived, through the ignorance or inattention of his patients, or of their attendants. Again, the steady exhibition of purgative medicines, in full doses, is absolutely necessary to the success of the practice in the diseases of which I have spoken. The puny and debilitated state of the sufferer may on some occasions excite alarm in the breast of the prac- titioner; and the caprice of his patient, and the whims of relatives, may oppose obstacles to his conducting the cure in the most advantageous manner. But these he must disregard; for unless he can suppress his own improper feelings, and overcome the unreasonable ob- jections of others, he had better not adopt measures which, to prove successful, must be conducted with firmness. A contrary conduct will necessarily termi- nate in the vexation of the practitioner, the disappoint- ment of the patient and relatives, and in the discredit of that practice which it has been my wish and study to recommend. If some of the diseases of which I have treated be cured solely by purgative medicines, and if this cure be effected more or less speedily, in proportion to the length of time that constipation and the changed na- ture of the feces have subsisted, I am persuaded that the preservation of the regularity of the alvine evacua- tion will at all times prevent the accession of those dis- eases. If these expectations be not too sanguine, it is likely that the marasmus and chlorosis, the vomiting of blood, chorea and hysteria, of which I have spoken, t will, under this management, rarely, if ever, appear. 122 CONCLUSION. It is fitting, therefore, that this observation should be widely spread; that it should be conveyed to mothers and nurses, to superintendants of nurseries, of manu- factories, and of boarding-schools, and to all instruc- tors and protectors of children and young people; and strongly impressed on their minds by such of their me- dical advisers as think with me, and who will acknow- ledge, that to prevent disease is their paramount duty. To conclude, the reader must have observed the be- neficial effects of purgative medicines, in diseases ap- parently different, and incident to people at various periods of life. The facts are undeniable, and serve to prove the extent and importance of the subject; but of these I do not feel it to be incumbent on me to give any explanation at present. Such an attempt might be premature. I am satisfied to have established certain leading facts, and to have opened views, which, if pro- perly prosecuted, must give an opportunity to extend our knowledge respecting the utility and administra- tion of purgative medicines. It will then be time to generalize the facts, and to form a system of medical doctrines at once clear and comprehensive, and thence to deduce practical precepts, useful in proportion as they will be simple and precise. When these expec- tations are fulfilled, our posterity may see deceptive reasoning, how ingenious soever, banished from the schools of medicine; and from the practice of the heal- ing art, a multifarious prescription of inert and nause- ous medicines. APPENDIX. The Appendix consists of Ten Numbers. The first contains Tables of the Old and New Names of the articles of the Materia Medica and formula? of the compounded Medicines, peculiar to the Pharmacopoeia of the Royal Infirmary, which are mentioned in this Work. In the subsequent Numbers, from the Second to the Ninth inclusive, are given Histories of the disease treated of in the particular Chapter to which each Number refers. Histories of Anomalous Diseases have a place in the Tenth Number. Through- out the Appendix are inserted Opinions of Authors, and Commu- nications made to the Author, illustrative of the foregoing Obser- vations, 1 2 APPENDIX I. The fluctuating state of the Nomenclature of the Materia Me- dica, and of Pharmaceutical preparations, will explain why seve- ral old names and titles of both are found in the more early cases contained in this Appendix. And indeed such appear occasionally in the more recent cases; the force of habit, and the dre%d of com- mitting mistakes, while my attention was occupied by the variety of hospital business, have occasioned this deviation from the punc- tilious formality of prescription. On these accounts, and for the sake of perspicuity, I insert in this Number of the Appendix Ta- bles of reference from the old to the new, and from the new to the old names of such medicines as are mentioned in the following cases. I insert also another Table, which comprehends the for- mulae of the compounded medicines which are prescribed in the same cases, and which are peculiar to the Pharmacopoeia of the Royal Infirmary. As this Pharmacopoeia is not in every one's hands, this Table is the more necessary. TABULA PRIMA EXPONIT MEDICAMINUM TITULOS PRIORES ET POSTERIORES TITULI PRIORES. Alkali fixum vegetabile purifi- catum ....... Anitmonia preparata . . Antimonium tartarisatum Assafoetida...... TITULI POSTERIORES. Carbonas potassae. Carbonas ammoniae. Tartris antimonii. Gummi resina ferulae assaefoe- ticlae. MEDICAMINUM NOMENCLATURA. 3 TITULI PRIORES. Bolus jalapae cum mercurio Calomelas . Crystalli tartari Cornu cervi Cremor tartari Extractum catharticum Extractum colocynthid positum . Glycirrhiza Hydrargyrus precipitat reus Jalapa Laudanum . Limon Linum Lixiva purificata Lixivium causticum Magnesia alba Magnesia usta Magnesia vitriolati Mercurius cinereus Mercurius dulcis Pilulae stomachicae Pimenta Potio cretacea Sal catharticus amarus Sal Glauberi Sal rupellensis Senna Soda phosphorata Soda tartarizata . Soda vitriolata Spiritus Mindereri Squamae ferri purificatae Tartarus emeticus Tartarum vitriolatum Tinctura jalapae . Tinctura thebaica TITULI POSTERIORES. Bolus jalapae compositus. Submurias hydrargyri. Supertartris potassae. Carbonas ammoniae. Supertartris potassae. is com- I Pilulae aloes cum colocynthide. • Glycirrhiza glabra. i Oxydum hydrargyri cinereum. Convolvulus jalapa. Tinctura opii. Citrus medica. Linum usitatissimum. Carbonas potassae. Aqua potassae. Carbonas magnesiae. Magnesia. Sulphas magnesiae. Oxydum hydrargyri cinereum. Submurias hydrargyri. Pilulae rhei compositae. Myrtus pimenta. Potio carbonatis calcis. Sulphas magnesiae. Sulphas sodae. Tartris sodae et potassae. Cassia senna. Phosphas sodae. Tartris sodae et potassae. Sulphas sodae. Aqua acetitis ammoniae. C Oxidum ferri nigrum purifica- £ tum. Tartris antimonii. Sulphas potassae. Tinctura convolvuli jalapae. Tinctura opii. 4 APPENDIX I. TABULA SECUNDA EXPONIT MEDICAMINUM TITULOS POSTERIORES ET PRIORES. TITULI POSTERIORES. Aqua acetitis ammoniae Aqua potassae Bolus jalapae compositus Carbonas ammoniae Carbonas magnesiae Carbonas potassae Cassia senna Citrus medica^ . Convolvulus jalapa Giycirrhiza glabra Gummi resina ferulae assaefoe- tidae Linum usitatissimum Magnesia Myrtus pimenta Oxydum ferri nigrum purifi- catum . . . Oxydum hydrargyri cinereum. Phosphas sodae Pilulae aloes cum colocynthide Pilulae rhei compositae Potio carbonatis calcis Submurias hydrargyri Sulphas magnesiae Sulphas potassae Sulphas sodae Supertartris potassae TITULI PRIORES. Spiritus Mindereri. Lixivium causticum. Bolus jalapae cum mercuric Ammonia preparata. Magnesia alba. {Lixiva purificata. Alkali fixum vegetabile purifi-r catum. Senna. Limon. Jalapa. Giycirrhiza. i Assafoetida. Linum. Magnesia usta. Pimenta. i Squamae ferri purificatae. {Mercurius cinereus. Hydrargyrus praecipitatis cine- reus. Soda phosphorata. {Extractum catharticum. Extractum colocynthidis compo- situm. Pilulae stomachicse. Potio cretacea. Calomelas, mercurius dulcis. Sal catharticus amarus. Tartarum vitriolatum. 5 Sal Glauberi. I Soda vitriolata. CCrystalli tartari. i Cremor tartari. MEDICAMINUM FORMULA. 5 TITULI POSTERIORES. TITULI PRIORES. Tartris antimonii . . S ^ntimonium tartarisatum. 11 artarus emeticus. Tartris sodse.poUs,* . \ ^^Su. Tinctura convulvuli jalapae Tinctura jalapae. rr- . C Laudanum. Tinctura opu . . . J Tinctura thebaica. TABULA TERTIA EXHIBET FORMULAS MEDICAMINUM COMPOSITORUM, QUORUM MENTIO FIT IN HISCE PAGINIS, ET QUA PHARMACOPOEIA NOSOCOMH REGI1 EDINENSIS, PROPRIA SUNT. Bolus jalapae compositus. R. Pulveris radicis convolvuli jalapae granaq uindecim, Calomelanos grana quinque, Conservae rosae Gallicae quantum satis sit. Decoctum furfuris. Ri Furfuris uncias duas, Aquae fontanae libras duodecim, Coque ad libras novem, cum subsederint feces, elutri- andas. Enema domesticum. R. Muriatis sodae unciam dimidiam, Olei napi silvestris unciam, Aquae tepidae libram. Misce. Enema foetidum. R. Gummi resinae ferulae assaefcetidae drachmas duas, Aquae tepidae uncias decern. Solve 6 APPENDIX I. Enema purgans. R. Foliorum cassiae sennae drachmas tres, Sulphatis sodae unciam, Aquae fervidae libram. Infunde et cola. Haustus anodynus. R. Tincturae opii guttas viginti quinque, Aquae fontanae unciam, Syrupi simplicis drachmas duas. Misce. Haustus ex oleo ricini. R. Olei ricini unciam dimidiam. Aquae distillatae unciam, Spiritus myrti pimentae drachmam, Aquae potassae causticae guttas viginti. Misce. Haustus salinus effervescens. R. Carbonatis potassae purificati scrupulos quatuor, Aquae fontaiae uncias quatuor. Solve, et cum subsede- rint feces, c.oia. R. Succus citri medicae uncias duas, Syrupi simpiicis, Aquae fontanae utriusque unciam. Misce. Utriusque misturae uncia detur pro dosi; solutione carbona- tis potasse prius sumpta, mistura e succo citri medicae, illico porrigencia est. Infusum cassiae sennae. R. Foliorum cassiae sennae unciam et dimidiam, Seminum coriandri sativi contusorum unciam et dimi- diam, Supertartritis potassae drachmas duas, Aquae fontanae libram. Supertartritem potassae in aqua coquendo solve; deinde li- MEDICAMINUM FORMULA. ? quorem adhuc fervenlum sennae et seminibus affunde; macera per horum in vase operto, et frigefactum cola. iNFusuMlini usitatissimi. R. Seminum lini usitatissimi uncias duas, Radicis glycirrhizae glabrae unciam dimidiam, Aquae ferventis libras quatuor. Infunde ad focum per horas aliquot, et cola. Mistura cinchonse aromatica. R. Pulveris corticis cinchonas unciam dimidiam, Mucilaginis mimosae niloticae uncias duas. Tere simul et paulatim adde, Aquae fontanae uncias quinque, Tincturae lauri cassia unciam unam et dimidiam. Misce. Mistura diaphoretica antimonialis. R. Aquae fontanae uncias quinque et dimidiam, Sacchari purificati drachmam unam et dimidiam, 1 Vini tartritis antimonii drachmas duasj Tincturae opii guttas triginta. Misce. Mistura diaphoretica salina. R. Aquae acetitis ammoniae, Aquae fontanae, utriusque uncias tres, Carbonatis ammoniae grana decern, Syrupi simplicis drachmas sex. Misce, Mistura mucilaginosa. R. Decocti altheae officinalis uncias quatuor, Syrupi simplicis unciam dimidiam. Misce. Mistura salina ammoniata. R. Succi citri medicae unciam et dimidiam, Carbonatis ammoniae praeparati drachmam dimidiam, ye\ quantum suflkit ad acidum saturandum, 8 APPENDIX I. Aquae fontanae uncias tres et dimidiam, Syrupi simplicis unciam. Misce. Potus acidus vegetabilis. R. Decocti furfuris uncias triginta, Supertartritis potassae scrupulos quatuor, Syrupi simplicis uncias duas. Misce. Solutio gummi resinae ferulae assaefoetidae. R, Gummi resinae ferulae assaefoetidae drachmas quatuor, Aquae fervidae uncias viginti quatuor. Solve. \ APPENDIX II. TYPHUS. Sect. I. CASES OF PATIENTS WHO LABOURED UNDER TYPHUS FEVER, EXTRACTED FROM THE RECORDS OF THE ROYAL INFIRMARY. Royal Infirmary, 2\$t Aug. 1796. John Denham, .dEtatis 11.—Complains much of headach, ver- tigo, general uneasiness, and sickness. Pulse 120, skin very hot, tongue loaded, much thirst, belly rather slow, no appetite, indif- ferent nights. Complaints began on the 18th current. He had an emetic on the 19th, with some temporary relief. Injiciantur enema domesticum. 22d.—One stool, restless during night, skin dry, and of a pun- gent heat, tongue loaded, pulse about 120, and full, abdomen feels tense, and is painful. R. Mercurii dulcis, Pulveris jalapae, Sacchari alba singulorum grana tria. Tere in pulverem quam primum sumendum. Toast and water for drink. 23d Aug —A bad night, with delirium; skin continues hot, tongue more loaded, pulse towards 120, less full, much thirst, two scanty stools. Injiciantur quam primum enematis domestici unciae decern 2 10 APPENDIX II. R. Foliorum sennae drachmam unam, Extracti glycirrhizae drachmam dimidiam, Aquae fervidae uncias octo. Sitinfusum duabus vicibus sumendum. 24th.—A better night, with less delirium; skin less pungently hot, pulse about 120, and soft, tongue less loaded, and moist, complains of headach, considerable thirst, a copious stool from the injection, another since taking the physic, belly seems somewhat distended; he complains on its being pressed. Repetatur enema domesticum vespere, et habeat haustum, cum tincturae thebaicsc guttis quindecim. 25tb.—Easy during the first part of the night; restless with delirium since morning, belly more distended, and pained on pressure, tongue more loaded and parched, a loose feculent stool after the injection, a similar one since morning, which, as well as the urine, has been voided without notice, pulse about 120, of middling strength, skin moderately cool. R. Aquae uncias quatuor, Magnesiae ustae drachmam unam, Sacchari drachmam dimidiam. Sit mistura cujus sumatur uncia dimidia, omni hora. Repetatur haustus anodynus vespere. 26th Aug.—Three stools since yesterday, the first of a natural appearance, the two last watery and greenish, a lumbricus has been voided, fulness and pain of abdomen much abated, skin cool, tongue clean, pulse about 90, feeble, mixture used, a good night. Repetatur mistura cum magnesia, necnon haustus vespere. 27ih.—Two loose and green-coloured stools voided in bed since yesterday, fulness of abdomen gone, no complaint on pres- sure, tongue clean, pulse about SO, tolerably firm, skin cool, sen- sible to the stimulus of urine, a good night, appetite returning. Continuentur haustus et mistura cum magnesia. TYPHUS. 11 28th.—Is at present asleep, he has had a good night; two stools not passed in bed, some food taken this morning. Continuentur haustus et mistura. 29.—No stool, a good night, now asleep, appetite improving. Continuetur mistura e magnesia. Omittatur haustus anodynus. Habeat jusculi bovini libram unam, indies 31.—Another lumbricus, of a large size, voided since yesterday, belly regular, pulse about SO, and soft, tongue clean, appetite good, an easy night. Continuetur magnesia alba. 10th Sept.—Gradual convalescence. Dismissed cured. Royal Infirmary, Slst Aug. 1796. James M'Kechny, iEtatis 20.—Complains of headach, pain in his back, general uneasiness and sickness. Has at times a slight cough, but no particular uneasiness about his breast. Belly regular, considerable thirst, tongue white, pulse 110, pretty full, skin hot, tolerable nights. ^ Complaints began nine or ten days ago, and have been fre- quently attended with shivering. Has used no medicines. 1st Sept.—Sumat pulveris jalapae compositi drachmam dimi- diam. Habeat decoctum furfuris pro potu. 2d.—Headach abated, cough and thirst continue, pulse about 100, an indifferent night, as yet no stool. Repetatur quam primum pulvis jalapae compositus. Habeat vespere si opus sit enema domesticum. Haustum anodynum hora omni. 12 APPENDIX II. 5th.—Free passage of belly previous to the injection, headach and cough gone, pulse calm, appetite returning. 6th.—Convalescent. Full diet. I Oth.—Dismissed cured. Royal Infirmary, 29th Sept. 1796. Robert Grant, iEtatis 21.—Complains of headach, vertigo, nausea, chilly fits, succeeded by heat and sweating, great uneasi- ness and oppression, much thirst, and loss of appetite. Pulse 96, tongue very foul, skin at present moist, belly regular, sleeps indifferently; on the 19th, after exposure to cold, while on guard in the night-time, was seized with headach, coldness, shi- vering, and prostration of strength; he has continued daily worse since that time, although he took an emetic on the 20th. 30th Sept.—Febrile symptoms continue, pulse about 90, some- what full, tongue pretty clean and moist, a stool in the course of yesterday. R. Pulveris jalapae grana decern, Mercurii dulcis grana tria. Sit pulvis quam primum sumendus. Potum acidum vegetabilem, ad libitum. 1st Oct.—Two copious stools, after an injection in the evening, febrile symptoms much abated, skin moist, pulse calm. 2d.—Convalescent. Full diet. 12th.—Dismissed cured. Royal Infirmary, 5th Sept. 1796. Jonathan Green, iEtatis 22—Complains of headach, pain of back, general uneasiness, and sickness. Pulse 96, skin cool, tongue while, thirst natural, belly rather loose, appetite bad, urine high-coloured, sleeps ill Complaints began yesterday, with shivering, followed by in- TYPHUS. 13 creased heat and sweating; attributes them to cold and wet, hav- ing been exposed to the rain for a considerable time on Saturday last, 3d current. Has used no medicines. 6th Sept.—Habeat quam primum, Vini ipecacuanhas unciam unam pro emitico. Cras mane, Pulveris jalapae compositi drachmam dimidiam. 7th.—Full vomiting, febrile symptoms abated, pulse calm, three stools. Full diet. 10th.—Aggravation of headach, with feebleness and languor, pulse about J 20, belly slow. Habeat quam primum, pulveris jalapae compositi scrupulos duos. Low diet. 11th.—As yet no stool, headach continues, pulse about 100, rather feeble, Habeat vespere enema domesticum, et ni plene responde- nt alvus, pulveris jalapae compositi drachmam unam cras mane. 12th Sept.—One stool by the injection, four by the physic this morning, headach relieved, and countenance lightened. 13th.—Frequent scanty stools, since yesterday, with gripes and tenesmus, much thirst, tongue white, pulse about 100. R. Sodae tartarisatae drachmas sex, Aquae uncias duodecim. Sit solutio quam primum, duabus vicibus sumenda. Habeat haustum anodynum vespere, Toast and water for drink. 14th.—Gripes and purging gone, tongue white, rather loaded, pulse about 90. Repetatur eras mane solutio sodae tartarisatae. 14 appendix 11. 16th.—Convalescent. Full diet. 19th.—Slight headach at limes, belly open, pulse about 90. Habeat potionis cretaceae unciam unam ter de die. 21st.—Belly regular, slight headach continues. Sumat pulveris corticis Peruviani drachmam dimidiam qua- ter indies. Intermittatur potio eretacea. 26th.—Headach gone, belly regular. Dismissed cured. Royal Infirmary, 13th Sept. 1796. Robert Muckle, iEtatis 17.—Complains of pain of head, back, general uneasiness, and weakness. Pulse 84, skin natural, th'.rst urgent, tongue white, with bad taste in his mouth, appetite impaired, belly regular, urine natural, sleeps ill. Complaints first bpgan on Saturday the 10th inst. with shiver- ing, succeeded by increased heat, and sweating. Knows no cause. Took an emetic yesterday, with relief. 14th Sept.—Headach and thirst continue, pulse about SO, skin warm, two stools, indifferent night. Habeat quam primum, Bolum e julapa cum mercurii granis tribus. 15th.—Pain shifted to the hind-head and neck, thirst continues, no stool. » R. Foliorum sennae, Crystallorum tartari, utriusque drachmam unam, Aquae fervidae uncias octo. Sit infusum quam primum sumendum. TYPHUS. 15 17th.—Pain chiefly occupies the hind-neck, in other respects convalescent. Oblinatur cervix qua dolet, Oieo ammoniato et tegatur panno laneo. 21st.—Pain of head and neck gone, slight pain between the sca- pulae, otherwise well. Intermittatur oleum ammoniatum. Full diet. 26th.—Dismissed cured. Royal Infirmary, 14th Sept. 1796. John Fairgrave, jEtatis 19.—Complains of pain of head, vertigo, sickness, general uneasiness, and weakness. Pulse 68, skin hot, tongue white, thirst, appetite bad, urine na- tural, belly loose, sleeps pretty well. These complaints first commenced yesterday morning; he was seized with shivering, increased heat, succeeded by sweating. Knows no cause. Took an emetic yesterday forenoon, with relief. Two stools since admission. Habeat quam primum, Bolum jalapae cum mercurii granis tribus. 15th Sept.—One copious, and two smaller stools, an easy night, febrile symptoms abated, pulse about 60, and soft. 16th.—Convalescent. Full diet. 17th.—Psora. Habeat unguentum sulphuris more solito, !8th Sept.—Psora yields, pulse about 50. 16 APPENDIX 11. 23d.—Habeat balneum tepidum. Intermittatur unguentum sulphuris. 24th.—Dismissed cured. Royal Infirmary, 19th April, 1798. Donald Watson, JEtatis 23.—Complains of severe pain in his head, with general soreness, pulse about 90, tongue white, thirst considerable, appetite impaired, no stool since the 16th in- stant, on which day his complaints began with shivering. R. Mercuvii dulcis grana quinque, Pulveris jalapae grana duodecim. Sit pulvis quam primum suinendus. 20th April.—Two stools, tongue loaded, pulse towards 108, and full, thirst moderate, a tolerable night, and still disposed to sleep. Cias^nane repetatur pulvis e mercurio dulci et jalapa. 21st.—Another stool in the evening, none since the exhibition of the powder, headach continues, pulse about 90, and soft, tongue still loaded. Habeat, si opus sit, enema domesticum vespere. 22d.—Three scanty stools in the course of yesterday, headach relieved, tongue less loaded, skin cool and moist, pulse calm, a good night. Cras mane habeat pulveris jalapae compositi drachmam unam. 23d.—A good night, several stools, tongue clean, pulse calm. 27th.—Convalescent. Dismissed cured. TYPHUS, 17 Royal Infirmary, 20th April, 1798. James Dennet, iEtatis 12.—Complains of pain in his head, and in his belly, of vertigo, great sickness, and occasional vomit- ing, pulse about 100, tongue white, considerable thirst, appetite impaired, belly hound. These symptoms commenced with shi- vering on the 16th, and he had been exposed to the contagion of ijever. 21st April.—A natural stool, no recurrence of vomiting, head- ach and sickness continue, pulse about 120, skin hot. Habeat pulveris jalapae compositi scrupulum. Haustum cum tincturae thebaicae guttis quindecim hora somni. 22d.—Headach and sickness relieved, tongue clean and moist, pulse quick and feeble, two stools previous to giving the powder, and two since, a good night. Habeat misturae diaphoreticae salinae unciam tertia quaque hora. Repetatur haustus, hora somni. 23d.—A good night, still disposed to sleep, free of complaint. Omittatur haustus. 24th.—Gripes in the* course of yesterday, two stools since morning, fifteen grains of compound powder of jalap being given, pulse quick, skin warm, tongue white, still drowsy, gripes con- tinue. Habeat vjni ipecacuanhae drachmas sex, pro emetico. 25th.—Two dark-coloured stools, no vomiting, gripes gone, a quiet night. 30th.—Convalescent. Full diet. 11th May.—-Dismissed cured. 3 18 APPENDIX II. Royal Infirmary, 17tfi May, 1798. James Grant, iEtatis 18.—Complains of great pain in the umbilical and epigastric regions; of severe headach and much sickness, with general uneasiness and lassitude. His internal fau- ces are painful, and there is an eruption of reddish spots over his face and most of his body. Pulse about 90, belly slow, appetite impaired, tongue rather white, has great thirst. On the 12th current he was affected with shivering; the spots appeared about the 15th, and have been increasing since that time; the affection of his throat has likewise been increasing. He had been recovered eight days from a febrile attack, which had continued for a fortnight without any eruption. He took an emetic on the 13th, which relieved in some degree the pain of his head. He took also some pills on the 15th, which acted as a laxative. Habeat enema purgans. 18th May.—Pain of abdomen, affection of internal fauces and eruption continue, skin moderately warm, pulse about 80, and soft, a costive stool. Habeat quam primum, Palveris jalapae, Mercurii dulcis, utriusque grana sex. Potum acidum vegetabilem ad libitum. 19th.—A costive stool in the evening, after an injection, pain of abdomen, affection of throat, and eruption, stationary, tongue load- ed, much thirst, pungent heat of skin, pulse about 80. R. Sodae vitriolatae drachmas sex, Sacchari drachmas duas, Crystallorum tartari, Foliorum sennae, utriusque drachmam, Aquae fervidae uncias sedecim. Fiat infusum quam primum sumendum.—Tegantur fauces panno laneo. TYPHUS. 19 20tb.—Complaints stationary, a bad night, tongue still loaded, with thirst, skin cooler, pulse about 80, four dark-coloured stools. Habeat haustum anodynum vespere. Cras mani infusi sennae unciam et dimidiam. Seri venosi libras duas, partitis vicibus indies. 21st.—Pain of abdomen is abated, that of internal fauces, which appear considerably inflamed, continues; eruption, copious on the face, is less frequent on the rest of the body, heat of skin again more pungent, pulse about 100, thirst urgent, no stool, in- different night. Habeat si opus sit enema domesticum. 22d.__A copious dark-coloured stool after the injection, affec- tion of throat and eruption continue, pulse about 90, of moderate strength, skin of a less pungent heat, thirst not abated. Addantur hausti tincturae thebaicae guttae decern. 23d.__Pain of epigastrium has recurred, pain of fauces conti- nues, skin less hot, pulse about 80, Soft and firm, no stool, an in- different night. Habeat quam primum infusi sennae uncias duas. Repetatur haustus. Intermittatur serum vinosum. 24th.—Two dark-coloured stools, pain of epigastrium and fau- ces relieved, eruption fading, tongue cleaner, pulse about £0, and soft, skin moist, thirst abated, a good night. 26th.—Convalescent, belly rather slow. Habeat omni mane pulveris rhei grana decern. Intermittatur haustus. Full diet. 30th.—Belly has been regular. Dismissed cured. 20 APPENDIX II. Royal Infirmary, 7f/t Aug. 1801. John Baird, ^Itatis 11.—On the 2d instant, by account, was suddenly attacked with rigors, increased heat, and general sweat. Since admission, he has been very indistinrct, and frequently, while awake, is observed to mutter and speak to himself; while asleep, he often starts, and awakes in a fright. Pulse 130, and weak, skin very warm, tongue clean, some thirst, the day before his illness was exposed to febrile contagion, a scanty stool since admission, no remedies employed. Habeat quam primum enema domesticum. 8th Aug.—A scanty loose stool, pulse about 120, and rather feeble, tongue white, more distinct, injection not given. Habeat quam primum bolum e jalapa, cum mercurii granis tribus. Decoctum furfuris ad libitum. 9th.—Two or three stools, skin cool, pulse about 90, a good night, and disposed to sleep, making no complaint. Continuetur decoctum furfuris. 10th.—Has had delirium, and irregular convulsive motions, belly slow, pulse feeble. Repetatur bolus e jalapa cum mercurio, Abradatur capillitium, Habeat vini rubri uncias octo, Cujus sumat unciam subinde. 11th.—Delirium and involuntary motions still continue, a bet- ter night, two loose stools, pulse towards 120, and feeble, wine not much relished. Adhibeatur vesicatorium toti capiti. Habeat haustum cum laudani guttis quindecim. Intermittatur vinum rubrum. 12th.—Delirium much aggravated towards evening, quietness TYPHUS. 21 succeeded the exhibition of the draught, which still continues, ir- regular convulsive motions abated, pulse about 120, and firmer. Habeat misturae diaphoreticae salinae unciam, tertia quaque hora. Repetatur haustus, vespere. 13th.—A tolerable night, disposed to be drowsy; on awaking, he appears agitated, screaming occasionally, but makes no com- plaint, appetite indifferent, pulse quick and feeble, belly slow, in- voluntary motions not perceived, face more or less flushed, copious discharge by the blister. Habeat quam primum infusi sennae uncias duas, necnon ejusdem infusi unciam semel indies. Pilulum e mercurio cinereo, mane et vespere. Intermittatur haustus anodynus. 14th.—An indifferent night, although less drowsy, has on the whole slept much, tongue clean and moist, skin cool and soft, pulse about 100, and feeble, expression of countenance more natural, one stool, but little food taken. Continuentur pilula hydrargyri et mistura. 17th.—Appetite mending, looks improving, sleep natural, pulse calm, skin cool, belly open. Intermittatur pilula hydrargyri. An egg to dinner. 27th.—Dismissed cured. Royal Infirmary, 21th March, 1804. Donald Stewart, ^Etatis 19.—Complains of violent head- ach, vertigo, nausea, and occasional vomiting, pain under the ster- num, with frequent short cough, and slight dyspnoea, debility, ge- neral uneasiness, pulse 90, skin hot, tongue loaded, belly, by ac- 23 APPENDIX II. count, regular. Was attacked two days ago, with rigors, has used no remedies. 28th March.-—Imponatur vesicatorium quam primum sterno, et sumat bolum jalapae compositum. Misturae salinae ammoniatae unciam, subinde. 29th.—Headach and sickness, cough, and pain of breast re- lieved, frequent stools, pulse calm, skin cool and moist, tongue white, thirst inconsiderable, an indifferent night, blister has an- swered well. Habeat haustum anodynum, vespere. Continuetur mistura salina ammoniata. 31st.—Purging gone, cough returns at times, with uneasy breathing, pulse 90, and feeble. R. Misturae mucilaginosse uncias quatuor, Vini e tartrite antimonii drachmas duas, Tincturae thebaicae guttas triginta. Misturae agitatae sumat unciam dimidiam, subinde. Intermittatur mistura salina ammoniata. 3d April.—Belly having been slow, a laxative was given last evening, as yet without effect. Face at times is flushed, and he is somewhat delirious, cough is however abated, breathing easy, pulse calm. Habeat quam primum, infusi sennae uncias tres. Continuetur mistura tartritis antimonii. 4th.—No stool till he got an injection, two since, pulse 80, tongue foul, but moist, eyes suffused. Continuetur mistura e tartrite antimonii. 5th.—Headach and delirium gone, a good night, complains of pain of throat, with difficult deglutition, pulse 80, skin hot, belly slow. typhus. 23 Adhibeatur oleum ammoniatum cum panno laneo faucibus externis. Habeat pulveris jalapae compositi scrupulos duos. 7th.—Pain of throat gone, a good night, passage of belly, pulse 80, skin cool. 13th.—Convalescent. Intermittantur medicamenta. Full diet. 17th.—Four loose stools. Potionis cretaceae unciam unam, secunda quaque hora ; pilulam thebaicam, bis de die. 18th.—Four stools. Habeat sodae tartarisatae drachmas sex. Continuentur potio cretacea et pilulae thebaicae. 20th.—Purging gone, tongue appears loaded, headach, pulse calm. Habeat infusi amari unciam dimidiam, quater in dies. Intermittantur potio cretacea, et pilulae thebaicae. 21st.—Stools have become frequent, and of a natural appear- ance, with gripes, and occasionally sickness, and spontaneous vo- miting, tongue white, thirsty. Habeat ipecacuanhae scrupulum unum, pro emetico. Con- tinuetur infusum amarum. 22d.—Stomach appears to have been loaded, gripes relieved. 23d.—General uneasiness and pain, tendency to delirium, eyes are suffused, pulse feeble, indifferent nights. R. Vini rubri uncias quatuor, Aquae uncias quatuor. Misce. Sumat unciam dimidiam, subinde; haustum anodynum, vespere. 24 APPENDIX II. 24th.—Restless, and more delirious, without particular com- plaint. Eyes less suffused, but heavy, tongue somewhat loaded, pulse at the wrist hardly felt, a natural stool in the evening, wine relished, and some food taken. Habeat vini rubri uncias duodeeim, Aquae uncias octo. Sit mistura, ut heri porrigenda. 25th.—Has had a quieter night, but continues indistinct, with feeble pulse, parched tongue, and involuntary twitching, no stool. Habeat quam primum bolum e jalapa cum mercurio, et vespere, si opus sit, ad alvum dejiciendam enema domes- ticum. Continuetur vinum. 26th.—A quiet night, disposed to sleep since morning, counte- nance more florid, and of a more natural appearance, a copious, dark-coloured, and fetid stool, after the injection. Repetatur bolus e jalapa, cum mercurio, et ene'ma domes- ticum, si opus sit. Repetatur etiam vinum. 27th.—One stool by the injection, and another an hour after, continues to sleep much, pulse 120, still feeble. Repetatur enema vespere. Continuetur vinum. 28th.—Continues drowsy and indistinct, with tremor of hand, and slight subsultus tendinum, tongue loaded, pulse feeble, wine relished. Imponatur vesicatorium capillitio abraso. Repetatur bolus e jalapa cum mercurio ut supra, necnon enema domesticum, si opus sit, vespere. Repetatur vi- num. 29th.—A fetid and rather.scanty stool after the injection. A good discharge by the blister, appears less drowsy, has been more distinct, tremor and subsultus at present gone, tongue dry and TYPHUS. 25 less loaded, pulse feeble, wine still relished, and little food taken. Repetatur bolus e jalapa cum mercurio, necnon enema. Continuetur vinum. 30th.—A copious, but still fetid and dark-coloured stool, from the injection. Has passed an easy night, wine still relished, and a little more food taken, slight subsultus with appearance of floc- citatio. In other respects as yesterday, pulse feeble. Repetatur bolus e jalapa cum mercurio, necnon enema si opus sit, et continuetur vinum. 1st May.>—Two stools after the injection, the last copious, dark, and fetid, a quiet night, tremors and floccitatio abated, pulse 80, and of good strength. Repetatur vinum. 2d.—A good night, with less delirium, tremor and floccitatio gone, pulse 80. Repetatur vinum. 3d.—Febrile symptoms continue to abate, free of complaint, pulse calm, belly rather slow. Habeat pulveris jalapae compositi scrupulos duos. Vespere enema domesticum, ni prius soluta sit alvus. Continuetur vinum. 6th.—Two stools in the course of yesterday, continues appa- rently convalescent, but is greatly emaciated, tongue clean, pulse calm, improving appetite. Habeat vini rubri uncias octo, Aquae uncias quatuor. 30th.—Intermittatur vinum. Fuji diet. 15th June.—Dismissed cured. 4 26 APPENDIX II. Royal Infirmary, 1th Oct. 1805. Margaret Manson, iEtatis 20.—Complains of headach, ver- tigo, nausea, and occasional vomiting; pain of back, and general pains; pulse 180, and weak, skin hot, tongue very foul, belly cos- tive; complaints of two days duration, for which she knows of nc cause. Habeat bolum jalapae compositum cras mane. 8th Oct.—Two full stools of natural appearance; headach con- tinues; two or three attacks of vomiting during the night, none since morning; sickness relieved, tongue still much loaded. Repetatur bolus jalapae compositus vespere. 9th —Headach is relieved, no return of vomiting, sickness abated, tongue less loaded, surface of natural heat, pulse 100 and soft, three copious stools. Decoctum furfuris ad libitum. 10th.—Pulse calm, skin cool, tongue clean, makes no com- plaint, good night, with returning appetite. 15th.—Convalescent. Full diet. 18th.—Dismissed cured. Royal Infirmary, Glh Nov. 1805r. Margaret Kennedy, iEtatis 17.—Complains of severe head- ach, vertigo, and nausea, with pain in the small of her back, and general uneasiness; pulse 100, and feeble, skin cool, tongue furred, belly slow, says she has been subject to flying pains for some weeks, but they have been aggravated for two days with headach and other symptoms of general fever. TYPHUS. 27 Habeat bolum jalapae compositum cras mane. 7th Nov.—Pain of loins, and other symptoms of general fever, as described; alternate attacks of chilly and warm fits, followed by sweating; by her account headach has morning remissions; pulse about 100 and feeble; as yet no stool. Habeat quam primum, Infusi sennae, Infusi lini, utriusque uncias tres. 8th.—Pain of loins and headach continue, with nausea, and one attack of spontaneous vomiting; complains still of alternate rigors and hot fits; pulse about 100, and feeble, skin cool, tongue moist, little thirst, full alvine evacuation, of a dark colour and fetid smell, a quiet night. Decoctum furfuris ad libitum. Cras primo mane, Pulveris jalapae compositi drachmam. 9th.—Copious and natural stool in the course of yesterday, ap- petite good, easy night. 11 th. Dismissed cured. Royal Infirmary, 6th June, 1806. Jean Wyllie, jEtatis 25.—Complains of severe headach, nausea, and vomiting, pain of back and loins, and general pains. Surface rather warm, tongue foul, belly slow, face flushed, pulse 110, and sharp. Complaints are of four days duration; has had one small dose of the supertartrite of potass, which scarcely moved her bowels. Cras primo mane, habeat Bolum jalapae compositum. 7th June.—Headach and sickness are relieved, surface of natu- ral heat, countenance less flushed, tongue clean, pulse about 80 and 28 APPENDIX II. soft, an indifferent night, but disposed to sleep since morning, two copious and natural stools. Habeat misturae diaphoreticae salinae unciam, alternis horis. Decoctum furfuris ad libitum. 9th.—Convalescent. Intermittantur medicamenta. 12th.—Dismissed cured. Royal Infirmary, 24th June, 1806. William Mackay, iEtatis 36.—Complains of headach, ver- tigo, and slight nausea, pain of breast, wilh general pains. Pulse about 100 and soft,.tongue white, belly slow, appetite bad, pros- tration of strength. Complaints are of three days duration; he can assign no cause for them Had an emetic last night, which he thinks gave him great relief. Sumat bolum jalapae compositum. 25th June.—Vertigo, headach, and other febrile symptoms much declined, skin cool, pulse calm, tongue clean, one easy al- vine evacuation. 28th.—Free of complaint. Dismissed cured. Royal Infirmary, 1st July, 1806. Mary Stalker, JEtatis 18.—Complains of headach, debility, general soreness and uneasiness, wilh vertigo, when in the erect posture, alternation of heat and cold, great thirst, sleep disturbed, pulse 108, belly and catamenia natural. TYPHUS. 29 These complaints began on the 29th ultimo, with rigors, head- ach, and prostration of strength, and are attributed to cold. Sumat hora somni haustum cum tincturae thebaicae guttis triginta, et cras primo mane bolum jalapae compositum. 2d July.—Headach, vertigo, and lassitude continue, a bad night, with much heat of surface, which is now however moderately cool and rather moist, tongue clean, pulse about 90 and soft, two scanty alvine evacuations, scybalous, but of natural colour. Habeat quam primum infusi sennae uncias tres, infusi lini uncias quinque. Decoctum furfuris ad libitum. 3d.—Vertigo, headach, and sense of lassitude are relieved, skin cool, tongue clean. Plentiful alvine evacuation, with gripes; the latter feces fluid, of a dark, somewhat bloody colour, an indifferent night. Habeat, ineunte nocte, haustum cum laudani guttis triginta. 5th.—Belly has been regular, complaints are gone. Dismissed cured. Royal Infirmary, 1th September, 1806. Ann Henderson, ^tatis 18.—Complains of headach, vertigo, nausea, and vomiting, general pains, with severe pain of breast, greatly impeding respiration. Pulse about 100 and soft, tongue white, belly slow; skin rather hot, thirsty, appetite bad, sleeps ill. Her complaints are of eight days duration. She was blooded two days ago, and had a blister applied to her breast, but without relief. Habeat bolum jalapae compositum cras mane. 8th Sept.—Headach, vertigo, nausea, and retching continue, pain of breast is relieved. Pulse about 100 and feeble, skin mo- derately cool. Bolus given as yet without effect. 30 APPENDIX 11. Accipiat enema anodynum cum tincturae opii guttis sexa- ginta, Habeat pilulas aloeiicas octodecim, sumat tres omni tri- horio. 9th.—Headach, sickness, and retching gone, skin cool, pulse calm, tongue clean. Pills having been taken, some additional ones have been followed by full alvine evacuations. Intermittantur pilulae aloeticae. 13th.—Has continued convalescent. Dismissed cured. Sect. II. SENTIMENTS OP AUTHORS ON THE USE OF PURGATIVE MEDICINES IN FEVER. Lommius de Curandis Febribus continuis, edit. Lond. 1718. Pp. 131, 132, 133, 134. "Atque haec quidem purganditem- pora certa sunt, nisi materia protinus turgere coeperit, id est, effer- vescere, ac de loco in locum mobilis rapi. Tum enim quam pri- mum humor, quamvis nondum coctus, auctore Hippocrate auferri purgatione debet; idque, ne vel in partem delatus principem, le- thalem ibi excitet inflammationem, vel repente, si venenatus est, naturae calorem oppiimens, occidat. Illud quoque scire licet, in- terdum, et declinante febre, iterari purgationem posse, cum per imperfectum judicationem natura majorem quidem materiae par- tem exclusit. reliquam vero excludere potis non fuit, quae ipsa jam tum, (ne post iterum morbum faciat,) recte medicamenlo ducitur. Nam quae post judicationes (ut diligenter observat Hippocrates) TYPHUS. 31 relinquuntur in morbis, recidivas facere consueverunt. Adeo vero demiror inconsulta complurium judicia medicorum, ex quibus cum multi, incipiente morbo, purgent, haud pauci etiam consis- tenle, nonnulli quoque declinante, paucissimi tanien sint, qui in- crementi provectiorum partem arripiant. Quasi, certe, data opera, id tempus praeterierint, quod ad hanc curationem in acutis febribus est aptissimum. " Porro non loquor hactenus id medicamenti genus quod passim lenitivum appellant, sine vi, ullave corporis turba sordes inlestino- rum expurpans." " Haud leve commodum acute febricitantibus ex hujusmodi accedit alvi ductionibus. Nam siccum oletum va- cuatur, putredine offendens sua, ardor febrilis mitescit, corruptae- que bilis colluvies, quae ju#a est, eluitur. Verum mitia plane haec esse debent, sic ut alvum semel, aut, ad summum bis, non amplius, si fieri potest, moveant." Glass (Thomas.)—Commentarii 12 de Febribus ad Hippocratis disciplinam adcommodati. Lond. 1742. Pp. 102, 103. " Materia ergo turgens est aliquid molest urn circa primas vias haerens, quod aut per os, aut per alvum, plerum- que excuti potest; atque haud raro ventriculum aut intestinum ad id ipsum expellendum irritat." Pp. 103, 104. " Infra autem praecoidia turgere materiam, et intestines insidere, significant; genuum gravitas, lumborum dolor ventris distentionis, murmura, tormina, alvi egestiones liquidae, sincerae, corruptee, et acres. Caeterum haec mala accidentia, nec- non febres ab eadem causa concitatae, non prius ulla arte cessant, quam materia turgens contemperata sit, vel commoda purgatione expulsa. " Neutiquam vero expectare aequum est, ut ex his evacuation*!- bus febres, quae crudae sunt, judicentur; sed spes est ut gravia ilia accidentia, quae materiam turgentem indicant, leventur; ex quo ajgri facilius ferent febres, et illae citius finientur." 32 APPENDIX II. Langrish (Browne.)—The Modern Theory and Practice of Physic. Lond. 1764. P. 343, par. 589. " Purges also are detrimental in the beginning and increase of slow fevers: for daily experience sufficiently informs us, that whenever there is a general relaxation or flaccidity of the solids, a poverty of the fluids, and a languor upon the spirits, the gentlest purging medicine createsrgreat uneasiness; and, indeed, if any excretion be considerably enforced, some inconvenience or other will be sure to succeed it, at such times, especially, where there is no morbid matter fit for expulsion, nor no critical discharge to be made from the blood." P. 344, par. 591. " As purging has been proved to be inju- rious in the beginning and increment of this disease, we need not, therefore, be solicitous about stools unless the patient happens to be more than ordinary costive; and then the most lenient clysters that can be contrived may be sufficient." Pp. 346, 347, par. 596. " But if there be a peculiar idiosyn- crasy in the patient, or if the morbific febrile matter be so tough, viscous, or obstinate, as not to give way to the efforts of nature, assisted by the above-mentioned medicines, in some reasonable time, the symptoms will necessarily increase and grow worse, and then we have scarcely any chance left for the recovery of our pa- tient, but by the use of moderate purging medicines: for since the natural excretions by perspiration, sweat, urine, &c. are diminish- ed, or at least they are not sufficient to excrete the morbid matter, this evacuation seems to bid the fairest at this time of day. For though all the bad symptoms proceed from weak and relaxed nerves, yet if the febrile matter be fitted for excretion, and the biliary and the renal ducts deny it a passage, however assisted by our art, the retained matter will inevitably grow putrid, the vital vigour will decay, and death will most certainly ensue, unless the body be timely relieved by some few loose stools." Par. 5^97. " Experience assures us, that gentle lenient cathar- tics, rightly ordered, where the morbid matter is properly attenu- ated, diluted, and divided fit for expulsion, are not only safe, but typhus. 33 necessary ; and the whole system of nerves, instead of being weakened, will gain strength thereby; so that when these fevers have continued for a long time, and there has been no perfect crisis, they will hardly admit of any other cure than what is car- ried on by gentle cathartics." Dr. Cullen's First Lines of the Practice of Physic. Edin. 1789. Vol. I. p. 201, par. 149. " If, notwithstanding these doubts, (146, 147, 148,) it shall be asserted, that purging, even from the exhibition of purgatives, has often been useful in fevers, I would beg to maintain that this has not happened from a large evacua- tion, and therefore, not by moderating the violence of reaction, excepting in the case of a more purely inflammatory fever, or of exanthemata of an inflammatory nature. In other cases of fever, I have seen a large evacuation by purging of mischievous conse- quence ; and if, upon occasion, a more moderate evacuation has appeared to be useful, it is apprehended to have been only by tak- ing off the irritation of retained feces, or by evacuating corrupted humours which happened to be present in the intestines; for both of which purposes, frequent laxatives may be properly employed." HuxhaM (John.)—An Essay on Fever, 6th edition. Chap. 8.—Of putrid, malignant petechial fevers. Pp. Ill, 112. "Not only the stomach, but the whole intesti- nal canal, should be unloaded in the beginning of these fevers, but I am sure, reason and experience shew the necessity of doing it by very gentle methods."—" The above soft easy emetics and eccoprotics have this further advantage, that they may be repeated, and given from time to time, as the putrid bilious colluvies drains into the first passages. By such means I never feared to puke, or 5 34 APPENDIX II. promote a stool or two, when indicated at any time of the fever, by a nauseous bitter taste in the mouth, sickness at stomach, nido- rosc and fetid eructations; or by too great costiveness, tumid abdo- men, borborygmi, griping pains," &c. Pp. 113, 114. " Where, therefore, there are signs of it," the bile, " being redundant, it should forthwith be discharged by vo- mit, or stool, as nature points out. I have many times, wilh the greatest pleasure, in these putrid fevers, seen an amazing change for the better immediately succeed a fit of vomiting, and a stool or two, where an inexpressible anxiety, load on the prcecordia, perpetual sickness, eructation and singultus had preceded. The extreme foulness of the tongue, sickness and load at stomach, with a loathsome bitter taste, and horrible offensive stinking breath and eructations, shew the condition of the stomach; and the abomina- bly fetid, black, bilious stools, the necessity and advantage of that discharge. Surely if a poison of any kind was lodged in the sto- mach, or bowels, we should not hesitate about the necessity of car- rying it off as soon as possible, and truly putrid bile is little less pernicious than an actual poison." Dr. Huxham, declining the use of strong purgatives in this fever, says, p. 115, " Nature, indeed, without such powerful stimulants, too frequently overacts her part, and runs into a profuse diarrhoea, a dysentery, soon fatal if not restrained; but this most commonly happens, from suffering the corrupt bilious matter to lodge and pu- trefy too long a time in the bowels; and the best way to prevent it is to dislodge it at proper seasons, and due intervals." Currie (James.)—Medical Reports on the effects of Water, told and warm, as a Remedy in Fever, and other diseases. Lond. 1805. Vol. I. p. 256. " What then ought to be the indications of practice in fever ? To diminish the cold in the cold stage ; to mo- derate the heat in the hot stage; and to resolve the stricture on the extreme vessels, by which the morbid heat is retained, and the re- action prolonged; and where the inordinate action of the vascular TYPHUS. 35 system continues after these objects have been attained, to support the powers of life, till the morbid associations, or habits of action, gradually die away, from the removal of the causes by which they were introduced. In addition to these general indications, it will be essential to secure the proper action of the bowels, and, in every case, to unload the alimentary canal of its morbid contents, whe- ther these contents hav» become diseased through the action of ge- neral fever; or, as there is reason to believe in some of the fevers of the warm climates, be the remote cause by which fever is pro- duced." VPPENJJIX III. SCARLATINA Sect. I. CASES OF PATIENTS WHO LABOURED UNDER SCARLATINA, EX- TRACTED FROM THE RECORDS OF THE ROYAL INFIRMARY. Royal Infirmary, XlthNov. 1804. James Rjtchie, soldier, iEtatis 19.—Feels great pain and dif- ficulty of deglutition, the internal fauces being of a deep red co- lour, and the tonsils considerably swelled, with a large greyish- coloured slough, occupying the left one: complains of headach, general oppression, and debility. Appetite is bad, pulse 100, skin very hot, tongue very dry, thirsty, belly slow. He was attacked with these symptoms four days ago, and can assign n© cause for his complaints. Has used no remedies. Habeat bolum e jalapa cum mercurio. R. Acidi muriatici oxygenati drachmas duas. Aquae fontanae uncias sedecim. Sit mistura in loco te- nebroso servanda, cujus sumat unciam unam e cya- tho vitreo, secunda quaque hora. 18th Nov.—Headach, sickness, and oppression, are relieved, tongue less parched, surface less pungently hot, pulse about 100, rather feeble, state of internal fauces as described, wilh difficult deglutition, countenance pale, no stool. R. Tincturae jalapae drachmas sex. Aquae canellae albae drachmas duas, Sacchari drachmam unam. scarlatina. 37 Sit haustus quam primum sumendus. Oleum ammoniatum cum panno laneo faucibus externis. Continuetur acidum muriaticum oxygenatum. 20th.—One easy stool, skin cool, pulse calm, countenance less pale, deglutition more free. Repetatur haustus e tinctura jalapae. Continuetur acidum muriaticum oxygenatum. 24th.—Affection of internal fauces, and febrile symptoms gone. appetite improves. 25th.—Tongue clean, belly regular. Intermittatur acidum muriaticum oxygenatum. 29th.—Continues feeble, countenance pale, and expressive of languor. Habeat misturae corticis cinchonae aromaticae unciam unam. tenia quaque hora. Full diet. 3d Dec.—Since yesterday, considerable oedema has occurred By account, urine has been in natural quantity, and bowels regu- lar, pulse about 70. Habeat quam primum bolum e jalapa cum mercurio, ves pere repetendum, necnon cras primo mane, ni prius so- luta fuerit alvus. Intermittatur mistura cinchonae. 4th.—Three stools; the last of natural appearance, oedema abated. Two boluses taken. Cras mane repetatur bolus e jalapa cum mercurio. No stool. 5th.—R. Sodae tartarisatae unciam unam, Infusi sennae uncias duas, Decocti furfuris libram unam. Sit solutio partitis vicibus sumenda. 38 APPENDIX hi. 6th.—Five watery stools, oedema continues, rather aggravated, with considerable dyspnoea, particularly during last night, pulse 60, and soft. R. Submuriatis hydrargyri grana duodecim, Pulveris jalapae drachmam dimidiam, Simul terantur et dividantur in doses quatuor aequales. Sumat unam omni trihorio. 7th.—Has had plentiful alvine discharge, of natural appear- ance, urine is also natural and abundant, oedema seems abated, and dyspnoea relieved, the powders taken, mouth not affected. Repetantur pulveres, ut heri praescriptum, cras mane. 8th.—Has had two stools, rather scanty, dyspnoea still farther relieved, one powder only taken. Continuentur pulveres, unus omni trihorio sumendus, R. Sodae tartarisatae drachmas sex, Infusi sennae uncias duas, Aquae fontanae libram. Sit mistura tribus vicibus sumenda, cras mane. 9th.—Three powders taken, four stools, but the alvine discharge^ on the whole, scanty, of a green colour, and fetid, urine scanty, of a dark and almost bloody colour, oedema continues, breathing easy, mouth is affected. Repetatur solutio sodae tartarisatae ut heri praescriptum, quam primum; cras mane iterum repetanda. 10th.—Sickness and vomiting after the last dose of solution this morning, alvine discharge more abundant and natural, urine also in greater quantity, and more natural, oedema abated. Juris bovini libram unam, indies. Basin of tea to breakfast. 11th.—(Edema still more abated, feculent discharge, of natu- ral quantity and appearance. SCARLATINA. 39 Habeat pilulas aloeticas duas, omni mane ct vespere. Vini rubri uncias octo, indies. 13th.—Belly regular, oedema gone, and countenance more lively than hitherto. Continuentur vinum et pilulae aloeticae. 16th.—Has had two stools daily, in abundant quantity, and of natural appearance. Sumat pilulas aloeticas duas tantum indies. 24th.—Dismissed cured. Royal Infirmary, llth Feb. 1805. William Gordon, iEtatis 22.—Complains of pain of throat, with some difficulty of deglutition, the internal fauces are of a deep red colour, general redness of surface, frequent scanty stools, with tenesmus, loss of appetite, pulse 98, tongue loaded, thirsty, skin warm. Was attacked three days ago with general pains. The efflo- rescence appeared yesterday. Has used no remedies. Habeat tartritis sodae et potassae drachmas sex, Infusi sennae uncias duas, Ex infusi lini unciis sex, duabus vicibus sumendas. 12th Feb.—Has had several stools, efflorescence faded, internal fauces relieved, pulse calm, tongue loaded, much thirst and lan- guor. Vespere habeat haustum anodynum. Cras mane solutionem catharticam, ut heri praescriptum, Decoctum furfuris tepidum, ad libitum. 13th.—Tongue cleaner, febrile symptoms and eruption gone, a "ood night, is less languid, pulse calm, four stools. 10 APPENDIX III. Vespere repetatur haustus anodynus. 14th.—A quiet night, two stools of natural appearance, free of complaint. Repetatur haustus anodynus. Habeat omni mane pulveris radicis thei grana octo. 15th.—One stool. Convalescent. Repetatur haustus anodynus. 17lh.—Belly regular, stools natural. Full diet. 23d.—Belly open, tongue loaded. Habeat ipecacuanhae scrupulum unam, vespere. Haustum anodynum, hora somni. 24th.—No vomiting, tongue clean, purging gone. 28th.—Dismissed cured. Royal Infirmary, 6th Jan. 1805. Alexander Corner, iEtatis 7.—Complains of almost con- stant headach, and occasional vertigo, pain of abdomen, with some tension, and swelling, the pupils appear dilated, disturbed sleep, from which he sometimes awakes with a loud scream, loss of ap- petite, feebleness, pulse 90, skin rather hot, tongue moist, thirsty, belly costive, he has a slight excoriation on each haunch from lying on them long. The above symptoms have been present three weeks, and suc- ceeded a fever, which was accompanied with general efflores- cence of surface, and sore throat, followed by desquamation of the cuticle; during the fever he took an emetic. Two days ago he took a dose of senna and manna, but with little effect. SCARLATINA 4$ Habeat pulveris jalapae grana sex, Submuriatis hydrargyri grana tria. Sit bolus quam primum sumendus. 7th Jan.—As yet no stool. Injiciantur quam primum per anum, enematis domestic unciae octo. Habeat bolos quatuor, ut heri praescriptum ; sumat unum omni trihorio. 8th.—Three stools, dark and fetid, and in considerable quan- tity; the first, after the injection; the second, after the third bolus; the third, this morning, the fourth bolus being previously given; has passed a bad night, awaking suddenly, screaming, from short sleeps, but complains less of headach, and more of pain of abdo- men; pupils seem to possess more contractility, appetite indifferent, pulse 80, and soft. 9th.—An easier night; sleep being of longer continuance; he awakes less suddenly, and without screaming; by his account, is free of headach, but complains of pain of abdomen; countenance at present pale, pulse towards 100 and feeble, a fetid, and dark- coloured stool, urine in small quantity, and high-coloured, little food taken. Habeat pulveris jalapae compositi scrupulum unum quam primum; cras primo mane repetendum. A small basin of tea, morning and evening. 10th.—Countenance more florid, and expression more lively, pain of abdomen gone, tongue clean, pulse calm, surface cool, two stools, both abundant, and of more natural appearance and odour, some food taken, and seemingly relished, both powders given, a good night. Repetatur pulvis, ut heri praescriptum. Uth.—Free and full feculent discharge, and he continues free of complaint 42 APPENDIX 111. Habeat secum pulveris jahpse compositos, ut supra pize* scriptum, duodecim. Signa, one to be taken daily. Dismissed cured. Royal Infirmary, 14th Jan. 1805. Catharine Stewart, iEtatis 18.—Complains of pain of back and of loins, occasional headach, vertigo, with uneasiness and sense of weight at the epigastrium, increased on pressure, and af- ter taking food, pain and weakness of knee-joints, strength is im- paired, pulse 84, skin cool, tongue rather white, belly slow, cata- menia have not appeared for three months, at which time they were suddenly suppressed by exposure to cold. Habeat bolum jalapae compositum. 15th Jan.—One stool, rather scanty, fluid, and of natural ap- pearance, symptoms not relieved. Habeat pilulas aloeticas octo. Sumat duas quam primum; et deinde, duas omni trihorio. Cras mane infusi sennae uncias duas, ex infusi lini unciis octo. 26th —Copious feculent discharge, headach, vertigo, and sto- machic distress relieved, pain of loins continues, remarks a swell- ing and fulness of face; about four months since laboured under fever, which, by her account, seems to have been scarlatina anginosa; since when «he has never fully recovered her usual health. R. Sulphatis magnesiae drachmas tres, Supertartritis potassae drachmam, Infusi sennae unciam, Infusi lini uncias octo. Sit solutio omni mane duabus vicibus sumenda. Full diet. SCARLATINA. 43 18th.—A copious alvine discharge of greenish colour, headach continues relieved, pain of loins easier, stomachic distress relieved, fulness of features continues. Continuetur solutio sulphatis magnesiae. 20th.—A copious and to appearance a natural stool, pain of loins is relieved, complains still of headach, fulness of features gone, urine abundant, pulse calm. Continuetur adhuc sulphas magnesiae, 22d.—Headach and pain of loins are gone, alvine discharge has been regular and full. R. Sulphatis magnesiae uncias tres, Supertartritis potassae drachmas sex. Mice, et divide in doses octo aequales. Signentur ; Laxative powders, one to be taken dissolved in water once a day, or every two clays. Dismissed cured. Royal Infirmary, 2Sth Nov. 1806. John Johnstone, iElatis 12.—Complains of pain of throat, with difficulty of deglutition, the internal fauces are of a deep red colour, and on both tonsils several sloughs, of a greyish colour, are observed; general redness of surface, considerable debility, much thirst, appetite impaired, heat moderate, tongue pretty clean, belly by account regular, pulse 100, face flushed, sleeps pretty well. The affection of the throat, accompanied with rigors, began on the evening of the*23d current; the efflorescence began to appear in about 48 hours after; has used some remedies with advantage, Sumat pulveris jalapae compositi scrupulos duos, Utatur infuso rosarum pro gargarismate, 44 APPENDIX III 29th Nov.—Flushing of countenance, with efflorescence, and moderate heat of surface, and tumefaction and ulceration of inter- nal fauces, with increased pain, continue; pulse about 108, soft, considerable thirst, a quiet night, a pretty copious alvine evacua- tion, consisting of formed detached pieces of hardened feces. R. Infusi sennae uncias tres, Infusi lini uncias sex, Extracti radicis glycirrhizae drachmam unam. Solve. Sumat uncias tres omni hora. Continuetur infusum rosarum. A basin of tea, morning and evening. 30th.—A quiet night, surface cool, pulse about 90, soft, efflo- rescence much faded, flushing of face gone, internal fauces less pained, full alvine evacuation of dark-coloured and fetid feces. Infusion taken. Sera nocte habeat bolum jalapae compositum, et cras mane repetatur infusum sennae, ut heri praescriptum. 1st Dec.—Internal fauces continue easy, pulse calm, tongue clean, surface of natural heat, urine of natural appearance, and in full quantity, two alvine evacuations, feces soft, and of more natu- ral appearance. Intermittatur infusum rosarum. 2d.—Ulceration of internal fauces healed or healing, in other respects convalescent, urine abundant, passage of belly, feces nearly of natural appearance. Habeat supertartritis potassae scrupulum unum ter de die 4th.—Belly regular, and urine abundant. Continuetur supertartris potassae. 5th.—No stool since yesterday, urine abundant, surface dry desquamation of cuticle SCARLATINA. 45 Habeat quam primum pulveris jalapae compositi scrupulos duos. Continuetur supertartris potassae. 6th.—Copious and consistent alvine evacuation, urine continues abundant, improving in strength and appetite. Continuetur supertartris potassae. 8th.—Habeat supertartritis potassae uncias duas. Signa, a tea-spoonful in water once or twice a day. Dismissed cured. Sect. II. NARRATIVE OF SCARLATINA, AS IT AFFECTED THE CHILDREN IN GEORGE HERIOT'S HOSPITAL, IN AUTUMN 1804. George Heriot's Hospital is a large building, of noble archi- tecture, forming a quadrangular court. By this construction, and by means of cross windows in the different apartments, complete ventilation is procured. The house occupies a dry situation, on the highest part of a ridge immediately to the south of the city, and is placed in the middle of an inclosure, consisting of several acres. On the south and west, it commands extensive views of the country: it is more confined on the north and east by the cas- tle, and by the buildings in the Old Town, from both of which, however, it is at a considerable distance. Great attention to the cleanliness and airiness of every part of the hospital is added to these advantages of situation. The diet of the children is well regulated; there is an abundant supply of spring-well water, from the city's reservoir, which adjoins the house; and the medical gentlemen attached to the hospital, and acting under the regulations of the governors, put a nagative on the admission of any child who appears to them to labour under scrofula. These circumstances are so favourable to the health of the in- mates of this foundation, that I have the satisfaction to say, that 46 APPENDIX III. during thirty-eight years that I have had the medical superintend- ence of it, I have seldom known any serious illness prevailing among them. The sons of burgesses, freemen of Edinburgh, are received into 'his hospital. They are admitted when between the seventh and eleventh year of their age; and are maintained and educated till they reach their fourteenth year. Their present number is one hundred and twenty, and they, together with the matron, masters, and domestics, form a family of about one hundred and forty persons. Towards the end of September, 1804, I visited one of the youngest of the children in fever. I found him labouring under symptoms of scarlatina, which had been epidemic in the town for some months. He was moved immediately to the sick-room, and thus secluded from his companions; and I directed every pre- caution to be employed, in washing and ventilating the apartment or ward which he had left. The whole of the children were con- fined wiihin the precincts of the hospital, lest, through communi- cation with their relations in town, they might be affected with the fever, and thus add to the accumulation of contagion. I was not, however, fortunate enough, indeed I did not expect to be so, to make this the solitary instance of the disease, in the midst of so numerous a family. Day after day my sick list increased; and, during three months that the fever prevailed in the hospital, upwards of fifty of the children passed through it. And I re- marked, that by far the greatest number of the sick came from the ward in which my first patient had lain. About the end of the year, the last of my little patients left the sick room, which was then shut, and it has fortunately continued so to this date, 15th of March, 1805; and some weeks have now elapsed since communication with the town has been opened. In all the children, particularly in those who were first affected, the symptoms were so mild, that but for my knowledge of the pre- valence of the epidemic in town, I might have mistaken the dis- ease on its first appearance, and been lulled into a blameable se- curity. The throat was not much affected. The uvula and amyg- dalae were slightly swelled and inflamed in every instance; in a SCARLATINA. 47 few cases, superficial suppuration and sloughing appeared. The efflorescence on the surface was partial, and in general transitory, leaving a peculiar paleness of countenance. The eye was dull and heavy Sickness and prostration of appetite continued through- out (he disease. The thirst was moderate; great debility prevail- ed in every case; and in some a peculiar dejection and despon- dency, hardly to be looked for in subjects so young. The pulse was variable; always quick, till towards the end of ihe disease, when it sometimes sunk below the natural standard; it was never full. The surface of the body was occasionally of a pungent heat. Obstinate constipation prevailed in general. My patients were objects of serious attention for twelve or fourteen days; the convalescent state of almost all of them was protracted for nearly the same length of time; and six weeks elapsed before some who entered the sick room left it. Such was the appearance, and such is the history of this epi- demic in Heriot's Hospital; in conducting the cure of which, I employed purgative medicines fully; while food suited to the weak appetite and feeble powers of digestion was directed. The effect of the purgatives was favourable. The feces were hard, generally of a black, or greenish colour, and fetid; and some- times of the colour and consistence of clay, and less fetid. In proportion to the evacuation of these feces, relief was perceptible. Returning appetite and vivacity accompanied the decline and ces- sation of the various symptoms. As the weather had become cold, and otherwise inclement, the children were detained in the sick-room for many days after they were perfectly well; purgatives were administered, as the state of the bowels demanded; and the general warm bath was repeatedly used, on the supposition that, by its restoring a perspirable state of the skin, it would, in concert with the purgative medicines, tend to prevent dropsical swelling, which, from the symptoms, I greatly- dreaded. At last, healthy and robust, and impatient of farther restraint, the convalescents were permitted to return to their particular wards, and, in no longtime,to mix with their companions in school,and at play, 48 APPENDIX III. Happy I am that I had been thus careful and provident in using these precautions; for I have to relate the fate of three boys, who, in two or three weeks from their passing from under my care, were again reported as unwell, and again appeared in the sick- room. Their symptoms and their fate were the same. They had a leucophlegmatic look, incipient anasarca, total prostration of ap- petite, scanty, if not suspended secretion of urine, swelling of abdomen, obstinate constipation, nausea, extreme debility, and feeble pulse. Alarmed by these symptoms, I requested Messrs. Alexander and George Wood, surgeons to the hospital, to join me in consul- tation. Suitable cordials were ordered, and purgative medicines of appropriate quality, and in repeated doses, were directed. The disease, in all the three, proceeded with a rapidity which afforded little farther opportunity for deliberation or action. The stomach gave way; all food, cordials, and medicines, were rejected, by vo- miting. The watery effusion rapidly filled the cellular membrane, and inundated every cavity. Within less than thirty-six hours from the recurrence of the ailment, the boys died, labouring un- der symptoms, denoting ascites, hydrothorax, and hydrocephalus. This termination was altogether new; I had never seen dropsy from scarlatina fatal. In consequence of this event, I approached the hospital for many days under deep anxiety, because I was con- scious that other children were at the time in a situation which might lead to the same unfortunate issue I continued to pay unceasing attention to the alimentary canal, which every day's experience proved to be much disordered. Strong purgatives were given in large and repeated doses, some- times twice and thrice in the same day, before the necessary eva- cuation was procured. In some instances, the colon, hard and distended, could be traced by the finger, in those places where it approaches the parietes of the abdomen. In two cases, general fulness of the belly, oedema of the lower extremities, nausea, retching, and scanty secretion of bloody-co- loured urine, shewed themselves. In these stimulating clysters supported and promoted the efficacy of the purgatives, and insured a determination downwards; without which, I am satisfied, I should SCARLATINA. 49 have had to regret the loss of two other boys; one of whom had taken, within the space of twenty four hours, a drachm of the mass of the aloetic pill, and thirty grains of the submuriate of mercury. The other, when danger was over, was much distressed, by affection of the mouth, and bloody ptyalism, the consequence of the quantity of calomel previously given. For greater security, an additional apartment was opened for convalescents. Here they were sedulously watched; purgative medicines were occasionally employed, to secure and establish a regular state of the belly; and returning appetite was satisfied with light and nourishing food. I always inspected the alvine discharge of the sick; the quan- tity of which, varying in consistence, colour, and fetor, daily eva- cuated during the fever by each boy, was astonishing to me. An emetic was given occasionally, but not generally, on the ap- proach of the fever; and towards its decline a moderate quantity of wine was allowed. This seemed to be necessary, in a few in- stances; bnt to avoid the appearance of partiality, the practice of giving it was general. Gargles, composed of port wine, diluted with water, or of vinegar and water, sweetened with honey or su- gar, were also employed in a few cases; as were saline and dia- phoretic mixtures. At length, under this management, care and anxiety on the present occasion came to a period. HerioPs Hospital, 15th March, 1805. Sect. III. TESTIMONY OF AUTHORS WHO ARE FAVOURABLE TO THE USE OF PURGATIVE MEDICINES IN SCARLATINA. Dr. Cullen observes, par. DCLXI. of the First Lines of the Practice of Physic, " an open belly is proper in every form of this disease, and when the nauseating doses of emetics operate a little downwards, they are more seviceable." 7 bO APPENDIX III. Dr. Rush, in his " Medical Facts and Observations," second edition, gives an account of the scarlatina anginosa, as it appeared in Philadelphia, in the years 1783 and 1784; and in pages 124, 125, says, u I gave calomel in moderate doses in every stage of the disorder. To restrain its purgative effects when necessary, I added to it a small quantity of opium. During the whole course of the disorder, when the calomel failed of opening the bowels, I gave lenient purges, when disposition to costiveness required them." In the Memoirs of the Medical Society of London, Vol. I p. 412, Dr. Sims, treating of scarlatina anginosa, says, " As I had always seen the greatest advantage in putrid or malignant dis- eases from the use of gentle laxatives, and have ever found rhu- barb most consonant to the bowels of a Londoner, I began in the very first instance, with ordering it: my common prescription con- sisted of equal parts of rhubarb and sal polychrest, of which mix- ture as much was taken as procured about two motions a day." Again, page 440, u The best preventative of the disease I found to be rhubard, taken in the quantity of a few grains every morn- ing, so as to procure one laxative motion in the day. I did not see one who used this confined afterwards to bed, though several per- sons obviously began it after they were infected, but before the time of their sickening." Dr. Blackburne, on scarlet fever, Lond. 1803, remarking on Dr. Withering's practice in a particular instance, says, page 52, " Dr. Withering's fear of purging was so great, that he suffered his patient to remain costive eight days. Would not the interposition of a mild laxative or two have mitigated the most violent of the symptoms, and have rendered the frequent repetition of vomiting less necessary?" SCARLATINA. 51 Again, among other remarks on the symptom of purging. Dr. Blackburne savs, "It certainly does not occur in the moderate instances of scarlatina, and the dread of its presence ought not to prohibit the use of mild laxatives, which, so far as I have observ- ed, uniformly abate the heat, thirst, headach, restlessness, &c. which enhance greatly the patient's sufferings, and protract as well as aggravate the febrile state." APPENDIX IV, MARASMUS. Sect. I. CASES OF PATIENTS WHO LABOURED UNDER MARASMUS, EXTRACTED FROM THE RECORDS OF THE ROYAL INFIRMARY. Royal Infirmary, Dec. 29th, 1804. Malcolm Morrison, JEtatis 5.—Complains of pain of the right side, near the false ribs, attended by a dry hard cough, pain of forehead, and loss of appetite; pupils appeared dilated. By account, awakes frequently during the night with a scream, is fre- quently observed to pick his nose, feces of a grey colour, and clayey consistence, urine turbid and scanty, countenance sallow, skin hot, pulse 120, and weak; complaints are, by account, of three weeks standing; has used no medicines. R. Submuriatis hydrargyri grana decern, Sacchari drachmam dimidiam, Tere intime et divide in doses quatuor. Sumat unam quaque hora. Jusculi bovini libram unam, indies. 30th Dec.—Two stools, of the appearance of that described, general fulness of abdomen; no hardness observed in the right hy- pochondrium, pressure on which does not seem to give pain; some food taken. R. Submuriatis hydrargyri grana tria, Sacchari, Jalapae, singulorum grana sex Sit pulvis cras mane sumendus. MARASMUS. 53 51st.—As yet no stool. Si opus sit injiciatur enema domesticum vespere, et cras re- petatur pulviB submuriatis hydrargyri. 1st Jan.—Copious alvine discharge, in all respects similar to former ones. Considerable fulness of abdomen continues, but pain of right hypochondrium and sallowness gone; injection not given. Cras mane repetatur pulvis e submuriate hydrargyri cum jalapa. 2d.—A pretty copious, clay-coloured, and fetid stool; food taken. Repetatur cras mane pulvis, ut heri praescriptum. 3d.—Spontaneous vomiting this morning of the contents of the stomach. Fetid and clay-coloured, but more scanty alvine eva- cuation, indifferent nights. R. Tincturae jalapae, Syrupi sacchari, utriusque drachmas duas. Sit haustus mane et vespere sumendus. Haustui vespertino, instillentur tincturae thebaicae guttae decern. Habeat vini rubri uncias tres indies. 4th.—Has passed an easier night, and is now asleep, no vomit- ing, no stool. Habeat haustum e tinctura jalapa mane, meridie, et ves- pere, cum laudano in haustu vespertino, ut heri prae- scriptum. 5th.__A copious dark-coloured stool, no return of vomiting, a good night, appetite indifferent; but he appears to have gained in point of strength. Continuetur haustus ut heri praescriptum, necnon vinum et jusculum bovinum. 6th.—No stool. *4 APPENDIX IV R. Carbonatis magnesae scrupulum unum, Supertartritis potassae, Sacchari, utriusque grana f the aloetic mass have been taken. Continuentur pilulje aloeticae. 6th.—Forty grains of the aloetic mass have been taken, one stool rather fluid, but, in respect of appearance, more natu- ral than hitherto, appetite still keen, involuntary motions ceased last night, during sleep, 100 APPENDIX VIII. R. Cummi aloes drachmam unam, Calbmelanoa, Saponis, singulorum scrupulum unum, Mucilaginis gummi arabicae quantum satis sit, ut fiat massa, quam divide in pilulas viginti aequales, quarum sumat duas omni bihorio ad quintam vicem. 7th.—Fourteen pills taken, one copious, consistent, dark, and fetid stool, an easy night, motions suspended during sleep, are weaker and more regular this morning. Sumat quid reliqui sit pilularum heri praescriptarum. 8th.—The six pills taken; two stools of dark colour, and in part of a clayey consistence, adhering to the sides of the contain- ing vessel; eye is more languid, and cheeks paler than usual. She cannot as yet articulate; an easy night, without motion; mouth somewhat pained, with mercurial fetor of the breath. R. Foliorum sennae drachmas tres, Cremoris tartari, Extracti glyoirrhizae, singulorum drachmam unam. Infunde per horam, in aquae fervidae unciis duodecim. Sumat infusi colati quartam partem omni bihorio. Habeat cyathum unum vel alterum vini (Port.) indies. 9th.—Alvine discharge similar to the last, but more copious, a quiet night. R. Calomelanos grana sex, Pulveris jalapae, Saponis, singulorum grana decern, Mucilaginis gummi arabici quantum satis sit, ut fiant pilulae sex vespere sumendae. R. Sodae tartarisatae drachmas quatuor, Foliorum sennae drachmas duas, Extracti glycirrhizae drachmam unam, Aquae fervidae uncias duodecim. Fiat infusum, cras mane, quatuor vicibus sumendum. Continuetur vinum. 10th.—Pills taken; vomiting succeeded the third dose of the CHOREA. 101 infusion, on account of which it was intermitted. One fluid fetid dark green coloured stool, accompanied with much flatus; ful- ness of abdomen more subsided, eyes more lively, and some colour in the cheek, a good night, mouth easier. Continuetur vinum; et vespere sumat quid reliqui sit in- fusi. 11th.—Infusion not taken, no stool, an indifferent night. She seems, by description, to have laboured for a short time under general rigidity, and has been given to involuntary laughter; in- voluntary motions more violent at times, food taken. R. Gambogiae scrupulum unum, Saponis grana decern, Mucilaginis gummi arabici quantum satis sit, ut flair': pilulae octo. Sumat duas omni bihorio, et vespere quid reliqui sit infusi sennae. Continuetur vinum. 12th.—Being sickened by the pills, four of them only were given, and the infusion was not given; she is much as yesterday,but the rigidity and involuntary laughter have not recurred, no stool. R. Tincturae jalapae uncias duas, cujas sumat quantum capiat cochleare parvum, ex aqua, omni hora. Continuetur vinum. 13th.—Two-thirds of the tincture taken; a fluid stool, more natural than hitherto, no sickness, a quiet night, motions less fre- quent and less violent. R. Calomelanos grana sex, Pulveris jalapae grana duodecim. Fiat pulvis, vespere sumendus. R. Foliorum sennae, drachmas tres, Extracti glycirrhizae drachmam. Infunde in aquae fervidae unciis duodecim, quarum suma' quartam partem omni hora, cras mane, Continuetur vinum. 102 APPENDIX VIII. 14tb.—A quiet night; under greater involuntary agitation than yesterday, gripes and vomiting succeeded the third dose of the infusion, a copious stool of a light green colour, fluid and fetid. Repetatur pulvis ut heri; et cras mane sumat quid reliqui sit infusi. Continuetur vinum. 15th.—A copious, partly fluid, green coloured, and highly fetid stool, slight nausea after the infusion, and indifferent night, mo- tions continue violent, food taken. R. Saponis, Aloes utriusque drachmam, forma in pilulas triginta, quarum sumat duas omni hora. Habeat enema, quod domi parari solet vespere. Continuetur vinum. 16th.—A better night, scanty evacuation after the injection, a copious feculent one this morning, motions less violent. Coniinuetur pilulae ut heri, et vinum. Repetatur enema, et sumat phosphatis sodae drachmas duas e jusculo bovino, omni trihorio. 17th.—The remaining ten pills, and an ounce and a half of the phosphat of soda have been taken; injection not well receiv- ed, one scanty, feculent stool, an easy night, fulness of abdomen continues, and motions are less violent. Sumat massae pilularum ex aloe cum colocynthide grana duodecim, omni trihorio. Repetatur enema. Continuentur phosphas sodae et vinum. 18th.—Half a drachm of the above mass, and half an ounce of phosphas sodae taken; injection better received, a large fecu- lent stool, in consistence approaching to costive, has been passed, a restless night, motions less violent, and articulation at times dis- tinct, abdomen still full. Continuentur pilulae, phosphas sodae, enema, et vinum, ut heri. Habeat tincturae opii guttas duodecim vespere. CHOREA. 103 19th.—One scruple of the mass of pills, and an ounce and a half of phosphas sodas have been taken; injection retained for some time; a stool, copious as that of yesterday, slept during the first part of the night, restless, with much agitation, in the morn- ing, but at eleven A. M. more calm, and motions less violent. Continuentur pilulae, phosphas sodae, enema et vinum, Ornittatur tinctura opii. 20th.—A restless night, involuntary motions more violent; but countenance clear, and eyes lively, fulness of abdomen continues, feculent discharge of more natural appearance, but more scanty. Sumat tartritis potassae et sedae unciam unum e jusculo bovino partitis vicibus. Omktantur enema, pilulae ex aloe cum colocynthide, et phosphas sodae. 21st.—A better night, motions more staid, a copious alvine evacuation, somewhat costive, fulness of abdomen not diminish- ed) food and wine taken. Capiat tres pilulas ex aloe et calomelane, ut die mensis sexta praescriptum est. Continuetur vinum. Repetatur tartris potassae et sodae, ut heti. 22d.—Nearly in the same state as yesterday. Continuentur pilulae* tartris potassae et sodae et vinum, ut heri. 23d.—A restless night, motions more irregular and violent, a scanty and unnatural stool, fulness of abdomen continues, looks improve, but she appears to be thinner, and muscular flesh to be more flaccid. Capiat pilulae ex aloe et calomelane duas omni bihorio, necnon tartritis potassae et sodae unciam unam, e juscu- lo bovini partitis vicibus. 24th.—An indifferent night, but motions more staid. Fulness of abdomen continues, a copious alvine discharge, partly of a 104 APPENDIX VIII. natural, and partly of a clayey tough consistence; six pills and the Rochelle salts taken. Sumat pilulas ex aloe et calomelane tres omni bihorio ad tertiam vicem, necnon tartritis potassae et sodae unciam unam, e jure bovino partitis vicibus. Continuetur vinum. 25th.—A better night, motions more staid, cease now alto- gether during sleep, articulation improves, and looks continue lively, fulness of lower abdomen unchanged, a copious alvine dis- charge, feces are more natural, hard, and in detached pieces, some- thing resembling scybala. Sumat omni bihorio massae pilularum ex aloe et colocyn- thide grana octo. Repetatur tartritis potassae et sodae uncia una. Continuetur vinum. Omittantur pilulae ex aloe et calomelane. 26th.—A good night, involuntary motions and fulness of abdo- men as last described; seventy grains of the pills, and the Ro- chelle salts taken; copious fluid alvine discharge. Sumat pulveris jalapae compositi scrupulum unum, omni trihorio. Repetatur tartris potassae et sodae, necnon vinum. Omittantur pilulae ex aloe et colocynthide. 27th.—Three doses of the powder, and the ounce of Rochelle salts taken; copious evacuation of feces, of natural appearance, and, for the first time, of natural form, a good night, with much refreshing sleep; involuntary motions less violent than hitherto. Repetatur pulvis jalapae acompositus, necnon tartris potassae et sociae ut heri. Continuetur vinum. 28th.—A good night, motions still less violent, looks are cheerful, a copious, natural, and well-formed alvine discharge. Sumat pulveris jalapae compositi scrupulos duos ter in CHOREA. 105 dies, necnon tartritis potassae et sodae unciam et dimi- diam, e jure bovino partitis vicibus. Continuetur vinum. 29th.—Jalap and Rochelle salts taken, a quiet night, motions as yesterday; a natural, but less formed, and less copious alvine discharge. R. Pulveris jalapae compositi drachmas duas, in doses tres divisas, Sumat unam statim, et alteram vespere; necnon tartritis potassae et sodae drachmas sex, e jure bovino, interdiu. Continuetur vinum. 30th.—In respect of sleep, motions, and alvine evacuations, as yesterday, appears to lose flesh, and looks are more wan, articu- lation does not improve. R. Pulveris jalapae drachmam unam, Divide in doses sex, quarum sumat unam omni bihorio. Sumat etiam tartritis potassae et sodae drachmas sex e jus- culo bovino. Continuetur vinum. Ornittatur pulvis jalapae compositus. 31st.—Medicines, wine, and full nourishment taken, wan looks, and enfeebled state continue; a good night, much quiet sleep, motions weaker, and more under command, than hitherto; a verv copious alvine evacuation, in part costive, and not so natu- ral in appearance as late ones. R. Pulveris jalapae, drachmam unam et dimidiam in doses sex divisam; sumat unam omni bihorio. Repit-tur tartris potassae et sodae ut supra, et continuetur vinum. 1st April.—The salts, and five doses of the powder taken, alvine discharge and symptoms as yesterday. Repetatur pulvis jalapae, necnon tartris potassae et sodae; Continuetur vinum. 14 106 APPENDIX VIII. 2(j.__Salts and five powders taken, countenance fresh, looks lively motions still more u-ider command. R. Puueris jalapae drachmas duas, Divide in doses sex, sumat unam quater indies. Repetatur tartris potassae et sodae. Continuetur vinum. 3d.__The salts and five powders taken; copious, feculent, con- sistent, and natural alvine discharge. Continuentur vinum et pulvis jalapae, ut heri. Ornittatur tartris potassae et sodae. 4th.—Five powders taken; alvine evacuation as yesterday, a quiet night, refreshing sleep, she walks with a steady, but rather feeble gait, involuntary motions, but to no extent, of the superior extremities continue, those of the trunk of the body are gone, fulness of abdomen almost subsided. Habeat pulveris jalapae scrupulum unum, ter indies. Intermittatur vinum. Multum api icetur, coelo, nunc temporis, benigno existente. 5th.—Four scruples of the powder of jalap taken; sickness and slight vomiting, natural alvine evacuation, fulness of ab- domen gone, motions regular and voluntary, power of articula- tion much recovered, looks lively; she enjoys the open air much, and she walked a little. Sumat omni mane, pulveris jalapae scrupulum unum. 9th —Eyes clear, countenance expressive of vivacity, power of articulation recovered, motions regular and voluntary, daily alvine evacuation in full quantity, stools are formed, consistent, and in all respects natural. Sumat omni mane, pulveris jalapae grana decern. 17th.—Finding my patient fully convalesced, the belly regular, the feces formed, and of natural appearance, 1 recommended exer- cise in the open air, and fresh vegetables in diet; and 1 intimated, that I ceased to take farther charge. On the eighth day of the following month (May,) I passed CHOREA. 107 near to the house where my late patient, Ann Ross, lived. Cu- riosity led me to i.iq ;irc for her. She was employed in work; she was abundantly muscular and active, and she approached me in a cheerful, playful manner. This has proved the most protracted case of chorea, under the treatment of purgatives, that has occurred to me; which may be owing, in part, to the duration of the ailment, before! saw the patient, and in part, to her sex. The strong and repeated purga- tives that were given, are a proof that the constipation was great; and the almost daily alvine evacuation, and the nature of the stools shew the accumulation of feculent matter to have been abundant and offensive. My directions in the conduct of this case were faithfully complied with, by an anxious and sensible mother, whom I encouraged to persevere in the exhibition of purga- tives, by positive assurances that a perfect recovery was to be ob- tained; while my little patient was enticed to compliance, by oc- casional presents suited to her time of life. Royal Infirmary, 25th April, 1805. Elizabeth Webster, iEtatis 9.—Is subject to constant irre- gular and involuntary motions of both the superior and inferior ex- tremities; but the left arm and leg appear less affected than the right. The trunk of the body is also frequently affected by these irregular motions, and there is constant grinding of the teeth dur- ing sleep, when these motions are suspended, and she appears calm and easy. This ailment has existed for about five weeks; and sinee the 2d of April she has been under a regular course of purgative medi- cines, which have had various effects, but have given no relief of symptoms; had two spoiled teeth extracted, and on the 22d in- stant she passed a worm of the lumbricus kind, about ten inches in length; her appetite is good, and food is relished; her abdomen is soft, without fulness; power of articulation nearly suspended. R. Submuriatis hydrargyri drachmam dimidiam, Sacchari albi drachmam unam, Optime terantur, et in pulveres decern aequales dividantur. Sumat unum omni bihorio ad quintam vicem- 108 APPENDIX Till. R. Tartritis sodae et potassae drachmas sex, Jusculi bovim libram unam. Sit solutio partitis vicibus sorbenda. 27th.—A rather scanty alvine evacuation, fluid, partly of natu- ral appearance, and partly of a greenish colour, not fetid, has passed a bad night, with but little sleep; five of the powders, and about half of the beef-tea taken. Continuetur submurias hydrargyri, ut heri. R. Tincturae jalapae, Syrupi, utriusque drachmas tres, Aquae unciam unam. Sit haustus cras mane sumendus. Intermittatur tartris sodae et potassae. 28th.—Has had three stools, of a deep green colour, and fetid; the discharge upon the whole is scanty, has passed a better night, and this morning the involuntary motions are less general and less violent; vomiting succeeded the first dose of the mixture; five powders taken. R. Pulveris radicis jalapae, Sacchari rubri, utriusque drachmam unam, Tere intime et divide in doses duodecim. Sumat unam secunda vel tertia quaque hora; supra prae- scriptis omissis. ^9th.—Has passed a quiet night, enjoying soft sleep, has had ten stools, the feces upon the whole are abundant, of a light green- ish colour, partly fluid, and partly somewhat in separate knots, approaching in appearance to scybala; these evacuations are highly fetid, the convulsive motions are still more staid and less violent; nine powders, taken without reluctance, have been given. Continuetur pulvis jalapae ut heri praescriptum. 30th.-—Alvine discharge, in respect of quantity, cannot be ascertained, feces having been voided without notice in bed- but on the whole they have not been so abundant as yesterday: they are of a lighter colour and fetid; involuntary motions still CHOREA. 109 less violent, appetite for food abates, thirsty, articulation still sus- pended, and deglutition is difficult. Habeat vini rubri, Aquae, utriusque uncias sex, Sumat unciam, subinde. 1st May.—Four fetid stools, but rather of more natural appear- ance, since yesterday; evacuation on the whole copious, has been voided without notice; abdomen seems more distended, involun- tary motions still abate, pulse is feeble, and looks are rather lan- guid, and muscular flesh apparently wasted, appetite still indiffer- ent; eight powders taken, and wine relished. Habeat jusculi bovini libram et, dimidiam, indies. R. Submuriatis hydrargyri, Sacchari, utriusque grana tria. Sit pulvis vespere porrigendus. Continuetur pulvis jalapae, cujus sumat dosem, omni tri- horio. Repetatur vinum. 2d.—The powder of the evening, and twelve of jalap taken; ske appears more languid, and excoriations of different parts of the surface, and some of considerable extent, have appeared in succession for two days past; pulse at the wrist is feeble, and sur- face is disposed to be cold, no stool, urine passed insensibly, wine has been relished, and little food taken, has had an indifferent night, involuntary motions as last described. R. Vini rubri uncias octo, Aquae uncias sex. Sit mistura partitis vicibus indies sumenda, Injiciantur per anum enematis domestici unciae decern; dein accipiat per anum, omni trihorio, juris bovini uncias quatuor ; in hunc finem habeat jusculi bovini libras tres ; necnon fistulam armatam. Curentur partes excoriatae more solito. Intermittatur pulvis jalapa. 110 APPENDIX VIII. 3d.—A stool previous to the injection, pretty copious, of a dark green colour, and fetid; a smaller one after the house in- jection; those of beef-tea have been retained; has had a better night; and appears somewhat revived, motions as described, wine relished, and a little beef-tea has been swallowed. R. Magnesiae ustae drachmas duas, Pulveris jalapae drachmam unam, Mucilaginis Gummi Arabici, Syrupi, Aquae cinnamomi singulorum, unciam dimidiam. Probe mistis affunde Aquae uncias quatuor cum semisse. Misturae agitatae por- rigatur uncia una, ter indies. Continuentur vinum et jusculum bovinum, ut heri. 4th.—Three doses of the mixture taken, injections of beef-tea have been continued and retained; some beef-tea and a little food have also been taken, wine is relished; one pretty copious green coloured and fetid stool passed in bed, excoriations mend. Continuentur mistura e magnesia, vinum, et enemata e jus- culo bovino. 5th.—Four stools, of a dark green colour and fetid smell; the evacuation upon the whole has been copious, and passed in bed, spasmodic motions cease altogether at times, and again re- turn with some violence; has passed an indifferent night, appetite mends. Continuentur vinum, jus bovinum, et mistura e magnesia. A night nurse. 6th.—Has passed a good night, involuntary motions as last de- scribed, with longer intervals between different attacks, appetite more improved, and excoriations more disposed to heal, four alvine evacuations, consistent, dark, and fetid; on the whole in small quantity. CHOREA. Ill R. Submuriatis hydrargyri, Sacchari, utri-usque grana sex. Sit pulvis vespere sumendus. Continuetur mistura e magnesia, ut supra praescriptum, addita pulveris jalapae drachma. Continuentur vinum et jusculum bovinum. 7th.—Has passed an easy night; irregular spasmodic motions are now but little perceived; appetite continues to improve, expres- sion of countenance is more lively, pulse calm, and firmer than hitherto, excoriations healing, alvine evacuation of a lighter co- lour, less fetid, and also less copious than for some days past; calomel given, and mixture as prescribed taken. R. Phosphatis sodae drachmas quatuor e juris bovini un- ciis sex s'lmendas. Continuetur mistura e magnesia et jalapa. Habeat vinum et jus bovinum, Ut supra praescriptum est. 8th.—Involuntary motions nearly gone, appetite good, a quiet night, sensible to the stimulus of urine and of feces; the latter has been passed in abundance, is partly fluid and feculent, partly scybalous and of a greenish colour, and still fetid; wine is re- lished, salts and mixture taken, as prescribed. Repatatur phosphas sodae. Continuetur mistura e magnesia et jalapa, necnon vinum. Intermittantur enemata e jusculo bovino. 9th.—Alvine evacuation more in quantity, feculent, of natural colour, with less fetor, irregular motions nearly, if not altogether gone, good night, mixture, and salts, and full allowance of nourish- ment taken. Habeat vini rubri uncias quatuor tantum, quibus admis- ceantur aquae unciae quatuor. Continuetur adhuc cathartica. 10th.—Involuntary motions have not recurred, deglutition is free, and she begins to articulate, stools feculent, and natural in appearance and smell. 112 APPENDIX VIII. Continuetur vinum, necnon mistura e magnesia, adempte pulvere jalapae. Ornittatur phosphas sodae. 11th.—The alvine discharge since yesterday is abundant, fluid of a greenish colour, and more fetid than the last; excoriations are healed, pulse firm and regular, disposition to coldness of the sur- face has gradually yielded, skin now of natural heat. R. Submuriatis hydrargyri, Sacchari, utriusque grana quinque. Sit pulvis cras primo mane sumendus. Continuetur mistura e magnesia. 12th—A more copious and more natural stool; continues con- valescent. Habeat omni mane pulveris radicis jalapae grana quinde- cim, cum totidem sacchari rubri, Intermittantur mistura e magnesia, et vinum. 14__puiSe about a hundred in the minute, surface still 134 APPENDIX VIII. warmer than natural, tongue somewhat loaded. Leeching suc- ceeded well. Vespere habeat pilulas aloeticas duas. 18th.—About the commencement of the febrile attack, the in- voluntary motions became more violent; they are now miiigated. At the request of friends, the patient was removed from the Hos- pital. The treatment of the case was conducted at their house by my assistant, Mr. Fyfe, who favoured me with the following account and result of his practice. 19th.—No alvine evacuation. Headach easier. Habeat vespere pilulas aloeticas octo, duabus vicibus. 20th.—Five pills have been taken; feces rather scanty, partly lumpy, of dark colour, and fetid. Habeat vespere pilulas aloeticas quatuor. 21st.—Feces soft, scanty, of more natural colour, less fetid. Habeat vespere pilulas aloeticas quinque. 22d.—Alvine evacuation as yesterday. Omittantur pilulae aloeticae. 23d.—No alvine evacuation. Habeat vespere pilulas aloeticas sex. 24th.—Alvine evacuation, feces partly fluid, partly scybalous, little fetid. Repetantur pilulae aloeticae sex. 25th.—Alvine evacuation as yesterday, but less copious. Repetantur pilulae aloeticae sex. 26th.—Feces still scybalous, but more of natural colour CHOREA. 135 headach gone. Irregular motions are considerably diminished, during sleep he lies perfectly quiet, and articulation is more dis- tinct. Appetite improving. Repetantur pilulae aloeticae sex. 27th.—Alvine evacuation more copious, feces lumpy, and of darker colour. Repetantur pilulae aloeticae sex. 28th.—Feces nearly as yesterday, but less lumpy. Repetantur pilulae aloeticae sex. 30th.—Alvine evacuation of yesterday reported to have resem- bled that of the preceding day. Six pills were given last even- ing; feces of to-day more copious than usual, and still lumpy. Repetantur pilulae aloeticae sex. 1st Jan. 1815.—Alvine evacuation of yesterday reported to have been as before. Three pills were given last night; feces of to-day lumpy, but of natural colour, and without peculiar odour. The irregular motions have subsided entirely, except a little about the mouth and eyes. Articulation is still more distinct, his looks are improved, his memory is reported to be as strong as it was before the commencement of the ailment. He is cheerful and lively. Habeat vespere pilulas aloeticas quatuor. 2d.__Feces resemble those last described. Continuentur pilulae aloeticae quatuor. 3d__Feces are copious, consistent, and of darker colour than those of yesterday. Habeat vespere pilulas aloeticas sex. 4th.—Feces are in part lumpy, and in part fluid. Habeat pilulas aloeticas duas tantum. 136 APPENDIX VIII. 5th.—Feces as yesterday in appearance, but less copious. Habeat pilulam aloeticam unam. 6th.—Alvine evacuation resembles that of yesterday. Connnuetur pilula aloetica. 7th.—Alvine evacuation copious, consistent, and in part formed and of natural colour. Appetite much improved. Continuetur pilula aloetica. 8th.—Feces more fluid than those of yesterday, nearly of na- tural colour. Continuetur pilula aloetica. 9th.—Feces not formed, but otherwise natural. Continuetur pilula aloetica. Habeat vini rubri, (Port) dicti, uncias quatuor indies. 11th.—-Feces of darker colour than of late, and more copious. Habeat hac norte pilulas, aloeticas duas. Continuetur vinum. 12th.—Feces of to-day, of natural colour, not formed. Habeat p:lulam aloeticam, Secunda quaque nocte tantum. 14th.—Alvine evacuation nearly natural, no pills given. Omittantur pilulae aloeticae et vinum. 16th.—Alvine evacuation quite natural. Irregular motions of mouth and eyes have disappeared com- pletely; and he articulates well. Debility excepted, he is free of ailment. 25th.—Appetite good, bowels regular, feces natural. He re- covers strength daily. CHOREA. 137 16th Feb. 1815.—The boy appeared at the hospital this day. Since last report he has gained flesh and strength daily. He has had no return of irregular motions; his articulation is distinct, his bowels are regular, his tongue is clean, and his appetite good. This protracted case shows how necessary perseverance in the use of purgative medicines is, when they are given for the cure of chorea. And the attentive enquirer will, on comparing the earlier cases narrated in this number of the appendix, with the present one, observe in the former a certain restless change in the employment of various purgatives, the offspring of the doubt and anxiety which beset me when I first deviated from established opinions; and in the latter, a simple and uniform tenor of practice, the result of confidence acquired from experience. I consider this to be a valuable case. From it, it would appear, that the cure of chorea sancti viti, may be effected by the purgative treat- ment, in the most simple form. 18 APPENDIX IX. TETANUS. Sect. I. CASES OF PATIENTS WHO LABOURED UNDER TETANUS. EXTRACTED FROM THE RECORDS OF THE ROYAL INFIRMARY. Royal Infirmary, 21th Aug. 1805. David M'Kenzie, iEtatis 66—Complains of most excruciat- ing pains in his legs, thighs, and arms, and about the scrobieulus cordis; the muscles of his legs and thighs feel hard and contract- ed, and are frequently agitated by violent, irregular and involun- tary motions. The muscles of the thorax and abdomen are occa- sionally affected with the same involuntary motions, giving a sense of suffocation, and severe pain. Has sometimes a difficuhy in swallowing; pulse 90, weak and hard, features much shrunk, tongue foul, complains of constant purging, with gripes; is unable to ariculate but in a low whisper. Says, that last night, about twelve o'clock, when asleep, he was roused with severe pain in his legs; they were contracted, and he was unable to stretch them out. In about an hour, the pain be- came easier, and he could move them a little, but the pains and spasm have continued to recur every half hour since. Injciatur quam primum enema anodynum, cui addantur tincturae opii guttae ocoginta. 28!h Aug.—Last night, about the time he was first seized, the spasmodic action became very violent. The muscles of his legs were much agitated and contracted, and the knees drawn up to- wards the abdomen; he was unable to speak or move; the injec- tion, which was given about two hours before, was retained only a few minutes. TETANUS. 139 R. Camphorae grana decern, Sacchari drachmas duas, tere et adde Mucilaginis mimosae niloticae drachmam dimidiam, Aquae unciam. Sit haustus statim sumendus. 28th.—Noon. Since the exhibition of the draught he has been quiet, and slept some; the spasmodic action of the muscles of the lower extremities has recurred, but not so severely; complains still of pain about the scrobiculus cordis, thirst urgent, diarrhoea conti- nues; has passed only about four ounces of urine since admission. Continuetur haustus e camphora. R. Tartritis sodae et potassae drachmas sex, Infusi sennae uncias duas, Aquae uncias sex ; Sit solutio statim sumenda. Habeat vini rubri uncias octo* 29th.—Paucity of urine, and prevalence of diarrhoea; the stools were scanty, white coloured, and fetid; since the exhibition of the cathartic, a very copious alvine evacuation has taken place; it is fluid, of a mixed greenish and clayey colour, of a somewhat acid smell, and otherwise of a peculiar fetor. Two camphor draughts have been given, and wine has been used; pulse is less hard, cramps of the lower extremities occa- sionally recur since morning, but the involuntary action of other muscles has ceased; countenance lightened; he has enjoyed some sleep. Repetatur quam primum solutio cathartica, qua sumpta, et horis quatuor elapsis, accipiat enema purgans, alvo reddita, habeat haustum cum tincturae opii guttis qua- draginta. Habeat juris bovini libras duas. Repetatur vinum. Intermittatur haustus cum camphora 140 APPENDIX IX. 30th.—Injection given was soon returned; he has had very copious alvine evacuation, fluid, of a dark green colour, and of a high and peculiar fetor; pain of epigastrium gone; two slight at- tacks of spasm of the lower extremities last night, no other irre- gular muscular action has occurred, tongue clean and moist, pulse feeble; a peculiar fulness, and general tension of abdomen is per- ceived; wine has been relished, and he has passed a good night Habeat pilulas aloeticas duodecim ; sumat tres omni biho- rio; hisce sumptis, habeat enema domesticum, ni prius exoneretur alvus. Repetantur vinum et haustus anodynus. 31st.—Pills and injection given; feculent discharge less copious than yesterday, and less fetid; is of a clay colour, partly fluid, and partly scybalous. Fulness and tension of abdomen gone ; a slight return of spasm of the lower extremities was of short duration; surface inclines to be cold, pulse feeble, drowsy, with pain across the forehead; pills taken. Foveantur crura tenia quaque hora, semihorae spatium. Continuentur jusculum bovinum et vinum. Ornittatur haustus anodynus. 1st Sept.—Has had further alvine evacuation, fluid of a more natural appearance, without fetor or scybala, spasmodic affection has once appeared, and has been slight; surface warm, pulse firmer, painful affection of both eyes, headach and drowsiness gone. Abluta oculos solutione sulphatis zinci subinde. Habeat cras mane pulveris jalapae compositi scrupulos duos. Continuetur vinum. 2d.—Pain and inflammation of eyes are relieved, one short and slight return of cramp of the lower extremities, countenance has a more natural and more lively appearance, appetite improving, no stool. TETANUS. 141 Repetatur quam primum pulvis jalapae compositus, et ves- pere, si opus sit, accipiat enema domesticum. Repetatur vinum. 3d.—Has passed an indifferent night; has had longer and more severe attacks of cramp in the lower extremities; a costive, green, and fetid stool followed the injection, when previous uneasiness subsided. He appears more languid, but pulse continues firmer, and surface warm, tongue clean, appetite declines. Habeat infusi sennae uncias sex. Unciam quam primum omni hora repetendam. Infuso sumpto, accipiat iterum enema domesticum. Repetatur vinum. 4th.—No return of spasmodic affection; has used more food, affection of eyes gone, and looks are improved; has had copious alvine evacuation, and more natural than hitherto, after receiving the injection, the infusion having been previously taken; com- plains of gripes. R. Mucilaginis mimosas niloticae unciam dimidiam, Magnesiae drachmas duas, Pulveris jalapae drachmam, Probe mistis affunde aquae uncias sex. Misturae agitatae sumat unciam, secunda vel tertia quaque hora. Habeat vini rubri libram indies. 5th.__Fluid and natural alvine evacuation in full quantity: gripes continue. Sumat dosim misturae e magnesia, quarta quaque hora. Pilulam thebaicam vespere. Repetatur vinum. 7tj,__Gripes are gone, spasms have not recurred, alvine eva- cuation natural and plentiful, appetite good. Intermittantur medicamenta et vinum. 142 APPENDIX IX. 9th.—Belly rather open. Habeat aquae calcis uncias tres, quater indict. 13th.—Belly has been regular. Dismissed cured. In this case the early exhibition of camphor was accidental; and the use of it was speedily relinquished. I ordered laudanum in compliance with common custom; but we may learn, from the re- port of the first September, that it was given with no good effect. The small quantity of wine which I prescribed, respected the ge- neral debility and exhausted state of the poor patient suffering under a painful disease; I did not view it in the light of a medi- cine operating towards a cure, which I conceive to have been ef- fected by purgative medicines. Royal Infirmary, 2d Nov. 1805. Alexander Buller, iEtatis 35 —Twice in the course of last night, and once since morning, he has been affected with a violent spasmodic action of the muscles of the thorax and lower extremi- ties, during the continuance of which he was unable to speak or move, and breathed with much difficulty. The muscles of the extremities felt like stretched cords, with several small knots in different parts. There were also two lumps near the scrobiculus cordis, evidently formed by the contraction of the muscles; these lumps on the chest were only of momentary duration, but returned frequently for the space of five or six minutes. The affection of the extremities was stationary for that period; he complains of constant pain in his arms and shoulders, impeding the free motion of the joints, and after each attack of the cramp he had frequent flatulent eructations; pulse quick and sharp, tongue foul, belly very costive. Has been in the hospital for about a month for a slight venereal TETANUS. 143 affection, for which he used mercury in the form of ointment; the chancres have healed; and his mouth, which was affected, is now quite well. As he complained of costiveness, he was ordered yesterday, previous to the present complaints, a drachm of the compound powder of jalap, and in the course of the night he had three fetid, dark coloured and costive stools. R. Infusi sennae uncias quinque, Tincturae sennae compositae unciam, Infusi lini uncias sex. Sit mistura cujus sumat uncias tres omni hora, usque- dum fluat alvus, et vespere ni plene alvus soluta fuerit accipiat enema purgans. 3d Nov.—One slight attack of pain of breast, with affected respiration as described, and also of the lower extremity; no farther recurrence of spasmodic affection; pain of superior extre- mity continues, with swelling of left wrist since yesterday; pulse quick and full; infusion being given, a copious costive light co- loured stool ensued; injection having been also given, was follow- ed by a fluid dark coloured alvine evacuation. R. Haustum ex oleo ricini, cum olei uncia, Tincturae sennae compositae unciam. Sit mistura statim porrigenda, et vespere si opus sit, repe- tatur enema purgans. Applicentur hirudines quatuor metacarpo dolenti. 4th.—No return of spasm, wrist less pained, tongue clean, pulse calm; has had full alvine evacuation; little or no food taken. Habeat juris bovini libram, Cerevisiae tenuis libras duas vel tres indies. 5th.__Spasmodic affection, with oppressed breathing and gene- ral uneasiness of the muscles of the abdomen yesterday evening. This attack continued only for a few minutes, but left him for a considerable time sick and faint; pain of left wrist is gone, pain of right arm and of right wrist has supervened; pulse calm, a dark coloured stool in the course of the evening. 144 APPENDIX IX. Habeat quam primum pilulas ex aloe et colocynthide duodecim. Sumat tres omni bihorio. R. Infusi sennae uncias quatuor, Infusi, lini, uncias sex. Sit mistura, pilulis sumptis, duabus vicibus porrigenda. 6th.—Pain and swelling of right wrist continue, spasmodic affection has not recurred, pulse about 70 and soft, copious, fluid, and fetid alvine discharge; a bad night. Applicentur hirudines quatuor carpo dolenti. Habeat haustum anodynum vespere. Cras mane haustum ex oleo ricini, cum olei uncia, et tincturae sennae compositae drachmas quatuor. 7th.—Pain of wrist relieved, no return of cramp, an easier night, thirst, of which he had complained, is abated, pulse soft, alvine evacuation scanty, of a clay colour and fetid. Habeat pilulas aloeticas duodecim, sumat tres omni tri horio. 8th.—Thirst more abated, with improving appetite, an easy night, no return of cramp, alvine discharge more copious than hitherto, partly fluid, and partly of unusual consistence, fetid, and of a clay colour; twelve pills taken. Pulveris jalapae compositi scrupulos duos omni mane. Continuetur haustus. 9th.—He continues convalescent; pretty copious alvine dis- charge, discoloured and fetid. Repetatur pulvis jalapae compositus. 10th.—Three copious alvine evacuations, of more natural ap- pearance and consistence, and less fetid than hitherto; free of ailment, appetite good. Habeat pulveris jalapae compositi semidrachmam omni mane. TETANUS. 145 full diet. 13th.—Belly open, feces natural. A bit of beef-steak daily. 14th.—Belly rather open, stools natural, free of ailment, strength and appetite much recovered. Habeat aquae oalcias uncias duodecim, partitis vicibus indies. 17th.—Belly regular. Ornittatur aqua calcis. 19th.—Dismissed cured. If the symptoms in this case are not precisely those of tetanus, they certainly denote a disease greatly resembling it. And if mer- cury, as some maintain, removes the severest tetanic spasm, it may appear singular that it bad no effect in averting that, which, in the present instance, supervened immediately upon a full mercurial course. Royal Infirmary, 29th Dec. 1805. Betty: Nesbit, iEtatis 24.—Complains of severe pain at the scrobiculus cordis, and along the margin of the false ribs of the left side, also of shooting pains in the back of the neck, descend- ing along the spine, occasional severe headach, accompanied with pain in the orbits, and much dimness of sight, general debility and loss of appetite; pulse 96 and soft, tongue clean, belly slow; cata- menia have been suppressed for three months, during which time she has had these complaints, which, however, have been much aggravated for the last fortnight, and attended with obstinate cos- tiveness; was blooded, and got some medicines, of which she can give no account. 146 APPENDIX IX. Habeat cras mane bolum jalapae compositum. 30th Dec.—One scanty fluid green coloured stool. Habeat pilulas aloeticas duodecim, sumat duas omni biho rio. Pilulas sumptis, accipiat enema purgans si opus sit. 31st.—Headach and pain of the orbit of both eyes are relieved; pain of scrobiculus cordis, and along the margin of the false rib3, stiffness and pain of hind neck, shooting down the spine, continue. This last seems to excite, or is accompanied with occasional spas- modic affections of both arms; has had copious and dark coloured alvine evacuation; pills have been taken and injection given. Repetantur pilulae aloeticae, ut heri. Cras primo mane, habeat infusi sennae uncias quatuor, ex infusi lini unciis sex, duabus vicibus. 1st Jan. 1806.—Sickness farther relieved, and headach and pain of the orbits less uneasy than yesterday; affection of hind- neck, of spine, and the spasms continue; has had plentiful alvine evacuation; the first motion was costive, latter ones less so, but consistent; the whole of natural appearance. Repetantur pilulae aloeticae et infusum sennae, ut heri. 2d.—The affections of hind neck, of spine, and of both arms, have been more severe during last night and this morning; all of these, but particularly the latter, she now admits to have been present twelve months, and came on after much mental agitation. Has had spontaneous vomiting, alvine discharge has been copious, and consists chiefly of large scybala, floating in a dark green fetid fluid. Coniinuentur pilulae aloelicse et infusum sennae. 3d.—Pretty copious alvine discharge, containing scybala, but in other respects more natural than yesterday; retching has oc- curred. TETANUS. 147 R. Carbonatis magnesiae, Pulveris radicis rhei, utriusque grana quindecim. Misce, fiant pulveres tales duodecim. Sumat unum omni bihorio ex aquae menthae uncia dimidia, usquedum iterum fluat alvus. 4th.—Twelve powders taken, alvine evacuation scanty, more natural, and less scybalous; pain of the orbits still more relieved, that of hind-neck and spasmodic affection considerably abated; no return of vomiting, headach continues, gastrodynia aggravated- Habeat quam primum pilulas thebaicas tres. Vespere enema purgans. Intermittantur pulveres rhei. 5th.—Gastrodynia continued severe during the first part of the night; it remitted towards morning, and is now nearly gone; head- ach is abated, pain of hind-neck, of orbits, and spasm have dis- appeared; has had scanty alvine evacuation. 6th.—R. Sulphatis magnesiae drachmas quinque, Supertartritis potassae drachmam, Infusi sennae uncias tres, Infusi lini uncias sex. Sit Solutio quam primum duabus vicibus sumenda. 8th.__Alvine evacuation upon the exhibition of the last physic rather scanty; headach and pain of orbits are returned. Repetatur solutio sulphatis magnesiae, ut supra. 9th.—Has had full alvine evacuation; headach is gone, pain of orbits continues. Applicentur cucurbitulae cum ferro utrique tempori et e singulis temporibus, effluant sanguinis unciae tres vel quatuor. 10th—Pain of orbits gone, and otherwise free of ailment; full quantity of blood taken. 148 APPENDIX IX. Habeat pilulas aloeticas tres omni nocte. Sulphatis magnesiae drachmas quatuor omni mane Full diet. 13th.—Belly has been fully regular. Habeat pilulas aloeticas triginta sex. Laxative pills; two, three, or four for a dose, when necessary, Dismissed cured. Royal Infirmary, 10th May, 1812. John Lapslev, iEtatis 29, a soldier.—Labours under consi- derable spasmodic affection of the muscles of the hind-neck, and back, lower jaw, abdomen and lower extremities, by which the head and trunk are bent backwards, the jaw locked, deglutition somewhat impaired, and the limbs extended and stiff. The ab- domen feels hard, and pressure thereon gives uneasiness. He complains of a constant pain at the bottom of the sternum, from thence shooting into the back, which is violently increased every two or three minutes, and with it the other spasms, particularly of the neck and jaw. This takes place on any attempt to swallow or move, and often without any evident cause. The superior ex- tremities are free of spasm; he can articulate distinctly, and re- spiration is natural; surface is warm and moist; pulse quick, full and soft; has considerable thirst; no alvine evacuation these four days. On the 7th instant, having for two days previous experienced a sense of uneasiness at the bottom of the sternum, he began to feel a stiffness in the muscles of the neck and jaw. This continued gradually to increase, as did the pain at the sternum, till this morning, when the other muscles became affected, and since then the jaw has been locked. Has of late been on a march, in which he was much fatigued TETANUS. 149 and exposed to rain; and for some days previous to the attack of spasm, had made immoderate use of spirituous liquors. Venesection' was employed this forenoon without relief, and he had a draught supposed to contain compound powder of jalap, but without any sensible effect. R. Aquae libram et dimidiam, Tincturae assaefoetidae, drachmas duas, Miscepro enemate quam primum injiciendo. R. Infusi sennae uncias tres, Sulphatis magnesiae unciam, Infusi lini uncias sex. Sit solutio cujus sumat uncias tres omni hora usque dum plene soluta fuerit alvus. 1 lth May.—Injection was retained for about an hour and a half, and was followed soon after midnight with a copious discharge of soft dark coloured feces. The solution was then given, the last dose about four in the morning, and since seven o'clock two eva- cuations have taken place. The first in respect of quantity and appearance resembling that now mentioned. The second less abundant, more formed, and of more natural appearance. Spasms have been of more frequent recurrence, but have been less se- vere, except in one instance, when he was projected from bed, and with difficulty restrained, and in which he seems to have bit his tongue. He describes the pain about the scrobiculus cordis, that of the abdomen and of the extremities to have remitted. Pulse continues quick and full. A little milk has been taken. R. Infusi sennae uncias duodecim, Sulphatis magnesiae unciam et dimidiam. Supertartritis potassae drachmas duas. Sit solutio cujus sumat uncias duas, toties quoties ventri- culus facile ferat. Habeat jusculi bovini libras duas. 12th.__Pulse about 90, and soft; surface warm and moist. Spasms return, but at longer intervals, and with still abated se- verity. He reports his feelings to be in general much relieyed, 150 APPENDIX IX. and he has enjoyed some sleep. The lower jaw to a certain ex- tent is moved with more freedom. He is distinct and recollected. The solution and beef tea have been taken. The alvine evacua- tion is on the whole pretty copious; feces are fluid, and of peculiar disagreeable fetor. Habeat jusculi bovini libras quatuor. Quam primum haustum ex oleo ricini cum olei uncia ves- pere repetendum. Milk diet. 13th.—He has passed a comparatively easy night, but has had little or no sleep. Within these few minutes, has had an attack of severe spasm, under which he still labours. The beef tea and milk have been taken pretty freely. Both draughts, to the last of which four drachms of the compound tincture of senna were added, have been given, as yet without effect. Accipiat quam primum enema domesticum, et sumat etiam bolum e jalapa compositum cum mercurii granis decern, e quo sumpto, bihorio exacto, sumat infusi sennae uncias tres omni hora usque dum fluxerit alvus. 14th.—The paroxysm noticed yesterday was of short duration. One not very seveie occurred in the afternoon, and another about three this morning, both of short duration. A pretty severe cough with expectoration accompanies each attack of spasm: during the interval between which, he has been easy, and has enjoyed sleep; and he has taken food of the soft kind in sufficient quan- tity. He is at present distinct, countenance is good, and he ex- presses no uneasiness; pulse is quick, of good strength, surface cool and moist. The injection ordered was not well received, and was speedily returned with some feculent admixture. The bolus, and eighteen ounces of infusion of senna, being subsequently given, an injec- tion, containing a drachm and a half of Socotrine aloes, was thrown up, and being retained about twenty minutes, procured another scanty evacuation of soft feces. Since morning a drachm TETANUS. 151 of aloes dissolved in six ounces of water have been taken, as yet without effect. R. Gummi aloes drachmam unam, Aquae uncias septem, Tincturae aromaticae drachmas quatuor. Sit solutio cujus sumat uncias duas omni bihorio, habeat primam dosem quam primum. Accipiat enematis domestici uncias viginti quatuor. Continuetur jusculuin bovinum. Table broth at dinner. Tea morning and evening. 15th.—He has continued easy, with little or no return of spasm or of cough ; food has been taken, and he has enjoyed refreshing sleep; pulse about 90, and soft; the aloes being taken and injec- tion given, he has had evacuation of feces rather scanty but scy- balous, a subsequent one more scanty, and with more scybala, took place towards morning; since when three drachms of sublimed sulphur have been taken, and a fluid, feculent, more abundant stool has been passed. Sumat sulphuris sublimati lati drachmam et dimidiam e lactis pauxillo omni hora ad quartam vicem. 16th.—Sulphur was taken with five additional doses; no alvine evacuation; no return of spasm; one pretty severe attack of cough. He now complains of pain of breast, and respiration is hurried; he has in a great measure declined food since the even- ing; he has been drowsy and rather indistinct, and since morning expresses despondency respecting his situation; he voids urine in natural quantity; pulse quick, but of good strength; surface warm. Accipiat quam primum enema domesticum. R Vini rubri uncias octo. Aquae libram. Sit mistura cujus sumat unciam vel alteram subinde 152 APPENDIX IX. 17th.—Soon after last report, he expired under a slight attack of spasm. DISSECTION. On opening the abdomen, the intestines were in many places observed to be of a dark yellow colour, and in some places there were observed a greater number of red vesicles than usual, rami- fied upon their coats. In the small intestines, a considerable quan- tity of bile was observed, and particularly in the ileum a few hard scybala were found, which, upon examination, appeared to be of a dirty green colour, and very fetid. In the sigmoid flexure of the colon, and in the whole of the rectum, a pretty large quantity of these scybala was also found, resembling in every respect those in the small intestines. The intestines, however, did not seem in the least to be preternaturally distended. The stomach, liver, and other abominal viscera, were of their natural appearance. The gall-bladder was empty. In the thorax all the viscera were in a healthy state. The brain was likewise examined, and excepting a slight effu- sion of coagulable lymph under the dura mater, was found in a healthy state. Notwithstanding the unfortunate issue of this case, the relief obtained by promoting the alvine evacuation is evident. Whe- ther the effusion of coagulable lymph under the dura mater, dis- covered on dissection, was in part the cause, or solely the effect of the ailment, may be doubtful; yet,in either case, it is reasonable to suppose that the exhibition of high stimulants to the extent said to be necessary for subduing tetanus, must have increased this effusion, and proved injurious. Indeed, these remedies did not ap- pear to have been required at any time. The alvine evacuation did not induce debility, and daily and particular enquiry showed that sufficient nourishment was taken, while the quality of the feces evacuated during the progress of the disease, and the con- tents of the bowels observed after death, sanction the conclusion TETANUS. 153 that the indication on which the treatment was conducted was well founded. The following case, slight indeed, in the comparison, terminat- ed favourably. Royal Infirmary, 29th Dec. 1811. Andrew Warrender, JEtatis 65.—Was brought into the hospital this evening; is unable to give any account of himself, but appears to suffer great anxiety, has frequent short cough, with yawning; features appear shrunk, skin is dry, tongue parched, pulse quiet and small; it would seem that he had been in good health on the 26th inst. He is a seafaring man, and employed in a ferry or passage boat. Accipiat enema domesticum quam primum. Habeat mistura salinae ammoniatae unciam vel alteram su- binde. 30th Dec.—Injection was not returned; he has passed a restless night, and swallowed little or nothing; he is unable, or unwilling to speak; he labours under considerable spasm of the muscles of the superior extremities, and of those of the abdomen, slight pres- sure on which excites uneasiness. R. Aquae libram et dimidiam, Tincturae assaefoetidae drachmas duas. Misce, pro en- emate quam primum injiciendo; et vespere repcten- do pro re nata. R. Submuriatis hydrargyri grana decern, Conservae rosarum pauxillum. Sit bolus quam primum porrigendus, et etiam pro re nata vespere repetendus. Foveatur abdomen more solito. R. Vini rubri uncias sex, Aquae uncias duodecim. Sit mistura, cujus agitatae porriganlur unciae duae vel ires subinde. Habeat jusculi bovini libras duas. 20 154 APPENDIX IXc 31st.—Both boluses and injections were given; he has had alvine evacuation; feces are neither abundant nor of unnatural appearance, but somewhat of a gluey consistence; has passed a tolerable night, and been distinct. Focd and drink have been taken, and spasmodic affection is for the present gone. Habeat infusi sennae uncias duodecim ; sumat uncias tres omni bihorio usquedum plene soluta fuerit alvus. Repetantur vinum et jusculum bovinum. 1st Jan. 1812.—Has passed a good night, and continues free of spasm; tongue is clean, and pulse calm; the alvine evacuation has been more abundant, feces are dark coloured and fetid; infu- sion has been taken, and desire expressed for a little spirits. R. Spiritus vini tenuoris uncias quatuor, Aquae uncias duas. Misce sumat uncias duas quarto- vel sexta quaque hora. Habeat vesper-, pilulas aloeticas sex. Cras mane, mfusi sennae uncias quatuor. Intermittatur vinum. 2d.—Farther evacuation of more natural feces, pulse calm, tongue clean and moist, no return of spasm; improving appetite. Habeat pilulas aloeticas, quatuor vespere. Continuetur spiritus vini unuior. 3d.—One farther alvine evacuation consists of soft, dark co- loured and fetid feces. Pills having produced no effect, were re- peated this morning, but have not as yet operated. Continues free of spasm, with calm pulse, and clean tongue. Vespere repetantur pilulae aloeticae, et cras mane. Si opus sit, habevt infusi sennae uncias quatuor. Continuetur spiritus vini tenuior. 4th.—Has had pretty satisfactory alvine evacuation; he has slight gripes, but is otherwise well. TETANUS. 155 R. Carbonatus magnesiae drachmam, Pulveris radicis rhaei grana decern. Sit pulvis cras pimo mane sumendus. A little animal food at dinner. 5tb. Continuetur pulvis e magnesia et rhaeo. Intermittatur spiritus vini tenuior. 6th.—Gripes continue. Intermittatur pulvis rhaei. 7th.—Gripes gone. R. Pulvis radicis rhei drachmas duas, Divide in doses quindecim aequales, Signa, one every morning. Dismissed cured. Sect. II. EXTRACT OP A LETTER FROM MR. JOHN BURNS, SURGEON IN GLAS- GOW, ADDRESSED TO THE AUTHOR. " Glasgow, 13th Aug. 1811. "I lately had a patient labouring under tetanic affection, whom I attended along with Dr. Freer, Professor of Medicine in our University, and Mr. Wilson, surgeon, of this place. The follow- ing is the narrative of the case, which you have my permission to publish. " A Z. aetatis 50, of temperate habits, and, to use his own ex- pression, as regular as clo k-work in the alvine discharge, was seized on the 1st of June 1811 with cougb, some degree of oppression in breathing, and pain in the head during the fits of 156 APPENDIX IX. coughing. For these complaints he was, between the 1st and 7th, bled freely, purged, blistered, and had a pectoral mixture con- taining squills and digitalis. By these means, the pectoral symp- toms were removed, but he still complained of want of appetite, languor, flatulence, and some degree of costiveness. For these he took, between the 10th and 17th, tincture of steel, and open- ing powders, containing magnesia, rhubarb, and a little ginger. On the 18th, the bowels being more obstinate, he took six grains of calomel, with only a very slight effect. On the 19th, he was seized, early in the morning, with violent and almost incessant spasms: the diaphragm seemed to be the part first affected, as he felt, a constriction there, instantly, however, followed by a slight extension of the spine, like an approach to tetanus, and startings of the arms and legs. The pulse was natural, the tongue furred, and there was a little, but only a very little, confusion in the head. For these symptoms he took, in divided doses, the following mix- ture within three hours. R. Camphorae grana decern, Magnesiae albae scrupulum unum, Syrupi simplicis drachmas duas, Tincturae opii guttas sexaginta, Aquae mentae piperitidis unciam nnan , Aquae fontanae uncias tres. Misce. " This produced as little effect, as I have invariably found from anodynes and antispasmodics in chorea. He then took a purg- ing mixture, containing salts and senna, and also a dose of calo- mel. The greatest part of these medicines he rejected speedily, and unfortunately he could not swallow pills. He had also fre- quent inclination to vomit, even after taking the mildest drink, and the mere sight of food excited nausea. The spasms conti- nued to recur very often. In the afternoon he had a smart clyster, which brought away some fetid stools, and the spasm became less severe and less frequent. Next day he had opening medicines, particularly calomel, which he kept, and in the afternoon he had a clyster. This operated pretty well, probably in consequence of having taken the calomel; the spasm, though less severe, still con- TETANUS. M7 tinued. The pulse, as formerly, was good. On the 21st, he took a solution of the phosphate of soda, part of which he re- tained, and it operated once or twice, the stools being fetid, and dark coloured. In the evening he had an anodyne draught, with- out any good effect. Next day the laxative was repeated, and the clyster at night, which brought away two or three very offen- sive stools, with manifest remission of the symptoms; and from that time, his bowels could be kept open easily with laxatives, and the occasional exhibition of a clyster. The spasm went entirely off, and, by strict attention to the bowels, he regained his appe- tite and strength. " The principal difficulty here arose from the ticklish, irritable state of the stomach, by which the medicines were often rejected; and pills, which would have likely remained, could not be swal- lowed. Much benefit, in these circumstances, was derived from the saline clysters." APPENDIX X. ANOMALOUS DISEASES. The following histories cannot be classed with any of the dis- eases of which I have treated. But as they afford examples of the extensive utility of purgative medicines, and as they may jus- tify the adoption of a successful practice in similar instances of disease, which might be protracted, and perhaps terminate fatally under any other treatment, I submit them to the consideration of the medical public. Heriofs Hospital, 30th October, 1805. James Macallum, iEtatis 14—This boy had suffered severely from toothach for some days, but was quite recovered from the violence of the pain, when, on the 6th instant, he became suddenly affected with a fit of anxiety and terror, in which he appeared much agitated, with a wild expression of eye; his countenance, at the same time, indicated great distress. A purgative medicine which was given operated well, and he made no further complaint till the evening of the 12th, when another fit of anxiety and ter- ror seized hirn, and attacked him repeatedly in the course of that night. Another purgative medicine was given the following morn- ing, which also operated well, and seemed to procure relief. 14th Oct.—He has passed a restless night, the fit above de- scribed returning when he was about to* drop asleep. Thf1 fits are frequent this morning. He appears much agitated when in the fit, complains of a noise in his head, and has involuntary twitching of the muscles of both fore arms. He is not trusted by himself, and he seems to be relieved when addressed in a soothing and encouraging manner. His pulse is calm, and tongur ANOMALOUS DISEASES. 159 white. When free of this fit of distress, he has the appearance of one in full health. R. Pulveris ipecacuanhae scrupulum pro emetico. 15th.—Vomit operated briskly; stomach not loaded, had an attack immediately after the vomit, and frequently since. Sumat quam primum pulveris jalapae compositi drachmam dimidiam ; vespere pro re nata repetendam. 16th.—Both doses of the powder, and two aloetic pills given; a formed rather scanty stool of a dark brown colour this morning. Attacks frequent through the night. Habeat quam primum pulveris jalapae compositi drach- mam. 17th.—A stool similar to that of yesterday, but more fluid, R. Foliorum sennae drachmas duas, Tartriiis potassae et soc'-ae drachmas octo, Extracti glycirrhizae drachmam, Aquae fervidae libram. Sit infusum quam primum tribus vicibus sumendum. 18th.—Copious alvine evacuation. Sumat vespere pulveris jalaj-ae compositi drachmam dimi- diam. 19th.—Farther regular alvine evacuation. No return of fits of anxiety and terror since the night of the 16th instant. Habeat indies ad tertiam vel quartum vicem pulveris jala- pae compositi scrupulum. This boy continued to recover, and soon after the last report left the sick-room. 160 APPENDIX X. Edinburgh, October, 1805. A young woman of a delicate constitution, but not liable to general bad health, was seized with frequent violent and bound cough, unattended with pain of breast, dyspnoea, and quickness of pulse, or heat of surface. In order to mitigate the cough, the severity of which excited much alarm, lest rupture of vessels and haemoptysis should ensue, blood-letting was practised once and again, and a blister was applied to the breast, while a low regimen was enjoined, and laudanum was given to procure sleep, which the cough had altogether banished. These means, so likely to have procured relief, were of no avail. The experience of the effect of some purgative medicines, which had been given in the course of the disease, proved that the patient was either of a peculiarly constipated habit of body, or laboured under temporary constipation. It seemed, therefore, reasonable to me, as well as to another medical gentleman in at- tendance, to force the alvine evacuation by more powerful medi- cines than we had as yet employed. We succeeded, but not without difficulty, in obtaining the object in view. The appear- ance and odour of the feces evinced their morbid state; while the quantity that was dislodged proved that the feculent accumula- tion had been great. And there was no doubt of these circum- stances having been the cause of the ailment, for the cessation of the cough, and the progress of convalescence, kept pace with the gradual unloading of the bowels. Our patient was so satisfied of this, that she readily agreed to follow out a course of purgative medicines, in order to preserve her bowels in a regular state of daily and full evacuation. This patient, four months afterwards, had another attack of pec- toral symptoms, different however from the former one. She now complained of acute fixed pain across the lower part of the sternum, aggravated by the gentlest bodily exertion, and attended with great languor and feebleness. Her appetite was altogether gone, she passed sleepless nights, her countenance betokened much distress, her cheeks were alternately flushed and pale. With these symptoms she had no cough, and when completely at rest, even in the recumbent posture, no dyspnoea. ANOMALOUS DISEASES. 161 On the first attack, the pain was so violent as to threaten in- stant suffocation, which appeared to have been averted only by a prompt and copious blooding. Blood-letting was afterwards re- peated, which, as well as blistering, was of no use; the applica- tion of leeches seemed to mitigate the pain; and, on account of it, low diet was enjoined. The other medical gentleman in attendance, and I, trusting to the account of our patient, and to the appearance of one alvine evacuation, were satisfied that the belly was regular; and we were the more readily so, as our patient, ever since her former indis- position, had been accustomed to attend to this circumstance. Disappointed in our expectations of relief, we now became se- riously alarmed, dreading the existence of vomica, with which we connected apprehensions of impending phthisis. These fears were not altogether concealed from the friends of our patient, who immediately asked the assistance of another medical gentleman. Our joint opinion now turned upon the probability, that the disease might depend upon nervous irritation. Exercise in the open air, a fuller diet, and a tonic powder and mixture were pro- posed. The patient's inability to bear the slightest motion, and her total want of appetite, precluded compliance with the two first proposals; and the tonic medicines, taken with great reluc- tance, were scarcely in use, when a copious fluid, dark coloured, and peculiarly fetid stool arrested our attention. The previous history of this patient's health, and the present occurrence, indi- cated clearly our line of practice. Much fetid feculent matter was brought off by appropriate purgative medicines; immediate abatement of pain took place, and complete relief in all respects soon ensued. In eight or ten days, no vestige of complaint re- mained. The patient is now perfectly well. SUBSTANCE OF THE NARRATIVE OP HER OWN CASE, TRANSMITTED BY A LADY TO THE AUTHOR. " In the end of June, 1805, as a summer residence, I went to the neighbourhood of Moffat, in perfect health. For the sake of a walk and social amusement, I, every morning, repaired to the 21 162 APPENDIX X. sulphureous well, and drank a bottle of the water; and being of a full habit, which I found a little reduced by the exercise and use of the water, 1 persisted in this 'ill the beginning of Septem- ber Then I became much annoyed during the night wilh a most profuse cold perspiration, which could not be removed hy the appli- cation of beat. Sleep entirely left me; for I no sooner closed my eyes than I was roused by frightful nervous starting, and a confusion in my head so strange, that I dreaded approaching de- rangement. " I was informed that my ailment was a stomachic attack, oc- casioned by my having over-drank the water, and was ordered an infusion of bark, cinnamon, and hot spices, which a good deal relieved me. I got home pretty free from the above complaints, but wih a stomach so much weakened, that there were very few things which I durst admit into it, without suffering great pain in consequence of it. Bitters, air, and exercise were recommended. These I used all winter without any material change, except be- coming very thin. All this time I was so obstinately costive, that I never had passage without the force of powerful medicine. As spring advanced, I lost my strength and flesh entirely, each sto- machic attack leaving me weaker and weaker. Costiveness was now considered to be the principal disease, and the pain of sto- mach only the consequence of it; and purgative pills, a laxative diet, and moderate exercise were recommended. " When I became your patient, towards the end of July, 1S06, I was reduced to a skeleton, and scarcely able to creep about, and so costive that it required sixteen of the pills which you ordered, pilula aloetica, to procure a passage. In the course of one week half the number had an equally good effect; and at the end of a fortnight, four pills were sufficient. The feces then began to as- sume a natural appearance, and the intolerable smell from them abated. During the above period, the quantity of strange unna- tural stuff discharged from my bowels was inconceivable, and my strength, so far from being wasted, was daily increasing, with a light and comfortable feeling of returning health, to which 1 had been long a stranger. About the middle of August, I went a little way into the country, and took a mercurial medicine, which kept my bowels open, and made my mouth sore after the fourth dose. ANOMALOUS DISEASES. 163 " You then ordered me powders, composed as you told me of bark and rhubarb, a dose of which I take twice a day with a laxative effect. " Since the commencement of this course of medicines, I have had few returns of the pain of my stomach, and those but slight. I now take, without any fear, moderate exercise, and a variety of simple foods. I sleep amazingly well; my appetite and spirits are excellent, my flesh and strength are returning daily; and I am happy in being one of many who can bear testimony to the general usefulness of purgative medicines." " October, 1806." I have frequently heard of this lady; she has enjoyed uninter- rupted good health from the above to the present date. Edinburgh, May, 1815. The following Letter I received from Mr. James Anderson, Surgeon in Edinburgh. My Dear Sir, The inclosed are the principal circumstances of the case which I hinted at the other day, and you may use what liberty you choose with them, if you think they can be of any service—I am, Respectfully yours, James Anderson. 10, St. James's Square, 8th Feb. 1809. Dr. Hamilton. " Mrs. B. aged 40, about five years ago, was seized with pain, accompanied with a sense of weight in the left lumbar region. She was, at that time, about six months pregnant. " A warming plaster was applied to the part, and she was de- sired to keep her bowels open with supertartris potasses. 164 APPENDIX X. " After delivery, (which was accomplished by a quick and natu- ral labour) the pain was not in the least alleviated; but, in other respects, her recovery from the puerperal state went on as usual, " In a few months after this period, the pain became more se- vere and diffused, shooting towards the interior part of the abdo- men; the limbs became considerably debilitated, swelled, and pained; and she was soon after rendered altogether unable to walk without the aid of crutches. " She used a variety of medicines, also cold and warm bathing, without deriving any benefit from them. " These symptoms continued, and varied little, during five years; in this situation she became twice pregnant; the first labour was laborious, the second preternatural. " She now began to put little confidence in the use of medi- cines, and to lose all hopes of ever regaining her former strength, when she was accidentally met by a female acquaintance, who had laboured three years under a similar disease, from which she recovered by the use of strong purges. Mrs. B. had recourse to the same means, and, by their frequent and continued use, the strength of the limbs speedily recovered, so that within three weeks she was able to walk five or six miles in the day, without the aid of either crutch or staff. She describes the stools to have been dark-coloured, copious, lumpy, and very, fetid. She had a large flow of urine while under the operation of the cathartic, and the pulvis jalapa compositus was the one she used most con- stantly." Dr. King, of Glasgow, has been so obliging as to send me the following case, and has permitted me to publish it. " 2d Jan. 1811.—John F-------, three years of age, was at- tacked after breakfast with vomiting, which has continued at in- tervals all the forenoon. Pulse 100, countenance dejected, eye dim, tongue white, belly tense and hard. Has been unusually cross for the two last days. Has had a stool, in general, every day, except one, last week, when a dose of magnesia produced ANOMALOUS DISEASES. IDJ a proper effect; yet for the last three months he has often com- plained of his belly. Let five grains of calomel be given immediately. "3d.—Vomited much daring the night; no stool; other symp- toms as yesterday. R. Ol. ricin. unciam dimidiam, Tinct. jalap. Tinct. sennae comp. utriusque drachmas duas. Let a dessert spoonful be given every two hours, till the whole is taken, or a free stool procured. " 4th.—Has taken all the medicine; had a small dark coloured watery stool after the first spoonful, and again during the night, but without any appearance of feces. No sleep; complains much of his belly. Has not vomited; other symptoms as before. R. Tinct. jalap. Syrup, simp, utriusque unciam dimidiam. This to be given as the last mixture. " At seven in the evening he had taken all the medicines with- out effect, a purgative clyster was given, and returned without feces. Rep. tinct. jalap, e syrup, simp. " 5th.—Has taken all the medicine; no stool; appears worse; passed a very restless night, with some approach to delirium. Pulse very quick. R. Fol. sennae drachmas duas, coq. ex aq. font, unciis qua- tuor ad uncias duas, et cola. Let one half be given immediately, and the rest in four hours. " 6th.—Has been restless all night. Took all the decoction without effect. 166 APPENDIX X. Let six grains of calomel be given now, and ten grams of jalap in the evening. " 7th.—Had a very small stool after the calomel, and a little also after the jalap, but too trifling to produce any effect on his dis- ease; slept a little in the night; had again an inclination to stool, without passing any thing but a very little dark coloured fluid. As antimonials, after producing their full emetic effect, have often been observed to operate by stool also, he took this day a saline mixture, with tartrite of antimony. A great quantity of dark coloured bile was thrown up, and a little of thinner dark fluid passed by stool, both without any feces. " 8th.—Last evening, at seven, he was kept ten minutes in the warm bath; after which he started much and screamed wildly; in the night he slept little, and was completely delirious, making frequent attempts to bite his left arm, seemingly insensible of the pain produced by his teeth, though the marks were evident. Let him take one of the pil. colocynth. c. aloe immediately; and in the forenoon, at two doses, the following mix- ture. R. Decoct, sennae in. aq. unciis duabus. Tinct. jalap, drachmas duas. Misce. , " 9th.—Yesterday's medicines produced little or no effect. The warm bath again aggravated all the symptoms, as it did this day, when it was thought unadvisable to persist in it; strength much exhausted; has several times fallen suddenly and profoundly asleep in the midst of the most violent struggles. Has slept from the commencement of his illness, with his eyes half open. His sight appears much impaired. Capt. pil. aloes colocynth. duas. Applic. emp. epispast. inter scapulas, Injic. enem. purg. vesp. u 10th.—The clyster was returned nearly as injected; no stool; about six hours after the blister was applied became calm, and slept well till morning. Is evidently much easier, though no change of consequence has been produced on his bowels from the beginning of his illness to the present hour. ANOMALOUS DISEASES. 167 R. Ol. ricin. Tinct. sennae utriusque unciam unam. Let him take a table spoonful every two hours.^ " 11th.—Symptoms as yesterday; has taken all the mixture without effect. Let it be repeated. « 12th.—Still no effect, though the medicine has again been all given. Let it be repeated. " 13th.—The mixture has been all taken; some trifling evacu- ation, but no real feces. Let him take a tea-spoonful of calcined magnesia three or four times a day. " 14th.—Several doses of calcined magnesia were given at in- tervals yesterday; and at length the purgative medicines, thus ac- cumulated, have begun to produce some good effects. He has had several large stools of green glutinous matter, mixed with dry hardened feces in round compact balls, amounting in all to a large quantity, sufficient to account for all the symptoms: and however singular it may appear, I have no hesitation in avowing my belief, that the feces evacuated on the 12th or 13th day were, from the commencement, lodged in some part of the intestines. " From the time that his bowels began to act, the purgative plan was continued till all the symptoms were removed. Par- ticular directions were given to attend to the state of his evacua- tions, and he now continues in perfect health." "Glasgow, Oct. 12, 1811." How numerous soever and minute the histories of the cases contained in this Appendix may appear to some readers, their im- portance, in my opinion, is such as to justify my retaining them. I have reason to believe they have tended in some degree to pro- duce a material change in medical practice, and they serve, at the same time, to establish its utility and success. They may be con- 168 APPENDIX X. sidered as a kind of land-marks, to guide the young practitioner on his way in the acquisition of experience; they will teach him what he will not find in books; they will instruct him in that de- cision, steadiness, and attention, so necessary to insure success in conducting that particular administration of purgative medicines, which my inquiries and practice have emboldened me to recom- mend. They are therefore not to be read merely, they ought to be studied. Besides these considerations, I am supported on this occasion by very respectable authority. In treating on purging in ' the putrid fever that follows the confluent small-pox, Dr. Friend, after relating at great length the progress of this fever in a particular instance, subjoins the following remarks applicable to my pur- pose " Historia haec a me paulo latitus atque prolixius deducta est, eo tantum animi consilio, ut, quia neque ex consuetudine esset, neque communi medicorum sententiae congrueret hoc purgandi institutum, quid hoc tandem valeat efficere, aut quid inde boni expectare conveniat, lector ex hac explicatione distinctius facta internoscere possit. Quod quidem medicinse genus ita parum usu esse receptum fateor, ut minime mirer plerosque huic admo- dum adversari. Liberum cuique suum sit judicium: nee dubito quin ii, a quibus dissenseram, habeant ea argumentorum pondera quibus sententiam suam tueantur. Sua iilis placuit opinio mihi fortasse nimium mea. Siquid liberius sit dictum, id non contra- dicendi, sed veritatis in re tam gravi aperiendae studio dictum putetur." Hippocratis de morbis popularibus, Liber primus et tertius Gr. et hat. His accomodavit novem de febribus commentarios Johannes Friend, 4to. Lond. 1717, p. 97.