'■N.'N«#! Cw-V. *• '"",'1' OBSERVATIONS UTILITY AND ADMINISTRATION PURGATIVE MEDICINES SEVERAL DISEASES. BY JAMES HAMILTON, M. D. Fellow of the Royal College of Physicians, of the Royal Society of Edin- burgh, Senior Physician to the Royal Infirmary of that city, and Corresponding Member of the Medical Lyceum of Philadelphia. ^:&wm^ FROM THE FIFTH EDINBURGH XDITIOrf<> ■> - V ^ , « ,- ■ r -\ — V'-'-'y PHILADELPHIA. ^-~ i^i^- PUBLISHED BY THOMAS KITE, 64 WALNUT STREET. 1829. HZ/1. I&1 TO JAMES RUSSELL, Esq. professor op clinical surgery in the university op edinburgh. My Dear Sir, If the following Observations had been of that importance in respect of science, as to have made a particular Dedication of them necessary, or proper; and if I had been to select a pa- tron 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 obli- gations to you for many instances of your private friendship ; and to thank you for the encouragement you gave me on the present occasion, without which, I probably neither would have undertaken, nor have accomplished this little work. I am, Dear Sir, With much regard, Your faithful and obedient Servant, JAMES HAMILTON. EDINBURGH, > 1st November, 1805. $ 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 opportuni- ties which I have enjoyed for collecting accurate and extensive 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 discharged i.he 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- rious occupations, in which I have been engaged, my attention was, many years ago, attracted to the pur- gative effect of medicines given in Typhus fever. The facts which then presented themselves to my notice, induced me to repeat these medicines again and again; till, by slow advances, I at last acquired con- fidence in the practice. Many opportunities have since occurred to me of confirming these observa- tions, which, in my apprehension, clearly establish the VI PREFACE. 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 experi- ence. Thus my views respecting the use of purgative me- dicines became more and more extended; and, in process 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 common 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 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 shew 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 mu- tual and valuable aid to one another. The medical education, it was evident, would be rendered more complete, by giving the students of the University ac- cess to the Infirmary, where they might learn the prac- PREFACE. Vll tical 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 conducted 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 practical knowledge of his profession, seldom to be found in other hospitals. 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 relative to the conduct of their cure. The two Physicians named by the Managers have an equal share of duty, and divide the patients equal- ly between them. A clerk is attached to each Physician. He is com- monly a young Gentleman who is advanced in his studies. He resides in the Hospital, and has a gene- ral 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 written 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 bedside 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 ot the symptoms, of the remedies prescribed, and of the ef- Vlll PREFACE. fects of these, are given daily, or as often as the chro- nic nature of the case may make them necessary. These reports are the result of the accounts which the patients give of themselves, of the accounts which are received from the nurses, or of both together; they are 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 publici- ty 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 au- thenticity peculiar to themselves; and, in the esta- blishing of medical facts, may be produced as an au- thority, that cannot be controverted. Indeed, I es- teem myself fortunate in having documents of this kind to adduce, in support of a practice which may be thought to require all the confirmation which the most incontrovertible evidence can afford. These cases, inserted in the different numbers of the Appen- dix, are dated from the Royal Infirmary. Again, in further support of the exhibition of pur- PREFACE. IX gatives, in the diseases of which I treat, I insert, in the proper numbers of the Appendix, histories of ca- ses 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 private practice, likewise enables me to give farther evidence 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, which they have seen me employ with so much ad- vantage. By this means, the peculiarities of my practice here have passed silently into the world, un- explained and unsupported by the proofs and illustra- tions which it was in my power to produce; they have been partially noticed in one periodical publication; and made the subject of hasty and mistaken criti- cism 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 X PREFACE. hearing, by placing it before the public, in my own words. To the public decision I will submit, with defer- ence and respect; at the same time, I rely with con- fidence 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 observed. Edinburgh, 1st Nov. 1805. PREFACE. TO THE FOURTH EDITION. My acknowledgments are equally due to the pro- fession 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 mis- informed, the practice which it recommends still con- tinues 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 ascribed 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 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 association established in the mind between that effect and the exhibition of purgative Xll PREFACE. medicines; while some of my early remarks on the subject have not been duly weighed. For, when speaking of the distinction that is usually made be- tween purgative and laxative medicines, and object- ing to it as not quite correct, I say, page 28, " 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 experi- ence of their superior usefulness, I employ almost solely what are understood to be purgative medicines, while I avoid their full effect of purging." And again, page 28, " This explanation obviates one objection, not unfrequently made to the employment of purga- tive medicines, namely, that they are apt to reduce farther the strength of a patient already too weak. Purging will undoubtedly debilitate the body, by caus- ing a flow of fluids greater than usual into the cavity of the intestines, 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 obser- vations, in which the sole intention is to evacuate the contents of the bowels, which, being out of the course of the circulation, are in a manner already ex- traneous 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 improved; and the patient, so far from being weak- ened, 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 purg- ing would defeat this end: in fact it would quickly exhaust and destroy the patient. The principle, then, on which I steadily proceed, is PREFACE. Xlll to obviate constipation, and, at the same time, to avoid purging. Many passages in my book bear directly on this point, pages 37, 46, 47, 44, 61, 79; the general scope of my observations attests its importance; and the detail of cases in the Appendix shews 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 ne- cessary to insure its ultimate success. Every one knows, that purgative medicines act ac- cording to pecularities of constitution, and the nature and progress of disease. Hence the inspection of the feces is requisite to regulate the strength of subse- quent 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 care- fully avoided. Whether these medicines operate in the chronic diseases, of which I treat, by unloading or stimulating the bowels, a course of them is necessary to the at- tainment of either effect; and it is equally necessary to persevere in this course till the cure is complete; otherwise this disease, subdued only in part, may soon reappear, 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 125, 126, shew 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 in the administration of purgative medicines. These quotations, and the passages to which I have referred, explain and illustrate the principle of my XIV PREFACE. 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 my views with regard to some diseases, and the success 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 laboured to guard the reader in the last paragraph of the Preface to the first edition. " To the public decision I will submit, with deference and respect; at the same time, I rely with confidence on its imparti- ality ; and trust, that no person of character will con- demn the practice, which I now recommend, till after repeated trials, agreeably to the plan which I have myself observed." Edinburgh, March. 1811. On revising the following Work, previous to its being sent to the press for the fifth edition, some alterations, more or less important and a few additions, appeared to me to be proper. I give an extract from Mr. Price's letter, bearing on the sub- ject to which it relates in the twelfth chapter, instead of insert- ing it entire, as formerly, in the Appendix. 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 105th 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 121, and that of Andrew Warrender at page 125, 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. CONTENTS. 17 Page CHAP. I. Observations on Impediments to the Improvement of Medi cine,.......... II. Observations on the Functions of the Stomach and Intes- tines, . • ■ . • • 21 III. General Observations on Purgative Medicines, . . 26 IV. Observations on the Utility and Administration of Purgative Medicines in Typhus Fever, . . . . 31 V. On Purgative Medicines in Scarlatina, 41 On Purgative Medicines in Cynanche Maligna, . .48 VI. On Purgative Medicines in the Marasmus which appears in Childhood and early Youth, . . . . 56 VII. On Purgative Medicines in Chlorosis, , . . 65 VIII. On Purgative Medicines in Vomiting of Blood, . . 74 IX. On Purgative Medicines in Hysteria, .... 80 X. On Purgative Medicines in Chorea Sancti Viti, or St. Vitus's Dance, . • ... • • ^9 XL On Purgative Medicines in Tetanus, . ... 103 XII. Conclusion,........113 APPENDIX. APPENDIX 1....... 2 Tabula Prima, exponit medicaminum titulos pnores et pos- teriores, , ...... lb. Tabula Secunda, exponit medicaminum titulos postenores et priores,.....• • ' . ' Tabula Tertia exhibet formulas medicaminum composito- rum, quorum mentio fit in hisce paginis, et quae Pharma- copoeias Nosocomii Regii Edinensis, propria? sunt, . 5 II. TYPHUS,......• • 7 Sect. I. Cases of Patients who laboured under Typhus Fever, • • • • \ lb" Sect. II. Sentiments of Authors on the Use of Purgative Medicines in Fever, . 25 ---------—ofLommius,.....«>• __________-of Glass,......26 .---------—of Langrish, , ib. -----------ofCullen,......27 -----------ofHuxham, , .... ■-----------ofCurrie,......29 XVI CONTENTS. Page APPENDIX III. SCARLATINA, . . . . 29 Sect. I. Cases of Patients who laboured under Scarlatina, ib. Sect. II. Narrative of Scarlatina, as it affected the chil- dren in George Heriot's Hospital in Autumn 1804, . 37 Sect. III. Testimony of Authors who are favourable to the use of Purgative Medicines in Scarlatina, • • 41 -----------efCullen,......ib. > -----------of Rush, ...... ib. —-------of Sims, ...... ib. -----------of Blackbume, ... . ib. IV. MARASMUS,.....42 Sect. I. Cases of Patients who laboured under Maras- mus, ... ......ib. Sect. II. Case of Euphemia Winter, from the Trades Maiden Hospital, . ... 50 Sect. III. Communications on the Treatment of Maras- mus by Purgative Medicines, . . . . 51 Case of H. T. by Mr. Stewart, Surgeon at Gogar, . ib. Letter from Mr. James Russel, Surgeon, Edinburgh, to the Author,...... . 52 Letter from Dr. Benjamin Bell to the Author, . 53 V. CHLOROSIS,.....56 Cases of Patients who laboured under Chlorosis, . ib. VI. VOMITING OF BLOOD, ... 60 Cases of Patients who laboured under Vomiting of Blood, .. . . . . . ib. VII. Hysteria, . . . . 66 Sect. I. Cases of Patients who laboured under Hysteria, ib. Sect. II. Letter from Mr. James Law, Surgeon in Edin- burgh, addressed to the Author, ... 71 VIII. CHOREA,....... 73 Sect. I. Cases of Patients who laboured under Chorea, ib, IX. TETANUS,.....113 Sect. I. Cases of Patients who laboured under Tetanus, ib. Sect. II. Letter from Mr. John Burns, Surgeon in Glas- gow, to the Author, ...... 127 X. ANOMALOUS DISEASES, . . .129 Case of a Boy in Heriot's Hospital, ... ib. ------a Young Woman, . . . . .130 Substance of the Narrative of her own Case, transmitted by a Lady to the Author,.....132 Letter from Mr. James Anderson, Surgeon, Edinburgh to the Author, . . .... 133 Case of Constipation, transmitted by Dr. King of Glas- gow, to the Author, . . . . 134 Conclusion,....... . 137 OBSERVATIONS UTILITY AND ADMINISTRATION PURGATIVE MEDICINES. CHAP. I. OBSERVATIONS ON IMPEDIMENTS TO THE IMPROVEMENT OF MEDICINE. PHYSICIANS are guided in their more early pro- fessional pursuits, by the doctrines which they have imbibed in the schools, by the sentiments of authors whom they have chiefly consulted, and by the exam- ple of those whose practice they have purposed to follow. Subsequent information, however, derived from new discoveries 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 medi- cine is fluctuating and uncertain, but, in my opinion, with no good reason. The innovations which are in- troduced are unavoidable; they result from the situ- ation in which practitioners are placed ; and indicate neither want of steadiness on their part, nor of cer- tainty in the profession. They always tend to im- 18 OBSERVATIONS ON IMPEDIMENTS prove the science, when they originate in good sense and attentive observation. To represent, therefore, the practice of medicine as variable, in consequence of changes inseperable 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 prin- cipal employments of life are liable to a similar ob- jection. 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 ge- nius, and the learning of its cultivators, and by the spirit of prevailing philosophies, always interwoven with reasoning in medicine. 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 opportunitv neces- sary for committing his observations to writing. This kind of information, therefore, which constitutes, in a great measure, what is understood to be experience in medicine, too often dies with the individual, and is lost to the accumulative stock of medical knowledge Practitioners, during a long period, forged shac- kles for themselves, by placing too implicit a confi- dence m the opinions of the ancient physicians They not only respected those 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 expect- ed, or inquired for, beyond the pale of their authority TO THE IMPROVEMENT OF MEDICINE. 19 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 disposed to bend with too humble defer- ence to the fathers of physic. A prepossession in favour of early speculations re- presses that freedom of inquiry so necessary to the improvement of medicine. Under this prepossession, practitioners do not always see what is passing be- fore their eyes in a just and proper light. They are thus apt to be deceived themselves, and to give to their observations a shade or colouring which de= ceives 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 employ- ment of different active remedies, or to the adoption of them in so quick a succession, as to make it fre- quently uncertain to which of these remedies, changes which may take place in the course of the ailment are to be referred. Much of the slow progress of medical improvement may be attributed to this cir- cumstance. The history of medicine, also, clearly shows, that theory or reasoning has contributed in no small de- gree to impede its progress. Physicians have at all times indulged the propensity, natural to man, to form hypotheses, 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 independent systems, the humoral or chemical, the mechanical, and nervous pathologies. Each of these systems, considered separately, affords many just and important conclusions, which do not however serve as a basis for general theory. 20 OBSERVATIONS ON IMPEDIMENTS Again, a strong passion for distinction and fame in the professors of medicine themselves, has prevented the happy combination of these systems, and coun- teracted the utility which might have been thence de- rived. The glory of establishing a new theory, and of constituting 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 form- ing their systems, have sometimes assumed data, which, unsupported by facts and experience, rest on a train of conjectural reasoning. Systems of this de- scription have checked rational inquiry; have brought into discredit useful practice, because discordant with the principles on which they are founded; and, lead- ing us to reject the most obvious explanation of im- portant facts, have on many occasions introduced much obscure language and vague reasoning into medical doctrines, from which, it is to be feared, and therefore to be regretted, that erroneous practical conclusions have been drawn. I do not dwell with pleasure upon these causes, which I apprehend have retarded the progress of me- dicine. I venerate the memory of those of our pre- decessors, whose labours have obtained for the heal- ing art an important rank in the estimation of man- kind. As they have occasionally failed, however, in promoting the advancement of medicine, we ought to take a lesson from their failure, and avoid the cir- cumstances which have occasioned it. We should not tamely acquiesce in opinions, how respectable soever from age and authority. We should receive, with laudable distrust, statements of facts proposed by others, till such time as we ascertain their accura- cy. We should restrain within due bounds an over- TO THE IMPROVEMENT OF MEDICINE. 21 weening self-confidence, and scrupulously 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 business, by a cir- cumspect 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, independent of theory or reasoning, however incor- rect. CHAP. II. OBSERVATIONS ON THE FUNCTIONS OF THE STOMACH AND 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 assistance of fluids secreted from the liver, spleen, and pancreas, is perfected 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, consti- 22 OBSERVATIONS ON THE FUNCTIONS tutes part of the fecal evacuation which is made di- rectly 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 small- er and larger intestines, which is not commonly notic- ed. The former complete the preparation of the nourishment, and afford opportunity of its being ab- sorbed ; while the latter receive and detain the fecal part till after it has accumulated, and perhaps under- gone certain changes, when it is voided in a given quantity, and at stated intervals. Besides, the intestines exhale and throw off fluids 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 kidney. 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 necessary to the enjoyment of perfect health, and the continuance of life; and the regularity of the intestinal evacuation is connected, in a particular manner, with the well-being and healthy state of the stomach and intestines 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, affect upon the general system; but the skin and the kidney remain uninjured. It is otherwise with the intestines: secluded from that communication with the atmos- OF THE STOMACH AND INTESTINES. 23 phere by which the perspirable matter is carried off, and unprovided with an appendage 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 period of evacuation comes round. Different circumstances are apt to in- duce irregularity in this evacuation; these, together with the facility with which the larger intestines admit of distention without uneasiness being excited, give frequent opportunity for a progressive accumulation of feces, whence arise interrupted action of the sto- mach and smaller intestines, and consequent danger- ous 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 formed, is to be apprehended. For it is not to be ima- gined, that organs of so great importance in the ani- mal economy, as the stomach and bowels are, can be long in a state of inaction, and the general health re- main unimpaired. I am indeed aware, that constipa- tion may sometimes prevail, even to a great extent, in robust and otherwise healthy people, without imme- diate injury. In such persons, the circulating system is powerful; the excrementitious fluids, therefore, may be so quickly discharged by the other organs, as to leave a comparatively small proportion to be secreted into the intestines, incapable, from its bulk, to give a stimulus sufficient to excite a regular propensity to evacuate the bowels ; this bulk, however, being gra- 24 OBSERVATIONS ON THE FUNCTIONS dually 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 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 medi- cines are employed to remedy this torpid state. I use this language, and speak of the torpor of the bowels, although my ideas respecting it do not correspond with those of others. 1 am inclined to think, that the symptoms referred to loss of tone, proceed, on many occasions, more directly from the impeded peristaltic motion, the consequence of constipation. In this si- tuation, we may easily understand, that the distended colon cannot, for want of space, receive the contents of the smaller intestines, which will of course stagnate throughout the whole canal; the action of which be- ing thus interrupted, will soon altogether cease, and be at last inverted. The various ailments which thence ensue are daily before our eyes; and the relief which, under these circumstances, we observe to follow soon after the exhibition 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 retain- ed beyond the usual period, undergo changes, and ac- quire injurious acrimony; and if, moreover, we advert to the sympathy which many of the organs of the com- plicated animal frame have with the stomach and in- testines, we rannot but recognise the great influence OF THE STOMACH AND INTESTINES. 25 which these must possess over the comfort, the health, and the life, of the individual. 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, sedentary occupations in confined or otherwise tainted air. Besides, in a therapeutic view, we are encourag- ed to exercise this attention. It is admitted that di- aphoretic and diuretic medicines, employed to remedy interrupted 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 attainment of our object. The diseases of the stomach and bowels are many and important; they have excited much theoretical discussion, and have called forth a variety of practice. To enter, however, upon so wide a subject, and to in- vestigate it in a satisfactory manner, would be to en- gage myself beyond my present intention. I propose to confine my observations within narrower limits, and to take a practical view of a few diseases only, which I 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- derable novelty, but in which, I trust, the following sheets will satisfy the medical reader, there is an equal 26 GENERAL OBSERVATIONS 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 valetudina- rian to forsake the haunts and habits of fashionable life; to quit the crowded city, alluring amusements, and various occupations carried on in airless, or even in tainted rooms; to shun luxurious tables, indolence, and 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 al- though followed, it may not always remove constipa- tion and its attendant evils. In this event, as well as in those cases where constipation induces or accom- panies disease, the interposition of purgative medi- cines becomes necessary. CHAP. III. GENERAL OBSERVATIONS ON PURGATIVES MEDICINES. The connection which subsists between organs that are distant from one another, and whose functions are distinct, has always presented difficulties to that ar- rangement of the articles of the Materia Medica, which is founded on the operation or effect of medi- cines 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 deviate ON PURGATIVE MEDICINES. 27 from their usual course, and excite the alvine evacua- tion. In like manner, different 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 bathing, 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 of 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 im- mediately to the rectum. In the dawn of physic, purgative medicines were employed. But although they have been recommend- ed by the earlier as well as by later writers, and al- though the indications they are meant to fulfil have been an object of attention to the practitioners in all ages, yet I do not think that the extent of their utility has been always clearly perceived, or that their ad- ministration 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 va- nished in the course of regular practice; and can now be traced only in directing the sage advice of the ma- tron of the village and the hamlet. The favourers of the humoral pathology called in the aid of purgative medicines to expel peccant mat- ter, supposed to have been previously separated from the mass of blood by an appropriate fermentation. 28 GENERAL OBSERVATIONS They also taught, that different purgatives possessed distinct powers, and moved different fluids by a speci- fic action. Hence they talked of cholagogues, phle- magogues, hydragogues, melanagogues; and they displayed no little sagacity in the selection of the pur- gative adapted to the expulsion of the fluid supposed to be prevalent at the time. This fermentation, how- ever, and consequent deposition of peccant humours, have ceased to hold a place in the doctrines of physic ; while the specific operation of purgatives, in expelling particular fluids, is neither confirmed by subsequent experience, nor allowed to have much influence in practice. Modern physicians have two objects in view in ad- ministering purgative medicines; the one to empty the 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 between laxative and purgative medicines, which is not perhaps altogether correct. Purgative medicines act by their stimulating power, which will be in proportion to the quantity or dose in which they are given. Four or six grains of submuriate of mer- cury, 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 al- most solely what are understood to be purgative me- dicines, 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 ON PURGATIVE MEDICINES. 29 fluids, greater than usual, into the cavity of the intesti- nal canal, and probably by hurrying oft* 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 circulation, are in a manner already extraneous to the body. Purgative medicines, given under this condi- tion, will not induce debility; on the contrary, in the state of disease of which I treat, the bowels, being ex- cited to propel their contents, their functions are re- stored ; appetite and digestion are improved ; and the patient, so far from being weakened, is nourished, sup- ported, 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 unusual stimuli, and will counteract their effect in such manner, that, if the stimulus be suddenly with- drawn, 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 promis- cuous use of purgatives given unnecessarily during the enjoyment of perfect health. In many instances, however, of disease, constipation and accumulation of feces demand this stimulus to restore the healthy state of the intestines, and to promote the expulsion of their indurated contents. In proportion as these ob- jects are accomplished, the stimulus from the same purgative becomes more and more powerful; and so little is the necessity for continuing it, or for increas- 30 GENERAL OBSERVATIONS ing its dose, that, on the contrary, were not the acti- vity of the purgative diminished, or were it not with- drawn altogether, as convalescence 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- tions are neither requisite nor to be expected. The residue of food unfit for the purpose of nutrition con- tributes, no doubt, its share of feculent matter; yet the abundant secretion from different organs, and the exhalation of excrementitious fluids made into the ca- vity 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 pro- duced, independently of much solid food, as to per- ceive the necessity of their daily evacuation during the course of fever, and of other diseases of long con- tinuance. 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, unhappily, they make part of the creed of many practitioners, and, leading to narrow and improper views, they give an unpropitious direction to the conduct of the cure of diseases: for this reason 1 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 pro- mote their respective secretions; and, to this effect, much of the utility of purgatives is attributed. I think it unnecessary 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 ON PURGATIVE MEDICINES. 31 observe, that I refer the benefits arising from them to their sensible effect in unloading the bowels, rather than to one which is less obvious; and that, for the sake of perspicuity, I speak of this effect, as remov- ing a cause of irritation, 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 prose- cuting this subject, when I question the opinions of respectable men, I trust 1 shall speak with that defer- ence which I feel to be due to them; and when I pro- pose 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 explanations that have hitherto been given. Great learning and ingenuity have been shewn in their class- ification. It will, however, be admitted, I believe, that Dr. Cullen has proposed the best arrangement of this subject in his Synopsis Nosologic Methodical. The class Pyrexiae, according to him, comprehends five orders; and the first order is that of fever. Dr. 32 ON PURGATIVE MEDICINES Cullen admits two genera of fever only, the intermit- ting and the continued; of the latter, typhus or nerv- ous fever is most frequent, and is 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 manhood without hav- ing passed through it. Symptoms peculiarly distress- ing 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 origen 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, pre- cedes headach, languor, debility, and inaptitude for the usual mental and bodily exertions; morbid affec- tions of the surface of the body, of the sanguiferous system, and of different secretions, soon succeed; to which, in the more advanced stage, delirium, subsul- tus tendinum, floccitatio, and singultus, are superadd- ed. These are generally supposed to arise from a considerable impression made upon the nervous sys- tem. 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 accompany the others as they arise, and may possibly influence their mildness or severity. They are, therefore, of great import, and demand particu- lar attention in the treatment of fever. I was appointed physician to the Royal Infirmary forty years ago. At this time, the cure of tvphus was thought to consist chiefly in the removal of atony and spasms of the extreme vessels of the surface of the IN TYPHUS FEVER. 33 body. For this purpose, together with other medi- cines, weak antimonials were given freely. An emetic and a purgative medicine were commonly exhibited on the first approach of the attack, but the state of the stomach and bowels was little regarded in the af- ter periods of fever. An alvine evacuation was occa- sionally procured by a mild clyster, while purgatives were given with extreme diffidence, lest by their ope- ration they should rivet the spasm of the extreme ves- sels, 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 prisoners 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. Nevertheless, they had been obliged, by the circum- stances 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 convoy; of these, twenty-three died; and of forty men who were landed from the Egmont, ano- ther of the convoy, eight died. Such of the sick as could not be accommodated in a temporary hospital, were quartered in Leith, two, three, or four, being billeted in one house. E 34 ON PURGATIVE MEDICINES 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 af- terwards. These circumstances, the proximity of Leith to Edinburgh, and the reciprocal intercourse of the inhabitants, 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 antimonii nitrata, Ph. Edin. cditce anno 1774. I gave four or six grains of this preparation for a dose, which was repeated three or four times, at an inter- val of two hours, unless sweating, vomiting, or purg- ing, were previously excited. 1 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 entertained 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 subsultus tendinum, which had prevailed, were abated; the tongue, which had been dry and furred, became moist- er and cleaner; and a feeble creeping pulse acquired a firmer beat. On reflecting afterwards on these circumstances, it appeared to me to be probable, that, as the purgative effect of the calx antimonii nitrata had been the use- ful 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. IN TYPHUS FEVER. 35 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 re- lieves the oppression of the stomach, cleans the load- ed and parched tongue, and mitigates thirst, restless- ness, and heat of surface; and that thus the later and more formidable impression on the nervous system is prevented, recovery more certainly and speedily pro- moted, 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 irritating. Constipation, together with the change which fever appears to produce in the fluids secreted into the intestines, seems to be the cause of this alte- ration in the state of the feces. The necessity of ex- pelling this noxious mass is therefore apparent; and, if my opinion be correct, the operation of a clyster, the stimulus of which is confined to the rectum, must be altogether inadequate to procure the full evacua- tion which the circumstances of the case require. Ac- cordingly, it is now some years since I have relin- quished almost entirely the use of emetics and clys- ters in fever; I trust to a purgative medicine to insure a regular alvine evacuation, although the daily exhi- bition of a purgative for this purpose is not always required. By this mode of treatment, I avoid the 36 ON PURGATIVE MEDICINES 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 prac- tice 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 had formerly thought. This may be owing in part to ty- phus 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 me- dicines 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 commonly entertained; but I am confident that it is consonant 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 satisfaction 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 advo- cate for exciting unusual secretion into the cavity of the intestines, and for the procuring copious watery stools; these, while they are not necessary, might increase the debility so much dreaded. In most instances of fever, this practice, by purga- tives, is conducted with ease, and a tolerable degree of certainty. The observation and experience of in- dividuals may be necessary, on some occasions, for directing measures where it is not easy to lay down IN TYPHUS FEVER. 37 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 powder 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. 2nd, Under this limitation, they may and ought to be exhibited at any period from the commencement to the termination of the fever. 3d, The early exhibition of purgatives relieves the first symptoms, prevents the accession of more formi- dable ones, and thus cuts short the disease. 4th, In the advanced period of typhus gravior, symptoms that indicated the greatest danger were re- lieved by the evacuation of the bowels, and the pa- tients, in this instance, recovered. 5th, Reconvalescence from typhus is greatly pro- moted and confirmed, by the preservation of a regular state of the body. The same means secure against the danger of a relapse. In corroboration of these conclusions, and in confir- mation of the practice of exhibiting purgative medi- cines in the course of fever, I have inserted, in the Appendix, p. 7, several cases of fever from the re- 38 ON PURGATIVE MEDICINES cords of the Royal Infirmary, which I treated almost solely with purgative medicines. And I subjoin, at p. 25 of the Appendix, the sentiments of several respect- able 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 re- commend them to be studied by those who are enter- ing upon the profession of physic, I here subjoin an abstract of each case of typhus fever, for the satisfac- tion of others, whom leisure does not permit, and whom inclination does not lead, to engage in the pe- rusal of histories of disease given so much in detail. These abstracts are in the order in which the cases follow one another in the Appendix. 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. James M'-Kcchny, aged twenty.—No medicines be- ing previously given, he had a purgative without effect on the eleventh day of fever. The purgative was re- peated 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 emetic on the second day of fever, without relief. No farther medical interposition took place till the eleventh 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 patient 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 vomit- ing, three stools, and abatement of symptoms. These being aggravated on the seventh day, purgatives were IN TYPHUS FEVER. 39 given freely, and besides them one anodyne 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 emetic 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 medi- cines 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 ano- dyne draught for two nights, the mistura salina ammo- niata, 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. Purgatives 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 prescence 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 40 ON PURGATIVE MEDICINES had eight ounces of wine for one day, the mistura dia- phoretica salina for seven days, a mercurial pill for four, and an anodyne draught for two nights, and his head was blistered. Donald Steivart, 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 purgatives were given in its advanced period, and in the reduced state of a patient. Margaret Manson, aged twenty.—Became my pa- tient on the third day of fever. She had two brisk purgatives, and no other medicine; and she was con- valescent 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 respects 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 convales- cent 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. IN SCARLATINA. 41 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 had a full alvine evacuation, in consequence of a large dose of a purgative medicine; an anodyne injec- tion having been premised, to insure the retention of the purgative. The febrile symptoms immediately ceased, and, on the seventh day after her appearance in the hospital, she was dismissed cured. CHAP. V. OBSERVATIONS ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES IN SCARLATINA. No disease has attracted greater attention than scarlatina. Its frequent appearance, and its fatal ten- dency, 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 differ- ent 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 aggra- vated than relieved, by the " nimia medici diligentia." p. 225, editio tertia, London, 1705. Huxham and Fothergill afterwards wrote on scar- F 42 ON PURGATIVE MEDICINES Iatina, and the ulcerated sore throat: and since their time, many British and foreign physicians have pub- lished their sentiments with regard to this disease, and have generally spoken of it under the title of scarlatina anginosa. These different accounts of scarlatina have given rise to much nosological discussion respecting the identity of the disease, as described under different names. Little doubt is now entertained on the sub- ject, so far as scarlatina and scarlatina anginosa are concerned. It appears to be admitted that the affec- tion of the throat in the latter may give a variety, while the diseases are the same in their origin, pro- gress, 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 respecta- bility, 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 comprehen- sive and accurate. The time may not be far distant when scarlatina will be received as the generic dis- ease, the full history of which will include the more aggravated symptoms as they appear in scarlatina anginosa, and in cynanche maligna; in the same man- ner as the history of variola comprehends the varie- ties 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 be denominated scarlatina simplex, scarlatina anginosa, and scarlatina maligna." IN SCARLATINA. 43 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 scarlatina (or an- gina) 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 de- pends, in part, upon the varying nature and constitu- tion of scarlatina itself, independently of all extrinsic circumstances; 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 temperature of the air, the kindliness or inclem- ency of the weather, together with other unknown qua- lities of the atmosphere, and in part upon circum- stances which apply to individuals subjected to the disease,—their general habit of body and constitution, their particular state of health at the time of the at- tack, and their situation with respect to lodging, ven- tilation, and cleanliness. These circumstances concur in modifying the cha- racter of the epidemic; and while they introduce a variety 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 practice to the particular nature of the case. Hence different opinions have been entertained of the nature of scarlatina, and apparently discordant methods of cure have been proposed. Undoubtedly varying epidemics of scarlatina have led to the prac- tice of blood-letting, in some instances, and to the rejection of it in others; to the adoption of emetics and of blisters, by some practitioners, while others neglect and positively forbid them. It is owing to the 44 ON PURGATIVE MEDICINES same cause, that chinchona is warmly recommended, and almost exclusively trusted, for the cure of scarla- tina ; 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 re- moved. In like manner, purgatives have been con- demned as useless, if not dangerous; and lately, the effusion of cold water over the surface, or the ablu- tion 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 embarks in this undertaking, and executes it with suc- cess, will render an useful service to the public. These reflections occurred to me, upon turning my thoughts towards the subject of scarlatina; and I conceive them of sufficient importance to merit the attention 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 con- sidering scarlatina, and scarlatina anginosa, to be the same disease, using always the term scarlatina as in- cluding both. And, in compliance with common cus- tom, and for a reason which will afterwards appear, I shall treat of this modification of the disease sepa- rately from cynanche maligna, of which I shall take notice in the sequel. IN SCARLATINA. 45 SCARLATINA. An inflammatory diathesis frequently prevails on the first attack, and during the early period of scarla- tina. 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 exis- tence of the inflammatory diathesis may have dispos- ed others to give purgative medicines more freely in scarlatina than in typhus. But this practice has not been universal; for many physicians do not admit the good effects of purgatives, 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. 1 had learned, that the symptoms of debility which take place in typhus fever, so far from being increas- ed, were obviously relieved by the evacuation of the bowels. I was, therefore, under little apprehension 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 efflores- cence, from the exhibition of purgatives. According- ly, in treating scarlatina, 1 have confided much in the use of purgative medicines; and no variety of the 46 ON PURGATIVE MEDICINES 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 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 complete and regular expulsion of their contents; and thus to prevent the accumulation of feces, which ne- ver 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 scarlatina, 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 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 rnedici," although Syden- IN SCARLATINA. 47 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 regu- lar exhibition of purgative medicines. Besides these motives for the exhibition of purga- tives, I have observed, that the febrile state in scar* latina 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. 37, the bowels were peculiarly constipat- ed, the termination in dropsy was frequent, and, from this circumstance, the mortality was great. I have not 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 mer- cury. In scarlatina, as in typhus, we should keep in view the procuring the effect of purgatives during the day, 48 ON PURGATIVE MEDICINES 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, circumstances necessary to determine the subsequent dose of the purgative, and the frequency of its exhibi- tion. 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 ex- hibition of purgative medicines, conjoined with per- sonal 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. In corroboration of these my sentiments, I give, in the Appendix, p. 29, the cases of a few of my patients in the Royal Infirmary, who laboured under scarlatina; also, p. 37, a narrative of an epidemical scarlatina . which prevailed in Edinburgh in 1804-5, as it appear- ed among the children in George Heriot's Hospital; and p. 41, 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 cynanche maligna are distinct diseases, has 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 IN SCARLATINA. 49 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. 1 have declined, however, to enter upon any argu- ment on this subject, that I might be at liberty to con- sider 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 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 pass- ed 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 ob- jection to evacuations of any kind in the treatment of it, and particularly to that procured by purgative me- dicines. It would indeed appear, that this objection has been urged with effect against the use of purga- tives, even in scarlatina, in consequence of the con- nexion which had been observed to subsist between it and cynanche maligna; 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 in- duced by the purgatives used in scarlatina. The re- stricted use of purgative medicines, however, to the extent of unloading the bowels only, does not increase 50 ON PURGATIVE MEDICINES this debility, while it relieves the symptoms of the ge- neral fever; and may thus prevent either its termina- tion in cynanche maligna, or alleviate the attack. Writers also condemn purgatives in cynanche ma- ligna, from an apprehension that they serve to diffuse the acrid matter, descending from the throat into the stomach, over the whole surface of the intestines, and thus to increase the source of contagion, and to ag- gravate 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 becoming more offensive, in consequence of re- tention in the stomach and bowels, will produce greater mischief, and greater irritation, than can possibly pro- ceed from the gentle operation of a purgative medi- cine, while they lose the benefit ensuing from the movement and expulsion 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 conceived 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 em- ployed 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 purging. Under these impressions, I have formed a favoura- ble opinion of the utility of purgative medicines in cy- nanche maligna. But let me here caut on the reader, that I have, in this instance, departed from the rule which I had formed to myself. It is a theoretical opi- nion on my part, and not so fully supported by expe- rience, as to enable me to deliver it with confidence. IN SCARLATINA. 51 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 ulcer- ous sore throat, London, 1757, remarks, page 297, "However improper purging might be at the begin- ning of this distemper, gentle easy cathartics, as rhu- barb, manna, &c. were necessary at the end, to carry off the putrid colluvies of the intestines, which other- wise 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 re- covered 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 become scarce, and is generally to be found only in public libraries; I insert it therefore at length, for the gratification 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 52 ON PURGATIVE MEDICINES any further apology 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, answered the description given of it by Dr. Fothergill; and therefore a repetition of the symptoms and ap- pearances would be needless. I shall only relate what appears to me to be the predisposing cause, the prox- imate 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 primal 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 consi- derable number of people have been instantly seized with the disease. " 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 eva- cuations, which are little else but acrid or putrid bile. " The treatment I have given the sick is, immedi- ately 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 constitu- tion. " The evacuating medicines 1 have given are the following: u Recipe—Ras. c. c. antimon. Crud. pulv. an. p. ae. calcinentur simul in crucibulo donee fumi sulphuris evanescant, et regulus antimonii manifestus sit; deinde ab igne remove, et in pulverem subtilissimum redige. IN SCARLATINA. 53 " Recipe—Pulv. supradict. partes tres.—Mercurii dulcis sexies sublimati, et subtilissime triturati, partem unam. Misce. " 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 Mendereri, tincturse myrrhae uncia dimidia, decocti 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 Peru- viani Huxhami, unciam unam et dimidiam,—Rhabar- bari spirit, unciam dimidiam; drachmam unam vel drachmas duas, bis indies, horis medicinae in aqua para. " The liquors I have used, have been water-gruel, 54 ON PURGATIVE MEDICINES barley-water, chicken-water, sage tea, rosemary tea, or balm tea, occasionally. Of these 1 have recom- mended the sick to drink freely, cold or just tepid; keeping 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 interno." " 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 evidence of the safety and efficacy of purgative me- dicines 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; 1 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 prevail- ed in Edinburgh in 1804 ; as will be evident from my narrative of this epidemic, as it appeared in George Heriot's Hospital, Appendix, p. 37. Dr. Willan, in his description and treatment of cu- taneous diseases, gives extracts from an account of scarlatina, as prevailing among the children at Ack- worth school, drawn up by Dr. Binns. In a note, page 281, edit. 1805, we have a description of this epide- mic, as it affected the throat. " The affection of the throat has occurred with us in every possible state; mere erythema, sometimes with a swelling of the ton- sils : aphthous specks; deeper ulcerations, with white sloughs; ash-coloured sloughs, which I consider as IN SCARLATINA. 55 gangrenous; also darker-coloured sloughs, with ex- treme 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 twen- ty-four hours, for several successive days."—" Al- though 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 addi- tion of brandy to the red port. Sometimes strong brandy and water, sometimes brandy unmixed, was given with comfort and advantage to the patient." Inthisepidemic, 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 frequent attendance, but for his removal of a pre- judice against laxatives in the early stage of the dis- ease, imbibed from various authors, and confirmed by the dreadful consequences I had seen when a diarr- hoea came on in this fever. By his persuasion, small doses of calomel and other laxatives were occasion- ally administered; and, so far from producing injury, I believe that, by evacuating the acrid matter, which is often swallowed, they had a tendency to prevent the excoriations of the intestinal canal, and the con- sequent diarrhoea which I dreaded. But it should be remarked, that particular care was taken to support the patient during the operation." 56 ON PURGATIVE MEDICINES 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 of Marasmus, a variety of symptoms which affect the young of both sexes. A sluggishness, lassitude on slight exertion, depra- vity and loss of appetite, wasting of the muscular flesh, fulness of the features and paleness of the counte- nance, swelling of the abdomen, an irregular and ge- nerally 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 be- ginning of the disease. When these symptoms have continued for some time, they are followed by alternate paleness and flush- ing of the countenance, heat and dryness of skin, fee- ble and quick pulse, thirst, fretfulness, increasing de- bility and disturbed sleep, during which the patients grind or gnash their teeth, and are subject to involun- tary starting, and twitching of different muscles. Every case of marasmus does not necessarily in- clude all the symptoms which I have enumerated. 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 delica- cy of constitution, or from incidental causes. It is particularly prevalent in large and populous cities, where children are deprived of ready access to exer- cise in the pure air, and sicken and pine in the nur- sery; or when they are confined in crowded and air- less school-rooms, whither they are sent, partly for the IN MARASMUS. 57 purposes of education, and partly, to use a common phrase, with the view of being kept out of harm's way. Children also, who are employed in manufactories, where their occupation and confinement in impure air are such as to weaken and enervate them, are lia- ble 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 food and vegetable articles from the garden. In proof of the operation of those causes, I remark, that I have held the office of physician to George Heriot's Hospital for forty-two years. During this long period, I scarcely recollect an instance of this marasmus among the children entertained in that in- stitution. This may be attributed to the healthy site of the building; 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 enjoying their infant sports. See Appendix, p. 37. Marasmus has been generally attributed to the pre- sence of worms in the alimentary canal. This sup- position, however, is questionable. Ascaris, Tenia, and Lumbricus, are the worms most commonly found in the human intestines. Ascarides, which are often passed in great num- bers 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 H 58 ON PURGATIVE MEDICINES 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 notic- ed. On the contrary, after the best directed course of anthelmintic medicines, when the symptoms of the disease are going off, no lumbrici have been seen, unless we admit, that the worms destroyed by the effi- cacy of the medicines, constitute the unnatural and fetid feces which, in such instances, are voided in great abundance. 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 vermi- fuge is employed. Farther, the presence of lumbrici in the bowels is 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 mili- tate against the received opinion, that lumbrici, with- in the intestines, are the cause of marasmus; for if they are so in a single case, they should be so in eve- ry 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 conceived 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 ex- IN MARASMUS. 59 perience, into oblivion. The utility of such anthel- mintics as have been found to be most beneficial, has, in my opinion, been in proportion to the purgative powers which they possessed. Wrhen I consider the languor and lassitude which precede this marasmus; when I recollect the consti- tutional or acquired debility of those who are more particularly exposed to be affected by it, instead of adopting 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 immediate cause of the disease; whence proceed costiveness, distention of the bowels, and a peculiar irritation, the consequence of remora of the feces. I have accordingly been long in the habit of employing purgative medicines for the cure of this marasmus ; the object is, to remove indurated and fetid feces, the accumulation perhaps of months; and, as this object is accomplishing, 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 dis- ease 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 altogeth- er torpid and inactive, neither are they overloaded with accumulated feces. Mild purgatives, therefore, repeated at proper intervals, effect a cure. They pre- serve the bowels in proper action, carry off feces which had begun to be offensive and hurtful, and pre- vent farther accumulation. Neglect, on some occasions, and too great confi- dence in inert medicines on others, allow the confirm- 60 ON PURGATIVE MEDICINES ed stage of marasmus to steal on imperceptibly. Manifest danger now threatens the young sufferer, whose remaining flesh and strength are rapidly wast- ed by the supervening fever: prostration and depra- vity of appetite withhold necessary nourishment, while the more inactive bowel, and greater bulk of feculent matter, throw additional difficulties in the way of a cure. Under 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 the effects of the preceding ones. When the bowels are once opened, stronger purgatives, given at longer intervals, 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, dissolved in a suitable quantity of beef tea, are also convenient purgatives; but calomel will prove, on se- veral 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 recognis- ing the mercurial fetor accurately, the mouth may be affected unnecessarily and unexpectedly. While I thus give appropriate purgative medicines, 1 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 crite- rion of the progress we make in the cure, and direct the farther administration of the purgatives. This inspection is the more necessary, as we cannot ex- pect the information we want from our little patients; and we will often look for it in vain from the atten- dants, whose prejudices, and whose ignorance of our IN MARASMUS. 61 views, prevent their seeing the propriety of the inqui- ry. 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 ap- pear upon the first exhibition of the purgative medi- cines. 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 purga- tives does not fail to produce. 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 disappear- ed, it is expedient to continue a mild stimulus to the bowels. As they have recently suffered, and have been weakened by over-distention, they are apt to fa- vour subsequent accumulation of feces, the forerunner of a relapse, which is to be dreaded the more, as the patients have been weakened by the previous disease. This gentle solicitation of the alvine evacuation, for it ought to be gentle, is not attended with 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. Besides, 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 motions, 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. 62 ON PURGATIVE MEDICINES 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- water, infusions of vegetable bitters, and chalybeates, are of this description; and, provided they do not, by any peculiar effect on the stomach, prevent nourish- ment being taken, will advance the return of the tone and vigorous 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 stimulus of purgative medicines, which brings the sluggish bowels into regular action, and evacuates their contents; and as the disease attacks the young and thoughtless, who can hardly explain their feelings, it behoves mothers, nurses, superintend ants of nurse- ries and of manufactories, to whom the care of the young is committed, to watch over their charge with assiduity. Prostration and depravity of appetite, a changing complexion, tumefaction of the abdomen, scanty and unnatural stools, and fetid breath, indicate approaching danger. When these, therefore, are ob- served, assistance should be asked; by the prompt in- terposition 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 atten- tion of physicians. They have endeavoured to inves- tigate its nature, to assign the causes which induce it, and to propose curative indications. Different sen- IN MARASMUS. 63 timents on these subjects have led them to employ numerous and discordant remedies. Nevertheless, even now they are not agreed as to the causes of hy- drocephalus, so involved 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 incipi- ent marasmus. Till some better theory, therefore, is established, it is not unreasonable to suppose, that the marasmus, of which I have treated, may on some oc- casions 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 resemble those of incipient and even of confirmed ma- rasmus, they have been removed by the diligent ex- hibition of purgative medicines. The truth of this observation has 1 ^n repeatedly confirmed in my pri- vate practice ; a it affords an additional reason for the exercise of atchful attention to prevent the con- firmed state o xiiarasmus, which may, in more in- stances than we are aware of, have been the forerun- ner, if not the cause of hydrocephalus. 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 con- firmed by the repetition of the fits, till their frequency and the force of habit fix it, and make it a constitu- tional disease 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 benefit that arises from them in practice, hold out lit- tle inducement to enter on the discussion. 64 ON PURGATIVE MEDICINES 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 irri- tation of the body inducing epilepsy. When no other is evident the loaded intestine, and the change indu- ced on its contents in the course of the marasmus, of which 1 have spoken, may be suspected of giving the irritation 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 deci- ded and active course of purgative medicines; and not peradventure to allow the disease to strike root, while we are idly employed in the exhibition of inert and useless vermifuge 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 42,1 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 50, and of one by Mr. Stewart, surgeon at Gogar, page 51. I insert also, page 52, 53, commu- nications from Mr. James Russel, 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, and corroborates, the sentiments I entertain respect- ing marasmus, as inducing, or as being connected with, hydrocephalus internus. Stronger and more decided proofs of the utility of purgatives given in these instances, which had so much of the character and appearance of hydrocephalus, cannot be desired. IN CHLOROSIS. 65 They inspire confidence in the prosecution of a simple practice, which will rob this scourge of infancy, of childhood, and early youth, of much of the terror which its most distant approach has been wont to ex- cite, by obviating, in many instances, a tendency to a disease, for which, when once fully formed, we are without a remedy. CHAP. VII. ON THE UTILITY AND ADMINISTRATION OF PURGATIVE 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 odour; 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. A rosy complexion now gives place to a pale, and sometimes to a greenish, and at other times to a yel- lowish colour of skin. The lips and gums exchange their vermillion 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 66 ON PURGATIVE MEDICINES 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 soli- tude. In the progress of the disease, the flesh becomes loose and flaccid, the urine is diminished, and the per- spiration seems to be checked. 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 en- tertained. 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 Boerhavian school was so much oc- cupied. 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 attention. Even in the present improved state of chemistry, we are little able to ascertain the nature of the animal fluids, either in a state of health or of disease ; so as to say in what the former consists, or by what deviations the latter is induced. Neverthe- less, 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, incrassating, and strengthening medicines, and to rectifiers of peculiar acrimonies. According- ly, a crude, multifarious, and often inert practice has been adopted; little calculated for the speedy remo- IN CHLOROSIS. 67 val of a disease, which gains strength by delay, and which, in some instances, becomes quickly too formi- dable to be cured by any means that can be devised. When 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- be-\:y, and in the female, either before, or soon after tne iirst flow of the menstrual flux, many have sup- posed the retention or suppression of the menses to be the immediate cause of the disease. This supposi- tion, however, is liable to objections. We cannot as- certain the precise time at which the retention of the menses may be considered as a circumstance connect- ed with disease. The age of puberty is not the same in every female: 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 argument is adduced, from the circum- stance of chlorosis appearing occasionally among the more feeble and delicate of the male sex; for although females are attacked more frequently and more se- verely with chlorosis, 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 respectable authority, and it has obtained many prose- lytes. Dr. Cullen thus expresses himself in paragraphs M, MI, Mil, Mill, 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 menses; and attending to these symptoms, ihe cause of this retention may, I think, be perceived. 68 ON PURGATIVE MEDICINES " These symptoms, manifestly, shew a considera- ble laxity and flaccidity of the whole system, and therefore 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 generally 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 pre- pares 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, con- nected 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 system; 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 IN CHLOROSIS. 69 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 co-existent diseases, appearing about the age of pu- berty, and originating in a defective communication of a due stimulus from the genital organs, on which the tone and tension of the whole system depend. While 1 acknowledge the great importance of the 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 uncertainty 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, and 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 be merely a begging of the question, and lead to no certain conclusion, as to the nature or cause of this 70 ON PURGATIVE MEDICINES 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, 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 un- healthy set of men. Reasoning from this analogy, I do not understand how the influence of the female ge- nitals 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. Insinuations, injurious to the purity of mind, and of- fensive 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 appro- priate counsel. Into what contradictions do the re- finements of dogmatism lead us! Can passion exist, when the organs which rouse it have not been, as yet, evolved into action, or if evolved, have been after- wards rendered effete by disease ? What bounds can we set to regret, if, in consequence of this ungener- ous, 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! 1 could not avoid entering upon these discussions, which 1 have conducted with all brevity; I thought it was necessary to shew, that the doctrines on the sub- IN CHLOROSIS. 71 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 propose ; a candour perhaps not the less wanted on this account, that my opinion of the disease may ap- pear at first sight too simple; and my practice too little adorned with the show of varied prescription. 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 ge- nitals 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 appearances 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 fecu- lent odour of the breath, disordered stomach, deprav- ed appetite, and impaired digestion. These preclude a sufficient supply of nourishment, at a period of growth when it is most wanted : hence paleness, lax- ity, flaccidity, the nervous symptoms, wasting of the muscular 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 72 ON PURGATIVE MEDICINES than the robust. Females are, in general, more de- licate, 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 well known, that the alvine evacuation is periodi- cal, and subjected to the power of habit: if the regu- lar call be not obeyed, the necessity for the evacua- tion 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 impact- ed. Hence costiveness is more obstinate, and chlo- rosis, and other diseases originating 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 previous favourable opinion of the utility of purgative medicines in other ailments, I many years ago adopt- ed the use of them in chlorosis. I expected, by ob- viating costiveness, to remove the stomachic symp- toms, and of course, others that depended upon them. I pursued this practice with the greater readiness, because I had experienced, on many occasions, the uncertain and protracted cure of chlorosis, by the re- medies 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 IN CHLOROSIS. 73 commencement to its confirmed state; so I found, according to the progress which it had made, that the bowels were more or less easily moved; for as the feculent matter is often accumulated in great quanti- ty, so the expulsion of it is sometimes difficult. Great attention and assiduity, therefore, is requisite in the exhibition of purgative medicines in chlorosis, and the strength of their dose, and the frequency of its re- petition, 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 pa- tients, or the caprice of their relations, does not stea- dily pursue his plan of cure, will be disappointed, his abilities will be called in question, and his practice vilified and neglected. When this intestinal canal has been duly evacuat- ed, recovery may be promoted by the interposition of tonic 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 frequent 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 recommend- ed a gentle purge, at intervals, to carry off whatever loads the intestines. Others advise the same prac- tice, that the stimulus excited by the purgative may be communicated to the vessels of the uterus, which have connection 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. 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 K 74 ON PURGATIVE MEDICINES with the propriety, nay, with the absolute necessity 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 56, contains cases of chloro- sis, which I treated in the Royal Infirmary. They il- lustrate the utility of purgative medicines in this dis- ease. CHAP. VIII. ON THE UTILITY AND ADMINISTRATION OF PURGATIVE MEDICINES IN VOMITING OF BLOOD. Vomiting of blood is an alarming and often a dis- tressful disease; but having been generally consider- ed 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 vomiting 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- vations which I am about to make, will not apply to vomitings of blood, which originate in organic affec- tion of the stomach, and viscera connected with it, either as a constitutional disease, or as the conse- quence of previous irregularities and intemperance. IN VOMITING OF BLOOD. 57 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 praecordia; and by a sense of fulness of the praecordia ; by cough, dyspnoea, and sometimes by pain of breast; by loss of appetite, 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 return of a similar attack. This disease, under the usual management, is of uncertain 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 consider- ed as the sole cause of the disease. It has been said to be a haemorrhagy vicarious of the menses. 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 specula- tive inquirer; and ingenuity has been taxed to invent theories in explanation of them, and of their influence, in health and in disease. The menstrual flux, the most obvious of the uterine 76 ON PURGATIVE MEDICINES 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 expos- ed. Its overflow, or its suppression, are the ready expounders 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 impor- tance 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 opinions respecting the menses, and seem to adopt them, although he may question, in some respects, the foundation 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. 1, for one, am inclined to think, that too much has been imputed to the influence of the menses, in circumstances of disease. In explaining these cir- cumstances, we seem to have reasoned too much on a subject that is but too little understood. Interruption of the menses frequently take place for a length of time, without prejudice to the health. Fe- males often complain, about the usual period of men- struation ; and,if the menses do not appear, the pre- vious disease is hastily attributed to this circum- stance, which, however, may be said, with greater reason, to have caused the suppression. If these things be so, we cannot but regret theoretical disqui- sitions, which have, in other instances, as well as in the present one, led us to an attempt of difficult ac- IN VOMITING OF BLOOD. 77 complishment, and of uncertain issue, the restoration of suppressed menstruation; while' a different prac- tice, more certain, and more useful, and founded on different views of the case, has either never been de- vised, or has been entirely nv.g^'^d. 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, pro- ceeds upon limited, or mistaken information. Sus- pended menstruation is not a necessary concomitant of this haemorrhagy, which appears when the menses are regular. I do not know in what proportion of in- stances 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 conceive it ought to have one, among idiopa- thic 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 purgative medicines on several diseases : I 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 emenagogues, to no good purpose. He re- quested me to open her bowels with calomel; he spoke with the decision which experience gives, and I followed 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 exhibition of the purgative, was copious, and of unnatural appearance. She obtained immediate re- lief; vomiting of blood did not return; and a few 78 ON PURGATIVE MEDICINES more purgatives established her recovery. She left the hospital, strongly enjoined to preserve a regular state of her body, means for this purpose being fur- nished to her. In three or four months this patient returned, la- bouring 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 hospi- tal, again cured, and again admonished to be more attentive 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 cir- cumstance which I had not before suspected. I have followed the practice which this case sug- gested, in the instances of the disease which I have since met with; and my success has been so uniform, that I now lay it down as a certain position, that the proper exhibition of purgative medicines affords sure and effectual means of removing the vomiting of blood of which 1 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 presenee 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, IN VOMITING OF BLOOD. 79 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 costive- ness, that bane of health, and source of manifold dis- tress. 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 perceived by the cases inserted in the Appendix, page 60. 1 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 con- sists in the discharge of blood by the anus, when the patient is at stool. It is not accompanied with haemor- rhoidal or local affection, or with pain. It takes place at uncertain intervals, and is of longer or shorter du- ration on each attack. It generally excites alarm, and is so profuse at times, as to induce weakness and leucophlegmatic tendency. I have witnessed this haemorrhagy more frequently in the male than in the female; upon inquiry, constipation was found to at- tend it in every instance; and 1 have not failed in general to remove it, in a short time, by means of purgative medicines, so exhibited as to insure satis- factory alvine evacuations. The discharge has some- times ceased after the first purgative ; and I have rea- son to believe that my patients, by observing my di- rections respecting a regular state of the bowels, obtained complete cures, as none of them have ap- plied to me a second time for the same ailment. I 80 ON PURGATIVE MEDICINES have found aloes to be the most useful purgative in this species of haemorrhagy. In one instance my ex- pectations of a cure were not fujfilled; but there was some ambiguity in the case, and the patient had for years indulged freely in the pleasures of the table. 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 to the disease which is embarrassing to young practitioners. The most common symptoms of hysteria, and those which are esteemed to be pathognomonic, are acuet pain in the forehead, or over either orbit, which is confined to a small spot; shifting pains of the abdo- men, flatulence, constipation of the body; sometimes, though rarely, vomiting and purging; acid and fetid eructations; an irritable, and occasionally a despon- i dent state of mind ; unquiet sleep, which is frequently disturbed 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-coloured 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 ceso- IN HYSTERIA. 81 jphagus and larynx, producing difficult deglutition and sense of suffocation. After this the patient falls down, and is violently agitated with convulsions of different muscles, parti- cularly of those of the abdomen, which is thereby greatly contracted and drawn inwards. This convul- sive motion continues for some time, when sleep su- pervenes. From this sleep, the patient awakes sobbing and sighing, and with a murmuring noise throughout the abdomen; and most commonly without any recol- lection 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 inter- vals. Hysteria is more frequent and more severe in wo- men 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 accompanies 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 constitution- al 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. I have felt the necessity of premising this short his- tory of a disease, which it is indeed difficult to des- cribe, because I shall refer to it in the subsequent part of this chapter. Frequent disappointments in curing hysteria led me 82 ON PURGATIVE MEDICINES 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, as 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 immedi- ate cause. This doctrine, however, is now so little regarded, 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 epistolari ad Gulielmum Cole, third edition, page 362, speaks thus of hysteria. " Pendent ergo, affectiones itae, quas in feminis hystericas, in maribus hypochondriacas insi- gnire 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 prae- ditas irruunt, atque organorum, turn ejus in quod se ingerunt, turn istius a quo abscedunt, functiones per- vertentes; cum utrumque ab hac tarn iniqua parti- tione, quae naturae ceconomiae penitus adversatur, haud parum detrimenti capiat." " Hie jam spiritus, facto quasi agmine in ventre in- feriore, catervatim, magnoque impetu in fauces irruen- tes, spasmos excitant per omnen quam transeuent re- gionem, ventrem inflantes ad instar globi prae grandis, qui tamen nihil aliud est quam partium spasmo tenta- tarum convolutio et quasi conglobatio quaedam, quae non nisi magna vi reprimi potest et coerceri." Page 363. IN HYSTERIA. 83 • Satis itaquejam constat opinor, omnem huncmor- bum ad spiritus animales non rite dispositos referri de- bere; nee a semine aut sanguine menstruo corruptis, quod asserunt nonnulli auctores, et halitus malignos in partes affectas elevantibus, produci; nee a succorum nescio qua perversa depravatione, sive etiam humo- rum 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 respects to this, I think it will, in the first place, be obvious, that its paroxysms begin by a convulsive and spasmodic affec- tion of the alimentary canal, which is afterwards com- municated to the brain, and to a great part of the nervous system. Although the disease appears to begin in the alimentary canal, yet the connexion which the paroxysms so often have with the menstrual flux, 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 sys- tem. " 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 84 ON PURGATIVE MEDICINES 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 dis- ease, 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 a 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 sensibility, and consequently a mobility, are acquired, which often appear, when neither a general plethera can be supposed to subsist, nor an occasional tumes- cence 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 turges- cence of the blood in the vessels of the lungs seems to produce asthma; so analogy leads me to suppose, that a turgescence of blood in the uterus, or in other parts of the genital system, may occasion the spas- modic or convulsive motions which appear in hyste- ria. It will, at the same time, be evident, that this af- fection of the genitals must especially occur in ple- thoric habits ; and every circumstance mentioned in the history of the disease, serves to confirm this opi- nion, 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 IN HYSTERIA. 85 the uterine or genital system in vomiting of blood and chlorosis, and my conclusion from thence, that this influence, if it does exist, is not of that magnitude which is commonly 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 com- manded 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 *T*|i«, or irregular motions of the animal spirits, proposed by the former, appear to convey the same idea, as the sensibility and mobility of the system of the latter. Setting aside, therefore, the antiquated notion of the suffoca- tion of the womb, we may be said to have only one theory of this disease ; a theory which has engrossed the attention of the speculative physician, and which has directed the conduct of the practitioner for up- wards of a century. But although this coincidence may not be perceiv- ed or admitted by others; yet whatever difference, whether apparent or real, may exist between the opi- nions 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 alleviate the violence and shorten the duration of particular fits; blood-letting is not excluded from the practice of either in hysteria, but Sydenham is dis- posed to employ it more freely than Dr. Cullen. I do not perceive that Dr. Cullen any where mentions pur- gative medicines as proper in hysteria; Sydenham gives them, previous to the exhibition of other medi- cines, for three or four following mornings, page 371. Dr. Cullin proposes to remove plethora, by blood-let- ting, a spare diet, and regular exercise; while, at the 86 ON PURGATIVE MEDICINES same time, he cautions us, that increased mobility may, on some occasions, proceed from inanition, when a fuller supply of nourishment, and tonic me- dicines are indicated, as in epilepsy, paragraphs MCCCXXV, and following oaes. 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 regu- lating the irregular motion of the animal spirits, or of obviating 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 pe- culiarity and violence of the fits seem to have attract- ed all their thoughts, and prevented them from be- stowing the necessary attention on other circum- stances 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, those which precede the fit, those which accompany the fit, and those which immediately fol- low it, are clearly ascertained and distinguished. Among the symptoms which mark the hysteric con- stitution, shifting pains of the abdomen, flatulence, constipation at one time, at another vomiting and purging, together with acid and fetid eructations, are conspicuous. The sensation of a ball wandering through the ab- domen, and ascending to the stomach, and from thence through the oesophagus to the pharynx, is a prominent symptom among those which immediately precede, 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 cessa- tion of which, a murmuring noise throughout the ab- domen is frequently heard. IN HYSTERIA. 87 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 em- ploy, in the first place, purgative medicines, to remove the constipation of the body, which most commonly prevails in hysteria. I have seldom seen vomiting and purging in cases of pure hysteria : but even their presence would not deter me from exhibiting purga- tives, the efficacy of which, in removing these symp- toms in other circumstances of disease, is well known. I was the more disposed to adopt this practice in hys- teria, from my experience of its general safety and peculiar 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 employ- ed in hysteria, exclusively of other medicines. With- in certain limits, 1 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 68 and 69. 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, 88 ON PURGATIVE MEDICINES until such time as the feces are natural, or until the disease 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 instance, 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 oppres- sive mass of accumulated feces. There are instances of counterfeited hysteria, when 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 him- self that the disease really exists ; otherwise the fail- ure of promoting a cure, as in feigned cases he must fail, will bring discredit on the practice, which, hav- ing found useful, I have endeavoured to recommend. I have subjoined, in the Appendix, page 66, 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 Appen- dix, page 71, a letter from Mr. Law, one of the sur- geons 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 successfully by purgative medicines. IN CH0RIA SANCTI VITI. 89 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 circumstance 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 in- volves, those whom it attacks. Dr. Sydenham describes 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 this subject. Sydenham, in his " Schedula Monitoria de novae febris ingressu," gives the history of chorea Sancti Viti, in the following words: " Chorea Sancti Viti convulsionis est species, quae ut plurimum pueros puellasve a decimo aetatis anno, ad pubertatem usque invadit; primd se prodit claudi- cation quadam velpoitusinstabilitate alterutrius curis quod aeger post se trahit fatuorum more; postea in manu ejusdem lateris cernitur, quam, hoc morbo af- fectus, vel pectori, vel alii alicui parti adplicitam, nullo pacto potest continere in eodem situ vel horae mo- menta, sed in alium situm, aliumque locum convul- sione quadam distorquebitur quicquid aeger contra nitatur. Si vas aliquod potu repletum irr manus por- rigatur, antequam ilfud 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 90 ON PURGATIVE MEDICINES haurit, tanquam miscellus 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 natural 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 symp- toms 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 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 different times, and in different instances, affected by it. In this state, the patient does not walk steadily; IN CHOREA SANCTI VITI. 91 his gait resembles a jumping and starting; he some- times cannot walk, and seems palsied; he cannot per- form 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 ex- pressive of vacancy and languor. These circum- stances gives the patient a fatuous appearance. In- deed, there is every reason to believe, that, when the disease has subsisted for some time, fatuity to a cer- tain extent interrupts the exercise of the mental fa- culties. Fever, such as arises in marasmus, is not a neces- sary attendant on chorea; nevertheless, in the ad- vanced periods of the disease, flaccidity and wasting of the muscular flesh takes place, the consequence of constant irritation, of abating appetite, and impair- ed digestion, the common attendants of protracted chorea; and which, I doubt not, may, in some instan- ces, although contrary to the opinion that chorea is not fatal, have been the forerunners of death. From this history, chorea may be considered as consisting 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. 92 ON PURGATIVE MEDICINES " Cum affectus iste," (chorea scilicet,) " ab humore aliquo in nervos irruente, quorum irritatione istius- modi motus praeternaturales producuntur, pendere mihi videretur; indicationes curativas primum ad hu- mores illos tarn venaesectione, quam purgatione mi- nuendos, dein ad corroborandum genus nervosum omnino dirigendas censebam. Quem in finem hac utor methodo. Sanguinem ex aegri brachio ad uncias septem, plus vel minus, pro ratione aetatis, educi jubeo. Die sequente vel dimidiam partem, vel quiddam am- plius, (pro ratione vel aetatis, vel etiam majoris mino- risve corporis, ad subeundasn catharsin, aptitudine,) potionis purgantis communis exhibeo. " Recipe—Tamarind, unciam dimidiam; fol. senn. drachmas duas; rhubarb, drachmam unam et dimi- diam ; coq. suf. 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 parego- ricum iisdem noctibus. Postea sanguinem rursus extrahi euro, dein ut ad catharsin, uti prius, aeger re- vertatur. Atque ita, alternatim sanguinem mitto, et subduco alvum donee oegro vena ter quaterve fuerit incisa, et post singulas venaesectiones toties fuerit pur- gatus, quoties vires ferre posse vinerentur; eo tamen temporis spatio inter alternas evacuationes diligenter observato, ut nihil inde periculi aegro immineat. Die- bus a purgatione evacuis, sequentia prescribo." Hcec sunt medicamenta stimuiantia, uti dicuntur, corroborantia, et alterantia quce hie recensere inutile est. " Quanto magis convalescit aeger, tanto minus pe- dem ducit, tanto pariter et diutius, et constantius ma- num in eodem situ continet, et scyphum ori magis di- recta via admovet: quae certissima sunt indicia quan- tum profecerit in sanitate redintegranda. Ad quam quidem consummates perficiendam, licet auctor non sim ut plus ter quaterve ut plurimum sanguinem emit- IN CHOREA SANCTI VITI. 93 tat aeger, attamen remedia cathartica et alterantia eousque in usum sunt revocanda donee rectissime tandem valeat." Sydenham mentions his success under this manage- ment : " Quo morbo," chorea scilicet, " haud pauci- ores 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 pur- gative and paregoric medicines were given, and the injunction to continue the use of cathartics and alte- ratives, 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 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 6f Sydenham, and the credit which his opinions obtained, encouraged and protected the practice which he recommended. It is certain, how- ever, that a doctrine and practice discordant with his have long prevailed. And it is probable, that the anxiety expressed by Sydenham, that, in the adminis- tration 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 introduced this change. Be this as it may, physicians are now inclined to refer chorea to a cer- tain debility, or loss of tone, in which the convulsive involuntary motions originate. They of course neglect the " humor aliquis in nervos irruens;" they convert the caution of Sydenham into a total prohibition of 94 ON PURGATIVE MEDICINES blood-letting and purging; and in the cure of chorea they adopt the exclusive 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 authority only which attaches to solitary facts. De Haen is an advocate for electricity. In his Ratio Me- dendi he gives several cases, in which it appears to have been exhibited with success. Medical electri- city has, however, lost much of its early celebrity. Notwithstanding the employment of these reme- dies, chorea has been found a tedious disease ; expe- rienced practitioners having admitted that it is con- tinued 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 mo- dern practice, or of the doctrine on which it rests. It is melancholy 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 acquisition of the necessary arts; with the hazard of permanent fatuity, to a certain extent, or of a gro- tesque appearance, from the unconquerable remains of irregular motions being imposed on the young suf- ferers for life. To these certain consequences of pro- tracted 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- IN CHOREA SANCTI VITI. 95 selves while 1 yet employed tonic andstimulating 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 indiscrimi- nate use of the cold-bath, a remedy not always suited to the exhausted 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. I conceived that the debility and spasmodic motions, hitherto so much considered, might not be the lead- ing symptoms of the disease, but might depend upon previous and increasing derangement of health, as in- dicated by irregular appetite, and constipation of the bowels. Under this impression with regard to the erroneous opinions which I had heretofore entertained concern- ing the nature of the disease, and the consequent im- proper practice which I had employed for the cure of of it, I resolved to alter my mode of treatment, in or- der 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, the 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 medi- cines, 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 medicines 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 96 ON TURGATIVE MEDICINES founded; the success of the practice confirmed the justness of the opinion on which it was formed, and encouraged me to persevere with steadiness and de- cision. The purgatives which I employed in the first in- stance were of the weaker kind, and inadequate to the object to be obtained. Stronger ones were found to be necessary to move and discharge the indurated and fetid feces. I observed the quantity of feculent matter collect- ed, to vary in different subjects, and at different pe- riods of the ailment. I could not ascertain this by any previous circumstance. One would think, that the accumulation would be in proportion to the ful- ness and prominence of the abdomen; but 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 feculent accumulation. I think my observa- tion bears me out in this conjecture, as in the instance of David Anderson, the history of whose case will be found at page 76 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 observ- able, to the twenty-fifth day of the same month, the quantity of feces discharged was most wonderful, such as I had never seen before. It appeared to me, dur- ing the above period, to have nearly equalled in weight that of the whole body of the extenuated pa- tient. 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 stage, more sedulous attention is IN CHOREA SANCTI VITI. 97 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 move- ment and expulsion of the accumulated matter are ef- fected, when symptoms of returning health appear. Whoever undertakes the cure of chorea by purgative medicines, must be decided, and firm to his purpose. The confidence which he assumes is necessary to carry home, to the friends of the patient, conviction of ultimate success. Their prejudices will otherwise throw insurmountable obstacles in the way. Half measures, in instances of this kind, will prove unsuc- cessful ; and were it not for perseverance in unloading the alimentary 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 confirmed, are, ere long, followed up by com- plete 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 purga- tives 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 relapse. 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. Ve- N 98 ON PURGATIVE MEDICINES getable bitters, or the preparations of steel, may perhaps be the most useful for accomplishing these ends. I have not felt the necessity of having recourse to medicines 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 medicines; 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 80 and 87 of the Appendix. Some time ago I visited a boy, about twelve years of age, labouring under chorea, who was the object of my daily atten- tion for five months. During this time, the amount of purgative medicines which were given, and the quan- tity 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 latter instances. This observation is aptly illus- trated by the case of Elizabeth Webster, inserted at IN CHOREA SANCTI VITI. 99 page 87 of the Appendix. This girl, after a protract- ed 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 patient on the third of February 1806, Appendix, page 95; 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 appli- cable to every case of chorea. Nelly Parker, Appen- dix, page 97, 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 mention- ed, must be taken into consideration, when we at- tempt 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 necessa- ry for ascertaining the effect of the medicines, the ex- tent of the subsequent dose, or the frequency of its repetition. I have said that chorea consists of two stages, a circumstance which should induce those who have the superintendance of children to attend most care- fully, 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 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 100 ON PURGATIVE MEDICINE.* medicines in chorea, which I had found useful in ma- rasmus. I have inserted, in the Appendix, page 73, 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 va- riolas morbillosque, primo tussis frequens, deinde spu- tum purulentum aderat, sputum demum plane cessa- bat, chorea Sancti Viti prehendit, sinistro potissimum brachio pedeque, ac diversimoda faciei convulsio. Bimestri spatio, adhibita vi electrica, pustulae co- piosae, eaeque turpiter crustosae, brachium et crus cin- gunt, interpolatis purgantibus perfecta salus redivit." Maximillian Stoll supposed to have been the suc- 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 df 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 IN CHOREA SANCTI VITI. 101 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. " 28th.—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 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. 102 ON PURGATIVE MEDICINES " At length the symptoms were relieved by saline laxatives, but the disease was not cured. " The extract of belladona 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 e. 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, belladona, the flowers of zinc, and electricity, have appeared hurtful in that species of chorea which arises from pi- tuita and worms of the intestinal canal."—M. Stoll Ration. Medendi, pars 3tia,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." IN TETANUS. 103 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. Tetanus often approaches in a gradual manner; the first symptoms of the disease appearing, on many occasions, at a period more or less remote from the exposure 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 became stiff, and cannot be open- ed without pain. The patient, about this time, feels a sudden and painful traction about the cartilago en- siformis, which tends towards the spine, with an ag- gravation 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 ensifor- mis, or the pain, as it appears to be, of the epigastri- um, which is accounted the pathognomonic symptom of tetanus, becomes now more violent, and returns every ten or fifteen minutes, and is instantly succeeded 104 ON PURGATIVE MEDICINES by a stronger Tetraction of the head, and greater rigi- dity and pain around the neck, which, extending in the course of the spine to the lower extremities, these are instantly 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 attempt to force them open hurries on the gene- ral spasm. The muscles concerned in deglutition, and the pec- toral and deltoid muscles, are most violently contract- 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 attempt 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 load- ed; the urine is high-coloured; and the body con- tinues 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 dura- tion. The contraction of the muscles is more gene- IN TETANUS. 105 ral; and according as one set of muscles is more strongly contracted than their antagonists, the body is forced into different and highly painful postures. ■ The belly feels to be hard; it is flat and drawn in- wards. The abdominal muscles do not yield on pres- sure, and do not seem to favour the descent of the diaphragm, in inspiration. The body is often pro- jected with violence in different directions, and the patient is only secured from injury by the care of the attendants. Geniturae jactura inopinata saepe sequi- tur tentiginem invitam. The tongue is frequently darted forward and miserably torn between the teeth. The countenance is much contracted; copious sweat flows ; the pulse becomes quick and irregular; respiration is variable, sometimes it is hurried and la- borious, and again it is less so, and natural. Articu- lation is indistinct; the sound of the voice is chang- ed, it is grating and horrible to the ears. The heart throbs violently, and a palpitating motion is felt over the epigastric region. The eyes are watery and lan- guid; the jaws are so fast locked, that drink or nour- ishment, 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 com- pletely 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 will accidentally survive, and with care and attention make a slow recovery; and, in the course of some 106 ON PURGATIVE MEDICINES months, feel himself restored to a certain share of comfort and happiness. Tetanus is a disease of every country, but it is 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 ac- cording as one set of muscles, under a stronger spasm than their antagonists, give a particular curvature or posture to the body. Thus trismus, emposthotonos, and opisthotonos, denominate varieties, which are now recognised as constituting the generic disease, tetanus. 1 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 Isl- and 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 men- struation; too copious evacuations, particularly such as happen in cholera morbus; retrocedent gout and exanthemata; putrid fevers ; and worms. Hysteria, hypochondriasis, and chorea, have also, in the excess of their spasmodic affection, on some occasions, em- ulated the milder symptoms of tetanus, while at the same time they have retained their own generic cha- racter. In the Appendix, page 76, the case of David Anderson, and that of Anne Ross, page 80, exhibit proofs of tetanic affection in chorea. Tetanus, induced by the above-mentioned causes, IN TETANUS. 107 must be considered as a symptomatic disease; and the cure must be conducted according to the indica- tions which apply to the particular case. Idiopathic tetanus is said to be owing, in the first place, to exposure to the vicissitudes of the atmos- phere, 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 cli- mate or season. In the second place, wounds of the soft parts, whe- ther severe or slight, are mentioned as causes of te- tanus, which sometimes supervenes soon after the ac- cident, 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 to the consideration of a single symptom, and have thereby committed mistakes both in theory and practice. In my apprehension, tetanus affords ano- ther instance of the bad effects which arise from a li- mited, or perhaps erroneous view of a disease. From the days of Hippocrates to the present time, the agonizing spasms, the prominent symptom of te- tanus, 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, 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 te- 108 ON PURGATIVE MEDICINES tanus, 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 mis- chievous effects. Dr. Hillary has observed, that in- stantaneous death has followed warm-bathing in teta- nus. 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 in- ference. However just the foregoing observations may be, I 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 1 apprehend will warrant the expectation of considerable benefit from the full andVree exhibition of purgative medicines; and they are supported by the following considera- tions : In the first place, it appears, from the history of te- tanus, 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- 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 increas- ed 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 IN TETANUS. 109 with great uniformity, make it exceedingly probable, that the functions of the stomach and intestines are materially 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 fevci, chorea, 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 also be relieved, if not cured, by a proper admi- nistration 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 acknowledged. Dr. Wright revived the practice of cold-bathing in 110 ON PURGATIVE MEDICINES 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 water 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 belly. 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 Edinburgh Medical and Philosophical Commenta- 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 IN TETANUS. Ill 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 suppos- ed to have yielded, and the patient to have been in the way of recovery. The spasms remitted in about thirty-six hours from the first application of the mer- curial 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, occasional 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 treatment of tetanus, appears to be established by the direct 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 exhibited early, dislodge a quantity of unnatural matter that seems to have been collected in the stomach and in- testines, and arrest the formation and progress of the disease which, previous to the adoption of this prac- tice, 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 113. The communication from Mr. John Burns, sur- geon in Glasgow, Appendix, page 127, 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 112 ON PURGATIVE MEDICINES - 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 derangement of the stomach, also subsequent to the accident, may be the cause of the disease; and that when tetanus follows the injury immediately, and when excision, scarification, and cauterizing of the wounded part, have failed of procuring relief, and they almost always fail, I would in both instances re- sort to the use of purgatives, rather than to that of an- tispasmodic medicines, which have so often disap- pointed our hopes. If I am not mistaken, in the view which I have taken of the communication from Dr. Monro, it affords an instance of the utility of purga- tives in tetanus from wounds. Such are the facts, and such the reasoning, on which I rest the probable utility of purgative medi- cines in tetanus. Every one will judge of, and appre- ciate them for himself. It would have been more agreeable to me, however, to have withheld my senti- ments on this subject, 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 opportuni- ties of doing so. And although these speculations may not be confirmed 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 prac- tical medicine. To my observations on spasmodic diseases, I beg to subjoin an extract from Camper's Anatomico-Pa- thological Demonstrations, which has been lately pointed out to me. I submit it without comment to the reader's consideration. " Nervis descriptis ad symptomata accedo, quae ex CONCLUSION. H3 eorum unionibus facile explanantur; ordiar autem a pedum iremore, qui hystericis familiaris est. In anteces- sum vere monere debeo, omnia terribilia hysterica symptomata, quae turn in singulis, turn in universi cor- poris locis quotidie videmus, ab acrimonia putrida primas vias occupante omnino dependere; excremen- torum enim foetor intolerabihs, fauces, et alia quae praeter naturam sunt, rigorum et convulsionum acces- sum annuntiant. Res igitur ita se habere videtur; plexu mesenterico inferiori affecto, nervi omnes cum eo conjuncti, lumbales scilicet, et proinde crurales atque obturatores nervi afficiuntur. Si acrimonia tanta est ut etiam rectum intestinum irritare' queat, nervi Ischadici in concensum trahentur, rigebitque pes integer, concucietur, et per vices quiescet, donee animi deliquium tumultum sedet. " Infantum' inferiorum extremorum convulsiones, ex ascaridibus rectum intestinum occupantibus, banc theoriam confirmant. " Purgantia, etiam drastica licet imprudenter adhi- bita, propterea forsan, epilepsias spurias, choream Sancti Viti, aliosque spasmodicos sanarunt morbos, qui desperati a medicis habebantur." Peteri Camperi, Demonstrationum Anatomico Patho- logicarum, liber secundus,p. 8. Amstelaedami, 1762. 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 purga- tive medicines, and to incite to a farther investigation P 114 CONCLUSION. of a subject, which I conceive to be far from being ex- hausted. 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 ten- dency of speculative disquisitions, which I merely open, and which 1 leave to be prosecuted by others, when the number of well authenticated facts will ren- der 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- 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- CONCLUSION. 115 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 inti- mately connected with the early, the full, and regular- ly continued 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: " 1st, It raised the pulse when low, and reduced it when preternaturally tense or full. " 2nd, 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, w^ hen an attack of the fever was ex- pected in the course of the night. " kth, 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. "tith, It removed obstructions in the lymphatic system. « 1th, By discharging the bile through the bowels, 116 CONCLUSION. 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 summer 1792, which, on perusing the publication of Dr. Rush and Dr. Crisholm, after his return in 1795, he found to be the same with that described by these gentlemen, 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 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 purga- tives were employed, by means of which, provided early recourse 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.—" 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 cer- CONCLUSION. 117 tainly did the symptoms disappear; their good effects were so instantaneous, that a man carried upon deck perfectly delirious, with subsultu3 tendinum, and in the state of the greatest apparent debility, after a co- pious evacuation of this kind, has returned of himself, composed, astonished at his newly acquired strength, and declaring himself to be infinitely recovered; which was indeed evident to every one from his changed countenance and general appearance." Here Mr. Bryce remarks, " that he never saw a disease where the countenance so surely indicated either dan- ger or returning health. Pages 33, 34. Mr. James Anderson, late Surgeon of his Majesty's 60th Regiment, published at Edinburgh, 1798. " A few Facts and Observations on the Yellow Fever of the West Indies." Mr. Anderson says, page 19, " I am 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,'1'' 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 medi- cine. 118 CONCLUSION. " I found nothing so effectually removed the great irritation of the stomach, which is so much to be dreaded in this disease, as the operation of these me- dicines ; and the James's powder had likewise the ef- fect of bringing on a free and equal perspiration." 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,c 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 climates, 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 re- lative to that disease only. " In treating the disease, the remedy I principally CONCLUSION. 119 relied on was mercury, given internally, so as to pro- 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 ef- fect, and as 1 am inclined to believe that the good effects of that remedy were fairly referrible to its ope- ration 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 myself. " 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 disappear- ed. "When the affection of the head, the tension and tumor 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 unpleasant 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 consist- ence and colour of chocolate; lastly, pure bile, with a glairy matter like the whites of eggs. Matter of the last description I have often seen voided without 120 CONCLUSION. any admixture of bilious or feculent matter. I have frequently observed worms and putrid substances of a most offensive smell. When a full evacuation was effected, the fever abated, and the head was conside- rably 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 assumed the remittent or intermittent type. It is to be remaiked, that notwithstanding the fever was fre- quently terminated in this way, yet there was a ten- dency to constipation during the state of convales- cence, accompanied with violent spasms of the sto- mach. To remove the latter symptoms, opium, aether, volatile alkali, &c. were administered unsuccessfully, yet they-always yielded to a purgative. The reme- dies I generally employed were aloes and rhubarb. " I cannot precisely state what proportion of my patients recovered; but that a far greater number re- covered 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, inspect- or, who was at the head of the medical department, from the departure of Mr. Young for Europe till the British army left that country." SCARLATINA. The benefits which I have shown to follow the ex- hibition of purgatives in scarlatina, might be expected from a similar practice in some other exanthemata. Experience 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 pur- gative medicines. CONCLUSION. 121 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 1 have shewn 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 fre- quently tumid bellies, the effect of tardy bowels, and of accumulated feces, which are again undoubtedly a secondary cause of some symptoms, improperly re- ferred to the general scrofulous contamination, and for which remedies are sought in various specifics, which, though innocent in themselves, lead to the postponement or careless exhibition of the more effi- cacious 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 disease. As I have shewn that chlorosis in all its stages, perhaps indeed the last of extreme debility ex- cepted, is to be cured by purgative medicines, I con- clude, that dyspepsia, whether simple, or complicated with a diseased state of the mind, under the appear- ance of hysterical or hypochondriacal mania, may be very much relieved, if not entirely cured, by purgative medicines duly administered, as the remedy upon which the patient's recovery depends, and not as at present, with a secondary view only, in aid of tonic Q 122 CONCLUSION. and stimulant medicines, 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 pur- gative 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 case. Palpitation of the heart deserves particular notice in this place. It is not an uncommon attendant on disorders 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 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 I 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 prac- tice at once grateful and salutary to the sufferer, a practitioner, without indulging too much in the appli- CONCLUSION. 123 cation 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 leading features, bear a striking resemblance to tetanus, and equal it in severity and fatality. Under the impression which I entertain of the utility of pur- gative 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 hydrophobia: for this disease has hardly, in any in- stance, yielded to the most powerful antispasmodic, even when carried to an extent which has bordered on the extinction of life. Antispasmodics are direct- ed, how fruitlessly soever, with the view of alleviating a single symptom. Purgatives are proposed to re- move a cause which frequently induces, and which may always aggravate spasmodic affections. 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- prising that there are some things respecting these medicines themselves, of which I cannot give a satis- factory account. I am at a loss to distinguish pre- cisely between those that act more particularly on the smaller, and those whose influence is exerted on the larger intestines. I am likewise unable to speak al- ways decisively on the mode of exhibiting purgative medicines, whether in full doses at long intervals, or in reduced doses more frequently repeated; whether, on some occasions, a course of purgatives at home, will not be equally serviceable as one of purging mi- neral waters at their fountain heads; and whether and how far collateral aid may be derived from blood-let- ting, 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 system- 124 CONCLUSION. atic manner. These, and other circumstances con- nected with the important practice by purgatives, will therefore remain the subjects 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 infi- nite importance to the success of the practice. One is, the regular and accurate examination of every al- vine evacuation; and the other, the steady exhibition of the purgative medicines, so that its full effect may be daily procured during the continuance of the dis- ease for which it is given. The present state of the practice, and of the public mind respecting it, requires this admonition. By inspection, the practitioner learns the nature of the alvine discharge, is enabled to form a probable conjecture with regard to the ailment; and to regu- late the strength, and to determine the frequency of the repetition of each succeeding dose of the purga- tive. Without 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 medi- cines, in full doses, is absolutely necessary to the suc- cess of the practice in the diseases of which I have spoken. The puny and debilitated state of the suf- ferer may on some occasions excite alarm in the breast of the practitioner; and the caprice of his pa- tient, and the whims of relatives, may oppose obsta- cles to his conducting the cure in the most advan- tageous manner. But these he must disregard; for unless he can suppress his own improper feelings, and overcome the unreasonable objections of others, he had better not adopt measures which, to prove suc- cessful, must be conducted with firmness. A con- trary conduct will necessarily terminate in the vexa- tion of the practitioner, the disappointment of the pa- CONCLUSION. 125 tient 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 eva- cuation will at times prevent the accession of those diseases. If these expectations be not too sanguine, it is likely that the marasmus and chlorosis, the vo- miting of blood, chorea and hysteria, of which I have spoken, will, under this management, rarely, if ever, appear. It is fitting, therefore, that this observation should be widely spread; that it should be conveyed to mothers and nurses, to superintendants of nurse- ries, of manufactories, and of boarding-schools, and to all instructors and protectors of children and young people; and strongly impressed on their minds by such of their medical advisers as think with me, and who will acknowledge, that to prevent disease is their paramount duty. To conclude, the reader must have observed the beneficial effects of purgative medicines, in diseases apparently 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 esta- blished certain leading facts, and to have opened views, which, if properly prosecuted, must give an op- portunity to extend our knowledge respecting the utility and administration of purgative medicines. It will then be time to generalize the facts, and to form a system of medical doctrines at once clear and com- prehensive, and thence to deduce practical precepts 126 conclusion. useful in proportion as they will be simple and pre- cise. When these expectations are fulfilled, our pos- terity may see deceptive reasoning, how ingenious so- ever, banished from the schools of medicine; and from the practice of the healing art, a multifarious prescription of inert and nauseous 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 formulae of the compounded medicines, peculiar to the Pharma- copoeia 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 Communications made to the author, illustrative of the foregoing observations. 2 APPENDIX I. The fluctuating state of the Nomenclature of the Materia Medica, and of Pharmaceutical preparations, will explain why several old names and titles of both are found in the more early cases contained in this Appendix. And indeed such appear oc- casionally in the more recent cases; the force of habit, and the dread of committing mistakes, while my attention was occupied by the variety of hospital business, have occasioned this devia- tion from the punctilious formality of prescription. On these accounts, and for the sake of perspicuity, I insert in this Num- ber of the Appendix, Tables 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 formulas 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 POSTE- RIORES. TITUL1 PRIORES. TITULI POSTERIORES. Alkali fixum vegatabile purifi- ) ^ . catum . . . $ Carbonas potassae. Ammonia preparata . Carbonas ammonias. Antimoniurn tartarisatum . Tartris antimonii. /•s«?faetida \ Gummi resina ferulae assasfae- 5 tide?. r.*lns Hapa? cum mercurio Bolus jalapae comp.,situs. Calomelus . . . Submurias hydrargyri. • Crystalli tartari . . Supertartris potassae. Cornu cervi . . . Carbonas ammonias. Cremor tartari . Supertartris potassae. MEDICAMINUM NOMENCLATURA. „ 3 TITULI PRIORES. Extractum catharticum Extractum colocynthidis positum Glycirrhiza Hydrargyrus precipitatus reus Jalapa Laudanum Limon Linum Lixiva purificata Lixivium causticum Magnesia alba Magnesia usta Magnesia vitriolata 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 Squama? ferri purificatas Tartarus emeticus Tartarum vitriolatum Tinctura jalapas Tinctura thebaica TITULI POSTERlORES. com- \ Pilulae aloes cum colocynthide. Glycirrhiza glabra. > Oxydum hydrargyri cinereum. Convolvulus jalapa. Tinctura opii. Citrus medica. Linum usitatissimum. Carbonas potassas. Aqua potassae. Carbonas magnesiae. Magnesia. Sulphas magnesiae. Oxydum hydrargyri cinereum. Submurias hydrargyri. Pilulas rhei copositae. Myrtus pimenta. Potio carbonatis calcis. Sulphas magnesiae. Sulphas sodas. Tartris sodae et potassae. Cassia senna. Phosphas sodas. Tartris sodae et potassae. Sulphas sodas. Aqua acetitis ammonias. ) Oxidurn ferri nigrum purifica- $ turn. Tartris antimonii. Sulphas potassae. Tinctura convolvulii jalapae. Tinctura opii. 4 APPENDIX 1. TABULA SECUNDA EXPONIT MEDICAMINUM TITULOS POSTERlORES ET PRIO- RES. TITULI POSTERlORES. Aqua acetitus ammonias Aqua potassas Bolus jalapas compositus Carbonas ammonias Carbonas magnesias . Carbonas potassae TITULI PRIORES. Spiritus Mindereri. Lixivium causticum. Bolus jalapas cum mercuric Ammonia preparata. Magnesia alba. Lixiva purificata. Alkali fixum vegetabile purifica- tum. Senna. Limon. Jalapa. Glycirrhiza. Cassia senna . Citrus medica . Convolvulus jalapa Glycirrhiza glabra Gummiresina ferulae assasfcetidas Assafastida Linum usitatissimum . Linum. Magnesia . . . Magnesia usta. Myrtus pimenta . . Pimenta. Oxydum ferri nigrum purificatum Squamae ferri purificatas C Mercurius cinereus Oxydum hydrargyri cinereum I Hydrargyrus prascipitatus cine- { reus. Soda phosphorata. C Extractum catharticum. Pilulas aloes cum colocynthide < Extractum cojocynthidis composi- ( turn. Pilulas stomachicas. Potio cretacea. Calomelas, mercurius dulcis. Sal catharticus amarus. Tartarum vitriolatum. ( Sal Glauberi. \ Soda vitriolata. i Crystalli tartari. ( Cremor tartari. i Antimonium tartarisatum. ) Tartarus emeticus. i Sal rupellensis. { Soda tartarisata. Tinctura jalapas. ( Laudanum. t Tinctura thebaica. Phosphas sodas Pilulas rhei composites Potio carbonatis calcis Submurias hydrargyri Sulphas magnesias Sulphas potassas Sulphas sodas . Supertartris potassas . Tartris antimonii Tartris sodas et potassas Tinctura convulvuli jalapas Tinctura opii MEDICAMINUM FORMULA. 5 TABULA TERTIA. EXHIBET FORMULAS MEDICAMINUM COMPOSITORUM, QUORUM MENTIO FIT IN HISCE PAGINIS, ET QUA PHARMACOPOEIA NOSOCOMII REGII EDINENSIS, PROPRIA SUNT. Bolus jalapae compositus. R. Pulveris radicis convolvuli jalapas grana quindecim, Calomelanos grana quinque, Conservas rosas Gallicas quantum satis sit. Decoctum furfuris. R. Furfuris uncias duas, Aquas fontanas libras duodecim, Coque ad libras novem, cum subsederint feces, elutriandas. Enema domesticum. R. Muriatis sodas unciam dimidiam, Olei napi silvestris unciam, Aquas tepidas libram. Misce. Enema fcetidum. R. Gummi resinas ferulae assaefastidae drachmas duas, Aquas tepidas uncias decern. Solve. Enema purgans. R. Foliorum cassias sennas drachmas tres, Sulphatis sodas unciam, Aquae fervidas libram. Infunde et cola. Haustus anodynus. R. Tincturas opii guttas viginti quinque, Aquas fontanas unciam, Syrupi simplicis drachmas duas. Misce. Haustus ex oleo ricini. R. Olei ricini unciam dimidiam, Aquas distillatas unciam, Spiritus myrti pimentas drachmam, Aquae potassas causticas guttas viginti. Misce. • • APPENDIX I. Haustus salinus effervescens. R. Carbonatis potassae purificati scrupulos quatuor, Aquae fontanas uncias quatuor. Solve, et cum subsederint feces, cola. R. Succi citri medicas uncias duas, Syrupi simplicis, Aquas fontanas utriusque unciam. Misce. Utriusque misturas uncia detur pro dosi ; solutione carbonatis potassas prius sumpta, mistura e succo citri medicas, illico por- rigenda est. Infusum cassias sennae, R. Foliorum cassias sennas unciam et dimidiam, Seminum coriandri sativi contusorum unciam et dimidiam, Supertartritis potassas drachmas duas, Aquas fontanas libram. Supertartritem potassae in aqua coquendo solve; deinde liquo- rem adhuc ferventem. sennas et seminibus affunde; macera per horam in vase operto, et frigefactum cola. Infusum lini usitatissimi. R. Seminum lini usitatissimi uncias duas, Radicis glycirrhizas glabrae unciam dimidiam, Aquas ferventis libras quatuor. Infunde ad focum per horas aliquot, et cola. Mistura cinchonas aromatica, R. Pulveris corticis cinchonas unciam dimidiam, Mucilaginis mimosas niloticae uncias duas. Tere simul et paulatirn adde, Aquas fontanas uncias quinque, Tincturas lauri cassias unciam unam et dimidiam. Misce. Mistura diaphoretica antimonialis. R. Aquas fontanas uncias quinque et dimidiam, Sacchari purificati drachmam unam et dimidiam, Vini tartritis antimonii drachmas duas, Tincturas opii guttas triginta. Misce. Mistura diaphoretica salina. R. Aquas acetitis ammonias, Aquae fontanas, utrusque uncias tres, Carbonatis ammonias grana decern, Syrupi simplicis drachmas sex. Misce. MEDICAMINUM FORMULAE. / Mistura mucilaginosa. R. Decocti altheas officinalis uncias quatuor, Syrupi simplicis unciam dimidiam. Misce. Mistura salina ammoniata. R. Succi citn medicas unciam et dimidiam, Carbonatis ammonias prasparati drachmam dimidiam, vel quantum sufficit ad acidum saturandum, Aquas fontanas uncias tres et dimidiam, Syrupi simplicis unciam. Misce. Potus acidus vegetabilis. R. Decocti furfuris uncias triginta, Supertartritis potassas scrupulos quatUor, Syrupi simplicis uncias duas. Misce. Solutio gummi resinae ferulae assasfoetidse. R. Gummi resinae ferulae assasfoetidas drachmas quatuor, Aquas 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, 21s£ Aug. 1733. John Denham, .Etatis 11.—Complains much of headach, vertigo, general uneasiness, and sickness. Pulse 120, skin very hot, tongue loaded, muca thirst, belly rather slow, no appetite, indifferent nights. Complaints began on the 18th current. He had an emetic on the 19th, with some temporary relief. Injiciatur enema domesticum. 22nd-.—One stool, restless during night, skin dry, and of a 8 APPENDIX II. pungent heat, tongue loaded, pulse about 120, and full, abdomen feels tense, and is painful. R. Mercurii dulcis. Pulveris jalapas, Sacchari albi 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 uncias decern. R. Foliorum sennas drachmam unam, Extract! glycirrhizas drachmam dimidiam, Aquas fervidas uncias octo. Sit infusum 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 some- what distended ; he complains on its being pressed. Repetatur enema domesticum vespere, et habeat haustum, cum tincturas thebaicas guttis quindecim. 25th.—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. Aquas uncias quatuor, Magnesias ustas 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 natu- ral appearance, the two last watery and greenish, a lumbricus has been voided, fulness and paid of abdomen much abated, skin cool, tongue clean, pulse about 90, feeble, mixture used, a good night. Repetatur mistura cum magnesia, necnon haustus vespere. typhus. 9 27th.—Two loose and green-coloured stools voided in bed since yesterday, fulness of abdomen gone, no complaint on pres- sure, tongue clean, pulse about 80, tolerably firm, skin cool, sensible to the stimulus of urine, a good night, appetite return- ing. Continuentur haustus et mistura cum magnesia. 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. 29th.—No stool, a good night, now asleep, appetite improv- ing. Continuetur mistura e magnesia. Omittatur haustus anodynus. Habeat jusculi bovini libram unam, indies. 31.—Another lumbricus, of a large size, voided since yester- day, belly regular, pulse about 80, and soft, tongue clean, appe- tite good, an easy night. Continuetur magnesia alba. 10th Sept.—Gradual convalescence. Dismissed cured. Royal Infirmary 31 st 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 dimidiam. 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 jalapas compositus. ^ Habeat vespere si opus sit enema domesticum. ; •$■■ Haustum anodynum hora omni. ^ 10 APPENDIX II. 5th—Free passage of belly previous to the injection, headach and cough gone, pulse calm, appetite returning. 6th.—Convalescent. Full diet. 10th.—Dismissed cured. Royal Infirmary, <2§th Sept. 1796. Robert Grant, iEtatis 21.—Complains of headach, vertigo, nausea, chilly fits, succeeded by heat and sweating, great unea- siness and oppression, much thirst, and loss of appetite. Pulse 96, tongue very foul, skin at present moist, belly regu- lar, sleeps indifferently; on the 19th, after exposure to cold, while on guard in the night-time, was seized with headach, coldness, shivering, and prostration of strength; he has con- tinued daily worse since that time, although he took an emetic on the 20th. 30th Sept.—Febrile symptoms continue, pulse about 90, somewhat full, tongue pretty clean and moist, a stool in the course of yesterday. R. Pulveris jalapas grana decern, Mercurii dulcis grana tria. Sit pulvis quam primum su- mendus. Potum acidum vegetabilem, ad libitum. 1st Oct.—Two copious stools, after an injection in the even- ing, 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 white, thirst natural, belly rather loose, appetite bad, urine high-coloured, sleeps ill. Complaints began yesterday, with shivering, followed by in- creased heat and sweating; attributes them to cold and wet, having been exposed to the rain for a considerable time on Sa- turday last, 3d current. Has used no medicines, TYPHUS. 11 6th Sept.—Habeat quam primum, Vini ipecacuanhas unciam unam pro emitico. Cras mane, Pulveris jalapas compositi drachmam dimidiam. 7th.—Full vomiting, febrile symptoms abated, pulse calm, three stools. Full diet. 10th.—Aggravation of headach, with feebleness and langour, pulse about 120, belly slow. Habeat quam primum, pulveris jalapas compositi scrupulos duos. Low diet. Hth.—As yet no stool, headach continues, pulse about 100, rather feeble. Habeat vespere enema domesticum, et ni plene respondent al- vus, pulveris jalapas 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. Sodas 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 cras mane solutio sodas tartarisatae. 16 th—Convalescent. Full diet. 19th.—Slight headach at times, belly open, pulse about 90. Habeat potionis cretaceas unciam unam ter de die. 21st.—Belly regular, slight headach continues. Sumat pulveris corticis Peruviani drachmam dimidiam quater indies. Intermittatur potio cretacea. 26th.—Headach gone, belly regular. Dismissed cured. 12 APPENDIX II. Royal Infirmary, 13th Sept. 1796. Robert Muckle, iEtatis 17.—Complains of pain of head, back, general uneasiness, and weakness. Pulse 84, skin natural, thirst urgent, tongue white, with bad taste in his mouth, appetite impaired, belly regular, urine natu- ral, sleeps ill. Complaints first began on Saturday the 10th inst. with shi- vering, succeeded by increased heat, and sweating. Knows no cause. Took an emetic yesterday, with relief. 14th Sept.—Headach and thirst continue, pulse about 80, skin warm, two stools, indifferent night. Habeat quam primum, Bolum e jalapa cum mercurii granis tribus. 15th.—Pain shifted to the hind-head and neck, thirst con- tinues, no stool. R. Foliorum sennas, Crystallorum tartari, utriusque drachmam unam, Aquas fervidas uncias octo. Sit infusum quam primum sumendum. 17th.—Pain chiefly occupies the hind-neck, in other respects convalescent. Oblinatur cervix qua dolet, Oleo ammoniato et tegatur panno laneo. 21st.—Pain of head and neck gone, slight pain betwixt the scapulas, otherwise well. Intermittatur oleum ammoniatum. Full diet. 26th.—Dismissed cured. Royal Infirmary, 14th Sept. 1796. John Fairgrave, iEtatis 19.—Complains of pain of head, vertigo, sickness, general uneasiness, and weakness. Pulse 68, skin hot, tongue white, thirst, appetite bad, urine natural, belly loose, sleeps pretty well. These complaints first commenced yesterday morning; he was seized with shivering, increased heat, succeeded by sweat- ing. TYPHUS. 13 Knows no cause. Took an emetic yesterday forenoon, with relief. Two stools since admission. Habeat quam primum, Bolum jalapas 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 ungueritum sulphuris more solito. 18th Sept.—Psora yields, pulse about 50. 23d,—Habeat balneum tepidum. Intermittatur unguentum sulphuris. 24th.—Dismissed cured. Royal Infirmary, 19th April, 1798. Donald Watson, ^tatis 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 instant, on which day his complaints began with shivering. R. Mercurii dulcis grana quinque, Pulveris jalapas grana duodecim. Sit pulvis quam primum sumendus. 20th April.—Two stools, tongue loaded, pulse towards 108, and full, thirst moderate, a tolerable night, and still disposed to sleep. Cras mane repetatur pulvis e mercurio dulci et jalapa. 21st.—Another stool in the evening, none since the exhibi- tion 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, head- ach relieved, tongue less loaded, skin cool and moist, pulse calm, a good night. Cras mane habeat pulveris jalapae compositi drachmam unam. 14 APPENDIX II. 23.—A good night, several stools, tongue clean, pulse calm. 27th.—Convalescent. Dismissed cured. Royal Infirmary, *20th April, 1798. James Dennet, .Etatis 12.—Complains of pain in his head, and in his belly, of vertigo, great sickness, and occasional vo- miting, pulse about 100, tongue white, considerable thirst, appe- tite impaired, belly bound. These symptoms commenced with shivering on the 16th, and he had been exposed to the conta- gion of fever. 21st April.—A natural stool, no recurrence of vomiting, head- ach and sickness continue, pulse about 120, skin hot. Habeat pulveris jalapas compositi scrupulum. Haustum cum tincturas thebaicas guttis quindecim hora somni. 22nd.—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 misturas diaphoreticas salinas 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 continue. Habeat vini ipecacuanhas drachmas sex, pro emetico. 25th.—Two dark-coloured stools, no vomiting, gripes gone, a quiet night. 30th.—Convalescent. Full diet. 1 lth May.—Dismissed cured* Royal Infirmary, 1 lth May, 1798. James Grant, iEtatis 18.—Complains of great pain in the umbilical and epigastric regions; of severe headach and much TYPHUS. 15 sickness, with general uneasiness and lassitude. His internal fauces are painful, and there is an eruption of reddish spots over his face and most of his body. Pulse about 90, belly slow, ap- petite 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 increas- ing. 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 de- gree the pain of his head. He took also some pills on the 15th, which acted as a laxative. Habeat enema purgan. 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, Pulveris jalapas, 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 loaded, much thirst, pungent heat of skin, pulse about 80. R. Sodas vitriolatas drachmas sex, Sacchari drachmas duas, Crystallorum tartari, Foliorum sennas, utriusque drachmam, Aquas fervidas uncias sedecim. Fiat infusum quam primum sumendum.—Tegantur fauces pan- no laneo. 20th.—Complaints stationary, a bad night, tongue still load- ed, with thirst, skin cooler, pulse about 80, four dark-coloured stools. Habeat haustum anodynum vespere. Cras mani infusi sennas unciam et dimidiam. Seri venosi libras duas, partitis vicibus indies. 21st.—Pain of abdomen is abated, that of internal faucesf which appear considerably inflamed, continues; eruption, co- pious on the face, is less frequent on the rest of the body, heat 16 APPENDIX II. of skin again more pungent, pulse about 100, thirst urgent, no stool, indifferent 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 mode- rate strength, skin of a less pungent heat, thirst not abated. Addantur hausti tincturas thebaicas guttas decern. 23d.—Pain of epigastrium has recurred, pain of fauces con- tinues, skin less hot, pulse about 80, soft and firm, no stool, an indifferent night. Habeat quam primum infusi sennas uncias duas. Repetatur haustus. Intermittatur serum vinosum. 24th.—Two dark-coloured stools, pain of epigastrium and fauces relieved, eruption fading, tongue cleaner, pulse about 80, 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. Royal Infirmary, lth Aug. 1801. John Baird, iEtatis 11.—On the 2nd instant, by account, was suddenly attacked with rigors, increased heat, and general sweat. Since admission, he has been very indistinct, and fre- quently, while awake, is observed to mutter and speak to him- self; 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. TYPHUS. 17 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 better 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, quiet- ness succeeded the exhibition of the draught, which still con- tinues, irregular convulsive motions abated, pulse about 120, and firmer. Habeat misturae diaphoreticae salinas unciam, tertia quaque hora. Repetatur haustus, vespere. 13th.—A tolerable night, disposed to be drowsy; on awak- ing, he appears agitated, screaming occasionally, but makes no complaint, appetite indifferent, pulse quick and feeble, belly slow, involuntary motions not perceived, face more or less flush- ed, copious discharge by the blister. Habeat quam primum infusi sennas uncias duas, necnom ejus- dem 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. 18 APPENDIX If, Intermittatur pilula hydrargyri. An egg to dinner. 27th.—Dismissed cured. Royal Infirmary, 21th March, 1804; Donald Stewart, iEtatis 19.—Complains of violent head- ach, vertigo, nausea, and occasional vomiting, pain under the sternum, with frequent short cough, and slight dyspnoea, debili- ty, general uneasiness, pulse 90, skin hot, tongue loaded, belly, by account, regular. Was attacked two days ago, with rigors, has used no remedies. 28th March.—Imponatur vesicatorium quam primum sterno, et sumat bolum jalapas compositum. Misturas salinas ammoniatas 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. Misturas mucilaginosas uncias quatuor, Vini e tartrite antimonii drachmas duas, Tincturas thebaicas guttas triginta. Misturas agitatas 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 sennas 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 TYPHUS. J 9 pam of throat, with difficult deglutition, pulse 80, skin hot, belly slow. Adhibeatur oleum ammoniatum cum panno laneo faucibus ex- ternis. Habeat pulveris jalapas 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 cretacae unciam unam, secunda quaque hora ; pilu- lam thebaicam, bis de die. 18th.—Four stools. Habeat sodas tartarisatae drachmas sex. Continuentur potio cretacea et pilulas thebaicas. 20th.—Purging gone, tongue appears loaded, headach, pulse calm. Habeat infusi amari unciam dimidiam, quater in dies. Intermittantor potio cretacea, et pilulas thebaicas. 21st.—Stools have become frequent, and of a natural ap pearance, with gripes, and occasionally sickness, and spontane- ous vomiting, tongue white, thirsty. Habeat ipecacuanhae scrupulum unum, pro emetico. Con- tinuetur infusum amarunu 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 qyatuor, Aquas uncias quatuor. Misce. Sumat unciam dimidiam, subinde; haustum anodynum, ves- pere. 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. 20 APPENDIX II. Habeat vini rubri uncias duodecim, 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 ves- pere, si opus sit, ad alvum dejiciendam, enema domesticum. Continuetur vinum. 26th.—A quiet night, disposed to sleep since morning, coun- tenance more florid, and of a more natural appearance, a co- pious, dark-coloured, and fetid stool, after the injection. Repetatur bolus e jalapa, cum mercurio, et enema domesti- cum, 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 ene- ma domesticum, si opus sit, vespere. Repetatur vinum. 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 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 relish- ed, and a little more food taken, slight subsultus with appear- ance of floccitatio. In other respects as yesterday, pulse feeble. Repetatur bolus e jalapa cum mercurio, necnon enema si opus sit, et continuetur vinum. TYPHUS. 21 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 jalapas compositi scrupulos duos. Vespere enema domesticum, ni prius soluta sit alvus. Continuetur vinum. 6th.—Two stools in the course of yesterday, continues ap- parently convalescent, but is greatly emaciated, tongue clean, pulse calm, improving appetite. Habeat vini rubri uncias octo. Aquas uncias quatuor. 30th.—Intermittatur vinum. Full diet. 15th June.—Dismissed cured. Royal Infirmary, lth Oct. 1805. Margaret Manson, iEtatis 20.—Complains of headach, ver- tigo, nausea, and occasional vomiting ; pain of back, and gene- ral pains; pulse 180, and weak, skin hot, tongue very foul, belly costive ; complaints of two days duration, for which she knows of no cause. Habeat bolum jalapas compositum cras mane. 8th Oct.—Two full stools of natural appearance; headach continues; two or three attacks of vomiting during the night, none since morning; sickness relieved, tongue still much load- ed. Repetatur bolus jalapas 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. 22 APPENDIX II. 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, 6th Nov. 1805. 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 6low, 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. Habeat bolum jalapae compositum cras mane. 7th. Nov.—Pain of loins, and other symptoms of general fe- ver, as described ; alternate attacks of chilly and warm fits, fol- lowed by sweating; by her account headach has morning re- missions; pulse about 100 and feeble; as yet no stool. Habeat quam primum, Infusi sennas, Infusi lini, utriusque uncias tres. 8th.—Pain of loins and headach continue, with nausea, and one attack of spontaneous vomiting; complains still of alter- nate rigors and hot fits; pulse about 100, and feeble, skin cool, tongue moist, little thirst, full alvine evacuation, of a dark co- lour 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, appetite good, easy night. 11 th.—Dismissed cured. Royal Infirmary, 6th June, 1806. Jean Wyllie, iEtatis 25.—Complains of severe headach, nausea, and vomiting, pain of back and loins, and general pains. TYPHUS. 23 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 supertartrate of potass, which scarcely moved her bowels. Cras primo mane, habeat Bolum jalapas compositum. 7th June.—Headach and sickness are relieved, surface of natural heat, countenance less flushed, tongue clean, pulse about 80 and soft, an indifferent night, but disposed to sleep since morning, two copious and natural stools. Habeat misturas diaphoreticae salinae unciam, alternis horis. Decoctum furfuris ad libitum. 9th.—Convalescent. Intermittantur medicamenta. 12th.—Dismissed cured. Royal Infirmary, 24th June, 1806. William Meckay, iEtatis 36.—Complains of headach, ver- tigo, and slight nausea, pain of breast, with general pains. Pulse about 100 and soft, tongue white, belly slow, appetite bad, prostration 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 jalapas compositum. 25th June.—Vertigo, headach, and other febrile symptoms much declined, skin cool, pulse calm, tongue clean, one easy alvine evacuation. 28th.—Free of complaint. Dismissed cured. Royal Infirmary 1st July, 1806. Mary Stalker, ^tatis 18.—Complains of headach, debility, general soreness and uneasiness, with vertigo, when in the erect 24 APPENDIX II. posture, alternation of heat and cold, great thirst, sleep disturb- ed, pulse 108, belly and catamenia natural. These complaints began on the 29th ultimo, with rigors, headach, and prostration? of strength, and are attributed to cold. Sumat hora somni haustum cum tincturas thebaicas guttis tri- ginta, et cras primo mane bolum jalapas compositum. 2d July.—Headach, vertigo, and lassitude continue, a bad night, with much heat of surface, which is now however mode- rately cool and rather moist, tongue clean, pulse about 90 and soft, two scanty alvine evacuations, scybalous, but of natural co- lour. Habeat quam primum infusi sennas uncias tres, infusi lini un- cias 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, lth September, 1806. Ann Henderson, iEtatis 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 with- out 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 moderately cool. Bolus given as yet without effect. Accipiat enema anodynum cum tincturas opii guttis sexaginta, Habeat pilulas alceticas octodecim, sumat tres omni trihorio. TYPHUS. 25 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 pilulas aloeticae. 13th.—Has continued convalescent. Dismissed cured. Sect. II. sentiments of authors on the use of purgative medi- cines in fever. Lommius de Curandis Febribus continuis, edit. Lond. 1718. Pp. 131, 132, 133, 134. "Atque haecquidem purgandi tem- pora certa sunt, nisi materia protinus turgere coeperit, id est, effervescere, ac de loco in locum mobilis rapi. Tum enim quam primum humor, quamvis nondum coctus, auctore Hippocrate auferri purgatione debet; idque, ne vel in partem delatus prin- cipem, lethalem ibi excitet inflammationem, vel repente, si ve- nenata est, naturas calorem opprimens, occidat. Illud quoque scire licet, interdum, et declinante febre, iterari purgationem posse, cum per imperfectum judicationem natura majorem qui- dem materias partem exclusit, reliquam vero excludere potis non fuit, quae ipsa jam tum, (ne post iterum morbum faciat) recte medicamento ducitur. Nam quas post judicationes (ut di- ligenter observat Hippocrates) relinquuntur in morbis, recidivas facere consueverunt. Adeo vero demiror inconsulta complu- rium iudicia medicorum, ex quibus cum multi, incipiente morbo, purgent, haud pauci etiam consistente, nonnulli quoque decli- nante, paucissimi tamen sint, qui incrementi provectiorem par- tem arripiant. Quasi, certe, data opera, id tempus praetenennt, quod ad hanc curationem in acutis febribus est aptissimum. " Porro non loquor hactenus id medicamenti genus quod pas- sim lenitivum appellant, sine vi, ullave corporis turba sordes m- testinorum expurgans." " Haud leve commodum acute febn- citantibus ex hujusmodi accedit alvi ductionibus. Nam siccurn oletum vacuatur, putredineoffendens sua, ardor febnhs milescit, 26 APPENDIX II. corruptasque bilis colluvies, quaa juxta est, eluitur. ' Verum mitia plane haec esse debent, sic ut alvum'semel, aut, ad sum- mum bis, non amplius, si fieri potest, moveant.'1 Glass (Thomas.)—Commenlarii 12 de Febribus ad Hippocratis disciplinam adcommodati. Lond. 1742. Pp. 102, 103. "Materia ergo turgens est aliquid molestum circa primas vias hasrens, quod aut per os, aut per alvum, ple- rumque excuti potest; atque haud raro ventriculum aut intesti- num ad id ipsum expellendum irritat." Pp. 103, 104. " Infra autem praecordia turgere materiam, et intestines insidere, significant; genuum gravitas, lumborum dolor ventris distentionis, murmura, tormina, alvi egestiones liquidae, sincerae, corruptee, et acres. Caeterum haec mala ac- cidentia, necnon febres ab eadem causa concitatas, non prius ulla arte cessant, quam materia turgens contemperata sit, vel commoda purgatione expulsa. " Neutiquam vero expectare aequum est, ut ex his evacua- tionibus febres, quae crudae sunt, judicentur; sed spes est ut gravia ilia accidentia, quae materiam turgentem indicant, leven- tur; ex quo aegri facilius ferent febres, et illae citius finientur." Langrish (Browne.)—The Modern Theory and Practice of Physic. Lond. 1764. P. 343, par. 589. " Purges also are detrimental in the begin- ning and increase of slow fevers: for daily experience sufficient- ly 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 creates great un- easiness ; and, indeed, if any excretion be considerably enforc- ed, some inconvenience or other will be sure to succeed it, at such times, especially, where there is no morbid matter tit 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 hap- pens to be more than ordinarily costive ; and then the most le- nient clysters that can be contrived may be sufficient" TYPHUS. 27 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 scarce any chance left for the recovery of our patient, but by the use of moderate purging medicines: for since the. natural excretions by perspiration, sweat, urine, &c. are diminished, 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. 597. " Experience assures us, that gentle lenient ca- thartics, rightly ordered, where the morbid matter is properly attenuated, diluted, and divided fit for expulsion, are not only safe, but 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 carried 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 fe- ver, I have seen a large evacuation by purging of mischievous consequence; and if, upon occasion, a more moderate evacua- tion has appeared to be useful, it is apprehended to have been only by taking off the irritation of retained feces, or by evacuat- ing corrupted humours which happened to be present in the 28 APPENDIX II. 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. 111, 112. " Not only the stomach, but the whole intes- tinal canal, should be unloaded in the beginning of these fevers, but I am sure, reason and experience shew the necessity of do- ing 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 col- luvies drains into the first passages. By such means I never feared to puke, or promote a stool or two, when indicated at any time of the fever, by a nauseous bitter taste in the mouth, sickness at stomach, nidorose and fetid eructations ; or by too great costiveness, tumid abdomen, 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, with 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 pracordia, perpetual sickness, eructation and singultus had pre- ceded. 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 sto- mach ; and the abominably fetid, black, bilious stools, the ne- cessity and advantage of the discharge. Surely if a poison of any kind was lodged in the stomach, or bowels, we should not hesi- tate about the necessity of carrying 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 pro- fuse diarrhoea, a dysentery, soon fatal if not restrained ; but this most commonly happens, from suffering the corrupt bilious matter to lodge and putrify too long a time in the bowels; and the best way to prevent it is to dislodge it at proper seasons, and due intervals." SCARLATINA. 29 Currie (James.)—Medical Reports on the Effects of Water, cold 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 moderate the heat in the hot stage; and to resolve the stricture on the extreme vessels, by which the morbid heat is retained, and the reaction prolonged; and where the inordinate action of the vascular system continues after these objects have been at- tained, to support the powers of life, till the morbid associa- tions, 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 pro- per action of the bowels, and, in every case, to unload the ali- mentary canal of its morbid contents, whether these contents have become diseased through the action of general fever, or as there is reason to believe in some of the fevers of the warm cli- mates,.be the remote cause by which fever is produced." APPENDIX III. SCARLATINA. Sect. I. CASES OF PATIENTS WHO LABOURED UNDER SCARLATINA, EX- TRACTED FROM THE RECORDS OF THE ROYAL INFIRMARY. Royal Infirmary, 11th Nov. 1804. James Ritchie, soldier, iEtatis 19.—Feels great pain and difficulty of deglutition, the internal fauces being of a deep red colour, and the tonsils considerably swelled, with a large grey- ish-coloured slough, occupying the left one : complains of head- ach, 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 as- sign no cause for his complaints. Has used no remedies. 30 APPENDIX III. Habeat bolum e jalapa cum mercurio. R. Acidi muriatici oxygenati drachmas duas. Aquas fontanas uncias sedecim. Sit mistura in loco tene- nebroso servanda, cujus sumat unciam unam e cyatho 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, with difficult deglutition, countenance pale, no stool. R. Tincturas jalapas drachmas sex, Aquas canellae albas drachmas duas, Sacchari drachmam unam. 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 jalapas. 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 cinchonas aromaticas unciam unam, tertia quaque hora. Full diet. 3d Dec,—Since yesterday, considerable oedema has occurred. By account, urine has been in natural quantity, and bowels re- gular, pulse about 70. Habeat quam primum bolum e jalapa cum mercurio, vespere repetendum, necnon cras primo mane, ni prius soluta fuerit alvus. Intermittatur mistura cinchonae. 4th.—Three stools; the last of natural appearance, oedema abated. Two boluses taken. SCARLATINA. 31 Cras mane repetatur bolus e jalapa cum mercurio. No stool. 5th.—R. Sodas tartarisatae unciam unam, Infusi sennas uncias duas, Decocti furfuris libram unam. Sit solutio partitis vicibus sumenda. 6th.—Five watery stools, cedema continues, rather aggravat- ed, with considerable dyspnoea, particularly during last night, pulse 60, and soft. R. Submuriatis hydrargyri grana duodecim, Pulveris jalapas drachmam dimidiam, Simul terantur et dividantur in doses quatuor asquales. 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 prasscriptum, cras mane. 8th.—Has had two stools, rather scanty, dyspnoea still farther relieved, one powder only taken. Continuentur pulveres, onus omni trihorio sumendus. R. Sodas tartarisatae drachmas sex, Infusi sennas uncias duas, Aquas fontanas libram. Sit mistura tribus vicibus sumenda, cras mane. 9th.—Three powders taken, four stools, but the alvine dis- charge, on the whole, scanty, of a green colour, and fetid, urine scanty, of a darE and almost bloody colour, cedema continues, ' breathing easy, mouth is affected. Repetatur solutio sodae tartarisatas ut heri prasscriptum, 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. 1 lth.—(Edema still more abated, feculent discharge, of natu- ral quantity and appearance. 32 APPENDIX III. Habeat pilulas aloeticas duas, omni mane et vespere. Vini rubri uncias octo, indies. 13th.—Belly regular, oedema gone, and countenance more lively than hitherto. Continuentur vinum et pilulas aloeticas. 16th.—Has had two stools daily, in abundant quantity, and of natural appearance. , Sumat pilulas aloeticas duas tantum indies. 24th.—Dismissed cured. Royal Infirmary, 11th 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 sodas et potassas drachmas sex, Infusi sennas uncias duas, Exanfusi lini unciis sex, duabus vicibus sumendas. 12th Feb.—Has had several stools, efflorescence faded, inter- nal fauces relieved, pulse calm, tongue loaded, much thirst and languor. 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 good night, is less languid, pulse calm, four stools. Vespere repetatur haustus anodynus. 14th.—A quiet night, two stools of natural appearance, free of complaint. Repetatur haustus anodynus. Habeat omni mane pulveris radicis rhei grana octo. 15th.—One stool. Convalescent. SCARLATINA. 33 Repetatur haustus anodynus. 17th.—Belly regular, stools natural. Full diet. 23d.—Belly open, tongue loaded. Habeat ipecacuanhas scrupulum unum, 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 appetite, 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 succeeded a fever, which was accompanied with general efflo- rescence 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. Habeat pulveris jalapae grana sex, Submuriatis hydrargyri grana tria. Sit bolus quam primum sumendu3. 7th Jan.—As yet no stool. Injiciantur quam primum per anum, enematis domestici uncias octo. Habeat bolos quatuor, ut heri prasscriptum; 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 bo- lus ; 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 abdomen; pupils seem to possess more contractility, appetite indifferent, pulse 80, and soft. 9th.—An easier night, sleep being of longer continuance; he 5 34 APPENDIX III. awakes less suddenly, and without screaming; by his account, is free of headach, but complains of pain of abdomen ; counte- nance at present pale, pulse towards 100 and feeble, a fetid, and dark-coloured stool, urine in small quantity, and high-co- loured, little food taken. Habeat pulveris jalapas compositi scrupulum unum quam pri- mum ; 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 prasscriptum. 1 lth.—Free and full feculent discharge, and he continues free of complaint. Habeat secum pulveres jalapas composites, ut supra prasscrip- tum, duodecim. Signa, one to be taken daily. Dismissed cured. Royal Infirmary, 14^ 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 after taking food, pain and weakness of knee-joints, strength is impaired, pulse 84, skin cool, tongue rather white, belly slow, catamenia have not appeared for three months, at which time they were suddenly suppressed by exposure to cold. Habeat bolum jalapas 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 sennas uncias duas, ex infusi lini unciis octo. 16th.—Copious feculent discharge, headach, vertigo, and stomachic distress relieved, pain of loins continues, remarks a SCARLATINA. 35 swelling and fulness of face; about four months since laboured under fever, which, by her account, seems to have been scarla- tina anginosa; since when she has never fully recovered her usual health. R. Sulphatis magnesias drachmas tres, Supertartritis potassas drachmam, Infusi sennas unciam, Infusi lini uncias octo. Sit solutio omni mane duabus vicibus sumenda. Full diet. 18th.—A copious alvine discharge of greenish colour, head- ach continues relieved, pain of loins easier, stomachic distress relieved, fulness of features continues. Continuetur solutio sulphatis magnesias. 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. Continueter 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. Misce, et divide in doses octo aequales. Signentur; Laxative powders, one to be taken dissolved in water once a day, or every two days. Dismissed cured. Royal Infirmary, 22th Nov. 1806. John Johnstone, Jltatis 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 co- lour, are observed; general redness of surface, considerable de- bility, much thirst, appetite impaired, heat moderat, tongue pretty clean, belly by account regular, pulse 100, face flushed, sleeps pretty well. .,.,.. u 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. 36 APPENDIX III. Sumat pulveris jalapae compositi scrupulos duos. Utatur infuso rosarum pro gargarismate. 29th Nov.—Flushing of countenance, with efflorescence, and moderate heat of surface, and tumefaction and ulceration of in- ternal fauces, with increased pain, continue; pulse about 108, soft, considerable thirst, a quiet night, pretty copious alvine eva- cuations, consisting of formed detached pieces- of hardened feces. R. Infusi sennas 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 the face gone, internal fauces less pained, full alvine evacuation of dark-coloured and fetid feces. Infusion taken. Sera nocte habeat bolum jalapas compositum, et cras mane re- petatur infusum sennas, ut heri prasscriptum. 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 natural appearance. Intermittatur infusum rosarum. 2d.—Ulceration of internal fauces healed or healing, in other respects convalescent, urine abundant, passage of belly, fecfes nearly of natural appearance. Habeat supertartritis potassae scrupulum unum ter de die. 4th.—Belly regular, and urine abundant. Continuetur supertartris potassas. 5th.—No stool since yesterday, urine abundant, surface dry, desquamation of cuticle. Habeat quam primum pulveris jalapas compositi scrupulos duos. Continuetur supertartris potassas. 6th.—Copious and consistent alvine evacuation, urine con- tinues abundant, improving in strength and appetite. SCARLATINA. 37 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, consist- ing of several acres. On the south and west, it commands ex- tensive views of the country : it is more confined on the north and east by the castle, 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 negative on the admission of any child who appears to them to labour under scrofula. These circumstances are so favourable to the health of the inmates of this foundation, that I have the satisfaction to say, that during thirty-eight years that 1 have had the medical supe- rintendence of it, I have seldom known any serious illness pre- vailing among them. The sons of burgesses, freemen, of Edinburgh, are received into this hospital. They are admitted when between the seventh and eleventh year of their age; and are maintained and educat- ed till they reach their fourteenth year. Their present number is one hundred and twenty, and they, together with the matron, masters, and domestics, forma family of about one hundred and forty persons. 38 APPENDIX III. 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 precaution to be employed, in washing and ventilating the apart- ment or ward which he had left. The whole of the children were confined within the precincts of the hospital, lest, through communication with their relations in town, they might be af- fected with the fever, and thus add to the accumulation of con- tagion. 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 in- creased ; and, during three months that the fever prevailed in the hospital, upwards of fifty of the children passed through it. And I remarked, 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 open- ed. In all the children, particularly in those who were first affect- ed, the symptoms were so mild, that but for my knowledge of the prevalence of the epidemic in town, I might have mistaken the disease on its first appearance, and been lulled into a blame- able security. The throat was not much affected. The uvula and amygdalae were slightly swelled and inflamed in every in- stance ; in a few cases, superficial suppuration and sloughing appeared. The efforescence 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 ap- petite continued throughout the disease. The thirst was mo- derate ; great debility prevailed in every case; and in some a peculiar dejection and despondency, hardly to be looked for in subjects so young. The pulse was variable; always quick, till towards to the end of the disease, when it sometimes sunk be- low the natural standard; it was never full. The surface of the body was occasionally of a pungent heat. Obstinate constipa- tion prevailed in general. My patients were objects of serious attention for twelve or fourteen days; the convalescent state of almost all of them was SCARLATINA. 39 prostrated 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 eolour, and fetid; and sometimes of the colour and consistence of clay, and less fetid. In proportion to the evacuation of these feces, relief was percep- tible. Returning appetite and vivacity accompanied the de- cline and cessation 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 per- spirable 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 long time, to mix with their companions in school, and at play. Happy 1 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 pro- stration of appetite, scanty, if not suspended secretion of urine, swelling of abdomen, obstinate constipation, nausea, extreme debility, and feeble pulse. Alarmed by these symptoms, f requested Messrs. Alexander and George Wood, surgeons to the hospital, to join me in con- sultation. Suitable cordials were ordered, and purgative medi- cines of appropriate quality, and in repeated doses, were direct- ed. The disease, in all the three, proceeded with a rapidity which afforded little farther opportunity for deliberation or ac- tion. The stomach gave way ; all food, cordials, and medicines, were rejected, by vomiting. 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 40 APPENDIX III. boys died, labouring under symptoms, denoting ascites, hydro- thorax, and hydrocephalus. This termination was altogether new ; I had never seen dropsy from scarlatina fatal. In consequence of this event, I approach- ed the hospital for many days under deep anxiety, because I was conscious that other children were at the time in a situa- tion 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 evacuation 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 in- sured a determination downwards; without which, I am satis- fied, I should have had to regret the loss of two other boys; one of whom had taken, within the space of twenty-fonr 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 the affliction of the mouth, and bloody ptyalism, the consequence of the quantity of calomel previous- ly 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 evacuated during the fever by each boy, was astonishing to me. An emetic was given occasionally, but not generally, on the approach of the fever; and towards its decline a moderate quantity of wine was allowed. This seemed to be necessary, in a few instances; but 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 sugar, were also employed in a few cases; as were saline and diaphoretic mixtures. At length, under this management, care and anxiety on the present occasion came to a period. Heriofs Hospital, loth March 1805. SCARLATINA. 41 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 serviceable." Dr. Rush, in his "Medical Facts and Observations," second edition, gives an account of the scarlatina anginosa, as it appear- ed in Philadelphia, in the years 1783 and 1784; and in pages 124, 125, says, " 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 open- ing the bowels, I gave lenient purges, when disposition to costi- veness 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 prescrip- tion consisted of equal parts of rhubarb and sal polychrest, of which mixture as much was taken as procured about two mo- tions a day." Again, page 440, " The best preventative of the disease I found to be rhubarb, taken in the quantity of a few grains every morning, so as to procure one laxative motion in the day. I did not see one who used this confined afterwards to bed, though several persons 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 suffer- ed his patient to remain costive eight days. Would not the inter- position of a mild laxative or two have mitigated the most violent 42 APPENDIX IV. of the symptoms, and have rendered the frequent repetition of vomiting less necessary?" Again, among other remarks on the symptom of purging, Dr. Blackburne says, "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 ob- served, 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, EX- TRACTED FROM THE RECORDS OF THE ROYAL INFIRMARY. Royal Infirmary, Dec. 29th, 1804. Malcolm Morrison, iEtatis 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 frequently 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 remedies. 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 hypochondrium, pressure on which does not seem to give pain; some food taken. MARASMUS. 43 R Submuriatis hydrargyri grana tria, Sacchari, Jalapas, singulorum grana sex. Sit pulvis cras mane sumendus. 31st.—As yet no stool. Si opus sit injiciatur enema domesticum vespere, et eras repe- tatur pulvis 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 ja- lapa. 2d.—A pretty copious, clay-coloured, and fetid stool; food taken. Repetatur eras mane pulvis, ut heri praescriptum. 3d.—Spontaneous vomiting this morning of the contents of the stomach. Fetid and clay-coloured, but more scanty alvine evacuation, indifferent nights. • R.«Tinctura jalapae, Syrupi sacchari, utriusque drachmas duas. Sit haustus mane et vespere sumendus. Haustui vespertino, instillentur tincturas thebaicas guttas decern. Habeat vini rubri uncias tres indies. 4th.—Has passed an easier night and is now asleep, no vo- miting, no stool. Habeat haustum e tinctura jalapae mane, meridie, et vespere, cum laudano in haustu vespertino, ut heri praescriptum. 5th.—A copious dark-coloured stool, no return of vomiting, a good night, appetite indifferent; but he appears to have gain- ed in point of strength. Continuetur haustus ut heri prasscriptum, necnon vinum et jus- culum bovinum. 6th.—No stool. R. Carbonatis magnesiae scrupulum unum, Supertartritis potassas, Sacchari, utriusque grana decern. 44 APPENDIX IV. Sit pulvis, omni mane sumendus Continuetur haustus cum tinctura jalapae. 7th.—Has had a copious alvine discharge, of a clayish colour and consistence, abdomen continues prominent, and somewhat tense. Continuentur medicamenta. 9th.—Copious and dark-coloured alvine discharge continues ; that since yesterday more watery and fluid than hitherto ; abdo- men less prominent and less tense, pulse 100 and feeble, appe- tite for food has declined. Habeat vini rubri, Aquae, utriusque uncias, tres indies. Continuetur pulvis carbonatis magnesias, et supertartritis pot- assae, intermisso haustu e tinctura jalapae. 10th.—Two stools, both scanty, but of more natural appear- ance than hitherto, and less fetid, considerable fulness of abdo- men, without pain, wine relished, appetite variable, pulse quick and feeble. R. Submuriatis hydrargyri grana duo, Pulveris jalapas, Sacchari, utriusque grana sex. Sit pulvis, vespere sumendus. Continuetur pulvis e carbonate magnesias, necnon vinum. 11th.-—Fulness of abdomen continues, with pain, particular- ly during night, which' prevents sleep, copious alvine discharge, partly fluid, and partly consistent. Habeat pilulas aloeticas octo ; sumat duas omni tres horas. R. Tincturas jalapas drachmas tres, Syrupi drachmam unam, Aquae uncias duas. Sit haustus cras primo mane sumendus. Continuetur vinum. Intermittatur pulvis e carbonate magnesiae. 12th.—Four copious fluid stools, of more natural appearance, but still very fetid, fulness of abdomen diminished, pain still continues, preventing sleep during the night, pills rejected by vomiting, pulse rather quick. Repetatur haustus e tinctura jalapae cras mane. Continuetur vinum. MARASMUS. 45 13th.—Spontaneous vomiting of contents of stomach this morning after breakfast, one fetid stool, natural, and in moderate quantity; distention and pain of abdomen, preventing sleep, still continue; pulse feeble. R. Magnesias ustae drachmam unam, Mucilaginis gummi Arabici unciam dimidiam, Spiritus lavandulae compositus drachmas duas, Tincturas thebaicas guttas viginti, Aquas uncias tres. Misce. Sumat hujusce misturas agitatae unciam dimidiam, secunda quaque hora. Oblinatur abdomen linimenti anodyni pauxillo, ter vel quatuor indies, et circumdeter panno laneo. Habeat vini rubri uncias quatuor indies. 14th.—Has had a pretty copious fluid and feculent alvine dis- charge, accompanied with much flatus; passed a bad night; but pain of abdomen, and accompanying tension, for the present, are subsided ; has nearly declined all nourishment, the wine has been taken with reluctance; mixture sparingly given, on account of its exciting retching. Pulse quick, but firmer. R. Solutionis assasfoetidas unciam unam, Aquae, uncias quinque. Sit mistura, ope fistulas armatas, per anum injicienda. Continuentur alia ut heri. 15th.—Injection, after being retained for some time, was re- turned, accompanied with much flatus and feculent evacuation. This last, since yesterday, has been copious, nearly of natural appearance, but containing somewhat resembling scybala ; food has been taken; wine relished, and mixture used ; complains less of pain of abdomen, swelling and tension of which are abated. Repetatur enema e solutione assasfoetidae. Continuentur alia. 16th.—Injection retained till the morning ; discharge of fla- tus and feculent evacuation has been less abundant, but tension and pain of abdomen continue relieved; food, wine, and mix- ture, taken. Continuentur vinum et mistura e magnesia. A little beef-steak to dinner. 46 APPENDIX HI. 17th.—Three stools, copious, and of a clay colour; belly ra- ther tense, a good night; appetite continues to improve. Continuentur vinum et mistura e magnesia. 18th.—Copious feculent discharge, resembling that which has been voided for some days past; belly less tense, and less pained; much flatus has been voided ; appetite and strength are improved, and looks are more lively ; injection has not been given. Omisso eriemate, continuentur alia. 20th.—Daily and copious alvine discharge, partly fluid, and partly costive, as formerly, somewhat resembling scybala, but now of more natural appearance and odour; pain and tension of abdomen continue to abate, and strength to improve. Continuentur medicamenta. 21st.—Continuetur vinum, necnon mistura e magnesia cujus su- mat dimidium tantum indies. 24th.—Belly continues regular; stools, except being some- what of a whitish colour, natural; some fulness of abdomen re- mains, but pain is gone; quiet nights ; appetite good ; is be- come more active and more lively. Intermittatur vinum. 28th.—Has continued convalescent. Habeat pulveris jalapae compositi unciam unam, in doses sede- cim dividendum. Signa, one to be taken once or twice a day, so as to preserve a regular state of the bowels ; warmth of surface and nourish- ing food recommended. Dismissed cured. Royal Infirmary 18th Jan. 1806. Alicia Cassidy, iEtatis 7.—Complains of a constant and frequently severe pain about the umbilicus, and of occasionally severe headach; she is observed to pick her nose much, and to start in her sleep, screaming violently : her abdomen is full and prominent; pulse quick and 6mall; tongue loaded; belly very irregular; appetite voracious; her countenance is pale MARASMUS. 47 and languid, and she is said to have been falling off in respect of flesh and strength for the last eighteen months. 19th Jan.—R. Submuriatis hydrargyri grana duodecim, Pulveris jalapas, Sacchari, utriusque semi drachmam. Misce, et divide in doses octo, quarum sumat unam mane et vespere. 20th.—Plentiful alvine evacuation, partly fluid, partly con- sistent, and of a whitish clay colour. Continuentur pulveres ut heri praescriptum. 21st.—Has had copious, partly fluid, and partly consistent, dark-coloured alvine evacuation. Sumat pulveres ut supra praescriptum ter indies. 22d.—Alvine evacuation is scanty, consisting chiefly of dark- coloured scybala. Continuetur submurias hydrargyri, et cras primo mane sumat duabus vicibus. Infusi sennas, uncias quatuor. 24. that follows the confluent small-pox, Dr. Friend, after relating ^ at great length the progress of this fever in a particular instance, a subjoins the following remarks applicable to my purpose. X "Historia haec a me paulo latitus atque prolixius deductaest, 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 1 expectare conveniat, lector ex hac explicatione distinctius facta 1 internoscere possit. Quod quidem medicinae genus ita parum usu esse receptum fateor, ut minime mirer plerosque huic ad- modum adversari. Liberum cuique suum sit judicium: nee dubito quin ii, a quibus dissenseram, habeant ea argumentorum pondera quibus sententiam suam tueantur. Sua illis placuit opinio mini fortasse nimium mea. Siquid liberius sit dictum, id non contradicendi, sed veritatis in re tam gravi aperiendae studio dictum putetur." Hippocratis de morbis popular ibus, Liber primus et tertius Gr. et Lat. His accommodavit novem de febribus commentarios Jo- hannes Friend, 4to Lond. 1111, p. 97. m'Ci ' I-/-,!-:-; /:.n::n:n /! #■: •■'-,,': ^.'^;!~.'faM'"® KffftMj i:'^:::r.''.;^!;;Vj^J;wu5{;!HK5{rf